What is breast screening?

Breast screening is a method of detecting breast cancer at a very early stage. The first step involves an x-ray of each breast – a mammogram – which is taken while carefully compressing the breast. Most women find it a bit uncomfortable and a few find it painful. The mammogram can detect small changes in breast tissue which may indicate cancers which are too small to be felt either by the woman herself or by a doctor.

Women between the ages of 50 and 70 are invited for regular breast screening (every three years) under the NHS Breast Screening Programme. Coverage is the percentage of women in the population who are eligible for screening who have been screened within the last three years. The national lower threshold is 70% and the agreed standard for coverage is 80%.

Breast screening coverage in England increased from 64% in 2002 to 77% in 2009, where it remained stable until 2012 when it gradually began to decrease. In 2018, breast screening coverage was 75%; six million women were eligible for screening and 4.5 million women had been screened within the last three years. Coverage was highest in the 65-69 age group (76%) and lowest in the 53-54 age group (73%). There was also regional variation, with the East Midlands reporting the highest coverage at 78% and London reporting the lowest coverage at 69%.

If you have been invited for screening, or have been for screening and have any questions about the result, you should contact the name and address shown on your invitation letter or result letter. If you are worried about a specific problem, or otherwise worried about the risks of cancer, then you should talk to your GP. You GP can arrange the appropriate investigations such as a breast ultrasound scan to diagnose your symptoms.

What does the NHS Breast Screening Programme do?

The NHS Breast Screening Programme provides free breast screening every three years for all women aged 50 and over. Because the programme is a rolling one which invites women from GP practices in turn, not every woman receives an invitation as soon as she is 50. But she will receive her first invitation before her 53rd birthday. Once women reach the upper age limit for routine invitations for breast screening, they are encouraged to make their own appointment.

The programme is now phasing in an extension of the age range of women eligible for breast screening to those aged 47 to 73. This started in 2010 and is expected to be complete by 2016.

In September 2000, research was published which demonstrated that the NHS Breast Screening Programme had lowered mortality rates from breast cancer in the 55-69 age group1. In 2010, research undertaken by Stephen Duffy and others demonstrated that the benefit of mammographic screening in terms of lives saved is greater than the harm in terms of overdiagnosis. Between 2 and 2.5 lives are saved for every overdiagnosed case.

 

Why are women under 50 not routinely invited for breast screening?

Women under 50 are not currently offered routine screening. Research has shown that routine screening in the 40 to 50 age group is less effective. As a woman goes through the menopause the glandular tissue in her breast “involutes”, that is to say, the proportion of fat in her breast increases. This makes the mammogram easier to interpret.

However the DMIST study has shown that digital mammography is better for screening younger women and women with denser breasts, and is equally effective as film mammography in older women.

So the programme is now being gradually extended to women aged 47 to 49, as well as to those aged 71 to 73. The age extension of the programme is expected to be complete by 2016.

It is important to note that women of any age can ask their GP to refer them to a hospital breast clinic if they are concerned about a specific breast problem or otherwise worried about the risk of breast cancer. Although this is not part of the NHS Breast Screening Programme, the same techniques are used in both breast screening units and hospital breast clinics for diagnosing breast cancer and many staff work in both settings. Symptomatic patients sometimes choose to opt for a private ultrasound to avoid the waiting times.

 

Are women screened over the age of 70?

The NHS Breast Screening Programme screens women over the age of 70 but they are not sent routine invitations. They are encouraged, however, to request mammograms at their local unit every three years. We produce cards to help them remember to do this, which are handed out at their last routine breast screening appointment.

It is important to remember that all women, whatever their age, who are worried about new symptoms, should consult their GP without delay.

The NHSBSP in England is starting to extend routine invitations to women aged 71 to 73. This should be completed by 2016.

After this, women over 73 will still be able to request three yearly screening.

Screening women at higher risk

The Cancer Reform Strategy 2007 recognised that the opportunities and protocols for the surveillance of women identified as being at increased risk of developing breast cancer varied across the country. The strategy recommended that all women identified as being at higher risk, (for example, because of their family history), should be offered the opportunity to have their risk formally assessed and, where appropriate, to discuss their risk management options.

Improving Outcomes; A Strategy for Cancer [PDF 1Mb] (Published January 2011) reported that the NHS Breast Screening Programme would manage the surveillance of women at higher risk across England to national standards, thus ensuring that this group received a consistent and high quality service. The report concluded that surveillance with digital X-ray mammography and magnetic resonance imaging should be provided where appropriate.

Following successful pilots at three demonstration sites, this higher risk screening is now being rolled out across England.

Referrals into the NHSBSP will be via a genetics service or an oncologist (in the case of women treated with supradiaphragmatic radiotherapy) and will follow a set of imaging protocols agreed by the Advisory Committee for Breast Cancer Screening in January 2012.

When was the NHS Breast Screening Programme set up?

The programme was set up by the Department of Health in 1988 in response to the recommendations of a working group, chaired by Professor Sir Patrick Forrest, which had been set up to consider whether or not to implement a population screening programme in the UK. The report Breast Cancer Screening was published in 1986, and became known as The Forrest Report. The NHS Breast Screening Programme was the first of its kind in the world. It began inviting women for screening in 1988 and national coverage was achieved by mid 1990s.

