Breast screening QI module
About this module
Studies shows that strong primary health care involvement is associated with greater breast cancer screening participation rates. Specifically, the following primary health care activities have led to higher participation rates:
- adopting a patient centred approach by understanding your patient population to assist with identifying high risk populations and those people who are under screened or have never screened
- taking an all-practice approach
- having a general practitioner endorse a screening test invitation
- using recall and reminder systems
- participation in quality improvement programs incorporating audit and feedback on screening.
Watch the videos
Learn more about breast screening in primary care and view the instructional video on how to use this module.
- Breast Screening: a quick reference guide (PDF) to help you get started
- Breast Screening: QI activity - level 1 (PDF)
- Breast Screening: QI activity - level 2 (PDF)
- Breast Screening: QI activity - level 3 (PDF)
- An overview of breast cancer screening
- Patient centred care
- Team approach
- Quality Improvement
- Data and systems
Contact us: email@example.com
Breast cancer screening
Breast cancer is a collection of abnormal cells in the breast tissue that grow in an uncontrolled way. Finding breast cancer early improves survival. A mammogram is the best method to detect breast cancer early for women over the age of 50.1
Visit the Cancer Institute NSW website, for more information about breast cancer incidence, mortality and survival.
About BreastScreen NSW
- BreastScreen NSW is a population-based screening program funded by the Commonwealth and state governments. Managed by the Cancer Institute NSW, the program is delivered by nine Screening and Assessment Services which are located and managed within local health districts.
- BreastScreen NSW is a free service delivered at more than 200 screening locations across NSW. The service invites women aged 50–74 years to screen every two years.
- BreastScreen NSW is for asymptomatic women. Women with symptoms should be referred for diagnostic radiology.
Want more information?
Visit the BreastScreen NSW website.
The need to improve breast cancer screening participation
- Nearly half of eligible NSW women are overdue for a screening mammogram.1
- Mammograms can find very small cancers before they can be felt or noticed by an individual or a doctor. Early detection leads to better treatment outcomes.
- Women whose breast cancer is detected by BreastScreen NSW are less likely to need a mastectomy.2
- Breast cancer risk factors include family history, physical inactivity, alcohol consumption and smoking.
- 9 out of 10 women diagnosed with breast cancer do not have a family history of the disease,3 so regular screening is important for all women in the target age range.
- Screening rates are lower for women from Aboriginal communities.
Patient centred care
Knowing your patient population is essential to delivering patient-centred care. Having supportive systems and accurate information in clinical software is key to effectively identifying at-risk patients, so that you can ensure information is tailored and care is responsive to people’s individual needs and preferences.
Populations with lower levels of participation in cancer screening can experience higher cancer incidence and mortality.4,5,6 Communities less likely to participate in breast screening include:
- Aboriginal people
- Culturally and linguistically diverse people
- People with disability
- People of Diverse Genders and Sexualities
- People who live very remotely
- People in the lowest socioeconomic (SES) group
The Australian Institute of Health and Welfare BreastScreen Australia monitoring report provides national participation data on some of these communities.
- Understand your under-screened patient population by cleaning up your practice data and seeking support from your PHN. This will help you decide which population group/s your practice will prioritise.
- Seek patient feedback to understand what prevents women from screening and the actions your practice can take to promote screening as being safe, comfortable and accessible. The RACGP Patient feedback guide provides a comprehensive guide on methods for collecting and acting on patient feedback.
- Some women are apprehensive about having a mammogram. They may be embarrassed about the nature of the procedure, or feel anxious about pain or discomfort. The following statements from you may help women prepare for their appointment, and may reduce their level of concern:
- “The appointment will only take 20 minutes.”
- “All radiographers are female and you are screened in private.”
- “When you’re ready, the x-ray machine will press firmly on your breasts to take a picture.”
- “Your breasts will only be compressed for a few seconds; usually twice for each breast.”
- “You can talk to your radiographer about any discomfort or sensitivity. You can also ask them to stop the procedure at any time.”
- “BreastScreen NSW provides group bookings for some women – ask when you make your appointment.”
- BreastScreen NSW factsheets, posters and brochures developed by and for Aboriginal women.
