M. D. Anderson suggests that women with a strong family history of the disease consider speaking with a genetic counselor to better assess their risk (that may also include tests for specific mutations). If the risk of breast cancer is 20 percent or greater over a lifetime, you fall into the increased risk category. The American Cancer Society also says women with a 15 to 20 percent lifetime risk are at moderately increased risk.
If you are at higher than usual risk of breast cancer, you should talk to your doctor about what your best screening schedule might be. The ACS, for example, recommends that women with a 20 percent or higher risk get both a mammogram and an MRI every year (it doesn't recommend a starting age), while women in the moderate-risk category should weigh the benefits and limitations of adding MRI to an annual mammogram. M. D. Anderson's guidelines include, for example, a clinical breast exam every six to 12 months, on top of an annual mammogram, for women with a history of LCIS. Sloan-Kettering's recommendations for women with one or more first-degree relative with a history of the disease include a clinical breast exam every three to six months and an annual mammogram starting 10 years before the age at which the youngest relative with breast cancer was diagnosed. It's worth noting that breast density, which is assessed by mammogram, is also a risk factor for breast cancer. Because regular mammography is a particularly poor tool for detecting cancers in dense breasts, women with this risk factor should talk to their doctor about whether digital mammography or ultrasound may be a better option.
The tough part of all of this is that most women who get breast cancer have no significant risk factors at all, says Daly—and yet they get sick anyway. (While you may have heard that things like weight and activity level influence breast cancer risk, no one suggests that a woman who has no major risk factors other than being overweight should act differently when it comes to screening.) And most healthy women attempting to gauge their own risk will not fit into any of these defined categories.
For most women, we simply don't have the tools to predict individual risk with any confidence, says Gralow. Because of that lack of information, for most women, the discussion with her doctor about whether she should get a mammogram in her 40s, or whether it should be an annual or biennial event if she is 50 or older, is pretty much limited to how she feels about the potential harms of the test (false positives and biopsies, and also the risk of diagnosing and treating something that never would have been life-threatening) rather than whether she's more likely than the average Jane to develop the disease. Those on both sides of the debate agree that this is a big problem. "We urgently need risk models with better discriminatory accuracy (than that of current models) that can correctly identify persons at all levels of risk," wrote Karla Kerlikowske, director of the women's clinic at the Veterans Affairs Medical Center in San Francisco, in the editorial accompanying the task force report. (Both were published in the Annals of Internal Medicine.) In addition, she wrote, "healthcare systems would need to develop mechanisms for routinely assessing risk factors, calculating breast cancer risk, and reporting risk to women and providers in an easily understandable format."