Cancer fatalism: deterring early presentation and increasing social inequalities?

Racial disparities in prostate cancer in the UK and the USA: similarities, differences and steps forwards

In the USA, Black men are approximately twice as likely to be diagnosed with and to die of prostate cancer than white men. In the UK, despite Black men having vastly different ancestral contexts and health-care systems from Black men in the USA, the lifetime risk of being diagnosed with prostate cancer is two-to-three times higher among Black British men than among white British men and Black British men are twice as likely to die of prostate cancer as white British men. Examination of racial disparities in prostate cancer in the USA and UK highlights systemic, socio-economic and sociocultural factors that might contribute to these differences. Variation by ancestry could affect incidence and tumour genomics. Disparities in incidence might also be affected by screening guidelines and access to and uptake of screening. Disparities in treatment access, continuity of care and outcomes could contribute to survival differences. In both localized and metastatic settings, equal access could diminish the observed disparities in both the USA and the UK. An understanding of behavioural medicine, especially an appreciation of cultural beliefs about illness and treatment, could inform and improve the ways in which health systems can engage with and deliver care to patients in minoritized groups affected by prostate cancer. Methods of promoting equity include targeting systemic barriers including systemic racism, proportional recruitment of patients into clinical trials, diversifying the health-care workforce and facilitating care informed by cultural humility. Actively engaging patients and communities in research and intervention might enable the translation of research into increasingly equitable care for patients with prostate cancer in the UK, the USA and globally.

Relationship Between Fatalistic Cancer Beliefs and Risky Health Behaviors

BACKGROUND

There is limited research on how fatalism influences risky health behaviors that are linked to higher cancer risks. This study investigates the relationship between risky health behaviors (tobacco smoking, electronic cigarette use, and heavy alcohol drinking) and fatalistic cancer beliefs while controlling for health care-related self-efficacy and sociodemographic and clinical factors among adults without a history of cancer.

METHODS

We used cross-sectional data from the 2020 Health Information National Trends Survey (HINTS) 5 Cycle 4. The study sample included noninstitutionalized adults (aged ≥18 years without a self-reported cancer history (n = 2464). The outcome variable was risky health behaviors comprised of tobacco smoking, electronic cigarette use, and heavy alcohol drinking. We combined these 3 risky behaviors into a binary variable (0, not having risky health behavior; 1, having ≥1 risky health behavior). The key independent variable was cancer fatalistic beliefs. We used descriptive statistics and multivariate logistic regression analyses.

RESULTS

Overall, 50% of the sample were women, 64.7% of participants self-identified as non-Hispanic White, 16.4% as Hispanic, and 10.6% as non-Hispanic Black. About 43% of participants reported having at least one risky health behavior. While holding all other factors constant, each unit increase in cancer fatalism score was associated with 30.0% higher odds of increased risky health behaviors (odds ratio = 1.30, 95% confidence interval 1.04-1.62, P = .021) among adults without a history of cancer.

CONCLUSION

By understanding the relationship between cancer-related fatalistic beliefs and risky health behaviors, cancer prevention outreach programs can be personalized to suit the unique needs of specific individuals and communities.

Impact of a Cancer Health Education Curriculum Among Milwaukee Public High School Students

In Milwaukee and nationwide, cancer incidence, late-stage diagnosis, and mortality are notably higher among some racial/ethnic populations. Cancer education has the potential to impact cancer burden and reduce cancer disparities. In particular, the addition of a service-learning component to academic curriculums has been shown to improve student learning as well as positively impact the surrounding community. This study implemented a cancer health education curriculum (CHEC) at a Milwaukee public high school with the goal of addressing cancer knowledge, fear and fatalism beliefs, and risk behaviors. The curriculum included interactive learning sessions and a service-learning final project. Five-hundred twenty-one students also completed pre- and post-surveys assessing cancer knowledge, fear and fatalism, risk behaviors, cancer-related communication, and a qualitative question asking what they hoped to gain (pre) or did gain (post) from the course. Results indicate (1) a significant improvement in cancer knowledge (p < 0.0001), (2) a decrease in cancer fear and fatalism (p < 0.0001), (3) an increase in fruit consumption (p < 0.0001), (4) a decrease in screen time (p = 0.0004), and (5) an increase in how often students spoke with their family about cancer (p < 0.0001). Qualitative data reflect important gains such as increased interest in sharing their knowledge about cancer with their community. Providing cancer education and leveraging a service-learning requirement led to notable changes in high school students' cancer knowledge, fear and fatalism, and risk behaviors. Students also communicated more with family/friends about cancer. Such efforts could have broader implications for student, family, and community cancer burden.

Relationship between mental health disorder symptoms and negative cancer perceptions among U.S. adults

PURPOSE

Although much emphasis has been placed on the impact of ambiguity on cognitive processes, the impact of mental health disorder symptoms and racial/ethnic disparities in cancer perception of fatalism and ambiguity remains less explored. This study explored the association between mental health disorder symptoms and negative cancer perceptions. Also, we assessed differences in these outcomes within mental health disorder symptoms and racial/ethnic subgroups to investigate the association between cancer perceptions and the other covariates within the aforementioned subgroups.

METHODS

We used the 2019-2020 Health Information National Trends Survey data (N = 9,303) to assess the perception of cancer fatalism and cancer communication ambiguity and employed weighted multivariable logistic regression to determine the effects of mental health disorder symptoms using the Patient Health Questionnaire-4 (PHQ-4) scale on these negative cancer perceptions among United States adults.

RESULTS

People with moderate [Adjusted Odds Ratio (AOR) = 1.58, 95% Confidence Interval (CI) = 1.09, 2.31] and severe anxiety/depression (AOR = 1.88, 95% CI = 1.12, 3.14) symptoms were more likely to have cancer fatalism perceptions than people with no anxiety/depression symptoms. People with mild (AOR = 1.33, 95% CI = 1.06, 1.69) or severe (AOR = 1.80, 95% CI = 1.03, 3.16) anxiety/depression symptoms were more likely to perceive cancer communication as ambiguous compared to people who had no anxiety/depression symptoms.

CONCLUSIONS

The study showed that mental health status was associated with both cancer fatalism and perceived cancer communication ambiguity. This suggests that interventions aimed at reducing mental health disorder symptoms may potentially reduce these negative perceptions, thereby improving participation in cancer prevention programs.

Status and Determinants of Early Detection of Oral Premalignant and Malignant Lesions in India

It has been over four decades since the launch of the National Cancer Control Programme in India, yet the cancer screening rates for oral cancer remain unremarkable. Moreover, India is bracing a large burden of oral cancer with poor survival rates. An effective public health programme implementation relies on a multitude of factors related to cost-effective evidence-based interventions, the healthcare delivery system, public health human resource management, community behaviour, partnership with stakeholders, identifying opportunities and political commitment. In this context, we discuss the various challenges in the early detection of oral premalignant and malignant lesions and potential solutions.

Understanding patient barriers and facilitators to uptake of lung screening using low dose computed tomography: a mixed methods scoping review of the current literature

BACKGROUND

Targeted lung cancer screening is effective in reducing mortality by upwards of twenty percent. However, screening is not universally available and uptake is variable and socially patterned. Understanding screening behaviour is integral to designing a service that serves its population and promotes equitable uptake. We sought to review the literature to identify barriers and facilitators to screening to inform the development of a pilot lung screening study in Scotland.

METHODS

We used Arksey and O'Malley's scoping review methodology and PRISMA-ScR framework to identify relevant literature to meet the study aims. Qualitative, quantitative and mixed methods primary studies published between January 2000 and May 2021 were identified and reviewed by two reviewers for inclusion, using a list of search terms developed by the study team and adapted for chosen databases.

RESULTS

Twenty-one articles met the final inclusion criteria. Articles were published between 2003 and 2021 and came from high income countries. Following data extraction and synthesis, findings were organised into four categories: Awareness of lung screening, Enthusiasm for lung screening, Barriers to lung screening, and Facilitators or ways of promoting uptake of lung screening. Awareness of lung screening was low while enthusiasm was high. Barriers to screening included fear of a cancer diagnosis, low perceived risk of lung cancer as well as practical barriers of cost, travel and time off work. Being health conscious, provider endorsement and seeking reassurance were all identified as facilitators of screening participation.

CONCLUSIONS

Understanding patient reported barriers and facilitators to lung screening can help inform the implementation of future lung screening pilots and national lung screening programmes.

