NHS Breast Cancer Screening Programme Research Articles

O075 Pausing NHSBSP during COVID-19 did not increase advanced cancers and may have avoided overdiagnosis

Abstract Introduction We ascertained the impact of the paused NHS breast cancer screening programme (NHSBSP) during COVID-19 on number and presentation of breast cancer patients. Methods We analysed, breast cancer patients diagnosed across 2 large London NHS trust hospitals in sets: the referral source and numbers in all patients from 2019 to 2021 (n=3,353), and patient/tumour characteristics and treatments received during 6 selected months in 2019 and 2020 (n=318). We analysed proportions using chi-square test. Results Overall, there were 31% fewer patients in 2020 compared with 2019 (1281 vs 886, p=0.002). However, there was no corresponding increase in the number of patients during 2021 (n=1186). The reduction was mainly due to fewer referrals from NHSBSP rather than from GPs (53% reduction vs 13%, p<0.00001). In 2020 vs 2019, there were fewer grade 1 (35 vs 9) and node negative tumours (143 vs 72), without a corresponding increase in grade 2 or 3 (159 vs 104), or node positive cases (54 vs 49); also fewer T1 cases (84 to 37) without a corresponding increase in >T1 cases (113 vs 84); reduced breast conservations (111 vs 71) and negative sentinel nodes (114 vs 69), without increase in mastectomies (35 vs 25) or axillary clearances (32 vs 27). There were no receptor status changes. Conclusion The COVID-19 pause in NHSBSP avoided diagnosis of good prognosis cancers without rapid increase in worse prognosis cancers or more extensive surgery, suggesting that it may have simply avoided overdiagnosis.

Correction to: An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme

The original version of this article, published on 04 February 2019, unfortunately contained a mistake.

An analysis of 11.3 million screening tests examining the association between needle biopsy rates and cancer detection rates in the English NHS Breast Cancer Screening Programme

To examine the association between recall, needle biopsy, and cancer detection rates to inform the setting of target ranges to optimise the benefit to harm ratio of breast screening programmes. Annual screening programme information from 2009/10 to 2015/16 for the 80 screening units of the English National Health Service Breast Screening Programme (totalling 11.3 million screening tests) was obtained from annual (KC62) returns. Linear regression models were used to examine the association between needle biopsy rates and recall rates and non-linear regression models to examine the association between cancer detection rates and needle biopsy rates. The models show and quantify the diminishing returns for prevalent screens with increasing biopsy rates. A biopsy rate increase from 10 to 20 per 1,000 increases the cancer detection rate by 2.13 per 1,000 with four extra biopsies per extra cancer detected. Increasing the biopsy rate from 40 to 50 per 1,000, increases the cancer detection rate by only 0.25 per 1,000, with 40 extra biopsies per extra cancer detected. Although diminishing returns are also seen at incident screens, screening is generally more efficient. Increasing needle biopsy rates leads to rapidly diminishing returns in cancer detection and a marked increase in non-malignant/benign needle biopsies. Much of the harms associated with screening in terms of false-positive recall rates and non-cancer biopsies occur at prevalent screens with much lower rates at incident screens. Needle biopsy rate targets should be considered together with recall rate targets to maximise benefit and minimise harm.

An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme.

To develop methods to model the relationship between cancer detection and recall rates to inform professional standards. Annual screening programme information for each of the 80 English NHSBSP units (totalling 11.3 million screening tests) for the seven screening years from 1 April 2009 to 31 March 2016 and some Dutch screening programme information were used to produce linear and non-linear models. The non-linear models estimated the modelled maximum values (MMV) for cancers detected at different grades and estimated how rapidly the MMV was reached (the modelled 'slope' (MS)). Main outcomes include the detection rate for combined invasive/micro-invasive and high-grade DCIS (IHG) detection rate and the low/intermediate grade DCIS (LIG) detection rate. At prevalent screens for IHG cancers, 99% of the MMV was reached at a recall rate of 7.0%. The LIG detection rate had no discernible plateau, increasing linearly at a rate of 0.12 per 1000 for every 1% increase in recall rate. At incident screens, 99% of the MMV for IHG cancer detection was 4.0%. LIG DCIS increased linearly at a rate of 0.18 per 1000 per 1% increase in recall rate. Our models demonstrate the diminishing returns associated with increasing recall rates. The screening programme in England could use the models to set recall rate ranges, and other countries could explore similar methodology. • Question: How can we determine optimum recall rates in breast cancer screening? • Findings: In this large observational study, we show that increases in recall rates above defined levels are almost exclusively associated with false positive recalls and a very small increase in low/intermediate grade DCIS. • Meaning: High recall rates are not associated with increases in detection of life-threatening cancers. The models developed in this paper can be used to help set recall rate ranges that maximise benefit and minimise harm.

