Barriers and Facilitators to the Implementation of a Personalized Breast Cancer Screening Program: Views of Spanish Health Professionals

Primary care providers' experience and satisfaction with personalised breast cancer screening risk communication: a descriptive cross-sectional study

OBJECTIVE

To describe primary care providers' (PCPs) experience and satisfaction with receiving risk communication documents on their patient's breast cancer (BC) risk assessment and proposed screening action plan.

DESIGN

Descriptive cross-sectional study.

SETTING

A survey was distributed to all 763 PCPs linked to 1642 women participating in the Personalized Risk Assessment for Prevention and Early Detection of Breast Cancer: Integration and Implementation (PERSPECTIVE I&I) research project in Quebec, approximately 1-4 months after the delivery of the risk communication documents. The recruitment phase took place from July 2021 to July 2022.

PARTICIPANTS

PCPs.

MAIN OUTCOME MEASURES

Descriptive analyses were conducted to report participants' experiences and satisfaction with receiving risk communication. Responses to two open-ended questions were subjected to content analysis.

RESULTS

A total of 168 PCPs answered the survey, from which 73% reported being women and 74% having more than 15 years of practice. Only 38% were familiar with the risk-based BC screening approach prior to receiving their patient risk category. A majority (86%) agreed with the screening approach and would recommend it to their patients if implemented at the population level. A majority of PCPs also reported understanding the information provided (92%) and expressed agreement with the proposed BC screening action plan (89%). Some PCPs recommended simplifying the materials, acknowledging the potential increase in workload and emphasising the need for careful planning of professional training efforts.

CONCLUSION

PCPs expressed positive attitudes towards a risk-based BC screening approach and were generally satisfied with the information provided. This study suggests that, if introduced in Canada in a manner similar to the PERSPECTIVE I&I project, risk-based BC screening would likely be supported by most PCPs. However, they emphasised the importance of addressing concerns such as professional training and the potential impact on workload if the approach were to be implemented at the population level. Future qualitative studies are needed to further explore the training needs of PCPs and to develop strategies for integrating this approach with the high workloads faced by PCPs.

Personalized screening based on risk and density: prevalence data from the RIBBS study

PURPOSE

To present the prevalence screening results of the RIsk-Based Breast Screening (RIBBS) study (ClinicalTrials.gov NCT05675085), a quasi-experimental population-based study evaluating a personalized screening model for women aged 45-49. This model uses digital breast tomosynthesis (DBT) and stratifies participants by risk and breast density, incorporating tailored screening intervals with or without supplemental imaging (ultrasound, US, and breast MRI), with the goal of reducing advanced breast cancer (BC) incidence compared to annual digital mammography (DM).

MATERIALS AND METHODS

An interventional cohort of 10,269 women aged 45 was enrolled (January 2020-December 2021. Participants underwent DBT and completed a BC risk questionnaire. Volumetric breast density and lifetime risk were used to assign five subgroups to tailored screening regimens: low-risk low-density (LR-LD), low-risk high-density (LR-HD), intermediate-risk low-density (IR-LD), intermediate-risk high-density (IR-HD), and high-risk (HR). Screening performance was compared with an observational control cohort of 43,838 women undergoing annual DM.

RESULTS

Compared to LR-LD, intermediate-risk groups showed a 4.9- (IR-LD) and 4.6-fold (IR-HD) higher prevalence of BC, driven by a 7.1- and 7.1-fold higher prevalence of pT1c tumors. The interventional cohort had lower recall rate (rate ratio, 0.5), higher surgery rate (1.9) and increased prevalence of DCIS (2.9), pT1c (2.3) and grade 3 tumors (2.4), compared to controls.

CONCLUSION

The prevalence screening demonstrated the feasibility of using DBT and -in high-density subgroups- supplemental US. The stratification criteria effectively identified subpopulations with different BC prevalence. Increasing the detection rate of pT1c tumors is not sufficient but necessary to achieve a reduction in advanced BC incidence.

Acceptability of risk-based breast cancer screening among professionals and healthcare providers from 6 countries contributing to the MyPeBS study

BACKGROUND

To evaluate the acceptability of a risk-based breast cancer screening (BCS) strategy among professionals involved in MyPeBS study in 6 countries.

