Customized appeals may increase cancer screening

Using messages that fit patients' needs and knowledge, psychologists encourage people to get screened.

By Bridget Murray
Monitor staff

Colorectal cancer is one of those silent killers that creeps in quietly. Tiny pre-cancerous polyps--little flaps of skin--stealthily line the inner walls of the intestine. They cause not a second's pain nor discomfort; nothing that would give away their ominous presence.

Unless, that is, they're detected by a screening test.

Unfortunately though, fewer than a third of those at risk for the disease--people 50 and older--get regular colorectal screenings.

"Colorectal cancer is the most preventable cancer but the least prevented," says William Redd, PhD, a researcher at the Ruttenberg Cancer Center at Mount Sinai School of Medicine. "Through a safe and relatively easy outpatient procedure pre-cancerous lesion in the intestine can be detected and removed, thereby effectively preventing the development of a highly lethal cancer. However, most people don't have it done."

But Redd is one of a number of psychologists who believe they've hit on an effective way of motivating screening. With funding from the U.S. Centers for Disease Control and Prevention (CDC), Redd is developing an educational campaign that tailors educational messages to people's varying levels of cancer knowledge and screening frequency, as opposed to a 'one-size-fits-all' approach. In other words, the person who's never had a screening needs a different motivational message from the person who thinks one screening is enough.

And while Redd's focus is colorectal cancer, other psychologists are finding the same tailored method an effective way to bolster screening for other "silent" cancers--the type that, when caught early, can be stopped short. These include cervical, ovarian and breast cancer, among others.

"A tailored intervention means determining who your targeted group is, finding out what they need to know and giving them information they need," says Redd.

With their insight into behavior change, motivation and survey research, he says, psychologists are well positioned to custom-fit messages to populations and test which delivery methods work best--phone calls, letters, in-person chats or various combinations thereof.

Who they are

The first step in a tailored campaign is finding out all you can about the group whose screening levels you wish to boost, says Redd. For his colorectal study, he's surveying members of a health-maintenance organization about their demographics, education level, cancer knowledge, screening history and perceived risk. As with many cancers, people with family members who developed colorectal cancer at early ages are at highest risk, he notes.

Often such high-risk subgroups, or groups with especially low screening rates, are the ones psychologists target. For example, with funding from the Cancer Research Foundation of America, psychologist Robert Hamm, PhD, of the University of Oklahoma's College of Medicine, is studying the demographics and psychological status of women who test positive for a cervical growth, but don't return to their gynecologist to see if it's spread or become cancerous.

He hopes that his research into their backgrounds will shed light on why they don't come back for life-saving screening, so that medical professionals can intervene accordingly. Possible reasons include depression, fear of surgical pain or lack of empowerment in their lives or relationships, says Hamm.

Another high-risk group, women who have low screening rates for breast cancer--the leading cause of cancer deaths for women--is the focus of a number of public education campaigns. These include a program run by the National Cancer Institute (NCI) and another coordinated by the Iowa Psychological Association (IPA). (Using materials from APA's public education campaign, IPA passes out pamphlets on psychological support for breast-cancer patients at Iowa's annual Race for the Cure.)

Among psychologists trying to boost mammography rates are Rosalind Dorlen, PsyD, president of the New Jersey Psychological Association and nurse/psychologist Victoria Champion, PhD, associate dean for research and director of cancer care at the Indiana University Cancer Center. Champion has been examining women's mammography adherence for more than a decade in a series of studies funded by NCI. And Dorlen's work with breast cancer is the latest in a series of community health interventions she and several other health organizations have been helping to develop for Overlook Hospital, a division of the Atlantic Health System.

Focusing in particular on African-American women, who have especially low rates of mammography, Dorlen and her colleagues have started by asking participants into which stage of motivation they fit:

* Precontemplators--Have never had a mammogram, and have no plans for having one in the coming year.

* Contemplators--Have never had a mammogram, but plan to have one at some point.

* Women of action--Have had one or more mammograms, and may or may not plan to have one in the coming year.

* Women of maintenance--Have had more than one mammogram, and plan to have one in the coming year. This is the desired motivation stage.

Using these stages of motivation, Dorlen and her team will vary the educational message so that the message's tone matches the person. For the precontemplator it's "How small is the head of a pin? Not too small for a mammogram to find," with a focus on reducing women's fears about mammography-related discomfort. For the contemplator the message is "Small is better. Think small, think mammogram," with a strong emphasis on prevention. And for the maintenance woman it's, "Looking out for little things is smart. Keep on getting mammograms," with the accent on upkeep.

Champion, who in separate research has also been trying to increase women's mammography adherence with a similar model, has some encouraging results. She finds that at least half of precontemplators seek a mammogram after receiving tailored messages.

Why they don't get screened

In addition to pinpointing knowledge levels and stages of motivation, psychologists are also determining what stops people from getting screened, whether it's concerns about time required, monetary expense, lack of transportation, fear of finding out they have cancer or lack of awareness of cancer prevention.

Often people don't seek screening simply because they don't know of its benefits--that finding precancerous cells means doctors can stop cancer before it starts, says Mount Sinai's Redd. And in the case of colorectal screening, another deterrent is the rather unpleasant nature of the test, involving enemas, intestinal scopes and fecal examination. But Redd argues that colorectal screening is actually less invasive than screening that requires scraping and incisions. This, and the fact that early detection saves lives, is the message people need to hear, he says, noting that the CDC is also seeking to raise public awareness of colorectal screening with the recent launch of its national "Screen for Life" campaign.

How to cast the message

Armed with an understanding of what deters each person from screening and of messages that can motivate behavior change, psychologists then design a campaign of letters, phone calls and personal visits--usually at least two of these means are used--to correct misperceptions and help people surmount barriers.

A person who fears the pain involved might receive a campaign letter or phone call explaining exactly what kind of pain to expect and how to manage it. And a person who fears testing positive for cancer might receive a letter or personal visit explaining that early discovery is a lifesaver. The messages can get quite specific, right down to, "We know it's hard for you to get off work, here are some other times to go for screening," says Champion.

Other strategies include telling people about screening locations near them, or if they're low-income, that screening is covered by Medicare and Medicaid. The messages may seem simple, but for many people, the difference between hearing them or not hearing them is the difference between getting screened or not getting screened, psychologists say.

Champion's research suggests that a combination of letters and phone calls works just as well as personal visits for motivating screening, and is more cost effective. She's also experimenting with interactive education programs delivered on computers.

But Dorlen says there's nothing so effective as having campaign staff talk to women directly at community churches, shopping centers and supermarkets, which she plans to do for her study. She also points out the need for psychologists to collaborate with physicians on the front lines--sharing knowledge with them about educational messages that work.

"Ultimately, a collaborative approach holds more promise than just getting information to women or physicians alone," says Dorlen. "Through partnerships with physician and community groups, psychology needs to roll up its sleeves and show what it can do."