Men and women: beliefs about cancer and about screening

Background  

Cancer screening programmes in England are publicly-funded. Professionals' beliefs in the public health benefits of screening can conflict with individuals' entitlements to exercise informed judgement over whether or not to participate. The recognition of the importance of individual autonomy in decision making requires greater understanding of the knowledge, attitudes and beliefs upon which people's screening choices are founded. Until recently, the technology available required that cancer screening be confined to women. This study aimed to discover whether male and female perceptions of cancer and of screening differed.     

Measurement of community beliefs about colorectal cancer

Few educational campaigns have focused on bowel cancer, though studies have indicated that members of the community need and want current information about relevant issues. In order to facilitate research in this area, reliable and valid measures of community attitudes are needed. Content validity of a survey instrument was obtained through use of a Delphi process with Directors of Education from the Australia Cancer Council and focus group discussions with informed members of the public. The subsequent survey of community perceptions about colorectal cancer included a broad range of content areas related to the risk of bowel cancer, preventing and coping with bowel cancer and beliefs about susceptibility and severity. The construct validity of these content areas was investigated by use of a factor analysis and confirmation of an association with related predictor variables. Two measures related to personal influence and anticipated coping responses showed favourable psychometric properties, including moderate to high levels of internal consistency and test-retest reliability. A test of the concurrent validity of these measures requires further development of instruments related to colorectal cancer or adaptation of measures from other areas of health research.     

The CAUSE model: a research-supported aid for physicians communicating with patients about cancer risk

"Talk to your doctor" may be one of the most common pieces of advice given to help patients manage cancer risk. In fact, though, the support given to physicians for talking with patients about cancer prevention is not extensive. To address this need, we propose a decision aid for physicians. The CAUSE model draws on existing research, identifying common sources of tension or confusion in physician patient interaction. Specifically, the model assists physicians in anticipating common barriers to effective communication and overcoming them to establish credibility, create awareness and understanding, gain agreement about solutions, and help patients enact solutions for the prevention of cancer.     

Perceptions of genetic risk assessment and education among first-degree relatives of colorectal cancer patients and implications for physicians

BACKGROUND: Genetic risk assessment and education is a clinical service that provides an opportunity for individuals with a strong family history of cancer to understand their risk better, identify a screening regimen and discuss benefits and limitations of genetic testing. OBJECTIVES: The aim of this study was to assess knowledge of and attitudes to genetic risk assessment and education among first-degree relatives of patients with colorectal cancer. METHODS: We conducted focus groups among first-degree relatives of patients with colorectal cancer to assess perceptions of genetic risk assessment and education. In the groups, we elicited reactions using two definitions of genetic risk assessment and education-one brief and one more detailed-that might be used by a health practitioner during the referral process. RESULTS: Findings revealed a number of misconceptions and concerns including: (i) what is required to prepare for a session and a lack of desire to collect a family history; (ii) what is involved in a session (including assuming that genetic testing is always included in a session); (iii) distrust over accuracy and possible subjectivity of information provided; and (iv) fear of the effect that participation in a session might have on insurance status. CONCLUSIONS: The findings suggest that health practitioners should educate individuals about genetic risk assessment and education during the initial referral process. Further studies should explore how best to do this.     

Increased cancer risk among relatives of nonsmoking lung cancer cases

Lung cancer has been shown to aggregate in families of nonsmoking lung cancer cases with an earlier age at onset. The current study evaluates whether relatives of nonsmoking lung cancer cases are at increased risk of cancers at sites other than lung. Families were identified through 257 population‐based, nonsmoking lung cancer cases and 277 population‐based, nonsmoking controls residing in metropolitan Detroit. Data were collected for 2,252 relatives of cases and 2,408 relatives of controls. First‐degree relatives of nonsmoking lung cancer cases were at 1.52‐fold (95% CI, 1.02–2.27) increased risk of cancer of the digestive system after adjustment for each relative's age, race, sex, and smoking status. Relative risk estimates also were elevated, but not significantly, for tobacco‐related cancers (RR = 1.39) and breast cancer (RR = 1.72). Among first‐degree relatives of younger probands (age 40–59), risk was non‐significantly increased 72% (95% CI 0.95–3.10) for all cancers combined and 3.14‐fold for cancers of the digestive system (95% CI 0.76–12.9). Nonsmoking relatives of cases were at increased risk of all cancer sites combined (RR = 1.32; 95% CI 1.003–1.73), cancers other than lung (RR = 1.37; 95% CI 1.03–1.82), and digestive system cancers (RR = 2.01; 95% CI 1.20–3.37). These findings of moderate familial aggregation for cancers of the lung, digestive system, breast, and tobacco‐related sites suggest that common susceptibility genes may act to increase risk for a variety of cancers in families. Genet. Epidemiol. 17:1–15, 1999. © 1999 Wiley‐Liss, Inc.     

