- BreastScreen Australia selects women on the basis of age alone.
- Decisions on eligibility based on the presence or absence of symptoms would be impractical.
- It is program policy that women with symptoms are actively discouraged from attending the program.
- BreastScreen Australia has a responsibility to those women who attend for screening and who have symptoms and therefore requires protocols to be in place for this situation.
- It screens such women, and recommends further investigation (either within the program or through the women's doctor) regardless of the outcome of the mammogram.
Rationale and practice
The primary purpose of BreastScreen Australia is to detect cancer sufficiently early so that prognosis is enhanced for those women found to have the disease. It aims to screen a large proportion of women in the age group for which mammography has been proven to be effective in reducing mortality - those 50-69 years.
In the scientific trials on which the Program was based, no distinction was made between women who had symptoms and those without symptoms. Mammography was offered to all women in the appropriate age group. It can be expected then, that the mortality benefits may be anticipated where screening is offered to the whole eligible population.
The basis on which women are eligible for screening must be clear and unequivocal. The recommendation of the Breast Cancer Screening Evaluation Committee that "a national mammography screening program should select women on the basis of age alone" provides such a basis. Generally there is no dispute about a women's age, regardless of any lack of consensus about what the age of eligibility should be.
There is no such clarity about the meaning of "symptom". The program defines a symptom of breast malignancy as a lump or serous or bloody nipple discharge, although it does collect information on other "symptoms" nominated by the woman or health professional or observed during screening. Women themselves may define breast pain or other signs as "symptoms". There are obvious difficulties associated with any attempt to use the presence or absence of symptoms as a primary criteria for eligibility.
In a system where women are recruited through the use of a population register and through generalised recruitment strategies, age is the only practical basis on which letters of invitation can be issued and eligibility promoted in general.
Population based mammographic screening is directed primarily at women without symptoms, and this is the practice throughout BreastScreen Australia. Publicity and educational material stress that women who have symptoms should consult their general practitioner. If the practitioner considers it necessary they will be referred to the usual diagnostic services.
A letter mailed to all general practitioners in September 1992, from the Commonwealth spokesperson on Women's Health, Dr Margaret Dean, stated clearly that "women who have symptoms or indications of breast malignancy should not be referred to the National Program".
In all States women with symptoms are actively discouraged from attending for screening in all information available to women, - in publicity material and/or in letters. In some States women are discouraged when they attempt to make an appointment. This latter practice has ethical and resource implications in that appropriate clinical staff must be available to assess whether the woman does have symptoms, and to recommend appropriate action.
Another aspect of direct discouragement of this nature may be that women may disguise the presence of symptoms. Where the mammogram is then negative, the woman will not automatically receive the additional investigation (either at a Program Assessment Service, or by specific referral back to her general practitioner) which she would be offered had the symptom been declared.
BreastScreen Australia recognises that, whatever the discouragement, some women with symptoms will present for screening. It accepts a responsibility to those women who indicate at presentation that they have a symptom, or who insist that they will not attend elsewhere for investigation or who are unable to attend elsewhere. In these cases the women are screened.
Each Service is required to have a protocol governing procedures for the screening of women with symptoms. The existence of such protocols does not indicate that the Program encourages woman with symptoms to be screened, but is a reflection of the responsibility indicated above.
The existing National Accreditation Standards require that all women in whom symptoms are identified be recommended for further assessment, regardless of the result of the mammogram. In some situations a clinical examination is performed at the time of screening. In others women are referred to their general practitioner or recalled to an assessment clinic for further investigation.
In all cases the Program policy is that the women will be advised to have significant symptoms further investigated. Where a woman has nominated a general practitioner she/he will also be provided with that advice.
BreastScreen Australia closely monitors its performance and data will be collected and reported on the screening of women who have identified symptoms.