Should a letter with a fixed appointment vs. a letter alone be used for inviting asymptomatic women to organised population-based breast cancer screening programmes?

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.