Diet and physical activity behaviors: how are they related to illness perceptions, coping, and health-related quality of life in young people with hereditary cancer syndromes?

Individuals with inherited cancer syndromes, such as Li-Fraumeni syndrome (LFS), may be motivated to adopt health-protective behaviors, such as eating more fruits and vegetables and increasing physical activity. Examining these health behaviors among young people with high lifetime genetic cancer risk may provide important insights to guide future behavioral interventions that aim to improve health-related quality of life (HRQOL). We used a self-regulatory framework to investigate relationships among diet and physical activity behaviors and psychosocial constructs (e.g., illness perceptions, coping, HRQOL) in adolescents and young adults (AYAs; aged 15-39 years) with LFS. This longitudinal mixed-methods study included 57 AYAs aged 16-39 years at enrollment), 32 (56%) of whom had a history of one or more cancers. Participants completed one or two telephone interviews and/or an online survey. We thematically analyzed interview data and conducted regression analyses to evaluate relationships among variables. AYAs described adopting healthy diet and physical activity behaviors to assert some control over health and to protect HRQOL. More frequent use of active coping strategies was associated with greater reported daily fruit and vegetable intake. Greater reported physical activity was associated with better quality of psychological health. Healthy diet and physical activity behaviors may function as LFS coping strategies that confer mental health benefits. Clinicians might emphasize these potential benefits and support AYAs in adopting health behaviors that protect multiple domains of health. Future research could use these findings to develop behavioral interventions tailored to AYAs with high genetic cancer risk.

The Long Behavioral Tail of the COVID-19 Pandemic-A Cancer Control Perspective.

This Viewpoint discusses the impact of the COVID-19 public health emergency on the trajectory of cancer deaths.

Health Information in 2023 (and Beyond): Confronting Emergent Realities With Health Communication Science.

This Viewpoint describes how health communication science can be used to improve response to health challenges by providing credible health information to the public.

Genetic Testing and Other Healthcare Use by Black and White Individuals in a Genomic Sequencing Study.

INTRODUCTION: Early adopters play a critical role in the diffusion of medical innovations by spreading awareness, increasing acceptability, and driving demand. Understanding the role of race in the context of other characteristics of potential early adopters can shed light on disparities seen in the early implementation of genomic medicine. We aimed to understand the association between self-identified race and individual experience with genetic testing outside of the research context. METHODS: We assessed factors associated with the odds of having ever received genetic testing prior to enrollment in a genomic sequencing study among 674 self-identified white and 407 self-identified African, African American, or Afro-Caribbean ("Black") individuals. RESULTS: Controlling for individual determinants of healthcare use (demographics, personality traits, knowledge and attitudes, and health status), identifying as Black was associated with lower odds of prior genetic testing (OR = 0.43, 95% CI [0.27-0.68], p < 0.001). In contrast, self-identified race was not associated with the use of non-genetic clinical screening tests (e.g., echocardiogram, colonoscopy). Black and white individuals were similar on self-reported personality traits tied to early adoption but differed by sociodemographic and resource facilitators of early adoption. CONCLUSION: Persistent racial disparities among early adopters may represent especially-entrenched disparities in access to and knowledge of genomic technologies in clinical settings.

Motivations to learn genomic information are not exceptional: Lessons from behavioral science.

Whether to undergo genome sequencing in a clinical or research context is generally a voluntary choice. Individuals are often motivated to learn genomic information even when clinical utility-the possibility that the test could inform medical recommendations or health outcomes-is low or absent. Motivations to seek one's genomic information can be cognitive, affective, social, or mixed (e.g., cognitive and affective) in nature. These motivations are based on the perceived value of the information, specifically, its clinical utility and personal utility. We suggest that motivations to learn genomic information are no different from motivations to learn other types of personal information, including one's health status and disease risk. Here, we review behavioral science relevant to motivations that may drive engagement with genome sequencing, both in the presence of varying degrees of clinical utility and in the absence of clinical utility. Specifically, we elucidate 10 motivations that are expected to underlie decisions to undergo genome sequencing. Recognizing these motivations to learn genomic information will guide future research and ultimately help clinicians to facilitate informed decision making among individuals as genome sequencing becomes increasingly available.

