Effect on breast cancer screening response in The Netherlands of inviting women for an additional scientific investigation

Factors associated with attendance at screening for breast cancer: a systematic review and meta-analysis

OBJECTIVE

Attendance at population-based breast cancer (mammographic) screening varies. This comprehensive systematic review and meta-analysis assesses all identified patient-level factors associated with routine population breast screening attendance.

DESIGN

CINAHL, Cochrane Library, Embase, Medline, OVID, PsycINFO and Web of Science were searched for studies of any design, published January 1987-June 2019, and reporting attendance in relation to at least one patient-level factor.

DATA SYNTHESIS

Independent reviewers performed screening, data extraction and quality appraisal. OR and 95% CIs were calculated for attendance for each factor and random-effects meta-analysis was undertaken where possible.

RESULTS

Of 19 776 studies, 335 were assessed at full text and 66 studies (n=22 150 922) were included. Risk of bias was generally low. In meta-analysis, increased attendance was associated with higher socioeconomic status (SES) (n=11 studies; OR 1.45, 95% CI: 1.20 to 1.75); higher income (n=5 studies; OR 1.96, 95% CI: 1.68 to 2.29); home ownership (n=3 studies; OR 2.16, 95% CI: 2.08 to 2.23); being non-immigrant (n=7 studies; OR 2.23, 95% CI: 2.00 to 2.48); being married/cohabiting (n=7 studies; OR 1.86, 95% CI: 1.58 to 2.19) and medium (vs low) level of education (n=6 studies; OR 1.24, 95% CI: 1.09 to 1.41). Women with previous false-positive results were less likely to reattend (n=6 studies; OR 0.77, 95% CI: 0.68 to 0.88). There were no differences by age group or by rural versus urban residence.

CONCLUSIONS

Attendance was lower in women with lower SES, those who were immigrants, non-homeowners and those with previous false-positive results. Variations in service delivery, screening programmes and study populations may influence findings. Our findings are of univariable associations. Underlying causes of lower uptake such as practical, physical, psychological or financial barriers should be investigated.

TRIAL REGISTRATION NUMBER

CRD42016051597.

Beneficial role of vitamin K supplementation on insulin sensitivity, glucose metabolism, and the reduced risk of type 2 diabetes: A review

Micronutrients are gaining acceptance as an important nutritional therapy for the prevention and/or management of diabetes and its associated health risks. Although a very small quantity of micronutrients are required for specific functions in our bodies, moderate deficiencies can lead to serious health issues. Impaired insulin sensitivity and glucose intolerance play a major role in the development of diabetic pathophysiology. Vitamin K is well known for its function in blood coagulation. Moreover, several human studies reported the beneficial role of vitamin K supplementation in improving insulin sensitivity and glucose tolerance, preventing insulin resistance, and reducing the risk of type 2 diabetes (T2 D). Both animal and human studies have suggested that vitamin K-dependent protein (osteocalcin [OC]), regulation of adipokine levels, antiinflammatory properties, and lipid-lowering effects may mediate the beneficial function of vitamin K in insulin sensitivity and glucose tolerance. This review for the first time provides an overview of the currently available preclinical and clinical evidences on the effect of vitamin K supplementation in the management of insulin sensitivity and glucose tolerance. The outcome of this review will increase understanding for the development of a novel adjuvant therapy to achieve better control of glycemia and improve the lives of diabetic patients.

Effect of a pre-screening survey on attendance in colorectal cancer screening: a double-randomized study in Finland

OBJECTIVES

To explore effects of a pre-screening life style survey on the subsequent attendance proportion in colorectal cancer screening.

SETTING

Finnish colorectal cancer screening programme in 2011.

DESIGN

Double randomized and controlled follow-up design.

METHODS

The study population comprised of 31,951 individuals born in 1951. In 2010 to a random sample of every sixth (n = 5,312) person we sent a 7-paged life style questionnaire, and to another random sample of every sixth person (n = 5,336) a 10-paged life style and quality of life questionnaire. One year later, in 2011, 31,484 individuals of the original cohort were independently randomized (1:1) for colorectal cancer screening (n = 15,748) or control group (n = 15,736). Of those who were invited for screening, 5185 had received a questionnaire during the previous year.

RESULTS

5870 individuals (55.1 %) responded to the questionnaire in 2010. The overall attendance at screening in 2011 was 59.0 % in those born in 1951 (i.e. the 60-year-olds). In those who had been sent the survey the attendance in screening was 56.6% (57.3% for the short and 56.0% for the long questionnaire) and in those who had not received the questionnaire it was 60.2% (P < 0.001).

