November 4, 2012
Cancer Screening Campaigns -- Getting Past Uninformative Persuasion (Steven Woloshin, M.D., Lisa M. Schwartz, M.D., William C. Black, M.D., and Barnett S. Kramer, M.D., M.P.H., 11/01/12, N Engl J Med 2012)
Posted by Orrin Judd at November 4, 2012 9:25 AMFor nearly a century, public health organizations, professional associations, patient advocacy groups, academics, and clinicians largely viewed cancer screening as a simple, safe way to save lives.1 Public health messages and campaigns reflected and amplified this view, aiming to maximize the population's uptake of screening. One obvious approach was to use powerful tools of persuasion -- including fear, guilt, and a sense of personal responsibility -- to convince people to get screened.A simple recipe for persuasion is to make people feel vulnerable and then offer them hope, in the form of a simple strategy for protecting themselves. The standard approach is to induce vulnerability by emphasizing the risk people face, often framing statistics so as to provoke alarm, and then offer hope by exaggerating the benefit (and ignoring or minimizing the harms) of a risk-reducing intervention.For example: "If you're a woman over 35, be sure to schedule a mammogram. Unless you're still not convinced of its importance. In which case, you may need more than your breasts examined. Find the time. Have a mammogram. Give yourself the chance of a lifetime" (see image). This screening campaign is an example of pure persuasion. No nuance here: breast cancer is so common and deadly, and mammograms so effective, that you'd have to be crazy to forgo screening.Although the American Cancer Society ended that campaign in the 1970s, the use of persuasion is still going strong. For example, Memorial Sloan-Kettering Cancer Center, a top-rated cancer hospital, ran an ad in the New York Times Magazine that read, "The early warning signs of colon cancer: You feel great. You have a healthy appetite. You're only 50" (see slide show at NEJM.org). Many 50-year-olds who find this message scary may be surprised (and relieved) to learn that most 50-year-olds who feel great and have a healthy appetite do not have -- and will not soon develop -- colon cancer. The National Cancer Institute estimates that a 50-year-old's risk of developing colon cancer over the next 10 years is 6 in 1000, and his or her risk of dying from colon cancer is 2 in 1000.
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