Cultural Differences in Cancer Information Acquisition: Cancer Risk Perceptions, Fatalistic Beliefs, and Worry as Predictors of Cancer Information Seeking and Avoidance in the U.S. and China

Cancer is one of the most common causes of death in China and the United States. Past studies found that cancer risk perceptions, fatalistic beliefs, and worry were prominent predictors of health-related behaviors. Perceived cancer risks, fatalistic beliefs, and worry were associated with cancer information acquisition in the United States. However, little is known about whether these factors played comparable roles in China. This study investigates the psychological antecedents of cancer information acquisition using data from Health Information National Trends Surveys (HINTS) in both countries. Results showed that cancer worry was negatively related to cancer information avoidance in the U.S. but positively related to information avoidance in China. Also, whereas cancer fatalistic beliefs were negatively associated with cancer information seeking in the U.S., the relationships between fatalistic beliefs and cancer information seeking exhibited more complex patterns in China. Implications for cancer communication in different cultures are discussed.

Identifying key barriers to effective breast cancer control in rural settings

Breast cancer is the most common cancer and the second most common cause of cancer mortality among women in the United States. Efforts to promote breast cancer control in rural settings face specific challenges. Access to breast cancer screening, diagnosis, and treatment services is impaired by shortages of primary care and specialist providers, and geographic distance from medical facilities. Women in rural areas have comparable breast cancer mortality rates compared to women in urban settings, but this is due in large part to lower incidence rates and masks a substantial rural/urban disparity in breast cancer survival among women diagnosed with breast cancer. Mammography screening utilization rates are slightly lower among rural women than their urban counterparts, with a corresponding increase in late stage breast cancer. Differences in breast cancer survival persist after controlling for stage at diagnosis, largely due to disparities in access to treatment. Travel distance to treatment centers is the most substantial barrier to improved breast cancer outcomes in rural areas. While numerous interventions have been demonstrated in controlled studies to be effective in promoting treatment access and adherence, widespread dissemination in public health and clinical practice remains lacking. Efforts to improve breast cancer control in rural areas should focus on implementation strategies for improving access to breast cancer treatments.

Competing risks of women and men who use fentanyl: "The number one thing I worry about would be my safety and number two would be overdose"

BACKGROUND

Standard public health approaches to risk communication do not address the gendered dynamics of drug use. The aim of this study was to explore perceptions of fentanyl-related risks among women and men to inform future risk communication approaches.

METHODS

We conducted a qualitative study, purposively sampling English-speaking women and men, aged 18-25 or 35+ years, with past 12-month illicitly manufactured fentanyl use. In-depth individual interviews explored experiences of women and men related to overdose and fentanyl use. We conducted a grounded content analysis examining specific codes related to overdose and other health or social risks attributed to drug use. Using a constant comparison technique, we explored commonalities and differences in themes between women and men.

RESULTS

The study enrolled twenty-one participants, 10 women and 11 men. All participants had personal overdose experiences. Both women and men described overdosing as a "chronic" condition and expressed de-sensitization to the risk of overdose. Women and men described other risks around health, safety, and state services that often superseded their fear of overdose. Women feared physical and sexual violence and prioritized caring for children and maintaining relations with child protective services, while men feared violence arising from obtaining and using street drugs and incarceration. Only women reported that fear of violence prevented their utilization of harm reduction services.

CONCLUSIONS

Experiences with overdose and risk communication among people who use fentanyl-containing opioids varied by gender. The development of gender-responsive programs that address targeted concerns may be an avenue to enhance engagement with harm reduction and treatment services and create safe spaces for women not currently accessing available services.

Fear of breast cancer among young Spanish women: Factor structure and psychometric properties of the Champion breast cancer fear scale

Heightened fear of breast cancer (FBC) has been linked to increased distress following breast cancer diagnosis and to avoidance of mammography screening. To our knowledge, however, no studies have examined the nature of FBC exclusively among young females, even though they are overrepresented in media stories of breast cancer. Given that no instruments are available to assess FBC in the Spanish language, we sought to 1) evaluate the psychometric properties and factor structure of the Champion Breast Cancer Fear Scale (CBCFS), and 2) offer preliminary data on the nature of FBC among young women. Participants (N = 442, mean age = 21.17, range 17-35) completed the translated CBCFS (CBCFS-es) and the Spanish version of the Short Health Anxiety Inventory. The CBCFS-es demonstrated good concurrent validity, internal consistency, and test-retest reliability. Confirmatory factor analysis showed adequate fit to a one-factor solution. The majority of participants reported considerably high levels of FBC, as 25.34% and 59.73% of them scored above the moderate- and high-FBC cut-offs, respectively. Moreover, FBC could not be explained by general concerns regarding health and illness, given that levels of health anxiety were low. Implications for health education, research, and clinical practice are discussed.

Negative emotions and cancer fatalism are independently associated with uptake of Faecal Immunochemical Test-based colorectal cancer screening: Results from a population-based study

Although systematic colorectal cancer screening is efficacious, many programmes suffer from low uptake. Few behavioural or attitudinal factors have been identified as being associated with participation in colorectal cancer screening. We explored knowledge, beliefs about cancer, subjective health literacy, emotional attitudes to screening, and social influences among individuals invited to a population-based screening programme. Regression modelling of a cross-sectional survey of 2299 individuals (users and non-users) of a population-based Faecal Immunochemical Test (FIT) screening programme in Dublin was conducted. Questions were derived from previous theoretically-informed qualitative work and assessed using previously used and validated measures. The primary outcome variable was uptake status (User/Participation or Non-User/Non-participation); multivariable logistic regression was used to estimate the odds ratios (OR) for screening participation. Stronger fatalistic beliefs independently predicted lower uptake (OR = 0.94; 95% CI 0.90-0.98; P = 0.003). Those aged <65 who disagreed that "cancer can often be cured" also had lower uptake (OR = 0.43; 95% CI 0.22-0.82: P = 0.017). Agreement that the test was disgusting and tempting fate predicted lower uptake (OR = 0.16: 95% CI 0.10-0.27: p < 0.001), while the influence of a partner on decision to be screened was associated with higher uptake (OR = 1.32; 95% CI 1.15-1.50: P < 0.001). Negative cancer-related and screening-related beliefs and emotions are associated with non-participation in FIT (-based screening). Research is warranted to explore if these negative beliefs and emotions are modifiable and, if so, whether this would improve screening uptake. The association between the influence of a partner and screening participation present a challenge around improving uptake among those not in co-habiting relationships.

Rural barriers to early lung cancer detection: Exploring access to lung cancer screening programs in New Hampshire and Vermont

BACKGROUND

Rural populations face many health disadvantages compared to urban areas. There is a critical need to better understand the current lung cancer screening landscape in these communities to identify targeted areas to improve the impact of this proven tool.

METHODS

Data from the County Health Rankings of New Hampshire and Vermont was reviewed for population density, distribution of adult smokers, and level of education compared to the distribution of Lung Cancer Screening Facilities throughout these two states.

RESULTS

Screening programs in southern counties of Vermont with lower levels of education have decreased access. In New Hampshire, there are no programs within 30 miles of the areas with the largest distribution of smokers, and decreased access in some areas with the lowest levels of education.

CONCLUSIONS

Improving equitable access to high-quality screening services in rural regions and the creation of targeted interventions to address decreased access in areas of high tobacco use and low education is vital to decreasing the incidence of latestage presentations of lung cancer within these populations.

Ethnic inequalities in older adults bowel cancer awareness: findings from a community survey conducted in an ethnically diverse region in England

Background

To date, research exploring the public’s awareness of bowel cancer has taken place with predominantly white populations. To enhance our understanding of how bowel cancer awareness varies between ethnic groups, and inform the development of targeted interventions, we conducted a questionnaire study across three ethnically diverse regions in Greater London, England.

Methods

Data were collected using an adapted version of the bowel cancer awareness measure. Eligible adults were individuals, aged 60+ years, who were eligible for screening. Participants were recruited and surveyed, verbally, by staff working at 40 community pharmacies in Northwest London, the Harrow Somali association, and St. Mark’s Bowel Cancer Screening Centre. Associations between risk factor, symptom and screening awareness scores and ethnicity were assessed using multivariate regression.

Results

1013 adults, aged 60+ years, completed the questionnaire; half were of a Black, Asian or Minority ethnic group background (n = 507; 50.0%). Participants recognised a mean average of 4.27 of 9 symptoms and 3.99 of 10 risk factors. Symptom awareness was significantly lower among all ethnic minority groups (all p’s < 0.05), while risk factor awareness was lower for Afro-Caribbean and Somali adults, specifically (both p’s < 0.05). One in three adults (n = 722; 29.7%) did not know there is a Bowel Cancer Screening Programme. Bowel screening awareness was particularly low among Afro-Caribbean and Somali adults (both p’s < 0.05).

