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Women's misconceptions about cancer screening: implications for informed decision-making
Patient Education and Counseling 57 (2005) 280–285 www.elsevier.com/locate/pateducou
Women’s misconceptions about cancer screening: implications for informed decision-making Thomas D. Denberga,*, Sabrina Wongb, Angela Beattiec a
Division of General Internal Medicine, University of Colorado Health Sciences Center, B-180, Denver, CO 80262, USA b School of Nursing, University of British Columbia, Vancouver, BC, Canada c Department of Anthropology, History, and Social Medicine, University of California, San Francisco, USA Received 25 March 2004; received in revised form 15 July 2004; accepted 15 July 2004
Abstract Informed decision-making about cancer screening requires that patients have a correct understanding of a test’s purpose, benefits, and risks. Misconceptions, however, may be common. Semi-structured interviews were carried out and thematically coded using a purposive sample of 24 socioeconomically diverse white, African American, Latino and Chinese American women recruited from general medicine practices and community settings. Interviews focused on participants ideas related to cancer prevention and screening. Women expressed cancer-related beliefs characterized by inaccuracies, distortions, and over-simplifications. Many of these beliefs may go unrecognized in clinical settings yet have a profound influence on risk communication and, therefore, informed decision-making. Effective communication depends, first, on clinicians and patients sharing an accurate understanding of background concepts such as ‘‘prevention,’’ ‘‘screening,’’ and ‘‘cancer.’’ # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Health beliefs; Cultural factors; Cancer screening; Risk communication; Informed decision-making
1. Introduction The strongest predictor of participating in cancer screening is having a usual source of medical care and the recommendation of a physician [1]. Nonetheless, even with physician recommendation, patient non-acceptance or non-completion of screening is high [2,3]. Various aspects of the patient–physician relationship may be implicated, including trust, communication, and race and gender concordance [4]. In addition, common sense and some evidence [5,6] suggest that patient misconceptions about a screening test’s purpose or side effects have an adverse effect on adherence. Viewed in another way, misconceptions about cancer prevention may compromise the quality of patient decisions around screening. Increasingly, informed decision-making rather than simple adherence to physician recommendation * Corresponding author. Tel.: +1 303 372 9432; fax: +1 303 372 9082. E-mail address: [email protected] (T.D. Denberg).
– is the dominant paradigm, especially when the benefits of a screening test are uncertain, or when downstream testing or treatment is controversial or associated with unacceptable side effects [7]. Examples include the prostate specific antigen (PSA) test for men [8] and, for women, mammography starting at age 40 [9] and the discontinuation of PAP smears over age 65 [10]. Even when there is significant medical consensus about the benefits of screening, as is the case for colorectal cancer, many believe that informed decision-making by patients should be the norm [11]. This study addresses the following question: what misconceptions do patients have about screening that, unrecognized or overlooked by clinicians, might influence informed decision-making? To our knowledge, the relationship between patient misconceptions and informed decisionmaking has received little systematic attention. By assessing how patient beliefs deviate from biomedical understandings, we will lay the groundwork for follow-up studies and interventions to improve the quality of informed decisionmaking.
0738-3991/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2004.07.015
T.D. Denberg et al. / Patient Education and Counseling 57 (2005) 280–285 Table 1 Participant characteristics (n = 24) Race/ethnicity
n
Mean age (range)
Educational level
African American Chinese American Hispanic White, non-Hispanic
6 6 6 6
64 61 71 65
High school–Ph.D.
(50–79) (50–79) (60–80) (57–71)
2. Methods The data reported here were part of a larger study designed to understand factors influencing self-perceived risk and decision-making in the context of cancer screening for women. A purposive sample of 24 women aged 50 years and older, and of diverse socioeconomic and racial/ethnic backgrounds, was invited (Table 1) to take part in in-depth, semi-structured interviews of 60–90 min duration. All had access to cancer screening through Medicare or private insurance. Using HIPAA procedures, the majority were recruited from the University of California, San Francisco (UCSF) general medicine clinics using patient lists but, because of the low number of Chinese women using these clinics, face-to-face recruitment through the Chinatown Public Health department was also used. In the general medicine clinics, participants were first sent a letter describing the study in English, Spanish and Chinese and then contacted by phone to arrange an interview if they indicated an interest in participating. Based on prior experience with this kind of research, this sample size was regarded as sufficient to exhaust the elicitation of new information or insights [12]. The interview, based on a relevant literature review and pilot testing, was conducted in the participants’ language of choice (English, Spanish, and Cantonese) and focused on knowledge of, expectations for, and prior experiences with cancer screening; self-perceived cancer risk; interpretation of risk messages in varying formats; and factors influencing decision-making around screening. An open-ended protocol allowed respondents to express themselves completely before the interviewer introduced possibly new or unfamiliar concepts. Participants were given US$ 25 compensation for their time. This study was approved by the University of California, San Francisco Institutional Review Board. All interviews were audio-recorded and transcribed verbatim using numerical codes to protect participant identities. The data were coded using NVivo (QSR NVivo, copyright 1999–2002), a software package for qualitative research. Using grounded theory methodology [13], each investigator independently read the transcripts and came to a consensus regarding the major themes. Subsequently, the three authors independently analyzed the data and produced separate summary statements. One of the authors is a medical anthropologist and internist (TD), another is a medical anthropologist (AB), and the third (SW) is a research nurse with prior experience in qualitative research.
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Jointly, the investigators then reviewed the summaries and the original transcriptions to produce consensus documents for each transcription. This process involved comparing findings, discussing divergent coding, and resolving differences of interpretation when necessary. Finally, based on the summary and consensus statements, the investigators independently prepared synopses of recurrent themes applicable to the entire sample. Synopses focused on the following two broad categories of belief: (1) screening/early detection and (2) cancer prevention and preventability.
