BreastScreen Victoria Annual Statistical Report

BreastScreen Victoria Annual Statistical Report

CONTENTS FIGURES AND TABLES... Figures... Tables... 3 INTRODUCTION... 5 SECTION MAXIMISING PARTICIPATION... 6 Program acceptance... 6 Eligibility... 6 Inviting women... 6 Reinviting women... 6 Response to invitation... 6 Screening... 6 Summary of screening in 3... 6 Family history of breast cancer... 8 Personal history of breast cancer... 8 Breast symptoms... 9 Breast implants... 9 Hormone replacement therapy... Participation... Women from special groups... Rescreen... 3 SECTION MINIMISING HARM... 4 Imaging quality...4 Minimising unnecessary investigations...4 Recall to assessment... 4 Assessment procedures... 4 Preoperative diagnosis of breast cancer... 7 Benign open biopsy... 7 Outcome of assessment... 8 Early review... 8 Malignant diagnosis... 8 Recommendation for routine rescreening... 8 SECTION 3 MAXIMISING CANCER DETECTION...9 Summary of cancer detection... 9 Invasive cancer detection... 9 Small cancer detection... Ductal carcinoma in situ detection... Interval cancer... 3 SECTION 4 BREAST CANCER TREATMENT... 4 Surgical treatment... 4 Women in rural and remote areas... 4 Nodal status... 6 Invasive breast cancer... 6 Ductal carcinoma in situ... 6 Radiotherapy... 6 APPENDIX... 8

Figures Figure Summary of outcomes for all women attending for breast cancer screening. in 3 Figure Women screened, 994 3 Figure 3 Screening: women who reported a. family history of breast cancer, 3 Figure 4 Screening: women who reported a. personal history of breast cancer, 3 Figure 5 Screening: women who reported. breast symptoms, 3 Figure 5 Surgical treatment: type of surgery, 3 Figure 6 Surgical treatment: breast conservation surgery, 996 3 Figure 7 Surgical treatment: mastectomy for. invasive breast cancer, 996 3 Figure 8 Invasive breast cancer: tumour size and nodal status, 3 Figure 9 Surgical treatment: axillary dissection for DCIS, 996 3 Figure 6 Screening: women who reported. having breast implants, 3 Figure 7 Screening: women who reported. HRT use, 3 Figure 8 Screening: women who reported HRT use, 994 3 Figure 9 Participation: 994 995 to 3 Figure Participation: area of residence,. January to 3 December 3 Figure Participation: CALD women,. January to 3 December 3 Figure Participation: ATSI women,. January to 3 December 3 Figure 3 Rescreen: January to. 3 December Figure 4 Recall to assessment: women aged. 5 69 years, 996 3 Figure 5 Assessment: procedures performed, 3 Figure 6 Biopsy procedures: women aged. 5 69 years, 996 3 Figure 7 Preoperative diagnosis, 994 3 Figure 8 Malignant diagnosis, 3 Figure 9 Breast cancer detection, 3 Figure Invasive breast cancer detection:. women aged 5 69 years, 996 3 Figure Invasive breast cancer detection:. women aged 5 69 years, 3 Figure Invasive breast cancer: tumour size. by grade, 3 Figure 3 DCIS detection: women aged 5 69 years, 996 3 Figure 4 Proportion of cancers diagnosed as DCIS: women aged 5 6 years, 996 3

Tables Tables in Sections Table. Response to invitation Table. Summary of screening by age and round Tables in Appendix Table See Figure Table Attendance by age and round, 3 Table 3 Attendance by age and country of. birth, 3 Table 4 Attendance by age and Aboriginal and/or Torres Strait Islander status, 3 Table 5 Attendance by age and symptom. status, 3 Table 6 Attendance by age and family history. of breast cancer, 3 Table 7 Attendance by age and personal history. of breast cancer, 3 Table 8 Attendance by age and breast implant. status, 3 Table 9 Attendance by age and hormone replacement therapy use, 3 Table Participation rates by age and language spoken at home, January to 3 December 3 Table Participation rates by age, area of residence and language spoken at home, January to 3 December 3 Table Participation rates by age and area. of residence, January to. 3 December 3 Table 3 No table for 3 Table 4 Participation rates by age and Aboriginal and/or Torres Strait Islander status,. January to 3 December 3 Table 5 Rescreen rates by age and round,. for women who attended in Table 6 No table for 3 Table 7 Number of films taken per woman. by age, 3 Table 8 Number of technical repeat films taken. by age, 3 Table 9 Outcome of screening by age and. round, 3 Table Range of assessment procedures performed by age, 3 Table Outcome of assessment by age and. round, 3 Table Outcome of fine needle aspiration biopsy. by age, 3 Table 3 Outcome of core biopsy by age, 3 Table 4 Outcome of open biopsy by age, 3 Table 5 Breast cancer diagnosis by age and. most invasive biopsy procedure, 3 Table 6 Recommendation for routine rescreen. by age, 3 Table 7 Breast cancer detection rate by age, round, mammography status, symptom status and personal history of breast cancer, 3 Table 8 Invasive breast cancer detection rate by. age and tumour size for first screen, 3 Table 9 Invasive breast cancer detection rate by age and tumour size for subsequent screens, 3 Table 3 Invasive breast cancer and DCIS detection rate by age and round, 3 Table 3 Invasive breast cancer by tumour size. and histologic type, 3 Table 3 Invasive breast cancer by tumour grade. and size, 3 Table 33 Interval cancer rate by age and symptom status for first screens in Table 34 Interval cancer rate by age and symptom status for subsequent screens in Table 35 Nodal status for invasive breast cancer. (by tumour size) and for DCIS, 3 Table 36 Surgical treatment for invasive breast cancer (by tumour size) and for DCIS, 3 Table 37 Surgical treatment for invasive breast. cancer (by tumour size) and for DCIS. by area of residence, 3 Table 38 Adjuvant therapy for invasive breast cancer by size, 3 Table 39 Adjuvant radiotherapy for invasive breast cancer by type of surgery and nodal. status, 3 Table 4 Adjuvant radiotherapy for invasive breast cancer treated with breast conservation surgery by size, 3 Table 4 Systemic adjuvant therapy for invasive. breast cancer by age and nodal. status, 3 3

