Barriers to breast screening
Breast screening may be uncomfortable but it’s one means of reducing deaths from breast cancer, and pharmacy teams can help women access information in their local communities
Every 45 minutes a woman dies from breast cancer, the most common cancer in the UK.
Early diagnosis – from women (and men) looking out for any changes in their breasts to rapid assessment in general practice – and screening using mammography are the two best strategies for reducing these figures, according to the World Health Organization.
The NHS breast screening programme, which invites all women between 50 and 70 years of age for a mammogram every three years, was set up in 1988 and is one of the largest and longest running cancer screening programmes in the world. Lowenergy x-rays are used to identify any abnormalities in the breast.
Although it saves around one life for every 200 women screened, some argue that the service has the potential to cause unnecessary interventions and anxiety if a suspected problem does not turn out to be cancer. It has been claimed that for every life saved by breast screening, three women could undergo unnecessary surgery.
Does screening work?
A large study, based on data from over 50,000 women over a period of 39 years, recently confi rmed that women who take part in breast screening have a significantly greater benefit from treatments. The screened women had a 60 and 40 per cent lower risk of dying from breast cancer within 10 and 20 years after diagnosis.
“Recent improvements in treatments have led to reduced deaths from breast cancer,” says Stephen Duffy, study author and professor at Queen Mary University of London. “However, these new results demonstrate the vital role that screening also has to play, giving women a much greater benefi t from modern treatments. We need to ensure that participation in breast screening programmes improves, especially in socio-economically deprived areas.”
That’s not for me?
Participation rates in the NHS breast screening programme average 70 per cent, with fewer women tending to take up the invitation in poorer, inner city areas. So why do some women choose not to attend a mammogram? Admittedly, it’s not the most pleasant experience, with women asked to take off their upper clothing and have each breast in turn compressed between two plates on a machine.
Beverley Scragg, lecturer in radiography in the School of Health Sciences at University of Salford, has been performing mammography for 15 years. “The top concern is whether the procedure is painful or not. For the vast majority of women I have screened it has been uncomfortable rather than painful, but for a woman who has breasts that are tender to the touch anyway, it defi nitely will be painful,” she says. “We used to advise that taking a painkiller 20 minutes prior to the appointment could help, but this effectiveness is based on anecdotal rather than empirical evidence.”
Some women are worried that compressing the breasts will damage them. Beverley says: “The equipment is limited to a force of 20dN anyway, but, mostly mammographers compress to a lesser amount: around 10dN. Pain felt does not tend to correlate to breast size, but as we’re measuring force rather than pressure, there’s research being undertaken across Europe to see whether there’s a better way of compressing using this measure.”
When it comes to women with breast implants, acreening can still be carried out, says Beverley, but there is “a trade-off in image quality, which is more likely to be blurred, and the amount of breast tissue that can be seen is drastically reduced due to the implant being radiopaque”.
In England, mammography has always been carried out by a female radiographer, although employment equality is starting to put pressure on this, which could be an issue for some women if the policy did change, Beverley comments.
In the headlines
Reporting in December 2018, an independent review found that around 5,000 women, over a period of nine years, might not have been invited to screening when they should have been. Some of these women will have gone on to develop breast cancer that may otherwise have been detected.
This error resulted from misunderstandings around policy in the health service about the age that women should stop being invited for breast screening (around the age of 70) and incompatibility between the different IT systems used to invite them. The screening service now needs “a reset” says the review, redefining the ages that women should be invited for screening and ensuring clarity for staff.
Support and advice
The Word of Mouth Mammogram e-Network (WoMMeN) hub is an award winning online forum set up by Salford University, mammography practitioners and service users. The hub offers information and gives women the opportunity to fi nd answers to common questions, for example, why they may not have been called for screening even though they are over 50, whether breast size makes a difference to screening effectiveness and what happens if they don’t want to be screened.
Deciding whether or not to attend breast-screening appointments is a personal decision, says Catherine Priestley, Breast Cancer Care’s clinical nurse specialist. “We believe in screening as being a good tool and part of being breast aware. We can’t deny that the majority of cancers are found by people themselves, or their partners, rather than being found at screening. Yet we know that if we can instigate treatment for breast cancer when it’s found on screening, it is likely to be smaller, and is likely to be more successful.”
Breast Cancer Care runs a nurse advisor helpline (0808 800 6000), which pharmacy customers can be signposted to if they need advice.
Being older increases risk
Anyone concerned about a family risk of breast cancer should be advised to visit their GP, whatever their age, suggests Catherine. They may be easily reassured, or can be referred to a family history clinic where they will complete a detailed questionnaire and a decision made as to whether further investigation is required.
