NHS Breast Screening Programme
Annual Review 2012
Contents
1
Foreword
nna Soubry MP, Parliamentary Under Secretary of State for
A
Public Health
2Introduction
P rofessor Julietta Patnick CBE, Director of the NHS Cancer
Screening Programmes
4Reviewing the evidence for breast screening
Professor David Cameron
Professor John Newton
6
Transition to Public Health England
8Advisory Committee on Breast Cancer
Screening
Professor Martin Vessey
10Promoting Early Presentation Intervention:
From research to practice
Professor Amanda Ramirez
Professor Stephen Duffy
12Screening women out of hours: The results
14Statistics
Foreword
The total number of women invited to attend breast screening has
risen again this year by over 100,000 to 2,862,370. Almost three
quarters of women accepted their invitation (73.4%), resulting in
the detection of more than 17,000 cancers.
Anna Soubry MP
Parliamentary Under
Secretary of State for
Public Health
The Marmot Review into the evidence for the
benefits and harms of breast cancer screening
in the UK was published in October 2012. It is
an incredibly thorough piece of work that has
important implications for the Programme. We
welcome the findings of the panel, which have been
noted by the UK National Screening Committee
(NSC). The key now is how we communicate the
panel’s conclusions to women so that they can
make an informed choice for themselves. Work
to do this is well under way, with academics from
King’s College London assisting the national office
team in preparing new materials.
This year also saw the publication of Public
Health Outcomes Framework, which sets out our
objectives of increasing healthy life expectancy and
reducing differences between communities. The
prevention and early detection of cancer are crucial
components of the public health agenda and the
Government recognises the important contribution
made by breast screening in this area.
Under the health improvement domains of the
Public Health Outcomes Framework, there are
indicators on cancer screening coverage, and we
are pleased to see from this year’s breast screening
statistics that coverage has remained steady.
Elsewhere this year we have seen good progress on
the conversion to digital mammography, although
some work still needs to be done. Over 1 million
women are now taking part in the age extension
randomisation trial, in which breast screening is
extended to women aged 47 – 49 and 71 – 73, and
we expect all eligible units to be taking part in the
trial in 2013.
The NHS Breast Screening Programme has come
a long way over the past two decades. As this
review highlights, 2012 has seen the continued
development of our world-class service. I would
like to take this opportunity to thank you all
personally for your continued hard work and
commitment to make the Programme a success.
1
Introduction
2
NHS Breast Screening Programme Annual Review 2012
This has been a significant year for the NHS Breast Screening
Programme. On the eve of our move to Public Health England,
Professor Sir Michael Marmot and his panel published their
Independent Review on Breast Screening.
Professor Julietta
Patnick CBE
Director of the NHS Cancer
Screening Programmes
We were pleased that the panel concluded that the
Programme confers significant benefit and should
continue. However, the Review also estimated that
for every breast cancer death that is prevented
through screening, about three extra cases will
be identified and treated during the screening
period. Only one or two of those would have been
diagnosed during the woman’s remaining lifetime.
The challenge over the next year will be to devise
a way of explaining this to women in a clear and
concise way, and we look forward to working with
all partners to take the panel’s recommendations
forward. In this Annual Review, we speak to
Professor David Cameron about the findings of
the Marmot Review and their implications for the
Programme’s future.
April 2013 will see the launch of Public Health
England, the new executive agency designed to
lead on public health at a national level. As the
national office and Quality Assurance arms of the
NHS Cancer Screening Programmes will be moving
into the new body in the spring, we speak to Public
Health England’s incoming Chief Knowledge Officer,
John Newton, about the importance of sharing our
considerable knowledge, experience and expertise
with other health programmes.
The Advisory Committee on Breast Cancer
Screening (ACBCS) has worked hard to ensure that
the NHS Breast Screening Programme is based
on the best and most recent scientific evidence.
Professor Martin Vessey, who chaired the ACBCS
for over a decade, reflects on the Committee’s
history, and on the way in which it has handled the
challenges and issues the Programme has faced in
the past.
There are a number of interesting research projects
running at the moment, including the Promoting
Early Presentation (PEP) pilot and the Out of Hours
study. The PEP pilot scheme encourages women
over the age of 70 to take more responsibility for
their health and we hear from Professor Amanda
Ramirez about the progress this exciting study has
made to date. Meanwhile, the Out of Hours study
has explored the effect of offering weekend and
out of hours appointments on breast screening
attendance rates in Bristol and Manchester, with
some interesting results.
At the end of a busy year, I want to thank all
those involved in the delivery of our screening
Programme. Without your hard work the
Programme would not be the success that it is.
I look forward to working with you in the future
to bring the highest possible standards of service
to the women we serve.
3
Reviewing the evidence for
breast screening
The Independent Breast Screening Review panel, which published
its findings in October 20121, sought to review the evidence on the
benefits and harms of breast screening in the context of the UK
Screening Programmes. We discuss the importance of the report and
its implications for the future with a member of the panel, Professor
David Cameron, Clinical Director of the Edinburgh Cancer Research
Centre, Director of Cancer Services at NHS Lothian and Professor of
Oncology at Edinburgh University.
Since the NHS Breast Screening Programme was
established, there has been a debate, often sharply
polarised, over the extent of its benefits and harms,
and the balance between them. Divergent views
have arisen partly from disagreements over the
validity and applicability of evidence from existing
randomised controlled trials of breast screening,
and partly from questions about the usefulness of
observational data for breast cancer mortality and
incidence.
