The scientific premise behind BCAN-RAY rests on a decade of progress in breast cancer risk prediction. Statistical models such as BOADICEA, developed by researchers including Antonis Antoniou and colleagues, and the Tyrer-Cuzick model now integrate genetic variants, family history, mammographic density and lifestyle factors to estimate an individual woman’s likelihood of developing breast cancer over her lifetime. Risk-stratified screening programmes such as MyPeBS in Europe and the WISDOM trial in the United States are testing whether tailoring screening intensity to predicted risk can outperform one-size-fits-all mammography. But these efforts focus on women already old enough to attend routine screening, typically from age 50 in the United Kingdom. Women in their thirties who carry elevated risk are largely invisible to the system, despite evidence that identifying them early could open a window for preventive interventions such as risk-reducing medication and earlier surveillance.

BCAN-RAY was designed to fill that gap. Between May 2023 and May 2025, seventeen general practices operating across twenty-five sites in Greater Manchester and Cheshire searched their electronic records to identify women aged 30 to 39 who were biologically female, able to give informed consent, and free of a strong family history of breast cancer, defined as a first-degree relative diagnosed under the age of 50 or two or more second-degree relatives diagnosed at any age. Women already under follow-up in a family history clinic, those with known mutations in moderate or high-risk breast cancer genes, anyone with a prior malignancy other than non-melanoma skin cancer, women who had undergone double mastectomy or breast augmentation, those who were pregnant or recently breastfeeding, and women unable to understand written English were excluded. In total, 14,366 women were invited by postal letter from their own general practice, with no reminders sent and an identical invitation process at every site.

Those who enrolled undertook a genuinely comprehensive assessment. Participants completed a self-reported risk factor questionnaire, provided a saliva sample for genetic analysis, and attended the Nightingale Centre in Manchester, a centre of excellence for breast cancer treatment and research, for a hospital visit including low-dose mammography to measure breast density. Appointments were available on weekdays and Saturday mornings, could be rescheduled if needed, and travel and parking costs were reimbursed. Women found to be at increased risk were offered a telephone consultation with an experienced breast oncologist to discuss early screening and preventive options, including risk-reducing medication, in line with National Institute for Health and Care Excellence recommendations. Study uptake was defined as completion of this full risk assessment process.

The headline numbers are sobering. Overall uptake was just 5.2 percent, with 750 of 14,366 invited women completing the assessment. More striking still was the pattern of who those 750 women were. Among women whose records could be mapped to the five high-level ethnic categories used in the 2021 Census for England, uptake among White women stood at 13.1 percent, with 654 of 5,005 invited White women enrolling. By contrast, only 10 of 511 invited Black women took part, an uptake of 2.0 percent, and just 50 of 2,089 Asian women, or 2.4 percent. Uptake among women of Mixed or multiple ethnic groups was 4.6 percent and among the Other ethnic group 5.5 percent. A chi-squared test confirmed a highly significant association between ethnicity and participation, with a test statistic of 219.86 on four degrees of freedom and a p-value below 0.001. After Holm correction for the ten possible pairwise comparisons, every contrast between the White group and each of the four minority groups remained statistically significant at an adjusted p-value of 0.010, while no differences between minority groups themselves survived adjustment.

Socioeconomic gradients told a parallel story. The researchers used the 2019 Index of Multiple Deprivation, a standardized geographic measure that combines seven domains including income, employment, education, health, crime, barriers to housing and services, and living environment, to classify residential neighbourhoods into quintiles from most to least deprived. Of 14,078 women with complete deprivation data, uptake ranged from 3.4 percent in the most deprived quintile to 7.7 percent in the least deprived, with a highly significant overall association of chi-squared 75.31 on four degrees of freedom. Holm-corrected post hoc tests showed that the statistically significant gaps were specifically between the least deprived quintile and the two most deprived quintiles, at an adjusted p-value of 0.010, indicating that the sharpest divide in participation runs between women in the wealthiest and poorest areas.

