Table 4. Overview of the synthesised findings: Intervention characteristics.
| Construct: | Sub-themes: | Illustrative quotes: |
|---|---|---|
| Intervention source | Views of stakeholders and the public should inform the intervention | “Participants identified individual beliefs about risk and knowledge of breast cancer and screening as key factors that will impact how women could respond to low-risk stratification. Participants felt this should guide the development of communication and information about a low-risk pathway to facilitate understanding.” [34]. |
| Concern about cost driving the intervention | “… people might be concerned that the reason this was being done was to save money, and not necessarily for a health benefit for the wider population, or particularly of benefit for the women of low-risk” (Academic) [34]. | |
| Evidence strength & quality | Concern about extending screening intervals for low-risk individuals | “I’m not aware that it’s possible to say that because you’re a low-risk woman, if you do get a cancer, it’s going to be that kind of cancer and not this kind of cancer” (Healthcare professional) [34]. |
| Stability and accuracy of variables included in risk models | “I’m just thinking about those who might think, right, okay, I’ve got a low-risk, but what if circumstances change? And sometimes they might have breast cancer in the family and they might not know, because a lot of women don’t tell.” (Cancer Screening Improvement Lead) [36] | |
| Relevance of risk models in different patients | “…genetic counsellors indicated they find RPMs generally easy to use, but not necessarily essential, because they often considered their experience and clinical judgement to be sufficient. Rather, they were concerned about the relevance of available RPMs and which of these to use for a particular patient.” [35] | |
| Relative advantage or disadvantage | Anticipated advantages of risk stratification | “They explained that the breast screening service receives criticism for the harms it can cause and that a risk-stratified service would go some way to address this perception: “I think we get criticised all the time for overtreatment and over diagnosis and we should be seen to be trying to personalise it a bit more, but we shouldn’t overthink it and overcomplicate it in the process.” (Consultant Radiologist)” [36] |
| Anticipated disadvantage of risk stratification | “…already the UK programme gets criticised for having three yearly intervals because most European programmes have a two-year interval and they feel that 3 years, there’s much less of a safety net. You know, if a cancer’s missed at one screen there’s still quite a good chance that it’ll be still at an early stage at the next one two years later. But if the next one’s three years later there’s a bit more concern. So, I would think there’s not that much point going beyond 4 years.” (Academic) [34]. | |
| Anticipated neutral impact of risk stratification | “… my sense of all of this is that what you’re doing is trying to increase the frequency for people, who are at higher risk and reduce it for people at lower risk […] I think probably in terms of screening visits, consultations and so on, the overall volume of work probably wouldn’t change all that much.” (Academic) [34]. | |
| Complexity | Concerns about time and resources | “Among the major obstacles to implementation acknowledged by both types of health providers was the lack of time for PCPs during a typical 20–25-min appointment. Many felt that there is simply not enough time to introduce the program, explain risks and benefits of participation, enter the data in BOADICEA, calculate the risks, and explain the test results.” [33] |
| Equity and ethical considerations | “Other participants were concerned that even if it were more feasible to introduce screening only to those entering the programme, this would create inequity of access given that all women would not have the opportunity of risk assessment.” [34] | |
| Lack of consensus around implementation | “There was no real consensus on how best to introduce a low-risk pathway aside from stressing the importance of obtaining the views of women themselves.” [34] | |
| Considerations for transitioning to risk stratification | “… do you start the new regime for just new women coming into the programme and continue the current policy for those existing in the screening programme? If you do that you create an inbuilt inequality and a two-tiered service. Or do you allow women the choice to be given a baseline test and then a new regime, or allow them to continue on their old one?” (Screening operations/management; 2027) [34]. | |
| Design quality & communications | A need for risk communication tools | “We must have good computerized medical records and the same for everybody, as well as governmental tools we can access in them. It should be integrated in our electronic system in which there is a tab for risk assessment. Once you have filled it up, it adds to the patient’s medical records. It would be ideal…” [35] |
| Considerations for communicating low risk | “I mean it’s quite a subtle message, isn’t it? For years and years we’ve been telling ladies you must go and have your screenings, and I think screening in the public mind is very much wrapped around screening is good always. I think it’s very hard to discuss subtleties of potential screening harms with people.” (GP) [36] | |
| Cost | “…the financial aspects for the healthcare system were also addressed: “Because of limited resources, it must be considered (…) whether it is actually necessary for us to screen all women” (public health service).” [31] |
BOADICEA–Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm
FG–focus group
GP–general practitioner
PCP–primary care provider/practitioner
RPM–risk prediction model
TI–telephone interview
UK–United Kingdom
Quotes in italics represent those from HCPs. Quotes that are not in italics represent those of the author.
HCPs roles have been included where available in the original paper.