Inequalities in health? An update on the effect of social deprivation for patients with breast cancer in South East Wales

BackgroundBreast cancer, historically a disease of more affluent women, has increased in incidence for women from areas of greater social deprivation, yet prognosis is worse for these women. This study identifies differences in presentation, treatment and prognostic factors between the socioeconomic groups. MethodsPatient data obtained from the prospectively maintained Welsh national Cancer Network Information System Cymru, for an 11-year period, were categorised according to Welsh Index of Multiple Deprivation quintiles. Quintiles were compared for differences in variables relating to patient characteristics, detection of cancer, tumour biology and treatment. Results1570 patients were included. Analysis showed that in the more socially deprived quintiles, there are proportionally fewer women being diagnosed through the NHS breast cancer screening programme and as a consequence greater numbers of women from poorer areas being diagnosed outwith the screening age parameters. Screen detection is strongly associated with better prognosis in terms of Nottingham Prognostic Index. Similarly, increasing levels of social deprivation are associated with higher incidence of oestrogen receptor negative and triple negative tumours, both features associated with a shorter disease free and overall survival. Other variables of tumour biology, rates and type of surgical and adjuvant treatment were similar across social deprivation quintiles. ConclusionThere is a trend of reduced early detection of breast cancer in South East Wales in those patients living in areas of higher social deprivation. Given that there is equity in access to treatment within NHS, which is free for patients at the point of care, further study is warranted to address this existing disparity. Population cancer surveillance will need to inform both public health and NHS service responses, to continue to achieve improvements. Health trends may yet alter depending on current and future shifts in governmental health policy.

320 (PB-115) - Breast cancer incidence as a function of the number of previous mammograms: Analysis of the NHS screening programme

The discrepancy between the protective effect of early surgery of breast cancer and the poor benefits of mammography screening programs in the long term can be explained if mammography induces breast cancer at a much higher rate than anticipated. Mammography screening is associated in most countries with a higher incidence of breast cancer, attributed to overdiagnosis. X-ray-induced cancers can be distinguished from overdiagnosed cancers by the fact that their incidence depends on the number of previous mammograms, whereas overdiagnosis solely depends on the last screening mammogram, leading to diagnosis. The unbiased relationship between the number of mammograms and breast cancer incidence was evaluated from the data of the NHS Breast Cancer screening programme in women aged from 50 to 64 years in the United Kingdom. The delay between mammography and increased breast cancer incidence was confirmed from the data of the Age trial, a randomized trial of annual screening starting at age 40 in the UK. In women aged 50-64 attending screening at the NHS Breast Cancer programme, in situ breast cancer incidence increased linearly from 1993 to 2005 as a function of the number of mammograms. Incidence did not increase anymore after 2005 when the number of mammograms and the delay after screening was stable. Invasive breast cancer incidence increased more specifically in the 60-69 age group. The risk of breast cancer almost doubled after 15 years of screening. Additional cancers began to occur less than 6 years after mammography. These results are evidence that X-ray-induced carcinogenesis, rather than overdiagnosis, is the cause of the increase in breast cancer incidence.

Exploring Factors Contributing to Low Uptake of the NHS Breast Cancer Screening Programme among Black African Women in the UK

Breast cancer is the most common cancer among women in the United Kingdom (UK) accounting for about 15% of cancer deaths. The National Breast Cancer Screening Programme in the UK was introduced in 1988 to assist with early detection and better management of breast cancer. Black and Minority Ethnic (BME) women however have a low uptake of the National Breast Screening programme when compared to their White counterparts. Within the BME group, Black African women have the lowest uptake of screening services and are more likely to have an advanced stage of the disease at diagnosis, leading to poorer survival rates than White women. This study aimed to explore the factors that lead to low uptake of the National Breast Cancer Screening Programme among Black African women living in Luton and present action points to local breast cancer services. Using a qualitative research design, six focus groups were conducted with a total of twenty-five Black African women residing in Luton between May and June in 2013. Data was analysed thematically using the framework approach. Four main themes emerged across the focus group discussions: knowledge and beliefs about breast cancer and risk factors, prevention of breast cancer and awareness of the NHS breast screening service, delays in attending the NHS breast screening service and suggestions for improving information on breast cancer and the NHS breast cancer screening service. The findings from this study suggest the need for more targeted information on breast cancer and screening services for Black African women. This could help improve the uptake of the NHS breast screening service, promote early help-seeking behaviour and improve breast cancer outcomes for this ethnic group.

Long-term survival of interval breast cancers in breast cancer screening in Wales

Breast Test Wales is part of the NHS Breast Cancer Screening Programme, and oversees the screening programme in Wales. It is successful in identifying asymptomatic cancers; however, interval cancers (IC) still occur between screenings. We aim to evaluate the overall long-term survival of IC and compare that with screen-detected cancers (SDC).

