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Practicing Prevention

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NEW ALBANY, IN Last November, MD-UPDATE’s Oncology Issue (#81) featured an article with Ifeoma Roseline Okeke, MD, board-certified medical oncologist and hematologist with Floyd Memorial’s Cancer Center of Indiana and a proponent of breast cancer prevention. Okeke set a goal to create a breast cancer prevention clinic, and in March of this year, that goal became a reality when Okeke instituted the High Risk Breast Clinic at the Cancer Center of Indiana.

The clinic offers a novel approach to preventive breast care, offering thorough risk assessment, medical imaging, clinical exams, genetic testing, counseling, and cancer prevention recommendations. Patients can access the clinic one of two ways – either through physician-referral or self-referral.

The first step in the clinic process is a full consultation with Okeke herself. “We do a full risk assessment, including family history and medical history, review mammogram reports, and perform a physical breast exam. Based on their family history, we decide if genetic testing is a recommendation for them,” says Okeke. She also does a personal risk assessment for all patients and, in addition to family history, considers factors such as prior multiple breast biopsies, breast density, and hormone replacement therapy that may contribute to risk for breast cancer.

Patients are deemed high risk if they screen positive for a genetic mutation or if they screen negative but score high on the personal risk assessment, which means, “They have more than a 20 percent lifetime risk for developing breast cancer,” she says.

In terms of genetic testing, the Cancer Center now offers a more comprehensive genetic analysis that goes beyond BRCA1 and BRCA2. My Risk comprehensive genetic testing evaluates for 21 genes, including not just those for breast but also for other cancers, such as Lynch syndrome for colon cancer. “Many patients have overlapping cancer syndromes in their families, and sometimes it is difficult to determine what genes may be affected,” says Okeke.

A Four-Tiered Approach

Once patients are determined to be high risk, Okeke works with each woman to determine their best preventive course of action. The recommendations follow a four-tiered approach: lifestyle modifications, prophylactic surgery, chemoprevention, and aggressive screening. “Everybody gets lifestyle modification education – stop smoking, limit alcohol, avoid post-menopausal weight gain, and avoid hormone replacement therapy, especially combined estrogens and progesterone,” says Okeke. These patients also have access to a multidisciplinary team of specialists, including medical oncologists, plastic surgeons, general surgeons, psychiatrists, and radiologists.

The most effective prevention is prophylactic surgery, although Okeke cautions this is a very personal decision and not one that is recommended in all cases. BRCA 1 and BRCA 2 mutations carry up to an 84 percent lifetime risk for breast cancer and a 15 to 50 percent risk of ovarian cancer. Prophylactic mastectomy reduces breast cancer risk by approximately 90 percent, and prophylactic oophorectomy reduces breast cancer risk by up to 50 percent. Although hysterectomy is not routinely performed in patients with BRCA mutations, a growing number of uterine cancers have been detected in some BRCA2 families.

The next level of care is chemoprevention, which reduces cancer risk by 50 to 60 percent, and is utilized in both those who screen positive for genetic mutations and those who screen negative but are deemed high risk. Current chemoprevention medications include tamoxifen and raloxifene (Evista®), which are both FDA-approved, and exemestane and anastrazole (Arimidex®), which are not yet FDA-approved but have been shown to be effective.

For patients who do not have a genetic mutation or who simply do not qualify for genetic testing but are considered high risk, Okeke recommends aggressive screenings with breast MRIs and mammograms every year and clinical breast exams every six months. These women are also encouraged to perform monthly self-breast exams.

Getting Results

So far, the High Risk Breast Clinic has screened 95 patients. They have identified four patients with genetic mutations and three patients with breast cancer, who were at high risk but did not have the mutation. Thanks to the prevention program, all three cancers were found at stage 1.

Because the Center now tests for 21 gene mutations, they are looking at developing other specialty prevention clinics, the next of which may be a GI cancer prevention clinic.

“We are so used to treating breast cancer. I think the paradigm is shifting to preventing cancer, but a lot of us are not on board yet,” says Okeke. “It is important for women to realize they can be their own health care advocates. They need to ask about cancer risk just like they ask about body weight, BMI, and cholesterol. We can educate women through community outreach programs. My goal is eventually for everybody to be on-board.”