Labels, Language and Other Strategies to Improve Communication About Lower Grade Ductal Carcinoma in Situ: Integration of Findings from Theoretical Review and Interviews

Labels, Language and Other Strategies to Improve Communication About Lower Grade Ductal Carcinoma in Situ: Integration of Findings from Theoretical Review and Interviews | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Labels, Language and Other Strategies to Improve Communication About Lower Grade Ductal Carcinoma in Situ: Integration of Findings from Theoretical Review and Interviews Suzanna Apostolovski, Nicole J. Look Hong, Frances C. Wright, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9202416/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Ductal carcinoma in situ (DCIS) is characterized by abnormal cells confined to the milk ducts of the breast. Despite being confined to milk ducts, untreated DCIS can progress to invasive disease. Women diagnosed with low-grade DCIS are often advised to undergo surgery, radiation, and/or chemotherapy, despite the possibility that the condition may never progress. This frequently leads to confusion, distress, and long-term anxiety. Clear, consistent, and patient-centred communication is therefore critical to support informed decision-making for women with DCIS. The objective of this study was to identify preferred terminology, language, and strategies that would act as recommendations to improve communication about DCIS. Methods A mixed-methods design was employed, integrating a theoretical review with interviews to capture both conceptual insights and lived experience to inform recommendations. Findings from the theoretical review and interviews were analyzed using Communication Accommodation Theory (CAT) and then mapped to five domains—approximation, interpretability, interpersonal control, discourse management, and emotional regulation—to assess how clinicians adapt communication to meet women's needs. This approach highlighted areas of alignment and misalignment between women and clinician perspectives. Results Mapping results to CAT demonstrated that language and interaction styles strongly influenced women’s understanding and emotional responses. Women consistently preferred clear, non-threatening terms such as “abnormal cells,” while clinicians tended to rely on more technical terminology. Communication improved when clinicians adapted their language, acknowledged uncertainty, and engaged in collaborative dialogue. Recommendations to improve communication included using plain language, visual aids, extended consultations, reassurance, and active listening to reduce distress and enhance informed decision-making. Conclusion Terminology significantly shapes women’s understanding of DCIS and their emotional reactions. Misalignment between women’s preferences and clinicians language can hinder communication. Applying CAT-informed strategies, including preferred terminology and clarification of distinctions from invasive cancer, can improve understanding, reduce anxiety, and support patient-centred care. women ductal carcinoma in situ communication nomenclature preferences patient-centred care theoretical review interviews communication accommodation theory Figures Figure 1 Background Ductal carcinoma in situ (DCIS) is characterized by abnormal epithelial cells confined within the milk ducts of the breast without invasion into surrounding tissue [1]. Although DCIS is non-invasive, it is widely considered a precursor lesion that can progress to invasive carcinoma if left untreated [2, 3]. DCIS accounts for approximately 20–25% of all breast lesions detected through mammography, and its incidence has risen substantially over recent decades due to the widespread implementation of breast screening programs [1]. As detection rates have increased, attention has also turned to the communication challenges surrounding DCIS diagnosis and management. Communication plays a crucial role in women’s health, where clinical conversations frequently involve complex and sensitive issues related to diagnosis, treatment decisions, uncertainty, and risk interpretation. Effective patient–clinician communication has been shown to improve patients’ understanding of their condition, support shared decision-making, and reduce anxiety and decisional conflict in cancer care [4, 5]. In the context of breast cancer and screening-related conditions such as DCIS, communication is particularly important because patients must navigate nuanced information about prognosis, treatment options, and potential overtreatment [6, 7] Research in women’s health has also demonstrated that clear, empathetic, and patient-centered communication can improve satisfaction with care, treatment adherence, and psychosocial outcomes [5, 8]. These issues are especially salient for DCIS, where uncertainty about the condition’s progression and differing interpretations of risk can complicate discussions between clinicians and patients. Discussions about DCIS can be confusing for many women. Clinicians often use cancer-related terms such as “pre‑cancer” or “stage 0 cancer,” while simultaneously reassuring patients that DCIS is “only” an early or non‑invasive condition [9, 10]. This inconsistency leads to uncertainty about the seriousness of the diagnosis and the need for treatment. Communication challenges are heightened by emerging evidence from active surveillance trials such as COMET, LORIS, and LORD, which are exploring whether selected women with low‑risk DCIS can safely undergo monitoring rather than immediate surgery or radiation [11]. While these findings are promising, they make clinical explanations more complex and increase uncertainty for both patients and providers. Communication plays a crucial role in women’s health, where conversations often involve complex and sensitive issues related to diagnosis, treatment, and risk [12, 13]. Research consistently shows that clear, empathetic, and patient-centered communication improves women’s understanding, emotional well-being, decision-making, and trust in healthcare providers [14–16]. In the context of breast conditions such as DCIS, communication has an especially significant impact on psychological outcomes, treatment satisfaction, and overall quality of life [15, 18]. Therefore, understanding how communication occurs and how it can be improved between women and clinicians is essential to supporting informed, person-centered care. Existing literature on DCIS has primarily focused on renaming the condition to reduce fear and overtreatment, including recommendations to remove the term “carcinoma” from the label [19–21]. Studies have also shown that terminology affects women’s emotional responses, perceived disease severity, and treatment preferences [22, 23]. However, few studies have examined communication beyond labeling, such as how clinicians explain risk, address emotions, or tailor discussions to improve understanding and shared decision-making [24]. Educational materials often combine DCIS with invasive breast cancer information, which may increase confusion and distress for women [25]. Moreover, little is known about how non‑physician clinicians—such as nurses and patient navigators—communicate about DCIS despite their important role in patient education and support [26]. To address these gaps, this study applies an integrative, theory-informed approach. Communication Accommodation Theory (CAT) offers a useful lens for examining how clinicians adapt communication to meet patients’ informational and emotional needs [27]. Combined with a patient-centered care framework, CAT helps identify specific, theory-driven strategies that can enhance understanding, promote trust, and reduce anxiety among women diagnosed with DCIS. In light of these challenges, further research is needed to better understand how communication practices influence women’s experiences of DCIS and shape their understanding of diagnosis, risk, and treatment options. Examining how clinicians describe and frame DCIS is particularly important because the language used during clinical encounters can influence patients’ interpretations of the condition, their emotional responses, and subsequent decision-making processes. By exploring how women interpret and respond to the terminology used by clinicians to describe DCIS, this study contributes to a growing body of research focused on improving communication in women’s health and promoting patient-centered care. In doing so, the research directly aligns with the aims and scope of BMC Women’s Health , which seeks to advance knowledge on health issues affecting women and to identify strategies that improve health care delivery, communication, and outcomes for women across diverse contexts. Specifically, this study aims to examine how terminology used to describe DCIS is communicated and understood in clinical interactions, and to identify opportunities for improving patient–clinician communication to better support informed, patient-centered decision-making in breast health care. Methods This integrative study draws on two complementary sources of evidence. First, it builds on a prior theoretical review examining the labels and language used to describe DCIS and the implications of these terms for patient understanding, risk perception, and communication in clinical contexts [19]. That review aimed to synthesize existing literature on the terminology used to describe DCIS and to examine how different labels—such as “abnormal cells,” “pre-cancer,” or “cancer”—may influence patients’ interpretations of the condition, emotional responses, and treatment decision-making. Second, the present analysis incorporates findings from a qualitative interview study involving women diagnosed with DCIS and clinicians involved in DCIS care [21]. The aim of that study was to explore how DCIS is explained and discussed during clinical encounters, how patients interpret the language used by clinicians to describe the condition, and how these communicative practices shape patients’ understanding, perceptions of risk, and preferences regarding terminology. By integrating insights from these two studies, the current work provides a more comprehensive examination of how language, labeling, and communication strategies influence women’s experiences of DCIS and highlights opportunities to improve patient–clinician communication in breast health care. Data integration followed principles of integrative synthesis, a method designed to bring together diverse forms of evidence (e.g., conceptual, theoretical, and empirical) to develop more comprehensive and practice-relevant insights [22]. Integrative methodologies are increasingly used in women’s health research to bridge conceptual and experiential data, deepen understanding of patient–clinician interactions, and strengthen implications for practice [23, 24]. Our goal was not to re-analyze original data but to synthesize and integrate key findings across the two sources to identify common themes and generate actionable recommendations for improving communication about DCIS. This approach enabled the generation of insights that neither source alone could have provided and reflects a growing methodological trend toward mixed and integrative syntheses in women’s and clinical communication research [25, 26]. The University of Toronto Research Ethics Board approved the study (REB #44709). