Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study

Anticipated time to seek medical advice for possible lung cancer symptoms and barriers to timely presentation in Palestine: a national cross-sectional study

BACKGROUND

Lung cancer (LC) has poor survival outcomes mainly due to diagnosis at late stages. This study explored the anticipated time to seek medical advice for possible LC symptoms and barriers to early presentation in Palestine.

METHODS

This cross-sectional study recruited adult participants from hospitals, primary healthcare centers, and public spaces of 11 governorates using convenience sampling. A modified, translated-into-Arabic version of the validated LC awareness measure was used to assess LC symptom awareness, the time needed to seek medical advice and barriers to early presentation.

RESULTS

A total of 4762 participants were included. The proportion that would immediately seek medical advice for possible LC symptoms varied according to the symptoms' nature. For respiratory symptoms, this ranged from 15.0% for 'painful cough' to 37.0% for 'coughing up blood'. For non-respiratory symptoms, this ranged from '4.2% for 'unexplained loss of appetite' to 13.8% for 'changes in the shape of fingers or nails'. Participants with good LC symptom awareness were more likely to seek medical advice within a week of recognizing most LC symptoms. About 13.0% would delay their visit to see a doctor after recognizing an LC symptom. The most reported barriers were emotional with 'disliking the visit to healthcare facilities' (59.8%) as the leading barrier.

CONCLUSION

LC respiratory symptoms were more likely to prompt early seeking of medical advice. Good LC symptom awareness was associated with a higher likelihood of help-seeking within a week. Educational interventions are needed to promote LC awareness and address the perceived barriers to early presentation in low-resource settings, such as Palestine.

Pan-cancer analyses of the associations between 109 pre-existing conditions and cancer treatment patterns across 19 adult cancers

Comorbidities present considerable challenges to cancer treatment and care. However, little is known about the effect of comorbidity on cancer treatment decisions across a wide range of cancer types and treatment modalities. Harnessing a cohort of 280,543 patients spanning 19 site-specific cancers, we explored pan-cancer frequencies of 109 comorbidities. Multinomial logistic regression was used to analyse the relationship between comorbidities and cancer treatment types, while binomial logistic regression examined the association between comorbidities and chemotherapy drug types, adjusting for demographic and clinical factors. Patients with comorbidity exhibited lower odds of receiving chemotherapy and multimodality treatment. End-stage renal disease was significantly associated with a decreased odds of receiving chemotherapy and surgery. Patients with prostate cancer who have comorbid non-acute cystitis, obstructive and reflux uropathy, urolithiasis, or hypertension were less likely to receive chemotherapy. Among patients with breast cancer, dementia, left bundle branch block, peripheral arterial disease, epilepsy, Barrett's oesophagus, ischaemic stroke, unstable angina and asthma were associated with lower odds of receiving multimodal chemotherapy, radiotherapy and surgery. Comorbidity is also consistently associated with the lower odds of receiving chemotherapy when comparing across 10 drug classes. Patients with comorbid dementia, intracerebral haemorrhage, subarachnoid haemorrhage, oesophageal varices, liver fibrosis sclerosis and cirrhosis and secondary pulmonary hypertension were less likely to receive antimetabolites. Comorbidity can influence the effectiveness and tolerability of cancer treatment and ultimately, prognosis. Multi-specialty collaborative care is essential for the management of comorbidity during cancer treatment, including prophylactic measures to manage toxicities.

Socioeconomic position and the pre-diagnostic interval among patients diagnosed with head and neck squamous cell carcinoma - a population-based study from DAHANCA

BACKGROUND

The socioeconomic differences in survival are pronounced for patients diagnosed with head and neck cancer; disease stage at diagnosis is suggested to be a main driver of this association. This nationwide, population-based study investigates socioeconomic differences in the pre-diagnostic interval and disease stage at diagnosis.

MATERIAL AND METHODS

Information on patient-reported symptoms, symptom onset and disease-specific factors was obtained from the nationwide population-based Danish Head and Neck Cancer Group (DAHANCA) database for patients diagnosed with head and neck squamous cell carcinoma between 2008 and 2019 in Denmark. Socioeconomic position (SEP) was measured by individual-level education, income and cohabitation status obtained from administrative registers. Socioeconomic differences in the interval from symptom onset to diagnosis were investigated in general linear models with 95% confidence intervals (CIs); overall and by subsite, symptom and comorbidity score. Consultation patterns prior to diagnosis were examined using methods for change-point detection. Associations with advanced-stage disease were estimated in logistic regression models.

RESULTS

Patients with low, medium and high SEP had a similar interval from patient-reported symptom onset to diagnosis of 10 weeks. Although this interval varied according to primary symptom and anatomical subsite, no apparent socioeconomic differences were observed within these subgroups. Aligned with the patient-reported symptom onset, a distinct increase in consultation rates was observed at 9 weeks (95% CI [7.3; 10.7]) for patients with low SEP and 7 weeks (95% CI [4.8; 9.2]) for patients with high SEP, with overlapping CIs. Patients with low compared to high SEP had increased odds for advanced-stage glottic and oral cavity squamous cell carcinoma. For the remaining subsites the association varied according to SEP-indicator and TNM-edition.

CONCLUSION

The interval from symptom onset to diagnosis and consultation patterns were similar across SEP groups. Still, socioeconomic differences in stage at diagnosis were observed for some - but not all - subsites.

Delays in Lung Cancer Diagnosis: Observations from a Tertiary Care Centre in Kerala, India

Merin YohannanIntroduction  Timely diagnosis of lung cancer is critical because treatment outcomes correspond to the stage of disease. This study identified patient and physician determined reasons for diagnostic delays. Materials and Method s This was an observational cross-sectional study, conducted at a tertiary care institution in South India, for 12 months. From 207 consecutively selected patients, with a presumptive lung cancer diagnosis, 150 were enrolled utilizing a prefixed questionnaire. The time intervals from appreciation of initial respiratory symptoms to a final tissue diagnosis were defined sequentially as approach interval, referral interval, and diagnostic interval and factors causing delay in each interval were identified. Results  In a state with 100% literacy, the mean time to approach a doctor was 8 weeks (range: 0-336 days; SD: 7.95) with a delay seen in 52% of the study group. Referring a suspect lung cancer diagnosis to a specialist, took an average of 4.98 weeks (range: 1-26 weeks; SD: 5.64) with referral delays in 47.3% of patients. The mean diagnostic interval was 9.21 days (range: 3-41 days; SD: 7.18) and 16.7% of cases had diagnostic delays in spite of a definite procedure. Conclusion  In a tuberculosis endemic location, empirical treatment with anti-tuberculosis therapy and prolonged antibiotic courses without serially monitoring the course of disease are responsible for referral delays. Also, 88.2% of the total females studied, presented late due to family and work pressures, fear of being stigmatized and being on prolonged home remedies. A wider dissemination and awareness on lung cancer are needed especially among females. A low threshold to reinvestigate and an early referral to a pulmonary or lung cancer specialist, when expected clinicoradiological improvement is lacking, in microbiologically negative tuberculosis should be highlighted.

Trends of cancer incidence among Chinese older adults from 2005 to 2016: A log-linear regression and age-period-cohort analysis

Background

To study the corresponding strategies for controlling cancer in older adults aged 60 and above in China, a comprehensive assessment of disease burden is required. Therefore, we will introduce the cancer epidemiological characteristics of older adults in China over a recent 12 year period.

Methods

The age-period-cohort model was constructed using the cancer incidence data from the Chinese Cancer Registry Annual Report published in 2008-2019. The annual change percentage (APC) was estimated by log-linear regression to reflect the time trend. The data from the GLOBOCAN 2020 database was selected for worldwide comparative analysis.

Results

The cancer incidence in older adults aged 60 and above in China showed a decreasing trend (APC = -0.73%, P = 0.009). The urban/rural ratio of cancer incidence increased from 0.94 to 1.07 (t = 3.52, P < 0.05), while the sex ratio (male/female) showed a significant decreasing trend only in rural areas (t = -6.77, P < 0.05), and the ratio decreased from 2.02 to 1.72. The results of the age-period-cohort model showed that the cancer incidence increased with age in both males and females, urban and rural areas. The RR of period effect increased from 2005 to 2010, then decreased from 2010 to 2015, and the downward trend was more obvious. The RR of the later-born cohort was lower than that of the earlier-born cohort in rural areas. Lung, gastric, colorectal, esophageal, liver, and breast cancers were common cancers in Chinese older adults. Lung cancer incidence ranked first in males, and it decreased with time in the 75-79 and 80-84 age groups (APC_{75 - 79} = -1.10%, APC_{80 - 84} = -0.88%, all P < 0.05). Breast cancer incidence ranked first among female in the 60-64 age group and showed an increasing trend (APC_{60 - 64} = 1.52%, P < 0.05).

