A new study has raised concerns about the way women under 50 are assessed for their risk of breast cancer, suggesting that NHS referral criteria may fail to identify the vast majority of younger women who go on to develop the disease.

It is believed that the Health Service Breast Screening misses 95% of young women who go on to develop cancer, researchers have found. Research has raised concerns in the way the NHS identifies younger women who may be at sufficiently high risk to warrant enhanced screening, specialist assessment or preventative treatment.

Once relatively rare, cases of breast cancer in women under 50 have rapidly increased in the UK over the past few decades – rising by around 1.4% every year. The disease is very treatable if caught in its early stages, before it has a chance to spread.

The research, led by scientists from the University of Cambridge and the Institute of Cancer Research, found that current criteria used in primary care identified only 4.4% of women under 50 who went on to develop breast cancer within 10 years.

The current NHS Breast Screening programme invites all women from the age of 50 – 70 for screening every 3 years. This screening is for people with no symptoms and aims to find breast cancer at an early stage.

For women under 50, who are at a particularly high risk or have symptoms, they can nevertheless be referred for assessment. NICE Guidelines rely heavily on family history. However, researchers argue that this does not capture everyone who is at increased risk.

In the recent study, 73% of women under 50 who were estimated to be at above population risk did not have a family history of breast cancer. This means that a woman can have a significant risk, even when there is no obvious breast cancer among relatives.

The researchers analysed data from 1,258 women under 50 who had participated in the study. The women had information available on factors including family history, reproductive history, lifestyle and genetic risk. There were 392 breast cancer cases in the study population.

This information was then compared by the current NICE approach, with a more comprehensive risk assessment model known as BOADICEA.

What is BOADICEA

BOADICEA stands for Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm and is a computer model. It aims to predict a person’s chance of getting breast cancer or ovarian cancer. BOADICEA looks at family history, genes, lifestyle

and other traits. It is believed this comprehensive model should enable high levels of breast cancer risk stratification in the general population and women with family history, and facilitate individualised, informed decision-making on prevention therapies and screening.

The researchers found a substantial difference between the two approaches. Under the current NICE criteria just 1.4% of women would have met the referral threshold, but by comparison, using the full BOADICEA model across women under 50, would classify 26.5% as meeting the referral threshold, and would identify approximately 34.8% of women who subsequently developed breast cancer within 10 years.

However, an important caveat to the study is that if the assessment were offered to every woman under 50, a much larger proportion of women would be referred for further assessment, and this could place additional burden on GPs, specialist breast and genetics services. It is therefore acknowledged that there is a balance between finding more women at risk, and avoiding unnecessary referrals, investigations, anxiety and pressure on NHS resources.

What should women under 50 do?

The research should not cause women to panic or conclude that routine breast screening is ineffective. Women should focus on body awareness and report any unusual changes to a doctor immediately.

What are the signs of breast cancer?

• Lumps and swelling: A hard, painless or tender lump in the breast, upper chest, or armpit.
• Skin texture shifts: Pitting, puckering, or dimpling of the breast skin that resembles an orange peel.
• Visual and structural changes: Unexplained shifts in the size, contour, or symmetry of one or both breasts.
• Nipple irregularities: A nipple that pulls inward (becomes inverted), changes direction, or develops a crusty, scaly, or eczema-like rash.
• Unusual discharge: Fluid leaking from the nipple when not pregnant or breastfeeding, which may contain blood.
• Persistent discomfort: Ongoing pain or tenderness in the breast or armpit area that does not go away with your cycle

Early detection of breast cancer is crucial because it significantly increases the chances of successful treatment and improves long-term outcomes. Identifying breast cancer at an early stage can allow treatment to begin before the disease has spread, often resulting in less extensive treatment and higher survival rates. Prompt investigation of any breast symptoms can lead to earlier diagnosis, providing patients with a greater range of treatment options and a better overall prognosis.