More than 500,000 women 'should take tamoxifen' to prevent breast cancer, guidance has said for the first time
More than 500,000 women at risk of breast cancer because of their family history should take tamoxifen as preventive measure, 'historic' new guidance has said for the first time.
9:24AM GMT 15 Jan 2013
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It is the first time the drug has been officially recommended as a preventive
measure in women who have not yet been diagnosed with breast cancer and the
new guidelines could save thousands of lives.
The move has been hailed as a 'historic step in the prevention of cancer'.
Families with a strong history of breast cancer should be offered genetic
testing to establish the risk to younger women, the National Institute for
Health and Clinical Excellence said.
According to their individual risk women between the ages of 30 and 49 should
be offered tamoxifen for five years which has been shown to reduce the
chances of developing cancer.
A recent study showed that 29 cancers and nine deaths could be prevented for
every 1,000 women taking tamoxifen for five years.
It means just over 500,000 women in England and Wales, covered by the Nice
guideline, could eventually be offered the drug.
Breast cancer is the most common cancer in the UK with around 50,000 women and 400 men diagnosed with the condition each year. The guidance also applies to men.
One in 20 breast cancers are caused by BRCA1 or BRCA2 genes that can be passed down through families and other genes have also been linked to the disease.
Professor Gareth Evans, an oncologist at Christie Hospital, said only about 1% of the female population were considered "high-risk".
But for some of those women, taking tamoxifen could be an alternative to having a preventative mastectomy, or breast removal.
"That surgery can reduce the risk by 90-95%, so it doesn't eliminate the risk. It's impossible to remove every last breast cell and depending on whether women keep their nipple or not, and that's a big decision for some women, the risk may only be reduced by about 90%," he told BBC Breakfast.
"We think that in about half of women, tamoxifen actually reduces the risk by 70% - if we can actually identify which women get that extra benefit, that may be enough for those very high-risk women to change their minds and say 'I'll go for the tamoxifen instead'."
But Prof Evans said these drugs were not vaccines.
"We're a long way from a vaccine, the problem is breast cancer isn't one disease really, it's many different types of breast cancer through many different genetic routes," he said.
"The likelihood of developing a single vaccine against breast cancer is many, many years away.
"But it has something akin to a vaccine in that it reduces your chances of ever getting the problem."
Women at high or moderate risk should also be offered annual screening tests instead of the standard three-yearly and may be advised to start them at an earlier age.
Women carrying the gene have opted for preventive mastectomies because they are at such high risk of developing breast cancer.
The guidance said the risks and benefits of this surgery should be discussed and they should be referred for counselling before the operation. This surgery should only be carried out by specialist cancer plastic surgeons, it said.
The new draft guidance said where possible the family member who has suffered cancer should have genetic tests to determine if they are carrying a fault that could have been passed on. Where that is impossible, the nearest family member at risk should be offered the test, it said.
Women at high risk of an inherited cancer should be offered annual mammograms from the age of 40, the guidance said.
Annual MRI scans, which are more accurate at detecting tumours in younger women, should be offered to those as young as 20 if they have a certain faulty gene, are at more than 30 per cent risk of having that fault.
Annual MRI scans should be offered to women who have been confirmed as having BRCA1 or BRCA2 faults from the age of 30 to 49 along with those calculated as being at a 30 per cent or greater risk of carrying either fault.
Chris Askew, Chief Executive of Breakthrough Breast Cancer, said: “This draft guideline represents a historic step for the prevention of breast cancer – it is the first time drugs have ever been recommended for reducing breast cancer risk in the UK.
"This is exciting as, even though most women do not have a significant family history of the disease, it’s crucial that those who do have an array of options to help them control their risk.
"An update to this guideline is long overdue and we’re especially pleased it has been extended to include both women who have had breast cancer, and men, for the first time.
"Once finalised, this guideline will pose new challenges for the NHS as it will need to deliver on its recommendations, including a potentially large increase in genetic testing.
"Breakthrough Breast Cancer will strive to ensure the final recommendations are implemented swiftly. We urge women with concerns about their family history of breast cancer to speak to their doctor.”
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "The causes of cancer are complex and not fully known.
"However, we do know that having a family history of breast, ovarian or a related cancer can significantly increase the risk of developing breast cancer, including developing the cancer at a younger age.
"It is also more likely that people with family members affected by cancer who then develop breast cancer themselves could develop a separate tumour in the other breast following initial treatment.