Conclusion

Awareness of bowel cancer symptoms, risk factors and screening varies by ethnicity. Interventions should be targeted towards specific groups for whom awareness of screening and risk factors is low.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10536-y.

Beliefs, fear and awareness of women about breast cancer: Effects on mammography screening practices

AIM

This study sought to investigate the beliefs, fear and awareness about breast cancer and mammography screening practices of women in Iran.

METHODS

This descriptive-correlational study was conducted at Tabriz, East Azerbaijan Province, northwest of Iran from February-July 2017. One hundred and fifty-two women aged 40 years and older, who were referred to 12 health centres for health services were selected via clustering sampling. Associations between variables and mammography screening practices were examined using bivariate and multivariate logistic regression analyses. Participants who had a mammogram within the last 24 months were compared with those who had none. Sociodemographic questionnaire, Champion's Breast Cancer Fear Scale, Champion's Health Belief Model Scale for Mammography Screening, Breast Cancer Awareness Scale and Powe Fatalism Inventory were the tools used for data gathering.

RESULTS

Just 38.2% of women reported having a mammogram within the last 24 months. Self-efficacy (OR = 5.36, B = 1.68, p < .001), susceptibility (OR = 2.83, B = 1.04, p < .001), motivation (OR = 2.11, B = 0.75, p = .024) and lower perceived barriers (OR = 0.25, B = -1.37, p < .001) were associated with being screened. Neither fatalistic belief nor awareness towards breast cancer was significant.

Feel Worried, Overloaded, or Fatalistic? The Determinants of Cancer Uncertainty Management Preferences

Uncertainty in the context of cancer involves a complex and conflicting decision-making process. Individual preferences of seeking or avoiding information in the decisions of maintaining, reducing, or increasing uncertainty often depend on key cancer-related beliefs. The present study investigates whether cancer worry (CW), information overload (CIO), or fatalism (CF) can predict four constructs of uncertainty management preferences - avoid to maintain hope, avoid insufficient information, seek to increase uncertainty, and seek to reduce uncertainty. A hybrid model with structural and measurement components was specified and tested. The model analysis shows that cancer-related beliefs influenced individuals' needs and preferences for uncertainty management through seeking or avoiding information. CW was positively related to all but avoiding insufficient information. CIO was positively associated with all four preferences. CF was only associated with avoiding to maintain uncertainty. Theoretical and practical implications were discussed.

Symptom appraisal, help-seeking and perceived barriers to healthcare seeking in Uganda: an exploratory study among women with potential symptoms of breast and cervical cancer

OBJECTIVE

We assessed the process of recognising abnormal bodily changes, interpretations and attributions, and help-seeking behaviour among community-based Ugandan women with possible symptoms of breast and cervical cancer, in order to inform health interventions aiming to promote timely detection and diagnosis of cancer.

DESIGN

Qualitative in-depth interviews.

SETTING

Rural and urban communities in Uganda.

PARTICIPANTS

Women who participated in the African Women Awareness of CANcer cross-sectional survey who disclosed potential breast and cervical cancer symptoms were eligible; recruitment was purposive. Interviews were conducted in women's homes, lasted between 40 and 90 min, were audio-recorded, transcribed verbatim and translated to English. Thematic analysis was used to identify themes and subthemes, underpinned by the conceptual framework of the Model of Pathways to Treatment.

RESULTS

23 women were interviewed: 10 had potential symptoms of breast cancer and 13 of cervical cancer. Themes regarding symptom appraisal and help-seeking included the: (1) detection and interpretation of abnormal bodily sensations; (2) lay consultations regarding bodily changes; (3) iterative process of inferring and attributing illnesses to the bodily changes; (4) restricted disclosure of symptoms to lay people due to concerns about privacy and fear of stigmatisation; (5) help-seeking from multiple sources including both traditional and biomedical health practitioners, and (6) multiple perceived barriers to help-seeking including long waiting times, lack of medicines, absenteeism of healthcare professionals, and lack of money for transport and medical bills.

CONCLUSION

Women with potential symptoms of breast and cervical cancer undergo complex processes of symptom interpretation, attributing symptoms or inferring illness, and lay consultations before undertaking help-seeking and management. Increasing community understanding of breast and cervical cancer symptoms, and tackling perceived barriers to health-seeking, could lead to prompt and appropriate symptom appraisal and help-seeking, and contribute to improving cancer outcomes.

Public perceptions of the effectiveness of recommended non-pharmaceutical intervention behaviors to mitigate the spread of SARS-CoV-2

Background

The COVID-19 pandemic is an unprecedented public health threat, both in scope and response. With no vaccine available, the public is advised to practice non-pharmaceutical interventions (NPI) including social distancing, mask-wearing, and washing hands. However, little is known about public perceptions of the effectiveness of these measures, and high perceived effectiveness is likely to be critical in order to achieve widespread adoption of NPI.

Methods

In May 2020, we conducted a cross-sectional survey among U.S. adults (N = 3,474). The primary outcome was a six-item measure assessing perceived effectiveness of recommended behaviors to prevent SARS-CoV-2 infection from 1 (not at all effective) to 5 (extremely effective). The sample was divided into “higher” and “lower” perceived effectiveness groups. Covariates included demographics, healthcare characteristics, and health beliefs. Variables that were significant at p<0.01 in bivariate analyses were entered into a multivariable logistic regression and a best-fit model was created using a cutoff of p<0.01 to stay in the model.

Results

Mean age was 45.5 years and most participants were non-Hispanic White (63%) and female (52.4%). The high perceived effectiveness group was slightly larger than the low perceived effectiveness group (52.7% vs. 47.3%). Almost all health belief variables were significant in the best-fit regression model. COVID-19-related worry (aOR = 1.82; 95% CI = 1.64–2.02), and perceived threat to physical health (aOR = 1.32; 95% CI = 1.20–1.45) were positively associated with perceived effectiveness while perceived severity of COVID-19 (0.84; 95% CI = 0.73–0.96) and perceived likelihood of infection (0.85; 95% CI = 0.77–0.94) switched directions in the adjusted model and were negatively associated with perceived effectiveness.

Conclusions

This research indicates people generally believe NPI are effective, but there was variability based on health beliefs and there are mixed rates of engagement in these behaviors. Public health efforts should focus on increasing perceived severity and threat of SARS-CoV-2-related disease, while promoting NPI as effective in reducing threat.

Does the Flemish colorectal cancer screening programme reach equity in FIT uptake?

BACKGROUND

To investigate colorectal cancer (CRC) screening rates by the faecal immunochemical test (FIT) according to sociodemographic characteristics and nationality.

METHODS

Men and women, aged 56-74, invited to participate in the Flemish CRC screening programme in 2013 and 2014 were included in this study. We analysed the association between CRC screening uptake and sex, age, (first and current) nationality and several proxies for socio-economic status (SES). The statistical analysis was based on descriptive analyses and logistic regression models.

RESULTS

A total of 1 184 426 persons were included in our analysis. The overall screening uptake was 52.3%, uptake varied by sex, age, nationality and SES. Lower participation rates were associated with the youngest and oldest age categories (56-60 and 70-74) and being male. All nationalities other than Belgian or Dutch were significantly less screened. Lower uptake of screening was also associated with several proxy's for low SES, such as having an allowance for being disabled, not being able to work, being an extended minor and having a social allowance/minimum wage. The descriptive analysis showed a 27% difference in CRC screening uptake between the (early) retired and the people entitled to a minimum wage.

CONCLUSIONS

There is a significant difference between screening uptake and demographic and socio-economic variables in the first 2 years of the population-based screening programme in Flanders. Based on the study results, implementing strategies to improve participation in those subgroups is needed.

Negative cancer beliefs: Socioeconomic differences from the awareness and beliefs about cancer survey

OBJECTIVE

Socioeconomic gaps in cancer mortality may be driven partially by poorer uptake of early detection behaviors among lower socioeconomic status (SES) groups. Lower SES groups may hold both fewer positive and more negative cancer beliefs that discourage these behaviors. We examined SES differences in positive and negative cancer beliefs in US adults.

METHODS

We conducted telephone interviews with a population-representative sample, aged 50+, using the Awareness and Beliefs about Cancer instrument (N = 1425). Cancer beliefs were measured using three positively and three negatively framed items. We used multivariable logistic regression models to examine associations between beliefs and education, which served as a marker of individual-level SES.

