In 1985 Mr. Kenneth Clarke, then Minister of Health, convened an expert committee chaired by Professor Sir Patrick Forrest, known as the 'Forrest Committee', to report on the effectiveness of screening for breast cancer, and how a screening programme would work in this country.
The committee presented its report to ministers in 1986, and concluded that ‘screening by mammography can lead to prolongation of life for women aged 50 and over. There is a convincing case on clinical grounds for a change in UK policy on the provision of mammographic facilities and the screening of symptomless women.’
The NHS Breast Screening Programme was established in March 1987 and began inviting women in 1988, at that time aiming to offer routine mammographic screening to each woman in the UK aged 50-64 once every three years.
The committee reviewed evidence on the effectiveness of screening for breast cancer from trials in the USA (HIP trial), Sweden (two counties study) and the Netherlands (Nijmegen), and two trials in the UK (UKTEDBC and Edinburgh trials). They recommended that screening units should be set up across the country, which would screen a certain number of women once every three years (a Forrest Unit) and provided capital and revenue funding to set up these units.
Office staff, radiographers, radiologists and breast clinicians were recruited, and an intensive programme of training was begun, with training centres in Nottingham, Guildford, Manchester and King’s College Hospital, London, and in Edinburgh, Cardiff and Belfast.
The screening programme in the UK, unlike many others which advise women that screening is available, actually sends out an invitation for a mammogram appointment, thus encouraging attendance. It is free, and covers the process of screening for breast cancer from the initial invitation for the screening mammogram, to include the investigation of the woman with the abnormal mammogram as far as the point of possible cancer diagnosis, at which point the woman will be referred to a local breast surgeon for treatment.
The screening programme also checks the training qualifications of all breast surgeons who see women with screen detected breast cancer, and continues to check the effectiveness of these surgeons on an annual basis. It was also realised that quality assurance had to be an underpinning principle of the screening programme. Overall standards were set, and the Department of Health supported the need for a Quality Assurance Manager and reference centre in each region. Guidance was issued in a health circular, and funding was provided for each of the 14 regional health authorities.
Every woman who is invited for screening has her results entered on a national database, which is checked and verified by the individual screening units, and by the QA reference centres. Every screening unit is visited once every two years for an in depth evaluation of the quality of their service by a team of QA experts, and a report is produced which is sent to the host Trust and to the PCT’s.
Our last formal visit was in 2014, and the report was very complimentary. Throughout the year all units continuously check all aspects of their work, and report any problems, and solutions, in order that all units can share improvements in good practice.
As a result, the UK Breast Screening Programme is a model of good practice. Professional quality assurance groups were developed with the relevant associations and royal colleges at a national level.
The NHSBSP now diagnoses about half of all breast cancers found in women in the target age range of 50-70 years, with the remainder occurring in women who do not attend for screening, or who present symptomatically between screens.
Since the inception of the breast screening programme, the influence of its good practice has spread beyond its target population. By the early 1990’s the symptomatic service was seen as increasingly old fashioned, but took its lead from the screening programme in redesigning its practices. From 1992 the Department of Health funded symptomatic mammography equipment over a three year period, and at the same time multidisciplinary teams were developing improved diagnostic techniques for women presenting symptomatically, and “One Stop” clinics were becoming widespread as this was seen as a better way of working for both staff and patients.
The National Breast Screening Programme continues to develop and to improve the quality of its performance year on year. Latest challenges have included randomisation trials of screening across a wider age group of 47-73 years, the first round was completed by 2012. We have also converted from film to digital mammography, for images taken at a hospital and now also on all mobile screening units. We have also developed an advisory and surveillance role in Family History screening.
As a direct result of screening, and as an indirect result of improved practice across breast symptomatic services, and greater public awareness, breast cancer is being detected at an earlier stage, and treatment outcomes are continually improving.