Figure Summary of outcomes for all women attending for breast cancer screening in 3, The source tables used may exclude data for a small number of women. First Screen Subsequent Screen Details are provided in footnotes to the table(s). Attendance a Screening Mammograms 5,69 (3.6%) Screening Mammograms 63,99 (86.4%) In all tables, percentages may not add up to due to rounding. Screening Outcome b Assessment. Recommended.,995 (.7%) Routine Rescreen. Recommended.,693 (88.3%) Routine Rescreen. Recommended. 55,363 (95.3%) Assessment. Recommended. 7,79 (4.7%) Assessment Procedures Performed c Imaging 6,4 (6.3%) Clinical Examination,437 (4.%) Fine Needle Aspiration 754 (7.4%) Core Biopsy,543 (5.%) Open Biopsy 3 (.9%) Assessment Outcome d No Malignant Lesion,794 (93.3%) Malignant Lesion 83 (6.%) Early Review 7 (.6%) Other (.3%) No Malignant Lesion 6,86 (88.8%) Malignant Lesion 8 (.5%) Early Review 47 (.6%) Other (.4%) Cancer Detection e Invasive DCIS Total 35 (5.5 per, screens) 47 (8.3 per, screens) 8 (7.8 per, screens) Invasive DCIS Total 64 (39.3 per, screens) 63 (. per, screens) 84 (49.3 per, screens) Surgical Treatment f No Surgery. 3 (.3%) Breast Conservation Surgery. 793 (8.8%) Mastectomy. 85 (8.9%) Interval Cancers g Year Year 3 (8.4 per, women years) 38 (.7 per, women years) Year (8. per, women years) Year 9 (.5 per, women years) SOURCE a Table, b Table 9, c Table, d Table, e Table 3, f Table 36, g Table 33,34 4

Introduction 3 All data in this Statistical Report exclude two women who attended for screening in 3 but who were aged less than 4 years. 4 The lag time for the presentation of interval cancer data is to allow database matching to capture diagnoses of breast cancer occurring in the cohort of women screened in that year (). 5 Participation is calculated as the percentage of the eligible female population attending for screening within a 4 month period. 6 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4. BreastScreen Victoria is part of an organised national breast cancer screening program for women without breast cancer symptoms or signs. The program aims to reduce deaths from breast cancer through early detection of the disease. BreastScreen Victoria provides free screening mammograms at two yearly intervals for women. aged 5 69 (those for whom the studies of mammography screening have demonstrated. greatest benefit). Women aged 4 49 years. and over 7 years are also eligible to attend. The BreastScreen Victoria Program is managed. by the Coordination Unit, which develops and. reviews program policy, monitors service provision, coordinates special projects and administers the funding for the Program s Services. A network of. 8 assessment centres, around 4 screening sites. and over mobile screening locations ensures. that the Program is accessible to all Victorian. women. While a doctor s referral is not required. to attend the service, BreastScreen Victoria liaises closely with General Practitioners. A comprehensive accreditation system ensures that. all BreastScreen services delivered in Victoria operate under and comply with national standards. Services are assessed regularly by an independent multidisciplinary team. This Annual Statistical Report provides summary. data on women who attended for screening in the Victorian program during 3 3 and the results. of their screening. In addition, interval cancer and rescreen data are presented for women screened. in. 4 Participation 5 data refers to the period. January to 3 December 3. Statistical reports for the BreastScreen Victoria Program are produced for each year and present comparable data so that time trends can be readily identified. Where appropriate, limitations of the. data in this report are described. The 3 report has been revised and restructured from previous year s reports to improve its quality. and readability. Additional references to the National Accreditation Standards 6 have been introduced and are now located throughout the body of the report. More descriptive text and figures have been added, including trends over time. Data tables have been relocated to the rear of the report as appendices. In some sections of this report, the numbers presented are small and may place limitations on the data in terms of interpretation of results and comparison. of trends over time. The simple descriptive statistics contained in this report are intended to provide a snapshot of the BreastScreen Victoria Program. Further information about the BreastScreen Victoria Program can be obtained from the BreastScreen Victoria website at www.breastscreen.org.au This is BreastScreen Victoria s tenth Annual. Statistical Report. 5

