Promoting Participation in a Population Screening Program for Breast and Cervical Cancer: A Randomized Trial of Different Invitation Strategies

The effect of a pre-scheduled appointment on attendance in a population-based mammography screening programme

BACKGROUND

Pre-scheduled appointments can increase attendance in breast cancer screening programmes compared to 'open invitations' but relatively few randomized controlled trials exist. We investigated the effect of a pre-scheduled appointment on uptake in the Flemish population-based mammography screening programme.

METHODS

Between September and December 2022, a total of 4798 women were randomly assigned to receive either a pre-scheduled appointment or open invitation. The difference in attendance was compared with Poisson regression analysis for the primary endpoint (attendance ≤92 days after date of invitation), yielding relative risks (RRs). This was done separately for three groups: women invited to a mobile unit and a history of nonattendance (group M-NA); women invited to a hospital-based unit and a history of nonattendance (group HB-NA); women invited to a hospital-based unit and a history of irregular attendance (group HB-IA). There were no women invited to a mobile unit and a history of irregular attendance.

RESULTS

The RRs in favour of the pre-scheduled appointment were 2.3 [95% confidence interval (CI) 1.80-2.88], 1.8 (95% CI 1.07-2.97) and 1.8 (95% CI 1.43-2.39), for groups M-NA, HB-NA and HB-IA, respectively. We found no statistically significant difference between the various RRs. The respective absolute gains in attendance between pre-scheduled appointment and open invitation were 8.3%, 4.4% and 15.8%.

CONCLUSIONS

Sending an invitation with a pre-scheduled appointment is an effective tool to increase screening attendance in both mobile and hospital-based screening units. The pre-scheduled appointment is associated with a considerable absolute gain in attendance which varies depending on the screening history.

Did the use of open invitations in place of timed appointment invitations reduce the uptake of breast screening in the London region during the COVID-19 recovery?

OBJECTIVE

The Covid-19 pandemic created a backlog of women awaiting an invitation for breast screening in the UK. To recover in a timely fashion, the National Health Service programme opted to issue open invitations (OI) to women rather than the standard pre-booked timed appointments (TA). Historically, OIs have been shown to result in lower uptake. The aim of this study was to make use of a natural experiment to compare uptake in groups sent an OI with those sent a TA during a period when both invitation methods were in use.

METHODS

Women invited for routine screening at one of the six London breast screening services from September 2020 to March 2021 were included and grouped according to the type of invitation they had received (TA or OI). The outcome was attendance within 6 months of opening the screening episode. Data were analysed by logistic regression.

RESULTS

During the period of the study, 78,192 (32.5%) women received a TA and 162,680 (67.5%) received an OI. In the TA group, 47,391 (60.6%) attended within six months of offered appointment and in the OI group 86,430 (53.1%) attended. This difference was significant (p < 0.001). The odds ratio (95% CI) for the attended outcome was 1.44 (1.33-1.55) adjusted for differences in deprivation and for invitation category (first invitation or subsequent invitation).

CONCLUSIONS

This study supports the view that TA delivers a higher uptake than OI. It suggests that during this period over 12,000 women in London, who would have been expected to attend if given the standard TA, did not attend their appointment having received an OI.

Cervical cancer screening uptake: A randomized controlled trial assessing the effect of sending invitation letters to non-adherent women combined with sending their general practitioners a list of their non-adherent patients (study protocol)

Introduction

Cervical cancer (CC) is the fourth most common cancer among women. It can be cured if diagnosed at an early stage and treated promptly. The World Health Organization suggests that 70% of women should be screened with a high-performance test by the age of 35. This paper reports a protocol to assess the effect of two modalities of organized CC screening programmes on CC screening uptake.

Methods and analysis

Design and setting: The design involves a 3-arm randomized controlled study performed in a French geographic area on the west coast. A total of 1,395 general practitioners will be randomized, depending on their general practice surgeries. Participants: The design is based on a total of 94,393 women aged 40 to 65 years who are eligible for CC screening. Intervention: In the "optimized cancer screening" group, the intervention will combine sending invitation letters to non-adherent women with sending general practitioners (GPs) a list of their non-adherent patients. In the "standard cancer screening" group, the intervention will be limited to sending invitation letters to non-adherent women. In the "usual care" group, no letter will be sent either to women or to their GPs. Primary endpoint: CC screening test uptake will be assessed after a 6-month follow-up period. Statistical analysis: The percentage of women who are up-to-date with their screening at 6 months after the intervention will be compared across arms using a generalized mixed linear model.

Discussion

A large-scale randomized trial of this nature is unprecedented. The study will enable us to assess a strategy relying on GPs, identified as the coordinators in this screening strategy. The study results should help policy makers to implement organized CC screening programs in the future.

Ethics and dissemination

The study was approved was approved by the Ethics Committee of the National College of Teaching General practitioners (IRB00010804). It was recorded in ClinicalTrials.gov on the number NCT04689178 (28 December 2020). The study findings will be used for publication in peer-reviewed scientific journals and presentations in scientific meetings.

Factors associated with attendance at screening for breast cancer: a systematic review and meta-analysis

OBJECTIVE

Attendance at population-based breast cancer (mammographic) screening varies. This comprehensive systematic review and meta-analysis assesses all identified patient-level factors associated with routine population breast screening attendance.

DESIGN

CINAHL, Cochrane Library, Embase, Medline, OVID, PsycINFO and Web of Science were searched for studies of any design, published January 1987-June 2019, and reporting attendance in relation to at least one patient-level factor.

DATA SYNTHESIS

Independent reviewers performed screening, data extraction and quality appraisal. OR and 95% CIs were calculated for attendance for each factor and random-effects meta-analysis was undertaken where possible.

RESULTS

Of 19 776 studies, 335 were assessed at full text and 66 studies (n=22 150 922) were included. Risk of bias was generally low. In meta-analysis, increased attendance was associated with higher socioeconomic status (SES) (n=11 studies; OR 1.45, 95% CI: 1.20 to 1.75); higher income (n=5 studies; OR 1.96, 95% CI: 1.68 to 2.29); home ownership (n=3 studies; OR 2.16, 95% CI: 2.08 to 2.23); being non-immigrant (n=7 studies; OR 2.23, 95% CI: 2.00 to 2.48); being married/cohabiting (n=7 studies; OR 1.86, 95% CI: 1.58 to 2.19) and medium (vs low) level of education (n=6 studies; OR 1.24, 95% CI: 1.09 to 1.41). Women with previous false-positive results were less likely to reattend (n=6 studies; OR 0.77, 95% CI: 0.68 to 0.88). There were no differences by age group or by rural versus urban residence.

