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Breast awareness and screening

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How improving breast awareness and screening uptake can help increase survival rates

In this article…

  • How to practise effective breast awareness
  • Breast cancer symptoms and risk factors for the disease
  • What nurses can do to improve breast awareness and screening uptake
  • The NHS Breast Screening programme


Victoria Harmer is clinical nurse specialist, breast care unit, Imperial College Healthcare Trust, London.


Harmer V (2011) Breast awareness and screening. Nursing Times; 107: 25, early online publication.

Breast cancer is the most commonly diagnosed cancer in the UK. Breast awareness and screening, along with better treatment, can significantly improve outcomes, and more women than ever are now surviving the disease.

This article discusses breast awareness and screening, symptoms and risk factors for breast cancer, and how nurses can raise breast awareness and screening uptake.

Keywords: Breast awareness/Breast cancer/Breast screening

  • This article has been double-blind peer reviewed


5 key points

  • The majority of breast cancers are detected by women checking their breasts and being breast aware
  • Symptoms include changes in breast shape or size, dimpling or puckering of the skin, and changes in nipples
  • Risk factors include bineg a woman, increasing age, history of breast cancer, early menarche and late menopause
  • Nurses can help improve breast awareness. Survival can be improved by raising awareness of screening, particularly among minority groups
  • All UK women aged 47-73 should be invited for screening every three years. Survival after treatent is directly related to stage at diagnosis

Breast cancer is the most commonly diagnosed cancer in the UK, with around 46,000 new cases diagnosed every year. One in eight UK women will develop breast cancer at some point (Cancer Research UK, 2011a), and around 1,000 women die of it in the UK every month (CRUK, 2009).

However, increasing numbers of women are surviving breast cancer thanks to better awareness, screening and treatment. The five-year relative survival rate for UK women with breast cancer is 83.3%, compared with 50% for those diagnosed between 1971 and 1975 (Office for National Statistics, 2005) (Box 1).

Box 1. facts

  • Breast cancer is the most commonly diagnosed cancer in the UK
  • Nearly 46,000 women are diagnosed with it each year in the UK
  • One in eight women in the UK will develop breast cancer at some point
  • Around 1,000 women die of breast cancer every month in the UK
  • Around 300 men are diagnosed with breast cancer every year in the UK
  • More women than ever in the UK are surviving breast cancer thanks to better awareness, better screening and better treatments
  • The five-year relative survival rate for women with breast cancer is now estimated to be 83.3% compared with 50% for women diagnosed in 1971–75

Sources: CRUK (2011a), CRUK (2009); Office for National Statistics (2005)

This article discusses breast awareness, and breast cancer symptoms and risk factors. It explores the NHS Breast Screening Programme, and what nurses can do to promote breast awareness and screening.

Breast awareness

The majority of breast cancers are detected by women checking their breasts and being “breast aware” – knowing what their breasts look and feel like normally.

Breast awareness should be practised at the same time each month. For premenopausal women, this is at the end of menstruation when breasts are less dense; postmenopausal or pregnant women should check their breasts on the same day each month.

Breast awareness can be performed standing up, lying down or in the shower. Some women find it helpful to use soap or a moisturiser to help the hand to glide over the breast.

The shape of the breast should be examined first in the mirror, checking the position and direction of the nipples examined and looking for any skin dimpling. Lumps should be checked for using the flats of the fingers, and nipples for any rash or scabbing (Leonard, 2007). All parts of the breast should be checked, as well as the armpits and the area up to the collarbone (Breast Cancer Care, 2010). The Department of Health (2006) has produced a five-point code for breast awareness (Box 2).

Box 2. awareness five-point code

  • Know what is normal for you
  • Look and feel
  • Know what changes to look for
  • Report any changes without delay
  • Attend breast screening every three years when invited

Source: DH (2006)

Breast cancer symptoms

Symptoms to look for include:

  • Changes in the shape or size of either or both breasts;
  • Dimpling or puckering, like the skin of an orange, of the skin of either or both breasts;
  • Changes in either or both nipples. This includes changes in the appearance of the nipple, the direction it is pointing, if it becomes inverted, or if there is any clear or blood-stained discharge;
  • Redness, rash or eczema;
  • Thickening or lumps in the breast or axilla;
  • Constant pain in one or both breasts or axillas.

Women with any of these symptoms, should see their GP or practice nurse to be referred to a breast unit. It is important to practise breast awareness during pregnancy, and keep an eye on any changes.

Risk factors

These are listed in Box 3. It has been known for many years that gender, increasing age, and reproductive and menstrual factors increase the risk of developing breast cancer. Other factors, such as obesity and alcohol intake, have also been discovered.

