Original ArticleUnderstanding why women delay in seeking help for breast cancer symptoms☆
Introduction
This paper aims to improve our understanding of why women delay in seeking help for breast cancer symptoms. It summarises the evidence for the adverse effect of delay on survival and critically reviews the evidence for the risk factors for delayed presentation. To understand the process of delayed presentation, a model in which the empirical risk factors may be placed is described. This model, incorporating the empirical risk factors, should inform the development of effective interventions to reduce delay and thereby save lives.
Across a broad range of types of cancer, the prognosis for patients with small, localised tumours is much better than that of patients with advanced or metastatic disease. For some cancers, e.g., breast and cervical cancers, there is good evidence that diagnosis and treatment at a presymptomatic phase of the disease is associated with improved survival rates. This has led to the implementation in the UK of national screening programmes for such cancers. However, the majority of patients with cancer present symptomatically.
Section snippets
What is meant by delay?
The period of time between a woman first noticing a breast cancer symptom and receiving treatment for this can be referred to as “delay” or “total delay”. This delay can be divided into “patient” delay and “provider” delay [1]. Patient delay in help-seeking refers to the period between an individual's first awareness of a sign or symptom of illness and initial medical consultation. The stages and underlying psychological processes within this period of “patient” delay are given further
What is the extent of patient delay?
A systematic review of the world's literature suggests that whilst most women seek help promptly if they discover a symptom of breast cancer, a significant minority (20–30%) do not and instead delay help seeking for three months or sometimes considerably longer [2], [3]. The convention in most studies is to take 3 months as the cut-off for early versus delayed presentation. It is interesting that the extent of delay between symptom discovery and definitive treatment has reduced over the second
Do delays affect survival?
A systematic review of the literature examining the effect of delayed presentation on survival found that longer delays were associated with poorer survival. Meta-analyses of 38 papers published between 1907 and 1996 showed that patients who delayed for 3 months or more before seeking help had, on average, a 12% lower 5-year survival rate than did those with shorter delays. This finding may be affected by lead-time bias. A patient with a substantial delay (e.g., a year or more) may have a worse
What factors contribute to delay?
A variety of sociodemographic, clinical and psychosocial factors have been examined in relation to patient delay. According to a systematic literature review published in 1999 and subsequent research, there is strong evidence of an association between older age and patient delay [5], [6]. The systematic review found less strength of evidence for socioeconomic status and ethnicity and strong evidence that marital status was unrelated to patient delay. A general population based study examining
Developing a theoretically derived model for understanding delayed presentation
The empirical evidence presented above suggests that delay in help seeking for breast cancer symptoms is influenced by a complex interaction of demographic, clinical, cognitive, behavioural and social factors. It is not, for example, simply lack of knowledge about breast cancer symptoms that leads to delayed help-seeking. An explanatory model that explicitly describes the process and its complexity would be a useful aid to understanding the influences on delay behaviour. Such a model enables
Future directions
The evidence presented above suggests that encouraging women to seek help early for a breast cancer symptom by focusing on risk factors for delay (such as knowledge of symptoms, appropriate attribution of symptoms, disclosure to another and attitudes to help seeking) has the potential to significantly improve survival from breast cancer. It is therefore important to develop effective interventions based on this empirical evidence to encourage prompt help seeking. Equally, it is important to
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Supported by the Cancer Research UK Programme Grant Ref C20/A1578.