3. Results The overall response rate for this study was 46%, however this varied by race/ethnicity (86% for whites, 40% for African Americans, 46% for Latinas, and 35% for Chinese Americans), suggesting that the recruitment of older, minority women was more difficult. Key beliefs that emerged from the interviews are summarized in Table 2 and elaborated below. 3.1. Screening is only indicated with symptoms or a family history Despite the ubiquity of public health messages proclaiming the importance of asymptomatic cancer screening, several women held contrasting opinions. Typically, these Table 2 Cancer prevention and screening beliefs Screening is only indicated with symptoms or a family history: Screening is indicated only when one has worrisome or unpleasant bodily signs or symptoms. If one does not have a family history of cancer, screening is not needed. Lack of knowledge of pre-malignancy: The only purpose of screening (or early detection) is to find cancer. Preventing cancer means preventing death from cancer: ‘‘Preventing cancer’’ means preventing death from cancer. Preventing (the emergence of) cancer is not possible. Pessimistic cancer beliefs: Cancer is a death sentence. The worry that goes along with cancer is just as bad as having cancer itself. Cancer always causes physical pain and suffering. Screening finds cancer when it is too late. Screening tests are inconvenient/physically unpleasant. Non-scientific benefits of screening: Screening provides a ‘‘routine’’ and ‘‘general exam’’ of a body part. The primary benefit of screening is ‘‘peace of mind.’’ Screening provides a ‘‘clean bill of health.’’ Screening offers protection from developing or dying of cancer. [Magical beliefs that frequent and regular screening safeguards against developing or dying of cancer.] Screening tests are highly accurate. A failure to get cancer screening can cause cancer.
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Table 3 Respondent statements – screening depends on the presence of bodily symptoms or family history
Table 4 Respondent statements – preventing cancer means preventing death from cancer; the emergence of cancer itself is not preventable
Before getting screening I’d need to think about what’s been going on in my life, my body and my health. How much I felt that related to what we’d be doing. – African American, 65. If I’m healthy, why would I get breast cancer? – White, 59. I would not go see a doctor unless I was ill. – Latina, 54. I’m not at risk for cancer because I have no problems with my bowel movements and I drink a lot of water. – Chinese, 50. Nobody in my family had cancer, so I’m not worried about it. – African American, 54.
Finding cancer early is good, before one is assigned to a death sentence. –Latina, 62. I believe early detection enhances your ability to recover without any, well hopefully without any, possibility of a reoccurence.– African American, 50. Cancer cannot be prevented because it’s just too complex. – African American, 65. I don0 t believe there0 s a prevention for cancer. . . because I don’t know the causes of cancer. – Chinese, 79. Cancer can’t be prevented. Some people have been eating right, staying fit and having no family history of cancer. Yet they are still diagnosed with cancer. – Chinese, 64. I would hope cancer can be prevented, but I can’t be sure because what has been studied today is being disagreed with by the study of tomorrow or next week. They go back and forth so I’m really convinced nobody knows. –White, 67. There’s no prevention for cancer. Every person is different. Every cancer is different. – White, 65.
involved the idea that cancer screening is relevant only when something is perceptibly wrong with one’s body. Although these kinds of beliefs were expressed more commonly among immigrant and less-educated women, they were by no means exclusive to these groups. Also encountered was the notion that screening is most important when there is a family history of cancer; otherwise, it may be irrelevant (see Table 3). 3.2. Lack of knowledge of pre-malignancy Although some women valued screening only in the context of acute illness, the majority did affirm the value of catching cancer ‘‘early’’ or ‘‘in time,’’ by which they meant when it is still small, before it causes physical symptoms, before it has a chance to grow and spread, and when it is therefore more easily treatable. The vast majority of these women, however, believed that ‘‘cancer screening’’ is simply and only that – screening for cancer. Very few understood that certain forms of screening (e.g. PAP and colonoscopy) aim to identify abnormal cells before transformation to malignancy. 3.3. Preventing cancer means preventing death from cancer When asked, ‘is cancer preventable?’ about half the women responded with their opinions about whether cancer deaths are preventable. The meaning of ‘‘prevention’’ drew strongly on ideas of survivability and the ability to identify and treat cancer early. A recurring theme was that cancer caught ‘‘too late’’ is not survivable and, therefore, is not ‘‘preventable’’ either. At the same time, respondents conveyed in a variety of ways the idea that the emergence of cancer itself is not preventable, even if death might be (see Table 4). 3.4. Pessimistic cancer beliefs Hopefulness about the ability of screening to prevent death existed in an uncertain and complex relationship with, and did little to mitigate, pervasive and pessimistic attitudes about cancer (see Table 5). In addition, several women felt that most screening tests involve considerable inconve-
Table 5 Respondent statements – pessimistic cancer beliefs If one has cancer, it’s best to die quickly. – Latina, 79. Once cancer is found, there’s nothing that can be done about it. –Chinese, 79. You will have to face the pain and illness. I always think that death is not a problem, but the worse thing is to suffer from pain and illness. Pain does not let you escape for 1 min. – White, 62. The worry is just as bad as the cancer itself. – African American, 66.
nience and physical discomfort. Several patients discounted the value of screening altogether, saying that any time one finds cancer it is ‘‘too late,’’ meaning there is no hope for survival. Only if ‘‘absolutely necessary,’’ they avowed, would they consent to screening. While many women were averse to screening because of pessimistic beliefs about cancer, when we asked about risks associated with screening itself no one mentioned possible adverse physical effects (e.g. infection, bleeding and perforation with colonoscopy) or psychological harms associated with false positives and negatives, awaiting test results, and undergoing diagnostic follow-up procedures. 3.5. Non-scientific benefits of screening Contrasting with these generally pessimistic ideas, almost all respondents manifested optimistic but incorrect beliefs about screening. For example, about three-fourths of participants regarded screening as valuable by itself, without a clear-cut reference to cancer. A prominent aspect of this was ritualistic (‘‘routine or regular or yearly screening is important’’) and another was metonymic, in which screening represented the somewhat vague benefits of a medical ‘‘check-up’’ more generally (Table 6). In several instances, participants had had screening tests without knowing these were cancer-related, believing that screening provides a general evaluation of a body part (Table 6).
