Oswald Graf, MD
Austria Roentgen Society
Breast Imaging Group
Managing Editor, HealthManagement
Austria's formal breast screening programme started this year. Please explain the background.
Although there has not been organised mammography screening in Austria, breast cancer mortality has significantly decreased since the 1990s. With the exception of some local pilot projects, early breast cancer detection depended on unorganised opportunistic breast cancer screening in individual radiology practices.
In January 2014 organised mammography screening was introduced in Austria. One of the main goals was to utilise the existing robust infrastructure of local radiology practices. Performing screening exams in locations distributed all over the country should help to achieve high participation rates in the female population. Specific qualifications similar to screening programmes in other European countries are required for all institutions that want to participate in the screening programme.
Women aged 45 - 69 years are invited for screening. Women aged 40 – 44 years and 70 - 75 years may opt in for screening. Invitation to screening and evaluation of the entire programme is supported by central data management, which is provided by healthcare government authorities.
What features does the programme have?
The National Austrian Screening Programme has some specific features. Only digital mammography equipment is used, and, in addition to mammography, ultrasound is added as an adjunct test in women with dense breast tissue. This approach is supported by multiple studies, which showed that ultrasound is able to find a significant number of invasive cancers in dense breasts that will remain otherwise undetected at mammography.
In Austria ultrasound has been widely used in opportunistic breast cancer screening in the past, and radiologists are quite experienced using this technique. However, the impact of the use of supplemental ultrasound for early detection has not been systematically evaluated throughout the country. The practice of double reading of screening mammograms - intended to reduce the number of false negative results due to human error, and widely used in many other countries - has been applied only in some institutions in Austria.
In the first ever screening programme of its kind, the National Austrian Screening Programme combines mammography with ultrasound in women with dense breasts by the first line radiologist. Double reading of the mammograms is performed by a second radiologist. Regarding the limited value of mammography in dense breasts and the influence of human errors in reading screening mammograms, both steps should increase the overall sensitivity for early breast cancer detection.
This combined approach is a major logistic and scientific challenge. Most Austrian radiology practices in remote areas are run by single radiologists, with groups of radiologists found only in larger urban areas. Therefore, the process of double reading requires some logistic efforts. Teleradiology networking is used for the double reading process now in many institutions.
What has been the progress in the first few months?
The National Austrian Breast Cancer Screening Programme officially started on January 1st 2014 and invitations were rolled out. However, there were some setbacks in the last months.
In autumn 2013, physicians, predominantly gynaecologists and GPs were instructed by government authorities and officials in charge not to refer women to screening mammography anymore, as they used to do in the past.
From January 2014 referrals to mammography by physicians were restricted only to a dedicated list of specific indications, i.e. in the case of palpable abnormalities.
In the months from January to April 2014 experience in real life was rather disillusioning. Only 10% of women who were invited to screening actually scheduled an exam. This is a major setback, since approximately 50% of women used the access for mammography by referral in the past.
Furthermore, of all the women who showed up for screening, less than one percent never had a mammogram before or the last mammogram was performed more than three years ago. Thus, one of the main goals, to motivate new women for screening, was completely missed. Simultaneously, due to the limited access by referral the overall number of mammograms in Austria has dramatically decreased by 31%, in some regions up to 60%. The abrupt change of a system that has been prevalent for many years was not accepted by the majority of Austrian women and dissatisfaction rose, raising pressure on healthcare politicians.
In May 2014, this alarming development has led to an opinion change by politicians and officials in charge. Starting in July 2014, physicians will be allowed to send women for screening mammography again, following the age and screening interval guidelines of the programme. Furthermore, women over 45 years of age may come to a screening mammogram every other year without an invitation or a referral by a physician.