Public knowledge of benefits of breast and prostate cancer screening in Europe

Associations between knowledge of health issues and health care satisfaction and propensity to complain: a cross-sectional survey of adult men in Denmark

OBJECTIVES

The objective of this study was to investigate associations between knowledge of health issues and healthcare satisfaction and propensity to complain including the association between knowledge and greater patient involvement.

DESIGN

The present study is a secondary analysis of a larger cross-sectional case vignette survey.

SETTING

Survey conducted in adult Danish men.

PARTICIPANTS

Participants included 6755 men aged 45-70 years.

INTERVENTIONS

Participants responded to a survey with scenarios illustrating prostate-specific antigen (PSA) testing and different information provision.

PRIMARY AND SECONDARY OUTCOME MEASURES

Using Likert scales (scored 1-5), participants rated their satisfaction with the care described and their inclination to complain and responded to a short quiz (scored 0-3) assessing their knowledge about the PSA test.

RESULTS

Satisfaction with healthcare increased with better quiz performance (Likert difference 0.13 (95% CI .07 to 0.20), p <0.001, totally correct vs totally incorrect responders) and correspondingly, the desire to complain significantly decreased (Likert difference -0.34 (95% CI 0.40 to -0.27), p <0.001). Respondents with higher education performed better (mean quiz score difference 0.59 (95% CI 0.50 to 0.67), p <0.001, most educated vs least educated). Responders who received information about the PSA test generally performed better (quiz score difference 0.41 (95% CI 0.35 to 0.47), p<0.001, neutral vs no information). Overestimation of PSA merits was more common than underestimation (7.9% vs 3.8%).

CONCLUSIONS

Mens' knowledge of the benefits of screening varies with education, predicts satisfaction with care and the desire to complain, and may be improved through greater involvement in decision-making.

Communicating the results of risk-based breast cancer screening through visualizations of risk: a participatory design approach

BACKGROUND

Risk-based breast cancer (BC) screening raises new questions regarding information provision and risk communication. This study aimed to: 1) investigate women's beliefs and knowledge (i.e., mental models) regarding BC risk and (risk-based) BC screening in view of implications for information development; 2) develop novel informational materials to communicate the screening result in risk-based BC screening, including risk visualizations of both quantitative and qualitative information, from a Human-Centered Design perspective.

METHODS

Phase 1: Interviews were conducted (n = 15, 40-50 years, 5 lower health literate) on women's beliefs about BC risk and (risk-based) BC screening. Phase 2: In three participatory design sessions, women (n = 4-6 across sessions, 40-50 years, 2-3 lower health literate) made assignments and created and evaluated visualizations of risk information central to the screening result. Prototypes were evaluated in two additional sessions (n = 2, 54-62 years, 0-1 lower health literate). Phase 3: Experts (n = 5) and women (n = 9, 40-74 years) evaluated the resulting materials. Two other experts were consulted throughout the development process to ensure that the content of the information materials was accurate. Interviews were transcribed literally and analysed using qualitative thematic analysis, focusing on implications for information development. Notes, assignments and materials from the participatory design sessions were summarized and main themes were identified.

RESULTS

Women in both interviews and design sessions were positive about risk-based BC screening, especially because personal risk factors would be taken into account. However, they emphasized that the rationale of risk-based screening and classification into a risk category should be clearly stated and visualized, especially for higher- and lower-risk categories (which may cause anxiety or feelings of unfairness due to a lower screening frequency). Women wanted to know their personal risk, preferably visualized in an icon array, and wanted advice on risk reduction and breast self-examination. However, most risk factors were considered modifiable by women, and the risk factor breast density was not known, implying that information should emphasize that BC risk depends on multiple factors, including breast density.

CONCLUSIONS

The information materials, including risk visualizations of both quantitative and qualitative information, developed from a Human-Centered Design perspective and a mental model approach, were positively evaluated by the target group.

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.

Medizinische Evidenz kompetent kommunizieren

Wie alle Patienten in Deutschland sollen auch jene in der Herzchirurgie, soweit wie möglich, in die klinische Entscheidungsfindung eingebunden werden. Was möglich ist, hängt – neben Patientenvoraussetzungen – maßgeblich von den kommunikativen Fähigkeiten und Werkzeugen ab, die der beratende Arzt einsetzt, um informiertes Entscheiden auf Basis der besten verfügbaren medizinischen Erkenntnisse zu ermöglichen. Anhand von Schlüsselherausforderungen strukturiert dieser narrative Überblick Lösungsansätze für die Nutzung medizinischer Evidenz in Entscheidungsprozessen: unbestimmte Bezugsrahmen, relative Risiken, komplexe Informationen zu Entscheidungsoptionen bis hin zur Interpretation vorangehender diagnostischer Testergebnisse. Die dargestellten Lösungsansätze stellen in die Versorgung integrierbare Werkzeuge dar. Sie erfordern eine Kompetenzstärkung des Fachpersonals und qualitätsgesicherte medizinische Informationsangebote.

Health Literacy and eHealth: Challenges and Strategies

Given the impact of health literacy (HL) on patients' outcomes, limited health literacy is a major barrier to improve cancer care globally. HL refers to the degree in which an individual is able to acquire, process, and comprehend information in a way to be actively involved in their health decisions. Previous research found that almost half of the population in developed countries have difficulties in understanding health-related information. With the gradual shift toward the shared decision making process and digital transformation in oncology, the need for addressing low HL issues is crucial. Decision making in oncology is often accompanied by considerable consequences on patients' lives, which requires patients to understand complex information and be able to compare treatment methods by considering their own values. How health information is perceived by patients is influenced by various factors including patients' characteristics and the way information is presented to patients. Currently, identifying patients with low HL and simple data visualizations are the best practice to help patients and clinicians in dealing with limited health literacy. Furthermore, using eHealth, as well as involving HL mediators, supports patients to make sense of complex information.

Perspectives on cancer screening participation in a highly urbanized region: a Q-methodology study in The Hague, the Netherlands

BACKGROUND

The Netherlands hosts, as many other European countries, three population-based cancer screening programmes (CSPs). The overall uptake among these CSPs is high, but has decreased over recent years. Especially in highly urbanized regions the uptake rates tend to fall below the minimal effective rate of 70% set by the World Health Organization. Understanding the reasons underlying the decision of citizens to partake in a CPS are essential in order to optimize the current screening participation rates. The aim of this study was to explore the various perspectives concerning cancer screening among inhabitants of The Hague, a highly urbanized region of the Netherlands.

