The biggest shake-up in breast cancer screening for thirty years
First mammogram at 40. Gene test to get a personal risk score. And four-year gaps between checks for some women. Just three steps experts are exploring in ...
TOP cancer doctors are carrying out research that may lead to the most radical shake-up of the NHS breast screening programme since its launch more than 30 years ago. Trials have been launched in a bid to remedy long-running concerns that the system is prone to false alarms and misses cases in some women.
Although more research would be needed before NHS screening chiefs would consider issuing new advice, if studies prove successful, women could be invited for their first mammogram at the age of 40 – a decade earlier than they are now.
Instead of a single scan they would be offered a battery of tests to determine a personalised breast cancer risk score, with the results used to decide when they next attend a screening.
In trials currently underway, those
identified as low risk – an estimated one in five women – are being told they don’t need to come back for another four years. Women at higher risk are invited for more frequent scans. The news comes after the outcry when health chiefs in Wales announced a big change to their cervical cancer screening programme – that women would get a smear test every five years, instead of every three.
Despite studies proving new testing methods are more accurate, meaning that a greater number of cancers will be detected even with less frequent tests, Public Health Wales was criticised for not explaining the move properly.
As revealed by this newspaper, NHS England quietly paused plans to follow suit, with insiders admitting they would ‘have to think carefully about how to present the decision in a more positive light’. Breast cancer screening is currently offered to all women in the
UK aged between 50 and 70 every three years. The programme aims to pick up the cancer at the earliest stages – before lumps can be felt and when a cure is more likely. Yet experts have long criticised the methods used. Mammograms – a type of X-ray – throw up false positives in roughly three in 100 women, causing unnecessary worry.
BREAST density – the term used to describe the ratio of fat, glandular and fibrous tissues within the breast – also represents a problem. Young women tend to have dense breasts, with higher amounts of glandular and fibrous tissue, and lower amounts of fat. Dense breast tissue appears white on X-rays – just like tumours – making the mammogram harder to interpret.
Research suggests the scans can miss up to 40 per cent of tumours in dense breasts, giving a falsenegative result.
Doctors also say that breast screening leads to the discovery of tiny, early-stage tumours that may never go on to grow or cause problems. The difficulty facing medical teams is that it is impossible to tell which of these will progress and which won’t, so they all get treated. This means surgery and possibly radiotherapy, chemotherapy and other drug treatments. In some cases, these lifechanging interventions may have been given unnecessarily.
Speaking on The Mail on Sunday’s Medical Minefield podcast this week, University of Cambridge radiologist Professor Fiona Gilbert, who is spearheading the new research in the UK, argued that regular mammograms were ‘proven to be a life-saver’ but accepted the criticisms. ‘We can do better,’ she said, adding that under the current system, ‘there will be some women who are labelled as having cancer which might never have harmed them’.
News reports earlier this month suggested some low-risk women may not need to ‘face the anxiety’ of regular screening at all, although the plans outlined to The Mail on Sunday prove doctors are taking a more cautious approach, with the potential to catch more cancers and tackle the downsides of screening.
In light of the earlier reports, last week The Mail on Sunday’s GP columnist Dr Ellie Cannon asked readers how they felt about their three-yearly mammograms – and she was flooded with responses. The verdict was near-unanimous: women felt regular mammograms were essential.
Many told stories of being diagnosed with breast cancer, thanks to the screening, which had been otherwise symptomless.
‘I would be dead and buried if it wasn’t for that scan,’ wrote Margaret Brown, 72, from Greater Manchester, summing up the general theme.
Sue Brown, from Sheringham, Norfolk, whose scan in 2020 picked up a breast tumour that she’d not been able to feel, wrote: ‘As a 62-year-old who doesn’t smoke and rarely drinks, I am low risk. Without regular screening this would have been missed.’
Hampshire-based Dinah Perkins, 59, said she had been diagnosed with breast cancer after a mammogram in early January. ‘It’s been caught early and is very small, but I’m still going to need surgery, radiotherapy and hormone therapy. It’s deep within my breast, so it might well be that, before I became aware of it, it could have already spread, with a much worse outcome.’
But not everyone felt this way. Marcia Kenny, 68, from Newport in South Wales, said: ‘I haven’t attended a scan for years.’
The retired Passport Office worker said she had given the matter a lot of thought: ‘I check myself regularly and I know my breasts are often lumpy. My big fear is that I’ll go for a mammogram and they’ll end up trying to investigate one of these lumps. I had a friend this happened to. She spent a month thinking she was going to die before being told it was nothing.
‘If something appeared in my breast that wasn’t supposed to be there, I’d know, and I’d go to the doctor straight away. I have done, in the past, just to be sure. If one day it’s cancer, then so be it.’
Marcia said her GP is aware she doesn’t attend her screening appointments. ‘I told her, I’m not on HRT [hormone replacement therapy, medication known to slightly increase the risk of breast cancer], I’m not a smoker or a big drinker, and I keep a healthy weight. I don’t have breast cancer in my family.
‘She agreed that I’m probably low risk and said she wouldn’t tell me what to do. In a couple of years, I’ll turn 70 and I’ll no longer be invited to have mammograms. Does that mean I’m suddenly safe from breast cancer? No. But I’ll keep checking myself, like I’m used to.’
AT PRESENT, just over 70 per cent of eligible women – more than two million a year – attend breast screening, and there are no plans to halt the programme. To the contrary, doctors are hard at work looking for ways to improve the system, and potentially better accommodate women like Marcia.
