Breast Cancer
        Screening
        Risk modification
        Breast conservation therapy for BRCA1/2 mutation carriers
        Role of BRCA1 and BRCA2 in response to chemotherapy
Ovarian Cancer
        Screening
        Risk Modification

Few data exist on the outcomes of interventions to reduce risk in people with a genetic susceptibility to breast or ovarian cancer. As a result, recommendations for management are primarily based on expert opinion.[1-5] In addition, as outlined in other sections of this summary, uncertainty is often considerable regarding the level of cancer risk associated with a positive family history or genetic test. In this setting, personal preferences are likely to be an important factor in patients’ decisions about risk reduction strategies.

Refer to the PDQ summary on Screening for Breast Cancer for information on screening in the general population, and to the PDQ summary Cancer Genetics Overview for information on levels of evidence related to screening and prevention.

In the general population, evidence for the value of breast self-examination (BSE) is limited. Preliminary results have been reported from a randomized study of BSE being conducted in Shanghai, China.[6] At 5 years, no reduction in breast cancer mortality was seen in the BSE group compared with the control group of women, nor was a substantive stage shift seen in breast cancers that were diagnosed. (Refer to the PDQ summary on Screening for Breast Cancer for more information.)

Little direct prospective evidence exists regarding BSE among female carriers of a BRCA1 or BRCA2 high-risk mutation, male carriers of a BRCA2 mutation, or women at inherited risk of breast cancer. In the Canadian National Breast Screening Study, women with first-degree relatives with breast cancer had statistically significantly higher BSE competency scores than those without a family history. In a study of 251 high-risk women at a referral center, five breast cancers were detected by self-examination less than a year after a previous screen (as compared with one cancer detected by clinician exam and 11 cancers detected as a result of mammography). Women in the cohort were instructed in self-examination, but it is not stated whether the interval cancers were detected as a result of planned self-examination or incidental discovery of breast masses.[7] In another series of BRCA1/2 mutation carriers, four of nine incident cancers were diagnosed as palpable masses after a reportedly normal mammogram, further suggesting the potential value of self-examination.[8] A task force convened by the Cancer Genetics Studies Consortium has recommended “monthly self-examination beginning early in adult life (e.g., by age 18-21) to establish a regular habit and allow familiarity with the normal characteristics of breast tissue. Education and instruction in self-examination are recommended.”[9]

Level of evidence: 5

Few prospective data exist regarding clinical breast examination (CBE) among female carriers of a BRCA1 or BRCA2 high-risk mutation, male carriers of a BRCA2 mutation, or women at inherited risk of breast cancer.

The Cancer Genetics Studies Consortium task force concluded, “as with self-examination, the contribution of clinical examination may be particularly important for women at inherited risk of early breast cancer.” They recommended that female carriers of a BRCA1 or BRCA2 high-risk mutation undergo annual or semiannual clinical examinations beginning at age 25 to 35 years.[9]

Level of evidence: 5

In the general population, strong evidence suggests that regular mammography screening of women aged 50 to 59 years leads to a 25% to 30% reduction in breast cancer mortality. (Refer to the PDQ summary on Screening for Breast Cancer for more information.) For women who begin mammographic screening at age 40 to 49 years, a 17% reduction in breast cancer mortality is seen, which occurs 15 years after the start of screening.[10] Observational data from a cohort study of more than 28,000 women suggest that the sensitivity of mammography is lower for young women. In this study, the sensitivity was lowest for younger women (aged 30-49 years) who had a first-degree relative with breast cancer. For these women, mammography detected 69% of breast cancers diagnosed within 13 months of the first screening mammography. By contrast, sensitivity for women younger than 50 years without a family history was 88% (P = .08). For women aged 50 years and older, sensitivity was 93% at 13 months and did not vary by family history.[11] Preliminary data suggest that mammography sensitivity is lower in BRCA1 and BRCA2 carriers than in noncarriers.[8] Subsequent observational studies have found that the positive predictive value (PPV) of mammography increases with age and is highest among older women and among women with a family history of breast cancer.[12] Higher PPVs may be due to increased breast cancer incidence, higher sensitivity, and/or higher specificity.[13] One study found an association between the presence of pushing margins, a histopathologic description of a pattern of invasion, and false-negative mammograms in 28 women, 26 of whom had a BRCA1 mutation and two of whom had a BRCA2 mutation. Pushing margins, characteristic of medullary histology, is associated with an absence of fibrotic reaction.[14] In addition, rapid tumor doubling times may lead to tumors presenting shortly after an apparently normal study. In one study, mean tumor doubling time in BRCA1/2 carriers was 45 days, compared with 84 days in noncarriers.[15] Another study that evaluated mammographic breast density in women with BRCA mutations found no association between mutation status and mammographic density; however, in both carriers and noncarriers, increased breast density was associated with increased breast cancer risk.[16]

The randomized Canadian National Breast Screening Study-2 (NBSS2) compared annual CBE plus mammography to CBE alone in women aged 50 to 59 years from the general population. Both groups were given instruction in BSE.[17] Although mammography detected smaller primary invasive tumors and more invasive as well as ductal carcinomas in situ (DCIS) than CBE, the breast cancer mortality rates in the CBE-plus-mammography group and the CBE- alone group were nearly identical, and compared favorably with other breast cancer screening trials. After a mean follow-up of 13 years (range 11.3-16.0 years), the cumulative breast cancer mortality ratio was 1.02 (95% confidence interval (CI) = 0.78 to 1.33). One possible explanation of this finding was the careful training and supervision of the health professionals performing CBE.

In a prospective study of 251 individuals with BRCA mutations who received uniform recommendations regarding screening and risk-reducing, or prophylactic, surgery, annual mammography detected breast cancer in six women at a mean of 20.2 months after receipt of BRCA results.[7] The Cancer Genetics Studies Consortium task force has recommended for female carriers of a BRCA1 or BRCA2 high-risk mutation, “annual mammography, beginning at age 25 to 35 years. Mammograms should be done at a consistent location when possible, with prior films available for comparison.”[9] Data from prospective studies on the relative benefits and risks of screening with an ionizing radiation tool versus CBE or other nonionizing radiation tools would be useful.[18-20]

Certain observations have led to the concern that BRCA mutation carriers may be more prone to radiation-induced breast cancer than women without mutations. The BRCA1 and BRCA2 proteins are known to be important in cellular mechanisms of DNA damage repair, including those involved in repairing radiation-induced damage. Mouse embryos lacking Brca1 or Brca2 are hypersensitive to the effects of ionizing radiation. Some studies have suggested intermediate radiation sensitivity in cells that are heterozygous for a BRCA mutation, but this is not consistent and varies by experimental system and endpoint. A large international case-control study of 1,601 mutation carriers described an increased risk of breast cancer (hazard ratio (HR) = 1.54) among women who were ever exposed to chest x-rays, with risk being highest in women age 40 years and younger, born after 1949, and those exposed to x-rays only before age 20 years.[21] In contrast, two studies of the effect of mammogram exposure on carriers (n = 1,600, n = 162) did not support an association between such exposure and subsequent breast cancer risk.[22,23] In a small study,[23] there was a modest association between lifetime mammogram exposure and risk in BRCA1 mutation carriers (HR = 1.08, P = .03). No significant effect was seen after exclusion of postdiagnosis mammograms. At this time there is insufficient evidence to suggest that mutation carriers should avoid mammography.

Level of evidence: 5

The limited sensitivity of mammography and an interest in methods of screening that do not involve ionizing radiation has led to evaluation of other screening techniques, including magnetic resonance imaging (MRI), breast ultrasound, breast ductal lavage, and digital mammography.

Because of the relative insensitivity of mammography in women at hereditary risk for breast cancer, a number of screening modalities have been proposed and investigated in high-risk women, including BRCA mutation carriers. Several studies have described the experience with breast MRI screening in women at risk for breast cancer, including descriptions of relatively large multi-institutional trials.[24-30] Several considerations must be kept in mind when reviewing these reports:

• The studies are variable in terms of the underlying population being studied, equipment and signal processing protocols, the manner of reporting results, and the manner in which sensitivity and specificity are calculated.
• The different screening tests (MRI and mammogram with or without ultrasound) are performed nearly simultaneously in these studies, and the screening modalities are compared to each other. Therefore, sensitivity is defined somewhat differently in these studies than in the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) of follow-up and outcome reporting.
• The number of screening rounds is limited, and the distinction between prevalent (first round) and incident cancer detection rates is often unclear.

Despite these caveats, the reported studies consistently demonstrate that breast MRI is more sensitive than either mammography or ultrasound for the detection of hereditary breast cancer. The results of four large studies are presented in Table 5, Summary of MRI Screening Studies in Women at Hereditary Risk for Breast Cancer.[24-28] Most cancers in these programs were screen detected with only 6% of cancers presenting in the interval between screenings. The sensitivity of MRI (as defined by the study methodology) ranged from 71% to 100%. Of the combined studies, 82% of the cancers were identified by MRI compared with 40% by mammography.

Concerns have been raised about the reduced specificity of MRI compared with other screening modalities. In one study, after the initial MRI screen, 16.5% of the patients were recalled for further evaluation, and 7.6% of subjects were recommended to undergo a short-interval follow-up examination at 6 months.[28] These rates declined significantly during later screening rounds, with fewer than 10% of the subjects recalled for more detailed MRI and fewer than 3% recommended to have short interval follow-up. In a second study, Magnetic Resonance Imaging for Breast Screening (MARIBS), the recall rate for additional evaluation was 10.7% per year.[27] The benign biopsy rates in the first study were 11% at first round, 6.6% at second round, and 4.7% at third round.[28] In the MARIBS study, the aggregate surgical biopsy rate was 9 per 1,000 screening episodes, though this may underestimate the burden because follow-up ultrasounds, core-needle biopsies, and fine-needle aspirations have not been included in the numerator of the MARIBS calculation.[27] The PPV of MRI has been calculated differently in the various series and fluctuates somewhat, depending on whether all abnormal examinations or only the examinations that result in a biopsy are counted in the denominator. Generally, the PPV of a recommendation for tissue sampling (as opposed to further investigation) is in the range of 50% in most series.

These trials appear to establish that MRI is superior to mammography in the detection of hereditary breast cancer, and that women participating in these trials including annual MRI screening were less likely to have a cancer not detected by screening.[31] However, mammography clearly identifies some cancers that are not identified by MRI. Most of these mammographically detected cancers in women with a negative MRI appear to be ductal carcinomas in situ, presumably presenting as microcalcifications without significant ductal enhancement. While MRI does appear to be more sensitive than mammogram, it is unknown whether MRI screening results in a survival benefit or even in downstaging compared to mammography alone. One screening study demonstrated that patients were more likely to be diagnosed with small tumors and node-negative disease than women in two nonrandomized control groups.[25] However, a randomized study of screening with or without MRI using tumor stage or mortality as an endpoint has not been performed. Despite the apparent sensitivity of MRI screening, some women in MRI-based programs will nevertheless develop life-threatening breast cancer. The American Cancer Society and the National Comprehensive Cancer Network (NCCN) have recommended the use of annual MRI screening for women at hereditary risk for breast cancer.[3,32]

Several studies have reported instances of breast cancer detected by ultrasound that were missed by mammography, as discussed in one review.[34] In a pilot study of ultrasound as an adjunct to mammography in 149 women with moderately increased risk based on family history, one cancer was detected, based on ultrasound findings. Nine other biopsies of benign lesions were performed. One was based on abnormalities on both mammography and ultrasound, and the remaining eight were based on abnormalities on ultrasound alone.[34] Uncertainties about ultrasound include the effect of screening on mortality, the rate and outcome of false-positive results, and access to experienced breast ultrasonographers.

Digital mammography refers to the use of a digital detector to detect and record x-ray images. This technology improves contrast resolution,[35] and has been proposed as a potential strategy for improving the sensitivity of mammography. A screening study comparing digital with routine mammography in 6,736 examinations of women aged 40 years and older found no difference in cancer detection rates;[36] however, digital mammography resulted in fewer recalls. In another study (ACRIN-6652) comparing digital mammography to plain-film mammography in 42,760 women, the overall diagnostic accuracy of the two techniques was similar.[37] When Receiver Operating Characteristic (ROC) curves were compared, digital mammography was more accurate in women younger than 50 years, in women with radiographically dense breasts, and in premenopausal or perimenopausal women.

Refer to the PDQ summary on Prevention of Breast Cancer for information on prevention in the general population, and to the PDQ summary Cancer Genetics Overview for information on levels of evidence related to screening and prevention.

In the general population, breast cancer risk increases with early menarche and late menopause, and is reduced at early first full-term pregnancy. (Refer to the PDQ summary on Prevention of Breast Cancer for more information.) In the Nurses’ Health Study, these were risk factors among women who did not have a mother or sister with breast cancer.[38] Among women with a family history of breast cancer, pregnancy at any age appeared to be associated with an increase in risk of breast cancer, persisting to age 70 years.

One study evaluated risk modifiers among 333 female carriers of a BRCA1 high-risk mutation. In women with known mutations of the BRCA1 gene, early age at first live birth and parity of three or more have been associated with a lowered risk of breast cancer. A relative risk (RR) of 0.85 was estimated for each additional birth, up to five or more; however, increasing parity appeared to be associated with an increased risk of ovarian cancer.[39,40] In a case-control study from New Zealand, investigators noted no difference in the impact of parity upon the risk of breast cancer between women with a family history of breast cancer and those without a family history.[41]

Studies of the effect of pregnancy on breast cancer risk have revealed complex results. Although the relationship of parity has been inconsistent, several studies have shown that among parous women, an increased number of full-term births is associated with a decrease in breast cancer risk. The influence of age at first birth may differ between BRCA1 and BRCA2 mutation carriers.[42-44] Of note, neither therapeutic nor spontaneous abortions appear to be associated with an increased breast cancer risk.[42,45]

Level of evidence: 3

In the general population, breastfeeding has been associated with a slight reduction in breast cancer risk in a few studies, including a large collaborative reanalysis of multiple epidemiologic studies,[46] and at least one study suggests that it may be protective in BRCA1 mutation carriers. In a multicenter breast cancer case-control study of 685 BRCA1 and 280 BRCA2 mutation carriers with breast cancer and 965 mutation carriers without breast cancer drawn from multiple-case families, among BRCA1 mutation carriers, breastfeeding for 1 year or more was associated with approximately a 45% reduced risk of breast cancer.[47] No such reduced risk was observed among BRCA2 mutation carriers. A second study failed to confirm this association.[42]

Among the general population, oral contraceptives may produce a slight, short-term increase in breast cancer risk. (Refer to the PDQ summary on Prevention of Breast Cancer for more information.) In a meta-analysis of data from 54 studies, family history of breast cancer was not associated with any variation in risk associated with oral contraceptive use.[48] In a study of 50 Jewish women younger than 40 years with breast cancer, those with a BRCA1 or BRCA2 high-risk mutation had a higher likelihood of long-term oral contraceptive use (>48 months) before their first pregnancy.[49] The authors concluded that oral contraceptive use might increase the risk of breast cancer among carriers of a BRCA1 or BRCA2 mutation more than in noncarriers. In a case-control study of more than 1,300 pairs of women, each case was matched to a woman with a mutation in the same gene, born within 2 years of the case, and in the same country, who had not developed cancer. Oral contraceptive use was associated with a statistically significant 20% (CI, 2%-40%) increase in risk of breast cancer among BRCA1 mutation carriers, particularly if use:

• Began before 1975, a period when estrogen doses were relatively high (38% increase, CI 11%-72%).
• Began before age 30 years (29% increase, CI, 9%-52%).
• Lasted for 5 or more years (33% increase, CI, 11%-60%).[50]

There was no increased risk associated with use among BRCA2 mutation carriers. A Swedish population-based study of 245 women with breast cancer diagnosed before age 41 years, 19 of whom were BRCA1/BRCA2 mutation carriers, suggested that oral contraceptive use before age 20 years was associated with increased breast cancer risk in both mutation carriers and noncarriers, though the small number of carriers limits the conclusions for this subgroup.[51]

In contrast, a population-based study of 47 BRCA1 and 36 BRCA2 mutation carriers with breast cancer diagnosed before age 40 years, matched to population controls without mutations, found no increased risk of early-onset breast cancer associated with ever use of low-dose contraceptive pills for BRCA2 mutation carriers (odds ratio (OR) = 1.02) and a significantly reduced risk for BRCA1 mutation carriers (OR = 0.22; 95% CI, 0.10-0.49).[52]

One study examined proliferation of normal breast epithelium among women undergoing reduction mammoplasty.[53] The study found a substantially higher cellular proliferation rate among women who used oral contraceptives before their first full-term pregnancy. In addition, among women currently on oral contraceptives, women with a family history of breast cancer had much higher cellular proliferation rates than those women without a family history. These findings are consistent with increased breast cancer risk among women with a family history of breast cancer who use oral contraceptives.