- Cancer Institute NSW ‘What is cancer screening?’ factsheet and brochure (PDF) for Aboriginal communities explaining bowel, breast and cervical screening.
- BreastScreen Australia posters, brochures and videos about breast screening are available for Aboriginal women.
- BreastScreen Australia translated brochures about breast cancer screening in different languages.
- BreastScreen NSW multicultural resources available in different languages including brochures, posters and community service announcements.
- Cancer Institute NSW ‘Breast Health and Screening’ flipchart and facilitator manual which are educational tools to support those providing education on breast cancer and breast cancer screening to women and men from multicultural backgrounds.
- Cancer Institute NSW ‘What is cancer screening?’ factsheets and brochures explaining bowel, breast and cervical screening in different languages.
Do any of your patients need, or prefer to speak languages other than English?
Access an interpreter through the Translating and Interpreting Service (TIS National) Doctors Priority Line on 131 450.
- Women with additional needs can be screened by BreastScreen NSW. Women are advised to discuss their needs when making their appointment.
- BreastScreen NSW clinics and mobile vans can accommodate most wheelchairs.
- BreastScreen NSW staff are experienced in assisting women to safely complete their mammogram when adjustments are needed.
- Family Planning NSW ‘Just Checking’ website provides a range of information and resources for people with intellectual disability, and their carers, to support bowel, breast and cervical screening.
BreastScreen NSW is committed to meeting the needs of trans and gender diverse patients and provides information and training for staff.
It is recommended that people screen once every two years from the age of 50, if they currently have, or have ever had breast tissue. Breast/chest screening is recommended for trans people who:
- Have been on feminising hormones for 5+ years
- Have not had top surgery (mastectomy for gender alignment)
- Have had top surgery and have some remaining tissue
- Transhub provides additional information about communicating inclusively with trans and gender diverse patients about their needs and medical history such as breast/chest screening.
- It can be challenging for transgender people to access mainstream health services and for this reason it is important to support screening through a provider who is able to support transgender care such as BreastScreen NSW.
- BreastScreen NSW provides screening information for trans and gender diverse people.
- ACON’s ‘Our United Front’ campaign promotes the importance of breast cancer screening for all LGBTQ people with breasts, regardless of gender identity. This include trans men and non-binary people who have not had ‘top surgery’ (gender affirming double mastectomy).
- ACON’s ‘Talk Touch Test’ breast health campaign for all lesbian, bisexual, and queer women to increase awareness about the importance of breast checks and breast cancer screening.
The toolkit recognises that each team is unique. It provides examples of members’ roles and responsibilities in quality improvement projects. Having a team member who champions quality improvement within your practice can be the key to successful quality improvement activities.
Learn more information about team approach.
- Assessment process.
- BreastScreen NSW can provide GPs with progress updates if their patient provides details.
- BreastScreen NSW is rolling out the delivery of electronic results via compatible practice software.
While a doctor’s request is not required for BreastScreen NSW appointments, research shows that GP’s have a significant influence on your patient’s decision to screen. In fact, women are more likely to have a mammogram if they are advised by their GP than by anyone else.7
BreastScreen NSW practice visits
To arrange for a BreastScreen NSW professional to talk about breast screening at your practice, call BreastScreen NSW on 13 20 50 and ask to speak to a health promotion officer.
Flipcharts with pictures written in plain English or in language are a good way to talk to your patients about the breast screening experience. These are available from BreastScreen NSW.
Visit the Cancer Institute NSW's Information for Health Professionals
Cancer Institute NSW ‘What is cancer screening?’ factsheets and brochures for communities explaining bowel, breast and cervical screening in different languages.
Breast cancer treatment: Online modules for rural health professionals
Cancer Australia, in collaboration with the Australian College of Rural and Remote Medicine (ACRRM), has developed a series of online modules about breast cancer treatment and care for rural health professionals.
These modules are accredited with the following professional colleges:
- ACRRM for one core continuing professional development point.
- Royal Australian College of General Practitioners (RACGP) Quality Improvement and Continuing Professional Development Program (QI&CPD) for two Category 2 points.