Public perceptions of communicating information about bowel cancer screening

Objectives  The National Health Service has recently begun the introduction of a Bowel Cancer Screening Programme (BCSP), offering biennial screening to men and women aged 60–69 years. This study aimed to explore public perceptions regarding the communication of information designed to facilitate informed choice in relation to this new screening programme. Methods  Fourteen single sex focus groups were conducted in England with 86 individuals aged 60–69 years. Focus groups were conducted either with individuals who had participated in the pilot phase of the BCSP, or with members of the public living outside the pilot areas. Results  The majority of participants expressed positive attitudes towards bowel cancer screening, identifying items highlighting the benefits of the programme as important for others to know. Whilst some believed it was appropriate for information regarding the potentially negative aspects of the programme to be communicated at the outset, others expressed concerns about the generation of anxiety and potential for decreased participation. A number of participants questioned the concept of informed choice, arguing that once in place, a screening programme should be vigorously promoted. Conclusions  There is some variation in the type of information favoured by those eligible for bowel cancer screening. This may present challenges for the provision of information aiming to facilitate informed choice in the BCSP. Flexible approaches to information provision that recognize the perceptions of patients may be required.     

Mammographers' perception of women's breast cancer risk.

OBJECTIVE: To understand mammographers' perception of individual women's breast cancer risk. MATERIALS AND METHODS: Radiologists interpreting screening mammography examinations completed a mailed survey consisting of questions pertaining to demographic and clinical practice characteristics, as well as 2 vignettes describing different risk profiles of women. Respondents were asked to estimate the probability of a breast cancer diagnosis in the next 5 years for each vignette. Vignette responses were plotted against mean recall rates in actual clinical practice. RESULTS: The survey was returned by 77% of eligible radiologists. Ninety-three percent of radiologists overestimated risk in the vignette involving a 70-year-old woman; 96% overestimated risk in the vignette involving a 41-year-old woman. Radiologists who more accurately estimated breast cancer risk were younger, worked full-time, were affiliated with an academic medical center, had fellowship training, had fewer than 10 years experience interpreting mammograms, and worked more than 40% of the time in breast imaging. However, only age was statistically significant. No association was found between radiologists' risk estimate and their recall rate. CONCLUSION: U.S. radiologists have a heightened perception of breast cancer risk.     

Unraveling women's perceptions of risk for breast cancer

Inconsistent reports of the prevalence of risk perception accuracy may be related to the use of different classification strategies. The purpose of this study was to compare two approaches for assessing the accuracy of women's breast cancer risk perceptions. A telephone survey was conducted with an age-stratified random sample of British Columbian women 20-79 years of age without a breast cancer diagnosis (n = 761). A comparison of two methods employed to determine perception accuracy revealed substantial differences between the methods with regard to the classification of women as under- and over-estimators. The study highlights the need for researchers to consider the method used to determine the accuracy of risk perceptions and the implications of using different strategies to assess risk perception accuracy when such information is used in research or to guide interventions.     

Uptake of cervical cancer screening in The Netherlands is mainly influenced by women's beliefs about the screening and by the inviting organization