METHODS

A Q-methodology study was conducted to provide insight in the prevailing perspectives on partaking in CSPs. All respondents were inhabitants of the city of The Hague, the Netherlands. In an online application they ranked a set of 31 statements, based on the current available literature and clustered by the Integrated Change model, into a 9-column forced ranking grid according to level of agreement, followed by a short survey. Respondents were asked to participate in a subsequent interview to explain their ranking. By-person factor analysis was used to identify distinct perspectives, which were interpreted using data from the rankings and interviews.

RESULTS

Three distinct perspectives were identified: 1). "Positive about participation", 2). "Thoughtful about participation", and 3). "Fear drives participation". These perspectives provide insight into how potential respondents, living in an urbanized region in the Netherlands, decide upon partaking in CSPs.

CONCLUSIONS

Since CSPs will only be effective when participation rates are sufficiently high, it is essential to have insight into the different perspectives among potential respondents concerning partaking in a CSP. This study adds new insights concerning these perspectives and suggests several ideas for future optimization of the CSPs.

Breast Cancer in Asia: Incidence, Mortality, Early Detection, Mammography Programs, and Risk-Based Screening Initiatives

Simple Summary

Nearly all breast cancer patients survive for more than five years when the tumor is found early and in the localized stage. Regular clinical breast examinations, mammograms, and monthly self-exams of the breasts all contribute to early detection. However, late-stage breast cancers are common in many Asian countries. Low-income countries suffer from a lack of resources for breast cancer screening. High-income countries, on the other hand, are not benefiting fully from national breast screening programs due to an underutilization of the preventive healthcare services available. Existing reviews on Asian breast cancers are heavily focused on risk factors. The question of whether we should adopt or adapt the knowledge generated from non-Asian breast cancers would benefit from an extension into screening guidelines. In addition, several Asian countries are piloting studies that move away from the age-based screening paradigm.

Abstract

Close to half (45.4%) of the 2.3 million breast cancers (BC) diagnosed in 2020 were from Asia. While the burden of breast cancer has been examined at the level of broad geographic regions, literature on more in-depth coverage of the individual countries and subregions of the Asian continent is lacking. This narrative review examines the breast cancer burden in 47 Asian countries. Breast cancer screening guidelines and risk-based screening initiatives are discussed.

[Health Professionals expectations' about the benefit of regular Primary Care interventions]

AIM

Examine the expectations expressed by healthcare professionals about the benefit of several primary prevention interventions that are usually carried out in The Primary Care Consultations with evidence from moderate-high validity studies.

DESIGN

Descriptive Cross-sectional Study by Survey.

SITTING

Spanish Primary Healthcare Centers, between February 6 and May 5, 2020.

PARTICIPANTS

General Practitioner and other practicing Primary Care professionals.

MAIN MEASUREMENTS

a) the number and percentage of participants whose estimate of benefit deviates from the benefit supported by the evidence; b) the magnitudes of OVERestimation, NORMOestimation and UNDERestimation of each participant and each professional subgroup.

RESULTS

Of the 701 respondents (67% women), 694 answered all eight questions and 4 between one and seven. The overestimation of benefit in the 8 interventions ranged from 86% to 90% of all medical participants and between 90% and 96% of all nursing participants.

CONCLUSIONS

Most of the surveyed (healthcare) professionals overestimate both, prevention activities and preventive treatments, this may lead them to instil false hope in patients, to put patients at risk of serious side effects arising from such interventions and to squander resources.

Why do people take part in atrial fibrillation screening? Qualitative interview study in English primary care

OBJECTIVES

There is insufficient evidence to support national screening programmes for atrial fibrillation (AF). Nevertheless, some practitioners, policy-makers and special interest groups have encouraged introduction of opportunistic screening in primary care in order to reduce the incidence of stroke through earlier detection and treatment of AF. The attitudes of the public towards AF screening are unknown. We aimed to explore why AF screening participants took part in the screening.

DESIGN

Semistructured longitudinal interview study of participant engagement in the SAFER study (Screening for Atrial Fibrillation with ECG to Reduce stroke). We undertook initial interviews face to face, with up to two follow-up telephone interviews during the screening process. We thematically analysed and synthesised these data to understand shared views of screening participation.

SETTING

5 primary care practices in the East of England, UK.

PARTICIPANTS

23 people taking part in the SAFER study first feasibility phase.

RESULTS

Participants were supportive of screening for AF, explaining their participation in screening as a 'good thing to do'. Participants suggested screening could facilitate earlier diagnosis, more effective treatment, and a better future outcome, despite most being unfamiliar with AF. Participating in AF screening helped attenuate participants' concerns about stroke and demonstrated their commitment to self-care and being a 'good patient'. Participants felt that the screening test was non-invasive, and they were unlikely to have AF; they therefore considered engaging in AF screening was low risk, with few perceived harms.

CONCLUSIONS

Participants assessed the SAFER AF screening programme to be a legitimate, relevant and safe screening opportunity, and complied obediently with what they perceived to be a recommendation to take part. Their unreserved acceptance of screening benefit and lack of awareness of potential harms suggests that uptake would be high but reinforces the importance of ensuring participants receive balanced information about AF screening initiatives.

TRIAL REGISTRATION NUMBER

ISRCTN16939438; Pre-results.

Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

"It's about our bodies… we have the right to know this stuff": A qualitative focus group study on Australian women's perspectives on breast density

OBJECTIVE

This study aimed to explore Australian women's current knowledge, perspectives and attitudes about breast density (BD); and information needs to inform effective evidence-based communication strategies.

METHODS

Fourteen online focus group sessions with a total of 78 women in New South Wales and Queensland, Australia aged 40-74 years without a personal diagnosis of breast cancer were conducted. Audio-recorded data was transcribed and analysed thematically.

RESULTS

Women had a very limited knowledge of BD. Overall, women expressed a preference for more frequent mammograms and/or supplemental screening should they be told they had dense breasts, despite being presented with information on potential downsides of additional testing. The majority of women were supportive of the notion of BD notification, often suggesting they had a 'right to know' and they would prefer to be educated and informed about it.

CONCLUSION

The potential of being informed and notified of BD is found to be of interest and importance to Australian women of breast screening age despite lacking current knowledge.

PRACTICE IMPLICATIONS

This study highlights that policy makers and screening services need to consider how to weigh up these views and preferences of women with current evidence surrounding BD in deciding about implementing population-based BD notification.

