Policy context

Breast Cancer Prevention Policy

BreastScreen Australia

BreastScreen Australia is a population-based mammography screening program. The program commenced in 1991, jointly funded by the Australian Government and State and Territory Governments, as the National Program for the Early Detection of Breast Cancer.

Access to BreastScreen Australia by Australian women is determined by age alone^[1]. While screening mammography is available to all women aged 40 and over, BreastScreen Australia is targeted specifically at well women with no symptoms aged 50–69 years; with the target group being extended to women aged 70–74 from 2013. Mammography screening is offered biennially at minimal or no cost to eligible women^[1].

Women aged 40–49 years at average risk of breast cancer may attend the BreastScreen program for biennial mammography screening, but are not actively invited to participate. This recommendation is based on consideration of breast cancer incidence, mortality benefit and potential risks of mammography screening in this age group.

Women aged 70 and over at average risk of breast cancer may attend the BreastScreen program for biennial mammography screening. Prior to 2013, women in this age group were not actively invited to attend for screening. However, from 2013, women aged 70–74 will be actively targeted by the program. The recommendations for women aged 70 and over are based on breast cancer incidence, and the mortality benefit and potential harms of screening, taking account of life expectancy for older women. In 2017-2018, 55.8% of women screened in BreastScreen Australia were aged 70 74 years.^[2]

BreastScreen Australia commits to providing information and support to women accessing the program. This includes advising women of the effectiveness and harms of screening mammography. Women are actively involved in decisions regarding any further assessment or treatment^[1].

BreastScreen Australia has a number of aims focused on program access and delivery, to maximise the impact of the program on breast cancer morbidity and mortality in Australia^[3]. The aims of the program are to^[3]:

implement the program such that statistically significant reductions can be achieved in breast cancer morbidity and mortality;
maximise early detection of breast cancer in the target population;
provide breast cancer screening in dedicated and accredited services;
ensure equitable access to the program for women in the target population;
provide services acceptable and appropriate to the needs of the eligible population; and
achieve high standards of program management, service delivery, monitoring and evaluation, and accountability.

All BreastScreen Australia services are reviewed and accredited every two years.

Program Participation

In 2017-2018, over 1.8 million women aged 50-74 received screening mammograms through BreastScreen Australia.^[2] This represents a participation rate of 55% of women in the target age group.^[2]

One of the key objectives of BreastScreen Australia is to achieve 70% participation by women in the target group^[3]. The BreastScreen Australia Evaluation indicated that the greatest potential improvement in screening-associated mortality benefit would be achieved with increased participation of women aged 50–69 years^[4]. Table 1 outlines the mortality benefit for specific age groups associated with 60% and 70% program participation.

Table 1. Mortality benefit associated with 60% and 70% participation in BreastScreen Australia, shaded area indicates BreastScreen Australia target age^[4]

Participation by the target group has mostly remained steady at 55–58% since reporting began in 1997–98, to the most recent reporting period of 2017–2018^[5][2]. However, due to population changes, the actual number of women participating in the program has steadily increased over this time^[6].

Despite the participation rate of 70% for the target group not currently being met, reductions in breast cancer mortality have been observed^[6]. The extent to which screening has affected breast cancer mortality ranges between estimates. See Potential benefits of screening for more information.

Rescreening rates are low. Just over 60% of women return for screening within the recommended two-year period following their first screen, this increases to 70% following a second screen and 85% following subsequent screens^[6].

Participation among population groups

The program aims to have patterns of participation reflect the socioeconomic, ethnic and cultural profiles of the target population^[3]. Screening rates in the target group do not differ substantially across socioeconomic tiers, but there is some variation in participation by remoteness area, with women in regional areas having the highest participation rates and women in very remote areas having the lowest participation rates^[6].

Across states, participation rates are highest in Tasmania (59.3%) and lowest in the Northern Territory (38.4%).^[2] (see Table 2).

Table 2. BreastScreen Australia age standardised state-based participation rates for women aged 50–74 in 2017-2018^[2]

From 2001 to 2017, screening participation by Aboriginal and Torres Strait Islander women aged 50-69 increased from 32% to 41%. However participation by the target group (40.7%) remained significantly lower than that of non-Indigenous women (54.2%)^[6]. After adjustment for socio-demographic differences, studies have found that women from Aboriginal and Torres Strait Islander communities participate less frequently in screening and re-screening, although this difference appeared to be lessening^[7][8].

There is evidence that breast screening participation among migrant groups is lower than that of Australian-born women. Migrants from East Asia, North Africa and the Middle East in particular have lower rates of participation in population-based mammography screening^[9].

BreastScreen Australia Program Evaluation

In 2005, the Australian Health Ministers’ Advisory Council instigated a full evaluation of BreastScreen Australia as the program had been fully functional for over a decade. The BreastScreen Australia Evaluation was undertaken by a committee of Australian and international experts, with the purpose of assessing the appropriateness, efficiency and effectiveness of the program.