 

Does breast screening save lives?

The Department of Health’s Improving Outcomes: A Strategy for Cancer, published January 2011, recognised that cancer screening was an important way to detect cancer early and that around a third of breast cancers are now diagnosed through screening.

Between 1 April 2009 and 31 March 2010, 2,133,189 women were screened by the NHSBSP in England, Wales, Northern Ireland and Scotland, and 17,013 cancers were detected in women of all ages.1

5-year relative survival for women with screen-detected invasive breast cancer improved significantly from 93.5 per cent in 1992/93 to 97.1 per cent in 2002/031

In 2010, research undertaken by Stephen Duffy and othersdemonstrated that the benefit of mammographic screening in terms of lives saved was greater than the harm in terms of overdiagnosis. Between 2 and 2.5 lives are saved for every overdiagnosed case.

In 2010, drawing on evidence from trends in population based mortality rates, Beral and Peto argued that
“In the UK, breast cancers are diagnosed earlier and treated more effectively than they were in the 1980s, and breast cancer mortality in middle age has been falling steeply, more so than in any other major European country”2

 

What happens at an NHS Breast Screening Unit?

The invitation

Every woman registered with a GP will receive her first invitation to attend for a mammogram at her local breast screening unit sometime between her 50th and 53rd birthdays. In some areas, where the programme has been extended, the first invitation could be at 47. She will then be invited every three years until her 70th birthday: By 2016, women should be routinely invited up to the age of 74. The NHS call and recall system holds up-to-date lists of women compiled from GP records, and records levels of attendance and non-attendance.

Women who have special needs, such as a physical or a learning disability, are asked to contact the breast screening unit at the address shown on the invitation letter. The screening unit can arrange a special appointment, usually at the hospital screening unit, where there is easier wheelchair access, better provision for a supporter to accompany the woman if she wishes, and more time can be allowed than is possible on a mobile screening unit.

At the screening unit

A visit to a screening unit for breast screening takes about half an hour. The woman is greeted by a receptionist or female mammography practitioner who checks her personal details (name, age and address). The mammography practitioner asks the woman about any symptoms or history of breast disease, explains what will happen when the mammograms are taken, and answers any questions about breast screening. If the woman is happy to proceed, the mammography practitioner then takes the mammogram. She explains when and how the woman will get her results, and reminds her of the need to be breast aware between screening appointments. If it is the woman’s last routine screening invitation, the mammography practitioner also reminds her that she can ask for another screening appointment in three years’ time.

The mammogram

The mammogram is a low dose x-ray. Each breast is placed in turn on the x-ray machine and gently but firmly compressed with a clear plate. The compression only lasts a few seconds and does not cause any harm to the breasts. Compression is needed to keep the breast still and to get the clearest picture with the lowest amount of radiation possible. Some women find compression slightly uncomfortable and some feel short-lived pain. Research has shown that for most women it is less painful than having a blood test and compares with having blood pressure measured.

The results

The mammograms are examined and the results sent to the woman and her GP within two weeks. In 2008/09 around 8.6 per cent of women attending for a first screen, and around 3.2 per cent1 of those attending a subsequent screen, were asked to go to an assessment clinic for a further mammogram, either for technical reasons (if the picture was not clear enough) or because a potential abnormality was detected.

Further investigation

At the assessment clinic, more tests are carried out. These may include a clinical examination, more mammograms at different angles or with magnification, or examination using ultrasound. A needle test (core biopsy) to sample the breast tissue may be carried out if the further tests confirm an abnormality. Core biopsy is done with a local anaesthetic.

 

Open biopsy

Some women (less than one per cent), may need a biopsy1.

What happens if cancer is found?

If a woman is found to have cancer, she is referred to a consultant surgeon for a discussion of the options available to her. This is essential before making any decisions on treatment. Many women have a choice about the type of treatment they receive depending on the type and location of their cancer.

Is there anyone to talk to?

Assessment clinics have a specialist breast care nurse available to give advice and help to women who are undergoing diagnostic tests or who have been diagnosed as having breast cancer.

Treatment

This usually involves some form of surgery: a lumpectomy where just the lump and a small amount of surrounding tissue is removed, or a mastectomy where the whole breast is removed. Surgery is likely to be followed by radiotherapy, chemotherapy or hormone therapy or a mixture of these. The exact course of treatment will depend on the type of cancer found and the woman’s personal preferences. Women might also be offered the opportunity to participate in research trials.

 

 

Further information about screening

Questions about screening results

  • For pregnancy or baby screening results, contact your midwife or health visitor.
  • For abdominal aortic aneurism or diabetic eye screening, contact your GP or your local screening programme.
  • For breast screening, cervical screening or bowel cancer screening, contact your GP, who should receive a copy of your results. You can also contact your local breast screening unit.

Questions about symptoms

Speak to your GP if you have any concerns about your health or need to ask about a family history of cancer.