Likely effect of the COVID-related cessation of the NHS Breast Screening Programme

It does not come as news to any of us that the COVID-19 pandemic caused considerable disruption to health services in 2020 and 2021. The NHS Breast Screening Programme in England is no exception.
Published in Cancer
Likely effect of the COVID-related cessation of the NHS Breast Screening Programme
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Between late March and the end of June 2020, almost no screening activity took place. Services gradually resumed from July 2020 onwards, but monthly numbers screened remained considerably below pre-pandemic figures for some time, due to transmission control measures limiting the number of screening slots on offer, and reluctance of invitees to attend for screening for fear of infection.

A collaboration of academics, screening programme management and policy personnel, and health professionals has estimated the likely effect of the hiatus in screening and the subsequent reduced screening activity during the recovery phase on:
•    detection mode (screening or symptomatic) of cancers diagnosed in 2020 and 2021, and its implications for prognostic factors tumour size, node status and histological grade; 
•    stage at diagnosis of screen-detected invasive cancers in 2020 and 2021;
•    progression of ductal carcinoma in situ (DCIS) to invasive breast cancer; and
•    Implications of the above three for ten-year survival.
The aim of the researchers was to keep the process as simple and transparent as possible. The basic principle was to estimate the extent to which tumours were allowed to grow and therefore become more life-threating in terms of prognostic factors, combine this with published survival rates by prognostic factors, and thus estimate the additional breast cancer deaths over the coming ten years as a result of the reduced screening activity.
In terms of concept, this simplicity was largely achieved, but the arithmetic was necessarily convoluted, involving extrapolation of trends in screening activity, and taking account of missing data on prognostic factors and changes in survival over time.
Depending on assumptions, it was estimated that between 148 and 687 additional breast cancer deaths will occur in the next ten years, as a result of the cessation and time taken to catch up afterwards. Sadly, the assumptions associated with the lower figure (missingness at random, no effect of delayed screen detection, no effect of progression of DCIS) are somewhat implausible, so the true answer is likely to be towards the upper end of that range.
There is, however, some comfort. These deaths have not happened yet, and whether they do will depend on how rapidly the programme recovers from the cessation. We are no longer in the response phase to the pandemic, but in the recovery phase. There is a need to catch up on missed screens as quickly as possible. As some of the areas worst hit by the pandemic are also underserved in other areas of healthcare, including participation in cancer screening, there is a need for the recovery process to focus on rectifying, or at least not worsening, health inequalities.
While commendable efforts are being made to catch up on missed invitations, it should be acknowledged that invitation of itself does not save lives: screening saves lives. Thus a crucial component of the recovery effort must be a drive to achieve high participation rates.

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