An appraisal of strategies to reduce the incidence of breast cancer

Prophylactic mastectomy; evolving perspectives

It is not at all uncommon for surgeons dealing with breast disease to be confronted with the issue of prophylactic mastectomy. Recent advances in understanding the genetic basis of susceptibility to breast cancer and a better identification of the histological factors affecting a woman's lifetime risk of developing breast cancer have contributed to placing prophylactic mastectomy in a proper clinical perspective. Existing data suggest that prophylactic total mastectomy significantly reduces, but does not totally eliminate, the risk of subsequent development of cancer. However, the benefit of prophylactic mastectomy over alternative strategies (surveillance and chemoprevention) remains to be proven. Currently, prophylactic mastectomy may be considered in a few, carefully selected patients. The decision to perform a prophylactic mastectomy should be a multidisciplinary one. Detailed patient' counselling is very important; the patient should understand the limitations of prophylactic mastectomy and the need for postoperative follow-up. Furthermore, she should be well informed about the alternative strategies.

Assessment of preference for breast cancer chemoprevention in Japanese young women

Pills containing estrogen and progesterone or gonadotropin releasing hormone agonist have been considered valuable to prevent breast cancer. This study assessed preference for the combination-type pill for preventing breast cancer, to evaluate the hypothetical preventive effect of this agent among young Japanese women. The standard gamble method was applied. Fifty-five college students and 44 nursing school students aged between 18 and 41 years were asked to decide the probability of being affected by breast cancer at which they would start to take this agent. Preference score was calculated by subtracting the probability given by each respondent from 1, which corresponds to the value (utility) she allotted to the agent. The means of preference score were 0.58, 0.48, 0.37, and 0.27 for 100, 75, 50, and 25% of efficacy levels of the agent, respectively. Preference score was significantly lower in nursing school students and those whose knowledge about hormones were relatively high. Score of Health Locus of Control (HLC) was nonsignificantly negatively correlated with preference score at any efficacy level. HLC score was significantly higher among those who refused the agent with 50 and 25% efficacy levels at 100% level of breast cancer risk. The data suggest that perceived risk of this agent was not negligibly small in this population and school status, knowledge about hormones, and beliefs about health would affect preference for the agent. Understanding of preference for chemopreventive agents for breast cancer, especially those containing hormones, is important to assess their potential as future preventive agents and is helpful when planning a strategy of chemoprevention.

Identification and management of the woman at increased risk for breast cancer development

Multiple factors which increase a women's breast cancer risk have been identified. These range from conditions such as lobular carcinoma in situ which increase risk to relatively high levels, to reproductive factors such as nulliparity which are associated with only a small increase in risk. When determining an individual's risk, all her potential breast cancer risk factors must be considered. In order for risk information to be meaningful to a woman, risk must be expressed as absolute risk over a defined time interval since there is no uniform agreement on what risk level is high enough to require intervention. At present, careful follow-up or prophylactic mastectomy are the management options available for the woman at increased risk. The efficacy of follow-up including breast self exam, physician exams, and screening mammography for early detection of cancer in a high risk population is unknown. Prophylactic mastectomy, while highly effective, does not provide complete protection from breast cancer and is more radical than the surgery done for established cancer in many cases. Which of these options is chosen by an individual woman is dependent on how much risk she is willing to assume.