Risky feelings: Why a 6% risk of cancer does not always feel like 6%

Abstract

Objective

Emotion plays a strong role in the perception of risk information but is frequently underemphasized in the decision-making and communication literature. We sought to discuss and put into context several lines of research that have explored the links between emotion and risk perceptions.

Methods

In this article, we provide a focused, “state of the science” review of research revealing the ways that emotion, or affect, influences people's cancer-related decisions. We identify illustrative experimental research studies that demonstrate the role of affect in people's estimates of cancer risk, their decisions between different cancer treatments, their perceptions of the chance of cancer recurrence, and their reactions to different methods of presenting risk information.

Results

These studies show that people have strong affective reactions to cancer risk information and that the way risk information is presented often determines the emotional gist people take away from such communications.

Conclusion

Cancer researchers, educators and oncologists need to be aware that emotions are often more influential in decision making about cancer treatments and prevention behaviors than factual knowledge is.

Practice implications

Anticipating and assessing affective reactions is an essential step in the evaluation and improvement of cancer risk communications.

Introduction

When the U.S. National Cancer Institute funded the initial Centers of Excellence for Cancer Communications Research (CECCR) in 2003, it sought to encourage research that would “produce new knowledge about and techniques for communicating complex health information to the public” [1]. One specific type of information had a particularly prominent place in the CECCR projects: information about cancer risks and the risks and benefits of cancer treatments. For example, CECCR-funded projects have examined cultural issues in the communication of colorectal cancer risk information [2], communications about breast cancer risk [3], [4], and media coverage of cancer risks [5].

Each of the authors of this paper has been affiliated with the CECCR site based at the University of Michigan since its inception, and we have worked together to develop innovative techniques for visualizing cancer risks [6], [7], [8], [9], [10] and helping women at high risk of developing breast cancer to compare their cancer risk with the risks of cancer prevention medications [3]. Yet, our research has convinced us that simply increasing the public's knowledge of cancer risks can often be insufficient. Even when people are presented with accurate and clear risk information in ways that support understanding and recall, they sometimes make medical decisions or perform health behaviors that are at odds with the situation. Even well-informed patients sometimes “go with their gut, instead of their head,” and choose options that appear to increase their risks or conflict with their own stated values.

Until recently, most research on both medical and non-medical decision making assumed that most biased or flawed decisions were the result of cognitive limitations [11]. In fact, over the past 40 years, researchers in the field of judgment and decision making (JDM) have been documenting the many different ways that people's judgments and decisions fall short of rational ideals. In particular, researchers have demonstrated that people are not good at generating accurate probability (risk) estimates. Their estimates are susceptible to numerous heuristics, including anchoring biases (e.g., by being pulled higher or lower if they are asked to state the last two digits of their social security number before making their estimates [12]) and availability biases (e.g., by providing higher estimates for occurrences that are “primed” to be more readily available in their minds [13]).

While traditional communications have focused on helping people overcome such cognitive limitations, emotions also play an important role in people's cancer-related medical decisions. In healthcare contexts, especially those involving cancer, emotions often run high. When patients learn that they have cancer, for example, they often feel fear, alarm, anxiety, confusion, or dread. In the midst of such strong emotions, patients can have a hard time weighing the pros and cons of their treatment alternatives.

Even though medical professionals have long recognized that healthcare decisions can be influenced by people's emotions, few recognize how central emotions are to all such decisions. Even decision making researchers are just beginning to grapple with a profound concept – that whenever people think their way through decisions, they feel their way, too [14], [15], [16], [17], [18]. As people think cognitively about the pros and cons of their decision alternatives, the affective centers of their brain also react to those same pros and cons [19]. Multiple theorists now argue that we use two parallel processes to process information and learn from it [20], [21], [22], [23]. One process is generally seen as rational and analytical, but the other is described as intuitive, experiential, and/or emotional. Sometimes these two processes agree. When they do not, in many cases it is the affective centers that rule the day and determine people's decisions and actions [14].

In this article, we provide a focused, “state of the science” review of research revealing the ways that emotion, or affect, influences people's cancer-related decisions. (For the purposes of this article, we will use the terms emotion and affect interchangeably.) We do not attempt a systematic review of either the vast literature on decision making and risk perceptions or the many studies that have considered the interplay between affect and decisions. Instead, we familiarize readers with several lines of inquiry that we have pursued within the University of Michigan CECCR in our attempts to improve the ways patients make cancer treatment and prevention decisions. We discuss the progress that has been made in identifying the specific ways that affect can influence decisions by highlighting specific illustrative studies and placing them within the larger context of research in this area. In so doing, we provide evidence that anyone who wishes to inform patients about cancer risks needs to be cognizant of the determinants of patients’ emotional reactions to risk information. Only then, we argue, will clinicians and educators be able to craft their cancer risk communications and patient decision aids to not only transfer cancer risk information to patients but also to calibrate patients’ often-powerful “risky feelings.”