Breast screening pathway requirements

Question 1

Breast screening

Accepted Answer

The aim of breast screening is to reduce mortality from breast cancer by diagnosing cancer at an early stage when treatment is more successful.

In England, the NHS currently offers breast screening to women aged from 50 up to their 71st birthday, every 3 years. Women aged 71 and over may self refer every 3 years by contacting their local breast screening unit.

Women invited for breast screening have X-rays (mammograms) at a clinic or mobile breast screening unit. A female mammographer carries out breast screening, taking 2 mammograms of each breast. The appointment takes around 30 minutes, but the mammograms take only a few minutes.

Breast screening is a 2 stage screening process involving mammography initially for all women, followed by further screening tests for a small proportion of women. The additional tests are to confirm the presence of breast cancer or to reassure women that they have no sign of cancer and can be discharged back to routine screening.

Find out more about breast screening in the programme overview.

Question 2

End-to-end pathway

Accepted Answer

The pathway for the breast screening programme consists of the following elements.

The dotted boxes and numbered labels show how the different parts of the screening pathway map to the generic pathway themes used in the sub-headings below.

An accessible text-only version version of this pathway is also available.

Question 3

1.  Before screening test

Accepted Answer

These requirements relate to making sure that screening is offered to the correct people.

Providers must have systems in place to:

identify the eligible population using the IT system BS Select, according to programme guidance on maintaining round length
ensure all eligible women registered with a GP in the catchment area, and those resident in the area without a GP, are invited for screening
ensure that women who are not on the patient demographic service system (which holds details of all individuals registered with a GP) have access to screening, and that local arrangements are made to cover residential institutions, including prisons and defence medical service (DMS) practices
routinely cease only those women who have had bilateral mastectomies, women who are excluded due to a best interests decision or who request to opt-out from screening (in line with programme guidance on opting out of breast screening)
upload all supporting evidence onto BS Select for any woman who is ceased from the programme so there is an indefinite record if the woman moves screening services
carry out annual audits (see ‘8. Ceasing audits’ in Guidance on opting out (cease) from breast screening) on ceased women to ensure that women have been ceased appropriately in compliance with programme guidance
accept referrals for women fulfilling eligibility criteria for very high risk screening using the national referral proforma in line with higher risk screening protocols
always use the appropriate national public information and letters at all stages of the screening pathway to allow people to make a personal informed choice
provide appropriate support for women with additional needs, for example longer appointments and easy read information
update information for women throughout the screening pathway using NHS BSP IT systems according to National Breast Screening System (NBSS) guidance
ensure appropriate management of women who choose to be screened at an out-of-area service

Question 4

2.  Screening test

Accepted Answer

Coverage/uptake

Coverage requirements relate to making sure eligible women who accept a screening offer are tested within appropriate timescales. Providers must have systems in place to return data for:

coverage standard BSP-S02: coverage

Uptake requirements relate to the proportion of the eligible population offered screening and who attend and have a screening result documented. Providers must have systems in place to validate and return the appropriate data for:

Carrying out the screening test

Providers must have systems in place to:

make sure all tests are delivered and supported by suitably trained, competent and qualified clinical and non-clinical staff who, where relevant, participate in recognised ongoing continuing medical education (CME), continuing professional development (CPD) and external quality assurance schemes; the latter are mandatory schemes organised for breast image readers and breast pathologists
ensure all reasonable adjustments are made to enable effective mammography for each individual attending (see ‘Specific client groups’ in Guidance for breast screening mammographers)
carry out mammography in a way that minimises the possible adverse aspects of screening (such as radiation exposure, physical discomfort or anxiety) and that maximises the benefits (detecting abnormalities at an early stage)
ensure that image quality and radiation dose are optimised, with technical repeats minimised (repeated mammography if images are not clear enough to get a screening result); and return and validate data for test standard BSP-S05: repeat mammography rate
ensure that women with implants are screened using routine mammography techniques including the Eklund technique
ensure that all screening examinations are subject to double reading by readers fulfilling all requirements of the quality assurance standards in radiology, and are reported directly onto the NBSS promptly by the reader who is directly responsible for those results
return individuals without breast cancer to routine recall as soon as possible, send results to the woman and her GP within 2 weeks of screening attendance and return and validate data for test standard BSP-S06: timeliness of screening results letters that do not require further assessment
ensure that women who are invited are not screened if they have had mammography within the past 6 months
have audit and service evaluation embedded in the service to maximise safety and accessibility of the service for all groups in the eligible population

Question 5

3.  After screening test (diagnosis)

Accepted Answer

These requirements relate to the process of referring women and carrying out further tests at an assessment clinic to get a confirmed result.

