Quality Determinants of Organized Breast Cancer Screening Programs

Recruitment and Capacity

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2.1 Enrollment Objectives

• An organized breast cancer screening program should have an enrollment objective of a minimum of 70% of eligible women in the 50-69 age group. In order to achieve a 30% mortality reduction through breast screening, this goal should be reached as soon as possible.
• Organized screening programs should collect appropriate statistics on the proportions of women screened in the target age groups.
• Screening programs should have a strategic plan that will outline how women will be recruited and how specific populations will be reached.

The success and effectiveness of a population screening program is dependent on obtaining high participation rates. The aims of organized screening programs include maximizing the early detection of breast cancer and ensuring equitable access to the program for women in the target age groups. To achieve these aims, organized screening programs need to allocate sufficient resources for the recruitment of women in order to achieve high recruitment rates.

The primary target age group of breast cancer screening programs is 50-69 years of age. Although programs may choose to screen women 40-49 or 70 and over, this should not detract from meeting the enrollment targets in the 50-69 age group. Screening is recommended at 2-year intervals for women in this age group. Programs that choose to screen more often should ensure that they are first meeting the target of screening 70% of women 50-69 every second year. Screening programs should monitor statistics to measure participation.

The recruitment plan should cite all strategies that can be used to encourage women's participation, including personal invitation, community information programs, involvement of physicians and other health professionals, and strategies targeted at groups of women with lower participation rates. Strategies for retention should also be outlined.

Participation rates vary by screening program, from 54% to 89%:

• 89% of women from 50 to 59 years old, 1987-1997, Finland¹;
• 81% of women from 40 to 74 years old, 1995-1996, Sweden²;
• 78% of women from 50 to 69 years old, 1990-1995, the Netherlands³;
• 75% of women from 50 to 64 years old, 1999-2000, United Kingdom⁴;
• 54% of women from 50 to 69 years old, 1997-1998, Australia⁵.

In Canada, participation rates among women from 50 to 69 years old varied among the provinces from 11.5% to 54.7% in 1997 and 1998⁶.

2.2 Capacity

• Programs should have the capacity to screen all the eligible population.

In order to offer screening and investigation services and to reach 100% of eligible women, the program needs the capacity to offer these services, i.e. facilities, workforce, and infrastructure. A lack of centres, staff, or radiologists will limit capacity and delay implementation of the program and access to screening for women².

In Canada, in addition to the above organizational barriers, some programs face problems such as difficulty in obtaining lists of women who are eligible for screening and substantial delays between the invitation for screening mammography and the mammogram itself^6-8.

Over the next 20 years, an increase in the number of eligible women will put more pressure on screening services.

2.3 Promotion - Strategies to Recruit Women

Letters of invitation

• Organized breast cancer screening programs in the provinces/territories should send letters of invitation to all women in target age groups.
• It is vital to the success of the screening program that it use the most complete, up-to-date sources of information. Such lists should be available to the program itself so that it, and not a third party, can issue invitations. Screening programs must ensure the confidentiality of these lists and allow no access to them for any purposes other than invitational letters.

Content of letter/information package/brochure

• Invitational letters should be reassuring in tone.
• A brochure, which should contain information about the possibility of extra tests in the event of an abnormal screen result or other information, should be included with the letter.
• In referring to the possibility of an abnormal screening result, women should be informed that this is a normal part of screening, that a certain number of women require further investigation, and that the program will ensure that women with abnormalities have their problem identified to a responsible party.
• The written information should be easily readable, and all written information should be tested and evaluated before it is widely used.

Reminders

• Women who have not booked appointments should be sent a reminder letter 3 to 6 weeks after the initial letter of invitation.
• Reminder letters should be short, and the risk of breast cancer should not be emphasized.

2.3.1 Letter of invitation

The letter of invitation is a simple and efficient tool to promote participation in screening^9-11, as demonstrated by repeated studies in several countries^12-17. Individualized invitations have also been shown to be far more cost-effective than other promotional efforts¹⁸.

All Canadian organized breast screening programs currently use letters of invitation at least to some groups of women and consider them a key component of an organized screening program. However, there may be special population groups, such as Aboriginal and immigrant communities, for which letters of invitation are not appropriate or sufficient. Programs in such areas may wish to examine the value of letters of invitation in comparison with other methods.

For invitation systems to be successful, there must be an accurate listing of the target population with current addresses¹⁵. Because of the mobility of the population, lists that are several years out of date will result in a high proportion of women not receiving invitations. This can have a substantial impact on the ultimate screening rates achieved. Sources of population lists include health insurance plans, electoral lists, physician practice lists, and motor vehicle licensing lists. Obtaining lists from physician practices is by far the most complicated and the most costly. Although drivers' licences may be up to date, there are many women, especially in the older groups, who do not drive. The best option would be to receive up-to-date lists from the province or territory's health insurance plan.

Although some provinces/territories are able to receive up-to-date lists from their provincial/territorial health insurance plans, confidentiality of information is of extreme concern. In some provinces/territories, screening programs cannot access such lists. Confidentiality is a concern for the screening programs as well, as they must ensure that the list received is used only for invitational letters and for no other purpose.