BACKGROUND: This study aims to examine the impact of women's characteristics (demographics, risk behaviour, and beliefs) on the uptake of cervical cancer screening, taking practice characteristics (demographic and organizational) into account. METHODS: Routinely collected data of screening status were sampled from electronic medical records of 32 Dutch general practices. Additionally, a questionnaire was sent to a sample of 2224 listed women-1204 screened, 1020 unscreened. We used a step-by-step, logistic, multilevel approach to examine determinants of the screening uptake. RESULTS: Analyses of data for 1392 women (968 screened and 424 unscreened) showed that women's beliefs about cervical screening and attendance are the best predictors of screening uptake, even when demographic and organizational aspects are taken into account. Women aged 40-50 years who felt high personal moral obligation, who had only one sexual partner ever, and who were invited and reminded by their own general practice had the greatest likelihood of screening uptake. A non-response study was performed; the non-responders to the questionnaire (mainly unscreened) thought they had less risk of cervical cancer, were less motivated, less often intended to get future screening, and were more convinced that cervical cancer cannot be cured. CONCLUSION: To improve the uptake rate, we should focus on the personal moral obligation of eligible women, beliefs about the risks of cervical cancer, and available cures. Invitations and reminders within general practices enhance the uptake rate.     

The meaning of risk to first degree relatives of women with breast cancer

Breast cancer represents a serious health concern for women. It is estimated that hereditary breast cancer accounts for approximately 5-10% of all breast cancer cases and as many as 25% of early-onset cases. We conducted a qualitative study of 26 first degree relatives of women with breast cancer (FDRs) in order to gain a deeper understanding of the effect of risk perception on their screening adherence. The method relied upon semi-structured, in-depth, face-to-face interviews with first degree relatives of women with breast cancer. We characterized FDRs by their response to a single query about their perceived risk. "Risk adopters" (N = 13) were defined as those who expressed a lifetime risk of breast cancer of 50% or more, and "normalizers" (N = 13) were those who indicated a lifetime risk of 49% or less. We conducted content analysis on the responses to the open-ended queries concerning perceived risk for breast cancer, searching for consistent themes among the responses. Surveillance behaviors were high among these FDRs relative to population-based comparisons. The difference between perceived and objective risk for breast cancer was significantly greater among risk adopters than normalizers (p < .0001). Three themes, derived from a content analysis of the FDR's natural language, further distinguish the two groups of women from one another: (1) causal attributions; (2) acceptance of labeling by the physician or other health care provider; and (3) current or remembered surveillance reminders from salient members of the social support network. We suggest different health care provider approaches to FDRs who are normalizers and those who are risk adopters, as well as additional studies of the impact of risk status (as manifest in the FDR's natural language) and surveillance behaviors, over time, among more diverse subgroups.     

Increased familial risk for non-lung cancer among relatives of lung cancer patients

Reports of two or more anatomically distinct cancer types clustering in families suggest the possible existence of a susceptibility-to-cancer gene. To determine whether a genetic predisposition accounts for such familial aggregation, a retrospective case-control study was conducted in 1976-1979 of 337 southern Louisiana families in each of which a deceased lung cancer patient was used as the proband. A comparison of first-degree relatives of proband families with spouse (control) families revealed a significantly greater overall risk of cancer (odds ratio (OR) = 2.0, p less than 0.0001) in the proband group. Using logistic regression techniques to control for the confounding effects of age, sex, cigarette smoking, and occupational/industrial exposures, relatives of lung cancer probands maintained an increased risk of non-lung cancer (p less than 0.05). The crude odds ratio of a proband family having one family member with cancer was 1.67 compared with control families. Proband families were 2.16 times more likely to have two other family members with cancer. For three cancers and four or more cancers, the risk increased to 3.66 and 5.04, respectively. Each risk estimate was significant at the 0.01 level. The most striking differences in cancer prevalence between proband and control families were noted for cancer of the nasal cavity/sinus, mid-ear, and larynx (OR = 4.6); trachea, bronchus and lung (OR = 3.0); skin (OR = 2.8); and uterus, placenta, ovary, and other female organs (OR = 2.1). These data support the hypothesis of a genetic susceptibility to cancer in families with lung cancer.     

