Cancer screening for the right patients at the right level of cancer risk can save lives, but over the last several years many expert groups have de-intensified mammography screening recommendations because of evidence of net harm for certain populations. Newer recommendations for mammography screening highlight a tailored approach based on age and risk and comorbidities, aiming to minimize harms and reach women who could benefit the most. For example, according to the United States Preventive Services Task Force guidelines, women age 40-49 should talk with their doctor and make an informed choice about whether to initiate screening. The change in emphasis from strongly promoting annual mammograms for all women over 40 to promoting informed choice in this age group constitutes a medical reversal, in the sense that this new message is very different from past messages and people?s expectations. Moreover, the recommendation for informed choice can elicit negative reactions in some women. Many women express disbelief when told about overdiagnosis and overtreatment, which are significant harms of screening. The notion of risk-based screening?that is, creating a screening plan tailored to a woman?s objective cancer risk?can raise suspicions of healthcare rationing. The result is a delicate situation in which there is need to convey the evidence to women so they can make an informed choice, but also a need to do it in a way that maintains credibility and trust despite this health message reversal. In this research we focus on four types of concerning responses that women may express in reaction to mammography evidence: Reactance (i.e. perceived manipulation or influence, e.g. ?this is trying to ration healthcare?), self-Exemption (e.g., ?this doesn?t apply to me?), Disbelief (e.g., ?you can?t believe all the research anyway?), and Source derogation (e.g., ?I don?t trust this source?), which we shorten to REDS. This research will identify affective and cognitive predictors of these reactions, and identify the consequences of these reactions for screening preferences and shared decision-making.
In Aim 1 we will conduct a nationally representative survey of women age 40-49 and test affective and cognitive predictors of REDS reactions and consequences for screening intentions.
In Aim 2 we will conduct a longitudinal survey and identify how women?s attitudes toward the evidence predicts shared decision making for mammography in an upcoming primary care appointment, and we will also examine how these attitudes change over time and are influence by women?s broader social environment.
In Aim 3, we will conduct interviews and focus groups to identify strategies for communicating more effectively about screening, to avoid negative REDS responses, and promote positive responses like empowerment and desire for shared decision making. We will modify an existing mammography decision aid to incorporate these improvements, and then conduct randomized pilot tests of these improvements to provide preliminary evidence that they reduce REDS and improve women?s positive responses to mammography evidence.
Given past health messages that strongly promoted mammography screening, recent revisions to guidelines that promote informed choice constitute a health message reversal that can be difficult for many women to accept. This research will employ nationally representative and longitudinal surveys of women 40-49 that aim to understand women?s affective reactions to screening evidence and the consequences of those reactions for screening preferences and shared decision making with a primary care provider. This research will directly inform how to more effectively communicate about breast cancer screening to maintain credibility and trust when health messages change.