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Dr. Hollingsworth served as Dr. Mark Skolnick’s host
in Oklahoma City just months after Skolnick led the team that sequenced
the BRCA1 gene. Dr. Skolnick went on to help launch Myriad Genetics, the
premier company in genetic testing. |
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 Risk Assessment
Risk Assessment is the calculation
of a woman’s risk for the development of breast cancer over a defined
period of time, and the comparison of that number to the general
population. Women without risk factors tend to underestimate their risk,
while women with risk factors tend to overestimate. The greatest benefit
of risk assessment is providing perspective. Multiple mathematical
models are available, but on occasion, they can be very misleading when
all the facts are considered. Some risk factors are not included in
these models, while protective factors (such as early-age removal of the
ovaries) are not included at all. As a result, some women who believe
themselves to be at increased risk may actually be below the risk of the
general population. Because of Dr. Hollingsworth’s interest in benign
breast biopsy results as risk factors for future cancer, all previous
breast biopsies are reviewed under the microscope when specific findings
are going to impact decision-making. This exercise is unprecedented for
risk assessment programs across the country. If these microscopic
findings are ‘borderline’, Dr. Hollingsworth asks for the input from Dr.
David Page, noted breast pathology expert at Vanderbilt.
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Risk Stratification with Ductal Fluid Cytology
Several methods are available to procure cells from the breast, with the
intent being similar to the Pap smear. The difference here is that there
is no current method that allows a thorough sampling of the lining of
the complex ductal system. Each method has its advantages and
disadvantages. The more invasive methods (ductal lavage or random fine
needle aspirations) retrieve more cells for study, but have poor patient
compliance. limiting the practicality of these approaches. Nipple
aspirate fluid retrieves fewer cells, but enjoys a much higher
compliance rate.
Regardless of the method used, it should be kept in
mind that this approach is not designed as a diagnostic test for breast
cancer. The purpose is for risk stratification, part of a risk
assessment program that tries to predict probabilities of a future
cancer. If you have atypical cells discovered through any of the above
methods, your risk for future breast cancer is elevated approximately
four-fold. Your risk may be even higher if you have other known risks
such as a strong family history.
Dr. Hollingsworth no longer performs ductal lavage
or random fine needle aspirations. but arrangements can be made for
these studies if you are interested. His focus is on the cytology that
is most easily procured trough nipple aspirate fluid (NAF), and he
currently serves on the Scientific Advisory Board of Neomatrix, Inc., a
company based in Irvine, CA that is attempting to improve acceptance of
this strategy with their HALO™ device for NAF retrieval. To find out
more about the HALO™ Breast Pap Test and where you can have the
procedure performed,
CLICK HERE.
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Risk Reduction Counseling and Treatment
Risk
Reduction Counseling and Treatment is the discussion and therapy that
surrounds three general categories of risk reduction: 1) lifestyle/diet,
2) SERM (Selective Estrogen Receptor Modulator) risk reduction, & 3)
Surgical Risk Reduction, through oophorectomy (removal of ovaries)
and/or preventive mastectomy. Risk reduction is NOT a list of
“recommendations,” but rather a dialogue between patient and counselor
in a process of discovery for the approach most suited for your
personality. Risk reduction with SERMs or surgery should always be a
joint decision, made within the framework of the patient’s desires. The
delicacy with which a subject such as preventive mastectomy must be
handled is why Dr. Hollingsworth believes that risk reduction and
genetic counseling is well-managed by a breast disease specialist. Most
patient questions are not taxing with regard to complex genetics, but
instead bring up difficult issues related to breast cancer management,
detection, and prevention. Counseling for (and sometimes prescribing)
SERM risk reduction is lengthy and complex, and must be coordinated with
the patient’s primary care physician and/or OB-GYN. This complexity
persists in counseling surgical options. While preventive mastectomy is
often called “mutilating,” it doesn’t have to be that way. Dr.
Hollingsworth can introduce you to the wide variety of reconstruction
options that are now available.
