Journal of General Internal Medicine

, Volume 33, Issue 11, pp 1905–1912 | Cite as

How Do Women View Risk-Based Mammography Screening? A Qualitative Study

  • Xiaofei He
  • Karen E. Schifferdecker
  • Elissa M. Ozanne
  • Anna N. A. Tosteson
  • Steven Woloshin
  • Lisa M. Schwartz
Original Research



Decades of persuasive messages have reinforced the importance of traditional screening mammography at regular intervals. A potential new paradigm, risk-based screening, adjusts mammography frequency based on a woman’s estimated breast cancer risk in order to maximize mortality reduction while minimizing false positives and overdiagnosis. Women’s views of risk-based screening are unknown.


To explore women’s views and personal acceptability of a potential risk-based mammography screening paradigm.


Four semi-structured focus group discussions about screening mammography and surveys before provision of information about risk-based screening. We analyzed coded focus group transcripts using a mixed deductive (content analysis) and inductive (grounded theory) approach.


Convenience sample of 29 women (40–74 years old) with no personal history of breast cancer recruited by print and online media in New Hampshire and Vermont.


Twenty-seven out of 29 women reported having undergone mammography screening. All participants were white and most were highly educated. Some women accepted the idea that early cancer detection with traditional screening was beneficial—although many also reported hearing inconsistent recommendations from clinicians and mixed messages from media reports about mammography. Some women were familiar with a risk-based screening paradigm (primarily related to cervical cancer, n = 8) and thought matching screening mammography frequency to personal risk made sense (n = 8). Personal acceptability of risk-based screening was mixed. Some believed risk-based screening could reduce the harms of false positives and overdiagnosis (n = 7). Others thought screening less often might result in missing a dangerous diagnosis (n = 14). Many (n = 18) expressed concerns about the feasibility of risk-based screening and questioned whether breast cancer risk estimates could be accurate. Some suspected that risk-based mammography was motivated by a desire to save money (n = 6).


Some women thought risk-based screening made sense. Willingness to abandon traditional screening for the new paradigm was mixed. Broad acceptability of risk-based screening will require clearer communication about its rationale and feasibility and consistent messages from the health care team.


risk-based screening mammography over-diagnosis health communication 



We also wish to express our gratitude to the focus group participants who shared their valuable insights and experiences.


This study was supported in part by funding from the National Cancer Institute (R25CA134286, P01CA154292, and P30CA023108).

Compliance with ethical standards

All study materials and procedures were approved by the Committee for the Protection of Human Subjects at Dartmouth College.

Conflicts of interest

Drs. Schwartz and Woloshin have served as medical experts in testosterone litigation and were the cofounders of Informulary, Inc., a company that provided data about the benefits and harms of prescription drugs, which ceased operations in December 2016. Other authors declare no conflicts of interest.

Supplementary material

11606_2018_4601_MOESM1_ESM.docx (29 kb)
ESM 1 (DOCX 28 kb)