Conclusions

The cancer incidence in Chinese older adults aged 60 and above showed a decreasing trend, but it was still at a relatively high level. The key targets of prevention and treatment should be males, urban areas, younger people, older adults aged 60-69, lung, gastrointestinal, and breast cancers in the future.

Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study

BACKGROUND

The majority of lung cancer (LC) cases are diagnosed at an advanced stage. Poor awareness of LC symptoms is a contributor to late diagnosis. This study aimed to assess the awareness of LC symptoms among Palestinians, and to examine the factors associated with displaying good awareness.

METHODS

Participants were recruited from hospitals, primary healthcare centers and public spaces using convenience sampling. A translated-into-Arabic version of the validated LC awareness measure was used to assess recognition of 14 LC symptoms. One point was given for each recognized symptom. The total score was calculated and categorized based on the number of symptoms recognized: poor (0-4), fair (5-9), and good (10-14). Multivariable logistic regression was used to examine the association between participant characteristics and having good awareness. The multivariable analysis adjusted for age-group, gender, education, monthly income, occupation, residence, marital status, any chronic disease, knowing someone with cancer, smoking history, and site of data collection.

RESULTS

Of 5174 potential participants approached, 4817 completed the questionnaire (response rate = 93.1%) and 4762 were included in the final analysis. Of these, 2742 (56.9%) were from the West Bank and Jerusalem (WBJ) and 2020 (43.1%) were from the Gaza Strip. Participants from the WBJ were older, had higher monthly income but lower education, and suffered from more chronic diseases. The most recognized respiratory LC symptom was 'worsening in an existing cough'(n = 3884, 81.6%) while the least recognized was 'a cough that does not go away for two or three weeks'(n = 2951, 62.0%). The most recognized non-respiratory LC symptom was 'persistent tiredness or lack of energy'(n = 3205, 67.3%) while the least recognized was 'persistent shoulder pain'(n = 1170, 24.6%). A total of 2466 participants (51.8%) displayed good awareness of LC symptoms. Participants from both the Gaza Strip and the WBJ had similar likelihoods to have good awareness levels. Factors associated with a higher likelihood to display good awareness included female gender, having post-secondary education, being employed, knowing someone with cancer, and visiting hospitals and primary healthcare centers.

CONCLUSION

About half of the study participants displayed a good level of awareness of LC symptoms. Further improvement in public awareness of LC symptoms by educational interventions might reduce LC mortality by promoting early diagnosis.

Awareness of Palestinians about lung cancer symptoms: a national cross-sectional study

BACKGROUND

The majority of lung cancer (LC) cases are diagnosed at an advanced stage. Poor awareness of LC symptoms is a contributor to late diagnosis. This study aimed to assess the awareness of LC symptoms among Palestinians, and to examine the factors associated with displaying good awareness.

METHODS

Participants were recruited from hospitals, primary healthcare centers and public spaces using convenience sampling. A translated-into-Arabic version of the validated LC awareness measure was used to assess recognition of 14 LC symptoms. One point was given for each recognized symptom. The total score was calculated and categorized based on the number of symptoms recognized: poor (0-4), fair (5-9), and good (10-14). Multivariable logistic regression was used to examine the association between participant characteristics and having good awareness. The multivariable analysis adjusted for age-group, gender, education, monthly income, occupation, residence, marital status, any chronic disease, knowing someone with cancer, smoking history, and site of data collection.

RESULTS

Of 5174 potential participants approached, 4817 completed the questionnaire (response rate = 93.1%) and 4762 were included in the final analysis. Of these, 2742 (56.9%) were from the West Bank and Jerusalem (WBJ) and 2020 (43.1%) were from the Gaza Strip. Participants from the WBJ were older, had higher monthly income but lower education, and suffered from more chronic diseases. The most recognized respiratory LC symptom was 'worsening in an existing cough'(n = 3884, 81.6%) while the least recognized was 'a cough that does not go away for two or three weeks'(n = 2951, 62.0%). The most recognized non-respiratory LC symptom was 'persistent tiredness or lack of energy'(n = 3205, 67.3%) while the least recognized was 'persistent shoulder pain'(n = 1170, 24.6%). A total of 2466 participants (51.8%) displayed good awareness of LC symptoms. Participants from both the Gaza Strip and the WBJ had similar likelihoods to have good awareness levels. Factors associated with a higher likelihood to display good awareness included female gender, having post-secondary education, being employed, knowing someone with cancer, and visiting hospitals and primary healthcare centers.

CONCLUSION

About half of the study participants displayed a good level of awareness of LC symptoms. Further improvement in public awareness of LC symptoms by educational interventions might reduce LC mortality by promoting early diagnosis.

Defining timeliness in care for patients with lung cancer: a scoping review

OBJECTIVES

Early diagnosis and reducing the time taken to achieve each step of lung cancer care is essential. This scoping review aimed to examine time points and intervals used to measure timeliness and to critically assess how they are defined by existing studies of the care seeking pathway for lung cancer.

METHODS

This scoping review was guided by the methodological framework for scoping reviews by Arksey and O'Malley. MEDLINE, EMBASE, CINAHL and PsycINFO electronic databases were searched for articles published between 1999 and 2019. After duplicate removal, all publications went through title and abstract screening followed by full text review and inclusion of articles in the review against the selection criteria. A narrative synthesis describes the time points, intervals and measurement guidelines used by the included articles.

RESULTS

A total of 2113 articles were identified from the initial search. Finally, 68 articles were included for data charting process. Eight time points and 14 intervals were identified as the most common events researched by the articles. Eighteen different lung cancer care guidelines were used to benchmark intervals in the included articles; all were developed in Western countries. The British Thoracic Society guideline was the most frequently used guideline (20%). Western guidelines were used by the studies in Asian countries despite differences in the health system structure.

CONCLUSION

This review identified substantial variations in definitions of some of the intervals used to describe timeliness of care for lung cancer. The differences in healthcare delivery systems of Asian and Western countries, and between high-income countries and low-income-middle-income countries may suggest different sets of time points and intervals need to be developed.

Factors Influencing Total Delay of Breast Cancer in Northeast of China

Objectives

Delay in diagnosis and treatment, called total delay, could probably result in lower survival rates in breast cancer patients. This study aimed to investigate the factors associated with the comprehensive delay behaviors and to evaluate its effect on outcomes in patients with breast cancer in Dalian, a northeast city of China.

Methods

A retrospective chart review was conducted using a cancer registry dataset including 298 patients. The Kaplan–Meier survival analysis was used to identify the threshold of total delay, dividing the patients into a group with significant uncertainty and a group without substantial delay. The factors associated with the significant total delay were investigated from the potential candidates, like income level and marital status, by using the chi-squared test. The difference of the clinicopathologic characteristics between the patients grouped by the significant total delay, like tumor size and lymph node metastasis, was also investigated to find out the effect of the total delay.

Results

A total of 238 charts were used for analysis. The mean age was 57.3. The median of total delays was 3.75 months. Thirty days was identified as a threshold, more than which the total delay can lead to worse survival. Patients’ marital status (p = 0.010), income levels (p = 0.003), smoking status (p = 0.031), initial visiting hospital level (p = 0.005), self-health care (p = 0.001), and self-concern about initial symptom (p ≈ 0.000) were identified as the independent predictors of the total delay. Metastasis (p ≈ 0.000) was identified as the significant result relating to the significant total delay.

Conclusions

A total delay of more than 30 days predicts worse survival in breast cancer patients in Dalian. Several factors, like patients’ marital status and income levels, can be considered to be relevant to the significant total delay. We recommend that these factors be used to predict the potential patients with the significant total delay in the clinical practice.

The lived experience during the peri-diagnostic period of breast cancer: A scoping review

OBJECTIVES

The aim of this scoping review is to provide an overview of the existing research that investigates the lived experience during the peri-diagnostic period of breast cancer.

METHODS

Nine databases were searched for relevant literature between January 2007 and April 2019. Data were extracted and categorized using deductive and inductive approaches.

