Age of uptake of early cancer detection facilities by low-risk and high-risk patients with familial breast and ovarian cancer

Imaging surveillance programs for women at high breast cancer risk in Europe: Are women from ethnic minority groups adequately included? (Review)

Women from ethnic minority groups, including immigrants and refugees are reported to have low breast cancer (BC) screening rates. Active, culturally-sensitive outreach is vital for increasing participation of these women in BC screening programs. Women at high BC risk and who belong to an ethnic minority group are of special concern. Such women could benefit from ongoing trials aimed at optimizing screening strategies for early BC detection among those at increased BC risk. Considering the marked disparities in BC survival in Europe and its enormous and dynamic ethnic diversity, these issues are extremely timely for Europe. We systematically reviewed the literature concerning European surveillance studies that had imaging in the protocol and that targeted women at high BC risk. The aim of the present review was thereby to assess the likelihood that women at high BC risk from minority ethnic groups were adequately included in these surveillance programs. Twenty-seven research groups in Europe reported on their imaging surveillance programs for women at increased BC risk. The benefit of strategies such as inclusion of magnetic resonance imaging and/or more intensive screening was clearly documented for the participating women at increased BC risk. However, none of the reports indicated that sufficient outreach was performed to ensure that women at increased BC risk from minority ethnic groups were adequately included in these surveillance programs. On the basis of this systematic review, we conclude that the specific screening needs of ethnic minority women at increased BC risk have not yet been met in Europe. Active, culturally-sensitive outreach is needed to identify minority women at increased BC risk and to facilitate their inclusion in on-going surveillance programs. It is anticipated that these efforts would be most effective if coordinated with the development of European-wide, population-based approaches to BC screening.

Adherence to breast and ovarian cancer screening recommendations for female relatives from the Ontario site of the Breast Cancer Family Registry

This study compares adherence to breast and ovarian cancer screening recommendations among a population cohort of women at familial risk of breast and/or ovarian cancer. This cross-sectional study included 1039 first-degree female relatives without breast cancer identified from the Ontario site of the Breast Cancer Family Registry. We compared breast and ovarian cancer screening behaviors, using a telephone-administered questionnaire among three groups of women defined by their familial risk (high, moderate, and low) of breast and/or ovarian cancer. Associations between screening behaviors and familial risk were assessed using multinomial regression models adjusted by familial clustering. Women, 40-49 years of age, at moderate or high familial risk were significantly more likely to have had a screening mammogram within the past 12 months [odds ratio (OR): 2.80; 95% confidence interval (CI): 1.40-5.58], and women of less than 50 years of age were more likely to have a clinical breast examination (OR: 1.84; 95% CI: 1.02-3.31) compared with women at low familial risk. Compared with women at low or moderate familial risk, women at high familial risk were significantly more likely to have ever had a genetic test for the BRCA 1/2 genes (OR: 2.67; 95% CI: 1.76-4.05). Although the overall level of adherence among high-risk women is suboptimal in the community, women at a higher familial risk are adhering more often to cancer screening recommendations than women at a lower familial risk.

Screening for gynaecologic cancers in genetically predisposed women

Hereditary breast and ovarian cancer syndrome and hereditary non-polyposis colon cancer syndrome are the two most important syndromes responsible for inherited cancers in gynaecology. Genetic testing is available for both these syndromes. Breast cancer gene testing is affordable and easy in women with ancestry where the mutation patterns are known, whereas other population groups need full gene screening. Hereditary non-polyposis colon cancer syndrome can now be diagnosed more frequently with the use of immunohistochemistry. Ovarian cancer risk is high in hereditary breast and ovarian cancer syndromes, and advanced screening techniques should be used when preventive surgery is not an option. Early detection techniques offer less protection than prophylactic removal, but enable women to retain their reproductive organs. Oophorectomy has the advantage of reducing breast cancer risk. In colorectal cancer syndromes, the risk for endometrial and ovarian cancer is much elevated. These risks should be recognised and addressed as these diseases are easy to prevent.

Influence of perceived breast cancer risk on screening behaviors of female relatives from the Ontario site of the Breast Cancer Family Registry

Few studies have examined the influence of perceived risk on breast screening behaviors among women with an increased familial breast cancer risk. This study included 1019 women aged 20-71 years from the Ontario site of the Breast Cancer Family Registry who had at least one first-degree relative diagnosed with breast and/or ovarian cancer. Information was obtained from a self-administered questionnaire completed at the time of recruitment and a follow-up telephone questionnaire. The associations between breast screening behaviors and perceived risk of developing breast cancer, measured on both a numerical and Likert-type verbal scale, were estimated using logistic regression analyses. Women who rated their risk of developing breast cancer as greater than 50% compared with less than 50% were significantly more likely to have a screening mammogram within the last 12 months (odds ratio: 1.91; 95% confidence interval: 1.15-3.16). Women were significantly more likely to have a screening mammogram (odds ratio: 1.82; 95% confidence interval: 1.17-2.81) in the past 12 months if they rated their risk as above or much above average compared with same as average or below. These findings may inform educational messages for improving risk communication of women at elevated familial breast cancer risk.

