Methods for Development of the European Commission Initiative on Breast Cancer Guidelines A Cluster-Randomized Trial of a Primary Care Informatics-Based System for Breast Cancer Screening The mammographic screening trials: commentary on the recent work by Olsen and Gøtzsche. Telephone counseling and attendance in a national mammography-screening program a randomized controlled trial. The effect of information about overdetection of breast cancer on women's decision-making about mammography screening: study protocol for a randomised controlled trial Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial Breast Cancer Surveillance Consortium: a national mammography screening and outcomes database. Mammography Screening and Risk of Breast Cancer Death: A Population-Based Case–Control Study The impact of different communication and organizational strategies on mammography screening uptake in women aged 40-45 years. Detroit's avoidable mortality project: breast cancer control for inner-city women. Mammographic breast cancer screening--a randomized trial in Malmö, Sweden. A prospective cohort study investigating psychosocial predictors of attendance at a mobile breast screening service. Sociodemographic Determinants of Nonattendance in a Population-Based Mammography Screening Program in the City of Manisa, Turkey A community peer-volunteer telephone reminder call to increase breast cancer-screening attendance. Psychosocial predictors of first attendance for organised mammography screening Counselling interventions to address the psychological consequences of screening mammography: a randomised trial. Women's perception of the benefits of mammography screening: population-based survey in four countries.
In December 2003 , the European Council identified best practice as key for ensuring development of high- quality cancer-screening programs . To support national policies on cancer control , the European Union institutions progressed several initiatives on cancer . The European Commission ( EC ) Initiative on Breast Cancer ( ECIBC ) is the most recent of these projects and the most implementation driven . Within this initiative , the European Guidelines for Breast Cancer Screening and Diagnosis ( in short , European Breast Guidelines ) are being developed ( http://ecibc.jrc.ec.europa.eu/ ) . Guidelines are approaches to generally improve prevention , diagnosis , treatment , and follow-up of diseases , overcoming inappropriate variations by providing recommendations for best care . The new era of guidelines promises recommendations that are based on the best available evidence summarized in systematic review s while providing the necessary flexibility needed to individualize decisions . The best methods for development of practice guidelines have experienced intense elaboration and attention during the past decades ( 17 ) . The impetus for this attention has been the change from expert- or consensus-based to evidence -based health care recommendations . Although this change in terminology should express the shift from un systematic development of guidelines to systematic and trustworthy recommendations , it is often misunderstood and misconstrued as meaning that experts are now meaningless in the process or as if consensus through discussion is a matter of the past . Neither is correct . Experts from various disciplines and consensus as a result of deliberation remain a mainstay of health care guideline development ( 810 ) . These experts are responsible for prioritization of questions that should be addressed in guidelines ; judgments that result from interpretation of evidence , including the rating of the certainty of the available evidence ; and decisions about how the judgments on the different criteria bear on recommendations . What has changed over time in guideline development are the rules , the structure and explicitness of the process , and the guideline product . Indeed , review s of guideline development methodology and how guidelines can be improved have led to more structured and documented processes that allow a reduction of bias and provide balanced views of appropriately composed guideline panels ( 2 , 5 , 6 ) . Core components for trustworthy guideline development ( 13 , 5 , 7 , 11 ) include that guidelines be developed by a knowledgeable , multidisciplinary panel of experts and representatives from key affected groups ; be based on a systematic review of the existing evidence ; consider important patient subgroups and patient preferences as appropriate ; be based on an explicit and transparent process that minimizes distortions , biases , and conflicts of interest ( 12 ) ; provide a clear explanation of the logical relationships between alternative care options and health outcomes and provide ratings of both the quality of evidence and the strength of the recommendations ( 1316 ) ; and be reconsidered and revised as appropriate when important new evidence warrants modifications . In addition , greater transparency in linking the considered research evidence and the recommendations , as well as the requirement of making structured expert judgments , represents a shift in the guideline development paradigm ( 5 , 11 , 1719 ) . At the same time , developing guidelines for a large number of member states and those that aim to adapt the guidelines poses challenges , such as the feasibility of implementing strategies that may exist in some member countries but not others ( for example , organized population -based screening in Italy but not Greece ) . Addressing