Following growing criticism and an increasingly
public debate, Professor Sir Mike Richards, National
Cancer Director, England, and Dr Harpal Kumar,
Chief Executive Officer of Cancer Research UK,
commissioned a review to evaluate both the
benefits and the harms associated with population
breast screening programmes, and to make
recommendations to the UK Programmes.
Professor Cameron explains how the panel was
chosen and how they went about reviewing the
evidence: “Under the leadership of Professor
Marmot, a panel of nationally and internationally
recognised experts in epidemiology, medical
statistics, or current breast cancer diagnosis and
treatment practices was convened. Importantly,
no member of the panel had previously published
on breast screening: this helped to ensure an
objective and independent assessment of the
evidence, and allowed all those round the table to
come to the subject with an open mind. We also
had patient advocate Maggie Wilcox on the panel,
who provided vital input into the Review from a
patient’s perspective.
“In conducting the Review, we examined evidence
from randomised trials and observational studies,
performing a meta-analysis of available data to
assess the extent to which population-based breast
screening leads to a reduction in mortality. We
also reviewed a range of data to estimate the rate
4
of overdiagnosis and called on a range of experts,
from all sides of the debate to give evidence
for consideration.”
The panel concluded that the NHS breast screening
programmes confer significant benefit to women
and should continue. Evidence suggested they offer
a 20% relative risk reduction in mortality to women
who participate in a 20-year screening programme.
This equates to the prevention of around 1,300
deaths from the disease every year in the UK.
However, estimates also suggest that around 4,000
additional women are diagnosed with breast cancer
each year as a result of screening which equates to
approximately three overdiagnosed cases for each
breast cancer death prevented. This is, in part, due
to the current limitations of scientific knowledge:
clinicians are not currently able to distinguish with
certainty between breast cancers that will cause
harm during a woman’s lifetime, and those that will
not. Professor Cameron explains: “Overdiagnosis
occurs when a woman is told that she has cancer
diagnosed via screening, even though that cancer
would not have given rise to any symptoms during
her lifetime. On the positive side then, screening
confers a risk reduction in mortality from breast
cancer because of early detection and treatment.
On the negative side however, there is the
knowledge that women have a one per cent chance
of having a cancer diagnosed and treated that
would never have caused problems had they not
been screened.”
The panel made a number of policy recommendations
based on their findings, amongst them the suggestion
that the information given to women on the harms
and benefits of screening should be improved.
Professor Cameron continues: “Clear communication
of the harms and benefits of screening to women
is essential. It is at the core of how a modern health
system should function. However, the worry is
NHS Breast Screening Programme Annual Review 2012
Professor David
Cameron
Clinical Director of
the Edinburgh Cancer
Research Centre, Director
of Cancer Services at
NHS Lothian and Professor
of Oncology at Edinburgh
University
“Clear
communication
of the harms
and benefits
of screening
to women is
essential. It is at
the core of how
a modern health
system should
function.”
that, as the harms are communicated more
clearly, women may interpret this to mean that
breast screening is no longer safe and decide not
attend their screening appointment. While it is,
of course, up to the individual woman to make
her own decision, we would be very concerned
if this translated into a reduced rate of breast
cancer screening.”
The panel also called for further research into
the natural progression of some cancer types,
particularly ductal carcinoma in situ. They
concluded that further randomised trials are
needed to elucidate the appropriate treatment
of screen-detected ductal carcinoma in situ of
different grades, in order to improve outcomes
for women and reduce overdiagnosis rates. The
Sloane Project is conducting a UK-wide audit of
screen-detected non-invasive cancers and atypical
hyperplasias of the breast, in order to better
understand the natural progression of certain types
of breast cancer.
The NHS Breast Screening Programme is now
looking to implement the recommendations of the
Review. Professor Amanda Ramirez and her team at
King’s Health Partners (King’s College London) are
developing new patient invitation support materials
to provide women with clearer statements on the
benefits and harms associated with screening and
better support them as they make an informed
choice about screening.
As part of this work, Professor Ramirez’s team is
undertaking steps to devise a way of explaining
overdiagnosis to women in a clear and concise
way. Their initial ‘citizens jury’2 suggested that
women felt the term ‘overtreatment’ was easier
to understand than ‘overdiagnosis’. Overdiagnosis
describes cancers picked up as a result of screening
which would not have been diagnosed in a woman’s
lifetime. However, it is impossible to predict which
of these cancers will progress, or how quickly,
and therefore it is impossible to tell whether a
particular woman has been overdiagnosed. As a
result, overtreatment occurs as treatment advice
is offered to women on the basis that all of the
cancers might develop. Professor Ramirez is
working to convey these issues in a new screening
leaflet for women.
When asked for his views on how the report will
impact the NHS Breast Screening Programme,
Professor Cameron responded: “Ultimately our
Review came out in favour of a population-wide
breast screening programme in the UK, but that
is not to say that we didn’t recognise the right of
indivduals to make their own choice about the
balance between benefits and harms.”
1 ‘The benefits and harms of breast cancer screening: an independent
review’, Professor Sir Michael Marmot, The Lancet, published 30
October 2012
2 ‘Citizens’ jury’ disagrees over whether screening leaflet should put
reassurance before accuracy, Nigel Hawkes, BMJ 2012; 345:e8047
5
Transition to Public Health England
The advent of Public Health England (PHE) marks a new era for
the NHS Cancer Screening Programmes. As the newly emerging
executive agency prepares for its launch in April 2013, we talk to
Professor John Newton, Chief Knowledge Officer of PHE, about what
the transition will mean for those involved in breast screening, and
the way other public health programmes can benefit from the wealth
of experience and expertise within the Programmes.
