A randomised controlled trial of an intervention to promote early presentation of breast cancer in older women: effect on breast cancer awareness

Determine knowledge and belief of Somalian young women about breast cancer and breast self-examination with champion health belief model: a cross-sectional study

BACKGROUND

Breast cancer (BC) is an important reason for mortality rates in Somalian women. In Somalia, many women are late in applying to the hospital for the diagnosis of BC. Breast self-examination (BSE) is considered an important early detection method for BC in encouraging women to learn to practice BSE, especially for women in developing countries. This study purposed to determine knowledge, and belief of BC and BSE and BSE practice among women in Mogadishu, Somalia using the champion health belief model (CHBM).

METHODS

This cross-sectional study was conducted on 413 women who were between 18 and 49 years of age. The data were collected by using sociodemographic variables (age, marital status, education level, income status), Champion's Health Belief Model Scale (CHBMS), and an introductory questionnaire with questions about BC and BSE and between October 2020 and January 2021 in Mogadishu, Somalia. Further descriptive statistics, the Mann-Whitney U test, and Kruskal-Wallis analysis test were used to assess data that were not normally distributed.

RESULTS

Average age of participants was 22 ± 11.21 years. Only 35.4% of participants had information about BC, 37.8% had heard about BSE before, 25.2% knew BSE, and only 17.2% had done it. Income status, marital status, and age of first birth family were significantly associated with perceived sensitivity, health motivation, convenience, perceived benefits, and self-efficacy for BSE. Overall, the total scores of CHBMS were significantly higher among those who had heard and knowledge about BSE and practiced clinical breast examination (CBE). For the sub-dimensions of perceived sensitivity, health motivation, perceived benefits, barrier, and self-efficacy BSE with hearing about BSE, practicing BSE, knowing to practice BSE, knowing early detection methods of BC and practice CBE significant differences were observed (P < 0.005).

CONCLUSION

This study showed that BSE practice among Somalian women was very low, and they don't have sufficient knowledge about BSE and BC. Furthermore, this study revealed that many CHBMS significantly related to BSE practice in Somalian women, suggesting that BSE health education programs with CHBMS.

Bladder Cancer and Google Trends: Associations Between US Search Patterns and Disease Outcomes May Show Need for Improved Awareness Strategies

Interest in and awareness of bladder cancer may translate to better health-seeking behaviors and earlier detection, given modifiable risk factors such as smoking. We assessed bladder cancer interest in the USA over the past 15 years as reflected by Internet search trends, and correlated these trends with epidemiologic patterns in bladder cancer. Google Trends was used to estimate US bladder cancer interest in the unit search volume index (SVI), which estimates the volume of online search activity for a specified period relative to the highest volume of searches within a specified location. Between January 2004 and June 2019, SVIs were collected for the search term "bladder cancer" and other related search terms. To evaluate the effect of public awareness campaigns, the SVIs for the month of May (US bladder cancer awareness month) were compared with the SVIs of all other months. Correlations between "bladder cancer" SVI and incidence, mortality, and mortality-to-incidence ratio (proxy for survival) by state were evaluated. There was no increase in the relative search volumes for "bladder cancer" during the national bladder cancer awareness month compared with all other months (p = 0.27). By state, there were positive correlations between SVIs of "bladder cancer" and incidence (R = 0.72, p < 0.001) and mortality (R = 0.47, p < 0.001). However, there was no correlation between SVIs and mortality-to-incidence ratio (R = - 0.24, p = 0.08). Interest in bladder cancer is positively associated with disease incidence and mortality but not survival, suggesting interest is driven by new diagnoses or deaths, and not early detection that can improve survival. Our findings may show the need for better public education endeavors.

Determinants of Delayed Presentation and Advanced-Stage Diagnosis of Breast Cancer in Africa: A Systematic Review and Meta-Analysis

Background/Objective:

Breast cancer (BC) mortality is exceptionally high in Africa due to late presentation and advanced-stage diagnosis. Previous studies examining barriers to early BC presentation are markedly inconsistent, showing conflicting findings within and between African regions, making resource allocation and designing interventional campaigns challenging. Our objective was to assess the strength or magnitude of the association between determinants/risk factors and delayed presentation/advanced-stage diagnosis of BC in Africa.

Methods:

Electronic searches in PubMed, AJOL, Google, ResearchGate, ScienceDirect, and PubMed Central found eligible articles between 2000 and 2020. The meta-analytical procedure in Meta-XL used the quality effect model. I-squared (I²) above 75% indicated high heterogeneity. The summary effect size was the odds ratio with 95% confidence intervals.

Results:

The effect of socio-economic and demographic determinants on delay varies across African regions. Low level of education (1.63, 95% CI 1.01-2.63), and not performing breast self examination (BSE) (13.59, 95% CI 3.33-55.4) were significantly associated with delayed presentation. Younger patients had more significant delays in West Africa (WA, 1.41, 95%CI 1.08-1.85), and the reverse occurred in North Africa (0.68, 95%CI 0.48-0.97). Lack of BC knowledge (1.59, 95% CI 1.29-1.97), not performing BSE, or no history of undergoing clinical breast examination (CBE) (2.45, 95% CI 1.60-3.40), were associated with advanced-stage disease at diagnosis. Older patients had significantly more advanced disease in WA, and the reverse occurred in South Africa. Aggressive molecular BC subtypes [Triple negative (OR 1.62, 95% CI 1.27-2.06) or HER2 positive (1.56, 95% CI 1.10-2.23)] were significant determinants of advanced-stage diagnosis.

