Delay versus help seeking for breast cancer symptoms: a critical review of the literature on patient and provider delay

Non-practice of breast self examination and marital status are associated with delayed presentation with breast cancer

Delay in seeking treatment for breast cancer is a barrier to the early diagnosis and management of the disease, resulting in a poorer prognosis. We here estimated the prevalence of delayed presentation for breast cancer and identified possible influential sociodemographic factors in a cross-sectional study of 250 patients diagnosed with primary breast cancer at the Radiotherapy and Oncology Clinic in Kuala Lumpur Hospital. Data were collected by face-to-face interview using a structured questionnaire and from medical records. We examined associations between delayed presentation (presenting to a physician more than 3 months after self-discovery of a symptom) and sociodemographic characteristics, practice of breast self examination (BSE), history of benign breast disease, family history of breast cancer and type of symptom, symptom disclosure and advice from others to seek treatment using multiple logistic regression. Time from self-discovery of symptom to presentation ranged from tghe same day to 5 years. Prevalence of delayed presentation was 33.1% (95%CI: 27.4, 39.3). A significantly higher proportion of delayers presented with late stages (stage III/IV) (58.3% vs. 26.9%, p<0.001). Divorced or widowed women (OR: 2.23, 95% CI: 1.11, 4.47) had a higher risk of delayed presentation than married women and women who never performed breast self examination were more likely to delay presentation compared to those who regularly performed BSE (OR: 2.74, 95% CI: 1.33, 5.64). Our findings indicate that delayed presentation for breast cancer symptoms among Malaysian women is high and that marital status and breast self examination play major roles in treatment-seeking for breast cancer symptoms.

Breast cancer patients' experiences within and outside the safety net

BACKGROUND

Following reforms to the breast-cancer referral process for our city's health Safety Net (SN), we compared the experiences from first abnormality to definitive diagnosis of breast-cancer patients referred to Siteman Cancer Center from SN and non-SN (NSN) providers.

MATERIALS AND METHODS

SN-referred patients with any stage (0-IV) and NSN-referred patients with late-stage (IIB-IV) breast cancer were prospectively identified after diagnosis during cancer center consultations conducted between September 2008 and June 2010. Interviews were taped and transcribed verbatim; transcripts were independently coded by two raters using inductive methods to identify themes.

RESULTS

Of 82 eligible patients, 57 completed interviews (33/47 SN [70%] and 24/35 NSN [69%]). Eighteen SN-referred patients (52%) had late-stage disease at diagnosis, as did all NSN patients (by design). A higher proportion of late-stage SN patients (67%) than either early-stage SN (47%) or NSN (33%) patients reported feelings of fear and avoidance that deterred them from pursuing care for concerning breast findings. A higher proportion of SN late-stage patients than NSN patient reported behaviors concerning for poor health knowledge or behavior (33% versus 8%), but reported receipt of timely, consistent communication from health care providers once they received care (50% versus 17%). Half of late-stage SN patients reported improper clinical or administrative conduct by health care workers that delayed referral and/or diagnosis.

CONCLUSIONS

Although SN patients reported receipt of compassionate care once connected with health services, they presented with higher-than-expected rates of late-stage disease. Psychological barriers, life stressors, and provider or clinic delays affected access to and navigation of the health care system and represent opportunities for intervention.

The importance of contextualization. Anthropological reflections on descriptive analysis, its limitations and implications

This paper regards a concern for the quality of analyses made on the basis of qualitative interviews in some parts of qualitative health research. Starting with discussions departing in discussions on studies exploring 'patient delay' in healthcare seeking, it is argued that an implicit and simplified notion of causality impedes reflexivity on social context, on the nature of verbal statements and on the situatedness of the interview encounter. Further, the authors suggest that in order to improve the quality of descriptive analyses, it is pertinent to discuss the relationship between notions of causality and the need for contextualization in particular. This argument targets several disciplines taking a qualitative approach, including medical anthropology. In particular, researchers working in interdisciplinary fields face the demands of producing knowledge ready to implement, and such demands challenge basic notions of causality and explanatory power. In order to meet these, the authors suggest an analytic focus on process causality linked to contextualization.

Journey of patients with cancer: a systematic evaluation at tertiary care center in India

In cancer patients early institution of therapy placed a very important role and delay in the diagnosis and treatment can cause catastrophe. Affirm step to cut shot this delay requires detailed information about each step of patient referral journey and for fulfillment of above aim, we interviewed 101 patients, to calculate the elapsed time at each step. Result revealed that onset of symptoms to median time of presentation to general practitioner is 20 (9 - 28) days, time consumed in state based hospital is 100 (15- 167) days while in Delhi based hospital is 56 (18 - 100) days. Higher cure rate (38.2%) in patients presented within 3 months of development of cancer symptoms than those presented late. Study concluded that primary physician and all the referral hospital attributed important role in early diagnosis and treatment of cancer.

Causes of delay in seeking treatment in patients with breast cancer in Iran: a qualitative content analysis study

BACKGROUND

In the Middle East, including Iran, breast cancer is the most frequent malignancy among women. Without treatment, a malignant breast tumor advances in stage, diminishing a woman's chances of survival. In this study we aimed to gain insight into the causes of delay in seeking treatment in patients with breast cancer.

METHODS

The participants in this qualitative, content analysis study were 10 women in whom a diagnosis of breast cancer in the stages of II b, III or IIV had been made. They were selected from patients of a major oncology clinic in Kerman, Iran. Data were collected by means of semi-structured interviews that lasted between 20 to 30 minutes. Sampling was discontinued when data saturation was achieved. Content analysis was conducted by classifying the data into themes and sub-themes.