Uncertainty: a neglected determinant of health behavior?

Health behaviors are critical determinants of the well-being of individuals and populations, and understanding the determinants of these behaviors has been a major focus of research. One important determinant that has received little direct attention in past health research is uncertainty: a complex phenomenon that pertains not only to scientific issues regarding the diagnosis, prognosis, prevention, and treatment of health problems, but also to personal issues regarding other important health-related concerns. Here, we make the case for greater attention to uncertainty in health behavior theory and research, and especially to personal uncertainties. We discuss three exemplary types of personal uncertainty-value uncertainty, capacity uncertainty, and motive uncertainty-which relate, respectively, to moral values, capacities to enact or change behaviors, and the motives and intentions of other persons or institutions. We argue that that personal uncertainties such as these influence health behaviors, but their influence has historically been obscured by a focus on other constructs such as self-efficacy and trust. Reconceptualizing and investigating health behavior as a problem of uncertainty can advance both our understanding of the determinants of healthy behaviors and our ability to promote them.

Which Intervention Strategies Promote the Adoption and Maintenance of Physical Activity? Evidence From Behavioral Trials With Cancer Survivors.

BACKGROUND/PURPOSE: We address four questions about interventions to promote physical activity in cancer survivors: (a) How often is both the adoption and maintenance of behavior change tested in trials? (b) How often do interventions generate adoption-plus-maintenance of behavior change? (c) Are intervention strategies specifically geared at promoting maintenance of behavior change deployed in trials? and (d) Which intervention strategies distinguish trials that promote both the adoption and maintenance of physical activity from trials that promote adoption-only or generate no behavioral changes? METHODS: Computerized literature searches identified 206 reports of randomized trials that measured physical activity in the wake of the intervention. RESULTS: Only 51 reports (24%) measured both behavioral adoption (postintervention) and behavioral maintenance (≥3 months follow-up). The 51 reports included 58 tests of interventions; 22% of tests observed both adoption and maintenance of physical activity, 26% reported adoption-only, and 52% found no change in behavior. Change techniques designed to promote behavioral maintenance were used much less frequently than adoption techniques or adoption and maintenance techniques. Interventions that aimed to improve quality of life, used supervised exercise sessions, were undertaken in community centers, and deployed fewer behavior change techniques were associated with adoption-plus-maintenance of physical activity in cancer survivors. CONCLUSIONS: The present findings offer new insights into the adoption and maintenance of physical activity and highlight the need to routinely assess these forms of behavior change in future trials. More extensive testing of intervention strategies specifically geared at maintenance of behavior change is warranted.

Cancer survivors need to not only adopt, but also maintain, physical activity to benefit their health and wellbeing. We undertook a systematic review of interventions to promote the adoption and maintenance of physical activity in cancer survivors. Out of 206 physical activity interventions for cancer survivors that we identified, only 51 (24%) measured both the adoption and maintenance of behavior change. Of these 51 intervention studies, only 22% were effective in promoting both the adoption and maintenance of physical activity. We developed a new classification of behavior change techniques used in interventions and discovered that techniques specifically designed to promote behavioral maintenance were used only rarely. We found that interventions that aimed to improve quality of life, used supervised exercise sessions, and were undertaken in community centers predicted adoption-plus-maintenance of physical activity in cancer survivors. These findings underscore the need for more trials that assess the adoption and maintenance of physical activity and for new research programs focused on evaluating the efficacy of maintenance techniques.

Perceptions and tolerance of uncertainty: relationship to trust in COVID-19 health information and vaccine hesitancy.