- Royal College of Nursing Australia (RCNA) for one continuing professional development (CPD) hour as part of RCNA’s Life Long Learning Program (3LP).
For more information, visit the Cancer Australia website.
GPs play a key role in ensuring that program participants progress through the screening pathway. GPs can encourage patients to participate in breast screening by:
- encouraging women to screen if it is clinically relevant for them
- providing patients will clinical advice to assist them to make informed decisions
- recommending BreastScreen NSW as a quality service
- managing patients who are at increased risk of breast cancer as per the NHMRC-approved guidelines. See iPrevent for risk assessment and management
- managing patients (of any age) with symptoms as per the NHMRC-approved guidelines.
- acting as a clinical champion for breast screening and quality improvement activities in your practice.
What is iPrevent?
iPrevent™ is a breast cancer risk assessment and risk management decision support tool designed to facilitate prevention and screening discussions between women and their doctors
Practice nurses have an important role to play in encouraging and supporting patients to participate in breast screening. Primary Care Nurses can encourage patients to participate in breast screening by1:
- promoting BreastScreen NSW and breast screening in your practice
- conducting a screening audit of practice records
- talking to women aged 49 to 74 about screening
- sending a letter to 49-year-old women to encourage participation in the program
- referring patients (of any age) with symptoms to a GP
- being a clinical champion for breast screening and quality improvement activities.
Practice management and administrative staff play an important role in the organisation and delivery of services within general practice. In relation to breast cancer screening, management and adminstrative staff can:
- support systems in cancer screening
- oversee and support data and systems with up to date patient records
- direct patients to available cancer screening information in the practice
- engage in QI activities by supporting practice facilitation or technical expertise.
Aboriginal Community Controlled Health Services (ACCHS) have an important role to play in supporting Aboriginal women to screen:
- Support early detection and diagnosis of breast cancer.
- Provide strategies to encourage participation in breast screening.
- Provide culturally appropriate early assessment, diagnosis, surveillance and treatment pathways.
- Encouraging Aboriginal patients to have their annual 715 assessments, which includes cancer screening.
Information on BreastScreen NSW's 'PUTUWA' pilot project
Aboriginal women are diagnosed at an earlier age and with more advanced breast cancers. BreastScreen NSW is delivering a pilot project in 2022 to engage Aboriginal women aged 40-49 years in breast screening. Key messages will be updated to general practice to support the implementation of the pilot which will involve active recruitment of Aboriginal women from 40 years.
Ngununggula - Walking and Working Together: A manual for health professionals supporting Aboriginal people with Cancer
Developed by The Illawarra Aboriginal Medical Service. This project has been a collaboration between AH&MRC, University of Sydney (Michelle Dickson), UOW, and Menzies SHR and Coordinare PHN, and funded by Cancer Australia.
Quality Improvement (QI) encompasses a combination of factors that can improve processes and systems within your practice, which ultimately improve patient outcomes.
Refer to the Breast Screening: a quick reference guide (PDF) which will help your practice to assess current processes in place to encourage participation in breast screening and where improvements can be made.
The Quick Reference Guide includes a breast cancer screening readiness checklist and example Model for Improvement based on the Plan Do Study Act cycle (PDSA).
Quality Improvement (QI) activities in relation to breast cancer screening can be broken down into three categories, depending on how engaged your practice is with QI.
Level 1 QI Activities
Introductory level, starts with improving data quality. Level 1 QI ideas include:
Identify under screened or never screened patients who are at higher risk of developing breast cancer, utilising a clinical audit tool. Filter for women (People of Diverse Genders and Sexualities) aged between 50 and 74 years with a mammogram recorded in the past 2 years, between >2 years and 3 years ago, between >3 years and 4 years ago,>4 years ago.
Perform a data clean within clinical software, for example: marking relevant patients as ‘inactive’, delete or update all reminders/recalls once complete, create a defined list of breast screening reminder codes.
Consider high risk populations as a focus in those identified.
