Family Practice Vol. 17, No. 1, 42-45
© Oxford University Press 2000
Patient adherence to family practitioners' recommendations for breast cancer screening: a historical cohort study
Department of Family Medicine, Rabin Medical Center, Beilinson Campus, Petah Tiqva and
a Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
E Kahan, Department of Family Medicine, Rabin Medical Center (Beilinson Campus), Petah Tiqva, 49100, Israel.
Giveon S and Kahan E. Patient adherence to family practitioners' recommendations for breast cancer screening: a historical cohort study. Family Practice 2000; 17: 42–45.
Received 4 May 1999; Revised 17 August 1999; Accepted 6 September 1999.
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Abstract |
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Background. Breast cancer is the most prevalent malignancy among women in Israel, and routine screening is recommended for early detection. In 1997, a health management organization primary care centre in rural Israel established a 1-year programme wherein family physicians were encouraged to remind their patients to undergo breast cancer examinations. This study evaluates the impact of the physicians' intervention on patient compliance.
Methods. Family practitioners from two practices were requested to discuss the importance of early breast cancer detection with all eligible patients who visited the clinic for any reason and to assist them in scheduling an appointment for screening. The files of the patients who received the recommendation were stamped accordingly. On completion of the programme, the physicians' files were audited, and the potential candidates for breast cancer screening were divided into two groups: those who had received the intervention (n = 251) and those who had not (n = 187); results were also compared with those of a third group of patients who had gone for an examination on their own initiative (n = 100) prior to the study (i.e. did not require intervention). A random sample of half the patients also completed an ad hoc questionnaire covering sociodemographic variables and the impact of the doctors' intervention on their behaviour.
Results. Patients in the intervention group showed a significantly greater change in behaviour regarding breast cancer screening than the controls (32% versus 13%, P = 0.001). This change was manifested particularly in the group of women aged 50–74 years who received the recommendation for mammography to be performed (according to the guidelines).
Conclusion. Although this is a study in only two practices, the results suggest that primary care physicians can significantly alter the behaviour of their patients regarding regular breast examinations. The use of a special reminder can also help the individual doctor to ensure that each patient has been properly instructed.
Keywords. Breast cancer, family practice, reminders, screening..
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Introduction |
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It is well recognized that early detection and prevention have a positive effect on cancer control. Tomatis1 reported that a woman aged 50 years or more who undergoes regular breast cancer screening can reduce her risk of dying from the disease by at least 40%. In the USA, a major goal of the National Cancer Institute for the year 2000 is to provide at least 80% of all women aged 50–70 years with an annual physical examination and mammography.2
A 1991 study by Fox and Stein3 showed that the most important variable predicting compliance with regular breast cancer screening in all racial groups is discussion with the family practitioner. Nevertheless, Kee4 found that GPs showed poor adherence to recommendations to send a reminder to female patients who had not complied with their first call for a screening mammography, and that only 20% of the women who received the reminder went for the test.
In Israel, breast cancer is by far the most common cancer in women, both Jewish and non-Jewish (mostly Arab). Approximately 2000 new cases are registered yearly in the Israel Cancer Registry; the 1992 age-adjusted incidence rate for females was 70 per 100 000 population.5 In 1996, the Kupat Holim General Health Insurance Fund, the largest health management organization (HMO) in Israel, established a 1-year experimental programme to promote regular breast examinations in a primary care centre in rural Israel. Physicians in two medical practices were requested to discuss the need for an annual breast and gynaecological examination with female patients aged 25–74 years who visited the clinic for whatever reason and who had not had a regular breast examination for the past 2 years and, following the guidelines, to indicate a mammography every 2 years if the woman was aged 50–74 years. They were also asked actively to assist the patients in scheduling an appointment, with their consent. The aim of the present study was to evaluate the compliance of the patients with their practitioner's recommendation.
Setting
The Kupat Holim Health Insurance Fund covers ~60% of the population in Israel. According to the Israel National Health Law, every citizen is entitled to health care by one of the four HMOs recognized by the law and must be assigned to a specific family medicine practice within the HMO of his/her choice. All HMOs follow a gatekeeper policy. The primary care centre in this study has a catchment area of ~3000 individuals and employs two family medicine practitioners (specialists in family medicine with 4 years' residency training), each with ~1500 patients, in addition to two nurses and specialists in gynaecology, dietology and mental health, who see patients once a week.