RESULTS

The results of our study revealed several factors that interfered with patients' professional consultation seeking and prompt treatment. These factors included; lack of knowledge, fear of being diagnosed with cancer, not seeing oneself at risk, mental preoccupation and wrong diagnosis by physicians.

CONCLUSIONS

This study suggests that women and even physicians need further information about breast cancer symptoms. Women need encouragement to seek medical advice when they encounter suspicious symptoms. Additionally, women may benefit from awareness of the pros of early detection and reassurance about the improvements in the success of breast cancer treatment.

Ovarian cancer symptom awareness and anticipated time to help-seeking for symptoms among UK women

OBJECTIVES

To determine levels of awareness of ovarian cancer symptoms and to identify barriers to help-seeking and predictors of a longer time to help-seeking in a UK female population-based sample.

METHODS

A UK population-based sample of women [n=1000, including a subsample of women at higher risk due to their age (≥45 years, n=510)] completed the Ovarian Cancer Awareness Measure by telephone interview. Questions measured symptom awareness (using recall and recognition), barriers to medical help-seeking and anticipated time to help-seeking. Regression analyses identified predictors of a higher score on a scale of anticipated time to help-seeking.

RESULTS

Most women (58% overall sample; 54% subgroup) were unable to recall any symptoms but 99% recognised at least one. Recognition was lowest for difficulty eating and persistently feeling full. In the sample overall, higher socio-economic status and higher endorsement of practical and service barriers independently predicted a longer anticipated time to help-seeking for more symptoms. White ethnicity was an additional predictor in the older subgroup.

CONCLUSIONS

This study suggests awareness of ovarian cancer symptoms is low in the UK, and varies widely between symptoms. It identifies variables that may be involved in a longer time to help-seeking for possible ovarian cancer symptoms and highlights the need for more in-depth research into the factors related to time to help-seeking in real-world situations.

Care-seeking behavior of Japanese gynecological cancer survivors suffering from adverse effects

Background

Post-treatment follow-up visits for gynecological cancer survivors should provide opportunities for management of adverse physical/psychological effects of therapy and early recurrence detection. However, the adequacy of such visits in Japan is poorly documented. We qualitatively explored care-seeking experiences of Japanese gynecological cancer survivors and deduced factors influencing care-seeking behaviors and treatment access.

Methods

We conducted 4 semi-structured focus groups comprising altogether 28 Japanese gynecological cancer survivors to collect a variety of participants’ post-treatment care-seeking behaviors through active interaction with participants. Factors influencing access to treatment for adverse effects were analyzed qualitatively.

Results

Survivors sought care through specialty clinic visits when regular post-treatment gynecological follow-ups were inadequate or when symptoms seemed to be non-treatment related. Information provided by hospital staff during initial treatment influenced patients’ understanding and response to adverse effects. Lack of knowledge and inaccurate symptom interpretation delayed help-seeking, exacerbating symptoms. Gynecologists’ attitudes during follow-ups frequently led survivors to cope with symptoms on their own. Information from mass media, Internet, and support groups helped patients understand symptoms and facilitated care seeking.

Conclusions

Post-treatment adverse effects are often untreated during follow-up visits. Awareness of possible post-treatment adverse effects is important for gynecological cancer survivors in order to obtain appropriate care if the need arises. Consultation during the follow-up visit is essential for continuity in care.

Development and validation of a questionnaire to assess delay in treatment for breast cancer

Background

This study reports the reliability and validity of a questionnaire designed to measure the time from detection of a breast cancer to arrival at a cancer hospital, as well as the factors that are associated with delay.

Methods

The proposed questionnaire measures dates for estimation of the patient, provider and total intervals from detection to treatment, as well as factors that could be related to delays: means of problem identification (self-discovery or screening), the patients’ initial interpretations of symptoms, patients’ perceptions of delay, reasons for delay in initial seeking of medical care, barriers perceived to have caused provider delay, prior utilisation of health services, use of alternative medicine, cancer-screening knowledge and practices, and aspects of the social network of support for medical attention. The questionnaire was assembled with consideration for previous research results from a review of the literature and qualitative interviews of patients with breast cancer symptoms. It was tested for face validity, content validity, reliability, internal consistency, convergent and divergent validity, sensitivity and specificity in a series of 4 tests with 602 patients.

Results

The instrument showed good face and content validity. It allowed discrimination of patients with different types and degrees of delay, had quite good reliability for the time intervals (with no significant mean differences between the two measurements), and fairly good internal consistency of the item dimensions (with Cronbach’s alpha values for each dimension between 0.42 and 0.85). Finally, sensitivity and specificity were 74.68% and 48.81%, respectively.

Conclusions

To the best of our knowledge, this is the first published report of the development and validation of a questionnaire for estimation of breast cancer delay and its correlated factors. It is a valid, reliable and sensitive instrument.

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

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

Patient and process factors associated with late-stage breast cancer diagnosis in Safety-Net patients: a pilot prospective study

BACKGROUND

Following reforms to our city's Safety-Net (SN) breast cancer referral process, we investigated whether factors often associated with late-stage diagnosis would differ by referral source--SN versus non-Safety-Net (NSN)--or, among SN patients, by stage at diagnosis.

METHODS

From September 2008 to June 2010, SN patients with any-stage (0-IV) and NSN patients with late-stage (IIB-IV) breast cancer were identified prospectively during initial cancer-center consultations. Data were analyzed using logistic regression, chi-square, and t tests; two-tailed P < 0.05 was considered significant.

