BRCA Testing Age Recommendations
BRCA genetic testing should generally be offered starting at age 18 years (legal adulthood), though medical management and screening interventions typically begin at age 25 years. 1
When to Perform BRCA Testing
Minimum Age for Testing
- Age 18 years is the recommended minimum age for BRCA genetic testing when individuals meet clinical criteria, as this represents legal adulthood and allows for autonomous decision-making 1
- Age 25 years is when actionable medical management begins, making this the practical age when testing becomes most clinically relevant according to ASCO recommendations 1
- Testing in children should generally be deferred until adulthood since no medical interventions are recommended before age 18 years 1
Clinical Criteria That Trigger Testing (Regardless of Age ≥18)
Personal History Criteria:
- Breast cancer diagnosed at age ≤45 years 2, 3
- Breast cancer diagnosed at age ≤50 years with ≥1 close blood relative with breast cancer 2, 3
- Triple-negative breast cancer diagnosed before age 50 years 3
- Two primary breast cancers, especially when first diagnosis occurred before age 50 years 2, 3
- Male breast cancer at any age 2, 3
- Epithelial ovarian/fallopian tube/primary peritoneal cancer at any age 2, 3
Family History Criteria:
- First- or second-degree relative meeting any of the above personal history criteria 2, 3
- Ashkenazi Jewish ancestry with breast cancer diagnosed before age 60 years 3
- Known BRCA1/2 mutation in the family 2, 3
Screening Initiation After Positive BRCA Testing
Ages 18-24 Years
- Breast self-examination training and monthly practice starting at age 18 years 2, 1
- No imaging recommended during this age range 2
Ages 25-29 Years
- Clinical breast examination every 6-12 months starting at age 25 years 2, 1
- Annual breast MRI with contrast (preferred) starting at age 25 years 2, 1
- Mammography only if MRI is unavailable 2, 1
- Screening may begin earlier (5-10 years before youngest affected family member) if family history includes breast cancer diagnosis before age 30 years 2
Ages 30-75 Years
- Annual mammogram AND breast MRI with contrast 2, 1
- Clinical breast examination every 6-12 months 2, 1
After Age 75 Years
- Management should be individualized based on overall health status 2
Pre-Testing Requirements
Mandatory genetic counseling must occur before testing and should include: 1, 3
- Psychosocial assessment and support 2, 1
- Risk counseling and education about hereditary cancer syndromes 2, 1
- Discussion of test implications for patient and family members 1, 3
- Informed consent process 2, 1
- Discussion of potential psychological impact, insurance considerations, and privacy concerns 3
Critical Pitfalls to Avoid
Do not delay testing based solely on age if clinical criteria are met - Young age at diagnosis (≤45 years) is itself a strong indication for testing, even without family history 2, 3, 4
Do not use mammography alone in BRCA carriers aged 25-29 years - MRI demonstrates significantly higher sensitivity (77-94%) compared to mammography (33-59%) in this high-risk population 2
Do not ignore paternal family history - Both maternal and paternal lineages must be evaluated independently, as BRCA mutations can be inherited from either parent 2, 4
Do not overlook triple-negative breast cancer patients under age 50 - These patients have elevated BRCA1 mutation rates (22.6% overall, with 64.2% in those ≤30 years) even without family history 5
Account for anticipation phenomenon - BRCA-related cancers appear 7.9 years earlier in subsequent generations, so screening should begin earlier if family members were diagnosed young 6