European guidelines on breast cancer screening and diagnosis

The GDG based its decision on the balance between desirable and undesirable effects that favours the intervention and the fact that the intervention would probably increase equity and is probably acceptable and feasible.

Language barriers and barriers based on numeracy and education may exist and may require specific communication strategies. The GDG developed specific recommendations on how to invite socially disadvantaged women and non-native speaking women to an organised breast cancer screening programme, these recommendations are available on our website.

The following points should be taken into account when implementing this type of intervention:

• If information (including the numbers) is not provided appropriately, confusion may arise and certain subgroups (e.g. those with less numeracy skills) may be at a disadvantage.
• The GDG considered advantageous to pre-test the presentation format before and during implementation of the recommendation.
• Information should be provided taking into account the age of the target population of the recommendation.
• According to a Cochrane review, when communicating risk reductions, relative risk reduction, compared with absolute risk reduction, may be perceived to be larger and is more likely to be persuasive (Akl EA, 2011).
• The information should be provided using the same denominators for all the outcomes presented.

​​​​Specific studies on the impact of these approaches in mammography screening should be encouraged and implemented, with particular attention to the effect on certain subgroups of the population, especially those with less numeracy skills.

The GDG based this decision on the balance between desirable and undesirable effects that probably favours the intervention and the fact that the intervention would probably increase equity and is probably acceptable and feasible.

Language barriers and barriers based on numeracy and education may exist and may require specific communication strategies. The GDG developed specific recommendations on how to invite socially disadvantaged women and non-native speaking women to an organised breast cancer screening programme, these recommendations are available on our website.

The following points should be taken into account when implementing this type of intervention:

• Considering the strong recommendation on using numbers in addition to plain language for informing women about the benefits and harms of participating in an organised breast cancer screening programme, infographics should be offered in addition to plain language with numbers.
• If information (including the numbers) is not provided appropriately, confusion may arise and certain subgroups (e.g. those with less numeracy skills) may be at a disadvantage.
• The GDG considered advantageous to pre-test the presentation format before and during implementation of the recommendation.
• Information should be provided taking into account the age of the target population of the recommendation.
• According to a Cochrane review, when communicating risk reductions, relative risk reduction, compared with absolute risk reduction, may be perceived to be larger and is more likely to be persuasive (Akl EA, 2011).
• The information should be provided using the same denominators for all the outcomes presented.

Specific studies on the impact of these approaches in mammography screening should be encouraged and implemented, with particular attention to the effect on certain subgroups of the population, especially those with less numeracy skills.

The GDG based its decision mainly on the trivial desirable and undesirable effects and the very low certainty of the evidence. 

This type of intervention is often designed to increase the knowledge and improve the decision making of vulnerable populations. The GDG developed specific recommendations on how to invite socially disadvantaged women and non-native speaking women to an organised breast cancer screening programme, these recommendations are available on our website.

Specific studies on the impact of these approaches in mammography screening should be encouraged and implemented, with particular attention to the effect on certain subgroups of the population, especially those with less numeracy skills.

The GDG supported a strong recommendation for using a letter in women between the ages of 50-69 as it judged that the benefits measured by the increase in participation in screening (an adequate outcome for this age group) would outweigh the costs of producing and sending the letter. In addition, equity would increase with this intervention.

The GDG noted that for women between the ages of 50 and 69, in whom screening is strongly recommended, the balance would favour the intervention because participation rate is an appropriate outcome. Participation rate was not considered an appropriate outcome for the other age ranges.

For women in the age groups 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges (please see point 2 in the implementation considerations).

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by the ECIBC.
• It is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening with this intervention. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention would be desirable to increase participation.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making, particularly for women where a conditional recommendation was made (45-49 and 70-74).
• Research on the best modality for inviting women in the age ranges where a conditional recommendation was made (45-49 and 70-74).
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG supported a strong recommendation for using letters as it judged that the benefits measured by the increase in participation in screening would outweigh the costs of producing and sending the letter. In addition, equity would increase with this intervention.

The GDG noted that for this intervention no differences were highlighted for the subgroup of women who had a false positive result in the previous screening round. 

The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by ECIBC.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making.
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG made a conditional recommendation for the intervention by consensus, based on the desirable effects of fixed appointments, the moderate resources required and the understanding that it would probably be feasible to implement.

The GDG noted that for women between the ages of 50 and 69, in whom screening is strongly recommended, the balance would favour the intervention because participation rate is an appropriate outcome. Participation rate was not considered an appropriate outcome for the other age ranges. For the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges (please see point 2 in the implementation considerations).