CONCLUSIONS

Attendance was lower in women with lower SES, those who were immigrants, non-homeowners and those with previous false-positive results. Variations in service delivery, screening programmes and study populations may influence findings. Our findings are of univariable associations. Underlying causes of lower uptake such as practical, physical, psychological or financial barriers should be investigated.

TRIAL REGISTRATION NUMBER

CRD42016051597.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Impact of postal correspondence letters on participation in cancer screening: a rapid review

The purpose of this rapid review was to identify and synthesize evidence on the impact of postal correspondence letters on participation in cancer screening and to determine whether impact varied by cancer site or inclusion of the participant's physician's name within the letter (i.e., physician-linked). PubMed and the Cochrane Database of Systematic Reviews were searched for English-language systematic reviews and randomized controlled trials (RCTs) published up until October 2019. One reviewer completed citation screening and data extraction with 30% verification by a second reviewer. Systematic reviews and RCTs were appraised using A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 and Cochrane Risk of Bias 2.0 tools, respectively, by one reviewer with complete verification by a second reviewer. Findings from systematic reviews and RCTs were examined separately and presented narratively. Six systematic reviews and 18 RCTs of generally low quality were included. Evidence generally demonstrated a positive impact of a letter as compared to no letter or usual practice on screening participation. This finding was consistent for breast cancer and cervical screening participation but inconsistent for colorectal cancer screening participation. Studies comparing physician-linked letters to no letters or usual practice reported similar effect estimates as those examining letters in general. Limited and inconsistent evidence was identified on the impact of physician-linked letters as compared to non-physician-linked letters on screening participation. Evidence identified in this rapid review, and other contextual and implementation considerations, may be useful for jurisdictions considering how to promote cancer screening participation.

Comparison of vaginal self-sampling and cervical sampling by medical professionals for the detection of HPV and CIN2+: A randomized study

Primary screening with human papillomavirus (HPV) test is more effective in reducing cervical cancer incidence than cytology and it also offers the opportunity to self-sample. We conducted a randomized study to compare vaginal self-sampling with cervical sampling by medical professionals for HPV testing concerning prevalence of HPV and detection of cervical intraepithelial neoplasia (CIN) of grade 2 or worse (CIN2+) or grade 3 or worse (CIN3+) in primary screening. In total, 11 951 women aged 30-60 years were randomized into two groups, 5961 for self-sampling (SS arm) and 5990 for sampling by medical professionals (SMP arm). Sampling was performed with a RoversViba-brush in the SS arm and a cytobrush in the SMP arm. All samples were applied to an indicating FTA elute card and analyzed for HPV using a clinically validated real-time PCR test (hpVIR). All HPV-positive women performed repeated sampling about 6 months later using the same procedure as used initially. All HPV-positive women in the second sampling were referred to colposcopy. The prevalence of HPV in the first test did not differ between the SS arm (6.8%, 167/2466) and the SMP arm (7.8%, 118/1519) (P = .255). The prevalence of CIN2+ per 1000 screened women was 17 (43/2466 × 1000) (95%CI 13-24) in the SS arm and 21 (32/1519 × 1000) (95%CI 15-30) in the SMP arm. For CIN3+, the prevalence per 1000 screened women was 14 (35/2466 × 1000) (95%CI 10-20) in the SS arm and 15 (23/1519 × 1000) (95%CI 10-23) in the SMP arm. In conclusion, self-sampling and sampling by medical professionals showed the same prevalence of HPV and detection rate of CIN2+ and CIN3+ in histology.

General Practitioners and Mammographic Screening Uptake: Influence of Different Modalities of General Practitioner Participation

Aims and background

To compare the impact of different modalities of general practitioner (GP) involvement, including the introduction of target payments, on the attendance rate of organized population-based screening programs for breast cancer in Italy.

Study design

The study was conducted between 1994 and 1996 in four Italian cities where mammographic screening programs are active: Caltanissetta (CL), Firenze (Fl), Modena (MO) and Torino (TO). The impact on attendance rate of different invitation strategies based on active GP involvement was tested in each center. The additional effect of economic incentives was also assessed. The incentives were proportional to the level of compliance attained by each GP and weighted by the size of his eligible patients’ list.

Results

In the Firenze project, an invitation signed by the GP and the project co-ordinator attained a statistically significant higher participation (difference: 4.2%, χ2 = 7.42, P = 0.006). In Caltanissetta and Torino there was a significant increase of about 7% in the response rate to the postal reminder in the groups contacted by the GPs. No difference was observed in the Modena project between the two groups.

Conclusions

The main contributions of GP involvement can be: “cleaning up'’ the invitation lists, especially when computerized archives with the mammographic history of the target population are not available; increasing the women's participation by signing the invitation letter, by counseling and active participation in the invitation phase; co-operating in the reminder phase by recalling women non responders at first invitation. The offer of target payment had a certain impact on the screening uptake, but not easily distinguishable from GP signature of the invitation letter; further studies of appropriate design should be planned. Organizational factors, such as availability of a list of non-responders, might be crucial in order to enhance the effect of the GPs’ action.

Increasing breast-cancer screening uptake: A randomized controlled experiment

Early screening increases the likelihood of detecting cancer, thereby improving survival rates. National screening programs have been established in which eligible women receive a letter containing a voucher for a free screening. Even so, mammography use is often considered as remaining too low. We test four behavioral interventions in a large-scale randomized experiment involving 26,495 women. Our main assumption is that, due to biases in decision-making, women may be sensitive to the content and presentation of the invitation letter they receive. None of our treatments had any significant impact on mammography use. Sub-sample analysis suggests that this lack of a significant impact holds also for women invited for the first time and low-income women.

Participants, Physicians or Programmes: Participants' educational level and initiative in cancer screening

This study is an in-depth examination of at whose initiative (participant, physician or screening programme) individuals participate in cervical, breast and colorectal cancer screening across the EU-28. Special attention is paid to (1) the association with educational attainment and (2) the country's cancer screening strategy (organised, pilot/regional or opportunistic) for each type of cancer screened. Data were obtained from Eurobarometer 66.2 'Health in the European Union' (2006). Final samples consisted of 10,186; 5443 and 9851 individuals for cervical, breast, and colorectal cancer, respectively. Multinomial logistic regressions were performed. Surprisingly, even in countries with organised screening programmes, participation in screenings for cervical, breast and colorectal cancer was most likely to be initiated by the general practitioner (GP) or the participant. In general, GPs were found to play a crucial role in making referrals to screenings, regardless of the country's screening strategy. The results also revealed differences between educational groups with regard to their incentive to participate in cervical and breast cancer screening and, to a lesser extent, in colorectal cancer screening. People with high education are more likely to participate in cancer screening at their own initiative, while people with less education are more likely to participate at the initiative of a physician or a screening programme. Albeit, the results varied according to type of cancer screening and national screening strategy.

