Breast cancer remains a major health concern, accounting for a quarter of all cancer diagnoses among women globally. Population-based mammography screening programmes (PMSPs) have become a cornerstone of early detection strategies. To increase participation, many European initiatives, including the Flemish PMSP, use pre-scheduled appointments. While this approach boosts attendance, it also leads to no-shows, causing inefficiencies. As a potential solution, requiring appointment confirmation has been introduced in some regions. However, the impact of this requirement on participation rates varies. A recent non-interventional study in Flanders examined whether mandatory confirmation affects attendance, with implications for how to best allocate resources while preserving equitable access.
Diverging Impacts by Screening History
The study analysed 291,127 eligible women aged 50–69 invited to participate in the Flemish PMSP between June 2022 and May 2023. Invitations either required confirmation of the pre-scheduled appointment or did not mention confirmation. Participants were stratified by screening history into four categories: first-time invitees, regular attendees, irregular attendees and non-attendees. This stratification allowed a more precise evaluation of the impact of mandatory confirmation across different behavioural profiles.
Findings revealed that first-time invitees were significantly deterred by the confirmation requirement. Attendance within 60 days of the appointment was 19% lower for this group when confirmation was required. In contrast, the other three groups showed only minimal or statistically nonsignificant changes in attendance. This suggests that while the additional step of confirmation can pose a barrier for newcomers, it has little to no impact on those with prior screening experience. These differences may reflect varying levels of familiarity and confidence with the screening system.
Operational Considerations and Resource Optimisation
Screening units face a delicate balance between optimising their resources and maximising participation. No-shows disrupt scheduling and waste time and staff availability. By encouraging or requiring confirmation, units can reduce uncertainty and allocate appointments more effectively. However, blanket policies mandating confirmation may unintentionally reduce access for certain population segments, particularly those unfamiliar with the process.
The Flemish PMSP addressed this challenge by allowing screening units to choose among three invitation formats: no confirmation, appreciated confirmation or obligatory confirmation. For those using the mandatory format, women who arrived without confirming were still screened or rescheduled within the same week. Despite these accommodations, the requirement still led to reduced participation among first-time invitees, implying that the barrier lies in the psychological or logistical burden of the confirmation step itself, rather than enforcement strictness.
Moreover, attendance patterns highlight that many screenings occur outside the originally scheduled day. This reinforces the importance of analysing attendance within a broader timeframe rather than focusing solely on punctuality. Notably, over 95% of women who will participate within a year do so within 60 days, validating the study’s chosen outcome metric.
Implications for Screening Policy and Practice
The results offer a compelling case for tailoring confirmation requirements based on screening history. Given the negligible impact on women with previous participation, units could target confirmation protocols to this group without fear of reducing attendance. Conversely, exempting first-time invitees from such requirements could maintain or even improve initial participation rates, which are crucial for building long-term engagement with the programme.
Beyond confirmation protocols, the study underscores the value of using historical data to inform programme design. By leveraging past participation and socioeconomic indicators, the Flemish PMSP stratifies invitations and predicts attendance likelihood. This enables nuanced strategies that account for demographic diversity and behavioural tendencies, further enhancing efficiency and inclusivity.
Nevertheless, the findings must be interpreted within the study’s limitations. At the same time, the matching process controlled for key covariates, but unmeasured factors such as health literacy or cultural attitudes were not accounted for. In addition, rescheduling by some participants in the confirmation group may have inadvertently fulfilled the confirmation requirement, potentially underestimating the true impact of the mandate. Despite these caveats, the large, population-based cohort and stratified approach lend strength to the conclusions.
Conclusion
Requiring confirmation of pre-scheduled appointments in breast cancer screening can improve operational efficiency, but may come at the cost of lower participation among first-time invitees. To preserve equitable access while managing resources effectively, screening units should consider limiting confirmation requirements to women with previous screening experience. This differentiated approach aligns operational needs with participant behaviour, supporting both programme effectiveness and public health equity.
Source: European Journal of Public Health
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