T.D. Denberg et al. / Patient Education and Counseling 57 (2005) 280–285 Table 6 Respondent statements – non-scientific beliefs in the benefits of screening Screening confers the benefits of a regular medical check-up Mammography is a commonplace test, part of a yearly check-up. – White, 54. I don’t think the doctor would emphasize, at my age, to have the screening for cancer. It was just part of the regular check-ups. – Chinese, 57. Early screening is a faith and a habit. – Chinese, 62. Screening provides a general evaluation of a body part I had my PAP just to make sure everything was okay down there, and the doctor said there was no problem.’’ – White, 67. [Sigmoidoscopy]. . .is an annual thing. . . that’s all. Tests should be done to make sure nothing is wrong.’’ – Chinese, 57 Screening protects one from developing cancer in the future If you have [a screening test] done as often as you are supposed to have it done, then your risk is getting lower. – African American, 54. I feel better and more secured with positive test results. – Chinese, 62. . . .now that I don’t have my womb, they tell me I don’t need [a Pap smear]. Although I like to get it every two to three years because it’s better. . .It makes things safer. – Latina, 62. The primary benefit of screening is peace of mind Greatest benefit is learning you don’t have cancer, the greatest detriment is learning you have cancer and having to have a part of your body removed. Very painful. – Latina, 79. I think screening helps to eliminate certain fears, you know. –African American, 59. I do know that an intelligent person needs the tests routinely, just to make sure everything is cool. – White, 63. Screening helps to comfort you. – Chinese, 65. Screening offers a ‘‘clean bill of health’’ I had a colonoscopy and they removed some polyps, so I’m going to be okay. – White, 63 Screening tests are highly accurate False positives are extremely unlikely – everyone makes mistakes. . . early detection would not harm you. – African American, 53. If the results are normal, I’m not worried about risk. – Latina, 62.
A common theme was that rather than prevention, screening confers protection against the future development of cancer (or perhaps any other abnormality in a body part). Whereas prevention connotes impeding, hindering, or taking precautions against some future, uncertain event, protection is more directly linked with the body itself and with the sense that one’s physical state has undergone transformation. Many women felt that by getting screening their body was now armored or shielded. There was magical thinking and a fetishistic aspect involved, in which something tangible (a medical test) is more than simply diagnostic – it confers physical safety and security. In this way, some participants suggested that the more screening one receives, the safer one becomes. Ultimately, it appears that protection has more concrete, definite, and immediately beneficial connotations than prevention (Table 6). Nearly ubiquitous was the notion that the primary reward of screening is ‘‘peace of mind.’’ Even if catching cancer
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early is ‘‘good’’ from one perspective, a more prominent viewpoint is that a cancer diagnosis and (the unpleasantness of) treatment are not at all desirable. Thus, participants stressed first and foremost the ability of screening to provide reassurance, emphasizing this over the timely opportunity to identify and take care of a health problem (Table 6). One woman seemed to extrapolate from this to the idea that, once a screening test provides a ‘‘clean bill of health,’’ future screening is no longer important. The perceived ability of screening to eliminate anxiety or to offer a clean bill of health went hand-in-hand with a prevailing lack of understanding regarding false positives and negatives. In general, participants believed there were no disadvantages to screening, that these tests are simple, highly accurate, and in most cases reassuring (Table 6). The more ‘routine’ or less ‘invasive’ a test was perceived to be, the less resistance there was to having it done. Five participants, however, discounted the value of screening altogether, saying that any time one finds cancer it is ‘‘too late,’’ meaning there is no hope for survival. In one of the most forceful assertions regarding the value of screening, a few women related that a failure to get screened might, itself, cause cancer. A variant of the screening-offersprotection theme, there was apparent slippage between the (correct) concept of more advanced-stage cancer diagnoses without screening and the (incorrect) idea that not getting screening actually increases one’s risk of developing cancer de novo. For example, when asked, ‘‘What things cause cancer?,’’ one respondent replied, ‘‘Doing things you know you are not supposed to do. Drinking a lot, eating foods you should not eat. Not having screenings.’’ (Latina 77).
4. Discussion and conclusion Within a multi-ethnic and socioeconomically diverse sample of women this study illuminated a number of recurring beliefs related to cancer prevention and screening. We classified these beliefs under the following headings: beliefs that screening is indicated only with symptoms or family history; lack of knowledge of pre-malignancy; interpreting cancer prevention as the prevention of death; pessimistic cancer beliefs; and non-scientific beliefs about the benefits of screening. Common to each category, these beliefs are characterized by inaccuracies, distortions, and over-simplifications. We are unaware of any prior studies that systematically illustrate misconceptions about cancer screening within a diverse sample of women. We suspect that these beliefs often remain undisclosed in clinician– patient encounters and therefore have important implications for informed decision-making. The idea that there are many misconceptions about cancer and screening is not a new one, and many of our findings replicate those of other investigators. One particularly novel aspect of our findings, however, includes
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the idea that screening is exclusively intended to find cancer, with virtually no understanding of pre-malignancy. Similarly, ‘‘prevention’’ was more strongly associated with preventing death from cancer than with preventing the development of cancer itself. These kinds of beliefs, while perhaps accurate in relation to mammography and PSA testing, are off the mark when it comes to cervical and colon cancer screening. Thus, with these two tests in particular, greater emphasis on clarifying the concept of premalignancy may be particularly important for enhancing patients’ ability to make informed decisions about screening. Perhaps most crucially, the relevance of patient misconceptions depends on whether one subscribes to an adherence or informed decision-making model. With adherence, the overarching goal is to increase rates of screening. This is the traditional emphasis of public health programs. In these contexts, a common exercise is to discredit any erroneous beliefs that bias against screening (cons), such as ‘‘I would probably not have a mammogram unless I had some breast symptoms or discomfort’’ [14]. With informed decision-making, on the other hand, the goal is to help individual patients understand both the risks and benefits of screening in such