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided informed consent prior to interviews. The researchers collecting data did not have prior relationships with the participants. We utilized a Standards for Reporting Qualitative Research checklist. Data Integration We integrated findings from the theoretical review and qualitative interviews to develop a comprehensive understanding of how DCIS communication can be improved [19, 21]. First, we re-visited both datasets and extracted the key concepts, themes, and recommendations identified in each source. Both the theoretical review and interview study explored labels, language and other strategies, For the theoretical review, this included summarized findings on the terminology, framing, and communication strategies used to describe DCIS in the literature. For the interview data, we referred to themes extracted from women and clinicians to identify patterns and illustrative quotes reflecting perceptions of labels, preferred language, and communication needs. Next, we conducted a comparative synthesis to identify areas of convergence, divergence, and complementarity across the two data sources. This process involved creating a matrix to map themes from both datasets, examining how theoretical insights aligned with, or differed from, lived experiences and clinical perspectives. Through iterative discussion, we integrated converging and diverging concepts and refined them into higher-order themes that captured priorities for improving DCIS communication. Finally, these integrated findings generated recommendations for patient-centered communication about DCIS. This integrative process enabled us to develop nuanced insights that would not have emerged from analyzing either dataset in isolation. Theoretical Framework It is important to highlight that we first integrated data from the two studies, then the integrated data was analyzed using Communication Accommodation Theory (CAT). CAT is a well-established theoretical framework developed in 1970 to explain how individuals modify their communication behaviour during social interactions [27]. CAT posits that communicators actively adjust their speech, tone, terminology, and nonverbal behaviour to either converge with or diverge from their conversational partners. Convergence, in this context, refers to adapting communication to align with the other person’s language, preferences, and emotional state, thereby enhancing mutual understanding, rapport, and perceived credibility. Divergence, in contrast, occurs when communicators emphasize differences, which can create distance, misunderstanding, or reduced satisfaction in the interaction [27]. CAT includes five core strategies that influence convergence or divergence: approximation, interpretability, discourse management, emotional expression, and interpersonal control [27, 28]. Approximation captures how clinicians adjust language to match patient preferences and reduce anxiety. Interpretability examines the clarity and comprehensibility of the information provided. Discourse management focuses on how clinicians structure and guide the flow of conversation to ensure effective communication. Emotional expression addresses how communicators respond to and regulate emotional content in interactions. Interpersonal control considers the balance of power in the conversation and the degree to which patients are able to participate actively. Using CAT as a framework allowed for a theory-informed analysis of both the theoretical review and interview data, highlighting areas of alignment and misalignment between clinician behaviours and patient preferences, and providing a foundation for evidence-based recommendations to enhance patient-centred communication about DCIS. Analytic Procedure Two researchers (SA and ARG) independently extracted data from both sources (theoretical review findings and interview transcripts). From the theoretical review, we entered synthesized findings on labels, language used to explain labels, other strategies used to support or supplement communication identified in the literature. From the interviews, we entered participant quotes and summarized interpretations that reflected women’s and clinicians’ preferences, concerns, and rationales for label and language use. Each data point was then mapped to one or more of the five domains of CAT: approximation, interpretability, interpersonal control, discourse management, and emotional regulation. A codebook was developed to define how each CAT domain manifested in communication practices (e.g., approximation reflected clinicians’ linguistic alignment with patients’ understanding of DCIS). Discrepancies in coding or interpretation were resolved through iterative discussion and verification against the original transcripts and extracted literature findings. This process produced a transparent and theoretically grounded synthesis of how clinicians accommodate or fail to accommodate patients’ informational and emotional needs when communicating about DCIS. Results Integration Matrix The integration of prior literature and interview data produced a matrix that aligned women’s and clinicians’ reported experiences with communication about DCIS. The matrix consolidated themes across both datasets. It included excerpts from interviews and synthesized findings from the theoretical review, allowing for a direct comparison of how each group discussed labels, language, and communication strategies (Table 1.0). The matrix identified both points of convergence, where women and clinicians described similar communication practices, and points of divergence, where perspectives differed. An example of this is that women frequently described confusion, anxiety, and uncertainty when hearing labels such as “abnormal cells,” “precursor,” or “cancer.” In contrast, clinicians expressed confidence in using these labels and believed they were reassuring to patients, highlighting a considerable difference in the expectations and preferences of women and clinicians. The matrix also revealed broader areas of divergence. Women emphasized the need for plain, non-technical language, emotional reassurance, and more opportunities for discussion, whereas clinicians largely perceived their current communication strategies as sufficient. These comparisons laid the foundation for the subsequent mapping, which illuminated how communication behaviours either facilitated or hindered accommodation. Mapping to CAT Domains Mapping the integrated findings to CAT revealed specific communication dynamics and practical implications for patient-centred care in DCIS. All five CAT domains were considered equally important in understanding DCIS communication. Each domain—approximation, interpretability, interpersonal control, discourse management, and emotional expression—captured distinct yet interrelated aspects of communication that collectively influenced how participants experienced and interpreted discussions about DCIS. Initial orientation to DCIS discussions differed in several ways between women and clinicians, although areas of overlap were also evident. Women often approached the encounter seeking clarity and reassurance regarding the meaning of the diagnosis and its implications for their health, reflecting a need for psychological accommodation to the uncertainty surrounding DCIS. In contrast, clinicians tended to frame these early conversations in terms of clinical classification, treatment pathways, and risk management. Despite these differences in orientation, both groups expressed a shared concern for ensuring that information was communicated in ways that supported understanding and reduced distress. These similarities and differences shaped how accommodation unfolded during the interaction, influencing how language, explanations, and emotional support were provided and interpreted. Within the approximation domain, both groups supported the use of plain, lay language, but women emphasized that changing the diagnostic label itself. For example, avoiding the term “cancer”, would better convey meaning and reduce anxiety. Under interpretability, clinicians reported using visual aids and educational materials to clarify concepts, whereas women expressed the need for more comprehensive explanations, printed or digital resources, and opportunities to revisit information after appointments. In the interpersonal control domain, clinicians noted that additional time was sometimes allocated to address patient questions, but women consistently desired longer appointments and more thorough explanations of pathology and imaging results. In the discourse management domain, both groups valued discussions about recurrence risk and prognosis, although women uniquely suggested receiving information in advance and having these conversations outside cancer centre environments to reduce distress. Within the emotional regulation domain, both groups recognized the importance of emphasizing favourable prognosis, but women highlighted the additional need for explicit reassurance that DCIS is not invasive cancer and opportunities for emotional expression through follow-up visits or supportive dialogue. The matrix and CAT mapping illustrate that women and clinicians often identify similar communication goals but differ in their perceptions of effectiveness and sufficiency. The integrated findings extend prior publications by generating concrete, theory-informed recommendations for practice. These include reconsidering the terminology used to describe DCIS, structuring appointments to allow more dialogue, providing anticipatory educational resources, and explicitly addressing emotional reassurance. Figure 1.0 visually represents these findings, illustrating how clinicians’ language choices and communication strategies either accommodate (convergent) or fail to accommodate (divergent) patient needs across CAT’s five domains. Table 1.0 Matrix of integrated findings mapped to CAT domains. CAT domain Reported by participants Recommended improvements by participants Women affected by DCIS Clinicians Women affected by DCIS Clinicians Approximation Adjusting one's language and communication to resemble that of another Use plain/lay language to describe DCIS characteristics Use plain/lay language to describe DCIS characteristics -- -- Interpretability Adapting one's communication to suit the comprehension level of the other person Used visual aids Provided educational materials Used visual aids Provided educational material Change label to be more clear Give detailed explanation of treatment options Visual aids/guides Provide or refer patients to print or online resources Change label to be more clear Provide clinicians with visual aids/guides Provide or refer patients to print or online resources Interpersonal control Adjusting communication strategies according to one's position and authority Took extra time to discuss concerns and answer questions Took extra time to discuss concerns and answer questions Took time to explain the pathology or radiology report Longer visits with time for discussion and questions Longer visits with time for discussion and questions Discourse management Modifying communication to meet the requirements or preferences of the other party Described risk of recurrence or chance of survival Referred to stage, grade or continuum/spectrum to explain risk of or relation to cancer Described risk of recurrence or chance of survival Referred to stage, grade or continuum/spectrum to explain risk of or relation to cancer Ensure patients are not being seen out of a cancer centre -- Provide patients with information in advance of visit during which diagnosis will be discussed Emotional expression Addressing the emotional and relational needs of the other party in one's response Explained DCIS has favourable prognosis Explained DCIS have favourable prognosis Explicitly state that it’s not cancer Asked patient to articulate specific concerns Arrange follow-up visit to discuss further Connect patients with support services or groups Connect patients with support services or groups Figure 1.0 illustrates how beliefs and motivations impact interactions between women and clinicians, either accommodating (convergent) or failing to accommodate (divergent), according to CAT’s five domains. Figure 1.0 visually represents how the communication dynamics between women and clinicians align with the five domains of CAT. The figure depicts the interplay of accommodating (convergent) and non-accommodating (divergent) communication strategies used by clinicians during discussions about DCIS. The results show how specific language choices influence patient understanding, anxiety, and satisfaction in clinical consultations. Convergent strategies are shown as arrows moving toward alignment between clinician and patient preferences, these strategies reflect accommodation, such as the use of plain language and patient centred communication, which enhance understanding and reduce anxiety. Divergent strategies are represented by arrows moving in opposing directions, these indicate non-accommodation, where clinicians maintain medicalized language or fail to address patient emotions, leading to increased anxiety and confusion. In summary, this analysis revealed that communication about DCIS is often hindered by mismatches between clinicians’ language and women’s interpretations, leading to confusion, and anxiety. Effective communication between clinicians and women is crucial for achieving convergence, especially regarding DCIS. This analysis highlights significant areas