Would shared decision-making be useful in breast cancer screening programmes? A qualitative study using focus group discussions to gather evidence from French women with different socioeconomic backgrounds

BACKGROUND

To inform the development of an online tool to be potentially used in shared decision-making about breast cancer screening, French women were questioned about participation in breast cancer screening, the health professional's role, and their perceptions of the proposed tool.

METHODS

We organised focus group discussions with 55 French women. Two different strategies were used to recruit women from high and low socioeconomic backgrounds. We applied both inductive and deductive approaches to conduct a thematic analysis of the discussions. We analysed the responses by using the main determinants from different health behaviour models and compared the two groups.

RESULTS

Independently of socioeconomic status, the most important determinant for a woman's participation in breast cancer screening was the perceived severity of breast cancer and the perceived benefits of its early detection by screening. Cues to action reported by both groups were invitation letters; recommendations by health professionals, or group/community activities and public events were reported by women from high and low socioeconomic backgrounds, respectively. Among other positive determinants, women from high socioeconomic backgrounds reported making informed decisions and receiving peer support whereas women from low socioeconomic backgrounds reported community empowerment through group/community events. Fear of cancer was reported as a barrier in both groups. Among other barriers, language issues were reported only by women from low socioeconomic backgrounds; women from high socioeconomic backgrounds reported breast cancer screening-related risks other than overdiagnosis and/or overtreatment. Barriers to accessing the online tool to be developed were mainly reported by women from high socioeconomic backgrounds.

CONCLUSION

Limitations in implementing shared decision-making for women from low socioeconomic backgrounds were highlighted. An online tool that is suitable for all women, regardless of socioeconomic status, would provide "on-demand" reliable and tailored information about breast cancer screening and improve access to health professionals and social exchanges.

Functional forms of socio-territorial inequities in breast cancer screening - A French cross-sectional study using hierarchical generalised additive models

To reduce the breast cancer burden, the French National Organised Breast Cancer Screening Programme (FNOBCSP) was implemented in 2004. The recommended participation rate has never been achieved and socio-territorial inequities in participation have been reported on several occasions. We investigated the functional forms and consistency of the relationships between neighbourhood deprivation, travel time to the nearest accredited radiology centre and screening uptake. We used two-level hierarchical generalised additive models in 8 types of territories classified by socio-demographic and economic factors. The first level was 368,201 women aged 50-72 invited to the 2013-2014 screening campaign in metropolitan France. They were nested in 41 départements, the level of organisation of the FNOBCSP. The effect of travel time showed two main patterns: it was either linear (with participation decreasing as travel time increased) or participation first increased with increasing travel time to a peak around 5-15 min and decreased afterward. In nearly all types and départements, the probability of participation decreased linearly with increasing deprivation. Territorial inequities in participation were more context-dependent and complex than social inequities. Inequities in participation represent a loss of opportunity for individuals who already have the worst cancer outcomes. Evidence-based public health policies are needed to increase the effectiveness and equity of breast cancer screening.

How do women comply with cancer screenings? A study in four regions of France

BACKGROUND

This article looks at the behaviour of women facing different cancer screening options available to them from the age of 50 onward. The study was conducted in 2019 in four departments of the French territory with the objective of identifying the factors that influence acceptance of a population-based screening proposal.

METHODS

A questionnaire was sent to women who had received three invitations to organised screenings (OS) for both breast and colorectal cancer. The categories of participants in both OS were designed from data from the regional cancer screening coordination centres in each department. Participation in opportunistic cervical cancer screening was evaluated as self-reported data.

RESULTS

4,634 questionnaires were returned out of the 17,194 sent, giving a global return rate of 27%. The highest rate of return (73.5%) was obtained from women who had participated at least once in both breast and colorectal cancer OS. An intermediate rate was obtained from women participating in breast cancer OS only (18.7%). Poor levels of return came from women who had participated in colorectal cancer OS only (3.6%) and from non-participants (4.1%). Our results suggest that women with lower educational levels tend to be the most regular attendants at OS (50.3%), compared to highly educated women (39.7%). 11.8% of women were overdue in their opportunistic cervical cancer screening. This percentage rose to 35.4% in the category of non-participants. In addition, women's comments provide a better understanding of the reasons for irregular attendance and non-participation.

