乳腺磁共振在乳腺癌诊断治疗中的运用

乳腺MRI具有很好的软组织分辨率和无射线辐射等优点,对乳腺癌的早期诊断和局部分期明显优于乳腺X线摄影和超声检查。随着乳腺癌个体化、规范化综合治疗理念的推广,乳腺MRI在综合治疗中的作用日益受到重视,伴随对乳腺MRI临床应用的开展和研究的深入,其在乳腺癌分期中的评估、保乳手术病例术前的筛选、腋窝淋巴结转移原发不明者的诊断、新辅助化疗(neoadjuvant chemotherapy, NAC)的疗效评估、随访监测中的应用价值也得到了很好的评估。同时,乳腺MRI对肿瘤范围的客观准确的评估也是正确选择治疗方式的依据。     

The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience

BACKGROUND: Advances in the diagnosis and treatment of breast carcinoma have led to a multidisciplinary approach to management for patients with breast carcinoma. To assess the effect of this approach, the authors performed an evaluation for a cohort of patients examined in a multidisciplinary breast cancer center. METHODS: An analysis was performed for the records of 75 consecutive women with 77 breast lesions examined in consultation in a multidisciplinary breast cancer center between January and June 1998. Each patient's case was evaluated by a panel consisting of a medical oncologist, surgical oncologist, radiation oncologist, pathologist, diagnostic radiologist, and, when indicated, plastic surgeon. A comprehensive history and physical examination was performed, and the relevant mammograms, pathology slides, and medical records were reviewed. Treatment recommendations made before this evaluation were compared with the consensus recommendations made by the panel. RESULTS: For the 75 patients, the multidisciplinary panel disagreed with the treatment recommendations from the outside physicians in 32 cases (43%), and agreed in 41 cases (55%). Two patients (3%) had no treatment recommendation before consultation. For the 32 patients with a disagreement, the treatment recommendations were breast-conservation treatment instead of mastectomy (n = 13; 41%) or reexcision (n = 2; 6%); further workup instead of immediate definitive treatment (n = 10; 31%); treatment based on major change in diagnosis on pathology review (n = 3; 9%); addition of postmastectomy radiation treatment (n = 3; 9%); or addition of hormonal therapy (n = 1; 3%). CONCLUSIONS: The multidisciplinary breast cancer evaluation program provided an integrated program in which individual patients were evaluated by a team of physicians and led to a change in treatment recommendation for 43% (32 of 75) of the patients examined. This multidisciplinary program provided important second opinions for many patients with breast carcinoma.     

Access to multidisciplinary cancer care: is it linked to the use of breast-conserving surgery with radiation for early-stage breast carcinoma?

BACKGROUND: Breast-conserving surgery (BCS) with radiation (BCSR) requires a multidisciplinary care approach between surgeons and radiation oncologists. METHODS: This retrospective cohort study examined the use of preoperative radiation oncology consultation and whether use of or distance to this care was associated with treatment choice among 1188 women age > or = 65 years who were diagnosed with local or regional breast carcinoma in Washington State in 1994 and 1995. Study outcomes included rates of BCSR; BCS alone; and mastectomy; and radiation therapy among women who underwent BCS. RESULTS: Only 29% of patients in the current study consulted with a radiation oncologist preoperatively, and less than half of the patients (46.6%) consulted with either a medical oncologist or a radiation oncologist. Among women who underwent either BCSR or mastectomy, the odds of undergoing BCSR among women who had a preoperative radiation oncology consultation were 6.7 times the odds of women who did not have the consultation (P < or = 0.001). Similarly, the odds of receiving radiation therapy among women who underwent BCS and had a preoperative radiation oncology consultation were 5 times the odds of women who did not have the consultation (P < 0.001). The 3.4% of women who lived > 50 miles from the radiation therapy center had the lowest BCSR rate (15.8%) and had the lowest radiation therapy rate among women who underwent BCS (54.5%), although these findings were not statistically significant in adjusted analyses. CONCLUSIONS: A preoperative visit with a radiation oncologist was associated strongly with BCSR use. More should be done to evaluate the role of multidisciplinary consultation in the decision to use BCSR.     

