Personalized Risk Estimates Research Articles

Accuracy of Personal Breast Cancer Risk Estimation in Cancer-Free Women During Primary Care Visits

ABSTRACT To determine the accuracy of personal breast cancer risk estimation, interviews were conducted of 110 women between November 2004 and May 2005 during primary care visits. The average age of the women was 39 years. Considering their lifetime breast cancer risk, 49% of women perceived their risk to be low, 35% average, and 11% high. Compared to Gail-model lifetime risk scores, 62% of women were inaccurate and underestimated or overestimated risk. Factors affecting accuracy of risk prediction were race, family history of cancer, alcohol use and exercise. Our study highlights the need for personalized breast cancer education between an individual woman and her health care provider.

Using Hypothetical Data to Assess the Effect of Numerical Format and Context on the Perception of Coronary Heart Disease Risk

To test the hypothesis that responses to coronary heart disease (CHD) risk estimates are heightened by use of ratio formats, peer group risk information, and long time frames. Cross-sectional, experimental, between-factors design. Three regions in England. A total of 740 men and women ages 30 to 70 years. Risk perception, "emotional" response, intention to change lifestyle. Logistic regression was used to investigate the impact of numerical format (ratio vs. percentage), peer group risk (personal vs. peer group), and time frame (10-year vs. 30-year) on risk perception. Analysis of variance was used to investigate the impact of these factors on emotional response and intention to change lifestyle questions. Higher perceived risk was observed when risk was presented as a ratio (p < .001) and when it was supplemented with peer group risk estimates (p = .006). Emotional responses to risk information were heightened when risk was presented as a ratio (p = .0004) and supplemented with peer group risk estimates (p = .002). Presentation with ratios also increased intention to make lifestyle changes (p = .047). Perception of CHD risk information is affected by the presentation format. Where absolute risks may appear low, use of ratios and supplementation of personal risk estimates with peer group risk may increase risk perception.

Risk perception, fuzzy representations and comparative optimism

Rather than a unitary value, individuals may represent health risk as a fuzzy entity that permits them to make a number of specific possible estimates. Comparative optimism might be explained by people flexibly, using such a set to derive optimistic risk estimates. Student participants were asked to rate the likelihood of eight harmful alcohol-related outcomes occurring to themselves and to an average student. Participants made either unitary estimates or estimates representing the upper and lower bounds of a set denoting 'realistic probability' estimates. Personal risk estimates were lower when they were made as unitary estimates than those calculated from the mid-points of the bounded estimates. Unitary estimates of personal risk made after the bounded estimates were lower than initial unitary estimates. There were no effects for estimates made with regard to the average student. Risk may be internally represented as a fuzzy set, and comparative optimism may exist partly because this set allows people the opportunity to make optimistic unitary estimates for personal risk within what they see as realistic parameters.

The inhibitory effect of a distressing anti-smoking message on risk perceptions in smokers

We tested the hypothesis that people strategically reduce their estimates of personal risk when they are confronted with a potentially distressing health message. One hundred and two smokers were exposed to either an anti-smoking message presented using an imagery designed to maximize emotional distress, or the same message presented using less distressing images. We found lower personal risk estimates in the distressing image message condition. A path analysis showed that this effect may be mediated by a tendency to make more negative evaluations of the distressing message. Participants also spent less time attending to the distressing message, but this did not mediate the effects of the experimental manipulation. We suggest that these lowered risk estimates are partly the outcome of defensive processes activated by distress associated with perceptions of personal vulnerability.

Mammographic density and breast cancer risk in germline BRCA1/2 mutation-carriers

