Cancer screening campaigns--getting past uninformative persuasion

Evolving paradigms in breast cancer screening: Balancing efficacy, personalization, and equity

Breast cancer remains a significant global health challenge, with projections indicating a troubling increase in incidence. Breast cancer screening programs have long been hailed as life-saving initiatives, yet their true impact on mortality rates is a subject of ongoing debate. Screening poses the risk of false positives and the detection of indolent tumors, potentially leading to overtreatment. Bias factors, including lead time, length time, and selection biases, further complicate the assessment of screening efficacy. Recent studies suggest that AI-driven image analysis may revolutionize breast cancer screening, maintaining diagnostic accuracy while reducing radiologists' workload. However, the generalizability of these findings to diverse populations is a critical consideration. Personalized screening approaches and equitable access to advanced technologies are essential to mitigate disparities. In conclusion, the breast cancer screening landscape is evolving, emphasizing the need for risk stratification, appropriate imaging modalities, and a personalized approach to reduce overdiagnosis and focus on cancers with the potential to impact lives while prioritizing patient-centered care.

Estimated Lifetime Gained With Cancer Screening Tests: A Meta-Analysis of Randomized Clinical Trials

Importance

Cancer screening tests are promoted to save life by increasing longevity, but it is unknown whether people will live longer with commonly used cancer screening tests.

Objective

To estimate lifetime gained with cancer screening.

Data Sources

A systematic review and meta-analysis was conducted of randomized clinical trials with more than 9 years of follow-up reporting all-cause mortality and estimated lifetime gained for 6 commonly used cancer screening tests, comparing screening with no screening. The analysis included the general population. MEDLINE and the Cochrane library databases were searched, and the last search was performed October 12, 2022.

Study Selection

Mammography screening for breast cancer; colonoscopy, sigmoidoscopy, or fecal occult blood testing (FOBT) for colorectal cancer; computed tomography screening for lung cancer in smokers and former smokers; or prostate-specific antigen testing for prostate cancer.

Data Extraction and Synthesis

Searches and selection criteria followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Data were independently extracted by a single observer, and pooled analysis of clinical trials was used for analyses.

Main Outcomes and Measures

Life-years gained by screening was calculated as the difference in observed lifetime in the screening vs the no screening groups and computed absolute lifetime gained in days with 95% CIs for each screening test from meta-analyses or single randomized clinical trials.

Results

In total, 2 111 958 individuals enrolled in randomized clinical trials comparing screening with no screening using 6 different tests were eligible. Median follow-up was 10 years for computed tomography, prostate-specific antigen testing, and colonoscopy; 13 years for mammography; and 15 years for sigmoidoscopy and FOBT. The only screening test with a significant lifetime gain was sigmoidoscopy (110 days; 95% CI, 0-274 days). There was no significant difference following mammography (0 days: 95% CI, -190 to 237 days), prostate cancer screening (37 days; 95% CI, -37 to 73 days), colonoscopy (37 days; 95% CI, -146 to 146 days), FOBT screening every year or every other year (0 days; 95% CI, -70.7 to 70.7 days), and lung cancer screening (107 days; 95% CI, -286 days to 430 days).

Conclusions and Relevance

The findings of this meta-analysis suggest that current evidence does not substantiate the claim that common cancer screening tests save lives by extending lifetime, except possibly for colorectal cancer screening with sigmoidoscopy.

To Consent or Not to Consent to Screening, That Is the Question

The objective of this article is to address the controversial question of whether consent is relevant for persons invited to participate in screening programs. To do so, it starts by presenting a case where the provided information historically has not been sufficient for obtaining valid informed consent for screening. Then, the article investigates some of the most relevant biases that cast doubt on the potential for satisfying standard criteria for informed consent. This may indicate that both in theory and in practice, it can be difficult to obtain valid consent for screening programs. Such an inference is profoundly worrisome, as invitees to screening programs are healthy individuals most suited to make autonomous decisions. Thus, if consent is not relevant for screening, it may not be relevant for a wide range of other health services. As such, the lack of valid consent in screening raises the question of the relevance of one of the basic ethical principles in healthcare (respect for autonomy), one of the most prominent legal norms in health legislation (informed consent), and one of the most basic tenets of liberal democracies (individual autonomy). Thus, there are good reasons to provide open, transparent, and balanced information and minimize biases in order to ascertain informed consent in screening.

Cancer overdiagnosis: a challenge in the era of screening

"Screening" is a search for preclinical, asymptomatic disease, including cancer. Widespread cancer screening has led to large increases in early-stage cancers and pre-cancers. Ubiquitous public messages emphasize the potential benefits to screening for these lesions based on the underlying assumption that treating cancer at early stages before spread to other organs should make it easier to treat and cure, using more tolerable interventions. The intuition is so strong that public campaigns are sometimes launched without conducting definitive trials directly comparing screening to usual care. An effective cancer screening test should not only increase the incidence of early-stage preclinical disease but should also decrease the incidence of advanced and metastatic cancer, as well as a subsequent decrease in cancer-related mortality. Otherwise, screening efforts may be uncovering a reservoir of non-progressive and very slowly progressive lesions that were not destined to cause symptoms or suffering during the person's remaining natural lifespan: a phenomenon known as "overdiagnosis." We provide here a qualitative review of cancer overdiagnosis and discuss specific examples due to extensive population-based screening, including neuroblastoma, prostate cancer, thyroid cancer, lung cancer, melanoma, and breast cancer. The harms of unnecessary diagnosis and cancer therapy call for a balanced presentation to people considering undergoing screening, even with a test of accepted benefit, with a goal of informed decision-making. We also discuss proposed strategies to mitigate the adverse sequelae of overdiagnosis.

Assessing the quality of cancer screening leaflets using the International Patient Decision Aids Standards instrument: A cross-sectional content analysis

OBJECTIVE

To assess the quality of national cancer screening program leaflets in Japan from the informed-decision perspective.

METHODS

Cross-sectional content analysis of invitation leaflets issued by centralized organizations and used nationwide in Japan was conducted. Three members independently evaluated the materials using International Patient Decision Aids Standards six-item minimum criteria for qualifying patient decision aids.

PATIENT PUBLIC INVOLVEMENT

Co-author KH is a cancer patient himself. We also sought feedbacks from three other cancer survivors and two bereaved family members.

