Asymptomatic Patients with a Family History of Breast Cancer

 

This guideline applies to adults over 18 years who do not have any symptoms of breast cancer.

 

Introduction:

• The lifetime risk of breast cancer is 1 in 8 (regardless of family history).
• Most patients with breast cancer do not have a gene fault/ mutation.
• Each child of a gene mutation carrier has a 1 in 2 (50%) chance of inheriting the gene mutation.

 

Key Features of Assessment:

1. If any breast symptoms follow the RMS Breast guidelines (note those patients already under the family history service can contact them with symptoms also)
    
2. Check if any known genetic fault (i.e. high risk) e.g. BRCA 1 or 2
    
3. Check if meets moderate risk criteria (see below)
    
4. Check if meets any familial breast cancer additional risk criteria

Management:

• Breast symptoms:
  • Follow RMS breast guidelines (e.g. breast lump and suspected breast cancer, nipple discharge)
     
• Low risk patients (i.e. not meeting criteria or deemed low risk after assessment):
  • Reassure them that their risk of developing breast cancer is similar to that of the general population (about 1 in 8 women).
  • Advise them to seek advice if another relative is diagnosed with cancer as their risk may change.
     
• Moderate/High risk patients:
  • Please see Referral guidelines below
     

• General advice on decreasing breast cancer risk:
  • Give advice on reducing alcohol, stopping smoking, exercise and weight reduction.
  • Advise about self-examination. See leaflet: Coppafeel – Boob Check Basics
  • Useful leaflets:
    • Breast Cancer Now: Breast Cancer Symptoms
    • Breast Cancer Now: Family History and Breast Cancer

• Combined Oral Contraceptive Pill (COCP) and the risk of breast cancer:
  • Significantly reduces risk of developing ovarian cancer (but this must be weighed against the increased breast cancer risk in families where there is a predisposition to breast or ovarian cancer).
  • Small possible increased risk of breast cancer which returns to normal 10 years after stopping the COCP.
     

• HRT and the risk of breast cancer:
  • Oestrogen-only HRT= little or no change in risk of breast cancer, but increased risk of ovarian cancer
  • Combined HRT = small increased risk of breast cancer (the risk is related to duration of HRT use and decreases after stopping it)
  • Patients with a moderate risk of familial breast cancer:
    • HRT is not contra-indicated
    • HRT can be associated with a small increase in the risk of breast cancer. This risk is in addition to any family history risk but does not multiply it.
    • Advise the patient to use the lowest dose possible to manage their symptoms, for the shortest period of time.
  • Advise patients on HRT it is especially important to attend breast screening appointments.
  • If the patient has a personal history of cancer they should discuss the risks of HRT with their specialist.
  • If clinical uncertainty or needing advice about starting/continuing HRT/COCP in a patient:send an advice and guidance request to the family history clinic. Do not write directly.

 

 

Advice and Guidance

There is a Family History Breast Cancer Advice and Guidance service available. All requests should be sent via e-RS.

 

 

Referral:

• Known genetic fault history in family (any age) e.g. BRCA 1 or 2 
  • Refer Peninsula Clinical Genetics
     

• Younger than 60 years old (no known genetic fault):
  • With moderate breast cancer risk criteria: Refer Family History Clinic at the Mermaid Centre
  • With additional breast cancer criteria: Refer advice and guidance to family history Clinic at the Mermaid Centre

Inform patient:
1. They will be sent a link to a secure web-based app where they will be asked to complete family history details (paper-based still an option for those who need it).

2. Patient will be offered an opportunity for a telephone call if required or family history more complex.

Following assessment:

If the family history clinic assesses a patient as:

 - High risk they will refer the patient to Peninsula Genetics

 - Moderate risk they will have:

Annual mammograms aged 40-50 years

A small number of patients will have surveillance until 60 years

 

• Older than 60 years (no known genetic fault):
  • Patients over 60 years old meeting the moderate or additional risk criteria are not eligible for surveillance, but they can still be referred if they wish to be considered for chemoprevention (following a risk assessment).

 

Supporting Information

For professionals:

• Clinical Knowledge Summaries (CKS) – Scenario: Breast Cancer – Managing Family History: What Information and Support Should I Provide?
• NICE Guidelines – Familial Breast Cancer: Classification, Care and Managing Breast Cancer and Related Risks in People with a Family History of Breast Cancer

 

For patients:

• Breast Cancer Now:
  • Family History: Assessing Your Breast Cancer Risk
  • Family History of Breast Cancer: Managing Your Risk
• Women’s Health Concern:
  • Understanding the risks of breast cancer
  • HRT and breast cancer risk

 

 

Page Review Information

 

Review date	May 2024
Next review date	May 2026
Clinical editor	Dr Madeleine Attridge
Contributors	Dr Eleanor Thorpe Dr Rachel Evers Dr Rebecca Osborne GPwSI Breast, RCHT