Breast screening - achieving equity

Breast cancer is the most commonly diagnosed cancer in women and is a leading cause of cancer death in New Zealand women. A woman’s chance of developing breast cancer increases with age. Approximately 70% of women diagnosed with breast cancer are aged over 50 years and of those who die from breast cancer, 80% are aged 50 years and over.¹

The incidence of breast cancer is similar for all women. However Māori and Pacific women are over 1.5 times more likely to die as a result of breast cancer compared to other women in New Zealand (Figure 1).² Māori and Pacific women are diagnosed later than other ethnic groups with larger, higher grade tumours with more lymph nodes involved.³

The national target for breast screening is for 70% of all eligible women to have been screened within a two year screening interval. This target has not been met for any ethnic group, and there are significant differences in screening rates between Māori and Pacific women, and other women (Figure 2).

General practice has a key role in improving breast screening rates in Māori and Pacific women

Figure 1: Breast cancer incidence and mortality2

Figure 2: Breast screening coverage by ethnicity (women aged 50 to 69 years, June 2007–09)

The aim of breast screening is to identify breast cancers at an early stage, allowing treatment to commence sooner, leading to reduced morbidity and mortality. Many women miss out on breast screening because there is no national system available which identifies and enrols them for screening as they become eligible.

The challenge, in the absence of a national system is for individual general practices to commit to ensuring all eligible women in their practice population are encouraged and assisted to enrol in the breast screening programme.

Raising the profile of breast screening in a practice

Practice Nurse, Waitemata DHB

We have had huge success, working in partnership with BreastScreen Aotearoa. Before the mobile caravan is due to come to our area, we have regular meetings and brainstorms with other health providers on how to reach eligible women. Together with BreastScreen Aotearoa we do an audit of our 45-69 year old female patients that are not enrolled with BreastScreen Aotearoa each year. We then rule out the patients who have gone privately, declined, or have other health issues preventing them from having a mammogram through breast screening.

BreastScreen Aotearoa gives us appointment times and we then phone these woman and enrol then over the phone and book them an appointment on the spot. We target the high needs Māori and Pacific women first. This method has been very successful as it means the patients do not have to phone BreastScreen Aotearoa and arrange it themselves. We also ask if there are any transport issues and can arrange transport for them through our local Māori Health provider or other community initiatives. The initial phone contact is useful to allay some women’s fears and to answer questions about mammograms. BreastScreen Aotearoa reimbursed the practice for the time and phone call costs to do this.

Through this initiative we have improved our screening rates dramatically and it continues to improve each year. BreastScreen Aotearoa provided all the staff in the practice with shirts and fleeces with BreastScreen Aotearoa and the age limits written on them. It was surprising how many patients saw the shirts and were prompted to ask questions and subsequently go for a mammogram. Raising the profile of breast screening and working closely together with BreastScreen Aotearoa and other community groups seems to be the key.

PATIENT INFORMATION supporting the breast screening programme, in a variety of languages, and free of charge and can be ordered online at: www.healthed.govt.nz

Increasing the uptake of breast screening in Māori women⁵

A general practitioner led initiative at the Te Whānau ā Apanui Community Health Service (TWAACH) in the Eastern Bay of Plenty, has been successful in increasing the uptake of breast cancer screening in a predominantly Māori community (approximately 90% Māori). Screening rates have increased from 45% of eligible Māori women in 2003 to about 98% in both 2005 and 2007.

The starting point was agreement from the general practice team to set a goal and a clear focus on improving breast cancer screening participation rates for their predominantly Māori population. Changes were achieved using the current staff and resources, but with local input, flexibility and collaboration between existing services.

The strategy had two broad aims – to increase local involvement and to reduce barriers to participation and included the following:

• The PMS system was used to create a master list of eligible women who were sent letters inviting them to enrol for breast screening
• TWAACH received agreement from Breast Screening Aotearoa to coordinate registration and make appointments. Staff were encouraged to be flexible and resourceful to ensure no one was turned away and all available appointments were filled. Staff were able to arrange group bookings for women who lived in the same household, whānau (family) group or area
• Two weeks prior to screening, telephone or face-to-face contact was made with all women who had not enrolled, breast screening discussed and enrollment encouraged
• The day before their appointment women were contacted to confirm the appointment time and assistance was offered if there were going to be difficulties in attending
• Women who “dropped in” were not turned away. Instead there was flexibility to allow them to be enrolled and screened
• Women who did not arrive were contacted and offered further assistance and a rescheduled appointment at another mobile unit or fixed site

Issues that were predicted to affect participation in the screening programme were identified through discussions with practice staff and patients. These included transport difficulties, travel time, inconvenience, concern, fear and the influence of negative reports from other women. A number of strategies were used by TWAACH to help overcome these barriers to participation. They found:

• Booking directly with women helped overcome issues with an unreliable rural mail delivery, literacy, and competing priorities
• Arranging group bookings for women who lived in the same household, whānau (family) group or area, helped with travel difficulties as well as providing support
• Providing a cup of tea afterwards allowed the opportunity for women to share and debrief with each other, resulting in positive feedback and encouragement of other whānau to attend.

TWAACH also followed up abnormal results.

Breast screening was strongly advocated in the community. The staff of TWAACH were encouraged to promote breast screening at any opportunity. The dates of the mobile unit visits were advertised repeatedly in the TWAACH newsletter, marae and local businesses.

Breast screening was promoted and information provided at a number of community events. Two well known women who had previously been diagnosed with breast cancer shared their stories and support of the breast screening programme. Registration forms were available at these events.