RESULTS

Inter-rater agreement was substantial (Fleiss' kappa=0.62). The median score was 2 out of 6 (range: 2-3). All leaflets described the cancer (Q1: 7/7) and screening modality (Q2: 7/7). None stated not undergoing screening as an option. One stated another screening modality (Q3: 1/7). None stated both the positive and negative features of multiple options (Q4: 0/7. Q5: 0/7). One described the psychological and social experience of screening but only its positive side (Q6: 1/7).

CONCLUSIONS

There is room for improvement in the content of the public cancer screening invitation leaflets in Japan from informed-decision perspective.

PRACTICE IMPLICATIONS

Cancer screening leaflets should provide evidence-based, well-balanced, easy-to-understand information to educate people on cancer screening while maintaining people's autonomy.

Does retirement affect secondary preventive care use? Evidence from breast cancer screening

This paper examines the causal impact of retirement on preventive care use by focusing on breast cancer screening. It contributes to a better understanding of the puzzling results in the literature reporting mixed effects on health care consumption at retirement. We use five waves of data from the Eurobarometer surveys conducted between 1996 and 2006, covering 25 different European countries. We address the endogeneity of retirement by using age thresholds for pension eligibility as instrumental variables in a bivariate probit model. We find that retirement reduces mammography use and other secondary preventive care use. Our results suggest that health status, income, and knowledge on cancer prevention and treatment contribute little to our understanding of the effects of retirement. Instead, our evidence suggests important effect heterogeneity based on the generosity of the social health insurance system and organized screening programs.

UK Women's Views of the Concepts of Personalised Breast Cancer Risk Assessment and Risk-Stratified Breast Screening: A Qualitative Interview Study

Simple Summary

Risk-based breast screening will involve tailoring the amount of screening to women’s level of risk. Therefore, women at high-risk may be offered more frequent screening and over a longer period of time than those at low risk for whom less screening may be recommended. As this will involve considerable changes to the NHS Breast Screening Programme, it is important to explore what women in the UK think and feel about this approach. Analysis of in-depth interviews revealed that some women would find both high and low-risk screening options acceptable whereas others were resistant to the prospect of reduced screening if they were assessed as low-risk. We also found that the idea of risk-based screening had little influence on the attitudes of women who were already sceptical about breast screening. These findings highlight the communication challenges that will be faced by those introducing risk-based screening and suggest a need for tailored support and advice.

Abstract

Any introduction of risk-stratification within the NHS Breast Screening Programme needs to be considered acceptable by women. We conducted interviews to explore women’s attitudes to personalised risk assessment and risk-stratified breast screening. Twenty-five UK women were purposively sampled by screening experience and socioeconomic background. Interview transcripts were qualitatively analysed using Framework Analysis. Women expressed positive intentions for personal risk assessment and willingness to receive risk feedback to provide reassurance and certainty. Women responded to risk-stratified screening scenarios in three ways: ‘Overall acceptors’ considered both high- and low-risk options acceptable as a reasonable allocation of resources to clinical need, yet acceptability was subject to specified conditions including accuracy of risk estimates and availability of support throughout the screening pathway. Others who thought ‘more is better’ only supported high-risk scenarios where increased screening was proposed. ‘Screening sceptics’ found low-risk scenarios more aligned to their screening values than high-risk screening options. Consideration of screening recommendations for other risk groups had more influence on women’s responses than screening-related harms. These findings demonstrate high, but not universal, acceptability. Support and guidance, tailored to screening values and preferences, may be required by women at all levels of risk.

The Role of the Innate Immune System in Cancer Dormancy and Relapse

Metastatic spread and recurrence are intimately linked to therapy failure, which remains an overarching clinical challenge for patients with cancer. Cancer cells often disseminate early in the disease process and can remain dormant for years or decades before re-emerging as metastatic disease, often after successful treatment. The interactions of dormant cancer cells and their metastatic niche, comprised of various stromal and immune cells, can determine the length of time that cancer cells remain dormant, as well as when they reactivate. New studies are defining how innate immune cells in the primary tumor may be corrupted to help facilitate many aspects of dissemination and re-emergence from a dormant state. Although the scientific literature has partially shed light on the drivers of immune escape in cancer, the specific mechanisms regulating metastasis and dormancy in the context of anti-tumor immunity are still mostly unknown. This review follows the journey of metastatic cells from dissemination to dormancy and the onset of metastatic outgrowth and recurrent tumor development, with emphasis on the role of the innate immune system. To this end, further research identifying how immune cells interact with cancer cells at each step of cancer progression will pave the way for new therapies that target the reactivation of dormant cancer cells into recurrent, metastatic cancers.

Informing Women About Overdetection in Breast Cancer Screening: Two-Year Outcomes From a Randomized Trial

BACKGROUND

Supporting well-informed decisions about breast cancer screening requires communicating that inconsequential disease may be detected, leading to overdiagnosis and overtreatment. Having previously shown that telling women about overdetection improved informed choice, we investigated effects on screening knowledge and participation over 2 years.

METHODS

We conducted a community-based, parallel-group, randomized controlled trial in Australia. Participants were women aged 48-50 years, without personal or strong family history of breast cancer, who had not undergone mammography in the past 2 years. We randomly assigned 879 women to receive the intervention decision aid (evidence-based information on overdetection, breast cancer mortality reduction, and false-positives) or control decision aid (identical but without overdetection information). We interviewed 838 women postintervention and recontacted them for follow-up at 6 months and 1 and 2 years. Main outcomes for this report are screening knowledge and participation.

RESULTS

We interviewed 790, 746, and 712 participants at 6 months, 1, and 2 years, respectively. The intervention group demonstrated superior knowledge throughout follow-up. After 2 years, conceptual knowledge was adequate in 123 (34.4%) of 358 women in the intervention group compared with 71 (20.1%) of 354 control participants(odds ratio = 2.04, 95% confidence interval = 1.46 to 2.85). Groups were similar in total screening participation (200 [55.1%] vs 204 [56.0%]; = 0.97, 95% confidence interval = 0.73 to 1.29).

CONCLUSIONS

A brief decision aid produced lasting improvement in women's understanding of potential consequences of screening, including overdetection, without changing participation rates. These findings support the use of decision aids for breast cancer screening.

Harms and Benefits of Cancer Screening

In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.

