Table 3 Example quotations from interviewed primary care clinicians describing risk assessment practices and awareness/approach to B-PREP referrals

Focus on family history

“I always take a family history and I always update the family history once a year…that’s kind of the red flag for me…into whether they need further evaluation in terms of their risk.”

“I ask every single patient when I'm scheduling a mammogram about their family history, if I have not done so already.”

“I generally ask a patient history: their own history, family history, menarche….There’s not really anything else.”

“I tend to focus on family history in order to assess risk and I usually have a brief discussion about USPSTF guidelines (and) the ACS guidelines…then we use that plus our gestalt of that patient’s risk to make a plan.”

Timing and frequency of risk discussions

“If they don't have a strong family history, then I just start the discussion at age 40.”

“I try to talk about (breast cancer risk) with every patient, either when they turn 40 or – and then I update it at age 45 and age 50.”

“I start at age 40 because some guidelines recommend women start screening at age 40.”

“At age 40, that’s when I have a more directive conversation (about risk), and I might be more inclined to do a formal assessment if somebody is having trouble deciding whether they want to get a mammogram or not.”

“(I discuss risk) usually every year, at least to some extent. It’s probably not a long conversation, but at least I will check to see have they had a mammogram. Do they need one? Has anything changed?”

Use of risk assessment tools

“There might be some (tools) that I should be using but I don't use. I'm certainly aware of other risk factors, but I don't really use (the tools) in changing what I would do, you know?”

“I either use the BRCA risk tool from – on the NIH website, or the breast cancer surveillance consortium risk tool. Rarely, if a patient has a complicated family history, I might use the Tyrer-Cuzick model.”

“I know there are some online tools, and I haven’t accessed them recently, so I can’t tell you what they are. But I'd do a search if I needed to or felt like I needed to. But I haven’t – I probably should.”

Time constraints

“I don’t (use breast cancer risk assessment tools) that often. That is something that I can’t fit into a 30-min visit, so if I (use them), it tends to be…after the visit. We might use the Gail model (or) the Tyrer-Cuzick model that’s more helpful with family history, but realistically am I doing that all the time in a 30-min visit? No.”

Awareness of B-PREP and patient clustering

“I think I personally am taking care of about 25 percent of all of the minority patients at (our clinic), so my lack of knowledge about (B-PREP) is probably one factor (contributing to lower referral rates). And I think many of our minority patients – Black and Latinx patients are cared for by our residents. And I'm not certain – you know, I think that if I hadn’t figured out that the program existed, I don't know how our residents would have known that it existed

“I think that they – there’s a lack of awareness among many of the providers, it sounds like, taking care of the Black and Latinx women.”

“At many centers like the Brigham where a higher percentage of the minority patients are taken care of by residents, we run the risk that every single one of the preventive measures our counseling measures are being done less actively for the minority patients.”

Confusion between B-PREP and genetics

“If there’s multiple family members (with cancer) that’s when (I will) talk about a genetics referral. It’s very confusing from our side when to refer to B-PREP versus genetics. I tend to use genetics more often, because we’re trying to figure out is there a genetic factor involved with a strong family history…I usually have to remind people multiple times to go.”

Limited value of B-PREP

“I don’t send (many) people to B-PREP because I feel like I have a pretty good understanding of this area.”

“In my practice I would say, I’m not sure B-PREP is critical because I can offer a lot of what B-PREP does. And I think a really good PCP should be able to do that.”