CONCLUSIONS

We believe that the observed reduction in attendance in those who had been sent a questionnaire earlier is generally true. Thus, if any survey is enclosed in the screening invitation, this finding should be taken into account when planning the programme. Any extra effort requested may reduce the attendance proportion for screening, reducing the population level impact of screening.

Use of research questionnaires in the NHS Bowel Cancer Screening Programme in England: impact on screening uptake

BACKGROUND

The NHS Bowel Cancer Screening Programme in England offers biennial screening to those aged 60-74 using a faecal occult blood test (FOBt) sent by post. Data from this national clinical programme can also be used for research. Awareness of the impact of such studies on screening participation is important.

AIMS

To investigate the effect on screening uptake of adding a research questionnaire to the postal screening invitation.

METHODS

People invited for screening in 2008-10 in two areas of England were randomized to receive or not to receive an additional research study questionnaire, consent form and study information, either with their test kit or 2-3 days later. Uptake of screening was examined in relation to study mailings.

RESULTS

Among 11,579 people invited for screening by the Midlands and North West Bowel Cancer Screening Hub, screening uptake was significantly lower in those who received study documents with their FOBt kit than in those who did not (48.6% vs 53.5% respectively: p < 0.001). The reduction in uptake was similar in men and women, and was greater in people living in more deprived areas. Among a further 36,195 people invited for screening by the Midlands and North West and Southern Hubs, sending study documents by separate mailing 2-3 days after the FOBt kit did not affect screening uptake (uptake with and without additional study mailing: Midlands and North West, 56.7% and 56.2% respectively, p = 0.6; Southern, 52.0% and 51.4% respectively, p = 0.5).

CONCLUSIONS

Researchers planning studies that include contact with potential participants within the NHS Bowel Cancer and similar screening programmes should be aware of the potential impact on uptake.

Increasing participant recruitment into large-scale screening trials: experience from the CADET II study

Objectives

Multicentre randomized trials frequently encounter difficulties in meeting their recruitment targets, resulting in extension of the trial and delays in implementation of the findings. We report on recruitment strategies implemented in a randomized evaluation of computer-aided detection in women attending routine screening in the UK Breast Screening Programme.

Setting

The target population for the trial was identified from an existing NHS database of women aged 50–70 invited for routine mammography in Coventry, Manchester and Nottingham, UK. Women were asked to consent to their mammograms being randomly allocated (in a ratio of 28:1:1) to one of three film-reading protocols. Trial information was mailed to women, along with the invitation to attend screening, and informed consent was obtained at the mammography appointment. Several strategies were implemented to increase recruitment rates.

Results

Recruitment rate increased significantly over time in the study ( P < 0.0010 in all centres) with an overall acceptance rate of 46% of those attending screening. Mailing of the trial information sheet separate from the screening invitation in Coventry and Nottingham increased the recruitment rate, even after adjustment for the trend over time and for socioeconomic status of the attendees ( P < 0.001). Extension of recruitment to mobile screening units in Nottingham, and the presence of an additional member of staff also improved recruitment ( P < 0.001). Simplification of the trial information sheet had little effect. Increases in recruitment rate were not attributable to socioeconomic status of the attendees.

Conclusions

In multicentre trials, monitoring of local recruitment protocols is required to ensure that each centre can maximize accrual targets.

Breast cancer screening programme as setting for an adjunct research project: effect on programme attendance

The purpose of this randomized controlled trial was to examine if an adjunct research project to a breast cancer screening programme would affect the high programme attendance. Women residing in the municipality of Tromsø aged 55 years or older, scheduled to receive an invitation letter to their first screening round in the Norwegian Breast Cancer Screening Programme during our 15-week recruitment period, were eligible. We randomly selected up to 25 invitees per screening day to receive a mailed request to participate in the research project named the Tromsø Mammography and Breast Cancer study. These women constituted the study arm, while the remaining eligible invitees served as the control arm. The attendance rate to the screening programme was 80.1% among the 253 women in the study arm and 74.8% among the 397 women in the control arm (P = 0.09). Our trial finds no effect on the high attendance to the breast cancer screening programme indicating that cancer screening programmes might be suitable settings for adjunct research projects.

