Typical and atypical presenting symptoms of breast cancer and their associations with diagnostic intervals: Evidence from a national audit of cancer diagnosis

Self-reported symptoms among participants in a population-based screening program

BACKGROUND

A limited number of studies have explored the association between self-reported symptoms and the risk of breast cancer among participants of population based screening programs.

METHODS

We performed descriptive statistics on recall, screen-detected and interval cancer, positive predictive value and histopathological tumour characteristics by symptom group (asymptomatic, lump, and skin or nipple changes) as reported from 785,642 women aged 50-69 when they attended BreastScreen Norway 1996-2016. Uni- and multivariable mixed effects logistic regression models were used to analyze the association between symptom group and screen-detected or interval cancer. Results were presented as odds ratios and 95% confidence intervals (CI).

RESULTS

A lump or skin/nipple change was reported in 6.2% of the 3,307,697 examinations. The rate of screen-detected cancers per 1000 examinations was 45.2 among women with a self-reported lump and 5.1 among asymptomatic women. Adjusted odds ratio of screen-detected cancer was 10.1 (95% CI: 9.3-11.1) and 2.0 (95% CI: 1.6-2.5) for interval cancer among women with a self-reported lump versus asymptomatic women. Tumour diameter, histologic grade and lymph node involvement of screen-detected and interval cancer were less prognostically favourable for women with a self-reported lump versus asymptomatic women.

CONCLUSION

Despite targeting asymptomatic women, 6.2% of the screening examinations in BreastScreen Norway was performed among women who reported a lump or skin/nipple change when they attended screening. The odds ratio of screen-detected cancer was higher for women with versus without symptoms. Standardized follow-up guidelines might be beneficial for screening programs in order to take care of women reporting signs or symptoms of breast cancer when they attend screening.

Presentation of self-detected breast mass in minority women with limited access to care: Can self-examination assist in early cancer detection?

OBJECTIVE

The United States Preventive Services Task Force recommends against breast self-examination. However, racial disparities exist in mammogram screening. We aimed to evaluate the presentation of women with newly diagnosed breast cancer in the underserved African-American and Hispanic community to provide insight regarding breast cancer screening in this population.

METHODS

This retrospective cohort study included women newly diagnosed with breast cancer from 1/1/2016 to 1/1/2018 in an inner city public community hospital. Data was collected via chart review. Patients were divided based on whether they presented with self-detected breast mass. Logistic regression was used for analysis.

RESULTS

59 women were newly diagnosed with breast cancer. 34 women (58%) were African-American, 20 (34%) were Hispanic, and 5 (8%) were other race. Of 59 women, 36 (61%) presented with self-detected breast mass, and only 21 (36%) reported prior mammography. For women who presented with breast mass, the odds of having prior mammography were 78% lower (OR = 0.22, 95% CI 0.07-0.69, p = 0.009), while the odds of having invasive ductal carcinoma were 4.33 times higher (OR = 4.33, 95% CI 1.09-17.25, p = 0.037), as compared to the odds for women not presenting with breast mass.

CONCLUSION

Many of our newly diagnosed breast cancer patients were African-American or Hispanic women presenting with self-detected breast mass without prior screening mammography. Further studies should evaluate whether supplemental screening methods, such as breast self-examination or clinical examination, can help with early breast cancer detection in minority women with limited access to care, and such disparities should be considered by organizations when creating screening guidelines.

Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa

Background

Breast and cervical cancer are leading causes of cancer burden in Sub-Saharan Africa (SSA). We measured breast and cervical cancer symptom and risk factor awareness and lay beliefs in Uganda and South Africa (SA).

Methods

Between August and December 2018 we conducted a cross-sectional survey of women ≥18 years in one urban and one rural site per country. Households were selected using systematic random sampling, then one woman per household randomly selected to participate. Data were collected by interviewers using electronic tablets customised with the locally validated African Women Awareness of Cancer (AWACAN) tool. This has unprompted questions (testing recall) followed by prompted questions (testing recognition) on risk factor, symptom awareness and lay beliefs for breast and cervical cancer. Mann Whitney and Kruskal Wallis tests were used to compare the association between socio-demographic variables and outcomes. Poisson regression with robust variance was conducted to identify independent socio-demographic predictors.