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Comparison of breast and bowel cancer screening uptake patterns in a common cohort of South Asian women in England

BackgroundInequalities in uptake of cancer screening by ethnic minority populations are well documented in a number of international studies. However, most studies to date have explored screening uptake for a single cancer only. This paper compares breast and bowel cancer screening uptake for a cohort of South Asian women invited to undertake both, and similarly investigates these women's breast cancer screening behaviour over a period of fifteen years.MethodsScreening data for rounds 1, 2 and 5 (1989-2004) of the NHS breast cancer screening programme and for round 1 of the NHS bowel screening pilot (2000-2002) were obtained for women aged 50-69 resident in the English bowel screening pilot site, Coventry and Warwickshire, who had been invited to undertake breast and bowel cancer screening in the period 2000-2002. Breast and bowel cancer screening uptake levels were calculated and compared using the chi-squared test.Results72,566 women were invited to breast and bowel cancer screening after exclusions. Of these, 3,539 were South Asian and 69,027 non-Asian; 18,730 had been invited to mammography over the previous fifteen years (rounds 1 to 5). South Asian women were significantly less likely to undertake both breast and bowel cancer screening; 29.9% (n = 1,057) compared to 59.4% (n = 40,969) for non-Asians (p < 0.001). Women in both groups who consistently chose to undertake breast cancer screening in rounds 1, 2 and 5 were more likely to complete round 1 bowel cancer screening. However, the likelihood of completion of bowel cancer screening was still significantly lower for South Asians; 49.5% vs. 82.3% for non-Asians, p < 0.001. South Asian women who undertook breast cancer screening in only one round were no more likely to complete bowel cancer screening than those who decided against breast cancer screening in all three rounds. In contrast, similar women in the non-Asian population had an increased likelihood of completing the new bowel cancer screening test. The likelihood of continued uptake of mammography after undertaking screening in round 1 differed between South Asian religio-linguistic groups. Noticeably, women in the Muslim population were less likely to continue to participate in mammography than those in other South Asian groups.ConclusionsCulturally appropriate targeted interventions are required to reduce observed disparities in cancer screening uptakes.

Who evaluates public health programmes? A review of the NHS Breast Screening Programme.

Breast screening with mammography was introduced in the UK in 1988, and the Annual Review 2008 from the NHS Breast Cancer Screening Programme (NHS BSP) summarizes the 20-year experience. Twenty years is a long time and it seems reasonable to ask what might be expected from such a review from a public health institution. First and foremost, one would expect to see an analysis that shows that screening has lowered breast cancer mortality in the UK. Secondly, one would wish to see a comparison of this benefit with a quantification of the most important harms, as this would allow the readers to judge for themselves whether the programme has been worth its large cost. If the screening programme had lived up to the expected mortality reduction that was the basis for its introduction, it should have been easy for the NHS Breast Cancer Screening Programme to demonstrate this for the politicians and other interested parties. This is not what the 26-page publication does, however. It celebrates 20 years of breast screening, as one of the headlines says. As with all good birthdays, it is the qualities of the celebrated that are mentioned, not the shortcomings. In line with the positive framing, the first sentence in the Review refers to the 20th anniversary as a ‘momentous occasion’. The Review exaggerates the benefit, omits the harms, and looks like propaganda aimed at persuasion. It comes wrapped in a beautiful layout that would pride any marketing department if it had been a sales brochure for a drug (Figure 1). The first words on the cover page are: ‘Saving lives through screening’, and the symbolism is strong. Most of the cover space is taken up by a picture of a delicate rose in the distinctive pink colour that has become iconic for the fight against breast cancer. The rose is transparent, symbolizing the scientific illumination and radiological technique through which the programme operates.

Breast and bowel cancer screening uptake patterns over 15 years for UK south Asian ethnic minority populations, corrected for differences in socio-demographic characteristics.

