Cancer incidence, treatment, and survival in the prison population compared with the general population in England: a population-based, matched cohort study.

BACKGROUND: The growing and ageing prison population in England makes accurate cancer data of increasing importance for prison health policies. This study aimed to compare cancer incidence, treatment, and survival between patients diagnosed in prison and the general population. METHODS: In this population-based, matched cohort study, we used cancer registration data from the National Cancer Registration and Analysis Service in England to identify primary invasive cancers and cervical cancers in situ diagnosed in adults (aged ≥18 years) in the prison and general populations between Jan 1, 1998, and Dec 31, 2017. Ministry of Justice and Office for National Statistics population data for England were used to calculate age-standardised incidence rates (ASIR) per year and age-standardised incidence rate ratios (ASIRR) for the 20-year period. Patients diagnosed with primary invasive cancers (ie, excluding cervical cancers in situ) in prison between Jan 1, 2012, and Dec 31, 2017 were matched to individuals from the general population and linked to hospital and treatment datasets. Matching was done in a 1:5 ratio according to 5-year age group, gender, diagnosis year, cancer site, and disease stage. Our primary objectives were to compare the incidence of cancer (1998-2017); the receipt of treatment with curative intent (2012-17 matched cohort), using logistic regression adjusted for matching variables (excluding cancer site) and route to diagnosis; and overall survival following cancer diagnosis (2012-17 matched cohort), using a Cox proportional hazards model adjusted for matching variables (excluding cancer site) and route to diagnosis, with stratification for the receipt of any treatment with curative intent. FINDINGS: We identified 2015 incident cancers among 1964 adults (1556 [77·2%] men and 459 [22·8%] women) in English prisons in the 20-year period up to Dec 31, 2017. The ASIR for cancer for men in prison was initially lower than for men in the general population (in 1998, ASIR 119·33 per 100 000 person-years [95% CI 48·59-219·16] vs 746·97 per 100 000 person-years [742·31-751·66]), but increased to a similar level towards the end of the study period (in 2017, 856·85 per 100 000 person-years [675·12-1060·44] vs 788·59 per 100 000 person-years [784·62-792·57]). For women, the invasive cancer incidence rate was low and so ASIR was not reported for this group. Over the 20-year period, the incidence of invasive cancer for men in prison increased (incidence rate ratio per year, 1·05 [95% CI 1·04-1·06], during 1999-2017 compared with 1998). ASIRRs showed that over the 20-year period, overall cancer incidence was lower in men in prison than in men in the general population (ASIRR 0·76 [95% CI 0·73-0·80]). The difference was not statistically significant for women (ASIRR 0·83 [0·68-1·00]). Between Jan 1, 2012, and Dec 31, 2017, patients diagnosed in prison were less likely to undergo curative treatment than matched patients in the general population (274 [32·3%] of 847 patients vs 1728 [41·5%] of 4165; adjusted odds ratio (OR) 0·72 [95% CI 0·60-0·85]). Being diagnosed in prison was associated with a significantly increased risk of death on adjustment for matching variables (347 deaths during 2021·9 person-years in the prison cohort vs 1626 deaths during 10 944·2 person-years in the general population; adjusted HR 1·16 [95% CI 1·03-1·30]); this association was partly explained by stratification by curative treatment and further adjustment for diagnosis route (adjusted HR 1·05 [0·93-1·18]). INTERPRETATION: Cancer incidence increased in people in prisons in England between 1998 and 2017, with patients in prison less likely to receive curative treatments and having lower overall survival than the general population. The association with survival was partly explained by accounting for differences in receipt of curative treatment and adjustment for diagnosis route. Improved routine cancer surveillance is needed to inform prison cancer policies and decrease inequalities for this under-researched population. FUNDING: UK National Institute for Health and Care Research, King's College London, and Strategic Priorities Fund 2019/20 of Research England via the University of Surrey.

Diabetes management in older adults who fall: a study amongst older adults presenting to the emergency department.