Results

Of the 1758 women interviewed, 90.8% had heard of breast and 89.4% of cervical cancer. 8.7% recalled at least one breast risk factor and 38.1% recalled at least one cervical cancer risk factor. 78.0% and 57.7% recalled at least one breast/cervical cancer symptom respectively. Recognition of risk factors and symptoms was higher than recall. Many women were unaware that HPV, HIV, and not being screened were cervical cancer risk factors (23.7%, 46.8%, 26.5% respectively). In SA, urban compared to rural women had significantly higher symptom and risk factor awareness for both cancers. In Uganda married women/living with a partner had higher awareness of breast cancer risk factors and cervical cancer symptoms compared to women not living with a partner. Women mentioned several lay beliefs (e.g. putting money in their bra as a breast cancer risk factor).

Conclusion

We identified gaps in breast and cervical cancer symptom and risk factor awareness. Our results provide direction for locally targeted cancer awareness intervention programs and serve as a baseline measure against which to evaluate interventions in SSA.

Sustained Weight Loss and Risk of Breast Cancer in Women 50 Years and Older: A Pooled Analysis of Prospective Data

BACKGROUND

Excess body weight is an established cause of postmenopausal breast cancer, but it is unknown if weight loss reduces risk.

METHODS

Associations between weight change and risk of breast cancer were examined among women aged 50 years and older in the Pooling Project of Prospective Studies of Diet and Cancer. In 10 cohorts, weight assessed on three surveys was used to examine weight change patterns over approximately 10 years (interval 1 median = 5.2 years; interval 2 median = 4.0 years). Sustained weight loss was defined as no less than 2 kg lost in interval 1 that was not regained in interval 2. Among 180 885 women, 6930 invasive breast cancers were identified during follow-up.

RESULTS

Compared with women with stable weight (±2 kg), women with sustained weight loss had a lower risk of breast cancer. This risk reduction was linear and specific to women not using postmenopausal hormones (>2-4.5 kg lost: hazard ratio [HR] = 0.82, 95% confidence interval [CI] = 0.70 to 0.96; >4.5-<9 kg lost: HR = 0.75, 95% CI = 0.63 to 0.90; ≥9 kg lost: HR = 0.68, 95% CI = 0.50 to 0.93). Women who lost at least 9 kg and gained back some (but not all) of it were also at a lower risk of breast cancer. Other patterns of weight loss and gain over the two intervals had a similar risk of breast cancer to women with stable weight.

CONCLUSIONS

These results suggest that sustained weight loss, even modest amounts, is associated with lower breast cancer risk for women aged 50 years and older. Breast cancer prevention may be a strong weight-loss motivator for the two-thirds of American women who are overweight or obese.

Symptom Disclosure Process Among Iranian Women With Self-discovered Breast Cancer

BACKGROUND

Breast cancer is the most common malignancy among Iranian women. Symptom disclosure plays an important role in help-seeking behavior among women with self-discovered breast cancer.

OBJECTIVE

The aim of this study was to explain how symptoms are disclosed by Iranian women.

METHODS

This study was conducted based on the grounded theory qualitative approach. Twenty-two Iranian women with breast cancer, who discovered the symptoms themselves and were referred to 2 teaching hospitals in Tehran and Qazvin, were included via purposive and theoretical sampling. The data were collected through semistructured interviews and were analyzed based on the Corbin and Strauss approach.

RESULTS

The process of symptom disclosure had 5 stages including identifying the symptoms, evaluating and interpreting the symptoms, weighing the disclosure conditions, selecting the disclosure audience, and disclosing. The perceived threat was identified as the core category. On the basis of the level of threat perception and the seriousness of the symptoms, the 3 patterns of immediate disclosure, delayed disclosure, and nondisclosure were recognized.

CONCLUSION

Perceived threat is the main motivator for rapid disclosure in Iranian women with potential breast cancer symptoms and leads to a better follow-up of the symptoms. Therefore, increasing women's awareness about breast cancer symptoms, treatments, and non-follow-up consequences leads to a better perception of the threat level.

IMPLICATIONS FOR PRACTICE

According to these findings, it is very important to increase Iranian women's awareness about the symptoms of breast cancer (especially the nonspecific ones). For this purpose, it is necessary to design educational interventions.

