Roadmap for Optimising Screening in Australia — Breast

Key Findings

The ROSA Breast project found that momentum towards risk-based breast cancer screening is critical in a context of various changes and developments already underway. These include increasing advocacy for Australian women to be notified about their breast density, improved tools for assessing breast cancer risk at a population level, and changes to breast imaging technologies available outside BreastScreen for surveillance of a significant population of higher-risk women. It is also notable that under current health service policies and practices, women can receive different risk assessment, advice and management depending on who they see and where they live.

Key findings in relation to current evidence and practices include:

• Multiple factors in addition to age and in relation to age increase breast cancer risk in individual women, however evidence on how to identify, screen and manage women in high-risk groups at a programmatic level remains in development.
• Breast density is an important consideration in relation to risk-based breast screening, given its association with both breast cancer risk and potential reduced accuracy of screening tests.
• There is widespread and varied activity in breast cancer detection and referral within and outside the BreastScreen Australia program.
• There is a wide range of professionals involved in early detection of breast cancer, including multiple medical and health disciplines, diagnostic technologies and familial cancer centres, yet coordination between disciplines is limited.
• There are ongoing studies in a wide range of related areas from biology to behavioural research, however gaps in the evidence remain in relation to translation and implementation options.
• There is significant international activity relating to risk-based breast cancer screening, but insufficient evidence to inform changes to Australian policy.
• There is some ad hoc tailoring of services within and outside BreastScreen Australia according to identified risk, and some evidence of improved outcomes, however data is limited and varied. This includes current annual screening by BreastScreen Australia, which requires significant resourcing yet is difficult to evaluate using currently available data.

In terms of the consideration of how risk-based screening might be implemented in Australia, project findings include:

• There are key opportunities to improve data collection and analysis to inform incremental approaches towards risk-based breast cancer screening within BreastScreen Australia.
• There is no current national framework for evidence- and consensus-based guidelines to support incremental changes in policy and practice towards risk-based breast cancer screening.
• Clinical and health economics modelling indicates tailored screening pathways based on different risk profiles (risk-based screening) for the current target age range of 50-74 years from 1 Jan 2025 could, in the first 10 years of implementation, reduce population level breast cancer mortality, with further reductions possible through extending risk-based screening to younger age groups (40-74 or 45-74). The greatest differences are noted for the approximately 20% of women allocated to the highest risk group in the modelled scenarios.
• There is strong support among key stakeholders for a roadmap towards risk-based breast cancer screening in Australia.
• Uncertainty remains about how screening behaviour might change with the introduction of risk-based screening.
• Based on other areas of cancer screening reform and advice from stakeholders, real-world pilot study in Australia would be required to publish the level of evidence to underpin programmatic policy reform and related changes in clinical practice.

Overall, the ROSA project findings indicate that risk-based breast cancer screening could save lives, and the broader context suggests that risk-based breast screening would help future-proof BreastScreen. The ROSA report includes a roadmap and key recommendations for collecting that evidence as technologies continue to evolve, and engaging with key stakeholders to ensure any changes are feasible, equitable and widely supported.