Orginal articleAdjusting the frequency of mammography screening on the basis of genetic risk: Attitudes among women in the UK
Introduction
Breast cancer screening by mammography has been identified as reducing deaths from breast cancer; nonetheless, false positives, overdiagnosis and overtreatment have all been identified as potential harms [1], [2]. Routine screening is usually recommended for women above age 50 [http://www.cancerscreening.nhs.uk/; http://www.who.int/cancer/detection/variouscancer/en/; http://www.cdc.gov/cancer/dcpc/prevention/screening.htm]; although women with a strong family history of breast cancer may be offered screening from an earlier age [3] http://www.cancerscreening.nhs.uk/; http://www.cdc.gov/cancer/dcpc/prevention/screening.htm). However, approximately 20% of all breast cancers occur in women younger than age 50 [4]; with a substantial proportion in women without a family history. These cancers tend to be aggressive with a poorer prognosis [5], [6], and therefore early identification, irrespective of known family history, might be beneficial.
Given the number of genetic markers for breast cancer risk that have been identified [7], [8], [9], incorporating genetic risk assessment into current mammography screening has been proposed as one way to maximise benefits and minimise harms [10]. Modifying screening eligibility and frequency to account for genetic risk could make it possible to ‘tailor’ screening and risk management efforts to those at the highest risk, for example by shortening screening intervals, or by offering screening using alternative modalities such as Magnetic Resonance Imaging (MRI) and ultrasound. At the same time, it would minimise exposure to potential harms of screening for those at the lowest risk; for example by starting screening later or by making a recommendation against routine mammography screening in this group. Risk-stratified mammography screening based on genetic risk could therefore be superior to current age-stratified approaches [11], [12].
However, implementation of genomic risk-stratified breast screening would require the support of the wider public. The public is generally very enthusiastic about screening [13], [14]. Women perceive high benefits of mammography screening [15], [16]; reflected in the high attendance rates (around 70%) across countries [17], [18], [19]; although lower socioeconomic status (SES) and ethnic minority status have both been associated with lower participation rates [20], [21], [22]. Perceived risk of breast cancer has been cited as encouraging some individuals to be screened, while deterring others [16], [23], [24]; so predicting the impact of giving genetic risk information on screening uptake is difficult. There has also been attention to public perceptions of a ‘right to be screened’, which may militate against the acceptability of reducing breast screening frequency for those at the lowest risk.
Few studies to date have investigated public attitudes to ‘personalised’ cancer screening, despite calls for empirical research on the topic [10], [25]. One qualitative study in the Netherlands found that women were supportive of both increases and reductions in breast screening frequency, although there was an important proviso that any woman who was worried about breast cancer despite having low genetic risk, should still be able to access screening [26]. A small qualitative study in the UK found enthusiasm for risk-stratified ovarian cancer screening based on genetic risk [27], but these findings cannot be assumed to generalise to an existing and very popular mammography breast screening programme; especially given evidence from two studies that show that information on overdiagnosis is not a deterrent for mammography screening for most women [14], [28].
Given that research is under way to test the feasibility of ‘personalising’ mammography screening based on individual risk factors, including genetic risk [29], the primary aim of this study was to investigate public attitudes towards amending the frequency of breast cancer screening based on genetic risk in the current UK National Health Service Breast Cancer Screening Programme. Data were from a large, population-based study, making it possible to identify demographic and personal predictors of support for raising or lowering frequency of cancer screening based on genetic risk.
Section snippets
Sample
Data were collected by adding a question module on ‘genetics and screening’ to the ‘Opinions and Lifestyle’ survey, which is conducted monthly by the UK Office of National Statistics (ONS) on behalf of government departments, non-governmental agencies and academic institutions. Each month, 2010 households are identified from the Royal Mail's Postcode Address File using stratified random probability sampling. Selected addresses are contacted up to eight times at different times and days of the
Results
In the January wave, 8% (n = 166) of the 2010 selected households were not eligible because they were businesses or empty properties. Of 1844 eligible households, 9% (n = 171) could not be contacted and 33% (n = 608) declined to take part in the ONS survey. In the March wave, 1853 households were eligible (92%). Of those, 13% (n = 237) could not be contacted and 31% (n = 578) chose not to take part. Therefore, the overall response rate was 57%; comparable to previous ONS surveys (//www.ons.gov.uk/ons/index.html
Discussion
This is the first population-based study investigating women's attitudes to risk-stratified mammography screening based on genetic risk assessment. Although the majority of women were enthusiastic about a risk-stratified approach to breast screening, this was particularly with respect to increasing screening frequency for those at higher genetic risk. Fewer were supportive of a reduction in screening frequency for those at lower risk.
Since most women were of the opinion that genetic testing
Conclusion
The results of this study indicate that women are generally positive towards risk-stratified mammography screening based on genetic risk assessment; although it will be important to develop effective communication materials to minimise resistance to reduction in screening frequency for those at lower genetic risk. The findings give confidence that the general public would support the integration of novel genomic technologies into mainstream healthcare.
Conflict of interest statement
The authors have no conflict of interest to declare.
Acknowledgements
This research was funded by grants from the Eve Appeal (grant code: 509050) and Cancer Research UK (grant code: 508007). Jane Wardle is supported by CR-UK as part of the CRUK-UCL Cancer Centre.
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