Educational differences in likelihood of attributing breast symptoms to cancer: a vignette-based study

Knowledge of breast and cervical cancer symptoms and perceived barriers to seek treatment among urban underserved women

A significant number of Malaysian women are diagnosed with breast and cervical cancers at advanced stages, highlighting the need for early symptom recognition to improve treatment outcomes and reduce mortality. This study aimed to assess knowledge of breast and cervical cancer symptoms among underserved women and identify the barriers preventing them from seeking treatment. A cross-sectional survey involving 401 women at a public health clinic was conducted using validated questionnaires and convenience sampling. Descriptive statistics, chi-square tests, and logistic regression were used to analyze the data. Over half of the women demonstrated poor knowledge of both breast (55 percent) and cervical (69 percent) cancer symptoms, while only a smaller proportion exhibited good knowledge, 12 percent for breast cancer and 6 percent for cervical symptoms, respectively. Commonly recognized symptoms included a "lump or thickening in the breast' and 'persistent, unpleasant-smelling vaginal discharge." The most reported barrier to seeking treatment was fear of diagnosis, reported by 49 percent of women. Logistic regression identified being married and having higher level of education were significantly associated with greater perceived barriers to seeking treatment. The research highlights the need for personalized health education to address individual concerns and barriers, ensuring content is relevant and effective.

How "Breast Aware" are the Indian Women? A Study among the Women Visiting a Tertiary Care, Referral, and Teaching Hospital

INTRODUCTION

"Who will educate us" lamented a School Principal after she took part in our study and education session. There is palpable low breast cancer (BC) literacy with rising incidence and disproportionate mortality rates.

METHODOLOGY

Breast Cancer Awareness Measure (BCAM) developed by Cancer Research UK was administered to 944 women. BCAM measures knowledge, age-related risk, and reported frequency of breast checking and other components. A woman is BC aware if she identified five or more nonlump symptoms, age-related risk, and reported breast checking once a week/month. At the end, each participant was given "Be Breast Aware" education; what/how to look for demonstrated on a model.

RESULTS

2.8% health professionals. 3.1% BC survivors. 78.8% had lump knowledge and 55.3% had non-lump knowledge of BC, 10% had age-related risk knowledge. 24.3% check breasts once a week/month. 41.9% aware BC is common after 50 years. 14/944 (1.5%) had BC awareness. 59.9% had breast symptoms, but never consulted a doctor, 31.1% were embarrassed, and 29.4% were scared to consult. Nearly 43% heard of breast screening, 28.4% had mammography, 26.3% had ultrasound. About 44.1% knew family history risk. Those practicing breast checking looked for a size change (24.5%), nipple position (17.4%), discharge (22.1%), pain (32.5%), and lump (24.7%) in standing (17.8%), supine (8.5%) using finger pads (15.8%) fingertips (21.6%), using circular movements (16.4%), and pinching breast tissue (19.6%).

CONCLUSION

Health-care workers and BC survivors lack breast awareness which is alarming and indicates the need for BC awareness and post-BC treatment follow-up care education in these two groups and the general population. Some practice the wrong method (e.g., pinching tissue) of breast checking, which may lead to anxiety and unnecessary investigative costs. "Be Breast Aware" education based on the National Health Service 5-point plan given to 944 participants.

An Updated Insight into Phytomolecules and Novel Approaches used in the Management of Breast Cancer

Breast cancer is a widespread condition that kills more women from cancer-related causes than any other type of cancer globally. Women who have estrogen-dependent, initial metastatic breast cancer frequently receive treatment with surgery, radiation therapy, and chemotherapy. They may also get more specialized treatments like tamoxifen or aromatase inhibitors (anastrozole or letrozole). The World Health Organisation reported in 2012 that by 2030, breast cancer will be more common worldwide. There are several phytochemicals, such as isoflavones, coumestans, lignans, and prenylflavonoides. Isoflavones have been shown in studies to prevent the spread of breast cancer and to trigger apoptosis. Targeting BCs in metastatic breast cancer may be made possible by combining well-formulated phytochemicals in nanoparticles or other novel drug delivery agents with currently accepted endocrine and/or conventional chemotherapies. Cell signaling, regulation of cell cycles, oxidative stress action, and inflammation could be positively impacted by phytoconstituents. They have the ability to alter non-coding RNAs, to prevent the proliferation and regeneration of cancer cells. The availability of novel approaches helps in disease targeting, safety, effectiveness and efficacy. The current literature helps to know the available drugs i.e. phytoconstituents or novel drug delivery like nanoparticle, microsphere, micelles, liposomes and neosomes. The literature has been taken from PubMed, Google Scholar, SciFinder, or other internet sites.

