NHS Breast Screening Programme, England 2020-21

Coverage is defined as the percentage of women in a population eligible¹ for screening at a specific point in time who have had a test result recorded in the last three years.

Acceptable level is defined as attaining uptake levels of 70% or greater².

Achievable level is defined as attaining uptake levels of 80% or greater². All BSUs should be aiming for this standard.

Coverage in other UK countries

Wales: https://phw.nhs.wales/services-and-teams/screening/breast-screening/reports/

Coverage figures are not currently available for Scotland and Northern Ireland.

National coverage as at 31 March, 2011 to 2021

• In 2021, 6.25 million women were eligible for screening.
• Coverage was 64.2%, a decrease of 9.9 percentage points from the previous year.

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

National and regional (ages 53 to <71)

National coverage by age band, 31 March 2020 and 2021

• In 2021, coverage was highest amongst those in the 65-69 age group and for those aged 70 (65.4% and 65.6% respectively).
• Coverage declined in all age groups compared to 2020. The greatest decline was in the 53-54 and 65-69 age groups with a decrease of 10.1 percentage points.

Regional coverage as at 31 March, 2020 and 2021

• In 2021, coverage decreased notably in all regions. Coverage ranged from 55.2% in London to 68.4% in the South East.
• No screening regions reached the acceptable coverage level of 70%
• The COVID-19 pandemic affected different parts of the country at different times and to different severity during 2020-21. See covid impact summary for more details.

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

Local authority (LA) (ages 53 to <71)

LA coverage as at 31 March 2021

• 29 of 149 LAs reached the acceptable level of 70% coverage, a decrease of 89 compared to 2020.
• No LAs reached the achievable threshold of 80%.
• The Covid-19 pandemic affected different parts of the country at different times and to different severity during 2020-21. See covid impact summary for more details.

*The total number of LAs displayed in 2020-21 is 149. This is the same as in 2019-20.

The Frequency chart below shows the number of LAs in each coverage category in 2020-21.

• The lowest coverage reported at LA level was 41.8%, the highest was 78.2%.

Overall activity is measured for women aged 45 and over to include all screening activity; both those invited as part of the programme and those screened as a result of GP or self-referral.

• Since 2004, the programme screened women aged 50-<71 years.
• In 2009, the programme began to include a broader age range as part of the AgeX research trial, 47-49 years at the lower end and 71-73 at the upper end. Recruitment to the trial stopped in March 2020.
• Activity levels in 2020-21 were impacted by the programme ceasing for three months due to the Covid-19 pandemic. See covid impact summary for more details.

National activity, 2010-11 to 2020-21

• 1.19 million women aged 45 and over were screened within the programme in 2020-21, a decrease of 44.1% from 2019-20.

National activity, by age, 2015-16 to 2020-21

• In 2020-21, 94.0% of women screened were in the 50-<71 age category.

• The Age-X trial recruitment ceased in March 2020, resulting in fewer invitations for the 45-59 and 71-74 age groups in 2020-21.

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

National activity, by invitation and referral, 2015-16 to 2020-21

• In 2020-21, 95.3% of women screened were invited as part of the programme; the remaining 4.7% were screened as a result of self or GP referral.

Self / GP referrals (ages 45 and over)

National activity for self / GP referral, by age, 2010-11 to 2020-21

• In 2020-21, 55,992 women were screened as a result of self or GP referral, a decrease from 123,900 in 2019-20.
• Most self / GP referrals were for women aged 71 or over (37.5% in 2020-21).
• Self / GP referrals are the most common point of entry to the screening programme for women aged 71 or over; these women are outside the target age group for invitation, but the programme does accept such referrals from this age group at three-yearly intervals. (See Appendix A).
• In 2020-21, there was a decrease in the number of self / GP referrals for all age groups. Contributory factors to this decrease include disruption from the Covid-19 pandemic, with services instructed to pause self-referrals for a number of months. See COVID impact summary for details

Women are eligible to receive an invitation to be screened if they are in the screening age range (core 50 - <71), unless they are ceased due to having had bilateral mastectomies³ or individually opt out of screening⁴ or are ceased under a best interests decision.

