With a large national screening programme, is there anything we can do to improve mortality and early diagnosis of breast cancer?
people die from breast cancer each year
According to Cancer Research UK, breast cancer is one of the most common cancer in the UK, taking around 12,000 lives a year.
Changes to breast screening
There have been changes to breast screening in which the age range for invitation has been extended to 47-49 and for some women 71-73. The Cancer Reform Strategy 2007 announced a policy of extending the range of women eligible for routine breast screening from 47 to 73 years of age, which is currently being rolled out across England. There is also an on-going study to evaluate whether extending the age range of breast screening reduces deaths from breast cancer. This is being carried out in 65 breast screening units across England. One important thing to note is that women aged 47-49 can request a screen without an invite if they live in an area that has started the age extension.
According to evidence in 2002 from the World Health Organisation’s International Agency for Research on Cancer (IARC), it was concluded that:
- Breast screening can reduce mortality in women aged 50–59 years by 25%, based on an intention-to-treat analysis.
- If the results of the trials were adjusted to allow for the effect of non-acceptance of the invitation by some women it could be estimated that the reduction in mortality from breast cancer in women aged 50–69 years who accept an invitation for breast screening is 35%.
- There is only limited evidence for screening women aged 40 to 49 years in whom the estimated reduction is 19%. However this figure may be lower as the effect may have been due to screening women when they were over 50 years of age.
A Marmot review on the NHS breast screening programme in 2012, concluded the following:
- 2,862,370 women screened (100, 000 more than the year before)
- 73.4% uptake
- More than 17,000 cancers detected
- The publication of a information leaflet, ‘NHS breast screening – helping you decide’
- Age extension being rolled out
- High-risk screening has been updated
Who is eligible for breast cancer national screening?
- Healthy women aged 50–70 years are offered routine screening every 3 years. The age extension roll out is due to be completed by 2016.
- Women at an increased risk of breast cancer (such as with a strong family history of breast cancer) may be eligible for breast screening before 47 years of age. Women who may be at increased risk can be referred to have their risk formally assessed and their management options, which include screening, discussed.
Women older than the maximum age for screening in their area are currently excluded from the routine screening programme. However, if they wish to continue to receive breast screening they can do so by contacting their local NHS Breast Screening Service directly.
NICE (2013) reviewed recent evidence and concluded that,
“women with an affected first-degree relative have approximately twice the risk of breast cancer compared to other women…The risk of breast cancer increases with the number of affected relatives, and increases as the age of those affected decreases.”
So how do you assess a woman's risk of breast cancer and need for referral?
NICE (2013) recommend the following: People without a personal history of breast cancer can be cared for in primary care if they have only one first-degree or second-degree relative diagnosed with breast cancer when over 40 years of age, provided that none of the following are present in the family history:
Bilateral breast cancer
- Male breast cancer
- Ovarian cancer
- Jewish ancestry
- Sarcoma in a relative younger than 45 years of age
- Glioma or childhood adrenal cortical carcinomas
- Complicated patterns of multiple cancers at a young age
- Two or more relatives with breast cancer on the father's side of the family
Refer people to secondary care who have:
- One first-degree female relative diagnosed with breast cancer under the age of 40 years.
- One first-degree male relative diagnosed with breast cancer at any age.
- One first-degree relative with bilateral breast cancer where the first primary was diagnosed under the age of 50 years.
- Two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age.
- One first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative).
- Three first-degree or second-degree relatives diagnosed with breast cancer at any age.
Refer directly to a specialist genetics service if a high-risk predisposing gene mutation has been identified (for example BRCA1, BRCA2, or TP53).
So what advice can you give as a GP in the prevention of breast cancer?
NICE (2013) recommend the following advice:
- Women at no increased risk of breast cancer
Encourage attendance at the local breast-screening programme for women 50 years of age and older.
Women who are older than the maximum eligible screening age in their area will not be sent for routinely but will still be able to self-refer.
- Women at increased risk of breast cancer
Ensure that women at increased risk of breast cancer are 'breast aware' in line with the Department of Health advice for all women.
Explain the principles of breast awareness, reporting promptly any changes. These can include: discomfort or pain; lumps, thickening, or bumpy areas; nipple changes or discharge; or changes in the appearance of the breast, such as in the shape or the presence of dimpling of the skin.
Advise women that the following can reduce the risk of breast cancer:
- Reduction of alcohol intake
- Maintenance of a healthy weight after the menopause
- Increasing physical exercise
- Having a first child at a younger age
- Having a large family
- Breastfeeding where possible