Barriers to Implementation of Breast Cancer Risk Assessment: The Healthcare Team Perspective

ABSTRACT:

Purpose:

To assess healthcare professionals’ perceptions of barriers to utilization of breast cancer risk assessment tools in the public health setting through a series of one-on-one interviews with healthcare team members.

Methods:

We conducted a cross-sectional qualitative study consisting of one-on-one semi-structured phone interviews with healthcare team members in the public health setting in the state of Tennessee between May 2020 and October 2020. An iterative inductive/deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual framework to depict influences of provider behavior in utilization of breast cancer risk assessment.

Results:

A total of 24 interviews were completed and a framework of influences of provider behavior in utilization of breast cancer risk assessment was developed. Participants identified barriers to utilization of breast cancer risk assessment (knowledge and understanding of risk assessment tools, workflow challenges, and availability of personnel); patient-level barriers as perceived by healthcare team members (psychological, economic, educational, and environmental); and strategies to increase utilization of breast cancer risk assessment at the provider-level (leadership buy-in, training, supportive policies, and incentives) and patient-level (improved communication and better understanding of patients’ perceived cancer risk and severity of cancer).

Conclusions:

Understanding barriers to implementation of breast cancer risk assessment and strategies to overcome these barriers as perceived by healthcare team members offers an opportunity to improve implementation of risk assessment and to identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.

Article Summary Sentence:

Understanding barriers to implementation of breast cancer risk assessment offers an opportunity to increase risk assessment uptake and identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.

INTRODUCTION:

Early screening for breast cancer in high-risk women improves breast cancer morbidity and mortality.^1–3 Breast cancer risk assessment (RA) is an evidence-based practice that offers an opportunity for healthcare providers to identify women at high risk for developing breast cancer.^4–9 The American College of Radiology and American Society of Breast Surgeons recently issued recommendations for women to have breast cancer RA performed no later than age 30 to ensure they are provided screening at appropriate levels.^10,11 Yet, while breast cancer RA tools are widely available, they are not used routinely in standard clinical practice.¹² This gap in evidence-based practice may lead to missed opportunities to identify women at high risk for breast cancer who should be screened at an earlier age.

Healthcare providers perform breast cancer RA by gathering information from a patient about her personal and family medical history and clinical breast history through a brief conversation. Providers can simultaneously use an electronic tool that immediately calculates a woman’s lifetime risk of breast cancer.^4–9 Women identified at high risk for breast cancer (lifetime risk greater than 20%) should be offered guideline-based screening mammography at earlier ages than that recommended for average risk women and/or supplemental breast cancer screening with MRI.^10,13,14

Despite the existence of evidence-based practices such as breast cancer RA that have the potential to improve patient care, their translation to regular clinical practice is often delayed by many years.^15,16 Rigorous implementation science approaches can aid in expediting the translation of evidence-based practices such as breast cancer RA, into regular clinical use.^17,18 Understanding healthcare team members’ perception of barriers and facilitators to implementation of RA is an important initial step in framing an implementation science-driven approach to increase utilization.^19,20 The Consolidated Framework for Implementation Research (CFIR), an established implementation science framework, defines the elements that should be explored in order to better understand these barriers and facilitator and provides guidance for exploring these barriers and facilitators.^19,21,22

The objective of this study was to assess healthcare professionals’ perception of barriers to the utilization of breast cancer RA tools in the public health setting through a series of one-on-one interviews with healthcare team members. This study is embedded within a larger parent study, the Breast cancer Risk Assessment – achieVing Equity (BRAVE) study, that aims to develop and test strategies to increase breast cancer RA utilization.

METHODS:

Study Design and Data Sources:

We conducted a cross-sectional qualitative study consisting of one-on-one semi-structured phone interviews with healthcare team members in the public health settings in the state of Tennessee. The findings of this study are reported following the guidelines of the Consolidated Criteria for Reporting Qualitative Studies (COREQ), an evidence-based qualitative methodology.²³

This study was reviewed and approved by both the INSTITUTION A IRB (#191772) and the INSTITUTION B IRB (#20–05-996). While informed consent was obtained from each participant, written consent was not obtained as a waiver for written consent was granted by the IRB.