RESULTS

Fifty-seven women completed interviews (33 SN, 24 NSN); 52% of SN-referred patients were diagnosed with late-stage disease. Compared with NSN late-stage patients, SN late-stage patients were more likely to be African-American (83% vs. 21%, P < 0.001), to have an annual household income <$25,000 (89% vs. 38%, P < 0.001), and to report having a health problem in the preceding year but not being able to see a doctor because of cost (67% vs. 25%, P = 0.012); they were less likely to be married/partnered (22% vs. 79%, P < 0.001) and to have post-college education (0% vs. 25%, P < 0.03), any insurance (61% vs. 96%, P < 0.005), and to have sought medical attention within 1 week of realizing they had concerning breast findings (50% vs. 79%, P = 0.047). Married/partnered patients were more likely to delay medical care by >1 week (odds ratio = 9.9, P = 0.038).

CONCLUSIONS

SN patients presented with higher-than-expected rates of late-stage disease despite improvements in mammography rates and the referral process. Efforts to further facilitate access to care for this vulnerable SN patient population are needed.

Diagnosis delay in Libyan female breast cancer

AIMS

To study the diagnosis delay and its impact on stage of disease among women with breast cancer on Libya.

METHODS

200 women, aged 22 to 75 years with breast cancer diagnosed during 2008-2009 were interviewed about the period from the first symptoms to the final histological diagnosis of breast cancer. This period (diagnosis time) was categorized into 3 periods: <3 months, 3-6 months, and >6 months. If diagnosis time was longer than 3 months, the diagnosis was considered delayed (diagnosis delay). Consultation time was the time taken to visit the general practitioner after the first symptoms. Retrospective preclinical and clinical data were collected on a form (questionnaire) during an interview with each patient and from medical records.

RESULTS

The median of diagnosis time was 7.5 months. Only 30.0% of patients were diagnosed within 3 months after symptoms. 14% of patients were diagnosed within 3-6 months and 56% within a period longer than 6 months. A number of factors predicted diagnosis delay: Symptoms were not considered serious in 27% of patients. Alternative therapy (therapy not associated with cancer) was applied in 13.0% of the patients. Fear and shame prevented the visit to the doctor in 10% and 4.5% of patients, respectively. Inappropriate reassurance that the lump was benign was an important reason for prolongation of the diagnosis time. Diagnosis delay was associated with initial breast symptom(s) that did not include a lump (p < 0.0001), with women who did not report monthly self examination (p < 0.0001), with old age (p = 0.004), with illiteracy (p = 0.009), with history of benign fibrocystic disease (p = 0.029) and with women who had used oral contraceptive pills longer than 5 years (p = 0.043). At the time of diagnosis, the clinical stage distribution was as follows: 9.0% stage I, 25.5% stage II, 54.0% stage III and 11.5% stage IV.Diagnosis delay was associated with bigger tumour size (p <0.0001), with positive lymph nodes (N2, N3; p < 0.0001), with high incidence of late clinical stages (p < 0.0001), and with metastatic disease (p < 0.0001).

CONCLUSIONS

Diagnosis delay is very serious problem in Libya. Diagnosis delay was associated with complex interactions between several factors and with advanced stages. There is a need for improving breast cancer awareness and training of general practitioners to reduce breast cancer mortality by promoting early detection. The treatment guidelines should pay more attention to the early phases of breast cancer. Especially, guidelines for good practices in managing detectable of tumors are necessary.

The effect of age on delay in diagnosis and stage of breast cancer

BACKGROUND

Young women with breast cancer are more likely to present with more advanced disease and are more likely to die as a result of breast cancer than their older counterparts. We sought to examine the relationship among young age (≤40 years), the likelihood of a delay in diagnosis, and stage.

METHODS

We examined data from women with newly diagnosed stage I-IV breast cancer presenting to one of eight National Comprehensive Cancer Network centers in January 2000 to December 2007. Delay in diagnosis was defined as time from initial sign or symptom to breast cancer diagnosis >60 days.

RESULTS

Among 21,818 women with breast cancer eligible for analysis, 2,445 were aged ≤40 years at diagnosis. Young women were not more likely to have a delay in diagnosis >60 days (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.98-1.19) after adjustment for type of initial sign or symptom. Young women were only modestly more likely to present with higher stage disease after a similar adjustment (OR, 1.18; 95% CI, 1.07-1.31). Women presenting with symptomatic disease, more common in younger women, were more likely to have a delay in diagnosis (OR, 3.31; 95% CI, 3.08-3.56) and higher stage (OR, 4.31; 95% CI 4.05-4.58).

CONCLUSION

Young age is not an independent predictor of delay in diagnosis of breast cancer and only modestly is associated with higher stage disease. Presenting with symptoms of breast cancer predicts delay and higher stage at diagnosis.

Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study

OBJECTIVES

To find out factors that are responsible for the patient or provider delays in the diagnosis of breast cancer in India.

DESIGN

This prospective study was designed to be conducted over a period of two years including a cohort of 100 patients with locally advanced breast cancer. The delays were assessed using questionnaires prepared according to the Indian scenario.

SETTING

A prospective study in an Indian setting.

PARTICIPANTS

One hundred patients with locally advanced breast cancer receiving neoadjuvant chemotherapy were included after providing informed consent and receiving ethical committee clearance.

MAIN OUTCOME MEASURES

The most common factor responsible for delays in diagnosis was observed to be the health providers, although illiteracy and lack of adequate healthcare services also contributed significantly. Unregistered medical practitioners or quacks contributed significantly to the delays in reporting and diagnosis of the disease.

