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Overview: Breast screening

Screening aims to detect cancer at a very early stage, it does not prevent cancer. In the UK, national screening is available for cancers of the breast and cervix. Screening is also being looked at for bowel, ovarian and prostate cancer.

Our section on cervical screening provides more specific information.

Breast screening

In the UK, women aged 50 to 70 are invited to attend for breast screening every three years as part of a national breast screening programme. This programme aims to find breast cancer very early so that women have the best chance of the cancer being cured. If you are aged over 70 you can continue to have regular screening by making your own appointments at the breast screening clinic.

You may also be referred to a breast clinic for tests at any age if you find a change or lump in your breast tissue that worries you, even if you are already having screening as part of the breast screening programme. Your GP can refer you.

The breasts

The breasts are made up of fat, connective tissue and glandular tissue that contains lobes. These are shown in the diagram below. The lobes are where breast milk is produced. A network of milk ducts connects the lobes to the nipple.


Two diagrams, one showing the lymph nodes close to the breast and a second showing the structures of the breast.

A woman's breasts are rarely the same size as each other, and may feel different at different times of the menstrual cycle, sometimes becoming lumpy just before a period. Under the skin, an area of breast tissue extends into the armpit (axilla).

The armpits also contain a collection of lymph glands (lymph nodes), which are part of the lymphatic system. The lymphatic system is a network of lymph glands throughout the body that are connected by tiny vessels called lymph vessels.


Breast cancer

Breast cancer is the most common cancer in women. Over 41,000 women in the UK are diagnosed with breast cancer each year. One in nine women in the UK will develop breast cancer at some time in their life. However, it can usually be cured if it is found early.

Breast cancer almost never occurs in women in their teens or early twenties and it is rare in women under 35. As women get older, their risk of developing breast cancer increases. Eight out of ten breast cancers (80%) occur in women who have had the change of life (menopause).

Breast screening

Breast screening is a way of finding breast cancers early, when they are too small for you or your doctor to see or feel. The first stage of breast screening is a mammogram. A mammogram is an x-ray of each breast.

Under the present Department of Health guidelines all women registered with a GP and aged 50 to 70 are offered a free mammogram every three years. If you are over 70 you will not be automatically invited for breast screening, but you can still have free mammograms by making your own appointment every three years. It is important to do this, as the risk of developing breast cancer increases as women get older.

Each year around one and a half million women in the UK have breast cancer screening as part of the NHS Breast Cancer Screening Programme (NHSBSP). The NHSBSP is nationally coordinated and sets national standards.

Breast screening under 50

This information is about breast screening in women below the age of 50. It covers mammography (the main method used for breast screening) and MRI scanning, and why they might be offered to women under 50.

It should ideally be read with our general information about breast screening. You might find it helpful to discuss things with the staff at your family history clinic.


Breast screening

Breast screening is a way of finding breast cancers early, when they are too small for you or your doctor to see or feel. In the UK, around 1 in 9 women will develop breast cancer at some time in their life.

Women with a significant family history of the disease may carry a higher risk of developing breast cancer, but it is important to recognise that:

  • Most women do not develop breast cancer. Of those who do, most will not have a known family history of the disease.
  • For most women, increasing age is the greatest risk factor for developing breast cancer.
  • The majority of women with a family history of breast cancer do not fall into a high-risk category and do not develop breast cancer.
  • The majority of women with a relative with breast cancer are not at a substantially increased risk of developing breast cancer themselves.

Each year, around one and a half million women in the UK have breast screening as part of the NHS Breast Screening Programme (NHSBSP). The NHSBSP is nationally coordinated and sets national standards.

Mammography

A mammogram is a low-dose x-ray of the breast tissue. It tests for early breast cancer. You will need to remove your clothes from the top part of your body, including your bra. The radiographer will then position you so that each breast is placed, in turn, on the x-ray machine and gently but firmly compressed (squashed) against a flat, clear, plastic plate.

The breast tissue needs to be compressed to keep the breast still in order to get the clearest picture, using the lowest amount of radiation possible. Some women find the examination uncomfortable for a few seconds, while the breast is being compressed. Only a very few find this painful. You will need to stay still for less than a minute while the picture is being taken. The radiographer takes two pictures of each breast, in two different positions, to make sure they examine all the breast tissue.

Under the present Department of Health guidelines, all women registered with a GP and aged between 50 and 70, are offered a free mammogram every three years. If you are 70 or over, you are not automatically invited for breast screening. You can, however, make your own appointments for free mammograms every three years if you wish.

MRI (magnetic resonance imaging)

MRI scans use magnetism instead of x-rays to build up a detailed picture of the breasts. During the scan you will be asked to lie very still on the couch inside a long tube for about 30 minutes. It is painless but can be uncomfortable, and some women feel a bit claustrophobic during the scan. It is also noisy, but you will be given earplugs or headphones.

Some women are given an injection of dye into a vein in the arm, but this usually does not cause any discomfort.

