The
Mammogram Experiment: How Emotions Can Affect High-Stakes
Decision-Making
A breast cancer scare that turns out to be a false alarm is
cause for relief, but may also trigger delays in future
mammogram screenings, according to new Wharton research.
In a controlled experiment that surveyed women waiting for
mammograms at the Hospital of the University of Pennsylvania,
Wharton marketing professors Barbara Kahn and Mary Frances Luce found that the emotional stress of
believing they may have breast cancer, even for just a few
days, causes patients to indicate they would be likely to
delay mammograms.
With mammogram error rates estimated to be as high as 20%,
the findings could have broad implications for health-care
providers and patients, said the researchers, who are also
senior fellows at Wharton’s Leonard Davis Institute of Health
Economics.
"The personal testing experience itself, and false positive
results in particular, could in and of themselves
significantly influence future decisions about whether to get
tested regularly," the authors write in a paper titled
Understanding High-Stakes Consumer Decisions: Mammography
Adherence Following False Alarm Test Results, forthcoming
in Marketing Science.
"Since preventive screening
is most successful if women get mammograms annually or
bi-annually as recommended, understanding and managing this
testing experience is obviously important," the paper
continues.
The study could also have implications for the diagnostics
industry, a growing sector in the nation’s $1.5 trillion
health care market. The National Cancer Institute estimates 31
million women each year have a mammogram at an average cost of
$100. "In general consumers are now much more responsible for
their own health care and the opportunity to engage in medical
testing is really exploding," said Luce.
In addition, the authors note, there may be spillover
effects in other areas of health-screening, such as
cholesterol testing, as well as other screening measures such
as those for radon or lead in the home.
Kahn said the decision to schedule a mammogram is just one
example of high-stakes decision-making that increasingly is
shifting to consumers. The move from traditional
defined-benefit pension plans to defined-contribution 401(k)
retirement plans is another important example. "We used to
have a more paternal society where the doctor or the benefits
officer made these decisions for you," Kahn noted. "More and
more the consumer is becoming empowered – which is good. But
the question is, ‘How do the emotional aspects frame their
decisions?"
According to Luce, emotions can kick in when it comes to
other big decisions, such as purchasing insurance, a costly
consumer-durable, such as a car, or even choosing which
college a child should attend. "It’s not hard to think of
stresses."
Delay as a Way to Cope One might suppose that the
fear generated by several days of worrying about whether they
may have breast cancer would make women more conscientious
about future testing. That way they would have a better chance
of surviving the disease. But Luce and Kahn found the opposite
occurs. "One coping strategy to deal with the stress is to
delay," said Kahn.
Luce compares the fear of thinking about having breast
cancer to an "emotional roller coaster" in which a woman can
conjure up a sense of vulnerability to the disease, even after
learning the mammogram results were wrong. "There are
lingering effects from the time spent thinking about why it
might be positive. They’re thinking, ‘I smoke’ or ‘my aunt had
breast cancer.’ Some of that tends to stick around and create
further anxiety, so we do think there are likely to be some
lasting negative effects."
Luce said the experiment’s results did not indicate that
the women would never be tested again, only that they might
put it off.
The findings showed there would be no delay for women who
were told their results were normal. Women who were asked
whether they would delay if they had an increased risk of
breast cancer, such as a family history of the disease, also
said they would not put their mammograms off.
The results held up against a control experiment in which
the women were asked to simulate responses to learning the
density of their skin made them prone to wrinkles. That news,
presumably, was less traumatic and did not suggest the
likelihood for delay, the researchers found.
"It’s interesting that one of the characteristics of
medical testing is that sometimes it can be extremely
emotionally stressful for people, but other times it can be
very different psychologically," said Luce. "Getting a test
for strep or the flu might be different than getting tested
for a life-threatening illness such as cancer."
The difference in a patient’s potential response to future
testing is something that doctors – and patients themselves –
need to understand, and may have important implications over
time, Luce suggested.
Only a small percentage of mammograms that initially
indicate trouble – an estimated 2-6% – result in a breast
cancer diagnosis. But the cumulative risk of a patient facing
a false positive over 10 tests is 49.1%, according to research
cited by Luce and Kahn. "It’s more important to get tested as
patients get older. But if false alarms are going to scare
people away, they may become less likely to take the test as
they get older," said Luce.
The Power of Information The research by Kahn and
Luce also found some potential prescriptions to prevent delays
in testing generated by a false positive. They found that if
the subjects who were told they had a false positive were
given information about preventative care, including
breast-self examination, they were less likely to delay future
screenings.
Likewise, if the same subjects were given information about
the odds of a false positive at the time of the first
screening, before they had time to stew about it, they also
were likely to follow up with regularly scheduled
mammograms.
"Thus, in contexts where repeated false positives are
likely, policy makers should ensure that patients are given
tools to deal with test- and disease-related stress," the
paper states.
Luce said the results of the experiment may actually
underplay the extent to which women in a larger sampling would
respond. She noted that the women surveyed in the research
project were among those that were conscientious enough to
come for the exam in the first place. And, she added, the
women may have been hesitant to give the "wrong" answer, which
would be to delay.
She also did not think the "emotional" response would be
any less for a prostate test or any other screening
administered to men. "Women are much better about medical
decision-making than men are," she said. "Women are usually
the ones who make the health-care decisions in the family. I
think men are even more likely to deal with the stress by
total avoidance. They might not even think about
testing."
Published: February 26, 2003 |