A qualitative study on detecting cancer symptoms and seeking medical help; an application of Andersen's model of total patient delay

The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis

Objective

Patient pathways to presentation to health care professionals and initial management in primary care are key determinants of outcomes in cancer. Reducing diagnostic delays may result in improved prognosis and increase the proportion of early stage cancers identified. Investigating diagnostic delay could be facilitated by use of a robust theoretical framework. We systematically reviewed the literature reporting the application of Andersen's Model of Total Patient Delay (delay stages: appraisal, illness, behavioural, scheduling, treatment) in studies which assess cancer diagnosis.

Methods

We searched four electronic databases and conducted a narrative synthesis. Inclusion criteria were studies which: reported primary research, focused on cancer diagnosis and explicitly applied one or more stages of the Andersen Model in the collection or analysis of data.

Results

The vast majority of studies of diagnostic delay in cancer have not applied a theoretical model to inform data collection or reporting. Ten papers (reporting eight studies) met our inclusion criteria: three studied several cancers. The studies were heterogeneous in their methods and quality. The review confirmed that there are clearly identifiable stages between the recognition of a symptom, first presentation to a health care professional, subsequent diagnosis and initiation of treatment. There was strong evidence to support the existence and importance of appraisal and treatment delay as defined in the Andersen Model, although treatment delay requires expansion. There was some evidence to support scheduling delay which may be contributed to by both patient and the health service. Illness delay was often difficult to distinguish from appraisal delay. It was less clear whether behavioural delay exists as a separate significant stage.

Conclusions

Greater consistency is required in the conduct and reporting of studies of diagnostic delay in cancer. We propose refinements to the Andersen Model which could be used to increase its validity and improve the consistency of reporting in future studies.

Internet use for prediagnosis symptom appraisal by colorectal cancer patients

BACKGROUND

This study explored the characteristics of colorectal cancer (CRC) patients who accessed Internet-based health information as part of their symptom appraisal process prior to consulting a health care provider.

METHOD

Newly diagnosed CRC patients who experienced symptoms prior to diagnosis were interviewed. Brief COPE was used to measure patient coping. Logistic and linear regressions were used to assess Internet use and appraisal delay.

RESULTS

Twenty-five percent of the sample (61/242) consulted the Internet prior to visiting a health care provider. Internet use was associated with having private health insurance (odds ratio [OR] = 2.55; 95% confidence interval [CI] = 1.20-5.43) and experiencing elimination symptoms (OR = 1.43; 95% CI = 1.14-1.80) and was marginally associated with age (OR = 0.96; 95% CI = 0.93-0.99). Internet use was not related to delayed medical care seeking.

CONCLUSION

Internet use did not influence decisions to seek medical care. The Internet provided a preliminary information resource for individuals who experienced embarrassing CRC symptoms, had private health insurance, and were younger.

Social support, gender and patient delay

BACKGROUND

The purpose of this study was to examine the relationship between perceived social support and patient delay (PD) among female and male cancer patients.

METHODS

A population-based study with register-sampled cancer patients was designed. Patient delay was defined as the time interval between the patient's experience of the first symptom and the first contact with a health-care professional. Both dates were provided by the patients (n=910). The patients completed a purpose-designed questionnaire, which assessed the patient's perceptions of how the partner reacted ('Partner Avoidance' and 'Partner Support') and how others in the social network responded ('Other Avoidance' and 'Other Support') to the patient's worries about the symptoms. The associations between the social support subscales and PD were analysed separately for men and women.

RESULTS

In female patients, Partner Support and Other Support were associated with shorter PD, whereas Other Avoidance was associated with longer PD. In the multivariate analysis, Other Avoidance remained associated with longer PD. Moreover, disclosure of symptoms to someone reduced the likelihood of a long PD in female patients. In male patients, none of the social support scales significantly increased or decreased the risk of a long PD in the univariate analysis, but Partner Support significantly decreased risk of a long PD in the multivariate analysis.

CONCLUSIONS

The results of this study suggest that social support and avoidance from network members influence length of PD differently in male and female cancer patients. This gender difference may explain previous mixed findings obtained in this field.

Male and non-English-speaking patients with fracture have poorer knowledge of osteoporosis

BACKGROUND

Prior fracture is a strong independent risk factor for subsequent fracture. To date, few studies have examined the level of osteoporosis knowledge specifically in the population of patients who have sustained a fracture. This study was designed to assess the knowledge of osteoporosis among patients who sustained a fracture and who were forty years of age or older, as well as to identify what social factors and health and fracture characteristics determine the level of osteoporosis knowledge in this population.

METHODS

Patients who had sustained a fracture and were attending fracture clinics at two Toronto hospitals were identified and invited to fill out a questionnaire during their visit. This questionnaire included questions that could be answered by checking "true," "false," or "don't know" and that were designed to assess the patient's knowledge of osteoporosis. The questionnaire also included questions about the respondent's background.

