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K E Y P O I N T S

Breast screening uses X-rays - called mammograms - of each breast. Mammograms can reveal changes in breast tissue that are too small to be felt as lumps.

In the UK more than 14 million women have been screened so far and over 80,000 cancers have been discovered.

Swedish researchers compared breast cancer mortality rates in two Swedish counties 20 years before and after screening was introduced. The breast cancer death rate of screened women was nearly half that of non-screened women.

Sweden screens women from 40 years of age. In the UK, routine NHS screening involves 50 - 64-year-olds.

Private clinics can provide mammograms at an earlier age.

This research finds that mammography is beneficial and some experts suggest that routine screening from an earlier age in the UK should be considered.

Breast screening proves its worth

Bupa investigative news - 2 May 2003
written by Rachel Newcombe, reporter for Bupa's Health Information Team

Every year thousands of women are routinely screened for breast cancer. Early detection saves lives, yet the value of mammography has been debated. Important new research from Sweden has confirmed its benefits, showing a significant reduction in deaths after the introduction of screening. It's also raised the controversial issue of whether women should be screened from the age of 40.

What were the headlines?

Following the publication of research in The Lancet, most newspapers in the UK featured details of the key findings. Reports ranged from front page leads, to a few paragraphs, but most mentioned the issue of screening from an earlier age.

Headlines included, "Breast screening from 40 'could halve deaths'", "Breast cancer: screen women aged 40", "New study backs breast screening for the over 40s", and "Screening 'halves breast cancer death rates".

What is the bigger picture?

A team led by Laszlo Tabar from Falun Central Hospital in Sweden compared breast cancer mortality rates in two Swedish counties 20 years before and after screening was introduced in 1978. Women between 40 and 54 were screened every 18 months; older women were screened every two years. Included in the analysis were 210,000 women aged between 20 and 69 years old who were diagnosed with breast cancer. The results were published in The Lancet.

They discovered that women aged between 40 and 69 who received screening had a 44 per cent reduced risk of dying from breast cancer compared to those in the same age group who were diagnosed before the introduction of screening. For women who were not screened during the period after national screening was introduced, the reduced risk was 16 per cent. When the results for women aged 40 to 49 were looked at separately, the reduction in mortality was 48 per cent for those who were screened and 19 per cent for those not screened.

There was no evidence that improved treatment had a significant effect on breast cancer mortality for women younger than 40, an age group that is not routinely offered screening by the NHS.

Professor Stephen Duffy, a researcher involved in the study and professor of cancer screening at Cancer Research UK, said, "This produces very strong evidence that screening women for breast cancer, along with other improvements in breast cancer care, can almost halve the number of women who might otherwise die from the disease."

"Sweden gives us an unique opportunity to study the results of breast cancer screening over 20 years, as the NHS screening programme was only gradually introduced between 1989 and 1993," explained Professor Duffy.

Lead researcher Lazlo Tabar commented that, "Taking account of potential biases, changes in clinical practice and changes in the incidence of breast cancer, mammography screening is contributing to substantial reductions in breast cancer mortality in these two counties."

Although some question the value of screening, Professor Duffy thinks, "This study goes a long way towards silencing the dissenting voices." He added that, "It also suggests there is a good case for offering younger women the chance to be screened if they have any additional risk of getting breast cancer such as a strong family history of the disease."

According to Sir Paul Nurse, from Cancer Research UK, "We have always believed in the value of the National Screening Programme. Now we have even more powerful evidence that screening saves lives. This is the kind of research that has a direct impact on the health and well-being of women and should reinforce the Government's policy in urging women to take up their invitations to breast screening."

“I'm pleased the research produced such positive results, as it backs up what we've been doing for some years - screening women from age 40. A debate occurred about a year ago, in The Lancet, saying mammography wasn't worthwhile. It looks like this is a more substantial study and is much more in line with all the previous studies. Mammography is currently the best method of picking up very early breast cancer. It isn't foolproof and, just because you've had a normal mammogram it doesn't guarantee you will not get breast cancer, but it makes it much less likely.”

