Guidance

Breast screening: guidance on partial or incomplete screening mammography

Published 7 January 2021

This publication provides guidance on managing a mammographic episode that cannot be completed, due to technical constraints or withdrawal of consent during the screening episode. This is to make sure that:

• any woman who undergoes a partial screening mammogram is informed of the examination’s limitations
• any woman who attends for screening but does not have a complete set of images taken, receives standardised information regarding the reasons why the screening was not completed
• mammographers understand the concept of justifying the mammograms and the importance of consent
• any images taken are correctly managed and reported
• screening outcomes are correctly recorded on the National Breast Screening System (NBSS), to make sure that all women receive the right results
• any woman who attends for screening but does not have a mammogram and chooses to delay imaging to a later date is managed appropriately
• there is clarity of situations where partial mammography should not be used

Information for women who have partial or incomplete mammography is available.

Partial mammography

If the examining mammographer believes that at least half of the breast can be demonstrated on one or more views of the routine examination, these views should provide sufficient useful information to be reported as a screening mammogram. Although it may result in partial mammography, such an examination can therefore be justified under the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2017.

Some women withdraw consent during a screening mammogram. This also results in partial mammography and must be documented appropriately. Some examples of breast screening scenarios are detailed below.

The national template results letter (LT005v2 PM) must be sent to women returned to routine recall following a partial mammogram. Mammographers should remember that:

• the partial mammography guidance does not apply if the x-ray equipment failed before all images can be achieved – in this situation, women will be sent a technical recall appointment
• when partial mammography is identified, you should speak with the woman or her carer to explain this decision and its implications on the screening test results
• you should follow the health and safety manual handling policies of the host trust(s) when positioning a woman for mammography – particular care should be taken with medical aids such as wheelchairs

The partial mammography option on NBSS should not be used routinely where:

• booking a further appointment on another day when a woman’s mobility or compliance is improved would mean that the examination would be successfully completed
• a woman has undergone a single, unilateral mastectomy
• a woman did not attend when invited for a technical recall
• a woman has had implants
• a woman has a congenital absence of breast tissue on one or both sides (Poland’s Syndrome)

Data entry and identification of partial mammography on NBSS

There are various ways in which a partial mammogram can be recorded in NBSS:

• via the Mammographer Direct Entry (SMDE) function
• via the NBSS Daybook, used where live access to NBSS is not available
• via the screening film record, within the clinical record

The image below shows how a woman is marked in the NBSS Daybook and SMDE screens as having had a partial mammogram within NBSS.

You should read all images in accordance with the breast screening services’ usual image reading protocol. An automatic alert will display in NBSS to highlight to image readers where a woman has been recorded as having partial mammography. Following partial mammography, if a woman is being returned to routine recall a partial mammography results letter (LT005v2 PM) will be generated.

An audit of the use of partial mammography indicates that the most common reasons are:

• unable to attain or maintain position due to restricted mobility
• withdrew consent
• unable to co-operate due to limited understanding of procedure
• examination limited due to pacemaker (only relevant if included in the image field or obscuring breast tissue), Hickman line or loop recorder
• examination limited due to chronic disease condition
• examination performed in a wheelchair which restricted positioning

The presence of a medical device, such as pacemaker, does not mean the woman will automatically have partial mammography. In many cases radiographers will achieve a high diagnostic image regardless of the device placement. More information is available within the guidance for breast screening mammographers.

Examples

The following section provides example breast screening scenarios, with instruction on how the women should be managed.

Scenario 1 – attended, not screened

A woman attends but declines the examination either at reception or in the x-ray room before any images were taken. No images taken.

Daybook and SMDE

Tick ‘Not screened’ box and insert appropriate reason in the comments box.

NBSS episode

Close as NS (not screened).

No letter needed

The mammographer should advise the woman:

• that she can contact the office at any time to reschedule her appointment
• to continue to be breast aware and contact her GP as soon as possible with any concerns

Leaflet

The mammographer should give the woman a copy of the information for women who have partial or incomplete mammography leaflet during the appointment.

GP report

The GP report is issued automatically.

Scenario 2 – attended, not screened

A woman attends but no images can be justified. This may include, but is not exclusive to, previous breast imaging less than 6 months ago or where a severe disability prevents imaging being achieved. No images are taken.

Daybook and SMDE

Tick ‘Not screened’ box and insert appropriate reason in the comments box.

NBSS episode

Close as NS (not screened).

No letter needed

The mammographer should advise the woman that she can contact the office at any time to reschedule her appointment to continue to be breast aware and contact her GP as soon as possible with any concerns.

Leaflet

Mammographer to give the woman a copy of the information for women who have partial or incomplete mammography leaflet during the appointment.

GP report

The GP report is issued automatically.

Scenario 3 – partial mammography

A woman attends but withdraws consent part way through the examination. Not all images were taken and the examination is incomplete. The woman declines to come back to complete the examination.

The mammographer should advise the woman to continue to be breast aware and report any breast changes to her GP as soon as possible.

Daybook and SMDE

Tick ‘Partial mammogram’ box and select appropriate reason.

NBSS episode

Mark as attended. Close with the appropriate outcome once images taken have been reported.

If the woman contacts the service to complete the examination at a later date:

• if less than 6 months have passed since her date of first offered appointment (DOFOA), the screening office can reopen the episode and book another screening appointment
• if more than 6 months have passed since her DOFOA, the screening office will need to create a new episode as a non-batch referral (NBR)
• if more than 6 months have passed since her original images were taken, a full set should be taken when she attends (not just those images not taken originally)

Leaflet

The mammographer should give the woman a copy of the information for women who have partial or incomplete mammography leaflet during the appointment.