RESULTS

Of 259 patients identified as eligible for the study, 204 (78.8%) agreed to participate. The mean number of correct responses was 16.5 (55%) out of thirty responses. Variables significantly associated with greater numbers of correct responses were female sex, English as a first language, being currently employed, exercising regularly, and having received information from a health-care provider or from a newspaper or magazine.

CONCLUSIONS

The level of osteoporosis knowledge was fairly low among the surveyed patients, indicating that more education is needed. This study also highlighted certain characteristics (i.e., male sex, English as a second language, being unemployed, and not exercising) that are associated with a lower level of knowledge. Our results can help target certain groups for osteoporosis educational initiatives, especially ethnic groups whose first language is not English, so as to appropriately reduce the risk of future fractures in this high-risk population.

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.

How does the media profile of cancer compare with prevalence?

INTRODUCTION

Knowledge and understanding of disease can influence time to presentation and potentially, therefore, cancer survival rates. The media is one of the most important sources of public health information and it influences the awareness and perception of cancer. It is not known if the reportage of cancer by the media is representative to the true incidence of disease.

MATERIALS AND METHODS

The top 10 UK daily newspapers were assessed over a 1-year period for the 10 most common UK cancers via their on-line search facilities.

RESULTS

Of the 5832 articles identified, there was marked over-representation of breast, kidney and stomach cancer with ratios of prevalence to reporting of 1.4, 1.9 and 3.2 to 1, respectively. Colorectal, non-Hodgkin lymphoma, bladder and oesophageal cancers are all markedly under-represented with ratios of 0.4, 0.2, 0.6 and 0.4 to 1, respectively.

CONCLUSIONS

A policy of media advocacy by health professionals could enhance the information provided by the media and thus reflect the true extent of disease. A partnership between health professionals and journalists could result in articles that are relevant to the population, informative and in a style and format that is easily comprehendible. Targeted public health information could highlight the 'red-flag' symptoms and break down any stigma associated with cancer. This enhanced awareness could improve the health-seeking behaviour of the general population and reduce the delay from symptoms to diagnosis.

The impact of the intensity of fear on patient's delay regarding health care seeking behavior: a systematic review

OBJECTIVES

This systematic review focuses on the role of the intensity of fear in patient's delay in cancer and in myocardial infarction.

METHODS

In a search of literature published between 1990 and June 2009, 161 articles were found. After the use of inclusion and exclusion criteria, 11 articles in cancer and 4 articles in myocardial infarction remained.

RESULTS

High levels of fear are associated with earlier help-seeking in both diseases; for low levels of fear, the picture is unclear.

CONCLUSION

The level of fear is an important factor, which should be taken into account when facilitating help-seeking by patients.

Patient understanding of moles and skin cancer, and factors influencing presentation in primary care: a qualitative study

Background

Melanoma incidence in the UK has doubled over two decades, yet there is conflicting evidence about factors which prompt or delay patients seeking advice. Aim: To explore patient understanding of pigmented skin lesions (moles) and skin cancer, and factors which influence seeking help in primary care.

Method

Semi-structured interviews with forty MoleMate Trial participants, analysed using the theoretical framework of the Safer-Andersen model of Total Patient Delay.

Results

Patient understanding and awareness was influenced by personal, family and friends' experiences of moles, skin cancer and other cancers, knowledge of risk factors, and the lay media. The route to consulting was complex and often iterative. For lesions that people could see, detecting and appraising change was influenced by comparisons with a normal mole on themselves, a family member, friend or image. Inferring illness came about with recognition of changes (particularly size) as serious, and associated 'internal' symptoms such as pain. For lesions that people could not see, family, friends and health professionals detected and appraised changes. Deciding to seek help was often prompted by another person or triggered by rapid or multiple changes in a mole. Three of four people subsequently diagnosed with melanoma did not seek help; instead, their GP opportunistically noticed the lesion.

Conclusions

Changing moles are often perceived as trivial and not signifying possible skin cancer. This study contributes to current national strategies to improve patient awareness and earlier diagnosis of cancer by highlighting factors that can trigger or act as barriers to seeking help.

(ISRCTN79932379)

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.

