Australia's national breast screening program 18 years on: time for a new direction?

Mammographic screening for breast cancer has been almost universally accepted as reducing mortality in the screened population through early detection. National breast screening services are now well established in many countries, including Australia, where BreastScreen was established in 1991. Since then BreastScreen has provided a high-quality service to Australian women. A major evaluation of the BreastScreen Program is underway, commissioned by the Australian Health Minister’s Advisory Council. This is an opportunity to reflect on the role of BreastScreen in the provision of breast care in Australia, to establish new and innovative directions, and to ensure the future relevance of the program. This article discusses the issues from the viewpoint of clinicians at the coalface, who are providing breast screening and treatment services, but who appear to be under-represented in the review process. Recent discussion in the international literature about the information provided to women attending breast screening programs further highlights issues with the process of breast cancer screening. The BreastScreen Australia National Accreditation Standards, against which individual services are evaluated, were set when the program was established and were updated in 2004. Individual services across Australia structure their programs quite differently while striving for these same standards. There is a lack of uniformity in many aspects of service provision, such as structure of the administration, quality assurance procedures, approach to women with a family history of breast cancer, use of clinical staff, data collection procedures, forms used and the approach to issuing results. Many of these processes could be standardized, and successful ideas from one service implemented across others. BreastScreen Australia aims for a participation rate of 70% of the target population (women aged 50–69); the current national participation rate is only around 52%. While there are a number of variables affecting participation rates, one of the key factors may be that this figure reflects participation in the BreastScreen, but this may not reflect participation in mammography screening in general. An unknown (and probably very significant) number of women have screening outside BreastScreen, and this ‘de facto’ screening is not monitored, partly because there is no Medicare rebate for screening mammography. In the 12 months from July 2007 to June 2008, Medicare paid rebates for 314,000 bilateral mammograms and 40,000 unilateral mammograms. Many of these private ‘diagnostic’ mammograms (eligible for a rebate) in women with a family history, past breast cancer or nodularity/mastalgia may be performed with screening intent. In addition, it is likely that a large (and unknown) number of women attend private screening (without a rebate). Ideally, de facto screening rates need to be monitored and matched to BreastScreen statistics to determine true screening participation rates and strategies to integrate de facto screening clients with BreastScreen could be developed. A challenge is to integrate women who choose to have yearly mammography plus ultrasound privately who may only be eligible for 2-yearly mammography alone in BreastScreen. A potential solution is to provide an Medicare item number for screening mammography in private practices when strict quality standards are met. This would increase the number of women registered as screened and provide more accurate population data. The information currently provided to women about the aims of BreastScreen and what it can realistically achieve for the individual is often given in the form of advertising material, which is possibly biased towards the benefits of screening and varies from one service to another. Such information provided during the initial consent process has been the subject of recent media attention following the publication of an article in the BMJ recommending the inclusion of information about ‘over-detection’ (over-diagnosis of non-lethal lesions with resultant treatment morbidity). While there is dispute about the extent of over-detection in screening, it must be acknowledged that there seem to be some in situ lesions that will never have the biological potential for invasion/metastasis, and it is reasonable that women be informed of this and some of the other disadvantages of screening to provide balanced information with which women can make choices. It is outside the mandate of screening services to manage the symptomatic population. This is still not understood by many women (who may self-refer to BreastScreen when they develop a symptom) and some referring medical practitioners (who refer symptomatic women to BreastScreen expecting they will have diagnostic mammography and assessment). Symptomatic women attending the screening program are problematic for several reasons: (1) BreastScreen is not resourced to investigate women with symptoms, all of whom require clinical breast examination (and often ultrasound and biopsy) in addition to mammography. (2) Women and their general practitioners may be falsely reassured by a negative result and not pursue the essential further investigation. (3) Cancers in symptomatic women may be incorrectly reported as ‘screen detected’, artificially increasing the reported cancer detection rate of BreastScreen. (4) ‘Screen-detected’ symptomatic cancers inflate the BreastScreen average tumour size, as these cancers are likely to be larger than screen-detected asymptomatic cancers, making it more difficult to achieve accreditation standards requiring a high percentage of cancers to be small. The approach to symptomatic women varies widely from one screening service to another. Those with the resources may recall all symptomatic women to an assessment clinic; others will refer the patient back to their general practitioner if mammography shows no suspicious features. This, however, puts the general practitioner (or specialist if referred) in a difficult situation as they do not have immediate access to the original and previous screening films. The decision must be made about whether to wait for and use copied BreastScreen films (technically inferior unless they are digital images) or to repeat the study (in conjunction with ultrasound and further work-up) at a private radiology practice that may not have a breast-trained specialist available. 674 Perspectives