Theoretical Frameworks:

We selected the CFIR to guide our exploration of existing barriers and facilitators to implementation of breast cancer RA from the healthcare team perspective.¹⁹ The CFIR implementation science framework provides a comprehensive taxonomy of operationally defined constructs that are likely to influence implementation of evidence-based practices. These constructs include the inner and outer settings where an evidence-based practice (i.e. breast cancer RA) will be deployed (public health setting), the characteristics of the individuals involved in implementing the evidence-based practice (providers/staff) and the characteristics of the evidence-based practice itself. Our current study focuses on exploring the CFIR inner setting of public health clinic sites (structural setting, implementation climate, access to knowledge, and available resources), the characteristics of individual healthcare team members (knowledge, beliefs, and motivation), and current healthcare system processes. Qualitative data analysis and development of the framework to understand barriers and facilitators to implementation of breast cancer RA further incorporated the Health Belief Model, a social psychological theory of health decision making.²⁴

Recruitment and Study Population:

Study inclusion criteria were healthcare team members ages 18 and older in the public health setting in Tennessee with a role in breast cancer screening. We purposively recruited via word of mouth and personal referral from three organizations: the state breast cancer screening program, a federally qualified health center, and a local safety net hospital. Direct participant remuneration was not offered at the request of the organizations that we recruited from. An initial recruitment goal of 30 participants was estimated. Study recruitment was stopped when thematic saturation was reached and no new themes were identified in participant response analysis.

Interviews:

The research team developed a semi-structured open-ended interview guide using the CFIR and with the guidance of a PhD psychologist (initials), affiliated with the INSTITUTION A Qualitative Research Core (see Supplement A). Study team members pilot tested and refined the interview guide. The interview guide contained demographic questions about age, gender, race, role in organization, and time in role. The interview guide predominantly contained questions about breast cancer risk assessment and participants’ experiences with breast cancer risk assessment.

Following the interview guide, a trained member of the INSTITUTION A Qualitative Research Core (initials, MA in Social Psychology, female, 10 years of qualitative research experience) conducted the telephone interviews. This interviewer had no prior relationship with any of the interviewees.

All interviews were conducted via telephone between May 2020 and October 2020. All interviews were audio recorded and audio data was stored on an encrypted drive on a secured server. Audio files were submitted to an IRB-approved transcription service (rev.com), and the transcripts were anonymized. Transcripts were not reviewed by study participants.

Data Analysis and Framework Development:

Qualitative data coding and analysis was managed by the INSTITUTION A Qualitative Research Core, led by a PhD-level psychologist. A hierarchical coding system was developed and refined using the interview guide and a preliminary review of the transcripts. Major categories included 1) clinical practice; 2) RA tool characteristics; 3) patient factors; 4) recommendations for high-risk women; 5) facilitators and barriers of using a RA tool; 6) suggestions for improvement; and 7) stakeholder details. Major categories were further divided from one to 13 subcategories, with some subcategories having additional levels of hierarchical division. Definitions and rules were written for the use of the coding categories.

Three experienced qualitative coders first established reliability in using the coding system by coding two transcripts. Coding of the transcripts was compared, and any discrepancies reconciled. Coders then divided and coded the remaining transcripts independently. Each statement was treated as a separate quote and could be assigned up to 10 different codes. Transcripts were combined and sorted by code. Microsoft Excel 2016 and SPSS version 28.0 were used to manage and analyze the coded transcripts.

An iterative inductive/deductive approach was used during the qualitative analysis, leading to the development of a conceptual framework to depict influencers of provider behavior in utilization of breast cancer RA (Figure 1).^25–27 Inductively, we used the coded quotes to identify higher-ordered themes and associations between themes. Deductively, we were guided by the CFIR and elements of the Health Belief Model.^19,24 The analysis was iterative in that the conceptual framework is theoretically informed, while the detailed content within the framework is derived inductively from the qualitative data.

Figure 1.

Provider Perceptions of the Influences of Behavior in Utilization of Breast Cancer Risk Assessment (RA). This framework describes provider perceived barriers and facilitators of utilization of breast cancer RA at both the provider-level and patient-level and depicts challenges with resultant RA results.

