[The population-based mammography screening programme in Germany: uptake and first experiences of women in 10 federal states]

Sociodemographic inequalities in breast cancer screening attendance in Germany following the implementation of an Organized Screening Program: Scoping Review

BACKGROUND

Organized breast cancer screening (BCS) programs are effective measures among women aged 50-69 for preventing the sixth cause of death in Germany. Although the implementation of the national screening program started in 2005, participation rates have not yet reached EU standards. It is unclear which and how sociodemographic factors are related to BCS attendance. This scoping review aims to identify sociodemographic inequalities in BCS attendance among 50-69-year-old women following the implementation of the Organized Screening Program in Germany.

METHODS

Following PRISMA guidelines, we searched the Web of Science, Scopus, MEDLINE, PsycINFO, and CINAHL following the PCC (Population, Concept and Context) criteria. We included primary studies with a quantitative study design and reviews examining BCS attendance among women aged 50-69 with data from 2005 onwards in Germany. Harvest plots depicting effect size direction for the different identified sociodemographic inequalities and last two years or less BCS attendance and lifetime BCS attendance were developed.

RESULTS

We screened 476 titles and abstracts and 33 full texts. In total, 27 records were analysed, 14 were national reports, and 13 peer-reviewed articles. Eight sociodemographic variables were identified and summarised in harvest plots: age, education, income, migration status, type of district, employment status, partnership cohabitation and health insurance. Older women with lower incomes and migration backgrounds who live in rural areas and lack private insurance respond more favourably to BCS invitations. However, from a lifetime perspective, these associations only hold for migration background, are reversed for income and urban residency, and are complemented by partner cohabitation. Finally, women living in the former East German states of Saxony, Mecklenburg-Western Pomerania, Saxony-Anhalt, and Thuringia, as well as in the former West German state of Lower Saxony, showed higher BCS attendance rates in the last two years.

CONCLUSION

High-quality research is needed to identify women at higher risk of not attending BCS in Germany to address the existing research's high heterogeneity, particularly since the overall attendance rate still falls below European standards.

PROTOCOL REGISTRATION

https://osf.io/x79tq/ .

German mammography screening program: adherence, characteristics of (non-)participants and utilization of non-screening mammography-a longitudinal analysis

BACKGROUND

In Germany, all women aged 50-69 have been invited to biennial mammography screening since 2009. We aimed to assess longitudinal adherence over ten years in women aged 50 in 2009 and characterize the different adherence groups.

METHODS

Using the German Pharmacoepidemiological Research Database (GePaRD, ~ 20% of the German population), we included women aged 50 in 2009 (baseline) with continuous health insurance coverage and without breast cancer or in-situ-carcinoma. We followed them until age 59 and categorized them according to mammography screening participation into the following groups: never, 1-2, 3-4, 5-6 times. We characterized these groups, inter alia, regarding the use of other preventive measures, non-screening mammography (i.e., mammography outside the organized screening program) and menopausal hormone therapy.

RESULTS

Overall, 82,666 women were included. Of these, 27.6% never participated in the screening program, 15.1% participated 1-2 times, 31.7% participated 3-4 times and 25.6% participated regularly (5-6 times). Among regular participants, 91% utilized other preventive measures (e.g., cervical cancer screening, general health checkup) before baseline as compared to 66% among non-participants. Menopausal hormone therapy was least common among non-participants (11% vs. 18% among regular participants). Among non-participants, the proportions using ≥ 1, ≥ 2, and ≥ 3 non-screening mammographies between age 50-59 were 25%, 18%, and 15%, respectively.

CONCLUSIONS

Using a large cohort based on claims data, this study provides novel insights into longitudinal adherence to the mammography screening program and the use of mammography outside of the program in Germany. Between age 50-59, 57% of eligible women participated at least three times in the German mammography screening program and 28% (~ 3 in 10 women) never participated. Among non-participants, 15% had at least three non-screening mammographies during this period, indicating potential gray screening. Participants more often utilized other preventive measures as compared to non-participants.

Breast cancer and breast cancer screening use-beliefs and behaviours in a nationwide study in Malaysia

BACKGROUND

Many upper-middle-income countries (UMICs), including Malaysia, continue to face low breast cancer (BC) screening rates and patients with delayed presentation of BC. This study investigated the role of beliefs about BC and use of screening (e.g. beliefs about whether or not screening reduced the possibility of dying from BC).