Overview of Breast Cancer and Implications of Overtreatment of Early-Stage Breast Cancer: An Indian Perspective

The prevalence and mortality of breast cancer is increasing in Asian countries, including India. With advances in medical technology leading to better detection and characterization of the disease, it has been possible to classify breast cancer into various subtypes using markers, which helps predict the risk of distant recurrence, response to therapy, and prognosis using a combination of molecular and clinical parameters. Breast cancer and its therapy, mainly surgery, systemic therapy (anticancer chemotherapy, hormonal therapy, targeted therapy, and immunotherapy), and radiation therapy, are associated with significant adverse influences on physical and mental health, quality of life, and the economic status of the patient and her family. The fear of recurrence and its devastating effects often leads to overtreatment, with a toxic cost to the patient financially and physically in cases in which this is not required. This article discusses some aspects of a breast cancer diagnosis and its impact on the various facets of the life of the patient and her family. It further elucidates the role of prognostic factors, the currently available biomarkers and prognostic signatures, and the importance of ethnically validating biomarkers and prognostic signatures.

Pattern of Presentation of Patients With Breast Cancer in Iraq in 2018: A Cross-Sectional Study

PURPOSE

This study aims to describe the pattern of presentation of Iraqi female patients with breast cancer by assessing the grades and stages of their cancers at the time of presentation, to identify patients’ main complaints, and to discover whether there is any difference in presentation between patients in Iraq and those in other countries.

PATIENTS AND METHODS

This is a retrospective cross-sectional study that was performed in the National Center of Cancer in 2018. The target population was female patients with breast cancer who came to the Center for treatment and follow-up. A sample of 171 patients was drawn from this population. Self-evaluation forms were used in interviews with the patients to collect personal and sociodemographic data; clinical and histologic characteristics of the patients’ tumors were obtained from their medical records. Ethical approval was obtained.

RESULTS

Forty-five percent of the patients were younger than age 50 years, and 25% were younger than age 45 years. In all, 42.9% of the patients were diagnosed with stage III and 25% with stage IV cancer, and metastasis was diagnosed in 24.1%. In our study population, 53.4% of the tumors were found in the right breast, and 3.9% of patients had bilateral breast tumors. The most common histopathologic type was invasive ductal carcinoma (81.4%) followed by invasive lobular carcinoma (6.9%) and tubular carcinoma (5.9%). The patients’ most common complaints were breast lump (71.3%) and pain (18.9%). No correlation was found between tumor stage and breast self-examination, family history, education, occupation, histopathology, or grade.

CONCLUSION

Most of the patients are diagnosed at a late stage when treatment is less effective.

Utility of Diagnostic Mammography as the Primary Imaging Modality for Palpable Lumps in Women With Almost Entirely Fatty Breasts

OBJECTIVE. The purpose of this study was to assess the performance of diagnostic mammography alone for evaluation of palpable symptoms in women with almost entirely fatty breast composition. MATERIALS AND METHODS. All diagnostic mammograms performed for palpable symptoms in women who had been assigned a breast density of "almost entirely fatty" over an 8-year period (2009-2017) at an academic breast center were retrospectively identified. Each symptomatic breast was considered a separate case and analyses were performed at the case level. Clinical, imaging, and pathologic results were reviewed. Descriptive statistics and 2 × 2 contingency table analyses were performed. RESULTS. The study cohort included 323 cases evaluated with mammography. Of these, 294 (91%) had undergone targeted ultrasound. At mammography, 240 (74%) had no correlate to the palpable lump; 38 (12%), a benign correlate; and 45 (14%), a suspicious correlate. Three cases had incidental suspicious mammographic findings, for a total of 48 positive mammography cases. Twenty-seven (8%) cases were malignant. Mammography alone detected all but one cancer, which was detected by ultrasound. In retrospect, the woman from whom this single false-negative mammogram was obtained did not have almost entirely fatty breast density. Mammography alone yielded a negative predictive value of 99.6%, percentage of diagnostic examinations recommended for biopsy that resulted in a tissue diagnosis of malignancy within 1 year of 54%, sensitivity of 96%, and specificity of 93%. Adjunct ultrasound contributed to 11 false-positives but also identified benign correlates in eight cases with no mammographic finding. CONCLUSION. In patients with almost entirely fatty breast tissue presenting with palpable symptoms, mammography alone had a high sensitivity and specificity. Our results support that mammography alone may be sufficient for evaluation of palpable symptoms in these women as long as density criteria are strictly applied.

Health and health belief factors associated with screening and help-seeking behaviours for breast cancer: A systematic review and meta-analysis of the European evidence

PURPOSE

The aim of this systematic review was to identify health or health belief factors associated with mammography attendance or with self-initiated medical help-seeking for breast cancer symptoms among women in Europe.

