Mammographic Screening Programmes in Europe: Organization, Coverage and Participation

BackgroundMany breast, colorectal, and cervical cancer screening programs were disrupted due to the COVID-19 pandemic. This study aimed to estimate the short-term impact of the temporary shutdown (from March until May- June) of the cancer screening programs invitations in Flanders (Belgium) by looking at invitation coverage, percentage of people screened after invitation and the screening interval.MethodsYearly invitation coverage was calculated as the number of people who received an invitation, as a proportion of the people who should have received an invitation that year. Weekly response to the invitation was calculated as the number of people who were screened within 40 days of their date of invitation, as a percentage of the people who received an invitation that week (as a proxy for willingness to screen). Weekly screening interval was calculated as the mean number of months between the current screening and the previous screening of all the people who screened that week. The two last indicators were calculated for each week in 2019 and 2020, after which the difference between that week’s value in 2020 and 2019 with 95% confidence intervals. Results of these two indicators were also analysed after stratification for gender, age and participation history.ResultsInvitation coverage was not impacted in the colorectal and cervical cancer screening program. In the breast cancer screening program invitation coverage went down from 97.5% (2019) to 88.7% (2020), and the backlog of invitations was largely resolved in the first six months of 2021. The willingness to screen was minimally influenced by COVID-19. The breast cancer screening program had a temporary increase in screening interval in the first months following the restart after COVID-19 related shutdown, when it was on average 2.1 months longer than in 2019.ConclusionsWillingness to screen was minimally influenced by COVID-19, but there may be an influence on screening coverage because of lower invitation coverage, mainly for the for breast Cancer Screening Program. The increases in screening intervals for the three Cancer Screening Program seem reasonable and would probably not significantly increase the risk of delayed screening cancer diagnoses. When restarting a Cancer Screening Program after a COVID-19 related shutdown, monitoring is crucial.

Evaluation of breast cancer screening programmes: Candidate performance indicators and their association with breast cancer mortality

Background: Breast cancer (BC) is one of the most important public health issues; so, knowledge about signs, symptoms, and screening programs has impressive role in BC prevention. Objectives: The objective of this study was measuring general physician’s knowledge regarding BC screening programs. Methods: This cross sectional study was performed among 200 general physicians (GP) of urban and rural areas from Jun to September, 2017 in Hamadan, Iran, using a self-administered semi-structured questionnaire. The data were analyzed by SPSS. Significance level was set at P < 0.05. Results: The mean score of total knowledge on breast cancer screening, risk factors, signs, and symptoms for 23 questions was 15.07 ± 2.4 (max: 20; min: 9), which meant that correct answers were given to more than half of them. In symptom knowledge area, 45.3 of physicians had correct answer to 4 questions, whereas about risk factor, 61.4 recorded correct answer to 8 questions. There was a significant reverse correlation between knowledge about screening programs and age of participants (r =-0.3; P < 0.001), and their years of work experience (r =-0.26; P < 0.001). Conclusions: In the current study, family physician knowledge on breast cancer signs, symptom, and screening programs was insufficient. It is recommended that there should be a well-designed health education program to compensate physicians’ knowledge deficits, especially in older ages in order to raise awareness toward cancer, with emphasis on the role of prevention and screening. Importance of early diagnosis in breast cancer and its high rate in our country are adequate reasons for considering this issue on top of our priorities. © 2019, Author(s).

A population's acceptance of a screening programme is reflected by its participation. Participation can be measured by cross-section, in an individual screening round, or by cumulative examination rate, which covers participation in numerous rounds at a pre-specified frequency. To establish an informed overview of programme performance, the relationship between these measures was analysed. The Central Population Register (CPR) of Denmark was used to define the total population. The data sources were mammography screening programmes in Copenhagen (1991-2008) and Funen (1993-2008) and participation and coverage rates were calculated according to European guidelines. Long-term adherence was defined as the cumulative examination rate. The participation rates were 71% in Copenhagen and 91% in Funen. The cumulative examination rates across all invitation rounds were between 21 and 24% lower than the average participation rates. If the cumulative examination rate across all, or the majority of, invitation rounds is substantially lower than the average participation rate it may suggest that standard cross-sectional performance indicators overestimate the level of protection provided to the women targeted by the programme. Consequently, it may prove valuable to include cumulative examination rate as a performance indicator of mammography screening.

