Canadian Medical Association Journal 1996; 154: 1353-1355
© 1996 Canadian Medical Association (text and abstract/résumé)
It may be useful to put the results of this study in some perspective. The 1990 Health Promotion Survey revealed that the rates for mammography in Canada were far from ideal: 45% of women aged 50 to 59 and 34% of women aged 60 to 69 reported having had a mammogram within the 2 years before the survey.[2] Because some of these mammograms may have been done for diagnostic rather than screening purposes, the prevalence rate of appropriate screening behaviour was likely lower still. Similarly, Beaulieu and associates found that 40% of the women in the target age group seen during the study period had already undergone mammography in the previous 2 years. The interventions were thus directed only to the 60% of the population who had not recently been screened. Some women were ineligible for other reasons, and physicians forgot to give the advice to another 11% of the remaining eligible women. Two thirds of those who actually received the advice acted on it within 2 months. If one adds to this number the women who had already undergone mammography in the previous 2 years it is possible that 70% to 80% of women in the target age group in this practice were screened. This is not a bad success rate.
None the less, we must ask ourselves why some women chose not to participate in screening mammography. A number of explanations bear further consideration. First, it must be noted that the time given for follow-up was relatively short: 2 months. Women who did not act on the prescription in that time were considered to be noncompliant. Although we would expect a more rapid response among patients seeking investigation for an established health problem, it may not be reasonable to expect the same sense of urgency from those attending for a health maintenance visit.
It is easy for procrastination to slip into noncompliance in the case of many health-related manoeuvres. However, it may simply not have been possible for some women who intended to comply with the screening advice to arrange a convenient time for mammography in the allotted 8 weeks. This can be a particular difficulty if mammography facilities do not have flexible hours or a convenient location, or if women cannot predict how long a screening visit will take so that they can conveniently arrange for transportation or time off work. Although the study situation may have addressed these issues, barriers such as these could be addressed in other contexts, to the benefit of many women.
The authors express surprise that some of the women who did not comply stated that a recommendation by their family physician was unlikely to influence their decision to obtain a screening mammogram. Certainly, we should recognize that this was the feeling of a minority. Another study revealed that over 85% of a sample of women drawn from the general population stated that they would act on advice given to them by a physician to obtain a mammogram.[3] Nevertheless, it is important to recognize that most women have some opinion about screening mammography before the subject is raised by their physician. Women's magazines and other media are replete with articles on breast cancer and mammography, and most of these reports adhere to the basic journalistic tenet that "controversy sells newspapers."
This emphasis on controversy was one of the concerns expressed at the National Forum on Breast Cancer, held in Montreal in 1993.[4] The report of the Forum acknowledged that there is debate about whether mammography is of benefit to women under the age of 50 but noted that it was time to focus on the consensus message: randomized controlled trials have demonstrated the benefit of mammography for women aged 50 to 69 years, and many of these women are not being reached. It may be worthwhile, then, for physicians to follow up on their recommendations for screening mammography and to ask women who choose not comply what factors have influenced this decision. If the lack of action stems from a woman's confusion about the controversy, this can be discussed; some, but by no means all, women may decide to move forward once their questions have been answered.
Beaulieu and associates followed an admirable practice by offering women advice on appropriate screening interventions whether or not they were attending the clinic for a wellness check. However, many of the women, particularly those seeking advice for an acute health problem, may not have been in the most receptive state for additional health information. This is not to suggest that preventive recommendations should not be made in such a context: many women did, in fact, take the physicians up on their advice. However, repeated efforts may be needed to reach women at a time when they are likely to act on the message. Many women, in fact, may respond to a second suggestion to be screened even though the first suggestion is declined; a study of letters of invitation to a screening program, for example, showed that women who were sent a letter inviting them to screening (without specifying an appointment time) were 12 times as likely to comply as women not sent such a letter.[5] When the women who did not respond were mailed a second letter several months later, they were 13 times as likely to respond as women not sent any letters - a response rate that was even better than that for the original letter. Thus, we should not necessarily take the failure to act immediately as refusal or noncompliance; it may be that we need to discuss the matter again at a time when a positive response is more likely.
Finally, physicians need to be aware of their role as one of many agents of change in society. As was noted in a preface to the recommendations of the Canadian Task Force on the Periodic Health Examination,
The one-to-one doctor/patient relationship serves to reinforce large-scale public education and community wide health promotion efforts. It is well recognized that it is the interplay among multiple reinforcing approaches and the collaboration of numerous partners in both the public and private sectors that ultimately lead to a change in individuals' behaviour.[6]
In order to act collaboratively, of course, physicians need to be aware of the information their patients are obtaining from other sources. They may also want to consider becoming involved in community health promotion efforts that go beyond their own practice setting. Potentially important partnerships could be developed, for example with voluntary cancer agencies or provincial screening programs.
There is little doubt that we need to make more progress in reaching women in the target age group with appropriate, high-quality mammographic screening. However, we must be careful not to interpret slow uptake or failure to act on our advice as a rebuff and give up in despair. We need only to look back on the history of screening for cervical cancer and note that in 1961 similar concerns were being expressed about the failure to reach a substantial proportion of the population with Papanicolaou screening:
Undoubtedly lack of acceptance and application have hindered the proper expansion of cytologic screening tests. Upon this pivot rest most preventive measures and without it permanent success is impossible. There are many reasons why women have not accepted this test. The chief ones are lack of personal knowledge and interest.[7]
There is still much progress to be made in cervical screening, particularly in the provision of coordinated programs and in efforts to reach women who are still unscreened, but we should take heart that we have achieved a level of screening thought impossible 35 years ago. This has been achieved through a combination of public education, a demonstrated willingness of women to act appropriately on health information when the benefits are clear, and the steady efforts of primary care practitioners to provide advice and services to the patients who entrust them with their care. Primary care practitioners are right to be concerned about the challenges in achieving similar saturation of the population with breast cancer screening, but working collaboratively to achieve this goal -- with the community, breast screening programs, other health professionals and women themselves -- is the most likely route to success.