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NHS breast screening: a model national programme

The United Kingdom’s NHS Breast Screening Programme is an impressive example of a high-coverage mammography screening service. The recent report from the Advisory Committee on Breast Cancer Screening (see pages 59–61) traces the history of the programme since its inception in 1988. As it was set up, the programme offered free threeyearly, single-view mammography to women aged 50–64. It has now been expanded to offer two-view mammography to women aged 50–70, and it achieves 75% coverage of the target population. The programme is estimated to save around 1400 lives per year, one per eight women regularly screened. This is consistent with estimates of the benefit of mammography programmes in the US. The costs have been estimated as £3000 per year of life saved. While more sophisticated cost effectiveness analyses are possible, it is clear that the UK programme represents value for money in health economic terms. The screening regimen, as it was initiated in 1988, might be considered minimal, and indeed some colleagues might still consider it so in view of the three-year interscreening interval. However, its spareness and simplicity may be an important contributor to its success. In offering secondary preventive services at a national level, delicate balances have to be struck with respect to effectiveness, cost, deliverability and acceptability. The three-yearly programme is deliverable within the financial resources and the numbers of appropriately qualified staff available. It is acceptable to the public, as evidenced by the high coverage, and it is saving lives. As treatment options improve, the mutually adjusted benefits of screening and adjuvant therapies will take on some importance. These may lead to further refinement of the target population, so that screening is offered only to those most likely to benefit from it. Primary prevention strategies may also have implications for the effectiveness of screening or the appropriate target population. In the meantime, the UK’s Breast Screening Programme has led to a reduction in deaths from breast cancer, in the size of tumours at presentation and in the number of mastectomies. Indirect effects include the mass of downstream research, which has added to our understanding of breast cancer natural history and control, and to the standardization and dissemination of good practice in diagnosis and treatment of breast cancer. Other countries may do well to look to the UK programme as one to emulate. Graham A Colditz Associate Director, Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 181 Longwood Avenue, Boston MA 02115, USA