METHODS

After qualitative interviews, a questionnaire was built with a Delphi method: to evaluate professionals' basic understanding, satisfaction and reactions to each stage of the trial, opinions on BCS and its future. The questionnaire was distributed by emailing 698 investigators, who forwarded it to all categories of professionals involved in trial recruitment (physicians, medical secretaries, nurses, and mammography technicians). Descriptive statistics were used to summarize views on acceptability.

RESULTS

Among the 198 respondents, most declared being at ease with the trial design and the concept of breast cancer risk estimation. They were mostly comfortable explaining the different trial steps, communicating risk estimation, and answering women's questions. Some professionals were not comfortable explaining high (7.1%) and low-risk categories (9%) and did not feel sufficiently trained (26.5%). Although professionals were mostly confident about risk-based approaches and the potential of this to improve breast cancer screening (93.5%), 58% called for further validation of the risk-models to predict risk before implementation in population-based programs. They expressed concerns about the complexity of this screening strategy, stressing the need to properly inform the public and to train professionals in delivering risk assessment.

CONCLUSION

This first study assessing the perspectives of professionals delivering risk-based BCS. As professional acceptability is key for successful implementation, training for all professionals and tools to help them communicate risk to women will be necessary to develop risk assessment in BCS.

TRIAL REGISTRATION

Study sponsor: Unicancer. My personalised breast screening (MyPeBS).

CLINICALTRIALS

gov (2018) available at https://www.

CLINICALTRIALS

gov/ct2/show/NCT03672331 .

Barriers and Facilitators to Delivering Multifactorial Risk Assessment and Communication for Personalized Breast Cancer Screening: A Qualitative Study Exploring Implementation in Canada

Many jurisdictions are considering a shift to risk-stratified breast cancer screening; however, evidence on the feasibility of implementing it on a population scale is needed. We conducted a prospective cohort study in the PERSPECTIVE I&I project to produce evidence on risk-stratified breast screening and recruited 3753 participants to undergo multifactorial risk assessment from 2019-2021. This qualitative study explored the perspectives of study personnel on barriers and facilitators to delivering multifactorial risk assessment and risk communication. One focus group and three one-on-one interviews were conducted and a thematic analysis conducted which identified five themes: (1) barriers and facilitators to recruitment for multifactorial risk assessment, (2) barriers and facilitators to completion of the risk factor questionnaire, (3) additional resources required to implement multifactorial risk assessment, (4) the need for a person-centered approach, and (5) and risk literacy. While risk assessment and communication processes were successful overall, key barriers were identified including challenges with collecting comprehensive breast cancer risk factor information and limited resources to execute data collection and risk communication activities on a large scale. Risk assessment and communication processes will need to be optimized for large-scale implementation to ensure they are efficient but robust and person-centered.

Acceptability and perceptions of personalised risk-based cancer screening among health-care professionals and the general public: a systematic review and meta-analysis

BACKGROUND

Personalised risk-based screening (PRBS) can enhance the efficiency of cancer screening programnes, but little is known about support for its implementation among the general public and health-care professionals. We aimed to summarise the acceptability and perceptions of PRBS for breast, cervical, colorectal, lung, and prostate cancer screening among these groups.

METHODS

We conducted a systematic review and meta-analysis of original research studies reporting on breast, cervical, colorectal, lung, and prostate cancer screening; personalised risk assessments to guide PRBS; and the acceptability of and receptibility towards these approaches among the general public, health-care professionals, or both. We searched MEDLINE, Embase, Cochrane Central, PsycINFO, and CINAHL Plus for articles published between Jan 1, 2010, and April 30, 2024. Studies not reporting on the outcomes of interest and with insufficient data for analysis were excluded. Six reviewers independently screened articles, and risk of bias was assessed using the Mixed Methods Appraisal Tool. Qualitative data were analysed thematically. Quantitative data were analysed with use of random-effects meta-analysis for outcomes that had at least two studies. The study protocol was registered at PROSPERO, CRD42022354287.

FINDINGS

Our search identified 4491 unique records. After screening, 63 studies were included in our analysis, of which 36 (57%) included the general public, 21 (33%) included health-care professionals, and six (11%) included both. The majority of studies focused on breast cancer screening (43 [68%] studies), and were from North America (28 [44%]) and Europe (28 [44%]). Qualitative findings were analysed thematically, and the extracted quantitative findings were synthesised under the following topics: acceptability and perceptions of personalised risk assessments among the general public; acceptability and perceptions of PRBS among the general public; acceptability and perceptions of PRBS among health-care professionals; and barriers and facilitators to PRBS implementation among health-care professionals. The general public and health-care professionals generally found PRBS acceptable, but they needed more information about how risk was calculated and the accuracy of risk scores. Additionally, both groups were cautious about reducing screening frequencies for individuals at low risk and cited barriers such as the time and resources needed to implement an effective PRBS programme. The pooled estimate for acceptability of PRBS was 78% (95% CI 66-88) among the general public and 86% (64-99) among health-care professionals.