MRI scanning is not generally used in breast screening on the NHS.

Why women under 50 are not usually screened

Breast cancer is not common in women under 50 and large research trials have shown that regular screening of this group doesn't help save lives. Other trials have shown that for most women under 50, the additional radiation exposure from regular mammography is more of a risk.

We also know that mammograms are less effective at detecting breast cancer in women who have not had the menopause (pre-menopausal women). The menopause happens, on average, around the age of 50. After the menopause, the glandular tissue in the breast decreases, which makes x-rays of the breast easier to read and so the results are more reliable.

This is why the effectiveness of breast screening is uncertain for women under the age of 50, and why it isn't routinely offered.

Benefits and disadvantages of breast screening

To help you decide whether or not to go for screening, the main benefits and difficulties are described below:

Benefits

  • Breast screening may find cancers early
  • Breast screening in women over 50 saves lives
  • With breast screening, any cancer is more likely to be found early. If a cancer is found, it is likely to be smaller. It may, therefore, be possible to remove the lump (by a lumpectomy) rather than remove the whole breast (a mastectomy)

Disadvantages

  • Mammograms can be uncomfortable
  • Mammograms involve x-rays. They only use a low amount of radiation. The radiation dose given by breast screening x-rays is continually monitored to make sure that it remains as low as possible, while still providing a good-quality image. However, if you start screening at a younger age, over your lifetime you will be exposed to more radiation. There is a very small risk that this could affect your health
  • Abnormal mammogram results may cause unnecessary worry. Around 1 in 20 women who go for screening will be called back for further investigations. Most women who have further tests will turn out not to have cancer. However, women who are called back often find this a very worrying time
  • Mammograms sometimes need to be repeated (for example, if the films are not very clear)
  • Breast screening will not pick up all breast cancers. It is more likely that cancers will be missed in women below the age of 50
  • Cancer may still occur in women having regular breast screening.

It is important to understand that breast screening cannot prevent cancer. You can read more about the pros and cons of mammography further on in this section.

Risk assessment

The definition of whether a woman has a significant family history of breast cancer is quite complicated.

A member of the breast care team will talk to you about your family history. Then, possibly using questionnaires or computer programmes, they estimate your risk of developing breast cancer. This is a 'risk assessment'. If your risk level is similar to that of the general population, you can begin mammography when you reach 50. However, if your family history changes, you can contact the team for reassessment.

The National Institute for Health and Clinical Excellence (NICE) is an independent body that gives guidance to doctors on the prevention and treatment of ill health. NICE has produced guidance on the screening of women with an increased risk of developing breast cancer because of their family history. The guidelines currently classify women who have a higher chance of developing breast cancer, because of their family history, into two groups:

  • moderate risk
  • high risk

The type of care that will be recommended for you depends on your level of risk.

Moderate risk

If it is estimated that you are at moderate risk of developing breast cancer, you will generally receive care from the breast care team. You should be offered support and information appropriate to your individual needs and, depending on your age, you may also be offered mammography. If you are under the age of 50, you will be offered yearly mammograms from the age of 40. Women under 40 should only be offered regular mammograms as part of a research study.

According to the NICE guidelines, examples of women likely to be at moderate risk include women with one of the following in their family history:

  • One first-degree relative diagnosed with breast cancer before the age of 40. (Your first-degree relatives are your mother, father, daughter, son, sister, brother.)
  • Two first-degree or second-degree relatives diagnosed with breast cancer at an average age of over 50 years old. (Your second-degree relatives are your grandparents, grandchildren, aunt, uncle, niece, nephew, half sister and half brother.)
  • Three first-degree or second-degree relatives diagnosed with breast cancer at an average age of over 60 years old.

(Note: these are only some examples taken from the NICE Guidelines so this is not an exhaustive list).

Where more than one relative is mentioned above, all relatives must be on the same side of the family, and must be blood relatives, of the person being assessed (and of each other).

High risk

Women thought to be at high risk of developing breast cancer will be offered referral to a specialist genetics service. Here, a specialist will carry out a more detailed assessment, to investigate the possibility of a genetic link in the family.

Less than one in 100 women are at high risk of developing breast cancer because of their family history.

According to the NICE Guidelines, examples of women who are likely to be at high risk include women with one of the following in their family history:

  • two first-degree or second-degree relatives diagnosed with breast cancer before the average age of 50 (at least one must be a first-degree relative). (Your first-degree relatives are your mother, father, daughter, son, sister, brother. Second-degree relatives include grandparents, grandchildren, aunt, uncle, niece and nephew; half sister and half brother)
  • three first-degree or second-degree relatives diagnosed with breast cancer before the average age of 60 (one must be a first-degree relative)
  • four relatives diagnosed with breast cancer at any age (one must be a first- degree relative)
  • one first-degree relative with cancer in both breasts where the first cancer was diagnosed before the age of 50
  • one first-degree or one second-degree relative diagnosed with ovarian cancer at any age and one first or second-degree relative diagnosed with breast cancer before the age of 50
  • two first or second-degree relatives diagnosed with ovarian cancer at any age

(Note: these are only some examples taken from the NICE Guidelines so this is not an exhaustive list).