RESULTS

Agreement with positive statements was high (>80%) and did not vary with education, while agreement with negative statements varied. Relative to adults with a bachelor's degree, adults with a high school degree or less were more likely to agree that "treatment is worse than cancer" (45.2% vs. 68.2%; adjusted odds ratio (aOR) = 2.43, 99% CI = 1.50-3.94), cancer is "a death sentence" (17.4% vs. 33.2%; aOR = 2.51, 99% CI = 1.45-4.37), and they "would not want to know if I have cancer" (15.7% vs. 31.6%; aOR = 2.88, 99% CI = 1.54-5.36).

CONCLUSIONS

Positive cancer statements were generally endorsed, but negative statements were more frequently endorsed by lower SES groups. Additional work is needed to understand how negative beliefs develop and coexist alongside positive beliefs. Interventions to improve detection behaviors targeting lower SES groups may benefit from focusing on reducing negative beliefs, rather than increasing positive beliefs.

Cancer Perceptions Among Smokeless Tobacco Users: A Qualitative Study of US Firefighters

Background

Prevalence rates of smokeless tobacco (SLT) use among firefighters are remarkably high and substantially higher than similar occupational groups and the general U.S. population. The purpose of this study was to explore the perspectives of fire service personnel regarding cancer and its associations with tobacco and SLT use.

Methods

This descriptive study used a qualitative approach. Key informant interviews were conducted in 39 career firefighters and fire service administration from across the U.S. Discussion were recorded, transcribed verbatim and transferred to NVivo software for narrative analysis. Topics explored included cancer perceptions, attitudes and beliefs, and cultural factors related to SLT use behaviors. Results: Major themes that emerged among fire service personnel included concerns about cancer and its risk factors including firefighting tasks, such as fire overhaul operations, and from their lifestyle behaviors, such as alcohol and tobacco use. Firefighters also suggested a number of reasons for their increased SLT use, such as fire department tobacco-free policy and fire service culture.

Conclusion

The current study provides a rich foundation for future research, prevention, and intervention efforts for the fire service and research communities regarding tobacco and SLT use and cancer risk. Additional research on firefighters' cancer beliefs deserves future research in order to improve messaging about the risks of cancer due to firefighting.

A Survey of Areca (Betel) Nut Use and Oral Cancer in the Commonwealth of the Northern Mariana Islands

Areca nut use is a cause of higher rates of oral cavity cancer in the Commonwealth of the Northern Mariana Islands (CNMI). Little is known about patient insights into the risks of areca nut use worldwide. The purpose of this study is to evaluate perceptions of areca nut use and oral cancer among chewers in the CNMI. This is a survey study undertaken at the CNMI's only regional health center-300 adult participants completed a 21-question survey that assessed demographics, chewing behaviors, perceptions of areca nut use and oral cancer, and the willingness to participate in cessation and screening programs. Data was analyzed using chi-squared tests, at a significance value of P < .05. The participant average age was 38, and 41% were male. Almost all (92%) knew that chewing areca nut causes oral cancer, but only 13% correctly identified the actual areca nut as a carcinogen. About half (59%) believed that oral cancer could be treated. Most people (74%) were willing to participate in screening programs for oral cancer. Those who chewed areca nut daily were more likely to be interested in medicated replacement products relative to those who chewed less frequently (P = .048). In conclusion, there are drastic misperceptions about areca nut and oral cancer in the CNMI. Efforts should be made towards promoting awareness of the carcinogenicity of the actual areca nut, and the treatability of oral cancer. Mandated educational warnings should be required with areca nut sales. Further research evaluating substitution methods and screening programs is indicated.

Environmental Exposures Such as Smoking and Low Vitamin D Are Predictive of Poor Outcome in Cutaneous Melanoma rather than Other Deprivation Measures

A lack of basic resources within a society (deprivation) is associated with increased cancer mortality, and this relationship has been described for melanoma. We have previously reported the association of smoking and low vitamin D levels with melanoma death. In this study, we further explored the associations of these with melanoma in addition to deprivation and socio-economic stressors. In this analysis of 2,183 population-ascertained primary cutaneous melanoma patients, clinical, demographic, and socio-economic variables were assessed as predictors of tumor thickness, melanoma death and overall death. Using the Townsend deprivation score, the most deprived group did not have thicker tumors compared to the least deprived. Of the World Health Organization 25x25 risk factors for premature death, smoking and body mass index (BMI) were independently associated with thicker tumors. Low vitamin D was also independently associated with thicker tumors. No socio-economic stressors were independent predictors of thickness. Smoking was confirmed as a key predictor of melanoma death and overall death, as were low vitamin D levels, independent of other measures of deprivation. Neither BMI nor the Townsend deprivation score were predictive in either survival analysis. We report evidence for the role of smoking, vitamin D, and BMI in melanoma progression independent of a postcode-derived measure of deprivation.

The impact of cancer information online on cancer fatalism: education and eHealth literacy as moderators

One critical yet understudied concept associated with cancer information is cancer fatalism, i.e. deterministic thoughts about the cause of cancer, the inability to prevent it and the unavoidability of death upon diagnosis. The aim of this study is to understand how information seeking about cancer online influences cancer fatalism and whether and to what extent education and eHealth literacy moderate the relationship between them. Findings from an online survey of a nationally representative sample in the United States (N = 578) showed differential impacts of using the internet to search for information about cancer among the more and the less educated. For the less educated, more exposure to information about cancer via medical and health websites led to an increased level of cancer fatalism, whereas among the more educated, greater exposure lowered cancer fatalism. These differences were explained by the fact that the more educated were equipped with a higher level of eHealth literacy skills than the less educated. Findings show that only when one has necessary skills to apply digital resources can those resources help mitigate cancer fatalism. We suggest the need to enhance eHealth literacy skills among the less educated to reduce cancer fatalism.

Sociodemographic correlates of cancer fatalism and the moderating role of religiosity: Results from a nationally-representative survey

In general, it has been found that cancer fatalism is negatively associated with important cancer prevention and control behaviors, whereas religiosity is positively associated with these behaviors. Yet, the notion that religiosity gives rise to fatalistic beliefs that may discourage health behaviors is deeply ingrained in the public health literature. In addition, racial/ethnic group membership is associated with higher reports of cancer fatalism, though this association may be confounded by socioeconomic status (SES). A better understanding of the relationships between racial/ethnic group membership, SES, and religiosity may contribute to the development of effective interventions to address cancer fatalism and improve health behaviors. In this study, we examined associations between racial/ethnic group membership, SES, and cancer fatalism as the outcome. In addition, we tested whether religiosity (as measured by religious service attendance) moderated these relationships.

Predictors of an early death in patients diagnosed with colon cancer: a retrospective case-control study in the UK

OBJECTIVE

Despite considerable improvements, 5-year survival rates for colon cancer in the UK remain poor when compared with other socioeconomically similar countries. Variation in 5-year survival can be partly explained by higher rates of death within 3 months of diagnosis in the UK. This study investigated the characteristics of patients who died within 3 months of a diagnosis of colon cancer with the aim of identifying specific patient factors that can be addressed or accounted for to improve survival outcomes.

DESIGN

A retrospective case-control study design was applied with matching on age, sex and year diagnosed. Patient, disease, clinical and service characteristics of patients diagnosed with colon cancer in a UK region (2005-2010) who survived less than 3 months from diagnosis (cases) were compared with patients who survived between 6 and 36 months (controls). Patient and clinical data were sourced from general practice notes and hospital databases 1-3 years prediagnosis.

RESULTS

Being older (aged ≥78 years) and living in deprivation quintile 5 (OR=2.64, 95% CI 1.15 to 6.06), being unmarried and living alone (OR=1.64, 95% CI 1.07 to 2.50), being underweight compared with normal weight or obese (OR=3.99, 95% CI 1.14 to 14.0), and being older and living in a rural as opposed to urban area (OR=1.96, 95% CI 1.21 to 3.17) were all independent predictors of early death from colon cancer. Missing information was also associated with early death, including unknown stage, histological type and marital/accommodation status after accounting for other factors.

CONCLUSION

Several factors typically associated with social isolation were a recurring theme in patients who died early from colon cancer. This association is unexplained by clinical or diagnostic pathway characteristics. Socially isolated patients are a key target group to improve outcomes of the worst surviving patients, but further investigation is required to determine if being isolated itself is actually a cause of early death from colon cancer.

Lung cancer symptom appraisal among people with chronic obstructive pulmonary disease: A qualitative interview study

OBJECTIVE

The incidence of lung cancer is four times higher in people with chronic obstructive pulmonary disease (COPD) compared with the general population. Promotion of a shorter time from symptom onset to presentation is one potential strategy for earlier lung cancer diagnosis, but distinguishing respiratory symptoms can be difficult. We investigated how the experience of COPD influences symptom appraisal and help seeking for potential lung cancer symptoms.