Breast cancer-specific mortality is increased among women with intellectual disability (ID), and knowledge about participation in breast cancer screening in this group is needed. To examine participation in the Danish national breast cancer screening program among women with ID compared with women without ID. This dynamic population-based cohort study assessed participation in the Danish national breast cancer screening program initiated in 2007, targeting women aged 50 to 69 years with a screening interval of 2 years. In all, 6357 women with ID born between 1941 and 1967 and eligible for the screening program were identified in national registers. Women entered the study between January 1, 2007, and December 31, 2017. Subsequently, 273 women were excluded due to a history of carcinoma in situ or breast cancer, and 489 due to registration errors in registers. Each woman was individually age-matched with 10 women without ID (reference group). All women were followed up until March 31, 2021, or censoring (due to death, carcinoma in situ, or breast cancer). Data were analyzed from December 1, 2021, to June 31, 2022. Intellectual disability was defined as being registered with an ID diagnosis or a diagnosis most likely leading to ID or residing at an institution for persons with ID. Participation in breast cancer screening (fully, partly, and never). A total of 5595 women with ID and 49 423 age-matched women in the reference group were included in the analysis. Of these, 2747 women with ID (49%) and 24 723 in the reference group (50%) were 50 years of age at study entry; for those older than 50 years, the median age was 51 years (IQR, 50-58 years) in both groups. In all, 1425 women with ID (25%) were fully screened according to guidelines for the Danish breast cancer screening program compared with 30 480 women in the reference group (62%). Women with ID had nearly 5 times higher odds of never being screened compared with the reference group (odds ratio, 4.90 [95% CI, 4.60-5.22]). In all, 2498 women with ID (45%) and 6573 in the reference group (13%) were never screened. The proportion of never-screened women increased with severity of ID, from 834 of 2287 (36%) among women with mild ID to 173 of 212 (82%) among women with profound ID. The findings of this cohort study suggest that women with ID are markedly less likely to participate in breast cancer screening compared with women without ID. These findings further suggest a need for tailored guidelines and approaches for breast cancer screening in this group of women.

ObjectiveTo investigate the associations between national breast cancer screening programmes and breast cancer mortality globally.MethodsWe collected data on breast cancer screening programmes and breast cancer mortality from the World Health Organization’s Global Health Observatory, the Global Burden of Diseases 2021 study and the Eurostat database. We assessed differences in breast cancer mortality between countries with regular and irregular screening programmes, adjusting for sociodemographic index. We calculated annual changes in breast cancer mortality from 2015 to 2021 and assessed differences in mortality changes between countries with regular and irregular screening programmes.FindingsBetween 2015 and 2021, 94 of 194 countries reported having national breast cancer screening programmes. In 2021, countries with regular breast cancer screening programmes had 3.74 fewer deaths (95% uncertainty interval, UI: 1.69–5.81) per 100 000 population than countries with irregular screening programmes. This difference was more pronounced in women aged 50–74 years: 10.13 fewer deaths (95% UI: 4.47–15.80) per 100 000. From 2015 to 2021, the age-standardized mortality rate decreased by 1.02% (95% UI: 0.71–1.36) annually in countries with regular breast cancer screening programmes, whereas countries with irregular programmes had an annual increase of 0.45% (95% UI: 0.23–0.69). Higher breast cancer screening coverage rates were associated with lower mortality in the European region.ConclusionCountries with breast cancer screening programmes had a significant reduction in breast cancer mortality. Reducing breast cancer mortality globally will require adopting national breast cancer screening programmes and increasing screening coverage, particularly among women aged 50–74 years.

