Breast screening under 50

Breast screening is a way of finding breast cancers| early, when they are too small for you or your doctor to see or feel. In the UK, around 1 in 9 women will develop breast cancer at some time in their life.

A woman with a significant family history| of the disease may carry a higher risk of developing breast cancer, but it's important to remember that:

• most women don't develop breast cancer – of those who do, most will not have a known family history of the disease
• for most women, increasing age is the greatest risk factor for developing breast cancer
• the majority of women with a family history of breast cancer don't fall into a high-risk category and don't develop breast cancer
• most women with a relative with breast cancer are not at a substantially increased risk of developing breast cancer themselves.

Each year, around one and a half million women in the UK have breast screening as part of the NHS Breast Screening Programme (NHSBSP). The NHSBSP is nationally coordinated and sets national standards.

A mammogram| is a low-dose x-ray of the breast| tissue. It tests for early breast cancer.
You'll need to remove your clothes from the top part of your body, including your bra. The radiographer will then position you so that each breast in turn is placed on the x-ray machine and gently but firmly compressed (squashed) against a flat, clear, plastic plate.

The breast tissue needs to be compressed to keep the breast still, in order to get the clearest picture, using the lowest amount of radiation possible. Some women find the examination uncomfortable for a few seconds while the breast is being compressed. Only very few women find this painful. You'll need to stay still for less than a minute while the picture is being taken. The radiographer takes two pictures of each breast, in two different positions, to make sure they examine all the breast tissue.

NHS Breast Screening Programme

In the UK, women aged 50–70 (64 in Northern Ireland) are invited to attend breast screening every three years as part of the NHS Breast Screening Programme. Each country within the UK has its own screening programme.

As part of the Government’s Cancer Reform Strategy (for England), the Department of Health plans to extend the age range for breast screening from 47–73 years. It aims for every woman to have their first breast screening before the age of 50. This age extension is gradually being introduced and is expected to be complete by 2016.

At the moment, if you're 70 or over, you're not automatically invited for breast screening. You can, however, make your own appointments| for free mammograms every three years if you wish.

MRI scanning is not generally used for breast screening on the NHS but is available for screening some women who are under 50 and at very high risk.

MRI scans use magnetism instead of x‑rays to build up a detailed picture of the breasts. During the scan, you'll be asked to lie very still on a couch inside a long tube for about 30 minutes. It's painless but can be uncomfortable, and some women feel a bit claustrophobic during the scan. It's also noisy, but you'll be given earplugs or headphones.

Some women are given an injection of dye into a vein in the arm, but this does not usually cause any discomfort.

To help you decide whether or not to go for screening the main benefits and disadvantages are described below:

Benefits

• Breast screening may find cancers early.
• Breast screening in older women saves lives.
• With breast screening, any cancer is more likely to be found early. If a cancer is found, it's likely to be smaller. It may, therefore, be possible to remove the lump (by a lumpectomy) instead of removing the whole breast (a mastectomy).

Disadvantages

• Mammograms can be uncomfortable.
• Mammograms involve x-rays and use only a low amount of radiation. The radiation dose given by breast screening x-rays is continually monitored to make sure it remains as low as possible, while still providing a good-quality image. However, if you start screening at a younger age, over your lifetime you'll be exposed to more radiation. There's a very small risk that this could affect your health.
• Abnormal mammogram results may cause unnecessary worry. Some women may be recalled for further tests. Most women who have further tests will not have cancer. However, women who are called back often find this a very worrying time.
• Mammograms sometimes need to be repeated – for example, if the films are not very clear).
• Breast screening will not pick up all breast cancers. It's more likely that cancers will be missed in women who are pre-menopausal (under 50).
• Cancer may still occur in women having regular breast screening.
• Screening may find a cancer that would never have caused a problem during a woman's lifetime.

It's important to understand that breast screening cannot prevent cancer.

The definition of whether a woman has a significant family history of breast cancer is quite complicated. 

A member of the breast care team will talk to you about your family history. Then, possibly using questionnaires or computer programmes, they estimate your risk of developing breast cancer. This is called a 'risk assessment'. If your risk level is similar to that of the general population, you can begin mammography when you're around 50 years old. However, if your family history changes, you can contact the team for reassessment. 

The National Institute for Health and Clinical Excellence (NICE|) is an independent body that currently gives guidance to doctors on the prevention and treatment of ill health. NICE has produced guidance on the screening of women with an increased risk of developing breast cancer because of their family history. The guidelines currently classify women who have a higher chance of developing breast cancer, because of their family history, into two groups:

• moderate risk
• high risk.

The type of care that will be recommended for you depends on your level of risk.

