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Damhus CS, Risør MB, Brodersen JB, Jønsson ABR. Rethinking the logic of early diagnosis in cancer. Health (London) 2024:13634593241234481. [PMID: 38407179 DOI: 10.1177/13634593241234481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
To reduce morbidity and mortality of cancer, more countries have implemented strategies to detect cancer, based on the logic of 'the sooner the better'. Time is thereby an essential component in how cancer research, policies, and prevention are practiced today. Where the logic of early diagnosis benefits some, the logic also produces harms. In this article, we use a cross-disciplinary case-study design to discuss how different notions of time and linearity are essential in today's research ontology of cancer, describe the individual and societal consequences of such ontology, and invite a rethinking of time in cancer. Drawing on theoretical concepts of time together with cancer epidemiological, historical and ethnographical data, we analyse how the logic of early diagnosis has been established as a stable concept. Although evidence supporting the logic points in different directions, the message 'the sooner the better' is currently not being challenged by research, policy or society. This at least partly, can be explained by a linear perception of time and societal traces of neoliberalism and acceleration in our society together with cancer still being a somewhat enigmatic disease that requires acute action. To support a sustainable healthcare sector, we argue there is a need to nuance the logic of early diagnosis. Continuing the linear perception of symptoms and cancer, risks doing more harm than good by making more people patients unnecessarily and by spending health resources on those with the least need.
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Affiliation(s)
- Christina Sadolin Damhus
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Research Unit for General Practice in Region Zealand, Denmark
| | - Mette Bech Risør
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Norway
| | - John Brandt Brodersen
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Research Unit for General Practice in Region Zealand, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Norway
| | - Alexandra Brandt Ryborg Jønsson
- The Centre of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Norway
- Department of People and Technology, Roskilde University, Denmark
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2
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Damhus CS, Brodersen JB, Risør MB. Luckily-I am not the worrying kind: Experiences of patients in the Danish cancer patient pathway for non-specific symptoms and signs of cancer. Health (London) 2023; 27:1059-1075. [PMID: 35502689 DOI: 10.1177/13634593221096244] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In Denmark, due to the implementation of the Non-specific Symptoms and Signs of Cancer-Cancer Patient Pathway (NSSC-CPP), more people with symptoms such as fatigue and weight loss are informed that their symptoms might indicate cancer and they are referred to the pathway. But what do patients in the NSSC-CPP experience, in particular, with respect to being in an affective state of anticipation of a cancer diagnosis? We conducted participant observation and semi-structured interviews with patients to investigate their experience of the NSSC-CPP with a specific focus on their perception of symptoms and their thoughts on worrying about cancer. We found that the phrase 'worried about cancer' was not recognised by the participants, but worry was visible in their increased healthcare use and their interpretation of bodily sensations. Our study indicates the need to explore the impact of anticipation and potential cancer worries in participants' everyday lives, as this context mediates their moral roles and responsibilities and restructures their social lives, while keeping uncertainty and probabilities on the table.
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Affiliation(s)
| | - John Brandt Brodersen
- Department of Public Health, The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Denmark
- Primary & eHealth Care, Region Zealand, Denmark
| | - Mette Bech Risør
- Department of Public Health, The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Denmark
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT, The Arctic University of Norway, Norway
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3
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Kirby E, MacArtney JI. Pandemic delay: social implications and challenges for palliative
care. Palliat Care Soc Pract 2023; 17:26323524231159146. [PMID: 36970304 PMCID: PMC10034307 DOI: 10.1177/26323524231159146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Affiliation(s)
| | - John I MacArtney
- Unit of Academic Primary Care, Division of
Health Sciences, Warwick Medical School, University of Warwick, Coventry,
UK
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Kristensen BM, Andersen RS, Nicholson BD, Ziebland S, Smith CF. Cultivating Doctors' Gut Feeling: Experience, Temporality and Politics of Gut Feelings in Family Medicine. Cult Med Psychiatry 2022; 46:564-581. [PMID: 34564779 DOI: 10.1007/s11013-021-09736-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 11/26/2022]
Abstract
For the past decade, within family medicine there has been a focus on cultivating doctors gut feelings as 'a way of knowing' in cancer diagnostics. In this paper, building on interviews with family doctors in Oxford shire, UK we explore the embodied and temporal dimensions of clinical reasoning and how the cultivation of doctors' gut feelings is related to hierarchies of medical knowledge, professional training, and doctors' fears of litigation. Also, we suggest that the introduction of gut feeling in clinical practice is an attempt to develop a theory of clinical reasoning that fits the biopolitics of our contemporary. The turn towards predictive medicine and the values introduced by accelerated diagnostic regimes, we conclude, introduce a need for situated and embodied modes of reading bodies. We contribute theoretically by framing our analysis within a sensorial anthropology approach.
