An analysis of 11.3 million screening tests examining the association between recall and cancer detection rates in the English NHS breast cancer screening programme

  • R. G. BlanksEmail author
  • R. M. Given-Wilson
  • S. L. Cohen
  • J. Patnick
  • R. J. Alison
  • M. G. Wallis



To develop methods to model the relationship between cancer detection and recall rates to inform professional standards.


Annual screening programme information for each of the 80 English NHSBSP units (totalling 11.3 million screening tests) for the seven screening years from 1 April 2009 to 31 March 2016 and some Dutch screening programme information were used to produce linear and non-linear models. The non-linear models estimated the modelled maximum values (MMV) for cancers detected at different grades and estimated how rapidly the MMV was reached (the modelled ‘slope’ (MS)). Main outcomes include the detection rate for combined invasive/micro-invasive and high-grade DCIS (IHG) detection rate and the low/intermediate grade DCIS (LIG) detection rate.


At prevalent screens for IHG cancers, 99% of the MMV was reached at a recall rate of 7.0%. The LIG detection rate had no discernible plateau, increasing linearly at a rate of 0.12 per 1000 for every 1% increase in recall rate. At incident screens, 99% of the MMV for IHG cancer detection was 4.0%. LIG DCIS increased linearly at a rate of 0.18 per 1000 per 1% increase in recall rate.


Our models demonstrate the diminishing returns associated with increasing recall rates. The screening programme in England could use the models to set recall rate ranges, and other countries could explore similar methodology.

Key Points

• Question: How can we determine optimum recall rates in breast cancer screening?

• Findings: In this large observational study, we show that increases in recall rates above defined levels are almost exclusively associated with false positive recalls and a very small increase in low/intermediate grade DCIS.

• Meaning: High recall rates are not associated with increases in detection of life-threatening cancers. The models developed in this paper can be used to help set recall rate ranges that maximise benefit and minimise harm.


Breast neoplasms Mass screening Mammography Recall rate 



Trial age extension trial


Ductal carcinoma in situ


False positive (non-cancer) recalls


Korner return used to collect NHS data (breast screening return is no. 62)


Low/intermediate grade (DCIS)


Modelled maximum value


Modelled slope (how rapidly MMV is reached)


National Health Service Breast Screening Programme


Recall rate at which 95% of MMV is reached


Positive predictive value


The Surveillance, Epidemiology and End Results Program of the National Cancer Institute



The work arose from initial discussions at the Clinical Advisory Group for NHSBSP assessment work (members Roger Blanks, Claire Borrelli, Sue Cohen, Alison Duncan, Rosalind Given-Wilson, Jacquie Jenkins, Olive Kearins, Sarah Pinder, Mark Sibbering, Nisha Sharma, Jim Steel, Anne Turnbull and Matthew Wallis).


Roger Blanks and Rupert Alison receive funding from the Public Health England.

Compliance with ethical standards


The scientific guarantor of this publication is Prof. Julietta Patnick.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was not required for this study because there is no identifiable patient data.

Ethical approval

Institutional Review Board approval was not required because there is no identifiable patient data.


• retrospective

• observational

• multicentre

Supplementary material

330_2018_5957_MOESM1_ESM.doc (98 kb)
ESM 1 (DOC 98 kb)


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Cancer Epidemiology Unit, Nuffield Department of Population HealthOxford UniversityOxfordUK
  2. 2.Department of RadiologySt Georges University Hospital Foundation TrustLondonUK
  3. 3.Public Health EnglandLondonUK
  4. 4.Cambridge Breast Unit and NIHR Cambridge Biomedical Research CentreCambridge University Hospitals NHS TrustCambridgeUK

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