Trust Guideline for the inclusion of women at High Risk of Breast Cancer in the NHS Breast Screening Programme For Use in: By: For: Division responsible for document: Key words: Name and job title of document author: Name and job title of document author s Line Manager: Supported by: Norwich Breast Screening Unit, Norwich Breast Service, and NNUH Oncology Dept Director of Breast Screening, Consultant Breast Surgeons and Breast Clinicians, and Consultant Oncologists Women at high risk of Breast Cancer Surgical Division High Risk Breast Screening Dr Simon Girling, Director of Norwich Breast Screening Unit Richard Goodwin, Consultant Radiologist Mr Maged Hussien, Consultant General Surgery, Dr Adrian Harnett Consultant Oncology, Dr Carole Wyatt, Speciality Doctor Clinical Guidelines Assessment Panel (CGAP) Assessed and approved by the: If approved by committee or Governance Lead Chair s Action; tick here Date of approval: 29/11/2016 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Reference and / or Trust Docs ID No: 9492 Version No: 4 Description of changes: Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? Clinical Standards Group and Effectiveness Sub-Board 29/11/2019 Director of Norwich Breast Screening Unit No clinical changes None N/A This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Available via Trust Docs Version: 4 Trust Docs ID: 9492 Page 1 of 6
Trust Guideline for the inclusion of women at High Risk of Breast Cancer in the NHS Breast Screening Programme Quick reference guideline/s Patients to whom this guideline applies - Women at greater than average risk of developing breast cancer. These women are identified within the symptomatic Breast Service at NNUH. Increased risk due to a family history will be confirmed by the regional Genetics service in Cambridge. Others will have had supradiaphragmatic radiotherapy in the past. This guideline sets out the role of the Norwich breast screening programme in relation to women at greater than average risk of breast cancer, and describes the organisational arrangements that need to be in place, including appropriate use of the computer system, the National Breast Screening System (NBSS). (4) The guideline will be used by staff in Oncology, Breast Surgery, Radiology and the Breast Screening Unit. Objective/s The NHS Breast Screening Programme (NHSBSP) is now responsible for managing the imaging surveillance of women who are assessed as being at higher risk of developing breast cancer. Their elevated risk may be due to a genetic predisposition to the disease, a significant family history of breast cancer, or previous supradiaphragmatic radiotherapy (e.g. treatment for Hodgkin s disease). This guideline sets out the role of a breast screening programme in relation to women at greater than average risk of breast cancer, and describes the organisational arrangements that need to be in place, including appropriate use of the computer system, the National Breast Screening System (NBSS). Rationale The Department of Health s Cancer reform strategy (2007) recognised a high degree of local variability in guidelines for the surveillance of women identified as being at elevated risk of developing breast cancer (1). A subsequent publication, Improving outcomes: a strategy for cancer (2011) reported that the NHS Breast Screening Programme (NHSBSP) was in a position to manage the surveillance of women at higher risk across England and to ensure a consistent and high-quality service that conformed with rigorous national standards (2). The report concluded that surveillance with digital x-ray mammography and magnetic resonance imaging (MRI) should be provided to women at higher risk where appropriate. Available via Trust Docs Version: 4 Trust Docs ID: 9492 Page 2 of 6
Trust Guideline for the inclusion of women at High Risk of Breast Cancer in the NHS Breast Screening Programme Broad recommendations 1. Woman identified as potentially high risk in breast clinic, and referred to Cambridge genetics service. Confirmation of genetic abnormality or similar risk by Genetics service. Breast clinic refers woman to the Director of Norwich Breast Screening Unit. 2. Woman at high risk because of chest radiotherapy at young age (usually given as part of treatment for lymphoma), identified by Oncology department, and referred to the Director of Breast Screening Unit. 3. Director of Breast Screening informs the breast screening administration manager, and a minimum data set is entered on to NBSS, including selection of imaging protocol. 4. Woman added to separate data-base to allow tracking. 5. Screening Director writes to woman (copied to referrer) describing the screening process, and outlining the imaging protocol they should expect in the years ahead. Approximate date of first invitation included in the letter. 6. Screening Director organises MRI scan if required. Mammography arranged for same day if possible. 7. Woman and referrer (Breast clinic or Oncology) informed of normal results. 8. Abnormalities will be recalled to an assessment clinic for further investigation, as in the rest of the NHSBSP. Case then discussed at weekly multidisciplinary team meeting (MDT). 9. In January 2012, the Advisory Committee on Breast Cancer Screening agreed a set of imaging protocols for a selected group of women at elevated risk of breast cancer. These have now been published and updated as NHSBSP Publication no 74 version 4, Guidelines for the surveillance of women at higher risk of developing breast cancer (3). Available via Trust Docs Version: 4 Trust Docs ID: 9492 Page 3 of 6
Trust Guideline for the inclusion of women at High Risk of Breast Cancer in the NHS Breast Screening Programme Available via Trust Docs Version: 4 Trust Docs ID: 9492 Page 4 of 6
Trust Guideline for the inclusion of women at High Risk of Breast Cancer in the NHS Breast Screening Programme Clinical audit standards Audited as part of the NHSBSP by the National Quality Assurance (QA) Reference Centre. Annual audits will take place on the workload and outcomes of higher-risk screening. A national return (KC62 and KC63) is expected from each screening programme, although the numbers of higher-risk cases gathered for these returns are expected to be small. An additional annual audit of the Quality Management System (QMS) to ensure that the guideline governing right results is met for higher-risk screening. This is particularly important as the pathways are likely to be complex and to cover multiple organisations. All breast screening services are subject to formal triennial QA visits. The process and outcomes of the higher-risk screening programme will be reviewed during the standard visit. The right results walkthrough conducted by the QA service will incorporate the entire screening process for both population-based screening and higher-risk surveillance. Summary of development and consultation process undertaken before registration and dissemination The authors listed above drafted this guideline. During its development it has been circulated for comment to: Mr M Hussien, lead Breast Surgeon; Dr A Harnett, Oncologist; Mrs M Ballantyne, Breast Screening Admin Manager; Dr C Wyatt, Breast Clinician; Mrs R Hiscock, Breast Screening Superintendent Radiographer; and Dr Paul Malcolm, MRI lead. This version has been endorsed by the Clinical Guidelines Assessment Panel. Distribution list/ dissemination method Trust Intranet References/ source documents 1. Cancer reform strategy. London: Department of Health, 2007. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov. uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_08100 7.pdf 2. Improving outcomes: a strategy for cancer. London: Department of Health, 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/2 13785/dh_123394.pdf Available via Trust Docs Version: 4 Trust Docs ID: 9492 Page 5 of 6
Trust Guideline for the inclusion of women at High Risk of Breast Cancer in the NHS Breast Screening Programme 3. Guidelines for the surveillance of women at higher risk of developing breast cancer. Sheffield: NHS cancer Screening Programmes, 2013. http://www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp74.pdf 4. Guidelines on organising the surveillance of women at higher risk of developing breast cancer in an NHS Breast Screening Programme. NHS Cancer Screening Programmes, March 2013 http://www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp73.pdf Available via Trust Docs Version: 4 Trust Docs ID: 9492 Page 6 of 6