1
|
Scherer LD, Lewis CL, McCaffery K, Hersch J, Cappella JN, Tate C, Morse B, Arnett K, Mosley B, Smyth HL, Schapira MM. Mammography Screening Preferences Among Screening-Eligible Women in Their 40s : A National U.S. Survey. Ann Intern Med 2024; 177:1069-1077. [PMID: 39008858 DOI: 10.7326/m23-3325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND The U.S. Preventive Services Task Force (USPSTF) recently changed its recommendation for mammography screening from informed decision making to biennial screening for women aged 40 to 49 years. Although many women welcome this change, some may prefer not to be screened at age 40 years. OBJECTIVE To conduct a national probability-based U.S. survey to investigate breast cancer screening preferences among women aged 39 to 49 years. DESIGN Pre-post survey with a breast cancer screening decision aid (DA) intervention. (ClinicalTrials.gov: NCT05376241). SETTING Online national U.S. survey. PARTICIPANTS 495 women aged 39 to 49 years without a history of breast cancer or a known BRCA1/2 gene mutation. INTERVENTION A mammography screening DA providing information about screening benefits and harms and a personalized breast cancer risk estimate. MEASUREMENTS Screening preferences (assessed before and after the DA), 10-year Gail model risk estimate, and whether the information was surprising and different from past messages. RESULTS Before viewing the DA, 27.0% of participants preferred to delay screening (vs. having mammography at their current age), compared with 38.5% after the DA. There was no increase in the number never wanting mammography (5.4% before the DA vs. 4.3% after the DA). Participants who preferred to delay screening had lower breast cancer risk than those who preferred not to delay. The information about overdiagnosis was surprising for 37.4% of participants versus 27.2% and 22.9% for information about false-positive results and screening benefits, respectively. LIMITATION Respondent preferences may have been influenced by the then-current USPSTF guideline. CONCLUSION There are women in their 40s who would prefer to have mammography at an older age, especially after being informed of the benefits and harms of screening. Women who wanted to delay screening were at lower breast cancer risk than women who wanted screening at their current age. Many found information about the benefits and harms of mammography surprising. PRIMARY FUNDING SOURCE National Cancer Institute.
Collapse
Affiliation(s)
- Laura D Scherer
- School of Medicine, University of Colorado, and Denver VA Center of Innovation, Aurora, Colorado (L.D.S.)
| | - Carmen L Lewis
- School of Medicine, University of Colorado, Aurora, Colorado (C.L.L., C.T., B.Morse, K.A., B.Mosley, H.L.S.)
| | - Kirsten McCaffery
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia (K.M., J.H.)
| | - Jolyn Hersch
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia (K.M., J.H.)
| | - Joseph N Cappella
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, Pennsylvania (J.N.C.)
| | - Channing Tate
- School of Medicine, University of Colorado, Aurora, Colorado (C.L.L., C.T., B.Morse, K.A., B.Mosley, H.L.S.)
| | - Brad Morse
- School of Medicine, University of Colorado, Aurora, Colorado (C.L.L., C.T., B.Morse, K.A., B.Mosley, H.L.S.)
| | - Kelly Arnett
- School of Medicine, University of Colorado, Aurora, Colorado (C.L.L., C.T., B.Morse, K.A., B.Mosley, H.L.S.)
| | - Bridget Mosley
- School of Medicine, University of Colorado, Aurora, Colorado (C.L.L., C.T., B.Morse, K.A., B.Mosley, H.L.S.)
| | - Heather L Smyth
- School of Medicine, University of Colorado, Aurora, Colorado (C.L.L., C.T., B.Morse, K.A., B.Mosley, H.L.S.)
| | - Marilyn M Schapira
- Perelman School of Medicine, University of Pennsylvania, and Philadelphia VA Medical Center, Philadelphia, Pennsylvania (M.M.S.)
| |
Collapse
|
2
|
Kelley Jones C, Scott S, Pashayan N, Morris S, Okan Y, Waller J. Risk-Adapted Breast Screening for Women at Low Predicted Risk of Breast Cancer: An Online Discrete Choice Experiment. Med Decis Making 2024; 44:586-600. [PMID: 38828503 PMCID: PMC11283735 DOI: 10.1177/0272989x241254828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/08/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND A risk-stratified breast screening program could offer low-risk women less screening than is currently offered by the National Health Service. The acceptability of this approach may be enhanced if it corresponds to UK women's screening preferences and values. OBJECTIVES To elicit and quantify preferences for low-risk screening options. METHODS Women aged 40 to 70 y with no history of breast cancer took part in an online discrete choice experiment. We generated 32 hypothetical low-risk screening programs defined by 5 attributes (start age, end age, screening interval, risk of dying from breast cancer, and risk of overdiagnosis), the levels of which were systematically varied between the programs. Respondents were presented with 8 choice sets and asked to choose between 2 screening alternatives or no screening. Preference data were analyzed using conditional logit regression models. The relative importance of attributes and the mean predicted probability of choosing each program were estimated. RESULTS Participants (N = 502) preferred all screening programs over no screening. An older starting age of screening, younger end age of screening, longer intervals between screening, and increased risk of dying had a negative impact on support for screening programs (P < 0.01). Although the risk of overdiagnosis was of low relative importance, a decreased risk of this harm had a small positive impact on screening choices. The mean predicted probabilities that risk-adapted screening programs would be supported relative to current guidelines were low (range, 0.18 to 0.52). CONCLUSIONS A deintensified screening pathway for women at low risk of breast cancer, especially one that recommends a later screening start age, would run counter to women's breast screening preferences. Further research is needed to enhance the acceptability of offering less screening to those at low risk of breast cancer. HIGHLIGHTS Risk-based breast screening may involve the deintensification of screening for women at low risk of breast cancer.Low-risk screening pathways run counter to women's screening preferences and values.Longer screening intervals may be preferable to a later start age.Work is needed to enhance the acceptability of a low-risk screening pathway.
Collapse
Affiliation(s)
| | - Suzanne Scott
- Professor of Health Psychology, Queen Mary University London, London, UK
| | - Nora Pashayan
- Professor of Applied Cancer Research, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Stephen Morris
- Rand Professor of Health Services Research, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Yasmina Okan
- Department of Communication, Pompeu Fabra University, Barcelona, Spain
- Centre for Decision Research, Leeds University Business School, Leeds, UK
| | - Jo Waller
- Professor of Cancer Behavioural Science, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| |
Collapse
|
3
|
Pillay J, Guitard S, Rahman S, Saba S, Rahman A, Bialy L, Gehring N, Tan M, Melton A, Hartling L. Patient preferences for breast cancer screening: a systematic review update to inform recommendations by the Canadian Task Force on Preventive Health Care. Syst Rev 2024; 13:140. [PMID: 38807191 PMCID: PMC11134964 DOI: 10.1186/s13643-024-02539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/17/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Different guideline panels, and individuals, may make different decisions based in part on their preferences. Preferences for or against an intervention are viewed as a consequence of the relative importance people place on the expected or experienced health outcomes it incurs. These findings can then be considered as patient input when balancing effect estimates on benefits and harms reported by empirical evidence on the clinical effectiveness of screening programs. This systematic review update examined the relative importance placed by patients on the potential benefits and harms of mammography-based breast cancer screening to inform an update to the 2018 Canadian Task Force on Preventive Health Care's guideline on screening. METHODS We screened all articles from our previous review (search December 2017) and updated our searches to June 19, 2023 in MEDLINE, PsycINFO, and CINAHL. We also screened grey literature, submissions by stakeholders, and reference lists. The target population was cisgender women and other adults assigned female at birth (including transgender men and nonbinary persons) aged ≥ 35 years and at average or moderately increased risk for breast cancer. Studies of patients with breast cancer were eligible for health-state utility data for relevant outcomes. We sought three types of data, directly through (i) disutilities of screening and curative treatment health states (measuring the impact of the outcome on one's health-related quality of life; utilities measured on a scale of 0 [death] to 1 [perfect health]), and (ii) other preference-based data, such as outcome trade-offs, and indirectly through (iii) the relative importance of benefits versus harms inferred from attitudes, intentions, and behaviors towards screening among patients provided with estimates of the magnitudes of benefit(s) and harms(s). For screening, we used machine learning as one of the reviewers after at least 50% of studies had been reviewed in duplicate by humans; full-text selection used independent review by two humans. Data extraction and risk of bias assessments used a single reviewer with verification. Our main analysis for utilities used data from utility-based health-related quality of life tools (e.g., EQ-5D) in patients; a disutility value of about 0.04 can be considered a minimally important value for the Canadian public. When suitable, we pooled utilities and explored heterogeneity. Disutilities were calculated for screening health states and between different treatment states. Non-utility data were grouped into categories, based on outcomes compared (e.g. for trade-off data), participant age, and our judgements of the net benefit of screening portrayed by the studies. Thereafter, we compared and contrasted findings while considering sample sizes, risk of bias, subgroup findings and data on knowledge scores, and created summary statements for each data set. Certainty assessments followed GRADE guidance for patient preferences and used consensus among at least two reviewers. FINDINGS Eighty-two studies (38 on utilities) were included. The estimated disutilities were 0.07 for a positive screening result (moderate certainty), 0.03-0.04 for a false positive (FP; "additional testing" resolved as negative for cancer) (low certainty), and 0.08 for untreated screen-detected cancer (moderate certainty) or (low certainty) an interval cancer. At ≤12 months, disutilities of mastectomy (vs. breast-conserving therapy), chemotherapy (vs. none) (low certainty), and radiation therapy (vs. none) (moderate certainty) were 0.02-0.03, 0.02-0.04, and little-to-none, respectively, though in each case findings were somewhat limited in their applicability. Over the longer term, there was moderate certainty for little-to-no disutility from mastectomy versus breast-conserving surgery/lumpectomy with radiation and from radiation. There was moderate certainty that a majority (>50%) and possibly a large majority (>75%) of women probably accept up to six cases of overdiagnosis to prevent one breast-cancer death; there was some uncertainty because of an indication that overdiagnosis was not fully understood by participants in some cases. Low certainty evidence suggested that a large majority may accept that screening may reduce breast-cancer but not all-cause mortality, at least when presented with relatively high rates of breast-cancer mortality reductions (n = 2; 2 and 5 fewer per 1000 screened), and at least a majority accept that to prevent one breast-cancer death at least a few hundred patients will receive a FP result and 10-15 will have a FP resolved through biopsy. An upper limit for an acceptable number of FPs was not evaluated. When using data from studies assessing attitudes, intentions, and screening behaviors, across all age groups but most evident for women in their 40s, preferences reduced as the net benefit presented by study authors decreased in magnitude. In a relatively low net-benefit scenario, a majority of patients in their 40s may not weigh the benefits as greater than the harms from screening whereas for women in their 50s a large majority may prefer screening (low certainty evidence for both ages). There was moderate certainty that a large majority of women 50 years of age and 50 to 69 years of age, who have usually experienced screening, weigh the benefits as greater than the harms from screening in a high net-benefit scenario. A large majority of patients aged 70-71 years who have recently screened probably think the benefits outweigh the harms of continuing to screen. A majority of women in their mid-70s to early 80s may prefer to continue screening. CONCLUSIONS Evidence across a range of data sources on how informed patients value the potential outcomes from breast-cancer screening will be useful during decision-making for recommendations. The evidence suggests that all of the outcomes examined have importance to women of any age, that there is at least some and possibly substantial (among those in their 40s) variability across and within age groups about the acceptable magnitude of effects across outcomes, and that provision of easily understandable information on the likelihood of the outcomes may be necessary to enable informed decision making. Although studies came from a wide range of countries, there were limited data from Canada and about whether findings applied well across an ethnographically and socioeconomically diverse population. SYSTEMATIC REVIEW REGISTRATION Protocol available at Open Science Framework https://osf.io/xngsu/ .
Collapse
Affiliation(s)
- Jennifer Pillay
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada.
| | - Samantha Guitard
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Sholeh Rahman
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Sabrina Saba
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Ashiqur Rahman
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Nicole Gehring
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Maria Tan
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Alex Melton
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| |
Collapse
|
4
|
Zhao X, Yan L, Yang Z, Zhang H, Kong L, Zhang N, He Y. A novel signature incorporating genes related to lipid metabolism and immune for prognostic and functional prediction of breast cancer. Aging (Albany NY) 2024; 16:8611-8629. [PMID: 38771140 PMCID: PMC11164511 DOI: 10.18632/aging.205828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/10/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE Breast cancer prognosis and functioning have not been thoroughly examined in relation to immunological and lipid metabolism. However, there is a lack of prognostic and functional analyses of the relationship between lipid metabolism and immunity in breast cancer. METHODS DEGs in breast cancer were obtained from UCSC database, and lipid metabolism and immune-related genes were obtained from GSEA and Immune databases. A predictive signature was constructed using univariate Cox and LASSO regression on lipid metabolism and immune-related DEGs. The signature's prognostic significance was assessed using Kaplan-Meier, time-dependent ROC, and risk factor survival scores. Survival prognosis, therapeutic relevance, and functional enrichment were used to mine model gene biology. We selected IL18, which has never been reported in breast cancer before, in the signature to learn more about its function, potential to predict outcome, and immune system role. RT-PCR was performed to verify the true expression level of IL18. RESULTS A total of 136 DEGs associated with breast cancer responses to both immunity and lipid metabolism. Nine key genes (CALR, CCL5, CEPT, FTT3, CXCL13, FLT3, IL12B, IL18, and IL24, p < 1.6e-2) of breast cancer were identified, and a prognostic was successfully constructed with a good predictive ability. IL18 in the model also had good clinical prognostic guidance value and immune regulation and therapeutic potential. Furthermore, the expression of IL18 was higher than that in paracancerous tissue. CONCLUSIONS A unique predictive signature model could effectively predict the prognosis of breast cancer, which can not only achieve survival prediction, but also screen out key genes with important functional mechanisms to guide clinical drug experiments.
