Influence of delay on survival in patients with breast cancer: a systematic review

Cancer diagnosis in primary care

Around a quarter of those in the developed world die of cancer. Most cancers present to primary care with symptoms, even when there is a screening test for the particular cancer. However, the symptoms of cancer are also symptoms of benign disease, and the GP has to judge whether cancer is a possible explanation. Very little research examined this process until relatively recently. This review paper examines the process of primary care diagnosis, especially the selection of patients for rapid investigation. It concentrates on the four commonest UK cancers: breast, lung, colon, and prostate as these have been the subject of most recent studies.

Psychosocial determinants of mammography follow-up after receipt of abnormal mammography results in medically underserved women

This article targets the relationship between psychosocial determinants and abnormal screening mammography follow-up in a medically underserved population. Health belief scales were modified to refer to diagnostic follow-up versus annual screening. A retrospective cohort study design was used. Statistical analyses were performed examining relationships among sociodemographic factors, psychosocial determinants, and abnormal mammography follow-up. Women with lower mean internal health locus of control scores (3.14) were two times more likely than women with higher mean internal health locus of control scores (3.98) to have inadequate follow-up (OR=2.53, 95% CI=1.12-5.36). Women with less than a high school education had lower cancer fatalism scores than women who had completed high school (47.5 vs. 55.2, p-value=.02) and lower mean external health locus of control scores (3.0 vs. 5.3) (p-value<.01). These constructs have implications for understanding mammography follow-up among minority and medically underserved women. Further comprehensive study of these concepts is warranted.

Pregnancy after breast cancer. A comprehensive review

Pregnancy after breast cancer treatment has become an important issue since many young breast cancer patients have not completed their family. Generally, these patients should not be discouraged to become pregnant when they want to, since published data suggest no adverse effect of pregnancy on survival. As fertility may be impaired by chemotherapy, different fertility preserving strategies have been developed. Births seem to sustain no adverse effects, while breastfeeding appears to be feasible and safe.

Socio-economic disparities in access to treatment and their impact on colorectal cancer survival

BACKGROUND

Significant socio-economic disparities have been reported in survival from colorectal cancer in a number of countries, which remain largely unexplained. We assessed whether possible differences in access to treatment among socio-economic groups may contribute to those disparities, using a population-based approach.

METHODS

We retrospectively studied 71 917 records of colorectal cancer patients, diagnosed between 1997 and 2000, linked to area-level socio-economic information (Townsend index), from three cancer registries in UK. Access to treatment was measured as a function of delay in receipt of treatment. We assessed socio-economic differences in access through logistic regression models. Based on relative survival < or =3 years after diagnosis, we estimated excess hazard ratios (EHRs) of death for different socio-economic groups.

RESULTS

Compared with more affluent patients, deprived patients had poorer survival [EHR = 1.20; 95% confidence interval (CI) 1.16-1.25], were less likely to receive any treatment within 6 months [odds ratio (OR) = 0.87, 95% CI 0.82-0.92] and, if treated, were more likely to receive late treatment. No disparities in survival were detected among patients receiving treatment within 1 month from diagnosis. Disparities existed among patients receiving later or no treatment (EHR = 1.30; 95% CI 1.22-1.39), and persisted after adjustment for age and stage at diagnosis (EHR = 1.15; 95% CI 1.08-1.24).

CONCLUSIONS

Tumour stage helped explain socio-economic disparities in colorectal cancer survival. Disparities were also greatly attenuated among patients receiving early treatment. Aspects other than those captured by our measure of access, such as quality of care and patient preferences in relation to treatment, might contribute to a fuller explanation.

Validation of a measurement tool to assess awareness of breast cancer

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Timely care after an abnormal mammogram among low-income women in a public breast cancer screening program

BACKGROUND

Since 1990, the National Breast and Cervical Cancer Early Detection Program (BCCEDP) has funded breast cancer screening and diagnostic services for low-income, underinsured women. Case management was implemented in 2001 to address barriers to follow-up after an abnormal mammogram, and free treatment was introduced in 2004. However, the effect of these policies on timeliness of care has not been empirically evaluated.

METHODS

Among 2252 BCCEDP participants in Massachusetts during 1998 through 2007, we conducted a time-to-event analysis with prepolicy-postpolicy comparisons to examine associations of case management and free treatment with diagnostic and treatment delays (>60 days and >90 days, respectively) after an abnormal mammogram.

RESULTS

The proportion of women experiencing a diagnostic delay decreased from 33% to 23% after the introduction of case management (P < .001), with a significant reduction in the adjusted risk of diagnostic delay (relative risk [RR], 0.65; 95% confidence interval [CI], 0.53-0.79) that did not differ by race and ethnicity. However, case management was not associated with changes in treatment delay (RR, 0.93; 95% CI, 0.80-1.10). Free treatment was not associated with changes in the adjusted risk of diagnostic delay (RR, 0.61; 95% CI, 0.33-1.14) or treatment delay (RR, 0.77; 95% CI, 0.43-1.38) beyond improvements associated with case management.

CONCLUSIONS

Case management to assist women in overcoming logistic and psychosocial barriers to care may improve time to diagnosis among low-income women who receive free breast cancer screening and diagnostic services. Programs that provide services to coordinate care, in addition to free screening and diagnostic tests, may improve population health.

Evaluation of breast cancer awareness among female university students in Malaysia

Breast cancer is the most common cancer and the leading cause of cancer death among women of all ethnic and age groups in Malaysia.

The symptom interval in children and adolescents with soft tissue sarcomas

BACKGROUND

In a series of 575 patients < or =21 years of age with soft tissue sarcomas (STSs), the authors investigated the association patterns between symptom interval (ie, the period between the onset of the first symptoms or signs of the disease and its definitive diagnosis) and patient/tumor characteristics or disease outcome (in terms of survival).

