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      Risk factors for delayed presentation and referral of symptomatic cancer: evidence for common cancers

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          Abstract

          Background:

          It has been suggested that the known poorer survival from cancer in the United Kingdom, compared with other European countries, can be attributed to more advanced cancer stage at presentation. There is, therefore, a need to understand the diagnostic process, and to ascertain the risk factors for increased time to presentation.

          Methods:

          We report the results from two worldwide systematic reviews of the literature on patient-mediated and practitioner-mediated delays, identifying the factors that may influence these.

          Results:

          Across cancer sites, non-recognition of symptom seriousness is the main patient-mediated factor resulting in increased time to presentation. There is strong evidence of an association between older age and patient delay for breast cancer, between lower socio-economic status and delay for upper gastrointestinal and urological cancers and between lower education level and delay for breast and colorectal cancers. Fear of cancer is a contributor to delayed presentation, while sanctioning of help seeking by others can be a powerful mediator of reduced time to presentation. For practitioner delay, ‘misdiagnosis' occurring either through treating patients symptomatically or relating symptoms to a health problem other than cancer, was an important theme across cancer sites. For some cancers, this could also be linked to inadequate patient examination, use of inappropriate tests or failing to follow-up negative or inconclusive test results.

          Conclusion:

          Having sought help for potential cancer symptoms, it is therefore important that practitioners recognise these symptoms, and examine, investigate and refer appropriately.

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          Most cited references59

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          Factors predicting delayed presentation of symptomatic breast cancer: a systematic review.

          Delayed presentation of symptomatic breast cancer is associated with lower survival. Understanding of the factors that influence delay is important for the development of strategies to shorten delays. We did a systematic review to assess the quality and strength of evidence on risk factors for delays by patients and providers. We generated hypotheses about the relation between each putative risk factor and delay, against which we tested studies. We did searches to identify papers containing original data related to risk factors for delays by patients (n=86) and providers (n=28). We critically appraised the papers for inclusion in the review according to predefined criteria. The small number of studies of adequate quality did not allow formal meta-analysis. We therefore assigned strength of evidence according to a combination of the number and size of studies supporting, not supporting, or refuting the hypotheses. Most studies were deemed to be of poor quality and were excluded. Among 23 studies of adequate quality, however, there was strong evidence for an association between older age and delay by patients, and strong evidence that marital status was unrelated to delays by patients. Younger age and presentation with a breast symptom other than a lump were strong risk factors for delays by providers. Moderate evidence was shown for several other factors. The strength of the current evidence is inadequate to inform the development of specific strategies to shorten delays by patients or providers. Clarification of the findings of this review through a major programme of primary research is urgently required.
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            Ovarian carcinoma diagnosis.

            Ovarian carcinoma often is called the "silent killer" because the disease usually is not detected until an advanced stage. The authors' goal was to evaluate preoperative symptoms and factors that may contribute to delayed diagnosis for women with ovarian carcinoma. A two-page survey was distributed to 1500 women who subscribe to CONVERSATIONS!, a newsletter about ovarian carcinoma. Because the survey could be copied and given to other patients, 1725 surveys were returned from women in 46 states and 4 Canadian provinces. The median age of the surveyed women was 52 years, and 70% had Stage III or IV disease (International Federation of Gynecology and Obstetrics). When asked about symptoms before the diagnosis of ovarian carcinoma, 95% reported symptoms, which were categorized as abdominal (77%), gastrointestinal (70%), pain (58%), constitutional (50%), urinary (34%), and pelvic (26%). Only 11% of women with Stage I/II and 3% with Stage III/IV reported no symptoms before their diagnosis. Women who ignored their symptoms were significantly more likely to be diagnosed with advanced disease compared with those who did not (P = 0.002). The time required for a health care provider to make the diagnosis was reported as less than 3 months by 55%, but greater than 6 months by 26% and greater than 1 year by 11%. Factors significantly associated with delay in diagnosis were omission of a pelvic exam at first visit; having a multitude of symptoms; being diagnosed initially with no problem, depression, stress, irritable bowel, or gastritis; not initially receiving an ultrasound, computed tomography, or CA 125 test; and younger age. The type of health care provider seen initially, insurance, and specific symptoms did not correlate with delayed diagnosis. This large national survey confirms that the majority of women with ovarian carcinoma are symptomatic and frequently have delays in diagnosis. Copyright 2000 American Cancer Society.
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              Knowledge, attitudes, and behavioral intentions in relation to the early detection of colorectal cancer in the United Kingdom.

              Colorectal cancer (CRC) mortality is high. Understanding the social, psychological, and cognitive predictors of early detection practices such as screening may help improve CRC outcomes. This study examined knowledge of CRC and the relationship between knowledge, attitudes to cancer, and intentions to engage in early detection behaviors for CRC in a national representative population sample. An interview-based survey was carried out in a British population sample of adults ages 16 to 74 years (n = 1637), assessing knowledge, attitudes, and intention with regard to colorectal cancer. Knowledge levels were very low; 58% (n = 995) of respondents could not list any colorectal cancer risk factors and 24% (n = 393) were unable to identify any warning signs for cancer. Knowledge was lower among men (chi(2)[2] = 52.8, P < 0.0001), younger respondents (chi(2)[10] = 79.9, P <.0001), and those with less education (chi(2)[4] = 73.9, P < 0.0001). Attitudes to cancer were more negative among women (chi(2) [2] = 7.4, P = 0.025), younger participants (chi(2)[10] = 22.4, P = 0.013), and those with less education (chi(2) [4] = 75.0, P < 0.0001). Low knowledge was associated with negative attitudes (P < 0.0001) and both factors were associated with lower intentions to participate in colorectal cancer screening (P < 0.0001). Multivariate analysis indicated that attitudes partially mediated the effect of knowledge on screening intentions. Increasing knowledge may reduce negative public perceptions of cancer which may impact positively on intentions to participate in screening.
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                Author and article information

                Journal
                Br J Cancer
                British Journal of Cancer
                Nature Publishing Group
                0007-0920
                1532-1827
                03 December 2009
                03 December 2009
                03 December 2009
                : 101
                : S2
                : S92-S101
                Affiliations
                [1 ]General Practice and Primary Care, Division of Community Based Sciences, Faculty of Medicine, University of Glasgow 1 Horselethill Road, Glasgow G12 9LX, UK
                [2 ]Division of Clinical and Population Sciences and Education, Tayside Centre for General Practice, University of Dundee Mackenzie Building, Kirsty Semple Way, Dundee, UK
                [3 ]Kings College London, Cancer Research UK Promoting Early Presentation Group, Institute of Psychiatry, St Thomas' Hospital London, UK
                Author notes
                [* ]Author for correspondence: u.macleod@ 123456clinmed.gla.ac.uk
                Article
                6605398
                10.1038/sj.bjc.6605398
                2790698
                19956172
                41b148a8-8d12-47ab-a3cd-622327a8b6de
                Copyright 2009, Cancer Research UK
                History
                Categories
                Papers

                Oncology & Radiotherapy
                delay,diagnosis,systematic review
                Oncology & Radiotherapy
                delay, diagnosis, systematic review

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