Recommendations from the European Breast Cancer Guidelines

Should a tailored communication strategy vs. a general communication strategy be used for socially disadvantaged women?

Recommendation

The ECIBC's Guidelines Development Group suggests against using a tailored letter instead of a general communication strategy to improve participation in breast cancer screening programmes for socially disadvantaged women (conditional recommendation, moderate certainty in the evidence).

Recommendation strength

  •   Strong recommendation against the intervention
  • Conditional recommendation against the intervention
  •   Conditional recommendation for either the intervention or the comparison
  •   Conditional recommendation for the intervention
  •   Strong recommendation for the intervention

A recommendation can be strong or conditional.

When a recommendation is strong, most women will want to follow it. When a recommendation is conditional, the majority of women want to follow it but may need more discussion with their healthcare professional first.

Subgroup

No further subgroups were identified.

Justification

Overall justification

On the basis of the specific tailored communication strategy providing individualised cancer risk considered, the GDG suggests against tailoring interventions for socially disadvantaged women, as some tailored interventions appear to do more harm than good. However, the impact of other types of tailored interventions is unknown.

Detailed justification

Desirable Effects:
No desirable effects of tailored communication were identified.

Undesirable Effects:
The GDG notes that this recommendation is based on a single intervention from one RCT study, which shows a lower participation rate with a specific tailored communication strategy. There may be different impacts with other tailored interventions.

Resources required:
No evidence was identified.

Considerations

Implementation

The GDG suggests against tailored interventions for socially disadvantaged women. Therefore, no implementation considerations were identified.

Monitoring and Evaluation

Monitoring and evaluation of tailored communication strategies that differ from that considered in the RCT for this recommendation is suggested to assess the impact of alternative interventions for tailored communication.

Research Priorities

1. Due to the scarcity of evidence in the different approaches to tailoring communication, the GDG suggests research exploring other tailored interventions for this population. Need to have a narrower definition of what tailored interventions are.
2. The GDG noted that there is incongruity with the research evidence that was found for tailored interventions for communication strategies for socially disadvantaged women. On the basis of the specific tailored communication strategy in the RCT reviewed, the GDG suggests against tailoring interventions for socially disadvantaged women, however, the impact of other tailored interventions is unknown. Further research examining all interventions targeting or tailoring to socially disadvantaged women is suggested.

Evidence

Download the evidence profile

Assessment

Background

Breast cancer is the most common cancer among women worldwide, with an estimated 1.7 million new cases occurring in 2012(Ferlay J, 2013) and the second leading cause of cancer death among women in high-income countries. The importance of early detection and treatment of breast cancer is well recognised (Cancer, 2016)(Organization, 2014) and is supported by the observed decrease in breast cancer deaths among women in high-resource regions undergoing screening mammography (Moss SM et al., 2015, Broeders M1, 2012).
For breast cancer screening programmes to bring about reductions in breast cancer mortality at the population level, a substantial proportion of the population must participate. In order to see the impact of breast cancer screening at the population level, >70% of the population invited should participate (Perry N, 2006, Giordano L, 2012). In addition, those populations that are classically far from the health system should be specifically targeted. Programmes with low uptake can be ineffective. There are several socio-demographic, economic, motivational and organisational barriers that influence the participation in breast cancer screening programmes and create inequalities in cancer care (Deandrea S, 2016, Vahabi M, 2016, Moser K, 2009)(Cuthbertson(Cuthbertson SA, 2009, Palència L, 2010). Because of this, certain subpopulations of women (e.g. socially disadvantaged) represent vulnerable populations who participate less in breast cancer screening programmes.