a way that they can decide whether or not screening is personally acceptable to them. With regard to an adherence model, some of the misconceptions we identified would seem to act as barriers to screening. For example, patients who value screening only in the context of physical symptoms or in the setting of a family history misunderstand its purpose and may be reluctant to obtain it. Similarly, adherence may be compromised when patients believe that the only purpose of screening is to identify cancer after it has already developed and when their perceptions of cancer are distinctly nihilistic (e.g. that cancer is a death sentence, that cancer cannot be prevented, or that cancer causes unbearable pain or anxiety). Again, when pertinent, we might be able to mitigate these barriers to screening by better educating patients about the concept of pre-malignancy: if patients understand that certain screening tests (e.g. PAP smears and colonoscopies) can actually prevent the emergence of cancer and, consequently, its terrible ramifications, they may be more likely to accept it. In the end, simply imparting basic information about the benefits of screening may be insufficient: increased adherence may require special efforts to identify and counteract erroneous beliefs that bias against screening. When viewed from the perspective of informed decisionmaking, patients who have misconceptions that bias against screening are clearly not in a position to make adequately informed choices. It is here that adherence and informed decision-making most closely overlap. Informed decisionmaking, however, does not aim to increase adherence, per se, nor does it implicitly privilege the benefits of screening over the risks: instead, it aims to help patients understand risks and benefits equally so that they can make decisions that are
congruent with their personal values and preferences. As evidenced by the present study, many erroneous patient beliefs reflect pros of screening (e.g. that screening provides a general check-up of a body part, or that the more screening one has the more protected one is against future cancer). The implication is that informed decision-making requires the active thwarting of misinformation – not only against screening, but for screening as well. Significantly, this is rarely emphasized within an adherence model. This looms in importance, however, when the benefits of screening are controversial or uncertain (e.g. PSA testing, mammography between ages 40 and 49, and colonoscopy as the initial preferred mechanism for colon cancer prevention). It was also quite noteworthy that almost none of the women in the study recognized the well-known biomedical risks of screening, including psychological harms associated with false positive and negatives, awaiting test results, and undergoing diagnostic procedures. This is another area deserving of increased attention in health education materials and clinician–patient discussions. In fact, patient misconceptions can impair the quality of patient–clinician communication more generally. Just as clinicians and patients are unlikely to concur in their interpretation of numerical risks, our findings suggest that they are also unlikely to coincide in their interpretation of key concepts. This is not always obvious, however, because both employ a common vocabulary (‘‘cancer,’’ ‘‘screening,’’ and ‘‘prevention’’) while attributing different meanings to it. The appearance of mutual understanding belies an unrecognized ‘‘talking past’’ each other, thereby frustrating possibilities for informed decision-making. Finally, much research on cancer prevention has emphasized the ‘‘culture-specific’’ beliefs and attitudes of specific racial/ethnic groups [15–19] (e.g. Latinos are ‘‘fatalistic,’’ African Americans ‘‘distrust’’ the health care system). Although certain kinds of beliefs might be more common, intense, or expressed in unique ways among particular groups (e.g. the importance of emotional balance among older Chinese immigrants), and in certain cases might be quite important for decision-making, our findings suggest that many beliefs about prevention and screening recur, in basic form, across racial/ethnic and socioeconomic boundaries, and that there is also great variability in beliefs within racial/ethnic groups. A potential downside of emphasizing ‘‘culture-specific’’ beliefs tied to race/ethnicity is that of reinforcing stereotypes and perpetuating the notion that only non-white minority groups have unusual or exotic beliefs. In fact, as we found in our small sample, white (and relatively well-educated) women were no less likely than others to hold strong, non-biomedically-informed ideas about cancer and prevention. Ultimately, we believe it may be more productive to identify cross-cutting beliefs within heterogeneous populations or, alternatively, to seek culturally-specific beliefs by studying groups much narrower than those characterized by conventional categories of race/ ethnicity [20].
T.D. Denberg et al. / Patient Education and Counseling 57 (2005) 280–285
This study was limited by a small sample located in a single geographic area, and by the inability to rigorously explore the influence of particular beliefs on actual screening preferences and prior screening behavior. On the other hand, face-to-face interviews are considered a gold standard for qualitative research. We were also able to conduct interviews until the emergence of new data or themes was exhausted. Finally, in a way that would not have otherwise been possible, the qualitative approach brought context and richness to an understanding of women’s beliefs about cancer screening and prevention. 4.1. Suggesions for future research Specific misconceptions that women have about cancer, prevention, and screening may have a key influence on informed decision-making around screening. Quantitatively-oriented studies should help to reveal more about how ubiquitous, influential, and amenable to change patient misconceptions might be, a project that should complement more conventional approaches to eliciting utilities and communicating numerical risk. Ideally, such knowledge will contribute to improved, conceivably tailored, forms of health education preparatory to realizing more effective risk communication and patient decision-making. 4.2. Practice implications The results of this study highlight the importance of eliciting patients’ own perspectives regarding the risks and benefits of screening. Particular emphasis should be placed on determining whether patients believe screening is predicated on the presence of physical symptoms or a family history, and whether they accurately understand the concept of pre-malignancy and the prevention of de novo cancers in settings such as colonoscopy and PAP smears. Finally, if the goal is to promote informed decision-making over simple adherence, it is also essential to identify and correct patient misconceptions that bias in favor of screening.
Acknowledgements This study was supported in part by a grant from the Agency for Healthcare Research and Quality/National Institutes of Health, P01 HS10856, ‘‘Promoting Effective Communication and Decision-Making for Diverse Populations,’’ Eugene A. Washington, M.D., M.Sc. (PI). We thank Eliseo Pe´ rez-Stable, Deirdra Forte, Julissa Saavedra, and Lei-Chun Fung for their assistance in planning and carrying out the interviews.
