UK National Breast Screening Programme Research Articles

The co-development of personalised 10-year breast cancer risk communications: a ‘think-aloud’ study

BackgroundRisk stratified breast cancer screening is being considered as a means of improving the balance of benefits and harms of mammography. Stratified screening requires the communication of risk estimates. We aimed to co-develop personalised 10-year breast cancer risk communications for women attending routine mammography.MethodsWe conducted think-aloud interviews on prototype breast cancer risk letters and accompanying information leaflets with women receiving breast screening through the UK National Breast Screening Programme. Risk information was redesigned following feedback from 55 women in three iterations. A deductive thematic analysis of participants’ speech is presented.ResultsOverall, participants appreciated receiving their breast cancer risk. Their comments focused on positive framing and presentation of the risk estimate, a desire for detail on the contribution of individual risk factors to overall risk and effective risk management strategies, and clearly signposted support pathways.ConclusionProvision of breast cancer risk information should strive to be personal, understandable and meaningful. Risk information should be continually refined to reflect developments in risk management. Receipt of risk via letter is welcomed but concerns remain around the acceptability of informing women at higher risk in this way, highlighting a need for co-development of risk dissemination and support pathways.

Insights from outside BJOG

Insights from outside BJOG

Using Record Linkage to Examine the Impact of Poor Mental Health on Breast Screening Uptake

BackgroundThe UK National Breast Screening Programme is estimated to reduce breast cancer mortality by 20%. To maximise the benefits of the programme, we first need to understand the underlying factors contributing to variations in screening uptake. One potentially significant factor which may contribute to these gradients in screening uptake is poor mental health.
 ObjectivesThe objectives of this study were to examine the impact of poor mental health on breast screening uptake, and whether this explained any of the previously observed socio-demographic gradients in screening uptake.
 MethodsBreast screening records were obtained from the National Breast Screening System (NBSS) and were subsequently linked to 2011 Census data within the Northern Ireland Longitudinal Study (NILS). The NILS encompasses 28\% of Census data. This was then linked to psychotropic prescribing information from the Enhanced Prescribing Database (EPD), to produce a de-identified research dataset containing 57,328 women.
 FindingsWomen with self-reported poor mental health were over 20% less likely to attend screening compared to their counterparts who didn't have poor mental health. Using psychotropic prescribing information as a proxy for the presence of mental illness yielded similar results, with those taking anxiolytics, antipsychotics or hypnotics in the three months before screening invitation significantly less likely to attend than those who were not.
 ConclusionWomen with poor mental health were significantly less likely to attend breast screening. However, poor mental health did not explain any of the previously determined socio-demographic gradients in screening uptake.

Abstract P4-01-07: Recall for assessment after post-treatment surveillance mammograms in breast cancer

Abstract Background: Patients treated for breast carcinoma are usually followed up with regular mammograms. The aims are early diagnosis of locally recurrent disease in the ipsilateral breast or new cancers in the contralateral breast, and to provide reassurance. When the mammograms are considered abnormal patients are recalled for further assessment. The aim of this study is to review all mammographic recalls in a single institution over a 5-year period to study the patient population recalled, reasons for the recall and the outcome. Materials and Methods: We identified all breast cancer patients who were recalled for assessment following a routine post-treatment surveillance mammogram from April 2010 to March 2015 from the breast unit database. We reviewed their original presentation with breast cancer, treatment received, reason for recall, the assessment process and the outcome. The mammographic follow-up policy of the unit during the study period was as follows; after breast conserving surgery (BCS), yearly bilateral mammograms for 5 years or until the age of 50 whichever the later; following mastectomy, mammogram of the opposite breast at years 1, 3 and 5 post-surgery, and if the patient is aged under 50 after 5 years, 2-yearly till 50 years of age. Patients were then discharged to UK National Breast Screening Programme where mammograms are performed 3-yearly. Results: During the study period 1809 patients had 3685 surveillance mammograms. 149 patients were recalled (a recall rate of 8% of patients and 4% of mammograms over 5-years). 122 patients had BCS and 27 patients had mastectomy. The original diagnosis was invasive cancer in 131 and DCIS in 18. The reason for recall was a density or mass in 63, microcalcification in 61, distortion in 14 and a mixture of these or other reasons in 11. Eighty one patients were recalled for a problem on the ipsilateral side and 66 for contralateral side (2 patients had bilateral cancer). Among 149 patients recalled, 50 had further imaging only (further mammographic views, ultrasound or both) after the recall and 79 underwent a needle biopsy under ultrasound or stereo guidance. 8 patients underwent US-guided aspiration of benign cysts. 21 biopsy results were malignant. The final diagnosis was ipsilateral recurrence in 10 patients and contralateral cancer in 11. Conclusions: There is not much published data in the literature on the outcome of post-treatment surveillance mammograms despite the fact that such mammographic surveillance is commonly practiced. This study shows that over a 5-year period, 8% of the patients and 4% of the mammograms were recalled. A third of patients recalled only required further imaging. Although biopsies were performed in over half the patients, only 14% of patients recalled were proved to have ipsilateral or contralateral carcinoma after the assessment. Citation Format: Wassermann M, Swinson C, Shrestha D, Kirkpatrick K, Ravichandran D. Recall for assessment after post-treatment surveillance mammograms in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-07.