9677 Background: Mammographic density (MD) is a known risk factor for breast cancer and demonstrates heritability. Germline BRCA1/2 mutation-carriers are at markedly increased lifetime risk for breast cancer, but providing a personalized risk estimate for breast cancer is problematic. We investigated MD of BRCA1/2 mutation-carriers to determine (1) if it can predict for BRCA1/2 mutation status and (2) if it is an independent risk factor for breast cancer. Methods: Mammograms were collected from a cross section of germline BRCA1/2 mutation-carriers both affected (Pos Aff) and unaffected (Pos Unaff) by breast cancer and from women negative for a known familial BRCA1/2 mutation (Negs). MD was scored using the Wolfe and Boyd six category classification (SCC) systems and a computer-assisted thresholding algorithm. Odds ratios (ORs) for the effect of MD on the presence of a BRCA1/2 mutation or breast cancer risk were estimated using unconditional logistic regression, using the least dense categories as reference categories for each classification system. ORs were compared using the X2 test for trend with increasing density. Results: In the pilot phase, MD was scored for 34 Pos Aff, 21 Pos Unaff, 33 Negs. For both Wolfe and Boyd SCC systems, a statistically significant difference in density between the Pos Aff and Pos Unaff groups was observed (P=0.034 and 0.043 respectively) with a trend to increased density in the Pos Aff group. No difference in density was observed between mutation-carriers and non-carriers. Mammograms from a further 74 Pos Aff, 117 Pos Unaff and 129 Negs have been located, digitised and scored using all the classification systems and the final analysis will be complete by ASCO 2005. Conclusions: In the pilot phase MD is greater in BRCA1/2 mutation-carriers affected by breast cancer and merits further investigation to investigate potential clinical applications for personalising breast cancer risk estimates and selection of appropriate risk management strategies. MD does not appear to be predictive for BRCA1/2 mutation status suggesting that the reported heritability of mammographic density is associated with genes other than BRCA1/2. No significant financial relationships to disclose.

Adolescents' beliefs about the risks involved in smoking "light" cigarettes.

Light cigarettes have been marketed by the tobacco industry as being a healthier smoking choice, a safe alternative to cessation, and a first step toward quitting smoking altogether. Research, however, has failed to show a reduction in smoking-related health risks, an increase in rates of smoking cessation, a decrease in the amount of carbon monoxide or tar released, or a reduction in the rates of cardiovascular disease or lung cancer associated with light cigarette use, compared with regular cigarette use. Nevertheless, more than one-half of adolescent smokers in the United States smoke light cigarettes. This study is the first to investigate adolescents' perception of the risks associated with smoking light cigarettes, as well as adolescents' attitudes and knowledge about the delivery of tar and nicotine, health risks, social effects, addiction potential, and ease of cessation with light cigarettes, compared with regular cigarettes. Participants were 267 adolescents (mean age: 14.0 years) who completed a self-administered questionnaire during class time. After reading scenarios in which they imagined that they smoked regular or light cigarettes, participants estimated the chances that they would personally experience 7 smoking-related health risks and 3 addiction risks. Participants also responded to 14 items concerning their attitudes and knowledge about light cigarettes versus regular cigarettes. Participants thought that they would be significantly less likely to get lung cancer, have a heart attack, die from a smoking-related disease, get a bad cough, have trouble breathing, and get wrinkles when smoking light cigarettes, compared with regular cigarettes, for the rest of their lives. Furthermore, when participants were asked how long it would take to become addicted to the 2 cigarette types, they thought it would take significantly longer to become addicted to light versus regular cigarettes. Adolescents also thought that their chances of being able to quit smoking were higher with light versus regular cigarettes. Similarly, when participants were asked how easy it would be to quit smoking the 2 cigarette types, they thought it would be significantly easier for them to quit smoking light cigarettes than regular cigarettes. Adolescents agreed or strongly agreed that regular cigarettes deliver more tar than light cigarettes and that light cigarettes deliver less nicotine than regular cigarettes. Overall, the results of this study show that adolescents hold misperceptions in both their personal risk estimates and their general attitudes about the health risks, addictive properties, and ease of cessation associated with light cigarettes. With a variety of light and ultralight cigarettes on the market, adolescents are led to think that there is a progression of safety levels to choose from when deciding which cigarettes to smoke. This illusion of control over health outcomes contributes to an underestimation of risks associated with smoking light cigarettes and supports these misperceptions. These results are of concern, given evidence suggesting that, if adolescents think they are less vulnerable to smoking-related health risks (ie, lung cancer), then they are more likely to initiate smoking. Furthermore, there is evidence that adolescents are not fully aware of the addictive nature of cigarettes and therefore think that they can experiment with smoking during adolescence without becoming addicted or experiencing any health consequences. The data presented here support concerns regarding smoking addiction; adolescents might be even more inclined to smoke light cigarettes to delay addiction. Without correct information about light cigarettes, adolescents are unable to make informed decisions about their smoking behaviors. The findings presented here strongly suggest that health care practitioners need to talk to their adolescent clients not only about the overall risks of smoking but also about the specific risks associated with smoking light cigarettes and other tobacco varieties, including the potential for addiction and long-term health consequences. Information shared with adolescents about light cigarettes, both individually by health care practitioners and at the population level via counter-advertising campaigns, may be successful in changing current misperceptions, and ultimately light cigarette smoking patterns, among youth.

