Title: Perceived guideline clarity impacts guideline-concordant care for breast cancer screening
in women age 40-49
Version: 2 Date: 18 Nov 2022
Reviewer:  Maria José Pérez-lacasta
Reviewer's report:
Thank you for proposing me to review this work.
- The authors have already published a paper (reference 13) where they identify the barriers
or facilitators of variation amongst family physicians related to five behaviours we defined
as necessary to support guideline-concordant care for women aged 40-49: (i) breast cancer
risk assessment; (ii) discussion of benefits, harms, and preferences (‘shared decision-making’
SDM); (iii) decision/referral for screening mammogram; (iv) genetics referral; and (v) high-
risk screening enrolment. In the paper I am reviewing, only three determinants of breast cancer
screening best-practice behaviours are evaluated: 1) risk assessment; 2) discussion regarding
benefits and harms; and 3) referral for screening.
I found it difficult to follow the thread of this paper at times. As far as I understood it,
- In this paper, the authors stablish an operational definition of guideline-concordant care (best-
practice) in mammography screening in women aged 40-49 years, and identify two contextual
elements that influence physicians' behaviour in applying guidelines for breast cancer screening:
the perceived clarity of the guidelines and deferral to patient preferences defined as "screening
referral without a complete discussion of benefits and harms".
o if physicians do not clearly perceive the practices recommended in the clinical guidelines,
the risk assessment and discussion are affected.  PCPs who (rightly) perceived that guidelines
recommended against routine screening had greater knowledge of harms and stronger beliefs
about capabilities to explain why screening is not recommended routinely. Some physicians
did not interpret that the guidelines suggested a screening discussion with each woman in
this age group or interpreted the discussion as important, but were unclear on the guideline-
recommended content or purpose of the discussion. Some of them considered that all women in
their practice would value their personal health and accept any screening offered to them. Some
providers questioned the credibility of the guidelines, having more faith in the recommendations
of radiologists.
o If physicians had low knowledge regarding harms and/or if they experienced regret, then
deferral to patient preference occurs more often.
- the authors describe four demographic chacarteristics to explain sources of variation within
the dataset for the third behaviour (referral for mammography):
o gender,
o location of practice (urban versus sub-urban),
o Canadian versus non-Canadian medical graduate, and
o age (above or below average)
- And they describe four TDF domains:
o Social influence
o Beliefs in capabilty
o Beliefs about consequences
o Emotions
The two recommendations/suggestions I would make to the authors, in case they might be of
interest to them, are:
- Try to structure the article in a way that makes it easier to follow the underlying reasoning. To
this end, it might be appropriate to make explicit from the outset what the contexts, domains,
and the underlying cause-effect reasoning are.
- I understand that when clinical guidelines are not perceived as clear, this is the cause that
reduces good practice and concordance of BC screening guidelines. However, deferral to patient
preferences seems more a consequence than a cause (a consequence of the PCPs had low
knowledge regarding harms and/or if they experienced regret). Perhaps this causal relationship
should be better explained.
These suggestions are intended to make the paper easier to read for those unfamiliar with the
TDF methodology.
- Please, include OHIP in list of abbreviations