Behind The Knife: The Surgery Podcast24 Sep

Clinical Challenges in Breast Surgery: Managing Breast Cancer Risk - From Assessment to Interventions

Breast cancer risk varies widely across patients, and surgeons play a central role in recognizing elevated risk and guiding appropriate management. In this episode, we review the spectrum of breast cancer risk and discuss practical strategies for risk assessment and risk reduction. We’ll cover surveillance, lifestyle interventions, risk-reducing medications, high-risk breast lesions, and prophylactic surgery—with an emphasis on translating the available evidence into individualized clinical care.

Hosts:
- Rashmi Kumar, MD, PhD
Resident, University of Michigan General Surgery Residency Program
Twitter/X: @RashmiJKumar
- Melissa Pilewskie, MD
Attending Breast Surgical Oncologist, Co-Director of the Weiser Family Center for Breast Cancer, Michigan Medicine
Twitter/X: @MPilewskie
- Stephanie Downs-Canner, MD
Attending Breast Surgical Oncologist & Physician-Scientist, Memorial Sloan Kettering Cancer Center, Program Director of the Breast Surgical Oncology Fellowship Training Program
Twitter/X: @SDownsCanner

Learning Objectives:

Identify major modifiable and nonmodifiable breast cancer risk factors, including genetic predisposition, family history, breast density, high-risk lesions, prior chest radiation, and lifestyle factors.
Select and interpret commonly used breast cancer risk-assessment tools—including the Gail, Tyrer-Cuzick, and BCSC models—while recognizing their important limitations.
Recommend appropriate risk-management strategies based on a patient’s risk level, including enhanced surveillance, lifestyle interventions, genetic evaluation, and endocrine risk-reducing therapy.
Explain the indications, benefits, limitations, and tradeoffs of managing high-risk breast lesions and pursuing risk-reducing surgery, including bilateral mastectomy and salpingo-oophorectomy.

References:
Risk-Assessment Tools

National Cancer Institute. Breast Cancer Risk Assessment Tool.https://bcrisktool.cancer.gov/
National Breast Cancer Foundation. What is the Tyrer-Cuzick model?https://www.nationalbreastcancer.org/blog/tyrer-cuzick-model/
Breast Cancer Surveillance Consortium. BCSC Breast Cancer Risk Calculator.https://tools.bcsc-scc.ucdavis.edu/BC5yearRisk/#/

Chemoprevention Guideline

Bevers TB, Ward JH, Arun BK, et al. Breast cancer risk reduction, version 2.2015. J Natl Compr Canc Netw. 2015;13(8):880-915. doi:10.6004/jnccn.2015.0105

CDC Overview of Risk Factors

Centers for Disease Control and Prevention. Breast cancer risk factors. https://www.cdc.gov/breast-cancer/risk-factors/index.html

Emerging Techniques in Risk Assessment

Breastcancer.org. Polygenic risk score may help predict invasive breast cancer risk. https://www.breastcancer.org/news/polygenic-risk-score-invasive-cancer-risk
Breast Cancer Research Foundation. Clairity Breast: The first FDA-authorized AI platform to predict breast cancer risk from a mammogram. https://www.bcrf.org/blog/clairity-breast-ai-artificial-intelligence-mammogram-approved/

Risk reduction

Pilewskie ML, Dimick JB. Bariatric Surgery for Breast Cancer Risk Reduction—Benefit May Not Be One Size Fits All. JAMA Surg. 2023;158(6):641–642. doi:10.1001/jamasurg.2023.0534 https://pubmed.ncbi.nlm.nih.gov/37043229/
Boraka Ö, Klintman M, Rosendahl AH. Physical Activity and Long-Term Risk of Breast Cancer, Associations with Time in Life and Body Composition in the Prospective Malmö Diet and Cancer Study. Cancers (Basel). 2022 Apr 13;14(8):1960. doi: 10.3390/cancers14081960. PMID: 35454864; PMCID: PMC9025884. https://pubmed.ncbi.nlm.nih.gov/35454864/
Tzenios N, Tazanios ME, Chahine M. The impact of BMI on breast cancer - an updated systematic review and meta-analysis. Medicine (Baltimore). 2024 Feb 2;103(5):e36831. doi: 10.1097/MD.0000000000036831. PMID: 38306546; PMCID: PMC10843423. https://pubmed.ncbi.nlm.nih.gov/38306546/
Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. New England Journal of Medicine 1999; 340(2):77-84. https://pubmed.ncbi.nlm.nih.gov/9887158/
Domchek SM, Friebel TM, Singer CF, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA 2010; 304(9):967–975. https://pubmed.ncbi.nlm.nih.gov/20810374/
Rebbeck TR, Friebel T, Lynch HT, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: The PROSE Study Group. Journal of Clinical Oncology 2004; 22(6):1055-1062. https://pubmed.ncbi.nlm.nih.gov/14981104/
Matteo Lazzeroni et al. Randomized Placebo Controlled Trial of Low-Dose Tamoxifen to Prevent Recurrence in Breast Noninvasive Neoplasia: A 10-Year Follow-Up of TAM-01 Study. J Clin Oncol 41, 3116-3121(2023).
Elizabeth S. McDonald et al. GLP-1 Agonists Are Associated With a Significant Reduction in Breast Cancer Incidence in Women. JCO Oncol Pract 22, 1341-1348(2026).

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