Guidance

Eligibility criteria and screening protocols for women at very high risk of breast cancer

Updated 29 April 2025

Applies to England

This guidance sets out the eligibility criteria and associated test requirements for women in the very high risk (VHR) programme.  Further information regarding the programme including the requirement for review of breast density for women entitled to VHR screening at the age of 50 years (and thereafter as required) is available in the Guidance for the surveillance of women at very high risk of developing breast cancer. 

Women who have more than one risk meeting the eligibility criteria

Where women fulfil more than one risk criteria for very high risk screening (for example, BRCA1 likely pathogenic variant and previous radiotherapy to breast tissue when aged 15), their screening protocol should be determined  on a case by case basis and reviewed by a consultant radiologist, consultant practitioner or breast clinician.

Breast cancer (BRCA) gene carriers and equivalent genetic proven risks

This group of women at very high genetic risk of developing breast cancer includes:

• BRCA1 carriers

• BRCA2 carriers

• PALB2

Age	Test	Frequency of testing
25 to <40	Magnetic resonance imaging (MRI)	Annual
40 to <51	MRI + mammography	Annual
51 to <71	Mammography +/- MRI	Annual

• women who have a likely pathogenic/pathogenic variant in another high-risk gene including:
• ATM c.7271T>G
• CHEK2 biallelic
• PTEN
• STK11
• CDH1

Age	Test	Frequency of testing
30 to <40	MRI	Annual
40 to <51	MRI + mammography	Annual
51 to <71	Mammography +/- MRI	Annual

Women with likely pathogenic/pathogenic variant in TP53 (Li-Fraumeni) syndrome

Age	Test	Frequency of testing
20 to <71	MRI	Annual

Mammography tests are contraindicated for this group of women.

Women with ATM biallelic likely pathogenic/pathogenic variants (have Ataxia Telangiectasia)

Age	Test	Frequency of testing
25 to <71	MRI	Annual

Mammography tests are contraindicated for this group of women.

Women with proven genetic equivalent risks

Any other gene must be specified and may include:

• CHEK2
• ATM
• RAD51C
• RAD51D
• Any other specified gene

Women with likely pathogenic/pathogenic variants in any of these genes must have evidence of equivalent 10 year risk via CanRisk assessment at the following levels to be eligible for referral:

• At age 30 to <40 years: ≥ 8% calculated from age 30 (or)
• At age 40 to <50 years: ≥ 12% calculated from age 40

Age	Test	Frequency of testing
30 to <40	MRI	Annual
40 to <51	MRI + mammography	Annual
51 to <71	Mammography +/- MRI	Annual

Women who are risk equivalent but not tested for familial variant in BRCA1, BRCA2 or PALB2

• To access screening between ages 25 to <30

Women who are risk equivalent but not tested for a familial variant in BRCA1, BRCA2 or PALB2 must have evidence of equivalent 10 year risk via CanRisk assessment at the following levels to be eligible for referral:

• At age 25 to <30 years: ≥8% 10 year risk calculated from age 25 and commence screening at the age at which the 8% threshold is met.

If women who are untested for a familial variant in BRCA1 or BRCA2 are referred at the age of 30 years or older, they are eligible for VHR screening until the age of <51 years.

Age	Test	Frequency of testing
25 to <40	MRI	Annual
40 to <51	MRI + mammography	Annual

Other women untested for a familial variant (including PALB2 and other gene mutations) must have evidence of the equivalent 10 year risk via a CanRisk assessment:

• At age 30 to <40 years: ≥8% calculated from age 30 (or)
• At age 40 to <50 years: ≥12% calculated from age 40

Age	Test	Frequency of testing
30 to <40	MRI	Annual
40 to <51	MRI + mammography	Annual

• Risk equivalent women are not screened via the Very High Risk programme after the age of 50 years

Women who are risk equivalent but not tested for familial variant in TP53 (Li-Fraumeni)  (must have a first degree relative who has a TP53 likely pathogenic/pathogenic variant

Age	Test	Frequency of testing
20 to <51	MRI	Annual

Women who are risk equivalent but genetic cause not identified

Women who are risk equivalent but a genetic cause is not identified, must have evidence of equivalent 10 year risk via CanRisk assessment at the following levels to be eligible for referral:

• At age 30 to <40 years: ≥8% calculated from age 30 (or)
• At age 40 to <50 years: ≥12% calculated from age 40

Age	Test	Frequency of testing
30 to <40	MRI	Annual
40 to <51	MRI + mammography	Annual

• Risk equivalent women are not screened via the Very High Risk programme after the age of 50 years

Women who have had radiotherapy to breast tissue

Females irradiated below the age of 10 years

Testing is not applicable to these females.

Females irradiated between ages of 10 and <20 years

Age	Test	Frequency of testing
25 to <40	MRI	Annual
40 to <51	MRI + mammography	Annual
51 to <71	Mammography +/- MRI Annual

Surveillance starts at age 25 or 8 years after first irradiation, whichever is the later

Females irradiated between ages of 20 and <36years

Age	Test	Frequency of testing
30 to <40	MRI	Annual
40 to <51	MRI + mammography	Annual
51 to <71	Mammography +/- MRI	Annual

Surveillance starts at age 30 or 8 years after first irradiation, whichever is the later

Women meeting VHR screening eligibility but aged 71 years and over

Women aged >70 years meeting the VHR screening eligibility criteria may be referred into the VHR breast screening programme via the standard referral routes. Following an initial screen, they will need to self-refer to their local service for screening on an annual basis if they wish to continue accessing screening.

Age	Test	Frequency of testing
>70	MRI + mammography density review	Initial test, thereafter mammography +/- MRI upon self-referral