where womens experiences diverge from clinician intentions, revealing the urgent need for improved communication strategies. Applying CAT to integrate findings from the theoretical review and interviews highlighted the need for clearer terminology, greater emotional sensitivity and more collaborative dialogue. Interpretation Integrating the findings from the two studies revealed several higher-level patterns in how language and communication strategies shape women’s experiences of DCIS. First, a consistent misalignment between clinical language and patient interpretation emerged. Clinicians tended to prioritize medically precise terminology, such as “precursor to cancer,” whereas women interpreted many of these labels through the emotional and symbolic meanings associated with cancer more broadly. As a result, the same terminology often carried different cognitive and emotional implications for each group. This divergence highlights the importance of interpretability within CAT, as patients frequently struggled to translate clinical terminology into personally meaningful understanding. Second, the integrated findings demonstrated that language used to describe DCIS functions not only as information but also as an emotional signal. Women frequently reported that labels such as “cancer” triggered fear and uncertainty even when clinicians emphasized the non-invasive nature of DCIS. Clinicians, in contrast, often used such terms to convey risk or clinical classification. This disconnect illustrates how emotional regulation within communication is central to accommodation, as the emotional consequences of terminology may differ from clinicians’ intended meanings. Third, the analysis revealed a broader structural imbalance in communication dynamics, particularly in terms of interpersonal control and discourse management. Conversations were typically clinician-led and focused on conveying biomedical information, which sometimes limited opportunities for women to ask questions, express concerns, or shape the discussion according to their informational and emotional needs. Women expressed a preference for more collaborative and dialogic interactions that allowed greater participation in decision-making. Taken together, these integrated findings suggest that communication challenges in DCIS consultations stem less from isolated terminology choices and more from systematic differences in orientation to the interaction. Clinicians tend to prioritize clinical precision and efficiency, whereas women seek clarity, reassurance, and opportunities to contextualize the diagnosis within their personal experiences. From a CAT perspective, these patterns reflect varying degrees of convergence and divergence in approximation, interpretability, interpersonal control, discourse management, and emotional regulation. When clinicians adjusted language, pacing, and conversational structure to align more closely with women’s informational and emotional needs, communication was perceived as more supportive and understandable. Conversely, persistent reliance on medicalized language and clinician-dominated discourse often intensified anxiety and confusion. Overall, the integration of the two studies highlights that effective communication about DCIS requires coordinated accommodation across multiple communicative domains, including terminology, emotional responsiveness, and conversational structure. Addressing these areas may help bridge interpretive gaps between clinicians and women diagnosed with DCIS and support clearer understanding, reduced distress, and more informed decision-making. Discussion This study explored how women affected by DCIS and clinicians perceive and communicate about DCIS, with a focus on preferred terminology, language, and strategies to improve patient–clinician interactions. Integrating findings from prior research including a theoretical review and qualitative interviews revealed communication patterns that are directly relevant to patient-centred care. Women frequently described confusion and anxiety when terminology emphasized “cancer,” particularly when such labels were introduced without accompanying explanations that clarified the non-invasive nature of DCIS. From a CAT perspective, this reflected challenges in interpretability, as the language used by clinicians did not always align with women’s informational frameworks or expectations. Women often interpreted these terms through broader cultural associations with invasive cancer, which heightened emotional responses and uncertainty. In contrast, clinicians generally viewed existing terminology as medically precise approximations intended to convey risk accurately and, in some cases, believed that emphasizing the favorable prognosis would provide reassurance. This difference illustrates how communicative intent and interpretation diverged between groups: clinicians prioritized biomedical precision, whereas women evaluated the language primarily through its emotional and explanatory implications. This disconnect illustrates the broader challenge of communicating clinical uncertainty in ways that are both accurate and sensitive to emotional impact. Contribution to Existing Literature This study builds on the body of prior research showing that the label “ductal carcinoma in situ” causes confusion and anxiety among women and creates challenges for clinicians when discussing its clinical significance [13, 15, 29]. Prior studies from Australia, the United Kingdom, and the United States have found that many women misinterpret DCIS as invasive breast cancer and consequently overestimate recurrence and mortality risk [30, 31, 32]. Clinicians likewise report difficulty balancing accuracy with reassurance, which often results in inconsistent explanations [33]. This study makes several contributions that extend beyond prior research on DCIS communication. First, whereas much of the existing literature has primarily documented challenges associated with terminology and patient understanding, prior studies have rarely examined practical solutions for improving communication . In contrast, this study explicitly sought to identify potential solutions to these challenges. Second, the analysis is unique in its integrative design , combining a comprehensive review of prior research on DCIS terminology and communication with additional qualitative data from interviews with women diagnosed with DCIS and clinicians involved in their care. Importantly, the qualitative component was designed not only to explore experiences but also to identify potential communication strategies that could address observed gaps in understanding and emotional support. Third, this study is distinctive in its application of CAT as an analytic framework. By using CAT, the study moves beyond descriptive accounts of communication difficulties to examine how specific communicative processes—such as approximation, interpretability, interpersonal control, discourse management, and emotional expression—shape interactions between women and clinicians. This theoretical lens enabled the identification of concrete opportunities for communicative convergence that may improve patient understanding, reduce distress, and support more patient-centered discussions about DCIS. Together, these contributions provide a more comprehensive and solution-oriented understanding of DCIS communication than has been offered in prior research. Using this method allowed the identification of key recommendations to implement practical strategies that could improve communication about DCIS. The findings also align with research from other medical conditions where relabeling has reduced patient distress and improved understanding. For example, replacing “cervical intraepithelial neoplasia” with “low-” or “high-grade squamous intraepithelial lesion” lessened anxiety and improved comprehension [33]. Comparable efforts in thyroid and prostate cancer have sought to remove the word “cancer” from indolent lesions to prevent overtreatment and mitigate psychological harm [35, 36, 37]. Extending this evidence to DCIS, the present study underscores the potential benefits of terminology reform and highlights the need for patient-informed language to support shared decision-making. Implications for Practice and Policy The study findings have several implications for clinical practice and policy. Non-cancer labels alone are unlikely to resolve the communication challenges identified in this study. Rather, the findings suggest that divergence emerged across at least two CAT domains—interpretability and approximation—where clinicians tended to prioritize medically precise terminology (e.g., “precursor to cancer”) while women evaluated terminology primarily in terms of clarity, emotional impact, and personal meaning. Addressing this divergence requires strategies that reconcile clinical accuracy with patient interpretability. One approach may involve pairing terminology with clearer contextual explanations, visual aids, or analogies that situate DCIS within a spectrum of breast disease, thereby improving comprehension without sacrificing precision. Similar approaches have been successfully implemented in other areas of medicine, including genetic counseling and risk communication in screening contexts, where clinicians routinely combine technical language with explanatory framing to enhance patient understanding. In addition, the study identified several areas of agreement between women and clinicians regarding preferred communication strategies, including the use of plain language, opportunities for patients to ask questions, and clearer explanations of risk and prognosis. Implementing these strategies may require structural changes to clinical communication practices, such as incorporating patient-centered communication training, decision-support tools, and consultation frameworks that encourage dialogue rather than one-directional information delivery. There is precedent for such approaches in health communication research, particularly in shared decision-making models and patient-centered oncology care, where structured communication strategies have been shown to improve understanding, reduce anxiety, and enhance patient engagement. Together, these approaches suggest that improving DCIS communication requires not simply changing terminology but fostering greater communicative accommodation between clinicians and patients through clearer explanations, collaborative dialogue, and supportive informational resources. Knowledge of preferred labels, language, and communication strategies could inform the design of DCIS-specific educational resources, including informational materials and conversation guides for both women and clinicians. These findings also resonate with international efforts such as a name change, to promote clear and non-alarming terminology in breast pathology reporting while maintaining clinical accuracy [38, 39]. Knowledge about preferred DCIS labels and language may prompt international nomenclature bodies to consider revising terminology for low-risk forms of DCIS, as has been advocated by researchers, clinicians, and affected women [40, 41]. Engagement with professional societies such as the American Joint Committee on Cancer, the International Collaboration on Cancer Reporting, and the World Health Organization Classification of Tumours Group will be crucial in facilitating such reform. Recommendations The findings of this study highlight the nuanced and sometimes divergent perspectives of women and clinicians regarding DCIS terminology and communication. Non-cancer labels and carefully considered language have the potential to reduce confusion and anxiety, supporting more patient-centred care. Future research should further examine the psychological and behavioural impacts of DCIS terminology, ideally through interdisciplinary collaborations among oncologists, pathologists, psychologists, and patient advocates. Such work could inform the development of alternative nomenclature for low-risk lesions and guide updates to existing terminology standards. Additionally, communication aids [42, 43]—such as question prompt lists, visual infographics, and decision aids—may facilitate clearer and more empathetic discussions, enabling women to ask informed questions and clinicians to align explanations with patient preferences. Embedding communication accommodation strategies in clinician training, including tailoring explanations, checking for