Australia's national breast screening program 18 years on: time for a new direction?

Mammographic screening for breast cancer has been almost universally accepted as reducing mortality in the screened population through early detection. National breast screening services are now well established in many countries, including Australia, where BreastScreen was established in 1991. Since then BreastScreen has provided a high-quality service to Australian women. A major evaluation of the BreastScreen Program is underway, commissioned by the Australian Health Minister's Advisory Council. 1 This is an opportunity to reflect on the role of BreastScreen in the provision of breast care in Australia, to establish new and innovative directions, and to ensure the future relevance of the program. This article discusses the issues from the viewpoint of clinicians at the coalface, who are providing breast screening and treatment services, but who appear to be under-represented in the review process. Recent discussion in the international literature about the information provided to women attending breast screening programs further highlights issues with the process of breast cancer screening. 2 The BreastScreen Australia National Accreditation Standards, against which individual services are evaluated, were set when the program was established and were updated in 2004. 3 Individual services across Australia structure their programs quite differently while striving for these same standards. There is a lack of uniformity in many aspects of service provision, such as structure of the administration , quality assurance procedures, approach to women with a family history of breast cancer, use of clinical staff, data collection procedures, forms used and the approach to issuing results. Many of these processes could be standardized, and successful ideas from one service implemented across others. BreastScreen Australia aims for a participation rate of 70% of the target population (women aged 50–69); the current national participation rate is only around 52%. 1 While there are a number of variables affecting participation rates, one of the key factors may be that this figure reflects participation in the BreastScreen, but this may not reflect participation in mammography screening in general. An unknown (and probably very significant) number of women have screening outside BreastScreen, and this 'de facto' screening is not monitored, partly because there is no Medicare rebate for screening mammography. Medicare paid rebates for 314,000 bilateral mammograms and 40,000 unilateral mammograms. 4 Many of these private 'diagnostic' mammograms (eligible for a rebate) in women with a family history, past breast cancer or nodularity/mastalgia may be performed with screening intent. In addition, it is likely …