Quality Determinants of Organized Breast Cancer Screening Programs

Retention

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3.1 Return Visits to Mammography Screening Programs

• Programs should try to reach close to 100% attendance for rescreening in order to
• reduce mortality from breast cancer through screening.

Reductions in breast cancer mortality as evidenced in screening trials require mammographic screening to be routinely repeated^1-5, as cancers are frequently detected even after several normal screens have been achieved^3,6.

Despite the benefits of early detection obtainable through mammography, regular screening according to guidelines has not yet been widely attained. Although in most settings the majority of women report having had a mammogram, fewer report having had one recently, and still fewer (20%-27%) report having had multiple screens or an age-appropriate number^7-9. Although repeated screening seems to be more prevalent in organized programs, results from nine rounds of screening in Nijmegen, the Netherlands, showed that less than 40% of women completed all rounds, despite 90% participating at least once^5,6.

Participation in screening programs declines at subsequent screening rounds^5,10, although women who do return are more compliant^10,11. Women are more receptive of mammography if they have previously had a mammogram, and prior screening is strongly predictive of return for further screening^12-15. Previous attenders are more likely to reattend than those who previously did not attend or who were previously ineligible to do so16. In a variety of settings, the proportion of previous attenders returning for rescreen was high (70%-90%), depending on the interval measured and the number of examinations considered^14,17-24.

Despite the fact that prior screening increases the likelihood that women will return, in some settings even these women are unlikely to be rescreened, with reported frequencies of repeat screening as low as 25% to 57%^25-29. The statistical cutoff interval for considering women as having returned for screening can have a major influence on the actual rate of repeat screening^28,30.

Although many programs have successfully achieved high levels of attendance at rescreening, attendance within the recommended time intervals for rescreening is lower. Regardless of the recommended screening interval specified by the program, compliant attendance appears to be a further challenge. In a study of the National Health Service breast screening program in the United Kingdom, fewer than half of screened women had been rescreened within the recommended 3-year interval, although by 38 months nearly three-quarters had been rescreened and eventually nearly 90% returned for rescreen¹⁹. In an Australian program with a recommendation for biennial screening, the median time from first to second screen was 27 months, so more than half the returning women were noncompliant with program recommendations¹⁷.

Compliance with mammography screening recommendations can be affected by a number of factors, and achieving compliant attendance in programs that screen annually may be even more difficult. In a Canadian screening trial, half the participants preferred screening every 2-3 years over annual screening, but despite this preference many women can comply with annual screening regimens or at least return for future screening¹². Still, in the British Columbia screening program, of the women who returned within 15 months, only 41% returned in the recommended annual interval²⁹, and in another U.S. program that provided women with annual reminders, a substantial number of women waited up to 2 years to have a repeat mammogram²⁸.

Previous studies of regular adherence to mammographic screening have been limited. Some, particularly those from the United States, have relied on self-reported information^{8-9,26,28,31-34}. This method is likely to overestimate mammography use because of social desirability biases and to underestimate the time that has elapsed since previous mammography as a result of telescoping biases. Others studies are unable to distinguish the extent to which participation in subsequent rounds is due to reattenders or new recruits and thus have not distinguished determinants of participation from determinants of reattendance^5,10,13. However, the most prominent factor limiting comparisons among both programs and prior studies is the use of varying definitions of reattendance and compliance.

Disentangling the separate effects of reattendance, compliance with recommended intervals, and long-term compliance has been hampered by a lack of quantitative data¹⁹, but efforts have been made to assess these various factors independently^19,30,35. Some studies have looked at repeat mammography but provided limited or no information about the timing of such return visits or reattendance patterns outside of the chosen time interval, and therefore did not consider that women may return within an interval that will still offer some advantages of early detection^7,8,25,26,28. Sometimes reattendance and compliance issues are not considered separately. For example, the proportion of eligible women receiving a screen in the previous 3 years ("coverage") is a performance indicator in breast screening programs in the United Kingdom¹⁹ and can be adversely affected if women do not attend for initial or repeat screening or if they do not do so within the recommended interval.

Finally, a number of factors come into play that challenge or aid programs in maintaining participation for subsequent screening.

3.2 Factors Associated with Reattendance and/or Compliance

• Programs should identify the factors (age, demographic variables, facility) that play a role in reattendance.
• Programs should plan recruitment strategies to address the identified gaps in achieving reattendance.