understanding, and responding to emotional cues, could further enhance trust, understanding, and satisfaction in these interactions. Feedback mechanisms, such as reflective debriefs or communication audits, may help identify discrepancies between patient and clinician perspectives, highlighting opportunities for improvement in routine practice. Finally, promoting dissemination of these strategies through professional networks, conferences, and patient advocacy collaborations will be essential to ensure consistent implementation across diverse healthcare settings. Strengths and Limitations This study has several strengths. It applied a rigorous and transparent methodological approach, including comprehensive literature searches and independent, duplicate screening and extraction. The integration of findings from published studies and qualitative interviews allowed for a broader understanding of DCIS communication than either dataset could provide alone. The use of a theoretical framework provided structure for identifying how (mis)alignments in communication occur and allowed for the identification of key recommendations. Nonetheless, several limitations should be acknowledged. The study did not include other healthcare perspectives, such as nurses or allied health professionals, and did not systematically capture time since diagnosis, both of which may influence views on DCIS terminology and warrant exploration in future research. Conclusion This study highlights the complex and often distressing nature of communication about DCIS especially in cases where women are advised to undergo invasive treatments for a condition that may never progress to invasive cancer. By integrating findings from the theoretical review and interviews, we captured a more nuanced understanding of the disconnect between how women and clinicians perceive and discuss DCIS. Women consistently expressed confusion and anxiety when clinicians used labels such as “pre-cancer” or “stage 0 cancer” without clear explanation, while clinicians assumed that these terms were adequately understood. Mapping the results to CAT provided a valuable framework for interpreting these communication gaps. Differences in initial orientation and psychological accommodation were evident, but both groups identified similar strategies to support more effective communication in all domains of CAT. These findings underscore the importance of tailoring communication to individual patient needs and expectations, and of explicitly addressing uncertainty, risk, and the nature of DCIS using clear and consistent language. Addressing these areas through patient-centred, empathetic communication can bridge gaps in understanding, improve emotional outcomes, and support informed, shared decision-making. While CAT helped frame many of the interpersonal dynamics in clinician–patient interactions, some participant insights—particularly those related to dissemination strategies and systemic influences—extended beyond the scope of the framework. Future research should explore these areas further to inform more inclusive and equitable communication practices for women. Overall, this study highlights the importance of integrating theoretical, empirical lived experience perspectives to inform patient-centred communication. By identifying language preferences, communication strategies, and practical recommendations for women with low-risk DCIS, this work addresses a critical aspect of breast health that directly impacts women’s emotional well-being, understanding of their care, and ability to make informed decisions. These findings contribute to advancing the broader goals of women’s health research by promoting patient-centred care, reducing disparities in access to clear and supportive information, and enhancing the quality of care and health outcomes. Declarations Ethics Approval and Consent The University of Toronto Research Ethics Board approved the study (REB #44709). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided informed consent prior to interviews. Author Contributions Suzanna Apostolovski carried out the research as a PhD student at the University of Toronto. She assisted in conceptualizing the study, developed methodology, collected and analyzed data, and drafted and finalized the manuscript. ARG, NLH and FCW conceptualized the study, acquired funding, assisted in developing methodology, took part in data collection and analysis, and assisted in drafting and editing the manuscript. Acknowledgements Not applicable. Consent for Publication Not applicable. Funding This work was supported by the Canadian Cancer Society under Grant [number 707644] Competing Interests The authors declare no competing interests. Data availability statement All data are available in the manuscript. References Kerlikowske K. Epidemiology of ductal carcinoma in situ. J Natl Cancer Inst Monogr. 2010;(41):139–41. doi:10.1093/jncimonographs/lgq027. Tomlinson-Hansen S, Tomlinson-Hansen SE. Breast ductal carcinoma in situ. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. 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JAMA. 2025;333(11):972–980. doi:10.1001/jama.2024.26698. Schmitz RSJM, Engelhardt EG, Gerritsma MA, et al. Active surveillance versus treatment in low-risk DCIS: women's preferences in the LORD trial. Eur J Cancer. 2023;192:113276. doi:10.1016/j.ejca.2023.113276. Wheelwright S, Matthews L, Jenkins V, et al. Recruiting women with ductal carcinoma in situ to a randomised controlled trial: lessons from the LORIS study. Trials. 2023;24:670. doi:10.1186/s13063-023-07703-4. Partridge AH, Elmore JG, Saslow D, McCaskill-Stevens W, Schnitt SJ. Challenges in ductal carcinoma in situ risk communication and decision-making: report from an American Cancer Society and National Cancer Institute workshop. CA Cancer J Clin. 2012;62(3):203–210. doi:10.3322/caac.21140. Gagliardi AR, Wright FC, Look Hong N, et al. National consensus recommendations on patient-centered care for ductal carcinoma in situ. Breast Cancer Res Treat. 2019;174(3):561–570. doi:10.1007/s10549-019-05132-z. McCaffery K, Nickel B, Moynihan R, et al. How different terminology for ductal carcinoma in situ impacts women's concern and treatment preferences: a randomised comparison within a national community survey. BMJ Open. 2015;5(11):e008094. doi:10.1136/bmjopen-2015-008094. Nyhof J, Prady S, Gagliardi A. Communication about ductal carcinoma in situ: Challenges for clinicians and patients. Patient Educ Couns. 2020;103(1):71–77. doi:10.1016/j.pec.2019.07.011 McCaffery KJ, Smith SK, Wolf MS, Sheridan S. The influence of cancer terminology on patient anxiety and treatment choices. Psychooncology. 2015;24(12):1657–1663. doi:10.1002/pon.3801 Nickels E, Nyhof-Young J, Hawley S. Patient experiences of ductal carcinoma in situ diagnosis and communication: A qualitative study. Breast Cancer Res Treat. 2015;154(3):589–597. doi:10.1007/s10549-015-3627-3 Apostolovski S, Look Hong NJ, Wright FC, Gagliardi AR. Labels, language and other strategies to improve communication about lower grade ductal carcinoma in situ: theoretical review. Health Commun. In press 2025. Esserman LJ, Thompson IM, Reid B. Rethinking the taxonomy of breast cancer. J Natl Cancer Inst. 2014;106(6):dju169. doi:10.1093/jnci/dju169 Apostolovski S, Look Hong NJ, Wright FC, Gagliardi AR. Labels, language and other strategies to improve communication about lower grade ductal carcinoma in situ: qualitative interviews. Psychooncology. In press 2025. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–553. doi:10.1111/j.1365-2648.2005.03621.x. Sandelowski M, Voils CI, Barroso J. Defining and designing mixed research synthesis studies. Res Sch. 2006;13(1):29–40. Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy. 2005;10(1):45–53. doi:10.1177/135581960501000110. Armour M, Sinclair J, Chalmers KJ, Smith CA. The role of integrative synthesis in women’s health research: insights from endometriosis studies. BMC Womens Health. 2019;19(1):122. doi:10.1186/s12905-019-0814-2. Mallick L, Temmerman M, Thwin SS, et al. Integrating quantitative and qualitative findings in family planning systematic reviews: a convergent synthesis approach. BMJ Glob Health. 2021;6(8):e006337. doi:10.1136/bmjgh-2021-006337. Farzadnia S, Giles H. Patient-provider interaction: A communication accommodation theory perspective. Int J Soc Cult Lang. 2015;3:17–34. Gallois C, Ogay T, Giles H. Communication accommodation theory: A look back and a look ahead. In: Gudykunst WB, editor. Theorizing about intercultural communication. Thousand Oaks: Sage; 2005. p. 121–148. Pusic A, King TA, Rounds J, Morrow M. Understanding ductal carcinoma in situ: patient and surgeon perspectives. J Am Coll Surg . 2005;201(4):516–26. Han E, Silverstein MJ. Ductal carcinoma in situ: an update of current data. Oncologist . 2021;26(2):e217–24. DeMorgan S, Redman S, White KJ, Cakir B, Boyages J. “Well, have I got cancer or haven’t I?” The psycho-social issues for women diagnosed with ductal carcinoma in situ. Health Expect . 2002;5(4):310–8. Ong CS, Manders JB, Thorne H, Farber R, Mann GB, McKinley J. Ductal carcinoma in situ terminology: what do women think? Breast . 2018;42:135–41. Elmore JG, Thompson E, Carney PA, Geller BM, Weaver DL, Oster NV, et al. Pathologists’ diagnosis of invasive melanoma and melanocytic proliferations: observer accuracy and reproducibility study. BMJ . 2017;357:j2813. Moscicki AB, Cox JT. Practice improvement in cervical screening and management (PICSM): revising terminology to improve understanding. J Low Genit Tract Dis . 2010;14(4):275–80. Esserman LJ, Thompson IM, Reid B. Overdiagnosis and overtreatment in cancer: an opportunity for improvement. JAMA . 2013;310(8):797–8. Nickel B, Barratt A, Moynihan R, McCaffery K. Renaming low risk conditions labelled as cancer. BMJ . 2018;362:k3322. Donovan JL, Hamdy FC, Lane JA, Mason M, Metcalfe C, Walsh E, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med . 2016;375(15):1425–37. Lakhani SR, Ellis IO, Schnitt SJ, Tan PH, van de Vijver MJ, editors. WHO Classification of Tumours of the Breast . 5th ed. Lyon: IARC Press; 2019. Allison KH, Brogi E, Ellis IO, Fox SB, Lakhani SR, Lazar AJ, et al. WHO Classification of Tumours, 5th Edition, Breast Tumours: Major updates and emerging issues. Histopathology . 2020;77(2):181–5. Francis A, Thomas J, Fallowfield L, Wallis M, Bartlett JM, Brookes C, et al. Addressing overtreatment of screen detected DCIS; the LORIS trial. Eur J Cancer . 2015;51(16):2296–303. Gagliardi AR, Wright FC, Dubin JA, Booth CM, Strother D, McCready DR, et al. Translating knowledge about ductal carcinoma in situ into practice: the need for shared terminology and communication strategies. Breast . 2019;44:136–43. Shepherd HL, Barratt A, Trevena LJ, McGeechan K, Carey K, Epstein RM, et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial. Patient Educ Couns . 2011;84(3):379–85. Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev . 2017;4(4):CD001431. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9202416","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626345780,"identity":"19134129-5f8e-4ca0-b44e-912e271a5f01","order_by":0,"name":"Suzanna Apostolovski","email":"data:image/png;base64,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","orcid":"","institution":"University of Toronto","correspondingAuthor":true,"prefix":"","firstName":"Suzanna","middleName":"","lastName":"Apostolovski","suffix":""},{"id":626345781,"identity":"6c2211dc-ff42-4a0a-9026-21ef4830672c","order_by":1,"name":"Nicole J. Look Hong","email":"","orcid":"","institution":"Odette Cancer Centre","correspondingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"J. Look","lastName":"Hong","suffix":""},{"id":626345782,"identity":"f6629220-5293-459e-898b-654ce0021b60","order_by":2,"name":"Frances C. Wright","email":"","orcid":"","institution":"Odette Cancer Centre","correspondingAuthor":false,"prefix":"","firstName":"Frances","middleName":"C.","lastName":"Wright","suffix":""},{"id":626345783,"identity":"74e05f2f-06b8-4672-ae8f-c636d5495fca","order_by":3,"name":"Anna R. Gagliardi","email":"","orcid":"","institution":"Toronto General Hospital Research Institute, University Health Network, University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"R.","lastName":"Gagliardi","suffix":""}],"badges":[],"createdAt":"2026-03-23 15:25:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9202416/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9202416/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107659638,"identity":"7025fd01-6367-43d3-bcc7-44b2dbd029d7","added_by":"auto","created_at":"2026-04-23 16:47:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":125438,"visible":true,"origin":"","legend":"\u003cp\u003eCommunication accommodation for DCIS.