Why does breast screening stop at 71 in the UK?

Breast cancer risk increases with age, yet the UK's NHS Breast Screening Programme stops automatically inviting women for screening once they reach their 71st birthday. Understanding the evidence-based rationale behind this policy is essential for women considering their options for continued care.

Quick Summary

The cessation of automatic NHS breast screening invitations at age 71 is based on the evolving balance of benefits and harms, including a higher risk of overdiagnosis in older women where a cancer might not become life-threatening. It is not a hard stop, and women over 71 can continue screening every three years by making a self-referral.

Key Points

• End of Automatic Invitations: The NHS stops sending automatic breast screening invites at age 71, shifting to a self-referral system.

• Changing Risk-Benefit Ratio: Beyond 71, the potential harms of screening, like overdiagnosis, become more significant relative to the benefits.

• Higher Overdiagnosis Risk: Older women face an increased risk of overdiagnosis, where slow-growing cancers are found and treated unnecessarily.

• Emphasis on Shared Decision-Making: The policy encourages women and their doctors to have a personalized discussion about the pros and cons of continued screening based on overall health.

• Right to Self-Refer: Any woman over 71 can continue to receive free, triennial NHS breast screening by contacting her local unit.

• Importance of Breast Awareness: Regardless of screening choices, all women, including those over 71, should remain vigilant for breast changes and report any concerns to their GP.

The NHS Screening Policy Explained

The National Health Service (NHS) Breast Screening Programme automatically invites women registered with a GP for triennial screening between the ages of 50 and 71. Once a woman turns 71, these automatic invitations cease. However, this does not mean screening is no longer available; rather, the responsibility shifts from an automatic invite system to a voluntary, self-referral basis. Women over 71 can request screening every three years by contacting their local breast screening unit.

The Shift in the Risk-Benefit Ratio

The primary reason for the shift in policy at age 71 is the changing risk-benefit ratio of mammographic screening in older age groups. For women between 50 and 71, the benefits of screening—primarily the reduction in breast cancer mortality—clearly outweigh the potential harms. However, the evidence is less certain for women over 71.

Key considerations for older women include:

• Higher Overdiagnosis Rate: As women age, the risk of overdiagnosis increases significantly. Overdiagnosis occurs when screening detects a cancer that would never have progressed or caused problems during the woman's lifetime. A Yale study found that overdiagnosis risk substantially increases after 70, with some estimates suggesting over 30% of screen-detected cancers in women 70-74 might be overdiagnosed, rising further with age.
• Increased Competing Risks: Older women are more likely to die from other health conditions, such as heart disease, rather than from a slow-growing breast cancer. This means that for some older women, treating a slow-growing breast cancer found via screening may not improve their overall life expectancy but could significantly reduce their quality of life due to invasive treatments.
• Limited Evidence: The randomized controlled trials that proved the mortality benefits of breast screening primarily involved women under the age of 70. There is less direct evidence regarding the effectiveness and optimal screening strategy for women over 70. The AgeX trial, which extended the screening age range in some areas of England to 73, was designed to provide more evidence but is not the basis for the current national policy.

The Importance of Shared Decision-Making

Given the complexity of the risks and benefits, shared decision-making is a critical aspect of senior care. Instead of an automatic system, the NHS policy requires women over 71 to self-refer, prompting a conversation with their GP or healthcare provider about their personal health and preferences. This allows for a more personalized approach, considering factors such as overall health, life expectancy, potential impact of treatment, and personal values.

The Decision to Continue Screening

For many women, the decision to continue breast screening after 71 is a very personal one. A healthcare professional can help weigh the pros and cons based on individual circumstances. The benefits of early detection remain, but they must be balanced against potential harms like overdiagnosis, which becomes more common with age. Additionally, the treatment for screen-detected cancers can be more burdensome for older individuals who may have other health conditions.

