Jolyn Hersch

Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial

BACKGROUND Mammography screening can reduce breast cancer mortality. However, most women are unaware that inconsequential disease can also be detected by screening, leading to overdiagnosis and overtreatment. We aimed to investigate whether including information about overdetection of breast cancer in a decision aid would help women aged around 50 years to make an informed choice about breast screening. METHODS We did a community-based, parallel-group, randomised controlled trial in New South Wales, Australia, using a random cohort of women aged 48-50 years. Recruitment to the study was done by telephone; women were eligible if they had not had mammography in the past 2 years and did not have a personal or strong family history of breast cancer. With a computer program, we randomly assigned 879 participants to either the intervention decision aid (comprising evidence-based explanatory and quantitative information on overdetection, breast cancer mortality reduction, and false positives) or a control decision aid (including information on breast cancer mortality reduction and false positives). Participants and interviewers were masked to group assignment. The primary outcome was informed choice (defined as adequate knowledge and consistency between attitudes and screening intentions), which we assessed by telephone interview about 3 weeks after random allocation. The primary outcome was analysed in all women who completed the relevant follow-up interview questions fully. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613001035718. FINDINGS Between January, 2014, and July, 2014, 440 women were allocated to the intervention group and 439 were assigned to the control group. 21 women in the intervention group and 20 controls were lost to follow-up; a further ten women assigned to the intervention and 11 controls did not answer all questions on attitudes. Therefore, 409 women in the intervention group and 408 controls were analysed for the primary outcome. 99 (24%) of 409 women in the intervention group made an informed choice compared with 63 (15%) of 408 in the control group (difference 9%, 95% CI 3-14; p=0·0017). Compared with controls, more women in the intervention group met the threshold for adequate overall knowledge (122/419 [29%] vs 71/419 [17%]; difference 12%, 95% CI 6-18; p<0·0001), fewer women expressed positive attitudes towards screening (282/409 [69%] vs 340/408 [83%]; 14%, 9-20; p<0·0001), and fewer women intended to be screened (308/419 [74%] vs 363/419 [87%]; 13%, 8-19; p<0·0001). When conceptual knowledge alone was considered, 203 (50%) of 409 women in the intervention group made an informed choice compared with 79 (19%) of 408 in the control group (p<0·0001). INTERPRETATION Information on overdetection of breast cancer provided within a decision aid increased the number of women making an informed choice about breast screening. Becoming better informed might mean women are less likely to choose screening. FUNDING Australian National Health and Medical Research Council.

Women’s views on overdiagnosis in breast cancer screening: a qualitative study

Objective To elicit women’s responses to information about the nature and extent of overdiagnosis in mammography screening (detecting disease that would not present clinically during the woman’s lifetime) and explore how awareness of overdiagnosis might influence attitudes and intentions about screening. Design Qualitative study using focus groups that included a presentation explaining overdiagnosis, incorporating different published estimates of its rate (1–10%, 30%, 50%) and information on the mortality benefit of screening, with guided group discussions Setting Sydney, Australia Participants Fifty women aged 40–79 years with no personal history of breast cancer and with varying levels of education and participation in screening. Results Prior awareness of breast cancer overdiagnosis was minimal. Women generally reacted with surprise, but most came to understand the issue. Responses to overdiagnosis and the different estimates of its magnitude were diverse. The highest estimate (50%) made some women perceive a need for more careful personal decision making about screening. In contrast, the lower and intermediate estimates (1–10% and 30%) had limited impact on attitudes and intentions, with many women remaining committed to screening. For some women, the information raised concerns, not about whether to screen but whether to treat a screen detected cancer or consider alternative approaches (such as watchful waiting). Information preferences varied: many women considered it important to take overdiagnosis into account and make informed choices about whether to have screening, but many wanted to be encouraged to be screened. Conclusions Women from a range of socioeconomic backgrounds could comprehend the issue of overdiagnosis in mammography screening, and they generally valued information about it. Effects on screening intentions may depend heavily on the rate of overdiagnosis. Overdiagnosis will be new and counterintuitive for many people and may influence screening and treatment decisions in unintended ways, underscoring the need for careful communication.

