THE IMPACT OF COMMUNICATION ON CANCER RISK, INCIDENCE, MORBIDITY, MORTALITY, AND QUALITY OF LIFE
Kreps Gary L.
Health communication has the great potential to help reduce cancer risks, incidence, morbidity, and mortality, while enhancing quality of life across the continuum of cancer care (prevention, detection, diagnosis, treatment, survivorship, and end-of-life care). Effective health communication can encourage cancer prevention, inform cancer detection and diagnosis, guide cancer treatment, support successful cancer survivorship, and promote the best end-of-life care. This paper examines the influences of health communication in confronting cancer and promoting important health outcomes. Implications of this analysis are drawn for directing informed cancer communication research and practice.
Communication is a central human process that enables individual and collective adaptation to health risks at many different levels. Health information is the critical resource derived from effective health communication (Kreps, 1988a; 2001). Effective communication enables consumers and providers of health care to gather relevant health information that educates them about significant threats to health, and helps them identify strategies for avoiding and responding to these threats.
Cancer poses a series of significant health threats that demand effective health communication (Kreps & Chapelsky Massamilla, in-press). This paper examines the powerful potential to strategically use health communication to reduce cancer risks, incidence, morbidity, and mortality, while enhancing quality of life across the continuum of cancer care (prevention, detection, diagnosis, treatment, survivorship, and end-of-life care) (Byock, 2000; Hiatt & Rimer, 1999). Effective health communication can encourage cancer prevention, inform cancer detection and diagnosis, guide cancer treatment, support successful cancer survivorship, and finally to promote the best end-of-life care. Implications of this analysis are drawn for directing informed cancer communication research and practice.
COMMUNICATION AND HEALTH OUTCOMES
A large body of health communication literature has demonstrated the powerful influences of communication interventions on a broad range of health behaviors and health outcomes. For example, Kreps and O'Hair (1995) report a series of studies showing the influences of intrapersonal, interpersonal, group, organizational, and societal communications on health knowledge, behaviors, and outcomes. Similarly, Greenfield, Kaplan, and Ware (1985) demonstrate the positive influences of increased patient communicative involvement in treatment on desired health outcomes. Dearing, Rogers, Meyer, Casey, Rao, Campo, and Henderson (1996) illustrate the positive influences of social marketing and diffusion-based strategies in encouraging at-risk populations to adopt important prevention behaviors. Large-scale longitudinal communication intervention programs, such as the Stanford Five City Heart Health Program and the Minnesota Heart Health communication program demonstrate the influences of these campaigns on promoting adoption of lifestyle changes to prevent cardiovascular disease and reducing gaps in public health knowledge (Flora, Maccoby, & Farquhar, 1989; Pavlik, Finnegan, Strickland, Salman, Viswanath, & Wackman, 1993).
In a recent review of the literature, Kreps and Chapelsky Massimilla, (in-press) examined current (1990-2000) published research on cancer communications that provide strong outcome data on the effectiveness of strategic communications in cancer control. The studies were examined across six topic areas based on the communications strategy used and behavior targeted: 1) strategic communications on adoption of prevention behaviors in diverse populations; 2) strategic communications on promotion of cancer detection and screening behaviors; 3) tailored communications on promotion of cancer prevention and control; 4) tailored communications on promotion of screening and detection behaviors; 5) interpersonal communications on provision of social support to cancer patients; and 6) social-marketing and diffusion-based communications encouraging at-risk populations to adopt prevention behaviors. This review clearly illustrated that many of the health communication interventions led to important cancer control and prevention outcomes and demonstrates the power of communication in cancer prevention and control. The Kreps and Chapelsky Massimilla (in-press) review also showed that past research provides a large body of evidence that new communication technologies and an enhanced understanding of the communication needs of targeted audiences can significantly alter health behaviors associated with cancer risk reduction.
THE UNIQUE DEMANDS OF CANCER COMMUNICATIONS
Cancer is a complex array of different kinds of health challenges, with many different sites, stages, causes, screening strategies, treatment strategies, and responses to treatment. Due to the broad range of different cancer conditions and issues, there is a great deal of specific information that needs to be conveyed to different individuals depending upon their unique situations. To add to this complex information environment, active programs of cancer research are generating new information about the biological mechanisms underlying different forms of cancer, new screening and diagnostic techniques, new forms of treatment and care for different cancers. It is imperative that cancer communications programs provide complete and up-to-date information about the key cancer issues of concern to specific audiences.
