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Abuali I, Mathew A, Rugengamanzi E, Sainamthip P, Verduzco-Aguirre H, Parikh AR. Guiding Principles for Community Building in Global Oncology. Am Soc Clin Oncol Educ Book 2024; 44:e100045. [PMID: 38768401 DOI: 10.1200/edbk_100045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
With the escalating incidence and prevalence of cancer worldwide disproportionately affecting low- and middle-income countries, there is an urgent need for the global oncology community to foster bidirectional partnerships and an equitable exchange of knowledge, resources, and expertise. A dedicated Global Oncology Community of Practice (CoP) can serve as a self-organizing, grassroots approach for members, with common goals and values, to coordinate efforts, maximize impact, and ensure sustainable outcomes. It is imperative, however, when outlining goals and priorities to adhere to an ethical and appropriate framework during community building efforts to avoid perpetuating inequities and power imbalances. This article reviews the core guiding principles for ASCO's Global Oncology CoP which includes responsibility, amplification, accessibility, sustainability, and decolonization.
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Affiliation(s)
- Inas Abuali
- Mass General Cancer Center, Harvard Medical School, Boston, MA
| | - Aju Mathew
- Ernakulam Medical Centre and MOSC Medical College, Kochi, India
| | - Eulade Rugengamanzi
- Butaro Cancer Center of Excellence, University of Global Health Equity, Butaro, Rwanda
| | - Panot Sainamthip
- Dana-Farber Cancer Institute, Boston, MA
- Chulalongkorn University, Bangkok, Thailand
| | - Haydeé Verduzco-Aguirre
- Department of Hemato-Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Aparna R Parikh
- Mass General Cancer Center, Harvard Medical School, Boston, MA
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Bhardwaj PV, Dulala R, Rajappa S, Loke C. Breast Cancer in India: Screening, Detection, and Management. Hematol Oncol Clin North Am 2024; 38:123-135. [PMID: 37330342 DOI: 10.1016/j.hoc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Breast cancer is the most common cancer in urban Indian women and the second most common cancer in all Indian women. The epidemiology as well as biology of this cancer seems to be different in the Indian subcontinent when compared with the West. The lack of population-based breast cancer screening programs and delay in seeking a medical consult due to financial and social reasons, including lack of awareness and fear related to a cancer diagnosis, results in delayed diagnosis.
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Affiliation(s)
- Prarthna V Bhardwaj
- Division of Hematology-Oncology, University of Massachusetts Chan Medical School - Baystate, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Renuka Dulala
- Division of Hematology-Oncology, Holyoke Medical Center, 575 Beech Street, Holyoke, MA 01040, USA
| | - Senthil Rajappa
- Department of Medical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Road no. 10, Banjara Hills, Hyderabad, Telangana 500034, India
| | - Chandravathi Loke
- Division of Hematology-Oncology, University of Massachusetts Chan Medical School - Baystate, 759 Chestnut Street, Springfield, MA 01199, USA.
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Bhan AD, Jayaram J. Screening, Self-Examination and Awareness in Breast Cancer. Breast Cancer 2022. [DOI: 10.1007/978-981-16-4546-4_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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McCutchan G, Weiss B, Quinn-Scoggins H, Dao A, Downs T, Deng Y, Ho H, Trung L, Emery J, Brain K. Psychosocial influences on help-seeking behaviour for cancer in low-income and lower middle-income countries: a mixed-methods systematic review. BMJ Glob Health 2021; 6:bmjgh-2020-004213. [PMID: 33531348 PMCID: PMC7868297 DOI: 10.1136/bmjgh-2020-004213] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/09/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction Starting cancer treatment early can improve outcomes. Psychosocial factors influencing patients’ medical help-seeking decisions may be particularly important in low and lower middle-income countries (LMIC) where cancer outcomes are poor. Comprehensive review evidence is needed to understand the psychosocial influences on medical help-seeking for cancer symptoms, attendance for diagnosis and starting cancer treatment. Methods Mixed-methods systematic review registered on PROSPERO (CRD42018099057). Peer-reviewed databases were searched until April 2020 for studies assessing patient-related barriers and facilitators to medical help-seeking for cancer symptoms, diagnosis and treatment in adults (18+ years) living in LMICs. Quality of included studies was assessed using the Critical Appraisal Skills Programme tool. Data were synthesised using meta-analytic techniques, meta-ethnography or narrative synthesis as appropriate. Results Of 3963 studies identified, 64 were included. In quantitative studies, use of traditional, complementary and alternative medicine (TCAM) was associated with 3.60 higher odds of prolonged medical help-seeking (95% CI 2.06 to 5.14). Qualitative studies suggested that use of TCAM was a key barrier to medical help-seeking in LMICs, and was influenced by causal beliefs, cultural norms and a preference to avoid biomedical treatment. Women face particular barriers, such as needing family permission for help-seeking, and higher stigma for cancer treatment. Additional psychosocial barriers included: shame and stigma associated with cancer such as fear of social rejection (eg, divorce/disownment); limited knowledge of cancer and associated symptoms; and financial and access barriers associated with travel and appointments. Conclusion Due to variable quality of studies, future evaluations would benefit from using validated measures and robust study designs. The use of TCAM and gender influences appear to be important barriers to help-seeking in LMIC. Cancer awareness campaigns developed with LMIC communities need to address cultural influences on medical help-seeking behaviour.