Socio-economic and demographic determinants affecting participation in the Swedish cervical screening program: A population-based case-control study

Background

Cervical screening programs are highly protective for cervical cancer, but only for women attending screening procedure.

Objective

Identify socio-economic and demographic determinants for non-attendance in cervical screening.

Methods

Design: Population-based case-control study.

Setting: Sweden.

Population: Source population was all women eligible for screening. Based on complete screening records, two groups of women aged 30–60 were compared. The case group, non-attending women, (N = 314,302) had no smear registered for 6–8 years. The control group (N = 266,706) attended within 90 days of invitation.

Main outcome measures: Risk of non-attendance by 9 groups of socioeconomic and demographic variables.

Analysis: Unadjusted odds ratios (OR) and OR after adjustment for all variables in logistic regression models were calculated.

Results

Women with low disposable family income (adjOR 2.06; 95% confidence interval (CI) 2.01–2.11), with low education (adjOR 1.77; CI 1.73–1.81) and not cohabiting (adjOR 1.47; CI 1.45–1.50) were more likely to not attend cervical screening. Other important factors for non-attendance were being outside the labour force and receiving welfare benefits. Swedish counties are responsible for running screening programs; adjusted OR for non-participation in counties ranged from OR 4.21 (CI 4.06–4.35) to OR 0.54 (CI 0.52–0.57), compared to the reference county. Being born outside Sweden was a risk factor for non-attendance in the unadjusted analysis but this disappeared in certain large groups after adjustment for socioeconomic factors.

Conclusion

County of residence and socio-economic factors were strongly associated with lower attendance in cervical screening, while being born in another country was of less importance. This indicates considerable potential for improvement of cervical screening attendance in several areas if best practice of routines is adopted.

Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis

Background

Although cervical cancer is largely preventable through screening, detection and treatment of precancerous abnormalities, it remains one of the top causes of cancer-related morbidity and mortality globally.

Objectives

The objective of this systematic review is to understand the evidence of the effect of cervical cancer education compared to control conditions on cervical cancer screening rates in eligible women population at risk of cervical cancer. We also sought to understand the effect of provider recommendations for screening to eligible women on cervical cancer screening (CCS) rates compared to control conditions in eligible women population at risk of cervical cancer.

Methods

We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework as described in the Cochrane Collaboration Handbook to develop our search strategy. The details of our search strategy has been described in our systematic review protocol published in the International Prospective Register of systematic reviews (PROSPERO). The protocol registration number is CRD42016045605 available at: http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42016045605. The search string was used in Pubmed, Embase, Cochrane Systematic Reviews and Cochrane CENTRAL register of controlled trials to retrieve study reports that were screened for inclusion in this review. Our data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). We did a qualitative synthesis of evidence and, where appropriate, individual study effects were pooled in meta-analyses using RevMan 5.3 Review Manager. The Higgins I² was used to assess for heterogeneity in studies pooled together for overall summary effects. We did assessment of risk of bias of individual studies included and assessed risk of publication bias across studies pooled together in meta-analysis by Funnel plot.

Results

Out of 3072 study reports screened, 28 articles were found to be eligible for inclusion in qualitative synthesis (5 of which were included in meta-analysis of educational interventions and 8 combined in meta-analysis of HPV self-sampling interventions), while 45 were excluded for various reasons. The use of theory-based educational interventions significantly increased CCS rates by more than double (OR, 2.46, 95% CI: 1.88, 3.21). Additionally, offering women the option of self-sampling for Human Papillomavirus (HPV) testing increased CCS rates by nearly 2-fold (OR = 1.71, 95% CI: 1.32, 2.22). We also found that invitation letters alone (or with a follow up phone contact), making an appointment, and sending reminders to patients who are due or overdue for screening had a significant effect on improving participation and CCS rates in populations at risk.

Conclusion

Our findings supports the implementation of theory-based cervical cancer educational interventions to increase women’s participation in cervical cancer screening programs, particularly when targeting communities with low literacy levels. Additionally, cervical cancer screening programs should consider the option of offering women the opportunity for self-sample collection particularly when such women have not responded to previous screening invitation or reminder letters for Pap smear collection as a method of screening.

Effect of second timed appointments for non-attenders of breast cancer screening in England: a randomised controlled trial

BACKGROUND

In England, participation in breast cancer screening has been decreasing in the past 10 years, approaching the national minimum standard of 70%. Interventions aimed at improving participation need to be investigated and put into practice to stop this downward trend. We assessed the effect on participation of sending invitations for breast screening with a timed appointment to women who did not attend their first offered appointment within the NHS Breast Screening Programme (NHSBSP).

METHODS

In this open, randomised controlled trial, women in six centres in the NHSBSP in England who were invited for routine breast cancer screening were randomly assigned (1:1) to receive an invitation to a second appointment with fixed date and time (intervention) or an invitation letter with a telephone number to call to book their new screening appointment (control) in the event of non-attendance at the first offered appointment. Randomisation was by SX number, a sequential unique identifier of each woman within the NHSBSP, and at the beginning of the study a coin toss decided whether women with odd or even SX numbers would be allocated to the intervention group. Women aged 50-70 years who did not attend their first offered appointment were eligible for the analysis. The primary endpoint was participation (ie, attendance at breast cancer screening) within 90 days of the date of the first offered appointment; we used Poisson regression to compare the proportion of women who participated in screening in the study groups. All analyses were by intention to treat. This trial is registered with Barts Health, number 009304QM.

FINDINGS

We obtained 33 146 records of women invited for breast cancer screening at the six centres between June 2, 2014, and Sept 30, 2015, who did not attend their first offered appointment. 26 054 women were eligible for this analysis (12 807 in the intervention group and 13 247 in the control group). Participation within 90 days of the first offered appointment was significantly higher in the intervention group (2861 [22%] of 12 807) than in the control group (1632 [12%] of 13 247); relative risk of participation 1·81 (95% CI 1·70-1·93; p<0·0001).

INTERPRETATION

These findings show that a policy of second appointments with fixed date and time for non-attenders of breast screening is effective in improving participation. This strategy can be easily implemented by the screening sites and, if combined with simple interventions, could further increase participation and ensure an upward shift in the participation trend nationally. Whether the policy should vary by time since last attended screen will have to be considered.

