A physician's signed letter to women overdue for a screening mammogram is an effective intervention and a powerful addition to the standard postcard reminder, according to a study presented at the Breast Cancer Symposium (Abstract 1).
The meeting is sponsored by the American Society of Breast Disease, the American Society of Breast Surgeons, the American Society of Clinical Oncology, the American Society for Radiation Oncology, the National Consortium of Breast Centers, and the Society of Surgical Oncology.
In the randomized study from British Columbia, the letters from family physicians added to a standard postcard reminder resulted in 50 percent more of the recipients coming in for mammograms, compared with the number of women who were sent the postcard only.
Speaking at an ASCO telecast for reporters before the meeting, the study's first author, Elisa K. Chan, MD, formerly a research fellow at the BC Cancer Agency and now a radiation oncologist at St. John Regional Hospital in New Brunswick, Nova Scotia, and Assistant Professor at Dalhousie University in Halifax, explained that the study was conducted through the BC Cancer Agency Screening Mammography Program, which was established in 1988 and is fully government funded.
She noted that the current recommendations in Canada are for women ages 50 to 74 to have screening mammograms once every two years, and in the current process, several reminder postcards are sent to women who are due or overdue for their next screening. Typically two reminder letters are sent around the time of the two-year anniversary of the last mammogram, five weeks before and five weeks after, and then another two reminders are sent around the three-year anniversary.
Among women who are routine participants in the Screening Mammography Program, this approach results in an overall on-time (defined as within 30 months) participation rate of 80 percent, Chan said. But for all women in British Columbia, the reminder results in only a 54 percent participation rate.
For the study the researchers identified 822 family physicians who had women in their practice who were eligible for screening mammograms, were previously enrolled in the program, and were overdue for a screening mammogram.
The physicians were provided with a reminder letter for their patients, which the physician signed and sent back to the researchers. The physicians could not change the text of the letter and were not sent reminders about participating in the program.
Women were selected for the study if they had one or more previous screening mammograms. Participants were randomly assigned to receive either the standard reminder postcard alone or the postcard and the signed physician letter.
The age, number of prior screening mammograms, and time overdue were not statistically different between the arms, Chan reported.
The database was analyzed six months after the mailings to determine which overdue women attended their scheduled screening mammogram appointment.
Among women randomly selected to receive the postcard alone, 22 percent (600 of 2,689 women) returned for a screening mammogram, compared with 33 percent (894 of 2,696) who received both the signed letter and the postcard.
The data also showed that women who had more than one previous screening mammogram were twice as likely to return as women who had only one, and women who were 30 to 36 months overdue for the exam were twice as likely to return as women 42 to 48 months overdue.
Chan also noted that compared with some other methods, such as telephone reminders, physician letters are less time consuming and resource intensive. The approach is probably effective, she speculated, because women typically have a trusting and long-term relationship with their family doctor.
The research was supported by the Canadian Breast Cancer Foundation, BC/Yukon Division, and the BC Cancer Agency.
‘One of the Simple Things We Can Do’
“This is one of the simple things we can do to encourage women to return for their screening mammogram, which remains a very important tool for lowering the chances of death from breast cancer,” said the moderator of the telecast, Harold J. Burstein, MD, PhD, a member of the ASCO Cancer Communications Committee, who is Associate Professor of Medicine at Harvard Medical School and a breast cancer specialist at Dana-Farber Cancer Institute.
“According to the British Columbia study, only about half of women respond to the reminder postcards, which means the other half do not, and the challenge is to get those women to engage more with the screening program. We know it saves lives.”
This study, he said, is “an extraordinary tribute to the power of what that personal connection [with her physician] can mean to a woman who is thinking about the health care choices she has.”
It also speaks to the importance of having specialists in oncology work with primary care teams to extend themselves, so that women in the general population are getting this very important access to screening mammography, Burstein added.