RESULTS

A majority of the 66 studies included used qualitative methods to retrospectively explore the treatment decision making process of female breast cancer patients. Patients experienced uncertainty, emotional distress, and a need for more information from providers and relied on social support and family guidance during this period.

CONCLUSIONS

The results of this review show that the burdens experienced during the peri-diagnostic period parallel those in later periods of cancer care. However, these burdens are prompted by different circumstances. More research is needed to explore the lived experience during this period through the use of mixed-methods and by recruiting a diverse sample with regards to role in the breast cancer experience, age, gender, race, and ethnicity.

PRACTICE IMPLICATIONS

Interventions positioned at earlier points in the breast cancer experience should provide informational support, which could be delivered through shared decision making models. Additional support could be facilitated by patient navigation programs and health information technology.

Olfactometric diagnosis of lung cancer by canine scent - A double-blinded study

BACKGROUND

Lung cancer is one of the most often diagnosed tumours in the world with the highest mortality. A major problem and reason for the high mortality from lung cancer is its diagnosis in the late stages. The main goal of preventing lung cancer deaths is early detection in the early stages and accurate diagnosis, which must be followed by targeted treatment. Nevertheless, even top diagnostic techniques do not have the same accuracy and sensitivity as a dog's sense of smell.

METHODS

The study aims to present the results of olfactometric detection of lung cancer using the smell of dogs in unblinded, single-blinded and double-blinded studies. 115 serum samples or breath from patients with lung cancer and 101 samples from healthy people were used for the training. The group consisted of women and men of Indo-European origin, mostly from the Moravian-Silesian region in Czech Republic. Two dogs were selected for the study.

RESULTS

In the case of tumor detection in the form of unblinded tests, Bugs had a sensitivity of 91% and a specificity of 92%. Boolomo had a sensitivity of 89% and a specificity of 81%. For single-blinded tests, Bugs had a sensitivity of 71%. The sensitivity of Boolomo was set at 90%. After meeting the sensitivity limit of 70%, dogs were included in the double-blinded studies. The highest accuracy was set at 68% for Bugs, 83% for Boolomo.

CONCLUSION

When a tumour is diagnosed in the late stages, it is a great burden on both the health and economic systems of the state. Unfortunately, there is still no suitable screening test to detect the tumour at an early stage, so any other method of detection seems desirable. Trained dogs are used in many fields, why not also in medicine and the diagnosis of tumours?

Lung Cancer Screening Policy in Alaska and Occupational Therapy

Lung cancer claims more lives than any other cancer in the world and remains difficult to diagnose in the early stages. This article examines the current state of lung cancer detection and screening via low-dose computed tomography (LDCT) in Alaska and considers potential opportunities for occupational therapy practitioners in primary care settings. Medicare requires at least one documented shared decision-making encounter between provider and patient before LDCT lung cancer screening occurs. As a result of time constraints, documentation requirements, and the plethora of preventive health services they provide, primary care physicians often lack the time and training to conduct this essential service. This provides an opportunity for occupational therapy practitioners to perform these services as part of their practice and to play a role in this area as patient educators and prevention specialists in primary care settings. What This Article Adds: This article explores the national health crisis of lung cancer and describes how occupational therapists can participate in providing care in primary care settings.

Evaluating the delay prior to primary care presentation in patients with lung cancer: a cohort study

Background

Little is known about 'within-patient delay', which is the time from first symptom of lung cancer to contacting primary care.

Aim

Primary outcomes were length of within-patient delay and the proportion of total delay it represents. Secondary outcomes were factors causing delay and survival.

Design & setting

A cohort study of newly diagnosed patients with lung cancer at two hospitals in Norfolk.

Method

Patients completed questionnaires regarding onset of symptoms, whether they had delayed, and their reasons. GPs completed correlating questionnaires. Pathway times and other data were extracted from cancer registry and hospital records, and outcomes obtained prospectively. Factors causing delay were compared using ratios of geometric means.

Results

In 379 patients, mean within-patient delay and pre-secondary care delay were 188.6 days and 241 days (61.4% and 78.5% of total delay, respectively). It was found that 38.8% of patients felt they had delayed. Patient-related causes of delay were denial (ratio of means [ROM] = 4.36; P = 0.002, 95% confidence interval [CI] = 1.71 to 11.1); anxiety (ROM = 3.36; P = 0.026; 95% CI = 1.16 to 9.76); non-recognition of symptoms (ROM = 2.80; P = 0.004; 95% CI = 1.41 to 5.59); and smoking (ROM = 1.76; P = 0.021; 95% CI = 1.09 to 2.86), respectively. These symptoms were associated with delay: finger swelling or discomfort (ROM = 2.72; P = 0.009, 95% CI = 1.29 to 5.74); cough (ROM = 2.53; P<0.001; 95% CI = 1.52 to 4.19); weight loss (ROM = 2.41; P<0.001; 95% CI = 1.49 to 3.88); weakness (ROM = 2.35; P = 0.001; 95% CI = 1.45 to 3.83); dyspnoea (ROM = 2.30; P = 0.001; 95% CI = 1.40 to 3.80); voice change (ROM = 1.90; P = 0.010; 95% CI = 1.17 to 3.10); and sputum (ROM = 1.66; P = 0.039; 95% CI = 1.03 to 2.67), respectively, also having more than five symptoms (compared with 1–3) (ROM = 3.69; P<0.001; 95% CI = 2.05 to 6.64). No overall relation between within-patient delay and survival was seen.

Conclusion

Using smoking registers, awareness literature, and self-care manuals, primary care staff could liaise with people who have ever smoked regarding their symptoms to ensure early referral to secondary care.

The expanding role of CDR1-AS in the regulation and development of cancer and human diseases

CircRNAs are a superabundant and highly conserved group of noncoding RNAs (ncRNAs) that are characterized by their high stability and integrity compared with linear forms of ncRNAs. Recently, their critical role in gene expression regulation has been shown; thus, it is not far-fetched to believe that their abnormal expression can be a cause of different kinds of diseases such as cancer, neurodegenerative, and autoimmune diseases. They can have a function in variety of biological processes such as microRNA (miRNA) sponging, interacting with RNA-binding proteins, or even an ability to translate to proteins. A huge challenge in finding diagnostic biomarkers is finding noninvasive biomarkers that can be detected in human fluids, especially blood samples. CircRNAs are becoming candidate biomarkers for diagnosis and prognosis of these diseases through their ability to transverse from the blood-brain barrier and their broad presence in circulating exosomes. The circRNA for miRNA-7 (ciRS-7) is newly recognized, and acknowledged to being related to human pathology and cancer progression. In this review, we first briefly summarize the latest studies about their characteristics, biogenesis, and their mechanisms of action in the regulation and development of human diseases. Finally, we provide a list of diseases that are linked to one member of this novel class of ncRNAs called ciRS-7.

The promises and challenges of early non-small cell lung cancer detection: patient perceptions, low-dose CT screening, bronchoscopy and biomarkers

Lung cancer survival statistics are sobering with survival ranking among the poorest of all cancers despite the addition of targeted therapies and immunotherapies. However, improvements in tools for early detection hold promise. The Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial recently corroborated the findings from the previous National Lung Screening Trial low‐dose Computerised Tomography (NLST) screening trial in reducing lung cancer mortality. Biomarker research and development is increasing at pace as the molecular life histories of lung cancers become further unravelled. Low‐dose CT screening (LDCT) is effective but targets only those at the highest risk and is burdensome on healthcare. An optimally designed CT screening programme at best will only detect a low proportion of overall lung cancers as only those at very high‐risk meet screening criteria. Biomarkers that help risk stratify suitable patients for LDCT screening, and those that assist in determining which LDCT detected nodules are likely to represent malignant disease are needed. Some biomarkers have been proposed as standalone lung cancer diagnosis tools. Bronchoscopy technology is improving, with better capacity to identify and obtain samples from early lung cancers. Clinicians need to be aware of each early lung cancer detection method’s inherent limitations. We anticipate that the future of early lung cancer diagnosis will involve a synergistic, multimodal approach, combining several early detection methods.

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.

Lung cancer awareness and palliative care interventions implemented in low-and middle-income countries: a scoping review

BACKGROUND

Lung cancer is the most diagnosed cancer worldwide. In low- and middle-income countries (LMICs), lung cancer is often diagnosed at a late stage due to poor knowledge and awareness of its signs and symptoms. Increasing lung cancer awareness is likely to reduce the diagnosis and treatment delays. The implementation of early palliative care has also been reported to improve a patient's quality of life, and even survival. The aim of this scoping review was to map evidence on lung cancer awareness and palliative care interventions implemented in sub-Saharan Africa (SSA) and other LMICs.