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9202416/v1/d59a04521bf9b7aceb104693.png"},{"id":107706302,"identity":"8a91edce-e8d4-4c64-8ce7-b1301c68e8dd","added_by":"auto","created_at":"2026-04-24 09:17:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":347354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9202416/v1/58658cf0-226a-418f-8d04-5f38ce90d61b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Labels, Language and Other Strategies to Improve Communication About Lower Grade Ductal Carcinoma in Situ: Integration of Findings from Theoretical Review and Interviews","fulltext":[{"header":"Background","content":"\u003cp\u003eDuctal carcinoma in situ (DCIS) is characterized by abnormal epithelial cells confined within the milk ducts of the breast without invasion into surrounding tissue [1]. Although DCIS is non-invasive, it is widely considered a precursor lesion that can progress to invasive carcinoma if left untreated [2, 3]. DCIS accounts for approximately 20\u0026ndash;25% of all breast lesions detected through mammography, and its incidence has risen substantially over recent decades due to the widespread implementation of breast screening programs [1]. As detection rates have increased, attention has also turned to the communication challenges surrounding DCIS diagnosis and management. Communication plays a crucial role in women\u0026rsquo;s health, where clinical conversations frequently involve complex and sensitive issues related to diagnosis, treatment decisions, uncertainty, and risk interpretation. Effective patient\u0026ndash;clinician communication has been shown to improve patients\u0026rsquo; understanding of their condition, support shared decision-making, and reduce anxiety and decisional conflict in cancer care [4, 5]. In the context of breast cancer and screening-related conditions such as DCIS, communication is particularly important because patients must navigate nuanced information about prognosis, treatment options, and potential overtreatment [6, 7] Research in women\u0026rsquo;s health has also demonstrated that clear, empathetic, and patient-centered communication can improve satisfaction with care, treatment adherence, and psychosocial outcomes [5, 8]. These issues are especially salient for DCIS, where uncertainty about the condition\u0026rsquo;s progression and differing interpretations of risk can complicate discussions between clinicians and patients.\u003c/p\u003e\n\u003cp\u003eDiscussions about DCIS can be confusing for many women. Clinicians often use cancer-related terms such as \u0026ldquo;pre‑cancer\u0026rdquo; or \u0026ldquo;stage 0 cancer,\u0026rdquo; while simultaneously reassuring patients that DCIS is \u0026ldquo;only\u0026rdquo; an early or non‑invasive condition [9, 10]. This inconsistency leads to uncertainty about the seriousness of the diagnosis and the need for treatment. Communication challenges are heightened by emerging evidence from active surveillance trials such as COMET, LORIS, and LORD, which are exploring whether selected women with low‑risk DCIS can safely undergo monitoring rather than immediate surgery or radiation [11]. While these findings are promising, they make clinical explanations more complex and increase uncertainty for both patients and providers.\u003c/p\u003e\n\u003cp\u003eCommunication plays a crucial role in women\u0026rsquo;s health, where conversations often involve complex and sensitive issues related to diagnosis, treatment, and risk [12, 13]. Research consistently shows that clear, empathetic, and patient-centered communication improves women\u0026rsquo;s understanding, emotional well-being, decision-making, and trust in healthcare providers [14\u0026ndash;16]. In the context of breast conditions such as DCIS, communication has an especially significant impact on psychological outcomes, treatment satisfaction, and overall quality of life [15, 18]. Therefore, understanding how communication occurs and how it can be improved between women and clinicians is essential to supporting informed, person-centered care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExisting literature on DCIS has primarily focused on renaming the condition to reduce fear and overtreatment, including recommendations to remove the term \u0026ldquo;carcinoma\u0026rdquo; from the label [19\u0026ndash;21]. Studies have also shown that terminology affects women\u0026rsquo;s emotional responses, perceived disease severity, and treatment preferences [22, 23]. However, few studies have examined communication beyond labeling, such as how clinicians explain risk, address emotions, or tailor discussions to improve understanding and shared decision-making [24]. Educational materials often combine DCIS with invasive breast cancer information, which may increase confusion and distress for women [25]. Moreover, little is known about how non‑physician clinicians\u0026mdash;such as nurses and patient navigators\u0026mdash;communicate about DCIS despite their important role in patient education and support [26].\u003c/p\u003e\n\u003cp\u003eTo address these gaps, this study applies an integrative, theory-informed approach. Communication Accommodation Theory (CAT) offers a useful lens for examining how clinicians adapt communication to meet patients\u0026rsquo; informational and emotional needs [27]. Combined with a patient-centered care framework, CAT helps identify specific, theory-driven strategies that can enhance understanding, promote trust, and reduce anxiety among women diagnosed with DCIS.\u003c/p\u003e\n\u003cp\u003eIn light of these challenges, further research is needed to better understand how communication practices influence women\u0026rsquo;s experiences of DCIS and shape their understanding of diagnosis, risk, and treatment options. Examining how clinicians describe and frame DCIS is particularly important because the language used during clinical encounters can influence patients\u0026rsquo; interpretations of the condition, their emotional responses, and subsequent decision-making processes. By exploring how women interpret and respond to the terminology used by clinicians to describe DCIS, this study contributes to a growing body of research focused on improving communication in women\u0026rsquo;s health and promoting patient-centered care. In doing so, the research directly aligns with the aims and scope of \u003cem\u003eBMC Women\u0026rsquo;s Health\u003c/em\u003e, which seeks to advance knowledge on health issues affecting women and to identify strategies that improve health care delivery, communication, and outcomes for women across diverse contexts. Specifically, this study aims to examine how terminology used to describe DCIS is communicated and understood in clinical interactions, and to identify opportunities for improving patient\u0026ndash;clinician communication to better support informed, patient-centered decision-making in breast health care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis integrative study draws on two complementary sources of evidence. First, it builds on a prior theoretical review examining the labels and language used to describe DCIS and the implications of these terms for patient understanding, risk perception, and communication in clinical contexts [19]. That review aimed to synthesize existing literature on the terminology used to describe DCIS and to examine how different labels\u0026mdash;such as \u0026ldquo;abnormal cells,\u0026rdquo; \u0026ldquo;pre-cancer,\u0026rdquo; or \u0026ldquo;cancer\u0026rdquo;\u0026mdash;may influence patients\u0026rsquo; interpretations of the condition, emotional responses, and treatment decision-making. Second, the present analysis incorporates findings from a qualitative interview study involving women diagnosed with DCIS and clinicians involved in DCIS care [21]. The aim of that study was to explore how DCIS is explained and discussed during clinical encounters, how patients interpret the language used by clinicians to describe the condition, and how these communicative practices shape patients\u0026rsquo; understanding, perceptions of risk, and preferences regarding terminology. By integrating insights from these two studies, the current work provides a more comprehensive examination of how language, labeling, and communication strategies influence women\u0026rsquo;s experiences of DCIS and highlights opportunities to improve patient\u0026ndash;clinician communication in breast health care.\u003c/p\u003e\n\u003cp\u003eData integration followed principles of integrative synthesis, a method designed to bring together diverse forms of evidence (e.g., conceptual, theoretical, and empirical) to develop more comprehensive and practice-relevant insights [22]. Integrative methodologies are increasingly used in women\u0026rsquo;s health research to bridge conceptual and experiential data, deepen understanding of patient\u0026ndash;clinician interactions, and strengthen implications for practice [23, 24]. Our goal was not to re-analyze original data but to synthesize and integrate key findings across the two sources to identify common themes and generate actionable recommendations for improving communication about DCIS. This approach enabled the generation of insights that neither source alone could have provided and reflects a growing methodological trend toward mixed and integrative syntheses in women\u0026rsquo;s and clinical communication research [25, 26]. The University of Toronto Research Ethics Board approved the study (REB #44709). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided informed consent prior to interviews. The researchers collecting data did not have prior relationships with the participants. We utilized a Standards for Reporting Qualitative Research checklist.\u003c/p\u003e\n\u003cp\u003eData Integration\u0026nbsp;\u003cbr\u003eWe integrated findings from the theoretical review and qualitative interviews to develop a comprehensive understanding of how DCIS communication can be improved [19, 21]. First, we re-visited both datasets and extracted the key concepts, themes, and recommendations identified in each source. Both the theoretical review and interview study explored labels, language and other strategies, For the theoretical review, this included summarized findings on the terminology, framing, and communication strategies used to describe DCIS in the literature. For the interview data, we referred to themes extracted from women and clinicians to identify patterns and illustrative quotes reflecting perceptions of labels, preferred language, and communication needs.\u003c/p\u003e\n\u003cp\u003eNext, we conducted a comparative synthesis to identify areas of convergence, divergence, and complementarity across the two data sources. This process involved creating a matrix to map themes from both datasets, examining how theoretical insights aligned with, or differed from, lived experiences and clinical perspectives. Through iterative discussion, we integrated converging and diverging concepts and refined them into higher-order themes that captured priorities for improving DCIS communication. Finally, these integrated findings generated recommendations for patient-centered communication about DCIS. This integrative process enabled us to develop nuanced insights that would not have emerged from analyzing either dataset in isolation.