Breast Cancer Risk Assessment Can Provide Reassurance and Guide Additional
According to the American Cancer Society, about one in eight women in the
United States will develop invasive breast cancer during her lifetime.
Fortunately, death rates for breast cancer patients have been declining
since about 1989, partly because of earlier detection through regular
screenings and increased awareness.
“Finding breast cancer early reduces the risk of dying from the disease
by 35 percent in women over 50 years of age,” notes radiologist
Dr. Mimi Lin, director of mammography for the Washington Radiologists
“Mammography and other screenings for breast cancer are obviously
important, but it’s also important to screen for a patient’s
breast cancer risk level,” Dr. Lin says. “We started conducting
breast cancer risk assessments in October 2013 as part of our regular
mammography screenings to identify patients who are at a statistically
increased risk for breast cancer. Assessing women for their breast cancer
risk can be reassuring for those who are at low risk, and it can help
guide the timing and methods for breast cancer screenings for women at
The decision to offer breast cancer risk assessments resulted from community-needs
surveys conducted in the communities served by Washington Hospital.
“The surveys noted that compared to national averages, there were
a higher number of women in our communities who were being diagnosed with
breast cancer at stage III or higher,” explains oncologist Dr. Vandana
Sharma, medical director of Washington Hospital’s Oncology Program
and Genetic Counseling Program. “Those rates were higher than we
had expected, and they indicated that women in our communities were not
being screened appropriately to detect cancer at earlier stages. We wanted
to improve our service to the community and encourage women to get breast
cancer screenings at appropriate intervals.”
The Breast Cancer Risk Assessment Tool adopted by Washington Hospital was
developed in 1989 as part of the Breast Cancer Detection and Demonstration
Project. It is a statistical tool to estimate a patient's risk for
breast cancer. The assessment is based on a statistical model known as
the "Gail model," which is named after Dr. Mitchell Gail, Senior
Investigator in the Biostatistics Branch of National Cancer Institute’s
Division of Cancer Epidemiology and Genetics. The model uses a woman's
own personal medical history, her own reproductive history and the history
of breast cancer among her first-degree relatives (mother, sisters, daughters)
to estimate her risk of developing invasive breast cancer over specific
periods of time.
“The Breast Cancer Risk Assessment Tool is a well-established and
valid statistical measure that is considered appropriate by most insurance
providers, including Medicare,” Dr. Sharma notes. “The risk
factors evaluated in the assessment tool are ones that highly correlate
with increased risk for breast cancer. In addition, the questions in the
risk assessment are designed to be easy for women to answer, so it doesn’t
require a lot of time."
Dr. Lin adds, "Prior to October of 2013, women having screening mammograms
were asked questions similar to those in the Gail model. Formalizing the
questions with the Gail model provides the benefit of risk stratification."
The Breast Cancer Risk Assessment Tool is appropriate only for women over
age 35, and considers lifetime risk to age 90. It is important to remember
that the risk assessment is based on population statistics. While the
tool may accurately estimate a woman's risk of developing breast cancer,
these risk estimates cannot say precisely which women will develop breast
cancer or when. In addition, the tool cannot accurately calculate the
risk of redeveloping breast cancer for women who already have a diagnosis
of breast cancer, or of developing breast cancer in women with a medical
history of ductal carcinoma in situ or lobular carcinoma in situ. These
women are considered to be in the moderate risk category. Although the
tool has been used successfully for some women with strong family histories
of breast cancer, more specific methods of estimating risk are appropriate
for women known to have breast cancer-producing mutations in the BRCA1
or BRCA2 genes.
A few examples of questions included in the Breast Cancer Risk Assessment
Tool – and the reasons for asking those questions – include:
- What is the woman’s age? The great majority of breast cancer cases
occur in women older than age 50, and the risk of developing breast cancer
increases with age.
- What was the woman’s age at the time of her first menstrual period?
Women who had their first menstrual period before age 12 have a slightly
increased risk of breast cancer that may be linked to their longer lifetime
exposure to estrogen.
- How many of the woman's first-degree relatives – mother, sisters,
daughters – have had breast cancer? Having one or more first-degree
relatives who have had breast cancer increases a woman's chances of
developing this disease.
The general recommendation from the American Cancer Society for women at
high risk for developing breast cancer (having a lifetime risk greater
than 20 percent) would be to have a breast MRI in addition to a mammogram
and clinical breast exam every year. Women at moderately increased lifetime
risk (15 to 20 percent) should talk to their doctors about the benefits
and limitations of adding breast MRI screening to their yearly mammograms.
Yearly MRI screening is not recommended for women whose lifetime risk
is less than 15 percent.
“Women who are at high risk for developing breast cancer are counseled
to talk to their doctors about enhanced screenings and risk-reduction
strategies,” says Dr. Sharma. “Most insurance plans will cover
a breast MRI if the woman’s lifetime risk is greater than 20 percent.
These women also might consider use of medications such as tamoxifen or
raloxifene, which can cut their risk of developing breast cancer by 45
to 50 percent. Women at high risk also might be referred for genetic counseling.”
The Washington Cancer Genetics Program is a collaboration between Washington
Hospital and UCSF Medical Center. The program offers genetic counseling
for individuals concerned with the risk of an inherited cancer predisposition.
The clinic staff includes genetic counselors, a medical oncologist and
The Washington Women’s Center generally performs between 400 and
500 screening mammograms each month. Between the introduction of the Breast
Cancer Risk Assessment Tool in October 2013 and May of this year, a total
of 107 patients were identified as having a lifetime risk of breast cancer
greater than 20 percent.
“The median age of these patients is 50,” says Dr. Lin. “About
35 percent of these high-risk patients have had screening breast MRIs.
Two patients were referred for genetic counseling. One of those two patients
was subsequently diagnosed with early stage breast cancer, which is the
most easily treated and has a much higher cure rate than more advanced
The Washington Women’s Center, located in the Washington West building
at 2500 Mowry Avenue in Fremont, combines screening mammography with other
advanced diagnostic services, including breast MRI. Services are provided
in warm, soothing, spa-like surroundings with personal amenities designed
to help women feel calm and comforted. For more information about Washington
Women’s Center, visit http://whhs.com/services/specialized-programs/women-s-center/default.aspx.
To schedule an appointment for a mammogram, call (510) 791-3410.To schedule
an MRI appointment, call (510) 608-1380. All mammogram and MRI screenings
require a physician referral.
For more information about the Washington Cancer Genetics Program, visit
For more information about the Breast Cancer Risk Assessment Tool, including
questions asked in the assessment, visit www.cancer.gov/bcrisktool/.