Management of Conflicts of Interest (CoI): CoIs for all Guidelines Development Group (GDG) members were assessed and managed by the Joint Research Centre (JRC) following an established procedure in line with European Commission rules. GDG member participation in the development of the recommendations was restricted, according to CoI disclosure. Consequently, for this particular question, the following GDG members were recused from voting: Roberto d'Amico. Miranda Langendam, as external expert, was also not allowed to vote, according to the ECIBC rules of procedure.
For more information please visit http://ecibc.jrc.ec.europa.eu/gdg-documents

Is the problem a priority?
Yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
Breast cancer is one of the most common forms of cancer and the leading cause of death in women in Europe (Ferlay, 2018). The implementation of mammography screening programmes has been identified as an effective public health intervention to reduce breast cancer mortality (Cancer, 2016)(Organization, 2014). Several studies have demonstrated a reduction in mortality for breast cancer in Europe after the implementation of population-based breast cancer screening programmes (Moss SM, 2012) (Broeders M1, 2012). For these reasons, mammography screening is a well-established public health intervention in Europe and elsewhere (Ponti A, 2017). Organised breast cancer screening involves a pathway of activities from promoting and inviting potential participants undergoing the screening test procedure, recall after the appropriate time lapse for those who screened negative and for those that screen positive, to providing timely diagnostic procedures and treatment. Inequalities could arise at any point along the pathway, and inequalities in outcomes are likely to be the result of the cumulative effects of inequalities along the entire pathway.
Moreover, it is intuitive that, in order to achieve a reduction in mortality for breast cancer, it is essential to reach most target populations and maximise participation rates. Programmes that fail to achieve this are likely to introduce serious inequalities in the population, as it is shown that women belonging to the most disadvantaged groups of the population are also those who participate less (Deandrea S, 2016). To avoid this situation tailored strategies may identify and address barriers for these particular subpopulations of women.
Additional Considerations

The GDG prioritised this question for the ECIBC.

How substantial are the desirable anticipated effects?
Trivial *
* Possible answers: ( Trivial , Small , Moderate , Large , Varies , Don't know )
Research Evidence
The tailored intervention in the study identified was a personalised tailored letter which included specific risk factor data extracted from the woman’s medical chart. The comparison group received a letter that contained generic information about risk factors for breast and cervical cancer, and the importance of screening and early detections. Recipients were encouraged to schedule a visit for clinical breast examination and a mammogram.
Outcomes№ of participants
(studies)
Follow up
Certainty of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with general communication strategyRisk difference with tailored communication strategy
Participation rate478
(1 RCT)
1

MODERATE
a
RR 0.42
(0.29 to 0.62)
Study population
31 per 10018 fewer per 100
(22 fewer to 12 fewer)
Low
15 per 1009 fewer per 100
(11 fewer to 6 fewer)
Number of people making informed choices - not measured-----
Better/increased accessibility to information - not measured-----
Confidence in making decisions - not measured-----
Increased awareness of information - not measured-----
Satisfaction with the decision-making process - not measured-----
  1. Jibaja-Weiss ML, Volk RJ Kingery P Smith QW Holcomb JD.. Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data.. Education and Counselling; 2003.
  1. Downgraded for indirectness because the study was conducted in USA.
Additional Considerations

The GDG notes that a decrease in participation was observed with the only RCT found. Therefore, no desirable anticipated effects were noted. The GDG agreed by consensus that the desirable anticipated effects were trivial.

How substantial are the undesirable anticipated effects?
Moderate *
* Possible answers: ( Large , Moderate , Small , Trivial , Varies , Don't know )
Research Evidence
The tailored intervention in the study identified was a personalised tailored letter which included specific risk factor data extracted from the woman’s medical chart. The comparison group received a letter that contained generic information about risk factors for breast and cervical cancer, and the importance of screening and early detections. Recipients were encouraged to schedule a visit for clinical breast examination and a mammogram.
Outcomes№ of participants
(studies)
Follow up
Certainty of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with general communication strategyRisk difference with tailored communication strategy
Participation rate478
(1 RCT)
1