In the above examples, where more than one relative is mentioned, all relatives must be on the same side of the family, and must be blood relatives of the person being assessed (and of each other).

Other factors that may influence familial breast cancer risk

There are other factors that may influence your risk of familial breast cancer. For example, if you:

  • have a close relative who has had breast cancer diagnosed in both breasts
  • have a male relative with breast cancer
  • have relatives with breast and ovarian cancer on the same side of the family
  • have Jewish ancestry
  • have a history of any rare, or childhood, cancers on the same side of the family.

You will be asked about such factors in your family during your consultation. It is also important to let your breast care team know if there are any changes in your family history as time goes on, as this may change your risk assessment.

Breast screening before the age of 50 for women at increased risk

For women under 50, who have an increased risk of developing breast cancer because of their family history, the current view of experts in the UK is that the benefits of screening are likely to outweigh any potential disadvantages.

Therefore you may be offered a yearly mammogram and sometimes an MRI scan before reaching 50, because your family history places you at a significantly greater risk level than that of the general population. Some women may be offered a combination of mammograms and MRI scans.

The NICE Familial Breast Cancer Guideline recommends that women with a moderate or high risk of breast cancer should be offered yearly mammograms between the ages of 40 and 49. Women aged 30 to 39 should only be offered a mammogram as part of a research study or when they can be closely monitored. Women aged between 20 and 49 may be offered an annual MRI scan if they have a high risk of developing breast cancer. This includes women who are known to have one of the faulty breast cancer genes.

Most women over 50 are usually offered a mammogram every three years as part of the National Breast Screening Programme. This is because breast cancer is easier to find in women over 50 and breast cancers are usually slower-growing in this age group. For women over 50, MRI scans will not be routinely widely available for breast cancer screening.

This screening advice may change in future, when the results of the study described below are known.

An NHS-funded research study is looking into whether or not there is actually a benefit in screening women who are at moderate or greater risk (because of their family history), aged 40-49 years. This study is called the FH01 Study, or Evaluation of Mammographic Surveillance Services in Women under 50 with a Family History of Breast Cancer. If you are aged between 40 and 44, and have a family history of breast cancer, you may be asked to take part in the study.

Other scans

Other scans, such as ultrasound scans, can pick up changes in the breasts, but are not used routinely. They are sometimes used in individual cases (where a woman is at high risk of developing breast cancer) if a doctor feels they might be of help.

Your feelings

It is difficult to face any uncertainty about health. Making decisions about screening can be tough, and you may experience a range of powerful emotions, including anxiety and fear. Your breast care team will be able to support you, and in some centres specialist counsellors are available. Our nurses can also give you details of helpful organisations, throughout the UK.

References

This information has been compiled using information from a number of reliable sources, including:

  • FH01 Study ‘Information for Patients’
  • Familial Breast Cancer: the classification and care of women at risk of familial breast cancer in primary, secondary and tertiary care (partial update of CG14). National Institute for Health and Clinical Excellence (NICE). October 2006.

Benefits of breast screening

Breast screening finds cancers early

In women who have breast screening, most cancers are found at an early stage when there is a good chance of them making a successful recovery. In the UK more than half of the breast cancers found through screening are found very early: when they are very small and have not spread to the lymph nodes close to the breast.

Breast screening saves lives

Over 19 million women have had breast screening in the UK since the breast screening programme was set up in 1988. In this time, it has found more than 117,000 cancers.

A report in 2006, by the Advisory Committee on Breast Cancer Screening, shows that screening saves 1,400 lives a year in England. Research by the International Association for Cancer Research has shown that for every 500 women who have breast screening one life will be saved.

Women who take part in breast screening reduce their risk of dying from breast cancer.

Breast conserving surgery is possible

In women who have breast screening, any cancer is more likely to be found early. This means that the cancer is small and more likely to be removed with lumpectomy (removal of the lump) rather than needing a mastectomy (removal of the whole breast). 70% of women whose breast cancer is diagnosed by screening have breast conserving therapy, compared with 55% of women diagnosed outside the screening programme.

Difficulties with breast screening

Breast screening cannot prevent cancer

It only helps to find a breast cancer if it is already there.

Having a mammogram is uncomfortable

Many women find mammography uncomfortable or painful, but this is normally just for a short time, although some women may find that the pain or soreness lasts for a few days.

Having a mammogram involves x-rays

Any x-ray involves radiation, but mammograms only give a very low amount of radiation. The amount of radiation given during a screening appointment is about the same as the dose a person can receive in everyday life, for example in an aeroplane when flying from the UK to Australia and back. The risk that such a low dose of radiation could cause a cancer is considered far outweighed by the benefits of detecting a breast cancer early.

