Interventions for raising breast cancer awareness in women

Review question
We reviewed the evidence about the effect of different interventions for raising breast cancer awareness in women. We found two randomised controlled trials, the highest quality of research evidence.

Background
Breast cancer is the most commonly diagnosed cancer in women. Early detection, diagnosis and treatment of breast cancer are key to better outcomes. Since many women will discover a breast symptom themselves, it is important that they are breast cancer aware i.e. that they have the knowledge, skills and confidence to notice any breast changes and visit their doctor promptly.

Study characteristics
A search for trials investigating interventions on breast cancer awareness in women was run in January 2016. We found two trials with a total of 997 women.

The Promoting Early Presentation (PEP) study, funded by Breast Cancer UK, involved randomising 867 women to receive one of three interventions: (1) a written booklet and usual care, (2) a written booklet and usual care plus one-to-one discussion with a healthcare professional or (3) usual care only. Women were aged between 67 to 70 years and recruited into the study at breast cancer screening units in the UK.

The Zahedan University of Medical Sciences (ZUMS) study involved randomising 130 women into two groups that received either: (1) an educational programme using written and oral materials that focused on "breast cancer preventive behaviours" (e.g. having a healthy diet and positive beliefs towards breast self-examining behaviour) or (2) no intervention. Women were employed at ZUMS and aged between 35 and 39 years.

Key outcomes
Study outcomes were measured differently in the two studies. The PEP study assessed outcomes at one month, one year and two years after the intervention. The ZUMS study measured outcomes at one month after the intervention. Since the studies were very different in terms of the participants' age, interventions, outcomes and time points measured, the results are reported separately.

Knowledge of breast cancer symptoms
In PEP: women's knowledge of breast cancer symptoms seemed to somewhat improve after receiving either the written booklet or written booklet plus verbal interaction. These results improved when compared to usual care at 2 years postintervention. In ZUMS: women’s awareness of breast cancer symptoms increased one month after the educational programme.

Knowledge of age-related risk of breast cancer
In PEP: knowledge of age-related risk increased for women who had received a written booklet and interacted with a healthcare professional compared to usual care at 2 years postintervention. For women who only received the booklet, there was less of a comparable increase in knowledge. In ZUMS: this study only measured if women perceived themselves to be at risk of getting breast cancer. This self-perception of risk did increase at one month following the intervention.

Self-reported breast checking
In PEP: women's reported monthly breast checking increased, but not significantly, at 2 years postintervention compared to usual care. In ZUMS: women's reported "breast cancer preventive behaviours" increased one month after the intervention. Specifically, this refers to their positive beliefs towards breast self-examining behaviour.

Overall breast cancer awareness
In PEP: women's breast cancer awareness overall did not change after receiving a booklet alone compared to usual care at 2 years after the intervention. However, breast cancer awareness increased in women who had received a written booklet and interacted with a healthcare professional. This behaviour change was in comparison to usual care at 2 years postintervention. In ZUMS: women's "breast cancer preventive behaviours" were reported to increase at one month.

None of the studies reported on other parts of breast awareness, the intention to seek help, quality of life, adverse effects of the interventions, or breast cancer-related outcomes.

Quality of the evidence
The evidence was considered to be moderate quality in the PEP study and low quality in the ZUMS study. Neither study clearly defined ‘breast cancer awareness’. The lack of high quality studies limited our ability to draw conclusions. However, the PEP study results suggest that combining written information and a one-to-one discussion had a long-term effect on increasing women’s breast cancer awareness. In the future, studies should use larger samples and follow the women for a longer time.

Authors' conclusions: 

Based on the results of two RCTs, a brief intervention has the potential to increase women’s breast cancer awareness. However, findings of this review should be interpreted with caution, as GRADE assessment identified moderate-quality evidence in only one of the two studies reviewed. In addition, the included trials were heterogeneous in terms of the interventions, population studied and outcomes measured. Therefore, current evidence cannot be generalised to the wider context. Further studies including larger samples, validated outcome measures and longitudinal approaches are warranted.

Read the full abstract...
Background: 

Breast cancer continues to be the most commonly diagnosed cancer in women globally. Early detection, diagnosis and treatment of breast cancer are key to better outcomes. Since many women will discover a breast cancer symptom themselves, it is important that they are breast cancer aware i.e. have the knowledge, skills and confidence to detect breast changes and present promptly to a healthcare professional.

Objectives: 

To assess the effectiveness of interventions for raising breast cancer awareness in women.