METHODS

The analysis was based on multivariate models (linear for associations with patient/tumor characteristics and Cox's for survival).

RESULTS

The symptom interval ranged between 1 week and 60 months (median, 2 months) and tended to be longer the older the patient (ie, the interval was longer in adolescents than in children) and the larger the tumor's size, and for tumors located at the extremities and for nonrhabdomyosarcoma STSs (as opposed to rhabdomyosarcomas). A longer symptom interval unfavorably influenced survival (P = .002), which was also significantly affected by the patient's age and the size and surgical stage of the tumor. A different pattern of association between symptom interval and survival emerged for different types of STS histology.

CONCLUSIONS

Our study points to an independent prognostic effect of symptom interval that cannot be explained by its associations with other factors, such as patient's age or the site, size, stage, and histology of the tumor. Future studies should focus more on the possible causes of symptom interval in pediatric STS populations to enable corrective measures to be implemented to reduce the diagnostic delay.

Misconceptions about breast lumps and delayed medical presentation in urban breast cancer patients

BACKGROUND

Despite current recommendations for women to be screened for breast cancer with mammography every 1 to 2 years, less than half of all newly diagnosed breast cancers are initially detected through screening mammography. Prompt medical attention to a new breast symptom can result in earlier stage at diagnosis, yet many patients delay seeking medical care after becoming aware of a breast symptom.

METHODS

In a population-based study of breast cancer, we examined factors potentially associated with patient delay in seeking health care for a breast symptom among 436 symptomatic urban breast cancer patients (146 white, 197 black, and 95 Hispanic). Race/ethnicity, socioeconomic status, health care access and utilization, and misconceptions about the meaning of breast lumps were the key independent variables.

RESULTS

Sixteen percent of patients reported delaying more than 3 months before seeking medical advice about breast symptoms. Misconceptions about breast lumps and lacking a regular provider, health insurance, and recent preventive care were all associated with prolonged patient delay (P < 0.005 for all). Misconceptions were much more common among ethnic minorities and women of lower socioeconomic status.

CONCLUSION

Reducing patient delay and disparities in delay will require educating women about the importance of getting breast lumps evaluated in a timely manner and providing greater access to regular health care.

Religiosity, spirituality, and cancer fatalism beliefs on delay in breast cancer diagnosis in African American women

African American women are more likely than any other racial or ethnic group to present with a later stage of breast cancer at initial diagnosis. Delay in breast cancer detection is a critical factor in diagnosis at a later stage. Available data indicate a delay of 3 months or more is a significant factor in breast cancer mortalty. Numerous factors have been reported as contributing to delay in time to seek medical care including religiosity, spirituality, and fatalistic beliefs. This study examined the influence of religiosity, spirituality, and cancer fatalism on delay in diagnosis and breast cancer stage in African American women with self-detected breast symptoms. A descriptive correlation, retrospective methodology using an open-ended questionnaire and three validated measurement scales were used: the Religious Problem Solving Scale (RPSS), the Religious Coping Activity Scale (RCAS) subscale measuring spiritually based coping, and the modified Powe Fatalism Inventory (mPFI). A convenience sample of 129 women ages between 30 and 84 years who self-reported detecting a breast symptom before diagnosis of breast cancer within the preceding 12 months were included in the study. Outcome variables were time to seek medical care and breast cancer stage. Other variables of interest included marital status, income, education, insurance status, and to whom the women spoke about their breast symptoms. Data were analyzed using descriptive statistics, logistic regression analysis, Pearson r correlations, Mann-Whitney U analysis, and Chi Square analysis. Participants were found to be highly religious and spiritual but not fatalistic. While most women delayed more than 3 months in seeking medical care, no associations were found between the three predictor variables and time to seek medical care. The median delay in time from self detection of a breast symptom to seeking medical care was 5.5 months. Women who were less educated, unmarried, and talked to God only about their breast change were significantly more likely to delay seeking medical care. An association was found between disclosing a breast symptom to God only and delay in seeking medical care. In contrast, women who had told a person about their breast symptom were more likely to seek medical care sooner. African American women who delayed seeking medical care for longer than 3 months were more likely to present with a later stage of breast cancer than women who sought care within 3 months of symptom discovery.

Australian women's awareness of breast cancer symptoms and responses to potential symptoms

OBJECTIVES

Poor awareness of breast cancer symptoms has been associated with patient delay in seeking help; thus reduced survival, more aggressive treatment, and fewer treatment choices. The aim of this study was to develop a representative picture of Australian women's knowledge of symptoms, experienced potential symptoms, and behavioral responses.

METHODS

A general population sample of approximately 3,000 women aged 30-69 completed a telephone survey; results were compared to previous surveys conducted in 1996 and 2003.

RESULTS

The most commonly cited potential symptom of breast cancer was a lump in the breast, identified by 86% of respondents (an increase from 75% in 2003). Other commonly mentioned symptoms were discharge from the nipple, pain/soreness, skin puckering, or dimpling; and a change in breast shape. The proportion unable to name any potential symptoms of breast cancer decreased from one in ten in 2003 to approximately one in twenty in 2007. The primary reason for not seeking medical advice in response to a potential symptom was the belief that breast cancer was not present.

CONCLUSIONS

Health promotion efforts need to continue to aim at increasing community understanding of potential breast cancer symptoms and encouraging women to act on potential symptoms by seeking medical advice.

Racial differences in follow-up of abnormal mammography findings among economically disadvantaged women

BACKGROUND

In the United States, and particularly in South Carolina, African-American women suffer disproportionately higher mortality rates from breast cancer than European-American women. The timeliness of patient adherence to the follow-up of mammographic abnormalities may influence prognosis and survival. The objective of the current investigation was to examine racial differences in the completion and completion time of a diagnostic workup after the finding of a suspicious breast abnormality.