these challenges requires considerations that extend beyond strictly clinical efforts in guideline development and mastering the many factors that influence recommendations and their implementation . This article describes the rationale , methods , and processes the ECIBC has adopted to develop the European Breast Guidelines in the context of evolving international st and ards . It also describes an innovative approach to presenting , disseminating , and accelerating implementation of recommendations . Guideline Methodology and Development To adhere to the core requirements for guideline development , the EC has taken several steps . First , it selected , via an open call ( https://ecibc.jrc.ec.europa.eu/ guidelines -team ) , a panel with broad representation of expertise , knowledge , and background , which includes patients , health care professionals , epidemiologists , guideline method ologists , and others ( Appendix ) . These individuals voluntarily participate in the ECIBC and compose the guidelines development group ( GDG ) . Second , it ensured that all recommendations were supported by systematic review s of the evidence conducted by independent scientists from Cochrane Iberoamricathe systematic review team (SRT)following st and ard Cochrane Collaboration methods ( 20 , 21 ) . Third , because this is a women-centered initiative , we included women advocates in the GDG as full voting guideline group members . We separately considered important subgroups of women during recommendation development ( for example , different age groups ) , and we specifically focused on evidence that supports best ways of communicating this information to women to inform their decisions . Fourth , we applied EC conflict of interest rules ( http://ecibc.jrc.ec.europa.eu/rules ) , which are consistent with international recommendations , and used GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) Evidence to Decision ( EtD ) frameworks to minimize the influence of competing interests on the recommendations ( 12 , 17 , 18 ) . These EtD frameworks help guideline panels use evidence in a structured , transparent way to inform decisions with a series of criteria , such as anticipated harms and benefits of the options considered , the certainty of the evidence for those effects , and the costs and feasibility of the options , to help them reach their decision . Fifth , using the GRADE approach to guideline development and its EtD frameworks , we focused our questions and recommendations on outcomes that matter to women and provided a rating of the certainty or quality of evidence and the strength of recommendations that is widely accepted as the reference st and ard ( Figures 1 and 2 ) . Sixth , our evidence review s are up to date when the recommendations are formulated , and we engage in international stakeholder feedback to ensure that recommendations remain timely and relevant to public health and clinical practice . The ECIBC is committed to review ing and updating the recommendations as required when new evidence becomes available . The general process is explained in Figure 3 and is based on the Guidelines International NetworkMcMaster Guideline Development Checklist ( https://hei grade .mcmaster.ca/ guideline -development/using-checklist ) ( 5 ) . Figure 1 . According to GRADE , certainty , quality , strength of evidence , or confidence in the estimate of effect is determined on the basis of a systematic review of the evidence for each outcome ( based on the domains risk of bias , indirectness , imprecision , inconsistency , and publication bias that lower certainty and , usually only for nonr and omized studies , large effects , doseresponse relations and opposing plausible residual confounding that may increase the certainty ) . For recommendations , the overall certainty is determined across outcomes based on the lowest certainty outcome among those critical for decision making for the specific context . The guidelines development group applies the GRADE Evidence -to-Decision frameworks to make recommendations that are made available on the European Commission Web site . ( Reproduced from reference 15 , with permission from Schnemann HJ . ) . GRADE = Grading of Recommendations Assessment , Development and Evaluation . Figure 2 . GRADE EtD frameworks . The GRADE EtD frameworks as available in the GRADE pro software ( www . grade pro.org ) . They help with structuring the entire guideline process into 4 sections and support the conduct of guideline group meetings , presentation , and implementation . They clarify the perspective that is taken by the guideline panel or decision maker and the type of question that is asked in the question section . The section on assessment includes the criteria if the problem is a priority , the balance of health benefits and harms , values and preferences related to the outcomes , cost , re sources and cost-effectiveness , equity , acceptability , and feasibility . Conclusions provide the decision or recommendation with a justification and implementation , as well as research considerations . The presentation function supports the conduct of guideline group meetings and facilitates the output of EtD frameworks to other implementation tools , such as Web sites , h and -held apps , and interactive decision aids . EtD = Evidence to Decision ; GRADE = Grading of Recommendations Assessment , Development and Evaluation ; HTA = health technology assessment ; PICO = population , intervention , comparators , and outcomes . Figure 3 . Approach to guideline