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Affiliation(s)
- Grace McCutchan
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK .,Wales Cancer Research Centre, Cardiff University, Cardiff, UK
| | - Bahr Weiss
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, USA
| | - Harriet Quinn-Scoggins
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.,PRIME Centre Wales, Cardiff University, Cardiff, UK
| | - Anh Dao
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, USA
| | - Tom Downs
- Department of Acute Medicine, Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Bangor, Gwynedd, UK
| | - Yunfeng Deng
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee, USA
| | - Ha Ho
- Center for Research, Information and Services in Psychology, Vietnam National University, Hanoi, Vietnam
| | - Lam Trung
- Danang Psychiatric Hospital, Da Nang, Vietnam
| | - Jon Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Sahu DP, Subba SH, Giri PP. Cancer awareness and attitude towards cancer screening in India: A narrative review. J Family Med Prim Care 2020; 9:2214-2218. [PMID: 32754476 PMCID: PMC7380789 DOI: 10.4103/jfmpc.jfmpc_145_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/13/2020] [Accepted: 03/31/2020] [Indexed: 11/04/2022] Open
Abstract
Cancer awareness is the key to early detection and better health-seeking behaviour. Cancer is quite common in both developing as well as developed countries, but awareness is yet poor among the general population. Poor awareness may lead to poor uptake of screening modalities and delay in diagnosis. One factor that has been consistently shown to be associated with late diagnosis and treatment is a delay in seeking help for cancer-like symptoms. This paper reviews the literature on cancer awareness among the general population and attitude towards screening modalities. The poor awareness level among the Indian population shows the need for health education and sensitisation regarding cancer and its different aspects. This will be helpful in the successful implementation of health programmes related to cancer.
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Affiliation(s)
- Dinesh Prasad Sahu
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sonu H Subba
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Prajna Paramita Giri
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Suhani, Oberoi AS. Instagram or mammogram: What are Indian women more aware of? Indian J Cancer 2020; 57:498-499. [PMID: 32594070 DOI: 10.4103/ijc.ijc_555_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Suhani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Ajit S Oberoi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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Gadgil A, Sauvaget C, Roy N, Muwonge R, Lucas E, Sankaranarayanan R. Setting up a Breast Cancer Awareness Project in Mumbai: Methodology, Experiences and Challenges. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:579-588. [PMID: 30863980 DOI: 10.1007/s13187-019-01500-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
More than two thirds of breast cancers in developing countries are diagnosed at a late stage. Awareness-based screening programmes, integrated into existing infrastructure, are the way forward for cancer control in these countries. We aim to describe a structured screening programme established in an urban community in Mumbai, India. We conducted a breast cancer awareness survey in this urban community covered by employees' health scheme. A brochure was designed to inform women about early signs of breast cancer and was posted for the women in the community. We described early signs and symptoms of breast cancer and encouraged the women to seek healthcare in the breast clinics specifically designed for early referral. A multidisciplinary team was established for further in-house care at the community hospital. A database of the detected cancers was maintained. A total of 22,500 brochures were sent in each round of mailing. Four such rounds were conducted in 3 years. A total of 3547 women reported for clinical breast examination (CBE) for various breast complaints or screening. Of these women, 53% were asymptomatic. CBE was normal in 2843 women, and 767 (21%) women were referred for further investigations. Eighty-three breast cancers were detected with 72% having early (stage I-II) cancers. Our exploratory study revealed that awareness-based screening programmes with organised infrastructure and referral pattern could lead to diagnosing early cancers.