Young adult Ecstasy users who forego necessary medical care: a fairly common occurrence with important health implications

This study examines the practice of foregoing necessary medical care in a population of young adult Ecstasy users. The objectives are to (1) investigate how the failure to receive needed medical care is related to drug-related outcomes, and (2) identify factors that are associated with receiving versus foregoing needed medical care. Face-to-face, computer-assisted, structured interviews were conducted with 283 active young adult Ecstasy users in Atlanta, Georgia between August 2002 and October 2007. Study participants were recruited using a targeted sampling approach. Results indicated that almost one-third of the young adult Ecstasy users interviewed did not receive the medical care that they needed during the preceding year. Foregoing such care was associated with a variety of adverse drug-related outcomes, including experiencing a greater number of negative effects from using Ecstasy, experiencing a larger number of drug dependency symptoms, a greater likelihood of ever having binged on Ecstasy, and a greater likelihood of being classified as a "high end" polydrug abuser. Several factors were found to be associated with a greater tendency not to receive the medical care they needed, including race (not being African American), educational attainment (having completed at least high school), self-identification as belonging to the lowest socioeconomic status grouping, low self-esteem, and having experienced sexual abuse during one's formative years.

Fear, knowledge, and efficacy beliefs differentially predict the frequency of digital rectal examination versus prostate specific antigen screening in ethnically diverse samples of older men

Emotional and cognitive characteristics have been studied in the context of women's cancer screening but have received scant attention in the study of men's screening behavior. Researchers know little about how such factors interact to predict screening or whether digital rectal examination (DRE) and prostate specific antigen (PSA) screens are predicted by the same characteristics. This study examines the relevance of emotional and cognitive characteristics to DRE and PSA screening among 180 U.S.-born African American, U.S.- born European American, and immigrant Jamaican men. The study identifies the expected effects in which fear is negatively related and efficacy beliefs positively related to DRE and PSA screening. Greater efficacy and (marginally) knowledge appear to "offset" the negative impact of fear on screening, and fear appears particularly relevant to DRE frequency. Results are discussed in terms of their implications for the development of health belief and self-regulatory models in the context of prostate cancer screening among minority men.

Public perceptions of the harms and benefits of testicular cancer education: a qualitative study

BACKGROUND

The value of testicular cancer (TC) education, and in particular advice on testicular self-examination (TSE), has been widely debated by health professionals. One concern centres on its potential to cause unnecessary anxiety among the target population. Views outside the health professional community about TC education's potential benefits and harms have not previously been described. The objective of this study was to investigate the range of views expressed by specific groups thought to have an interest in provision of TC education.

METHODS

One-to-one, in-depth interviews with 37 men and women were completed. Participants included TC patients, men with no prior diagnosis of TC, and parents and teachers of adolescent boys. Verbatim transcripts were analysed using the Framework approach to produce a thematic description of views expressed.

RESULTS

Participants were unanimously in favour of TC education. Key perceived benefits included earlier cancer detection through increasing knowledge of symptoms leading to better treatment outcomes, and motivating help-seeking by reducing emotional barriers such as fear of cancer or embarrassment. Anxiety was acknowledged as a possible harm but was not expected to be widespread or serious.

CONCLUSION

TC education is viewed favourably by members of the public likely to be interested in its provision. Education's potential to cause anxiety was not considered a disincentive to promoting disease awareness.

Factors triggering medical consultation for symptoms of colorectal cancer and perceptions surrounding diagnosis

This study aims to find out how the presenting symptoms of colorectal cancer are interpreted by those who get them, to identify the main triggering factors that lead someone with colorectal cancer symptoms to consult a doctor, and to describe how those affected perceive the process of being diagnosed with colorectal cancer. It is a qualitative study performed within the theoretical framework of symbolic interactionism and from a gender perspective. Grounded theory has been used for the analysis. Semi-structured interviews were conducted. Twelve individuals with colorectal cancer - seven men and five women - were interviewed. At first, both the men and women attributed their symptoms to trivial causes. Changes in symptoms or the persistence of symptoms trigger medical consultation. Close relatives, especially the closest female family members, can trigger medical consultation, particularly among men. The women said nothing to their families until they had already gone to the doctor. Knowledge about colorectal cancer could be a factor triggering medical consultation. The time between consulting the family doctor and seeing a specialist feels drawn out. Gender-related differences have been observed in respect to help-seeking in colorectal cancer. Health education programmes focusing on knowledge about cancer are needed.

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

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

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

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

Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms? A pilot survey in Western Australia

Background

Smokers attribute respiratory symptoms, even when severe, to everyday causes and not as indicative of ill-health warranting medical attention. The aim of this pilot study was to conduct a structured vignette survey of people attending general practice to determine when they would advise a person with respiratory symptoms to consult a medical practitioner. Particular reference was made to smoking status and lung cancer.

Methods

Participants were recruited from two general practices in Western Australia. Respondents were invited to complete self-administered questionnaires containing nine vignettes chosen at random from a pool of sixty four vignettes, based on six clinical variables. Twenty eight vignettes described cases with at least 5% risk of cancer. For analysis these were dubbed 'cancer vignettes'. Respondents were asked if they would advise a significant other to consult a doctor with their respiratory symptoms. Logistic regression and non-parametric tests were used to analyse the data.