Section Maximising participation A high participation rate among women aged 5 69 years is necessary to achieve substantial reductions in mortality from breast cancer across the Australian community. 7 Program acceptance Eligibility Women aged 4 years and over are eligible for the BreastScreen Victoria Program. The target age group is women aged 5 69 as current research shows that breast cancer screening is most effective in detecting early breast cancer in this age group. Women aged 4 49 and 7 and over are also eligible, however, current evidence indicates that the benefits for breast cancer screening in these age groups are not strong enough to actively encourage participation in the Program. There is no evidence of benefit from breast cancer screening in women under 4 years of age and these women are advised by BreastScreen Victoria to consult their doctor if they are concerned about breast cancer. Inviting women Women who turn 5 years of age and who have not previously attended BreastScreen Victoria are identified via the electoral roll. 8 These women are sent a written invitation to participate in the Program. If within one month no response is received to the invitation letter, a second letter is posted. Services supplement the. use of invitation letters with a range of other recruitment initiatives. Reinviting women Women aged 5 to 74 years receive a reminder for rescreening 3 months 9 after their last mammogram. if no appointment is made at the woman s initiative. For women aged 4 49 years, reminders are sent if a woman has reported a strong family history of breast cancer, a personal history of breast cancer or a past diagnosis of lobular carcinoma in situ or atypical ductal hyperplasia. If there is no response within. six months, a second reminder letter is posted. Table. Response to invitation Number of women invited Response to invitation In 3 over 8% of the women reinvited made an appointment for rescreening. The response rate for women attending for a subsequent screen is more than twice as high as that for women attending for. the first time (see Table.). Screening Each woman who attends a BreastScreen Victoria Service completes a registration and consent form before her screening mammogram. The information obtained from the form is used by BreastScreen Victoria to provide appropriate breast cancer screening and assessment services to women, to monitor the attendance and participation of women. in the Program and for quality assurance purposes (See Tables 9). The form captures personal and health information such as name, address, symptoms, personal and family history of breast cancer and use of hormone replacement therapy. Relevant State privacy and other legislation is observed in the. use of this information by BreastScreen Victoria. For the purpose of this report women screened refers to the number of screening appointments attended, not individual women. For example, if a woman on an annual recall regime attends two screening appointments within the twelve month period those screens would be counted twice in the screening totals for that year. Summary of screening in 3 BreastScreen Victoria screened 88,79 women during 3. Most women screened were in the target age group of 5 69 years, and were subsequent screens (see Table.). Appointments made Response rate 7 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4: 3. 8 The Victorian Electoral Commission has made available the names and addresses of Victorian women aged 5 69 years so they can be invited to attend the BreastScreen Victoria Program. They have made this information available under the Electoral Act because BreastScreen Victoria is a public health program which will benefit Victorian women. 9 Women who are recommended for annual screening will receive an invitation after months if no appointment has been made. A woman is considered to have a strong family history of breast cancer if she has reported a mother, sister or daughter who was diagnosed with breast cancer before 5 years of age, or a father, brother or son diagnosed with breast cancer at any age. Of these reinvitations, % of the letters were returned unable to be delivered. Invitation 5,74 5,78 37.8% Reinvitation 74,898 4,58 8.3% 6

Section Maximising Participation Classification of screening status is based on screening within BreastScreen Victoria. It is acknowledged that women attending for a first screen to BreastScreen Victoria may have had previous mammography outside of the BreastScreen Victoria Program. Table. Summary of screening by age and round 4 49 5 69 7+ First screen 8,837 6,3 83 Subsequent screen 5,5 3,97 6,55 Total 4,88. (7.5%) For more information see Table. 47,3 (78.%) 7,38. (4.5%) Since the initial establishment of the Program the proportion of women returning for subsequent screening has continued to increase. Figure Women screened, 994 3 7

Family history of breast cancer Women with a family history of breast cancer are at increased risk of developing breast cancer. 3 BreastScreen Victoria recommends screening at two-yearly intervals for women over 5 with a family history of breast cancer. Women aged 4 49 who have a strong family history 4 and who elect to participate in BreastScreen, are automatically reinvited for screening every two years. Of the 88,79 women screened in 3, 4.% of women screened reported a strong family history and 4.8% reported an other family history 5 (see Table 6). The rate of reported family history in both categories has remained stable since 994. Women aged 4 49 years reported both categories of family history of breast cancer more often than women aged 5 years and above (see Figure 3). Figure 3 Screening: women who reported a family history of breast cancer, 3 Personal history of breast cancer Women with a personal history of breast cancer are at higher risk of breast cancer, through either a recurrence or a new primary breast cancer. 6 BreastScreen Victoria advises women with a personal history of breast cancer that the special follow up care they require is more appropriately provided by their breast specialist outside the Program. If a screening appointment is still requested by the woman following this advice, eligibility and access to the Program are dependent upon the type of treatment they have received for their previous breast cancer. A small number of women who report a personal history of breast cancer do attend for screening. at BreastScreen Victoria (see Table 7). The data in Table 7 should not be interpreted as representing. the prevalence of breast cancer among the female population of Victoria. Of the 88,79 women screened in 3,.% reported a personal. history of breast cancer. As seen in earlier years, the proportion of women reporting a personal history of breast cancer. increases with age (see Figure 4). Figure 4 Screening: women who reported a personal history of breast cancer, 3 3 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4:. 4 A woman is considered to have a strong family history of breast cancer if she has a mother, sister or daughter who was diagnosed with breast cancer before 5 years of age, or a father, brother or son diagnosed with breast cancer at any age. 5 A woman who reports that other family members have had breast cancer is classified as other family history. 6 National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. nd ed. Canberra: NHMRC, : 97 98. 8