The AgeX research trial, which invites women aged 47-49 and 71-73, stopped recruitment in March 2020.

National invites, 2019-20 and 2020-21

• In 2020-21, the number of women invited for screening was 1.84 million, a decrease of 36.9% from 2019-20 (45-74 years).
• The pause in screening due to COVID-19 during 2020-21 reduced the number invitations sent during the year. See COVID impact summary for more details.
• There was a decrease of 77.9% in the 45-49 age group. The decrease in this age group is also a result of the Age-X trial no longer recruiting individuals from March-2020.
• There were 40,530 invitations in the 71-74 age group in 2020- 21, a decrease of 64.3% from 2019-20. 

The table below shows a breakdown of national invites by age for 2019-20 and 2020-21.

Source: KC62 (Part 1, tables A to D) NHS Digital - see data table 4.

National, core programme (ages 50 to <71)

The programme categorises invitations into 5 groups, as summarised in the table (for further detail see Appendix C).

• In 2020-21, for women aged 50-<71 most invites (63.9%) were routine invitations to previous attenders where the last screen was within 5 years.
• The number of 1st invitations increased in 2020-21 by 13.5% from 2019-20.
• The majority of first invitations were to those in the 50-52 years age group, 172,848 in 2020-21 (13.1% from 198,975). See table 4 in data tables.

National invites, 2019-20 and 2020-21

The table below shows a breakdown of invitation type for 2019-20 and 2020-21 for thoes ages 50 to <71.

The sum of components may not equal totals due to rounding.
Source: KC62 (Part 1, tables A to D) NHS Digital – see data table 4.

Uptake is the proportion of eligible women who have a technically adequate screen ≤6 months of date of first offered appointment. (see Appendix B).

Acceptable level is defined as attaining uptake levels of 70% or greater².

Achievable level is defined as attaining uptake levels of 80% or greater². All BSUs should be aiming for this standard.

One of the objectives of the screening programme is to maximise the number of eligible women who attend for screening. This is set out in the NHS Breast Screening Programme screening standards². The performance levels provide a way to monitor progress.

Where ‘routine invitation’ is used this indicates that short term recall invitations⁵ are not included. Measurement of the national standard excludes short term recall invitations and self / GP referrals.

In September 2020, in response to COVID-19, open invitations were recommended rather than timed invitations to maximise utilisation of screening slots. This may have impacted uptake of invitations. See COVID impact summary for more details.

Uptake in other UK countries

Northern Ireland

http://www.cancerscreening.hscni.net/Breast_Uptake_Rates.htm

Scotland

https://publichealthscotland.scot/publications/scottish-breast-screening-programme-statistics/scottish-breast-screening-programme-statistics-annual-update-to-31-march-2020/

Wales

https://phw.nhs.wales/services-and-teams/screening/breast-screening/reports/

Uptake* of invitations

National and regional (ages 50 to <71)

National uptake, 2010-11 to 2020-21 

• In 2020-21, 1.08 million women who received an invitation** were screened by the programme. Down from 1.79 million in 2019-20.
• Uptake of invitations** dropped to 61.8% in 2020-21, down from 69.1.% in 2019-20.

Regional uptake, 2019-20 and 2020-21 

• Uptake by women aged 50-<71 decreased in all reporting regions in 2020-21. 
• Uptake ranged from 54.1% (London) to 65.0% (East Midlands).

*All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

** Invitation figure used to calculate uptake includes first and all routine invitations. This does not include short term recalls.

By invitation type

National uptake, 2020-21, by invitation type, ages 50-<71

• 53.4% of women receiving their first invitation in 2020-21 were adequately screened.
• Uptake was lowest (14.5%) amongst women who received a routine invitation, having failed to respond to a previous invitation(s).
• Uptake was highest (98.0%) amongst those receiving short term recall invitations.