METHODS

Five databases were searched for articles published between 2005 and 2018. Meta-analyses were conducted for 13 factors related to screening attendance and two factors associated with help-seeking behaviour. Where there were too few studies to include in the meta-analysis, a narrative synthesis was undertaken.

RESULTS

Sixty-five studies were included. Never having had cervical screening (d = -.72, p < .001) and higher perceived barriers to mammography (d = -.40, p < .001) were associated with lower levels of screening attendance. Possessing health insurance (d = .49, p < .001), greater perceived benefits (d = .31, p < .001) and motivation (d = .36, p = .003) towards screening, and higher perceived seriousness (d = .24, p = .019) and susceptibility (d = .20, p = .024) towards breast cancer were associated with a higher level of screening attendance. Presenting with a non-lump symptom was associated with a longer time to presentation (d = .32, p < .001). The narrative synthesis revealed that previous benign breast disease was associated with a higher level of screening attendance but with a longer time to presentation.

CONCLUSIONS

The review identified key similarities in factors associated with screening and help-seeking behaviours which offer scope for combined interventions aimed at women that target both behaviours. Furthermore, the review highlighted that fewer studies have focused on help-seeking behaviour, despite two thirds of breast cancer cases being self-detected. Future research should further examine predictors of help-seeking behaviour including a focus on modifiable factors, such as BMI, and physical activity.

Towards the early detection of ductal carcinoma (a common type of breast cancer) using biomarkers linked to the PPAR(γ) signaling pathway

Breast cancer is a leading cause of morbidity and mortality among women comprising about 12% females worldwide. The underlying alteration in the gene expression, molecular mechanism and metabolic pathways responsible for incidence and progression of breast tumorigenesis are yet not completely understood. In the present study, potential biomarker genes involved in the early progression for early diagnosis of breast cancer has been detailed. Regulation and Gene profiling of Ductal Carcinoma In-situ (DCIS), Invasive Ductal Carcinoma (IDC) and healthy samples have been analyzed to follow their expression pattern employing normalization, statistical calculation, DEGs annotation and Protein-Protein Interaction (PPI) network. We have performed a comparative study on differentially expressed genes among Healthy vs DCIS, Healthy vsIDC and DCIS vs IDC. We found MCM102 and SLC12A8as consistently over-expressed and LEP, SORBS1, SFRP1, PLIN1, FABP4, RBP4, CD300LG, ID4, CRYAB, ECRG4, G0S2, FMO2, ADAMTS5, CAV1, CAV2, ABCA8, MAMDC2, IGFBP6, CLDN11, TGFBR3as under-expressed genes in all the 3 conditions categorized for pre-invasive and invasive ductal breast carcinoma. These genes were further studied for the active pathways where PPAR(γ) signaling pathway was found to be significantly involved. The gene expression profile database can be a potential tool in the early diagnosis of breast cancer.

Effect of Sociodemographic Variables on Patient and Diagnostic Delay of Breast Cancer at the Foremost Health Care Institution in Nigeria

PURPOSE

Breast cancer (BC) has the highest mortality rate among women with any form of cancer in developing countries. Unfortunately, patients with BC in Nigeria commonly present with late-stage disease. The current study examined the types and magnitude of delay in BC diagnosis at the foremost hospital in Nigeria and also identified the influencing factors.

MATERIALS AND METHODS

This cross-sectional study involved questionnaires given to 275 patients with BC at University College Hospital, Ibadan, Nigeria, from August to October 2018. Sociodemographic characteristics and information relevant to management of their health problem were obtained after ethical committee approval. Data collected were analyzed by SPSS (version 23; SPSS, Chicago, IL) to assess the types and magnitude of delay experienced by patients, as well as identify related determinants using the appropriate statistical test with P = .05.

RESULTS

The mean age of respondents was 49 (± 11.9) years with the majority being Yoruba (n = 154; 56%), Christians (n = 211; 76.7%), married (n = 193; 70.2%), employed (n = 151; 54.9%), having tertiary education (n = 142; 51.6%) and an average income of more than 18,000 naira (n = 176; 64%). Patient delay and diagnostic delay were observed among 97 respondents (35.3%) and 84 respondents (30.5%), respectively. Although patient delay was significantly associated with age, ethnicity, and marital status, the only variable significantly associated with diagnostic delay was marital status (P < .05). Level of income, education, employment status, and religion did not significantly (P > .05) contribute to either of these delays.