FUNDING

National Health Service Cancer Screening Programmes and Department of Health Policy Research Programme.

Rapid review of evaluation of interventions to improve participation in cancer screening services

Objective

Screening participation is spread differently across populations, according to factors such as ethnicity or socioeconomic status. We here review the current evidence on effects of interventions to improve cancer screening participation, focussing in particular on effects in underserved populations.

Methods

We selected studies to review based on their characteristics: focussing on population screening programmes, showing a quantitative estimate of the effect of the intervention, and published since 1990. To determine eligibility for our purposes, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search and expanded this until the search yielded eligible papers on title review which were less than 1% of the total. We classified the eligible studies by intervention type and by the cancer for which they screened, while looking to identify effects in any inequality dimension.

Results

The 68 papers included in our review reported on 71 intervention studies. Of the interventions, 58 had significant positive effects on increasing participation, with increase rates of the order of 2%–20% (in absolute terms).

Conclusions

Across different countries and health systems, a number of interventions were found more consistently to improve participation in cancer screening, including in underserved populations: pre-screening reminders, general practitioner endorsement, more personalized reminders for non-participants, and more acceptable screening tests in bowel and cervical screening.

Effect of Fee on Cervical Cancer Screening Attendance--ScreenFee, a Swedish Population-Based Randomised Trial

BACKGROUND

Attendance in the cervical cancer screening programme is one of the most important factors to lower the risk of contracting the disease. Attendance rates are often low in areas with low socioeconomic status. Charging a fee for screening might possibly decrease attendance in this population. Screening programme coverage is low in low socio-economic status areas in Gothenburg, Sweden, but has increased slightly after multiple interventions in recent years. For many years, women in the region have paid a fee for screening. We studied the effect of abolishing this fee in a trial emanating from the regular cervical cancer screening programme.

METHOD

Individually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (≈11 €). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out.

RESULTS

Attendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85-1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking.

CONCLUSION

Abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02378324.

The costs of offering HPV-testing on self-taken samples to non-attendees of cervical screening in Finland

Background

Offering self-sampling to non-attendees of cervical screening increases screening attendance.

Methods

We used observations from two Finnish studies on the use of self-sampling among the non-attendees to estimate in a hypothetical screening population of 100,000 women the possible costs per extra screened woman and costs per extra detected and treated CIN2+ with three intervention strategies; 1) a primary invitation and a reminder letter, 2) a primary invitation and a mailed self-sampling kit and 3) two invitation letters and a self-sampling kit. The program costs were derived from actual performance and costs in the original studies and a national estimate on management costs of HPV related diseases.

Results

The price per extra participant and price per detected and treated CIN2+ lesion was lower with a reminder letter than by self-sampling as a first reminder. When self-sampling was used as a second reminder with a low sampler price and a triage Pap-smear as a follow-up test for HPV-positive women instead of direct colposcopy referral, the eradication of a CIN2+ lesion by self-sampling was not more expensive than in routine screening, and the addition of two reminders to the invitation protocol did not increase the price of an treated CIN2+ lesion in the entire screened population.

Conclusions

As a first reminder, a reminder letter is most likely a better choice. As second reminder, the higher costs of self-sampling might be compensated by the higher prevalence of CIN2+ in the originally non-attending population.

Attending cervical cancer screening, opportunities and obstacles: a qualitative study on midwives' experiences telephoning non-attendees in Sweden

AIM

As part of a research project aimed at increasing participation in the cervical cancer screening program (CCS), we explored midwives' unique experiences of telephoning non-attendees and offering Pap smear appointments.

METHODS

Twenty midwives, in four focus groups, discussed their experiences of a study investigating ways to increase participation in the CCS. The group discussions were tape-recorded and transcribed verbatim and underwent qualitative content analysis.

RESULTS

Speaking with more than 1000 non-attendees provided the midwives with new perspective on the CCS and they realised that improving it might address a number of reasons for not participating. These reasons were often related to logistics, such as scheduling flexibility and appointment booking. The telephone conversations revealed that some women required more individual attention, while it was discovered that others did not require screening. The midwives considered the CCS to be life-saving; participating in this screening activity gave them a sense of satisfaction and pride.

CONCLUSIONS

This study shows that midwives can improve access and prevent non-attendance at the cervical cancer screening program when they are aware of women's varying requirements for attending screening.

Reasons for non-attendance to cervical screening and preferences for HPV self-sampling in Dutch women

OBJECTIVES

High attendance rates in cervical screening are essential for effective cancer prevention. Offering HPV self-sampling to non-responders increases participation rates. The objectives of this study were to determine why non-responders do not attend regular screening, and why they do or do not participate when offered a self-sampling device.

METHODS

A questionnaire study was conducted in the Netherlands from October 2011 to December 2012. A total of 35,477 non-responders were invited to participate in an HPV self-sampling study; 5347 women did opt out. Finally, 30,130 women received a questionnaire and self-sampling device.

RESULTS

The analysis was based on 9484 returned questionnaires (31.5%) with a self-sample specimen, and 682 (2.3%) without. Among women who returned both, the main reason for non-attendance to cervical screening was that they forgot to schedule an appointment (3068; 32.3%). The most important reason to use the self-sampling device was the opportunity to take a sample in their own time-setting (4763; 50.2%). A total of 30.9% of the women who did not use the self-sampling device preferred after all to have a cervical smear taken instead.

CONCLUSIONS

Organisational barriers are the main reason for non-attendance in regular cervical screening. Important reasons for non-responders to the regular screening to use a self-sampling device are convenience and self-control.

The value of improving failures within a cervical cancer screening program: an example from Norway

Failures in cervical cancer (CC) screening include nonparticipation, underscreening and loss to follow-up of abnormal results. We estimated the long-term health benefits from and maximum investments in interventions targeted to improving compliance to guidelines while remaining cost-effective. We used a mathematical model empirically calibrated to simulate the natural history of CC in Norway. A baseline scenario reflecting current practice using cytology-based screening was compared to scenarios that target different sources of noncompliance: (i) failure to follow-up women with abnormal results, (ii) screening less frequently than recommended (i.e., underscreening) and (iii) absence of screening. A secondary analysis included human papillomavirus (HPV)-based screening as the primary test. Model outcomes included reductions in lifetime cancer risk and incremental net monetary benefit (INMB) resulting from improvements with compliance. Compared to the status quo, improving all sources of noncompliance leads to important health gains and produced positive INMBs across a range of developed-country willingness-to-pay (WTP) thresholds. For example, a 2% increase in compliance could reduce lifetime cancer risk by 1-3%, depending on the targeted source of noncompliance and primary screening method. Assuming a WTP threshold of $83,000 per year of life saved and cytology-based screening, interventions that increase follow-up of abnormal results yielded the highest INMB per 2% increase in coverage [$19 ($10-21)]. With HPV-based screening, recruiting nonscreeners resulted in the largest INMB [$23 ($18-32)]. Considerable funds could be allocated toward policies that improve compliance with screening under the current cytology-based program or toward adoption of primary HPV-based screening while remaining cost-effective.

