© 1999 by Oxford University Press
Journal of the National Cancer Institute Monographs, No. 25, 52-58,
1999
© 1999 Oxford University Press
Cancer Screening Decisions
Affiliation of authors: Department of Psychology, North Dakota State University, Fargo.
Correspondence to: Kevin D. McCaul, Ph.D., Department of Psychology, North Dakota State University, 201 Stevens Hall, Fargo, ND 58105 (e-mail: mccaul{at}badlands.nodak.edu).
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ABSTRACT |
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 Top Abstract IntroductionPhysician RecommendationsRisk and WorryCosts and Benefits of...Research NeedsPractice ImplicationsNotesReferences |
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This review focuses on why people decide to obtain or to avoid screening for cancer. We discuss three topics: (a) physician prompts that may elicit compliant screening behavior, (b) the independent and joint effects of risk perceptions and worry, and (c) the costs and benefits of getting screened. Overall, the data suggest that each of these factors will influence screening. So, for example, people are more likely to seek screening if a physician recommends the behavior, if they feel personally vulnerable and worry a little about cancer, if insurance covers the screening, and if they believe that the test is an effective early detection procedure. Future research needs include studies comparing theories, longitudinal rather than cross-sectional studies, and true experiments. We also need to know more about why physicians are such powerful change agents and the trade-offs of increasing personal risk versus exacerbating worry. Practical recommendations for promoting cancer screening include encouraging physician interventions, explaining risk, and lowering the costs while emphasizing the benefits of screening.
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INTRODUCTION |
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A variety of screening procedures, varying in effectiveness, is available for early detection of cancer. People also take advantage of such procedures to varying degrees (1). Most women aged 18 years and over, for example, have had at least one Pap test—a remarkable adherence rate for a screening procedure. However, a much smaller proportion of Americans more than 50 years has had an examination for colon cancer, although this cancer can be cured if detected early (2). How can we explain why people sometimes obtain and sometimes avoid cancer screening tests? The purpose of this review is to suggest empirical answers to this question, to propose directions for future research, and to address the implications of the literature for changing screening rates.
The literature review is organized into three sections. Within each section, we first look at correlational evidence and then, when possible, report experimental manipulations of the relevant variables. The three sections cover partially overlapping types of studies.
We propose that some cancer screening decisions may not be decisions in the typical sense of that word at all but rather may be more-or-less automatic responses to social influence. So, for example, when a 50-year-old man obtains a physical, he may participate in several screening procedures (an ear examination, a brief cardiogram, and a digital rectal examination) without actively deciding to do so. Instead, he simply might comply with the health professional's instructions. In the first section, we review the effects of a physician's recommendation on cancer screening rates.
The second section addresses two variables that theoretically set the stage for making more thoughtful, proactive decisions about screening: perceived risk of, and worry about, cancer. Most theories about health-protective behavior assume that people act to protect themselves against risk. Thus, people may decide to be screened because they feel vulnerable to cancer; in contrast, feelings of invulnerability should lead to reduced motivation to engage in cancer screening. Perceived risk is also related to worry about cancer, and each of these two variables may affect screening behavior.
Even if one feels vulnerable to cancer and worries about the disease, other psychosocial variables will influence the decision to be screened. These variables all fall under the general rubric of subjective utility theory (3). This model suggests that people make rational decisions: They weigh the costs and benefits of a behavior before deciding whether to adopt it. Thus, people should see screening as valuable while carrying few costs if they are going to pursue a test.
The selection of variables comes from our analysis of the literature and existing theoretical approaches. In essence, we are proposing that these three conceptual categories will capture most of the important variance in predicting screening. This suggestion, however, could fairly be phrased as a hypothesis rather than a statement of fact. Future research may either attest to or disconfirm some of the conclusions that we draw.
