Breast cancer is the most common cause of death in women aged 35-50 years in the UK. Despite this, screening for breast cancer is not routinely offered until women reach the age of 50. Here, Dr Sarah Hindmarch, Dr Sacha Howell and Professor David French outline their research exploring the delivery of breast cancer risk assessment to young women and what is needed to make this a reality in policy and practice.

• In a new trial in Greater Manchester, nearly one in five younger women were found to be at increased risk of breast cancer, and were invited for earlier screening.
• This method of risk assessment was acceptable to younger women, who valued the ability to plan for, and mitigate, their future chances of developing breast cancer.
• A larger rollout of this trial would support policymakers’ objectives to improve early diagnosis of cancers, and shift the health and care system from sickness to prevention.

Breast cancer is the most common cancer in women in the UK, with around 55,000 new cases and 11,500 deaths each year, and regular mammography screening for breast cancer is offered to women from age 50. Approximately 20% of new cases are diagnosed in women under 50 years old, with breast cancer the leading cause of death in women aged 35-50 years. The risk of developing breast cancer for individual women varies enormously. The National Institute for Health and Care Excellence (NICE) recommend that women identified as being at increased risk of breast cancer (≥3% 10-year risk) are offered breast screening at earlier ages and risk-reducing strategies, including weight loss interventions and medication.

Current risk assessment within this age group is limited to women with a family history of breast cancer. Only about 5% of women would be identified as being at increased risk based solely on their family history of breast cancer, and more than two-thirds of women who develop breast cancer, even at younger ages, do not have any family history of the disease. Currently, there is no systematic mechanism to identify this group of women.

Identifying those at risk

One proposed approach to identify women at increased risk of breast cancer involves the use of personalised breast cancer risk estimates. It is now possible to assess an individual’s risk of breast cancer using a combination of three measures:

1. A self-reported questionnaire of known breast cancer risk factors, including family history, hormonal history (such as the age at which a woman started her periods), and reproductive history (for example, the age of first pregnancy).
2. DNA (genetic material) analyses from a saliva sample.
3. An assessment of breast density, (the amount of non-fatty tissue compared to fatty tissue in the breast), usually from a mammogram, with a higher proportion of dense tissue associated with increased breast cancer risk.

Personalised risk assessment for breast cancer has so far been explored within screening age women attending for mammography, which by definition excludes younger, pre-screening age, women. Increasing access to screening and risk reduction strategies in younger women will likely lead to improvements in early detection and survival. Consequently, there is a growing interest in offering comprehensive breast cancer risk assessment from an earlier age.

Making risk assessment work for younger women

Against this background, we explored young women’s views on, and requirements for, the delivery of breast cancer risk assessment. Thirty-seven women aged 30-39 years from across Greater Manchester took part in focus group discussions or an individual interview about the prospect of participating in breast cancer risk assessment. We were particularly interested in identifying preferences for delivery and information, and support needs to develop acceptable invitation, risk assessment, and feedback processes.

Our findings showed that breast cancer risk assessment was acceptable to younger women, providing that a risk management plan and support from healthcare professionals with appropriate expertise is available. The main benefit of participating in breast cancer risk assessment was perceived to be the ability to plan and prepare for the future in terms of accessing earlier screening and risk reduction strategies.

The findings were used to inform the design and delivery of a risk assessment strategy that is currently being offered to women in Greater Manchester as part of the Breast CANcer Risk Assessment in Younger women (BCAN-RAY) study. Of the first 500 participants, 88 have been identified as being at increased risk, with 78 of those so far having phone consultations to discuss starting breast screening at or before age 40 (depending on their personal precise risk estimate).  So far 24 women have already started their mammograms and had discussions about risk reducing strategies such as the medication tamoxifen and changes to health-related behaviours like diet and exercise.

22 BCAN-RAY participants who underwent breast cancer risk assessment and received a breast cancer risk estimate have taken part in interviews to discuss the process. Overall, participants found the BCAN-RAY approach acceptable, with no evidence of prolonged anxiety or cancer worry resulting from participation. This showed that the breast cancer risk assessment process was experienced as acceptable in practice, as well as being anticipated as acceptable in principle.

Recommendations

The findings suggest a larger rollout of breast cancer risk assessment to women aged 30-39 years would be appropriate. This rollout would follow the success of the Lung Health Check, as praised by Lord Darzi in this independent investigation of the NHS in England, which successfully targeted those communities most at risk of lung cancer. Previous efforts to implement risk assessment at the time of mammography screening have recruited low numbers of women from ethnic minority populations and more deprived backgrounds, exacerbating existing inequalities.

We have also experienced difficulties recruiting these populations in BCAN-RAY.  To overcome this, we have another project (PREVENT-Breast) underway that is examining how several underserved groups of women would like a service to be organised to optimise acceptability. Additionally, we are looking at novel approaches to density assessment in Black communities to increase accessibility. Informed by our research findings, the Department for Health and Social Care, working with the Office for Health Improvement and Disparities, should develop strategies to deliver this assessment in communities most at risk of developing aggressive breast cancers at a younger age.

The government has identified early diagnosis as critical for improving survival, noting that cancers diagnosed in stages 1 and 2 can be treated more effectively. The draft National Cancer Plan highlights targeted interventions – including case finding to identify patients most at risk of certain cancers – as a method to improve early diagnosis. The government has also set a priority of “sickness to prevention” for the NHS, as one of its three strategic shifts, promising that women’s health will be embedded across all health policy.

Therefore, a national rollout of breast cancer risk assessment to younger women would help contribute towards increasing early diagnosis rates and as a result should be reflected as a priority in an update to the Women’s Health Strategy, and the forthcoming National Cancer Plan.