Fictitious case narratives as a method in communication about cancer screening harms

Objectives Communicating the harms and overdiagnosis in cancer screening may be ineffective, as evidence about harms is discordant with existing lay beliefs about the benefits of screening and early prevention. Cancer itself has an accessibility bias, which hinder lay people to rationally weigh the benefits and harms, and properly consider participation. Projective techniques are often used in market research to identify preferences and values, while imaginary narratives have been employed in educational contexts to enhance learning outcomes. We aimed to develop a fictitious case narrative as a projective technique to improve communication and discussion about benefits and harms of opportunistic PSA screening for prostate cancer.

Method We conducted two focus groups to examine expectations, preferences, and drivers of opportunistic PSA screening for prostate cancer. We developed an imaginary case of a typical Danish couple named Flemming and Anne to encourage both emotional and cognitive openness in the discussion about the benefits and harms of PSA screening. The focus group participants were told The Flemming-Anne narrative, informed about benefits and harms of PSA screening, and were engaged in two discussion activities related to the case. The information material comprised lay-formulated evidence about incidence, false positives, overdiagnosis, and complications from follow-up procedures and treatment.

Results We found that the projective methodology allowed the participants to personally distance themselves from the discussion and project feelings onto the case as a way of effective communication. Male participants directed statements to the case when these were considered irrational or contradictory with norms of medical consumer behavior or masculinity. Cognitively, the participants showed contextual understanding of harms as a result of the distance to the fractional bits of evidence. However, participants still had difficulties relating the knowledge to their own decision of testing. Overdiagnosis was particularly difficult to grasp in relation to their own situation and remained an abstract concept.

Conclusions It is important that lay people are informed and are able to understand both the benefits and harms of screening, to truly be able to give informed consent to get tested. As a result of the deployed projective methodology, the participants we more open to discussing and understanding the harms of PSA testing, including overdiagnosis. However, the case needs further development to enable participants to transfer the knowledge, of especially overdiagnosis, to their own decision about screening.