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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Prevention and early detection of breast cancer

Author Dr Nadia Lusis 
Expert reviewers  Dr Vijenti Chandra

Background

Breast cancer is the most common cancer diagnosed in Aboriginal and Torres Strait Islander women, despite an under-reporting rate of at least 10%.41 Despite the age standardised incidence of breast cancer being estimated at around 30% lower for Aboriginal compared to non-Aboriginal women,3,4 it is estimated that there is a similar burden of disease, that the years of life lost may be 1.5 times higher and mortality rates may be up to 1.5 times greater for Aboriginal women.1,4,41

Aboriginal and Torres Strait Islander women have lower participation rates in mammographic screening programs. The estimated participation of Aboriginal and Torres Strait Islander women in the BreastScreen program for the target age range of 50–69 years, using self identification, has remained constant from 2002–03 to 2007–08 at 36%, while participation of non-Indigenous women rose from 50.0% to 54.8% over the same timeframe.42

Estimating risk based on family history

Estimations of the risk of breast cancer based on family history are available (see Resources). Table 15.2 highlights risk categories based on the National Breast and Ovarian Cancer Centre recommendations.43 The risk calculation may differ from the more up-to-date online resource but is provided for situations where the online resource may not be available.44

Table 15.2. Risk categories for breast cancer based on family history
Category 1
At or slightly above average risk (no more than 1.5 times the population average risk)
Category 2
Moderately increased risk (1.5–3 times the population average risk)
Category 3
Potentially high risk (may be more than 3 times the population average risk)
No confirmed family history of breast cancer
One first degree relative diagnosed with breast cancer at age 50 years or older
One second degree relative diagnosed with breast cancer at any age
Two second degree relatives on the same side of the family diagnosed with breast cancer at age 50 years or older
Two first degree or second degree relatives diagnosed with breast cancer, at age 50 years or older, but on different sides of the family (ie. one on each side of the family)
One first degree relative diagnosed with breast cancer before the age of 50 years (without the additional features of the potentially high risk group – see category 3)
Two first degree relatives, on the same side of the family, diagnosed with breast cancer (without the additional features of the potentially high risk group – see category 3 )
Two second degree relatives, on the same side of the family, diagnosed with breast cancer, at least one before the age of 50 years, (without the additional features of the potentially high risk group – see category 3)
Two first degree or second degree relatives on one side of the family diagnosed with breast or ovarian cancer plus one or more of the following on the same side of the family:
  • additional relative(s) with breast or ovarian cancer
  • breast cancer diagnosed before the age of 40 years
  • bilateral breast cancer
  • breast and ovarian cancer in the same woman
  • Jewish ancestry
  • breast cancer in a male relative
One first degree or second degree relative diagnosed with breast cancer at age 45 years or younger plus another first degree or second degree relative on the same side of the family with sarcoma (bone/soft tissue) at age 45 years or younger
Member of a family in which the presence of a high risk breast cancer or ovarian cancer gene mutation has been established
Source: National Breast and Ovarian Cancer Centre 201043

Interventions

Mammographic screening for women at average or slightly above average risk is currently recommended at 50–69 years, and is available but not recommended as routine for women in this risk group aged 40–49 years. For both of these age groups, mammographic screening has been shown to reduce breast cancer mortality.

There are some concerns about an increased risk of overdiagnosis and overtreatment of breast cancers that may never become clinically significant and the psychological effects of increased investigation for false positive results; this warrants more definitive research to quantify the magnitude of these effects. It should be noted that the risk of breast cancer increases from age 40–69 years, and thus there may possibly be more benefit for older women in each age group. Women should be provided with information to allow an informed decision based on their individual risk and preferences. Routine mammographic screening is not recommended for women younger than 40 years. Routine mammographic screening is not recommended for women aged 70 years or older. The risk of breast cancer increases with age, but decisions about mammographic screening need to take into account general health and other patient factors to decide on potential benefits of screening.45–50 

Participation in mammographic screening may be improved by organised patient reminder and recall systems.51 Strategies to increase participation of Aboriginal and Torres Strait Islander women need to be tailored to suit the local circumstances, including provision of appropriate information on prevention and early detection of breast cancer, female health staff, collaboration between Aboriginal health services and BreastScreen Australia, use of mobile screening units and coordination of screening with health assessment recalls.15–18

Magnetic resonance imaging (MRI) screening combined with mammography has been shown to be more sensitive than mammography alone in women younger than 50 years at high risk of breast cancer. This option may be considered as part of specialist review. A Medicare rebate is available when referred by a specialist.52

Population screening by regular clinical breast examination cannot be recommended due to lack of evidence that it reduces mortality from breast cancer.48,50,53

Regular breast self examination cannot be recommended due to lack of evidence that it reduces mortality from breast cancer.50,53–55

Hormone replacement therapy (HRT), ie. combined (oestrogen-progesterone) at or around the time of menopause increases the risk of breast cancer. The risk increases with duration of use, especially after 5 years. Women should be informed of the risks and benefits of HRT use to allow an informed decision to be made. For women who have had a hysterectomy, oestrogen-only HRT may be a better choice.56 Current evidence suggests that use of combined HRT does not have an additive effect when combined with a family history risk of breast cancer.57

