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Keywords:

  • disparities;
  • decision making;
  • preferences;
  • communication;
  • psycho-oncology;
  • hospice;
  • palliative care;
  • end-of-life;
  • quality of life;
  • behavior;
  • ethics;
  • public health

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES

BACKGROUND:

Because cancers are a leading cause of death, these diseases receive a great deal of news attention. However, because news media frequently target specific racial or ethnic audiences, some populations may receive different information, and it is unknown whether reporting equally informs all audiences about the options for care at the end of life. This study of news reporting compared “mainstream” (general market) media with African American media, which serves the largest minority group. The specific goal of this study was to determine whether these news media communicate differently about cure-directed cancer treatment and end-of-life alternatives.

METHODS:

This content analysis included 660 cancer news stories from online and print media that targeted either African American or mainstream audiences. The main outcome measures included whether reporting discussed adverse events of cancer treatment, cancer treatment failure, cancer death/dying, and end-of-life palliative or hospice care.

RESULTS:

Unadjusted and adjusted analyses indicated that the news stories in the African American media are less likely than those in mainstream media to discuss each of the topics studied. Comparing the proportions of news stories in mainstream versus African American media, 31.6% versus 13.6% discussed adverse events (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.51-5.66; P = .001); 14.1% versus 4.2% mentioned treatment failure (OR, 3.79; 95% CI, 1.45-9.88; P = .006); and 11.9% versus 3.8% focused on death/dying (OR, 3.42; 95% CI, 1.39-8.38; P = .007). Finally, although very few news stories discussed end-of-life hospice or palliative care, all were found in mainstream media (7/396 vs 0/264).

CONCLUSION:

The African American news media sampled are less likely than mainstream news media to portray negative cancer outcomes and end-of-life care. Given media's segmented audiences, these findings raise concerns that not all audiences are being informed equally well. Because media content is modifiable, there may be opportunities to improve public cancer communication. Cancer 2012. © 2011 American Cancer Society.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES

The Institute of Medicine (IOM) has emphasized that all individuals should be informed about the options for care at the end of life.1, 2 Because cancer is a leading cause of death, the IOM has specifically stressed the need to inform everyone about the potential risks and benefits of pursuing cure-directed cancer treatments versus alternatives, such as hospice care, that focus on comfort rather than cures.1, 2 Citing ethical principles, these arguments have highlighted the need to provide everyone with access to this important health information.

Health information is disseminated not only by health care providers but also public information sources. In particular, news media frequently and prominently report on cancer, and this coverage has become an easily accessible and commonly used source of cancer information.3 Moreover, news coverage has been shown to influence cancer treatment decisions, as well as other highly personal health behaviors.4-10

Because many news media target specific racial or ethnic audiences,11 some populations may receive different information about end-of-life care. The goal of this study was to determine whether African American news media (which serve the largest racial minority group in the United States) and “mainstream” (ie, general market) news media communicate differently about cure-directed cancer treatment and end-of-life alternatives. This is the first known comparative study of this topic, and differences in media messages might help to explain the greater preference for cure-directed therapies in the face of poor prognosis among African Americans compared with Caucasians.12-16 Importantly, if different media messages lead to different preferences, communication may play a role in decision making. Decisions based on inadequate or biased communication may not reflect true preferences, thereby contributing to health disparities.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES

Study Design and Data Collection

We conducted a content analysis of news stories in African American and mainstream online and print media. To ensure reliable coding, we used a coding instrument to determine the presence or absence of 4 specific variables in each news story. News stories were coded to determine whether they reported on 1) adverse events of cancer treatment, defined as mentioning any unintended, negative consequences attributed to cancer treatments, including long- and short-term adverse effects such as neuropathy, pain, hair loss, and nausea; 2) cancer treatment failure, defined as mentioning that cancer treatment can fail to extend the life of the patient or prevent reoccurrence, or that (late stage) disease can be incurable or untreatable; 3) cancer death/dying, defined as focusing on 1 or more individuals dead from cancer, dying from cancer, or given a terminal diagnosis; and 4) end-of-life palliative or hospice care, defined as using the term “palliative” or “hospice” or mentioning related symptom management.