Use of research questionnaires in the NHS Bowel Cancer Screening Programme in England: impact on screening uptake

BACKGROUND

The NHS Bowel Cancer Screening Programme in England offers biennial screening to those aged 60-74 using a faecal occult blood test (FOBt) sent by post. Data from this national clinical programme can also be used for research. Awareness of the impact of such studies on screening participation is important.

AIMS

To investigate the effect on screening uptake of adding a research questionnaire to the postal screening invitation.

METHODS

People invited for screening in 2008-10 in two areas of England were randomized to receive or not to receive an additional research study questionnaire, consent form and study information, either with their test kit or 2-3 days later. Uptake of screening was examined in relation to study mailings.

RESULTS

Among 11,579 people invited for screening by the Midlands and North West Bowel Cancer Screening Hub, screening uptake was significantly lower in those who received study documents with their FOBt kit than in those who did not (48.6% vs 53.5% respectively: p < 0.001). The reduction in uptake was similar in men and women, and was greater in people living in more deprived areas. Among a further 36,195 people invited for screening by the Midlands and North West and Southern Hubs, sending study documents by separate mailing 2-3 days after the FOBt kit did not affect screening uptake (uptake with and without additional study mailing: Midlands and North West, 56.7% and 56.2% respectively, p = 0.6; Southern, 52.0% and 51.4% respectively, p = 0.5).

CONCLUSIONS

Researchers planning studies that include contact with potential participants within the NHS Bowel Cancer and similar screening programmes should be aware of the potential impact on uptake.

Methods to increase participation in organised screening programs: a systematic review

BACKGROUND

The European Community recommends the implementation of population-based screening programmes for cervical, breast, and colorectal cancers. This recommendation is supported by many observational studies showing that organised programmes effectively reduce mortality and control the inappropriate use of screening tests. We conducted a systematic review of studies assessing the efficacy of interventions to increase participation in organised population-based screening programs.

METHODS

We included all studies on interventions aimed at increasing screening participation published between 1/1999 and 7/2012. For those published before 1999, we considered the Jepson et al. (2000) review (Health Technol Assess 4:1-133, 2000).

RESULTS

Including studies from the Jepson review, we found 69 with quantitative information on interventions in organised screening: 19 for cervical, 26 for breast, 20 colorectal cancers, and 4 for cervical and breast cancer together.Effective interventions were: postal (breast RR = 1,37 95% Confidence Interval (95% CI): 1.25-1.51; cervical RR = 1.71 95% CI: 1.60-1.83; colorectal RR = 1.33 95% CI: 1.17-1.51) and telephone reminders (with heterogeneous methods for implementation); GP's signature on invitation letter (breast RR = 1.13 95% CI: 1.11-1.16; cervical RR = 1.20 95% CI: 1.10-1.30; colorectal RR = 1.15 95% CI: 1.07-1.24); scheduled appointment instead of open appointment (breast RR = 1.26 95% CI: 1.02-1.55; cervical RR = 1.49 95% CI: 1.27-1.75; colorectal RR = 1.79 95% CI: 1.65-1.93). Mailing a kit for self-sampling cervical specimens increased participation in non-responders (RR = 2.37 95% CI: 1.44-3.90).

CONCLUSION

Although some interventions did prove to be effective, some specific variables may influence their effectiveness in and applicability to organised population-based screening programs.

Randomised trial investigating the relationship of response rate for blood sample donation to site of biospecimen collection, fasting status and reminder letter: the 45 and Up Study

Background

Various options exist for collecting biospecimens and biomarkers from cohort study participants, and these have important logistic, resource and scientific implications. Evidence on how different collection methods affect participation and data quality is lacking. This parallel-design randomised trial, the Link-Up Study, involved blood sample donation and other data collection among participants in an existing cohort study, The 45 and Up Study. It aimed to investigate the relation of fasting status, reminder letters and data collection site to response rates, data quality and biospecimen yield.

Methods

Individuals aged 45 and over participating in The 45 and Up Study and living ≤20 km from central Wagga Wagga, NSW (regional area) or ≤10 km from central Parramatta, NSW (urban area) (n = 2340) were randomised, stratified by area of residence, to be invited to give a blood sample and additional data by attending either a clinic established specifically for the trial, with an appointment time (“dedicated clinic”, n = 1336) or an existing local commercial pathology centre (n = 1004). Within dedicated clinic groups, participants were randomised into fasting (n = 668) or non-fasting (n = 668) and, at the Parramatta pathology centre site, reminder letter after two weeks (n = 336) or no reminder (n = 334).

Results

Overall, 33% (762/2340) of invitees took part in the Link-Up Study; 41% (410/1002) among regional and 26% (352/1338) among urban-area residents (p < 0.0001). At the dedicated clinics, response rates were 38% (257/668) not fasting and 38% fasting (257/668) (participation rate ratio (RR) = 1.00, 95%CI 0.91-1.08, p = 0.98). The response rate was 22% among individuals randomised to attend the Parramatta pathology centre without a reminder and 23% among those sent a reminder letter (RR = 1.01, 0.93-1.09, p = 0.74). In total, the response rate was 38% (514/1336) at the dedicated clinics and 25% (248/1004) at the pathology centres (RR = 0.67, 0.56-0.78, p < 0.01); measures of height, weight and systolic and diastolic blood pressure did not vary materially between these groups, nor did the median number of aliquots of plasma, buffy coat and red cells collected.

Conclusions

Among cohort study participants, response rates for an additional study involving biospecimen collection, but not data quality or average biospecimen yield, were considerably higher at dedicated clinics than at existing commercial pathology sites.

Women's knowledge about cervical cancer risk factors, screening, and reasons for non-participation in cervical cancer screening programme in Estonia

Background

The attendance rate in Estonian cervical cancer screening programme is too low therefore the programme is hardly effective. A cross-sectional population based survey was performed to identify awareness of cervical cancer risk factors, reasons why women do not want to participate in cervical screening programme and wishes for better organisation of the programme.