METHODS

Study participants of the Best Chance Network, a statewide service program that provides free mammography screening to economically disadvantaged and medically underserved women, were included in the study. Racial differences in tumor characteristics and adherence to recommended workup were tested using chi-square tests and t tests. Logistic and Cox regression modeling was used to assess the relation between workup completion and other factors among African-American women and European-American women.

RESULTS

Completion of the workup was associated with the number of previous procedures and income, and no significant differences were noted by race. The amount of time to completion of the workup was influenced by previous procedures, income, and race. After accounting for completion time, African-American women were 12% less likely than European-American women to complete the recommended workup (hazard ratio, 0.88; P=.01).

CONCLUSIONS

The results from this study established a racial disparity in the time to completion of a diagnostic workup among Best Chance Network participants. These findings highlight the importance of understanding the factors associated with delays in and adherence to completing the recommended workup when breast abnormalities are detected in mammograms.

Delay in diagnostic testing after abnormal mammography in low-income women

PURPOSE/OBJECTIVES

To identify factors associated with diagnostic delay after an incomplete or abnormal mammogram among women participating in a state mammography screening program.

RESEARCH APPROACH

Retrospective case-control design using bivariate and multivariate logistic regression analyses to explore the associations between age, race, ethnicity, marital status, breast cancer history, and self-reported breast symptoms and delay.

SETTING

A statewide program of free screening mammography for women who are under- or uninsured.

PARTICIPANTS

11,460 women enrolled in a free, statewide screening program from 2002-2006.

METHODOLOGIC APPROACH

Using the Tennessee Breast and Cervical Cancer Screening Program database, further analyses were conducted.

MAIN RESEARCH VARIABLES

The outcome measure was delay in completion of all diagnostic tests and was defined as women who did not complete testing within 60 days.

FINDINGS

Thirty-seven percent of women required follow-up, and of a subset used in the analysis, 30% experienced delay of more than 60 days. Controlling for marital status, age, and breast cancer history, women who experienced delay were more likely to be African American versus Caucasian (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.13, 1.85) or Hispanic (OR = 0.72, 95% CI = 0.55, 0.93) and to have self-reported breast symptoms (OR = 1.50, 95% CI = 1.27, 1.77).

CONCLUSIONS

In a sample of women with low income needing mammography follow-up, delay was associated with three intrapersonal variables, potentially reducing the effectiveness of mammography screening for women who were African American, or Hispanic, or had self-reported breast symptoms.

INTERPRETATION

Nurses providing cancer screening examinations are uniquely positioned to assess the knowledge, beliefs, and resources of women using the program and to navigate women through barriers to completion. Knowledge of factors associated with delay is valuable for planning interventions and allocating program resources.

Do diagnostic delays in cancer matter?

BACKGROUND

The United Kingdom has poorer cancer outcomes than many other countries due partly to delays in diagnosing symptomatic cancer, leading to more advanced stage at diagnosis. Delays can occur at the level of patients, primary care, systems and secondary care. There is considerable potential for interventions to minimise delays and lead to earlier-stage diagnosis.

METHODS

Scoping review of the published studies, with a focus on methodological issues.

RESULTS

Trial data in this area are lacking and observational studies often show no association or negative ones. This review offers methodological explanations for these counter-intuitive findings.

CONCLUSION

While diagnostic delays do matter, their importance is uncertain and must be determined through more sophisticated methods.

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

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

Public awareness of cancer in Britain: a population-based survey of adults

Objective:

To assess public awareness of cancer warning signs, anticipated delay and perceived barriers to seeking medical advice in the British population.

Methods:

We carried out a population-based survey using face-to-face, computer-assisted interviews to administer the cancer awareness measure (CAM), a newly developed, validated measure of cancer awareness. The sample included 2216 adults (970 males and 1246 females) recruited as part of the Office for National Statistics Opinions Survey using stratified probability sampling.

Results:

Awareness of cancer warning signs was low when open-ended (recall) questions were used and higher with closed (recognition) questions; but on either measure, awareness was lower in those who were male, younger, and from lower socio-economic status (SES) groups or ethnic minorities. The most commonly endorsed barriers to help seeking were difficulty making an appointment, worry about wasting the doctor's time and worry about what would be found. Emotional barriers were more prominent in lower SES groups and practical barriers (e.g. too busy) more prominent in higher SES groups. Anticipated delay was lower in ethnic minority and lower SES groups. In multivariate analysis, higher symptom awareness was associated with lower anticipated delay, and more barriers with greater anticipated delay.

Conclusions:

A combination of public education about symptoms and empowerment to seek medical advice, as well as support at primary care level, could enhance early presentation and improve cancer outcomes.

Development of a measurement tool to assess public awareness of cancer

Objective:

We aimed to develop and validate a measurement tool to assess cancer awareness in the general population: the cancer awareness measure (CAM).

Methods:

Items assessing awareness of cancer warning signs, risk factors, incidence, screening programmes and attitudes towards help seeking were extracted from the literature or generated by expert groups. To determine reliability, the CAM was administered to a university participant panel (n=148), with a sub-sample (n=94) completing it again 2 weeks later. To establish construct validity, CAM scores of cancer experts (n=12) were compared with those of non-medical academics (n=21). Finally, university students (n=49) were randomly assigned to read either a cancer information leaflet or a leaflet with control information before completing the measure, to ensure the CAM was sensitive to change.

Results:

Cognitive interviewing indicated that the CAM was being interpreted as intended. Internal reliability (Cronbach's α=0.77) and test–retest reliability (r=0.81) were high. Scores for cancer experts were significantly higher than those for non-medical academics (t(31)=6.8, P<0.001). CAM scores were higher among students who received an intervention leaflet than the control leaflet (t(47)=4.8, P<0.001).

Conclusions:

These studies show the psychometric properties of the CAM and support its validity as a measure of cancer awareness in the general population.