Letter

Send either the partial mammography routine recall letter LT005 PM or the recall to assessment letter LT008 RC.

GP report

The GP report is issued automatically.

Scenario 4 – partial mammography

A woman attends but only a partial mammogram could be justified. Not all breast imaged on at least one image and, or, at least one image not taken. Examination therefore incomplete.

The mammographer should advise the woman to continue to be breast aware and report any breast changes to her GP as soon as possible. In some situations, the reason preventing a complete set of images being taken may be temporary, such as a shoulder injury, and it may be possible for a full set of x-rays to be taken in the future. If the woman feels that the reason preventing a complete examination may change in the future, she can return and complete the examination at any time.

Daybook and SMDE

Tick ‘Partial mammogram’ box and select appropriate reason.

NBSS episode

Mark as attended. Close with the appropriate outcome once images taken have been reported.

If the woman does contact the service to complete the examination at a later date:

• if less than 6 months have passed since her DOFOA, the screening office can reopen the episode and book another screening appointment
• if more than 6 months have passed since her DOFOA, the screening office will need to create a new episode as a NBR
• if more than 6 months have passed since her original images were taken, a full set should be taken when she attends (not just those images not taken originally)

Leaflet

The mammographer should give the woman a copy of the information for women who have partial or incomplete mammography leaflet during the appointment.

Letter

Send either the partial mammography routine recall letter LT005 PM or the recall to assessment letter LT008 RC.

GP report

The GP report is issued automatically.

Scenario 5 – not attended technical recall

A woman is called back for technical reasons but fails to attend after several attempts.

NBSS episode

Close as OT (opted out temporarily).

Letter

Send a manual letter to the woman (copying to the GP), after the images taken have been reported, explaining that the screen is incomplete.

Mammograms

Under IR(ME)R regulations, all images taken must be reported and a results letter issued. This should not be reported as a partial mammogram.

GP report

The GP report is issued automatically.

Scenario 6 – technical recall, reason code R1B

A woman did not complete the examination at her initial appointment and agrees to come back on another day to complete.

NBSS episode

Record the requirement for a new appointment on the client record and clinic sheet, with a note explaining the reason. The original images need to be reported as technical recall (TR) with reason code R1B (inadequate positioning client). The woman needs to be booked a new appointment.

No leaflet needed

The mammographer should advise the woman that a new invitation letter will be sent in the post.

Letters

Send a new appointment letter – LT007 TR.

Send either the routine recall letter LT004 RR or the recall to assessment letter LT008 RC.

If the woman does not attend her TR appointment, refer to the actions required in scenario 5.

GP report

The GP report is issued automatically.

Scenario 7 – breast implants

A woman attends with bilateral implants and is managed following the screening women with breast implants guidance.

NBSS episode

Mark as attended with appropriate outcome.

Leaflet

The radiographer should give the woman a copy of breast implants and breast screening leaflet.

Automatic letter

Either the routine recall letter LT004 RR or the recall to assessment letter LT008 RC will be sent automatically.

The partial mammography routine recall (LT005 PM) letter must not be used.

GP report

The GP report is issued automatically.

Scenario 8 – implanted devices

A woman attends with a pacemaker and is managed following the guidance for breast screening mammographers. All views were completed.

NBSS episode

Mark as attended with appropriate outcome.

No leaflet needed

Letter

Either the routine recall letter LT004 RR or the recall to assessment letter LT008 RC will be sent automatically.

The partial mammography routine recall (LT005 PM) letter must not be used.

GP report

The GP report is issued automatically.

Summary

This good practice guidance applies to cases where it has not been possible to perform an optimal mammogram, or where no mammogram has been taken because the woman withdrew consent during the appointment. It also contains situations where partial mammography should not be used.

The partial mammography option on NBSS should not be used for women:

• with implants
• who have had a mastectomy
• with incomplete imaging at their first appointment who intend to return to complete their screen at another appointment

Breast screening services should have a system in place to make sure that all women attending screening are issued with the right result, and managed appropriately.

Data entry should be standardised, as outlined in these guidelines, to make sure that women receive the correct information and that any future audit of these cases will be robust.

There are no changes to the NBSS outcome or end code as a result of a partial mammogram. It is recorded as a flag within the screening episode.

As a minimum, screening services should complete internal audits annually to check that partial mammography is being used appropriately and recorded correctly. A crystal report (SR034 National Partial Mammography Audit Report) is available for this purpose.

Background

To comply with the Equality Act 2010 and with PHE Screening guidance, all women must be given the same access to the breast screening service. You should make every attempt to produce a diagnostic screening mammogram for every woman.

The IR(ME)R 2017 state that an exposure must not be made unless it can be justified as being of net benefit to the woman. An exposure should not take place unless the resulting image demonstrates enough of the breast, as described below, to be evaluated as a screening mammogram.

It may not be possible to perform a diagnostic mammogram on some women. This could be due to difficulty in achieving and maintaining the required position throughout the exposure time. It could therefore be argued that unless a complete and diagnostic 4-view screening mammogram can be achieved, no exposures at all are justified under IR(ME)R 2017.

Although incomplete coverage of the breast will reduce the probability of finding a cancer, there may still be benefit if a sufficient proportion of the breast is imaged. It is justifiable to produce a partial mammogram under the circumstances outlined in these guidelines. The decision making process of whether the examination should be undertaken must be by an employee entitled as an IR(ME)R practitioner by the employer. This entitlement must be documented in employers’ procedures.

Many services have written justification guidelines which detail the circumstances under which the mammogram may be taken. These guidelines must be approved by the director of screening or lead radiologist, who then becomes the practitioner for all exposures justified by those guidelines. Radiographers, assistant practitioners or associate practitioners carrying out these mammograms are therefore authorising each exposure under protocol.