Associations between reporting of cancer alarm symptoms and socioeconomic and demographic determinants: a population-based, cross-sectional study

Associations of Obesity, Physical Activity, and Screening With State-Level Trends and Racial and Ethnic Disparities of Breast Cancer Incidence and Mortality in the US

IMPORTANCE

Breast cancer causes disproportionate disease burden among various racial and ethnic groups in the US. However, state-level temporal trends and racial and ethnic disparities and whether metabolic and lifestyle factors and screening access are associated with temporal changes remain largely unknown.

OBJECTIVES

To investigate temporal trends and racial and ethnic variations at the state level and ecological correlations between obesity, physical activity, and mammography screening and breast cancer incidence and mortality trends among women in the US.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was conducted to analyze breast cancer incidence and mortality trends among women in the US from January 1, 1999, to December 31, 2017, whereas an ecological analysis was performed to assess the associations. Data were analyzed from March 1, 2021, to September 30, 2021. Population-based cancer registry data were obtained from US Cancer Statistics incidence and mortality data. Prevalence of obesity, physical activity, and mammography screening were obtained from the Behavioral Risk Factor Surveillance System.

EXPOSURES

Prevalence of obesity, physical activity, and mammography screening.

MAIN OUTCOMES AND MEASURES

Breast cancer incidence and mortality trends from 1999 to 2017 in the 50 US states and the District of Columbia.

RESULTS

A total of 4 136 123 breast cancer cases and 782 454 deaths were included in the analysis, with a significant reduction in incidence (average annual percent change [AAPC], -0.4% [95% CI, -0.6% to -0.2%)]) and mortality (AAPC, -1.7% [95% CI, -1.8% to -1.5%]) during the study period. A significant state-level variation in breast cancer incidence and mortality between White women and those of other races and ethnicities was observed. A significant positive correlation was found between obesity and breast cancer incidence (r = 0.316; P = .02) and mortality (r = 0.400; P = .004) and an inverse correlation was found between physical activity and incidence (r = -0.577; P < .001) in women 55 years or older and mammography screening and mortality trends (r = -0.644; P < .001) in women 40 years or older.

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that racial and ethnic disparities exist at the state level with regard to breast cancer incidence and mortality among women in the US. Metabolic and lifestyle factors and screening access were associated with the observed trends and racial and ethnic disparities. Interventions targeting these factors may help reduce the incidence of breast cancer and related deaths.

Retrospective Observational Study on the Characteristics of Pain and Associated Factors of Breakthrough Pain in Advanced Cancer Patients

Objective

This study aimed to conduct a retrospective observational study to understand the status of characteristics of pain and identify potential variables influencing the clinical presentation of breakthrough cancer pain (BTP) in advanced cancer patients.

Methods

Advanced cancer patients over 18 years of age; diagnosed with cancer of any type and stage III or IV in the palliative care ward with available data were enrolled between 2018 and 2020. Demographic data and pain-related information were collected by using structured electronic extraction form from Hospital Information System (HIS). Patients who had well-controlled background pain with an intensity ≤4 on a 0–10 numerical scale for >12 hours/day, the presence of transient exacerbations of pain with moderate-severe intensity (≧5), and clearly distinguish from background pain were regarded to have suffered BTP. Spearman correlation was conducted to explore the relationship between pain score and demographics characteristics. Factors significant in univariate analysis were included in the multiple regression model to explore independent predictive factors associated with the BTP.

Results

Of 798 advanced cancer patients, the mean age was 56.7 (SD = 11.84) years. Lung cancer (29.95%) was the most common cancer, and pain (93%) was the most common symptom. More than half (n = 428, 53.6%) of the patients experienced BTP. The median number of BTP episodes was 4 (IQR = 2, 7, range: 1–42). The median intensity of BTP was 6 (IQR = 6, 7, range 5–10). Patients with severe background pain or BTP had longer hospital stay and more symptoms. Besides, more severe background pain was related to higher activity of daily living. Intramuscular injection of hydromorphone hydrochloride was the main medication for BTP onset. Younger age, background pain, anorexia, and constipation were independently associated with the presentation of BTP. BTP pain intensity was independently associated with bloating. Symptom numbers were an independent factor and positively associated with BTP episodes.