Chemoprophylaxis (ie. tamoxifen and raloxifene) have shown some benefit in preventing breast cancers, though with a risk of adverse effects. At December 2010, neither had Pharmaceutical Benefits Scheme approval for primary prevention of breast cancer in Australia. Trials of aromatase inhibitors are also being conducted.54,58–60

Recommendations: Breast cancer prevention and detection
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All women Ask about family history of breast cancer to ascertain the individual risk of developing breast cancer (see Table 15.2) As part of an annual health assessment GPP43
Discuss ‘breast awareness’ rather than promoting regular breast self examination (ie. ‘get to know what your breasts normally look and feel like’) and ask women to promptly report persistent or unusual changes IIC50,53–55
Women aged 40–49 years at or slightly above average risk (see Table 15.2) Routine mammographic screening is not recommended
If requested, provide information about mammographic screening to allow an informed decision based on individual risk and preferences
N/A IB46,49,50,61
Women aged 40–49 years at moderately increased risk (see Table 15.2) Consider annual mammography starting at age 40 years
Consider referral to family cancer clinic or specialist cancer clinic where available for initial assessment of risk of developing cancer. This includes advice on the role of genetic testing, strategies to reduce risk of cancer, and information about early detection (see Resources)
Annually GPP43
Women aged 50–69 years at or slightly above average risk (see Table 15.2) Recommend mammography screening and provide information to allow an informed decision based on individual risk and preferences Every 2 years IB45–50,62
Women aged 50–69 years at moderately increased risk (see Table 15.2) Recommend routine mammography screening
Consider referral to family cancer clinic* or specialist cancer clinic for initial assessment
Every 2 years GPP43
Women at potentially high risk of breast cancer (see Table 15.2) Recommend mammographic screening regardless of age Consider annually GPP43
Offer referral to a family cancer clinic* for risk assessment, possible genetic testing and development of a management plan When calculated to be at potentially high risk, and as needed GPP43
Consider MRI breast screening in addition to mammography if aged <50 years. (Specialist referral is required to claim a Medicare rebate) Consider annual screening depending on specialist advice IIIB52
Consider clinical breast examination As part of a well women’s check GPP43
Behavioural All women Promote physical activity as physical inactivity increases the risk of breast cancer (see Chapter 1: Lifestyle, section on physical activity) As part of an annual health assessment (see Chapter 1: Lifestyle,)   IIIB1,63,64
Advise that alcohol consumption increases the risk of breast cancer, and that if alcohol is consumed it should be done at safe levels (see Chapter 1: Lifestyle, section on alcohol) IIIB38,64–66
Advise that cigarette smoking increases the risk of breast cancer, and support people who smoke to quit (see Chapter 1: Lifestyle, section on smoking) IIIC67,68
Advise that maintaining a healthy weight lowers the risk of breast cancer (see Chapter 1: Lifestyle, section on overweight/obesity) IIIB64
Pregnant and breastfeeding women Advise that breastfeeding has been shown to reduce the risk of breast cancer, and support women to breastfeed their infants (see Chapter 2: Child health, section on anaemia) During and following pregnancy IIIB64,69
Women on combined hormone replacement therapy (HRT) Advise about risks and benefits of combined HRT; in particular advise about increased risk of breast cancer with continuous use for more than 5 years When considering commencing HRT and every 6 months for women on combined HRT I-IIIA56,70,71
Chemoprophylaxis Women at potentially high risk, and women aged >35 years at moderate risk Consider specialist referral to discuss preventive treatment with tamoxifen or raloxifene
Use is not currently approved for subsidy under the Pharmaceutical Benefits Scheme for the primary prevention of breast cancer
(See Resources)
IIID54,58–60
* Family cancer clinics provide counselling and information for families with a history of cancer on inheriting cancer, individual risk, screening, cancer risk reduction strategies, and genetic testing where appropriate. Clinics are conducted through the public hospital system and there is no direct cost to the patient for consultation or genetic testing. Location of family cancer clinics in Australia can be found at
www.cancer.org.au/ File/Aboutcancer/Family_Cancer_Clinics_ 31OCT06.pdf

Resources

Family cancer clinics (Cancer Australia)
http://canceraustralia.nbocc.org.au/ fraboc/clinic.html

Online calculator, familial risk assessment – breast and ovarian cancer (National Breast and Ovarian Cancer Centre)
www.nbocc.org.au/fraboc/ or http://canceraustralia.nbocc.org.au/fraboc

Advice about familial aspects of breast cancer and epithelial ovarian cancer (National Breast and Ovarian Cancer Centre
www.nbocc.org.au/ view-document-details/bog-advice-about-familial-aspects-of-breast-cancer-and-epithelial-ovarian-cancer

Advice for women seeking advice about risk reducing medication (Cancer Australia)
http://canceraustralia.nbocc.org.au/ view-document-details/rrm-risk-reducing-medication-for-women-at-increased-risk-of-breast-cancer-due-to-family-history.

References

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