The COVID-19 crisis has exposed the public to considerable scientific uncertainty, which may promote vaccine hesitancy among individuals with lower tolerance of uncertainty. In a national sample of US adults in May-June 2020, we examined how both perceptions of uncertainty about COVID-19 and trait-level differences in tolerance of uncertainty arising from various sources (risk, ambiguity, and complexity) are related to vaccine hesitancy-related outcomes, including trust in COVID-19 information, COVID-19 vaccine intentions, and beliefs that COVID-19 vaccines should undergo a longer testing period before being released to the public. Overall, perceptions of COVID-19 uncertainty were not associated with trust in information, vaccine intentions, or beliefs about vaccine testing. However, higher tolerance of risk was associated with lower intentions to get vaccinated, and lower tolerance of ambiguity was associated with lower intentions to get vaccinated and preferring a longer period of vaccine testing. Critically, perceptions of COVID-19 uncertainty and trait-level tolerance for uncertainty also interacted as predicted, such that greater perceived COVID-19 uncertainty was more negatively associated with trust in COVID-19 information among individuals with lower tolerance for risk and ambiguity. Thus, although perceptions of uncertainty regarding COVID-19 may not reduce trust and vaccine hesitancy for all individuals, trait-level tolerance of uncertainty arising from various sources may have both direct and moderating effects on these outcomes. These findings can inform public health communication or other interventions to increase COVID-19 vaccination uptake.

Increasing Receptivity to COVID-19 Public Health Messages with Self-Affirmation and Self vs. Other Framing.

There remains an urgent need for effective communication about the importance of widespread adherence to behavioral recommendations to control the COVID-19 pandemic that will also reduce resistance to such guidance. We examined two strategies for COVID-19 communication- (1) self-affirmation (reflecting on a personal value in order to boost self-integrity and reduce defensiveness to potentially threatening information); and (2) manipulating self/other message framing - and moderation of these strategies by COVID-19 risk. 600 participants (Mage = 32.55, 51% female) were recruited for an online study and, after assessment of risk factors for severe COVID-19 infection, were exposed to the experimental manipulations. Three classes of defensive responses were considered as outcomes of interest: reactance, attitudinal responses, and behavioral responses. We found that participants derogated the self-focused message more than the other-focused message. Further, other-focused messaging and/or self-affirmation were more likely to elicit positive responses among individuals at higher risk for COVID-19 complications. Our findings suggest having individuals affirm values prior to viewing COVID-19 messages, and framing messages in terms of the importance of protecting others, may be beneficial strategies for encouraging responsiveness - particularly if the targets of such messages are at risk of COVID-19 complications themselves.

Do Beliefs about Alcohol and Cancer Risk Vary by Alcoholic Beverage Type and Heart Disease Risk Beliefs?

BACKGROUND: Alcohol is a leading risk factor for cancer, yet awareness of the alcohol-cancer link is low. Awareness may be influenced by perceptions of potential health benefits of alcohol consumption or certain alcoholic beverage types. The purpose of this study was to estimate awareness of the alcohol-cancer link by beverage type and to examine the relationship between this awareness and concomitant beliefs about alcohol and heart disease risk. METHODS: We analyzed data from the 2020 Health Information National Trends Survey 5 Cycle 4, a nationally representative survey of U.S. adults. RESULTS: Awareness of the alcohol-cancer link was highest for liquor (31.2%), followed by beer (24.9%) and wine (20.3%). More U.S. adults believed wine (10.3%) decreased cancer risk, compared with beer (2.2%) and liquor (1.7%). Most U.S. adults (>50%) reported not knowing how these beverages affected cancer risk. U.S. adults believing alcoholic beverages increased heart disease risk had higher adjusted predicted probabilities of being aware of the alcohol-cancer link (wine: 58.6%; beer: 52.4%; liquor: 59.4%) compared with those unsure (wine: 6.0%; beer: 8.6%; liquor: 13.2%), or believing alcoholic beverages reduced (wine: 16.2%; beer: 21.6%; liquor: 23.8%) or had no effect on heart disease risk (wine: 10.2%; beer: 12.0%; liquor: 16.9%). CONCLUSIONS: Awareness of the alcohol-cancer link was low, varied by beverage type, and was higher among those recognizing that alcohol use increased heart disease risk. IMPACT: These findings underscore the need to educate U.S. adults about the alcohol-cancer link, including raising awareness that drinking all alcoholic beverage types increases cancer risk. See related commentary by Hay et al., p. 9.