National uptake, 2010-11 and 2020-21, by invitation type

The interactive dashboard shows that for the two largest age groups, 45-49 years and 50-52 years, their uptake rates for first invites in 2020-21 were 58.1% and 58.3% respectively.

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

Breast screening unit (BSU) (ages 50 to <71)

National uptake, 2020-21, by BSU

9 of 78 BSUs reached the acceptable level of 70%, 41 BSUs fewer than in 2019-20.

Uptake ranged from 48.3% to 73.6% at BSU level. All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

Uptake data by BSU can be explored further in the dashboard:

http://bit.ly/breast_screen_annual_stats

National (45 and over)

National uptake, by age, 2020-21

Uptake by women ranged from 57.7% (aged 45-49) to 63.8% (aged 65-70).

The uptake amongst women in the 45-49 and 71-74 age groups will include those in the AgeX trial, which stopped recruitment in March 2020.

In 2020-21, the 45-49 age group primarily includes women who were not invited as part of the AgeX trial but were invited in the calendar year of their 50th birthday while they were still 49 (see Appendix A).

NB. Uptake data is collected in an aggregate form, therefore it is not possible to produce uptake figures specifically for the 47-49 and 71-73 age groups.

Uptake data by age can be explored further in the dashboard: http://bit.ly/breast_screen_annual_stats

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

Women are referred to an assessment clinic for further tests if a potential abnormality is detected at initial screening (see Appendix A).

Referrals for assessment are reported by two distinct screening types as the percentage of referrals is expected to vary according to type:

Prevalent screening refers to first invitations for routine screening and invitations to previous non-attendees.

Incident screening refers to routine invitations to previous attendees screened.

The programme aims to minimise the adverse effects of screening, such as anxiety and unnecessary investigations, and therefore the number of women this affects through referral for assessment.

The percentage of women referred for assessment is expected to be lower in incident screening than in prevalent screening, as image readers interpreting images will have previous images for comparison which aids the detection of breast abnormalities and reduces recall.

Outcome of screening

National, referrals for assessment (ages 45 and over)

• In 2020-21, 7.3% of women attending for the first time (prevalent screening) were referred for assessment.
• 3.3% of women who had been previously screened (incident screening) were referred for assessment.

(a) Including women referred for cytology, core biopsy or open biopsy. See glossary for more information.
(b) Women invited under short term recall are invited to an assessment clinic rather than to routine screening.
Source: KC62 (Part 1, tables A to F2) NHS Digital – see data table 6.

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

National, referrals for assessment by category (ages 45 and over), 2020-21

47,198 women were referred for assessment in 2020-21, down from 76,440 in 2019-20.

47.8% of women referred for assessment in 2020-21 underwent fine-needle aspiration cytology and/or core biopsy.

For further information see Appendix A.

1.1% of women referred for assessment were referred for open biopsy. The same proportion as in 2019-20

(a) Including women referred for open biopsy after being referred for cytology and/or core biopsy.
(b) Including women referred for further imaging, or subsequently referred for cytology, core biopsy or open biopsy. See Appendix A for more information.
(c) The percentages for ‘Referred for cytology and/or core biopsy’ and ‘Referred for open biopsy’ are calculated using the total number of women referred for assessment as the denominator.
Source: KC62 (Parts 1 and 2, tables A to F2) NHS Digital – see data table 6.

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see COVID impact summary for details

National, short term recall outcomes (ages 45 and over), 2020-21

Amongst women who are referred for assessment following breast screening, a definitive diagnosis cannot be made in a very small number of cases. When this occurs women are recalled early for further assessment.

0.8% of women referred for assessment were recommended for short term recall.

(a) Including all women whose final outcome was short term recall, whether after initial screen, assessment, cytology or biopsy (core or open).
(b) Including women subsequently referred for cytology, core biopsy or open biopsy. See Appendix A for more information.
(c) Note that the percentage of assessment outcomes that were ‘short term recalls’ is calculated using the total number of women referred for assessment as the denominator.
This differs from data tables 6, 7 and 7a where the denominator is the number of women screened.
Source: KC62 (Part 1, tables A to F2) NHS Digital – see data table 6.

