On 14 May 2013, a 37-year-old woman wrote in the New York Times that she was at high risk of breast cancer, and that she'd had both her breasts removed because of it. She didn't have breast cancer. Nothing had shown up on a scan. She'd had three months of operations, kept it private and carried on working. Her name was Angelina Jolie.
Her mum had died of ovarian cancer at 56. Her mum's sister had had breast cancer. And a blood test had found a change in a gene called BRCA1. Her doctors put her chance of breast cancer at 87 in 100. After the surgery, it was under 5.
In the two weeks after she wrote it, the number of women in the United States having the same gene test went up by almost two thirds. But when researchers at Harvard looked at who'd had those extra tests, they seemed to have gone mostly to women at lower risk (Desai and Jena, BMJ 2016). So the women who were most worried weren't always the ones at high risk. And the ones at high risk weren't always the ones asking about a test.
So what did her family have that most families don't? And would you spot it in yours?
Watch the video
Am I High Risk for Breast Cancer? How to Tell
This post is the written version of my video. If you'd rather watch, it covers the same ground, with the family trees drawn out on screen.
Watch on YouTube →What "high risk" actually means
High risk has a definition as well as a feeling. We sort women into three groups by their chance of getting breast cancer over their whole life. For a woman in New Zealand, the average is about 1 in 10 (Breast Cancer Foundation NZ). That's common.
Most women with a relative who's had breast cancer assume they're in the top group. But more than 95 in 100 women are in the first one: average, or a little above average. Fewer than 4 in 100 are in the second group, the moderate one. Fewer than 1 in 100 are in the third, the high-risk group (the categories used in New Zealand and Australia).
The cut-offs differ from country to country
In New Zealand and Australia, the moderate group starts at a lifetime risk of about 1 in 8, and the high-risk group at more than 1 in 4. The UK draws the lines higher: moderate from about 1 in 6 (17%), high from 30%. In the US, 20% or more is usually the level for yearly MRI. So the same family can be called moderate in one country and high in another. Your own team will place you.
"My mum had it. Does that mean I'll get it?"
Out of 100 women with no mother, sister or daughter who's had breast cancer, about 8 are diagnosed by the age of 80. With one of them affected, it's about 13 in 100 (Collaborative Group on Hormonal Factors in Breast Cancer, Lancet 2001).
So yes, one relative raises it. But 13 in 100 also means 87 women in 100 whose mum had breast cancer never get it. One relative on her own doesn't put you in the high-risk group.
And no relative doesn't make you safe either. Eight out of nine women who get breast cancer have no mother, sister or daughter who had it (same study). So no family history isn't a reason to skip your mammogram.
What decides your group is the detail about each relative. And Angelina Jolie's family had all three details.
Three things about each relative
For each relative who's had cancer, three things matter: which side of the family, which cancer, and how old they were when it was found.
Which side. Her family was all on her mum's side, and that's the version most people recognise. But most women only ever check their mum's side, and your dad's side counts exactly as much. Half your genes come from your dad. Men rarely get breast cancer, so a gene change can pass down through a father's side without anyone noticing, and turn up in his sister, his mum or his daughter.
Which cancer. Breast cancer, yes. But Angelina Jolie's mum had ovarian cancer, and that matters a lot, because the same genes cause both. So does breast cancer in a man, at any age. And prostate, pancreatic, uterine, kidney and stomach cancer matter too. Most women wouldn't think to put those on a breast cancer family tree. But some of the genes that raise your breast cancer risk raise the risk of these other cancers as well, so they go on the tree. If you're not sure whether a cancer counts, put it on.
How old. Breast cancer before 50 matters more than breast cancer at 75. Most breast cancer is found after 50, so a young one is less likely to be bad luck and more likely to run in the family.
Which group your family points to
This is a rough guide, not the official criteria, which have more detail. But it's close to how I think about it in clinic.
- Most likely the first group: nobody's had it; or your mum or sister had it after 50; or one or two grandmothers or aunts had it after 50.
