Final Recommendation Statement
BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing
August 20, 2019
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
The US Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Potentially harmful mutations of the BRCA1/2 genes are associated with increased risk for breast, ovarian, fallopian tube, and peritoneal cancer.1-6 For women in the United States, breast cancer is the most common cancer after nonmelanoma skin cancer and the second leading cause of cancer death.7 In the general population, BRCA1/2 mutations occur in an estimated 1 in 300 to 500 women and account for 5% to 10% of breast cancer cases and 15% of ovarian cancer cases.8-11 A woman’s risk for breast cancer increases if she has clinically significant mutations in the BRCA1/2 genes.12,13 Mutations in the BRCA1/2 genes increase breast cancer risk to 45% to 65% by age 70 years. Risk of ovarian, fallopian tube, or peritoneal cancer increases to 39% for BRCA1 mutations and 10% to 17% for BRCA2 mutations.12,13
Genetic risk assessment and BRCA1/2 mutation testing is a multistep process that begins with identifying patients with family or personal histories of breast, ovarian, tubal, or peritoneal cancer; family members with known harmful BRCA1/2 mutations; or ancestry associated with harmful BRCA1/2 mutations. Risk for clinically significant BRCA1/2 mutations can be further evaluated with genetic counseling by suitably trained health care clinicians, followed by genetic testing of selected high-risk individuals and posttest counseling about results. The USPSTF found adequate evidence that familial risk assessment tools are accurate in identifying women with increased likelihood of BRCA1/2 mutations. These tools can be used by primary care clinicians to guide referrals to genetic counseling.
The USPSTF has previously established that there is adequate evidence that current genetic tests can accurately detect known BRCA1/2 mutations.14
Benefits of Screening, Genetic Counseling, and Genetic Testing
The USPSTF found adequate evidence that the benefits of risk assessment, genetic counseling, and genetic testing are moderate in women whose family history is associated with an increased risk for harmful mutations in the BRCA1/2 genes.
The USPSTF found adequate evidence that the benefits of risk assessment, genetic counseling, and genetic testing are small to none in women whose family history is not associated with an increased risk for harmful mutations in the BRCA1/2 genes.
Harms of Screening, Genetic Counseling, and Genetic Testing
The USPSTF found adequate evidence that the harms associated with risk assessment, genetic counseling, genetic testing, and interventions are small to moderate.
The USPSTF concludes with moderate certainty that the net benefit of risk assessment for increased risk of BRCA1/2 mutations, testing for BRCA1/2 mutations, and use of risk-reducing interventions outweighs the harms in women whose family or personal history is associated with an increased risk for potentially harmful mutations in the BRCA1/2 genes.
The USPSTF concludes with moderate certainty that the harms of risk assessment for increased risk of BRCA1/2 mutations, testing for BRCA1/2 mutations, and use of risk-reducing interventions outweigh the benefits in women whose family or personal history is not associated with an increased risk for potentially harmful mutations in the BRCA1/2 genes.
Patient Population Under Consideration
This recommendation applies to women who are asymptomatic for BRCA-related cancer and have unknown BRCA mutation status. It includes women who have never been diagnosed with BRCA-related cancer, as well as those with a previous breast, ovarian, tubal, or peritoneal cancer diagnosis who have completed treatment and are considered cancer free but have not been previously tested. While this recommendation applies to women, the net benefit estimates are driven by biological sex (ie, male/female) rather than gender identity. Persons should consider their sex at birth to determine which recommendation best applies to them.
Assessment of Risk
Mutations in the BRCA1/2 genes cluster in families, showing an autosomal dominant pattern of inheritance in either the mother’s or father’s family. When taking medical and family history information from patients, primary care clinicians should ask about specific types of cancer, primary cancer sites, which family members were affected, and whether relatives had multiple types of primary cancer. Clinicians should also inquire about the age at diagnosis, age at death, and sex of affected family members, both immediate (ie, parents and siblings) as well as more distant (ie, aunts, uncles, grandparents, and cousins).
For women who have family members with breast, ovarian, tubal, or peritoneal cancer or have a personal history of these types of cancer, primary care clinicians may use appropriate brief familial risk assessment tools to determine the need for in-depth genetic counseling. Tools evaluated by the USPSTF include the Ontario Family History Assessment Tool (Table 1), Manchester Scoring System (Table 2), Referral Screening Tool (Table 3), Pedigree Assessment Tool (Table 4), 7-Question Family History Screening Tool (Table 5), International Breast Cancer Intervention Study instrument (Tyrer-Cuzick) (Table 6), and brief versions of BRCAPRO. Each of these tools has been validated and accurately estimate the likelihood of carrying a harmful BRCA1/2 mutation. They can be used to guide referrals to genetic counseling for more definitive risk assessment.28 General breast cancer risk assessment models (eg, the National Cancer Institute Breast Cancer Risk Assessment Tool, which is based on the Gail model) are not designed to identify BRCA-related cancer risk and should not be used for this purpose.
In general, these brief familial risk assessment tools include factors associated with increased likelihood of potentially harmful BRCA1/2 mutations. These include breast cancer diagnosis before age 50 years, bilateral breast cancer, presence of both breast and ovarian cancer in one individual, male family members with breast cancer, multiple cases of breast cancer in the family, 1 or more family members with 2 primary types of BRCA-related cancer (such as ovarian cancer), and Ashkenazi Jewish ancestry. The USPSTF recognizes that each risk assessment tool has advantages and limitations and found insufficient evidence to recommend one over another.
The process of genetic counseling includes detailed kindred analysis and risk assessment for potentially harmful BRCA1/2 mutations. It also includes identification of candidates for testing, patient education, discussion of the benefits and harms of genetic testing, interpretation of results after testing, and discussion of management options. Genetic counseling about BRCA1/2 mutation testing should be performed by trained health professionals, including suitably trained primary care clinicians. Several professional organizations describe the skills and training necessary to provide comprehensive genetic counseling.
Testing for BRCA1/2 mutations should be performed only when an individual has personal or family history that suggests an inherited cancer susceptibility, when an individual is willing to talk with a health professional who is suitably trained to provide genetic counseling and interpret test results, and when test results will aid in decision-making. Clinical practice guidelines recommend that BRCA1/2 mutation testing begin with a relative with known BRCA-related cancer, including male relatives, to determine if a clinically significant mutation is detected in the family before testing individuals without cancer.29 If an affected family member with a BRCA-related cancer is not available, then the relative with the highest probability of mutation should be tested. The type of mutation analysis required depends on family history. Individuals from families with known mutations or from ancestry groups in which certain mutations are more common (eg, Ashkenazi Jewish founder mutations) can be tested for these specific mutations. Because risk assessment is primarily based on family history, it is unclear how women with a limited or unknown family history should be assessed for BRCA1/2 mutation risk and potential referral to counseling or genetic testing.
Tests for BRCA1/2 mutations are highly sensitive and specific for known mutations. The availability of testing options has changed since the 2013 US Supreme Court ruling that determined human genes are not patentable (Association for Molecular Pathology et al v Myriad Genetics Inc et al).30 Previously, BRCA1/2 mutation testing in the United States was mainly conducted by 1 laboratory. Since the ruling, the number of testing options has significantly increased, with more than 80 multigene panels that include BRCA1/2, as well as tests marketed directly to consumers.31
Guidelines from the American College of Medical Genetics and Genomics, which were updated in 2015, recommend new standard terminology for reporting BRCA1/2 mutations identified by genetic tests. These include a 5-tier terminology system using the terms “pathogenic,” “likely pathogenic,” “uncertain significance,” “likely benign,” and “benign.”32
Treatment and Interventions
Management of increased cancer risk related to BRCA1/2 mutations is beyond the scope of this Recommendation Statement. In general, care for women with harmful BRCA1/2 mutations consists of a variety of interventions to lower future cancer risk. This includes intensive screening, risk-reducing medications, and risk-reducing mastectomy and salpingo-oophorectomy.