Funding Sources:

Funding for this study includes INSTITUTION A Support Grant CA68485, INSTITUTION A SPORE in Breast Cancer (P50CA098131), NIH 2U54CA163072-12, NCATS 5UL1TR002243-03, and the Kaye and Frank Delfino Caring Hearts Fund.

RESULTS:

Study Participants and Demographics:

Of 73 participants invited, a total of 27 healthcare members agreed to participate in an interview. Of those, 24 completed an interview. Data from these 24 interviews comprised the final analytic sample. Table 1 demonstrates the demographic characteristics of healthcare team members participating in an interview including age, race, team member type, and organizational affiliation. Participants self-identified these characteristics. Providers included advanced practice providers, primary care physicians, obstetrician/gynecologists and surgeons.

Table 1.

Participant Demographics

Variable	n (%), N=24
Age (years), mean (IQR)*	48 (39–58)
Sex
Female	22 (92)
Male	1 (4)
Declined to Answer	1 (4)
Race
African American/Black	8 (33)
White	14 (58)
Multiple Races	1 (4)
Declined to answer	1 (4)
Team Member Type
Clinical Trainer	1 (4)
Medical Assistant	1 (4)
Program Coordinator/Director	13 (55)
Program Director	4 (17)
Provider	9 (38)
Organizational Affiliation
Academic Medical Center	5 (21)
Community Health Center	2 (8)
Faith-based Organization	1 (4)
Health Department	12 (50)
Not currently employed	1 (4)
Surgical Center	1 (4)
Women’s Health Center	1 (4)
Declined to Answer	1 (4)

^*2 participants declined to provide age

The duration of interviews ranged from 12.20 to 41.47 minutes (median 22.27 minutes; IQR: 16.52 – 30.17).

Framework for Influences of Provider Behavior in Utilization of Breast Cancer RA:

Figure 1 presents the conceptual framework we created to summarize the influences of provider behaviors for utilization of breast cancer RA. To perform breast cancer RA, both the provider and the patient must agree to screening. The left side of the figure represents the barriers and facilitators identified by healthcare team members that may influence the decision to perform RA. Provider-level barriers were described to us by participants and included their thoughts about influences that affect themselves and other providers. The patient-level barriers and facilitators represent provider perceptions of factors that might influence a patient’s willingness to have her risk assessed. Providers also described facilitators that might be used as strategies to improve utilization of breast cancer RA.

The central area labeled “Breast Cancer Risk Assessment” represents key elements of the tool that providers described including complexity, cost, and design. The double arrow depicts the provider’s decision to use different tools which might calculate different risk scores. Providers identified follow-up challenges for women identified as high-risk including referrals, scheduling, and compliance with follow-up recommendations.

Major Themes:

We discuss each major emerging theme and the subthemes (Table 2) with supporting quotes from participants. Each quote identifies self-identified participant role and status of breast cancer RA utilization in the participant’s organization (currently using RA tool, planning to use a RA tool, using a paper version of a RA tool, or are not using a RA tool at all).

Table 2.

Emerging Themes and Subthemes

Major Themes	Subthemes
Barriers to Breast Cancer Risk Assessment Utilization	Knowledge and Understanding Workflow Personnel
Perceptions of Patient Barriers to Engaging with Breast Cancer Risk Assessment	Psychological Barriers Economic Barriers Knowledge
Perceptions of Patient Barriers to High-Risk Follow-Up	Psychological Barriers Economic Barriers Environmental Barriers
Perceptions of Electronic Breast Cancer Risk Assessment Tools	Complexity Cost Design Increased Identification of Women at High-Risk for Breast Cancer
Strategies to Improve Breast Cancer Risk Assessment Utilization	Create Buy-In Develop Policy and Incentives Improve Education and Training Improve Communication Understand Patients’ Perceived Risk of Cancer and Severity of Cancer

Barriers to Breast Cancer RA Utilization

Participants identified provider-level and systems-level challenges associated with incorporating a breast cancer RA tool into clinic workflow. Identified challenges included knowledge and understanding, workflow issues, and personnel.