In the new public health landscape, the
NHS Cancer Screening Programmes will be
commissioned directly by the NHS Commissioning
Board. While the national office will continue
to offer guidance, support and advice, its staff will
be employed by PHE.
It is important to ensure that initiatives to promote
informed choice around screening are tailored to
the specific needs of local populations. Therefore,
future initiatives to improve screening uptake
will be run by Local Authorities and the Directors
of Public Health who will sit within them. This is
part of their statutory duty to improve the health
and wellbeing of the population for which they
are responsible.
be the responsibility of PHE. All this means that, at
a regional level, QA will continue to be managed
by some of the same teams and will be delivered
in broadly the same way, building on the excellent
work of the current Quality Assurance Reference
Centres (QARCs). However, these will be managed
in a more consistent way nationally under PHE’s
newly appointed Director for Health Improvement
& Population Health.
“At present, there are examples across the country
of high-quality training, auditing and inspection
services, but there are major regional variations
in the way QARCs operate. We want to come
up with a common model that allows for better
coordination and best practice sharing, meaning
all women in England can benefit from the highest
Professor Newton talks through the benefits of the
possible standards of service. By running cancer
changes, particularly in relation to the way breast
screening QA from PHE – a national organisation –
screening Quality Assurance (QA) is carried out:
we have an opportunity to bring in central support
“Cancer Screening QA has been extremely successful.
and infrastructure for QA data management.
There has been an ongoing effort to ensure that
quality is at the heart of the NHS Cancer Screening “QARCs largely developed from the bottom up,
Programmes, and women undergoing breast
which has its advantages. However, there are
screening can be reassured that they are receiving
important benefits to being part of a national
an excellent service. We’d like to see some of this
system and we are keen for these to be realised.
fantastic work replicated elsewhere in the public
For example, if QA teams feel their reports are not
health arena.
being properly addressed by local commissioners
in the new landscape, they will be able to escalate
“That is why, under the PHE umbrella, we’re very
them up to the PHE Population Health Directorate
keen to support different QA processes and
and the NHS Commissioning Board. Having looked
see how they can help each other. As well as
at QA results, these organisations will be in a
sharing the QA model with other non-screening
position to advocate on behalf of cancer screening
programmes, the transition also offers an important
at a national level.
opportunity to build on and improve the QA
system within breast screening.
“It’s not all about top-down centralisation but
we feel QA can benefit from a certain degree
“On a structural point, we think it has been very
of standardisation. It is crucial for QARCs to get
helpful in the past, and will be in the future, for the
access to underlying data – hence they are, and will
QA role to be separated from the commissioning
continue to be, aligned with the eight public health
and delivery of screening. In the past, Regional
evidence and intelligence networks across England.
Directors of Public Health in PCTs were responsible
If there is anything we can do nationally to help
for receiving QA screening reports. In the future,
improve this process we will work to do it.”
this role won’t exist in the same form and QA will
6
NHS Breast Screening Programme Annual Review 2012
Professor John Newton
Chief Knowledge Officer
of PHE and formerly
a Regional Director
of Public Health
“The transition
to Public Health
England offers
an important
opportunity
to build on and
improve the valued
breast screening
QA system.”
In addition to the NHS Cancer Screening
Programmes, both the UK National Screening
Committee (NSC) and the Joint Committee for
Vaccinations and Immunisation (JCVI) will also move
to PHE. Professor Newton concludes by reiterating
the potential for information sharing between
organisations under the PHE umbrella: “We’re keen
to look for opportunities to support different QA
processes and see how they can help each other. As
we enter the final phase of transition, I would like
to welcome the NHS Cancer Screening Programmes
into Public Health England and look forward to
working closely with them. The move will allow us
to build on the valued expertise of staff working
within the Programme and help them continue to
deliver an ever-improving service to women.”
7
Advisory Committee on Breast
Cancer Screening
Since 1988, the Advisory Committee on Breast Cancer Screening
(ACBCS), an independent panel of experts, has monitored
the effectiveness and efficiency of the NHS Breast Screening
Programme and provided advice on new research and screening
developments. Professor Martin Vessey CBE, who chaired the
Committee from 1988 to 1999, reflects on the panel’s history, the role
it has played, and the way it has handled some of the more important,
and at times challenging, issues facing the NHS Breast Cancer
Screening Programme.
The origins of the NHS Breast Cancer Screening
Programme can be traced back to 1985 when the
former Minister of Health, Kenneth Clarke, called
for an independent review into the benefits and
harms of population-wide breast cancer screening.
An expert committee of leading academics and
clinicians was convened and in 1986 the Chair of the
group, Professor Sir Patrick Forrest, reported back
to Ministers. He concluded that there was sufficient
research evidence to support the implementation
of a national screening service for breast cancer.
Following this recommendation, the NHS Breast
Screening Programme was formally announced
in March 1987, with the intention that invitations
would be sent to women in early 1988. At the same
time, an Advisory Committee was established to
oversee the implementation of the Programme.