In considering contraceptive options and preventive actions, the potential impact of oral contraceptive use upon the risk of both breast and ovarian cancer, as well as other health-related effects of oral contraceptives, needs to be considered. With regard to breast cancer risk associated with oral contraceptive use, despite conflicting results based on small numbers of carriers, several studies have found a significantly increased risk. A number of important issues remain unresolved including the potential differences between BRCA1/2 mutation carriers, age and duration of exposure, and formulation.

Levels of evidence for oral contraceptive studies: 3B, 3

Both observational and randomized clinical trial data suggest an increased risk of breast cancer associated with hormone replacement therapy (HRT) in the general population.[54-57] The Women’s Health Initiative (WHI) is a randomized controlled trial of approximately 160,000 postmenopausal women investigating the risks and benefits of strategies that may reduce the incidence of heart disease, breast and colorectal cancer, and fractures, including dietary interventions and two trials of hormone therapy. The estrogen-plus-progestin arm of the study, which randomized more than 16,000 women to receive combined hormone therapy or placebo, was halted early because health risks exceeded benefits.[56,57] One of the adverse outcomes prompting closure was a significant increase in both total (245 vs. 185 cases) and invasive (199 vs. 150) breast cancers (RR =1.24; 95% CI, 1.02-1.50, P <.001) in women randomized to receive estrogen and progestin.[57] HRT-related breast cancers had adverse prognostic characteristics (more advanced stages and larger tumors) compared with cancers occurring in the placebo group, and HRT was also associated with a substantial increase in abnormal mammograms.[57]

Breast cancer risk associated with postmenopausal HRT has been variably reported to be increased [58-60] or unaffected by a family history of breast cancer;[39,61,62] risk did not vary by family history in the meta-analysis.[48] The WHI study has not reported analyses stratified on breast cancer family history, and subjects have not been systematically tested for BRCA1/2 mutations.[57] Short-term use of hormones for treatment of menopausal symptoms appears to confer little or no breast cancer risk in the general population.[63]

The effect of HRT on breast cancer risk among carriers of a BRCA1 or BRCA2 mutation has only been studied in the context of bilateral oophorectomy, a procedure known to reduce the risk of breast cancer. In a prospective study of 462 women with BRCA1 or BRCA2 mutations, 155 who had undergone bilateral oophorectomy (139 before age 50 years), the breast cancer risk reduction of 37% was essentially the same among the 93 women who took HRT compared with the reduction of 38% among those without HRT.[64] This finding needs to be confirmed in a larger study but suggests that HRT in this particular setting does not negate the protective effect of oophorectomy on breast cancer risk.

Level of evidence: 4B

Tamoxifen (a synthetic antiestrogen) increases breast-cell growth inhibitory factors and concomitantly reduces breast-cell growth stimulatory factors. The National Surgical Adjuvant Breast and Bowel Project Breast Cancer Prevention Trial (NSABP-P1), a prospective randomized double-blind trial, compared tamoxifen (20 mg/day) to placebo for 5 years. Tamoxifen was shown to reduce the risk of invasive breast cancer by 49%. The protective effect was largely confined to estrogen receptor–positive breast cancer, which was reduced by 69%. The incidence of estrogen receptor–negative cancer was not significantly reduced.[65] Similar reductions were noted in the risk of preinvasive breast cancer. Reductions in breast cancer risk were noted among women with a family history of breast cancer and in those without a family history. These benefits were associated with an increased incidence of endometrial cancers and thrombotic events among women older than 50 years. Interim data from two European tamoxifen prevention trials did not show a reduction in breast cancer risk with tamoxifen after a median follow-up of 48 months [66] or 70 months,[67] respectively. In one trial, however, reduction in breast cancer risk was seen among a subgroup who also used HRT.[66] These trials varied considerably in study design and populations. (Refer to the PDQ summary on Prevention of Breast Cancer for more information.)

A substudy of the NSABP-P1 trial evaluated the effectiveness of tamoxifen in preventing breast cancer in BRCA1/2 mutation carriers older than 35 years. BRCA2-positive women benefited from tamoxifen to the same extent as BRCA1/2 mutation–negative participants; however, tamoxifen use among healthy women with BRCA1 mutations did not appear to reduce breast cancer incidence. These data must be viewed with caution in view of the small number of mutation carriers in the sample (eight BRCA1 carriers and 11 BRCA2 carriers).[68]

Level of evidence: 1

In contrast to the very limited data on primary prevention in BRCA1 and BRCA2 mutation carriers with tamoxifen, several studies have found a protective effect of tamoxifen on the risk of contralateral breast cancer.[69-71] In one study involving approximately 600 BRCA1/2 mutation carriers, tamoxifen use was associated with a 51% reduction in contralateral breast cancer.[69] An update to this report examined 285 BRCA1/2 mutation carriers with bilateral breast cancer and 751 BRCA1/2 mutation carriers with unilateral breast cancer (40% of these patients were included in their initial study). Tamoxifen was associated with a 50% reduction in contralateral breast cancer risk in BRCA1 mutation carriers and a 58% reduction in BRCA2 mutation carriers. Tamoxifen did not appear to confer benefit in women who had undergone an oophorectomy, although the numbers in this subgroup were quite small.[71] Another study involving 160 BRCA1/2 mutation carriers demonstrated that tamoxifen use following treatment of breast cancer with lumpectomy and radiation was associated with a 69% reduction in the risk of contralateral breast cancer.[70] These studies are limited by their retrospective, case-control designs and the absence of information regarding estrogen-receptor status in the primary tumor.

The STAR trial (NSABP; P-2) included more than 19,000 women and compared 5 years of raloxifene with tamoxifen in reducing the risk of invasive breast cancer.[72] There was no difference in incidence of invasive breast cancer at a mean follow-up of 3.9 years; however, there were fewer noninvasive cancers in the tamoxifen group. The incidence of thromboembolic events and hysterectomy was significantly lower in the raloxifene group. Detailed quality of life data demonstrate slight differences between the two arms.[73] Data regarding efficacy in BRCA1 or BRCA2 mutation carriers are not available.

Level of Evidence: 1

In the general population, both subcutaneous mastectomy and simple (total) mastectomy have been used for prophylaxis. Only 90% to 95% of breast tissue is removed with subcutaneous mastectomy.[74] In a total or simple mastectomy, removal of the nipple-areolar complex increases the proportion of breast tissue removed compared with subcutaneous mastectomy. However, some breast tissue is usually left behind with both procedures. The risk of breast cancer following either of these procedures has not been well established.

The effectiveness of risk-reducing mastectomy (RRM) in women with BRCA1 or BRCA2 mutations has been evaluated in several studies. In one retrospective cohort study of 214 women considered to be at hereditary risk by virtue of a family history suggesting an autosomal dominant predisposition, three women were diagnosed with breast cancer after bilateral RRM, with a median follow-up of 14 years.[75] As 37.4 cancers were expected, the calculated risk reduction was 92% (95% CI, 76.6–98.3). In a follow-up subset analysis, 176 of the 214 high-risk women in this cohort study underwent mutation analysis of BRCA1 and BRCA2. Mutations were found in 26 women (18 deleterious, eight variants of uncertain significance). None of those women had developed breast cancer after a median follow-up of 13.4 years.[76] Two of the three women diagnosed with breast cancer after RRM were tested, and neither carried a mutation. The calculated risk reduction among mutation carriers was 89.5% to 100% (95% CI, 41.4%–100%), depending on the assumptions made about the expected numbers of cancers among mutation carriers and the status of the untested woman who developed cancer despite mastectomy. The result of this retrospective cohort study has been supported by a prospective analysis of 76 mutation carriers undergoing RRM and followed prospectively for a mean of 2.9 years. No breast cancers were observed in these women, whereas eight were identified in women undergoing regular surveillance (HR for breast cancer after RRM = 0 [95% CI, 0–0.36]).[77]

The Prevention and Observation of Surgical End Points (PROSE) study group estimated the degree of breast cancer risk reduction after RRM in BRCA1/2 mutation carriers. The rate of breast cancer in 105 mutation carriers who underwent bilateral RRM was compared with that in 378 mutation carriers who did not choose surgery. Bilateral mastectomy reduced the risk of breast cancer after a mean follow-up of 6.4 years by approximately 90%.[78]

Another study evaluated the effectiveness of contralateral RRM in affected women with hereditary breast cancer. In a group of 148 BRCA1 or BRCA2 mutation carriers, 79 of whom underwent RRM, the risk of contralateral cancer was reduced by 91% and was independent of the effect of risk-reducing oophorectomy. Survival was better among women undergoing RRM, but this result was apparently caused by higher mortality due to the index cancer or metachronous ovarian cancer in the group not undergoing surgery.[79]

Studies describing histopathologic findings in RRM specimens from women with BRCA1 or BRCA2 mutations have been somewhat inconsistent. In two series, proliferative lesions associated with an increased risk of breast cancer (lobular carcinoma in situ, atypical lobular hyperplasia, atypical ductal hyperplasia, DCIS) were noted in 43% to 46% of women with mutations undergoing either unilateral or bilateral RRM.[80,81] In these series, 13% to 15% of patients were found to have previously unsuspected DCIS in the prophylactically removed breast. Among 47 cases of risk-reducing bilateral or contralateral mastectomies performed in known BRCA1 or BRCA2 mutation carriers from Australia, 3 (6%) cancers were detected at surgery.[82]

These findings were not replicated in a third retrospective cohort study. In this study, proliferative fibrocystic changes were noted in none of 11 bilateral mastectomies from patients with deleterious mutations and in only two of seven contralateral unilateral risk-reducing mastectomies in affected mutation carriers.[83]

Although data are sparse, the evidence to date indicates that while a substantial proportion of women with a strong family history of breast cancer are interested in discussing RRM as a treatment option, uptake varies according to culture, geography, healthcare system, insurance coverage, provider attitudes, and other social factors. For example, in one setting where the providers made one to two field trips to family gatherings for family information sessions and individual counseling, only 3% of unaffected carriers obtained RRM within 1 year of follow-up.[84] Among women at increased risk of breast cancer due to family history, fewer than 10% opted for mastectomy.[85] Selection of this option was related to breast cancer–related worry as opposed to objective risk parameters (e.g., number of relatives with breast cancer). In addition, self-perceived risk has been closely linked to interest in RRM.[85]

Assuming risk reduction in the range of 90%, a theoretical model suggests that for a group of 30-year-old women with BRCA1 or BRCA2 mutations, RRM would result in an average increased life expectancy of 2.9 to 5.3 years.[86] While these data are useful for public policy decisions, they cannot be individualized for clinical care as they include assumptions that cannot be fully tested. Another study of at-risk women showed a 70% time-tradeoff value, indicating that the women were willing to sacrifice 30% of life expectancy in order to avoid RRM.[87] A cost-effectiveness analysis study estimated that risk-reducing surgery (mastectomy and oophorectomy) is cost-effective compared with surveillance with regard to years of life saved, but not for improved quality of life.[88]

In contrast, in a Dutch study of highly motivated women being followed every 6 months at a high-risk center, more than half (51%) of unaffected carriers opted for RRM. Almost 90% of the RRM surgeries were performed within 1 year of DNA testing. In this study, those most likely to have RRM were women younger than 55 years and with children.[89]

The Society of Surgical Oncology has endorsed RRM as an option for women with BRCA1/2 mutations or strong family histories of breast cancer.[90]

Individual psychological factors have an important role in decision-making about RRM by unaffected women. Research is emerging about psychosocial outcomes of RRM. (Refer to the Psychological Aspects of Medical Interventions section of this summary.)

Level of evidence: 3B

In the general population, removal of both ovaries has been associated with a reduction in breast cancer risk of up to 75%, depending on parity, weight, and age at time of artificial menopause. (Refer to the PDQ summary on Prevention of Breast Cancer for more information.) A Mayo Clinic study of 680 women at various levels of familial risk found that in women younger than 60 years who had bilateral oophorectomy, the likelihood of breast cancers developing was reduced for all risk groups.[91] Ovarian ablation, however, is associated with important side effects such as hot flashes, impaired sleep habits, vaginal dryness, dyspareunia, and increased risk of osteoporosis and heart disease. A variety of strategies may be necessary to counteract the adverse effects of ovarian ablation.

In support of early small studies,[92,93] a retrospective study of 551 women with disease-associated BRCA1 or BRCA2 mutations found a significant reduction in risk of breast cancer (HR 0.47; 95% CI, 0.29–0.77) as well as ovarian cancer (HR 0.04, 95% CI, 0.01–0.16) after risk-reducing salpingo-oophorectomy (RRSO).[94] A prospective single-institution study of 170 women with BRCA1 or BRCA2 mutations showed a similar trend. With RRSO, the HR was 0.15 (95% CI, 0.02–1.31) for ovarian, fallopian tube, or primary peritoneal cancer, and 0.32 (95% CI, 0.08–1.2) for breast cancer; the HR for either cancer was 0.25 (95% CI, 0.08–0.74).[95]

Levels of evidence: 3aii

While lumpectomy plus radiation therapy has become standard local-regional therapy for women with early stage breast cancer, its use in women with a hereditary predisposition for breast cancer who do not choose immediate bilateral mastectomy is less clear. Concern about its use, particularly in women with deleterious BRCA1 and BRCA2 mutations, centers around two issues. The first is the potential for an increased rate of ipsilateral cancers in the treated breast. The second is the potential for therapeutic radiation to induce tumors in BRCA1/2 defective cells. Most of the early studies that used family history of breast/ovarian cancer as a surrogate for hereditary risk failed to find an increase in ipsilateral cancers in women treated with breast conservation.[96-100] However, with the availability of clinical genetic testing for BRCA1/2 mutations, treatment outcomes for carriers of deleterious mutations in BRCA1/2 can now be compared with those of noncarriers.