The radiation dose given by breast screening x-rays is continually monitored to make sure that it is as low as possible while still giving a good-quality image.

You can find detailed information about the radiation risk of breast screening at www.cancerscreening.nhs.uk/breastscreen/publications/mp-rrbs-01.html You can also telephone the NHS Response Line on 08701 555 455.

False-positive results may cause unnecessary worry

Sometimes a mammogram will show an abnormal area in the breast and a woman will need to have more tests. This can be very worrying, but often further tests will show that the abnormality is not a cancer. This is known as a false-positive result. The tests may include biopsies of the breast tissue, which can cause pain or scarring of the breast tissue.


Mammograms sometimes need to be repeated

One or two mammograms in every 100 have to be taken again because:

  • The x-ray picture is blurred and cannot be read by the doctor.
  • There is some kind of equipment failure, for example the machine that processes the x-ray films breaks down (this is very rare).
  • The mammogram misses part of the breast and it needs to be retaken so that the whole breast can be seen.

Breast screening occasionally misses a cancer

Although mammography is the most effective and reliable way of detecting breast cancer early, it is not perfect. A breast cancer may not be detected by mammogram because:

  • Some cancers are very difficult to see on the x-ray.
  • Some cancers, even though they are there, cannot be seen on the x-ray at all.
  • The person reading the x-ray may miss the cancer (this will happen occasionally, no matter how experienced the person reading the x-ray is).

Cancer may occur even in women having regular breast screening

For the reasons given above, women having three-yearly breast screening as part of the NHSBSP may be diagnosed with breast cancer in the time between their screening appointments, even if they had a normal result after their last mammogram. This is known as an interval cancer.

If an interval cancer is diagnosed, the mammography films taken at the time of diagnosis will be compared to the previous mammograms. Women diagnosed with an interval cancer will always have the results of this review discussed with them. Research shows that the outlook and cure rates for women with interval cancers are better than for women who have never attended screening.

Breast screening occasionally diagnoses a cancer which would never have needed treatment

Some cancers found by screening would never have caused a problem during the woman's lifetime. Unfortunately, it is not possible to tell the difference between cancers which will spread and cause problems and those that will not.

As breast screening cannot pick up every cancer, you should see your GP if you have any unexplained changes in your breasts (eg lumps, pain, discharge from the nipples) even if you are having regular breast screening.

There are many reasons for changes in breast tissue. Most of them are harmless, but you should always get them checked as there is a small chance that they could be the first sign of cancer.


How do I get an appointment for breast screening?

There are more than 90 breast screening units across the UK. All women registered with a GP will receive their first invitation to attend for a mammogram some time between their 50th and 53rd birthdays. Invitations are then sent every three years until a woman reaches her 71st birthday. If you have not received an invitation, your GP can arrange for one to be sent to you. If you have any worrying breast symptoms while waiting for a breast screening appointment, contact your GP, who can refer you to the breast clinic if necessary.

When you are sent your invitation from your local breast screening unit, you will be given a date, time and place to attend. There are specialised screening units across the country, which can either be mobile (like a large van), hospital-based, or permanently based in a convenient place such as a shopping centre. If the appointment is inconvenient for you, you can telephone the breast screening unit and they will arrange an alternative appointment. The phone number for the breast screening unit will be on the letter.

A visit to a breast screening unit usually takes about half an hour. You will be met and welcomed by a receptionist or a female radiographer who will check your personal details (name, age and address). The radiographer will ask you some questions about your general health and whether you have had any previous breast problems.

The radiographer will explain how the mammograms are taken, and can answer any questions that you have about breast screening. If you are happy to go ahead, you will then go into the mammography room to have your mammogram.

The mammogram

A mammogram is a low-dose x-ray of the breast tissue. It is a test to look for early breast cancers. You will need to take off the clothes from the top part of your body, including your bra. The radiographer will then position you so that each breast is placed in turn on the x-ray machine and gently but firmly compressed with a flat, clear, plastic plate.

The breast tissue needs to be compressed (squashed) to keep the breast still and to get the clearest picture with the lowest amount of radiation possible. Most women find this uncomfortable and for some women it is painful for a short time while the breast is being compressed. You will need to stay still for less than a minute while the x-ray is taken. Usually two mammograms are taken of each breast from different angles.

When mammograms have been taken of both breasts you can get dressed again and are free to go.

How do I find out about my result?

You and your GP should receive the results of your mammogram in writing within two weeks. If you do not hear anything after this time, you can phone your breast screening unit and ask them to check your results.

Seven out of eight women will have a normal result and will be invited for a mammogram again in three years time.

If you have a normal result you will not need to go back for more mammograms until you receive your next invitation from the screening clinic in three years time. If you find any changes in your breasts in the meantime you can go to your GP who can arrange tests for you. See breast awareness for details of any changes in your breasts that you should report to your GP.