Section Maximising Participation 7 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4: 44. 8 The category breast lump and/or nipple discharge includes women reporting a breast lump, or a bloodstained or watery nipple discharge. Questions on the BreastScreen Victoria Registration and Consent form specifically relating to symptoms were reviewed in and modified questions introduced in September. 9 A suspicious symptom is defined as a breast lump present less than months and not investigated by a doctor, or a current blood stained or watery nipple discharge. The category other breast symptoms includes a variety of symptoms, particularly breast pain or tenderness. Questions on the BreastScreen Victoria Registration and Consent form specifically relating to symptoms were reviewed in and modified questions introduced in September. Breast symptoms The BreastScreen Program is designed for well women without breast symptoms or problems. Women aged over 5 years with breast symptoms suspicious of breast cancer are more likely to be diagnosed with breast cancer than those without symptoms. 7 BreastScreen Victoria advises women with symptoms to see their own doctor, however, Services will screen women who arrive for their appointment and subsequently report a symptom. Of the 88,79 women screened in 3, 5,764 (8.4%) reported having a symptom at time of screening. A breast lump and/or nipple discharge 8 was reported by 5,376 women. Among this group,. 956 (7.8%) women were recommended for assessment as the symptom was considered suspicious of breast cancer. 9 Other breast symptoms were reported by,388 women. As in previous years, younger women reported symptoms more frequently than older women. (see Figure 5). Figure 5 Screening: women who reported breast symptoms, 3 Breast implants There is no evidence to date that women with breast implants have a higher risk of developing breast cancer. However, the presence, type and position of the implant within the breast affects how much breast tissue can be seen on the mammogram, so mammography may be less effective for women with breast implants. Of the 88,79 women screened in 3,,49 (.6%) women reported that they had breast implants (see Figure 6). As in earlier years, the proportion of women who reported having breast implants was highest in the 4 49 year age group. Figure 6 Screening: women who reported having breast implants, 3 9

Hormone replacement therapy Current evidence suggests that long-term hormone replacement therapy (HRT) use (greater than five years) is associated with an increased risk of breast cancer. HRT also increases the risk of false positive mammographic findings, in both current and past users. Modification of the data system in inadvertently resulted in the system being unable to record information regarding the use of HRT for,897 (.%) of the 88,79 women screened in 3 (see Table 9). Of the women with information available, 9,87 (7.9%) reported HRT use at the time of screening. As in earlier years, the proportion of women using HRT is highest in the target age group (see Figure 7). Reported HRT use among women aged under 6 years decreased between 995 and.. A sharp decline in reported HRT use for all age groups was seen in 3. Figure 8 Screening: women who reported HRT use, 994 3 Figure 7 Screening: women who reported HRT use, 3 National Health and Medical Research Council. Hormone replacement therapy: a summary of the evidence for general practitioners and other health professionals. Canberra: NHMRC, 5: 6. The reason for the decline is unclear, however, it may have been contributed to by the modification of the data system for a new registration and consent form in September. The modification resulted in the data system being unable to record specific information regarding the use of hormone replacement therapy at the time of attending for screening for.8% of women screened in, and.% of women screened in 3. In addition, publicity about studies proposing a link between some forms of HRT and breast cancer may also have been a contributing factor.

Section Maximising Participation 3 The participation rate was calculated using the average of the and 3 Australian Bureau of Statistics Estimated Resident Population of Victoria as the denominator (eligible women). The participation rate is for women residing in Victorian postcodes allocated to BreastScreen Victoria catchments. Participation Participation is used to describe the percentage of the eligible female population attending for screening within a twenty-four month period. National Accreditation Standard Result Participation rates are shown for women who. were screened between January and. 3 December 3. For women in the target age group the participation rate was 58.8%. Participation rates for women outside the target age group were lower. For women aged 4 49 years and 7 79 years the participation rates were 8.4% and 33.3% respectively 3 (see Table )... 7% of women aged 5 69 years participate in screening in the most recent 4 month period. 58.8% The participation rate for women in the target age group rose steadily until 998 99. Since then the participation rate has remained stable at around 6%. The rate for women in the target age group remains below the accreditation standard of 7%. Figure 9 Participation: 994 995 to 3

Women from special groups BreastScreen Victoria seeks to provide equitable access to all eligible Victorian women. Our Services aim to achieve the same participation rates for special groups as for the general population. 4 The category special groups includes women in rural and remote areas, Aboriginal and/or Torres Strait Islander (ATSI), and women from culturally and linguistically. diverse backgrounds. Women from some of these groups may be less likely to participate in screening. Where participation rates from women in special groups are below 7%, services identify these groups in their recruitment plans and develop targeted recruitment strategies. 5 Women in rural and remote areas Among women in the target age group, participation rates were higher for those in other major urban, rural and remote areas (see Figure ). Figure Participation: area of residence, January to 3 December 3 6 Women from culturally and linguistically diverse backgrounds For the purposes of this report women who indicated that they usually speak a language other than English at home are described as culturally and linguistically diverse (CALD). Participation rates were lower for women of CALD backgrounds across all age groups (see Figure ). Figure Participation: CALD women, January to 3 December 3 7 In the target age group, participation rates for women of CALD backgrounds were lower for those living outside the capital city (see Table ). Aboriginal and/or Torres Strait Islander women Participation rates for ATSI women are lower than the Victorian average for all age groups (see Figure ). However as the number of women identifying themselves as ATSI is small, comparisons of participation rates between ATSI and non-atsi women should be treated with caution. 4 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4: 8. 5 Ibid.: 9. 6 Participation by area of residence is classified according to the Rural/Remote Areas Classification (Department of Human Services and Health. Rural/ remote areas classification. [Canberra]: Department of Human Services and Health, 994). The classifications of capital city, other major urban, rural major, rural other, remote major and remote other are based on population size and density. In areas that are neither wholly rural nor remote, judgments about relative remoteness are applied. 7 Area/country of birth, language spoken at home and ATSI status are only available in census years. Data from the Australian Bureau of Statistics Census of Population and Housing were used to calculate participation rates by CALD status. The participation rate is for women residing in Victorian postcodes allocated to BreastScreen Victoria catchments. The estimated number of eligible CALD women (denominator) differs from that presented in the statistical report due to the inclusion of nine postcodes previously allocated to the Albury/Wodonga catchment (New South Wales) and now allocated to the BreastScreen Victoria Wangaratta Mobile Screening Service catchment.

