1. Breast screening for people at increased risk
2. Breast screening for people at increased risk who have had breast cancer
3. Drug treatment to reduce the risk of breast cancer
4. Risk-reducing surgery
5. Clinical trials
6. Fertility and risk-reducing treatment
If you are at moderate or high risk of developing breast cancer, your specialist will talk to you about having breast screening (such as regular mammograms) and/or risk-reducing treatment (such as drug treatment or surgery) to manage your risk. You can find more information below on the options that might be available.
This information is also for gene carriers (people who have been confirmed as having inherited an altered gene), and people who have had breast cancer and are at increased risk of developing another breast cancer.
If you have been assessed as being moderate or high risk of breast cancer, you will be offered regular scans and/or mammograms to check for breast cancer. This is known as screening. The aim of screening is to pick up breast cancer before there are any obvious signs or symptoms.
The sooner breast cancer is diagnosed, the more effective treatment is likely to be. However, going for breast screening will not prevent a breast cancer from developing. Find out more about the possible benefits and risks of screening.
The type of screening you’ll be offered will depend on:
- your age
- whether you’ve had breast cancer
- your level of risk.
If you’re at high risk, the type of screening will also depend on your individual likelihood of being a gene carrier. If you are told that you have more than a 30% chance of being a gene carrier, your screening will start earlier and go on for longer.
Screening may include a mammogram (a breast x-ray) or an MRI (magnetic resonance imaging) scan (uses magnetic fields and radio waves to produce a series of images of the inside of the breast).
Younger women won’t usually be offered mammograms as they are more likely to have dense breast tissue, making the mammogram images less clear.
NICE screening recommendations for women at moderate or high risk of breast cancer who haven’t had breast cancer
Once your increased screening stops, you’ll usually be transferred onto a national (sometimes called population) breast screening programme.
Men are not offered screening, even if they are gene carriers. This is because even though a man’s risk for developing breast cancer increases, the increased risk is still less than women in the general population.
If you’ve had breast cancer you will have increased screening for five years as part of your follow-up care.
Once your follow-up period ends, if you are at moderate risk you will have the same screening recommendations as women at moderate risk who have not had breast cancer (as above).
If you remain at high risk of developing another breast cancer or are a BRCA gene carrier, once your follow-up care ends you should be offered:
- yearly MRI scans if you’re aged 30–49
- yearly mammograms if you’re 50–69.
If you’re over 70 (or 73) and your follow-up period has ended, you can still ask for a mammogram every three years as part of a national breast screening programme.
If you have an altered TP53 gene, you will not be offered mammograms but you may be offered yearly MRI scans between the ages of 20-69.
If you’re at moderate or high risk, your healthcare professional should talk to you about the possibility of treatment to reduce your risk.
You should be told about all the possible risks and benefits of these treatments, and by how much they may reduce your risk of developing breast cancer.
Men are not offered risk-reducing treatment, even if they are at increased risk or are gene carriers. This is because even though their risk is increased it is still less than women in the general population.
Research has shown that taking drugs called tamoxifen, anastrozole or raloxifene for five years can help reduce the risk of developing breast cancer in women at moderate or high risk. However, the evidence for gene carriers is limited. Current evidence suggests while drug treatment may be useful in BRCA2 gene carriers, the benefit for BRCA1 gene carriers is less certain.
Who might be offered drug treatment?
For pre-menopausal women (women who haven’t yet been through the menopause) at high risk, your genetics team may recommend tamoxifen for five years. This may also be considered if you are pre-menopausal and at moderate risk.
For post-menopausal women at high risk of breast cancer, your genetics team may recommend tamoxifen, anastrozole or raloxifene for five years. This may also be considered if you are post-menopausal and at moderate risk.
NICE (National Institute for Health and Care Excellence) have produced several decision aids to help women at moderate or high risk decide whether to have drug treatment. You can find them on their website under 'Tailored education support'.
Oral contraceptive pill and cancer risk
Evidence has shown that taking the oral contraceptive pill (OCP) can protect women from developing ovarian cancer, and the longer you take it the greater the benefit. However, it can also slightly increase the risk of developing breast cancer, but when you stop taking it this increased risk starts to decrease and goes back to that of the general population after 10 years.