METHODS

A nationwide cross-sectional study was conducted in which a total of 813 women (aged ≥ 40 years old) were randomly selected and surveyed using the validated Awareness and Beliefs about Cancer (ABC) measure. The association between BC screening use, sociodemographic characteristics, and negative beliefs about BC screening were analysed using stepwise Poisson regressions.

RESULTS

Seven out of ten Malaysian women believed that BC screening was necessary only when experiencing cancer symptoms. Women > 50 years and from households with more than one car or motorcycle were 1.6 times more likely to attend a mammogram or a clinical breast examination (mammogram: Prevalence Ratio (PR) = 1.60, 95% Confidence Interval (CI) = 1.19-2.14, Clinical Breast Examination (CBE): PR = 1.61, 95% CI = 1.29-1.99). About 23% of women expected to feel anxious about attending BC screening, leading them to avoid the procedure. Women who held negative beliefs about BC screening were 37% less likely to attend a mammogram (PR = 0.63, 95% CI = 0.42-0.94) and 24% less likely to seek a CBE (PR = 0.75, 95% CI = 0.60-0.95).

CONCLUSIONS

Public health strategies or behaviour interventions targeting negative beliefs about BC screening among Malaysian women may increase uptake and reduce late presentation and advanced-stage cancer. Insights from the study suggest that women under 50 years, in the lower income group without a car or motorcycle ownership, and of Malay or Indian ethnicity (compared to Chinese-Malay) are more likely to hold beliefs inhibiting BC screening.

Determinants of mammography screening participation-a cross-sectional analysis of the German population-based Gutenberg Health Study (GHS)

PURPOSE

We investigated the association between social inequality and participation in a mammography screening program (MSP). Since the German government offers mammography screening free of charge, any effect of social inequality on participation should be due to educational status and not due to the financial burden.

METHODS

The 'Gutenberg Health Study' is a cohort study in the Rhine-Main-region, Germany. A health check-up was performed, and questions about medical history, health behavior, including secondary prevention such as use of mammography, and social status are included. Two indicators of social inequality (equivalence income and educational status), an interaction term of these two, and different covariables were used to explore an association in different logistic regression models.

RESULTS

A total of 4,681 women meeting the inclusion criteria were included. Only 6.2% never participated in the MSP. A higher income was associated with higher chances of ever participating in a mammography screening (odds ratios (OR): 1.67 per €1000; 95%CI:1.26-2.25, model 3, adjusted for age, education and an interaction term of income and education). Compared to women with a low educational status, the odds ratios for ever participating in the MSP was lower for the intermediate educational status group (OR = 0.64, 95%CI:0.45-0.91) and for the high educational status group (0.53, 95%CI:0.37-0.76). Results persisted also after controlling for relevant confounders.

CONCLUSIONS

Despite the absence of financial barriers for participation in the MSP, socioeconomic inequalities still influence participation. It would be interesting to examine whether the educational effect is due to an informed decision.

mHealth Interventions to Improve Cancer Screening and Early Detection: Scoping Review of Reviews

BACKGROUND

Cancer screening provision in resource-constrained settings tends to be opportunistic, and uptake tends to be low, leading to delayed presentation and treatment and poor survival.

OBJECTIVE

The aim of this study was to identify, review, map, and summarize findings from different types of literature reviews on the use of mobile health (mHealth) technologies to improve the uptake of cancer screening.

METHODS

The review methodology was guided by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Ovid MEDLINE, PyscINFO, and Embase were searched from inception to May 2021. The eligible criteria included reviews that focused on studies of interventions that used mobile phone devices to promote and deliver cancer screening and described the effectiveness or implementation of mHealth intervention outcomes. Key data fields such as study aims, types of cancer, mHealth formats, and outcomes were extracted, and the data were analyzed to address the objective of the review.

RESULTS

Our initial search identified 1981 titles, of which 12 (0.61%) reviews met the inclusion criteria (systematic reviews: n=6, 50%; scoping reviews: n=4, 33%; rapid reviews: n=1, 8%; narrative reviews: n=1, 8%). Most (57/67, 85%) of the interventions targeted breast and cervical cancer awareness and screening uptake. The most commonly used mHealth technologies for increasing cancer screening uptake were SMS text messages and telephone calls. Overall, mHealth interventions increased knowledge about screening and had high acceptance among participants. The likelihood of achieving improved uptake-related outcomes increased when interventions used >1 mode of communication (telephone reminders, physical invitation letters, and educational pamphlets) together with mHealth.