Application of the theory of regulatory fit to promote adherence to evidence-based breast cancer screening recommendations: experimental versus longitudinal evidence

OBJECTIVES

To reduce overtreatment caused by overuse of screening, it is advisable to reduce the demand for mammography screening outside the recommended guidelines among women who are not yet eligible for inclusion in systematic screening programmes. According to principles of regulatory fit theory, people make decisions motivated by either orientation to achieving and maximising gains or avoiding losses. A study developed in two phases investigated whether video messages, explaining the risks and benefits of mammography screening for those not yet eligible, are perceived as persuasive DESIGN: Phase 1 was an experimental study in which women's motivation orientation was experimentally induced and then they were exposed to a matching video message about mammography screening. A control group received a neutral stimulus. Phase 2 introduced a longitudinal component to study 1, adding a condition in which the messages did not match with the group's motivation orientation. Participants' natural motivation orientation was measured through a validated questionnaire PARTICIPANTS: 360 women participated in phase 1 and another 292 in phase 2. Participants' age ranged from 30 to 45 years, and had no history of breast cancer or known BReast CAncer gene (BRCA) 1/2 mutation.

RESULTS

In phase 1, a match between participants' motivation orientation and message content decreased the intention to seek mammography screening outside the recommended guidelines. Phase 2, however, did not show such an effect. Fear of breast cancer and risk perception were significantly related to intention to seek mammography screening CONCLUSIONS: Public health researchers should consider reducing the impact of negative emotions (ie, fear of breast cancer) and risk perception when promoting adherence to evidence-based breast cancer screening recommendations.

Effect of different communication strategies about stopping cancer screening on screening intention and cancer anxiety: a randomised online trial of older adults in Australia

OBJECTIVE

To assess different strategies for communicating to older adults about stopping cancer screening.

DESIGN

4 (recommendation statement about stopping screening)×(2; time) online survey-based randomised controlled trial.

SETTING

Australia.

PARTICIPANTS

271 English-speaking participants, aged 65-90, screened for breast/prostate cancer at least once in past decade.

INTERVENTIONS

Time 1: participants read a scenario in which their general practitioner (GP) informed them about the potential benefits and harms of cancer screening, followed by double-blinded randomisation to one of four recommendation statements to stop screening: control ('this screening test would harm you more than benefit you'), health status ('your other health issues should take priority'), life expectancy framed positively ('this test would not help you live longer') and negatively ('you may not live long enough to benefit'). Time 2: in a follow-up scenario, the GP explained why guidelines changed over time (anchoring bias intervention).

MEASURES

Primary outcomes: screening intention and cancer anxiety (10-point scale, higher=greater intention/anxiety), measured at both time points.

SECONDARY OUTCOMES

trust (in their GP, the information provided, the Australian healthcare system), decisional conflict and knowledge of the information presented.

RESULTS

271 participants' responses analysed. No main effects were found. However, screening intention was lower for the negatively framed life expectancy versus health status statement (6.0 vs 7.1, mean difference (MD)=1.1, p=0.049, 95% CI 0.0 to 2.2) in post hoc analyses. Cancer anxiety was lower for the negatively versus positively framed life expectancy statement (4.8 vs 5.8, MD=1.0, p=0.025, 95% CI 0.1 to 1.9). The anchoring bias intervention reduced screening intention (MD=0.8, p=0.044, 95% CI 0.6 to 1.0) and cancer anxiety (MD=0.3, p=0.002, 95% CI 0.1 to 0.4) across all conditions.

CONCLUSION

Older adults may reduce their screening intention without reporting increased cancer anxiety when clinicians use a more confronting strategy communicating they may not live long enough to benefit and add an explicit explanation why the recommendation has changed.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001306202; Results).

Assessment of Lung Cancer Screening Program Websites

IMPORTANCE

The US Preventive Services Task Force recommends that individuals at high risk for lung cancer consider benefits and harms before pursuing lung cancer screening. Medical centers develop websites for their lung cancer screening programs, but to date little is known about the websites' portrayal of benefits and harms or what next steps they recommend for individuals considering screening.

OBJECTIVE

To assess the presentation of potential benefits and harms and recommended next steps on lung cancer screening program websites.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional content analysis of 162 lung cancer screening program websites of academic medical centers (n = 81) and state-matched community medical centers (n = 81) that were randomly selected from American College of Radiology lung cancer screening-designated centers was conducted. The study was performed from December 1, 2018, to January 31, 2019.

MAIN OUTCOMES AND MEASURES

Website presentation of screening-associated benefits and harms was the primary outcome. Benefit was defined as any description related to the potential reduction in lung cancer mortality. Harms were based on the US Preventive Services Task Force recommendations and included false positives, false negatives, overdiagnosis, radiation exposure, and incidental findings. The secondary outcome was next steps that are recommended by websites.

RESULTS

Overall, the 162 lung cancer screening program websites described the potential benefits more frequently than they described any potential harms (159 [98%] vs 78 [48%], P < .01). False-positive findings were the most frequently reported (72 [44%]) potential harm. Community centers were less likely than academic centers to report any potential harm (32 [40%] vs 46 [57%], P = .03), potential harm from radiation (20 [25%] vs 35 [43%], P = .01), and overdiagnosis (0% vs 11 [14%], P < .01). One hundred nineteen websites (73%) did not explicitly recommend that individuals personally consider the potential benefits and harms of screening; community centers were less likely than academic centers to give this recommendation (15 [19%] vs 28 [35%], P = .02). Most institutions (157 [97%]) listed follow-up steps for screening, but few institutions (35 [22%]) recommended that individuals discuss benefits and harms with a health care professional.

CONCLUSIONS AND RELEVANCE

Information on public-facing websites of US lung cancer screening programs appears to lack balance with respect to portrayal of potential benefits and harms of screening. Important harms, such as overdiagnosis, were commonly ignored in the sites evaluated, and most of the centers did not explicitly guide individuals toward a guideline-recommended, shared decision-making discussion of harms and benefits.

How is cervical cancer screening information communicated in UK websites? Cross-sectional analysis of content and quantitative presentation formats

OBJECTIVES

To investigate whether UK websites about cervical cancer screening targeted to the public include (1) information about benefits and risks of screening, possible screening results and cervical cancer statistics, (2) quantitative presentation formats recommended in the risk communication literature and (3) appeals for participation and/or informed decision-making.

DESIGN

Cross-sectional analysis of websites using a comprehensive checklist of information items on screening benefits, risks, possible results and cervical cancer statistics.