To understand the role of germline BRCA1/2 mutations in determining outcome among women treated conservatively for breast cancer, the records of Ashkenazi Jewish (AJ) women treated with lumpectomy and radiation therapy for invasive breast cancer were reviewed.[101] Archival pathology material was obtained for analysis of the three founder AJ mutations. Deleterious BRCA mutations were found in 56 (11.3%) of the cases. The rate of ipsilateral cancer for founder mutation carriers was 12% at 10 years compared with 8% for women without mutations (not statistically significant). Women with founder AJ mutations were over three times more likely than women without mutations to develop contralateral cancer, 27% versus 8% (P = .0001). The same investigators also described a separate case series of 87 women with BRCA mutations who were treated with breast conserving surgery.[102] They reported a 12.6% rate of ipsilateral breast cancer at a median of 51.8 months, and a 23% rate of contralateral breast cancer at a median of 67.4 months. No control group was included.[102]

A case-control study from the Netherlands compared women with hereditary breast cancer (identified as either BRCA1/2 positive, or by a strong family history) with women without hereditary breast cancer for treatment outcome after breast conservation therapy. Although rates of ipsilateral breast recurrence were similar at 2 years following diagnosis, by 5 years the rate was twice as high in the hereditary cases (14% vs. 7%), and remained twice as high at 10 and 15 years after diagnosis (30% and 49% in the hereditary group, and 16% and 20% in the sporadic group).[103]

A multi-institution retrospective cohort study compared outcomes after breast conserving treatment between women with known BRCA1/2 mutations and those whose family history was not suggestive of a hereditary pattern. At 10 years, overall rates of ipsilateral breast cancer were not significantly different. However, BRCA1/2 mutation status was significantly associated with a risk of ipsilateral breast cancer when those carriers who underwent oophorectomy were removed from the analysis (7.8% for noncarriers vs. 16.3% for carriers). The 10-year estimates for contralateral breast cancer were 3% for noncarriers and 26% for carriers.[70] One study reported an approximately 40% risk of contralateral breast cancer in BRCA mutation carriers, a risk which is reduced by taking tamoxifen or undergoing oophorectomy.[104]

A study of selected patients diagnosed at age 42 years or younger who had undergone conservative therapy were offered genetic testing for BRCA1/2 mutations. Of 127 participants, 22 were found to have deleterious mutations.[105] At a median of 12.7 years of follow-up, the rate of ipsilateral events was 49% in the mutation carriers and 21% in the noncarriers (P = .007). Clinical and pathological features of the ipsilateral tumors were more consistent with second primaries than with local recurrence. Similarly, the rate of contralateral cancers was 42% in the carriers and 9% in the noncarriers (P = .001). This study has been criticized as having an unacceptable rate of ipsilateral events overall, calling into question the adequacy of the local-regional treatment.[106]

As noted above, there is a growing indication that women with BRCA1/2 mutations who are treated conservatively have an increased, not decreased, rate of ipsilateral breast cancer, occurring usually after 5 years of follow-up.

The second concern stems from the emerging understanding of the role of the BRCA genes in DNA repair activities within the cell, and the implication of the loss of these functions for radiation hypersensitivity. Both BRCA1 and BRCA2 are involved in DNA double-strand break repair, and loss of function in these genes could potentially accelerate the rate of cell kill caused by ionizing radiation. Another potentially relevant mechanism is the defect in the G2-M phase checkpoint displayed by BRCA1-deficient cells, which also alters radiation sensitivity.[107] Furthermore, murine models of Brca1- and Brca2-deficient mice have demonstrated evidence of hypersensitivity to ionizing radiation.[18,108] Clinical manifestations of these findings could include:

1. An increased response to adjuvant radiation therapy with a decrease of in-breast recurrence rates.
2. An increase in ipsilateral and contralateral breast cancers secondary to genetic instability.
3. An increase in radiation-related toxicity.

In one study, the rate of local recurrence among women with strong family histories who were treated with lumpectomy was highest when radiation was omitted, suggesting that these tumors are radiosensitive.[98] Rates of contralateral disease are consistently elevated in this population, but are equal for women treated with conservative therapy and for those who chose mastectomy without radiation, indicating that the increased risk is due to the mutation, not the exposure to radiation. And finally, studies have failed to find an increase in either early acute radiation tissue reactions or late radiation reactions to the skin, underlying tissue or bone.[109-111]

These data are consistent with a model in which hereditary BRCA1/2 cancers are sterilized by radiation therapy equally well, but due to the underlying genetic predisposition, the increased risk of second primaries in the treated breast remains. The findings of a significantly increased risk of contralateral breast cancer in this population is consistent across studies, and increasingly women with BRCA1/2 mutations are considering bilateral mastectomy at the time of first diagnosis of breast cancer, regardless of stage. Finally, there is no evidence for an increase in radiation toxicity among BRCA1/2 mutation carriers.

A small but growing body of preclinical and clinical literature suggests a differential response of BRCA-related breast cancers to systemic chemotherapy. This is based on the emerging understanding of the functions of these genes in response to DNA damage and mitotic spindle machinery control. As several chemotherapeutic agents target either DNA or mitotic spindle structural integrity, the lack of BRCA functions could alter response to these agents. The absence of BRCA-mediated DNA repair could potentially increase sensitivity to these agents, which induce DNA breaks. On the other hand, the failure to activate cell cycle checkpoints in response to DNA damage could allow damaged tumor cells to avoid apoptosis and survive, leading to chemotherapy resistance. In the case of spindle poisons, BRCA1 has a role in the detection of microtubule disruption and induces apoptosis to prevent aberrant mitosis. Its absence could circumvent this mitotic regulation and thereby enhance sensitivity to spindle poisons. Several in vitro studies have begun to explore potential mechanisms for a differential response of BRCA-related breast cancers to several classes of chemotherapy. There are no clinical data at this time indicating that BRCA-associated cancers should be treated with different chemotherapy than non-BRCA-associated cancers.

Cell lines with inducible expression of BRCA1 were generated to explore its potential role in the cellular response to various chemotherapeutic agents.[112] In the presence of the antimicrotubule agents Taxol and vincristine, expression of BRCA1 resulted in a significant increase in cell death associated with an acute arrest in G2/M, suggesting that BRCA1 expression may be an important mediator of response to antimicrotubule agents by preventing progression of the cell into mitosis. BRCA1-deficient tumors, therefore, may exhibit resistance to this class of drugs.

The ability of BRCA1 to sensitize breast cancer cell lines to G2/M arrest in response to antimicrotubule agents was confirmed in a second study.[113] In contrast, BRCA1 induced resistance to DNA-damaging agents that induce double-strand breaks in DNA. Both of these opposing effects were mediated by inhibition or induction of apoptosis.

It has been shown that cell lines deficient in BRCA1 are defective in homology-directed chromosomal break repair, and highly sensitive to the interstrand cross-linking agent mitomycin-C.[114] Additional evidence supporting a role of BRCA1 in response to DNA-damaging drugs is seen in cisplatinum-resistant breast and ovarian cancer cell lines, in which BRCA1 is overexpressed and DNA repair is enhanced.[115]

Decreasing expression of BRCA1 in cell lines has been associated with increased sensitivity to cisplatinum and etoposide, and resistance to the tubule-damaging agents Taxol and vincristine.[116] Resistance was linked to transcriptional modifications in the JNK pathway which mediates apoptosis. Increased sensitivity to cisplatinum was associated with a time-dependent and dose-dependent increase in apoptosis in a mouse mammary epithelial cell line.[117] Another mechanism suggested for increased cisplatinum sensitivity in BRCA mutant cells is the role of both BRCA1 and BRCA2 in the promotion of subnuclear Rad51 foci for DNA repair.[118] A cell culture model was used to study the interaction of cyclin-dependent kinase 2 (CDK2) inhibition and BRCA1 deficiency.[119] CDK2 is a serine/threonine kinase that has a role in cell cycle control. Inhibitors of CDK2 cause delays in DNA damage signaling. CDK2 inhibition was fourfold more toxic in the presence of BRCA1 mutations, suggesting that CDK2 inhibition may be a sensitive target in patients with BRCA1 mutations. Another specific pathway to exploit in BRCA1/2 deficient tumors is the poly (ADP-ribose) polymerase (PARP) pathway. PARP is active in the repair of double-strand breaks by homologous recombination. In vitro studies have shown that PARP inhibition kills BRCA mutant cells with high specificity. This specificity has not yet been demonstrated in vivo,[120] although phase I studies of PARP inhibitors in combination with chemotherapeutic agents are underway.

Overall, the preclinical data supports the conclusion that BRCA1 inhibits apoptosis after treatment with DNA-damaging agents, and its absence promotes apoptosis leading to increased sensitivity. In contrast, BRCA1 promotes apoptosis after exposure to spindle poisons and its absence supports survival of cells damaged by spindle poisons and thereby confers drug resistance.[121] Similarly, an animal model of Brca2 deficiency in murine small intestine showed a reduction in clonogenic survival after exposure to either cisplatinum or mitomycin C.[122]

Evidence of the role of BRCA1/2 mutations in human studies is retrospective in design and very preliminary. Among 38 women treated with neoadjuvant therapy for stages I-III breast cancer, those with BRCA1/2 mutations were significantly more likely to achieve a clinical and pathological complete response, independent of clinical stage.[123]

Thus the preclinical and clinical data are consistent with the emerging understanding of BRCA1 function in DNA-damage response as well as cell cycle regulation. While these findings raise the possibility that germline status may influence treatment choices, there is insufficient evidence at this time to support treating mutation carriers with different regimens.

Refer to the PDQ summary on Screening for Ovarian Cancer for information on screening in the general population, and to the PDQ summary Cancer Genetics Overview for information on levels of evidence related to screening and prevention. The latter also outlines the five requirements that must be met before it is considered appropriate to screen for a particular medical condition as part of routine medical practice.

In the general population, clinical examination of the ovaries has neither the specificity nor the sensitivity to reliably identify early ovarian cancer. No data exist regarding the benefit of clinical examination of the ovaries (bimanual pelvic examination) in women at inherited risk of ovarian cancer.

Level of evidence: None assigned

In the general population, transvaginal ultrasound (TVUS) appears to be superior to transabdominal ultrasound in the preoperative diagnosis of adnexal masses. Both techniques have lower specificity in premenopausal women than in postmenopausal women, due to the cyclic menstrual changes in premenopausal ovaries (e.g., transient corpus luteum cysts) that can cause difficulty in interpretation. A screening trial of TVUS in 1,300 postmenopausal, asymptomatic women detected abnormalities in 2.5% of women. More than 90% of the lesions found were benign. Women with a family history of ovarian cancer were more likely to be found with an ovarian malignancy (RR = 4.0). No such association was noted for those with a family history of breast cancer or colon cancer.[124]

One study reported on the use of transvaginal color Doppler ultrasonography in the evaluation of 126 women with adnexal masses who subsequently underwent surgery. Twenty epithelial ovarian cancers were detected, as well as two dysgerminomas, two ovarian tumors of low malignant potential, one immature teratoma, and one Sertoli-Leydig cell tumor. It was concluded that color Doppler ultrasonography was able to increase the PPV and negative predictive value (NPV) due to increased sensitivity and specificity of ultrasound evaluation.[125]

Another study reported that the addition of color Doppler ultrasonography was able to increase the PPV of ultrasound imaging from 25% to 60% among women with a personal history of breast cancer undergoing screening for ovarian cancer.[126] As noted, however, clinical studies of color Doppler imaging have shown that normal physiologic changes in the premenopausal ovary near the time of ovulation have low impedance flow characteristics similar to those seen in malignancy.[127]

Data are limited regarding the potential benefit of pelvic ultrasound in screening women at inherited risk of ovarian cancer. A 10-year observational study in the United Kingdom of 2,500 asymptomatic women with at least one relative with ovarian cancer has evaluated TVUS and reported sensitivity and specificity with 10 years of follow-up and retrospective analysis of serum CA 125 levels.[128] Most women were screened once, unless the initial scan was positive or the family history was especially strong. There were 11 screening-detected cancers, one false-negative (a stage III cancer occurring within 12 months of ultrasound screening), and 93 false-positive tests, for a test sensitivity of 92% and a specificity of 97.8%. Among the 11 screening-detected cancers, four were stage IA invasive, four borderline stage IA, one invasive stage IC, and two stage II/III serous carcinomas. Sixty-five percent of the subjects were premenopausal, and 9 of the 12 cancers occurred in this group. TVUS was quite sensitive in this high-risk group, but there were still large numbers of women screened (n = 227) and false-positives (n = 9) for each cancer detected. The retrospective analysis of serum CA 125 levels in this study also allowed its evaluation as a potential first-stage screen to reduce the number of ultrasound tests required and the number of false-positives.[128] If only women with CA 125 levels of 20 or higher were to have undergone ultrasound screening, an additional four cancers would have been missed (sensitivity of 58%), but only 22% of the subjects would have been referred for ultrasound screening, reducing the number of false-positives to 21. Ultrasound screening only of those with CA 125 levels of 35 would have resulted in a sensitivity of 33% (seven additional cancers missed).

Another study evaluated 383 high-risk women (152 BRCA1/2 mutation carriers) with annual TVUS and CA 125.[129] Abnormal screening results were noted in 74 women (19.3%), but these resolved spontaneously in 47 women (63.5%). Of the 20 women undergoing exploratory surgery, only one had cancer, which proved to be a breast cancer metastatic to the ovary. No epithelial ovarian cancers were found as a result of screening.

Another study used gynecologic examination, TVUS, and CA 125 to screen 180 women at high risk of ovarian cancer with or without a prior history of breast cancer. (Refer to the Serum CA 125 section in this summary.) Abnormal ultrasounds were noted in all five women with invasive epithelial ovarian carcinomas. Of these, however, one had stage II disease and four had stage III disease.[130] A study from the Netherlands used annual TVUS and CA 125 to screen 269 women at high risk of hereditary ovarian cancer. Of the four prevalent and four incident cancers found, six were detected at an advanced stage.[131]

One study screened 597 women at risk of ovarian cancer with serum CA 125, TVUS, and color Doppler (described in the Serum CA 125 section). No epithelial ovarian cancers were found. However, one ovarian tumor of low malignant potential was identified.[127,132]

Another study reported screening 386 women with first- or second-degree relatives with ovarian cancer. The study used TVUS, color flow Doppler, and serum CA 125. Initial ultrasound was abnormal in 89 of 381 women (23%). Ovarian masses persisted in 15 patients; all of these were benign at surgery. CA 125 levels were higher than 35 U/mL in 42 of 386 women (11%). Two patients who underwent surgery for rising CA 125 levels had normal ovaries.[133]

Level of evidence: 4

Limited data are available on the potential benefit of screening with serum CA 125 in women at inherited risk of ovarian cancer. When 180 women considered at high risk of ovarian cancer based on family history were screened for ovarian cancer by gynecologic examination, transvaginal ultrasound (TVUS), and serum CA 125, one granulosa cell tumor, three tumors of low malignant potential, and five epithelial ovarian tumors (one stage II and four stage III) were detected. CA 125 levels were elevated in one of the tumors of low malignant potential and in three of the four stage III ovarian carcinomas.[130]

A 10-year observational study of 2,500 asymptomatic women with a family history of ovarian cancer who underwent transvaginal ultrasound screening and retrospective analysis of serum CA 125 levels is described in more detail in the Pelvic Ultrasound section of this summary.[128]

Another study found elevated CA 125 levels in 68 of 597 (11.4%) women screened for ovarian cancer. Most of these women had a first-degree or second-degree relative with ovarian cancer, though 51 had a pedigree consistent with inherited susceptibility to breast or ovarian cancer, and seven had a pedigree consistent with Lynch syndrome. Among the premenopausal patients, the elevations in CA 125 were associated with ultrasonographic evidence of endometriosis, adenomyosis, or leiomyomas. Among the eight postmenopausal patients, all had normal ovarian architecture on ultrasound.[127,132] No data are available to address the effectiveness of ovarian cancer screening in preventing deaths from ovarian cancer.