\u003c/p\u003e\n\u003cp\u003eTheoretical Framework\u003cbr\u003e\u0026nbsp;It is important to highlight that we first integrated data from the two studies, then the integrated data was analyzed using Communication Accommodation Theory (CAT). CAT is a well-established theoretical framework developed in 1970 to explain how individuals modify their communication behaviour during social interactions [27]. CAT posits that communicators actively adjust their speech, tone, terminology, and nonverbal behaviour to either converge with or diverge from their conversational partners. Convergence, in this context, refers to adapting communication to align with the other person\u0026rsquo;s language, preferences, and emotional state, thereby enhancing mutual understanding, rapport, and perceived credibility. Divergence, in contrast, occurs when communicators emphasize differences, which can create distance, misunderstanding, or reduced satisfaction in the interaction [27]. CAT includes five core strategies that influence convergence or divergence: approximation, interpretability, discourse management, emotional expression, and interpersonal control [27, 28]. Approximation captures how clinicians adjust language to match patient preferences and reduce anxiety. Interpretability examines the clarity and comprehensibility of the information provided. Discourse management focuses on how clinicians structure and guide the flow of conversation to ensure effective communication. Emotional expression addresses how communicators respond to and regulate emotional content in interactions. Interpersonal control considers the balance of power in the conversation and the degree to which patients are able to participate actively. Using CAT as a framework allowed for a theory-informed analysis of both the theoretical review and interview data, highlighting areas of alignment and misalignment between clinician behaviours and patient preferences, and providing a foundation for evidence-based recommendations to enhance patient-centred communication about DCIS.\u003c/p\u003e\n\u003cp\u003eAnalytic Procedure\u003c/p\u003e\n\u003cp\u003eTwo researchers (SA and ARG) independently extracted data from both sources (theoretical review findings and interview transcripts). From the theoretical review, we entered synthesized findings on labels, language used to explain labels, other strategies used to support or supplement communication identified in the literature. From the interviews, we entered participant quotes and summarized interpretations that reflected women\u0026rsquo;s and clinicians\u0026rsquo; preferences, concerns, and rationales for label and language use.\u003c/p\u003e\n\u003cp\u003eEach data point was then mapped to one or more of the five domains of CAT: approximation, interpretability, interpersonal control, discourse management, and emotional regulation. A codebook was developed to define how each CAT domain manifested in communication practices (e.g., approximation reflected clinicians\u0026rsquo; linguistic alignment with patients\u0026rsquo; understanding of DCIS). Discrepancies in coding or interpretation were resolved through iterative discussion and verification against the original transcripts and extracted literature findings. This process produced a transparent and theoretically grounded synthesis of how clinicians accommodate or fail to accommodate patients\u0026rsquo; informational and emotional needs when communicating about DCIS.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIntegration Matrix\u003cbr\u003eThe integration of prior literature and interview data produced a matrix that aligned women\u0026rsquo;s and clinicians\u0026rsquo; reported experiences with communication about DCIS. The matrix consolidated themes across both datasets. It included excerpts from interviews and synthesized findings from the theoretical review, allowing for a direct comparison of how each group discussed labels, language, and communication strategies (Table 1.0).\u003c/p\u003e\n\u003cp\u003eThe matrix identified both points of convergence, where women and clinicians described similar communication practices, and points of divergence, where perspectives differed. An example of this is that women frequently described confusion, anxiety, and uncertainty when hearing labels such as \u0026ldquo;abnormal cells,\u0026rdquo; \u0026ldquo;precursor,\u0026rdquo; or \u0026ldquo;cancer.\u0026rdquo; In contrast, clinicians expressed confidence in using these labels and believed they were reassuring to patients, highlighting a considerable difference in the expectations and preferences of women and clinicians.\u003c/p\u003e\n\u003cp\u003eThe matrix also revealed broader areas of divergence. Women emphasized the need for plain, non-technical language, emotional reassurance, and more opportunities for discussion, whereas clinicians largely perceived their current communication strategies as sufficient. These comparisons laid the foundation for the subsequent mapping, which illuminated how communication behaviours either facilitated or hindered accommodation.\u003cbr\u003e\u003cbr\u003eMapping to CAT Domains\u003cbr\u003eMapping the integrated findings to CAT revealed specific communication dynamics and practical implications for patient-centred care in DCIS. All five CAT domains were considered equally important in understanding DCIS communication. Each domain\u0026mdash;approximation, interpretability, interpersonal control, discourse management, and emotional expression\u0026mdash;captured distinct yet interrelated aspects of communication that collectively influenced how participants experienced and interpreted discussions about DCIS.\u003c/p\u003e\n\u003cp\u003eInitial orientation to DCIS discussions differed in several ways between women and clinicians, although areas of overlap were also evident. Women often approached the encounter seeking clarity and reassurance regarding the meaning of the diagnosis and its implications for their health, reflecting a need for psychological accommodation to the uncertainty surrounding DCIS. In contrast, clinicians tended to frame these early conversations in terms of clinical classification, treatment pathways, and risk management. Despite these differences in orientation, both groups expressed a shared concern for ensuring that information was communicated in ways that supported understanding and reduced distress. These similarities and differences shaped how accommodation unfolded during the interaction, influencing how language, explanations, and emotional support were provided and interpreted.\u003c/p\u003e\n\u003cp\u003eWithin the approximation domain, both groups supported the use of plain, lay language, but women emphasized that changing the diagnostic label itself. For example, avoiding the term \u0026ldquo;cancer\u0026rdquo;, would better convey meaning and reduce anxiety. Under interpretability, clinicians reported using visual aids and educational materials to clarify concepts, whereas women expressed the need for more comprehensive explanations, printed or digital resources, and opportunities to revisit information after appointments.\u003c/p\u003e\n\u003cp\u003eIn the interpersonal control domain, clinicians noted that additional time was sometimes allocated to address patient questions, but women consistently desired longer appointments and more thorough explanations of pathology and imaging results. In the discourse management domain, both groups valued discussions about recurrence risk and prognosis, although women uniquely suggested receiving information in advance and having these conversations outside cancer centre environments to reduce distress. Within the emotional regulation domain, both groups recognized the importance of emphasizing favourable prognosis, but women highlighted the additional need for explicit reassurance that DCIS is not invasive cancer and opportunities for emotional expression through follow-up visits or supportive dialogue.\u003c/p\u003e\n\u003cp\u003eThe matrix and CAT mapping illustrate that women and clinicians often identify similar communication goals but differ in their perceptions of effectiveness and sufficiency. The integrated findings extend prior publications by generating concrete, theory-informed recommendations for practice. These include reconsidering the terminology used to describe DCIS, structuring appointments to allow more dialogue, providing anticipatory educational resources, and explicitly addressing emotional reassurance. Figure 1.0 visually represents these findings, illustrating how clinicians\u0026rsquo; language choices and communication strategies either accommodate (convergent) or fail to accommodate (divergent) patient needs across CAT\u0026rsquo;s five domains.\u003c/p\u003e\n\u003cp\u003eTable 1.0 Matrix of integrated findings mapped to CAT domains.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"681\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eCAT domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eReported by participants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eRecommended improvements by participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eWomen affected by DCIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eClinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eWomen affected by DCIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eClinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eApproximation\u003c/p\u003e\n \u003cp\u003eAdjusting one\u0026apos;s language and communication to resemble that of another\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eUse plain/lay language to describe DCIS characteristics\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026nbsp;Use plain/lay language to describe DCIS characteristics\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eInterpretability\u003c/p\u003e\n \u003cp\u003eAdapting one\u0026apos;s communication to suit the comprehension level of the other person\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eUsed visual aids\u003c/li\u003e\n \u003cli\u003eProvided educational materials\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eUsed visual aids\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProvided educational material\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eChange label to be more clear\u003c/li\u003e\n \u003cli\u003eGive detailed explanation of treatment options\u003c/li\u003e\n \u003cli\u003eVisual aids/guides\u003c/li\u003e\n \u003cli\u003eProvide or refer patients to print or online resources\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eChange label to be more clear\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProvide clinicians with visual aids/guides\u003c/li\u003e\n \u003cli\u003eProvide or refer patients to print or online resources\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eInterpersonal control\u003c/p\u003e\n \u003cp\u003eAdjusting communication strategies according to one\u0026apos;s position and authority\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTook extra time to discuss concerns and answer questions\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTook extra time to discuss concerns and answer questions\u003c/li\u003e\n \u003cli\u003eTook time to explain the pathology or radiology report\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLonger visits with time for discussion and questions\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLonger visits with time for discussion and questions\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eDiscourse management\u003c/p\u003e\n \u003cp\u003eModifying communication to meet the requirements or preferences of the other party\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDescribed risk of recurrence or chance of survival\u003c/li\u003e\n \u003cli\u003eReferred to stage, grade or continuum/spectrum to explain risk of or relation to cancer\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDescribed risk of recurrence or chance of survival\u003c/li\u003e\n \u003cli\u003eReferred to stage, grade or continuum/spectrum to explain risk of or relation to cancer\u003c/li\u003e\n \u003cli\u003eEnsure patients are not being seen out of a cancer centre\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eProvide patients with information in advance of visit during which diagnosis will be discussed\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eEmotional expression\u003cbr\u003e\u0026nbsp;Addressing the emotional and relational needs of the other party in one\u0026apos;s response\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eExplained DCIS has favourable prognosis\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eExplained DCIS have favourable prognosis\u003c/li\u003e\n \u003cli\u003eExplicitly state that it\u0026rsquo;s not cancer\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAsked patient to articulate specific concerns \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eArrange follow-up visit to discuss further\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eConnect patients with support services or groups\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eConnect patients with support services or groups\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1.0\u003c/strong\u003e illustrates how beliefs and motivations impact interactions between women and clinicians, either accommodating (convergent) or failing to accommodate (divergent), according to CAT\u0026rsquo;s five domains. Figure 1.0 visually represents how the communication dynamics between women and clinicians align with the five domains of CAT. The figure depicts the interplay of accommodating (convergent) and non-accommodating (divergent) communication strategies used by clinicians during discussions about DCIS. The results show how specific language choices influence patient understanding, anxiety, and satisfaction in clinical consultations. Convergent strategies are shown as arrows moving toward alignment between clinician and patient preferences, these strategies reflect accommodation, such as the use of plain language and patient centred communication, which enhance understanding and reduce anxiety. Divergent strategies are represented by arrows moving in opposing directions, these indicate non-accommodation, where clinicians maintain medicalized language or fail to address patient emotions, leading to increased anxiety and confusion.