Referral for assessment

Providers must have systems in place to:

refer women to assessment with significant mammographic or magnetic resonance imaging (MRI) abnormalities, or presenting with significant breast cancer signs or symptoms and validate and return data for referral standard BSP-S07: rate of referral to assessment
offer women an appointment to an assessment clinic within 3 weeks of their initial screen and validate and return data for referral standard BSP-S09: time to first offered appointment for assessment
notify women in writing of their assessment clinic appointment and ensure that they have at least 24 hours’ notice of the appointment
ensure women attending assessment have clear information about the assessment process which is appropriate to them

Assessment

Providers must have systems in place to:

ensure (where possible) that a trained interpreter is present during assessment appointments for women whose functional language is not English, along with appropriate written information, and where this is not possible, access to a comprehensive translation service is available
ensure all women attending an assessment appointment meet a clinical nurse specialist (CNS) in breast screening at the start of assessment, to assess anxiety and offer appropriate support (see guidance for clinical nurse specialists)
ensure the CNS sees all women undergoing needle biopsy procedures
undertake triple assessment (clinical examination/additional imaging/needle test) and diagnosis of individuals with initial screening results of ‘further tests needed’ in appropriately staffed and equipped settings, meeting the clinical guidelines for screening management
ensure adequate equipment and staffing levels are in place so that women can be fully assessed in the course of a single visit wherever possible; keep repeat assessment visits to a minimum and validate and return data for diagnosis/intervention standard BSP-S10: definitive diagnosis of cancer made ≤3 assessment visits
ensure that every woman’s management in assessment is overseen by a responsible assessor (RA) who is named on the breast IT system (NBSS), to ensure that all appropriate investigations have been adequately performed and documented - the RA must be an accredited breast radiologist, consultant radiographic practitioner or breast clinician experienced in the full range of triple assessment
ensure that when no biopsies have been undertaken, a second assessor reviews the case where possible before returning a woman to routine recall
ensure that biopsy specimen imaging is available whilst the woman is still positioned in the stereo X-ray equipment
ensure that vacuum-assisted excision is used for re-biopsy of the same lesion and the investigation of B3 lesions
only place women on short-term recall from assessment in exceptional circumstances
carry out localisations only in facilities that meet the NHS BSP requirements outlined in best practice guidance on leading a breast screening service (see ‘3. Organisation of screening services)
validate and return data for:

Multidisciplinary team (MDT) meeting

At an MDT meeting the provider should:

discuss all women who have undergone biopsy with an outcome agreed by all disciplines; document the outcome in one single, accessible record which clearly documents the future management of the woman
accurately diagnose cancers, with reference to MDT decisions, and refer women for treatment by appropriately trained and qualified specialists
refer women for open surgical biopsy if this is necessary to confirm or exclude malignancy, before discharge or onwards referral from the programme, and validate and return data for diagnosis/intervention standard BSP-S11: rates of benign open biopsies
notify women and their GPs on the outcome of assessment as soon as possible
ensure all malignant results are given to the women by a member of the clinical team, in person, accompanied by the CNS who is the patient’s advocate and offers support and information
ensure that assessment test results (whether normal, benign, or abnormal) are communicated clearly, accurately, and promptly, in person, by a member of the clinical team - deviations from this are only acceptable if:
- there is a very strong suspicion that malignancy is not present, in which case offer the option of results by clinic appointment or telephone
- the woman has specifically requested her results by telephone (this is not be routinely offered due to the possibility of a malignant outcome which will require an appointment in person with a member of the clinical team and CNS)

Question 6

4.  After screening test (intervention)

Accepted Answer

These requirements relate to the process of following-up people with a confirmed diagnosis and maximising the overall benefits from screening in terms of the final outcome to the person being screened.

Intervention/treatment

Providers must have systems in place to:

maintain effective communication and cooperation between health professionals undertaking screening, diagnostic tests and treatment to ensure women are referred promptly and safely to treatment services (refer to guidance on leading a breast screening service)
refer women promptly to treatment services once diagnosis with breast cancer is confirmed
advise women who have received a diagnosis of breast cancer that they can contact the screening office for advice about future breast screening in their particular case
ensure the treatment service has responsibility for any post-treatment follow-up

Treatment for breast cancer is undertaken within a local hospital setting and is not part of screening.

Pathway outcome

Providers must have systems in place to:

ensure that all information on NBSS is high quality and validated to support data collection and reporting to support monitoring the efficacy of their screening service
produce an annual report of screening services, signed off by the NHSE breast screening programme board
ensure there is regular monitoring and audit of the screening service as part of the organisation’s clinical governance arrangements, and that the programme board is assured of the quality and integrity of the screening service
return women to routine recall as appropriate, or are advised that they can self-refer for screening if they will be aged 71 or over when they are next due
undertake a radiological review for any woman diagnosed with a cancer in between screening appointments (an interval cancer) within prescribed timescales outlined in interval cancer guidance, and complete disclosure of audit and duty of candour processes as necessary
validate and return data for outcome standard BSP-S17: rates of invasive interval cancers

Breast screening pathway requirements

Applies to England