21

SHORT REPORT

Breast cancer screening prevalence of disease in women

who only respond after an invitation reminder
Solveig Hofvind
..................................................................................................

J Med Screen 2007;14:2122

See end of article for

authors affiliations An analysis of the Norwegian Breast Cancer Screening Programme, including 1,390,310 screening
............... examinations, showed an attendance rate of 71.7% in response to one invitation letter (ordinary
Correspondence to: attendees) and a further 4.5% increase only after an additional reminder (reminded attendees). Our
Dr Solveig Hofvind, aim was to examine the prevalence of breast cancer in ordinary and reminded attendees, the
Department of Screening
Based-research, The Cancer
frequency of positive mammograms, and the positive predictive value in the two groups.
Registry of Norway, The prevalence of breast cancer in ordinary attendees was 5.6 per 1000 screens compared with
Montebello, 0310 Oslo, 6.3 per 1000 screens in reminded attendees (Po0.001). The frequencies of positive mammograms
Norway; solveig.hofvind were 3.5% and 4.0% (Po0.001), and the positive predictive values were 15.9% and 15.2%
@kreftregisteret.no/
shofvind@uvm.edu (P 0.387), respectively, in ordinary and reminded attendees.
The risk of breast cancer is higher in women who respond only after a reminder letter, indicating that
Accepted for publication the value of sending a reminder should be assessed in the light of these results, as well as by the
6 December 2006
............... increase in the attendance rate.

INTRODUCTION brings an increased economic cost, but it seems efficient for

the attendance rate. Travelling, being too busy, low income,

A
high participation rate is crucial in breast cancer
screening programmes aimed at reducing mortality
from the disease.1 Despite knowledge about efforts to
influence screening attendance and the underlying mechan-
isms of the behavior,25 little attention has been paid to the
screening outcome in women who attend subsequent to an
ordinary invitation letter, and those who respond only after
a reminder letter.
The Norwegian Breast Cancer Screening Programme
(NBCSP) is a population-based screening programme invit-
ing all women aged 5069 years to receive a bilateral two-
view mammography biennially.6 A personal letter is mailed,
inviting the women to a prearranged place and time for the
examination. Women, who do not attend for screening are
sent one reminder 38 weeks after their scheduled time. The
reminder letter does not have a stated time and place for the
examination. Thus, the women have to call the breast
centre to make the appointment. This study examines the
prevalence of breast cancer in women who participated after
an ordinary invitation (ordinary attendees, n 996,846),
and only after an ordinary invitation followed by a reminder
(reminded attendees, n 62,463). The study period was
November 1995 to January 2006. The trends were tested
using a w2 test, and a P value less than 0.05 was regarded as
statistically significant. All analyses were conducted using
SPSS (SPSS, version 12.0.1 for Windows, SPSS Inc.,
Chicago, IL, USA).
RESULTS AND DISCUSSION
A total of 996,846 attendances were registered subsequent
to 1,390,310 mailed ordinary invitations (71.7%). A
reminder letter was sent to 393,464 women who did not
respond after an ordinary invitation. The reminders lead to
further 62,463 attendances (15.9%), which increased the
entirely attendance rate by 4.5%, to 76.2% (1,059,309/
1,390,310). The Norwegian system of sending a reminder
illness and anxiety have been reported as reasons for non-
attendance.35 It is also well known that including a
prearranged time and place for the mammography exam-
ination, and the co-pay are factors of influence for the
attendance rate.7,8 These factors seem properly ensured in
the NBCSP.6
The recall rates due to positive mammography were 3.5%
in women responding after an ordinary invitation, and 4.0%
in those responding only after a reminder (Po0.001, Table 1).
The breast cancer detection rates per 1000 screens were 5.6 in
ordinary and 6.3 in reminded attendees (Po0.001). The
higher recall and cancer detection rate among the reminded
compared with the ordinary attendees could be a result of a
womans feeling that something is wrong in her breast. She
thus needs the time between her invitation and the reminder
letter to prepare for the examination. A higher detection
rate in those participating after just a reminder was observed
for all age groups (5054, 5559, 6064 and 6569 years
old) (data not shown). The need for preparation time could
thus be regarded as independent of age, which seems
reasonable.
The recall rate due to a self-reported lump was 0.4% and
0.6% in ordinary and reminded attendees, respectively
(Po0.001). However, the number of breast cancer cases
among women reporting a lump was very small, resulting in
a positive predictive value (PPV) of 2.4% (103/4248) for
ordinary, and 3.0% (11/364) for reminded attendees. This
result indicates that women reporting symptoms when they
attend the screening unit contribute only to a small fraction
of the total number of breast cancer cases in the NBCSP. The
interpretation should, however, be read carefully because
symptomatic women also could have a positive mammo-
graphy, which overrules self-reported symptoms in the
NBCSPs database.
A not statistically significant higher proportion of invasive
cancer, tumours X15 mm and Grade III tumours was found
among reminded compared with the ordinary attendees