INTRODUCTION: Type 2 diabetes mellitus (T2D) is associated with poor health outcomes whilst tight glycaemic targets are questionable in those aged over 70 years with increased frailty. Our aim was to examine whether people with T2D admitted to hospital with a fall, were more likely to have greater frailty, increased mortality and co-morbidity burden, or risk factors for falls than people without T2D, and whether these differences were associated with medications used for the treatment of T2D. METHODS: The Older Persons Assessment Service (OPAS) is a local emergency department (ED) service, which accepts patients on frailty criteria. The OPAS accepts patients primarily aged over 70 years who present with frailty and geriatric syndromes such as falls, with retrieval from the ED department directly to the service from triage. The OPAS databank was analysed for people with T2D admitted with a fall between June 2020-September 2022. We examined clinical outcomes relating to medication, age, Charlson co-morbidity index (CCI) and clinical frailty score (CFS). RESULTS: 1081 patients were included: 294 (27.2%) with T2D and a mean HbA1c of 53.9 (± 15.8) mmol/mol [7.1%]. People with T2D had a similar mean CFS and age compared to those without T2D, but higher mean CCI (7.0 ± 2.2 vs 5.9 ± 2.1, p < 0.001). Of those people with T2D, 175 (59.5%) and 240 (81.6%) had a HbA1c ≤ 53 mmol/mol [7.0%] and ≤ 64 mmol/mol [8.0%], respectively. In total, 48 (16.3%) people with T2D were identified to have a capillary blood glucose below 4.0 mmol/L on admission to the ED. At 12 months' follow-up, 831 (76.9%) patients were alive and 250 (23.1%) had died. People with T2D treated with insulin and/or gliclazide had a greater 1-year mortality (36.6% vs 23.6%, p < 0.05), greater frequency of hypoglycaemia (35.4% vs 11.8%, p < 0.001), and greater HbA1c (65.5 ± 17.2 mmol/mol [8.2] vs 48.9 ± 12.1 mmol/mol [6.6%]) compared to those who used other agents. Logistic regression confirmed a diagnosis of T2D was associated with 1-year mortality, but mortality was not significantly associated with hypoglycaemic-inducing agents. People with T2D were not more likely to live in deprived areas. CONCLUSIONS: A diagnosis of T2D is associated with greater 1-year mortality, and may be influenced by use of hypoglycaemia-inducing diabetes medications. Clinician awareness can support de-prescribing for patients with frailty and HbA1c < 64 mmol/mol.

The Influence of Ethnicity on Survival from Malignant Primary Brain Tumours in England: A Population-Based Cohort Study.

BACKGROUND: In recent years, the completeness of ethnicity data in the English cancer registration data has greatly improved. Using these data, this study aims to estimate the influence of ethnicity on survival from primary malignant brain tumours. METHODS: Demographic and clinical data on adult patients diagnosed with malignant primary brain tumour from 2012 to 2017 were obtained (n = 24,319). Univariate and multivariate Cox proportional hazards regression analyses were used to estimate hazard ratios (HR) for the survival of the ethnic groups up to one year following diagnosis. Logistic regressions were then used to estimate odds ratios (OR) for different ethnic groups of (1) being diagnosed with pathologically confirmed glioblastoma, (2) being diagnosed through a hospital stay that included an emergency admission, and (3) receiving optimal treatment. RESULTS: After an adjustment for known prognostic factors and factors potentially affecting access to healthcare, patients with an Indian background (HR 0.84, 95% CI 0.72-0.98), Any Other White (HR 0.83, 95% CI 0.76-0.91), Other Ethnic Group (HR 0.70, 95% CI 0.62-0.79), and Unknown/Not Stated Ethnicity (HR 0.81, 95% CI 0.75-0.88) had better one-year survivals than the White British Group. Individuals with Unknown ethnicity are less likely be diagnosed with glioblastoma (OR 0.70, 95% CI 0.58-0.84) and less likely to be diagnosed through a hospital stay that included an emergency admission (OR 0.61, 95% CI 0.53-0.69). CONCLUSION: The demonstrated ethnic variations associated with better brain tumour survival suggests the need to identify risk or protective factors that may underlie these differences in patient outcomes.

Impact of pre-existing mental health disorders on the receipt of guideline recommended cancer treatments: A systematic review.

OBJECTIVE: Disparities in cancer outcomes for individuals with pre-existing mental health disorders have already been identified, particularly for cancer screening and mortality. We aimed to systematically review the influence on the time from cancer diagnosis to cancer treatment, treatment adherence, and differences in receipt of guideline recommended cancer treatment. METHODS: We included international studies published in English from 1 January 1995 to 23 May 2022 by searching MEDLINE, Embase, and APA PsycInfo. RESULTS: This review identified 29 studies with 27 being published in the past decade. Most studies focused on breast, non-small cell lung and colorectal cancer and were of high or medium quality as assessed by the Newcastle Ottawa Scale. All studies were from high-income countries, and mostly included patients enrolled in national health insurance systems. Five assessed the impact on treatment delay or adherence, and 25 focused on the receipt of guideline recommended treatment. 20/25 studies demonstrated evidence that patients with pre-existing mental health disorders were less likely to receive guideline recommended therapies such as surgery or radiotherapy. In addition, there was a greater likelihood of receiving less intensive or modified treatment including systemic therapy. CONCLUSIONS: Across different cancer types and treatment modalities there is evidence of a clear disparity in the receipt of guideline recommended cancer treatment for patients with pre-existing mental health disorders. The effect of pre-existing mental health disorders on treatment delay or adherence is under-researched. Future research needs to include low- and middle-income countries as well as qualitative investigations to understand the reasons for disparities in cancer treatment.

