Health authorities/governments are guided by World Health Organisation (WHO) internationally recognised criteria on population screening programs. The primary principle underpinning criteria is to assess if the program will do more good than harm at a reasonable cost. Assessment often involves program trialling ie. Pilot to provide information to support full program. BreastScreen and the bowel cancer program ( Australia) began their lives as pilots. BreastScreen program piloted in 10 sites throughout Australia. In Victoria pilot program (1987) located at Essendon hospital.
WHO criteria used to assess BreastScreen program the pilot phase. The WHO has defined 10 principle to assess and endorse public health screening programs. 1. The condition will be a major health problem 2. There should be an acceptable treatment for patients 3. Facilities for diagnoses and treatment should be available 4. There should be a recognisable latent or early symptomatic stage 5. There should be a suitable screening test or examination 6. The test should be acceptable to the population 7. The natural history of the disease should be adequately understood 8. There should be an agreed policy on who to test and treat as patients 9. It should be a cost-effective means of controlling the disease 10. The process should be a continuing one – not a ‘one-off’ project
In Australia we have three national cancer screening programs Papscreen and Bowel screening and Breast screen that fit the modified WHO criteria for screening
The evidence or rationale to support mammography based population screening programs to reduce deaths from breast cancer come from a number of studies and randomised controlled trials. These trials first commenced in 60s and conducted in 4 different countries: USA, Sweden, Canada, Scotland over a period of about 20 years. The first mammography based population screening programs for breast cancer were introduced in Iceland and Sweden in 1987. Many other western countries soon followed suit.
breast cancer is a significant health issue for Australian women. BreastScreen Victoria: seven screening and assessment services established across the state over four years. All Australian states/territories have a breast cancer screening program. Program is free, employs mammography screening and aims to detect breast cancer in its early stage. The target population for the program is women aged 50-69. The program is implemented locally and jointly funded by the federal and state governments. The quality and operation of the program is monitored through a continuous accreditation process which measures the performance of each service against a set of nationally agreed standards.
O’seas study from Sweden indicate that screening 70% of the target population we will see a 30% reduction in mortality. Breast Cancer is the most common cause of cancer-related death in women in Australia. Research shows screening women 50-69 is an effective way to reduce mortality. 5 year survival rate increased from (70.9% 1982-1986) to 86.6% 1998-2002) [Breast Cancer in Australia: an overview, 2006). Early detection means early in the life of the disease. Why? For a better chance of successful treatment & recovery
Breast cancer size and survival Finding breast cancer early increases the chance of surviving the disease. Women diagnosed with smaller tumours have considerably higher survival rates than women diagnosed with larger tumours. The five-year relative survival for women with smaller tumours at diagnosis (≤10mm) was 98 per cent compared with 73 per cent for women with larger tumours (≥30mm).
Survival Survival figures provide information on the likelihood that a woman will still be alive at a specified point in time (such as five years) following a diagnosis of breast cancer. Women diagnosed with breast cancer are now surviving significantly longer than ever before. Out of every 100 women diagnosed with invasive breast cancer 25 years ago, only 73 women were alive five years later. Today 88 out of every 100 women are alive five years after a diagnosis of breast cancer. Improvements in survival are attributed to earlier detection of breast cancer through mammography screening and improved treatments for breast cancer. Survival is even higher for those diagnosed with very early breast cancer.
No screening test for lung and ovarian as there is no test out there that meets the criteria of a screening program.
In Victoria too, since the introduction of the BreastScreen Victoria program we have seen similar results. Graph, taken from the latest statistics Cancer Council Victoria, shows number of new cases diagnosed in Victoria has become stable after a rise coinciding with the introduction of the BreastScreen Victoria program in the early 90s (Canstat: Cancer in Victoria 2005, The Cancer Council Victoria Epidemiology Centre 2008: 16). In Victoria number of women who have died from the disease, has shown a downward trend (Canstat: Cancer in Victoria 2005, The Cancer Council Victoria Epidemiology Centre 2008).
What we do
Recruitment strategies are targeted at women aged 50-74 These women receive a letter of invitation from electoral roll Women aged 40-49 years and over 74 are eligible. – but they won’t be sent an invitation or reminder. It is recommended that well women routinely attend BreastScreen every 2 years and a reminder is sent to them The program complements Breast Awareness and educating women about breast awareness is a key feature of the program
Increasing age is one of the strongest risk factors with about 3 out of every 4 cases of breast cancer occurs in women aged 50 years and older (Risk factors fact sheet, NBOCC website, 2008). And as we have learned, screening using mammography is the best early detection method available for reducing deaths from breast cancer (Breast Cancer Screening, IARC Handbooks of Cancer Prevention, Volume 7, 2002; Early Detection of Breast Cancer, Position Statement, NBCC, 2004) Evidence of the benefit is strongest for women aged 50 to 69 years (Breast Cancer Screening, IARC Handbooks of Cancer Prevention, Volume 7, 2002; National Information Statements, BreastScreen Australia, 2003). About 1 in 250 women in their 30s will develop breast cancer in the next ten years and about 1 in 30 women in their 70s (Risk factors fact sheet, NBOCC website, 2008). So younger women and women over 70 are still at risk.
We can see here an example of the difference between younger and older women’s breast tissue and how it shows up on a mammogram in this comparison between two mammograms. The tissue of younger women’s breasts is usually more dense than that of older women and can show up as white areas on the x-ray. Breast cancers also show up as white areas on x-rays. This makes breast cancer more difficult to detect in screening mammograms. This means that screening mammograms could be less accurate at finding breast cancer for women in their 40s compared to women aged 50 to 74. Therefore, for women in their 40s compared to older women: - It is less likely that breast cancers will be detected and - more women will be asked to come back for further tests when they don’t actually have cancer (National Information Statements, BreastScreen Australia, 2003).
