The surgeon's role in breast cancer chemoprevention

An individual woman's level of risk for the development of invasive breast cancer can be accurately estimated using the Gail model. This model is not appropriate for use in women with prior breast cancer (invasive or in situ) or a family history suggestive of a genetic predisposition. Tamoxifen is an option for breast cancer risk reduction. The magnitude of benefit varies based on the factors that increase a woman's level of risk, but benefit has been seen in all risk subgroups that have been studied. The risks associated with tamoxifen for prevention vary with menopausal status. In premenopausal women, there are no life threatening toxicities, and quality-of-life issues predominate. In postmenopausal women, the increased risk of endometrial cancer and venous thrombosis mandate a careful assessment of the presence of other risk factors for these conditions prior to considering tamoxifen for prevention. At present, prevention options for the high-risk woman include surveillance, tamoxifen for five years, participation in the STAR trial (if postmenopausal), and bilateral prophylactic mastectomy.