Developing sustainable patient and public involvement in mesothelioma research: multi-method exploration with researchers, patients, carers, and patient organisations

BACKGROUND

Rare diseases where prognosis is poor provide limited scope for patient and public involvement (PPI). One such disease is mesothelioma, a cancer of the lung pleura or of the peritoneum caused by exposure to asbestos, where PPI is poorly documented. We undertook to explore how PPI could be facilitated in mesothelioma research.

METHODS

An online survey with mesothelioma researchers (n = 23) assessed the perceived benefits and challenges of PPI in mesothelioma. Six online workshops and thirteen in-depth interviews with patients and the public explored their views on how PPI could be increased in mesothelioma and their motivations to become PPI representatives in the future. The survey data were analysed using descriptive statistics and the interviews, using Thematic Analysis.

RESULTS

In the survey, 26% (n = 6) of the researchers did not include PPI in their research, while 74% (n = 17) did, finding it most beneficial at the stages of applying for funding and dissemination. The main perceived benefits of PPI were clarifying the research question and outcome measures, making research more credible and relevant to patients' needs, and increasing its impact. The main perceived challenges to PPI were the general poor prognosis in mesothelioma, and funding timescales which hindered timely recruitment of PPI representatives. The analysis of the interviews with the patients and public revealed three main themes: "Motivations to become a PPI representative in the future", "Understanding the nature of PPI during the project", and "Perceived challenges to PPI in mesothelioma". Altruism and the need for hope were the main reasons to wish to become involved in PPI in the future. For many participants, the project proved to be a journey of understanding the nature of PPI, a concept that was not easy to grasp from the start. The participants perceived certain barriers to PPI such as high symptom burden in mesothelioma, the abstract concept of PPI, and the use of scientific language.

CONCLUSIONS

The present research provides a detailed picture of the benefits and challenges of PPI in mesothelioma. We recommend long-term engagement with mesothelioma support groups so that researchers achieve meaningful and sustainable PPI in mesothelioma research.

Secondhand smoke exposure for different education levels: findings from a large, nationally representative survey in Turkey

OBJECTIVES

The aim of this study is to determine the factors that influence individuals' exposure to tobacco smoke in Turkey according to their education level.

DESIGN

Secondary data analysis.

PARTICIPANTS

Altogether, 17 084 individuals aged 15 and over were included in this study.

SETTINGS

Data set of the Turkey Health Survey in 2019.

METHODS

Binary logistic regression analysis was used to determine the factors associated with individuals' exposure to tobacco smoke.

PRIMARY AND SECONDARY OUTCOME MEASURES

The variables age, gender, marital status, general health status, employment status, receipt of psychosocial support and tobacco use were found to be correlated with exposure to tobacco smoke.

RESULTS

The study determined that individuals who are illiterate/unschooled were exposed to tobacco smoke at a rate of 32.61%, primary school graduates at a rate of 34.32%, primary education graduates at a rate of 41.75%, high school graduates at a rate of 41.04% and university graduates at a rate of 40.34%.

CONCLUSION

As a result of the study, it is emphasised that men, young individuals, individuals with moderate and very good general health status, those who use tobacco, those who are unemployed and those who receive psychosocial support should be targeted. In addition, appropriate strategies for reducing secondhand smoke (SHS) exposure should be developed, taking into account public health strategies for increasing awareness of the adverse health effects of SHS exposure and the determinants of tobacco exposure according to the study.