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References [1] Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R. Progress in cancer screening over a decade: results of cancer screening from the 1987 and 1998 National Health Interview Surveys. J Natl Cancer Inst 2001;93:1704–13. [2] O’Malley AS, Forrest CB, Mandelblatt J. Adherence of low-income women to cancer screening recommendations. J Gen Intern Med 2002;17:144–54. [3] Burack RC, Liang J. The early detection of cancer in the primary-care setting: factors associated with the acceptance and completion of recommended procedures. Prev Med 1987;16:739–51. [4] Garcia JA, Paterniti DA, Romano PS, Kravitz RL. Patient preferences for physician characteristics in university-based primary care clinics. Ethn Dis 2003;13:259–67. [5] Becker M. The Health Belief Model and preventive health behavior. Health Educ Q 1974;2:324–508. [6] Bauman LJ, Wright E, Leickly FE, Crain E, Kruszon-Moran D, Wade SL, Visness CM. Relationship of adherence to pediatric asthma morbidity among inner-city children. Pediatrics 2002;110:6. [7] Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med 2004;140:54–9. [8] Purvis Cooper C, Merritt TL, Ross LE, John LV, Jorgensen CM. To screen or not to screen, when clinical guidelines disagree: primary care physicians’ use of the PSA test. Prev Med 2004;38:182–91. [9] Holmes-Rovner M, Charles S. The mammography screening controversy: who and what is heard in the press? Patient Educ Couns 2003;51:75–81. [10] Sawaya GF. Should routine screening Papanicolaou smears be done for women older than 65 years? Arch Intern Med 2004;164:243–5. discussion 247–248. [11] Wolf AM, Schorling JB. Does informed consent alter elderly patients’ preferences for colorectal cancer screening? Results of a randomized trial J Gen Intern Med 2000;15:24–30. [12] Kuzel AJ, Engel JD, Addison RB, Bogdewic SP. Desirable features of qualitative research. Fam Pract Res J 1994;14:369–78. [13] Strauss A, Corbin J. Basics of qualitative research techniques and procedures for developing grounded theory. second Ed. London: Sage Publications; 1990. [14] Rakowski W, Clark MA, Pearlman DN, Ehrich B, Rimer BK, Goldstein III MG, Dube CM, Woolverton H. Integrating pros and cons for mammography and Pap testing: extending the construct of decisional balance to two behaviors. Prev Med 1997;26: 664–73. [15] Byrd TL, Peterson SK, Chavez R, Heckert A. Cervical cancer screening beliefs among young Hispanic women. Prev Med 2004;38:192–7. [16] Chan EC, Haynes MC, O’Donnell FT, Bachino C, Vernon SW. Cultural sensitivity and informed decision making about prostate cancer screening. J Community Health 2003;28:393–405. [17] Goldman RE, Risica PM. Perceptions of breast and cervical cancer risk and screening among Dominicans and Puerto Ricans in Rhode Island. Ethn Dis 2004;14:32–42. [18] Wolff M, Bates T, Beck B, Young S, Ahmed SM, Maurana C. Cancer prevention in underserved African American communities: barriers and effective strategies: a review of the literature. WMJ 2003;102: 36–40. [19] Wong-Kim E, Sun A, DeMattos MC. Assessing cancer beliefs in a Chinese immigrant community. Cancer Control 2003;10:22–8. [20] McGarvey EL, Clavet GJ, Johnson II JB, Butler A, Cook KO, Pennino B. Cancer screening practices and attitudes: comparison of lowincome women in three ethnic groups. Ethn Health 2003;8:71–82.
Women’s misconceptions about cancer screening: implications for informed decision-making Thomas D. Denberga,*, Sabrina Wongb, Angela Beattiec a
Division of General Internal Medicine, University of Colorado Health Sciences Center, B-180, Denver, CO 80262, USA b School of Nursing, University of British Columbia, Vancouver, BC, Canada c Department of Anthropology, History, and Social Medicine, University of California, San Francisco, USA Received 25 March 2004; received in revised form 15 July 2004; accepted 15 July 2004
Abstract Informed decision-making about cancer screening requires that patients have a correct understanding of a test’s purpose, benefits, and risks. Misconceptions, however, may be common. Semi-structured interviews were carried out and thematically coded using a purposive sample of 24 socioeconomically diverse white, African American, Latino and Chinese American women recruited from general medicine practices and community settings. Interviews focused on participants ideas related to cancer prevention and screening. Women expressed cancer-related beliefs characterized by inaccuracies, distortions, and over-simplifications. Many of these beliefs may go unrecognized in clinical settings yet have a profound influence on risk communication and, therefore, informed decision-making. Effective communication depends, first, on clinicians and patients sharing an accurate understanding of background concepts such as ‘‘prevention,’’ ‘‘screening,’’ and ‘‘cancer.’’ # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Health beliefs; Cultural factors; Cancer screening; Risk communication; Informed decision-making
1. Introduction The strongest predictor of participating in cancer screening is having a usual source of medical care and the recommendation of a physician [1]. Nonetheless, even with physician recommendation, patient non-acceptance or non-completion of screening is high [2,3]. Various aspects of the patient–physician relationship may be implicated, including trust, communication, and race and gender concordance [4]. In addition, common sense and some evidence [5,6] suggest that patient misconceptions about a screening test’s purpose or side effects have an adverse effect on adherence. Viewed in another way, misconceptions about cancer prevention may compromise the quality of patient decisions around screening. Increasingly, informed decision-making rather than simple adherence to physician recommendation * Corresponding author. Tel.: +1 303 372 9432; fax: +1 303 372 9082. E-mail address: [email protected] (T.D. Denberg).
– is the dominant paradigm, especially when the benefits of a screening test are uncertain, or when downstream testing or treatment is controversial or associated with unacceptable side effects [7]. Examples include the prostate specific antigen (PSA) test for men [8] and, for women, mammography starting at age 40 [9] and the discontinuation of PAP smears over age 65 [10]. Even when there is significant medical consensus about the benefits of screening, as is the case for colorectal cancer, many believe that informed decision-making by patients should be the norm [11]. This study addresses the following question: what misconceptions do patients have about screening that, unrecognized or overlooked by clinicians, might influence informed decision-making? To our knowledge, the relationship between patient misconceptions and informed decisionmaking has received little systematic attention. By assessing how patient beliefs deviate from biomedical understandings, we will lay the groundwork for follow-up studies and interventions to improve the quality of informed decisionmaking.
0738-3991/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2004.07.015
T.D. Denberg et al. / Patient Education and Counseling 57 (2005) 280–285 Table 1 Participant characteristics (n = 24) Race/ethnicity
n
Mean age (range)
Educational level
African American Chinese American Hispanic White, non-Hispanic
6 6 6 6
64 61 71 65
(50–79) (50–79) (60–80) (57–71)
2. Methods The data reported here were part of a larger study designed to understand factors influencing self-perceived risk and decision-making in the context of cancer screening for women. A purposive sample of 24 women aged 50 years and older, and of diverse socioeconomic and racial/ethnic backgrounds, was invited (Table 1) to take part in in-depth, semi-structured interviews of 60–90 min duration. All had access to cancer screening through Medicare or private insurance. Using HIPAA procedures, the majority were recruited from the University of California, San Francisco (UCSF) general medicine clinics using patient lists but, because of the low number of Chinese women using these clinics, face-to-face recruitment through the Chinatown Public Health department was also used. In the general medicine clinics, participants were first sent a letter describing the study in English, Spanish and Chinese and then contacted by phone to arrange an interview if they indicated an interest in participating. Based on prior experience with this kind of research, this sample size was regarded as sufficient to exhaust the elicitation of new information or insights [12]. The interview, based on a relevant literature review and pilot testing, was conducted in the participants’ language of choice (English, Spanish, and Cantonese) and focused on knowledge of, expectations for, and prior experiences with cancer screening; self-perceived cancer risk; interpretation of risk messages in varying formats; and factors influencing decision-making around screening. An open-ended protocol allowed respondents to express themselves completely before the interviewer introduced possibly new or unfamiliar concepts. Participants were given US$ 25 compensation for their time. This study was approved by the University of California, San Francisco Institutional Review Board. All interviews were audio-recorded and transcribed verbatim using numerical codes to protect participant identities. The data were coded using NVivo (QSR NVivo, copyright 1999–2002), a software package for qualitative research. Using grounded theory methodology [13], each investigator independently read the transcripts and came to a consensus regarding the major themes. Subsequently, the three authors independently analyzed the data and produced separate summary statements. One of the authors is a medical anthropologist and internist (TD), another is a medical anthropologist (AB), and the third (SW) is a research nurse with prior experience in qualitative research.
