Samantha L. Quaife

Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK

Background:Not recognising a symptom as suspicious is a common reason given by cancer patients for delayed help-seeking; but inevitably this is retrospective. We therefore investigated associations between recognition of warning signs for breast, colorectal and lung cancer and anticipated time to help-seeking for symptoms of each cancer.Methods:Computer-assisted telephone interviews were conducted with a population-representative sample (N=6965) of UK adults age ⩾50 years, using the Awareness and Beliefs about Cancer scale. Anticipated time to help-seeking for persistent cough, rectal bleeding and breast changes was categorised as >2 vs ⩽2 weeks. Recognition of persistent cough, unexplained bleeding and unexplained lump as cancer warning signs was assessed (yes/no). Associations between recognition and help-seeking were examined for each symptom controlling for demographics and perceived ease of health-care access.Results:For each symptom, the odds of waiting for >2 weeks were significantly increased in those who did not recognise the related warning sign: breast changes: OR=2.45, 95% CI 1.47–4.08; rectal bleeding: OR=1.77, 1.36–2.30; persistent cough: OR=1.30, 1.17–1.46, independent of demographics and health-care access.Conclusion:Recognition of warning signs was associated with anticipating faster help-seeking for potential symptoms of cancer. Strategies to improve recognition are likely to facilitate earlier diagnosis.

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

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.

Socioeconomic inequalities in attitudes to cancer: an international cancer benchmarking study

Socioeconomic status (SES) differences in attitudes towards cancer have been implicated in the differential screening uptake and the timeliness of symptomatic presentation. However, the predominant emphasis of this work has been on cancer fatalism, and many studies focus on specific community subgroups. This study aimed to assess SES differences in positive and negative attitudes towards cancer in UK adults. A population-based sample of UK adults (n=6965, age≥50 years) completed the Awareness and Beliefs about Cancer scale, including six belief items: three positively framed (e.g. ‘Cancer can often be cured’) and three negatively framed (e.g. ‘A cancer diagnosis is a death sentence’). SES was indexed by education. Analyses controlled for sex, ethnicity, marital status, age, self-rated health, and cancer experience. There were few education-level differences for the positive statements, and overall agreement was high (all>90%). In contrast, there were strong differences for negative statements (all Ps<0.001). Among respondents with lower education levels, 57% agreed that ‘treatment is worse than cancer’, 27% that cancer is ‘a death sentence’ and 16% ‘would not want to know if I have cancer’. Among those with university education, the respective proportions were 34, 17 and 6%. Differences were not explained by cancer experience or health status. In conclusion, positive statements about cancer outcomes attract near-universal agreement. However, this optimistic perspective coexists alongside widespread fears about survival and treatment, especially among less-educated groups. Health education campaigns targeting socioeconomically disadvantaged groups might benefit from a focus on reducing negative attitudes, which is not necessarily achieved by promoting positive attitudes.

Socioeconomic inequalities in attitudes towards cancer: An international cancer benchmarking partnership study

Socioeconomic status (SES) differences in attitudes towards cancer have been implicated in the differential screening uptake and the timeliness of symptomatic presentation. However, the predominant emphasis of this work has been on cancer fatalism, and many studies focus on specific community subgroups. This study aimed to assess SES differences in positive and negative attitudes towards cancer in UK adults. A population-based sample of UK adults (n=6965, age≥50 years) completed the Awareness and Beliefs about Cancer scale, including six belief items: three positively framed (e.g. ‘Cancer can often be cured’) and three negatively framed (e.g. ‘A cancer diagnosis is a death sentence’). SES was indexed by education. Analyses controlled for sex, ethnicity, marital status, age, self-rated health, and cancer experience. There were few education-level differences for the positive statements, and overall agreement was high (all>90%). In contrast, there were strong differences for negative statements (all Ps<0.001). Among respondents with lower education levels, 57% agreed that ‘treatment is worse than cancer’, 27% that cancer is ‘a death sentence’ and 16% ‘would not want to know if I have cancer’. Among those with university education, the respective proportions were 34, 17 and 6%. Differences were not explained by cancer experience or health status. In conclusion, positive statements about cancer outcomes attract near-universal agreement. However, this optimistic perspective coexists alongside widespread fears about survival and treatment, especially among less-educated groups. Health education campaigns targeting socioeconomically disadvantaged groups might benefit from a focus on reducing negative attitudes, which is not necessarily achieved by promoting positive attitudes.

Smoking is associated with pessimistic and avoidant beliefs about cancer: results from the International Cancer Benchmarking Partnership.