Women's barriers for contacting general practice when experiencing gynecological cancer symptoms: a population-based study

BACKGROUND

A prerequisite for general practitioners (GPs) being able to refer patients with gynecological cancer alarm symptoms for further investigations is that individuals present the symptoms to the GP. Not all symptoms are presented to the GP, and knowledge of barriers for healthcare-seeking is sparse. The aim of this study was to analyze associations between age, socioeconomic status, and common barriers ("being too embarrassed", "being too busy", "worried about wasting the doctors time" and "worried what the GP might find") towards GP contact with gynecological alarm symptoms.

METHODS

Nationwide population-based study in Denmark based on a random sample of 51 090 women aged 20 years or older. A web-based questionnaire regarding experience of four predefined alarm symptoms of gynecological cancer, decisions about contact to GPs, and barriers towards GP contact was distributed. Information about socioeconomic status was collected from Statistics Denmark.

RESULTS

A total of 26 466 women (54.5%) completed the questionnaire. The proportion of women with no contact to the GP varied between 64.6% and 78.1% for postmenopausal bleeding and pain during intercourse, respectively. Between 32.3% (bleeding during intercourse) and 45.3% (postmenopausal bleeding) of the women reported no barriers for GP contact. The proportions of reported barriers ranged from 7.5% for being too embarrassed (pelvic pain) to 26.8% for being too busy (bleeding during intercourse). Women aged 40-59 years had lower odds of reporting "being too embarrassed" and "worried about wasting the GP´s time", while women aged 60 + years of age had lower odds of reporting "being too busy" compared to the youngest age group. Women in the highest income groups had lower odds of reporting "being too embarrassed" and "wasting the GP´s time" compared to those with a low income, while those with high educational level had lower odds of reporting "being too embarrassed" and "worried what the GP might find" compared to those with low educational level.

CONCLUSIONS

More than half of the respondents with no contact to the GP, reported one or more barriers towards GP contact. Lower age and socioeconomic status were significantly associated with higher odds of reporting barriers. As this may explain the differences in healthcare seeking behavior, healthcare planners, policy makers and clinicians should be aware of these findings.

The role of chronic conditions in influencing symptom attribution and anticipated help-seeking for potential lung cancer symptoms: a vignette-based study

BACKGROUND

Very little is known about the influence of chronic conditions on symptom attribution and help-seeking for potential cancer symptoms.

AIM

To determine if symptom attribution and anticipated help-seeking for potential lung cancer symptoms is influenced by pre-existing respiratory conditions (often referred to as comorbidity), such as asthma or chronic obstructive pulmonary disease (COPD).

DESIGN & SETTING

A total of 2143 adults (1081 with and 1062 without a respiratory condition) took part in an online vignette survey.

METHOD

The vignette described potential lung cancer symptoms (persistent cough and breathlessness) after which questions were asked on symptom attribution and anticipated help-seeking.

RESULTS

Attribution of symptoms to cancer was similar in participants with and without respiratory conditions (21.5% and 22.1%, respectively). Participants with respiratory conditions, compared with those without, were more likely to attribute the new or changing cough and breathlessness to asthma or COPD (adjusted odds ratio [OR] = 3.64, 95% confidence interval [CI] = 3.02 to 4.39). Overall, 56.5% of participants reported intention to seek help from a GP within 3 weeks if experiencing the potential lung cancer symptoms. Having a respiratory condition increased the odds of prompt help-seeking (OR = 1.25, 95% CI = 1.04 to 1.49). Regular healthcare appointments were associated with higher odds of anticipated help-seeking.

CONCLUSION

Only one in five participants identified persistent cough and breathlessness as potential cancer symptoms, and half said they would promptly seek help from a GP, indicating scope for promoting help-seeking for new or changing symptoms. Chronic respiratory conditions did not appear to interfere with anticipated help-seeking, which might be explained by regular appointments to manage chronic conditions.

Cancer Symptom Recognition and Anticipated Delays in Seeking Care Among U.S. Adults

INTRODUCTION

Early stage diagnosis strongly predicts cancer survival. Recognition of potential symptoms of cancer may improve survival by reducing time to seeking care.

