A model of cancer prevention in British Columbia: The Breast Cancer Prevention and Risk Assessment Clinic

Cancer has now surpassed cardiovascular disease as the leading cause of death in Canada, and accounts for 29.6% of Canadian deaths.1 As the most common invasive female cancer in Canada, breast cancer represents a significant burden for women and society. Approximately 1 in 9 Canadian wo­men will develop breast cancer at some time in life, while 1 in 29 can be expected to die from the disease. 

In 2011, 23 400 new breast cancers diagnoses were expected for Canada, accounting for 28% of all new cancers diagnosed in Canadian women. In addition, an estimated 5100 Canadian women will have died from breast cancer in 2011.[1] 

In British Columbia, these figures mean 2800 women will have been diagnosed with breast cancer, and 600 will have died from the disease.[2] If age-standardized incidence rates remain constant, the annual incidence may increase to more than 4223 by the year 2025, driven by population growth and aging. This could represent a 69% increase in new breast cancer cases over the 3054 diagnosed in 2010.[2]

Breast cancer prevention
While there have been positive developments in breast cancer control, including reduced mortality rates due to earlier diagnosis and treatment ad­vances, this disease continues to place an enormous burden on women and society across Canada, and calls for an evidence-based prevention effort.

Research indicates that a large proportion of breast cancer is potentially preventable. Breast cancer genes, such as BRCA1 and BRCA2, confer consid­erable increased nonmodifiable risk. However, these mutations account for only 5% to 10% of all breast cancers. 

Other factors, including sociodemographics (e.g., higher income), reproductive history (e.g., parity, older age at first birth), and personal health history (e.g., exposure to ionizing radiation, the use of combined hormone replacement therapy), are also linked to increased breast cancer risk. Some of these modifiable factors are unlikely to be the target of public health interventions (e.g., age at first birth).

However, convincing epidemiological evidence also points to several more readily modifiable lifestyle risk factors that may account for considerable numbers of breast cancers. Spe­cifically, the World Cancer Research Fund states that 38% to 42% of breast cancers in developed countries are caused by obesity, physical inactivity, and/or alcoholic beverage consumption. In fact, obesity may become the biggest attributable cause of cancer in women in the next decade.[3]

Despite the potential benefit of modifying risk factors, this information about breast cancer prevention remains unknown to many women. In addition, a large body of research has demonstrated that women’s perceptions of their breast cancer risk do not reflect their actual risk. 

A BC-based study of 761 women found that wo­men’s ratings of their own breast cancer risk were, on average, 19% higher than their objective risk calculated by a standard risk assessment tool using the Gail model.[4] A study based on a large sample of 1700 women expanded on this finding when it showed that women at average ob­jective risk overestimated their risk, whereas women at high risk un­derestimated their risk.[5] 

Given that a recent meta-analysis[6] showed women’s ac­cep­tance of chemo­therapy for breast cancer prevention depended on an accurate perception of their risk, women need to be provided with accurate risk information. This important information, as well as counseling regarding approaches to reduce risk, is not systematically incorporated in medical care on a wide-scale basis.[7,8]

Breast Cancer Prevention and Risk Assessment Clinic
The Breast Cancer Prevention and Risk Assessment Clinic demonstration project will provide risk assessments and counsel women on strategies for reducing their risks. The clinic will use two validated breast cancer risk assessment tools as well as evidence-based lifestyle counseling regarding physical activity, weight management, and nutrition. Participants will be referred to community resources, and selected participants will be offered options for evidence-based chemoprevention.

Organization and structure
The clinic is supported by 2 years of funding through a grant from the Canadian Breast Cancer Foundation, BC/Yukon, to the University of British Columbia (Carolyn Gotay, principal investigator). The clinic is located at BC Women’s Hospital and Health Centre in Vancouver. The phone number is 604 822-9548 and the clinic website is http://breastcancerprevention.med.ubc.ca. 

The clinic is staffed by a medical oncologist specializing in breast cancer (medical director Dr Joseph Ragaz), a lifestyle counselor/health educator (Tracey Mager), an evaluation leader (Bonnie McCoy), and an administrator (Marliese Dawson). 

A multidisciplinary advisory board consisting of leading breast cancer and breast cancer prevention experts in BC, including representatives from the BC Cancer Agency Research Centre, the UBC surgical department specializing in breast cancer, the InspireHealth Integrative Cancer Care Centre, and community organizations, has been advising on the development of the clinic and will review its ongoing development.

Populations to be served
The clinic will focus on women at increased risk of breast cancer who do not meet the criteria for increased genetic risk required for referral to the Hereditary Cancer Program at the BC Cancer Agency. 