Level of evidence: 5

The National Institutes of Health (NIH) Consensus Statement on Ovarian Cancer recommended against routine screening of the general population for ovarian cancer with serum CA 125. The NIH Consensus Statement did, however, recommend that women at inherited risk of ovarian cancer undergo TVUS and serum CA 125 screening every 6 to 12 months, beginning at age 35 years.[134] The Cancer Genetics Studies Consortium task force has recommended that female carriers of a deleterious BRCA1 mutation undergo annual or semiannual screening using TVUS and serum CA 125 levels, beginning at age 25 to 35 years.[9] Both recommendations are based solely on expert opinion and best clinical judgment.

In the United States, the National Cancer Institute (NCI) is conducting a large controlled clinical trial in which 74,000 women were randomized to regular medical care or research-based screening for lung, colorectal, and ovarian cancer. The ovarian cancer screening consisted of serum CA 125 (baseline, and annually for 6 years) and TVUS (baseline, and annually for 4 years).[135] NCI's Clinical Genetics Branch, the Gynecologic Oncology Group, and the Cancer Genetics Network are collaborating on a prospective study (GOG-0199) of women at increased genetic risk of ovarian cancer in which risk-reducing surgery and a novel CA 125-based screening strategy are being evaluated.

The PDQ Cancer Screening and Prevention Board has reviewed the evidence related to the efficacy of pelvic examination, TVUS and serum CA 125 screening for ovarian cancer in the general population and concluded “There is inadequate evidence to determine whether routine screening for ovarian cancer…. would result in a decrease in mortality from ovarian cancer.” (Refer to the Ovarian Cancer Screening summary for more information.)

Level of evidence: 5

The need for effective ovarian cancer screening is particularly important for women carrying mutations in BRCA1 and BRCA2, and the mismatch repair genes (e.g., MLH1, MSH2, MSH6, PMS2), disorders in which the risk of ovarian cancer is high. There is a special sense of urgency for BRCA1 mutation carriers, in whom cumulative lifetime risks of ovarian cancer may exceed 40%.

Thus, it is expected that many new ovarian cancer biomarkers (either singly or in combination) will be proposed as ovarian cancer screening strategies during the next 5 to 10 years. While this is an active area of research with a number of promising new biomarkers in early development, it is important to acknowledge that, at present, none of these biomarkers alone or in combination have been sufficiently well studied to justify their routine clinical use for screening purposes, either in the general population or in women at increased genetic risk.

Before addressing information related to emerging ovarian cancer biomarkers, it is important to consider the several steps that are required to develop and, more importantly, validate a new biomarker. One useful framework is that published by NCI Early Detection Research Network investigators.[136] They indicated that the goal of a cancer-screening program is to detect tumors at an early stage so that treatment is likely to be successful. The gold standard by which such programs are judged is whether the death rate from the cancer for which screening is performed is reduced among those being screened. In addition, the screening test must be sufficiently noninvasive and inexpensive to allow widespread use in the population to be screened. Maintaining high test specificity (i.e., few false-positive results) is essential for a population screening test, because even a low false-positive rate results in many people having to undergo unnecessary and costly diagnostic procedures and psychological stress. It is likely that the use of several such cancer biomarkers in combination will be required for a screening test to be both sensitive and specific.

Furthermore, a clinically useful test must have a high PPV (a parameter derived from sensitivity, specificity and disease prevalence in the screened population). Practically speaking, a biomarker with a PPV of 10% implies that ten surgical procedures would be required to identify one case of ovarian cancer; the remaining nine surgeries would represent false-negative test findings. In general, the ovarian cancer research community considers biomarkers with a PPV less than 10% to be clinically unacceptable, given the morbidity related to bilateral salpingo-oophorectomy. Finally, it is important to keep in mind that while novel biomarkers may be present in the sera of women with advanced ovarian cancer (which comprise the vast majority of cases analyzed in the early phases of biomarker development), they may or may not be detectable in women with early stage disease, which is essential if the screening test is to be clinically useful.

It has been suggested that there are five general phases in biomarker development and validation:

Phase I — Preclinical exploratory studies

• Identify potentially discriminating biomarkers.
• Usually done by comparing gene over- or under-expression in tumor compared with normal tissue.
• Since many exploratory analyses in large numbers of genes are performed at this stage, one or more may seem to have good discriminating ability between cancers and normal tissue by random chance alone.

Phase 2 — Clinical assay development for clinical disease

• Develop a clinical assay that can be obtained on noninvasively obtained samples (e.g., a blood specimen).
• Often the test targets the protein product of one of the genes found to be of interest in phase I.
• The goal is to describe the performance characteristics of the assay for distinguishing between subjects with and without cancer. At this point, the assay should be in its final configuration and remain stable throughout the following phases.
• IMPORTANT: Since the case subjects in a phase 2 study already have cancer, with assay results obtained at the time of disease diagnosis, one cannot determine if disease can be detected early with a given biomarker.

Phase 3 — Retrospective longitudinal repository studies

• Compare clinical specimens collected from cancer case subjects before their clinical diagnosis with specimens from subjects who have not developed cancer.
• Evaluate, as a function of time before clinical diagnosis, the biomarker’s ability to detect preclinical disease.
• Define the criteria for a positive screening test in preparation for phase 4.
• Explore the influence of other patient characteristics (e.g., age, gender, smoking status, medication use) on the ability of the biomarker to discriminate between those with and without preclinical disease.

Phase 4 — Prospective screening studies

• Determine the operating characteristics of the biomarker-based screening test in a population for which the test is intended.
• Measure the detection rate (number of abnormal tests among all those with the disease) and the false-positive rate (the number of abnormal tests among all those who do not have the disease).
• Evaluate whether the cancers detected by the test are being found at an early stage, a point at which treatment is more likely to be curative.
• Assess whether the test is acceptable in a population of persons for whom it is intended. Will subjects comply with the test schedule and results?

Phase 5 — Cancer control studies

• Ideally, randomized controlled clinical trials in clinically relevant populations, in which one arm is subjected to screening and appropriate intervention if screen-positive, while the other arm is not screened.
• Determine whether the death rate of the cancer being screened for is reduced among those who use the screening test.
• Obtain information about the costs of screening and treatment of screen-detected cancers.

Finally, for a validated biomarker test to be considered appropriate for use in a particular population, it must have been evaluated in that specific population without prior selection of known positives and negatives. In addition, the test must demonstrate clinical utility, that is, a positive net balance of benefits and risks associated with the application of the test. These may include improved health outcomes, as well as net psychosocial and economic benefits.[137]

Ovarian cancer poses a unique challenge relative to the potential impact of false-positive test results. There are no reliable noninvasive diagnostic tests for early stage disease, and clinically-significant early stage cancer may not be grossly visible at the time of exploratory surgery.[138] Consequently, it is likely that some patients will only be reassured that their abnormal test does not indicate the presence of cancer by having their ovaries and fallopian tubes surgically removed and examined microscopically. High test specificity (i.e., a very low false-positive rate) is required to avoid unnecessary surgery and induction of premature menopause in false positive women.

An ovarian cancer symptom index for predicting the presence of cancer was evaluated in 75 cases and 254 high-risk controls (BRCA mutation carriers or women with a strong family history of breast and ovarian cancer).[139] Women had a positive symptom index if they reported any of the predefined symptoms (bloating or increase in abdominal size, abdominal or pelvic pain, and difficulty eating or feeling full quickly) more than 12 times per month occurring only within the prior 12 months. CA 125 values greater than 30 U/mL were considered abnormal. The symptom index independently predicted the presence of ovarian cancer, after controlling for CA 125 levels (p < 0.05). The combination of an elevated CA 125 and a positive symptom index correctly identified 89.3% of the cases. The symptom index correlated with the presence of cancer in 50% of the affected women who did not have elevated CA 125 levels, but 11.8% of the high-risk controls without cancer also had a positive symptom index. The authors suggested that a composite index including both CA 125 and the symptom index had better performance characteristics than either test used alone, and that this strategy might be used as a first screen in a multi-step screening program. Additional test performance validation and determination of clinical utility are required in unselected screening populations.

Level of evidence: 5

A novel modification of CA 125 screening is based on the hypothesis that rising CA 125 levels over time may provide better ovarian cancer screening performance characteristics than simply classifying CA 125 as normal or abnormal, based on an arbitrary cut-off value. This has been implemented in the form of the Risk of Ovarian Cancer Algorithm (ROCA), an investigational statistical model that incorporates serial CA 125 test results and other covariates into a computation which produces an estimate of the likelihood that ovarian cancer is present in the screened subject. The first report of this strategy – based on reanalysis of 5,550 average-risk women from the Stockholm Ovarian Cancer screening trial – suggested that ovarian cancer cases and controls could be distinguished with 99.7% sensitivity, 83% specificity, and a PPV of 16%. That PPV represents an eight-fold increase over the 2% PPV reported with a single measure of CA 125.[140] This report was followed by applying the risk of ovarian cancer algorithm (ROCA) to 33,621 serial CA 125 values obtained from the 9,233 average-risk postmenopausal women in a prospective British ovarian cancer screening trial.[141] The area under the receiver operator curve increased from 84% to 93% (P = 0.01) for ROCA compared with a fixed CA 125 cutoff. These observations represented the first evidence that preclinical detection of ovarian cancer might be improved using this screening strategy. A prospective study of 13,000 normal volunteers aged 50 years and older in England used serial CA 125 values and the ROCA to stratify participants into low, intermediate and elevated risk subgroups.[142] Each had its own prescribed management strategy, including transvaginal ultrasound and repeat CA 125 either annually (low risk) or at 3 months (intermediate risk). Using this protocol, ROCA was found to have a specificity of 99.8% and a PPV of 19%.

Currently, there are two prospective trials underway in England which utilize the ROCA : the United Kingdom Collaborative Trial of Ovarian Cancer Screening targets normal-risk women randomized either to (1) no screening, (2) annual ultrasound or (3) multimodal screening using the ROCA (n = 202,638; accrual completed; follow-up ends in 2011); and the U.K. Familial Ovarian Cancer Screening Study which targets high-risk women (accrual ongoing). There are also two high-risk cohorts using the ROCA under evaluation in the United States: the Cancer Genetics Network ROCA Study (n = 2,500; follow-up complete; analysis underway), and the Gynecologic Oncology Group Protocol 199 (GOG-0199) (n = 1,575 screening subjects; enrollment complete; follow-up ends in late 2011).[143] Thus, additional data regarding the utility of this currently investigational screening strategy will become available within the next few years.

Level of evidence: 4

A wide array of new candidate ovarian cancer biomarkers has been described during the past decade, including HE4; mesothelin; kallekreins 6, 10, and 11; osteopontin; prostasin; M-CSF ;OVX1; lysophosphatidic acid; vascular endothelial growth factor (VEGF) B7-H4; and interleukins 6 and 8, to name just a few [reviewed in references 9-11].[144-146] These have been singly studied, in combination with CA 125, or in various other permutations. Most of the study populations are relatively small and comprise highly-selected known ovarian cancer cases and healthy controls of the type evaluated in early biomarker development phases I and II. Results have not been consistently replicated in multiple studies; presently, none are considered ready for widespread clinical application.

Level of evidence: 5

Initially, mass spectroscopy of serum proteins was combined with complex analytic algorithms to identify protein patterns that might distinguish between ovarian cancer cases and controls.[147] This approach assumed that pattern recognition alone would be sufficient to permit such discrimination, and that identification of the specific proteins responsible for the patterns identified was not required. Subsequently, this strategy has been modified, using similar laboratory tools, to identify finite numbers of specific known serum markers that may be used in place of, or in conjunction with, CA 125 measurements for the early detection of cancer.[148] These studies[146,149] have generally been small case-control studies that are limited by sample size and the number of early-stage cancer cases included. Further evaluation is needed to determine whether any additional markers identified in this fashion have clinical utility for the early detection of ovarian cancer in the unselected clinical population of interest.

Level of evidence: 5

Because individual biomarkers have not met the criteria for an effective screening test, it has been suggested that it may be necessary to combine multiple ovarian cancer biomarkers in order to obtain satisfactory screening test results. This strategy was employed to quantitatively analyze six serum biomarkers (leptin, prolactin, osteopontin, insulin-like growth factor II, macrophage inhibitory factor, and CA 125), using a multiplex, bead-based platform.[150] A similar assay is available commercially under the trade name OvaSure™.

The cases in this study were newly-diagnosed ovarian cancer patients who had blood collected just prior to surgery: 36 were stage I/II; 120 were stage III/IV. The controls were healthy age-matched individuals who had not developed ovarian cancer within 6 months of blood draw. Neither cases nor controls in this study were well-characterized regarding their familial/genetic risk status, but they have been suggested to comprise a high-risk population.

First, 181 controls and 113 ovarian cancer cases were tested to determine the initial panel of biomarkers that best discriminated between cases and controls (training set). The resulting panel was applied to an additional 181 controls and 43 ovarian cancer cases (test set). Pooling both early and late stage ovarian cancer across the combined training and test sets, performance characteristics were reported as a sensitivity of 95.3% and a specificity of 99.4%, with a PPV of 99.3% and a NPV of 99.2%, using a formula that assumed an ovarian cancer prevalence of about 50%, as seen in the highly-selected research population. In order to avoid biases which may make test performance appear to be better than it really is, it is worth noting that combining training and test populations in analyses of this sort is generally not recommended.[151]

However, the most appropriate prevalence to use is the disease prevalence in the unselected population to be screened. The prevalence of ovarian cancer in the general population is 1 in 2,500. In a recently published correction to their manuscript, the authors assumed that the prevalence of ovarian cancer in the screened population was 1/2500 (0.04%) and recalculated the PPV to be only 6.5%. If this test were used in patients at increased risk of ovarian cancer, the actual prevalence in such a target population is likely to be higher than that observed in the general population, but well below the assumed 50% figure used in the published analysis. This revised PPV of 6.5% indicates that approximately 1 in 15 women with a positive test would in fact have ovarian cancer, and only a fraction of those with ovarian cancer would be stages I or II. The remaining 14 positive tests would represent false-positives, and these women would be at risk of exposure to needless anxiety and potentially morbid diagnostic procedures, including bilateral salpingo-oophorectomy.

