Access to BreastScreen Australia screening services

National BreastScreen Australia program

BreastScreen Australia is a joint initiative of the Australian and state and territory governments and is the only nationally accredited breast cancer screening program. Early detection can reduce illness and death from breast cancer by providing opportunities for earlier treatment. Each jurisdiction operates BreastScreen services offering free breast screenings (mammograms) to detect breast cancer early. Women over 40 years can have a free screening mammogram every 2 years. Women aged 50–74 are actively encouraged to screen every 2 years, whereas eligible women aged 40–49 and over 74 years can have a free screening mammogram but are not actively invited. Participation in screening is a key performance indicator. The National Preventive Health Strategy 2021–2030 sets a participation rate target of at least 65% by 2025 (Department of Health 2021). In 2020–2021, 48% of women aged 50–74 were screened through BreastScreen Australia (AIHW 2023a). Participation in 2020–2021 was impacted by the COVID-19 pandemic, however, as services had to reduce capacity due to the need to implement COVID-19 safety measures.

BreastScreen Australia provides screening services via fixed and mobile sites. Fixed sites that offer services year-round (permanent sites) provide convenience in relation to time; women can choose an appointment for a time convenient to them. Mobile and fixed sites offering services only for a short time span (visiting sites) could provide access to screening mammograms to women who would otherwise face excessively long drive times to attend a permanent site. In comparison to permanent sites, visiting sites may provide greater convenience in relation to one’s home location, however, they do not offer the same level of convenience in relation to time. Instead of offering services year-round, visiting sites offer services for a limited or discrete period, for example, a one-week screening block held every 2 years. Women whose availability does not match the scheduled visit may not be able to participate in screening at that visiting site at the recommended frequency of every 2 years. The impact is greater for the small proportion of women who are advised to have more frequent annual screenings. This effect could be reduced with timely access via screening services that operate more often.

Note: In Australia, breast screening also occurs outside the National BreastScreen Australia program. This has previously been shown to equate to about 3.5% of BreastScreen Australia activity (BreastScreen Australia 2009 as cited in Nickson et al. 2019). A subset of women who participate in screening are recalled for further testing at an assessment centre. Some Australians experience barriers to accessing assessment services, which can differ to those affecting access to screening services, and were out of scope for the work presented here.

Supporting the participation of First Nations and rural and remote women

BreastScreen Australia aims to provide equitable and timely access to screening mammograms to all eligible women in Australia. Each jurisdiction’s BreastScreen service aims to achieve the same participation rates for priority populations, as for women from the general population. Two priority populations include Aboriginal and/or Torres Strait Islander (First Nations) women and women living in rural and remote areas (BreastScreen Australia 2022).

Breast cancer incidence, mortality and screening participation among women aged 50–74 varies geographically and by Indigenous status. First Nations women aged 50–74 have a lower incidence and participation rate, but a higher mortality rate than non-‍Indigenous women (AIHW 2023a). In relation to rural and remote women, incidence is lower with increasing remoteness and participation is lowest in remote areas (AIHW 2022). Mortality was highest for those living in Inner regional areas and lowest for those in Very remote areas (AIHW 2023a).

Variation in participation by Indigenous status and Remoteness Areas

In comparison to the target of at least 65% participation by 2025 in breast screening, the participation rate was 35% for First Nations and 48% for non-‍Indigenous women aged 50–74 in 2020–2021 (AIHW 2023a). Note that the age-standardised rates, which are normally used for comparisons between First Nations and non-‍Indigenous people, were similar (35% and 47% respectively).

In 2019–2020, age-standardised participation was lowest among women from the target group who lived in Very remote areas, at 36% (AIHW 2022). This was followed by Remote areas and Major cities at 49% and 48%, respectively, and Outer regional and Inner regional areas at 55% and 53%, respectively (AIHW 2022). Despite shared characteristics of remoteness and lower socioeconomic position, there are meaningful differences in the participation rates by Indigenous status. In 2019–2020, First Nations women had lower age-standardised participation rates than that of non-‍Indigenous women across all Remoteness Areas, with a rate difference of -11% to -18% (AIHW 2023b; see Table 1). The rate difference was largest in Very remote, Remote, and Outer regional areas. For example, the participation rate was 23% of First Nations women and 39% of non-‍Indigenous women in Very remote areas (rate difference was -16%) (AIHW 2023b; see Table 1).

Early detection can reduce the risk of dying from breast cancer. Disparities in participation may contribute to an uneven distribution of the timeliness of breast cancer detection and its impact on illness and death. These disparities may be partly attributed to variation in access to screening services.

1. Rates are the number of women screened as a percentage of the eligible female population, calculated as the average of the 2019 and 2020 population estimates modelled by the AIHW (see note 2). Rates are age-standardised; rates are directly age-standardised to the Australian 2001 standard population in 5-year age groups between 50 and 74.
2. Rate difference is the age-standardised rate for First Nations women minus the age-standardised rate for non-Indigenous women.

Notes:

1. Women in the ‘not stated’ category for Indigenous status are excluded from these data.
2. Rates are calculated using population estimates based on Bayesian smoothing and Iterative Proportional Fitting of ABS projected populations (using the 2016 Census).
3. In 2020, the participation of First Nations women from the Northern Territory and those in Remote and Very remote areas was impacted by both the COVID-19 pandemic and the absence of the BreastScreen NT mobile truck, which was being upgraded.

Source: AIHW (2023b).

Translating findings into practice

This report shows the minimum time that women, living in different parts of Australia, need to drive to reach a BreastScreen Australia screening mammogram service, given the distribution of permanent and visiting sites. It provides evidence for the general population as well as two priority populations: First Nations women and women living in rural and remote areas. The findings can be used to identify areas where long drive times to reach screening services could make participation and timely diagnosis of breast cancer more challenging.

This report can help to guide service delivery and planning, including the optimal allocation of screening services. In translating this evidence into decisions, mechanisms to support equity of physical access should be judged in context of the enablers and barriers faced by First Nations women and women living in rural and remote areas, along with other factors that enhance service delivery. Furthermore, specific local areas may have unique characteristics that affect physical access such as the road conditions, availability of infrastructure to operate screening units, availability of organised group transportation, and the needs of clients from that area such as out-of-work screening hours, and issues with transport and parking. Users of this report can combine the drive time findings with other information to judge the feasibility of options to improve physical access and their anticipated effect on improving participation.

This report also provides opportunities for strengthened cross-jurisdictional coordination and increased cross-sectoral engagement. This may include greater community engagement with BreastScreen Australia, as well as improved service delivery and health promotion initiatives for women living in areas near state/‌territory borders who can participate in screening operated by a different jurisdiction. These are important enablers for participation that, when implemented together with strategically planned service delivery, will help progress towards the participation target of at least 65% by 2025 and towards achieving the same participation rates for priority populations, as for women from the general population.