CONCLUSION

BC management at the pioneer Nigerian teaching hospital is challenged by both delays in patient presentation at clinics and delays in the process of being diagnosed. Such delays need to be addressed to achieve favorable outcome of patients with BC in Nigeria.

What symptoms are important to patients? Developing a symptom burden measure for women with breast cancer

PURPOSE

The American Cancer Society predicted that 266,120 women would be diagnosed with breast cancer in 2018. Women experience significant symptom burden in response to tumor and treatment-related adverse effects, particularly in advanced disease. Use of valid and reliable patient-reported outcomes (PRO) symptom measures may assist clinicians in systematically monitoring and managing symptoms. The MD Anderson Symptom Inventory (MDASI) is a brief PRO measure of cancer symptom burden; specific symptoms can be added to the core symptoms to produce disease- and treatment-specific modules. The purpose of this study was to describe the patient symptom experience, define the content domain, and generate items for a breast cancer-specific MDASI module for measuring symptom burden in women with breast cancer.

METHODS

Women with breast cancer were qualitatively interviewed about their experiences of disease and treatment. Descriptive exploratory analysis identified symptoms and symptom interference to define the symptom burden of breast cancer. An expert panel rated the relevance of the identified symptoms to patients with breast cancer.

RESULTS

A conceptual model of breast cancer symptom burden was developed from interviews with 36 women (mean age of 57.9 years, 86.1% had stages I-III, and 52.8% were on chemotherapy and/or radiation therapy) across the breast cancer disease and treatment trajectory. Thirty-six symptoms and 6 interference categories were identified. Symptoms specific to treatment modalities and breast cancer met the criteria for inclusion in the provisional instrument for psychometric testing.

CONCLUSIONS

We generated an instrument with content validity for measuring symptom burden specific to women with breast cancer.

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

BACKGROUND:

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

AIM:

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

METHOD:

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

FINDINGS:

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

CONCLUSION:

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

Knowledge, attitude, and practice of breast self-examination amongst female IT professionals in Silicon Valley of India

Introduction:

Breast cancer is one of the leading causes of cancer deaths among women in India today. Overall outcome of this disease is largely dependent on early detection and medical intervention. Breast self-examination (BSE) is an easy, cost effective, and safe method of screening for the same.

Materials and Methods:

A cross-sectional descriptive questionnaire-based study was conducted among female IT professionals and their scores in the fields of knowledge, attitude, and practice were calculated. The scores were categorized linearly as good, fair, and poor, then analyzed in detail. The correlation between knowledge and attitude, attitude and practice, and knowledge and practice were ascertained using the Spearman's rank correlation coefficient.

Results:

About 356 women spanning from 18 to 55 years of age were included in the study, out of which 44 women (12.35%) gave family history of breast cancer. The mean scores in knowledge, attitude, and practice fields were 18.17 ± 2.90, 27.07 ± 8.14, and 19.11 ± 5.08, respectively. Spearman's rank correlation coefficient revealed that knowledge and attitude were not correlated, attitude and practice were not correlated; but knowledge and practice were extremely correlated.

Conclusion:

Educational programs to create awareness regarding breast cancer and its occurrence, risk factors, screening including BSE, symptoms, need for early help-seeking practices, diagnosis, and treatment modalities are the need of the hour.

Factors associated with time to breast cancer diagnosis and treatment in unscreened women in Portugal

Delays in detection, diagnosis and treatment may lead to poorer prognosis in women with breast cancer. We quantified time intervals from first detection (FD) to diagnosis (D) and first treatment (FT) and identified associated factors. We studied 282 patients diagnosed with breast cancer during 2012 at the Breast Clinic of the Portuguese Institute of Oncology in Porto, Portugal using face-to-face interview and medical records. Associations of sociodemographic and clinical characteristics with time intervals was computed using adjusted percentage differences (adjPD) after logarithmic transformation, odds ratios (adjOR) for comparing the highest and lowest thirds of the distribution and 95 percent confidence intervals (CI) for both measures, using linear and logistic regression, respectively. The median times between FD and D and FT were 31 and 44 days, respectively. Significantly longer periods between FD and D were found in symptomatic women (adjPD = 99.5, 95 percent CI: 37.1, 190.0; adjOR = 3.16, 95 percent CI: 1.57, 6.33). More advanced stage was associated with shorter intervals between D and FT (adjPD = -33.8, 95 percent CI: -44.2, -21.5; adjOR = 0.14, 95 percent CI: 0.05, 0.34). Although some differences according to clinical characteristics were observed, they did not seem to translate into inequities in access to public healthcare in this group of women.

