Does the evidence justify national funding of breast cancer family history clinics?

Abstract

Over the last 10 years efforts to prevent the morbidity, mortality and cost to society of breast cancer have concentrated on detecting early impalpable cancer and carcinoma in situ. Breast screening by mammography for women aged Xl-64 years reduces the number of symptomatic cancers and reduces mortality from this disease.’ Unfortunately, mammography is far from the perfect screening tool; at best reducing mortality in the over 50 year age group by 20-30%.’ For the majority of younger women, overall life expectancy from breast cancer has changed little over the last 50 years3 Increased understanding of the aetiology of breast cancer combined with enhanced ability to perform genetic screening has enabled a more accurate assessment of those at significant increased risk of developing the disease. For these women considered to be at high risk, many breast units have introduced ‘Family History Clinics’. For these clinics to be beneficial, they must ultimately lead to a reduction in the mortality from breast cancer. Women who attend family history clinics undergo a primary assessment during which lifetime risk for breast cancer development is calculated based on a detailed family history with or without genetic screening. Following assessment of risk, women are advised about correct examination techniques, and may then be enrolled into a screening programme consisting of regular clinical breast examination and annual mammography. Women considered to be at very high risk are considered for prophylactic surgery by either simple or subcutaneous mastectomy. Are such interventions justified?