Table 1.

Examples of clinical and educational issues arising from the patient’s concerns

PATIENT ISSUE	CLINICAL ISSUES	EDUCATIONAL ISSUES
The patient may not be aware of the trade-offs between the harms and benefits of screening¹³	What information does the physician need to inform this discussion? What is the best way to present this information to the patient? Some issues to consider: Approximately 50% of Canadians have inadequate health literacy and numeracy skills¹³ Well-designed knowledge translation tools can provide information on harms and benefits that support decision making	What is the natural history of cancer progression and the natural history of breast cancer? What is the concept of overdiagnosis, and how does it apply to screening for breast cancer? What outcome measures should be used to determine the benefits of screening? What outcome measures are potentially misleading? How should knowledge translation tools be used to support decision making on screening?
The patient feels she should be screened more frequently than recommended for breast cancer	There are conflicting guideline recommendations on screening intervals for mammography: The Canadian Task Force on Preventive Health Care recommends screening every 2-3 y¹⁴ The Canadian Association of Radiologists and the Canadian Society of Breast Imaging recommend screening every 1-2 y¹⁵	How do we assess the quality of guidelines providing recommendations on screening for breast cancer? How are screening interval recommendations determined?
The patient is anxious and has concerns regarding her risk for breast cancer¹⁶	In clinical circumstances where there is a trade-off between harms and benefits, shared decision making is the desired approach Patient values and preferences do influence screening decisions The physician might feel pressured to pursue further screening as a way to manage the patient’s health anxiety	Adequate skills in shared decision making (communicating risk and eliciting the patient’s preferences and values) are necessary Adequate skills in the management of health anxiety are required
The patient has increased awareness of breast cancer because of her friend’s illness	Strong statements and beliefs on the benefits of screening are often provided by cancer survivors and advocacy groups	Understand the paradox of screening, which is an increased incidence and a perceived sense of benefit as a result of increased screening¹⁷