About 1 in 12 women (7%) who go for screening are asked to go to a breast assessment clinic for further tests. This may be because a possible problem with the breast tissues was seen on the mammogram. This problem may not be a cancer, as there are many breast conditions that can show up on a mammogram.

Occasionally, the need for more tests is due to technical reasons; for example, if the mammogram picture was not clear enough. Around 2 women in every 100 (2%) are called back for technical reasons.


What happens at the assessment clinic?

Breast assessment clinics are usually based in hospitals and you will have more tests carried out there. Assessment clinics always have a specialist breast care nurse present who can give you advice, information and support while you are having your tests.

You may have a range of emotions from anxiety to fear. It is important to remember that about 7 out of 8 women who are asked to go to the assessment clinic will find that their tests show that there is nothing wrong, or that they have a benign breast condition. These women will be asked to attend again for their routine mammogram in three years time. Only 1 in 8 women who are asked to go to an assessment clinic will have breast cancer.

The tests might include any of the following:

  • A clinical examination in which a doctor or nurse practitioner will very carefully examine and feel your breast tissue and the lymph glands under your arms and in your neck.
  • More mammograms taken at different angles or using magnification.
  • A breast ultrasound, which uses sound waves to build up a picture of the breast tissue. Ultrasound can often tell whether a lump is a solid lump (made of cells) or is a fluid-filled cyst. You will be asked to take off the clothes from the upper part of your body and lie down on a couch. An ultrasound specialist will then put gel onto the breast and gently rub a small microphone-like device over the affected area. This shows a picture of the internal tissue of the breast on a screen.

    Ultrasound is usually a painless procedure and only takes a few minutes. Areas of scar tissue or lumpiness in the breast may be sore or painful when the ultrasound probe is moved over them. Let the person doing the ultrasound know if it is painful for you.
  • Needle (core) biopsy A doctor uses a needle to take a small piece of tissue from the lump or abnormal area. A local anaesthetic is injected into the area first to numb it. Once the anaesthetic has taken effect, a small cut is made in the skin of the breast. The doctor will then insert a needle through the cut and remove a section of tissue measuring about 10mm x 2mm. This is not painful but you may feel a sensation of pressure. Sometimes several biopsies may be taken at the same time. The sample is then sent to a laboratory to be looked at by a pathologist. Pathologists are doctors who are expert at diagnosing illness by looking at cells.

    Depending on the number of biopsies taken, the breast tissue may be quite bruised afterwards, and this may take a couple of weeks to completely disappear.
  • Fine needle aspiration (FNA) cytology A thin needle is inserted through the skin of the breast into the lump or suspicious area. The needle is used to draw off some breast cells and fluid. This may be done during a breast ultrasound. The cells and fluid are then sent to the pathology laboratory. If the lump is a cyst, the needle can draw off the fluid and the lump may disappear. If the lump is solid, the cells will be examined to see whether they are benign (non-cancerous) or cancerous. A fine needle aspiration can be painful but only for a short time. You may have some bruising for a few days afterwards.

Sometimes core biopsies or FNA will be done by just feeling the breast lump for guidance. Sometimes the biopsy needle is guided using ultrasound. If the needle is guided by mammogram, this is known as a stereotactic biopsy. You will be positioned on a mammography machine that has a special device attached. In most units the test is done while you are sitting down, but in a few you will lie on your front. The radiographer then takes a picture of your breast from two different angles to work out the exact position of the abnormal area and put the needle into the right place.

If you have any questions about the above tests you can ask the nurse in the assessment clinic. You can also contact the nurses at Cancerbackup.

You may be able to have the results of your tests on the same day or a few days later, but if you have a core biopsy you may have to wait for your results for up to 14 days. This waiting can be a very anxious time and you might like to have support from one of the organisations listed.


Possible results of assessment

You will be given the results of your tests by a doctor at the assessment clinic.

No problem seen

The tests may have found that there was no problem with the breast tissue. This means that the first mammogram showed evidence of a potential abnormal area in the breast, but further tests did not find a problem. In this situation, the first mammogram is said to have had a false-positive result. You will not need to have any further tests or treatment and can just go back to the screening unit for a routine mammogram in three years' time.

Many false-positive results are due to tiny deposits of calcium in the milk ducts, known as microcalcification. Microcalcification occurs in many women over the age of 50. It may occur when cancer is present, but in most women just happens without there being a breast cancer or any other breast problem. We can send you information about breast calcification.

Benign condition (not cancer)

Most women will be told that they do not have cancer, but have a benign (non-cancerous) condition. Many benign conditions of the breast can be seen on a mammogram. If you have a benign condition, you may be referred to a hospital breast care specialist for advice and any necessary monitoring or treatment.

Unsure diagnosis

This happens very rarely. It means that no definitive diagnosis can be made after assessment. In this situation you will be invited for early recall, which means that you will have another invitation for a mammogram in 12 months.