\u003c/p\u003e\n\u003cp\u003eIn summary, this analysis revealed that communication about DCIS is often hindered by mismatches between clinicians\u0026rsquo; language and women\u0026rsquo;s interpretations, leading to confusion, and anxiety. Effective communication between clinicians and women is crucial for achieving convergence, especially regarding DCIS. This analysis highlights significant areas where womens experiences diverge from clinician intentions, revealing the urgent need for improved communication strategies. Applying CAT to integrate findings from the theoretical review and interviews highlighted the need for clearer terminology, greater emotional sensitivity and more collaborative dialogue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterpretation\u003cbr\u003eIntegrating the findings from the two studies revealed several higher-level patterns in how language and communication strategies shape women\u0026rsquo;s experiences of DCIS. First, a consistent misalignment between clinical language and patient interpretation emerged. Clinicians tended to prioritize medically precise terminology, such as \u0026ldquo;precursor to cancer,\u0026rdquo; whereas women interpreted many of these labels through the emotional and symbolic meanings associated with cancer more broadly. As a result, the same terminology often carried different cognitive and emotional implications for each group. This divergence highlights the importance of interpretability within CAT, as patients frequently struggled to translate clinical terminology into personally meaningful understanding.\u003c/p\u003e\n\u003cp\u003eSecond, the integrated findings demonstrated that language used to describe DCIS functions not only as information but also as an emotional signal. Women frequently reported that labels such as \u0026ldquo;cancer\u0026rdquo; triggered fear and uncertainty even when clinicians emphasized the non-invasive nature of DCIS. Clinicians, in contrast, often used such terms to convey risk or clinical classification. This disconnect illustrates how emotional regulation within communication is central to accommodation, as the emotional consequences of terminology may differ from clinicians\u0026rsquo; intended meanings.\u003c/p\u003e\n\u003cp\u003eThird, the analysis revealed a broader structural imbalance in communication dynamics, particularly in terms of interpersonal control and discourse management. Conversations were typically clinician-led and focused on conveying biomedical information, which sometimes limited opportunities for women to ask questions, express concerns, or shape the discussion according to their informational and emotional needs. Women expressed a preference for more collaborative and dialogic interactions that allowed greater participation in decision-making.\u003c/p\u003e\n\u003cp\u003eTaken together, these integrated findings suggest that communication challenges in DCIS consultations stem less from isolated terminology choices and more from systematic differences in orientation to the interaction. Clinicians tend to prioritize clinical precision and efficiency, whereas women seek clarity, reassurance, and opportunities to contextualize the diagnosis within their personal experiences. From a CAT perspective, these patterns reflect varying degrees of convergence and divergence in approximation, interpretability, interpersonal control, discourse management, and emotional regulation. When clinicians adjusted language, pacing, and conversational structure to align more closely with women\u0026rsquo;s informational and emotional needs, communication was perceived as more supportive and understandable. Conversely, persistent reliance on medicalized language and clinician-dominated discourse often intensified anxiety and confusion.\u003c/p\u003e\n\u003cp\u003eOverall, the integration of the two studies highlights that effective communication about DCIS requires coordinated accommodation across multiple communicative domains, including terminology, emotional responsiveness, and conversational structure. Addressing these areas may help bridge interpretive gaps between clinicians and women diagnosed with DCIS and support clearer understanding, reduced distress, and more informed decision-making.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored how women affected by DCIS and clinicians perceive and communicate about DCIS, with a focus on preferred terminology, language, and strategies to improve patient\u0026ndash;clinician interactions. Integrating findings from prior research including a theoretical review and qualitative interviews revealed communication patterns that are directly relevant to patient-centred care. Women frequently described confusion and anxiety when terminology emphasized \u0026ldquo;cancer,\u0026rdquo; particularly when such labels were introduced without accompanying explanations that clarified the non-invasive nature of DCIS. From a CAT perspective, this reflected challenges in interpretability, as the language used by clinicians did not always align with women\u0026rsquo;s informational frameworks or expectations. Women often interpreted these terms through broader cultural associations with invasive cancer, which heightened emotional responses and uncertainty. In contrast, clinicians generally viewed existing terminology as medically precise approximations intended to convey risk accurately and, in some cases, believed that emphasizing the favorable prognosis would provide reassurance. This difference illustrates how communicative intent and interpretation diverged between groups: clinicians prioritized biomedical precision, whereas women evaluated the language primarily through its emotional and explanatory implications. This disconnect illustrates the broader challenge of communicating clinical uncertainty in ways that are both accurate and sensitive to emotional impact.\u003c/p\u003e\n\u003cp\u003eContribution to Existing Literature\u003c/p\u003e\n\u003cp\u003eThis study builds on the body of prior research showing that the label \u0026ldquo;ductal carcinoma in situ\u0026rdquo; causes confusion and anxiety among women and creates challenges for clinicians when discussing its clinical significance [13, 15, 29]. Prior studies from Australia, the United Kingdom, and the United States have found that many women misinterpret DCIS as invasive breast cancer and consequently overestimate recurrence and mortality risk [30, 31, 32]. Clinicians likewise report difficulty balancing accuracy with reassurance, which often results in inconsistent explanations [33].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study makes several contributions that extend beyond prior research on DCIS communication. First, whereas much of the existing literature has primarily documented challenges associated with terminology and patient understanding, prior studies have rarely examined \u003cstrong\u003epractical solutions for improving communication\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e In contrast, this study explicitly sought to identify potential solutions to these challenges. Second, the analysis is unique in its \u003cstrong\u003eintegrative design\u003c/strong\u003e, combining a comprehensive review of prior research on DCIS terminology and communication with additional qualitative data from interviews with women diagnosed with DCIS and clinicians involved in their care. Importantly, the qualitative component was designed not only to explore experiences but also to \u003cstrong\u003eidentify potential communication strategies that could address observed gaps\u003c/strong\u003e in understanding and emotional support. Third, this study is distinctive in its application of \u003cstrong\u003eCAT\u0026nbsp;\u003c/strong\u003eas an analytic framework. By using CAT, the study moves beyond descriptive accounts of communication difficulties to examine how specific communicative processes\u0026mdash;such as approximation, interpretability, interpersonal control, discourse management, and emotional expression\u0026mdash;shape interactions between women and clinicians. This theoretical lens enabled the identification of concrete opportunities for communicative convergence that may improve patient understanding, reduce distress, and support more patient-centered discussions about DCIS. Together, these contributions provide a more comprehensive and solution-oriented understanding of DCIS communication than has been offered in prior research.\u003c/p\u003e\n\u003cp\u003eUsing this method allowed the identification of key recommendations to implement practical strategies that could improve communication about DCIS.\u003c/p\u003e\n\u003cp\u003eThe findings also align with research from other medical conditions where relabeling has reduced patient distress and improved understanding. For example, replacing \u0026ldquo;cervical intraepithelial neoplasia\u0026rdquo; with \u0026ldquo;low-\u0026rdquo; or \u0026ldquo;high-grade squamous intraepithelial lesion\u0026rdquo; lessened anxiety and improved comprehension [33]. Comparable efforts in thyroid and prostate cancer have sought to remove the word \u0026ldquo;cancer\u0026rdquo; from indolent lesions to prevent overtreatment and mitigate psychological harm [35, 36, 37]. Extending this evidence to DCIS, the present study underscores the potential benefits of terminology reform and highlights the need for patient-informed language to support shared decision-making.\u003c/p\u003e\n\u003cp\u003eImplications for Practice and Policy\u003c/p\u003e\n\u003cp\u003eThe study findings have several implications for clinical practice and policy. Non-cancer labels alone are unlikely to resolve the communication challenges identified in this study. Rather, the findings suggest that divergence emerged across at least two CAT domains\u0026mdash;interpretability and approximation\u0026mdash;where clinicians tended to prioritize medically precise terminology (e.g., \u0026ldquo;precursor to cancer\u0026rdquo;) while women evaluated terminology primarily in terms of clarity, emotional impact, and personal meaning. Addressing this divergence requires strategies that reconcile clinical accuracy with patient interpretability. One approach may involve pairing terminology with clearer contextual explanations, visual aids, or analogies that situate DCIS within a spectrum of breast disease, thereby improving comprehension without sacrificing precision. Similar approaches have been successfully implemented in other areas of medicine, including genetic counseling and risk communication in screening contexts, where clinicians routinely combine technical language with explanatory framing to enhance patient understanding.\u003c/p\u003e\n\u003cp\u003eIn addition, the study identified several areas of agreement between women and clinicians regarding preferred communication strategies, including the use of plain language, opportunities for patients to ask questions, and clearer explanations of risk and prognosis. Implementing these strategies may require structural changes to clinical communication practices, such as incorporating patient-centered communication training, decision-support tools, and consultation frameworks that encourage dialogue rather than one-directional information delivery. There is precedent for such approaches in health communication research, particularly in shared decision-making models and patient-centered oncology care, where structured communication strategies have been shown to improve understanding, reduce anxiety, and enhance patient engagement. Together, these approaches suggest that improving DCIS communication requires not simply changing terminology but fostering greater communicative accommodation between clinicians and patients through clearer explanations, collaborative dialogue, and supportive informational resources.