Recommendations from the European Breast Cancer Guidelines

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

Recommendation

The ECIBC's Guidelines Development Group suggests in favour of using a targeted communication strategy instead of a general communication strategy to improve participation in screening programmes of socially disadvantaged women between the ages of 50 and 69 (conditional recommendation, low 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

The conditional recommendation (rather than strong) in favour of using a targeted communication strategy instead of a general communication strategy to improve participation in screening programmes of socially disadvantaged women between the ages of 50 and 69, was a result of a moderate increase in participation rates that probably favours the intervention, in the context of low certainty in the evidence about these effects.

Consensus was reached by the GDG. However, one patient representative, Sue Warman, later during the GDG meeting expressed a lack of support for this recommendation.

Detailed justification

Desirable Effects:
The GDG noted that because this population is hard to reach, a lower increase in participation may be significant. The GDG set a clinical relevance threshold of 10 more socially disadvantaged women per 100 participating in order to consider the effect of the intervention meaningful. The estimate at a mid-level baseline participation rate of 15% saw a meaningful increase of 12 more per 100, however the confidence interval ranged from 5 to 21 and therefore there was low certainty in the desirable effect. The GDG notes that studies report only changes to participation rates, not other important outcomes such as patient satisfaction and informed decision-making.

Resources required:
No evidence was identified.

Considerations

Implementation

1. The GDG emphasises that 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.
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. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention is recommended as this intervention is desirable to increase participation in screening.
2. Baseline participation rate: if the baseline participation rate for socially disadvantaged women is already low, the GDG notes that this intervention will have a small impact on increasing participation rates.
3. The GDG notes that avoidance of stigma is important for screening programmes targeting socially disadvantaged women.
4. The GDG noted that this population would need to first be identified in a feasible manner in order to target communication.
5. 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 in the screening programmes must be considered to assess the feasibility of targeting socially disadvantaged women.

Monitoring and Evaluation

1. The GDG suggests that health providers analyse the distribution of test coverage in order to identify the socially disadvantaged women who need to be targeted.
2. The GDG notes that effectiveness outcomes are an important monitoring and evaluation focus.

Research Priorities

1. The GDG suggests additional research on important patient outcomes, including informed decision making, satisfaction and the potential undesirable effects of targeted communication for socially disadvantaged women.
2. The GDG noted that there is incongruity with the research evidence that was found for these interventions. An RCT comparing a tailored communication intervention to a general communication strategy favoured the general communication strategy, while another RCT comparing a different tailored strategy to targeted strategy favoured the tailored communication strategy. For this reason the GDG notes that, 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.
Further research examining all types of interventions aimed at 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, 2012)(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 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 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 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
For a detailed description of the different targeted interventions please see the considerations tab, under the evidence section.

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 targeted communication strategy
Participation rate6178
(8 RCTs)

LOW
a,b,c
RR 1.81
(1.35 to 2.41)
Low
7 per 100d6 more per 100
(2 more to 10 more)
Moderate
15 per 100e12 more per 100
(5 more to 21 more)
High
54 per 100f44 more per 100
(19 more to 76 more)
Number of people making informed choices - not measured-----
Better/increased accessibility to information - not measured-----
Confidence in making process - not measured-----
Increased awareness of information - not measured-----
Satisfaction with the decision making process - not measured-----
  1. High statistical heterogeneity (I2=94), without a relevant impact on the certainty of the evidence. The majority of studies show a consistent direction of effect, with overlapping 95% confidence intervals; therefore no downgrading.
  2. Downgraded for indirectness because out of 8 studies, 4 were conducted in USA, 1 in Chile and just 3 in Europe, more specifically 2 in UK and 1 in Spain.
  3. Rated down for imprecision because the panel judged that the threshold in this population is an increase of at least 10 more women participating per 100 invited.
  4. The low value of the control risk corresponds to the median of the three lower values of participation rate.
  5. The moderate value of the control risk corresponds to the median of all values of participation rate.
  6. The high value of the control risk corresponds to the median of the three higher values of participation rate.

Additional Considerations

The GDG noted that there was significant variability in the baseline participation rates in the studies included from 7% to 54%. The GDG noted that the studies with a higher participation rate were from European settings that have organised screening programmes that send out an invitation.

The objective of the studies included was to increase participation, not to increase communication, and this may account for the difference in baseline participation rates between studies.

The GDG notes that important outcomes such as satisfaction and informed decision-making were not considered by the studies included. Therefore, the GDG agreed this recommendation would only be applicable in the age group where they issued a strong recommendation.

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 judged that an increase in 10 more women participating per 100 would be clinically relevant.

The GDG judged 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
For a detailed description of the different targeted interventions please see the considerations tab, under the evidence section.

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 targeted communication strategy
Participation rate6178
(8 RCTs)

LOW
a,b,c
RR 1.81
(1.35 to 2.41)
Low
7 per 100d6 more per 100
(2 more to 10 more)
Moderate
15 per 100e12 more per 100
(5 more to 21 more)
High
54 per 100f44 more per 100
(19 more to 76 more)
Number of people making informed choices - not measured-----
Better/increased accessibility to information - not measured-----
Confidence in making process - not measured-----
Increased awareness of information - not measured-----
Satisfaction with the decision making process - not measured-----
  1. High statistical heterogeneity (I2=94), without a relevant impact on the certainty of the evidence. The majority of studies show a consistent direction of effect, with overlapping 95% confidence intervals; therefore no downgrading.
  2. Downgraded for indirectness because out of 8 studies, 4 were conducted in USA, 1 in Chile and just 3 in Europe, more specifically 2 in UK and 1 in Spain.
  3. Rated down for imprecision because the panel judged that the threshold in this population is an increase of at least 10 more women participating per 100 invited.
  4. The low value of the control risk corresponds to the median of the three lower values of participation rate.
  5. The moderate value of the control risk corresponds to the median of all values of participation rate.
  6. The high value of the control risk corresponds to the median of the three higher values of participation rate.

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?
Low *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The certainty of evidence was rated down for indirectness as most of the studies were from outside Europe. As the clinically relevant threshold for a significant effect was set at 10 more per 100, the certainty was further rated down for imprecision.

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 noted that the intervention is directed at socially disadvantaged women, where it may be difficult to determine their preferences.

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 )
Additional Considerations

The GDG judged by consensus 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 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 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 programmes.

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, targeted 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

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
  • 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