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					EALING PCT CANCER SCREENING PROGRAMMES

Appendix

Item 7a The Cancer Reform Strategy 2007 highlighted how in general, the earlier a cancer can be diagnosed the greater the chance of a cure. Late diagnosis is the major factor contributing to poor cancer survival rates in this country. The current position of Ealing PCT cancer screening programmes is outlined below. Screening is vital to diagnosing some cancers early. To improve and expand cancer screening, the government has set new targets for development of the existing screening programme. These are referred to in the relevant sections below:       To build on progress on cervical cancer screening, by reducing the variation of coverage between PCTs Informing women of the result of their cervical screening test within two weeks Tackling the falling participation of women aged 25 to 35 Extend breast screening to nine screening rounds between 47 and 73 years, with a guarantee that women will have their first screening before the age of 50, Roll out of digital mammography Expand the NHS Bowel Cancer Screening Programme from 2010 to invite men and women aged 70 to 75.

A. THE BOWEL CANCER SCREENING PROGRAMME
This is the most recently introduced cancer screening programme which offers the opportunity of participating from the privacy of home. The NHS Bowel Cancer Screening Programme is being rolled out nationally and will achieve nation wide coverage by 2009. The programme was launched in Ealing PCT on 16th November 2007. Bowel cancer is the 3rd most common cancer in the UK and the 2nd most common cause of death. It is the third most common cancer in the UK, and the second leading cause of cancer deaths, with over 16,000 people dying from it each year.1   1 in 20 is affected in their lifetime. Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16 per cent2.

What is the purpose of bowel screening? Bowel cancer screening aims to detect bowel cancer at an early stage (in people with no symptoms), when treatment is more likely to be effective. Bowel cancer screening can also detect polyps. These are not cancers, but may develop into cancers over time. They can easily be removed, reducing the risk of bowel cancer developing. Who is eligible for bowel cancer screening?   The Programme offers screening every two years to all men and women aged 60– 69 registered with a GP People over 70 can request a screening kit by calling a freephone helpline

How is the NHS Bowel Cancer Screening Programme organised? The Programme hub for London is 1 of 5 national hubs. It is based at St Mark’s Hospital Trusts. The ‘hub’ operates a call and recall system to send out faecal occult blood (FOB) test kits, analyse

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samples and despatch results. The hub is responsible for coordinating the programme and working with local screening centres for the Ealing population of 368,598. The London programme has received 53,175 calls to the Helpline since November 2006. During the week ending 11July there were 998 calls. The eligible population for bowel screening for Ealing PCT is 33,208. Charing Cross Hospital and St Mark’s Hospital Screening Centres provide endoscopy services and specialist screening nurse clinics for people receiving an abnormal result. Screening centres are also responsible for referring those requiring treatment to the local hospital multidisciplinary team (MDT). 9,995 eligible men and women will be covered by St Mark’s Screening Centre and 23,213 by Charing Cross Hospital Screening Centre. What is GPs involvement? GPs are not directly involved in the delivery of the NHS Bowel Cancer Screening Programme but they are notified when invitations for bowel cancer screening are sent out in their area. They will also receive a copy of the results letters sent to their patients. It is important that practice staff are well informed about the programme so that they are in a position to encourage participation and to advise re: sample collection. All practices have had an information pack and the PCT has provided lunch time awareness events for GPs and their practice staff. Practices have been provided with promotional materials and advised how to obtain further supplies. Furthermore it is critical the practice lists are maintained as efficiently as possible as details of eligible men and women are extracted off the Exeter database. (Refer to section below re: returned mail) How does the screening process work? Men and women eligible for screening:     Receive an invitation letter explaining the programme and an information leaflet entitled Bowel Cancer Screening - The Facts. About a week later, an FOB test kit will be sent out along with step-by-step instructions for completing the test at home Samples collected in the privacy of their home are sent to the hub laboratory in prepaid post envelope. The test will then be processed and the results sent within two weeks.

How does the FOB test work? Polyps and bowel cancers sometimes bleed. The faecal occult blood (FOB) test works by detecting tiny amounts of blood which cannot normally be seen in bowel motions. The FOB test does not diagnose bowel cancer, but the results will indicate whether further investigation (usually a colonoscopy) is needed. People who receive an abnormal result will be offered an appointment with a specialist nurse. The nurse will explain what a colonoscopy involves, assess the patient's fitness for the procedure, and answer any questions.