Delay in diagnostic workup and treatment of esophageal cancer

INTRODUCTION

Esophageal cancer should preferably be detected and treated at an early stage, but this may be prohibited by late onset of symptoms and delays in referral, diagnostic workup, and treatment. The aim of this study was to investigate the impact of these delays on outcome in patients with esophageal cancer.

METHODS

For 491 patients undergoing esophagectomy for cancer between 1991 and 2007, patients' short- and long-term outcome were analyzed according to different time intervals between onset of symptoms, diagnosis, and surgical treatment.

RESULTS

Length of prehospital delay (from onset of symptoms until endoscopic diagnosis) did not affect patient's short- or long-term outcome. A shorter hospital delay between establishing the diagnosis of esophageal cancer on endoscopy and surgery was associated with lower overall morbidity and in-hospital mortality. Patients of ASA classes I and II experienced a shorter hospital delay than patients of ASA classes III and IV. Length of hospital delay between endoscopic diagnosis and surgery did not affect pathological tumor-node-metastasis stage or R0-resection rate. Longer hospital delay did not result in worse survival: Overall survival after esophagectomy for cancer was not significantly different between patients with hospital delay <5, 5-8, or >8 weeks (24.7%, 21.7%, and 32.3%, respectively; p = 0.12).

CONCLUSION

A longer hospital delay (between endoscopic diagnosis and surgery) resulted in worse patient's short-term outcome (higher overall morbidity and mortality rates) but not in a worse long-term outcome (overall survival). This may be explained by a more time-consuming diagnostic workup in patients with a poorer physical status and not by tumor progression.

Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program, 1996-2005

OBJECTIVES

To determine the effects of program policy changes, we examined service delivery benchmarks for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

We analyzed NBCCEDP data for women with abnormal mammogram or clinical breast examination (n=382 416) from which 23 701 cancers were diagnosed. We examined time to diagnosis and treatment for 2 time periods: 1996 to 2000 and 2001 to 2005. We compared median time for diagnostic, treatment initiation, and total intervals with the Kruskal-Wallis test. We calculated adjusted proportions (predicted marginals) with logistic regression to examine diagnosis and treatment within program benchmarks (<or=60 days) and time from screening to treatment (<or=120 days).

RESULTS

Median diagnostic intervals decreased by 2 days (25 vs 23; P<.001). Median treatment initiation intervals increased by 2 days (12 vs 14; P<.001). Total intervals decreased by 3 days (43 vs 40; P<.001). Women meeting the 60-day benchmark for diagnosis improved the most for women with normal mammograms and abnormal clinical breast examinations from 77% to 82%.

CONCLUSIONS

Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.

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

BACKGROUND

There is virtually no evidence for the effectiveness of interventions to promote early presentation in breast cancer. We aimed to test the efficacy of an intervention to equip older women with the knowledge, skills, confidence and motivation to detect symptoms and seek help promptly, with the aim of promoting early presentation with breast cancer symptoms.

METHODS

We randomised 867 women aged 67-70 years attending for their final routine appointment on the UK NHS Breast Screening Programme to receive: a scripted 10-min interaction with a radiographer plus a booklet, a booklet alone or usual care. The primary outcome was whether or not a woman was breast cancer aware based on knowledge of breast cancer symptoms and age-related risk, and reported breast checking.

RESULTS

At 1 month, the intervention increased the proportion who were breast cancer aware compared with usual care (interaction arm: 32.8% vs 4.1%; odds ratio (OR): 24.0, 95% confidence interval (CI): 7.7-73.7; booklet arm: 12.7% vs 4.1%; OR: 4.4, 95% CI: 1.6-12.0). At 1 year, the effects of the interaction plus booklet, and the booklet, on breast cancer awareness were largely sustained, although the interaction plus booklet remained much more effective.

CONCLUSIONS

An intervention to equip older women with the knowledge, skills, confidence and motivation to detect breast cancer symptoms and seek help promptly increases breast cancer awareness at 1 year. Future research will evaluate whether the intervention promotes early presentation and reduces breast cancer mortality.

The size of the prize for earlier diagnosis of cancer in England

BACKGROUND

This supplement presents a wide range of observations, reviews, novel research and analyses underpinning the National Awareness and Early Diagnosis Initiative (NAEDI). The preceding three papers present and discuss different aspects of the data from European cancer survival comparison studies. I conclude here by attempting to quantify the extent to which delayed diagnosis in England accounts for observed survival differences and by outlining areas for further research.

METHODS

Analysis of indirect evidence related to late diagnosis, surgical intervention rates and utilisation of radiotherapy and chemotherapy in England and other European countries in the late 1990s for breast, colorectal and lung cancer.

RESULTS

Late diagnosis was almost certainly a major contributor to poor survival in England for all three cancers. Low surgical intervention rates are very likely to have contributed to low survival rates for lung cancer and possibly for the other two cancers. Any differences in the use of radiotherapy or chemotherapy are likely to have had only a minor impact on survival differences.

CONCLUSION

Between 5000 and 10000 deaths within 5 years of diagnosis could be avoided every year in England if efforts to promote earlier diagnosis and appropriate primary surgical treatment are successful. Detailed international benchmarking studies are to be recommended.

The impact of Medicaid coverage and reimbursement on access to diagnostic mammography

BACKGROUND

Women of low socioeconomic status are at risk for delayed evaluation of abnormal mammograms and later stage presentations of breast cancer. Medicaid reimbursement for clinical services is lower than Medicare reimbursement, yet it is unclear whether low Medicaid reimbursement is a barrier to accessing mammography. The objective of the current study was to determine the association between reported insurance type (Medicaid vs Medicare), Medicaid reimbursement rate, and access to diagnostic mammography (DM).