Collapse
Affiliation(s)
- Xiao Zhao
- Clinical Laboratory, People’s Hospital of Xinjin District, Chengdu 611430, China
| | - Lvjun Yan
- Tumor and Hematology Department, University-Town Hospital of Chongqing Medical University, Chongqing 401331, China
| | - Zailin Yang
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing 400030, China
| | - Hui Zhang
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing 400030, China
| | - Lingshuang Kong
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing 400030, China
| | - Na Zhang
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing 400030, China
| | - Yongpeng He
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing 400030, China
| |
Collapse
|
5
|
Riganti P, Ruiz Yanzi MV, Escobar Liquitay CM, Sgarbossa NJ, Alarcon-Ruiz CA, Kopitowski KS, Franco JV. Shared decision-making for supporting women's decisions about breast cancer screening. Cochrane Database Syst Rev 2024; 5:CD013822. [PMID: 38726892 PMCID: PMC11082933 DOI: 10.1002/14651858.cd013822.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND In breast cancer screening programmes, women may have discussions with a healthcare provider to help them decide whether or not they wish to join the breast cancer screening programme. This process is called shared decision-making (SDM) and involves discussions and decisions based on the evidence and the person's values and preferences. SDM is becoming a recommended approach in clinical guidelines, extending beyond decision aids. However, the overall effect of SDM in women deciding to participate in breast cancer screening remains uncertain. OBJECTIVES To assess the effect of SDM on women's satisfaction, confidence, and knowledge when deciding whether to participate in breast cancer screening. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 August 2023. We also screened abstracts from two relevant conferences from 2020 to 2023. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs) and cluster-RCTs assessing interventions targeting various components of SDM. The focus was on supporting women aged 40 to 75 at average or above-average risk of breast cancer in their decision to participate in breast cancer screening. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and conducted data extraction, risk of bias assessment, and GRADE assessment of the certainty of the evidence. Review outcomes included satisfaction with the decision-making process, confidence in the decision made, knowledge of all options, adherence to the chosen option, women's involvement in SDM, woman-clinician communication, and mental health. MAIN RESULTS We identified 19 studies with 64,215 randomised women, mostly with an average to moderate risk of breast cancer. Two studies covered all aspects of SDM; six examined shortened forms of SDM involving communication on risks and personal values; and 11 focused on enhanced communication of risk without other SDM aspects. SDM involving all components compared to control The two eligible studies did not assess satisfaction with the SDM process or confidence in the decision. Based on a single study, SDM showed uncertain effects on participant knowledge regarding the age to start screening (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.61 to 2.28; 133 women; very low certainty evidence) and frequency of testing (RR 0.84, 95% CI 0.68 to 1.04; 133 women; very low certainty evidence). Other review outcomes were not measured. Abbreviated forms of SDM with clarification of values and preferences compared to control Of the six included studies, none evaluated satisfaction with the SDM process. These interventions may reduce conflict in the decision made, based on two measures, Decisional Conflict Scale scores (mean difference (MD) -1.60, 95% CI -4.21 to 0.87; conflict scale from 0 to 100; 4 studies; 1714 women; very low certainty evidence) and the proportion of women with residual conflict compared to control at one to three months' follow-up (rate of women with a conflicted decision, RR 0.75, 95% CI 0.56 to 0.99; 1 study; 1001 women, very low certainty evidence). Knowledge of all options was assessed through knowledge scores and informed choice. The effect of SDM may enhance knowledge (MDs ranged from 0.47 to 1.44 higher scores on a scale from 0 to 10; 5 studies; 2114 women; low certainty evidence) and may lead to higher rates of informed choice (RR 1.24, 95% CI 0.95 to 1.63; 4 studies; 2449 women; low certainty evidence) compared to control at one to three months' follow-up. These interventions may result in little to no difference in anxiety (MD 0.54, 95% -0.96 to 2.14; scale from 20 to 80; 2 studies; 749 women; low certainty evidence) and the number of women with worries about cancer compared to control at four to six weeks' follow-up (RR 0.88, 95% CI 0.73 to 1.06; 1 study, 639 women; low certainty evidence). Other review outcomes were not measured. Enhanced communication about risks without other SDM aspects compared to control Of 11 studies, three did not report relevant outcomes for this review, and none assessed satisfaction with the SDM process. Confidence in the decision made was measured by decisional conflict and anticipated regret of participating in screening or not. These interventions, without addressing values and preferences, may result in lower confidence in the decision compared to regular communication strategies at two weeks' follow-up (MD 2.89, 95% CI -2.35 to 8.14; Decisional Conflict Scale from 0 to 100; 2 studies; 1191 women; low certainty evidence). They may result in higher anticipated regret if participating in screening (MD 0.28, 95% CI 0.15 to 0.41) and lower anticipated regret if not participating in screening (MD -0.28, 95% CI -0.42 to -0.14). These interventions increase knowledge (MD 1.14, 95% CI 0.61 to 1.62; scale from 0 to 10; 4 studies; 2510 women; high certainty evidence), while it is unclear if there is a higher rate of informed choice compared to regular communication strategies at two to four weeks' follow-up (RR 1.27, 95% CI 0.83 to 1.92; 2 studies; 1805 women; low certainty evidence). These interventions result in little to no difference in anxiety (MD 0.33, 95% CI -1.55 to 0.99; scale from 20 to 80) and depression (MD 0.02, 95% CI -0.41 to 0.45; scale from 0 to 21; 2 studies; 1193 women; high certainty evidence) and lower cancer worry compared to control (MD -0.17, 95% CI -0.26 to -0.08; scale from 1 to 4; 1 study; 838 women; high certainty evidence). Other review outcomes were not measured. AUTHORS' CONCLUSIONS Studies using abbreviated forms of SDM and other forms of enhanced communications indicated improvements in knowledge and reduced decisional conflict. However, uncertainty remains about the effect of SDM on supporting women's decisions. Most studies did not evaluate outcomes considered important for this review topic, and those that did measured different concepts. High-quality randomised trials are needed to evaluate SDM in diverse cultural settings with a focus on outcomes such as women's satisfaction with choices aligned to their values.
Collapse
Affiliation(s)
- Paula Riganti
- Family and Community Medicine Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M Victoria Ruiz Yanzi
- Family and Community Medicine Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Nadia J Sgarbossa
- Health Department, Universidad Nacional de La Matanza, Buenos Aires, Argentina
| | - Christoper A Alarcon-Ruiz
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Karin S Kopitowski
- Family and Community Medicine Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Va Franco
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
6
|
Fransen MP, Damman OC, Bas S, Uiters E, Timmermans DR. Decision-making in breast cancer screening: A qualitative exploration of the match between women's beliefs and screening information in the Netherlands. PATIENT EDUCATION AND COUNSELING 2024; 122:108155. [PMID: 38325207 DOI: 10.1016/j.pec.2024.108155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Decision-making about breast cancer screening requires balanced and understandable information that takes prior beliefs of screening invitees into account. METHODS In qualitative interviews with 22 Dutch women who were invited for screening for the first time (49-52 years of age, varying health literacy levels), we gained insight in their beliefs on breast cancer and breast cancer screening, and explored how the current screening information matched these beliefs. RESULTS Breast cancer was perceived as an unpredictable, severe, and uncontrollable disease. Women considered screening as self-evident and an important mean to gain some control over breast cancer. Information on benefits of screening was in line with women's prior beliefs and confirmed women's main reasons to participate. Information about false-positive outcomes, overtreatment, and false negative outcomes did not correspond to women's prior beliefs and this information was generally not considered relevant for decision-making. Preferences for additional information merely concerned practical information on the screening procedure. CONCLUSION Complex information on the harms of screening does not match women's beliefs and is not taken into account in their decision-making. PRACTICE IMPLICATIONS Information regarding breast cancer screening could be further aligned to prior beliefs by taking into account values, filling knowledge gaps and correct misconceptions.
Collapse
Affiliation(s)
- Mirjam P Fransen
- National Institute for Public Health and the Environment, Centre for Prevention, Lifestyle and Health, Bilthoven, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Public and Occupational Health, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Public Health Research institute, Quality of Care, Amsterdam, the Netherlands.
| | - Olga C Damman
- Amsterdam Public Health Research institute, Quality of Care, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit Amsterdam, Public and Occupational Health, Van der Boechorststraat 7 1081 Amsterdam, the Netherlands
| | - Sharell Bas
- National Institute for Public Health and the Environment, Centre for Prevention, Lifestyle and Health, Bilthoven, the Netherlands
| | - Ellen Uiters
- National Institute for Public Health and the Environment, Centre for Prevention, Lifestyle and Health, Bilthoven, the Netherlands
| | - Daniëlle Rm Timmermans
- Amsterdam Public Health Research institute, Quality of Care, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit Amsterdam, Public and Occupational Health, Van der Boechorststraat 7 1081 Amsterdam, the Netherlands
| |
Collapse
|
7
|
Schoenborn NL, Gollust SE, Schonberg MA, Pollack CE, Boyd CM, Xue QL, Nagler RH. Development and Evaluation of Messages for Reducing Overscreening of Breast Cancer in Older Women. Med Care 2024; 62:296-304. [PMID: 38498875 PMCID: PMC10997450 DOI: 10.1097/mlr.0000000000001993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Many older women are screened for breast cancer beyond guideline-recommended thresholds. One contributor is pro-screening messaging from health care professionals, media, and family/friends. In this project, we developed and evaluated messages for reducing overscreening in older women. METHODS We surveyed women ages 65+ who were members of a nationally representative online panel. We constructed 8 messages describing reasons to consider stopping mammograms, including guideline recommendations, false positives, overdiagnosis, and diminishing benefits from screening due to competing risks. Messages varied in their format; some presented statistical evidence, and some described short anecdotes. Each participant was randomized to read 4 of 8 messages. We also randomized participants to one of 3 message sources (clinician, family member, and news story). We assessed whether the message would make participants "want to find out more information" and "think carefully" about mammograms. RESULTS Participants (N=790) had a mean age of 73.5 years; 25.8% were non-White. Across all messages, 73.0% of the time, participants agreed that the messages would make them seek more information (range among different messages=64.2%-78.2%); 46.5% of the time participants agreed that the messages would make them think carefully about getting mammograms (range =36.7%-50.7%). Top-rated messages mentioned false-positive anecdotes and overdiagnosis evidence. Ratings were similar for messages from clinicians and news sources, but lower from the family member source. CONCLUSIONS Overall, participants positively evaluated messages designed to reduce breast cancer overscreening regarding perceived effects on information seeking and deliberation. Combining the top-rated messages into messaging interventions may be a novel approach to reduce overscreening.
Collapse
Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah E Gollust
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
| | - Mara A Schonberg
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Craig E Pollack
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Center on Aging and Health, Baltimore, MD
| | - Qian-Li Xue
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Center on Aging and Health, Baltimore, MD
| | - Rebekah H Nagler
- Hubbard School of Journalism and Mass Communication, University of Minnesota College of Liberal Arts, Minneapolis, MN
| |
Collapse
|
8
|
Dickson-Swift V, Adams J, Spelten E, Blackberry I, Wilson C, Yuen E. Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review. BMC Womens Health 2024; 24:256. [PMID: 38658945 PMCID: PMC11040767 DOI: 10.1186/s12905-024-03094-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND This scoping review aimed to identify and present the evidence describing key motivations for breast cancer screening among women aged ≥ 75 years. Few of the internationally available guidelines recommend continued biennial screening for this age group. Some suggest ongoing screening is unnecessary or should be determined on individual health status and life expectancy. Recent research has shown that despite recommendations regarding screening, older women continue to hold positive attitudes to breast screening and participate when the opportunity is available. METHODS All original research articles that address motivation, intention and/or participation in screening for breast cancer among women aged ≥ 75 years were considered for inclusion. These included articles reporting on women who use public and private breast cancer screening services and those who do not use screening services (i.e., non-screeners). The Joanna Briggs Institute (JBI) methodology for scoping reviews was used to guide this review. A comprehensive search strategy was developed with the assistance of a specialist librarian to access selected databases including: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Web of Science and PsychInfo. The review was restricted to original research studies published since 2009, available in English and focusing on high-income countries (as defined by the World Bank). Title and abstract screening, followed by an assessment of full-text studies against the inclusion criteria was completed by at least two reviewers. Data relating to key motivations, screening intention and behaviour were extracted, and a thematic analysis of study findings undertaken. RESULTS A total of fourteen (14) studies were included in the review. Thematic analysis resulted in identification of three themes from included studies highlighting that decisions about screening were influenced by: knowledge of the benefits and harms of screening and their relationship to age; underlying attitudes to the importance of cancer screening in women's lives; and use of decision aids to improve knowledge and guide decision-making. CONCLUSION The results of this review provide a comprehensive overview of current knowledge regarding the motivations and screening behaviour of older women about breast cancer screening which may inform policy development.
Collapse
Affiliation(s)
- Virginia Dickson-Swift
- Violet Vines Centre for Rural Health Research, La Trobe Rural Health School, La Trobe University, P.O. Box 199, Bendigo, VIC, 3552, Australia
| | - Joanne Adams
- Violet Vines Centre for Rural Health Research, La Trobe Rural Health School, La Trobe University, P.O. Box 199, Bendigo, VIC, 3552, Australia.
| | - Evelien Spelten
- Violet Vines Centre for Rural Health Research, La Trobe Rural Health School, La Trobe University, P.O. Box 199, Bendigo, VIC, 3552, Australia
| | - Irene Blackberry
- Care Economy Research Institute, La Trobe University, Wodonga, Australia
| | - Carlene Wilson
- Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Australia
- Melbourne School of Population and Global Health, Melbourne University, Melbourne, Australia
- School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Eva Yuen
- Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Australia
- Institute for Health Transformation, Deakin University, Burwood, Australia
- Centre for Quality and Patient Safety, Monash Health Partnership, Monash Health, Clayton, Australia
- School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| |
Collapse
|
9
|
van Strien-Knippenberg IS, Arjangi-Babetti H, Timmermans DRM, Schrauwen L, Fransen MP, Melles M, Damman OC. Communicating the results of risk-based breast cancer screening through visualizations of risk: a participatory design approach. BMC Med Inform Decis Mak 2024; 24:78. [PMID: 38500098 PMCID: PMC10949766 DOI: 10.1186/s12911-024-02483-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Inge S van Strien-Knippenberg
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands.
