Screening Decisions Research Articles

Shared medical decision in prostate cancer screening in primary care: a systematic literature review of current evidence.

Prostate cancer screening has not significantly reduced mortality. International guidelines strongly endorse shared decision-making to navigate risks, emphasizing its crucial role prior to prescribing a prostate-specific antigen test. This study aims to provide insight into the current role of shared decision-making in primary care for prostate cancer screening and suggest ways to improve the process. PubMed, Cochrane, and Lissa databases were searched for following terms: 'prostate-specific antigen' or 'prostate cancer screening' combined with 'shared decision making', 'informed decision making' or 'decision support' and 'primary care'. All studies were screened by two independent reviewers. This systematic review followed the PRISMA guidelines. Of 85 articles screened, 34 were included. Key findings included heterogenous and poor quality implementation of shared decision-making in practice, patients with limited knowledge of shared decision-making, clinicians infrequently discussing patients' views, decision aids that could be better integrated into practice, and finally, changes in care systems to support the expansion of shared decision-making in prostate cancer screening. Decision aids are essential tools in the informed decision-making process. Integrating these elements into practice would require training for doctors and adjustments to the healthcare system.

Employing a Risk Assessment Tool for Shared Decision-Making in Breast Cancer Screening.

Background: The existing guidelines for breast cancer screening incorporate assessing individual risk but contain no universally recommended risk assessment tool in the primary care setting. Local Problem: A family planning program utilizing nurses and nurse practitioners for assessment, education, and referral lacked a risk assessment tool for assessing breast cancer risk. Methods: A breast cancer risk assessment tool was implemented in practice. Interventions: The interventions involved assessing the patient's risks, providing education on risk reduction strategies, and determining the need for clinical breast exams and referrals for mammography. Results: The study demonstrated a clear correlation between the number of breast cancer risks identified and the extent of education provided to patients based on their specific risk profiles (0 vs. 1.5 risks; 2 vs. 4.6 educational components). Among patients under age 35, 80% opted for a clinical breast exam, while 100% of patients age 40 and above agreed to both clinical breast exams and referrals for mammography after discussing individual risks. Conclusions: The use of a breast cancer risk assessment tool provided an evidence-based foundation for the shared decision-making conversation between patient and nurse/provider on risk reduction. The discussion included current evidence on the risk versus benefit of age-based screening options for breast cancer, allowing for an informed decision made jointly between the patient and provider.

Decision-making in breast cancer screening: A qualitative exploration of the match between women’s beliefs and screening information in the Netherlands

ObjectiveDecision-making about breast cancer screening requires balanced and understandable information that takes prior beliefs of screening invitees into account. MethodsIn qualitative interviews with 22 Dutch women who were invited for screening for the first time (49–52 years of age, varying health literacy levels), we gained insight in their beliefs on breast cancer and breast cancer screening, and explored how the current screening information matched these beliefs. ResultsBreast cancer was perceived as an unpredictable, severe, and uncontrollable disease. Women considered screening as self-evident and an important mean to gain some control over breast cancer. Information on benefits of screening was in line with women’s prior beliefs and confirmed women’s main reasons to participate. Information about false-positive outcomes, overtreatment, and false negative outcomes did not correspond to women’s prior beliefs and this information was generally not considered relevant for decision-making. Preferences for additional information merely concerned practical information on the screening procedure. ConclusionComplex information on the harms of screening does not match women’s beliefs and is not taken into account in their decision-making. Practice ImplicationsInformation regarding breast cancer screening could be further aligned to prior beliefs by taking into account values, filling knowledge gaps and correct misconceptions.

Uses and Misuses of Commercial Reading Assessment: An Applied Framework for Decision Making in Grades K through 6

AbstractThe purpose of this article was to offer guidance to educators in evaluating the strengths, weaknesses, and most effective uses of commercial reading assessment suites. We provide three resources to help educators who are responsible for making instructional decisions in reading using formal screening, benchmark, interim, and progress‐monitoring assessment suites. First, we recommend a framework for how one can judiciously select and use reading assessment. Then we identify a few common misuses of reading assessment scores and ways to reframe them into more effective uses. Finally, we detail the specific strengths and limitations of six commercial assessment suites commonly used in elementary schools for screening and other specific instructional decisions. The framework we describe could also generalize to other subject matter, grade levels, and types of assessment scores.

