Coding was organised under three themes: (1) Acceptability of risk-based screening, (2) Barriers to implementation, and (3) Facilitators to implementation.
Theme 1: acceptability of risk-based screening
Encourages women to take mitigating action
A strong consensus across sites and professions was that implementing risk-stratified screening was a positive step for the next generation of breast screening. An individualised risk assessment was perceived as more logical than providing identical screening for all women regardless of risk.
“…there’s a good sort of foundation to run a service that offers different elements to a patient so it’s not just having the mammogram, it’s about looking at it holistically. I think if we were able to embrace things a bit like that more, then we’d be providing a better service…” (HCP0011; Mammographer/Radiographer).
Participants across the pathway and sites perceived risk-stratified breast screening as beneficial for women attending screening, by identifying those who may otherwise be unaware of their risk and providing them with information and services to manage their risk.
“It is good picking up women who haven’t really accessed the service via their GP, who did have quite a prevalent family history. Then it’s a good avenue to pick up those women and bring them in and offer them a higher screening service.” (HCP010; FHRPC Nurse).
Participants discussed how risk-stratification enables agency by offering women different options to make decisions about risk reduction:
“It’s going the next level, it’s saying, we know what the risk factors are but here’s what we’re going to do about it, we’re going to offer these women some tangible benefits to help reduce their risk or improve the chances of early detection.” (HCP008; FHRPC Doctor).
It appeared a strong consensus across participants that the concept of risk-stratification was largely positive; HCPs valued the benefit to both services and women in implementing this approach.
Low burden to routine tasks
Whilst screening office managers and radiographers across sites described challenges of setting up the software for BC-Predict, this was a short-term obstacle. Following study set-up, participants across the pathway and sites highlighted the minimal impact on their workload:
“Once it was set up, it seemed to, run from our perspective, it ran quite well. There didn’t seem to be many hiccups in terms of the technical aspects. To be honest, from my personal perspective, I didn’t really notice it.” (HCP013; Screening Office Manager).
This was echoed by radiographers/mammographers and those responsible for risk-consultations, who reported minimal impact on appointments and tasks similar or the same as current roles:
“…in terms of our mammogram itself, I don’t think it alters it at all. It was part of the interview process that we do with every patient anyway and there’s always going to be extra questions of whatever nature that you’d have to deal with.” (HCP011; Mammographer/radiographer manager).
When considering national implementation, some participants perceived minimal burden on workload but only if mammogram and risk consultation formats remain unchanged.
Ethical considerations: anxiety and screening disparities
HCPs across the pathway at the site conducting risk-consultations discussed how risk-stratification could potentially alleviate or worsen anxiety for women, but this was not seen as sufficient grounds to advise against implementation of risk-stratification. Participants at this site discussed how women informed of being moderate or high-risk would naturally feel more anxious, particularly if this risk result was not anticipated by the individual. However, having a secure pathway for high-risk women was perceived by one participant to minimise any anxiety induced in higher risk women:
“I think it’s quite clear that, yes, they may be made aware that they are at higher risk. However, they’re not just told they’re at higher risk and then, sort of, left to deal with it. You know, they have, like, a clear pathway of what’s going to happen because I think that should reassure them because it reassures us” (HCP003; Screening Office Manager).
Participants also discussed potential NHSBSP disengagement from women. Due to a complicated risk-stratified process, women may be left feeling overwhelmed with information. Additional concerns from FHRPC staff and a radiographer highlighted that women might subsequently opt for private healthcare if unable to access genetic testing or enhanced screening at their screening site:
“We can’t do MRI screening for every woman with high breast density. But you could consider to have that done privately. But then, that’s not very fair for the women who can’t afford private health care.” (HCP010; FHRPC Nurse).
The potential alleviation or increase of anxiety for women was also perceived as dependant on the individual’s pre-existing level of anxiety or worry. Participants thus highlighted ensuring implementation does not exacerbate service and health inequalities for women accessing risk-based screening.