Interest in genetic testing among first-degree relatives of colorectal cancer patients

PURPOSE: The present study examined colorectal cancer screening behaviors, risk perceptions, and willingness to receive genetic testing to determine colorectal cancer susceptibility. METHODS: We recruited 95 first-degree relatives of colorectal cancer patients, then conducted a brief telephone interview using a structured questionnaire that elicited information on sociodemographics, cancer screening behaviors, risk perceptions, and interest in genetic testing. RESULTS: Among these high-risk individuals who were aged 40 years or older, only 31% reported fecal occult blood testing within the past year and 59% reported undergoing sigmoidoscopy or colonoscopy within the past 5 years. The majority of participants believed their relative risk of colorectal cancer was increased (68%). Eighty-four percent of the participants indicated that they would have a genetic test if one were available. Participants who believed that <50% of colorectal cancers were caused by heredity were more likely to be interested in genetic testing than were participants who believed that 50% or more of colorectal cancers were caused by heredity. Referral source, sociodemographic factors, clinical factors, and perceived personal risk were not significantly associated with interest in genetic testing. CONCLUSION: Our results suggest that the demand for colorectal cancer susceptibility testing may be high among individuals with a family history of colorectal cancer. We also observed that a substantial number of first-degree relatives were not adhering to colorectal cancer screening guidelines. Accurate information on the genetic aspects of colorectal cancer and the benefits and limitations of genetic testing may help relatives of colorectal cancer patients make informed decisions about whether to undergo enhanced screening and genetic testing.     

Lung cancer risk in white and black Americans

PURPOSE: To test whether differences in smoking-related lung cancer risks in blacks and whites can explain why lung cancer incidence is greater in black males than in white males but about equal in black and white females, given that a greater proportion of blacks are smokers, but smoke far fewer cigarettes per day than do whites. METHODS: A hospital-based case-control study was conducted between 1984 and 1998 that included interviews with 1,710 white male and 1,321 white female cases of histologically confirmed lung cancer, 254 black male and 163 black female cases, and 8,151 controls. Relative risks were estimated via odds ratios using logistic regression, adjusted for age, education, and body mass index. RESULTS. We confirmed prior reports that smoking prevalence is higher but overall dosage is lower among blacks. Overall ORs were similar for blacks and whites, except among the heaviest smoking males (21+ cigarettes per day or 37.5 pack-years), in whom ORs for blacks were considerably greater than for whites. Long-term benefits of cessation were similar for white and black ex-smokers. Smokers of menthol flavored cigarettes were at no greater risk for lung cancer than were smokers of unflavored brands. CONCLUSIONS. Lung cancer risks were similar for whites and blacks with similar smoking habits, except possibly for blacks who were very heavy smokers; this sub-group is unusual in the general population of African American smokers. Explanations of racial disparities in lung cancer risk may need to account for modifying factors including type of cigarette (yield, mentholation), diet, occupation, and host factors such as ability to metabolize mainstream smoke carcinogens.     

Comparison of smoking-related risk factors among black and white males

The lung cancer risk factors of smoking prevalence, amount smoked, and age started to smoke were compared for blacks and whites, using the 1970 and 1979/80 National Health Interview Survey (NHIS) survey data. For both survey years, proportionally more blacks were never smokers and fewer were ever smokers (although more were current and fewer former smokers). The average adult black smoker smoked approximately 65% of the number of cigarettes smoked by the average white adult. Blacks started smoking later than whites for almost all occupational categories. Thus, it could be argued that whites had higher smoking-associated risk factors than did blacks. At the same time, a much greater proportion of blacks than whites were in the types of occupation where they would have been exposed to occupational hazards. The sharp rise in and the larger incidence of lung cancer among blacks compared to whites may not be due to differences in black and white smoking, but more likely are a reflection of occupational differences.     

‘It's their blood not mine’: Who's responsible for (not) telling relatives about genetic risk?

With advances in the ‘new genetics’, an increasing number of people will have access to genetic information and predictive or susceptibility testing. Genetic knowledge has implications for individuals themselves, as well as other family members. In general, health professionals encourage people to pass on genetic risk information to their relatives. However, the disclosure of such information is not always straightforward and, consequently, some people may not be aware of their risk. If risk information is actively withheld, genetic counsellors may need to determine whether they have a duty to pass this on, particularly when preventive action can be taken. To date, little research has explored the barriers and facilitators in family communication about genetic risk. This paper draws on empirical data from a qualitative study exploring communication in families with late-onset familial disease. Interviews were conducted with participants who received genetic counselling for risk of Huntington's disease and hereditary breast or ovarian cancer. Participants' experiences of who was responsible for (not) telling relatives in their families is studied. A number of themes were identified. These were: (1) ‘whose place is it to tell’, (2) the gendering of disclosure, and (3) who is ‘family’. The implications of these findings are considered.