Variability in Occult Injury Screening Among Siblings/Household Contacts of Physical Abuse Victims.

The objective of this study is to examine radiologic occult injury screening performance/yield among contacts presenting for precautionary medical assessments and assess factors associated with deferred screening. Data were collected retrospectively from charts of contacts younger than 8 years presenting for precautionary evaluation to a level 1 pediatric emergency department January 1, 2018 to March 31, 2023. Demographics, radiologic performance/yield, physical examination, social work-based psychosocial assessment, reasons for deferred imaging, and diagnostic codes were abstracted. Descriptive statistics and χ 2 analysis are reported. Three hundred ninety contacts were identified; 364 (93.3%) were biological siblings. Most (276, 70.8%) were 2 to 8 years old. Statistically significant relationships were identified with age, insurance, and hospital social work assessment and screening. Thirty-four infants (54%) underwent neuroimaging; no studies were abnormal. Of 114 contacts, <2 years old, 97 (85%) underwent skeletal survey (SS); 9 (9%) SS were abnormal. Twenty-seven (24%) returned for follow-up SS; 4 (14.8%) were abnormal. For 2 contacts, an abnormal initial SS was refuted by follow-up imaging. Physical examinations were abnormal for 11% of contacts. Reasons for deferred imaging included contact well appearance, caregiver concerns, and clinician disagreement with indications. Encounter International Classification of Diseases codes varied, commonly reflecting nonspecific screening assessments. Despite national clinical practice guidelines, studies of abusive injury prevalence and radiologic yield among at-risk contacts exposed to unsafe environments are few. Screening evaluations inclusive of physical examination and radiologic studies identify abuse concerns among at-risk contacts. Further study of factors impacting radiologic screening decisions is needed. Considerations to advance epidemiologic research include standardized diagnostic coding and prospective assessment of radiologic yield.

Unpacking the relationship between shared decision-making and decisional quality, decision to screen, and screening completion in lung cancer screening

ObjectivesLung cancer screening is a complex and individualized decision. To understand how best to support patients in this decision, we must understand how shared decision-making is associated with both decisional and behavioral outcomes. MethodsObservational cohort study combining patient survey data with electronic health record data of lung screening-eligible patients who recently engaged in a shared decision-making discussion about screening with a primary care clinician. ResultsUsing multivariable analysis (n = 529), factors associated with higher lung cancer screening decisional quality include higher knowledge (OR = 1.33, p < .0001), lower perceived benefits (OR = 0.90, p = .0004), higher perceived barriers (OR = 1.07, p < .0001), higher self-efficacy (OR = 1.13, p < .0001), and higher levels of perceiving the discussion was shared (OR = 1.04, p < .0001). Factors associated with the patient’s decision to screen include older age (OR = 1.12, p = .0050) and higher self-efficacy (OR = 1.11, p = .0407). Factors associated with screening completion included older age (OR = 1.05, p = .0050), higher knowledge (OR = 1.24, p = .0045), and higher self-efficacy (OR = 1.12, p = .0003). ConclusionsShared decision-making in lung cancer screening is a dyadic process between patient and clinician. As we continue to strive for high-quality patient-centered care, patient decision quality may be enhanced by targeting key factors such as high-quality knowledge, self-efficacy, and fostering a shared discussion to support patient engagement in lung cancer screening decisions.

Shared decision-making before prostate cancer screening decisions.

Decisions around prostate-specific antigen screening require a patient-centred approach, considering the benefits and risks of potential harm. Using shared decision-making (SDM) can improve men's knowledge and reduce decisional conflict. SDM is supported by evidence, but can be difficult to implement in clinical settings. An inclusive definition of SDM was used in order to determine the prevalence of SDM in prostate cancer screening decisions. Despite consensus among guidelines endorsing SDM practice, the prevalence of SDM occurring before the decision to undergo or forgo prostate-specific antigen testing varied between 11% and 98%, and was higher in studies in which SDM was self-reported by physicians than inpatient-reported recollections and observed practices. The influence of trust and continuity in physician-patient relationships were identified as facilitators of SDM, whereas common barriers included limited appointment times and poor health literacy. Decision aids, which can help physicians to convey health information within a limited time frame and give patients increased autonomy over decisions, are underused and were not shown to clearly influence whether SDM occurs. Future studies should focus on methods to facilitate the use of SDM in clinical settings.