Patient Utilization of Online Information and its Influence on Orthopedic Surgeon Selection: Cross-sectional Survey of Patient Beliefs and Behaviors

Background

Patient attitudes and behavior are critical to understand owing to the increasing role of patient choice. There is a paucity of investigation into the perceived credibility of online information and whether such information impacts how patients choose their surgeons.

Objective

The purpose of this study was to explore the attitudes and behavior of patients regarding online information and orthopedic surgeon selection. Secondary purposes included gaining insight into the relative importance of provider selection factors, and their association with patient age and education level.

Methods

This was a cross-sectional study involving five multispecialty orthopedic surgery groups. A total of 329 patients who sought treatment by six different orthopedic surgeons were asked to anonymously answer a questionnaire consisting of 25 questions. Four questions regarded demographic information, 10 questions asked patients to rate the importance of specific criteria regarding the selection of their orthopedic surgeon (on a 4-point Likert scale), and 6 questions were designed to determine patient attitude and behaviors related to online information.

Results

Patient-reported referral sources included the emergency room (29/329, 8.8%), friend (42/329, 12.8%), insurance company (47/329, 14.3%), internet search/website (28/329, 8.5%), primary care physician (148/329, 45.0%), and other (34/329, 10.3%). Among the 329 patients, 130 (39.5%) reported that they searched the internet for information before their first visit. There was a trend of increased belief in online information to be accurate and complete in younger age groups (P=.02). There was an increased relative frequency in younger groups to perceive physician rating websites to be unbiased (P=.003), provide sufficient patient satisfaction information (P=.01), and information about physician education and training (P=.03). There was a significant trend for patients that found a surgeon’s website to be useful (P<.001), with the relative frequency increased in younger age groups.

Conclusions

This study shows that insurance network, physician referrals, appointment availability, and office location are important to patients, whereas advertising and internet reviews by other patients were considered to be not as helpful in choosing an orthopedic surgeon. Future studies may seek to identify obstacles to patients in integrating online resources for decision-making and strategies to improve health-seeking behaviors.

Using a Deliberative Poll on breast cancer screening to assess and improve the decision quality of laypeople

Balancing the benefits and harms of mammography screening is difficult and involves a value judgement. Screening is both a medical and a social intervention, therefore public opinion could be considered when deciding if mammography screening programmes should be implemented and continued. Opinion polls have revealed high levels of public enthusiasm for cancer screening, however, the public tends to overestimate the benefits and underestimate the harms. In the search for better public decision on mammography screening, this study investigated the quality of public opinion arising from a Deliberative Poll. In a Deliberative Poll a representative group of people is brought together to deliberate with each other and with experts based on specific information. Before, during and after the process, the participants’ opinions are assessed. In our Deliberative Poll a representative sample of the Danish population aged between 18 and 70 participated. They studied an online video and took part in five hours of intense online deliberation. We used survey data at four timepoints during the study, from recruitment to one month after the poll, to estimate the quality of decisions by the following outcomes: 1) Knowledge; 2) Ability to form opinions; 3) Opinion stability, and 4) Opinion consistency. The proportion of participants with a high level of knowledge increased from 1% at recruitment to 56% after receiving video information. More people formed an opinion regarding the effectiveness of the screening programme (12%), the economy of the programme (27%), and the ethical dilemmas of screening (10%) due to the process of information and deliberation. For 11 out of 14 opinion items, the within-item correlations between the first two inquiry time points were smaller than the correlations between later timepoints. This indicates increased opinion stability. The correlations between three pairs of opinion items deemed theoretically related a priori all increased, indicating increased opinion consistency. Overall, the combined process of online information and deliberation increased opinion quality about mammography screening by increasing knowledge and the ability to form stable and consistent opinions.

Statements considering intervention effects in Finnish clinical practice guidelines: Recommending interventions with non-numeric effect-sizes or unspecified outcomes

RATIONALE, AIMS AND OBJECTIVES

Representation of benefits and harms associated with specific interventions in an understandable and comparable way is crucial for informed decision making that clinical practice guidelines (CPGs) aim to enhance. Therefore, we investigated how statements concerning the effects of interventions considered and described benefits and harms, magnitude of effect and its uncertainty, numeric and non-numeric information, and outcomes in Finnish CPGs.

METHODS

We selected 10 CPGs on common diseases and risk factors published by The Finnish Medical Society, Duodecim. All the statements which were graded with the level of evidence from high to very low (levels A-D) were included in analyses. From these statements, assessments were made regarding whether the statement considered benefits or harms, whether relative or absolute numeric measures were shown, whether the statement supported or was against the intervention considered, and what outcome was reported.

RESULTS

Of the 10 CPGs, 448 statements were assessed. Most of the statements of effects considered intervention benefits (87%) rather than harms. Half of the statements considering harms were represented in a way that supported the intervention. Most of the statements (94%) did not include numeric estimates of magnitude of the effect. When numeric estimates of magnitude of the effect were present, they were most frequently relative measures and were typically placed in a statement considering (a) intervention benefits with a primary outcome, (b) given the grade of A for level of evidence, and (c) that supported the use of intervention.

CONCLUSIONS

In the Finnish CPGs, the statements were rarely framed with both absolute and relative numeric measures of an intervention's effect. Harms were rarely reported with a grade indicating the level of evidence. The users of CPGs would benefit from more consistent and understandable framing of statements considering both benefits and harms of interventions.

Acceptance of criteria for health and driver scoring in the general public in Germany

Numerous health insurers offer bonus programmes that score customers’ health behaviour, and car insurers offer telematics tariffs that score driving behaviour. In many countries, however, only a minority of customers participate in these programmes. In a population-representative survey of private households in Germany (N = 2,215), we study the acceptance of the criteria (features) on which the scoring programmes are based: the features for driver scoring (speed, texting while driving, time of driving, area of driving, accelerating and braking behaviour, respectively) and for health scoring (walking distance per day, sleeping hours per night, alcohol consumption, weight, participation in recommended cancer screenings, smoking status). In a second step, we model participants’ acceptance of both programmes with regard to the underlying feature acceptance. We find that insurers in Germany rarely use the features which the participants consider to be the most relevant and justifiable, that is, smoking status for health scoring and smartphone use for driver scoring. Heuristic models (fast-and-frugal trees) show that programme acceptance depends on the acceptance of a few features. These models can help to understand customers’ preferences and to design scoring programmes that are based on scientific evidence regarding behaviours and factors associated with good health and safe driving and are thus more likely to be accepted.