We also wanted to determine whether differences in reporting might be attributable to characteristics of the African American or mainstream news media. For this reason, we measured potential confounders, including whether each targeted mostly female or high-income audiences, as reported by industry demographic audience data. Because each of the news media studied targets adult audiences within a similar age span, we did not include audience age as a potential confounder. However, we did measure staff size, because literature suggests that this can influence the quality of scientific reporting, and African American media companies may have smaller staff.17 In addition, we measured characteristics of the news story, including the number of words, the type of cancers discussed, and whether reporting focused on a cancer diagnosis for which the survival rate is <50% according to the National Cancer Institute's classification.18

For all study variables, coders were trained to use the instrument's decision rules reliably. Reliability in coding was tested in a random 10% sample double-coded to ensure quality.19 Interrater reliability between coders for all study variables was high20 whereby Krippendorff's alpha for each variable exceeded 0.70.

Data Sources

We analyzed content available online and in print from magazines and newspapers because African Americans are more likely to use and rate these media as a trusted source of health information than other news sources, such as radio or television.21, 22 For example, according to surveys, between 82% and 90% of African American households report regularly using African American newspapers and magazines for health information.21

We sampled 4 newspapers with the largest African American audience (Chicago's Chicago Crusader, Los Angeles' Herald Dispatch, and New York City's Daily Challenge, and Philadelphia's Philadelphia Tribune) and 8 mainstream newspapers with large audiences in the same geographic areas (Chicago Tribune, Chicago Sun-Times, Los Angeles Times, New York Times, New York Daily News, New York Post, Philadelphia Inquirer, and Philadelphia Daily News). In addition, to sample national magazines, we included 4 African American magazines with a large audience (Ebony, Jet, Essence, and Heart & Soul) and 4 mainstream magazines with a large audience (Time, Family Circle, Redbook, and People). The media classified as African American is explicitly self-defined as such and, according to industry demographic data, has an audience that is 90% or greater African American. All newspapers and magazines were available online and in print.

Selection of News Stories

Using methods similar to those used in other content analyses of reporting,23, 24 we randomly selected news stories accessible through electronic databases including Lexis-Nexis, ProQuest, EBSCO, and Factiva. Using a computer-automated process and programmed, validated search terms,25 we identified 1889 cancer-focused news stories that were at least 200 words. (Because we did not exclude certain types of reporting, the reporting included coverage of research findings, patient profiles, and other types of news stories.) We then created a random sample (35%) of news stories by selecting 33 news stories from each publication (appearing 2003-2010), while manually confirming that they met these inclusion criteria.

Analysis

We calculated and compared the proportion of news stories in the African American and mainstream media containing each study variable. Inference was based on unadjusted and adjusted odds ratios (ORs) obtained with logistic regression.26 Tests and estimates of bivariate associations between media type (ie, African American or mainstream media) and reporting content were based on the OR with approximate 95% confidence intervals (CIs) and a 2-tailed chi-square test (significance level, P < 0.05) that the OR equals 1. Adjusted ORs were computed similarly, with the exception that the model included additional variables that could explain the reporting differences. These covariates were determined using a stepwise regression approach. For each reporting content variable, a pool of covariates was screened one by one using logistic regression. Those that achieved marginal significance at a moderate level (P <. 25) were included. The final model for the adjusted analyses included only covariates that provide a difference in the media-type OR greater than 10% or acted as independent predictors.26

In all analyses, to control for the potential effect of clustering due to multiple news stories from the same periodical, we adjusted the standard errors of the associations and tests under the logistic regressions for such clustering. This adjustment uses the generalized estimating equation approach of Zeger and Liang27 and is available in SAS PROC GENMOD. The OR confidence intervals and Wald test statistics were computed using the sandwich estimator of variance.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES

We analyzed a sample of 660 cancer-focused news stories, including 264 from African American media and 396 from mainstream media. Additional characteristics of the sample are reported in Table 1. The below results report whether the African American news media are significantly less likely than mainstream news media to report on each of the topics studied: adverse events of cancer treatment; cancer treatment failure; cancer death/dying; and end-of-life palliative and hospice care.

Table 1. Characteristics of African American and Mainstream Media News Stories
 African American News (n = 264)Mainstream News (n = 396)P
  1. Data are presented as no. (%) unless noted otherwise.