Fat mass rather than muscle strength is the major determinant of physical function and disability in postmenopausal women younger than 75 years of age

OBJECTIVE

Few studies have investigated the relationships between body composition, functional ability, and age-related disability in postmenopausal women. We investigated the relative role of fat mass, lean mass, and muscle strength in the development of disability in a group of healthy postmenopausal women younger than 75 years.

DESIGN

We performed a cross-sectional study among 396 independently living women aged 56-73 years, randomly selected between 8 and 30 years after menopause. Lean mass and fat mass were assessed by dual-energy x-ray absorptiometry. Muscle strength (grip and leg extensors) was assessed using dynamometry. Functional ability was estimated by Physical Performance Score, physical activity during the preceding year, and impairment in activities of daily living.

RESULTS

Of the participants, 43.7 % were overweight (25 > or = BMI < 30 kg/m2), and 17.7% were obese (BM I > or = 30 kg/m2). Higher muscle strength was observed with increasing lean body mass, and participants with higher muscle strength scored better in the physical performance score and activities of daily living. Higher fat mass was significantly associated with a lower physical performance score, lower physical activity, and a higher frequency of disability. Increasing fat mass was associated with increasing lean mass and decreasing lean/fat ratio. The increase in lean mass and muscle strength associated with higher fat mass was mainly localized in the legs.

CONCLUSIONS

Our results support the role of fat mass as the primary risk marker for disability, which might later accelerate by the age-related decrease in lean mass and the development of sarcopenia after the age of 75 years.

Endogenous oestrogens are related to cognition in healthy elderly women

OBJECTIVE

To investigate whether levels of endogenous hormones, in particular circulating oestrogens and SHBG, are associated with cognition in healthy postmenopausal women.

DESIGN

Cross-sectional study.

PATIENTS

Four hundred and two healthy postmenopausal women aged 50-74 years between 8 and 30 years after menopause, none taking oestrogen.

MEASUREMENTS

Serum concentration of oestradiol, oestrone, and sex hormone binding globulin (SHBG) determined by immunoassay. Cognition assessed using the mini-mental state examination questionnaire (MMSE).

RESULTS

In this group, 149 individuals had a MMSE score < 27, while only 89 individuals had a MMSE score < 26, indicating a relatively healthy population with regard to cognitive ability. Cognition decreased with age, time since menopause and blood pressure, and was better with higher age at menopause. Serum oestrogens and SHBG levels were not related to age, age at menopause, or time since menopause, and oestrogen levels were positively associated with blood pressure. After adjustment for mean arterial pressure and SHBG, the frequency of mild cognitive impairment decreased significantly with higher oestradiol and oestrone serum levels [ORs Q5 vs. Q1: 0.41 (95% CI 0.20-0.84) and 0.51 (95% CI 0.20-0.99) for oestradiol and oestrone, respectively].

CONCLUSIONS

Postmenopausal women with higher remaining circulating oestradiol levels appear less likely to suffer from cognitive impairment. This effect is independent of age at menopause, time since menopause and BMI. These findings support the hypothesis that endogenous oestrogens may protect against cognitive decline with ageing.

Predicting attendance for breast screening using routinely collected data

The aim of this paper is to predict attendance if the age range for routine invitation to breast screening were to be extended. The response to the most recent screening invitation is modelled for women eligible for screening if the age range were extended. The independent variables include (i) the woman's characteristics: her screening history; the deprivation score of the area she lives in and (ii) the characteristics of the screening: whether the screening took place in a mobile van or at a static site; and time of the year. The predictive ability of the regression model is tested by goodness of fit measures and by predicting attendance for a holdout sample of the data and for women who participated in a demonstration project. The modelling of attendance is quite successful in that most hypothesised variables have the expected sign. Moreover, the predictive ability of the model is satisfactory in terms of goodness of fit statistics and in terms of accuracy of predictions for a holdout sample. The model predicts less well for the demonstration project possibly because it is less representative of usual screening practice.

Alcohol consumption in relation to aortic stiffness and aortic wave reflections: a cross-sectional study in healthy postmenopausal women

OBJECTIVE

Moderate alcohol consumption has been postulated to be cardioprotective. Such an effect might be reflected in large-artery properties, such as arterial stiffness and wave reflections.