Results

Three hundred questionnaires were distributed and one hundred and forty completed responses were collected over six weeks. The majority (70.3%) of respondents were female aged forty and older. A history of six weeks' of symptoms, weight loss, cough and breathlessness independently increased the odds of recommending a consultation with a medical practitioner by a factor of 11.8, 2.11, 1.40 and 4.77 respectively. A history of smoking independently increased the odds of the person being thought 'likely' or 'very likely' to have cancer by a factor of 2.46. However only 32% of cancer vignettes with a history of cigarette smoking were recognised as presentations of possible cancer.

Conclusion

Even though a history of cigarette smoking was more likely to lead to the suggestion that a symptomatic person may have cancer we did not confirm that smokers would be more likely to be advised to consult a doctor, even when presenting with common symptoms of lung cancer.

Intervals between symptom onset and clinical presentation in cancer patients

OBJECTIVE

We aimed to investigate relative values of the intervals between symptom onset and clinical presentation in cancer patients and to correlate them with diagnosis of distant metastasis.

METHODS

Cancer registry and medical records of all cancer patients for over a 10-year period in a medical center of Japan were reviewed. We examined the intervals of symptom onset to clinical presentation and the presence of metastasis at diagnosis.

RESULTS

In 3,893 cancer patients, the mean interval of symptom onset to clinical presentation was 89 days (median, 30 days). The cancer group with a short interval of only days to weeks included hepatobiliary, ovary, brain, and acute leukemia. The group with a long interval of months to years included head and neck, thyroid, and skin cancers. Other types of cancer were included in the middle group with an interval of weeks to months. Among patients with head & neck, skin, and ovarian cancers, the longer interval was significantly associated with a lower likelihood of distant metastasis. A longer interval with an increment of each month was associated with a lower likelihood for distant metastasis with an odds ratio of 0.97 (95% CI, 0.96-0.99).

CONCLUSION

Hepatobiliary, ovary, brain, and acute leukemia are among the cancer types with an interval of days to weeks, while head and neck, thyroid, and skin cancers are among the types with an interval of months to years. Among patients with solid tumors, those with metastasis are likely to present to a physician more promptly.

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.

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.

Delay in seeking medical advice and late presentation of female breast cancer patients in most of the world. Could we make changes? The experience of 23 years in port said, egypt

BACKGROUND

In the low and middle income countries delays in seeking consultation, late presentation, and the availability of breast cancer management for all patients, represent major challenges.

MATERIALS AND METHODS

The delay in seeking medical advice and the pathological tumor size of females breast cancer patients in the years 2004-2006 in Port Said, Egypt were studied and compared with previous studies by Elzawawy published since 1987. We report the progress of availability of breast cancer management from 1984 until the end of June 2007.

RESULTS

There was a decline in advanced cases. Mean time from a symptom to seeking advice was 18, 8, 3, and 1 month respectively in 1987, 1989, 1999, and 2007. Since 1984, facilities for all lines of comprehensive management have been established, interconnected, and been made accessible for all citizens, free of charge.

CONCLUSION

Breast cancer problems are characterized by a certain multi-complexity. There is no one single cause for late cases. However, we report that the availability of cancer management facilities could lead to earlier presentation. Early detection programs would be frustrating for both patients and health authorities if patients were unable to afford accessible treatment.

Women's perceptions of events impeding or facilitating the detection, investigation and treatment of breast cancer

An integrated network is currently being implemented in the province of Quebec in order to improve the cancer care continuum. In this context, formal trajectories for cancer patients through healthcare services are being established. The investigation of patients' perceptions of the healthcare continuum is essential as it allows us to identify the issue of continuity/discontinuity of health services. In addition, patients' perceptions of continuity of cancer care should be documented since they could influence the implementation of optimal trajectories through the healthcare services. An exploratory qualitative study was conducted in order to identify events, based on the perceptions of women with breast cancer, that made the patient progress more rapidly, facilitating events, or more slowly, impeding events, within the cancer care continuum. Two consecutive series of women receiving adjuvant radiation therapy in 2002 and 2003 at the University Hospital of Quebec City were recruited, for a total of 120 participants. A semi-structured interview was administered in order to identify women's perceptions regarding impeding and facilitating events during the detection, investigation and treatment periods of cancer, as well as the actors and reasons involved. Overall, 64% of women reported having at least one impeding event, while 68% reported at least one facilitating event. The periods most frequently affected by impeding or facilitating events were the investigation period, followed by the treatment period. The main stages affected by impeding or facilitating events were the scheduling of an appointment, during the investigation period, and the onset of treatment. Impeding events particularly affected the scheduling of mammography, the initial exam of the investigation for breast cancer, as well as the onset of radiation treatment. On the other hand, facilitating events mainly occurred at the time of the scheduling of medical consultations with specialists, during the investigation period, and of the onset of surgery. Finally, women generally perceived that impeding events were due to a lack in the availability of services and that facilitating events resulted from human intervention. Patients' perceptions, such as those regarding the importance of human intervention in the process of continuity of care, should be taken into account by healthcare authorities in charge of implementing cancer control programmes.

Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis

In this paper, we review the literature on psychosocial influences on breast cancer screening and treatment adherence with an eye to identifying common cognitive, emotional, and social network factors that may lead to poor screening adherence and suboptimal treatment in the case of diagnosed breast cancer. Nonadherence to breast cancer screening and treatment guidelines can significantly and negatively impact the prospects for prevention and control of breast cancer. Psychosocial factors are an especially important focus for research, inasmuch as belief structures and psychosocial characteristics (such as patterns of emotion regulation and the quality of social relations) are modifiable and are, thus, eminently suitable to intervention.

The process of symptom appraisal: cognitive and emotional responses to detecting potentially malignant oral symptoms

OBJECTIVE

Following the self-discovery of symptoms of oral cancer, approximately 30% of patients wait for more than 3 months before seeking attention from a health care professional. Although symptom appraisal is known to be an important stage in the decision to seek help, little is known about the process of symptom appraisal. The aims of the current study were to produce a theory-guided investigation of the specific cognitive interpretations and emotional reactions to the self-discovery of potentially malignant oral symptoms and to gain understanding as to why these may change prior to help seeking.

METHODS

In-depth semi-structured interviews were conducted with 57 consecutive patients who had been referred with potentially malignant oral symptoms. Participants were asked about symptom detection, initial and subsequent beliefs about symptoms, and emotional responses prior to their first visit to a health care professional. The tape-recorded interviews were transcribed verbatim and analyzed using "framework analysis."

RESULTS

Patients often attributed the symptoms to transient, minor conditions such as mouth ulcers, physical trauma, or dental problems and, in turn were unconcerned about their presence. Patients infrequently attributed their symptoms to cancer. Origins of specific interpretations included previous experiences, specific symptomatology, logical associations with the perceived cause, and information from medical literature. Stimuli for reinterpretation included receipt of new information, symptom development, and persistence of symptoms.

CONCLUSION

This study has documented the process of symptom appraisal and indicates that an individual's interpretation of potentially malignant oral symptoms is often misguided.

Passive cancer detection and medical help seeking for cancer symptoms: (in)adequate behavior and psychosocial determinants

The present study explored the performance and psychosocial determinants of passive cancer detection behavior, that is, attentiveness to cancer symptoms, and medical help seeking, and investigated potential dependency between these two behaviors. A detailed telephone survey was conducted among 459 respondents, aged 55 years or older. The survey assessed passive detection behavior and appropriately timed medical help seeking, regarding 14 cancer symptoms. Knowledge of cancer symptoms and various other psychosocial determinants were also measured. Knowledge of cancer symptoms and adequate passive detection behavior was low to moderate. Timely medical help-seeking behavior was low to moderate for urgent symptoms but relatively high for prolonged symptoms. Overall, women had higher knowledge levels, paid more attention to cancer symptoms, and performed more timely help seeking than men. Passive detection behavior was positively associated with premotivational awareness factors (knowledge and awareness), female gender, and perceived advantages. Timely medical help seeking was positively related to cognitive motivational factors (perceived advantages, self-efficacy expectations, and intention) and negatively related to educational level and perceived susceptibility to cancer. Furthermore, a strong positive association was found between the performance of passive detection behavior and timely medical help seeking. The suboptimal levels of knowledge and performance of early cancer detection behaviors found in this study emphasize a need for educational efforts in the area of early cancer detection. The effectiveness of these efforts may benefit from considering the distinct sets of determinants of passive detection behavior and medical help seeking.

A study of patients who appear with far advanced cancer at Yaounde General Hospital, Cameroon, Africa

BACKGROUND

This is a preliminary study to identify patients with cancer who appeared with very advanced disease and to report the common reasons for their delay. It was undertaken because the numbers of such patients appeared to be increasing.

METHOD

A convenience sample of 20 patients were identified by the oncologist (P.N.) as appearing with very late stage disease or appearing and not returning until a late stage. They were interviewed by the psychologist (A.E.) to determine: symptom onset; treatment sought; reasons for seeking consultation; beliefs, fears, and level of information about cancer; and willingness to be treated.

RESULTS

The primary reasons given for waiting so long to seek care were: inability to pay for medical care (10); inadequate diagnosis by general doctors leading to time lost before coming for consultation; (9); beliefs, fears, cultural factors, ignorance (9). More than one factor could be identified in half the patients.