Additional Tools and Resources
The National Cancer Institute Cancer Genetics Services Directory provides a list of professionals who offer services related to cancer genetics, including cancer risk assessment, genetic counseling, and genetic testing.33
The USPSTF recommends that clinicians offer to prescribe risk-reducing medications such as tamoxifen, raloxifene, or aromatase inhibitors to women at increased risk for breast cancer and at low risk for adverse medication effects (B recommendation). It recommends against the routine use of medications for risk reduction of primary breast cancer in women not at increased risk for breast cancer (D recommendation).34
The USPSTF recommends against screening for ovarian cancer in women (D recommendation). This recommendation does not apply to women with known genetic mutations that increase their risk for ovarian cancer (eg, BRCA1/2 mutations).35 The USPSTF found insufficient evidence to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic women for the early detection and treatment of a range of gynecologic conditions (I statement).36
Research Needs and Gaps
Research on risk assessment and testing for BRCA1/2 mutations has focused on short-term outcomes for highly selected women in referral centers. To determine the best approaches for population-based risk assessment and testing, more research is needed about mutation prevalence and effects on the general population as well as ethnicities or ancestries associated with BRCA1/2 mutations. Because risk assessment is primarily based on family history, more research is needed to better understand how women with an unknown family history should be assessed for BRCA1/2 mutation risk. Additional studies are needed, including comparative effectiveness trials, of approaches to risk screening and strategies to improve access to genetic counseling, as well as BRCA1/2 testing for high-risk individuals.
It would be helpful to understand which methods of delivery of genetic counseling are most effective, including those that can increase access to genetic counseling in rural or other settings with limited access. Trials comparing types of clinicians and protocols could address these questions. The consequences of genetic testing for individuals and their relatives require more study. Well-designed investigations using standardized measures and diverse study populations are needed.
An expanded database or registry of patients receiving genetic counseling for inherited breast and ovarian cancer susceptibility or who are tested for BRCA1/2 mutations would provide useful information about predictors of cancer and response to interventions. Additional data are needed from women of varying socioeconomic and racial/ethnic groups.
For women who are BRCA1/2 mutation carriers, studies about the effectiveness of intensive cancer screening and risk-reducing medications and the effects of age at intervention on improving long-term outcomes are needed. This research would increase knowledge of the relative benefits and harms of interventions that are provided on the basis of genetic risk information.
Burden of Disease
For women, breast cancer is the most common cancer in the United States after nonmelanoma skin cancer and the second leading cause of cancer death.37 In 2017, an estimated 252,710 women were diagnosed with breast cancer in the United States and 40,610 died of the disease.37 Ovarian cancer is the fifth leading cause of cancer death in women in the United States.37 In 2017, an estimated 22,440 women were diagnosed with ovarian cancer and 14,080 died of the disease.37 Mutations of the BRCA1/2 genes are estimated to occur in 1 in 300 to 500 women in the general population8-11 and account for 5% to 10% of breast cancer cases and 15% of ovarian cancer cases.9,11,38
Estimates of the prevalence of potentially harmful BRCA1/2 mutations vary by population. The estimated prevalence is 0.2% to 0.3% in the general population of women, 6.0% in women with cancer onset before age 40 years, and 2.1% in the general population of Ashkenazi Jewish women.39 In a meta-analysis of studies in which recruitment was based on family history of breast or ovarian cancer, BRCA1 mutation prevalence was 13.6%, BRCA2 mutation prevalence was 7.9%, and prevalence of either mutation was 19.8%.39
Scope of Review
To update its 2013 recommendation, the USPSTF commissioned a systematic review28,40 on risk assessment, genetic counseling, and genetic testing for potentially harmful BRCA1/2 mutations in asymptomatic women who have never been diagnosed with BRCA-related cancer, as well as those with a previous breast, ovarian, tubal, or peritoneal cancer diagnosis who have completed treatment and are considered cancer free. The USPSTF reviewed interventions to reduce the risk for breast, ovarian, tubal, or peritoneal cancer in women with potentially harmful BRCA1/2 mutations, including intensive cancer screening (eg, earlier and more frequent mammography or magnetic resonance imaging [MRI] of the breast), medications (eg, tamoxifen, raloxifene, or aromatase inhibitors), and risk-reducing surgery (eg, mastectomy or salpingo-oophorectomy). Although male breast cancer, pancreatic cancer, prostate cancer, and melanoma are associated with BRCA1/2 mutations, discussion of these types of cancer is outside the scope of this recommendation.
Accuracy of Familial Risk Assessment
The USPSTF reviewed studies of familial risk stratification tools that could be used in primary care settings to determine the likelihood of potentially harmful BRCA1/2 mutations. These tools are primarily intended for use by health care clinicians untrained in genetic cancer risk assessment to guide referral to genetic counselors for more definitive evaluation. In general, these tools elicit information about factors associated with increased likelihood of BRCA1/2 mutations, including family and personal history of cancer (including types of cancer and age of diagnosis) and ancestry (Ashkenazi Jewish). Because risk assessment is primarily based on family history, it is unclear how women with an unknown family history should be assessed for BRCA1/2 mutation risk.
Models that have been validated in studies include the Ontario Family History Assessment Tool (Table 1),15-18 Manchester Scoring System (Table 2),16-21,41 Referral Screening Tool (Table 3),22 Pedigree Assessment Tool (Table 4),23,24 7-Question Family History Screening Tool (Table 5),25 and the International Breast Cancer Intervention Study instrument (also known as Tyrer-Cuzick) (Table 6), and their variations.26 The USPSTF found that these tools are clinically useful predictors of which individuals should be referred for genetic counseling. Compared with results of other models or genetic testing in studies, these tools all have sensitivity estimates between 77% and 100% and areas under the receiver operating characteristic curve between 0.68 and 0.96,28 although some models have been evaluated in only 1 study.22,25,26 The USPSTF reviewed a study of brief versions of BRCAPRO (eg, BRCAPRO-LYTE), designed for primary care clinicians, followed by the full BRCAPRO (used by genetic counselors) and found that the sequential testing scheme identified a similar number of BRCA mutation carriers as the full BRCAPRO.42 The USPSTF recognizes that each risk assessment tool has advantages and limitations and found insufficient evidence to recommend one tool over another.
Effectiveness of Genetic Counseling, Genetic Testing, and Interventions
To understand the full benefits and harms of genetic counseling, the USPSTF reviewed studies on pretest and posttest counseling, BRCA1/2 mutation testing, and interventions.
Pretest and Posttest Counseling
The USPSTF reviewed 28 studies on pretest counseling.43-72 Studies reported measures of distress associated with genetic counseling for BRCA-related cancer, including cancer worry (17 studies), anxiety (13 studies), and depression (7 studies). In general, pretest genetic counseling either decreased or had no effect on breast cancer worry, anxiety, and depression.28 Twenty-two studies examined understanding of risk, with most reporting either improved understanding (14 studies)45,48,53,55-58,61,64,65,67-69,72,73 or no association (6 studies),43,52,59,62,70,71 1 study reporting decreased understanding,60 and 1 study reporting mixed results.46 Five studies that evaluated the effects of genetic counseling on BRCA1/2 mutation testing intention found decreased intent to test in 4 studies45,53,58,67 and increased intent in 1 study.74
Although several studies included discussion of management options as part of the pretest counseling process, none evaluated benefits or harms of counseling conducted after receiving test results.
BRCA1/2 Mutation Testing
One good-quality trial (n = 1034) of women and men of Ashkenazi Jewish ancestry evaluated population-based BRCA1/2 mutation testing vs family history–based testing.75 Results showed that a strategy of population-based testing for founder mutations detected more BRCA1/2 mutation carriers than testing persons who met family history criteria. However, no clinical outcomes were reported and, because not all participants had BRCA1/2 mutation testing, the accuracy of this strategy could not be determined. Genetic testing generally improved risk perception, with increased perceived risk of breast and ovarian cancer risk in BRCA1/2 mutation carriers and decreased perceived risk in persons testing negative.76,77
Studied interventions to reduce risk for cancer in women who are BRCA1/2 mutation carriers include earlier, more frequent, or more intensive cancer screening (eg, breast MRI or mammography); use of risk-reducing medications (eg, selective estrogen receptor modulators or aromatase inhibitors); and risk-reducing surgery (eg, mastectomy or salpingo-oophorectomy).