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The FOBt kit, and cardboard sticks used for sample collection

Every 1,000 who complete the Faecal Occult Blood test: 20 will have a positive & are offered colonoscopy.

↓
16 undergo colonoscopy procedure

↓

↓

↓
6 polyps 2 bowel cancer

8 nothing abnormal detected

What is a colonoscopy? A colonoscopy is an investigation that involves looking directly at the lining of the large bowel. If polyps are found, most can be removed painlessly. A colonoscopy is the most effective way to diagnose bowel cancer. As with most medical procedures, there is the possibility of complications.    1 in 150 heavy bleeding 1 in 1,500 colonoscope could perforate in the wall of the bowel. 1 in 10,000 colonoscopy may result in death.

Ealing PCT Uptake rates
Since the programme commenced in November 2007, 8,144 invitation letters and screening kits have been sent to Ealing PCT men and women aged 60 – 69. Of these, 3,117 have been returned, an uptake rate of 39%. The national average is 39.9% and the take up within London PCTs ranges from 22% Lambeth PCT (start date March 08) to 50% Richmond & Twickenham PCT (Start date January 07). A consequence of the mobile population of the capital the London hub receives far more returned mail than the other 4 regional hubs within England. In 1st quarter, April - June 08, 116 letters were returned from identified eligible men and women in Ealing PCT. The local programme in conjunction with the hub is starting to compile more detailed reporting data which will support targeted work to improve uptake of bowel screening. Currently efforts are being made to report postal code and ethnicity uptake rates. As with other screening programmes there is a variance between practice uptake rates. During the first 6 months of bowel screening there a difference of between 23% to 52% uptake rates for Ealing practices. Interestingly the lowest rates have been identified in Southall and Chiswick practices and the highest in Acton and Hanwell. Ethnicity data collated by the hub Cancers Detected: Total of 6 have been detected. Female 4; Male 2. 3

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Health Promotional Work: Screening Centres work in conjunction with Ealing PCT to
raise awareness of the bowel screening programme. Awareness amongst health professionals: Prior to the launch of the programme all GPs and practice staff were sent information packs and promotional materials. PCT Community staff and administrative staff were alerted to the programme with key messages and contact details. Displays informing PCT staff about the new programme were evident during the launch month. Patient Advisory Liaison Service was briefed. Articles have appeared in Ealing Matters the PCT magazine. Lunch time event open to general practices and community staff to launch the programme was hosted at the Ealing Golf Club in November 2007. April 2008 was Bowel Cancer Awareness month and further information and promotional materials were circulated to general practices and health centres. Launch events were staged at the screening centres and media invited. Media coverage included patient stories. Awareness amongst the general public :The awareness campaign has involved articles in local newspapers, Age Concern newsletters, displays at bus stops, libraries, shopping centre stalls, local radio interview, ethnic magazine exposure ‘Desi Eye’, ‘Around Ealing’ local authority magazine and posters in community pharmacies. Outreach work has been engaging hard to reach groups such as those with learning disabilities, house-bound, ethnic minorities where English is not the first language. Promotional materials are available in 20 different languages including Somali and Polish. Every opportunity is taken to promote awareness of the new programme. Health fayres at schools have provided the opportunity to engage parents and grandparents as well as informing young people. The PCT ran an event in June 08 at Dormer’s Wells Community Centre which gave the opportunity to pilot the use of a giant inflatable bowel to enhance understanding and promotion of the screening programme. There was very positive feed-back from health professionals and the PCT are currently working with a company to refine the product for use with the public .

Health professionals can order English copies of the leaflets from the Department of Health publication orderline: Telephone: 0300 123 1002, Email orders: dh@prolog.uk.com. There is a large print version available published in February 2007. Audio and video resources. Contains recordings of the following leaflets:  Bowel Cancer Screening - The Facts  The Colonoscopy Investigation  How to use the NHS Bowel Cancer Screening test kit
Languages included: English, Arabic, Bengali, Cantonese, Polish, Punjabi and Urdu.