development used by the European Commission Initiative on Breast Cancer . The European Commission JRC has oversight of the organization , budgeting , planning , and training . The JRC also manages conflicts of interest , documents all aspects of the work , and manages the membership and group processes . The guideline development group and JRC formulate the questions and work with the systematic review team on identifying and assessing the evidence . The guidelines development group is responsible for developing the recommendations . The JRC is responsible for most other aspects as described in the figure under dissemination , implementation , and updating . JRC = Joint Research Centre ; PICO = population , intervention , comparator , and outcomes . ( Reproduced with adaptation to the JRC process from BACKGROUND Information technology offers the promise , as yet unfulfilled , of delivering efficient , evidence -based health care . OBJECTIVE To evaluate whether a primary care network-based informatics intervention can improve breast cancer screening rates . DESIGN Cluster-r and omized controlled trial of 12 primary care practice s conducted from March 20 , 2007 to March 19 , 2008 . PATIENTS Women 42–69 years old with no record of a mammogram in the prior 2 years . INTERVENTIONS In intervention practice s , a population -based informatics system was implemented that : connected overdue patients to appropriate care providers , presented providers with a Web-based list of their overdue patients in a non-visit-based setting , and enabled “ one-click ” mammography ordering or documented deferral reasons . Patients selected for mammography received automatically generated letters and follow-up phone calls . All practice s had electronic health record reminders about breast cancer screening available during clinical encounters . MAIN MEASURES The primary outcome was the proportion of overdue women undergoing mammography at 1-year follow-up . KEY RESULTS Baseline mammography rates in intervention and control practice s did not differ ( 79.5 % vs 79.3 % , p = 0.73 ) . Among 3,054 women in intervention practice s and 3,676 women in control practice s overdue for mammograms , intervention patients were somewhat younger , more likely to be non-Hispanic white , and have health insurance . Most intervention providers used the system ( 65 of 70 providers , 92.9 % ) . Action was taken for 2,652 ( 86.8 % ) intervention patients [ 2,274 ( 74.5 % ) contacted and 378 ( 12.4 % ) deferred ] . After 1 year , mammography rates were significantly higher in the intervention arm ( 31.4 % vs 23.3 % in control arm , p < 0.001 after adjustment for baseline differences ; 8.1 % absolute difference , 95 % CI 5.1–11.2 % ) . All demographic subgroups benefited from the intervention . Intervention patients completed screening sooner than control patients ( p < 0.001 ) . CONCLUSIONS A novel population -based informatics system functioning as part of a non-visit-based care model increased mammography screening rates in intervention practice s . TRIAL REGISTRATION Clinical Trials.gov ; 68 CA A Cancer Journal for Clinicians Since the publication of the results of the Greater New York Trial and the Swedish Two-County Trial in the 1970s and 1980s , there has been a general consensus that screening for breast cancer with mammography reduces mortality from the disease . The results of these pioneering trials for the most part have been subsequently confirmed by later trials in Sweden , Canada , and the United Kingdom . Although some issues endure , most notably those regarding cost-effectiveness of screening in particular age groups , as well as concerns about harms associated with false positive results , the evidence that screening reduces deaths from breast cancer has steadily increased , and the consensus regarding the benefit of screening has grown stronger . The evidence that screening with mammography is associated with a lower breast cancer death rate recently was challenged when The Lancet published a research letter by Olsen and Gotzsche ( OG ) describing their overview of the mammographic screening trials . OG asserted that “ ... the reliable evidence does not indicate any survival benefit of mass screening for breast cancer , ” and they maintained that screening leads to more aggressive treatment ; thus , screening is not only without benefit , but in addition to representing a waste of health re sources , it actually results in net harms . This article has generated considerable print and electronic media attention , with a spectrum of opinions ranging from complete support for the conclusions of OG to complete dissent . Yet , despite the public exchange , the OG report has failed to convince institutional leaders in the United Kingdom , Sweden , the Netherl and s , or the United States to change screening policy . Most have publicly reaffirmed the current recommendations supporting regular mammography . Having thoroughly considered all available information , including the OG report , the US Preventive Services Task Force retained its current recommendation that women have regular mammograms every one to two years , and in fact , exp and ed the recommendation to include women in their forties . In addition , 10 leading medical organizations published a full-page open letter in the New York Times on January 31 , 2002 , supporting the value of early breast cancer detection . In our opinion , which is based on evidence accrued over decades of scientific research on breast cancer screening , and countless , independent expert peer review s of the study design s , data , and conclusions of the trials , the scientific foundation for the value of early breast cancer detection with mammography is sound . To see why , consider Figure 1 , which summarizes the most recently published results of the mammographic screening trials . The results indicate that there is a statistically significant 24 % reduction in  breast cancer mortality associated with an invitation to screening .  