National Health Service Breast Screening Research Articles

Screening for breast cancer in England: a review

This year, the National Health Service Breast Screening Programme in the UK (NHSBSP) celebrates its 20th anniversary. Since 1988, it has evolved with the help of randomized control studies to become more efficient at picking up in-situ disease and small invasive cancers. This review will address these new developments and discuss their impact on screening. The introduction of extra mammographic views, the reading of films by two specialists and digital mammography as well as age extension have all made significant differences to the detection of breast cancer through screening. A discussion of how less obvious factors such as organization and structure as well as rigorous national audit have improved matters is also included. Controversial topics such as the screening interval and screening women under 50 will also be addressed in this review. Population-based breast screening will continue to evolve in England. It is unique and with its annual national audit it continues to drive the development of breast services nationally.

CADET 2 results/computer-aided detection update

Computer-aided detection (CAD) systems that attract the reader's attention to potentially suspicious features on a mammogram are now in clinical use in screening mammography in the USA and some European countries. However, recent publications have debated the benefit of CAD systems in screening mammography and have highlighted the need for robust evidence from prospective randomised trials. The evidence from these studies will be reviewed, including a recently published meta-analysis of double reading versus single reading with CAD. The CADET II trial was a prospective multicentre randomised comparison of single reading with CAD and double reading in the UK National Health Service Breast Screening Programme. Over 30,000 women (age 50 to 70 years), attending routine mammo-graphy at three UK breast screening centres, were recruited into the trial. Film batches from screening sessions were randomly assigned in a ratio of 28:1:1 to one of three film-reading regimes: double reading and single reading with CAD, or double reading only, or single reading with CAD only. The primary outcome measures were matched comparisons of the cancer detection rates and the number of women recalled for assessment by the two reading regimes. The results of the study will be presented at the conference. The implications of this study will be discussed together with further work that needs to be undertaken.

Full field digital mammography: which equipment?

A wide variety of digital mammography systems are now commercially available. These include digital radiography (DR) systems such as the CSi/amorphous silicon detector (for example, GE Senographe 2000D, DS and Essential models), amorphous selenium (for example, LoRad Selenia, Siemens Novation and Inspiration models, IMS Giotto, Planmed Nuance) and a scanning system with silicon detectors (for example, Sectra Micro Dose Mammography). A variety of computerised radiography (CR) systems for mammography are also available (for example, Fuji Profect, Kodak DirectView, Konica Regius 190, Agfa CR 85-X). Recently the CR manufacturers have introduced new designs of phosphor plates. Such a wide variety of systems raises the question of how the performances of these systems compare with each other and with film-screen technology. Another factor to be considered is the radiation dose required by each system to reach an acceptable level of image quality. To help answer these questions, the National Health Service Breast Screening Programme and European Guidelines specify minimum and achievable standards for dose and image quality. The minimum standard is designed to ensure that new digital systems are at least as good as the previous film-screen systems. This lecture compares the measurements on a wide range of digital systems against the standards in the European Guidelines. The overall conclusion is that the DR systems can generally meet the achievable image quality standards for a dose lower than that used for film-screen systems. While the new designs of CR plate have brought about measurable improvements, most CR systems still require doses higher than film-screen systems to meet the minimum standards for image quality.

Digital screening on a mobile unit: the Coventry experience

Many National Health Service Breast Screening Programme Screening Services are changing from analogue to digital technology. Coventry was the first Screening Service to screen digitally on a mobile unit. There are several factors that need to be considered when planning to staff and equip a Full-field Digital Mammography Breast Screening Service. In view of the planned age expansion announced in the Cancer Reform Strategy, most units will need to consider planning for these changes. These considerations will include our local experience of drivers for change, workforce planning, managing extended working days, maintaining screening-round length, and some equipment issues.

Assessing mammography film-reader performance

Mammography film-readers in the National Health Service Breast Screening Programme are required to read 5,000 screening mammograms per year, and to participate in Personal Performance in Mammographic Screening (PERFORMS). It is known that individual cancer detection rates are higher when individuals perform high volumes of breast imaging annually, and that poor performance may be identified by PERFORMS. We have looked more closely at details of reader performance to guide individuals on how practice may be improved.

