Psychological impact of risk-stratified screening as part of the NHS Breast Screening Programme: multi-site non-randomised comparison of BC-Predict versus usual screening (NCT04359420)

Are Women's Breast Cancer Risk Appraisals in Line with Updated Clinical Risk Estimates Communicated? Results from a UK Family History Risk and Prevention Clinic

BACKGROUND

The incorporation of breast density and a polygenic risk score (PRS) into breast cancer risk prediction models can alter previously communicated risk estimates. Previous research finds that risk communication does not usually change personal risk appraisals. This study aimed to examine how women from the family history risk study appraise their breast cancer risk following communication of an updated risk estimate.

METHODS

In the family history risk study, 323 women attended a consultation to receive an updated breast cancer risk estimate. A subset (n = 190) completed a questionnaire, assessing their subjective breast cancer risk appraisals, satisfaction with the information provided, and cancer-related worry. One hundred and three were notified of a decreased risk, 34 an increased risk, and 53 an unchanged risk.

RESULTS

Women's subjective risk appraisals were in line with the updated risk estimates provided, with age, a PRS, and breast density explaining most of the variance in these appraisals. Those notified of an increased risk demonstrated higher subjective risk perceptions compared with those whose risk remained unchanged or decreased.

CONCLUSIONS

Women's subjective breast cancer risk appraisals are amenable to change following updated risk feedback, with new information breast density and a PRS accepted and integrated into existing risk appraisals. Trust in the service, the analogies, and visual communication strategies used may have positively influenced the integration of this new information.

IMPACT

Further research is warranted to assess whether similar patterns emerge for other illnesses and in different clinical contexts to determine the best strategies for communicating updated risk estimates.

Ethical Dimensions of Population-Based Lung Cancer Screening in Canada: Key Informant Qualitative Description Study

Normative issues associated with the design and implementation of population-based lung cancer screening policies are underexamined. This study was an exposition of the ethical justification for screening and potential ethical issues and their solutions in Canadian jurisdictions. A qualitative description study was conducted. Key informants, defined as policymakers, scientists and clinicians who develop and implement lung cancer screening policies in Canada, were purposively sampled and interviewed using a semi-structured guide informed by population-based disease screening principles and ethical issues in cancer screening. Interview data were analyzed using qualitative content analysis. Fifteen key informants from seven provinces were interviewed. Virtually all justified screening by beneficence, describing that population benefits outweigh individual harms if high-risk people are screened in organized programs according to disease screening principles. Equity of screening access, stigma and lung cancer primary prevention were other ethical issues identified. Key informants prioritized beneficence over concerns for group-level justice issues when making decisions about whether to implement screening policies. This prioritization, though slight, may impede the implementation of screening policies in a way that effectively addresses justice issues, a goal likely to require justice theory and critical interpretation of disease screening principles.

Risk stratification in breast screening workshop

Population screening for breast cancer (BC) is currently offered in the UK for women aged 50 to 71 with the aim of reducing mortality. There is additional screening within the national programme for women identified as having a very high risk of BC. There is growing interest in further risk stratification in breast screening, which would require a whole population risk assessment and the subsequent offer of screening tailored to the individual's risk. Some women would be offered more intensive screening than others or no screening. This might provide a better balance of screening benefits and harms for each individual than the current population age-based programme alone. The UK National Screening Committee (UK NSC) is considering using decision-analytic and other models to evaluate different risk stratification screening strategies and identify remaining gaps in evidence. This paper reports the proceedings of a UK NSC workshop where experts in the field discussed both risk prediction models, as well as decision-analytic models providing a benefit-harm analysis/economic evaluation of risk-stratified screening programmes (see Table 1). The aim of the meeting was to present and discuss the current work of experts, including some data which had not been published at the time of the meeting, to inform the UK NSC. The workshop was not intended to present a balanced evaluation of how to deliver screening in future. Areas for further work identified included methods for comparing models to assess accuracy, the optimum risk assessment tools, the digital screening infrastructure, acceptability of stratification, choice of screening test and reducing inequalities. A move to risk stratification of the whole programme would require a careful phased introduction with continuing assessment of real-world evidence during deployment.