The Modest Effects of Fact Boxes on Cancer Screening

As health care becomes increasingly personalized to the needs and values of individual patients, informational interventions that aim to inform and debias consumer decision-making are likely to become important tools. In a randomized controlled experiment, we explore the effects of providing participants with published fact boxes on the benefits and harms of common cancer screening procedures. Female participants were surveyed about breast cancer screening by mammography, while male participants were surveyed about prostate cancer screening by prostate-specific antigen (PSA) testing. For these screening procedures, we expect consumers to have overly optimistic prior beliefs about the benefits and harms. We find that participants update their beliefs about the net benefits of screening modestly, but we observe little change in their stated preferences to seek screening. Participants who scored higher on a numeracy test updated their beliefs about screening benefits more in response to the fact boxes than did participants who scored lower on the numeracy test.

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.

Health information provision, health knowledge and health behaviours: Evidence from breast cancer screening

Many public health interventions aim to provide individuals with health information on the consequences of behaviours such as smoking, alcohol consumption or preventive care use, with the intention of changing health behaviour through better health knowledge. This paper examines whether the provision of health information in organised breast cancer screening programs affects mammography utilisation via changes in health knowledge. We use unique data on 10,610 European women from the Eurobarometer survey collected in 1997/1998, and we exploit variation in the availability and coverage of organised breast cancer screening programs for causal identification in a difference-in-differences design. We find that health information provision improves health knowledge. Yet, these changes in health knowledge had little to no effects on mammography utilisation in the overall population. Our findings imply that health information provision contributes little to health behaviour change. Although screening programs are effective at increasing preventive care use, their effect can be attributed almost entirely to factors other than health knowledge.

•

We estimate a difference-in-differences model and conduct a mediation analysis.

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We exploit variation in screening program existence and eligibility ages in Europe.

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Screening program eligibility improves health knowledge about breast cancer.

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Changes in health knowledge contribute little to screening program uptake.

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Health information provision has a stronger impact on less educated women.

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.

Improving informed consent by enhancing the role of nurses

From a legal perspective, before a physician engages in a serious medical intervention they must obtain informed consent. In this paper, we argue that there are serious deficits in our processes of obtaining informed consent; it is often seen as just a bureaucratic hurdle, and people agree to interventions without being in an appropriate epistemic state. We explore some possible reasons for this, including ignorance, trust in physicians' authority, and the minimal time physicians spend with patients. We trace many of these issues to one central cause, which is that in the United States obtaining informed consent is the purview of physicians. We argue that a simple shift in how we obtain informed consent can help to ameliorate these issues. Specifically, we argue that obtaining informed consent should be the responsibility of nurses rather than physicians. While there are several reasons for this, the central ideas are that (1) since nurses are the ones who know the patient, they will be in better position to tell when patients are genuinely informed, and (2) patients will be more comfortable asking questions and admitting ignorance to nurses rather than physicians. While we focus on US law, our conclusions are more broadly applicable.

[Assessing the quality of digital health services: How can informed decisions be promoted?]

An important prerequisite for the success of the digitisation of the healthcare system are risk-literate users. Risk literacy means the ability to weigh potential benefits and harms of digital technologies and information, to use digital services critically, and to understand statistical evidence. How do people find reliable and comprehensible health information on the Internet? How can they better assess the quality of algorithmic decision systems? This narrative contribution describes two approaches that show how the competence to make informed decisions can be promoted.Evidence-based and reliable health information exists on the Internet but must be distinguished from a large amount of unreliable information. Various institutions in the German-speaking world have therefore provided guidance to help laypersons make informed decisions. The Harding Center for Risk Literacy in Potsdam, for example, has developed a decision tree ("fast-and-frugal tree"). When dealing with algorithms, natural frequency trees (NFTs) can help to assess the quality and fairness of an algorithmic decision system.Independent of reliable and comprehensible digital health services, further tools for laypersons to assess information and algorithms should be developed and provided. These tools can also be included in institutional training programmes for the promotion of digital literacy. This would be an important step towards the success of digitisation in prevention and health promotion.

Translation and cultural adaptation of a prostate cancer screening decision aid: a qualitative study in Portugal

OBJECTIVES

To translate and culturally adapt an English language patient decision aid addressing prostate cancer screening, so it can be used by Portuguese men.

DESIGN

Qualitative study. We followed the European Centre for Disease Prevention and Control's (ECDC) five-step, stakeholder-based approach to adapting health communication materials: (1) selection of materials and process coordinators, (2) early review, (3) translation and back translation, (4) comprehension testing with cognitive semi-structured interviews and (5) proofreading. Content analysis was performed using Ligre software.

SETTING AND PARTICIPANTS

Cognitive interviews with 15 men to refine a decision aid after its translation. Eligible participants were Portuguese native-speaking men aged 55-69 years old recruited from the local community (urban and suburban) of Oporto district through advertisements in social media and senior universities between January and March 2019. A previous diagnosis of prostate cancer was the single exclusion criterion.

RESULTS

Five main themes are presented: informational content, information comprehension, sociocultural appropriateness, feelings and main message and personal perspective concerning prostate cancer screening. Most men found the translated version of the decision aid to be clear, comprehensive and appropriate for its target population, although some suggested that medical terms could be a barrier. The data collected from men's interviews afforded the researchers the opportunity to clarify concepts and expand existing content.

CONCLUSIONS

A decision aid was successfully translated and adapted to the Portuguese cultural setting. Our ECDC based approach can be replicated by other workgroups to translate and culturally adapt decision aids.

Mammography perceptions and practices among women aged 30-49: The role of screening programme availability and cultural affiliation

OBJECTIVE

To explore the role of systematic screening programme availability and cultural affiliation as drivers of mammography perceptions/practices among women aged 30-49, who are not eligible for screening.

METHODS

Cross-sectional survey about mammography perceptions/practices among N = 918 Swiss women (30-49), across three cultural-linguistic regions (Swiss-German, Swiss-French, Swiss-Italian) and 26 cantons.

RESULTS

In cantons offering systematic screening programmes, women appeared more likely to ask for a mammogram, felt more susceptible to breast cancer, and perceived more benefits to screening. Swiss-German women engaged less in screening and felt less susceptible to breast cancer than women in other cultural-linguistic regions. Within the Swiss-German region, women living in cantons with programmes were more likely to ask for a mammogram than in cantons without.

