Chemoprevention of Breast Cancer to Be Offered in UK

Zosia Chustecka

January 15, 2013

For the first time, guidelines in the United Kingdom will recommend chemoprevention for breast cancer.

Postmenopausal women who are at high risk for breast cancer but not at risk for thromboembolism or endometrial cancer should be offered 5 years of tamoxifen or raloxifene, according to the National Institute for Health and Clinical Excellence (NICE).

The recommendation is one of several strategies added in an update of the guidelines on familial breast cancer (breast cancer in an individual with a family history of the disease). About 1 in 5 of all breast cancer has this hereditary component.

The updated guidelines were published in draft form on January 14, and will be open for consultation until February 25. They were compiled by a team chaired by Maggie Alexander; Gareth Evans, MD, was the lead clinician.

The update recommends more genetic testing and regular surveillance for women who are at high risk for breast cancer, and describes when genetic testing should be offered, and when and how often surveillance (with mammography and/or magnetic resonance imaging) should be carried out. It also discusses the option of risk-reducing surgery, such as prophylactic mastectomy and oophorectomy, in women shown to be at very high risk.

However, it is the chemoprevention strategy that has made headlines, because tamoxifen and raloxifene are not licensed for breast cancer prevention in the United Kingdom, even though much of the work showing the benefit of tamoxifen in this setting comes from clinical trials conducted there.

Although both drugs are licensed for breast cancer prevention in the United States, uptake is low. Very few women who are eligible for chemopreventive tamoxifen choose to take it, which is frustrating to experts who call for greater use of this strategy.

This is the first time that chemoprevention has been recommended in the United Kingdom. The move was described as "historic" and welcomed by several breast cancer charities.

"We're really pleased to see these guidelines include new recommendations for women at high risk of breast cancer," said Baroness Delyth Morgan, chief executive of Breast Cancer Campaign. "The biggest changes are preventive drug treatments for breast cancer being considered for the first time, and wider access to genetic testing, which could bring about an earlier diagnosis," she said in a statement.

Compare With Aromatase Inhibitors

The draft guidelines recommend that a clinical trial should compare the clinical and cost effectiveness of aromatase inhibitors and tamoxifen in the reduction of the incidence of breast cancer in women with a family history of breast or ovarian cancer. They note that the aromatase inhibitor exemestane was found to be effective in reducing the risk for breast cancer in women at high risk, but no comparator trials have been conducted to see how aromatase inhibitors compare with the selective estrogen-receptor modulators tamoxifen and raloxifene.

"Such a trial could better inform women of the best available approach for chemoprevention of breast cancer," the authors of the guidelines write.

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