Knowledge and Understanding

Participants discussed barriers related to knowledge and understanding of performing breast cancer RA and downstream care. The primary challenge identified was knowing what to do with RA results.

“I think for the physicians, there would need to be some education on why you should use this tool and then also what to do with it. I don’t know that all the physicians know how to respond if people are found to be high risk.” (Family Physician, Not Using)

“I think it’s a breast centers due diligence to offer a risk assessment, but then helping the referring providers and the patient to understand what it means. I think those are going to be some barriers.” (Program Director, Navigator, In progress)

Some healthcare team members had difficulty utilizing RA tools, despite formal training and indicated reluctance to working with a new tool.

“Some were very confused by it [the RA tool], despite having very detailed instructions and going over it with them and answering questions from both nursing.” (Program Director, Currently using and refining)

Workflow

Much discussion focused on workflow disruption and the time needed to assess the patient versus the time available.

“… there are several other screens that we perform, and it depends, to be quite frank with you, it depends on what guidelines we’re trying to meet. So, for instance…the depression screenings, the colorectal cancer screenings, the cervical cancer screenings tend to take priority, not to say the breast cancers should not have a priority there because, obviously being a leading cause of death in women, it should, it just kind of sometimes gets lost in the shuffle. That’s not the best answer, but that’s the truthful answer.” (Physician, Not Using)

Participants emphasized that RA tools must be integrated into the electronic medical record (EMR) if they are to be utilized.

“So, generally, if it’s not integrated into the current medical record, that is probably going to be the biggest obstacle because everything else is integrated there.” (Physician, Not Using)

Personnel

Limited staffing was seen as a significant barrier to successful RA tool utilization. The potential opportunity for non-physician personnel to participate in the breast cancer RA process was raised.

“There’s not a lot of support staff, so it’s basically just the physicians. So, there would need to be additional people to help.” (Family Physician, Not Using)

Participants indicated that lack of interpreters available for patients with limited English proficiency poses a significant challenge in utilizing RA tools efficiently.

“I think one of our biggest barriers is a language barrier because we have a lot of Spanish speaking patients. Then that requires the only one interpreter that we have. That can slow the flow of clinic with regards to if you’re just tied up with one patient doing multiple assessments.” (Obstetrician/Gynecologist, Currently Using)

Perceptions of Patient Barriers to Engaging with Breast Cancer RA

Participants discussed a number of challenges that might be experienced by patients during the breast cancer RA process. Participants identified perceived psychological, economic, and knowledge-based barriers to patients agreeing to have their risk for breast cancer assessed.

Psychological Barriers

Fear and mistrust about RA and breast cancer screening were seen as potential barriers.

“We are concerned about patients that may just not be interested or they may be frightened, or they may be suspicious of motives, for a group that’s coming to a screening exam and then gets told that, ‘Hey, you need this and this done, or you need to have this evaluation.’” (Program Director, Surgeon, In progress)

“Sometimes patients don’t want to participate in those type of assessments because they feel like it will be in their records. And if there’s a review, that information will be known and it can affect their coverage, because it could be looked at maybe as a preexisting condition.” (Program Coordinator, Currently Using)

Economic Barriers

Healthcare team members indicated concerns that patients are primarily concerned with costs of care and that patients might decline out of fear of added costs. If there is a potential cost associated with having their risk for breast cancer assessed, patients may be less likely to engage. Patients need assurance that resources are available to them should the need follow-up care.

“I think a lot of our patients are concerned more about costs. If their insurance will cover breast cancer risk assessment screening for the genetic testing versus if that’s something that they’re going to have to pay out of pocket.” (Obstetrician/Gynecologist, Currently Using)

Knowledge (affecting data quality)

Some patients’ lack knowledge regarding the personal and family health history required to perform breast cancer RA, or willingness to disclose this information, was seen as a potential challenge.

“A lot of our patients don’t know if their relative was BRCA positive or not, if it was ever assessed, if it was ever tested.” (Program Coordinator, Currently Using)

“Just getting the information…Some patients don’t disclose it freely. You sort of have the pry for it and ask the pertinent questions to get them to open up for the family history.” (Screening Coordinator, Currently Using)

Perceptions of Patient Barriers to High-Risk Follow-Up

Although most clinic settings facilitate and coordinate follow-up care for high-risk women, there are still a number of patient-level challenges perceived by the healthcare team.

