Table 4 Example clinician quotations regarding perceived contributors to disparities in B-PREP referrals

Patient concern and discussions with patients

“The higher socioeconomic patients, which in my practice generally are White, are more attuned to breast cancer risk, more nervous about breast cancer, more aware of risk reduction and risk…do they need a MRI…do they want an ultrasound. That probably contributes to (who I refer).”

“The people that I’ve sent to B-PREP are (those) that want more than I can give, and they…are doubting (me). Am I enough of an expert in this area to give them all the answers that they want? That (then) leads me to say: there’s this great clinic called B-PREP and they can answer your questions.”

“It is not always feasible for underrepresented populations to be as assertive and to get the same outcome.”

“Maybe through racism, providers are less likely to have the nuanced discussion (with people of color) that often precedes referring to B-PREP.”

“I think, personally, doctors are more likely to dismiss minority patients’ concerns and see them as being angry or over advocating for themselves or being anxious or all sorts of demeaning ways of seeing it when they do advocate for themselves… I do think that communication problems between Black patients and Latinx patients with doctors who are different from them may contribute, or not, you know, like letting them talk enough or not listening to their concerns or focusing on other things and not making enough time to talk about these sorts of things.”

Awareness of breast cancer risk

“When it comes to these screening programs and risk modification programs, there is a perception that it’s just for White women.”

“I think part of cultural and our American society has kind of steered the conversation toward breast cancer as more common in White women. Even though we know that’s not true, but that perception is out there.”

“(For) White women, breast cancer is all those pink ribbon things – even though there’s been an attempt to change that,…the image is that breast cancer is for White women.”

Competing morbidities

“I think that competing priorities operate both for patients and for providers.”

“Due to socioeconomic (factors) and structural racism, Black women are more likely to have more medical problems, so that the visit is like more tied up with that.”

“The things that would make me more likely to refer someone would be if I actually took the time to talk to them and hear about their risk factors. And so, maybe there’s a difference in the kinds of conversations that doctors have with their patients depending on the patient’s race.”

Language barriers

“For my Spanish-speaking patients, they’re often more comfortable being seen at the health center. We have a lot of specialists who are available and come to our health center and that can be much easier geographically and logistically (for Spanish-speaking patients than going into Boston main campus for B-PREP).”

“It is harder for me to have a nuanced discussion about risk in Spanish than it is in English…our phone interpreters are very variable and the time that you have to spend with a Spanish-speaking patient is the same as the time that you have with an English-speaking patient, however, the visit is literally one half as long because everything has to get said twice.”