Original Article
Understanding why women delay in seeking help for breast cancer symptoms

https://doi.org/10.1016/j.jpsychores.2004.10.007Get rights and content

Abstract

Objective

The aim of this study was to improve our understanding of why women delay their presentation with breast cancer.

Methods

A review of the evidence for the adverse effect of delayed presentation on survival and the risk factors for delay was conducted. The description and rationale for a model to explain the delay process are presented.

Results

Delays of 3 months or more adversely affect survival. Older age, the nature of the breast symptom, not disclosing the symptom to someone close, negative attitudes towards general practitioner (GP) and fears about cancer treatment are risk factors for delay. Using elements of self-regulation theory, the theory of planned behaviour (TPB) and implementation intentions, a theoretical model is proposed to explain delayed help-seeking. The model incorporates stages of symptom appraisal, attitudes towards help-seeking and translating intentions into behaviour.

Conclusions

Placing the empirical risk factors for delayed presentation in a theoretically derived model should enable the development of an effective intervention to reduce delay and thereby save lives.

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

References (41)

  • E Grunfeld et al.

    Women's knowledge and beliefs regarding breast cancer

    Br J Cancer

    (2002)
  • M Hunter et al.

    Help-seeking intentions for breast-cancer symptoms: a comparison of the self-regulation model and the theory of planned behaviour

    Br J Health Psychol

    (2003)
  • CC Burgess et al.

    Who and what influences delayed presentation in breast cancer?

    Br J Cancer

    (1998)
  • C Nosarti et al.

    Delay in presentation of symptomatic referrals to a breast clinic: patient and system factors

    Br J Cancer

    (2000)
  • RJ Coates et al.

    Differences between black and white women with breast cancer in time from symptom recognition to medical consultation

    J Natl Cancer Inst

    (1992)
  • CC Burgess et al.

    A qualitative study of delay among women reporting symptoms of breast cancer

    Br J Gen Pract

    (2001)
  • S Michie et al.

    Interventions to change health behaviours: evidence-based or evidence-inspired

    Psychol Health

    (2004)
  • B Andersen et al.

    Delay in seeking a cancer diagnosis: stages and psychophysiological comparison processes

    Br J Soc Psychol

    (1995)
  • M Safer et al.

    Determinants of three stages of delay in seeking care at a medical clinic

    Med Care

    (1979)
  • H Leventhal et al.

    Illness representations and coping with health threats

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    Supported by the Cancer Research UK Programme Grant Ref C20/A1578.

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