INTERPRETATION

The general public and health-care professionals both viewed personalised risk assessments as providing valuable information and PRBS as a logical next step to increase the quality of patient care and improve cancer mortality. However, implementation barriers at the public, health-care professional, and system level need to be addressed.

FUNDING

National Cancer Institute and Cancer Prevention and Research Institute of Texas.

The risk-based breast screening (RIBBS) study protocol: a personalized screening model for young women

The optimal mammography screening strategy for women aged 45-49 years is a matter of debate. We present the RIBBS study protocol, a quasi-experimental, prospective, population-based study comparing a risk- and breast density-stratified screening model (interventional cohort) with annual digital mammography (DM) screening (observational control cohort) in a real-world setting. The interventional cohort consists of 10,269 women aged 45 years enrolled between 2020 and 2021 from two provinces of the Veneto Region (northen Italy). At baseline, participants underwent two-view digital breast tomosynthesis (DBT) and completed the Tyrer-Cuzick risk prediction model. Volumetric breast density (VBD) was calculated from DBT and the lifetime risk (LTR) was estimated by including VBD among the risk factors. Based on VBD and LTR, women were classified into five subgroups with specific screening protocols for subsequent screening rounds: (1) LTR ≤ 17% and nondense breast: biennial DBT; (2) LTR ≤ 17% and dense breast: biennial DBT and ultrasound; (3) LTR 17-30% or LTR > 30% without family history of BC, and nondense breast: annual DBT; (4) LTR 17-30% or > 30% without family history of BC, and dense breast: annual DBT and ultrasound; and (5) LTR > 30% and family history of BC: annual DBT and breast MRI. The interventional cohort is still ongoing. An observational, nonequivalent control cohort of 43,000 women aged 45 years participating in an annual DM screening programme was recruited in three provinces of the neighbouring Emilia-Romagna Region. Cumulative incidence rates of advanced BC at three, five, and ten years between the two cohorts will be compared, adjusting for the incidence difference at baseline.Trial registration This study is registered on Clinicaltrials.gov (NCT05675085).

Implementation considerations for risk-tailored cancer screening in the population: A scoping review

BACKGROUND

Risk-tailored screening has emerged as a promising approach to optimise the balance of benefits and harms of existing population cancer screening programs. It tailors screening (e.g., eligibility, frequency, interval, test type) to individual risk rather than the current one-size-fits-all approach of most organised population screening programs. However, the implementation of risk-tailored cancer screening in the population is challenging as it requires a change of practice at multiple levels i.e., individual, provider, health system levels. This scoping review aims to synthesise current implementation considerations for risk-tailored cancer screening in the population, identifying barriers, facilitators, and associated implementation outcomes.

METHODS

Relevant studies were identified via database searches up to February 2023. Results were synthesised using Tierney et al. (2020) guidance for evidence synthesis of implementation outcomes and a multilevel framework.

RESULTS

Of 4138 titles identified, 74 studies met the inclusion criteria. Most studies in this review focused on the implementation outcomes of acceptability, feasibility, and appropriateness, reflecting the pre-implementation stage of most research to date. Only six studies included an implementation framework. The review identified consistent evidence that risk-tailored screening is largely acceptable across population groups, however reluctance to accept a reduction in screening frequency for low-risk informed by cultural norms, presents a major barrier. Limited studies were identified for cancer types other than breast cancer.

CONCLUSIONS

Implementation strategies will need to address alternate models of delivery, education of health professionals, communication with the public, screening options for people at low risk of cancer, and inequity in outcomes across cancer types.

"For and against" factors influencing participation in personalized breast cancer screening programs: a qualitative systematic review until March 2022

BACKGROUND

Personalized breast cancer screening is a novel strategy that estimates individual risk based on age, breast density, family history of breast cancer, personal history of benign breast lesions, and polygenic risk. Its goal is to propose personalized early detection recommendations for women in the target population based on their individual risk. Our aim was to synthesize the factors that influence women's decision to participate in personalized breast cancer screening, from the perspective of women and health care professionals.

