original papers - Advances in Clinical and Experimental Medicine

original papers - Advances in Clinical and Experimental Medicine

ORIGINAL PAPERS
Adv Clin Exp Med 2009, 18, 6, 609–614
ISSN 1230−025X
© Copyright by Wroclaw Medical University
BARTŁOMIEJ SZYNGLAREWICZ1, RAFAŁ MATKOWSKI1, 2, PIOTR KASPRZAK3,
MAŁGORZATA STRYCHALSKA3, URSZULA STASZEK1, 2, KRZYSZTOF SZEWCZYK1, 2,
JÓZEF FORGACZ1, MAREK PUDEŁKO1, JAN KORNAFEL2
Recruitment Methods for First−Round Mammographic
Screening for Breast Cancer in Lower Silesia
Metodyka rekrutacji na mammografię
podczas pierwszej rundy badań przesiewowych
raka piersi na Dolnym Śląsku
1
2nd Department of Surgical Oncology, Lower Silesian Oncology Center, Wroclaw, Poland
Department of Oncology and Gynacecological Oncology Clinic, Wroclaw Medical University, Wroclaw, Poland
3
Breast Imaging and Minimal Invasive Biopsy Department, Lower Silesian Oncology Center, Wroclaw, Poland
2
Abstract
Background. A population−based mammographic screening program can significantly reduce breast cancer mor−
tality. One of the most important factors of well−organized screening is an effective invitation system resulting in
a high attendance rate.
Objectives. The aim of this study was to assess the effectiveness of invitation methods during the first round of
a breast cancer screening program and to compare it in the years 2007 and 2008.
Material and Methods. Questionnaire data of 153,807 women 50–69 years of age who were screened during
2007–2008 in the region of Lower Silesia were analyzed. Before mammography they were asked about the invita−
tion method which induced them to participate in the screening examination. The answers were prospectively col−
lected in a computer data base.
Results. For 54% of the women their decision was mostly influenced by the invitational letter (2007 vs. 2008: 59%
vs. 47.6%), 11% by mass−media (10% vs. 12%), 11.5% by health professionals (9.8% vs. 14%), 2.5% by texting
via mobile phone (2.2% vs. 2.7), and 21% by other ways (19% vs. 23.7%), i.e. leaflet, advertising, telephone hot−
line, or web−site. The women invited by letter or leaflet were most often screened in high−volume specialized breast
care centers. Those invited by media rather chose small services near their homes. In multi−disciplinary institutions,
the women were most effectively invited by medical professionals.
Conclusions. Communication using invitational letters should be intensified and improved because of the signifi−
cant reduction in the amount of participants responding to this method. Leaflets, advertising, and media remain
effective especially in specialized high−volume breast care centers. The activity of health professionals increases,
being the most helpful in multi−disciplinary institutions with mammography units. Texting invitations seems to be
insufficient (Adv Clin Exp Med 2009, 18, 6, 609–614).
Key words: breast cancer, mammography, screening, invitation methods.
Streszczenie
Wprowadzenie. Badania przesiewowe raka piersi mogą istotnie zmniejszyć umieralność na ten nowotwór pod wa−
runkiem, że programem jest objęty duży odsetek kobiet z docelowej populacji. Skuteczny system rekrutacji jest za−
tem podstawowym warunkiem prowadzenia badań przesiewowych.
Cel pracy. Analiza różnych metod rekrutacji podczas pierwszej rundy badania przesiewowego oraz porównanie
ich skuteczności między pierwszym i drugim rokiem prowadzenia programu.
Materiał i metody. Analizą objęto 153 807 kobiet w wieku 50–69 lat, które wykonały przesiewową mammogra−
fię na Dolnym Śląsku podczas pierwszej rundy programu (lata 2007–2008). Przed badaniem pacjentki podawały
źródło informacji, które skłoniło je do wzięcia udziału w badaniach przesiewowych. Odpowiedzi w sposób pro−
spektywny gromadzono w komputerowej bazie danych.