Psychological Barriers

Some of the barriers to follow-up care were seen as psychological in nature, such as motivation, fear, uncertainty, and procrastination.

“I guess there’s a lot of different reasons it [lack of motivation] could be about. Maybe they don’t have self-esteem, they don’t have enough knowledge, they are afraid, they’re really, really afraid of what might lie ahead for them… seeking follow up care is, should not be something feared.” (Outreach Coordinator, Currently Using)

“I think it’s [procrastination] just a combination of things. They just don’t feel that they are empowered to go in, and get checked, and get their checkups for their breast health. Oftentimes they just don’t know about the programs that provide free services for them.” (Program Manager, Uses paper version)

Economic Barriers

Participants discussed that a barrier to access to quality follow-up care for patients identified as high-risk is potential cost or lack of health insurance.

“I would say if it’s a poor woman, it [lack of follow-u]) would be the fact that another physician would not see her. I think that would be the major obstacle, was having someone to see her if she doesn’t have the insurance.” (Primary Care Physician, Not Using)

“MRIs are extremely expensive, and a lot of patients now have very, very high deductibles. If they have an MRI, the whole cost would go into their deductible and they would pay it out of pocket. The cost of MRI is a huge barrier.” (Program Director, Surgeon, In progress)

Environmental Barriers

Participants described a number of environmental barriers to follow-up care. These were primary discussed in the context of rural patients.

“A lot of it’s transportation, a lot of it’s insurance, a lot of it’s that they don’t trust doctors outside of their community. A lot of them don’t come, if they live on the mountain, a lot of them don’t come down to the city or go to the next city up that has the facilities to do the screenings.” (Screening Coordinator, Currently Using)

Perceptions of Electronic Breast Cancer RA Tools

Elements of electronic breast cancer RA tools such as complexity, cost, and tool design were discussed. Providers acknowledged that deliberate selection of a certain breast cancer RA tool might obtain a higher score, making it easier to refer a patient for additional breast cancer screening.

Complexity

The primary workflow challenge identified for RA tools is lack of standardized protocol for which tool to use and which cancer screening guidelines to use.

“I think one barrier, specifically for us, is trying to get everybody on the same page … because there’s not one consensus breast cancer guideline, and there’s not one consensus breast cancer tool.” (Program Director, Currently Using)

“We had so many questions that we decided that getting that template in there was going to answer those questions and give them a protocol, give them a step-by-step guide, and also allow the provider to be notified if they were at a higher risk of breast cancer.” (Program Director, Currently Using)

Cost

Much discussion on cost of using electronic breast cancer RA tools centered on EMR challenges. Modification of an EMR system is complicated and requires multiple departmental approvals, time, and money.

“Right, so it’s been an unbelievable ordeal of a multifaceted push that took us an awfully long time because just trying to get anything like this through our IT committee was an ordeal.” (Program Director, Surgeon, In progress)

“…the biggest setback is when you change stuff is you have to work with the EHR people themselves, which sometimes takes 30 to 60 days. The only bad thing is when you change, you pay by the hour for them to do it.” (Chief Medical Officer, Not Using)

Design

Much discussion centered on the breast cancer RA tool design. Real-time data entry in the presence of the patient, or auto-populating of a calculator from data already in the EMR, was seen as an advantage.

“If it’s something that patients can do ahead of time, or the nursing staff could do some of it ahead of time, or if it can auto-populate some of that information to us. Say it says current age, weight, height. If it auto-populated that, that would be great.” (Primary Care Physician, Not Using)

“We’ve already been in the process of trying to make it as easy as possible. We’ve incorporated the links into the EMR that take them directly to that risk assessment. So, they don’t have to have a tab saved, and then go to the tab, and trying to remove extra steps to, to try to save time...” (Program Director, Currently using and refining)

Increased Identification of Women at High-Risk for Breast Cancer

Implementation of an electronic breast cancer RA tool could potentially create new challenges, such as identification of a large number of women at high-risk needed follow-up. Limited availability for necessary follow-up specialty appointments may be a barrier.