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by the GDG.
• The GDG noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening with this intervention. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention is recommended and desirable to increase participation in screening.
• The GDG noted that geographic accessibility to screening centres will affect implementation because fixed appointment times may not be possible for women who live far from screening centres or those requiring special transportation to attend.
• The GDG noted that in the context of mobile units for screening, fixed appointments are necessary as knowing when and where the unit will be located is essential.
• The GDG noted that certain software programmes exist that can be low cost to implement appointment scheduling with letters and that implementation will vary based on availability of this software.
• The GDG discussed that electronic messages are being sent more frequently and these will have lower costs than paper and postage letters in the future.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making, particularly for women where a conditional recommendation was made (45-49 and 70-74).
• Research on the best modality for inviting women in the age ranges where a conditional recommendation was made (45-49 and 70-74).
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG made a conditional recommendation for the intervention, based on desirable anticipated effects, the moderate costs, the probably increased equity and the judgement that the intervention was probably feasible to implement. 

The GDG noted that for this intervention no differences were highlighted for the subgroup of women who had a false positive results in the previous screening round. 

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons on methods for inviting women to screening programmes evaluated by ECIBC.
• The GDG considered that in certain countries it may not be feasible to implement due to the additional resources required to call women for phone reminders.
• The GDG noted that implementation will have to consider access to cell phones or land lines for women to receive reminder calls and whether laws limiting access to and use of phone numbers for contacting women are applicable in the specific context.
• The recommendation does not cover informed choice, due to a lack of evidence on this important outcome. The GDG suggests that informed choice is an important implementation consideration for this intervention.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making.
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG made a conditional recommendation by consensus for the intervention based on the desirable anticipated effects, negligible costs and savings of the intervention, and varied feasibility and acceptability concerns.

The GDG noted that for women between the ages of 50 and 69, in whom screening is strongly recommended, the balance favours the intervention because participation rate is an appropriate outcome. Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges (please see point 2 in the implementation considerations). As recommending for an intervention that increases participation may not be beneficial, but detrimental.

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by the GDG.
• It is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening with this intervention. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention is recommended as it is desirable to increase participation in screening.
• In certain countries there may be a difference in who is defined as a GP or what their status and relationship is with women.
• The GDG noted that extrapolation may be necessary to the signatures of other individuals on the letter, where GP signatures are not the most appropriate. No evidence on other signatures (e.g. screening programme directors) was identified.
• The GDG considered that the GP's consent for the use of their signature on the letters is essential for this intervention to be implemented.
• The GDG noted that the desirable benefits may vary depending on the relationship of women with the GP whose signature is on the letter.
• This intervention may only be possible in settings where the GP of women for screening programmes can be accessed or linked to the screening programme.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making, particularly for women where a conditional recommendation was made (45-49 and 70-74).
• Research on the best modality for inviting women in the age ranges where a conditional recommendation was made (45-49 and 70-74).
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG made a conditional recommendation by consensus for the intervention based on the desirable anticipated effects, negligible costs and savings of the intervention, and varied feasibility and acceptability concerns. 

The GDG noted that for this intervention no differences were highlighted for the subgroup of women who had a false positive results in the previous screening round.

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by the GDG.
• In certain countries there may be a difference in who is defined as a GP or what their status and relationship is with women.
• The GDG noted that extrapolation may be necessary to the signatures of other individuals on the letter, where GP signatures are not the most appropriate. No evidence on other signatures (e.g. screening programme directors) was identified.
• The GDG considered that the GP's consent for the use of their signature on the letters is essential for this intervention to be implemented.
• The GDG noted that the desirable benefits may vary depending on the relationship of women with the GP whose signature is on the letter.
• This intervention may only be possible in settings where the GP of women for screening programmes can be accessed or linked to the screening programme.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making.
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG made a conditional recommendation for the intervention, based on the large desirable anticipated effects, the large costs, the probably increased equity and the judgement that the intervention is probably feasible to implement.

The GDG noted that for women between the ages of 50 and 69, in whom screening is strongly recommended, the balance would favour the intervention because participation rate is an appropriate outcome. Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges (please see point 2 in the implementation considerations).

