Boosting Mammogram Screening Rates: What Really Works for Overdue Women?

Introduction

Breast cancer remains one of the most common cancers affecting women worldwide, and early detection through mammography is a cornerstone of reducing mortality. Most organized screening programs recommend regular mammograms every two years for women aged 50 to 69 years to detect early, often asymptomatic tumors. However, adherence to surveillance mammography—especially among women overdue for repeat screens—remains a significant challenge globally, including in countries with established screening infrastructures.

This gap in adherence represents a missed opportunity for early intervention and underscores an urgent need for effective, scalable strategies to re-engage women who have not kept up with recommended mammogram schedules. A recent randomized clinical trial conducted in Singapore explored various pragmatic behavioral interventions aimed at boosting mammogram uptake among overdue repeat screeners. The trial’s findings offer valuable insights for health systems, clinicians, and public health practitioners.

What the Data Tell Us: The Singapore Pragmatic Trial

This large-scale trial enrolled 9,000 women aged 50 to 69 years who were overdue for their biennial mammogram—defined as having at least one prior mammogram but not having undergone screening in the previous two years. Conducted in Singapore’s integrated tertiary hospital system from September to December 2024, participants were randomized into five groups that all began with a personalized mailed reminder (MR). The groups differed by additional interventions:

1. Group 1: Personalized mailed reminder (MR) only.
2. Group 2: MR plus a conditional US$7.50 voucher incentive.
3. Group 3: MR plus a conditional chance to win a US$3,750 lottery.
4. Group 4: MR plus motivational videos.
5. Group 5: MR plus access to a dedicated scheduling hotline.

Each group also received three push notifications through the hospital’s mobile health application spaced three weeks apart.

After three months, mammogram uptake rates were as follows:

Interestingly, women who were more than 10 years overdue showed slightly higher uptake in groups 2 and 5 (voucher and hotline) compared to reminders alone, though this did not reach conventional thresholds for statistical significance. Engagement with digital content such as motivational videos was low, with fewer than 5% viewing the webpages.

Moreover, when considering cost-effectiveness, the simple mailed reminder was more efficient than more resource-intensive interventions.

Understanding Barriers and Misconceptions

Non-adherence to mammogram screening has multifactorial roots. Common barriers include fear of radiation or cancer diagnosis, inconvenience, lack of awareness of current recommendations, and competing life priorities. Some women who have been overdue for long periods may also hold misconceptions that mammograms are not beneficial or necessary, especially if they are currently asymptomatic.

In this trial, additional behavioral nudges such as financial incentives or motivational media did not substantially improve screening uptake, suggesting that these may not overcome the more entrenched barriers or misinformation held by overdue populations.

Practical Approaches: What Works

The study reinforces the power of even simple interventions. A personalized mailed reminder was enough to prompt an 11.2% mammogram uptake among women who had lapsed in screening for years—an impactful result in a setting without a routine reminder system. This suggests that personalization and direct communication remain critical.

The minor improvements seen with a dedicated scheduling hotline suggest that reducing logistical barriers and providing tailored assistance may help some women, especially those long overdue. However, the cost and resource allocation required for these efforts should be carefully weighed.

Moreover, low engagement with motivational videos points to limitations in digital literacy or digital engagement preferences in this population segment. Health promotion strategies should consider preferred communication modes and cultural contexts.

Expert Insights and Commentary

Dr. Susan Carter, a breast oncologist not involved in the study, notes, “This trial is a powerful reminder that high-tech or high-cost interventions are not always the answer. Sometimes, the simple act of reminding a patient personally can bridge the gap to screening adherence. Health systems should not overlook the implementation of basic, reliable reminders as fundamental tools in cancer prevention efforts.”

Public health policy must balance innovation with practicality. As digitization expands, ensuring equitable access and engagement remains paramount.

Conclusions and Implications

This randomized clinical trial conducted in Singapore highlights that for populations overdue for mammography screening, a one-time personalized mailed reminder is a pragmatic, cost-effective way to improve uptake modestly. Additional behavioral interventions—financial incentives, lotteries, motivational videos, or scheduling hotlines—did not significantly enhance screening rates beyond reminders alone.

Health systems aiming to increase breast cancer screening among overdue women may consider focusing resources on establishing and maintaining simple, personalized reminder systems before investing in more complex interventions.

For women like Mary, a 63-year-old who had not had a mammogram in nearly seven years, receiving a clear, personalized reminder in the mail prompted her to schedule and complete her screening—potentially changing the trajectory of her health.

Funding and Trial Registration

The trial was conducted within the Singapore Ministry of Health’s integrated hospital system and funded through institutional public health research grants. The study is registered at ClinicalTrials.gov (Identifier: NCT06733155).

References

Lee SC, Lucky SS, Zhu J, Ow S, Loh L, Tan JH, Lim SE, Hairom Z, Mehta S, Tai BC, Goh BC. Pragmatic Interventions to Boost Surveillance Mammogram Uptake Among an Overdue Population: A Randomized Clinical Trial. JAMA Intern Med. 2025 Nov 10:e255873. doi:10.1001/jamainternmed.2025.5873. Epub ahead of print. PMID: 41212556; PMCID: PMC12603945.