High-Risk Breast Cancer Screening

The American Cancer Society describes high risk as a lifetime risk of breast cancer of about 20% to 25% or greater, based on risk assessment tools that rely mainly on family history. It also includes women who:

For scale: the average lifetime risk for a woman is about 13%. The American Cancer Society says a woman with a BRCA1 or BRCA2 gene change has, on average, up to a 70 in 100 chance of being diagnosed with breast cancer in her lifetime.

It starts with questions, not a test. Your provider asks about breast, ovarian, tubal and peritoneal cancer in your family on both sides: who, which cancer, and at what age. Those answers go into a short, validated screening tool.

The U.S. Preventive Services Task Force recommends that primary care clinicians do exactly this for women with a personal or family history of those cancers, or with an ancestry associated with BRCA1 and BRCA2 gene changes. The American College of Radiology goes further and recommends that all women have a risk assessment by age 25, so that those who need earlier screening are identified in time.

When the screening tool comes back positive, the Task Force recommends genetic counseling and, if indicated after counseling, genetic testing. Counseling comes first because a test result is only useful when you know what it can and cannot tell you, and what you would do with it.

The same recommendation says the opposite for women without that history: routine risk assessment, counseling or testing for BRCA gene changes is not recommended when nothing in your personal or family history points to one.

Most health plans cover BRCA genetic counseling for women at higher risk as preventive care. See mammogram cost and insurance.

For women at high risk, the American Cancer Society recommends a breast MRI and a mammogram every year, typically starting at age 30. The American College of Radiology recommends that MRI surveillance begin between ages 25 and 30 for women with a genetic predisposition, a calculated lifetime risk of 20% or more, or chest radiation at a young age.

MRI is added to the mammogram, not swapped for it. Each finds some cancers the other misses.

A risk assessment is a primary care conversation, and it is one we have at a screening visit. We take your family history, tell you whether it points toward standard screening or something more, and refer you for genetic counseling or to a breast specialist when it does. We do not perform genetic testing, mammograms or MRI in our office.