Matching strength of message to strength of evidence: a discussion.

The four discussions in this session present different and sometimes contrasting aspects of cancer screening from the perspective of behavioral science. As a nonbehavioral scientist, I have tried to compare the behavioral aspects from the perspective of the public health professional in the field of cancer screening and to see the implications of a given behavioral strategy. I picked up, in essence, three general approaches or themes from the three papers on general population screening (Table 1). The genetic screening paper adds complexity that I will address at the end. One (1) of the papers that we discussed today was primarily aimed at removing barriers to screening. For example, there was a statement in the paper that “the doctor should simply recommend screening.” Some examples were given for mammography and prostate cancer screening, and McCaul and Tulloch in their presentation said some physicians urge prostate cancer screening to patients as the standard of care. In their paper, O’Connor et al. (2) refer to this approach as “supplier induced demand.” In essence, that is what happens to some patients during a routine checkup. The supplier virtually demands that the patient get a prostate-specific antigen test. We are seeing much of that in the medical practice today. The pharmaceutical or industrial suppliers are going straight to the public and advertising, or doctors are creating the demand for the types of things they do. The paper by Rothman and Kiviniemi (3) dealt with a conceptualized approach. Some of the means suggested to supply context were the provision of testimonials, imagery, and fear. More about that in a bit. The third paper O’Connor et al. (2) was a personal values-based approach or “informed choice” strategy, as they term it. From my perspective, each of the three approaches has advantages and disadvantages. I listed attendant potential pros and cons in Table 2. The first approach is removing barriers. One of its advantages is that it is quite direct. You go for what you would like the patient’s behavior to be. On the con side, the strategy can be directive. I think being direct has advantages but being directive has downsides, such as oversimplification of complex decisions or unproven interventions. The contextual approach has a great deal of intuitive appeal. The word that comes to mind in terms of pros is “poignant.” I could see how it would be extremely poignant and very compelling for someone to hear the context in which he or she is making the decision. In point of fact, we get a lot of contextual information these days. Congressional hearings are full of contextual approaches in which you will often, if not universally, have a panel of people who testify to very personal and moving experiences while a given committee is contemplating legislation on national policy. The recent Internal Revenue Service (IRS) hearings are an example. A panel of people gave stories of personal sufferings in dealings with the IRS. That is extremely poignant because most people will resonate with the suffering and fear. The problem is one of numerator versus denominator. You do not know how large the numerator of suffering people is. The denominator is many, in this case more than 100 million people. The question is: How reflective is the contextual story (i.e., numerator) of the general? This also has happened in hearings that have dealt with a variety of medical issues. You have someone who is personally affected. You have seen on national television people lamenting what happened to them within the medical system. And although it is poignant, it is hard to know whether it is oversimplified or if the problem is general. It is hard to know whether it is an anecdote and, sometimes, it is hard to verify its accuracy in the first place. In other words, accuracy of inference may suffer at the altar of poignancy. Finally, informed choice has the pros of empowerment in engaging the patient in an informed decision. It does have its downsides as well. It can be time consuming for the health professional. It can be quite confusing to the person trying to choose among options. And it can affect compliance. If you, as a health provider or health professional, think you know exactly what the right thing is to do, and you complicate the message