Professor Vessey explains some of the early
responsibilities of the Committee: “Following the
publication of the Forrest Report, the Government
exerted enormous political pressure to achieve
national roll-out as quickly as possible, which
was obviously a huge challenge for all concerned,
including the Committee. There were a lot of
different aspects of the Programme to bring
together – ensuring professional staff had the
necessary capacity and skills; producing materials
to educate women on the benefits and risks of
screening; and solving logistical problems, such as
the organisation, structure and monitoring of the
Programme.
“From the outset, quality was always the highest
priority for the Committee. In practice this
meant developing a first-class Quality Assurance
system, ensuring an excellent training system for all
professional staff, and ultimately, providing the best
possible service for women.
8
“Professor Sir Muir Gray was one of the key
founders and played an instrumental role in
transforming breast screening in England into an
official national Programme. This was a remarkable
achievement. As the Programme evolved, both
he and his successor, Professor Julietta Patnick,
continued to recognise the benefits of having an
official panel of independent experts to advise
the Programme and the Government, to review
relevant scientific evidence and to make practical
recommendations accordingly.”
As well as ensuring that quality remained strong,
the Committee started to review existing screening
practices in light of new technologies and advances,
thus ensuring the Programme remained world-class:
“There was an ever-increasing number of items
on our agenda as the Programme rolled out. We
were concerned about the occurrence of interval
cancers, the management of ductal carcinoma in
situ and minimal invasive lesions, mammogram
storage and retrieval, single view versus double
view mammography, the double reading of
mammograms, the possible role of computerassisted diagnosis and the development of
information systems. During my tenure as Chairman
we focused on dealing with all these features.”
Recommendations by the Committee have always
been based on thorough analyses of credible
scientific data. Some have caused more controversy
than others: “Our decision to extend breast
screening to older women up to the age of 70 in
2000 caused some critics to suggest that this would
lead to overtreatment of the older age group.
However, two years later the International Agency
for Research on Cancer (IARC) conducted their
own review which endorsed our view that offering
screening to women up to the age of 70 would
deliver greater benefit than harm. This validated the
Advisory Committee’s earlier findings and I believe
NHS Breast Screening Programme Annual Review 2012
Professor
Martin Vessey CBE
Founder Chairman of the
Advisory Committee on
Cervical Screening
“Decisions
around screening
programmes must
be evidence-based.
The benefit of
an independent
panel is that
we can review
the evidence
together and make
consensus-based
recommendations.”
demonstrates how, on many issues, the NHS
Breast Screening Programme led the way for the
international community.”
Not everyone is an advocate for breast cancer
screening, and in recent years opponents have
become increasingly vocal about the harms –
including some who were once great supporters
of the Programme. Professor Vessey reflects
on how the Committee has dealt with these
challenges: “With every screening programme there
is always the real possibility of doing more harm
than good. It was our job to try and ensure that the
benefits outweighed the harms and that women
received as effective a service as possible. Always
taking an evidence-based approach, we focused
on quality control, training, good practice and
the provision of high-quality information to help
women make decisions around screening. Many of the concerns raised by the critics, such as overtreatment, were our concerns too.
the potential to cause harm, and it is important
to review the evidence as it becomes available to
ensure the benefits continue to outweigh the risks.”
“Ultimately, decisions around screening programmes
must be evidence-based. The benefit of an
independent panel is that we can review the
evidence together and make consensus-based
recommendations. I think that over the past 24
years, it has been important for all those involved in
screening to be confident that any recommended
changes are carefully considered and scrutinised by
a panel of experts, and piloted where necessary.”
This issue came to a head last year, when the
National Clinical Director for Cancer, Professor Sir
Mike Richards, announced a review of the evidence
on breast screening. Professor Vessey takes an
optimistic view of this: “Whilst some may see the
Marmot Review as a threat to the Programme and
the work of the Committee, I prefer to view it as
an opportunity. All screening programmes have
9
Promoting Early Presentation
Intervention:
From research to practice
In June 2011, the British Journal of Cancer published the results of
a randomised controlled trial led by Professor Amanda Ramirez to
investigate the Promoting Early Presentation (PEP) intervention.
The intervention aims to equip older women who are no longer
routinely invited for screening with the knowledge and motivation
to present promptly to primary care in the event they suffer
symptoms of breast cancer. The scheme has been rolled out across
four breast screening pilot sites. We caught up with Amanda to
discuss the key challenges she has encountered in incorporating the
PEP intervention into routine clinical practice and her hopes for the
future of the intervention.
There is strong evidence to suggest that women
diagnosed with breast cancer after the age of 70
have a poorer one-year survival and present at a
more advanced stage than younger women. The
PEP intervention aims to reverse this worrying
trend by providing older women with the skills and
confidence to recognise breast cancer symptoms at
an early stage and seek clinical advice.
The scripted intervention, which is to be delivered
by health professionals, was developed by Professor
Ramirez and her team at King’s College, University of
London. She explains: “The intervention is delivered
to a woman by either a radiographer or assistant
practitioner, one-to-one, at the final round of
breast screening to which the woman is invited. It is
supported by a booklet that women are then given
to take home.”
A randomized controlled trial was carried out to
evaluate the effectiveness of the intervention in
increasing breast cancer awareness. The findings of
the trial were published in 2011 and showed that at
one year, the intervention increased the proportion
of women who were breast cancer aware six-fold.1
The effect also appears to be enduring: two years
after the PEP intervention 21% of women remained
breast aware, compared with just 6% who received
the current standard care.2 Overall, the effect of the
intervention was found to be greater than that of
any other intervention of its kind to date.3
Professor Ramirez explains: “We were extremely
encouraged by the results of the randomised
controlled trial but were keen to see whether the
intervention could work in a real-life screening
programme setting. The NHS Breast Screening
Programme provides an invaluable platform for
10
us to test this and we were delighted when the
Programme allowed us to trial the intervention
in four breast screening services: Cambridge &
Huntingdon; Warwickshire, Solihull & Coventry;
Maidstone; and Medway.
