Barriers and benefits of breast cancer prevention programs in Poland Bariery i korzyści programów profilaktycznych raka piersi w Polsce

Breast cancer is the leading kind of malignancy among women in Poland. Mammography is recognised as a non-invasive diagnostic technique; yet, there exists a notable deficiency in the frequency of routine preventative screenings among Polish women. The aim of this research was to address the following inquiries: why there is a lack of widespread participation among women in Poland in cost-free tests that have the potential to save their lives, and what factors might motivate their engagement in preventative programmes. In order to achieve this objective, a survey was undertaken. The early detection of breast cancer significantly enhances the likelihood of achieving a full remission. Although most Polish women are aware that they can take a preventive test, still too few women take a mammogram. There is a need for modifications to be made in the precautionary screening system in order to enhance women’s motivation to engage in preventive care.


INTRODUCTION
According to the National Cancer Registry, 17 511 women in Poland will develop breast cancer in 2020 (crude incidence rate 88/100 000, world-standardised incidence rate 50/100 000) [1].In the 21st century, early detection remains the most effective way to fight this cancer, which determines the success of treatment [2,3].

Bariery i korzyści programów profilaktycznych raka piersi w Polsce
With a non-invasive test such as mammography (MMG), breast cancer can be detected even before it becomes clinically apparent.And detecting the cancer just one stage earlier increases the chances of a complete cure by approximately 25% [2].According to the World Health Organisation (WHO), effective screening programmes have
Słowa kluczowe: skryning, rak piersi, nowotwory, profilaktyka raka piersi, mammografia reduced mortality from breast cancer in women by 25-45% over 8-10 years [4].According to the Council of the European Union recommendations of 2 December 2003 on screeningscreening as part of social health policy was targeted at women aged 50-69 years and offered mammography screening at two-year intervals [5].The new Council recommendations of 29 November 2022 suggest extending the age group to 45-74 years [6].Prior to the launch of the Population-based Early Cancer Detection Programme in Poland, a sharp increase in the incidence of breast cancer was observed [7], and the results of 5-year survival were unsatisfactory (particularly in relation to other European countries: Poland 73.9%, Sweden 86.3%, Iceland 93.4%) [8,9].Poland is one of the few countries in the European Union where breast cancer mortality is increasing, which is largely due to the fact that the cancers are detected too late.According to data from the Prevention Monitoring Information System (SIMP), several years after the launch of the population-based programme, it is still not possible to exceed the threshold of 70% of Polish women being screened.On 1 April 2023, 1,798,533 out of 5,422,420 Polish women aged 50-69 participated, representing 36% of the population [10].

MATERIAL AND METHODS
The orginal questionnaire survey was designed under the direction of the article's author and conducted by students of electroradiology at the Poznan University of Medical Sciences between June and August 2022.It involved 531 women aged 50-69 years (mean age 57.6).The aim of the survey was to ask about the reasons for not attending a preventive examination and to find out women's opinions on what would encourage them to attend such examinations.The students themselves searched for women willing to participate in the study throughout the Wielkopolska region.The prerequisite was gender (only women), age (between 50 and 69 years) and diversity of the group in terms of place of residence (urban, rural) and education (primary, basic vocational, secondary with upper secondary school certificate, higher education -at least a bachelor's degree).Participants were assured anonymity and the possibility to withdraw at any time from completing the questionnaire.They were also all informed about the aims and principles of the study.
By design, the survey questions were intended to be short and focused on two specific issues: • indicate the reasons for not undergoing a preventive examination, • suggest solutions that respondents felt would encourage women to get tested.

RESULTS
The largest group were women aged 50 (48), and the smallest -women aged 69 (9), Fig. 1.The study group was dominated In terms of education, the largest group were women from Wielkopolska with higher and secondary education (38% each), Fig. 2.

Impact of education and place of residence on survey participation
Only 48% of the respondents have performed a mammography test in the last 2 years (in urban areas 50%, in rural areas 45%).Regular participation in preventive examinations increases with education (41% primary education, 53% tertiary education), Fig. 3. Every fourth respondent does not perform breast self-examination (in rural areas 34% perform, 42% in urban areas; with primary education 59% do not perform, 17% with tertiary education (Fig. 4).The vast majority (87%) of respondents have heard that any woman aged 50-69 can take part in a prevention programme, a percentage not much influenced by place of residence (89% urban, 85% rural) or education (89% tertiary, 81% primary), Fig.