METHODS

This scoping review was guided by Arksey and O'Malley's framework. Databases such as the EBSCOhost, PubMed, Science Direct, Google Scholar, World Health Organization (WHO) library and grey literature were used to perform systematic searches of relevant articles. The methodological quality assessment of included primary studies was assessed using the Mixed Method Appraisal Tool (MMAT). NVivo version 10 software was used to perform the thematic content analysis of the included studies.

RESULTS

A total number of screened articles was 2886, with 236 meeting the eligibility criteria and 167 further excluded following abstract screening. Sixty-nine (69) articles qualified for full-article screening and 9 were selected for detailed data extraction and methodological quality assessment. Of the included nine studies, eight described at least one lung cancer warning signs and symptoms, while one described the effectiveness of palliative care for lung cancer. Eight articles recognized the level of lung cancer knowledge, risk factors awareness of warning signs and symptoms in LMICs, mostly Africa and Asia.

CONCLUSIONS

Most of the participants were aware of tobacco use as the major risk factor for lung cancer but lacked knowledge on the other pre-disposing risk factors. Evidence on palliative care is scarce, therefore, awareness interventions packaged with evidence on the value of timely access to palliative care services in improving the quality of life of the lung cancer patients and their families, are required.

The pathway to diagnosis and treatment for surgically managed lung cancer patients

BACKGROUND

Most lung cancer is diagnosed at an advanced stage, resulting in poor survival. This study examined diagnostic pathways for patients with operable lung cancer to identify factors contributing to early diagnosis.

METHODS

Surgically treated lung cancer patients (aged ≥40, within 6 months of diagnosis), approached via the population-based Cancer Registry, with their primary care physicians (PCPs) and specialists completed cross-sectional surveys assessing symptoms, diagnostic route (symptomatic or 'investigation' of other problem), tests, key event dates and treatment. Time intervals to diagnosis and treatment were determined, and quantile regression examined differences between the two diagnostic routes. Cox proportional hazard regression analyses examined associations between survival and diagnostic route adjusting for stage, sex and age.

RESULTS

One hundred and ninety-two patients (36% response rate), 107 PCPs and 55 specialists participated. Fifty-eight per cent of patients had a symptomatic diagnostic route reporting an average of 1.6 symptoms, most commonly cough, fatigue or haemoptysis. Symptomatic patients had longer median primary care interval than 'investigation' patients (12 versus 9 days, P < 0.05) and were more likely to report their PCP first-ordered imaging tests. Secondary care interval was shorter for symptomatic (median = 43 days) than investigation (median = 62 days, P < 0.05) patients. However, 56% of all patients waited longer than national recommendations (6 weeks). While survival estimates were better for investigation than symptomatic patients, these differences were not significant.

CONCLUSION

Many operable lung cancer patients are diagnosed incidentally, highlighting the difficulty of symptom-based approaches to diagnosing early stage disease. Longer than recommended secondary care interval suggests the need for improvements in care pathways.

Patterns of symptoms possibly indicative of cancer and associated help-seeking behaviour in a large sample of United Kingdom residents-The USEFUL study

BACKGROUND

Cancer awareness campaigns aim to increase awareness of the potential seriousness of signs and symptoms of cancer, and encourage their timely presentation to healthcare services. Enhanced understanding of the prevalence of symptoms possibly indicative of cancer in different population subgroups, and associated general practitioner (GP) help-seeking behaviour, will help to target cancer awareness campaigns more effectively.

AIM

To determine: i) the prevalence of 21 symptoms possibly indicative of breast, colorectal, lung or upper gastrointestinal cancer in the United Kingdom (UK), including six 'red flag' symptoms; ii) whether the prevalence varies among population subgroups; iii) the proportion of symptoms self-reported as presented to GPs; iv) whether GP help-seeking behaviour varies within population subgroups.

METHODS

Self-completed questionnaire about experience of, and response to, 25 symptoms (including 21 possibly indicative of the four cancers of interest) in the previous month and year; sent to 50,000 adults aged 50 years or more and registered with 21 general practices in Staffordshire, England or across Scotland.

RESULTS

Completed questionnaires were received from 16,778 respondents (corrected response rate 34.2%). Almost half (45.8%) of respondents had experienced at least one symptom possibly indicative of cancer in the last month, and 58.5% in the last year. The prevalence of individual symptoms varied widely (e.g. in the last year between near zero% (vomiting up blood) and 15.0% (tired all the time). Red flag symptoms were uncommon. Female gender, inability to work because of illness, smoking, a history of a specified medical diagnosis, low social support and lower household income were consistently associated with experiencing at least one symptom possibly indicative of cancer in both the last month and year. The proportion of people who had contacted their GP about a symptom experienced in the last month varied between 8.1% (persistent cough) and 39.9% (unexplained weight loss); in the last year between 32.8% (hoarseness) and 85.4% (lump in breast). Nearly half of respondents experiencing at least one red flag symptom in the last year did not contact their GP about it. Females, those aged 80+ years, those unable to work because of illness, ex-smokers and those previously diagnosed with a specified condition were more likely to report a symptom possibly indicative of cancer to their GP; and those on high household income less likely.

CONCLUSION

Symptoms possibly indicative of cancer are common among adults aged 50+ years in the UK, although they are not evenly distributed. Help-seeking responses to different symptoms also vary. Our results suggest important opportunities to provide more nuanced messaging and targeting of symptom-based cancer awareness campaigns.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Engaging high-risk groups in early lung cancer diagnosis: a qualitative study of symptom presentation and intervention preferences among the UK's most deprived communities

OBJECTIVES

People at high-risk for lung cancer-current/former smokers, aged 40+ years, with serious lung comorbidity (ie, chronic obstructive pulmonary disease) and living in highly deprived areas-are more likely to delay symptom presentation. This qualitative study aimed to understand the influences on early presentation with lung cancer symptoms in high-risk individuals and intervention preferences.

METHODS

Semi-structured qualitative interviews with 37 high-risk individuals (without a cancer diagnosis), identified through seven GP practices in socioeconomically deprived areas of England, Scotland and Wales (most deprived 20%). A symptom attribution task was used to explore lung symptom perception and help seeking, developed using Leventhal's Common Sense Model. Four focus groups with 16 high-risk individuals and 12 local stakeholders (healthcare professionals and community partners) were conducted to explore preferences for an intervention to promote early lung cancer symptom presentation. Data were synthesised using Framework analysis.

RESULTS

Individual and area level indicators of deprivation confirmed that interview participants were highly deprived. Interviews. Preoccupation with managing 'treatable' short-term conditions (chest infections), led to avoidance of acting on 'inevitable and incurable' long-term conditions (lung cancer). Feeling judged and unworthy of medical help because of their perceived social standing or lifestyle deterred medical help seeking, particularly when difficult life circumstances and traumatic events led to tobacco and alcohol addiction. Focus groups. Participants recommended multifaceted interventions in community venues, with information about lung cancer symptoms and the benefits of early diagnosis, led by a trained and non-judgemental facilitator.

CONCLUSIONS

This study was novel in engaging a high-risk population to gain an in-depth understanding of the broader contextual influences on lung cancer symptom presentation. Perceived lack of health service entitlement and complex lives facilitated avoidance of recognising and presenting with lung cancer symptoms. Community-based interventions have the potential to empower disadvantaged populations to seek medical help for lung symptoms.

Lung cancer symptom appraisal among people with chronic obstructive pulmonary disease: A qualitative interview study

OBJECTIVE

The incidence of lung cancer is four times higher in people with chronic obstructive pulmonary disease (COPD) compared with the general population. Promotion of a shorter time from symptom onset to presentation is one potential strategy for earlier lung cancer diagnosis, but distinguishing respiratory symptoms can be difficult. We investigated how the experience of COPD influences symptom appraisal and help seeking for potential lung cancer symptoms.

METHODS

We conducted qualitative interviews with men (n = 17) and women (n = 23) aged 40 to 83 years with COPD. Topic guides drew on the integrated symptom-response framework and covered symptom experience, interpretation, action, recognition, help seeking, evaluation, and reevaluation. We used the framework method to analyse the data.

RESULTS

Participants said that they attributed chest symptoms to their COPD; no other cause was considered. Participants said that family/friends noticed changes in their symptoms and encouraged help seeking. Others felt isolated by their COPD because they could not get out, were fatigued, or were embarrassed. Participants visited health professionals frequently, but increased risk of lung cancer was not discussed.

