Familial breast cancer: summary of updated NICE guidance

We disagree with the NICE guidance on familial breast cancer in that it is wrong to wait until women with a family history of breast cancer are over age 35 years before informing them that taking oral contraceptives (OCs) increases their risk of breast cancer.1 By that age most use is long past.

OCs are recognised by WHO as Group 1 carcinogens.2. However, teenagers as young as age 13 are being provided with long-acting hormonal contraception which may be used for years although breast cancer risks increase with longer use.3-5 Among women starting OC use before age 18 and developing breast cancer by age 36, 80% had taken OCs for more than 4 years.5 (Fig 1) Promoting hormonal contraception to younger ages encourages longer use.

Unsurprisingly, invasive breast cancer is increasing in the USA in young women. From 1976 to 2009 invasive breast cancer doubled in incidence in women aged 20 to 34 years from 1.53 to 2.90 per 100,000/year. The national 5-year survival for distant disease was 31% for women aged 25-39 years.6

In contrast, breast cancer incidences and mortality decreased In older women after taking hormones as HRT was discredited in 2004.7,8

Breast cancer increases and decreases have matched changes in hormone use from 1962 in England and Wales.9 (Fig 2) Progesterone suppresses immunity and can be both carcinogenic and genotoxic. Family health is also at risk.

It is not good enough to hide behind absolute risks while young age breast cancers continues to increase and more teenagers have a close family history of breast cancer.

1 Gareth Evans D, Graham J, O,Connell S, Arnold S, Fitzsimons D. Familial breast cancer: summary of updated NICE guidance BMJ 2013;346:f3829 (Published 25 June 2013)

2 IARC. Combined estrogen-progestogen contraceptives and combined estrogen-progestogen menopausal therapy. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans 2007; Volume 91

3 Grant ECG. Steroid and sexual abuse of adolescents BMJ (Published 14 January 2005)

4 Grant ECG. Re: Newer non-oral hormonal contraception BMJ (Published 11 March 2013
5 UK National Case-Control Study Group. Oral contraceptive use and breast cancer risk in young women. Lancet 1989 May 6;1(8645):973-82.

6 Johnson RH, Chein FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009. JAMA 2013;309(8):800-805

7 Grant ECG. Fall in HRT use would have reduced breast cancer mortality. BMJ (Published 28 January 2005)

8 Colditz GA. Decline in breast cancer incidence due to removal of promoter: combination estrogen plus progestin. Breast Cancer Res. 2007;9:108.

r
9 Grant ECG. Re: Understanding recent trends in incidence of invasive breast cancer in Norway: age-period-cohort analysis based on registry data on mammography screening and hormone treatment use BMJ (Published 31 January 2012)