Guidelines for preventive activities in general practice

The Red Book
9.3 Breast cancer
☰ Table of contents

Age range chart

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 70-79 >80

Increasing age is a major risk factor for developing breast cancer. Other major risk factors include a personal history of atypical hyperplasia or lobular carcinoma in situ, a strong family history of the disease or mutation in a breast cancer predisposition gene, and previous radiotherapy (eg for previous cancer). Breast cancer risk factors that reflect hormonal exposures in the distant past, such as age at menarche or age at first birth, are less predictive of late-life breast cancer than factors indicating recent hormonal exposures such as high bone mass or obesity (refer to Cancer Australia for further information).

Breast cancer risk is not normally distributed: most women have a low (<4%) lifetime risk; and the remainder 4% to more than 80%.39,40


Prevention of breast cancer

Physical activity,41 adequate folate,42 a Mediterranean diet,43 normal BMI (in postmenopausal women only) and decreased alcohol consumption44 are associated with a decreased risk of breast cancer in observational studies. For women at moderate (ie 1.5–3 times the population risk) or high (ie >3 times the population risk) risk, additional interventions such as risk-reducing medication45 (moderate and high risk) and risk-reducing surgery46 (high risk) are available. Referral to specialist genetic assessment is available for women assessed at high risk.



The screening strategy employed for an individual woman depends on her individual degree of risk. Validated tools are available that can assess an individual woman’s breast cancer risk (eg International Breast Cancer Intervention Study (IBIS) tool, available here).47 For asymptomatic, low-risk women, BreastScreen Australia recommends screening mammograms every two years for women aged 50–74 years (B).48

The benefits of screening are obvious. However, the risks must not be forgotten: assuming that screening reduces breast cancer mortality by 15%, and that overdiagnosis and overtreatment is at 30%, then for every 2000 women invited for screening over 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily.49,50 An extra 200 women will experience important psychological distress including anxiety and uncertainty from false positive findings. The substantial advances in treatment, and greater breast cancer awareness since the trials were carried out, mean that presented breast cancers are detected earlier and survive better, so screening today is less effective than at the time of the trials. Recent observational studies show more overdiagnosis than in the trials and very little or no reduction in the incidence of advanced cancers with screening.51

The decision to start screening mammogram should be an individual one. This is especially for women aged <50 years, where the benefits–harms ratio is less favourable.48

Some points:

  • Screening mammogram in women aged 40–49 years may reduce 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 are larger (C). Some women put a higher value on the potential benefit than the potential harms, and may choose to begin screening between the ages of 40–49 years (C).48
  • For women at average risk (ie <1.5 times population risk) of breast cancer, most of the benefit of a mammogram will result from biennial screening during ages 50–74 years of age.48
  • Of all age groups, women aged 60–69 years are most likely to avoid a breast cancer death through mammogram screening (C).48
  • All women undergoing regular screening mammogram are at risk of overdiagnosis – the detection (and then treatment) of non-invasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during her lifetime (C).48
  • Women with a parent, sibling, or child with breast cancer may benefit more than average-risk women from beginning screening between 40 and 49 years of age (C).48
  • Cancer Australia recommends considering annual mammograms from 40 years of age if the woman has a first-degree relative <50 years of age diagnosed with breast cancer (refer to Table 9.3.1).48
  • There is insufficient evidence to assess the balance of benefits and harms of screening mammogram in women aged >75 years (I).48 Randomised trials of the benefits of screening mammogram did not include women >74 years of age. However observational studies favour extending screening mammogram to older women who have a life expectancy of not less than 10 years.52
  • There is insufficient evidence to recommend that clinical breast examination offers any benefits to women, of any age (C).48 However, it is recommended that all women, whether or not they undergo mammogram 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, pain in a breast) to their GP. No one method for women to use when checking their breasts is recommended over another.

The recommended screening strategy for women at different individual degrees of risk is outlined in Table 9.3.1. Cancer Australia recommends that women at any age at increased risk (ie >1.5 times population risk) are offered an individualised surveillance program by their GP and/or specialist.53 This might include regular clinical breast examination and breast imaging with mammography and/or ultrasound and magnetic resonance imaging (MRI). There is government funding available for MRI screening for women <50 years of age at high risk of developing breast cancer.54

Table 9.3.1. Breast cancer: Managing risk

Who is at risk?

What should be done?

How often

Average or only slightly higher* risk (>95% of the female population)


Clarify risk here55


No confirmed family history of breast cancer

  • One first-degree relative diagnosed with breast cancer aged ≥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 aged ≥50 years
  • Two first-degree or second-degree relatives diagnosed with breast cancer, aged ≥50 years, but on different sides (ie on each side) of the family

As a group, risk of breast cancer up to 75 years of age is between 1:11 and 1:8


Breast awareness (I, A)

Every two years from 50 to 74 years of age 

Regular (Practice Point)

Moderately increased risk† (<4% of the female population)

  • One first-degree relative diagnosed with breast cancer aged <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 aged <50 years (without the additional features of the potentially high-risk group)

As a group, the relative risk of breast cancer up to 75 years of age is between 1:8 and 1:4

Clarify risk here 55 

Mammogram (III, C) 

Breast awareness 

Consider referral to or consultation with a family cancer clinic for further assessment and management plan

At least every two years from 50 to 74 years of age 

Annual mammograms from 40 years of age may be recommended if the woman has a first-degree relative aged <50 years diagnosed with breast cancer (Practice Point)

Potentially high risk†‡ or carrying a mutation (<1% of the female population)

  • Women who are at potentially high risk of ovarian cancer
  • 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 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-degree or second-degree relative diagnosed with breast cancer aged <45 years plus another first-degree or second-degree relative on the same side of the family with sarcoma (bone/soft tissue) aged <45 years
  • Member of a family in which the presence of a high-risk breast cancer gene mutation has been established
  • Refer to the Cancer Australia guidelines here

As a group, risk of breast cancer up to 75 years of age is between 1:2 and 1:4

Clarify risk here55 

Advise referral to a cancer specialist or family cancer clinic for risk assessment, possible genetic testing and management plan, which might include treatment with chemo-prevention with selective oestrogen-receptor modulators (SERMs [eg tamoxifen or raloxifene] or aromatase inhibitors [AIs; eg exemestane and anastrozole]), which reduce the risk of cancer in women at moderate or high risk of breast cancer. Tamoxifen has greater efficacy (and can be used in premenopausal women), but raloxifene has fewer adverse effects 

An alternative treatment is mastectomy or salpingo-oophorectomy (which has a greater effect on ovarian cancer risk reduction), which also reduces the risk of breast cancer 46–56 

These decisions requires careful assessment of risk and benefits for individual women. Information tailored for GPs is available here 

Ongoing surveillance strategies may include regular clinical breast examination, breast imaging with mammography, magnetic resonance imaging (MRI) or ultrasound, and consideration of ovarian cancer risk (III, C)

Individualised surveillance program 

This may include regular clinical breast examination, and annual breast imaging with mammography, MRI or ultrasound (Practice Point)

* About 1.5 times the population average 

† About 1.5–3 times the population average 

‡ More than three times the population average. Individual risk may be higher or lower if genetic test results are known

Implementation of breast cancer screening


A systematic review of strategies for increasing the participation of women in community breast cancer screening found five favourable active strategies: letter of invitation, mailed educational material, letter of invitation plus phone call, phone call, and training activities plus direct reminders.57


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