Factors affecting delay in the presentation of breast cancer symptoms among women in Gaza, occupied Palestinian territory: a cross-sectional survey.

OBJECTIVE: To identify factors related to women's delay in presenting with breast cancer symptoms to improve diagnosis in the occupied Palestinian territory (oPt). DESIGN: Cross-sectional. SETTING: Two government cancer hospitals. PARTICIPANTS: A consecutive sample of 130 Palestinian women living in Gaza with newly diagnosed breast cancer were approached in the waiting rooms of cancer hospitals in Gaza between 1 January 2017 and 31 December 2017. 120 women took part and returned the completed questionnaire. PRIMARY AND SECONDARY OUTCOME MEASURES: Clinical information about breast cancer was collected from hospital cancer records. An interval of 3 months or more between women's self-discovery of symptoms and their first presentation to a medical provider was considered as a delay. RESULTS: 94% (122/130) of women attending cancer hospitals in Gaza agreed to take part in the study. Their mean age was 51 years (range: 23-72), 33.6% (31/122) had a family history of breast cancer and 74.5% (41/55) of those whose cancer stage was known had been diagnosed at stage III or IV. Around one-half (62/122) said they had not recognised the seriousness of their breast changes but only 20% (24/122) of women delayed seeking healthcare by 3 months and more. The two only factors associated to late presentation were that the woman considered their symptoms not serious (p<0.001) and lack of pain (p=0.012). Lower socioeconomic status, older age, lower education and negative family history of breast cancer were not statistically associated with women's delay. CONCLUSIONS: Women's awareness about the seriousness of breast changes and the critical importance of seeking prompt diagnosis needs to be improved using context-relevant and evidence-based awareness campaigns. This should be accompanied with training of female nurses on promoting early detection and improvement in diagnostic facilities to ensure timely diagnosis of cancer in the oPt.

Factors influencing cancer patients' experiences of care in the USA, United Kingdom, and Canada: A systematic review.

The extent to which individual and structural factors influence cancer patients' reports of their experiences are not yet well understood. We sought to identify which groups of patients consistently report poorer experiences and whether structural care factors might also be associated with better or worse reports. We conducted a systematic review of literature in PubMed and Web of Science with the date of last search as 27th of February 2022 following PRISMA guidelines. We focused on studies from three established population-based surveys datasets and instruments. After screening 303 references, 54 studies met the inclusion criteria. Overall, being from an ethnic minority group, having a more deprived socioeconomic status, poorer general or mental health status, being diagnosed with poor prognosis cancers, presenting to care through an emergency route, and having delayed treatment were consistently associated with poorer cancer care experiences. Conversely being diagnosed with earlier stage disease, perceiving communication as effective, positive patient-provider relationships, and receiving treatment with respect were overall associated with better reports of cancer care experiences. Improvement efforts aimed at delivering better experiences of patient-centred care need to take account much more explicitly patients' differing characteristics, prognoses, and trajectories they take through their care journeys.

Being assigned a clinical nurse specialist is associated with better experiences of cancer care: English population-based study using the linked National Cancer Patient Experience Survey and Cancer Registration Dataset.

OBJECTIVE: This study aimed to examine whether being given the name of a clinical nurse specialist (CNS) is associated with better cancer patients' experiences across different points along their cancer care pathway. METHODS: We identified 100,885 colorectal, lung, breast and prostate cancer patients who responded to the National Cancer Patient Experience Survey between 2010 and 2014. We compared experiences of four key aspects of cancer care among patients who reported being given a CNS name with those who did not, adjusting for age, sex, socio-economic deprivation, ethnicity, route to diagnosis and disease stage. RESULTS: Across all cancers, patients who reported being given the name of a CNS reported better experiences with involvement in treatment decisions, care coordination, treatment with more respect and dignity, and overall care experience. Experience of being involved in treatment decisions was the aspect of care most strongly associated with being given a CNS name (colorectal: OR 2.69, 95% CI: 2.45-2.96; lung: OR 2.41, 95% CI: 2.07-2.78; breast: OR 2.68, 95% CI: 2.47-2.92; and prostate: OR 2.11, 95% CI: 1.92-2.32). CONCLUSION: These findings may provide new evidence of the vital contribution CNS make to cancer care and suggest their input and support should be available to all patients after the diagnosis.