MODERATE
a
RR 0.42
(0.29 to 0.62)
Study population
31 per 10018 fewer per 100
(22 fewer to 12 fewer)
Low
15 per 1009 fewer per 100
(11 fewer to 6 fewer)
Number of people making informed choices - not measured-----
Better/increased accessibility to information - not measured-----
Confidence in making decisions - not measured-----
Increased awareness of information - not measured-----
Satisfaction with the decision-making process - not measured-----
  1. Jibaja-Weiss ML, Volk RJ Kingery P Smith QW Holcomb JD.. Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data.. Education and Counselling; 2003.
  1. Downgraded for indirectness because the study was conducted in USA.
Additional Considerations

The GDG notes that the baseline participation rate in this study was 31%, (Jibaja-Weiss 2003). This is higher than in the recommendation of targeted strategy vs. general communication strategy which was 15%. Therefore, the relative reduction in participation may be lower if the baseline participation rate was lower.

The GDG felt the baseline participation in this study from the United States, was lower than in European settings, which is why they rated the quality of the evidence down for indirectness.

The GDG also notes that no undesirable outcomes were measured in the study and so this judgement is based only on the decrease in the participation rate.

The GDG judged by consensus that the undesirable anticipated effects were moderate.

What is the overall certainty of the evidence of effects?
Moderate *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The GDG judged by consensus that the overall certainty of the evidence of effects was moderate as that is the quality of the evidence of the only outcome measured.

Is there important uncertainty about or variability in how much people value the main outcomes?
Possibly important uncertainty or variability *
* Possible answers: ( Important uncertainty or variability , Possibly important uncertainty or variability , Probably no important uncertainty or variability , No important uncertainty or variability , No known undesirable outcomes )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG judged by consensus that there is possibly important uncertainty or variability in how much people value the main outcomes.

Does the balance between desirable and undesirable effects favor the intervention or the comparison?
Probably favors the comparison *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , Don't know )
Additional Considerations

The GDG judged by consensus that should the tailored intervention use the approach in the trial included as evidence, where a decreased participation rate was observed, the balance of effects probably favours the comparison. The GDG expressed their concern with the type of intervention used in this trial.

How large are the resource requirements (costs)?
Don't know *
* Possible answers: ( Large costs , Moderate costs , Negligible costs and savings , Moderate savings , Large savings , Varies , Don't know )
Research Evidence
No relevant economic evaluations were identified.
What is the certainty of the evidence of resource requirements (costs)?
No included studies *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Research Evidence
No relevant economic evaluations were identified.
Does the cost-effectiveness of the intervention favor the intervention or the comparison?
No included studies *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , No included studies )
Research Evidence
No relevant economic evaluations were identified.
What would be the impact on health equity?
Probably reduced *
* Possible answers: ( Reduced , Probably reduced , Probably no impact , Probably increased , Increased , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG agreed by consensus that if the tailored interventions targeting socially disadvantaged women were similar to the one used in the trial analysed, health equity would probably be reduced.

Is the intervention acceptable to key stakeholders?
Don't know *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Is the intervention feasible to implement?
Varies *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG noted that this population would need to first be identified in a feasible manner in order to target communication. The biggest barrier is actively reaching these women.

Access to phone numbers for socially disadvantaged women may impact feasibility of this intervention if targeted communication is conducted by phone.

The GDG notes that consideration of the invitation process to the screening programme, whether it is by postal code or just age, must be considered in order to assess the feasibility of reaching and targeting socially disadvantaged women.