Section Maximising Participation 8 Area/country of birth, language spoken at home and ATSI status are only available in census years. Data from the Australian Bureau of Statistics Census of Population and Housing were used to calculate participation rates by ATSI status. The participation rate is for women residing in Victorian postcodes allocated to BreastScreen Victoria catchments. The estimated number of eligible ATSI women (denominator) differs from that presented in the statistical report due to the inclusion of nine postcodes previously allocated to the Albury/Wodonga catchment (New South Wales) and now allocated to the BreastScreen Victoria Wangaratta Mobile Screening Service catchment. 9 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4:. 3 In this report the rescreen rate is the proportion of women screened between January and 3 December who were recommended for routine rescreening and returned to be rescreened within 7 months (8 days) of the previous () mammogram. 3 For the first time, rescreen rates are reported by round in accordance with the National Accreditation Standards. Figure Participation: ATSI women, January to 3 December 3 8 Rescreen The rescreen rate measures the proportion of women who return for screening in the Program within the recommended screening interval. The long-term effectiveness of the screening program depends on women in the target age group continuing to be screened at regular intervals. 9 National Accreditation Standard.. 75% of women aged 5 69 years. who attend for their first screen within the Program are rescreened within. 7 months... Of women aged 5 69 years participating in their second and subsequent rescreens within the Program, 9% are rescreened. within 7 months of their previous screening episode. Result 66.4% 83.% While the recommended screening interval is. 4 months, a 7 month time period is set to allow. a reasonable timeframe for women to respond to subsequent invitations. 3 The rescreen rate in this section is for women screened between January to. 3 December. For women in the target age group, rescreen rates 3 for the first and subsequent screening rounds did. not meet the accreditation standards. Rescreen rates were higher for subsequent screens across all age groups (see Figure 3). Figure 3 Rescreen: January to 3 December 3

Section Minimising Harm High quality screening and assessment is necessary to ensure that as many cancers are found while at the same time minimising the number of unnecessary investigations. 3 Imaging quality Women who attend for screening generally have. two x-rays of each breast, giving a total of four films. Repeat mammograms may inconvenience and increase discomfort for the woman, involve an additional radiation dose and add to screening costs. Therefore, the rate of repeated mammograms is to some extent an indicator of imaging quality. 33 National Accreditation Standard..3 The overall repeat rate for the Service. is <3% of all screening films. Result Overall, 9,798 (.%) of the total 8,89 films taken were technical repeat films, with the percentage varying little across women of different age groups (see Tables 7 and 8). BreastScreen Victoria has met this accreditation standard for the past 9 years..% Minimising unnecessary investigations Accreditation standards which measure the. Program s performance in minimising unnecessary investigations include: recall for assessment rate pre-operative diagnosis rate benign open biopsy rate 34 Recall to assessment Services must achieve an appropriate balance between cancer detection and recall to assessment. 35 National Accreditation Standards.6. <% of women aged 5 69 years who attend for their first screen are recalled for assessment..6. <5% of women aged 5 69 years who attend for their second or subsequent screen are recalled for assessment. Result.5% 4.7% 3 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4: 33. 33 Ibid.: 39. 34 Ibid.: 34. 35 Ibid. 36 Of the,74 women recommended for assessment, 4 women either declined or failed to attend for assessment, 4 women were assessed privately, and 34 women were cleared for routine rescreen without any further investigations being performed. The accreditation standard for recall rate was achieved for subsequent screens, but not for first screens. Women are recalled to assessment for a number of reasons including abnormal mammography, symptoms of possible breast cancer, presence of breast implants and a personal history of breast cancer. If confined to women with abnormal mammography, and abnormal mammography and symptoms and signs, recall rates for women aged 5 69 years are.% for first screens and 4.% for subsequent screens. (see Table 9). Assessment procedures Of the,74 36 women recommended for assessment 94.9% underwent assessment investigations within BreastScreen Victoria. The majority of these women (74.5%) received an outcome without the need for an invasive procedure, such as fine needle aspiration or tissue biopsy (see Figure 5). 4

Section Minimising Harm 37 Figure 5 shows the range of assessment procedures performed, using the same sequence of investigations as in Table. For example, if a woman underwent a core biopsy but not an open biopsy, she is counted in the core biopsy column. She may also have undergone a combination of further x-rays, ultrasound, clinical examination and fine needle aspiration prior to the core biopsy. Recall rates for women attending for a first screen aged 5 69 years have increased over time,. while rates for women attending for subsequent screens have remained relatively steady. Figure 4 Recall to assessment: women aged 5 69 years, 996 3 Figure 5 Assessment: procedures performed, 3 37 5

The rate of core biopsy use has increased since 996, while the rate of FNA use has trended downwards over the same period of time. Figure 6 Biopsy procedures: women aged 5 69 years, 996 3 6

