BACKGROUND:Strategiesfor reducingbreast cancermortality in western countries have focused onscreening, at least forwomenaged 50 to 69 years. One of the requirements of anycommunityscreeningprogram is to achieve a highparticipationrate, which is related to methods of invitation. Therefore, it was decided to systematically review the scientific evidence on the differentstrategiesaimed at improvingwomen'sparticipationinbreast cancerscreeningprograms and activities.OBJECTIVES:To assess the effectiveness of differentstrategiesforincreasingtheparticipationrate ofwomeninvited tocommunity(population-based)breast cancerscreeningactivities or mammography programs.SEARCH STRATEGY:MEDLINE (1966-2000), CENTRAL (2000), and EMBASE (1998-1999) searches for 1966 to 1999 were supplemented by reports and letters to the EuropeanScreeningBreast CancerPrograms (Euref Network).SELECTION CRITERIA:Both published and unpublished trials were eligible for inclusion, provided thewomenhad been invited to acommunitybreastscreeningactivity or program and had been randomised to an intervention group or a control group with no active intervention.DATA COLLECTION AND ANALYSIS:We identified 151 articles, which were reviewed independently by two people. The discrepancies were resolved by a third reviewer in order to reach consensus. Thirty-four studies were excluded because they lacked a control group; 58 of the other 117 articles were considered as opportunistic and notcommunity-based; 59 articles, which reported 70community-based randomised controlled trials or clinical controlled trials, were accepted. In 24 of these, the control group had not been exposed to any active intervention, but 8 of the 24 had to be excluded because the denominator for estimating attendance was unknown. At the end, 16 studies constituted the material for this review, although two studies were further excluded because their groups were not comparable at baseline. Data from all but one study were based on or converted to an intention-to-treat analysis. Attendance in response to the mammogram invitation was the main outcome measure.MAIN RESULTS:The evidence favoured five activestrategiesfor invitingwomenintocommunitybreast cancerscreeningservices: letter of invitation (OR 1.66, 95% CI 1.43 to 1.92), mailed educational material (OR 2.81, 95% CI 1.96 to 4.02), letter of invitation plus phone call (OR 2.53, 95% CI 2.02 to 3.18), phone call (OR 1.94, 95% CI 1.70 to 2.23), and training activities plus direct reminders for thewomen(OR 2.46, 95% CI 1.72 to 3.50). Home visits did not prove to be effective (OR 1.06, 95 % CI 0.80 to 1.40) and letters of invitation to multiple examinations plus educational material favoured the control group (OR 0.62, 95 % CI 0.32 to 1.20).REVIEWER'S CONCLUSIONS:Most active recruitmentstrategiesforbreast cancerscreeningprograms examined in this review were more effective than no intervention. Combinations of effective interventions can have an important effect. Some costlystrategies, as a home visit and a letter of invitation to multiplescreeningexaminations plus educational material, were not effective. Further reviews comparing the effective interventions and studies that include cost-effectiveness,women's satisfaction and equity issues are needed.
