Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa.

BACKGROUND: Breast and cervical cancer are leading causes of cancer burden in Sub-Saharan Africa (SSA). We measured breast and cervical cancer symptom and risk factor awareness and lay beliefs in Uganda and South Africa (SA). METHODS: Between August and December 2018 we conducted a cross-sectional survey of women ≥18 years in one urban and one rural site per country. Households were selected using systematic random sampling, then one woman per household randomly selected to participate. Data were collected by interviewers using electronic tablets customised with the locally validated African Women Awareness of Cancer (AWACAN) tool. This has unprompted questions (testing recall) followed by prompted questions (testing recognition) on risk factor, symptom awareness and lay beliefs for breast and cervical cancer. Mann Whitney and Kruskal Wallis tests were used to compare the association between socio-demographic variables and outcomes. Poisson regression with robust variance was conducted to identify independent socio-demographic predictors. RESULTS: Of the 1758 women interviewed, 90.8% had heard of breast and 89.4% of cervical cancer. 8.7% recalled at least one breast risk factor and 38.1% recalled at least one cervical cancer risk factor. 78.0% and 57.7% recalled at least one breast/cervical cancer symptom respectively. Recognition of risk factors and symptoms was higher than recall. Many women were unaware that HPV, HIV, and not being screened were cervical cancer risk factors (23.7%, 46.8%, 26.5% respectively). In SA, urban compared to rural women had significantly higher symptom and risk factor awareness for both cancers. In Uganda married women/living with a partner had higher awareness of breast cancer risk factors and cervical cancer symptoms compared to women not living with a partner. Women mentioned several lay beliefs (e.g. putting money in their bra as a breast cancer risk factor). CONCLUSION: We identified gaps in breast and cervical cancer symptom and risk factor awareness. Our results provide direction for locally targeted cancer awareness intervention programs and serve as a baseline measure against which to evaluate interventions in SSA.

Tracking cancer occurrence in the 5 years after referral for suspected head and neck cancer.

OBJECTIVES: Very little is known about those who receive a negative (benign) result after referral for suspected cancer, including their risk for future cancer. This service evaluation aimed to track the occurrence of cancer (of any type) in the 5 years after an appointment for suspected head and neck cancer (HNC) and compare to those referred to hospital for routine ear nose and throat reasons. MATERIALS & METHODS: Patient identifiers of referrals to one hospital Trust with either a) suspected HNC cancer on a two week wait (TWW) pathway, or b) routine ear, nose & throat problems, were linked with the National Cancer Registry data to determine the occurrence, site and stage of subsequent cancer. RESULTS: 10,314 patients were referred between 2009 and 2011. Cancer occurrence in the 5 years after their appointment for those who had initially received a negative diagnosis, was 4.0% for those referred via TWW and 2.1% for those routinely referred. Lung cancer was the most common subsequent cancer site in the TWW group. Those in higher age groups, those with previous cancer, and those referred via the TWW pathway were significantly more likely be diagnosed with subsequent cancer. CONCLUSION: Given the increased risk of subsequent cancer, it could be beneficial to improve the service provision (e.g. advice on screening attendance, ways to reduce risk, advice on timely help-seeking for symptoms of cancer) at the point of a negative diagnosis on the TWW pathway, especially in older patients and those with a previous diagnosis of cancer.

Development and validation of the African Women Awareness of CANcer (AWACAN) tool for breast and cervical cancer.