OUTCOME MEASURES

We recorded the number of websites that contained each of the information items, and the presentation format used for probabilistic information (no quantification provided, verbal quantifiers only, different types of numerical formats and/or graphs). We also recorded the number of websites containing appeals for participation and/or informed decision-making.

SETTING

Websites were identified through the most common Google search terms used in the UK to find information on cervical screening, according to GoogleTrends and a commercial internet-monitoring programme. Two additional websites were identified by the authors as relevant.

RESULTS

After applying exclusion criteria, 14 websites were evaluated, including websites of public and private health service providers, charities, a medical society and a pharmacy. The websites mentioned different benefits, risks of screening and possible results. However, specific content varied between websites. Probabilistic information was often presented using non-recommended formats, including relative risk reductions to express screening benefits, and verbal quantifiers without numbers to express risks. Appeals for participation were present in most websites, with almost half also mentioning informed decision-making.

CONCLUSIONS

UK websites about cervical cancer screening were generally balanced. However, benefits and risks were presented using different formats, potentially hindering comparisons. Additionally, recommendations from the literature to facilitate understanding of quantitative information and facilitate informed decisions were often not followed. Designing websites that adhere to existing recommendations may support informed screening uptake.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

Cancer screening risk literacy of physicians in training: An experimental study

We investigated what factors may foster or hinder physicians' cancer screening risk literacy-specifically the ability to understand evidence regarding screening effectiveness and make evidence-based recommendations to patients. In an experiment, physicians in training (interns and residents) read statistical information about outcomes from screening for cancer, and had to decide whether to recommend it to a patient. We manipulated the effectiveness of the screening (effective vs. ineffective at reducing mortality) and the demand of the patient to get screened (demand vs. no demand). We assessed participants' comprehension of the presented evidence and recommendation to the patient, as well as a-priori screening beliefs (e.g., that screening is always a good choice), numeracy, science literacy, knowledge of screening statistics, statistical education, and demographics. Stronger positive a-priori screening beliefs, lower knowledge of screening statistics, and lower numeracy were related to worse comprehension of the evidence. Physicians recommended against the ineffective screening but only if they showed good comprehension of the evidence. Physicians' recommendations were further based on the perceived benefits from screening but not on perceived harms, nor the patient's demands. The current study demonstrates that comprehension of cancer screening statistics and the ability to infer the potential benefits for patients are essential for evidence-based recommendations. However, strong beliefs in favor of screening fostered by promotion campaigns may influence how physicians evaluate evidence about specific screenings. Fostering physician numeracy skills could help counteract such biases and provide evidence-based recommendations to patients.

[An integral view of cancer (I). The study, classification and reprogramming of the tumoral microclimate]

The group of diseases that we call cancer share a biological structure formed by a complex ecosystem, with altered intercellular communication, information fields, development and tissue function. Beyond the genetic alterations of the tumor cell, the demonstration of an altered ecosystem, with interconnections at systemic levels, opens up a new perspective on cancer biology and behavior. Different tumor facets, such as morphology, classification, clinical aggressiveness, prognosis and response to treatment now appear under a comprehensive vision that offers a new horizon of study, research and clinical management. The Somatic Mutation Theory in cancer, in force for more than one hundred years, is now completed by the study of the tumor microenvironment, the extracellular matrix, the stromal cells, the immune response, the innervation, the nutrition, the mitochondria, the metabolism, the interstitial fluid, the mechanical and electromagnetic properties of the tissue and many other areas of emerging knowledge; thus opening the door to a reprogramming exercise of the tumor phenotype through the modification of the keys offered by this new paradigm. Its recognition makes it possible to go from considering the oncological process as a cellular problem to a supracellular alteration based on the disorganization of tissues, immersed in the relationships of the complex system of the living being.

Evaluation of Promotional Materials To Promote Low-Dose Computed Tomography (LDCT) Screening to High-Risk Consumers and Health Care Providers

Low-dose computed tomography (LDCT) screening is a promising screening modality for increasing the detection rate of early stage lung cancers among high-risk individuals. Despite being recommended by the US Preventative Services Task Force, uptake of LDCT remains low. The objective of the current study was to gather feedback from high-risk consumers and health care providers on LDCT promotional materials. Focus group discussions were conducted with high-risk individuals (8 focus groups; N = 38) and primary care providers (9 focus groups; N = 23). Participants reviewed existing LDCT promotional materials to assess their perceptions of media materials created to publicize LDCT. Data were analyzed using the constant comparative method. Several key themes emerged from focus groups that can be used to inform development of future LDCT promotional materials. High-risk (HR) participants expressed greater receptivity for promotional materials that did not further stigmatize lung cancer and/or smoking and expressed preferences for materials that clearly outlined the risks/benefits of screening. Primary care providers (PCPs) offered suggestions to facilitate the referral process such as diagnostic codes and requested a design that clearly outlined eligibility criteria. A clear and thorough explanation of LDCT eligibility, cost, harms, and benefits was of chief importance for both PCP and HR audiences. Given that PCPs and HR audiences are not well informed on the specifics of LDCT screening eligibility and insurance coverage, creating provider and patient education opportunities will aid in shared decision-making opportunities. Promotional materials that meet the needs of the target audience are needed to facilitate discussions of risks/benefits of screening with HR individuals.

'I just want to be able to make a choice': Results from citizen deliberations about mammography screening in Ontario, Canada

Despite Canada's long history with mammography screening, little is known about citizens' perspectives about mammography and how best to support women to make informed choices about screening. To address this gap, a series of four citizen deliberation events were held in 2015-16 in Ontario, a Canadian province with an organized population-based breast screening program in place since 1990. Forty-nine individuals participated in four citizen panels, each comprising an information session highlighting the evidence about mammography, and large- and small-group deliberations about approaches to support informed decision making for screening. Following their engagement with the research evidence about mammography, participants expressed concern about their lack of full awareness of the risks and benefits and a strong desire for choice when it comes to screening. To support informed choice, mammography programs need to reflect the values of information sharing, trust and transparency, financial accountability, and allow for personal interactions and shared decision-making. Citizens are looking for balanced information about the risks and benefits of screening presented in an easy to understand, comprehensive, and transparent manner. Primary health care providers and organized screening programs are important sources of information about mammography and must be vigilant in their efforts to support informed decision-making in this area by ensuring that the information materials they are using are balanced and reflect current evidence.

