Breast Cancer Prevention for the Rural Healthcare Provider

1. Breast Cancer Prevention for the Rural Healthcare Provider A CME workshop presented by

2. Workshop Learning Objectives • Assess breast cancer risk for individual women patients. • Identify patients for whom breast cancer risk reduction is feasible and should be considered. • Describe the reduction in breast cancer risk in older women being treated for osteoporosis with Selective Estrogen Receptor Modulators (SERMs) • Analyze the risks and benefits of SERMs in breast cancer prevention.

3. Epidemiology of Breast Cancer • Most common cancer in women. • Second only to lung cancer as cause of cancer-related deaths in women. • One women diagnosed every 3 minutes and one women dies of disease every 13 minutes. • In 2006, over 200,000 women were diagnosed with invasive breast cancer. • A woman’s lifetime risk for developing breast cancer is 12.5% (1 in 8).

4. Risk Factor for Breast Cancer • Ethnic and Familial • Hormonal and Reproductive • Dietary/Lifestyle • Risk Factor Assessment

5. Ethnic Variations in Breast Cancer Risk

6. Familial Risk Factors • Two- to three-fold increased risk for women whose first-degree relative was diagnosed with breast cancer. • The risk declines significantly if only second-degree relatives are affected.

7. Reproductive/Hormonal Risk Factors • Nulliparity • Early menses (< age 12) • Late menopause (> age 55) • First full-term pregnancy after age 35 • Use of oral contraceptives • Before first full-term pregnancy • Use for longer duration in BRCA mutation carriers • Use of hormone replacement therapy

8. Dietary/Lifestyle Risk Factors • In post-menopausal women: • Higher weight • Higher body mass index (BMI) • Alcohol use (<2 drinks per day) • Regular exercise associated with a decreased risk, but lack of exercise not associated with an increased risk • Exposure to ionizing radiation • Before 40 years of age • Exposure between 10 and 14 years of age most critical.

9. Risk Factor Assessment • Important for healthcare professionals to identify high risk factors: • Previous medical history of breast cancer. • History of lobular carcinoma in situ or ductal carcinoma in situ. • Family history of breast cancer. • Presence of BRCA 1 and 2 mutations. • In the absence of personal or family history, the presence of multiple risk factors can result in an elevated risk

10. The Gail Model • Internet-based tool • Projects a women’s estimated risk of breast cancer over a 5-year period and over her lifetime. • Includes assessment of: • Age and race • First-degree relative history • Hormonal factors • Does not take into account: • Personal history of cancer, • Second degree relative history of breast cancer • Family history of breast cancer before age 50 • Family history of bilateral disease and ovarian cancer • BRCA1/2 mutations

11. The Gail Model Example The Gail Model is available at: http://www.cancer.gov/bcrisktool

12. Pedigree Assessment Tool • Useful in identifying those individuals most at risk for hereditary breast cancer. • More information available at: https://myosfhealth.osfhealthcare.org/sites/OSF/BCRA/default.aspx

13. Prevention • Primary prevention • Modifiable risk factors • Chemoprevention • Genetic screening • Secondary prevention • Self breast exam • Clinical breast exam • Mammography • Tertiary prevention

14. Primary Prevention: Modifiable Risk Factors Modifiable risk factors Non-modifiable risk factors • Use of hormone replacement therapy • Obesity • Physical activity • Alcohol use • Breastfeeding • Pregnancy (number, age, etc) • Age • Gender • Race/ethnicity • Age of menarche/menopause • Personal history of breast cancer • Familial history • Genetic mutations

15. Primary Prevention: Chemoprevention • Selective estrogen receptor modulators (SERMS). • Tamoxifen • FDA approved for risk reduction of breast cancer in high-risk women. • Raloxifene • The FDA Advisory Committee recently recommended approval of Raloxifene for breast cancer risk reduction (July 2007). • Only recommended for high risk women, not those with low or average risk.

16. Chemoprevention: Tamoxifen • The Breast Cancer Prevention Trial (BCPT) • 50% reduction in the incidence of breast cancer after receiving tamoxifen for 5 years. • Other studies • Statistically significant reductions in the incidence of contralateral breast cancer in those treated with tamoxifen. • Side effects: • Increased risk of endometrial cancer and thrombosis • Hot flashes.

17. Chemoprevention: Raloxifene • Multiple Outcomes of Raloxifene Evaluation (MORE) • 76% reduction in invasive breast cancer compared to placebo when treatment continued for a median of 40 months. • Side effects: • Thrombosis • Hot flashes • STAR Trial • Raloxifene as effective as tamoxifen in reducing risk of invasive breast cancer. • Raloxifene had a lower risk of thromboembolic events and cataracts, but a nonstatistically significant higher risk of noninvasive breast cancer compared to tamoxifen.