BACKGROUND: Measuring factors influencing time to presentation is important in developing and evaluating interventions to promote timely cancer diagnosis, yet there is a lack of validated, culturally relevant measurement tools. This study aimed to develop and validate the African Women Awareness of CANcer (AWACAN) tool to measure awareness of breast and cervical cancer in Sub-Saharan Africa (SSA). METHODS: Development of the AWACAN tool followed 4 steps: 1) Item generation based on existing measures and relevant literature. 2) Refinement of items via assessment of content and face validity using cancer experts' ratings and think aloud interviews with community participants in Uganda and South Africa. 3) Administration of the tool to community participants, university staff and cancer experts for assessment of validity using test-retest reliability (using Intra-Class Correlation (ICC) and adjusted Kappa coefficients), construct validity (comparing expert and community participant responses using t-tests) and internal reliability (using the Kuder-Richarson (KR-20) coefficient). 4) Translation of the final AWACAN tool into isiXhosa and Acholi. RESULTS: ICC scores indicated good test-retest reliability (≥ 0.7) for all breast cancer knowledge domains and cervical cancer risk factor and lay belief domains. Experts had higher knowledge of breast cancer risk factors (p < 0.001), and cervical cancer risk factors (p = 0.003) and symptoms (p = 0.001) than community participants, but similar knowledge of breast cancer symptoms (p = 0.066). Internal reliability for breast cancer risk factors, lay beliefs and symptom and cervical cancer symptom subscales was good with KR-20 values > 0.7, and lower (0.6) for the cervical cancer risk subscale. CONCLUSION: The final AWACAN tool includes items on socio-demographic details; breast and cervical cancer symptom awareness, risk factor awareness, lay beliefs, anticipated help-seeking behaviour; and barriers to seeking care. The tools showed evidence of content, face, construct and internal validity and test-retrest reliability and are available for use in SSA in three languages.

Uptake of screening for type 2 diabetes risk in general dental practice; an exploratory study.

Aim The objective of this study was to determine dental patients' uptake of two preliminary screening tools for risk of diabetes (the Finnish Diabetes Risk Score -FINDRISC- and HbA1c finger-prick testing) in general dental practice, and to determine the number of patients at risk of type 2 diabetes (T2D) based on the results of these screening tests.Methods Patients aged 45 and over, who did not already have a diagnosis of diabetes, visiting primary dental practitioners for routine appointments in London (N = 244) and Staffordshire (N = 276), were offered the chance to be screened for diabetes risk using the FINDRISC a self-report screening tool to assess risk of development of diabetes in the next ten years. If a patient's score showed them to be at risk, they were offered an instant HbA1c finger-prick test to further screen for possible type 2 diabetes, where they were given their result instantaneously. Patients found to be at risk on either screening test, were referred to their GP for formal diagnostic testing.Results A total of 1,035 patients eligible for inclusion were asked to take part. Five hundred and twenty patients consented to screening. Of these, 258 patients (49.6%) were found to be at risk of developing diabetes based on FINDRISC scores and were referred to the GP for further testing and offered a further screening finger-prick blood test at the dental practice. A total of 242 (93.8% of those offered the test) accepted the on the spot finger-prick test. On this A1c test, had a result of 5.7% or higher, indicating increased risk for diabetes. Of the 258 who were referred to their GP for formal diabetes testing, 155 (60%) contacted their doctor. There was a significant association between the number of 'at risk' screening results a person received and whether or not a patient contacted their GP (P <0.0001). The odds of patients contacting the GP was 3.22 times higher if they were referred with two positive diabetes risk results (positive FINDRISC, positive HbA1c) rather than just one (positive FINDRISC, negative HbA1c).Conclusions The study demonstrates a two-step method of diabetes screening that appears to be acceptable by dental patients, a sizeable proportion of whom were identified as at risk of developing diabetes, and the majority following the recommendation for further testing with their GP. While the majority followed the recommendation for further testing with their GP, patients were three times more likely to contact their GP if they received a positive risk result on both screening tools.

Oral cancer awareness in young South-Asian communities in London.