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Affiliation(s)
- Anita Gadgil
- Department of Surgery, Bhabha Atomic Research Centre Hospital, WHO-CC for Surgical Care Delivery in LMIC, Mumbai, India
| | - Catherine Sauvaget
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372, Lyon CEDEX 08, France.
| | - Nobhojit Roy
- Department of Surgery, Bhabha Atomic Research Centre Hospital, WHO-CC for Surgical Care Delivery in LMIC, Mumbai, India
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372, Lyon CEDEX 08, France
| | - Eric Lucas
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372, Lyon CEDEX 08, France
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Bonsu AB, Ncama BP, Bonsu KO. Breast cancer knowledge, beliefs, attitudes and screening efforts by micro-community of advanced breast cancer patients in Ghana. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2019. [DOI: 10.1016/j.ijans.2019.100155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Ströbele L, Kantelhardt EJ, Traoré Millogo TFD, Sarigda M, Wacker J, Grosse Frie K. Prevalence of breast-related symptoms, health care seeking behaviour and diagnostic needs among women in Burkina Faso. BMC Public Health 2018; 18:447. [PMID: 29615015 PMCID: PMC5883529 DOI: 10.1186/s12889-018-5360-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/22/2018] [Indexed: 11/29/2022] Open
Abstract
Background The prevalence of breast cancer has been increasing in sub-Saharan Africa over the last few years. Patients often present with late stage disease, resulting in a high mortality rate. This study aims to estimate the prevalence of breast -related symptoms in the female population of Burkina Faso. The findings can be used to advise on adequate diagnostic health services for breast symptoms to ensure early detection and down-staging of breast cancer. Methods A cross-sectional, population based study of 996 women was conducted to investigate the proportion of women with breast-related symptoms. A semi-structured questionnaire was used to collect sociodemographic data, information about breast cancer knowledge and details about breast-related symptoms, health care seeking and medical care. Breast-related symptoms were categorised as currently present/not currently present to estimate the current prevalence of women requiring a diagnostic service. Results Among the 996 women, 120 reported having had a breast-related symptom in their life. Only 36 women sought medical advice and eight women had diagnostic confirmation by histological or imaging techniques. Current breast-related symptoms were reported by 33 women (3.3% of the sample). An extrapolation to Burkina Faso’s female population suggests that 184,562 women are in current need of diagnostic services due to any breast-related symptoms. Conclusions Imaging techniques at the community and referral level are needed in order to triage women with breast-related symptoms. Specialised services need to be strengthened to ensure appropriate diagnosis and treatment of breast diseases. Education campaigns among the general population and among health care professionals are required to increase awareness of breast cancer and improve prompt health care seeking and referral.
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Affiliation(s)
- Leonie Ströbele
- Martin-Luther-University Halle-Wittenberg, Institute for Medical Epidemiology, Biostatistics and Informatics, Magdeburger Straße 8, 06112, Halle, Germany
| | - Eva Johanna Kantelhardt
- Martin-Luther-University Halle-Wittenberg, Institute for Medical Epidemiology, Biostatistics and Informatics, Magdeburger Straße 8, 06112, Halle, Germany.,Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle, Germany
| | | | - Maurice Sarigda
- Unité de Formation en Sciences de la Santé, Université Ouaga 1 Professeur Joseph Ki Zerbo 03 B.P. 7021, Ouagadougou, 03, Burkina Faso
| | - Jürgen Wacker
- Fürst-Stirum-Klinik Bruchsal, Gutleutstraße 1-14, 76646, Bruchsal, Germany
| | - Kirstin Grosse Frie
- Martin-Luther-University Halle-Wittenberg, Institute for Medical Epidemiology, Biostatistics and Informatics, Magdeburger Straße 8, 06112, Halle, Germany.
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Srivastava A, Suhani. Mammographic Screening or Breast Cancer Awareness? Time to Ponder. Indian J Surg 2017; 79:446-449. [PMID: 29089707 DOI: 10.1007/s12262-017-1672-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 06/29/2017] [Indexed: 12/29/2022] Open
Abstract
Breast cancer in India is becoming the leading cause of cancer-related mortality in urban women. In developed countries, the mortality from breast cancer has decreased in the past few years attributable to better awareness of disease, screening programs, early detection and more effective treatment available. Although widely used, the screening programs running in the western countries have been a point of criticism in the recent years as they lead to increased healthcare cost and detection of otherwise benign and clinically insignificant breast lesion (both benign and malignant). Also in a developing country like ours where the awareness about breast cancer among the ladies is itself poor, whether screening is feasible and cost-effective is a matter of ongoing debate. We conducted this literature review to ascertain the importance of breast cancer awareness, breast self-examination, and clinical breast examination as effective screening tools in a resource deficient country like India.