“I think as a risk assessment ramps up, I think we’re going to have trouble... I think we’re going to have trouble having enough genetics appointments…we always seem to not have enough MRI times available.” (Program Director, Navigator, In progress)

Strategies to Improve Breast Cancer RA Utilization

Strategies at the provider-level and patient-level to increase utilization of breast cancer RA were offered. Participants emphasized the importance of buy-in, policies and incentives, training, improved communication, and better understanding of patients’ perceived risk of cancer and severity of cancer.

Create Buy-In (Provider-Level)

Participants emphasized the importance of creating leadership and organizational buy-in. Assurances that performing RA would not impact other workflow would be critical.

“I think it would start with the department first. Get buy in from the department to do it. And then after the chair decided, “Yes, this is something that I want to do.” Then it would be just a matter of talking to IT.” (Physician, Uses paper version)

“We had to get the mammography staff and administrators to buy into this…and to show them that this really does not add to their workload because they actually ask a lot of the questions the patients are going to answer.” (Program Director, Surgeon, In progress)

Develop Policy and Incentives (Provider-Level)

Another strategy to increase the utilization of RA relates to policy and incentives.

Financial policies were identified as a key facilitator. Improved billing codes and understanding of billing codes was identified as an opportunity for improvement.

“Those [billing codes] would be a great incentive if you had a way that they can recoup the cost of their time to implement these types of assessments… I think that would be a great incentive.” (Program Manager, Uses paper version)

Participants suggested incentivizing opportunities to learn more about RA through continuing medical education credits.

“Incorporating it into a grand rounds, particularly in an academic center like ours, would probably get a lot more awareness and a lot more people utilizing it…Kind of, embedding it into that curriculum. And that way … everybody gets CMEs from it.” (Physician, Not Using)

Improve Education and Training (Provider-Level)

Participants described strategies for education and training. Some preferred hands-on learning style. Some hospitals have designated learning days for providers. Some identified on-line learning opportunities as useful.

“You could learn in a presentation online versus learning better, with hands on, then of course… hands on always works better for me.” (Outreach Coordinator, Currently Using)

“I think the easiest thing would be a lunch and learn …you have a captive audience because we’re not in clinic, we’re not seeing patients during this time, so everybody is free.” (Physician, Uses paper version)

“Webinars are pretty good. That way, they could probably show more examples and show up step by step what needs to be done or even like a mock exam. I think webinars are pretty good to get across most people.” (Program Manager, Nurse, Not Using)

Participants were asked who should lead the education and training.

“Probably the person who is like the super user of the electronic medical record. And then we have a couple physician super users. Once they learn how to use it, then it becomes their responsibility of the other super users to teach the rest of the faculty and residents and staff.” (Obstetrician/Gynecologist, Currently Using)

“So, a RN perhaps who has worked in a breast clinic or has used the screening tools pretty consistently… someone who has the experience and we know has know how in doing it, I think it would be appropriate.” (Physician, Not Using)

Access to knowledge was emphasized as important for users who get stuck or have follow-up questions not asked in training.

“Having somebody in person from time to time is great that if you have specific questions because then they can’t ask that of a video.” (Program Manager, Nurse, Not Using)

Improve Communication (Patient-Level)

Participants discussed the need for improved communication and access to resources.

“It’s helpful to communicate with different levels. It’s not unusual for a patient to call our hotline, which rings to central office, and … say, “Hey, I found out I have a gene mutation and I need to get a mammogram done, because that’s what I was told that we can do. And I don’t have insurance but I can’t go to whatever place.” It’s a matter of trying to find communication and utilizing resources within the community to try to make things happen.” (Program Director, Currently using and refining)

Understand Patients’ Perceived Risk of Cancer and Severity of Cancer (Patient-Level)

Participants noted that patients’ perceived risk of cancer and severity of cancer facilitates motivation for follow-up care. Patients who have witnessed the fatal nature of cancer, specifically a death of a family member, are more likely to bypass cost concerns.

