REFERRAL criteria for NHS breast cancer screenings are missing 95% of women aged under 50 years who will go on to develop the disease later in life, new research shows1.
According to the study, the current standards laid out by the National Institute for Health and Care Excellence (NICE) for deciding who should be referred to GPs for risk assessment and specialist care identify as few as 5% of those at higher-than-average risk of the disease.
In the UK, women over the age of 50 are offered routine mammogram breast screening for cancer. Those under that age are only referred for testing prior to any symptoms when the NICE model identifies a family history of breast cancer.
Researchers from the University of Cambridge, UK; and the Institute of Cancer Research, London, UK, analysed data from 1,258 women aged under 50 years recruited to the Breast Cancer Now Generations Study between 2004–2011. Using a new, comprehensive risk assessment model known as BOADICEA, they looked at a range of factors that may put women at a higher risk of breast cancer, including family history, lifestyle, reproductive history, and genetic information.
The team found that using the BOADICEA model in all women under the age of 50 would categorise 26.5% of women as at above-population level risk and eligible for further assessment. This approach would include 34.8% of women under 50 who develop breast cancer within 10 years.
The NICE model, which focuses solely on family history as its assessment criteria, would result in just 1.4% of women under 50 being referred for investigations, which would include only 4.4% of those who would later develop the disease.
Researchers believe that the primary reason for the disparity between the results of the NICE model and BOADICEA is that most women aged under 50 diagnosed with breast cancer within 10 years (73.0%) have no family history of the disease, which is the key factor considered by NICE.
Breast cancer is the most common cancer worldwide, with cases increasing steadily year on year. It is responsible for around 1% of cancer-related deaths in women, making it one of the leading causes of death in woman under the age of 50.
Breast cancer is the most common cancer among women worldwide and is responsible for around 15.4 % of cancer deaths in women globally2. In 2024, it was the leading cause of death in women aged 35–49 and 50–64 in England and Wales3.
Researchers involved in the study recommended a review of the current NICE referral criteria to include a wider range of risk factors, with the aim of increasing the number of high-risk women identified for screening.
The study’s senior author, Juliet Usher-Smith, from the Department of Public Health and Primary Care at the University of Cambridge, said: “We need to get better at identifying women at highest risk of breast cancer so that we can intervene early, when there are more options for treating, or even preventing, their disease.”
“The current NICE criteria used in general practice are missing up to 95% of women under 50 who will go on to develop breast cancer. It’s time to look again at these criteria in the light of our findings.”
A further study by the same group of researchers found that the public are overwhelmingly in favour of a proactive approach to identifying breast cancer risk in women aged 30–49, rather than waiting for women to come forward with their own concerns over their family history.
Women reported that they appreciated invitations to screenings rather than having to ask their GP, and agreed that they would be willing to undergo more assessments, including genetic testing, if it resulted in more high-risk women being identified.
According to the authors of the study, the next step is to test how multifactorial risk assessment, such as the BOADICEA model, can be implemented into the current system in a cost-effective, equitable, and safe manner. Multiple groups are currently assessing how this could be done.
The research was supported by Cancer Research UK and Breast Cancer Now.
References
1 Frost R et al, Comparison of NICE criteria with the BOADICEA multifactorial risk model to guide breast cancer risk assessment and referral amongst women under age 50 within primary care, British Journal of Cancer, 2026
2 Zhang Y et al, Global burden of female breast cancer: new estimates in 2022, temporal trend and future projections up to 2050 based on the latest release from GLOBOCAN, J Natl Cancer Cent., 2025 Feb 13;5(3):287-296. doi: 10.1016/j.jncc.2025.02.002. eCollection 2025 Jun.
3 Breast Cancer, 2026, UK, https://www.breastcanceruk.org.uk/about-breast-cancer/facts-and-figures/?utm_source=chatgpt.com
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