Experience of young women diagnosed with breast cancer who undergo fertility preservation consultation.

BACKGROUND: Fertility preservation (FP) is of increasing concern to young patients with breast cancer. The American Society of Clinical Oncology has recommended referral to a reproductive specialist as early as possible before beginning systemic adjuvant therapy. AIM: To gather information from young patients with breast cancer about their experiences with FP referral, consultation, and decision making. METHODS: An anonymous questionnaire was mailed to consecutive patients with breast cancer who were referred, from January 2005 to January 2010, from our center to the CReATe fertility clinic. Topics included demographics; cancer stage and treatment; previous fertility problems; referral source and timing; options presented and chosen; and satisfaction with the referral, consultation, and decision-making processes. RESULTS: Of the 53 women identified, 27 (51%) participated. The mean age was 31 years (range, 24-41 years). Fifteen (56%) women opted for embryo or oocyte cryopreservation, 2 for ovarian suppression, and 10 for no FP. The choice was not affected by disease stage or by already having a child. Of the 22 women who responded, 14 (64%) were satisfied or very satisfied overall. Eighteen out of 23 (78%) respondents felt that the right amount of information was given. Thirty-nine percent had difficulty with decision making, but only 1 (4%) woman indicated that cost was a deciding factor. A common theme among respondents was inadequate time for decision making. A common complaint was the lack of written material before and/or after their consultation. Sixty-three percent expressed an interest in meeting with a psychosocial counselor. CONCLUSIONS: (1) FP referral should be initiated by the surgeon as soon as a diagnosis of invasive cancer is made, (2) women need written materials before and after FP consultation is needed, and (3) a FP counselor who is able to spend additional time after the consultation could help with decision making.

Psychological impact of recall on women with BRCA mutations undergoing MRI surveillance.

OBJECTIVE: The addition of magnetic resonance imaging (MRI) to mammography for surveillance of women with BRCA mutations significantly increases sensitivity but lowers specificity. This study aimed to examine whether MRI surveillance, and particularly recall, is associated with increased anxiety, depression, or breast cancer worry/distress. METHODS: Women with BRCA mutations in an MRI surveillance study were invited to complete: Hospital Anxiety and Depression Scale (HADS), Lerman's Breast Cancer Worry Scale, Breast Cancer Worry Interference Scale, and a quality of life rating at 3 time points: 1-2 weeks before (T1), 4-6 weeks after (T2) and 6 months after their annual surveillance (T3). Repeated measures analyses were performed over the 3 time points for recalled and non-recalled women. RESULTS: 55 women (30 BRCA1, 25 BRCA2) completed study instruments at T1 and T2, and 48 at T3. Eighteen women (32%) were recalled for additional imaging. At T1, 27 women (49%) were above HADS threshold for "possible cases" for anxiety (score≥8). Recalled (but not non-recalled) women had a significant increase of HADS anxiety at T2 which dropped to below baseline by T3. No group differences were observed in terms of change over time in other quantitative psychological measures. CONCLUSIONS: While breast MRI surveillance did not have a detrimental psychological impact on women with a BRCA1 or BRCA2 mutation, recalling these very high-risk women for further imaging after a false positive MRI scan temporarily increased their global anxiety.

Improvement in DCIS detection rates by MRI over time in a high-risk breast screening study.

Although magnetic resonance imaging (MRI) is much more sensitive than mammography for detecting early invasive breast cancer, in many high-risk screening studies MRI was less sensitive than mammography for detecting ductal carcinoma in situ (DCIS). We reviewed our experience detecting DCIS in our single center study of annual MRI, mammography, ultrasound and clinical breast examination (CBE) for screening very high-risk women. All cases of DCIS±microinvasion and invasive cancer were compared in two time frames: before (period A) and after (period B) July 2001-when we acquired expertise in the detection of DCIS with MRI-with respect to patient demographics, method of detection, and rates of detection of invasive cancer and DCIS. In period A there were 15 cases (3.1% of 486 screens) in 223 women, of which 2 (13%) were DCIS-one with microinvasion-neither detected by MRI. In period B there were 29 cases (3.3% of 877 screens) in 391 women, of which 10 (34%) were DCIS±microinvasion (p=0.04), all 10 detected by MRI but only one by mammography. No DCIS cases were detected by ultrasound or CBE. Specificity was lower in period B than in period A but acceptable. The ability to detect DCIS with screening MRI improves significantly with experience. MRI-guided biopsy capability is essential for a high-risk screening program. In experienced centers the increased sensitivity of MRI relative to mammography is at least as high for DCIS as it is for invasive breast cancer.

