Evidence from Sweden shows that screening for breast cancer is as effective in reducing mortality from the disease in women aged 65-69 as it is in women aged 50-64.1 However, although the British government’s Forrest report recognised that older women were more likely to develop breast cancer, it recommended that they should not be routinely invited for screening because of low cost effectiveness from a likely low uptake and shorter life expectancy.2 Instead women over 64 years are entitled to self refer every three years—although few do so.3
A three-centre pilot study was established in which women aged 65-69 are routinely invited for breast screening. This study investigates the problems of extending the programme to this age group, and cost effectiveness. Based on the results a policy decision should be possible.
The East Sussex service started inviting women in May 1996, followed in 1997 by the Leeds and Wakefield, and Nottingham centres. We report on the uptake rate of women invited to attend for breast screening and the cancer detection rate in East Sussex during 1996-7.
Subject, methods, and results
Women aged 65-69 registered with general practitioners in East Sussex, Brighton, and Hove are invited for breast screening over a three year period. They attend two mobile screening units, which are also used for women aged 50-64. The pilot is integrated into the main breast screening programme, which is now in its third round.
The table summarises the results of the first year of the pilot. The results are computed in the same way as the annual statistics submitted to the Department of Health. Only 7.3% (121/1655) of all invited women aged 68 or 69 had their last screen within 5 years; this is the proportion who volunteered for screening three years ago in the second round. Most (59.0%, 976/1655) of the women aged 68 or 69 had their last screen over 5 years ago. They attended when last invited but were too old for a routine invitation three years ago. Of these women, 88% (858/976) attended when invited in the pilot study compared with 92% reattendance in women aged under 65 and 65-67 (10 954/11 945 and 1707/1859 respectively) who attended last time after routine invitations.
The overall uptake was 80% (16 535/20 810) for women under 65, 76% (2386/3153) for those aged 65-67, and 73% (1204/1655) for those aged 68 or 69. The total cancer detection rate in women under 65 was 7.1/1000 (117/16 535), higher than expected, rising to 8/1000 (19/2386) in women aged 65-67. In women aged 68 or 69 the rate was 17.4/1000 (21/1204), reflecting both advancing age and that most had not been screened for six years.
Comment
These preliminary results show that those women who have previously attended for breast screening will continue to do so if invited after age 64, even if they have not been invited for six years. Yet only 7% (121/1655) of older women had previously self referred, possibly owing to lack of information on entitlement or an assumption that they would continue to be invited if screening were advisable.3
It is possible that women currently aged 50-64 may be even more likely to continue to attend after age 65 than the pilot group, because they contain a smaller proportion of those who did not attend after previous invitations, and are therefore less likely to reattend.4
The final results from all three pilots, covering about 65 000 women being invited, will not be available until the year 2000. These preliminary results indicate the potential for a high uptake rate and a high cancer detection rate in older women routinely invited for breast screening. Other possible enhancements to the programme are under consideration including taking two views at incident screens or reducing the screening interval. Any national implementation of routine invitations for older women will thus have to compete for resources.
Table.
Audit of East Sussex Brighton and Hove breast screening programme, 1996-7 (routine invitations only)
| Invitation group (age (years)) | Invited (%)* | No screened | % Uptake† (95% CI) | Total cancers detected‡ (per 1000 women screened) (95% CI) |
|---|---|---|---|---|
| A (first invitation in East Sussex): | ||||
| <65 | 5 272 (25.3) | 4 086 | 75.5 (76.4 to 78.7) | 31 (7.1, 5.4 to 10.8) |
| 65-69 | 275 (5.7) | 166 | 60.4 (54.6 to 66.1) | 5 (30.1, 12.5 to 72.3) |
| B (previous non-attenders): | ||||
| <65 | 2 393 (11.4) | 640 | 26.7 (25.0 to 28.5) | 7 (10.9, 5.2 to 22.9) |
| 65-69 | 961 (20.0) | 250 | 26.0 (23.2 to 28.8) | 4 (16, 4.0 to 31.6) |
| C1 (previous attenders: last screen within 5 years): | ||||
| <65 | 11 945 (57.4) | 10 954 | 91.7 (91.2 to 92.2) | 72 (6.6, 5.2 to 8.3) |
| 65-67 | 1 859 (60.0) | 1 707 | 91.8 (90.6 to 93.1) | 12 (6.6, 3.8 to 11.6) |
| 68 or 69 | 121 (7.3) | 113 | 93.4 (89.0 to 97.4) | |
| C2 (previous attenders: last screen >5 years ago): | ||||
| <65 | 1 200 (5.8) | 858 | 71.5 (69.0 to 74.1) | 7 (8.2, 3.9 to 17.2) |
| 65-67 | 619 (19.6) | 495 | 80.0 (76.8 to 83.1) | 17 (12.5, 7.8 to 20.1) |
| 68 or 69 | 976 (59.0) | 858 | 87.9 (85.9 to 90.0) | |
| Total invitations: | ||||
| <65 | 20 810 | 16 535 | 79.5 (78.9 to 80.0) | 117 (7.1, 5.8 to 8.3) |
| 65-67 | 3 153 | 2 386 | 75.7 (74.2 to 77.2) | 19 (8.0, 4.5 to 11.4) |
| 68 or 69 | 1 655 | 1 204 | 72.8 (70.6 to 74.9) | 21 (17.4, 10.7 to 24.3) |
% is total of age range in invitation group.
Screened/invited by age and group.
Includes ductal carcinoma in situ.
Acknowledgments
We thank all the staff of the East Sussex Brighton and Hove breast screening programme, especially J Oswald, T Jeyakumar, and C Sonksen.
See p 376 and Editorial by Werneke and McPherson
Footnotes
Funding: The evaluation is funded by the Department of Health’s research and development directorate.
Conflict of interest: None.
References
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