Breast cancer

Only 5 in every 1,000 women who have breast screening will be diagnosed with breast cancer. If your tests show that you have breast cancer, you will be referred to a consultant surgeon or a cancer specialist (a medical oncologist) at a cancer treatment hospital. You may have a range of emotions: from shock and anxiety to fear. You will be able to talk to a breast care nurse who can support you and your family.

Our section on the emotional effects of cancer discusses the feelings that you may have. It gives advice on how to deal with your emotions and has details of sources of support.

Treatment

The consultant surgeon or medical oncologist will be able to discuss the treatment with you. Sometimes you may be offered a choice of treatments and it is important to consider the benefits, risks and disadvantages of each very carefully before deciding which treatment is best for you.

You can discuss your treatment with the breast care nurse. The nurses at Cancerbackup can also give you information about the different treatment options.

Treatment for breast cancer usually involves some type of surgery: a lumpectomy where just the lump and a small amount of surrounding tissue is removed, or a mastectomy where the whole breast is removed. Surgery is likely to be followed by radiotherapy, chemotherapy, hormonal therapy (such as tamoxifen or an aromatase inhibitor) or a biological therapy. Sometimes a combination of these treatments is given.

The treatment may take a few months. In women who attend breast screening the cancer is likely to be found early, when the chance of cure is high. About half of the cancers found during breast screening are small enough to be removed with lumpectomy, rather than needing a mastectomy.

Our section on breast cancer gives information about breast cancer, its treatment and coping with cancer.

DCIS

Your tests may have shown a condition known as DCIS (ductal carcinoma in situ). One in every thousand women who attend for breast screening is diagnosed with DCIS. This is when the breast cancer cells are completely contained within the breast ducts and have not spread into the surrounding breast tissue. DCIS may also be referred to as non-invasive or intraductal cancer. Most women with DCIS have no signs or symptoms so it is mostly found through breast screening.

The DCIS usually shows up on a mammogram as an area in which calcium has been deposited in the milk ducts (microcalcification). A small number of women with DCIS may have symptoms such as a breast lump or discharge from the nipple.

If DCIS is left untreated it may, over a period of years, begin to spread into (invade) the breast tissue surrounding the milk ducts. It is then known as invasive breast cancer. It is important to remember that DCIS is not harmful, but treatment is given to prevent it from developing into an invasive breast cancer.

Some areas of DCIS will never develop into invasive breast cancer even if no treatment is given. However, treatment is usually given for DCIS, because it is not currently possible to tell which areas of DCIS will definitely develop into an invasive cancer.

Treatment

The treatment almost always cures DCIS. If you have DCIS you will be referred to a breast surgeon or cancer specialist (oncologist). It is important to discuss with them the benefits and possible side effects of any treatment in your particular case.

The treatment for DCIS is surgery. This usually involves removal of the area of DCIS and some surrounding healthy tissue (a lumpectomy). Sometimes, if several areas are affected or if the area is large and high-grade, the whole breast will have to be removed (a mastectomy). The surgery may be followed by treatment with radiotherapy or hormonal therapy.

We have a section on DCIS, which gives detailed information about this condition.

The NHS Breast Screening Programme is carrying out a long‑term study, known as the Sloane study, to improve the care and treatment for women with DCIS found during the breast screening programme. The study aims to get good-quality information about DCIS, to find out which is the best treatment for this condition. The study is taking place over the next few years, but the results will not be known until at least 2009.

Breast awareness

What is breast awareness?

All women should be aware of how their breasts normally feel and look so that they can detect any changes, even if they are having regular breast screening. Breast awareness is part of general body awareness. It is a process of getting to know your own breasts and becoming familiar with their appearance. Learning how your breasts look and feel at different times will help you to know what is normal for you.

You can become familiar with your breast tissue by looking and feeling your breasts – you can do this in any way that is best for you: for example, in the bath or shower with a soapy hand, or when you are getting dressed.

If you are not sure what to look for, or if examining your breasts makes you anxious, you can ask your practice nurse or GP to show you. You can also go to a well-woman clinic to learn how to check your breasts. NHS Direct (0845 4647) can give you details of your nearest well-woman clinic.

The normal breast

There is no such thing as a 'standard' breast. What is normal for one woman may not be for another. Throughout your life your breasts will change; below are some descriptions of a normal breast at different stages of your life:

  • Before the menopause, normal breasts feel different at different times of the month. The milk-producing tissue in the breast becomes active in the days before a period starts. In some women, the breasts at this time feel tender and lumpy, especially near the armpits.
  • After a hysterectomy the breasts usually show the same monthly differences until the time when your periods would have stopped, unless your ovaries have also been removed.
  • After the menopause, activity in the milk-producing tissue stops. Breasts normally feel soft, less firm and not lumpy.

Changes to look for

Appearance Any change in the outline or shape of the breast, especially caused by arm movements or by lifting the breasts. Any puckering or dimpling of the skin.

Feelings Discomfort or pain in one breast that is different from normal for you.