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Genetic Counseling and Testing
Genetic Counseling
and Testing is a natural product of risk assessment, wherein some
patients who have a strong family history enter into a program that can
involve multiple family members in testing for Hereditary Breast-Ovarian
Cancer Syndrome, the result of an alteration in either the BRCA-1 or
BRCA-2 gene (or other rare genetic disorders). Women with a strong
family history of breast cancer are often surprised that they are
unlikely to have alterations in BRCA-1 or BRCA-2 (we use various
mathematical models to determine this…different from the models used for
general risk assessment). Tip-offs that make a BRCA alteration in the
family more likely are early-onset breast cancer in family members, the
presence of ovarian cancer at any age, or male breast cancer. A detailed
family pedigree is drawn to determine the probability of a BRCA mutation
in the patient (as well as her family members) who presents for
counseling. Even when patients qualify for testing (by having a
probability of BRCA mutation in excess of 10%), many choose NOT to
undergo testing for personal reasons after the counseling session is
complete. If the process is started in a family, we begin testing with
someone who has already developed breast or ovarian cancer in order to
document the BRCA alteration in the family. If this person is “normal,”
with regard to the BRCA genes, then the process is over for the entire
family. If she is “positive,” then many lives can be affected in the
family (both men and women). This is a very confusing area where we
spend a great deal of time with our patients. Gene testing is a one-time
“blood test” that is analyzing the DNA make-up of all the cells in your
body with regard to the BRCA genes. Thus, an alteration in the DNA of
the white cells of your blood means that every breast cell will have
this same (congenital) alteration. Most families with an excess of
breast cancers are probably transmitting groups of genes that then
interact with the environment – we have no blood test for this
ill-defined phenomenon. We are testing for those families where a single
mutation in one of the BRCA genes strongly predisposes to breast and
ovarian cancer. (All cancers have genetic alterations within the tumor
tissue, one example being the HER2-neu gene, but the BRCA mutation is in
the “genome,” that is, every cell in the body has the same mutation.).
Our consultative sessions often include multiple family members who
might be affected by outcomes, and often the decision to enter this
process is made by the family as a whole, rather than an individual.
BRCA results can dramatically alter our estimated risk for developing
breast cancer. For instance, if a woman calculates to be at a 30%
lifetime risk for breast cancer, but later is found to be in a BRCA
family…her risk for breast cancer may go as high as 85% if she tests
positive, or may return to a baseline 10% (general population risk) if
she tests negative. For more information on this complex health care
option, CLICK HERE.
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High Risk Surveillance Program
High Risk
Surveillance Program is chosen by most women after undergoing risk
assessment and includes: digital mammography, frequent clinical exams by
Dr. Hollingsworth, the liberal use of ultrasound, and more recently
magnetic resonance imaging (MRI). For those women who meet the American
Cancer Society guidelines for high-risk screening, we generally follow
those recommendations as outlined elsewhere on this
website. However, for all others, two factors
determine the strategy recommended for you: 1) the degree of density
(white) on your mammograms, and 2) your level of risk. (For women at no
increased risk and low density mammograms, we do not recommended
auxiliary imaging with ultrasound or MRI on a routine basis.)
If your mammograms are considered extremely dense (a
"white-out") the odds of detecting breast cancer at an early stage drop
below 50%. In addition, the density itself is a risk factor for breast
cancer. Then, if you have additional risks, you still many not meet the
threshold of the ACS guidelines, yet in actuality be at a greater risk
than some women who do (all this is a function of the weakness inherent
in the mathematical models). Regardless, with dense mammograms and risk
factors, you deserve more than "routine annual mammography." Our
strategies range from adding MRI every 3 years to annual mammograms, all
the way to performing MRI yearly and mammography yearly, staggering the
two studies at 6-months intervals. Ultrasound is commonly added as well,
especially if there are findings on mammography or MRI, but we use it
for screening as well, depending on the situation.
In addition to clinical exams performed at the same
time as your imaging, we offer the opportunity to participate in our
research in developing a screening blood test for the detection of
breast cancer. Click here for more information.
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