Age, demographic variables, facility characteristics, provider factors, health history, prior mammography, psychosocial factors and recruitment factors are all associated with reattendance or compliance.

Participation, reattendance, and compliance with mammography have been reported to occur less frequently in both younger^29,36,37 and older women^{3,5,10,14,18,22}. Consistent with these results is the finding that repeat screening is highest among women aged 55-64 as compared with levels of screening among both younger and older groups^9,25 . However, the findings are inconsistent: some have found that younger women are more likely to participate in a full series of four annual mammograms11, adhere to screening guidelines^8,13, drop out of screening trials after just one or two screens³⁷, and obtain annual mammograms³³. Others have reported that age is unrelated to having repeat mammograms^17,26,38.

Various studies^{8,11,26,27,32,33,37,39,40} have shown that women with higher socioeconomic status are more likely to have multiple mammograms, to return for repeat mammography, and to adhere to screening guidelines. However, education seems to be the most consistent factor, as negative findings have been demonstrated for several other factors such as employment status and home ownership^11,17. Being married has been shown to be both unrelated to rescreening11 and related to compliance with annual mammography and to long-term repeated screening^26,37,39. Various ethnic and cultural factors have been examined^9,11,40,41, and findings have been inconsistent, though foreign-born women were less likely to participate in rescreens^11,41.

Several facility-related factors have been examined, and accessibility of the screening clinic has been prominently associated with reattendance and compliance with rescreening recommendations^11,12,17,29. One study found that hospital sites were preferable to clinics²⁵. Staff at screening facilities also appear to play a role in promoting reattendance: compared with reattenders, non-reattenders have reported finding clinic staff less courteous, less welcoming, unhelpful, harder to question, or unsupportive with problems arising from the test and, with regard to technologists, less competent^12,20,21. When reminder systems are in place, women are more likely to adhere to screening guidelines⁸, but the capacity of the centre also plays a role. Overwhelmed centres are unable to screen women within the time recommended by guidelines without increased resources¹⁹. If women must wait a long time between their physician's recommendation and the mammography screening appointment they may be less likely to get rescreened^7,12.

A woman's usual physician plays a major role in whether women reattend and comply with mammography intervals. Physician referral for a mammogram is a strong promotor of screening. Increased referrals for mammography result in increased screening mammography and are strongly associated with women having had repeat mammograms^7,27,32. Women with a regular physician and women who had visited a physician in the year before recruitment have been shown to be more likely to comply with repeat mammography screening^11,42. Having a physician who criticizes or does not encourage screening is a barrier to reattendance and compliance^12,29. The type of practitioner may also have an impact. One study found that routinely visiting a gynecologist was positively associated with having multiple screens³⁴. Women were more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened⁸.

A woman's health status can also affect her attendance and compliance with screening. Those who fail to reattend have frequently cited acute illness as the reason²⁰, and women who did return for repeat screening had better self-reported health¹¹. A family history of breast cancer is a commonly reported factor associated with increased likelihood of reattending^21,27 and long-term compliance with a program³⁵, although some evidence shows that this has no impact^11,17.

Women who have had previous mammography, either screening or diagnostic, are more likely to reattend and comply with recommended screening intervals^15,17,6,35. Reporting breast problems (e.g. lumps) did not affect reattendance at a second round of screening in one study¹⁷, but women were less likely to reattend in another⁴⁰. In others studies, reporting of breast problems was associated with adhering to screening guidelines^8,9. Regular performance of clinical breast examination has a positive association with mammography adherence^9,33,35.

Despite indications that women suffer long-term morbidity, increased anxiety about breast cancer⁴³, and recent unnecessary biopsy¹², most studies show that women are either equally likely^{16,17,20,21,26,43-45} or more likely^25,44,46 to return or intend to return if they experienced prior false-positive mammography results. Few contrary findings have been published. One study found that women who returned annually for screening were more likely to have had a normal initial study than were late compliers or noncompliers⁴⁷. Another found that a false-positive screening result was associated with nonattendance at the next round in six screening rounds⁵. In both cases, it is uncertain whether this was the result of a negative attitude toward screening or toward continued clinical follow-up⁵. However, in a British study, 15% of women who had had an initial false-positive result did not attend for subsequent mammography, as compared with 8% of women whose first mammogram was negative⁴⁸.

