NICE referral criteria ‘miss 95% of women under 50 with higher breast cancer risk’
New research reveals NICE referral criteria used by GPs to decide who should be referred for further breast cancer risk assessment and specialist care miss up to 95% of women under 50 who go on to develop breast cancer within 10 years.
Researchers at the University of Cambridge and The Institute of Cancer Research, London analysed data from 1,258 women taking part in the Breast Cancer Now Generations Study.
Using BOADICEA – a comprehensive risk assessment tool – they identified 8 times as many women in this age group who developed breast cancer as the NICE criteria.
Finding new ways to identify women at increased risk could help to prevent some breast cancers or detect them earlier, when treatment is more likely to be successful.
Identifying women at higher risk
Breast cancer is the most common cancer worldwide, with steady increases in incidence over the last decades. Identifying women at higher risk can allow for additional screening or preventive treatment.
In England, most women at higher risk of breast cancer are identified after being referred by their GP for further assessment and specialist care. The assessment with their GP is based on family history, following criteria set out by the National Institute for Health and Care Excellence (NICE).
Previous studies have shown that risk models that look at multiple risk factors can identify more women at increased risk of breast cancer than family history alone.
So, scientists analysed data from 1,258 women aged under 50 years recruited to the Generations Study between 2004 and 2011.
They compared how good the NICE criteria and several risk assessment approaches using a risk model called BOADICEA were at identifying women who would go on to develop breast cancer. BOADICEA combines factors such as family history, lifestyle, reproductive history and genetic information.
Comparing risk models
The team showed that the NICE criteria fail to identify as many as 95% of women under 50 who are at higher-than-average risk of breast cancer and 95% of women who go on to develop breast cancer within 10 years.
Completing a risk assessment with the full BOADICEA model for all women aged under 50 would result in 26.5% of women being categorised as at above-population level risk and referred for further assessment. This would include 34.8% of women under 50 who develop breast cancer within 10 years.
By comparison, the current NICE criteria would result in 1.4% of women under 50 being referred for further assessment, which would include just 4.4% of those women who develop breast cancer.
A main reason for the disparity, say the researchers, is because 73% of women under 50 years who develop breast cancer within 10 years have no family history of breast cancer.
We need to get better at identifying women at highest risk of breast cancer so that we can intervene early, when there are more options for treating, or even preventing, their disease. The current NICE criteria used in general practice are missing up to 95% of women under 50 who will go on to develop breast cancer. It’s time to look again at these criteria in the light of our findings.
Looking to the future
The researchers recognise that changing the criteria – offering the full BOADICEA risk assessment to all women under 50, for example – would be far more resource intensive and lead to more referrals, many of whom will not develop breast cancer.
Now, the next step is to test how multifactorial risk assessment like this could be implemented safely, equitably, and cost-effectively in routine care.
Overall, this study highlights the value of long-term research like the Breast Cancer Now Generations Study, which is helping us better understand who is most at risk of developing breast cancer and why.
These findings highlight the limitations of NICE’s current referral criteria, and so this research must now be carefully considered as part of the current review of its Family History guidelines. However, it’s equally important that any changes come with the needed investment in family history services, so they can be implemented effectively and fairly across the NHS.
This project was published in the British Journal of Cancer and supported by Cancer Research UK and Breast Cancer Now.
The Generations Study
The Breast Cancer Now Generations Study was set up in 2004 to help understand the causes of breast cancer. This landmark study is uncovering why breast cancer develops – giving hope to the generations of tomorrow.