Messaging Strategies to Reduce Breast Cancer Over-Screening in Older Women

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PROJECT SUMMARY This administrative supplement proposal focuses on bioethics research around the use of persuasion in health communication, specifically in the context of reducing breast cancer over-screening. Mammography screening may decrease breast cancer mortality and morbidity but the potential benefits are often delayed for many years while significant harms can occur in the short term. The harms of routine screening outweigh the benefits among older women with limited life expectancies, but many of these women continue to be screened, highlighting the need for interventions to promote appropriate screening cessation and reduce over-screening in older women. Our project (R01AG066741) is studying the novel use of messaging interventions, via clinician-patient communication and other sources (family, friends, and the media), to reduce over-screening. Numerous health communication strategies, such as establishing credibility, using emotional appeals, and using stories, are inherently persuasive and used to change behaviors. The parent R01 project plans to test various messages employing such persuasive strategies but the potential ethical implications are unclear. One perspective asserts that using persuasion may be manipulative and threat patient autonomy while others argue that it is essential to guide patients towards options that promote benefits (beneficence) and minimize harms (non-maleficence). It is not clear at what point across the benefits/harms balance spectrum it may be ethically acceptable to shift from informing to persuading or what forms of persuasion are acceptable in the context of reducing over-screening. This supplement project aims to build upon the parent project to address ethical issues around using persuasion to reduce breast cancer over-screening. First, we will examine older women’s moral beliefs and values on this topic. We propose both qualitative in-depth interviews of 30 older women (Aim 1) and quantitative surveys of 3000 older women (Aim 2), where the latter leverages a nationally representative online survey that is already planned as part of the parent project. Then, we will convene an expert panel of bioethicists, clinicians, health communication and cancer screening researchers. The panel will deliberate and reflect upon the empirical results from Aims 1 and 2, existing literature on breast cancer screening and messaging, and the competing ethical principles of patient autonomy and beneficence/non-maleficence, to make recommendations on how to use persuasion in de-implementing over-screening (Aim 3). The proposed project will build on the existing R01 and 1) identify messages that are not only effective for reducing over-screening but are also ethically acceptable, and 2) develop an ethical framework to guide the next-step messaging intervention. More broadly, the results will help address the appropriate and effective use of health communication tools in both clinical care and public health in the context of de-implementation.