1. Managing your risk
There are options to help manage your risk if a breast cancer risk assessment shows you have an increased risk of developing breast cancer because of an inherited altered gene, or your risk is increased because of your family history.
If you have an altered gene, such as BRCA1, BRCA2, PALB2 or TP53, your risk level will depend on which altered gene you have. Learn more about how different inherited altered genes affect breast cancer risk.
You cannot reduce your family history risk of breast cancer. If you’d like information about breast cancer risk and lifestyle factors like alcohol, smoking and physical activity, see our Reducing your risk of breast cancer page.
2. Breast screening for people at increased risk
Breast screening
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If you’ve been assessed as being at moderate or high risk of developing breast cancer, depending on your age you’ll be offered regular breast screening to check for breast cancer. This is known as enhanced screening or surveillance.
The aim of screening is to detect breast cancer early, before there are any obvious signs or symptoms.
The sooner breast cancer is diagnosed, the more successful treatment is likely to be.
Your family history clinic or genetics team will arrange your breast screening. Depending on your risk level, this will either be within the breast clinic or through referral to a local NHS breast screening programme.
You can find out more about screening recommendations depending on your risk level and age in our booklet Family history of breast cancer: managing your risk.
What does breast screening involve?
Breast screening may include a and/or an .
The type of breast screening you’re offered will depend on:
- Your age
- Whether you’ve had breast cancer
- Your level of risk
As well as carrying out a family history risk assessment, some genetic clinics may also do a more detailed cancer risk assessment to decide what screening you should have.
Younger women are not usually offered mammograms. This is because they’re more likely to have dense breast tissue, which can make mammogram images less clear.
If you’re at high risk, the type of breast screening will also depend on your individual likelihood of being a gene carrier.
Your genetics team should give you information about the possible advantages and disadvantages of breast screening.
Whether you go for breast screening is your choice. It’s important you have the information you need to make your decision.
A small number of women at very high risk will be offered breast screening before the age of 30. Your genetics team will assess your individual risk and refer you to the NHS breast screening programme for regular MRI scans if you’re eligible.
Screening recommendations for women who have had breast cancer
If you have had breast cancer, you’ll have increased breast screening as part of your follow-up care. You will have this for 5 years or longer, depending on your age. The screening you have after the 5-year period ends will be tailored to your individual risk level.
National (population) breast screening programmes
Once your increased breast screening stops, you’ll usually be transferred onto a national (sometimes called population) breast screening programme.
If you’re 70 or under, you’ll be invited for a routine mammogram every 3 years.
After the age of 70 you can still have a mammogram every 3 years, but you’ll have to contact your local breast screening unit to get an appointment.
Is there screening for ovarian cancer?
There’s currently no NHS screening programme for ovarian cancer. This is because there isn’t an effective way of detecting ovarian cancer at an early stage.
However, the National Institute for Health and Care Excellence (NICE) guidance on familial ovarian cancer does state that screening can be “considered” for some people who have a known increased risk.
Ongoing research is looking at ways of screening for ovarian cancer. Your genetics team will talk to you about any trials that may be suitable for you.
Why are men with an altered gene not offered breast screening or risk-reducing options?
Men are not offered breast screening or risk-reducing options, even if they have an altered gene. This is because their overall risk of breast cancer is lower than women in the general population.
It’s still important to check your chest area regularly and know what looks and feels normal for you.
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3. Medication to reduce the risk of breast cancer
If you’re at moderate or high risk, your genetics team should talk to you about the possibility of medication to reduce your risk.
Taking medication to reduce the risk of breast cancer is known as chemoprevention. This is not the same as chemotherapy, which is used to treat cancer.
You should be told about all the possible risks and benefits of these medications, and by how much they may reduce your risk of developing breast cancer.
Tamoxifen, anastrozole and raloxifene are available on the NHS for some women with an increased risk of developing breast cancer.
Research shows taking tamoxifen, anastrozole or raloxifene for 5 years can help reduce the risk of developing breast cancer in women at moderate or high risk due to their family history.
However, the evidence remains uncertain for people with an altered gene. Current evidence suggests while risk-reducing medication may benefit people with an altered BRCA2 gene, the benefit for people with an altered BRCA1 gene is less clear.
At the moment, it’s unclear whether risk-reducing medication benefits people with other altered genes. If you have questions about this, speak to your genetics team.
Who might be offered risk-reducing medication?
Your team may recommend you take tamoxifen for 5 years if:
- You’re at high risk
- You’re over 35 years old
- You have not been through the menopause (are pre-menopausal)
Tamoxifen may also be considered if you are pre-menopausal and at moderate risk.
If you’re at high risk and post-menopausal (no longer having periods), your team may recommend anastrozole, tamoxifen or raloxifene for 5 years. This may also be considered if you are post-menopausal and at moderate risk.