The distinction between “ invited to screening ” versus “ screened ” becomes clear when you consider that a r and omized trial of screening examines mortality rates in the study arm offered screening versus the study arm offered usual care . Mr. Duffy is Principal Scientist , Cancer Research UK , London , Engl and BACKGROUND In Germany , a  mammography-screening program  ( MSP ) was implemented on a national level . It complies with all criteria of the European guidelines for quality assurance in screening mammography ; however , the attendance rate is 54 % , falling short of the target attendance rate of 70 % . The aim of this study was to investigate whether additional telephone counseling improves attendance among nonresponders and the level of satisfaction with telephone counseling . DESIGN In a prospect i ve RCT , women identified as nonresponders in the MSP were r and omized to a control group that received written reminders or to an intervention group that additionally received telephone counseling . In a follow-up , a subset of the intervention group was contacted by telephone regarding their satisfaction with telephone counseling . SETTING / PARTICIPANTS In 2008 , a total of 5477 women aged 50 - 69 years who were eligible for the German MSP but had not participated up to 6 weeks after the first invitation were included in the study . INTERVENTIONS Individual telephone counseling consisted of scripted calls from a trained counselor who provided information on MSP and answered the woman 's questions . MAIN OUTCOME MEASURES Report of mammography use provided by the screening unit 3 months after the reminder was sent . RESULTS Analysis was conducted in 2009 . Comparison of screening attendance revealed a significantly higher attendance rate in the intervention group compared with controls ( 29.7 % vs 26.1 % , p=0.0035 ) . When only women for whom telephone numbers were available were analyzed , attendance was even better ( 35.5 % vs 29.7 % , p=0.0004 ) . In the follow-up , 278 of 404 women were actually surveyed . Of those , 33 % stated that telephone counseling had influenced their decision , 56 % stated that they had undergone screening mammography , and 77 % agreed that personal telephone counseling should be used routinely to encourage nonresponders to go for screening . CONCLUSIONS Individual telephone counseling for nonresponders to a national program for breast cancer screening was well accepted by participants and effective . TRIAL REGISTRATION This study is registered at the Australian New Zeal and Clinical Trials Registry ACTRN12611000645954 Introduction Women are largely unaware that mammography screening can cause overdetection of inconsequential disease , leading to overdiagnosis and overtreatment of breast cancer . Evidence is lacking about how information on overdetection affects women 's breast screening decisions and experiences . This study investigates the consequences of providing information about overdetection of breast cancer to women approaching the age of invitation to mammography screening . Methods and analysis This is a r and omised controlled trial with an embedded longitudinal qualitative sub study . Participants are a community sample of women aged 48–50 in New South Wales , Australia , recruited in 2014 . Women are r and omly allocated to either quantitative only follow-up ( n=904 ) or additional qualitative follow-up ( n=66 ) . Women in each stream are then r and omised to receive either the intervention ( evidence -based information booklet including overdetection , breast cancer mortality reduction and false positives ) or a control information booklet ( including mortality reduction and false positives only ) . The primary outcome is informed choice about breast screening ( adequate knowledge , and consistency between attitudes and intentions ) assessed via telephone interview at 2 weeks postintervention . Secondary outcomes measured at this time include decision process ( decisional conflict and confidence ) and psychosocial outcomes ( anticipated regret , anxiety , breast cancer worry and perceived risk ) . Women are further followed up at 6 months , 1 and 2 years to assess self-reported screening behaviour and long-term psychosocial outcomes ( decision regret , quality of life ) . Participants in the qualitative stream undergo additional in-depth interviews at each time point to explore the views and experiences of women who do and do not choose to have screening . Ethics and dissemination The study has ethical approval , and results will be published in peer- review ed journals . This research will help ensure that information about overdetection may be communicated clearly and effectively , using an evidence -based approach , to women considering breast cancer screening . Trial registration number Australian New Zeal and Clinical Trials Registry ACTRN12613001035718 BACKGROUND Mammography screening can reduce breast cancer mortality . However , most women are unaware that inconsequential disease can also be detected by screening , leading to overdiagnosis