Ductal lavage for breast cancer risk assessment

Genetic analysis of human milk by fluorescence in situ hybridization

Ductal lavage is a technique for early breast cancer detection in high-risk women. During this procedure, exfoliated epithelial cells are flushed out of the milk ducts of nonlactating women and the collected cells are analyzed for cellular changes associated with breast cancer. A recently developed protocol uses interphase fluorescence in situ hybridization (I-FISH) to detect specific chromosomal aneusomies known to be associated with breast cancer. The ability to perform I-FISH on breast milk will prove to be valuable to lactating women who are at high risk for breast cancer or who develop symptoms while breastfeeding. Using established protocols for analyzing peripheral blood lymphocytes, amniocytes, and epithelial cells in urine and breast duct lavage samples as a guide, a protocol for I-FISH of human breast milk has been developed. Cell isolation, fixation, pretreatment, denaturation, hybridization, and washings were optimized to produce slides of high quality, sensitivity, and specificity.

Ductal lavage for breast cancer risk assessment

Ductal lavage is a minimally-invasive procedure that permits sampling of breast ductal fluids for cytopathologic analysis. The technique is performed with topical anesthesia and involves cannulation of any fluid-yielding nipple orifice with a specially-designed catheter for lavage and aspiration of the ductal system. The procedure is used for women who have clinical evidence of increased breast cancer risk; if atypia is detected, it may strengthen a woman's interest in committing to a risk-reducing strategy or a chemoprevention trial. The technology also is being used as a tool in ongoing translational research studies.

Evaluation of Breast Cancer Risk Assessment Techniques: A Cost-effectiveness Analysis

Objective: Assess the effectiveness and cost-effectiveness of using biomarkers and risk assessment tools to stratify women for breast cancer preventive interventions.

Methods: A Markov model was developed to compare risk management strategies for high-risk women considering chemoprevention. Annual screening is compared to the use of chemoprevention for all women and the use of risk assessment technologies to stratify patients for chemoprevention. The biomarker atypia was used to stratify women by risk. Random fine-needle aspiration (rFNA) and ductal lavage (DL) were evaluated and compared as the risk assessment tools used to discover atypia. Sensitivity analyses explore assumptions regarding the prognostic and predictive characteristics of atypia, both the relative breast cancer risk and benefit from chemoprevention women with atypia incur.

Results: Risk assessment strategies using rFNA or DL in combination with chemoprevention are found to be cost-effective (<$50,000 per life year saved) in high-risk groups under most scenarios. Both strategies were more effective and less costly in younger cohorts. Effectiveness of the risk assessment strategies increased when higher risk and increased benefit from chemoprevention were associated with atypia. Within the scenarios tested, rFNA is less costly than DL.

Conclusion: rFNA and DL appear to be cost-effective in high-risk women, assuming women with detected atypia choose tamoxifen. The tools are largely effective for women who are not motivated to take tamoxifen but would be if atypia were found. As biomarker risk assessment tools better predict the risk of breast cancer and or benefit of interventions, their cost-effectiveness increases.

Advances in breast cancer detection and management

Breast cancer detection and management have undergone dramatic changes over the past three decades. Women are increasingly diagnosed with early stage disease, and leaving them with breast conserving options versus mastectomy. Furthermore, advances in the chemoprevention arena offer the promise of reduced overall breast cancer burden in the future.