What are the recommendations for women at high risk for breast cancer?

From the Guidelines

Women at high risk for breast cancer should consider enhanced surveillance, preventive measures, and risk-reducing medications, such as tamoxifen or raloxifene, to decrease their risk of developing breast cancer by 40-65%. According to the most recent guidelines, women with a 5-year risk of breast cancer of 3.0% or greater, or those with a history of atypical hyperplasia or lobular carcinoma in situ, should be offered risk reduction medications 1. Regular clinical breast exams every 6-12 months and annual mammograms starting at age 30 are recommended, often supplemented with breast MRI, especially for women with genetics-based increased risk or a history of chest or mantle radiation therapy at a young age 1.

Risk Reduction Medications

• Tamoxifen (20mg daily for 5 years) is recommended for premenopausal women
• Raloxifene (60mg daily for 5 years) or aromatase inhibitors like exemestane (25mg daily) or anastrozole (1mg daily) are recommended for postmenopausal women These medications may cause side effects, including hot flashes, vaginal dryness, and increased risk of blood clots (tamoxifen) or bone loss (aromatase inhibitors) 1.

Lifestyle Modifications and Genetic Counseling

Lifestyle modifications, such as maintaining a healthy weight, limiting alcohol consumption, regular exercise, and avoiding hormone replacement therapy, are also important for reducing breast cancer risk. Genetic counseling is essential for women with strong family histories to determine appropriate risk management strategies based on their specific risk factors 1.

High-Risk Women

For women with BRCA mutations or very high risk, prophylactic mastectomy and/or oophorectomy may be considered after age 35 or when childbearing is complete. Breast MRI is recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed by age 50 1. Ultrasound can be considered for those who qualify for but cannot undergo MRI. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk no later than age 30, so that those at higher risk can be identified and can benefit from supplemental screening 1.

From the FDA Drug Label

1.3 Reduction in the Risk of Invasive Breast Cancer in Postmenopausal Women at High Risk of Invasive Breast Cancer 14.4 Reduction in Risk of Invasive Breast Cancer in Postmenopausal Women at High Risk of Invasive Breast Cancer 17.4 Reduction in Risk of Invasive Breast Cancer in Postmenopausal Women with Osteoporosis or at High Risk of Invasive Breast Cancer

Recommendations for women at high risk for breast cancer: Raloxifene is indicated for the reduction in the risk of invasive breast cancer in postmenopausal women at high risk of invasive breast cancer 2.

• The drug may be considered as an option for these women.
• However, the decision to use Raloxifene should be made after careful consideration of the benefits and risks, including the increased risk of venous thromboembolism and death from stroke.

From the Research

Recommendations for Women at High Risk for Breast Cancer

• The US Preventive Services Task Force recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects 3.
• The American College of Radiology recommends annual screening beginning at age 40 for women of average risk and earlier and/or more intensive screening for women at higher-than-average risk, with breast MRI as the supplemental screening method of choice for most women at higher-than-average risk 4.
• Women with genetics-based increased risk, those with a calculated lifetime risk of 20% or more, and those exposed to chest radiation at young ages are recommended to undergo MRI surveillance starting at ages 25 to 30 and annual mammography 4.
• For women at increased risk for breast cancer, preventive medication can greatly decrease risk and is vastly underutilized, and women's health clinicians are poised to evaluate risk, promote breast cancer risk reduction, and manage overall health 5.
• Personalized tailor-made screening adjusted for risk factors has been conducted in accordance with guidelines, and the use of imaging modalities other than mammography, including contrast-enhanced MRI, and other various strategies for improving screening are discussed 6.

Screening Guidelines

• The US Preventive Services Task Force recommends against the routine use of risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, in women who are not at increased risk for breast cancer 3, 7.
• Women diagnosed with breast cancer before age 50 or with personal histories of breast cancer and dense breasts should undergo annual supplemental breast MRI, and others with personal histories, and those with atypia at biopsy, should strongly consider MRI screening, especially if other risk factors are present 4.
• All women should undergo risk assessment by age 25, especially Black women and women of Ashkenazi Jewish heritage, so that those at higher-than-average risk can be identified and appropriate screening initiated 4.