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Background: National recommendations allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70 y/o with early-stage, hormone-receptor positive invasive breast cancer, but these therapies remain common. Previous work demonstrates an individual's maximizing-minimizing trait-an inherent preference for more or less medical care-may influence the preference for low-value care., Materials and Methods: We recruited an equal number of women ≥ 70 yrs who were maximizers, minimizers, or neutral based on a validated measure between September 2020 and November 2020. Participants were presented a hypothetical breast cancer diagnosis before randomization to one of three follow-up messages: maximizer-tailored, minimizer-tailored, or neutral. Tailored messaging aimed to redirect maximizers and minimizers toward declining SLNB and radiotherapy. The main outcome measure was predicted probability of choosing SLNB or radiotherapy., Results: The final analytical sample (n = 1600) was 515 maximizers (32%), 535 neutral (33%) and 550 (34%) minimizers. Higher maximizing tendency positively correlated with electing both SLNB and radiotherapy on logistic regression (P < 0.01). Any tailoring (maximizer- or minimizer-tailored) reduced preference for SLNB in maximizing and neutral women but had no effect in minimizing women. Tailoring had no impact on radiotherapy decision, except for an increased probability of minimizers electing radiotherapy when presented with maximizer-tailored messaging., Conclusions: Maximizing-minimizing tendencies are associated with treatment preferences among women facing a hypothetical breast cancer diagnosis. Targeted messaging may facilitate avoidance of low-value breast cancer care, particularly for SLNB., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Multiple studies have demonstrated the safety of omitting therapies in older women with breast cancer. Despite de-implementation guidelines, up to 65% of older women continue to receive one or more of these low-value services. Previous work has investigated the role of both provider and patient attitudes as barriers to de-implementation; however, the importance of the patient's maximizing-minimizing preferences within this context remains unclear., Methods: In this qualitative study, we conducted 30 semi-structured interviews with women ≥ 70 years of age without a previous diagnosis of breast cancer to elicit perspectives on breast cancer treatment in relation to their medical maximizing-minimizing preferences, as determined by the single-item maximizer-minimizer elicitation question (MM1). We used an interpretive description approach in analysis to produce a thematic survey., Results: Participants were relatively evenly distributed across the MM1 (minimizer, n = 8; neutral, n = 13; maximizer, n = 9). Despite being told of recommendations allowing for the safe omission of sentinel lymph node biopsy and post-lumpectomy radiotherapy, maximizers consistently stated preferences for more medical intervention and aggressive therapies over minimizers and neutral individuals., Conclusion: Medical maximizing-minimizing preferences in older women correspond with preferences for breast cancer treatment options that guidelines identify as potentially unnecessary. Increased awareness of patient-level variability in maximizing-minimizing preferences may be valuable in developing optimal intervention strategies to reduce utilization of low-value care.

Background: Breast cancer patients' misunderstanding of their systemic cancer recurrence risk has consequences on decision-making and quality of life. Little is known about how women derive their risk estimates., Methods: Using Los Angeles and Georgia's SEER registries (2014-2015), a random sample of early-stage breast cancer patients was sent surveys about 2 to 3 months after surgery ( N = 3930; RR, 68%). We conducted an inductive thematic analysis of open-ended responses about why women chose their risk estimates in a uniquely large sub-sample ( N = 1,754). Clinician estimates of systemic recurrence risk were provided for patient sub-groups with DCIS and with low-, intermediate-, and high-risk invasive disease. Women's perceived risk of systemic recurrence (0% to 100%) was categorized as overestimation, reasonably accurate estimation, or underestimation (0% for invasive disease) and was compared across identified factors and by clinical presentation., Results: Women identified 9 main factors related to their clinical experience (e.g., diagnosis and testing; treatment) and non-clinical beliefs (e.g., uncertainty; spirituality). Women who mentioned at least one clinical experience factor were significantly less likely to overestimate their risk (12% v. 43%, P < 0.001). Most women who were influenced by "communication with a clinician" had reasonably accurate recurrence estimates (68%). "Uncertainty" and "family and personal history" were associated with overestimation, particularly for women with DCIS (75%; 84%). "Spirituality, religion, and faith" was associated with an underestimation of risk (63% v. 20%, P < 0.001)., Limitations: The quantification of our qualitative results is subject to any biases that may have occurred during the coding process despite rigorous methodology., Conclusions: Patient-clinician communication is important for breast cancer patients' understanding of their numeric risk of systemic recurrence. Clinician discussions about recurrence risk should address uncertainty and relevance of family and personal history.