CONCLUSIONS

mHealth interventions increase cancer screening uptake, although multiple modes used in combination seem to be more effective.

The Mode of Detection Is Not Associated with Quality of Life in Women with Breast Cancer

Introduction

Apart from saving lives, mammography screening programs (MSP) are expected to reduce negative side effects of treatment by detecting cancer earlier, when it is more responsive to less aggressive treatment. This study compared quality of life (QoL) among women with breast cancers that were detected either by screening mammography, as interval cancers, or clinically among women not participating in the MSP.

Methods

Retrospective study of first-ever invasive breast cancers detected among MSP-eligible women aged 50-69 years between 2006 and 2012 in Münster, Germany. EORTC QLQ-C30 and -BR23 questionnaires were mailed to 1,399 cases still alive in 2015 (response rate 64.1%).

Results

Women's responses were obtained on average 6.1 years after diagnosis. Mean crude and age-adjusted scores for overall QoL, breast and body image (BBI), and five functional scales (FS) were comparable between groups of detection mode. Clearly lower adjusted means for most scores were observed in women with interval cancers, if time since diagnosis was less than 5 years. Cases younger than 60 years showed lower values for some FS, particularly among interval and screen-detected cases.

Discussion/Conclusion

In summary, cases with breast cancer showed health-related score values that were similar to the general population of the same age. There was also no indication that mode of detection markedly influenced these scores. However, after adjusting for tumor stage and other influential factors, screening participants appeared more susceptible to score declines after a diagnosis of cancer than non-participants.

Health disparities among breast cancer patients with/without disabilities in Germany

BACKGROUND

Prevalence and incidence of cancer are increasing in people with disability. Nevertheless, little is known about cancer care for people with disabilities.

OBJECTIVE

The goal of this study was to examine the quality of care of breast cancer patients with pre-existing disabilities regarding diagnosis and type of breast surgery in Germany.

METHODS

Within the framework of quality assurance of breast cancer centers, a patient survey was conducted by the University of Cologne. Survey data from 4626 newly-diagnosed breast cancer patients treated in 86 hospitals were analyzed using multilevel modeling. Data about socio-demographics, disability specific data as well as data about diagnosis and type of surgery were collected.

RESULTS

About 13% (n = 568) of the patients indicated they had a pre-existing disability prior to their breast cancer. The majority of patients with disabilities have physical impairments (PI n = 385; 68.0%) or sensory impairments (SI n = 131; 23.1%). 16.7% of the patients indicated they have a mental illness (MI n = 95; 16.7%) and 8 patients indicated to have an intellectual disability (ID n = 8; 1.4%). Patients with PI and SI are less often diagnosed for cancer through a mammography screening (OR PI = 0.70; p < 0.05; OR SI = 0.58; p < 0.05). Patients with PI are less likely to receive breast conserving treatment (OR = 0.58; p < 0.00) and more likely to have a mastectomy without reconstruction (OR = 1.96; p < 0.00) compared to patients without disabilities.

CONCLUSION

Our data show that there are differences in the frequency of cancer diagnosis through mammography screening and in surgery applied between breast cancer patients with and without disabilities.

[Influence of Sociodemographic Factors on Type of and Stage at Diagnosis in Breast Cancer]

This study examines the influence of sociodemographic factors on the type of and stage at diagnosis in breast cancer in Germany.

METHOD

As part of the certification of the breast cancer centers by the German Cancer Society (DGK), the Institute of Medical Sociology, Health Services and Rehabilitation Science (IMVR) conducted nationwide post-stationary postal patient surveys (n=852). The influence of sociodemographic factors on the type of diagnosis and on the stage at diagnosis were each analyzed using a multinomial logistic regression.

RESULTS

45.5% palpated the tumor by themselves, 33.4% were diagnosed by mammography screening and 16.6% by gynecological check-up. Being diagnosed by screening was associated with an early stage cancer. Furthermore, breast cancer patients without private health insurance or with a low educational level were less likely to be diagnosed by a gynecological check-up. Patients within screening age (50-69) had higher odds for an early stage breast cancer. Patients with a low educational level had lower odds for an early stage breast cancer.

