Healthcare is provided exclusively or mainly by public authorities, reflecting the European tradition of universal public coverage in health care in 88 % of the 25 countries included in the survey performed by the Joint Research Centre [7]. However, each health care system in Europe has a unique composition, which reflects the history, the political context and the financial means of each country. The systems have great influence on how the screening programmes are organised and managed [8]. The Netherlands, Germany, Iceland, Norway, and UK have national population-based screening programmes with national recommendations and organisation, while Belgium, France, Italy, Sweden, Switzerland have regional programmes (administered and run by the region, county or cantons). An organised screening programme requires a high degree of management, in contrast to non-organised services. In organised programmes the target population, screening test and intervals are given and the programme policy specifies the procedures for performance, surveillance, and quality assurance according to guidelines, rules and recommendations.

Most screening programmes for breast cancer in Europe are population-based, in contrast to the U.S. [9]. Population-based means that all women in the target population living in the area, are served by the programme. The target group are identified and personally invited to attend each round of screening.

Some organised programmes send an appointment with a fixed date and time for the examination. The procedure ensures higher participation rates compared to programmes where the women have to schedule her appointment herself. The disadvantage of this system is that there are timeslots that are not used. Overbooking is thus usual to avoid down time and fill up all the timeslots. Other programmes send invitations where the client must make herself an appointment at a specific institute. In this case, clients usually show up for appointments. General practitioners and gynaecologists in some countries (e.g. Germany) play an important role in motivating clients to participate. Participation rates are substantially higher (≈25 % higher) in programmes with appointments with fixed time and places for screening examination. Attending organised mammographic screening is free of charge in most countries. In Norway and Switzerland, a small fee is required. In most countries, the additional work up and eventual further follow-up and treatment is free of charge or paid by the insurance companies. However, sometimes subjects do co-payments.

The screening examination can take place at mobile or stationary units (e.g. dedicated screening units, private radiological institutes, and radiological departments in public hospitals). The mobile units are placed at easy accessible places that facilitate participation. In addition, mobile units do not interfere with patients in hospitals and therefore strengthen the message that screening is offered to healthy clients without symptoms of disease. In the Netherlands, there are 52 mobile units and one fixed unit offering 1.1 million screening examinations every year [11]. The UK, Norway, Sweden, and Germany combine mobile and stationary units, while Belgium, France, and Switzerland use mainly stationary units. France, for instance has one of the highest number of mammography devices per inhabitant, in Europe as illustrated in Fig. 8.2 [10].

Screening programmes for breast cancer have a centralised or decentralised organisation [6]. The annotation is related to the organisation of the screening and reading facilities. If both image readers read the screening mammograms in a reading centre (usually a screening centre), the reporting delay is managed because the image readers discuss and agree on a result on whether to recall the client or not at the center for assessment. In countries were the screening mammograms are read by one image reader at geographically spread units and/or one reader at a breast centre, it is more difficult to organise daily consensus, certainly if the mammograms have to be sent from one place to another. The distinction between centralised and decentralised screening is now fading out due to implementation of digital mammography. Image reading can be done on any high resolution workstation and phone, or video conferences consensus can be held to discuss discrepancy cases.

Many screening examinations are performed in a diagnostic or clinical context, so-called “grey”, “wild,” or “opportunistic” screening. Grey screening may or may not be performed according to the public screening policy. Apparently healthy clients, older or younger than the recommended age for mammographic screening use the grey screening. Grey screening might be available as the only possibility or as an additional option in some countries (Norway, Switzerland, Belgium, and France). Some countries and health care systems allow mammographic screening outside an organised programme and consider grey screening a valid earning model. For example, the U.S. does not offer organised screening programmes while this does not fit in their health care system. Grey screening may or may not be public financed, depending on the rules for reimbursement and/or payment of diagnostic mammography in the country. This means that governments, insurance companies, cantons, and private institutions fund the programmes.

The screening examination usually includes two-view mammography of each breast. In the early days of screening, only the oblique view was utilised. Most screening programmes changed during the last decade to two-view mammography because it has a higher sensitivity and specificity compared with one-view [5].

Centralised programmes invite up to 15 clients every hour. Assuming a 75 % participation rate, this means 5–6 min for the imaging procedure of each client. The workload differs depending on the organisation in the screening unit. In Norway, it is usual that three practitioners work in a team – one does the registration and checks the questionnaire of the client, the two others performing the image, one the left breast the other the right breast. In other programmes, only one practitioner performs the imaging, while other screening centres prefer one practitioner following the client from her entrance at the screening unit until her examination is completed.

A comprehensive quality assurance scheme of the screening programme is necessary to guarantee high quality screening [5]. Quality assurance is a team effort of all screening professionals to ensure that all aspects of the screening service achieve optimal quality performance. Desirable and acceptable quality parameters are defined; standardisation of epidemiological calculations and harmonisation of data collection allows comparison between regions and countries [5]. The implementation of the quality assurance parameters are thus important tools for monitoring, evaluation, identifying weaknesses for improvements and development of screening programmes for breast cancer.

The “European guidelines for quality assurance in breast cancer screening and diagnosis” is probably the most important tool in the implementation of European breast cancer screening services [5]. Most European countries follow the recommendation formulated in these guidelines. The guidelines are not a blueprint of how screening must be organised but rather description of important parameters that should be measured according to acceptable and desirable levels of quality. These quality assurance parameters are required to ensure an optimal service for the clients and to maximise the public health effects. Some countries have created their own version of the guidelines, usually based on the European version, but with national adaptation.

The 4th edition of the European Guideline includes 12 chapters [5]: