The recent push to educate women about the effects of breast density on breast cancer screening may not be as effective as was hoped due to poor understanding of the notifications sent to them, according to a research letter published in JAMA.
The researchers looked at the laws requiring dense breast notifications (DBNs) that went into effect as of January 1, 2016. Much of the legislation sets out the exact language that must be used in the DBN. They measured the readability of the DBNs using both the Flesch-Kincaid reading grade level in Microsoft Word (range: theoretical lower bound, -3.4; no upper bound) and the Dale-Chall readability score (range ≤ 4 to ≥ 16). The Patient Education Materials Assessment Tool (range, 1% to 100%) was used to measure understandability. Further, the researchers acquired data on the proportion of adults who lacked basic prose literacy skills in the researched states.
Overall there were 24 states that required a DBN; letters from all except Delaware were analyzed. For 19 states (83%) the letters contained specific language mandated by the state legislature; only certain components required by the legislature were included in the DBN from the other 4 states (17%). Thirty percent of the states required that a generic DBN be provided to any woman who received a screening mammogram. The other states only require notification of women who were found to have dense breasts.
All of the DBNs mentioned increased cancer risk; 17 mentioned the link between breast density and increased cancer risk; and 15 of the DBNs mentioned supplemental screening. Of the 15 DBNs that mentioned additional screening, 6 said that further screening may provide a benefit and 4 mentioned specific modalities.
In terms of understandability, the DBNs had a Flesch-Kincaid readability level that ranged from 7 to 19.4 (average, 11.1), in excess of the recommended reading level of grades 7 – 8. A similarly high range was seen with the Dale-Chall readability score. None of the DBNs scored well with the Patient Education Materials Assessment Tool. Only 3 states had a DBN with a readability level of grade 8 or less and the states with the highest readability grade levels on the DBNs were likely to have the lowest literacy levels.