Nudging in screening: Literature review and ethical guidance

OBJECTIVES

Nudging is the purposeful alteration of choices presented to people that aims to make them choose in predicted ways. While nudging has been used to assure high uptake and good outcome of screening programs, it has been criticized for being paternalistic, undermining free choice, and shared decision making. Accordingly, the objective of this study is to explore a) nudging strategies identified in screening, b) arguments for and against nudging; and on basis of this, to c) suggest a tentative conclusion on how to handle nudging in screening.

METHODS

Literature searches in Ovid MEDLINE and PsycINFO for combinations of screening and nudging. Screening based on content analysis of titles, abstracts, and articles.

RESULTS

239 references were identified and 109 were included. Several forms of nudging were identified: framed information, default bias, or authority bias. Uptake and public health outcome were the most important goals. Arguments for nudging were bounded rationality, unavoidability, and beneficence, while lack of transparency, crowding out of intrinsic values, and paternalism were arguments against it. The analysis indicates that nudging can be acceptable for screenings with (high quality) evidence for high benefit-harm ratio (beneficence), where nudging does not infringe other ethical principles, such as justice and non-maleficence. In particular, nudging should not only focus on attendance rates, but also on making people "better choosers."

PRACTICE IMPLICATIONS

Four specific recommendations follow from the review and the analysis: 1) Nudging should be addressed in an explicit and transparent manner. 2) The means of nudging have to be in proportion to the benefit-harm ratio. 3) Disagreement on the evidence for either benefits or harms warrants special care. 4) Assessing and assuring the intended outcome of nudging appears to be crucial, as it can be context dependent.

Guidelines for early detection of breast cancer in Brazil. III - Challenges for implementation

The objective of the current article is to present the main challenges for the implementation of the new recommendations for early detection of breast cancer in Brazil, and to reflect on the barriers and the strategies to overcome them. The implementation of evidence-based guidelines is a global challenge, and traditional strategies based only on disseminating their recommendations have proven insufficient for changing prevailing clinical practice. A major challenge for adherence to the new guidelines for early detection of breast cancer in Brazil is the current pattern in the use of mammographic screening in the country, which very often includes young women and a short interval between tests. Such practice, harmful to the population's health, is reinforced by the logic of defensive medicine and the dissemination of erroneous information that overestimates the benefits of screening and underestimates or even omits its harms. In addition, there is a lack of policies and measures focused on early diagnosis of symptomatic cases. To overcome these barriers, changes in the regulation of care, financing, and implementation of shared decision-making in primary care are essential. Audit and feedback, academic detailing, and the incorporation of decision aids are some of the strategies that can facilitate implementation of the new recommendations.

Extent and cost of inappropriate use of tumour markers in patients with pulmonary disease: a multicentre retrospective study in Shanghai, China

OBJECTIVES

The currently implemented healthcare reform in China requires substantial capital investment. Although overtreatment results in serious waste, inappropriate laboratory use is widespread, and overuse of tumour markers (TMs) has attracted increasing attention.

DESIGN

Retrospective study.

SETTING

The respiratory, thoracic surgery and oncology departments of three hospitals in Shanghai from 2014 to 2015.

PARTICIPANTS

Patients with chronic obstructive pulmonary disease (COPD) and primary bronchogenic lung cancer (PLC). Based on clinical guidelines and physician experience, the criteria of suitability of TM examinations were determined, and the number, cost and proportion of inappropriate TM requests were analysed.

RESULTS

The area under the receiver operating characteristic curve for carcinoembryonic antigen+cytokeratin fragment 21-1+squamous cell carcinoma antigen+neuron-specific enolase in patients with COPD and PLC was 0.813, in accordance with the cost-effectiveness principle, indicating good clinical and health economics values. In the 2706 patients, 12 496-16 956 (58.27%-79.06%) of TM requests were inappropriate. Furthermore, the involved expense was 650 200-1 014 156 yuan, accounting for 7.69%-12.00% of examination expenses and 1.35%-2.11% of hospitalisation costs.

CONCLUSIONS

We found that the inappropriate use of TMs was widespread for patients with pulmonary disease. Clinicians should use TMs strictly according to the guidelines to effectively manage laboratory resources and control costs.

Decision-making about mammographic screening: pursuing informed choice

For decades, persuasive techniques have been used to communicate to women about breast cancer screening with the aim of maximizing screening uptake. However, more recently this has shifted to an approach which recognizes that it is important for women to be aware of harms, such as overdiagnosis, as well as benefits of breast screening. There is a lack of consensus in the literature around whether benefits clearly outweigh harms for population-based breast cancer screening. In light of this, the gold standard for communication about breast cancer screening is now to try and support informed decision-making - that is, to help women understand both the advantages and disadvantages of screening, allowing them to make individual decisions about their screening participation that reflect their informed preferences. In this review, we summarize relevant research to identify theoretical and practical aspects of improving communication and decision-making about breast cancer screening, and discuss future implications.

Decision aid on breast cancer screening reduces attendance rate: results of a large-scale, randomized, controlled study by the DECIDEO group

Controversies regarding the benefits of breast cancer screening programs have led to the promotion of new strategies taking into account individual preferences, such as decision aid. The aim of this study was to assess the impact of a decision aid leaflet on the participation of women invited to participate in a national breast cancer screening program. This Randomized, multicentre, controlled trial. Women aged 50 to 74 years, were randomly assigned to receive either a decision aid or the usual invitation letter. Primary outcome was the participation rate 12 months after the invitation. 16 000 women were randomized and 15 844 included in the modified intention-to-treat analysis. The participation rate in the intervention group was 40.25% (3174/7885 women) compared with 42.13% (3353/7959) in the control group (p = 0.02). Previous attendance for screening (RR = 6.24; [95%IC: 5.75-6.77]; p < 0.0001) and medium household income (RR = 1.05; [95%IC: 1.01-1.09]; p = 0.0074) were independently associated with attendance for screening. This large-scale study demonstrates that the decision aid reduced the participation rate. The decision aid activate the decision making process of women toward non-attendance to screening. These results show the importance of promoting informed patient choices, especially when those choices cannot be anticipated.

