Strategies for increasing the participation of women in community breast cancer screening

Abstract

Strategies for reducing breast cancer mortality in western countries have focused on screening, at least for women aged 50 to 69 years. One of the requirements of any community screening program is to achieve a high participation rate, which is related to methods of invitation. Therefore, it was decided to systematically review the scientific evidence on the different strategies aimed at improving women's participation in breast cancer screening programs and activities. To assess the effectiveness of different strategies for increasing the participation rate of women invited to community (population‐based) breast cancer screening activities or mammography programs. MEDLINE (1966‐2000), CENTRAL (2000), and EMBASE (1998‐1999) searches for 1966 to 1999 were supplemented by reports and letters to the European Screening Breast Cancer Programs (Euref Network). Both published and unpublished trials were eligible for inclusion, provided the women had been invited to a community breast screening activity or program and had been randomised to an intervention group or a control group with no active intervention. We identified 151 articles, which were reviewed independently by two people. The discrepancies were resolved by a third reviewer in order to reach consensus. Thirty‐four studies were excluded because they lacked a control group; 58 of the other 117 articles were considered as opportunistic and not community‐based; 59 articles, which reported 70 community‐based randomised controlled trials or clinical controlled trials, were accepted. In 24 of these, the control group had not been exposed to any active intervention, but 8 of the 24 had to be excluded because the denominator for estimating attendance was unknown. At the end, 16 studies constituted the material for this review, although two studies were further excluded because their groups were not comparable at baseline. Data from all but one study were based on or converted to an intention‐to‐treat analysis. Attendance in response to the mammogram invitation was the main outcome measure. The evidence favoured five active strategies for inviting women into community breast cancer screening services: letter of invitation (OR 1.66, 95% CI 1.43 to 1.92), mailed educational material (Odds Ratio(OR) 2.81, 95% Confidence Interval (CI) 1.96 to 4.02), letter of invitation plus phone call (OR 2.53, 95% CI 2.02 to 3.18), phone call (OR 1.94, 95% CI 1.70 to 2.23), and training activities plus direct reminders for the women (OR 2.46, 95% CI 1.72 to 3.50). Home visits did not prove to be effective (OR 1.06, 95 % CI 0.80 to 1.40) and letters of invitation to multiple examinations plus educational material favoured the control group (OR 0.62, 95 % CI 0.32 to 1.20). Most active recruitment strategies for breast cancer screening programs examined in this review were more effective than no intervention. Combinations of effective interventions can have an important effect. Some costly strategies, as a home visit and a letter of invitation to multiple screening examinations plus educational material, were not effective. Further reviews comparing the effective interventions and studies that include cost‐effectiveness, women's satisfaction and equity issues are needed. 增加婦女參與社區乳癌篩檢之策略 西方國家減少乳癌死亡率之策略已聚焦於篩檢，至少為50歲到69歲婦女做篩檢。 任何社區篩檢計劃其中最重要的要求是達到一個高參與率，其與邀請參與的方法有關。 所以，本文內容為系統性地分析不同改進婦女參與乳癌篩檢計劃和活動策略之科學證據。 估計增加婦女受邀參與社區(根據人口的)乳癌篩檢活動或乳房攝影檢查計劃參與率之不同策略的成效。 MEDLINE (1966 – 2000)，CENTRAL(2000)和EMBASE (1998 – 1999)查尋1966年到1999年由給歐洲篩檢乳癌計劃(Euref Network)的報告和致編輯的信來補充。 只要是假設婦女被邀請參與社區乳房篩檢活動或計劃，是被隨機分成干預組或控制組，並且沒有積極干預之已發表和未發表的試驗均是有資袼被納入評論。 我們尋得151篇文章,由兩個人獨立地分析。 不一致者是由第三個評論者解決而達成一致意見。有34項研究因缺乏對照組而被排除; 其他117篇文章中的58篇被認定為伺機性和非以社區為根據; 另59篇文章報告70個社區隨機分配對照實驗勝算比臨床對照實驗被納入了。 其中的24個，其控制組未被暴露於任何積極干預，但是24個中的8個必須被排除，因為估計出席參與數的分母是未知的。最後，剩下來的16個研究構成此回顧性文章的主要評論材料，雖然其中2項研究進一步被排除了，因為他們的分組與其他研究在基準上是不可比較的。除了其中一項研究外，其餘所有研究之結果數據均根據或轉換成治療意向分析法而產生。出席參與乳房攝影檢查邀請是主要結果指標。 證據支持邀請婦女參與社區乳癌篩檢服務的五個積極策略：信件邀請(勝算比1.66， 5% 信賴區間 1.43 – 1.92)，郵寄的衛教資料(勝算比(OR) 2.81， 95% 信賴區間(CI .96 – 4.02)，信件加上電話通知(勝算比2.53， 5% 信賴區間 2.02 – 3.18)，電話通知(勝算比1.94， 5% 信賴區間 1.70 – 2.23)及訓練活動加上直接提醒婦女(勝算比2.46， 5% 信賴區間 1.72 – 3.50)。家庭訪視不被證明是有效的(勝算比1.06， 5% 信賴區間 0.80 – 1.40)，並且邀請參與多次檢查加上郵寄教育材料傾向控制組(勝算比0.62， 5% 信賴區間 0.32 – 1.20)。...