Conclusion:

Promoting early presentation and reducing advanced-stage BC throughout Africa should focus on modifiable factors, including providing quality education, improving breast health awareness and BC knowledge, and developing strategies to increase BSE and CBE. Interventions targeting socio-demographic determinants should be context-specific.

Husbands' Knowledge of Breast Cancer and Their Wives' Attitudes and Practices Related to Breast Cancer Screening in Saudi Arabia: Cross-sectional Online Survey

BACKGROUND

Despite Saudi Arabia's free and well-established cancer care program, breast cancer incidence and mortality are rising. Husbands' knowledge, and wives' attitudes and practices related to breast cancer screening are not well understood in Saudi Arabia.

OBJECTIVE

The aim of this study was to investigate husbands' knowledge, and wives' attitudes and practices related to breast cancer screening in Saudi Arabia.

METHODS

This cross-sectional study collected data from 403 husbands in the holy city of Makkah through an online self-reported questionnaire over a period of 2 months, from May 6 to July 7, 2020. Tabulation, bivariate, and multiple regression analyses were the major tools used for data analysis. Multivariate logistic regressions were used to examine the association between husbands' knowledge and wives' behavior regarding breast cancer screening methods.

RESULTS

Husbands' knowledge score (a 1-point increase) was significantly associated with the wives' utilization of mammograms (adjusted odds ratio [AOR] 1.089, 95% CI 1.024-1.159) and breast self-examination (AOR 1.177, 95% CI 1.105-1.255). Husbands' knowledge also influenced the wives' attitudes toward learning about breast self-examination (AOR 1.138, 95% CI 1.084-1.195). There was no significant association between husbands' knowledge and wives' utilization of clinical breast examination. However, richer husbands showed a socioeconomic gradient concerning their wives' utilization of clinical breast examinations (AOR 2.603, 95% CI 1.269-5.341).

CONCLUSIONS

Overall, husbands' knowledge of breast cancer influences wives' attitudes and practices related to breast cancer screening methods in Saudi Arabia. Thus, interventions delivered to husbands might increase breast cancer awareness and survival.

Improving cancer symptom awareness and help-seeking among adults living in socioeconomically deprived communities in the UK using a facilitated health check: A protocol for the Awareness and Beliefs About Cancer (ABACus) Randomised Control Trial

BACKGROUND

Cancer survival is lower in socioeconomically deprived communities, partly due to low awareness of symptoms, negative beliefs and delayed help-seeking. We developed an interactive health check questionnaire facilitated by trained lay advisors. It entails 29 questions about background, lifestyle and health with tailored behaviour change advice. Personalised results are printed using a traffic light (red/amber/green) system, highlighting areas where action should be taken. This is an individually randomised control trial to test effectiveness of the health check on symptom recognition.

METHODS

A total 246 participants aged 40+ years will be recruited from community and healthcare settings in socioeconomically deprived areas of Yorkshire and South Wales. Participants will be randomised to receive the health check or standard care (1:1 ratio). Outcome measures include: adapted Awareness and Beliefs about Cancer (primary outcome), brief State Trait Anxiety Inventory, intentions and motivation to adopt recommended health behaviours (early symptom presentation, cancer screening and lifestyle behaviours), adapted Client Service Receipt Inventory, brief medical history/screening and demographic questionnaire at: baseline; 2-weeks; and 6-months post-randomisation. A purposive sample of intervention sessions will be audio-recorded (n = 24) and half will additionally be observed (n = 12). Semi-structured interviews will take place at 2-weeks (n = 30) and 6-months (n = 15-20) post-randomisation. The primary analysis will compare cancer symptom recognition scores between arms at 2-weeks. Secondary analysis will assess cancer beliefs, barriers/time to presentation, screening and lifestyle behaviours, anxiety and costs. A process evaluation will assess intervention fidelity, dose and contamination. The London-Surrey NHS Research Ethics Committee (Ref: 17/LO/1507) approved this trial.

DISCUSSION

This is a trial of a theoretically underpinned complex intervention which has undergone phase 1 and 2 development work. The findings will evaluate evidence about the effect of the health check on symptom awareness. Although there are few exclusion criteria there are limitations regarding the population we are able to reach, who may have even higher risks of late diagnosis and poor cancer prognosis. However, the health check has the potential to improve cancer symptom awareness and encourage early help-seeking behaviour in deprived populations, thereby reducing inequalities in longer term cancer outcomes.

TRIAL REGISTRATION

Retrospectively registered with ISRCTN (Ref: ISRCTN16872545 ) on 12.01.2018.

Promoting breast cancer awareness in older women during the seasonal flu vaccination campaign

BACKGROUND:

older women are at high risk of presenting with breast cancer when it has reached a late stage, which may be partly because of poor breast cancer awareness.

AIM:

the aim of this project was to implement and evaluate a new way of delivering the Promoting Early Presentation (PEP) Intervention during flu vaccination appointments in primary care. The PEP Intervention is a 1-minute intervention, accompanied by a booklet and delivered by primary care health professionals to provide older women with the knowledge, confidence and skills to present promptly on discovering symptoms of breast cancer.

METHOD:

health professionals delivered the PEP Intervention to older women at six general practices in south London. The authors measured changes in breast cancer awareness after the intervention and interviewed practice staff about their experiences of using it.