Objective: Fear of cancer recurrence, although distinct from distress continues to be under-evaluated, captured, or treated when standard distress scales are used to assess concerns of cancer survivors. We tested a model assessing the association of demographic and clinical factors, illness representations, and perceived risk with fear of cancer recurrence in breast cancer survivors., Methods: We recruited 117 breast cancer survivors at least one year after completing breast cancer treatment from Internet discussion boards for this cross-sectional, descriptive, correlational study. Participants completed a survey that assessed their level of fear of cancer recurrence as well as their illness representations, perceived risk of recurrence, and demographic and medical characteristics., Results: Our model explained 62% of the variance in fear of cancer recurrence. Emotional representations (β = .46, p < .01), symptom attribution (β = .21, p < .01), timeline (β = .23, p < .01), and consequences (β = .16, p < .03) were significantly related to fear of recurrence. By contrast, the majority of clinical and demographic variables were not significant contributors to fear of recurrence., Conclusions: Upon completion of cancer treatment, survivors with more emotional representations of the experience and those who attribute unrelated symptoms to their breast cancer have a higher level of fear of recurrence. Evaluation of these factors during treatment may help mitigate fear of recurrence in the survivorship phase of the breast cancer trajectory. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Purpose: Doctor-patient communication is the primary way for women diagnosed with breast cancer to learn about their risk of distant recurrence. Yet little is known about how doctors approach these discussions., Methods: A weighted random sample of newly diagnosed early-stage breast cancer patients identified through SEER registries of Los Angeles and Georgia (2013-2015) was sent surveys about ~2 months after surgery (Phase 2, N = 3930, RR 68%). We assessed patient perceptions of doctor communication of risk of recurrence (i.e., amount, approach, inquiry about worry). Clinically determined 10-year risk of distant recurrence was established for low and intermediate invasive cancer patients. Women's perceived risk of distant recurrence (0-100%) was categorized into subgroups: overestimation, reasonably accurate, and zero risk. Understanding of risk and patient factors (e.g. health literacy, numeracy, and anxiety/worry) on physician communication outcomes was evaluated in multivariable regression models (analytic sample for substudy = 1295)., Results: About 33% of women reported that doctors discussed risk of recurrence as "quite a bit" or "a lot," while 14% said "not at all." Over half of women reported that doctors used words and numbers to describe risk, while 24% used only words. Overestimators (OR .50, CI 0.31-0.81) or those who perceived zero risk (OR .46, CI 0.29-0.72) more often said that their doctor did not discuss risk. Patients with low numeracy reported less discussion. Over 60% reported that their doctor almost never inquired about worry., Conclusions: Effective doctor-patient communication is critical to patient understanding of risk of recurrence. Efforts to enhance physicians' ability to engage in individualized communication around risk are needed.