Activation Versus Change as a Principle Underlying Intervention Strategies to Promote Health Behaviors.

BACKGROUND AND PURPOSE: Interventions are effective in promoting health behavior change to the extent that (a) intervention strategies modify targets (i.e., mechanisms of action), and (b) modifying targets leads to changes in behavior. To complement taxonomies that characterize the variety of strategies used in behavioral interventions, we outline a new principle that specifies how strategies modify targets and thereby promote behavior change. We distinguish two dimensions of targets-value (positive vs. negative) and accessibility (activation level)-and show that intervention strategies operate either by altering the value of what people think, feel, or want (target change) or by heightening the accessibility of behavior-related thoughts, feelings, and goals (target activation). METHODS AND RESULTS: We review strategies designed to promote target activation and find that nudges, cue-reminders, goal priming, the question-behavior effect, and if-then planning are each effective in generating health behavior change, and that their effectiveness accrues from heightened accessibility of relevant targets. We also identify several other strategies that may operate, at least in part, via target activation (e.g., self-monitoring, message framing, anticipated regret inductions, and habits). CONCLUSIONS: The Activation Vs. Change Principle (AVCP) offers a theoretically grounded and parsimonious means of distinguishing among intervention strategies. By focusing on how strategies modify targets, the AVCP can aid interventionists in deciding which intervention strategies to deploy and how to combine different strategies in behavioral trials. We outline a research agenda that could serve to further enhance the design and delivery of interventions to promote target activation.

Future-oriented Emotions and Decisions to Receive Genomic Testing Results Among U.S. Adults of African Ancestry.

BACKGROUND: Future-oriented emotions are associated with consequential health decision-making, including genomic testing decisions. However, little is known about the relative role of various future-oriented emotions in such decisions. Moreover, most research on predictors of decision making regarding genomic testing is conducted with white participants. PURPOSE: This study examined the role of future-oriented emotions in decisions to receive genomic testing results in U.S. individuals of African descent. METHODS: We analyzed cross-sectional survey data from a genomic sequencing cohort (N = 408). All participants identified as African, African-American, or Afro-Caribbean (Mage = 56.3, 74.7% female). Participants completed measures assessing anticipatory affect (worry about genetic testing results), anticipated distress (feeling devastated if genetic testing showed an increased risk for fatal disease), and anticipated regret (regretting a decision not to learn results). Outcomes were intentions for learning actionable, nonactionable, and carrier results. RESULTS: Anticipated regret was robustly positively associated with intentions to receive actionable (b = 0.28, p < .001), nonactionable (b = 0.39, p < .001), and carrier (b = 0.30, p < .001) results. Anticipated distress was negatively associated with intentions to receive nonactionable results only (b = -0.16, p < .01). Anticipatory negative affect (worry) was not associated with intentions. At higher levels of anticipated regret, anticipated distress was less strongly associated with intentions to receive nonactionable results (b = 0.14, p = .02). CONCLUSIONS: Our results highlight the role of future-oriented emotions in genomic testing among participants who are typically underrepresented in genomic testing studies and behavioral medicine broadly. Future work should examine whether interventions targeting future-oriented emotions such as anticipated regret may have clinically meaningful effects in genetic counseling in similar cohorts.