- More likely the second, moderate group: your mum, sister or daughter had it before 50, or two of them had it at any age.
- Where we start thinking about a gene and the high-risk group: two or more relatives on the same side with breast or ovarian cancer, plus one more thing. One was under 50, or had cancer in both breasts, or had both cancers; or a man in the family had breast cancer or prostate cancer; or there's Ashkenazi Jewish ancestry.
That was Angelina Jolie's family. But picture the same two cancers on your dad's side: his mum, his sister, and then he has prostate cancer himself. That's the family that often never gets asked about.
So two things to keep hold of. One relative over 50 doesn't make you high risk. And your dad's side counts as much as your mum's.
If you've found a lump or a change in your breast, that's a different question. It doesn't wait for a family tree. It needs examining this week, so ring your GP.
The genes, and what they change
What put Angelina Jolie in the high-risk group for certain was the gene. BRCA1 and BRCA2 are the best known. So you'd think most breast cancer must be genetic. It isn't. Only about 5 to 10 in 100 breast cancers come from a gene change passed down in the family (Breast Cancer Foundation NZ).
But if you carry one of those genes, the numbers change completely. Out of 100 women with a BRCA1 or BRCA2 change, about 70 get breast cancer by 80 (Kuchenbaecker et al., JAMA 2017). That's an average across a lot of families. Some sit higher, some lower, and your own family history moves it.
And BRCA isn't the only gene. When we test now, we usually test a panel of genes at the same time.
- PALB2 is the closest to BRCA: about 53 in 100 by 80 (Yang et al., J Clin Oncol 2020).
- CHEK2 and ATM are more common, but the risk is lower, roughly double the average (Breast Cancer Association Consortium, NEJM 2021).
- RAD51C and RAD51D mostly raise the risk of ovarian cancer, and of breast cancer a bit too.
- PTEN, TP53 and CDH1 are rarer. CDH1 goes with lobular breast cancer and a type of stomach cancer, and it was found here in New Zealand, in a Māori whānau, in the late 1990s (Guilford et al., Nature 1998).
The other cancers each gene goes with
- BRCA2 and PALB2: pancreatic; BRCA2 also prostate
- CHEK2 and ATM: prostate; ATM also pancreatic
- RAD51C and RAD51D: ovarian
- PTEN: uterine, thyroid, kidney
- TP53: very young breast cancer, and cancers in children and young adults
- CDH1: lobular breast cancer and stomach cancer
So a dad with prostate cancer, an aunt with pancreatic cancer, or a grandmother with stomach cancer can all be part of the same pattern. And if your family has bowel and uterine cancer, that can point to something different, called Lynch syndrome, which is worth a referral in its own right.
Getting tested in New Zealand
So testing matters for the families who fit. In New Zealand it's done through the Genetic Health Service, and it's free if your family meets their criteria. When the threshold was last changed, in 2016, it was roughly a 1 in 10 chance or more that you carry a gene change (Breast Cancer Foundation NZ). Criteria get reviewed, so whoever refers you will check the current ones.
Your GP or your breast specialist can refer you. It helps a lot if you know the ages, and any cancers or precancers that anyone has had, on both sides of the family.
Other ways into the high-risk group
Family isn't the only way in. Radiotherapy to your chest when you were young, usually for Hodgkin lymphoma before the age of 30, puts you there too. A breast biopsy in the past that showed atypical cells, or something called lobular carcinoma in situ, raises your risk as well. Those are in your own pathology reports, not your family's.
And dense breasts? Density on its own doesn't put you in the high-risk group. It's one piece we add in. I've written about that separately: Have Dense Breasts? Here's What to Do Next.
What changes once you know your group
In New Zealand, quite a lot. The free programme is the same for everyone in the first group, and it doesn't start until 45.
If you're in the first group, BreastScreen Aotearoa is built for you: a free mammogram every two years from 45 to 69. The upper age is being extended to 74, in stages, with the whole country expected to be covered by the end of 2029 (Health NZ). Call 0800 270 200 to enrol.