CONCLUSIONS

Our study provides insight into different levels of influence on symptom appraisal and targets for intervention. Greater awareness of increased lung cancer risk and support to act on symptom changes is essential and could be achieved through a concerted information campaign. Health professionals working with people with COPD could also optimise appointments to support symptom appraisal of potential lung cancer symptoms.

Cough in pulmonary tuberculosis: Existing knowledge and general insights

Cough is a prominent symptom of pulmonary tuberculosis (TB), one of the oldest and most prevalent infectious diseases. Coughing probably has a pivotal role in transmission of the causative organism Mycobacterium tuberculosis. Despite this, little research to date has addressed this subject. Current knowledge of the mechanisms of cough in TB and how exactly coughing patterns predict infectiousness is scant, but this is changing. This overview summarises the existing evidence for the infectiousness of cough in TB, clinical correlates, and possible causes of cough in TB. Potential unique characteristics of cough in the disease are discussed, as is treatment and the subjective awareness of coughing in the disease.

Patient and carer perceived barriers to early presentation and diagnosis of lung cancer: a systematic review

Background

Lung cancer is typically diagnosed at a late stage. Early presentation and detection of lung cancer symptoms is critical to improving survival but can be clinically complicated and as yet a robust screening method for diagnosis is not available in routine practice. Accordingly, the barriers to help-seeking behaviour and diagnosis need to be considered. This review aimed to document the barriers to early presentation and diagnosis of lung cancer, based on patient and carer perspectives.

Methods

A systematic review of databases was performed for original, English language articles discussing qualitative research on patient perceived barriers to early presentation and diagnosis of lung cancer. Three major databases were searched: Scopus, PubMed and EBSCOhost. References cited in the selected studies were searched for further relevant articles.

Results

Fourteen studies met inclusion criteria for review. Barriers were grouped into three categories: healthcare provider and system factors, patient factors and disease factors.

Conclusions

Studies showed that the most frequently reported barriers to early presentation and diagnosis of lung cancer reported by patients and carers related to poor relationships between GPs and patients, a lack of access to services and care for patients, and a lack of awareness of lung cancer symptoms and treatment. Addressing these barriers offers opportunities by which rates of early diagnosis of lung cancer may be improved.

Do pharmacists contribute to patients' management of symptoms suggestive of cancer: a qualitative study

OBJECTIVES

Limited awareness of cancer symptoms results in patient delay in seeking help and contributes to delay in diagnosis. Few UK studies have investigated the potential for community pharmacists to facilitate earlier detection of cancer. This study aimed to investigate what actions patients take to manage their early cancer symptoms, to identify the extent of current community pharmacy involvement and to consider the potential role for community pharmacists to facilitate appropriate management and appraisal of potential early cancer symptoms.

METHODS

Patients diagnosed with lung, colorectal or gastro-oesophageal cancer in the preceding 12 months were identified during clinic visits by consultants. Semi-structured interviews were conducted, audio-recorded, transcribed and thematically analysed, using the Framework Approach.

KEY FINDINGS

Twenty-five consenting patients were interviewed: two-thirds were male and more than half had lung cancer. Although all had experienced potential cancer symptoms prior to diagnosis, most underestimated seriousness and misattributed causation. Symptoms were managed by lifestyle changes and self-selecting medicines from local shops, supermarkets and pharmacies but without engaging with the pharmacist.

CONCLUSIONS

For symptom management, participants self-selected medicines from community pharmacies, but pharmacy staff were rarely involved. Involving community pharmacists or their staff at the point of sale of these medicines might have facilitated earlier cancer diagnosis. Further research is needed to quantify how many patients with symptoms suggestive of cancer present in community pharmacies to understand if a pharmacist's role in facilitating symptom management and appraisal of potential cancer symptoms would be acceptable and effective, before developing any interventions.

Times to Diagnosis and Treatment of Lung Cancer in New South Wales, Australia: A Multicenter, Medicare Data Linkage Study

INTRODUCTION

Earlier access to lung cancer specialist (LCS) care improves survival. We examined times to diagnosis and treatment of patients with lung cancer in rural and metropolitan New South Wales (NSW) Australia, benchmarked against recent timeframe recommendations.

MATERIALS AND METHODS

Semistructured interviews of recently diagnosed patients with lung cancer from five NSW cancer centers were used to determine standardized time intervals to diagnosis and treatment, triangulated with Medicare data linkage and medical records. We used descriptive statistics to evaluate the primary end points of median time intervals from general practitioner (GP) referral to first LCS visit (GP-LCS interval) and to treatment start (Secondary Care interval). Univariable and multivariable analyses were used to study associations with delays in end points. Post hoc survival analyses were performed.

RESULTS

Data linkage was performed for 125 patients (68% stage IV; 69% metropolitan), with 108 interviewed. The median GP-LCS interval was 4 days, with 83% of patients seeing an LCS within the recommended 14 days. The median Secondary Care interval was 42 days (52% within 42 days). There were no significant differences between time intervals faced by rural and metropolitan patients overall, although metropolitan patients took 18 days less than rural counterparts to commence radiation/chemoradiation (95% CI, -33.2 to -2.54; P = .02). One third of patients perceived delays. Delays did not affect survival.

CONCLUSION

Rural and metropolitan NSW patients face comparable time lines to diagnosis and treatment of lung cancer. Most patients are seen by an LCS within recommended timeframes, but transition through Secondary Care and addressing patient expectations could be improved.

How long is too long? A scoping review of health system delays in lung cancer

Earlier access to lung cancer specialist (LCS) care improves survival, highlighting the need for streamlined patient referral. International guidelines recommend 14-day maximum time intervals from general practitioner (GP) referral to first LCS appointment (“GP–LCS interval”), and diagnosis to treatment (“treatment interval”). We compared time intervals in lung cancer care against timeframe benchmarks, and explored barriers and facilitators to timely care.

We conducted a scoping review of literature from MEDLINE, Embase, Scopus and hand searches. Primary end-points were GP–LCS and treatment intervals. Performance against guidelines and factors responsible for delays were explored. We used descriptive statistics and nonparametric Wilcoxon rank sum tests to compare intervals in studies reporting fast-track interventions.

Of 1343 identified studies, 128 full-text articles were eligible. Only 33 (26%) studies reported GP–LCS intervals, with an overall median of 7 days and distributions largely meeting guidelines. Overall, 52 (41%) studies reported treatment intervals, with a median of 27 days, and distributions of times falling short of guidelines. There was no effect of fast-track interventions on reducing time intervals. Lack of symptoms and multiple procedures or specialist visits were suggested causes for delay.

Although most patients with lung cancer see a specialist within a reasonable timeframe, treatment commencement is often delayed. There is regional variation in establishing timeliness of care.

Delays to lung cancer care occur, especially in secondary care; variation in timeframe guidelines needs addressinghttp://ow.ly/hZt730kvKAb

Do comorbidities influence help-seeking for cancer alarm symptoms? A population-based survey in England

Background

We examined associations between different chronic morbidities and help-seeking for possible cancer symptoms.

Methods

Postal survey of individuals aged >50 years in England. Participants could report prior morbidities in respect of 12 pre-defined conditions. Among patients experiencing possible cancer symptoms we examined associations between specific morbidities and self-reported help-seeking (i.e. contacted versus not contacted a GP) for each alarm symptom using regression analyses.

Results

Among 2042 respondents (42% response rate), 936 (46%) recently experienced 1 of 14 possible cancer symptoms considered in our analysis. Of them, 80% reported one or more morbidities, most frequently hypertension/hypercholesterolemia (40%), osteomuscular (36%) and heart diseases (21%). After adjustment for socio-demographic characteristics, patients with hypertension/hypercholesterolemia were more likely to report help-seeking for possible cancer symptoms, such as unexplained cough (OR = 2.0; 95% confidence interval (CI) 1.1-3.5), pain (OR = 2.2; 95% CI 1.0-4.5) and abdominal bloating (OR = 2.3; 95% CI 1.1-4.8). Urinary morbidity was associated with increased help-seeking for abdominal bloating (OR = 5.4; 95% CI 1.2-23.7) or rectal bleeding (OR = 5.8; 95% CI 1.4-23.8). In contrast, heart problems reduced help-seeking for change in bowel habits (OR = 0.4; 95% CI 0.2-1.0).