CONCLUSION

Overall, similar behaviours towards screening were observed in the four departments. Our analysis suggests that participation in one cancer OS increases the likelihood of participating in others. This adhesion could be an interesting lever for raising women's awareness of other cancer screenings.

Participation in breast cancer screening and its influence on other cancer screening invitations: study in women aged 56 years old in four French departments

BACKGROUND

Today, women 50 years of age are offered three types of cancer screening in France. However, participation is not optimal. The aim was to describe (1) participation in organised breast cancer screening (OS) of women aged 56 years old, and the influence of this participation on colorectal and cervical cancer screening, (2) the reasons for non-participation in breast cancer OS, and (3) the reasons for screening before age 50.

METHODS

A questionnaire was sent to 56-year-old women in four French departments to identify their participation behaviour in three breast cancer OS invitations and their reasons for non-participation. Three groups were determined according to the number of participations in breast cancer OS (3, 1-2 and 0). We described the quantitative responses and grouped the qualitative responses thematically.

RESULTS

A total of 4634 women responded to the questionnaire. Seventy-six percent had undergone all three breast cancer OS, 16% irregular and 7% non-participant. Among women who irregularly perform breast cancer OS, 50.5% also irregularly perform colorectal cancer OS. Women who participated in all three invitations for the breast cancer OS performed more smear tests than women in the other groups. Many of the irregular participants or non-participants underwent opportunistic screening, often initiated before the age of 50. The reasons for non-participation in breast cancer OS were mainly medical or participation in opportunistic screening.

CONCLUSION

There is no fundamental opposition to participation in breast cancer screening. However, it remains of the utmost importance that women should be better informed about OS and its benefits.

Coverage rate of opportunistic and organised breast cancer screening in France: Department-level estimation

OBJECTIVE

In France, the national breast cancer screening programme (NBCSP), targeting women aged 50-74 years was rolled out nationwide in 2004. It aims at reducing breast cancer mortality. In addition to the NBCSP, the use of opportunistic screening is permitted in France. The objective of this study is to estimate both opportunistic use and overall coverage rates of breast cancer screening, among women 40-84 years of age, in France.

METHODS

The French medico-administrative health data system (SNDS) was used to identify women performing an opportunistic or organised mammography screening in France in 2016-2017.

RESULTS

The two-yearly opportunistic mammography screening is 18 % among women aged 40-84; it is 11 % among women aged 50-74, i.e., the target age range for organised screening, 36 % among women aged 40-49 and 13 % among women aged 75-84. The overall two-yearly screening coverage is 48 % for all women aged 40-84; it is 60 % among women aged 50-74, 36 % among women 40-49 and 16 % for those aged 75-84. Geographical variations in screening are lessened when the two screening strategies are considered, as they balance each other.

CONCLUSION

Although coverage in the NBCSP is around 50 % in France, more than one third of the women make use of opportunistic screening within and outside the target age range. Organized screening appears to improve equity of access to mammography screening service. The lack of data on opportunistic screening practices hinders the evaluation of French screening practices as a whole.

[Early detection of breast cancer: study of the socio-technical impact of an "intelligent" bra]

INTRODUCTION

The SBra (Smart Bra) project aims to develop an intelligent bra, combining sensors for measuring skin temperature and the electrical impedance of breast tissue, which could be used for breast cancer screening. The objective of this study is to anticipate both the hindrances to usage and acceptability of SBra with respect to the breast cancer screening practices of healthcare professionals and patients, and then to propose ways to modify the shape and functions of the device to facilitate its potential insertion into the healthcare system.

METHODS

A qualitative survey was conducted between September 2019 and December 2020, consisting of a series of interviews conducted with hospital and private healthcare professionals (N = 22) working in Burgundy-Franche-Comté and related to breast cancer, and with women aged 38 to 74 years old living in Burgundy-Franche-Comté and Auvergne-Rhône-Alpes (N = 21) who have or have not had breast cancer, and who either practice or refuse screening.

RESULTS

If patients say they are ready to use such a device, at most once a year, and subject to its usability, the majority of them prefer an examination in the office, performed by a gynecologist or a general practitioner. Health professionals point out that this option generates institutional (remuneration and cost of the procedure) and organizational needs, which are both material and human.