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Affiliation(s)
- Benedikte Møller Kristensen
- Region Zealand, Primary Health Care, Alléen 15, 4180, Sorø, Denmark
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins allé 2, 8000, Århus, Denmark
- Department of Public Health, Research Unit for General Practice, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen, Denmark
| | - Rikke Sand Andersen
- Department of Public Health, Research Unit for General Practice, Southern University, JB. Winsløws vej 9B, 5000, Odense S, Denmark.
- Department of Anthropology, Aarhus University, Moesgaard Alle 15, 8270, Højbjerg, Denmark.
| | - Brian David Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
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Fish JA, Prichard I, Ettridge K, Grunfeld EA, Wilson C. Predicting men’s intentions to seek help for cancer symptoms: a comparison of the Theory of Planned Behaviour and the Health Belief Model. AUSTRALIAN JOURNAL OF PSYCHOLOGY 2022. [DOI: 10.1080/00049530.2022.2039042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jennifer A. Fish
- Flinders Health & Medical Research Institute, College of Medicine & Public Health, Flinders University, Adelaide, Australia
- Rosemary Bryant Ao Research Centre, Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- School of Psychology, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Ivanka Prichard
- College of Nursing & Health Sciences, Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Kerry Ettridge
- School of Psychology, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Health Policy Centre, South Australian Health & Medical Research Institute, Adelaide, Australia
| | | | - Carlene Wilson
- Flinders Health & Medical Research Institute, College of Medicine & Public Health, Flinders University, Adelaide, Australia
- Olivia Newton John Cancer and Wellness Research Centre, Austin Health, Heidelberg, Australia
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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Hultstrand C, Coe AB, Lilja M, Hajdarevic S. Shifting between roles of a customer and a seller - patients' experiences of the encounter with primary care physicians when suspicions of cancer exist. Int J Qual Stud Health Well-being 2021; 16:2001894. [PMID: 34784840 PMCID: PMC8604522 DOI: 10.1080/17482631.2021.2001894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Sweden has tried to speed up the process of early cancer detection by standardization of care. This increased focus on early cancer detection provides people with a conflicting norm regarding the importance of recognizing possible cancer symptoms and the responsibility of not delaying seeking care.Based on existing norms about patients' responsibility and care seeking, this study explores how patients experience encounters with primary care physicians when they seek care for symptoms potentially indicating cancer. METHODS Thirteen semi-structured interviews were conducted with patients receiving care for symptoms indicative of cancer in one county in northern Sweden. Data was analysed with thematic analysis. RESULTS The common notion of describing patients as customers in a healthcare context does not sufficiently capture all aspects of what counts as being a person seeking care. Instead, people interacting with primary care face a twofold role in where they are required to take the role not only of customer but also of seller. Consequently, people shift between these two roles in order to legitimize their care seeking. CONCLUSIONS Standardization oversimplifies the complexity underlying patients' experience of care seeking and interaction with healthcare. Hence, healthcare must acknowledge the individual person within a standardized system.
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Affiliation(s)
- Cecilia Hultstrand
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | | | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
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Bernhardson BM, Tishelman C, Rasmussen BH, Hajdarevic S, Malmström M, Overgaard Hasle TL, Locock L, Eriksson LE. Sensations, symptoms, and then what? Early bodily experiences prior to diagnosis of lung cancer. PLoS One 2021; 16:e0249114. [PMID: 33780498 PMCID: PMC8007036 DOI: 10.1371/journal.pone.0249114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 03/11/2021] [Indexed: 11/26/2022] Open
Abstract
Lung cancer (LC) generally lacks unique core symptoms or signs. However, there are a multitude of bodily sensations that are often non-specific, not easily understood, and many times initially not recognized as indicative of LC by the affected person, which often leads to late diagnosis. In this international qualitative study, we inductively analyzed retrospective accounts of 61 people diagnosed with LC in Denmark, England and Sweden. Using the bodily sensations they most commonly spoke about (tiredness, breathlessness, pain, and cough), we constructed four sensation-based cases to understand the pre-diagnostic processes of reasoning and practice triggered by these key indicators of LC. We thereafter critically applied Hay's model of sensations to symptoms transformation, examining its central concepts of duration, disability and vulnerability, to support understanding of these processes. We found that while duration and disability are clearly relevant, vulnerability is more implicitly expressed in relation to perceived threat. Tiredness, even when of long duration and causing disability, was often related to normal aging, rather than a health threat. Regardless of duration, breathlessness was disturbing and threatening enough to lead to care-seeking. Pain varied by location, duration and degree of disability, and thus also varied in degree of threat perceived. Preconceived, but unmet expectations of what LC-related cough and pain would entail could cause delays by misleading participants; if cough lasted long enough, it could trigger health care contact. Duration, disability, and sense of threat, rather than vulnerability, were found to be relevant concepts for understanding the trajectory to diagnosis for LC among these participants. The process by which an individual, their family and health care providers legitimize sensations, allowing them to be seen as potential symptoms of disease, is also an essential, but varying part of the diagnostic processes described here.
