Breast Cancer Risk Assessment

What is a breast cancer risk assessment?

A breast cancer risk assessment is a tool that predicts the likelihood you’ll develop breast cancer at some point in your life. One in 8 people assigned female at birth (AFAB) in the United States (around 12%) will develop breast cancer during their lifetime. Tools like risk assessments can help your healthcare provider determine how likely you’ll be among the 12%, so they can monitor your breast health closely.

The word likely is important here. A breast cancer risk assessment can’t tell if you will (or won’t) develop breast cancer. It’s all about probability — whether you have an above-average risk of developing breast cancer compared to others of a similar age and background.

Currently, breast cancer risk assessments are designed for people AFAB. They don’t score male breast cancer risk.

How do breast cancer risk assessments work?

At least 24 breast cancer risk assessment models currently exist. Most are questions you can complete online in 10 minutes or less. You answer questions, and the tool calculates a score based on your risk factors. A risk factor is a characteristic that increases your odds of having a condition, like breast cancer.

Breast cancer risk factors include:

• Age: Breast cancer risk increases with age.
• Family history of breast cancer: A family history of breast cancer (especially a first-degree relative or multiple cases within your family) increases your risk.
• Genetic mutations: Carrying mutated copies of the BRCA1 or BRCA2 gene increases your risk.
• Race/ethnicity: Certain ethnic groups are at a higher risk. For example, people of Ashkenazi Jewish descent are more likely to develop breast cancer because they’re more likely to inherit BRCA1 or BRCA2 genetic mutations.
• Breast density: People with dense breast tissue are more likely to develop breast cancer than people with mostly fatty breast tissue.
• Previous breast biopsies: People who’ve had breast biopsies with abnormal results (atypical hyperplasia) are at a greater risk of developing breast cancer.
• Hormone exposure: Long-term exposure to high estrogen or progesterone levels can increase your risk. This includes exposure to the hormones your body naturally produces during your menstrual cycle (periods). It also includes exposure through medication. For example, some forms of hormone-containing birth control and hormone replacement therapy may increase your risk of breast cancer.
• Age when you got your period: Starting your period (menarche) at a younger age exposes you to hormones for longer, increasing your breast cancer risk.
• Age when your periods stopped: Experiencing menopause (the end of your periods) at an older age exposes you to hormones for longer, increasing your risk.
• Childbirth history: People who haven’t given birth are at increased risk of developing breast cancer. They have more periods, which means they’ve been exposed to hormones longer than people who’ve given birth. Related, breast cancer risk decreases if you’ve given birth, especially if you had your baby before age 35. Having more than one child lowers your risk with each birth.

Still, not all risk factors are the same. For example, while breast cancer risk increases somewhat with age, having a BRCA1 genetic mutation increases your odds of developing breast cancer to 60%. This single factor makes you high-risk.

The various risk assessment tools consider and weigh factors differently in their scoring systems. A description of some of the most common breast cancer risk assessments follows.

The Gail model (BCRAT)

The most popular breast cancer risk assessment is the (U.S.) National Cancer Institute’s Breast Cancer Risk Assessment Tool (BCRAT). It’s also called the Gail model, after Dr. Mitchell Gail, who developed it. Originally developed in 1989, the Gail model has gone through several updates to predict a person’s risk of developing invasive breast cancer within five years and up to age 90. It takes as little as five minutes to complete.

The assessment asks about your:

• Age.
• Race/ethnicity.
• Childbirth history.
• Previous breast biopsies.
• Age when you got your period.
• Family history of breast cancer.

A five-year risk score of 1.67% or more is considered “high-risk.” At this point, your healthcare provider may recommend medications, including Tamoxifen and Raloxifene, that can reduce your chances of developing breast cancer.

Still, the Gail model doesn’t predict breast cancer risk for everyone. It’s not a reliable tool for predicting risk if you’ve had a previous breast cancer diagnosis or if you have a genetic mutation that increases your risk.

IBIS (Tyrer-Cuzik model)

This tool predicts the likelihood of developing cancer within 10 years or within your lifetime.

The assessment asks about your:

• Age.
• Race/ethnicity.
• Breast density.
• Childbirth history.
• Body mass index (BMI).
• Previous breast biopsies.
• History of ovarian cancer.
• Family history of breast cancer.
• Age when you had your first period.
• Age when your periods stopped.
• Use of hormone replacement therapy.
• Knowledge of having the BRCA1 or BRCA2 gene mutation.

Like the Gail model, it can’t predict risk for people with a past breast cancer diagnosis. Your healthcare provider may use these results to determine how frequently you should be screened for breast cancer or if you should be tested for the BRCA1 or BRCA2 genetic mutations.

Breast Cancer Surveillance Consortium’s (BCSC) Risk Calculator

This tool predicts your chances of developing invasive breast cancer within the next five years or advanced (metastatic) breast cancer within the next six years. Metastatic breast cancer is cancer that spreads from your breast to other parts of your body.

