Guidelines for preventive activities in general practice

Cancer

Breast cancer

      1. Breast cancer

Cancer | Breast cancer

Screening and case finding age bar

0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44* 45–49* 50–54 55–59 60–64 65-69 70–74 75–79 ≥80

*Case finding

Breast cancer is the most common cancer in women and the second most common cause of cancer deaths in women in Australia. In 2022, it was estimated that 20,640 new cases of breast cancer would be diagnosed in Australia (20,428 in women, 212 in men). The risk of being diagnosed with breast cancer by the age of 85 years is currently estimated as 1 in 8 (or 13%) for women and 1 in 668 (or 0.15%) for men.1

An assessment should be undertaken to understand a patient’s individual degree of risk (see Table 1) in order to provide evidence-based guidance for preventive activities. Breast cancer risk is not normally distributed: most women have a low (<4%) lifetime risk.2

Table 1. Risk of breast cancer3

Risk level Average or slightly higher Moderately increased (<4% of the female population) Potentially high riskA or carrying mutation (<1% of the female population)
Risk in relation to the population average Approximately 1.5 times the population average Approximately 1.5–3 times the population average More than threefold times the population average
Individual risk may be higher or lower if genetic test results are known
Lifetime prevalence of breast cancer up to age 75 years Between 9% and 12.5% Between 12% and 25% Between 25% and 50%
Relevant history
  • No confirmed family history of breast cancer
  • One first-degree relative diagnosed with breast cancer at age ≥50 years
  • 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
  • Two first- or second-degree relatives diagnosed with breast cancer at age ≥50 years, but on different sides (ie on each side) of the family
  • One first-degree relative diagnosed with breast cancer at age <50 years (without the additional features of the potentially high-risk group)
  • 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)
  • Two second-degree relatives, on the same side of the family, diagnosed with breast cancer, at least one at age <50 years (without the additional features of the potentially high risk group)
  • Two first- or second-degree relatives on one side of the family diagnosed with breast or ovarian cancer, plus one or more of the following features on the same side of the family:
    • additional relative(s) with breast or ovarian cancer
    • breast cancer diagnosed before age 40 years
    • bilateral breast cancer
    • breast and ovarian cancer in the same woman
    • Ashkenazi Jewish ancestry
    • breast cancer in a male relative
  • One first- or second-degree relative diagnosed with breast cancer at age <45 years plus another first- or second-degree relative on the same side of the family with sarcoma (bone/soft tissue) at age <45 years
  • Member of a family in which the presence of a high-risk breast cancer gene mutation (eg BRCA1, BRCA2) has been established
 

There are multiple risk factors for breast cancer (genetic, hormonal, lifestyle and environmental).3 However, BreastScreen, Australia’s national breast cancer screening program, focuses on age, inviting all Australian women aged between 50 and 74 years for biennial mammographic screening. Women are able to self-refer for biennial mammographic screening in BreastScreen from the age of 40 years.

Clinicians have an important role in identifying people with a strong family history of breast cancer, as well as other cancers, associated with high-risk genetic variants (eg in BRCA1 and BRCA2) and offering referral to a familial cancer service. The Genetics chapter provides further information on family history and the use of the family history questionnaire.

Screening

Recommendation Grade How often References
Women at average risk or slightly higher than average risk of breast cancer should participate in mammographic screening from ages 50 to 74 years as part of the national BreastScreen program.
 
Conditionally recommended Every 2 years 2
Screening by mammography is not recommended in women aged ≥75 years due to insufficient evidence to assess the balance of benefits and harms.
 
Generally not recommended N/A 4
Clinical breast examination for breast cancer screening of average risk women in general practice is not recommended.
 
Generally not recommended N/A 5
Do not use magnetic resonance imaging (MRI) as a stand-alone screening test for women at average risk of breast cancer.
 
Not recommended (strong) N/A 6
Do not use thermography in breast cancer screening or as an adjunctive tool to mammography. Not recommended (strong)
 
N/A 7 8 9

Case finding

Recommendation Grade How often References
Undertake mammographic screening from ages 40 to 74 years for women at moderately increased risk. Conditionally recommended At least every 2 years 5

Preventive activities and advice

Recommendation Grade How often References
Counsel all women that the following are associated with lower breast cancer risk:
  • physical activity
  • maintaining a normal body mass index (for postmenopausal breast cancer)
  • minimising alcohol consumption
  • having children
  • breastfeeding
Practice point N/A 3
It is recommended that all women, whether or not they undergo mammographic screening, are aware of how their breasts normally look and feel, and promptly report any new or unusual changes (such as a lump, nipple changes, nipple discharge, change in skin colour, skin texture, pain in a breast) to their GP. No one method for women to use when checking their breasts is recommended over another.
 
Practice point N/A 5

Screening

For asymptomatic, average-risk women, BreastScreen Australia recommends screening mammograms every two years for women aged 50–74 years and actively recalls women in this age bracket.2 However women at average risk may choose to commence mammography through BreastScreen from the age of 40 years.

