Fragmented ownership and multilevel barriers to breast MRI screening among high-risk women: A qualitative study informing development of clinical decision support.

Background: Women at high risk for breast cancer include those with pathogenic variants in hereditary breast cancer predisposition genes, high-risk benign breast lesions, or a lifetime risk over 20% based on validated models. Supplemental breast MRI screening improves early detection and reduces interval cancers in high-risk women. Despite recommendations from professional organizations for breast MRI screening among high-risk women, uptake remains low. To better understand breast MRI utilization, we conducted a qualitative study exploring healthcare provider and patient perspectives to inform development of a screening module within our patient-facing web-based decision aid, Methods: We conducted semi-structured interviews with 20 women at high risk for breast cancer and 17 healthcare providers at an urban academic medical center in New York City. All interviews were transcribed verbatim and coded using Dedoose software. Transcripts were analyzed thematically to identify patterns in clinician communication strategies, MRI screening practices, as well as barriers and facilitators shaping implementation. Results: All enrolled providers were female, including six primary care providers (PCPs), five gynecologists, four breast radiologists, and two cancer genetic counselors. Among enrolled patients, mean age was 51.8 years (SD, 14.8) and 40% were Hispanic, 40% non-Hispanic White, 10% non-Hispanic Black, and 10% other. More than half of providers (59%) had ordered a breast MRI for high-risk patients, and 55% of patients had previously undergone MRI screening. The three themes that emerged included: 1) responsibility in initiating MRI screening was fragmented across specialties; 2) patients and providers encountered barriers at every step of the screening process, including knowledge gaps and uncertainty about insurance coverage; 3) both groups identified a need for clearer, consolidated guidelines and accessible resources to support informed decision-making. Conclusion: Our findings highlight the need to address structural and communication barriers to improve MRI screening uptake among high-risk women and their providers. Integrating electronic medical record (EMR)-based risk assessment and patient educational materials into clinical workflows may support informed, shared decision-making. Future work will involve design and usability testing of the