Viewed in the context of the criteria previously described,[136] this assay would be classified as phase 2 in its development. While this appears to be a promising avenue of ovarian cancer screening research, additional validation is required, particularly in an unselected population representative of the clinical screening population of interest. A recent position statement by the Society of Gynecologic Oncologists regarding this assay indicated “it is our opinion that additional research is needed to validate the test’s effectiveness before offering it to women outside of the context of a research study conducted with appropriate informed consent under the auspices of an Institutional Review Board.”

Level of evidence: 5

Refer to the PDQ summary on Prevention of Ovarian Cancer for information on prevention in the general population, and to the PDQ summary Cancer Genetics Overview for information on levels of evidence related to screening and prevention.

It has been suggested that incessant ovulation, with repetitive trauma and repair to the ovarian epithelium, increases the risk of ovarian cancer. In epidemiologic studies in the general population, physiologic states that prevent ovulation have been associated with decreased risk of ovarian cancer. It has also been suggested that chronic overstimulation of the ovaries by luteinizing hormone (LH) plays a role in ovarian cancer pathogenesis.[152] Most of these data derive from studies in the general population, but some information suggests the same is true in women at high risk due to genetic predisposition.

Among the general population, parity decreases the risk of ovarian cancer by 45% compared with nulliparity. Subsequent pregnancies after the first appear to decrease ovarian cancer risk by 15%.[153] Earlier studies of women with BRCA1/2 mutations showed that parity decreases the risk of ovarian cancer.[154,155] In a large case-control study, parity was associated with a significant reduction in ovarian cancer risk in women with BRCA1 mutations, OR 0.67 (CI 0.46–0.96).[156] For each birth, BRCA1 mutation carriers had an OR of 0.87 (CI 0.79–0.95). In this same study, parity was associated with an increase in ovarian cancer risk in BRCA2 mutation carriers; however, there was no significant trend for each birth, OR 1.08 (0.90–1.29). Further studies are necessary to define the association of parity and risk of ovarian cancer in BRCA2 mutation carriers, but for BRCA1 carriers, each live birth significantly decreases risk of ovarian cancer, as it does in sporadic ovarian cancer.

In the general population, breast feeding is associated with a decrease in ovarian cancer risk.[157] In BRCA mutation carriers, data are limited. One study found no protective effect with breast feeding.[154] A case-control study among women with BRCA1 or BRCA2 mutations demonstrates a significant reduction in risk of ovarian cancer (OR = 0.39) for women who have had a tubal ligation. This protective effect was confined to those women with mutations in BRCA1 and persists after controlling for oral contraceptive pill use, parity, history of breast cancer, and ethnicity.[158] A case-control study of ovarian cancer in Israel found a 40% to 50% reduced risk of ovarian cancer among women undergoing gynecologic surgeries (tubal ligation, hysterectomy, unilateral oophorectomy, ovarian cystectomy, excluding bilateral oophorectomy).[159] The mechanism of protection is uncertain. Proposed mechanisms of action include decreased blood flow to the ovary, resulting in interruption of ovulation and/or ovarian hormone production; occlusion of the fallopian tube, thus blocking a pathway for potential carcinogens; or a reduction in the concentration of uterine growth factors that reach the ovary.[160] (Refer to the PDQ summary on Prevention of Ovarian Cancer for information relevant to the general population.)

Oral contraceptives have been shown to have a protective effect against ovarian cancer in the general population.[161] Several studies including a large, multicenter case-control study showed a protective effect,[54,156,158,162,163] while one population-based study from Israel failed to demonstrate a protective effect.[155]

A multicenter study of 799 ovarian cancer patients with BRCA1 or BRCA2 mutations, and 2,424 control patients without ovarian cancer but with a BRCA1 or BRCA2 mutation, showed a significant reduction in ovarian cancer risk with use of oral contraceptives, OR 0.56 (CI 0.45–0.71). Compared to never use of oral contraceptives, duration up to one year was associated with an OR of 0.67 (0.50–0.89). The OR for each year of oral contraceptive use was 0.95 (CI 0.92–0.97) with a maximum observed protection at 3 years to 5 years of use. This study included women from a prior study by the same authors and confirmed the results of that prior study.[54] A population-based case-control study of ovarian cancer did not find a protective benefit of oral contraceptive use in BRCA1 or BRCA2 mutation carriers, (OR = 1.07 for ≥5 years of use), though they were protective, as expected, among noncarriers (OR = 0.53 for ≥5 years of use).[155] A small population-based case-control study of 36 BRCA1 mutation carriers, however, observed a similar, protective effect in both mutation carriers and noncarriers (OR = approximately 0.5).[163] Finally, a multicenter study of subjects drawn from numerous registries observed a protective effect of oral contraceptives among the 147 BRCA1 or BRCA2 mutation carriers with ovarian cancer compared with the 304 matched mutation carriers without cancer (OR = 0.62 for ≥6 years of use).[162]

As noted under oral contraceptives in the Breast Cancer Risk Modification section of this summary, there are conflicting data regarding their effect on breast cancer risk, with some retrospective case-control studies suggesting that oral contraceptive use increases the risk of breast cancer in women at inherited risk of breast cancer,[49,164] including BRCA1 mutation carriers,[50] while a population-based study found a reduced risk among BRCA1 mutation carriers.[52]

Level of evidence: 3

Numerous studies have found that women at inherited risk of breast and ovarian cancer have a decreased risk of ovarian cancer following risk-reducing salpingo-oophorectomy (RRSO). A retrospective study of 551 women with disease-associated BRCA1 or BRCA2 mutations found a significant reduction in risk of breast cancer (HR = 0.47; 95% CI, 0.29–0.77) and ovarian cancer (HR = 0.04; 95% CI, 0.01–0.16) after bilateral oophorectomy.[94] A prospective single-institution study of 170 women with BRCA1 or BRCA2 mutations showed a similar trend.[95] With oophorectomy, the HR was 0.15 (95% CI, 0.02–1.31) for ovarian, fallopian tube, or primary peritoneal cancer, and 0.32 (95% CI, 0.08–1.2) for breast cancer; the HR for either cancer was 0.25 (95% CI, 0.08–0.74). In a case-control study in Israel, bilateral oophorectomy was associated with reduced ovarian/peritoneal cancer risks (OR = 0.12; 95% CI, 0.06–0.24).[159]

In addition to a reduction in risk of ovarian and breast cancer, RRSO may also significantly improve overall survival, as well as breast and ovarian cancer specific survival. A prospective cohort study of 666 women with germline mutations in BRCA1 and BRCA2 found an HR for overall mortality of 0.24 (95% CI, 0.08–0.71) in women who had RRSO compared with women who did not.[165] This study provides the first evidence to suggest a survival advantage among women undergoing RRSO.

Studies on the degree of risk reduction afforded by RRSO have begun to clarify the spectrum of occult cancers discovered at the time of surgery. Primary fallopian tube cancers, primary peritoneal cancers, and occult ovarian cancers have all been reported. Several case series have reported a prevalence of malignant findings among mutation carriers undergoing risk-reducing oophorectomy to be in the range of 2.3% to 33%, with a median age of the affected women in the range of 42 to 48 years.[166-170] The wide variation in prevalence is likely due to differences in surgical technique and pathologic handling of the tissues. In addition to occult cancers, premalignant lesions have also been described in fallopian tube tissue removed for prophylaxis. In one series of 12 women with BRCA1 mutations undergoing risk-reducing surgery, 11 had hyperplastic or dysplastic lesions identified in the tubal epithelium. In several of the cases the lesions were multifocal.[171] These pathologic findings are consistent with the identification of germline BRCA1 and BRCA2 mutations in women affected with both tubal and primary peritoneal cancers.[170,172-177] One study suggests a causal relationship between early tubal carcinoma, or tubal intraepithelial carcinoma, and subsequent invasive serous carcinoma of the fallopian tube, ovary or peritoneum.[178]

These findings support the inclusion of fallopian tube cancers, which account for less than 1% of all gynecologic cancers in the general population, as a component of hereditary ovarian cancer, and underscore the need for the routine collection of peritoneal washings and careful pathologic evaluation of all tissue obtained at the time of risk-reducing surgery. They also raise questions about the optimal surgical approach to provide maximal cancer risk reduction. Some surgeons have recommended hysterectomy in addition to RRSO to remove the remnant of fallopian tube tissue embedded in the uterus, but there is no consensus on this issue, and most, if not all, fallopian tubes cancers appear to arise in the more distal segments of the tube.[170] Several studies have examined whether BRCA1 or BRCA2 mutation carriers are at increased risk of endometrial cancer.[179-183] While case reports and smaller studies suggested an association between BRCA mutations and a specific histology of endometrial cancer called uterine papillary serous cancer,[180] other studies have not found an increased risk of either uterine papillary serous cancer or endometrial cancer in BRCA1 or BRCA2 mutation carriers.[181,182] One cohort study of 857 BRCA1 or BRCA2 mutation carriers reported an increased endometrial cancer risk but found that this risk was largely due to tamoxifen use associated with breast cancer treatment.[183] Therefore, in the absence of tamoxifen use or other underlying uterine or cervical problems, hysterectomy is not a necessary component of risk–reducing salpingo-oophorectomy.

The peritoneum, however, appears to remain at low risk for the development of a Mullerian-type adenocarcinoma, even after oophorectomy.[184-188] Of the 324 women from the Gilda Radner Familial Ovarian Cancer Registry who underwent risk-reducing oophorectomy, six (1.8%) subsequently developed primary peritoneal carcinoma. No period of follow-up was specified.[189] Among 238 individuals in the Creighton Registry with BRCA1/2 mutations who underwent risk-reducing oophorectomy, five subsequently developed intra-abdominal carcinomatosis (2.1%). Of note, all five of these women had BRCA1 mutations.[190] A study of 1,828 women with a BRCA1 or BRCA2 mutation found a 4.3% risk of primary peritoneal cancer at 20 years after RRSO.[191]

Given the current limitations of screening for ovarian cancer and the high risk for the disease in BRCA1 and BRCA2 mutation carriers, NCCN Guidelines recommend RRSO between the ages of 35 and 40 years or upon completion of childbearing, as an effective risk-reduction option. Optimal timing of RRSO must be individualized, but evaluating a woman's risk for ovarian cancer based on mutation status can be helpful in the decision-making process. In a large study of U.S. BRCA1 and BRCA2 families, age-specific cumulative risk of ovarian cancer at age 40 years was 4.7% for BRCA1 mutation carriers and 1.9% for BRCA2 mutation carriers.[192] In a combined analysis of 22 studies of BRCA1 and BRCA2 mutation carriers, risk of ovarian cancer for BRCA1 mutation carriers increases most sharply between the ages of 40 years and 50 years, while for BRCA2 mutation carriers the risk is low before age 50 years, but increases sharply between the ages of 50 years and 60 years.[193] In a population-based study of BRCA mutations in ovarian cancer patients, patients with BRCA2 mutations had a significantly later age of onset than patients with BRCA1 mutations (57.3 years [40-72] vs. 52.6 [31-78]).[194] In summary, women with BRCA1 mutations may consider RRSO for ovarian cancer risk reduction at a somewhat earlier age than women with BRCA2 mutations; however, women with BRCA2 mutations may still consider early RRSO for breast cancer risk reduction.

For women who are premenopausal at the time of surgery, the symptoms of surgical menopause (e.g., hot flashes, mood swings, weight gain, and genitourinary complaints) can cause a significant impairment in their quality of life. To reduce the impact of these symptoms, providers have often prescribed a time-limited course of systemic HRT after surgery. The effect of HRT on breast cancer risk among carriers of a BRCA1 or BRCA2 mutation has only been studied in the context of risk-reducing oophorectomy, a procedure known to reduce the risk of breast cancer. In a prospective study of 462 women with BRCA1 or BRCA2 mutations, 155 who had undergone bilateral oophorectomy (139 before age 50 years), the breast cancer risk reduction of 37% was essentially the same among the 93 women who took HRT compared with the reduction of 38% among those without HRT.[64] This finding needs to be confirmed in a larger study but suggests that HRT in this particular setting does not negate the protective effect of oophorectomy on breast cancer risk.

Studies have examined the effect of RRSO on quality of life (QOL). One study examined 846 high-risk women of whom 44% underwent RRSO and 56% had periodic screening.[195] Of the 368 BRCA1/2 mutation carriers, 72% underwent RRSO. No significant differences were observed in QOL scores (as assessed by the Short Form-36) between those with RRSO or screening or compared with the general population; however, women with RRSO had fewer breast and ovarian cancer worries (P < .001), more favorable cancer risk perception (P < .05) but more endocrine symptoms (P < .001) and worse sexual functioning (P < .05). Of note, 37% of women used HRT following RRSO, although 62% were either peri-menopausal or postmenopausal.[195] Researchers then examined 450 premenopausal high-risk women who had chosen either RRSO (36%) or screening (64%). Of those in the RRSO group, 47% used HRT. HRT users (n = 77) had fewer vasomotor symptoms than nonusers (n = 87) (p<0.05), although more vasomotor symptoms than women in the screening group (n = 286). Likewise, women who underwent RRSO and used HRT had more sexual discomfort due to vaginal dryness and dyspareunia than those in the screening group (p < 0.01). Therefore, while such symptoms are improved via HRT use, HRT is not completely effective and additional work needs to be done.

References

1. U.S. Preventive Services Task Force.: Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med 143 (5): 355-61, 2005.  [PUBMED Abstract]
   
   
2. American College of Medical Genetics.: Genetic susceptibility to breast and ovarian cancer: assessment, counseling and testing guidelines. New York: New York State Department of Health, American College of Medical Genetics Foundation, 1999. Also available online. Last accessed March 8, 2007. 
   
   
3. National Comprehensive Cancer Network.: NCCN Clinical Practice Guidelines in Oncology: Genetic/Familial High-Risk Assessment: Breast and Ovarian. Version 1.2006. Rockledge, PA : National Comprehensive Cancer Network, 2006. Available online. Last accessed March 8, 2007. 
   
   
4. American Society of Clinical Oncology.: American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol 21 (12): 2397-406, 2003.  [PUBMED Abstract]
   
   
5. ACOG committee opinion. Breast-ovarian cancer screening. Number 239, August 2000. American College of Obstetricians and Gynecologists. Committee on genetics. Int J Gynaecol Obstet 75 (3): 339-40, 2001.  [PUBMED Abstract]
   
   
6. Thomas DB, Gao DL, Self SG, et al.: Randomized trial of breast self-examination in Shanghai: methodology and preliminary results. J Natl Cancer Inst 89 (5): 355-65, 1997.  [PUBMED Abstract]
   
   
7. Scheuer L, Kauff N, Robson M, et al.: Outcome of preventive surgery and screening for breast and ovarian cancer in BRCA mutation carriers. J Clin Oncol 20 (5): 1260-8, 2002.  [PUBMED Abstract]
   
   
8. Brekelmans CT, Seynaeve C, Bartels CC, et al.: Effectiveness of breast cancer surveillance in BRCA1/2 gene mutation carriers and women with high familial risk. J Clin Oncol 19 (4): 924-30, 2001.  [PUBMED Abstract]
   
   
9. Burke W, Daly M, Garber J, et al.: Recommendations for follow-up care of individuals with an inherited predisposition to cancer. II. BRCA1 and BRCA2. Cancer Genetics Studies Consortium. JAMA 277 (12): 997-1003, 1997.  [PUBMED Abstract]
   
   
10. Shapiro S: Periodic screening for breast cancer: the Health Insurance Plan project and its sequelae, 1963-1986. Baltimore, Md: Johns Hopkins University Press, 1988. 
    
