From the Guidelines
For a 36-year-old patient with a family history of breast cancer, I recommend starting annual screening MRI from age 25, with the addition of annual mammography from age 30, as well as clinical breast exams every 6-12 months by a healthcare provider. This approach is based on the guidelines from the ESMO clinical practice guidelines for cancer prevention and screening, which recommend annual screening MRI from age 25 and annual mammography from age 30 for individuals with a family history of breast cancer 1.
The patient's family history of breast cancer increases their risk, and early detection through appropriate screening can lead to better treatment outcomes if cancer develops.
- Genetic testing for BRCA1/2 and other breast cancer-related genes should be considered, especially if there are multiple affected relatives, early-onset cases (before age 50), or Ashkenazi Jewish ancestry.
- A comprehensive risk assessment using models like Gail or Tyrer-Cuzick should be performed to determine if the patient qualifies for enhanced surveillance.
- Breast awareness (being familiar with the normal appearance and feel of one's breasts) is also important for early detection of changes.
- The decision to start screening should be individualized based on the potential benefits and risks of screening in the context of overall health status and estimated longevity.
It is essential to note that the USPSTF recommends screening women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2) 1.
However, the most recent and highest-quality study from the ESMO clinical practice guidelines for cancer prevention and screening should be prioritized when making a definitive recommendation 1.
From the FDA Drug Label
High risk is defined as women at least 35 years of age with a 5 year predicted risk of breast cancer ≥ 1.67%, as calculated by the Gail Model. Examples of combinations of factors predicting a 5 year risk ≥ 1.67% include: One first degree relative with a history of breast cancer, 2 or more benign biopsies, and a history of a breast biopsy showing atypical hyperplasia; For women whose risk factors are not described in the above examples, the Gail Model is necessary to estimate absolute breast cancer risk.
The recommended testing for a 36-year-old patient with a family history of breast cancer is to use the Gail Model to estimate the absolute breast cancer risk. The patient's risk factors should be assessed to determine if they meet the criteria for high risk, which is defined as a 5-year predicted risk of breast cancer ≥ 1.67%. If the patient's risk factors are not described in the examples provided, the Gail Model Risk Assessment Tool can be used to estimate the risk 2.
From the Research
Recommended Testing for a 36-year-old Patient with a Family History of Breast Cancer
- The patient's age and family history of breast cancer are important factors to consider when determining the recommended testing [ 3, 4 ].
- For women with a family history of breast cancer, the American College of Radiology recommends supplemental annual screening with contrast-enhanced MRI or contrast-enhanced mammography for those with a high risk (≥20% lifetime risk) or dense breasts [ 5 ].
- Studies have shown that magnetic resonance imaging (MRI) is more sensitive for detecting breast cancers than mammography, ultrasound, or clinical breast examination (CBE) alone in women with BRCA1 and BRCA2 mutations [ 4 ].
- Alternating screening mammography and breast MRI every 6 months has been shown to be effective in detecting breast cancers in women with deleterious BRCA mutations [ 6 ].
- The cost-effectiveness of alternating MRI and digital mammography screening in BRCA1 and BRCA2 gene mutation carriers has been evaluated, with results suggesting that alternating screening at 6-month intervals beginning at age 30 years may be a clinically effective approach [ 7 ].
- However, it is essential to note that the patient's individual risk factors, breast density, and genetic susceptibility should be taken into account when determining the most appropriate screening strategy [ 5 ].