METHODS

We conducted qualitative interviews with men (n = 17) and women (n = 23) aged 40 to 83 years with COPD. Topic guides drew on the integrated symptom-response framework and covered symptom experience, interpretation, action, recognition, help seeking, evaluation, and reevaluation. We used the framework method to analyse the data.

RESULTS

Participants said that they attributed chest symptoms to their COPD; no other cause was considered. Participants said that family/friends noticed changes in their symptoms and encouraged help seeking. Others felt isolated by their COPD because they could not get out, were fatigued, or were embarrassed. Participants visited health professionals frequently, but increased risk of lung cancer was not discussed.

CONCLUSIONS

Our study provides insight into different levels of influence on symptom appraisal and targets for intervention. Greater awareness of increased lung cancer risk and support to act on symptom changes is essential and could be achieved through a concerted information campaign. Health professionals working with people with COPD could also optimise appointments to support symptom appraisal of potential lung cancer symptoms.

Two-month follow-up evaluation of a cancer awareness training workshop ("Talk Cancer") on cancer awareness, beliefs and confidence of front-line public health staff and volunteers

People working across the health service, local government, community and voluntary sectors are appropriately placed to have discussions about cancer prevention and early diagnosis with members of the public. Cancer Research UK's training workshop ("Talk Cancer") aims to increase awareness of cancer screening programmes and risk factors, promote more positive beliefs about cancer and increase confidence to discuss cancer with members of the public, among people working in these roles. This study evaluated "Talk Cancer" by surveying 178 trainees immediately before, immediately after, and two months after training in the United Kingdom. Results showed that "Talk Cancer" was effective at promoting and maintaining more positive beliefs about cancer and confidence to discuss cancer. While there was an improvement in awareness of risk factors immediately after the workshop, there was less evidence that this was maintained at two-months, but awareness was improved relative to baseline in most cases. Increased awareness of the national bowel screening programme was maintained at two-months. While awareness that screening programmes do not exist for oral, skin and prostate cancers was not maintained, awareness was higher than baseline. The majority of trainees (86%) indicated they had applied their learning in their role and 59% reported having had more conversations about cancer prevention and early diagnosis since training. The impact of "Talk Cancer" on trainees' beliefs and confidence persists beyond the workshop, however, ongoing support is required to maintain improvements in awareness of cancer risk factors and which cancer types do not have national screening programmes.

Beyond fatalism: Information overload as a mechanism to understand health disparities

BACKGROUND

Fatalism - beliefs about the causes and controllability of disease - has been negatively associated with prevention behaviors. Fatalism has been suggested as a mechanism for health disparities because ethnic minorities are especially likely to hold fatalistic beliefs. However, the construct has been criticized: Fatalism fails to account for structural barriers to health faced by vulnerable populations that also score highly on measures of fatalism. Another critique suggests that operationalizations of fatalism expose communication failures: "Fatalism" rather reflects information overload from an environment riddled with misinformation and contradictions. This study aimed to expand understanding of one mechanism through which communication may contribute to disparities by considering the context of nutrition among bicultural Latinas, who face increased risk from dietary acculturation.

METHOD

Mixed-methods (semi-structured in-depth interview, survey) with Mexican-American women ages 18-29 (n = 24) in rural California.

RESULTS

Contrary to previous studies, the majority of this sample of Mexican-American women did not endorse fatalistic beliefs; most demonstrated clear understanding of the link between diet and risk of diseases: Diabetes and heart disease were understood to result from behaviors within one's control. Yet despite articulating links between diet and disease, participants felt overloaded and confused about conflicting information from public and interpersonal sources. Moreover, despite reporting feeling inundated with information, participants noted critical information gaps, distinguishing between information available and information needed.

CONCLUSIONS

We found minimal support for fatalistic beliefs among a sample of Mexican-American women, but considerable information overload and confusion, together with a desire for specific knowledge and skills. Results extend understanding of how communication may influence disparities: Information overload may be conflated with fatalism, challenging the notion that fatalism is a cultural belief. Moreover, inequalities in access to and ability to process information compound overload effects. We discuss opportunities to improve the clarity of communication about nutrition science and dietary recommendations.

Effect of Cultural, Folk, and Religious Beliefs and Practices on Delays in Diagnosis of Ovarian Cancer in African American Women

BACKGROUND

Certain cultural, folk, and religious beliefs that are more common among African Americans (AAs) have been associated with later-stage breast cancer. It is unknown if these beliefs are similarly associated with delays in diagnosis of ovarian cancer.

METHODS

Data from a multicenter case-control study of ovarian cancer in AA women were used to examine associations between cultural/folk beliefs and religious practices and stage at diagnosis and symptom duration before diagnosis. Associations between cultural/folk beliefs or religious practices and stage at diagnosis were assessed with logistic regression analyses, and associations with symptom duration with linear regression analyses.

RESULTS

Agreement with several of the cultural/folk belief statements was high (e.g., 40% agreed that "if a person prays about cancer, God will heal it without medical treatments"), and ∼90% of women expressed moderate to high levels of religiosity/spirituality. Higher levels of religiosity/spirituality were associated with a twofold increase in the odds of stage III-IV ovarian cancer, whereas agreement with the cultural/folk belief statements was not associated with stage. Symptom duration before diagnosis was not consistently associated with cultural/folk beliefs or religiosity/spirituality.

CONCLUSIONS

Women who reported stronger religious beliefs or practices had increased odds of higher stage ovarian cancer. Inaccurate cultural/folk beliefs about cancer treament were not associated with stage; however, these beliefs were highly prevalent in our population and could impact patient treatment decisions. Our findings suggest opportunities for health education interventions, especially working with churches, and improved doctor-patient communication.

Income Difference in Attitudes towards Cancer in General Population: Findings from a National Survey

BACKGROUND

To better understand cancer-related health behaviors, it is critical to know how general populations with different socioeconomic and demographic backgrounds perceive cancer. The current paper explored differences in general attitudes and beliefs towards cancer among Koreans.

METHODS

A cross-sectional national survey was conducted for 1,000 Korean participants who were not cancer patients and did not have immediate family members with cancer via proportional quota random sampling. General attitudes and beliefs about cancer were measured by face-to-face interview using the awareness and beliefs about cancer (ABC) measure.

RESULTS

Most respondents (84.8%-88.5%) had optimistic attitudes towards cancer. However, 35.6% to 87.7% agreed with negative cancer beliefs across all age groups simultaneously. Socioeconomic disparity of positive cancer beliefs was not evident. Unexpectedly, the highest income group agreed more strongly with the negatively framed statements that cancer treatment is worse than the cancer itself (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.31-5.53), that they would not want to know if they have cancer (OR, 1.61; 95% CI, 0.94-2.75), and that a cancer diagnosis is a death sentence (OR, 2.32; 95% CI, 1.34-4.01), than the lowest income group.

CONCLUSION

The present results imply a complicated context of cancer beliefs in Korea, unlike those shown in the studies of western populations. While the contradictory attitudes toward cancer can be attributable to the dual nature of information processing, social environment might have played a role. The association between socioeconomic status and negative attitudes toward cancer may vary depending on the diversity of the contexts.

Perceptions and beliefs of lay people from northern Uganda regarding surgery for diagnosis and treatment of cervical cancer

OBJECTIVE

To explore perceptions and beliefs of people in a rural community in northern Uganda regarding surgery for the diagnosis and treatment of cervical cancer. The aim of the study was to inform interventions to reduce delay and improve timely diagnosis and prompt appropriate treatments for patients with symptoms of cervical cancer.

METHODS

A semi-structured study guide informed by Kleinman's explanatory model for illness was used to collect data during 24 focus group discussions involving 175 men and women aged 18 to 59 years in Gulu, northern Uganda. Using thematic analysis, themes and subthemes were identified from the data through an iterative process and consensus among the authors.

RESULTS

Surgery for diagnosis and management of cervical cancer was perceived as (1) appropriate when performed at early stage of cancer and by senior doctors, but (2) a potential catalyst for the spread of cancer and early death; and (3) a challenge to childbearing and motherhood as well as a source of distress to women and families if surgery involved removal of the uterus with subsequent permanent infertility.

CONCLUSIONS

There are some negative perceptions about surgery for cervical cancer that may deter prompt help-seeking for symptoms. However, targeted messages for public awareness interventions to promote help-seeking can be built on the positive perceptions and beliefs that surgery could be curative when undertaken for early-stage cancer and by skilled doctors.

