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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
EALING PCT CANCER SCREENING PROGRAMMES                                              Appendix
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.




                                                2
EALING PCT CANCER SCREENING PROGRAMMES                                           Appendix




                           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
       ↓               ↓                 ↓
        8 nothing abnormal detected           6 polyps         2 bowel cancer

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
EALING PCT CANCER SCREENING PROGRAMMES                                                   Appendix
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.

                                                  4
EALING PCT CANCER SCREENING PROGRAMMES                                                                                                   Appendix
Recommendations:

                                           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
CancerResearch UK, 2005. Cancerstats
2
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
                                     6.00                     England Trendline
                                                              EHH Trendline

                                     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                    First invitation
25 - 49               3 yearly
50 - 64               5 yearly
                      Only screen those who have not been screened since age 50 or have
65+
                      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
EALING PCT CANCER SCREENING PROGRAMMES                                                               Appendix
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 multi-
ethnic, 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
                                                                                                       02/03
                   100.00%
                                                                                                        03/04
                    90.00%
                    80.00%                                                                             04/05
 5 Yr % Coverage




                    70.00%
                                                                                                       05/06
                    60.00%
                    50.00%
                    40.00%
                    30.00%
                    20.00%
                    10.00%
                     0.00%
                             <20   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+
                                                                Age bands



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                                           Appendix
The recording can be viewed on www.becervixsavvy.co.uk




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
EALING PCT CANCER SCREENING PROGRAMMES                                            Appendix
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
EALING PCT CANCER SCREENING PROGRAMMES                                                          Appendix
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.




                                                      10
EALING PCT CANCER SCREENING PROGRAMMES                                                     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          ENGLAND
               LONDON
   40
               Ealing PCT
   20          Hounslow PCT
               Hammersmith and Fulham PCT
    0
        1993   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                                                            Appendix
Ealing                58.3%         41.6%         52.9%          57.1%         64.2%      63.3%      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




                                                                 07/08          07/08             07/08
                                                                 No. Invited    No.    Attended   % Uptake
                                                                 Round6         Round6            Round 6
LCG's                                                             Year 3        Year 3            Year 3
EALING ACTON (EACG)                                              3915           2250              57.5%
NORTH                                                            528            261               49.4%
SOUTHALL (SPCCG)                                                 84             37                43.8%
SOUTHALL COMMISS (SCC)                                           2336           1355              58.0%
UNAFILIATED                                                      2              0                 0.0%
WEST EALING                                                      1441           972               67.4%
Ealing PCT                                                       8306           4875              58.7%

Source: Charing Cross Breast Screening Unit, Crystal reporting


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
EALING PCT CANCER SCREENING PROGRAMMES                                         Appendix
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




                                             13
EALING PCT CANCER SCREENING PROGRAMMES                                           Appendix




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




                                           14
EALING PCT CANCER SCREENING PROGRAMMES                                         Appendix




                                                     Cervical                  Breast      %
Ward                                                 % Uptake                  Uptake
Acton Central                                        70.8%                     63.1%
Cleveland                                            68.5%                     48.6%
Dormers Wells                                        73.7%                     59.5%
Ealing Broadway                                      52.6%                     45.0%
Ealing Common                                        79.2%                     56.6%
East Acton                                           79.0%                     62.5%
Elthorne                                             76.6%                     52.6%
Greenford Broadway                                   79.3%                     50.8%
Greenford Green                                      78.9%                     64.0%
Hanger Hill                                          77.9%                     60.8%
Hobbayne                                             77.3%                     43.4%
Lady Margaret                                        73.6%                     53.8%
North Greenford                                      76.0%                     54.2%
Northfield                                           75.9%                     63.3%
Northolt Mandeville                                  78.5%                     64.3%
Northolt West End                                    78.2%                     60.1%
Perivale                                             78.0%                     41.6%
South Acton                                          75.9%                     59.7%
Southall Broadway                                    73.4%                     51.2%
Southall Green                                       76.6%                     61.7%
Southfield                                           70.4%                     53.9%
Walpole                                              73.8%                     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
EALING PCT CANCER SCREENING PROGRAMMES                                                                                           Appendix
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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