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EALING PCT CANCER SCREENING PROGRAMMES Recommendations:      

Appendix

Continue to work closely with screening Centre and London Hub on promoting awareness of the programme Clarification on future funding allocation to Screening Centres for health promotion Continue to develop robust data monitoring systems including ethnicity and postal codes Work with general practices on promoting awareness and understanding of the screening programme. Continue to target support to practices where uptake is lowest. Identify factors influencing uptake at those with higher rates Advice on development of product Giant Inflatable Bowel in conjunction with suppliers ‘Europcolon’ & purchase to facilitate outreach events within PCT.

1 2

CancerResearch UK, 2005. Cancerstats Cochrane Database of Systematic Reviews, 2006. Screening for colorectal cancer using the faecal occult blood test: an update.

B. CERVICAL CYTOLOGY SCREENING PROGRAMME
Cervical screening is not a test for cancer. It is a method of preventing cancer by detecting and treating early abnormalities which, if left untreated, could lead to cancer in a woman's cervix (the neck of the womb). The first stage in cervical screening is taking a sample using Liquid based Cytology (LBC). Early detection and treatment can prevent 75 per cent of cancers developing but like other screening tests, it is not perfect. It may not always detect early cell changes that could lead to cancer. Aim of NHS Cervical Screening Programme. The programme aims to reduce the number of women who develop invasive cervical cancer (incidence) and the number of women who die from it (mortality). It does this by regularly screening all women at risk so that conditions which might otherwise develop into invasive cancer can be identified and treated.

Cervical Cancer Incidence Directly Standardised Rates 1993 - 2004 for England & London - All Ages

14.00
Standard Mortality Rate (SMR)

12.00

10.00

8.00

ENGLAND LONDON England Trendline EHH Trendline

6.00

4.00 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Years

Since the introduction of the cervical cytology screening programme in 1989 there has been a sustained decline in the diagnosis of invasive cervical carcinomas. The 5

EALING PCT CANCER SCREENING PROGRAMMES

Appendix

chart above compares the incident rate for England, London and the local programme area of Ealing Hammersmith & Fulham and Hounslow PCTs. In 2005 there were 4 deaths from invasive cervical cancer in Ealing PCT. Who is eligible for cervical screening? All women between the ages of 25 and 64 are eligible for a free cervical screening test every three to five years. In the light of evidence published in 20031 the NHS Cervical Screening Programme now offers screening at different intervals depending on age. This means that women are provided with a more targeted and effective screening programme. Ealing PCT has 96,868 women identified as eligible for cervical cytology screening.

The screening intervals are:
Age group (years) Frequency of screening 25 25 - 49 50 - 64 65+ First invitation 3 yearly 5 yearly Only screen those who have not been screened since age 50 or have had recent abnormal tests

The NHS call and recall system invites women who are registered with a GP. It also keeps track of any follow-up investigation, and, if all is well, recalls the woman for screening in three or five years time. It is therefore important that all women ensure their GP has their correct name and address details and inform them if these change. Women who have not had a recent test may be offered one when they attend their GP or family planning clinic on another matter. Women should receive their first invitation for routine screening at 25. Circa 90% of screening tests taken within Ealing PCT are done within general practice. In 2006-07, 90% of screening tests taken within Ealing PCT were done within general practice. Over 95% of tests were negative. Severe abnormalities accounted for 0.3%. England and London average is 0.6%. Since the introduction of liquid based cytology inadequate test result rates have reduced to 3%, the lowest ever recorded for the PCT. This has had a direct impact on the quality of the screening experience for women as far less women now have to re-attend for a repeat test Why are women under 25 and women over 65 not invited? Cervical cancer is rare in women under 20. Teenagers' bodies, particularly the cervix, are still developing, which means young women may get an abnormal result when there is nothing wrong. This could lead to unnecessary treatment so screening young women might do more harm than good. Under the age of 25 years, invasive cancer is extremely rare, but changes in the cervix are common. Although lesions treated in very young women may prevent cancers from developing many years later, the evidence1 suggests that screening could start at age 25. Younger women will not have to undergo unnecessary investigations and treatments. Any woman under 25 who is concerned about her risk of developing cervical cancer or her sexual health generally, should contact her GP or Genito-Urinary Medicine (GUM) clinic. Women aged 65 and over who have had three consecutive negative results are taken out of the call recall system. The natural history and progression of cervical cancer means it is 6