and overtreatment . We aim ed to investigate whether including information about overdetection of breast cancer in a decision aid would help women aged around 50 years to make an informed choice about breast screening . METHODS We did a community-based , parallel-group , r and omised controlled trial in New South Wales , Australia , using a r and om cohort of women aged 48 - 50 years . Recruitment to the study was done by telephone ; women were eligible if they had not had mammography in the past 2 years and did not have a personal or strong family history of breast cancer . With a computer program , we r and omly assigned 879 participants to either the intervention decision aid ( comprising evidence -based explanatory and quantitative information on overdetection , breast cancer mortality reduction , and false positives ) or a control decision aid ( including information on breast cancer mortality reduction and false positives ) . Participants and interviewers were masked to group assignment . The primary outcome was informed choice ( defined as adequate knowledge and consistency between attitudes and screening intentions ) , which we assessed by telephone interview about 3 weeks after r and om allocation . The primary outcome was analysed in all women who completed the relevant follow-up interview questions fully . This trial is registered with the Australian New Zeal and Clinical Trials Registry , number ACTRN12613001035718 . FINDINGS Between January , 2014 , and July , 2014 , 440 women were allocated to the intervention group and 439 were assigned to the control group . 21 women in the intervention group and 20 controls were lost to follow-up ; a further ten women assigned to the intervention and 11 controls did not answer all questions on attitudes . Therefore , 409 women in the intervention group and 408 controls were analysed for the primary outcome . 99 ( 24 % ) of 409 women in the intervention group made an informed choice compared with 63 ( 15 % ) of 408 in the control group ( difference 9 % , 95 % CI 3 - 14 ; p=0·0017 ) . Compared with controls , more women in the intervention group met the threshold for adequate overall knowledge ( 122/419 [ 29 % ] vs 71/419 [ 17 % ] ; difference 12 % , 95 % CI 6 - 18 ; p<0·0001 ) , fewer women expressed positive attitudes towards screening ( 282/409 [ 69 % ] vs 340/408 [ 83 % ] ; 14 % , 9 - 20 ; p<0·0001 ) , and fewer women intended to be screened ( 308/419 [ 74 % ] vs 363/419 [ 87 % ] ; 13 % , 8 - 19 ; p<0·0001 ) . When conceptual knowledge alone was considered , 203 ( 50 % ) of 409 women in the intervention group made an informed choice compared with 79 ( 19 % ) of 408 in the control group ( p<0·0001 ) . INTERPRETATION Information on overdetection of breast cancer provided within a decision aid increased the number of women making an informed choice about breast screening . Becoming better informed might mean women are less likely to choose screening . FUNDING Australian National Health and Medical Research Council M ammography is the primary method of detecting early stage breast cancer and has been shown in r and omized clinical trials to reduce breast cancer mortality , especially among women 50 years old and older [ 1 - 5 ] . Authorities in cancer screening have bong recognized that the level of efficacy of screening demonstrated in r and omized clinical trials may not pertain to community practice for several reasons [ 6 ] . These reasons include possible differences in the population groups receiving screening , lower accuracy of screening mammography in the community , and lower compliance with diagnostic follow-up and treatment in community practice , which may result in more adverse outcomes . Screening effectiveness in community practice today could exceed that estimated in trials because the technical and interpretative quality of mammography has improved since the trials were performed . Furthermore , clinical trial efficacy has been estimated on the basis of assignment to receive screening ; to the extent that women assigned to screening were not screened or that women in the control groups were screened , efficacy in trials may have been underestimated . To optimally evaluate the performance of mammography in a community setting , the screening prevalence and patterns and the associated sensitivity , specificity , and predictive value of mammography in community screening programs should be determined by linkage with cancer outcomes [ 7 , 8 ] . A program of monitoring should also provide data on specific population s , such as rural and minority subgroups , that are traditionally underserved by screening programs and that may have different breast cancer mortality rates [ 9 ] . Before the Mammography Quality St and ards Act ( MQSA ) of 1992 , most mammography facilities in the United States did not maintain records that could provide reliable and comprehensive data to evaluate the performance of screening  mammography  [ 10 ] . The concept of a medical audit of outcomes data had been proposed [ 1 1 ] but has not been routinely practice d in the community . The interim regulations of the MQSA m and ated maintaining mammography data and performing a medical outcomes audit [ 12 ] . In practical terms , the medical audit requirement of the MQSA was limited to an analysis of patients with tests interpreted as “ suspicious abnormality ” or “ highly suggestive for malignancy , ” which permits evaluation of the positive predictive value of such interpretations . However , the MQSA does not require linkage to population based cancer registry data or another source of pathology data , without which it is impossible to accurately assess the outcomes of patients with mammograms interpreted as having normal findings . To underst and the full effect Background : Because the efficacy of mammography screening had been shown in r and omized controlled trials , the focus has turned on its effectiveness within the daily practice . Using individual data of women invited to screening  , we conducted a case – control study to assess the effectiveness of the  Dutch population –based program of mammography screening .  