Decision making about cancer screening: an assessment of the state of the science and a suggested research agenda from the ASPO Behavioral Oncology and Cancer Communication Special Interest Group

Public cancer screening services and participation: What meanings in users' narratives to promote engagement?

Despite the effectiveness of cancer screening (CS) in providing timely diagnoses and early treatments, the participation of citizens remains very low in particular in Southern Italy. This study aims to investigate the meanings that intervene in the relationship between the individual and their active participation in CSs within public healthcare. A total of 101 ad hoc semi-structured interviews were collected with CS users in public service of Campania Region, Italy. The interviews were analyzed through a qualitative-quantitative methodology by T-Lab software. A cluster analysis and multiple matching analysis were conducted. Findings show five clusters: prevention as a sensory and emotional burden; prevention as a strategy to manage the hereditary risk of death; individual's internal demand for health; the times and places of prevention; and the concreteness of doing prevention; and two factors: from the risk of disease diagnosis to preventive measures and from external healthcare settings to internal self-care settings. Findings shed light on how to construct better well-being promotion strategies and foster a subjective health and prevention demand accounting for the continuous experiences of those participating in CSs to encourage greater citizen engagement.

Risk-Adapted Breast Screening for Women at Low Predicted Risk of Breast Cancer: An Online Discrete Choice Experiment

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.

Development of FamilyTalk: an Intervention to Support Communication and Educate Families About Colorectal Cancer Risk

IFamily members of individuals with colorectal cancer (CRC) may be at increased risk of developing the disease. However, the majority of CRC can be prevented through colonoscopy screening and family members may not be aware if they are recommended to pursue earlier screening because of their family history of CRC. As such, tools must be developed to effectively communicate potential changes to the recommended age for colonoscopy screening and other important CRC-related information to family members. We modified and adapted a successful intervention for families with melanoma to be appropriate for families with CRC to increase communication and screening in family members. The multistep process included the following: (1) developing a paper version of the intervention, (2) piloting the paper version among families with CRC, (3) developing the web-based version, and (4) testing the intervention for usability. Qualitative data was collected and analyzed for pilot testing. Usability testing utilized both qualitative and quantitative data. Patients with CRC liked the paper version and had multiple suggestions, including adding a better introduction, sections on genetics and family history, and clearer communication assistance. The web-based tool was well received and improved upon the linear book format with links, better section instructions, and more proactive communication tools for families. These processes produced materials that satisfied individuals from various families with assistance and support for communicating about CRC. Evaluating the effects of the tools in rigorous research projects is the next step.

Variation in Cervical Cancer Screening Preferences among Medically Underserved Individuals in the United States: A Systematic Review

Underutilization of effective screening is one driver of disparities in cervical cancer incidence and mortality. Consideration of patient preferences could help to improve screening rates in populations facing substantial barriers to preventive care. We conducted a systematic review of the literature on cervical cancer screening preferences among medically underserved patients in the United States. We searched six electronic databases (PubMed, Web of Science, EMBASE, Scopus, CINAHL, and PsycINFO) for articles published through February 2019 (Prospero ID: CRD42019125431). Among the 43 articles included, 23 reported screening modality preferences, 11 reported preferences related to provider demographics and attributes, six reported screening scheduling and results delivery preferences, and nine reported preferences related to health education and communication. This review demonstrates the wide variety of medically underserved patient preferences related to cervical cancer screening. It also draws attention to two key preference trends that emerged despite heterogeneity in study design, populations, and preference assessment. Consistent preferences for human papillomavirus self-testing over traditional Pap testing highlight a key potential mechanism for increasing cervical cancer screening uptake among medically underserved populations. In addition, preferences for gender- and language-concordant providers underscore the need for continued efforts toward expanding diversity among medical professionals.

Predicting Colonoscopy Screening Behavior and Future Screening Intentions for African Americans Older than 50 Years

African Americans experience a disproportionate burden of morbidity and mortality from colorectal cancer, which may be due to low adherence to screening recommendations. Previous studies have found relationships between decision-making factors and screening behavior, but few have looked at both cognitive and affective factors or within a specifically African American sample. To better understand determinants that drive screening behavior, this study examines affective, cognitive, and social variables as predictors of colonoscopy in an age-eligible African American population. Participants completed surveys assessing affective associations with colonoscopy, perceived benefits and barriers, self-efficacy, knowledge, fear of colonoscopy, perceived risk, and colorectal cancer worry and fear. Regression analysis was used to model decision-making constructs as predictors of screening behavior/intentions. Affective, cognitive, and health care experience variables predicted colonoscopy completion and intentions. Provider-level factors and previous cancer screenings predicted prior screening only, but not intentions. Affective and cognitive components of perceived risk were associated with decreased likelihood of colonoscopy behavior, but increased likelihood of colonoscopy intentions. These findings suggest that colonoscopy decision making involves a complex array of both cognitive and affective determinants. This work extends our knowledge of colorectal cancer screening decision making by evaluating the effects of these multiple determinants on screening behavior in an African American sample. Future work exploring the interplay of affect and cognitions as influences on colonoscopy decision making and how health care experiences may moderate this effect is needed to develop effective intervention approaches and reduce screening disparities.