The literature for the review was obtained with the use of two main search strategies. First, we searched the CD-ROM databases, PsychLIT® and MEDLINE®, from 1981 through 1998. The key terms used included "physician," "cancer screening," "breast cancer screening," "cervical cancer," "colorectal cancer," "predictors," "motivation," "skin cancer," "melanoma," "decisions," "perceived risk," "worry," "mammography," and "mammogram." This search process resulted in articles examining screening for six types of cancer: breast, colon, skin, cervical, prostate, and ovarian. Because we were interested in why people obtain cancer screening, we included articles for all of these types of cancers, although the different screening tools vary widely in their effectiveness (4). The second approach was to examine the reference lists of the published articles found. Given the space limitations, we have not attempted to cite all articles about each conceptual issue. Instead, we have selected articles to illustrate the conceptual arguments and to suggest that the answers generalize across different cancer screening procedures.
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PHYSICIAN RECOMMENDATIONS |
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Most theories of health-protective behavior probably underestimate the effects of social influence. An exception would be the general model of volitional behavior offered by Fishbein and Ajzen (5), the Theory of Reasoned Action (TRA). The TRA states that normative beliefs (and the more general "subjective norm") is one of two immediate precursors of intentions to act. Normative beliefs include a person's evaluation of what significant others believe he or she should do and how motivated he or she is to comply with them. The TRA does not suggest a priori that one person should be more influential in affecting our cancer screening decisions than any other individual. However, although some data support the effects of people other than physicians in influencing screening decisions (6,7), findings from many studies show the power of physicians to affect screening behavior. Thus, we have created a separate category for physician recommendation based more on empirical findings than because of any special theoretical significance.
Most research concerning physician recommendations (indeed, most research about cancer screening overall) comes from the breast cancer screening literature. Women who have had mammograms, for example, report that a physician recommendation motivated their behavior (8). Women who have not had mammograms report the obverse: "My doctor did not tell me I needed to be screened" (9,10). A physician recommendation correlates with both initial and repeat mammograms (11), and the power of such a recommendation extends to other kinds of cancer screenings and beyond North America. For example, inner-city American women reported that they had not obtained a Pap smear because a doctor had not told them to do so [(12); also, see (13)]. In London, U.K., a survey showed that physician practices in which staff contacted women to encourage screening had higher breast and cervical cancer screening rates (14). Finally, the data suggest not only that a physician recommendation is correlated with screening but that it is also the single most powerful determinant of screening (15).
Correlational data, of course, are only suggestive of cause and effect, and most of the data supporting the importance of physician recommendations are correlational. Still, some researchers have attempted to increase screening by changing physician behavior [see (16)]. A recent review of cervical cancer screening interventions noted that physician and patient prompts were successful in promoting Pap smears and that "opportunistic screening" intervention (same-day examinations during an outpatient or hospital visit) were especially effective (17). Adding a computerized physician reminder increased mammography rates compared with an intervention that did not require direct physician participation (18). A physician letter and phone call produced fourfold increases in cancer screening (Pap smear and mammography) compared with a no-treatment condition (19). Although most experiments have compared physician interventions with control conditions with no additional interventions beyond usual care, a few experiments have compared physician interventions with more sophisticated alternative attempts to increase screening. Clover et al. (20), for example, found that physician interventions produced higher mammography rates than did media or comprehensive community campaigns.
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RISK AND WORRY |
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General theories of attitude-behavior linkages, such as the TRA, do not specifically address the importance of perceived risk [Stasson and Fishbein (21) even argued that differentiating perceived risk from other beliefs is unnecessary]. However, all theoretical models specifically addressing health-protective behaviors emphasize perceived risk (22,23).1 Risk is defined here as the likelihood that one might have cancer at some future date; investigators also use the term "susceptibility" and "vulnerability" to mean the same thing. Other elements of risk (e.g., novelty) could be related to screening (24), but health-protective theories have focused on the likelihood dimension.
The relationship between risk and screening can be tested directly by correlating perceived risk with screening frequency. However, the relationship can also be inferred from correlations with two other "susceptibility" variables: whether one has a family history of cancer and whether one has experienced problems or symptoms related to cancer. Perceived cancer risk is also related, although imperfectly, to worry about cancer. Some theorists suggest that risk, a cognitive variable, and worry, an affective variable, may each be related to action, and we will examine that possibility. The remainder of this section reviews each of these four risk-related variables: perceived risk, family history, symptoms, and worry.