    
11. Kerlikowske K, Grady D, Barclay J, et al.: Effect of age, breast density, and family history on the sensitivity of first screening mammography. JAMA 276 (1): 33-8, 1996.  [PUBMED Abstract]
    
    
12. Kerlikowske K, Carney PA, Geller B, et al.: Performance of screening mammography among women with and without a first-degree relative with breast cancer. Ann Intern Med 133 (11): 855-63, 2000.  [PUBMED Abstract]
    
    
13. Kerlikowske K, Grady D, Barclay J, et al.: Positive predictive value of screening mammography by age and family history of breast cancer. JAMA 270 (20): 2444-50, 1993.  [PUBMED Abstract]
    
    
14. Tilanus-Linthorst M, Verhoog L, Obdeijn IM, et al.: A BRCA1/2 mutation, high breast density and prominent pushing margins of a tumor independently contribute to a frequent false-negative mammography. Int J Cancer 102 (1): 91-5, 2002.  [PUBMED Abstract]
    
    
15. Tilanus-Linthorst MM, Kriege M, Boetes C, et al.: Hereditary breast cancer growth rates and its impact on screening policy. Eur J Cancer 41 (11): 1610-7, 2005.  [PUBMED Abstract]
    
    
16. Mitchell G, Antoniou AC, Warren R, et al.: Mammographic density and breast cancer risk in BRCA1 and BRCA2 mutation carriers. Cancer Res 66 (3): 1866-72, 2006.  [PUBMED Abstract]
    
    
17. Miller AB, To T, Baines CJ, et al.: Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst 92 (18): 1490-9, 2000.  [PUBMED Abstract]
    
    
18. Sharan SK, Morimatsu M, Albrecht U, et al.: Embryonic lethality and radiation hypersensitivity mediated by Rad51 in mice lacking Brca2. Nature 386 (6627): 804-10, 1997.  [PUBMED Abstract]
    
    
19. Gowen LC, Avrutskaya AV, Latour AM, et al.: BRCA1 required for transcription-coupled repair of oxidative DNA damage. Science 281 (5379): 1009-12, 1998.  [PUBMED Abstract]
    
    
20. Abbott DW, Freeman ML, Holt JT: Double-strand break repair deficiency and radiation sensitivity in BRCA2 mutant cancer cells. J Natl Cancer Inst 90 (13): 978-85, 1998.  [PUBMED Abstract]
    
    
21. Andrieu N, Easton DF, Chang-Claude J, et al.: Effect of chest X-rays on the risk of breast cancer among BRCA1/2 mutation carriers in the international BRCA1/2 carrier cohort study: a report from the EMBRACE, GENEPSO, GEO-HEBON, and IBCCS Collaborators' Group. J Clin Oncol 24 (21): 3361-6, 2006.  [PUBMED Abstract]
    
    
22. Narod SA, Lubinski J, Ghadirian P, et al.: Screening mammography and risk of breast cancer in BRCA1 and BRCA2 mutation carriers: a case-control study. Lancet Oncol 7 (5): 402-6, 2006.  [PUBMED Abstract]
    
    
23. Goldfrank D, Chuai S, Bernstein JL, et al.: Effect of mammography on breast cancer risk in women with mutations in BRCA1 or BRCA2. Cancer Epidemiol Biomarkers Prev 15 (11): 2311-3, 2006.  [PUBMED Abstract]
    
    
24. Kuhl CK, Schrading S, Leutner CC, et al.: Surveillance of "high risk" women with proven or suspected familial (hereditary) breast cancer: First midterm results of a multi-modality clinical screening trial . [Abstract] Proceedings of the American Society of Clinical Oncology 22: A-4, 2, 2003.. 
    
    
25. Kriege M, Brekelmans CT, Boetes C, et al.: Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med 351 (5): 427-37, 2004.  [PUBMED Abstract]
    
    
26. Lehman CD, Blume JD, Weatherall P, et al.: Screening women at high risk for breast cancer with mammography and magnetic resonance imaging. Cancer 103 (9): 1898-905, 2005.  [PUBMED Abstract]
    
    
27. Leach MO, Boggis CR, Dixon AK, et al.: Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS). Lancet 365 (9473): 1769-78, 2005 May 21-27.  [PUBMED Abstract]
    
    
28. Warner E, Plewes DB, Hill KA, et al.: Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA 292 (11): 1317-25, 2004.  [PUBMED Abstract]
    
    
29. Lehman CD, Isaacs C, Schnall MD, et al.: Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening study. Radiology 244 (2): 381-8, 2007.  [PUBMED Abstract]
    
    
30. Sardanelli F, Podo F, D'Agnolo G, et al.: Multicenter comparative multimodality surveillance of women at genetic-familial high risk for breast cancer (HIBCRIT study): interim results. Radiology 242 (3): 698-715, 2007.  [PUBMED Abstract]
    
    
31. Lord SJ, Lei W, Craft P, et al.: A systematic review of the effectiveness of magnetic resonance imaging (MRI) as an addition to mammography and ultrasound in screening young women at high risk of breast cancer. Eur J Cancer 43 (13): 1905-17, 2007.  [PUBMED Abstract]
    
    
32. Saslow D, Boetes C, Burke W, et al.: American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 57 (2): 75-89, 2007 Mar-Apr.  [PUBMED Abstract]
    
    
33. Kuhl CK, Schrading S, Leutner CC, et al.: Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol 23 (33): 8469-76, 2005.  [PUBMED Abstract]
    
    
34. O'Driscoll D, Warren R, MacKay J, et al.: Screening with breast ultrasound in a population at moderate risk due to family history. J Med Screen 8 (2): 106-9, 2001.  [PUBMED Abstract]
    
    
35. Shtern F: Digital mammography and related technologies: a perspective from the National Cancer Institute. Radiology 183 (3): 629-30, 1992.  [PUBMED Abstract]
    
    
36. Lewin JM, D'Orsi CJ, Hendrick RE, et al.: Clinical comparison of full-field digital mammography and screen-film mammography for detection of breast cancer. AJR Am J Roentgenol 179 (3): 671-7, 2002.  [PUBMED Abstract]
    
    
37. Pisano ED, Gatsonis C, Hendrick E, et al.: Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med 353 (17): 1773-83, 2005.  [PUBMED Abstract]
    
    
38. Colditz GA, Rosner BA, Speizer FE: Risk factors for breast cancer according to family history of breast cancer. For the Nurses' Health Study Research Group. J Natl Cancer Inst 88 (6): 365-71, 1996.  [PUBMED Abstract]
    
    
39. Narod S, Lynch H, Conway T, et al.: Increasing incidence of breast cancer in family with BRCA1 mutation. Lancet 341 (8852): 1101-2, 1993.  [PUBMED Abstract]
    
    
40. Narod SA, Goldgar D, Cannon-Albright L, et al.: Risk modifiers in carriers of BRCA1 mutations. Int J Cancer 64 (6): 394-8, 1995.  [PUBMED Abstract]
    
    
41. McCredie M, Paul C, Skegg DC, et al.: Family history and risk of breast cancer in New Zealand. Int J Cancer 73 (4): 503-7, 1997.  [PUBMED Abstract]
    
    
42. Andrieu N, Goldgar DE, Easton DF, et al.: Pregnancies, breast-feeding, and breast cancer risk in the International BRCA1/2 Carrier Cohort Study (IBCCS). J Natl Cancer Inst 98 (8): 535-44, 2006.  [PUBMED Abstract]
    
    
43. Jernström H, Lerman C, Ghadirian P, et al.: Pregnancy and risk of early breast cancer in carriers of BRCA1 and BRCA2. Lancet 354 (9193): 1846-50, 1999.  [PUBMED Abstract]
    
    
44. Cullinane CA, Lubinski J, Neuhausen SL, et al.: Effect of pregnancy as a risk factor for breast cancer in BRCA1/BRCA2 mutation carriers. Int J Cancer 117 (6): 988-91, 2005.  [PUBMED Abstract]
    
    
45. Friedman E, Kotsopoulos J, Lubinski J, et al.: Spontaneous and therapeutic abortions and the risk of breast cancer among BRCA mutation carriers. Breast Cancer Res 8 (2): R15, 2006.  [PUBMED Abstract]
    
    
46. Collaborative Group on Hormonal Factors in Breast Cancer.: Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet 360 (9328): 187-95, 2002.  [PUBMED Abstract]
    
    
47. Jernström H, Lubinski J, Lynch HT, et al.: Breast-feeding and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst 96 (14): 1094-8, 2004.  [PUBMED Abstract]
    
    
48. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies. Collaborative Group on Hormonal Factors in Breast Cancer. Lancet 347 (9017): 1713-27, 1996.  [PUBMED Abstract]
    
    
49. Ursin G, Henderson BE, Haile RW, et al.: Does oral contraceptive use increase the risk of breast cancer in women with BRCA1/BRCA2 mutations more than in other women? Cancer Res 57 (17): 3678-81, 1997.  [PUBMED Abstract]
    
    
50. Narod SA, Dubé MP, Klijn J, et al.: Oral contraceptives and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst 94 (23): 1773-9, 2002.  [PUBMED Abstract]
    
    
51. Jernström H, Loman N, Johannsson OT, et al.: Impact of teenage oral contraceptive use in a population-based series of early-onset breast cancer cases who have undergone BRCA mutation testing. Eur J Cancer 41 (15): 2312-20, 2005.  [PUBMED Abstract]
    
    
52. Milne RL, Knight JA, John EM, et al.: Oral contraceptive use and risk of early-onset breast cancer in carriers and noncarriers of BRCA1 and BRCA2 mutations. Cancer Epidemiol Biomarkers Prev 14 (2): 350-6, 2005.  [PUBMED Abstract]
    
    
53. Olsson H, Jernström H, Alm P, et al.: Proliferation of the breast epithelium in relation to menstrual cycle phase, hormonal use, and reproductive factors. Breast Cancer Res Treat 40 (2): 187-96, 1996.  [PUBMED Abstract]
    
    
54. Narod SA, Risch H, Moslehi R, et al.: Oral contraceptives and the risk of hereditary ovarian cancer. Hereditary Ovarian Cancer Clinical Study Group. N Engl J Med 339 (7): 424-8, 1998.  [PUBMED Abstract]
    
    
55. Chen CL, Weiss NS, Newcomb P, et al.: Hormone replacement therapy in relation to breast cancer. JAMA 287 (6): 734-41, 2002.  [PUBMED Abstract]
    
    
56. Writing Group for the Women's Health Initiative Investigators.: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 288 (3): 321-33, 2002.  [PUBMED Abstract]
    
    
57. Chlebowski RT, Hendrix SL, Langer RD, et al.: Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women's Health Initiative Randomized Trial. JAMA 289 (24): 3243-53, 2003.  [PUBMED Abstract]
    
    
58. Schuurman AG, van den Brandt PA, Goldbohm RA: Exogenous hormone use and the risk of postmenopausal breast cancer: results from The Netherlands Cohort Study. Cancer Causes Control 6 (5): 416-24, 1995.  [PUBMED Abstract]
    
    
59. Steinberg KK, Thacker SB, Smith SJ, et al.: A meta-analysis of the effect of estrogen replacement therapy on the risk of breast cancer. JAMA 265 (15): 1985-90, 1991.  [PUBMED Abstract]
    
    
60. Colditz GA, Egan KM, Stampfer MJ: Hormone replacement therapy and risk of breast cancer: results from epidemiologic studies. Am J Obstet Gynecol 168 (5): 1473-80, 1993.  [PUBMED Abstract]
    
    
61. Sellers TA, Mink PJ, Cerhan JR, et al.: The role of hormone replacement therapy in the risk for breast cancer and total mortality in women with a family history of breast cancer. Ann Intern Med 127 (11): 973-80, 1997.  [PUBMED Abstract]
    
    
62. Stanford JL, Weiss NS, Voigt LF, et al.: Combined estrogen and progestin hormone replacement therapy in relation to risk of breast cancer in middle-aged women. JAMA 274 (2): 137-42, 1995.  [PUBMED Abstract]
    
    
63. Gorsky RD, Koplan JP, Peterson HB, et al.: Relative risks and benefits of long-term estrogen replacement therapy: a decision analysis. Obstet Gynecol 83 (2): 161-6, 1994.  [PUBMED Abstract]
    
    
64. Rebbeck TR, Friebel T, Wagner T, et al.: Effect of short-term hormone replacement therapy on breast cancer risk reduction after bilateral prophylactic oophorectomy in BRCA1 and BRCA2 mutation carriers: the PROSE Study Group. J Clin Oncol 23 (31): 7804-10, 2005.  [PUBMED Abstract]
    
    
65. Fisher B, Costantino JP, Wickerham DL, et al.: Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 90 (18): 1371-88, 1998.  [PUBMED Abstract]
    
    
66. Veronesi U, Maisonneuve P, Costa A, et al.: Prevention of breast cancer with tamoxifen: preliminary findings from the Italian randomised trial among hysterectomised women. Italian Tamoxifen Prevention Study. Lancet 352 (9122): 93-7, 1998.  [PUBMED Abstract]
    
    
67. Powles T, Eeles R, Ashley S, et al.: Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomised chemoprevention trial. Lancet 352 (9122): 98-101, 1998.  [PUBMED Abstract]
    
    
68. King MC, Wieand S, Hale K, et al.: Tamoxifen and breast cancer incidence among women with inherited mutations in BRCA1 and BRCA2: National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) Breast Cancer Prevention Trial. JAMA 286 (18): 2251-6, 2001.  [PUBMED Abstract]
    
    
69. Narod SA, Brunet JS, Ghadirian P, et al.: Tamoxifen and risk of contralateral breast cancer in BRCA1 and BRCA2 mutation carriers: a case-control study. Hereditary Breast Cancer Clinical Study Group. Lancet 356 (9245): 1876-81, 2000.  [PUBMED Abstract]
    
    
70. Pierce LJ, Levin AM, Rebbeck TR, et al.: Ten-year multi-institutional results of breast-conserving surgery and radiotherapy in BRCA1/2-associated stage I/II breast cancer. J Clin Oncol 24 (16): 2437-43, 2006.  [PUBMED Abstract]
    
    
71. Gronwald J, Tung N, Foulkes WD, et al.: Tamoxifen and contralateral breast cancer in BRCA1 and BRCA2 carriers: an update. Int J Cancer 118 (9): 2281-4, 2006.  [PUBMED Abstract]
    
    
72. Vogel VG, Costantino JP, Wickerham DL, et al.: Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes: the NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 trial. JAMA 295 (23): 2727-41, 2006.  [PUBMED Abstract]
    
    
73. Land SR, Wickerham DL, Costantino JP, et al.: Patient-reported symptoms and quality of life during treatment with tamoxifen or raloxifene for breast cancer prevention: the NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 trial. JAMA 295 (23): 2742-51, 2006.  [PUBMED Abstract]
    