The USPSTF reviewed 11 randomized clinical trials of selective estrogen receptor modulators and aromatase inhibitors, although none were conducted specifically in women who were BRCA1/2 mutation carriers. Results of meta-analysis78 indicated clinically significant reductions in invasive breast cancer with the use of tamoxifen, raloxifene, and aromatase inhibitors, with 7 fewer events per 1000 women for tamoxifen (4 trials),79-82 9 fewer events per 1000 women for raloxifene (2 trials),83,84 and 16 fewer events per 1000 women for aromatase inhibitors (2 trials),85-89 assuming 5 years of treatment. Tamoxifen reduced invasive breast cancer more than raloxifene in the head-to-head trial (relative risk, 1.24 [95% CI, 1.05-1.47]).90 Risk reduction persisted at least 8 years after discontinuation in the 2 tamoxifen trials providing long-term follow-up data. All medications reduced estrogen receptor–positive, but not estrogen receptor–negative, invasive breast cancer. Breast cancer–specific and all-cause mortality were not reduced.78
In cohort studies of high-risk women and women who were BRCA1/2 mutation carriers, risk-reducing surgery such as mastectomy (6 studies),91-97 oophorectomy (7 studies),98-104 or salpingo-oophorectomy (2 studies)91,105 were associated with reduced risk for breast or ovarian cancer. Bilateral mastectomy was associated with a 90% to 100% reduced breast cancer incidence and 81% to 100% reduced breast cancer mortality. Oophorectomy was associated with 81% to 100% reduced ovarian cancer incidence. In general, there was no association between oophorectomy or salpingo-oophorectomy and reduced breast cancer risk, although some studies showed reduced risk in younger women (age <50 years).78,98,99
The USPSTF found no studies on the benefits of intensive screening for BRCA-related cancer on clinical outcomes in women who are BRCA1/2 mutation carriers.
Harms of Genetic Counseling, Genetic Testing, and Interventions
The USPSTF reviewed the psychological effects of test results. Nine studies evaluated breast cancer worry or distress after genetic testing. Increased worry was found in 7 studies,77,106-111 particularly in women who are BRCA1/2 mutation carriers, and 2 studies reported decreased worry.112,113 Studies reporting anxiety related to genetic testing were mixed, with 4 reporting increased anxiety,106,109,113,114 2 reporting decreased anxiety,111,115 and 6 reporting no association.75,108,112,116-118 Two studies noted higher anxiety in women who were not tested compared with those who were tested.111,119 Of the 8 studies evaluating depression, none reported increases in anxiety after genetic testing.75,108,111,112,115,117,118,120
Intensive screening for breast and ovarian cancer is associated with false-positive results, additional imaging tests, and surgery for women without cancer. In a retrospective analysis of a cohort of women with potentially harmful BRCA1/2 mutations or first-degree relatives with BRCA1/2 mutations, women screened with mammography were more likely to have additional imaging tests than those screened with MRI.121 In 2 studies comparing mammography with MRI for breast cancer screening in which 18% to 100% of study participants were BRCA1/2 mutation carriers, MRI was associated with higher false-positive rates (14% vs 5.5% in the first round of screening; P<0.001;122 15% vs 11% in another study121). Intensive screening for ovarian cancer using transvaginal ultrasound demonstrated high false-positive rates (3.4%).123 A second study in women who were BRCA1/2 mutation carriers reported a diagnostic surgery rate of 55% after annual screening with transvaginal ultrasound and serum tumor marker cancer antigen125 measurements for women without cancer.124 Most women did not experience anxiety after screening with MRI, mammography, or clinical breast examination, although women recalled for additional testing reported transient anxiety.125
Eight placebo-controlled trials and 1 head-to-head trial of tamoxifen and raloxifene reported harms of risk-reducing medications. Raloxifene and tamoxifen increased risk for thromboembolic events compared with placebo, and raloxifene caused fewer events than tamoxifen in the head-to-head trial.78,126,127 An increased risk of endometrial cancer was seen with tamoxifen (4 cases per 1000 women) but not with raloxifene or aromatase inhibitors. Women using tamoxifen had more cataract procedures compared with placebo or raloxifene.79,90 The most common adverse effects were vasomotor symptoms and vaginal discharge, itching, or dryness for tamoxifen and vasomotor symptoms and leg cramps for raloxifene.28
Thirteen studies of mastectomy128-140 and 9 studies of oophorectomy or salpingo-oophorectomy141-145 reported harms associated with surgical interventions, although most were small in size and had mixed outcomes. For mastectomy, complication rates ranged from 49% to 69%.28 Complications included numbness, pain, tingling, infection, swelling, breast hardness, bleeding, organizing hematoma, failed reconstruction, breathing problems, thrombosis, and pulmonary embolism.28 Postsurgical complications associated with oophorectomy/salpingo-oophorectomy included bleeding, pain, infection, and hematoma formation, with 1% to 3% of women in 1 study reporting such complications.142 In another small study of women who were BRCA1/2 mutation carriers, most women reported worsening vasomotor symptoms and decreased sexual function.146 Seven studies reported psychological outcomes in women receiving risk-reducing mastectomy132-140 and 3 studies in those receiving risk-reducing oophorectomy/salpingo-oophorectomy.143-145 Commonly reported symptoms included reductions in body image, sexual activity/satisfaction, and general mental health (anxiety/depression symptoms); however, many of these symptoms were transient.28
Estimate of Magnitude of Net Benefit
For women whose family or personal history is associated with an increased risk for harmful mutations in the BRCA1/2 genes, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are moderate. For women whose family history is not associated with an increased risk for harmful mutations in the BRCA1/2 genes, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are small to none.
The USPSTF found adequate evidence that the overall harms of risk assessment, genetic counseling, genetic testing, and interventions are small to moderate.
For women whose family history is associated with an increased risk for harmful mutations in the BRCA1/2 genes, the USPSTF concludes with moderate certainty that the net benefit outweighs the harm of risk assessment and referral to genetic counseling for consideration of testing, detection, and intervention is moderate. For women whose family history is not associated with an increased risk for harmful mutations in the BRCA1/2 genes, the USPSTF concludes with moderate certainty that the harms of risk assessment and referral to genetic counseling for consideration of testing, detection, and intervention outweigh the benefits.
How Does the Evidence Fit With Biological Understanding?
The BRCA1 and BRCA2 genes are tumor suppressor genes. Harmful mutations of these genes have been linked to hereditary breast and ovarian cancer. Risks for breast, ovarian, and other types of BRCA-related cancer are greatly increased in patients who have inherited potentially harmful BRCA1/2 mutations. Genetic testing may identify these mutations. Several options are available to reduce cancer risk in patients found to be mutation carriers.
Response to Public Comment
A draft version of this Recommendation Statement was posted for public comment on the USPSTF website from February 19 through March 18, 2019. In response to public comments, the USPSTF clarified language regarding risk assessment and included additional information on the risk assessment tools referenced in the recommendation. It also incorporated language clarifying that the recommendation includes women with a personal history of BRCA-related cancer who have completed treatment and are considered cured.
Comments requested that the population under consideration be expanded to include other BRCA-associated cancers such as pancreatic cancer, melanoma, and prostate cancer, as well as men with breast or prostate cancer. The USPSTF recognizes the association of BRCA1/2 mutations with cancers such as pancreatic, prostate, and melanoma. However, the scope of the recommendation is limited to the prevention of breast, ovarian, tubal, and peritoneal cancer because the net benefit demonstrated was in the prevention of these cancers. The USPSTF did not review evidence on the benefits or harms of risk assessment, genetic counseling, and genetic testing in men.
Several comments requested changes to the recommendation related to newer genetic testing options. This includes the use of multigene panels, expanding the recommendation to include other gene mutations linked to increased risk of cancer (eg, TP53, ATM, PALB2), and the use of direct-to-consumer testing. The USPSTF acknowledges that there is increasing access to multigene panels; however, the clinical significance of identifying pathogenic variants in multigene panels requires further investigation. The evidence is currently limited on other moderate penetrance genes, given their relatively low incidence in the population. The USPSTF’s recommendation focuses on BRCA1/2 mutations because they are more prevalent and the findings are clinically actionable. The USPSTF found no evidence on the benefits or harms associated with the use of direct-to-consumer testing. Current National Comprehensive Cancer Network guidelines recommend that multigene testing be offered in the context of professional genetic expertise for pretest and posttest.29 The USPSTF added language emphasizing that the net benefit relies on genetic counseling to accompany testing results, including results from direct-to-consumer testing.