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Affiliation(s)
- Anurag Srivastava
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Suhani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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A Survey on Breast Cancer Awareness Among Medical, Paramedical, and General Population in North India Using Self-Designed Questionnaire: a Prospective Study. Indian J Surg Oncol 2017; 9:323-327. [PMID: 30287991 DOI: 10.1007/s13193-017-0703-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022] Open
Abstract
Breast cancer (BC) has become the most common cancer in urban women. Unfortunately, most women are not aware of BC symptoms/signs, prevention, and management. In resource-limited countries like India where we do not have structured screening/awareness programs, a majority of women present with locally advanced BC. The aim of our study is to identify the present status of awareness about BC prevention, early detection, symptoms, and management in urban and rural Indian women (medical, paramedical, and nonmedical) and to assess whether education and socioeconomic strata have any role in better awareness about BC or not. We did a prospective cross-sectional observation study among the medical, paramedical, and nonmedical women in the northern part of India. We designed a questionnaire keeping in mind the three domains about BC-knowledge (questions 1-25 include risk factors, genetics, lifestyle changes, hormones, associated cancers, and modes of presentation like lump, nipple/skin changes), breast self-examination (questions 25-37), and attitude to prevention and early detection (questions 38-44). We also asked how many do breast self-examination (BSE) and what they think are the three main factors responsible for late presentation and the three main ways to increase BC awareness. The Likert scale was used for objective assessment. We analyzed the whole data using SPSS software version 15. A total of 220 women out of 270 completed the questionnaire. Out of 220 women, 26.4% were medical, 20.9% paramedical, and 52.7% nonmedical. Most women were educated (82.7%) and married (65%). 59.5% women resided in urban areas and the rest (40.5%) were from rural areas. We found that there was relatively more knowledge in the medical group; however, the skills of BSE and attitude to prevention and early detection in all the three subgroups and among rural and urban women were suboptimal and not different significantly. The three main factors responsible for delayed presentation were shyness and not knowing BSE, ignorance about BC symptoms, and social stigma of cancer along with financial constraints. The three main ways to improve BC awareness suggested were to have more advertisements on television and social media, roadside campaigns and in colleges along with group discussions and debates, and at grassroots level to involve Anganwadi workers and nurses to create more awareness in villages. There was less breast cancer knowledge and awareness among the nonmedical women compared to those among the medical and paramedical, the skills of BSE and attitude to prevention and early detection were suboptimal in all the three groups. Rural or urban dwellings did not make much difference in BC knowledge, skills of BSE, and attitude to prevention. More awareness regarding breast cancer symptoms with early detection and BSE need to be addressed with more information dissemination via social media, campaigns, and involvement of paramedics and social workers.
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Gadgil A, Sauvaget C, Roy N, Muwonge R, Kantharia S, Chakrabarty A, Bantwal K, Haldar I, Sankaranarayanan R. Cancer early detection program based on awareness and clinical breast examination: Interim results from an urban community in Mumbai, India. Breast 2017; 31:85-89. [DOI: 10.1016/j.breast.2016.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/25/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022] Open
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Akinyemiju T, Ogunsina K, Sakhuja S, Ogbhodo V, Braithwaite D. Life-course socioeconomic status and breast and cervical cancer screening: analysis of the WHO's Study on Global Ageing and Adult Health (SAGE). BMJ Open 2016; 6:e012753. [PMID: 27881528 PMCID: PMC5129035 DOI: 10.1136/bmjopen-2016-012753] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Socioeconomic differences in screening have been well documented in upper-income countries; however, few studies have examined socioeconomic status (SES) over the life-course in relation to cancer screening in lower-income and middle-income countries. Here, we examine individual, parental and life-course SES differences in breast and cervical cancer screening among women in India, China, Mexico, Russia and South Africa. SETTING Data from the WHO's Study on Global Ageing and Adult Health (SAGE) 2007-2008 data were used for survey-weighted multivariable regression analysis. We examined the association between individual, parental and life-course SES in relation to breast and cervical cancer screening using education-based and employment-based measures of SES. PARTICIPANTS 22 283 women aged 18-65 years, recruited from China, India, Mexico, Russia and South Africa. RESULTS Having a college degree (OR 4.18; 95% CI 2.36 to 7.40) increased the odds of breast cancer screening compared with no formal education. Women with higher parental SES were almost 10 times more likely to receive breast cancer screening (OR 9.84; 95% CI 1.75 to 55.5) compared with women with low parental SES. Stable higher life-course (OR 3.07; 95% CI 1.96 to 4.79) increased breast cancer screening by threefold and increased cervical cancer screening by more than fourfold (OR 4.35; 95% CI 2.94 to 6.45); however, declining life-course SES was associated with reduced breast cancer screening (OR 0.26; 95% CI 0.08 to 0.79) compared to low life-course SES. CONCLUSIONS Higher individual, parental and life-course SES was positively associated with breast and cervical cancer screening, although education-based SES measures were stronger predictors of screening compared with employment-based measures. Improving knowledge of the benefits of cancer screening and integrating cancer screening into routine healthcare practice for low SES women are actionable strategies that may significantly improve screening rates in low-income and middle-income countries.
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Affiliation(s)
- Tomi Akinyemiju
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kemi Ogunsina
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Swati Sakhuja
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Valentine Ogbhodo
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dejana Braithwaite
- Division of Cancer Epidemiology, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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