• Take a family history of breast cancer when the woman expresses concerns about her family history, or if concerns arise during the consultation (for example the woman has breast symptoms, or concerns relating to use of hormone replacement therapy or oral contraceptives).
• Ask whether a faulty gene has been identified in the family.
• Ask whether any first- or second-degree relatives (on the maternal or paternal side of the family) have had breast cancer (see Table 1).
• To be considered relevant, all affected relatives must be on the same side of the family and be blood relatives of the woman and of each other.
• Paternal history is relevant if there are two or more relatives diagnosed with breast cancer (or related cancer) on the woman's father's side of the family.
• Try to gather detailed information (such as the age when diagnosed, certainty of the diagnosis).
• If there is a positive first- or second-degree family history, also determine:
• Whether other cancers have occurred in the family, specifically:
• Ovarian cancer.
• Sarcoma at younger than 45 years of age.
• Glioma, or childhood adrenal cortical cancer.
• Complicated patterns of multiple cancers at a young age.
• If any family member has had bilateral breast cancer (each breast cancer has the same count-value for risk as one relative, that is, the family member would count twice: once for each breast with cancer).
• If there is Jewish ancestry.
• Where appropriate encourage the woman to discuss the family history with relatives.

The following recommendations represent minimum criteria for referral. Locally-developed guidelines may be available and should be followed.

• If a faulty gene has been identified in the family, offer direct referral to a specialist genetics service (if the person has not already been seen by such a service).
• If there is no first- or second-degree maternal or paternal family history of breast cancer, manage in primary care by offering appropriate information and reassurance.
• If there is a first- or second-degree family history, but of only one relative who developed breast cancer after 40 years of age, manage in primary care.
• If there is a first- or second-degree family history of breast cancer affecting a relative 40 years of age or younger, or more than one relative:
• Offer referral to secondary care if the woman is likely to be at more than moderate risk of developing breast cancer (see Table 1).
• Otherwise:
• If the woman is likely to be at moderate risk (see Table 1), and the woman is 40–49 years of age, offer referral.
• If the woman is likely to be at moderate risk (see Table 1), but the woman is younger than 40–49 years of age, inform her that she will not generally be offered additional mammography. However, if she requests risk counselling/management or wants to be considered for prevention trials, seek advice from secondary care regarding her level of risk and whether referral is appropriate.
• If the woman is likely to be at less than moderate risk (see Table 1), manage in primary care.
• If the woman has a positive first- or second-degree family history and does not fulfil any of the above criteria for referral but there is a history of unusual cancers in the family (see Unusual cancers), there is a paternal history of breast cancer, or there is Jewish ancestry, seek advice from secondary care regarding her level of risk and whether referral is indicated.
• Consider referring, or discussing with secondary or tertiary care, those women who are particularly concerned about their risk of breast cancer but in whom it is impossible to assess risk accurately, such as:
• Where there is doubt over the diagnosis of breast cancer in their relatives or the age at which the cancer occurred.
• Those women with a small family (for example who have no sisters or aunts).
• Women who were adopted and do not know their family history.

• Recommend breast awareness to all women.
• Explain the principles of breast awareness. This is a process whereby the woman becomes familiar with her own breasts by looking and feeling and reporting promptly any changes. Changes could include: discomfort or pain; lumps, thickening, or bumpy areas; nipple changes or discharge; or changes in the appearance of the breast, such as in the shape or the presence of dimpling of the skin.
• For more information, see the NHS Cancer Screening Programme information on Breast awareness (pdf).
• Encourage attendance at the local breast-screening programme for women 50 years of age and older. From 2012 the NHS breast screening programme will be extended to cover women 47–73 years of age. Women who are older than the eligible age range will still be able to self-refer, as at present.
• Discuss known (potentially modifiable) risk factors for breast cancer.
• An increased risk of breast cancer is associated with:
• Alcohol consumption.
• Being postmenopausal and overweight.
• Older age of first birth.
• A reduced risk of breast cancer is associated with:
• Moderate physical activity.
• Breastfeeding.
• Increased number of births.
• Smoking is not thought to be a risk factor for breast cancer, but smokers should be encouraged to quit because of the other health benefits (for further information see the CKS topic on Smoking cessation).

• Inform all women concerned about developing breast cancer that their risk may change with age and with changes in their family history.
• Advise women younger than 40 years of age with any of the following to return for referral upon reaching 40 years of age:
• One first-degree relative diagnosed with breast cancer when younger than 40 years of age.
• One first-degree and one second-degree relative diagnosed when older than an average of 50 years of age (to calculate the average age, add the ages of both together and divide by two).
• Two first-degree relatives diagnosed when older than an average of 50 years of age.
• Remind woman older than 50 years of age that they are already eligible for mammographic surveillance.