RESULTS

One hundred patients of locally advanced breast cancer were evaluated using standardized questionnaires to assess the delays in diagnosis. Provider delays were found to be significant (the unregistered doctors or quacks being a significant cause of delays).The average time lapse before diagnosis for rural patients was higher (67.5 days) compared to urban patients (53.7 days). The literacy levels of the patients also had a significant impact on the delays at diagnosis. The delay in illiterates was 60.6 days compared to 49.5 days for literates.

CONCLUSIONS

The most common factor responsible for delays in reporting and diagnosis was observed to be at the end of the health providers, although illiteracy and lack of adequate healthcare services also contributed significantly. Unregistered medical practitioners or quacks contributed significantly to the delays in reporting and diagnosis of the disease.

Does the organizational structure of health care systems influence care-seeking decisions? A qualitative analysis of Danish cancer patients' reflections on care-seeking

OBJECTIVE

The absence of a more significant improvement in cancer survival in countries such as the UK and Denmark may be partly rooted in delayed care-seeking among cancer patients. Past research on patient delay has mainly focused on patient characteristics (e.g. sociodemographic and psychological factors and symptom recognition) as causes of delayed care-seeking, while few studies have examined how the organizational structure of health care systems may influence patients' reflections on seeking care. The aim of this study was to explore this relationship.

DESIGN

The analysis presented is based on semi-structured interviews with 30 cancer patients and their families.

RESULTS

The article raises two hypotheses on the relationship between structural elements of a health care system and people's reflections on seeking health care: (1) Gatekeeping introduces an asymmetrical relationship between the patient and the GP which potentially results in self-restricting care-seeking, (2) Continuity in the doctor-patient relationship may negatively influence patient reflections on access to health care, as the focus shifts from the medical issues of the consultation to reflections on how to properly interact with the GP and the system in which she/he is situated.

CONCLUSION

It is concluded that these hypotheses form a sound basis for further primary care research on how the organizational structure of health care systems influences patient reflections on access to medical care.

Women's help seeking behaviour for self discovered breast cancer symptoms

PURPOSE OF THE RESEARCH

The aim of the study was to explore women's Help Seeking Behaviour (HSB) for a self discovered breast symptom, in order to gain understanding of women's experience of finding a breast symptom and how this influenced their HSB. In addition, the study sought to confirm the appropriateness of the "Help Seeking Behaviour & Influencing Factors" framework, for use in phase two of the study.

METHODS AND SAMPLE

A qualitative descriptive method was used involving semi-structured interviews with ten women, ranging in age from 25 to 55 years, who had discovered a breast symptom.

KEY RESULTS

Women's HSB ranged from up to one month (n = 6), one to three months (n = 2) and over three months (n = 2), following symptom discovery. The key variables linked to delayed help seeking were denial, fear, social factors and knowledge and beliefs. The study verified that the variables within the "Help Seeking Behaviour and Influencing Factors" framework act as both facilitators and barriers to women's HSB. Thus, confirming the appropriateness of this framework for a larger quantitative study of women's help seeking behaviour.

CONCLUSIONS

The study highlights that despite continued emphasis on early help seeking for breast cancer symptoms, delay is still prevalent amongst women. This reiterates the need for continued emphasis on the message of early detection for breast cancer symptoms. To this end, nurses have a significant role to play in educating women in both clinical and community settings, about breast cancer and early detection practices.

Time from Diagnosis to Surgical Treatment of Breast Cancer: Factors Influencing Delays in Initiating Treatment

No clear guidelines exist defining the appropriate time frame from diagnosis to definitive surgical treatment of breast cancer. Studies have suggested that treatment delays greater than 90 days may be associated with stage migration. We sought to evaluate demographic factors that influence 30-day and 90-day benchmarks for time from diagnosis to definitive surgical treatment of breast cancer. Between 2004 and 2007, 19,896 women with stage I to III invasive breast cancer were treated with primary surgical therapy and did not receive preoperative systemic therapy in the California Cancer Registry. Overall, 75.7 per cent of patients were treated within 30 days of diagnosis, and 95.5 per cent of patients were treated within 90 days of diagnosis. Multivariate analyses revealed that treatment delays were associated with smaller tumor size, use of total mastectomy, lower socioeconomic status, and Hispanic and nonHispanic black race/ethnicity. Furthermore, disparities in those that did not meet 30-day benchmark timeframes were exaggerated with 90-day treatment delays. These benchmarks can be used to measure disparities in health care delivery.

Patient delay in presentation of possible cancer symptoms: the contribution of knowledge and attitudes in a population sample from the United kingdom

BACKGROUND

Qualitative studies implicate knowledge of cancer symptoms and attitudes towards help-seeking as important factors in patient delay. The present study uses quantitative data from a population-based survey to test the hypotheses that (a) a greater knowledge of early cancer symptoms is associated with a higher likelihood of having appraised a symptom as possibly due to cancer, and (b) more negative attitudes towards help-seeking are associated with a lower likelihood of having sought medical advice for that symptom.

METHODS

Two thousand and seventy-one adults were asked whether they had experienced a symptom that they worried might be cancer in the past 3 months, and if so, whether they had seen a doctor. Respondents also completed the Cancer Awareness Measure (CAM) assessing symptom knowledge and barriers to help-seeking.

