Using an Internet-Based Breast Cancer Risk Assessment Tool to Improve Social-Cognitive Precursors of Physical Activity

Patient Perspectives on the Risk-Based NLST Outcomes Tool for Lung Cancer Screening

Researchers at the NCI have developed the Risk-Based NLST Outcomes Tool (RNOT), an online tool that calculates risk of lung cancer diagnosis and death with and without lung cancer screening, and false-positive risk estimates. This tool has the potential to facilitate shared decision making for screening. The objective of this study was to examine how current heavy and former smokers understand and respond to personalized risk estimates from the RNOT. Individuals who were eligible for lung cancer screening and were visiting Walter Reed National Military Medical Center were invited to participate in a semi-structured interview to assess their experiences with and perceptions of the RNOT. Results were analyzed using template analysis. Participants found their risk of lung cancer death to be lower than anticipated and were confused by changes in risk for lung cancer diagnosis with and without screening. Most participants indicated that the RNOT would be helpful in making screening decisions, despite reporting that there was no maximum risk for a false positive that would lead them to forgo lung cancer screening. Participants provided actionable needs and recommendations to optimize this tool. Risk-based screening tools may enhance shared decision making. The RNOT is being updated to incorporate these findings.

Adherence of Internet-Based Cancer Risk Assessment Tools to Best Practices in Risk Communication: Content Analysis

BACKGROUND

Internet-based risk assessment tools offer a potential avenue for people to learn about their cancer risk and adopt risk-reducing behaviors. However, little is known about whether internet-based risk assessment tools adhere to scientific evidence for what constitutes good risk communication strategies. Furthermore, their quality may vary from a user experience perspective.

OBJECTIVE

This study aims to understand the extent to which current best practices in risk communication have been applied to internet-based cancer risk assessment tools.

METHODS

We conducted a search on August 6, 2019, to identify websites that provided personalized assessments of cancer risk or the likelihood of developing cancer. Each website (N=39) was coded according to standardized criteria and focused on 3 categories: general website characteristics, accessibility and credibility, and risk communication formats and strategies.

RESULTS

Some best practices in risk communication were more frequently adhered to by websites. First, we found that undefined medical terminology was widespread, impeding comprehension for those with limited health literacy. For example, 90% (35/39) of websites included technical language that the general public may find difficult to understand, yet only 23% (9/39) indicated that medical professionals were their intended audience. Second, websites lacked sufficient information for users to determine the credibility of the risk assessment, making it difficult to judge the scientific validity of their risk. For instance, only 59% (23/39) of websites referenced the scientific model used to calculate the user's cancer risk. Third, practices known to foster unbiased risk comprehension, such as adding qualitative labels to quantitative numbers, were used by only 15% (6/39) of websites.

CONCLUSIONS

Limitations in risk communication strategies used by internet-based cancer risk assessment tools were common. By observing best practices, these tools could limit confusion and cultivate understanding to help people make informed decisions and motivate people to engage in risk-reducing behaviors.

Risk Ladder, Table, or Bulleted List? Identifying Formats That Effectively Communicate Personalized Risk and Risk Reduction Information for Multiple Diseases

BACKGROUND

Personalized medicine may increase the amount of probabilistic information patients encounter. Little guidance exists about communicating risk for multiple diseases simultaneously or about communicating how changes in risk factors affect risk (hereafter "risk reduction").

PURPOSE

To determine how to communicate personalized risk and risk reduction information for up to 5 diseases associated with insufficient physical activity in a way laypeople can understand and that increases intentions.

METHODS

We recruited 500 participants with <150 min weekly of physical activity from community settings. Participants completed risk assessments for diabetes, heart disease, stroke, colon cancer, and breast cancer (women only) on a smartphone. Then, they were randomly assigned to view personalized risk and risk reduction information organized as a bulleted list, a simplified table, or a specialized vertical bar graph ("risk ladder"). Last, they completed a questionnaire assessing outcomes. Personalized risk and risk reduction information was presented as categories (e.g., "very low"). Our analytic sample (N = 372) included 41.3% individuals from underrepresented racial/ethnic backgrounds, 15.9% with vocational-technical training or less, 84.7% women, 43.8% aged 50 to 64 y, and 71.8% who were overweight/obese.

RESULTS

Analyses of covariance with post hoc comparisons showed that the risk ladder elicited higher gist comprehension than the bulleted list (P = 0.01). There were no significant main effects on verbatim comprehension or physical activity intentions and no moderation by sex, race/ethnicity, education, numeracy, or graph literacy (P > 0.05). Sequential mediation analyses revealed a small beneficial indirect effect of risk ladder versus list on intentions through gist comprehension and then through perceived risk (b_{IndirectEffect} = 0.02, 95% confidence interval: 0.00, 0.04).

CONCLUSION

Risk ladders can communicate the gist meaning of multiple pieces of risk information to individuals from many sociodemographic backgrounds and with varying levels of facility with numbers and graphs.

Commentary: 20 years online with "Your Disease Risk"

The Your Disease Risk tool (yourdiseaserisk.wustl.edu) went live to the public in January 2000 and was one of the first personalized health risk assessment sites on the Internet. Its launch marked the culmination of years of work by a large, multi-disciplinary university team whose primary goal was to translate the science on cancer prevention into accurate, engaging, and useful messages for the public. Today, 20 years on, Your Disease Risk has expanded from its initial four cancers to include 18 different tools designed for today’s users. This commentary reviews important moments and lessons learned in the first two decades of Your Disease Risk.