Cancer information is often highly emotionally charged, due to the serious, often life-threatening, nature of many forms of cancer. Receiving a diagnosis of cancer can be a major shock to most people. It is important that cancer communications programs are strategically designed to address the important psychological and socio-emotional issues surrounding different individuals' experiences with cancer. Care must be taken to coordinate content and relational aspects of communication to both inform people about cancer and cancer treatment, without confusing or upsetting them (Buckman, 1996; Gillotti, Thompson, & McNeilis, 2002).
To further complicate cancer communication programs, we must recognize the complexities of effective communication. Cancer communication messages must be designed and delivered to match the communication skills, needs, and pre-dispositions of specific audiences. To influence entrenched health behaviors, messages need to be relevant and compelling, with health information that provides direction and rationale for making the best health-related decisions and adopting health-preserving behaviors (Maibach, Kreps, & Bonaguro, 1996).
COMMUNICATION AND THE CONTINUUM OF CANCER CARE
Communication is central to quality cancer care, from primary prevention to survivorship (Hewitt & Simone, 1999). Interpersonal, group, organizational, and mediated communication are critical parts of cancer prevention, control, and care. The following section of this paper will describe how the process of communication is central to each of the major activities described in the stages of the continuum of cancer care:
Communication is the primary process for promoting cancer prevention. Cancer prevention efforts typically involve designing and implementing strategic communication campaigns to promote healthy behaviors (such as refraining from smoking or using tobacco products, following a low-fat, high fiber diet, and engaging in a program of regular exercise) (Viswanath & Finnegan, 2002). Cancer prevention efforts typically involve the development and distribution of persuasive and informative cancer education programs and materials, as well as the development of behavioral intervention programs to influence, often entrenched, health behaviors (see for example: Buller, Morrill, Taren, Aickin, Sennot-Miller, Buller, Larkey, Alatorre, & Wentzel, 1999; Marcus, Heimendinger, Wolfe, Fairclough, Rimer, Morra, Warnecke, Himes, Darrow, Davis, Julesberg, Slevin-Perocchia, Steelman, & Wooldridge, 2001; Pierce, Macaskill, & Hill, 1990; Ziant, 1993).
Communication is the primary process for informing and motivating people to seek screening for early detection of cancers (Gates, 2001). Communication is essential for encouraging audiences to engage in early detection and screening behaviors, to promote the development and adoption of screening programs in different health care and organizational settings, and for monitoring cancer trends to determine the best opportunities for screening and cancer detection. Promotion of early cancer detection and screening often involves the use of communication campaigns, educational materials, and behavioral intervention programs (see for example: Lerman, Hanjani, Caputo, Miller, Delmoor, Nolte, & Engstrom, 1992; Marcus, & Crane, 1998; Rakowski, Ehrich, Goldstein, Rimer, Pearlman, Clark, Velicer, & Woolverton, 1998; Skinner, Campbell, Rimer, Curry, & Prochaska, 1999; Skinner, Strecher, & Hospers, 1994).
Communication is the critical process used for gathering and interpreting diagnostic cancer information from patients (often by checking suspicious symptoms, collecting health histories, examining biological evidence of cancer, etc.) (Guttman, 1993; Street, 1991; Waitzkin, 1985). Due to the complexity of many cancer diagnoses, interpersonal and group communication is often used as indispensable tools for interpreting and clarifying diagnostic information (such as by eliciting second opinions, engaging in multidisciplinary consultations, and conducting tumor boards). Once a diagnosis is reached, communication is the channel for presenting the diagnosis and plans for treatment to patients. Care must be taken to communicate cancer diagnoses as clearly and as sensitively as possible to help patients overcome the initial shock of receiving a cancer diagnosis, understand the intricacies of the diagnosis, and begin evaluating different plans for treating the condition (Baile, & Beale, 2001; Parker, Baile, de Moor, Lenzi, R., Kudelka, & Cohen, 2001; Radziewicz, & Baile, 2001).
Cancer treatment is an active, and ideally, a collaborative communication process between health care providers and consumers (Jones, Kreps, & Phillips, 1985). Providers must explain treatment options, and refinements to treatment strategies, to their patients to help them make informed decisions about the best available programs of treatment. Once an initial cancer treatment regimen is implemented, the patient's response to specific treatments must be monitored and evaluated, so the treatments can be refined to produce the best effects and cause the least possible discomfort to the patient. Interpersonal and sometimes group communication are essential processes for seeking information about patients' responses to treatments and making informed decisions about revised treatment strategies (Liang, Burnett, Rowland, Meropol, Eggert, Hwang, Silliman, Weeks, & Mandelblatt, 2002; Larsson, Widmark-Peterson, Lampic, von Essen, & Sjoden, 1998; Samarel, Fawcett, Davis, & Ryan, 1998; van der Kam, Branger, van Bemmel, & Meyboom-de Jong, 1998).
