How To Calculate Your Risk For Breast Cancer

Using known risk factors for breast cancer, mathematical models can be developed to help answer important questions. These mathematical models are useful tools for researchers and for patients as follows:

1. Research on risk factors – The Claus risk assessment model was used to discover the subpopulation of people who had an autosomal dominant genetic allele that increased their risk from 10% to 92%. This led to the discovery of the BRCA genes associated with breast, ovarian, and prostate cancer.
2. Clinical trial eligibility – The Gail risk assessment model was developed to help researchers determine who to enroll in the NSAPB Breast Cancer Prevention Trials
where chemoprevention was shown to reduce breast cancer risk.
3. Guidelines for doing BRCA testing – BRCA testing is very expensive and practically worthless if done on everyone (because it is so rare to be homozygous for BRCA1 or BRCA2). Mathematical models such as the BRCAPRO, BOADICEA, and Tyrer-Cuzick models can help determine what patients should undergo BRCA testing. The decision for testing is usually made when one of these models predicts a 10% or greater chance that there is a mutation of the BRCA1, BRCA2, or both genes.
4. Guidelines for doing MRI screening for breast cancer - MRI screening for breast cancer is not a cost effective screening test for the general population, but in specific groups, there are clear cut reasons to do so. In general, screening MRI is recommended for women with 20-25% or greater lifetime risk of breast cancer. The BRCAPRO and Tyrer-Cuzick models have been used to help make clinical decisions about ordering MRIs for breast cancer screening.
5. Guidelines for breast cancer therapy – The Gail model is used clinically to help
determine who should be put on tamoxifen or raloxifene for chemoprevention. Other models have been used to help make decisions about breast cancer risk reduction with prophylactic mastectomy.

For these reasons, it is important to understand these models. These models are collectively refered to as “risk assessment tools”. The following paragraphs summarize the most popular and most widely used risk assessment tools. Keep in mind that none of these risk assessment tools apply to breast cancer survivors. No mathematical model has been widely accepted to determine cancer risk in cancer survivors.

General Risk Assessment Tools

Gail Model: The Gail model is a validated risk-assessment model that focuses primarily on nonhereditary risk factors, with limited information on family history. It was developed by scientists at the National Cancer Institute and the National Surgical Adjuvant Breast and Bowel Project (NSABP) to assist health care providers in discussing breast cancer risk to determine their eligibility for the Breast Cancer Prevention Trial. The tool allows one to project a woman's individual estimate of breast cancer risk over a five-year period of time and over her lifetime. It also compares the woman's risk calculation with the average risk for a woman of the same age. The Gail Model is an on-line quiz that has 13 questions and is interactive. This calculator is based on published risk statistics and methods gathered from peer-reviewed journals, and has been extensively tested for its validity.

The major limitation of the Gail model is the inclusion of only first-degree relatives, which results in underestimating risk in the 50% of families with cancer in the paternal lineage and also takes no account of the age of onset of breast cancer. It may underestimate risk in certain groups, such as obese patients.

National Cancer Institute Model: The NCI risk assessment tool is essentially a simplified Gail Model that also factors in race. Race is a factor in determining breast cancer risk but is excluded when determining eligibility for clinical trials. This tool is probably the most popular risk assessment tool available to the public as an on-line, interactive risk calculator. The on-line quiz is a shorter, nine-point questionnaire that includes multiple factors, giving a woman her future five-year risk of breast cancer and her lifetime risk of breast cancer.

The NCI tool does not account for a lot of risk factors that can be modified. For this reason, it is difficult to use this test as a motivation tool to show people how lifestyle can alter their risk of breast cancer. It also cannot be used in breast cancer survivors, in patients with DCIS, LCIS, or people who carry one of the BRCA genes.

BRCAPRO model: This is a statistical model available as a computer program that uses two different algorithms to evaluate family history and helps a doctor determine the likelihood of finding either a BRCA1 mutation or a BRCA2 mutation in a family. The results of this can be used to determine if BRCA testing is indicated. This is very useful in light of the high cost of BRCA testing ($3,000). None of the nonhereditary risk factors can yet be incorporated into the model, however. In a comparison of four different methods for estimating breast cancer risk in patients with a family history of breast cancer, the BRCAPRO model was the least accurate. It predicted only 49% of the breast cancers that actually occurred in the screened group of patients with a family history of breast cancer.
Harvard Center for Cancer Prevention Risk Assessment Tool: This is another breast cancer risk assessment tool that includes more lifestyle factors than the NCI or Gail Model tools. It has not been studied as extensively as the Gail Model or the simplified NCI model, but it is promising in that it includes many lifestyle factors that people can do to modify their risk of developing cancer. It is also an on-line questionnaire that can be used by both women and men to estimate their breast cancer risk.