If you have an altered gene, you may be offered risk-reducing medication, depending on the type of gene.
If you decide to take risk-reducing medication, you’ll still be offered regular breast screening.
You will not be offered medication if you have already had risk-reducing surgery (see more about this further down).
Deciding whether to have risk-reducing medication
Your genetics or breast team will talk to you about the possible benefits and side effects of medication.
They’ll also tell you by how much the medication may reduce your chances of developing breast cancer. This will depend on your individual situation.
NICE has decision aids for both pre- and postmenopausal women who may be considering medication to reduce their risk of developing breast cancer.
Side effects
Like all drugs, tamoxifen, anastrozole and raloxifene can cause side effects.
Tamoxifen and anastrozole commonly cause menopausal symptoms. These include:
- Hot flushes
- Night sweats
- Vaginal dryness
- Reduced sex drive
- Mood changes
These symptoms are often more intense than when the menopause happens naturally.
Raloxifene can cause side effects such as hot flushes and sweats, and flu-like symptoms.
Tamoxifen and raloxifene increase the risk of blood clots, such as a DVT (deep vein thrombosis). If you have a history of blood clots, you may not be able to take these drugs.
You should not take tamoxifen, anastrozole or raloxifene if you’re pregnant or planning to start a family as the drugs may be harmful to a developing baby.
Life during treatment
Going through breast cancer treatment can affect you physically and emotionally. Read our tips to help you cope.
If you have had or are having treatment for breast cancer
If you’ve had breast cancer, because of your family history you’ll have a slightly higher risk of developing a new primary breast cancer. This is different from the original breast cancer coming back (recurrence).
If your family history puts you at moderate or high risk, you may continue to have increased screening after your follow-up period ends.
If you had genetic testing during your breast cancer treatment and were found to have an altered gene, your treatment team may discuss additional surgery to reduce your risk of developing a new breast cancer.
This may be offered at the same time as the surgery to treat your breast cancer. Having an altered BRCA gene may also affect the breast cancer treatments you’re offered.
If you have genetic testing after finishing treatment for breast cancer, your genetics or treatment team may talk to you about your individual risk of recurrence when discussing options for managing your genetic risk.
Your treatment team will talk through your options and support you with your decision. Your genetics team may also arrange for you to see a women’s reproductive health specialist (gynaecologist) or cancer specialist (oncologist) to discuss surgery to reduce the risk of ovarian cancer.
4. Risk-reducing surgery
Risk-reducing surgery involves removing the breast tissue from both breasts. This type of surgery is called a bilateral mastectomy.
A bilateral mastectomy can significantly reduce the risk of developing breast cancer by 90 to 95%, but it cannot completely remove the risk. This is because it’s not possible to remove all the breast tissue during a mastectomy.
Who might be offered risk-reducing surgery?
Your genetics or breast team should discuss the possibility of risk-reducing surgery if:
- You’re at high risk of developing breast cancer
- You have an altered BRCA1, BRCA2, PALB2 or TP53 gene
Risk-reducing surgery may also be an option if you’ve had breast cancer and are at high risk of developing another breast cancer.
If you have an altered CHEK2 or ATM gene, surgery may be discussed with you depending on your family history.
What does risk-reducing surgery involve?
The 2 main types of risk-reducing surgery are:
- Bilateral mastectomy – removal of both breasts including the nipples
- Nipple-sparing mastectomy – removal of both breasts but leaving the nipples
Breast reconstruction
Breast reconstruction is surgery to create a new breast shape after mastectomy.
Your surgeon should discuss with you all the possible risks and benefits of having risk-reducing surgery. They may explain why they think a particular breast reconstruction option is best for you.
Breast reconstruction is usually offered at the time of your risk-reducing surgery (immediate reconstruction). However, you can have reconstruction months or years after your risk-reducing surgery (delayed reconstruction).
You may be advised not to have a breast reconstruction or to consider a delayed reconstruction. This is usually because of other medical conditions or lifestyle factors that may increase the risk of complications during or after surgery.
Some women choose not to have reconstruction and prefer to wear an external breast form (prosthesis). Others choose not to have a reconstruction or use a prosthesis.
Deciding whether to have risk-reducing surgery
Choosing whether to have risk-reducing surgery is a very personal decision.
There’s no right or wrong choice and it’s important to do what feels right for you.
There are lots of factors to consider, including the type of surgery to have and the timing of your surgery.
You can find more information about making this decision in our booklet Family history of breast cancer: managing your risk. You may also find it helpful to talk to someone else who has been through this decision process – find out about our Someone Like Me service at the bottom of this page.
Surgery to remove the ovaries and fallopian tubes
If you have an altered BRCA1 or BRCA2 gene, you’re also at higher risk of developing ovarian cancer.
