Effect of population breast screening on breast cancer mortality up to 2005 in England and Wales: an individual-level cohort study

Background: Population breast screening has been implemented in the UK for over 25 years, but the size of benefit attributable to such programmes remains controversial. We have conducted the first individual-based cohort evaluation of population breast screening in the UK, to estimate the impact of the NHS breast screening programme (NHSBSP) on breast cancer mortality. Methods: We followed 988 090 women aged 49-64 years in 1991 resident in England and Wales, who because of the staggered implementation of the NHSBSP, included both invited subjects and an uninvited control group. Individual-level breast screening histories were linked to individual-level mortality and breast cancer incidence data from national registers. Risk of death from breast cancer was investigated by incidence-based mortality analyses in relation to intention to screen and first round attendance. Overdiagnosis of breast cancer following a single screening round was also investigated. Results: Invitation to NHSBSP screening was associated with a reduction in breast cancer mortality in 1991-2005 of 21% (RR = 0.79, 95% CI: 0.73-0.84, P<0.001) after adjustment for age, socioeconomic status and lead-time. Breast cancer deaths among first invitation attenders were 46% lower than among non-attenders (RR = 0.54, 95% CI: 0.51-0.57, P<0.001) and 32% lower following adjustment for age, socioeconomic status and self-selection bias (RR = 0.68, 95% CI: 0.63-0.73, P<0.001). There was little evidence of overdiagnosis associated with invitation to first screen. Conclusions: The results indicate a substantial, statistically significant reduction in breast cancer mortality between 1991 and 2005 associated with NHSBSP activity. This is important in public health terms.