Objective 

In a randomized controlled trial, the Promoting Early Presentation intervention increased older women’s breast cancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breast screening self-referral.



Methods 

We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting Early Presentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years.



Results 

Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years than the usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited.



Conclusion 

The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear

Alice S Forster

All Party Parliamentary Group on Breast Cancer

Amanda J Ramirez

Aradhna Kaushal

Caroline Burgess

Fiona Warburton

Health &amp

Lindsay JL Forbes

Lorraine Tucker

Louise Linsell

Lynne Omar

Office for National Statistics

Objective In a randomized controlled trial, the Promoting Early Presentation intervention increased older women's breast cancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breast screening self-referral. Methods We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting Early Presentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years. Results Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years than the usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited. Conclusion The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear

Kaushal, A

Ramirez, AJ

Warburton, F

Forster, AS

Linsell, L

Burgess, C

Tucker, L

Omar, L

Forbes, LJ

Oxford University Research Archive (ORA)

Journal of Medical Screening

"Promoting Early Presentation" intervention sustains increased breast cancer awareness in older women for three years: A randomized controlled trial.

Objective In a randomized controlled trial, the Promoting Early Presentation intervention increased older women’s breast cancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breast screening self-referral. Methods We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting Early Presentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years. Results Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years than the usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited. Conclusion The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear. </jats:sec

Crossref

“Promoting Early Presentation” intervention sustains increased breast cancer awareness in older women for three years: A randomized controlled trial

Kaushal, Aradhna

Ramirez, Amanda J.

Warburton, Fiona

Forster, Alice S.

Linsell, Louise

Burgess, Caroline

Tucker, Lorraine

Omar, Lynne

Forbes, Lindsay J.L.