610
B. SZYNGLAREWICZ et al.
Wyniki. Dla 54% kobiet najważniejszym źródłem informacji, na podstawie których podjęły decyzję o poddaniu
się przesiewowej mammografii był list zapraszający (2007 vs 2008: 59% vs 47,6%), dla 11% media (10% vs 12%),
dla 11.5% personel ochrony zdrowia (9,8% vs 14%), dla 2.5% sms (2,2% vs 2,7), a dla 21% inne metody (19% vs
23,7%): ulotka informacyjna, promocja bezpośrednia, informacyjna linia telefoniczna lub strona internetowa. Ko−
biety zapraszane za pomocą listów i ulotek najczęściej wykonywały badanie w dużych i wyspecjalizowanych
ośrodkach, kobiety zapraszane przez media najchętniej wybierały małe ośrodki blisko miejsca swojego zamieszka−
nia. W wieloprofilowych placówkach dysponujących także pracownią mammografii najskuteczniejsze zaproszenia
pochodziły od pracowników ochrony zdrowia.
Wnioski. Należy znacznie zintensyfikować kolportowanie i być może zmodyfikować treść listów wysyłanych przez
NFZ ze względu na znaczące zmniejszenie liczby kobiet, które odpowiedziały na zaproszenie. Ulotki, promocja bez−
pośrednia i media pozostają skutecznym sposobem rekrutacji na badanie przesiewowe raka piersi, szczególnie pro−
wadzone w wyspecjalizowanych ośrodkach o dużej liczbie wykonywanych badań mammograficznych. Zwiększa się
rola pracowników ochrony zdrowia, szczególnie w mniej wyspecjalizowanych wieloprofilowych placówkach me−
dycznych. Wydaje się, że wysyłanie zaproszeń przez sms jest wątpliwe (Adv Clin Exp Med 2009, 18, 6, 609–614).
Słowa kluczowe: rak piersi, mammografia, badania przesiewowe, metody rekrutacji.
Breast cancer is the most common female
malignancy in Poland, with approximately 12,000
new cases each year [1]. In Lower Silesia, a region
with 3 million inhabitants, there were over 1000
new breast cancer cases and nearly 400 deaths reg−
istered due to this malignancy in 2004. The inci−
dence has increased to 6.5% a year during the last
two decades [2]. Breast cancer control is slowly
getting better in Poland. In Lower Silesia, progno−
sis has significantly improved since the 1990s, but
the recent 67.6% five−year relative survival rate
remains lower than the average European rate [2,
3]. The important role of periodic mammographic
screening in reducing breast cancer mortality has
been well established since the introduction of the
Health Insurance Plan in New York in the
1960s [4]. To achieve this, a sufficient, cost−effec−
tive, carefully planned and well−organized invita−
tion system resulting in a high attendance rate
seems to be one of the crucial factors.
The aim of this study was to assess the effec−
tiveness of invitation methods during the first
round of mammographic screening (2007–2008)
in the region of Lower Silesia.
Material and Methods
The National Health Fund (NFZ) introduced
population−based breast cancer screening in
Poland on January 1, 2007. This nationwide pro−
gram targets women 50–69 years old who are eli−
gible for breast cancer screening. Women under−
going treatment or being followed up due to breast
cancer are excluded. Two−view (cranio−caudal and
oblique), full−field screen−film mammography
without clinical examination is used as the stan−
dard screening test. Because of the NFZ’s limited
budget, mammography is evaluated with a single
reading. The screening interval is two years.
Before mammography, all attendees had to fill
in a special questionnaire designed by the NFZ for
breast cancer screening. Among other questions
(e.g. family history, hormone replacement ther−
apy) the women were also asked which invitation
method was the most helpful in the decision−mak−
ing process and which prompted them to partici−
pate in the screening program. The effectiveness
of the invitation methods was also evaluated with
regard to the women’s place of residence and the
location and volume of the mammography units
they chose. The data were collected in a prospec−
tive manner in the SIMP database, the official NFZ
computer database for screening programs. Data
analysis was performed in summary for the two−
year period of the first round of screening.
Comparison of the first and second years of the
program was also made.
Results
During 2007–2008 in the region of Lower
Silesia, a population of 327,249 women was eligi−
ble for breast cancer screening. Of them, 153,807
were examined, giving a coverage rate of 47%.
