Recommendations from the European Breast Cancer Guidelines

Should a targeted communication strategy vs. a general communication strategy be used for non-native speakers?

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 non-native speaking women (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

None were considered.

Justification

Overall justification

The GDG felt that this intervention, one type of targeted communication, was useful. However, a conditional recommendation was made due to the variability in the capacity to implement this type of intervention depending on the country context.

Detailed justification

Desirable Effects:
The GDG judged that the targeted communication strategy in the only study included had a large desirable effect with 58 more women per 100 participating in screening.

 Acceptability:

The GDG noted that targeted communication to non-native speakers in their own language would be desirable and acceptable to most women who do not speak the native language in a given context.

 Feasibility:

The GDG noted that access to phone numbers to contact non-native speakers may be variable and this will impact the ability to implement targeted communication.

Considerations

Implementation

1. The GDG noted that both the intervention and control strategies are not routinely used in Europe for invitation to screening.
2. In certain contexts, if screening programme staff do not generally have the ability to speak another language, implementation of this intervention will be more difficult.
3. In certain countries the ability of newly arrived immigrants to speak the local language may vary.
4. Access to telephone numbers of non-native speaking women may not be available or may be limited by laws protecting access to telephone numbers in certain contexts.
5. Health providers who are already working with non-native speaking populations in other health areas should be collaborators to this type of intervention.

Monitoring and Evaluation

The GDG identified that monitoring the success of targeting communication to this specific subgroup and the impact on participation rates should be considered.

Research Priorities

The GDG supports additional research on targeted communication strategies for invitation to screening programmes for non-native speaking 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 subpopulation of women (e.g. non-native speakers) 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?
Probably 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.
How substantial are the desirable anticipated effects?
Large *
* Possible answers: ( Trivial , Small , Moderate , Large , Varies , Don't know )
Research Evidence

Outcomes№ of participants
(studies)
Follow up
Quality of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with general communication strategyRisk difference with targeted communication strategy
Participation rate848
(1 RCT)

HIGH
a
RR 1.23
(1.12 to 1.36)
Study population
58 per 10013 more per 100
(7 more to 21 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. Only one study

Additional Considerations

The GDG noted that the intervention in the study was telephone counselling plus educational material, compared to usual care that also involved telephone reminders.

The GDG judged that 58 more participants per 100 women observed in this study was a large desirable effect.

How substantial are the undesirable anticipated effects?
Trivial *
* Possible answers: ( Large , Moderate , Small , Trivial , Varies , Don't know )
Research Evidence

Outcomes№ of participants
(studies)
Follow up
Quality of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with general communication strategyRisk difference with targeted communication strategy
Participation rate848
(1 RCT)

HIGH
a
RR 1.23
(1.12 to 1.36)
Study population
58 per 10013 more per 100
(7 more to 21 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. Only one study

Additional Considerations

The GDG noted that the targeted communication may be intrusive for certain individuals, however, for most women the GDG felt that targeted communication in their own language would be desirable.

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

The GDG judged that the certainty of the evidence was low, as that is the quality 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. 
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

In places were baseline participation in screening programmes are very low, such as this case, these interventions can have a large effect because there is plenty of room for improvement, but in those where the participation is already about 60%, the improvement may not be so great.

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
Additional Considerations

Both interventions used in limited numbers. cost implications may be high because of the need of interpreters.

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 non native speakers would increase equity and 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

Women: The GDG noted that targeted communication in their own language would be desirable and acceptable to most women who do not speak the native language in a given context.

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 access to phone numbers to contact non-native speakers may be variable and this will impact on the ability to implement this type of targeted communication. Also if you have several different non-native speakers and the size of each of these communities is large, implementation may not be feasible.


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