To avoid sending letters of invitation to families of deceased patients or to patients with previous breast cancer, health insurance plan lists should be cross-referenced with cancer registry lists and vital statistics. Further cross-referencing should be done with the screening program so that women who already participate in the screening program do not receive the same letter as women who are being invited for the first time. In provinces where names are not released to the screening centres but letters are sent directly to the women, mass mailings are often done. Since the centres cannot control the rate of mail outs, women may have to wait lengthy periods of time for an appointment. This compromises the efficiency of the centres.

2.3.2 Content of letter/brochures

The content of the invitational letter has implications for attendance and even reattendance. Letters should be reassuring in their tone and include informational brochures¹⁹. The idea of screening as a continuum of steps should be addressed, indicating the possibility of further assessment. Brochures generally describe the program and answer the common questions and concerns women have about mammography.

Although the differences were not large, it has been found that women were less likely to worry about recall for further assessment if they had received information about the possibility of recall in the initial invitational letter¹⁹. They were more likely to worry if the word "cancer" was used in the context of recall in the letter of invitation¹⁹.

Information about recall should be given in more than one way, beginning with the initial invitation package and then later by the screening technologist at first screening¹⁹. Other countries, such as the United Kingdom, include scheduled appointments in the letters of invitation. This has been shown to improve compliance with screening^20-23. Offering a specific appointment date and time, and including a paid reply card to indicate acceptance²⁴ make it easier for women to respond; it may also eliminate the effects of social class by not requiring women to exercise social skills they may not possess¹⁴. The organization of appointments may be especially important for older women, women from lower socioeconomic strata, and those from non-English-speaking backgrounds²⁴.

However, including an appointment time may not be the most cost-effective approach. Hurley and colleagues¹⁸ have shown that when the cost of reserving an appointment is considered, an invitational letter without a specific appointment time followed by a second letter to nonattenders is a more cost-effective approach. However, costs may vary depending on the situation of each individual program. One study has demonstrated that by considering clients' previous history of screening mammography it was possible to maximize the number of appointments by day and thus reduce the required time, especially in mobile units²⁵.

Scheduled appointments with invitational letters are not used in Canada, and there is no indication of the factors that may determine acceptance of such an approach. It would be advantageous if one of the programs were to undertake a trial of letters with and without appointment times.

Endorsement by the family physician may yield somewhat higher screening rates, but cost-effectiveness and practicality have not been established. There is not a large difference in response rates to invitations for screening from general practitioners (GPs) and from sources not personally known to women^15,22,23.

The literature is split on whether tailoring of letters improves attendance. Physicians' recommendations for mammography tailored to individual women's specific perceptions about mammography and breast cancer, their risk factors for breast cancer, and their mammography screening status have been shown to be a more effective medium for delivering the message. Tailored letters were more likely to be remembered and, among women who remembered the letters, were more thoroughly read¹². However, tailored letters may have had a greater chance of capturing attention at first glance because of their tailored pictures, captions, and headlines, so that it may not be the tailoring itself that is effective. In the United States, context-tailored letter receipt was associated with higher mammography rates among women with incomes below $26,000 and among Black women¹². Among women with a family history of breast cancer, the personalized risk invitation has also been associated with significantly higher participation¹³. However, tailored letters that made reference to the woman's screening history had no significant effect on uptake rates²⁶.

For most Canadian screening programs, it is impractical to have invitational letters or reminder letters sent from GPs. Unless a practice-based approach is used to begin with, such letters cannot be used. There is no evidence to justify the additional cost of building up practice-eligible lists in provinces where other lists are available.

2.3.3 Reminders

Reminders target specific women who have not responded to an initial invitation. Strategies include letters, appointments, telephone calls, or personal contacts.

A second letter of invitation results in increased screening rates. In Australia, Hurley et al. found only a 13% response to the initial invitation, but there was an additional 26% response rate among those sent a second invitation after 4 weeks. A telephone follow-up instead of a second invitational letter yielded similar results¹⁸. A study conducted by the Ontario Breast Screening Program in a rural family practice yielded a l6% response to the initial invitational letter (after 8 weeks), an additional 22% response rate to a reminder letter, and a further 19% response to a telephone call, for a cumulative response rate of 50%. Three-quarters of the women attending for screening in response to the first or second invitations had not heard of the program before receiving the letter of invitation.

Women receiving a reminder letter are more likely to have mammography than those who do not receive one^21,22,27. As in the case of the first invitational letter, offering an appointment in the reminder letter should promote participation²⁸. In a Scottish study, which compared a reminder letter from the screening program alone to one accompanied by a letter signed by the woman's own physician, the accompanying letter doubled the attendance rate, from 10% to 21%²⁹.

A letter of invitation followed by a telephone call is also an effective strategy^9,30 and could be helpful in reaching groups of women from different ethnic backgrounds or those in lower socioeconomic circumstances⁹.

For women who do not participate after an invitational letter followed by a reminder letter, telephone counselling³¹ or a home visit³² should benefit participation more than a second reminder letter. In one study carried out in a lower socioeconomic area in England, a personal letter from the GP was found to be at least as effective as visits by a nurse at increasing the uptake of breast screening in nonattenders. Following a letter from their own GP, 13% of previous nonattenders participated in breast screening³³. In a British study, a telephone call or letter from specially trained receptionists also proved to be effective³⁴.