For 54% of the women their decision was
mostly influenced by the invitational letter (2007
vs. 2008: 59% vs. 47.6%), 11% by the media (10%
vs. 12%), 11.5% by health professionals (9.8% vs.
14%), 2.5% by texting via mobile phone (2.2% vs.
2.7), and 21% by another method (19% vs.
23.7%), mainly leaflet and advertising or, inciden−
tally, by telephone hot−line or web−site. Women
invited by letter, texting, or other methods (leaflet,
advocacy group, women’s organization, advertis−
ing activity of the Regional Coordinating Center
for Screening Programs) were most often screened
in high−volume specialized breast cancer care cen−
ters, with 80% of those induced by letter to attend
breast cancer centers vs. 11% small services vs.
9% multidisciplinary institutions, by texting: 82%
vs. 9% vs. 9%, and by other methods: 83% vs.
11% vs. 6%, respectively. Women invited by
611
Recruitment Methods for Mammographic Screening
media rather chose small services located near
their homes, with 17% in breast centers vs. 65%
small services vs. 18% multidisciplinary institu−
tions. The women were most effectively invited to
multidisciplinary institutions by medical profes−
sionals: 9% breast cancer centers vs. 15% small
services vs. 76% multidisciplinary institutions.
The data are shown in Table 1.
should be directed to women 50–69 years of age
employing two−view mammography performed
every two years [7].
For the last decade the EU has gained new
members with varying levels of experience and
infrastructure for breast cancer screening. The
European Parliament called for the establishment
of a program by 2008 which should lead to
a future 25% reduction in breast cancer mortality
rates in the EU and also a reduction of the dispar−
ity in the survival rates between members states to
5% [8]. To achieve this goal, the Polish govern−
ment and National Health Fund adopted popula−
tion−based breast cancer screening in 2007 accord−
ing to the IARC and EC recommendations. This is
a centrally organized program supervised locally
and regionally by sixteen Regional Coordinating
Centers. In Lower Silesia, the area served by the
present authors institution, the size of the target
population is nearly twenty times higher than the
European and NHSBSP minimum standards for
local programs [9, 10].
A breast cancer screening program is a com−
plex multidisciplinary undertaking. The effective−
ness of a program is a function of the quality of the
individual components. One of these is a high
attendance rate, which can be obtained by an
effective invitation system. It is emphasized that
Discussion
Control randomized trials and systematic
overviews clearly showed that population−based
mammographic screening program can signifi−
cantly reduce breast cancer mortality by up to 40%
[5]. The published reduction rates probably vary
depending on the type and intensity of the inter−
vention, the length of the screening interval,
awareness of the disease, and the quality of screen−
ing. Nevertheless, the reported favorable results
have led to the introduction of breast cancer
screening programs for well−defined populations
in over twenty countries [6]. Based on a review of
published evidence, the International Agency for
Research on Cancer (IARC) and the European
Council (EC) recommended that breast cancer
screening be offered as a public health policy and
Table 1. Effectiveness of the invitation methods
Tabela 1. Skuteczność metod rekrutacji
Invitation method
(Metoda rekrutacji)
2007
(%)
2008
(%)
2007 + 2008
(%)
Preferred institution
(Wybrany ośrodek)
Health professionals
(Personel ochrony zdrowia)
9.8
14.0
11.5
multidisciplinary institutions with
mammography units
(wieloprofilowe ZOZ−y z pracownią
mammografii)
Media
(Media)
10.0
12.0
11.0
small services located near home
(małe ośrodki położone blisko miejsca
zamieszkania)
Texting (mobile phone)
(SMS)
2.2
2.7
2.5
high−volume specialized breast cancer
treatment centers
(duże specjalistyczne ośrodki diagnostyki
i leczenia raka piersi)
Invitational letter
(List zapraszający)
59.0
47.6
54.0
high−volume specialized breast cancer
treatment centers
(duże specjalistyczne ośrodki diagnostyki
i leczenia raka piersi)
Other*
(Inne)
19.0
23.7
21.0
high−volume specialized breast cancer
treatment centers
(duże specjalistyczne ośrodki diagnostyki
i leczenia raka piersi)
* leaflet, phone hot−line, web−site, advocacy groups, women’s organizations, advertising activity of the Regional
Coordinating Center for Screening Programs in Wroclaw
* ulotka, infolinia, strona internetowa, organizacje kobiece, grupy wsparcia, promocja bezpośrednia prowadzona przez
Wojewódzki Ośrodek Koordynujący Programy Badań Przesiewowych we Wrocławiu.
