Video-assisted Intervention for Increasing Mammography Uptake in Private Primary Care in Singapore
Condition: Mammogram Scheduled
Study type: Interventional

Summary: 
      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.
    

Detailed description: 
      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.
    

Intervention name(s): Video Screening and Counselling
Intervention type(s): Behavioral
Intervention description(s): The intervention comprises 1) GP counseling, 2) 3-minute promotional video on mammography and 3) an informational brochure with relevant contact details and information for arranging a mammography screening. Pre- and post-consultation questionnaire were administered to participants to evaluate their health beliefs, with emphasis on breast cancer and mammography.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Screening