Fatalistic Cancer Beliefs and Information Seeking in Formerly Incarcerated African-American and Hispanic Men: Implications for Cancer Health Communication and Research

African-American and Hispanic men are disproportionately affected by cancer experiencing higher rates of cancer-related morbidity and mortality for many cancers (but not all). These challenges may be magnified for a subpopulation of African-American and Hispanic men who have been incarcerated. A survey assessing demographics, incarceration experience, psychosocial, behavioral, and cancer health information seeking was administered to 230 previously incarcerated men aged 35 years and older. Data analysis was performed to assess the association between fatalism, perceived susceptibility, and health information seeking in this population. This study revealed the following: the majority of the participants (68.7%) held the fatalistic belief: "When I think of cancer, I automatically think of death." Second, the fatalistic belief, "There's not much you can do to lower your chances of getting cancer," is more prevalent among those who perceived a higher risk of developing cancer. Third, older participants (those between 55 and 70 years old) and widowed are less likely to think of death when they think of cancer. In addition, those who use the Internet to look for health or medical information (i.e., engaging in health information seeking) are less likely to agree with the fatalistic belief: "It seems like everything causes cancer." Given the high incidence of certain cancers among African-American and Hispanic men and the vulnerability of those involved in the criminal justice system, our findings highlight the importance of understanding perceived susceptibility to cancer, fatalistic beliefs about cancer, and information seeking in formerly incarcerated men.

Participants, Physicians or Programmes: Participants' educational level and initiative in cancer screening

This study is an in-depth examination of at whose initiative (participant, physician or screening programme) individuals participate in cervical, breast and colorectal cancer screening across the EU-28. Special attention is paid to (1) the association with educational attainment and (2) the country's cancer screening strategy (organised, pilot/regional or opportunistic) for each type of cancer screened. Data were obtained from Eurobarometer 66.2 'Health in the European Union' (2006). Final samples consisted of 10,186; 5443 and 9851 individuals for cervical, breast, and colorectal cancer, respectively. Multinomial logistic regressions were performed. Surprisingly, even in countries with organised screening programmes, participation in screenings for cervical, breast and colorectal cancer was most likely to be initiated by the general practitioner (GP) or the participant. In general, GPs were found to play a crucial role in making referrals to screenings, regardless of the country's screening strategy. The results also revealed differences between educational groups with regard to their incentive to participate in cervical and breast cancer screening and, to a lesser extent, in colorectal cancer screening. People with high education are more likely to participate in cancer screening at their own initiative, while people with less education are more likely to participate at the initiative of a physician or a screening programme. Albeit, the results varied according to type of cancer screening and national screening strategy.

Is lower symptom recognition associated with socioeconomic inequalities in help-seeking for potential breast cancer symptoms?

OBJECTIVE

Socioeconomic inequalities in recognising signs and symptoms of cancer may result in inequalities in timely help-seeking and subsequent prognosis of breast cancer. We explored the mediating role of symptom attribution and concern on the relationship between level of education and help-seeking for potential breast cancer symptoms.

METHODS

Women aged ≥47 years (n = 961) were purposively recruited (by education) to complete an online vignette-based survey that included nipple rash and axillary lump (in separate vignettes) as potential symptoms of breast cancer. Women completed questions relating to medical help-seeking (yes/no), cancer attribution, symptom concern, cancer avoidance, family history, and demographics.

RESULTS

Women with low education and mid education attributed nipple rash less often to cancer (26% and 27% mentioned cancer) than women with a degree or higher (40%). However, women with a degree or higher (63%) or mid education (64%) were less likely to anticipate seeking help for the nipple rash than women with no formal qualifications (73%). This association was statistically significant in the 60- to 69-year-old age group. There was no significant association between education and help-seeking for axillary lump. Mediation analysis adjusting for potential confounders confirmed that the association between education and help-seeking for nipple rash was fully mediated by symptom concern.

CONCLUSIONS

Socioeconomic inequalities in stage at diagnosis and survival of breast cancer may not always be explained by lower likelihood of suspecting cancer and subsequent impact on help-seeking. Reducing inequalities in stage at diagnosis will involve understanding a broader range of bio-psycho-social factors (eg, comorbidities and healthcare system factors).

Anticipated health behaviour changes and perceived control in response to disclosure of genetic risk of breast and ovarian cancer: a quantitative survey study among women in the UK

BACKGROUND

Genetic risk assessment for breast cancer and ovarian cancer (BCOC) is expected to make major inroads into mainstream clinical practice. It is important to evaluate the potential impact on women ahead of its implementation in order to maximise health benefits, as predictive genetic testing without adequate support could lead to adverse psychological and behavioural responses to risk disclosure.

OBJECTIVE

To examine anticipated health behaviour changes and perceived control to disclosure of genetic risk for BCOC and establish demographic and person-specific correlates of adverse anticipated responses in a population-based sample of women.

DESIGN

Cross-sectional quantitative survey study carried out by the UK Office for National Statistics in January and March 2014.

SETTING

Face-to-face computer-assisted interviews conducted by trained researchers in participants' homes.

PARTICIPANTS

837 women randomly chosen from households across the UK identified from the Royal Mail's Postcode Address File.

OUTCOME MEASURES

Anticipated health behaviour change and perceived control to disclosure of BCOC risk.

RESULTS

In response to a genetic test result, most women (72%) indicated 'I would try harder to have a healthy lifestyle', and over half (55%) felt 'it would give me more control over my life'. These associations were independent of demographic factors or perceived risk of BCOC in Bonferroni-corrected multivariate analyses. However, a minority of women (14%) felt 'it isn't worth making lifestyle changes' and that 'I would feel less free to make choices in my life' (16%) in response to BCOC risk disclosure. The former belief was more likely to be held by women who were educated below university degree level (P<0.001) after adjusting for other demographic and person-specific correlates.

CONCLUSION

These findings indicate that women in the UK largely anticipate that they would engage in positive health behaviour changes in response to BCOC risk disclosure.

Understanding middle-aged and older adults' first associations with the word "cancer": A mixed methods study in England

Objective

Cancer is still widely feared and often associated with death. Fatalistic beliefs adversely affect help‐seeking for cancer symptoms and engagement in cancer prevention. This study aims to understand middle‐aged and older adults' first association with the word “cancer” and their relationship with sociodemographic factors, cancer fear, and cancer information avoidance.

Methods

We conducted a cross‐sectional survey of 1464 community‐based adults aged 50 to 70 living in England in April 2015. First associations with cancer were measured qualitatively and analysed using content analysis. We used binary logistic regression to analyse associations between the most common first association of cancer and sociodemographic characteristics, cancer fear, and cancer information avoidance.

Results

Cancer was most commonly associated with “death” (26%). Respondents with lower levels of education, living in the Midlands or North of England where cancer mortality is higher, or with close friends or family members with a cancer history, were more likely to associate cancer with death. Cancer fear was significantly associated with death associations, but cancer information avoidance was not.

Conclusions

Despite improved cancer outcomes, middle‐aged and older adults often associate cancer with death. Further efforts to decrease fatalistic associations in this age group may be needed.

Fear of cancer and older people's beliefs about cancer treatment in Poland

Throughout Europe and the United States, more than 60% of all cancer incidents occur in older people. Therefore, the aim of this study was to understand the level of fear people have regarding cancer and older people's beliefs about cancer pain, cancer treatment, and the curability of cancer. We conducted a survey in 2012, in which the sample was comprised of 910 adult residents of Wroclaw, Poland, to ascertain the beliefs people have about cancer and the degree of fear people have with respect to cancer. The majority of the respondents reported having a high level of fear, and this level of fear increased with age. Moreover, the oldest people (65 years and above) expressed fatalistic beliefs with respect to cancer. Our observations may guide health promotion campaigns and cancer prevention programs.

Attitudes towards lung cancer screening in socioeconomically deprived and heavy smoking communities: informing screening communication

BACKGROUND

While discussion continues over the future implementation of lung cancer screening, low participation from higher risk groups could limit the effectiveness of any national screening programme.

OBJECTIVES

To compare smokers' beliefs about lung cancer screening with those of former and never smokers within a low socioeconomic status (SES) sample, to explore the views of lower SES smokers and ex-smokers in-depth, and to provide insights into effective engagement strategies.

DESIGN, SETTING AND PARTICIPANTS

Using proactive, community-based recruitment methods, we surveyed 175 individuals from socioeconomically deprived communities with high smoking prevalence and subsequently interviewed 21 smokers and ex-smokers. Participants were approached in community settings or responded to a mail-out from their housing association.

