Goal should be ‘prevention, not just early detection’ when it comes to breast cancer

A comprehensive approach to screening for breast cancer and working with patients to reduce their lifestyle risks can save more lives, Lisa Larkin, MD, FACP, NCMP, IF, said during the NAMS Annual Meeting.

“Despite having very robust screening in our country with women getting annual mammography at a rate that’s higher than other developed countries, mortality for breast cancer in the United States is not lower than other countries,” said Larkin, founder and CEO of Ms.Medicine, during her presentation.

Based on population, Larkin said, women have a one in eight (12.5%) lifetime risk of developing breast cancer. But that risk can substantially increase for individuals based on many factors, Larkin said, and doctors should take a different approach to evaluating those risks for each patient.

Lisa Larkin

“I want you to think about breast cancer now in the way that we’ve been taught to think about cardiovascular disease, which is we really look at risk,” said Larkin, adding that health care’s reliance on annual mammography would be like cardiovascular doctors simply relying on annual stress tests or coronary calcium scores.

To improve outcomes, doctors can focus on both non-modifiable and modifiable risk factors.

“We’re failing to identify the majority of women who carry hereditary cancer mutations, and we’re failing to identify those women who are at very elevated risk for non-genetic reasons,” she said.

According to Larkin, 5% to 10% of breast cancers associated with genetics are linked to BRCA mutation carriers, and 10% to 15% of them are connected to other known genetic mutations. But the mutations in the other 75% or so are nonidentifiable and related to reproductive risk factors such as early puberty, late menopause and parity.

“Age of first live birth is important, with risk being higher in women who have their first live birth over age 30, and even higher in women who have their first child over 35,” Larkin said.

Larkin also implored doctors who have patients with prior breast biopsies to go back and check their pathologies.

“I’ve far too many times seen that women have had a prior biopsy with atypical hyperplasia, and that hasn’t been identified for them,” Larkin said. “Women who have atypical hyperplasia or LCIS [lobular carcinoma in situ] are at very high risk of developing breast cancer in their lifetime.”

Breast density is another risk factor doctors should consider, Larkin said. Women with heterogeneously dense breasts have an RR of 1.2, whereas women with extremely dense breasts have an RR of 2.1.

“If the only thing you have time to do is look at their mammogram report and find those women that have extremely dense breasts, that would be a great first step in identifying women at elevated risk,” she said.

Screenings also should include active dialogue with patients, Larkin said. For example, many patients tell Larkin that they don’t want hormone therapy because they have heard it causes breast cancer. Larkin suggests that doctors put these concerns in context since other factors present even greater risks.

“Often at midlife, women are starting to consume more alcohol, and alcohol confers a high risk of developing breast cancer, and we need to compare that to hormone therapy,” she said.

Such lifestyle changes can have a positive effect on both cardiovascular and breast cancer risks, Larkin said, and doctors should talk with patients about making these changes gradually but effectively.

“There is a large body of data to suggest that diet has a huge impact on breast cancer risk,” she said. “You can’t take a sedentary patient and make them a marathon runner. And you can’t take someone that has a really poor diet and make them vegan.”

Instead, doctors should encourage these patients to make very subtle changes in their diet incrementally, which can decrease these risks.

“Increasing number of servings of fruits and vegetables, increasing the number of servings of cruciferous vegetables, really trying to move to a plant-based diet has clear benefit in terms of breast cancer risk reduction and prevention,” Larkin said.

Larkin also cited a dietary modification trial conducted by the Women’s Health Initiative involving approximately 50,000 women followed for almost 20 years. Women who were randomly assigned to a low-fat diet saw their breast cancer mortality decrease by more than 20%.

“Diet matters when it comes to breast cancer,” Larkin said.

Overall, Larkin said that doctors should do more and focus on lifestyle early because there are limited opportunities to impact care among younger women.

“We need to really be focusing on lifestyle and encouraging them to have ideal lifestyle behaviors,” she said. “The goal is breast cancer prevention, not just early detection.”

More than 30% of breast cancers and more than 76,000 cases of breast cancer could be prevented each year if women had these ideal metrics, Larkin said, adding that one of the reasons why breast cancer is increasing in the U.S. is the obesity epidemic.

Family histories are vital to successful screenings as well, Larkin said.

“You’re trying to identify those individuals who in a family history have had early cancer, multi-generational cancer in multiple families, or a triple-negative cancer,” Larkin said.

“You want to incorporate, as a clinician, routine family history screening, and there are simple forms that can help make identifying people who meet these criteria that you can incorporate into your practice,” she said.

Patients who meet National Comprehensive Cancer Network (NCCN) guidelines should be sent to genetic counseling for genetic panel testing, which now costs about $250, Larkin said.

“This is really a great new technology where multiple genes can be analyzed quickly and cost-effectively,” she said. “We’re not doing enough of this.”

Larkin also recommends using the Gail and Tyrer-Cuzick models for assessing breast cancer risks.

Although it has some limitations, Larkin said, the Gail model has five questions and takes a minute to complete, so it is easy.

“This is the kind of report that you can print for a patient or show them. It’s very easy to understand how an individual’s risk then correlates compared to population risk,” she said. “I believe this can be very impactful for patients early on again, when we really want to talk to them about lifestyle.”

When patients have their annual wellness visits, Larkin sits down with them at the computer and walks them through the Tyrer-Cuzick model. It incorporates multi-generation family history and biometrics such as breast density to provide a more robust risk assessment in about 2 minutes, Larkin said.

“What I like to do with patients is I actually play around and I show them the impact of weight loss. I show them the impact of family history. I show them the impact of breast density, again, to try to have a conversation with them about modifiable risk factors that they can do in terms of lifestyle,” she said.

Finally, Larkin said there should be a greater effort to conduct population testing. Even when NCCN guidelines are applied, she said, 50% of genetic mutation carriers are missed. Mass population testing, however, would be cost effective.

Ultimately, it is up to individual doctors to assess each patient they see.

“The reason I’m doing risk assessment on all patients is because I want to talk to patients about their individual risk and how it compares to population risk,” she said. “I want to talk about lifestyle with all women in terms of prevention strategies. I also want to find the women who are at very high risk.”