RESULTS

Two hundred and thirty-six (11.4%) respondents reported having experienced a possible cancer symptom. In logistic regression analyses controlling for age, sex, and self-rated health, higher CAM symptom knowledge scores were associated with a greater likelihood of having experienced a possible cancer symptom (odds ratio = 1.09; 95% confidence interval, 1.01-1.17). Of those who had experienced a symptom, 75% (177/236) had seen a doctor. Higher scores on the CAM barriers scale were associated with being less likely to have seen a doctor (odds ratio, 0.74; 95% confidence interval, 0.63-0.87).

CONCLUSIONS

Better knowledge of the signs and symptoms of cancer might help people recognize possible cancer symptoms and therefore reduce appraisal delay, whereas more positive attitudes towards help-seeking might reduce behavioral delay.

IMPACT

Campaigns to educate the public about cancer symptoms and reduce help-seeking barriers could play a role in promoting early diagnosis.

Factors associated with late presentation of cancer: a limited literature review

According to the World Health Organization (WHO 2006), cancer is one of the leading causes of death worldwide. Deaths from cancer are projected to continue rising, with an estimated 9 million people dying from cancer in 2015 and 11.4 million dying in 2030 (WHO 2006). Delayed presentation or late diagnosis of cancer is associated with low survival. The aim of this review is to identify factors associated with delayed presentation of cancer that were reported by previous studies. Published studies which identified the most common factors attributed to the late presentation of cancer were reviewed. Publications were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), the Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and EMBASE (Excerpta Medica Database) databases. A Critical Appraisal Skills Programme (CASP) was used to assess the methodological quality of the studies. A total of 24 studies met the inclusion criteria. A data extraction sheet was used to systematically record relevant factors. Twenty-four studies met the inclusion criteria which identified factors associated with patients’ delay including patients’ knowledge, stress and fear, and nature of the disease. Other factors were attributed to health providers such as general practitioner (GP) experience, referral delay, and a younger age group being considered as low risk, so symptoms were missed.

Factors that influence the incidence of breast cancer in Arica, Chile (Review)

Breast cancer is a common disease estimated to occur in 1 in 9 women over their lifetime. Epidemiological research has identified a number of risk factors for breast cancer. Racial and ethnic differences in breast cancer mortality rates have been difficult to ascertain. The present review reports that there was an increase in the incidence of breast cancer in Arica, Chile, from 1997 to 2007, particularly in 2005, reaching 55.1% per 100,000 women, while the percentage decreased in 2006 and 2007. A greater percentage of breast cancer was found in individuals between 46 and 65 years of age when the population was distributed by age. The Indian population, Aymara, had only a 13.9% incidence of the disease. The incidence for breast cancer for patients with no family background reached approximately 88%, with or without Indian ethnicity, and 98.4% of these women did not have prior hormonal therapy. When the stage of the disease and the number of pregnancies were considered, results showed that there was an increase in the progression of the disease from stage I to stage III in women that had 1-3 pregnancies. Results also showed that 20.9 and 33.2% who received prior tamoxifen treatment were in stages I and IIA, respectively. The breast cancer incidence reached 42.4% when patients had a sister with the disease. It can be concluded that important differences in the risk factors of breast cancer should be identified in the future for a comparison with other biological factors, such as genetic and molecular factors. This may provide greater insight into breast cancer aetiology in different populations.

Latina self-reported mental health and delay in health care in a new Latino destination

Understanding how depression and/or anxiety affects use of health care among Latinas in rapidly growing new Latino destinations, population where the growth rate of the Latino population exceeds the national average, may enhance community engagement efforts. Using community-based participatory research, a questionnaire assessing health care use was administered to 289 Latinas. Most (70%) reported delaying healthcare, and self-reported depression/anxiety was associated with a 3.1 fold (95% CI: 1.6-5.9) increase in delay, after adjusting for current health status, acculturation, age, education, and place of birth. Mental health disparities exist among Latinas, which are related to delays in use of health care. A gap exists regarding health education interventions for Latinas. More research is needed to identify successful models, especially in new Latino destinations as they may be particularly vulnerable to delay care.

Is early diagnosis of oral cancer a feasible objective? Who is to blame for diagnostic delay?

Worldwide, oral cancer has one of the lowest survival rates and poor prognosis remains unaffected despite recent therapeutic advances. Reducing diagnostic delay to achieve earlier detection is a cornerstone to improve survival. Thus, intervention strategies to minimize diagnostic delays resulting from patient factors and to identify groups at risk in different geographical areas seem to be necessary. The identification of a 'scheduling delay' in oral cancer justifies the introduction of additional educational interventions aimed at the whole health care team at dental and medical practices. The access to and the kind of healthcare system in a particular country are also relevant in this context, particularly the referral system. The design of a simple, clear, fail-safe, fast-track referral scheme for those suspected with cancer may diminish greatly the length of the delay. Moreover, there is a need for future investigations, which are methodologically adequate, that consider cultural and geographical aspects and use patient survival as the final outcome, that are able to recognize the agents/factors responsible for diagnostic delay by patients as well as healthcare providers and those attributable to the healthcare systems.

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.

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.

“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.

Losing faith and using faith: older African Americans discuss spirituality, religious activities, and depression

BACKGROUND AND OBJECTIVES

Older African Americans are often under diagnosed and under treated for depression. Given that older African Americans are more likely than whites to identify spirituality as important in depression care, we sought to understand how spirituality may play a role in the way they conceptualize and deal with depression in order to inform possible interventions aimed at improving the acceptability and effectiveness of depression treatment.

DESIGN

Cross-sectional qualitative interview study of older African American primary care patients.