Regional chemotherapy is indicated after surgical resection of colorectal metastases to the liver: a debate

Surgical resection for selected patients with hepatic metastases from colorectal cancer can cure approximately one-fourth of these patients. The addition of regional chemotherapy as an attempt to improve this statistic has been extensively investigated in clinical trials. As part of a multidisciplinary educational program, a series of debates on various topics in oncology are held at the Roswell Park Cancer Institute, Buffalo, New York, involving the medical, surgical, and radiation oncology departments. One such debate focused on the use of regional chemotherapy after potentially curative resection of hepatic metastases from colorectal cancer. The representative medical and surgical oncology fellows (N.I.K. and B.P.M.), with guidance from their respective mentors (C.G.L., J.F.G., and N.J.P.), presented concise reviews from the literature arguing for and against the use of regional chemotherapy in this setting. They appear as Parts 1 and 2 in this article. This exercise is purely educational and does not in any way reflect the opinion or the clinical practice of the authors. .     

New multidisciplinary prostate bone metastases clinic: first of its kind in Canada

Prostate cancer is the most common non-skin malignancy in men. Almost all men who die from prostate cancer have hormone-refractory prostate cancer with metastasis to bone. Emerging supportive treatments-including chemotherapy, bisphosphonates, and surgery-require integration that is optimized in a multidisciplinary setting. A multidisciplinary clinic for bone metastases has been in place at Toronto-Sunnybrook Regional Cancer Centre since 1999, combining orthopedic surgery, radiation oncology, interventional radiology, and palliative medicine for all patients with bone metastases. The addition of a prostate-focused multidisciplinary clinic integrates these services for patients with advanced prostate cancer.     

New Systemic Therapy Options for Advanced Sarcomas

OPINION STATEMENT: The outcome of patients with advanced soft tissue sarcomas (STS) has not improved much during the last decade. Apart from non-pleomorphic rhabdomyosarcoma, adjuvant chemotherapy has no standard role in high risk STS. In metastatic disease little progress has been made, but during recent years much effort has been put into the development of better clinical study protocols, with stratification of patients to at least the most common histological subtypes, preventing the dilution of potential treatment efficacy when measuring results over the total heterogeneous group of STS. The outcome of patients with advanced STS is however not only dependent on the introduction of new drugs, but also on the availability of dedicated sarcoma centers in which multidisciplinary teams with the input of all experts from different disciplines, such as pathology, radiology, nuclear medicine, surgery, orthopedics radiotherapy and medical oncology is present. Long delay, wrong histological diagnoses, under- and overtreatment are not in the favor of these patients, neither with regard to outcome, nor with respect to short- and long-term toxicity. Disappointedly, centralization is not a routine part of daily care of STS patients and their care givers. Patient advocacy groups are more and more aware of the relevance of treatment in centers of expertise and are active in guiding the patients to these hospitals. At the same time the sarcoma centers should be pro-active in putting patients into clinical trials, also for rare indications within the STS group, as only in this way a better outcome for this group of patients can be reached.     

The cost of adjuvant chemotherapy in patients with early-stage breast carcinoma

BACKGROUND: In the U.S., the majority of premenopausal patients with early-stage breast carcinoma are treated with adjuvant chemotherapy. However, to the authors' knowledge, there have been few formal analyses of adjuvant chemotherapy cost performed to date, especially in premenopausal women. The objective of the current study was to evaluate the direct medical cost of adjuvant chemotherapy in women with early-stage breast carcinoma. METHODS: The attributable cost of adjuvant chemotherapy was evaluated by comparing the total cost of care for patients with breast carcinoma (cases) during the period from diagnosis to 9 months subsequent with the cost for age-matched and gender-matched control patients without breast carcinoma over an equivalent time period. The authors identified cases from a linked database of claims records from a managed care organization, and the Cancer Surveillance System registry. Controls were identified from the managed care organization from which the cases originated. Resource prices were based on reimbursements from the managed care organization. RESULTS: The attributable cost of adjuvant chemotherapy was estimated to be dollar 23,019 (95% confidence interval, dollar 19,596-dollar 26,441), based on 1239 women. The cost appeared to decrease with increasing age at diagnosis, with total costs of dollar 26,834, dollar 19,889, and dollar 17,098 for women < 50, 50-59, and > or = 60 years, respectively. Also, costs were higher for regional versus local disease (dollar 36,076 vs. dollar 12,659), for women who had a mastectomy versus breast-conserving surgery (dollar 31,075 vs. dollar 17,889), and for women who had no comorbidities versus > or = 1 comorbidity (dollar 23,606 vs. dollar 21,340). Contributors to high chemotherapy cost included use of chemotherapy agents not included in clinical guidelines during the study period, use of supportive care agents, and hospitalizations. CONCLUSIONS: The attributable cost of adjuvant chemotherapy in patients with early-stage breast carcinoma is significant. The integration of managed care claims data with clinical data from the Cancer Surveillance System registry offered a unique opportunity to derive more informative and accurate disease burden estimates in oncology.     

