Mammography Promotion and Facilitated Appointments Through Community-based Influenza Clinics

Breast cancer is the leading cancer diagnosis in women in the United States, aside from non-melanoma skin cancer, and the second leading cause of cancer death in women, after lung cancer. In 2007, 202,964 women were diagnosed with breast cancer, and 40,598 women died from breast cancer. Older women are particularly at risk: about two of three women with invasive breast cancer are 55 or older when the cancer is found. By detecting tumors at earlier, more treatable stages, routine mammography among women over 50 can reduce breast cancer mortality by more than 30%. There is considerable evidence that mammography use declines with advancing age, despite findings that screening mammography saves lives up to age 79 and older. 

Annual influenza clinics are an ideal setting for promoting breast-cancer screening among older women. Influenza vaccine campaigns are targeted annually at more than 100 million people aged 50 and over. These clinics are likely to attract women across a broad racial, ethnic, and socioeconomic range because economic barriers to receiving influenza immunizations are minimal (they are usually provided free of charge or are reimbursed by Medicare). Moreover, for both influenza immunizations and screening mammograms, the most conservative recommended interval is 12 months. Combining these two clinical preventive services creates an opportunity to boost the use of a service with lower utilization rates (annual mammograms) through its link with a service with higher rates (annual influenza immunizations). 

Mammography Promotion and Facilitated Appointments Through Community-Based Influenza Clinics was developed by a community-based disease prevention organization called Sickness Prevention Achieved through Regional Collaboration (SPARC). The program makes use of annual influenza clinics as an opportune setting for promoting breast-cancer screening among older women and for facilitating mammography appointments. 

The purpose of the program is to facilitate easy and convenient mammogram appointments, increasing the likelihood that women will obtain mammograms. To promote this cancer screening service, a program facilitator first obtains permission from one or more providers of public influenza clinics in the community to conduct the program during their clinic. Next, the facilitator contacts the certified mammogram providers in the county to obtain their agreement to participate. Paid or volunteer outreach workers, preferably with a background in health, are recruited and trained to enroll women in the project at the influenza clinics and hand out brochures and other promotional items. The outreach workers forward the participants' contact information to the mammogram providers to schedule mammogram appointments. The providers notify the program facilitator of the number of women who receive their mammogram, and the results of the mammogram are communicated to both the patient and her personal physician. 

Program planning and implementation take approximately 8 months. The program facilitator should begin identifying and meeting with influenza clinic providers in the April prior to the opening of the influenza clinics in the fall. The program is implemented from October through December. 

The intended audience for this intervention is women aged 50 or older who have not received a mammogram in the last year. 

Suitable settings for this intervention are annual influenza clinics.

The required resource is the SPARC Program Implementation Manual, which gives the program facilitator step-by-step instruction on how to implement the program. The guide contains all the needed materials and provides sources for ordering brochures and other promotional items. The program can be managed by one person on a part-time basis, with the help of paid or volunteer outreach workers. 

Using a quasi-experimental study design, the authors evaluated whether offering women attending community-based influenza clinics the opportunity to receive a telephone call from a radiology department of choice to schedule a mammogram would result in an increase in mammograms performed over a 6-month period. Women who had not received a mammogram in the preceding year and who were aged 50 or older were targeted. Nine of the 52 advertised influenza clinics in Litchfield County, Connecticut, were randomly selected and invited to participate in the mammography initiative. The nine clinics were further randomized into control (five) or intervention (four) clinics. The intervention group was composed of 137 women (mean age 73.1), and the control group was composed of 147 women (mean age 72.4). In each intervention clinic, participants were asked if a local hospital-based radiology facility of their choice could call them at home to schedule a mammogram. In the control group, women were asked if they would accept a call in 6 months concerning "a few brief questions about the use of preventive care in our community." Following the completion of each intervention clinic, mammography providers were given a list of names and phone numbers of participants who agreed to receive a call for scheduling. 

Researchers followed up with each hospital to determine the number of mammograms performed among women in the intervention group who agreed to receive a scheduling phone call from the radiology department. Six months after the date of the visit to the influenza clinic, follow-up calls were made to women in the intervention group who had declined to receive a call from a mammography provider to ascertain the date of their last mammogram. Similar telephone calls were made to women in the control group unless they had declined to receive a 6-month follow-up call.

• Mammography use for women from intervention influenza clinics (35%) was more than twice that of women in the control group attending influenza clinics where access to mammography was not offered (15%). In analyzing the data, the authors tested three different assumptions regarding participants whose mammography status was unknown: excluding those with unknown mammogram status, applying the known rate of the control group to all women with unknown mammogram status, and applying the known rate of the intervention group to all women with unknown mammogram status. For all three analyses, the relative risks ranged between 1.6 and 2.1. For each assumption, the results were statistically significant (p<.001).