Methods : Cases were women who died from breast cancer between 1995 and 2003 and were closely matched to five controls on year of birth , year of first invitation , and number of invitations before case 's diagnosis . ORs and 95 % confidence intervals ( CI ) for the association between attending either of three screening examinations prior to diagnosis and the risk of breast cancer death were calculated using conditional logistic regression and corrected for self- selection bias . Results : We included 755 cases and 3,739 matched controls . Among the cases , 29.8 % was screen-detected , 34.3 % interval-detected , and 35.9 % never-screened . About 29.5 % of the never-screened cases had stage IV tumor compared with 5.3 % of the screen-detected and 15.1 % of the interval-detected cases . The OR ( 95 % CIs ) , all ages ( 49–75 years ) , was 0.51 ( 0.40–0.66 ) and for the age groups 50–69 , 50–75 , and 70–75 years were 0.61 ( 0.47–0.79 ) , 0.52 ( CI 0.41–0.67 ) , and 0.16 ( 0.09–0.29 ) , respectively . Conclusion : The study provides evidence for a beneficial effect of early detection by mammography screening in reducing the risk of breast cancer death among women invited to and who attended the screening . Impact : This is the first case – control study that accurately accounts for equal screening opportunity for both cases and matched controls by number of invitations before case 's diagnosis . Cancer Epidemiol Biomarkers Prev ; 21(1 ) ; 66–73 . © 2011 AACR 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 r and omly assigned to be given letters with : ( i ) a pre-fixed appointment plus st and ard 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 r and omized . 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 Mammography remains substantially under-used in low-income minority population s despite its well-established efficacy as a means of breast cancer control . The Metropolitan Detroit Avoidable Mortality Project is a 2-year controlled clinical trial of coordinated interventions which seek to improve the use of early breast cancer detection services at five clinical sites providing primary health care services to inner-city women . Baseline assessment for two of the five participating clinic population s demonstrated that only one-quarter of women who visited these clinics were referred for mammography  in 1988 , and only half of those who were referred were able to complete the procedure . Patient characteristics including age , marital status , ethnicity , and insurance status were not associated with use of mammography during the baseline period . Each of the project 's intervention components is a cue to action : a physician prompt for mammography referral within the medical record of procedure-due women , a reminder postcard for scheduled appointments , and a telephone call to encourage rescheduling of missed appointments . The interventions are initiated by a computerized information management system in the existing network of health care services . The patient 's out-of-pocket mammography expense has been eliminated in three of the five sites . Although their efficacy as individual interventions has been well established , a controlled trial of computer prompts to  physicians  , reduced expense for patients , and patient appointment reminders as an integrated system in inner-city medical care setting s has not been previously described . We have implemented the prompting , facilitated rescheduling procedures , and eliminated patient expense for mammography at three of five eventual clinical sites . This report provides an overview of the study 's design , data management system , and methodology for evaluation A r and omized trial is presented on the effect of repeated invitation to  breast cancer screening with mammography  on mortality from breast cancer . The invited group and the control group each consisted of approximately 21,000 women aged 45 - 69 yr at the start of the screening . The attendance rate was 74 % at the first screening and 70 % at the two subsequent screening rounds . The cancer detection rate was 7.5 per 1000 women examined in the first screening round and 2.2 and 2.0 per 1000 woman-years in the second and third screenings with an incidence of 0.9 in the intervals . The incidence in the control group was 2.7 per 1000 woman-years . The proportion of positive biopsies was 61 % in the first screening round , 33 % in the second , and 58 % in the third . After the prevalence screening , the stage distribution was more favourable in the invited group ( including non-attenders ) than in the control group . In the two most recent periods of the programme , 62 out of 160 women with cancer ( 39 % ) in the invited group were in stage II-IV compared with 91 out of 159 ( 57 % ) in the control group . More than 60 % of cancers detected at screening were either non-invasive or invasive with a diameter of 1 cm . The corresponding percentage in the control