METHODS

Standardized patients (SPs) called 521 mammography facilities in defined geographic regions of 11 states in 2005. Facilities were divided between high, middle, and low reimbursing states based on the state's relative Medicaid-to-Medicare reimbursement rate for DM. SPs contacted each facility twice to schedule a DM using the same clinical vignette but switching insurance status (Medicaid vs Medicare). The authors measured the proportion of SPs who were offered 1) any appointment and 2) a timely appointment, defined as a third available appointment within 20 business days.

RESULTS

SPs with Medicaid were less likely to receive an appointment than SPs with Medicare (91% vs 99.1%; difference, 8.1%; 95% confidence interval, 5.3%-10.9% [P < .001]). Among facilities that offered appointments to both callers, the proportion of timely appointments did not differ between Medicaid (93.7%) and Medicare (92.9%; P = .51). States' Medicaid reimbursement rates for DM were not associated with the percentage of SPs with Medicaid who were offered any appointment (P = .50) or a timely appointment (P = .69).

CONCLUSIONS

Callers with Medicaid were offered appointments for DM less frequently than callers with Medicare, although both were widely accepted. State Medicaid reimbursement rates did not affect access to mammography.

Promoting early presentation of breast cancer by older women: a preliminary evaluation of a one-to-one health professional-delivered intervention

OBJECTIVE

To test the early effects of a novel one-to-one health professional-delivered intervention designed to increase awareness and thereby promote early presentation of breast cancer among older women.

METHODS

Women attending their final routine appointment in the English NHS Breast Screening Programme received a booklet or a booklet supplemented by a brief interview, in addition to usual care. This was a within-group before-and-after evaluation of the two versions of the intervention. The primary outcome was change in the knowledge of breast cancer symptoms from baseline to 1 month postintervention. Secondary outcomes were knowledge of risk of developing breast cancer, confidence to detect a breast change, and likelihood of disclosure to someone close. Levels of cancer worry and any adverse effects caused by the intervention were also monitored.

RESULTS

One hundred seventy-six women received the booklet and 116 received the booklet-plus-interview. At 1-month postintervention, the mean number of breast cancer symptoms identified (out of 11) increased from 5.3 by 1 symptom (P<.001) in the booklet group and by 1.9 (P<.001) in the booklet-plus-interview group. Improvements were sustained at 6 months. Positive improvements were made in the knowledge of risk of developing breast cancer and the confidence to detect a breast change in both groups; however, neither version of the intervention had an impact on encouraging women to disclose to someone close immediately on discovery of a breast symptom. No adverse effects were reported, and there was no significant increase in the level of cancer worry.

DISCUSSION

Both versions of the intervention are worthy of testing in randomized trials to assess the impact on breast cancer awareness and ultimately on delayed presentation of breast cancer and mortality.

Association between mode of breast cancer detection and diagnosis delay

We investigated the association between mode of breast cancer (Bca) detection and diagnosis delay in a case-series of primary, histologically confirmed Bca patients from Southern Italy. Nine hundred and fifty nine women diagnosed with incident, primary Bca were recruited in two southern Italian regions. We grouped the mode of detection into two categories: Self-Detection (S-D) and Mammography (MG). Diagnosis delay was defined as the time between detection and a histologically confirmed diagnosis of invasive Bca. 20.9% detected Bca with MG while 79.1% had S-D Bca. Women who detected Bca themselves (S-D) were more likely to delay breast cancer diagnosis than women who were diagnosed by a mammography (MG) (OR: 2.0; 95% CI: 1.39-2.87); when considering the model adjusted for health system-related characteristics, the risk increased (OR: 2.13; 95% CI: 1.47-3.09). Our study indicates a disadvantage in terms of diagnostic delay for women who were admitted and treated in community hospitals compared to women admitted and treated in breast health services.

Association of routine pretreatment magnetic resonance imaging with time to surgery, mastectomy rate, and margin status

BACKGROUND

The benefit of breast MRI for newly diagnosed breast cancer patients is uncertain. This study characterizes those receiving MRI versus those who did not, and reports on their short-term surgical outcomes, including time to operation, margin status, and mastectomy rate.

STUDY DESIGN

All patients seen in a multidisciplinary breast cancer clinic from July 2004 to December 2006 were retrospectively reviewed. Patients were evaluated by a radiologist, a pathologist, and surgical, radiation, and medical oncologists.

RESULTS

Among 577 patients, 130 had pretreatment MRIs. MRI use increased from 2004 (referent, 13%) versus 2005 (24%, p=0.014) and 2006 (27%, p=0.002). Patients having MRIs were younger (52.5 versus 59.0 years, p < 0.001), but its use was not associated with preoperative chemotherapy, family history of breast or ovarian cancer, presentation, or tumor features. MRI was associated with a 22.4-day delay in pretreatment evaluation (p=0.011). Breast conserving therapy (BCT) was attempted in 320 of 419 patients with complete surgical data. The odds ratio for mastectomy, controlling for T size and stage, was 1.80 after MRI versus no MRI (p=0.024). Patients having MRIs did not have fewer positive margins at lumpectomy (21.6% MRI versus 13.8% no MRI, p=0.20), or conversions from BCT to mastectomy (9.8% MRI versus 5.9% no MRI, p=0.35).

CONCLUSIONS

Breast MRI use was not confined to any particular patient group. MRI use was not associated with improved margin status or BCT attempts, but was associated with a treatment delay and increased mastectomy rate. Without evidence of improved oncologic outcomes as a result, our study does not support the routine use of MRI to select patients or facilitate the performance of BCT.