Method

An anonymous questionnaire with a covering letter and a prepaid envelope was sent together with the screening invitation to 2942 randomly selected women. Results are based on the analysis of 1054 (36%) returned questionnaires.

Results

Main reasons for non-participation in the national screening programme were a recent visit to a gynaecologist (42.3%), fear to give a Pap-smear (14.3%), long appointment queues (12.9%) and unsuitable reception hours (11.8%). Fear to give a Pap-smear was higher among women aged 30 and 35 than 50 and 55 (RR 1.46; 95% CI: 0.82-2.59) and women with one or no deliveries (RR 1.56, 95% CI: 0.94-2.58). In general, awareness of cervical cancer risk factors is poor and it does not depend on socio-demographic factors. Awareness of screening was higher among Estonians than Russians (RR 1.64, 95% CI: 1.46-1.86). Most women prefer to receive information about screening from personally mailed invitation letters (74.8%).

Conclusions

Women need more information about cervical cancer risk factors and the screening programme. They prefer personally addressed information sharing. Minority groups should be addressed in their own language. A better collaboration with service providers and discouraging smears outside the programme are also required.

The impact of different communication and organizational strategies on mammography screening uptake in women aged 40-45 years

BACKGROUND

Several factors can influence access to population breast cancer screening. The aim of the study was to evaluate the impact of different information approaches, women's socio-demographic characteristics and organizational factors on mammography screening uptake.

METHODS

We selected 5744 women aged 40-45 years who were randomly assigned to be given letters with: (i) a pre-fixed appointment plus standard leaflet (Group 1); (ii) a pre-fixed appointment plus a more comprehensive booklet (Group 2); (iii) point (ii) plus the offer of a counselling session (Group 3); and (iv) an invitation to contact the centre to get information and arrange participation (Group 4).

RESULTS

Ninety-five women were excluded before the invitation and 5649 were randomized. After excluding undelivered letters (n = 41) and women reporting an exclusion criterion following our invitation (n = 248), the final eligible population was 5360 women. Participation rates following the first contact were 36.5, 39.9, 35.8 and 16.5% for Groups 1-4, respectively. The rates increased to 40.9, 43.6, 40.1 and 35.1% after the reminder letters. Women receiving more complete information had a higher uptake (Group 2), although not statistically significant. Differences among the four groups were maintained by controlling the effect of socio-demographic and attendance determinants. Regardless of intervention, participation was higher among married, higher educated, white-collared women, those born in northern Italy, living closer to the screening unit and with a female-collaborative doctor.

CONCLUSION

Invitation letters with a fixed appointment correlate with a higher attendance rate. Providing women with more information on procedures, risks and benefits of mammography screening does not modify their participation.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Randomized controlled trial of mammography intervention in insured very low-income women

BACKGROUND

The expectation that insurance coverage mitigates health disparities and equalizes use of healthcare assumes that services are equally accessed; however, the insured low-income target population in this research had a mammography rate of 23.4%, well below the general population. Our objective was to determine the most effective intervention to improve mammography use in low-income women insured by a managed care organization (MCO).

METHODS

The study was a randomized controlled trial. Participants were 2,357 women noncompliant with screening mammography randomly assigned to one of three groups: control (n = 786) received usual care; simple intervention (n = 785) received prompt letter from the MCO medical director; and stepwise intervention (n = 786) received the same prompt letter from the MCO; if noncompliant, a second prompt letter from their primary care physician and, if still noncompliant, counseling from lay health workers. Outcome was completion of screening mammography extracted from medical records.

RESULTS

Screening rates were 13.4% for the control, 16.1% for the simple intervention, and 27.1% for the stepwise intervention. Compared with the control, the primary care physician letter in the stepwise intervention increased the likelihood of screening by 80% [Relative Risk (RR) = 1.80; P < 0.001], and counseling tripled the likelihood of screening (RR = 3.11; P < 0.001).

CONCLUSIONS

Compared with the control and simple intervention, a stepwise intervention to increase mammography is effective in a target population of hard-to-reach, low-income, insured women.

IMPACT

The research provides evidence for the impact of stepwise interventions to improve cancer screening in low-income insured populations, although the screening rates remain well below those of the general population.

Endorsement by the primary care practitioner consistently improves participation in screening for colorectal cancer: a longitudinal analysis

OBJECTIVES

To investigate the effect of general practice (GP) and general practitioner (GPR) endorsement for faecal occult blood test (FOBT)-based screening on maintenance of participation in screening over four successive screening rounds.

SETTING

South Australian residents aged > or = 50 years.

METHODS

Random selection of four groups (n = 600 per group): one from the Commonwealth electoral roll (ER) and three from the combined patient lists of two collaborating GPs (GP1, GP2, GP3). Subjects were mailed offers to screen using a faecal immunochemical test over four successive rounds, spaced approximately 18 months apart. The GP1 and ER groups were invited to screen without any endorsement from a GPR or medical practice; GP2 invitees received an invitation indicating support for screening from their medical practice; and GP3 invitations were printed on practice letterhead and were signed by a GPR.

RESULTS

Multivariate analyses indicated that initial participation as well as re-participation over four successive rounds was significantly enhanced in the GP2 (39%, 42%, 45% and 44%) and GP3 groups (42%, 47%, 48% and 49%) relative to the ER group (33%, 37%, 40% and 36%). The analyses also indicated that 60-69 year olds were most likely to participate in all rounds (relative risk [RR] 1.49, 1.39, 1.43 and 1.25), and men were generally less likely to participate than women in all screening rounds (RR 0.86, 0.84, 0.80 and 0.83).

CONCLUSIONS

Associating a GPR or medical practice of recent contact with an invitation to screen achieves better participation and re-participation than does an invitation from a centralized screening unit. Furthermore, enhanced participation can be achieved by practice endorsement alone without requiring actual GPR involvement.

The impact of interventions to improve attendance in female cancer screening among lower socioeconomic groups: a review

OBJECTIVE

To review the scientific evidence on the effectiveness of interventions to promote attendance to breast and cervical cancer screening among lower socioeconomic groups.

METHODS

We performed a computerized literature search looking for relevant papers published between 1997 and 2006. Papers were classified into three groups based on the type of intervention evaluated: (1) implementation of organized population screening programs; (2) different strategies of enhancing attendance within an organized program; (3) local interventions in disadvantaged populations.