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highly unlikely that such women will go on to develop the disease. Women aged 65 and over who have never had a test are entitled to one. Coverage of the target population The effectiveness of the programme can also be judged by coverage. This is the percentage of women in the target age group (25 to 64) who have been screened in the last five years. If overall coverage of 80 per cent can be achieved, the evidence suggests that a reduction in death rates of around 95 per cent is possible in the long term. In 2006/7 the national coverage of eligible women was 79.2 per cent2. Historically London PCTs have struggled to reach the national coverage rate. The multiethnic, transient nature of the population poses a challenge to all screening programmes which are dependent on accurate GP registration lists. Ealing PCT coverage 2006/07 was 72.9%. All eligible women registered with a GP practice are invited to attend for screening .The uptake rate indicates the percentage of women to attend for a screening test after receiving an invitation letter. Ealing PCT’s latest uptake rate is 74.2%. Out of 96,828 eligible women 72,313 have had an adequate screening test within the last 5 years. There is a variance of 4.5% between the LCGs. Southall Consortium having the lowest at 72.2%. Only 12 GP practices have attained the 80% target for cervical screening. * Exeter data June 08 Over the past 5years there has been a small, but sustained decline in the number of young women attending fro screening. This is consistent with other PCTs within London and across England. The chat below shows the coverage rate by age group over 5 years.
5 year % Coverage for Ealing PCT by Age Band
100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
<20 Age bands

02/03 03/04 04/05 05/06

5 Yr % Coverage

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

80+

Health Promotion Ealing PCT is part of pan London group which meets at London Quality Assurance Reference Centre and evaluates health promotion initiatives. A CD recording was released in 2008 which was aimed at women under 30 living in London. It was a joint venture between Camden PCT and ‘Jo’s Trust' a charity campaigning for effective screening programme for women. This recording used professional actors and was unusual in that young men are used to promote a punchy message to young women. Ealing PCT has promoted the video to test takers and school health workers to use in Personal Health & Social Education lessons. The PCT is planning to place the recording on the Life channel system to increase accessibility in practices. 7

EALING PCT CANCER SCREENING PROGRAMMES The recording can be viewed on www.becervixsavvy.co.uk

Appendix

Every invitation letter has a short message in 10 major languages spoken within Ealing PCT on the reverse. The letters are accompanied by an information leaflet. Practices can download versions in large print and in 20 different languages including Polish, Somali and Urdu. A Braille version of 'Cervical Screening - THE FACTS and an audio tape in English are available Email orders: dh@prolog.uk.com. A range of new posters designed to appeal to younger women are now available from the national programme. Ealing PCT plans to disseminate these widely.

What is LBC? The introduction of liquid based cytology (LBC) a new way of preparing cervical samples for examination in the laboratory has had an impact on the quality of samples screened. The sample is collected in a similar way to the conventional smear, however, rather than smearing the sample onto a microscope slide the head of the sampling brush, where the cells are lodged, is rinsed directly into preservative fluid in a vial. The sample is sent to the laboratory where it is spun and treated to remove obscuring material. A thin layer of the cells is deposited onto a slide. The slide is examined in the usual way under a microscope by a cytologist. 8

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All test takers and cytologists underwent training and laboratories converted to liquid based cytology screening at the end of 2006. Inadequate rates are now at the lowest the programme has ever recorded. In Ealing PCT the most recent data indicates a 3% rate. This has had a direct impact on the quality of the screening experience for women as far less women now have to re-attend because the specimen did not contain sufficient cells or could not be seen adequately under the microscope by the cytologist. New Laboratory Service Provider: In April 2008 a new provider was identified for laboratory cytology screening for the majority of Ealing PCT practices. After a formal tendering process the contract was awarded to The Doctor’s Laboratory (TDL) who provides general pathology services for Ealing PCT. An estimated 20,000 tests per annum will be screened by TDL. Practices in the east of the PCT and north continue to use Imperial College NHS Trust (estimated 1,500 screens p.a.) and Northwick Park Hospital (estimated 2,600 screens p.a.) for their cytology and pathology services. Turnaround Times for test results .The introduction of liquid based cytology combined with improved efficiencies within the laboratories have led to improved turnaround times for laboratory screening. Over 98% of samples are now screened within 4 weeks. The Doctor’s Laboratory and Imperial College NHS Trust screen over 90% of their samples within 2 weeks. The current national standard is for women to receive their test result in writing within 4 weeks (80%) and 6 weeks (100%). However by 2010 as recommended in Cancer Reform Strategy all women should be receiving their test results within 2 weeks. As well as supporting laboratories to improve their turnaround times the PCT has been working with the FHS Shared Services Screening Department which is responsible for the call/recall aspect of the programme, to improve the efficiency of operational aspects.       Electronic transfers of data are occurring daily. Results letters are now printed & posted daily Result letters now sent directly to women rather to test takers. As from 1st October 2008 all result letters will be sent by 1st class post. To encourage all GP practices to utilise Open Exeter facilities for ePNLs To increase number of GP Practices printing HMR101 laboratory request forms directly from Open Exeter.