FINDINGS:

knowledge of breast symptoms and breast checking was greater in women aged 70 years and above after the implementation than before. Health professionals' found it acceptable and feasible to implement.

CONCLUSION:

this intervention is a novel way of increasing breast cancer awareness in older women, which could contribute to earlier presentation and diagnosis of breast cancer in the UK.

Promoting prompt help-seeking for symptoms - assessing the impact of a gynaecological cancer leaflet on presentations to primary care: a record-based randomised control trial

Background

Information leaflets have been shown to significantly improve awareness of the symptoms of gynaecological cancers and to reduce perceived barriers to seeking medical help. This record-based, parallel, randomised control trial study aimed to assess whether receipt of a leaflet would change the behaviour of women experiencing symptoms indicative of gynaecological cancers by prompting them to visit their general practitioner (GP).

Methods

15,538 women aged 40 years or over registered with five general practices in Northamptonshire, UK were randomised to two groups using the SystmOne randomise facility. Those in the intervention group received an educational leaflet from their general practice explaining the symptoms of gynaecological cancers and advising symptomatic women to visit their GP. The control group were not contacted. Electronic records were interrogated to extract sociodemographic data and details of GP consultations for symptoms, tests, referrals and diagnoses relating to gynaecological cancers in the 4-month period following the mail-out of the leaflets.

Results

7739 records were extracted from the intervention group and 7799 from the control group. 231 (3.0%) of the women in the intervention group, and 207 (2.7%) of the controls, presented to their GP with a relevant symptom during the 4-month period following leaflet distribution. The slightly higher rate in the intervention group did not reach statistical significance at the 5% level (RR = 1.11; 95% CI 0.92–1.33; z = 1.08; p = 0.28). There was a significantly lower mean time to first presentation in the symptomatic intervention group (57.2 days, sd = 36.5) compared to the control group (65.2 days, sd = 35.0) (t = − 2.415; p = 0.016). Survival analysis did not reveal a difference between the patterns of presentation in the two cohorts (Log Rank (Mantel-Cox) χ² = 1.42; p = 0.23).

Conclusion

There was no difference between intervention and control groups in the proportion of women presenting with symptoms identified in the leaflet in the four months following leaflet distribution, although the women who had been sent a leaflet presented earlier than those in the control group. A larger study is needed to test for a modest effect of leaflet distribution.

Trial registration

Listed on the ISRCTN registry with study ID ISRCTN61738692 on 23–8-2017 (retrospectively registered).

Interventions developed with the Intervention Mapping protocol in the field of cancer: A systematic review

OBJECTIVES

The Intervention Mapping (IM) protocol provides a structured framework to develop, implement, and evaluate complex interventions. The main objective of this review was to identify and describe the content of the interventions developed in the field of cancer with the IM protocol. Secondary objectives were to assess their fidelity to the IM protocol and to review their theoretical frameworks.

METHODS

Medline, Web of Science, PsycINFO, PASCAL, FRANCIS, and BDSP databases were searched. All titles and abstracts were reviewed. A standardized extraction form was developed. All included studies were reviewed by 2 reviewers blinded to each other.

RESULTS

Sixteen studies were identified, and these reported 15 interventions. The objectives were to increase cancer screening participation (n = 7), early consultation (n = 1), and aftercare/quality of life among cancer survivors (n = 7). Six reported a complete participatory planning group, and 7 described a complete logic model of the problem. Ten studies described a complete logic model of change. The main theoretical frameworks used were the theory of planned behaviour (n = 8), the transtheoretical model (n = 6), the health belief model (n = 6), and the social cognitive theory (n = 6). The environment was rarely integrated in the interventions (n = 4). Five interventions were reported as effective.

CONCLUSIONS

Culturally relevant interventions were developed with the IM protocol that were effective to increase cancer screening and reduce social disparities, particularly when they were developed through a participative approach and integrated the environment. Stakeholders' involvement and the role of the environment were heterogeneously integrated in the interventions.

Promoting early presentation of breast cancer in older women: sustained effect of an intervention to promote breast cancer awareness in routine clinical practice

Background

Older women have poorer survival from breast cancer, which may be at least partly due to poor breast cancer awareness leading to delayed presentation and more advanced stage at diagnosis. In a randomised trial, an intervention to promote early presentation of breast cancer in older women increased breast cancer awareness at 1 year compared with usual care (24 versus 4%). We examined its effectiveness in routine clinical practice.

Methods

We piloted the intervention delivered by practising health professionals to women aged about 70 in four breast screening services. We measured the effect on breast cancer awareness at 1 year compared with comparison services, where women did not receive the intervention.

Results

At 1 year, 25% of women in pilot services were breast cancer aware compared with 4% in comparison services (p = 0.001). The components of breast cancer awareness were knowledge of breast cancer non-lump symptoms (pilot: 63% vs comparison: 82% at 1 year; OR = 2.56, 95% CI 1.92-3.42), knowledge of age related risk (pilot: 8% vs comparison: 36% at 1 year; OR = 5.56, 95% CI 4.0-7.74) and reported breast checking (pilot: 70% vs comparison: 78% at 1 year; OR = 1.49, 95% CI 1.13-1.96).

Conclusion

The intervention may be as effective in routine clinical practice as in a randomised controlled trial. This intervention has the potential to reduce patient delay in the diagnosis of breast cancer in older women.

Trial registration

The PEP trial was registered with the International Standard Registered Clinical/soCial sTudy Number (ISRCTN) as a clinical trial (ISRCTN31994827) on 3rd October 2007.