What we do
Invasive cancer: A primary malignancy invading surrounding tissue within breast DCIS: Ductal carcinoma in situ (DCIS) is an abnormal proliferation of cells confined to the mammary ducts. If left untreated DCIS may increase the risk of developing invasive breast cancer in the future 11-12 = 206,178 (actual) 12-13 = 223,000 (target)
Current research shows that the benefits of having regular screening mammograms outweigh any possible risks from radiation. This means that sometimes a woman’s screening mammogram may look abnormal, and she might be recalled for further tests. Most women who are called back for further tests do not have breast cancer. It also means that for a small number of women the screening mammogram might not find a breast cancer that is present. It is not possible to be sure which breast cancers found by screening will develop into a life-threatening cancer. Therefore, some women receive treatment that might not have been necessary in an effort to reduce their risk of a life-threatening cancer in the future.
Creating anxiety For some women anxiety associated with the test may be greater than the perceived benefit, Particularly for 7% recalled for further investigation Just because there are changes doesn’t mean there is cancer. (9 out of 10 changes are not cancer). For some women the time between being recalled and a final result will cause a lot of anxiety. Over Treatment Some women may be diagnosed with breast cancer that would not develop into a life-threatening cancer. Unfortunately it is not possible to differentiate between a breast cancer that would become life threatening and one that would remain dormant for the duration of the woman&apos;s life. Therefore, some women receive treatment that might not have been necessary in an effort to reduce their risk of a life-threatening cancer in the future. Exposure to radiation dose dose of radiation used in screening mammography is very low, so small the benefits of screening are deemed to far outweigh any radiation risk. the Breast tissue is easy to penetrate and a small dose is sufficient to produce an adequate image
Thank audience for attention If you would like any further information… Questions?
BreastScreen Victoria overview for Radiographers
BreastScreen Victoria (Australia)
Overview of BreastScreen Program
Nikki McGrath, Health Promotion Manager
• Background on Population Health Screening
• BreastScreen Australia
• BreastScreen Victoria Program
Where can women screen
Set criteria by World Health Organisation with a principle that
‘programs do more good than harm’ at a reasonable cost.
World Health Organisation Principles
• Aim to increase detection and reduce the impact of disease by
testing a healthy population
• There must be a good chance that subsequent treatment can
increase survival from the disease
• Australia uses modified WHO principles to guide screening
• Acceptable screening test repeated at intervals
Population based Australian cancer screening
Evidence for a population screening program for
• Studies and randomised controlled trials over 20 years in 4
• First mammography programs 1987 - Iceland and Sweden
• Now standard in many western countries - U.S.A, Canada,
U.K., Israel, France, Germany and Switzerland.
BreastScreen Australia – a population screening
program for breast cancer
• BreastScreen Australia established 1991
• Joint funding state/territory and Commonwealth
• State/territory implementation, local services manage
• National Accreditation Standards
To reduce breast
by 30% through
To screen 70% of
women in the 50 to 74
New cases and deaths in 2011 for cancers in
Victorian Cancer Registry
698 765 336
Breast Bowel Lung Ovary
New cases/deaths in 201
Type of Cancer
BreastScreen Victoria – The facts
• Free breast cancer screening program
• Asymptomatic women aged between 50-74
• GP referral not required
• Female radiographers
* In May 2013 the Commonwealth Government announced an extension to the target age range to 50-74. This
will be a staggered roll-out over the next 3 years
Recommendations for breast screening
• Communication strategies target 50-74 year olds
• All women over 40 are eligible
• Recommended every 2 years
• Complements Breast Awareness
BreastScreen Victoria program
Why women aged 50 to 74?
• Evidence shows breast screening reduces the most deaths in
this age group
• Mammograms are the most effective screening method for
finding early breast cancer in this age group
• Women in 40s and over are 74 still at risk
2008 age specific incidence and mortality
Under 30 30-39 40-49 50-59 60-69 70-79 Over 80
Age group at diagnosis / death
New cases / deaths in 2008
Victorian Cancer Registry
Pre/post menopause breast tissue
woman in her 40s
BSV Results- 11/12 financial year
• 204,279 women screened
• 83% women were aged between 50-69 years
• 84% women returning for 2nd + screen
• 996 invasive cancers and 308 DCIS diagnosed
• 608 invasive cancers were 15mm or less
Benefits of BreastScreen
• Regular screening prevents deaths from breast cancer
• Breast screens can detect majority of cancers early – even
before they can be felt or noticed.
• If breast cancer is found early, it is more likely to be small,
and successfully treated
• The earlier breast cancer is found, the better your chance
of surviving it
Limitations of BreastScreen
• Over – treatment:
• Some women may be diagnosed with breast cancer that would not
develop into a life-threatening cancer, therefore, some women may
receive treatment that might not have been necessary.
• Exposure to radiation
• Modern mammography machines use the smallest amount of radiation
possible while still getting a high quality X-ray picture. The radiation
from screening (which involves two X-rays of each breast) is about the
same as 18 weeks of exposure to natural radiation in the environment.
For more information or to make an
Or call 13 20 50
• Wilson JMG and Junger G (1968), Principles and practice of
screening for disease. WHO Public Health Paper 34, WHO,
• Breast cancer screening in Australia: future directions (1990)
• Breast Cancer Screening (2002) IARC Handbooks of Cancer
Prevention. IARC Press.
• National Breast and Ovarian Cancer Centre. Breast cancer risk
factors: a review of the evidence. National Breast and Ovarian
Cancer Centre, Surrey Hills, NSW, 2009