UK National Health Service Breast Research Articles

An evaluation of the current role of radiographer film readers in breast screening

Literature suggests that both the government and professional bodies are supportive of role development and changing of professional boundaries, but is this representative of current clinical practice? All 97 mainland UK National Health Service Breast Screening Programme (NHSBSP) centres were surveyed. Postal questionnaires were sent to both radiographer film readers and departmental superintendent radiographers centring on practical, clinical and managerial issues concerning the current practice and implementation of extended roles. An overall response rate of 79% was achieved. Of radiographers working in breast screening, 10% are trained in image interpretation and reporting in mammography. Only 43% of these read annually a minimum of 5,000 mammograms – the quality guidelines for radiologists. Many barriers inhibiting the utilisation of radiographer film readers were identified: 1. Resource constraints, both human and financial 2. Time constraints 3. Quality assurance issues 4. National structure. This study demonstrated under-utilisation of radiographer film readers in the UK NHSBSP, raising the issue of 'Is training radiographers to film read an efficient and effective use of scarce health care resources?' Further research into this contentious issue is necessary to fully evaluate and ensure effective use of clinical skills; better service to the patient; and efficient use of health care resources is undertaken.

A study of breast cancers detected in the incident round of the UK NHS Breast Screening Programme: the importance of early detection and treatment of ductal carcinoma in situ

One hundred and seventy eight cancers detected on incident round screening in the UK National Health Service Breast Screening Programme were reviewed. Critical review of the immediately preceding screening films (from 3 years previously) found abnormalities at the site of the subsequently detected cancer in 93 cases (52%). Forty-eight of these (27% of the total) had microcalcification as the sole abnormality. All of these 48 women had invasive ductal carcinoma and/or ductal carcinoma in situ (DCIS) (including four cases in which DCIS was associated with another type of primary invasive breast cancer). The finding of microcalcification on the previous mammograms at the site of a subsequently detected cancer was a strong predictor for the presence of DCIS (with or without associated invasive disease) (P<0.0001). Of the women with invasive ductal carcinoma, those with microcalcification on previous films were significantly more likely to have intermediate or high grade (grade 2 or 3) tumours than those women without microcalcification on previous films (P=0.0015).Previous films were also read blind by two independent experienced breast radiologists. Cancers were correctly identified by one or both readers in 39 cases. However, 35 of the remaining 139 cases showed microcalcification which was not detected or considered significant by the readers. If only these 139 ‘true negative’ screens are analysed, similar associations are seen between microcalcification on previous films and subsequent finding of DCIS (P=0.03) and between microcalcification on previous films and high grade invasive ductal carcinomas (P=0.015).These findings provide support for the hypothesis that microcalcification seen on previous screening films at the site of a subsequently detected invasive ductal carcinoma represents ductal carcinoma in situ. In this series, 19 of 82 women (23%) with invasive ductal carcinoma in the ‘true negative’ screen group had microcalcification suggestive of DCIS on mammograms taken, on average, 3 years previously. Significant microcalcification is often overlooked using current detection criteria. Early detection and treatment of DCIS is essential in order to prevent the development of aggressive invasive disease. Revision of the NHSBSP targets for DCIS detection is recommended.

Dosimetric implications of age related glandular changes in screening mammography

The UK National Health Service Breast Screening Programme is currently organized to routinely screen women between the ages of 50 and 64, with screening for older women available on request. The lower end of this age range closely matches the median age for the menopause (51 years), during which significant changes in the composition of the breast are known to occur. In order to quantify the dosimetric effect of these changes, radiographic factors and compressed breast thickness data for a cohort of 1258 women aged between 35 and 79 undergoing breast screening mammography have been used to derive estimates of breast glandularity and mean glandular dose (MGD), and examine their variation with age. The variation of mean radiographic exposure factors with age is also investigated. The presence of a significant number of age trial women within the cohort allowed an extended age range to be studied. Estimates of MGD including corrections for breast glandularity based on compressed breast thickness only, compressed breast thickness and age and for each individual woman are compared with the MGD based on the conventional assumption of a 50:50 adipose/glandular composition. It has been found that the use of the conventional 50:50 assumption leads to overestimates of MGD of up to 13% over the age range considered. By using compressed breast thickness to estimate breast glandularity, this error range can be reduced to 8%, whilst age and compressed breast thickness based glandularity estimates result in an error range of 1%.

Breast cancer screening sensitivity in the NHSBSP: recent results and implications

This paper reviews the lessons learnt from the UK National Health Service Breast Screening programme.

The Million Women Study: design and characteristics of the study population. The Million Women Study Collaborative Group.