The National Comprehensive Cancer Network provides specific criteria for genetic counseling and testing.29 The American College of Medical Genetics and the American Society of Clinical Oncology recommend testing for BRCA1/2 mutations only when an individual has personal or family cancer history suggestive of inherited cancer susceptibility, the test can be adequately interpreted, and the results will aid in management.148,149 The American College of Obstetricians and Gynecologists recommends performing a hereditary cancer risk assessment and subsequent referral to a specialist in cancer genetics if necessary.150 The Society for Gynecologic Oncology recommends that individuals with a likelihood of inherited predisposition to cancer based on personal or family history should be offered genetic counseling.151 The American Society of Breast Surgeons recommends that genetic testing be made available to all patients with a personal history of breast cancer.152 The National Institute for Health and Care Excellence recommends that health care professionals respond to a patient who presents with concerns but should not, in most instances, actively seek to identify persons with a family history of breast cancer.153 It recommends that in some circumstances, including when a patient has concerns about relatives with breast cancer, a first- and second-degree family history be taken in primary care to assess risk. Referral to secondary care is recommended if risk factors are identified in family history taking.153 The European Society for Medical Oncology follows the recommendations of the National Institute for Health and Care Excellence for initial risk assessment and the decision when to perform genetic counseling and testing.154
In 2005 and 2013, the USPSTF recommended that women whose family history is associated with an increased risk for potentially harmful mutations in the BRCA1/2 genes be referred for genetic counseling and evaluation for BRCA1/2 testing. It also recommended against routine referral for genetic counseling or routine BRCA1/2 mutation testing for women whose family history is not associated with an increased risk for potentially harmful mutations in the BRCA1/2 genes.14,147 This Recommendation Statement is consistent with the USPSTF’s previous recommendation.
Since 2013, the validity of genetic testing for BRCA1/2 mutations has been established and the potential benefits and harms of previously reviewed interventions, such as risk-reducing medications and surgery, have been studied for longer follow-up periods. In addition, there have been more studies of newer imaging techniques (breast MRI), surgical procedures (salpingo-oophorectomy rather than oophorectomy alone), and medications (aromatase inhibitors). The updated recommendation expands the population eligible for screening to include women with a previous breast, ovarian, tubal, or peritoneal cancer diagnosis who have completed treatment and are considered cancer free and more explicitly includes ancestry associated with BRCA1/2 mutations (ie, founder mutations) as a risk factor.
The US Preventive Services Task Force (USPSTF) members include the following individuals: Douglas K. Owens, MD, MS (Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Stanford University, Stanford, California); Karina W. Davidson, PhD, MASc (Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York); Alex H. Krist, MD, MPH (Fairfax Family Practice Residency, Fairfax, Virginia, and Virginia Commonwealth University, Richmond); Michael J. Barry, MD (Harvard Medical School, Boston, Massachusetts); Michael Cabana, MD, MA, MPH (University of California, San Francisco); Aaron B. Caughey, MD, PhD (Oregon Health & Science University, Portland); Chyke A. Doubeni, MD, MPH (Mayo Clinic, Rochester, MN); John W. Epling Jr, MD, MSEd (Virginia Tech Carilion School of Medicine, Roanoke); Martha Kubik, PhD, RN (Temple University, Philadelphia, Pennsylvania); C. Seth Landefeld, MD (University of Alabama at Birmingham); Carol M. Mangione, MD, MSPH (University of California, Los Angeles); Lori Pbert, PhD (University of Massachusetts Medical School, Worcester); Michael Silverstein, MD, MPH (Boston University, Boston, Massachusetts); Melissa A. Simon, MD, MPH (Northwestern University, Evanston, Illinois); Chien-Wen Tseng, MD, MPH, MSEE (University of Hawaii, Honolulu); John B. Wong, MD (Tufts University School of Medicine, Boston, Massachusetts).
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Authors followed the policy regarding conflicts of interest described at https://www.uspreventiveservicestaskforce.org/Page/Name/conflict-of-interest-disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.
Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.
Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.
Copyright Notice: USPSTF recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient's needs. To encourage widespread discussion, consideration, adoption, and implementation of USPSTF recommendations, AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate USPSTF work into other materials provided that it is reproduced without any changes to the work of portions thereof, except as permitted as fair use under the US Copyright Act.
AHRQ and the US Department of Health and Human Services cannot endorse, or appear to endorse, derivative or excerpted materials, and they cannot be held liable for the content or use of adapted products that are incorporated on other Web sites. Any adaptations of these electronic documents and resources must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is strictly prohibited.
This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. §320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.
1. Brody LC, Biesecker BB. Breast cancer susceptibility genes. BRCA1 and BRCA2. Medicine (Baltimore). 1998;77(3):208-226.
2. Mersch J, Jackson MA, Park M, et al. Cancers associated with BRCA1 and BRCA2 mutations other than breast and ovarian. Cancer. 2015;121(2):269-275.
3. Miki Y, Swensen J, Shattuck-Eidens D, et al. A strong candidate for the breast and ovarian cancer susceptibility gene BRCA1. Science. 1994;266(5182):66-71.
4. Wooster R, Weber BL. Breast and ovarian cancer. N Engl J Med. 2003;348(23):2339-2347.
5. Sherman ME, Piedmonte M, Mai PL, et al. Pathologic findings at risk-reducing salpingo-oophorectomy: primary results from Gynecologic Oncology Group Trial GOG-0199. N Engl J Med. 2014;32(29):3275-3283.
6. Norquist BM, Garcia RL, Allison KH, et al. The molecular pathogenesis of hereditary ovarian carcinoma: alterations in the tubal epithelium of women with BRCA1 and BRCA2 mutations. Cancer. 2010;116(22):5261-5271.
7. American Cancer Society (ACS). Cancer Facts & Figures 2018. ACS website. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2018.html. Published 2018. Accessed July 3, 2019.
8. Antoniou AC, Gayther SA, Stratton JF, Ponder BA, Easton DF. Risk models for familial ovarian and breast cancer. Genet Epidemiol. 2000;18(2):173-190.
9. Anglian Breast Cancer Study Group. Prevalence and penetrance of BRCA1 and BRCA2 mutations in a population-based series of breast cancer cases. Br J Cancer. 2000;83(10):1301-1308.
10. Antoniou AC, Pharoah PD, McMullan G, et al. A comprehensive model for familial breast cancer incorporating BRCA1, BRCA2 and other genes. Br J Cancer. 2002;86(1):76-83.
11. Peto J, Collins N, Barfoot R, et al. Prevalence of BRCA1 and BRCA2 gene mutations in patients with early-onset breast cancer. J Natl Cancer Inst. 1999;91(11):943-949.
12. Antoniou A, Pharoah PD, Narod S, et al. Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case series unselected for family history: a combined analysis of 22 studies. Am J Hum Genet. 2003;72(5):1117-1130.
13. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. N Engl J Med. 2007;25(11):1329-1333.
14. U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(4):271-281.
15. Gilpin CA, Carson N, Hunter AG. A preliminary validation of a family history assessment form to select women at risk for breast or ovarian cancer for referral to a genetics center. Clin Genet. 2000;58(4):299-308.
16. Oros KK, Ghadirian P, Maugard CM, et al. Application of BRCA1 and BRCA2 mutation carrier prediction models in breast and/or ovarian cancer families of French Canadian descent. Clin Genet. 2006;70(4):320-329.
17. Panchal SM, Ennis M, Canon S, Bordeleau LJ. Selecting a BRCA risk assessment model for use in a familial cancer clinic. BMC Med Genet. 2008;9:116.
18. Parmigiani G, Chen S, Iversen ES Jr, et al. Validity of models for predicting BRCA1 and BRCA2 mutations. Ann Intern Med. 2007;147(7):441-450.