Moderate risk

If it's estimated that you're at moderate risk of developing breast cancer, you'll generally receive care from the breast care team. You should be offered support and information appropriate to your individual needs and, depending on your age, you may also be offered mammography.

According to the NICE guidelines, examples of women likely to be at moderate risk include women with one of the following in their family history:

• one first-degree relative diagnosed with breast cancer before the age of 40 (your first-degree relatives are your mother, father, daughter, son, sister and brother)
• two first-degree or second-degree relatives diagnosed with breast cancer at an average age of over 50 years old (your second-degree relatives are your grandparents, grandchildren, aunt, uncle, niece, nephew, half sister and half brother)
• three first-degree or second-degree relatives diagnosed with breast cancer at an average age of over 60 years old.

(Note: these are only some examples taken from the NICE Guidelines, so this is not an exhaustive list).

Where more than one relative is mentioned above, all relatives must be on the same side of the family and must be blood relatives of the person being assessed and of each other.

High risk

Women thought to be at high risk of developing breast cancer will be offered a referral to a specialist genetics service. A specialist will carry out a more detailed assessment to investigate the possibility of a genetic link in the family.

Fewer than 1 in 100 women are at high risk of developing breast cancer because of their family history.

According to the NICE Guidelines, examples of women who are likely to be at high risk include women with one of the following in their family history:

• two first-degree or second-degree relatives diagnosed with breast cancer before an average age of 50 – at least one must be a first-degree relative (your first-degree relatives are your mother, father, daughter, son, sister, brother and second-degree relatives include grandparents, grandchildren, aunts, uncles, nieces, nephews, half sisters and half brothers)
• three first-degree or second-degree relatives diagnosed with breast cancer before an average age of 60 (one must be a first-degree relative)
• four relatives diagnosed with breast cancer at any age (one must be a first- degree relative)
• one first-degree relative with cancer in both breasts where the first cancer was diagnosed before the age of 50
• one first-degree or one second-degree relative diagnosed with ovarian cancer at any age and one first- or second-degree relative diagnosed with breast cancer before the age of 50
• two first or second-degree relatives diagnosed with ovarian cancer at any age.

(Note: these are only some examples taken from the NICE Guidelines, so this is not an exhaustive list).

In the above examples, where more than one relative is mentioned, all relatives must be on the same side of the family and must be blood relatives of the person being assessed.

There are other factors that may influence your risk of familial breast cancer. For example, if you:

• have a close relative who has had breast cancer diagnosed in both breasts
• have a male relative with breast cancer
• have relatives with breast and ovarian cancer on the same side of the family
• have Jewish ancestry
• have a history of any rare or childhood cancers on the same side of the family.

You'll be asked about such factors in your family during your consultation. It's also important to let your breast care team know if there are any changes in your family history as time goes on, as this may change your risk assessment.

For women under 50 who have an increased risk of developing breast cancer because of their family history, the current view of experts in the UK is that the benefits of screening are likely to outweigh any potential disadvantages.

Therefore, you may be offered a yearly mammogram before reaching 50, because your family history places you at a significantly greater risk level than that of the general population. Women who are at a very high risk because of their family history may also be offered an MRI scan.

The NICE Familial Breast Cancer Guideline recommends that women with a moderate or high risk of breast cancer should be offered yearly mammograms between the ages of 40 and 49. Women aged 30–39 should only be offered a mammogram as part of a research study or when they can be closely monitored. Women aged between 20 and 49 may be offered an annual MRI scan if they have a very high risk of developing breast cancer. This includes women who are known to have one of the faulty breast cancer genes.

Most women over 50 are usually offered a mammogram every three years as part of the National Breast Screening Programme. This is because breast cancer is easier to find in women over 50 and breast cancers are usually slower-growing in this age group. For women over 50, MRI scans will not be routinely widely available for breast cancer screening.

Screening advice may change in the future when the full results of research studies, such as the FH01 trial (also called the Evaluation of Mammographic Surveillance Services in Women under 50 with a Family History of Breast Cancer), are known.

The FH01 trial is an NHS-funded research study looking into whether or not there's actually a benefit in screening women aged 40–49 years who are at moderate or greater risk (because of their family history). Initial results suggest that, for this group of women, annual mammography may help detect a cancer and find cancers at an earlier stage.

There are plans to include screening for women at increased risk because of family history in the NHS breast screening programme. As a result of this, and the above research studies, the screening advice for women in this group may change.

If you're worried about your risk of breast cancer, you can use Macmillan Cancer Support’s online tool OPERA|, where you answer questions about your family history and print out a personal assessment. If a risk is identified, you can take the print-out to your GP.