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

Chapter 15: Prevention and early detection of cancer
Prevention and early detection of breast cancer
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☰ Table of contents

Recommendations: Prevention and early detection of breast cancer

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

 All women
 		 Ask about family history of breast cancer to ascertain the individual risk of developing breast cancer (refer to Box 1 and to ‘Resources’ for online calculator and more detail) As part of annual health assessment GPP 56–59
Discuss ‘breast awareness’ rather than promoting regular breast self-examination and ask women to promptly report persistent or unusual changes

Note: Women with symptoms should be investigated rather than screened for breast cancer		   II, III–IIC 69–72, 79, 80
Women aged 40–49 years at or slightly above average risk* Routine mammographic screening is not recommended

If requested, provide information about mammographic screening to allow an informed decision based on individual risk and preferences		   I, III–IIB 60–65, 81
Women aged 40–49 years at moderately increased risk* Consider annual mammography starting at age 40 years if relative with breast cancer aged <50 years
Consider referral to family cancer clinic or specialist cancer clinic, where available, for further assessment of risk of developing cancer and advice about genetic testing, screening and prevention		 Every 1–2 years GPP 56, 68
Women aged 50–74 years at or slightly above average risk* Recommend mammography screening and provide information to allow an informed decision based on individual risk and preferences

Consider use of a decision aid to facilitate these discussions (refer to ‘Resources’)		 Every two years I, III–IIB 60–65, 81
Women aged 50–69 years at moderately increased risk* Recommend routine mammography screening.

Consider annual mammography if relative with breast cancer aged <50 years

Consider referral to family cancer clinic or specialist cancer clinic for further assessment of risk of developing cancer and advice about genetic testing, screening and prevention		 Every 1–2 years GPP 56, 68
Women at potentially high risk of breast cancer*
 		 Advise 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 GPP 56, 68
Screening may involve magnetic resonance imaging (MRI) if aged <50 years, ultrasound, mammography and clinical breast examination. Specialist referral is required to claim a Medicare rebate for MRI Consider annual screening depending on specialist advice III–IIB 56, 6, 68

Behavioural

 All women Provide lifestyle risk factor counselling on the benefits of regular physical activity, maintaining healthy weight, alcohol intake in the low-risk range, avoiding smoking, restricting energy intake and dietary fat (refer to Chapter 1: Lifestyle) As part of annual health check assessment (refer to Chapter 1: Lifestyle) III–IIB 82–85
Pregnant and breastfeeding women Advise that breastfeeding has been shown to reduce the risk of breast cancer, and support women to breastfeed their infants (refer also to Chapter 3: Child health, ‘Anaemia’) During and following pregnancy III–IIB 86, 87
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 >5 years When considering commencing HRT and every six months for women on combined HRT I, III–IIA 73, 88

Chemo-prophylaxis

 Women at potentially high risk, and women aged >35 years at moderate risk Consider specialist referral to discuss preventive treatment with tamoxifen or raloxifene

Tamoxifen is approved for subsidy under the PBS for the primary prevention of breast cancer and is able to be prescribed by GPs as well as medical specialists		 When calculated to be at potentially high risk, and as needed I, III–IIB 68, 74–77
*Refer to Box 1 for risk categories.

 

Box 1. Breast cancer risk categories based on family history56

1. At or slightly above average risk

Covers more than 95% of the female population

As a group, risk of breast cancer up to age 75 is between 1 in 11 and 1 in 8. This risk is no more than 1.5 times the population average.

  • No confirmed family history of breast cancer
  • One 1° relative diagnosed with breast cancer at age 50 or older
  • One 2° relative diagnosed with breast cancer at any age
  • Two 2° relatives on the same side of the family diagnosed with breast cancer at age 50 or older
  • Two 1° or 2° relatives diagnosed with breast cancer, at age 50 or older, but on different sides of the family (ie one on each side of the family)

2. Moderately increased risk

Covers less than 4% of the female population

As a group, risk of breast cancer up to age 75 is between 1 in 8 and 1 in 4. This risk is 1.5 to 3 times the population average.

  • One 1° relative diagnosed with breast cancer before the age of 50 (without the additional features of the potentially high-risk group – refer to category 3)
  • Two 1° relatives, on the same side of the family, diagnosed with breast cancer (without the additional features of the potentially high-risk group – refer to category 3)
  • Two 2° relatives, on the same side of the family, diagnosed with breast cancer, at least one before the age of 50, (without the additional features of the potentially high-risk group – refer to category 3)

3. Potentially high risk

Covers less than 1% of the female population

As a group, risk of breast cancer up to age 75 is between 1 in 4 and 1 in 2. Risk may be more than 3 times the population average. Individual risk may be higher or lower if genetic test results are known.