Conclusions

Comorbidities are common and may facilitate help-seeking for possible cancer symptoms, but associations vary for specific symptom-comorbidity pairs. The findings can contribute to the design of future cancer symptom awareness campaigns.

Mass media and risk factors for cancer: the under-representation of age

BACKGROUND

Increasing age is a risk factor for developing cancer. Yet, older people commonly underestimate this risk, are less likely to be aware of the early symptoms, and are more likely to be diagnosed with advanced stage cancer. Mass media are a key influence on the public's understanding health issues, including cancer risk. This study investigates how news media have represented age and other risk factors in the most common cancers over time.

METHODS

Eight hundred articles about the four most common cancers (breast, prostate, lung and colorectal) published within eight UK national newspapers in 2003, 2004, 2013 and 2014 were identified using the Nexis database. Relevant manifest content of articles was coded quantitatively and subjected to descriptive statistical analysis in SPSS to identify patterns across the data.

RESULTS

Risk was presented in half of the articles but this was rarely discussed in any depth and around a quarter of all articles introduced more than one risk factor, irrespective of cancer site. Age was mentioned as a risk factor in approximately 12% of all articles and this varied by cancer site. Age was most frequently reported in relation to prostate cancer and least often in articles about lung cancer. Articles featuring personal narratives more frequently focused on younger people and this was more pronounced in non-celebrity stories; only 15% of non-celebrity narratives were about people over 60. Other common risks discussed were family history and genetics, smoking, diet, alcohol, and environmental factors. Family history and genetics together featured as the most common risk factors. Risk factor reporting varied by site and family history was most commonly associated with breast cancer, diet with bowel cancer and smoking with lung cancer.

CONCLUSION

Age and older adults were largely obscured in media representation of cancer and cancer experience. Indeed common risk factors in general were rarely discussed in any depth. Our findings will usefully inform the development of future cancer awareness campaigns and media guidelines. It is important that older adults appreciate their heightened risk, particularly in the context of help-seeking decisions.

Does gender matter? An analysis of men's and women's accounts of responding to symptoms of lung cancer

Men are often portrayed - in research studies, 'common-sense' accounts and popular media - as reluctant users of health services. They are said to avoid going to the GP whenever possible, while women are portrayed, in presumed opposition, as consulting more readily, more frequently and with less serious complaints. Such stereotypes may inadvertently encourage doctors to pay greater heed to men's symptoms in 'routine' consultations. Although previous research has challenged this view with evidence, and suggested that links between gender identities and help-seeking are complex and fluid, gender comparative studies remain uncommon, and particularly few studies (either qualitative or quantitative) compare men and women with similar morbidity. We contribute here to gender comparative research on help-seeking by investigating men's and women's accounts of responding to symptoms later diagnosed as lung cancer. A secondary analysis of qualitative interviews with 27 men and 18 women attending Scottish cancer centres revealed striking similarities between men's and women's accounts. Participants were seen as negotiating a complex and delicate balance in constructing their moral integrity as, on the one hand, responsible service users who were conscious of the demands on health care professionals' time, and as patients who did not take undue risks with their health, in the context of an illness for which people are often held culpable, on the other. In accounting for their responses to symptoms, men and women drew equally on culturally-embedded moral frameworks of stoicism and responsible service use. Regardless of gender, the accounts portrayed participants as stoic in response to illness and responsible service users; and as people seeking explanations for bodily changes and taking appropriate and timely action. Our analysis challenges simplistic, 'common-sense' views of gendered help-seeking and highlights that both men and women need support to consult their doctor for investigation of significant or concerning bodily changes.

Experience of, awareness of and help-seeking for potential cancer symptoms in smokers and non-smokers: A cross-sectional study

Background

Presenting to primary care with potential cancer symptoms is contingent on one’s ability to recognize potentially serious symptoms. We investigated differences between smokers and non-smokers in symptoms experienced, awareness and consulting of potential respiratory, head and neck cancer symptoms.

Methods

Smokers and non-smokers aged over 50 from Yorkshire general practice lists were sent a postal questionnaire asking about symptoms, consulting and awareness of cancer symptoms. Data were analysed using STATA14.

Results

Response rate after one reminder was 30.5% (1205/3954). Smoking status was associated with experience of cough (p<0.001), breathlessness (p = 0.002) and tiredness (p = 0.004) with smokers (25.8% of population) more likely than never-smokers (53.6% of population) to experience all three symptoms (cough OR = 2.56;95%CI[1.75–3.75], breathlessness OR = 2.39;95%CI[1.43–4.00], tiredness OR = 1.57;95%CI[1.12–2.19]). Smoking status was associated with awareness of breathlessness as a potential cancer symptom (p = 0.035) and consulting for cough (p = 0.011) with smokers less likely to consult than never-smokers (OR = 0.37;95% CI[0.17–0.80]).

Conclusion

Our findings suggest that current smokers are more likely to experience cough, breathlessness and tiredness, but are less likely to consult for cough than never-smokers. To increase cancer awareness and promote consulting among smokers, innovative interventions improving symptom recognition and empowering smokers to seek help are required.

Measures of psychosocial factors that may influence help-seeking behaviour in cancer: A systematic review of psychometric properties

Advanced stage cancer is frequently attributed to delays in presentation to a healthcare professional. To reduce undue delay, it is imperative to understand the reasons underlying help-seeking behaviour and to measure those using valid and reliable tools. This systematic review aimed to identify how studies have measured psychosocial factors affecting time to presentation for (potential) cancer symptoms. A total of 35 studies were included. Most studies failed to use valid and reliable tools, and predominantly provided inconclusive results regarding psychosocial factors and time to presentation when no or minimal psychometric evidence was present. Consequently, measure selection and future measure development should be guided by psychometric principles.

Facilitating early diagnosis of lung cancer amongst primary care patients: The views of GPs

Early diagnosis of lung cancer (LC) is a policy priority. However, symptoms are vague, associated with other morbidities, and frequently unrecognised by both patients and general practitioners (GPs). This qualitative study, part of a larger mixed methods study, explored GP views regarding the potential for early diagnosis of LC within primary care. Five focus group discussions (FGDs) were conducted with GPs (n = 16) at primary care practices (n = 5) across four counties in south England. FGDs were audio‐recorded, transcribed verbatim and analysed using a framework approach. Four broad themes emerged: patients’ reporting of symptoms; GP response to symptoms; investigating LC, and; potential initiatives for early diagnosis. GPs reported they often required high levels of suspicion to refer patients on to specialist respiratory consultations, and concerns of ‘system overload’ were prevalent. Greater access to more sensitive diagnostic investigations such as computed tomography, was argued for by some, particularly for symptomatic patients with negative chest X‐rays. GPs challenged current approaches to promoting earlier diagnosis through national symptom awareness campaigns, arguing instead that interventions targeted at high‐risk individuals might be more effective without burdening services already under pressure. Further work is needed to identify primary care patients who might most benefit from such targeted interventions.

Promoting Help-Seeking in Response to Symptoms amongst Primary Care Patients at High Risk of Lung Cancer: A Mixed Method Study

BACKGROUND

Lung cancer symptoms are vague and difficult to detect. Interventions are needed to promote early diagnosis, however health services are already pressurised. This study explored symptomology and help-seeking behaviours of primary care patients at 'high-risk' of lung cancer (≥50 years old, recent smoking history), to inform targeted interventions.

METHODS

Mixed method study with patients at eight general practitioner (GP) practices across south England. Study incorporated: postal symptom questionnaire; clinical records review of participant consultation behaviour 12 months pre- and post-questionnaire; qualitative participant interviews (n = 38) with a purposive sample.

RESULTS

A small, clinically relevant group (n = 61/908, 6.7%) of primary care patients was identified who, despite reporting potential symptoms of lung cancer in questionnaires, had not consulted a GP ≥12 months. Of nine symptoms associated with lung cancer, 53.4% (629/1172) of total respondents reported ≥1, and 35% (411/1172) reported ≥2. Most participants (77.3%, n = 686/908) had comorbid conditions; 47.8%, (n = 414/908) associated with chest and respiratory symptoms. Participant consulting behaviour significantly increased in the 3-month period following questionnaire completion compared with the previous 3-month period (p = .002), indicating questionnaires impacted upon consulting behaviour. Symptomatic non-consulters were predominantly younger, employed, with higher multiple deprivation scores than their GP practice mean. Of symptomatic non-consulters, 30% (18/61) consulted ≤1 month post-questionnaire, with comorbidities subsequently diagnosed for five participants. Interviews (n = 39) indicated three overarching differences between the views of consulting and non-consulting participants: concern over wasting their own as well as GP time; high tolerance threshold for symptoms; a greater tendency to self-manage symptoms.