Background:Smoking cessation is the key cancer prevention behaviour for smokers; nonetheless, smokers can still benefit from earlier diagnosis of cancer. However, fewer smokers participate in screening despite their increased risk, which may reflect different beliefs about cancer.Methods:A UK population-representative sample of ⩾50 year-olds (n=6965) was surveyed using the Awareness and Beliefs about Cancer measure. These analyses examine six items on cancer beliefs (e.g., ‘cancer can often be cured’), and four on help-seeking barriers (e.g., ‘I would be too embarrassed’).Results:Smokers were more likely to hold pessimistic cancer beliefs than never-smokers or former-smokers on four of six items. For example, 34% agreed ‘a cancer diagnosis is a death sentence’, compared with 24% of non/former-smokers (P<0.001). More smokers (18%) than non/former-smokers (11%) would not want to know if they had cancer (P<0.01). The only barrier to symptomatic help-seeking differing by smoking status was ‘worry about what the doctor might find’ (36% vs 28%, P<0.01). Associations were independent of demographics, self-rated health and cancer experience.Conclusions:Smokers held more pessimistic and avoidant beliefs about cancer, which could deter early-detection behaviour. A better understanding of these beliefs is needed to increase engagement in early diagnosis by this high-risk group.

Pulmonary nodules and CT screening: the past, present and future

Lung cancer screening has come a long way since the early studies with chest X-ray. Advancing technology and progress in the processing of images have enabled low dose CT to be tried and tested, and evidence suggests its use can result in a significant mortality benefit. There are several issues that need refining in order to successfully implement screening in the UK and elsewhere. Some countries have started patchy implementation of screening and there is increased recognition that the appropriate management of pulmonary nodules is crucial to optimise benefits of early detection, while reducing harm caused by inappropriate medical intervention. This review summarises and differentiates the many recent guidelines on pulmonary nodule management, discusses screening activity in other countries and exposes the present barriers to implementation in the UK.

Attitudes towards lung cancer screening within socioeconomically deprived and heavy smoking communities: a qualitative study

Abstract Background Implementation of screening for lung cancer is being considered in the UK, but trials show a paradox in uptake—ie, individuals at highest risk of lung cancer are least likely to attend. Heavy life-long smokers are over-represented in socioeconomically deprived communities, and engaging this group in public health research is a pervasive problem. Using a proactive community-based approach to recruitment, we aimed to explore the views of smokers and ex-smokers of lower socioeconomic status towards the offer of screening. Methods Recruitment was facilitated through contact with community organisations in socioeconomically deprived areas. Settings and organisations were preferentially chosen on the basis that they did not provide a health service (ie, housing associations). Potential participants were approached or contacted directly by the researcher. Semi-structured interviews were audiorecorded, transcribed verbatim, and analysed thematically. Verbal consent was given, and ethics approval granted by University College London. Findings 21 smokers and ex-smokers (aged 47–73 years) were interviewed. Saturation was achieved with that number. Most participants (n=15) were from the UKs most socioeconomically deprived quintile and had left school aged 15 years or younger. Most were supportive of screening, citing the benefits of reassurance, better outcomes with early detection, and getting ones affairs in order. Discussions gave insight into potential barriers to screening, including fear that it was too late (age and smoking history were cited), control over lung cancer (other causes, fatalism, lung cancer as incurable), and concern about treatment (living without lungs, quality of life). Conversations sometimes led participants to explain their smoking history, with some identifying the need to normalise the offer of screening so as to avoid recipients feeling singled out. Smoking cessation advice after screening was regarded as appropriate if delivered sensitively. Interpretation The recruitment of smokers of lower socioeconomic status indicates that this hard-to-reach target group can be engaged in public health research by use of existing community networks, although these methods are labour-intensive and difficult to replicate. The generalisability of our findings is restricted to English-speaking urban communities. Our findings indicate that attitudes towards lung cancer screening are complex and not wholly positive, and must be considered carefully in designing screening invitations. Funding SLQ is supported by a Medical Research Council studentship. JW is supported by Cancer Research UK.

Cancer worries and uptake of breast, cervical, and colorectal cancer screening: A population-based survey in England

Objective Some degree of general worry about cancer may facilitate screening participation, but specific worries about the potential consequences (e.g. treatment, death) may act as deterrents. No studies have examined these associations in the same sample. We assessed associations between general versus specific cancer worries and cancer screening participation. Methods In 2016, a population-based cross-sectional survey of adults living in England was carried out. This paper reports analyses of a subsample (n = 1694). Measures included (i) frequency of general cancer worry, (ii) specific worries about the emotional and physical consequences of a cancer diagnosis, and (iii) specific worries about the social consequences of a cancer diagnosis. Logistic regression analyses examined their association with self-reported screening uptake among participants eligible for cervical (n = 671), breast (n = 323), and colorectal (n = 368) cancer screening. Results Frequency of general cancer worry was not associated with screening participation. Specific worry about the emotional and physical consequences increased the odds of participants reporting regular uptake of colorectal screening (OR 1.41, 95% CI 1.04–1.90). Specific worry about the social consequences of diagnosis was negatively associated with regular attendance for cervical and breast screening in unadjusted analyses only. In adjusted models, the associations were no longer statistically significant for cervical (OR 0.82, 95% CI 0.65–1.03) or breast (OR 0.69, 95% CI 0.45–1.04) screening. Conclusions Specific worries about cancer may be differentially associated with participation across screening programmes. Further research is needed, as interventions to optimise informed participation may be improved if the specific worries associated with low participation in each programme are understood.