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by ECIBC.
• It is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening with this intervention. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention is recommended as this intervention is desirable to increase participation in screening.
• The GDG considered that in certain countries it may not be feasible to implement due to the additional resources required to call women for phone reminders.
• The GDG noted that implementation will have to consider access to cell phones or land lines for women to receive reminder calls and whether laws limiting access to and use of phone numbers for contacting women are applicable in the specific context.
• The recommendation does not cover informed choice, due to a lack of evidence on this important outcome. The GDG suggests that informed choice is an important implementation consideration for this intervention.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making, particularly for women where a conditional recommendation was made (45-49 and 70-74).
• Research on the best modality for inviting women in the age ranges where a conditional recommendation was made (45-49 and 70-74).
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG made a conditional recommendation for the intervention, based on desirable anticipated effects and equity. 

The GDG noted that for the subgroup of women who had a false positive results in the previous screening round the intervention may have moderate costs due to the smaller number of women involved. 

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons on methods for inviting women to screening programmes evaluated by ECIBC.
• The GDG considered that in certain countries it may not be feasible to implement due to the additional resources required to call women for phone reminders.
• The GDG noted that implementation will have to consider access to cell phones or land lines for women to receive reminder calls and whether laws limiting access to and use of phone numbers for contacting women are applicable in the specific context.
• The recommendation does not cover informed choice, due to a lack of evidence on this important outcome. The GDG suggests that informed choice is an important implementation consideration for this intervention.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making.
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG noted that this comparison should be interpreted in the context of the other comparisons related to methods used to invite women to organised screening programmes.

The GDG noted that for women between the ages of 50 and 69, in whom screening is strongly recommended, the balance would favour the intervention because participation rate is an appropriate outcome. Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges (please see point 4 in the implementation considerations).

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by ECIBC.
• It is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening with this intervention. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention is recommended as this intervention is desirable to increase participation in screening.
• Due to the large costs associated with this intervention, the GDG felt that this intervention was not feasible to implement in some countries.
• The GDG noted that implementation will have to consider access to cell phones or land lines for women to receive reminder calls and whether laws limiting access to and use of phone numbers for contacting women are applicable in this specific context.

The GDG noted that the more important research priority is the question comparing a letter plus a phone call vs. a letter alone, as this is the comparison that is common practice in most countries.

The GDG supported a conditional recommendation for using letters plus written reminders in women between the ages of 50-69 as it judged that the benefits measured by the increase in participation in screening (an adequate outcome for this age group) would outweigh the undesirable effects of some women receiving a reminder when they had perhaps already made an informed decision not to participate in screening, as well as the moderate costs of the intervention.

The GDG noted that for women between the ages of 50 and 69, in whom screening is strongly recommended, the balance would favour the intervention because participation rate is an appropriate outcome. Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges (please see point 3 in the implementation considerations).

• The GDG noted that it is easy to measure the additional costs of a reminder letter, which were assumed to be lower than the costs of the initial letter.
• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by the GDG.
• It is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening with this intervention. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention is recommended as this intervention is desirable to increase participation in screening.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making, particularly for women where a conditional recommendation was made (45-49 and 70-74).
• Research on the best modality for inviting women in the age ranges where a conditional recommendation was made (45-49 and 70-74).
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG supported a conditional recommendation for using letters followed by written reminders as it judged that the benefits measured by the increase in participation in screening would outweigh the undesirable effects of some women receiving a reminder when they had perhaps already made an informed decision not to participate in screening, as well as the moderate costs of the intervention.

The GDG noted that for this intervention no differences were highlighted for the subgroup of women who had a false positive results in the previous screening round.

• The GDG noted that it is easy to measure the additional costs of a reminder letter, which were assumed to be lower than the costs of the initial letter.
• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by the GDG.

• The GDG recommends research on the effect of this intervention on other important outcomes such as informed decision-making.
• Research evaluating the use of electronic messages including e-mail, social media and SMS as compared to paper letters for invitation to screening.

The GDG made a conditional recommendation against the intervention. The judgement was based mainly on the imprecise estimates of the desirable effects and the large costs anticipated. The GDG did not think this intervention is feasible to implement where not already being used.

The GDG judged that the intervention may be feasible for specific sub-populations, particularly those in deprived areas, harder to reach using other methods.

• The GDG was not aware of any countries currently using face to face invitation in addition to letters for invitation to screening programmes.
• The GDG judged the intervention not feasible to implement, given the monetary costs.
• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons of methods for inviting women to screening programmes evaluated by ECIBC.
• It is noted that for age groups where the recommendations made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening with this intervention.

The GDG recommends research into doing an online interview vs. face-to-face interview.

The GDG made a conditional recommendation against the intervention and the judgement was based mainly on the imprecise estimates of the desirable effects and the large costs that were anticipated. The GDG did not think this intervention was feasible to implement in jurisdictions where it is not already being used.