Invitational letters are an effective recruitment strategy only when followed up with letters or telephone calls to those who do not respond to the initial invitation. For women being recruited for their first screen, the option of a telephone follow-up is not available, as the women are not yet registered in the screening programs.

There is no real evidence in the literature as to the timing of this second letter. Such reminders have generally been sent between 4 and 8 weeks after the first letter. However, most bookings take place in the first week after receipt of the letter. Thus, a 3 to 6 week interval between letters may be more appropriate. For mobile units, it may be difficult to anticipate too far in advance the exact time when the unit will be in the community. The time between the initial letter and the reminder letter may therefore need to be even shorter.

A card sent 6 months after the initial letter, asking for reasons for nonattendance, serves two purposes: it is an additional reminder, and it yields information for the program about its nonattenders.

2.3.4 Other recruitment strategies

Sending informational material and making telephone calls are other ways of encouraging participation in screening⁹. Telephone counselling is considered effective²² but may be no more so than the usual methods when targeting women who do not attend mammography screening or attend irregularly³⁵.

With regard to home visits, one meta-analysis based on studies of nonparticipating Asian women or black women of low income concluded that such visits are not adequate.⁹ However, in a Spanish study involving poor income women, a home visit by a nonprofessional person led to better participation (63.5%) than a program invitational letter (52.1%)³⁶. Results from studies on home visits remain equivocal because of difficulties in recruiting subjects³⁷.

Yabroff and Mandelblatt³⁸ have reviewed studies on interventions targeting women for screening mammography. The authors categorized them by type of intervention and concluded that behavioural interventions (e.g. telephone calls, letters of invitation) increased screening in comparison to usual practices (by 13.2%) and to active controls (by 5.6%). Theory-based cognitive interventions and sociologic interventions also improved participation (by 23.6% and 12.6% respectively as compared with usual practices). Cognitive strategies aimed to improve knowledge and to clarify perceptions (perceived risk, benefits, barriers), and sociologic interventions used social norms or peers (friends, counsellors, the media).

Yabroff and Mandelblatt's results may give the impression that some interventions are more efficient than others. However, using a different model of analysis (PRECEDE), Ratner et al. concluded that receiving an intervention, no matter what type, promotes participation, but that screening rates do not significantly differ according to whether the intervention targets predisposing, facilitating, or enforcing factors³⁹. After taking into account some methodological factors, however, the authors noted that recent studies (from 1990 to 1996 versus 1980 to 1989) reported increased screening rates and that interventions based in the community (versus in the clinic) were the most effective. According to Sin and St Leger, simple and efficient interventions promoting screening do exist, but studies on organizational aspects, social networks, or a combination of several strategies are rare²³. In inner city areas, the approach most likely to offer good results would involve several strategies together.

2.3.5 Factors related to participation

Many factors influence participation. For all aspects of promotion and recruitment, including the writing of pamphlets and letters, planning outreach initiatives, determining where a mobile will be set up, determining promotion messages, etc, these factors should be considered.

The most important factors related to women's participation in breast cancer screening include age, education, having a consistent source of health care, being told by a physician to have a mammogram, perceiving the need for mammography, and fear of a positive screen result⁴⁰.

Demographic factors associated with mammography screening include age, race, income, education, urban living, and marital status. Women 65 years of age and older are less likely than younger women to have ever had a mammogram or to have had a recent mammogram^41-47, and rates drop even more substantially among women over 75 years of age⁴⁸. Higher education and higher income are also positively associated with mammography use^{41,42,45,47,49-52}. White women are more likely than women of racial minorities to have mammograms^41,42, as are urban versus rural women⁵³ and married versus never-married women^41,50,54,55.

Explanations women give for not having mammography include having "put it off", cost or lack of insurance, embarrassment, and concerns about radiation^{41,45,47,56-60}. Statements showing significant differences between compliers and noncompliers include the following: "I have no symptoms, so I don't need a mammogram"; "It's too much trouble, I don't have the time for one"; "I'd rather not think about it"; "I'm worried about radiation"; and "Getting a mammogram would be inconvenient"⁵⁷. Apathy, lack of concern, lack of perceived need and lack of knowledge about screening mammography are thus important reasons for nonattendance, as is the fear of a positive screen result⁶¹.

Additional barriers that have been noted include poor personal health practices⁵¹, general fear of medical tests and unwillingness to know if cancer is present⁶², lack of transportation (especially for rural women), lack of time (especially for working women and care givers), lack of high-quality facilities, the need for mammography equipment that meets the special needs of women with disabilities, and health beliefs^63,64.

Many of these factors interact and may be additive for particular individuals. Women of higher socioeconomic status are more likely to be influenced by the print media and less likely to be influenced by what their physicians think⁵². Women with less of a preventive orientation, as measured by smoking status, who have concerns about screening or who believe that symptoms are a prerequisite for a mammogram are less likely to have mammograms⁶⁵.

According to a Canadian survey, factors predictive of never having had a mammogram are higher age level, living in a rural area, being born in an Asian country, nonparticipation in volunteer groups, no regular physician or recent medical visit, smoker, no regular physical activity, and nonuser of hormone replacement therapy⁶⁶.