19. Antoniou AC, Hardy R, Walker L, et al. Predicting the likelihood of carrying a BRCA1 or BRCA2 mutation: validation of BOADICEA, BRCAPRO, IBIS, Myriad and the Manchester scoring system using data from UK genetics clinics. J Med Genet. 2008;45(7):425-431.
20. Barcenas CH, Hosain GMM, Arun B, et al. Assessing BRCA carrier probabilities in extended families. N Engl J Med. 2006;24(3):354-360.
21. Evans DG, Eccles DM, Rahman N, et al. A new scoring system for the chances of identifying a BRCA1/2 mutation outperforms existing models including BRCAPRO. J Med Genet. 2004;41(6):474-480.
22. Bellcross CA, Lemke AA, Pape LS, Tess AL, Meisner LT. Evaluation of a breast/ovarian cancer genetics referral screening tool in a mammography population. Genet Med. 2009;11(11):783-789.
23. Hoskins KF, Zwaagstra A, Ranz M. Validation of a tool for identifying women at high risk for hereditary breast cancer in population-based screening. Cancer. 2006;107(8):1769-1776.
24. Teller P, Hoskins KF, Zwaagstra A, et al. Validation of the pedigree assessment tool (PAT) in families with BRCA1 and BRCA2 mutations. Ann Surg Oncol. 2010;17(1):240-246.
25. Ashton-Prolla P, Giacomazzi J, Schmidt AV, et al. Development and validation of a simple questionnaire for the identification of hereditary breast cancer in primary care. BMC Cancer. 2009;9:283.
26. Fischer C, Kuchenbäcker K, Engel C, et al; German Consortium for Hereditary Breast and Ovarian Cancer. Evaluating the performance of the breast cancer genetic risk models BOADICEA, IBIS, BRCAPRO and Claus for predicting BRCA1/2 mutation carrier probabilities: a study based on 7352 families from the German Hereditary Breast and Ovarian Cancer Consortium. J Med Genet. 2013;50(6):360-367.
27. Cuzick J. IBIS Breast Cancer Risk Evaluation Tool, v8. http://www.ems-trials.org/riskevaluator/. 2017. Accessed July 25, 2019.
28. Nelson HD, Pappas M, Cantor A, Haney E, Holmes R, Stillman L. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer: A Systematic Review for the US Preventive Services Task Force: Evidence Synthesis No. 182. Rockville, MD: Agency for Healthcare Research and Quality; 2019. AHRQ publication 19-05251-EF-1.
29. National Comprehensive Cancer Network (NCCN). Genetic/Familial High-Risk Assessment: Breast and Ovarian. NCCN website. https://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf. Published 2012. Accessed July 3, 2019.
30. Association for Molecular Pathology et al v Myriad Genetics Inc et al, 133 S Ct 2107 (June 13, 2013).
31. Petrucelli N, Daly MB, Pal T. BRCA1- and BRCA2-associated hereditary breast and ovarian cancer. Seattle, WA: University of Washington, Seattle; 2016.
32. Richards S, Aziz N, Bale S, et al; ACMG Laboratory Quality Assurance Committee. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med. 2015;17(5):405-424.
33. National Cancer Institute (NCI). NCI Cancer Genetics Services Directory. NCI website. https://www.cancer.gov/about-cancer/causes-prevention/genetics/directory. Accessed July 3, 2018.
34. U.S. Preventive Services Task Force. Medications to decrease the risk for breast cancer in women: recommendations from the U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(10):698-708.
35. US Preventive Services Task Force. Screening for ovarian cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(6):588-594.
36. US Preventive Services Task Force. Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(9):947-953.
37. American Cancer Society (ACS). Cancer Facts & Figures 2018. 2018; https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2018/cancer-facts-and-figures-2018.pdf. Accessed November 19, 2018.
38. Whittemore AS, Gong G, John EM, et al. Prevalence of BRCA1 mutation carriers among U.S. non-Hispanic whites. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2078-2083.
39. Nelson HD, Fu R, Goddard K, et al. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 101. Rockville, MD: Agency for Healthcare Research and Quality; 2013. AHRQ Publication No. 12-05164-EF-1.
40. Nelson HD, Pappas M, Cantor A, Haney E, Holmes R. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;322(7):666-685.
41. Kast K, Schmutzler RK, Rhiem K, et al. Validation of the Manchester scoring system for predicting BRCA1/2 mutations in 9,390 families suspected of having hereditary breast and ovarian cancer. Int J Cancer. 2014;135(10):2352-2361.
42. Biswas S, Atienza P, Chipman J, et al. A two-stage approach to genetic risk assessment in primary care. Breast Cancer Res Treat. 2016;155(2):375-383.
43. Albada A, van Dulmen S, Dijkstra H, Wieffer I, Witkamp A, Ausems MG. Counselees' expressed level of understanding of the risk estimate and surveillance recommendation are not associated with breast cancer surveillance adherence. J Genet Couns. 2016;25(2):279-289.
44. Bowen DJ, Burke W, Yasui Y, McTiernan A, McLeran D. Effects of risk counseling on interest in breast cancer genetic testing for lower risk women. Genet Med. 2002;4(5):359-365.
45. Burke W, Culver JO, Bowen D, et al. Genetic counseling for women with an intermediate family history of breast cancer. Am J Med Genet. 2000;90(5):361-368.
46. Cull A, Miller H, Porterfield T, et al. The use of videotaped information in cancer genetic counselling: a randomized evaluation study. Br J Cancer. 1998;77(5):830-837.
47. Lerman C, Narod S, Schulman K, et al. BRCA1 testing in families with hereditary breast-ovarian cancer. A prospective study of patient decision making and outcomes. JAMA. 1996;275(24):1885-1892.
48. Bowen DJ, Burke W, McTiernan A, Yasui Y, Andersen MR. Breast cancer risk counseling improves women's functioning. Patient Educ Couns. 2004;53(1):79-86.
49. Armstrong K, Micco E, Carney A, Stopfer J, Putt M. Racial differences in the use of BRCA1/2 testing among women with a family history of breast or ovarian cancer. JAMA. 2005;293(14):1729-1736.
50. Bennett P, Wilkinson C, Turner J, et al. Factors associated with intrusive cancer-related worries in women undergoing cancer genetic risk assessment. Fam Cancer. 2009;8(2):159-165.
51. Bennett P, Wilkinson C, Turner J, et al. Psychological factors associated with emotional responses to receiving genetic risk information. J Genet Couns. 2008;17(3):234-241.
52. Bloom JR, Stewart SL, Chang S, You M. Effects of a telephone counseling intervention on sisters of young women with breast cancer. Prev Med. 2006;43(5):379-384.
53. Bowen DJ, Burke W, Culver JO, Press N, Crystal S. Effects of counseling Ashkenazi Jewish women about breast cancer risk. Cultur Divers Ethnic Minor Psychol. 2006;12(1):45-56.
54. Brain K, Parsons E, Bennett P, Cannings-John R, Hood K. The evolution of worry after breast cancer risk assessment: 6-year follow-up of the TRACE study cohort. Psychooncology. 2011;20(9):984-991.
55. Braithwaite D, Sutton S, Mackay J, Stein J, Emery J. Development of a risk assessment tool for women with a family history of breast cancer. Cancer Detect Prev. 2005;29(5):433-439.
56. Fry A, Cull A, Appleton S, et al. A randomised controlled trial of breast cancer genetics services in South East Scotland: psychological impact. Br J Cancer. 2003;89(4):653-659.
57. Gurmankin AD, Domchek S, Stopfer J, Fels C, Armstrong K. Patients' resistance to risk information in genetic counseling for BRCA1/2. Arch Intern Med. 2005;165(5):523-529.
58. Helmes AW, Culver JO, Bowen DJ. Results of a randomized study of telephone versus in-person breast cancer risk counseling. Patient Educ Couns. 2006;64(1-3):96-103.
59. Hopwood P, Wonderling D, Watson M, et al. A randomised comparison of UK genetic risk counselling services for familial cancer: psychosocial outcomes. Br J Cancer. 2004;91(5):884-892.