RESULTS

Interviewees were supportive of screening in principle, but many were doubtful about its ability to deliver long-term survival benefit for their generation of "heavy smokers." Lung cancer was perceived as an uncontrollable disease, and the survey data showed that fatalism, worry and perceived risk of lung cancer were particularly high among smokers compared with non-smokers. Perceived blame and stigma around lung cancer as a self-inflicted smokers' disease were implicated by interviewees as important social deterrents of screening participation. The belief that lungs are not a treatable organ appeared to be a common lay explanation for poor survival and undermined the potential value of screening.

CONCLUSIONS

Attitudes towards screening among this high-risk group are complex. Invitation strategies need to be carefully devised to achieve equitable participation in screening.

Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data

BACKGROUND

Emergency diagnosis of cancer is common and aetiologically complex. The proportion of emergency presenters who have consulted previously with relevant symptoms is uncertain.

AIM

To examine how many patients with cancer, who were diagnosed as emergencies, have had previous primary care consultations with relevant symptoms; and among those, to examine how many had multiple consultations.

DESIGN AND SETTING

Secondary analysis of patient survey data from the 2010 English Cancer Patient Experience Survey (CPES), previously linked to population-based data on diagnostic route.

METHOD

For emergency presenters with 18 different cancers, associations were examined for two outcomes (prior GP consultation status; and 'three or more consultations' among prior consultees) using logistic regression.

RESULTS

Among 4647 emergency presenters, 1349 (29%) reported no prior consultations, being more common in males (32% versus 25% in females, P<0.001), older (44% in ≥85 versus 30% in 65-74-year-olds, P<0.001), and the most deprived (35% versus 25% least deprived, P = 0.001) patients; and highest/lowest for patients with brain cancer (46%) and mesothelioma (13%), respectively (P<0.001 for overall variation by cancer site). Among 3298 emergency presenters with prior consultations, 1356 (41%) had three or more consultations, which were more likely in females (P<0.001), younger (P<0.001), and non-white patients (P = 0.017) and those with multiple myeloma, and least likely for patients with leukaemia (P<0.001).

CONCLUSION

Contrary to suggestions that emergency presentations represent missed diagnoses, about one-third of emergency presenters (particularly those in older and more deprived groups) have no prior GP consultations. Furthermore, only about one-third report multiple (three or more) consultations, which are more likely in 'harder-to-suspect' groups.

Educational differences in responses to breast cancer symptoms: A qualitative comparative study

OBJECTIVE

Advanced stage at diagnosis for breast cancer is associated with lower socio-economic status (SES). We explored what factors in the patient interval (time from noticing a bodily change to first consultation with a health care professional) may contribute to this inequality.

DESIGN

Qualitative comparative study.

METHODS

Semi-structured interviews with a sample of women (≥47 years) from higher (n = 15) and lower (n = 15) educational backgrounds, who had experienced at least one potential breast cancer symptom. Half the participants (n = 15) had sought medical help, half had not (n = 15). Without making breast cancer explicit, we elicited women's sense-making around their symptoms and help-seeking decisions.

RESULTS

Containment of symptoms and confidence in acting upon symptoms emerged as two broad themes that differentiated lower and higher educational groups. Women from lower educational backgrounds tended to attribute their breast symptoms to trivial factors and were reticent in using the word 'cancer'. Despite 'knowing' that symptoms could be related to cancer, women with lower education invoked lack of medical knowledge - 'I am not a doctor' - to express uncertainty about interpreting symptoms and accessing help. Women with higher education were confident about interpreting symptoms, seeking information online, and seeking medical help.

CONCLUSIONS

Our findings suggest that knowledge of breast cancer alone may not explain socio-economic differences in how women respond to breast cancer symptoms as women with lower education had 'reasons' not to react. Research is needed on how to overcome a wider spectrum of psycho-social factors to reduce future inequality. Statement of contribution What is already known on this subject? Seven of ten breast cancers in the UK are diagnosed after people contact their doctor with symptoms. Women from lower socio-economic backgrounds are more likely to be diagnosed with advanced disease. There is little evidence related to potential drivers of this SES inequality. What does this study add? We qualitatively explored socio-economic (SES) differences in help-seeking for breast symptoms. Women with higher education were more confident about interpreting symptoms and navigating health care. Women with lower education were more reluctant to seek help due to fear of cancer.

Diagnosis of cancer as an emergency: a critical review of current evidence

Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumour, patient and health-care factors, often in combination. Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. In this Review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this under-researched aspect of cancer diagnosis.

Barriers to cancer symptom presentation among people from low socioeconomic groups: a qualitative study

BACKGROUND

Socioeconomic inequalities in cancer survival can in part be explained by long patient intervals among people from deprived groups; however, the reasons for this are unclear. This qualitative study explores the actual and anticipated barriers to cancer symptom presentation in the context of socioeconomic deprivation.

METHODS

Thirty participants were recruited through the International Cancer Benchmarking Partnership Welsh database (n = 20), snowball sampling (n = 8) and community partners (n = 2). Semi-structured qualitative interviews were conducted with symptomatic and asymptomatic adults over the age of 50 years, who were identified as being from a low socioeconomic group based on multiple individual and group level indicators. Transcripts were analysed using a Framework approach based on the COM-B model (Capability, Opportunity, Motivation-Behaviour).

RESULTS

There was evidence of poor awareness of non-specific cancer symptoms (Capability), fearful and fatalistic beliefs about cancer (Motivation), and various barriers to accessing an appointment with the family physician (Opportunity) and full disclosure of symptoms (Capability). These in combination were associated with a lengthened patient interval among participants. Social networks (Opportunity) were influential on the formation of knowledge and beliefs about cancer. Participants' behavioural and normative beliefs were usually formed and reinforced by people they knew with cancer, and such beliefs were considered to lengthen the patient interval. Discussing symptoms with a family member or friend before a visit to the family physician was the norm, and could act as a barrier or facilitator depending on the quality of advice given (Opportunity). Economic hardship meant fulfilling basic day-to-day needs such as finding money for food were prioritised over medical help seeking (Opportunity).

CONCLUSIONS

The complex interaction between individual characteristics and socio-environmental factors is important for understanding cancer symptom presentation behaviour, especially in the context of socioeconomic deprivation. Interventions targeted at deprived communities should take into account the wider social influences on symptom presentation behaviour.

Symptoms and patient factors associated with diagnostic intervals for pancreatic cancer (SYMPTOM pancreatic study): a prospective cohort study

Background

Pancreatic cancer is the tenth most common cancer in the UK; however, outcomes are poor, in part due to late diagnosis. We aimed to identify symptoms and other clinical and sociodemographic factors associated with pancreatic cancer diagnosis and diagnostic intervals.

Methods

We did this prospective cohort study at seven hospitals in two regions in England. We recruited participants aged 40 years or older who were referred for suspicion of pancreatic cancer. Data were collected by use of a patient questionnaire and primary care and hospital records. Descriptive and regression analyses were done to examine associations between symptoms and patient factors with the total diagnostic interval (time from onset of the first symptom to the date of diagnosis), comprising patient interval (time from first symptom to first presentation) and health system interval (time from first presentation to diagnosis).

Findings

We recruited 391 participants between Jan 1, 2011, and Dec 31, 2014 (24% response rate). 119 (30%) participants were diagnosed with pancreatic cancer (41 [34%] had metastatic disease), 47 (12%) with other cancers, and 225 (58%) with no cancer. 212 (54%) patients had multiple first symptoms whereas 161 (41%) patients had a solitary first symptom. In this referred population, no initial symptoms were reported more frequently by patients with cancer than by those with no cancer. Several subsequent symptoms predicted pancreatic cancer: jaundice (51 [49%] of 105 patients with pancreatic cancer vs 25 [12%] of 211 patients with no cancer; p<0·0001), fatigue (48/95 [51%] vs 40/155 [26%]; p=0·0001), change in bowel habit (36/87 [41%] vs 28/175 [16%]; p<0·0001), weight loss (55/100 [55%] vs 41/184 [22%]; p<0·0001), and decreased appetite (41/86 [48%] vs 41/156 [26%]; p=0·0011). There was no difference in any interval between patients with pancreatic cancer and those with no cancer (total diagnostic interval: median 117 days [IQR 57–234] vs 131 days [IQR 66–284]; p=0·32; patient interval 18 days [0–37] vs 15 days [1–62]; p=0·22; health system interval 76 days [28–161] vs 79 days [30–156]; p=0·68). Total diagnostic intervals were shorter when jaundice (hazard ratio [HR] 1·38, 95% CI 1·07–1·78; p=0·013) and decreased appetite (1·42, 1·11–1·82; p=0·0058) were reported as symptoms, and longer in patients presenting with indigestion (0·71, 0·56–0·89; p=0·0033), back pain (0·77, 0·59–0·99; p=0·040), diabetes (0·71, 0·52–0·97; p=0·029), and self-reported anxiety or depression, or both (0·67, 0·49–0·91; p=0·011). Health system intervals were likewise longer with indigestion (0·74, 0·58–0·95; p=0·0018), back pain (0·76, 0·58–0·99; p=0·044), diabetes (0·63, 0·45–0·89; p=0·0082), and self-reported anxiety or depression, or both (0·63, 0·46–0·88; p=0·0064), but were shorter with male sex (1·41, 1·1–1·81; p=0·0072) and decreased appetite (1·56, 1·19–2·06; p=0·0015). Weight loss was associated with longer patient intervals (HR 0·69, 95% CI 0·54–0·89; p=0·0047).