Risk perception and concern among brothers of men with prostate carcinoma

It is important for clinicians, researchers, and others who shape public health policy to understand the demographic correlates and psychologic factors that drive health behaviors, such as screening for early detection of cancer, particularly among individuals at high risk for developing the disease. One-hundred eleven men whose brothers were diagnosed with prostate carcinoma completed a computer-assisted telephone interview aimed to assess their perception of absolute risk and concern about developing prostate carcinoma over the next 10 years and across their lifetime. Comparisons were made between selected demographic, behavioral, family pedigree characteristics, and measures of perceived risk and concern. The majority of men perceived their personal risk of developing prostate carcinoma to be > or =50%. Men who at the time of the interview were younger than their affected brother were significantly more concerned about prostate carcinoma and perceived their risk to be higher than men who were older than their brother. Estimates of personal risk and concern were also uniformly higher among men with more than one first-degree relative affected with prostate carcinoma compared to men with only one affected first-degree relative. Risk perception and concern about an impending prostate carcinoma diagnosis were associated with the use of supplements marketed for prostate health. The findings indicated that birth order in relation to a brother diagnosed with prostate carcinoma is significantly associated with risk perception and concern in unaffected family members. These results highlight the need for further study of the familial dynamics and characteristics that drive health behaviors and stress importance of public health education to inform men of personal risk assessment as well as the risks and benefits of screening. These studies ultimately can contribute to the success of strategies for the primary prevention and early detection of cancer.

Women’s Perceptions of Breast Cancer Risk: Are They Accurate?

The objective was to compare women's personal estimates of their risk with objective breast cancer risk estimates and to describe the risk factors for breast cancer identified by women. Telephone survey of a random sample of 761 rural and urban women with no history of breast cancer. Survey instrument included measures of perceptions of lifetime risk for breast cancer for themselves and for the average woman, perceptions of risk factors that influenced their risk and the average woman's risk for breast cancer. Objective estimates of breast cancer risk were calculated using the Gail et al. algorithm. Descriptive statistics and multiple linear regression were used to analyze the data. Women's estimates of their own lifetime risk for breast cancer were significantly higher than their Gail model risk estimates (mean difference = 19%, p < 0.001). The women's personal breast cancer risk estimates were lower than estimates of risk for a hypothetical average woman (mean difference = -8%, p < 0.001). Fifty percent of the sample reported a perceived risk estimate at least 15% above their Gail risk estimate. The risk factors for breast cancer most frequently identified included family history, nutrition/diet, smoking, lifestyle, environment, stress and age. Although the risk factors used to calculate the Gail model risk estimates were reported by some study participants, these women consistently identified only family history as their personal risk factor. Women have difficulty accurately estimating their breast cancer risk and identifying known risk factors for breast cancer. Individual risk information may be more useful in enhancing accurate risk perceptions than the "1 in 9" message.

Attributions in explanations of risk estimates.

In the spring of 1993, nearly 40 percent of Milwaukee-area residents experienced a nationally publicized outbreak of cryptosporidium, a parasite that infested the metropolitan drinking water supply. Using open-ended survey data gathered from 610 adult residents in the wake of that outbreak, this study looks at factors related to the ways in which people make sense of their quantitative personal risk estimates. The concepts of informal reasoning and attribution aided this endeavor. Analysis of open-ended comments about the risk of getting ill from a waterborne parasite indicated that explanations of personal risk were consistent with predictions made by attribution theory. Good outcomes, which included having remained healthy during the outbreak, were associated with a greater likelihood that respondents would attribute causation to themselves, while one specific bad outcome, having experienced the illness, was associated with a greater likelihood that respondents would attribute causation externally. This study also examined predictors of whether respondents employed probabilistic language in those attributions. Analysis indicated that income was positively related to the use of probability-oriented language, while age and race were negatively related to the use of such language (i.e., persons of color and older individuals were less likely to use such language).