For women at moderate risk, annual mammograms from age 40 years may be recommended. Annual mammograms are not recommended for women with a single relative diagnosed at age >50 years, because there is no clear evidence of benefit.10

Ongoing surveillance strategies for women at high risk of breast cancer may include imaging with MRI.

A Medicare rebate is available for MRI scans for asymptomatic patients aged <60 years at high risk of breast cancer.11

Reviews of evidence from randomised controlled trials of mammography estimate rates of overdiagnosis of breast cancer of between 11% and 19%.12 More recent modelling data from the US estimate that biennial screening from ages 40 to 74 years would result in 14 overdiagnosed cases of breast cancer per 1000 women screened over the lifetime of screening (estimated range 4–37 overdiagnosed cases).13 Screening mammography in women aged 40–49 years reduces the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women, and the number of false-positive tests and unnecessary biopsies is larger.13

There is controversy on how to screen women with dense breasts. The current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasound or MRI in women identified to have dense breasts on an otherwise negative screening mammogram.4

Thermography is associated with high false-positive and false-negative rates and is not recommended as a screening modality. Polygenic risk scores to determine breast cancer risk may have a role in the future, but are not currently recommended in general practice.

A single nucleotide polymorphism (SNP)-based breast cancer risk assessment test should only be undertaken after an in‐depth discussion led by a clinical professional familiar with the implications of genetic risk assessment and testing, including the potential insurance implications. Genetic testing should be offered only with pre- and post-test counselling to discuss the limitations, potential benefits and possible consequences.14

Estimated risks for factors for which there is sufficiently strong evidence of an association with risk of breast cancer (ie factors for which the body of evidence was classified as either ‘Convincing’ or ‘Probable’, are summarised in table 5.2 of the 2018 Cancer Australia publication Risk factors for breast cancer: A review of the evidence.15

For specific recommendations for Aboriginal and Torres Strait Islander people, please refer to the Prevention and early detection of breast cancer chapter in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.

For women at potentially high risk or carrying a mutation, offer referral to a familial cancer clinic for risk assessment, possible genetic testing and a risk reduction management plan.

Individualised surveillance and risk reduction plan, including consideration of associated risks for other cancers (eg ovarian), may include:

  • regular clinical breast examination and annual breast imaging with mammography, MRI or ultrasound
  • chemoprevention with selective oestrogen receptor modulators (SERMs; eg tamoxifen or raloxifene) or aromatase inhibitors (eg exemestane and anastrozole)16
  • mastectomy and/or salpingo-oophorectomy.

iPrevent is a validated tool to help in the assessment of breast cancer risk.

  1. Cancer Australia. Breast cancer –in Australia statistics. Australian Government, 2024 [Accessed 21 February 2024].
  2. Department of Health and Aged Care. BreastScreen Australia program. Australian Government, 2024 [Accessed 21 February 2024].
  3. Cancer Australia. Breast cancer: The risk factors. Australian Government, 2024 [Accessed 21 February 2024].
  4. U.S. Preventive Services Task Force (USPSTF). Breast cancer: Screening. USPSTF, 2023 [Accessed 19 May 2023].
  5. Cancer Australia. Early detection of breast cancer. [Position statement] Australian Government, 2015 [Accessed 16 May 2023].
  6. Cancer Council. Magnetic resonance imaging screening in high-risk women. In: Screening: Breast cancer prevention policy. Cancer Council, 2014 [Accessed 16 May 2023].
  7. Cancer Council. Thermography. In: Screening breast cancer prevention policy. Cancer Council, 2014 [Accessed 16 May 2023].
  8. Cancer Australia. Statement on use of thermography to detect breast cancer. Australian Government, 2010 [Accessed 16 May 2023].
  9. Royal Australian and New Zealand College of Radiologists (RANZCR). Policy on use of thermography to detect breast cancer. RANZCR, 2018 [Accessed 16 May 2023].
  10. Cancer Australia. Advice about familial aspects of breast cancer and epithelial ovarian cancer. Australian Government, 2015 [Accessed 12 December 2023].
  11. Cancer Australia. MRI for high risk women. Australian Government, n.d [Accessed 16 May 2023].
  12. Henderson JT, Webber, EM, Weyrich M, Miller M, Melnikow J. Screening for breast cancer: A comparative effectiveness review for the U.S. Preventive Services Task Force. Evidence synthesis no. 231. Agency for Healthcare Research and Quality, 2023.
  13. Trentham-Dietz A, Chapman CH, Jinani J, et al. Breast cancer screening with mammography: An updated decision analysis for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, 2023.
  14. The Royal Australian College of General Practitioners (RACGP). Genomics in general practice. RACGP, 2022 [Accessed 22 February 2024].
  15. Cancer Australia. Risk factors for breast cancer: A review of the evidence 2018. Australian Government, 2018 [Accessed 16 May 2023].
  16. Cancer Australia. Risk-reducing medication for women at increased risk of breast cancer due to family history. Australian Government, 2018 [Accessed 16 May 2023].
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