CONCLUSION

Fifty percent of the breast cancer patients were not diagnosed by screening. Mammography screening appears to be more sensitive in detecting early stage cancer, since we found an association between diagnosis by screening and an early stage cancer. Age outside of the screening range and a low educational level might be risk factors for an advanced stage breast cancer. High screening rates, especially for these risk groups, seem to be important for early detection of breast cancer.

Mammography Screening 2.0 - How Can Risk-Adapted Screening be Implemented in Clinical Practice?: Results of a Focus Group Discussion with Experts in the RISIKOLOTSE.DE Project

INTRODUCTION

The mammography screening programme has been the subject of criticism for some time. Invitation to take part is currently based only on the risk factors of age and female sex, whereby women with an above-average risk are screened too seldom and women with a low risk are possibly screened too often. In future, an individualised risk assessment could make a risk-adapted procedure possible in breast cancer screening. In the RISIKOLOTSE.DE project, schemes are devised to calculate the individual breast cancer risk and evaluate the results. The aim is to assist doctors and screening participants in participatory decision-making. To gauge the baseline situation in the target groups, qualitative and quantitative surveys were conducted.

METHOD

At the start of the project, a guideline-based focus group discussion was held with 15 doctors and representatives of the public health service. The transcript of this discussion was evaluated by means of a qualitative content analysis.

RESULTS

The participants assessed the concept of risk-adapted screening positively overall. At the same time, the majority of them were of the opinion that the results of individualised risk calculation can be understood and evaluated adequately only by doctors. The great communication requirement and lack of remuneration were given as practical obstacles to implementation.

DISCUSSION

The suggestions and new ideas from the focus group ranged from administrative and regulatory changes to new forms of counselling and adaptable practice aids. An important indicator for the RISIKOLOTSE.DE conception and for planning future surveys was that risk calculation for mammography screening 2.0 was regarded as a purely medical function and that the concept of participatory decision-making played hardly any part in the discussion.

Can facts trump unconditional trust? Evidence-based information halves the influence of physicians' non-evidence-based cancer screening recommendations

Informed decision making in medicine, defined as basing one’s decision on the best current medical evidence, requires both informed physicians and informed patients. In cancer screening, however, studies document that these prerequisites are not yet met. Many physicians do not know or understand the medical evidence behind screening tests, do not adequately counsel (asymptomatic) people on screening, and make recommendations that conflict with existing guidelines on informed choice. Consistent with this situation, nation-wide studies showed that the general public misperceives the contribution of cancer screening but that understanding considerably improves when evidence-based information is provided. However, can evidence-based patient information about cancer screening make people also less likely to simply follow a physician’s non-evidence-based advice? A national sample of 897 German citizens, surveyed in face-to-face computer-assisted personal interviews, received either evidence-based (e.g., absolute risks on benefits and harms; n = 451) or non-evidence-based (e.g., relative risks on benefits only; n = 446) patient information about a cancer screening test and were then asked to make their initial cancer screening choice. Thereafter, participants received a hypothetical physician’s recommendation, which was non-evidence-based in terms of existing guidelines on informed decision making (i.e., reporting either benefits or harms but not both; no provision of numbers). When provided with non-evidence-based patient information (n = 446), a mean of 33.1% of 235 participants whose initial screening choice contradicted the hypothetical physician's non-evidence-based recommendation adjusted their choice in deference to that recommendation (95% CI: 27.4 to 39.4%), whereas with evidence-based patient information (n = 451), only half as many, a mean of 16.0% of 225 (95% CI: 11.8 to 21.4%), modified their choice. Thus, evidence-based patient information makes people less likely to simply follow non-evidence-based recommendations of physicians and supports people in making evidence-based decisions even when not adequately counseled on cancer screening.

Participation in breast cancer screening among women of Turkish origin in Germany - a register-based study

Background

Population-based breast cancer screening programs were implemented to reduce breast cancer mortality and to improve recovery chances. Breast cancer screening participation among migrant women differs from that of autochthonous populations in several European countries. Here we investigate for the first time participation among women of Turkish origin in Germany.