Control of Metastasis by NK Cells

The metastatic spread of malignant cells to distant anatomical locations is a prominent cause of cancer-related death. Metastasis is governed by cancer-cell-intrinsic mechanisms that enable neoplastic cells to invade the local microenvironment, reach the circulation, and colonize distant sites, including the so-called epithelial-to-mesenchymal transition. Moreover, metastasis is regulated by microenvironmental and systemic processes, such as immunosurveillance. Here, we outline the cancer-cell-intrinsic and -extrinsic factors that regulate metastasis, discuss the key role of natural killer (NK) cells in the control of metastatic dissemination, and present potential therapeutic approaches to prevent or target metastatic disease by harnessing NK cells.

Message Received: African American Women and Breast Cancer Screening

African American women are more likely than other women to be diagnosed with breast cancer at a young age, to be diagnosed at a late stage, and to die from the disease. Yet we see evidence of irregular screening and follow-up. Previous research on psychosocial factors influencing decisions to screen reveals barriers: fear, fatalistic perceptions of cancer, inaccurate perceptions of risk, and associations with stigma. The current qualitative research with, largely, insured African American women ( n = 26), health navigators ( n = 6), and community stakeholders ( n = 24) indicates both positive and negative factors influencing decision making. The women in our sample believe in the value of early detection and are motivated to screen in response to encouragement from health providers. However, they also report several factors that contribute to their decisions to delay or not screen. These include (1) perceptions that the health community itself is confused about the need for screening, (2) perceptions that White women are the priority population for breast cancer, (3) family roles that prohibit self-care and encourage secrecy, and (4) fear of diagnosis. Participants report not feeling included in national-level health promotion campaigns. It is argued that African American women, in particular, may benefit from more nuanced health information about their risk.

Population-based screening for cancer: hope and hype

Several important lessons have been learnt from our experiences in screening for various cancers. Screening programmes for cervical and colorectal cancers have had the greatest success, probably because these cancers are relatively homogenous, slow-growing, and have identifiable precursors that can be detected and removed; however, identifying the true obligate precursors of invasive disease remains a challenge. With regard to screening for breast cancer and for prostate cancer, which focus on early detection of invasive cancer, preferential detection of slower-growing, localized cancers has occurred, which has led to concerns about overdiagnosis and overtreatment; programmes for early detection of invasive lung cancers are emerging, and have faced similar challenges. A crucial consideration in screening for breast, prostate, and lung cancers is their remarkable phenotypic heterogeneity, ranging from indolent to highly aggressive. Efforts have been made to address the limitations of cancer-screening programmes, providing an opportunity for cross-disciplinary learning and further advancement of the science. Current innovations are aimed at identifying the individuals who are most likely to benefit from screening, increasing the yield of consequential cancers on screening and biopsy, and using molecular tests to improve our understanding of disease biology and to tailor treatment. We discuss each of these concepts and outline a dynamic framework for continuous improvements in the field of cancer screening.

Presentation of Benefits and Harms in US Cancer Screening and Prevention Guidelines: Systematic Review

BACKGROUND

Cancer prevention and screening guidelines are ideally suited to the task of providing high-quality benefit-harm information that informs clinical practice. We systematically examined how US guidelines present benefits and harms for recommended cancer prevention and screening interventions.

METHODS

We included cancer screening and prevention recommendations from: 1) the United States Preventive Services Task Force, 2) the American Cancer Society, 3) the American College of Physicians, 4) the National Comprehensive Cancer Network, and 5) other US guidelines within the National Guidelines Clearinghouse. Searches took place November 20, 2013, and January 1, 2014, and updates were reviewed through July 1, 2015. Two coders used an abstraction form to code information about benefits and harms presented anywhere within a guideline document, including appendices. The primary outcome was each recommendation's benefit-harm "comparability" rating, based on how benefits and harms were presented. Recommendations presenting absolute effects for both benefits and harms received a "comparable" rating. Other recommendations received an incomplete rating or an asymmetric rating based on prespecified criteria.

RESULTS

Fifty-five recommendations for using interventions to prevent or detect breast, prostate, colon, cervical, and lung cancer were identified among 32 guidelines. Thirty point nine percent (n = 17) received a comparable rating, 14.5% (n = 8) received an incomplete rating, and 54.5% (n = 30) received an asymmetric rating.

CONCLUSIONS

Sixty-nine percent of cancer prevention and screening recommendation statements either did not quantify benefits and harms or presented them in an asymmetric manner. Improved presentation of benefits and harms in guidelines would better ensure that clinicians and patients have access to the information required for making informed decisions.

Distress and patient-centered communication among veterans with incidental (not screen-detected) pulmonary nodules. A cohort study

RATIONALE

Incidental pulmonary nodule detection is postulated to cause distress, but the frequency and magnitude of that distress have not been reported. The quality of patient-clinician communication and the perceived risk of lung cancer may influence distress Objectives: To evaluate the association of communication processes with distress and the perceived risk of lung cancer using validated instruments.

METHODS

We conducted a prospective cohort study of patients with incidentally detected nodules who received care at one Department of Veterans Affairs Medical Center. We measured distress with the Impact of Event Scale and patient-centered communication with the Consultation Care Measure, both validated instruments. Risk of lung cancer was self-reported by participants. We used multivariable adjusted logistic regression to measure the association of communication quality with distress.

MEASUREMENTS AND MAIN RESULTS

Among 122 Veterans with incidental nodules, 23%, 12%, and 4% reported experiencing mild, moderate, and severe distress, respectively, at the time they were informed of the pulmonary nodule. Participant-reported risk of lung cancer was not associated with distress. In the adjusted model, high-quality communication was associated with decreased distress (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.08-1.00, P = 0.05). Among participants who reported a risk of malignancy of 30% or less, high-quality communication was associated with decreased distress (OR = 0.15, 95% CI = 0.02-0.92, P = 0.04), but was not associated with distress for those who reported a risk greater than 30% (OR = 0.12 (95% CI = 0.00-3.97, P = 0.24), although the P value for interaction was not significant.

CONCLUSIONS

Veterans with incidental pulmonary nodules frequently reported inadequate information exchange regarding their nodule. Many patients experience distress after they are informed that they have a pulmonary nodule, and high-quality patient-clinician communication is associated with decreased distress. Communication strategies that only target improved knowledge of the risk of malignancy may not be sufficient to reduce the distress associated with nodule detection.