La réunion de concertation pluridisciplinaire de cancérologie pour valider la mastectomie prophylactique: atouts et faiblesses

The evolution of our health care system strengthens multidisciplinary collaboration in medical practice. Today, the tumor board meeting (TBM) has become mandatory for treatment decision-making in oncology. Experts recommend that such a multidisciplinary tool be extended to prophylactic mastectomy. We will discuss the relevance of this extension on the basis of a survey with female patients and health professionals confronted with prophylactic mastectomy. Health professionals find the TBM necessary because it allows more reasoned and consensual proposals to be made, reduces the burden of difficult decisions, and promotes a comprehensive view of those who receive care. However, this approach has also drawn criticism. Unlike medical consultation, which focuses on a patient's singularity, the TBM seems poorly suited to take into account psychosocial factors governing the decision-making process. It may be easier for a group to reach a complex decision, but it does not mean that the TBM allows for decisions to be adapted on a singular basis. Therefore, we suggest to modify the TBM so that it better suits the needs of patients susceptible to breast cancer. The referring physician, who knows the patient best, should guide the content of multidisciplinary deliberations and put the focus on individual criteria raised during medical consultations.     

Impact of neoadjuvant chemotherapy on breast reconstruction

BACKGROUND:

With advances in oncologic treatment, cosmesis after mastectomy has assumed a pivotal role in patient and provider decision making. Multiple studies have confirmed the safety of both chemotherapy before breast surgery and immediate reconstruction. Little has been written about the effect of neoadjuvant chemotherapy on decisions about reconstruction.

METHODS:

The authors identified 665 patients with stage I through III breast cancer who received chemotherapy and underwent mastectomy at Dana‐Farber/Brigham & Women's Cancer Center from 1997 to 2007. By using multivariate logistic regression, reconstruction rates were compared between patients who received neoadjuvant chemotherapy (n = 180) and patients who underwent mastectomy before chemotherapy (n = 485). The rate of postoperative complications after mastectomy was determined for patients who received neoadjuvant chemotherapy compared with those who did not.

RESULTS:

Reconstruction was performed immediately in 44% of patients who did not receive neoadjuvant chemotherapy but in only 23% of those who did. Twenty‐one percent of neoadjuvant chemotherapy recipients and 14% of adjuvant‐only chemotherapy recipients underwent delayed reconstruction. After controlling for age, receipt of radiotherapy, and disease stage, neoadjuvant recipients were less likely to undergo immediate reconstruction (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.37, 0.87) but were no more likely to undergo delayed reconstruction (OR, 1.29; 95% CI, 0.75, 2.20). Surgical complications occurred in 30% of neoadjuvant chemotherapy recipients and in 31% of adjuvant chemotherapy recipients.

CONCLUSIONS:

The current results suggest that patients who receive neoadjuvant chemotherapy are less likely to undergo immediate reconstruction and are no more likely to undergo delayed reconstruction than patients who undergo surgery before they receive chemotherapy. Cancer 2011. © 2011 American Cancer Society.     

中国胃癌放疗指南(2020版)

胃癌是我国高发的恶性肿瘤之一,且多数患者诊断时已处于进展期,放疗是多学科诊疗的重要组成部分。《中国胃癌放疗指南》由来自代表国内胃癌治疗领先水平的22家医院的放疗科、外科、内科、影像科的35位专家共同编写完成。作为中国首部胃癌放疗指南,将为我国胃癌放射治疗及综合治疗提供重要依据和参考,其在临床实践中的不断完善和更新,将会造福广大胃癌患者并促进学科的发展。     

Changes in medical oncology admissions for the management of breast cancer complications: an Australian institution's experience