CONCLUSIONS

Programme availability and cultural affiliation both appear related to young women's screening perceptions/practices. While the interaction between these factors should be further explored, this study provides some preliminary evidence that cultural affiliation is the more important driver.

PRACTICE IMPLICATIONS

Health communication efforts should consider the impact of these drivers on women's intentions to have a mammogram, prior to the recommended age. Tailored communication - public and interpersonal - should be directed towards facilitating informed decision-making and avoidance of mammography overuse.

The physical examination: a survey of patient preferences and expectations during primary care visits

Background: Little is known about patient preference regarding the physical exam in non-urgent primary care settings.Objective: To determine the differences between a patient's expectations of the physical exam and the actual components of the physical examination performed during a non-urgent visit.Design: A total of 452 surveys administered in the waiting room of a VA primary care clinic in West Haven, CT.Key results: The response rate was 91.6% (n = 414). For 15 of 16 maneuvers on the survey, more respondents believed a reasonable provider should conduct it than received it at their annual physical exam; for 7 of them (breast, axillary, rectal, pelvic, total body skin exam, electrocardiogram, and stress test), over twice as many respondents believed they should be done than received them. There was an association between a patient's perception of their primary care provider and the number of maneuvers recalled at their annual exam (P < 0.001), and a gap in the number of maneuvers expected from a reasonable provider by nonwhite and white patients (P < 0.001).Limitations: Convenience sample, response bias (healthy patients are more likely to respond) and recall bias.Conclusion: Patient perception of their primary care provider is strongly associated with the number of maneuvers recalled during an annual physical. Furthermore, the number of maneuvers expected by a patient is influenced by race, with nonwhite patients desiring more. This suggests the need for further research on the role of race in the expectations of healthcare providers.

Effect of Tabular and Icon Fact Box Formats on Comprehension of Benefits and Harms of Prostate Cancer Screening: A Randomized Trial

BACKGROUND

Fact boxes employ evidence-based guidelines on risk communication to present benefits and harms of health interventions in a balanced and transparent format. However, little is known about their short- and long-term efficacy and whether designing fact boxes to present multiple outcomes with icon arrays would increase their efficacy.

METHOD

In study 1, 120 men (30-75 y) completed a lab study. Participants were randomly assigned to 1 of 3 fact box formats on prostate cancer screening: a tabular fact box with numbers, a fact box with numbers and icon array, and a fact box with numbers, separate icon arrays, and text to describe each benefit and harm. Comprehension of information (while materials were present) and short-term knowledge recall were assessed. Study 2 recruited an online sample of 244 German men (40-75 y). Participants were randomly assigned to 1 of the 3 fact box formats or widely distributed health information, and knowledge was assessed at baseline, shortly after presentation, and at 6-mo follow-up, along with comprehension while materials were present.

RESULTS

In both studies, comprehension and knowledge-recall scores were similar when comparing tabular and icon fact boxes. In the 6-mo follow-up, this positive effect on knowledge recall disappeared. Fact boxes increased knowledge relative to baseline but did not affect decision intentions or perceptions of having complete information to make decisions.

CONCLUSIONS

This study shows that fact boxes with and without icon arrays are equally effective at improving comprehension and knowledge recall over the short-term and are simple formats that can improve on current health information. Specifically, if fact boxes are used at the time or immediately before a decision is made, they promote informed decisions about prostate cancer screening.

Untargeted Metabolomic Profile for the Detection of Prostate Carcinoma-Preliminary Results from PARAFAC2 and PLS-DA Models

Prostate-specific antigen (PSA) is the main biomarker for the screening of prostate cancer (PCa), which has a high sensibility (higher than 80%) that is negatively offset by its poor specificity (only 30%, with the European cut-off of 4 ng/mL). This generates a large number of useless biopsies, involving both risks for the patients and costs for the national healthcare systems. Consequently, efforts were recently made to discover new biomarkers useful for PCa screening, including our proposal of interpreting a multi-parametric urinary steroidal profile with multivariate statistics. This approach has been expanded to investigate new alleged biomarkers by the application of untargeted urinary metabolomics. Urine samples from 91 patients (43 affected by PCa; 48 by benign hyperplasia) were deconjugated, extracted in both basic and acidic conditions, derivatized with different reagents, and analyzed with different gas chromatographic columns. Three-dimensional data were obtained from full-scan electron impact mass spectra. The PARADISe software, coupled with NIST libraries, was employed for the computation of PARAFAC2 models, the extraction of the significative components (alleged biomarkers), and the generation of a semiquantitative dataset. After variables selection, a partial least squares-discriminant analysis classification model was built, yielding promising performances. The selected biomarkers need further validation, possibly involving, yet again, a targeted approach.

Systematic evaluation of written health information on PSA based screening in Germany

Background

Prostate-specific antigen (PSA) based screening for early detection of prostate cancer is common although it is associated with both benefits and potential harms (e.g., the risk of overdiagnosis). Evidence-based health information could help individuals make informed decisions about whether to undergo PSA testing or not. This evaluation aimed to determine whether the written health information materials available in Germany provide appropriate information for informed decision-making on PSA based screening.

Methods

A list of criteria was developed and used to systematically assess the quality of information on the benefits and harms of prostate cancer screening included in written health information materials. Fourteen information materials identified by information requests and online searches were evaluated independently by two of three reviewers. Consensus was achieved with a third reviewer.

Results

Of the 14 information materials evaluated, 10 (71%) list the ability to reduce the absolute risk of death from prostate cancer as a benefit of PSA testing, 9 (64%) point out the risks of follow-up diagnostics, 13 (93%) describe the risks of the available prostate cancer treatments, and all 14 specify the risk of overdiagnosis. The minority provide numerical data on benefits and risks. Partially mismatched framing was identified in four cases: two information materials report only the relative frequencies of benefits, and two report only the absolute frequencies of harms. Half of the materials encouraged participation using downplaying or frightening language.

Conclusions

The majority of health information materials in Germany describe the benefits and harms of PSA based screening, including overdiagnosis, but often lack adequate balance, neutrality and numbers.

Are We Choosing Wisely? Older Adults' Cancer Screening Intentions and Recalled Discussions with Physicians About Stopping

BACKGROUND

National guidelines recommend against cancer screening for older individuals with less than a 10-year life expectancy, but it is unknown if this population desires ongoing screening.

OBJECTIVE

To determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening.

DESIGN

National Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey.

PARTICIPANTS

Community-dwelling adults 55-97 years old (n = 3816).

MAIN MEASURES

Self-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates.

KEY RESULTS

Among women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001).