Kent Academic Repository

Research Letter‘‘Promoting Early Presentation’’ interventionsustains increased breast cancer awareness inolder women for three years: A randomizedcontrolled trialAradhna Kaushal, Amanda J Ramirez, Fiona Warburton,Alice S Forster, Louise Linsell, Caroline Burgess, Lorraine Tucker,Lynne Omar and Lindsay JL ForbesAbstractObjective: In a randomized controlled trial, the Promoting Early Presentation intervention increased older women’s breastcancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breastscreening self-referral.Methods:We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting EarlyPresentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years.Results:Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years thanthe usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited.Conclusion: The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women.The effect on self-referral for breast screening is unclear.KeywordsCancer early diagnosis, cancer screening, breast cancer awareness, health knowledge, attitudes, practiceDate received: 22 March 2016; accepted: 11 August 2016Women who delay presentation of breast cancer symp-toms have poorer outcomes, probably because they pre-sent with more advanced disease.1,2 This is a particularproblem in older women, who are more likely to havepoor breast cancer awareness, to delay presentation withbreast cancer symptoms, and have worse survival from thedisease.3,4 Women in the UK are invited for breast screen-ing every three years from age 50 to 70, with some invitedfrom 47 to 73 as part of a trial.5 Following their ﬁnalinvited appointment, women may request further screen-ing (self-referral), however, only about 20% of womenaged 70 and over self-refer.6We developed the Promoting Early Presentation (PEP)intervention, a scripted 10-min one-to-one interactiondelivered by a health professional and supported by abooklet, to provide older women with the knowledge,motivation, conﬁdence, and skills to present promptlywith breast cancer symptoms.7,8 In our trial, 867 womenaged 67–70 attending their ﬁnal routine appointment forbreast screening in the NHS Breast Screening Programmewere randomly allocated to receive the PEP interventionor usual care.9 The main outcome was breast cancerawareness, a validated composite score encompassingknowledge of breast cancer symptoms, age-related riskof breast cancer, and frequency of breast checking.10Participants were considered breast cancer aware if theyrecognized ﬁve or more non-lump symptoms, identiﬁed a70 year old as most at risk of developing breast cancer(compared with a 30 year old, a 50 year old, or a womanof any age), and reported checking their breasts at leastonce a month. These items were combined to form anPromoting Early Presentation Group, King’s College London, London, UKCorresponding author:Aradhna Kaushal, MRC Unit for Lifelong Health and Ageing at UCL, 33Bedford Place, London WC1B 5JU, UK.Email: aradhnakaushal@gmail.comJ Med Screen0(0) 1–3! The Author(s) 2016Reprints and permissions:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/0969141316667408msc.sagepub.com J Med Screen OnlineFirst, published on October 9, 2016 as doi:10.1177/0969141316667408 at Kings College London - ISS on October 14, 2016msc.sagepub.comDownloaded from ordinal composite score of breast awareness. Each com-ponent was given equal weighting and contributed onepoint to the total score, ranging from 0 to 3, with ascore of 3 being breast cancer aware. The trial data andconsort diagram have been previously published.11 ThePEP intervention increased breast cancer awareness com-pared with usual care at two years follow up.12This report summarizes further results of the trial: theeﬀect of the PEP intervention on breast cancer awarenessafter three years, and self-referral for breast screening inthe four years after randomization. Breast cancer aware-ness was assessed by postal questionnaire three years afterreceiving the intervention. Four years after every partici-pant had attended their ﬁnal routine breast screeningappointment, we asked NHS Breast Screening Servicesto tell us which women in the trial had self-referred forfurther breast screening. We used generalized estimatingequations to analyse the change in proportion that wasbreast cancer aware from baseline to three years, compar-ing PEP intervention with usual care. The analyses werecarried out by intention-to-treat. In subsequent analyses,we adjusted the estimates, controlling for health profes-sional, centre, and demographic characteristics at base-line. We examined