“During 2011, we trained 27 mammographers from
these breast screening services to deliver the PEP
intervention. The facilitator-led training involved
two half-day group sessions, two to four weeks
apart, plus practice sessions with performance
feedback provided by coaching radiographers.”
From the outset, Professor Ramirez and her team
recognised that the intervention would need to
be tailored to the demands of a real-life clinical
setting: “In order to address cost and capacity
challenges, we had to develop a ‘leaner and meaner’
intervention. We shortened the intervention to
5 minutes and decided to have it delivered in the
X-ray room, immediately after the mammogram,
where the radiographer or assistant practitioner
could have the woman demonstrate on themselves.
By contrast, in the randomised clinical trial the
intervention was delivered before the mammogram,
in a separate room and demonstrated on a model.”
Preliminary findings from the pilot suggest that
this more concise intervention has been just as
successful in raising breast awareness as the
randomised controlled trial. “We were surprised to
find that the PEP intervention can be implemented
in routine clinical practice with an efficacy similar to
that achieved in a randomised controlled trial. This
was encouraging because interventions are often
less effective in routine clinical practice than in
randomised controlled trials. The full results from
the pilot study have now been published in the
NHS Breast Screening Programme Annual Review 2012
Professor Amanda
Ramirez
Director of the Promoting
Early Presentation Group,
King’s College London
“The Promoting
Early Presentation
(PEP) intervention
aims to provide
older women with
the skills and
confidence to
recognise breast
cancer systems
at an earlier stage
and seek clinical
advice.”
Journal of Cancer Epidemiology. In the meantime
though, we are continuing to measure the costs and
feasibility of implementation.”
Looking forward, Professor Ramirez has further
aspirations for the PEP intervention: “What we’ve
managed to achieve so far is the easy bit, so to
speak. The next challenge will be to show that
increased breast awareness can improve survival
and reduce mortality. Long term follow-up is critical
for obtaining this kind of information. Our hope
is that we can show that the intervention reduces
mortality, and that it will therefore become an
integral part of the Programme.”
1 L insell, L., et al., A randomised controlled trial of an intervention to
promote early presentation of breast cancer in older women: effect on
breast cancer awareness. British Journal of Cancer, 2009. 101: p. s40-s48.
2 F orbes, L.J.L., et al., A promoting early presentation intervention
increases breast cancer awareness in older women after 2 years: a
randomised controlled trial. British Journal of Cancer, 2011. 105: p. 18-21.
3 A
ustoker, J., et al., Interventions to promote cancer awareness and early presentation: systematic review. British Journal of Cancer, 2009.
101: p. s31-s39.
11
Screening women out of hours:
The results
In 2010 the NHS Breast Screening Programme commissioned
Stephen Duffy, Professor of Cancer Screening at Queen Mary,
University of London, to examine the effect on attendance rates
of offering ‘out of hours’ screening appointments on evenings and
weekends. In this article, Professor Duffy and his colleague, Dr Mary
Wilson, of the Greater Manchester Breast Screening Programme,
discuss the impact of the additional sessions on women and
Programme staff.
The Out of Hours study ran at selected sites across
Bristol and Manchester from the summer of 2010.
Women who were called for routine screening were split into four groups, each of which was
invited to an appointment during a different
time slot. One group was invited during weekday
working hours, another on evenings, a third on
a Saturday, and the final group were given an
appointment during weekday working hours with
the option to change to an evening or a Saturday.
Throughout the year, 9,000 women were offered
the usual weekday working hours appointment,
while 3,000 women were placed in the other three
appointment groups.
Professor Stephen Duffy and his colleagues found
that the uptake rate was greatest in this fourth
group. Women offered a weekday appointment
with the opportunity to change to an evening or
weekend appointment were slightly more likely
to attend than those offered a working hours
appointment without the option to change. Only
a small proportion of those offered the option to
change chose to do so, with an even split between
those selecting evening and those choosing
weekend appointments.
Offering an initial evening or weekend appointment
did not improve uptake. Of the women offered
an evening or weekend appointment, substantial
numbers switched back to an appointment during
working hours.
As Professor Duffy explains: “The results suggest
that offering an out of hours appointment as the
initial option does not improve uptake, as many
women contacted us to change it. However, offering
women the usual working hours appointment
with an alternative to change to an out of hours
appointment seemed to be very popular.”
12
Uptake rose amongst those offered a choice to
switch to an out of hours slot in the summer and
autumn, and the option to change to a weekend
appointment was more popular with older women:
“This was certainly one of the more surprising
findings, as you would think the option to change
to an out of hours appointment would chime
better with younger women and those more likely
to be in full-time work,” said Duffy.
The trial was well received by both the pilot sites,
with each recording positive feedback from women
offered the service. Dr Mary Wilson, Director of the
Greater Manchester Breast Screening Programme,
says: “We had a lot of positive feedback from the
women involved who really liked the idea of having
the option to reschedule their appointment to an
evening or weekend. The older women were happy
enough to come on the Saturday but didn’t seem
to want to come in the evening. The younger ones
seemed to prefer the evening appointments as they
didn’t have to take time off work.”