METHODS AND RESULTS

Three hundred seventy-one healthy postmenopausal women aged 50 to 74 years were sampled from a population-based study. Alcohol intake was calculated from a standardized questionnaire. Applanation tonometry was applied to assess the augmentation index and aortic pulse-wave velocity. Those drinking 1 to 3, 4 to 9, 10 to 14, and 15 to 35 glasses of alcoholic beverages per week had a 0.044 (95% CI -0.47 to 0.56), -0.085 (95% CI -0.59 to 0.43), -0.869 (95% CI -1.44 to -0.29), and -0.225 (95% CI -0.98 to 0.53) m/s difference in mean pulse-wave velocity compared with nondrinkers, respectively, which indicates a J-shaped relationship. Adjustment for potential confounders of pulse-wave velocity or alcohol intake did not materially change the strength of the association. Adjustment for HDL further attenuated the relationship. The augmentation index was not related to alcohol consumption when adjustments were made for physiological determinants such as age, height, and ejection duration.

CONCLUSIONS

Among postmenopausal women, alcohol consumption is inversely associated with pulse-wave velocity. This supports the presence of a decreased risk of cardiovascular disease with moderate alcohol consumption, which may be mediated in part by HDL cholesterol.

Prospect-EPIC Utrecht: study design and characteristics of the cohort population. European Prospective Investigation into Cancer and Nutrition

The European Prospective Investigation into Cancer and Nutrition (EPIC), which has been established in order to investigate the relations between nutrition and cancer, was initiated in 1990 and involves 10 European countries with heterogeneous dietary patterns and differing cancer incidence rates. This manuscript presents the design, recruitment and baseline characteristics of the Prospect-EPIC cohort co-ordinated in Utrecht, The Netherlands. The cohort is based on volunteers recruited among women participating in a regional breast cancer screening program. It comprises of 17,357 subjects aged 50-69 years at enrolment from Utrecht and vicinity, who have consented to participate in the study and its follow-up. Each participant filled out a general questionnaire and a food frequency questionnaire. Participants were also physically examined and have donated a blood sample. Participation rate was 34.5%. Blood samples were donated by most participants (97.5%) and detailed informed consents were obtained from 87.4% of participants. Mean age at enrolment was 57 years. Anthropometric, lifestyle and morbidity characteristics of the cohort population did not differ largely from those of similar study populations in The Netherlands. Based on the Prospect-EPIC population, we intend to conduct prospective total cohort, nested case-control or case-cohort studies, in order to investigate relations between consumption of certain food groups or nutrients and chronic diseases, including hormone dependant cancers such as breast, colon, endometrial and ovary cancers.

Arterial stiffness in postmenopausal women: determinants of pulse wave velocity

OBJECTIVE To investigate the degree and potential cardiovascular determinants of arterial stiffness, assessed by aortic pulse wave velocity (PWV) measurements, and to relate arterial stiffness to absolute 10-12-year risks of stroke, coronary heart disease and death, as estimated by available risk functions, in postmenopausal women. METHOD We performed a cross-sectional study among 385 postmenopausal women, aged 50-74 years, sampled from the general population. Arterial stiffness was assessed non-invasively by measurement of aortic PWV using applanation tonometry. Information on health was obtained by medical history, registration of current medication, and physical examination. Height, weight, waist and hip circumferences, fasting glucose, total and high-density lipoprotein (HDL) cholesterol, triglycerides, resting blood pressure, and heart rate were measured. Three risk scores were used to estimate, for each individual, the absolute risk of stroke, coronary heart disease, and death within 10-12 years as a function of their cardiovascular risk factor profile. The relationship between PWV and these risk scores was subsequently determined. RESULTS Significant positive relationships with PWV were found for body mass index, fasting glucose, diabetes mellitus, and triglycerides in analyses adjusted for age, mean arterial blood pressure, and heart rate. Height and HDL cholesterol were inversely related to PWV. The risks of stroke, coronary heart disease, and death increased with increasing PWV in a linear graded manner. CONCLUSIONS This cross-sectional study among postmenopausal women provides evidence that most of the established cardiovascular risk factors are determinants of aortic PWV. Increased PWV marks an increased risk of stroke, coronary heart disease, and death within 10-12 years.