Barriers and benefits
Key to the study were 'arguments against [11]' (i.e.barriers) and "arguments for" (i.e.benefits).According to Professor Luszczynska's definition: 'Barriers are women's beliefs, feelings and thoughts that make it difficult for them to participate in a preventive study.Barriers make them reluctant to participate in such examinations, they do not plan to participate in the future, they do not feel motivated to engage in breast cancer prevention, they do not go for their first ever mammogram, and if they have participated in the past, they decide not to go for it again.The benefits, on the other hand, are women's beliefs, feelings and thoughts that make women feel motivated to attend screening mammography, intend to go for it, decide to attend again, regardless of past experiences with mammography want to attend regularly, etc.' [11].Barriers to participation in preventive screenings can be divided into individual barriers (which depend on women themselves) and organisational/structural barriers (which depend on women to a lesser extent).The multiple-choice cafeteria suggested 24 specific barriers (and one open-ended answer), and the same was true for the question on benefits.
When it came to barriers, the most commonly identified were: • lack of time, In an open question, 7 women mentioned what else discourages them from being tested: the belief that the disease will not affect them (breast cancer does not concern her), laziness, arrogant staff, the COVID-19 pandemic, one lady wrote about the fact that preventive examinations in general are not promoted effectively enough in Poland.Furthermore, she wrote that women are largely discouraged by a certain type of arrogance and the belief that if I don't get tested, I won't get sick.Too little motivation from women themselves.Lack of the habit of taking care of their health.One respondent thinks that women are discouraged by the indication of being over 50, it should be over 40.One respondent thinks her breasts are too small to be examined.
When asked what would encourage women to get tested, the most frequently mentioned items were: • the possibility of carrying out the examination in a GP surgery, • in the event of cancer detection, an easy and rapid further diagnostic and treatment pathway, • the opportunity to be examined by a gynaecologist and to receive a personal invitation by post (Figure 7).When the responses were grouped by subject area, it became apparent that: • 75 per cent of women would be encouraged by the possibility of having the test at a GP or gynaecologist's surgery, • 62% would be encouraged by receiving an invitation by post or directly from their GP, • for 33% if cancer is detected -easy and quick further diagnosis and treatment.
In an open-ended question, 8 women mentioned that they prefer breast ultrasound diagnostic to mammography: because it is more reliable (2 people), that they would do this test if it was painless (2 people), one mentioned the possibility of a free breast ultrasound at the same time as mammography, because in her opinion mammography alone is insufficient, it does not give a complete picture.Another suggested the possibility of screening mammography from the age of 35 to 90, as she feels that the age of 50-69 is very truncated.A similar suggestion was made by the last respondent, who wrote about information for women before the age of 50 that a breast ultrasound could be performed, e.g. by an oncologist who can refer for mammography, and abolishing the upper age range, as this misleads women into thinking they no longer need to be screened.One woman pointed out the cost of testing.
Interestingly, almost 87% of respondents believe that mammography screening is safe.This belief has a strong influence on performing or not performing the test (Fig. 8).
Electroradiology students were also interested in whether women knew who performs the mammography test?The correct answer (i.e.electroradiologist) was indicated by 76% of respondents.