Medical therapeutic itineraries of women with breast cancer diagnosis affiliated to the People's Health Insurance in San Luis Potosí, central Mexico

This study aims to describe the medical itineraries followed by breast cancer women affiliated to the People's Health Insurance in San Luis Potosí, central Mexico. We used an ethnographic approach based on oral histories of 12 women diagnosed with breast cancer in the year prior to the first meeting. Two face-to-face sessions per participant lasting 60 minutes each were conducted followed by a telephone interview. Content and diachronic analyses were used. Three main itineraries were identified: (1) diagnostic process, (2) final diagnosis to treatment, and (3) cancer control and relapse. Findings suggested that infrastructure and human resources to adequately screen and timely diagnose breast cancer were scant and insufficiently trained, respectively. Deferral of medical assessment was related with lack of information about breast cancer consequences, with women being afraid of a positive result, and with economic constraints. The current screening program needs to be redesigned to prevent diagnostic delays, as these seem to explain the high frequency of advanced stages reported at the time of diagnosis.

Gastrointestinal cancer screening: screening may release new research funding to improve health service also in routine clinics

We are far from having seen the ideal method of screening for colorectal cancer (CRC) and the downsides of screening have not been fully addressed. Funding of adequately sized screening trials with a 10-15-year perspective for endpoints CRC mortality and incidence is difficult to get. Also, with such time horizons, there will always be an ongoing study to be awaited before feeling obliged to invest in the next. New, promising screening methods may, however, emerge far more often than every 10th year, and the knowledge gap may easily widen unless research is made a key responsibility for any ongoing cancer screening program. Previous lost battles on screening research may be won if accepting that scientific evidence may be obtained within the framework of screening programs - provided that they are designed as platforms for Comparative Effectiveness Research (CER). Accepting that CER-based screening programs should be preferred to non-CER programs and seriously compete for their funding sources, then CER screening programs may not be considered so much as contenders for ordinary clinical research funds. Also, CER within a screening framework may benefit patients in routine clinics as shown by screening research in Nordic countries. The Nordic countries have been early contributors to research on CRC screening, but slow in implementing screening programs.

Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial

BACKGROUND

Mammography screening can reduce breast cancer mortality. However, most women are unaware that inconsequential disease can also be detected by screening, leading to overdiagnosis and overtreatment. We aimed to investigate whether including information about overdetection of breast cancer in a decision aid would help women aged around 50 years to make an informed choice about breast screening.

METHODS

We did a community-based, parallel-group, randomised controlled trial in New South Wales, Australia, using a random cohort of women aged 48-50 years. Recruitment to the study was done by telephone; women were eligible if they had not had mammography in the past 2 years and did not have a personal or strong family history of breast cancer. With a computer program, we randomly assigned 879 participants to either the intervention decision aid (comprising evidence-based explanatory and quantitative information on overdetection, breast cancer mortality reduction, and false positives) or a control decision aid (including information on breast cancer mortality reduction and false positives). Participants and interviewers were masked to group assignment. The primary outcome was informed choice (defined as adequate knowledge and consistency between attitudes and screening intentions), which we assessed by telephone interview about 3 weeks after random allocation. The primary outcome was analysed in all women who completed the relevant follow-up interview questions fully. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613001035718.

FINDINGS

Between January, 2014, and July, 2014, 440 women were allocated to the intervention group and 439 were assigned to the control group. 21 women in the intervention group and 20 controls were lost to follow-up; a further ten women assigned to the intervention and 11 controls did not answer all questions on attitudes. Therefore, 409 women in the intervention group and 408 controls were analysed for the primary outcome. 99 (24%) of 409 women in the intervention group made an informed choice compared with 63 (15%) of 408 in the control group (difference 9%, 95% CI 3-14; p=0·0017). Compared with controls, more women in the intervention group met the threshold for adequate overall knowledge (122/419 [29%] vs 71/419 [17%]; difference 12%, 95% CI 6-18; p<0·0001), fewer women expressed positive attitudes towards screening (282/409 [69%] vs 340/408 [83%]; 14%, 9-20; p<0·0001), and fewer women intended to be screened (308/419 [74%] vs 363/419 [87%]; 13%, 8-19; p<0·0001). When conceptual knowledge alone was considered, 203 (50%) of 409 women in the intervention group made an informed choice compared with 79 (19%) of 408 in the control group (p<0·0001).

INTERPRETATION

Information on overdetection of breast cancer provided within a decision aid increased the number of women making an informed choice about breast screening. Becoming better informed might mean women are less likely to choose screening.

FUNDING

Australian National Health and Medical Research Council.

[Towards informed choice: design and results of projects on (cancer) screening funded by the Federal Ministry of Health]

There has been a gradual paradigm shift in the area of screening and early detection of diseases. For many years, the sole focus of public health policies was increasing the uptake rates in screening programs. However, today there is an increasing awareness of the importance of informed decision making -- particularly in the area of screening. The provision of high-quality, evidence-based, and comprehensive information on benefit and harm is an important approach in achieving this objective. The current paper presents a project that was funded by the Federal Ministry of Health. It examines whether existing information material is appropriate to support informed decision making. In the first phase of the project, different screening procedures were assessed systematically and compared using several indicators. Based on the results of an expert workshop, the subsequent research activities focused on colorectal cancer (CRC) screening as one example. Phase II included the systematic search and assessment of print media, e.g., flyers and brochures, while phase III applied the same methods to websites on CRC screening. The information material was analyzed with a mix of methods, involving both experts and users. Finally, the results were presented and discussed with the authors/providers of the information material. Based on the results of this project, the Federal Center for Health Education developed a module on CRC screening for an Internet platform on women's health that is currently being evaluated. In sum, this research project contributes to the development of evidence-based and balanced information as well as informed decision making.

Offering informed choice about breast screening

Over the last few years, there has been growing international concern about the risk of overdiagnosis in breast screening and about how to communicate this to women. There has also been an increasing policy drive to provide people with information to enable them to make an informed choice about screening. In response to this, a novel approach to developing the information about cancer screening has been adopted in England. This approach has integrated the perspectives of people eligible for screening, and experts in public engagement, informed choice, and communicating risk, as well as experts in screening. New information based on this approach has been provided to women invited for breast screening from September 2013. The new information explicitly sets out the choice to be made, and provides much more detail than previous information about overdiagnosis, the balance of benefits and harms, and the scientific uncertainties. The novel approach has also been adopted to develop new information for the bowel and cervical screening programmes in England, and could provide a model for communicating about cancer screening in other countries.