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Affiliation(s)
- Britt-Marie Bernhardson
- Division of Innovative Care Research, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Carol Tishelman
- Division of Innovative Care Research, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services (SLSO), Stockholms County Council (SLL), Stockholm, Sweden
| | - Birgit H. Rasmussen
- Department of Health Sciences, Lund University, Lund, Sweden
- The Institute for Palliative Care, Lund University and Region, Skåne, Sweden
| | | | - Marlene Malmström
- Department of Health Sciences, Lund University, Lund, Sweden
- The Institute for Palliative Care, Lund University and Region, Skåne, Sweden
| | - Trine Laura Overgaard Hasle
- Department of Public Health, Research Centre for Cancer, Diagnosis in Primary Care, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Louise Locock
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
- Nuffield Department of Primary Care Health Sciences, Health Experiences Research Group, University of Oxford, Oxford, United Kingdom
| | - Lars E. Eriksson
- Division of Innovative Care Research, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- School of Health Sciences, University of London, London, United Kingdom
- Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
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Combining patient talk about internet use during primary care consultations with retrospective accounts. A qualitative analysis of interactional and interview data. Soc Sci Med 2021; 272:113703. [PMID: 33540151 PMCID: PMC7938220 DOI: 10.1016/j.socscimed.2021.113703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/06/2020] [Accepted: 01/11/2021] [Indexed: 11/22/2022]
Abstract
Despite widespread acknowledgement of internet use for information about health, patients report not disclosing use of online health information in consultations. This paper compares patients' reported use of the internet with matched video recordings of consultations. The concepts of doctorability and epistemics are employed to consider similarities and differences between patients’ reports in interviews and actions in the consultation. Data are drawn from the Harnessing Resources from the Internet study conducted in the UK. The data set consists of 281 video-recorded general practice consultations, with pre-consultation questionnaires completed by all patients, interviews with all 10 participating doctors and 28 selected patients. We focus on the 28 patient interviews and associated consultation recordings. A conversation analytic (CA) approach is used to systematically inspect both the interview and consultation data. In interviews patients presented use of the internet as associated with appropriate self-management and help-seeking. In consultations patients skilfully translated what they had found on the internet in order to provide grounds for the actions they sought. We conclude that patients translate and utilise what they have found on the internet to assert the doctorability of their presenting problems. Furthermore, patients design their talk in both interviews and consultations to accord with their understanding of the epistemic rights of both doctors and patients. Patients search the internet so they are informed about their medical problem, however they carefully manage disclosure of information to avoid disrupting the smooth running of medical interactions. Patients seek information from the internet to support decisions to consult. Patients seek information from the internet to support appropriate self-management. Patients skilfully translate what they find on the internet to support requests. Patients skilfully use the internet to invite action from their doctors. Patients do not openly challenge the epistemic authority of the doctor.
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MacArtney JI, Andersen RS, Malmström M, Rasmussen B, Ziebland S. The convivial and the pastoral in patient-doctor relationships: a multi-country study of patient stories of care, choice and medical authority in cancer diagnostic processes. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:844-861. [PMID: 32103515 PMCID: PMC7318254 DOI: 10.1111/1467-9566.13067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Experiences of cancer diagnosis are changing in light of both the increasingly technological-clinical diagnostic processes and the socio-political context in which interpersonal relations take place. This has raised questions about how we might understand patient-doctor relationship marked by asymmetries of knowledge and social capital, but that emphasise patients' empowered choices and individualised care. As part of an interview study of 155 participants with bowel or lung cancer across Denmark, England and Sweden, we explored participants' stories of the decisions made during their cancer diagnostic process. By focusing on the intersections of care, choice and medical authority - a convivial pastoral dynamic - we provide a conceptual analysis of the normative ambivalences in people's stories of their cancer diagnosis. We found that participants drew from care, choice and medical authority to emphasise their relationality and interdependence with their doctors in their stories of their diagnosis. Importantly negotiations of an asymmetrical patient-doctor relationship were part of an on-going realisation of the healthcare processes as a human endeavour. We were therefore able to draw attention to the limitations of dichotomising emancipatory-empowerment discourses and argue for a theorisation of the patient-doctor relationship as a contextually bounded and relationally ambivalent humanity.