OBJECTIVES: First, to evaluate awareness of oral cancer amongst the young South-Asian community in London and identify any aspects of knowledge about oral cancer that are lacking; and, second, to determine whether demographic factors or health-related behaviours are associated with knowledge of oral cancer. RESEARCH DESIGN: Cross-sectional questionnaire survey. PARTICIPANTS: South Asians aged 18-44 years attending community centres or places of worship in London. MAIN OUTCOME MEASURES: Oral cancer awareness; health-related behaviours. RESULTS: Respondents (n = 201) were mainly male (61%), Indian (77%) and Hindu (35%). Over half (58%; n = 113) had one or more negative health-related behaviours and only 18% had attended a dentist in the previous two years. Chewing paan with betel nut (OR = 4.08, 95% CI = 1.58-10.59, p < 0.01), and time since last visit to a dentist (OR = 4.90, 95% CI = 2.13-11.28, p < 0.01) were independently associated with respondents level of knowledge of mouth cancer; the former positively and the latter negatively. CONCLUSIONS: The results suggest that young adults in the South Asian Community are exposed to a number of risk factors for oral cancer yet have poor knowledge of the implications of these health-related behaviours, and ways in which oral cancer can be detected earlier. The survey highlighted specific issues for action.

Pilot study to train dentists to communicate about oral cancer: the impact on dentists' self-reported behaviour, confidence and beliefs.

OBJECTIVES: To evaluate the effect of a brief, focused training session on the use of an oral cancer communication guide on dentists' intentions, self-efficacy and beliefs with regards to communicating about oral cancer with patients. DESIGN: Pre-post intervention study. SETTING: The training session took place in a lecture theatre at King's College London. SUBJECTS AND METHODS: Dentists working in various settings were trained on the use of the oral cancer communication guide via a structured session that included an update on oral cancer, modelling the use of the guide in practice, and role playing. Dentists (n = 39) completed questionnaires pre-training, immediately post-training (n = 31) and after 2 weeks (n = 23). Questionnaires assessed current practice, self-efficacy and barriers to discussing oral cancer. RESULTS: A significantly higher proportion of dentists reported that they informed patients that they were being screened for oral cancer post-training (44%) than pre-training (16%). Significantly fewer perceived barriers and higher self-efficacy to discuss oral cancer were also reported. CONCLUSION: Training dentists in the use of the guide showed positive impact by reducing perceived barriers and increasing self-efficacy.

Why don't dentists talk to patients about oral cancer?

OBJECTIVES: Up to half of oral cancer patients are diagnosed with advanced lesions. One route to early diagnosis could involve dentists raising awareness of oral cancer through discussions with patients, emphasising prompt help-seeking. This study explores opinions and practices of dentists regarding discussing oral cancer with patients including views on barriers and facilitators. DESIGN: Qualitative in-depth interviews.Setting Dentists working in general dental practices in the United Kingdom were interviewed in 2013. SUBJECTS AND METHODS: In-depth interviews with dentists (n = 16) were conducted. Interviews were audio-recorded and transcribed. Data was analysed using framework analysis. RESULTS: Dentists recognised the importance of raising awareness but identified several barriers to discussions including system factors (for example, time constraints and a lack of financial incentive), patient factors (for example, fear of invoking undue anxiety) and dentist factors (for example, a lack of sufficient knowledge, training and self-confidence). Facilitators included developing practice standards and good dentist-patient relationships. CONCLUSION: Identified barriers may hold back efforts to raise awareness of oral cancer and could be targeted in future initiatives to encourage early detection.

Applying symptom appraisal models to understand sociodemographic differences in responses to possible cancer symptoms: a research agenda.

BACKGROUND: Sociodemographic inequalities in the stage of diagnosis and cancer survival may be partly due to differences in the appraisal interval (time from noticing a bodily change to perceiving a reason to discuss symptoms with a health-care professional). A number of symptom appraisal models have been developed describing the psychological factors that underlie how people make sense of symptoms, although none explicitly focus on sociodemographic characteristics. METHODS: We therefore conducted a conceptual review synthesising all symptom appraisal models, and focus on potential links with sociodemographics that could be the focus of future research. RESULTS: Common psychological elements across nine symptom appraisal models included knowledge, attention, expectation and identity, all of which could be sensitive to sociodemographic factors. For example, lower socioeconomic status (SES), male sex and older age are associated with lower health literacy generally and lower cancer symptom knowledge. Limited attentional resources, lower expectations about health and lack of social support also hamper symptom interpretation, and would be likely to be more prevalent in those from lower SES backgrounds. Symptom heuristics ('rules of thumb') may lead to symptoms being normalised because they are common within the social network, potentially disadvantaging older populations. CONCLUSIONS: A better understanding of the processes through which people interpret their symptoms, and the way these processes differ by sociodemographic factors, could help guide the development of interventions with the aim of reducing inequalities in cancer outcomes.