PARTICIPANTS AND SETTING

Forty-seven older African American patients recruited from primary care practices in the Baltimore, MD area, interviewed in their homes.

MEASUREMENTS

Semi-structured interviews lasting approximately 60 minutes. Interviews were transcribed and themes related to spirituality in the context of discussing depression were identified using a grounded-theory approach.

MAIN RESULTS

Participants in this study held a faith-based explanatory model of depression with a particular emphasis on the cause of depression and what to do about it. Specifically, participants described depression as being due to a "loss of faith" and faith and spiritual/religious activities were thought to be empowering in the way they can work together with medical treatments to provide the strength for healing to occur.

CONCLUSIONS

The older African Americans in this study described an intrinsically spiritual explanatory model of depression. Addressing spirituality in the clinical encounter may lead to improved detection of depression and treatments that are more congruent with patient's beliefs and values.

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.

Concept analysis of symptom disclosure in the context of cancer

Although symptoms suggestive of cancer are the most common reason that people seek healthcare, the process undertaken to disclose the symptoms is unclear. The purpose of this article is to critically analyze the concept of symptom disclosure in the context of cancer. Rodgers' evolutionary approach was applied to analyze the concept of symptom disclosure. Concept analysis indicates that symptom disclosure is a decision-making process in which a person chooses to tell significant others and a healthcare provider about self-identified symptoms. Characteristics of the concept include symptom interpretation, weighing the risks and benefits of disclosure, and taking action. Influencing factors are knowledge, cancer risk perception, personal or family history of cancer, socioeconomic and cultural factors, and access to care. The concept analysis of symptom disclosure provides guidance for developing strategies to promote healthcare-seeking behavior in practice and suggest areas for future research.

Breast cancer screening: evidence for false reassurance?

Tumour stage distribution at repeated mammography screening is, unexpectedly, often not more favourable than stage distribution at first screenings. False reassurance, i.e., delayed symptom presentation due to having participated in earlier screening rounds, might be associated with this, and unfavourably affect prognosis. To assess the role of false reassurance in mammography screening, a consecutive group of 155 breast cancer patients visiting a breast clinic in Rotterdam (The Netherlands) completed a questionnaire on screening history and self-observed breast abnormalities. The length of time between the initial discovery of breast abnormalities and first consultation of a general practitioner ("symptom-GP period") was compared between patients with ("screening group") and without a previous screening history ("control group"), using Kaplan-Meier survival curves and log-rank testing. Of the 155 patients, 84 (54%) had participated in the Dutch screening programme at least once before tumour detection; 32 (38%) of whom had noticed symptoms. They did not significantly differ from control patients (n = 42) in symptom-GP period (symptom-GP period > or = 30 days: 31.2% in the symptomatic screened group, 31.0% in the control group; p = 0.9). Only 2 out of 53 patients (3.8%) with screen-detected cancer had noticed symptoms prior to screening, reporting symptom-GP periods of 2.5 and 4 years. The median period between the first GP- and breast clinic visit was 7.0 days (95% C.I. 5.9-8.1) in symptomatic screened patients and 6.0 days (95% C.I. 4.0-8.0) in control patients. Our results show that false reassurance played, at most, only a minor role in breast cancer screening.

Intended coping responses to cancer symptoms in healthy adults: the roles of symptom knowledge, detection behavior, and perceived threat

BACKGROUND

To date, the causal effects of the knowledge of cancer-related symptoms and detection behavior on coping with cancer-related symptoms have not been identified. Therefore, the current study explored the effects of active or passive detection of supposedly well-known or less-known cancer-related symptoms on intended coping responses. In addition, we were interested in the extent to which these effects are driven by heightened perceptions of threat.

METHODS

In an experimental study using a 2 x 2 within-subject design, 221 Dutch adults from the general population responded to a survey study sent to their homes (18.4% response). They were asked to read scenario information about four cancer-related symptoms that were (a) well known or less known and (b) actively or passively detected (e.g., self-examination versus unusual blood loss). The authors measured intended coping responses to the detection of cancer-related symptoms as either adaptive (e.g., visiting a general practitioner) or maladaptive (e.g., denial of the symptom).

RESULTS

As expected, the findings revealed that well-known symptoms resulted in more anticipated adaptive coping and less anticipated maladaptive coping than less-known symptoms. Unfortunately, the findings also suggest that the active as opposed to passive detection of cancer symptoms (e.g., self-examination versus unusual blood loss) is likely to result in more maladaptive coping. These effects were mediated by heightened perceptions of threat.

CONCLUSIONS

Future health education programs that aim to motivate people to be more active in the early detection of cancer symptoms should first focus on increasing people's knowledge about the early warning signs of cancer.

Pathways to breast cancer diagnosis and treatment: exploring the social relations of diagnostic delay

In epidemiological studies, inequitable access to breast cancer care aligns with such variables as income, age, education, ethnicity and residential location. These variables correspond to structural patterns of advantage and disadvantage, which in turn may constrain or facilitate timely access to care. The purpose of this study was to understand the complexities of women's pathways to diagnosis. Thirty-five women from diverse backgrounds and who had clinically detectable breast symptoms at time of diagnosis participated in semi-structured interviews. All were receiving or completing treatment when they participated. Data were analyzed using the strategies of induction, comparison and abduction. All of the participants described a variety of activities involved in seeking care for breast cancer. The findings illustrate how the social relations of health care, rather than simply patient or provider delay, may contribute barriers to timely diagnosis. We illustrate how women's widely differing social and material contexts offer opportunities and barriers to access.