A practical perspective of computerised radiography on a mobile screening van

Prohibitive costs of implementing direct digital mammography throughout our unit, as we would need to replace analogue machines on two mobile screening vans and at one satellite static unit, directed us towards the interim solution of computerised radiography (CR). An agreement was made between ourselves and Fuji to pilot the use of CR on a mobile screening van. We looked at the practicalities of installation of equipment, training and changes to working practices for radiographers, film-reader comparison of images and technical recall rates. The pilot has been in place for 1 year; 720 independent observations have been made by one consultant radiologist and three mammographic film-readers, comparing hardcopy CR images with previous analogue films, using the criteria set out in the National Health Service Breast Screening Programme evaluation of digital equipment document. The results demonstrate that CR printed films are at least as good as analogue films, and in many cases better. The spread of relative diagnostic value was between -1 (0.4%) and +2 (14.4%) in favour of CR. This was most marked in the dense breast patterns, as shown in previous publications. Aspects of physics testing will also be discussed.

Promoting early presentation of breast cancer

Amongst patients with breast cancer there is strong evidence that delays in excess of 3 months between onset of symptoms and diagnosis/treatment are associated with worse survival rates than shorter delays. The predominant risk factors for patient delays in breast cancer include lack of awareness that breast symptoms could be due to cancer and lack of awareness of personal risk. Ideally an intervention to reduce delayed presentation of breast cancer would promote early help-seeking behaviour by patients at high risk of having cancer, but would not promote anxiety amongst people at low risk. It is important that patients should not be made unnecessarily anxious, and nor should general practitioners be overburdened with consultations with the worried well population. Based on the empirical evidence for the risk factors for patient delay and using effective behavioural change techniques, we have developed and are evaluating a psycho-educational intervention to promote early presentation of breast cancer by older women. We have focused our intervention on older women who are at greater risk of breast cancer and are also more likely to delay their presentation. The intervention is delivered by trained diagnostic radiographers at the point when the women leave the routine protection afforded by the National Health Service Breast Screening Programme and is in line with government recommended practice and complementary to the Breast Screening Programme. The ultimate aim of the intervention is to reduce the proportion of older women with breast cancer who delay their presentation, and thereby save lives. I will outline this work and other current initiatives within the United Kingdom to promote awareness and early presentation of breast cancer and how these might inform the development of policy initiatives to improve outcomes for patients within the National Health Service.

The future of breast radiography: UK perspective

The current presentation reviews the radiography career structure within the mammography speciality in the United Kingdom, focusing particularly on the National Health Service Breast Screening Programme (NHSBSP). Factors influencing role design will be discussed, including national job profiles, the professional body and NHSBSP guidance, service needs and cost-effectiveness. Barriers to developing the workforce will be considered. Results from the 2008 National Breast Screening Programme workforce survey, currently underway, will be presented – concentrating on the consultant radiographer role, and comparing actual job specifications with those indicated in the relevant guidance and with managers' views on ideal job design. It is postulated that while the radiography workforce has developed enormously during recent years, further development is needed to respond to current and future opportunities and challenges.

Maximising round length in a large National Health Service breast screening unit

Within the National Standards for Breast Screening is the objective to ensure that women are recalled for screening at appropriate intervals. The Manchester Breast Screening Unit has utilised the ability to specify batches from the health authorities in a specific order, to maximise the call and recall system for women eligible for primary screening. The minimum standard for the criterion of the percentage of eligible women whose first offered appointment is within 36 months of their previous screen is ≥ 90%. Using the computer program has maximised the appointment scheduling, but in addition has derived benefits to the Commissioning Primary Care Trusts. The appointment timescales, offering women screening on mobile vans, has enabled the Primary Care Trusts the opportunity to promote breast screening effectively to the eligible women who have failed to attend their first appointment. In low-uptake areas, this has facilitated the efforts to increase uptake to the national standard of 70%.

Should prior film mammograms be digitised during the transition to digital mammography?

National Health Service breast screening centres will soon make the transition to digital mammography, and how that transition is conducted may affect both performance and workflow. A trial of digitising the prior film mammograms was conducted at University Hospital (Coventry). Radiologists/advanced practitioners (n = 8) read screening cases for 1.5 hours in two conditions: either prior mammograms digitised (2905 digitiser at 75 μm; Array, USA) and presented onscreen alongside the current mammograms; or displayed in film format on a multiviewer. Measurements of eye movements showed readers look at the prior mammograms a greater number of times per case when digitised (t(7) = -2.73, P = 0.03). This could have implications for performance, as use of prior mammograms is known to improve performance. After the study, seven out of the eight readers expressed a preference for digitisation of prior mammograms. Digitisation was trialled at two different points in the workflow: before the screening session resulted in 30% wastage due to women not attending; and after the screening session caused a bottle-neck in workflow that slowed the screening process by approximately half a day (3 minutes per woman) in this implementation. The present study indicates that digitising prior mammograms is beneficial for readers, but may delay the production of results in the screening process.