Ovarian cancer risk starts to increase significantly:
- From the age of 40 for people who have an altered BRCA1 gene
- From the age of 45 for people who have an altered BRCA2 gene
For pre-menopausal women who have an altered BRCA1 or BRCA2 gene, having surgery to remove the ovaries and fallopian tubes has been shown to reduce the risk of ovarian cancer by up to 90 to 95%.
This type of surgery is known as a risk-reducing bilateral salpingo-oophorectomy (RRBSO).
For pre-menopausal women who have an altered BRCA2 gene, some studies suggest having an RRBSO may also reduce the risk of breast cancer.
Your genetics team can explain more about the risks and benefits of the surgery.
PROTECTOR trial
There is ongoing research looking at performing RRBSO surgery over 2 operations. The fallopian tubes are removed first, and the ovaries are removed during a later operation. The benefit of this approach is that it delays the onset of menopausal symptoms.
This surgery is currently only offered in the UK as part of a clinical trial called the PROTECTOR trial. Your specialist team will let you know if this is offered at your hospital and if you’re eligible for this trial.
Deciding whether to have surgery
You’ll see a gynaecologist who can advise you on when you may want to consider risk-reducing surgery to the ovaries and fallopian tubes.
Deciding whether or when to have an RRBSO is a very personal decision.
Things to consider include:
- Your age
- If you want to have children or add to your existing family
- Whether you have an altered BRCA1 or BRCA2 gene
The womb is not usually removed as part of an RRBSO. However, if you have any other benign (not cancer) womb conditions, your genetics team may also discuss removing the womb at the same time as your ovaries and fallopian tubes. This is known as a total hysterectomy.
Managing menopausal symptoms after surgery
If you’re pre-menopausal, having an RRBSO will cause an early menopause. You’ll stop having periods and you’ll no longer be able to get pregnant.
Menopausal symptoms can sometimes be severe and have a significant impact on quality of life. Learn more about managing these symptoms.
5. The pill and cancer risk
If you have a family history of breast cancer, you can usually still take the oral contraceptive pill.
However, if you’re over 35 your GP will discuss this with you. This is because there is a very slight increased risk of breast cancer associated with taking the contraceptive pill. This risk increases with age.
If you have an altered BRCA1 gene, this will also be discussed with you. This is because the contraceptive pill can slightly increase your risk of breast cancer while reducing ovarian cancer risk.
The pill should not be taken just to reduce the risk of ovarian cancer. Your genetics team can discuss this with you.
Learn more about the pill and breast cancer risk.
6. HRT and cancer risk
Hormone replacement therapy (HRT) and breast cancer risk
Find out if HRT increases the risk of breast cancer and what to consider if you’re deciding whether to take HRT.
If you’re taking, or thinking about taking, hormone replacement therapy (HRT), it’s important to discuss this with your GP, treatment team or a menopause specialist. They will consider your individual family history and risk level, as well as other factors like your age, to help decide if HRT would be suitable for you.
If your family history means you have a moderate or high risk of developing breast cancer, or you have an inherited altered gene such as BRCA1, BRCA2 or PALB2, you may be advised not to take HRT as it could increase your risk further.
Alternatives to HRT are available to help manage menopausal symptoms. Your genetics team or GP can provide information and advice about these.
7. Useful organisations
Breast reconstruction
Flat Friends
A UK charity dedicated to supporting people who have chosen not to have breast reconstruction, as well as those waiting for delayed reconstruction or still deciding.
Keeping abreast
Provides information, support, practical help and advice for those considering breast reconstruction, as well as real-life patient stories.
Restore: Breast Cancer Reconstruction Support
Information and support around breast reconstruction.
Family history, cancer risk and altered genes
FORCE (Facing Our Risk of Cancer Empowered)
For individuals and families with an altered gene or at high risk of breast and ovarian cancer. Based in the USA but has a UK support network.
Macmillan Cancer Support
Provides information about family history, genetics and cancer risk. Also publishes a booklet called “Understanding risk-reducing breast surgery”.
Royal Marsden NHS Foundation Trust
Publishes a booklet called “A beginner’s guide to BRCA1 and BRCA2”, also available online.
Menopause and menopausal symptoms
Women’s Health Concern
The patient arm of the British Menopause Society (BMS).
Ovarian cancer
Eve appeal
Funds research and raises awareness of gynaecological cancers, including ovarian cancer, and has information on inherited risk.
Ovacome
Support and information for women affected by ovarian cancer, their families and friends.
Ovarian Cancer Action
Provides information and support to women with ovarian cancer.
8. Further support
For more information about managing your risk of breast cancer, as well as your family’s risk, see our Family history of breast cancer: managing your risk booklet.
If you have any concerns about breast cancer risk and your family history, you can speak to our specialist nurses through our free helpline – see below.
Our Someone Like Me service can also put you in touch with someone who has been through a similar experience to you. They’ll be on hand to answer your questions and offer support – see below.
You can also talk to other people about how they manage their risk through our online forum.
