Correspondence strategies and follow-up – Canadian Partnership Against Cancer

CORRESPONDENCE STRATEGIES AND FOLLOW-UP FOR BREAST SCREENING

Recall letters or other forms of communication are used to notify individuals who have been screened by the program in the past that they are eligible to return for screening. Individuals who have a normal screening result are invited back at regular intervals (as per provincial and territorial screening guidelines) for subsequent screening. Individuals who have an abnormal screening result are invited for follow-up.

4.1 Follow-Up After a Normal Mammogram

All provinces and territories, with the exception of Nunavut, send results letters to participants after a normal mammography result, and send follow-up recall reminders by mail or via phone call. Recall reminders are usually sent out at a 2-year interval, as recommended by the radiologist, or based on identified risk factors.

Table 8: Receiving Results and Follow-Up for Normal Breast Screening Test Results

	Receive normal results (✓)		Recall Method (✓)				Recall Interval (✓)
Jurisdiction	Mailed to participant	Sent to PCP/ healthcare provider	Recall mailed	Phone call	Process varies by site	No formal recall	1 – 2 years	2 years	Or based on radiologist recommendation	Or based on identified risk factors
YT	✓	✓	✓	✓			✓	✓	✓	✓
NT	✓		✓	✓				✓	✓	✓
NU*		✓ (varies by site)				✓
BC	✓	✓	✓	✓			✓			✓
AB	✓		✓					✓	✓
SK	✓	✓	✓					✓	✓	✓
MB	✓	✓	✓					✓	✓	✓
ON	✓	✓	✓					✓^
QC	✓	✓	✓					✓	✓	✓
NB	✓	✓		✓	✓ (phone call or letters)			✓	✓	✓
NS	✓	✓	✓					✓	✓
PE	✓	✓	✓					✓	✓	✓
NL	✓	✓	✓				✓		✓	✓

NU: * For screens done out of territory, would follow out of territory jurisdictional protocols
ON: ^In Ontario, most participants are recalled every 2 years; however, some participants are recalled in one year based on identified risk factors and/or radiologist recommendation.
Most provinces and territories send out reminder notifications via letter if no response was received after the first communication. Nine jurisdictions issue reminders if participants do not initiate screening after the first recall attempt.

Table 9: Breast Screening Reminder Notifications

Jurisdiction	Reminder notifications
YT	None
NT	Reminder letter sent to patient 2 weeks before the beginning of the month screening is due, second reminder letter sent 15 days after appointment is due if patient has not been seen or booked for a mammogram
NU	No organized screening program available
BC	A series of up to 3 postcards are sent over a 23-month period as reminder notifications
AB	Reminder letter is sent from the program once when >120 days overdue
SK	Reminder letter sent 2 weeks after initial invite if no appointment is booked.
MB	Reminder letter is sent 3 weeks after the invitation/recall letter if an appointment is not scheduled. If continued no response, a recall letter will be sent annually until response or participant ages out (75) of program. A maximum of 4 sets of letters (invitation, recall, and reminder) will be sent.
ON	Recall reminder letter sent by screening program approximately 10 weeks after the recall letter if screening is not initiated
QC	Recall reminder letter sent by screening program approximately 10 weeks after the recall letter if screening is not initiated
NB	None
NS	Reminder postcards are sent 3 months prior to the woman’s due date if screening appointment has not been scheduled. Email reminders are currently being explored.
PE	Reminder letter sent 5 months prior to women’s due date with an overdue letter 2 months following the women’s due date if screening is not initiated
NL	Appointment reminder letter sent to women 4 weeks prior to scheduled appointment. If a women books or changes her appointment within the 4-week window a reminder letter is not sent. Women are given their recall appointment to screening when they receive their result letter.

