Population notification about mammographic breast density is expanding internationally, with widespread adoption in some countries and policy discussion in others. Against this backdrop, a multisite randomised controlled trial embedded in Queensland’s BreastScreen programme examined immediate psychosocial effects of telling women their breasts are dense and explored resulting intentions to seek healthcare. Women aged 40 years and older with automated categories corresponding to higher density were allocated to standard care without density notification or to notification accompanied by written information or a link to video information. Outcomes after eight weeks focused on anxiety, confusion and perceived ability to make decisions, along with intentions to consult a general practitioner (GP), consider supplemental screening and alter mammography frequency.
Trial Design and Participants
The trial operated across 13 BreastScreen sites. Of 39 422 invitees, 12 183 consented, and 3107 women were randomised equally to three groups. After loss to follow-up, 2401 participants were included in the primary analysis at eight weeks. The mean age at baseline was 57.4 years. Baseline characteristics were similar across groups, including density distribution, previous screening, self-rated health and health literacy.
Notification letters in the intervention arms stated that no sign of breast cancer was found on the recent mammogram but that the screening showed dense breasts, described as common. The written and video materials explained the meaning of density and its potential implications, using content co-designed by a multidisciplinary team and presented at a grade 8 reading level. Letters were sent 4–6 weeks after screening and the online questionnaire was administered at eight weeks, aligning measurement across groups.
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Psychosocial Impact and Care Intentions
Compared with standard care, notification was associated with higher odds of feeling anxious and confused at eight weeks. The addition of written material or a video link did not improve the proportion of women who felt informed to make decisions about breast health. The pattern indicates that notification itself, rather than the format of supplemental information, primarily shaped emotional responses and perceived readiness.
Notification shifted intentions towards primary care. Plans to talk to a GP about screening results were more common in the notified groups than in control, with 22.8% in the written arm and 19.4% in the video arm compared with 12.9% in standard care. More women in the notified groups also reported being unsure about consulting a GP. Reliance on GPs for advice about supplemental screening rose after notification across both formats.
Intentions to pursue supplemental screening remained low overall. Declining further tests was common across groups, ranging from 78.9% to 91.3%. The proportion intending supplemental screening increased modestly with notification to 2.7% with written information and 3.2% with video, compared with 1.5% in control. Most women anticipated no change in future mammography frequency, although the video arm showed a small increase in those expecting to screen more often.
Knowledge Gains and Communication Quality
Objective knowledge about breast density improved with notification. Both written and video formats led to higher knowledge scores than standard care, with the written format outperforming the video on the total score. Nevertheless, perceived ability to make decisions did not increase, highlighting a gap between measured knowledge and subjective confidence in decision-making.
Perceptions of understandability and accessibility of the results letters were generally high but lower in the notified groups compared with control. Differences between written and video formats were not evident for the primary psychosocial outcomes, reinforcing that the act of notification was the key driver of emotional impact. Engagement with the optional video was limited: only 6.3% of women in the video arm accessed and watched it in full, suggesting that supplementary online content alone may not be sufficient to address concerns or uncertainty provoked by notification.
Within a population breast screening programme, notifying women that they have dense breasts increased anxiety and confusion at eight weeks, did not enhance perceived decision-making readiness and redirected intentions towards consulting GPs, while most did not plan supplemental screening. Notification improved objective knowledge yet coincided with lower perceived understandability and accessibility of communications. The results indicate potential additional demand in primary care following density notification and suggest that changing the information format did not mitigate the primary effects. Longer term follow-up will clarify whether stated intentions translate into service use and how any resulting changes affect programme delivery.
Source: BMJ
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