Main outcomes   
 Hospice/palliative care mentioned0 (0)7 (1.77).05
 Focus on dead/dying patients10 (3.78)47 (11.87)<.001
 Treatment failure mentioned11 (4.16)56 (14.14)<.001
 Adverse events mentioned36 (13.64)125 (31.57)<.001
Covariates   
 News story characteristics   
  No. of words, median472587<.001
  Focus on breast cancer91 (34.47)141 (35.61).765
  Focus on prostate cancer59 (22.35)28 (7.07)<.001
  Focus on cancer (not specified)61 (23.11)64 (16.16).026
  Low survival rate cancers discussed15 (5.68)62 (15.66)<.001
 Media characteristics   
  Female audience66 (25.00)66 (16.67).01
  High-income audience0 (0)132 (33.33)<.001
  Staff size (large)66 (25.00)264 (66.67)<.001

Reporting on Adverse Events

Overall, 161/660 (24.4%) news stories about cancer mentioned adverse events of cancer treatment. Among the mainstream media, 125/396 (31.6%) of the news stories discussed adverse events, compared with just 36/264 (13.6%) stories in African American news media (OR, 2.92; 95% CI, 1.51-5.66; P = .001). In the final adjusted analysis, the mainstream news media remained significantly more likely to mention adverse events (adjusted OR [AOR], 3.86; 95% CI, 1.56-9.56; P = .004). The final adjusted analysis included the following covariates: whether the media targets a female audience, whether it's a magazine or newspaper, and its staff size.

Reporting on Cancer Treatment Failure

Among all news stories about cancer, 67/660 (10.2%) mentioned that aggressive cancer treatments can fail to cure or extend life, or that certain cancers (such as late-stage disease) can be incurable. Among the mainstream news media, 56/396 (14.1%) of the news stories mentioned (possible or actual) treatment failure, whereas only 11/264 (4.2%) of news stories from the African American news media did so (OR, 3.79; 95% CI, 1.45-9.88; P = .006). In the final adjusted analysis, the mainstream media remained significantly more likely than the African American media to mention treatment failure (AOR, 3.47; 95% CI, 1.61-7.51; P = .002). The final adjusted analysis included the following covariates: whether targeting a female audience and whether the news story reports on a cancer diagnosis with low survival rates.

Reporting on Death and Dying

Among the entire sample of news stories, 57/660 (8.6%) focused on individuals who were dead or dying from cancer. Among the mainstream news media, 47/396 (11.9%) of the articles focused on death/dying, whereas only 10/264 (3.8%) of news stories in the African American news media did so (OR, 3.42; 95% CI, 1.39-8.38; P = .007). In the final adjusted analysis, the mainstream news media remained significantly more likely than the African American media to focus on death/dying (AOR, 3.28; 95% CI, 1.42-7.59; P = .005). The final adjusted analysis included the following covariates: whether the news story reported on a cancer diagnosis with low survival rates, and whether it was provided by a magazine or newspaper.

Reporting on End-of-Life Cancer Care

Among all news stories in our sample, only 7/660 (1.1%) discussed end-of-life hospice or palliative care, and all were found in mainstream media. This difference appeared to be significant (7/396 vs 0/264). Because of the small number of news stories, the analysis above could not be applied. No adjusted analyses were conducted due to the lack of reporting on end-of-life care by the African American news media.

As reported above, unadjusted as well as adjusted analyses indicate that the probability of a randomly chosen news story discussing each of the reporting topics is significantly less if published by the African American news media. In addition, because some of the mainstream media but none of the African American media reported for high-income audiences, we repeated the above analyses excluding high-income periodicals from the analysis and obtained similar results (data not shown).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES

To our knowledge, this is the first study that has systematically examined racial differences in news coverage to investigate how differences may influence end-of-life care preferences. In our sample, we found that the news stories in African American news media are significantly less likely than those in mainstream news media to report on each of the topics studied: adverse events; treatment failure; death/dying; and end-of-life palliative and hospice care. This conclusion is based on unadjusted and adjusted analyses, given that the adjusted ORs were about the same or stronger than the unadjusted odds ratios, and cannot be attributed to differences in the characteristics measured.

It is unclear why these African American and mainstream news media appear to report differently, and this determination was not an objective of the current study. It is possible that patterns in reporting reflect culturally different beliefs about cancer treatment and outcomes. Alternatively, it is possible that African American journalists and editors perceive their professional role to be different from mainstream media,28 and may thus prefer to generate more “positive” messages.