Section Minimising Harm 38 Of the 993 women diagnosed with breast cancer in 3, 973 were assessed within the BreastScreen Victoria Program. Preoperative diagnosis of breast cancer BreastScreen Victoria aims to reach a diagnosis without the need for open biopsy, which involves. a general anaesthetic and hospitalisation. National Accreditation Standard Result National Accreditation Standards.8..35% of women who attend for their first screen are found not to have invasive cancer or DCIS after a diagnostic open biopsy. Result.7%.7. 75% of invasive cancers or DCIS are diagnosed without the need for diagnostic open biopsy 9.3%.8..6% of women who attend for their second or subsequent screen are found not to have invasive cancer or DCIS after a diagnostic open biopsy..% Of the 973 38 women diagnosed with breast cancer who were assessed within the Program, 9.3% received their diagnosis without needing an open biopsy (see Table 5). This result meets the accreditation standard. Benign open biopsy BreastScreen Victoria aims to minimise the proportion of women who undergo a diagnostic open biopsy for a benign lesion..8.3 4.% of women assessed after their first screen are found not to have invasive cancer or DCIS after a diagnostic open biopsy..8.4 <3.% of women assessed after their second or subsequent screen are found not to have invasive cancer or DCIS after a diagnostic open biopsy..5%.% BreastScreen Victoria met all accreditation standards for benign open biopsy. The rate of preoperative diagnosis has increased since 994. Figure 7 Preoperative diagnosis, 994 3 7

Outcome of assessment Some women recommended for assessment were assessed privately. This section of the report includes outcomes for women who were assessed both within and outside the BreastScreen Victoria Program. Early review Women may be recommended for early review 39. if a definitive diagnosis has not been achieved after assessment. Early review is only used in exceptional circumstances as it may have a significant adverse psychological effect on the woman. 4 National Accreditation Standard.. <.% of women who attend for screening are recommended for early review for further assessment. Result.% Of the 88,79 women who attended for screening, 4 (.%) were recommended to return within months of the screening date following an equivocal assessment visit. This result is slightly above the accreditation standard for early review. At the time this data was extracted 64 women were still in early review (see Table ). Malignant diagnosis A total of,74 women were recommended for assessment and 993 malignant lesions 4 (9.3%) were diagnosed. The proportion of women diagnosed with a malignant lesion increased with age, as shown in Figure 8. Figure 8 Malignant diagnosis, 3 Recommendation for routine rescreening Of the 88,79 women who attended for screening, 78,56 were recommended for routine rescreening without requiring assessment (see Table 9). Of the,74 women 4 who were recommended for assessment, 9,655 women who were assessed as having no malignant lesion were also recommended for routine rescreening (see Table ). A total of 87,7 (99.4%) women were ultimately recommended for routine rescreening. Women at increased risk of breast cancer The usual recommendation for women without. an increased risk of breast cancer is for routine rescreening at two years. Annual screening is offered to women at substantially increased risk of developing breast cancer (see Table 6). This group includes women with a personal history of breast cancer, atypical ductal hyperplasia or lobular carcinoma in situ. 39 The recall for further assessment of a screen detected abnormality in the period within up to months of the screen. 4 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4: 5. 4 Where a woman was determined to have multiple lesions, only the most significant of these is counted. Malignant lesion includes a diagnosis of invasive cancer or DCIS. 4 This total excludes women for whom the outcome of screening was unknown as they were requested to return for further screening but elected not to attend. National Accreditation Standard.5. The Service offers annual screening for % of women aged 5 69 years. Result.3% BreastScreen Victoria has met the accreditation standard for annual screening since 994. 8

Section 3 Maximising cancer detection 43 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4: 5. 44 Ibid. 45 Of the 993 cancers, seven met the criteria for classification as an interval cancer. Five cancers were diagnosed at early review more than six months after the screening examination. Two cancers were diagnosed at early rescreen at which time a lump and/or bloodstained or watery nipple discharge was present in the same breast in which the cancer was diagnosed. BreastScreen Australia aims to reduce deaths from breast cancer by the early detection of invasive breast cancer in women aged 5 to 69. 43 Accreditation standards which indicate progress. in reducing deaths from breast cancer include: invasive cancer detection rate small invasive cancer detection rate ductal carcinoma in situ (DCIS) detection rate interval cancer rate 44 Summary of cancer detection There were 993 breast cancers diagnosed among the 88,79 women who attended for screening in 3. Of these 993 cancers, only 986 are considered screendetected cancers, that is, diagnosed within the program and not classified as an interval cancer. 45 Of the 986 screen detected cancers, 776 (78.7%). were invasive and (.3%) were DCIS. Invasive breast cancer detection rates are higher. for older women (see Figure 9). Figure 9 Breast cancer detection, 3 Invasive cancer detection National Accreditation Standards.. 5 per, women aged 5 69 years who attend for their first screen are diagnosed with invasive breast cancer... 35 per, women aged 5 69 years who attend for their second or subsequent screen are diagnosed with invasive breast cancer Result BreastScreen Victoria meets the accreditation standards for invasive cancer detection. For more information on cancer detection rates see Table 3. 54.3 37.7 9

Invasive cancer detection rates for subsequent screens have remained steady from 3. Figure Invasive breast cancer detection: women aged 5 69 years, 996 3 Small cancer detection BreastScreen Victoria aims to detect invasive cancers when they are small and low grade, prior to spread to the regional lymph nodes. National Accreditation Standard.. 5 per, women aged 5 69 years who attend for screening are diagnosed with small ( 5 mm) invasive breast cancer Result BreastScreen Victoria met the accreditation standard for small invasive breast cancer detection. Of the 776 invasive breast cancers detected 497 were small (less than or equal to 5 mm). 5. Small cancer detection rates were higher for both first and subsequent screens (see figure ). Figure Invasive breast cancer detection: women aged 5 69 years, 3