Theme 2: barriers to implementation
Managing additional demand
An anticipated increase of women into screening and capability of services to manage this demand was perceived a barrier, exacerbated by current increased demand, such as recovering round-length due to COVID-19.
“The demand on the service is already I think at a point where we’re struggling to stay on top. So I think anything added would just increase the pressures” (HCP007; mammographer/radiographer).
Across the pathway, participants expressed concerns regarding the scale of high-risk women accessing additional screening, even if numbers were small. Additional reporting of images appeared problematic for radiologists and screening managers at two sites, particularly if the time to download the images onto a risk-based screening system significantly added to their reporting time.
“It just depends on how long it takes for each of these things to get uploaded into something and downloaded into something, and then for us to evaluate it and put our report in…if it’s going double that or triple that there will be a significant increase overall in the reporting times and it will impact on staff.” (HCP009;Radiologist).
In addition, one FHRPC doctor experienced doubled clinic capacity accounting for BC-Predict during the study.
“Even it was only another five per cent of women that needed to be having annual mammograms, that’s still quite an increase.” (HCP008; FHRPC Doctor).
When questioned on implementation, different HCPs reported workforce shortages and high mammography staff turnover exasperating concerns to manage additional screening and reporting, and for staff to manage a possible influx of queries from women. This coupled with the national misalignment of resources between different sites (equipment, departmental structure, genetic testing, and chemoprevention knowledge), meant implementation demands will be unique to each site:
“A lot of family history nurses are actually breast care nurses that have their symptomatic workload and their risk assessment of family history is added on to their other workload. […] the service is very different in different parts of the country.” (HCP009; Radiologist).
In line with this, funding for staff and screening infrastructure, and for equipment was viewed by participants at all sites as a pre-requisite across the pathway.
Clarity requirements to implement nationally
When prompted about the pathway, participants were unclear how women risk-stratified to low, medium, or high-risk would align with future screening pathways and FHRPC. This was especially true for those sites operating mobile screening vans as these set locations were dependent on the screening interval and invited population.
“It seems a lot more complicated once you do the risk stratification if they go into like, say, a one-year pathway, a five-year pathway, a three-year pathway.” (HCP014; Radiologist).
Participants across sites were unclear if high-risk women identified through risk-stratification would be referred in to a local, national, or new service. Radiologists at one site alluded to potential risks for women potentially missing their screening or being invited at the wrong time. An additional layer of complexity was highlighted with contradictory NHSBSP and national surveillance guidance for high-risk/very high-risk women and how that might impact women referred from different areas.
“There’s a national breast screening, which this is involved in, but then we’ve got local… We’ve already got very high risk, which are the genes and everything but where would these women fit? (HCP001; Screening Office Manager)
Participants from FHRPCs outlined staff and structural differences across the country which impact on high-risk referrals through this pathway.
“Most family history clinics would tend to want to do their own risk assessment from a referral and it, whether that counteracts what the BC-Predict has given to that patient, that can create confusion.” (HCP010; FHRPC Nurse).
Simplifying and standardising the pathway that aligned within the NHSBSP and supported equal screening opportunities for women was perceived as a logical step by many participants. Participants in FHRPCs identified the need for protocols to support this.
Inadequate screening software and hardware
Despite all UK screening services using the same software, this was described by many participants as antiquated and lacking the ability to support risk-stratified screening:
“It just seems really complicated and a bit of a concern that the technology and the software can’t really cope with that, and we could end up, you know, with incidents because we don’t actually invite everybody correctly.” (HCP014; Radiologist).
During BC-Predict, unanticipated software setup challenges imposed additional workload for sites, particularly in obtaining images for mammographic density from mobile units:
“There were all sorts of implications here and there that we maybe hadn’t realised would be such an issue. What with the aerial, extending the height… They did get them eventually, but it was probably a bit more of a longer, more complex process than we probably first anticipated. (HCP013; Screening Office Manager)
It appeared the lack of an integrated screening software to safely gather risk information and the complexity of screening invite systems was a prominent concern across participants, highlighting constraints of the present software used across breast screening.