  1. 1.
    Silverman E, Woloshin S, Schwartz LM, Byram SJ, Welch HG, Fischhoff B. Women’s Views on Breast Cancer Risk and Screening Mammography: A Qualitative Interview Study. Med Decis Making. 2001;21(3):231–240. doi: Scholar
  2. 2.
    Woloshin S, Schwartz LM. The Benefits and Harms of Mammography Screening: Understanding the Trade-offs. JAMA. 2010;303(2):164–165. doi: Scholar
  3. 3.
    Onega T, Beaber EF, Sprague BL, Barlow WE, Haas JS, Tosteson ANA, et al. Breast cancer screening in an era of personalized regimens: A conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level. Cancer. 2014;120(19):2955–2964. doi: Scholar
  4. 4.
    National Center for Health Statistics. Health, United States, 2016 with Charterbook on Long-term Trends in Health. Hyattsville, MD. 2017. Available at: Accessed Feb 3, 2018.
  5. 5.
  6. 6.
    Trentham-Dietz A, Kerlikowske K, Stout NK, Miglioretti DL, Schechter CB, Ergun MA , et al. Tailoring Breast Cancer Screening Intervals by Breast Density and Risk for Women Aged 50 Years or Older: Collaborative Modeling of Screening Outcomes. Annals of Internal Medicine. 2016. doi: Scholar
  7. 7.
    Pace LE, Keating NL. A Systematic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions. JAMA. 2014;311(13):1327–1335. doi: PubMedCrossRefGoogle Scholar
  8. 8.
    Myers ER, Moorman P, Gierisch JM, Havrilesky LJ, Grimm LJ, Ghate S, et al. Benefits and Harms of Breast Cancer Screening: A Systematic Review. JAMA. 2015;314(15):1615–1634. doi: Scholar
  9. 9.
    Spring LM, Marshall MR, Warner ET. Mammography decision making: Trends and predictors of provider communication in the Health Information National Trends Survey, 2011 to 2014. Cancer. 2017;123(3):401–409. doi: PubMedCrossRefGoogle Scholar
  10. 10.
    Bleyer A. Screening Mammography. Academic Radiology. 2015;22(8):949–960. doi: Scholar
  11. 11.
    Meads C, Ahmed I, Riley RD. A systematic review of breast cancer incidence risk prediction models with meta-analysis of their performance. Breast Cancer Res Treat. 2012;132(2):365–377. doi: PubMedCrossRefGoogle Scholar
  12. 12.
    Cuzick J, Brentnall A, Dowsett M. SNPs for breast cancer risk assessment. Oncotarget 2017;8(59):99211–99212. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Guest G, Bunce A, Johnson L. How Many Interviews Are Enough? An Experiment with Data Saturation and Variability. Field Methods. 2006;18(1):59–82. doi: CrossRefGoogle Scholar
  14. 14.
    Final Recommendation Statement: Breast Cancer: Screening - US Preventive Services Task Force. Accessed May 23, 2018.
  15. 15.
    Dedoose Version 7.0.23, web application for managing, analyzing, and presenting qualitative and mixed method research data (2016). Los Angeles, CA: SocioCultural Research Consultants, LLC. Available at Accessed February 6, 2018.
  16. 16.
    Corbin J, Strauss AL. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Sage Publications Inc.; 2008.Google Scholar
  17. 17.
    Akinyemiju TF, Soliman AS, Yassine M, Banerjee M, Schwartz K, Merajver S. Healthcare access and mammography screening in Michigan: a multilevel cross-sectional study. Int J Equity Health. 2012;11(16). doi: PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Coughlin SS, Leadbetter S, Richards T, Sabatino SA. Contextual analysis of breast and cervical cancer screening and factors associated with health care access among United States women, 2002. Soc Sci Med. 2008; 66(2):260–275. doi: CrossRefGoogle Scholar
  19. 19.
    Hubbard RA, O’Meara ES, Henderson LM, Henderson LM, Hill D, Braithwaite D, et al. Multilevel factors associated with long-term adherence to screening mammography in older women in the U.S. Prev Med. 2016; 89:169–177. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Rosenberg L, Wise LA, Palmer JR, Horton NJ, Adams-Campbell LL. A multilevel study of socioeconomic predictors of regular mammography use among African-American women. Cancer Epidemiol Biomarkers Prev. 2005;14(11): 2628–2633. doi: PubMedCrossRefGoogle Scholar
  21. 21.
    McCaffery KJ, Jansen J, Scherer LD, Thornton H, Hersch J, Carter SM, et al. Walking the tightrope: Communicating overdiagnosis in modern healthcare. BMJ 2016;352:I348. doi: PubMedCrossRefGoogle Scholar
  22. 22.
    Taplin SH, Price RA, Edwards HM, Edwards HM, Foster MK, Breslau ES, et al. Introduction: Understanding and influencing multilevel factors across the cancer care continuum. J Natl Cancer Inst Monogr. 2012;44:2–10. doi: doi:
  23. 23.
    Stange KC, Breslau ES, Dietrich AJ, Glasgow RE. State-of-the-art and future directions in multilevel interventions across the cancer control continuum. J Natl Cancer Inst Monogr. 2012;44:20–31. doi: CrossRefGoogle Scholar
  24. 24.
    Zapka J, Taplin SH, Ganz P, Grunfeld E, Sterba K. Multilevel Factors Affecting Quality: Examples From the Cancer Care Continuum. J Natl Cancer Inst Monogr. 2012;2012(44):11–19. doi: Scholar