Section 3 Maximising Cancer Detection 46 Tumour grade was known for 479 out of 497 women with small invasive breast cancer. 47 BreastScreen Australia. National Accreditation Standards: BreastScreen Australia Quality Improvement Program. Rev. ed. Canberra: BreastScreen Australia, 4: 8. Tumour grade is an important prognostic indicator. Tumours that are well differentiated (Grade ) are associated with a better prognosis. Small invasive breast cancers (less than or equal to 5 mm) are. more likely to be Grade than are larger tumours. Information about tumour grade was known for. 75 (96.6%) of the 776 women diagnosed with invasive breast cancer. Of the 479 46 small cancers detected, 8 (43.4%) were Grade (see Figure ). Figure Invasive breast cancer: tumour size by grade, 3 Ductal carcinoma in situ detection In this report DCIS refers to in situ cancer alone with no invasive component. Women with DCIS are at increased risk of subsequent development of invasive breast cancer. 47 National Accreditation Standards.3. per, women aged 5 69 years who attend for their first screen are diagnosed with DCIS.3. 7 per, women aged 5 69 years who attend for their second or subsequent screen are diagnosed. with DCIS. Result BreastScreen Victoria meets the accreditation standards for DCIS detection. For more information on DCIS detection see Table 3.. 9.4

DCIS detection rates for subsequent screens have increased in the 8 year period from 996 3. Figure 3 DCIS detection: women aged 5 69 years, 996 3 A rising proportion of breast cancers are diagnosed as DCIS. Figure 4 Proportion of cancers diagnosed as DCIS: women aged 5 6 years, 996 3

Section 3 Maximising Cancer Detection 48 Interval cancer rates are reported using the national definition endorsed by the BreastScreen Australia National Advisory Committee in November 998. The national definition excludes DCIS for reporting purposes, and corresponds with that used in the BreastScreen Victoria 999,, and Annual Statistical Reports. 49 Interval cancer rates are calculated separately for women who attended for their first screen in and for women who were subsequent screens in. Interval cancer An interval cancer is an invasive breast cancer. that is diagnosed during the time interval after a negative screen and prior to the next scheduled screening examination. 48 The interval cancer rates in this section are for women screened at BreastScreen Victoria from January to 3 December. 49 Interval cancers are determined annually through a matching process between the BreastScreen Victoria database and the Victorian Cancer Registry. The accreditation standard for interval cancers diagnosed in the first year after screening was raised from <6.5 to <7.5 cancers per, women in 4. At this time BreastScreen Australia has not set a standard for interval cancers for either 4 or. 4 months following a negative screen. National Accreditation Standard.4. (a) <7.5 per, women aged. 5 69 years who attend for screening are diagnosed with an invasive interval breast cancer between and less than months following a negative screening episode. Result 8. BreastScreen Victoria did not achieve the accreditation standard for interval cancers. Among women aged 5 to 69 years in there were 8 invasive breast cancers diagnosed in the first twelve months after screening, giving an interval cancer rate of 8. (95% C.I. 6.8 9.8). For more information on interval cancer rates see Tables 33 and 34. 3

Section 4 Breast cancer treatment In 3, 776 women were diagnosed by BreastScreen Victoria with invasive breast cancer and with DCIS. This section describes the treatment these women received after their discharge from the Program. Surgical treatment Where appropriate, women with invasive breast cancer should be given a choice of either mastectomy or breast conservation surgery followed by radiotherapy. 5 Treatment details were recorded for. all but four women who were diagnosed with invasive breast cancer. Of those women for whom treatment details were recorded, 8.% underwent breast conservation surgery. 5 Women with tumours measuring greater than 5 mm were almost three times as likely to undergo mastectomy as women with tumours less than or equal to 5 mm (3.6% and.8% respectively) (see Table 36). For DCIS the choice of mastectomy or breast conservation surgery depends on a number of factors including grade and size. 5 Treatment details were recorded for all but one of the women diagnosed with DCIS. Of those women for whom treatment details were recorded, 75 (83.7%) had breast conservation surgery (see Figure 5). Figure 5 Surgical treatment: type of surgery, 3 Women in rural and remote areas Of the 776 women diagnosed with invasive breast cancer, 7.6% were living in rural areas. Mastectomy rates for rural women with invasive cancer were almost double those for urban women (see Table 37). 5 National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. nd ed. Canberra: NHMRC, : 53. 5 These women may or may not have had systemic therapy and/or radiotherapy. 5 National Breast Cancer Centre. The clinical management of ductal carcinoma in situ, lobular carcinoma in situ and atypical hyperplasia of the breast. Camperdown, NSW: NBCC, 3: 36. 4

Section 4 Breast Cancer Treatment 53 References to urban areas include capital city and other major urban areas according to the Rural/remote areas classification. [Canberra]: Department of Human Services and Health, 994). 54 References to rural areas include rural major, rural other, remote major and remote other according to the Rural/remote areas classification. [Canberra]: Department of Human Services and Health, 994). A rising proportion of women underwent breast conservation surgery. Figure 6 Surgical treatment: breast conservation surgery, 996 3 Mastectomy rates for urban 53 women remain lower than those for rural 54 women. Figure 7 Surgical treatment: mastectomy for invasive breast cancer, 996 3 5