CONCLUSION

Understanding the factors that influence delay is important to improving the outcomes for cancer patients. Factors that contribute to delay in developing countries appear to be largely the paucity of appropriate health care, coupled with poor information, and beliefs and fears about cancer.

Developing a partnership model for cancer screening with community-based organizations: the ACCESS breast cancer education and outreach project

There is growing enthusiasm for community-academic partnerships to promote health in underserved communities. Drawing upon resources available at a comprehensive cancer center, we developed the ACCESS program to guide community based organizations through a flexible program planning process. Over a three-year period, ACCESS partnered with 67 agencies serving various medically underserved populations. Organizations included hospitals, parishes, senior centers, harm reduction programs, and recreational facilities. Program outcomes at the organizational level were quantified in terms of introduction of new cancer information, referral or screening programs, as well as organizational capacity building. ACCESS represents a viable model for promoting partnership to transfer behavioral health programs and adapt interventions for new audiences. Plans to further evaluate and enhance this model to promote cancer screening efforts are discussed. We argue that, ultimately, formation and development of community partnerships need to be understood as a fundamental area of practice that must be systematically integrated into the mission of major academic medical institutions in every area of public health.

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.

The role of child abuse and age in vulnerability to emotional problems after surgery for breast cancer

Emotional problems are common after breast cancer, but patients differ in their vulnerability. Childhood abuse is a risk factor for emotional problems in adult women, and we tested whether it explains some of the variability in emotional problems after breast cancer. Women with primary breast cancer (N=355) 2-4 d after surgery (mastectomy or wide local excision) self-reported current emotional distress, post-traumatic stress, self-blame, bodily shame and recollections of childhood sexual, physical and emotional abuse. Multiple logistic regression analyses tested the relationship of each emotional problem to abuse, distinguishing three age-groups, divided at 50 and 65 years. Emotional distress, post-traumatic stress, self-blame and shame were present in 49%, 8%, 22% and 13% of women, respectively. Each problem was more common in women who recalled one or other form of abuse. Apart from emotional distress, emotional problems were less common in older women. Older women were also less likely to recall abuse, and recall of abuse contributed statistically to explaining the relationship of youth to emotional problems. Childhood abuse is a risk factor for emotional problems after surgical treatment for breast cancer, and the challenge of identifying and helping those patients in whom emotional problems reflect pre-morbid vulnerabilities needs careful consideration. Because both emotional problems and abuse are strongly age-linked, future research should avoid generalisations across the age spectrum.

Impact of age and diagnosis on waiting times between important healthcare events among children 0 to 19 years cared for in pediatric units: the Canadian Childhood Cancer Surveillance and Control Program

BACKGROUND

The objectives were to describe and compare waiting times to diagnosis and treatment of children and adolescents who accessed pediatric oncology centers in Canada for healthcare, and to assess the effects and relative contributions of age, sex, and diagnosis to waiting times.

METHODS

Waiting times were assessed for 2,365 children (0 to 14 y) and 375 adolescents (15 to 19 y) diagnosed with cancer between 1995 and 2000 inclusive and followed by the Treatment and Outcome Surveillance system of the Canadian Children's Cancer Surveillance and Control Program. Differences were assessed using the chi2 test, Fisher exact test, and Wilcoxon test statistic.

RESULTS

Median waiting times between first assessment by treating oncologist or surgeon and definitive diagnostic procedure, and the subsequent interval to first therapeutic event, were 2 days each. Significant variation existed in both periods when stratified by age and diagnosis but not sex. The most significant differences between age groups were eliminated when stratified by diagnosis.

INTERPRETATION

This analysis suggests that once they enter the healthcare system, children and adolescents treated in pediatric centers in Canada experience short waiting times to key diagnostic and treatment events. Differences in wait times between the 2 age groups are not clinically significant and can be attributed to the differences in the types of cancer experienced by adolescents compared with children.

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.

Psychological factors related to delay in consultation for cancer symptoms

This research investigated psychological characteristics associated with delay in seeking help for symptoms of rectal cancer. Sixty nine subjects reconstructed pivotal events beginning with symptom onset and ending with medical consultation, and completed the Temperament and Character Inventory (TCI) and the State-Trait Anxiety Inventory (STAI). The mean delay time was around 6 months, with about 1 out of 6 subjects waiting one year or more. Subjects estimated the lengths of two sequential segments of total time to consultation: (1) Symptom Appraisal time (from symptom onset to recognition of possible seriousness), and (2) Action Appraisal time (from recognition of seriousness to medical consultation). Symptom Appraisal time accounted for over two-thirds of total time and was associated with low scores on the TCI Harm Avoidance scale (TCI-HA), indicating dispositional insensitivity to threat, and marginally associated with less education and younger age. Action Appraisal time was not associated with any demographic or psychological variables. Low TCI-HA scores were also associated with lower likelihood of previous cancer screening, and with better judgments of premorbid health. Low STAI Trait scores were associated with better judgments of premorbid health and fewer doctor visits. Results are discussed regarding the importance of understanding dispositional characteristics related to health behavior.