CONCLUSION

Over 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.

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.

Do cancer risk and benefit-harm ratios influence women's consideration of risk-reducing mastectomy? A scenario-based experiment in five European countries

BACKGROUND

Personal cancer risk assessments enable stratified care, for example, offering preventive surgical measures such as risk-reducing mastectomy (RRM) to women at high risk for breast cancer. In scenario-based experiments, we investigated whether different benefit-harm ratios of RRM influence women's consideration of this, whether this consideration is influenced by women's perception of and desire to know their personal cancer risk, or by their intention to take a novel cancer risk-predictive test, and whether consideration varies across different countries.

METHOD

In January 2017, 1,675 women 40 to 75 years of age from five European countries-Czech Republic, Germany, UK, Italy, and Sweden-took part in an online scenario-based experiment. Six different scenarios of hypothetical benefit-harm ratios of RRM were presented in accessible fact box formats: Baseline risk/risk reduction pairings were 20/16, 20/4, 10/8, 10/2, 5/4, and 5/1 out of 1,000 women dying from breast cancer.

RESULTS

Varying the baseline risk of dying from breast cancer and the extent of risk reduction influenced the decision to consider RRM for 23% of women. Decisions varied by country, risk perception, and the intention to take a cancer risk-predictive test. Women who expressed a stronger intention to take such a test were more likely to consider having RRM. The desire to know one's risk of developing any female cancer in general moderated women's decisions, whereas the specific desire to know the risk of breast cancer did not.

CONCLUSIONS

In this hypothetical scenario-based study, only for a minority of women did the change in benefit-harm ratio inform their consideration of RRM. Because this consideration is influenced by risk perception and the intention to learn one's cancer risks via a cancer risk-predictive test, careful disclosure of different potential preventive measures and their benefit-harm ratios is necessary before testing for individual risk. Furthermore, information on risk testing should acknowledge country-specific sensitivities for benefit-harm ratios.

Resisting recommended treatment for prostate cancer: a qualitative analysis of the lived experience of possible overdiagnosis

OBJECTIVE

To describe the lived experience of a possible prostate cancer overdiagnosis in men who resisted recommended treatment.

DESIGN

Qualitative interview study SETTING: Australia PARTICIPANTS: 11 men (aged 59-78 years) who resisted recommended prostate cancer treatment because of concerns about overdiagnosis and overtreatment.

OUTCOMES

Reported experience of screening, diagnosis and treatment decision making, and its impact on psychosocial well-being, life and personal circumstances.

RESULTS

Men's accounts revealed profound consequences of both prostate cancer diagnosis and resisting medical advice for treatment, with effects on their psychological well-being, family, employment circumstances, identity and life choices. Some of these men were tested for prostate-specific antigen without their knowledge or informed consent. The men felt uninformed about their management options and unsupported through treatment decision making. This often led them to develop a sense of disillusionment and distrust towards the medical profession and conventional medicine. The findings show how some men who were told they would soon die without treatment (a prognosis which ultimately did not eventuate) reconciled issues of overdiagnosis and potential overtreatment with their own diagnosis and situation over the ensuing 1 to 20+ years.

CONCLUSIONS

Men who choose not to have recommended treatment for prostate cancer may avoid treatment-associated harms like incontinence and impotence, however our findings showed that the impact of the diagnosis itself is immense and far-reaching. A high priority for improving clinical practice is to ensure men are adequately informed of these potential consequences before screening is considered.

The Barrier to Informed Choice in Cancer Screening: Statistical Illiteracy in Physicians and Patients

An efficient health care requires both informed doctors and patients. Our current healthcare system falls short on both counts. Most doctors and patients do not understand the available medical evidence. To illustrate the extent of the problem in the setting of cancer screening: In a representative sample of some 5000 women in nine European countries, 92% overestimated the reduction of breast cancer mortality by mammography by a factor of 10-200, or did not know. For a similar sample of about 5000 men with respect to PSA screening, this number was 89%. Of more than 300 US citizens who regularly attended one or more cancer screening test, more than 90% had never been informed about the biggest harms of screening-overdiagnosis and overtreatment-by their physicians. Among 160 German gynecologists, some 80% did not understand the positive predictive value of a positive mammogram, with estimates varying between 1 and 90%. In a national sample of 412 US primary care physicians, 47% mistakenly believed that if more cancers are detected by a screening test, this proves that the test saves lives, and 76% wrongly thought that if screen-detected cancers have better 5-year survival rates than cancers detected by symptoms, this would prove that the screening test saves lives. And of 20 German gynecologists, not a single one provided a woman with all information on the benefits and harms of cancer screening required in order to make an informed choice. Why is risk literacy so scarce in health care? One frequently discussed explanation assumes that people suffer from cognitive deficits that make them predictably irrational and basically hopeless at dealing with risks, so that they need to be "nudged" into healthy behavior. Yet research has demonstrated that the problem lies less in stable cognitive deficits than in how information is presented to physicians and patients. This includes biased reporting in medical journals, brochures, and the media that uses relative risks and other misleading statistics, motivated by conflicts of interest and defensive medicine that do not promote informed physicians and patients. What can be done? Every medical school should teach its students how to understand evidence in general and health statistics in particular. To cultivate informed patients, elementary and high schools should start teaching the mathematics of uncertainty-statistical thinking. Guidelines about complete and transparent reporting in journals, brochures, and the media need to be better enforced, and laws need to be changed in order to protect patients and doctors alike against the practice of defensive medicine instead of encouraging it. A critical mass of informed citizens will not resolve all healthcare problems, but it can constitute a major triggering factor for better care.

Reaping the Benefits and Avoiding the Risks: Unrealistic Optimism in the Health Domain

People's perceptions of benefits and risks play a key role in their acceptance or rejection of medical interventions, yet these perceptions may be poorly calibrated. This online study with N = 373 adults aged 19-76 years focused on unrealistic optimism in the health domain. Participants indicated how likely they were to experience benefits and risks associated with medical conditions and completed objective and subjective numeracy scales. Participants exhibited optimistic views about the likelihood of experiencing the benefits and the side effects of treatment options described in the scenarios. Objective and subjective numeracy were not associated with more accurate ratings. Moreover, participants' underestimation of the risks was significantly greater than their overestimation of the benefits. From an applied perspective, these results suggest that clinicians may need to ensure that patients do not underestimate risks of medical interventions, and that they convey realistic expectations about the benefits that can be obtained with certain procedures.