Lexical Precision in Skilled Readers: Individual Differences in Masked Neighbor Priming.

Two experiments investigated the relationship between masked form priming and individual differences in reading and spelling proficiency among university students. Experiment 1 assessed neighbor priming for 4-letter word targets from high- and low-density neighborhoods in 97 university students. The overall results replicated previous evidence of facilitatory neighborhood priming only for low-neighborhood words. However, analyses including measures of reading and spelling proficiency as covariates revealed that better spellers showed inhibitory priming for high-neighborhood words, while poorer spellers showed facilitatory priming. Experiment 2, with 123 participants, replicated the finding of stronger inhibitory neighbor priming in better spellers using 5-letter words and distinguished facilitatory and inhibitory components of priming by comparing neighbor primes with ambiguous and unambiguous partial-word primes (e.g., crow#, cr#wd, crown CROWD). The results indicate that spelling ability is selectively associated with inhibitory effects of lexical competition. The implications for theories of visual word recognition and the lexical quality hypothesis of reading skill are discussed.

Psychosocial interventions and quality of life in gynaecological cancer patients: A systematic review

Objective: Women with gynaecological cancer are at risk of poor quality of life outcomes. Although various psychosocial interventions have been developed to address these concerns, such interventions have not yet been systematically evaluated in this population. The current review provides an up‐to‐date and comprehensive summary of the evidence regarding the effectiveness of psychosocial interventions in women with gynaecological cancers.

Walking the tightrope: communicating overdiagnosis in modern healthcare

Communication that empowers the public, patients, clinicians, and policy makers to think differently about overdiagnosis will help support a more sustainable healthcare future for all, argue Kirsten McCaffery and colleagues

How do we achieve informed choice for women considering breast screening

OBJECTIVE In current medical literature, mammography and other cancer screening programs are subject to controversy because of debate about the magnitude and nature of the benefits and harms. This paper discusses the issues around informed choice for women considering breast screening. METHOD We discuss qualitative and quantitative studies of womens attitudes to breast screening and informed choice. RESULTS Women view breast screening as a way of avoiding potential regret, and reassurance from normal results is highly valued. Screening participants acknowledge anxiety about false positives but awareness regarding potential overdetection of indolent breast cancer is minimal, and research is needed to assess how better understanding of screening downsides may affect womens views. In any case, weighing up screening advantages and disadvantages is sensitive to personal preferences. CONCLUSIONS Communicators have an ethical obligation to make balanced information available to women, which is flexible enough to respond to the level of detail and involvement desired by each individual. Many women want to know more and to participate more actively in screening decisions. Techniques have been developed to present balanced information and support individual decision making in ways that are accessible and empowering for the wider community. Evaluations of breast cancer screening must integrate clinical data with evidence on the perspectives of women themselves.

Lexical Quality and Reading Skill: Bottom-Up and Top-Down Contributions to Sentence Processing

This research investigated whether spelling ability, an index of precise lexical representations, predicts the balance between bottom-up and top-down processing in online sentence processing among skilled readers, over and above contributions of reading ability, vocabulary, and working memory. The results showed that the combination of superior reading and spelling was associated with more accurate report of rapidly presented sentences and that spelling uniquely predicted reduced reliance on context to identify words. These findings support the lexical quality hypothesis by demonstrating that individual differences in the reading strategies used by skilled readers reflect differences in the precision of their lexical representations.

