For women identified as being at high risk of breast cancer, standard population screening is not sufficient. The evidence is clear that high-risk women benefit from a more intensive, more personalised surveillance program that begins earlier, uses more sensitive imaging, and is reviewed and adjusted by a specialist team over time.

At Breast & Surgical Oncology at The Poche Centre, high-risk screening assessment and imaging surveillance is a structured and well-established part of our practice. We design individualised surveillance programs for high-risk women, coordinate the imaging components with specialist breast radiologists, and provide ongoing specialist review to ensure the program remains appropriate as circumstances change.

Who Is Considered High Risk?

Women are generally classified as high risk when their estimated lifetime breast cancer risk exceeds approximately 20 to 25%, or when specific clinical criteria are met that independently justify intensive surveillance regardless of the numerical risk estimate.
High-risk categories include the following.

Confirmed carriers of a pathogenic mutation in BRCA1, BRCA2, PALB2, CDH1, PTEN, or other high-penetrance breast cancer genes. Women with an untested first-degree relative who is a known gene mutation carrier. Women with a very strong family history meeting high-risk criteria even in the absence of a confirmed gene mutation — for example, multiple affected first-degree relatives diagnosed at young ages, or a family history of both breast and ovarian cancer. Women with a personal history of DCIS, LCIS, or atypical hyperplasia in the context of other elevated risk factors. Women who received chest wall radiotherapy before age 30, for example for Hodgkin's lymphoma, whose lifetime breast cancer risk is significantly elevated as a result. Women whose quantitative risk assessment using a validated model such as Tyrer-Cuzick places them in the high-risk category.

Components of a High Risk Surveillance Program

High-risk surveillance combines multiple modalities to maximise the sensitivity of detection, with the specific program tailored to the individual's risk level, age, breast density, and personal circumstances.

Annual breast MRI is the cornerstone of high-risk surveillance and is significantly more sensitive than mammography for detecting breast cancer in high-risk women, particularly those under 50 with dense breast tissue. MRI detects cancers at a smaller size and earlier stage than mammography in this population and has been shown to reduce interval cancer rates. It is recommended annually for women with a confirmed high-risk gene mutation or equivalent risk, typically commencing from age 30 for BRCA1 carriers and age 30 to 35 for BRCA2 carriers. MRI requires intravenous contrast and takes 15-30 minutes. It is available for high-risk women through the public and private hospital systems and attracts a Medicare rebate for eligible patients.

Annual mammography is used alongside MRI in high-risk surveillance, as the two modalities are complementary — mammography is particularly good at detecting microcalcifications that may not be visible on MRI. The two tests are typically staggered six months apart so that the breast is imaged in some form every six months. The age at which annual mammography commences in high-risk women is earlier than the population program, generally from age 40 or earlier depending on individual risk.

Clinical breast examination by a specialist breast surgeon is incorporated into the surveillance program at regular intervals, typically annually or six-monthly depending on risk level. Clinical examination provides information that imaging alone cannot, including assessment of breast texture, asymmetry, skin and nipple changes, and axillary lymph node status.

Breast ultrasound is used as a supplementary tool in specific circumstances — to further characterise a finding on mammogram or MRI, or as an adjunct in younger women with very dense breast tissue — but is not recommended as a standalone surveillance tool in the high-risk setting.

Planning Mastectomy — What Happens Before Surgery

The period between deciding on mastectomy and the day of surgery is an important time for planning, particularly if reconstruction is being considered.

Pre-operative appointments — you will have at least one pre-operative appointment with your surgeon to review the planned procedure, confirm your understanding and consent, and answer any remaining questions. If reconstruction is planned, your reconstruction planning will be finalised at this stage. Pre-operative photographs are typically taken for surgical planning and record purposes.

Discussing reconstruction — if you are considering breast reconstruction, the conversation about reconstruction options occurs before your mastectomy so that the most appropriate type of reconstruction can be planned and performed at the same time (immediate reconstruction). See our dedicated breast reconstruction page for a full overview of the options available.

Breast care nurse — your breast care nurse is actively involved in preparation for mastectomy, providing information, emotional support, and practical preparation. She can help answer questions about what to expect, what to bring to hospital, how to set up at home for recovery, and what support services are available.

What to arrange before surgery — depending on the complexity of the procedure and your home circumstances, you may benefit from arranging practical help at home for the first one to two weeks after surgery. Driving should not be planned for at least two weeks. If you have drains (see below), someone will need to be available to help you monitor them at home.

Frequency and Duration of Surveillance

High-risk surveillance is a long-term commitment. For confirmed gene mutation carriers, annual MRI and mammography is recommended from the age specified by current guidelines through to age 70 to 75, at which point the surveillance program is reviewed. The frequency and modalities used are adjusted as the patient ages, as breast density changes, and as new evidence or updated guidelines emerge.

For women who proceed with risk-reducing mastectomy, formal breast imaging surveillance of the chest wall is not routinely required after surgery, as the risk is substantially reduced. However, clinical review and ongoing surveillance of the residual risk continues under specialist oversight.

Coordination of High Risk Surveillance

An effective high-risk surveillance program requires coordination between the specialist breast surgeon or breast physician, the breast radiologist, the genetic counsellor or geneticist, and the patient's GP. At our practice, we take responsibility for initiating and overseeing the surveillance plan, communicating the program clearly to all involved clinicians, and reviewing findings at each cycle to determine whether any change in management is indicated.

Where a finding requires further assessment — an area of enhancement on MRI, a new mammmographic abnormality, or a change on clinical examination — we ensure prompt investigation through the appropriate diagnostic pathway without delay.

Medicare Rebates for High Risk Surveillance

Annual breast MRI for women at high genetic risk attracts a Medicare rebate for eligible patients, including confirmed BRCA1 and BRCA2 mutation carriers and certain other high-risk groups. Your surgeon will advise on your eligibility at consultation and ensure the appropriate referral documentation is in place to facilitate rebatable imaging.

Booking an Appointment

If you believe you may be at high risk of breast cancer and have not yet had a formal risk assessment or been enrolled in a structured surveillance program, a GP referral to our practice is the appropriate first step. We will assess your risk, design a personalised surveillance program, and coordinate all components of your ongoing monitoring.