Aims: There is a scarcity of data regarding medical hospitalizations for breast cancer. The aim was to determine whether the burden of inpatient care for breast cancer was declining. Methods: A retrospective study was conducted of all admissions to a single medical oncology inpatient unit in 1996 and 2006 related to the treatment of breast cancer. The total number of hospitalizations, patients' length of stay in hospital, clinical indications for hospitalization and utilization of inpatient services were determined. Data analysis involved pairwise comparisons between the cohorts. Results: The total number of breast cancer hospitalizations was similar in 1996 and 2006. However, the number of hospitalizations for adjuvant treatment complications was 50% lower in 2006, attributable to a lower rate of chemotherapy‐associated febrile neutropenia. Acute clinical problems necessitating inpatient care differed between 1996 and 2006. Fewer hospitalizations for symptomatic hypercalcemia, uncontrolled pain and chemotherapy toxicity were required in 2006 but a significant increase was seen in central nervous system complications. Recent practice involved greater inpatient consultation of other medical and surgical teams. There was a trend towards a shorter duration of admissions in 2006 in both adjuvant and metastatic patients. Conclusion: Although total annual breast cancer admission numbers and length of stay did not change significantly, hospitalization for treatment‐related complications was less frequent in 2006. The clinical manifestations of metastatic breast cancer appear to be changing, and in our institution are being managed with broader multidisciplinary care.     

American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The purpose of the American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer. A systematic review of the literature was conducted using PubMed through April 2015. A multidisciplinary expert workgroup with expertise in primary care, gynecology, surgical oncology, medical oncology, radiation oncology, and nursing was formed and tasked with drafting the Breast Cancer Survivorship Care Guideline. A total of 1073 articles met inclusion criteria; and, after full text review, 237 were included as the evidence base. Patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer‐related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence. Primary care clinicians should counsel patients about the importance of maintaining a healthy lifestyle, monitor for post‐treatment symptoms that can adversely affect quality of life, and monitor for adherence to endocrine therapy. Recommendations provided in this guideline are based on current evidence in the literature and expert consensus opinion. Most of the evidence is not sufficient to warrant a strong evidence‐based recommendation. Recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, assessment and management of physical and psychosocial long‐term and late effects of breast cancer and its treatment, health promotion, and care coordination/practice implications are made. CA Cancer J Clin 2016;43–73. © 2015 American Cancer Society.     

Neoadjuvant chemotherapy for unresectable ovarian carcinoma: a French multicenter study.

BACKGROUND: Initial debulking surgery followed by chemotherapy is the current treatment for International Federation of Gynecology and Obstetrics Stage IIIC/IV ovarian carcinoma but has a limited efficacy when optimal cytoreduction is not achieved at the end of the surgical procedure. An alternative treatment for these patients could be neoadjuvant chemotherapy. The purpose of this retrospective study was to report the results of neoadjuvant chemotherapy in operable patients (no medical contraindication to surgery) presenting with primary unresectable tumors. METHODS: Between January 1996 and March 1999, operable patients presenting with Stage IIIC or IV ovarian carcinoma underwent, in six French gynecologic oncology departments, surgical staging to evaluate tumor resectability. When the tumor was deemed unresectable by standard surgery, the patient received three to six cycles of platinum-based neoadjuvant chemotherapy according to the response and the center's usual protocol. Patients were surgically explored after completion of neoadjuvant chemotherapy when the tumor did not progress during treatment. Debulking was performed during this secondary surgery when a response to chemotherapy was observed. RESULTS: Fifty-four patients were treated by neoadjuvant chemotherapy. The first surgical staging procedure was laparoscopy in 33 patients (61%) and laparotomy in 21 patients (39%). The median number of neoadjuvant chemotherapy cycles was 4 (range, 0-6). Forty-three patients (80%) responded to neoadjuvant chemotherapy and then tumors were debulked. Optimal cytoreduction was obtained in 39 patients (91% of the patients who underwent debulking) and with standard surgery in 32 patients (82%). For patients whose tumors were optimally debulked, blood transfusions were administered to 17 patients (43%), median intensive care unit stay was 0 days (range, 0-7 days), and median postoperative hospital stay was 10 days (range, 4-62 days). Median overall survival for the total series was 22 months. Survival was better for patients debulked after neoadjuvant chemotherapy compared with patients with nondebulked tumors (P < 0.001). CONCLUSIONS: Neoadjuvant chemotherapy for primary unresectable ovarian carcinoma leads to the selection of a subset of patients sensitive to chemotherapy in whom optimal cytoreduction can be achieved after chemotherapy by standard surgery in a high proportion of cases. Conversely, aggressive surgery can be avoided in patients with initial chemoresistance, in whom the prognosis is known to be poor regardless of treatment.     

