Breast Cancer Prevention: The New Primary Care?

Kathy D. Miller, MD


November 11, 2011

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Hi. I am Dr. Kathy Miller from Indiana University, back for our Medscape Oncology video blog series. Another October and another Breast Cancer Awareness Month is about to become history. I was talking about breast cancer prevention and screening in our Department of Medicine grand rounds today. In reality, we could prevent breast cancer today.

Here is what we would need to do: Mandate that every woman has her first child, the first of at least 7 or 8, at about age 15, with a prophylactic mastectomy after delivery of that last child, and absolutely mandatory breastfeeding, for at least a year per child, with a prophylactic mastectomy after the last child is weaned. Everybody has to do an hour of exercise daily and follow a diet with a maximum of 20% of calories from fat.

Obesity is outlawed, or at least taxed, particularly postmenopausal weight gain. We would return to Prohibition -- so no more cocktail hour, no more wine with dinner. Prempro® would be absolutely removed from every pharmacy. Think about selling selective estrogen receptor modulator (SERM) or aromatase inhibitor (AI)-fortified foods (particularly for women) in health food stores. If you do all of these things, I am blissfully out of business.

I know we are not going to do these things. But there is something we could do, which is take a lesson from our cardiology colleagues. Cardiologists have made preventive cardiology internal medicine's bread and butter. In reality, we treat hypertension primarily to prevent heart disease and strokes, and also to prevent kidney disease, but primarily to prevent heart disease and strokes. We also treat hypercholesterolemia to prevent heart disease and strokes. When was the last time your internist said, "Oh, my dear, your cholesterol is 250. That puts you at risk for heart disease, so I'm going to send you to a cardiologist." Cardiologists have made primary prevention a primary care priority. We have not done that.

We have kept preventive oncology in the realm of oncology. That means that primary care physicians simply don't think this is their job. They don't feel equipped and well trained. They are not comfortable with our medicines. In their minds, the benefits of a SERM or an AI for prevention are too small to justify prescribing it.

If you look at the number of patients you need to treat with a statin to prevent 1 heart attack or 1 stroke, depending on which study and which statin you look at, you come up with a number-needed-to-treat of somewhere between 275 and 325 people. That is identical to the number of patients needed to treat with a SERM or the number of patients needed to treat with an AI to prevent 1 case of breast cancer.

So here is my plea: Make primary oncology prevention an internal medicine primary care issue. There is no reason not to, and if it takes off, we could be a lot less busy.


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