Background: Although worry about recurrence is a persistent concern among breast cancer survivors, little is known about physicians' confidence about presenting recurrence risk information, identifying women with considerable worry, and helping women manage worry., Methods: Between January and June 2012, we surveyed 750 surgeons and 750 medical oncologists randomly sampled from the American Medical Association Physician Masterfile. We tested differences between surgeons and medical oncologists on confidence of presenting risk, identifying and managing worry using chi-square statistic and Student's t-tests and developed multiple variable logistic regression models to explain odds regarding confidence and use of different strategies for managing worry., Results: The analytic sample included 403 surgeons and 363 medical oncologists (n = 766; response rate = 60%). Compared with surgeons, medical oncologists were significantly more likely to report confidence in: presenting risk information (87.5% vs 73.2%), identifying women who are worried (74.1% vs 63.9%), and managing worry (66.9% vs 52.4%). Confidence in managing worry was associated with more regular inquiry about worry (p = 0.009). Models of the likelihood of using different management strategies varied by provider type (e.g., surgeons more likely than medical oncologists to recommend support group or online resources, oncologists more likely to refer to psychologist or use medications, all p < 0.05)., Conclusion: Cancer providers, particularly surgeons, may benefit from educational training to raise confidence in identifying women with high levels of worry and managing women with considerable worry. Communication between specialties and primary care physicians on efforts to manage worry is necessary for coordinated, quality care for women with breast cancer., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background: Previous research has examined the impact of patient narratives on treatment choices, but to our knowledge, no study has examined the effect of narratives on information search. Further, no research has considered the relative impact of their format (text vs video) on health care decisions in a single study., Objective: Our goal was to examine the impact of video and text-based narratives on information search in a Web-based patient decision aid for early stage breast cancer., Methods: Fifty-six women were asked to imagine that they had been diagnosed with early stage breast cancer and needed to choose between two surgical treatments (lumpectomy with radiation or mastectomy). Participants were randomly assigned to view one of four versions of a Web decision aid. Two versions of the decision aid included videos of interviews with patients and physicians or videos of interviews with physicians only. To distinguish between the effect of narratives and the effect of videos, we created two text versions of the Web decision aid by replacing the patient and physician interviews with text transcripts of the videos. Participants could freely browse the Web decision aid until they developed a treatment preference. We recorded participants' eye movements using the Tobii 1750 eye-tracking system equipped with Tobii Studio software. A priori, we defined 24 areas of interest (AOIs) in the Web decision aid. These AOIs were either separate pages of the Web decision aid or sections within a single page covering different content., Results: We used multilevel modeling to examine the effect of narrative presence, narrative format, and their interaction on information search. There was a significant main effect of condition, P=.02; participants viewing decision aids with patient narratives spent more time searching for information than participants viewing the decision aids without narratives. The main effect of format was not significant, P=.10. However, there was a significant condition by format interaction on fixation duration, P<.001. When comparing the two video decision aids, participants viewing the narrative version spent more time searching for information than participants viewing the control version of the decision aid. In contrast, participants viewing the narrative version of the text decision aid spent less time searching for information than participants viewing the control version of the text decision aid. Further, narratives appear to have a global effect on information search; these effects were not limited to specific sections of the decision aid that contained topics discussed in the patient stories., Conclusions: The observed increase in fixation duration with video patient testimonials is consistent with the idea that the vividness of the video content could cause greater elaboration of the message, thereby encouraging greater information search. Conversely, because reading requires more effortful processing than watching, reading patient narratives may have decreased participant motivation to engage in more reading in the remaining sections of the Web decision aid. These findings suggest that the format of patient stories may be equally as important as their content in determining their effect on decision making. More research is needed to understand why differences in format result in fundamental differences in information search.