Eliciting vulnerable patients' preferences regarding colorectal cancer screening: a systematic review

BACKGROUND

Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening.

METHODS

We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes.

RESULTS

A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found.

CONCLUSION

The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.

Designing a randomized controlled trial to evaluate a community-based narrative intervention for improving colorectal cancer screening for African Americans

OBJECTIVE

To describe the methodology of a 2-arm randomized controlled trial that compared the effects of a narrative and didactic version of the Witness CARES (Community Awareness, Reach, & Empowerment for Screening) intervention on colorectal cancer screening behavior among African Americans, as well as the cognitive and affective determinants of screening.

METHODS

Witness CARES targeted cognitive and affective predictors of screening using a culturally competent, community-based, narrative or didactic communication approach. New and existing community partners were recruited in two New York sites. Group randomization allocated programs to the narrative or didactic arm. Five phases of data collection were conducted: baseline, post-intervention, three-month, six-month, and qualitative interviews. The primary outcome was screening behavior; secondary outcomes included cognitive and affective determinants of screening.

RESULTS

A total of 183 programs were conducted for 2655 attendees. Of these attendees, 19.4% (N=516) across 158 programs (50% narrative; 50% didactic) were study-eligible and consented to participate. Half (45.6%) of the programs were delivered to new community partners and 34.8% were delivered at faith-based organizations. Mean age of the total sample was 64.7years and 75.4% were female.

CONCLUSION

The planned number of programs was delivered, but the proportion of study-eligible attendees was lower than predicted. This community-based participatory research approach was largely successful in involving the community served in the development and implementation of the intervention and study.

Can you un-ring the bell? A qualitative study of how affect influences cancer screening decisions

BACKGROUND

The belief that early detection is the best protection against cancer underlies cancer screening. Emerging research now suggests harms associated with early detection may sometimes outweigh the benefits. Governments, cancer agencies, and organizations that publish screening guidelines have found it is difficult to "un-ring the bell" on the message that "early detection is your best protection" because of its widespread communication and enduring resonance. This study explores affective factors-and their interplay with relevant analytical factors-in public/laypersons' decision making about cancer screening.

METHODS

A total of 93 people (47 men, 46 women) attended focus groups about, respectively, prostate cancer screening and breast cancer screening in two Canadian cities.

RESULTS

Affective factors were a major influence on many focus group participants' decision making about cancer screening, including fear of cancer and a generalized enthusiasm for prevention/screening, and they were often inspired by anecdotes about the cancer experiences of family and friends. Affect also existed alongside more analytical factors including assessments of reduced risk in the management of any cancer diagnosis if caught early, and, for men, the belief that an unreliable test is "better than nothing," and that men deserve prostate cancer screening because women have breast and cervical cancer screening. Affective factors were particularly noticeable in the sub-groups most supportive of screening and the "early detection" message: older women who felt that mammogram screening should begin at age 40 rather than 50, and older men who felt that prostate cancer screening should be expanded beyond its current unorganized, opportunistic usage. In contrast, younger participants displayed less affective attachments to "early detection" messages and had greater concerns about harms of screening and were more receptive to nuanced messages informed by evidence.

CONCLUSION

Policymakers attempting to communicate more nuanced versions of the "early detection" message need to understand the role of affect alongside other judgments brought into laypersons' decision making processes and anticipate how affective responses to their messages will be shaped, transformed, and potentially subverted by external forces beyond their control. Particularly overt external factors are campaigns by cancer advocacy organizations actively promoting breast and prostate cancer awareness and screening to younger women and men using affectively-charged messages.

Primary Care Physicians' Action Plans for Responding to Results of Screening Tests Based on the Concept of Quaternary Prevention

Since noncommunicable diseases (NCDs) are generally controllable rather than curable, more emphasis is placed on prevention than on treatment. For the early detection of diseases, primary care physicians (PCPs), as well as general practitioners and family physicians, should interpret screening results accurately and provide screenees with appropriate information about prevention and treatment, including potential harms. The concept of quaternary prevention (QP), which was introduced by Jamoulle and Roland in 1995, has been applied to screening results. This article summarizes situations that PCPs encounter during screening tests according to the concept of QP, and suggests measures to face such situations. It is suggested that screening tests be customized to fit individual characteristics instead of being performed based on general guidelines. Since screening tests should not be carried out in some circumstances, further studies based on the concept of prevention levels proposed by Jamoulle and Roland are required for the development of strategies to prevent NCDs, including cancers. Thus, applying the concept of QP helps PCPs gain better insights into screening tests aimed at preventing NCDs and also helps improve the doctor-patient relationship by helping screenees understand medical uncertainties.

Disgusted, embarrassed, annoyed: affective associations relate to uptake of colonoscopy screening

BACKGROUND

Uptake of colorectal cancer screening is lower than desired. Screening decision making research has traditionally focused on benefits and barriers to screening. This study examines the relation of affective associations with screening (feelings and emotions associated with screening) to colonoscopy screening uptake.