All statistics for 2020-21 were impacted by covid - see covid impact summary for details

Cancer detection rates in other UK countries

Scotland (women aged 53-70)

Scottish breast screening programme statistics - Annual update to 31 March 2020 - Scottish breast screening programme statistics - Publications - Public Health Scotland

Wales (women aged 49 and over)

https://phw.nhs.wales/services-and-teams/screening/breastscreening/programme-reports/

Northern Ireland (women aged 50-70)

Please note, most recent data relates to 2016-17

http://www.cancerscreening.hscni.net/Breast_Professional_Pubs.htm

Number of women with cancers detected

The number of women each year with cancer detected can be attributed to factors including changes to the number of women eligible for screening as a result of changes to the population.

i.e. as the population of women within the screening age range increases, the number of women eligible for screening will also increase. Therefore, the more women who are screened, the more potential cancers which will be detected. This is independent of the rate of detection.

Rate of cancer detection

• The cancer detection rate may be influenced by the following factors:
• The age distribution of women screened in any one year, as the incidence of breast cancer increases with age⁶.
• The expansion of the screening programme to broader, largely older, age groups in the last ten years.
• Targeted awareness campaigns.
• The introduction of digital mammography in 2008 which was fully implemented by 2016.

In 2020-21, as a result of covid, the large reduction in number of women screened meant fewer cancers were detected.
The rate of cancer detection increased in 2020-21 (see COVID impact summary for details).

National (ages 45 and over)

National detection, by age, 2019-20 and 2020-21

• In 2020-21, 10,813 women had cancers detected by the programme, a rate of 9.1 cases per 1,000 women screened (an increase from a rate of 8.4 in 2019-20)
• Amongst the core programme (50-<71 years), the detection rate was 8.9 per 1,000 in 2020-21

Source: KC62 (Parts 1 and 3, table T) NHS Digital - see data table 9a.

National detection, by age, 2010-11 to 2020-21

• The incidence of breast cancer detected through screening increases with age. 
• In 2020-21, detection rates were lowest for women aged 45-49 (6.4 per 1,000) and highest for women age 71 or over (16.7 per 1,000)
• There was an increase in detection rates for every age group in 2020-21. All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

National detection, by age (45 and over), 2020-21

• In prevalent screens, the rate of women aged 45 and over with cancer detected was 9.1 per 1,000 women screened. In incident screens, the rate was 8.9 per 1,000.
• The cancer detection rate was highest in short term recalls (47.7 per 1,000 women).
• It would be expected that the detection rate is highest for short term recalls as in these cases women have been referred for assessment following an abnormal mammogram but following further tests a definitive diagnosis could not be made. Short term recalls should be an exceptional outcome of assessment and will only occasionally occur.

- = Zero.
*   Rate based on fewer than 2,000 women screened.
Source: KC62, Parts 1 and 3 (tables A to F2, T) - see data tables 8 and 9a.
All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

National (ages 45 and over)

The overarching aim of breast screening is to reduce mortality by finding breast cancer at an early stage when the changes in the breast are often too small to detect by hand.

Cancers are reported in two main categories, non-invasive and invasive. Invasive cancers are then reported by two further sub categories.

Non-invasive or micro-invasive cancer is one which demonstrates no or only very slight (<1mm) invasion into adjacent tissues.

Invasive cancer is one which has spread beyond the layer of tissue in which it has developed and is growing into surrounding, healthy tissues.

• Small invasive cancers (size of less than 15mm)
• Invasive cancers (size of 15mm or greater)

National detection, by cancer type or size, 2010-11 to 2020-21

In 2020-21, detection rates were highest for small invasive cancers (3.5 per 1,000 women) and lowest for non-invasive or micro-invasive cancers (1.9 per 1,000 women).

