Policy context and impact

Breast cancer in Australia

In 2021, 19,866 women in Australia were diagnosed with breast cancer, accounting for 28% of all cancers diagnosed in women.⁽¹⁾ The incidence of breast cancer is similar across states and territories, with the lowest incidence reported in the Northern Territory (126 cases per 100,000 females), and the highest incidence seen in the ACT (157.6 cases per 100,000 females). The number of breast cancer cases diagnosed in Australian women increased significantly between 1983 and 2023, from 5,316 to a projected 20,458 cases.⁽²⁾ This is in part due to a growing and ageing population, however age-standardised rates have also increased between 1983 and 2023, from 81.1 to 128.6 cases per 100,000 women.⁽²⁾ Breast cancer incidence increases with age, with the highest age-specific incidence seen among females between 70-74 years.⁽²⁾ In Australia, women who have been diagnosed with breast cancer will account for approximately 24% of the population of people living with or beyond cancer in 2040.⁽³⁾

Breast cancer caused 3,159 deaths in Australia in 2021, making it the second most common cause of cancer death in women in Australia, after lung cancer. The five-year relative survival rate for women diagnosed with breast cancer in 2016-20 was 92%.⁽⁴⁾ It is important to highlight the survival rates in communications to eligible persons and emphasize the increasing survival rates when breast cancer in diagnosed at an earlier stage.

Breast cancer was estimated to be the ninth leading cause of disease impact in Australian women in 2018, measured by disability-adjusted life years. It accounted for 3% of the total disease burden in women.⁽⁵⁾ Although much more common in women, breast cancer also affects a small number of men each year. In 2019, 163 men were diagnosed with breast cancer. During this same year, there were 28 breast cancer deaths in men.⁽²⁾

Aboriginal and Torres Strait Islander women are 12% less likely to be diagnosed with breast cancer compared to non-Indigenous women. Aboriginal and Torres Strait Islander women are also 19% more likely to die of breast cancer.⁽⁶⁾ In 2012-2016, Aboriginal and Torres Strait Islander women were found to have a disproportionately lower five-year relative survival rate compared to non-Indigenous women (85% and 91% respectively).⁽²⁾

Economic impact

Breast cancer had the highest health system expenditure of all cancers in 2015-16, costing $1,056 million, including $269 million which was spent on the BreastScreen Australia program.⁽⁷⁾ The health system costs in 2013 for people diagnosed with breast cancer in Australia between 2009-13 was $0.8 billion, which was the second most expensive of all cancer costs and contributed to approximately 13% of the ~$6.3 billion spent on cancer during this time period.⁽⁸⁾

The estimated average lifetime financial cost faced by households for women with breast cancer was $28,500. ^{(9, 10)} An additional survey conducted by the Breast Cancer Network Australia on the out-of-pocket costs for women for breast cancer treatment and care in the first five years after their diagnosis found that 88% of women had an out-of-pocket cost, with an average amount of $5,000 across the five years.⁽¹¹⁾

BreastScreen Australia

Population-based breast screening in Australia is managed through the BreastScreen Australia program. The BreastScreen Australia program aims to reduce illness and death from breast cancer through a systematic approach, with the aim of early detection through regular screening mammography (breast x-rays).⁽¹²⁾

The optimal care pathway for people with breast cancer provides advice as to when screening should take place outside of the BreastScreen Australia program, based on an individual’s risk, and when diagnostic assessments for breast cancer should be completed.⁽¹³⁾

Screening participation

In 2021-2022, approximately 1.8 million women aged 50-74 participated in the BreastScreen Australia Program, equivalent to 48% of the eligible population.⁽¹⁴⁾ From 2019-2021, the number of women participating in the BreastScreen Australia Program had reduced from 1.9 to 1.7 million, most likely due to the effects of the COVID-19 pandemic.⁽¹⁴⁾

Participation during 2021-2022 was highest among women aged 65-69 (54.5%), and lowest for women aged 50-54 (45.4%).⁽¹⁴⁾ Across states and territories, participation rates varied, with the highest rate reported by Tasmania (59%), and the lowest rate reported by the Northern Territory (34%). (See Table 1).

