Understanding Breast Cancer Risk in Military Service Members and Veterans

For Bethany Niell, MD, PhD, the effort to better understand breast cancer risk among military service members and veterans hits close to home.

Her older brother, Ryan Fisher, served as an officer in the U.S. Army Corps of Engineers from 1997 to 2001. Through him, Niell has seen the lasting connections formed through military service and developed a deep appreciation for those who serve.

Ryan Fisher served in the U.S. Army Corps of Engineers. He spent his time on active duty at Fort Bragg, North Caolina, assigned to the 20th Engineer Brigade. He inspired his sister, Bethany Niell, MD, PhD, to better understand breast cancer risk among military service members and veterans.

As a breast radiologist at Moffitt Cancer Center, she also recognized an opportunity to address an important gap in cancer care: ensuring that active-duty service members and veterans understand their individual breast cancer risks when making screening decisions.

“I care deeply about my brother and his colleagues who have served our country,” Niell said. “And I wanted to raise awareness around the breast cancer risk factors that are concentrated in active-duty military service members and veterans.”

That goal led Niell to collaborate with military physicians and breast imaging specialists on a review of breast cancer risk and screening in active-duty service members and veterans, published in the Journal of Breast Imaging.

The review examines what researchers know about breast cancer rates in military populations, potential risk factors and the challenges some service members and veterans face when accessing screening and follow-up care. It also highlights areas where more research is needed.

Understanding Breast Cancer Risk

Breast cancer is the most common cancer, not including skin cancer, among women in the military and female veterans. Research suggests that women ages 40 to 59 who serve in the military have higher breast cancer incidence rates than women in the general population.

In one study examining data from 1990 to 2013, breast cancer incidence rates among military women ages 40 to 59 were 15% higher for white women and 17% higher for Black women than rates among their counterparts in the general population.

Researchers are still working to understand what accounts for the disparity. Certain established breast cancer risk factors that may be more common among women in the military include differences in reproductive patterns, such as shorter breastfeeding duration and older age at first childbirth. Military service also can involve frequent relocations and deployments that affect family planning and access to healthcare.

Other potential factors are specific to military service, including exposure to environmental hazards such as burn pits and certain chemicals.

“We don’t yet understand what may cause increased cancer risk in active duty and veterans,” Niell said. “More studies are needed to identify the factors that contribute to cancer risk in military populations, not only for breast cancer, but for other cancer types as well.”

Screening Should Reflect Individual Risk

A central message of the review is that screening decisions should be informed by a person’s individual risk, rather than relying on age alone.

“It’s important that our active-duty personnel and our veterans have conversations with their healthcare provider about their cancer risk factors,” Niell said.

Those conversations should begin early. Niell emphasizes that breast cancer risk assessment is recommended no later than age 25, giving patients and providers an opportunity to identify elevated risk and discuss appropriate screening and risk-reduction strategies over time.

That message is particularly important for military populations, she says. Active-duty service members are often younger and expected to maintain a high level of physical fitness. Being young and physically fit, however, does not mean someone is free from cancer risk.

“There’s a tendency for a healthy-person paradox,” Niell said. “No matter what your age and your physical fitness level, it’s important to be thinking about your cancer risk factors and cancer risk-reduction strategies at an early age and throughout your entire lifetime.”

Family history is one part of a risk assessment, but it is not the only factor. A person’s reproductive history, lifestyle, medical history and other factors also can contribute to breast cancer risk.

No matter what your age and your physical fitness level, it’s important to be thinking about your cancer risk factors and cancer risk-reduction strategies at an early age and throughout your entire life.

Bethany Niell, MD, PhD

At Moffitt, all patients undergoing screening mammography are offered a breast cancer risk assessment. Niell helped implement that process in 2017, with the goal of identifying patients who may benefit from additional evaluation or screening.

Expanding Screening Access for Veterans

For some military women and veterans, accessing appropriate breast imaging has presented additional challenges.

The Supporting Expanded Review for Veterans in Combat Environments (SERVICE) Act, signed into law in 2022, expanded access to breast cancer risk assessments and screening mammography for certain female veterans who served in specific locations and time periods.

Under the law, eligible veterans can receive a breast cancer risk assessment and, when clinically appropriate, screening mammography before age 40.

“Patients at increased risk of developing breast cancer, including subsets of active-duty service women and veterans, benefit from earlier and more intensive breast cancer screening regimens,” she said.

But access to screening is only part of the picture. Military families may relocate frequently, and service members may move between healthcare providers.

“Sometimes it can be difficult for them to have longitudinal care or to get follow-up imaging studies,” Niell said.

Improving communication among healthcare systems and making sure patients can access their previous imaging and results are important steps toward more consistent care.

More Research and More Conversations

Although the review identifies important gaps in breast cancer risk and screening for military populations, Niell says there is still much to learn.

Researchers need better information about potential risk factors, including military-related environmental exposures, as well as evidence to determine whether people identified as being at higher risk would benefit from additional screening or supplemental imaging.

For now, she encourages service members and veterans to discuss their personal and service-related histories with their healthcare providers. Questions about deployments, potential exposures, reproductive history and family history can help providers develop a more complete picture of a patient’s risk.

She also hopes the broader message reaches everyone: Cancer risk can change over a person’s lifetime, and screening recommendations may need to change with it.

“We want to move away from everyone being treated the same and toward doing things based on risk,” Niell said. “First, you have to know your risk. Most people don’t.”

Ultimately, Niell says, those who have served in the military deserve access to the highest-quality clinical care available.

“We want to get all people, including our active-duty servicewomen, active-duty servicemen and veterans, the appropriate cancer screening and prevention services at the appropriate time, based on their level of risk,” she says.