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Jointly, the investigators then reviewed the summaries and the original transcriptions to produce consensus documents for each transcription. This process involved comparing findings, discussing divergent coding, and resolving differences of interpretation when necessary. Finally, based on the summary and consensus statements, the investigators independently prepared synopses of recurrent themes applicable to the entire sample. Synopses focused on the following two broad categories of belief: (1) screening/early detection and (2) cancer prevention and preventability.
3. Results The overall response rate for this study was 46%, however this varied by race/ethnicity (86% for whites, 40% for African Americans, 46% for Latinas, and 35% for Chinese Americans), suggesting that the recruitment of older, minority women was more difficult. Key beliefs that emerged from the interviews are summarized in Table 2 and elaborated below. 3.1. Screening is only indicated with symptoms or a family history Despite the ubiquity of public health messages proclaiming the importance of asymptomatic cancer screening, several women held contrasting opinions. Typically, these Table 2 Cancer prevention and screening beliefs Screening is only indicated with symptoms or a family history: Screening is indicated only when one has worrisome or unpleasant bodily signs or symptoms. If one does not have a family history of cancer, screening is not needed. Lack of knowledge of pre-malignancy: The only purpose of screening (or early detection) is to find cancer. Preventing cancer means preventing death from cancer: ‘‘Preventing cancer’’ means preventing death from cancer. Preventing (the emergence of) cancer is not possible. Pessimistic cancer beliefs: Cancer is a death sentence. The worry that goes along with cancer is just as bad as having cancer itself. Cancer always causes physical pain and suffering. Screening finds cancer when it is too late. Screening tests are inconvenient/physically unpleasant. Non-scientific benefits of screening: Screening provides a ‘‘routine’’ and ‘‘general exam’’ of a body part. The primary benefit of screening is ‘‘peace of mind.’’ Screening provides a ‘‘clean bill of health.’’ Screening offers protection from developing or dying of cancer. [Magical beliefs that frequent and regular screening safeguards against developing or dying of cancer.] Screening tests are highly accurate. A failure to get cancer screening can cause cancer.
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Table 3 Respondent statements – screening depends on the presence of bodily symptoms or family history
Table 4 Respondent statements – preventing cancer means preventing death from cancer; the emergence of cancer itself is not preventable
Before getting screening I’d need to think about what’s been going on in my life, my body and my health. How much I felt that related to what we’d be doing. – African American, 65. If I’m healthy, why would I get breast cancer? – White, 59. I would not go see a doctor unless I was ill. – Latina, 54. I’m not at risk for cancer because I have no problems with my bowel movements and I drink a lot of water. – Chinese, 50. Nobody in my family had cancer, so I’m not worried about it. – African American, 54.
Finding cancer early is good, before one is assigned to a death sentence. –Latina, 62. I believe early detection enhances your ability to recover without any, well hopefully without any, possibility of a reoccurence.– African American, 50. Cancer cannot be prevented because it’s just too complex. – African American, 65. I don0 t believe there0 s a prevention for cancer. . . because I don’t know the causes of cancer. – Chinese, 79. Cancer can’t be prevented. Some people have been eating right, staying fit and having no family history of cancer. Yet they are still diagnosed with cancer. – Chinese, 64. I would hope cancer can be prevented, but I can’t be sure because what has been studied today is being disagreed with by the study of tomorrow or next week. They go back and forth so I’m really convinced nobody knows. –White, 67. There’s no prevention for cancer. Every person is different. Every cancer is different. – White, 65.
involved the idea that cancer screening is relevant only when something is perceptibly wrong with one’s body. Although these kinds of beliefs were expressed more commonly among immigrant and less-educated women, they were by no means exclusive to these groups. Also encountered was the notion that screening is most important when there is a family history of cancer; otherwise, it may be irrelevant (see Table 3). 3.2. Lack of knowledge of pre-malignancy Although some women valued screening only in the context of acute illness, the majority did affirm the value of catching cancer ‘‘early’’ or ‘‘in time,’’ by which they meant when it is still small, before it causes physical symptoms, before it has a chance to grow and spread, and when it is therefore more easily treatable. The vast majority of these women, however, believed that ‘‘cancer screening’’ is simply and only that – screening for cancer. Very few understood that certain forms of screening (e.g. PAP and colonoscopy) aim to identify abnormal cells before transformation to malignancy. 3.3. Preventing cancer means preventing death from cancer When asked, ‘is cancer preventable?’ about half the women responded with their opinions about whether cancer deaths are preventable. The meaning of ‘‘prevention’’ drew strongly on ideas of survivability and the ability to identify and treat cancer early. A recurring theme was that cancer caught ‘‘too late’’ is not survivable and, therefore, is not ‘‘preventable’’ either. At the same time, respondents conveyed in a variety of ways the idea that the emergence of cancer itself is not preventable, even if death might be (see Table 4). 3.4. Pessimistic cancer beliefs Hopefulness about the ability of screening to prevent death existed in an uncertain and complex relationship with, and did little to mitigate, pervasive and pessimistic attitudes about cancer (see Table 5). In addition, several women felt that most screening tests involve considerable inconve-
Table 5 Respondent statements – pessimistic cancer beliefs If one has cancer, it’s best to die quickly. – Latina, 79. Once cancer is found, there’s nothing that can be done about it. –Chinese, 79. You will have to face the pain and illness. I always think that death is not a problem, but the worse thing is to suffer from pain and illness. Pain does not let you escape for 1 min. – White, 62. The worry is just as bad as the cancer itself. – African American, 66.