Conclusions

BTP resulted in poor prognosis, which has a variable presentation depending on interdependent relationships among different characteristics. Good controlling of background pain and assessment of pain-related symptoms are essential for BTP management. BTP should be managed individually, especially the invisible pain among aged patients. Furthermore, BTP-related education and training were still needed.

Symptomatic Features and Factors Associated With Do-Not-Resuscitate Consent in Advanced Cancer Patients Admitted to Palliative Care Ward

This study aimed to conduct a retrospective cross-sectional study to investigate the prevalence of symptoms and symptom clusters on sociodemographic and disease characteristics, as well as factors associated with Do-Not-Resuscitate (DNR) consent. Advanced cancer patients were enrolled between 2018 and 2020 with available data. Demographic and clinical data were obtained for analysis from Hospital Information System (HIS) in China. Symptom clusters were extracted by hierarchical cluster analysis. Chi-square test and multiple logistic regression were conducted to investigate the prevalence characteristics of symptoms and influencing factors of DNR consent, respectively. 798 advanced cancer patients were enrolled. The most prevalent symptoms were pain (93%), anorexia (36.5%), and sleep disorders (34.2%). High heart rate was associated with poor performance status and more symptoms. Three clusters were extracted: fatigue-related, respiratory-circulatory system, and digestive system symptom clusters. The incidence of symptoms was statistically significant in age, gender, education level, residence, BMI, performance status, distress score, ADL, and primary pain level. The DNR signature rate was 15.5%. Female, distant metastasis, in-ward rescue, and appearance of dyspnea were independent influencing factors of DNR signature.Chinese hospitalized cancer patients had more symptoms burden that were influenced by various demographic characteristics, especially pain and fatigue-related symptoms. Concerning the trajectory of vital signs is important among advanced cancer patients. The DNR signature rate was lower and our finding indicating an urgency to accurately assess the prognosis and give more palliative care education to enhance DNR rates and early signing in Chinese context.

Patterns of symptoms possibly indicative of cancer and associated help-seeking behaviour in a large sample of United Kingdom residents-The USEFUL study

BACKGROUND

Cancer awareness campaigns aim to increase awareness of the potential seriousness of signs and symptoms of cancer, and encourage their timely presentation to healthcare services. Enhanced understanding of the prevalence of symptoms possibly indicative of cancer in different population subgroups, and associated general practitioner (GP) help-seeking behaviour, will help to target cancer awareness campaigns more effectively.

AIM

To determine: i) the prevalence of 21 symptoms possibly indicative of breast, colorectal, lung or upper gastrointestinal cancer in the United Kingdom (UK), including six 'red flag' symptoms; ii) whether the prevalence varies among population subgroups; iii) the proportion of symptoms self-reported as presented to GPs; iv) whether GP help-seeking behaviour varies within population subgroups.

METHODS

Self-completed questionnaire about experience of, and response to, 25 symptoms (including 21 possibly indicative of the four cancers of interest) in the previous month and year; sent to 50,000 adults aged 50 years or more and registered with 21 general practices in Staffordshire, England or across Scotland.

RESULTS

Completed questionnaires were received from 16,778 respondents (corrected response rate 34.2%). Almost half (45.8%) of respondents had experienced at least one symptom possibly indicative of cancer in the last month, and 58.5% in the last year. The prevalence of individual symptoms varied widely (e.g. in the last year between near zero% (vomiting up blood) and 15.0% (tired all the time). Red flag symptoms were uncommon. Female gender, inability to work because of illness, smoking, a history of a specified medical diagnosis, low social support and lower household income were consistently associated with experiencing at least one symptom possibly indicative of cancer in both the last month and year. The proportion of people who had contacted their GP about a symptom experienced in the last month varied between 8.1% (persistent cough) and 39.9% (unexplained weight loss); in the last year between 32.8% (hoarseness) and 85.4% (lump in breast). Nearly half of respondents experiencing at least one red flag symptom in the last year did not contact their GP about it. Females, those aged 80+ years, those unable to work because of illness, ex-smokers and those previously diagnosed with a specified condition were more likely to report a symptom possibly indicative of cancer to their GP; and those on high household income less likely.

