Cancer screening decisions: The role of feelings vs. beliefs Laura D. Scherer K.D. Valentine Niraj Patel S. Glenn Baker Angela Fagerlin

Affect and Decision Making Many ways in which affect influences judgments/decisions Affect as information (Schwarz & Clore, 1988) Affect as a heuristic (Slovic et al., 2007; Slovic & Peters, 2006) Feelings is for doing (Zeelenberg et al., 2008) People often make judgments/decisions by asking “How do I feel about it?” (Schwarz & Clore, 1988)

Feelings vs. Beliefs What happens when feelings and beliefs obviously conflict? Feelings say “do something!” Beliefs (and objective fact) say “don’t do that—it’s not going to work” A real life case...

The case of prostate cancer screening PSA screening for prostate cancer was broadly recommended for years Now, it is not strictly recommended at all United States Preventive Services Task Force recommends against the test American Cancer Society recommends that men may choose to get test only after they are informed Evidence suggests it may save no lives, and causes harm There is no replacement test https://www.harding-center.mpg.de/en https://www.uspreventiveservicestaskforce.org

Theoretical Perspectives Feeling: Cancer is scary! Belief: There’s nothing I can do! Health behavior models: Protection Motivation Theory/Extended Parallel Process Model (Rogers, 1975; Witte, 1992): Fear/anxiety + screening is ineffective = defensive coping But...feelings can sometimes influence decisions directly, independent of beliefs: Fear/anxiety + screening is ineffective = do it anyway

Observed disconnect between beliefs and screening preferences After being informed about revised recommendation against prostate cancer screening...(Squiers et al., 2013) 62% of men agreed with recommendation to not get screened only 13% planned to follow recommendation People want screening under other dubious conditions E.g. 1/2 want test to detect benign cancers, or “pseudo-disease” E.g. 2/3rds want test when nothing could be done about the cancer (Schwartz, Woloshin, Fowler & Welch, 2004; Waller, Osborne & Wardle, 2016) What is going on here? A: Perhaps they still believe there is a chance for benefit A: Perhaps they understand the low chance of benefit, but feelings—e.g. anxiety—drive desire to do something to prevent cancer.

The Present Research Would anyone want a cancer screening test that unambiguously had no mortality benefit whatsoever? Make it completely clear: This test does not reduce the chance of death from cancer or extend the length of life If a substantial proportion of people accept such a test, what is driving their decisions? Beliefs: Refusal to believe that screening does not affect death rate Feelings: e.g., cancer anxiety

A hypothetical test with no benefit Posed a hypothetical scenario to nationally representative sample of U.S. adults 1606 men and women surveyed online Age: 40-70, M=54, SD=8.6 Demographics matched U.S. population statistics (race/ethnicity, education, income) Funding source: Time Sharing Experiments for the Social Sciences (TESS) and the National Science Foundation

A hypothetical test with no benefit “Imagine that the following is true: There is a new test to screen for [breast/prostate] cancer that uses diagnostic technology to look for abnormalities that may be early stage cancer. “However, years of research have unquestionably shown that the test does not extend life or reduce the chance of death from [breast/prostate] cancer. Studies have shown that when comparing two groups of [women/men], one who received this test yearly and one who never received the test, both groups had equal numbers of [women/men] who died from [breast/prostate] cancer. In these studies, the group of [women/men] who got the screening test had more cancers diagnosed and treated, but this did not reduce the number of cancer deaths or extend the length of life.

A hypothetical test with no benefit “One problem with the test is that it may detect cell abnormalities that will never develop into dangerous cancer. This can lead to unnecessary treatment. The test can also fail to detect dangerous cancers. Finally, the most dangerous cancers grow and spread so quickly that they are more likely to be detected between screenings from symptoms.”

Method Baseline measures: Worry about getting cancer, 1=not at all, 7=extremely Perceived lifetime cancer risk, 1=low risk, 7=high risk Read about test with no mortality benefit No detailed harms Detailed list of screening harms Outcome measures

Outcome measures Critical outcome: If this was the only test that was available to you, would you want to get this test, or not? What we are really asking: Is getting this test viewed as better than no test at all? Other important outcomes: What did you believe about this test? Did you believe that this test saves lives, does not save lives, or were you unsure? In your opinion, how risky is this test? 1-7, not at all risky-very risky

Results 54% 31%

Beliefs Only 55% of respondents believed that the test does not save lives (891/1606)

Predictive strength of beliefs vs. feelings

Summary A surprising proportion of people want screening in the clear absence of benefit Many wanted screening even though they believed that the test does not save lives Anxiety predicted decisions controlling for perceived benefits and risks Suggests that emotions create desire for action despite acknowledged futility Points to the need to “just do something” when it comes to extreme perceived threats; emotions motivate action (e.g. Zeelenberg et al., 2008) Want to take action even when they know the action is futile “If it can’t hurt me, why not?” Cancer anxiety can potentially lead a person to seek a useless screening test even when their beliefs about the risks and benefits indicate that doing so is irrational.

Thank you Contact: schererl@missouri.edu This study was supported by Time Sharing Experiments for the Social Sciences (TESS) and the National Science Foundation

Moyer, V.A., 2012, https://www.uspreventiveservicestaskforce.org PSA screening data Moyer, V.A., 2012, https://www.uspreventiveservicestaskforce.org