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Breast cancer - managing family history - Management
What is likely to happen in tertiary care?
- Women at high risk of breast cancer (that is, meeting the criteria for a referral to tertiary care) should be offered genetic counselling.
- Provide standardized information beforehand, detailing the process of genetic counselling and genetic testing. Advise the woman that referral to a genetics service may involve the investigation of other relatives with breast cancer, including a histological diagnosis.
- Advise the woman that she will be offered an estimate of her personal risk of breast cancer. She will also be informed about the uncertainties of the estimate regarding the risk of inheriting a predisposing gene, of penetrance, and hence of developing cancer [NICE, 2006a].
- After discussion of the risks and benefits, advise the woman that she may be offered:
- Mammographic or magnetic resonance imaging (MRI) surveillance.
- Genetic testing. If there is greater than a 20% risk of BRCA1, BRCA2, or TP53 mutation in the family and there is an affected relative available, then genetic testing should be offered after two sessions of pre-test counselling. The affected relative is always screened initially.
- Risk-reduction surgery (prophylactic bilateral mastectomy and/or oophorectomy).
- All women considering risk-reduction surgery should have access to a support group and be able to discuss reconstruction options, the effects and management of early menopause (after oophorectomy), and possible psychosocial and sexual consequences of surgery.
- If risk-reduction surgery is being considered and no mutation has been identified, confirmation of the family history should be sought through medical records, the cancer registry, or death certificates. When it is impossible to verify the family history, agreement should be sought from a multidisciplinary team before proceeding.
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