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: 13 Feb 2022
Reviewer:  Montserrat Rué
Reviewer's report:
General comment
The study assessed NHS staff perspectives on the optimal pathway for delivering personalized
breast cancer risk feedback for all women, and further prevention and early detection services
within the NHS-BSC and Family History Risk and Prevention Clinics for women identified as
being at higher risk of breast cancer. The healthcare staff were asked for their views as part of
formative work for the Breast Cancer Predict (BC-Predict) study, with the expectation that these
pathways were to be implemented for eight months at the sites where they worked.
The study was designed as a qualitative  study of focus groups with healthcare professionals
working in three UK breast screening services. The authors mention a study protocol, published
in BMC Cancer in 2020 by French et al. (reference #6), that provided information on a sub-
study of the PROCAS-2 project. It seems to me that the protocol sub-study corresponds to the
present study, although I see a design difference. The sub-study protocol says: "General Practice,
Radiology and FHRP Clinic staff will be invited to participate in focus groups 2 months after
BC-Predict has stopped being provided in each location". However, in the present study, the
authors state that the professionals had the expectation that the pathways were to be implemented
for eight months, the time that corresponds to the BC-Predict phase of the trial. Logistic issues
probably explain this difference.
In my opinion, the study is technically sound. The results shed light on relevant issues that need
to be taken into account before implementing personalized breast cancer screening.
Some specific comments are mentioned below.
Title: I would include the word "qualitative" or "focus groups".
Abstract and introduction: Both seem fine to me.
Methods: I recommend a more explicit and complete report of the methods, as recommended
by the COREQ checklist (Tong A et al. Consolidated criteria for reporting qualitative research
(COREQ): a 32-item checklist for interviews and focus groups, Int J Quality in Health Care,
19 (6): 349–357).
If the authors have omitted the reporting criteria because the protocol already specifies them,
they should include reference #6 in this section. Even if the authors mention the study protocol,
a brief description of the theoretical framework or methodological perspective, of the quality
and rigor of the study, and of the demographic characteristics of the focus groups participants,
would be worthwhile. Also, the number of participants in each focus group or the minimum and
maximum would be useful.
Results:
In “Theme 3-Accentuating inequity”, in the first sub-theme "Personal barriers" I assume that the
authors refer to women's personal barriers, not professionals' personal barriers. Better to clarify.
Discussion:
The second paragraph of the discussion could include additional references, such as:
Esquivel-Sada D et al. Envisioning implementation of a personalized approach in breast cancer
screening programs: Stakeholder perspectives. Healthcare policy 2019; 15(2), 39–54. https://
doi.org/10.12927/hcpol.2019.26072
Although based on theoretical scenarios, recent publications by our research group may also be
of interest to the authors:
Laza-Vásquez C et al. Views of health professionals on risk-based breast cancer screening and
its implementation in the Spanish National Health System: A qualitative discussion group study.
PLoS One. 2022; 17(2): e0263788. https:// doi.org/10.1371/journal.pone.0263788
Laza-Vásquez C et al. Barriers and Facilitators to the Implementation of a Personalized Breast
Cancer Screening Program: Views of Spanish Health Professionals. Int. J. Environ. Res. Public
Health. 2022; 19, 1406. https://doi.org/10.3390/ ijerph19031406
Academic
The third paragraph could also include some additional references that show lack of consensus
when providing notification to high-risk women. The fifth paragraph could also include the
Lévesque et al. reference.
Hagan J et al. Influence des facteurs organisationnels sur l’implantation d’une approche
personnalisée de dépistage du cancer du sein. Santé Publique. 2016;28:353-361
Lévesque E et al. Organizational challenges to equity in the delivery of services within a new
personalized risk-based approach to breast cancer screening, New Genetics and Society. 2019;
38:1, 38-59, DOI: 10.1080/14636778.2018.1549477
Rainey L et al. Are we ready for the challenge of implementing risk-based breast
cancer screening and primary prevention? The Breast. 2018; 39,24-32. https://doi.org/https://
doi.org/10.1016/j.breast.2018.02.029
In the fifth paragraph, in relation to women's anxiety, the following paper with participation of
the present study authors, could be cited:
Rainey L et al. Women's health behaviour change after receiving breast cancer risk estimates
with tailored screening and prevention recommendations. BMC Cancer. 2022; 22(1):69. doi:
10.1186/s12885-022-09174-3.
In the last paragraph of the discussion, the authors mention the difficulty of recruiting
Primary Care professionals for the focus groups. As far as I know, the BC-Predict study is
testing the implementation of personalized screening in the current screening services. In our
theoretical studies with health professionals we have explored the scenario where Primary
Care professionals have an active role and the screening services coordinate the tasks of other
professionals. In fact, the trust relationship between women and general practitioners was
considered a strong facilitator for the implementation of risk-based screening. I recommend that
the authors discuss that other organizational implementations, besides the BC-Predict one, could
be explored.
Conclusion: Seems fine to me
References:  Some references are a bit old (e.g. 11-14, 16, 18, 21). People may have different
attitudes, values and preferences with respect to screening.