"Abstract

Background In England, NICE guidance recommends enhanced screening and prevention for women at increased breast cancer risk. This study aimed to map current risk assessment pathways for women under 50, explore existing challenges and opportunities for improvement, and assess the healthcare system's capacity and readiness for potential systemic change. Methods Informed by the systems engineering framework and the Consolidated Framework for Implementation Research, we conducted semi-structured interviews and a post interview questionnaire. Participants were 29 healthcare professionals and policy stakeholders across England with relevant expertise spanning all stages of the breast cancer risk assessment and management pathway. They were purposefully recruited through the research team’s networks and by using the snowball method. Data were analysed by using deductive thematic analysis. Questionnaire data were analysed descriptively. Results Participants discussed the challenges of the current pathway and consistently described it as fragmented with access often influenced more by ethnicity, geographic and socioeconomic factors than by clinical need. Participants identified six key areas where reform is needed, including a standardised national service, developing digital and flexible tools, a shift towards being proactive, division of responsibilities, need for funding, and strengthening skills in risk assessment. Conclusions This study demonstrates challenges, variation and missed opportunities in care within the current pathway for breast cancer risk assessment and management in women under 50. The readiness of the system to change is clear, and recommendations are made to support systemic reform which could contribute to the development of a more standardised, proactive, and equitable breast cancer risk assessment and management pathway."