Kreps, G.L. (2003).

The impact of communication on cancer risk, incidence, morbidity,

mortality, and quality of life. Health Communication, 15: 2, 163-171.

The Impact of Communication on Cancer Risk, Incidence, Morbidity, Mortality, and

Quality of Life

Gary L. Kreps, Ph.D., Chief

Health Communication and Informatics Research Branch
National Cancer Institute

ABSTRACT
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.

INTRODUCTION
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 endof-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:
Cancer Prevention
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, SlevinPerocchia, Steelman, & Wooldridge, 2001; Pierce, Macaskill, & Hill, 1990; Ziant, 1993).
Cancer Detection
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).
Cancer Diagnosis
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
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 patients
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).
Cancer Survivorship
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, inpress). 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, inpress). 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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