But if you're in the second or third group, a mammogram every two years from 45 isn't enough on its own. Your GP should refer you for screening outside the programme.
What I do in my own clinic
- The moderate group: I recommend a yearly mammogram. If a woman has dense breast tissue, I might consider a contrast mammogram or an MRI as well.
- The high-risk group, and women who carry a gene change: I recommend a yearly MRI and a yearly mammogram, starting 10 years before the age of the youngest person in the family who was diagnosed with breast cancer.
Health insurance usually doesn't cover an MRI for screening, even with a strong family history. But your GP or specialist can refer you to a high-risk family history clinic. Most places in New Zealand, and most breast clinics, have one in the public system.
If you're paying yourself, a breast MRI in New Zealand is around $1,000 for a shorter version, which not every centre offers, and about $2,500 for a complete one.
Some women in the high-risk group decide on risk-reducing surgery, like Angelina Jolie did. That's a referral to a public or private provider. It's usually done once a woman has finished breastfeeding and doesn't want more children. It can come earlier if breast cancers in the family were found very young and she's decided not to breastfeed. It's a big decision, and it's yours, with the numbers in front of you.
What to say to your GP
It's tempting to ring and say "there's cancer in my family". But that doesn't give your GP enough to go on. Write your family down first, then give the details. Something like:
"My dad had prostate cancer at 55. His sister had breast cancer at 41, and his mum had ovarian cancer. Can you check whether I should be referred to the Genetic Health Service, or have extra screening?"
Draw your family tree
Get a piece of paper. Draw your family, both sides, back to your grandparents, or further if you know. Next to anyone who's had cancer, write three things: which side, which cancer, and how old they were. That's the thing I most want you to write down.
Then take three questions to your GP:
- Which risk group do my family details put me in?
- Should I be referred to the Genetic Health Service?
- What screening should I be having, and from what age?
And if someone told you years ago that you're average risk, that answer was about your family as it was then. Families change. If a relative has been diagnosed since, it's a new conversation.
It is entirely appropriate to ask again.
You have time. Ask the question. Then make the decision yourself.
The video
Am I High Risk for Breast Cancer? How to Tell
The whole thing on YouTube, if you'd rather watch, or want to send it to a sister or cousin on the same side of the family.
Watch on YouTube →Read next
- Male Breast Cancer: What Tyler Mane's Diagnosis Tells Us
- What Is Invasive Lobular Breast Cancer? The Type That Doesn't Always Make a Lump
- Have Dense Breasts? Here's What to Do Next
Sources
- Angelina Jolie, "My Medical Choice", New York Times, 14 May 2013.
- Gene testing after the op-ed: Desai S, Jena AB. BMJ 2016;355:i6357 (US insurance data; the shift to lower-risk women is the authors' reading of what happened afterwards).
- Average lifetime risk in New Zealand and the inherited share: Breast Cancer Foundation NZ, risk factors we can't change.
- Risk groups used in New Zealand: Te Aho o Te Kahu, screening and surveillance of women at increased breast cancer risk (categories from Cancer Australia, 2010). UK cut-offs: NICE CG164.
- One affected relative, and 8 in 9: Collaborative Group on Hormonal Factors in Breast Cancer. Lancet 2001;358:1389–1399 (women in high-income countries).
- BRCA1 and BRCA2: Kuchenbaecker KB et al. JAMA 2017;317:2402–2416.
- PALB2: Yang X et al. J Clin Oncol 2020;38:674–685.
- CHEK2, ATM, RAD51C, RAD51D: Breast Cancer Association Consortium (Dorling L et al.). NEJM 2021;384:428–439.
- CDH1 in New Zealand: Guilford P et al. Nature 1998;392:402–405.
- Funded genetic testing: Breast Cancer Foundation NZ, lower threshold for BRCA testing (2016).
- Screening to 74: Health NZ, extending the age for free breast screening.
This article is general information, not personal medical advice. Talk through your own family history with your GP or breast specialist. MRI prices are a guide as of November 2026 and vary by provider.