Patient drawings of their melanoma: a novel approach to understanding symptom perception and appraisal prior to health care.

OBJECTIVE: This pilot study investigated the use of patient drawings to explore patient experiences of symptoms of melanoma prior to health care use. DESIGN: Patients (n = 63) with melanoma were interviewed within 10 weeks of diagnosis. Participants were asked to draw what their melanoma had looked like when they first noticed it, and to make additional drawings to depict changes as it developed. MAIN OUTCOME MEASURE: The size and features of the drawings were compared between participants and with clinical data (thickness of the melanoma; histological diameter; clinical photographs). RESULTS: Eighty-four percent of participants were able to produce at least one drawing. This facilitated discussion of their lesion and recall of events on the pathway to diagnosis. Common features of the drawings related to the view, presence of shading, inclusion of sections and the shape and border of the lesion. There was potential for disparity between the details in awareness resources and the perceptions of patients. The drawings resembled the clinical photographs and the size of the drawings was positively associated with the histological diameter, but did not differ according to tumour thickness. CONCLUSION: Asking patients to make drawings of their melanoma appears to be an acceptable, inclusive, feasible and insightful methodological tool.

Navigating healthcare: a qualitative study exploring prostate cancer patients' and doctors' experience of consultations using a decision-support intervention.

BACKGROUND: Men with prostate cancer face preference-sensitive decisions when choosing among treatments with similar survival outcomes but different procedures, risks and potential complications. A decision-support intervention, 'Decision Navigation' assists men with prostate cancer to prepare a question list (consultation plan) for their doctors and provides them with a consultation summary and audio recording. A randomised controlled trial of Decision Navigation showed advantages over usual care on quantitative measures including confidence in decision-making and regret. OBJECTIVE: The aim of this study was to gain a qualitative understanding of patient's and doctor's perspectives on Decision Navigation. METHODS: Six patients who received Decision Navigation were purposively selected for interview out of 62 randomised controlled trial participants. All four doctors who consulted Navigated patients were interviewed. Interview data was analysed using framework analysis. RESULTS: Patients reported that planning for the consultation helped them to frame their questions, enabling them to participate in consultations and take responsibility for making decisions. They reported feeling more confident in the decisions made, having a written report of the key information and an audio recording. Patients considered routine information relating to side effects was inadequate. Doctors reported that consultation plans made them aware of patients' concerns and ensured comprehensive responses to questions posed. Doctors also endorsed implementing Decision Navigation as part of routine care. CONCLUSION: Results suggest that Decision Navigation facilitated patients' involvement in treatment decision-making. Prostate patients engaging in preference-sensitive decision-making welcomed this approach to personalised tailored support.

The model of pathways to treatment: conceptualization and integration with existing theory.

BACKGROUND: Studying and understanding pathways to diagnosis and treatment is vital for the development of successful interventions to encourage early detection, presentation, and diagnosis. An existing framework posited to describe the decisional and behavioural processes that occur prior to treatment (Andersen et al.'s General Model of Total Patient Delay) does not appear to match the complex and dynamic nature of the pathways into and through the health care system or provide a clear framework for research. Therefore a revised descriptive framework, the Model of Pathways to Treatment, has been proposed. PURPOSE: This paper presents the concepts and definitions of the Model of Pathways to Treatment and specifies how the model can encompass existing psychological theory, with particular focus on the Appraisal and Help-seeking intervals. The potential and direction for future work is also discussed. STATEMENT OF CONTRIBUTION: WHAT IS ALREADY KNOWN ON THIS SUBJECT?: • The use of theory is often lacking in existing research into delays in presentation, diagnosis and treatment of illness. WHAT DOES THIS STUDY ADD?: • A detailed account of the concepts and definitions of a revised framework: the Model of Pathways to Treatment. • Specification of how the Model of Pathways to Treatment can encompass existing psychological theory such as the Common Sense Model of Illness Self-regulation and Social Cognitive Theory.