whether, four years after recruitment,there were diﬀerences in the proportions that had self-referred for breast screening between the PEP interventionand usual care using logistic regression. All analyses wereperformed using Stata version 11.2 (College Station, TX).At three years, 457/565 (81%) of randomized womencompleted the breast cancer awareness questionnaire,222/279 (78%) in the PEP intervention arm and235/286 (82%) in the usual care arm. Women who com-pleted the questionnaire were more likely to be white andto live in less socioeconomically deprived areas than thosewho did not, but there were no diﬀerences in educationalstatus or baseline breast cancer awareness. Non-responseby these characteristics was very similar in both arms.Women in the intervention arm were more likely to bebreast cancer aware compared with the usual care armat three years (17% versus 4%, odds ratio (OR): 10.4,95% conﬁdence interval (CI) 3.1 to 34.8; p< 0.001)(Table 1). The most striking eﬀect of the interventionwas on knowledge of the age at which women weremost at risk of breast cancer. In the PEP intervention,the proportion who knew that a 70 year old was athigher risk than a younger woman or a woman of anyage was about 22%, compared with 8% in the usualcare arm (OR: 3.7; CI: 1.9–7.4; p< 0.001). In the usualcare arm, 64.9% identiﬁed 5–9 non-lump symptoms com-pared with 73.2% in the PEP intervention group (OR: 1.2;CI: 0.8–1.8; p¼ 0.3,); 66.2% in usual care checked breastsat least monthly compared with 78.2% in the interventiongroup (OR: 1.7; CI: 1.1–2.5; p< 0.01). Including centre,health professional, and baseline demographics in themodel made very little diﬀerence to the results.The analysis of breast screening attendance included341 women. We excluded 232 women from this analysisbecause they had died or withdrawn consent (n¼ 33), wereknown to be taking part in other studies of breast screen-ing or promoting early presentation of breast cancer(n¼ 157), or were invited for an additional roundof screening by the breast screening service (n¼ 42).Table 1. Breast cancer awareness at baseline and three years post-randomization.Baseline Three yearsUsual care PEP intervention Usual care PEP InterventionBreast cancer awarenessNumber (%) breast cancer awarea 9/267 5/272 9/225 36/210(3.4) (1.8) (4.0) (17.1)Odds ratiob (95% CI), p value (versus usual care) 1.0 10.4 (3.1 to 34.8), p< 0.001Knowledge of breast cancer symptomsIdentified five or more non-lump symptoms 111/284 122/280 148/228 158/216(39.1) (43.6) (64.9) (73.2)Odds ratiob (95% CI), p value (versus usual care) 1.0 1.2 (0.8 to 1.8), p¼ 0.3Knowledge that risk increases with ageIdentified a 70-year-old as at highest risk of breast cancer 30/269 28/276 18/233 47/215(11.2) (10.1) (7.7) (21.9)Odds ratiob (95% CI), p value (versus usual care) 1.0 3.7 (1.9 to 7.4), p4 0.001Breast checkingReported breast checking at least once a month 152/285 154/284 155/234 172/220(53.3) (54.2) (66.2) (78.2)Odds ratiob (95% CI), p value (versus usual care) 1.0 1.7 (1.1 to 2.5), p< 0.01PEP: Promoting Early Presentation.aA woman was considered breast cancer aware if she: identified at least five non-lump symptoms AND identified that a 70-year-old woman is most at risk ofbreast cancer (rather than a 30 year old, a 50 year old or a woman of any age) AND reported checking her breasts at least once a month.bCrude odds ratios – not adjusted for baseline characteristics.2 Journal of Medical Screening 0(0) at Kings College London - ISS on October 14, 2016msc.sagepub.comDownloaded from There were no signiﬁcant diﬀerences in the proportionswho had self-referred for breast screening between PEPintervention and usual care arms (35/168 versus 31/173;21% versus 18%; OR 0.8; CI 0.5 to 1.4).The PEP intervention increased breast cancer aware-ness in older women; the eﬀect was sustained at threeyears but diminished over the three years. The eﬀect wasmost striking for knowledge that the risk of breast cancerincreases with age. We found no eﬀect of the PEP inter-vention on self-referral for breast screening. A strength ofthe analysis of breast cancer awareness is the very highresponse rate, and we found no evidence that responsebias (i.e. diﬀerences in pattern of response by arm) couldexplain the results. In both arms, knowledge that the riskof breast cancer increases with age was low compared withknowledge of breast cancer symptoms and frequency ofbreast checking, limiting the overall proportion of partici-pants being able to achieve a score of 3 for breast cancerawareness. Future work should investigate why know-ledge that risk of