| | - Hannah Arjangi-Babetti
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Danielle R M Timmermans
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Laura Schrauwen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Mirjam P Fransen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Marijke Melles
- Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - Olga C Damman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| |
Collapse
|
10
|
Supplemental Screening as an Adjunct to Mammography for Breast Cancer Screening in People With Dense Breasts: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2023; 23:1-293. [PMID: 39364436 PMCID: PMC11445669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
Background Screening with mammography aims to detect breast cancer before clinical symptoms appear. Among people with dense breasts, some cancers may be missed using mammography alone. The addition of supplemental imaging as an adjunct to screening mammography has been suggested to detect breast cancers missed on mammography, potentially reducing the number of deaths associated with the disease. We conducted a health technology assessment of supplemental screening with contrast-enhanced mammography, ultrasound, digital breast tomosynthesis (DBT), or magnetic resonance imaging (MRI) as an adjunct to mammography for people with dense breasts, which included an evaluation of effectiveness, harms, cost-effectiveness, the budget impact of publicly funding supplemental screening, the preferences and values of patients and health care providers, and ethical issues. Methods We performed a systematic literature search of the clinical evidence published from January 2015 to October 2021. We assessed the risk of bias of each included study using the Cochrane Risk of Bias or RoBANS tools, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature review and conducted cost-effectiveness analyses with a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding supplemental screening as an adjunct to mammography for people with dense breasts in Ontario. To contextualize the potential value of supplemental screening for dense breasts, we spoke with people with dense breasts who had undergone supplemental screening; performed a rapid review of the qualitative literature; and conducted an ethical analysis of supplemental screening as an adjunct to mammography. Results We included eight primary studies in the clinical evidence review. No studies evaluated contrast-enhanced mammography. Nonrandomized and randomized evidence (GRADE: Very low to Moderate) suggests that mammography plus ultrasound was more sensitive and less specific, and detected more cancers compared to mammography alone. Fewer interval cancers occurred after mammography plus ultrasound (GRADE: Very low to Low), but recall rates were nearly double that of mammography alone (GRADE: Very low to Moderate). Evidence of Low to Very low quality suggested that compared with supplemental DBT, supplemental ultrasound was more sensitive, detected more cancers, and led to more recalls. Among people with extremely dense breasts, fewer interval cancers occurred after mammography plus supplemental MRI compared to mammography alone (GRADE: High). Supplemental MRI after negative mammography was highly accurate in people with extremely dense breasts and heterogeneously dense breasts in nonrandomized and randomized studies (GRADE: Very Low and Moderate). In people with extremely dense breasts, MRI after negative mammography detected 16.5 cancers per 1,000 screens (GRADE: Moderate), and up to 9.5% of all people screened were recalled (GRADE: Moderate). Contrast-related adverse events were infrequent (GRADE: Moderate). No study reported psychological impacts, breast cancer-specific mortality, or overall mortality.We included nine studies in the economic evidence, but none of the study findings was directly applicable to the Ontario context. Our lifetime cost-effectiveness analyses showed that supplemental screening with ultrasound, MRI, or DBT found more screen-detected cancers, decreased the number of interval cancers, had small gains in life-years or quality-adjusted life-years (QALYs), and was associated with savings in cancer management costs. However, supplemental screening also increased imaging costs and the number of false-positive cases. Compared to mammography alone, the incremental cost-effectiveness ratios (ICERs) for supplemental screening with handheld ultrasound, MRI, or DBT for people with dense breasts were $119,943, $314,170, and $212,707 per QALY gained, respectively. The ICERs for people with extremely dense breasts were $83,529, $101,813, and $142,730 per QALY gained, respectively. In sensitivity analyses, the diagnostic test sensitivity of mammography alone and of mammography plus supplemental screening had the greatest effect on ICER estimates. The total budget impact of publicly funding supplemental screening with handheld ultrasound, MRI, or DBT for people with dense breasts over the next 5 years is estimated at $15 million, $41 million, or $33 million, respectively. The corresponding total budget impact for people with extremely dense breasts is $4 million, $10 million, or $9 million.We engaged directly with 70 people via interviews and an online survey. The participants provided diverse perspectives on broad access to supplemental screening for people with dense breasts in Ontario. Themes discussed in the interviews included self-advocacy, patient-doctor partnership, preventive care, and a shared preference for broad access to screening modalities that are clinically effective in detecting breast cancer in people with dense breasts.We included 10 studies in the qualitative evidence rapid review. Thematic synthesis of these reports yielded three analytical themes: coming to know and understand breast density, which included introductions to and making sense of breast density; experiences of vulnerability, which influenced or were influenced by understandings and misunderstandings of breast density and responses to breast density; and choosing supplemental screening, which was influenced by knowledge and perception of the risks and benefits of supplemental screening, and the availability of resources.The ethics review determined that the main harms of supplemental screening for people with dense breasts are false-positives and overdiagnosis, both of which lead to unnecessary and burdensome health care treatments. Screening programs raise inherent tensions between individual- and population-level interests; they may yield population-level benefit, but are statistically of very little benefit to individuals. Entrenched cultural beliefs about the value of breast cancer screening, combined with uncertainty about the effects of supplemental screening on some outcomes and the discomfort of many health care providers in discussing screening options for people with dense breasts suggest that it may be difficult to ensure that patients can provide informed consent to engage in supplemental screening. Funding supplemental screening for people with dense breasts may lead to improved equity in the effectiveness of identifying cancers in people with dense breasts (compared to mammography alone), but it is not clear whether it would lead to equity in terms of improved survival and decreased morbidity. Conclusions Supplemental screening with ultrasound, DBT, or MRI as an adjunct to mammography detected more cancers and increased the number of recalls and biopsies, including false-positive results. Fewer interval cancers tended to occur after supplemental screening compared to mammography alone. It is unclear whether supplemental screening as an adjunct to mammography would reduce breast cancer-related or overall mortality among people with dense breasts.Supplemental screening with ultrasound, DBT, or MRI as an adjunct to mammography in people aged 50 to 74 years improved cancer detection but increased costs. Depending on the type of imaging modality, publicly funding supplemental screening in Ontario over the next 5 years would require additional total costs between $15 million and $41 million for people with dense breasts, and between $4 million and $10 million for people with extremely dense breasts.The people we engaged with directly valued the potential clinical benefits of supplemental screening and emphasized that patient education and equitable access should be a requirement for implementation in Ontario. Our review of the qualitative literature found that the concept of breast density is poorly understood, both by people with dense breasts and by some general practitioners. People with dense breasts who receive routine mammography (especially those who receive health care in their nonpreferred language or are perceived to have lower economic status or health literacy) and their general practitioners may not have the awareness or knowledge to make informed decisions about supplemental screening. Some people with dense breasts experienced emotional distress from barriers to accessing supplemental screening, and many wanted to engage in supplemental screening, even when educated about its potential harms, including false-positives and overdiagnosis.Given an overall lack of robust evidence about morbidity and mortality associated with supplemental screening for people with dense breasts, it is not possible to determine whether funding supplemental screening for dense breasts delivers on the ethical duties to maximize benefits and minimize harms for populations and individuals. It is likely that existing inequities in access to breast screening and cancer treatment will persist, even if supplemental screening for dense breasts is funded. Continued efforts to address these inequities by removing barriers to screening might mitigate this concern. It will be important to identify and minimize sources of uncertainty related to benefits and risks of supplemental screening for dense breasts to optimize the capacity for everyone involved to live up to their ethical obligations. Some of these may be resolved with further evidence related to the outcomes of supplemental screening for dense breasts.
Collapse
|
11
|
Brockhoven F, Raphael M, Currier J, Jäderholm C, Mody P, Shannon J, Starling B, Turner-Uaandja H, Pashayan N, Arteaga I. REPRESENT recommendations: improving inclusion and trust in cancer early detection research. Br J Cancer 2023; 129:1195-1208. [PMID: 37689805 PMCID: PMC10575902 DOI: 10.1038/s41416-023-02414-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 08/01/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023] Open
Abstract
Detecting cancer early is essential to improving cancer outcomes. Minoritized groups remain underrepresented in early detection cancer research, which means that findings and interventions are not generalisable across the population, thus exacerbating disparities in cancer outcomes. In light of these challenges, this paper sets out twelve recommendations to build relations of trust and include minoritized groups in ED cancer research. The Recommendations were formulated by a range of stakeholders at the 2022 REPRESENT consensus-building workshop and are based on empirical data, including a systematic literature review and two ethnographic case studies in the US and the UK. The recommendations focus on: Long-term relationships that build trust; Sharing available resources; Inclusive and accessible communication; Harnessing community expertise; Unique risks and benefits; Compensation and support; Representative samples; Demographic data; Post-research support; Sharing results; Research training; Diversifying research teams. For each recommendation, the paper outlines the rationale, specifications for how different stakeholders may implement it, and advice for best practices. Instead of isolated recruitment, public involvement and engagement activities, the recommendations here aim to advance mutually beneficial and trusting relationships between researchers and research participants embedded in ED cancer research institutions.
Collapse
Grants
- EICEDAAP\100011 Cancer Research UK
- Cancer Research UK (CRUK)
- The International Alliance for Cancer Early Detection, an alliance between Cancer Research UK [EICEDAAP\100011], Canary Center at Stanford University, the University of Cambridge, OHSU Knight Cancer Institute, University College London and the University of Manchester.
- This work was supported by the International Alliance for Cancer Early Detection, an alliance between Cancer Research UK [EICEDAAP\100011], Canary Center at Stanford University, the University of Cambridge, OHSU Knight Cancer Institute, University College London and the University of Manchester.
Collapse
Affiliation(s)
| | - Maya Raphael
- Department of Social Anthropology, University of Cambridge, Cambridge, UK
| | - Jessica Currier
- Division of Oncological Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Christina Jäderholm
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Perveez Mody
- Department of Social Anthropology, University of Cambridge, Cambridge, UK
| | - Jackilen Shannon
- Division of Oncological Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Bella Starling
- Vocal, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Nora Pashayan
- Department of Applied Health Research, University College London, London, UK
| | - Ignacia Arteaga
- Department of Social Anthropology, University of Cambridge, Cambridge, UK.
- Early Cancer Institute, University of Cambridge, Cambridge, UK.
| |
Collapse
|
12
|
Scherer LD, Suresh K, Lewis CL, McCaffery KJ, Hersch J, Cappella JN, Morse B, Tate CE, Mosley BS, Schmiege S, Schapira MM. Assessing and Understanding Reactance, Self-Exemption, Disbelief, Source Derogation and Information Conflict in Reaction to Overdiagnosis in Mammography Screening: Scale Development and Preliminary Validation. Med Decis Making 2023; 43:789-802. [PMID: 37705500 PMCID: PMC10843591 DOI: 10.1177/0272989x231195603] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
PURPOSE Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet some people may react to overdiagnosis with doubt and skepticism. The present research assessed 4 related reactions to overdiagnosis: reactance, self-exemption, disbelief, and source derogation (REDS). The degree to which the concept of overdiagnosis conflicts with participants' prior beliefs and health messages (information conflict) was also assessed as a potential antecedent of REDS. We developed a scale to assess these reactions, evaluated how those reactions are related, and identified their potential implications for screening decision making. METHODS Female participants aged 39 to 49 years read information about overdiagnosis in mammography screening and completed survey questions assessing their reactions to that information. We used a multidimensional theoretical framework to assess dimensionality and overall domain-specific internal consistency of the REDS and Information Conflict questions. Exploratory and confirmatory factor analyses were performed using data randomly split into a training set and test set. Correlations between REDS, screening intentions, and other outcomes were evaluated. RESULTS Five-hundred twenty-five participants completed an online survey. Exploratory and confirmatory factor analyses identified that Reactance, Self Exemption, Disbelief, Source Derogation, and Information Conflict represent unique constructs. A reduced 20-item scale was created by selecting 4 items per construct, which showed good model fit. Reactance, Disbelief, and Source Derogation were associated with lower intent to use information about overdiagnosis in decision making and the belief that informing people about overdiagnosis is unimportant. CONCLUSIONS REDS and Information Conflict are distinct but correlated constructs that are common reactions to overdiagnosis. Some of these reactions may have negative implications for making informed screening decisions. HIGHLIGHTS Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet when provided information about overdiagnosis, some people are skeptical.This research developed a measure that assessed different ways in which people might express skepticism about overdiagnosis (reactance, self-exemption, disbelief, source derogation) and also the perception that overdiagnosis conflicts with prior knowledge and health messages (information conflict).These different reactions are distinct but correlated and are common reactions when people learn about overdiagnosis.Reactance, disbelief, and source derogation are associated with lower intent to use information about overdiagnosis in decision making as well as the belief that informing people about overdiagnosis is unimportant.
Collapse
Affiliation(s)
- Laura D Scherer
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- CO Center of Innovation (COIN), VA Eastern Colorado, Aurora, CO, USA
| | - Krithika Suresh
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carmen L Lewis
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kirsten J McCaffery
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jolyn Hersch
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Joseph N Cappella
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Annenburg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | - Brad Morse
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Channing E Tate
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Bridget S Mosley
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah Schmiege
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marilyn M Schapira
- Department of Medicine, University of Pennsylvania School of Medicine, Center for Health Equity Research & Promotion (CHERP), Philadelphia VA Medical Center, Philadelphia, PA, USA
| |
Collapse
|
13
|
Wang S, Sultana F, Kavanagh A, Nickson C, Karahalios A, Gurrin LC, English DR. Benefits and harms of breast cancer screening: Cohort study of breast cancer mortality and overdiagnosis. Cancer Med 2023; 12:18120-18132. [PMID: 37548277 PMCID: PMC10524083 DOI: 10.1002/cam4.6373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/15/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Quantifying the benefits and harms of breast cancer screening accurately is important for planning and evaluating screening programs and for enabling women to make informed decisions about participation. However, few cohort studies have attempted to estimate benefit and harm simultaneously. AIMS We aimed to quantify the impact of mammographic screening on breast cancer mortality and overdiagnosis using a cohort of women invited to attend Australia's national screening program, BreastScreen. METHODS In a cohort of 41,330 women without prior breast cancer diagnosis, screening, or diagnostic procedures invited to attend BreastScreen Western Australia in 1994-1995, we estimated the cumulative risk of breast cancer mortality and breast cancer incidence (invasive and ductal carcinoma in situ) from age 50 to 85 years for attenders and non-attenders. Data were obtained by linking population-based state and national health registries. Breast cancer mortality risks were estimated from a survival analysis that accounted for competing risk of death from other causes. Breast cancer risk for unscreened women was estimated by survival analysis, while accounting for competing causes of death. For screened women, breast cancer risk was the sum of risk of being diagnosed at first screen, estimated using logistic regression, and risk of diagnosis following a negative first screen estimated from a survival analysis. RESULTS For every 1,000 women 50 years old at first invitation to attend BreastScreen, there were 20 (95% CI 12-30) fewer breast cancer deaths and 25 (95% CI 15-35) more breast cancers diagnosed for women who attended than for non-attendees by age 85. Of the breast cancers diagnosed in screened women, 21% (95% CI 13%-27%) could be attributed to screening. DISCUSSION The estimated ratio of benefit to harm was consistent with, but slightly less favourable to screening than most other estimates from cohort studies. CONCLUSION Women who participate in organised screening for breast cancer in Australia have substantially lower breast cancer mortality, while some screen-detected cancers may be overdiagnosed.
