The BreastCheck programme has helped to monitor the health of 30,000 women in its first year - and the results, just released, are impressive. But what can women expect when they attend for screening?
NUMBER 36 Eccles Street is one of the old Georgian houses beside the Mater hospital. When you walk through the door, you are struck by two contradictions: although it is a clinic, it neither looks like one nor has the sanitised odour of a hospital.
I am in the hallway of the Eccles Unit, one of the two BreastCheck centres in Dublin. The National Breast Screening Programme's other facility is the Merrion Unit, on the campus of St Vincent's Hospital. A mobile unit completes the trio of locations where women from the Eastern Regional Health Authority area, and those of the North Eastern and Midland health boards, have been screened for breast cancer over the past year.
Funded by the Department of Health and Children, the BreastCheck screening programme aims to reduce deaths from breast cancer by 20 per cent. Available only to women aged between 50 and 64, this free service has been operating on a phased basis since February 2000. In the first year of the programme, 30,000 women were invited for screening.
The Republic has the fourth highest overall incidence of breast cancer in the EU, but the highest mortality rate from the disease in women under the age of 65. Approximately one woman in 10 will develop breast cancer. The incidence increases with age, especially in the years coming up to the menopause.
Why screen for breast cancer? Put simply, the earlier the cancer is detected, the higher the chance of treatment bringing about a cure. Cancer survival rates are usually measured in terms of the number of people alive five years after treatment. For stage-1 disease, in which a small tumour is confined to the breast, the five-year survival rate for a cancer less than 1cm in diameter is more than 95 per cent.
The BreastCheck programme uses a mammogram - a specialised X-ray of the breast - as its screening test. Taken by radiographers, the X-rays are then read by radiologists. A breast-care nurse is also part of the primary screening team, backed up by administrative staff.
Dr Fidelma Flanagan, the lead radiologist at the Eccles Unit, and Dr Ann O'Doherty, the lead radiologist at the Merrion Unit, outline the screening process. BreastCheck compiles a register of women from several sources. Using information supplied by the VHI, the GMS and the Department of Social, Community and Family Affairs, a database for each electoral area is put together. This covers only 86 per cent of the target population and so self-registration is also encouraged.
The first communication a woman receives from BreastCheck is a general letter of invitation, the purpose of which is to ask permission to arrange an appointment for a mammogram. An information leaflet is enclosed, and you are told to do nothing if you wish to be called for an appointment.
Otherwise, you have 21 days to write back to say you do not wish to be screened. If you change your mind, however, you are still welcome to phone for an appointment, even if the programme has left your area. Assuming you wish to take part, you will be sent an appointment time that you can change if it is unsuitable.
At this stage you have still not formally consented to screening; this takes place on the day, following a discussion with the radiographer about any concerns you might have. So far in the Eccles Unit, only four women out of 6,000 have refused consent. But it is important to emphasise that you can opt out right up to the last moment.
There are seven stages to BreastCheck, with a defined time scale between each. You are guaranteed the result of the mammogram within three weeks, for example. Dr Michelle McNicholas, a consultant radiologist, and Jackie McAleese, superintendent radiographer at the Eccles Unit, take me through the screening process as if I am a patient.
Having checked in, I am brought to a waiting room that bears a closer resemblance to an up-market sitting room than it does to a hospital waiting area.
There is a television, attractive plants and a decent selection of magazines. Next to this is a changing area with a series of cubicles. Again, the deep carpet and wood panelling are welcoming and unclinical. Here you remove your bra and slip your jumper back on.
Next stop is the scan room, across the corridor, where the radiographer will discuss the procedure with you before you give your final consent. McAleese points out that mammography is not contra-indicated - or ruled out - in patients who have had breast surgery or have implants.
The mammogram takes less than 10 minutes. Four films are taken, two of each breast. While standing, you place your breast against the X-ray machine, and a perspex plate gently presses it downwards. The compression helps to increase the accuracy of the scan; it also reduces the number of films required.
Is it painful? Dr O'Doherty describes it as possibly uncomfortable for a minority of women. She studied women's experience of breast screening in Northern Ireland. Of the 600 women she surveyed, two-thirds reported no problems with the mammogram. A further 180 described the experience as uncomfortable, with just 20 reporting breast pain during the procedure.