CONCLUSION

Symptoms possibly indicative of cancer are common among adults aged 50+ years in the UK, although they are not evenly distributed. Help-seeking responses to different symptoms also vary. Our results suggest important opportunities to provide more nuanced messaging and targeting of symptom-based cancer awareness campaigns.

Metformin as an adjuvant in breast cancer treatment

Breast cancer is one of the most common malignancies in females. It is an etiologically complex disease driven by a multitude of cellular pathways. The proliferation and spread of breast cancer is intimately linked to cellular glucose metabolism, given that glucose is an essential cellular metabolic substrate and that insulin signalling has mitogenic effects. Growing interest has focused on anti-diabetic agents in the management of breast cancer. Epidemiologic studies show that metformin reduces cancer incidence and mortality among type 2 diabetic patients. Preclinical in vitro and in vivo research provides intriguing insight into the cellular mechanisms behind the oncostatic effects of metformin. This article aims to provide an overview of the mechanisms in which metformin may elicit its anti-cancerous effects and discuss its potential role as an adjuvant in the management of breast cancer.

Differences in Breast Cancer Stage at Diagnosis by Ethnicity, Insurance Status, and Family Income in Young Women in the USA

PURPOSE

Describe the clinical and epidemiological data from young women with breast cancer and determine the association between ethnicity, insurance status, family income, and breast cancer stage at the diagnosis in this population.

METHODS

Women under the age of 40 diagnosed with invasive breast cancer from 2010 to 2014 and identified in the Surveillance, Epidemiology, and End Results (SEER) 18 registries database were included. Binary logistic regression was applied in order to estimate the odds ratios (ORs) for factors that were potentially predictive for receiving a breast cancer diagnosis at stage I.

RESULTS

Of 14,379 young women with invasive breast cancer, 70.9% of the patients were white, 15.9% black, and 13.2% classified as other ethnicity (American Indian, Asian, Pacific Islander). The initial clinical stage at diagnosis was stage I in 28.2%, II in 45.2%, III in 19.0%, and IV in 7.6%. The chi-square test showed a significant association between clinical stage at diagnosis and family income (p < 0.0001), insurance status (p < 0.0001), and ethnicity (p < 0.0001). The ORs for being diagnosed at stage I, regarding different factors, revealed that women with family income higher than US$ 85,000 were more likely to be diagnosed with stage I (OR [95%CI], 1.306 [1.173-1.454]; p value < 0.0001) when compared with patients with family income of less than US$ 60,000. Black women were less likely to be diagnosed with stage I (OR [95%CI], 0.676 [0.605-0.755]; p value < 0.0001), when compared with white women. Uninsured women were less likely to be diagnosed with stage I (OR [95%CI], 0.586 [0.529-0.648]; p value < 0.0001) when compared with women with insurance coverage.

CONCLUSION

Among young US women diagnosed with invasive breast cancer, most of them presented early stage disease. Women with black ethnicity, low income, and uninsured are at risk for late-stage presentation. Improvements in strategies to allow earlier breast cancer diagnosis in these at risk population are urged.