Collapse
Affiliation(s)
- Sabrina Wang
- Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Cancer Epidemiology DivisionCancer Council VictoriaMelbourneVictoriaAustralia
| | | | - Anne Kavanagh
- Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Carolyn Nickson
- Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
- The Daffodil CentreThe University of SydneySydneyNew South WalesAustralia
| | - Amalia Karahalios
- Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Lyle C. Gurrin
- Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Dallas R. English
- Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Cancer Epidemiology DivisionCancer Council VictoriaMelbourneVictoriaAustralia
| |
Collapse
|
14
|
Cavers D, Nelson M, Rostron J, Robb KA, Brown LR, Campbell C, Akram AR, Dickie G, Mackean M, van Beek EJR, Sullivan F, Steele RJ, Neilson AR, Weller D. Understanding patient barriers and facilitators to uptake of lung screening using low dose computed tomography: a mixed methods scoping review of the current literature. Respir Res 2022; 23:374. [PMID: 36564817 PMCID: PMC9789658 DOI: 10.1186/s12931-022-02255-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Targeted lung cancer screening is effective in reducing mortality by upwards of twenty percent. However, screening is not universally available and uptake is variable and socially patterned. Understanding screening behaviour is integral to designing a service that serves its population and promotes equitable uptake. We sought to review the literature to identify barriers and facilitators to screening to inform the development of a pilot lung screening study in Scotland. METHODS We used Arksey and O'Malley's scoping review methodology and PRISMA-ScR framework to identify relevant literature to meet the study aims. Qualitative, quantitative and mixed methods primary studies published between January 2000 and May 2021 were identified and reviewed by two reviewers for inclusion, using a list of search terms developed by the study team and adapted for chosen databases. RESULTS Twenty-one articles met the final inclusion criteria. Articles were published between 2003 and 2021 and came from high income countries. Following data extraction and synthesis, findings were organised into four categories: Awareness of lung screening, Enthusiasm for lung screening, Barriers to lung screening, and Facilitators or ways of promoting uptake of lung screening. Awareness of lung screening was low while enthusiasm was high. Barriers to screening included fear of a cancer diagnosis, low perceived risk of lung cancer as well as practical barriers of cost, travel and time off work. Being health conscious, provider endorsement and seeking reassurance were all identified as facilitators of screening participation. CONCLUSIONS Understanding patient reported barriers and facilitators to lung screening can help inform the implementation of future lung screening pilots and national lung screening programmes.
Collapse
Affiliation(s)
- Debbie Cavers
- Usher Institute, University of Edinburgh, Doorway 1, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Mia Nelson
- Usher Institute, University of Edinburgh, Doorway 1, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Jasmin Rostron
- The National Institute of Economic and Social Research, 2 Dean Trench Street, London, NW1P 3HE UK
| | - Kathryn A. Robb
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ UK
| | - Lynsey R. Brown
- School of Medicine, University of St. Andrews, North Haugh, St. Andrews, KY16 9TF UK
| | - Christine Campbell
- Usher Institute, University of Edinburgh, Doorway 1, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Ahsan R. Akram
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Graeme Dickie
- Usher Institute, University of Edinburgh, Doorway 1, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Melanie Mackean
- Edinburgh Cancer Centre, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU UK
| | - Edwin J. R. van Beek
- Edinburgh Imaging, Queen’s Medical Research Institute, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4TJ UK
| | - Frank Sullivan
- School of Medicine, University of St. Andrews, North Haugh, St. Andrews, KY16 9TF UK
| | - Robert J. Steele
- School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY UK
| | - Aileen R. Neilson
- Usher Institute, University of Edinburgh, Doorway 1, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - David Weller
- Usher Institute, University of Edinburgh, Doorway 1, Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| |
Collapse
|
15
|
Piessens V, Heytens S, Van Den Bruel A, Van Hecke A, De Sutter A. Do doctors and other healthcare professionals know overdiagnosis in screening and how are they dealing with it? A protocol for a mixed methods systematic review. BMJ Open 2022; 12:e054267. [PMID: 36220316 PMCID: PMC9557257 DOI: 10.1136/bmjopen-2021-054267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Overdiagnosis is the diagnosis of a disease that would never have caused any symptom or problem. It is a harmful side effect of screening and may lead to unnecessary treatment, costs and emotional drawbacks. Doctors and other healthcare professionals (HCPs) have the opportunity to mitigate these consequences, not only by informing their patients or the public but also by adjusting screening methods or even by refraining from screening. However, it is unclear to what extent HCPs are fully aware of overdiagnosis and whether it affects their screening decisions. With this systematic review, we aim to synthesise all available research about what HCPs know and think about overdiagnosis, how it affects their position on screening policy and whether they think patients and the public should be informed about it. METHODS AND ANALYSIS We will systematically search several databases (MEDLINE, Embase, Web of Science, Scopus, CINAHL and PsycArticles) for studies that directly examine HCPs' knowledge and subjective perceptions of overdiagnosis due to health screening, both qualitatively and quantitatively. We will optimise our search by scanning reference and citation lists, contacting experts in the field and hand searching abstracts from the annual conference on 'Preventing Overdiagnosis'. After selection and quality appraisal, we will analyse qualitative and quantitative findings separately in a segregated design for mixed-method reviews. The data will be examined and presented descriptively. If the retrieved studies allow it, we will review them from a constructivist perspective through a critical interpretive synthesis. ETHICS AND DISSEMINATION For this type of research, no ethical approval is required. Findings from this systematic review will be published in a peer-reviewed journal and presented at the annual congress of 'Preventing Overdiagnosis'. In addition, the results will serve as guidance for further research on this topic. PROSPERO REGISTRATION NUMBER CRD42021244513.
Collapse
Affiliation(s)
- Veerle Piessens
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Stefan Heytens
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Ann Van Den Bruel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Flanders, Belgium
| | - Ann Van Hecke
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| |
Collapse
|
16
|
Ross RL, Rubio K, Rodriguez HP. Mammography and Decision Aid Use for Breast Cancer Screening in Older Women. Am J Prev Med 2022; 63:630-635. [PMID: 35718630 PMCID: PMC9509405 DOI: 10.1016/j.amepre.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Decision aids for breast cancer screening are increasingly being used by physicians, but the association between physician practice decision-aid use and mammography rates remains uncertain. Using national data, this study examines the association between practice-level decision-aid use and mammography use among older women. METHODS Physician practice responses to the 2017/2018 National Survey of Healthcare Organizations and Systems (n=1,236) were linked to 2016 and 2017 Medicare fee-for-service beneficiary data from eligible beneficiaries (n=439,684) aged 65-74 years. In 2021, multivariable generalized linear models estimated the association of practice decision-aid use for breast cancer screening and advanced health information technology functions with mammography use, controlling for practice and beneficiary characteristics. RESULTS Overall, 60.1% of eligible beneficiaries had a screening mammogram, and 37.3% of physician practices routinely used decision aids for breast cancer screening. In adjusted analyses, advanced health information technology functions (OR=1.19, p=0.04) were associated with mammography use, but practice use of decision aids was not (OR=0.95, p=0.21). Beneficiary clinical and socioeconomic characteristics, including race, comorbidities, Medicare and Medicaid eligibility, and median household income were more strongly associated with mammography use than practice-level decision-aid use or advanced health information technology functions. CONCLUSIONS Health information technology‒enabled automation of mammography reminders and other advanced health information technology functions may support mammography, whereas breast cancer decision aids may reduce patients' propensities to be screened through the alignment of their preferences and screening decision. More resources may be needed for decision aids to be routinely implemented to improve solicitation of patient preferences and targeting of mammography services.
Collapse
Affiliation(s)
- Rachel L Ross
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Karl Rubio
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Hector P Rodriguez
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, California.
| |
Collapse
|
17
|
Grayek E, Yang Y, Fischhoff B, Schifferdecker KE, Woloshin S, Kerlikowske K, Miglioretti DL, Tosteson ANA. A Procedure for Eliciting Women's Preferences for Breast Cancer Screening Frequency. Med Decis Making 2022; 42:783-794. [PMID: 35067067 PMCID: PMC9277327 DOI: 10.1177/0272989x211073320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND We evaluate the construct validity of a proposed procedure for eliciting lay preferences among health care policy options, suited for structured surveys. It is illustrated with breast cancer screening, a domain in which people may have heterogeneous preferences. METHODS Our procedure applies behavioral decision research principles to eliciting preferences among policy options expressed in quantitative terms. Three-hundred women older than 18 y without a history of breast cancer were recruited through Amazon MTurk. Participants evaluated 4 screening options for each of 4 groups of women, with varying risk of breast cancer. Each option was characterized by estimates of 3 primary outcomes: breast cancer deaths, false alarms, and overdiagnosis resulting in unnecessary treatment of cancers that would not progress. These estimates were based on those currently being developed by the Breast Cancer Surveillance Consortium. For each risk group, participants stated how frequently they would wish to receive screening, if the predicted outcomes applied to them. RESULTS A preregistered test found that preferences were robust enough to be unaffected by the order of introducing and displaying the outcomes. Other tests of construct validity also suggested that respondents generally understood the task and expressed consistent preferences. Those preferences were related to participants' age and mammography history but not to measures of their numeracy, subjective numeracy, or demographics. There was considerable heterogeneity in their preferences. CONCLUSIONS Members of the public can be engaged more fully in informing future screening guidelines if they evaluate the screening options characterized by the expected health outcomes expressed in quantitative terms. We offer and evaluate such a procedure, in terms of its construct validity with a diverse sample of women. HIGHLIGHTS A novel survey method for eliciting lay preferences for breast cancer screening is proposed and evaluated in terms of its construct validity.Participants were generally insensitive to irrelevant task features (e.g., order of presentation) and sensitive to relevant ones (e.g., quantitative estimates of breast cancer risk, harms from screening).The proposed method elicits lay preferences in terms that can inform future screening guidelines, potentially improving communication between the public and policy makers.
Collapse
Affiliation(s)
- Emily Grayek
- Department of Engineering and Public Policy,
Carnegie Mellon University, Pittsburgh, PA, USA
| | - Yanran Yang
- Department of Engineering and Public Policy,
Carnegie Mellon University, Pittsburgh, PA, USA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy,
Carnegie Mellon University, Pittsburgh, PA, USA
- College of Engineering, Institute for Politics
and Strategy, Carnegie Mellon University,Pittsburgh, PA, USA
| | - Karen E. Schifferdecker
- The Dartmouth Institute for Health Policy and
Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine
at Dartmouth, Lebanon, NH, USA
| | - Steven Woloshin
- The Dartmouth Institute for Health Policy and
Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine
at Dartmouth, Lebanon, NH, USA
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and
Biostatistics, University of California, San Francisco, CA, USA
- General Internal Medicine Section, Department
of Veterans Affairs, University of California, San Francisco, CA, USA
| | - Diana L. Miglioretti
- Division of Biostatistics, Department of Public
Health Sciences, University of California, Davis, Davis, CA, USA
| | - Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and
Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine
at Dartmouth, Lebanon, NH, USA
| |
Collapse
|
18
|
Impact of Care Coordination on the Content of Communication Between Surgeons and Patients With Rectal Cancer. ANNALS OF SURGERY OPEN 2022; 3:e177. [PMID: 36199484 PMCID: PMC9508969 DOI: 10.1097/as9.0000000000000177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/04/2022] [Indexed: 11/25/2022] Open
|
19
|
Pickles K, Hersch J, Nickel B, Vaidya JS, McCaffery K, Barratt A. Effects of awareness of breast cancer overdiagnosis among women with screen-detected or incidentally found breast cancer: a qualitative interview study. BMJ Open 2022; 12:e061211. [PMID: 35676016 PMCID: PMC9185559 DOI: 10.1136/bmjopen-2022-061211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/04/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To explore experiences of women who identified themselves as having a possible breast cancer overdiagnosis. DESIGN Qualitative interview study using key components of a grounded theory analysis. SETTING International interviews with women diagnosed with breast cancer and aware of the concept of overdiagnosis. PARTICIPANTS Twelve women aged 48-77 years from the UK (6), USA (4), Canada (1) and Australia (1) who had breast cancer (ductal carcinoma in situ n=9, (invasive) breast cancer n=3) diagnosed between 2004 and 2019, and who were aware of the possibility of overdiagnosis. Participants were recruited via online blogs and professional clinical networks. RESULTS Most women (10/12) became aware of overdiagnosis after their own diagnosis. All were concerned about the possibility of overdiagnosis or overtreatment or both. Finding out about overdiagnosis/overtreatment had negative psychosocial impacts on women's sense of self, quality of interactions with medical professionals, and for some, had triggered deep remorse about past decisions and actions. Many were uncomfortable with being treated as a cancer patient when they did not feel 'diseased'. For most, the recommended treatments seemed excessive compared with the diagnosis given. Most found that their initial clinical teams were not forthcoming about the possibility of overdiagnosis and overtreatment, and many found it difficult to deal with their set management protocols. CONCLUSION The experiences of this small and unusual group of women provide rare insight into the profound negative impact of finding out about overdiagnosis after breast cancer diagnosis. Previous studies have found that women valued information about overdiagnosis before screening and this knowledge did not reduce subsequent screening uptake. Policymakers and clinicians should recognise the diversity of women's perspectives and ensure that women are adequately informed of the possibility of overdiagnosis before screening.
Collapse
Affiliation(s)
- Kristen Pickles
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Kirsten McCaffery
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
20
|
Ritchie D, Van Hal G, Van den Broucke S. Factors affecting intention to screen after being informed of benefits and harms of breast cancer screening: a study in 5 European countries in 2021. Arch Public Health 2022; 80:143. [PMID: 35599312 PMCID: PMC9125943 DOI: 10.1186/s13690-022-00902-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Participation in mammography screening comes with harms alongside benefits. Information about screening provided to women should convey this information yet concerns persist about its effect on participation. This study addressed factors that may influence the intention to screen once a woman has been informed about benefits and harms of participation. METHODS A cross-sectional survey of women from five countries (Belgium, France, Italy, Spain, and the United Kingdom) was performed in January 2021. The survey contained a statement regarding the benefits and harms of mammography screening along with items to measure cognitive variables from the theory of planned behaviour and health belief model and the 6-item version of the European Health Literacy Survey Questionnaire (HLS-EU-Q6). Logistic regression and mediation analysis were performed to investigate the effect of cognitive and sociodemographic variables. RESULTS A total of 1180 participants responded to the survey. 19.5% of participants (n = 230) were able to correctly identify that mammography screening carries both benefits and harms. 56.9% of participants (n = 672) responded that they would be more likely to participate in screening in the future after being informed about the benefits and harms of mammography screening. Perceived behavioural control and social norms demonstrated were significant in predicting intention, whereas, the effect of health literacy was limited. CONCLUSIONS Informing women about the presence of benefits and harms of in mammography screening participation did not negatively impact upon intention to be screened. Information should also address perception on implementation factors alongside messages on benefits and harms. Overall, screening programme managers should not be discouraged by the assumption of decreased participation through increasing efforts to address the lack of knowledge on benefits and harms.