METHODS

Telephone interviews with a population-representative sample of English-speaking adults (aged ≥50 years) in the U.S. (N=1,425) were conducted in 2014 using an instrument adapted from the International Cancer Benchmarking Partnership Awareness and Beliefs about Cancer survey. Anticipated time to seeking care for four cancer symptoms (persistent cough, rectal bleeding, mole changes, and breast changes) was assessed, and delay was defined as waiting >2 weeks. Recognition of symptoms as potential cancer signs was assessed dichotomously. Multivariate logistic regression models were used to assess associations between symptom recognition and anticipated delay, adjusting for demographics, cancer experience, self-reported health, and healthcare access. Analyses were weighted and conducted in 2017.

RESULTS

Symptom recognition varied but was relatively high across all symptoms (76.9%-95.5%). Anticipated delay varied by symptom and was highest for persistent cough (41.2%) and lowest for rectal bleeding (9.1%). For rectal bleeding (AOR=2.65, 95% CI=1.31, 5.36) and mole changes (AOR=3.30, 95% CI=1.48, 7.33), anticipated delay was more likely among individuals who did not recognize the symptom as a warning sign. Adults with lower education levels (p<0.05) and African Americans (p<0.05) were less likely to delay for some symptoms.

CONCLUSIONS

Lack of symptom recognition was associated with anticipated delay in seeking care for some cancer symptoms. Differences in recognition and delays by symptom could be driven partly by screening messaging or by ambiguity and functional impact of each symptom.

Do cognitive heuristics underpin symptom appraisal for symptoms of cancer?: A secondary qualitative analysis across seven cancers

OBJECTIVES

To explore the evidence for cognitive heuristics or "rules of thumb" used within patients' reports of symptom appraisal and decisions to seek help for symptoms of cancer.

METHODS

A secondary analysis of interviews from existing studies that explored symptom appraisal in patients who had sought help for potential symptoms of cancer. Transcripts from n = 50 in-depth interviews with patients referred with symptoms suspicious of cancer (pancreas, colorectal, oral, lung, melanoma, breast, and prostate) were re-analysed using a deductive thematic approach underpinned by the heuristics outlined in the Common Sense Model of Illness Self-regulation as set within the Model of Pathways to Treatment.

RESULTS

The most dominant heuristic in patient reports was the Rate of change rule (ie, symptoms that are worsening, increasing, or have a sudden onset [rather than improving, stable or decreasing in number] are more likely to indicate illness). There was also support for the Duration rule, Pattern rule, Chronology rule, Severity (of interference) rule, Age-illness rule, Novelty rule, Similarity rule, Location rule, and Optimistic bias rule. There was a lack of evidence for the Prevalence and Stress-illness rules.

CONCLUSIONS

People do appear to use heuristics to guide their appraisal of symptoms and their perceived need for healthcare. Heuristics may be an important aspect underlying symptom misinterpretation, thus making them key targets for interventions. For instance, campaigns could tackle cognitive biases rather than focusing on specific symptom awareness. Myth-busting messages could highlight that intermittent, mild symptoms, and symptoms that are not worsening can be signs of a serious health problem.

Online Information-Seeking About Potential Breast Cancer Symptoms: Capturing Online Behavior With an Internet Browsing Tracking Tool

Background

People engage in health information-seeking online when experiencing unusual or unfamiliar bodily changes. It is not well understood how people consult the internet for health information after the onset of unfamiliar symptoms and before receiving a potential diagnosis and how online information-seeking can help people appraise their symptoms. This lack of evidence may be partly due to methodological limitations in capturing in real time the online information-seeking process.

Objective

We explored women’s symptom attribution and online health information-seeking in response to a hypothetical and unfamiliar breast change suggestive of cancer (nipple rash). We also aimed to establish the feasibility of capturing in real time the online information-seeking process with a tool designed to track participant online searches and visited websites, the Vizzata browser tracker.

Methods

An online survey was completed by 56 cancer-free women (mean age 60.34 [SD 7.73] years) responding to a scenario asking them to imagine noticing a red scaly rash on the nipple. Participants were asked to make symptom attributions when presented with the scenario (T1) and again after seeking information online (T2). The online tracking tool, embedded in the survey, was used to capture in real time participant search terms and accessed websites.