To describe the design of the Million Women Study and the characteristics of the study population. Population-based cohort study of women aged 50-64 in the UK. Women are asked to join the Million Women Study when they are invited to routine screening for breast cancer at 61 of the screening centres of the UK National Health Service Breast Screening Programme (NHSBSP). An estimated 71% of women screened by the NHSBSP return a completed questionnaire. 800 000 women were recruited between May 1996 and June 1999, and it is planned that an additional 200 000 will be recruited by the year 2000. The characteristics of the first 121 000 women recruited into the Million Women Study are described here. At recruitment 33% of the study population were currently using hormone replacement therapy and 47% had used it at some time. Over half (54%) had used oral contraceptives, and 18% were current smokers at the time of recruitment. Before they were screened 1.4% of the women had been diagnosed with breast cancer in the past, 6% had a mother with a history of breast cancer and 3.7% had a sister with a history of breast cancer. It is estimated that 1 million women will have been recruited by early in the year 2000, and that by the end of the year 2002 there will be 5000 screen-detected breast cancers and 23 000 deaths in the cohort, the majority of which will be attributed to cancer (12 600 deaths) and circulatory disease (8000 deaths). By the end of the year 2002, the Million Women Study will have sufficient statistical power to detect relative risks of 0.8 or less, or of 1.2 or more in current users compared with never users of hormone replacement therapy for mortality from breast cancer, colorectal cancer, lung and ovarian cancer, ischaemic heart disease and stroke.

Incident screening cancers detected with a second mammographic view: Pathological and radiological features

Previous studies and epidemiological data from the UK National Health Service Breast Screening Programme (NHSBSP) have indicated significantly increased sensitivity for cancer detection with two-view rather than one-view mammography screening. The radiological and pathological features of these extra cancers have not been previously reported in detail. We have studied all screen-detected cancers found as incident cases in the South West London Breast Screening Service between 1994–1997 on the second round of screening. To assess the effect of two-view versus one-view mammography on cancer detection, these cases were mixed with controls in a 1:2 ratio in nine test sets and each set read independently by three film readers. They initially read the oblique view, then the craniocaudal views, and recorded abnormalities on the films and likelihood of recall. Radiological and histological data were recorded for each case. Using two views, 8.9% ( P < 0.05) more invasive cancers were detected. The sensitivity increase was highest for invasive cancers less than 1Omm (11%) and cancers of low grade (11.9%). These sensitivity increases may underestimate the increase in `real life' because of over-recalling of normal mammograms, particularly with one view, under study conditions. The most significant radiological feature of invasive cancers was an irregular mass, which, seen on one view had a positive predictive value of 82.2% and 89.9% with two views. The craniocaudal view was helpful, firstly, because some cancers were not visible on the oblique view only. Secondly, benign appearing round masses and asymmetric densities seen with the oblique view only were resolved as more suspicious irregular masses with both views, leading to recall. In conclusion, there are cancers that cannot be adequately visualized on the oblique view alone. These are most commonly the small invasive cancers, which are of the greatest prognostic significance in breast cancer screening.

An evaluation of breast cancer screening in the South Thames (West) Region of the UK NHS Breast Screening Programme: the first 10 years

<h2>Abstract</h2> We have determined the progress of breast cancer screening in the South Thames (West) region of the UK National Health Service Breast Screening Programme (NHSBSP) from the start of screening in 1987 to 31 March 1997, by evaluating uptake, cancer detection rates, and interval cancer rates. Regional performance measures have been compared with NHSBSP targets. Uptake rates have been consistently close to the target of 70%, although marginally lower than the national average. Between 1 April 1990 and 31 March 1997 the region detected 1161 invasive cancers at prevalent (first) screen compared with a calculated age standardized expected number of 1164.2, a Standardised Detection Ratio (SDR) of 1.00 (95% Cl 0.94–1.06). During the same period, for incident (subsequent) screens, the region detected 640 invasive cancers compared with an expected 602.6, an SDR of 1.06 (95% Cl 0.98–1.15). The target SDR for both prevalent and incident screen is 1. The interval cancer rates over the period 1 April 1990 to 31 March 1994 for 0–23 months after a negative screen were 1.23 per 1000 (95% Cl 1.06–1.42) compared with a current national target of 1.20 per 1000. The evidence presented suggests that NHSBSP targets for both invasive cancer detection and interval cancer rates can be achieved.

The Scottish breast screening programme's experience of monitoring interval cancers.

