Breast cancer screening recommendations: Dynamic extrapolation of limited data

The decrease in breast cancer mortality in the US in the last 3 years has been attributed, in part, to adherence to screening mammography, an important accomplishment in public health [1]. For women who are at average risk, namely those who have 12.3% probability of being diagnosed with breast cancer in their lifetime, the greatest benefit was seen in screening older patients [2], especially those over 60. However, just as is the case with personalized therapeutics for breast cancer, personalized prevention implies a tailored comprehensive package of risk evaluation, prevention, and early detection/screening recommendations appropriate to the level of risk, as determined, at present, largely from clinical models based on family history and reproductive risk factors. Most consensus guidelines define high risk as greater than a 20% lifetime risk of breast cancer or a greater than 1.7% 5-year risk for a woman 35 years or older and recommend earlier screening in these patients [3]. The article by Brandt et al. in this issue attempts to validate and more precisely define the current primarily expert opinion-based recommendations by incorporating scientifically [4] estimates of family history-centered risk, derived from the extraordinary resources of the Swedish Family-Cancer Database, a welcomed effort [4]. Although the direct application of these findings to patients of diverse ethnicities who are evaluated in clinical practice will not be immediate, screening modalities for women in different risk categories must be undertaken now, even with admittedly incomplete knowledge. If the recommendations encompass the best evidence and they are appropriately modified in a dynamic and nimble manner as research continues, everyone benefits and society obtains the greatest value for the screening costs. The population studied by Brandt et al. is a relative ethnically homogenous subset; therefore, caution must me exercised when generalizing these results to other patient groups. Other predictive models, such as the Gail and Claus models which were originally validated in Caucasian populations to provide risk assessment for white women, have been determined to be somewhat unreliable in predicting African-American risk [5]. Though breast cancer incidence is lower in African-American women compared to Caucasians in the United States, based on Surveillance, Epidemiology, and End Results (SEER) program data, their mortality rates are significantly higher [6]. Studies have revealed variation in tumor biology and phenotype between racial groups. For example, triple-negative breast cancers affect younger African-American women more frequently, with the diagnosis made more often in later stages and having poorer survival by subtype, stage-forstage [7]. Further evidence from recent adjuvant Southwest Oncology breast cancer trials have suggested that, even when controlling for early discontinuation and treatment delays, African-American women have worse survival than Caucasians undergoing similar treatments, thereby reinforcing the importance of adequate screening tools in this population at higher risk for poorer outcomes [8]. The results found in the Brandt et al. study have greatest relevance to the population studied, namely Swedish and Scandinavian women. Other populations, such as AfricanAmericans, require further specific investigation; however, given the available clinical data and expert opinion, screening recommendations for this patient population with high-risk family histories would suggest earlier and This is an invited commentary to article doi:10.1007/s10549-009-0486-y.