BMJ 1998;317:263-264 ( 25 July )

Information in practice

How risks of breast cancer and benefits of screening are communicated to women: analysis of 58 pamphlets

Editorial by Coulter

Emma K Slaytor, postgraduate fellow,  Jeanette E Ward, director. 

Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Locked Bag 8, Newtown, 2042, NSW, Australia

Correspondence to: Associate Professor Ward jward{at}nah.rpa.cs.nsw.gov.au

Informed participation in population based screening programmes requires an explicit sharing of information about risks and benefits.1 However, many factors influence perceptions of risk and the value of risk reduction promised through screening. Campaigns that selectively quote incidence to "frighten" women into undergoing mammography have been criticised.2 Perceived risk, not objective risk, explains readiness to undergo screening in most models of health behaviour. Furthermore, the willingness of health purchasers to fund mammographic screening has been shown to be significantly influenced by the way in which data about effectiveness are presented: a programme achieving a 30% reduction in relative risk was more likely to be funded than two others described in terms of absolute risk reduction or numbers needed to screen to avert one death from breast cancer, even though all three were objectively identical in effectiveness.3 No studies have examined how risks of breast cancer and benefits of screening are communicated to women themselves.

    Methods and results
Top
Methods and results
Comment
References

In July 1997 we telephoned all cancer organisations, health departments, and mammographic screening programmes throughout Australia and asked for any information leaflets currently available for women about mammography. For each brochure, EKS used a 10 item score sheet to record its content. Independent assessment was performed by another staff member. Discrepancies were noted and resolved by consensus.

All organisations responded, resulting in 58 brochures. Independent agreement between the assessors was 98.9%. Lifetime risk of developing breast cancer was the most commonly stated risk (table), with considerable variation of estimates ranging from one in 11 to one in 16. Only one brochure provided information about the risk of dying from breast cancer. Three provided information about survival from breast cancer but only as "more than 70% of women survive," "two thirds of women survive," and "most women outlive this disease."

                              
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Information about risks and benefits of mammographic screening in 58 Australian pamphlets for women

Relative risk reduction was the epidemiological information most often provided to communicate the benefits of mammographic screening (table), but the estimates included "about 30%," "about 40%," and "up to 50%," and six pamphlets from one state advised unequivocally that "women who have regular screening mammograms every two years halve their chances of dying from breast cancer." No pamphlets expressed benefit as absolute risk reduction or numbers needed to screen.

Information about the accuracy of screening tests was provided only occasionally. Sensitivity was expressed as: "mammograms pick up 90% of breast cancers." Six brochures stated that mammograms "are not 100% accurate (or foolproof)" without giving any detail.

    Comment
Top
Methods and results
Comment
References

Our study is the first to show the emphasis on incidence rather than mortality to communicate the risk of breast cancer to women. Since mammographic screening reduces mortality but not incidence,2 this partiality is worrying. In addition, mammographic screening increases the incidence of breast cancer by detecting innocuous disease that would never become clinically important. Thus, it is a circular argument to encourage participation in mammographic screening only because of an increasing number of cases.

The benefits of mammography were reported inconsistently and only ever as relative risk reduction and never as absolute risk reduction or numbers needed to screen to change an outcome for one woman. In a compelling reflection on mammographic screening in the United Kingdom, Maureen Roberts argued for a "truthful account of the facts" to be given to women: "It will not be what they want to hear."4 Ominously, perhaps, the provision of specific risk information discourages participation in mammography.5 If, like purchasers' willingness to pay,3 women's participation in screening can be manipulated by partial disclosure of epidemiological data, then informed decision making by consumers necessitates a disinterested presentation of all pertinent facts.

    Acknowledgments

Inspiration for this study was provided by the Sydney Breast Cancer Foundation, particularly Janet McDonald, Harriett Harrison, Frances Randall, Liz Story, and Lyn Trumbull.

Contributors: JEW conceived the study and supervised protocol development, including design of rating scale, by EKS. EKS collected data and analysed pamphlet content. JEW and EKS jointly wrote the paper. Terry Slevin, Corry Dobson, Lynne Flemming, and Julie Sladden assisted with telephone calls. Vincenza Colaluce assessed reliability of rating of pamphlets. JEW is guarantor for the paper.

Funding: The Sydney Breast Cancer Foundation.

Conflict of interest: None.

    References
Top
Methods and results
Comment
References

  1. McCormick J. Medical hubris and the public health: the ethical dimension. J Clin Epidemiol 1996; 49: 619-621[Medline].
  2. Baines C. Women and breast cancer: is it really possible for the public to be well informed? Can Med J Assoc 1992; 142: 2147-2148.
  3. Fahey T, Griffiths S, Peters TJ. Evidence based purchasing: understanding results of clinical trials and systematic reviews. BMJ 1995; 311: 1056-1059[Abstract/Free Full Text].
  4. Roberts MM. Breast screening: time for a rethink? BMJ 1991; 299: 1153-1155.
  5. Curry SJ, Taplin SH, Anderman C, Barlow WE, McBride C. A randomised trial of the impact of risk assessment and feedback on participation in mammographic screening. Prev Med 1993; 22: 350-360[Medline].

(Accepted 20 March 1998)

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