Family History of Breast/Ovarian Cancer

Overview

Refer to Local Genetics Service Referral Pathway (PDF) for detailed advice. Please take note of the addendum below when using this pathway and that the contact number for the on-call genetic Counsellor is now: 0117 342 5107.

These guidelines have been designed to direct appropriate referrals for breast/ovarian cancer family history to Clinical Genetics and/or the Family Breast Clinic and are based on published guidelines (Familial Breast Cancer. NICE clinical guidance 41 (2006). These guidelines only apply to asymptomatic individuals.

Addendum:

Please note the following from the UHB Genetics Team when using the above pathway until this can be amended:

'The above pathway predates the updated NICE guidance, but broadly speaking is still relevant. When we initially designed the pathway, both moderate & high risk females were offered annual mammography between the age of 40-50, but were all returned to the national programme aged 50. The updated guidance is that for moderate risk women ( lifetime risk of 17-29% or 3-8% between aged 40 & 50) are still returned to the national programme aged 50, but high risk women (lifetime risk   30-40%) are offered annual mammography until 60. Only females with BRCA1 or 2 ( or equivalent) are offered more intensive surveillance. The changes we would have to make to the flow diagram is to change the age of referral to a family breast screening clinic to 40 & also to make it explicit that moderate risk women aged over 50 should not be referred to the family breast screening clinic as they are not eligible for surveillance.'

Advice on BRCA

A useful reference for patients who have had a diagnosis of BRCA and also for GPs - The Royal Marsden. A beginners guide to BRCA1 and BRCA2

Prophylactic Mastectomy - This criteria based access policy confirms that patients who are identified as having a High Risk of developing Breast Cancer are eligible to access a Prophylactic Mastectomy without the need to secure additional funding.

Referrals

Referrals for asymptomatic women can be made to:

The Family Breast Clinic for surveillance  if appropriate - available via eRS: Specialty: Surgery- Breast. Clinic type – FH of Breast Cancer (non 2WW)

or

The Clinical Genetics Clinic at St Michaels is available via eRS (Update December 2022 - current restrictions apply to routine referrals)

Chemoprevention therapy

Anastrozole and tamoxifen are TLS Amber Specialist Recommended on the BNSSG Joint Formulary (scroll down to section 8.2.4 - Hormone Responsive Breast Cancer).

Referral to Chemoprevention Therapy Clinic

Patients requesting chemoprevention therapy who are eligible and have reviewed the appropriate decision making aid can be referred.

See NICE CG 164 (section 1.7.20 - Chemoprevention for women with no personal history of breast cancer)

Prior to referral to the chemoprevention clinic, please complete the following baseline blood tests: Lipids, LFTs, renal function and FBC.

Please include the following details : Name, DOB, NHS number, menopausal status and relevant family history of breast or ovarian cancer (alongside ages at diagnosis if possible).

Referrals should be made via email to: FamilyHistoryBreastCare@nbt.nhs.uk marked FAO: Chemoprevention Clinic.

Follow up of Patients on Chemoprevention Therapy

Anastrozole requires bone mineral density monitoring but tamoxifen does not.

If anastrozole is recommended by the specialist team following assessment at the chemoprevention clinic, the GP should arrange a DEXA scan to assess bone mineral density before treatment is started. The responsibility for arranging the DEXA scan and managing results sits in primary care. The DEXA scan should be repeated at regular intervals (frequency is as advised by reporting radiologist or at 2 years of treatment).

Chemoprophylaxis with anastrozole and tamoxifen should be stopped at 5 years.

Information and education for GPs

The following information and education about primary prevention of breast cancer was shared by the breast team:

• Licensing of anastrozole for primary prevention of breast cancer - Association of Breast Surgery (information)
• NHSE elfh Hub (e-lfh.org.uk) (Breast cancer primary prevention education)

Resources

Overview | Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer | Guidance | NICE

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.