Description

Women who are at increased risk for breast cancer without current or previous diagnosis of breast cancer or ductal carcinoma in situ (DCIS) can be referred to a breast specialty clinic to consider risk reduction interventions.

Mid-Level Flow

Patient population	Age group	Recommendation
Genetic marker or syndrome	Any	Referral for high risk breast specialty evaluation Consider life expectancy
History of chest radiation	Any	Referral for high risk breast specialty evaluation Consider life expectancy
Previous high-risk finding on biopsy	Any	Referral for high risk breast specialty evaluation Consider life expectancy
5 year risk >= 3%	>= 35	Referral for high risk breast specialty evaluation Consider life expectancy
5 year risk >= 1.67%	>= 35	Consider referral for high risk breast specialty evaluation Consider life expectancy
Compelling family history of breast cancer	>= 35	Perform risk assessment
Personal risk factors conferring increased risk of breast cancer	>= 35	Perform risk assessment

Semi-Structured Logic Statements

Inclusions

Name	Description
Age 18 years and older	Even for high risk individuals, routine clinical monitoring or screening is not recommended prior to age 21 y and risk reduction modalities are generally not offered at this age. Source: NCCN
Patient age >= 18
Assigned female at birth	Referenced guidelines apply to individuals assigned female at birth. For transgender women, refer to specialty guidelines.
'Assigned female at birth' is TRUE

Exclusions

Name	Description
Patient is not eligible for screening
See 'Screening Eligible' flow logic
Previous diagnosis of breast cancer	No indication for primary risk reduction in patient with breast cancer in remission. Secondary risk reduction would be determined by Oncologic team.
'Previous breast cancer' is TRUE

Events

Name	Description
Patient population
Population to which the patient fits criteria
Age group
Patient age group
Any
Any age
>= 35
Patient age >= 35 years
Genetic marker or syndrome
'Genetic marker or syndrome associated with a high risk of breast cancer' is TRUE
History of chest radiation
'History of high-dose radiation therapy to the chest' is TRUE
Previous high-risk finding on biopsy	High-risk benign pathology on previous breast biopsy, particularly ADH, LCIS, ALH.
'High-risk benign breast lesion on previous biopsies' is TRUE
5 year risk >= 3%	Estimated 5 year risk of breast cancer, either performed using formal assessment model or informal assessment, is >= 3%
Formal clinical risk assessment tool output suggests 5 year risk >= 3% OR assessment of breast cancer risk factors without using a formal tool suggests higher than average risk
5 year risk >= 1.67%	Estimated 5 year risk of breast cancer, either performed using formal assessment model or informal assessment, is >= 1.67%
Formal clinical risk assessment tool output suggests 5 year risk >= 1.67% OR assessment of breast cancer risk factors without using a formal tool suggests higher than average risk
Compelling family history of breast cancer	Pedigree of blood relatives on both maternal and paternal side includes compelling history of breast cancer.
'Compelling family history of breast cancer' is true
Personal risk factors conferring increased risk of breast cancer	Patient has risk factors that contribute to risk of developing breast cancer. These may include increasing age, younger age at menarche, older age at first live birth, nulliparity/lower parity, number of prior breast biopsies, heterogeneously and/or extremely dense breasts.
EXISTS > 1 DIAGNOSTIC REPORT of type `BREAST BIOPSY` OR BI-RADS breast density score in 'Last mammography result' is C OR D

Actions

Consider life expectancy Description Patient may not be a candidate for chemoprevention if estimated life expectancy is < 10 years. Factors that may impact this estimation should be considered prior to referral. A validated tool such as www.eprognosis.com can help guide decision making. Pseudocode 'Indicators of reduced life expectancy'

Referral for high risk breast specialty evaluation Description Consider referral to breast specialist to discuss primary risk reduction interventions such as chemoprevention. Women at greater risk, such as those with at least a 3% risk for breast cancer in the next 5 years, are likely to derive more benefit than harm from risk-reducing medications. Source: USPSTF Pseudocode REFERRAL for high risk breast clinic evaluation if none previously

Consider referral for high risk breast specialty evaluation Description Consider referral to breast specialist to discuss primary risk reduction interventions such as chemoprevention. Source: USPSTF Pseudocode REFERRAL for high risk breast clinic evaluation if none previously

Perform risk assessment Description The NCI Breast Cancer Risk Assessment Tool and the Breast Cancer Surveillance Consortium Risk Calculator are based on models tested in US populations and are publicly available for clinicians and patients to use as part of the process of shared, informed decision-making about taking risk-reducing medications for breast cancer. Source: USPSTF Pseudocode Perform risk assessment using a formal clinical risk assessment tool OR Perform assessment of breast cancer risk factors without using a formal tool