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Roadmap for Optimising Screening in Australia - Breast

A project to build evidence and consensus to improve early detection of breast cancer.

Cancer Council Australia has been funded by the Australian Government to explore options for more risk-based, personalised approaches to early detection of asymptomatic breast cancer in Australia. 

Early detection services for women without breast cancer symptoms include population screening through BreastScreen Australia as well as risk-based surveillance services outside the screening program, such as Medicare-funded breast imaging for women with a strong family history and services provided through family cancer centres. 

The Roadmap for Optimising Screening in Australia – Breast (ROSA)*  project began in 2018. The research team is assembling evidence, undertaking modelling evaluations and working with stakeholders to reach evidence-based consensus on optimal pathways for risk-based approaches to the early detection of breast cancer. 



Background 

There is increasing interest in risk-based, personalised approaches to population breast cancer screening in Australia. 

This is driven by a growing body of evidence on breast cancer risk assessment and risk-based management, the emergence of new breast imaging technologies and a greater awareness among women of the personal, lifestyle and other risk factors associated with developing breast cancer. 

For example, breast density is an established risk factor for both breast cancer and reduced accuracy of mammograms. However, there is no conclusive evidence nor scientific consensus on how breast density should be measured and combined with other risk factors, how to best screen women with high or low breast density, or how best to communicate information about breast density and related risk factors to women and their health care professionals.

Population breast screening may be more effective if services are personalised to suit each woman’s estimated risk of breast cancer and to maximise the accuracy of screening tests.  



Roadmap update 2021

Based on research findings and consultation with various stakeholders, in 2019 the project developed a Roadmap outlining an evidence-based approach to evaluate, and potentially implement, more risk-based, personalised approaches to population breast screening and risk-based surveillance in Australia. This Roadmap specifies the key steps required to achieve a clear and feasible implementation plan, guided by stakeholder engagement and the best available evidence. 

The 2019 Roadmap will be adjusted in 2021 in light of the COVID-19 pandemic and other priority areas. 

Roadmap activities will draw on a wide range of expertise including the project Expert Advisory Group.



Clinical and stakeholder scans  

In 2019, the project completed environmental scans to help understand current risk-based practices within the current BreastScreen Australia program and other clinical services involved in the early detection of asymptomatic breast cancer. 

This included an overview of the range of clinical guidelines involving risk assessment and advice, existing practices around risk assessment tools, current trends in risk-based clinical practices, international practices, and Australian stakeholder activity and perspectives relating to risk-based practices.  

This analysis confirmed that while the majority of early detection services for asymptomatic women are provided through population screening by BreastScreen Australia, various primary care and specialist services contribute to risk-based surveillance of asymptomatic women outside the BreastScreen program. Various clinical guidelines are available for individual women’s risk assessment and management, and these guidelines currently differ in their definitions of risk and recommended management of different risk groups. This means that women can be provided with different information, advice and management depending on who they see, or where they live.

This work highlighted the importance of taking a whole-system approach in considering the impact of more risk-based, personalised approaches to population breast screening which also takes into account the guidelines and practices of risk-based surveillance services for women without breast cancer symptoms.



Summaries of evidence  

To support work towards evidence-based consensus, the project has produced detailed summaries of evidence on the following topics:  

  • Risk assessment tools  
  • Mammographic density assessment tools 
  • Risk-based screening modalities 
  • Overdiagnosis by risk group 
  • Critical appraisal of current trials of risk-based screening
  • Modelled estimates of risk-based screening 
  • BreastScreen Australia participation and outcomes by risk group  

These summaries confirm that breast cancer risk can be assessed at a population-level, identifying groups of women at higher, lower or average risk of breast cancer. Mammographic density can potentially be assessed at a population level, using automated or reader-assessed methods, to help estimate breast cancer risk and groups of women at higher risk of an interval cancer (a cancer diagnosed following a negative screening result). The evidence is mixed and would be best combined through rigorous systematic reviews.

There is potential for improved screening test accuracy for different risk groups through supplemental or alternative imaging, but the balance of benefits (improved sensitivity) and harms (poorer specificity, increased overdiagnosis) is not yet clear. Several current international trials may be relevant to Australia, although their findings would not translate directly to the Australian health setting. Modelling studies indicate both potential benefits and harms of risk-based screening, with findings specific to the health settings in which they are set.

There is the potential to enhance current routine collection and reporting of BreastScreen data for different risk groups. This is important to better understand current outcomes, and to establish baseline information if more risk-based approaches are introduced.

