Finding hope in high breast cancer risk

By Jessica Saenz

Most breast cancers develop sporadically from random cell changes that occur throughout your lifetime. And until recently, predicting the likelihood of breast cancer development was an educated guess at best.

As cancer experts have learned more about the factors that fuel breast cancer development and growth, it’s become clear that standard screening isn’t enough for some people — especially those at high risk.

Knowing you are at high risk for breast cancer can be overwhelming, but it also can bring unexpected hope in the form of preparedness, personalized screening and prevention strategies.

So, how do you know if you are at high risk for breast cancer, and what do you do with that information?

Get a breast cancer risk assessment.

“Ideally, everyone should have a breast cancer risk assessment by age 25. This is especially important if you have a family history of breast cancer. I don’t think that’s happening a lot of the time, but it’s something people should bring up at their wellness exam,” says Jessica Fraker, M.D., a specialist in women’s internal medicine at the High Risk Breast Clinic at Mayo Clinic in Arizona.

Your healthcare professional can estimate your breast cancer risk using one of several risk assessment models and a combination of other factors. Some of the most common risk assessment models weigh factors such as age, family history, genetic predispositions linked to cancer, menstrual and childbirth history, body mass index (BMI), and race and ethnicity.

Your healthcare professional will also ask about other factors that could indicate a high risk for breast cancer including previous breast tissue biopsy findings and prior radiation therapy to the chest before age 30.

Risk assessments also consider breast density, which can only be determined through a mammogram. “It’s not something you can feel,” says Jewel Kling, M.D., chair of the Women’s Health Center at Mayo Clinic in Arizona. “Breast density is based on what your breast tissue looks like on a mammogram. Having dense breasts elevates your risk of breast cancer and makes cancer harder for radiologists to see on a standard mammogram.”

As of September 2024, the Food and Drug Administration requires mammography facilities to notify patients about their breast density to help them make informed decisions about future screening and care.

“For average-risk people, the recommended age to begin annual breast cancer screenings is 40,” says Dr. Fraker. Insurance companies may not cover mammograms for people younger than 40. If your healthcare team recommends you start screening early, ask your healthcare professional to request approval from your insurance company.

Mayo Clinic is also researching the use of polygenic risk scores, which evaluate your DNA to produce a more individualized breast cancer risk score. “I think polygenic risk could be a way to better understand individualized risk, but we are still learning about it,” says Dr. Fraker.

Get assessed early if you have a family history of cancer.

If you have a family history of breast, ovarian, pancreatic or prostate cancer — especially multiple cancers or multiple affected people on one side of the family — it’s important to get your breast cancer risk assessed sooner rather than later.

“If you have a family member who was diagnosed young, we start screening earlier — about 10 years before that person was diagnosed,” says Dr. Fraker. “If you’re a 25-year-old who maybe isn’t thinking about these things, but you know that your mom had breast cancer when she was 45, it’s something to bring up now.”

Inherited genetic changes, also called mutations, can be linked with a family history of breast cancer, but Dr. Fraker says this is not usually the case. “Only 5% to 10% of breast cancers are hereditary, which could be related to a BRCA gene or something similar. That’s still not the most common scenario. Most breast cancer is sporadic and arises without a family history, but some of it is familial, meaning there is a strong family pattern of breast cancer without a known genetic variant,” she says.

Your clinician can help you decide if genetic testing is right for you.

If you are at high risk of breast cancer, find specialized care.

If you are at high risk of breast cancer, ask your healthcare professional about options for breast cancer screening and risk reduction. Some people may benefit from being seen in a high-risk breast clinic — a specialized program that can offer a personalized care plan and options tailored to your risk factors and risk level. If you are unsure where to find a high-risk clinic, ask your healthcare professional about local available resources.

“‘High risk’ is a lifetime risk above 20%, but that could be 20% to 99%,” says Dr. Fraker. “That’s a big range, so specialized care requires a lot of individualization.” Depending on your risk level, your care may include earlier, more frequent or supplemental breast cancer screenings in addition to mammograms. Supplemental or enhanced screenings can include 3D mammograms, breast MRI, breast ultrasound, molecular breast imaging and, in some cases, contrast-enhanced mammography.

In addition to a personalized screening plan, your care program should offer prevention and risk-reduction management, which can include risk-reducing medication or lifestyle modifications. “Prevention and lifestyle interventions have an impact. That’s an important part of our counseling,” she says. “Healthy lifestyle habits — exercising, eating a balanced diet, minimizing processed foods, not smoking, and minimizing or avoiding alcohol — are associated with reduced breast cancer risk. And you don’t have to be high-risk to do those things.”

If your breast cancer risk is extreme, your healthcare team might discuss surgery like prophylactic mastectomy as a risk-reducing option. Dr. Fraker says understanding their personal risk and all risk-reducing options often helps give her patients peace of mind.

“Early detection is very advanced compared to what it was 10 or 20 years ago,” she says. “I regularly have patients who are really anxious when they come in because, for example, their mom got breast cancer when she was 45 and died from it. To know that as a 35-year-old they’re getting enhanced screening to catch anything as early as we can allows them to feel empowered in their choices.”

Embrace hope.

“Anything related to breast cancer can be super stressful,” says Dr. Kling. “A lot of us get caught up in the anxiety about whether or not we’re going to get breast cancer. It feels like you have no control over it.”

Though you may not be able to control whether you develop breast cancer, preventive measures and ongoing conversations with your healthcare team can help prepare you to take action if it becomes necessary.

“I’ve heard people say, ‘Had this been around when my mom was my age, maybe she wouldn’t have died from breast cancer,’” says Dr. Fraker. “It’s a difficult thing to think about, but it speaks to how far we’ve come. And that’s what we try to keep the focus on as the research on this disease advances.”

Learn more

Learn more about breast cancer and the High Risk Breast Clinic at Mayo Clinic.

Find a breast cancer clinical trial at Mayo Clinic.

Join the Breast Cancer Support Group on Mayo Clinic Connect, an online community moderated by Mayo Clinic for patients and caregivers.

Also, read these articles:

• Management of women with high risk of breast cancer
• Breast cancer surgery: Understanding your options
• Mayo Clinic Q&A: Options for breast reconstruction
• How a different mammogram experience led to a lifesaving cancer diagnosis