2.4 Promotion - Family Physicians and Screening

• Screening programs should have ongoing liaison with their medical associations.
• Screening programs should inform physicians about mammography screening programs.
• Screening programs should offer organized recruitment programs, high-quality service, and follow-up on patients in order to encourage physicians to refer their patients.
• The recruitment plan should include approaches to ensure that referring physicians and other relevant health and community service providers understand the program and encourage women in the target group to participate.

Some of the most important factors associated with whether women have or do not have a mammogram are related to physicians. The most important is whether the physician mentions mammography to the woman⁶⁷. Having a usual source of care or a regular physician is the first step^{40,45,54,55,68,69}: women are about three times more likely to have had a mammogram in the previous 12 months if they have a regular physician or report an annual check-up^55,69. The woman's belief that her doctor advocates regular mammography is another important predictor of compliance⁵⁷. Doctors' instructions not to have a mammogram or lack of any instruction are major reasons quoted for not undergoing mammography^{41,45,47,56,59}. Another closely related reason is not being aware of the need for a mammogram. Physicians and women may also be concerned about "unnecessary" biopsies and over-diagnosis⁵⁹.

Women who perceive that their physicians have some enthusiasm for mammography are far more likely to have a mammogram: physician encouragement increases mammography use by at least fourfold^70,71, and this effect is even more dramatic in older women (7 to 12 fold)⁴³.

Although Canadian breast screening programs do not require physician referral, studies from other countries on women's use of mammography indicate that women rely on physicians to tell them whether they need the test and how often⁴⁰, and suggest that physician factors are likely to be important in this country as well. Physicians' encouragement remains an important factor in women's decision to be screened.

Since referral to screening programs requires a change from established referral patterns, education of physicians about mammography screening needs to focus not only on the need for screening but also on the advantages of having the screening done in a screening centre, rather than in a diagnostic unit. Mammography through screening programs is oriented toward the asymptomatic patient and can provide high-quality, efficient service at substantially lower cost than the same service in a diagnostic unit.

Some of the current confusion about diagnostic centres has arisen as a result of screening centres not being available in many locations when provincial programs are started. It is then difficult to break referral habits. If provincial programs are province-wide from inception, this confusion could be prevented. Physicians will also be more likely to refer to screening programs if they present an advantage by offering organized recruitment programs, high-quality service, and follow-up of patients.

Mandelblatt and Yabroff⁷² have analyzed the efficiency of interventions aimed at physicians or health professionals. Interventions were categorized as behavioural, cognitive, or sociological: for example, a behavioural intervention might be a reminder system in effect in a physician's office; cognitive interventions are concerned especially with perception, information, and educational material; sociological interventions are, for example, interventions done by a nurse in a medical centre. All types were found to be effective, increasing rates of mammography utilization by up to 13.2%, 18.6%, and 13.1% respectively. Interventions targeting women and health professionals at the same time were not significantly more efficient than those targeting health professionals only. Moreover, multiple-strategy interventions (for example, both behavioural and cognitive) were no more efficient that a single-strategy intervention.

Manual prompts in medical records or computer-generated reminders or flags to tell physicians the date of the last screen and when the next is due appear to be an effective approach to improving preventive practices^22,73,74. Whenever a woman consults her doctor there is an opportunity for the doctor to discuss screening^27,75.

The involvement of physicians and other primary health care providers is key to the success of screening programs. Involvement would be beneficial from the program's inception and should be facilitated through liaison with organizations such as medical associations.

Ongoing liaison with the Canadian College of Family Physicians occurs in Canada through the External Advisory Committee of the Canadian Breast Cancer Initiative. Further efforts could be made to keep physicians informed about the benefits and value of breast screening through articles and notices appearing in the Canadian Family Physician.

2.5 Community Promotion

• Promotional programs should be evaluated for their effectiveness.
• Promotional programs should be targeted to specific groups depending upon local conditions.

Promotional campaigns have been used extensively to increase attendance at screening and to improve knowledge and attitudes. At this time, there is no substantial evidence of the effectiveness of such campaigns in relation to mammography. Even extensive promotional campaigns using mass media, community approaches, and physician education have achieved attendance rates of only 20%-28%^76-79.

Publicity alone is thus insufficient to achieve the high attendance rates necessary for a screening program to be effective. Further strategies are needed. Letters of invitation are one such strategy.

Does publicity increase knowledge and receptivity to letters of invitation and thereby add to compliance? Several studies have shown some limited success of public campaigns in this regard. An Australian study demonstrated that promotion did increase attendance at mammography screening sites, although there was little change in acquisition of appropriate knowledge about breast cancer as a result of the campaign⁷⁶. In North Carolina, there was a greater increase in the percentage of women who reported receiving a mammogram in the previous year in an experimental community (35% to 55%) than in the control community (30% to 40%)⁸⁰.

One of the potential adverse effects of a massive screening campaign is heightened anxiety about breast cancer in the population. Neither the Australian nor the North Carolina programs found any indications of a negative psychological impact from the promotion^76,80.