To present the Scottish interval cancer data from 1991 to 1995, compare the Scottish experience with results published by other programmes and trials, and document appropriate methodologies to achieve maximum ascertainment of interval cancers. Scottish breast screening programme (part of the UK National Health Service breast screening programme). Interval cancers were identified by linking breast screening data with registrations of invasive breast cancers from the National Scottish Cancer Register. The main outcome measures were the numbers, rates, and proportionate incidence of interval cancers, and rates of total and small (< 10 mm) screen detected invasive cancers diagnosed in this cohort of women. Women who attended the Scottish breast screening programme (Scottish NHSBSP) from 1 April 1991 to 31 March 1995. Interval cancer rates of 4.8, 12.1, and 12.1 per 10,000 women screened were calculated for the first, second, and third year after the last negative screen. Expressed as a proportion of the underlying incidence, the figures are 23%, 60%, and 59%. The Scottish data are comparable with those reported by other UK NHS breast screening programmes for the first and second years after the last negative screen. The interval cancer rate for the third year is appreciably lower. A longer follow up period would be of interest to provide greater evidence on which to base comparisons. Ascertainment of interval cancers depends vitally on the availability of complete, accurate, and timely national cancer registration data and highlights the value of national datasets.

Early rescreen/recall in the UK National Health Service breast screening programme: epidemiological data.

In the United Kingdom in 1994-95 about 16,500 women aged 50 to 64 were asked to come back earlier than the usual three yearly screening interval for further mammography (early rescreen (ES)) or for a range of further investigations at an assessment centre (early recall (ER)). This study aimed at providing epidemiological data on ES/ER, in particular, how often and why it is used, and what the outcome is of using it. National Health Service breast screening programme in the United Kingdom. All breast screening units were invited to complete a postal questionnaire. Two reminders were sent. The units were asked retrospectively to provide breast screening data about women aged 50 to 64 from their local computer systems. Women placed on ES/ER were followed up for at least one year. The response rate was 71% (69/97), of which 14% (10/69) were unable to provide the required data, leaving 59 completed questionnaires (61%). The rate of placing women on ES/ER was above 1.0% for 26/54 (48%) responding breast screening units and above 2.0% for 13/54 (24%) units. Women were placed on ES/ER because of (a) previous breast cancer (21% of cases; cancer detection rate 2.4%), (b) diagnostic uncertainty (51%; cancer detection rate 3.0%), or (c) family history (27%; cancer detection rate 0.6%). Breast screening units with a high rate of placing women on ER were significantly more likely to have a high recall rate (rs = 0.63; n = 53; p < 0.0005) or a high benign surgical biopsy rate (rs = 0.33; n = 49; p < 0.05), or both. The cancer detection rate of ES/ER tended to decrease with increasing ES/ER rates (rs = -0.37; n = 51; p < 0.01). A relatively large number of women were placed on ES or ER for a range of reasons. If the recommendations given are followed, the number of women placed on ER may be reduced while maintaining the cancer detection rate at the required level. The option of ES should not be used.

Prediction of local recurrence of ductal carcinoma in situ of the breast using five histological classifications: A comparative study with long follow-up

The increased detection of ductal carcinoma in situ (DCIS) by mammographic screening and the more widespread use of breast-conserving surgery have led to a search for histological features associated with the risk of recurrence. In a case control study of 141 patients with long follow-up, we compared the ability of five morphological classifications to predict recurrence after local excision. A significant correlation was not found between recurrence and growth pattern when a traditional classification based on architecture was used nor with necrosis when a scheme based principally on this feature was employed. A correlation was, however, found between recurrence and “differentiation” as defined by nuclear features and cell polarization in a classification recently formulated by the European Pathologists Working Group (EPWG), but this failed to reach statistical significance at the 5% level. A stronger and statistically significant correlation was found between nuclear grade as defined by the EPWG and recurrence when cell polarization was disregarded, using the classification currently employed by the UK National Health Service and European Commission-funded Breast Screening Programmes. This was attributable to a small number of recurring cases being downgraded as a consequence of exhibiting polarized cells. A significant correlation between histology and recurrence was also observed using the Van Nuys classification, which is based on nuclear grade and necrosis. Whether the tumor recurred as in situ or invasive carcinoma was unrelated to histological classification, as was the time course over which it occurred. These findings strongly support the use of nuclear grade to identify cases of DCIS at high risk of recurrence after local excision, but further work is necessary to determine whether nuclear grade or necrosis is more appropriate to subdivide the non-high-grade cases.

Breast screening: adverse psychological consequences one month after placing women on early recall because of a diagnostic uncertainty. A multicentre study.

It was the original intention of the UK National Health Service Breast Screening Programme (NHSBSP) to place women who were not diagnosed with cancer on three yearly routine recall (RR). In 1994-5 approximately 16,500 women, aged 50 to 64, were placed on early recall (ER) at a shorter time interval, of which about 98% will have a normal result. This large number exceeds the expectations of the NHSBSP. To establish the adverse psychological consequences (PCs) for women one month after placement on ER because of a diagnostic uncertainty, and if detected, to suggest practical solutions to reduce them. Thirteen breast screening centres throughout the UK participated in the study. From March to October 1995 all women who were placed on ER because of a diagnostic uncertainty were identified and compared with groups of women placed on RR (after mammography, assessment, fine needle aspiration, and a benign biopsy). These women were invited to complete a postal questionnaire one month after they were placed on ER or RR. One reminder was sent. Overall 75% of women completed the questionnaire. The adverse PCs of placing women on ER because of a diagnostic uncertainty were higher (63%; n = 81 of 130) than those of women placed on RR after mammography (29%; n = 38 of 130) (P < 0.00001) or assessment (50%; n = 64 of 128) (P < 0.05), but lower than the adverse PCs of women who underwent a benign biopsy (87%; n = 26 of 30) (P < 0.05). Factors that were significantly associated with subsequent adverse PCs were identified. The adverse PCs of being placed on ER because of a diagnostic uncertainty were significantly higher than those of women who turned out to have a false-positive mammographic result after assessment. Possible practical solutions are discussed.