An automatic glaucoma grading method based on attention mechanism and EfficientNet-B3 network.

Glaucoma infection is rapidly spreading globally and the number of glaucoma patients is expected to exceed 110 million by 2040. Early identification and detection of glaucoma is particularly important as it can easily lead to irreversible vision damage or even blindness if not treated with intervention in the early stages. Deep learning has attracted much attention in the field of computer vision and has been widely studied especially in the recognition and diagnosis of ophthalmic diseases. It is challenging to efficiently extract effective features for accurate grading of glaucoma in a limited dataset. Currently, in glaucoma recognition algorithms, 2D fundus images are mainly used to automatically identify the disease or not, but do not distinguish between early or late stages; however, in clinical practice, the treatment of early and late glaucoma is not the same, so it is more important to proceed to achieve accurate grading of glaucoma. This study uses a private dataset containing modal data, 2D fundus images, and 3D-OCT scanner images, to extract the effective features therein to achieve an accurate triple classification (normal, early, and moderately advanced) for optimal performance on various measures. In view of this, this paper proposes an automatic glaucoma classification method based on the attention mechanism and EfficientNetB3 network. The EfficientNetB3 network and ResNet34 network are built to extract and fuse 2D fundus images and 3D-OCT scanner images, respectively, to achieve accurate classification. The proposed auto-classification method minimizes feature redundancy while improving classification accuracy, and incorporates an attention mechanism in the two-branch model, which enables the convolutional neural network to focus its attention on the main features of the eye and discard the meaningless black background region in the image to improve the performance of the model. The auto-classification method combined with the cross-entropy function achieves the highest accuracy up to 97.83%. Since the proposed automatic grading method is effective and ensures reliable decision-making for glaucoma screening, it can be used as a second opinion tool by doctors, which can greatly reduce missed diagnosis and misdiagnosis by doctors, and buy more time for patient's treatment.

Streamlined Genetic Education and Cascade Testing in Men from Hereditary Breast Ovarian Cancer Families: A Randomized Trial.

When a pathogenic BRCA1 or BRCA2 mutation is identified in a family, cascade genetic testing of family members is recommended since the results may inform screening or treatment decisions in men and women. However, rates of cascade testing are low, and men are considerably less likely than women to pursue cascade testing. To facilitate cascade testing in men, we designed a Web-based genetic education tool that addressed barriers to cascade testing, was individually tailored, delivered proactively, and could be used in lieu of pretest genetic counseling to streamline the cascade testing process. We randomized 63 untested men from hereditary cancer families to Web-based genetic education (WGE) versus enhanced usual care (EUC). WGE participants were provided access to a genetic education website after which they could accept or decline genetic testing or opt for pretest genetic counseling. EUC participants received an informational brochure and a letter informing them of their eligibility for genetic testing and recommending they schedule genetic counseling. The primary outcome was the uptake of genetic testing. Men in the WGE group were more likely to complete genetic counseling and/or genetic testing (43% vs. 12.1%; χ2 [n = 63, df = 1] = 7.77, p = 0.005). WGE participants were also more likely to complete genetic testing compared to men in the EUC group (30% vs. 9.1%; χ2 [n = 63, df = 1] = 4.46, p = 0.03). This preliminary trial suggests that a streamlined approach to genetic testing using proactively delivered genetic education may reduce barriers to cascade testing for at-risk men, leading to increased uptake. These results should be interpreted cautiously given the select sample and high rate of non-response.

Colorectal cancer in 45-49-year-olds: systematic or targeted screening?

Principles to guide and inform population-based screening decisions cover a wide range of aspects beyond the screening test. Colorectal cancer (CRC) meets these requirements for individuals at moderate risk aged 50 to 69. In Switzerland, screening using a biennial faecal occult blood test or colonoscopy every 10 years is reimbursed free of deductible in 12 programs covering 15 cantons. This article assesses the appropriateness of systematic screening from age 45 in the Swiss context. Prioritizing measures to raise awareness among healthcare professionals and high-risk subjects rather than lowering the age of eligibility would not only be more sensible but would also benefit to the population over 50 years old.