Do Women With High eHealth Literacy Profit More From a Decision Aid on Mammography Screening? Testing the Moderation Effect of the eHEALS in a Randomized Controlled Trial

Background: Our decision aid on mammography screening developed according to the criteria of the International Patient Decision Aids Standards Collaboration increases knowledge compared to usual care. However, it remains unclear whether this decision aid is more effective in women with higher eHealth literacy. Our objective was to test whether the positive effect of the decision aid on knowledge is moderated by eHealth literacy.

Methods: A total of 1,206 women aged 50 from Westphalia-Lippe, Germany, participated (response rate of 16.3%) in our study and were randomized to usual care (i.e., the standard information brochure sent with the programme's invitation letter) or the decision aid. eHealth literacy was assessed at baseline with the Electronic Health Literacy Scale (eHEALS); knowledge was assessed at baseline and post-intervention. First, we compared the 2-factor model of the German eHEALS (information-seeking and information-appraisal) found in previous research and the 3-factor model we hypothesized for decision aid use to the originally proposed 1-factor model. Second, we modeled the measurement model according to the superior factor model found in step one and tested whether the eHEALS moderated the effect of the decision aid on knowledge.

Results: The 3-factor model of the eHEALS had a better model fit than the 1-factor or 2-factor model. Both information-seeking, information-appraisal, and information-use had no effect on knowledge post-intervention. All three interactions of the decision aid with information-seeking, information-appraisal, and information-use were not significant. Equally, neither education nor its interaction with the decision aid had an effect on knowledge post-intervention.

Conclusion: The decision aid developed in this project increases knowledge irrespective of level of eHealth literacy. This means that not only women with high eHealth literacy profit from the decision aid but that the decision aid has been successfully conceptualized as a comprehensible information tool that can be used by women of varying eHealth literacy levels.

Trial registration: German Clinical Trials Register DRKS00005176 (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005176).

Too much medicine? Scientific and ethical issues from a comparison between two conflicting paradigms

BACKGROUND

The role of medicine in society appears to be focused on two views, which may be summarized as follows: "Doing more means doing better" (paradigm A) and "Doing more does not mean doing better" (paradigm B).

MAIN BODY

I compared paradigms A and B both in terms of a single clinical condition and in the general context of a medical system. For a single clinical condition, I analyzed breast cancer screening. There are at least seven interconnected issues that influence the conflict between paradigms A and B in the debate on breast cancer screening: disconnection between research and practice; scarcity of information given to women; how "political correctness" can influence the choice of a health policy; professional interests; doubts about effectiveness; incommensurability between harms and benefits; and the difficulty in making dichotomous decisions with discrete variables. As a general approach to medicine, the main representative of paradigm A is systems medicine. As representatives of paradigm B, I identified the following approaches or movements: choosing wisely; watchful waiting; the Too Much Medicine campaign; slow medicine; complaints against overdiagnosis; and quaternary prevention. I showed that both as a single condition and as a general approach to medicine, the comparison was entirely reducible to a harm-benefit analysis; moreover, in both cases, the two paradigms are in many respects incommensurable. This transfers the debate to the ethical level; consequently, scientists and the public have equal rights and competence to debate on this subject. Moreover, systems medicine has many ethical problems that could limit its spread.

CONCLUSION

I made some hypotheses about scenarios for the future of medicine. I particularly focused on whether systems medicine would become increasingly accessible and widespread in the population or whether it would be downsized because its promises have not been maintained or ethical problems will become unsustainable.

What do European women know about their female cancer risks and cancer screening? A cross-sectional online intervention survey in five European countries

OBJECTIVES

Informed decisions about cancer screening require accurate knowledge regarding cancer risks and screening. This study investigates: (1) European women's knowledge of their risk of developing breast, ovarian, cervical or endometrial cancer, (2) their knowledge about mammography screening and (3) whether an evidence-based leaflet improves their knowledge.

DESIGN

Cross-sectional online intervention survey.

SETTING

National samples from five European countries (Czech Republic, Germany, UK, Italy and Sweden)-drawn from the Harris Interactive and the Toluna panel, respectively, in January 2017-were queried on their knowledge of age-specific risks of developing breast, cervical, ovarian or endometrial cancer within the next 10 years and of mammography screening before and after intervention.

PARTICIPANTS

Of 3629 women (inclusion criteria: age 40-75 years) invited, 2092 responded and 1675 completed the survey (response rate: 61.4%).

INTERVENTION

Evidence-based leaflet summarising information on age-adjusted female cancer risks, mammography and aspects of cancer prevention.

PRIMARY OUTCOME MEASURES

Proportion of women (1) accurately estimating their risk of four female cancers, (2) holding correct assumptions of mammography screening and (3) changing their estimations and assumptions after exposure to leaflet.

FINDINGS

Across countries, 59.2% (95% CI 56.8% to 61.6%) to 91.8% (95% CI 90.3% to 93.0%) overestimated their female cancer risks 7-33 fold (medians_{across tumours}: 50.0 to 200.0). 26.5% (95% CI 24.4% to 28.7%) were aware that mammography screening has both benefits and harms. Women who accurately estimated their breast cancer risk were less likely to believe that mammography prevents cancer (p<0.001). After leaflet intervention, knowledge of cancer risks improved by 27.0 (95% CI 24.9 to 29.2) to 37.1 (95% CI 34.8 to 39.4) percentage points and of mammography by 23.0 (95% CI 21.0 to 25.1) percentage points.

CONCLUSION

A considerable number of women in five European countries may not possess the prerequisites for an informed choice on cancer screening. Evidence-based information in patient leaflets can improve this situation.

African American Women's Involvement in Promoting Informed Decision-Making for Prostate Cancer Screening Among Their Partners/Spouses

Routine prostate cancer screening is not recommended but African American men who are at higher risk for the disease should be offered the opportunity for shared decision-making with their health-care providers. This qualitative study sought to better understand the potential role of women in educating their male spouses/partners about prostate cancer screening. Nine focus groups were conducted ( n = 52). Women were recruited from a variety of community venues. Those eligible were African American and married to or in a partnership with an African American male age ≥ 45. Women provide numerous types of support to their male partners in an effort to facilitate participation in preventive health care. While women agreed that they would like to educate their partners about prostate cancer screening, they had little information about screening guidelines or the potential harms and limitations. The current findings suggest that women are eager information-seekers and can disseminate information to men and facilitate their efforts to make more informed decisions about prostate cancer screening. Women should be included in educational interventions for to promote informed decision-making for prostate cancer screening.