Collapse
Affiliation(s)
- David Ritchie
- Faculty of Medicine and Health Sciences, Campus Drie Eiken, Universiteitsplein 1, 2610, Wilrijk, Belgium.
| | - Guido Van Hal
- Faculty of Medicine and Health Sciences, Campus Drie Eiken, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | | |
Collapse
|
21
|
Housten AJ, Hoover DS, Britton M, Bevers TB, Street RL, McNeill LH, Strong LL, Hersch J, McCaffery K, Volk RJ. Perceptions of Conflicting Breast Cancer Screening Recommendations Among Racially/Ethnically Diverse Women: a Multimethod Study. J Gen Intern Med 2022; 37:1145-1154. [PMID: 35015260 PMCID: PMC8971222 DOI: 10.1007/s11606-021-07336-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Conflicting breast cancer screening recommendations have the potential to diminish informed decision making about screening. OBJECTIVE We examined the knowledge, attitudes, and intentions related to divergent recommendations for breast cancer screening among racially/ethnically diverse women. DESIGN We used a multimethod study design employing focus groups and questionnaires. Focus groups included: (1) two 10-min presentations on the national screening recommendations and the potential benefits and harms of screening and (2) an interactive discussion. Data were collected: 8/3/2017 to 11/19/2019. Analysis occurred from 1/21/2019 to 7/24/2020. PARTICIPANTS Participants were (1) women 40-75 years; (2) English or Spanish speaking; (3)self-identified as Latina, Black, or non-Latina White; and (4) no known increased risk for breast cancer. MAIN MEASURES Main outcomes were participants' knowledge and perceptions of benefits and harms of screening mammography and their screening intentions. Focus groups were transcribed and analyzed using a qualitative descriptive approach. Quantitative data were summarized using descriptive statistics. KEY RESULTS One hundred thirty-four women (n=52, 40-49 years; n=82, 50-75 years) participated in 28 focus groups. Participants were Latina (n=44); Black (n=51); and non-Latina White (n=39). Approximately one-quarter (n=32) had limited health literacy and almost one-fifth (n=23) had limited numeracy. In the context of differing national screening recommendations, participants questioned the motives of the recommendation-making agencies, including the role of costs and how costs were considered when making screening recommendations. Participants expressed concern that they were not represented (e.g., race/ethnicity) in the data informing the recommendations. Immediately following the focus groups, most participants expressed intention to screen within the upcoming year (pre n=100 vs. post n=107). CONCLUSIONS Divergent breast cancer screening recommendations may lead to mistrust and paradoxically reinforce high overall enthusiasm for screening.
Collapse
Affiliation(s)
- Ashley J Housten
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
| | - Diana S Hoover
- Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maggie Britton
- Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, TX, USA
| | - Therese B Bevers
- Department of Clinical Cancer Prevention, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard L Street
- Department of Communication, College of Liberal Arts, Texas A&M University, College Station, Texas, TX, USA
| | - Lorna H McNeill
- Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larkin L Strong
- Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn Hersch
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Robert J Volk
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
22
|
Smith CF, Kristensen BM, Andersen RS, Ziebland S, Nicholson BD. Building the case for the use of gut feelings in cancer referrals: perspectives of patients referred to a non-specific symptoms pathway. Br J Gen Pract 2022; 72:e43-e50. [PMID: 34844921 PMCID: PMC8714524 DOI: 10.3399/bjgp.2021.0275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/02/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gut feelings may be useful when dealing with uncertainty, which is ubiquitous in primary care. Both patients and GPs experience this uncertainty but patients' views on gut feelings in the consultation have not been explored. AIM To explore patients' perceptions of gut feelings in decision making, and to compare these perceptions with those of GPs. DESIGN AND SETTING Qualitative interviews with 21 patients in Oxfordshire, UK. METHOD Patients whose referral to a cancer pathway was based on their GP's gut feeling were invited to participate. Semi-structured interviews were conducted from November 2019 to January 2020, face to face or over the telephone. Data were analysed with a thematic analysis and mind-mapping approach. RESULTS Some patients described experiencing gut feelings about their own health but often their willingness to share this with their GP was dependent on an established doctor-patient relationship. Patients expressed similar perspectives on the use of gut feelings in consultations to those reported by GPs. Patients saw GPs' gut feelings as grounded in their experience and generalist expertise, and part of a process of evidence gathering. Patients suggested that GPs were justified in using gut feelings because of their role in arranging access to investigations, the difficult 'grey area' of presentations, and the time- and resource-limited nature of primary care. When GPs communicated that they had a gut feeling, some saw this as an indication that they were being taken seriously. CONCLUSION Patients accepted that GPs use gut feelings to guide decision making. Future research on this topic should include more diverse samples and address the areas of concern shared by patients and GPs.
Collapse
Affiliation(s)
| | | | - Rikke Sand Andersen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
23
|
Tsuruda KM, Veierød MB, Houssami N, Waade GG, Mangerud G, Hofvind S. Women's conceptual knowledge about breast cancer screening and overdiagnosis in Norway: a cross-sectional study. BMJ Open 2021; 11:e052121. [PMID: 34907059 PMCID: PMC8671979 DOI: 10.1136/bmjopen-2021-052121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To investigate conceptual knowledge about mammographic screening among Norwegian women. DESIGN We administered a cross-sectional, web-based survey. We used multiple-choice questions and a grading rubric published by a research group from Australia. SETTING Our Norwegian-language survey was open from April to June 2020 and targeted women aged 45-74 years. PARTICIPANTS 2033 women completed our questionnaire. We excluded 13 women outside the target age range and 128 women with incomplete data. Responses from 1892 women were included in the final study sample. PRIMARY AND SECONDARY OUTCOME MEASURES The questionnaire focused on women's knowledge about the breast cancer mortality reduction, false positive results and overdiagnosis associated with mammographic screening. The primary outcome was the mean number of marks assigned in each of the three themes and overall. There were three potential marks for questions about breast cancer mortality, one for false positives and six for overdiagnosis. RESULTS Most women (91.7%) correctly reported that screened women are less likely to die of breast cancer than non-screened women. 39.7% of women reported having heard of a 'false positive screening result' and 86.2% identified the term's definition; 51.3% of women had heard of 'overdiagnosis' and 14.8% identified the term's definition. The mean score was 2.59 of 3 for questions about breast cancer mortality benefit and 0.93 of 1 for the question about false positive screening results. It was 2.23 of 6 for questions about overdiagnosis. CONCLUSIONS Most participants correctly answered questions about the breast cancer mortality benefit and false positive results associated with screening. The proportion of correct responses to questions about overdiagnosis was modest, indicating that conceptual knowledge about overdiagnosis was lower. Qualitative studies that can obtain in-depth information about women's understanding of overdiagnosis may help improve Norwegian-language information about this challenging topic.
Collapse
Affiliation(s)
- Kaitlyn M Tsuruda
- Department of Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Marit B Veierød
- Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Nehmat Houssami
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Gunvor G Waade
- Department of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Gunhild Mangerud
- Department of Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Solveig Hofvind
- Department of Breast Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
24
|
Cadet T, Pinheiro A, Karamourtopoulos M, Jacobson AR, Aliberti GM, Kistler CE, Davis RB, Schonberg MA. Effects by educational attainment of a mammography screening patient decision aid for women aged 75 years and older. Cancer 2021; 127:4455-4463. [PMID: 34374430 PMCID: PMC9152733 DOI: 10.1002/cncr.33857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/14/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND To help inform screening decisions, a mammography screening decision aid (DA) for women aged 75 years and older was tested in a cluster randomized clinical trial of 546 women. DA use increased women's knowledge of the benefits and harms of mammography and lowered screening rates. In the current study, the objective was to examine whether participants' views of the DA and/or its effects differed by educational attainment. METHODS A secondary analysis was conducted of 283 women who received the DA before a personal care provider (PCP) visit during the trial to examine the acceptability of the DA and its effects on knowledge of the benefits and harms of mammography, screening intentions, and receipt of screening by educational attainment. Adjusted analyses accounted for clustering by PCP. RESULTS Of the 283 participants, 43% had a college education or less. Regardless of educational attainment, 87.2% found the DA helpful. Women with lower educational attainment were less likely to understand all of the DA's content (46.3% vs 67.5%; P < .001), had less knowledge of the benefits and harms of mammography (adjusted mean ± standard error knowledge score, 7.1 ± 0.3 vs 8.1 ± 0.3; P < .001), and were less likely to lower screening intentions (adjusted percentage, 11.4% vs 19.4%; P = .01). Receipt of screening did not differ by educational attainment. CONCLUSIONS A mammography DA for women aged 75 years and older was helpful to women regardless of their educational attainment; however, those with a college degree or greater understood the DA and, possibly as a result, lowered their screening intentions. Future studies need to examine how to better support informed decision making around mammography screening in older women with lower educational attainment. LAY SUMMARY The authors examined data from a previous study to learn the effects of a mammography decision aid (DA) for women aged 75 years and older according to their level of education. Overall, women found the DA helpful, but women with lower educational attainment found it harder to understand the benefits and harms of mammography screening and were less likely to lower their screening intentions than women with a college degree. The findings suggest that women aged 75 years and older who have lower educational attainment may need an even lower literacy DA and/or more support from health care professionals.
Collapse
Affiliation(s)
- Tamara Cadet
- School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA
| | - Adlin Pinheiro
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Maria Karamourtopoulos
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Alicia R. Jacobson
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Gianna M. Aliberti
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Christine E. Kistler
- Division of Geriatric Medicine and Department of Family Medicine, University of North Carolina, Chapel Hill, NC
| | - Roger B. Davis
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mara A. Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
25
|
Sharma S, Traeger AC, Tcharkhedian E, Middleton PM, Cullen L, Maher CG. Effect of a waiting room communication strategy on imaging rates and awareness of public health messages for low back pain. Int J Qual Health Care 2021; 33:6384520. [PMID: 34623440 DOI: 10.1093/intqhc/mzab129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/22/2021] [Accepted: 09/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Few studies have investigated the effects of waiting room communication strategies on health-care behavior. OBJECTIVE We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the emergency department (ED). METHODS We conducted a controlled experimental study with a replicated time series design. The design included a 6-week run-in time. Following this there were alternating 1-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on a 55" LCD screen positioned in the ED waiting room. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on the same 55" LCD screen, and access to the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction and awareness of campaign messages) were collected from a sample of people presenting for any condition who responded to a text-message-based survey. RESULTS For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n = 99; control n = 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy [95% confidence interval (CI) = 18% to 35%] compared with 29% in those exposed to the standard waiting room messaging [95% CI = 23% to 35%; odds ratio (OR) = 0.83, 95% CI = 0.49 to 1.41]. For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n = 170; control n = 179; response rate = 33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR = 2.00, 95% CI = 0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages. CONCLUSION A communication strategy displayed in the ED waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging, although there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence health-care quality. TRIAL REGISTRATION ACTRN12620000300976, 05/03/2020.
Collapse
Affiliation(s)
- Sweekriti Sharma
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales 2050, Australia.,School of Public Health, The University of Sydney, New South Wales 2006, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales 2050, Australia.,School of Public Health, The University of Sydney, New South Wales 2006, Australia
| | - Elise Tcharkhedian
- Department of Physiotherapy, Liverpool Hospital, Sydney, NSW 2170, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Liverpool Hospital, Liverpool, NSW 2170, Australia.,Discipline of Emergency Medicine, University of Sydney, Sydney, NSW 2006, Australia
| | - Louise Cullen
- Emergency and Trauma Center, Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, QLD 4029, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales 2050, Australia.,School of Public Health, The University of Sydney, New South Wales 2006, Australia
| |
Collapse
|
26
|
Jensen MD, Hansen KM, Siersma V, Brodersen J. Using a Deliberative Poll on breast cancer screening to assess and improve the decision quality of laypeople. PLoS One 2021; 16:e0258869. [PMID: 34673826 PMCID: PMC8530304 DOI: 10.1371/journal.pone.0258869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/06/2021] [Indexed: 12/02/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Manja D. Jensen
- Department of Public Health, The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
- Primary Health Care Research Unit, Region Zealand, Denmark
- * E-mail:
| | - Kasper M. Hansen
- Department of Political Science, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- Department of Public Health, The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - John Brodersen
- Department of Public Health, The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
- Primary Health Care Research Unit, Region Zealand, Denmark
| |
Collapse
|
27
|
Pickles K, Scherer LD, Cvejic E, Hersch J, Barratt A, McCaffery KJ. Preferences for More or Less Health Care and Association With Health Literacy of Men Eligible for Prostate-Specific Antigen Screening in Australia. JAMA Netw Open 2021; 4:e2128380. [PMID: 34636915 PMCID: PMC8511975 DOI: 10.1001/jamanetworkopen.2021.28380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE Understanding personal factors that influence diverse responses to health care information, such as preferences for more or less health care, might be beneficial to more effective communication and better involvement in health care choices. OBJECTIVE To determine whether individuals' preferences for more or less health care are associated with informed choice and understanding of overdiagnosis in routine prostate cancer screening and to examine associations among preferences, educational status, and health literacy. DESIGN, SETTING, AND PARTICIPANTS This survey study included a community-based sample of men in Australia aged 45 to 60 years eligible for prostate-specific antigen (PSA) screening, recruited via an international social research company. Survey data were collected online from June 27 to July 26, 2018. Data were analyzed in April 2020. EXPOSURES Participants were randomized to 1 of 2 versions of an online decision aid (full-length or abbreviated) about PSA screening and completed an online survey that included a measure of preference for more or less health care, the Medical Maximizer-Minimizer Scale (MMS), in which higher score indicates preference for more health care. MAIN OUTCOMES AND MEASURES The primary outcome was informed choice; knowledge, attitudes, and intentions about screening for prostate cancer were also measured. RESULTS Of 3722 participants who began the survey, 2993 (80.4%) completed it (mean [SD] age, 52.15 [6.65] years). Stronger preferences for more heath care were observed in those without tertiary education (mean difference, 0.15; 95% CI, 0.09-0.22; P < .001) and with inadequate health literacy (mean difference, 0.16; 95% CI, 0.09-0.22; P < .001). After controlling for health and demographic variables, a 1-unit increase in MMS score was associated with reduced relative risk (RR) of making an informed choice (RR, 0.78; 95% CI, 0.74-0.82; P < .001) and of having adequate conceptual knowledge (RR, 0.87; 95% CI, 0.84-0.90; P < .001), correct numerical knowledge (RR, 0.93; 95% CI, 0.89-0.97; P = .001), and correct understanding of overdiagnosis (RR, 0.84; 95% CI, 0.79-0.90; P < .001). A 1-unit increase in MMS score was associated with a more positive attitude toward screening (RR, 1.18; 95% CI, 1.15-1.21; P < .001) and more positive intention to screen (RR, 1.20; 95% CI, 1.16-1.25; P < .001) after adjusting for control variables. CONCLUSIONS AND RELEVANCE This survey study examined associations between preferences for more or less health care and knowledge about overdiagnosis and informed choice among men in Australia. These results may motivate clinicians to elicit individual patient preferences to facilitate tailored discussions with patients about low-value care, such as prostate cancer screening, for which benefit is uncertain.