DISCUSSION

The study highlights the need to pluralize the system in order to respond to the multiplicity of local situations.

Approche qualitative des motifs à accepter ou à refuser la réalisation d’une mammographie : l’apport de la théorie du renversement

Objectif : Examiner les motifs conduisant les femmes à accepter ou à refuser la réalisation d’une mammographie et la manière dont ceux-ci s’organisent autour des états motivationnels de la théorie du renversement.

Méthode : Seize entretiens semi-directifs ont été réalisés. Des analyses lexicométriques et de contenu ont été effectuées en prenant appui sur les dix états motivationnels de la théorie du renversement.

Résultats : Consentir à réaliser une mammographie peut répondre à la volonté d’atteindre un objectif et/ou de suivre les règles communément admises à l’égard de cet examen. Refuser de réaliser une mammographie peut être influencé par la volonté d’atteindre un objectif, par un besoin de liberté, par des préoccupations personnelles et/ou par une aspiration à être au centre du soin. Ainsi, respectivement, les motifs facilitateurs les plus impliqués se rapportent aux états motivationnels télique et conformisme. Les motifs barrières les plus impliqués se rapportent aux états télique, négativiste, intra-autique (et plus modérément à l’état autocentrique).

Conclusion : Les résultats de cette étude, et plus particulièrement le rapport qu’entretiennent les femmes avec les normes établies en matière de dépistage du cancer du sein, peuvent amorcer de nouvelles réflexions dans le champ de la santé publique.

Socio-Territorial Inequities in the French National Breast Cancer Screening Programme-A Cross-Sectional Multilevel Study

Simple Summary

France implemented a national breast cancer screening programme in 2004, which, despite recommendations, still coexists with opportunistic screening practices. We aimed to study socio-territorial inequities in participation in the 2013–2014 screening campaign, using multilevel models. With a representative sample of 42% of the estimated eligible population, we found that the organized programme does not erase social or territorial inequities in participation. Social inequities, at multiple levels, were found in nearly all départements, whereas territorial inequities seemed more context dependent. The impact of the coexistence with opportunistic screening, beyond any control and evaluation, is adding more risks (over-diagnosis, over-treatment) and leads to underestimating the true coverage of the population, mainly in the wealthiest, therefore leading to an underestimation of the true social gradient in participation. The French breast cancer screening programme needs to evolve to be more efficient in coverage, notably through the reduction of the unfair inequities in participation.

Abstract

Background. France implemented in 2004 the French National Breast Cancer Screening Programme (FNBCSP). Despite national recommendations, this programme coexists with non-negligible opportunistic screening practices. Aim. Analyse socio-territorial inequities in the 2013–2014 FNBCSP campaign in a large sample of the eligible population. Method. Analyses were performed using three-level hierarchical generalized linear model. Level one was a 10% random sample of the eligible population in each département (n = 397,598). For each woman, age and travel time to the nearest accredited radiology centre were computed. These observations were nested within 22,250 residential areas called “Îlots Regroupés pour l’Information Statistique” (IRIS), for which the European Deprivation Index (EDI) is defined. IRIS were nested within 41 départements, for which opportunistic screening rates and gross domestic product based on purchasing power parity were available, deprivation and the number of radiology centres for 100,000 eligible women were computed. Results. Organized screening uptake increased with age (OR_1SD = 1.05 [1.04–1.06]) and decreased with travel time (OR_1SD = 0.94 [0.93–0.95]) and EDI (OR_1SD = 0.84 [0.83–0.85]). Between départements, organized screening uptake decreased with opportunistic screening rate (OR_1SD = 0.84 [0.79–0.87]) and départements deprivation (OR_1SD = 0.91 [0.88–0.96]). Association between EDI and organized screening uptake was weaker as opportunistic screening rates and as département deprivation increased. Heterogeneity in FNBCSP participation decreased between IRIS by 36% and between départements by 82%. Conclusion. FNBCSP does not erase socio-territorial inequities. The population the most at risk of dying from breast cancer is thus the less participating. More efforts are needed to improve equity.