A method for calculating effective lifetime risk of radiation-induced cancer from screening mammography

PurposeTo propose a method for evaluating the effective lifetime risk of radiation-induced cancer from screening mammography and to present initial data for the UK National Breast Screening Programme. Material and methodsThe imaging was undertaken using a Hologic Selenia full field digital mammographic unit. The proposed method utilises an ATOM phantom containing thermoluminescent dosimeters and a perspex-polyethylene breast phantom to measure organ doses during a standard four view screening mammogram. Effective dose was calculated and effective risk was modelled for a range of client ages. The total lifetime effective risk was then calculated for the UK national screening programme. Calculation of effective risk includes the radiation dose to examined and contralateral breasts in addition to other body organs; this is an advantage over the mean glandular dose. ResultsThe contralateral breast, thyroid, thymus, brain, lung, salivary glands, and bone marrow all receive more than 1 μGy radiation dose during screening mammography. A major difference exists for total effective lifetime risk of radiation-induced cancer between clients with average and high breast cancer risk. Differences are attributed to the commencement age of screening and time interval between screens. ConclusionThis study proposes a method to evaluate effective lifetime risk of radiation-induced cancer from screening mammography in order to compare different mammography screening programmes.

Estimation of mean glandular dose for contrast enhanced digital mammography: factors for use with the UK, European and IAEA breast dosimetry protocols

The UK, European and IAEA protocols for breast dosimetry in mammography use tabulations of conversion factors, which relate measurements of incident air kerma to the mean glandular dose to the breast. To supplement the existing tabulations, a Monte Carlo computer program has been used to calculate conversion factors for the high-energy spectra used for contrast enhanced digital mammography. The calculations were made for the x-ray spectra from a tungsten target (tube voltage range 40–50 kV) filtered by 0.28, 0.30 and 0.32 mm of copper, and from molybdenum and rhodium targets (tube voltage range 40–49 kV), each filtered by 0.30 mm of copper. The g-factors for all of these spectra were plotted for each breast thickness as a function of half value layer (HVL) and were found to lie on smooth curves within 0.3%. These reflect the fact that the characteristic x-rays present in the spectra from molybdenum and rhodium are heavily filtered and all the spectra are essentially Bremsstrahlung. As a consequence, the s-factor previously used in the dosimetry protocols to adjust for different target/filter combinations can be taken as unity for all of the spectra considered. Tables of g-factors and c-factors are provided for breast thicknesses in the range 20–110 mm and HVLs in the range 2.4–3.6 mm of aluminium. The tables of c-factors are given for breast glandularities in the range 0.1%–100% and for typical glandularities for women in the age bands 40–49 and 50–64 attending the UK national breast screening programme.