The assessment asks about your:

• Age.
• Race/ethnicity.
• Breast density.
• Childbirth history.
• Body mass index (BMI).
• Previous breast biopsies.
• History of breast cancer.
• Family history of breast cancer.
• Age when you got your period.
• Age when your periods stopped.
• Use of hormone replacement therapy.

Your provider may use your results to determine how often you need breast cancer screenings (mammograms).

BRCAPRO

This tool predicts the likelihood you have the BRCA1 or BRCA2 genetic mutation.

Questions focus on your family’s history of breast or ovarian cancer, including their:

• Age at diagnosis.
• Current age (or age at death).
• Race/ethnicity (especially if they’re of Ashkenazi Jewish descent).
• Test results for cancer-related genetic mutations (like BRCA1 or BRCA2).
• History of cancer-related surgeries, including mastectomy (removal of one or both breasts) or oophorectomy (removal of one or both ovaries).

The results can indicate whether you should get genetic testing to see if you carry a genetic mutation that increases your breast cancer risk.

Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA)

The BOADICEA is available via an online tool called CanRisk. It calculates your risk for both breast cancer and ovarian cancer. Like BRCAPRO, this tool relies mostly on family history and genetic information.

Questions ask about your:

• Age.
• Race/Ethnicity.
• Body mass index (BMI).
• Breast density.
• Childbirth history.
• History of birth control use.
• Age when you got your period.
• Family history of various cancer types.
• Knowledge of cancer-causing genetic mutations (like BRCA1 and BRCA2).

The results allow your provider to determine whether you should receive genetic testing. It also helps them recommend a screening schedule to catch breast cancer early.

Black Women’s Health Study (BWHS) Breast Cancer Risk Calculator

The BWHS predicts the risk of developing invasive breast cancer within the next five years for people who are Black. Race and ethnicity are important breast cancer predictors. Considering how your race affects your results is important when you’re interpreting your risk assessment score.

Assessment questions ask about your:

• Age.
• Body mass index (BMI).
• Childbirth history.
• Previous breast biopsies.
• History of birth control use.
• Age when you got your period.
• Age when your periods stopped.
• Family history of breast cancer.
• Whether you’ve had surgery to remove your ovaries.

How will my provider use the results?

It can be confusing and scary to take a risk assessment online without guidance from your healthcare provider, especially if you learn you’re high-risk. It’s important to remember that your results are a resource to discuss with your provider. They can help your provider determine how to monitor your breast health, so diagnosis and treatment can happen early.

Depending on the results, your provider may:

• Recommend more frequent breast cancer screenings.
• Refer you to genetic counseling to discuss whether you should be tested for cancer-causing genetic mutations. If you already know you have a mutation, counseling can help you understand what this means for your health and the health of your family members (for example, the likelihood you’ll pass the mutation on to a child).
• Prescribe medicines that can reduce breast cancer risk, including tamoxifen and raloxifene.
• Perform preventive surgery (prophylactic mastectomy), which can significantly reduce the risk of breast cancer developing.

How reliable are breast cancer risk assessment results?

The results are only as reliable as the data sets these tools use to predict risk. Breast cancer risk assessments compile information about people diagnosed with cancer and compare their risk factors to people taking the assessment. But population data can’t offer insight into anyone’s individual health with 100% accuracy. No two people are the same, no matter how many risk factors they share.

Limitations include:

• Racial/ethnic data differences: Depending on the population data an assessment uses, test results may not be as applicable to you. For example, much of the data on breast cancer diagnoses has historically captured the experiences of non-Hispanic people who are white. While current assessments are compiling more information about breast cancer diagnoses among people of other races and ethnicities, not all assessments account for these differences equally.
• Applicability extends only to certain cancers: Most tests predict invasive and advanced breast cancer among people who haven’t already been diagnosed. They don’t provide information about people who’ve already been diagnosed. They’re better at predicting some forms of breast cancer as opposed to others.
• Incomplete risk factors: No single tool considers all the risk factors associated with every type of breast cancer. Currently, most assessments either focus on genetic risk factors or risk factors relating to your health history. Your provider may ask you to complete multiple assessments to get a more complete picture that accounts for more risk factors.

Still, breast cancer risk assessments are effective enough at reporting the probability of a person’s risk that providers continue to use them. Researchers continue to study ways to maximize their effectiveness in clinical settings.

A note from Cleveland Clinic

A breast cancer risk assessment can’t predict whether you’ll get cancer. But it can alert your provider of the risk factors that could potentially increase your chances of a diagnosis. Breast cancer screening is important for everyone. A risk assessment is just a tool that provides additional information a provider can use to determine how to monitor your breast health. An assessment can lead you to BRCA testing. It can lead to more frequent screenings. Ultimately, it allows your provider to be more proactive in catching cancer early, while it’s treatable.