Mapping patients' experiences from initial change in health to cancer diagnosis: a qualitative exploration of patient and system factors mediating this process

Delays in the diagnosis of cancer are common, and they are attributed to both patient and healthcare system factors. Minimizing such delays and improving early detection rates is a key goal of the new cancer reform strategy in England, in light of recent data showing that survival rates in the UK are low. The aim of this study was to explore the pathway from initial persistent change in health to diagnosis of cancer in a sample of patients from seven diagnostic groups in the UK and the factors mediating this process. Qualitative interviews with patients diagnosed with cancer were carried out. Seventy-five cancer patients discussed their pre-diagnosis experience as part of a broader exploration of their symptom experience for a larger study. Data were analysed by using content analysis and chart events. A broader range of mediating factors affecting and extending the patient pathway to diagnosis were reported in relation to lung, gastrointestinal and head and neck cancers and lymphoma, compared with breast, gynaecological and brain cancer patients. Many of the mediating factors were patient-related (e.g. misattribution of symptoms to common ailments, underestimation of the seriousness of the symptoms, self-medication or monitoring of symptoms, etc.). Primary care practitioner-factors were also prominent, including the exploration of firstly more common possibilities for treating the presenting symptoms without follow-up of persisting symptoms. Public health education about common cancer signs and symptoms, educational approaches in primary care to improve early diagnoses of cancer and updated guidelines for referral of suspected cancers should be enhanced before we can see any improvements in survival rates from cancer in the UK.

“Nothing is Wrong, Doctor”: Understanding and Managing Denial in Patients with Cancer

From a psychological perspective, denial is the process by which the mind defends itself against painful or threatening thoughts, feelings, perceptions, or information and may manifest in healthy or sick persons as well as in patients or those who care for them. For someone with a possible cancer diagnosis, there are several individual steps involved in the denial process, as the threatened meaning of one or more symptoms is sculpted into a more acceptable reality. Although most often felt to be a dysfunctional response, denial of illness is widespread and may serve an important adaptive or coping function, especially in a person facing the challenge of cancer. It may help a person cope with the various stages of their illness and treatment by allowing them time to process distressing information at a manageable rate. However, denial may also be dysfunctional, especially if it causes delay in seeking treatment for symptoms that present in the context of a true malignancy. Many clinicians misdiagnose denial when avoidance, disavowal, or another coping mechanism is invoked or when cognitive impairment or sensory deficits adversely affect perception. This article discusses denial in the context of cancer diagnosis, treatment, and prognosis and strategies for managing this common condition.

Process of care failures in breast cancer diagnosis

BACKGROUND

Process of care failures may contribute to diagnostic errors in breast cancer care.

OBJECTIVE

To identify patient- and provider-related process of care failures in breast cancer screening and follow-up in a non-claims-based cohort.

DESIGN

Retrospective chart review of a cohort of patients referred to two Boston cancer centers with new breast cancer diagnoses between January 1, 1999 and December 31, 2004.

PARTICIPANTS

We identified 2,275 women who reported > or =90 days between symptom onset and breast cancer diagnosis or presentation with at least stage II disease. We then selected the 340 (14.9%) whose physicians shared an electronic medical record. We excluded 238 subjects whose records were insufficient for review, yielding a final cohort of 102 patients.

INTERVENTIONS

None

MEASUREMENTS

We tabulated the number and types of process of care failures and examined risk factors using bivariate analyses and multivariable Poisson regression.

MAIN RESULTS

Twenty-six of 102 patients experienced > or =1 process of care failure. The most common failures occurred when physicians failed to perform an adequate physical examination, when patients failed to seek care, and when diagnostic or laboratory tests were ordered but patients failed to complete them. Failures were attributed in similar numbers to provider- and patient-related factors (n = 30 vs. n = 25, respectively). Process of care failures were more likely when the patient's primary care physician was male (IRR 2.8, 95% CI 1.2 to 6.5) and when the patient was non-white (IRR 2.8, 95% CI 1.4 to 5.7).

CONCLUSIONS

Process failures were common in this patient cohort, with both clinicians and patients contributing to breakdowns in the diagnostic process.

The Breast and Cervical Cancer Prevention and Treatment Act in Georgia: effects on time to Medicaid enrollment

BACKGROUND

Implementation of the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (BCCPTA) allowed states to extend Medicaid to any woman aged <65 without insurance screened and found to need treatment either for breast or cervical cancer or for a precancerous cervical condition through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) or in Georgia, other provider sites.

METHODS

The authors used linked Georgia Comprehensive Cancer Registry (GCCR) and Medicaid data to test the: 1) likelihood of Medicaid enrollment in a given month and 2) time-to-enrollment (months) for those eventually enrolling. The authors used difference-in-differences analysis to estimate the effects of BCCPTA for breast or cervical cancer cases relative to a control group of women with other cancers. The authors controlled for sociodemographics, stage at diagnosis, year of diagnosis, and county level factors related to insurance levels in the area.

RESULTS

Compared with the control cancer group, the hazard ratio of Medicaid enrollment for women with breast and cervical cancers increased post- vs pre-BCCPTA implementation. The estimated effect of this increase was that out of every 1000 women with breast cancer, BCCPTA led to 1.7 more (from 2.8 to 4.5 per month) enrolling in Medicaid. The results for women with local or later stages of cervical cancer indicated that of 1000 women with these cancers, the number enrolling in a given month increased by 3.4 due to BCCPTA. Results on time-to-enrollment indicated that the time between cancer diagnosis and enrollment was shortened by 7 to 8 months.

CONCLUSIONS

The Georgia Medicaid program, in response to national legislation, increased the probability of women enrolling in Medicaid earlier and in turn, likely increased their cancer treatment options.

[Implication of late diagnosis for survival of patients with colorectal carcinoma]

BACKGROUND/AIM

Colorectal cancer (CRC) is one of the most frequent diseases and early diagnosis has a potential role to improve survival. The aim of this study was to analyze influence of delay in diagnosis on survival in patiens with colorectal cancer.

METHODS

A total of 119 patients with pathohystological diagnosis of CRC were included in the study. They were operated at our Department for Surgery from 2000 to 2002. They were divided into two groups according to the duration of symptoms: early operated patients - EOP (symptoms were presented for 3 months) and late operated patients - LOP (duration of symptoms was more than 3 months). Follow-up period was 5 year.