Future-oriented emotions (emotions directed toward a future outcome, such as worrying about a future outcome, or expecting to feel distress or regret if a particular outcome occurs) are important predictors of health decisions, including decisions to seek and receive genomic testing results. Understanding how such factors relate to decisions to receive genetic testing results is particularly important in medically-underserved groups such as individuals of African ancestry, who are underrepresented in genomics and behavioral science research. We analyzed survey responses from a genomic sequencing cohort where all 408 participants identified as African, African-American, or Afro-Caribbean, and were asked about their level of worry, anticipated distress, and anticipated regret about results, plus their interest in receiving three types of genomic testing results from the study. We found that participants who expected that they would regret their decision to not learn the results had stronger intentions to receive all three types of results; those who expected to feel distressed by a genetic testing result that showed an increased risk for a fatal disease were less interested in nonactionable genetic testing results specifically. Our results highlight the differing roles of specific types of future-oriented emotions in genomic testing decisions, among participants who are typically underrepresented in this type of research.

Awareness of Alcohol and Cancer Risk and the California Proposition 65 Warning Sign Updates: A Natural Experiment.

In 1986, California enacted Proposition 65 (P65), requiring businesses to display warning signs informing consumers that specific chemicals and alcohol exposure increase the risk of cancer and reproductive harm. In 2018, the P65 alcohol warning signs were updated to include an informational P65 website link, and the update was associated with media coverage and increased enforcement of warning requirements. This study examines knowledge of the association between alcohol use and cancer risk in California compared to the rest of the US before and after the 2018 P65 update. We analyzed state-level data on alcohol and cancer knowledge from the Health Information National Trends Survey from 2017 (n = 3285), 2019 (n = 5438), and 2020 (n = 3865). We performed multinomial logistic regressions to examine knowledge levels by survey year and location (California vs. all other states) and reported the predicted marginals of knowledge by survey year and location. The adjusted prevalence of respondents who reported an association between alcohol and cancer risk was higher in California (41.6%) than the remaining states (34.1%) (p = 0.04). However, knowledge levels decreased significantly over survey years, and there was no evidence for an effect of the P65 update on knowledge in California compared to other states based on the testing of an interaction between state and year (p = 0.32). The 1986 warning signs may have had an enduring effect on awareness, though the update, so far, has not. Further efforts are needed to determine how to increase alcohol and cancer knowledge to address the burden of alcohol-attributable cancers.

Understanding responses to different types of conflicting information about cancer prevention.

BACKGROUND: Individuals are regularly exposed to conflicting information about health; however, understanding of how individuals respond to different types of conflicting information is limited. METHODS: In total, 1027 US adults were randomly assigned to 1 of 8 conflicting information messages about nutrition and cancer risk, depicting 1/4 conflicting information types (conflict in evidence - sources A and B agree the evidence is mixed; conflict between two expert sources - sources A and B present conflicting evidence about nutrition and cancer risk; conflict within the same expert source - source A changes its own recommendation about the evidence; no conflict control) crossed by 1/2 baseline recommendations with which new information conflicted (limit vs. do not limit red meat intake to reduce cancer risk). RESULTS: Compared to the control, each conflicting information type led to lower perceived scientific consensus about how much red meat one should eat (p < .001); conflict in evidence (p = .004) and between sources (p = .006) led to lower trust in scientists. Intentions to consume red meat more frequently were higher in the conflicting information conditions than control in the group initially told to "limit red meat" and lower in the "do not limit red meat" group (p = .022). Conflict within the same source led to higher perceived scientific consensus compared to conflict in evidence (p = .007) and between sources (p = .013); it also lowered intentions to consume red meat more frequently compared to conflict in evidence, but only in the "do not limit red meat" condition (p = .033). Conflict in evidence (p = .007) and within the same source (p = .013) increased cancer fatalism compared to conflict between sources. CONCLUSIONS: Conflict in scientific evidence and conflict arising from the same expert source (e.g., a changing public health guideline) may have pernicious effects. Future efforts could investigate how best to publicly communicate these instances of scientific conflict to minimize negative impact.