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Affiliation(s)
- John I. MacArtney
- Unit of Academic Primary CareWarwick Medical SchoolUniversity of WarwickWarwickUK
| | - Rikke S. Andersen
- Research Centre for Cancer Diagnosis in Primary CareResearch Unit of General Practice & Department of AnthropologyAarhus UniversityAarhusDenmark
| | - Marlene Malmström
- The Institute for Palliative CareLund University and Region SkåneLundSweden
- Lund UniversityDepartment of Health SciencesLundSweden
| | - Birgit Rasmussen
- The Institute for Palliative CareLund University and Region SkåneLundSweden
- Lund UniversityDepartment of Health SciencesLundSweden
| | - Sue Ziebland
- Health Experiences Research GroupNuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
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Evans J, Macartney JI, Bankhead C, Albury C, Jones D, Ziebland S, Nicholson BD. How do GPs and patients share the responsibility for cancer safety netting follow-up actions? A qualitative interview study of GPs and patients in Oxfordshire, UK. BMJ Open 2019; 9:e029316. [PMID: 31515421 PMCID: PMC6747661 DOI: 10.1136/bmjopen-2019-029316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/22/2019] [Accepted: 09/04/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To explore patients' and General Practitioners' (GPs) accounts of how responsibility for follow-up was perceived and shared in their experiences of cancer safety netting occurring within the past 6 months. DESIGN In-depth interviews were recorded and transcribed verbatim. Data were analysed through an abductive process, exploring anticipated and emergent themes. Conceptualisations of 'responsibility' were explored by drawing on a transactional to interdependent continuum drawing from the shared decision-making literature. SETTINGS AND PARTICIPANTS A purposive sample of 25 qualified GPs and 23 adult patients in Oxfordshire, UK. RESULTS The transactional sharing approach involves responsibility being passed from GP to patient. Patients expected and were willing to accept responsibility in this way as long as they received clear guidance from their GP and had capacity. In interdependent sharing, GPs principally aimed to reach consensus and share responsibility with the patient by explaining their rationale, uncertainty or by stressing the potential seriousness of the situation. Patients sharing this responsibility could be put at risk if no follow-up or timeframe was suggested, they had inadequate information, were falsely reassured or their concerns were not addressed at re-consultation. CONCLUSION GPs and patients exchange and share responsibility using a combination of transactional and interdependent styles, tailoring information based on patient characteristics and each party's level of concern. Clear action plans (written where necessary) at the end of every consultation would help patients decide when to re-consult. Further research should investigate how responsibility is shared within and outside the consultation, within primary care teams and with specialist services.
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Affiliation(s)
- Julie Evans
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John I Macartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Daniel Jones
- Supportive care, early diagnosis and advanced disease research group, Hull York Medical School, Hull, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Hajdarevic S, Rasmussen BH, Overgaard Hasle TL, Ziebland S. Qualitative cross-country comparison of whether, when and how people diagnosed with lung cancer talk about cigarette smoking in narrative interviews. BMJ Open 2018; 8:e023934. [PMID: 30420351 PMCID: PMC6252649 DOI: 10.1136/bmjopen-2018-023934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/20/2018] [Accepted: 09/26/2018] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To compare and examine whether, when and how patients with lung cancer in three countries, with different survival rates, talk about cigarette smoking and its relationship with help-seeking. DESIGN A qualitative cross-country comparison with analysis of narrative interviews. SETTING Participants in Sweden, Denmark and England were interviewed during 2015-2016. Interviews, using a narrative approach, were conducted in participants' home by trained and experienced qualitative researchers. PARTICIPANTS Seventy-two men and women diagnosed with lung cancer were interviewed within 6 months of their diagnosis. RESULTS The English participants, regardless of their own smoking status, typically raised the topic of smoking early in their interviews. Smoking was mentioned in relation to symptom appraisal and interactions with others, including health professionals. Participants in all three countries interpreted their symptoms in relation to their smoking status, but in Sweden (unlike England) there was no suggestion that this deterred them from seeking care. English participants, but not Swedish or Danish, recounted reluctance to consult healthcare professionals with their symptoms while they were still smoking, some gave up shortly before consulting. Some English patients described defensive strategies to challenge stigma or pre-empt other people's assumptions about their culpability for the disease. A quarter of the Danish and 40% of the Swedish participants did not raise the topic of smoking at any point in their interview. CONCLUSION The causal relationship between smoking and lung cancer is well known in all three countries, yet this comparative analysis suggests that the links between a sense of responsibility, stigma and reluctance to consult are not inevitable. These findings help illuminate why English patients with lung cancer tend to be diagnosed at a later stage than their Swedish counterparts.
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Affiliation(s)
| | - Birgit H Rasmussen
- The Institute for Palliative Care, Lund University and Region Skåne, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Surgery, Lund, Sweden
| | - Trine L Overgaard Hasle
- Research Unit of General Practice, Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Aarhus, Denmark
| | - Sue Ziebland
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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