Finding the PSA-based screening stopping age using prostate cancer risk

BackgroundProstate Cancer screening was not rational for people who were suffered from other serious diseases and had a low quality of life. Biopsy and Prostate-Specific Antigen based screening also had imperfect information, pain, and costs. Finding the Prostate Cancer screening stopping age was important because after an age, Prostate-Specific Antigen test was not recommended and patients should not perform subsequent procedures. It could reduce the economic burden of Prostate Cancer. In this study, we modeled the effects of Prostate Cancer risk and comorbidities on the Prostate Cancer screening stopping age. Methodsfirst, using a Markov model for PC progression, we provided a model for optimal Prostate Cancer screening stopping age. Second, we explored the relationship between comorbidities effects, Prostate Cancer risk and the stopping age. ResultsOur results suggest that the stopping age was an increasing function of PC risk and comorbidities effects. Screening should be stopped before 70 years. Finding showed that for men with diseases such as stroke or heart diseases, screening should not be performed at any age. ConclusionsPersonalizing PC screening through paying more attention to PC risk can improve efficiency of screening. The role of personal characteristics such as race, family history, and previous PSA in PC screening decision-making was highlighted by stratifying men in different PC risk groups to find their stopping age. Incorporating comorbidity effects shows that severity of comorbidity was a crucial factor in PC screening stopping age decision-making process.

Patient message preferences to promote clinical conversations about chronic obstructive pulmonary disease (COPD): A discrete choice experiment.

The purpose of this study was to identify message features that motivate patients to initiate clinical conversations about Chronic Obstructive Pulmonary Disease (COPD). A secondary aim was to determine whether preferred message features vary by socio-demographic and behavioral characteristics. A discrete choice experiment was conducted in August 2020. Participants were asked to select which messages would motivate them to speak with a clinician about COPD. This included selecting messages across 8 choice sets, or a systematic combination of messages reflecting 6 attributes (e.g., susceptibility, call-to-action, emotion-frame, efficacy, message source, organizational support). The final sample was 928, which included adults (M=62.07; SD=10.14years old) who identified as non-Hispanic, white, and with at least some college experience. Message attributes ranked from most to least important were COPD susceptibility (25.53% [95% CI=24.39, 26.66]), message source (19.32% [95% CI=18.41-20.24]), COPD organization logo (19.13%; [95% CI=18.26, 20.01]), call-to-action (14.12%; [95% CI=13.40, 14.85], emotion-frame (13.24% [95% CI=12.55-13.94]), and efficacy (8.65%; [95% CI=8.20-9.09]). Participants preferred susceptibility messages about COPD signs/symptoms rather than risk behaviors related to smoking tobacco and environmental exposures. They also preferred messages from medical authorities (i.e., clinicians, COPD organization), a call-to-action that supports their autonomy in screening decision-making, and a message that conveys hope for living a healthy life with COPD and builds their self-efficacy to get screened. Differences in message preferences were detected according to age, gender, race, ethnicity, education level, and current vs. former smoking status. This study identified message features that motivate clinical conversations about COPD, especially those from subgroups who are disproportionately at-risk for its late-stage diagnosis.

Advances in Breast Cancer Risk Modeling: Integrating Clinics, Imaging, Pathology and Artificial Intelligence for Personalized Risk Assessment

Breast cancer risk models represent the likelihood of developing breast cancer based on risk factors. They enable personalized interventions to improve screening programs. Radiologists identify mammographic density as a significant risk factor and test new imaging techniques. Pathologists provide data for risk assessment. Clinicians conduct individual risk assessments and adopt prevention strategies for high-risk subjects. Tumor genetic testing guides personalized screening and treatment decisions. Artificial intelligence in mammography integrates imaging, clinical, genetic and pathological data to develop risk models. Emerging imaging technologies, genetic testing and molecular profiling improve risk model accuracy. The complexity of the disease, limited data availability and model inputs are discussed. A multidisciplinary approach is essential for earlier detection and improved outcomes.