The incidence of major subtypes of primary brain tumors in adults in England 1995-2017.

BACKGROUND: Primary brain tumors are a complex heterogenous group of benign and malignant tumors. Reports on their occurrence in the English population by sex, age, and morphological subtype and on their incidence are currently not available. Using data from the National Cancer Registration and Analysis Service (NCRAS), the incidence of adult primary brain tumor by major subtypes in England will be described. METHODS: Data on all adult English patients diagnosed with primary brain tumor between 1995 and 2017, excluding spinal, endocrinal, and other CNS tumors, were extracted from NCRAS. Incidence rates were standardized to the 2013 European Standard Population. Results are presented by sex, age, and morphological subtype. RESULTS: Between 1995 and 2017, a total of 133 669 cases of adult primary brain tumor were registered in England. Glioblastoma was the most frequent tumor subtype (31.8%), followed by meningioma (27.3%). The age-standardized incidence for glioblastoma increased from 3.27 per 100 000 population per year in 1995 to 7.34 in men in 2013 and from 2.00 to 4.45 in women. Meningioma incidence also increased from 1.89 to 3.41 per 100 000 in men and from 3.40 to 7.46 in women. The incidence of other astrocytic and unclassified brain tumors declined between 1995 and 2007 and remained stable thereafter. CONCLUSION: Part of the increase in the incidence of major subtypes of brain tumors in England could be explained by advances in clinical practice including the adoption of new diagnostic tools, classifications and molecular testing, and improved cancer registration practices.

Mammographic Screening in the Occupied Palestinian Territory: A Critical Analysis of Its Promotion, Claimed Benefits, and Safety in Palestinian Health Research.

PURPOSE: To critically review the evidence and opinions expressed about mammographic screening (MS) in research reports on breast cancer in the occupied Palestinian territory (oPt) and to assess whether benefits and harms in MS are presented in a balanced way. METHODS: Searches of PubMed, Cochrane, MEDLINE, EMBASE, CINAHL, and gray literature identified 14 eligible research reports relating to the oPt. We reviewed these documents and then used a thematic analysis to describe and analyze the evidence and the opinions about MS expressed in them. RESULTS: All 14 research reports mentioned that MS would improve survival rates in the oPt. Only three gave information on major harmful effects, and only two emphasized that MS must be accompanied by effective treatment to have any beneficial effects on population mortality. There was no consistency in the recommended frequency of MS. CONCLUSION: Most information presented by Palestinian health researchers was selective and failed to address the important established harms of MS. Thus, calls to support MS in the oPt are not based on a measured discussion of the risks and benefits for women or grounded in the systemic readiness of health care necessary for its effectiveness. As long as diagnostic and treatment facilities remain deficient, screening cannot lead to reduced mortality from breast cancer.

Cancer care during the COVID-19 pandemic: a perspective from Saudi Arabia.

The coronavirus disease 2019 (COVID-19) pandemic continues to disrupt many healthcare settings worldwide including cancer care. COVID-19 has been associated with worse outcomes amongst cancer patients. Saudi Arabia has experienced several Middle East respiratory syndrome coronavirus (MERS-CoV) outbreaks that affected the continuity of cancer care. In this paper, we describe how Saudi Arabia responded to COVID-19, how cancer care was re-restructured during this pandemic and how the recent MERS-CoV experience may have improved the Saudi response to COVID-19.

How do patients with malignant brain tumors experience general practice care and support? Qualitative analysis of English Cancer Patient Experience Survey (CPES) data.

