Know your breast cancer risk

What’s on your bucket list? See the northern lights? Skydiving? Visit all 50 states? Get a breast cancer risk assessment?

Hmmm...that last one might not have been on your list at all, but if you’re a woman, it could help ensure you have the health and lifespan to do the fun stuff.

While all women are at risk for breast cancer, some carry more risk than others, according to Cape Cod Healthcare breast surgeon Jill Oxley, MD, FACS. 

“The recommendations are that every woman 25 and over have a formal risk assessment -- certainly no later than age 30,” she said.

Factors that can increase a woman’s breast cancer risk, according to Dr. Oxley and other experts, include:

• Reproductive history. Women with early-onset menstruation or late-age menopause; who have had no full-term pregnancies or had their first full-term pregnancy after age 30; who don’t breastfeed; or who take hormone replacement therapy, will maintain higher hormone levels for longer periods of time. Estrogen fuels some breast cancers, increasing risk.
• Genetic mutations. Testing for two common mutations associated with breast cancer risk - ​​BRCA1 and BRCA2 - has been available for some time. But now, women can be tested for about two dozen gene mutations, Dr. Oxley said, and it’s recommended that women who had genetic testing more than five or six years ago be re-evaluated. A risk assessment includes a personal and family history that might be entered into a digital tool like the Tryer-Cuzick model that estimates probabilities for carrying the BRCA mutations.
• A family history of breast cancer. This includes “first-degree” relatives such as parents, siblings and children, as well as “second-degree” relatives, including grandparents, grandchildren, aunts and uncles. Most women with a family history of breast cancer will not have a detectable genetic mutation.
• Ethnicity. Black women, for example, are more likely to die of breast cancer or have aggressive types, and women of Ashkenazi Jewish ancestry are more likely to carry a genetic mutation.
• Dense breasts. Dense breast tissue can make it difficult to spot irregularities on mammograms, the first step in imaging.
• Exposure to chest radiation between the ages of 10 and 30. This includes women who received radiation treatment for an earlier cancer, such as Hodgkin's lymphoma.
• Weight, diet and lifestyle. Obesity is a risk factor for breast cancer, as is alcohol use and a sedentary lifestyle. An increase in fat cells increases the levels of estrogen in your body, and several studies have linked alcohol to breast cancer.
• A prior history of breast cancer.

“Seeing if there is something in someone’s personal or family history that does make them at increased risk is very helpful,” said Dr. Oxley. “Some women don’t realize they might be at increased risk of breast cancer.”

Even women who think they don’t fit in a high-risk category should be getting assessed no later than age 30, she said. “A risk assessment is individualized, and it can help someone figure out when to start screening and what screening modalities are best for them,” she said.

Once a woman and her medical team determine her risk, they can make decisions about future screening. Screening includes self-exams (now called “breast awareness”), clinical breast exams by a medical professional, and imaging.

“The American Society of Breast Surgeons, American College of Radiology and Society of Breast Imaging, all agree on annual mammography at age 40 for women at average risk of breast cancer,” Dr. Oxley said. But, anyone with a calculated lifetime risk greater than 20 percent, or women with dense breasts, or those diagnosed with breast cancer before age 50, should have access to annual MRIs as well, she said.

A risk assessment might also lead to a recommendation for genetic testing, either for the patient or a family member.

“If possible, if there’s a relative who’s had a cancer diagnosis, then they should be tested first,” Dr. Oxley said. “But sometimes that’s not always possible, and there are people who meet criteria for testing without a personal history of cancer.”

While a formal breast cancer risk assessment should be on every 20-something’s list, breast care is a habit to start early.

“A clinical breast exam and breast awareness should begin in the teens,” Dr. Oxley said. “I don’t think you’re ever too young for breast awareness, but certainly 18-year-olds should be having some sense of breast awareness and a physical exam.”