Box 3. risk factors

  • Being female
  • Increasing age
  • Early menarche
  • Late menopause
  • Having a first child after age 30 or having no children
  • Breastfeeding – reduces risk
  • HRT usage for over 10 years – raises risk
  • Family history – about 5-10% cases are thought to be genetic (Ardern-Jones, 2011)
  • History of breast cancer
  • Benign breast disease
  • Oral contraceptive pill – a small rise that stops 10 years after pill cessation
  • Mantle radiotherapy for Hodgkin’s under 30-35 years – regular screening needed
  • Alcohol intake
  • Obesity
  • Height – inconsistency in research – 5’9” or taller

Source: Grimsey (2011)

Alcohol: Every unit of alcohol consumed per day increases the risk of breast cancer by between 7% and 12%. This is independent of race, weight, family history, height, use of hormone replacement therapy, reproductive or menstrual factors (CRUK, 2011b);

Obesity: there is a complicated correlation between obesity and breast cancer. Obesity before menopause has been related to a lower premenopausal breast cancer risk while obesity after menopause has been related to a moderate increase in postmenopausal breast cancer (CRUK, 2011b). This is because obesity in premenopausal women is thought to interfere with ovulation (Key et al 2004), thus reducing circulating hormones. In postmenopausal women, oestrogen is synthesised in fat, and obese women with more fat will produce more hormones (CRUK, 2011b).

Height: Taller women have a small increased risk of developing breast cancer. The evidence on this is inconsistent, but it may be due to these women having more breast tissue (CRUK, 2011b).

Health promotion and education

Health promotion and education are vital in promoting breast awareness and screening.

Becoming breast aware is a simple and effective part of health promotion, and one that staff can easily endorse and facilitate (Harmer, 2009). Health promotion enables people to increase their control over and to improve their health (Harmer and Royston-Lee, 2011).

Breast awareness leaflets are available from breast cancer charities and health authorities. These are useful for teaching awareness and as a resource or memory aid.

NHS Breast Screening Programme

The NHS Breast Screening Programme was introduced in 1988. The aim was to reduce mortality from breast cancer by 25% in those screened (Harmer, 2008).

All women aged 50-70 should receive a screening invitation every three years; this programme will include those aged 47-73 by 2012. The programme has an uptake rate of 75% (NHS Cancer Screening Programme, 2006).

The breast screening programme has a budget of around £75m. This equates to around £37.50 for each woman invited, £45.50 per woman screened, and around £3,000 for every year of life saved (NHS CSP, 2006). This compares with an estimated five-year cost of £36,804 to treat a person with breast cancer (Karnon et al, 2007). This figure is thought to be an underestimate as it does not include expensive drugs available today (Gordon et al, 2011).


Survival after diagnosis and treatment is directly related to stage at diagnosis.

In 2009-10, 14,229 cases of breast cancer were diagnosed in women screened aged 45 and over, a rate of 7.9 per 1,000 women screened. Of the invasive cancers detected,  41.6% were 15mm or smaller, and could not have been detected by hand (NHS Information Centre, 2010).

Screening uptake

Black and minority ethnic women have less knowledge about breast cancer and have a lower uptake of breast screening (Scanlon and Wood, 2005). Partner gender (lesbian, bisexual or heterosexual) does not affect screening uptake; better educated women are more likely to attend (Clark et al, 2009; Oran et al, 2008).

Women with learning difficulties are less likely to attend breast screening (Sullivan et al, 2003; Davies and Duff, 2001). This may be due to vulnerability, communication problems or a low sense of worth (Bollard, 2002; Martin et al, 1997). Specialist patient information for people with learning difficulties on screening is available from charities and the DH.

Disadvantages of screening

Screening has been criticised for leading to overtreatment of pre-invasive disease, which may not develop into cancer (Fretwell, 2011).It results in 30% more surgery, 20% more mastectomies, and more radiotherapy due to overdiagnosis (Raffle and Gray, 2007; Gotzsche and Nielsen, 2006; Vainio and Bianchini, 2002). Patients are 10 times more likely to be overdiagnosed after mammography than to avoid death from breast cancer (Gotzsche and Nielsen, 2006; Jorgensen and Gotzsche, 2006). Gotzsche et al (2009) said screening 2,000 women regularly for 10 years would benefit one who would avoid dying from breast cancer, but 200 healthy women would experience a false alarm that could cause anxiety.

Around half of breast cancers requiring treatment are found between screens (these are called interval cancers), so screening can lead to a false sense of security (Vainio and Bianchini 2002). However, the prognosis for women with interval cancers is better than for those who have never attended screening (Moss et al, 1993).


This article has shown how to be breast aware and what symptoms to report, the risk factors for breast cancer and the theory of the breast screening programme.

More inclusive breast awareness education that is relevant to and appropriate for a diverse population is needed. Screening also needs to focus on increasing the numbers of attendees from deprived and multi-ethnic communities.

Health professionals should be an effective resource for breast screening and awareness, and champion healthy lifestyles. This will help to increase personalresponsibility for health, increase screening uptake and breast awareness, and help people make better lifestyle choices.

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