Is it feasible to train diagnostic radiographers to deliver a psycho-educational intervention to promote early presentation of breast cancer amongst older women? A pilot study

Objective To develop and pilot a training programme for radiographers to deliver a psycho-educational intervention to women receiving their final invited mammogram with the National Health Service Breast Screening Programme (NHSBSP). Background A 10-minute structured interview has been developed and tested, which aims to improve older women's knowledge about breast symptoms and personal risk, and to increase confidence to detect a breast change. The intervention is quality assured against competency ratings on the content and style of the interview. Training model Includes didactic teaching, communication skills training, experiential learning using role-play with actors and feedback on videotaped interviews. Skills are rehearsed in a clinic setting with mentoring from trained radiographers. Evaluation Feasibility of training in the NHSBSP was tested with four radiographers working in the South East and South West London breast screening services. Competence and confidence to deliver the interview were assessed before and after training. Results All four radiographers completed the training programme. Three of the four radiographers were assessed as competent and all increased their confidence to deliver the intervention. Conclusion It is feasible to train diagnostic radiographers to reliably deliver an intervention to promote early presentation of breast cancer, and thereby potentially save lives.

HILINA: minimising the breast compression time at stereoguided biopsy

With mammography alone it is often difficult to distinguish between benign and malignant microcalcifications in the breast, and image-guided biopsy is widely undertaken for clarification. National Health Service Breast Screening Guidelines recommend that representative microcalcifications must be demonstrated in core specimens on specimen radiography: to achieve high absolute sensitivity for malignancy, at least five flecks of calcium in three cores are required [1]. An innovative device (HILINA), which was designed and developed locally, fits onto the tube housing of the Novation/Nova with Opdima digital stereo biopsy unit (Seimens Corporation, Camberley, UK), and allows direct digital capture of core biopsy images during breast compression. This shortens the breast compression time and allows rapid termination of the biopsy procedure. Analysis of the visibility of microcalcifications in core biopsy specimens from 20 consecutive patients has demonstrated that this is a satisfactory, cost-effective method of documenting adequate sampling when compared with cabinet computed radiography.

Implementing barcode film-reading in the National Health Service Breast Screening Programme: the good, the bad and the ugly

The National Breast Screening Computer System (NBSS) was redeveloped in 2003 and was rolled out to the programme during 2004. Following the national initiative to convert all breast screening programmes in England to use the NBSS system, barcode film-reading functionality and the NBSS daybook software were developed and piloted during 2005/06. Although this functionality has been available now for nearly 3 years, services have been slow to implement this change for a variety of reasons. Lack of funding for new hardware, inappropriate accommodation, lack of space and a general unwillingness to change have been sited as reasons for not implementing barcode film-reading and/or the NBSS daybook. The Coventry Breast Screening Training Centre has invested considerable time with many breast screening services, helping them implement this functionality. The Centre has helped services adapt their processes to this new way of working whilst maintaining the integrity of their Right Results procedure. It is hoped that this practical guide will persuade the remaining services to convert to this new functionality during 2008 and to help those already using this functionality to overcome any issues.

Managing interval cancers

The new National Health Service Breast Screening Programme Interval Cancer Operational Manual (2008) has recently been launched and is a practical guide for quality assurance reference centres, cancer registries and breast screening units to record and report interval cancers, with the aim of standardising practice across the United Kingdom. Coventry has always been at the forefront of this important work and, as part of the skill mix, the role of collecting and reporting data has been taken on by radiography film-readers. Coventry is the base for four different primary care trusts and the film-readers have links with multidisciplinary team meetings, breast care nurses, pathology and X-ray departments from all these areas, and are also involved with symptomatic mammography and local and regional interval cancer audits. The present poster demonstrates the pathway taken to collect and record information for audit and to forward it to the quality assurance reference centre for regional and national review.

