Evaluation of a mobile mammography unit: concepts and randomized cluster trial protocol of a population health intervention research to reduce breast cancer screening inequalities.

BACKGROUND: Breast cancer is the leading cancer in women in France both in incidence and mortality. Organized breast cancer screening (OBCS) has been implemented nationwide since 2004, but the participation rate remains low (48%) and inequalities in participation have been reported. Facilities such as mobile mammography units could be effective to increase participation in OBCS and reduce inequalities, especially areas underserved in screening. Our main objective is to evaluate the impact of a mobile unit and to establish how it could be used to tackle territorial inequalities in OBCS participation. METHODS: A collaborative project will be conducted as a randomized controlled cluster trial in 2022-2024 in remote areas of four French departments. Small geographic areas were constructed by clustering women eligible to OBCS, according to distance to the nearest radiology centre, until an expected sample of eligible women was attained, as determined by logistic and financial constraints. Intervention areas were then selected by randomization in parallel groups. The main intervention is to propose an appointment at the mobile unit in addition to current OBCS in these remote areas according to the principle of proportionate universalism. A few weeks before the intervention, OBCS will be promoted with a specific information campaign and corresponding tools, applying the principle of multilevel, intersectoral and community empowerment to tackle inequalities. DISCUSSION: This randomized controlled trial will provide a high level of evidence in assessing the effects of mobile unit on participation and inequalities. Contextual factors impacting the intervention will be a key focus in this evaluation. Quantitative analyses will be complemented by qualitative analyses to investigate the causal mechanisms affecting the effectiveness of the intervention and to establish how the findings can be applied at national level. TRIAL REGISTRATION: Registered on ClinicalTrials.gov, December 21, 2021: NCT05164874 .

Recherche interventionnelle pour la réduction des inégalités sociales et territoriales de dépistage des cancers.

Social inequalities constitute a major obstacle to the social and economic cohesion of a country, particularly those affecting the health field. In the field of cancer screening, the current situation is that of a social gradient of participation and strong territorial inequalities. This paper reports on the results of two interventional investigations to add incentives to the existing device to provide screening tests for specific populations. A prospective trial with a collective randomization unit was set up from April 2011 to April 2013 in the 3 areas of Northern France (Aisne, Oise and Somme), to assess social workers' help with screening of colorectal cancer (Prado trial). A retrospective study was conducted on the experience of mammobile driving in the area of Orne for several years. The analysis of the results shows that each of these devices is capable of reducing or even erasing social and territorial inequalities at a reasonable cost to society. It also shows that in terms of screening, inequalities can only be reduced if additional devices dedicated to particular populations are added to the national system according to a principle of proportionate universalism.

Cost-Effectiveness Analysis of a Mobile Mammography Unit for Breast Cancer Screening to Reduce Geographic and Social Health Inequalities.

BACKGROUND: Breast cancer is the leading cancer in terms of incidence and mortality among women in France. Effective organized screening does exist, however, the participation rate is low, and negatively associated with a low socioeconomic status and remoteness. OBJECTIVES: To determine the cost-effectiveness of a mobile mammography (MM) program to increase participation in breast cancer screening and reduce geographic and social inequalities. METHODS: A cost-effectiveness analysis from retrospective data was conducted from the payer perspective, comparing an invitation to a mobile mammography unit (MMU) or to a radiologist's office (MM or RO group) with an invitation to a radiologist's office only (RO group) (n = 37 461). Medical and nonmedical direct costs were estimated. Outcome was screening participation. The mean incremental cost and effect, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. RESULTS: The mean incremental cost for invitation to MM or RO was estimated to be €23.21 (95% CI, 22.64-23.78) compared with RO only, and with a point of participation gain of 3.8% (95% CI, 2.8-4.8), resulting in an incremental cost per additional screen of €610.69 (95% CI, 492.11-821.01). The gain of participation was more important in women living in deprived areas and for distances exceeding 15 km from an RO. CONCLUSION: Screening involving a MMU can increase participation in breast cancer screening and reduce geographic and social inequalities while being more cost-effective in remote areas and in deprived areas. Because of the retrospective design, further research is needed to provide more evidence of the effectiveness and cost-effectiveness of using a MMU for organized breast cancer screening and to determine the optimal conditions for implementing it.

[Intervention research for the reduction of social and local inequalities in matters relating to cancer screening] / Recherche interventionnelle pour la réduction des inégalités sociales et territoriales de dépistage des cancers.