breast cancer increases with age is diﬃ-cult for participants to retain and to develop bettermethods of communicating this message. The analysis ofself-referrals was limited by low numbers. We would haveneeded a sample of about 7000 women to ﬁnd theobserved diﬀerence in proportions self-referring betweenPEP intervention and usual care arms statistically signiﬁ-cant, with 80% power and signiﬁcance level of 5%. It isalso possible that we collected data too soon after ran-domization (four years), and that some women mayhave self-referred for breast screening later.The PEP intervention has recently been tested in rou-tine clinical practice and has been found to be eﬀective atincreasing breast cancer awareness, with sustained eﬀectsat one year (Lindsay Forbes/Rachael Dodd, personalcommunication).12 In 2013, the All Party ParliamentaryGroup on Breast Cancer recommended that the PEPintervention should be rolled out in more breast screeningservices and tested in a variety of community-based healthcare settings to evaluate the eﬀect on stage at diagnosisand survival.13 If the PEP intervention were implementedacross the whole NHS Breast Screening Programme, it haspotential to prevent avoidable deaths from breast cancerresulting from delayed presentation of cancer symptomsin older women.AcknowledgementsWe thank the staﬀ and participating women from the South East London, SouthWest London, and Surrey Breast Screening Services for supporting the trial; LizKedge, Rachel Baxter, Ragini Jhalia, and Jo Sippitt for delivering the intervention;and Matthew Hotopf, Rebecca Walwyn, and Gunna Dietrich of the DataMonitoring Committee. Ethical approval was obtained from King’s CollegeHospital Research Ethics Committee 2007 (Ref. No.: 05/Q0703/51).Declaration of Conflicting InterestsThe author(s) declared no potential conﬂicts of interest with respect to the research,authorship, and/or publication of this article.FundingThis study was funded by Cancer Research UK (C4047/A12288). Trial registration:National Cancer Research Network and ISRCTN (31994827).References1. Richards MA, Westcombe AM, Love SB, et al. Influence of delay on survivalin patients with breast cancer: a systematic review. Lancet 1999; 353:1119–1126.2. Møller H, Sandin F, Bray F, et al. Breast cancer survival in England, Norwayand Sweden: a population-based comparison. Int J Cancer 2010; 127:2630–2638.3. Ramirez AJ, Westcombe AM, Burgess CC, et al. Factors predicting delayedpresentation of symptomatic breast cancer: a systematic review. Lancet 1999;353: 1127–1131.4. Office for National Statistics. One- and five-year survival (%) for adult patientsdiagnosed during 1998-2001, 21 common cancers, by sex and age. London:Office for National Statistics, 2009.5. Moser K, Sellars S, Wheaton M, et al. Extending the age range for breastscreening in England: pilot study to assess the feasibility and acceptability ofrandomization. J Med Screen 2011; 18: 96–102.6. Health & Social Care Information Centre. Breast screening programme,England: statstics for 2014-15. London: Health & Social Care InformationCentre, 2014–2015.7. Burgess CC, Bish AM, Hunter HS, et al. Promoting early presentation ofbreast cancer: development of a psycho-educational intervention. ChronIllness 2008; 4: 13–27.8. Burgess CC, Linsell L, Kapari M, et al. Promoting early presentation of breastcancer by older women: a preliminary evaluation of a one-to-one health pro-fessional-delivered intervention. J Psychosomat Res 2009; 67: 377–387.9. Linsell L, Forbes LJ, Kapari M, et al. A randomised controlled trial of anintervention to promote early presentation of breast cancer in older women:effect on breast cancer awareness. Br J Cancer 2009; 101(Suppl. 2): S40–S48.10. Linsell L, Forbes LJ, Burgess C, et al. Validation of a measurement tool toassess awareness of breast cancer. Eur J Cancer 2010; 46: 1374–1381.11. Forbes LJ, Linsell L, Atkins L, et al. A promoting early presentation interven-tion increases breast cancer awareness in older women after 2 years: a rando-mised controlled trial. Br J Cancer 2011; 105: 18–21.12. Forbes LJ, Forster AS, Dodd RH, et al. Promoting early presentation of breastcancer in older women: implementing an evidence-based intervention in routineclinical practice. J Cancer Epidemiol 2012; 2012: 835167.13. All Party Parliamentary Group on Breast Cancer. Age is just a number: thereport of the parliamentary enquiry into older age and breast cancer. London: AllParty Parliamentary Group on Breast Cancer, 2013.Kaushal et al. 3 at Kings College London - ISS on October 14, 2016msc.sagepub.comDownloaded from 