“…Usually, the patients are actually way more receptive once they know that they’ve been identified as high risk, because these women are usually the ones that are a little more proactive about their health, because they’re more worried because they’ve seen that first degree relative...” (Program Director, Currently using and refining)

“…I can tell you that the young women who have watched family members die from all these cancers just say, “Tell me how to sign up. I don’t even care how much it costs. I’ll do it. I mean, I want this to stop in our family. I don’t want anybody else in our family to ever have this again.” (Program Director, Surgeon, In progress)

DISCUSSION:

Healthcare team members described potential barriers to offering breast cancer risk RA and strategies to improve breast cancer utilization. Provider-level barriers to utilization of breast cancer RA include knowledge and understanding of RA tools, workflow challenges, and availability of personnel. Barriers to uptake of breast cancer RA at the patient-level, as perceived by providers, include psychological, economic, educational, and environmental barriers. Providers also discussed different elements of electronic breast cancer RA tools that must be considered such as tool complexity, cost, and design. Identified strategies to increase utilization of breast cancer RA at the provider-level include increasing leadership buy-in, developing supportive policies and incentives, and improving provider trainings. Strategies at the patient-level include improved communication and better understanding patients’ perceived risk of cancer and severity of cancer.

These findings support other work exploring provider perceived barriers to implementation of other evidence-based practices, including cancer screening. Commonly perceived barriers to implementation of new practices include lack of resources, staff shortage and turnover, lack of leadership buy-in, organizational culture, lack of expertise, and challenges with adaptation of implementing the practices.^28,29 A study in the Spanish National Health System found health professionals identified barriers to risk-based breast cancer screening to include resistance to change for health professionals, difficulties in risk communication, limited economic resources, and time necessary for organizational transformation.³⁰ The findings are also supported by our team’s concurrent work exploring patient perceptions of breast cancer RA.³¹

Increasing the utilization of breast cancer RA in regular clinical practice offers an opportunity to not only improve overall breast cancer morbidity and mortality outcomes, but also to address existing breast cancer outcome disparities. Breast cancer mortality disparities in young women result in increased early loss of life amongst women from low socioeconomic status (SES), those dwelling in rural areas, and those from racial minority groups.^32–38 Access to care, delays in diagnosis and treatment, and differences in tumor biology partially explain these disparities. Increasing utilization of breast cancer RA among a diverse population of young women offers an opportunity to address these disparities.^39–42

Strengths of this study include use of an established implementation science framework, expertise of an established qualitative research team, and qualitative study design that increases understanding of individual perspectives of barriers to implementation of breast cancer RA and strategies to overcome these barriers. Study limitations include the geographic location in a single state in the U.S., inclusion of predominantly women (although this may reflect the healthcare team in this setting), and the inclusion of English-speaking participants only. Recruitment via word of mouth rather than random selection may have also introduced selection bias, as the responses of these individuals may differ from those of a more general population. Further, we do not have demographic data on the overall characteristics of the healthcare providers in these organizations nor those who declined an interview to allow for demographic characterization of responders and non-responders, which may introduce non-responder bias.

Our results will inform a larger scale intervention study to develop and test implementation strategies to increase uptake of breast cancer RA for a diverse population of women. Understanding barriers to implementation of breast cancer RA offers an opportunity to increase RA uptake and identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.

Key Take Home Points:

Breast cancer risk assessment is an evidence-based practice that can identify women at high risk for developing breast cancer. Women at high risk for developing breast cancer may benefit from early and/or supplemental screening.

While breast cancer risk assessment tools are widely available, they are not used routinely in standard clinical practice.

Healthcare team members identified several barriers to utilization of breast cancer risk assessment at the provider-level including knowledge and understanding of risk assessment tools, workflow challenges, and availability of personnel.

Healthcare team members identified patient-level barriers to risk assessment including psychological, economic, educational, and environmental barriers.

Potential strategies to increase utilization of breast cancer risk assessment include leadership buy-in, provider training, supportive policies, and incentives along with improved communication and better understanding of patients’ perceived cancer risk and severity of cancer.

Understanding barriers to implementation of breast cancer risk assessment and strategies to overcome these barriers offers an opportunity to improve implementation of risk assessment and to identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.