The impact of breast cancer awareness interventions on breast screening uptake among women in the United Kingdom: A systematic review

The impact of breast screening awareness campaigns on mammography attendance among British women was explored. British Nursing Index, Medline, PsycINFO, Embase and Cumulative Index to Nursing and Allied Health were searched between October 2012 and February 2013. Searches identified research on breast cancer awareness interventions and breast self-examination. In total, 867 articles were identified and 14 met criteria for review. Breast cancer awareness interventions were found to increase the uptake of breast self-examination behaviours and increase the likelihood of breast cancer screening attendance. Predicting the impact of these interventions on survivability and general morbidity/mortality outcomes remains a challenge due to a shortage of suitably evaluated campaigns.

Interventions for raising breast cancer awareness in women

BACKGROUND

Breast cancer continues to be the most commonly diagnosed cancer in women globally. Early detection, diagnosis and treatment of breast cancer are key to better outcomes. Since many women will discover a breast cancer symptom themselves, it is important that they are breast cancer aware i.e. have the knowledge, skills and confidence to detect breast changes and present promptly to a healthcare professional.

OBJECTIVES

To assess the effectiveness of interventions for raising breast cancer awareness in women.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register (searched 25 January 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 12) in the Cochrane Library (searched 27 January 2016), MEDLINE OvidSP (2008 to 27 January 2016), Embase (Embase.com, 2008 to 27 January 2016), the World Health Organization's International Clinical Trials Registry Platform (ICTRP) search portal and ClinicalTrials.gov (searched 27 Feburary 2016). We also searched the reference lists of identified articles and reviews and the grey literature for conference proceedings and published abstracts. No language restriction was applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) focusing on interventions for raising women's breast cancer awareness i.e. knowledge of potential breast cancer symptoms/changes and the confidence to look at and feel their breasts, using any means of delivery, i.e. one-to-one/group/mass media campaign(s).

DATA COLLECTION AND ANALYSIS

Two authors selected studies, independently extracted data and assessed risk of bias. We reported the odds ratio (OR) and 95% confidence intervals (CIs) for dichotomous outcomes and mean difference (MD) and standard deviation (SD) for continuous outcomes. Since it was not possible to combine data from included studies due to their heterogeneity, we present a narrative synthesis. We assessed the quality of evidence using GRADE methods.

MAIN RESULTS

We included two RCTs involving 997 women: one RCT (867 women) randomised women to receive either a written booklet and usual care (intervention group 1), a written booklet and usual care plus a verbal interaction with a radiographer or research psychologist (intervention group 2) or usual care (control group); and the second RCT (130 women) randomised women to either an educational programme (three sessions of 60 to 90 minutes) or no intervention (control group). Knowledge of breast cancer symptomsIn the first study, knowledge of non-lump symptoms increased in intervention group 1 compared to the control group at two years postintervention, but not significantly (OR 1.1, 95% CI 0.7 to 1.6; P = 0.66; 449 women; moderate-quality evidence). Similarly, at two years postintervention, knowledge of symptoms increased in the intervention group 2 compared to the control group but not significantly (OR 1.4, 95% CI 0.9 to 2.1; P = 0.11; 434 women; moderate-quality evidence). In the second study, women's awareness of breast cancer symptoms had increased one month post intervention in the educational group (MD 3.45, SD 5.11; 65 women; low-quality evidence) compared to the control group (MD -0.68, SD 5.93; 65 women; P < 0.001), where there was a decrease in awareness. Knowledge of age-related riskIn the first study, women's knowledge of age-related risk of breast cancer increased, but not significantly, in intervention group 1 compared to control at two years postintervention (OR 1.8; 95% CI 0.9 to 3.5; P < 0.08; 447 women; moderate-quality evidence). Women's knowledge of risk increased significantly in intervention group 2 compared to control at two years postintervention (OR 4.8, 95% CI 2.6 to 9.0; P < 0.001; 431 women; moderate-quality evidence). In the second study, women's perceived susceptibility (how at risk they considered themselves) to breast cancer had increased significantly one month post intervention in the educational group (MD 1.31, SD 3.57; 65 women; low-quality evidence) compared to the control group (MD -0.55, SD 3.31; 65 women; P = 0.005), where a decrease in perceived susceptibility was noted. Frequency of Breast CheckingIn the first study, no significant change was noted for intervention group 1 compared to control at two years postintervention (OR 1.1, 95% CI 0.8 to 1.6; P = 0.54; 457 women; moderate-quality evidence). Monthly breast checking increased, but not significantly, in intervention group 2 compared to control at two years postintervention (OR 1.3, 95% CI 0.9 to 1.9; P = 0.14; 445 women; moderate-quality evidence). In the second study, women's breast cancer preventive behaviours increased significantly one month post intervention in the educational group (MD 1.21, SD 2.54; 65 women; low-quality evidence) compared to the control group (MD 0.15, SD 2.94; 65 women; P < 0.045). Breast Cancer AwarenessWomen's overall breast cancer awareness did not change in intervention group 1 compared to control at two years postintervention (OR 1.8, 95% CI 0.6 to 5.30; P = 0.32; 435 women; moderate-quality evidence) while overall awareness increased in the intervention group 2 compared to control at two years postintervention (OR 8.1, 95% CI 2.7 to 25.0; P < 0.001; 420 women; moderate-quality evidence). In the second study, there was a significant increase in scores on the Health Belief Model (that included the constructs of awareness and perceived susceptibility) at one month postintervention in the educational group (mean 1.21, SD 2.54; 65 women) compared to the control group (mean 0.15, SD 2.94; 65 women; P = 0.045).Neither study reported outcomes relating to motivation to check their breasts, confidence to seek help, time from breast symptom discovery to presentation to a healthcare professional, intentions to seek help, quality of life, adverse effects of the interventions, stages of breast cancer, survival estimates or breast cancer mortality rates.