Collapse
Affiliation(s)
- Kristen Pickles
- University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, Sydney, Australia
| | - Laura D. Scherer
- Division of Cardiology, University of Colorado School of Medicine, Aurora
- VA Denver Center for Innovation, Denver, Colorado
| | - Erin Cvejic
- University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, Sydney, Australia
| | - Jolyn Hersch
- University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, Sydney, Australia
| | - Alexandra Barratt
- University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, Sydney, Australia
| | - Kirsten J. McCaffery
- University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, Sydney, Australia
| |
Collapse
|
28
|
Cadet T, Aliberti G, Karamourtopoulos M, Jacobson A, Gilliam EA, Primeau S, Davis R, Schonberg MA. Evaluation of a mammography decision aid for women 75 and older at risk for lower health literacy in a pretest-posttest trial. PATIENT EDUCATION AND COUNSELING 2021; 104:2344-2350. [PMID: 33637391 PMCID: PMC8364563 DOI: 10.1016/j.pec.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 01/16/2021] [Accepted: 02/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The evaluation of the effect of a mammography decision aid (DA) designed for older women at risk for lower health literacy (LHL) on their knowledge of mammography's benefits and harms and decisional conflict. METHODS Using a pretest-posttest design, women > 75 years at risk for LHL reviewing a mammography DA before and after their [B] primary care provider visit. Women were recruited from an academic medical center and community health centers and clinics. RESULTS Of 147 eligible women approached, 43 participated. Receipt of the DA significantly affected knowledge of mammography's benefits and harms [B] (pre-test (M = 3.75, SD = 1.05) to post-test (M = 4.42, SD = 1.19), p = .03). Receipt of the DA did not significantly affect decisional conflict (pre-test (M = 3.10, SD = .97) to post-test (M = 3.23, SD = 1.02), p = .71, higher scores = lower decisional conflict). The majority of the women (97%) indicated that the DA was helpful. CONCLUSIONS Women found a mammography screening DA helpful and its use was associated with these women having increased knowledge of mammography's benefits and harms. PRACTICE IMPLICATIONS With the shift toward shared decision-making for women > 75 years, there is a need to engage women of all literacy levels to participate in these decisions and have tools such as the one tested in this study.
Collapse
Affiliation(s)
- Tamara Cadet
- Simmons University College of Social Sciences and Policy Practice, School of Social Work, 300 The Fenway, Boston, MA, USA.
| | - Gianna Aliberti
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | | | - Alicia Jacobson
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | - Elizabeth A Gilliam
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | - Sara Primeau
- Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA, USA
| | - Roger Davis
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Ste 202, Brookline, MA, USA
| |
Collapse
|
29
|
Clark SD, Reuland DS, Brenner AT, Pignone MP. What is the effect of a decision aid on knowledge, values and preferences for lung cancer screening? An online pre-post study. BMJ Open 2021; 11:e045160. [PMID: 34244253 PMCID: PMC8273450 DOI: 10.1136/bmjopen-2020-045160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To examine if a decision aid improves knowledge of lung cancer screening benefits and harms and which benefits and harms are most valued. DESIGN Pre-post study. SETTING Online. PARTICIPANTS 219 current or former (quit within the previous 15 years) smokers ages 55-80 with at least 30 pack-years of smoking. INTERVENTION Lung cancer screening video decision aid. MAIN MEASURES Screening knowledge tested by 10 pre-post questions and value of benefits and harms (reducing chance of death from lung cancer, risk of being diagnosed, false positives, biopsies, complications of biopsies and out-of-pocket costs) assessed through rating (1-5 scale) and ranking (top three ranked). RESULTS Mean age was 64.7±6.1, 42.5% were male, 75.4% white, 48.4% married, 28.9% with less than a college degree and 67.6% with income <US$50 000. Knowledge improved postdecision aid (pre 2.8±1.8 vs post 5.8±2.3, diff +3.0, 95% CI 2.7 to 3.3; p<0.001). For values, reducing the chance of death from lung cancer was rated and ranked highest overall (rating 4.3±1.0; 59.4% ranked first). Among harms, avoiding complications (3.7±1.3) and out-of-pocket costs (3.7±1.2) rated highest. Thirty-four per cent ranked one of four harms highest: avoiding costs 13.2%, false positives 7.3%, biopsies 7.3%, complications 5.9%. Screening intent was balanced (1-4 scale; 1-not likely 21.0%, 4-very likely 26.9%). Those 'not likely' to screen had greater improvement in pre-post knowledge scores and more frequently ranked a harm first than those 'very likely' to screen (pre-post diff:+3.5 vs +2.6, diff +0.9; 95% CI 0.1 to 1.8; p=0.023; one of four harms ranked first: 28.4% vs 11.3%, p<0.001). CONCLUSIONS Our decision aid increased lung cancer screening knowledge among a diverse sample of screen-eligible respondents. Although a majority valued 'reducing the chance of death from lung cancer' highest, a substantial proportion identified harms as most important. Knowledge improvement and ranking harms highest were associated with lower intention to screen.
Collapse
Affiliation(s)
- Stephen D Clark
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Daniel S Reuland
- Division of General Medicine & Clinical Epidemiology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Alison T Brenner
- Division of General Medicine & Clinical Epidemiology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Michael P Pignone
- Department of Medicine, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
- Cancer Institutes, Dell Medical School, LIVESTRONG, Austin, Texas, USA
| |
Collapse
|
30
|
Ding Y, Wu W, Ma Z, Shao X, Zhang M, Wang Z. Potential value of MicroRNA-21 as a biomarker for predicting the prognosis of patients with breast cancer: A protocol for meta-analysis and bioinformatics analysis. Medicine (Baltimore) 2021; 100:e25964. [PMID: 34087839 PMCID: PMC8183732 DOI: 10.1097/md.0000000000025964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The latest global cancer data from 2020 shows that breast cancer has replaced lung cancer as the number one cancer in the world. Searching for new biomarkers of breast cancer has important clinical significance for early diagnosis, prediction of prognosis, and targeted therapy. MicroRNA-21 (miRNA-21) can be used as a new molecular marker for early diagnosis, prognosis, and treatment of tumors. However, the expression of miRNA-21 in breast cancer and its prognosis are not clear. Therefore, this study conducted a meta-analysis to further clarify the relationship between the expression of miRNA-21 in breast cancer and prognosis. At the same time, we carried out bioinformatics analysis to further analyze the possible molecular mechanism of miRNA-21, so as to provide potential clinical indicators for the diagnosis, treatment, and prognosis of patients. METHODS PubMed, Medline, Embase, Web of Science, Wanfang, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, and other databases were used to retrieve the published relevant literatures. Include the eligible research, extract the survival data hazard ratios and 95% confidence intervals and other information. STATA16.0 software was used for meta-analysis. Download the miRNA data of breast cancer through the Cancer Genome Atlas (TCGA) database and Gene Expression Omnibus (GEO) database. The data extracted for independent sample t test and ROC curve was drawn. OncomiR plotted the survival curve of miRNA-21 on the prognosis of breast cancer. The target genes of miRNA-21 were predicted, and the Gene Ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway were analyzed. STRING database and Cytoscape construct protein-protein interaction (PPI) network to obtain Hub gene. The correlation between the expression level of Hub gene in breast cancer and the abundance of immune cell infiltration was analyzed by TIMER database and verified by Kaplan-Meien plotter database. RESULTS The results of this meta-analysis will be submitted to a peer-reviewed journal for publication. CONCLUSION In this study, meta-analysis and bioinformatics analysis were used to further explore the prognosis, mechanism, and related pathways of miRNA-21 in breast cancer. ETHICS AND DISSEMINATION The private information from individuals will not be published. This systematic review also should not damage participants' rights. Ethical approval is not available. The results may be published in a peer-reviewed journal or disseminated in relevant conferences. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/R32A9.
Collapse
|
31
|
Sharma S, Traeger AC, Tcharkhedian E, Harrison J, Hersch JK, Pickles K, Harris IA, Maher CG. "I would not go to him": Focus groups exploring community responses to a public health campaign aimed at reducing unnecessary diagnostic imaging of low back pain. Health Expect 2021; 24:648-658. [PMID: 33599389 PMCID: PMC8077077 DOI: 10.1111/hex.13211] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/19/2021] [Accepted: 01/31/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Community awareness of the harms of overdiagnosis remains low. OBJECTIVE To evaluate community responses to a public health campaign designed for health service waiting rooms that focuses on the harms of unnecessary diagnostic imaging for low back pain. METHODS We conducted two focus groups of 19 community members with or without low back pain in Sydney, Australia. This study formed the fourth and final stage of the development process of a public health campaign: (a) initial design, (b) expert review and revision, (c) online experiment and (d) community views & revision. We evaluated reactions to components of the campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of overdiagnosis. We conducted a qualitative thematic analysis to identify main themes. RESULTS Community members reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about overdiagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of overdiagnosis and the importance of not rushing to imaging. CONCLUSIONS Public health campaigns including posters and leaflets displayed in waiting rooms could raise awareness about overuse of diagnostic imaging and the harms of overdiagnosis more broadly. However, negative reactions are possible and must be managed carefully. PATIENT OR PUBLIC CONTRIBUTION We involved a community participation manager who provided advice on the focus group discussion guide, participant recruitment and manuscript presentation.
Collapse
Affiliation(s)
- Sweekriti Sharma
- Faculty of Medicine and HealthInstitute for Musculoskeletal HealthSydney School of Public HealthThe University of Sydney and Sydney Local Health DistrictSydneyNSWAustralia
- Wiser HealthcareSydney School of Public HealthThe University of SydneySydneyNSWAustralia
| | - Adrian C. Traeger
- Faculty of Medicine and HealthInstitute for Musculoskeletal HealthSydney School of Public HealthThe University of Sydney and Sydney Local Health DistrictSydneyNSWAustralia
- Wiser HealthcareSydney School of Public HealthThe University of SydneySydneyNSWAustralia
| | | | - Janet Harrison
- Clinical Governance DepartmentLiverpool HospitalSydneyNSWAustralia
| | - Jolyn K. Hersch
- Wiser HealthcareSydney School of Public HealthThe University of SydneySydneyNSWAustralia
- Faculty of Medicine and HealthSydney School of Public HealthThe University of SydneySydneyNSWAustralia
| | - Kristen Pickles
- Wiser HealthcareSydney School of Public HealthThe University of SydneySydneyNSWAustralia
- Faculty of Medicine and HealthSydney School of Public HealthThe University of SydneySydneyNSWAustralia
| | - Ian A. Harris
- Faculty of Medicine and HealthInstitute for Musculoskeletal HealthSydney School of Public HealthThe University of Sydney and Sydney Local Health DistrictSydneyNSWAustralia
- Ingham Institute for Applied Medical ResearchSouth Western Sydney Clinical SchoolUNSW SydneySydneyNSWAustralia
| | - Chris G. Maher
- Faculty of Medicine and HealthInstitute for Musculoskeletal HealthSydney School of Public HealthThe University of Sydney and Sydney Local Health DistrictSydneyNSWAustralia
- Wiser HealthcareSydney School of Public HealthThe University of SydneySydneyNSWAustralia
| |
Collapse
|
32
|
Fernández-Feito A, Canga-Gutiérrez C, Paz-Zulueta M. A mixed-methods study to evaluate the acceptability of information leaflets for breast cancer screening. J Clin Nurs 2021; 30:1760-1772. [PMID: 33655613 DOI: 10.1111/jocn.15735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 01/23/2021] [Accepted: 02/25/2021] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To obtain feedback regarding the comprehension and acceptability of an information leaflet on breast cancer screening among women. BACKGROUND Women usually receive a leaflet inviting them to participate in breast cancer screening programmes for early detection of breast cancer. These leaflets include relevant information about mammograms to aid with decision-making. It is important to know how the target population perceives these leaflets, as this may influence the attitude towards breast cancer screening. DESIGN A mixed-methods study (concurrent triangulation design). METHODS Participants were 41 women aged between 40-60 years in the north of Spain. The leaflet included information about breast cancer, mammograms, benefits/risks of screening, and the breast cancer mortality and survival rates in relation to screening. Three written methods were used to assess the leaflet: a readability assessment (Flesch Index) and two comprehension assessments (Cloze and multiple-choice questions). In addition, 26 semi-structured interviews were conducted to explore the women's opinions regarding comprehension, acceptability and the contribution of the leaflet as a decision aid. The COREQ checklist was used to guarantee the quality and rigour of the qualitative study. RESULTS Overall, women found the leaflet fairly easy to read and most understood the content. Some women found the information on mortality alarming, difficult to understand and a cause for rejection. The leaflet was viewed as a decision aid, although further information was requested on mammograms, the need for complementary tests and the risks and symptoms of breast cancer. CONCLUSION The leaflet was accepted by women and, overall, easy to understand. The participation of the target population enabled the content and format of the leaflet to be adjusted to their needs. RELEVANCE FOR CLINICAL PRACTICE Nurses can contribute towards improving the breast cancer screening leaflets, considering women's perceptions surrounding screening.
Collapse
Affiliation(s)
- Ana Fernández-Feito
- Nursing Area. Department of Medicine. University of Oviedo, Health Research Institute of Asturias (ISPA), Oviedo, Principado de Asturias, Spain
| | - Carlos Canga-Gutiérrez
- Multiprofessional Teaching Unit of Family and Community Care of Gipuzkoa, Gipuzkoa, Spain
| | - María Paz-Zulueta
- Nursing Department. University of Cantabria, Research Group 'Health Rights and Bioethics' GRIDES-IDIVAL, Santander, Cantabria, Spain
| |
Collapse
|
33
|
Shi W, Nagler RH, Fowler EF, Gollust SE. Predictors of Women's Awareness of the Benefits and Harms of Mammography Screening and Associations with Confusion, Ambivalence, and Information Seeking. HEALTH COMMUNICATION 2021; 36:303-314. [PMID: 31690128 DOI: 10.1080/10410236.2019.1687129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
In recent years, there has been a shift toward promoting informed decision making for mammography screening for average-risk women in their 40s. Professional organizations such as the American Cancer Society and U.S. Preventive Services Task Force recommend that women weigh the potential benefits and harms of mammography prior to initiating screening. This decision-making process assumes that women are aware of both the benefits and harms of screening, yet little is known about the prevalence and antecedents of such awareness. Moreover, it is conceivable that women who are aware of both the benefits and harms may interpret this information as conflicting - which could be concerning, as researchers have documented adverse effects of exposure to conflicting health information in prior research. Using data from a population-based survey of U.S. women aged 30-59 (N = 557), the current study found that awareness of mammography's harms is relatively low compared to awareness of benefits. Health news exposure and interpersonal communication about health were associated with greater awareness of harms. In addition, women's awareness of both the benefits and harms was positively associated with confusion about breast cancer screening recommendations, ambivalence about getting a mammogram, and mammogram-related information seeking from online sources. Implications for cancer screening communication are discussed.