Acceptability of de-intensified screening for women at low risk of breast cancer: a randomised online experimental survey

BACKGROUND

Risk-stratified approaches to breast screening show promise for increasing benefits and reducing harms. But the successful implementation of such an approach will rely on public acceptability. To date, research suggests that while increased screening for women at high risk will be acceptable, any de-intensification of screening for low-risk groups may be met with less enthusiasm. We report findings from a population-based survey of women in England, approaching the age of eligibility for breast screening, to compare the acceptability of current age-based screening with two hypothetical risk-adapted approaches for women at low risk of breast cancer.

METHODS

An online survey of 1,579 women aged 40-49 with no personal experience of breast cancer or mammography. Participants were recruited via a market research panel, using target quotas for educational attainment and ethnic group, and were randomised to view information about (1) standard NHS age-based screening; (2) a later screening start age for low-risk women; or (3) a longer screening interval for low-risk women. Primary outcomes were cognitive, emotional, and global acceptability. ANOVAs and multiple regression were used to compare acceptability between groups and explore demographic and psychosocial factors associated with acceptability.

RESULTS

All three screening approaches were judged to be acceptable on the single-item measure of global acceptability (mean score > 3 on a 5-point scale). Scores for all three measures of acceptability were significantly lower for the risk-adapted scenarios than for age-based screening. There were no differences between the two risk-adapted scenarios. In multivariable analysis, higher breast cancer knowledge was positively associated with cognitive and emotional acceptability of screening approach. Willingness to undergo personal risk assessment was not associated with experimental group.

CONCLUSION

We found no difference in the acceptability of later start age vs. longer screening intervals for women at low risk of breast cancer in a large sample of women who were screening naïve. Although acceptability of both risk-adapted scenarios was lower than for standard age-based screening, overall acceptability was reasonable. The positive associations between knowledge and both cognitive and emotional acceptability suggests clear and reassuring communication about the rationale for de-intensified screening may enhance acceptability.

Women's experiences of risk-stratified breast cancer screening in the MyPeBS trial: a qualitative comparative study across two European countries

OBJECTIVE

Risk-stratification should improve the benefits-to-harms ratio for breast screening, whereby higher-risk women receive additional screening and low-risk women are screened less. This study investigated the effects of healthcare context by comparing how women in England and France experienced risk-based breast screening.

METHODS AND MEASURES

Fifty-two women were purposively sampled from participants who underwent risk-based screening in the MyPeBS trial. Women received objectively-derived 5-year breast cancer risk estimates (low = < 1%, average = 1-1.66%, high = ≥ 1.67 to <6%, very-high-risk = ≥ 6%). This determined future trial-related screening schedules and prevention options. Semi-structured interviews were transcribed for thematic framework analysis.

RESULTS

Two overarching themes were produced: the importance of supported risk communication and accessibility of risk management. Overall, risk-based breast screening was viewed positively. However, trial procedures, especially in risk estimate provision, differed across sites. Women at increased risk were more reassured when appointments were with specialist healthcare professionals (HCP). When absent, this resulted in reduced satisfaction with risk communication and greater uncertainty about its personal relevance. Low-risk women's views on extended mammogram schedules seemed linked to how health services are organised differently.

CONCLUSIONS

Context is an important consideration regarding acceptability of healthcare innovations such as risk-stratified screening: it should not be assumed that findings from one country apply universally.

Clinical outcomes of screening and diagnostic mammography in a limited resource healthcare system

INTRODUCTION

Breast cancer is a significant public health concern in Jordan. It is the most common cancer among Jordanian women. Despite its high incidence and advanced stage at time of diagnosis, the uptake of breast cancer screening in Jordan is low. This study aims to compare clinical outcomes of both screening and diagnostic mammogram among women in Jordan.

METHODS

A retrospective cohort of 1005 women who underwent mammography in breast imaging unit in a tertiary hospital in Jordan. It aimed to investigate outcomes of screening and diagnostic mammography. recall rates, clinical manifestations and cancer rates were investigated.