DISCUSSION
During the European Economic Congress (25.04.2022), the then Minister of Health, A. Niedzielski, spoke about coming to the conclusion that in preventive examinations, voluntariness is not a good solution and it is necessary to build such mechanisms that will make prevention a kind of compulsion (occupational medicine).A similar view was expressed during this congress by the vice-chairman of the Parliamentary Health Committee, B. Piecha: "Prevention on the principle that we do not offer, we force certain things".In turn, the President of the Republic of Poland, A. Duda, during the inauguration of the "Healthy Life" project (3.06.2022), pointed out three conclusions reached by the Health Protection Council when analysing the state of health protection of Poles after the SARS-CoV-2 virus pandemic: -prevention and a healthy lifestyle are the most important remedies for the increasing number of illnesses and deaths caused by, among other things, cancer, -many Poles are unaware that they are ill and make little use of prevention programmes, -there is an insufficient level of health education among Poles, despite the fact that about 95% of therapeutic decisions are made by the patient himself.
A survey conducted among Wielkopolska women showed a great need to increase women's health awareness.The survey also confirmed that educated women and women with a higher socio-economic status know about examinations, perform self-examinations more frequently and attend preventive examinations.The knowledge of Polish women, especially the less educated ones, needs to be supplemented, e.g. through a large-scale, positive, well-thought-out and effective campaign to disseminate knowledge about breast cancer prevention, diagnosis and treatment in society.The strongest barriers to screening turn out to be fear and lack of knowledge.In order to increase the number of Polish women undergoing prophylactic screening, it is necessary to involve primary care physicians (PCPs) and outpatient specialist care (AOS) in taking appropriate action.The primary care physician and the gynaecologist were indicated by women as the authorities who could effectively invite them to undergo examinations; it is in these offices that they would like to have examinations.Obviously, it is not possible to place mammography equipment in every primary care or AOS office, but it is possible to invite a healthcare provider with a mammobile to a health centre (the study showed that participation in screening is influenced by the availability of screening -among rural residents, 34% had screening more than two years ago, which may mean that screening is highly dependent on the arrival of the mammobile).The decision not to send personal invitations by post seems to be definitely a wrong one.On the basis of positive examples, women need to be persuaded that early detection increases the chances of a cure that modern oncology can treat breast cancer effectively and that this treatment does not have to be mutilating (mastectomy).In the survey, it is encouraging to see an increase in confidence in the quality of mammography equipment -only 4% of respondents answered that they were discouraged from being tested by the fear that the test itself (mammography) would cause cancer.However, it must be remembered that this positive picture may be the result of recruiting a group of respondents from closer and further afield of electroradiology students.
Similar results were reached by the Oncology 2025 Foundation, which conducted a survey of 136 healthcare providers.Among the most common systemic reasons for low attendance at preventive screenings, it identified: lack of encouragement by PCPs (62%), failure to send invitations (54%) and lack of adequate publicity (46%).Among the reasons on the part of the patient are: low awareness of the nature and benefits of screening (64%), fear of detection of cancer (63%) and lack of care for their health (49%).Among the practical solutions that could improve screening attendance, the most frequently mentioned were: linking to employee screening (60%), being more active among PCPs (54%) and resuming sending invitations in the form of a letter (45%) [12].The We Patients Foundation, which conducted a survey on a group of 1,000 people, indicated among the most common reasons for not taking part in a preventive action that: the patient was not informed about prevention programmes by their doctor/nurse (20%), they did not know about the possibility of taking part in prevention programmes (17%), they did not want to (15%) [13].Participation in examinations would be encouraged by: sending invitations to preventive examinations, with agreement on the most convenient form of communication (letter, e-mail, SMS) (44%), handing an invitation to preventive examinations on the occasion of a visit to the PCP (34%), inclusion of examinations required for work (occupational medicine) preventive examinations for a specific age (31%).A. Prusarczyk et al., on the other hand, believes that the idea behind the current design of preventive care in Poland is suboptimal from start to finish.If everything, from the valuations, to the technology used, to the organisation, has been planned unprofessionally, then satisfactory results cannot be expected [14].In addition to poor organisation, we also have inadequate allocation of financial resources, lack of funding for individual stages and lack of identification and surveillance of groups at higher risk of disease, which should be the main task of primary care and outpatient specialist care (e.g.gynaecology).A viable overall strategy should be implemented, targets should be set, professionals should be hired, they should be entrusted with the organisation and allowed to operate fairly independently, and evaluation and control should be carried out.The vicepresident of the Board of the Medical and Diagnostic Centre Ltd., to which the percentage of requests for mammography and cytology reaches 85%, says that patients want to be invited to preventive examinations, but from their point of view, the invitation must be for an attractive package and the best form of invitation seems to be a telephone invitation [14].

CONCLUSIONS
For policy makers, prevention is important in the sense of a verbal statement, but much less so in the sense of effective action.The Polish patient exhibits a willingness to attend a medical examination, contingent upon receiving a comprehensive explanation from a healthcare practitioner about the rationale and benefits of undergoing such a procedure.[14].Coronavirus has left a demographic gap and an even bigger one in the health of the population.Prevention and treatment of conditions that have been neglected for two years would need to be addressed.Both infrastructural investments and organisational changes are needed.Unrealistic optimism, on the other hand, helps people cope with potential risks and protects their wellbeing.On the other hand, it may be inappropriate in life-threatening situations, as people underestimate the possibility of illness.As research shows, confidence in science is most strongly associated with the intention to take action and should, therefore, be an important component of communication campaigns to promote prevention.According to the concept of fear appeal, which refers to the role of fear in reinforcing protective behaviour -the threat generated by fear creates psychological stress and increases the willingness to engage in health-promoting behaviour.
There are increasing proposals to link preventive examinations to occupational medicine.There remains the problem of people who are unemployed but are receiving benefits.Furthermore, the granting of benefits cannot be made conditional on attendance at preventive examinations.This would mean taking away the individual's rights to selfdetermination.It should be borne in mind that according to WHO guidelines, as well as European standards, only if at least 70% of the population is covered by screening examinations should there be a 25% reduction in mortality of Polish women due to breast cancer (and benefits in the form of lower treatment costs, lower absenteeism from work, inability to work or death) [4,5].
Changes are therefore needed in the organisation of preventive examinations to motivate women to be screened and in the way decision-makers view prevention as an investment in health, rather than a cost and a broad distribution of responsibility for the state of implementation of programmes.

Fig. 1 Fig. 2
Fig. 1 Age distribution of female respondents participating in the survey.N=531 Source: Own elaboration

Fig. 5
Fig.5 Have you heard that any woman aged 50-69 can take part in a prevention programme that allows free mammograms once every 2 years without a referral?N=531 Source: Own study 5.
mary care doctor, gynaecologist or a lack of named invitations.Interestingly, only 8% of responses indicated that gifts would be an effective form of encouragement to get tested, 4% indicated that chocolate would encourage them to get tested.