A comprehensive evaluation of the program was undertaken including an economic evaluation, review of the accreditation system, policy analysis, participation studies and mortality studies. The evaluation reports are available on the Federal Department of Health cancer screening website.

Key recommendations

The BreastScreen Australia Evaluation Advisory Committee released the Evaluation Final Report in 2009. The report made a series of 19 recommendations on program delivery addressing^[4]:

changes to the target age range and program accessibility (see below);
participation rates in the target age group;
governance and management;
increasing program capacity;
screening policy for women at high risk;
reporting of program data;
quality improvement; and
exploring alternative service models.

Accessibility and participation

The Evaluation Final Report recommended that the program continue as a population-based screening program. However, changes to the accessibility of the program were recommended, principally that^[4]:

the target age range be extended to provide biennial screening for women ages 70–74 (implemented in 2013);
the program offer annual or biennial screening for women aged 45–49; and
that women aged 40–44 and women aged 75 years and older no longer be eligible to attend the program.

The BreastScreen Australian Evaluation reported that the greatest potential improvement in mortality benefit can be achieved by increased screening participation of women in the target group of 50–69 years^[4][10]. A greater mortality reduction among the target age group is associated with the target program participation rate of 70%, with the reduction in breast cancer mortality increasing from 21–28% to 25–34%^[4][10]. Improvement of participation rates was recommended particularly for Indigenous women, women from culturally and linguistically diverse backgrounds, and women living in very remote regions and major cities^[4]. A focus on improving rescreening participation rates, particularly after the first screening visit was also recommended^[4].

The final report concluded that there was no new evidence to support changing the screening interval from the current policy of biennial screening^[4].

Governance and management recommendations focused on improving national policy leadership to ensure consistency of policy across jurisdictions, and reviewing governance to ensure optimal capacity and efficiency^[4].

These recommendations were based on the available evidence and aim to deliver the greatest mortality benefit^[4].

References

BreastScreen Australia. BreastScreen Australia national accreditation standards: BreastScreen Australia quality improvement program. Canberra: Australian Government Department of Health and Ageing; 2008 Apr Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-accreditation/$File/standards.pdf.
Australian Institute of Health and Welfare. National cancer screening programs participation data. Canberra: AIHW; 2020 May 28 [cited 2020 Jun 5] Available from: https://www.aihw.gov.au/reports/cancer-screening/national-cancer-screening-programs-participation/contents/national-bowel-cancer-screening-program.
BreastScreen Australia. BreastScreen Australia national policy. Canberra: Department of Health and Ageing; 2010 Dec 17 [cited 2013 Mar 14] Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/national-policy.
BreastScreen Australia Evaluation Taskforce. BreastScreen Australia Evaluation. Evaluation final report. Canberra: Australian Government Department of Health and Ageing; 2009 Jun. Report No.: Screening Monograph No.1/2009. Available from: http://cancerscreening.gov.au/internet/screening/publishing.nsf/Content/programme-evaluation.
Australian Institute of Health and Welfare. National cancer screening programs participation data. Canberra: AIHW; 2019 Jul 11 [cited 2019 Jul 19]. Report No.: Cat. no: CAN 114. Available from: https://www.aihw.gov.au/reports/cancer-screening/national-cancer-screening-programs-participation/contents/summary.
Australian Institute of Health and Welfare. BreastScreen Australia Monitoring Report 2019. Canberra: AIHW; 2019 Oct 8 [cited 2019 Oct 15]. Report No.: Cat. no: CAN 128. Available from: https://www.aihw.gov.au/reports/cancer-screening/breastscreen-australia-monitoring-report-2019/contents/table-of-contents.
Roder D, Webster F, Zorbas H, Sinclair S. Breast screening and breast cancer survival in Aboriginal and Torres Strait Islander women of Australia. Asian Pac J Cancer Prev 2012;13(1):147-55 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22502658.
Cancer Australia. Study of breast cancer screening characteristics and breast cancer survival in Aboriginal and Torres Strait Islander women of Australia. Sydney: CA; 2012 May Available from: http://canceraustralia.gov.au/sites/default/files/publications/aboriginal_torres_strait_islander_women_breast_screening_report_may_2012_final_51183c0d8e50f.pdf.
Weber MF, Banks E, Smith DP, O'Connell D, Sitas F. Cancer screening among migrants in an Australian cohort; cross-sectional analyses from the 45 and Up Study. BMC Public Health 2009 May 15;9:144 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19442312.
Morrell S, Taylor R, Roder D, Dobson A. Mammography screening and breast cancer mortality in Australia: an aggregate cohort study. J Med Screen 2012 Mar;19(1):26-34 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22345322.