When the scan is finished, you return to the waiting area until the radiographer is satisfied that the films are technically acceptable. You are then free to go.
The mammogram films are read within a number of days by two radiologists working separately. If they disagree, a third specialist is asked to review the X-rays. A mammogram is either normal - in which case the results are sent by post within 21 days - or the woman is recalled for further screening within a fortnight. This does not mean she has breast cancer; it may simply indicate a problem with the quality of the Xrays, for example.
BreastCheck has recalled 5 per cent of women since it began screening. Experience shows that one in five of those recalled will have breast cancer. "We go to a lot of trouble to give the woman 48 hours' notice of call-back, so as to minimise anxiety but also to allow her time to absorb the information," Dr O'Doherty says.
The recall - or assessment - clinic usually carries out a further mammogram, as well as ultrasound and clinical examinations of the breast. This may be all that is required, although in some cases the radiologist will perform a fine-needle biopsy of a suspicious area. This is done at the assessment clinic under local anaesthetic. The cells from this procedure are then sent for laboratory examination, to check if they are cancerous.
Within a week, you will be back at the clinic for the results. During this interval, you can avail of the support of a breast cancer nurse, whom you will have met at the assessment clinic.
Most women will get good news at the results clinic. So far, BreastCheck has detected cancer in nine of every 1,000 women screened. Women with a positive diagnosis are guaranteed hospital admission within three weeks, whether public or private, although Michael Kerin, the lead surgeon with the Eccles Unit, says most women will have surgery within two weeks.
Dr Flanagan would like to see breast-cancer screening looked at in the same way as a cholesterol or blood-pressure check. "Women should regard this service as part of their routine health care," she says.
Before this can happen, Dr Flanagan and Dr O'Doherty accept that the quality of the BreastCheck programme must be thoroughly validated. So far, the statistics are impressive. At nine per 1,000 women screened, the cancer-detection rate of the programme exceeds its target of seven per 1,000.
The recall rate - the percentage of women called back for further assessment - is running at between 4 per cent and 5 per cent, which is less than the target of 7 per cent set by other international screening programmes. This is a particularly important statistic, as a high recall rate will cause unnecessary anxiety and would be a significant barrier to extending BreastCheck throughout the Republic. Finally, the acceptance-to-invitation rate, at 68 per cent, is just under the 70 per cent that the National Breast Screening Committee has said must be achieved "if optimal targets for reduction in mortality are to be met".
As someone who has been sceptical of mass-population screening, I am very impressed with the quality and attention to detail that the new service offers. The screening rate needs to exceed 70 per cent - and preferably 75 per cent - if the number of breast cancers detected is to rise to a level that will reduce mortality for the population as a whole. As awareness of BreastCheck increases, this figure should be achieved.
The potential adverse effects of breast screening, such as unnecessary recall and the possible discomfort of the procedure, as well as the fears and anxieties of patients, are being addressed by the programme.
It is important to point out 5 per cent of breast cancers will not be detected by mammography. There is also the possibility of a cancer arising in the twoyear interval between screenings, even though the original X-ray was negative.
When might the next phase of screening begin? Dr Sheelah Ryan, the chairwoman of BreastCheck, told The Irish Times that her board "will be carrying out a feasibility study in the coming months, and will then advise the Minister for Health during the summer about a roll-out nationally".
It is widely expected that funding for such an extension to the breast-screening programme will be included in next year's health estimates, but a potential barrier to the expansion of BreastCheck is an acute shortage of radiographers. The two Dublin units have filled only 10 of 18 approved posts.
The quality and teamwork that I witnessed at the Eccles Unit are impressive. BreastCheck is a beacon that shows what could be achieved with a properly funded and organised health service. It is hard to disagree with the words of Dr Ann O'Doherty: "If women knew the very high quality of this service, they would take the opportunity to come for screening, and we could then reduce the number of women dying from breast cancer by 20 per cent."
BreastCheck freephone information line: 1800-454555; Eccles screening unit: 01-8034900; Merrion screening unit: 01- 2094045