Developing ways to encourage early detection and presentation of oral cancer: what do high-risk individuals think?

The aim of this pilot research was to improve understanding of individuals at risk of oral cancer, to determine their attitudes towards and responses to early detection interventions. In-depth interviews with the target group (n = 25) were used to determine their views, attitudes and requirements for an intervention to encourage early detection of oral cancer. This data was used in combination with theory-based constructs to develop written material that aimed to increase awareness of oral cancer, encourage mouth self-examination (MSE) and early presentation. A second pilot study used a think-aloud protocol to assess the target groups' (n = 14) reactions to the written information. In both studies the tape-recorded responses were analysed using framework analysis. The target group had limited knowledge about oral cancer, particularly the signs and symptoms. Participants saw benefits in performing MSE but noted the main barriers were not knowing what signs to look for or where to look. The written information was generally well-received but required some modifications. In particular, the target group required further persuasion that their lifestyle contributed to an increased risk of oral cancer. The results of these pilot studies have informed the development of a theory-based intervention for the early detection of oral cancer.

Coping together and apart: exploring how patients and their caregivers manage terminal head and neck cancer.

Head and neck cancer (HNC) challenges the physical, social, and psychological well-being of the individual, and their family and friends, with 50% of patients facing the prospect of dying within 5 years of diagnosis. To enhance care at the end of life, further understanding of how patients and their loved ones cope is needed. Findings from a qualitative study are presented which suggest that patients with terminal HNC and their caregivers cope individually, with support and as a dyad. Relationship qualities which might facilitate coping together as a dyad are described. These may aid distinction between coping together and acts of social support.

The reality of identifying early oral cancer in the general dental practice.

Oral cancer has a good prognosis when detected at an early stage yet half of patients diagnosed with oral cancer in the UK have advanced stage disease, for which prognosis is poor. Although most oral tumours are preceded by pre-malignant lesions, the asymptomatic nature of oral cancer, diagnostic delay, and the possibility of hidden tumours, limit the ease at which oral cancer is detected early. Furthermore, in the UK, oral cancer is a relatively rare disease and does not have mutually exclusive signs or symptoms. Responsibility for the early detection of oral cancer is currently placed on the general dental practitioner. However, the current recommendations to screen for oral cancer at every routine check-up is not practical and has not produced the intended results. Selective opportunistic screening may be a more realistic and effective solution and a simple alert system is proposed to assist its implementation.

Patient delay in oral cancer: a qualitative study of patients' experiences.

Up to 30% of patients delay seeking the advice of a healthcare professional after self-discovery of symptom(s) of oral cancer. Reasons for this patient delay are poorly understood. The aim of the present study was to explore patients' initial experiences and reactions to developing symptoms of oral cancer, and to identify factors influencing their decision to consult a health care professional. In-depth semi-structured interviews were conducted with 17 consecutive patients who had received a diagnosis of oral squamous cell carcinoma, but had yet to start treatment. Participants were asked about their beliefs about their symptoms over the course of the disease and their decision to seek help. The tape-recorded interviews were transcribed verbatim and analysed using 'Framework analysis'. Oral symptoms were rarely attributed to cancer and were frequently interpreted as minor oral conditions. As a result of these beliefs, patients tended to postpone seeking help or fail to be concerned over their symptoms. Prior to seeking help, patients responded to symptoms by using self-medication, changing the way they ate and disclosing their discovery of symptoms to friends or family. Problems with access to healthcare professionals and patients' social responsibilities acted as barriers to prompt help-seeking. This study has documented that an individual's interpretation of oral cancer symptoms may be misguided and this can adversely affect subsequent help-seeking behaviour.

The idiosyncratic relationship between diagnostic delay and stage of oral squamous cell carcinoma.