Self-Affirmation Reduces Uncertainty Aversion for Potential Gains.

Decisions about one's health are often accompanied by uncertain outcomes, which may be either positively or negatively valenced. The presence of this uncertainty, which can range along a continuum from risk to ambiguity (i.e., decisions in which the outcome probabilities are known or unknown), can be perceived as threatening, and individuals tend to be averse to uncertain outcomes, and will attempt to avoid uncertainty when possible. We proposed that one way to reduce uncertainty aversion could be to provide opportunities to affirm one's core values, or "self-affirmation." Prior research has suggested that self-affirmation promotes health behaviour by providing a buffer against potential threats to the self. However, the degree to which self-affirmation affects decision-making is still unclear. Across two studies, we tested the effects of a self-affirmation manipulation on risk (Study 1) and ambiguity (Study 2) preferences for both potential gains and losses. In both studies, we found that, compared to the non-affirmed group, affirmed individuals were more accepting of uncertainty when the decision involved potential gains, but not for potential losses. Further, for risky decisions, the increased acceptance of uncertainty came at the expense of making choices consistent with expected value, such that self-affirmed individuals made more disadvantageous choices than non-affirmed individuals. Our results suggest both benefits and costs of self-affirmation in the context of risky choice, an important finding given the many applications of self-affirmation in behavioral decision making contexts.

Dispositional optimism and optimistic bias: Associations with cessation motivation, confidence, and attitudes.

OBJECTIVE: To test whether 2 conceptually overlapping constructs, dispositional optimism (generalized positive expectations) and optimistic bias (inaccurately low risk perceptions), may have different implications for smoking treatment engagement. METHOD: Predominantly Black, low-income Southern Community Cohort study smokers (n = 880) self-reported dispositional optimism and pessimism (Life Orientation Test-Revised subscales: 0 = neutral, 12 = high optimism/pessimism), comparative lung cancer risk (Low/Average/High), and information to calculate objective lung cancer risk (Low/Med/High). Perceived risk was categorized as accurate (perceived = objective), optimistically-biased (perceived < objective), or pessimistically-biased (perceived > objective). One-way ANOVAs tested associations between dispositional optimism/pessimism and perceived risk accuracy. Multivariable logistic regressions tested independent associations of optimism/pessimism and perceived risk accuracy with cessation motivation (Low/High), confidence (Low/High), and precision treatment attitudes (Favorable/Unfavorable), controlling for sociodemographics and nicotine dependence. RESULTS: Mean dispositional optimism/pessimism scores were 8.41 (SD = 2.59) and 5.65 (SD = 3.02), respectively. Perceived lung cancer risk was 38% accurate, 27% optimistically-biased, and 35% pessimistically-biased. Accuracy was unrelated to dispositional optimism (F(2, 641) = 1.23, p = .29), though optimistically-biased (vs. pessimistically-biased) smokers had higher dispositional pessimism (F(2, 628) = 3.17, p = .043). Dispositional optimism was associated with higher confidence (Adjusted odds ratio [AOR] = 1.71, 95% CI [1.42, 2.06], p < .001) and favorable precision treatment attitudes (AOR = 1.66, 95% CI [1.37, 2.01], p < .001). Optimistically-biased (vs. accurate) risk perception was associated with lower motivation (AOR = .64, 95% CI [.42, .98], p = .041) and less favorable precision treatment attitudes (AOR = .59, 95% CI [.38, .94], p = .029). CONCLUSIONS: Dispositional optimism and lung cancer risk perception accuracy were unrelated. Dispositional optimism was associated with favorable engagement-related outcomes and optimistically-biased risk perception with unfavorable outcomes, reinforcing the distinctiveness of these constructs and their implications for smoking treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Analysis of the components of cancer risk perception and links with intention and behaviour: A UK-based study.