In a Cancer Research UK backed trial, being run by Prof Gilbert in Cambridge and at other sites across the UK, 8,000 women with dense breast tissue are being offered a range of scans.
Some will get ultrasounds – similar to those used in pregnancy – while others are having magnetic resonance imaging (MRI) scans, which can produce detailed images of soft tissues inside the body.
Another group are being offered mammograms, but first being injected with a harmless contrast dye that helps differentiate tumours from other breast tissues in X-rays. ‘We hope this will tell us which types of scan work best for women with dense breasts, so we will pick up cancer earlier with screening,’ said Prof Gilbert.
In another trial, thousands of women all over Europe are being offered tests from as young as 40 to determine their personal breast cancer risk score.
At Addenbrooke’s Hospital, Cambridge, and in Manchester and Leeds, 10,000 women are being recruited. Half will have standard three-yearly mammograms, while the other half will be given an initial set of tests, including a mammogram and other scans, to assess breast density, a saliva test determine whether they carry little pieces of genetic material that put
them at increased risk, and a detailed health questionnaire. Low-risk women will be recalled for reassessment once every four years, while higher-risk women will be called back as often as once a year.
Prof Gilbert said: ‘We’re much more likely to find breast cancer when women are in their 60s or 70s – age is the biggest risk factor – but younger women do get breast cancer too. And at the moment, we don’t offer younger women anything, unless they have a strong family history.
‘Instead of having a screening programme that starts at 50 for everybody, we need to be thinking more smartly.’
Breast cancer will affect one in eight women in their lifetime – more than 150 are diagnosed every day. Huge leaps forward in detection and treatment over the past 50 years mean eight in ten survive it, but the disease still kills more than 11,500 a year in the UK.
Breast screening was introduced in the UK in 1988 after large trials suggested that women who had regular mammograms were far less likely to die of breast cancer.
Similar programmes are carried out across the world, although details differ. In America, where healthcare is private, women are advised to book in for screening every year from the age of 40, with no upper age limit. In many European countries, women are invited for a mammogram every two years.
There have also been plans to expand the programme in the UK, offering scans to all women between the aged of 47 and 73 – although trials of this were paused at the start of the Covid pandemic and have not resumed.
Measuring the long-term success of breast screening has also proved complex. A number of major reviews in recent years have come to conflicting conclusions, causing heated debate among cancer experts.
In 2012, a Government commissioned report suggested the programme was responsible for a 20 per drop in breast cancer deaths. But critics claim many of the studies have been poorly conducted, and ignore the downsides of screening, including over-diagnosis and over-treatment.
Another report, carried out in 2013 by medical research body Cochrane, found that screening 2,000 women led to one fewer death, resulted in ten healthy women with ‘harmless’ cancers being treated unnecessarily, and led to 200 women experiencing ‘distress and anxiety’ due to false positive findings. This, too, was criticised – with some experts suggesting the reviewers were biased, and did not look at the benefits over a long enough time period.
Patient leaflets were subsequently rewritten to fully explain that the tests had both benefits and potential harms. However, there are cancer specialists who feel this is not enough.
One of them is University College London’s Professor Michael Baum, who is responsible for setting up the UK screening programme. ‘Breast cancer is a complex problem,’ he said. ‘I wanted screening to work. I was one of the pioneers. But it didn’t.
‘The drop we have seen in breast cancer mortality is due to better treatment. The mantra “catch it early, save a life” sounds convincing, but it simply doesn’t work.’
Prof Baum points out that the drug tamoxifen, for instance, which reduces deaths from breast cancer by at least a third, was launched at around the same time as screening. Some screening trials allegedly ignore the positive impact of drugs like this, and attribute these benefits to regular mammograms.
Professor Peter Schmid, clinical director of the Barts Breast Cancer Centre, St Bartholomew’s Hospital, worries that the debate has caused confusion. ‘I have no doubt that screening is beneficial, but it’s not perfect,’ he said.
‘We can now cure many breast cancers, even if they’re found at a later stage. This means it’s difficult to prove screening itself, and catching early cancer, is responsible for saving lives. But it’s not just about survival. If you catch an early-stage cancer, less treatment may be needed, which is a good thing.’
PROF BAUM and others say that the major problem is that the programme, in its current form, is too blunt – but even he seems to welcome the idea of improvements. He said: ‘As the science gets better and better we may be able to narrow down the minority of women at high risk of dying of breast cancer and offer them screening, rather than simply inviting everybody.’
There is one other aspect of screening that doctors and patients all agree could be improved: the comfort, or rather discomfort, caused by the procedure. Some research suggests up to half of women who skip regular mammograms do so due to being afraid of the pain.
Mail on Sunday reader Marcia Kenny recalled: ‘In my 20s, I remember women who were my age now chatting about how having a mammogram was like medieval torture. They said, don’t worry Marcy, by the time you’re our age they’ll have found some way of doing it that isn’t so painful. But they haven’t. I stopped having mammograms because it felt like they were putting my very small breasts in the fridge door and slamming it. With all the pulling, stretching and squashing, I was tender and sore for days, and I’m sure this did more harm than good. I know women with large boobs, and they say it’s painful for them too.’
Thermal imaging and other kinds of scans are offered by private clinics, but as yet mammography is the only proven test.
Prof Gilbert agreed another option would be ‘fantastic’ and that scientists are hard at work coming up with ‘smarter’ methods – and in the meantime said: ‘Come for your screening when you’re invited.’
I have no doubt that screening is beneficial, but it’s not perfect