BACKGROUND: English Cancer Patient Experience Survey (CPES) data show patients with brain cancer report the least-positive experiences of general practice support. We aimed to understand these findings by identifying the issues described in qualitative survey feedback and suggest how care may be improved. METHODS: We reviewed 2699 qualitative comments made to open questions about what was good or might be improved about National Health Service care between 2010 and 2014. We identified 84 (3%) specific comments about general practice care and used open coding and framework analysis to develop a thematic framework. RESULTS: We identified 3 key themes and 12 subthemes: first, the experience of initial diagnosis by a general practitioner (GP), including apparent complexity of making the diagnosis, apparent slowness in referral for investigation, referral made by patient or family, delay in receiving scan results, and whether the GP quickly identified the problem and referred to a specialist; second, the experience of care and support from the general practice, including lack of supportive response from the GP, lack of follow-up care from the GP, lack of family involvement by the GP, lack of GP knowledge about management, and whether the GP responded in a supportive way to the diagnosis; and third, the experience of overall coordination in care, including lack of communication between the hospital and general practice and good communication about the care plan. CONCLUSION: Qualitative responses from patients with brain cancer reveal their needs for better emotional and practical support within primary care. Suggestions include increasing the speed of initial referral for investigation, the depth of discussion about diagnostic difficulties, and developing coordinated care plans with cancer centers.

Additional challenges faced by cancer patients in Gaza due to COVID-19.

Cancer patients in conflict settings experience significant barriers in accessing chemotherapy and radiotherapy as well as palliative care and psychosocial support. Now they face an additional possible risk of infection by SARS-CoV-2 novel coronavirus and the indirect impact of the COVID-19 pandemic on movement restrictions and their access to care. In this commentary, we highlight that despite the low COVID-19 burden in conflict settings like Gaza, COVID-19 could lead to further inequity in cancer care and poorer outcomes for Palestinians with cancer. This is due to the pre-existing shortage in cancer resources as well as the lack of context-specific guidelines to prepare for COVID-19 in war-torn settings.

How representative are colorectal, lung, breast and prostate cancer patients responding to the National Cancer Patient Experience Survey (CPES) of the cancer registry population in England? A population-based case control study.

OBJECTIVE: To assess the representativeness of National Cancer Patient Experience Survey (CPES) responders compared with the English cancer registry population in term of age, sex, socioeconomic deprivation, ethnicity, disease stage and median survival. DESIGN: Population-based case-control study. SETTING: England. POPULATION: We identified 103 186 colorectal, lung, breast and prostate cancer patients responding to at least one survey during 2010-2014 and randomly selected one non-responder from the cancer registry matched on cancer type and yearly quarter of diagnosis. MAIN OUTCOME MEASURE: We compared age, sex, socioeconomic deprivation, ethnicity and disease stage between the two groups using logistic regression. We also compared survival (in years) using the Mann-Whitney test. RESULTS: Across all cancer types survey responders were younger, more likely to have a White ethnic background, to be resident in less deprived areas and diagnosed with earlier stage disease although they varied between cancers. Median survival for responders was also higher than for the cancer registry population (colorectal: 4.8 vs 3.2; lung: 2.0 vs 0.3; breast: 5.7 vs 5.4; and prostate: 5.7 vs 5.2 years; all p-values<0.001). CONCLUSION: CPES responders with the four most common cancers do not necessarily represent all patients with these cancers in terms of demographic characteristics and tumour stage at diagnosis. These limitations should be considered when interpreting findings. To capture the experiences of patients currently underrepresented in CPES, different approaches may need to be taken.

Why we need more poetry in palliative care.

OBJECTIVES: Although many well-known poems consider illness, loss and bereavement, medicine tends to view poetry more as an extracurricular than as a mainstream pursuit. Within palliative care, however, there has been a long-standing interest in how poetry may help patients and health professionals find meaning, solace and enjoyment. The objective of this paper is to identify the different ways in which poetry has been used in palliative care and reflect on their further potential for education, practice and research. METHODS: A narrative review approach was used, drawing on searches of the academic literature through Medline and on professional, policy and poetry websites to identify themes for using poetry in palliative care. RESULTS: I identified four themes for using poetry in palliative care. These concerned (1) leadership, (2) developing organisational culture, (3) the training of health professionals and (4) the support of people with serious illness or nearing the end of life. The academic literature was mostly made up of practitioner perspectives, case examples or conceptual pieces on poetry therapy. Patients' accounts were rare but suggested poetry can help some people express powerful thoughts and emotions, create something new and feel part of a community. CONCLUSION: Poetry is one way in which many people, including patients and palliative care professionals, may seek meaning from and make sense of serious illnesses and losses towards the end of life. It may have untapped potential for developing person-centred organisations, training health professionals, supporting patients and for promoting public engagement in palliative care.

Comparing the case mix and survival of women receiving breast cancer care from one private provider with other London women with breast cancer: pilot data exchange and analyses.