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Methods |
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The programme
The programme stipulated that every female patient aged 25–74 years who presented to her family practitioner (FP) for whatever symptom or complaint was to be asked by the FP if she had had a gynaecological and breast examination within the past year, and for those aged 50–74 if she had had a mammography performed every 2 years. If the answer was in the affirmative, she was to be encouraged to continue these examinations, and her file was to be so marked. If the answer was negative, the FP was to spend 4–5 minutes discussing the importance of undergoing these examinations on a regular basis, determine the reasons for the patient not undergoing periodic examinations, and openly air the patient's fears or lack of knowledge. With the patient's consent, the FP was then to assist her in arranging a gynaecological examination (usually with the attending gynaecologist at the same primary care centre) and a mammography, as necessary, according to the guidelines. The patient's chart was then marked accordingly. Patient refusals to have an examination were also to be noted on the chart. All patients were to be given a brochure published by the Kupat Holim and the National Cancer Prevention Association and encouraged to read it and follow the recommendations.
Patients who visited the physician more than once within the year were to be asked if they had as yet undergone breast cancer screening. If not, the FP was to repeat the procedure.
Evaluation
In 1997, at the conclusion of the programme, all relevant patient files of the participating physicians were reviewed. The patients were divided into two groups: those with whom their FP had discussed breast cancer screening (n = 251, group A) and those with whom he had not (n = 187, group B). The results were also compared with those of a third group of patients who had gone for a mammography on their own initiative prior to the study (i.e. did not require intervention) (n = 100, group C). In addition, a questionnaire, specially designed for this study, was sent to a random sample of half the patients who had received the intervention (n = 125) and half of those who had not (n = 94), and to all patients in the third group. (Sampling for the questionnaire was done for economic reasons.) The questionnaire included items on sociodemographic variables and the patient's health behaviour and degree of knowledge about breast cancer, her presentation (or not) for a periodic breast examination within the past 2 years, her compliance with the recommendation of the FP (to check the accuracy of the file registry) and the degree to which the recommendation of the FP was a factor in her presenting for a breast examination (if she indeed had done so).
Statistical analysis
All results were processed with an Excel package. Student's t-test and chi-square test were used for comparison of continuous variables and of categorical variables, respectively, utilizing the Epi Info program. A P-value of <0.05 was considered significant. One-way analysis of variance was used for multiple comparisons in order to characterize those women who changed their behaviour after the intervention as opposed to those who did not.
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Results |
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Questionnaires were completed and returned by 218 of the 219 sampled patients in groups A and B. The high response rate was attributable to personal visits (up to four) to those patients who did not return the questionnaire. Of the 100 women in group C, 87 completed the questionnaire. In this group, no personal visits were undertaken because these patients were not included in the study for analysis of the impact of the recommendation, but only for the population characteristics.
There were no significant differences between groups A and B in sociodemographic variables (age distribution, level of education and country of origin), although there was a slightly higher number of women in group B from North Africa and in group A from Yemen; this was also true for parental country of birth. There were also no differences in the rate of chronic illness, with 63% of group A and 72% of group B being disease-free or in a self-reported state of good health; 13 and 10%, respectively, reported being consistently healthy, and 3.6 and 1.3%, respectively, reported being consistently sick. Both populations had approximately the same number of relatives who had breast or ovarian cancer. Most of the women (86.5 and 91%, respectively) declared that they knew about ovarian and breast cancer from the media.
Table 1
shows that 40 of the 125 questionnaire respondents in group A (32%) and 12 of the 93 in group B (13%) reported that they had started to undergo regular breast examinations. This difference was statistically significant (chi-square = 10.71, P = 0.001; relative risk = 2.48, 95% CI = 1.38 < RR < 4.46). Furthermore, of these 40 group A women, 34 (85%) noted that their decision was based on the physician's advice. The other six (15%) responded that the doctor's recommendation was important, but they were not sure that it was the main factor.
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Tables 2 and 3
show the analysis of the distribution of responders by age groups. In both groups, women aged 25–49 years (Table 2) and 50–74 years (Table 3), there is a significant difference between the intervention group and the control group in relation to the performance of the recommended screening: physical breast examination in the younger group (P = 0.05) and mammography in the group aged 50–74 years (P = 0.01).
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To characterize the women by their behaviour regarding breast cancer screening, groups A and B were redivided as follows: women who had started to go for regular breast examinations since the intervention (n = 52); and women who had not (n = 166). These too were compared with group C, i.e. women who went for regular breast examinations on their own initiative before the intervention (n = 87). The results indicated that the women who went for breast examinations and mammography on their own initiative were significantly younger (mean 47 years) than those who had changed their behaviour mainly in relation to mammography (54 years) (P = 0.0008). The women of group C were also significantly more interested in discussing preventive medicine and early detection of disease with their physician (P = 0.0009).