Translating Cancer Risk Prediction Models into Personalized Cancer Risk Assessment Tools: Stumbling Blocks and Strategies for Success

Cancer risk prediction models such as those published in Cancer Epidemiology, Biomarkers, and Prevention are a cornerstone of precision medicine and public health efforts to improve population health outcomes by tailoring preventive strategies and therapeutic treatments to the people who are most likely to benefit. However, there are several barriers to the effective translation, dissemination, and implementation of cancer risk prediction models into clinical and public health practice. In this commentary, we discuss two broad categories of barriers. Specifically, we assert that the successful use of risk-stratified cancer prevention and treatment strategies is particularly unlikely if risk prediction models are translated into risk assessment tools that (i) are difficult for the public to understand or (ii) are not structured in a way to engender the public's confidence that the results are accurate. We explain what aspects of a risk assessment tool's design and content may impede understanding and acceptance by the public. We also describe strategies for translating a cancer risk prediction model into a cancer risk assessment tool that is accessible, meaningful, and useful for the public and in clinical practice.

Participatory Design of a Personalized Genetic Risk Tool to Promote Behavioral Health

Despite major advancements in genomic medicine, research to optimize the design and communication of genetically informed interventions in behavioral health has lagged. The goal of this study was to engage potential end users in participatory codesign of a personalized genetically informed risk tool to intervene on high-risk health behaviors. We used structured interviews to examine end-user attitudes and interest in personalized genetics, qualitative interviews to guide iterative design of a genetically informed tool, and questionnaires to assess acceptability and potential utility of the tool. Participants expressed strong demand for using personal genetics to inform smoking and alcohol-related disease risk and guide treatment (78%-95% agreed). Via iterative design feedback, we cocreated a genetically informed risk profile featuring (i) explanation of genetic and phenotypic markers used to construct a risk algorithm, (ii) personalized risks and benefits of healthy behavior change, and (iii) recommended actions with referral to freely available resources. Participants demonstrated sufficient understanding and cited motivating behavior change as the most useful purpose of the tool. In three phases, we confirmed strong desire for personalized genetics on high-risk health behaviors; codesigned a genetically informed profile with potential end users; and found high acceptability, comprehensibility, and perceived usefulness of the profile. As scientific discovery of genomic medicine advances in behavioral health, we must develop the tools to communicate these discoveries to consumers who stand to benefit. The potential of genomic medicine to engage populations and personalize behavioral health treatment depends, in part, on preparatory studies to design for the future implementation of genetically informed interventions.

Alcohol and breast cancer risk: Middle-aged women's logic and recommendations for reducing consumption in Australia

BACKGROUND

We aimed to understand the factors shaping alcohol consumption patterns in middle-aged women (45-64), and to identify participant-driven population- and policy-level strategies that may be used to addresses alcohol consumption and reduce breast cancer risk.

METHODS

Semi-structured interviews (n = 35) were conducted with 'middle-aged' women conversant in English and living in South Australia with no history of breast cancer diagnosis. Data were deductively coded using a co-developed framework including variables relevant to our study objectives. Women were asked about their current level of awareness of the association between alcohol and breast cancer risk, and their personal recommendations for how to decrease consumption in middle-aged Australian women.

RESULTS

Women discussed their previous efforts to decrease consumption, which we drew on to identify preliminary recommendations for consumption reduction. We identified a low level of awareness of alcohol and breast cancer risk, and confusion related to alcohol as a risk for breast cancer, but not always causing breast cancer. Participants suggested that education and awareness, through various means, may help to reduce consumption.

CONCLUSIONS

Participants' description of strategies used to reduce their own consumption lead us to suggest that campaigns might focus on the more salient and immediate effects of alcohol (e.g. on physical appearance and mental health) rather than longer-term consequences. Critical considerations for messaging include addressing the personal, physical and social pleasures that alcohol provides, and how these may differ across socio-demographics.

Parental Optimism About Children's Risk of Future Tobacco Use and Excessive Weight Gain

BACKGROUND

Adults tend to underestimate their personal risk of disease, but little is known about parents' perceptions of children's risk.

METHODS

In total, 648 parents of children 0 to 18 years old attending 2 pediatric practices were surveyed about their children's exposure to smoking; 344 parents with children ≥2 years old also were asked about their children's sugar-sweetened beverage (SSB) consumption and physical activity. Children were categorized as "at risk" or "not at risk" for each factor. Parents estimated the risk of their child becoming a smoker or gaining excessive weight and were categorized as "optimistic" if they believed their children were less likely than others to use tobacco or gain weight.

RESULTS

Overall, 92% of parents thought their children were at lower risk than average for tobacco use, and 86% believed their children were at lower risk for excessive weight gain. A high frequency of optimistic bias occurred even among parents with "at-risk" children, including parents with children exposed to tobacco use (70.4%), SSB consumption (77.6%), >2 hours of screen time (82.1%), and low physical activity (84.1%). In multivariable analyses, parents with children exposed to tobacco smoke (odds ratio = 0.21, 95% confidence interval, 0.09-0.51); or who consumed SSBs daily (odds ratio = 0.44, 95% confidence interval 0.20-0.97) were less likely to be optimistic about their child's future tobacco use and excessive weight gain, respectively.

CONCLUSIONS

Most parents believed their children were at lower risk than average for tobacco use or excessive weight gain. Eliciting parents' optimistic biases might facilitate behavior change counseling in pediatric settings.