Abstract
BACKGROUND: Research indicates that incorporating supplemental breast ultrasound in addition to mammography can enhance the sensitivity of public mammography screening, particularly for women with dense breast tissue. However, little information exists regarding the feasibility of integrating ultrasound into public mammography screening. Moreover, limited data exist on the awareness, perceptions, and experiences of both screening clients and healthcare providers regarding dense breast tissue, its impact on screening effectiveness, and the acceptability and implications of incorporating additional ultrasound. METHODS: In a prospective, controlled mixed-methods study, 31 semi-structured telephone interviews were conducted with both screening professionals and clients identified as having dense breast tissue. Six mammography screening centres in Germany participated in the qualitative part of the DIMASOS2 study (Density-Indicated Mammographic-Sonographic Breast Cancer Screening), where additional ultrasound was offered to women aged 50 to 69 years identified as having dense breast tissue. The interviews were analysed using qualitative content analysis. RESULTS: Clients expressed appreciation for the additional ultrasound examination; half of them were already aware of their dense breast tissue but lacked knowledge about its implications for diagnostic accuracy. Healthcare professionals felt that diagnostic sensitivity of mammography screening needed to be improved, but also faced challenges such as insufficient evidence for adjunct measures, concerns about overdiagnosis and false positives, and substantial organisational barriers to implementing ultrasound examinations. CONCLUSIONS: This study highlights a gap in open discussions about breast density and its impact on screening accuracy. The absence of evidence-based information hampers informed decision making for both healthcare providers and clients. Moreover, substantial organisational constraints hinder the incorporation of breast ultrasound into public screening programme, leading to a complex and unsatisfactory situation for healthcare professionals and clients. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12885-025-15145-1.