CONCLUSIONS

This first study to examine symptoms and consulting behaviour amongst a primary care population at 'high- risk' of lung cancer, found symptomatic patients who rarely consult GPs, might respond to a targeted symptom elicitation intervention. Such GP-based interventions may promote early diagnosis of lung cancer or other comorbidities, without burdening already pressurised services.

Socio-economic inequalities in stage at diagnosis, and in time intervals on the lung cancer pathway from first symptom to treatment: systematic review and meta-analysis

Cancer diagnosis at an early stage increases the chance of curative treatment and of survival. It has been suggested that delays on the pathway from first symptom to diagnosis and treatment may be socio-economically patterned, and contribute to socio-economic differences in receipt of treatment and in cancer survival. This review aimed to assess the published evidence for socio-economic inequalities in stage at diagnosis of lung cancer, and in the length of time spent on the lung cancer pathway. MEDLINE, EMBASE and CINAHL databases were searched to locate cohort studies of adults with a primary diagnosis of lung cancer, where the outcome was stage at diagnosis or the length of time spent within an interval on the care pathway, or a suitable proxy measure, analysed according to a measure of socio-economic position. Meta-analysis was undertaken when there were studies available with suitable data. Of the 461 records screened, 39 papers were included in the review (20 from the UK) and seven in a final meta-analysis for stage at diagnosis. There was no evidence of socio-economic inequalities in late stage at diagnosis in the most, compared with the least, deprived group (OR=1.04, 95% CI=0.92 to 1.19). No socio-economic inequalities in the patient interval or in time from diagnosis to treatment were found. Socio-economic inequalities in stage at diagnosis are thought to be an important explanatory factor for survival inequalities in cancer. However, socio-economic inequalities in stage at diagnosis were not found in a meta-analysis for lung cancer.

PROSPERO PROTOCOL REGISTRATION NUMBER

CRD42014007145.

Knowledge of the signs and symptoms and risk factors of lung cancer in Australia: mixed methods study

BACKGROUND

Lung cancer is the leading cause of cancer death in Australia. There is potential that health promotion about the risks and warning signs of lung cancer could be used to reduce delays in symptom presentation when symptoms are first detected. This study investigated knowledge, attitudes and beliefs which might impact help-seeking behaviour and could provide insight into possible public health interventions in New South Wales (NSW).

METHODS

A convergent mixed method study design was used wherein data from 16 qualitative focus groups of residents (40+ years), purposefully recruited and stratified by smoking status, age and geography (metropolitan/regional), were compared with a CATI administered population-wide telephone survey (n = 1,000) using the Cancer Research UK cancer awareness measure (LungCAM). Qualitative findings were analysed thematically using NVIVO. Logistic regression analysis was used to investigate predictors of symptom knowledge in STATA. Findings were integrated using triangulation techniques.

RESULTS

Across focus groups, haemoptysis was the only symptom creating a sense of medical urgency. Life experiences evoked a 'wait and see' attitude to any health deterioration. Perceived risk was low amongst those at risk with current smokers preferring to deny their risk while former smokers were generally unaware of any ongoing risk. The quantitative sample consisted of females (62 %), 40-65 years (53 %), low SES (53 %), former (46 %) and current smokers (14 %). In quantitative findings, haemoptysis and dyspnoea were the most recognised symptoms across the sample population. Age (<65 years), sex (female) and high socio-economic status contributed to a higher recognition of symptoms. Smoking was recognised as a cause of lung cancer, yet ever-smokers were less likely to recognise the risk of lung cancer due to second-hand smoke (OR 0.7 95 % CI 0.5-0.9).

CONCLUSION

While there was some recognition of risk factors and symptoms indicative of lung cancer, there was disparity across the sample population. The qualitative findings also suggest that knowledge may not lead to earlier presentation; a lack of urgency about symptoms considered trivial, and smoking-related barriers such as stigma may also contribute to time delays in presentation. Public health interventions may be required to increase awareness of risk and emphasise the importance of seeking medical attention for ongoing symptoms.

Lifestyle factors and contact to general practice with respiratory alarm symptoms-a population-based study

Background

A prerequisite for early lung cancer diagnosis is that individuals with respiratory alarm symptoms (RAS) contact a general practitioner (GP). This study aims to determine the proportion of individuals in the general population who contact a GP with RAS and to analyse the association between lifestyle factors and contact to GPs with RAS.

Methods

A web-based survey of 100 000 individuals randomly selected from the Danish Civil Registration System. Items regarding experience of RAS (prolonged coughing, shortness of breath, coughing up blood, and prolonged hoarseness), GP contacts, and lifestyle factors (smoking status, alcohol intake, and body mass index) were included.

Results

In total 49 706 (52.5 %) individuals answered the questionnaire. Overall 7870 reported at least one respiratory alarm symptom, and of those 39.6 % (3 080) had contacted a GP. Regarding specific symptoms, the proportion of individuals that had contacted a GP varied from 27.4 % (prolonged hoarseness) to 47.9 % (shortness of breath). Being a woman and increasing age were significantly associated with a higher proportion of GP contacts. For both genders, current smoking and alcohol intake were significantly associated with lower odds of contacting a GP.

Conclusion

Among individuals with RAS, less than one-half contacted a GP. Gender, age, smoking status, and alcohol intake significantly influenced whether individuals with RAS contacted a GP.

Trial registration

The project has been approved by the Danish Data Protection Agency (journal no. 2011-41-6651).

Patients With Advanced Non-Small Cell Lung Cancer Requiring Inpatient Medical Oncology Consultation: Characteristics, Referral Patterns, and Outcomes

BACKGROUND

Patients with advanced non-small cell lung cancer (NSCLC) occasionally are hospitalized at the time of initial medical oncology consultation. We investigated the characteristics and outcomes of this population.

METHODS

With ethics approval, we performed a retrospective analysis of patients with advanced NSCLC at our institution whose initial consult occurred while hospitalized from 2007 to 2012. This was an exploratory analysis. Multivariate survival analysis was performed using Cox regression models.

RESULTS

A total of 223 patients were included. Baseline demographics were as follows: median age, 65 years; 52% were female; median Charlson Comorbidity Index of 10; 69% performance status (PS) 3 to 4; 49% were current smokers; 90% had stage IV disease; and 52% had ≥ 5% weight loss. Only 24% received chemotherapy. Among those treated, the median time from diagnosis to chemotherapy was 43 days. Common reasons for not receiving chemotherapy included poor PS (72%) and patient choice (9%). Factors associated with receiving chemotherapy in multivariate analysis were good PS (odds ratio [OR], 9.01; 95% confidence interval [CI], 3.55-23.26; P < .001), no leukocytosis (OR, 3.56; 95% CI, 1.35-9.35; P = .01), and age < 70 years (OR, 6.80; 95% CI, 1.78-26.32; P = .005). Factors associated with shorter overall survival in multivariate analysis were not receiving chemotherapy (hazard ratio [HR], 2.11; 95% CI, 1.28-3.48; P = .003), PS 3 to 4 (HR, 1.51; 95% CI, 1.01-2.26; P = .045), leukocytosis (HR, 2.13; 95% CI, 1.44-3.13; P < .001), and thrombocytosis (HR, 1.46; 95% CI, 1.03-2.09; P = .036).

CONCLUSIONS

Patients whose first consultation with medical oncologists occurs while hospitalized are an inherently sick population. Earlier diagnosis and referral would give more patients access to treatment options before a terminal functional decline.

Lifestyle factors and experience of respiratory alarm symptoms in the general population

Background

The first step in the diagnosis of lung cancer is for individuals in the general population to recognise respiratory alarm symptoms (RAS). Knowledge is sparse about RAS and factors associated with experiencing RAS in the general population. This study aimed to estimate the prevalence of RAS in the general population, and to analyse possible associations between lifestyle factors and experiencing RAS.

Methods

A web-based survey comprising 100 000 individuals randomly selected from the Danish Civil Registration System. Items regarding experience of RAS (prolonged coughing, shortness of breath, coughing up blood and prolonged hoarseness) and self-reported lifestyle factors (smoking status, alcohol intake and body mass index) were included in the analysis.