METHODS

Systematic review of qualitative evidence on factors influencing participation in personalized Breast Cancer Screening. We searched in Medline, Web of science, Scopus, EMBASE, CINAHL and PsycINFO for qualitative and mixed methods studies published up to March 2022. Two reviewers conducted study selection and extracted main findings. We applied the best-fit framework synthesis and adopted the Multilevel influences on the cancer care continuum model for analysis. After organizing initial codes into the seven levels of the selected model, we followed thematic analysis and developed descriptive and analytical themes. We assessed the methodological quality with the Critical Appraisal Skills Program tool.

RESULTS

We identified 18 studies published between 2017 and 2022, conducted in developed countries. Nine studies were focused on women (n = 478) and in four studies women had participated in a personalized screening program. Nine studies focused in health care professionals (n = 162) and were conducted in primary care and breast cancer screening program settings. Factors influencing women's decision to participate relate to the women themselves, the type of program (personalized breast cancer screening) and perspective of health care professionals. Factors that determined women participation included persistent beliefs and insufficient knowledge about breast cancer and personalized screening, variable psychological reactions, and negative attitudes towards breast cancer risk estimates. Other factors against participation were insufficient health care professionals knowledge on genetics related to breast cancer and personalized screening process. The factors that were favourable included the women's perceived benefits for themselves and the positive impact on health systems.

CONCLUSION

We identified the main factors influencing women's decisions to participate in personalized breast cancer screening. Factors related to women, were the most relevant negative factors. A future implementation requires improving health literacy for women and health care professionals, as well as raising awareness of the strategy in society.

Canadian Healthcare Professionals' Views and Attitudes toward Risk-Stratified Breast Cancer Screening

Given the controversy over the effectiveness of age-based breast cancer (BC) screening, offering risk-stratified screening to women may be a way to improve patient outcomes with detection of earlier-stage disease. While this approach seems promising, its integration requires the buy-in of many stakeholders. In this cross-sectional study, we surveyed Canadian healthcare professionals about their views and attitudes toward a risk-stratified BC screening approach. An anonymous online questionnaire was disseminated through Canadian healthcare professional associations between November 2020 and May 2021. Information collected included attitudes toward BC screening recommendations based on individual risk, comfort and perceived readiness related to the possible implementation of this approach. Close to 90% of the 593 respondents agreed with increased frequency and earlier initiation of BC screening for women at high risk. However, only 9% agreed with the idea of not offering BC screening to women at very low risk. Respondents indicated that primary care physicians and nurse practitioners should play a leading role in the risk-stratified BC screening approach. This survey identifies health services and policy enhancements that would be needed to support future implementation of a risk-stratified BC screening approach in healthcare systems in Canada and other countries.

What are the views of three key stakeholder groups on extending the breast screening interval for low-risk women? A secondary qualitative analysis

INTRODUCTION

There is increasing interest in risk-stratified breast screening, whereby the prevention and early detection offers vary by a woman's estimated risk of breast cancer. To date, more focus has been directed towards high-risk screening pathways rather than considering women at lower risk, who may be eligible for extended screening intervals. This secondary data analysis aimed to compare the views of three key stakeholder groups on how extending screening intervals for low-risk women should be implemented and communicated as part of a national breast screening programme.

METHODS

Secondary data analysis of three qualitative studies exploring the views of distinct stakeholder groups was conducted. Interviews took place with 23 low-risk women (identified from the BC-Predict study) and 17 national screening figures, who were involved in policy-making and implementation. In addition, three focus groups and two interviews were conducted with 26 healthcare professionals. A multiperspective thematic analysis was conducted to identify similarities and differences between stakeholders.

FINDINGS

Three themes were produced: Questionable assumptions about negative consequences, highlighting how other stakeholders lack trust in how women are likely to understand extended screening intervals; Preserving the integrity of the programme, centring on decision-making and maintaining a positive reputation of breast screening and Negotiating a communication pathway highlighting communication expectations and public campaign importance.

CONCLUSIONS

A risk-stratified screening programme should consider how best to engage women assessed as having a low risk of breast cancer to ensure mutual trust, balance the practicality of change whilst ensuring acceptability, and carefully develop multilevel inclusive communication strategies.

PATIENT AND PUBLIC CONTRIBUTION

The research within this paper involved patient/public contributors throughout including study design and materials input.