Methods

Data of five screening units covering 2010 and 2011 as well as associated population registries were analysed. Women of Turkish origin were identified using a name-based algorithm. Participation ratios among women of Turkish origin and odds ratios compared to women of non-Turkish origin were calculated. Analyses were stratified and adjusted for age-groups and screening unit.

Results

A total of 208,500 participants in the five breast screening units were included, out of 423,649 eligible women in the catchment areas (participation 49.2%). Women of Turkish origin have a slightly higher chance to participate in breast cancer screening than women without Turkish origin (OR 1.17; 95% CI: 1.14-1.21). Only women of Turkish origin aged 65–69 years have a lower chance to participate than women without Turkish origin (OR: 0.71; 95% CI: 0.66-0.75).

Conclusion

In spite of low participation in preventive measures among migrant populations, the overall breast cancer screening participation among women of Turkish origin in Germany seems to be higher compared to women of non-Turkish origin. Turkish women aged 65 years and above have a lower chance of participation than younger Turkish women. There is need for further research to study factors affecting participation in screening among migrant and non-migrant populations in Germany.

Valid comparisons and decisions based on clinical registers and population based cohort studies: assessing the accuracy, completeness and epidemiological relevance of a breast cancer query database

Background

Data accuracy and completeness are crucial for ensuring both the correctness and epidemiological relevance of a given data set. In this study we evaluated a clinical register in the administrative district of Marburg-Biedenkopf, Germany, for these criteria.

Methods

The register contained data gathered from a comprehensive integrated breast-cancer network from three hospitals that treated all included incident cases of malignant breast cancer in two distinct time periods from 1996–97 (N=389) and 2003–04 (N=488). To assess the accuracy of this data, we compared distributions of risk, prognostic, and predictive factors with distributions from established secondary databases to detect any deviations from these “true” population parameters. To evaluate data completeness, we calculated epidemiological standard measures as well as incidence-mortality-ratios (IMRs).

Results

In total, 12% (13 of 109) of the variables exhibited inaccuracies: 9% (5 out of 56) in 1996–97 and 15% (8 out of 53) in 2003–04. In contrast to raw, unstandardized incidence rates, (in-) directly age-standardized incidence rates showed no systematic deviations. Our final completeness estimates were IMR=36% (1996–97) and IMR=43% (2003–04).

Conclusion

Overall, the register contained accurate, complete, and correct data. Regional differences accounted for detected inaccuracies. Demographic shifts occurred. Age-standardized measures indicate an acceptable degree of completeness. The IMR method of measuring completeness was inappropriate for incidence-based data registers. For the rising number of population-based health-care networks, further methodological advancements are necessary. Correct and epidemiologically relevant data are crucial for clinical and health-policy decision-making.

Sentinel lymph node dissection only versus complete axillary lymph node dissection in early invasive breast cancer: a systematic review and meta-analysis

BACKGROUND

The Z0011-study, a landmark randomised controlled trial (RCT) challenged the benefits of complete axillary lymph node dissection (ALND) compared with sentinel lymph node dissection only (SLND) in breast cancer patients with positive sentinel nodes. The study, however, has been criticised for lack of power and low applicability. The aim of this review was to systematically assess the evidence on the comparative benefits and harms of ALND versus SLND for sentinel node positive breast cancer patients.

METHODS

We systematically searched PubMed, Embase, the Cochrane Library, and reference lists of pertinent review articles from January 2006 to August 2011. We dually reviewed the literature and rated the risk of bias of each study. For effectiveness, we included RCTs and observational studies of at least 1 year follow-up. In addition, we considered studies conducted in sentinel node-negative women to assess the risk of harms. If data were sufficient, we conducted random effects meta-analysis of outcomes of interest.

RESULTS

Meta-analysis of three studies with 50,120 patients indicated similar 5-year survival and regional recurrence rates between patients treated with ALND or SLND, although prognostic tumour characteristics varied among the 3 study-populations. Results from 6 studies on more than 11,500 patients reported a higher risk for harms for ALND than SLND. Long-term evidence on pertinent health outcomes is missing.

CONCLUSION

The available evidence indicates that for some women with early invasive breast cancer SLND appears to be a justifiable alternative to ALND. Surgeons need to discuss advantages and disadvantages of both approaches with their patients.