Download the Breast Screening: QI activity - level 1 (PDF)
Level 2 QI Activities
Clinical level, based on addressing breast cancer screening at a clinical level with activities focussed on care delivered by GPs and nurses. Level 2 QI ideas include:
- Incorporate breast screening questions (e.g. screening history and family history) and advice into health assessments
- Put in place processes and systems for clinician reminders within your clinical software, that prompts clinicians when age-eligible patients are due or overdue for breast cancer screening
Download the Breast Screening: QI activity - level 2 (PDF)
Level 3 QI Activities:
Practice level, the team may choose to focus on breast cancer screening as a major focus area for the practice. Level 3 QI ideas include:
- Support priority populations (e.g. Aboriginal, culturally and linguistically diverse, or rural and remote populations) to undertake screening for breast cancer. Some strategies to consider:
- For older women, consider following up reminder letters with phone calls.
- For multicultural and refugee women, liaise with relevant community groups, offer language-specific education sessions and assist with transport requirements.
- For Aboriginal women, liaise with your local ACCHO. Establish connections with female Aboriginal Health Workers and explore opportunities, this may include community “yarning” sessions.
- Partner with your local breast screening and assessment service to encourage women to be screened and create a practice environment that promotes breast screening. If in a rural area serviced by BreastScreen mobile van it is helpful to link promotions to the mobile van schedule. View the mobile van schedule. Contact BreastScreen NSW for further information
Data and systems
Good data and systems provide insight and understanding about your practice population who are eligible for breast screening. Understanding your practice population allows you to deliver targeted activities and supports staff to drive increased participation in breast screening.
Refer to the information below for tips on improving the quality of your breast screening data and systems.
Learn more information about data and systems.
The Cancer Institute NSW provides PHNs with LGA and local data on cancer screening rates in NSW.
Use the lists of test results in the links below to check that the breast cancer screening results used by your pathology and radiology providers are recognised by the software that you use to create patient reminder lists (i.e. data audit tools or your practice software). This will ensure that your practice generates accurate breast cancer screening participation statistics and identifies patients who are due for screening.
Recognised breast screening test results
For patients whose BreastScreen NSW result has not been recorded using one of the listed pathology codes, you will need to manually enter their test result.
A high-quality recall and reminder system for breast cancer screening will allow your practice to:
- systematically remind all eligible patients about breast cancer screening (often reminders are only set for when a result comes in, overlooking patients who are not screening)
- identify and appropriately engage under-screened patients
- support clinicians to deliver better care to patients who are under-screened
- track your breast cancer screening participation rates (which is key to knowing whether what you are doing is working or not).
It is important that the way your practice handles breast cancer screening recall and reminders is consistent. If you have multiple labels/codes for the same recall reason, it is difficult to accurately undertake recall searches.
Download breast screening recall and reminder labels/codes (PDF).
Stand Up to Cancer: How to use CAT plus to better manage cancer
Data-driven improvement in healthcare starts with correctly coded and up-to-date patient records. This guide demonstrates how to improve the data quality of your patient records and then focuses on cancer specific activities.
It is important to understand what diagnoses are excluded from breast cancer screening by your practice software to minimise the chance of sending a screening reminder to a patient inappropriately.
In addition to patients for whom “Not required” or “Excluded” has been manually selected in practice software, patients with the diagnoses listed in the link below will also be automatically excluded from breast cancer screening eligibility lists:
|Software provider||Breast cancer screening exclusions||Viewing patients excluded from breast cancer screening|
|Diagnosis codes that PEN uses to assign patients to ‘ineligible’||When you complete cancer screening searches using the provided recipes a pie chart will be produced, a section of which are ‘ineligible’, click on this section and export a list to excel using the standard process.|
- Have an appropriate staff member (practice nurse or GP) review the list to identify any patients who may be eligible to return to breast cancer screening.
- periodically review patients who have been excluded from breast cancer screening to assess the appropriateness of them returning to screening, based on clinical guidelines.
- If any patients are identified as being eligible to return to screening, it is important that the reason for the decision is explained to them prior to inclusion back into screening reminder processes.
Paper-based BreastScreen NSW results are sometimes managed in a way that cannot be ‘read’ by practice software or data audit tools, meaning that participation statistics and lists of under-screened patients are incorrect.
- CAT4 will not recognise paper-based BreastScreen NSW results recorded via a practice software’s conditions, past history, investigations, correspondence in, reason for visit or past history functions.