Waiting times for cancer care in Canadian children: impact of distance, clinical, and demographic factors

BACKGROUND

The objective of this study was to evaluate the impact of distance from residence to pediatric oncology centers on waiting times to diagnostic assessment and treatment in Canadian children with cancer.

PROCEDURE

Two thousand three hundred sixteen children (< 15 years of age) captured by the Canadian Childhood Cancer Surveillance and Control Program's (CCCSCP) Treatment and Outcome Surveillance (TOS) system were included in the analysis. The number of days between onset of symptoms and first anti-cancer therapy was compared for those living less than 25, 25-99, and more than 100 kilometers from their treating center. For each time period, the adjusted odds of falling into the longest time quartiles were estimated using logistic regression analysis.

RESULTS

Thirty-four percent (n = 786) of children lived more than 100 kilometers from their treating center. There were no significant differences in age at diagnosis (P = 0.33), sex (P = 0.68), or ICCC diagnosis (P = 0.02) by distance from center, though there was a significant difference in region of residence (P < 0.01) and the first health care professional contacted (P < 0.01). Except for waiting time from first health care contact to first assessment by treating oncologist which increased with increasing distance (P < 0.01), there were no significant differences in waiting times by distance. When adjusted for important demographic and clinical characteristics, distance to center did not affect the odds of waiting longer for any event.

CONCLUSIONS

Distance to treating center had no significant impact on waiting times for important diagnostic and treatment events, when adjusted for age at diagnosis, diagnosis, region, and first health care professional seen.

Common cancers in India: knowledge, attitudes and behaviours of urban slum dwellers in New Delhi

RESEARCH QUESTIONS

What is the level of knowledge and awareness of common cancers? What are the prevalent attitudes and behaviours relating to common cancers?

OBJECTIVES

To assess knowledge, attitudes and behaviours regarding common cancers amongst urban slum dwellers in New Delhi.

STUDY DESIGN

Field-based cross-sectional survey of an urban slum cluster.

SETTING

Slum clusters along Pankha Road, West New Delhi.

PARTICIPANTS

Slum dwellers of selected slums.

STUDY VARIABLES

Independent variables were sociodemographic factors. Dependent variables were knowledge, attitudes and behaviours regarding preventive and curative aspects of common cancers.

STATISTICAL ANALYSIS

Proportions, confidence intervals, tests of significance and multiple logistic regression.

RESULTS

Only 13% (10.6-15.7%) of the study participants were aware of Pap smears, and only 2% (1.1-3.3%) were able to identify all the common signs of cancer. However, 87% (84.4-89.5%) of the study participants knew that tobacco is a risk factor for cancer. Overall, 51% (47.2-54.7%) had some knowledge pertaining to cancer.

CONCLUSION

A focused, concerted and effective information, education and communication drive is urgently needed for all aspects of common cancers in India.

Knowledge about osteoporosis: assessment, correlates and outcomes

During the last 10 years, we have witnessed an impressive increase in the number of studies examining knowledge about osteoporosis. The aim of the present paper is to examine the status of research on knowledge about osteoporosis by reviewing and analyzing the current literature as it pertains to assessment of knowledge about osteoporosis, factors associated with knowledge, and relationship between knowledge about osteoporosis and participation in health-related behaviors. Finally, future directions in the field are discussed. Many of the studies are still characterized by the lack of a theoretical framework, as well as by various methodological flaws. Serious deficits in knowledge are reported among healthy and diagnosed women and men, as well as among health professionals. Educational interventions are accompanied by an increase in knowledge, but no change in behavior. There is need to expand the research on knowledge about osteoporosis, especially in an effort to increase its impact on the prevention and early diagnosis of the disease. The deficits found in the knowledge of both the general population and among health care professionals, should be addressed by providing updated and reliable information through appropriate health promotion and professional venues.

Diversity matters: Unique populations of women and breast cancer screening

BACKGROUND

Ethnic differences in breast cancer screening behaviors are well established. However, there is a lack of understanding regarding exactly what causes these differences and which characteristics in low-screening populations should be targeted in an effort to modify screening behavior.

METHODS

Stratified cluster sampling was used to recruit 1364 women (ages 50-70 years) from 6 ethnic groups: African-American women; U.S.-born white women; English-speaking Caribbean, Haitian, and Dominican women; and immigrant Eastern-European women. In interviews, respondents provided information concerning demographic and structural variables related to mammogram utilization (age, education, income, marital status, physician recommendation, access, and insurance) and a set of cognitive variables (fatalism, perception of personal risk, health beliefs concerning cancer) and socioemotional variables (stress, cancer worry, embarrassment, and pain).