Lumps Any new lumps, thickening or bumpy areas in one breast or armpit, which seem to be different from the same part of the other breast and armpit.

Nipple changes

  • Nipple discharge that is new for you and not milky.
  • Bleeding or moist, reddish areas that don't heal easily.
  • Any changes in nipple position – if the nipple is pulled in or pointing differently.
  • A rash on or around the nipple.

If you are aware of any change in your breast from what is normal for you, tell your doctor as soon as possible. If a cancer is present, the sooner it is reported, the simpler and more effective the treatment is likely to be. Remember, you are not wasting anyone's time.

There are many causes of changes in the breast. Most of them are harmless but all of them need to be checked by a doctor, as there is a small chance that they could be the first sign of cancer.

Common questions about breast screening

Hormone replacement therapy (HRT) and mammograms

Research has shown that taking HRT for five years or more may slightly increase the risk of developing breast cancer. It is also thought that this increased risk lessens after five years of stopping taking HRT. However, HRT can have health benefits such as reducing the effects of menopause, for example osteoporosis. The benefits and possible risks to you of taking HRT need to be weighed up. You may want to talk to your GP about the benefits and risks to you personally of taking HRT.

If you are aged 50 or over, you should attend your regular breast screening appointments whether or not you are taking HRT. You do not need to have mammograms any more often if you are taking HRT. However, HRT makes the breast tissue slightly denser and can make breast problems more difficult to see on mammograms. So, it is important to be breast aware if you are taking HRT.

Will breast implants affect my mammogram?

You should tell your breast screening unit if you have had breast implants, as you will need to have your mammogram at a screening unit where your mammogram can be looked at immediately. The mammogram technique used may need to be adapted to show as much breast tissue as possible on the x-ray. The pressure applied to your breasts during the screening is unlikely to damage your implants.

Mammograms for breast screening are not a check on your implants. If you think that there is a problem with your implants, please let the radiographer know.

If you have had all the breast tissue removed during a subcutaneous mastectomy and an implant put in, breast screening with mammography is not necessary for that breast.

Why are women under 50 not screened?

Breast cancer is rare in women under 50. At present, mammograms have not been shown to be as effective at detecting breast cancer in pre-menopausal women (women who have not had their menopause). The average age of the menopause in the UK is 50. After the menopause, the glandular tissue in the breast decreases and the breast tissue is increasingly made up of only fat. Fat shows up more clearly on the mammogram and makes interpretation of the x-ray more reliable.

Breast cancer is far more common in post-menopausal women and the risk of developing breast cancer increases as women get older.

If you are under 50 years of age and are concerned about a specific breast problem, you can ask your GP to refer you to a hospital breast clinic. This is not part of the National Health Service Breast Screening Programme; however, the same tests are used in both breast screening clinics and hospital breast clinics.

What happens to my mammogram x-rays?

The breast screening unit will keep your mammogram for at least eight years. They can then compare your latest mammogram with those that you have had taken before.

The NHS Breast Screening Programme regularly reviews all screening records, including mammograms, as part of its aim to offer a quality service and to help increase the expertise of its specialist staff. This means that staff who work elsewhere in the health service will need to see your records. If a review of mammograms shows that you should have been cared for differently, you will be contacted and offered more information about the review of your case if you would like to have it.

What if I am worried about screening?

The screening unit staff will do their best to reassure you and give you support during all stages of screening. Invitation and recall letters are carefully worded and give you the contact number of people to ring if you have any additional questions.

You will be sent a leaflet called 'BREAST SCREENING The facts', produced by the NHSBSP, with your invitation letter. This leaflet is also available on the NHS cancer screening website, where it is translated into 18 languages. Some translations are available in audio format. You will be given the number of the local breast screening unit and you can phone them or your own GP if you have any worries. You can also contact Cancerbackup or Breast Cancer Care.

What causes breast cancer?

Most breast cancers occur in women. Fewer than one in a hundred (0.6%) breast cancers occur in men. It is not clear exactly what causes breast cancer but many factors can slightly increase a woman's risk of developing breast cancer. These are mentioned below.

  • The risk of breast cancer increases with age. Over 80% of breast cancers occur in women over 50.
  • Having had breast cancer.
  • Having had certain types of benign breast disease (lobular carcinoma in situ or atypical lobular hyperplasia) in the past.
  • Women who have never breastfed are slightly more likely to develop breast cancer than women who have breastfed for more than a year.
  • Women who are taking hormone replacement therapy (HRT) or have recently been taking it have a slightly increased risk of breast cancer.
  • Women who do not have children are slightly more likely to develop breast cancer than women who do have children.
  • Women who start their periods early (early puberty) or have a late menopause have a slightly higher risk of breast cancer.
  • Being overweight, once you have had your menopause, can increase the risk of breast cancer.
  • Drinking a lot of alcohol over many years can increase the risk.

Having a family history of breast cancer:

About 5-10% of breast cancers are thought to be caused by inherited cancer genes. Two breast cancer genes have been identified (BRCA1 and BRCA2) and others may be found in the near future.