References summary

  • Ferlay J, Steliarova-Foucher E Lortet-Tieulent J Rosso S Coebergh JW Comber H Forman D Bray F., [Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012] Eur J Cancer; 2013
  • Palència L, Espelt A Rodríguez-Sanz M Puigpinós R Pons-Vigués M Pasarín MI Spadea T Kunst AE Borrell C, [Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program] Int J Epidemiol; 2010
  • Moss SM, Cuckle H Evans A Johns L Waller M Bobrow L, Group., Trial Management, [Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years´follow-up: a randomised controlled trial] Lancet Oncol; 2015
  • Perry N, Broeders M DeWolf C et al (editors), [European Guidelines for quality assurance in breast cancer screening and diagnosis] European Communities; 2006
  • Vahabi M, Lofters A Kumar M et al, [Breast cancer screening disparities among immigrant women by world region of origin: a population-based Study in Ontario, Canada] Cancer Medicine; 2016
  • Giordano L, von Karsa L Tomatis M et al. ., [Eunice Working Group (2012a). Mammographic screening programmes in Europe:organisation, coverage and participation] J Med Screen; 2012
  • Organization, World Health, [Breast Cancer: prevention and control] httpww.who.int/cancer/detection/breastcancer/en/; 2014
  • Moser K, Patnick J Beral V, [Inequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data] BMJ 2009;338:b2025; 2009
  • Cuthbertson SA, Goyder E Poole J, [. Inequalities in breast cancer stage at diagnosis in the Trent region, and implications for the NHS Breast Screening Programme] Journal of public health (Oxford, England); 2009
  • Cancer, International Agency for Research on, [Breast cancer screening, IARC Handbooks of Cancer prevention] Available from: http://publications.iarc.fr/; 2016
  • Broeders M1, Moss S Nyström L et al. EUROSCREEN Working Group, [The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies] J Med Screen; 2012
  • Ferlay, J, [Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer] Available from: https://gco.iarc.fr/today, accessed [03/12/2018].; 2018
  • Moss SM, Nyström L Jonsson H et al., [The impact of mammographic screening on breast cancer mortality in Europe: a review of trend studies] J Med Screen; 2012
  • Ponti A, Anttila A Ronco G Senore C Basu P Segnan N et al. (IARC), [Cancer screening in the European Union. Report on the implementation of the Council Recommendation on cancer screening (second report)] Brussels: European Commission; 2017
  • Deandrea S, Molina-Barceló A Uluturk A et al, [Presence, characteristics and equity of access to breast cancer screening programmes in 27 European countries in 2010 and 2014. Results from an international survey] Preventive Medicine; 2016