Cognitive Screening Beliefs and Behaviors Among Older US Adults: Results from the National Poll on Healthy Aging

AbstractBackgroundFewer than half of people with dementia have been formally diagnosed by a clinician. Consequently, the US National Plan to Address Alzheimer’s Disease (AD) has prioritized early disease detection. A critical first step to early detection is primary care‐based screening for cognitive decline. Greater understanding of public perceptions and use of cognitive screening is needed to optimize early detection of AD among older adults.MethodWe analyzed data from the March 2023 fielding of the University of Michigan National Poll on Healthy Aging, a nationally representative web and telephone survey of community‐dwelling US adults aged 50‐80 using the NORC AmeriSpeak panel. Respondents for this analysis were aged 65‐80 without AD or dementia. Our primary outcome was self‐reported history of cognitive screening (never versus ever had screening). Logistic regression was used to estimate associations between respondent characteristics (i.e., sociodemographic factors, health factors, beliefs about cognitive screening) and self‐report of cognitive screening, and to examine whether primary care provider status moderates the association between screening beliefs and self‐report of screening.ResultOf 1,242 respondents, 42% reported having ever undergone cognitive screening (21% within the past year). In adjusted analyses, sociodemographic factors (i.e., older age, higher level of education), insurance status (Medicare Advantage vs. traditional Medicare) and poorer physical health were associated with greater likelihood of cognitive screening (all p&lt;0.05). Respondents with positive versus negative beliefs about cognitive screening were 45% more likely to report screening (adjusted risk ratio: 1.45, p&lt;0.001). The probability of cognitive screening did not vary overall by provider status; however, among respondents with negative beliefs about screening, having a provider was associated with greater probability of having undergone screening (35% versus 11%, p&lt;0.05).ConclusionWe identified a range of factors associated with older adults’ self‐report of cognitive screening including age, health, and beliefs about the pros and cons of screening. Primary care providers may play an important role in cognitive screening decisions, particularly among patients with negative beliefs about screening. Providers can play an active role in initiating conversations about cognition with older adult patients on the advantages and disadvantages of screening to help patients make informed decisions.

Proactively tailoring implementation: the case of shared decision-making for lung cancer screening across the VA New England Healthcare Network

BackgroundShared Decision-Making to discuss how the benefits and harms of lung cancer screening align with patient values is required by the US Centers for Medicare and Medicaid and recommended by multiple organizations. Barriers at organizational, clinician, clinical encounter, and patient levels prevent SDM from meeting quality standards in routine practice. We developed an implementation plan, using the socio-ecological model, for Shared Decision-Making for lung cancer screening for the Department of Veterans Affairs (VA) New England Healthcare System. Because understanding the local context is critical to implementation success, we sought to proactively tailor our original implementation plan, to address barriers to achieving guideline-concordant lung cancer screening.MethodsWe conducted a formative evaluation using an ethnographic approach to proactively identify barriers to Shared Decision-Making and tailor our implementation plan. Data consisted of qualitative interviews with leadership and clinicians from seven VA New England medical centers, regional meeting notes, and Shared Decision-Making scripts and documents used by providers. Tailoring was guided by the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS).ResultsWe tailored the original implementation plan to address barriers we identified at the organizational, clinician, clinical encounter, and patient levels. Overall, we removed two implementation strategies, added five strategies, and modified the content of two strategies. For example, at the clinician level, we learned that past personal and clinical experiences predisposed clinicians to focus on the benefits of lung cancer screening. To address this barrier, we modified the content of our original implementation strategy Make Training Dynamic to prompt providers to self-reflect about their screening beliefs and values, encouraging them to discuss both the benefits and potential harms of lung cancer screening.ConclusionsFormative evaluations can be used to proactively tailor implementation strategies to fit local contexts. We tailored our implementation plan to address unique barriers we identified, with the goal of improving implementation success. The FRAME-IS aided our team in thoughtfully addressing and modifying our original implementation plan. Others seeking to maximize the effectiveness of complex interventions may consider using a similar approach.