Promoting Early Presentation intervention sustains increased breast cancer awareness in older women for three years: A randomized controlled trial

OBJECTIVE: In a randomized controlled trial, the Promoting Early Presentation intervention increased older women’s breast cancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breast screening self-referral.

METHODS: We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting Early Presentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years.

RESULTS: Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years than the usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited.

CONCLUSION: The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear

Forbes, LJL

UCL Discovery

 1   A promoting early presentation intervention sustains increased breast cancer awareness in older women for three years: a randomised controlled trial  Short title Promoting Early Presentation of Breast Cancer Authors Aradhna Kaushal1, Amanda J Ramirez1, Fiona Warburton1, Alice S Forster1, Louise Linsell1, Caroline Burgess1, Lorraine Tucker1, Lynne Omar1 and Lindsay JL Forbes1 Affiliations King’s College London Promoting Early Presentation Group, 4th Floor Capital House, 42 Weston Street, London, SE1 3QD.  Corresponding Author Aradhna Kaushal MRC Unit for Lifelong Health and Ageing at UCL, 33 Bedford Place, London, WC1B 5JU aradhnakaushal@gmail.com Corresponding Author The authors declare no conflict of interest.   2  Abstract  The Promoting Early Presentation intervention (PEP) increased older women’s breast cancer awareness after 2 years in a randomised controlled trial. We measured whether this increase was sustained at 3 years and the effect on breast screening self-referral. We randomly allocated 867 women attending their final invited breast screening appointment to the PEP Intervention or usual care. We examined breast cancer awareness after 3 years and breast screening self-referrals after 4 years. Women in the PEP intervention arm had higher breast cancer awareness at 3 years than the usual care arm (odds ratio 10.4, 95% confidence interval 3.1 to 34.8). There were no difference in proportions self-referring for breast screening between arms, but statistical power was limited. The PEP Intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear. Keywords  Cancer Early Diagnosis  Cancer Screening  Breast cancer awareness  Health Knowledge, Attitudes, Practice   3  Introduction  Women who delay presentation of breast cancer symptoms have poorer outcomes and evidence suggests this is because they present with more advanced disease 1, 2. This is a particular problem in older women, who are more likely to have poor breast cancer awareness, to delay presentation with breast cancer symptoms, and have worse survival from the disease 3, 4. In the UK, women are invited for breast screening every three years from the age of 50 to 70 with some women being invited from 47 to 73 as part of a trial 5. Following women’s final invited appointment for breast screening, women may contact the screening service every three years to request further screening.  This is known as self-referral, however, the proportion of women aged 70 and over who self-referring for breast screening is relatively low at about 20%6.This report summarises further results of the randomised controlled trial: the effect of the PEP Intervention on breast cancer awareness after three years, and self-referral for breast screening in the four years after randomisation. Methods We developed the Promoting Early Presentation (PEP) Intervention to provide older women with the knowledge, motivation, confidence and skills to present promptly with breast cancer symptoms 7, 8. Delivered by a health professional in a few minutes, it is supported by a booklet.  The PEP Intervention was delivered women attending their final invited breast screening appointment. The intervention was a scripted ten-minute one-to-one interaction which was supported by a booklet. The details of the trial’s methods have already been published; in brief, eight hundred and sixty seven women aged 67-70 attending their final routine  4  appointment for breast screening in the NHS Breast Screening Programme were randomly allocated to receive the PEP Intervention or usual care9.  The main outcome was breast cancer awareness, a validated composite score encompassing knowledge of breast cancer symptoms, age-related risk of breast cancer and frequency of breast checking 10. Participants were considered breast cancer aware if they recognised 5 or more non-lump symptoms, identified a 70 year old as most at risk of developing breast cancer (compared with a 30 year old, a 50 year old or a woman of any age) and reported checking their breasts at least once a month. These items were combined to form an ordinal composite score of breast awareness. Each component was given equal weighting and contributed one point to the total score ranging from 0 to 3 with a score of 3 being breast cancer aware.  