Taking the OCP may slightly increase and decrease your risk of some other cancers too. There aren’t any guidelines that recommend taking the OCP to reduce the risk of ovarian cancer and your genetics team can discuss this with you.
Risk-reducing surgery is an option for gene carriers and for some women at high risk, whether they have or haven’t had breast cancer. It will not be offered to women at moderate risk.
Surgery to remove both breasts
If you are at high risk of developing breast cancer, or are a BRCA1/2 or TP53 gene carrier, your healthcare professional should discuss the possibility of surgery to reduce your breast cancer risk.
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 90–95%, but it cannot completely remove the risk.
Risk-reducing mastectomy (to both breasts or to the remaining breast) is also an option for women who have had breast cancer and are at high risk of another breast cancer developing.
You’ll usually be offered breast reconstruction at the same time as a bilateral mastectomy.
Your healthcare professional should discuss with you all the possible risks and benefits of having risk-reducing surgery. You may also find it helpful to read Macmillan Cancer Support’s Understanding risk-reducing breast surgery booklet.
Surgery to remove both ovaries and fallopian tubes
Women who carry an altered BRCA1 or BRCA2 gene are also at higher risk of developing ovarian cancer. Ovarian cancer risk starts to increase significantly from the age of 40 for BRCA1 gene carriers and from the age of 50 for BRCA2 gene carriers.
For pre-menopausal women who are gene carriers, having surgery to remove the ovaries and fallopian tubes has been shown to reduce the risk of ovarian cancer by up to 90–95%. This type of surgery is known as a bilateral salpingo-oophorectomy (BSO). For pre-menopausal women who carry the altered BRCA2 gene, it may also reduce the risk of breast cancer.
Your specialist team will be able to advise you on when you may want to have risk-reducing surgery to the ovaries and fallopian tubes. Factors to consider will include your age, if you want to have children or add to an existing family and whether you are a BRCA1 or BRCA2 gene carrier.
If you have any other benign (not cancer) womb conditions, your specialist may also discuss removing the womb at the same time as your ovaries and fallopian tubes (a total hysterectomy).
Deciding whether, or when, to have a risk-reducing BSO is a very personal decision. You may also wish to find more information from OvDex (The Oophorectomy Decision Explorer), a computer program designed to help you make decisions developed by Cardiff University (ovdex.co.uk).
Managing menopausal symptoms following a bilateral salpingo-oophorectomy
If you are pre-menopausal, having a BSO will cause an early menopause. For some women, menopausal symptoms can be severe and have a negative effect on everyday life and intimate relationships.
If you’re under 50 and haven’t had breast cancer, your specialist will discuss the option of taking hormone replacement therapy (HRT) up until the age of a natural menopause (usually around the age of 50) to help with any menopausal symptoms as a result of your surgery. There is good evidence that taking HRT will not affect the reduction in breast cancer risk reduction gained from having the surgery.
If you have had breast cancer, taking HRT after risk-reducing BSO is not usually recommended. However, if your breast cancer was oestrogen receptor negative and your symptoms are affecting your everyday activities your specialist can discuss with you the risks and benefits of taking HRT.
Going through an early menopause can affect your bones, which can increase your risk of developing osteoporosis in the future. If your specialist team is concerned about your risk of developing osteoporosis, they may suggest a DEXA scan at the time of surgery to check your bone health. Follow-up DEXA scans may also be recommended in the future. You can find more information about bone health and osteoporosis on the National Osteoporosis Society website. If you’ve had breast cancer and would like to know more, see our information on breast cancer and bone health.
There are clinical trials to find out more about genes and breast cancer. It’s possible that you’ll be offered the chance to take part in one of these trials.
There is more information on clinical trials on our website, on the Cancer Research UK website or through the Be Part of Research website. BRCA PROTECT is a research clinic set up by University College London to look at new ways of reducing risk in BRCA gene carriers.
Some risk-reducing treatments may affect your fertility, for example surgery to remove the ovaries and fallopian tubes will affect fertility permanently. You will also be advised not to get pregnant while taking tamoxifen, and you should stop taking it for at least eight weeks before trying to conceive.
Your specialist will discuss any effects on fertility with you when considering risk-reducing treatment options.
If you have been diagnosed with breast cancer, some treatments for breast cancer can also affect fertility.