*Prior to 2021, the ROSA project was known as Optimising Early Detection of Breast Cancer in Australia (OEDBCA)



Project activities 2021-22

By March 2022, the project will produce: 

  • Clinical and health economics modelling to evaluate the likely benefits, harms and costs of various risk-based population screening protocols, with input from various stakeholders on priority protocols to include in the evaluation. 
  • A critical appraisal of international population-level trials of risk-based population screening in terms of (i) evidence about the benefits and harms for different risk groups and (ii) their potential translation to the Australian health setting. The translation component involves consultation with various stakeholders. 
  • Systematic reviews that critically review and compare available tools for breast cancer risk assessment and measurement of mammographic density.
  • Updates to other previously prepared summaries of evidence.
  • Updated information on BreastScreen Australia jurisdiction-level risk-based screening practices and policies, and related data and reports. 
  • A protocol, developed in collaboration with the Australian Institute of Health and Welfare (AIHW) and relevant stakeholders, for enhanced routine BreastScreen Australia data collection and reporting for women in different risk groups.
  • Additional analyses of linked breast cancer screening, cancer registry and mortality data, in collaboration with the AIHW. 
  • A special report on how project findings and plans relate to the COVID pandemic and its impact on Australian population breast cancer screening and related health services. 

What about COVID-19?

The COVID-19 pandemic has had a significant impact on the BreastScreen Australia program, leading to a temporary pause in services in early 2020 and ongoing changes in screening clinic protocols. While Australian Institute of Health and Welfare data shows 144,000 fewer women were screened in January-June 2020 compared with the same period in 2018, national throughput had recovered to around 85% by June.

We are working with the Australian Government Department of Health to ensure our project adapts as needed to reflect the impact of COVID-19. This includes finding the best options for more risk-based services for early detection of breast cancer in a COVID-impacted world.



Project team 

The project is led by Associate Professor Carolyn Nickson, supported by a Project Coordination Group.  

In 2018 the project established an Expert Management Group (EMG) of 30 members, who helped establish the range of evidence to be collected, reviewed the interim findings, and helped identify priority activities for the next stage of work. The current program of work is now guided by a smaller Expert Advisory Group of independent, multidisciplinary experts.

Project Coordination Group 

Associate Professor Carolyn Nickson, Project lead 

Cancer Council NSW 
Associate Professor, University of Melbourne
Adjunct Associate Professor, University of Sydney

Professor Karen Canfell – Executive Lead  

Cancer Council NSW, The University of Sydney 

Professor Bruce Mann – Co-Chair - Expert Advisory Group  

Professor of Surgery, The University of Melbourne 
Director of Breast Tumour Stream, Victoria Comprehensive Cancer Centre 

Paul Vardon - Co-Chair Expert Advisory Group 

Director Cancer Screening Unit, Queensland Heath 
Chair, BreastScreen Australia Program Management Group 

Megan Varlow - Stakeholder Engagement, Strategy 

Director, Cancer Control Policy  
Cancer Council Australia 

Paul Grogan - Project Adviser

Senior Strategic Adviser, Pathways  
Cancer Council NSW  

Project staff

Associate Professor Carolyn Nickson 

Stream lead 
Breast Cancer Policy and Evaluation
The Daffodil Centre
Associate Professor, University of Melbourne
Adjunct Associate Professor, University of Sydney

Dr Pietro Procopio 

Modeller 
Breast Cancer Policy and Evaluation
The Daffodil Centre
Melbourne School of Population and Global Health, The University of Melbourne 

Dr Louiza Velentzis 

Epidemiologist 
The Daffodil Centre
Melbourne School of Population and Global Health,  The University of Melbourne

Dr Lara Petelin 

Postdoctoral Research Fellow
Breast Cancer Policy and Evaluation
The Daffodil Centre

Dr Sabine Deij 

Economist and Data Analyst
The Daffodil Centre 
Melbourne School of Population and Global Health|
The University of Melbourne

Dr Saima Islam

Research Fellow
The Daffodil Centre
Breast Cancer Policy and Evaluation Stream

Amanda Tattam

Project Coordinator – stakeholder communications
Cancer Council NSW

Suzanne Hughes 

Systematic Reviewer  

Victoria Freeman 

Systematic Reviewer 

Denise Campbell  

Systematic Reviewer 

Chelsea Carle  

Systematic Reviewer 

Paige Todd

Administrative Support