Approximately half of patients with oral cancer present with advanced lesions when five-year survival rates are as low as 20%, however, diagnostic delay has repeatedly been found to be unrelated to the stage of oral cancer at diagnosis. The aim of this study was to investigate why diagnostic delay is frequently unrelated to the stage of oral cancer at diagnosis. The odds ratio (OR) of early versus advanced oral squamous cell carcinoma was calculated for 245 consecutive patients with untreated oral squamous cell carcinoma. Being female (OR=0.40; 0.19-0.80; p<0.05) and married (OR=0.27; 0.11-0.66; p<0.01) was predictive of early stage disease. Being non-white (OR=5.42; 1.66-17.67; p<0.01) was predictive of advanced stage disease. There is no evidence that these patient demographics are associated with faster growing tumours, yet it is possible that those who are male, unmarried and non-white may not notice an oral lesion until it is advanced in stage. It is concluded that differences in tumour biology are not a likely explanation for the absence of a delay-stage relationship but instead, a proportion of tumours may be silent until advanced in stage.

Low probability of chloroplast movement from oilseed rape (Brassica napus) into wild Brassica rapa.

Pollen-mediated movement of transgenes from transplastomic oilseed rape (Brassica napus) into wild relatives will be avoided if chloroplasts are maternally transmitted. We assess the probability of chloroplast exchange between conventional oilseed rape and wild Brassica rapa to model the future behavior of transplastomic cultivars. Primers specific to cpDNA were used to demonstrate maternal inheritance of chloroplasts in 47 natural hybrids between cultivated B. napus and wild B. rapa. We conclude that there will be no or negligible pollen-mediated chloroplast dispersal from oilseed rape. Transgene introgression could still occur in mixed populations, however, if B. napus acted as the recurrent female parent. Rate of transfer would then depend on the abundance of mixed populations, their persistence as mixtures, and hybridization frequency within stands. A low incidence of sympatry (0.6-0.7%) between wild B. rapa and cultivated B. napus along the river Thames, UK, in 1997 and 1998, suggests mixed stands will form only rarely. Eighteen feral populations of B. napus also showed a strong tendency toward rapid decline in plant number, seed return, and ultimately, extinction within 3 years. Conversely, hybrid production is significant in mixed stands, and the absence of control practices means that oilseed rape will have slightly greater persistence. We infer that some introgression from transplastomic B. napus into B. rapa is inevitable in mixed populations even though such populations will occur infrequently and will tend to lose B. napus plants relatively quickly. Chloroplast exchange will be extremely rare and scattered.

Efficacy and safety of monophasic and biphasic waveform shocks using a braided endocardial defibrillation lead system.

Endocardial lead systems for implantable cardioverter-defibrillators utilize large (12F) rigid catheters with spring defibrillation electrodes, and lead system failure has been observed during long-term implant. We evaluated a novel flexible 8F braided electrode catheter for pacing and defibrillation in canine experiments. Active fixation and pacing were accomplished using a screw-in distal electrode, and defibrillation pulses were delivered through a braided electrode. Two braided electrode catheters were positioned in the right ventricular apex (6 cm2) and in the superior vena cava-right atrial junction (5 cm2), respectively. An elliptical 13 cm2 surface area patch electrode was positioned along the left lateral cardiac border. Ventricular fibrillation (VF) was induced and monophasic and asymmetric biphasic shocks (leading voltages 260 to 1000 V) were delivered via dual and triple electrode configurations in each animal using a prospective randomized crossover study design. Mean right ventricular pacing threshold was 0.5 +/- 0.2 mA, with a mean electrogram amplitude of 11.1 +/- 2.8 mV during sinus rhythm prior to fibrillation and defibrillation. Two hundred seven VF inductions (mean 30 +/- 4 per animal) were analyzed. The mean defibrillation threshold could be reduced to 8.0 +/- 3.2 joules with biphasic shocks from 12.9 +/- 5.1 joules obtained for monophasic shocks using a dual electrode system (p less than 0.004). Mean shock leading voltage was correspondingly reduced to 488 +/- 100 V from 691 +/- 154 V (p less than 0.0006).(ABSTRACT TRUNCATED AT 250 WORDS)