Awareness of Cancer Signs and Barriers to Help Seeking: a National Survey

About 27% of cancer patients in Jordan are discovered in advanced stages; this resulted in poor prognosis and survival rates. One possible cause of late presentation is lack of awareness of warning signs and risk factors of cancer. The purpose of this study is to identify the level of awareness of cancer warning signs, risk factors, and barriers to seeking medical advice among the Jordanian public. A cross-sectional survey design was used. A convenience sample of 2292 participants from the Jordanian public was included in the study. The Cancer Awareness Measure (CAM) was used. Of the 2292 participants, 1206 were females with a mean age of 30.5 SD 11.3 years, ranging from 18 to 81 years. Recall (open question) was not good for all warning symptoms; the percentage of the participants who correctly recalled one of the nine symptoms ranged from 1.7 to 22.9%. However, the mean of the total number of recognized symptoms was also low 4.7 SD 2.4. The highest recognition percentages were as follows: lump/swelling (77.6%), weight loss (63%), and change in appearance of a mole (61.1%). In regard to recognizing risk factors, the most commonly known risk factor was being a smoker (81.4%), followed by drinking more than one unit of alcohol (74.8%). Overall, this study demonstrated that there is a low level of awareness on cancer symptoms and risk factors. This provided a room for improvement through public education which remains the mainstay for such improvement. Emotional barriers to seeking medical care should be addressed using behaviour-changing models.

The prognosis of invasive micropapillary carcinoma compared with invasive ductal carcinoma in the breast: a meta-analysis

Background

Invasive micropapillary carcinoma (IMPC) of the breast is a rare variant of invasive ductal carcinoma (IDC). The prognosis of IMPC compared with that of IDC remains controversial; we conducted a meta-analysis to evaluate the prognostic difference between IMPC and IDC.

Methods

We searched the PubMed, Cochrane Library, and EMBASE databases for relevant studies comparing overall survival (OS), disease-specific survival (DSS), relapse-free survival (RFS), local-regional recurrence-free survival (LRRFS) or distant metastasis-free survival (DMFS) rates between IMPC and IDC. Fixed-effect and random-effect models were utilized based on the heterogeneity of the eligible studies. Heterogeneity was further evaluated by subgroup and sensitivity analyses.

Results

Fourteen studies with 1888 IMPC patients were included in the meta-analysis. The summarized odds ratio (OR) and 95% confidence interval (95% CI) was calculated to estimate the prognostic difference between IMPC and IDC. IMPC patients showed an unfavorable prognosis for RFS (OR; 2.04; 95% CI: 1.63–2.55) and LRRFS (OR: 2.82; 95% CI: 1.90–4.17) compared with IDC. However, no significant difference was observed in OS (OR: 0.93; 95% CI: 0.78–1.10), DSS (OR: 1.16; 95% CI: 0.95–1.40) and DMFS (OR: 0.95; 95% CI: 0.67–1.35) between IMPC and IDC. No obvious statistical heterogeneity was detected, except for DSS. Funnel plots and Egger’s tests did not reveal publication bias, except for RFS.

Conclusions

This analysis showed that IMPC patients have a higher rate of loco-regional recurrence than IDC patients. However, OS, DSS and DMFS were not significantly different between IMPC and IDC. These results could help clinicians select therapeutic and follow-up strategies for IMPC patients.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3855-7) contains supplementary material, which is available to authorized users.

A Population-Based Cross-Sectional Study Comparing Breast Cancer Stage at Diagnosis between Immigrant and Canadian-Born Women in Ontario

There is limited information on stage at breast cancer diagnosis in Canadian immigrant women. We compared stage at diagnosis between immigrant women and Canadian-born women, and determined whether ethnicity was an independent factor associated with stage. 41,213 women with invasive breast cancer from 2007 to 2012 were identified from the Ontario Cancer Registry. Women were classified as either immigrants or Canadian-born by linkage with the Immigration, Refugees, and Citizenship Canada's Permanent Resident database. Women's ethnicity was classified as Chinese, South Asian, or remaining women in Ontario. Logistic regression was performed to calculate the odds ratio (OR) of being diagnosed at stage I breast cancer (versus stage II-IV). 4,353 (10.6%) women were immigrants and 36,860 (89.4%) were Canadian-born women. The mean age at breast cancer diagnosis was 53.5 years for immigrants versus 62.3 years for Canadian-born women (p < 0.0001). Immigrant women were less likely than Canadian-born women to be diagnosed with stage I breast cancers (adjusted OR = 0.85; 95% CI: 0.79-0.91; p < 0.0001). The adjusted OR of being stage I was 1.28 (95% CI: 1.14-1.43; p < 0.0001) for women of Chinese ethnicity and was 0.82 (95% CI: 0.70-0.96; p = 0.01) for women of South Asian ethnicity, compared to the remaining women in Ontario. Canadian immigrant women were less likely than Canadian-born women to be diagnosed with early-stage breast cancers. Ethnicity was a greater contributor to the stage disparity than was immigrant status. South Asian women, regardless of immigration status, might benefit from increased breast cancer awareness programs.