- CAT4 will only pick up test results that are listed here.
To resolve this issue and help establish more accurate breast cancer screening participation data, your practice needs to decide whether to prospectively (correctly record breast screening results from this point forward) or retrospectively (review patient files to ensure breast screening results have been recorded correctly) clean up your patient data.
Pros and cons of retrospective versus prospective data clean-up
Retrospective pros and cons
Accurate participation figures established faster
Accurate reminder list established faster
Time required to clean up data can limit engagement in other areas of cancer screening quality improvement
Higher level of certainty that you are reminding all eligible patients to attend BreastScreen NSW
Time required may limit practice decision-makers’ support for cancer screening quality improvement
Prospective pros and cons
Avoids the team getting ‘bogged down’ by data cleaning
|It may take up to two years to be able to generate an accurate list of patients overdue to attend BreastScreen NSW|
Allows more time to focus on other cancer screening quality improvement activities
If you want to send BreastScreen NSW reminders from your practice, manual review of reminder lists will be required until the data is clean
There are no MBS item numbers that cover mammography for screening of asymptomatic patients. A woman sent to a private provider for a screening mammogram may incur the full cost of the service.
Diagnostic radiology may be necessary for women who are symptomatic or women who are have been identified at higher risk.
Sometimes practices refer women to private providers for mammograms who should be directed to BreastScreen NSW. There are no MBS item numbers that cover mammography for screening of asymptomatic patients. A woman sent to a private provider for a screening mammogram may incur the full cost of the service.
Diagnostic radiology is appropriate for:
- a woman who has symptoms or clinical abnormalities
- a women who is under 40 and at high risk of developing breast cancer.
Diagnostic radiology is optimised to solve diagnostic problems. It has increased sensitivity and may have reduced specificity, this is appropriate for symptomatic women but may create a risk of ‘over-biopsy’ in asymptomatic women.
Your practice may wish to review patients who have had a mammogram through a private imaging provider to identify which of these women should be redirected to BreastScreen NSW for their next mammogram. There are two options to generate these lists of patients:
- Extract a list of patients aged 50–74 who have had a bilateral mammography result from a diagnostic imaging provider, OR
- Request a list from your preferred diagnostic imaging provider/s of your patients aged 50–74 who have had a bilateral mammogram under item numbers 59300/59301.
If your practice meets the pre-requisites for receiving BreastScreen NSW results electronically, then you should have been receiving electronic results since late 2018.
The pre-requisites are as follows:
Your practice must have an active account with Medical Objects or HealthLink.
- Your practice must use either Medical Director or Best Practice software.
- Your practice must be based in NSW or border-sharing locations.
Once secure messaging from BreastScreen NSW is enabled at your practice, the following results will be delivered electronically to your practice software, and will no longer be delivered via post:
Normal Result: No evidence of breast cancer detected.
- Normal Result: No evidence of breast cancer detected, but a breast change was reported; GPs to follow up.
- Recall to Assessment: Client to attend BreastScreen NSW Assessment Clinic.
- Assessment Outcome Report of clients who have NOT undergone biopsy.
If your practice does not have the above-mentioned prerequisites, it will be unaffected by this change and continue to receive all BreastScreen NSW results via post/fax.
Useful information and resources
- Frequently asked questions about BreastScreen NSW’s electronic transmission of results (PDF)
- A ‘quick guide’ to electronic BreastScreen NSW results in Medical Director (PDF)
- A ‘quick guide’ to electronic BreastScreen NSW results in Best Practice (PDF)
- Entering Breast Screening Results Medical Director (PDF)
- Entering Breast Screening Results Best Practice (PDF)
If your practice is not currently eligible for electronic results, it is very important to work with your practice team to introduce and maintain consistent management of paper-based results.
Ensuring paper-based BreastScreen NSW results are coded in the results section of your practice software (using test result names) will enable the use of CAT4 or POLAR to identify women overdue for screening and to monitor BreastScreen NSW participation rates in your practice.