60. Kelly KM, Senter L, Leventhal H, Ozakinci G, Porter K. Subjective and objective risk of ovarian cancer in Ashkenazi Jewish women testing for BRCA1/2 mutations. Patient Educ Couns. 2008;70(1):135-142.
61. Matloff ET, Moyer A, Shannon KM, Niendorf KB, Col NF. Healthy women with a family history of breast cancer: impact of a tailored genetic counseling intervention on risk perception, knowledge, and menopausal therapy decision making. J Womens Health (Larchmt). 2006;15(7):843-856.
62. Mikkelsen EM, Sunde L, Johansen C, Johnsen SP. Risk perception among women receiving genetic counseling: a population-based follow-up study. Cancer Detect Prev. 2007;31(6):457-464.
63. Mikkelsen EM, Sunde L, Johansen C, Johnsen SP. Psychosocial consequences of genetic counseling: a population-based follow-up study. Breast J. 2009;15(1):61-68.
64. Pieterse AH, Ausems MG, Spreeuwenberg P, van Dulmen S. Longer-term influence of breast cancer genetic counseling on cognitions and distress: smaller benefits for affected versus unaffected women. Patient Educ Couns. 2011;85(3):425-431.
65. Roshanai AH, Rosenquist R, Lampic C, Nordin K. Does enhanced information at cancer genetic counseling improve counselees' knowledge, risk perception, satisfaction and negotiation of information to at-risk relatives? A randomized study. Acta Oncol. 2009;48(7):999-1009.
66. Smerecnik CM, Mesters I, Verweij E, De Vries NK, De Vries H. A systematic review of the impact of genetic counseling on risk perception accuracy. J Genet Couns. 2009;18(3):217-228.
67. Brain K, Norman P, Gray J, Rogers C, Mansel R, Harper P. A randomized trial of specialist genetic assessment: psychological impact on women at different levels of familial breast cancer risk. Br J Cancer. 2002;86(2):233-238.
68. Hopwood P, Keeling F, Long A, Pool C, Evans G, Howell A. Psychological support needs for women at high genetic risk of breast cancer: some preliminary indicators. Psychooncology. 1998;7(5):402-412.
69. Lerman C, Schwartz MD, Miller SM, Daly M, Sands C, Rimer BK. A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style. Health Psychol. 1996;15(2):75-83.
70. Lobb EA, Butow PN, Barratt A, et al. Communication and information-giving in high-risk breast cancer consultations: influence on patient outcomes. Br J Cancer. 2004;90(2):321-327.
71. Watson M, Lloyd S, Davidson J, et al. The impact of genetic counselling on risk perception and mental health in women with a family history of breast cancer. Br J Cancer. 1999;79(5-6):868-874.
72. Watson M, Duvivier V, Wade Walsh M, et al. Family history of breast cancer: what do women understand and recall about their genetic risk? J Med Genet. 1998;35(9):731-738.
73. Livaudais-Toman J, Karliner LS, Tice JA, et al. Impact of a primary care based intervention on breast cancer knowledge, risk perception and concern: a randomized, controlled trial. Breast. 2015;24(6):758-766.
74. Lerman C, Hughes C, Benkendorf JL, et al. Racial differences in testing motivation and psychological distress following pretest education for BRCA1 gene testing. Cancer Epidemiol Biomarkers Prev. 1999;8(4 Pt 2):361-367.
75. Manchanda R, Loggenberg K, Sanderson S, et al. Population testing for cancer predisposing BRCA1/BRCA2 mutations in the Ashkenazi-Jewish community: a randomized controlled trial. J Natl Cancer Inst. 2014;107(1):379.
76. Julian-Reynier C, Mancini J, Mouret-Fourme E, et al. Cancer risk management strategies and perceptions of unaffected women 5 years after predictive genetic testing for BRCA1/2 mutations. Eur J Hum Genet. 2011;19(5):500-506.
77. Lumish HS, Steinfeld H, Koval C, et al. Impact of panel gene testing for hereditary breast and ovarian cancer on patients. J Genet Couns. 2017;26(5):1116-1129.
78. Nelson HD, Fu R, McDonagh M, Miller LB, Pappas M, Zakher B. Medication Use for the Risk Reduction of Primary Breast Cancer in Women: A Systematic Review for the US Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2019.
79. Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for the prevention of breast cancer: current status of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst. 2005;97(22):1652-1662.
80. Powles TJ, Ashley S, Tidy A, Smith IE, Dowsett M. Twenty-year follow-up of the Royal Marsden randomized, double-blinded tamoxifen breast cancer prevention trial. J Natl Cancer Inst. 2007;99(4):283-290.
81. Veronesi U, Maisonneuve P, Rotmensz N, et al; Italian Tamoxifen Study Group. Tamoxifen for the prevention of breast cancer: late results of the Italian randomized tamoxifen prevention trial among women with hysterectomy. J Natl Cancer Inst. 2007;99(9):727-737.
82. Cuzick J, Forbes JF, Sestak I, et al; International Breast Cancer Intervention Study I Investigators. Long-term results of tamoxifen prophylaxis for breast cancer—96-month follow-up of the randomized IBIS-I trial. J Natl Cancer Inst. 2007;99(4):272-282.
83. Lippman ME, Cummings SR, Disch DP, et al. Effect of raloxifene on the incidence of invasive breast cancer in postmenopausal women with osteoporosis categorized by breast cancer risk. Clin Cancer Res. 2006;12(17):5242-5247.
84. Grady D, Cauley JA, Geiger MJ, et al; Raloxifene Use for The Heart Trial Investigators. Reduced incidence of invasive breast cancer with raloxifene among women at increased coronary risk. J Natl Cancer Inst. 2008;100(12):854-861.
85. Cuzick J, Sestak I, Forbes JF, et al; IBIS-II Investigators. Anastrozole for prevention of breast cancer in high-risk postmenopausal women (IBIS-II): an international, double-blind, randomised placebo-controlled trial. Lancet. 2014;383(9922):1041-1048.
86. Goss PE, Ingle JN, Alés-Martínez JE, et al; NCIC CTG MAP.3 Study Investigators. Exemestane for breast-cancer prevention in postmenopausal women. N Engl J Med. 2011;364(25):2381-2391.
87. Sestak I, Singh S, Cuzick J, et al. Changes in bone mineral density at 3 years in postmenopausal women receiving anastrozole and risedronate in the IBIS-II bone substudy: an international, double-blind, randomised, placebo-controlled trial [published correction appears in Lancet Oncol. 2014;15(13):e587]. Lancet Oncol. 2014;15(13):1460-1468.
88. Spagnolo F, Sestak I, Howell A, Forbes JF, Cuzick J. Anastrozole-induced carpal tunnel syndrome: results from the International Breast Cancer Intervention Study II prevention trial. N Engl J Med. 2016;34(2):139-143.
89. Maunsell E, Goss PE, Chlebowski RT, et al. Quality of life in MAP.3 (Mammary Prevention 3): a randomized, placebo-controlled trial evaluating exemestane for prevention of breast cancer. N Engl J Med. 2014;32(14):1427-1436.
90. Vogel VG, Costantino JP, Wickerham DL, et al. Update of the National Surgical Adjuvant Breast and Bowel Project Study of Tamoxifen and Raloxifene (STAR) P-2 Trial: preventing breast cancer. Cancer Prev Res. 2010;3(6):696-706.
91. Domchek SM, Friebel TM, Singer CF, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA. 2010;304(9):967-975.
92. Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. New Engl J Med. 1999;340(2):77-84.
93. Hartmann LC, Sellers TA, Schaid DJ, et al. Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers. J Natl Cancer Inst. 2001;93(21):1633-1637.
94. Evans DG, Baildam AD, Anderson E, et al. Risk reducing mastectomy: outcomes in 10 European centres. J Med Genet. 2009;46(4):254-258.
95. Skytte AB, Cruger D, Gerster M, et al. Breast cancer after bilateral risk-reducing mastectomy. Clin Genet. 2011;79(5):431-437.