The appearance of breast cancer metastases on dry bone: Implications for forensic anthropology

Breast carcinoma is a major cause of morbidity and mortality in women. The study of bone pathologies presents considerable potential in anthropology, paleopathology, forensic science and medicine. In this paper, we present and discuss metastatic lesions found in the skeletons of known individuals from the CAL Milano Cemetery Skeletal Collection, clinically diagnosed with breast cancer during life. Fourteen skeletons from a contemporary and identified collection were macroscopically studied and metastases were identified by comparison with clinical literature. As a result, bone metastases were observed in 43% of the study sample. They were located most commonly on the ribs (28.1%), pelvic girdle (19.8%), vertebrae (15.6%), skull (15.6%), scapulae (10.2%) as well as proximal segment of the femora (8.4%) and humeri (2.4%) respectively, favoring sites of high vascularization. The majority of the lesions were osteolytic, although osteoblastic and mixed metastases did occur. Osteolytic metastases appear as coalescent porosity or round to oval perforating lesions on bones with denticulated margins and pitted surrounding bone, whereas osteoblastic metastases thickened the existing trabecula (spongiosclerosis). Mixed metastases were perforating lytic lesions exposing the osteoblastic activity in the underlying trabecular bone. These results, consistent with the data from the literature, strengthen the diagnostic criteria for metastases and illustrate the aspect of bone metastases in breast carcinoma.

Statin use and risk of contralateral breast cancer: a nationwide cohort study

Background

Statins have demonstrated antineoplastic effects in breast cancer cell lines, particularly in oestrogen receptor (ER)-negative cell lines. However, epidemiological studies have not supported a preventive effect of statin use against breast cancer. Therefore, we examined the association between statin use and contralateral breast cancer (CBC) risk among women with breast cancer.

Methods

We identified 52,723 women with non-metastatic breast cancer during 1996–2012 from the Danish Breast Cancer Group database. We defined time-varying post-diagnosis statin use as minimum two prescriptions lagged by 1 year. Cox regression analyses were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CBC associated with statin use.

Results

Statin use was associated with a lower CBC risk (HR = 0.88; 95% CI = 0.73–1.05). The inverse association was strongest for long-term use overall (HR = 0.64; 95% CI = 0.43–0.96), although the HR specifically for long-term consistent use and high-intensity use approached unity. Among ER-negative breast cancer patients, statin use was associated with a CBC risk reduction (HR = 0.67; 95% CI = 0.45–1.00).

Conclusions

We found some indication that statins reduce the risk of CBC. Further evaluations are needed to disentangle the equivocal results for long-term use and to establish if ER-negative breast cancer patients may benefit most from statin use.

The nature and frequency of abdominal symptoms in cancer patients and their associations with time to help-seeking: evidence from a national audit of cancer diagnosis

Background

Raising awareness of possible cancer symptoms is important for timely help-seeking; recent campaigns have focused on symptom groups (such as abdominal symptoms) rather than individual alarm symptoms associated with particular cancer sites. The evidence base supporting such initiatives is still emerging however; understanding the frequency and nature of presenting abdominal symptoms among cancer patients could inform the design and evaluation of public health awareness campaigns.

Methods

We examined eight presenting abdominal symptoms (abdominal pain, change in bowel habit, bloating/distension, dyspepsia, rectal bleeding, dysphagia, reflux and nausea/vomiting) among 15 956 patients subsequently diagnosed with cancer in England. We investigated the cancer site case-mix and variation in the patient interval (symptom-onset-to-presentation) by abdominal symptom.

Results

Almost a quarter (23%) of cancer patients presented with abdominal symptoms before being diagnosed with one of 27 common and rarer cancers. The patient interval varied substantially by abdominal symptom: median (IQR) intervals ranged from 7 (0-28) days for abdominal pain to 30 (4-73) days for dysphagia. This variation persisted after adjusting for age, sex and ethnicity (P < 0.001).

Conclusions

Abdominal symptoms are common at presentation among cancer patients, while time to presentation varies by symptom. The need for awareness campaigns may be greater for symptoms associated with longer intervals to help-seeking.

Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.