It is also unknown how the different media messages affect populations. The lack of reporting by the African American news media may give audiences unrealistic expectations, because these outcomes are in fact common. For instance, although the African American news media rarely focuses on patients dead or dying from cancer, half of all patients in the United States who are diagnosed with cancer will not survive, and cancer-related mortality rates for African Americans are substantially higher than those for other US racial groups.29

Previous studies have documented that African American cancer patients are more likely than Caucasians to prefer aggressive care at the end of life and less likely to use hospice care.12-16 Reflecting on these findings, some have hypothesized, but never empirically tested, that African American media and culture encourages the denial of death and even of terminal cancer.2, 30 Our findings could be interpreted as consistent with this possibility because, in our sample, the African American news media are less likely than the mainstream counterpart to discuss end-of-life care and less likely to focus on patients dead or dying from cancer. It has also been hypothesized that fears of being denied treatment create greater aggressive treatment preferences among African Americans. However, it is not clear exactly how this could explain the news reporting patterns, or how the patterns documented would instill fears of being denied treatment.

It should also be noted that reporting on end-of-life care was rare in both the African American and mainstream media. However, hospice and palliative care offer numerous, well-documented benefits for patients and families and are professionally recognized as an important part of comprehensive cancer care.1, 2, 31-33 Such information can be communicated by a variety of sources, including interpersonal and mass-mediated ones, and cross-sectional surveys have previously shown correlations between exposure to information about hospice and preferences for hospice, suggesting that information about this option may influence patient decision making.34, 35 If mass media increase the availability of information about hospice and palliative care, this communication may increase awareness of these options and change beliefs about their value. Indeed, when media bring increased attention to specific topics, they frequently enjoy greater individual, community, and political support.4, 10

Limitations of our study include the fact that we did not measure exposure or effects, and future investigation is warranted. Future studies could identify when news coverage generates realistic expectations, unrealistically optimistic expectations, or fatalism. Given that African Americans are often exposed to African American and mainstream news, the effects of this exposure may depend in part on the relative and absolute amount of exposure individuals have to each.

Because we studied magazines and newspapers with large audiences, the findings may not be generalizable to those with smaller audiences. In addition, because this study examines reporting available online and in print from newspapers and magazines, the results may not be generalizable to other news media targeting racially segmented audiences. For instance, radio stations also target racially segmented audiences, although African Americans are less likely to rely on them as sources of trusted health information.21, 22 News media have also successfully targeted Hispanic/Latino and Asian populations, among others, on the basis of ethnicity and language, and the content of such reporting also warrants investigation. It may also be useful for future studies to qualitatively analyze how the same stories are covered differently for distinct audiences. Furthermore, sources of health information include entertainment media36 and nonmedia sources, such as clinicians, who may also influence end-of-life decisions, even though previous work has also characterized them as reluctant to discuss end-of-life care.37, 38

Because media content is modifiable, there are opportunities to improve health communication. The goal of improving public communication is valuable because, as previously noted, media messages influence health behaviors, including highly personal health care decisions.4-10 Given that media frequently target specific racial and ethnic audiences, resulting in substantial audience segmentation11 it is also important to compare the content provided. For these reasons, other studies have compared the health messages in media targeting minority and general audiences and raised concerns over the differences uncovered.39-41

In conclusion, our findings suggest that the African American news media may be less likely than mainstream news media to realistically portray cancer treatments and outcomes and less likely to discuss end-of-life options. Ideally, patients make end-of-life decisions that realistically reflect the trade-offs between pursuing aggressive care and alternatives such as hospice care. Given media's segmented audiences, these findings raise concerns that not all audiences are being informed equally well.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES

We thank Kathleen Propert, Jens Praestgaard, Jeffrey Munson, Greg Bisson, Jo Ellen Stryker, Robert Hornik, and anonymous reviewers for thoughtful contributions. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute or the American Cancer Society.

FUNDING SOURCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES

This study was supported in part by research funds awarded to J.M.F. through the EPIC Center of Excellence in Cancer Communication Research (PI: Hornik, grant number 5P50CA095856-05 from the National Cancer Institute) and the American Cancer Society grant MRSGT-08-013-01-CPPB awarded to J.M.F.

CONFLICT OF INTEREST

The authors made no disclosures.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. FUNDING SOURCES
  9. REFERENCES
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