Purpose: Population-based studies suggest underuse of radiation therapy, especially after mastectomy. Because radiation oncology is a referral-based specialty, knowledge and attitudes of upstream providers, specifically surgeons, may influence patients' decisions regarding radiation, including whether it is even considered. Therefore, we sought to evaluate surgeons' knowledge of pertinent risk information, their patterns of referral, and the correlates of surgeon knowledge and referral in specific breast cancer scenarios., Methods and Materials: We surveyed a national sample of 750 surgeons, with a 67% response rate. We analyzed responses from those who had seen at least 1 breast cancer patient in the past year (n=403), using logistic regression models to identify correlates of knowledge and appropriate referral., Results: Overall, 87% of respondents were general surgeons, and 64% saw >10 breast cancer patients in the previous year. In a scenario involving a 45-year-old undergoing lumpectomy, only 45% correctly estimated the risk of locoregional recurrence without radiation therapy, but 97% would refer to radiation oncology. In a patient with 2 of 20 nodes involved after mastectomy, 30% would neither refer to radiation oncology nor provide accurate information to make radiation decisions. In a patient with 4 of 20 nodes involved after mastectomy, 9% would not refer to radiation oncology. Fewer than half knew that the Oxford meta-analysis revealed a survival benefit from radiation therapy after lumpectomy (45%) or mastectomy (32%). Only 16% passed a 7-item knowledge test; female and more-experienced surgeons were more likely to pass. Factors significantly associated with appropriate referral to radiation oncology included breast cancer volume, tumor board participation, and knowledge., Conclusions: Many surgeons have inadequate knowledge regarding the role of radiation in breast cancer management, especially after mastectomy. Targeted educational interventions may improve the quality of care., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To examine the effect of patient narratives that discuss decision processes versus patient experiences on decisions about treatments for early stage breast cancer., Methods: We recruited 300 women with no previous history of breast cancer to imagine that they had been diagnosed with early stage breast cancer and to choose between mastectomy and lumpectomy with radiation. Before learning about their treatment options, participants were randomly assigned to one of four conditions with videotaped stories from fictitious cancer survivors, using a 2 (content: experience versus process) × 2 (emotional valence: positive only vs. positive and negative) factorial design, or a control condition with no stories. We measured information search, treatment intentions, and decision satisfaction., Results: Participants viewing process narratives spent more time searching for information. Participants viewing experience narratives reported a greater ability to imagine what it was like to experience the treatments; they also evaluated their decision more positively on several dimensions., Conclusions: Process narratives appeared to guide information search, and experience narratives improved evaluations of the decision process., Practice Implications: There is no evidence that process and experience narratives 'bias' decisions in the same manner as outcome narratives. Further, their potential to focus patient attention on key information and increase patient confidence in decision making appears significant., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To assess the impact of Guide to Decide (GtD), a web-based, personally-tailored decision aid designed to inform women's decisions about prophylactic tamoxifen and raloxifene use., Methods: Postmenopausal women, age 46-74, with BCRAT 5-year risk ≥ 1.66% and no prior history of breast cancer were randomized to one of three study arms:intervention (n=690), Time 1 control (n=160), or 3-month control (n=162). Intervention participants viewed GtD prior to completing a post-test and 3 month follow-up assessment. Controls did not. We assessed the impact of GtD on women's decisional conflict levels and treatment decision behavior at post-test and at 3 months, respectively., Results: Intervention participants had significantly lower decisional conflict levels at post-test (p<0.001) and significantly higher odds of making a decision about whether or not to take prophylactic tamoxifen or raloxifene at 3-month follow-up (p<0.001) compared to control participants., Conclusion: GtD lowered decisional conflict and helped women at high risk of breast cancer decide whether to take prophylactic tamoxifen or raloxifene to reduce their cancer risk., Practice Implications: Web-based, tailored decision aids should be used more routinely to facilitate informed medical decisions, reduce patients' decisional conflict, and empower patients to choose the treatment strategy that best reflects their own values., (Published by Elsevier Ireland Ltd.)

Introduction: Tamoxifen and raloxifene are chemopreventive drugs that can reduce women’s relative risk of primary breast cancer by 50%; however, most women eligible for these drugs have chosen not to take them. The reasons for low uptake may be related to women’s knowledge or attitudes towards the drugs. We aimed to examine the impact of an online breast cancer chemoprevention decision aid (DA) on informed intentions and decisions of women at high risk of breast cancer., Methods: We conducted a randomized clinical trial, assessing the effect of a DA about breast cancer chemoprevention on informed choices about chemoprevention. Women (n = 585), 46- to 74-years old old, completed online baseline, post-test, and three-month follow-up questionnaires. Participants were randomly assigned to either an intervention group, a standard control group that answered questions about chemoprevention at baseline, or a three-month control group that did not answer questions about chemoprevention at baseline. The main outcome measures were whether women’s intentions and decisions regarding chemoprevention drugs were informed, and whether women who viewed the DA were more likely to make informed decisions than women who did not view the DA, using a dichotomous composite variable ‘informed choice’ (yes/no) to classify informed decisions as those reflecting sufficient knowledge and concordance between a woman’s decision and relevant attitudes., Results: Analyses showed that more intervention than standard control participants (52.7% versus 5.9%) made informed decisions at post-test, P <0.001. At the three-month follow-up, differences in rates of informed choice between intervention (16.9%) and both control groups (11.8% and 8.0%) were statistically non-significant, P = 0.067., Conclusions: The DA increased informed decision making about breast cancer chemoprevention, although the impact on knowledge diminished over time. This study was not designed to determine how much knowledge decision makers must retain over time. Examining informed decisions increases understanding of the impact of DAs. A standard for defining and measuring sufficient knowledge for informed decisions is needed., Trial Registration: ClinicalTrials.gov: NCT00967824

