Rationale and Objectives
Women who are invited for breast cancer screening should get enough information about the benefits and harms of screening to make an informed decision on participation. Personal invitations are an important source of information, because all invited women receive them. The objective of this study was to evaluate the information breast cancer screening units send to women invited for screening in Finland.
Materials and Methods
A questionnaire was sent to all breast cancer screening units in Finland in 2005 and 2008, and the information (eg, invitations, results letters, leaflets) the units sent to women was collected. Results from 2005 were sent as feedback to the units. Data were analyzed descriptively, and results from the 2 years were compared.
Results
Screening units sent personal invitation letters usually providing fixed appointment times. Most units informed about participation free of charge and the benefits of detecting breast cancer early. Harm associated with screening was seldom mentioned; no unit mentioned the possibility of false-negative results or overtreatment.
Conclusion
The screening units provided very variable information, which often was biased toward optimizing participation. The high participation rate (approximately 88%) in Finland may be due partly to the prescriptive nature of the invitation letters. National templates for information letters would be useful.
Breast cancer screening programs aim to reduce mortality from breast cancer. Mammography screening can detect tumors at a preclinical stage, providing a possibility for the early treatment of cancer. Earlier diagnosis may improve prognosis and reduce the need for invasive treatment. The limitations of mammography screening include false-positive and false-negative results, overdiagnosis, increased anxiety for screened women, and harm from radiation.
In Finland, legislation requires municipalities to arrange breast cancer screening biannually for women aged 50 to 69 years. The nationwide screening started gradually for women aged 50 to 59 years in 1987 and covered the whole country by the early 1990s. In 2006, the screening program was expanded to include women aged 60 to 69 years. The screening and further investigations are free of charge for all participants. Municipalities can provide screening at their own screening units or purchase it from commercial providers. The screening centers in Finland partly fulfill the process criteria given in the guidelines of the European Community ( Table 1 ).
Table 1
Performance Indicators of Breast Cancer Screening Programs in Finland and The Netherlands Compared to the Guidelines of the European Community ( first screening )
Performance Indicator Finland, Women Aged 50–69 Years The Netherlands, Women Aged 50–69 Years European Union Guidelines (Desirable Level) Attendance rate 90% 79% >75% Recall rate for further examinations 4.6% 1.3% <5% Breast cancer detection rate (of expected incidence rate) 2.74 2.95 >3 Proportion of screen-detected cancers that are carcinoma in situ 10% 14% 10%–20% Proportion of screen-detected cancers at stage ≥II 33% 20% <25% Proportion of screen-detected invasive cancers that are node negative 76% 67% >70% Benign/malignant biopsy ratio 1:1 0.5:1 <0.5:1
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Materials and methods
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Results
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Table 2
Information in the Invitation Letters (percentages of the screening units in Finland providing facts on each item)
2005 2008 Item ( n = 23) ( n = 26) Prevalence of breast cancer 26% 15% Early detection 83% 96% Better prognosis 78% 88% Possibility of benign lesions 74% 42% Positive predictive value 17% 7% Specificity of screening 17% 7% Free of charge 96% 96% Voluntary participation 9% 7% Painful procedure 17% 12% Hormonal therapy 57% 81%
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Invitation Letters
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Table 3
The Analyzed Materials (invitation letters, reminder letters, results letters, and other materials) Sent by the Screening Units
2005 2008 Material ( n = 23) ( n = 26) Invitation letter 23 26 Reminder letter 7 9 Normal results letter 23 25 Invitation for further investigations 14 20 Other (leaflet) 4 2 Total 71 72
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Results Letters
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Discussion
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