Introducing a low-risk breast screening pathway into the NHS Breast Screening Programme: Views from healthcare professionals who are delivering risk-stratified screening.

Victoria G Woof,David P French,Anthony Howell,Lorna Mcwilliams,Anthony J Maxwell,D Gareth Evans,Louise S Donnelly

doi:10.1177/17455065211009746

Abstract

Objectives:Proposals to stratify breast screening by breast cancer risk aim to produce a better balance of benefits to harms. Notably, risk estimation calculated from common risk factors and a polygenic risk score would enable high-risk women to benefit from more frequent screening or preventive medication. This service would also identify low-risk women who experience fewer benefits from attending, as lower grade and in situ cancers may be treated unnecessarily. It may therefore be appropriate for low-risk women to attend screening less. This study aimed to elicit views regarding implementing less frequent screening for low-risk women from healthcare professionals who implement risk-stratified screening.Methods:Healthcare professionals involved in the delivery of risk-stratified breast screening were invited to participate in a focus group within the screening setting in which they work or have a telephone interview. Primary care staff were also invited to provide their perspective. Three focus groups and two telephone interviews were conducted with 28 healthcare professionals. To identify patterns across the sample, data were analysed as a single dataset using reflexive thematic analysis.Results:Analysis yielded three themes: Reservations concerning the introduction of less frequent screening, highlighting healthcare professionals’ unease and concerns towards implementing less frequent screening; Considerations for the management of public knowledge, providing views on media impact on public opinion and the potential for a low-risk pathway to cause confusion and raise suspicion regarding implementation motives; and Deliberating service implications and reconfiguration management, where the practicalities of implementation are discussed.Conclusions:Healthcare professionals broadly supported less frequent screening but had concerns about implementation. It will be essential to address concerns regarding risk estimate accuracy, healthcare professional confidence, service infrastructure and public communication prior to introducing less frequent screening for low-risk women.

Highlights

Population-based breast cancer screening utilizes a ‘onesize-fits-all’ model, where most women within particular age ranges are screened with the same interval.[1]
This genetic information combined with common risk factors, such as family history, reproductive factors and mammographic density allows for an accurate breast cancer risk estimate
The reflexive thematic analysis produced three themes: (1) Reservations concerning the introduction of less frequent screening; (2) Considerations for the management of public knowledge; and (3) Deliberating service implications and reconfiguration management

Summary

Introduction

Population-based breast cancer screening utilizes a ‘onesize-fits-all’ model, where most women within particular age ranges are screened with the same interval.[1]. It is argued by some that the benefits of screening outweigh the harms, such as false-positive screens and over-diagnosis leading to overtreatment.[2] In the United Kingdom, it has been estimated that for every life saved from breast screening, three women are overdiagnosed.[3] For some, this balance of benefits to harms is too modest.[4]. A key benefit of risk estimation and a risk-stratified breast screening service is the ability to identify women at higher risk, affording them the opportunity to benefit from more frequent screening and preventive medications.[8] there are efforts globally to introduce risk stratification into national breast screening programmes.[9,10,11,12]

Objectives

Results

Discussion

Conclusion