Consensuses,controversies, and future directions in treatment deintensification for human papillomavirus-associated oropharyngeal cancer

The most common cancer caused by human papillomavirus (HPV) infection in the United States is oropharyngeal cancer (OPC), and its incidence has been rising since the turn of the century. Because of substantial long-term morbidities with chemoradiation and the favorable prognosis of HPV-positive OPC, identifying the optimal deintensification strategy for this group has been a keystone of academic head-and-neck surgery, radiation oncology, and medical oncology for over the past decade. However, the first generation of randomized chemotherapy deintensification trials failed to change the standard of care, triggering concern over the feasibility of de-escalation. National database studies estimate that up to one third of patients receive nonstandard de-escalated treatments, which have subspecialty-specific nuances. A synthesis of the multidisciplinary deintensification data and current treatment standards is important for the oncology community to reinforce best practices and ensure optimal patient outcomes. In this review, the authors present a summary and comparison of prospective HPV-positive OPC de-escalation trials. Chemotherapy attenuation compromises outcomes without reducing toxicity. Limited data comparing transoral robotic surgery (TORS) with radiation raise concern over toxicity and outcomes with TORS. There are promising data to support de-escalating adjuvant therapy after TORS, but consensus on treatment indications is needed. Encouraging radiation deintensification strategies have been reported (upfront dose reduction and induction chemotherapy-based patient selection), but level I evidence is years away. Ultimately, stage and HPV status may be insufficient to guide de-escalation. The future of deintensification may lie in incorporating intratreatment response assessments to harness the powers of personalized medicine and integrate real-time surveillance.     

Chimiothérapie néoadjuvante et carcinomes urothéliaux infiltrants de vessie de stade localisé. Des données de la littérature à la pratique quotidienne: it’s a long way to go...

In general oncology, neoadjuvant chemotherapy is given in patients at operable stages before local treatment for two principal reasons: to improve survival by eliminating micrometastases and to select patients for organ preservation strategies. In patients with muscle-invasive bladder cancer, data from clinical trials and meta-analyses have shown a significant benefit in overall survival, with a 5% absolute benefit at 5 years, provided neoadjuvant cisplatin-based combination chemotherapy is used. However, these results have not convinced the medical community since adjuvant chemotherapy after primary cystectomy is frequently used in daily practice. Additionally, bladder sparing in selected patients on the basis of response to neoadjuvant chemotherapy has been described as a feasible approach in some selected centres. These results have to be confirmed by large prospective cooperative studies. The identification of individual or multiple molecular markers, which may identify these patients who are more likely to benefit from neoadjuvant chemotherapy is a major endpoint for the next decade.     

Potential Financial Implications of Substituting Cognitive Medicine for Technical Radiation Oncology Billing Services

Respected authors recommend broadening the radiation oncology (RO) scope-of-practice by taking more responsibility for the general medical care of our patients, directing the delivery of systemic cancer treatments that avoid the high toxicity of cytotoxic chemotherapy, managing palliative care, and supervising inpatient services for brachytherapy cases and problems related to radiation toxicity. The purpose of these changes is to increase RO involvement in clinical decision making and to avoiding becoming pigeon-holed as technicians instead of oncologists. There are no data estimating the financial implications of substituting traditional radiation oncology practice with that of an expanded clinical role. We sought to fill this void with a general proof-of-principle analysis based on current benchmark data. To determine the relative value units (RVU) of a blended radiation oncology practice, we selected the specialties of general internal medicine, hospital medicine, and palliative care as these fields most closely match the scope of the broadened clinical roles, which supporters of a more diversified radiation oncology practice typically advocate. To estimate the financial implications of a blended radiation oncology practice, we retrieved salary data by specialty and academic rank from the Clinical Practice Solutions Center report of annual RVU generation and the American Association of Medical Colleges annual faculty salary survey. For an assistant professor, this simulation estimates an 11% to 15% decrease in RVU generation for the median assistant professor operating with a 20% blended practice which, in turn, translates to a 7% to 9% decrease in total salary. The calculations for full professor demonstrate a similar decrease in total salary of approximately 8% to 9%.     