Benefits and Harms: A Comparison Table

Feature	Benefits of Continued Screening (Age 71+)	Potential Harms of Continued Screening (Age 71+)
Early Detection	May find breast cancer early, when treatment is most effective.	Risk of overdiagnosis: finding and treating a cancer that would not have become life-threatening.
Treatment Options	Early diagnosis can lead to less invasive treatment options, like a lumpectomy.	Overtreatment: undergoing unnecessary surgery, radiotherapy, or chemotherapy for a harmless cancer, potentially impacting quality of life.
Reduced Mortality	Some studies suggest screening reduces breast cancer mortality in this age group, though evidence is limited and often based on different populations.	Potential for little or no reduction in overall mortality, especially if other health issues are present.
Anxiety	Can provide reassurance and peace of mind from a clear result.	False positives can cause significant anxiety and distress, leading to unnecessary follow-up procedures.
Screening Process	Regular check-ups can empower women to be proactive about their health.	Mammograms can be uncomfortable or painful for some women.

Alternatives and Next Steps for Older Women

For women who decide against continued routine mammography, or alongside it, several important steps can be taken to monitor breast health:

1. Be Breast Aware: Continuing to be aware of how your breasts normally look and feel is crucial at any age. Women should regularly perform checks and report any unusual changes to their GP immediately, regardless of their screening history.
2. Clinical Breast Exam: Regular examinations by a healthcare professional can be an effective way to detect lumps or other changes.
3. Personalized Consultations: The shift to self-referral encourages a discussion with a GP. This allows for a tailored approach based on individual risk factors, family history, and overall health status.

What the Research Says

Research continues to evolve regarding the best practices for older women. For example, some studies, such as the UK Age trial, have focused on younger women but highlight the complex nature of screening benefits. Another recent study highlights that while screening can find early-stage cancers in older women, it must be balanced against the risk of overdiagnosis. A key resource for understanding the complexities is the UK National Screening Committee's website, which outlines the evidence base for national screening programmes.

Conclusion: Making an Informed Choice

While the automatic invitation for breast screening in the UK stops at 71, this is a strategic public health decision based on balancing benefits and harms for a broad population. It is not an arbitrary cut-off or an indication that breast cancer risk has vanished. The policy empowers women to make an informed, personal choice about continuing with screening. By understanding the potential for overdiagnosis versus the benefits of early detection, and by discussing their individual situation with a healthcare professional, women over 71 can decide on the best path for their ongoing health and wellbeing.

Breast Awareness: Beyond Screening

Regardless of a woman's screening decision, being 'breast aware' is a lifelong practice. This involves regularly checking your breasts for changes and knowing what is normal for you. Changes to look out for include:

• A new lump or thickening in your breast or armpit.
• Changes to the skin on your breast, such as dimpling or puckering.
• Changes in the size or shape of your breast.
• Any unusual nipple discharge.
• Changes in the position of your nipple.
• A rash or redness on your breast or nipple.

By staying vigilant and maintaining open communication with your GP, you can ensure that any potential issues are addressed promptly. The end of automatic invitations is the beginning of a more personalized and dialogue-driven approach to senior breast health.

Frequently Asked Questions

Does breast cancer screening stop completely in the UK at age 71?

No, breast screening does not stop completely. The NHS stops automatically inviting women at 71, but you can continue to be screened every three years by contacting your local breast screening unit to arrange an appointment.

Why is overdiagnosis a greater concern for older women?

For older women, the risk of overdiagnosis is higher because they are more likely to have other health conditions that may become life-threatening sooner than a slow-growing breast cancer found through screening. This means they may undergo unnecessary treatment with associated side effects.

How do I arrange a mammogram after my 71st birthday?

You will need to contact your local NHS breast screening unit directly to book an appointment. Your GP can provide the contact details for your nearest service.

Is it safe for a woman over 71 to continue breast screening?

The safety and benefits depend on individual circumstances. While the risk of overdiagnosis increases, screening can still detect early-stage cancers. A discussion with a healthcare provider is recommended to weigh the risks and benefits based on your overall health and life expectancy.

Does having a family history of breast cancer change the policy?

The standard automatic invitation policy applies to average-risk women. If you have a strong family history, you may already be on a different screening pathway determined by a genetics clinic, which can extend beyond the age of 71.

What is meant by shared decision-making regarding breast screening?

Shared decision-making is the process where a woman and her healthcare provider discuss the benefits and harms of continued breast screening after 71. This allows the woman to make an informed choice that aligns with her personal health, values, and preferences.

Are there other options for monitoring breast health besides mammograms after 71?

Yes, it is important to remain 'breast aware' by regularly checking for any changes in how your breasts look and feel. Any concerns should be discussed with your GP, who may recommend a clinical breast exam or other diagnostic tests.