4.2 Follow-Up After an Abnormal Mammogram

All provinces and territories, with the exception of NU, send results letters to both primary care providers and participants after an abnormal (positive) mammography result, and many also follow-up with participants over the phone.
The location for conducting diagnostic mammograms after an abnormal result varies across Canada. Some jurisdictions conduct diagnostic mammograms at the screening centre/program while others conduct mammograms at diagnostic imaging centres or refer participants to Breast Risk Assessment units.
Table 10: Receiving Results and Follow-Up for Abnormal Breast Screening Test Results

Jurisdiction	Receive abnormal results	Follow up of abnormal results	Location of diagnostic mammogram after abnormal result	Return to screening?
YT	· Mailed to woman · Program may also contact women by phone depending on the follow up required (imaging)	· Program calls woman to arrange follow up appointments for imaging · If biopsy required, the woman must go back to her PCP for referral to biopsy or any other follow up	· Screening program	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist)
NT	· Women in the program receive a phone call as well as a letter	· Program calls woman to arrange follow up appointments for imaging · If biopsy required, the woman must go back to her PCP for referral to biopsy · Program notifies PCP that a patient requires biopsy	· Stanton Territorial Hospital or a facility in Edmonton, Alberta	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist)
NU	· Varies by site; generally sent to PCP who will contact woman to provide results	· PCP manages referrals for any follow up required
BC	· Participant receives phone call from diagnostic centre to book follow up · Results also sent to PCP and mailed to participant	· Diagnostic Centre books follow up and calls participant with appointments	· Affiliated Diagnostic imaging departments	· If follow up results are normal, participants are recalled for screening every 1-2 years per identified risk factor program policy
AB	· Most clinics notify PCPs and/or women in person or by phone. · Results also sent to PCP and mailed to woman	· Clinic or PCP contacts woman to arrange follow up · Some clinics book follow up directly (varies by site)	· If mammogram was completed at a facility that can do diagnostic mammograms, then usually done at that facility · Private clinics · Hospital facilities	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist)
SK	· Women receive results by phone, either from program (navigator) or their PCP	· Program navigator arranges follow up if given permission to do so by HCP (otherwise HCP will arrange follow up) · If program conducting follow up, they contact woman by phone to arrange appointments	· Diagnostic breast imaging centres (hospitals, private radiology clinics, and/or Breast Health Centres)	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist) · Women who are diagnosed with cancer return to regular screening once they have been cancer-free for five years although currently our software system does not re-invite them.
MB	· Women receive phone call from program to provide results · Results also sent by letter to participants and their healthcare provider	· Referral to diagnostic centre coordinated by program. Woman is advised of follow up appointment by program (phone).	· Diagnostic imaging centre	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist) · All women informed of their status (i.e., if they will be recalled for screening or are no longer eligible) by letter once diagnostic work up is complete
ON	· OBSP sites are expected to ensure that the participant’s PCP is informed of the abnormal breast screen results as soon as possible. · Participants’ receipt of abnormal results varies by site: some may call, others send letters, a few may liaise with the PCP who will contact participant to provide results.	· Follow up varies by site: some sites may coordinate appointments; at other sites the PCP may coordinate follow up · If participant does not have a PCP, the screening site will designate a physician who will manage follow up for the participant until diagnosis	· Program assessment sites (hospitals and independent health facilities) that conduct diagnostic imaging · Assessment sites outside of the program (hospitals and independent health facilities) that conduct diagnostic imaging	· If follow up results are normal, most participants are recalled for screening every 2 years
QC	· Mailed to woman · PCP or centre will contact woman to provide results	· Varies; women are directed to contact site or PCP in their results letter, some sites contact the woman proactively to arrange follow up	· Designated screening centres or Refence and diagnostic designated centres	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist)
NB	· Most sites contact women by phone	· Varies across sites, women typically referred automatically for diagnostic procedure	· Sites vary across zones	· Participants with an abnormal mammogram but no cancer diagnosis can return to the screening program and be re-invited for screening with a physician or nurse practitioner’s recommendation
NS	· Mailed to woman · Result letter e-faxed to PCP 3 days before letter sent to woman, so that PCP can notify woman of her abnormal results and of her follow-up appointment information.	· Program schedules follow-up appointments per radiologist recommendation; appointment information mailed to PCP and to women in results letters. · Booking process for needle core biopsy varies by site – some booked as per radiologist recommendation (without requisition), others require requisition from PCP	· Diagnostic breast imaging departments located in hospitals	· If follow-up results are normal, then women are recalled for screening every 2 years (or yearly if recommended by radiologist)
PE	· Notification of follow up imaging mailed to woman · Results letter mailed to PCP	· Notification through abnormal results letter l for follow up appointment · Woman is contacted by phone the day prior to appointment · If biopsy is required, the PCP contacts the woman	· Screening program & diagnostics performed at same 2 hospital sites · Biopsy at one site only	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist)
NL	· Mailed to woman · Results mailed to PCP 2 days before woman	· Program coordinates follow up testing appointments and provides to woman by mail along with abnormal results · Appointment with PCP may be made but is not required	· Diagnostic breast imaging departments located in hospital	· If follow up results are normal, women are recalled for screening every 2 years (or as recommended by radiologist or program protocols)