Abstract 16332: Atrial Fibrillation Monitoring in Patients on Ibrutinib

Introduction: Ibrutinib increases risk of atrial and ventricular arrythmias, especially atrial fibrillation (AF). No guidelines exist for arrhythmia monitoring, but experts suggest 24h Holter assessments for patients at risk of new or recurring AF or with CHA2DS2-VASc score ≥2. We sought to describe current practices in cardiac event monitoring in high risk or symptomatic patients on ibrutinib. Methods: We performed a single-center retrospective analysis of 168 ibrutinib-treated patients with no prior AF or atrial flutter (AFL). Patients were followed from 2013 to 2022. Event monitor data was obtained by a single reviewer through chart review. Results: Among 168 patients followed over a median of 6.4 years, 44 developed AF/AFL (25%) with 31 (70%) with paroxysmal AF. Mean (SD) age at ibrutinib initiation was 66 (11.1) years. Fewer than half (n=50; 30%) were female. Event monitoring was performed for 31 (18.4%) patients, 18 (58%) during treatment and 13 (42%) after treatment completion ( Table 1 ). The most common monitoring reasons were palpitations (10, 32%) and assessing AF burden (9, 29%). Cardiologists outside electrophysiology and cardio-oncology ordered the most monitors (17, 55%). Monitors most captured unspecified SVT (11, 36%) or no significant findings (9, 29%). Monitors most likely resulted in no management changes (19, 61%). The most common management changes were: placement of DC-PM (3, 10%), discontinuing anticoagulation (AC) (3, 10%) and diagnosis of AF (3, 10%). Of note, 14 monitors were done after AF diagnosis of which 7 (50%) showed no AF. Conclusions: Even with increased risk of arrythmias, use of monitors was low across a cohort of 168 patients. Notably, 3 monitors were used to discontinue AC and 3 monitors found new AF. Recent studies show most AF/AFL in ibrutinib users occurs within the first 6 months of initiation which may inform decisions in screening. Further guidance and standardization are needed for the use of monitors in the ibrutinib population.

Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults

Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. ClinicalTrials.gov Identifier: NCT02027545.

Assessing and Understanding Reactance, Self-Exemption, Disbelief, Source Derogation and Information Conflict in Reaction to Overdiagnosis in Mammography Screening: Scale Development and Preliminary Validation.

Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet some people may react to overdiagnosis with doubt and skepticism. The present research assessed 4 related reactions to overdiagnosis: reactance, self-exemption, disbelief, and source derogation (REDS). The degree to which the concept of overdiagnosis conflicts with participants' prior beliefs and health messages (information conflict) was also assessed as a potential antecedent of REDS. We developed a scale to assess these reactions, evaluated how those reactions are related, and identified their potential implications for screening decision making. Female participants aged 39 to 49 years read information about overdiagnosis in mammography screening and completed survey questions assessing their reactions to that information. We used a multidimensional theoretical framework to assess dimensionality and overall domain-specific internal consistency of the REDS and Information Conflict questions. Exploratory and confirmatory factor analyses were performed using data randomly split into a training set and test set. Correlations between REDS, screening intentions, and other outcomes were evaluated. Five-hundred twenty-five participants completed an online survey. Exploratory and confirmatory factor analyses identified that Reactance, Self Exemption, Disbelief, Source Derogation, and Information Conflict represent unique constructs. A reduced 20-item scale was created by selecting 4 items per construct, which showed good model fit. Reactance, Disbelief, and Source Derogation were associated with lower intent to use information about overdiagnosis in decision making and the belief that informing people about overdiagnosis is unimportant. REDS and Information Conflict are distinct but correlated constructs that are common reactions to overdiagnosis. Some of these reactions may have negative implications for making informed screening decisions. Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet when provided information about overdiagnosis, some people are skeptical.This research developed a measure that assessed different ways in which people might express skepticism about overdiagnosis (reactance, self-exemption, disbelief, source derogation) and also the perception that overdiagnosis conflicts with prior knowledge and health messages (information conflict).These different reactions are distinct but correlated and are common reactions when people learn about overdiagnosis.Reactance, disbelief, and source derogation are associated with lower intent to use information about overdiagnosis in decision making as well as the belief that informing people about overdiagnosis is unimportant.

Colorectal Cancer Screening Decision Based on Predicted Risk: Protocol for a Pilot Randomized Controlled Trial.