Making all this practical

Now after a thorough and confusing discussion of all these statistical models, it’s time to make all this information practical. What is the best way to help a patient accurately assess her risk of breast cancer and if possible, show her what positive factors are reducing her risk and what negative factors can be changed to reduce her risk? If possible, it would also be great to show the patient the value and indications for testing, imaging, chemoprevention, and in some cases surgery. A discussion of the practical aspect of each of these is addressed in a Q & A format below:

Q: What (free) online programs can be used to help a patient assess their risk of breast cancer?

A: Several of the risk assessment tools mentioned above can be accessed for free by the public. Here are the tests and their websites:

1. Your Disease Risk – English version: http://www.diseaseriskindex.harvard.edu
Spanish version: http://www.diseaseriskindex.harvard.edu/spanish
This is a great interactive questionnaire that calculates five-year and lifetime risk of breast cancer developed by the Harvard Center for Cancer Prevention and made public online in 2000. In 2005, they launched the Spanish version of the site, “Cuidar de su Salud”. The risk calculator includes lifestyle factors such as weight, dietary vegetables, alcohol intake, as well as Jewish ethnicity. It does not include other ethnicities, however, and is not accurate for BRCA mutation carriers or breast cancer survivors. Despite these issues, this is by far the best free online risk calculator since it is very interactive and gives you a personalized description of your risk in the form of a colored bar graph, which they can electronically manipulate to experience "virtual" risk reduction. The bar graph is a seven-level scale that compares users to a typical man or woman your age. Users learn where to focus their prevention efforts and how to make lifestyle changes by "clicking on" personalized strategies. With each click, the bar graph shrinks, and the user watches his/her predicted risk drop. This is a great concept to motivate people to participate and comply with lifestyle modification measures.

2. The NCI Risk Assessment Tool –regular web: http://www.cancer.gov/bcrisktool
Mobile web: http://www.cancer.gov/bcrisktoolmobile
This is the easy to use, on-line questionnaire based on a modified Gail model that also includes ethnicity. It does not factor in a personal history of breast cancer, DCIS, or LCIS. It does not account for other factors such as BRCA status, hormonal replacement therapy, lifestyle factors, breast feeding, menopause, or mammographic density. Despite these issues, it is a very useful tool that gives a woman her five-year and lifetime risk of breast cancer. It is the only risk assessment tool that can be used via mobile handheld devices (any type). A version of this can be downloaded for PDAs with Windows Pocket PC operating system as well.

Q: What programs can be used to help a doctor make decisions about ordering a breast MRI?

A: The American Cancer Society has developed some very good guidelines for breast cancer screening with MRI. It should be emphasized that MRI is an adjunct to mammography, not a replacement. Four programs can be used to help in clinical decision making. They are as follows:

1. A Cancer Journal for Clinicians – http://caonline.amcancersoc.org/cgi/content/full/57/2/75

2. BRCPRO – ver.4.3 available @ http://www4.utsouthwestern.edu/breasthealth/cagene/default.asp

3. Claus Model – available as a palm based software product version 1.0 at
http://www.palmgear.com/index.cfm?fuseaction=software.showsoftware&prodID=29820

4. IBIS - Breast Cancer Risk Evaluation Tool, RiskFileCalc version 1.0. This is the Tyrer-Cuzick model that includes hereditary and nonhereditary risk factors. Contact: ibis@cancer.org.uk

Mushrooms, Green tea cut breast cancer risk

SYDNEY: Chinese women who ate mushrooms and drank green tea significantly cut their risk of breast cancer and the severity of the cancer in those who did develop it, an Australian researcher said Wednesday.

Min Zhang, from the University of Western Australia, studied the diets of 2,018 women from the southeastern Chinese city of Hangzhou — half of whom had breast cancer — between July 2004 and September 2005.

While breast cancer was the most common type of cancer for women worldwide, Min said the rate in China was four to five times lower than that typically found in developed countries.

“We concluded that higher dietary intake of mushrooms decreased breast cancer risk in pre- and post-menopausal Chinese women, and an additional decreased risk of breast cancer from the joint effect of mushrooms and green tea was observed,” Min told French news agency.

“The risk of breast cancer significantly declined with the highest intake of dietary mushrooms,” she said, adding that fresh and dried mushrooms were equally effective.

Eating as little as 10 grams, or less than one button mushroom daily, would have a beneficial effect, Min found, with the women who consumed the most fresh mushrooms around two-thirds less likely to develop breast cancer compared with those who did not eat mushrooms.

In addition to lowering the cancer risk, green tea and mushrooms also cut the malignancy of any cancer which did form, Min found.

The fact that the combination of green tea and mushrooms was more effective than just mushrooms alone could partially explain the lower incidence of breast cancer amongst Chinese women, she said.