nience and physical discomfort. Several patients discounted the value of screening altogether, saying that any time one finds cancer it is ‘‘too late,’’ meaning there is no hope for survival. Only if ‘‘absolutely necessary,’’ they avowed, would they consent to screening. While many women were averse to screening because of pessimistic beliefs about cancer, when we asked about risks associated with screening itself no one mentioned possible adverse physical effects (e.g. infection, bleeding and perforation with colonoscopy) or psychological harms associated with false positives and negatives, awaiting test results, and undergoing diagnostic follow-up procedures. 3.5. Non-scientific benefits of screening Contrasting with these generally pessimistic ideas, almost all respondents manifested optimistic but incorrect beliefs about screening. For example, about three-fourths of participants regarded screening as valuable by itself, without a clear-cut reference to cancer. A prominent aspect of this was ritualistic (‘‘routine or regular or yearly screening is important’’) and another was metonymic, in which screening represented the somewhat vague benefits of a medical ‘‘check-up’’ more generally (Table 6). In several instances, participants had had screening tests without knowing these were cancer-related, believing that screening provides a general evaluation of a body part (Table 6).
T.D. Denberg et al. / Patient Education and Counseling 57 (2005) 280–285 Table 6 Respondent statements – non-scientific beliefs in the benefits of screening Screening confers the benefits of a regular medical check-up Mammography is a commonplace test, part of a yearly check-up. – White, 54. I don’t think the doctor would emphasize, at my age, to have the screening for cancer. It was just part of the regular check-ups. – Chinese, 57. Early screening is a faith and a habit. – Chinese, 62. Screening provides a general evaluation of a body part I had my PAP just to make sure everything was okay down there, and the doctor said there was no problem.’’ – White, 67. [Sigmoidoscopy]. . .is an annual thing. . . that’s all. Tests should be done to make sure nothing is wrong.’’ – Chinese, 57 Screening protects one from developing cancer in the future If you have [a screening test] done as often as you are supposed to have it done, then your risk is getting lower. – African American, 54. I feel better and more secured with positive test results. – Chinese, 62. . . .now that I don’t have my womb, they tell me I don’t need [a Pap smear]. Although I like to get it every two to three years because it’s better. . .It makes things safer. – Latina, 62. The primary benefit of screening is peace of mind Greatest benefit is learning you don’t have cancer, the greatest detriment is learning you have cancer and having to have a part of your body removed. Very painful. – Latina, 79. I think screening helps to eliminate certain fears, you know. –African American, 59. I do know that an intelligent person needs the tests routinely, just to make sure everything is cool. – White, 63. Screening helps to comfort you. – Chinese, 65. Screening offers a ‘‘clean bill of health’’ I had a colonoscopy and they removed some polyps, so I’m going to be okay. – White, 63 Screening tests are highly accurate False positives are extremely unlikely – everyone makes mistakes. . . early detection would not harm you. – African American, 53. If the results are normal, I’m not worried about risk. – Latina, 62.
A common theme was that rather than prevention, screening confers protection against the future development of cancer (or perhaps any other abnormality in a body part). Whereas prevention connotes impeding, hindering, or taking precautions against some future, uncertain event, protection is more directly linked with the body itself and with the sense that one’s physical state has undergone transformation. Many women felt that by getting screening their body was now armored or shielded. There was magical thinking and a fetishistic aspect involved, in which something tangible (a medical test) is more than simply diagnostic – it confers physical safety and security. In this way, some participants suggested that the more screening one receives, the safer one becomes. Ultimately, it appears that protection has more concrete, definite, and immediately beneficial connotations than prevention (Table 6). Nearly ubiquitous was the notion that the primary reward of screening is ‘‘peace of mind.’’ Even if catching cancer
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early is ‘‘good’’ from one perspective, a more prominent viewpoint is that a cancer diagnosis and (the unpleasantness of) treatment are not at all desirable. Thus, participants stressed first and foremost the ability of screening to provide reassurance, emphasizing this over the timely opportunity to identify and take care of a health problem (Table 6). One woman seemed to extrapolate from this to the idea that, once a screening test provides a ‘‘clean bill of health,’’ future screening is no longer important. The perceived ability of screening to eliminate anxiety or to offer a clean bill of health went hand-in-hand with a prevailing lack of understanding regarding false positives and negatives. In general, participants believed there were no disadvantages to screening, that these tests are simple, highly accurate, and in most cases reassuring (Table 6). The more ‘routine’ or less ‘invasive’ a test was perceived to be, the less resistance there was to having it done. Five participants, however, discounted the value of screening altogether, saying that any time one finds cancer it is ‘‘too late,’’ meaning there is no hope for survival. In one of the most forceful assertions regarding the value of screening, a few women related that a failure to get screened might, itself, cause cancer. A variant of the screening-offersprotection theme, there was apparent slippage between the (correct) concept of more advanced-stage cancer diagnoses without screening and the (incorrect) idea that not getting screening actually increases one’s risk of developing cancer de novo. For example, when asked, ‘‘What things cause cancer?,’’ one respondent replied, ‘‘Doing things you know you are not supposed to do. Drinking a lot, eating foods you should not eat. Not having screenings.’’ (Latina 77).