Participation rates (%)

^{Table 1. BreastScreen Australia participation data for women aged 50-74 in 2021-2022. (14)}

Rescreening rates from 2019-2021 were also lower than seen previously. Only 41% of participants aged 50-72 who were screened in 2019, rescreened within the recommended 27-month period, however this rate increased to 47% after the second screening round, and 65% after the third, and any subsequent screening rounds.⁽¹⁵⁾ 51% of participants aged 50-72 who were screened in 2020, rescreened within the recommended 27-month period, with this rate increasing to 60% after the second screening round, and 76% after the third and subsequent screening rounds. ⁽¹⁶⁾ Prior to the COVID-19 pandemic, the proportion of women aged 50-72 years who were screened in 2017 and rescreened within 27 months was 60.9%, and this rate increased to 70.5% after the second screening round, and 84.4% after the third and subsequent screening rounds.⁽¹⁷⁾

The BreastScreen program aims to have patterns of participation reflect the socioeconomic, ethnic and cultural profiles of the target population.⁽¹²⁾ In 2021-2022, screening rates in the target group did not differ substantially across socio-economic areas, with the age-standardised participation rate ranging from 47% to 50%.⁽¹⁶⁾ However, there is typically some variation in participation by remoteness area, with women in outer regional areas having the highest participation rates (54%), and those living in very remote areas having the lowest participation rates (39%).⁽¹⁶⁾ It is possible that some of this variation was due to differences in public health restrictions across regions throughout the COVID-19 pandemic, however this mirrors participation trends seen prior to the COVID-19 pandemic. In 2020-2021, participation rates for Aboriginal and Torres Strait Islander women was 35%, compared with 47% for non-Indigenous women.⁽¹⁵⁾ Language barriers have been significantly associated with fewer visits to BreastScreen Australia for Aboriginal and Torres Strait Islander women in the Northern Territory.⁽¹⁸⁾

There is also evidence that breast screening participation rates are lower among migrant groups than Australian born women. Results from the 45 and Up Study (New South Wales 2006-2010), revealed that in urban areas, women born in all Asian regions were significantly less likely to have a breast screening mammogram than Australian born women.⁽¹⁹⁾ In regional areas, a similar pattern of participation was observed, and women born in New Zealand, Oceania, and West Europe were also less likely to have a screening mammogram when compared to Australian born women.⁽¹⁹⁾

It is essential that culturally safe and accessible care is provided for all individuals participating in breast cancer screening and that there is appropriate education provided to ensure that all eligible women are aware of the BreastScreen program, and their eligibility, and understand the importance and benefits of breast cancer screening.

Australia has obligations to the World Health Organization (WHO) Breast Cancer Initiative, which has a focus on increasing cancer screening and prevention and includes a target to increase BreastScreen Australia participation to at least 65% by 2025.⁽²⁰⁾ The participation rate of 65% has not been achieved, and in 2020-21, 1.7 million of the 3.6 million eligible women aged 50-74 participated in the program (48%).⁽²⁰⁾ While lower participation rates were seen in 2020-21 versus 2018-19 (47.5% vs 54.8% respectively),^{(15, 17)} likely as a result of the COVID-19 pandemic, the participation target of 65% was still not met. Cancer Council supports efforts to increase participation of BreastScreen Australia services in recognition of the impacts which the COVID-19 pandemic may have had on individuals being able to attend their scheduled screening appointments.

Screening evaluation and cost-effectiveness

In Australia, a willingness-to-pay (WTP) threshold of $30,000-50,000 per life-year saved (LYS) is used to assess the cost-effectiveness of a screening program.⁽²¹⁾

In 2009, a government-led evaluation of the BreastScreen Australia program estimated the cost-effectiveness of the program for women aged 50-60 years was $38,302 per LYS over 20 years, and $23,713 over 40 years (equivalent to $65,065/LYS and $40,279/LYS, respectively in 2018 value).^{(21, 22)} However, cost-effectiveness has been estimated to decline for women older than 70 years.⁽²¹⁾ Updated, and comprehensive cost-analysis of the BreastScreen Australia program is required, and there may be options to improve cost-effectiveness through personalised and targeted approaches to breast screening.⁽²¹⁾