The PEP Intervention increased breast cancer awareness compared to usual care at two years follow up (Forbes 2012). This report focuses on reporting the re-assessment of breast cancer awareness at three years follow-up and the rates of self-referral for breast screening after four years. Breast cancer awareness was assessed by postal questionnaire 3 years after receiving the intervention. Four years after every participant had attended their final routine breast screening appointment we asked NHS Breast Screening Services to tell us which women in the trial had self-referred for further breast screening. Analysis We used generalized estimating equations to analyse the change in proportion that was breast cancer aware from baseline to three years, comparing PEP Intervention versus usual care arm. The analyses were carried out by intention-to-treat. In subsequent analyses, we  5  adjusted the estimates controlling for health professional, centre, and demographic characteristics at baseline.  We examined whether, four years after recruitment, there were differences in the proportions that had self-referred for breast screening between the PEP intervention and usual care using logistic regression.  All analyses were performed using Stata version 11.2 (College Station, TX). Results The data, and consort diagram for this trial have been shown in a previous report 11. At three years, 457/565 (81%) of randomised women completed the breast cancer awareness questionnaire: 222/279 (78%) in the PEP Intervention arm and 235/286 (82%) in the usual care arm. Women who completed the questionnaire at three years were more likely to be of White ethnic group and to live in less socioeconomically deprived areas than those who did not, but there were no differences in educational status or baseline breast cancer awareness. Non-response by these characteristics was very similar in both arms.  Breast cancer awareness Women in the PEP Intervention arm were more likely to be breast cancer aware compared with the usual care arm at three years (17% versus 4%, odds ratio (OR): 10.4, 95% confidence interval (CI) 3.1 to 34.8; p<0.001) (Table 1). The most striking effect of the PEP Intervention was on knowledge of the age at which women were most at risk of breast cancer. In the PEP Intervention, the proportion who knew that a 70 year old was at higher risk than a younger woman or a woman of any age was about 22%, compared with 8% in the  6  usual care arm (OR: 3.7; CI: 1.9-7.4; p<0.001). Including centre, health professional, and baseline demographic s in the model made very little difference to the results.  In the usual care arm 64.9% identified 5-9 non-lump symptoms compared to 73.2% in PEP intervention group (OR: 1.2; CI: 0.8-1.8; p=0.3) and 66.2% in usual care who check breasts at least once month to 78.2% in PEP intervention group (OR: 1.7; CI: 1.1-2.5; p<0.01). Self-referral for breast cancer screening Three-hundred and forty-one women were included in the analysis of breast screening attendance. We excluded 232 women from this analysis because they had died or withdrawn consent (n=33), they were known to be taking part in other studies of breast screening or promoting early presentation of breast cancer (n= 157), or they were invited for an additional round of screening by the breast screening service (n=42). There were no significant differences in the proportions who had self-referred for breast screening between PEP Intervention and usual care arms (35/168 versus 31/173; 21% versus 18%; OR 0.8; CI 0.5 to 1.4).   7  Table 1. Breast cancer Awareness at baseline and three years post-randomisation  Baseline Three years  Usual care PEP Intervention Usual care PEP Intervention Breast cancer awareness Number (%) breast cancer aware* 9/267 5/272 9/225 36/210 (3.4) (1.8) (4.0) (17.1) Odds ratio† (95% CI), p value   (versus usual care)   1.0 10.4 (3.1 to 34.8) p<0.001 Knowledge of breast cancer symptoms  Identified five or more non-lump symptoms 111/284 122/280 148/228 158/216 (39.1) (43.6) (64.9) (73.2) Odds ratio† (95% CI), p value (versus usual care)   1.0 1.2 (0.8 to 1.8) p=0.3 Knowledge that risk increases with age Identified a 70 year old as at highest risk of breast cancer 30/269 28/276 18/233 47/215 (11.2) (10.1) (7.7) (21.9) Odds ratio† (95% CI), p value (versus usual care)   1.0 3.7 (1.9 to 7.4) p=<0.001 Breast checking Reported breast checking at least once a month 152/285 154/284 155/234 172/220 (53.3) (54.2) (66.2) (78.2) Odds ratio† (95% CI), p value (versus usual care)   1.0 1.7 (1.1 to 2.5) p<0.01  * A woman was considered breast cancer aware if she: identified at least five non-lump symptoms AND identified that a 70 year old woman is most at risk of breast cancer (rather than a 30 year old, a 50 year old or a woman of any age)  AND reported checking her breasts at least once a month. † Crude odds ratios – not adjusted for baseline characteristics    8  Conclusion  The PEP Intervention increased breast cancer awareness in older women and the effect was sustained at three years but diminished over the three years. The effect was most striking for knowledge that the risk of breast cancer increases with age. We found no effect of the PEP intervention on self-referral for breast screening. A strength of the analysis of breast cancer awareness is the very high response rate. Moreover, we found no evidence that response bias i.e. differences in pattern of response by arm - could explain the results.  