96. Heemskerk-Gerritsen BA, Menke-Pluijmers MB, Jager A, et al. Substantial breast cancer risk reduction and potential survival benefit after bilateral mastectomy when compared with surveillance in healthy BRCA1 and BRCA2 mutation carriers: a prospective analysis. Ann Oncol. 2013;24(8):2029-2035.
97. Flippo-Morton T, Walsh K, Chambers K, et al. Surgical decision making in the BRCA-positive population: institutional experience and comparison with recent literature. Breast J. 2016;22(1):35-44.
98. Kramer JL, Velazquez IA, Chen BE, Rosenberg PS, Struewing JP, Greene MH. Prophylactic oophorectomy reduces breast cancer penetrance during prospective, long-term follow-up of BRCA1 mutation carriers. N Engl J Med. 2005;23(34):8629-8635.
99. Olson JE, Sellers TA, Iturria SJ, Hartmann LC. Bilateral oophorectomy and breast cancer risk reduction among women with a family history. Cancer Detect Prev. 2004;28(5):357-360.
100. Struewing JP, Watson P, Easton DF, Ponder BA, Lynch HT, Tucker MA. Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr. 1995(17):33-35.
101. Mavaddat N, Peock S, Frost D, et al. Cancer risks for BRCA1 and BRCA2 mutation carriers: results from prospective analysis of EMBRACE. J Natl Cancer Inst. 2013;105(11):812-822.
102. Shah P, Rosen M, Stopfer J, et al. Prospective study of breast MRI in BRCA1 and BRCA2 mutation carriers: effect of mutation status on cancer incidence. Breast Cancer Res Treat. 2009;118(3):539-546.
103. Rebbeck TR, Lynch HT, Neuhausen SL, et al; Prevention and Observation of Surgical End Points Study Group. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med. 2002;346(21):1616-1622.
104. Kotsopoulos J, Huzarski T, Gronwald J, et al; Hereditary Breast Cancer Clinical Study Group. Bilateral oophorectomy and breast cancer risk in BRCA1 and BRCA2 mutation carriers [published online September 6, 2016]. J Natl Cancer Inst. 2016;109(1).
105. Heemskerk-Gerritsen BA, Seynaeve C, van Asperen CJ, et al; Hereditary Breast and Ovarian Cancer Research Group Netherlands. Breast cancer risk after salpingo-oophorectomy in healthy BRCA1/2 mutation carriers: revisiting the evidence for risk reduction [published online March 18, 2015]. J Natl Cancer Inst. 2015;107(5):djv033.
106. Lieberman S, Tomer A, Ben-Chetrit A, et al. Population screening for BRCA1/BRCA2 founder mutations in Ashkenazi Jews: proactive recruitment compared with self-referral. Genet Med. 2017;19(7):754-762.
107. Smith KR, West JA, Croyle RT, Botkin JR. Familial context of genetic testing for cancer susceptibility: moderating effect of siblings' test results on psychological distress one to two weeks after BRCA1 mutation testing. Cancer Detect Prev. 1999;8(4 II):385-392.
108. Dagan E, Shochat T. Quality of life in asymptomatic BRCA1/2 mutation carriers. Prev Med. 2009;48(2):193-196.
109. van Dijk S, Timmermans DR, Meijers-Heijboer H, Tibben A, van Asperen CJ, Otten W. Clinical characteristics affect the impact of an uninformative DNA test result: the course of worry and distress experienced by women who apply for genetic testing for breast cancer. N Engl J Med. 2006;24(22):3672-3677.
110. Metcalfe KA, Mian N, Enmore M, et al. Long-term follow-up of Jewish women with a BRCA1 and BRCA2 mutation who underwent population genetic screening. Breast Cancer Res Treat. 2012;133(2):735-740.
111. Meiser B, Butow P, Friedlander M, et al. Psychological impact of genetic testing in women from high-risk breast cancer families. Eur J Cancer. 2002;38(15):2025-2031.
112. Andrews L, Meiser B, Apicella C, Tucker K. Psychological impact of genetic testing for breast cancer susceptibility in women of Ashkenazi Jewish background: a prospective study. Genet Test. 2004;8(3):240-247.
113. Foster C, Watson M, Eeles R, et al; Psychosocial Study Collaborators. Predictive genetic testing for BRCA1/2 in a UK clinical cohort: three-year follow-up. Br J Cancer. 2007;96(5):718-724.
114. Low CA, Bower JE, Kwan L, Seldon J. Benefit finding in response to BRCA1/2 testing. Ann Behav Med. 2008;35(1):61-69.
115. Arver B, Haegermark A, Platten U, Lindblom A, Brandberg Y. Evaluation of psychosocial effects of pre-symptomatic testing for breast/ovarian and colon cancer pre-disposing genes: a 12-month follow-up. Fam Cancer. 2004;3(2):109-116.
116. Ertmanski S, Metcalfe K, Trempala J, et al. Identification of patients at high risk of psychological distress after BRCA1 genetic testing. Genet Test Mol Biomarkers. 2009;13(3):325-330.
117. Reichelt JG, Møller P, Heimdal K, Dahl AA. Psychological and cancer-specific distress at 18 months post-testing in women with demonstrated BRCA1 mutations for hereditary breast/ovarian cancer. Fam Cancer. 2008;7(3):245-254.
118. Reichelt JG, Heimdal K, Møller P, Dahl AA. BRCA1 testing with definitive results: a prospective study of psychological distress in a large clinic-based sample. Fam Cancer. 2004;3(1):21-28.
119. Geirdal AO, Dahl AA. The relationship between coping strategies and anxiety in women from families with familial breast-ovarian cancer in the absence of demonstrated mutations. Psychooncology. 2008;17(1):49-57.
120. Geirdal AO, Reichelt JG, Dahl AA, et al. Psychological distress in women at risk of hereditary breast/ovarian or HNPCC cancers in the absence of demonstrated mutations. Fam Cancer. 2005;4(2):121-126.
121. Le-Petross HT, Whitman GJ, Atchley DP, et al. Effectiveness of alternating mammography and magnetic resonance imaging for screening women with deleterious BRCA mutations at high risk of breast cancer. Cancer. 2011;117(17):3900-3907.
122. Kriege M, Brekelmans CT, Boetes C, et al; Dutch MRI Screening (MRISC) Study Group. Differences between first and subsequent rounds of the MRISC breast cancer screening program for women with a familial or genetic predisposition. Cancer. 2006;106(11):2318-2326.
123. Bourne T, Campell S, Reynolds K. Screening for early familial ovarian cancer with transvaginal ultrasonography and colour blood flow imaging. BMJ. 1993;306(3884):1025-1029.
124. Hermsen BB, Olivier RI, Verheijen RH, et al. No efficacy of annual gynaecological screening in BRCA1/2 mutation carriers; an observational follow-up study. Br J Cancer. 2007;96:1335-1342.
125. Spiegel TN, Esplen MJ, Hill KA, Wong J, Causer PA, Warner E. Psychological impact of recall on women with BRCA mutations undergoing MRI surveillance. Breast. 2011;20(5):424-430.
126. Nelson HD, Fu R, Griffin JC, Nygren P, Smith ME, Humphrey L. Systematic review: comparative effectiveness of medications to reduce risk for primary breast cancer. Ann Intern Med. 2009;151(10):703-715, w-226-735.
127. Nelson HD, Smith ME, Griffin JC, Fu R. Use of medications to reduce risk for primary breast cancer: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158(8):604-614.
128. Arver B, Isaksson K, Atterhem H, et al. Bilateral prophylactic mastectomy in Swedish women at high risk of breast cancer: a national survey. Ann Surg. 2011;253(6):1147-1154.
129. Heemskerk-Gerritsen BA, Brekelmans CT, Menke-Pluymers MB, et al. Prophylactic mastectomy in BRCA1/2 mutation carriers and women at risk of hereditary breast cancer: long-term experiences at the Rotterdam Family Cancer Clinic. Ann Surg Oncol. 2007;14(12):3335-3344.
130. Alamouti R, Hachach-Haram N, Farhadi J. Multidisciplinary management of risk-reducing mastectomy and immediate reconstruction: treatment algorithm and patient satisfaction. Eur J Plast Surg. 2015;38(5):385-390.