Influences on Breast Cancer Screening Behaviors in Tamil Immigrant Women 50 Years Old and Over

Objective To investigate, using the Health Belief Model as a theoretical framework, the incentives and barriers to breast cancer screening in a recent immigrant group, older Tamil women from Sri Lanka. Method Tamil women who had had a mammogram and Tamil women who had never had a mammogram were compared on the following variables: socio-demographics, personal risk estimates for breast cancer, risk-reduction expectancies, beliefs and knowledge about breast cancer and screening recommendations, and acculturation. Results Groups differed significantly in terms of education, years living in North America, acculturation, and beliefs/knowledge about breast cancer. When education and acculturation were controlled, perceived barriers to mammography were most predictive of mammography utilization. Discussion Results are discussed with a view to developing culture-appropriate educational campaigns.

Mainstreaming, resonance, and impersonal impact..

People may use information from a variety of sources in constructing their judgments of crime risk, including direct experience, word-of-mouth, and the mass media. One hundred fifty-eight general population respondents provided 3 estimates of risk of violent crime: societal crime risk, personal crime risk to themselves in their own neighborhood, and personal crime risk to themselves in New York City. Respondents' level of television viewing was related to their estimates of societal crime risk and to their estimates of personal crime risk in New York City (p <.05) but not to their estimates of personal crime risk in their own neighborhood (p <.05). This pattern of results was qualified by a significant interaction (p <.05): all 3 risk estimates were related to respondents' level of television viewing only for those with high direct experience with crime, results that are consistent with Gerbner's concept of resonance (Gerbner et al., 1980). The implications for the concept of impersonal impact (Tyler, 1980) and Gerbner et al. concepts of cultivation and mainstreaming are also discussed.

A family history of breast cancer: women's experiences from a theoretical perspective

Individuals at increased risk of developing breast cancer due to their family history of the disease face a number of uncertainties. Personal cancer risk estimates are imprecise and current methods for early detection or prevention are not 100% effective. It is therefore not surprising that adverse psychosocial outcomes have been described within this population. Research attempting to predict the incidence of distress and dysfunction in individuals at increased risk of cancer has been largely a-theoretical and has overlooked a number of potentially important predictive variables. In particular, the influence of personal experience of cancer through involvement with affected relatives has been neglected. There are strong theoretical grounds for hypothesising that dimensions of personal experience may influence response to cancer risk. This paper discusses the potential impact of personal experience on risk perception, illness representations and decision-making. Systematic research in this area may improve predictions of outcome of cancer genetic counselling and inform the clinical process.

Do Moderators of the Optimistic Bias Affect Personal or Target Risk Estimates? A Review of the Literature

The optimistic bias is defined as judging one's own risk as less than the risk of others. Researchers have identified numerous personal and situational factors that moderate the extent to which people display the bias. It is unclear, however, whether these moderators affect the bias by influencing people's personal risk estimates or their risk estimates for a target. A review of moderators of the optimistic bias reveals evidence for both influences. Moderators associated with negative affect (negative mood, dysphoria, trait and state anxiety, event severity, and proximity of feedback) and control related moderators (perceived control and prior experience) appear primarily to affect personal risk estimates. Positive mood affects target risk estimates. Finally, moderators that surround the comparison process appear to have different effects. Specifically, the type of comparison target appears to affect target risk estimates, whereas attention to personal risk-related behaviors affects personal risk estimates.

Self-esteem, self-serving cognitions, and health risk behavior.