Perceived Risk
McCaul et al. (25) reported a meta-analysis relating perceived risk to mammography screening, obtaining a small but significant effect size of r = .16 from 19 studies. Perceived vulnerability is also positively correlated with screening for other cancers [e.g., colon cancer (26), skin cancer (27-29), and prostate cancer (30)]. However, perceived risk is but a single variable among many decision-making variables that could influence an infrequently performed behavior. Not surprisingly, then, one is likely to observe only modest effect sizes obtained for risk and screening behavior relationships. Given such effect sizes, it would also be expected that some individual studies will fail to produce statistically significant relationships (25).
Because risk perceptions play a central role in theories of health-protective behavior, we were surprised to find no experiments in which researchers explicitly manipulated risk and examined screening outcomes. In two studies, however, investigators emphasized risk status to people with or without a family history of cancer. Blalock et al. (31) told siblings of persons diagnosed with colorectal cancer about their individual risk and urged them to do a home screening test. These persons were more likely to do the test than persons without a family history who received more general risk feedback. Family history was also an important background variable in a study reported by Curry et al. (32) concerning mammography screening. Women with a family history of breast cancer who received a mammography invitation that mentioned their personal risk were more likely to obtain a mammogram than were similar women who received an invitation that only addressed their risk in general terms.
Family History
An observed relationship between family history of cancer and a greater likelihood of screening would not necessarily be related to active decision making. A positive family history could influence screening through multiple routes: prompts from physicians, an increased sense of personal vulnerability, or increased worry. It is likely that physicians are more likely to recommend screening for women with a positive family history, but there are few data. However, there is evidence that a family history correlates with increases in perceived risk of breast cancer (33) and skin cancer (34).2 A family history of breast cancer is also related to increased worry about breast cancer (35,36). McCaul et al. (35) asked women with and without a family history of breast cancer to self-monitor their thoughts and worry for a month. Worry declined over time, perhaps because it was elevated initially in association with the context of the study. However, women with a family history of the disease showed a smaller decline in worry, and the researchers suggested that such women could be chronically worried about the disease.
Although the mechanism is unclear, a positive family history of cancer clearly predicts higher screening levels. McCaul et al. (25) found an effect size of r = .27 from 19 studies examining a link between family history of breast cancer and mammography screening. That effect size was meaningfully higher than the effect size for perceived risk alone (r = .16), which makes sense if a family history creates several possible routes to increased screening. Similar relationships have also been observed for cancers other than breast cancer. A positive family history of prostate cancer predicts interest in prostate-specific antigen (PSA) testing (37), and a lack of a family history predicts poorer adherence to Pap smear screening (38). A family history of breast cancer is also related to higher intentions to do breast self-examination (BSE) (35). Richardson et al. (39) discovered that unaffected co-twins were screened for colorectal cancer at a rate three to four times higher than the general population. Sandler et al. (40) found that high-risk siblings of diagnosed colon cancer patients were more interested in fecal occult blood testing than controls.
Symptoms
Similar to a family history, a link between the presence of symptoms and screening is not necessarily related to active decision making about screening. Symptoms could prompt a physician recommendation (41), increase perceived risk, or elevate worry.3 We did not find data concerning the first two possibilities, but Cunningham et al. (42) found that women with benign breast problems reported more breast cancer worry than women without such problems.
Data show that symptoms predict higher screening rates. Women with breast problems, for example, are more likely to have had a mammogram (43). McCaul et al. (25) obtained an effect size of .30 between the discovery of breast problems and having had mammograms. The presence of risk factors, including symptoms, was associated prospectively with colorectal cancer screening (44). Cameron et al. (45) found that high-anxiety women on tamoxifen were more adherent to BSE than low-anxiety women. They attributed this finding to the possibility that high-anxiety women used the symptoms caused by tamoxifen as cues to prompt testing. One of the more frightening "symptoms" one could have is a false-positive mammogram that requires a surgical biopsy. One study has shown that women having such an experience may be more likely to obtain future mammograms as recommended by guidelines (46).