BackgroundA number of studies have reported low uptake of cancer screening programmes by South Asian populations in the UK. However, studies to date have not adjusted findings for differences in demographics and socio-economic status of these populations.MethodsSubjects: All residents in Coventry and Warwickshire, UK, eligible for screening. Uptakes compared for round 1 (2000–02) and round 2 (2003–05) of a national bowel cancer screening pilot, and for rounds 1, 2 and 5 of the established NHS breast cancer screening programme (commenced 1989).Data: Bowel screening data were analysed for 123,367 invitees in round 1 and 116,773 in round 2 (total 240,140 cases). Breast screening data were analysed for 61,934, 62,829 and 86,749 invitees in rounds 1, 2 and 5 respectively (total 211,512 cases).Analysis: Screening uptake was compared for two broad meta-categories (South Asian and non-Asian) and for five Asian subgroups (Hindu-Gujarati; Hindu-Other; Muslim; Sikh; South Asian Other). Univariate and multivariate analyses examined screening uptake and various demographic attributes of invitees, including age, gender, deprivation and ethnic group.ResultsSouth Asians demonstrated significantly lower (p < 0.001) unadjusted bowel screening uptake; 32.8% vs. 61.3% for non-Asians (round 1). Rates were particularly low for the Muslim subgroup: 26.1% (round 1), 21.5% (round 2). For breast screening, a smaller difference was observed between South Asians and non-Asians; initially 60.8% vs. 75.4% (round 1) and later 66.8% vs. 77.7% (round 5). Thus, the disparity reduced gradually over time, alongside an overall trend of increased uptake. However, figures remained consistently low for Muslims (51% in rounds 1 and 5). After adjusting for age, deprivation (and gender), bowel screening uptake remained significantly lower for all South Asian subgroups. After similar adjustments, breast screening uptake remained lower for all subgroups except Hindu-Gujaratis.For Muslims registered with an Asian (vs. non-Asian) GP, bowel screening uptake was significantly lower (p < 0.001). However, breast screening uptake for Muslims with an Asian (vs. non-Asian) GP showed no difference (p = 0.12) in the same period.Colonoscopy and breast assessment uptakes were similar for both meta-categories, but Asian response time appeared slower for colonoscopy. The percentage of abnormal FOBT results was significantly higher for South Asian invitees. A slight increase in abnormal mammograms was observed for Muslims over time (2.7% to 4.2% in rounds 1 and 5 respectively).ConclusionThe lower cancer screening uptakes observed for the South Asian population cannot be attributed to socio-economic, age or gender population differences. Although breast screening disparities have reduced over time, significant differences remain. We conclude that both programmes need to implement and assess interventions to reduce such differences.

Health promotion at NHS breast cancer screening clinics in the UK

Suboptimal diets, sedentary lifestyles, overweight and obesity expose two-thirds of women in England aged over 50 to a heightened risk of lifestyle-related morbidities. The UK's NHS Breast Cancer Screening Programme now reaches 75% of all women aged 53-64 but provides only mammography screening. This cross-sectional survey of 413 women attending two NHS breast screening clinics in North Yorkshire found that the majority of women were interested in having diet and exercise advice at screening clinics and anticipated a neutral or positive effect on their future screening appointments. Interest was highest among older, less educated and overweight women suggesting that this may be a particularly effective medium for reaching higher risk subgroups. Women showed most interest in problem-solving advice, which provided short-term, life-enhancing benefits such as looking and feeling better, having more energy, losing weight and reducing menopausal symptoms, as well as potentially reducing their disease risk. Most appeared to find doing sufficient exercise more problematic than eating healthily and this might be exacerbated by low awareness of exercise guidelines. Given a choice, preferences were to access advice in leaflets or one to one from an expert; however, many younger, professional women were also interested in computer access. Findings indicate the need first for flexible, multi-level access, combining some broad-based information dissemination with pathways to more personalized support and secondly for the relevant 'consumer benefits' associated with better diet and exercise to be promoted as well as longer-term disease prevention. Overall, this study indicates that the UK's NHS Breast Cancer Screening Programme may be uniquely placed to provide health-enhancing advice as well as mammography screening to the majority of women in England, throughout the course of their mid-life.

Review shows breast screening is effective

A review of the NHS Breast Cancer Screening Programme finds that the benefits outweigh the risks of breast screening. Professor Valerie Beral explains.

All radial scars/complex sclerosing lesions seen on breast screening mammograms should be excised

Aim To determine the incidence of pre-malignant and malignant conditions in radial scars identified from screening mammograms in women taking part in the UK NHS breast cancer screening programme. Methods All women in our screening population from 1988 to 2002 with a radiological diagnosis of radial scar or complex sclerosing lesion confirmed on subsequent histopathology were included in this study. Patients were investigated with fine needle aspiration cytology then localisation biopsy ( n=46) or straight to localisation biopsy ( n=78). Patients where divided into two groups, one with pure RS/CSL with no associated epithelial features and the second with associated ADH, DCIS or invasive cancer. Results One hundred and twenty-four lesions were confirmed histologically as radial scar or complex sclerosing lesions. The median age was 58 years. Of the 124 patients, 82 were pure RS/CSL. Forty-two had associated epithelial lesions, 22 patients had ADH and 20 patients had either in situ or invasive carcinoma. Where FNA was performed ( n=46), mammograms had shown three lesions suspicious of cancer, which were not proven histologically. Mammograms picked up five malignancies out of the nine RS/CSL with associated cancers. Of these, FNA confirmed malignancy in only two patients. Where FNA was not done ( n=78), mammogram had read five pure RS/CSL as cancers. It picked up only four cancers in RS lesions with DCIS/Ca out of 11. Conclusion All screen-detected stellate lesions should be excised due to their association with pre-malignant and malignant conditions.