In the absence of a primary care provider, seven provinces help participants find a suitable primary care provider in order to follow up after an abnormal mammography result. Other jurisdictions require participants to have a primary care provider in order to be eligible for a screening mammogram.
When participants cannot be reached (e.g., mail is returned), most provinces and territories contact the primary care provider or obtain current contact information from the primary care provider.

Table 11: Process When Participants Do Not Have a Primary Care Provider or Cannot Be Reached

Jurisdiction	Process when participants do not have a PCP	Process when participants cannot be reached
YT	PCP Identified when booking the mammogram	Follow-up with PCP
NT	Participant must have a PCP to be screened. PCP identified when booking the mammogram.	YKBSP: Program Booking Coordinator will contact the patient by telephone if further imaging is required. If it is something that cannot be completed in Yellowknife a letter is sent to inform the PCP, who is responsible for the referral. If letter is returned the program will check electronic and hospital systems to confirm address and then call patient to confirm address with them. HRBSP: No specific policy. Program Coordinator will call the patient’s listed phone number if patient is from Hay River or Enterprise, if patient lives in an outlying community a call is placed to the community health centre/PCP.
NU	PCP identified based on jurisdiction where scan takes place
BC	Participant must have a PCP to be screened. PCP Identified at time of booking the mammogram.	Follow-up with PCP
AB	PCP usually identified when booking the mammogram. Program will assist participant with finding a PCP either before the screen or after an abnormal result.	Screen site will notify PCP
SK	Client navigator works with participant to find PCP. Program can also refer women to a healthcare provider who will manage follow up.	Follow-up with HCP for current phone number
MB	Program will assist participant to obtain a PCP though the provincial ‘Doctor Finder’ initiative in the result of an abnormal result. If a PCP cannot be obtained, Program Medical Lead will assume care of patient for follow up testing.	A result letter is mailed to the participant and their PCP (includes a notation the we have been unable to reach the participant by phone)
ON	If participant does not have a PCP, the screening site will designate a physician who will manage follow up for the participant until diagnosis.	Program site will notify PCP and help schedule a follow up appointment. Program site may also continue to call and/or send a letter to the participant, requesting them to follow up with the site.
QC	Voluntary Program PCP is assigned to the participant to manage follow-up	Program coordinators contacts participant or PCP 45 days (or less) after an abnormal screening test if no supplementary exam has been confirmed in the information system. If participant is still unreachable after 90 days, send registered mail.
NB	No official process. Approach varies by site.	No official process. Approach varies by site.
NS	In the event of an abnormal screening report, the program works with the coordinator of each screening site to get a local PCP in the area to accept the report	Central booking site will call the participant. If not successful, central booking staff will contact the PCP to obtain participant’s current contact info
PE	Provincial Coordinator (designate), or surgeon contacts the participant about follow-up	Follow-up with phone call to PCP
NL	Program will assist participant with finding a PCP, but will still screen women. Medical Director and Cancer Screening Pathway Coordinator work with women to ensure all follow-up is complete

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