Modelling the likely effect of the increase of the upper age limit from 70 to 73 for breast screening in the UK National Programme

The UK National Breast Screening Programme is planned to have the age range for invitation to screening expanded from 50-70 to 47-73. At the upper limit, this represents one additional screen taking place in the early 70s. We aimed to estimate the likely effect of this on breast cancer mortality and on overdiagnosis of breast cancer. We used estimates of breast cancer incidence and survival by detection mode (screening or symptomatic), screening lead time and mortality from competing causes to estimate the likely numbers of breast cancer deaths prevented per 1000 women screened, using both a stochastic continuous time model and a semi-deterministic discrete time model. In the continuous model, we estimated that per 1000 women screened 1.2 deaths would be prevented and in the discrete model 0.91 deaths. In the latter model, we also estimated that there would be around 6.8 years of life saved per 1000 women screened and an additional two diagnoses of breast cancer. These results suggest that the expansion of the upper age limit will be cost-effective. They remain to be confirmed by evaluation of the age extension. They provide prior estimates that may inform the evaluation of the age extension.

Integration of the independent sector and the National Health Service in breast radiology: a working example

The UK National Breast Screening Programme in Exeter has been exclusively run by the National Health Service (NHS) since it started in the early 1990s. The current medical climate is rapidly undergoing change, with increasing utilisation of outsourcing to independent providers. Certain domains, such as orthopaedics, have a high usage of independent providers; however in other domains, including breast radiology, the use is sparse. Since 2005 the breast screening unit in Exeter has been privatised to Lister-in-Health on a separate site, whilst the symptomatic and surgical service has remained at the local hospital under the NHS. We would like to discuss how there is continuity in the care pathway for the screening patient, detailing how Lister Healthcare interacts with the local hospital breast service; how patient assessments and access to breast care nurses is carried out, and the point at which a patient leaves the screening service to enter the NHS treatment pathway. We also discuss the logistics of communication between the screening radiologists and surgeons, including discussion of histological findings, follow-up of nonsurgical lesions, assessment of B3 lesions, multidisciplinary teams and meetings.

An audit of assessment procedures in women who develop breast cancer after a negative result

A case audit was undertaken to determine the extent to which the early diagnosis of cancer could be improved by better adherence to screening guidelines, and to estimate the effect that this might have on breast cancer survival. Although affecting only a small proportion of the cancers of the screening programme, this exercise had an educational function for screening radiologists. The East Anglian breast screening programme, a group of seven centres offering screening to a total population of 2.2 million inhabitants. Women were screened every three years between the ages of 50 and 64. Adherence to the guidelines of the UK National Breast Screening Programme (as published in 2001) was tested in women assessed between the start of screening on 1 April 1989 and 31 December 1999, in cases where the screen was negative but who were subsequently diagnosed with breast cancer. In this period the programme screened 503,493 women, recalled 25,346 and diagnosed 3689 with cancer. 194 cancers in 193 women were reviewed, comprising those cancers that arose at the site of the lesion previously assessed. 96 women (49.5%) had calcifications, 48 (24.7%) had opacities. 139 of 194 cases were judged to have been inadequately assessed. A recurring theme showed that biopsies not undertaken or with false negative findings led to failure to diagnose lesions which were subsequently shown to be cancer. Microcalcifications and opacities were more likely to have been inadequately assessed than spiculate masses, parenchymal deformities, or asymmetric densities. In the earliest time period (1989-1993), there were a larger proportion of inadequately assessed cases than in the period 1994-1999. Scrupulous adherence to good guidelines will result in a greater proportion of cancers being diagnosed. Failure to perform effective percutaneous biopsy was the usual cause of missed diagnoses. Although an infrequent occurrence this may have an effect on subsequent survival from breast cancer.

The frequency of breast cancer screening: results from the UKCCCR Randomised Trial

The optimal frequency of breast cancer screening has been a subject of debate since the inception of the UK National Breast Screening Programme (NHSBSP). This paper reports on the only randomised trial directly comparing different screening intervals. 99 389 women aged 50–62 years who had been invited to a prevalent screen were randomly allocated after the scheduled prevalent screen date to the study arm (invited to three further annual screens), or to the control arm (invited to the standard single screen 3 years later). 37 530 women in the study arm and 38 492 in the control arm had attended the prevalent screen. The endpoint was predicted breast cancer deaths. The prediction was based on both the Nottingham Prognostic Index (NPI) and a similar method derived from survival data from a series of tumours in the Swedish Two-County screening trial (2CS). Both indices were based on the size, lymph node status and histological grade of the invasive tumours diagnosed in the two arms of the trial. The pathology of the cases diagnosed was subject to review by two pathologists using standard criteria. The tumours diagnosed in the study arm were significantly smaller than those diagnosed in the control arm ( P=0.05). The relative risk of death from breast cancer for the annual compared with the 3-yearly group was 0.95 (95% Confidence Interval (CI): 0.83–1.07, P=0.4) using the NPI and 0.89 (95% CI: 0.77–1.03, P=0.09) using the 2CS. Shortening of the screening interval in this age group is predicted to have a relatively small effect on breast cancer mortality. Improvements to the screening programme would be targeted more productively on areas other than the screening interval, such as improving the screening quality.