The current article reviews prospective and experimental research on the relation between self-esteem and perceptions of vulnerability. These studies demonstrate that individuals with high self-esteem who engage in risk behavior often utilize a variety of self-serving cognitive strategies that protect them from fully acknowledging their vulnerability to the potential negative consequences of their behavior; e.g., they minimize their estimates of personal risk and overestimate the prevalence of the risk behavior among their peers. The article also provides data on an additional self-serving cognitive strategy employed by adolescents with high self-esteem--alteration of perceptions of others' reactions to their own risk behavior. Finally, the article reviews the emerging literature on the relation between these cognitive strategies and maladaptive health behavior, and proposes that whether these strategies are maladaptive depends on the nature of the threat and the availability of opportunities to engage in compensatory self-enhancement.

Genetic counseling for women with an intermediate family history of breast cancer.

Women with a family history of breast cancer often over-estimate their personal risk for cancer and may view themselves as candidates for genetic testing even when the likelihood of an informative test result is low. We report here on genetic counseling of women with an intermediate family history of breast cancer, defined as women who have one or more biological relatives with breast cancer but whose pedigree suggests a low likelihood of autosomal dominant transmission. A genetic counseling protocol based on traditional genetic counseling strategies was developed with additional components added to address the needs of women with moderately increased breast cancer risk. These additional components included information about non-genetic risk factors, comparisons of high and moderate risk pedigrees, and evaluation of personal risk based on both genetic and nongenetic risk factors. Most participants liked the genetic counseling and found it useful. At baseline, participants over-estimated both their personal risk of breast cancer and that of the average woman. After counseling, estimates of personal and average risk of breast cancer were lower, although both remained higher than actual risk. Most participants reported that they felt less worried about breast cancer after receiving their personal-risk estimate. At baseline, most women judged themselves to be candidates for genetic testing and expressed interest in testing. The number who considered themselves candidates for testing was reduced after counseling (60% versus 82%) but still constituted a majority. Similarly, interest in testing was partially reduced by counseling (60% versus 91%). We conclude that genetic counseling can help women with an intermediate family history of breast cancer to develop more accurate views of their risk, reduce their breast cancer worry, and aid some of them in developing a more realistic view of genetic testing.

Psychosocial Implications of Prophylactic Bilateral Mastectomy

Introduction: The removal of healthy breast tissue to prevent the development of breast cancer is seen by many to be a radical surgical intervention. As the numbers of women contemplating such surgery are increasing it is essential that the psychological costs and benefits of prophylactic bilateral mastectomy are established. Aims: This prospective study aims to measure psychological morbidity, to describe the decision-making process and to determine communication and counselling needs in women who both opt for and decline prophylactic bilateral mastectomy. It also aims to identify preoperative factors that may predict post-operative distress in women who opt for this surgery. Method: The objective is to recruit 152 women who have a strong family history of breast cancer. This total will comprise two groups of 76, one group opting for surgery the other declining. To date the study has recruited 78 women who have opted for surgery and 63 who have declined. Women are interviewed before surgery, then at 6 and 18 months postoperatively. Those declining surgery are interviewed after first contact, then 18 months later. All women are given standard psychological questionnaires to complete at each interview. Results: Interim analysis shows that women opting for surgery have a more accurate perception of the general population risk, but when it comes to personal risk estimates, a much higher percentage of the surgical group felt it was inevitable that they would develop the disease. Analysis of the General Health Questionnaire, a screening tool for psychiatric distress, has shown that women opting for surgery are also more distressed than those opting for regular surveillance. Discussion: A strong factor that appears to be associated with those opting for surgery, and which also appears to influence decision making, is personal family history and experience of breast cancer within the family. Other issues that are emerging from the interviews include: the feelings of isolation being experienced by those women opting for this intervention; a lack of information about prophylactic mastectomy and reconstruction issues for those who have never had breast cancer; the inability to get funding for the operation in some areas of the UK and postoperative complications. Abstract

Absolute and Relative Biases in Estimations of Personal Risk1

Two studies examined the accuracy of personal risk estimates, as determined by comparing mean estimates made by college students with population statistics for college‐educated individuals. Study 1 suggested that optimistic biases (the tendency for people to think they are less at risk than the average person) arise more because people overestimating the average person's risk than because they underestimate their own risk. In Study 2, subjects rated their risk after being presented with risk statistics that were 150%, 100%, or 50% of the true values. Subjects' estimates decreased with decreases in the comparison statistics, as if subjects attempted to preserve their “below‐average” status, but they changed less than did the statistics and were actually pessimistic in comparison to the 50% values. Implications for interventions designed to influence risk perceptions are discussed.

