The influence of ethnicity on diagnosis of cancer

Symptom appraisal and help seeking in males with symptoms of possible prostate cancer: a qualitative study with an ethnically diverse sample in London

BACKGROUND

Prostate cancer mortality in Black males is disproportionately high. This problem may be overcome by reducing delays in the pathway to diagnosis, particularly those occurring before initial medical help seeking. A greater understanding of symptom appraisal and help seeking could support the development of targeted interventions for improving early presentation among Black males.

AIM

To provide an in-depth understanding of males' pre-consultation experiences following the onset of symptoms of possible prostate cancer, identifying both general trends as well as potential differences that may exist between Black and White males.

DESIGN AND SETTING

Qualitative study of 18 males (nine Black, nine White) in London, UK, who had recently seen their GP with urinary symptoms, erectile dysfunction, or haematuria.

METHOD

Semi-structured interviews from a previous multi-methods study of primary care use by males with symptoms of possible prostate cancer were analysed using thematic framework analysis.

RESULTS

Symptoms were often interpreted by patients as unimportant. Most delays occurred due to the absence of reasons to seek help, which, in Black males, often stemmed from poor awareness of prostate cancer. This lack of awareness could have been a consequence of their reluctance to seek health information and discuss health issues with others in their social network. Friends and relatives played an important role in symptom appraisal and help seeking.

CONCLUSION

Cognitive biases, cultural stigmas, and everyday interpersonal interactions should be important areas at which to target strategies seeking to reduce delays and improve early presentation in males with possible prostate cancer, particularly Black males.

Reducing Racial Disparities in the Timeliness of Potential Lung Cancer Evaluation With a Novel Application-Supported Rapid Outpatient Diagnostic Program: An Interrupted Time Series Analysis

INTRODUCTION

Rapid outpatient diagnostic programs (RODP) expedite lung cancer evaluation, but their impact on racial disparities in the timeliness of evaluation is less clear.

MATERIALS AND METHODS

This was a retrospective analysis of the impact of an internally developed application-supported RODP on racial disparities in timely referral completion rates for patients with potential lung cancer at a safety-net healthcare system. An application screened referrals to pulmonology for indications of lung mass or nodule and presented relevant clinical information that enabled dedicated pulmonologists to efficiently review and triage cases according to urgency. Subsequent care coordination was overseen by a dedicated nurse coordinator. To determine the program's impact, we conducted an interrupted time series analysis of the monthly fraction of referrals completed within 30 days, stratified by those identified as White, non-Hispanic and those that were not (racial and ethnic minorities).

RESULTS

There were 902 patients referred in the 2 years preintervention and 913 in the 2 years postintervention. Overall, the median age was 63 years, and 44.7% of referred patients were female. 44.2% were White, non-Hispanic while racial and ethnic minorities constituted 54.3%. After the intervention, there was a significant improvement in the proportion of referrals completed within 30 days (62.4% vs. 48.2%, P <.01). The interrupted time series revealed a significant immediate improvement in timely completion among racial and ethnic minorities (23%, P < .01) that was not reflected in the majority White, non-Hispanic subgroup (11%, not significant).

CONCLUSION

A thoughtfully designed and implemented RODP reduced racial disparities in the timely evaluation of potential lung cancer.

Early diagnosis of symptomatic ovarian cancer in primary care in the UK: opportunities and challenges

Background:

Ovarian cancer is the sixth most common cause of cancer-related death in the UK amongst women. Ovarian cancer presents particular challenges for general practitioners (GPs) to diagnose due to its rarity and presentation with non-specific symptoms.

Methods:

A narrative overview of the literature was conducted by searching PubMed and Researchgate for relevant articles, using keywords such as “ovarian cancer,” “primary care” and “diagnosis.”

Results and Discussion:

Studies have shown that in the UK, GPs have a lower readiness to refer and investigate potential cancer symptoms compared with their international counterparts; and this has been correlated with reduced survival. Early diagnosis can be facilitated through a people-focussed and system-based approach which involves both educating GPs and using risk algorithms, rapid diagnostic centres/multi-disciplinary centres and being data-driven through the identification of best practice from national audits. Further research is required into the best evidence-based early investigations for ovarian cancer and more effective biomarkers.

