Literature Review on Breast Cancer Research

Aashiyana Vadsariya

Introduction  

Evaluation is a process of reviewing of any programme, project or policy, its design and results. The main objective of doing evaluation is to measure the effectiveness of the programme or policy, its impact and sustainability. Evaluation helps to solve the problem as well as to build the knowledge and it enhances the decision making process and thus evaluation is an important part of quality improvement (The Health Foundation, 2015).

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There are different types of evaluation such as formative evaluation, outcome evaluation, process evaluation, impact evaluation and economic evaluation which can be conducted to ensure programme activities. Moreover, vigorous evaluation provides not only about intervention that is worked but it also describes why and how that allows an individual to discover new interventions in healthcare settings. Additionally, it involves ethical approval, collection and analysis of data (Centre for Disease Control and Prevention, 2015).

Background of the study

According to Ministry of Health (2015), Breast cancer is the third most common cancer in New Zealand. It causes more than 600 deaths every year. Breast cancer is most common over the age of 50 and risk of developing breast cancer increases as age increases. Approximate 80% of women are over 50 years of age who died because of breast cancer. There are 8 cases diagnosed with breast cancer every day, out of them 1 will be Maori and pacific women who are at higher risk of dying from breast cancer. Maori women are more likely to develop breast cancer about 33% than non-Maori women (The New Zealand Breast Cancer Foundation, 2013).

National Breast Cancer Foundation describes certain risk factors which increases the chance of developing cancer such as age, gender, positive family history, personal health history and genetic factors. Ministry of Health have started the programme called Breast Cancer Screen Aotearoa to fight against breast cancer by providing free breast screening to the women aged 45-69 years of age. The main objective of this programme is to reduce number of deaths from breast cancer by providing them regular screening (National Screening Unit, 2014).

This paper will critically evaluate five (5) research papers of breast cancer that were published worldwide focusing on their significance, methodology and quality and will analyse the four (4) audit and evaluation processes and approaches such as outcome, process, impact, economic evaluation from the evaluated breast cancer research papers.

Economic evaluation of the breast cancer screening programme in the Basque Country: retrospective cost-effectiveness and budget impact analysis.

This study evaluated the breast cancer early detection programme in Basque country in relation to cost effectiveness and budget impact from 1996 to 2011. The researcher has used population level and single cohort analysis methodology. Annual costs were taken into consideration for budget impact analysis. The results of this study showed that total cost of breast cancer screening program was 1,127 million euros and 6.7 million QALYs over the lifetime of the target population, bringing about a pickup of 8,666 QALYs for an extra cost of 36.4 million euros (Arrospide, Rue & Van Ravesteyn et al., 2016).

The researcher has finally summed up that the breast screening programme ran in Basque country was cost effective and as per determined budget impact. This study contributes to measure cost effectiveness of this breast cancer screening programme and evaluate its budget in order to decide the future of this programme.

A review of breast cancer awareness among women in India: Cancer literate or awareness deficit?

This study was conducted to assess the level of awareness about risk factors leads to breast cancer in Indian women and healthcare professionals through literature review. The researcher used bibliographic databases such as MEDLINE, SCOPUS, Cochrane database of systematic reviews and Cumulative Index to Nursing and Allied Health. The findings of the research suggested that total 7066 number of women between ages of 15-70 years reflected different level of awareness on risk factors such as family history (13-58%), obesity (11-50%) and reproductive history around 1-88% (Gupta, Shridhar & Dhillon, 2015).

Low cancer literacy on risk factors of breast cancer among Indian women and healthcare professional noted during research process irrespective of their socio-economic status and education was (Gupta, Shridhar & Dhillon, 2015). This study contributes to aware the nation about programmes and to improve the cancer literacy rate in India by engaging various stakeholders of society and health system.

National Breast Cancer Screening Programme, Singapore: Evaluation of participation and performance indicators.

The researcher evaluated participation rates and performance indicators in the National Breast Cancer screening programme in Singapore during this study. This study involved the use of retrospective evaluation approach by using the BSS system and the Singapore Cancer Registry data on women aged 40-69 screened in period of 2002-2009. The results showed that participation rate was more than 10% since 2005 and performance indicators (such as screen detection rates, small tumour detection rates, recall rates, accuracy and interval cancer rates were improved from 2002-2006 to 2007-2009 (Loy, Molinar & Chow, 2015).