Worry
Cancer is probably the most feared contemporary disease (47), so it is not surprising that people worry about it. Some authors have argued that worry can impede screening (48), but that suggestion conflicts with both theory and data. Theoretically, Leventhal (49) has most directly addressed the role of affect, suggesting that distress about a health threat will motivate self-protective behavior if an action exists that can reduce the threat. Thus, Leventhal would suggest that both risk and worry should contribute to higher screening levels [see (50)]. Leventhal's insertion of affect into what is typically seen as a more rational decision is important, and his parallel model fits with more general theorizing about the dual aspects of consciousness [cf. (51)].
McCaul et al. (25) observed a small but significant positive relationship (r = .14) between worry and mammography screening on the basis of only six studies. McCaul and colleagues have also found positive correlations between worry and higher levels of BSE. These relationships between worry and breast cancer screening hold both concurrently and prospectively (35,52,53). We were unable to find many reports of connections between cancer worry and screening for cancers other than breast cancer. However, De Rooij et al. (54) recently reported data from The Netherlands that fear of having skin cancer was an important reason given for attending a screening clinic for melanoma screening.
One might speculate that worry is not the crucial variable predicting screening but serves as a proxy for perceived risk. Risk and worry are related, although modestly. Linville et al. (55) have shown that correlations between risk and worry average about .30 across many behaviors. McCaul and O'Donnell (56) found a correlation of r = .36 between worry, defined as intrusive thoughts, and breast cancer risk. Webb et al. (34) obtained a risk-worry correlation for skin cancer of r = .19, and Schwartz et al. (57) observed an r = .25 between risk and worry about ovarian cancer. It is possible that both risk and worry predict more frequent screening. Some research suggests that this is the case—partial correlations between worry and breast cancer screening stayed significant after partialing out perceived risk (52,53). Schwartz et al. (58) also recently showed that family history (an indirect measure of perceived risk) and worry were both independent, positive predictors of screening for ovarian cancer.
Not surprisingly, researchers will not purposefully increase worry to determine whether increased negative affect increases cancer screening. However, some correlational data about the effects of mammography screening lend weight to the possibility that worry increases screening. Lerman et al. (59) interviewed women about their worry just after they had received a mammogram. Women who said that they were still worried about breast cancer also reported that they were more likely to obtain another mammogram. Similarly, in another study, Lerman et al. (60) reported that women who expressed relief after a mammogram were less likely to return for a subsequent screening.
The preponderance of data suggest that breast cancer worries do not lead to screening avoidance but just the opposite—worry leads people to try to protect themselves by taking advantage of screening opportunities. Some people, however, may use screening excessively. Two studies report data suggesting that affect can prompt excessive self-examination for breast cancer. Lerman et al. (61) discovered that young women who had both a family history of breast cancer and a high level of breast cancer anxiety were more likely to perform BSE more than once a month. More troublesome, perhaps, Epstein et al. (62) interviewed women who had recently had a first-degree relative diagnosed with a primary breast cancer. A few of those women (8%) reported that they examined their breasts for lumps every day. These women were more likely than the rest of the sample to report that thinking about breast cancer negatively affected their mood—one of three items that the authors used to measure worry. The women who were too frequently examining their breasts were also more confident about protecting their health and about doing something about their cancer worries, suggesting that they perceived the constant breast checks positively.
Finally, we should note that differentiating between anxiety and worry about cancer screening could be important. Worry clearly can have positive effects. Most prominently, worry predicts problem solving; Davey (63) called it "constructive worry" [see also (64)]. Anxiety may not have such positive outcomes, and measures of anxiety have typically not been associated with higher screening levels. McCaul et al. (35), for example, failed to observe a positive relationship between trait anxiety and screening. And, for women with a strong family history of breast cancer, Kash et al. (65) observed a negative relationship between anxiety and screening.
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COSTS AND BENEFITS OF ACTING |
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Some version of the costs and benefits of adopting a health-protective behavior is a part of all models of health protection. The Health Belief Model (66), for example, includes a single cost/benefit variable; Protection Motivation Theory (67) addresses the cost of performing and the likely effectiveness of the behavior. The "pros and cons" of adopting a health-protective behavior are also theoretically important in moving people to different stages in the Transtheoretical Model (68). Costs and benefits are also important factors in more general models of attitude-behavior linkages (e.g., the TRA). We next consider costs (barriers) and benefits in turn.