    
74. Ariyan S: Prophylactic mastectomy for precancerous and high-risk lesions of the breast. Can J Surg 28 (3): 262-4, 266, 1985.  [PUBMED Abstract]
    
    
75. Hartmann LC, Schaid DJ, Woods JE, et al.: Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 340 (2): 77-84, 1999.  [PUBMED Abstract]
    
    
76. Hartmann LC, Sellers TA, Schaid DJ, et al.: Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers. J Natl Cancer Inst 93 (21): 1633-7, 2001.  [PUBMED Abstract]
    
    
77. Meijers-Heijboer H, van Geel B, van Putten WL, et al.: Breast cancer after prophylactic bilateral mastectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med 345 (3): 159-64, 2001.  [PUBMED Abstract]
    
    
78. Rebbeck TR, Friebel T, Lynch HT, et al.: Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE Study Group. J Clin Oncol 22 (6): 1055-62, 2004.  [PUBMED Abstract]
    
    
79. van Sprundel TC, Schmidt MK, Rookus MA, et al.: Risk reduction of contralateral breast cancer and survival after contralateral prophylactic mastectomy in BRCA1 or BRCA2 mutation carriers. Br J Cancer 93 (3): 287-92, 2005.  [PUBMED Abstract]
    
    
80. Kauff ND, Brogi E, Scheuer L, et al.: Epithelial lesions in prophylactic mastectomy specimens from women with BRCA mutations. Cancer 97 (7): 1601-8, 2003.  [PUBMED Abstract]
    
    
81. Hoogerbrugge N, Bult P, de Widt-Levert LM, et al.: High prevalence of premalignant lesions in prophylactically removed breasts from women at hereditary risk for breast cancer. J Clin Oncol 21 (1): 41-5, 2003.  [PUBMED Abstract]
    
    
82. Scott CI, Iorgulescu DG, Thorne HJ, et al.: Clinical, pathological and genetic features of women at high familial risk of breast cancer undergoing prophylactic mastectomy. Clin Genet 64 (2): 111-21, 2003.  [PUBMED Abstract]
    
    
83. Adem C, Reynolds C, Soderberg CL, et al.: Pathologic characteristics of breast parenchyma in patients with hereditary breast carcinoma, including BRCA1 and BRCA2 mutation carriers. Cancer 97 (1): 1-11, 2003.  [PUBMED Abstract]
    
    
84. Lerman C, Hughes C, Croyle RT, et al.: Prophylactic surgery decisions and surveillance practices one year following BRCA1/2 testing. Prev Med 31 (1): 75-80, 2000.  [PUBMED Abstract]
    
    
85. Stefanek ME, Helzlsouer KJ, Wilcox PM, et al.: Predictors of and satisfaction with bilateral prophylactic mastectomy. Prev Med 24 (4): 412-9, 1995.  [PUBMED Abstract]
    
    
86. Schrag D, Kuntz KM, Garber JE, et al.: Decision analysis--effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 or BRCA2 mutations. N Engl J Med 336 (20): 1465-71, 1997.  [PUBMED Abstract]
    
    
87. Unic I, Stalmeier PF, Verhoef LC, et al.: Assessment of the time-tradeoff values for prophylactic mastectomy of women with a suspected genetic predisposition to breast cancer. Med Decis Making 18 (3): 268-77, 1998 Jul-Sep.  [PUBMED Abstract]
    
    
88. Grann VR, Panageas KS, Whang W, et al.: Decision analysis of prophylactic mastectomy and oophorectomy in BRCA1-positive or BRCA2-positive patients. J Clin Oncol 16 (3): 979-85, 1998.  [PUBMED Abstract]
    
    
89. Meijers-Heijboer EJ, Verhoog LC, Brekelmans CT, et al.: Presymptomatic DNA testing and prophylactic surgery in families with a BRCA1 or BRCA2 mutation. Lancet 355 (9220): 2015-20, 2000.  [PUBMED Abstract]
    
    
90. Giuliano AE, Boolbol S, Degnim A, et al.: Society of Surgical Oncology: position statement on prophylactic mastectomy. Approved by the Society of Surgical Oncology Executive Council, March 2007. Ann Surg Oncol 14 (9): 2425-7, 2007.  [PUBMED Abstract]
    
    
91. Olson JE, Sellers TA, Iturria SJ, et al.: Bilateral oophorectomy and breast cancer risk reduction among women with a family history. Cancer Detect Prev 28 (5): 357-60, 2004.  [PUBMED Abstract]
    
    
92. Struewing JP, Watson P, Easton DF, et al.: Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr (17): 33-5, 1995.  [PUBMED Abstract]
    
    
93. Rebbeck TR, Levin AM, Eisen A, et al.: Breast cancer risk after bilateral prophylactic oophorectomy in BRCA1 mutation carriers. J Natl Cancer Inst 91 (17): 1475-9, 1999.  [PUBMED Abstract]
    
    
94. Rebbeck TR, Lynch HT, Neuhausen SL, et al.: Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med 346 (21): 1616-22, 2002.  [PUBMED Abstract]
    
    
95. Kauff ND, Satagopan JM, Robson ME, et al.: Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med 346 (21): 1609-15, 2002.  [PUBMED Abstract]
    
    
96. Chabner E, Nixon A, Gelman R, et al.: Family history and treatment outcome in young women after breast-conserving surgery and radiation therapy for early-stage breast cancer. J Clin Oncol 16 (6): 2045-51, 1998.  [PUBMED Abstract]
    
    
97. Leonard CE, Sedlacek S, Shapiro H, et al.: Lumpectomy and breast radiotherapy in breast cancer patients with a family history of breast cancer, ovarian cancer, or both. Breast J 8 (3): 154-61, 2002 May-Jun.  [PUBMED Abstract]
    
    
98. Freedman LM, Buchholz TA, Thames HD, et al.: Local-regional control in breast cancer patients with a possible genetic predisposition. Int J Radiat Oncol Biol Phys 48 (4): 951-7, 2000.  [PUBMED Abstract]
    
    
99. Harrold EV, Turner BC, Matloff ET, et al.: Local recurrence in the conservatively treated breast cancer patient: a correlation with age and family history. Cancer J Sci Am 4 (5): 302-7, 1998 Sep-Oct.  [PUBMED Abstract]
    
    
100. Haas JA, Schultz DJ, Peterson ME, et al.: An analysis of age and family history on outcome after breast-conservation treatment: the University of Pennsylvania experience. Cancer J Sci Am 4 (5): 308-15, 1998 Sep-Oct.  [PUBMED Abstract]
     
     
101. Robson ME, Chappuis PO, Satagopan J, et al.: A combined analysis of outcome following breast cancer: differences in survival based on BRCA1/BRCA2 mutation status and administration of adjuvant treatment. Breast Cancer Res 6 (1): R8-R17, 2004.  [PUBMED Abstract]
     
     
102. Robson M, Svahn T, McCormick B, et al.: Appropriateness of breast-conserving treatment of breast carcinoma in women with germline mutations in BRCA1 or BRCA2: a clinic-based series. Cancer 103 (1): 44-51, 2005.  [PUBMED Abstract]
     
     
103. Seynaeve C, Verhoog LC, van de Bosch LM, et al.: Ipsilateral breast tumour recurrence in hereditary breast cancer following breast-conserving therapy. Eur J Cancer 40 (8): 1150-8, 2004.  [PUBMED Abstract]
     
     
104. Metcalfe K, Lynch HT, Ghadirian P, et al.: Contralateral breast cancer in BRCA1 and BRCA2 mutation carriers. J Clin Oncol 22 (12): 2328-35, 2004.  [PUBMED Abstract]
     
     
105. Haffty BG, Harrold E, Khan AJ, et al.: Outcome of conservatively managed early-onset breast cancer by BRCA1/2 status. Lancet 359 (9316): 1471-7, 2002.  [PUBMED Abstract]
     
     
106. Vaidya JS, Baum M: Management of early-onset breast cancer and BRCA1 or BRCA2 status. Lancet 360 (9333): 640; author reply 640-1, 2002.  [PUBMED Abstract]
     
     
107. Alpert TE, Haffty BG: Conservative management of breast cancer in BRCA1/2 mutation carriers. Clin Breast Cancer 5 (1): 37-42, 2004.  [PUBMED Abstract]
     
     
108. Shen SX, Weaver Z, Xu X, et al.: A targeted disruption of the murine Brca1 gene causes gamma-irradiation hypersensitivity and genetic instability. Oncogene 17 (24): 3115-24, 1998.  [PUBMED Abstract]
     
     
109. Leong T, Whitty J, Keilar M, et al.: Mutation analysis of BRCA1 and BRCA2 cancer predisposition genes in radiation hypersensitive cancer patients. Int J Radiat Oncol Biol Phys 48 (4): 959-65, 2000.  [PUBMED Abstract]
     
     
110. Pierce LJ, Strawderman M, Narod SA, et al.: Effect of radiotherapy after breast-conserving treatment in women with breast cancer and germline BRCA1/2 mutations. J Clin Oncol 18 (19): 3360-9, 2000.  [PUBMED Abstract]
     
     
111. Shanley S, McReynolds K, Ardern-Jones A, et al.: Late toxicity is not increased in BRCA1/BRCA2 mutation carriers undergoing breast radiotherapy in the United Kingdom. Clin Cancer Res 12 (23): 7025-32, 2006.  [PUBMED Abstract]
     
     
112. Mullan PB, Quinn JE, Gilmore PM, et al.: BRCA1 and GADD45 mediated G2/M cell cycle arrest in response to antimicrotubule agents. Oncogene 20 (43): 6123-31, 2001.  [PUBMED Abstract]
     
     
113. Quinn JE, Kennedy RD, Mullan PB, et al.: BRCA1 functions as a differential modulator of chemotherapy-induced apoptosis. Cancer Res 63 (19): 6221-8, 2003.  [PUBMED Abstract]
     
     
114. Moynahan ME, Cui TY, Jasin M: Homology-directed dna repair, mitomycin-c resistance, and chromosome stability is restored with correction of a Brca1 mutation. Cancer Res 61 (12): 4842-50, 2001.  [PUBMED Abstract]
     
     
115. Husain A, He G, Venkatraman ES, et al.: BRCA1 up-regulation is associated with repair-mediated resistance to cis-diamminedichloroplatinum(II). Cancer Res 58 (6): 1120-3, 1998.  [PUBMED Abstract]
     
     
116. Lafarge S, Sylvain V, Ferrara M, et al.: Inhibition of BRCA1 leads to increased chemoresistance to microtubule-interfering agents, an effect that involves the JNK pathway. Oncogene 20 (45): 6597-606, 2001.  [PUBMED Abstract]
     
     
117. Sgagias MK, Wagner KU, Hamik B, et al.: Brca1-deficient murine mammary epithelial cells have increased sensitivity to CDDP and MMS. Cell Cycle 3 (11): 1451-6, 2004.  [PUBMED Abstract]
     
     
118. Bhattacharyya A, Ear US, Koller BH, et al.: The breast cancer susceptibility gene BRCA1 is required for subnuclear assembly of Rad51 and survival following treatment with the DNA cross-linking agent cisplatin. J Biol Chem 275 (31): 23899-903, 2000.  [PUBMED Abstract]
     
     
119. Deans AJ, Khanna KK, McNees CJ, et al.: Cyclin-dependent kinase 2 functions in normal DNA repair and is a therapeutic target in BRCA1-deficient cancers. Cancer Res 66 (16): 8219-26, 2006.  [PUBMED Abstract]
     
     
120. De Soto JA, Wang X, Tominaga Y, et al.: The inhibition and treatment of breast cancer with poly (ADP-ribose) polymerase (PARP-1) inhibitors. Int J Biol Sci 2 (4): 179-85, 2006.  [PUBMED Abstract]
     
     
121. Kennedy RD, Quinn JE, Mullan PB, et al.: The role of BRCA1 in the cellular response to chemotherapy. J Natl Cancer Inst 96 (22): 1659-68, 2004.  [PUBMED Abstract]
     
     
122. Hay T, Patrick T, Winton D, et al.: Brca2 deficiency in the murine small intestine sensitizes to p53-dependent apoptosis and leads to the spontaneous deletion of stem cells. Oncogene 24 (23): 3842-6, 2005.  [PUBMED Abstract]
     
     
123. Chappuis PO, Goffin J, Wong N, et al.: A significant response to neoadjuvant chemotherapy in BRCA1/2 related breast cancer. J Med Genet 39 (8): 608-10, 2002.  [PUBMED Abstract]
     
     
124. Van Nagell JR Jr, DePriest PD, Puls LE, et al.: Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography. Cancer 68 (3): 458-62, 1991.  [PUBMED Abstract]
     
     
125. Fleischer AC, Cullinan JA, Peery CV, et al.: Early detection of ovarian carcinoma with transvaginal color Doppler ultrasonography. Am J Obstet Gynecol 174 (1 Pt 1): 101-6, 1996.  [PUBMED Abstract]
     
     
126. Weiner Z, Beck D, Shteiner M, et al.: Screening for ovarian cancer in women with breast cancer with transvaginal sonography and color flow imaging. J Ultrasound Med 12 (7): 387-93, 1993.  [PUBMED Abstract]
     
     
127. Karlan BY, Platt LD: Ovarian cancer screening. The role of ultrasound in early detection. Cancer 76 (10 Suppl): 2011-5, 1995.  [PUBMED Abstract]
     
     
128. Tailor A, Bourne TH, Campbell S, et al.: Results from an ultrasound-based familial ovarian cancer screening clinic: a 10-year observational study. Ultrasound Obstet Gynecol 21 (4): 378-85, 2003.  [PUBMED Abstract]
     
     
129. Meeuwissen PA, Seynaeve C, Brekelmans CT, et al.: Outcome of surveillance and prophylactic salpingo-oophorectomy in asymptomatic women at high risk for ovarian cancer. Gynecol Oncol 97 (2): 476-82, 2005.  [PUBMED Abstract]
     
     
130. Dørum A, Kristensen GB, Abeler VM, et al.: Early detection of familial ovarian cancer. Eur J Cancer 32A (10): 1645-51, 1996.  [PUBMED Abstract]
     
     
131. Gaarenstroom KN, van der Hiel B, Tollenaar RA, et al.: Efficacy of screening women at high risk of hereditary ovarian cancer: results of an 11-year cohort study. Int J Gynecol Cancer 16 (Suppl 1): 54-9, 2006 Jan-Feb.  [PUBMED Abstract]
     
     
132. Karlan BY, Raffel LJ, Crvenkovic G, et al.: A multidisciplinary approach to the early detection of ovarian carcinoma: rationale, protocol design, and early results. Am J Obstet Gynecol 169 (3): 494-501, 1993.  [PUBMED Abstract]
     
     
133. Muto MG, Cramer DW, Brown DL, et al.: Screening for ovarian cancer: the preliminary experience of a familial ovarian cancer center. Gynecol Oncol 51 (1): 12-20, 1993.  [PUBMED Abstract]
     
     
134. NIH consensus conference. Ovarian cancer. Screening, treatment, and follow-up. NIH Consensus Development Panel on Ovarian Cancer. JAMA 273 (6): 491-7, 1995.  [PUBMED Abstract]
     