Ealing PCT is working with all stakeholders to consolidate and sustain progress made to reach this 14 day target. Human papillomavirus (HPV) vaccination is being introduced into the national immunisation programme in September 2008, for girls aged 12-13 across the UK. Ealing PCT plans to implement the vaccination programme from December 2008. Then, starting in autumn 2009, a two year catch up campaign will vaccinate all girls up to 18 years of age. This catch up campaign will offer to vaccinate:
 girls aged between 16 and 18 from autumn 2009, and  girls aged between 15 and 17 from autumn 2010.

By the end of the catch up campaign, all girls under 18 will have been offered the HPV vaccine. When the HPV vaccination programme begins in 2008, women over the age of 18 will not be vaccinated as it would not be cost effective in preventing cervical cancer. This is because as soon as a woman becomes sexually active, she is at risk of infection with the virus. HPV vaccine will protect against the strains of the virus which cause around seven out of ten cases of cervical cancer. However, it will be many years before the vaccination programme 9

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has an effect upon cervical cancer incidence and does not give protection against all cervical cancers so all girls are advised to have cervical screening in later life and women are advised to continue accepting their invitations for cervical screening. A picture leaflet for women with learning disabilities describing what a cervical screening test is available. This has proven to be useful for using with women who may be illiterate or whose first language is not English This guide was published several years ago and Ealing PCT is interested in developing new materials. Camden PCT is willing to share a new promotional pack designed for working with women with learning disabilities.

Recommendations         Continue to consolidate actions working to meet 14 day target for women to receive their test results in writing To invest in publicity campaign targeting younger women Continue with roll out of open Exeter access for GP Practices To encourage utilisation of Open Exeter functionalities by practice staff e.g. printing HMR 101 laboratory forms; electronic Prior Notification forms To work with practices on projects to follow up non attenders and identification of factors influencing decision to DNA. To deliver update training to all test takers To consider pilot with electronic transfer of cytology results from TDL laboratory to GP practices To work with acute trusts and neighbouring PCTs towards direct referral from laboratory to colposcopy

1

P Sasieni, J Adams and J Cuzick, Benefits of cervical screening at different ages: evidence from the UK audit of screening histories, British Journal of Cancer, July 2003
2

Cervical Screening Programme, England: 2006-2007

C. BREAST SCREENING
Breast screening is a method of detecting breast cancer at a very early stage. A mammogram - which involves an x-ray of each breast, can detect small changes in breast tissue which may indicate cancers which are too small to be felt either by the woman herself or by a doctor. West of London Breast Screening Unit (WOLBSS) is the service provider for Ealing PCT. WOLBSS is based at Charing Cross Hospital, Imperial College NHS Trust.

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Appendix

How does the NHS Breast Screening Programme operate? Every three years women in the UK aged 50 – 70 are routinely invited for breast screening. Because the programme is a rolling one which invites women from GP practices in turn, not every woman will receive an invitation as soon as she is 50. But she will receive her first invitation before her 53rd birthday. Once women reach the upper age limit for routine invitations for breast screening, they are encouraged to make their own appointment. Women are invited to a screening unit, which can be hospital based or mobile. In September 2000, research was published which demonstrated that the screening programme had lowered mortality rates from breast cancer in the 55-69 age group1. The programme in the UK has screened more than 19 million women and has detected around 117,000 cancers. Whilst acknowledging improved treatments influence mortality rates the impact of the screening programme was identified as a contributory factor in reducing mortality rates The standardised mortality rate for Ealing PCT has decreased from 103 in 1993 to 96 in 2005. During 2006-07 30 breast cancers were screen detected within Ealing PCT. A report by the Department of Health Advisory Committee published in 1991 suggested that the programme would save 1,250 lives each year by 2010.2
Mortality from Breast Cancer for All Ages 1993-2006 by PCT
180 160 140 120 100 80 60 40 20 0 1993