No association between breast pain and breast cancer: a prospective cohort study of 10 830 symptomatic women presenting to a breast cancer diagnostic clinic

BACKGROUND

Women with breast pain constitute >20% of breast clinic attendees.

AIM

To investigate breast cancer incidence in women presenting with breast pain and establish the health economics of referring women with breast pain to secondary care.

DESIGN AND SETTING

A prospective cohort study of all consecutive women referred to a breast diagnostic clinic over 12 months.

METHOD

Women were categorised by presentation into four distinct clinical groups and cancer incidence investigated.

RESULTS

Of 10 830 women, 1972 (18%) were referred with breast pain, 6708 (62%) with lumps, 480 (4%) with nipple symptoms, 1670 (15%) with 'other' symptoms. Mammography, performed in 1112 women with breast pain, identified cancer in eight (0.7%). Of the 1972 women with breast pain, breast cancer incidence was 0.4% compared with ∼5% in each of the three other clinical groups. Using 'breast lump' as reference, the odds ratio (OR) of women referred with breast pain having breast cancer was 0.05 (95% confidence interval = 0.02 to 0.09, P<0.001). Compared with reassurance in primary care, referral was more costly (net cost £262) without additional health benefits (net quality-adjusted life-year [QALY] loss -0.012). The greatest impact on the incremental cost-effectiveness ratio (ICER) was when QALY loss because of referral-associated anxiety was excluded. Primary care reassurance no longer dominated, but the ICER remained greater (£45 528/QALY) than typical UK National Health Service cost-effectiveness thresholds.

CONCLUSION

This study shows that referring women with breast pain to a breast diagnostic clinic is an inefficient use of limited resources. Alternative management pathways could improve capacity and reduce financial burden.

The impact of health literacy on diagnosis and outcomes of symptomatic cancer by ethnicity: a systematic review protocol

BACKGROUND

Ethnic minorities in multi-ethnic societies like the UK and USA have poorer outcomes for some cancer types when compared with the majority. The causes of ethnic inequalities in cancer outcomes are complex and not fully understood. In particular, the potential role of health literacy on symptomatic presentation and diagnostic interval (the period between first consultation within primary care and definitive diagnosis of cancer) by ethnicity is unknown. Given the increasing need for shared decision-making and patient involvement in the diagnostic process, understanding the potential impact of the differences in health literacy may help redress ethnic inequality in cancer outcomes. The present study aims to critically examine the evidence in this area.

METHODS

Seven electronic databases will be searched using keywords and controlled vocabulary related to ethnicity, health literacy, cancer diagnosis and cancer outcomes. Citations and bibliography searches of included studies will be performed to identify relevant studies that have cited eligible articles. Authors of included studies will be contacted to identify unpublished studies. Eligible studies will be restricted to primary cancers. Study quality will be evaluated in using the Critical Appraisal Skills Programme (CASP) checklists. A descriptive summary of selected studies will be presented, and the synthesis will follow a narrative framework.

DISCUSSION

This systematic review will summarise the evidence regarding ethnic inequality in health literacy and how this impacts on diagnosis and outcomes of cancer. The review will identify possible areas for future research, and inform clinical practice and interventions to reduce ethnic inequalities in cancer diagnosis and outcomes.

Experience of Asian males communicating cardiac genetic risk within the family

The genetic nature of an inherited cardiac condition (ICC) places first- and second-degree relatives at risk of cardiac complications and sudden death, even in the absence of symptoms. Communication of cardiac genetic risk information allows at-risk relatives to clarify, manage, and potentially prevent ICC-associated risks through cardiac screening. Literature regarding family communication of genetic risk information are predominantly based on Western populations, with limited insight into the Asian experience. This qualitative exploratory study provides a male perspective into the communication of ICC risks within families in Singapore. Eight male participants with clinically diagnosed cardiomyopathy, who had all received genetic counseling, were recruited. A phenomenological perspective was used to identify emergent themes from semi-structured interviews. In this study, most participants recalled their healthcare professional's emphasis on family communication. Notably, participants revealed that at-risk relatives were not accessing screening, and many described family members as currently asymptomatic and "healthy." These findings coincide with documented Asian beliefs regarding perceptions of health, which have important implications for the provision of genetic counseling support within Asian communities, especially in facilitating family communication such that at-risk relatives are informed about their ICC risks and available management options.