4. Discussion and conclusion Within a multi-ethnic and socioeconomically diverse sample of women this study illuminated a number of recurring beliefs related to cancer prevention and screening. We classified these beliefs under the following headings: beliefs that screening is indicated only with symptoms or family history; lack of knowledge of pre-malignancy; interpreting cancer prevention as the prevention of death; pessimistic cancer beliefs; and non-scientific beliefs about the benefits of screening. Common to each category, these beliefs are characterized by inaccuracies, distortions, and over-simplifications. We are unaware of any prior studies that systematically illustrate misconceptions about cancer screening within a diverse sample of women. We suspect that these beliefs often remain undisclosed in clinician– patient encounters and therefore have important implications for informed decision-making. The idea that there are many misconceptions about cancer and screening is not a new one, and many of our findings replicate those of other investigators. One particularly novel aspect of our findings, however, includes
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the idea that screening is exclusively intended to find cancer, with virtually no understanding of pre-malignancy. Similarly, ‘‘prevention’’ was more strongly associated with preventing death from cancer than with preventing the development of cancer itself. These kinds of beliefs, while perhaps accurate in relation to mammography and PSA testing, are off the mark when it comes to cervical and colon cancer screening. Thus, with these two tests in particular, greater emphasis on clarifying the concept of premalignancy may be particularly important for enhancing patients’ ability to make informed decisions about screening. Perhaps most crucially, the relevance of patient misconceptions depends on whether one subscribes to an adherence or informed decision-making model. With adherence, the overarching goal is to increase rates of screening. This is the traditional emphasis of public health programs. In these contexts, a common exercise is to discredit any erroneous beliefs that bias against screening (cons), such as ‘‘I would probably not have a mammogram unless I had some breast symptoms or discomfort’’ [14]. With informed decision-making, on the other hand, the goal is to help individual patients understand both the risks and benefits of screening in such a way that they can decide whether or not screening is personally acceptable to them. With regard to an adherence model, some of the misconceptions we identified would seem to act as barriers to screening. For example, patients who value screening only in the context of physical symptoms or in the setting of a family history misunderstand its purpose and may be reluctant to obtain it. Similarly, adherence may be compromised when patients believe that the only purpose of screening is to identify cancer after it has already developed and when their perceptions of cancer are distinctly nihilistic (e.g. that cancer is a death sentence, that cancer cannot be prevented, or that cancer causes unbearable pain or anxiety). Again, when pertinent, we might be able to mitigate these barriers to screening by better educating patients about the concept of pre-malignancy: if patients understand that certain screening tests (e.g. PAP smears and colonoscopies) can actually prevent the emergence of cancer and, consequently, its terrible ramifications, they may be more likely to accept it. In the end, simply imparting basic information about the benefits of screening may be insufficient: increased adherence may require special efforts to identify and counteract erroneous beliefs that bias against screening. When viewed from the perspective of informed decisionmaking, patients who have misconceptions that bias against screening are clearly not in a position to make adequately informed choices. It is here that adherence and informed decision-making most closely overlap. Informed decisionmaking, however, does not aim to increase adherence, per se, nor does it implicitly privilege the benefits of screening over the risks: instead, it aims to help patients understand risks and benefits equally so that they can make decisions that are
congruent with their personal values and preferences. As evidenced by the present study, many erroneous patient beliefs reflect pros of screening (e.g. that screening provides a general check-up of a body part, or that the more screening one has the more protected one is against future cancer). The implication is that informed decision-making requires the active thwarting of misinformation – not only against screening, but for screening as well. Significantly, this is rarely emphasized within an adherence model. This looms in importance, however, when the benefits of screening are controversial or uncertain (e.g. PSA testing, mammography between ages 40 and 49, and colonoscopy as the initial preferred mechanism for colon cancer prevention). It was also quite noteworthy that almost none of the women in the study recognized the well-known biomedical risks of screening, including psychological harms associated with false positive and negatives, awaiting test results, and undergoing diagnostic procedures. This is another area deserving of increased attention in health education materials and clinician–patient discussions. In fact, patient misconceptions can impair the quality of patient–clinician communication more generally. Just as clinicians and patients are unlikely to concur in their interpretation of numerical risks, our findings suggest that they are also unlikely to coincide in their interpretation of key concepts. This is not always obvious, however, because both employ a common vocabulary (‘‘cancer,’’ ‘‘screening,’’ and ‘‘prevention’’) while attributing different meanings to it. The appearance of mutual understanding belies an unrecognized ‘‘talking past’’ each other, thereby frustrating possibilities for informed decision-making. Finally, much research on cancer prevention has emphasized the ‘‘culture-specific’’ beliefs and attitudes of specific racial/ethnic groups [15–19] (e.g. Latinos are ‘‘fatalistic,’’ African Americans ‘‘distrust’’ the health care system). Although certain kinds of beliefs might be more common, intense, or expressed in unique ways among particular groups (e.g. the importance of emotional balance among older Chinese immigrants), and in certain cases might be quite important for decision-making, our findings suggest that many beliefs about prevention and screening recur, in basic form, across racial/ethnic and socioeconomic boundaries, and that there is also great variability in beliefs within racial/ethnic groups. A potential downside of emphasizing ‘‘culture-specific’’ beliefs tied to race/ethnicity is that of reinforcing stereotypes and perpetuating the notion that only non-white minority groups have unusual or exotic beliefs. In fact, as we found in our small sample, white (and relatively well-educated) women were no less likely than others to hold strong, non-biomedically-informed ideas about cancer and prevention. Ultimately, we believe it may be more productive to identify cross-cutting beliefs within heterogeneous populations or, alternatively, to seek culturally-specific beliefs by studying groups much narrower than those characterized by conventional categories of race/ ethnicity [20].
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This study was limited by a small sample located in a single geographic area, and by the inability to rigorously explore the influence of particular beliefs on actual screening preferences and prior screening behavior. On the other hand, face-to-face interviews are considered a gold standard for qualitative research. We were also able to conduct interviews until the emergence of new data or themes was exhausted. Finally, in a way that would not have otherwise been possible, the qualitative approach brought context and richness to an understanding of women’s beliefs about cancer screening and prevention. 4.1. Suggesions for future research Specific misconceptions that women have about cancer, prevention, and screening may have a key influence on informed decision-making around screening. Quantitatively-oriented studies should help to reveal more about how ubiquitous, influential, and amenable to change patient misconceptions might be, a project that should complement more conventional approaches to eliciting utilities and communicating numerical risk. Ideally, such knowledge will contribute to improved, conceivably tailored, forms of health education preparatory to realizing more effective risk communication and patient decision-making. 4.2. Practice implications The results of this study highlight the importance of eliciting patients’ own perspectives regarding the risks and benefits of screening. Particular emphasis should be placed on determining whether patients believe screening is predicated on the presence of physical symptoms or a family history, and whether they accurately understand the concept of pre-malignancy and the prevention of de novo cancers in settings such as colonoscopy and PAP smears. Finally, if the goal is to promote informed decision-making over simple adherence, it is also essential to identify and correct patient misconceptions that bias in favor of screening.
Acknowledgements This study was supported in part by a grant from the Agency for Healthcare Research and Quality/National Institutes of Health, P01 HS10856, ‘‘Promoting Effective Communication and Decision-Making for Diverse Populations,’’ Eugene A. Washington, M.D., M.Sc. (PI). We thank Eliseo Pe´ rez-Stable, Deirdra Forte, Julissa Saavedra, and Lei-Chun Fung for their assistance in planning and carrying out the interviews.
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