Roadmap for Optimising Screening in Australia — Breast

Recommendations

Drawing on its key findings, the ROSA project recommended a set of activities to address priority evidence gaps and guide and support future implementation of risk-based screening in Australia. The types of activities recommended by the ROSA Breast project are summarised in the diagram below.

_{Types of recommended actions generated by the ROSA Breast project}

These activities include, for example, clinical studies to support the design of a large-scale trial, enhancements to BreastScreen data collection and reporting to support future risk-based screening, and improved management across health services of women at moderately higher risk. Priority evidence gaps include ongoing review of emerging evidence as well as insights from COVID-19 disruptions to BreastScreen including analyses related to prioritising client groups during periods of reduced throughput and recovery, and evidence related to extended screening intervals.

The project also recommended a staged clinical trial program to evaluate routine risk assessment and the targeted use of emerging and established screening technologies, in ways yet to be tested in Australia at a population level, commencing with pilot studies.

Recommendations in detail

Key recommendations, summarised, paraphrased and organised by topic, include:

1. Policy and guideline reviews

That national BreastScreen Australia guidelines are developed including current policies and practices in relation to women with different risk factors, including women presenting with known high-risk mutations.

That current management outside BreastScreen Australia of women assessed at moderately higher breast cancer risk be reviewed, aiming for clear and consistent guidelines and management pathways.

That health data sharing to support risk-based breast screening be planned and coordinated between health services.

2. Clinical studies to support trial design

That a well-validated automated breast density assessment tool is evaluated on a large scale in a BreastScreen Australia setting, reporting on outcomes in the setting such as cancer diagnosis rates, interval cancer rates and false positive screening rates for defined breast density groups.

That well-validated breast cancer risk assessment tools are evaluated in BreastScreen Australia settings to continue to build the evidence base towards risk-based breast cancer screening.

That priorities for future targeted research include a focus on the expected benefits and risks of potentially important technologies in relation to risk-based breast cancer screening.

That technologies for consideration in this context include digital breast tomosynthesis, ultrasound, MRI and contrast-enhanced mammography as primary or supplemental screening tools in some risk-stratified screening group/s.

3. Trial design

That ongoing monitoring and critical appraisal of international trials be used to inform the design of a prospective Australian trial, supported by observational studies where appropriate, recognising that international trials will not provide sufficient data to inform policy and practice without Australia-based trials/pilots. An Australian trial should capture both the benefits and harms of interventions, and carefully evaluate changes in screening behaviour.

That evidence on risk-based breast cancer screening is continually reviewed in relation to risk-based screening protocols.

4. Enhanced data collection and reporting

That BreastScreen Australia develop a framework for data collection and analysis to inform policy and practice for optimal risk-based breast screening.

That national BreastScreen Australia data on participants aged 40-44 and 45-49 is utilised to inform long-term considerations for targeted approaches to risk-based breast cancer screening.

That BreastScreen Australia annual screening policies be monitored and evaluated in more detail.

That BreastScreen Australia reporting for priority populations (e.g., Indigenous, rural/remote, culturally and linguistically diverse) is enhanced to help ensure any moves towards risk-based breast cancer screening do not widen gaps in outcomes between population groups.

5. Data linkage and evaluation of linked data

That BreastScreen data and other health records are linked and analysed to help evaluate ad hoc risk-based breast cancer screening occurring in asymptomatic women outside BreastScreen.

6. Targeted evidence reviews

That ongoing evidence review includes consideration of factors such as participant/patient history, genetic tests, breast density and evolving technologies.

That ongoing evidence review includes estimated group-level benefits and harms of risk-based breast screening technologies.

That any implemented approaches to risk-based breast screening technologies be regularly reviewed to ensure optimal approaches to policy and practice are being applied.

7. Research to address priority evidence gaps

That learnings from the management of COVID-19 and its impact on screening participation, service responses and outcomes are considered in relation to prioritised and stratified approaches to risk-based breast cancer screening.

That further evidence be collected on the benefits and risks of simplified breast cancer risk assessment tools in the Australian population, compared to more detailed approaches to risk assessment.

That priorities for future targeted research include a focus on the expected benefits and risks of potentially important technologies in relation to risk-based breast cancer screening.

That technologies for consideration in this context include digital breast tomosynthesis, ultrasound, MRI and contrast-enhanced mammography as primary or supplemental screening tools in some risk-stratified screening group/s, with different evidence gaps remaining for different technologies.

That any evolving approaches to introducing risk-based breast cancer screening are supported in parallel by coordinated evidence review, including modelling studies and analysis of other trials and pilot studies.

8. Consumer and stakeholder engagement

That steps towards risk-based breast cancer screening include increased engagement between policy, program and research leads and consumers and other key stakeholder groups, and ongoing exchange of clear, evidence-based information.

That there be further analysis about consumer attitudes about potential risk-based breast screening, to inform communication to support any change to more risk-based breast screening.