Synopsis
Elicit a three-generation cancer history, distinguish population, familial and modifiable contributors, and use validated models to guide referral without presenting estimates as certainty.
- Age is a major breast-cancer risk factor. Family pattern, prior high-risk breast lesions, breast density, reproductive-hormonal exposure, alcohol and postmenopausal excess weight can modify an individual estimate.
- Take a three-generation maternal and paternal history, recording cancer site, age at diagnosis, bilateral or multiple primaries, sex at birth where relevant, ancestry, pathology and genetic results.
- Paternal transmission matters because autosomal dominant susceptibility variants can pass through any parent; a small family or few female relatives can make the pedigree look falsely reassuring.
Reasoning priorities
Capture maternal and paternal cancer patterns with ages, primary sites and links between relatives.
Verify key diagnoses where possible. Absence of known cancer in a small or male-dominated family is less informative than a large well-documented pedigree.
Worked reasoning
Illustrative worked example: a 38-year-old reports breast cancer in her mother at 42 and ovarian cancer in a paternal aunt at 49; the initial appointment has no source reports.
- The clinician recorded a three-generation pedigree across both parental lineages and obtained consent to request the key pathology and genetics records.
- The records subsequently confirmed the mother's invasive breast primary and the aunt's primary epithelial ovarian cancer, with the reported ages correct. No familial pathogenic-variant result had yet been identified; the paternal history remained part of assessment.
- The supplied specialist assessment named CanRisk/BOADICEA as its modelling framework and reported a 32% lifetime breast-cancer risk from age 20. This is an illustrative reported output with a specified horizon; no real patient calculation is represented.
- The specialist classified the supplied lifetime estimate as high risk under NICE's threshold of 30% or greater, arranged genetics review of the informative affected relative and agreed a documented specialist surveillance and prevention discussion. A cancer-risk estimate was not substituted for carrier probability.
- At follow-up, the clinic confirmed receipt of the verified pedigree, recorded the high-risk category and sent the agreed surveillance/referral plan to the patient. She could explain that the estimate concerned future risk, while any new breast symptom still required assessment.