Towards more effective online information support for mammography screening decisions

We sought to determine the extent to which web-based patient-directed resources of U.S. public health agencies and professional groups offer consistent and relevant information on the benefits and harms of mammography screening. Between August 2016-February 2017, we identified, collected and analyzed information about mammography screening from the websites of 14 well-known governmental public health agencies and professional groups. We recorded and compared the qualitative and quantitative information the sites offered on (1) breast cancer mortality; (2) false-positive results; (3) unnecessary biopsy; and (4) overdetection. Our results show considerable variation on which benefits and harms are mentioned, whether they are discussed in qualitative and/or quantitative terms, and how this information is delivered and framed. We argue that it is ethically problematic that benefit and harm information is presented in inconsistent and incomplete ways, and we suggest that organizations work towards the adoption of uniform categories to genuinely support preference-sensitive decision making.

Crowd-figure-pictograms improve women's knowledge about mammography screening: results from a randomised controlled trial

Objective

To evaluate the effect of crowd-figure-pictograms on women’s numeric knowledge about mammography screening in a three-armed parallel randomised controlled trial.

Results

552 women were randomised to receive (1) non-numeric information (n = 192), (2) non-numeric and numeric information (n = 186), or (3) non-numeric and numeric information complemented by crowd-figure-pictograms (n = 174). Baseline numeric knowledge was low (control 0.61, numeric 0.66, and pictogram 0.51 on a scale ranging from 0 to 5). Women in the crowd-figure-pictogram group had a larger knowledge increase than women in the numeric group (2.42 vs 2.06, p = .03). Both groups had significant increases in knowledge compared to the control (0.20, p < .001). Providing numeric information in absolute numbers improves knowledge; even more so when crowd-figure-pictograms are added.

Trial registration German Clinical Trials Register DRKS00014736, retrospectively registered 11 May 2018

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3437-z) contains supplementary material, which is available to authorized users.

How a deliberative approach includes women in the decisions of screening mammography: a citizens' jury feasibility study in Andalusia, Spain

OBJECTIVES

To verify whether a citizens' jury study is feasible to the Andalusian population and to know if women, when better informed, are able to answer the research question of whether the Andalusian Public Health System must continue offering screening mammography to women aged 50-69. The reasons for the pertinent decision and recommendations to the political authorities will be stated.

DESIGN

Qualitative research study with the methodology of citizens' jury.

SETTING

Breast cancer screening programme in Andalusia (Spain).

PARTICIPANTS

Thirteen women aged 50-69 with secondary school or higher education accepted to participate as a jury. Two epidemiologists were the expert witnesses. The main researcher was the neutral moderator.

INTERVENTIONS

Jury met on Monday, 15 February 2016. The moderator indicated to the jury that it had to assess the screening programme's key benefits and main harm. On Tuesday, 16 February, the expert witnesses positioned for and against the programme. On Thursday, 18 February, the jury deliberated, reached final conclusions, submitted its vote and stated its recommendations to politicians. The deliberation session was transcribed and analysed with the support of ATLAS.ti.5.2 software.

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility in the Andalusian population, women's vote and opinion, reasons for votes and recommendations to political authorities.

RESULTS

Eleven participants voted yes and two voted no. There are three reasons to vote 'yes': health, the test nature, and individual freedom. Some women invoke the lack of efficacy and the cost to justify their negative vote, at least in universal terms. On completion, they made suggestions to be submitted to the pertinent authorities for the improvement of information, psychology services and research.

CONCLUSIONS

The deliberative strategy is feasible and causes a favourable positioning regarding screening mammography, although information changes the opinion of some women, who desire informed decision making and to keep or increase medicalisation in their lives.

Insights for public education provided by French media on ideas about prostate cancer – A media analysis study

Background: This study explored the French media’s presentation of ideas and medical information about prostate cancer (PC) that may influence men’s understanding, attitudes and behavior.

Methods: A qualitative media content analysis centered on PC information delivered by French professional media. The selected data were produced in the aftermath of the High Health Authority's decision in 2008 not to recommend systematic screening by prostate specific antigen(PSA) for men over 50. Source was the Media Archives of the French National Library. Content was analyzed from 15 television programs, 14 radio programs, and 55 articles from 35 popular French newspapers (online and printed, weekly and monthly) and 20 magazines. Audio content was narrated into textual form and submitted to manual coding along with the print content.

Results: Television and radio content focused on the nature of PC, screening and treatment,and conveyed a gender-centric position linked to male sexuality and virility. Newspapers and magazines targeted the testing controversy, the lack of consensus among professionals, and scientific advances in screening and treatment.

Conclusion: Media participation in the European testing debate is valuable for allowing patients to hear all opinions on PC risk factors. Debate on testing policy contributes to confusion and uncertainty regarding appropriate action.

Do doctors understand the test characteristics of lung cancer screening?

BACKGROUND

Screening for lung cancer with a low-dose computed tomography (CT) scan is estimated to prevent 3 deaths per 1000 individuals at high risk; however, false positive results and radiation exposure are relevant harms and deserve careful consideration. Screening candidates can only make an autonomous decision if doctors correctly inform them of the pros and cons of the method; therefore, this study aimed to evaluate whether doctors understand the test characteristics of lung cancer screening.

METHODS

In a randomized trial 556 doctors (members of the Austrian Respiratory Society) were invited to answer questions regarding lung cancer screening based on online case vignettes. Half of the participants were randomized to the group 'solutions provided' and received the correct solutions in advance. The group 'solutions withheld' had to rely on prior knowledge or estimates. The primary endpoint was the between-group difference in the estimated number of deaths preventable by screening. Secondary endpoints were the between-group differences in the prevalence of lung cancer, prevalence of a positive screening results, sensitivity, specificity, positive predictive value, and false negative rate. Estimations were also compared with current data from the literature.

RESULTS

The response rate was 29% in both groups. The reduction in the number of deaths due to screening was overestimated six-fold (95% confidence interval CI: 4-8) compared with the actual data, and there was no effect of group allocation. Providing the correct solutions to doctors had no systematic effect on their answers.

CONCLUSION

Doctors poorly understand the test characteristics of lung cancer screening. Providing the correct solutions in advance did not improve the answers. Continuing education regarding lung cancer screening and the interpretation of test characteristics may be a simple remedy.

CLINICAL TRIAL REGISTRATION

Clinical trial registered with www.clinicaltrials.gov (NCT02542332).