Evaluation of mathematical models for breast cancer risk assessment in routine clinical use

Chemoprevention, prophylactic surgery, and intensified screening can be offered to patients with an increased lifetime risk, p(life), for breast cancer. Estimation of p(life) includes BRCA analysis and risk estimation based on individual risk factors and family history. MENDEL and BRCAPRO are models that estimate the probability of BRCA1/2-mutations, p(mut), and p(life). In this study, the models are compared with Ford and Claus penetrance/frequency functions. The results were compared with the Tyrer-Cuzick model. Genetic analysis of 111 breast cancer-affected patients from 103 kindreds with a family history of breast and/or ovarian cancer (German Consortium for Hereditary Breast and Ovarian Cancer) was carried out by sequencing BRCA1 and BRCA2. p(life) and p(mut) were calculated with MENDEL, BRCAPRO(Claus), BRCAPRO(Ford), as well as the Tyrer-Cuzick model. The accuracy of p(mut) was analyzed by receiver operating characteristics, and p(life) of each model was compared. The strongest correlation of p(life) was shown by BRCAPRO(Ford)/MENDEL, at r=0.69; no correlation was shown by BRCAPRO(Claus)/MENDEL, at r=0.018. The Tyrer-Cuzick model had the strongest correlations with MENDEL and BRCAPRO(Ford). For MENDEL and BRCAPRO, low correlation or p(mut)-prediction was improved by excluding kindreds with ovarian cancer. p(mut) showed the best accuracy for BRCAPRO(Ford) and MENDEL. BRCAPRO and MENDEL are useful tools for calculating p(mut). They can provide support in decision-making for or against genetic analysis. Estimations of p(life) and p(mut) based on a mathematical model should use algorithms and penetrance/frequency data appropriate to the population counseled. Reproductive/hormonal data, should be incorporated as Tyrer-Cuzick does.

Risk and risk assessment for breast cancer: Molecular and clinical aspects

Chemoprevention, prophylactic surgery and intensified screening programs are options which can be offered the patients with an increased lifetime risk (p(life)) for breast cancer (BC). Estimation of p(life) includes BRCA mutation analysis and risk estimation based on individual risk factors and family history. MENDEL and BRCAPRO are models which can estimate mutation carrier status probability (p(mut)), p(life) and p(mut) can be estimated using Cyrillic3 software which incorporates BRCAPRO and MENDEL. To integrate age, hormonal factors and benign breast biopsies in risk assessment the Tyrer-Cuzick model can be used. These models support the decision pro or contra genetic analysis and improve the number of positive gene testing results. Estimations of p(life) and p(mut), based on a mathematical model, should deal with algorithms and penetrance/frequency data adequate to the population counselled. Being the main modulatory factors, reproductive/hormonal data should be incorporated like the Tyrer-Cuzick model does.

Cancer Genetics

OBJECTIVES

To provide a basic overview of genetics, focusing on breast and ovarian cancer susceptibility mutations on BRCA1 and BRCA2.

DATA SOURCES

Research and review articles and government internet sites.

CONCLUSION

The advances in molecular biology has enabled health care providers to be proactive rather than reactive in predicting some cancers and offering prevention strategies to greatly reduce the risk of developing cancer. Our expanding knowledge base of genetics may one day provide tailored treatment, and predict recurrence rates for all cancers.

IMPLICATIONS FOR NURSING PRACTICE

The science of genetics will impact every aspect of health care, from primary care to specialized care. Nurses are on the front line and will be expected to recognize patterns of disease that may indicate a possible genetic link, educate the family about the implications of a potential genetic susceptibility and refer the family for counseling. To accomplish this, each nurse should have a minimum basic knowledge of genetics, and formal education for those who educate and counsel.

Hereditary breast and ovarian cancer: review and future perspectives

Breast cancer (BC) is the most frequent carcinoma in women. The cumulative risk for the disease is 10% up to the age of 80 years. A familial history of BC and ovarian cancer (OC) is a significant risk factor. Some 5-10% of all cases of BC and 25-40% of cases in patients under the age of 35 years have a hereditary origin. BRCA1/BRCA2 mutations are responsible for 3-8% of all cases of BC and 30-40% of familial cases. Ten percent of patients with OC have a genetic predisposition. About 80% of families with a history of OC have BRCA1 mutations, while 15% have BRCA2 mutations. Women at risk can receive counseling from interdisciplinary cancer genetics clinics, while those at high risk can receive genetic testing. Risk calculation programs can define the risks and assist in decision making for genetic testing and clinical options. Clinical options require information on the risks of the disease and its mutation status. Chemoprevention is currently a controversial topic, while the use of oral contraceptives can be regarded as reducing the risk for OC. Prophylactic mastectomy and bilateral ovariectomy are the only options that lead to a demonstrable reduction in risk, but they do, of course, affect the patient's physical integrity. It is not currently known whether intensified early cancer detection is individually beneficial, but this is currently the option that is the least invasive and least burdensome to the patient. Although hereditary BC has different pathological characteristics and the BRCA mutation is an independent negative prognostic factor, there are currently no special treatment guidelines. Without adjuvant hormone therapy or chemotherapy, the overall survival in BRCA mutation carriers is reduced. Chemotherapy regimens involving platinum are particularly beneficial in the treatment of hereditary BC.