In both arms, knowledge that the risk of breast cancer increases with age was low compared to knowledge of breast cancer symptoms and frequency of breast checking, limiting the overall proportion of participants being able to achieve a score of 3 for breast cancer awareness. Future work should investigate why knowledge that risk of breast cancer increases with age is difficult for participants to retain and to develop better methods of communicating this message. The analysis of self-referrals was limited by low numbers: we would have needed a sample of about 7000 women to find the observed difference in proportions self-referring between PEP intervention and usual care arms statistically significant, with 80% power and significance level of 5%.  It is also possible that we collected data too soon after randomisation (four years) and that some women may have self-referred for breast screening later.  The PEP intervention has recently been tested in routine clinical practice and has been found to be effective at increasing breast cancer awareness with sustained effects at one year  (Lindsay Forbes/Rachael Dodd, personal communication)12. In 2013, the All Party  9  Parliamentary Group on Breast Cancer (2013) recommended that the PEP Intervention should be rolled out in more breast screening services, in order to evaluate the effect on stage at diagnosis and survival, and be tested in a variety of community-based health care settings 13. If the PEP Intervention is implemented across the whole NHS Breast Screening Programme, it has potential to prevent avoidable deaths from breast cancer, resulting from delayed presentation of cancer symptoms in older women.  Acknowledgements We thank the staff and participating women from the South East London, South West London and Surrey Breast Screening Services for their support of the trial; Liz Kedge, Rachel Baxter, Ragini Jhalia and Jo Sippitt for delivering the intervention; and Matthew Hotopf, Rebecca Walwyn and Gunna Dietrich of the Data Monitoring Committee. Ethics approval was obtained from King’s College Hospital Research Ethics Committee 2007 (Ref. No.: 05/Q0703/51). This study was funded by Cancer Research UK (C4047/A12288). Trial registration: National Cancer Research Network and ISRCTN (31994827). References 1. Richards MA, Westcombe AM, Love SB, Littlejohns P and Ramirez AJ. Influence of delay on survival in patients with breast cancer: a systematic review. Lancet. 1999; 353: 1119-26. 2. Møller H, Sandin F, Bray F, et al. Breast cancer survival in England, Norway and Sweden: a population‐based comparison. International Journal of Cancer. 2010; 127: 2630-8. 3. Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P and Richards MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet. 1999; 353: 1127-31. 4. Office for National Statistics. One- and five-year survival (%) for adult patients diagnosed during 1998-2001, 21 common cancers, by sex and age. London2009. 5. Moser K, Sellars S, Wheaton M, et al. Extending the age range for breast screening in England: pilot study to assess the feasibility and acceptability of randomization. Journal of medical screening. 2011; 18: 96-102. 6. Health & Social Care Information Centre. Breast Screening Programme, England: Statstics for 2014-15. 2014-2015.  10  7. Burgess CC, Bish AM, Hunter HS, et al. Promoting early presentation of breast cancer: development of a psycho-educational intervention. Chronic illness. 2008; 4: 13-27. 8. Burgess CC, Linsell L, Kapari M, et al. Promoting early presentation of breast cancer by older women: a preliminary evaluation of a one-to-one health professional-delivered intervention. Journal of psychosomatic research. 2009; 67: 377-87. 9. Linsell L, Forbes LJ, Kapari M, et al. A randomised controlled trial of an intervention to promote early presentation of breast cancer in older women: effect on breast cancer awareness. British journal of cancer. 2009; 101 Suppl 2: S40-8. 10. Linsell L, Forbes LJ, Burgess C, Kapari M, Thurnham A and Ramirez AJ. Validation of a measurement tool to assess awareness of breast cancer. European journal of cancer (Oxford, England : 1990). 2010; 46: 1374-81. 11. Forbes LJ, Linsell L, Atkins L, et al. A promoting early presentation intervention increases breast cancer awareness in older women after 2 years: a randomised controlled trial. British journal of cancer. 2011; 105: 18-21. 12. Forbes LJ, Forster AS, Dodd RH, et al. Promoting early presentation of breast cancer in older women: implementing an evidence-based intervention in routine clinical practice. Journal of cancer epidemiology. 2012; 2012: 835167. 13. All Party Parliamentary Group on Breast Cancer. Age is just a number: the report of the parliamentary enquiry into older age and breast cancer. 2013.   

‘‘Promoting Early Presentation’’ intervention

sustains increased breast cancer awareness in

older women for three years: A randomized

controlled trial

http://discovery.ucl.ac.uk/1522238/1/PEP%20year%203%20Manuscript%20UCLDisc.pdf

Promoting Early Presentation intervention sustains increased breast cancer awareness in older women for three years: A randomized controlled trial

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