RESULTS

The available evidence supports the hypothesis that while organized population screening programs are successful in increasing overall participation rates, they may not per se substantially reduce social inequalities. Some strategies were consistently found to enhance access to screening among lower socioeconomic groups, including cost-reducing interventions (e.g. offering free tests and eliminating geographical barriers), a greater involvement of primary-care physicians and individually tailored pro-active communication that addresses barriers to screening.

CONCLUSIONS

Evidence from studies suggests that the attendance of deprived women to cancer screening can be improved with organized screening programs tailored to their needs. The same may apply to the prevention of adverse outcomes of other health conditions, such as hypertension, hypercholesterolemia, and diabetes.

Expected reduction of colorectal cancer incidence within 8 years after introduction of the German screening colonoscopy programme: estimates based on 1,875,708 screening colonoscopies

In late 2002, colonoscopy was introduced as a primary screening tool for colorectal cancer (CRC) in Germany. We aimed to estimate the expected reduction in case numbers and incidence of CRC between 2003 and 2010 by detection and removal of advanced adenomas. Data from 1,875,708 women and men included in the national screening colonoscopy database were combined with estimates of transition rates of advanced adenomas and with national population projections. Despite relatively low screening participation, incident CRC cases are expected to be reduced by more than 15,000 between 2003 and 2010. The impact is expected to be largest in age groups 55-59, 60-64 and 65-69 in whom total case numbers in 2010 are expected to be reduced by 13%, 19% and 14% among women, and by 11%, 15% and 12%, respectively, among men. Our results forecast a major rapid reduction of the CRC burden in Germany by screening colonoscopy.

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Acceptability of reminder letters for Papanicolaou tests: a survey of women from 23 Family Health Networks in Ontario

OBJECTIVE

To explore women's perspectives on the acceptability and content of reminder letters from the family physician for Papanicolaou (Pap) test screening and the effect of reminder letters on compliance with screening recommendations.

METHODS

A population-based survey was conducted in 23 Family Health Networks and Primary Care Networks participating in a demonstration project to increase the delivery of preventive services in Ontario. Questionnaires were mailed to randomly selected women aged 35 to 69 years who had received a reminder letter for a Pap test from their family physician within the previous six months. Two focus groups were conducted with a volunteer sample of respondents.

RESULTS

The usable response rate was 54.3% (406/748). Two-thirds (65.8%, 267/406) of women who completed the survey recalled receiving the reminder letter. Overall, 52.3% (212/405) reported having a Pap test in the past six months. Among women who recalled the reminder letter and scheduled or had a Pap test, 71.4% (125/175) reported that the letter influenced their decision to be screened. The majority of respondents (80.8%, 328/406) wanted to continue to receive reminder letters for Pap tests from their physician, and 34.5% (140/406) wanted to receive additional information about cervical screening. Focus group interviews indicated that women who have had a Pap test may still be unsure about screening recommendations, what the test detects, and the rationale for follow-up procedures.

CONCLUSIONS

Reminder letters in family practice were viewed as useful and influenced women's decisions to undergo Pap test screening. Women who have had a Pap test may still need additional information about the test.

Cervical cancer incidence and mortality in the best and worst of worlds

BACKGROUND

Globally speaking, cervical cancer is a common cause of death. The cancer is caused by a human papillomavirus (HPV) infection, and hence is preventable. Pap smear screening allows for the early detection of precancerous lesions that are easily treated in a pre-invasive phase of the disease. New tests and treatment methods have the overall aim of lowering cervix cancer incidence and death. However, whether a woman will or will not develop cervix cancer depends on a complex number of interacting variables.

AIM

The aim of the present study was to identify factors that might have an impact on cervix cancer incidence and mortality, and rank them according to the weight of their relative influence.

METHODS

By using a forecasting model called the scenario method, factors were identified that could have an impact on cervix cancer development, and their relative importance was ranked by using a special matrix. The figures given for each factor were summed and presented in a System Grid, which made it possible to determine the most important variable.

RESULTS

The cultural structure of the female population, as well as women's habits and behaviour, all seem to be more important factors than the Pap smear test or the treatment in relation to cervical cancer incidence and mortality.

CONCLUSION

In the endeavour to prevent cervical cancer one must consider the whole chain of events, i.e. population-tests-treatment-outcome. New and improved test methods and treatment procedures are of little use if women refrain from coming for a test when called.

A systematic review of mammography educational interventions for low-income women

OBJECTIVE

We conducted a systematic review to examine the effectiveness of educational interventions in increasing mammography screening among low-income women.

DATA SOURCES

Bibliographic databases, including MEDLINE, The Cochrane Central Register of Controlled Trials, The Cochrane Database of Systematic Reviews, and the ISI Web of Science, were searched for relevant articles.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized, community-based trials targeting low-income women and published between January 1980 and March 2003 were included.

DATA EXTRACTION

The search yielded 242 studies; 24 met all inclusion criteria.

DATA SYNTHESIS

Three studies used mammography vans, three used low-cost vouchers or provided free mammograms, three used home visits, one used community education alone, one provided referrals, five incorporated multiple intervention strategies, two used phone calls, one used videos and print material, and five used primarily print material.

RESULTS

Of nine studies that reduced barriers to care via mammography vans, cost vouchers, or home visits, eight showed statistically significant increases in mammography screening. Seven of the eight studies that used peer educators had significant increases in screening, as did four of the five studies that used multiple (intervention) components.

CONCLUSIONS

Interventions that used peer educators, incorporated multiple intervention strategies, or provided easy access via vans, cost vouchers, or home visits were effective in increasing screenings. Mailed letter or telephone reminders were not effective in trials involving low-income women, which is contrary to findings from middle/upper-income studies.

Profile of women not attending in the Swiss Mammography Screening Pilot Programme

The Swiss Mammography Screening Pilot Programme was conducted between 1993 and 1998 in three areas of the French-speaking canton of Vaud. Socio-demographic characteristics were available for the whole of the target population and were used to identify determinants of initial (in the first round) and repeated (in both first and second rounds) non-attendance by means of logistic regression analyses. Initial non-attendance was higher among non-Swiss, single or divorced/separated women, and increased with distance between the residence and the screening centre. Being single and aged 65-70, not living in the vicinity of the screening centre and replying to decline the invitation to the initial screening session significantly increased the odds of persisting in non-attendance for screening within the programme. Factors such as age, nationality, marital status and screening centre differed in their influence on initial and repeated non-attendance, and the type of reply to the invitation was strongly predictive of non-attendance in the next round.

Mammography screening attendance: meta-analysis of the effect of direct-contact invitation

BACKGROUND

Personal or telephone contact methods are often used to increase attendance for mammography screening. A meta-analysis of the literature was performed to assess the overall effect of direct-contact recruitment on mammography participation.