AUTHORS' CONCLUSIONS

Based on the results of two RCTs, a brief intervention has the potential to increase women's breast cancer awareness. However, findings of this review should be interpreted with caution, as GRADE assessment identified moderate-quality evidence in only one of the two studies reviewed. In addition, the included trials were heterogeneous in terms of the interventions, population studied and outcomes measured. Therefore, current evidence cannot be generalised to the wider context. Further studies including larger samples, validated outcome measures and longitudinal approaches are warranted.

"Promoting Early Presentation" intervention sustains increased breast cancer awareness in older women for three years: A randomized controlled trial

Objective In a randomized controlled trial, the Promoting Early Presentation intervention increased older women's breast cancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breast screening self-referral. Methods We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting Early Presentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years. Results Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years than the usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited. Conclusion The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear.

Breast Cancer Knowledge and Breast Self-Examination Practices Among Female University Students in Kampala, Uganda: A Descriptive Study

OBJECTIVE

The purpose of the study was to assess female university students' knowledge of breast cancer risk factors, signs and symptoms, and identify breast self-examination (BSE) practices. Using this information we aimed to design an education intervention tailored to address any knowledge and practice gaps identified. .

METHODS

We conducted a cross-sectional study with 204 female Makerere University students. Data was obtained through the use of a structured questionnaire over a period of two months (1 April 2013 to 30 May 2013). .

RESULTS

Our study revealed a high awareness of breast cancer (98.0%) and BSE practices (76.5%) among female students. Over half the students (61.3%) had an intermediate level of knowledge about risk factors related to breast cancer and the signs and symptoms of the disease. Skills related to BSE practices were found to be low (43.6%). The majority (56.9%) of students received information about breast cancer via mass media. .

CONCLUSION

Pre- post-education intervention studies need to be conducted to evaluate the intervention outcomes related to breast cancer knowledge and BSE practices among female students in Uganda.

An Association of Cancer Physicians' strategy for improving services and outcomes for cancer patients

The Association of Cancer Physicians in the United Kingdom has developed a strategy to improve outcomes for cancer patients and identified the goals and commitments of the Association and its members.

Promoting early presentation of breast cancer in women over 70 years old in general practice

BACKGROUND

Delay in presentation contributes to poorer survival of older women with breast cancer. Research has shown the effectiveness of the promoting early presentation (PEP) intervention when delivered by radiographers in the NHS Breast Screening Programme. This paper investigates the effectiveness of the intervention when delivered by practice nurses in general practice.

METHODS

The Breast Cancer Awareness Measure was used to compare participants' awareness of breast cancer before, 1 month after and 12 months after the delivery of the PEP intervention. Five hundred and fifty-six women aged over 70 years took part, 308 of whom returned all three surveys.

RESULTS

The intervention was associated with increased awareness of non-lump breast symptoms and reported breast check frequency. There was a marked increase in breast cancer awareness which persisted for 12 months. Less than 5% of women were classified as 'breast cancer aware' before the intervention, rising to over 25% 1 month afterwards. This percentage dropped slightly after 1 year to just below 20%.

CONCLUSION

Delivery of the PEP intervention in general practice was very effective at raising the awareness of breast cancer among older women. Primary care settings are well placed to enhance the reach of this kind of intervention to at-risk women.

Promoting early presentation of breast cancer: a preliminary evaluation of a written intervention

OBJECTIVES

Older women are more likely to delay presentation with breast cancer, which contributes to poorer survival. We evaluated a written intervention that was designed to provide women with the knowledge, motivation, confidence and skills to present promptly with breast cancer symptoms.

METHODS

We assessed acceptability and understanding of the intervention by interviewing 43 women. We used their responses to refine the intervention. We tested the effect of the intervention on breast cancer awareness, confidence and intentions to check breasts and perceived barriers to help-seeking using a self-report questionnaire administered to 61 women prior to and one month after receiving the intervention. Quantitative data were analysed using the McNemar test.

RESULTS

Women were not made anxious by the intervention and understood its messages. At one month, a greater proportion of women knew that breast cancer risk increases with age, identified ≥5 non-lump symptoms and reported breast checking at least monthly in comparison to before the intervention was implemented.

DISCUSSION

The intervention does not induce anxiety, is understandable, and appears to increase breast cancer awareness. The results provide justification for a more rigorous trial to test efficacy.

Reducing the time before consulting with symptoms of lung cancer: a randomised controlled trial in primary care

BACKGROUND

Most individuals with lung cancer have symptoms for several months before presenting to their GP. Earlier consulting may improve survival.

AIM

To evaluate whether a theory-based primary care intervention increased timely consulting of individuals with symptoms of lung cancer.

DESIGN AND SETTING

Open randomised controlled trial comparing intervention with usual care in two general practices in north-east Scotland.

METHOD

Smokers and ex-smokers aged ≥55 years were randomised to receive a behavioural intervention or usual care. The intervention comprised a single nurse consultation at participants' general practice and a self-help manual. The main outcomes were consultations within target times for individuals with new chest symptoms (≤3 days haemoptysis, ≤3 weeks other symptoms) in the year after the intervention commenced, and intentions about consulting with chest symptoms at 1 and 6 months.