METHODS

Participants were 103 African American community adults. Participants completed a structured interview assessing perceived benefits of and barriers to colonoscopy screening, affective associations with colonoscopy, colonoscopy screening behavior, and intentions for future screening.

RESULTS

Higher positive and lower negative affective associations with screening were both significant predictors of colonoscopy uptake. Affective associations fully mediated the relation of perceived benefits and barriers to screening uptake. Affective associations were associated with intentions for future screening.

CONCLUSIONS

Incorporation of affective associations into models of screening decision making and intervention approaches to address screening compliance has utility for advancing our understanding of screening adherence as well as increasing screening rates.

Perceived risk for breast cancer and its relationship to mammography in Blacks, Hispanics, and Whites

A challenge for health behavior science is to develop theory and best practices that take cultural diversity into account. Using data from Black, Hispanic, and White respondents to the 2003 Health Information National Trends Survey, we examined racial/ethnic differences in: (1) breast cancer risk perceptions/worry; (2) the associations between perceived risk/worry and ever having received a mammogram; and (3) perceived risk/worry and having had at least 2 mammograms over a 4-year period (consecutive mammography). Compared to White race/ethnicity, Black race/ethnicity was associated with lower perceived absolute risk and comparative risk for developing cancer. For the sample as a whole, higher perceived risk (both absolute risk and comparative risk) and worry predicted greater odds of mammography use; however, this was not true for Hispanics. In stratified analyses, perceived risk and worry were not associated with mammography use for either Hispanics or Blacks whereas they were for Whites; however, this interaction effect was significant only for Hispanics vs. Whites. Results support the need for formative research to identify determinants of health behavior prior to cancer prevention message planning for diverse audiences in order to accommodate racial/ethnic differences not only in the level of perceived risk, but also the association between risk perception to behavior change in that community.

Longitudinal predictors of adherence to annual follow-up in a lung cancer screening programme

OBJECTIVE

To examine rates and factors associated with adherence to annual repeat lung cancer screening in two cohorts. Participants and methods The self-pay cohort (n = 2083) was individuals aged 40 years and older with no prior cancer and a smoking history. Participants had to obtain a prescription from their doctor for the low dose, computerized tomography scan (CT), and were responsible for payment of $300 as these CT scans are not typically covered by insurance. The no-pay cohort (n = 1304) was individuals aged 60 and older with a smoking history, and no prior cancer. The initial and one year repeat CT were provided free of charge. Rates of adherence for each cohort were analyzed by demographic variables, smoking history, family history of lung cancer, smoking status (former/current), perceived risk and worry of getting lung cancer and baseline screening CT.

RESULTS

Adherence to annual follow-up was lower for the self-pay than for the no-pay cohort (62% vs. 88%). Both the self-pay and no-pay cohorts had higher adherence rates among Caucasians and those who had a college degree. A greater perceived risk of getting lung cancer increased adherence among the self-pay cohort. Non-calcified nodules found on baseline CT increased the adherence for the self-pay cohort, but decreased the adherence for the no-pay cohort.

CONCLUSIONS

These findings should be used in developing educational materials and targeted retention strategies to increase adherence with repeat lung cancer screening.

Components of family history associated with women's disease perceptions for cancer: a report from the Family Healthware™ Impact Trial

PURPOSE

To determine the specific components of family history and personal characteristics related to disease perceptions about breast, colon, and ovarian cancers.

METHODS

Baseline, cross-sectional data on 2,505 healthy women aged 35-65 years enrolled from 41 primary care practices in the cluster-randomized Family Healthware™ Impact Trial, assessed for detailed family history and perceived risk, perceived severity, worry, and perceived control over getting six common diseases including breast, colon, and ovarian cancers.

RESULTS

Participants provided family history information on 41,841 total relatives. We found evidence of underreporting of paternal family history and lower perceived breast cancer risk with cancer in the paternal versus maternal lineage. We observed cancer-specific perceived risks and worry for individual family history elements and also found novel "spillover" effects where a family history of one cancer was associated with altered disease perceptions of another. Having a mother with early-onset breast or ovarian cancer was strongly associated with perceived risk of breast cancer. Age, parenthood, and affected lineage were associated with disease perceptions and ran counter to empiric risks.

CONCLUSIONS

Understanding patients' formulation of risk for multiple diseases is important for public health initiatives that seek to inform risk appraisal, influence disease perceptions, or match preventive interventions to existing risk perceptions.

Reactions to cancer: communicating with patients, family and carers

Effective communication has benefits for both patients and members of the health care team. Five main communication tasks in head and neck cancer are identified: Screening for head and neck cancer and communicating risk; Communicating the diagnosis of head and neck cancer; Providing information about treatment and pre-treatment; Communicating following treatment and dealing with fear of recurrence; Discussing the end of life. For each specific aspects of the communication situation are discussed. Underpinning each is the use of core communication skills.