The GDG noted that for the subgroup of women who had a false positive results in the previous screening round the intervention may be feasible and the cost are decreased (moderate) because of the smaller number of women involved. Moreover in this subgroup it is expected to have a larger effect (due to probably higher prevalence).

For these reasons the GDG suggests for inviting women who had a false positive result in the previous screening round to the subsequent ones using a letter followed by a face to face interviention (conditional recommendation, low certainty of the evidence).

• The comparison evaluated for this recommendation needs to be interpreted in the context of the other comparisons on methods for inviting women to screening programmes evaluated by ECIBC.
• The GDG was not aware of any countries currently using face-to-face invitation in addition to letters for invitation to screening programmes.
• The GDG judged that the intervention was not feasible to implement, given the monetary costs. For the subgroup of women who tested false positive in a previous screening round the intervention should be more feasible and the costs should be lower due to the smaller number of women involved.
• Most of the EU programmes involved in a survey about the way of communicating results of breast cancer screening reported that they do not differentiate between women who tested negative in the previous screening round and women who were false positive. Women are invited in the same way with identical invitation letters.

The GDG based their judgement on the balance of effects that does not favours either the intervention or the comparison.

• Possible disadvantages for women who don't have an email address.
• Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges.

Problems with SPAM emails should be considered. 

Satisfaction and informed decision making outcomes need to be addressed.

The GDG based his judgement on the balance of effects that does not favour either the intervention or the comparison.

• Possible problems of equity for women with hear impairment.
• Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges.

Satisfaction and informed decision making outcomes need to be addressed. 

The GDG made a conditional recommendation for the intervention, based on the moderate desirable effects, the moderate costs, the probably increased equity and the judgement that the intervention was probably feasible to implement. 

Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges. 

Satisfaction and informed decision making outcomes need to be addressed. 

The GDG made a conditional recommendation for the intervention, based on the moderate costs, the probably increased equity and the judgement that the intervention was probably acceptable to key stakeholders and feasible to implement.

Participation rate was not considered an appropriate outcome for the other age ranges. For women in the age groups, 45-49 and 70-74, outcomes such as confidence and satisfaction of the woman in making an informed decision are crucial and the GDG advises interpretation of this intervention in the context of the recommendations on screening age ranges. 

Access to phone numbers may differ by jurisdiction and that may have impact on feasibility. For instance, in some countries storing of phone numbers is permitted (e.g. through primary care), in others not. 

Satisfaction and informed decision making outcomes need to be addressed. 

The GDG made a conditional recommendation against the intervention, because it was judged as not feasible to implement and because of the large cost.

Satisfaction and informed decision making outcomes need to be addressed.

The conditional recommendation (rather than strong) in favour of using a targeted communication strategy instead of a general communication strategy to improve participation in screening programmes of socially disadvantaged women between the ages of 50 and 69, is the result of a moderate increase in participation rates that probably favours the intervention, in the context of low certainty of the evidence about these effects.

Consensus was reached by the GDG. However, one patient representative, Sue Warman, later during the GDG meeting expressed a lack of support for this recommendation.

• The GDG emphasises that for implementing this recommendation, it should be considered that the ECIBC's GDG already issued a strong recommendation for using letters, over no invitation, for inviting asymptomatic women.
• Furthermore, it is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening. Where the GDG made a strong recommendation for screening in women between the ages of 50 and 69, this intervention is recommended as this intervention is desirable to increase participation in screening.
• Baseline participation rate: if the baseline participation rate for socially disadvantaged women is already low, the GDG notes that this intervention will have a small impact on increasing participation rates.
• The GDG noted that avoidance of stigma is important for screening programmes targeting socially disadvantaged women.
• The GDG noted that this population would need to first be identified in a feasible manner in order to target communication.
• Access to phone numbers for socially disadvantaged women may impact feasibility of this intervention if targeted communication is conducted by phone. The GDG notes that consideration of the invitation process in the screening programmes must be considered to assess the feasibility of targeting socially disadvantaged women.

• The GDG suggests that health providers analyse the distribution of test coverage in order to identify the socially disadvantaged women who need to be targeted.
• The GDG notes that effectiveness outcomes are an important monitoring and evaluation focus.