Clinical audit and standard setting for symptomatic breast imaging in south thames region

Audit is recognized as an important part of the UK National Health Service Breast Screening programme. This paper describes a simple method of auditing breast imaging in symptomatic women which was applied in the South Thames (East) Region of England. No appropriate standards were available before this audit started. Standards were set at the end of the first cycle by the Regional Radiology Audit Committee and these were used in the second cycle of this audit. A comparison between hospitals which organize both breast screening and symptomatic imaging and those with units providing symptomatic breast imaging only shows no significant difference in the accuracy diagnosis and the false negative and false positive rates between the two. However non-screening units, are significantly more likely to issue an equivocal radiology report (P = 0.000001). Measures to reduce the incidence of equivocal reporting, by prospectively issuing an audit grade with the report and double reporting of equivocal images are recommended.

Stress and job satisfaction in mammography radiographers

Abstract Previous research suggests that substantial numbers of health professionals experience undue levels of occupational stress. Little is yet known, however, about a recently established specialized group, namely radiographers who work in the UK National Health Service Breast Screening Programme. All 134 radiographers in the first wave of the programme were sent a postal questionnaire to determine how stressed they felt at work, how satisfied they were with the job, and what were the principal causes of stress and dissatisfaction. A total of 103 were returned, a response rate of 77 %. The results showed that 30 % reported high levels of stress, which is more than in most other professions, and that only 17% described themselves as ‘very satisfied’ with their jobs. The most important predictors of stress were problems of communication (mainly knowing what to tell the client) and conflicts between home and work. The most important predictor of dissatisfaction was role ambiguity. Ways of reducing stress...

The efficacy of double reading mammograms in breast screening

The effect of double reporting the screening mammograms of 31,146 women attending as part of the UK National Health Service Breast Screening Programme was analysed. Ninety per cent had their mammograms read by two of three experienced radiologists. Overall 1846 (5.9%) women were recalled for further assessment. Two hundred and sixty-one patients (0.8%) underwent surgical intervention resulting in the detection of 191 cancers (6.1/1000 women screened). The benign-to-malignant ratio was 1:3.6 (PPV 73.2%). Of the invasive cancers detected 72% had no histological evidence of axillary lymph node metastases. Twenty-one of the 191 cancers detected (10.4%) were missed by one of the two reporters. Six of these were invasive cancers < or = 1 cm in diameter. Comparison of those lesions detected by both readers to those detected by only one, showed readers were more likely to detect those lesions appearing as an opacity (65% vs 38%), but less likely to detect significant microcalcification (15% vs 33%). The difference between the two groups when taken as a whole, however, failed to reach statistical significance (chi 2 = 6.76, d.f. = 3, P = 0.08). In summary, double reporting resulted in an increase in sensitivity of 10%. However, there was a decrease in specificity of 1.8% with 569 women being recalled unnecessarily for assessment and biopsy of 13 benign lesions. The estimated resultant additional financial cost was 13773 pounds.

Early experience in breast cancer screening: emphasis on development of protocols for triple assessment

The early experience of the Nottingham Breast Screening Service participating in the prevalent round of the UK National Health Service Breast Screening Programme is presented. Over a 3-year-period management protocols have been developed and refined. These protocols are based on the principle of multidisciplinary triple assessment, including imaging, clinical evaluation and fine needle aspiration cytology (FNAC). Throughout this period screening performance indicators well within the national guidelines were achieved. In addition, recall for assessment rates fell from 12% to 3.4%, the benign-to-malignant biopsy ratio falling from 1:1 to 0.3:1, while the cancer detection rate of 7 per 1000 women screened was maintained. A progressive increase in diagnostic specificity was achieved while retaining cancer detection sensitivity. Overall, 60% of carcinomas were diagnosed by FNAC. Using the Nottingham Prognostic Index, 47% of cancers were in the good prognostic group, previously shown to correlate with a 10 year survival of 83%. These results are encouraging and suggest that a significant mortality benefit can be predicted for screen detected breast cancers. The adoption of a multidisciplinary triple assessment increases the specificity of the screening test without compromising sensitivity.