METHODS

Two independent reviewers conducted two different search strategies. Each reviewer screened the search results for (quasi-)randomized-controlled trials that tested single women-targeted interventions. Twenty-one of 22 candidate studies that met the inclusion criteria could be included. These studies described 25 eligible interventions. Guided by a standardized protocol, a reviewer assessed the methodologic quality of each intervention and extracted the following data: (1) the number of women (from experimental and control groups) before and after the intervention, (2) details of the study population, (3) the type of intervention, and (4) the control condition. On the basis of a quality ranking, a cumulative random-effects meta-analysis was performed using relative risk as an indicator of intervention effect.

RESULTS

Depending on the cumulative step, the analysis revealed that direct-contact strategies improved attendance from 21% (95% confidence interval [CI]; 10%-34%) to 46% (95% CI; 32%-61%).

CONCLUSIONS

Evidence from experimental studies supports the effect of direct-contact strategies in which women are invited to participate in mammography screening. Future research will have to define the specific modalities in which these interventions can be adopted in a cost-effective manner.

Improving cancer screening among lesbians over 50: results of a pilot study

PURPOSE/OBJECTIVES

To explore the impact of two one-hour lesbian-specific educational interventions by a lesbian physician on the cancer screening behaviors of lesbians.

DESIGN

A pilot pre- and post-test intervention study.

SETTING

Two lesbian, gay, bisexual, and transgendered senior organizations in the San Francisco Bay Area (one urban, one suburban).

SAMPLE

36 participants aged 50-81 (meanX = 60.2, SD = 6.48). The majority were Caucasian (86%), single (61%), living in urban areas (67%), employed (56%), and educated beyond high school (meanX = 15.47 years, SD = 2.90, range 9-21). Eleven percent (n = 4) did not have any health insurance and were not on Medicaid or Medicare.

METHODS

A lesbian physician led a one-hour, didactic, lesbian- specific educational program on cancer screening, including a review of current research findings with regard to lesbians' risk for cancer and 45 minutes of information on recommended cancer screening, followed by a 15-minute question-and-answer period. Participants completed a pre- and postintervention survey.

FINDINGS

Follow-up data were available for 22 women. Of the six women (27%) who had not focused their attention on breast screening behaviors for two years or more, one-third had obtained mammograms and half began performing monthly breast self-examinations. Of the four women (18%) who had not undergone a pelvic examination for three years or more, one obtained a pelvic examination. The women reported no changes in colorectal cancer screening behaviors.

CONCLUSIONS

Some of these difficult-to-reach women changed their behavior in a very short period of time, supporting the need for a larger study to confirm these findings.

IMPLICATIONS FOR NURSING

A need exists to develop appropriate interventions for the underserved population of lesbians older than 50.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

Cervical cancer is the third most common cancer world-wide. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at increasing uptake, and informed uptake of cervical cancer screening.

SEARCH STRATEGY

Twenty-three electronic databases (to March 2000) were searched with no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs), or quasi-RCTs of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Data on study characteristics and quality were extracted independently by two reviewers. Where data were available, relative risks and 95% CI were calculated and a chi-squared test for heterogeneity was performed.

MAIN RESULTS

Thirty-five studies were included (27 RCTs and eight quasi-RCTs). Heterogeneity between studies limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. The number and quality of included studies limited evidence regarding effectiveness of other interventions. Informed uptake of cervical screening was not considered by any studies.

REVIEWER'S CONCLUSIONS

There was some evidence to support the use of invitation letters to increase the uptake of cervical screening. There was limited evidence to support educational interventions but it was unclear what format was most effective. The majority of the studies were from developed countries and so the relevance to developing countries is unclear.

Strategies for increasing women participation in community breast cancer screening

BACKGROUND

Strategies for reducing breast cancer mortality in western countries have focused on screening, at least for women aged 50 to 69 years. One of the requirements of any community screening program is to achieve a high participation rate, which is related to methods of invitation. Therefore, it was decided to systematically review the scientific evidence on the different strategies aimed at improving women's participation in breast cancer screening programs and activities.

OBJECTIVES

To assess the effectiveness of different strategies for increasing the participation rate of women invited to community (population-based) breast cancer screening activities or mammography programs.

SEARCH STRATEGY

MEDLINE (1966-2000), CENTRAL (2000), and EMBASE (1998-1999) searches for 1966 to 1999 were supplemented by reports and letters to the European Screening Breast Cancer Programs (Euref Network).

SELECTION CRITERIA

Both published and unpublished trials were eligible for inclusion, provided the women had been invited to a community breast screening activity or program and had been randomised to an intervention group or a control group with no active intervention.

DATA COLLECTION AND ANALYSIS

We identified 151 articles, which were reviewed independently by two people. The discrepancies were resolved by a third reviewer in order to reach consensus. Thirty-four studies were excluded because they lacked a control group; 58 of the other 117 articles were considered as opportunistic and not community-based; 59 articles, which reported 70 community-based randomised controlled trials or clinical controlled trials, were accepted. In 24 of these, the control group had not been exposed to any active intervention, but 8 of the 24 had to be excluded because the denominator for estimating attendance was unknown. At the end, 16 studies constituted the material for this review, although two studies were further excluded because their groups were not comparable at baseline. Data from all but one study were based on or converted to an intention-to-treat analysis. Attendance in response to the mammogram invitation was the main outcome measure.

MAIN RESULTS

The evidence favoured five active strategies for inviting women into community breast cancer screening services: letter of invitation (OR 1.66, 95% CI 1.43 to 1.92), mailed educational material (OR 2.81, 95% CI 1.96 to 4.02), letter of invitation plus phone call (OR 2.53, 95% CI 2.02 to 3.18), phone call (OR 1.94, 95% CI 1.70 to 2.23), and training activities plus direct reminders for the women (OR 2.46, 95% CI 1.72 to 3.50). Home visits did not prove to be effective (OR 1.06, 95 % CI 0.80 to 1.40) and letters of invitation to multiple examinations plus educational material favoured the control group (OR 0.62, 95 % CI 0.32 to 1.20).

REVIEWER'S CONCLUSIONS

Most active recruitment strategies for breast cancer screening programs examined in this review were more effective than no intervention. Combinations of effective interventions can have an important effect. Some costly strategies, as a home visit and a letter of invitation to multiple screening examinations plus educational material, were not effective. Further reviews comparing the effective interventions and studies that include cost-effectiveness, women's satisfaction and equity issues are needed.