Nodal status Invasive breast cancer Axillary node dissection is recommended for most women with early breast cancer. 55 Of the 776 women diagnosed with invasive cancer. in 3, 734 (94.6%) had axillary dissection. This proportion has remained relatively stable over the period 996 3. Women with invasive tumours less than or equal to. 5 mm who underwent axillary dissection were less likely to have positive nodes (see Figure 8). Figure 8 Invasive breast cancer: tumour size and nodal status, 3 Ductal carcinoma in situ Axillary dissection is not indicated in the management of localised DCIS. 56 Of the women diagnosed with DCIS, only 9.5% underwent axillary node dissection (see Figure 9). Radiotherapy Radiotherapy is recommended for all women. with invasive breast cancer treated by breast conservation surgery. 57 Radiotherapy is recommended after mastectomy for women at high risk of local or regional recurrence. 58 Of the 56 59 women with invasive breast cancer. and known nodal status, who underwent breast conservation surgery, most (84.%) received adjuvant radiotherapy. 6 In contrast, 8.8% of women who had. a mastectomy received adjuvant radiotherapy 6. (See Table 39). Radiotherapy rates for women treated with breast conservation surgery have remained stable at approximately 84% since (see Table 4. from 3 ASRs). 55 National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. nd ed. Canberra: NHMRC, : 58. 56 National Breast Cancer Centre. The clinical management of ductal carcinoma in situ, lobular carcinoma in situ and atypical hyperplasia of the breast. Camperdown, NSW: NBCC, 3: 37. 57 National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. nd ed. Canberra: NHMRC, : 67 68. 58 Ibid.: 7. 59 Adjuvant radiotherapy information was available for 56 out of 584 women with invasive breast cancer and known nodal status who underwent breast conservation surgery. 6 These women may or may not have had systemic therapy in addition to radiotherapy. 6 Adjuvant radiotherapy information was available for 8 out of 5 women with invasive breast cancer and known nodal status who had a mastectomy. 6

Section 4 Breast Cancer Treatment Following a sharp decrease from 997 to 998, the rate of axillary surgery has remained relatively stable. Figure 9 Surgical treatment: axillary dissection for DCIS, 996 3 7

Appendix All data in the following tables excludes women who attended for screening in 3 but who were aged less than 4 years. Table shows the type of attendance by age group for women who were screened during 3. Table Attendance by age and round, 3 Type of screen Age group 4 44 45 49 5 54 55 59 6 64 65 69 7 74 75 79 8+ 5 69 Total First screen 43 8.8% 474 5.7% 95 7.% 988 4.6% 87 3.3% 753.8% 46.9% 6 4.9% 64 7.9% 63.9% 569 3.6% Subsequent screen 855 7.% 4396 48.3% 3667 7.8% 4884 95.4% 3374 96.7% 637 97.% 68 98.% 58 95.% 753 8.% 397 89.% 6399 86.4% Total 4978 9 4486 487 346 75 86 5379 97 473 8879 8

Appendix Note In the Census, 6.7% of Victorian women aged 4 years or more were identified as being born in Australia. This information is only available in census years. Table 3 shows the country of birth by age group for the women who attended for screening in 3. Table 3 Attendance by age and country of birth, 3 Country of birth Australia 986 69.7% Age group 4 49 5 59 6 69 7 79 8+ 5 69 Total 5553 63.3% 3688 6.9% 8 68.% 667 7.7% 98 6.3% 35 63.7% United Kingdom 89 5.9% 7 8.% 584 8.9% 79 7.9% 7.7% 46 8.4% 54 8.% Italy 47.8% 35 4.% 453 7.% 749 6.6% 36 3.9% 7653 5.% 9685 5.% Greece 5.% 79 3.% 37 5.% 73.7% 7.8% 5799 3.9% 667 3.5% The former Yugoslavia 7.% 49.6% 86.% 76.%.% 65.8% 36.6% Germany 48.3% 33.5% 797.3% 459.7% 8.9%.4% 65.4% Netherlands 65.5% 5.4% 83.4% 4.5%.% 35.4% 5.3% Malta 9.8% 334.5% 737.% 33.9% 9.% 7.4% 4.3% Vietnam 44 3.% 6.3% 473.8% 4.5%.% 634.%.% New Zealand 8.6% 99.% 35.6%.4% 5.5% 69.9% 64.8% China 8.3% 65.7% 456.8% 38.5%.% 8.8% 48.8% Malaysia 46.% 77.9% 67.4% 73.3%.% 38.7% 57.7% Poland 64.5% 53.6% 36.6% 9.9%.% 893.6% 96.6% Sri Lanka 3.7% 64.7% 9.5% 34.5% 4.4% 93.6% 73.6% India 9.7% 559.6% 3.5% 3.5%.% 88.6% 6.6% Philippines 6.8% 666.8% 63.3% 45.%.% 89.6% 99.5% Egypt 34.% 465.5% 37.5% 7.5%.% 79.5% 955.5% Cyprus 54.4% 49.5% 58.4% 89.3%.% 687.5% 83.4% Turkey 93.7% 48.5%.3% 5.%.% 68.5% 799.4% South Africa 8.6% 49.5% 9.3% 7.3% 3.3% 69.4% 775.4% Other 9 7.% 583 6.6% 3645 6.% 45 4.7% 39 4.3% 9468 6.4% 77 6.% Total 488 87734 59586 6465 97 473 8879 9