Risk prediction models for breast cancer screening
- Joann G Elmore, MD, MPH
Joann G Elmore, MD, MPH
- Editor-in-Chief — Primary Care (Adult)
- Section Editor — General Medicine
- Professor of Medicine, Adjunct Professor of Epidemiology
- University of Washington School of Medicine
There is growing interest in trying to stratify women into groups of different levels of risk for developing breast cancer. Several breast cancer risk prediction tools have been developed that combine major risks factors. The purpose of the models is to better stratify women into risk categories that can be used to tailor screening decisions and strategies for clinical management of the individual patient .
Breast cancer risk assessment tools are helpful in determining the risk group a patient is in. However, their accuracy for individual women is only modest, partly because not all important risks have been identified and partly because accurate risk stratification requires strong risk factors and most risk factors for breast cancer are relatively weak and common in the population . Clinical judgment must be factored into the application of model-based predictions to determine an individual's appropriateness for genetic testing and/or preventive treatment .
This topic will discuss clinical implications of breast cancer risk prediction and provide an overview of tools that the primary care clinician can use to assess breast cancer risk for screening decisions. A more detailed discussion of risk assessment tools for genetic counseling and testing by oncologists, as well as discussions of screening for breast cancer, risk factors for breast cancer, and management options for women with a genetic predisposition to breast and ovarian cancer, are discussed separately. (See "Overview of hereditary breast and ovarian cancer syndromes" and "Screening for breast cancer: Strategies and recommendations" and "Factors that modify breast cancer risk in women" and "Management of patients at high risk for breast and ovarian cancer" and "Genetic counseling and testing for hereditary breast and ovarian cancer".)
CONCEPTS IN RISK DETERMINATION
Definitions of types of risk — For this discussion, there are three important types of "risk" (see "Glossary of common biostatistical and epidemiological terms"):
●Relative risk (or risk ratio), measured as the incidence of a disease in individuals with a particular characteristic (or exposure) divided by the incidence of the disease in individuals without the characteristic, indicates whether that particular exposure increases or decreases risk. For example, the relative risk of developing breast cancer is approximately 1.2 times higher for women who are taking combination estrogen/progesterone therapy compared with women taking no hormone therapy (table 1). Relative risk is helpful to identify characteristics that are associated with a disease, but by itself is not particularly helpful in guiding screening decisions because the frequency of the risk (incidence) is canceled out.
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- CONCEPTS IN RISK DETERMINATION
- Definitions of types of risk
- Time frame of risk
- Meaning of "average" risk
- Combining multiple risks
- Assessing model validity
- TOOLS TO PREDICT BREAST CANCER RISK
- Breast Cancer Risk Assessment Tool (Gail model)
- - Accuracy of Gail model
- Models emphasizing family risk
- - Computerized risk prediction models
- - Simple risk models for BRCA1 and BRCA2 susceptibility
- - Incorporation of non-BRCA genetic data
- CLINICAL USE OF RISK PREDICTION MODELS
- INFORMATION FOR PATIENTS