S14 Lung cancer risk profiles and eligibility of attendees in a lung cancer screening demonstration pilot

Introduction Lung cancer screening by Low-Dose CT (LDCT) has been shown to reduce mortality, and the harm-benefit balance of screening is optimised by screening those at higher risk. The Lung Screen Uptake Trial is a UK based randomised controlled trial of standard versus enhanced invitation methods for LDCT screening in more deprived communities. Methods Patients aged 60 to 75, at higher risk of lung cancer by virtue of their recorded smoking history, were invited to a ‘lung health check appointment’ on behalf of their GP. Attendees at one of two secondary care sites, underwent a nurse consultation that included a lung cancer risk assessment. Participants were eligible for LDCT if they met any of the following three criteria: NLST-like criteria* (≥30 pack-year smoking history and given up ≤15 years ago); PLCOm2012 score ≥1.51%; or LLP score ≥2.5%. This abstract focuses on the performance of the different eligibility criteria. Results At the time of analysis, 1997 individuals had been invited to screening and 936 attended and were enrolled into the study. 854 participants were eligible for LDCT by fulfilling any of the 3 criteria above, and 718 went on to have LDCT. The mean age of participants was 66.0 (SD 4.16), 54.4% were male and the mean smoking pack-year history was 39.7 (SD 24.9). After a median of 9.7 months follow up, 17 lung cancers were confirmed. Ten suspicious pulmonary nodules are undergoing diagnostic work up under the lung cancer multidisciplinary team (MDT) and 80 indeterminate nodules are under CT surveillance. The distribution of these cancers and nodules by eligibility criteria is shown in Table 1. Abstract S14 Table 1 Number of cancers and nodules by eligibility criteria *NLST criteria but with modified age range of 60 to 75 years PLCOm2012 positive LLP positive NLST-like* positive Total in cohort Had CT 576 661 493 718 Indeterminate nodules 64 74 58 80 Suspicious nodule referred to MDT 8 9 7 10 Confirmed cancers 17 16 13 17 Conclusions Using the NLST-like* criteria to determine eligibility would mean the fewest number screened, with 4 fewer cancers detected. The PLCOm2012 score was the most reliable way to detect cancers and resulted in less individuals screened than with use of the LLP score. Further follow up and review of the data is required to fully establish the most effective tool for determining eligibility into LDCT screening though the PLCOm2012 score shows the most promise with the available data.

Cancer worries and uptake of screening for breast, cervical, and colorectal cancer: a population-based survey in England

Abstract Background Moderate worry about cancer, defined as a negative emotional reaction to the threat of cancer, in general facilitates uptake of cancer screening, but some studies suggest that specific worries about potential consequences of cancer (eg, cancer treatments or dying) may act as deterrents. However, no studies have examined these associations in the same sample. We aimed to assess the impact of general versus specific cancer worries on cancer screening attendance. Methods We analysed data from a population-based survey of 2048 English adults (18–70 years, median 43 [IQR 30–58], 1098 [54%] female) using home-based, computer-assisted personal interviewing delivered via the TNS Omnibus survey tool. Cancer worries were measured with one item about the frequency of general cancer worry, and two subscales of six specific cancer worry items relating to cancer treatments and death, and to the social consequences of a cancer diagnosis (including its impact on identity, sexuality, important relationships, and finances). All items were adapted from a validated scale. Using logistic regression analysis, we examined the association between these three types of cancer worry and self-reported screening attendance (regular vs never or irregular) among participants eligible for cervical (n=673), breast (323), and bowel cancer (369) screening. Previous studies show that self-reported uptake is a reliable measure of actual attendance. All participants gave verbal informed consent. Ethics approval was given by University College London Research Ethics Committee (5771/002). Findings Regular screening attendance was reported by 74·7% (n=503), 82·0% (265), and 65·9% (243) of participants for cervical, breast, and bowel cancer screening, respectively. General cancer worry was not associated with screening attendance. Worries about the social consequences of a cancer diagnosis, but not about treatment and death, were associated with a lower likelihood of regular attendance for cervical screening (odds ratio 0·77, 95% CI 0·61–0·96; p=0·021) and breast screening (0·63, 0·43–0·92; p=0·016). By contrast, worries about treatment and death, but not social consequences, were associated with higher odds of regular uptake of bowel screening (1·47, 1·10–1·96; p=0·009). Interpretation Specific worries about cancer can affect attendance differently across screening programmes. Interventions to increase informed participation in screening could target the specific worries shown to deter participation in each programme. Funding Supported by a programme grant from Cancer Research UK programme grant (C1418/A14134). Cancer Research UK was not involved in the design of this study; collection, analysis, or interpretation of the results; the writing of the abstract; or the decision to submit for publication.