Results

A total of 49 706 individuals completed the questionnaire. 16 per cent reported at least one RAS. Prolonged coughing (8.4%) and shortness of breath (8%) were most prevalent, while coughing up blood was least prevalent (0.1%). More men than women reported RAS (p<0.001). Odds of reporting RAS increased with age (P_trend<0.001). In men and women, former and current smoking was associated with reporting at least one RAS (former smoking: OR_men=1.42, 95% CI 1.39 to 1.56; OR_women=1.25, 95% CI 1.15 to 1.36; current smoking: OR_men=2.58, 95% CI 2.35 to 2.83; OR_women=2.45, 95% CI 2.25 to 2.68). Individuals who were underweight or obese were significantly more likely to report at least one RAS. Odds of reporting at least one RAS increased with increasing alcohol intake for both genders (P_trend<0.001).

Conclusions

RAS are common in the general population. Men experience more symptoms than women, and prevalence increases with age. Being a former or current smoker and being underweight or obese are positively associated with experiencing RAS. The likelihood of experiencing RAS increases with increasing alcohol intake. Future research should investigate healthcare seeking for RAS among individuals with different lifestyles.

The effect of socioeconomic status on health-care delay and treatment of esophageal cancer

Background

Socioeconomic status (SES) has been focused on as a key determinant of the incidence of cancer, cancer stage at diagnosis as well as treatment choices in western countries. However, to the authors’ knowledge, little work has been done concerning the relationship of SES and esophageal cancer in China.

Methods

Patients diagnosed with primary esophageal cancer from January to December 2007 in Qilu hospital were included. Socioeconomic status was determined by a questionnaire including religion, years of schooling and high education, place of residence, occupation, annual household income, and insurance.

Results

A total of 238 cases were collected in this study. Linear-by-linear association testing revealed that health-care delay was significantly associated with SES (P = 0.009). Multivariable logistic regression analysis revealed that increased health-care delay (>2 months) was more frequently observed in patients with lower SES (OR 2.271; 95% CI 1.069–4.853). Patients diagnosed at TNM I and II were more frequently in higher SES groups (P = 0.017). The association test was statistically significant for undergoing surgical resection only (P = 0.015) and chemotherapy (P = 0.015). Multivariable logistic regression analysis revealed that surgical resection only was less performed in higher SES group compared with lower SES group (OR 0.372; 95% CI 0.188–0.734). For chemotherapy, higher SES patients had a three-fold higher likelihood compared with lower SES group (OR 3.042; 95% CI 1.335–6.928).

Conclusion

Socioeconomic status was found to be associated with health-care delay, tumor stage and treatment modalities in esophageal cancer.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-015-0579-9) contains supplementary material, which is available to authorized users.

Protocol for the CHEST Australia Trial: a phase II randomised controlled trial of an intervention to reduce time-to-consult with symptoms of lung cancer

INTRODUCTION

Lung cancer is the most common cancer worldwide, with 1.3 million new cases diagnosed every year. It has one of the lowest survival outcomes of any cancer because over two-thirds of patients are diagnosed when curative treatment is not possible. International research has focused on screening and community interventions to promote earlier presentation to a healthcare provider to improve early lung cancer detection. This paper describes the protocol for a phase II, multisite, randomised controlled trial, for patients at increased risk of lung cancer in the primary care setting, to facilitate early presentation with symptoms of lung cancer.

METHODS/ANALYSIS

The intervention is based on a previous Scottish CHEST Trial that comprised of a primary-care nurse consultation to discuss and implement a self-help manual, followed by self-monitoring reminders to improve symptom appraisal and encourage help-seeking in patients at increased risk of lung cancer. We aim to recruit 550 patients from two Australian states: Western Australia and Victoria. Patients will be randomised to the Intervention (a health consultation involving a self-help manual, monthly prompts and spirometry) or Control (spirometry followed by usual care). Eligible participants are long-term smokers with at least 20 pack years, aged 55 and over, including ex-smokers if their cessation date was less than 15 years ago. The primary outcome is consultation rate for respiratory symptoms.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from The University of Western Australia's Human Research Ethics Committee (RA/4/1/6018) and The University of Melbourne Human Research Committee (1 441 433). A summary of the results will be disseminated to participants and we plan to publish the main trial outcomes in a single paper. Further publications are anticipated after further data analysis. Findings will be presented at national and international conferences from late 2016.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry ACTRN 1261300039 3752.

Smoking is associated with pessimistic and avoidant beliefs about cancer: results from the International Cancer Benchmarking Partnership

Background:

Smoking cessation is the key cancer prevention behaviour for smokers; nonetheless, smokers can still benefit from earlier diagnosis of cancer. However, fewer smokers participate in screening despite their increased risk, which may reflect different beliefs about cancer.

Methods:

A UK population-representative sample of ⩾50 year-olds (n=6965) was surveyed using the Awareness and Beliefs about Cancer measure. These analyses examine six items on cancer beliefs (e.g., ‘cancer can often be cured'), and four on help-seeking barriers (e.g., ‘I would be too embarrassed').

Results:

Smokers were more likely to hold pessimistic cancer beliefs than never-smokers or former-smokers on four of six items. For example, 34% agreed ‘a cancer diagnosis is a death sentence', compared with 24% of non/former-smokers (P<0.001). More smokers (18%) than non/former-smokers (11%) would not want to know if they had cancer (P<0.01). The only barrier to symptomatic help-seeking differing by smoking status was ‘worry about what the doctor might find' (36% vs 28%, P<0.01). Associations were independent of demographics, self-rated health and cancer experience.

Conclusions:

Smokers held more pessimistic and avoidant beliefs about cancer, which could deter early-detection behaviour. A better understanding of these beliefs is needed to increase engagement in early diagnosis by this high-risk group.

Stigma as a barrier to diagnosis of lung cancer: patient and general practitioner perspectives

The prognosis for people with lung cancer may be worsened by delays in seeking medical help following the onset of symptoms. Previous research has highlighted that patients' experiences of stigma and blame may contribute to these delays. This short report focuses on stigma as a barrier to diagnosis of lung cancer, from patient and general practitioner (GP) perspectives. Semi-structured interviews were conducted with people diagnosed with lung cancer (n=20) and with GPs (n=10) in New South Wales, Australia. Participants' experiences of blame and stigma, GPs preconceptions of lung cancer risk and the impact of anti-smoking messaging were explored. Participants reported experiencing stigma owing to a diagnosis of lung cancer. For some, the anticipation of stigma resulted in delays in seeking diagnosis and hence treatment. The sense of blame associated with a lung cancer diagnosis was also reflected in GP interviews. Successful tobacco control activities have increased societal awareness of lung cancer as smoking related and potentially contributed to the participants' experiences of stigma. Removing blame associated with smoking is central to reducing delays in diagnosis of lung cancer.

Responding to symptoms suggestive of lung cancer: a qualitative interview study

Background

Late diagnosis of lung cancer can impact on survival rates. Patients delay seeking help for a number of reasons. This study explored symptom appraisal and help-seeking decisions among patients referred to specialist respiratory services with symptoms suggestive of lung cancer.

Methods

In-depth qualitative interviews with patients as soon as possible after referral, ideally before diagnosis and mainly within 10 weeks, explored factors impacting on their pathways prior to referral. Framework analysis, underpinned by the Model of Pathways to Treatment, was used to explore the data with particular focus on patients’ beliefs and experiences, disease factors and healthcare professional influences.

Results

35 patients were interviewed (aged 41–88 years, 15 women, 17 with lung cancer). All described similar presenting symptoms and triggers to seek help. Appraisal of symptoms was influenced by whether they had a lung comorbidity; seriousness of symptoms was interpreted within the context of previous illness experiences. Help-seeking was triggered when: symptoms failed to respond as expected; there was an increased awareness of symptoms of lung cancer; the public nature of a cough meant others were able to endorse help-seeking. Almost half visited the general practitioner (GP) two or more times before referral; during this period they reinterpreted initial symptoms and appraised new symptoms. The meaning given to symptoms changed over time and many became increasingly concerned they may have lung cancer. The GP played a role in ensuring timely further help-seeking but often there was little guidance on how to monitor symptoms or when to reconsult.

Conclusions

Patients diagnosed with and without lung cancer had similar symptom pathways. Findings provide guidance for lung cancer awareness campaigns on the importance of social networks in endorsing patient help-seeking. The importance of appropriate advice, monitoring and safety-netting procedures by GPs for people presenting with symptoms suggestive of lung cancer is also highlighted.