{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T10:31:23Z","timestamp":1787913083459,"version":"build-2784847793"},"reference-count":32,"publisher":"BMJ","issue":"7","license":[{"start":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T00:00:00Z","timestamp":1784764800000},"content-version":"unspecified","delay-in-days":22,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100015250","name":"NIHR Bristol Biomedical Research Centre","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100015250","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Flat Friends UK"},{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["NIHR 300588"],"award-info":[{"award-number":["NIHR 300588"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["NIHR 302601"],"award-info":[{"award-number":["NIHR 302601"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000659","name":"Research Trainees Coordinating Centre","doi-asserted-by":"publisher","award":["Academic Clinical Lectureship (KF)"],"award-info":[{"award-number":["Academic Clinical Lectureship (KF)"]}],"id":[{"id":"10.13039\/501100000659","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000659","name":"Research Trainees Coordinating Centre","doi-asserted-by":"publisher","award":["CS-2016-16-019"],"award-info":[{"award-number":["CS-2016-16-019"]}],"id":[{"id":"10.13039\/501100000659","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100014733","name":"Association of Breast Surgery","doi-asserted-by":"publisher","award":["The FLAME study"],"award-info":[{"award-number":["The FLAME study"]}],"id":[{"id":"10.13039\/100014733","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000297","name":"Royal College of Surgeons of England","doi-asserted-by":"publisher","award":["Surgical Trials Initiative"],"award-info":[{"award-number":["Surgical Trials Initiative"]}],"id":[{"id":"10.13039\/501100000297","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,7,13]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Up to 40% of women with breast cancer will require a mastectomy, and breast reconstruction is routinely offered to restore symmetry. While not all women want, or are suitable for, breast reconstruction, many want to be symmetrical following breast cancer surgery. For these women, contralateral mastectomy for \u2018flat symmetry\u2019 is a good alternative, but in the UK, access to contralateral \u2018symmetrising\u2019 mastectomy (CSM) is highly variable. Many women seeking this option describe feeling frustrated, unsupported and having to \u2018fight\u2019 to access care, while clinicians express concerns about decisional regret. The FLAME (FLat symmetry After Mastectomy for brEast cancer) study aims to work with key stakeholders to co-develop a consensus-based pathway to improve access and outcomes for women seeking CSM as an alternative to breast reconstruction after a unilateral mastectomy for breast cancer.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>Pathway development will be underpinned by the Medical Research Council (MRC) framework for the development of complex interventions, informed by the Behaviour Change Wheel and Capability, Opportunity, Motivation\u2014Behaviour framework, complemented by Intervention Mapping. There will be six key stages: (1) creation of a logic model of the issues that need to be addressed with the CSM pathway using a systematic literature review, national practice surveys and qualitative interviews with key stakeholders; (2) definition of the logic model of change objectives (performance objectives, change determinants and change objectives); (3) pathway design informed by appropriate behaviour change techniques; (4) co-development of the pathway in a co-design workshop involving key stakeholders; (5) co-development of an implementation plan and (6) future evaluation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>Ethical approval has been obtained from the University of Bristol Research Ethics Review Committee (ref: 27961). Written and verbal informed consent will be obtained from all participants before the interview study and again from individuals participating in the workshop. Findings will be presented at national\/international meetings and published in peer-reviewed journals. Dissemination materials will be co-produced with key stakeholders and shared widely with professional associations and patient support organisations to promote uptake and implementation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-120430","type":"journal-article","created":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T18:05:27Z","timestamp":1784829927000},"page":"e120430","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Co-development of a consensus-based pathway to improve access and outcomes for women seeking flat symmetry as an alternative to breast reconstruction after mastectomy for breast cancer: Protocol for the UK FLAME study"],"prefix":"10.1136","volume":"16","author":[{"given":"Eleanor","family":"Ferris","sequence":"first","affiliation":[{"name":"Bristol Surgical and Perioperative Care Complex Intervention Collaboration, Clinical Sciences, Bristol Medical School, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sam","family":"Brunsden","sequence":"additional","affiliation":[{"name":"Flat Friends UK, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-6348-786X","authenticated-orcid":false,"given":"Katherine","family":"Cowan","sequence":"additional","affiliation":[{"name":"Katherine Cowan Consulting, St Leonards-on-Sea, East Sussex, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katherine","family":"Fairhurst","sequence":"additional","affiliation":[{"name":"Bristol Surgical and Perioperative Care Complex Intervention Collaboration, Clinical Sciences, Bristol Medical School, Bristol, UK"},{"name":"Bristol Breast Care Centre, Bristol NHS Foundation Trust, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sue","family":"Hartup","sequence":"additional","affiliation":[{"name":"St James\u2019s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicola","family":"King","sequence":"additional","affiliation":[{"name":"Flat Friends UK, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4123-9611","authenticated-orcid":false,"given":"Stuart","family":"McIntosh","sequence":"additional","affiliation":[{"name":"The Johnston Cancer Research Centre, Queen\u2019s University Belfast School of Medicine Dentistry and Biomedical Sciences, Belfast, Northern Ireland, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2960-2940","authenticated-orcid":false,"given":"Nicola","family":"Mills","sequence":"additional","affiliation":[{"name":"Population Health Sciences, Bristol Medical School, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joanna","family":"Skillman","sequence":"additional","affiliation":[{"name":"Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1983-4470","authenticated-orcid":false,"given":"Samuel G","family":"Smith","sequence":"additional","affiliation":[{"name":"Leeds Institute of Health Sciences, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philippa","family":"Tollow","sequence":"additional","affiliation":[{"name":"University of the West of England, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6977-312X","authenticated-orcid":false,"given":"Shelley","family":"Potter","sequence":"additional","affiliation":[{"name":"Bristol Surgical and Perioperative Care Complex Intervention Collaboration, Clinical Sciences, Bristol Medical School, Bristol, UK"},{"name":"Bristol Breast Care Centre, Bristol NHS Foundation Trust, Bristol, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,23]]},"reference":[{"key":"2026072311052146000_16.7.e120430.1","unstructured":"MacNeill F , Irvine T . 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