Recommendations from the European Breast Cancer Guidelines

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

Recommendation

The ECIBC's Guideline Development Group suggests using tailored or targeted communication strategies to improve participation in breast cancer screening programmes for socially disadvantaged women (conditional recommendation, very low certainty of 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

None were considered.

Justification

Overall justification

The recommendation was agreed by the GDG by consensus.

The conditional recommendation in favour of using either a tailored or targeted communication strategy to improve participation in screening programmes of socially disadvantaged women, was a result of a moderate increase in participation rates that probably favours the intervention, in the context of very low certainty in the evidence about these effects, together with the serious issues that may arise in implementing these strategies, and the assumed costs. However, the GDG agreed that other kind of tailored strategies different from those in the study examined needed to be analysed.

The GDG noted that this recommendation is based on a single intervention from one RCT study, and there may be different effects with other tailored interventions.

Considerations

Implementation

The GDG made the following considerations:
1. For implementing this recommendation, it should be considered that the ECIBC's GDG already issued a strong recommendation for using letters, over no invitation, for inviting asymptomatic women between the ages of 50 and 69.
Furthermore, it is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening.
2. Regarding the baseline participation rate, if it is already low for socially disadvantaged women, this intervention would likely have a small impact on increasing participation rates.
3. Avoidance of stigma is important for screening programmes targeting socially disadvantaged women.
4. This population would first need to be identified in a feasible manner in order to target communication and the intervention evaluated in the single study identified is generally not feasible.
5. Access to phone numbers for socially disadvantaged women may impact feasibility of this intervention if targeted communication is conducted by phone. The invitation process in the screening programmes must be considered to assess the feasibility of targeting socially disadvantaged women.
 

Monitoring and Evaluation

The GDG made the following considerations:
1. Health providers should analyse the distribution of test coverage in order to identify the socially disadvantaged women who need to be targeted.
2. Effectiveness outcomes are an important monitoring and evaluation focus.

Research Priorities

The GDG made the following considerations:
1. More feasible tailored interventions that account for the already existing strategies for organised screening should be investigated.
2. Additional research on important patient outcomes, including informed decision making, satisfaction and the potential undesirable effects of targeted communication for socially disadvantaged women. Many factors impact the success of targeted and tailored invitations and, depending on the type of tailored intervention, participation of socially disadvantaged women in screening programmes may actually increase or decrease.
3. Further research examining all types of interventions aimed at targeting or tailoring to socially disadvantaged women.

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, 2018) 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 (Broeders M1, 2012, Moss SM, 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 et al., 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 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 Guideline 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 2016). To avoid this situation, targeted strategies are required that focus on identifying and addressing barriers for these particular subpopulations of women.
Additional Considerations

The GDG prioritised this question for the ECIBC.

How substantial are the desirable anticipated effects?
Moderate *
* Possible answers: ( Trivial , Small , Moderate , Large , Varies , Don't know )
Research Evidence
Intervention: tailored interactive computer-assisted instruction programme. Control: non-interactive intervention using a targeted pamphlet or video on mammography adherence in low-income African American women.
Outcomes№ of participants
(studies)
Follow up
Certainty of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with targeted communication strategyRisk difference with tailored communication strategy
Participation rate299
(1 RCT)

VERY LOW
a,b
RR 1.48
(1.07 to 2.05)
Study population
27 per 10013 more per 100
(2 more to 28 more)
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. Downgraded for very serious indirectness because the study was conducted in USA, in a very specific population, and because the very specific type of intervention is unlikely to be feasible.
  2. Downgraded for imprecision because the confidence interval shows a non-relevant benefit (the lower boundary suggests that only 2 more women out of 100 invited with a tailored communication strategy partecipate). The CI boundaries cross the clinical relevance threshold (at least an increase of 15 women participating per 100 invited).

Additional Considerations

The GDG noted that this population is hard to reach and in general screening in socially deprived areas have a lower uptake in screening a smaller increase in participation may be significant.
For this reason, the GDG agreed by consensus that the magnitude of the desirable effects was moderate.

How substantial are the undesirable anticipated effects?
Trivial *
* Possible answers: ( Large , Moderate , Small , Trivial , Varies , Don't know )
Research Evidence
Intervention: tailored interactive computer-assisted instruction programme. Control: non-interactive intervention using a targeted pamphlet or video on mammography adherence in low-income African American women.
Outcomes№ of participants
(studies)
Follow up
Certainty of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with targeted communication strategyRisk difference with tailored communication strategy
Participation rate299
(1 RCT)

VERY LOW
a,b
RR 1.48
(1.07 to 2.05)
Study population
27 per 10013 more per 100
(2 more to 28 more)
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. Downgraded for very serious indirectness because the study was conducted in USA, in a very specific population, and because the very specific type of intervention is unlikely to be feasible.
  2. Downgraded for imprecision because the confidence interval shows a non-relevant benefit (the lower boundary suggests that only 2 more women out of 100 invited with a tailored communication strategy partecipate). The CI boundaries cross the clinical relevance threshold (at least an increase of 15 women participating per 100 invited).

Additional Considerations

The GDG noted that outcomes related to undesirable effects were not included in any studies reviewed. However, the GDG did not explicitly identify any undesirable anticipated effects.

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

The GDG agreed the certainty of the evidence was very low. The evidence was very indirect. The tailored intervention in the study examined is a very specialised kind of population, therefore limiting its generalisability.

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 that there is possibly important uncertainty or variability in how much women value the main outcomes.

Does the balance between desirable and undesirable effects favor the intervention or the comparison?
Probably favors the intervention *
* 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 )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG judged that the balance of effects probably favours the intervention.

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 systematic review was conducted.
Additional Considerations

The GDG believed the intervention would be costly because it is a one on one intervention. The GDG agreed the cost would therefore probably not be small, but there was no research evidence available.

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 systematic review was conducted.
What would be the impact on health equity?
Probably increased *
* 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 assumed that interventions targeting specific vulnerable populations, such as disabled or socially disadvantaged women, reduce inequalities and ensure equal access to breast cancer screening programme.

Historically, segregation and stigmatisation may be of concern in this population, therefore this should be taken into account when implementing these types of interventions.

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

The GDG judged that if women were interested in participating in screening, tailored communication for socially disadvantaged women would probably be acceptable.

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

In general, the GDG believed the feasibility of implementing these types of strategies varies. However, they agreed that the specific tailoring done in the included study is generally not feasible in real practice (inability to identify women who are socially disadvantaged, the resources needed, etc.).

The GDG noted that this population would need to first be identified in a feasible manner in order to target or tailor communication. The biggest barrier is actively reaching these women. Access to phone numbers for socially disadvantaged women may impact feasibility of this intervention, particularly if the intervention 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.
For other types of tailored intervention (such as providing information in another language different to that of the country's language or similar strategies) may be more feasible than those investigated in the study used for this recommendation.


References summary

  • 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
  • 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
  • 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
  • Giordano L, von Karsa L Tomatis M Majek O Wolf CD Lancucki L Hofvind S Nystrom L Segnan N Ponti A, Group, the EUNICE Working, [Mammographic screening programmes in Europe: Organization, coverage and participation] 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