Should a letter followed by a phone call to remind 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, 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.