There is a growing population of long-term cancer survivors today due to advances in early cancer detection and improved cancer treatments. Rowland, Aziz, Tesauro, & Feuer (2001) predict that in the absence of other competing causes of death, more than 60% of those diagnosed with cancer today can expect to live for more than five years beyond their diagnosis (5 years survival is the general criteria often used for establishing long-term survivorship). Cancer survivors have unique communication needs to help them cope with the many uncertainties of living with cancer. For example, survivors typically have to cope with the fear of their cancer reoccurring. Survivors also need to access social support and relevant information to help them live with side affects of cancer treatments. Peer support from others who have adapted to living with cancer can often help cancer survivors overcome both physical and psycho-social challenges and enable them to readjust to their everyday lives (Kilpatrick, Kritjanson, Tataryn, & Fraser, 1998; Rowland, Aziz, Tesauro, & Feuer, 2001; Spiegel, 1994; 1995; 1997).
End of Life Care
Communicating with patients and their loved ones during the end-of-life process is often a very challenging part of cancer care for all involved parties (Curtis, Wenrich, Carline, Shannon, Ambrozy, & Ramsey, 2001; Spiegel, 1997). Death is not easy for most people to communicate about, yet the uncertainties surrounding death demand sensitive and caring communication (Kreps, 1988b). The quality of communication at the end-of-life is critical to providing effective cancer care for patients who are dying (Larson & Tobin, 2000). Increasing attention in recent years has been directed towards the role of communication in palliative cancer care, especially at the end-of-life (see for example, Baile, Glober, Lenzi, Beale, & Kudelka, 1999; Bruera, Neumann, Mazzocato, Stiefel, & Sala, 2001; Gattellari, Voigt, Butow, & Tatttersall, 2002; Maguire, 1999; von Gunten, Ferris, & Emanuel, 2000). The hospice movement has also focused attention on the unique communication needs of cancer patients and their loved ones during the transition to end-of-life (Derrickson, 1996; Lynn, 2001).
IMPLICATIONS FOR CANCER COMMUNICATIONS RESEARCH
Cancer communications research is the study and application of the process of exchanging and interpreting the array of ambient and strategically designed messages delivered interpersonally and through selected media that convey relevant health information to targeted audiences (of health care consumers, cancer survivors, health care providers, researchers, patients, at-risk populations, etc.) (Kreps & Chapelsky Massamilla, in-press). Cancer communications is a very exciting and potentially propitious area of research and intervention, since effective use of communication across the continuum of cancer care is often very complex and challenging (Kreps, in-press). For example, cancer prevention is not easy to accomplish. Campaigns need to be strategic and persuasive, recognizing the wide-range of influences on health behaviors in the modern world (Viswanath & Finnegan, 2002). Cancer screening is not an easy sell, especially when screening strategies appear uncomfortable, such as colonoscopy or mammography procedures (Gates, 2001; Skinner, Strecher, & Hospers, 1994). There are also many interpersonal communication demands on health care consumers and providers (examined above) in gathering data for effective cancer diagnosis, eliciting cooperation in cancer treatment, and providing support for end-of-life care. Similarly, the process of cancer survivorship demands both sensitive and informative communication to promote psycho-social adjustment and adaptation (Rowland, Aziz, Tesauro, & Feuer, 2001). There is much to learn about the role of communication in these different areas of cancer prevention and control.
There is a great need for cancer communications research to direct cancer prevention and care (Kreps, in-press). For example, in cancer prevention and detection we need to conduct controlled trials that compare different forms and intensities of communication-based behavior change interventions, and examine the use of tailored, interactive, computer-based health communications programs that can contribute to an improved understanding of these new technologies (Kreps & Massamilla Chapelsky, in-press). Research on consumer/provider communication can help identify strategies for increasing accurate exchange of relevant health information, promote cooperation in the cancer treatment process, and enhance the quality of care for people confronting cancer (Radziewicz & Baile, 2001). Further research is greatly needed to fill in knowledge gaps about information needs in cancer prevention and control, as well as to capitalize on the unusual opportunity presented by the advent of advanced communication technologies to help achieve cancer prevention and detection goals. A significant increase in the size of the cancer communications research enterprise is needed to develop the next generation of research and interventions. At the same time, the enterprise must be informed by a greater understanding of the mechanisms by which these communications work. New cancer communications research should both increase knowledge and identify practical strategies for enhancing cancer communications and improving prevention and control of cancer. The challenge ahead is to develop cancer communications research programs that can help reduce cancer risk, incidence, morbidity, and mortality, and promote the highest quality of life for people confronting cancer.
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Gary L. Kreps,
ChiefHealth Communication and Informatics Research Branch
National Cancer Institute
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