Table 2.

Thematised facilitators to uptake of risk reducing surgeries

Themes	Facilitators	Quotes
	RRESDO
Surgical complications; satisfaction with treatment choices	Positive experience with previous surgery	‘…the trade-off between having two surgeries as opposed to one, that does feel absolutely fine to me, and that’s maybe because I've had positive experiences with surgery before.’ (ID-18)
Menopause; satisfaction with treatment choices	Flexible timing of delayed oophorectomy	‘I know that there is no guarantee that it prevents ovarian cancer but I see it as being a positive thing I can do for myself for now, at my age and I know that if I had any concerns in the future, even before I hit menopause, that I could come back and approach you about having my ovaries removed, no-one’s telling me, “If you have your tubes out, you have to wait X, we won’t take your ovaries out for this”, so I think everyone’s been very open to discussing it and it’s been very focused around how I feel and what I want, which is very encouraging.’ (ID-16)
Menopause; satisfaction with treatment choices	Avoiding early menopause	‘…what I was most interested in was the fact that it would be two-step because I feel personally, I'm too young to be put into menopause, I don’t want to go down that road.’ (ID-03)
Menopause	Avoiding the need to take HRT	‘I'd rather just have a little surgery and deal with that for a small amount of time than have to take HRT all the time, I'm quite loathed to take drugs really.’ (ID-16) ‘I was worried about the financial implications of having to take something for life.’ (ID-18)
Menopause; satisfaction with treatment choices	Concerns HRT may not adequately alleviate menopausal symptoms and improve QoL	‘…HRT perhaps hasn’t worked out quite as expected or planned or it’s needed a lot of tweaking or maybe they haven’t received the level that they’ve needed to and, they haven’t regretted the decision because actually they’ve reduced their risk but they’ve actually noticed a significant drop in their quality of life that they didn’t actually expect. And, I think it’s really important for people to know that that might happen…’ (ID-05)
Cancer risk reduction: surgical choices; satisfaction with treatment choices	To reduce anxiety of doing nothing	‘Sometimes you just have to make a decision between two difficult things, where you don’t really want to do either of them and doing something is better than doing nothing…’ (ID-16)
Cancer risk reduction: surgical choices	Empowerment	‘…I just see it as being something positive that I can do for myself, to hopefully reduce my risk of cancer.’ (ID-08)
Cancer risk reduction: surgical choices; sequence of ovarian and breast prophylactic surgeries; satisfaction with treatment choices	Stronger FH of BC than OC	‘There’s more breast than ovary cancer in my family, so I’m probably at higher risk of breast cancer.’ (ID-18)
Fertility	Childbearing complete	‘I have finished having children so it was an easy decision to make.’ (ID-06)
	RRSO
Surgical complications	Single surgery and concerns over future health	‘…I think while you’re fit and well, it’s the time to have surgery. The longer you wait, who knows what happens when you get older.’ (ID-13)
Surgical complications	Straightforward day case surgery	‘…it (salpingo-oophorectomy)sounds like quite a straightforward minor operation and I can go home the same day…’ (ID-13)
Cancer risk reduction: surgical choices	Wanting maximum OC risk reduction	‘I just want the surgery that will protect me from developing ovarian cancer the most.’ (ID-22)
Menopause	Taking HRT acceptable	‘I don’t have any issue taking HRT.’ (ID-20)
Cancer risk reduction: surgical choices	Strong family history of OC	‘So many of my relatives have died from ovarian cancer.’ (ID-23)
Fertility	Childbearing complete	‘I’m finished having children.’ (ID-20)
Cancer risk reduction: surgical choices	No NHS OC screening programme	‘There is no screening on the NHS for ovarian cancer and that means my only other option is to have my ovaries out.’ (ID-20)
Cancer risk reduction: surgical choices	Inability to self-examine ovaries	‘From the very beginning I felt I was more concerned more about the ovarian cancer risk than the breast cancer risk, because I felt like I could effectively examine my own breasts and keep a check on that, but I can’t check my ovaries.’ (ID-04)
Cancer risk reduction: surgical choices	Poor OC prognosis	‘…it’s very hard to detect ovarian cancer and it has a very poor prognosis, it seemed to make complete sense.’ (ID-04)
Support with decision making; cancer risk reduction: surgical choices; sequence of ovarian and breast prophylactic surgeries	Physician recommendation	‘Counselling from my doctor really helped. She was knowledgeable, supportive and sympathetic of my situation. She recommended surgery as I have had all my kids, am 46 and because my aunt died of ovarian cancer at 45.’ (ID-04)
	RRM
Cancer risk reduction: surgical choices	BC screening anxiety	‘I never went away thinking, “I've got the all clear”, I went away feeling like, “As far as anyone can tell I've got the all clear”, and then the anxiety would start to rise again as we headed towards the next five month [screening] mark point when I could see it looming in the diary.’ (ID-13)
Fertility	Completion of childbearing and breast feeding	‘I have finished having kids, so I don’t really need them anymore.’ (ID-02)
Cancer risk reduction: surgical choices; sequence of ovarian and breast prophylactic surgeries	Strong FH of BC	‘I know that the risk is greater for cancer in the breast as compared to the ovaries because of my family history.’ (ID-02)
	Combined breast and ovarian cancer prevention surgeries
Sequence of ovarian and breast prophylactic surgeries	Fewer surgeries	‘Just throw everything at it, and let’s just get it all sorted in one.’ (ID-11)
Sequence of ovarian and breast prophylactic surgeries	Less anxiety associated with waiting for individual surgeries	‘It’s stressful waiting for all the appointment to see different specialists at different times. I would be happier if I could have got it all sorted in one go.’ (ID-05)
Sequence of ovarian and breast prophylactic surgeries	Fewer hospital appointments	‘The fewer times I need to visit hospital, the better.’ (ID-05)
Sequence of ovarian and breast prophylactic surgeries	Less delays waiting for individual surgeries	‘I guess there’s no thinking of delaying one or the other, if I've made a decision to reduce my risk, I think it would make sense to do them both at the same time.’ (ID-22)
Sequence of ovarian and breast prophylactic surgeries; support with decision making	Less time off work	‘I’m self employed, so the less time off work, the better.’ (ID-22)
Sequence of ovarian and breast prophylactic surgeries	Single postoperative recovery	‘I would prefer to recover just once from surgery.’ (ID-18)
Sequence of ovarian and breast prophylactic surgeries; fertility	Childbearing complete	‘Because I’m done having kids, I just want it all out.’ (ID-23)

BC, breast cancer; HRT, hormone replacement therapy; OC, ovarian cancer; QoL, quality of life; RRESDO, risk-reducing early salpingectomy with delayed oophorectomy; RRM, risk-reducing mastectomy; RRSO, risk-reducing-salpingo-oophorectomy.