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Informed choice for breast cancer screening may result in fewer mammograms
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Women who received information about breast cancer overdetection in the context of an evidence-based decision aid appeared less likely to undergo mammography screening, according to results of a study conducted in Australia.
Many women do not realize mammography screening can detect inconsequential disease, leading to overdiagnosis and unnecessary treatment that can cause physical and emotional harm, according to study background.
Kirsten McCaffery, PhD, associate professor and principal research fellow in the school of public health at the University of Sydney, and colleagues conducted a community-based randomized controlled trial in New South Wales, Australia, to assess whether use of a decision aid that included information about breast cancer overdetection would increase the likelihood that women would make an informed choice about screening.
The analysis included 879 women aged 48 to 50 years. The women had not undergone a mammogram in the past 2 years, and they had no personal history or strong family history of breast cancer.
Researchers randomly assigned 440 women to the intervention decision aid, which included evidence-based explanatory and quantitative information on overdetection, as well as information about false positives and breast cancer mortality reduction.
The other 439 women were assigned to the control group. They received information about false positives and breast cancer mortality reduction only.
Researchers defined the primary outcome measure as “adequate knowledge and consistency between attitudes and screening intentions.” Researchers assessed this outcome by phone interview 3 weeks after randomization.
Forty-one women were lost to follow-up and 21 women did not answer all questions about attitudes, leaving 817 women — 409 in the intervention group and 408 in the control group — available for analysis.
The researchers determined more women in the intervention group than the control group had adequate knowledge about breast cancer screening (29% vs. 17%; difference, 12%; 95% CI, 6-18). They also found more women in the intervention group made an informed choice whether to be screened than the control (24% vs. 15%; difference, 9%; 95% CI, 3-14).
Fewer women in the intervention group displayed positive attitudes about screening (69% vs. 83%; difference, 14%; 95% CI, 9-20) and expressed an intention to undergo screening (74% vs. 87%; 95% CI, 8-19).
“Our findings contribute evidence of the effectiveness of decision aids in supporting screening policy that values enabling informed choice rather than maximizing uptake,” McCaffery and colleagues wrote. “Women can incorporate overdetection information into their reasoning about screening, thereby improving the quality of their decisions.”
The design of this trial was particularly unique, Minna Johansson, postgraduate student in the department of public health and community medicine at The Sahlgrenska Academy at University of Gothenburg in Sweden, and John Brodersen, PhD, associate professor in the department of public health at University of Copenhagen in Denmark, wrote in an accompanying editorial.
“We could argue that to do a trial in which half of the participants are not given information about the harms of an intervention is ethically unacceptable,” Johansson and Brodersen wrote. “However, most breast screening programs do not include information about overdiagnosis or other relevant harms of screening in their invitations, which is why this study is so important.”
The results highlight the need for “reassessment of invitations to current screening programs,” and suggest adequate information about all important benefits and harms should be added, they wrote.
“We would also like to raise a note of caution,” Johansson and Brodersen wrote. “Informed choice must not be used to justify the introduction or continued use of screening programs in which the balance between benefits and harms is doubtful, and informed choice does not remove the responsibility for offering such screening programs from health authorities. True, informed choice remains utopic in our cultural context and does not solve the fundamental dilemma of screening; is it ethically acceptable to cause serious harm in some people to improve the prognosis of others?” – by Anthony SanFilippo
Disclosure: The researchers report no relevant financial disclosures.
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