"Highlights

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  Clinical breast cancer risk assessment should be initiated by age 25.

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  Screening guidelines now consider 5-year estimated risk actionable.

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  Individualized preventive strategy is informed by risk levels categorized as ‘Presumably average’, ‘Elevated’, and ‘Very high’.

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  Routine risk stratification reduces breast cancer burden and can mitigate disparities in outcome.

Abstract

Breast cancer, the most frequently diagnosed malignancy in women both in the United States and globally, represents a significant public health burden. While screening constitutes the cornerstone of early detection, enhanced surveillance, and preventive measures—including risk-reducing medication and lifestyle modification—are underutilized. The well-woman visit remains a pivotal opportunity for preventive care and individualized risk assessment. Assessment should begin with “genetics”: evaluation for a potential germline pathogenic variant in a breast cancer susceptibility gene. If prior genetic testing was conducted, results should be reviewed to determine the need for updated testing based on current clinical guidelines or changes in personal or family history. Negative genetic testing requires contextual interpretation within the broader family history. In the absence of a known causal variant, estimated short- and long-term risks can then be quantified using validated risk prediction models that incorporate traditional risk factors such as age, family history, reproductive history, breast density, and hormonal exposure. Despite the availability of effective tools, genetic testing and formal risk evaluation remain underutilized, especially among socioeconomically disadvantaged populations, contributing to significant outcome disparities. As such, clinicians should implement a standardized, technology-supported framework for risk assessment routinely, in all patients. Such an approach promotes early identification of higher-risk individuals and supports more targeted prevention, enhanced surveillance, and personalized management of breast health. This paper focuses on formal and informal processes for breast cancer risk assessment and the management of women at moderately increased risk.