Adolescents' perceived risk and personal experience with natural disasters: An evaluation of cognitive heuristics

Elevated risk judgments for negative life events have been linked to personal experience with events. We tested the hypothesis that cognitive heuristics are the underlying cognitive mechanism for this relation. The availability (i.e., memory for incidents) and simulation (i.e., imagery) heuristics were evaluated as possible mediators for the relation between personal experience and risk estimates for fatal weather events. Adolescents who had experienced weather disasters estimated their personal risk for weather events. Support was obtained for the simulation heuristic (imagery) as a mediator for the relation. Availability for lightning disaster experience was also found to be a mediator for the relation between personal lightning disaster experience and risk estimate for future events. The implications for risk perception research are discussed.

Acquired Immunodeficiency Syndrome/Human Immunodeficiency Virus Risk Behavior Among Gay Men in Small Cities

Most research on acquired immunodeficiency syndrome has been conducted in several of the country's largest cities, and little is known about the current level of human immunodeficiency virus risk taking among gay men in other geographical areas. The purpose of this study was to determine the frequency of risk behavior practices among gay men in smaller communities. A large sample of men who patronized gay bars in 16 small and moderate-size cities drawn from six states in four different regions of the country was surveyed to determine the frequency of high-risk behavior and factors influencing risk taking. Eighty-five percent of men in all cities' bars completed all survey measures. The community samples were 1991 men; mean age, 31.3 years; mean education, 10.6 years; 90% were white and 10% were of other ethnicities. All participants provided detailed information on their sexual behavior practices over the preceding 2 months and completed measures assessing their perceived peer norms concerning safer sex practices and risk avoidance, intentions to avoid risk, personal risk estimation, acquired immunodeficiency syndrome risk knowledge, perceived threat of acquired immunodeficiency syndrome/human immunodeficiency virus, and serostatus testing history. High-risk patterns were still common among gay men in these smaller cities; nearly one third of all men had engaged in unprotected anal intercourse an average of eight times in the past 2 months, usually outside monogamous relationships. High-risk behavior was most strongly associated with beliefs that safer sex practices would not be well accepted by peers, weak intentions to use condoms, underestimation of personal vulnerability to the acquired immunodeficiency syndrome, younger age, and higher levels of overall sexual activity. Nine percent of men tested said they were seropositive. Growing human immunodeficiency virus prevalence and continued high rates of risk behavior indicate that a new "front line" for human immunodeficiency virus prevention among homosexually active men has shifted to the country's smaller cities. Community prevention efforts in these areas are urgently needed to avert sharp increases in future human immunodeficiency virus infections in this population.

Changes in Acquired Immunodeficiency Syndrome-Related Risk Behavior After Adolescence: Relationships to Knowledge and Experience Concerning Human Immunodeficiency Virus Infection

This paper explores the extent of change in acquired immunodeficiency syndrome (AIDS) risk level and in the numbers of AIDS-related risk behaviors in 602 inner-city adolescents as they enter young adulthood. Youths' risk level for human immunodeficiency virus (HIV) infection during adolescence was categorized as high (engaging in prostitution, male homosexual or bisexual activity, or injectable drug use or having ulcerative sexually transmitted diseases), moderate (having six or more sex partners in a 1-year period or nonulcerative sexually transmitted diseases), or low (none of the above). Although a proportion at high or moderate risk during adolescence did move to lower risk levels by young adulthood, the overall risk level stayed fairly stable: 45% were at high or moderate risk levels during adolescence, and 35% were at those levels by young adulthood. Then change in the total number of risk behaviors engaged in by the youths was examined. Knowledge about AIDS or HIV infection and its prevention was not associated with any change in risk behavior, nor were the number of sources of information about the epidemic, acquaintance with those who are infected, estimates of personal risk, or exposure to HIV-test counseling. In fact, youths whose risk behaviors increased the most were more likely to know someone who had died of AIDS and to estimate their own risk as high. Most youths reported that they did not use condoms regularly, disliked them, and had little confidence in their protective ability. Changes in preventive strategies and further research on the causes of behavior change are needed.