Healthcare professionals' views following implementation of risk stratification into a national breast cancer screening programme

Background

It is crucial to determine feasibility of risk-stratified screening to facilitate successful implementation. We introduced risk-stratification (BC-Predict) into the NHS Breast Screening Programme (NHSBSP) at three screening sites in north-west England from 2019 to 2021. The present study investigated the views of healthcare professionals (HCPs) on acceptability, barriers, and facilitators of the BC-Predict intervention and on the wider implementation of risk-based screening after BC-Predict was implemented in their screening site.

Methods

Fourteen semi-structured interviews were conducted with HCPs working across the breast screening pathway at three NHSBSP sites that implemented BC-Predict. Thematic analysis interpreted the data.

Results

Three pre-decided themes were produced. (1) Acceptability of risk-based screening: risk-stratification was perceived as a beneficial step for both services and women. HCPs across the pathway reported low burden of running the BC-Predict trial on routine tasks, but with some residual concerns; (2) Barriers to implementation: comprised capacity constraints of services including the inadequacy of current IT systems to manage women with different risk profiles and, (3) Facilitators to implementation: included the continuation of stakeholder consultation across the pathway to inform implementation and need for dedicated risk screening admin staff, a push for mammography staff recruitment and guidance for screening services. Telephone helplines, integrating primary care, and supporting access for all language needs was emphasised.

Conclusion

Risk-stratified breast screening was viewed as a progressive step providing it does not worsen inequalities for women. Implementation of risk-stratified breast screening requires staff to be reassured that there will be systems in place to support implementation and that it will not further burden their workload. Next steps require a comprehensive assessment of the resource needed for risk-stratification versus current resource availability, upgrades to screening IT and building screening infrastructure. The role of primary care needs to be determined. Simplification and clarification of risk-based screening pathways is needed to support HCPs agency and facilitate implementation. Forthcoming evidence from ongoing randomised controlled trials assessing effectiveness of breast cancer risk-stratification will also determine implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10134-0.

Feasibility and Acceptability of Personalized Breast Cancer Screening (DECIDO Study): A Single-Arm Proof-of-Concept Trial

The aim of this study was to assess the acceptability and feasibility of offering risk-based breast cancer screening and its integration into regular clinical practice. A single-arm proof-of-concept trial was conducted with a sample of 387 women aged 40-50 years residing in the city of Lleida (Spain). The study intervention consisted of breast cancer risk estimation, risk communication and screening recommendations, and a follow-up. A polygenic risk score with 83 single nucleotide polymorphisms was used to update the Breast Cancer Surveillance Consortium risk model and estimate the 5-year absolute risk of breast cancer. The women expressed a positive attitude towards varying the frequency of breast screening according to individual risk and, especially, more frequently inviting women at higher-than-average risk. A lower intensity screening for women at lower risk was not as welcome, although half of the participants would accept it. Knowledge of the benefits and harms of breast screening was low, especially with regard to false positives and overdiagnosis. The women expressed a high understanding of individual risk and screening recommendations. The participants' intention to participate in risk-based screening and satisfaction at 1-year were very high.

Female Healthcare Workers' Knowledge, Attitude towards Breast Cancer, and Perceived Barriers towards Mammogram Screening: A Multicenter Study in North Saudi Arabia

Breast cancer is the most commonly diagnosed cancer among women in the Kingdom of Saudi Arabia and other Middle East countries. This analytical cross-sectional study assessed knowledge, attitude towards breast cancer, and barriers to mammogram screening among 414 randomly selected female healthcare workers from multiple healthcare facilities in northern Saudi Arabia. Of the studied population, 48.6% had low knowledge, and 16.1% had a low attitude towards breast cancer risk factors and symptoms. The common barriers to mammogram screening were fear to discover cancer (57.2%) and apprehension regarding radiation exposure (57%). Logistic regression analysis found that lack of awareness regarding mammogram was significantly associated with age (p = 0.030) and healthcare workers category (ref: physicians: p = 0.016). In addition, we found a significant negative correlation between knowledge and barrier scores (Spearman’s rho: −0.315, p < 0.001). It is recommended to develop target-oriented educational programs for the healthcare workers, which would empower them to educate the community regarding the risk factors and the importance of mammogram screening. Furthermore, a prospective study is warranted in other regions of the Kingdom of Saudi Arabia to understand the region-specific training needs for the healthcare workers.