Breast Cancer Chemoprevention: A Practical Guide for the Primary Care Provider
Breast Cancer Chemoprevention: A Practical Guide for the Primary Care Provider
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DOI：
10.1089/jwh.2018.7643
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发表时间：
2019-09-27
影响因子：
3.5
通讯作者：
DiNardo, Deborah
中科院分区：
文献类型：
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作者：
Farkas, Amy;Vanderberg, Rachel;DiNardo, Deborah
包括美国临床肿瘤学会、国家综合癌症网络和美国预防服务工作组在内的几个组织建议将基于乳腺癌风险的咨询和化学预防纳入常规的妇女保健。然而，初级保健提供者报告说，他们对这一问题感到不适，而且缺乏这方面的医学知识。在这篇综述中，我们提出了一个实用的，以证据为基础的指南，将乳腺癌风险评估和化学预防纳入常规护理。我们提倡一种逐步的方法，包括：（1）风险评估和沟通，（2）根据风险-效益分析选择适当的化学预防，（3）共同决策化学预防，（4）化学预防副作用的管理。我们鼓励提供者识别高风险女性，并将她们转介到遗传咨询或高风险乳腺癌诊所。对于不被认为是高风险的女性，我们建议使用盖尔模型来估计女性患浸润性乳腺癌的5年风险。通常情况下，一旦女性的5年浸润性乳腺癌风险达到3%，化学预防的益处超过化学预防的风险。对于这些妇女，在选择化学预防剂时需要考虑几个因素，包括患者偏好、血栓形成史、绝经状态、子宫的存在或缺失以及骨密度。我们提倡以证据为基础的共同决策方法，反映妇女的个人偏好时，沟通风险和咨询有关化学预防。在开始使用化学预防剂后，密切随访很重要，因为化学预防的副作用很常见，包括血管炎症状和关节痛。我们还回顾了化学预防副作用的循证管理。
Several organizations, including the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the United States Preventive Services Task Force, recommend incorporation of breast cancer risk-based counseling and chemoprevention into routine well-woman care. However, primary care providers report both discomfort with and a lack of medical knowledge on this topic. In this review we present a practical, evidence-based guide for incorporating breast cancer risk assessment and chemoprevention into routine care. We advocate a stepwise approach consisting of: (1) risk assessment and communication, (2) selection of appropriate chemoprevention based on risk-benefit analysis, (3) shared decision-making regarding chemoprevention, and (4) management of chemoprevention side effects. We encourage providers to identify high-risk women and refer them to genetic counseling or a high-risk breast cancer clinic. For women who are not considered high risk, we suggest using the Gail model to estimate a woman's 5-year risk of invasive breast cancer. Usually, the benefits of chemoprevention outweigh the risks of chemoprevention once a woman's 5-year risk of invasive breast cancer reaches 3%. For these women there are several factors that need to be considered when selecting a chemoprevention agent, including patient preference, thrombotic history, menopausal status, absence or presence of a uterus, and bone mineral density. We advocate an evidence-based shared decision-making approach that reflects the woman's individual preferences when communicating risk and counseling about chemoprevention. After starting a chemoprevention agent, close follow-up is important as side effects of chemoprevention are common, including vasomotor symptoms and arthralgias. We also review evidence-based management of chemoprevention side effects.