Search strategy: 

We searched the Cochrane Breast Cancer Group's Specialised Register (searched 25 January 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 12) in the Cochrane Library (searched 27 January 2016), MEDLINE OvidSP (2008 to 27 January 2016), Embase (Embase.com, 2008 to 27 January 2016), the World Health Organization’s International Clinical Trials Registry Platform (ICTRP) search portal and ClinicalTrials.gov (searched 27 Feburary 2016). We also searched the reference lists of identified articles and reviews and the grey literature for conference proceedings and published abstracts. No language restriction was applied.

Selection criteria: 

Randomised controlled trials (RCTs) focusing on interventions for raising women’s breast cancer awareness i.e. knowledge of potential breast cancer symptoms/changes and the confidence to look at and feel their breasts, using any means of delivery, i.e. one-to-one/group/mass media campaign(s).

Data collection and analysis: 

Two authors selected studies, independently extracted data and assessed risk of bias. We reported the odds ratio (OR) and 95% confidence intervals (CIs) for dichotomous outcomes and mean difference (MD) and standard deviation (SD) for continuous outcomes. Since it was not possible to combine data from included studies due to their heterogeneity, we present a narrative synthesis. We assessed the quality of evidence using GRADE methods.

Main results: 

We included two RCTs involving 997 women: one RCT (867 women) randomised women to receive either a written booklet and usual care (intervention group 1), a written booklet and usual care plus a verbal interaction with a radiographer or research psychologist (intervention group 2) or usual care (control group); and the second RCT (130 women) randomised women to either an educational programme (three sessions of 60 to 90 minutes) or no intervention (control group).

Knowledge of breast cancer symptoms

In the first study, knowledge of non-lump symptoms increased in intervention group 1 compared to the control group at two years postintervention, but not significantly (OR 1.1, 95% CI 0.7 to 1.6; P = 0.66; 449 women; moderate-quality evidence). Similarly, at two years postintervention, knowledge of symptoms increased in the intervention group 2 compared to the control group but not significantly (OR 1.4, 95% CI 0.9 to 2.1; P = 0.11; 434 women; moderate-quality evidence). In the second study, women’s awareness of breast cancer symptoms had increased one month post intervention in the educational group (MD 3.45, SD 5.11; 65 women; low-quality evidence) compared to the control group (MD −0.68, SD 5.93; 65 women; P < 0.001), where there was a decrease in awareness.

Knowledge of age-related risk

In the first study, women’s knowledge of age-related risk of breast cancer increased, but not significantly, in intervention group 1 compared to control at two years postintervention (OR 1.8; 95% CI 0.9 to 3.5; P < 0.08; 447 women; moderate-quality evidence). Women's knowledge of risk increased significantly in intervention group 2 compared to control at two years postintervention (OR 4.8, 95% CI 2.6 to 9.0; P < 0.001; 431 women; moderate-quality evidence). In the second study, women’s perceived susceptibility (how at risk they considered themselves) to breast cancer had increased significantly one month post intervention in the educational group (MD 1.31, SD 3.57; 65 women; low-quality evidence) compared to the control group (MD −0.55, SD 3.31; 65 women; P = 0.005), where a decrease in perceived susceptibility was noted.

Frequency of Breast Checking

In the first study, no significant change was noted for intervention group 1 compared to control at two years postintervention (OR 1.1, 95% CI 0.8 to 1.6; P = 0.54; 457 women; moderate-quality evidence). Monthly breast checking increased, but not significantly, in intervention group 2 compared to control at two years postintervention (OR 1.3, 95% CI 0.9 to 1.9; P = 0.14; 445 women; moderate-quality evidence). In the second study, women’s breast cancer preventive behaviours increased significantly one month post intervention in the educational group (MD 1.21, SD 2.54; 65 women; low-quality evidence) compared to the control group (MD 0.15, SD 2.94; 65 women; P < 0.045).

Breast Cancer Awareness

Women’s overall breast cancer awareness did not change in intervention group 1 compared to control at two years postintervention (OR 1.8, 95% CI 0.6 to 5.30; P = 0.32; 435 women; moderate-quality evidence) while overall awareness increased in the intervention group 2 compared to control at two years postintervention (OR 8.1, 95% CI 2.7 to 25.0; P < 0.001; 420 women; moderate-quality evidence). In the second study, there was a significant increase in scores on the Health Belief Model (that included the constructs of awareness and perceived susceptibility) at one month postintervention in the educational group (mean 1.21, SD 2.54; 65 women) compared to the control group (mean 0.15, SD 2.94; 65 women; P = 0.045).

Neither study reported outcomes relating to motivation to check their breasts, confidence to seek help, time from breast symptom discovery to presentation to a healthcare professional, intentions to seek help, quality of life, adverse effects of the interventions, stages of breast cancer, survival estimates or breast cancer mortality rates.

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