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Discussion |
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Breast cancer screening rates show great variation among general medicine practices. Majeed et al.,6 in a study of 43 063 women eligible for breast cancer screening, reported a range of 12.5–84.5%. These differences are usually explained by differences in patient and physician characteristics and attitudes.
Shapira et al.7 reported that encouragement by physicians is an important factor in increasing breast cancer screening rates. In our study, only 32% of the patients who received the intervention by their FP and completed the questionnaire (40 of 125) changed their behaviour accordingly. Nevertheless, this rate was significantly higher than that for the patients who had not received the intervention (13%). Furthermore, of the group A patients who changed their behaviour, 85% noted the physician's advice as the major factor in their doing so. This study is in agreement with that of Hardy et al.8 who reported on the impact of a simple intervention by an HMO (in the form of a letter to the patients) in improving screening behaviour. In the analysis by age groups, our study shows that the group aged 50–74 years responded very significantly to the recommendation to undergo mammography. This is very encouraging because mammography screening has been shown to reduce mortality in women under 50 years.9 A slightly significant difference (P = 0.05) was found in the 25–49 year age group who were advised to perform breast examination only; breast examination performed by clinicians has not been proven to be an effective method of early detection.9 Our findings confirm that family physicians can play a key role in modifying patient health behaviour regarding periodic breast examinations. Our positive results reinforce the claim of Morrison10 that family physicians, as advocates for women's health, are in a good position to provide leadership in controversial issues in women's health maintenance such as cancer screening.
The positive influence of the message itself has also been documented in the context of the attitude/social influence/efficacy (ASE) model.11,12 However, in those studies, the GP message was viewed as a supportive tool6 for an external invitation to the women to participate in breast cancer screening. In our study, the FP’s intervention was the initiating factor. It should be noted that messages which are worded or presented incorrectly can have a negative impact,13 and therefore FPs need to undergo thorough postgraduate training13,14 before intervening.
In conclusion, we present the results of two family medicine practices demonstrating that patients can be positively influenced by their physicians to change their behaviour regarding regular breast cancer screening. Although our findings cannot be generalized to the whole medical community as the study only focuses on two individual practices, the results are encouraging and worthy of consideration by our GP colleagues.
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References |
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1 Tomatis LV. Cancer: Causes, Occurrence and Control. World Health Organization. International Agency for Research on Cancer Publication No. 100. Lyon: IARC Scientific Publications, 1990.
2 Greenwald P, Soudik E. Cancer Control Objectives for the Nation: 1985–2000. National Cancer Institute Monograph No. 2. Washington, DC: US Department of Health and Human Services, 1986.
3 Fox SA, Stein JA. The effect of physician patient communication on mammography utilization by different ethnic groups. Med Care 1991; 29: 1065–1062.[Web of Science][Medline]
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5 Statistical Abstract of Israel 1996. Volume 47. Jerusalem: Central Bureau of Statistics, 1996.
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8 Hardy RE, Eckert C, Hargreaves MK, Belay Y, Jones TN, Cebrun AJ. Breast and cervical cancer screening among low-income women: impact of a simple centralized HMO intervention. J Natl Med Assoc 1996; 88: 381–384.[Medline]
9 Helzlsover KJ. Early detection and prevention of breast cancer. In Greenwald P, Kramer BS, Weed DL (eds). Cancer Prevention and Control. New York: National Cancer Institute, 1995: 509–535.
10 Morrison E. Controversies in women's health maintenance. Am Fam Physician 1997; 55: 1283–1290.[Web of Science][Medline]
11 Lechner L, De Vries H, Offermans N. Participation in breast cancer screening program: influence of past behavior and determinants on future screening participation. Preventive Med 1997; 26: 473–482.[Web of Science][Medline]
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De Vries H, Dijkstra M, Kuhlman P. Self-efficacy: the third factor besides attitude and subjective norms as a predictor of behavioral intentions. Health Educ Res 1988; 3: 273–282.
13 Boissel JP, Collet JP, Alborini A et al. Education program for general practitioners on breast and cervical cancer screening: a randomized trial. Rev Epidemiol Sante Publique 1995; 43: 541–547.[Web of Science][Medline]
14 Aalders CJ, Schade E. Role of the general practitioner in breast cancer screening in The Netherlands. J Cancer Educ 1991; 6: 175–178.[Medline]
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