The breakdowns in the chart above exclude the sub-categories ‘Invasive status not known’ (6 in 2020-21) and ‘Invasive – size not known’ (534 in 2020-21). See data tables 9a and 10 for full data.

All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

National (ages 45 and over)

National detection, by type / size of cancer, 2019-20 and 2020-21

NB: The sum of components may not equal totals due to rounding.
Source: KC62 (Part 3, table T) NHS Digital - see data table 10.
All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

• In 2020-21, 21.2% of women aged 45 and over with cancer detected had non-invasive or micro-invasive cancers.
• 78.7% had invasive cancers of any size.
• Small invasive cancers accounted for 48.6% of all invasive cancers, and 38.3% of all cancers.

National (ages 50-<71), 2020-21

• At the prevalent screen, 26.9% of all cancers detected were non-invasive cancers and 30.4% were small invasive cancers.
• At the incident screen, 20.4% of all cancers detected were non-invasive cancers and 39.7% were small invasive cancers.

(a) Includes some invasive cancers of unknown size.
Source: KC62 (Part 3, tables A to F2, T) NHS Digital - see data tables 8, 10 and 10a.
All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details

National (ages 50-<71), 2020-21

• In 2020-21, small cancers (less than 15mm in diameter) accounted for 48.7% of those with invasive cancer.
• In prevalent screens this figure is 41.6%.
• In incident screens this figure is 49.9%.

Source: KC62 (Part 3, Tables A to F2, T) NHS Digital - see Data Tables 8, 10 and 10a.
All statistics for 2020-21 were impacted by disruption from the COVID-19 pandemic - see covid impact summary for more details 

Women at higher risk are those who have been assessed by a specialist in genetics or oncology as being at more risk of developing breast cancer than women in the general population⁷. Women at very high risk⁷ are eligible for screening in the NHS BSP and are screened as part of the programme. 

Women at very high risk of developing breast cancer are offered breast screening at an earlier age and at different frequencies to women in the general population⁷.

In addition to a mammogram, these women may also be screened using a magnetic resonance imaging (MRI) scanner; a large tube surrounded by a strong magnetic field.

Since 2017-18, high-risk data in this section has been collected using a new and more comprehensive collection system.

Due to the infancy of this collection, data completeness is still being assessed, therefore it continues to be designated as an experimental statistic⁸ .

2020-21 is the first year that the new breakdowns have been available for use in the annual report.

By risk category

England, 2020-21

A total of 8,864 women at very high risk of developing breast cancer were screened in 2020-21.

Of those screened, the majority were in the BRCA 1 and BRCA 2 risk categories.

Cancer detection rates, by risk category

Cancer detection rates for the largest risk categories are presented in the table below

⁽¹⁾The national rate for cancers detected per 1,000 women screened in 2020-21, for women aged 45 and over is 9.1

⁽²⁾The national rate for invasive cancers detected per 1,000 women screened in 2020-21, for women aged 45 and over is 7.2

BRCA1 = Breast cancer gene 1, BRCA 2 = Breast cancer gene 2

By reporting region and sub-region

England, 2020-21

The South East region had the greatest number of women screened who were at higher risk of developing breast cancer.

Assessment ‘Further diagnostic tests’ that do not include ‘repeat examinations’⁹

Benign Not cancer. Not malignant. A benign tumour does not invade surrounding tissue or spread to other parts of the body¹⁰ .

Bilateral mastectomy Surgical removal of both breasts.

Biopsy A medical procedure that involves taking a small sample of tissue so that it can be examined under a microscope¹⁰.

Breast screening unit (BSU) In 2020-21 there were 78 breast screening units (BSU) in England which deliver local screening programmes.

Coverage The percentage of women in the population who are eligible for screening at a particular point in time (31 March 2021 in this report), who have had a test with a recorded result at least once within the screening round, i.e. in the previous three years. Currently coverage is best assessed using the 53-70 age group.