BackgroundThe population-based mammography screening program (MSP) was implemented by the end of 2005 in Germany, and all women between 50 and 69 years are actively invited to a free biennial screening examination. However, despite the expected benefits, the overall participation rates range only between 50 and 55 %. There is also increasing evidence that belonging to a vulnerable population, such as ethnic minorities or low income groups, is associated with a decreased likelihood of participating in screening programs. This study aimed to analyze in more detail the intra-urban variation of MSP uptake at the neighborhood level (i.e. statistical districts) for the city of Dortmund in northwest Germany and to identify demographic and socioeconomic risk factors that contribute to non-response to screening invitations.MethodsThe numbers of participants by statistical district were aggregated over the three periods 2007/2008, 2009/2010, and 2011/2012. Participation rates were calculated as numbers of participants per female resident population averaged over each 2-year period. Bayesian hierarchical spatial models extended with a temporal and spatio-temporal interaction effect were used to analyze the participation rates applying integrated nested Laplace approximations (INLA). The model included explanatory covariates taken from the atlas of social structure of Dortmund.ResultsGenerally, participation rates rose for all districts over the time periods. However, participation was persistently lowest in the inner city of Dortmund. Multivariable regression analysis showed that migrant status and long-term unemployment were associated with significant increases of non-attendance in the MSP.ConclusionLow income groups and immigrant populations are clustered in the inner city of Dortmund and the observed spatial pattern of persistently low participation in the city center is likely linked to the underlying socioeconomic gradient. This corresponds with the findings of the ecological regression analysis manifesting socioeconomically deprived neighborhoods as risk factors for low attendance in the MSP. Spatio-temporal surveillance of participation in cancer screening programs may be used to identify spatial inequalities in screening uptake and plan spatially focused interventions.

BackgroundBreast cancer is the most common diagnosed disease, and the second leading cause of death among women. Thus, due to its importance, the current research is aimed at identifying the preferences of individuals for improving breast cancer screening programs and the related policies.MethodA systematic search was applied on databases including - PubMed, Scopus, the Web of Science, Embase, Cochrane, SID- up to October 2022. The including articles were original or review papers that assessed individuals’ willingness to pay. Also, articles including the effective variables or attributes for breast cancer screening program were included. Meta-analysis was applied to calculate Willingness to Pay (WTP) as a mean for breast cancer screening followed by vote-counting for identifying the variables and attributes correlated with screening.ResultsA total of 721 articles were identified during the first phase. After the screening process, thirteen papers were chosen, out of which, nine assessed mammography as a breast cancer screening program. The results of random effect meta-analysis on the including studies indicated that the rate of willingness to pay for screening was 0.28% of GDP per capita (95%CI: 0.14–0.43), which was found to be statistically significant. The result of stratified meta- analysis indicated that the rate of willingness to pay for screening was 0.22% of GDP per capita (95%CI: 0.07–0.37), which was found to be statistically significant. Generally, income was the basic factor for receiving screening services, and cost was an effective attribute for participating in screening programs.ConclusionsTo increase women’s participation in breast cancer screening programs; it is essential to provide legitimate information and eliminate the barriers to women’s non-participation. Offering rapid tests at low costs in healthcare centers (both in terms of travel and screening time) delivered by female staff can lead to an increase in women’s willingness to participate in breast cancer screening programs.

Can population breast screening programs be leveraged to reduce the burden of breast cancer?

BackgroundBreast cancer (BC) is the most common cancer in women in the developed world. In order to find developing cancers in an early stage, BC screening is commonly used. In Flanders, screening is performed in and outside an organized breast cancer screening program (BCSP). However, the determinants of BC screening coverage for both screening strategies are yet unknown.ObjectiveTo assess the determinants of BC screening coverage in Flanders.MethodsReimbursement data were used to attribute a screening status to each woman in the target population for the years 2008–2016. Yearly coverage data were categorized as screening inside or outside BCSP or no screening. Data were clustered by municipality level. A generalized linear equation model was used to assess the determinants of screening type.ResultsOver all years and municipalities, the median screening coverage rate inside and outside BCSP was 48.40% (IQR: 41.50–54.40%) and 14.10% (IQR: 9.80–19.80%) respectively. A higher coverage rate outside BSCP was statistically significantly (P < 0.001) associated with more crowded households (OR: 3.797, 95% CI: 3.199–4.508), younger age, higher population densities (OR: 2.528, 95% CI: 2.455–2.606), a lower proportion of unemployed job seekers (OR: 0.641, 95% CI: 0.624–0.658) and lower use of dental care (OR: 0.969, 95% CI: 0.967–0.972).ConclusionCoverage rate of BC screening is not optimal in Flanders. Women with low SES that are characterized by younger age, living in a high population density area, living in crowded households, or having low dental care are less likely to be screened for BC in Flanders. If screened, they are more likely to be screened outside the BCSP.