Incidence of and mortality from colorectal cancer (CRC) can be effectively reduced by screening with the fecal immunochemical test (FIT) or colonoscopy. Individual risk to develop CRC within 15 years varies from <1% to >15% among people aged 50 to 75 years. Communicating personalized CRC risk and appropriate screening recommendations could improve the risk-benefit balance of screening test allocations and optimize the use of limited colonoscopy resources. However, significant uncertainty exists regarding the feasibility and efficacy of risk-based screening. We aim to study the effect of communicating individual CRC risk and a risk-based recommendation of the FIT or colonoscopy on participants' choice of screening test. We will also assess the feasibility of a larger clinical trial designed to evaluate the impact of personalized screening on clinical outcomes. We will perform a pilot randomized controlled trial among 880 residents aged 50 to 69 years eligible to participate in the organized screening program of the Vaud canton, Switzerland. Participants will be recruited by mail by the Vaud CRC screening program. Primary and secondary outcomes will be self-assessed through questionnaires. The risk score will be calculated using the open-source QCancer calculator that was validated in the United Kingdom. Participants will be stratified into 3 groups-low (<3%), moderate (3% to <6%), and high (≥6%) risk-according to their 15-year CRC risk and randomized within each risk stratum. The intervention group participants will receive a newly designed brochure with their personalized risk and screening recommendations. The control group will receive the usual brochure of the Vaud CRC screening program. Our primary outcome, measured using a self-administered questionnaire, is appropriate screening uptake 6 months after the intervention. Screening will be defined as appropriate if participants at high risk undertake colonoscopy and participants at low risk undertake the FIT. We will also measure the acceptability of the risk score and screening recommendations and the psychological factors influencing screening behavior. We will also assess the feasibility of a full-scale randomized controlled trial. We expect that a total sample of 880 individuals will allow us to detect a difference of 10% (α=5%) between groups. The main outcome will be analyzed using a 2-tailed chi-squared test. We expect that appropriate screening uptake will be higher in the intervention group. No difference in overall screening uptake is expected. We will test the impact of personalized risk information and screening recommendations on participants' choice of screening test in an organized screening program. This study should advance our understanding of the feasibility of large-scale risk-based CRC screening. Our results may provide insights into the optimization of CRC screening by offering screening options with a better risk-benefit balance and optimizing the use of resources. ClinicalTrials.gov NCT05357508; https://www.clinicaltrials.gov/study/NCT05357508. DERR1-10.2196/46865.

Validating a model for predicting breast cancer and nonbreast cancer death in women aged 55 years and older.

To support mammography screening decision making, we developed a competing-risk model to estimate 5-year breast cancer risk and 10-year nonbreast cancer death for women aged 55 years and older using Nurses' Health Study data and examined model performance in the Black Women's Health Study (BWHS). Here, we examine model performance in predicting 10-year outcomes in the BWHS, Women's Health Initiative-Extension Study (WHI-ES), and Multiethnic Cohort (MEC) and compare model performance to existing breast cancer prediction models. We used competing-risk regression and Royston and Altman methods for validating survival models to calculate our model's calibration and discrimination (C index) in BWHS (n = 17 380), WHI-ES (n = 106 894), and MEC (n = 49 668). The Nurses' Health Study development cohort (n = 48 102) regression coefficients were applied to the validation cohorts. We compared our model's performance with breast cancer risk assessment tool (Gail) and International Breast Cancer Intervention Study (IBIS) models by computing breast cancer risk estimates and C statistics. When predicting 10-year breast cancer risk, our model's C index was 0.569 in BWHS, 0.572 in WHI-ES, and 0.576 in MEC. The Gail model's C statistic was 0.554 in BWHS, 0.564 in WHI-ES, and 0.551 in MEC; IBIS's C statistic was 0.547 in BWHS, 0.552 in WHI-ES, and 0.562 in MEC. The Gail model underpredicted breast cancer risk in WHI-ES; IBIS underpredicted breast cancer risk in WHI-ES and in MEC but overpredicted breast cancer risk in BWHS. Our model calibrated well. Our model's C index for predicting 10-year nonbreast cancer death was 0.760 in WHI-ES and 0.763 in MEC. Our competing-risk model performs as well as existing breast cancer prediction models in diverse cohorts and predicts nonbreast cancer death. We are developing a website to disseminate our model.