“To our knowledge, this is the first human study to evaluate the joint effect of mushrooms and green tea on breast cancer,” she said.

“Our findings, if confirmed consistently in other research, have potential implications for protection against breast cancer development using an inexpensive dietary intervention.”

The study was published in the most recent issue of the International Journal of Cancer, and is one in a series of Asian studies by Min and her team on the anti-carcinogenic effects of phytochemicals.

Breast Cancer Facts

• Breast cancer is 100 times more common among women than men.
• A woman's risk of developing breast cancer increases with age.
• Only 5% to 10% of breast cancer cases are hereditary.
• Breast cancer risk is higher among women whose close blood relatives have this disease, or who themselves had previous bouts of breast cancer.
• Women who have had no children or who had their first child after age 30 have a slightly higher breast cancer risk.
• Long time use of Hormone Replacement Therapy, after menopause, may slightly increase the risk of breast cancer.
• Regular consumption of alcohol, cigarette smoking, and a diet high in polyunsaturated fats increases your risk of developing breast cancer.
• Breast cancer is the leading cause of cancer deaths for women aged 40-59.
• Every three minutes a woman is diagnosed with breast cancer.
• Every thirteen minute a woman dies from breast cancer.
• One in every eight women are at risk of developing breast cancer in her lifetime.
• During 2000, it is estimated that 182,800 women and 1,400 men will be diagnosed with breast cancer.
• Approximately 40,800 women and 400 men will die with breast cancer this year.
• During the 1990s, approximately 1.8 million women and 12,000 men were diagnosed with invasive brease cancer.
• When breast cancer is confined to the breast, the five-year survival rate is over 95 percent.

Yoga Benefits Women with Breast Cancer

In a study just published in the journal Psycho-Oncology, researchers conclude they've found a treatment that resulted in a 50% reduction in depression and a 12% increase in feelings of peace and meaning in women with breast cancer. The successful treatment isn't a new type of anti-depressant or anti-anxiety drug. In fact, it isn't a drug at all -- it's the ancient healing and exercise system known as yoga.

Wake Forest University School of Medicine scientists conducted a randomized study of 44 women, all with breast cancer; 34% were actively undergoing cancer treatment such as chemotherapy while the rest of the majority had already completed therapy. Half took a ten week program of 75 minute Restorative Yoga (RY) classes and half were in the waitlist control group. RY is a gentle type of yoga similar to other forms of yoga classes that gently moves the spine in all directions. Blankets, cushions, bolsters, and any other needed props provide support that results in deep relaxation with minimal physical exertion, allowing people at virtually any level of health to practice yoga more easily.

The women in both groups completed a questionnaire to assess the quality of their lives at the beginning and end of the ten week program. According to the Wake Forest research team, the results showed that the women who had been given the RY classes experienced significantly more benefits than the control group (who were later all invited to participate in identical RY classes).

Specifically, the yoga group was found to have improvements in mental health including depression, positive emotions, and spirituality (defined as feeling calm and peaceful) compared to the control group. In fact, the scientists found that women who started the yoga classes with higher negative emotions and lower emotional well-being experienced the most benefits from the gentle yoga exercises compared to the control group. In addition, while women in the control group did not report a change in their fatigue levels, the women taking yoga classes demonstrated a significant improvement in fatigue symptoms.

"Evidence from systematic reviews of randomized trials is quite strong that mind-body therapies improve mood, quality of life, and treatment-related symptoms in people with cancer. Yoga is one mind-body therapy that is widely available and involves relatively reasonable costs," Suzanne Danhauer, Ph.D., who headed the Wake Forest University School of Medicine research team, said in a statement to the media. "Given the high levels of stress and distress that many women with breast cancer experience, the opportunity to experience feeling more peaceful and calm in the midst of breast cancer is a significant benefit."

What is the screening process for breast cancer?

Screening for breast cancer before there are symptoms can be important. Screening can help doctors find and treat cancer early. Treatment is more likely to work well when cancer is found early.

Your doctor may suggest the following screening tests for breast cancer:

* Screening mammogram
* Clinical breast exam
* Breast self-exam

You should ask your doctor about when to start and how often to check for breast cancer.

Screening mammogram

To find breast cancer early, NCI recommends that:

* Women in their 40s and older should have mammograms every 1 to 2 years. A mammogram is a picture of the breast made with x-rays.

* Women who are younger than 40 and have risk factors for breast cancer should ask their health care provider whether to have mammograms and how often to have them.

Mammograms can often show a breast lump before it can be felt. They also can show a cluster of tiny specks of calcium. These specks are called microcalcifications. Lumps or specks can be from cancer, precancerous cells, or other conditions. Further tests are needed to find out if abnormal cells are present.