Objective: To estimate the cervical and breast cancer screening coverage and related factors among women aged 35-69 years who were in the National Cervical and Breast Screening Program, to provide evidence for improving cervical and breast cancer control and prevention strategy. Methods: Data used in this study were abstracted from the 2013 Chinese Chronic Diseases and Risk Factors Surveillance Program. A total of 66 130 women aged 35-64 years and 72 511 women aged 35-69 years were included for this study. Weighted prevalence, (with 95% confidence interval, CI) was calculated for complex sampling design. Rao-Scott χ(2) method was used to compare the screening coverage among subgroups. A random intercept equation which involved the logit-link function, was fitted under the following five levels: provincial, county, township, village and individual. Fix effects of all explanatory variables were converted into OR with 95%CI. Results: In 2013, 26.7% (95%CI: 24.6%-28.9%) of the 35-64 year-old women reported that they ever had been screened for cervical cancer and 22.5% (95% CI: 20.4%-24.6%) of the 35-69 year-olds had ever undergone breast cancer screening. Lower coverage was observed among women residing in rural and central or western China than those in urban or eastern China (P<0.000 1). The coverage among women aged 50 years or older was substantially lower than those aged 35-49 years. Those who were with low education level, unemployed, low household income and not covered by insurance, appeared fewer number on this cervical or breast cancer screening program (P<0.000 1). Women living in rural and western China were having less chance of receiving the breast cancer screening (P<0.05), but the difference was not statistically significant. Conclusion: It is essential to strengthen the community-based cervical and breast cancer screening programs, in order to increase the coverage. More attention should be paid to women aged 50 years or older, especially those socioeconomically disadvantaged ones.

BackgroundMeasurement of obesity using self-reported anthropometric data usually involves underestimation of weight and/or overestimation of height. The dual aim of this study was, first, to ascertain and assess the validity of new cut-off points, for both overweight and obesity, using self-reported Body Mass Index furnished by women participants in breast cancer screening programmes, and second, to estimate and validate a predictive model that allows recalculate individual BMI based on self-reported data.MethodsThe study covered 2927 women enrolled at 7 breast cancer screening centres. At each centre, women were randomly selected in 2 samples, in a ratio of 2:1. The larger sample (n = 1951) was used to compare the values of measured and self-reported weight and height, to ascertain new overweight and obesity cut-off points with self-reported data, using ROC curves, and to estimate a predictive model of real BMI using a regression model. The second sample (n = 976) was used to validate the proposed cut-off points and the predictive model.ResultsWhereas reported prevalence of obesity was 19.8%, measured prevalence was 28.2%. The sensitivity and specificity of this classification would be maximised if the new cut-off points were 24.30 kg/m2 for overweight and 28.39 kg/m2 for obesity. The probability of classifying women correctly in their real weight categories on the basis of these points was 82.5% in the validation sample. Sensitivity and specificity for determining obesity using the new cut-off point in the validation sample were 90.0% and 92.3% respectively. The predictive model for real BMI included the self-reported BMI, age and educational level (university studies vs lower levels of education). This model succeeded in correctly classifying 90.5% of women according to BMI categories, but its performance was similar to that obtained with the new cut-off points.ConclusionsQuantification of self-reported obesity entails a considerable underestimation of this problem, thereby questioning its validity. The new cut-off points established in this study and the predictive equation both allow for more accurate estimation of these prevalences.

