Acceptability of risk stratification within population-based cancer screening from the perspective of healthcare professionals: A mixed methods systematic review and recommendations to support implementation

PLOS ONE RESEARCH ARTICLE Acceptability of risk stratification within population-based cancer screening from the perspective of healthcare professionals: A mixed methods systematic review and recommendations to support implementation a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 Lily C. Taylor ID1*, Katie Law2, Alison Hutchinson2, Rebecca A. Dennison ID1☯, Juliet A. Usher-Smith1☯ 1 The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom, 2 School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom ☯ These authors contributed equally to this work. * OPEN ACCESS Citation: Taylor LC, Law K, Hutchinson A, Dennison RA, Usher-Smith JA (2023) Acceptability of risk stratification within population-based cancer screening from the perspective of healthcare professionals: A mixed methods systematic review and recommendations to support implementation. PLoS ONE 18(2): e0279201. https://doi.org/ 10.1371/journal.pone.0279201 Editor: Lanjing Zhang, University Medical Center of Princeton at Plainsboro, UNITED STATES Received: July 15, 2022 Abstract Background Introduction of risk stratification within population-based cancer screening programmes has the potential to optimise resource allocation by targeting screening towards members of the population who will benefit from it most. Endorsement from healthcare professionals is necessary to facilitate successful development and implementation of risk-stratified interventions. Therefore, this review aims to explore whether using risk stratification within population-based cancer screening programmes is acceptable to healthcare professionals and to identify any requirements for successful implementation. Accepted: December 1, 2022 Published: February 24, 2023 Copyright: © 2023 Taylor et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are contained within the paper and/or Supporting Information files. Funding: This study is funded by a National Institute for Health and Care Research Advanced Fellowship (NIHR300861). https://www.nihr.ac.uk/ JUS (Advanced Fellowship NIHR300861) is funded by the NIHR for this research project. The views expressed are those of the author(s) and not Methods We searched four electronic databases from January 2010 to October 2021 for quantitative, qualitative, or primary mixed methods studies reporting healthcare professional and/or other stakeholder opinions on acceptability of risk-stratified population-based cancer screening. Quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Data were analysed using the Joanna Briggs Institute convergent integrated approach to mixed methods analysis and mapped onto the Consolidated Framework for Implementation Research using a ‘best fit’ approach. PROSPERO record CRD42021286667. Results A total of 12,039 papers were identified through the literature search and seven papers were included in the review, six in the context of breast cancer screening and one considering screening for ovarian cancer. Risk stratification was broadly considered acceptable, with the findings covering all five domains of the framework: intervention characteristics, outer PLOS ONE | https://doi.org/10.1371/journal.pone.0279201 February 24, 2023 1 / 30 PLOS ONE necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared no competing interests exist. Acceptability of risk stratification within cancer screening from the perspective of healthcare professionals setting, inner setting, characteristics of individuals, and process. Across these five domains, key areas that were identified as needing further consideration to support implementation were: a need for greater evidence, particularly for de-intensifying screening; resource limitations; need for staff training and clear communication; and the importance of public involvement. Conclusions Risk stratification of population-based cancer screening programmes is largely acceptable to healthcare professionals, but support and training will be required to successfully facilitate implementation. Future research should focus on strengthening the evidence base for risk stratification, particularly in relation to reducing screening frequency among low-risk cohorts and the acceptability of this approach across different cancer types. Introduction Cancer is a leading cause of global mortality with approximately 10 million cancer deaths and over 19 million new cancer diagnoses occurring in 2020 [1]. Moreover, these figures are expected to increase by almost 50% over the next two decades, amounting to a predicted 28.4 million cases in 2040 [1]. Prevention and early detection through population-based screening programmes is an effective way to reduce cancer incidence and/or mortality [2, 3]. However, as well as these benefits, cancer screening programmes are associated with costs and harms. These harms include false positive or false negative screening tests, overdiagnosis and overtreatment (where a cancer that would never cause any symptoms is diagnosed and treated), physical harms from screening or subsequent tests, and negative psychological impacts [3, 4]. Screening also incurs financial and resource costs within healthcare systems and increasing screening capacity in response to rising cancer incidence is not feasible in settings where resources are both finite and overstretched [3, 5]. Most cancer screening programmes operate a fixed regime where eligibility is based on age and/or sex and screening intervals are determined by the screening results, rather than additional individual level risk factors [5]. For example, all women aged over 25 in England are invited for cervical screening and those with a positive HPV result are invited for further screening with a reduced interval irrespective of their age or other individual level risk factors for cervical cancer. There is increasing interest in risk stratification within cancer screening programmes in order to improve the balance of benefits and harms for patients and distribute limited healthcare resources in the most efficient way [5–7]. Risk stratification involves tailoring elements of the cancer screening programme, such as test modality, screening interval or eligibility criteria, based on personal risk determined using individual level characteristics. Such an approach ensures that screening is targeted to those with the highest cancer risk whilst minimising harm to people of lower risk [5, 7]. For example, hi (...truncated)