NHS Guidelines for Under-50 Breast Cancer Miss Most At-Risk Women

Study Finds NHS Guidelines Miss Most At-Risk Younger Women

The findings indicate that guidance from the National Institute of Health and Care Excellence (Nice) fails to identify up to 95% of women in this age group who have a higher-than-average risk of breast cancer. Breast cancer remains a leading cause of death in women under 50 in the UK, where about one in seven women develop the disease in their lifetime. While most cases occur in older individuals—with 96% in women over 40 and 25% in women over 75—about 2,500 people under 40 are diagnosed annually, and men can also be affected with roughly 420 new cases every year.

Limitations of Current NICE Criteria

Under current guidelines in England, Nice recommends that GPs ask about family history if a patient is worried about their risk, or if they are over 35 and using an oral contraceptive pill or considering hormone replacement therapy. Hormones have been linked to a slightly increased risk, though larger risk factors include alcohol intake and obesity.

The primary reason for the gap in detection is that the Nice criteria focus predominantly on inherited genes and family history. Researchers found that 73% of women under 50 who develop breast cancer within a decade have no family history of the disease.

The current Nice criteria result in just 1.4% of women under 50 being referred for further assessment, capturing only 4.4% of those who ultimately develop breast cancer. By comparison, using a multifactorial risk assessment tool identified eight times as many women in this age group who developed the disease.

Evaluating the Boadicea Risk Assessment Tool

The study evaluated a risk calculator known as Boadicea, which is available via the CanRisk platform and combines multiple factors to generate a risk score. These factors include:

• Family history
• Lifestyle
• Reproductive history
• Genetic information

If the Boadicea model were utilized for all women under 50, researchers estimate that 26.5% of women would be classified as having an above-population level risk and referred for further assessment. This broader approach would capture approximately 34.8% of women under 50 who develop breast cancer within 10 years.

Lead researcher Dr Juliet Usher-Smith from the University of Cambridge stated that the NHS should review the criteria in light of the findings. However, experts acknowledge that expanding referrals presents significant clinical and operational challenges. Dr Usher-Smith noted that referring more people would increase workloads and could cause unnecessary checks and anxiety for some patients.

Dr Sowmiya Moorthie from bbc.com, which funded the work alongside cam.ac.uk, emphasized that any changes must remain accessible and equitable while addressing potential anxiety from extra referrals. Professor Montserrat Garcia-Closas from the Institute of Cancer Research, London, added that a balance must be struck because while Nice criteria are easier to implement, full risk assessments involving genetic testing place a heavy burden on resources.

Nice responded by welcoming the findings and recognizing the potential of multifactorial risk assessment tools, while maintaining that current evidence does not yet warrant a change to its breast cancer guidelines.