Advice for Women with a moderate or high risk of developing breast cancer.
Introduction
Breast cancer is an unfortunately common disease affecting 1 in 11 women in the UK in their lifetime. The chance of developing cancer is greater as you get older and that is why the NHS breast screening program was started. You will be offered a screening mammogram every three years from the age of 50 until the automatic recall ends at 69 years. When you have reached this age, you are still at risk from breast cancer and can request a mammogram on the NHS (through the screening unit) every 3 years.
Some women have an increased chance of developing breast cancer and at a younger age. Your individual risk factors are calculated from things that have happened to you and to your immediate family. The number of close family members affected by cancer, the age at which their cancer was diagnosed and the type of cancer they had are all important. An approximate individual risk will have been calculated for you. See also www.brca.nci.nih.gov/bcr/q1.htm
Those at moderate risk of subsequent breast cancer include;
1. One first degree relative (mother, sister, daughter) diagnosed with cancer before the age of 40.
2. One first degree relative and one second degree relative (aunt, grandmother, niece and half sister) diagnosed with cancer after an average age of 50.
3. Two second degree relatives diagnosed with cancer after an average age of 50.
Those at higher risk of subsequent breast cancer include;
1. One first degree relative and one second degree relative diagnosed with cancer before an average age of 50.
2. Three first or second degree relatives
3. Male close relatives with breast cancer
4. First degree relatives with cancer in both breasts, the first diagnosed before the age of 50
5. One first or second degree relative with ovarian cancer and one first or second degree relative with breast cancer
6. Close relative with childhood cancers
7. Complex patterns of family cancers
8. Jewish ancestry
If a close relative develops cancer after your risk is assessed, then your risk may have changed and you can ask for a further consultation.
As you get older the chance of an inherited predisposition to cancer recedes and your risk tends to mirror that of the general population.
Personal factors that increase the likelihood of breast cancer include;
1. Mantle irradiation for Hodgkin’s lymphoma.
2. HRT use for more than 10 years (after the age of the natural menopause).
3. Early first period and late menopause
What can you do to reduce your chance of developing breast cancer?
Avoid the use of HRT. If impossible, reduce the dose of hormones and the length of time you use them.
There are alternatives to HRT for the prevention of osteoporosis (bone thinning).
Oestrogen only HRT preparations may be safer.
A soya based diet may prevent the development of breast cancer. Some herbal menopause remedies contain phytoestrogens or plant oestrogens that are found particularly in soya.
Follow a healthy diet with particular attention to the 5 a day fresh fruit and vegetables.
Dairy produce is an important source of calcium, essential for the avoidance of osteoporosis. If you are concerned about dairy produce try organic only.
The oral contraceptive pill may protect against bowel and ovarian cancer but non hormonal forms of contraception are preferable after the age of 35.
Breastfeeding protects against breast cancer and is strongly recommended.
There is an association between alcohol use and breast cancer possibly relating to dietary deficiencies.
Although smoking is not associated with breast cancer, it kills effective by other means.
Keep physically active and avoid being overweight – breast cancer developing after the menopause is more common in the overweight.
For those at high risk, medical or surgical prophylactic treatments may be appropriate and should be discussed with your clinician and breast care nurse. Tamoxifen use, although avoiding a small number of breast cancers, has too many side effects to be used for prevention.
Current clinical trials of an alternative to tamoxifen are being conducted. www.cancerhelp.org.uk/help/default.asp?page=6028
Breast cancer screening - the facts.
See Understanding Breast Screening published by Cancer Bacup.
Breast screening by mammography is a way of finding breast cancers early when there are too small for you or your doctor to feel.
The only proven method of reliably detecting early breast cancer is with mammograms.
Self examination is useful and should be performed no more than once a month preferably just after a period has started. (See Wessex Cancer trust leaflet – Looking for Change).
Routine examination by a professional has not been shown to be effective.
The use of the MRI scan is still being evaluated and women with particular types of breast cancer risk may be invited to take part in clinical trials.
Mammograms are not sensitive enough for routine use in women under 35 years.
Women at moderate to high risk of breast cancer are offered mammographic surveillance on the NHS from the age of 40 with annual mammography to the age of 50.
Screening for women over the age of 50 is offered at 3 yearly intervals on the NHS breast screening program. You will be automatically reminded for the first 20 years but then you will have to request a mammogram every 3 years after that. www.cancerscreening.nhs.uk/breastscreen/index.html
Some inherited patterns of cancer mean women may be more sensitive to the x-rays used in a mammogram and a different screening strategy will be arranged.
Disadvantages of mammography.
Mammography detects approximately 90% of breast cancers. It can pick them up at a stage when they are small, easier to treat with breast conserving surgery and less likely to have spread to the lymph glands in the armpit. The lymph glands are usually the first stop when breast cancer starts to spread. Not infrequently mammography picks up a precancerous lesion. This is readily curable by surgery alone (occasionally additional radiotherapy is recommended) with excellent long term outlook.
However, mammograms are not always sensitive enough to pick up cancerous changes particularly in younger women. If you notice changes in your breast even if you have just had a normal mammogram, you should see your doctor.
Mammograms also pick up changes that are not cancerous but require further evaluation. This may involve more x-rays, an ultrasound scan or even a needle biopsy. Occasionally a clear diagnosis can not be made and the area has to be removed surgically under a general anaesthetic. Being recalled for further tests is obviously very stressful.
Mammograms use very low doses of x-rays and although the risk of harm from these is small it is sensible to minimise the risk to just enough screens to remain effective.
There are some early indications that 2 yearly screening mammograms between the ages of 40 and 50 may improve overall breast cancer survival for all women. This is not available on the NHS but can be requested privately.
The following web sites may be useful;
www.nice.org.uk/CG014publicinfo
www.cancerresearchuk.org/
www.breastscreen.org.au/familyhistory.htm
www.brca.nci.nih.gov/bcr/q1.htm
Breast care nursing service 01962 824592
Breast Screening Unit 01962 824845
Breast Unit Office 01962 824889
Winchester breast unit web site
www.wehct.nhs.uk/
Winchester and Eastleigh Healthcare
Trust