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Current management of lesions associated with an increased risk of breast cancer

Nature Reviews Clinical Oncology volume 12, pages 227–238 (2015)Cite this article

Subjects

Key Points

  • Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), and ductal carcinoma in situ (DCIS) are high-risk breast lesions; flat epithelial atypia (FEA) has an uncertain risk level

  • ADH or ALH, and LCIS are associated with relative risk of breast cancer development, in either breast, of approximately 4 and 10, respectively

  • The degree of risk associated with ALH, ADH, and LCIS is sufficient to justify a discussion of chemoprevention in healthy women, particularly those who are premenopausal at diagnosis

  • DCIS is considered a precursor lesion and is routinely treated by surgical excision, sometimes necessitating mastectomy; radiotherapy and/or endocrine therapy are often added, although neither modality reduces breast-cancer-specific mortality

  • Clinicopathological features or molecular alterations identifying the individuals with high-risk breast lesions that will progress to invasive breast carcinoma remain to be identified

  • Until predictors of invasive carcinoma are found, management strategies must be defined by risk at the population level, rather than individual level, which might result in undertreatment or overtreatment in individual patients

Abstract

High-risk breast lesions, which comprise benign lesions and in situ carcinomas (lobular carcinoma in situ and ductal carcinoma in situ), are clinically, morphologically, and biologically heterogeneous and are associated with an increased risk of invasive breast cancer development, albeit to varying degrees. Recognition and proactive management of such lesions can help to prevent progression to invasive disease, and might, therefore, reduce breast cancer incidence, morbidity, and mortality. However, this opportunity comes with the possibility of overdiagnosis and overtreatment, necessitating risk-based intervention. Notably, despite the progress in defining the molecular changes associated with carcinogenesis, alterations identifying the individuals with high-risk lesions that will progress to invasive carcinoma remain to be identified. Thus, until reproducible clinicopathological or molecular features predicting an individual's risk of breast cancer are found, management strategies must be defined by population-level risks as determined by models such as the Gail or IBIS models, as well as patient attitudes toward the risks and benefits of interventions. Herein, we review the contemporary approaches to diagnosis and management of high-risk breast lesions. Progress in this area will ultimately be dependent on the ability to individualize risk prediction through better definition of the key drivers in the carcinogenic process.

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Figure 1: Histological appearance of atypical ductal hyperplasia.
Figure 2: Atypical lobular hyperplasia histology.
Figure 3: Flat epithelial atypia.
Figure 4: LCIS histology.
Figure 5: DCIS histology.

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  1. Department of Surgery, Breast Service, Memorial Sloan–Kettering Cancer Center, 1275 York Avenue, New York, 10065, NY, USA

    Monica Morrow

  2. Department of Medicine, Breast Cancer Medicine Service, Memorial Sloan–Kettering Cancer Center, 1275 York Avenue, New York, 10065, NY, USA

    Larry Norton

  3. Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, 02215, MA, USA

    Stuart J. Schnitt

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Morrow, M., Schnitt, S. & Norton, L. Current management of lesions associated with an increased risk of breast cancer. Nat Rev Clin Oncol 12, 227–238 (2015). https://doi.org/10.1038/nrclinonc.2015.8

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