Public Health England leads the NHS Breast Screening Programme. Its goal is to detect small changes in the breast before there are any other signs or symptoms of breast cancer, but some patients may arrive at the screening already having concerns. Early screening provides women between the age of 50 and 71 the opportunity of early diagnosis and enables them to receive early treatment, where necessary.
Jill Davies is currently investigating a case for a client who had, in fact, noticed changes in her breast tissue, prior to her routine screening and who had noticed a nipple inversion. Unfortunately, it was two years before she received a diagnosis of an invasive type of breast cancer called Invasive Pleomorphic Lobular Carcinoma.
During the course of our investigations, we reviewed the NHS (England) Breast Screening Programme Clinical Guidance for Breast Cancer Screening Assessment (“the NHSBSP guidance”) and felt that it would be helpful raise awareness amongst women around the possible symptoms or concerns that should result in a screening recall.
What is Breast Screening?
Breast screening involves an assessment of the breast tissues by using a mammogram, which uses low energy X-ray to examine the breasts.
Anyone registered with a GP as female will automatically be invited for NHS breast screening every three years between the ages of 50 and 71 and will be offered four mammograms, two for each breast.
It is important to note that the majority of women who take part in the breast screening programme have no breast cancer symptoms. If symptoms are suspected prior to being invited for screening, people are advised to contact their GP promptly.
The aim of breast cancer screening assessment is to obtain a definitive and timely diagnosis of all potential abnormalities detected during screening.
If abnormalities are suspected, the NHSBSP guidance recommends using a ‘triple assessment’ process, comprising of some form of imaging (usually mammography and ultrasound), a clinical examination and image guided needle biopsy for histological examination, in order to formulate a final diagnosis.
What could grant the need for a recall?
Further assessment following screening is indicated in the following circumstances:
- where there is significant mammographic abnormality
- where significant breast symptoms or signs identified at screening
- where there is the need for review of short-term recall
- where there is significant MRI abnormality in women at high risk
What could constitute Significant Breast Symptoms?
Significant symptoms and signs noted by the patient or the radiographer at screening should be documented and recalled. Such symptoms include:
- a lump
- distortion of the breast
- suspicious nipple or skin change including fixed nipple inversion
- a bloody discharge
On the day of her screening, our client completed the pre-screening form on which she stated that she felt pain in one of her breasts and had a nipple inversion which she had recently discussed with her GP.
After completing the pre-screening form prior to the mammogram, she also had a discussion with the radiographer. The radiographer advised our client that based on the information she had put on the form and due to our client’s history of cysts, it is likely that the client would need to be recalled for further screening. Our client then proceeded to have the mammogram which detected breast cysts. She was advised, at the time, that the cysts were the likely cause of the nipple indent. Shortly after the screening appointment, our client received a letter to say that there were no findings on the mammogram and was advised that she would be invited to a routine mammogram in 3 years. Our client felt reassured.
According to the NHSBSP guidance, despite mammography not showing a malignancy, a new nipple inversion or a breast indention (i.e., significant symptoms) should mandate a recall for screening assessment. However, in this lady’s case, a recall was not arranged.
The guidance also states that radiographers and assistant practitioners should be trained to recognise signs at the time of screening and that “recall for assessment of signs and symptoms may be appropriate even if the screening mammograms appear normal”. Although the ultimate responsibility for this rests with the authorised mammography readers, radiographers may still instigate recall for assessment where local protocols dictate.
NHS England acknowledges that there have been a number of “incidents in assessment”, often in circumstances when clinicians who had worked unsupported, and clearly suggest that screening directors should consider a second opinion before a final sign off is obtained and for a second assessor to review the case when there is any doubt. The guidance advises that this should ideally be done during the assessment clinic, and particularly in cases when a biopsy had not been taken.
Jill Davies, Principal Associate at Shoosmiths’ Thames Valley office, based in Reading says:
“Unfortunately, the failure to arrange a recall for our client led to a significantly delayed diagnosis of her breast cancer and in her receiving treatment. I hope that, by raising awareness of the fact that there are reasons for referral even with a normal mammogram, women will be armed with information to help them know when to question a decision not to recall”.
This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2022