\u003c/p\u003e\n\u003cp\u003eKnowledge of preferred labels, language, and communication strategies could inform the design of DCIS-specific educational resources, including informational materials and conversation guides for both women and clinicians.\u003c/p\u003e\n\u003cp\u003eThese findings also resonate with international efforts such as a name change, to promote clear and non-alarming terminology in breast pathology reporting while maintaining clinical accuracy [38, 39]. Knowledge about preferred DCIS labels and language may prompt international nomenclature bodies to consider revising terminology for low-risk forms of DCIS, as has been advocated by researchers, clinicians, and affected women [40, 41]. Engagement with professional societies such as the American Joint Committee on Cancer, the International Collaboration on Cancer Reporting, and the World Health Organization Classification of Tumours Group will be crucial in facilitating such reform.\u003c/p\u003e\n\u003cp\u003eRecommendations\u003c/p\u003e\n\u003cp\u003eThe findings of this study highlight the nuanced and sometimes divergent perspectives of women and clinicians regarding DCIS terminology and communication. Non-cancer labels and carefully considered language have the potential to reduce confusion and anxiety, supporting more patient-centred care. Future research should further examine the psychological and behavioural impacts of DCIS terminology, ideally through interdisciplinary collaborations among oncologists, pathologists, psychologists, and patient advocates. Such work could inform the development of alternative nomenclature for low-risk lesions and guide updates to existing terminology standards. Additionally, communication aids [42, 43]\u0026mdash;such as question prompt lists, visual infographics, and decision aids\u0026mdash;may facilitate clearer and more empathetic discussions, enabling women to ask informed questions and clinicians to align explanations with patient preferences. Embedding communication accommodation strategies in clinician training, including tailoring explanations, checking for understanding, and responding to emotional cues, could further enhance trust, understanding, and satisfaction in these interactions. Feedback mechanisms, such as reflective debriefs or communication audits, may help identify discrepancies between patient and clinician perspectives, highlighting opportunities for improvement in routine practice. Finally, promoting dissemination of these strategies through professional networks, conferences, and patient advocacy collaborations will be essential to ensure consistent implementation across diverse healthcare settings.\u003c/p\u003e\n\u003cp\u003eStrengths and Limitations\u003c/p\u003e\n\u003cp\u003eThis study has several strengths. It applied a rigorous and transparent methodological approach, including comprehensive literature searches and independent, duplicate screening and extraction. The integration of findings from published studies and qualitative interviews allowed for a broader understanding of DCIS communication than either dataset could provide alone. The use of a theoretical framework provided structure for identifying how (mis)alignments in communication occur and allowed for the identification of key recommendations. Nonetheless, several limitations should be acknowledged. The study did not include other healthcare perspectives, such as nurses or allied health professionals, and did not systematically capture time since diagnosis, both of which may influence views on DCIS terminology and warrant exploration in future research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the complex and often distressing nature of communication about DCIS especially in cases where women are advised to undergo invasive treatments for a condition that may never progress to invasive cancer. By integrating findings from the theoretical review and interviews, we captured a more nuanced understanding of the disconnect between how women and clinicians perceive and discuss DCIS. Women consistently expressed confusion and anxiety when clinicians used labels such as \u0026ldquo;pre-cancer\u0026rdquo; or \u0026ldquo;stage 0 cancer\u0026rdquo; without clear explanation, while clinicians assumed that these terms were adequately understood.\u003c/p\u003e \u003cp\u003eMapping the results to CAT provided a valuable framework for interpreting these communication gaps. Differences in initial orientation and psychological accommodation were evident, but both groups identified similar strategies to support more effective communication in all domains of CAT. These findings underscore the importance of tailoring communication to individual patient needs and expectations, and of explicitly addressing uncertainty, risk, and the nature of DCIS using clear and consistent language. Addressing these areas through patient-centred, empathetic communication can bridge gaps in understanding, improve emotional outcomes, and support informed, shared decision-making.\u003c/p\u003e \u003cp\u003eWhile CAT helped frame many of the interpersonal dynamics in clinician\u0026ndash;patient interactions, some participant insights\u0026mdash;particularly those related to dissemination strategies and systemic influences\u0026mdash;extended beyond the scope of the framework. Future research should explore these areas further to inform more inclusive and equitable communication practices for women. Overall, this study highlights the importance of integrating theoretical, empirical lived experience perspectives to inform patient-centred communication. By identifying language preferences, communication strategies, and practical recommendations for women with low-risk DCIS, this work addresses a critical aspect of breast health that directly impacts women\u0026rsquo;s emotional well-being, understanding of their care, and ability to make informed decisions. These findings contribute to advancing the broader goals of women\u0026rsquo;s health research by promoting patient-centred care, reducing disparities in access to clear and supportive information, and enhancing the quality of care and health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent\u003c/p\u003e\n\u003cp\u003eThe University of Toronto Research Ethics Board approved the study (REB #44709). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided informed consent prior to interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eSuzanna Apostolovski carried out the research as a PhD student at the University of Toronto. She assisted in conceptualizing the study, developed methodology, collected and analyzed data, and drafted and finalized the manuscript. ARG, NLH and FCW conceptualized the study, acquired funding, assisted in developing methodology, took part in data collection and analysis, and assisted in drafting and editing the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for Publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Canadian Cancer Society under Grant [number 707644]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData availability statement\u003c/p\u003e\n\u003cp\u003eAll data are available in the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKerlikowske K. 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Decision aids for people facing health treatment or screening decisions. \u003cem\u003eCochrane Database Syst Rev\u003c/em\u003e. 2017;4(4):CD001431.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"women, ductal carcinoma in situ, communication, nomenclature, preferences, patient-centred care, theoretical review, interviews, communication accommodation theory","lastPublishedDoi":"10.21203/rs.3.rs-9202416/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9202416/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDuctal carcinoma in situ (DCIS) is characterized by abnormal cells confined to the milk ducts of the breast. Despite being confined to milk ducts, untreated DCIS can progress to invasive disease. Women diagnosed with low-grade DCIS are often advised to undergo surgery, radiation, and/or chemotherapy, despite the possibility that the condition may never progress. This frequently leads to confusion, distress, and long-term anxiety. Clear, consistent, and patient-centred communication is therefore critical to support informed decision-making for women with DCIS. The objective of this study was to identify preferred terminology, language, and strategies that would act as recommendations to improve communication about DCIS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods design was employed, integrating a theoretical review with interviews to capture both conceptual insights and lived experience to inform recommendations. Findings from the theoretical review and interviews were analyzed using Communication Accommodation Theory (CAT) and then mapped to five domains\u0026mdash;approximation, interpretability, interpersonal control, discourse management, and emotional regulation\u0026mdash;to assess how clinicians adapt communication to meet women's needs. This approach highlighted areas of alignment and misalignment between women and clinician perspectives.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMapping results to CAT demonstrated that language and interaction styles strongly influenced women\u0026rsquo;s understanding and emotional responses. Women consistently preferred clear, non-threatening terms such as \u0026ldquo;abnormal cells,\u0026rdquo; while clinicians tended to rely on more technical terminology. Communication improved when clinicians adapted their language, acknowledged uncertainty, and engaged in collaborative dialogue. Recommendations to improve communication included using plain language, visual aids, extended consultations, reassurance, and active listening to reduce distress and enhance informed decision-making.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTerminology significantly shapes women\u0026rsquo;s understanding of DCIS and their emotional reactions. Misalignment between women\u0026rsquo;s preferences and clinicians language can hinder communication. Applying CAT-informed strategies, including preferred terminology and clarification of distinctions from invasive cancer, can improve understanding, reduce anxiety, and support patient-centred care.\u003c/p\u003e","manuscriptTitle":"Labels, Language and Other Strategies to Improve Communication About Lower Grade Ductal Carcinoma in Situ: Integration of Findings from Theoretical Review and Interviews","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 16:47:35","doi":"10.21203/rs.3.rs-9202416/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-08T08:05:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T18:14:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309889181023149538559310129988805823702","date":"2026-04-28T10:19:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9396483994014892947338438285264547534","date":"2026-04-23T17:50:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146025398587776128038115025461677383918","date":"2026-04-20T13:19:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T12:12:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-26T10:26:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-25T02:24:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T02:24:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2026-03-23T15:19:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e070c9ad-6b10-4dfd-ac43-4d7adec92d96","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-08T08:05:15+00:00","index":62,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T18:14:10+00:00","index":59,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T16:47:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 16:47:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9202416","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9202416","identity":"rs-9202416","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}