Cytology The medical and scientific study of cells. A branch of pathology, the medical specialty that deals with making diagnoses of diseases and conditions through the examination of tissue samples from the body¹⁰.

Eligibility Women are eligible for screening when in the screening age range, unless they are ceased due to the following: women who have had bilateral mastectomies. Note: Women who are excluded due to a best interests decision or who request to opt-out from screening will no longer receive invitations for screening but are included in the eligible population.

Fine-needle aspiration cytology Where samples of breast cells or fluid are drawn off through a very fine needle.

Incident Screening Screening of women who have been previously screened within the NHS Breast Screening Programme. In this statistical bulletin, incident screening figures relate only to routine invitations to previous attenders last screened within five years.

Invasive cancer Cancer which has spread beyond the layer of tissue in which it developed and is growing into surrounding, healthy tissues.

Magnetic resonance imaging (MRI) A type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body¹¹

Mammogram X-rays of each breast. Mammography can detect small changes in breast tissue which may indicate cancers which are too small to be felt either by the woman herself or by a doctor¹².

Mastectomy Surgical removal of the whole breast.

Non- or micro-invasive cancer A cancer which demonstrates no or only very slight invasion into adjacent tissues by malignant cells of a carcinoma in situ.

Open biopsy A minor operation to take one or more samples of tissue under general anaesthetic. Also known as excision or surgical biopsy.

Prevalent screening Screening of women never previously screened within the NHS Breast Screening Programme. In this statistical bulletin, prevalent screening figures relate to first invitations for routine screening and routine invitations to previous non-attendees.

Repeat examinations Repeat examinations include both those images repeated with the same view while the woman is still present in the unit, and those occasions when a woman is required to attend a second time to have a film repeated (same view) because of a technical inadequacy¹³.

Short term recall A second invitation to attend an assessment clinic at less than the routine (three year) screening interval¹³ .

Uptake The percentage of eligible women invited for screening in the year, who were screened adequately within six months of invitation¹⁴.

_{1. See glossary for definition of eligibility.}

_{2. Programme screening standards valid for data collected from 1 April 2017 https://www.gov.uk/government/publications/breast-screening-consolidated-programmestandards/nhs-breast-screening-programme-screening-standards-valid-for-data-collected-from-1- april-2017}

_{3. https://www.gov.uk/government/publications/breast-screening-consolidated-programme-standards}

_{4. https://www.gov.uk/government/publications/opting-out-of-breast-screening}

_{5. Short term recall is a non-routine invitation at less than a standard screening interval following assessment}

_{6. NHS Cancer Screening Programmes: http://www.nhs.uk/conditions/breast-cancer-screening/Pages/Introduction.aspx}

_{7. See https://www.gov.uk/government/publications/nhs-breast-screening-high-risk-women and https://www.gov.uk/government/publications/breast-screening-higher-risk-women-surveillance-protocols}

_{8. https://uksa.statisticsauthority.gov.uk/about-the-authority/what-we-do/uk-statistical-system/types-of-official-statistics/}

_{9. ‘Breast screening: consolidated programme standards’ https://www.gov.uk/government/publications/breast-screening-consolidated-programme-standards}

_{10. National Cancer Institute: https://www.cancer.gov/publications/dictionaries/cancer-terms}

_{11. NHS Choices - http://www.nhs.uk/Conditions/MRI-scan/Pages/Introduction.aspx}

_{12. NHS Breast Screening Programme: http://www.nhs.uk/conditions/breast-cancer-screening/Pages/Introduction.aspx}

_{13. ‘Guidance for breast screening mammographers ’, September 2020, NHS Breast Screening Programme https://www.gov.uk/government/publications/breast-screening-quality-assurance-for-mammography-and-radiography}

_{14. ‘Clinical guidance for breast cancer screening assessment ’, November 2016, NHS Breast Screening Programme https://www.gov.uk/government/publications/breast-screening-clinical-guidelines-for-screening-management}