• The GDG suggests additional research on important patient outcomes, including informed decision making, satisfaction and the potential undesirable effects of targeted communication for socially disadvantaged women.
• The GDG notes that there is incongruity with the research evidence that was found for these interventions. A randomised control trial (RCT) comparing a tailored communication intervention to a general communication strategy favoured the general communication strategy, while another RCT comparing a different tailored strategy to targeted strategy favoured the tailored communication strategy. For this reason the GDG notes that, many factors impact the success of targeted and tailored invitations and, depending on the type of tailored intervention, participation of socially disadvantaged women in screening programmes may actually increase or decrease.
• Further research examining all types of interventions aimed at targeting or tailoring to socially disadvantaged women is suggested.

On the basis of the specific tailored communication strategy providing individualised cancer risk considered, the GDG suggests against tailoring interventions for socially disadvantaged women, as some tailored interventions appear to do more harm than good. However, the impact of other types of tailored interventions is unknown.

Monitoring and evaluation of tailored communication strategies that differ from that considered in the randomised controlled trial reviewed for this recommendation is suggested to assess the impact of alternative tailored communication interventions.

• Due to the scarcity of evidence in the different approaches to tailoring communication, the GDG suggests research exploring other tailored interventions for this population. There is the need to have a narrower definition of what tailored interventions are.
• The GDG noted that there is incongruity with the research evidence that was found for tailored interventions for communication strategies for socially disadvantaged women. On the basis of the specific tailored communication strategy in the randomised controlled trial reviewed, the GDG suggests against tailoring interventions for socially disadvantaged women, however, the impact of other types of tailored interventions is unknown. Further research examining all interventions targeting or tailoring socially disadvantaged women is suggested.

The conditional recommendation in favour of using either a tailored or targeted communication strategy to improve participation in screening programmes of socially disadvantaged women, was a result of a moderate increase in participation rates that probably favours the intervention, in the context of very low certainty of the evidence about these effects, together with the serious issues that may arise in implementing these strategies, and the assumed costs. However, the GDG agreed that other kind of tailored strategies different from those in the study examined need to be analysed.

The GDG noted that this recommendation is based on a single intervention from one randomised control trial (RCT), and there may be different effects with other tailored interventions.

The GDG made the following considerations:

• For implementing this recommendation, it should be considered that the ECIBC's GDG already issued a strong recommendation for using letters, over no invitation, for inviting asymptomatic women between the ages of 50 and 69.
• Furthermore, it is noted that for age groups where the recommendation made by the GDG for screening is conditional (45-49 and 70-74 age groups) informed decision-making is crucial for implementation, and there would be concern about increasing inappropriate screening.
• Regarding the baseline participation rate, if it is already low for socially disadvantaged women, this intervention would likely have a small impact on increasing participation rates.
• Avoidance of stigma is important for screening programmes targeting socially disadvantaged women.
• This population would first need to be identified in a feasible manner in order to target communication and the intervention evaluated in the single study identified is generally not feasible.
• Access to phone numbers for socially disadvantaged women may impact feasibility of this intervention if targeted communication is conducted by phone. The invitation process in the screening programmes must be considered to assess the feasibility of targeting socially disadvantaged women.

• The GDG considered that health providers should analyse the distribution of test coverage in order to identify the socially disadvantaged women who need to be targeted.
• The GDG notes that effectiveness outcomes are an important monitoring and evaluation focus.

• The GDG suggests additional research on important patient outcomes, including informed decision making, satisfaction and the potential undesirable effects of targeted communication for socially disadvantaged women.
• The GDG noted that there is incongruity with the research evidence that was found for these interventions. A randomised control trial (RCT) comparing a tailored communication intervention to a general communication strategy favoured the general communication strategy, while another RCT comparing a different tailored strategy to targeted strategy favoured the tailored communication strategy. For this reason the GDG notes that, many factors impact the success of targeted and tailored invitations and, depending on the type of tailored intervention, participation of socially disadvantaged women in screening programmes may actually increase or decrease.
• Further research examining all types of interventions aimed at targeting or tailoring to socially disadvantaged women is suggested.

The GDG notes that it did not consider monetary interventions ethical to increase participation and that the targeted communication used does not include this form of intervention.

• The GDG notes that the impact on caregivers for women with intellectual disabilities should be considered in implementing a targeted communication strategy.
• The GDG notes that issues with equity for screening programmes for individuals with intellectual disabilities should be considered along with other health issues where equity is also a concern.
• Access to telephone numbers may not be available or may be limited by data protection laws in some contexts.
• Strategies need to be developed to identify the appropriate target group, and how to invite them, for all health related issues, not just breast cancer.

Monitoring the success of targeting communication to this specific subgroup and the impact on participation rates should be considered.

The GDG supports additional research on targeted communication strategies for invitation to screening programmes for women with intellectual disabilities.