1 Cancer Epidemiology Centre, Cancer Council Victoria, Carlton South, Victoria; 2 Breast Screen Victoria Inc., Carlton South, Victoria, Australia
Received 18 July 2002; accepted 3 April 2003
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Abstract |
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Key words: Australia, mammographic screening
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The BreastScreen Australia programme |
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BreastScreen Australia is overseen by a National Advisory Committee to which several working groups report in the areas of monitoring and evaluation, quality management, workforce and training, communication and education, and policy review. BreastScreen Australia aims to ensure that the programme is implemented in such a way that significant reductions can be achieved in morbidity and mortality attributed to breast cancer, to maximise early detection of breast cancer in the target population, to ensure equitable access to women in the target age range, to ensure that services are acceptable and appropriate, to ensure that screening is provided in dedicated accredited screening and assessment services and to achieve high standards of programme management, service delivery, monitoring and evaluation, and accountability [3].
The specific aims of the BreastScreen Australia programme are as follows: to achieve, after 5 years, 60% participation by women aged 5069 years and access by women aged 40 years; to rescreen all participants at 2-year intervals; to achieve agreed performance outcomes to minimise recalls, invasive procedures, false positives and negatives, and to maximise cancers detected (especially small cancers
10 mm in diameter); to refer women to appropriate treatment services and collect treatment information; and to ensure that funding is used only for services accredited according to national guidelines. In addition, BreastScreen Australia aims to: recognise and minimise real costs to participants; make information about mammographic screening available to all women in a comprehensible form; achieve patterns of participation representative of the target populations socioeconomicethniccultural profile; provide services in accessible non-threatening and comfortable environments; provide appropriate counselling, education and information; adopt sensitive procedures for notification of recall and minimise time between initial screen and assessment [3].
BreastScreen Australia has developed mechanisms to monitor performance. Programme sensitivity, rates of participation, re-screening, small cancer detection, ductal carcinoma in situ (DCIS) detection and interval cancers are reported on an annual basis by state and territory programmes and for Australia in addition to breast cancer incidence and mortality rates. With the intention of more comprehensive evaluation at the national level, a broad evaluation plan is being developed that would include morbidity indicators such as treatment types and patterns, waiting time in the assessment pathway, technical recalls and early reviews, invasive procedures, true- and false-positive outcomes, and true- and false-negative outcomes. Other monitoring areas that might be included in this plan concern equity of access, efficiency and satisfaction.
Essential to evaluation has been the development of systems and standards for data collection. Informed consent is obtained from participants so that their data are available for evaluation and research to improve the programme. In this way, programmes are matched to state and territory cancer registries and death registries to facilitate death clearance and interval cancer identification. A data dictionary has been developed to standardise definitions as these varied between geographic jurisdictions when the programme commenced, delaying national reporting. Information with which to measure national performance is contained in reports for 199495, 199697 and 199698 [46]. A report for women screened in 1999 and 2000 is in preparation.
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Evidence of potential benefit |
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The most recent national report [6] included three process indicators: the participation rate, the small cancer detection rate and programme sensitivity. The programme minimum standards require participation by 60% of women aged 5069 years for screening services that have been established for 5 years or more; and women aged 5069 years to be >60% of the total number screened. The crude participation rate in 199798 was 54.3%. Women aged 5069 years comprised 67.4%.
In 1998, 70% of all small invasive cancers were detected in women aged 5069 years. For women screened for the first time in 1998, the age-standardised rate (ASR) of small cancer detection was 18.6 of 10 000 women screened. The crude rates for all screening rounds combined ranged from 12.9 to 20.2 per 10 000 women screened in the target age group across the state and territory programmes. These rates comply with the National Accreditation Standard (more than eight cancers per 10 000 women screened). For women who had previously attended the programme, the ASR of small cancer detection for 1998 was 14.6 of 10 000 women screened aged 5069 years. Women attending for a subsequent screen had ASRs of small cancer detection ranging from 12.6 to 17.4 per 10 000 women screened in women aged 5069 years.
In 1998, 37% of invasive breast cancers were 10 mm. For women attending their first screening round, the ASR of all invasive breast cancers for women aged 5069 years was 59.3 per 10 000 women screened. The crude cancer detection rates for all women attending for the first time in 1998 was 47.5 cancers per 10 000 women screened (excluding DCIS), just under the National Accreditation Standard (>50 cancers, including DCIS, detected per 10 000 women screened). The ASR of all cancers for women aged 5069 years attending a subsequent screen in 1998 was 35.9. For women attending the programme for a subsequent screen in 1998, the crude national rate was 36.6 cancers per 10 000 women screened (excluding DCIS). These rates for the subsequent round comply with the National Accreditation Standard (>20 cancers, including DCIS, detected per 10 000 women screened).
Interval cancer rates were not available from all state and territory programmes and those from small services were based on small numbers. Excluding rates from programmes with <30 000 women screened aged 5069 years in a 2-year period, the range for first attendees is 2.46.5 and subsequent attendees 5.27.8 per 10 000 women years of observation (012 months after screening). Similarly, after excluding the smaller services, the age-standardised programme sensitivities for asymptomatic women aged 5069 years screened in 1996 ranged from 88.9% to 94.7%. These sensitivities are for women screened for the first time in 1996 and followed for 12 months after screening. The age-standardised programme sensitivity for asymptomatic women aged 5069 years who attended for a subsequent screen in 1996 ranged from 75.0% to 83.7%.
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The management of breast cancer in BreastScreen Victoria |
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Breast cancer incidence and mortality trends in Australia |
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Footnotes |
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References |
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2. Australian Health Ministers Advisory Council, Breast Cancer Screening Evaluation Steering Committee. Breast cancer screening in Australia: future directions. Australian Institute of Health: Prevention Program Evaluation Series No. 1. Canberra: AGPS 1990.
3. National Program for the Early Detection of Breast Cancer. National Accreditation Requirements, March 1994. Canberra: Commonwealth Department of Human Services and Health 1994.
4. BreastScreen Australia. BreastScreen Australia Statistical Report, 1994 and 1995. Canberra: BreastScreen Australia 1997.
5. Australian Institute of Health and Welfare (AIHW). Breast and cervical cancer screening in Australia 199697. AIHW Cat. No. CAN 3. Canberra: AIHW (Cancer Series number 8) 1998.
6. Australian Institute of Health and Welfare (AIHW). BreastScreen Australia Achievement Report 19971998. AIHW Cat. No. CAN 8. Canberra: AIHW (Cancer Series number 13) 2000.
7. BreastScreen Victoria: Annual Statistical Report, 2000. Carlton South, Victoria: BreastScreen Victoria 2001.