RESULTS

Weight loss, intermittent abdominal pain and anorexia were more frequent in LOP (p < 0.01). Young age, blood in stool, and tumor localized in rectum were dominant characteristics in EOP (p < 0.05). Overall delay in diagnosis was 2.19 +/- 0.79 months in EOP and 11.37 +/- 5.68 months in LOP. There was highly statistically significant difference between these two groups (p < 0.01). Overall survival was 44.75%. Five years survival was 65.9% in the group of EOP and 26.5% in the group of LOP (chi2 = 28.16, p < 0.01) Weight loss was dominant characteristics in the patients who did not survive five years (chi2 = 14.26, p < 0.01). A period of 2 months in delay in diagnosis is "cut-off' value in prediction of death (sensitivity of 75.5% and specificity of 90.3%).

CONCLUSION

A delay in diagnosis and stage of the disease are highly significant factors of patients with CRC survival. In everyday medical practice higher importance should be put on weight loss, intermittent abdominal pain, change in bowel habits, as well as on syderopenic anaemia.

Knowledge of risk factors, beliefs and practices of female healthcare professionals towards breast cancer in a tertiary institution in Lagos, Nigeria

Background

Breast cancer is the leading female malignancy in Nigeria. Screening for early detection has led to reduction in mortality from the disease. It is known that attitudes of physicians and motivation by community nurses influence uptake of screening methods by women. This study aims to investigate knowledge of breast cancer risk factors, beliefs about treatment and practice of screening methods among a cohort of female healthcare professionals in Lagos, Nigeria.

Methods

A cross-sectional study was conducted using a self-administered questionnaire to assess the knowledge of breast cancer risk factors, beliefs about treatment and practice of screening methods among 207 female doctors, nurses and other healthcare professionals working in a university teaching hospital in Lagos, Nigeria. Stratified random sampling method was employed. Chi square test, analysis of variance and Mantel-Haenszel test were performed in data analysis using SPSS v10.0 and Epi Info version 6 statistical packages.

Results

Female doctors obtained a mean knowledge score of 74% and were the only professional group that had satisfactory knowledge of risk factors. Majority (86%) believed that early breast cancer is curable while half of participants believed that prayer can make breast cancer disappear from the affected breast. Eighty three percent practice breast self-examination (BSE) once a month and only 8% have ever had a mammogram. Age, knowledge of risk factors, profession and beliefs were not significantly associated with rate of BSE in this study.

Conclusion

Results from this study suggest the need for continuing medical education programmes aimed at improving knowledge of breast cancer among female healthcare providers other than doctors.

Factors influencing women in seeking help from a health care professional on self discovery of a breast symptom, in an Irish context

AIM

To identify the extent of delay and the factors influencing women in seeking help from a health care professional on self discovery of a breast symptom, in an Irish context.

BACKGROUND

Breast cancer is the most common malignancy among women in the developed world. In Ireland, 2700 women are diagnosed with breast cancer and over 900 die from it annually. A longer delay in presenting with breast symptoms is associated with a lower rate of survival from breast cancer. However, many women wait for longer than three months before presenting to a health care professional on self discovery of a breast symptom.

DESIGN

A quantitative correlational design was used.

METHODS

Data were collected using the 'Women's help seeking for breast symptoms' questionnaire. Women were recruited in the breast clinic prior to their visit with the consultant.

RESULTS

A total of 100 women participated, 99 of whom fully completed the questionnaire. Mean age was 40 years. It was found that 72.7% (n = 73) of women visited their GP within one month, 14.1% (n = 14) within one to three months and 10% (n = 12) after three months. Delay time was significantly related to women's knowledge and beliefs and social issues. Conversely, help seeking also correlated to women's knowledge and beliefs about the symptom and the anxiety surrounding the initial symptom discovery period.

CONCLUSION

Despite breast health promotion campaigns, many women delay for one month or more, in seeking help from a health care professional for self discovered breast symptoms. Prolonged delay has potential to impact on survival from breast cancer. This highlights the need for continued education and breast health promotion for women.

RELEVANCE TO CLINICAL PRACTICE

Health care professionals need to be aware of possible reasons for delay in seeking help for self discovered breast symptoms and explore new ways to address these barriers.

Factors influencing time between biopsy and definitive surgery for malignant melanoma: do they impact clinical outcome?

BACKGROUND

Whether time between biopsy and surgery for malignant melanoma affects clinical outcomes is sparsely defined. This study evaluated factors influencing surgical interval and surgical interval effect on outcomes.

METHODS

We performed a review of a prospective 10-year, single-institution database.

RESULTS

There were 473 patients treated for 478 malignant melanomas. The mean surgical interval was 30.5 days. The mean thickness was 2.1 mm; 46% of patients had a surgical interval of more than 28 days whereas 8% had a surgical interval of more than 56 days. Residual melanoma was found at excision in 170 (36%) patients. Age, sex, and referral source significantly affected surgical interval, however, lesion thickness, sentinel lymph node status, ulceration, and residual melanoma at excision did not. In univariate Cox models, neither a surgical interval of 28 or less nor less than 56 days showed better overall survival (OS) or disease-free survival (DFS). In multivariate Cox models of OS and DFS including lesion thickness, sentinel lymph node status, ulceration, and residual melanoma at excision, neither a surgical interval of 28 days or fewer nor a surgical interval of 56 days or fewer significantly affected outcomes.

CONCLUSIONS

Age, sex, referral source, and lesion thickness were associated with surgical interval. Immediate surgery for malignant melanoma does not significantly impact OS or DFS.

