Comparative optimism in breast cancer risk perception: Effects of experience and risk factor knowledge

  • Absetz P
  • Aro A
  • Rehnberg G
 et al. 
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We studied the effects of experience and risk factor knowledge on
perceptions of breast cancer risk in a nationally representative
sample of 1,157 middle-aged women. Personal risk was perceived to
be lower than peers' risk, indicating comparative optimism. Optimism
was found to depend on experience with breast cancer. Only 19% of
women with affected first-degree relatives were comparative optimists,
while 63% believed their personal risk was equal to and 18% believed
it was higher than peers' risk. Among women having some other relative,
or knowing somebody else or knowing nobody with breast cancer, the
respective figures were 45-50% (lower), 45-50% (equal) and 5% (higher).
Knowledge that breast cancer can be inherited did not affect risk
perception, suggesting that a tendency to downplay one's personal
risk persisted even in the presence of medical risk factors.

Breast cancer is the most common female cancer in the western world:
approximately one out of eight women gets it during their lifetime
(American Cancer Society, 1998). Despite the high prevalence of breast
cancer, wide media attention on the disease, and even concern that
women may be overly worried (Rubin, 1993; Swanson, 1993), it seems
that in fact not very many women perceive themselves to be at increased
risk for the disease. On the contrary, the few studies that have
reported figures on perceived risk show that even among women with
increased risk the vast majority feel their risk of developing breast
cancer is only moderate or less (Fletcher et al., 1989; Polednak
et al., 1991; Vogel et al., 1990). This may be an indication of unrealistic
optimism or optimistic bias, a tendency to see one's own risk in
more favourable terms than the risk of other people. Since determining
whether perceived risk is realistic or unrealistic is problematic,
and the conditions under which optimism can be judged to be unrealistic
or biased are rather strict (Sutton, 1999), we prefer to use the
term 'comparative optimism'. The phenomenon has been commonly found
in risk literature (Fontaine & Smith, 1995; Hoorens & Buunk, 1993;
Reppucci et al., 1991; Strecher et al., 1995; Weinstein, 1980; 1982;
1987), but has not been studied in detail in the context of breast

Optimism in risk perception may be psychologically functional by protecting
people from anxiety (Taylor & Brown, 1988; Schwarzer, 1994; Weinstein
& Klein, 1995), but it may also be a serious obstacle from the viewpoint
of behaviour change and preventive behaviours (Schwarzer, 1994; Strecher
et al., 1995; Weinstein & Klein, 1995). Perceptions of high personal
risk for breast cancer have been shown to influence self-initiated
mammography participation positively (Aro, 1996; Lipkus et al., 1996;
McCaul et al., 1996), so it is likely that comparative optimism would
have an opposite effect. However, earlier research findings on optimistic
bias are not readily generalizable to women who would benefit from
mammography screening, because the research has been mainly conducted
among young, healthy student populations (e.g. Eiser et al., 1993;
Perloff & Fetzer, 1986; Weinstein, 1980) to whom many of the health
threats, especially cancer, may seem distant and unreal.

It is important to realize that women do differ in their actual risk.
Certain factors that discriminate those with elevated risk should
be taken into account when studying risk perception. Until the last
decade no breast cancer risk factors had definitely been identified
with the exception of age. Since then evidence of other risk factors
such as hormone-related factors (McPherson et al., 1994) and heredity
(Slattery & Kerber, 1993; Vogel, 1996) has cumulated. Even though
only about 5% of breast cancers result from an inherited susceptibility
gene (Hoskins et al., 1995), this risk factor seems to have received
the most media attention. Judging from the increasing demand for
risk assessment and counselling clinics, the information of hereditary
risk has reached women who have breast cancer in their family and
has affected their personal risk perception. Some studies (Drossaert
et al., 1996; Vernon et al., 1993; Vogel et al., 1990) imply that
family history of breast cancer influences risk perception through
other mechanisms besides knowledge of hereditary risk, i.e. through
experience at close range. Weinstein (1987; 1989) proposed that personal
experience reduces unrealistic optimism by leading people to think
about the risk more often and with greater clarity, and to see hazards
as more frequent and themselves as potential future victims.

As the provision of risk counselling and risk factor monitoring increases,
knowledge and understanding of people's risk perceptions has become
of utmost importance. Furthermore, breast cancer control relies on
active screening participation that may be hindered by phenomena
like optimism in risk perception. The earlier studies on optimistic
bias, conducted with a wide variety of hazards mainly among young
student populations, may not be generalizable to one specific disease
and a population to whom the risk is salient. Clearly, there was
a need for a study on comparative optimism in breast cancer risk
perception among people who are facing the threat in their everyday
lives--among women who are in the age when screening is recommended
and who may also have experienced the disease at close range.

In this study perceptions of personal and peers' risk were assessed
among women who either had or had not experienced breast cancer among
family or friends. The effect of knowing that heredity is a risk
factor was also examined. Based on earlier literature, we expected
women in general to exhibit comparative optimism when evaluating
their own versus peers' likelihood of developing breast cancer. However,
we expected the women with experience of breast cancer to be less
optimistic, comparative optimism decreasing the closer the relationship
with the person affected. We further predicted that women with both
affected family members and knowledge that heredity is a risk factor
would be the least optimistic regarding their personal risk

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