18. Primary Prevention: Genetic Screening • Family history patterns associated with increased risk for inherited BRCA mutations in non-Ashkenazi Jewish women: • 1st degree relative with a known BRCA mutation • Two 1st degree relatives with breast cancer, one who received the diagnosis at age 50 or younger • Three or more 1st or 2nd degree relatives with breast cancer regardless of age at diagnosis • Combination of both breast and ovarian cancers among 1st and 2nd degree relatives • 1st degree relative with bilateral breast cancer • Combination of two or more 1st or 2nd degree relatives with ovarian cancer • 1st or 2nd degree relative with both breast and ovarian cancers • Breast cancer in a male relative

19. Primary Prevention: Genetic Screening • Options for women who test positive BRCA mutations: • Prophylactic mastectomy and oophorectomy. • Increased surveillance, including: • Clinical breast exams 2-4 times per year. • Monthly self breast exams. • Annual mammograms starting at age 25. • Twice yearly ovarian cancer screening with ultrasound beginning at age 35. • Chemoprevention with SERMs.

20. Secondary Prevention: Self Breast Exam (SBE) • Noninvasive screening test. • Clinical evidence does not show clear benefit. • Patient and healthcare professional should discuss. • Women should be told to report any changes or abnormalities.

21. Secondary Prevention: Clinical Breast Exam (CBE) • Approximately 5% of breast cancers identified by CBE alone. • 54% Sensitivity • 94% Specificity • No clinical trial exist comparing CBE alone to no screening. Bobo JK, et al. J Natl Cancer Inst. 2000;92(12):971-976.

22. Secondary Prevention: Screening Mammography

23. Secondary Prevention: Other Modalities • Ultrasound • MRI • Recommended as annual screening tool for women who: • Have a BRCA 1 or 2 mutation. • Have a first-degree relative with a BRCA 1 or 2 mutation and are untested. • Have a lifetime risk of breast cancer of 20-25 percent or more using standard risk assessment models. • Received radiation treatment to the chest between ages 10 and 30, such as for Hodgkin Disease. • PET

24. Tertiary Prevention

25. Tertiary Prevention • Continue preventive screening. • No long-term survival benefit seen with intensive follow-up vs. routine mammograms and physical exams. • Continue ongoing primary care and screenings for other cancers (i.e.. Colon cancer). • Provide psychosocial support, education, and resource materials. • Encourage exercise and weight loss (if applicable).

26. Special Issues for Rural Providers • Compared to urban counterparts, the rural population: • Is generally older, poorer, and less educated. • Has fewer physicians and hospitals per capita. • This disparity results in: • Lower level of patient-reported health status. • Less confidence in being able to obtain needed care. • Fewer physician visits. • The need to travel farther to obtain care.

27. Poverty in Rural Regions Ormond B, et al. A Rural/Urban Differences in Health Care Are Not Uniform Across States. New Federalism: National Survey of America's Families [Number B-11 http://www.urban.org/publications/309533.html.

28. Barriers Facing Rural Providers • Negative patient attitudes about mammography. • Fear of pain, discomfort, and anxiety. • Cultural/racial norms and attitudes about disease processes. • Screening rates lower in women with no high school diploma or GED. • African-American and Hispanic women have fewer baseline and routine mammograms.

29. Barriers: Health Insurance • Percentage of patients uninsured: • 14.3 percent of urban residents • 17.5 percent of residents in rural adjacent counties • 21.9 percent in rural non-adjacent counties • Significantly more women with insurance received regular mammograms than did those without insurance (60% vs. 33%, respectively). • The National Breast Cancer and Cervical Cancer Early Detection Program Ormond B, et al. New Federalism: National Survey of America's Families [Number B-11 http://www.urban.org/publications/309533.html; Smith RA, et al. 2006. CA Cancer J Clin. Jan-Feb 2006;56(1):11-25.

30. Barriers: Screening Site Issues • Shortage of breast imaging specialists; however, new technologies may help: • Increase the accuracy of breast cancer detection. • Improve access to mammography. • Broaden the pool of medical personnel who can interpret mammograms. • Shortage of new visiting specialists • Rural Health Care programs help fund necessary telecommunications.

31. Barriers: Access Issues

32. Improving Communications • Learn about your community. If you are new to the community, learn about the demographics of your population. • With your staff, decide on a realistic target and set a goal. For example, develop a plan to increase the mammogram screening of your target population by 20% in the next year. • Visit the women in your community at adult education classes, coffee shops, and other places where women are gathering. Put together a “Grab Bag” with handouts and important date reminders.

33. Improving Communications • Use the office staff to teach and help with follow-up. Ask them for ideas on how to reach out into your community. • Create a “reward” for repeat positive behavior or change in behavior. For instance, create a “Bring a friend to your mammogram” program. • Use the Pink Ribbon symbol to remind women how important screening is. Contact the Susan G. Komen Foundation and others who offer free Pink Ribbons. • Be visible. Health care providers are viewed as the experts, and when you speak, others listen and will know the message is important.

34. Conclusions • Rural healthcare providers face challenges in addressing patient needs. • Acute issues vs. preventive measures. • Patient barriers • Assess individual risk factors • Discuss chemoprevention in applicable patients • Encourage regular screenings for all eligible patients.

35. Breast Cancer Prevention:An AAFP-AccreditedCME program