Title: The feasibility of implementing risk stratification into a national breast cancer screening
programme: A focus group study investigating perspectives of healthcare personnel responsible
for delivery
Version: 1 Date: 16 Feb 2022
Reviewer:  Julie Hagan
Reviewer's report:
This article examines the timely issue of implementing risk stratification approaches in breast
cancer screening programs. It is particularly relevant because it considers the feasibility of such
approaches in the context of a publicly funded and financially constrained health system. This
paper has the potential to grab the attention of a broad audience, including academics, public
health experts and policymakers. However, the paper presents some weaknesses that authors
should address before publication:
1. A major point that should be addressed before publication is the section entitled "Underserved
group resistance". The authors appear to be making unsubstantiated associations between
belonging to a group of low economic status, immigrant background, poorer health literacy and
the risk of developing breast cancer. On the contrary, many studies have shown that higher
socioeconomic status is associated with increased breast cancer risk (Pudrovska and Anikputa
2012; Yu et al. 2014; Palmer et al. 2012; Borugian et al. 2011). We strongly suggest that the
authors rewrite this section more critically without taking at face value the opinion of focus
group participant (radiograph 5 - site B) who associates low health literacy with poor lifestyle
choices and infers that it may increase cancer risk. While health literacy level influences the
clinical outcome of cancer – in part because people with lower health literacy are less likely to be
screened early – (Samoil, D., Kim, J., Fox, C., & Papadakos, J. K. 2021), it has no direct effect on
breast cancer risk itself. There are some correlations between lack of health literacy and lifestyle
choices (e.g., alcohol consumption, smoking, etc.) and between these choices and increased
cancer risk. However, correlation does not mean causation, and more nuance is needed to avoid
perpetuating prejudices and biases. In addition, the vocabulary in this section should be more
rigorous and in line with that of social inequalities in health. For example, the term "learning
disabilities" should be replaced with the more general term "low health literacy" as learning
disabilities are only one dimension of health literacy (along with age, language proficiency, etc.).
In general, the authors should be deliberate in distinguishing their description and analysis of
the data from the data itself (what was said by FG participants).
2. The data collection (focus groups) and analysis (thematic, inductive) methods chosen
are coherent with the research objective. However, they are not sufficiently described. We
recommend that the authors review the "Methods" section using the Consolidated criteria for
reporting qualitative research (COREQ) 32-item checklist. A methodological strength is the
diversity of HPC represented in the focus groups. The inclusion of many radiographers is
especially relevant given their role as the first point of contact for women.
3. Throughout the text, the authors alternately use the terms “estimating each woman’s risk
of breast cancer”, “individual estimation” and “high-risk”. It should be more explicitly stated
whether women will receive information about their individual risk or whether they will be
informed of the broader risk category in which they fall (ex. low, intermediate, high, etc.). This
has implications for risk communication, risk perception, and ultimately service delivery.
Despite these limitations, the paper is well-written and addresses an important and timely
issue. The authors make a convincing argument for service developments to ensure that risk-
stratification is implemented optimally in financially and time-constrained settings. Insofar as
the authors address the problems of the section "Underserved group resistance" and expand the
presentation of their methods, the manuscript is promising. It has the potential to contribute to
the development of much-needed knowledge as many health systems consider moving forward
with the implementation of risk stratification in their current breast cancer screening programs.