New research finds that NICE referral criteria fail to identify as many as 95% of women under 50 who are at higher-than-average risk of breast cancer, and 95% of those who develop breast cancer within 10 years.
Used to decide who should be referred by GPs for further breast cancer risk assessment and specialist care, it misses up to 95% of women under 50 who will go on to develop the disease in the next 10 years.
Using BOADICEA – a comprehensive risk assessment tool developed at the University of Cambridge with funding from Cancer Research UK – the researchers at Cambridge and The Institute of Cancer Research, London, found that NICE criteria missed eight times as many women in this age group who developed breast cancer.
The team analysed data from 1,258 women aged under 50 years recruited to the Breast Cancer Now Generations Study between 2004 and 2011.
They compared how good the NICE criteria and several risk assessment approaches using the BOADICEA risk model were at identifying those women who would go on to develop breast cancer.
BOADICEA combines factors such as family history, lifestyle, reproductive history and genetic information. It is available via the CanRisk platform.
Previous studies have shown that multifactorial risk models can identify more women at increased risk of breast cancer than family history alone. This is the first study to directly evaluate this approach in a UK population-based cohort of women under 50.
Completing a risk assessment using the full BOADICEA model for all women under 50 would result in 26.5% of women being categorised as at above-population-level risk and referred for further assessment. This would include 34.8% of women under 50 who develop breast cancer within 10 years.
By comparison, the current NICE criteria would result in 1.4% of women under 50 being referred for further assessment, of whom just 4.4% would develop breast cancer.
A main reason for the disparity, say the researchers, is that three-quarters of women (73%) under 50 who develop breast cancer within 10 years have no family history of the disease, the key criterion in the NICE guidelines.
Dr Juliet Usher-Smith, the study’s senior author from the Department of Public Health and Primary Care at the University of Cambridge, said: ‘We need to improve our ability to identify women at highest risk of breast cancer so we can intervene early, when there are more options for treating or even preventing their disease. The current NICE criteria used in general practice miss up to 95% of women under 50 who will go on to develop breast cancer. It’s time to review these criteria in light of our findings.’
The researchers recognise that changing the criteria – for example, offering the full BOADICEA risk assessment to all women under 50 – would be far more resource-intensive and lead to more referrals, many of whom will not develop breast cancer.
The next step is to test how to implement multifactorial risk assessment safely, equitably, and cost-effectively within routine care.
The research, supported by Cancer Research UK and Breast Cancer Now, was published in the British Journal of Cancer.