Communicating the benefits and harms of colorectal cancer screening needed for an informed choice: a systematic evaluation of leaflets and booklets

OBJECTIVE

Evidence-based health information (EBHI) can support informed choice regarding whether or not to attend colorectal cancer (CRC) screening. The present study aimed to assess if German leaflets and booklets appropriately inform consumers on the benefits and harms of CRC screening.

METHODS

A systematic search for print media on CRC screening was performed via email enquiry and internet search. The identified documents were assessed for the presence and correctness of information on benefits and harms by two reviewers independently using a comprehensive list of criteria.

RESULTS

Many of the 28 leaflets and 13 booklets identified presented unbalanced information on the benefits and harms of CRC screening: one-third did not provide any information on harms. Numeracy information was often lacking. Ten cross-language examples of common misinterpretations or basically false and misleading information were identified.

DISCUSSION

Most of the CRC screening leaflets and booklets in Germany do not meet current EBHI standards. After the study, the publishers of the information materials were provided feedback, including a discussion of our findings. The results can be used to revise existing information materials or to develop new materials that provide correct, balanced, quantified, understandable and unbiased information on CRC screening.

Addressing overdiagnosis and overtreatment in cancer: a prescription for change

A vast range of disorders--from indolent to fast-growing lesions--are labelled as cancer. Therefore, we believe that several changes should be made to the approach to cancer screening and care, such as use of new terminology for indolent and precancerous disorders. We propose the term indolent lesion of epithelial origin, or IDLE, for those lesions (currently labelled as cancers) and their precursors that are unlikely to cause harm if they are left untreated. Furthermore, precursors of cancer or high-risk disorders should not have the term cancer in them. The rationale for this change in approach is that indolent lesions with low malignant potential are common, and screening brings indolent lesions and their precursors to clinical attention, which leads to overdiagnosis and, if unrecognised, possible overtreatment. To minimise that potential, new strategies should be adopted to better define and manage IDLEs. Screening guidelines should be revised to lower the chance of detection of minimal-risk IDLEs and inconsequential cancers with the same energy traditionally used to increase the sensitivity of screening tests. Changing the terminology for some of the lesions currently referred to as cancer will allow physicians to shift medicolegal notions and perceived risk to reflect the evolving understanding of biology, be more judicious about when a biopsy should be done, and organise studies and registries that offer observation or less invasive approaches for indolent disease. Emphasis on avoidance of harm while assuring benefit will improve screening and treatment of patients and will be equally effective in the prevention of death from cancer.

Confusing Relative Risk with Absolute Risk Is Associated with More Enthusiastic Beliefs about the Value of Cancer Screening

Background. Reviews of how data are presented in medical literature document that the benefit from an intervention is often exaggerated relative to the harm (e.g., relative risk for benefit and absolute risk for harm). Such mismatched presentations may create unwarranted enthusiasm, especially among those who misinterpret the statistics presented. The objective was to determine whether misinterpretation of risk data predicts enthusiasm for cancer screening. Methods. The authors administered a survey with 14 items assessing beliefs about cancer screening and 6 items measuring data interpretation ability. Multiple linear regression was used to evaluate the association between data interpretation and enthusiasm for cancer screening, with adjustment for gender and year graduated from medical school. Results. Eighty-eight of 139 physicians at a state-wide professional meeting returned completed surveys (63% response rate). Lower data interpretation scores were associated with higher enthusiasm for cancer screening scores ( P = 0.004) in the adjusted primary analysis. Confusing relative risk with absolute risk appeared to drive the overall association. Conclusions. Biased presentations of risk data could affect general beliefs about the value of cancer screening, especially among physicians who uncritically accept mismatched presentations of data.

Mode Effects in Assessing Cancer Worry and Risk Perceptions: Is Social Desirability Bias at Play?

BACKGROUND

Risk perceptions and worry are important determinants of health behavior. Despite extensive research on these constructs, it is unknown whether people's self-reports of perceived risk and worry are biased by their concerns about being viewed negatively by others (social desirability).

METHODS

In this study, we examined whether reports of perceived risk and worry about cancer varied across survey modes differing in the salience of social desirability cues. We used data from the National Cancer Institute's 2007 Health Information National Trends Survey, which assessed perceived cancer risk and worry in 1 of 2 survey modes: an interviewer-administered telephone survey (higher likelihood of socially desirable responding; n = 3678) and a self-administered mail survey (lower likelihood of socially desirable responding; n = 3445). Data were analyzed by regressing perceived risk and worry on survey mode and demographic factors.

RESULTS

Analyses showed no effect of survey mode on cancer risk perceptions (B = 0.02, P = 0.55, d = 0.02). However, cancer worry was significantly higher in the self-administered mode than in the interviewer-administered mode (B = 0.24, P < 0.001, d = 0.26). Education moderated this effect, with respondents lower in education exhibiting a stronger mode effect. When cancer worry was dichotomized, the odds of reporting cancer worry were approximately twice as high in the self-administered mode compared with the interviewer-administered mode (OR = 2.13, P < 0.001).

CONCLUSIONS

These results bolster the veracity of self-reported cancer risk perceptions. They also suggest that interviewer-administered surveys may underestimate the frequency of cancer worry, particularly for samples lower in socioeconomic status. Studies are needed to test for this effect in clinical contexts.

[Leaflets and websites on colorectal cancer screening and their quality assessment from experts' views]

In Germany, individuals who have statutory health insurance have free access to colorectal cancer (CRC) screening tests, and can choose between a fecal occult blood test and a screening colonoscopy. Evidence-based health information may support informed choices regarding whether or not to undergo CRC screening. The aim of this study was to assess whether the available German information materials on CRC screening meet evidence-based health information standards. A systematic search was made for print media and websites on CRC screening addressed to German people with average CRC risk (search period for print media August 2010, for websites January-March 2012). The identified information was assessed with a newly developed comprehensive list of criteria. In all, 41 print media, including 28 flyers and 13 brochures, and 36 websites were identified and assessed. These materials reported more often the benefits than the risks of CRC screening, and quantified presentations of benefits and risks were less frequently given. Most of the materials called for participation and did not indicate the option to decide whether or not to attend CRC screening. This bias in favor of screening was increased by fear-provoking or downplayed wording. Most materials included false and misleading information. The requirements for evidence-based patient information were currently not met by most of the leaflets and websites in Germany. Feedback was given to the producers of the leaflets including a discussion of the findings. The results may be used to revise existing leaflets or to develop new health information on CRC screening.