11 June 2012:
Chemoprevention of breast cancer has the potential of a bright future in menopausal medicine. However, before chemoprevention can be implemented effectively, better methods for the reliable prediction of breast cancer are needed. Three major strategies for early prediction or risk assessment of breast cancer have been established. Next to the algorithm of epidemiological factors, as given by the Gail criteria, rank the assessment of the endocrine environment, mainly the circulating sex steroids, and mammographic density of the breast. The latter has been shown to provide an independent prediction of the breast cancer risk, although the link between enhanced mammographic density and the cellular and molecular pathways leading to breast cancer has not yet been elucidated.
Checka and co-workers  now present a retrospective analysis of a large cohort of more than 7000 women, in which the relationship between mammographic density, as given by the BI-RADS density categories, and age is analyzed. BI-RADS is the acronym for Breast Imaging-Reporting and Data System and was defined and published by the American College of Radiology. The BI-RADS assessment system consists of seven categories, but only those ranking from 1 to 4 can be used for the prediction of breast cancer risk, as they classify mammographic density differences from negative to suspicious. The median age of the cohort was 57 years. There was a significant inverse relationship between age and breast density (p g biopsy.
At present, neither an age-dependent, long-term, prospective follow-up of those women with a category 4 mammographic density assessment nor an algorithm for further refinement of the individual risk assessment are available. The authors of this manuscript favor breast MRI, possibly combined with an intravenously applied contrast dye. Of course, such a proposal is typical for any interventional group dealing with breast cancer. Alternatively, a more conservative assessment of the endocrine environment could be envisioned, as the identification of the circulating sex steroids could lead to the targeted administration of an adapted hormonal treatment, such as raloxifene, which has been shown in a number of large-scale prospective studies to reduce the incidence of invasive breast cancer.
Protocols with appropriate algorithms must now be set up to compare preventive strategies of breast cancer and for this purpose the collaboration between radiologists and menopausal endocrinologists would be helpful. Unfortunately, funding agencies currently may have little interest in supporting prospective studies dealing with early prediction or prevention of breast cancer in postmenopausal women.
Christian De Geyter
Division Chief and Research Group Leader, Gynecological Endocrinology and Reproductive Medicine, University of Basel, Switzerland
1. Checka CM, Chun JE, Schnabel FR, Lee J, Toth H. The relationship of mammographic density and age: implications for breast cancer screening. AJR 2012;198:W292-5.
Content updated June 11 2012