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NHS Breast Screening – The First 30 Years

NHS breast screening error affects 450,000 women

In May 2018, Health Secretary Jeremy Hunt announced to the House of Commons that a computer error had resulted in a failure to invite 450,000 women aged 68-71 in England for a screening mammogram, and that this had shortened the lives of as many as 270 women. A helpline has been set up (0800 169 2692), and the plan is to offer these women a screening mammogram within the next six months. Affected women who are concerned about recent changes in their breasts have been directed to their GP for advice and referral to a diagnostic breast clinic if necessary. 


For every 1000 women screened, approximately 70 women will be recalled for further assessment and 8 will be diagnosed with breast cancer. Based on a 70% uptake of the screening invitation, as many as 2000 breast cancers could therefore be diagnosed by screening the 315,000 women during the next six months, putting increased pressure on NHS waiting times for surgery and other breast cancer treatments. So can women now rely on the NHS breast screening programme moving forwards, especially those in their late sixties and early seventies?

How breast screening works

The NHS Breast Screening Programme was introduced in 1988, and offered 3-yearly mammography for women aged 50-65. The upper age limit has now been increased to 70 years old, and the age-extension trial is currently assessing breast screening for women aged 47-49 and 71-73. Although the invitation for breast screening stops at age 70, women over 70 can request a mammogram every 3 years by contacting the breast screening centre directly or via their GP. Currently, 7% of all screen detected breast cancers are now diagnosed in women aged 71-75, with a further 3% in women aged 76+, so screening of women aged 70+ remains an important part of the UK screening programme. So why should women accept the invitation for breast screening?

Many breast-screening trials have confirmed that the number of deaths from breast cancer is reduced by approximately 20% in women who attend for regular screening mammograms. The rational for this survival benefit is that screening enables breast cancers to be diagnosed at an earlier stage of

disease. It is now well documented that screen-detected cancers are

generally smaller, less aggressive and less likely to have spread beyond the breast compared to cancers that present as a lump or other symptom. As a result, women with a screen-detected breast cancer are likely to require less treatment and have a better outcome than those who present with a breast lump. Together with the establishment of specialist breast units in the UK, as well as increased awareness of the signs and symptoms of breast cancer, breast screening has contributed to a fall in the number of women dying from breast cancer since the late 1980’s onwards. 

Breast screening – the most audited NHS clinical service ever

The recent admission by the Department of Health that there was a failure to invite 450, 000 women aged 68-71 from 2009 onwards should not diminish the documented success of population-based breast screening programmes. Every year an audit of all screen-detected breast cancers is performed by the NHS screening programme in collaboration with the Association of Breast Surgery. These annual audits have reported that the detection rate of small cancers <15mm has increased from 2.7 per 1000 screened in 2000-2001 to 3.6 per 1000 screened in 2015/2016. The increased detection of smaller cancers will lead to less surgery and less overall treatment for those women diagnosed, as well as improved survival. A more worrying trend is the screening invitation acceptance rate has fallen to 71% in the UK, a 10-year low.

NHS breast screening – the future

An independent review of the NHS breast screening programme was conducted in 2012 and concluded that it prevents 1300 breast cancer deaths each year, while over-diagnosing 4000 women with a condition that would never have harmed them during their lifetime. With improved analysis of the genetic profile of breast cancers, it is hoped that the number of women over-treated due to this over-diagnosis will diminish going forward. The 2012 review however did not assess the frequency of screening, and whether women at higher risk should have more frequent screening and vice-versa.

Since the introduction of mammographic breast screening in the UK in the late 1980’s the UK had offered the same 3-yearly mammography programme to women regardless of their underlying breast risk. This has contributed to many women at low lifetime risk for developing breast cancer having unnecessary mammography and around 30% of women choosing not to accept the screening invitation, some of whom will be at high risk. There is now good evidence that risk-stratified breast screening, with the frequency of screening dictated by age and underling risk, can increase the efficiency of screening programmes while reducing their adverse consequences. 

Assessing a woman’s personal risk of breast cancer

In 2015, a multinational research group published a landmark paper that identified 77 minor genetic alterations (SNPs) that each cause a small increased lifetime breast cancer risk. The authors concluded that the overall risk score produced by testing these 77 SNPs could inform targeted screening and provide a powerful basis for stratified breast cancer screening. We now know that the result of this genetic test can be combined with a family history and lifestyle questionnaire and the density of the mammograms to provide a more accurate lifetime risk of developing breast cancer. 

By assessing each woman’s personal lifetime risk of developing breast cancer with these three components (genetic, breast density & family history/lifestyle) it is now possible to provide women with a personalised breast screening programme based on their age and risk. More than half of all breast cancers occur in the highest category of risk, so more effort should be made to target this high risk group with more frequent mammography and use of breast MRI scans. A Cambridge-based company has introduced the first worldwide breast cancer risk test (MyBreastRisk*) based on the 77 SNPs and family history questionnaire, but it is hoped that in time the NHS may consider adopting a similar strategy. 


The NHS breast screening programme has made a significant contribution to the reduction in the number of deaths in the UK from breast cancer during the last three decades. It is important that women are aware of the pros and cons before having breast screening, but in general women with a screen-detected breast cancer are likely to require less treatment and have a better outcome than those who present with a breast lump. In my opinion, the current screening programme could be enhanced by the introduction of risk-stratified breast screening as we have pioneered at Check4Cancer.

Professor Gordon Wishart is the Chief Medical Officer at Check4Cancer

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