Perioperative chemotherapy in muscle-invasive bladder cancer to enhance survival and/or as a strategy for bladder preservation

The use of perioperative chemotherapy in muscle-invasive bladder cancer patients is widely debated. It has been used both to improve survival and as a strategy for bladder preservation. A retrospective meta-analysis of randomized studies of neoadjuvant and adjuvant chemotherapy has revealed a 5% improvement in survival with neoadjuvant cisplatin-based combination chemotherapy. Whether all patients should be treated with chemotherapy is, however, a much debated topic. The goal of bladder preservation is to achieve cancer survival equivalent to radical cystectomy while maintaining quality of life. A multidisciplinary approach with either neoadjuvant chemotherapy alone or in combination with radiation therapy (RT) has been advocated, but randomized trials have not compared this approach with cystectomy. There are serious problems with the interpretation of results from analyses of randomized adjuvant chemotherapy trials after cystectomy for pT3-pT4a and/or pN(+)M0 disease. A retrospective meta-analysis of randomized adjuvant chemotherapy trials is hampered due to small patient numbers and underpowered survival curves. The urologic oncology community should actively support recruitment to ongoing adjuvant chemotherapy trials in order to answer this important question.     

Referral to medical oncology: a crucial step in the treatment of older patients with stage III colon cancer

PURPOSE: Adjuvant chemotherapy for stage III colon cancer produces a substantial survival benefit, but many older patients do not receive chemotherapy. This study examines factors associated with medical oncology consultation and evaluates the impact of such consultation on chemotherapy use. PATIENTS AND METHODS: We used the Surveillance Epidemiology and End Results-Medicare linked database and identified 7,569 patients, aged 66-99, with stage III colon cancer diagnosed from 1992-1999. Modified Poisson regression was used to assess the relative risk for seeing a medical oncologist and for receiving chemotherapy as a function of individual characteristics. RESULTS: 78.08% of patients saw a medical oncologist within 6 months of diagnosis. Patients who were female, white, married, had low comorbidity scores, were diagnosed in more recent years, or had four or more positive lymph nodes were more likely to see a medical oncologist. Patients seeing a medical oncologist were 10 times more likely to receive chemotherapy (odds ratio, 9.98; 95% confidence interval, 8.21-12.14), after controlling for demographic and tumor characteristics. Chemotherapy use increased over time, but was substantially lower among older, black, and unmarried patients. CONCLUSIONS: Referral to medical oncology is one of the most important factors associated with receipt of chemotherapy among older patients with stage III colon cancer. Comorbidity decreases the likelihood of receiving chemotherapy, but its effect is the same for those who see a medical oncologist and all patients combined. Ensuring that high-risk patients are referred to medical oncology is a crucial step in quality care for patients with colon cancer.     

Model-based predictions of BRCA1/2 mutation status in breast carcinoma patients treated at an academic medical center

BACKGROUND: Women with an existing breast carcinoma diagnosis who are found to carry a BRCA1/2 mutation have a substantial risk of developing both a contralateral breast carcinoma and ovarian carcinoma. In a newly diagnosed breast carcinoma patient, this genetic information may influence the management of her disease. To assess the volume of patients who may need genetic services at the time of diagnosis, the authors determined the proportion of women with newly diagnosed breast carcinoma at the study institution who would be eligible for genetic testing. METHODS: Fifty consecutive women with new breast carcinoma who were attending a multidisciplinary clinic were interviewed. Detailed, three-generation pedigrees were collected for each patient by a genetic counselor. Three commonly used probability models were used to calculate each woman's predicted risk of harboring a germline BRCA1/2 mutation. RESULTS: Eleven of 50 patients (22% [95% confidence interval, 12-36%]) were calculated to have a > or = 10% probability of carrying a BRCA1/2 mutation by at least one mathematic model and should have been offered genetic counseling that included the discussion of genetic testing. There were considerable discrepancies between probability calculations among the three mathematic models. One of the 11 patients who was eligible for genetic testing pursued genetic counseling within 12 months of diagnosis. CONCLUSIONS: At a large academic medical center, a substantial proportion of unselected women attending a multidisciplinary clinic were found to have a > or = 10% risk of carrying a BRCA1/2 mutation. The actual number of patients eligible to receive BRCA1/2 genetic testing outweighs the number of patients seen for genetic counseling at the study institution. Finally, limited correlation was found between current predictive models.