www.jmedscreen.com Journal of Medical Screening 2007 Volume 14 Number 1

22 Hofvind

Table1 Recall, prevalence of breast cancer, and positive predictive value in women who attend after an ordinary invitation and
only after an ordinary invitation followed by a reminder, in the Norwegian Breast Cancer Screening Programme
Women who attend for screening

Responding after Responding only after an

an ordinary invitation invitation reminder
N 996,846 N 62,463 P value
Positive mammograms (n) 34,389 2509
Recall rate 3.5% 4.0% o0.001

Breast cancers detected (n) 5584 394

Prevalence of breast cancer 5.6/1000 6.3/1000 o0.001

Breast cancers detected due to positive mammograms (n) 5454 381

Positive predictive value: breast cancers diagnosed 15.9% 15.2% 0.387
due to positive mammograms

(data not shown). The histological tumour characteristics REFERENCES

in the reminded attendees may thus be regarded as
somewhat in between screen-detected cancers and interval
cancers.7,8 A possible delay of diagnosis in reminded
attendees is insignificant since the reminders are sent 38
weeks after the ordinary scheduled day, and the reminders
who make an appointment have done so within a mean
of 30 days.
In conclusion, sending a reminder letter to women who
do not attend the NBCSP after an ordinary invitation is
valuable to increase the participation rate and for diagnosing
breast cancers that probably would have developed into a
more advanced stage before it was diagnosed if no reminder
letter was sent.
................
Authors affiliations
Solveig Hofvind, Researcher, The Cancer Registry of Norway,
Montebello, 0310 Oslo, Norway
1 Vainio H, Bianchini F, ed. IARC Handbooks of Cancer Prevention. Volume 7
Breast Cancer Screening. Lyon, France: IARC Press, 2002
2 Taplin SH, Barlow WE, Ludman E, et al. Testing reminder and motivational
telephone calls to increase screening mammography: a randomized study.
J Natl Cancer Inst 2000;92:23342
3 Hofvind S, Wang H, Thoresen S. The Norwegian Breast Cancer Screening
Program: Re-attendance related to the womens experiences, intentions and
previous screening result. Cancer Causes Control 2003;14:3918
4 Sutton S, Bickler G, Sancho-Aldridge J, Saidi G. Prospective study of
predictors of attendance for breast screening in inner London. J.Epidemiol.-
Community Health 1994;48:6573
5 Zackrisson S, Andersson I, Manjer J, Janzon L. Non-attendance in
breast cancer screening is associated with unfavourable socio-economic
circumstances and advanced carcinoma. Int.J.Cancer 2004;108:
75460
6 Hofvind S, Wang H, Thoresen S. Do the results of the process indicators in
the Norwegian Breast Cancer Screening Program predict a future mortality
reduction from breast cancer?. Acta Oncologica 2004;43:46773
7 Orton M, Fitzpatrick R, Fuller A, Mant D, Mlynek C, Thorogood M. Factors
affecting womens response to an invitation to attend for a second breast
cancer screening examination. Br J Gen Pract 1991;41:3202
8 Tinkler C, Pegington K, Baldwin R. Breast screening attendance: making
better use of an appointment system. J Med Screen 2001;8:368

Journal of Medical Screening 2007 Volume 14 Number 1 www.jmedscreen.com