The effect of information about overdetection of breast cancer on women's decision-making about mammography screening: study protocol for a randomised controlled trial

Introduction Women are largely unaware that mammography screening can cause overdetection of inconsequential disease, leading to overdiagnosis and overtreatment of breast cancer. Evidence is lacking about how information on overdetection affects womens breast screening decisions and experiences. This study investigates the consequences of providing information about overdetection of breast cancer to women approaching the age of invitation to mammography screening. Methods and analysis This is a randomised controlled trial with an embedded longitudinal qualitative substudy. Participants are a community sample of women aged 48–50 in New South Wales, Australia, recruited in 2014. Women are randomly allocated to either quantitative only follow-up (n=904) or additional qualitative follow-up (n=66). Women in each stream are then randomised to receive either the intervention (evidence-based information booklet including overdetection, breast cancer mortality reduction and false positives) or a control information booklet (including mortality reduction and false positives only). The primary outcome is informed choice about breast screening (adequate knowledge, and consistency between attitudes and intentions) assessed via telephone interview at 2 weeks postintervention. Secondary outcomes measured at this time include decision process (decisional conflict and confidence) and psychosocial outcomes (anticipated regret, anxiety, breast cancer worry and perceived risk). Women are further followed up at 6 months, 1 and 2 years to assess self-reported screening behaviour and long-term psychosocial outcomes (decision regret, quality of life). Participants in the qualitative stream undergo additional in-depth interviews at each time point to explore the views and experiences of women who do and do not choose to have screening. Ethics and dissemination The study has ethical approval, and results will be published in peer-reviewed journals. This research will help ensure that information about overdetection may be communicated clearly and effectively, using an evidence-based approach, to women considering breast cancer screening. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12613001035718.

How different terminology for ductal carcinoma in situ impacts women's concern and treatment preferences: a randomised comparison within a national community survey

Objective There have been calls to remove ‘carcinoma’ from terminology for in situ cancers such as ductal carcinoma in situ (DCIS), to reduce overdiagnosis and overtreatment. We investigated the effect of describing DCIS as ‘abnormal cells’ versus ‘pre-invasive breast cancer cells’ on womens concern and treatment preferences. Setting and participants Community sample of Australian women (n=269) who spoke English as their main language at home. Design Randomised comparison within a community survey. Women considered a hypothetical scenario involving a diagnosis of DCIS described as either ‘abnormal cells’ (arm A) or ‘pre-invasive breast cancer cells’ (arm B). Within each arm, the initial description was followed by the alternative term and outcomes reassessed. Results Women in both arms indicated high concern, but still indicated strong initial preferences for watchful waiting (64%). There were no differences in initial concern or preferences by trial arm. However, more women in arm A (‘abnormal cells’ first term) indicated they would feel more concerned if given the alternative term (‘pre-invasive breast cancer cells’) compared to women in arm B who received the terms in the opposite order (67% arm A vs 52% arm B would feel more concerned, p=0.001). More women in arm A also changed their preference towards treatment when the terminology was switched from ‘abnormal cells’ to ‘pre-invasive breast cancer cells’ compared to arm B. In arm A, 18% of women changed their preference to treatment while only 6% changed to watchful waiting (p=0.008). In contrast, there were no significant changes in treatment preference in arm B when the terminology was switched (9% vs 8% changed their stated preference). Conclusions In a hypothetical scenario, interest in watchful waiting for DCIS was high, and changing terminology impacted womens concern and treatment preferences. Removal of the cancer term from DCIS may assist in efforts towards reducing overtreatment.

Neurocognitive deficits and psychiatric disorders in a NSW prison population

Approximately 75% of inmates in New South Wales (NSW) have mental health issues (Butler & Alnutt, 2003). Scarce resources force the management of acute psychiatric symptoms only, meaning that co-morbid conditions such as neurocognitive deficits are less likely to be assessed. The objective of this study was to investigate the utility of a computerized battery in the assessment of inmates within the criminal justice system. Thirty male inmates were assessed. Data were compared to matched controls. The custodial sample was characterized by an increase in the prevalence of previous trauma; high levels of depression, anxiety and stress and neurocognitive deficits, including sustained attention, impulsivity and executive dysfunction.