Few studies have examined how specific emotions may affect decision-making processes. Anxiety may be especially relevant in health decisions such as those related to cancer in which thoughts of illness or death may be abundant. We examined associations between women's anxiety about developing breast cancer and variables related to their decision to take a medication that could reduce their chances of the disease. Six-hundred and thirty-two American women, who had an increased risk of breast cancer, reviewed a web-based decision aid about tamoxifen. We examined associations between their baseline, self-reported anxiety about developing the disease and post decision aid measures including knowledge about tamoxifen, attitude toward the medication, and behavioral intentions to look for more information and take the medication. Results showed that anxiety was not associated with knowledge about tamoxifen, but it was associated with attitude toward the medication such that women who were more anxious about developing breast cancer were more likely to think the benefits were worth the risks. Greater anxiety was also associated with greater behavioral intentions to look for additional information and take the medication in the next few months. Secondary analyses showed that behavioral intentions were related to knowledge of tamoxifen and attitude toward the medication only for women who were reporting low levels of anxiety. Overall, the findings suggest that anxiety about breast cancer may motivate interest in tamoxifen and not necessarily through affecting knowledge or attitudes., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: Using a cancer-treatment scenario, we tested whether descriptive norm information (e.g., the proportion of other people choosing a particular treatment) would influence people's hypothetical treatment choices., Methods: Women from an Internet sample (Study 1 N=2238; Study 2 N=2154) were asked to imagine deciding whether to take adjuvant chemotherapy following breast cancer surgery. Across participants, we varied the stated proportion of women who chose chemotherapy. This descriptive norm information was presented numerically in Study 1 and non-numerically in Study 2., Results: The descriptive norm information influenced women's decisions, with higher interest in chemotherapy when social norm information suggested that such chemotherapy was popular. Exact statistics about other people's decisions had a greater effect than when norms were described using less precise verbal terms (e.g., "most women")., Conclusion: Providing patients with information about what other people have done can significantly influence treatment choices, but the power of such descriptive norms depends on their precision., Practice Implications: Communication of descriptive norms is only helpful if prevailing decisions in the population represent good clinical practice. Strategic presentation of such statistics, when available, may encourage patient outliers to modify their medical decisions in ways that result in improved outcomes., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Comparative risk perceptions may rival other types of information in terms of effects on health behavior decisions., Purpose: We examined associations between comparative risk perceptions, affect, and behavior while controlling for absolute risk perceptions and actual risk., Methods: Women at an increased risk of breast cancer participated in a program to learn about tamoxifen which can reduce the risk of breast cancer. They reported comparative risk perceptions of breast cancer and completed measures of anxiety, knowledge, and tamoxifen-related behavior intentions. Three months later, the women reported their behavior., Results: Comparative risk perceptions were positively correlated with anxiety, knowledge, intentions, and behavior 3 months later. After controlling for participants' actual risk of breast cancer and absolute risk perceptions, comparative risk perceptions predicted anxiety and knowledge, but not intentions or behavior., Conclusions: Comparative risk perceptions can affect patient outcomes like anxiety and knowledge independently of absolute risk perceptions and actual risk information.