Barriers
In a recent review, Womeodu and Bailey (69) listed 25 barriers to cancer screening. Some factors that inhibit screening for different screening tests include financial cost [ovarian (70) and breast (71)]; concern about radiation [breast (72)]; embarrassment [cervical (73)], ease of access, including travel difficulties [breast (72) and ovarian (70)], anxiety about test results [mammography (74) and BSE (75)], not having symptoms [cervical (76) and prostate (77)], inconvenience [colorectal (78)], forgetting or procrastination (79), and discomfort associated with the screening test [prostate (80)].
Some researchers have tested interventions intended to reduce barriers, and these interventions are often successful. Wolosin (81), for example, showed that forgetting can be overcome by scheduling specific appointments and reminding women. Reminders increased screening for several forms of colorectal cancer screening (82). Several studies have relied on tailoring the interventions to the particular barriers that women express. King et al. (72) doubled mammography screening rates by calling older women and counseling them how to overcome screening barriers. Skinner et al. (83) tailored mailed messages to the barriers to mammography that women had reported earlier; this strategy produced a 13% increment in subsequent screening compared with a nontailored message. More recently, Rakowski et al. (84) tailored a mailed message to participants' "stage of change." They reported a significant difference in subsequent mammogram rates of 64% versus 55% in a no-mailing condition.
Benefits
Benefits to cancer screening seem fewer than possible barriers. The overriding benefit may be whether the screening test truly confers the likelihood of early detection (20,44) or at least that persons believe the test to be valuable for early detection (85). A related notion is whether the examination provides peace of mind (86). We did not identify any interventions that focused solely on benefits, which makes sense—researchers would be likely to balance such an emphasis by also reducing barriers. But almost any intervention, regardless of its particular components, will at least include information on the benefits of screening.
Thus far in this review, we have ignored demographic variables that could be associated with screening. We speculate that the effects of such variables are usually mediated through the sorts of psychosocial variables already covered. If, for example, income relates positively to screening levels, any of the following (among other) mediated relationships could explain the connection: (a) people with high income may visit physicians more frequently and thus receive screening recommendations; (b) people with higher income are also more educated, and they could be more knowledgeable about their risk; and (c) people with higher income are more likely to have insurance coverage, reducing the cost barrier. Other variables, such as age, may have their effects on screening levels through similarly mediated relationships.
One exception to the above could be ethnicity. Women from different cultural backgrounds may behave differently in terms of screening because of cultural beliefs (87,88). Hubbell et al. (89) discovered that cultural beliefs concerning risk factors might inhibit Latina immigrants from obtaining Pap smears.
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RESEARCH NEEDS |
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We suggest that cross-sectional studies correlating various demographic or psychosocial factors with screening behaviors are of less value at this time than other types of research. Studies that produce empirically, rather than theoretically, derived regression equations predicting screening are also not a priority. Two other kinds of correlational studies would prove more useful. First, theoretically driven studies that compare theories would help inform interventions (23). Second, such studies would be more valuable if researchers followed participants over time. Finally, we need research in which investigators manipulate variables in true experiments.
What is important to discover that we do not yet know? One possibility is to conduct further research to understand the relationship between physician recommendations and screening behavior. Why are physicians such powerful social influence agents? Is it merely obedience to authority? Is it because physicians are especially good at conveying a sense of personal vulnerability or worry? We do not know the answers to these kinds of questions. A second possible direction is to test the speculation in this paper concerning the effects of worry versus perceived risk. Does worry have different effects in predicting screening than other types of affective responses such as anxiety?
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PRACTICE IMPLICATIONS |
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If one wished to encourage screening, what could be done? Before considering plausible answers to this question, we should acknowledge that the goal may not always be to encourage people to be screened. Instead, it may be only to provide information so that people can decide for themselves. The latter goal should probably be primary when the value of screening is unknown, but some authors also argue that such a strategy is always the appropriate choice (90,91). Of course, when information alone is provided, the effects on screening may be to either increase or decrease rates. Wolf and Schorling (30), for example, showed that providing accurate information about the efficacy of the PSA test to detect prostate cancer reduced interest in obtaining the examination among elderly men. Of course, this is a cancer whose role in reducing mortality has not been proven.