Assessing the resource implications of extending routine invitation to breast screening to women aged 65-67 years

UK breast screening policy currently restricts routine 3-yearly invitation to screening to 50-64 year olds. However, it is likely that routine invitation will be extended to 65-67 year olds in 2001. This paper first predicts the additional demand for breast screening as a result of this new policy by modelling the response to the 1998 invitation of women eligible for screening in 2001. The independent variables include (i) the woman's characteristics: her screening history; the deprivation score of the area she lives in; and (ii) the characteristics of the screening: whether the screening took place in a mobile van or at a static site; and time of the year. The modelling of attendance is quite successful in that most hypothesised variables have the expected sign. It is estimated that an additional 10829 women will be screened per annum. The additional invitation, screening and assessment costs are expected to be approximately pound350000 in 2001.

Strategies for increasing women participation in community breast cancer screening

BACKGROUND

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.

OBJECTIVES

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.

SEARCH STRATEGY

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).

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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 (OR 2.81, 95% 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).

REVIEWER'S CONCLUSIONS

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.

Lipoprotein (a) is associated with endothelial function in healthy postmenopausal women

BACKGROUND

Lipoprotein (a) (Lp(a)) is an independent risk factor for atherosclerotic cardiovascular disease. The atherogenic potential of Lp(a) may be by impairment of endothelial function. Objectives. We investigated the relation of Lp(a) plasma levels to endothelium dependent and independent dilatation of the brachial artery in healthy postmenopausal women.

METHODS

One hundred and five healthy postmenopausal women aged 52-67 years were included in the study. Endothelial function was assessed non-invasively by measuring percent lumen diameter change in the brachial artery after reactive hyperemia and sublingual nitroglycerine spray.

RESULTS

Flow mediated dilatation was inversely related to the plasma logLp(a) level. Mean change per unit logLp(a) increase:-2.83% (95% CI: -5.22--0.43). Elevated Lp(a) (>239 mg/l) (upper quartile) was associated with an impaired flow mediated vasodilatation (2.4%+/-1. 2) compared to Lp(a) < or =239 mg/l (5.2%+/-0.7). Adjustment for other cardiovascular risk factors did not change the magnitude of the association. Nitroglycerine-induced vasodilatation was not significantly lower in the high Lp(a) level group, compared to the group with normal levels of Lp(a) (< or =239 mg/l) (8.0+/-1.2 vs. 11.4%+/-0.8).

CONCLUSION

Elevated lipoprotein (a) levels are associated with an impaired endothelial function in healthy postmenopausal women, independent of conventional risk factors for cardiovascular disease. Since Lp(a) may be pathogenetically important for early vascular damage, elevated Lp(a) levels might contribute to the increased cardiovascular risk seen in postmenopausal women.

Investigating Patient Satisfaction as an Outcome for Ultrasound-Guided Breast Procedures

An investigation of patient satisfaction with ultrasound-guided breast procedures (fine needle biopsy and cyst aspiration) was performed. The research was designed around a proposed imaging loop added to the Health Related Quality of Life model. A patient questionnaire, devised to assess three areas of the imaging loop—preanalytical, postanalytical, and overall satisfaction with the procedure—was administered. Results show a population of patients satisfied with these invasive procedures. Study patients' satisfaction levels were comparable with those of control subjects. Procedure anxiety was identified as a patient perception, but did not hamper level of satisfaction. Study patients also reported that ultrasound-guided breast procedures contributed to a perception of favorable overall health and gave a high level of patient satisfaction.

Effect on attendance at breast cancer screening of adding a self administered questionnaire to the usual invitation to breast screening in southern England

STUDY OBJECTIVE

The primary aim of the research described in this paper was to ascertain whether inclusion of a self administered questionnaire with the usual invitation to routine breast screening affected screening uptake. Secondary aims included establishing appropriate questionnaire distribution and collection methods within the framework of the National Health Service Breast Screening Programme and optimisation of questionnaire design.

DESIGN

Randomised study.

SETTING

Oxfordshire and West of London Breast Screening Units.

PARTICIPANTS/METHODS

6400 women invited for routine screening mammography were individually randomised to receive either the usual breast screening invitation alone, or to receive the usual invitation accompanied by a self administered questionnaire, to be returned at the time of screening. Participants were then followed up and attendance rates at screening were compared between groups.

MAIN RESULTS

Screening attendance rates were similar in women who did and did not receive a questionnaire (71% in each group). Of those who were sent a questionnaire and attended for screening, 77% returned a completed questionnaire. Screening uptake was not affected by the way in which the questionnaire was returned or by whether or not personal details and signed permission for follow up were requested.

CONCLUSIONS

The inclusion of a self administered questionnaire accompanying the invitation to breast screening did not adversely affect screening uptake. A high proportion of women completed the questionnaire.