Breast cancer is a common cancer and about one in nine women in the UK will develop it during their lifetime. So if you have just one or even two elderly relatives diagnosed with breast cancer it does not mean that you are at a much increased risk yourself. However, if you have any of the following in your close family you might want to speak to your GP and be referred to a family cancer clinic:

  • three close blood relatives (from the same side of the family) who developed breast cancer at any age, or
  • two close relatives (from the same side of the family) who developed breast cancer under the age of 60, or
  • one close relative who developed breast cancer under the age of 40, or
  • a case of male breast cancer, or
  • a case of bilateral breast cancer (cancer in both breasts).

Useful organisations: Breast screening

NHS Cancer Screening Programmes
Tel: 0114 271 1060
Fax: 0114 271 1089
Email: info@cancerscreening.nhs.uk
Website: www.cancerscreening.nhs.uk/breastscreen

The national office for the NHS Breast Screening Programme. The comprehensive website includes information for women and health professionals, including information about what happens at a breast screening centre. There are also links to web versions of several leaflets.

Breast Cancer Care
Tel: 0808 800 6000 (free helpline)
Website: www.breastcancercare.org.uk

Breast Cancer Care's website and information service include details about breast awareness and non-cancerous breast conditions, as well as breast cancer.


Helpful books and leaflets: Breast screening

Looking After My Breasts (Books Beyond Words Series)
Sheila Hollins & Wendy Perez
Gaskell/St George's Hospital Medical School, 2000
ISBN 1-901242-53-6
This book is designed to inform and guide supporters and carers of women with learning disabilities who are going for breast screening. Feelings, information and consent are all discussed in the book. It can be used to prepare women for breast screening.

Leaflets from the NHS Breast Screening Programme

Available free via the website: www.cancerscreening.nhs.uk/breastscreen/publications

They can also be ordered from the Department of Health publication orderline: 08701 555 455, fax: 01623 724 524, or email orders: dh@prolog.uk.com. (Please quote the title).

Breast Screening - The facts
Health Promotion England, NHS Cancer Screening Programmes
Health Promotion England, 2001
ISBN 0-752119-70-2
Website: www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp-the-facts.pdf
A short leaflet explaining what screening can and cannot achieve. The leaflet includes an explanation about false-positive and false-negative results. Available in a wide range of community languages as well as English and also a Braille version, via: www.cancerscreening.nhs.uk/breastscreen/publications/ia-02.html

Be Breast Aware
Website: www.cancerscreening.nhs.uk/breastscreen/breastaware.pdf
NHS Breast Screening Programme and Cancer Research UK.
A leaflet setting out a five-point plan for women to encourage them to get to know their own breasts.

50 or Over? Breast Screening Is For You
NHS Cancer Screening programmes, 2003
Website: www.cancerscreening.org.uk/breastscreen/publications/nhsbsp-the-facts.pdf
A picture leaflet for women with a learning disability to tell them about breast screening and where to get more information.

Breast Screening: A Pocket Guide
NHS Cancer Screening programmes, 2002
Website: www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp-pocket-guide.pdf
This booklet is a simple guide to breast screening designed for anyone who works with breast screening or takes an interest in the breast screening programme.

OVER 70? You Are Still Entitled To Breast Screening
NHS Cancer Screening Programme, 2004
Website: www.cancerscreening.nhs.uk/breastscreen/publications/l-02.html
This leaflet tells women over 70 that they are entitled to request breast screening every three years.

Breast Implants and Breast Screening
NHS Cancer Screening Programme, 2002
Website: www.cancerscreening.nhs.uk/breastscreen/publications/l-01.html
This leaflet is designed to give women information about how breast implants affect mammography.

Information for Women Considering Breast Implants
Department of Health, 2002
Website: www.dh.gov.uk/assetRoot/04/01/45/74/04014574.pdf
This booklet is for all women who are considering having breast implants, and has a short section about mammography.


References for the breast screening section

The information in this section is based on the Cancerbackup booklet, Understanding breast screening, which has been produced in accordance with the following sources and guidelines:

  • Screening for Breast Cancer in England: Past and Future, Advisory Committee on Breast Cancer Screening, 2006 (NHSBSP Publication no 61).
  • Breast Screening Programme, England 2004-05, National Statistics, NHS Social Care and Information Centre, 2006.
  • Breast Screening Results from the NHS Breast Screening Programme, (England, Wales, Scotland and Northern Ireland), Cancer Screening Evaluation Unit, 2003/04.
  • NHS Breast Screening Programme 2005 Review, NHS Cancer Screening Programmes, 2006.
  • NHSBSP No. 54 (2003). Review of Radiation Risk in Breast Screening. NHSBSP and NRPB.

Further relevant guidelines and documents can be accessed online at
www.cancerscreening.nhs.uk/breastscreen/statistics.html

You can access up-to-date guidelines in the health professional section of the website.