Punjabi women's stories of breast cancer symptoms: Gulti (lumps), bumps, and Darad (pain)

The purpose of this study was to examine experiences related to self-discovered breast cancer symptoms from the perspective of Punjabi immigrant women residing in Canada. Interviews were conducted with 25 women, 19 of whom had received a diagnosis of breast cancer. Using narrative analysis, 4 types of stories were identified. In the stories that were based on constructions of breast symptoms as "nothing serious," women emphasized that they had not even considered the possibility of breast cancer and were encouraged to dismiss concerns about their health. Stories focusing on suspicions about the presence of a health problem included descriptions of mounting concern and tension as the women began to realize that the breast symptoms they experienced might not be of the regular or normal variety. In stories dominated by worry, vivid descriptions of fears of breast cancer were juxtaposed with explanations about how women protected family members by downplaying their symptoms. Finally, in stories that focused on gaining strength in readiness to deal with whatever may lie ahead, women drew on the support of their extended families, their religious beliefs, and their need to care for their families. These findings provide a basis for guiding the development of culturally appropriate health education for Punjabi women.

Failure to consult for symptoms of heart failure in patients with a type-D personality

BACKGROUND

Self-management and adequate consultation behaviour are essential for the successful treatment of chronic heart failure (CHF). Patients with a type-D personality, characterised by high social inhibition and negative affectivity, may delay medical consultation despite increased symptom levels and may be at an increased risk for adverse clinical outcomes.

AIM

To examine whether type-D personality predicts poor self-management and failure to consult for evident cardiac symptoms in patients with CHF. Design/methods/

PATIENTS

178 outpatients with CHF (aged < or =80 years) completed the type-D Personality Scale at baseline, and the Health Complaints Scale (symptoms) and European Heart Failure Self-care Behaviour Scale (self-management) at 2 months of follow-up. Medical information was obtained from the patients' medical records.

RESULTS

At follow-up, patients with a type-D personality experienced more cardiac symptoms (OR 6.4; 95% CI 2.5 to 16.3, p<0.001) and more often appraised these symptoms as worrisome (OR 2.9; 95% CI 1.3 to 6.6, p<0.01) compared with patients with a non-type-D personality. Paradoxically, patients with a type-D personality were less likely to report these symptoms to their cardiologist/nurse, as indicated by an increased risk for inadequate consultation behaviour (OR 2.7; 95% CI 1.2 to 6.0, p<0.05), adjusting for demographics, CHF severity/aetiology, time since diagnosis and medication. Accordingly, of 61 patients with CHF who failed to consult for evident cardiac symptoms, 43% had a type-D personality (n = 26). Of the remaining 108 patients with CHF, only 14% (n = 16) had a type-D personality.

CONCLUSION

Patients with CHF with a type-D personality display inadequate self-management. Failure to consult for increased symptom levels may partially explain the adverse effect of type-D personality on cardiac prognosis.

The Delay and Worry Experience of African American Women With Breast Cancer

PURPOSE/OBJECTIVES

To examine the delay in seeking treatment and worry experiences of African American women with breast cancer.

DESIGN

Descriptive, correlational.

SETTING

Urban northeastern United States.

SAMPLE

60 African American women diagnosed with breast cancer.

METHODS

Consenting participants completed the worry subscale of the Ware Health Perception questionnaire and a Demographic and Illness-Related Information Sheet during a one-hour personal interview. Data analysis consisted of descriptive statistics and Pearson correlations.

MAIN RESEARCH VARIABLES

Delay in seeking treatment, worry about breast cancer and symptoms, and sociodemographic characteristics.

FINDINGS

Contrary to the literature, participants reported short patient and provider delay. As a result of little variability in delay, predicting those for whom worry was a deterrent or a motivator to seek prompt treatment was not possible.

CONCLUSIONS

Although delay does exist, African American women with sociodemographic characteristics similar to white women who do not delay are likely to have similarly short symptom durations. Further study to determine who is helped and who is hurt by worry and other possible intervening factors would be useful. Including biologic characteristics such as tumor staging and hormone receptor information in future studies would allow for a closer examination of stage at diagnosis and biologic influence.

IMPLICATIONS FOR NURSING

Interventions with African American women cannot assume that delay exists. Strategies that consider both individual and cultural group differences are essential to the early seeking of a diagnosis and treatment for breast cancer symptoms among African American women.

Care-seeking behaviors of African American women with breast cancer symptoms

In this descriptive correlational study, 48 African American women were assessed for delay in care-seeking for breast cancer symptoms by examining: (a) relationships between selected psychosocial variables (fear, denial, utility, and social norm) and delay, (b) relationships between delay and having an identified health provider, affordable health care services, and accessible health-care services, (c) whether denial would mediate the effect of fear on delay, (d) whether utility would moderate the effects of social norm and facilitating conditions on delay, and (e) whether denial was related to escape-avoidance coping. Participants completed mailed questionnaires. Pearson correlation and separate regression analyses showed that denial was associated with increased delay. Confrontive coping, social support, and problem-solving strategies had no relationship with delay. Interventions focusing on denial could help enhance early care seeking.

Patient's delay in oral cancer: a systematic review

Detecting oral cancer at an early stage is the most effective means of improving survival and reducing morbidity from this disease, yet a significant proportion of patients delay seeking help after the self-discovery of symptoms of oral cancer. The literature on factors associated with patient delay was searched systematically to access relevant data published between 1975 and 2005. Eight studies met the inclusion criteria for the review. In these studies, most clinical/tumour factors, sociodemographic variables, and patient health-related behaviours were not related to the duration of patient delay. Healthcare factors and psychosocial factors may play a role but the research in this area is sparse, atheoretical and of poor quality. Patient delay is a problem in oral cancer and yet at present the reasons for such delays are poorly understood and under-researched. Systematic, high-quality and theory-driven research in this area is urgently required.