Risk perception refers to how individuals interpret their susceptibility to threats, and has been hypothesised as an important predictor of intentions and behaviour in many theories of health behaviour change. However, its components, optimal measurement, and effects are not yet fully understood. The TRIRISK model, developed in the US, conceptualises risk perception as deliberative, affective and experiential components. In this study, we aimed to assess the replicability of the TRIRISK model in a UK sample by confirmatory factor analysis (CFA), explore the inherent factor structure of risk perception in the UK sample by exploratory factor analysis (EFA), and assess the associations of EFA-based factors with intentions to change behaviour and subsequent behaviour change. Data were derived from an online randomised controlled trial assessing cancer risk perception using the TRIRISK instrument and intention and lifestyle measures before and after communication of cancer risk. In the CFA analysis, the TRIRISK model of risk perception did not provide a good fit for the UK data. A revised model developed using EFA consisted of two separate "numerical" and "self-reflective" factors of deliberative risk perception, and a third factor combining affective with a subset of experiential items. This model provided a better fit to the data when cross-validated. Using multivariable regression analysis, we found that the self-reflective and affective-experiential factors of the model identified in this study were reliable predictors of intentions to prevent cancer. There were no associations of any of the risk perception factors with behaviour change. This study confirms that risk perception is clearly a multidimensional construct, having identified self-reflective risk perception as a new distinct component with predictive validity for intention. Furthermore, we highlight the practical implications of our findings for the design of interventions incorporating risk perception aimed at behaviour change in the context of cancer prevention.

Behavioral Research in Cancer Prevention and Control: Emerging Challenges and Opportunities.

It is estimated that behaviors such as poor diet, alcohol consumption, tobacco use, sedentary behavior, and excessive ultraviolet exposure account for nearly one-half of all cancer morbidity and mortality. Accordingly, the behavioral, social, and communication sciences have been important contributors to cancer prevention and control research, with methodological advances and implementation science helping to produce optimally effective interventions. To sustain these contributions, it is vital to adapt to the contemporary context. Efforts must consider ancillary effects of the 2019 coronavirus disease pandemic, profound changes in the information environment and public understanding of and trust in science, renewed attention to structural racism and social determinants of health, and the rapidly increasing population of cancer survivors. Within this context, it is essential to accelerate reductions in tobacco use across all population subgroups; consider new models of energy balance (diet, physical activity, sedentary behavior); increase awareness of alcohol as a risk factor for cancer; and identify better communication practices in the context of cancer-related decisions such as screening and genetic testing. Successful integration of behavioral research and cancer prevention depends on working globally and seamlessly across disciplines, taking a multilevel approach where possible. Methodological and analytic approaches should be emphasized in research training programs and should use new and underused data sources and technologies. As the leadership core of the National Cancer Institute's Behavioral Research Program, we reflect on these challenges and opportunities and consider implications for the next phase of behavioral research in cancer prevention and control.

Patient Perspectives on the Risk-Based NLST Outcomes Tool for Lung Cancer Screening.

Researchers at the NCI have developed the Risk-Based NLST Outcomes Tool (RNOT), an online tool that calculates risk of lung cancer diagnosis and death with and without lung cancer screening, and false-positive risk estimates. This tool has the potential to facilitate shared decision making for screening. The objective of this study was to examine how current heavy and former smokers understand and respond to personalized risk estimates from the RNOT. Individuals who were eligible for lung cancer screening and were visiting Walter Reed National Military Medical Center were invited to participate in a semi-structured interview to assess their experiences with and perceptions of the RNOT. Results were analyzed using template analysis. Participants found their risk of lung cancer death to be lower than anticipated and were confused by changes in risk for lung cancer diagnosis with and without screening. Most participants indicated that the RNOT would be helpful in making screening decisions, despite reporting that there was no maximum risk for a false positive that would lead them to forgo lung cancer screening. Participants provided actionable needs and recommendations to optimize this tool. Risk-based screening tools may enhance shared decision making. The RNOT is being updated to incorporate these findings.