Patients’ Defensive Thinking May Hinder Colorectal Cancer Screening

Patients may use specific defensive thinking strategies to avoid colorectal cancer screening, new research suggested.

Surveying more than 2,200 patients who had been invited to participate in a population-based fecal immunochemical test (FIT) screening program, investigators said that two key defensive thinking strategies — denying immediacy and self-exemption — were most strongly associated with non-participation.

More specifically, each one-unit increase in denying immediacy — “I’ll get tested when I’m less busy,” for example — was associated with 47% lower odds of getting screened (P<0.001). And each one-unit increase in self-exemption — “I don’t need screening because of my healthy lifestyle,” for example — was associated with 20% reduced likelihood (P<0.001), according to Nicholas Clarke, PhD, a psychology researcher at Dublin City University, and colleagues, reporting online in the journal Cancer.

“People who react defensively to the invitation to colorectal cancer screening are less likely to take part, and this seems to be due to such misconceptions that having a healthy lifestyle or having regular bowel movements means that they do not need to be screened,” Clarke said in a statement.

“Similarly, some people believe testing can be delayed while they wait for a ‘better’ test (even though the current test works very well) or wait until their other health concerns are under control,” Clarke explained. “Some people also react defensively because they believe cancer is always fatal, which is not true. All of these factors can result in people making a decision not to take the home-based screening test.”

The survey measured seven subscales of defensive information processing. These included opt-out behavior (“I don’t go to a doctor unless it’s really serious”), message rejection (“Few people get colon cancer”), and blunting (“I don’t think about colon cancer”).

“These observations suggest that encouraging consideration of future consequences of one’s health may encourage greater uptake among those who may not perceive any urgency to screen for colorectal cancer,” the researchers said. “Additionally, messages sent with FIT that create a sense of urgency (e.g., highlighting the often asymptomatic nature of colorectal cancer) may prompt more timely completion and reduce tendencies to procrastinate.”

Health professionals can play an important role in counteracting defensive thinking patterns, “particularly if electronic health record alerts at the point of care identify patients not responding to mailed outreach,” commented Beverly Green, MD, MPH, of the Kaiser Permanente Washington Health Research Institute in Seattle, in an editorial accompanying the study.

Green also noted that resources such as MisinfoRx can give clinicians tools for having productive conversations about misinformation. “The three C’s — compassionate understanding, connection, and collaboration — provide guiding principles for addressing misinformation and moving patients toward evidence-based health‐protective behaviors and actions,” she said.

Financial incentives may also work, the editorialist added, citing a randomized trial her group conducted in which a guaranteed $10 or chance at winning $50 in a lottery increased colorectal cancer screening uptake by approximately 7%. “Incentives may have counteracted blunting (procrastination) and suppression (denial of immediacy) by providing a short‐term financial benefit to encourage an activity with a possible long-term health benefit,” she explained.

For the present study, Clarke and colleagues sent a validated questionnaire to 7,476 individuals in Dublin who had been invited to participate in the home-based colorectal cancer screening program from 2008 to 2012. Half of these had completed the FIT test and half had not. Many more of those who chose to undergo screening responded to the survey (53%) compared with those who did not (8%).

The limited response rate of the latter group was a limitation of the study, study authors said. “We maximized the numbers of screening nonusers responding to the survey by approaching the entire nonuser group, but in light of the response rate, it is likely that those who took part in the survey are a self-selected group,” they cautioned.

The study’s primary outcome variable was screening use or nonuse. The researchers employed multivariable logistic regression and adjusted for sociodemographic and behavioral factors associated with screening uptake.