The type of promotion is likely an important feature. Although it is difficult to isolate the elements in many campaigns, an Australian study was able to examine separately the effects of local newspaper articles, promotion of the program to the community, and promotion of the program to GPs¹⁸. A particular article in a local newspaper increased the baseline attendance rate by 14% in the month in which it was published and by 49% over the ensuing 3 months, whereas no effect on attendance rates was detected as a result of promotion to physicians, and there was little effect from community promotion¹⁸.

An exception to these rates is a study from Australia in which attendance rates following media promotion were 34%, but increased to 51% and 63% with community participation and to 68% with family practitioner intervention⁸¹.

Other attempts to increase mammography use have involved educational and psychological programs. Reynolds et al. built an educational and psychological program around the Health Belief Model⁸². The educational program communicated accurate information about breast cancer, mammography, and potential barriers to obtaining a mammogram. The educational plus psychological program included four components designed specifically to reduce the perceived barriers to compliance with mammography. However, although both the educational and the educational plus psychological programs increased knowledge successfully and increased the intention to comply with mammography, there were no differences in actual compliance. This study may have been too small or too short to be able to properly detect these differences. However, it does not provide encouragement that such educational programs are effective or likely to be cost-effective in increasing mammography use.

Beyond general promotional campaigns, certain special groups may need additional interventions to improve compliance with breast screening. These groups include older women, nonwhite women, women of lower educational and socioeconomic status, rural women, and single women. Unfortunately, very few studies have sufficiently large samples of these groups to examine them specifically. However, the barriers to breast cancer screening in these groups seem to be the same as in other populations, although accentuated.

Although cost has been identified as an issue in the United States, the association of lower income with lower screening rates persists even when cost is not a barrier. Comparing mammography rates within the previous year among 23,521 women in Ontario and 23,932 women in the United States, one study found that the odds ratio of being screened was 2.7 in the United States and 1.8 in Ontario for women with incomes greater than US$45,600⁸³.

Most breast cancer public education programs in the United States target specific groups, low-income women being the most common target audience. Other target audiences are racial minorities, rural women and high-risk women⁶⁷.

The most common means of delivering educational messages to these groups are presentations held in clinics, churches, shelters for battered and homeless women, and work sites, and at meetings of women's organizations and business association educators. Outreach methods have included radio and television public service announcements, newspaper advertisements and articles, bus advertisements, posters, brochures, health fairs, press conferences, billboards, house-to-house recruitment, and targeted mailings. Some programs use interpersonal strategies, with community volunteers contacting women at risk, and then one-to-one teaching by public health nurses or lay educators. Unfortunately, only 30% of the programs are undergoing evaluation, and many count only the numbers of women screened or reached by the educational message.

With special groups, as in general population studies, it is often difficult to identify the specific components of successful programs. For example, several successful programs to reduce barriers to breast cancer screening have been described in the literature. Ansell and colleagues set up a breast cancer screening program in two public clinics and used nurse clinicians and public health workers to recruit women to the clinics. Their intervention addressed the barriers of accessibility to screening, knowledge about breast and cervical cancers, access to follow-up screening examinations, and access to treatment⁸⁴. Although they screened over 10,000 women and detected 84 cases of breast cancer, the study was not a randomized trial and the intervention had multiple components, so it is difficult to identify the aspects that were successful.

One component that has been shown to increase attendance is ease of access to the program^18,85. Accessibility can be a particular barrier for lower income women and rural women, for whom transportation is more difficult.

The use of lay health advisors may be an efficient means of promoting breast cancer screening in populations that are difficult to reach, as reported by some U.S. studies^37,86,87. Currently in Canada there is wide use of newspapers, radio, TV, video, newsletters, and media panels. All programs use newspaper advertising and articles, TV and radio public service announcements, and interviews. Most programs also use TV and radio advertising, media panels, video productions, and newsletters. All programs use brochures, posters, group presentations, health fairs, information displays, public meetings, and physician education.

Although the literature does not show cost-effective results from promotional programs compared with letters of invitation, such programs may improve compliance when combined with letters of invitation. Moreover, the increase in mammography screening is due, in part, to media coverage over the last several years. In general, media coverage seems to be more effective than media advertising of programs. However, both media coverage and letters of invitation will recruit the "easy to reach" women. There has to be special consideration for recruitment of "hard to reach" groups, and the methods used need to take into account any problems of language and culture.