RESULTS

Two hundred and twelve participants were randomised and 206 completed the trial. The consultation rate for new chest symptoms in the intervention group was 1.19 (95% confidence interval [CI] = 0.92 to 1.53; P = 0.18) times higher than in the usual-care group and the proportion of consultations within the target time was 1.11 (95% CI = 0.41 to 3.03; P = 0.83) times higher. One month after the intervention commenced, the intervention group reported intending to consult with chest symptoms 31 days (95% CI = 7 to 54; P = 0.012) earlier than the usual care group, and at 6 months this was 25 days (95% CI = 1.5 to 48; P = 0.037) earlier.

CONCLUSION

Behavioural intervention in primary care shortened the time individuals at high risk of lung disease intended to take before consulting with new chest symptoms (the secondary outcome of the study), but increases in consultation rates and the proportions of consultations within target times were not statistically significant.

The effectiveness of a community-based breast cancer education intervention in the New York State Capital Region

We determined the effectiveness of a community-based breast cancer education intervention among understudied populations in the New York State (NYS) Capital Region by assessing and comparing baseline and post-education breast cancer knowledge. Participants included 417 students recruited from five colleges/universities and 67 women from four community group organizations. Baseline and post-education knowledge was assessed via self-administered mostly multiple-choice questionnaires. An open-ended question soliciting opinions about public health prevention strategies against breast cancer was included on college/university students' questionnaires. Effectiveness of education intervention was estimated through a paired t test. Stratified analysis was done using demographic and descriptive variables. Answers to the open-ended questions were analyzed qualitatively. The mean percentage of correct answers increased from 39.9% at baseline to 80.8% post-education (P < 0.0001) among college/university students and from 43.5% to 77.8% (P < 0.0001) among community group members. Effectiveness remained statistically significant in all stratified analyses with similarly high percentage of correct answers achieved post-education irrespective of knowledge level at baseline. Stratified analysis also revealed similar patterns of improvement in overall knowledge and narrowing of the gap in post-education knowledge. Primary prevention emerged as the dominant theme post-education in students' responses to the open-ended question, signifying the effectiveness of our education in raising awareness about modifiable risk factors and inspiring proactive thinking about public health prevention strategies. This community-based education intervention was effective in increasing breast cancer knowledge among demographically diverse groups with low levels of baseline knowledge in the NYS Capital Region. Our findings provide leads for future public health prevention strategies.

Shedding light on women's help seeking behaviour for self discovered breast symptoms

PURPOSE

To describe women's help seeking behaviour (HSB) and the associated influencing factors on self-discovery of a breast symptom.

METHODS

A descriptive, correlational survey design was used. Following ethical approval, survey data were collected from women (n = 449) attending the breast clinics of two large urban hospitals within the Republic of Ireland.

RESULTS

The majority of women (69.9%; n = 314) sought help (by visiting their General practitioner, GP) within one month, 30.1% (n = 135) delayed help seeking for more than one month following symptom discovery and 16.7% (n = 75) delayed for three months or more. The factors most significantly associated with delayed HSB were knowledge around symptom identity (Odds Ratio (OR) = 4.80, p = 0.005); ignoring the symptom and hoping it would go away (OR = 10.72, p < 0.001) and women's belief that the symptom would persist for a long time (OR = 1.18, p = 0.023). Being afraid on symptom discovery (OR = 0.37, p = 0.005) was associated with reduced risk of delayed HSB.

CONCLUSIONS

It is encouraging to see that the majority of women who find a breast symptom seek help promptly. However, a small cohort of women delay seeking help from their GP. HSB is influenced by multiple factors which can impact on patient outcomes. Findings are important for oncology nurses who have a key role to play in promoting breast awareness, prompt help seeking and early detection and treatment of breast cancer, amongst women.

Management of operable breast cancer in older women

Older women are not being given the opportunity to benefit from the improvements in both local and systemic treatment for breast cancer. Mammographic screening call/recall system ceases at age 72, making access more difficult. Knowledge about breast cancer in those aged >75 is significantly reduced in terms of understanding symptoms and personal risk but studies have shown that intervention can improve this, at least in the short term. Although older women are more likely to have estrogen receptor positive tumours, nevertheless, more than one-third of women aged over 70 have grade III, aggressive breast cancers. Whenever possible, older women should be offered breast conserving therapy rather than mastectomy since this not only improves their quality of life but also reduces risk of subsequent mental health problems. Endocrine treatment alone should not be used other than in patients with severe co-morbidity and a life-expectancy of less than a year. As adjuvant treatment in those with estrogen receptor positive cancers, the choice between tamoxifen and an aromatase inhibitor will depend upon co-morbidity, side-effects and patient choice.

Women's awareness of cancer symptoms: a review of the literature

Improvements in cancer detection and treatment have led to consistent declines in mortality from many cancers. However, many patients present for treatment at a point where more invasive treatment is required and/or treatment outcomes are less than optimal. One factor that has been consistently shown to be associated with late diagnosis and treatment is delay in seeking help for symptoms. This paper reviews the literature on women's awareness of cancer symptoms and aims to identify knowledge gaps that need to be addressed in order to improve help-seeking behaviors. The discovery of substantial gaps in awareness suggest a need for improved community education regarding cancer symptoms.