Addressing Cancer Screening Inequities by Promoting Cancer Prevention Knowledge, Awareness, Self-Efficacy, and Screening Uptake Among Low-Income and Illiterate Immigrant Women in France

Objective: Cancer screening rates are suboptimal for disadvantaged populations in France, yet little evidence exists on their cancer-related knowledge and screening barriers. The main objective of this study was to examine cancer-related knowledge, awareness, self-efficacy, and perceptions of screening barriers among low-income, illiterate immigrant women in France following an 8-weeks cancer educational intervention. Methods: Semi-structured qualitative interviews were conducted with 164 female participants in the Ain department of France between January 2019 and March 2020. Adopting the Health Belief Model as an intervention and analytic framework, salient themes were identified using qualitative thematic analysis. Results: Increased levels of perceived susceptibility to and perceived severity of cancer contributed to higher motivation to get screened. Barriers to screening included low French proficiency, shame surrounding illiteracy, and constant worries due to precarious living conditions. Perceived benefits (e.g., valuing one's health and health-promoting behaviors), cues to action from a trusted source, and greater self-efficacy (e.g., more autonomous in healthcare-seeking) outweighed perceived barriers, including cultural barriers. Conclusions: Implications include developing audience-responsive targeted cancer screening communication strategies and educational materials to increase screening rates and reduce cancer and cancer screening inequities.

Comparison of mammography results from individual and organized screening for breast cancer

BACKGROUND

In France, the coexistence of individual screening (IS) and organized screening (OS) for breast cancer induces difficulties for primary care practitioners to position themselves. This study assessed whether the risk of having a mammography with a high risk of malignancy (BI-RADS 4 or 5) was different between patients aged from 50 to 74year performing it as part of an IS or of the OS.

METHOD

This cross-sectional multicenter study included women aged 50-74, with no personal history of breast cancer, performing mammography in radiology centers in Paris (France). The nature of the screening (OS or IS), breast cancer risk (high risk: BI-RADS 4 or 5), risk factors and clinical breast examination (CBE) abnormalities were collected. Patients in the IS and OS group were matched on age, breast density, history of benign lesions and family history of breast cancer using a propensity score. The association between the nature of screening and the risk of malignancy was evaluated by conditional logistic regression.

RESULTS

Among 2190 included patients, 77 % performed a mammography with the IS and had more CBE abnormalities (23 % vs 11 %, p<0,001), a history of benign lesion (15 % vs 11 %, p=0.01) and a family history of breast cancer (42 % vs 29 %, p<0,001). After matching 503 OS patients with 941 IS patients, the risk of malignancy and the nature of the screening were not associated (OR=0.72 [0.35-1.47], p=0.50).

CONCLUSION

The risk of malignancy was not different whether the mammography was performed as part of the OS or IS.

[Proportionate universalism: Towards “real equality” of prevention in France]

Although their design may feature a considerable amount of universalism, prevention strategies often produce results that are socially and/or spatially differentiated. This differentiation process can induce social or territorial gradients of access to and/or effectiveness of prevention and, in turn, worsen health inequalities. This process also accentuates the gap between the principles of certain public policies and their practical implementation, raising the question of the real benefit of these policies for beneficiaries. Although Sir Marmot considers proportionate universalism to be a strategy to tackle health inequalities, the practical modalities of implementation of this principle have been rarely described in the literature until very recently. This pragmatic paper therefore presents a causal analysis of differentiation processes, underlines the need for self-reflexive prevention strategies, and investigates practical implications of proportionate universalism.

The effect of organized breast cancer screening on mammography use: Evidence from France

In 2004, France introduced a national program of organized breast cancer screening. The national program built on preexisting local programs in some, but not all, départements. Using data from multiple waves of a nationally representative biennial survey of the French population, we estimate the effect of organized screening on the percentage of women obtaining a mammogram. The analysis uses difference-in-differences methods to exploit the fact that the program was targeted at women in a specific age group: 50 to 74 years old. We find that organized screening significantly raised mammography rates among women in the target age range. Just above the lower age threshold, the percentage of women reporting that they had a mammogram in the past 2 years increased by over 10 percentage points after the national program went into effect. Mammography rates increased even more among women in their 60s. Estimated effects are particularly large for women with less education and lower incomes, suggesting that France's organized screening program has reduced socioeconomic disparities in access to mammography.