  • Women who are at potentially high risk of ovarian cancer
  • Two 1° or 2° 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
    • bilateral breast cancer
    • breast and ovarian cancer in the same woman
    • Jewish ancestry
    • breast cancer in a male relative.
  • One 1° or 2° relative diagnosed with breast cancer at age 45 or younger plus another 1° or 2° relative on the same side of the family with sarcoma (bone/soft tissue) at age 45 or younger.
  • Member of a family in which the presence of a high-risk breast cancer gene mutation has been established.

Reproduced with permission from Cancer Australia. Advice about familial aspects of breast cancer and epithelial ovarian cancer: A guide for health professionals. Strawberry Hills, NSW: Cancer Australia, 2015; [Accessed 12 January 2018].


Background

Breast cancer is the most common cancer diagnosed in Aboriginal and Torres Strait Islander women.54 The age-standardised incidence of breast cancer is estimated to be 10% lower for Aboriginal and Torres Strait Islander women compared to non-Indigenous women, with mortality rates similar.3
Aboriginal and Torres Strait Islander women have lower participation rates in mammographic screening programs. The estimated participation of self-identified Aboriginal and Torres Strait Islander women in the BreastScreen program for the target age range of 50–69 years was 37% in the two years 2013–14, compared to 54% for non-Indigenous women in the same period, which is similar to the 2011–12 findings.3,55

Estimating risk based on family history

Calculators to estimate the risk of breast cancer based on family history are available. The online calculator (refer to ‘Resources’) provides the most accurate breast cancer risk calculation. However, Box 1 highlights risk categories based on the Cancer Australia recommendations and is provided for situations where the online resource may not be available. For women at potentially higher-than-average risk based on family or personal history of breast or ovarian cancer, referral for specialist advice and testing should be considered.56–59

 

Interventions

Mammographic screening for women at average or slightly above average risk is currently recommended for women aged 50–74 years, and is available but not routinely recommended for women at average risk aged 40–49 years due to a much smaller benefit than for older women. Routine mammographic screening is not recommended for women aged <40 years as there is no evidence of effectiveness and screening results in many false positive mammograms. Mammographic screening in women aged 40–74 years has been shown to reduce breast cancer mortality; however, there are harms associated with overdiagnosis and overtreatment of breast cancer, including psychological effects and costs of investigation for false positive results, and for breast cancers that may never become clinically significant.60,61

Since the start of mammographic screening, breast cancer treatment has improved, which has contributed to reduced mortality rates. In Australia, it is estimated that for every 1000 women who are asymptomatic and at average risk who are screened biannually with mammography from age 50 to 74 years, eight deaths will be prevented and approximately eight (range 2–21) women will be diagnosed with cancer that would not otherwise have been found in their lifetime. It should be noted that the risk of breast cancer increases from age 40 to 74 years, thus there is a greater benefit from screening older women in this age range. Women should be provided with information to allow an informed decision based on their individual risk and preferences. Mammographic screening is not routine for women aged ≥75 years as there is no evidence it is effective in reducing breast cancer mortality, and other health issues need to be taken into account.

Patient decision-aid tools may be helpful in discussing risks and benefits of breast screening with individual women.60–65
Participation in mammographic screening may be improved by organised client reminder and recall systems.66 Strategies to increase participation of Aboriginal and Torres Strait Islander women need to be tailored to suit 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.13,15

Magnetic resonance imaging (MRI) screening combined with clinical examination and/or other imaging techniques is more sensitive in women aged <50 years at high risk of breast cancer. MRI may be considered as part of a specialist review. A Medicare rebate is only available when patients meet the criteria and are referred for this test by a specialist or consultant physician.67,68

Regular breast examination is not recommended. Population screening for women at average risk with regular clinical breast examination is not recommended due to lack of evidence that it reduces mortality from breast cancer.61,69–71 Regular breast self-examination cannot be recommended due to lack of evidence that it reduces mortality from breast cancer. Women should be ‘breast aware’ (ie know what their breasts are usually like) and be reviewed and investigated if any breast symptoms are noted.69–72

Hormone replacement therapy (HRT) may be considered for intolerable peri-menopausal symptoms if not contraindicated and after discussion of risks and benefits to allow an informed decision to be made about use. Combined HRT (ie oestrogen and progesterone) at or around time of menopause increases the risk of breast cancer. The risk increases with duration of use, especially after five years’ use. For women who have had a hysterectomy, oestrogen-only HRT may be a better choice as evidence shows a non-statistically significant reduction in breast cancer risk after seven years’ use, and overall a more favourable risk profile.73

Chemoprophylaxis (eg with tamoxifen and raloxifene, aromatase inhibitors such as exemestane and anastrozole) has shown some benefits in preventing breast cancers and may be useful in those at moderate to high risk, although these medications have a risk of adverse effects. Currently (January 2018) only tamoxifen has PBS approval for primary prevention of breast cancer in women at moderate or high risk of breast cancer.68,74–77

Risk-reducing surgery may also be an option for high-risk women, although the effect of this on mortality is uncertain.58,78
 

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

 





 
 
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