Effectiveness of screening a small population

Guernsey provides healthcare for a population of 60,000. An on-island breast screening programme has existed since March 1995, with a 2-year screening round. Data have been analysed for six screening rounds to the end of March 2007, and have been evaluated against the National Health Service Breast Screening Programme (NHSBSP) Pritchard Standards. The small cohort size (<4,000 per annum) necessitates off-island screen reading by NHSBSP readers. Assessments are performed in Guernsey by a single breast radiologist. The majority of breast surgery is performed in Guernsey. Over the six screening rounds, a total of 39,166 screening mammograms have been performed, 2,542 assessment visits have been made, and 208 cancers have been identified (149 invasive, 59 ductal carcinoma in situ). Examples of standards evaluated for the six rounds: compliance, >90%; standardised detection rate, range 0.6 to 1.83; small cancer detection rates, 2.46/10,000 (average); interval cancers, 1.22 per 1,000 screened (average); 10-year survival from screen-detected cancers, 92%. These data show an effective screening programme assessed by Pritchard Standards, and demonstrate a model for the delivery of breast screening in a small isolated population.

Derby results and practical experience of breast imaging in women following supradiaphragmatic irradiation for Hodgkin's disease

The national recall programme for women who had supradiaphragmatic irradiation for Hodgkin's disease under the age of 30 years began in late 2003. In Derby, from an initial identified group of 56 women, 36 attended for a 1-hour consultation with a consultant oncologist. From these 36 women, 33 have attended for surveillance. In the group offered imaging surveillance, all 33 women took up the invitation. When magnetic resonance imaging (MRI) is indicated, it is done first; then the woman attends for mammography, MRI results and any focused ultrasound needed the following day. See Table ​Table11 for results. Five of the six MRI recalls were from a first screen, and the other from a second screen. One ductal carcinoma in situ was diagnosed in a lady with breast implants. Table 1 From the 56 eligible women, there were four with breast cancer: one woman diagnosed as above, two women from the National Health Service Breast Screening Programme and one woman symptomatically in 2007. The radiology and pathology of these cases will be presented. We commence family history screening with MRI soon and plan to apply this method, which works very well and within tight time limits.

Only skin deep: a pictorial review of skin and subcutaneous lesions

Many skin and subcutaneous lesions can be demonstrated on screening mammograms, and may mimic malignancy. Careful clinical history and meticulous annotation is paramount to avoid pitfalls in mammographic interpretation, inappropriate recall and further evaluation. The National Health Service Breast Screening Programme [1] states that radiographers should note on the screening sheet any significant or relevant symptoms reported by the women or observed during the examination. We shall illustrate 20 examples of radiographer-annotated lesions and correlate them with their corresponding mammograms and ultrasounds. Examples include sebaceous glands, seborrhoeic keratosis, skin tags, dimples from underlying malignancy, surgical scars, artefacts mimicking microcalcification, distended veins of Mondor's disease, central venous thrombosis, iliac vein thrombosis as well as peau d'orange. Correct annotation can help to avoid misdiagnosis, unnecessary recall, anxiety and further investigations. The importance of meticulous radiographer annotation is emphasized.

Promoting early presentation of breast cancer amongst older women: radiographers' experiences of taking on a new role

The London Psychosocial Group has been funded by Cancer Research UK to implement and evaluate a psychoeducational intervention to promote early presentation amongst older women with breast cancer. The intervention is designed to be radiographer-delivered to women receiving their final invited mammogram with the National Health Service Breast Screening Programme.

Improving Quality Outcomes in a Single-Payer System: Lessons Learned From the UK National Health Service Breast Screening Programme

The success of pay-for-performance initiatives in the United States as a function of improved quality of care is likely to be conditioned on the participation of all stakeholders. The ability of providers to develop quality improvement programs that receive sufficient resource support from the government represents a dynamic that has proved successful for the Breast Screening Programme, a part of the National Health Service, in the United Kingdom. A review of selected aspects of the program should serve as a template for consideration of how the deliberate coordination of clinical care can be improved under such circumstances.

Coverage in the National Health Service Breast Screening Programme, 1996-2005: correcting for the first invitation of women between 50 and 52 years

Coverage measures the ability of the National Health Service Breast Screening Programme (NHSBSP) to reach the eligible population and has a target of 70%. To estimate coverage accurately for women aged 50-64. Routine data from the KC63 return were used to calculate coverage for women aged 50-64 using an adjusted method that allows for the fact that women receive a first invitation to screening between 50 and 52.9 years. The adjusted average coverage between 1996 and 2005, for women aged 50-64 was 74.3% and the standard unadjusted average measure for the same period was 68.3%. Therefore, previous measures of coverage for this age group have underestimated coverage by approximately 9% and the adjusted figure is actually well above the target. In terms of coverage the programme has been performing better than previously reported. It is important to monitor the effect of an increasing workload on the programmes ability to re-invite women within three years of their last screen as maintaining coverage is an important factor in ensuring that the NHSBSP is effective in reducing mortality from breast cancer.