ENGLAND LONDON Ealing PCT Hounslow PCT Hammersmith and Fulham PCT
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

The World Health Organisation's International Agency for Research on Cancer (IARC) concluded that mammography screening for breast cancer reduces mortality. The IARC working group, comprising 24 experts from 11 countries, evaluated all the available evidence on breast screening and determined that there is a 35 per cent reduction in mortality from breast cancer among screened women aged 50 - 69 years old. This means that out of every 500 women screened, one life will be saved.3 Screening Coverage Nationally 76% of women aged 53 – 64 have been screened for breast cancer every 3 years. In London it is 65%. London is the only region not attaining the programme target of 70%. Ealing PCT has a population of 29,817 women aged 50 – 70. The PCT has attained its’ highest coverage rate since the start of the programme of 68% during 2007.
KC63 Breast Coverage - Annual Trends 53-64yrs 00/01 01/02 02/03

03/04

04/05

05/06

06/07

11

EALING PCT CANCER SCREENING PROGRAMMES
Ealing 58.3% 41.6% 52.9% 57.1% 64.2% 63.3%

Appendix
68.4%

The characteristics of the capital’s population, highly mobile and multi-ethnic lead to complex organisational problems. London Quality Assurance Reference Centre led in establishing a review of services under the Pan London Modernisation Project. Several work streams examined different aspects of the programme. Primary focus is now on review of commissioning and centralisation of a call/recall Centre. This function is currently undertaken by the screening units. A survey of all London Screening Units identified approximately 220 calls per office were received everyday. 77% were answered and it was estimated 300 calls across London were not answered each day. A centralised service would address operational problems and could provide enhanced service such as multilingual call operators. Screening Uptake Coverage is calculated as the percentage of eligible women within the PCT who have had a breast screen within 3 years. Uptake is the response rate to screening invitation by eligible women registered with GP practices. Hence there is a variance between coverage and uptake data. Women are called by GP cohort every 3 years therefore annual uptake rates reflect the cohort of women called during the particular year. During 2007 18,669 Ealing PCT women aged 53 – 64 were eligible for screening. Of these 12,915 were screened. Local Commissioning Groups Breast Screening Uptake rates

LCG's EALING ACTON (EACG) NORTH SOUTHALL (SPCCG) SOUTHALL COMMISS (SCC) UNAFILIATED WEST EALING Ealing PCT
Source: Charing Cross Breast Screening Unit, Crystal reporting

07/08 No. Invited Round6 Year 3 3915 528 84 2336 2 1441 8306

07/08 No. Attended Round6 Year 3 2250 261 37 1355 0 972 4875

07/08 % Uptake Round 6 Year 3 57.5% 49.4% 43.8% 58.0% 0.0% 67.4% 58.7%

How will the programme develop in the future? The NHS Cancer Plan, published by the Department of Health in September 2000, promised the extension of the NHS Breast Screening Programme. This has now taken place. Women up to and including the age of 70 now receive routine invitations for screening. In addition, all women now have two views of the breast taken at every screen. Research has shown that this increases small cancer detection rates by up to 43 per cent. In 2006-07 52% of cancers detected by screening programme were 15mm or less –not detectable by hand. The NHS Breast Screening Programme will extend the age range of women eligible for breast screening to ages 47 to 73 over next screening round 2008 - 2011. The current age range is 50 to 70. This will require the local screening to provide screening for an additional 9,087 women. Ealing PCT and West of London Breast Screening Service have identified additional costs and are supporting WOLBSS in developing a strategy to implement the age extension. As accommodating large mobile screening units across the borough becomes more and more difficult the PCT is planning to invest in establishing static screening units. Offers the opportunity to improve on the screening experience for women attending for a mammogram. 12

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Digital mammography Future developments in the breast screening programme will include the introduction of digital mammography. There has been a study of the acceptability to women of digital screening. This has looked at their perceived pain or discomfort and levels of satisfaction with the experience when compared with conventional mammography. Recommendations on commissioning and routine testing of full field digital mammography have also been prepared. Why are women under 50 not invited? Women under 50 are not offered routine screening. This is because mammograms are not as effective in pre-menopausal women as the density of the breast tissue makes it more difficult to detect problems, and also because the incidence of breast cancer is lower in this age group. Breast cancer is also far more common in post-menopausal women and the risk continues to increase with rising age. Women can ask their GP to refer them to a hospital breast clinic if they are concerned about a specific breast problem. This is not part of the NHS Breast Screening Programme, which uses a routine call and recall system to invite well women.