"This is why it’s wise for any person with a family history of cancer to receive appropriate investigations and screening that would otherwise be unnecessary if a family history did not exist.
"This guideline was last updated in 2006. Since then there has been new evidence published and new advances made in a number of clinical areas.
"All of our guidelines are reviewed in line with regular practice to ensure they remain based on the most up-to-date evidence.
"New recommendations for this guideline – which are still in draft form – have been developed as a result and we now want to hear the views of registered stakeholders in order to aid the development of this guideline update."
Breast cancer is the most common cancer in the UK with around 50,000 women and 400 men diagnosed with the condition each year. The guidance also applies to men.
One in 20 breast cancers are caused by BRCA1 or BRCA2 genes that can be passed down through families and other genes have also been linked to the disease.
Professor Gareth Evans, an oncologist at Christie Hospital, said only about 1% of the female population were considered "high-risk".
But for some of those women, taking tamoxifen could be an alternative to having a preventative mastectomy, or breast removal.
"That surgery can reduce the risk by 90-95%, so it doesn't eliminate the risk. It's impossible to remove every last breast cell and depending on whether women keep their nipple or not, and that's a big decision for some women, the risk may only be reduced by about 90%," he told BBC Breakfast.
"We think that in about half of women, tamoxifen actually reduces the risk by 70% - if we can actually identify which women get that extra benefit, that may be enough for those very high-risk women to change their minds and say 'I'll go for the tamoxifen instead'."
But Prof Evans said these drugs were not vaccines.
"We're a long way from a vaccine, the problem is breast cancer isn't one disease really, it's many different types of breast cancer through many different genetic routes," he said.
"The likelihood of developing a single vaccine against breast cancer is many, many years away.
"But it has something akin to a vaccine in that it reduces your chances of ever getting the problem."
Women at high or moderate risk should also be offered annual screening tests instead of the standard three-yearly and may be advised to start them at an earlier age.
Women carrying the gene have opted for preventive mastectomies because they are at such high risk of developing breast cancer.
The guidance said the risks and benefits of this surgery should be discussed and they should be referred for counselling before the operation. This surgery should only be carried out by specialist cancer plastic surgeons, it said.
The new draft guidance said where possible the family member who has suffered cancer should have genetic tests to determine if they are carrying a fault that could have been passed on. Where that is impossible, the nearest family member at risk should be offered the test, it said.
Women at high risk of an inherited cancer should be offered annual mammograms from the age of 40, the guidance said.
Annual MRI scans, which are more accurate at detecting tumours in younger women, should be offered to those as young as 20 if they have a certain faulty gene, are at more than 30 per cent risk of having that fault.
Annual MRI scans should be offered to women who have been confirmed as having BRCA1 or BRCA2 faults from the age of 30 to 49 along with those calculated as being at a 30 per cent or greater risk of carrying either fault.
Chris Askew, Chief Executive of Breakthrough Breast Cancer, said: “This draft guideline represents a historic step for the prevention of breast cancer – it is the first time drugs have ever been recommended for reducing breast cancer risk in the UK.
"This is exciting as, even though most women do not have a significant family history of the disease, it’s crucial that those who do have an array of options to help them control their risk.
"An update to this guideline is long overdue and we’re especially pleased it has been extended to include both women who have had breast cancer, and men, for the first time.
"Once finalised, this guideline will pose new challenges for the NHS as it will need to deliver on its recommendations, including a potentially large increase in genetic testing.
"Breakthrough Breast Cancer will strive to ensure the final recommendations are implemented swiftly. We urge women with concerns about their family history of breast cancer to speak to their doctor.”
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "The causes of cancer are complex and not fully known.
"However, we do know that having a family history of breast, ovarian or a related cancer can significantly increase the risk of developing breast cancer, including developing the cancer at a younger age.
"It is also more likely that people with family members affected by cancer who then develop breast cancer themselves could develop a separate tumour in the other breast following initial treatment.
"This is why it’s wise for any person with a family history of cancer to receive appropriate investigations and screening that would otherwise be unnecessary if a family history did not exist.
"This guideline was last updated in 2006. Since then there has been new evidence published and new advances made in a number of clinical areas.
"All of our guidelines are reviewed in line with regular practice to ensure they remain based on the most up-to-date evidence.
"New recommendations for this guideline – which are still in draft form – have been developed as a result and we now want to hear the views of registered stakeholders in order to aid the development of this guideline update."