group was 27 % . The importance of sampling bias is discussed . Although data on mortality still have to be awaited , the results so far clearly indicate a positive effect of screening This study aim ed to examine whether knowledge , attitudes and concerns predicted attendance at the  mobile Breast X-Ray Programme in Sydney . A cohort study design was used , whereby women were surveyed prior to the implementation of the program , and two years later records were checked to determine whether they had attended for screening . Telephone interviews were sought with r and omly selected women aged 45 to 70 years living in the central Sydney area ( the screening van 's catchment area ) . A total of 285 women was surveyed ( response rate : 50 per cent ) . Of these , 86 ( 30 per cent ) subsequently attended at the mobile van and 199 did not . Attendance did not appear to be related to any of the following factors : knowledge ; attitudes ; prior experience ; perceived susceptibility and morbid concern in relation to breast cancer ; the amount of information about screening mammography  to which a woman had been exposed . The results are interpreted in light of method ological considerations plus findings from our other research Objectives . Community based breast cancer screening has decreased breast cancer mortality in women . This study examined the predictors of nonattendence for invitational breast cancer screening in relation to socioeconomic status in the city of Manisa , in western Turkey . Study Design . For the evaluation of the reasons for refusing to participate in the study , two districts were selected . 446 women aged between 50 and 69 years were selected from the program data base by systematic r and om sampling . Methods . The question naire consisted of sociodemographic variables and the adapted version of Champion 's Health Belief Model Scale . Univariete and multivariete logistic regression analysis were performed throughout the data analysis . Results . Being from an urban district and being from the western region were the risk factors for not participating in the screening program  ( P = 0.014 , P = 0.023 ) . A statistical significance was found between mammography-benefit , mammography-barrier and program participation ( P = 0.044 , P = 0.006 ) . Although there were many more barriers for not participating in the screening program for the women of the slum district , the attendence rate of the slum district was higher than that of the urban district . Conclusions . Increased attendance may be achieved through enhancement of breast cancer awareness and by reducing some of the modifiable barriers PURPOSE / OBJECTIVES To assess the effect of a tailored telephone reminder call by community peer volunteers on mammography rates in women who do not attend a breast cancer-screening program . DESIGN Individual-level r and omized trial . SETTING Four semirural communities in Belgium . SAMPLE Women aged 50 - 69 years who had not had a mammogram . METHODS Women in the  usual care ( control ) arm received an invitation letter for screening mammography and an information leaflet ; women in the intervention arm received usual care as well as a telephone reminder call . The call was tailored on four variables : individual mammography history , mailing of the invitation letter , mammography appointment date , and type of mammography facility in the area ( e.g. , mobile unit versus fixed site ) . Community peer volunteers made up to three attempts to call the women in the intervention arm . MAIN RESEARCH VARIABLES Mammography rates verified by screening registration review and adverse events identified in contacts with peer volunteers , radiologists , and community workers of local authorities . FINDINGS A total of 3,880 women were included in the study and individually r and omized into control and intervention groups . Phone numbers were identified for 79 % of the women in the intervention group , and 69 % were contacted . Twenty-two percent had screening mammography , which was 4 % higher than controls ( relative risk = 1.22 ) . No adverse effects were identified . An additional mammogram came at an average cost of 17 phone conversations and two hours of volunteer work . CONCLUSIONS The tested telephone reminder call is suitable for Belgian women . IMPLICATION S FOR NURSING The telephone reminder call may be implemented in setting s similar to the studied context Objective To study psychosocial predictors of attendance at an  organised breast cancer screening programme .  Setting  Finnish screening programme  based on  personal first round invitations in 1992–94 , and with 90 % attendance rate . Methods Attenders ( n=946 ) belonged to a 10 % r and om sample ( n=1680 women , age 50 , response rate 64 % ) of the target population ( n=16 886 ) , non-attenders ( n=641 , 38 % ) came from the whole target population . Predictors were measured one month before the screening invitation . Measures included items for social and behavioural factors , Breast Cancer Susceptibility Scale , Illness Attitude Scale , Health Locus of Control Scale , Anxiety Inventory , and Depression Inventory . Univariate and multivariate logistic regression analyses were used to predict attendance . Results Those most likely to attend were working , middle income , and averagely educated women , who had not had a mass mammogram recently , but who regularly visited gynaecologists , attended for Pap smear screening , practised breast self examination , and who did not smoke . Low confidence in their own