Interpretation

Although we identified no initial symptoms that differentiated people diagnosed with pancreatic cancer from those without pancreatic cancer, key additional symptoms might signal the disease. Health-care professionals should be vigilant to the possibility of pancreatic cancer in patients with evolving gastrointestinal and systemic symptoms, particularly in those with diabetes or mental health comorbidities.

Funding

National Institute for Health Research and Pancreatic Cancer Action.

Educational differences in likelihood of attributing breast symptoms to cancer: a vignette-based study

BACKGROUND

Stage at diagnosis of breast cancer varies by socio-economic status (SES), with lower SES associated with poorer survival. We investigated associations between SES (indexed by education), and the likelihood of attributing breast symptoms to breast cancer.

METHOD

We conducted an online survey with 961 women (47-92 years) with variable educational levels. Two vignettes depicted familiar and unfamiliar breast changes (axillary lump and nipple rash). Without making breast cancer explicit, women were asked 'What do you think this […..] could be?' After the attribution question, women were asked to indicate their level of agreement with a cancer avoidance statement ('I would not want to know if I have breast cancer').

RESULTS

Women were more likely to mention cancer as a possible cause of an axillary lump (64%) compared with nipple rash (30%). In multivariable analysis, low and mid education were independently associated with being less likely to attribute a nipple rash to cancer (OR 0.51, 0.36-0.73 and OR 0.55, 0.40-0.77, respectively). For axillary lump, low education was associated with lower likelihood of mentioning cancer as a possible cause (OR 0.58, 0.41-0.83). Although cancer avoidance was also associated with lower education, the association between education and lower likelihood of making a cancer attribution was independent.

CONCLUSION

Lower education was associated with lower likelihood of making cancer attributions for both symptoms, also after adjustment for cancer avoidance. Lower likelihood of considering cancer may delay symptomatic presentation and contribute to educational differences in stage at diagnosis. Copyright © 2016 John Wiley & Sons, Ltd.

Using Specialist Screening Practitioners (SSPs) to increase uptake of the Bowel Scope (Flexible Sigmoidoscopy) Screening Programme: a study protocol for a feasibility single-stage phase II trial

Background

The NHS Bowel Scope Screening (BSS) programme offers men and women aged 55 years a once-only flexible sigmoidoscopy (FS), a test that can help reduce colorectal cancer (CRC) incidence and mortality. However, the benefits of BSS are contingent on uptake. This National Institute for Health Research-funded single-stage phase II trial will test the feasibility of using patient navigation (PN), an intervention that offers support to patients to overcome barriers to healthcare, to increase BSS uptake within a socially deprived area of England.

Methods/design

All individuals invited for BSS at South Tyneside NHS Foundation Trust during the 6-month recruitment period will be invited to take part in the study. Consenting participants will be randomised to receive PN or usual care in a 2:1 ratio. PN involves non-attenders receiving a phone call from a Specialist Screening Practitioner (SSP) who will elicit reasons for non-attendance and offer educational, practical, and emotional support as needed. If requested by the patient, another appointment for BSS will then be arranged. We anticipate 30 % of participants will be non-attenders. Using A’Hern single-stage design, with 20 % significance level and 80 % power, at least 35 participants who receive PN need to subsequently attend for PN to be considered worthy of further investigation in a definitive trial. The primary outcome measure will be the number of participants in the PN group who re-book and attend their BSS appointment. A qualitative analysis of the PN transcripts, and interviews with the SSPs, will also be conducted, alongside a quantitative analysis of completed patient-reported experience questionnaires. An economic analysis will calculate the costs of delivering PN.

Discussion

This feasibility study will be instrumental in deciding whether to conduct the first definitive trial of PN in BSS in England. If PN is subsequently shown to be cost-effective at increasing uptake of BSS, NHS policies could be modified to implement PN as a standard service. The results will be disseminated in peer-reviewed journals and at scientific conferences.

Trial registration

International Standard Randomised Controlled Trial Number, ISRCTN13314752

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-016-0093-8) contains supplementary material, which is available to authorized users.

Education differences in cancer fatalism: The role of information-seeking experiences

Cancer fatalism is the belief that cancer is uncontrollable and lethal. Individuals with less education are more likely to hold fatalistic beliefs about cancer, but the mechanism accounting for the relationship is unknown. We tested whether negative health information seeking experiences explain this relationship. Structural equation modeling was used to test this relationship across three datasets from the Health Information National Trends Survey. Across all datasets, the model showed good fit: Cycle 1 (coefficient of determination = .11, comparative fit index = .96, root mean square error of approximation = .047), Cycle 2 (coefficient of determination = .06, comparative fit index = .96, root mean square error of approximation = .046), and Cycle 3 (coefficient of determination = .08, comparative fit index = .95, root mean square error of approximation = .052). The link between lower education level and higher cancer fatalism was partially mediated by negative health information seeking experiences.

Symptoms and patient factors associated with longer time to diagnosis for colorectal cancer: results from a prospective cohort study

Background:

The objective of this study is to investigate symptoms, clinical factors and socio-demographic factors associated with colorectal cancer (CRC) diagnosis and time to diagnosis.

Methods:

Prospective cohort study of participants referred for suspicion of CRC in two English regions. Data were collected using a patient questionnaire, primary care and hospital records. Descriptive and regression analyses examined associations between symptoms and patient factors with total diagnostic interval (TDI), patient interval (PI), health system interval (HSI) and stage.

Results:

A total of 2677 (22%) participants responded; after exclusions, 2507 remained. Participants were diagnosed with CRC (6.1%, 56% late stage), other cancers (2.0%) or no cancer (91.9%). Half the cohort had a solitary first symptom (1332, 53.1%); multiple first symptoms were common. In this referred population, rectal bleeding was the only initial symptom more frequent among cancer than non-cancer cases (34.2% vs 23.9%, P=0.004). There was no evidence of differences in TDI, PI or HSI for those with cancer vs non-cancer diagnoses (median TDI CRC 124 vs non-cancer 138 days, P=0.142). First symptoms associated with shorter TDIs were rectal bleeding, change in bowel habit, ‘feeling different' and fatigue/tiredness. Anxiety, depression and gastro-intestinal co-morbidities were associated with longer HSIs and TDIs. Symptom duration-dependent effects were found for rectal bleeding and change in bowel habit.

Conclusions:

Doctors and patients respond less promptly to some symptoms of CRC than others. Healthcare professionals should be vigilant to the possibility of CRC in patients with relevant symptoms and mental health or gastro-intestinal comorbidities.

Cancer Fatalism, Literacy, and Cancer Information Seeking in the American Public

Information seeking is an important behavior for cancer prevention and control, but inequalities in the communication of information about the disease persist. Conceptual models have suggested that low health literacy is a barrier to information seeking, and that fatalistic beliefs about cancer may be a mediator of this relationship. Cancer fatalism can be described as deterministic thoughts about the external causes of the disease, the inability to prevent it, and the inevitability of death at diagnosis. This study aimed to examine the associations between these constructs and sociodemographic factors, and test a mediation model using the American population-representative Health Information and National Trends Survey (HINTS 4), Cycle 3 (n = 2,657). Approximately one third (34%) of the population failed to answer 2/4 health literacy items correctly (limited health literacy). Many participants agreed with the fatalistic beliefs that it seems like everything causes cancer (66%), that one cannot do much to lower his or her chances of getting cancer (29%), and that thinking about cancer makes one automatically think about death (58%). More than half of the population had "ever" sought information about cancer (53%). In analyses adjusted for sociodemographic characteristics and family cancer history, people with limited health literacy were less likely to have ever sought cancer information (odds ratio [OR] = 0.63; 0.42-0.95) and more frequently endorsed the belief that "there's not much you can do . . ." (OR = 1.61; 1.05-2.47). This fatalistic belief partially explained the relationship between health literacy and information seeking in the mediation model (14% mediation). Interventions are needed to address low health literacy and cancer fatalism to increase public interest in cancer-related information.