This study indicated that there is room for improvement in participation rate in breast cancer screening in Singapore by providing screening packages, reducing screening cost and targeting underserved populations. This study contributes to improve the participation rate of breast cancer screening programme for the effectiveness of the BreastScreen Singapore by providing training opportunities to the healthcare professionals.

Impact of mammographic screening on ethnic and socioeconomic inequities in breast cancer stage at diagnosis and survival in New Zealand: a cohort study.

This study was conducted to determine the impact of differences in rates of mammographic screening on inequities in cancer stage at diagnosis and survival between Maori and Pakeha women. The researcher used Waikato Breast Cancer Register and the National Screening Database to compare the data for diagnosis and survival between screen detected and non screen detected breast cancer by socio-economic status and ethnicity. The results indicated that there were lower rate of screen detected cancer in Maori women and also they had lower 10 year breast cancer survival rate as compared to Pakeha women (46.5% vs. 73.2%) (Seneviratne, Campbell & Scott, et al., 2015).

The study determined that lower rate of screening detected breast cancer was the important reason for lower rate of survival for Maori women in comparison to European women. This study contributes to assess the screening rates, to improve the survival for Maori women and to reduce inequity for the breast cancer survival among Maori and New Zealand European women.

An ongoing case-control study to evaluate the NHS breast screening programme

This research was carried out to evaluate the national breast screening programme in England. This study estimated the effects of the national breast screening programme in regards to breast cancer incidence, mortality and over-diagnosis of breast cancer. The researcher has used quantitative methodology and retrospective case control study to describe the policy on mammographic screening. The findings suggested that there is decrease in incidence by screening, excess risk of disease in screened ages from 47-54 years and potential deficit in risk seen between the ages of 65-69 years up to 15 years of screening (Massat, Sasieni & Parmar et al., 2013).

This research concluded that case control evaluation strategy relates the clinical endpoints to the screening history. This study contributes to measure the effectiveness of the national breast screening programme in England, benefits on mortality from and on incidence of invasive primary breast cancer and harms from over-diagnosis.

Audit and Evaluation processes

Economic evaluation of the breast cancer screening programme in the Basque Country: retrospective cost-effectiveness and budget impact analysis.

Economic evaluation is one of the most important forms of evaluation which measures the expenditure and their consequences and also describes about allocation of the resources (Cunningham, 2000). In this research, the researcher has used economic evaluation to measure cost effectiveness of the breast cancer screening programme in the Basque Country from 1996 to 2011. This study was mainly based on budget impact analysis and retrospective cost effectiveness evaluation to determine what resources are being used in programme and their costs as compare to outcomes (Arrospide, Rue & Van Ravesteyn et al., 2016).

Economic evaluation in this research took a step back and looked objectively in context to appropriate role and use of cost effective analysis in order to determine the outcome of the breast cancer screening programme. This research revealed that the breast screening programme was found to be cost effective within determined budget impact (Arrospide, Rue & Van Ravesteyn et al., 2016).

A review of breast cancer awareness among women in India: Cancer literate or awareness deficit?

Outcome evaluation identifies the effects of the programme in target populations by reviewing effectiveness of programme (Centre of Disease Control and Prevention, 2015).The researcher used outcome evaluation to determine awareness levels of risk factors for breast cancer among women and healthcare professional in India. This outcome evaluation was undertaken through a structured literature review by using bibliographic databases journals (Gupta, Shridhar & Dhillon, 2015).

The main purpose of this outcome evaluation in this study was to assess the cancer literacy among women in India because of the rising incidence and mortality rates from breast cancer. Furthermore, the researcher concluded that there was a low literacy rate among Indian women regarding risk factors that causes breast cancer through this evaluation study (Gupta, Shridhar & Dhillon, 2015).

National Breast Cancer Screening Programme, Singapore: Evaluation of participation and performance indicators.