612
women invited to take part in a screening program
should be given adequate information communi−
cated in an appropriate and unbiased manner to
enable them to make an informed choice about
attending the screening. Communicating about
cancer generates confusion which can lead to dif−
ficulties in the decision−making process [11].
However, women invited to attend mammograph−
ic screening are not ill, and few of them will devel−
op breast cancer during the course of their lives.
Thus it is very important that they know the bene−
fits and disadvantages of breast screening to help
them make a conscious decision [12, 13]. While
screening is a population−based program, each
individual has specific and different needs, values,
and beliefs. In addition, contextual, cultural,
racial, ethnic, personality, and class factors can
directly impact the motivations to participate in
breast cancer screening [14–16].
A good communication tool for breast cancer
screening should be easy to understand, accessi−
ble, comprehensive, user friendly, and easy and
cost effective to update, reproduce, and distribute.
Information provided to women to attend the
screening should be relevant, comprehensible,
including the benefits as well as the risks and dis−
advantages, tailored to meet the needs of special
groups, phase specific, and multilevel to take into
account the needs of women recalled [16, 17]. It is
well known what the optimal communication
should be, but there is a lack of information about
the most effective invitation method and the way
of presenting information about screening [18].
For 54% of the women the invitational letter
was a sufficient source of information that influ−
enced them to attend the breast cancer screening.
This is usually the first communication tool direct−
ly sent to women which includes logistic and orga−
nizational information related to the screening
appointment. In this study it was both the first con−
tact with the women and the most effective invita−
tion method. The invitational letter should be writ−
ten in a simple, clear, and readable style and
include the main information about breast screen−
ing (purpose, test, interval, appointment, getting
the result, possibility of being recalled), leaving
detailed information to be provided by another
communication instrument [9].
In the present study the effectiveness of health
professionals and media were similar; they were
chosen by 11.5% and 11% of the women, respec−
tively. Health professionals seem to be the most
obvious source of breast cancer information. The
specific and important role of health professionals
in providing information about screening was
recently well documented [19]. In the present
study their activity in inviting to breast cancer
B. SZYNGLAREWICZ et al.
screening was most important in multidisciplinary
institutions not focused on breast cancer with gen−
eral practices and a mammography service. The
personal and continuing relationship between gen−
eral practitioners and their patients puts them in
a privileged position to provide relevant informa−
tion to these women. They are also usually trusted
by their patients and their involvement in the deci−
sion−making process is accepted by women.
Moreover, they can significantly reduce misgiv−
ings and fear about the screening mammography.
They should use jargon−free language and avoid
incomprehensive statistical concepts expressing
risks and benefits. To overcome these problems,
appropriate training in communication skills is
needed [20].
The media play an important role in influenc−
ing opinion about the use of medical interventions
such as breast screening [21]. In the present cohort
their impact on decision−making was especially
effective in small towns and low−volume mam−
mography services. However, it often favors the
wishful view that medicine can cure all diseases
and that mammography screening can detect all
breast cancers. The information disseminated by
the media is not evidence−based and usually
ignores scientific controversies, underlining only
the benefits and glossing over uncertainties and
adverse side effects [22]. The message from the
media seems to suggest that screening is 100%
accurate and that any false−negative or false−posi−
tive result must be due to error. This misunder−
standing leads to the perception that any breast
cancer arising after a normal screening mammog−
raphy must have been missed and the diagnostic
delay has prognostic significance. This results in
high public expectations which cannot be realisti−
cally met by the services, causing anger, resent−
ment, and often litigation when this is not the case
[23].
In the present cohort, texting (text messages
via mobile phone) did not play a significant role in
the decision to attend breast cancer screening. Few
women were effectively convinced by this com−
munication method. The advantage of this tool is
its low cost. Due to its insufficient role (probably
because of the limited use of mobile phones in the
target population), the need for texting in the
future invitation system should be reconsidered.