Breast cancer patients must often decide between multiple adjuvant therapy options to prevent cancer recurrence. Standard practice, as implemented in current decision support tools, is to present information about all options simultaneously, but psychology research suggests that sequential decision processes might improve decision making. We tested whether asking women to consider hormonal therapy and chemotherapy separately would improve women's risk knowledge and/or affect treatment intentions. We conducted an Internet-administered experimental survey of a demographically diverse sample of 1,781 women ages 40-74. Participants were randomized to experience a standard, comprehensive decision process versus sequential (one at a time) decisions regarding adjuvant therapy options for a hypothetical breast cancer patient with an estrogen receptor-positive (ER+) tumor. We assessed comprehension of key statistics, perceptions of treatment effectiveness, and perceived interest in adjuvant chemotherapy, as well as participants' numeracy levels. When participants made sequential decisions, they demonstrated greater comprehension of decision-relevant risk statistics, as compared to when they made decisions all at once (all P's < 0.001). Among higher-numeracy participants, those making sequential decisions were less interested in chemotherapy (P < 0.001). Lower-numeracy participants who considered all options simultaneously were insensitive to the degree of risk reduction, but those who made sequential decisions were sensitive (P = 0.03). In conclusion, presenting adjuvant therapy options sequentially improves women's comprehension of incremental treatment benefit and increases less numerate women's sensitivity to the magnitude of the achievable risk reduction over standard, all at once approaches. Sequential approaches to adjuvant therapy decisions may reduce use of chemotherapy among those at low risk for recurrence.

Although tamoxifen can prevent primary breast cancer, few women use it as a preventive measure. A second option, raloxifene, has recently been approved. The objective of the study was to determine women's interest in tamoxifen and raloxifene after reading a decision aid (DA) describing the risks and benefits of each medication. Women with 5-year risk of breast cancer ≥ 1.66 from two large health maintenance organizations were randomized to receive a DA versus usual care. After reading an on-line DA that discussed the risks and benefits of tamoxifen and raloxifene, women completed measures of risk perception, decisional conflict, behavioral intentions, and actual behavior related to tamoxifen and raloxifene. 3 months following the intervention, 8.1% of participants had looked for additional information about breast cancer prevention drugs, and 1.8% had talked to their doctor about tamoxifen and/or raloxifene. The majority, 54.7%, had decided to not take either drug, 0.5% had started raloxifene, and none had started tamoxifen. Participants were not particularly worried about taking tamoxifen or raloxifene and did not perceive significant benefits from taking these drugs. Over 50% did not perceive a change in their risk of getting breast cancer if they took tamoxifen or raloxifene. After reading a DA about tamoxifen and raloxifene, few women were interested in taking either breast cancer prevention drug.

Background: Online tools such as Adjuvant! provide tailored estimates of the possible outcomes of adjuvant therapy options available to breast cancer patients. The graphical format typically displays 4 outcomes simultaneously: survival, mortality due to cancer, other-cause mortality, and incremental survival due to adjuvant treatment., Objective: To test whether simpler formats that present only baseline and incremental survival would improve comprehension of the relevant risk statistics and/or affect treatment intentions., Design: . Randomized experimental manipulation of risk graphics shown included in Internet-administered survey vignettes about adjuvant therapy decisions for breast cancer patients with ER + tumors., Participants: Demographically diverse, stratified random samples of women ages 40 to 74 y recruited from an Internet research panel., Intervention: Participants were randomized to view either pictographs (icon arrays) that displayed all 4 possible outcomes or pictographs that showed only survival outcomes., Measurements: Comprehension of key statistics, task completion times, graph evaluation ratings, and perceived interest in adjuvant chemotherapy., Results: In the primary study (N = 832), participants who viewed survival-only pictographs had better accuracy when reporting the total chance of survival with both chemotherapy and hormonal therapy (63% v. 50%, P < 0.001), higher graph evaluation ratings (x = 7.98 v. 7.67, P = 0.04), and less interest in adding chemotherapy to hormonal therapy (43% v. 50%, P = 0.04; adjusted odds ratio [OR] = 0.68, P = 0.008). A replication study (N = 714) confirmed that participants who viewed survival-only graphs had higher graph evaluation ratings (x = 8.06 v. 7.72, P = 0.04) and reduced interest in chemotherapy (OR=0.67,P=0.03)., Limitations: Studies used general public samples; actual patients may process risk information differently., Conclusions: Taking a ''less is more'' approach by omitting redundant mortality outcome statistics can be an effective method of risk communication and may be preferable when using visual formats such as pictographs.