131. Nurudeen S, Guo H, Chun Y, et al. Patient experience with breast reconstruction process following bilateral mastectomy in BRCA mutation carriers. Am J Surg. 2017;214(4):687-694.
132. den Heijer M, Seynaeve C, Timman R, et al. Body image and psychological distress after prophylactic mastectomy and breast reconstruction in genetically predisposed women: a prospective long-term follow-up study. Eur J Cancer. 2012;48(9):1263-1268.
133. Gopie JP, Mureau MA, Seynaeve C, et al. Body image issues after bilateral prophylactic mastectomy with breast reconstruction in healthy women at risk for hereditary breast cancer. Fam Cancer. 2013;12(3):479-487.
134. Isern AE, Tengrup I, Loman N, Olsson H, Ringberg A. Aesthetic outcome, patient satisfaction, and health-related quality of life in women at high risk undergoing prophylactic mastectomy and immediate breast reconstruction. J Plast Reconstr Aesthet Surg. 2008;61(10):1177-1187.
135. Stefanek ME, Helzlsouer KJ, Wilcox PM, Houn F. Predictors of and satisfaction with bilateral prophylactic mastectomy. Prev Med. 1995;24(4):412-419.
136. Brandberg Y, Sandelin K, Erikson S, et al. Psychological reactions, quality of life, and body image after bilateral prophylactic mastectomy in women at high risk for breast cancer: a prospective 1-year follow-up study. N Engl J Med. 2008;26(24):3943-3949.
137. Gahm J, Wickman M, Brandberg Y. Bilateral prophylactic mastectomy in women with inherited risk of breast cancer--prevalence of pain and discomfort, impact on sexuality, quality of life and feelings of regret two years after surgery. Breast. 2010;19(6):462-469.
138. Brandberg Y, Arver B, Johansson H, Wickman M, Sandelin K, Liljegren A. Less correspondence between expectations before and cosmetic results after risk-reducing mastectomy in women who are mutation carriers: a prospective study. Eur J Surg Oncol. 2012;38(1):38-43.
139. Wasteson E, Sandelin K, Brandberg Y, Wickman M, Arver B. High satisfaction rate ten years after bilateral prophylactic mastectomy: a longitudinal study. Eur J Cancer Care. 2011;20(4):508-513.
140. Metcalfe KA, Esplen MJ, Goel V, Narod SA. Psychosocial functioning in women who have undergone bilateral prophylactic mastectomy. Psychooncology. 2004;13(1):14-25.
141. Finch A, Metcalfe KA, Chiang JK, et al. The impact of prophylactic salpingo-oophorectomy on menopausal symptoms and sexual function in women who carry a BRCA mutation. Gynecol Oncol. 2011;121(1):163-168.
142. Kenkhuis MJ, de Bock GH, Elferink PO, et al. Short-term surgical outcome and safety of risk reducing salpingo-oophorectomy in BRCA1/2 mutation carriers. Maturitas. 2010;66(3):310-314.
143. Michelsen TM, Dorum A, Trope CG, Fossa SD, Dahl AA. Fatigue and quality of life after risk-reducing salpingo-oophorectomy in women at increased risk for hereditary breast-ovarian cancer. Int J Gynecol Cancer. 2009;19(6):1029-1036.
144. Bresser PJ, Seynaeve C, Van Gool AR, et al. The course of distress in women at increased risk of breast and ovarian cancer due to an (identified) genetic susceptibility who opt for prophylactic mastectomy and/or salpingo-oophorectomy. Eur J Cancer. 2007;43(1):95-103.
145. Borreani C, Manoukian S, Bianchi E, et al. The psychological impact of breast and ovarian cancer preventive options in BRCA1 and BRCA2 mutation carriers. Clin Genet. 2014;85(1):7-15.
146. Finch A, Narod SA. Quality of life and health status after prophylactic salpingo-oophorectomy in women who carry a BRCA mutation: a review. Maturitas. 2011;70(3):261-265.
147. U.S. Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med. 2005;143(5):355-361.
148. American College of Medical Genetics. Genetic Susceptibility to Breast and Ovarian Cancer: Assessment, Counseling and Testing Guidelines. Bethesda, MD: American College of Medical Genetics; 1999.
149. American Society of Clinical Oncology. Statement of the American Society of Clinical Oncology: genetic testing for cancer susceptibility, adopted on February 20, 1996. J Clin Oncol. 1996;14(5):1730-1736.
150. Committee opinion no. 634: hereditary cancer syndromes and risk assessment. Obstet Gynecol. 2015;125(6):1538-1543.
151. Lancaster J, Powell C, Chen L, Richardson L; SGO Clinical Practice Committee. Society of Gynecologic Oncology statement on risk assessment for inherited gynecologic cancer predispositions. Gynecol Oncol. 2015;136(1):3-7.
152. American Society of Breast Surgeons (ASBrS). Consensus Guideline on Genetic Testing for Hereditary Breast Cancer. ASBrS website. https://www.breastsurgeons.org/docs/statements/Consensus-Guideline-on-Genetic-Testing-for-Hereditary-Breast-Cancer.pdf. Accessed July 3, 2019.
153. National Institute for Health and Care Excellence. Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer. https://www.nice.org.uk/guidance/cg164/chapter/Recommendations. Published June 2013. Accessed July 3, 2019.
154. Paluch-Shimon S, Cardoso F, Sessa C, et al; ESMO Guidelines Committee. Prevention and screening in BRCA mutation carriers and other breast/ovarian hereditary cancer syndromes: ESMO clinical practice guidelines for cancer prevention and screening. Ann Oncol. 2016;27(suppl 5):v103-v110.
|Breast and ovarian cancer|
|Breast cancer relatives|
|Male relative (add to above)||2|
|Breast cancer characteristics|
|Onset age, y|
|Ovarian cancer relatives|
|Ovarian cancer onset age, y|
|Prostate cancer onset|
|Age <50 y||1|
|Colon cancer onset|
|Age <50 y||1|
|Risk Factor (Age at Onset for Relative in Direct Lineage)||BRCA1 Score||BRCA2 Score|
|Female breast cancer, y|
|Male breast cancer, y|
|Ovarian cancer, y|
|Prostate cancer, y|
|Total individual genes||10||10|
|Total for combined = 15|
a See Oros et al,16 Parmigiani et al,18 Antoniou et al,19 Barcenas et al,20 Evans et al.21
b A score of 10 in either column or a combined score of 15 for both columns would be equivalent to a 10% chance of identifying a BRCA1 or BRCA2 mutation.
c If testing for BRCA2.
d If testing for BRCA1.
Abbreviation: BRCA, breast cancer susceptibility gene.
|History of Breast or Ovarian Cancer in the Family? If Yes, Complete Checklist|
|Risk Factor||Breast Cancer at Age ≤50 y||Ovarian Cancer at Any Age|
|≥2 cases of breast cancer after age 50 y on same side of family|
|Male breast cancer at any age in any relative|
|Risk Factor||Score for Every Family Member With Breast or Ovarian Cancer Diagnosis, Including Second-/Third-Degree Relatives|
|Breast cancer at age ≥50 y||3|
|Breast cancer at age <50 y||4|
|Ovarian cancer at any age||5|
|Male breast cancer at any age||8|
|Ashkenazi Jewish heritage||4|
|1||Did any of your first-degree relatives have breast or ovarian cancer?|
|2||Did any of your relatives have bilateral breast cancer?|
|3||Did any man in your family have breast cancer?|
|4||Did any woman in your family have breast and ovarian cancer?|
|5||Did any woman in your family have breast cancer before age 50 y?|
|6||Do you have 2 or more relatives with breast and/or ovarian cancer?|
|7||Do you have 2 or more relatives with breast and/or bowel cancer?|
|1||Personal history: current age, age at menopause, age at menarche, childbirth history, menopausal status, use of menopausal hormone therapy|
|2||Personal breast history, breast density (optional), prior breast biopsy, history of cancer (breast or ovarian), genetic testing|
|3||Ashkenazi Jewish inheritance|
|4||Family history (genetic risk)—relatives with breast or ovarian cancer, age at diagnosis, genetic testing|