Collapse
Affiliation(s)
- Weijia Shi
- Hubbard School of Journalism and Mass Communication, University of Minnesota
| | - Rebekah H Nagler
- Hubbard School of Journalism and Mass Communication, University of Minnesota
| | | | - Sarah E Gollust
- Division of Health Policy and Management, University of Minnesota School of Public Health
| |
Collapse
|
34
|
Abstract
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.
Collapse
Affiliation(s)
- Bernt-Peter Robra
- Institute for Social Medicine and Health Services Research, Otto-von-Guericke-University Magdeburg, Leipziger Str. 44, D-39140, Magdeburg, Germany.
| |
Collapse
|
35
|
Riganti P, Ruiz Yanzi MV, Escobar Liquitay CM, Kopitowski KS, Franco JVA. Shared decision making for supporting women’s decisions about breast cancer screening. Hippokratia 2020. [DOI: 10.1002/14651858.cd013822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Paula Riganti
- Family and Community Medicine Division; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| | - M. Victoria Ruiz Yanzi
- Family and Community Medicine; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| | | | - Karin S Kopitowski
- Family and Community Medicine Division; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| | - Juan VA Franco
- Associate Cochrane Centre; Instituto Universitario Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| |
Collapse
|
36
|
Traeger AC, Checketts J, Tcharkhedian E, O'Connor DA, Klinner C, Sharma S, Vyas P, Albarqouni L, McCaffery K. Patient and general practitioner views of tools to delay diagnostic imaging for low back pain: a qualitative study. BMJ Open 2020; 10:e039936. [PMID: 33162393 PMCID: PMC7651716 DOI: 10.1136/bmjopen-2020-039936] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Delayed prescribing is a promising strategy to manage patient requests for unnecessary tests and treatments. The purpose of this study was to explore general practitioner (GP) and patient views of three communication tools (Overdiagnosis Leaflet, Dialogue Sheet and 'Wait-and-see' Note) to support delayed prescribing of diagnostic imaging. DESIGN Qualitative study. SETTING Primary and emergency care in Sydney, Australia. PARTICIPANTS 16 GPs and 14 patients with recent episode of low back pain. OUTCOME Views on the tools to delay diagnostic imaging for low back pain. Data were collected using a combination of focus groups and individual interviews. ANALYSIS Two researchers independently performed a thematic analysis, and the author team reviewed and refined the analysis. RESULTS GP participants responded positively to the Overdiagnosis Leaflet. The Dialogue Sheet and 'Wait-and-see' Note raised several concerns about patient pushback, adding to time pressure and being overwhelmed with hard-to-find paper resources. GPs preferred to communicate verbally the reasons to delay an imaging test. For patients, the reactions to the tools were more positive. Patients valued written information and a signed agreement to delay the test. However, patients expressed that a strong desire for diagnostic imaging would likely over-ride any effect of written advice to delay the test. The term 'false alarm' to describe overdiagnosis was poorly understood by patients. CONCLUSIONS GPs and patients agreed that a leaflet about overdiagnosis could support a delayed prescribing approach to imaging for low back pain. The Dialogue Sheet and 'Wait-and-see' Note were acceptable to patients but not to GPs.
Collapse
Affiliation(s)
- Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Juliet Checketts
- Australian Government Department of Health, Canberra, Australian Capital Territory, Australia
| | - Elise Tcharkhedian
- Department of Physiotherapy, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Denise A O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christiane Klinner
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sweekriti Sharma
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Parima Vyas
- Australian Government Department of Health, Canberra, Australian Capital Territory, Australia
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Bond University Faculty of Health Sciences and Medicine, Gold Coast, Queensland, Australia
| | - Kirsten McCaffery
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
37
|
Kotwal AA, Walter LC. Cancer Screening in Older Adults: Individualized Decision-Making and Communication Strategies. Med Clin North Am 2020; 104:989-1006. [PMID: 33099456 PMCID: PMC7594102 DOI: 10.1016/j.mcna.2020.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered more effective, easy to understand, and acceptable by older adults and clinicians.
Collapse
Affiliation(s)
- Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| |
Collapse
|
38
|
Elton L. Non-maleficence and the ethics of consent to cancer screening. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106135. [PMID: 32958694 PMCID: PMC8257550 DOI: 10.1136/medethics-2020-106135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/14/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
Cancer screening programmes cause harm to individuals via overdiagnosis and overtreatment, even where they confer population-level benefit. Screening thus appears to violate the principle of non-maleficence, since it entails medically unnecessary harm to individuals. Can consent to screening programmes negate the moral significance of this harm? In therapeutic medical contexts, consent is used as a means of rendering medical harm morally permissible. However, in this paper, I argue that it is unclear that the model of consent used within therapeutic medicine can be applied unproblematically to preventive medicine. Invitation to screening changes the pragmatic norms and expectations of the patient-doctor encounter such that two key principles of consent may be violated. First, the pragmatics of a medical invitation are such that patients may fail to be adequately informed, since patients appear to assume medical invitations are made with their best interests in mind, even where information to the contrary is outlined. Second, screening invitations may place pressure on patients; in the context of a medical encounter, to make an invitation to screening may constitute an inducement to accept. In order to be sure that a patient's consent to a screening invitation is valid, we must make clear to patients that their decision to accept screening may be shaped not only by how information about screening is presented, but by the pragmatic form of the invitation itself.
Collapse
Affiliation(s)
- Lotte Elton
- History and Philosophy and Science, University of Cambridge, Cambridge, UK
| |
Collapse
|
39
|
Abstract
OBJECTIVES The use of more medicalised labels can increase both concern about illness and the desire for more invasive treatment. This study analyses the media's coverage of an Analysis article in The BMJ which generated a large amount of high-profile international media coverage. It aims to understand how to better communicate messages about low-risk cancers and overdiagnosis to the public. DESIGN Content analysis of media coverage. SETTING Media was identified by Isentia Media Portal, searched in Google News and cross-checked in Factiva and Proquest databases from August 2018. METHODS Media headlines, full text and open access public comments responding to the coverage on the article proposing to 'rename low-risk conditions currently labelled as cancer' were analysed to determine the main themes. RESULTS 45 original media articles and their associated public comments (n=167) were identified and included in the analysis. Overall, headlines focused on cancer generally and there was little mention of 'low-risk', 'overdiagnosis' or 'overtreatment'. The full text generally presented a more balanced view of the evidence and were supportive of the proposal, however, public responses tended to be more negative towards the idea of renaming low-risk cancers and indicated confusion. Comments seemed to focus on the headlines rather than the full article. CONCLUSIONS This study offers a novel insight into media coverage of the complex and counterintuitive problem of overdiagnosis. Continued deliberation on how to communicate similar topics to the public through the mainstream media is needed. Future work in the area of low-risk cancer communication should consider the powerful impact of people's previous experience with a cancer diagnosis and the criticism about being paternalistic and concealing the truth from patients.
Collapse
Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ray Moynihan
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Alexandra Barratt
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Kirsten McCaffery
- Wiser Healthcare, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
40
|
Charvin M, Launoy G, Berchi C. The effect of information on prostate cancer screening decision process: a discrete choice experiment. BMC Health Serv Res 2020; 20:467. [PMID: 32456702 PMCID: PMC7249621 DOI: 10.1186/s12913-020-05327-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 05/14/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prostate cancer screening is controversial because of uncertainty about its benefits and risks. The aim of this survey was to reveal preferences of men concerning prostate cancer screening and to test the effect of an informative video on these preferences. METHODS A stated preferences questionnaire was sent by e-mail to men aged 50-75 with no history of prostate cancer. Half of them were randomly assigned to view an informative video. A discrete choice model was established to reveal men's preferences for six prostate cancer screening characteristics: mortality by prostate cancer, number of false positive and false negative results, number of overdiagnosis, out-of-pocket costs and recommended frequency. RESULTS A population-based sample composed by 1024 men filled in the entire questionnaire. Each attribute gave the expected sign except for overdiagnosis. The video seemed to increase the intention to abstain from prostate cancer screening. CONCLUSIONS The participants attached greater importance to a decrease in the number of false negatives and a reduction in prostate cancer mortality than to other risks such as the number of false positives and overdiagnosis. Further research is needed to help men make an informed choice regarding screening.
Collapse
Affiliation(s)
- M Charvin
- Normandie Univ, UniCaen, Inserm, Anticipe, 14000, Caen, France.
| | - G Launoy
- Normandie Univ, UniCaen, Inserm, Anticipe, 14000, Caen, France
- University Hospital of Caen, Caen, France
| | - C Berchi
- Normandie Univ, UniCaen, Inserm, Anticipe, 14000, Caen, France
| |
Collapse
|
41
|
Goto Y, Tsugawa K, Furuya Y, Maezato M, Tagami Y, Ogawa Y, Saisu M, Yamazaki M, Kuramochi F. Behavior of Japanese women after being informed about the benefits and disadvantages of breast cancer screening: a questionnaire survey. Breast Cancer 2020; 27:739-747. [PMID: 32140843 DOI: 10.1007/s12282-020-01071-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The US Preventative Services Task Force assessed the efficacy of breast cancer screening according to the sum of its benefits and disadvantages. We estimate that the balance of the benefits and disadvantages varies among women depending on their demographic background. METHODS Between March 2016 and March 2017, we conducted a questionnaire survey among Japanese women who underwent population-based or opportunistic breast cancer screening at our multicenter institutions. We investigated the behavior modification among women after being informed about the benefits and disadvantages of breast cancer screening depending on their demographic background. RESULTS Out of 3032 questionnaires that were returned, 2936 (96.8%) were evaluated. The percentage of women with prior knowledge about the benefits and disadvantages of breast cancer screening before reading the leaflets that we created was 24%. However, 95% of the women were willing to undergo screening next time, despite knowing the disadvantages. Regarding overdiagnosis, the young women tended to choose usual treatment, and the elderly women tended to choose active surveillance. In response to the question on the significance of screening, the young women wished to avoid death by breast cancer; whereas, the elderly women wished to live a safe life. CONCLUSION Our results indicate that the information of disadvantages does not lead to a reduction in screening rates. Additionally, we found that the balance between the benefits and disadvantages of breast cancer screening varies among women depending on their demographic background, especially age.
Collapse
Affiliation(s)
- Yuka Goto
- Advanced Breast Imaging Center of St. Marianna University School of Medicine, 6-7-2 Manpukuji Asao-ku, Kawasaki, Kanagawa, 215-8520, Japan.
| | - Koichiro Tsugawa
- Division of Breast Endocrine Surgery, Department of Surgery, St. Marianna University School of Medicine Hospital, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuko Furuya
- Advanced Breast Imaging Center of St. Marianna University School of Medicine, 6-7-2 Manpukuji Asao-ku, Kawasaki, Kanagawa, 215-8520, Japan
| | - Miwako Maezato
- Imaging Center of St. Marianna University School of Medicine Hospital, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yoshimi Tagami
- Imaging Center of St. Marianna University School of Medicine Hospital, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yuri Ogawa
- Imaging Center of St. Marianna University School of Medicine Hospital, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Misako Saisu
- Imaging Center of St. Marianna University School of Medicine Hospital, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Memi Yamazaki
- St. Marianna University Yokohama City Seibu Hospital, 1197-1 Yasashichou, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Fuyumi Kuramochi
- Kawasaki Municipal Tama Hospital, 1-30-37 Syukugawara, Tama-ku, Kawasaki, Kanagawa, 214-8525, Japan
| |
Collapse
|
42
|
Qualitative Research Methods. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
43
|
Ruparel M, Quaife S, Baldwin D, Waller J, Janes S. Defining the information needs of lung cancer screening participants: a qualitative study. BMJ Open Respir Res 2019; 6:e000448. [PMID: 31803474 PMCID: PMC6890387 DOI: 10.1136/bmjresp-2019-000448] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/09/2019] [Accepted: 11/06/2019] [Indexed: 01/10/2023] Open
Abstract
Introduction Lung cancer screening (LCS) by low-dose CT has been shown to improve mortality, but individuals must consider the potential benefits and harms before making an informed decision about taking part. Shared decision-making is required for LCS in USA, though screening-eligible individuals' specific views of these harms, and their preferences for accessing this information, are not well described. Methods In this qualitative study, we aimed to explore knowledge and perceptions around lung cancer and LCS with a focus on harms. We carried out seven focus groups with screening-eligible individuals, which were divided into current versus former smokers and lower versus higher educational backgrounds; and 16 interviews with health professionals including general practitioners, respiratory physicians, lung cancer nurse specialists and public health consultants. Interviews and focus groups were audio-recorded and transcribed. Data were coded inductively and analysed using the framework method. Results Fatalistic views about lung cancer as an incurable disease dominated, particularly among current smokers, and participants were often unaware of curative treatment options. Despite this, beliefs that screening is sensible and worthwhile were expressed. Generally participants felt they had the 'right' to an informed decision, though some cautioned against information overload. The potential harms of LCS were poorly understood, particularly overdiagnosis and radiation exposure, but participants were unlikely to be deterred by them. Strong concerns about false-negative results were expressed, while false-positive results and indeterminate nodules were also reported as concerning. Conclusions These findings demonstrate the need for LCS information materials to highlight information on the benefits of early detection and options for curative treatment, while accurately presenting the possible harms. Information needs are likely to vary between individuals and we recommend simple information materials to be made available to all individuals considering participating in LCS, with signposting to more detailed information for those who require it.
Collapse
Affiliation(s)
- Mamta Ruparel
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Samantha Quaife
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - David Baldwin
- Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jo Waller
- Research Department of Behavioural Science and Health, University College London, London, UK
- Cancer Prevention Group, King's College London, London, UK
| | - Samuel Janes
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| |
Collapse
|
44
|
Stiggelbout A, Copp T, Jacklyn G, Jansen J, Liefers GJ, McCaffery K, Hersch J. Women's Acceptance of Overdetection in Breast Cancer Screening: Can We Assess Harm-Benefit Tradeoffs? Med Decis Making 2019; 40:42-51. [PMID: 31722605 PMCID: PMC6985988 DOI: 10.1177/0272989x19886886] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background. Breast cancer screening has been presented to women as mostly positive for decades, despite voices raising issues related to harms since its introduction. Public communications about breast cancer screening tended to use persuasive techniques aimed at maximizing uptake. Concern about the harm of overdetection is more recent, and awareness of overdetection among the public is limited. We aimed to assess the impact of extensive information on treatment following overdetection in breast screening on women’s acceptance of screening, and to assess correlates of acceptance. Methods. We performed an online survey among women aged 45-75 from the general public in the Netherlands and Australia, asking women their maximum acceptable ratio of overdetection, per breast cancer death avoided, for four treatment scenarios (randomized order): mastectomy; lumpectomy; lumpectomy plus radiotherapy; lumpectomy plus radiotherapy and hormone therapy. The effect of treatment was assessed using General Linear Models, controlling for socio-demographics, experience, and psychological characteristics. Results. Four-hundred Australian and 403 Dutch women responded. Around half of the women would always screen, even at a 6:1 overdetection-to-death-avoided ratio. Acceptance was highest for the lumpectomy scenario, decreasing with more invasive treatment. In multivariate analyses the effect of treatment remained (p<0.001). Higher acceptance was seen for women with children (p=0.04), screening experience (p<0.001), and less understanding of overdetection (p<0.001). A learning effect was seen: acceptance was highest for the first scenario shown. Conclusions. Acceptance of overdetection was high, but decreased after the first scenario and with invasiveness of treatment. This provides a first indication that with more knowledge and understanding, women may move from uncritical acceptance of screening towards a more informed decision that involves a trade-off of the benefits and harms.