2.6 References

1. Dean PB, Pamilo M. Screening mammography in Finland - 1.5 million examinations with 97 percent specificity. Mammography Working Group, Radiological Society of Finland. Acta Oncol 1999;38 Suppl 13:47-54.
2. Olsson S, Andersson I, Karlberg I, Bjurstam N, Frodis E, Håkansson S. Implementation of service screening with mammography in Sweden: from pilot study to nationwide programme. J Med Screen 2000;7:14-18.
3. Fracheboud J, de Koning HJ, Beemsterboer PMM, Boer R, Hendriks JHCL, Verbeek ALM, van Ineveld BM, de Bruyn AE, van der Maas PJ. Nation-wide breast cancer screening in the Netherlands: results of initial and subsequent screening 1990-1995. National Evaluation Team for Breast Cancer Screening (NETB). Int J Cancer 1998;75(5):694-698.
4. NHS Cancer Screening Programmes. Informing Choice in Breast Screening - Breast Screening Programme Annual Review 2001. Sheffield, NHS Breast Screening Programme, 2001.
5. Australian Institute of Health and Welfare (AIHW). BreastScreen Australia Achievement Report 1997 and 1998. Canberra: Australian Institute of Health and Welfare, 2000.
6. Health Canada. Organized Breast Cancer Screening Programs in Canada 1997 and 1998 Report. Ottawa: Minister of Public Works and Government Services Canada, 2001.
7. Olivotto IA, Kan L, d'Yachkova Y, Warren Burhenne LJ, Hayes M, Hislop TG, Worth AJ, Basco VE, King S. Ten years of breast screening in the screening mammography program of British Columbia, 1988-97. J Med Screen 2000;7(3):152-159.
8. Paquette D, Snider J, Bouchard F, Olivotto I, Bryant H, Decker K, Doyle G. Performance of screening mammography in organized programs in Canada in 1996. Can Med Assoc J 2000;163(9):1133-8.
9. Bonfill X, Marzo M, Pladevall M, Martí J, Emparanza JI. Strategies for increasing women's participation in community breast cancer screening (Cochrane Review). In: The Cochrane Library 2001;issue 3. Oxford: Update Software.
10. Wagner TH. The effectiveness of mailed patient reminders on mammography screening: a meta-analysis. Am J Prev Med 1998;14(1):64-70.
11. Fett M. Description of Breast and Cervical Cancer Screening Programs in British Columbia (Canada), England, Sweden, Finland and the Netherlands. Canberra: Australian Institute of Health, Winston Churchill Memorial Trust, 1989.
12. Skinner CS, Strecher VJ, Hospers H. Physicians' recommendations for mammography: Do tailored messages make a difference? Am J Public Health 1994;84:43-49.
13. Curry SJ, Taplin SH, Anderman C, Barlow WE, McBride C. A randomized trial of the impact of risk assessment and feedback on participation in mammography screening. Prev Med 1993;22:350-360.
14. Dorsch MM, Cheok F, Ingham HM. The effectiveness of invitations from general practitioners in recruiting women to mammographic screening. Med J Aust 1991;155:623-625.
15. Turnbull D, Irwig L, Adelson P. A randomised trial of invitations to attend for screening mammography. Aust J Public Health 1991;15:33-36.
16. Hobbs P, Kay C, Friedman EHI, St Leger AS, Lambert C, Boggis CR, Howard TM, Owen AW, Asbury DL. Response by women aged 65-79 to invitation for screening for breast cancer by mammography: a pilot study. BMJ 1990;301(6764):1314-1316.
17. Somkin CP, Hiatt RA, Hurley LB, Grushkin E, Ackerson L, Larson P. The effect of patient and provider reminders on mammography and Papanicolaou smear screening in a large health maintenance organization. Arch Intern Med 1997;57(15):1658-1664.
18. Hurley SF, Jolley DJ, Livingston PM, Reading D, Cockburn J, Flint-Richter D. Effectiveness, costs, and cost-effectiveness of recruitment strategies for a mammographic screening program to detect breast cancer. J Natl Cancer Inst 1992;84:855-863.
19. Austoker J, Ong G. Written information needs of women who are recalled for further investigation of breast screening: results of a multicentre study. J Med Screening 1994;1:238-244.
20. Wilson A, Leeming A. Cervical cytology screening: a comparison of two recall systems. BMJ 1987;295:181-182.
21. Williams EMI, Vessey MP. Randomised trial of two strategies offering women mobile screening for breast cancer. BMJ 1989;299:158-159.
22. Jepson R, Clegg A, Forbes C, Lewis R, Sowden A, Kleijnen J. The determinants of screening uptake and interventions for increasing uptake: a systematic review. Health Technol Assess 2000;4(14).
23. Sin JP, St Leger AS. Interventions to increase breast screening uptake: Do they make any difference? J Med Screen 1999;6(4):170-181.
24. Hobbs P. The behavioural aspects of breast and cervical screening. Radiography 1986;52:287-290.
25. Tinkler C, Pegington K, Baldwin R. Breast screening attendance: making better use of an appointment system. J Med Screen 2001;8(1):36-38.
26. Meldrum P, Turnbull D, Dobson HM, Colquhoun C, Gilmour WH, McIlwaine GM. Tailored written invitations for second round breast cancer screening: a randomised controlled trial. J Med Screening 1994;1:245-248.
27. Bankhead C, Richards SH, Peters TJ, Sharp DJ, Hobbs FD, Brown J, Roberts L, Tydeman C, Redman V, Formby J, Wilson S, Austoker J. Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care. J Med Screen 2001;8(2):99-105.