Promoting early presentation of breast cancer in older women: implementing an evidence-based intervention in routine clinical practice

Background. Women over 70 with breast cancer have poorer one-year survival and present at a more advanced stage than younger women. Promoting early symptomatic presentation in older women may reduce stage cost effectively and is unlikely to lead to overdiagnosis. After examining efficacy in a randomised controlled trial, we piloted a brief health professional-delivered intervention to equip women to present promptly with breast symptoms, as an integral part of the final invited mammogram at age ~70, in the English National Health Service Breast Screening Programme. Methods. We trained mammographers, who then offered the intervention to older women in four breast screening services. We examined breast cancer awareness at baseline and one month in women receiving the intervention, and also in a service where the intervention was not offered. Results. We trained 27 mammographers to deliver the intervention confidently to a high standard. Breast cancer awareness increased 7-fold at one month in women receiving the intervention compared with 2-fold in the comparison service (odds ratio 15.2, 95% confidence interval 10.0 to 23.2). Conclusions. The PEP Intervention can be implemented in routine clinical practice with a potency similar to that achieved in a randomised controlled trial. It has the potential to reduce delay in diagnosis for breast cancer in older women.

A randomised controlled trial of a pilot intervention to encourage early presentation of oral cancer in high risk groups

OBJECTIVE

Prognosis for oral cancer is substantially improved when diagnosed early. This research aimed to evaluate an intervention to promote early presentation of oral cancer.

METHODS

Participants were randomly assigned to a leaflet group (n = 42), a one-to-one group (n = 46) or a control group (n = 24). Participants in the leaflet group read a theory-based (Extended Self-Regulatory Model; Social Cognitive Theory) leaflet on how to spot oral cancer early. Those in the one-to-one group received a brief, interactional discussion on early presentation of oral cancer and were then asked to read the leaflet. Participants in the control group received no information about oral cancer.

RESULTS

The leaflet and the one-to-one instruction led to more accurate knowledge of oral cancer, decreased anticipated delay, and increased understanding, likelihood and confidence to perform self-examination. Neither intervention raised participants' anxiety. There were minimal differences between the two interventions, yet both were superior to the control group.

CONCLUSION

This piloting indicates the initial effectiveness of an brief intervention purposefully designed for people at risk of developing oral cancer.

PRACTICE IMPLICATION

A low cost intervention may be a useful tool to encourage early detection of oral cancer. This could be embedded into routine consultations or an early detection programme.

Why don't older adults with subjective memory complaints seek help?

BACKGROUND

Subjective memory complaints (SMCs) are common among older adults, often causing significant distress and showing strong relationships to future cognitive decline. However, low rates of help-seeking for memory complaints are well documented. Little is known about the reasons behind the decision to seek or not to seek help with memory problems. The common-sense model of illness perception proposes that the beliefs people hold about their health underlie help-seeking behaviour. The present study investigated factors underlying the decision to seek help in people with SMCs within the framework of the common-sense model of illness perception.

METHODS

Cognition, illness perceptions, coping styles, depression and anxiety were assessed in 98 adults with SMCs, aged 50 years and above, including 60 attending a memory clinic and 38 non-help-seekers.

RESULTS

Objective cognitive performance did not differ between participants who had sought help and those who had not. Logistic regression revealed that illness perceptions including social comparison and causal attributions predict help-seeking behaviour. More general coping style did not predict help-seeking. Furthermore, participants who had sought help were more likely to have had a close relative with dementia.

CONCLUSIONS

The results suggest that beliefs about memory, rather than objective cognitive impairment, are associated with the decision to seek help for SMCs. The findings suggest that providing education regarding memory problems, in particular challenging causal attributions, may help to encourage help-seeking in people with SMCs and improve care in the early stages of dementia.

Screening outcomes in women over age 70 who self-refer in the NHSBSP in England

SETTING

The NHS breast screening programme (NHSBSP) in England currently invites women aged 50-70 every three years. Whilst screening is acknowledged as efficacious for women aged 50-69, several countries routinely invite women up to the age of 74. The NHSBSP in England is beginning to invite women up to the age of 73. Although the incidence of breast cancer increases with age, the possible benefits of screening older women must be balanced against shorter life expectancies and possible overdiagnosis. In England women can self-refer after reaching the invitation upper age limit.

OBJECTIVE

We examined the extent to which older women in England self-referred over a three-year period and studied the screening outcomes in these women.

METHODS

Routinely collected data from screening units in England were used to calculate screening performance measures for women who self-referred between 1 April 2005 and 31 March 2008. The tumour characteristics of all screen-detected cancers were examined by previous screening history and age group (71-74 and ≥75 years).

RESULTS

During the three-year period 139,910 women aged over 70 self-referred; equivalent to 4% of the female population aged over 70 having been screened. The majority of women who self-referred had been screened within the previous five years (76% of those aged 71-74 and 65% of those aged 75 or over). Approximately 4% of these women were recalled for assessment and cancer detection rates were similar in both age groups.

CONCLUSION

Only a small proportion of all women aged over 70 utilize the self-referral policy of the NHSBSP, and most such women are aged below 80.

Increasing awareness of gynecological cancer symptoms and reducing barriers to medical help seeking: does health literacy play a role?