Participants at in­creased risk will be identified based on biological or lifestyle criteria: histology (e.g., atypical ductal and lobular hyperplasia); family history (at increased risk but not eligible for the Hereditary Cancer Program); mammography findings (e.g., noncancer abnormality or high breast density); lifestyle indicators (e.g., obesity); and/or self-perception. The intervention strategies will evolve over time, based on emerging research results, as well as the interest and participation of the medical community and public.

Clinic activities
While women may self-refer to the clinic, information from a surgeon, mammography screening program phy­sician, or primary care physician will be required before an appointment is made. Information needed in­cludes mammography and ultrasound reports; biopsy results (open, core, fine needle); breast surgery reports; and any pertinent health information. 

When a woman arrives at the clinic, she will complete a survey asking questions about her medical history and medication use; lifestyle habits, including physical activity, nutrition and weight management, and smoking and alcohol use; use of hormone re­placement therapy; environmental ex­posures; and perceived risk of breast cancer. She will also use two self-assessment tools: the Breast Cancer Risk Assessment Tool (Gail model) and the Harvard Disease Risk Index.

The Gail model was developed by the National Cancer Institute and the National Surgical Adjuvant Breast and Bowel Project as a breast cancer risk assessment tool for health care providers. It calculates a woman’s risk of developing breast cancer within the next 5 years and over her lifetime (up to age 90), and is based on current age, age at menarche, age at first birth, family history of breast cancer (mother, sister, or daughter), number of past breast biopsies, number of breast bi­op­sies that showed atypical hyperplasia, and race/ethnicity.[9] 

Women who have a 5-year risk of 1.67% or higher using this tool (or the risk of an average 60-year-old woman) are classified as “high-risk.” This classification is the cut-off point for guidelines when prescribing tamoxifen and raloxifene for breast cancer prevention.[10]

The Harvard Disease Risk Index is an interactive tool that estimates breast cancer risk based on questions about lifestyle factors. The index provides a risk estimate that compares the level of risk to other women of the same age, along with lifestyle recommendations based on the respondent’s answers.[11]

Results from these two risk assessment tools will provide the foundation for personalized counseling and allow participants to receive tailored suggestions for lifestyle changes to re­duce breast cancer risk.[12] Clinic staff will employ motivational interviewing and counseling techniques to encourage each woman to follow evidence-based approaches (e.g., dietary changes, enhanced physical activity, reduced alcohol consumption, breastfeeding). 

Realistic and achievable goals will be set. If medical regimens (e.g., tamoxifen or raloxifene) are deemed appropriate, the medications will be prescribed, with follow-up by the clinic oncologist or the woman’s primary care physician. In addition, participants will be provided with in­formation about community resources matched to their needs. 

A 3-month follow-up telephone call will assess success in making lifestyle changes and provide additional suggestions and support. The family physician and any other physicians involved in the woman’s care will receive a consultation report after the initial visit, summarizing the risk assessment and interventions recommended.

Clinic evaluation
Evaluation of the clinic will include assessment of both implementation (e.g., success in recruitment and referrals, efficiency of clinic protocols) and outcomes (e.g., changes in risk perception and lifestyle behaviors, be­havioral outcomes such as weight change, adherence to exercise recommendations and preventive medications if indicated, and satisfaction of participants and clinicians). Evaluation of operating costs will also be undertaken to determine the economic sustainability of the clinic.

Summary 
Key contributions of the clinic are anticipated to be:

•    The development of an innovative model of cancer prevention in Bri­tish Columbia.
•    Stimulation of research and evaluation pertaining to breast cancer prevention and risk reduction.
•    An opportunity for physicians to refer their high-risk female patients for an evidence-based intervention.

In addition, the clinic is expected to help the population of high-risk women in BC learn how to lower their risk of breast cancer (see the Health Notes for patient information). We are exploring options beyond the one-to-one clinic setting, such as group programs and interventions delivered via Internet-assisted technologies, that would allow more women in more locations to benefit from these activities. 

Given that the clinic is a new initiative, evaluation is crucial and we invite comments, suggestions, and participation by anyone interested, so that together we can reduce the burden of breast cancer in BC.

Competing interests
None declared.

This article has been peer reviewed.

Dr Gotay is a professor and the Canadian Cancer Society Chair in Cancer Primary Prevention School of Population and Public Health (SPPH) at the University of British Columbia. She is also an associate at the British Columbia Cancer Agency Research Centre. Ms McCoy is a doctoral student at the SPPH. Ms Dawson is a research manager at the SPPH. Dr Ragaz is a medical oncologist and clinical professor at the SPPH, and medical director of the Breast Cancer Prevention and Risk Assessment Clinic at BC Women’s Hospital and Health Centre.