  25. 25.
    Allen JD, Bluethmann SM, Sheets M, Opdyke KM, Gates-Ferris K, Hurlbert M, et al. Women’s responses to changes in U.S. preventive task force’s mammography screening guidelines: results of focus groups with ethnically diverse women. BMC Public Health. 2013;13:1169. doi: Scholar
  26. 26.
    Kiviniemi MT, Hay JL. Awareness of the 2009 US Preventive Services Task Force recommended changes in mammography screening guidelines, accuracy of awareness, sources of knowledge about recommendations, and attitudes about updated screening guidelines in women ages 40–49 and 50+. BMC Public Health. 2012;12:899. doi: Scholar
  27. 27.
    Ghanouni A, Meisel SF, Renzi C, Wardle J, Waller J. Survey of public definitions of the term “overdiagnosis” in the UK. BMJ Open. 2016;6(4):e010723. doi: Scholar
  28. 28.
    Moynihan R, Nickel B, Hersch J, Doust J, Barratt A, Beller E, et al. What do you think overdiagnosis means? A qualitative analysis of responses from a national community survey of Australians. BMJ open. 2015;5(5):e007436. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Nagler RH, Franklin Fowler E, Gollust SE. Women’s Awareness of and Responses to Messages About Breast Cancer Overdiagnosis and Overtreatment: Results From a 2016 National Survey. Medical Care. 2017;55(10):879. doi: Scholar
  30. 30.
    Waller J, Douglas E, Whitaker KL, Wardle J. Women’s responses to information about overdiagnosis in the UK breast cancer screening programme: a qualitative study. BMJ Open. 2013;3(4):e002703. doi: Scholar
  31. 31.
    Toledo-Chávarri A, Rué M, Codern-Bové N, Carles-Lavila M, Perestelo-Pérez L, Pérez-Lacasta MJ, et al. A qualitative study on a decision aid for breast cancer screening: Views from women and health professionals. Eur J Cancer Care. 2017;26(3):n/a. doi: Scholar
  32. 32.
    Henriksen MJV, Guassora AD, Brodersen J. Preconceptions influence women’s perceptions of information on breast cancer screening: a qualitative study. BMC Research Notes. 2015;8:404. doi: Scholar
  33. 33.
    Festinger L. A Theory of Cognitive Dissonance. Stanford University Press; 1962.Google Scholar
  34. 34.
    Haas JS, Sprague BL, Klabunde CN, Tosteson ANA, Chen JS, Bitton A, et al. Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines. J GEN INTERN MED. 2016;31(1):52–59. doi: Scholar
  35. 35.
    Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, et al. Physician Adherence to U.S. Preventive Services Task Force Mammography Guidelines. Women’s Health Issues. 2014;24(3):e313-e319. doi: Scholar
  36. 36.
    Yasmeen S, Romano PS, Tancredi DJ, Saito NH, Rainwater J, Kravitz RL. Screening mammography beliefs and recommendations: a web-based survey of primary care physicians. BMC Health Services Research. 2012;12:32. doi: Scholar
  37. 37.
    Siu AL, U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(4):279–296. doi: PubMedCrossRefGoogle Scholar
  38. 38.
    Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Committee on Practice Bulletins—Gynecology. Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women. Obstet Gynecol. 2017;130(1):e1-e16. doi: CrossRefGoogle Scholar
  40. 40.
    Hersch J, Barratt A, Jansen J, et al. Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. The Lancet. 2015;385(9978):1642–1652. doi: CrossRefGoogle Scholar
  41. 41.
    Ivlev I, Hickman EN, McDonagh MS, Eden KB. Use of patient decision aids increased younger women’s reluctance to begin screening mammography: a systematic review and meta-analysis. J GEN INTERN MED. 2017;32(7):803–812. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Yang T-C, Matthews SA, Hillemeier MM. Is health care system distrust a barrier to breast and cervical cancer screening? Evidence from Philadelphia. American journal of public health. 2011;101(7):1297. doi: PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Fotaki M. Can consumer choice replace trust in the National Health Service in England? Towards developing an affective psychosocial conception of trust in health care. Sociology of Health & Illness. 36(8):1276–1294. doi: CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Xiaofei He
    • 1
  • Karen E. Schifferdecker
    • 1
    • 2
  • Elissa M. Ozanne
    • 3
  • Anna N. A. Tosteson
    • 1
    • 4
  • Steven Woloshin
    • 1
    • 2
    • 4
  • Lisa M. Schwartz
    • 1
    • 2
    • 4
  1. 1.Geisel School of Medicine at DartmouthThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonUSA
  2. 2.Department of Community and Family MedicineGeisel School of Medicine at DartmouthLebanonUSA
  3. 3.Department of Population Health SciencesUniversity of UtahSalt Lake CityUSA
  4. 4.Dartmouth-Hitchcock Norris Cotton Cancer CenterLebanonUSA

Personalised recommendations