RESULTS

For data analysis, the authors used a 2-step logistic regression with frequency of mammograms over a 10-year period (< or = 4 mammograms over 10 years or > or = 5 mammograms over 10 years) as a dependent variable. U.S.-born African-American women and Dominican women were screened as frequently as European-American women, but the remaining minority groups were screened with less frequency. With one exception, ethnicity ceased to predict screening frequency once cognitive and emotional variables were controlled.

CONCLUSIONS

Although women from clearly operationalized ethnic groups continue to screen at rates substantially below those of the majority groups, these differences appear to be explained substantially by differences in psychologic variables. This is encouraging because, rather than targeting culture for intervention, variables can be targeted that are amenable to change, such as emotions and beliefs.

Knowledge about symptoms of Alzheimer's disease: correlates and relationship to help-seeking behavior

OBJECTIVE

The aim of this study was to assess relationships between knowledge about symptoms of Alzheimer's disease (AD) and help seeking intention among the lay public.

DESIGN, SETTING AND PARTICIPANTS

A convenience sample of 150 community-dwelling persons aged over 45, who did not have a close relative diagnosed with AD, participated in the study.

MEASURES

Knowledge about 11 warning signs of AD as described in the information provided by the Alzheimer's Association, and four non-AD symptoms was assessed, together with intentions to seek help from professional and non-professional sources. Background characteristics included socio-demographic characteristics, personal experience with AD, and perceived threat.

RESULTS

Although participants' knowledge about AD symptoms overall was fair, only a slight percentage reported memory problems to be symptoms of the disease. Participants differentiated between AD warning and non-warning signs. Older participants reported consistently more AD and non-AD symptoms, while higher concerns about developing the disease was associated with reporting more non-AD symptoms. Higher knowledge about AD symptoms was associated with increased intentions to seek help from professional sources.

CONCLUSIONS

Efforts to increase knowledge about AD symptoms should be expanded, with special attention to risk groups. Improved recognition of AD symptoms will promote adequate help-seeking behaviors and will increase early identification and treatment of AD.

Early detection of cancer: knowledge and behavior among Dutch adults

This paper reports on knowledge and behavior among Dutch adults (n = 1530) regarding early detection of cancer (passive detection, active detection and help-seeking behavior). Written questionnaires assessed knowledge of detection methods and cancer symptoms, symptom recognition, detection behaviors, and help-seeking behaviors. Respondents did not have much general knowledge of detection methods and cancer symptoms, but recognized most cancer symptoms. More women than men paid attention to cancer symptoms. For most symptoms, medical help would be sought within the appropriate time by the majority of the respondents. Principal component analyses revealed relations between symptoms pertaining to the 'interior' body and those pertaining to the 'exterior' body. Correlations between symptom recognition, detection behavior and help-seeking behavior were low. Differences in demographic groups and differences in knowledge and behavior require adaptation of future health education on early detection of cancer to different groups.

Knowledge, attitudes, and behavioral intentions in relation to the early detection of colorectal cancer in the United Kingdom

BACKGROUND

Colorectal cancer (CRC) mortality is high. Understanding the social, psychological, and cognitive predictors of early detection practices such as screening may help improve CRC outcomes. This study examined knowledge of CRC and the relationship between knowledge, attitudes to cancer, and intentions to engage in early detection behaviors for CRC in a national representative population sample.

METHOD

An interview-based survey was carried out in a British population sample of adults ages 16 to 74 years (n = 1637), assessing knowledge, attitudes, and intention with regard to colorectal cancer.

RESULTS

Knowledge levels were very low; 58% (n = 995) of respondents could not list any colorectal cancer risk factors and 24% (n = 393) were unable to identify any warning signs for cancer. Knowledge was lower among men (chi(2)[2] = 52.8, P < 0.0001), younger respondents (chi(2)[10] = 79.9, P <.0001), and those with less education (chi(2)[4] = 73.9, P < 0.0001). Attitudes to cancer were more negative among women (chi(2) [2] = 7.4, P = 0.025), younger participants (chi(2)[10] = 22.4, P = 0.013), and those with less education (chi(2) [4] = 75.0, P < 0.0001). Low knowledge was associated with negative attitudes (P < 0.0001) and both factors were associated with lower intentions to participate in colorectal cancer screening (P < 0.0001). Multivariate analysis indicated that attitudes partially mediated the effect of knowledge on screening intentions.

CONCLUSIONS

Increasing knowledge may reduce negative public perceptions of cancer which may impact positively on intentions to participate in screening.