Breast Cancer Family Risk Assessment Clinic. Yvonne Hanhauser Clinical Nurse Specialist Breast Care

Transcription

1 Breast Cancer Family Risk Assessment Clinic Yvonne Hanhauser Clinical Nurse Specialist Breast Care

2 Contents Breast cancer risk factors Patterns of inheritance Referral pathway Family risk assessment clinic Assessment Management Role of CNS/ANP

3 Breast Cancer Multi-factorial Genetic Environmental Lifestyle

4 Patterns of Breast Cancer GENETIC BREAST CANCER FAMILIAL SPORADIC

5 Patterns of Breast Cancer

6 Breast Cancer and Genetics Understanding genetics and environmental factors which contribute to a particular cancer provides guidance in: Earlier detection Prevention strategies Management of at risk individuals With an aim of reducing: Number of new cases Deaths from the disease

7 Breast Cancer Risk Irish women have a 1:11 chance of developing breast cancer. Population risk= all women are exposed to certain risk factors. Sub population risk= risk related to a family history. Individual risk=individual risk exposure.

8 Risk Factors Non-Modifiable Family History Age Gender Reproductive Menstrual History Race/Ancestry History of Benign Breast Disease Radiation Exposure

9 Risk Factors Modifiable

10 Referral Pathway Asymptomatic patient attends with family risk concerns GP sends referral as patient considered >population risk or additional advice required Family history obtained by G.P and information sent to Family Risk Clinic Risk assessed by clinic GP advised that patient not at increased risk and can be followed up in primary care. Patient advised and reassured. GP advised that patient requires continued follow up at clinic and management plan advised.

11 Family Risk Assessment Clinic AIM: Identify individuals who are at an increased risk of developing breast cancer. Establish a risk category i.e low, medium or high. Establish appropriate management according to risk category.

12 Functions of the Family Risk Assessment Clinic Obtain a detailed family history Risk calculation for individual or family Counselling on cancer risk Deciding on referral to a cancer genetics clinic (tertiary level) Providing emotional follow up support Providing regular clinical examination Discussing the need for earlier mammographic screening (MRI if needed). Advise on risk reduction strategies if needed (e.g. prophylactic surgeries) Teaching breast awareness/lifestyle advise (Lalloo et al, 2005)

13 Risk Assessment Process Clinical assessment Establish family members affected by breast/ovarian cancer which requires the following information: Number of relatives (including pt.) affected. Type of relative to consultee (e.g 1 st,2 nd or 3 rd degree relative). Age of affected relative(s) at diagnosis. Use of clinical guidelines (NICE, 2006). Use of risk assessment models (e.g Manchester Score). Result Individual risk estimation (low, moderate or high).

14 Pedigree example

15 Other Significant Factors Early age of onset Bilateral breast cancer Male breast cancer Breast and ovarian cancers in family Multiple primaries Number of relatives and generations Ashkenazi Jewish ancestry

16 Clinical Guidelines National Institute of Clinical Excellence(NICE) Designed to provide information Categorise a risk estimate Assist in decision making Guidelines only

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18 Risk Assessment Models Models generate two types of information: Persons risk of developing a specific cancer presented as a risk over the next 10 years and over their lifetime (e.g. Claus Tables.) Persons risk of carrying a mutation in a particular cancer susceptibility gene (e.g. Manchester Score).

19 Management Low Risk: Reassurance No need for early breast screening imaging Education regarding breast awareness and healthy lifestyle behaviour Inform patient to be aware of changes in family history Follow up with primary care and commence screening with National Screening Programme (Breast Check)

20 Management Moderate Risk: Annual clinical breast examination at family risk clinic Annual mammography to commence for women aged years For women aged over 50 years mammography to take place in National Breast Screening Programme (Breast Check) Also education and information re: breast awareness and lifestyle behaviour

21 Management High Risk: 6 monthly clinical exam at family risk clinic Annual mammography for women aged between years Annual MRI of breast for women aged between years if high risk category reflects one or more of the following: TP53, BRCA1 or BRCA2 mutation. Women who have not been tested but have a high chance of carrying a BRCA or TP53 mutation

22 Case Study EW 44 Strong Family History Breast Ca. Followed up since 2005 Family Hx: Maternal Mother RIP 55- Breast Ca. Sister RIP 39- Breast Ca. Aunts x2 Dx Breast Ca. Aged 60+

23 Follow up Screening Mammography-2006/2007/Mar 2008 Normal Presented June Lump right breast Examination- E2 (benign findings) Mammogram- R5 2.2cm retroareolar lesion U/S Breast- R5 2.1cm hypoechoic lesion suggestive of Invasive Tumour U/S Guided Bx- B5b IDC grade 2, ER+, PR-, HER2-, No LVI

24 Management Right WLE + SLNB 25/06/2008 Multifocal Invasive Ductal Carcinoma Grade 3 22mm, 3 positive Margins LVI, SN negative ER+, PR-, HER2- pt2 N0 M0 Right Mastectomy-16/07/2008 No residual malignancy Adjuvant Chemo + Tamoxifen Rx

25 Follow up Breast Screening; Post Mastectomy Left Mammogram- 2009/Feb-2010 No Abnormality Genetic Screening BRCA 2 positive-jan 2010 Risk Reducing BSO-April 2010 Entered into MRI screening program

26 MRI Breast Aug 2010 Post Contrast 4mm lesion medial aspect below nipple U/S advised

27 US Breast + biopsy 3mm Hypoechoic lesion Correlation with MR Histology IDC Grade 2 LVI ER+, PR,HER2

28 Staging Isotope Bone Scan U/S Liver C-Xray No Evidence of Metastatic Disease

29 Management Right mastectomy and SLNB 6/10/2010 Bilateral reconstruction

30 Future Directions Standardised assessment clinics National Guidelines for triaging G.P involvement re: appropriate referrals to family risk assessment clinics. High potential for nursing involvement in delivery of care.

31 Role of the CNS Education Counsellor Research Advocate Clinical Competency

32 ANP Involvement Opportunity for Nurse Led Clinics for family risk population Ability to carry out physical assessment Advanced decision making regarding risk level Continuity of care/ patient rapport Holistic level of care (education, support, counselling and follow up).

33 ANP Involvement ANP role is ideally placed to act as educator and facilitator. Provision of accurate, current and relevant information. Facilitate lifestyle changes and screening practices. Cancer risk assessment and counselling are appropriate roles for advanced practice nurses. (Vogel, 2003)

34 THANK YOU! ANY QUESTIONS?

35 References Lallo et al ( NICE Vogel