Background: Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions., Objectives: To evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening., Setting: National sample of US adults identified by random-digit dialing., Design: Cross-sectional survey conducted between November 2006 and May 2007., Participants: English-speaking US adults aged 50 y and older who had discussed cancer screening with a health care provider within the previous 2 y., Measurements: Cancer screening survey modules that asked about demographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer screening decision-making processes., Results: Overall, 1082 participants completed 1 or more of the 3 cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even 1 open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of prostate-specific antigen tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64%-84%), and often recommended screening (73%-90%). However, participants reported that providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. Although more than 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening., Limitations: Recall bias is possible because screening process reports were not independently validated., Conclusions: Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision making occurs for cancer screening decisions.

Objective: Women at high risk of breast cancer face a difficult decision whether to take medications like tamoxifen to prevent a first breast cancer diagnosis. Decision aids (DAs) offer a promising method of helping them make this decision. But concern lingers that DAs might introduce cognitive biases., Methods: We recruited 663 women at high risk of breast cancer and presented them with a DA designed to experimentally test potential methods of identifying and reducing cognitive biases that could influence this decision, by varying specific aspects of the DA across participants in a factorial design., Results: Participants were susceptible to a cognitive bias - an order effect - such that those who learned first about the risks of tamoxifen thought more favorably of the drug than women who learned first about the benefits. This order effect was eliminated among women who received additional information about competing health risks., Conclusion: We discovered that the order of risk/benefit information influenced women's perceptions of tamoxifen. This bias was eliminated by providing contextual information about competing health risks., Practice Implications: We have demonstrated the feasibility of using factorial experimental designs to test whether DAs introduce cognitive biases, and whether specific elements of DAs can reduce such biases., (Published by Elsevier Ireland Ltd.)

Objective: We sought to estimate what proportion of adults plan to stop cancer screening tests among adults who recently considered screening and to explore factors associated with these screening plans., Design: Telephone Survey, Participants: A total of 1,237 participants aged 50 and older who reported having made one or more cancer screening decisions in the past 2 years completed 1,454 cancer screening modules for breast, prostate and colorectal screening., Main Results: Of all module respondents, 9.8% reported plans to stop screening, 12.6% for breast, 6.0 % for prostate and 9.5% for colon cancer. We found no statistically significant differences in plans to stop for those ages >or=70 (8.2%) compared to those ages 50 to 69 (10.2%) (p = 0.14.) Black respondents were less likely to report plans to stop than white respondents (OR = 0.32, 95% CI 0.12, 0.87). Participation in the decision-making process was associated with plans to stop screening; those who reported they made the final decision about screening (OR 5.9, 95% CI 1.4, 24.7) or made the decision with the health care provider (OR 4.1, 95% CI 1.0, 16.8) were more likely to have plans to stop screening compared to respondents who reported that their health care provider made the final decision., Conclusions: Plans to stop screening were uncommon among participants who had recently faced a screening decision. Given the recent US Preventive Services Task Force recommendations limiting routine cancer screening for older adults, additional efforts to educate adults about the potential risks and benefits of screening may be warranted.

Tamoxifen reduces primary breast cancer incidence, yet causes serious side effects. To date, few women with increased breast cancer risk have elected to use tamoxifen for chemoprevention. The objective of the study was to determine women's knowledge of and attitudes toward tamoxifen following exposure to a tailored decision aid (DA). A total of 632 women with a 5-year risk of breast cancer > or = 1.66% (Mean = 2.56, range = 1.7-17.3) were recruited from two healthcare organizations. Participants viewed an online DA that informed them about their 5-year risk of breast cancer and presented individually tailored content depicting the risks/benefits of tamoxifen prophylaxis. Outcome measures included behavioral intentions (to seek additional information about tamoxifen, to talk to a physician about tamoxifen, and to take tamoxifen); knowledge; and perceived risks and benefits of tamoxifen. After viewing the DA, 29% of participants said they intended to seek more information or talk to their doctor about tamoxifen, and only 6% believed they would take tamoxifen. Knowledge was considerable, with 63% of women answering at least 5 of 6 knowledge questions correctly. Participants were concerned about the risks of tamoxifen, and many believed that the benefits of tamoxifen did not outweigh the risks. This study is the largest to date to test women's preferences for taking tamoxifen and one of the largest to have tested the impact of a tailored DA. After viewing the DA, women demonstrated good understanding of tamoxifen's risks and benefits, but most were not interested in taking tamoxifen for breast cancer chemoprevention.