Results

The tracking tool captured the search terms and accessed websites of most of the participants (46/56, 82%). For the rest (10/56, 18%), there was evidence of engagement in online information-seeking (eg, medical terminology and cancer attribution at T2) despite their searching activity not being recorded. A total of 25 participants considered cancer as a potential cause for the nipple rash at T1, yet only one of these used cancer as a search term. Most participants (40/46, 87%) used rash-related search terms, particularly nipple rash and rash on nipple. The majority (41/46, 89%) accessed websites containing breast cancer information, with the National Health Service webpage “Paget disease of the nipple” being the most visited one. At T2, after engaging in the internet search task, more participants attributed the nipple rash to breast cancer than at T1 (37/46, 66% vs 25/46, 45%), although a small number of participants (6/46) changed from making a cancer attribution at T1 to a noncancer one at T2.

Conclusions

Making a cancer attribution for an unfamiliar breast change did not necessarily translate into cancer-termed searches. Equally, not all internet searches led to a cancer attribution. The findings suggest that online information-seeking may not necessarily help women who experience unfamiliar breast cancer symptoms understand their condition. Despite some technical issues, this study showed that it is feasible to use an online browser tracking tool to capture in real time information-seeking about unfamiliar symptoms.

Is lower symptom recognition associated with socioeconomic inequalities in help-seeking for potential breast cancer symptoms?

OBJECTIVE

Socioeconomic inequalities in recognising signs and symptoms of cancer may result in inequalities in timely help-seeking and subsequent prognosis of breast cancer. We explored the mediating role of symptom attribution and concern on the relationship between level of education and help-seeking for potential breast cancer symptoms.

METHODS

Women aged ≥47 years (n = 961) were purposively recruited (by education) to complete an online vignette-based survey that included nipple rash and axillary lump (in separate vignettes) as potential symptoms of breast cancer. Women completed questions relating to medical help-seeking (yes/no), cancer attribution, symptom concern, cancer avoidance, family history, and demographics.

RESULTS

Women with low education and mid education attributed nipple rash less often to cancer (26% and 27% mentioned cancer) than women with a degree or higher (40%). However, women with a degree or higher (63%) or mid education (64%) were less likely to anticipate seeking help for the nipple rash than women with no formal qualifications (73%). This association was statistically significant in the 60- to 69-year-old age group. There was no significant association between education and help-seeking for axillary lump. Mediation analysis adjusting for potential confounders confirmed that the association between education and help-seeking for nipple rash was fully mediated by symptom concern.

CONCLUSIONS

Socioeconomic inequalities in stage at diagnosis and survival of breast cancer may not always be explained by lower likelihood of suspecting cancer and subsequent impact on help-seeking. Reducing inequalities in stage at diagnosis will involve understanding a broader range of bio-psycho-social factors (eg, comorbidities and healthcare system factors).

Determinants of stage at diagnosis of breast cancer in Nigerian women: sociodemographic, breast cancer awareness, health care access and clinical factors

PURPOSE

Advanced stage at diagnosis is a common feature of breast cancer in Sub-Saharan Africa (SSA), contributing to poor survival rates. Understanding its determinants is key to preventing deaths from this cancer in SSA.

METHODS

Within the Nigerian Integrative Epidemiology of Breast Cancer Study, a multicentred case-control study on breast cancer, we studied factors affecting stage at diagnosis of cases, i.e. women diagnosed with histologically confirmed invasive breast cancer between January 2014 and July 2016 at six secondary and tertiary hospitals in Nigeria. Stage was assessed using clinical and imaging methods. Ordinal logistic regression was used to examine associations of sociodemographic, breast cancer awareness, health care access and clinical factors with odds of later stage (I, II, III or IV) at diagnosis.