A prospective study of peri-diagnostic and surgical wait times for patients with presumptive colorectal, lung, or prostate cancer

The objective of this study was to prospectively measure peri-diagnostic and surgical time intervals for patients with suspected colorectal, lung, or prostate cancer. Prospective eligible patients were referred to a regional hospital in Ottawa, Canada between February 2004 and February 2005 for diagnostic assessment of presumptive colorectal, lung, or prostate cancer. Chart abstractions were used to measure nine time intervals; the primary interval was the date of referral for diagnostic assessment to the date the patient was informed of the diagnosis. Health-related quality-of-life (HRQL) was assessed 5 days following the patient being informed of their diagnosis. The median (IQR) time for the primary interval was 71 (30-110), 37 (29-49), and 81 (56-100) days for colorectal, lung, and prostate patients, respectively (Kruskal-Wallis P=0.0001). This interval was significantly less for colorectal patients diagnosed with cancer than for those without cancer (median difference=59.0 days; Wilcoxon P=0.003). No differences in HRQL existed for patients with cancer and those without. Colorectal and prostate patients wait longer between referral for suspected cancer and being informed of their diagnosis than current recommendations. The shorter diagnostic intervals for colorectal patients with cancer suggest clinicians have an effective process for triaging patients referred for diagnostic assessment.

Delayed diagnosis of breast cancer in women recalled for suspicious screening mammography

PURPOSE

To determine the frequency, pathology and causes of a delay in cancer diagnosis in women recalled for suspicious screening mammography.

METHODS

We included all 290,943 screening mammograms of women aged 50-75 years, who underwent biennial screening mammography between 1st January 1995 and 1st January 2006. During a follow-up period of at least 2 years, clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all 3513 women with a positive screening result. Tumour stages of breast cancers with a diagnostic delay (defined as breast cancer confirmation more than 3 months following a positive mammography screen) were compared with those of cancers diagnosed within 3 months following referral and with interval cancers.

RESULTS

A diagnostic delay occurred in 97 (6.5%) of 1503 screen-detected cancers. These 97 false-negative assessments comprised significantly more ductal cancers in situ (26.8%) than did cancers with an adequate assessment after recall (15.5%, p=0.004) or interval cancers (3.7%, p<0.001). Compared with interval cancers, cancers with a false-negative assessment had a more favourable tumour size (T1a-c, 87.3% versus T1a-c, 46.4%; p<0.001) and showed significantly fewer cases with axillary lymph node metastases (22.5% versus 48.2%; p<0.001). Between hospitals having performed the workup of at least 500 referred women each, the percentage of women with a false-negative assessment varied from 5.0% to 9.1% (p=0.03). In these hospitals, improper classification of lesions at diagnostic mammography comprised 64.4% of false-negative assessments.

CONCLUSION

We found that 6.5% of recalled women experienced a delay in breast cancer diagnosis, with significant performance variations between hospitals.

Prognostic implications of emergency admission and delays in patients with breast cancer

INTRODUCTION

This study evaluates clinical-pathological characteristics and survival rates associated with emergency admission and delays in diagnosis and treatment of 411 consecutive breast cancer patients.

MATERIALS AND METHODS

Emergency admission and first symptom-first hospital visit delay were significantly associated with advanced tumor stages but only in the former case with short disease-free survival (RR 2.5, CI 95% 1.5-4.2).

RESULTS

Brief diagnostic delays were significantly associated with advanced disease stage and poor survival rates (RR 2.04; CI 95% 1.08-3.82) probably because sicker patients receive prompt medical attention.

Breast cancer survival among economically disadvantaged women: the influences of delayed diagnosis and treatment on mortality

Breast cancer affects thousands each year in the United States, and disproportionately affects certain subgroups. For example, the incidence of breast cancer in South Carolina is lower in African American compared with European American women by approximately 12% to 15%, but their mortality rate is twice as high as in European American women. The purpose of the study was to assess factors associated with breast cancer mortality between African American and European American women. Participants (n=314) in South Carolina's Breast and Cervical Cancer Early Detection Program (SCBCCEDP), which provides breast cancer screening and treatment services, during the years 1996-2004 were included in the study. Data, including tumor characteristics, delay intervals, and race, were examined using the chi(2) test and the Wilcoxon rank-sum test. Cox regression modeling was used to assess the relationship between delay intervals and other factors. No racial differences were found in age at diagnosis, tumor characteristics, or delay intervals. Time delay intervals did not explain differences and mortality rates by race. Survival, however, was affected by prognostic factors as well as by a significant interaction between hormone-receptor status and race. Despite the excellent record of the SCBCCEDP in screening and diagnostic or treatment referrals, the racial disparities in breast cancer mortality continue to exist in South Carolina. These findings highlight the need for future research into the etiology of racial differences, and their impact on breast cancer survival.

Delays in diagnosis and treatment among children and adolescents with cancer in Canada

BACKGROUND

Few studies have investigated delays in diagnosis and treatment among children and adolescents with cancer, especially from the perspective of an entire country. Detailed understanding of delays along the continuum of cancer patient care is important in order to establish appropriate benchmarks for timely oncological care. Our objective was to characterise the different components of delay in 2,896 Canadian children and adolescents (aged 0-19 years) with cancer that were enrolled in the Treatment and Outcome Surveillance component of the Canadian Childhood Cancer Surveillance and Control Program from 1995 to 2000.

PROCEDURE

We examined median and standardised means concerning the distribution of delay times across categories of pertinent variables and over time. The word "delay" was used simply to represent a time interval, measured in days, without implying whether this interval exceeded a particular threshold of clinical acceptability.

RESULTS

The median times (and inter-quartile ranges) for patient, diagnosis and healthcare system delays for all cancers were 9 (1-31), 30 (13-69) and 12 (4-35) days, respectively. The median total delay was 34 (16-76) days.

CONCLUSIONS

Patient and referral delays were the longest time segments influencing timely diagnosis. Differences in delays were observed across age groups, cancer types and geographical regions. There was a significant trend for decreasing delays to diagnosis and treatment.