BACKGROUND: Data from providers of private cancer care are not yet formally included in English cancer registration data. This study aimed to test the exchange of breast cancer data from one Hospital Corporation of America International (HCAI) hospital in London with the cancer registration system and assess the suitability of these data for comparative analyses of case mix and adjusted survival. METHODS: Data on 199 London women receiving 'only HCAI care', 278 women receiving 'some HCAI care' (HCAI and other services), and 31,234 other London women diagnosed between 2005 and 2011 could be identified and compared. Overall survival was estimated using the Kaplan-Meier method, and Cox regression was used to adjust for age, socioeconomic deprivation, year of diagnosis, stage of disease and recorded treatment. RESULTS: Women receiving 'only HCAI care' were younger, lived in areas of higher affluence (47.8 % vs 27.6 %) and appeared less likely to be recorded as having screen-detected (2.5 % vs 25.0 %) disease than other London women. Women receiving 'some HCAI care' were more similar to 'HCAI only' women. Although HCAI stage of disease data completeness improved during the study period, this was less complete overall than cancer registration data and limited the comparative survival analyses. An apparent survival advantage for 'HCAI only' women compared with other London women (hazard ratio 0.48, 95 % confidence interval (CI): 0.32-0.74) was attenuated and no longer statistically significant after adjustment (0.79, 95 % CI: 0.51-1.21). Women receiving 'some HCAI care' appeared to have higher survival (hazard ratio 0.24, 95 % CI 0.14-0.41) which was attenuated to 0.48 (95 % CI: 0.28-0.80) in the fully adjusted model. CONCLUSIONS: Exchange of data between the private cancer sector and the English cancer registration service can identify patients who receive all or some private care. The better survival of women receiving only or some HCAI breast cancer care appears to be at least partly explained by demographic, disease, and treatment factors. However, larger studies using similarly quality assured datasets and more complete staging data from the private sector are needed to produce definitive comparative results.

The varying influence of socioeconomic deprivation on breast cancer screening uptake in London.

BACKGROUND: We assessed the relationship between screening uptake and socioeconomic deprivation for London women aged 50-52 invited to their first routine screening appointment between 2006 and 2009. METHODS: We examined uptake for London overall and within six screening areas, using deprivation quintile, based on post code of residence. RESULTS: After adjustment for age, area and ethnicity, overall uptake decreased with increasing deprivation (adjusted odds ratio (OR) = 0.95, P < 0.001). However, in two screening areas with lower uptake, women living in deprived areas had higher uptake than women from affluent areas. CONCLUSIONS: These potential inequalities in early diagnosis across London require further investigation.

Barriers to early diagnosis of symptomatic breast cancer: a qualitative study of Black African, Black Caribbean and White British women living in the UK.

OBJECTIVES: Understanding barriers to early diagnosis of symptomatic breast cancer among Black African, Black Caribbean and White British women in the UK. DESIGN: In-depth qualitative interviews using grounded theory methods to identify themes. Findings validated through focus groups. PARTICIPANTS: 94 women aged 33-91 years; 20 Black African, 20 Black Caribbean and 20 White British women diagnosed with symptomatic breast cancer were interviewed. Fourteen Black African and 20 Black Caribbean women with (n=19) and without (n=15) breast cancer participated in six focus groups. SETTING: Eight cancer centres/hospital trusts in London (n=5), Somerset (n=1), West Midlands (n=1) and Greater Manchester (n=1) during 2012-2013. RESULTS: There are important differences and similarities in barriers to early diagnosis of breast cancer between Black African, Black Caribbean and White British women in the UK. Differences were influenced by country of birth, time spent in UK and age. First generation Black African women experienced most barriers and longest delays. Second generation Black Caribbean and White British women were similar and experienced fewest barriers. Absence of pain was a barrier for Black African and Black Caribbean women. Older White British women (≥70 years) and first generation Black African and Black Caribbean women shared conservative attitudes and taboos about breast awareness. All women viewed themselves at low risk of the disease, and voiced uncertainty over breast awareness and appraising non-lump symptoms. Focus group findings validated and expanded themes identified in interviews. CONCLUSIONS: Findings challenged reporting of Black women homogenously in breast cancer research. This can mask distinctions within and between ethnic groups. Current media and health promotion messages need reframing to promote early presentation with breast symptoms. Working with communities and developing culturally appropriate materials may lessen taboos and stigma, raise awareness, increase discussion of breast cancer and promote prompt help-seeking for breast symptoms among women with low cancer awareness.