Connecting with patients through provision of cancer screening reminders is an important preventative activity. Patients who are reminded by their GP are more likely to screen. The RACGP’s Putting prevention into practice lists organisational change and targeted reminders systems as the two most effective implementation strategies for improving preventative care in general practice (p.42).9
Breast Cancer Screening in health assessment and GPMP templates
The recall and reminder workflow (PDF) incorporates breast cancer screening into existing preventative practices for Aboriginal people, and those with (or at risk of) chronic disease. This is an excellent way to provide integrated person-centred care and lift screening participation rates among people who are not screening, or may have an increased risk of cancer due to age and/or lifestyle risk factors.
The breast cancer screening information below can be attached or embedded into your templates for Aboriginal and Torres Strait Islander health assessments (MBS item 715), 45 to 49 year old health assessments and GP Management Plans (GPMPs) and GPMP reviews:
|Goals (changes to
|Required treatments and services, including patient actions||Arrangements for treatments/
services (when, who and
Breast cancer screening
Patient understand the benefits of breast cancer screening.
Patient attends BreastScreen NSW every two years from ages 50–74.
The patient has increased familial or clinical risk and is screening as per clinical guidelines.
Date of last breast screening result: _____________
GP or patient to book a free mammogram by:
GP to set a screening reminder (if appropriate).
Establishing your baseline participation rates for breast cancer screening will allow you to:
Benchmark your performance against state averages.
Compare your actual performance against your perceived performance (practices often find that screening participation in their practice is lower than anticipated).
- Track your improvement over time as a result of your breast cancer screening quality improvement activities.
Before you begin, it is important to decide:
where you will record your participation rates.
how often you will monitor your participation rates (quarterly is recommended, as this allows some time to see change).
- how you will share and celebrate progress with the practice team (team newsletters, lunchroom display, team meetings, etc.).
|70%: The percentage of women aged between 50–74 years with a recorded result for a mammogram conducted in the previous 2 years.||Co-designing quality end of life care for culturally and linguistically diverse people with cancer|
Numerator: The number of active female patients, aged 50–74 years, who have had a bilateral breast screen mammogram within the previous two years.
Denominator: The number of active female patients aged 50–74 years eligible for a screening mammogram.
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Extracting breast cancer screening baseline data
If you are undertaking prospective clean-up of your BreastScreen NSW data:
- your BreastScreen NSW participation rate will become more accurate over time
- changes to your participation rate will reflect both improvements in data and increases in participation resulting from cancer screening quality improvement activities.
CAT recipe - Breast cancer screening participation rate
Once you have undertaken data quality and system improvements that have supported an improvement in screening mammogram results management, you may find that you have gaps in your data.
Consider requesting a list of women in your practice who have attended BreastScreen NSW
Use the ‘BreastScreen NSW GP Form’ to request a list of women who have attended BreastScreen NSW and listed a doctor from your practice as their GP. It is recommended that you have reformed your results management process before undertaking this activity.
1. Cancer Institute NSW. NSW Cancer Plan Performance Index. Available at https://www.cancer.nsw.gov.au/cancer-plan/performance-index (accessed 19 Feb 2019).
2. Shahabi-Kargar Z, Johnston A, Warner-Smith M, Creighton N, Roder D. Differences in breast cancer treatment pathways for women participating in screening through BreastScreen New South Wales (BSNSW). AMJ 2020; 13(6):189–200.
3. Cancer Institute NSW. About breast cancer. Available at https://www.breastscreen.nsw.gov.au/breast-cancer (accessed 17 August 2021).
4. Australian Institute of Health and Welfare. Access to health services by Australians with disability. Canberra: AIHW, 2017.
5. Carroll, B. Women’s Cancer Screening Program Consumer Research: Project Completion Report. Ballina, NSW: North Coast Primary Health Network, 2018.
6. Eastgate G, Scheermeyer E, van Driel M, Lennox M. Intellectual disability, sexuality and sexual abuse prevention – a study of family members and support workers. Aust Fam Physician 2012;Vols.41:135–9
7. Cancer Institute NSW. Information for health professionals: your role in breast screening. Available at https://www.breastscreen.nsw.gov.au/information-for-health-professionals/your-role-in-breast-screening (accessed 19 Feb 2019).