     
135. Kramer BS, Gohagan J, Prorok PC, et al.: A National Cancer Institute sponsored screening trial for prostatic, lung, colorectal, and ovarian cancers. Cancer 71 (2 Suppl): 589-93, 1993.  [PUBMED Abstract]
     
     
136. Pepe MS, Etzioni R, Feng Z, et al.: Phases of biomarker development for early detection of cancer. J Natl Cancer Inst 93 (14): 1054-61, 2001.  [PUBMED Abstract]
     
     
137. Grosse SD, Khoury MJ: What is the clinical utility of genetic testing? Genet Med 8 (7): 448-50, 2006.  [PUBMED Abstract]
     
     
138. Finch A, Shaw P, Rosen B, et al.: Clinical and pathologic findings of prophylactic salpingo-oophorectomies in 159 BRCA1 and BRCA2 carriers. Gynecol Oncol 100 (1): 58-64, 2006.  [PUBMED Abstract]
     
     
139. Andersen MR, Goff BA, Lowe KA, et al.: Combining a symptoms index with CA 125 to improve detection of ovarian cancer. Cancer 113 (3): 484-9, 2008.  [PUBMED Abstract]
     
     
140. Skates SJ, Xu FJ, Yu YH, et al.: Toward an optimal algorithm for ovarian cancer screening with longitudinal tumor markers. Cancer 76 (10 Suppl): 2004-10, 1995.  [PUBMED Abstract]
     
     
141. Skates SJ, Menon U, MacDonald N, et al.: Calculation of the risk of ovarian cancer from serial CA-125 values for preclinical detection in postmenopausal women. J Clin Oncol 21 (10 Suppl): 206s-210s, 2003.  [PUBMED Abstract]
     
     
142. Menon U, Skates SJ, Lewis S, et al.: Prospective study using the risk of ovarian cancer algorithm to screen for ovarian cancer. J Clin Oncol 23 (31): 7919-26, 2005.  [PUBMED Abstract]
     
     
143. Greene MH, Piedmonte M, Alberts D, et al.: A prospective study of risk-reducing salpingo-oophorectomy and longitudinal CA-125 screening among women at increased genetic risk of ovarian cancer: design and baseline characteristics: a Gynecologic Oncology Group study. Cancer Epidemiol Biomarkers Prev 17 (3): 594-604, 2008.  [PUBMED Abstract]
     
     
144. Gagnon A, Ye B: Discovery and application of protein biomarkers for ovarian cancer. Curr Opin Obstet Gynecol 20 (1): 9-13, 2008.  [PUBMED Abstract]
     
     
145. Hennessy BT, Murph M, Nanjundan M, et al.: Ovarian cancer: linking genomics to new target discovery and molecular markers--the way ahead. Adv Exp Med Biol 617: 23-40, 2008.  [PUBMED Abstract]
     
     
146. Badgwell D, Bast RC Jr: Early detection of ovarian cancer. Dis Markers 23 (5-6): 397-410, 2007.  [PUBMED Abstract]
     
     
147. Petricoin EF, Ardekani AM, Hitt BA, et al.: Use of proteomic patterns in serum to identify ovarian cancer. Lancet 359 (9306): 572-7, 2002.  [PUBMED Abstract]
     
     
148. Zhang Z, Bast RC Jr, Yu Y, et al.: Three biomarkers identified from serum proteomic analysis for the detection of early stage ovarian cancer. Cancer Res 64 (16): 5882-90, 2004.  [PUBMED Abstract]
     
     
149. Koehn H, Oehler MK: Proteins' promise--progress and challenges in ovarian cancer proteomics. Menopause Int 13 (4): 148-53, 2007.  [PUBMED Abstract]
     
     
150. Visintin I, Feng Z, Longton G, et al.: Diagnostic markers for early detection of ovarian cancer. Clin Cancer Res 14 (4): 1065-72, 2008.  [PUBMED Abstract]
     
     
151. Simon R: Roadmap for developing and validating therapeutically relevant genomic classifiers. J Clin Oncol 23 (29): 7332-41, 2005.  [PUBMED Abstract]
     
     
152. Risch HA: Hormonal etiology of epithelial ovarian cancer, with a hypothesis concerning the role of androgens and progesterone. J Natl Cancer Inst 90 (23): 1774-86, 1998.  [PUBMED Abstract]
     
     
153. Hankinson SE, Colditz GA, Hunter DJ, et al.: A prospective study of reproductive factors and risk of epithelial ovarian cancer. Cancer 76 (2): 284-90, 1995.  [PUBMED Abstract]
     
     
154. Gronwald J, Byrski T, Huzarski T, et al.: Influence of selected lifestyle factors on breast and ovarian cancer risk in BRCA1 mutation carriers from Poland. Breast Cancer Res Treat 95 (2): 105-9, 2006.  [PUBMED Abstract]
     
     
155. Modan B, Hartge P, Hirsh-Yechezkel G, et al.: Parity, oral contraceptives, and the risk of ovarian cancer among carriers and noncarriers of a BRCA1 or BRCA2 mutation. N Engl J Med 345 (4): 235-40, 2001.  [PUBMED Abstract]
     
     
156. McLaughlin JR, Risch HA, Lubinski J, et al.: Reproductive risk factors for ovarian cancer in carriers of BRCA1 or BRCA2 mutations: a case-control study. Lancet Oncol 8 (1): 26-34, 2007.  [PUBMED Abstract]
     
     
157. Whittemore AS, Harris R, Itnyre J: Characteristics relating to ovarian cancer risk: collaborative analysis of 12 US case-control studies. IV. The pathogenesis of epithelial ovarian cancer. Collaborative Ovarian Cancer Group. Am J Epidemiol 136 (10): 1212-20, 1992.  [PUBMED Abstract]
     
     
158. Narod SA, Sun P, Ghadirian P, et al.: Tubal ligation and risk of ovarian cancer in carriers of BRCA1 or BRCA2 mutations: a case-control study. Lancet 357 (9267): 1467-70, 2001.  [PUBMED Abstract]
     
     
159. Rutter JL, Wacholder S, Chetrit A, et al.: Gynecologic surgeries and risk of ovarian cancer in women with BRCA1 and BRCA2 Ashkenazi founder mutations: an Israeli population-based case-control study. J Natl Cancer Inst 95 (14): 1072-8, 2003.  [PUBMED Abstract]
     
     
160. Miracle-McMahill HL, Calle EE, Kosinski AS, et al.: Tubal ligation and fatal ovarian cancer in a large prospective cohort study. Am J Epidemiol 145 (4): 349-57, 1997.  [PUBMED Abstract]
     
     
161. Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, et al.: Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet 371 (9609): 303-14, 2008.  [PUBMED Abstract]
     
     
162. Whittemore AS, Balise RR, Pharoah PD, et al.: Oral contraceptive use and ovarian cancer risk among carriers of BRCA1 or BRCA2 mutations. Br J Cancer 91 (11): 1911-5, 2004.  [PUBMED Abstract]
     
     
163. McGuire V, Felberg A, Mills M, et al.: Relation of contraceptive and reproductive history to ovarian cancer risk in carriers and noncarriers of BRCA1 gene mutations. Am J Epidemiol 160 (7): 613-8, 2004.  [PUBMED Abstract]
     
     
164. Grabrick DM, Hartmann LC, Cerhan JR, et al.: Risk of breast cancer with oral contraceptive use in women with a family history of breast cancer. JAMA 284 (14): 1791-8, 2000.  [PUBMED Abstract]
     
     
165. Domchek SM, Friebel TM, Neuhausen SL, et al.: Mortality after bilateral salpingo-oophorectomy in BRCA1 and BRCA2 mutation carriers: a prospective cohort study. Lancet Oncol 7 (3): 223-9, 2006.  [PUBMED Abstract]
     
     
166. Leeper K, Garcia R, Swisher E, et al.: Pathologic findings in prophylactic oophorectomy specimens in high-risk women. Gynecol Oncol 87 (1): 52-6, 2002.  [PUBMED Abstract]
     
     
167. Olivier RI, van Beurden M, Lubsen MA, et al.: Clinical outcome of prophylactic oophorectomy in BRCA1/BRCA2 mutation carriers and events during follow-up. Br J Cancer 90 (8): 1492-7, 2004.  [PUBMED Abstract]
     
     
168. Colgan TJ, Murphy J, Cole DE, et al.: Occult carcinoma in prophylactic oophorectomy specimens: prevalence and association with BRCA germline mutation status. Am J Surg Pathol 25 (10): 1283-9, 2001.  [PUBMED Abstract]
     
     
169. Powell CB, Kenley E, Chen LM, et al.: Risk-reducing salpingo-oophorectomy in BRCA mutation carriers: role of serial sectioning in the detection of occult malignancy. J Clin Oncol 23 (1): 127-32, 2005.  [PUBMED Abstract]
     
     
170. Callahan MJ, Crum CP, Medeiros F, et al.: Primary fallopian tube malignancies in BRCA-positive women undergoing surgery for ovarian cancer risk reduction. J Clin Oncol 25 (25): 3985-90, 2007.  [PUBMED Abstract]
     
     
171. Piek JM, van Diest PJ, Zweemer RP, et al.: Dysplastic changes in prophylactically removed Fallopian tubes of women predisposed to developing ovarian cancer. J Pathol 195 (4): 451-6, 2001.  [PUBMED Abstract]
     
     
172. Paley PJ, Swisher EM, Garcia RL, et al.: Occult cancer of the fallopian tube in BRCA-1 germline mutation carriers at prophylactic oophorectomy: a case for recommending hysterectomy at surgical prophylaxis. Gynecol Oncol 80 (2): 176-80, 2001.  [PUBMED Abstract]
     
     
173. Rose PG, Shrigley R, Wiesner GL: Germline BRCA2 mutation in a patient with fallopian tube carcinoma: a case report. Gynecol Oncol 77 (2): 319-20, 2000.  [PUBMED Abstract]
     
     
174. Zweemer RP, van Diest PJ, Verheijen RH, et al.: Molecular evidence linking primary cancer of the fallopian tube to BRCA1 germline mutations. Gynecol Oncol 76 (1): 45-50, 2000.  [PUBMED Abstract]
     
     
175. Piek JM, Torrenga B, Hermsen B, et al.: Histopathological characteristics of BRCA1- and BRCA2-associated intraperitoneal cancer: a clinic-based study. Fam Cancer 2 (2): 73-8, 2003.  [PUBMED Abstract]
     
     
176. Levine DA, Argenta PA, Yee CJ, et al.: Fallopian tube and primary peritoneal carcinomas associated with BRCA mutations. J Clin Oncol 21 (22): 4222-7, 2003.  [PUBMED Abstract]
     
     
177. Aziz S, Kuperstein G, Rosen B, et al.: A genetic epidemiological study of carcinoma of the fallopian tube. Gynecol Oncol 80 (3): 341-5, 2001.  [PUBMED Abstract]
     
     
178. Kindelberger DW, Lee Y, Miron A, et al.: Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: Evidence for a causal relationship. Am J Surg Pathol 31 (2): 161-9, 2007.  [PUBMED Abstract]
     
     
179. Thompson D, Easton DF; Breast Cancer Linkage Consortium.: Cancer Incidence in BRCA1 mutation carriers. J Natl Cancer Inst 94 (18): 1358-65, 2002.  [PUBMED Abstract]
     
     
180. Lavie O, Hornreich G, Ben-Arie A, et al.: BRCA germline mutations in Jewish women with uterine serous papillary carcinoma. Gynecol Oncol 92 (2): 521-4, 2004.  [PUBMED Abstract]
     
     
181. Levine DA, Lin O, Barakat RR, et al.: Risk of endometrial carcinoma associated with BRCA mutation. Gynecol Oncol 80 (3): 395-8, 2001.  [PUBMED Abstract]
     
     
182. Goshen R, Chu W, Elit L, et al.: Is uterine papillary serous adenocarcinoma a manifestation of the hereditary breast-ovarian cancer syndrome? Gynecol Oncol 79 (3): 477-81, 2000.  [PUBMED Abstract]
     
     
183. Beiner ME, Finch A, Rosen B, et al.: The risk of endometrial cancer in women with BRCA1 and BRCA2 mutations. A prospective study. Gynecol Oncol 104 (1): 7-10, 2007.  [PUBMED Abstract]
     
     
184. Chen KT, Schooley JL, Flam MS: Peritoneal carcinomatosis after prophylactic oophorectomy in familial ovarian cancer syndrome. Obstet Gynecol 66 (3 Suppl): 93S-94S, 1985.  [PUBMED Abstract]
     
     
185. Lynch HT, Bewtra C, Lynch JF: Familial ovarian carcinoma. Clinical nuances. Am J Med 81 (6): 1073-6, 1986.  [PUBMED Abstract]
     
     
186. Lynch HT, Watson P, Bewtra C, et al.: Hereditary ovarian cancer. Heterogeneity in age at diagnosis. Cancer 67 (5): 1460-6, 1991.  [PUBMED Abstract]
     
     
187. Tobacman JK, Greene MH, Tucker MA, et al.: Intra-abdominal carcinomatosis after prophylactic oophorectomy in ovarian-cancer-prone families. Lancet 2 (8302): 795-7, 1982.  [PUBMED Abstract]
     
     
188. Truong LD, Maccato ML, Awalt H, et al.: Serous surface carcinoma of the peritoneum: a clinicopathologic study of 22 cases. Hum Pathol 21 (1): 99-110, 1990.  [PUBMED Abstract]
     
     
189. Piver MS, Jishi MF, Tsukada Y, et al.: Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer. A report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer 71 (9): 2751-5, 1993.  [PUBMED Abstract]
     
     
190. Casey MJ, Synder C, Bewtra C, et al.: Intra-abdominal carcinomatosis after prophylactic oophorectomy in women of hereditary breast ovarian cancer syndrome kindreds associated with BRCA1 and BRCA2 mutations. Gynecol Oncol 97 (2): 457-67, 2005.  [PUBMED Abstract]
     
     
191. Finch A, Beiner M, Lubinski J, et al.: Salpingo-oophorectomy and the risk of ovarian, fallopian tube, and peritoneal cancers in women with a BRCA1 or BRCA2 Mutation. JAMA 296 (2): 185-92, 2006.  [PUBMED Abstract]
     
     
192. Chen S, Iversen ES, Friebel T, et al.: Characterization of BRCA1 and BRCA2 mutations in a large United States sample. J Clin Oncol 24 (6): 863-71, 2006.  [PUBMED Abstract]
     
     
193. Antoniou A, Pharoah PD, Narod S, et al.: Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case Series unselected for family history: a combined analysis of 22 studies. Am J Hum Genet 72 (5): 1117-30, 2003.  [PUBMED Abstract]
     
     
194. Risch HA, McLaughlin JR, Cole DE, et al.: Population BRCA1 and BRCA2 mutation frequencies and cancer penetrances: a kin-cohort study in Ontario, Canada. J Natl Cancer Inst 98 (23): 1694-706, 2006.  [PUBMED Abstract]
     
     
195. Madalinska JB, Hollenstein J, Bleiker E, et al.: Quality-of-life effects of prophylactic salpingo-oophorectomy versus gynecologic screening among women at increased risk of hereditary ovarian cancer. J Clin Oncol 23 (28): 6890-8, 2005.  [PUBMED Abstract]
     
     

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