However, the sites had to address a number of
issues before offering women an out of hours
appointment. Dr Wilson explains: “First of all, we
had to undertake an extensive consultation process
with staff and management to discuss whether
radiographers could work the out of hours shifts
and at what rate they would be reimbursed. This
was a major logistical issue as most screening
radiographers are part-time. For many, the need to
work on a Saturday presented difficulties.”
She adds: “The trial also required quite a lot of
support from the administrative team to ensure
that women in each specific group received
the correct invitations. It required a lot of
micromanagement for the different batches.”
NHS Breast Screening Programme Annual Review 2012
Professor Stephen
Duffy
Professor of Cancer
Screening at Queen Mary,
University of London
“Offering women
the usual working
hours appointment
with an alternative
to change to
an out of hours
appointment
seemed to be very
popular.”
However, despite these issues, Dr Wilson believes
that the Programme would benefit from offering
women the option to change their appointment
to an out of hours slot if preferred: “I think that
giving these additional options will help improve
uptake and also make the service more user friendly,
particularly to people who are working.”
Results from the Out of Hours study are expected
to be published in spring 2013. The research will
then be reviewed by the NHS Cancer Screening
National Office to evaluate the value of offering an
out of hours service to women.
13
Statistics
14
NHS Breast Screening Programme Annual Review 2012
2010 – 2011 breast
screening statistics
The following data illustrate the performance of breast screening
programmes across the UK for the year April 2010 to March 2011.
Over 2.8 million women aged 45 – 74 were invited
for screening in 2010 – 11, an increase of more than
100,000 invitations on the previous year. Across
the UK, an average of 73% of women accepted their
invitation, an increase of 0.1% over last year’s figures.
However, uptake is significantly lower in London, at
59%, although this figure has also risen slightly yearon-year. We know that the population in London is
traditionally harder to reach due to its diverse and
mobile nature.
The age groups for these statistics reflect the
eligible age ranges for the Programme. The routine
Programme screens women aged 50 – 70. However,
women aged 47 – 49 and 71 – 73 may be invited as
part of the age extension to the Programme, and
women aged 71 – 74 may also refer themselves
for screening.
Some women aged under 50 may be invited to
screening early because they are at higher risk of
breast cancer. The statistics also reflect Programme
administration, which dictates that some women
will receive their first invitation to mammography
a few months before their 50th birthday, and will
attend for their first mammogram at the age of 49.
The figures are collated from each individual
screening unit, validated by Quality Assurance
teams and bought together by the Centre of Cancer
Prevention at the Wolfson Institute of Preventative
Medicine, Queen Mary College, University of
London. Figures for tables 9 and 10 are provided by
the Association of Breast Surgery (ABS). Thanks go
to all concerned for their efforts to ensure the data
are both accurate and timely. We are also grateful
to colleagues in Scotland, Wales and Northern
Ireland who have contributed their figures in order
that we can publish UK-wide data.
15
2010 – 2011 breast
screening statistics
Table 1: Screening activity
The total number of women aged 45 – 74 invited to attend breast
screening has risen again this year by more than 100,000 women
to 2,862,370. Almost three quarters of women accepted their
invitation (73.4%), resulting in the detection of more than 17,258
cancers this year – an increase of over 700 compared to last year’s figures.
Table 3: Acceptance by type of screening invitation –
women aged 45 – 74
The figures show the proportion of women aged 45 – 74 accepting
their invitations according to the type of invitation sent. Rates are
now fairly stable from one year to the next, with slight increases
in most categories, but a slight drop of 0.2% in those invited for the
first time.
2009/10
2010/11
2009/10
2010/11
Year
2009/10
2010/11
Age Range
50 – 70
50 – 70
45 – 74
45 – 74
1st invitation
70.0%
69.8%
Total number of women
invited
2,662,298 2,722,702
2,754,885
2,862,370
1st screen, previously non-attenders
17.8%
18.3%
Acceptance rate
73.5%
73.6%
73.3%
73.4%
Acceptance for routine re-screening
82.0%
82.3%
Number of women
screened (invitation)
1,956,314
2,003,683 2,019,956
2,100,799
Acceptance for short-term recall
98.0%
98.3%
Number of women
screened (self/GP
referral)
43,410
44,357
87,809
Total number of women
screened
1,999,724
2,048,040 2,104,423
2,188,608
Number of women
recalled for assessment
82,650
81,442
89,164
90,141
% women recalled for
assessment
4.1
4.0
4.2
4.1
Number of benign
biopsies
1,519
1,434
1,646
1,620
Number of cancers
detected
15,517
15,979
16,476
17,258
Number of in situ cancers 3,064
detected
3,236
3,257
3,527
Number of invasive
cancers <15 mm
6,544
6,584
6,939
7,053
Standardised detection
ratio (invited women
50 – 70) only
1.44
1.45
84,467
–
–
Table 2: Acceptance by age – all invitation types
These figures show that the number of women accepting their
invitation to screening varies with age. The number of women
aged 71 or more accepting their invitations decreased from 65% to
63.7% while the proportion of women aged 45 – 49 attending for
screening increased slightly by 1.5% to 70.5%. These variations may
be due to the fact that the number of women receiving invitations
in these two age groups remains small.
