The Screening Debate

In messaging, an unfair fight: ‘Save your life!’ vs. eyes-glazed-over explanation

Timothy Kelley

Cancer screening isn’t a public health imperative; it’s a personal choice,” says H. Gilbert Welch, MD, of the Dartmouth Institute. Skeptics like him insist they’re not out to stop screening, only to give consumers an honest account of its benefits and risks. But screening advocates fear that skeptics are muddying the water, helping people rationalize skipping mammograms and other recommended tests and thus putting lives at risk. Still, screening boosters can take comfort in one thing that’s firmly on their side in the public debate: emotion. A call to action to save your life is a lot more compelling than dull scientific prose full of qualifiers.

As Lisa Rosenbaum, MD, wrote in a 2014 New England Journal of Medicine editorial on mammography decision making, “the visceral appeal of ‘catching something early’ easily eclipses the difficult mental calculations one must undertake to figure out why early detection does not necessarily mean living longer.”

Screening tests play with our emotions, Rosenbaum argued. A negative finding is reassuring while a positive one brings “gratitude that disease was caught early.” If a positive turns out to be false, we’re mostly just happy we don’t have cancer. And if a positive finding leads to successful treatment, we’re ready to share our compelling story. But some of those dramatic testimonials proclaiming “Screening saved my life!” are from people whose cancers actually might never have bothered them.

In recent years, the U.S. Preventive Services Task Force (USPSTF) has cut back on some screening recommendations. In 2012, it came out against routine PSA screening for prostate cancer in men, although a draft recommendation last month revised that advice to a suggestion that screening should be an individual decision. The USPSTF advises that women get mammograms biennially between ages 50 and 74, adding that the tests may also be chosen by women in their 40s “who place a higher value on the potential benefit than the potential harms.” Set against slick marketing appeals—sometimes from hospitals looking to reel in new patients with free screening—such committee-wrought prose is pale stuff.

Sara E. Gorman

Health care organizations need to invest in research to develop “scientifically rigorous knowledge about what kind of messaging works, and what doesn’t,” says Sara E. Gorman, author and public health expert.

What can a health plan or provider organization do to rectify this imbalance and encourage judicious consideration of screening’s downside along with its up? “Work on making your message more appealing if you really want to persuade people that, for example, getting a mammogram every year might not be in their best interests,” advises Sara E. Gorman, author—with her father, psychiatrist Jack E. Gorman, MD—of the 2016 book Denying to the Grave: Why We Ignore the Facts That Will Save Us.

Gorman finds the USPSTF website “really boring—just numbers and statistics. It reflects the way scientists are taught to communicate, but it doesn’t take into account what we now know about how people interpret information.” She says health care organizations need to invest in research to develop “scientifically rigorous knowledge about what kind of messaging works, and what doesn’t.” (Another Gorman tip: Don’t get mad at consumers for making “stupid” choices that go against the science. Instead, seek to understand their biases—and your own.) What about screening backers’ claim that a test finding is simply information that a consumer can decide how to use? “You have to be careful giving patients information and make sure it’s given in the context of good doctor–patient communication,” Gorman warns.

Indeed, Rosenbaum suggests that in the messaging wars, simply following consumers’ wishes can be a copout. “Defaulting to patient preference in the face of uncertainty has become the moral high ground,” she writes. “But it is as much our job to figure out how to best help our patients lead healthier lives as it is to honor their preferences.”


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