28. Stead MJ, Wallis MG, Wheaton ME. Improving uptake in non-attenders of breast screening: selective use of second appointment. J Med Screen 1998;5:69-72.
29. Turner KM, Wilson BJ, Gilbert FJ. Improving breast screening uptake: persuading initial non-attenders to attend. J Med Screening 1994;1:199-202.
30. Taplin SH, Barlow WE, Ludman E, MacLehos R, Meyer DM, Seger D, Herta D, Chin C, Curry S. Testing reminder and motivational telephone calls to increase screening mammography: a randomized study. J Natl Cancer Inst 2000;92(3):233-242.
31. King ES, Rimer BK, Seay J, Balshem A, Engstrom PF. Promoting mammography use through progressive interventions: Is it effective? Am J Public Health 1994;84(1):104-106.
32. Seow A, Straughan PT, Lee HP. A randomized trial of the use of print material and personal contact to improve mammography uptake among screening non-attenders in Singapore. Ann Acad Med Singapore 1998;27(6):838-842.
33. Sharp DJ, Peters TJ, Bartholomew J, Shaw A. Breast screening: a randomised controlled trial in UK general practice of three interventions designed to increase uptake. J Epidemiol Community Health 1996;50:72-76.
34. Atri J, Falshaw M, Gregg R, Robson J, Omar RZ, Dixon S. Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders. BMJ 1997;315(7119):1356-1359.
35. Stoddard AM, Fox SA, Costanza ME, Lane DS, Andersen MR, Urban N, Lipkus I, Rimer B for the NCI Breast Screening Consortium. Effectiveness of telephone counseling for mammography: results from five randomized trials. Prev Med 2002;34(1):90-99.
36. Segura JM, Castells X, Casamitjana M, Macia F, Porta M, Katz SJ. A randomized controlled trial comparing three invitation strategies in a breast cancer screening program. Prev Med 2001;33:325-332.
37. Sung JFC, Blumenthal DS, Coates RJ, Williams JE, Alema-Mensah E, Liff JM. Effect of a cancer screening intervention conducted by lay health workers among inner-city women. Am J Prev Med 1997;13(1):51-57.
38. Yabroff KR, Mandelblatt JS. Interventions targeted toward patients to increase mammography use. Cancer Epidemiol Biomarkers Prev 1999;8(9):749-757.
39. Ratner PA, Bottorff JL, Johnson JL, Cook R, Lovato CY. A meta-analysis of mammography screening promotion. Cancer Detect Prev 2001;25(2):147-60.
40. Smith RA, Haynes S. Barriers to screening for breast cancer. Cancer 1992;69:(7 Suppl):1968-1978.
41. Dawson DA, Thompson GB. Breast Cancer Risk Factors and Screening: United States, 1987. National Center for Health Statistics, 1989.
42. Marchant DJ, Sutton SM. Use of mammography: United States, 1990. MMWR 1990;39:621-630.
43. Fox SA, Murata PJ, Stein JA. The impact of physician compliance on screening mammography for older women. Arch Intern Med 1991;151:50-56.
44. Harris RP, Fletcher SW, Gonzalez JJ, Lannin DR, Degnan D, Earp JA, Clark R. Mammography and age: Are we targeting the wrong women? A community survey of women and physicians. Cancer 1991;67(7):2010-2014.
45. NCI Breast Cancer Screening Consortium and National Health Interview Survey Studies. Screening mammography: A missed clinical opportunity? JAMA 1990;264:54-58.
46. Burg MA, Lane DS, Polednak AP. Age group differences in the use of breast cancer screening tests. J Aging Health 1990;2:514-530.
47. Rubenstein L. Strategies to overcome barriers to early detection of cancer among older adults. Cancer 1994;74:(7 Suppl):2190-2193.
48. Caplan LS, Wells BL, Haynes S. Breast cancer screening among older racial/ethnic minorities and whites: barriers to early detection. J Gerontol 1992;47:Spec No:101-110.
49. Buechner JS, Fulton JP, Feldman JP, DeBuono BA, Kovenock D. Trends in breast cancer screening: Rhode Island, 1987-1989. MMWR 1989;38:569-571.
50. Zapka JG, Stoddard AM, Costanza ME, Greene HL. Breast cancer screening by mammography: utilization and associated factors. Am J Public Health 1989;79:1499-1502.
51. Anda RF, Sienko DG, Remington PL, Gentry EM, Marks JS. Screening mammography for women 50 years of age and older: practices and trends, 1987. Am J Prev Med 1990;6:123-129.
52. Kruse J, Phillips DM. Factors influencing women's decision to undergo mammography. Obstet Gynecol 1987;70:744-748.
53. Bryant H, Mah Z. Breast cancer screening attitudes and behaviors of rural and urban women. Prev Med 1992;21:405-418.
54. Fox SA, Stein JA. Effect of physician-patient communication on mammography utilization by different ethnic groups. Med Care 1991;29:1068-1082.
55. Fulton JP, Buechner JS, Scott HD, DeBuono BA, Feldman JP, Smith RA, Kovenock D. A study guided by the Health Belief Model of the predictors of breast cancer screening of women ages 40 and older. Public Health Rep 1991;106(4):410-420.
56. Buechner JS, Fulton JP, Kaufmann RB, et al. Use of mammography for breast cancer screening: Rhode Island, 1987. MMWR 1989;37:357-360.
57. Rimer BK, Kemtz MK, Kessler HB, Engstrom PF, Rosan JR. Why women resist screening mammography: patient-related barriers. Radiology 1989;172:243-246.
