Access to breast cancer screening

More research is needed to better understand breast cancer risk and screening. Governments and funders should invest in research to improve breast cancer screening in the following ways:

• Understand and reduce barriers to breast cancer screening.
• Find better ways to increase screening participation.
• Improve how people are invited to screening, including digital methods that protect privacy.
• Improve early detection, diagnosis and treatment, especially for communities that are underserved.
• Find appropriate ways to screen people who are at elevated and high risk of breast cancer.
• Improve how we predict breast cancer risk in people and find better ways to screen people based on their risk level (also known as risk-based screening).
• Find new and innovative ways to detect breast cancer early.

Data is crucial to monitor the health of a population, improve healthcare quality and delivery, and inform research and practice. Important opportunities are found in the pan-Canadian cancer data strategy (including race-based data collection) and pan-Canadian Health Data Charter. The federal government should work with provinces, territories and others who collect and work with data to do the following:

• Identify areas to improve breast cancer screening data.
• Collect data to fill gaps in breast cancer screening, including race-based data collection across the cancer control continuum.
• Create a breast cancer screening surveillance system to collect data on risk, screening and screening outcomes.
• Connect databases to monitor, evaluate and report on breast cancer screening in Canada.
• Collect data to build more evidence on supplemental screening for breast density and share results to help other jurisdictions who are considering access to supplemental screening.

The Canadian Cancer Society calls on the federal government to create breast cancer screening guidelines for people at elevated and high risk of breast cancer. Guidelines should do the following:

• Clearly define who is at low, average, elevated and high risk of breast cancer.
• Provide clear guidelines on how to screen people who are at elevated and high risk of breast cancer, which may include more frequent mammograms or the use of other imaging technology such as MRI, ultrasound and tomosynthesis.
• Recommend tools to determine risk levels that are easy to access and to use.
• Encourage healthcare providers and support them with how to discuss the benefits and limitations of screening and consider patient values and preferences to help people make decisions about screening.
• Include a plan to ensure guidelines reach healthcare providers and people that are eligible for breast cancer screening.

Provinces and territories are responsible for reviewing and updating their breast cancer screening program clinical practice guidelines, including start and stop age. The Canadian Cancer Society calls on provinces and territories to do the following:

• Review and update their breast cancer screening guidelines so that they align with the latest research and the changing healthcare environment.
• Start organized breast cancer screening programs at age 40 for women and trans, non-binary and gender-diverse people (when applicable) who are at average risk.
• Allow self-referral for breast cancer screening starting at age 40 without needing a healthcare provider’s referral.
• Allow women and trans, non-binary and gender-diverse people (when applicable) who are 75 or older to continue screening for breast cancer where clinically appropriate.

Provinces and territories are responsible for understanding their population and tailoring breast cancer screening programs to their needs. The Canadian Cancer Society calls on provinces and territories to do the following:

• Provide access to a healthcare provider through screening programs to help patients understand the benefits and limits of screening and discuss their overall health, risks, values and preferences.
• Develop screening recommendations and programs or pathways for people at high risk of breast cancer.
• Allow self-referral for people at high-risk for breast cancer with risk assessment.
• Implement breast density notification in the remaining regions (Quebec and Northwest Territories), and expand notifications to include all breast density categories in Saskatchewan with clear guidance on what to do depending on level of density so people can discuss their risk and consider supplemental screening.
• Support pilots of supplemental screening and monitor outcomes to assess ability to find breast cancer early. Supplemental screening may include MRI, ultrasound, tomosynthesis and contrast-enhanced mammography for people with dense breasts.
• Support healthcare providers with how to discuss the benefits and limitations of supplemental screening and consider patient values and preferences to help people make decisions about supplemental screening.
• Involve patients – especially people from communities that are underserved – when developing guidelines to remove barriers and create culturally safer care.
• Evaluate emerging tools and methods for early detection including tomosynthesis and artificial intelligence.
• Invest in additional screening resources and system capacity to accommodate a lower screening age, increase overall participation and ensure barrier-free access to all eligible people.

Provinces and territories need to work together with healthcare providers and health organizations to raise awareness about breast cancer risk and early detection. The Canadian Cancer Society calls on provinces and territories to do the following:

• Reach people for screening at age 40 through different methods such as letters mailed directly to the individual or other preferred methods identified within specific communities.
• Mail letters to remind past participants about how often to get screened.
• Provide solutions to access healthcare providers through screening programs and offer support to people without a regular healthcare provider (e.g. discuss the decision to screen, ensure they receive their results and provide follow-up care).
• Notify both patients and healthcare providers of screening results and follow-up recommendations in a timely manner. Ensure patients have their screening facility’s contact information in case they do not receive their results in the timeframe they were expecting.
• Offer complete and easy-to-understand information about screening benefits and limitations using numbers, infographics and plain language. Tailor materials for different groups and provide them in various languages and formats.
• Give healthcare providers helpful tools and resources for discussing breast cancer risk and screening with patients.

Communities that are underserved face barriers to accessing and participating in breast cancer screening. The Canadian Cancer Society calls on provinces and territories to do the following:

• Use approaches in breast cancer screening that are culturally safe and meet the needs of people who have experienced trauma.
• Co-design with communities to create strategies for improving screening awareness, participation and experiences, including but not limited to First Nations, Inuit, Métis, racialized, rural, remote and 2SLGBTQI+ communities. This may include exploring innovative ways to reach communities like mobile mammography or screening navigation.

Healthcare providers are critical to expanding access and increasing participation in breast cancer screening. The Canadian Cancer Society calls on provinces and territories to do the following:

• Assess the number of mammogram technologists, radiologists and support staff in radiology needed to support existing programs and their growth. Depending on results, this may include increasing entry into university and college programs and placement and training positions.
• Ensure that breast screening health human resources represent the diversity of the population they serve.
• Ensure radiologists are meeting specific requirements to improve their performance (e.g. set a minimum number of mammograms to be read each year, ensure participation in mentorship programs and provide ongoing learning opportunities).
• Ensure screening facilities are accredited by the Canadian Association of Radiologists Mammography Accreditation Program (CAR-MAP) or the appropriate provincial or territorial body to ensure minimum standards for imaging are met.