Collapse
Affiliation(s)
- Anne Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands
| | - Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Gemma Jacklyn
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Gerrit-Jan Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - Jolyn Hersch
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, New South Wales, Australia
| |
Collapse
|
45
|
Willett MJ, Greig C, Rogers D, Fenton S, Duda J, Rushton A. Barriers and facilitators to recommended physical activity in lower-limb osteoarthritis: protocol for a qualitative study exploring patients and physiotherapist perspectives using the theoretical domains framework and behaviour change taxonomy. BMJ Open 2019; 9:e029199. [PMID: 31662360 PMCID: PMC6830663 DOI: 10.1136/bmjopen-2019-029199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Osteoarthritis (OA) is the leading cause of disability and pain in older adults. Although increasing physical activity (PA) can help reduce symptoms, patients with lower-limb OA are less active than the general public. Although physiotherapists commonly deliver PA programmes, they lack knowledge of key barriers and facilitators to adherence to prescribed PA that patients with lower-limb OA experience while attending physiotherapy appointments (treatment period) and after discharge (post-treatment period). This study aims to explore the perspectives of patients with lower-limb OA of barriers and facilitators to adherence to physiotherapy prescribed PA in the treatment and post-treatment time periods to inform the development of intervention underpinned by behaviour change theory. METHODS AND ANALYSIS A qualitative study, based on phenomenology, will purposively recruit patients with lower-limb OA who have had physiotherapy. In-depth semi-structured interviews will be undertaken following discharge from physiotherapy at a single time point. Participants' perspectives of physiotherapy interventions, including barriers and facilitators to prescribed PA and techniques that they felt optimised adherence to physiotherapist PA prescription will be explored (phase I). The acceptability and feasibility of delivering a physiotherapy intervention incorporating the techniques identified in the semi-structured interviews will then be explored through focus groups conducted with physiotherapists (phase II). Data will be coded following thematic analysis, with barriers and facilitators mapped to the constructs on the theoretical domains framework, and behaviour change techniques identified following definitions from Michie's V1 taxonomy. ETHICS AND DISSEMINATION Findings from this study will inform development of a physiotherapy intervention underpinned by behaviour change theory aiming to optimise adherence to PA prescription in patients with lower-limb OA during the treatment and post-treatment time periods. This study has ethical approval (IRAS 247904) and results will be disseminated through publications in peer-reviewed journals and presentations at conferences and to study participants.
Collapse
Affiliation(s)
- Matthew James Willett
- Centre of Precision Rehabilitation for Spinal Pain, University of Birmingham, Birmingham, UK
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Carolyn Greig
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- MRC-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, UK
| | - David Rogers
- Centre for Musculoskeletal Medicine, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Sally Fenton
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- MRC-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, UK
| | - Joan Duda
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- MRC-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, UK
| | - Alison Rushton
- Centre of Precision Rehabilitation for Spinal Pain, University of Birmingham, Birmingham, UK
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
46
|
Dodd RH, Nickel B, Wortley S, Bonner C, Hersch J, McCaffery KJ. Examining the information needed for acceptance of deintensified screening programmes: qualitative focus groups about cervical screening in Australia. BMJ Open 2019; 9:e029319. [PMID: 31630103 PMCID: PMC6803149 DOI: 10.1136/bmjopen-2019-029319] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Given the changing understanding of overdiagnosis of screen detected cancers and advances in technology to detect and prevent cancer, updating and scaling back cancer screening programmes is becoming increasingly necessary. The National Cervical Screening Programme (NCSP) in Australia was recently deintensified, with the changes implemented in December 2017. This study examines women's understanding and acceptance of the renewed screening protocol and how such changes can be communicated more effectively. DESIGN Focus groups structured around a presentation of information about the renewed NCSP, with discussions of the information facilitated throughout. Qualitative data analysis was conducted. SETTING Australia PARTICIPANTS: Six focus groups were conducted in November 2017 with a community sample of 49 women aged 18-74. RESULTS Women demonstrated little or no awareness of the upcoming screening changes in the period just before they occurred. Women expressed most concern and fear that the increased screening interval (from 2 to 5 years) and later age of first screening (from age 18 to 25 years) could lead to missing cancers. Concerns about exit testing were less common. Understanding of the natural history and the prevalence of both human papillomavirus and cervical cancer, and the nature of the new test (catching it 'earlier') was key to alleviate concerns about the increased screening interval. CONCLUSIONS Deintensifying screening programmes should be accompanied by clear and coherent communication of the changes, including the rationale behind them, to limit concerns from the public and facilitate acceptance of renewed programmes. In this case, understanding the biology of cervical cancer was crucial.
Collapse
Affiliation(s)
- Rachael H Dodd
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sally Wortley
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten J McCaffery
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
47
|
Klarenbach S, Sims-Jones N, Lewin G, Singh H, Thériault G, Tonelli M, Doull M, Courage S, Garcia AJ, Thombs BD. Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. CMAJ 2019; 190:E1441-E1451. [PMID: 30530611 DOI: 10.1503/cmaj.180463] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Scott Klarenbach
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Nicki Sims-Jones
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Gabriela Lewin
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Harminder Singh
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Guylène Thériault
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Marcello Tonelli
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Marion Doull
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Susan Courage
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Alejandra Jaramillo Garcia
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | - Brett D Thombs
- Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family Medicine (Lewin), University of Ottawa, Ottawa, Ont.; Departments of Internal Medicine and Community Health Sciences (Singh), University of Manitoba, Winnipeg, Man.; Department of Family Medicine (Thériault), McGill University, Montréal, Que.; Department of Medicine (Tonelli), University of Calgary, Calgary, Alta.; Public Health Agency of Canada (Sims-Jones, Courage, Doull, Jaramillo Garcia), Ottawa, Ont.; Department of Psychiatry (Thombs), McGill University, Montréal, Que
| | | |
Collapse
|
48
|
Mathioudakis AG, Salakari M, Pylkkanen L, Saz-Parkinson Z, Bramesfeld A, Deandrea S, Lerda D, Neamtiu L, Pardo-Hernandez H, Solà I, Alonso-Coello P. Systematic review on women's values and preferences concerning breast cancer screening and diagnostic services. Psychooncology 2019; 28:939-947. [PMID: 30812068 PMCID: PMC6594004 DOI: 10.1002/pon.5041] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/21/2019] [Accepted: 02/25/2019] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is still lack of consensus on the benefit-harm balance of breast cancer screening. In this scenario, women's values and preferences are crucial for developing health-related recommendations. In the context of the European Commission Initiative on Breast Cancer, we conducted a systematic review to inform the European Breast Guidelines. METHODS We searched Medline and included primary studies assessing women's values and preferences regarding breast cancer screening and diagnosis decision making. We used a thematic approach to synthesise relevant data. The quality of evidence was determined with GRADE, including GRADE CERQual for qualitative research. RESULTS We included 22 individual studies. Women were willing to accept the psychological and physical burden of breast cancer screening and a significant risk of overdiagnosis and false-positive mammography findings, in return for the benefit of earlier diagnosis. The anxiety engendered by the delay in getting results of diagnostic tests was highlighted as a significant burden, emphasising the need for rapid and efficient screening services, and clear and efficient communication. The confidence in the findings was low to moderate for screening and moderate for diagnosis, predominantly because of methodological limitations, lack of adequate understanding of the outcomes by participants, and indirectness. CONCLUSIONS Women value more the possibility of an earlier diagnosis over the risks of a false-positive result or overdiagnosis. Concerns remain that women may not understand the concept of overdiagnosis. Women highly value time efficient screening processes and rapid result delivery and will accept some discomfort for the peace of mind screening may provide.
Collapse
Affiliation(s)
- Alexander G Mathioudakis
- Biomedical Research Institute (IIB Sant Pau), Iberoamerican Cochrane Centre, Barcelona, Spain.,Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Minna Salakari
- Department of Public Health, Faculty of Medicine, University of Turku, Turku, Finland
| | - Liisa Pylkkanen
- Joint Research Centre, European Commission, Ispra, Italy.,Clinico-Pharmacological Unit, Finnish Medicines Agency Fimea, Turku, Finland
| | | | - Anke Bramesfeld
- Joint Research Centre, European Commission, Ispra, Italy.,Institute for Epidemiology Social Medicine and Health System Research, Hanover Medical School, Hannover, Germany
| | - Silvia Deandrea
- Joint Research Centre, European Commission, Ispra, Italy.,Health Protection Agency, Metropolitan city of Milan, Italy
| | - Donata Lerda
- Joint Research Centre, European Commission, Ispra, Italy
| | | | - Hector Pardo-Hernandez
- Biomedical Research Institute (IIB Sant Pau), Iberoamerican Cochrane Centre, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Ivan Solà
- Biomedical Research Institute (IIB Sant Pau), Iberoamerican Cochrane Centre, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Pablo Alonso-Coello
- Biomedical Research Institute (IIB Sant Pau), Iberoamerican Cochrane Centre, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| |
Collapse
|
49
|
Bromley HL, Petrie D, Mann GB, Nickson C, Rea D, Roberts TE. Valuing the health states associated with breast cancer screening programmes: A systematic review of economic measures. Soc Sci Med 2019; 228:142-154. [PMID: 30913528 DOI: 10.1016/j.socscimed.2019.03.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/21/2019] [Accepted: 03/15/2019] [Indexed: 12/26/2022]
Abstract
Policy decisions regarding breast cancer screening and treatment programmes may be misplaced unless the decision process includes the appropriate utilities and disutilities of mammography screening and its sequelae. The objectives of this study were to critically review how economic evaluations have valued the health states associated with breast cancer screening, and appraise the primary evidence informing health state utility values (cardinal measures of quality of life). A systematic review was conducted up to September 2018 of studies that elicited or used utilities relevant to mammography screening. The methods used to elicit utilities and the quality of the reported values were tabulated and analysed narratively. 40 economic evaluations of breast cancer screening programmes and 10 primary studies measuring utilities for health states associated with mammography were reviewed in full. The economic evaluations made different assumptions about the measures used, duration applied and the sequalae included in each health state. 22 evaluations referenced utilities based on assumptions or used measures that were not methodologically appropriate. There was significant heterogeneity in the utilities generated by the 10 primary studies, including the methods and population used to derive them. No study asked women to explicitly consider the risk of overdiagnosis when valuing the health states described. Utilities informing breast screening policy are restricted in their ability to reflect the full benefits and harms. Evaluating the true cost-effectiveness of breast cancer screening will remain problematic, unless the methodological challenges associated with valuing the disutilities of screening are adequately addressed.
Collapse
Affiliation(s)
- Hannah L Bromley
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Health Economics Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Dennis Petrie
- Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
| | - G Bruce Mann
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Carolyn Nickson
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Cancer Research Division, Cancer Council NSW, Australia
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit, University Hospital of Birmingham, Birmingham, West Midlands, UK
| | - Tracy E Roberts
- Health Economics Unit, University of Birmingham, Birmingham, West Midlands, UK.
| |
Collapse
|
50
|
Reder M, Berens EM, Spallek J, Kolip P. Development of the Informed Choice in Mammography Screening Questionnaire (IMQ): factor structure, reliability, and validity. BMC Psychol 2019; 7:17. [PMID: 30890190 PMCID: PMC6423759 DOI: 10.1186/s40359-019-0291-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/22/2019] [Indexed: 12/29/2022] Open
Abstract
Background Informed choice is of ethical and practical importance in mammography screening. To assess the level to which decisions regarding such screening are informed is thus imperative, but no specific instrument has been available to measure informed choice in the German mammography screening programme. The aims of this study were to develop the Informed Choice in Mammography Screening Questionnaire (IMQ) and to find first evidence for the factor structure, reliability and validity of its different components. Methods The IMQ was sent to 17.349 women aged 50 in Westphalia-Lippe, Germany. The instrument has been developed after consideration of (1) the results of qualitative interviews on decision making in the mammography screening programme, (2) relevant literature on other informed choice instruments and (3) a qualitative study on influencing factors. The IMQ comprises 3 scales (attitude, norms, and barriers), 1 index (knowledge) and singular items covering intention to participate and sociodemographic variables. To assess the psychometric properties of the components of the IMQ, confirmatory factor and item response theory analyses were conducted. Additionally, reliability, validity and item statistics were assessed. Results 5.847 questionnaires were returned (response rate 33.7%). For attitude, the confirmatory factor analysis supported a one-factor structure. For norms, the model fit was not acceptable. Reliability levels were good with a Cronbach‘s α of.793 for attitude (4 items) and.795 for norms (5 items). For barriers, 9 items were deleted because of low discrimination indices; 6 items remained. The hypothesised assumption-subscale and the importance-subscale were confirmed, but these subscales showed poor reliabilities with Cronbach‘s α=.525 (4 items) and.583 (2 items). For the knowledge index, item response theory analysis showed that 6 out of 7 items were suitable. Hypotheses concerning the correlations between the different components were confirmed, which supported their convergent and divergent validity. Conclusion The results of this study demonstrated that the IMQ is a multidimensional instrument. Further development of the barriers and norms scales is necessary. The IMQ can be utilised to assess the level of informed choices as well as influencing factors. Electronic supplementary material The online version of this article (10.1186/s40359-019-0291-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Maren Reder
- Bielefeld University, School of Public Health, Department of Prevention and Health Promotion, Universitätsstraße 25, Bielefeld, 33615, Germany. .,University of Hildesheim, Institute of Psychology, Universitätsplatz 1, Hildesheim, 31142, Germany.
| | - Eva-Maria Berens
- Bielefeld University, School of Public Health, Department of Health Services Research and Nursing Science, Universitätsstraße 25, Bielefeld, 33615, Germany
| | - Jacob Spallek
- Brandenburg University of Technology Cottbus-Senftenberg, Department of Public Health, Universitätsplatz 1, Senftenberg, 01968, Germany
| | - Petra Kolip
- Bielefeld University, School of Public Health, Department of Prevention and Health Promotion, Universitätsstraße 25, Bielefeld, 33615, Germany
| |
Collapse
|