Background: To help oncologists and breast cancer patients make informed decisions about adjuvant therapies, online tools such as Adjuvant! provide tailored estimates of mortality and recurrence risks. However, the graphical format used to display these results (a set of 4 horizontal stacked bars) may be suboptimal. The authors tested whether using simpler formats would improve comprehension of the relevant risk statistics., Methods: A total of 1,619 women, aged 40-74 years, completed an Internet-administered survey vignette about adjuvant therapy decisions for a patient with an estrogen receptor-positive tumor. Participants were randomized to view 1 of 4 risk graphics, a base version that mirrored the Adjuvant! format, an alternate graph that showed only 2 options (those that included hormonal therapy), a graph that used a pictograph format, or a graph that included both changes. Outcome measures included comprehension of key statistics, time required to complete the task, and graph-perception ratings., Results: The simplifying format changes significantly improved comprehension, especially when both changes were implemented together. Compared with participants who viewed the base 4-option bar graph, respondents who, instead, viewed a 2-option pictograph version were more accurate when they reported the incremental risk reduction achievable from adding chemotherapy to hormonal therapy (77% vs 51%; P< .001), answered that question more quickly (median time, 28 seconds vs 42 seconds; P< .001), and liked the graph more (mean, 7.67 vs 6.88; P< .001)., Conclusions: Although most patients will only view risk calculators such as Adjuvant! in consultation with their clinicians, simplifying design graphics could significantly improve patients' comprehension of statistics essential for informed decision making about adjuvant therapies.

Objective: To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers., Methods: We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge., Results: Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels., Conclusions: Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations., Practice Implications: Including graphs in risk communications is essential to support an informed treatment decision-making process.

Objective: To test whether providing comparative risk information changes risk perceptions., Methods: Two hundred and forty-nine female visitors to a hospital cafeteria were randomized to one of two conditions which differed in whether their hypothetical breast cancer risks was lower or higher than the average women's. Participants read a scenario describing a breast cancer prevention pill and indicated their: (1) likelihood of taking the pill and (2) perception of whether the pill provides breast cancer risk reduction., Results: Women told that their hypothetical risk of breast cancer was above average were more likely to endorse taking the pill (2.79 vs. 2.23, F=4.95, p=0.002) and more likely to believe that the pill provided a significant risk reduction in breast cancer (3.15 vs. 2.73, F=4.32, p=0.005), even though the risks were equivalent., Conclusions: Providing people with comparative risk information changes their risk perceptions. People who have above average risk may feel compelled to take a treatment because they are at above average risk and therefore may not thoroughly consider the trade-offs in the risks and benefits of treatment., Practice Implications: Physicians and decision aid developers must reconsider the practice of communicating "average risk" information to patients.

Counseling women about breast cancer risks has been found to decrease screening compliance. We investigated whether women's reactions to risk information are an artifact of requiring women to estimate the risk of breast cancer prior to receiving risk information. Three hundred and fifty-six women were randomized to either make or not make a risk estimate prior to receiving risk information. Outcome measures were participants' estimates of the average woman's breast cancer risk and their emotional response to the risk information. Women overestimated the lifetime risk of breast cancer (M = 46%). Women who made risk estimates felt more relieved about the risk and perceived the risk as being lower than women who did not make estimates (p's < 0.001). Asking people to estimate risks influenced their subsequent perceptions of the risk of breast cancer.