RESULTS

A total of 1005 participants were involved and divided into screening group (n = 634) and diagnostic group (n = 371). Women in the diagnostic group were more likely to be younger, premenopausal, smokers with higher BMI. Among the screening group, 22.3% were labeled with abnormal mammogram, 26% recalled for ultrasound, 46 patients underwent tissue biopsy and a total of 12 patients had a diagnosis of breast carcinoma. Among the diagnostic group, the most commonly reported symptoms were a feeling of breast mass, mastalgia and nipple discharge. Abnormal mammogram was reported in 50.4% of women, a complementary ultrasound was performed for 205 patients. A diagnostic Tru-cut biopsy for 144 patients and diagnostic excisional biopsy for 17 patients were performed. A total of 131 had a diagnosis of carcinoma.

CONCLUSION

With the high possibility of identifying a carcinoma in mammography among symptomatic women and low uptake of screening mammogram, efforts to increase awareness and improve access to screening services are crucial in reducing the burden of breast cancer in Jordan.

"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.

Feasibility and acceptability of offering breast cancer risk assessment to general population women aged 30-39 years: a mixed-methods study protocol

INTRODUCTION

Breast cancer incidence starts to increase exponentially when women reach 30-39 years, hence before they are eligible for breast cancer screening. The introduction of breast cancer risk assessment for this age group could lead to those at higher risk receiving benefits of earlier screening and preventive strategies. Currently, risk assessment is limited to women with a family history of breast cancer only. The Breast CANcer Risk Assessment in Younger women (BCAN-RAY) study is evaluating a comprehensive breast cancer risk assessment strategy for women aged 30-39 years incorporating a questionnaire of breast cancer risk factors, low-dose mammography to assess breast density and polygenic risk. This study will assess the feasibility and acceptability of the BCAN-RAY risk assessment strategy.

METHODS AND ANALYSIS

This study involves women undergoing risk assessment as part of the BCAN-RAY case-control study (n=750). They will be aged 30-39 years without a strong family history of breast cancer and invited to participate via general practice. A comparison of uptake rates by socioeconomic status and ethnicity between women who participated in the BCAN-RAY study and women who declined participation will be conducted. All participants will be asked to complete self-report questionnaires to assess key potential harms including increased state anxiety (State Trait Anxiety Inventory), cancer worry (Lerman Cancer Worry Scale) and satisfaction with the decision to participate (Decision Regret Scale), alongside potential benefits such as feeling more informed about breast cancer risk. A subsample of approximately 24 women (12 at average risk and 12 at increased risk) will additionally participate in semistructured interviews to understand the acceptability of the risk assessment strategy and identify any changes needed to it to increase uptake.

ETHICS AND DISSEMINATION

Ethical approval was granted by North West-Greater Manchester West Research Ethics Committee (reference: 22/NW/0268). Study results will be disseminated through peer-reviewed journals, conference presentations and charitable organisations.

TRIAL REGISTRATION NUMBER

NCT05305963.

How do women at increased risk of breast cancer make sense of their risk? An interpretative phenomenological analysis

OBJECTIVES

Offering breast cancer risk prediction for all women of screening age is being considered globally. For women who have received a clinically derived estimate, risk appraisals are often inaccurate. This study aimed to gain an in-depth understanding of women's lived experiences of receiving an increased breast cancer risk.

DESIGN

One-to-one semi-structured telephone interviews.

METHODS

Eight women informed that they were at a 10-year above-average (moderate) or high risk in a breast cancer risk study (BC-Predict) were interviewed about their views on breast cancer, personal breast cancer risk and risk prevention. Interviews lasted between 40 and 70 min. Data were analysed using Interpretative Phenomenological Analysis.

RESULTS

Four themes were generated: (i) encounters with breast cancer and perceived personal significance, where the nature of women's lived experiences of others with breast cancer impacted their views on the significance of the disease, (ii) 'It's random really': difficulty in seeking causal attributions, where women encountered contradictions and confusion in attributing causes to breast cancer, (iii) believing versus identifying with a clinically-derived breast cancer risk, where personal risk appraisals and expectations influenced women's ability to internalize their clinically derived risk and pursue preventative action and (iv) perceived utility of breast cancer risk notification, where women reflected on the usefulness of knowing their risk.

CONCLUSIONS

Providing (numerical) risk estimates appear to have little impact on stable yet internally contradictory beliefs about breast cancer risk. Given this, discussions with healthcare professionals are needed to help women form more accurate appraisals and make informed decisions.