• These recommendations are based on the guideline from the National Institute for Health and Clinical Excellence (NICE), Familial breast cancer: the classification and care of women at risk of familial breast cancer in primary, secondary and tertiary care [NICE, 2006a]. NICE commissioned the National Collaborating Centre for Primary Care to produce the evidence review and develop the clinical guidelines [McIntosh et al, 2004].

Breast self-examination

• NICE recommends that all women at increased risk of breast cancer should be breast aware [NICE, 2006a]. There is evidence from a Cochrane systematic review that screening (by either regular self-examination or clinical examination) is not beneficial. Therefore, current advice is for women to be 'aware' of any changes in their breasts and seek early advice if they detect any changes.

Breast screening

• The Cancer Reform Strategy sets a clear direction for cancer service development between 2007 and 2012. It outlines plans to extend the breast screening programme to nine screening rounds for women 47–73 years of age. Over 400,000 more women will be screened each year as a result [DH, 2007].

Alcohol

• NICE examined five meta-analyses, one systematic review, and one cohort study and concluded that there is no good evidence to suggest that the risk from drinking alcohol is any different for women with a family history of breast cancer compared with women as a whole. Women who drink a moderate amount of alcohol have a slightly higher risk of breast cancer than those who abstain.
• A subsequent case-controlled study investigated women with BRCA1 or BRCA2 mutations who had a history of breast cancer (cases) or did not (controls) [McGuire et al, 2006]. In the BRCA1 group there were 195 cases and 302 controls, and in the BRCA2 group there were 128 cases and 179 controls. No positive association was found between alcohol intake and the risk of breast cancer in women with either BRAC1 or BRCA2.

Weight

• NICE found evidence that a high body mass index is associated with a clinically significant increase in postmenopausal breast cancer risk in the general population.

Menstrual/reproductive factors

• After reviewing the available limited evidence, NICE concluded that the:
• Risk of breast cancer is increased by:
• Early menarche.
• Older age at first birth.
• A late menopause (55 years of age or older).
• Risk of breast cancer is decreased by:
• Pregnancy, with increasing numbers of pregnancies conferring greater risk reduction.
• However, in women who carry BRCA1 or BRCA2, an analysis of data from a cohort study of 1187 women with a BRCA1 mutation and 414 women with a BRCA2 mutation found no association between the age of either the menarche or the menopause on breast cancer risk [Chang-Claude et al, 2007].
• In women who carry mutations in BRCA1 or BRCA2, there is conflicting evidence about whether younger age at first birth alters the risk of breast cancer. However there is evidence that increased parity offers protection.
• In a case-controlled study, 1816 women with breast cancer who carried either the BRCA1 mutation (1405 women) or the BRCA2 mutation (411 women) were matched with women who carried the BRCA1 or BRCA2 mutation but who did not have breast cancer [Kotsopoulos et al, 2007]. An early first full-term birth did not appear to confer protection (OR 1.0, 95% CI 0.98 to 1.03).
• In a case-controlled study, 457 women who carried either a BRCA1 or BRCA2 mutation and who had breast cancer were compared with women carrying the same mutations who had not developed breast cancer [Antoniou et al, 2006]:
• Parous women older than 40 years of age were at lower risk.
• The risk of breast cancer increased with the age of the first live birth.
• A retrospective cohort study of 1601 women with a BRCA1 or BRCA2 who were included in the International BRCA1/2 Carrier Cohort Study found that [Andrieu et al, 2006]:
• A statistically significant decrease in the risk of breast cancer was associated with an increasing number of full-term pregnancies. The risk was reduced by 14% (95% CI 6 to 22) for each additional birth. This was the same in women with either a BRCA1 or BRCA2 mutation and was restricted to women older than 40 years of age.
• In BRCA2-mutation carriers, a late first birth was associated with an increased risk of breast cancer compared with first birth before 20 years of age.
• In BRCA1-mutation carriers, first birth at 30 years of age or later was associated with a reduced risk of breast cancer compared with first birth before 20 years of age.

Physical activity

• NICE reviewed the evidence and concluded that moderate physical exercise is associated with a decreased risk of breast cancer in the general population.

Breastfeeding

• After reviewing the available evidence (one meta-analysis, one systematic review, and a collaborative group re-analysis of individual data from 47 epidemiological studies) NICE concluded that breastfeeding confers a small protective effect on the risk of breast cancer.

Smoking

• There are many health benefits from stopping smoking. However, there is no good association between smoking and the risk of breast cancer (although results of studies have not been consistent).
• A recent case-controlled study compared 2538 women with breast cancer (1920 with a BRCA1 mutation and 618 with a BRCA2 mutation) with an equal number of women with a mutation but no breast cancer [Ginsburg et al, 2009]. There was no increased risk of breast cancer in current smokers (odds ratio [OR] 0.95, 95% CI 0.81 to 1.12) but there was a possible increased risk among BRCA1 carriers who were past smokers (OR 1.27, 95% CI 1.06 to 1.5).