The National Health Service Breast Screening Programme in the Trent region—are we meeting the targets?

Aims In the UK National Breast Screening Programme, women aged 50–64 years are invited for breast screening mammography. This study aimed to determine whether current quality assurance guidelines for the Breast Screening Programme were being achieved. Method A prospective analysis of key outcome measures was performed in the 11 breast screening units in the Trent region, between 1 January 1995 and 31 December 1995. Results All 11 units exceeded the 70% target for screening attendance. Ten units matched the invasive cancer detection target for the prevalent screen, but this fell to three for the incident screen. Seven units achieved the 50% target for small invasive cancers, but for special type and well-differentiated cancers only three units matched the target of 30% and there was wide variation between units. Pre-operative diagnosis rates were short of targets in most units. Only one unit achieved outcome measures for clear histological margins in patients completing operations for breast-conserving surgery. No unit provided histological node status on all its patients undergoing surgery for operable breast cancer, or met the target for benign biopsy weights. Conclusion Although results as a whole are good, changes can be made to improve performance and reduce the variation between units. Particular attention should focus on those areas which can be influenced directly by surgeons. In the UK National Breast Screening Programme, women aged 50–64 years are invited for breast screening mammography. This study aimed to determine whether current quality assurance guidelines for the Breast Screening Programme were being achieved. A prospective analysis of key outcome measures was performed in the 11 breast screening units in the Trent region, between 1 January 1995 and 31 December 1995. All 11 units exceeded the 70% target for screening attendance. Ten units matched the invasive cancer detection target for the prevalent screen, but this fell to three for the incident screen. Seven units achieved the 50% target for small invasive cancers, but for special type and well-differentiated cancers only three units matched the target of 30% and there was wide variation between units. Pre-operative diagnosis rates were short of targets in most units. Only one unit achieved outcome measures for clear histological margins in patients completing operations for breast-conserving surgery. No unit provided histological node status on all its patients undergoing surgery for operable breast cancer, or met the target for benign biopsy weights. Although results as a whole are good, changes can be made to improve performance and reduce the variation between units. Particular attention should focus on those areas which can be influenced directly by surgeons.

Second round cancers: How many were visible on the first round of the UK national breast screening programme, three years earlier?

The first round screening films of 100 women who had cancers detected in the second round of the NHS Breast Screening Programme, were reviewed blindly, and then retrospectively, with knowledge of the site of the subsequent cancer. On initial blind viewing of the first screening mammograms, a lesion, later histologically proven to be the cancer, was correctly identified in 25 false-negative lesions. However, 51 false positive lesions which did not develop into cancer were also identified. Review with knowledge of the site of the lesions at second round screening identified an additional 19 false negative lesions. The mammographic features of the 25 false negative lesions initially identified on blind review were ill-defined masses (52%), architectural distortion (20%), asymmetrical densities (16%), enlarged lymph nodes (8%) and a well defined lesion (4%). Sixteen of these lesions were classified as minimal change, suspicious change in four, clearly malignant in three and benign in two. Forty-eight percent of the false negative lesions occurred in the established review areas of the breast. On retrospective review, 25% of incident round screen detected breast cancers were potentially detectable on the previous screening mammograms and the majority of these lesions were ill-defined masses that were more likely to occur in the 'review areas' of the breast. However, only 7% demonstrated mammographic features that were clearly recognized as suspicious of malignancy. We therefore recommend that radiologists involved in screen reading should pay particular attention to abnormalities occurring in the so-called review areas.

