Nov 1, 2012


Sheldon Feldman, M.D.
Sheldon Feldman, M.D.

According to the National Cancer Institute, about 12% of American women will develop breast cancer some time during their lives. Doctors have devised screening recommendations designed to catch those cancers early, when they are most likely to be treatable, but these recommendations are still evolving.

The U.S. Preventive Services Task Force (USPSTF) recently issued new guidelines that annual screening start at age 50 with screening before that at the discretion of the doctor or patient. But many doctors, including Sheldon M. Feldman, M.D., the Chief of the Division of Breast Surgery at NewYork Presbyterian/Columbia University Medical Center, still adhere to earlier screening recommendations. These include a baseline mammogram at age 35 to 40 followed by annual mammograms, and a clinical breast exam for women over 40 at their annual gynecologic checkup.

Cases Where More Vigilance is Suggested

There are some exceptions, though, Dr. Feldman said, that would prompt doctors to be more vigilant.

If a woman's mother or sister was diagnosed with breast cancer at an early age, doctors would generally start screening her ten years before the age at which her relative was diagnosed with cancer. And in women with dense breasts, Dr. Feldman and other doctors recommend augmenting mammography with ultrasound screening, which can pick up more problems in tissue that X-rays don't penetrate well.

In addition, for women whose personal or family history suggests that they are at highest risk for the disease, doctors are likely to recommend genetic testing for a harmful mutation in genes called BRCA1 or BRCA2. These risk factors include a diagnosis of breast or ovarian cancer under age 50 or "pre-menopausally"; a diagnosis of triple negative breast cancer under the age of 60; a family tree that includes women who developed bilateral breast cancer or has men with breast cancer; or a diagnosis of the disease in someone with an Ashkenazi Jewish background.

BRCA mutations dramatically increase a woman's risk of developing breast cancer: women with a BRCA1 mutation have a 60 to 90 percent chance of developing breast cancer by age 70; for BRCA2 mutation carriers the chances range from 40 to 85 percent. Breast MRI in addition to mammography is recommended annually for patients with a BRCA mutation.

Genetic Testing

BRCA mutations are now detectable through a blood or saliva test, said Ann Carlson,M.S., a genetic counselor in the NewYork Presbyterian/Weill-Cornell Medical Center's Genetic Risk Assessment Program. Ms. Carlson meets with women whose doctors have referred them for genetic testing because of their family history or because they have been diagnosed with breast cancer and need to decide on a treatment approach. "During the first of two visits I go through their family tree, talk to them about the BRCA gene and what a mutation in the gene means, the cancer risks you have if you're positive for a mutation, what options you have to deal with the risks, and the implication to your other family members if you're positive," Ms. Carlson said.

Patients with breast cancer often need to know the results of their test in order to decide how far to take their surgery. "Some women might opt for a bilateral mastectomy if they know they have a BRCA mutation, but might have a unilateral mastectomy or a lumpectomy if they don't," she explained. At a follow up session with patients who have tested positive for a mutation, "if they've already had breast cancer we discuss the risk for a second breast cancer and their options going forward, which could include prophylactic mastectomy or enhanced surveillance."