RESULTS

A total of 316 women were included, with a mean age (SD) of 45.4 (11.4) years. Of these, 94.9% had stage information: 5 (1.7%), 92 (30.7%), 157 (52.4%) and 46 (15.3%) were diagnosed at stages I, II, III and IV, respectively. In multivariate analyses, lower educational level (odds ratio (OR) 2.35, 95% confidence interval: 1.04, 5.29), not believing in a cure for breast cancer (1.81: 1.09, 3.01), and living in a rural area (2.18: 1.05, 4.51) were strongly associated with later stage, whilst age at diagnosis, tumour grade and oestrogen receptor status were not. Being Muslim (vs. Christian) was associated with lower odds of later stage disease (0.46: 0.22, 0.94).

CONCLUSION

Our findings suggest that factors that are amenable to intervention concerning breast cancer awareness and health care access, rather than intrinsic tumour characteristics, are the strongest determinants of stage at diagnosis in Nigerian women.

Typical and atypical presenting symptoms of breast cancer and their associations with diagnostic intervals: Evidence from a national audit of cancer diagnosis

INTRODUCTION

Most symptomatic women with breast cancer have relatively short diagnostic intervals but a substantial minority experience prolonged journeys to diagnosis. Atypical presentations (with symptoms other than breast lump) may be responsible.

METHODS

We examined the presenting symptoms of breast cancer in women using data from a national audit initiative (n=2316). Symptoms were categorised topographically. We investigated variation in the length of the patient interval (time from symptom onset to presentation) and the primary care interval (time from presentation to specialist referral) across symptom groups using descriptive analyses and quantile regression.

RESULTS

A total of 56 presenting symptoms were described: breast lump was the most frequent (83%) followed by non-lump breast symptoms, (e.g. nipple abnormalities (7%) and breast pain (6%)); and non-breast symptoms (e.g. back pain (1%) and weight loss (0.3%)). Greater proportions of women with 'non-lump only' and 'both lump and non-lump' symptoms waited 90days or longer before seeking help compared to those with 'breast lump only' (15% and 20% vs. 7% respectively). Quantile regression indicated that the differences in the patient interval persisted after adjusting for age and ethnicity, but there was little variation in primary care interval for the majority of women.

CONCLUSIONS

About 1 in 6 women with breast cancer present with a large spectrum of symptoms other than breast lump. Women who present with non-lump breast symptoms tend to delay seeking help. Further emphasis of breast symptoms other than breast lump in symptom awareness campaigns is warranted.

Educational differences in responses to breast cancer symptoms: A qualitative comparative study

OBJECTIVE

Advanced stage at diagnosis for breast cancer is associated with lower socio-economic status (SES). We explored what factors in the patient interval (time from noticing a bodily change to first consultation with a health care professional) may contribute to this inequality.

DESIGN

Qualitative comparative study.

METHODS

Semi-structured interviews with a sample of women (≥47 years) from higher (n = 15) and lower (n = 15) educational backgrounds, who had experienced at least one potential breast cancer symptom. Half the participants (n = 15) had sought medical help, half had not (n = 15). Without making breast cancer explicit, we elicited women's sense-making around their symptoms and help-seeking decisions.

RESULTS

Containment of symptoms and confidence in acting upon symptoms emerged as two broad themes that differentiated lower and higher educational groups. Women from lower educational backgrounds tended to attribute their breast symptoms to trivial factors and were reticent in using the word 'cancer'. Despite 'knowing' that symptoms could be related to cancer, women with lower education invoked lack of medical knowledge - 'I am not a doctor' - to express uncertainty about interpreting symptoms and accessing help. Women with higher education were confident about interpreting symptoms, seeking information online, and seeking medical help.

CONCLUSIONS

Our findings suggest that knowledge of breast cancer alone may not explain socio-economic differences in how women respond to breast cancer symptoms as women with lower education had 'reasons' not to react. Research is needed on how to overcome a wider spectrum of psycho-social factors to reduce future inequality. Statement of contribution What is already known on this subject? Seven of ten breast cancers in the UK are diagnosed after people contact their doctor with symptoms. Women from lower socio-economic backgrounds are more likely to be diagnosed with advanced disease. There is little evidence related to potential drivers of this SES inequality. What does this study add? We qualitatively explored socio-economic (SES) differences in help-seeking for breast symptoms. Women with higher education were more confident about interpreting symptoms and navigating health care. Women with lower education were more reluctant to seek help due to fear of cancer.