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, PhDResident, University of Michigan General Surgery Residency ProgramTwitter/X: @RashmiJKumar- Melissa Pilewskie, MDAttending Breast Surgical Oncologist, Co-Director of the Weiser Family Center for Breast Cancer, Michigan Medicine Twitter/X: @MPilewskie- Stephanie Downs-Canner, MDAttending Breast Surgical Oncologist & Physician-Scientist, Memorial Sloan Kettering Cancer Center, Program Director of the Breast Surgical Oncology Fellowship Training Program Twitter/X: @SDownsCannerLearning 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 GuidelineBevers 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.2015.0105CDC Overview of Risk FactorsCenters 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.