Age
50 – 54
55 – 59
60 – 64
65 – 70
71 – 74
2009/10 69.0%
72.4%
73.7%
75.2%
72.6%
65.0%
2010/11
72.4%
73.8%
75.1%
73.2%
63.7%
16
45 – 49
70.5%
NHS Breast Screening Programme Annual Review 2012
Table 4: Screening quality – first screen
after first invitation
The data below refer to those women entering the breast
screening programme for the first time. This table includes both
those women aged 50 – 52 who have routinely received their first
invitation, and those women who have been invited for the first
time aged 47 – 49. The rates remain steady this year.
Standard
Age range
Achieved Achieved
50 – 70
45 – 74
Acceptance rate
≥70%
69.7%
69.8%
Recall rate
‹10%
8.0%
7.9%
Benign biopsies (per 1000)
≤3.6
1.8
1.8
In situ rate (per 1000)
≥0.4
2.0
2.0
Invasive cancer rate (per 1000)
≥2.7
5.0
5.0
Invasive cancers <15mm (per 1000)
≥1.5
2.0
2.0
Total number women screened for
first time following first invitation
–
285,726
369,978
SDR
1.0
1.45
–
Table 5: Screening quality – subsequent screen
Table 7: Assessment outcomes age 50 – 70
This table shows data for those women who have returned for
routine re-screening. All the quality standards set by the Programme
have been met. The data now include those women aged 71 – 73
who received invitations to re-screening as part of the age
extension to the Programme. The number involved is small, and has
made almost no difference to the achievement of quality standards.
The data in this table show the current use of non-operative
techniques within the Programme. These mean that a woman
can be diagnosed with breast cancer, or that cancer is ruled out,
without an operation being performed. Unfortunately there are a
few women who do have to have a surgical biopsy, and the table
shows the proportion of these women whose screening result is
normal or benign.
Standard
Achieved Achieved
Age
50 – 70
45 – 74
Acceptance rate
82.4%
82.3%
Recall rate
‹7%
3.1%
3.1%
Benign biopsies (per 1000)
‹2.0
0.5
0.5
In situ rate (per 1000)
≥0.5
1.5
1.5
Invasive cancer rate (per 1000)
≥1.6
6.2
6.1
Invasive cancers ‹15mm (per 1000)
≥1.7
3.3
3.3
Total number women rescreened
–
1,663,136
1,675,790
SDR
≥1.0
1.4
–
No. screened
Benign biopsy
No
%
Prevalent
339,364
580
0.17
Incident
1,663,136
794
0.05
Self/GP referral
44,357
42
0.09
Short-term recall
1,183
18
1.52
Table 8: Assessment outcomes age 45 – 74
Following the previous table, the data in this table show the current
use of non-operative techniques in women aged 45 – 74.
Table 6: Screening – women aged 71 and over
No. screened
This year 88,962 women aged 71 and over were screened – an
increase of 14,805. This continued rise can be attributed to the
age extension to the Programme. Before implementation of the
age extension, all but a few women in this age group had accessed
screening via a self-request.
Year
2009/10
2010/11
Total women screened
74,157
88,962
Recall rate
4.5%
4.3%
Benign biopsies (per 1000)
0.7
0.6
In situ rate (per 1000)
2.6
2.5
Invasive cancer rate (per 1000)
12
12.3
Invasive cancers ‹15mm (per 1000)
6.3
6.2
Benign biopsy
No
%
Prevalent
423,777
734
0.17
Incident
1,675,790
805
0.05
Self/GP referral
87,809
63
0.07
Short-term recall
1,232
18
1.5
17
2010 – 2011 breast
screening statistics
Table 9: Treatment of screen detected breast cancer
Table 10: Immediate reconstruction after mastectomy
Lumpectomy (which conserves the breast) remains the most
common treatment for breast cancer, whether in situ or invasive.
Just over a quarter of women diagnosed with invasive breast
cancer receive a mastectomy, while the figure is slightly higher for
in situ and micro-invasive disease. These figures come from the
Association of Breast Surgery (ABS) NHSBSP audit.
This year 23% of women received immediate reconstructive surgery
following a mastectomy, which is a slight increase on the year
before. This year’s figures show a continued trend towards women
receiving immediate reconstructive surgery following mastectomy.
The proportion of women undergoing immediate reconstruction
who have invasive or in situ disease remains constant.
Treatment for in situ cancers (non-invasive and micro-invasive)
2009/2010
77% No immediate
reconstruction
70% Conservation
29% Mastectomy
1% No surgery
2009/10
20% Immediate
reconstruction
3% Unknown
Of the % given immediate reconstruction
Treatment for invasive cancers
75% Conservation
24% Mastectomy
1% No surgery
64% Invasive
2009/10
36% Immediate In situ
(non-invasive/
micro-invasive)
2010/2011
76% No immediate
reconstruction
2010/11
23% Immediate
reconstruction
1% Unknown
Of the % given immediate reconstruction
62% Invasive
2010/11
18
NHS Breast Screening Programme Annual Review 2012
38% Immediate In situ
(non-invasive/
micro-invasive)
Table 11: Total screening activity for all ages
The information in this table represents complete data for all women
screened in the UK breast screening programmes. The number of
women screened aged under 50 and over 71 has increased in line
with expectations as the age extension to the Programme is rolled
out. The rise in incidence of breast cancer with age is reflected in an
increasing cancer rate as women get older and is highest in those aged 75 and over, all of whom will have accessed screening via self-request.
Cancers detected
Referred
for assessment
In situ and
micro invasive
Invasive
<15mm (<10mm)
Total*
Age group
No.
screened
No.
assessed
% of
screened
No.
detected
% of
screened
No.
detected
% of
screened
No.
detected
% of
screened
No.
