A 58-year-old woman, gravida 1 para 1, comes to the office for a routine health maintenance examination. The patient has been doing well. She has no chronic medical conditions, and her only surgery was a cesarean delivery at age 20. Menarche was at age 15, and menopause occurred 7 years ago. The patient used vaginal estrogen cream twice weekly for the first 3 years after menopause but currently takes no medications and has no allergies. A paternal cousin died of breast cancer this year, and the patient is concerned about her own risk for breast cancer. BMI is 23 kg/m². Physical examination and screening mammography are normal. Which of the following historical findings is the greatest risk factor for breast cancer in this patient?

Question

A 58-year-old woman, gravida 1 para 1, comes to the office for a routine health maintenance examination.  The patient has been doing well.  She has no chronic medical conditions, and her only surgery was a cesarean delivery at age 20.  Menarche was at age 15, and menopause occurred 7 years ago.  The patient used vaginal estrogen cream twice weekly for the first 3 years after menopause but currently takes no medications and has no allergies.  A paternal cousin died of breast cancer this year, and the patient is concerned about her own risk for breast cancer.  BMI is 23 kg/m².  Physical examination and screening mammography are normal.  Which of the following historical findings is the greatest risk factor for breast cancer in this patient?

Quizplus · Accepted Answer

11ec25c8_d25e_fce8_bc81_3b0c92c2e9c9_MD0003_00 Women in the United States have a 1 in 8 lifetime risk for being diagnosed with breast cancer. The most common risk factor is increasing age, which is primarily due to increasing probability for spontaneous genetic mutations. Aggressive breast cancers in young women, however, are more likely to be caused by inherited genetic mutations (eg, BRCA). Because increasing age is the most significant risk factor in most patients, breast cancer screening guidelines are age dependent. Therefore, most guidelines recommend screening mammography beginning at age ≥50 in most women because screening in this population has minimal risks and leads to decreased breast cancer mortality. In contrast, screening mammography is not recommended in patients age <40 due to high rates of overdiagnosis and overtreatment. (Choices A and B) Other common risk factors for breast cancer include nulliparity, early menarche (average: age 13), older age (>35) at time of first pregnancy, later menopause (average: age 51), and obesity, all of which contribute to increased lifetime estrogen exposure. In contrast, this patient's later menarche (eg, at age 15) and younger age at time of first pregnancy (eg, age 20) are protective factors. (Choice D) Patients with a first-degree relative (eg, mother, sister, daughter) with breast cancer have an increased lifetime risk of 1 in 4 for breast cancer. A cousin is a third-degree relative; therefore, a hereditary mutation (eg, BRCA) is less likely to be a significant risk factor in this patient who has no other affected family members. (Choice E) Prolonged, systemic hormone replacement therapy (eg, oral estrogen/progesterone) increases the risk for breast cancer. In contrast, the risk conferred by vaginal estrogen is minimal in most patients due to low dosages and limited systemic absorption. In addition, in women with prior or ongoing treatment for estrogen-dependent breast cancer, rates of cancer recurrence with vaginal estrogen use appear unchanged. Educational objective: The risk of breast cancer in women increases with age; therefore, routine screening mammography is age based and typically initiated at age ≥50. References: Preventive and risk reduction strategies for women at high risk of developing breast cancer: a review. (http://www.ncbi.nlm.nih.gov/pubmed/27039715) ACOG Committee Opinion No. 659 Summary: The use of vaginal estrogen in women with a history of estrogen-dependent breast cancer. (http://www.ncbi.nlm.nih.gov/pubmed/26901332)

A 58-Year-Old Woman, Gravida 1 Para 1, Comes to the Office