Is mammographic breast density a breast cancer risk factor in women with BRCA mutations?

PURPOSE: Increased mammographic breast density is well recognized as a breast cancer risk factor in the general population. However, it is unclear whether it is a risk factor in women with BRCA mutations. We present the results of a nested case-control screening study investigating the relationship between breast density and breast cancer incidence in this population. PATIENTS AND METHODS: Women ages 25 to 65 years with known BRCA mutations were enrolled onto a single-center, high-risk breast cancer screening program. Using a computer-aided technique (Cumulus), quantitative percentage density (PD) was measured for each participant on her baseline mammogram by a single, blinded observer. RESULTS: Between November 1997 and March 2008, 462 women (mean age, 44 years; 245 BRCA1 and 217 BRCA2) were screened and 50 breast cancers were diagnosed (38 invasive, 12 ductal carcinoma in situ [DCIS]). Density was not measured in 40 women of whom four developed cancer (three invasive, one DCIS). Mean PD (+/- standard deviation [SD]) for 376 women who did not develop breast cancer was 34% (23) compared with 31% (21) for 46 women with cancer (P = .51). Logistic regression model of breast cancer incidence and PD revealed an odds ratio of 0.99 (+/- 0.01 SD) for a one-unit increase in PD (P = .44). Results remained nonsignificant in multivariate analysis, as well as when women with pure DCIS were excluded. CONCLUSION: Increased mammographic breast density is not associated with higher breast cancer incidence in women with BRCA mutations. On the basis of these findings, density should not be considered a factor for these women in decision making regarding prophylactic surgery or chemoprevention.

The attitudes of women with BRCA1 and BRCA2 mutations toward clinical breast examinations and breast self-examinations.

AIMS: In screening studies of women with BRCA mutations, magnetic resonance imaging (MRI) plus mammography has >90% sensitivity for detecting breast cancer, with negligible benefit from the addition of breast self-examination (BSE) or clinical breast examination (CBE). Yet CBE is still frequently recommended, and BSE is encouraged for these women. We sought to determine the attitudes of high-risk women toward CBE and BSE. METHODS: Between November 2005 and May 2006, 137 women with BRCA mutations participating in a screening study consisting of annual MRI and mammography plus semiannual CBE were asked to complete a mailed Likert-type questionnaire. RESULTS: Of the 94 (67%) respondents, mean age 47 (range 28-67), 94% strongly agreed or agreed that CBE was an important way to detect breast cancer, and almost all believed it provided an important connection to the healthcare team. Only 10% said it increased anxiety. Of the 71 (77%) who performed BSE at least occasionally, 53 thought that regular BSE gave them a sense of control over their own health. Of the 21(23%) who did not practice BSE at all, only 3 did not believe that BSE was helpful, and it made 9 more worried about breast cancer CONCLUSIONS: Although CBE adds little to cancer detection rates in women with BRCA mutations screened with MRI, the majority of these women considered CBE to be reassuring and an important means of connecting with the healthcare team. Compliance with BSE was only moderate, but it gave a significant proportion of women a greater sense of control.

Is mammography adequate for screening women with inherited BRCA mutations and low breast density?