Although previous attenders appear to reattend more frequently, previous experience with mammography may result in nonattendance. Some disincentives to return have included radiation concerns^12,29 and negative views of initial screening, for example, that it was uncomfortable, painful, stressful, embarrassing, distressing, worse than expected, or not reassuring and that attendance was not worthwhile^12,20,21,49.

Whether women's concern over their breast cancer risk influences reattendance and compliance is uncertain: it has been shown to be associated with both a higher¹¹ and a lower likelihood of reattending²⁶. Some studies have found that women who perceive a higher susceptibility to breast cancer or are knowledgeable about lifetime risk are more likely to reattend^27,32,34. Others report that perceived breast cancer risk has no effect on reattendance²⁰. Women who perceive greater benefits of mammography have a higher frequency of mammography and shorter time interval since the last mammogram⁵⁰. Guideline adherence is associated with a belief that breast cancer is curable³¹, and reattenders are more likely to believe that mammography is efficacious in detecting and curing breast cancer^20,21. Women who have had multiple screens are more likely to express a willingness to pay $75-$100 for a mammogram, possibly indicating their view of its worth. On the other hand, women who express more anxiety about mammography or associate physical examinations with worry are less likely to obtain repeat mammography^11,27.

Women who are preventively oriented may be more likely to reattend and comply with recommended screening intervals^17,50. Other positive practices, such as participation in cervical screening⁸, regular breast self-examination^12,29, and being a nonsmoker³², have been associated with screening guideline adherence and repeat screening, although these findings have been contradicted elsewhere¹⁷.

Social support may influence a woman's decision to return¹². However, some studies have reported that the influence of a woman's friends, partner, children, co-workers, and physician did not affect second round attendance¹⁷, contrary to much of the literature on the role of the physician.

Women who do not reattend may be less aware of screening guidelines. Knowledge of the screening guideline recommendations has been found to be associated with adherence to screening within the recommended interval³¹. Some studies have shown that women who failed to reattend did not believe in or were unaware of the need for further screening^20,21,29. In some cases this view was supported by their physician²⁹.

Ease of recruitment plays a major role in women's reattendance and compliance with recommended rescreening intervals, as indicated by the literature on the "reluctant participant". Women who require repeated recruitment efforts are less likely to reattend or return for a series of screens than women who require minimal effort^{11,17,18,35,51}. Despite a reduced tendency to reattend, recruitment of reluctant participants has been demonstrated to be worthwhile in elevating participation levels and improving prognosis in detected breast cancers¹¹.

Even if women are invited in a timely fashion, compliance with recommended rescreen intervals may be adversely affected if there is delay in making an appointment or a change in the appointment time19. Women have cited lack of time and inconvenient appointment times as reasons for not reattending^12,20.

3.3 Recall

• Women should be sent a recall letter before their next screening date.
• The recall letter should stress the benefit of regular screening.
• Letters for rescreening should be tailored to the results of the most recent mammogram.

For 20 years of their lives women will have access to regular screening by mammography. Interventions aimed at maintaining this habit have an important role in the fight against breast cancer. Relatively simple interventions that can be maintained over the years should be the objective.

The advantages of invitations as a recruitment approach have been previously discussed. Recall letters, whether signed by the physician or the screening program, significantly increase participation in mammography as compared with no letter^52,53. Invitation by telephone can also be a useful strategy⁵⁴.

Use of tailored letters containing information about previous screening history is not effective, although such letters may be more helpful than a standard letter in improving reattendance of women with prior false-positive findings¹⁶. A tailored leaflet enclosed with every invitation and directed at women who had previously undergone mammography did not enhance reattendance⁵⁵.

A telephone follow-up can be considered for women who do not respond to the letter of invitation for rescreening. Use of the telephone carries the advantage that the reasons why women are not returning can be discussed and barriers can be addressed. Relative costing needs to be examined more formally.

A further concern regarding rescreening after the first screen is the tendency to increase the screening intervals. By scheduling an appointment one might minimize the chances of delays past 2 years. Other alternatives might be to schedule the next appointment for 2 years' time at the initial mammogram. A reminder card can be issued. The program can also advise women that when their rescreen is due, they will be sent an appointment letter with a time that could be changed if they so choose. An invitational letter with a scheduled appointment could then be sent out 1 to 2 months beforehand. Programs may want to consider trials of such alternatives.

3.4 References

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