The authors are careful about what these numbers can and cannot tell us. Because socioeconomic status was estimated from area-level postcode data rather than individual income or education, there is a risk of ecological fallacy, the error of assuming that patterns observed at the group level hold for every individual within that group. A further limitation is that a considerable proportion of ethnicity records could not be mapped onto the Census categories: of 14,342 records received, 515 women had not shared their ethnicity with their practice, 847 had missing data, and 3,908 had self-reported categories that did not map cleanly onto the five high-level groups, leaving a final analytical sample of 9,072. Sensitivity analyses testing alternative coding assumptions, however, produced consistent results, strengthening confidence in the central finding.

Why was uptake so low, and so skewed? The researchers point to several converging explanations. Unlike previous risk assessment studies embedded within routine mammographic screening, where uptake ranged from 12.7 to 38 percent because women were already attending an appointment, BCAN-RAY required a separate hospital visit, a meaningful ask of women juggling work, childcare and other commitments. Qualitative research by the same team has shown that women in their thirties perceive breast cancer as a future health concern rather than an immediate one, and report limited awareness that it is a potentially preventable disease. Women in this age group have also previously reported limited time and difficulty accessing healthcare services. Whether these knowledge gaps directly depress engagement is a question the authors say requires future quantitative research.

The ethnic disparities carry particular weight because they run counter to clinical need. Black women in the United Kingdom experience higher incidence of aggressive tumour types and higher mortality from breast cancer than their White counterparts, findings documented in large studies including the POSH cohort and an analysis of over 116,500 invasive breast cancers in England. Yet uptake among Black women was the lowest of any group. Previous research suggests that breast cancer is sometimes perceived within Black communities as a condition predominantly affecting White women, which may reduce perceived relevance and limit discussion, while misconceptions about the causes of breast cancer and personal risk have been identified as key barriers to screening attendance among Black women in the UK. The authors also note that historical instances of exploitation and unethical research practices have contributed to lasting mistrust of medical research among Black communities, a dynamic explored in recent qualitative work published in the journal Cancer.

The path forward, the researchers argue, lies in rethinking delivery rather than simply repeating the invitation. They propose general practice-based programmes that embed risk assessment into routine primary care, locally available one-stop-shop services that minimize the burden of separate hospital trips, and public health campaigns to raise awareness of the benefits of risk assessment. Crucially, they emphasize that community-based, culturally tailored interventions developed in partnership with trusted community leaders have been shown in systematic reviews and meta-analyses to improve uptake of cancer screening among ethnic minority groups. As risk-stratified prevention moves from research into routine practice, the BCAN-RAY experience serves as a warning: a programme that works only for the already advantaged does not merely fail to close health gaps, it actively widens them. Equity, the authors conclude, must be engineered into the design of these services from the outset, not retrofitted after disparities emerge.

Subject of Research: Ethnic and socioeconomic disparities in participation in breast cancer risk assessment among women aged 30-39 in the BCAN-RAY study

Article Title: Ethnic and socioeconomic disparities in participation in breast cancer risk assessment: findings from the BCAN-RAY study (NCT05305963)

Article References: Hindmarch, S., Howell, S. J., Usher-Smith, J. A., Horton, R., Moukala-Mankassa, D., Ng, S., Roberts, E., Ruane, H., Southworth, J., Stockton-Powdrell, C., & French, D. P. (2026). Ethnic and socioeconomic disparities in participation in breast cancer risk assessment: findings from the BCAN-RAY study (NCT05305963). Frontiers in Cancer Control and Society, 4, Article 1759843. https://doi.org/10.3389/fcacs.2026.1759843

Image Credits: AI Generated

DOI: 10.3389/fcacs.2026.1759843

Keywords: breast cancer, risk assessment, health inequalities, ethnicity, socioeconomic status, BCAN-RAY, risk stratification, screening, cancer prevention, primary care, deprivation, young women