If an abnormal area shows up on your mammogram, you may need to have more x-rays. You also may need a biopsy. A biopsy is the only way to tell for sure if cancer is present.

Mammograms are the best tool doctors have to find breast cancer early. However, mammograms are not perfect:

* A mammogram may miss some cancers. (The result is called a "false negative.")

* A mammogram may show things that turn out not to be cancer. (The result is called a "false positive.")

* Some fast-growing tumors may grow large or spread to other parts of the body before a mammogram detects them.

Mammograms (as well as dental x-rays, and other routine x-rays) use very small doses of radiation. The risk of any harm is very slight, but repeated x-rays could cause problems. The benefits nearly always outweigh the risk. You should talk with your health care provider about the need for each x-ray. You should also ask for shields to protect parts of your body that are not in the picture.

Clinical breast exam

During a clinical breast exam, your health care provider checks your breasts. You may be asked to raise your arms over your head, let them hang by your sides, or press your hands against your hips.

Your health care provider looks for differences in size or shape between your breasts. The skin of your breasts is checked for a rash, dimpling, or other abnormal signs. Your nipples may be squeezed to check for fluid.

Using the pads of the fingers to feel for lumps, your health care provider checks your entire breast, underarm, and collarbone area. A lump is generally the size of a pea before anyone can feel it. The exam is done on one side, then the other. Your health care provider checks the lymph nodes near the breast to see if they are enlarged.

A thorough clinical breast exam may take about 10 minutes.

Breast self-exam

You may perform monthly breast self-exams to check for any changes in your breasts. It is important to remember that changes can occur because of aging, your menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones. It is normal for breasts to feel a little lumpy and uneven. Also, it is common for your breasts to be swollen and tender right before or during your menstrual period.

You should contact your health care provider if you notice any unusual changes in your breasts.

Breast self-exams cannot replace regular screening mammograms and clinical breast exams. Studies have not shown that breast self-exams alone reduce the number of deaths from breast cancer.

General Info about Breast Cancer

Other than skin cancer, breast cancer is the most common type of cancer among women. Breast cancer mostly occurs in women over the age of 50, and the risk is especially high for women over age 60. Breast cancer is also found to occur more often in white women than African American or Asian women.

Each breast has 15 to 20 sections called lobes. Within each lobe are many smaller lobules (milk producing glands). Lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules and bulbs are all linked by thin tubes called ducts (milk passages that connect the lobules and the nipple). Fat surrounds the lobules and ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola.There are no muscles in the breast, but muscles lie under each breast and cover the ribs.Each breast also contains blood vessels and lymph vessels. The lymph vessels carry colorless fluid called lymph, and lead to small bean-shaped organs called lymph nodes. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest. Lymph nodes are also found in many other parts of the body.

Cancer cells may enter lymph vessels and spread out along these vessels to reach lymph nodes. Cancer cells may also enter blood vessels and spread through the blood stream to other parts of the body, bypassing lymph nodes. When breast cancer cells reach the lymph nodes, they continue to grow, often causing swelling of the lymph nodes. These swollen lymph nodes sometimes can be felt, especially in the armpit. If breast cancer cells have spread to the lymph nodes in the arm pit, there is a greater chance that cancer cells have spread to other organs of the body as well.

The Stages of Breast Cancer

Your doctor will look at a number of factors, including the size of the tumor, the role of lymph nodes, and how far the cancer has spread, to determine the stage of your breast cancer. There are early stages of breast cancer (0, I, II, and IIIA) and advanced stages (IIIB/C and IV).

Early stages of breast cancer

Stage 0

Cancer cells are present in either the lining of a breast lobule or a duct, but they have not spread to the surrounding fatty tissue. This stage is also called ductal carcinoma in situ, or DCIS.

Stage I

Cancer has spread from the lobules or ducts to nearby tissue in the breast. At this stage and beyond, breast cancer is considered to be invasive. The tumor is 2 cm or less in diameter (approximately 1 inch or less); the cancer has not spread to the lymph nodes.

Stage II

In this stage, the tumor can range from 2 cm to less than 5 cm in diameter (approximately 1 to 2 inches); sometimes cancer may have spread to the lymph nodes.

Stage IIIA

In this stage, the tumor is 5 cm or greater in diameter (approximately 2 inches or greater); or the tumor may be of any size where cancer cells have grown extensively into the axillary (underarm) lymph nodes.

Advanced stages of breast cancer

Stage IIIB/C

Known as locally advanced cancer; tumor may be of any size but has spread into the skin of the breast or tissues of the chest wall.

Stage IV

Known as metastatic; cancer has spread from the breast to other parts of the body, such as the bones, liver, lungs, or brain.

Breast cancer recurrence — the return of cancer following primary (initial) treatment — can occur at the same site as the original tumor or somewhere else in the body.