Mammogram Scheduled Clinical Trial
Official title:
Physician-led Video-assisted Intervention for Increasing Mammography Uptake in Private Primary Care Practice in Singapore: A Cluster-Randomized Trial
Breast cancer is the leading female cancer in Singapore, but 3 in 5 women are not going for their regular mammography screenings at recommended frequencies despite 15 years of nationwide efforts by Breast Screen Singapore. The investigators aim to determine the efficacy of opportunistic health promotion for uptake of mammography screening in Singaporean women attending private sector primary care clinics in Singapore by implementing a simple and feasible questionnaire to identify potential candidates for mammography screening, coupled with recommendations by the primary care provider and a directed promotional video produced by Kandang Kerbau Hospital (KKH) that is aimed at addressing some of the barriers to screening.
Breast cancer is the second leading cause of cancer-related deaths in women with an estimate
of 508 000 deaths in 2011 worldwide . Incidence rates vary from 19.3 per 100,000 women in
Eastern Africa to 89.7 per 100,000 women in Western Europe . Locally, 1 in every 16
Singaporean women in their lifetime is affected, making it the most common cancer in women
in Singapore, with 17.9% of cancer deaths in women attributed to it. The Singapore Cancer
Registry (2012) also revealed that the age-standardised incidence rates of newly diagnosed
breast cancer have increased from 22.0 per 100,000 in the 1973-1977 period to 62.4 per
100,000 in the 2008-2012 period .
Studies have consistently shown that mammography is effective in early detection of breast
cancer - , reducing breast cancer mortality of 20-22% . However, recent studies have
questioned the efficacy of mammography. Gotszche et al. challenged that past trials had
inadequate randomization , while a 1998 Cochrane Review questioned the potential confounding
effect of advances in adjuvant chemotherapy (i.e. Tamoxifen) on overall breast cancer
survival rates . With reference to the 2005 New England Journal of Medicine paper by Berry
et al, screening remains an effective tool, and with therapy, has contributed to the decline
in related mortality. In a 2011 local paper, Wang et al compared screen-detected and
symptomatic women, concluding that screen-detected patients had an overall higher survival
rates that their symptomatic counterparts .
For the past 15 years, the nationwide breast cancer-screening programme in Singapore has
been recommending women aged 40-69 to undergo screening mammography, emphasizing that women
in the younger age group of 40-49 should be screened once a year due to the unique local
age-specific incidence rates showing an unusually high incidence of 34.4% in women aged
45-54 . Despite aggressive efforts and incentives, mammography uptake rates poor. A National
Health Survey in 2010 revealed that 3 in 5 women are not going for their regular mammography
at recommended frequencies . A pre-pilot study by Seow et al in 2009 showed that up to 27.4%
of women surveyed had never had a mammogram before. A recent paper published in 2013 by Teo
et al. also reported that regular mammography uptake rates are at a dismal rate of 26% .
Dismal uptake rates are notably equally rampant in other countries, with a varying 40% to
90% of women quoted to be non-compliant to their respective breast cancer screening
programmes . Local studies have revealed fear of pain and a belief that cancer would not
happen to them as some barriers to screening . Teo et al. also revealed predictors of poor
uptake as that of low income group, poor educational level, fear of pain/discomfort as well
as being Malay. This illustrates the multidimensional influence of race, ethnicity,
knowledge and health-seeking behavior in determining the compliance to regular screening.
With previous studies identifying various barriers to Singapore's mammography-screening
program, the investigators hope to go further by evaluating the effectiveness of targeted
interventions in helping women overcome said barriers. While there have been multiple trials
done overseas - to determine the effectiveness of various interventions, there has only been
two such local trials by Seow et al in 2012 and 1998 done in a public sector primary care
setting - . As 80% of primary care in Singapore occurs in the private sector, conducting the
study there would represent a different demographic of patient characteristics that has
wider applicability. Furthermore, the strong doctor-patient relationship may help with the
effectiveness of General Practitioner (GP)-based intervention. A key factor may therefore be
lack of physician recommendation . Published evidence suggests patients were more likely to
follow up with mammography screening when their primary care practitioner ordered testing -
. As such, the investigators hope to design and evaluate a cost effective, feasible and
relevant intervention that can be realistically implemented with the resources available in
the workflow of the average GP clinic without additional resources and manpower
requirements.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Outcomes Assessor), Primary Purpose: Screening
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