BACKGROUND: Several observational studies have shown that magnetic resonance imaging (MRI) is significantly more sensitive than mammography for screening women over age 25 at high risk for hereditary breast cancer; however, MRI is more costly and less specific than mammography. We sought to determine the extent to which the low sensitivity of mammography is due to greater breast density. METHODS: Breast density was evaluated for all patients on a high-risk screening study who were diagnosed with breast cancer between November 1997 and July 2006. Density was measured in two ways: qualitatively using the four categories characterized by the Breast Imaging Reporting and Data System and quantitatively using a computer-aided technique and classified as (a) 50% density. Comparison of sensitivity of mammography (and MRI) for each individual density category and after combining the highest two and lowest two density categories was done using Fisher's exact test. RESULTS: A total of 46 breast cancers [15 ductal carcinoma in situ (DCIS) and 31 invasive] were diagnosed in 45 women (42 with BRCA mutations). Mean age was 48.3 (range, 32-68) years. Overall, sensitivity of mammography versus MRI was 20% versus 87% for DCIS and 26% versus 90% for invasive cancer. There was a trend towards greater mammographic sensitivity for invasive cancer in women with fattier breasts compared with those with greater breast density (37-43% versus 8-12%; P = 0.1), but this trend was not seen for DCIS. CONCLUSION: It is necessary to add MRI to mammography for screening women with BRCA mutations even if their breast density is low.

Incidental MRI detection of BRCA1-related solitary peritoneal carcinoma during breast screening--A case report.

BACKGROUND: The reported cumulative risk of developing primary peritoneal carcinoma (PPC) one to 20 years after prophylactic bilateral oophorectomy is 3.5% to 4.3%. Virtually all reported cases have been stage III or IV. CASE: During MRI screening of the breasts, an incidental mass on the surface of the liver was identified in a 56-year-old BRCA1 mutation carrier who had undergone prophylactic bilateral salpingo-oophorectomy several years previously with no evidence of malignancy. After four cycles of chemotherapy a localized, grade 3 serous papillary adenocarcinoma was resected followed by further chemotherapy and radiation. She remains disease-free 3 years post-treatment. CONCLUSION: The literature on PPC after prophylactic oophorectomy is reviewed. To the best of our knowledge, this is the first description of an apparently localized case of BRCA related PPC outside the pelvis.

Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination.

CONTEXT: Current recommendations for women who have a BRCA1 or BRCA2 mutation are to undergo breast surveillance from age 25 years onward with mammography annually and clinical breast examination (CBE) every 6 months; however, many tumors are detected at a relatively advanced stage. Magnetic resonance imaging (MRI) and ultrasound may improve the ability to detect breast cancer at an early stage. OBJECTIVE: To compare the sensitivity and specificity of 4 methods of breast cancer surveillance (mammography, ultrasound, MRI, and CBE) in women with hereditary susceptibility to breast cancer due to a BRCA1 or BRCA2 mutation. DESIGN, SETTING, AND PARTICIPANTS: A surveillance study of 236 Canadian women aged 25 to 65 years with BRCA1 or BRCA2 mutations who underwent 1 to 3 annual screening examinations, consisting of MRI, mammography, and ultrasound at a single tertiary care teaching hospital between November 3, 1997, and March 31, 2003. On the day of imaging and at 6-month intervals, CBE was performed. MAIN OUTCOME MEASURES: Sensitivity and specificity of each of the 4 surveillance modalities, and sensitivity of all 4 screening modalities vs mammography and CBE. RESULTS: Each imaging modality was read independently by a radiologist and scored on a 5-point Breast Imaging Reporting and Data System scale. All lesions with a score of 4 or 5 (suspicious or highly suspicious for malignancy) were biopsied. There were 22 cancers detected (16 invasive and 6 ductal carcinoma in situ). Of these, 17 (77%) were detected by MRI vs 8 (36%) by mammography, 7 (33%) by ultrasound, and 2 (9.1%) by CBE. The sensitivity and specificity (based on biopsy rates) were 77% and 95.4% for MRI, 36% and 99.8% for mammography, 33% and 96% for ultrasound, and 9.1% and 99.3% for CBE, respectively. There was 1 interval cancer. All 4 screening modalities combined had a sensitivity of 95% vs 45% for mammography and CBE combined. CONCLUSIONS: In BRCA1 and BRCA2 mutation carriers, MRI is more sensitive for detecting breast cancers than mammography, ultrasound, or CBE alone. Whether surveillance regimens that include MRI will reduce mortality from breast cancer in high-risk women requires further investigation.