Breast Q&A

I am 25 years old and had a fibroadenoma removed. There was atypical ductal hyperplasia (ADH) associated with the fibroadenoma. Should I take any medication to decrease my risk of breast cancer?

The finding of atypical ductal hyperplasia (ADH) on either needle or excision biopsies does increase the risk of subsequent breast cancer.

The risk of breast cancer associated with ADH was reported by studies that followed large cohorts of women undergoing breast biopsies. Most of these studies were done prior to the widespread use of screening mammography and image guided needle biopsies and do not report the indication for biopsy. Although not detailed, one can assume, based on the study years, that a palpable finding lead to many of these biopsies, questioning the ability to generalize these results to women undergoing image-guided biopsies today.

The most cited study is the work of Dupont and Page, which reported the outcome of women undergoing excisional biopsies between the years 1950–1968. In this study, women with ADH were at 4 times higher risk of subsequent invasive breast cancer when compared to the general population.

However, based on more recent studies such as Menes et al. (2017), we now know that the the risk of subsequent invasive breast cancer in women diagnosed with ADH by core needle and excisional biopsy is lower than previously reported. As the risk associated with ADH is modified in the presence of other risk factors, one should not recommend increased surveillance and risk reducing strategies without accounting for other risk factors. An assessment of your individual risk based on multiple risk factors is preferred before deciding on any prevention strategies.

Importantly, all the chemoprevention (medication that can be taken to reduce risk of breast cancer, such as tamoxifen, aromatase inhibitors, and selective estrogen receptor modulator (SERM) such as raloxifene) studies were done in women of age 35 and above, and would not necessarily benefit someone your age.

It is important, however, to evaluate your other risk factors for breast cancer, including family history of breast cancer. An appointment with a fellowship-trained breast surgeon would be recommended to adequately assess your unique situation.

Can I omit axillary surgery for invasive breast cancer?

The CALBG 9343 trial looked at hormone-receptor positive breast cancer less than 2 cm in size in women over age 70. The 16 plus year update of data from the trial demonstrated equivalent overall survival,  but an approximately 2 percent increased chance of locoregional recurrence in the axilla. This formed the basis for the Choosing Wisely Campaign of the Society for Surgical Oncology, recommending against routine axillary intervention for women in this category.

In addition, it is worth noting that adjuvant hormonal therapy is standard for all patients with hormone receptor positive disease. The omission of sentinel lymph node biopsy in clinically node negative women greater than 70 years of age treated with hormonal therapy does not result in increased rates of locoregional recurrence and does not impact breast cancer mortality. Patients greater than 70 years of with early stage hormone receptor positive breast cancer and no palpable axillary lymph nodes can be safely treated without axillary staging.