As breast cancer is so common, it is likely that most families will have a link, but this doesn’t necessarily mean that other relatives will have an increased risk themselves. “You have to dig a little deeper to fi nd out how old those women were and the type of breast cancer they had, for example. One in eight women in their lifetime will develop breast cancer and the majority are aged over 50 when they are diagnosed,” says Catherine. “The three main risk factors are being female, getting older and having a significant family history, but there are some things from the lifestyle point of view that we can make some modifi cations to.” General advice on healthy eating is useful, she suggests.
Play your part
Community pharmacies can play their part by encouraging women to adopt healthy lifestyles and signposting them to more information and advice about screening if they need it. Boots UK, for example, has a partnership with cancer charity Macmillan to help ensure people have the information they need about cancer.
Dr Rosie Loftus, joint chief medical officer at Macmillan Cancer Support says: “Pharmacy teams can play an important role in helping people access cancer information in their local communities. There are currently more than 2,000 Boots Macmillan Information Pharmacists working across the UK, providing support and signposting to local services. Macmillan and Boots UK train these professionals to offer face-to-face support for people living with cancer.”
However, not having a family history doesn’t mean someone won’t develop breast cancer. “It is a misconception that people have to have a family history to have a risk as 90 per cent or more of cancers are probably a chance happening,” Catherine says.
Signposting to expert sources of advice can be extremely useful for women who are going through treatment after diagnosis, as well as those looking for support about screening and reducing their breast cancer risk. “People can go on our website (breastcancercare.org.uk) and order our helpline cards,” says Catherine. “We also do a lot of signposting to Macmillan – they have a great service, including things like finances, benefits – and other organisations for people who are, for example, younger or older.”
Being breast aware
It is important to check breasts regularly for any changes. The NHS Breast Screening Programme has a five-point plan for breast awareness:
- Know what’s normal for you
- Look at your breasts and feel them
- Know what changes to look for
- Report any changes without delay
- Attend routine screening if you’re 50 or over.
“It doesn’t matter how old you are, it is good for a woman (and a man) to be breast aware,” advises Catherine. Check the breast tissue with the pads of the fingers, at regular intervals – probably no more often than every four to six weeks.
Advice has moved away from checking the breasts as often as monthly, because over-checking may mean that people will miss a lump or thickening that develops slowly. “It’s not about constantly checking, otherwise you can miss subtleties,” Catherine says. People often think they are only looking for lumps, but they should also be looking any thickening of the breast tissue, she advises.
All women should get anything they are worried about checked out, as the sooner it’s diagnosed, the more successful treatment is likely to be and in many cases, it will turn out to be nothing concerning. “Around the menopause, when hormones are changing, there are lots of reasons why lumps and cysts can occur that are nothing to do with breast cancer,” Catherine explains.
“We know that about a third of women don’t check their breasts regularly, and they would say they’re not really sure how to check, or are worried or scared about that. Older women may also stop checking – when we stop sending invites out for their screening they might think that they are no longer at risk but the opposite is true.”
Women over 70 are entitled to have breast screening every three years, but they need to book an appointment themselves. Currently, a trial is looking at extending the age range of screening down to 47 and up to 73 years of age.
Common women’s health issues
• Bladder weakness
One in three women experience bladder weakness at some point in their lives. It can occur at any age, but is more prevalent once the pelvic muscles are damaged or weakened, for example during pregnancy. The condition can be controlled with lifestyle measures, such as losing weight, drinking plenty of fluids, cutting down on caffeine and alcohol and doing pelvic floor exercises to strengthen the muscles. Pharmacy staff can also direct customers to the range of bladder weakness protection products available.
Cystitis is an inflammation of the bladder, usually caused by bacteria entering the urethra from outside and causing an infection. The main symptom is an intense pain and/or burning sensation when passing urine. Other symptoms include increased frequency of urination and passing small quantities of urine, which can be cloudy and foul smelling. Customers should be advised to drink plenty of fluids, take painkillers, if necessary, and always wipe front to back when going to the toilet. OTC treatments containing potassium or sodium citrate may also help.
• Thrush and bacterial vaginosis
Thrush is a yeast infection caused by Candida albicans. Symptoms include itching and soreness around the vagina and a white cottage cheese-like vaginal discharge. Hormonal changes, wearing tight or synthetic clothing or taking antibiotics can all trigger an infection, which can be treated with an OTC antifungal cream, tablet or pessary. Bacterial vaginosis (BV) is caused by an overgrowth of bacteria in the vagina and is characterised by a white/ grey, thin and watery discharge and often a noticeable fishy odour. OTC products that restore the pH balance of the vagina can be recommended. Pregnant women with suspected BV should be referred to the pharmacist.
Most women go through the menopause between 45 and 55 years of age. Symptoms include hot flushes, vaginal dryness, night sweats and reduced sex drive. If symptoms are troubling, women can be advised to see a GP who may prescribe hormone replacement therapy (HRT). Pharmacy teams can recommend lubricants for vaginal dryness and advice can also be given on eating a healthy, balanced diet and taking plenty of exercise, which may help to relieve symptoms.
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