To explore determinants of participation in breast cancer screening in orthodox Jewish women living in Antwerp, Belgium, and to uncover their opinions and attitudes towards screening, and thereby to detect ways to optimize participation. Focus group discussions were performed during the last months of 2011 and the first half of 2012 to explore motivation to participate or not in breast cancer screening. Groups consisted of five to seven women. Inclusion criteria were: being female, considering oneself as orthodox Jewish, aged between 50 and 69 years. Three focus group discussions with in a total of 20 women had taken place. All participants in the focus group discussions had a screening mammography taken on a regular base. All participants agreed that the social cohesion between Jewish orthodox women and the importance that is given to healthcare within the Jewish tradition are important contributors to their participation in a breast cancer screening program. Pain, lack of information during the exam, lack of confidence in the quality of the exam, perceived problems when the examining doctor/technician is male, and fear of the results are mentioned as barriers. The participants, however, state that these were not important enough to result in non-participation. Barriers could be diminished by information sessions specifically aimed at orthodox Jewish women. This qualitative research demonstrates a generally positive attitude of orthodox Jewish women living in Antwerp, Belgium, towards mammographic breast cancer screening. Increased and repeated structured information sessions are likely to improve breast cancer awareness in this population.

Introduction: Innovative interventions are needed to address the growing burden of breast cancer globally, especially among vulnerable patient populations. Given the success of Community Health Workers (CHWs) in addressing communicable diseases and non-communicable diseases, this scoping review will investigate the roles and impacts of CHWs in breast cancer screening programs. This paper also seeks to determine the effectiveness and feasibility of these programs, with particular attention paid to differences between CHW-led interventions in low- and middle-income countries (LMICs) and high-income countries (HICs).Methods: A scoping review was performed using six databases with dates ranging from 1978 to 2019. Comprehensive definitions and search terms were established for ‘Community Health Workers’ and ‘breast cancer screening’, and studies were extracted using the World Bank definition of LMIC. Screening and data extraction were protocolized using multiple independent reviewers. Chi-square test of independence was used for statistical analysis of the incidence of themes in HICs and LMICs.Results: Of the 1,551 papers screened, 33 were included based on inclusion and exclusion criteria. Study locations included the United States (n=27), Bangladesh (n=1), Peru (n=1), Malawi (n=2), Rwanda (n=1), and South Africa (n=1). Three primary roles for CHWs in breast cancer screening were identified: education (n=30), direct assistance or performance of breast cancer screening (n=7), and navigational services (n=6). In these roles, CHWs improved rates of breast cancer screening (n=23) and overall community member knowledge (n=21). Two studies performed cost-analyses of CHW-led interventions.Conclusion: This review extends our understanding of CHW effectiveness to breast cancer screening. It illustrates how CHW involvement in screening programs can have a significant impact in LMICs and HICs, and highlights the three CHW roles of education, direct performance of screening, and navigational services that emerge as useful pillars around which governments and NGOs can design effective programs in this area.

We aimed to examine the association between shift work types and participation in breast cancer screening (BCS) programs by comparing rates of participation for BCS among regular daytime workers and alternative shift workers using data from a nationally representative, population-based survey conducted in Korea. In addition, the results were analyzed according to sociodemographic factors, including occupation, education, income, private health insurance, age, and number of working hours a week. This secondary cross-sectional analysis used data from the 2012 Korean National Health and Nutritional Examination Survey. The target population included women aged≥40years who responded as to whether they had undergone BCS in the previous year. Accordingly, we analyzed survey data for a total of 1,193 women and used a multivariate logistic regression analysis to evaluate the differences in factors affecting BCS between regular daytime and alternative shift workers. A logistic regression analysis was performed considering private health insurance as a significant sociodemographic factor for BCS among regular daytime shift workers. In contrast, none of the tested variables could significantly predict adherence to BCS among alternative shift workers. The results of this study suggest the need for the development of comprehensive workplace breast cancer prevention programs by considering shift work types. More attention should be given to female workers with low education levels, those who are uninsured, and young workers to improve the participation rate for BCS at the workplace.