Health literacy may influence the efficacy of print-based public health interventions. A key part of the U.K. cancer control strategy is to provide information to the public on earlier diagnoses with a view to improving the United Kingdom's relatively poor 1-year cancer survival statistics. This study examined the effect of health literacy on the efficacy of a gynecological cancer information leaflet. Participants (n = 451) were recruited from 17 Cancer Research UK events. Health literacy was assessed with the Newest Vital Sign test. Gynecological cancer symptom awareness and barriers to medical help seeking were assessed before and after participants read the leaflet. Symptom awareness improved, and barriers to medical help seeking were reduced (ps < .001). Symptom awareness was lower in individuals in lower health literacy groups, both at baseline and at follow-up (p < .05, p < .001, respectively), but there were no significant differences in barriers to medical help seeking at either time point (p > .05). As predicted, individuals with lower health literacy benefited less after exposure to the leaflet (ps < .01 for interactions). Despite careful consideration of information design principles in the development of the leaflet, more intensive efforts may be required to ensure that inequalities are not exacerbated by reliance on print-based public health interventions.

A promoting early presentation intervention increases breast cancer awareness in older women after 2 years: a randomised controlled trial

Background:

We have developed the Promoting Early Presentation (PEP) Intervention to equip older women with the knowledge, skills, confidence and motivation to present promptly with breast symptoms, and thereby improve survival from breast cancer. The PEP Intervention consists of a 10-min interaction between a radiographer and an older woman, supported by a booklet. Our previous report showed that at 1 year, the PEP intervention increased the proportion who were breast cancer aware compared with usual care.

Methods:

We randomised 867 women aged 67–70 years attending for their final routine appointment on the National Health Service Breast Screening Programme to receive the PEP Intervention, a booklet alone or usual care. The primary outcome was breast cancer awareness measured using a validated questionnaire asking about knowledge of breast cancer symptoms, knowledge that the risk of breast cancer increases with age and breast checking behaviour.

Results:

At 2 years, the PEP Intervention increased the proportion who were breast cancer aware compared with usual care (21 vs 6% odds ratio 8.1, 95% confidence interval 2.7–25.0).

Conclusions:

The uniquely large and sustained effect of the PEP Intervention on breast cancer awareness increases the likelihood that a woman will present promptly should she develop breast cancer symptoms up to many years later.

Involving users in the design of a randomised controlled trial of an intervention to promote early presentation in breast cancer: qualitative study

Background

The purpose of this study was to explore women's views of the design of a large pragmatic cost-effectiveness randomised controlled trial of the policy of offering a health professional-delivered intervention to promote early presentation with breast symptoms in older women and thereby improve survival, with a view to informing protocol development. The trial will recruit over 100,000 healthy women aged 67+, and outcome data will be collected on those who develop breast cancer. The scale of the trial and the need for long-term follow-up presented a number of design challenges in relation to obtaining consent, ascertaining and contacting participants who developed breast cancer, and collecting outcome data.

Methods

Qualitative study involving 69 women participating in 7 focus groups and 17 in-depth interviews. 15 women had a previous diagnosis of breast cancer and 54 did not.

Results

The women held strong views and had a good understanding of the rationale of the design of clinical trials. The women recognised that in a very large trial with long-term follow-up it was necessary to incorporate design features to make the trial feasible and efficient. Most strikingly, they supported the idea of opt-out consent and identifying women with breast cancer using routine datasets.

Conclusions

This model of user involvement engaged women well with the design challenges of the trial and led to improvements to the protocol. The study strengthens the case for user involvement, in particular through focus groups and in-depth interviews, in the design of trials.

Validation of a measurement tool to assess awareness of breast cancer

AIM

Until now, there has been no universally accepted and validated measure of breast cancer awareness. This study aimed to validate the new Breast Cancer Awareness Measure (BCAM) which assesses, using a self-complete questionnaire, knowledge of breast cancer symptoms and age-related risk, and frequency of breast checking.

METHODS

We measured the psychometric properties of the BCAM in 1035 women attending the NHS Breast Screening Programme: acceptability was assessed using a feedback questionnaire (n=292); sensitivity to change after an intervention promoting breast cancer awareness (n=576), and test-retest reliability (n=167). We also assessed readability, and construct validity using the 'known-groups' method.

RESULTS

The readability of the BCAM was high. Over 90% of women found it acceptable. The BCAM was sensitive to change: there was an increase in the proportion of women obtaining the full score for breast cancer awareness one month after receiving the intervention promoting breast cancer awareness; this was greater among those who received a more intensive version (less intensive version (booklet): 9.3%, 95% confidence interval (CI): 4.5-14.1%; more intensive version (interaction with health professional plus booklet): 30%, 95% CI: 23.4-36.6%). Test-retest reliability of the BCAM was moderate to good for most items. Cancer experts had higher levels of cancer awareness than non-medical academics (50% versus 6%, p=0.001), indicating good construct validity.

CONCLUSIONS

The BCAM is a valid and robust measure of breast cancer awareness suitable for use in surveys of breast cancer awareness in the general population and to evaluate the impact of awareness-raising interventions.

The National Awareness and Early Diagnosis Initiative in England: assembling the evidence

A National Awareness and Early Diagnosis Initiative (NAEDI) has been established in England as part of the Government's strategy to improve cancer outcomes. One of the early priorities for this initiative has been to assemble the diverse evidence linking late diagnosis with poor survival and avoidable deaths. This supplement brings together new perspectives on existing research in this area together with findings from recently commissioned research. This paper describes a provisional model, the ‘NAEDI pathway’, for testing hypotheses relating to late diagnosis and its impact. Key findings from other papers in this supplement are also highlighted.