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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

Originally devised as a four-to five-year plan, the duration and scope of various activities is being adapted in light of the COVID-19 pandemic and to suit available resources, changes in clinical practice, and emerging evidence.

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)



Roadmap 

Based on these 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. 

In mid-2020 the project scope and timelines were expanded to incorporate priority activities drawn from the Roadmap and to complete new work relating to the COVID-19 pandemic. 

By December 2021, 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. 
  • Updates to the Roadmap as appropriate. 



Cancer Council Australia’s roadmap to evaluate, and potentially implement, more risk-based, personalised approaches to breast cancer detection and screening.

Topic 1. Evidence to guide decision making about risk-based breast cancer screening

1.1 Annual scoping-level summaries of evidence

a. Validated risk assessment tools (including new tools) plus high-quality case-control studies.

b. Overdiagnosis by risk group.

c. Risk-based screening modalities/protocols.

d. Modelled estimates of benefits and harms of risk-based screening protocols.

1.2 New activities to address gaps in evidence

a. Systematic review of validated risk assessment tools and breast density assessment tools.

b. Systematic review of modelled estimates.

c. Summary results from trials of risk-based population screening.

d. Collect complete information on current outcomes by risk group.

e. Develop protocols, in collaboration with AIHW and BreastScreen, to routinely report outcomes by risk group.

1.3 Clinical and health economics modelling

a. Selection of feasible and promising risk-based screening protocols for review (may include modelling current trials outside Australia).

b. Agreement about how to best measure the benefits, harms and costs of those protocols.

c. Collection of required clinical and health economics data, with careful management of sensitive financial information.

d. Modelling of selected screening protocols.

e. Consensus-based review of generated estimates (and further modelling as needed).

f. Recommendations for possible further evaluation of optimal protocols (e.g. by trial or evaluation studies).

Topic 2. Current clinical practices, and their role in risk-based breast cancer screening

2. Improved evidence on current clinical practices in risk assessment, advice and risk-based services

a. Updated information on BreastScreen jurisdiction-level practices, being mindful that data reporting requirements, including for ad hoc activities, are already significant.

b. Develop protocols, in collaboration with AIHW and BreastScreen, to routinely capture information on BreastScreen jurisdiction-level practices.

c. Evaluation of outcomes according to BreastScreen annual/biennial screening interval.

d. Evaluation of primary care risk-based management, including management of women referred to GPs by BreastScreen (due to increased risk and/or breast density) and women assessed as higher risk within primary care.

Topic 3. Stakeholders in risk-based breast cancer screening

3. Stakeholder engagement: 

a. Increased engagement with key stakeholders including BreastScreen jurisdiction Managers and other personnel as appropriate, existing BreastScreen committees, primary care organisations (e.g. RACGP), specialist groups (e.g. RANZCR), State and Territory health departments, and the AIHW.

b. A program website to share core activities and results.

c. Cancer Council led stakeholder forums.

d. Presentations of findings at public lectures, conferences and other stakeholder forums.

Topic 4. Consensus-based clinical recommendation

4. Activities to reach consensus-based recommendations

a. Establish suitable Expert Reference Groups for all project activities. This may require several different groups, selected for purpose.

b. Reach consensus on core evidence requirements to assess the relative benefits, harms and costs of risk-based screening protocols.

c. Review the core evidence as generated and assembled by this program and make consensus-based recommendations based on that evidence.

Topic 5. Trial or evaluation of risk-based screening protocols

5. Trials or evaluations

a. Review risk-based breast cancer screening trials in terms of their potential translation to the Australian setting.

b. Develop an implementation framework for evaluating any changes to the current program, including impact on disadvantaged populations, factoring in access to treatment, role of primary care in risk assessment, role of FCCs.

c. Undertake concurrent foundation activities to enable future trials/evaluations, e.g. BRAVO in other jurisdictions.

d. Design a trial or evaluation if warranted.



What about COVID?

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 

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

Dr Pietro Procopio 

Modeller 
Cancer Council NSW 
Melbourne School of Population and Global Health, The University of Melbourne 

Dr Louiza Velentzis 

Epidemiologist 
Cancer Council NSW 
Melbourne School of Population and Global Health,  The University of Melbourne

Dr Lara Petelin 

Postdoctoral Research Fellow
Cancer Council NSW 

Dr Sabine Deij 

Economist and Data Analyst, Cancer Council NSW 
Melbourne School of Population and Global Health, The University of Melbourne

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 

Emily Websdale

Administrative Support