% of
screened
Under 50
84,973
6,480
7.6
155
0.18
365
0.43
150
0.18
520
0.61
50 – 64
1,591,941
65,785
4.1
2,436
0.15
8,816
0.55
4,466
0.28
11,268
0.71
65 – 70
456,099
15,657
3.4
800
0.18
3,904
0.86
2,118
0.46
4,711
1.03
71 – 74
55,615
2,219
4.0
136
0.24
623
1.12
319
0.57
759
1.36
75 and over
33,347
1,567
4.7
86
0.26
469
1.41
230
0.69
556
1.67
Total (all ages)
2,221,975
91,708
4.1
3,613
0.16
14,177
0.64
7,283
0.33
17,814
0.80
* Discrepancies between totals are because the invasive status of some cancers is not known.
19
Regional Data
These four tables give a breakdown of the figures for breast cancer
screening across the UK. London continues to lag behind the rest
of the UK in terms of uptake, but matches the rest of the country in
terms of detection rate.
Table 12: Outcome of prevalent (first)
screens by region – women aged 50 – 70
Region
Table 13: Outcome of incident (subsequent)
screens by region – women aged 50 – 70
Acceptance Recall
Benign
biopsy
Invasive
cancer
detection
% of invited % of
screened
% of
screened
rate per
1,000
screened
North East
74.4
5.8
0.08
5.1
Yorkshire &
Humber
70.8
6.6
0.07
East Midlands
75.8
6.4
West Midlands
70.6
North West
Acceptance Recall
Benign
biopsy
Invasive
cancer
detection
% of invited % of
screened
% of
screened
rate per
1,000
screened
North East
83.8
2.5
0.03
6.0
5.5
Yorkshire &
Humber
82.8
2.8
0.03
5.9
0.13
5.7
East Midlands
85.1
2.6
0.03
5.8
6.8
0.21
4.9
West Midlands
83.0
2.6
0.05
6.0
68.6
8.5
0.19
5.2
North West
81.2
3.3
0.05
6.4
East of England
72.0
7.7
0.24
5.0
East of England
84.5
2.6
0.05
5.9
London
59.0
8.0
0.12
4.9
London
76.0
3.0
0.04
5.6
South Central
71.3
8.7
0.20
6.4
South Central
82.9
3.0
0.06
6.5
South East Coast
67.9
7.6
0.24
5.1
South East Coast
81.7
3.0
0.05
6.1
South West
71.6
9.6
0.23
5.5
South West
83.7
3.5
0.05
5.9
Scotland
73.2
9.4
0.16
5.7
Scotland
83.4
3.9
0.06
7.5
Wales
71.6
9.0
0.26
5.9
Wales
83.1
4.1
0.06
7.7
Northern Ireland
73.1
8.7
0.16
6.5
Northern Ireland
84.6
3.0
0.04
5.5
1
1 Data omitted where not comparable
The South East region (as referenced in previous annual reports) has now been
subdivided into two separate regions: South Central and South East Coast.
20
NHS Breast Screening Programme Annual Review 2012
Region
1
1 Data omitted where not comparable
The South East region (as referenced in previous annual reports) has now been
subdivided into two separate regions: South Central and South East Coast.
Table 14: Outcome of self/GP referrals
by region – women aged 50 – 70
Region
Referral
Table 15: Standardised detection ratio
by region – women aged 50 – 70
Benign
biopsy
Invasive
cancer
detection
% of
screened
% of
screened
rate per
1,000
screened
North East
4.3
0.06
6.1
Yorkshire &
Humber
4.5
0.03
8.1
East Midlands
3.6
0.06
7.1
West Midlands
4.9
0.06
5.4
North West
5.7
0.05
9.3
East of England
4.7
0.06
10.4
London
5.8
0.12
7.6
South Central
4.6
0.16
6.2
South East Coast
6.5
0.15
10.9
South West
6.2
0.09
7.7
Scotland1
6.9
0.11
6.1
Wales
6.3
0.20
8.1
Northern Ireland
6.4
0.11
7.4
1 Data omitted where not comparable
The South East region (as referenced in previous annual reports) has now been
subdivided into two separate regions: South Central and South East Coast.
Region
Prevalent
Incident
Overall
North East
1.29
1.40
1.38
Yorkshire &
Humber
1.53
1.38
1.40
East Midlands
1.57
1.35
1.38
West Midlands
1.36
1.44
1.43
North West
1.39
1.48
1.47
East of England
1.37
1.38
1.38
London
1.25
1.35
1.33
South Central
1.76
1.56
1.59
South East Coast
1.37
1.39
1.39
South West
1.54
1.39
1.42
Scotland
1.50
1.77
1.71
Wales
1.58
1.78
1.75
Northern Ireland
1.60
1.16
1.26
Total
1.45
1.46
1.45
(Total previous
year)
(1.47)
(1.44)
(1.44)
The South East region (as referenced in previous annual reports) has now been
subdivided into two separate regions: South Central and South East Coast.
21
NHS Breast Screening Programme
Fulwood House
Old Fulwood Road
Sheffield
S10 3TH
www.cancerscreening.nhs.uk
© NHSCSP 2012
ISBN 978-1-84463-093-6
Editor: Professor Julietta Patnick CBE, Director, NHS Cancer Screening Programmes
Production: hanover
Design: Straightedge.co.uk
Illustrations: David Holmes