To the extent that our goal is to increase screening, the three types of variables we have reviewed lead to obvious practical implications. First, health professionals should simply recommend to their patients that they obtain a screening, scheduling it at the same time as the recommendation, if possible. Do physicians do so? Lerman et al. (11) reported that only 60% of their respondents said that their physicians had recommended mammograms. These data come from early 1988, however, and it is likely that a greater proportion of physicians would recommend mammographies today. Other cancer screening tests are probably recommended less often. Demark-Wahnefried et al. (86), for example, discovered that only 28% of black or white men reported that their doctor ever discussed a prostate cancer test with them.
Although a physician recommendation will promote screening, some people still may not be screened for at least two reasons. First, of course, everyone does not visit a physician regularly; we must find other means to reach such individuals. Second, although we have described compliance with a physician recommendation as more or less "automatic," that description is not always accurate, especially because time often intervenes between the recommendation and actually scheduling or obtaining a screening. As the time interval following a recommendation increases, more active decision making may be important. Thus, a second recommendation would be to give people information showing that they are personally vulnerable to the cancer associated with the screening.
The recommendation to emphasize personal risk runs head on into possible ethical issues. Ensuring that accurate information is presented will occasionally mean convincing people that their risk is higher than they believe. The analysis presented earlier suggests that, if persuasion is effective, people will raise their risk estimates, worry more about cancer, and be more likely to adopt a screening behavior. Thus, this strategy has costs (occasional worry). We were unable to find any studies in the literature that addressed the use of risk counseling to increase risk estimates.
A more likely possibility is that counseling about accuracy will mean convincing many people that their risk is lower than they believe. This is because many people overestimate their risk, at least when absolute (rather than social comparative) measures of risk are used (56). Reducing risk estimates may have ironic costs according to our analysis—a lower perceived risk of screening accompanied by less worry but also reduced motivation to be screened. This would not necessarily have to be the case, however, because risk and worry—although important—are only two of many variables influencing screening. Counseling could effectively shift screening control from individual decision making to professional "control" (e.g., reminders from one's physician). Counseling could also focus on removing the barriers that inhibit screening (especially concern about the screening procedure per se) and influencing beliefs about the value of screening. Thus, although lower risk estimates should reduce screening if all other things are equal, the latter caveat is unlikely to hold for most counseling programs.
Preliminary data concerning the effects of providing accurate information have been interesting. Women who are overestimating their risk reduce their estimates, but not as low as the levels provided by the risk counselors (92). The only study (93) to measure actual screening behavior showed that a risk counseling program for women with a family history of breast cancer lowered risk estimates and distress, but reduced the number of women who had a mammogram during the subsequent year. Other studies (94,95), however, show that women report less distress about cancer but are no less motivated to engage in screening.
Finally, if we wish to increase screening levels, we can remove barriers and increase beliefs in the value of screening. Many interventions rely on this general strategy (96,97). Thus, for example, to the extent that screening has been shown to have a public health benefit, we can work to reduce costs, ease access, and improve screening technology. For effective screening techniques, all such attempts to improve the benefit/cost ratio will likely increase screening rates.
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NOTES |
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1 Although we do not describe how different theories might lead to different hypotheses for predicting screening behavior, it is possible to do so. Weinstein (23) outlines circumstances in which it is possible to test among different theories of health-protective behavior, a strategy that we recommend.
2 We have focused on family history as a risk factor that can
prompt increased risk perceptions. In theory, however, any risk factor should be associated with
increased screening rates, as long as people are aware of the risk factor/cancer relationship. Cody
and Lee (27), for example, found that fairer skin, a fairly well-known
predictor of skin cancer risk, predicted whether college students examined their skin for skin
cancer.
3 Screening in relation to symptoms is sometimes diagnostic
and is likely different in many ways from routine cancer screening. However, symptoms can
prompt screening motives, such as risk and worry, that are similar to those caused by other
individual characteristics (e.g., a family history). So, for example, a woman with a prior history
of "breast problems" may continue to seek out mammography screening because
that prior history increases her perceived risk and associated worry.
Supported in part by Public Health Service grant CA58659 from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services.
We thank Becky Johnson, Tanna Richard, and Katie Quinlan for helping with the literature review.
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