Attributions of cancer 'alarm' symptoms in a community sample

Background

Attribution of early cancer symptoms to a non-serious cause may lead to longer diagnostic intervals. We investigated attributions of potential cancer ‘alarm’ and non-alarm symptoms experienced in everyday life in a community sample of adults, without mention of a cancer context.

Methods

A questionnaire was mailed to 4858 adults (≥50 years old, no cancer diagnosis) through primary care, asking about symptom experiences in the past 3 months. The word cancer was not mentioned. Target 'alarm' symptoms, publicised by Cancer Research UK, were embedded in a longer symptom list. For each symptom experienced, respondents were asked for their attribution (‘what do you think caused it'), concern about seriousness (‘not at all’ to ‘extremely’), and help-seeking (‘did you contact a doctor about it’: Yes/No).

Results

The response rate was 35% (n = 1724). Over half the respondents (915/1724; 53%) had experienced an ‘alarm’ symptom, and 20 (2%) cited cancer as a possible cause. Cancer attributions were highest for ‘unexplained lump’; 7% (6/87). Cancer attributions were lowest for ‘unexplained weight loss’ (0/47). A higher proportion (375/1638; 23%) were concerned their symptom might be ‘serious’, ranging from 12% (13/112) for change in a mole to 41% (100/247) for unexplained pain. Just over half had contacted their doctor about their symptom (59%), although this varied by symptom. Alarm symptoms were appraised as more serious than non-alarm symptoms, and were more likely to trigger help-seeking.

Conclusions

Consistent with retrospective reports from cancer patients, ‘alarm’ symptoms experienced in daily life were rarely attributed to cancer. These results have implications for understanding how people appraise and act on symptoms that could be early warning signs of cancer.

Associations between health care seeking and socioeconomic and demographic determinants among people reporting alarm symptoms of cancer: a population-based cross-sectional study

BACKGROUND

Late diagnosis of cancer may partly be explained by the fact that some patients do not seek health care promptly when experiencing an alarm symptom. Socioeconomic and demographic differences exist concerning knowledge and awareness of cancer alarm symptoms in the general population and socioeconomic differences are found in cancer incidence and survival. We therefore hypothesise that socioeconomic and demographic differences in health care-seeking behaviour are present among people with alarm symptoms.

OBJECTIVES

To analyse associations between health care seeking and socioeconomic and demographic factors among people reporting cancer alarm symptoms.

METHODS

A questionnaire survey comprising 20000 people aged >20 from the Danish population. The questionnaire concerned alarm symptoms of common cancers and subsequent health care seeking. Data on socioeconomic factors were obtained from Statistics Denmark.

MAIN OUTCOMES

health care seeking and patient interval.

RESULTS

A total of 26.1% of all subjects reported that they did not seek health care when having experienced an alarm symptom. Women-subjects aged >40, subjects living with a partner and subjects having a cancer diagnosis-were more likely to seek health care, whereas medium educational level was negatively associated with health care seeking. Further, women were more likely to seek health care within 1 month, whereas subjects out of the workforce were less likely to do so.

CONCLUSIONS

Approximately three out of four subjects sought health care when having experienced an alarm symptom but 50% waited for at least 1 month. Some demographic factors were found to be associated with health care-seeking behaviour and the patient interval, whereas no consistent associations were found with regard to socioeconomics.