Process evaluation was conducted to assess how this breast screening programme is being implemented whereas outcome evaluation was conducted to measure the outcome and effectiveness of this programme (NYS Health Foundation, 2016). The researcher used outcome and process evaluation to evaluate the participation rates and performance indicators in the National Breast Cancer Screening programme in Singapore. Data was collected on women aged 40-69 screened during period of 2002-2009 from the BreastScreen Singapore and Singapore Cancer Registry (Loy, Molinar & Chow, 2015).

Process and outcome evaluation was helpful to determine the rate of participation and performance indicators, to measure the quality of the programme delivered and to assess the effectiveness of the breast screen Singapore programme. This evaluation allows researcher to examine the performance of this Breast Screen Singapore programme and to recommend further changes if required.

Impact of mammographic screening on ethnic and socioeconomic inequities in breast cancer stage at diagnosis and survival in New Zealand: a cohort study.

Impact evaluation measures whether the programme is effective in achieving its goal or not. Generally, it identifies long term effects and changes in outcome based on cause and effect analysis (Collins, 2017). The researcher utilised impact evaluation to determine the impact of mammographic screening on ethnic and socio economic inequities in breast cancer stage at diagnosis and survival between Maori and European women. The researcher collected data by using National Screening Database and Waikato Breast cancer Register (Seneviratne, Campbell & Scott, et al., 2015).

Impact evaluation was carried out to measure the impact of screening programme on ethnic and socio economic inequities for breast cancer survival rate which can be useful for government to take necessary actions and to form policies in healthcare settings to reduce inequalities in health.

An ongoing case-control study to evaluate the NHS breast screening programme

Process evaluation determines the effectiveness of the programme and how well the programme is working (Community Interventions for Health, 2017). The researcher used process and impact evaluation to evaluate the national breast screening programme in England. Impact evaluation was helpful to identify the impact of breast cancer screening on breast cancer incidence and mortality. Data was gathered by traditional retrospective case control study of deaths and incidences cases of breast cancer in England within 2 years of period during this ongoing evaluation (Massat, Sasieni & Parmar et al., 2013).

The main purpose of impact evaluation is to see that breast cancer screening programme is working effectively and is doing well than harm. Process evaluation can help to ensure that the breast screening programme continues to deliver the predicted health benefits and potentially improve the programme by assessing the good and bad practices.

Evaluative Model

The (CIPP) model

The CIPP evaluation model is developed by Stufflebeam in 1983 which provides comprehensive framework for the evaluation of the programmes. The CIPP model consists of four components which are context, Input, Process and product evaluation. The CIPP model mainly focuses on improvement of the programme rather than justifying about the programme. The main purpose of this CIPP model is to offer critical and rational basis for the programme decision making by applying different aspects of this evaluation model according to the needs of decision makers and programme activities based on the planning and implementation for the continuous improvement of the programme (Kellaghan & Stufflebeam, 2003).

The context, input and process evaluation approach are based on formative evaluation whereas product approach is useful for summative evaluation study. The four elements of the evaluation model must be taken into consideration otherwise it could reduce the effectiveness of the project. The context evaluation study can be conducted when a new programme is being planned which helps to identify the program goals and objectives by assessing needs whereas the input evaluation study can be conducted during resource allocation to assess the feasibility or the cost effectiveness of the alternate approaches. It provides systematic approach to programme design and helps the evaluators and experts to develop the programme which is most likely to work better (Frye & Hemmer, 2012).

Source: Adapted from Stufflebeam's CIPP Evaluation Model (1983). Retrieved from http://arcmit01.uncw.edu/jonesi/Evaluation.html

The process evaluation helps the evaluators and stakeholders to assess the implementation of the programme and to interpret the outcomes of the programme through document review, observation and participant interview. On the other hand, the product evaluation is similar to outcome evaluation which focuses on assessing the outcomes of the programme including positive or negative, short term or long term outcomes. In general, the CIPP model provides information about improvement of the programme, interpretation of the programme outcomes and information for accountability. However, careful planning is needed while applying this model. This model is useful for retrospective evaluation of a completed programme (Kellaghan & Stufflebeam, 2003).