Predicting reattendance in the second round of the UK National Breast Screening Programme: a prospective 3-year longitudinal analysis

In a prospective questionnaire study published in 1993, we examined the predictors of attendance for X-ray mammography in the first round of the UK National Breast Screening Programme. The present paper follows up the same women 3 years later to find out how many reattended in the second round and which of our original measures would predict reattendance. Attendance in the second round was slightly higher than in the first (82% against 79%), and 93% of first round attenders reattended. Reattendance was predicted by initial demographic characteristics, health behaviours and attitudes, but not by responses to the original screen. The main reasons for non-attendance were practical difficulties, experiences of previous screens, and misgivings about screening. We conclude that first time attendance is predicted by social and psychological characteristics — what women bring to screening — and reattendance is a matter of routine. If those who are unsure can be persuaded to attend once, they are likely to attend again.

The national breast screening service: is it economically efficient?

Currently the UK national breast screening programme only offers routine screening to women aged between 50 and 64. Whilst there are good clinical and economic reasons for not screening younger women, there is no compelling argument for not extending routine screening to older women. In this paper, we show that by diverting screening resources to older women, where cancer is more prevalent, more lives and life-years can be saved for no extra cost. Therefore, the current breast screening programme may be inefficient, and offering screening to older women should be given serious consideration.

Comparison of single reading with double reading of mammograms, and change in effectiveness with experience.

In the prevalence round of screening for breast cancer at a single centre, the benefit of the second radiological report has been assessed using data from 33,734 women, their screening results and knowledge of the interval cancers. The service was set up under the UK National Breast Screening Programme, and the data show evidence of learning by both individuals and the team as a whole. Of the 269 cancers detected by screening, 33 would not have been diagnosed if the only report available had been the first. The recall recommendation rate associated with the first report was 6.9% and 236 cancers were detected. The recall recommendation rate associated with all queries of all the reports was 10% (3354 queries). Had these 3354 queries all been investigated (instead of the 1423 actually recalled) only a further three cancers would have been detected. Sensitivity of the programme as a whole was substantially better than that of individual radiologists, while the specificity was maintained. The decision pathway by which recalls were agreed between the two radiologists resulted in a low recall rate (4.2%) for the programme as a whole, and is a critical factor in gaining the benefit of the improved sensitivity without a concomitant deterioration in the specificity. With the passage through the prevalent round, recall rates steadily fell, the malignant to benign biopsy ratio improved and sensitivity increased. The second radiological report yielded 14% additional cancers diagnosed and contributed very significantly to good sensitivity and so to the effectiveness of screening. Economic analysis of the results will be reported in a further paper.

How distressing is attendance for routine breast screening?

AbstractA prospective cohort study of 2357 women eligible for participation in the UK National Breast Screening Programme was carried out to evaluate the immediate emotional and behavioural effects of attending for routine mammography. Women completed the Hospital Anxiety and Depression Scale (HADS) in the context of a survey by their General Practitioner before they knew they were to receive an invitation to attend screening and again at screening some 6 weeks later. In addition, an ad hoc Health Questionnaire was administered when the women attended for screening to assess possible self‐perceived stress‐related behaviour changes in the previous week.2110 (89.5% response rate) women returned the initial postal baseline HADS and 1635 completed the HADS again at screening. Anxiety and depression scales were significantly lower at screening than at baseline (t = 3.16, p < 0.002, 95% CI = 0.07 to 0.31) and (t = 8.46, p < 0.0001, 95% CI = 0.32 to 0.52) respectively. Women scoring in the borderline range at baseline were more likely to move into the normal than the clinically significant range for anxiety (χ2 = 40.36, p < 0.001) and also for depression (χ2 = 56.04, p < 0.001), and women scoring in the clinically significant range for anxiety were more likely to become normal than vice versa (χ2 = 5.95, p < 0.02). The Health Questionnaire indicated that some women reported stress‐related behaviour changes in the week prior to screening, especially those who were most anxious or depressed.

