Case Recap
The patient is a 52-year-old postmenopausal woman with a 1.9 centimeter right breast mass, grade 3, ER/PR-negative, HER2/neu-negative. She was identified at age 45 as being BRCA1-positive. Sentinel node biopsy is negative. The patient desires breast-conserving surgery.
This case raises several issues regarding the management of breast cancer in the BRCA1-positive patient, including use of MRI, breast-conserving therapy, sibling risk, lifetime risk, and treatment options. These issues speak to the dynamic interplay among oncologists, surgeons, breast imagers, pathologists, and genetic counselors in determining the appropriate course of treatment.
Survey Results
A self-selected group of ASBD members responded to an electronic survey to provide their comments on this case. The following summarizes their responses:
Counseling patients on MRI prior to surgery
- With regard to screening female relatives with BRCA-1 mutations, the majority (78%) of survey respondents said they would advise patients that MRI has better sensitivity compared to mammogram in detecting breast cancer.
- Approximately 13% of respondents said they would tell patients that MRI has a high rate of false-positive results in detecting incidental cancer in the ipsilateral breast.
BRCA-1 Status in Siblings
- The vast majority of respondents (76%) would advise their patients that their affected siblings are more likely to develop ER/PR-negative compared to ER/PRpositive breast cancers.
Lifetime Risk
- Most responders thought that in the absence of any preventive surgical or medical therapy the lifetime risk of developing contralateral breast cancer was high.
- 39% of responders estimated the risk to be about 85%
- 52% thought the risk was about 50%.
- Only 8% of responders thought the risk was <20%.
Treatment Recommendations Following Breast-Conserving Surgery
- More than three-quarters of respondents (76%) believe that the patient should consider prophylactic oophorectomy following breast-conserving surgery
- 10% would recommend tamoxifen
- An additional 10% of the respondents (all medical oncologists) would recommend adjuvant chemotherapy.
Genetic Counseling
- Approximately 77% of survey respondents would refer this patient to a genetic counselor for additional counseling.
- The remaining respondents would not refer their patients (14%) or were unsure about referring (9%).
Survey Respondent Profile
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