58. Routledge DN, Hartmann WH, Kinman PO, Winfield AC. Exploration of factors affecting mammography behaviors. Prev Med 1988;17:412-422.
59. Howard J. Using mammography for cancer control: an unrealized potential. CA Cancer J Clin 1987;37:33-48.
60. Vogel VG, Graves DS, Vernon SW, Lord JA, Winn RJ, Peters GN. Mammographic screening of women with increased risk of breast cancer. Cancer 1990;66:1613-1620.
61. Munn EM. Nonparticipation in mammography screening: apathy, anxiety or cost? N Z Med 1993;106:284-286.
62. Hammond JA, Stewart M. Female patients' attitudes to mammography screening. Can Fam Physician 1994;40:451-455.
63. American Cancer Society. Older Women's Breast Cancer Education Interventions Workshop Report. 1992 (Abstract).
64. American Association of Retired Persons. You Can Make a Difference: Educating Older Women About Mammography. Washington, DC: American Association of Retired Persons, 1993.
65. McBride CM, Curry SJ, Taplin S, Anderman C, Grothaus L. Exploring environmental barriers to participation in mammography screening in an HMO. Cancer Epidemiol Biomarkers Prev 1993;2:599-605.
66. Maxwell CJ, Bancej CM, Snider J. Predictors of mammography use among Canadian women aged 50-69: findings from the 1996/97 National Population Health Survey. Can Med Assoc J 2001;164(3):329-334.
67. Coyne CA, Hohman K, Levinson A. Reaching special populations with breast and cervical cancer public education [review]. J Cancer Educ 1992;7:293-303.
68. Fajardo LL, Saint-Germain M, Meakem TJ, 3d, Rose C, Hillman BJ. Factors influencing women to undergo screening mammography. Radiology 1992;184:59-63.
69. Zapka JG, Stoddard AM, Maul L, Costanza ME. Interval adherence to mammography screening guidelines. Med Care 1991;29:697-707.
70. Fox SA, Siu AL, Stein JA. The importance of physician communication on breast cancer screening of older women. Arch Intern Med 1994;154:2058-2068.
71. Grady KE, Lemkau JP, McVay JM, Reisine ST. The importance of physician encouragement in breast cancer screening of older women. Prev Med 1992;21:766-780.
72. Mandelblatt JS, Yabroff KR. Effectiveness of interventions designed to increase mammography use: a meta-analysis of provider-targeted strategies. Cancer Epidemiol Biomarkers Prev 1999;8(9):759-767.
73. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. J Am Med Inform Assoc 1996;3(6):399-409.
74. Kupets R, Covens A. Strategies for the implementation of cervical and breast cancer screening of women by primary care physicians. Gynecol Oncol 2001;83(2):186-97.
75. Valanis BG, Glasgow RE, Mullooly J, Vogt TM, Whitlock EP, Boles SM, Smith KS, Kimes TM. Screening HMO women overdue for both mammograms and pap tests. Prev Med 2002;34(1):40-50.
76. Turnbull D, Irwig L, Simpson JM, Donnelly N. The psychosocial impact of implementing a mammography screening campaign in an Australian community. Soc Sci Med 1994;39:543-551.
77. Haiart DC, Henderson J, McKenzie L, Kirkpatrick AE. A mobile breast screening project in Scotland: lessons learned for national screening. Int J Health Plan Management 1990;15:201-213.
78. Haiart DC, McKenzie L, Henderson J, Pollock W, McQueen DV, Roberts MM, Forrest AP. Mobile breast screening: factors affecting uptake efforts to increase response and acceptability. Public Health 1990;104(4):239-247.
79. Williams EM, Vessey MP. Compliance with breast cancer screening achieved by the Aylesbury Vale mobile service (1984-1988). J Public Health Med 1990;12:51-55.
80. Fletcher SW, Harris RP, Gonzalez JJ, Degnan D, Lannin DR, Strecher VJ, Pilgrim C, Quade D, Earp JA, Clark RL. Increasing mammography utilization: a controlled study. J Natl Cancer Inst 1993;85(2):112-120.
81. Clover K, Redman S, Forbes J, Sanson-Fisher R, Callaghan T. Two sequential randomized trials of community participation to recruit women for mammographic screening. Prev Med 1996;25:126-134.
82. Reynolds KD, West SG, Aiken LS. Increasing the use of mammography: a pilot program. Health Educ Q 1990;17:429-441.
83. Katz SJ, Hofer TP. Socioeconomic disparities in preventive care persist despite universal coverage. Breast and cervical cancer screening in Ontario and the United States. JAMA 1994;272:530-534.
84. Ansell D, Lacey L, Whitman S, Chen E, Phillips C. A nurse-delivered intervention to reduce barriers to breast and cervical cancer screening in Chicago inner city clinics. Public Health Rep 1994;109:104-111.
85. Schofield PE, Cockburn J, Hill DJ, Reading D. Encouraging attendance at a screening mammography programme: determinants of response to different recruitment strategies. J Med Screening 1994;1:144-149.
86. Navarro AM, Senn KL, McNicholas LJ, Kaplan RM, Roppe B, Campo MC. Por La Vida model intervention enhances use of cancer screening tests among Latinas. Am J Prev Med 1998;15(1):32-41.
87. Slater JS, Ha CN, Malone ME, McGovern P, Madigan SD, Finnegan JR, Casey-Paal AL, Margolis KL, Lurie N. A randomized community trial to increase mammography utilization among low-income women living in public housing. Prev Med 1998;27(6):862-870.

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