ENGLAND — "The current Nice criteria used in general practice are missing up to 95% of women under 50 who will go on to develop breast cancer," researcher Juliet Usher-Smith said. "It’s time to look again at these criteria in the light of our findings."

Current National Institute for Health and Care Excellence criteria result in 1.4% of women under 50 being referred for further assessment. These criteria include 4.4% of women under 50 who develop breast cancer within 10 years. In contrast, if all women under 50 were assessed using the Boadicea tool, a higher proportion would be categorised as at above-average risk and referred for further assessment.

The Boadicea risk assessment system was developed by the University of Cambridge and funded by Cancer Research UK. Unlike the current guidelines, the Boadicea system assesses factors including reproductive history, lifestyle, and genetics. This broader scope allows for the identification of women who do not have a strong family history but possess other risk factors.

Breast cancer is one of the leading causes of death in women under 50. Women under 50 in England do not receive routine breast screening unless they have a strong family history of the disease. About one in seven women develop breast cancer in their lifetime. Breast cancer is the most common cancer worldwide and accounts for about one in four cases of cancer worldwide.

"We need to get better at identifying women at highest risk of breast cancer so that we can intervene early, when there are more options for treating, or even preventing, their disease," Usher-Smith said.

National Institute for Health and Care Excellence guidance recommends general practitioners ask about family history if a woman is worried about higher breast cancer risk. The guidance also recommends asking about family history if a woman is over 35 and using an oral contraceptive pill or considering hormone replacement therapy. Alcohol intake and obesity are larger risk factors for breast cancer than hormones.

Professor Montserrat García-Closas noted that there will be a balance to strike because the National Institute for Health and Care Excellence criteria are much easier to implement but miss a large proportion of women at elevated risk. "But a full risk assessment including genetic testing will place a heavy burden on resources," she said.

"Ultimately, it will be a trade-off between the practical, resource, and cost implications of data collection and risk assessment, and the potential benefits and harms associated with accurate and inaccurate classification of women," García-Closas said.

Simon Vincent, chief scientific officer, said these findings indicate the limitations of the National Institute for Health and Care Excellence’s current referral criteria. These findings indicate the limitations of Nice’s current referral criteria, and so this research must now be carefully considered as part of the current review of its family history guidelines, he said. "However, it’s equally important that any changes come with the needed investment in family history services, so they can be implemented effectively and fairly across the NHS," Vincent said. Sowmiya Moorthie, a representative, said any changes must be accessible and equitable, taking into consideration the anxiety that extra referrals might cause for women.

A spokesperson for the National Institute for Health and Care Excellence said the organization welcomes the findings of this study and recognises the potential of multifactorial risk models in improving the identification of women at increased risk of breast cancer in the future. "However, the current evidence does not warrant a change to our existing familial breast cancer guideline at this time," the spokesperson said.

The spokesperson added that the National Institute for Health and Care Excellence remains committed to reviewing new evidence and will consider further updates as more data on feasibility and clinical outcomes become available.

Background data indicates that 96% of breast cancer cases are in women over 40. Additionally, 25% of breast cancer cases are in women over 75. There are about 420 new cases of breast cancer in men every year in the U.K. Approximately 5-10% of breast cancer cases are linked to inherited genes.

Why It Matters

Current guidelines rely heavily on family history, missing up to 95% of women under 50 who will develop breast cancer within a decade. Since most young patients lack a family history, shifting to multifactorial risk models could significantly increase early detection rates for this leading cause of death. However, adopting broader assessment tools creates a trade-off between improved identification and the resource burden of processing substantially more referrals.