Women with a family history of breast cancer

• The UK Medical Eligibility Criteria (UKMEC) state that a family history of breast cancer is not a contraindication to any form of hormonal contraception or intrauterine device. The following may therefore be used without restriction (UKMEC category 1: a condition for which there is no restriction for the use of the contraceptive method):
• Combined oral contraceptive (COC).
• Progestogen-only pill.
• Depot medroxyprogesterone acetate (Depo-Provera^®).
• Etonogestrel-only implant (Implanon^®).
• The levonorgestrel-releasing intrauterine system (Mirena^®).

Women who are known carriers of a gene mutation

• If the woman is a carrier of a known gene mutation associated with breast cancer (for example BRCA1):
• The COC should generally not be used (UKMEC category 3: the theoretical or proven risks usually outweigh the advantages).
• The progestogen-only pill, depot medroxyprogesterone acetate (Depot-Provera^®), the etonogestrel-only implant (Implanon^®), or the levonorgestrel-releasing intrauterine system (Mirena^®) may generally be used (UKMEC category 2: a condition where the advantages of using the method generally outweigh the theoretical or proven risks).
• For further information, see the CKS topic on Contraception.

• Seek specialist advice if the woman is considering hormone replacement treatment (HRT) and fulfils the criteria for specialist assessment of her risk of breast cancer.
• Generally:
• Inform women who are considering taking, or who are already taking, HRT of the increase in breast cancer risk (associated with the type and duration of treatment).
• Ensure that oestrogen-only HRT is prescribed if the woman does not have a uterus.
• Keep the dose as low as possible for as short a time as possible.
• Generally, if the woman is at moderate-to-high risk of breast cancer, then HRT should only be given until she reaches 50 years of age.
• For women who have had breast cancer, see the section on Current or previous breast cancer in the CKS topic on Menopause.

• A more detailed family history will be taken, with a more accurate assessment of risk.
• All women satisfying referral criteria to secondary care (such as those with a moderate-to-high risk of breast cancer) will be offered mammographic surveillance from 40 years of age.
• From 40–49 years of age this will be annually.
• From 50 years of age this will be every 3 years as part of the NHS Breast Screening Programme.
• Individualized strategies will be developed for women 30–39 years of age and older than 50 years of age who:
• Are from families with BRCA1, BRCA2, or TP53 mutations.
• Have an equivalent high risk of breast cancer.
• Women younger than 30 years of age will not be offered mammographic surveillance.
• When mammography is recommended in women younger than 50 years of age, digital mammography should be used in preference to conventional mammography at centres where this is available to NHS Breast Screening Programme standards.
• Women who are thought to be at high risk (that is, a 10-year risk greater than 8% at 40–49 years of age, or a lifetime risk of 30% or greater, or who have a 20% chance of a faulty BRCA1, BRCA2, or TP53 gene) should be referred to a specialist genetics clinic 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.

• Genetic testing is appropriate only for a small number of women from high-risk families and is possible only if there is a living relative with the disease who is willing to be tested.
• Genetic testing is a two-stage process. It begins with a search for a genetic mutation in a relative with cancer to try to identify a mutation in the appropriate genes (BRCA1, BRCA2, and if the pedigree warrants it the TP53 gene as well). It may also be appropriate to test for a less common gene if the clinical features suggest a particular gene such as PTEN (Cowden's syndrome).
• If, in the initial testing of the relative with cancer:
• A causative mutation is not found: the unaffected woman who initially presented should be informed that genetic testing on her or any other unaffected family member is unlikely to be informative and is not recommended. However, the absence of an identifiable gene fault does not mean that there is definitely not one present (not all gene faults can be identified).
• A causative mutation is found: a predictive test (family-specific mutation test) is made available to all female blood relatives, including the unaffected woman who initially presented.
• If the predictive test is negative, the unaffected woman who has been tested should be reassured that a specific causative gene that was found in her relative has not been found in her, and there is no risk of transmitting that particular gene fault to her children. Her risk of breast cancer is the same as that of the general population.
• If the predictive test is positive, this means that the woman has inherited the gene fault from her relative and her risk of cancer is increased. Each of her children has a 50% risk of inheriting the gene fault.
• The Department of Health have set the following standards for the time taken for the results of genetic tests to be available:
• Within 2 weeks, where the potential genetic mutation is already known (such as where another family member has already been tested).
• Within 8 weeks, for unknown mutations in a large gene.