capabilities in breast cancer prevention , overoptimism about the sensitivity of mammography , and perception of breast cancer risk as moderate were also predictive of attendance . Expectation of pain at mammography was predictive of non-attendance . Conclusion Mammography screening organised as a public health service was well accepted . A recent mammogram , high reliance on self control of breast cancer , and an expectation of pain at mammography deterred attendance at screening . Further information about these factors and health information on screening are needed We examined the effectiveness of offering counselling to women undergoing screening mammography who are recalled for further investigations that do not lead to a diagnosis of cancer . Women were r and omised to being offered either face-to-face  ( n = 66 ) or telephone counselling  ( n = 68 ) or usual care  ( n = 71 ) at the recall clinic after being told that their screen-detected abnormality was not cancer . The PCQ ( a reliable and valid measure of the psychological consequences of screening mammography ) measured the emotional , social and physical functioning of women at the recall clinic ( Time 1 ) and after the counselling intervention ( Time 2 ) . Analyses of covariance ( ANCOVA ) showed no main effects for intervention on Time 2 levels of functioning after adjustment for the respective covariate of Time 1 functioning . Time 1 levels significantly predicted Time 2 levels of functioning . When data were analysed according to whether women actually received any type of counselling versus not receiving counselling , participation in counselling was associated with lower scores on dysfunction scales at Time 2 , after adjusting for Time 1 levels BACKGROUND Screening programmes are often actively promoted to achieve high coverage , which may result in unrealistic expectations . We examined women 's underst and ing of the likely benefits of  mammography screening . METHODS  Telephone survey of r and om sample s of the female population aged > or = 15 years in the US , UK , Italy , and Switzerl and using three closed questions on the expected benefits of mammography screening . RESULTS A total of 5964 women were contacted and 4140 women ( 69 % ) participated . Misconceptions were widespread : a majority of women believed that screening prevents or reduces the risk of contracting breast cancer ( 68 % ) , that screening at least halves breast cancer mortality ( 62 % ) , and that 10 years of regular screening will prevent 10 or more breast cancer deaths per 1000 women ( 75 % ) . In multivariate analysis higher number of correct answers was positively associated with higher educational status ( odds ratio [ OR ] = 1.44 , 95 % CI : 1.25 , 1.66 ) and negatively with having had a mammography in the last 2 years ( OR = 0.86 , 95 % CI : 0.73 , 1.01 ) . Compared with US women ( reference group ) and Swiss women ( OR = 0.98 , 95 % CI : 0.82 , 1.18 ) respondents in Italy ( OR = 0.61 , 95 % CI : 0.50 , 0.74 ) and the UK ( OR = 0.73 , 95 % CI : 0.60 , 0.88 ) gave fewer correct answers . CONCLUSION In the US and three European countries a high proportion of women overestimated the benefits that can be expected from screening mammography . This finding raises doubts on informed consent procedures within breast cancer screening programmes
For example , mammography screening does not seem to create anxiety in women who are given a clear result after a mammogram .
The incidence of breast cancer and mortality increases with age , and the GDG extrapolated that the absolute health benefits are greater in women aged 45 to 49 than those aged 40 to 44 years .
However , for the 45- to 49-year age group , the higher breast cancer incidence and mortality compared with women between the ages of 40 and 44 , as well as observational evidence showing a greater benefit in this age group ( 33 ) , led the GDG to judge that the balance of health effects probably favors screening , although the required re sources for screening likely differ across setting s ( 34 , 35 ) .
Other EtD criteria also were generally in favor of implementing organized mammography screening in this age group .
Despite intensified efforts by the European Council since 2003 , the implementation of organized , population -based mammography screening is not uniform across Europe and depends greatly on the policies in place in different countries , the organization of health care , and available re sources ( 1 ) .
Since the last edition of the European Guidelines on Breast Cancer Screening and Diagnosis was published in 2006 ( 2 ) , new evidence regarding breast cancer and innovation in guideline methodology prompted the European Commission Initiative on Breast Cancer ( ECIBC ) to develop new evidence -based recommendations ( in short , the European Breast Guidelines ) .
These guidelines inform women , health professionals , and policymakers about important questions related to organized mammography screening and breast cancer diagnosis , but recommendations may apply in context s in which organized screening programs are not in place .
Women generally consider these undesirable effects acceptable ( low certainty of evidence ) , and a systematic review suggested that women place a relatively low value on the psychosocial and physical effects of false-positive results and overdiagnosis ; however , some studies raised concerns about whether women fully underst and the result ing implication s ( 15 ) .
How Often Should Women Attend an Organized Mammography Screening Program ?