Health Promotion
 Promotional activities have continued with outreach work targeting vulnerable and hard to reach groups as well as more generic information campaigns around October Breast Awareness Month. This year all teenage school girls will be sent a promotional pack as well as the distribution of materials to all general practices and posters displayed in pharmacists. Practices are offered a visit to discuss the screening process and promotion to their patients prior to screening rounds. All practices receive a pack with promotional materials and information prior to their women being called for screening. An interpreter has been employed whilst the mobile screening unit was screening women in Southall area. The interpreter undertook a questionnaire with all women attending for a mammogram, over 1,000 forms are currently awaiting analysis. A video has been developed promoting breast screening with Life Channel the company which provides informational packages for screening in GP surgeries. Project work continues with practices supporting the follow up of non attenders. The evaluation of the first phase of this project work will be when the uptake data is published in October 2008, Training Workshop has been designed by coordinator for delivery to community staff, nurses/health visitors/district nurses The West of London Breast Screening Service (WOLBSS) has had a redesign of its website. Due to be operational September 2008.



    

Questionnaires undertaken by West of London Breast Screening Unit during 2007/08 and interviews with community and practice staff, identified that many women did not understand their lifetime risk of developing breast cancer. Promotional materials and outreach work will now focus more on this aspect

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Recommendations:
      WOLBSS to establish a web based booking system for appointments Support work of pan London modernisation project Continue targeted promotional activity – supported by improved ethnicity data Support efforts to maintain accurate general practice registration lists Continue with practice based project ‘follow up’ of non attenders – identifying causative factors e.g accessibility / private screening / symptomatic screens Establishment of static screening sites

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Appendix

Ward Acton Central Cleveland Dormers Wells Ealing Broadway Ealing Common East Acton Elthorne Greenford Broadway Greenford Green Hanger Hill Hobbayne Lady Margaret North Greenford Northfield Northolt Mandeville Northolt West End Perivale South Acton Southall Broadway Southall Green Southfield Walpole

Cervical % Uptake 70.8% 68.5% 73.7% 52.6% 79.2% 79.0% 76.6% 79.3% 78.9% 77.9% 77.3% 73.6% 76.0% 75.9% 78.5% 78.2% 78.0% 75.9% 73.4% 76.6% 70.4% 73.8%

Breast Uptake 63.1% 48.6% 59.5% 45.0% 56.6% 62.5% 52.6% 50.8% 64.0% 60.8% 43.4% 53.8% 54.2% 63.3% 64.3% 60.1% 41.6% 59.7% 51.2% 61.7% 53.9% 50.7%

%

Ealing PCT Breast & Cervical Screening Uptake Rates: 2007- 08

The above chart shows uptake data for breast and cervical screening within Ealing wards. These have been mapped against ethnicity within the wards. The wards shaded in blue had poorest rates for breast screening uptake and their demographics indicate over 70% residents are white, predominantly British. Those wards shaded lilac have some of the highest rates for breast screening with population breakdowns indicating 15% - 54% white ethnic groups. The relationship between white ethnic populations and uptake for cervical screening is not as apparent. As general practices are main service providers with this programme it is perhaps more a reflection of practice systems and dedication of staff in promoting screening. 15

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Analysis of ethnicity and residency data will support the targeting health promotional activities to improve screening programme coverage.
[1]

Effect of NHS Breast Cancer Screening Programme on Mortality from Breast Cancer in England and Wales, 1990-8: Comparison of Observed with Predicted Mortality. BMJ 2000:665-669 [2] Breast Cancer Screening 1991: Evidence and Experience since the Forrest Report, Department of Health Advisory Committee, NHS Breast Screening Programme 1991 [3] 7th Handbook on Cancer Prevention, IARC, Lyons 2002

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