Communicating side effect risks in a tamoxifen prophylaxis decision aid: the debiasing influence of pictographs.

Journal Article (Multicenter Study;Journal Article)


To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers.


We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge.


Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels.


Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations.

Practice implications

Including graphs in risk communications is essential to support an informed treatment decision-making process.

Full Text

Duke Authors

Cited Authors

  • Zikmund-Fisher, BJ; Ubel, PA; Smith, DM; Derry, HA; McClure, JB; Stark, A; Pitsch, RK; Fagerlin, A

Published Date

  • November 2008

Published In

Volume / Issue

  • 73 / 2

Start / End Page

  • 209 - 214

PubMed ID

  • 18602242

Pubmed Central ID

  • PMC2649664

Electronic International Standard Serial Number (EISSN)

  • 1873-5134

International Standard Serial Number (ISSN)

  • 0738-3991

Digital Object Identifier (DOI)

  • 10.1016/j.pec.2008.05.010


  • eng