This evaluation model can contribute to measure the effectiveness of the breast cancer screening programme run by Ministry of Health in New Zealand. The four elements of the model can be used to improve the programme by identifying the non-compliance of women for the breast screening programme. Auditing and evaluating the breast cancer screening programme helps to know the barriers and promote the awareness regarding breast cancer to provide beast quality care services to the New Zealanders. Furthermore, staying healthier is one of priorities of the Ministry of health. It can be achieved through evaluating the programme and implementing a change accordingly if needed.

Conclusion

Evaluation research is an essential tool to evaluate the effectiveness of the programme or to know how well the programme is working. Evaluation research helps managers and stakeholders of the organisation to improve the performance of the organisation and to provide the quality care health services. Staff and clients can be encouraged to provide useful feedback about the programme which helps in decision making and policy formation about the programme and thus improving the services provided by organisation.

References

Arrospide, A., Rue, M., Van Ravesteyn, N. T., Comas, M., Soto-Gordoa, M., Sarriugarte, G., & Mar, J. (2016). Economic evaluation of the breast cancer screening programme in the Basque Country: retrospective cost-effectiveness and budget impact analysis. BMC Cancer, 16(1). doi:10.1186/s12885-016- 2386-y

Centre for Disease Control and Prevention. (2015). Types of evaluation. Retrieved from https://www.cdc.gov/std/Program/pupestd/Types%20of%20Evaluation.pdf

Collins, K.B. (2017). What is Impact Evaluation. Retrieved from http://programs.online.american.edu/online-graduate-certificates/project- monitoring/resource/what-is-impact-evaluation

Community Interventions for Health. (2017). Process Evaluation. Retrieved from http://www.oxha.org/cih_manual/index.php/process-evaluation

Cunningham, S.J. (2000). Economics: Economic evaluation of healthcare - is it important to us? Retrieved from http://www.nature.com/bdj/journal/v188/n5/full/4800444a.html

Frye, A. W., & Hemmer, P. A. (2012). Program evaluation models and related theories: AMEE Guide No. 67. Medical Teacher, 34(5), e288-e299. doi:10.3109/0142159x.2012.66863

Gupta, A., Shridhar, K., & Dhillon, P. (2015). A review of breast cancer awareness among women in India: Cancer literate or awareness deficit? European Journal of Cancer, 51(14), 2058-2066. doi:10.1016/j.ejca.2015.07.008

Kellaghan, T., & Stufflebeam, D. L. (2003). International handbook of educational evaluation. Dordrecht: Kluwer Academic Publishers. Retrieved from http://link.springer.com/chapter/10.1007%2F978-94-010-0309-4_4

Loy, E. Y., Molinar, D., Chow, K. Y., & Fock, C. (2015). National Breast Cancer Screening Programme, Singapore: Evaluation of participation and performance indicators. Journal of Medical Screening, 22(4), 194-200. doi:10.1177/0969141315589644

Massat, N. J., Sasieni, P. D., Parmar, D., & Duffy, S. W. (2013). An ongoing case- control study to evaluate the NHS breast screening programme. BMC Cancer, 13(1). doi:10.1186/1471-2407-13-596

Ministry of Health. (2015). Breast Cancer. Retrieved from http://www.health.govt.nz/your-health/conditions-and-treatments/diseases- and-illnesses/breast-cancer

National Screening Unit. (2014). BreastScreen Aotearoa. Retrieved from https://www.nsu.govt.nz/breastscreen-aotearoa/about-breast-screening- programme

NYS Health Foundation. (2016). Process Evaluation. Retrieved from http://nyshealthfoundation.org/our-grantees/grantee-resources/process- evaluation

Seneviratne, S., Campbell, I., Scott, N., Shirley, R., & Lawrenson, R. (2015). Impact of mammographic screening on ethnic and socioeconomic inequities in breast cancer stage at diagnosis and survival in New Zealand: a cohort study. BMC Public Health, 15(1). doi:10.1186/s12889-015-1383-4

The Health Foundation. (2015). Evaluation: what to consider. Retrieved from http://www.health.org.uk/sites/health/files/EvaluationWhatToConsider.pdf

The New Zealand Breast Cancer Foundation. (2013). New Zealand Breast Cancer Facts. Retrieved from http://nzbcf.org.nz/BREASTCANCER/Overview/BreastCancerinNZ/Fastfacts.a spx