In over one−fifth of the women the decision−
making process was most strongly influenced by
the leaflet, advertising, telephone hot−line, and
web−site. The leaflet was especially designed by
the Regional Coordinating Center for Screening
Programs in Wroclaw to complement the invita−
tional letter. It provides descriptive information
about the screening program: the nature, purpose,
Recruitment Methods for Mammographic Screening
validity and process of the test, the screening inter−
val, further assessment, the result (how to obtain
and interpret), the benefits, side effects (pain, dis−
comfort, radiation risk), and disadvantages (false−
positive, false−negative, uncertain results). It
should reinforce the information already men−
tioned in the invitational letter, add useful details,
and show where women can get further informa−
tion [24]. In the group of women of the present
study, the telephone hot−line and web−site did not
play important roles. However, advertising activity
was found to be an effective tool in the invitation to
screening mammography. A significant improve−
ment in uptake due to this method was also noted
by others [25]. This is clearly shown in the approx−
imately 20% of the participants who decided to
attend the mammography as a result of the high
activity of the Regional Coordinating Center in the
promotion of the breast screening program.
The function of women’s advocacy groups
(such as Europa Donna) in breast cancer screening
is increasingly essential [26]. Their role includes
emphasizing the need for appropriate screening
and early detection, providing high−quality sup−
portive care during and after treatment, advocating
the appropriate training of health professionals,
and promoting the advancement of breast cancer
research [27]. Considering the present findings,
the activity of these groups in this region does not
seem to be sufficient, probably due to their limited
budgets.
Telephone hot−line information was the most
important for only 0.5% of the women, meaning
approximately 400 individuals. For many other
women it was an additional tool helpful in the
decision−making process. The usefulness of a hot−
line is increased by its being a convenient source
of detailed information about the benefits and lim−
itations of breast cancer screening for every inter−
ested or hesitant woman. There is still limited use
of the internet in Poland. A small minority of
younger and more educated women currently use
the internet to access information on breast screen−
ing [9]. Young females are not a target population,
and well−educated women can find information
about breast cancer screening also in other
613
sources. This is in concordance with presented
data. However, in the future it will be useful to
explore the use of the internet as a growing and
increasingly accessible technology as a source of
information.
There is a growing concern that women invited
for screening are often told about the positive
aspects of screening, with any negative aspects
being ignored in order to increase the attendance
rate and ensure the effectiveness of the screening
program [28, 29]. The information should be hon−
est, adequate, evidence−based, accessible, unbiased,
respectful, and tailored to individual needs [30].
In conclusion, the main disadvantage of the
breast cancer screening program at its start was its
poor coverage rate (47%), significantly lower than
both the acceptable (> 70%) and desirable (> 75%)
level [9]. This clearly indicates that special effort
must be made to enhance the effectiveness of the
invitation process. The differences in the effec−
tiveness of the methods between 2007 and 2008
are difficult to interpret. Invitation to screening is
a continuous process. On the other hand, the two−
year period which was studied covers one screen−
ing round. For these reasons the present findings
of the analysis of the summarized screening round
are more important than for those for the single
years separately.
There is a lack of some data in the SIMP com−
puter base of the NFZ, for example about how
many women were sent invitational letters and
how many attendees received an invitation by tex−
ting. This is a serious limitation of this study.
Moreover, no complex analysis of the most effec−
tive invitation method and the way of presenting
information about breast cancer screening has yet
been reported; therefore little is known about this
problem [18]. However, based on the initial find−
ings it can be concluded that communication using
letters, leaflets, advertising, and media should be
strongly intensified as the most valuable methods
to persuade women to attend the screening pro−
gram. The activity of health professionals is most
helpful in multidisciplinary institutions with mam−
mography units. Texting the invitations seems to
play only a marginal role in the invitation process.
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Address for correspondence:
Rafał Matkowski
Department of Oncology and Gynaecological Oncology Clinic
Wroclaw Medical University
Plac Hirszfelda 12
53−413 Wrocław
Poland
Tel.: +48 71 368 93 91
E−mail: [email protected]
Conflict of interest: None declared
Received: 20.08.2009
Revised: 26.10.2009
Accepted: 25.11.2009