Social inequalities constitute a major obstacle to the social and economic cohesion of a country, particularly those affecting the health field. In the field of cancer screening, the current situation is that of a social gradient of participation and strong territorial inequalities. This paper reports on the results of two interventional investigations to add incentives to the existing device to provide screening tests for specific populations. A prospective trial with a collective randomization unit was set up from April 2011 to April 2013 in the 3 areas of Northern France (Aisne, Oise and Somme), to assess social workers' help with screening of colorectal cancer (Prado trial). A retrospective study was conducted on the experience of mammobile driving in the area of Orne for several years. The analysis of the results shows that each of these devices is capable of reducing or even erasing social and territorial inequalities at a reasonable cost to society. It also shows that in terms of screening, inequalities can only be reduced if additional devices dedicated to particular populations are added to the national system according to a principle of proportionate universalism.

Cost-Effectiveness Analysis of a Navigation Program for Colorectal Cancer Screening to Reduce Social Health Inequalities: A French Cluster Randomized Controlled Trial.

BACKGROUND: Patient navigation programs to increase colorectal cancer (CRC) screening adherence have become widespread in recent years, especially among deprived populations. OBJECTIVES: To evaluate the cost-effectiveness of the first patient navigation program in France. METHODS: A total of 16,250 participants were randomized to either the usual screening group (n = 8145) or the navigation group (n = 8105). Navigation consisted of personalized support provided by social workers. A cost-effectiveness analysis of navigation versus usual screening was conducted from the payer perspective in the Picardy region of northern France. We considered nonmedical direct costs in the analysis. RESULTS: Navigation was associated with a significant increase of 3.3% (24.4% vs. 21.1%; P = 0.003) in participation. The increase in participation was higher among affluent participants (+4.1%; P = 0.01) than among deprived ones (+2.6%; P = 0.07). The cost per additional individual screened by navigation compared with usual screening (incremental cost-effectiveness ratio) was €1212 globally and €1527 among deprived participants. Results were sensitive to navigator wages and to the intervention effectiveness whose variations had the greatest impact on the incremental cost-effectiveness ratio. CONCLUSIONS: Patient navigation aiming at increasing CRC screening participation is more efficient among affluent individuals. Nevertheless, when the intervention is implemented for the entire population, social inequalities in CRC screening adherence increase. To reduce social inequalities, patient navigation should therefore be restricted to deprived populations, despite not being the most cost-effective strategy, and accepted to bear a higher extra cost per additional individual screened.

Patient navigation to reduce social inequalities in colorectal cancer screening participation: A cluster randomized controlled trial.

Despite free colorectal cancer screening in France, participation remains low and low socioeconomic status is associated with a low participation. Our aim was to assess the effect of a screening navigation program on participation and the reduction in social inequalities in a national-level organized mass screening program for colorectal cancer by fecal-occult blood test (FOBT). A multicenter (3 French departments) cluster randomized controlled trial was conducted over two years. The cluster was a small geographical unit stratified according to a deprivation index and the place of residence. A total of 14,556 subjects (72 clusters) were included in the control arm where the FOBT program involved the usual postal reminders, and 14,373 subjects (66 clusters) were included in the intervention arm. Intervention concerned only non-attended subjects with a phone number available defined as the navigable population. A screening navigator was added to the usual screening organization to identify and eliminate barriers to CRC screening with personalized contact. The participation rate by strata increased in the intervention arm. The increase was greater in affluent strata than in deprived ones. Multivariate analyses demonstrated that the intervention mainly with phone navigation increased individual participation (OR=1.19 [1.10, 1.29]) in the navigable population. For such interventions to reduce social inequalities in a country with a national level organized mass screening program, they should first be administered to deprived populations, in accordance with the principle of proportionate universalism. ClinicalTrials.gov Identifier: NCT01555450.

Could mobile mammography reduce social and geographic inequalities in breast cancer screening participation?

Evaluation of mobile mammography for reducing social and geographic inequalities in breast cancer screening participation. We examined the responses to first invitations to undergo breast cancer screening from 2003 to 2012 in Orne, a French department. Half of the participants could choose between screening in a radiologist's office or a mobile mammography (MM) unit. We calculated the participation rate and individual participation model according to age group, deprivation quintile and distance. Among participants receiving an MM invitation, the preference was for MM. This was especially the case in the age group >70years and increased with deprivation quintile and remoteness. There were no significant participation trends with regard to deprivation or remoteness. In the general population, the influence of deprivation and remoteness was markedly diminished. After adjustment, MM invitation was associated with a significant increase in individual participation (odds ratio=2.9). MM can target underserved and remote communities, allowing greater participation and decreasing social and geographic inequalities in the general population. Proportionate universalism is an effective principle for public health policy in reducing health inequalities.