Bibliography

Background
  • Ferlay J, Bray F, Steliarova-Foucher E et al. Cancer incidence in five continents, C15plus Iarc Cancer Based n. 9 (2014) Lyon, France.  International Agency for Research on Cancer. Available from: http://ci5iarc.fr Breast cancer screening, Vol 15. IARC Handbooks of Cancer prevention (2016). International Agency for Research on Cancer. Available from: http://publications.iarc.fr/ 
  • World Health Organization, Breast Cancer:prevention and control (2014). http://www.who.int/cancer/detection/breastcancer/en/ 
  • Moss SM, Nyström L, Jonsson H et al. The impact of mammographic screening on breast cancer mortality in Europe: a review of trend studies J Med Screen. 2012;19 Suppl 1:26-32. 
  • Broeders M1, Moss S, Nyström L et al. EUROSCREEN Working GroupThe impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies. J Med Screen. 2012;19 Suppl 1:14-25.
  • Perry N, Broeders M, DeWolf C et al (editors) European Guidelines for quality assurance in breast cancer screening and diagnosis. Fourth Edition – European Communities, 2006 
  • Giordano L, von Karsa L, Tomatis M et al.  Eunice Working Group (2012a). Mammographic screening programmes in Europe:organisation, coverage and participation. J Med Screen,19 (suppl 1):72-82. 
  • Deandrea S, Molina-Barceló A, Uluturk A et al.Presence, characteristics and equity of access to breast cancer screening programmes in 27 European countries in 2010 and 2014. Results from an international survey.  Preventive Medicine 91 (2016) 250–263 
  • Vahabi M, Lofters A, Kumar M et al. Breast cancer screening disparities among immigrant women by world region of origin: a population-based Study in Ontario, Canada. Cancer Medicine 2016; 5(7):1670–1686. 
  • Moser K, Patnick J,Beral VInequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data. BMJ 2009;338:b2025 
  • Cuthbertson SA, Goyder EC, Poole J Inequalities in breast cancer stage at diagnosis in the Trent region, and implications for the NHS Breast Screening Programme. J Public Health (Oxf). 2009 Sep;31(3):398-405. 
  • Palència L, Espelt A, Rodríguez-Sanz M, Puigpinós R, Pons-Vigués M, Pasarín MI, Spadea T, Kunst AE, Borrell C. Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program. Int J Epidemiol. 2010 Jun; 39(3):757-65. 
  • Ponti A, Anttila A, Ronco G et al.Cancer screening in the European Union.Report on the implementation of the Council Recommendation on Cancer Screening. European Commission 2017.
Evidence of effects
  •  Lennox N, Bain C, Rey-Conde T, Purdie D, Bush R, Pandeya N. Effects of a comprehensive health assessment program for Australian adults with intellectual disability: a cluster randomized trial. Int J Epidemiol 2007;36(1):139-146.
  • Peterson JJ, Suzuki R, Walsh ES, Buckley DI, Krahn GL. Improving cancer screening among women with mobility impairments: randomized controlled trial of a participatory workshop intervention. American journal of health promotion : AJHP. 2012;26(4):212-6
  • Chambers JA, Gracie K, Millar R, Cavanagh J, Archibald D, Cook A, et al. A pilot randomized controlled trial of telephone intervention to increase Breast Cancer Screening uptake in socially deprived areas in Scotland (TELBRECS). Journal of medical screening. 2015.
  • Chambers JA, Gracie K, Millar R, Cavanagh J, Archibald D, Cook A, et al. A pilot randomized controlled trial of telephone intervention to increase Breast Cancer Screening uptake in socially deprived areas in Scotland (TELBRECS). Journal of medical screening. 2015.
  • O’connor AM, Griffiths CJ, Undewood MR, Eldridge S. Can postal prompts from general practitioners improve the uptake of breast screening? A randomised controlled trial in one east London general practice. J Med Screen 1998;5:49-52.
  • Jibaja-Weiss ML, Volk RJ, Kingery P, Smith QW, Holcomb JD. Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data. Patient Education and Counseling. 2003;50(2):123-32.
  • Ahmed NU, Haber G, Semenya KA, Hargreaves MK. Randomized controlled trial of mammography intervention in insured very low-income women. Cancer Epidemiology Biomarkers and Prevention. 2010;19(7):1790-8.
  • Hendren S, Winters P, Humiston S, Idris A, Li SXL, Ford P, et al. Randomized, controlled trial of a multimodal intervention to improve cancer screening rates in a safety-net primary care practice. Journal of General Internal Medicine. 2014;29(1):41-9.
  • Lantz PM, Stencil D, Lippert MT, Beversdorf S, Jaros L, Remington PL. Breast and cervical cancer screening in a low-income managed care sample: The efficacy of physician letters and phone calls. American Journal of Public Health. 1995;85(6):834-6.
  • Champion VL, Springston JK, Zollinger TW, Saywell Jr RM, Monahan PO, Zhao Q, et al. Comparison of three interventions to increase mammography screening in low income African American women. Cancer detection and prevention. 2006;30(6):535-44.
  • Nuño T, Martinez ME, Harris R, Garcia F. A promotora-administered group education intervention to promote breast and cervical cancer screening in a rural community along the US-Mexico border: a randomized controlled trial. Cancer Causes Control 2011;22(3):367-74.
  • Puschel K, Coronado G, Soto G, Gonzalez K, Martinez J, Holte S, et al. Strategies for increasing mammography screening in primary care in Chile: Results of a randomized clinical trial. Cancer Epidemiology Biomarkers and Prevention. 2010;19(9):2254-61.
  • Segura JM, Castells X, Casamitjana M, Macia F, Porta M, Katz SJ. A randomized controlled trial comparing three invitation strategies in a breast cancer screening program. Preventive Medicine: An International Journal Devoted to Practice and Theory. 2001;33(4):325-32.
  • Beach ML, Flood AB, Robinson CM, Cassells AN, Tobin JN, Greene MA, et al. Can language-concordant prevention care managers improve cancer screening rates? Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 2007; 16(10):2058-64.
Values and preferences
 
No references included
 

Economic evidence
 
No references included


Acceptability

No references included