Dr. Peter Mace,
head of effectiveness and quality, Bupa Wellness

What does this mean?

Delyth Morgan, chief executive of Breakthrough Breast Cancer, welcomed the report, describing it as "a breath of fresh air in the breast screening debate." She said, "It echoes our long-held beliefs that early detection and diagnosis are vital to improve a woman's chances of survival from breast cancer and the essential role the NHS screening programme plays in ensuring this."

Clara Mackay, director of policy and research at Breast Cancer Care, was also pleased with the news. "Breast Cancer Care has always supported the NHS screening programme and this research shows that screening is indeed an effective tool in detecting breast cancer," she said.

In the UK women aged less than 50 aren't routinely screened. This is because their breast tissue is more dense - which makes spotting problems difficult - and the incidence of breast cancer is lower in this age group. But in Sweden women under the age of 50 are screened and the results of this study suggest that screening from 40 seems worthwhile. For this reason some organisations, such as Breast Cancer Care, believe the UK should consider screening from an earlier age.

Clara Mackay said, "We would strongly recommend a review of the breast screening programme to consider whether the age limit should be lowered. We need to be confident that screening services are available to everyone whom would benefit - regardless of age."

But Julietta Patrick, national co-ordinator of the NHS Breast Screening Programme (NHSBSP), stressed the benefits of the existing scheme. "The NHSBSP has always been based on sound research evidence and it has research programmes to examine the appropriateness of screening women under 50 and whether or not we need to alter the current screening interval," she said.

An NHSBSP frequency trial published in 2002 concluded that, "The screening interval for women over 50 is right at three years." An age trial involving 65,000 women aged 40 and 41 is underway looking at the benefits of screening in younger women - interim results are expected in 2005. "We await the findings of the age trial to see if it will be beneficial to screen women in England, annually from the age of 40," Julietta Patrick said.

A C T I O N P O I N T S

Be breast aware and follow Breast Cancer Care's five-point code:

Know what is normal for you
Know what to look and feel for
Look and feel
Report any changes to your GP without delay
Attend for routine breast screening if you are aged 50 or over

If you are aged more than 65, you can make an appointment for screening any time. Screening is available in many private clinics for 40-year-olds.

If you're worried about the risks of cancer, talk to your doctor.

What does this mean to me?

According to Julietta Patrick, women eligible for free NHS screening - all women between 50 and 64 years old - should be reassured by the findings. "This study will help reassure the 1.5 million women who are invited for screening in England, that the NHS Breast Screening Programme is an effective part of this country's efforts in reducing the death toll from breast cancer," she said.

If you're more than 65 years old, screening is also available whenever you feel the need. "Women aged 65 and over are entitled to, and can request a routine screening appointment every three years, whether or not symptoms are apparent," explained Delyth Morgan. "Your GP can arrange this for you."

Aware that some women may be concerned, Lisa Grosser, a younger women's breast cancer nurse at Breast Cancer Care, said, "Screening is an important part of the detection process for breast cancer, however as 80 per cent of lumps are detected by women themselves, we strongly encourage all women with presently no access to screening services to be breast aware."

Women who are at high risk of breast cancer can be screened by the NHS before the age of 50. Private clinics will provide the service to 40-year-olds and would consider a mammogram on a woman as young as 35 if their first-degree relative has breast cancer, said Dr. Mace. But, as Lisa Grosser pointed out, "It is important to remember that only 20 per cent of breast cancers occur in women under the age of 50." If a woman wishes to have an early mammogram, it is advisable to discuss her individual risks and benefits with her doctor to make a fully informed decision.

Summary

Screening for breast cancer aids early detection of the disease, speeding up the treatment and improving the chances of recovery. Whether or not the current age levels should be changed is a matter of continuing debate.