Theme 2: facilitators to implementation
Multidisciplinary conversations across all HCPs and with the national team were viewed as vital for coordinating national implementation of risk-stratified screening. Focus groups run to elicit challenges prior to BC-Predict implementation were viewed as a good opportunity to ask questions:
“I think the focus groups done at the beginning were a really, really good idea. They gave everybody involved the opportunity to, sort of, come up with queries and questions and ideas…so I’d say do that with every, sort of, programme that you go into.” (HCP003; Screening Office Manager).
Taking a similar approach, by engaging all stakeholders across the pathway and ensuring dialogue with all individuals, was viewed as a facilitator for national implementation:
“I think there has to be a huge sort of consultation with the service, the people that…all the stakeholders really to start with, just to understand what the practical issues may be.”(HCP012; Mammographer Radiographer Manager).
Participants with a variety of professional roles highlighted the importance of ensuring smaller sites are involved in subsequent consultation about this.
Supporting staff and training needs
Participants suggested how implementation could be supported, drawing upon current and future resource and training needs. Across all different professional groups, there was enthusiasm for risk-screening administration staff to oversee the programme and in particular “dedicated staff members to just look after the higher risk screening ladies.” (HCP006; Screening Programme Manager). Retention and recruitment of mammography staff was perceived as important and suggested by all radiographers. First, defining the workload and resource required across the pathway would be necessary:
“if that’s the way forward, they would have to look at how many x-ray machines you have and how many staff you have, if they’re able to be increased in mammograms” (HCP006; Screening Office Manager).
When participants were prompted on training needs, guidance for screening offices and mammographers to support women’s queries was identified. This included the hope for alignment of NHSBSP and high-risk screening guidance. Medical guidance for nurse specialists and primary care was also suggested including how to complete the risk questionnaire.
“With the chemoprevention aspect of it, which isn’t something that we get involved with at the moment, like a medicines medical point of view. So, I’m guessing there would have to be either some nursing involvement or some kind of medical guidelines or guidance for that” (HCP004; Screening Programme Manager).
HCPs identified possible solutions to support national implementation and key next steps including identifying and quantifying the additional need that will be required.
Supporting equitable access
Tools to support women’s information access was viewed as key for implementation. In BC-Predict, queries were managed by the study team by telephone and email. Screening programme managers and radiographers across sites, including a site who discussed the high ethnic diversity in their local population, viewed this a useful tool for women and for implementation. To ensure minimal impact on mammogram appointments, telephone helplines and information packs were suggested so this is available prior to appointments.
“Yes, some sort of helpline or just somebody to just ask a query. Maybe an online sort of forum, maybe. Some information that you could just go simply to a portal and just type a question in but I think a phone line’s probably the best thing from our local area point of view. (HCP012; Mammographer/Radiographer Manager)
Participants working at a site with a highly ethnically diverse population explained challenges with screening uptake in which the importance of communicating about risk-stratified screening in other languages was highlighted. Participants at other sites also discussed the need for standardised and simple information on risk-stratification
“So you have to provide the same information to every woman” (HCP010; FHRPC Nurse).
“We need to be able to communicate the study to all the women that are eligible for breast screening within our local area and not just the English-speaking ones or English…it’s more the English reading” (HCP012; Mammographer/Radiographer Manager).
To support women’s access, general practitioners (GPs) were suggested by different participants working across FHRPCs to support amalgamating risk factors and by also collecting risk factors at GP consultations that could be shared with the NHSBSP at the point of mammogram referral. GPs were also suggested for supporting risk-screening referrals, and aiding women’s decision-making. However, capacity and capability of GPs to support this was a consideration for implementation.
“Looking at all the risk factors. Some of this stuff would be readily accessible to the GP practice, even though it’s just maybe a question worth asking, whether or not it’s something that they could quickly facilitate” (HCP013; Screening Office Manager).
Ensuring risk-stratified screening meets the needs of all women across ethnically and culturally diverse communities was therefore a priority for these participants, particularly at the highly ethnically diverse site.