Mammographic film density and detection of small breast cancers

From its inception, the UK National Breast Screening Programme (NHSBSP) has recognized that optimum image quality of the mammographic screening test is a key objective. The overall optical density of the mammography film is one of the factors expected to have a significant effect on the image quality of the mammogram with the potential to influence cancer detection. In a previous review of the performance of mammography equipment in the NHSBSP, it was observed that there was a very wide range in the mammographic film densities used at different breast screening centres. In this study a mammography test object was used to show experimentally that, for a typical mammography system, image quality increased substantially with increased film density. Summary data was therefore requested from radiologists in the NHSBSP on the rate of detection of small invasive cancers (diam. < or = 10 mm) and the typical film density used during that year. Proforma were completed for 61 annual sets of results from 31 screening centres involving over 500,000 women. Where centres reported using film densities of less than 1.2D the average small cancer detection rate was 0.12% +/- 0.01%, as compared to an average of 0.17% +/- 0.01% for centres using higher film densities. The results indicate that there is a need for national guidelines in the setting of film densities, and a range for target film densities of 1.4D to 1.8D has been suggested. Attention to optimizing image quality by increasing film density is of particular importance to any screening centre where film densities of less than 1.2D are used, as there may be the potential to increase the detection of small breast cancers by as much as 50%.

Mammary hamartoma--a review of 35 cases.

Mammary hamartomas are macroscopically well-delineated tumours composed of a variable mixture of epithelial elements, fat and fibrous tissue. Such lesions are an under-recognized entity and, as they can be visualized by mammography, may be seen more frequently with the advent of the UK National Breast Screening Programme. The clinical and pathological features of 35 cases of mammary hamartoma seen at the Imperial Cancer Research Fund Clinical Oncology Unit at Guy's Hospital between 1979 and 1990 have been reviewed. Hormone receptor analysis on nine cases gave high progesterone with low oestrogen levels, probably reflecting their premenopausal status. Immunohistochemistry showed that the positive receptor staining was confined to the epithelial elements. In 25 cases pseudo-angiomatous hyperplasia was evident in the stroma of the lesion. The importance of distinguishing the inter-anastomosing stromal spaces seen in the latter condition from low-grade angiosarcoma is emphasized; the relationship between pseudo-angiomatous hyperplasia and mammary hamartoma is discussed; and the possibility that the former represents a permanently dilated form of the lymphatic labyrinth suggested.

The benefits and ethics of screening for breast cancer

Background Breast cancer is probably the disease feared most by women in the UK. Not only is the disease itself seen as fatal, but its treatment also poses tremendous psychological threats. The incidence of breast cancer has been steadily rising in the UK. In 1960, 20,000 women in England and Wales had a new diagnosis of breast cancer, at a rate of 60 per 100,000. By 1984 that number had risen to 24,000) Over the same period deaths from this disease have risen comparably from 12,000 to 15,000 per year. Indeed breast cancer mortality is one of the few things in which we lead the world. The UK rate is five times higher than that experienced by Japan, and almost twice as high as that experienced by most other countries of Western Europe} Whilst highlighting the seriousness of the disease in Britain these wide variations in mortality suggest that the disease is amenable to control if only we could understand the underlying basis of these differences. Sadly, despite much effort on epidemiological studies, we still know little of the cause of breast cancer or how to prevent it. Comparison of five-year survival rates in breast cancer show a relatively optimistic improvement. Of those diagnosed in 1960 60% were alive five years later, a figure that increased to 70% for those diagnosed in 1980. However, five-year survival rates are influenced by the point in time at which the disease is diagnosed. Simply diagnosing the tumour at an earlier time in its developmental course logically tends to longer survival following diagnosis (the 'lead time' effect). Therefore earlier diagnosis per se automatically produces better five-year survival rates. It is uncertain to what extent this earlier diagnosis is responsible for the increase in survival rates. Comparison with the overall mortality rate would suggest that much of the improvement in survival rates may be accounted for by lead-time. It remains true that around two-thirds of women who develop breast cancer will eventually die from the condition. Breast cancer therefore remains a substantial public health concern and the UK national breast screening programme can be seen within the political imperative of doing something about that concern, and being seen to be doing something.

Establishing and Managing Breast Screening Services

The UK National Breast Screening Programme provides a challenge to management in terms of the substantial effort its establishment will require. There are problems of manpower resources and availability of training. If the objective of reducing mortality from the disease is to be achieved, process objectives will have to be met by managers whose role will be to marshal the resources, match these to the population to be served, motivate both providers and recipients of the service, maintain standards and monitor both process and outcome.