Women can be cared for in primary care if the family history shows only one first-degree or second-degree relative diagnosed with breast cancer at older than age 40 years, provided that none of the following are present in the family history:
- bilateral breast cancer
- male breast cancer
- ovarian cancer
- Jewish ancestry
- sarcoma in a relative younger than 45 years of age
- glioma or childhood adrenal cortical carcinomas
- complicated patterns of multiple cancers at a young age
- paternal history of breast cancer (two or more relatives on the father's side of the family)
Women who do not meet the criteria for referral should be cared for in primary care by giving standard written information.
- risk information about population level and family history levels of risk, including a definition of family history
- the message that if their family history alters their risk may alter
- breast awareness information
- lifestyle advice regarding breast cancer risk, including information about
- HRT and oral contraceptives
- lifestyle including diet, alcohol, etc
- breastfeeding, family size and timing
- contact details of those providing support and information, including local and national support groups
- the message that to help provide support and understanding of the issues discussed, women should be informed prior to appointments that they can bring a family member/friend with them to appointments
- details of any trials or studies that may be appropriate for the women to consider taking part in Also women should be given advice to return to discuss any implications if there is a change in family history change or breast symptoms develop
Advice should be sought from the designated secondary care contact if any of the following are present in the family history in addition to breast cancers in relatives not fulfilling the above criteria:
- bilateral breast cancer
- male breast cancer
- ovarian cancer
- Jewish ancestry
- sarcoma in a relative younger than age 45 years
- glioma or childhood adrenal cortical carcinomas
- complicated patterns of multiple cancers at a young age
- paternal history of breast cancer (two or more relatives on the father's side of the family)
Discussion with the designated secondary care contact should take place if the primary care health professional is uncertain about the appropriateness of referral because the family history presented is unusual or difficult to make clear decisions about, or where the woman is not sufficiently reassured by the standard information provided
Direct referral to a specialist genetics service should take place where a high risk predisposing gene mutation has been identified (e.g. BRCA1, BRCA2 or TP53)
When considering referral regarding familial breast cancer, then consult the full NICE guidance (1).
Notes:
- People without a personal history of breast cancer who meet the following criteria should be offered referral to secondary care:
- one first-degree female relative diagnosed with breast cancer at younger than age 40 years or
- one first-degree male relative diagnosed with breast cancer at any age or
- one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years or two first-degree relatives, or
- one first-degree and one second-degree relative, diagnosed with breast cancer at any age or one first-degree or
- second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative) or
- three first-degree or second-degree relatives diagnosed with breast cancer at any age
Reference:
- NICE guidance (June 2013).The classification and care of women at risk of familial breast cancer in primary, secondary and tertiary care.