Medical and psychosocial predictors of delay in seeking medical consultation for breast symptoms in women in a public sector setting

We examined demographic, medical and psychosocial factors related to delay in seeking medical consultation for breast symptoms. In this cross-sectional survey, 124 women with breast symptoms attending an outpatient breast surgery clinic in a county general hospital completed questionnaires measuring demographic, medical and psychosocial variables. Our outcome variable was delay in seeking medical consultation. Younger age (p <or= 0.05), less education (p <or= 0.01), absence of a lump (p <or= 0.05), lower perceived risk (p <or= 0.001), less spirituality (p <or= 0.01), cost (p <or= 0.001) and not wanting to think about breast symptom(s) (p <or= 0.05) were related to delay. Multivariate analyses showed absence of a breast lump by education interaction (p <or= 0.05), risk perception (p <or= 0.001), spirituality (p <or= 0.01) and cost (p <or= 0.001) collectively accounted for 38.4% of the variance in delay. Health promotion programs targeting low-income populations should emphasize the importance of breast symptoms other than lumps, especially to younger and less educated women.

Patient delay in oral cancer: a qualitative study of patients' experiences

Up to 30% of patients delay seeking the advice of a healthcare professional after self-discovery of symptom(s) of oral cancer. Reasons for this patient delay are poorly understood. The aim of the present study was to explore patients' initial experiences and reactions to developing symptoms of oral cancer, and to identify factors influencing their decision to consult a health care professional. In-depth semi-structured interviews were conducted with 17 consecutive patients who had received a diagnosis of oral squamous cell carcinoma, but had yet to start treatment. Participants were asked about their beliefs about their symptoms over the course of the disease and their decision to seek help. The tape-recorded interviews were transcribed verbatim and analysed using 'Framework analysis'. Oral symptoms were rarely attributed to cancer and were frequently interpreted as minor oral conditions. As a result of these beliefs, patients tended to postpone seeking help or fail to be concerned over their symptoms. Prior to seeking help, patients responded to symptoms by using self-medication, changing the way they ate and disclosing their discovery of symptoms to friends or family. Problems with access to healthcare professionals and patients' social responsibilities acted as barriers to prompt help-seeking. This study has documented that an individual's interpretation of oral cancer symptoms may be misguided and this can adversely affect subsequent help-seeking behaviour.

Patients' help-seeking experiences and delay in cancer presentation: a qualitative synthesis

BACKGROUND

The reduction of delay in cancer diagnosis has been targeted as a way to improve survival. We undertook a qualitative synthesis of international research evidence to provide insight into patients' experiences of recognising symptoms of cancer and seeking help.

METHODS

We searched international publications (1985-2004) for delay in cancer diagnosis to identify the relevant qualitative research, and used meta-ethnography to identify the common themes across the studies. Our synthesis interpreted individual studies by identification of second-order constructs (interpretations offered by the original researchers) and third-order constructs (development of new interpretations beyond those offered in individual studies).

FINDINGS

We identified 32 papers (>775 patients and carers) reporting help-seeking experiences for at least 20 different types of cancer. The analysis showed strong similarities in patients with different cancer types. Key concepts were recognition and interpretation of symptoms, and fear of consultation. Fear manifested as a fear of embarrassment (the feeling that symptoms were trivial or that symptoms affected a sensitive body area), or a fear of cancer (pain, suffering, and death), or both. Such analyses allowed exploration of third-order constructs. The patient's gender and the sanctioning of help-seeking were important factors in prompt consultation.

INTERPRETATION

Strategies to understand and reduce patients' delay in cancer presentation can help symptom recognition but need to address patients' anxieties. The effect of the patient's sex in help-seeking also needs to be recognised, as does the important role of friends, family, and health-care professionals in the sanctioning of consultation. This meta-ethnography provides an international overview through the systematic synthesis of a diverse group of small-scale qualitative studies.

Delayed treatment for rectal cancer

PURPOSE

Reports of the relationship between length of delay before diagnosis of rectal cancer and stage of the disease have been mixed. The present study documented the magnitude and medical ramifications of delay in diagnosing rectal cancer.

METHODS

One hundred twenty patients who had been recently diagnosed with rectal cancer provided information regarding history of symptoms and initial perceptions of those symptoms. Patients also estimated the time elapsed from onset of symptoms until their first consultation with a physician, as well as time elapsed from consultation until the diagnosis of rectal cancer was made. Stage information was gathered from patient charts.

RESULTS

For 106 of the patients, the first sign of rectal cancer was in the form of symptoms, and the most common first symptom was rectal bleeding. For the remaining 14 patients, their cancer was first discovered through routine examination. Over 75 percent of patients with symptoms did not initially believe that they were caused by cancer or any other serious problem, and over 50 percent attributed their symptoms to hemorrhoids. There was a clear trend, albeit statistically nonsignificant, toward worsening disease with longer delays. Median delay times in weeks were Stage I (10.0 weeks), Stage II (14.0 weeks), Stage III (18.5 weeks), and Stage IV (26.0 weeks).

CONCLUSIONS

Delayed diagnosis for rectal cancer remains a significant problem, with instances of delay attributable to both patient and physician. Delayed diagnosis can result in more serious disease and, when attributable to the physician, can result in damaged trust and sometimes legal action.