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Women's knowledge and beliefs regarding breast cancer

Women's knowledge and beliefs regarding breast cancer British Journal of Cancer (2002) 86, 1373 – 1378 ã 2002 Cancer Research UK All rights reserved 0007 – 0920/02 $25.00 www.bjcancer.com ,1 2 2 2 EA Grunfeld* , AJ Ramirez , MS Hunter and MA Richards 1 2 Psychology Unit, Guy’s, King’s and St Thomas’ Medical School, Guy’s Campus, London SE1 9RT, UK ; Section of Liaison Psychiatry and ICRF Psychosocial Oncology Group, Guy’s, King’s and St Thomas’ Medical School, St Thomas’ Hospital, London SE1 7EH, UK Approximately 20 – 30% of women delay for 12 weeks or more from self-discovery of a breast symptom to presentation to a health care provider, and such delay intervals are associated with poorer survival. Understanding the factors that influence patient delay is important for the development of an effective, targeted health intervention programme to shorten patient delay. The aim of the study was to elicit knowledge and beliefs about breast cancer among a sample of the general female population, and examine age and socio-economic variations in responses. Participants were randomly selected through the Postal Address File, and data were collected through the Office of National Statistics. Geographically distributed throughout the UK, 996 women participated in a short structured interview to elicit their knowledge of breast cancer risk, breast cancer symptoms, and their perceptions of the management and outcomes associated with breast cancer. Women had limited knowledge of their relative risk of developing breast cancer, of associated risk factors and of the diversity of potential breast cancer-related symptoms. Older women were particularly poor at identifying symptoms of breast cancer, risk factors associated with breast cancer and their personal risk of developing the disease. Poorer knowledge of symptoms and risks among older women may help to explain the strong association between older age and delay in help-seeking. If these findings are confirmed they suggest that any intervention programme should target older women in particular, given that advancing age is a risk factor for both developing breast cancer and for subsequent delayed presentation. British Journal of Cancer (2002) 86, 1373 – 1378. DOI: 10.1038/sj/bjc/6600260 www.bjcancer.com ã 2002 Cancer Research UK Keywords: breast cancer ; symptoms; risk factors; age Delayed presentation of symptomatic breast cancer of three months routine breast screening to women up to the age of 70, and the or more is associated with lower survival rates (Richards et al, procedure will be available on request to women over 70 1999a). While some of this delay is health-provider related, an esti- (Department of Health, 2000b). It has been estimated that an mated 20 – 30% of women wait at least three months before effective screening programme may reduce mortality in the seeking medical help for breast symptoms (Richards et al, screening age group by up to 25% (Blamey et al, 2000). 1999b). A recent fall in deaths from breast cancer has been However women still need to be ‘breast aware’ and to accurately reported due to improved survival from a combination of earlier identify breast symptoms in order to receive treatment as quickly diagnosis, breast screening and improvement in treatment methods as possible (as symptoms may develop between screening (Richards et al, 2000; Peto et al, 2000). The relative contribution of appointments). Furthermore, approximately 44% of breast cancer these factors remains to be clarified. In the meantime, breast cancer cases occur in women within the screening age range; 21% of continues to represent a major public health problem, and further cases occur in women under the age of 50 and a further 35% gains in survival might be achieved by encouraging women to seek of cases occur in women aged over 70 years (Office for National help more promptly. Understanding the factors that influence Statistics, 2000). Therefore, women outside of the routine screen- patient delay is a prerequisite for the development of strategies ing age group will still need to be informed of the risks and to shorten delays. Strong evidence suggests that older women are symptoms of breast cancer. more likely to delay their presentation with breast cancer, although Women’s knowledge of breast cancer risk factors and of survival the strength of evidence for other risk factors for delay is inade- have been studied in Scottish, American and Australian popula- quate to inform any intervention (Ramirez et al, 1999). Such tions (Roberts et al, 1984; Breslow et al, 1997; Paul et al, 1999). factors are likely to relate to women’s knowledge and beliefs about No studies, however, have employed a UK national perspective breast cancer and its management. to examine women’s knowledge of the risks associated with breast The NHS Breast Screening Programme aims to invite all cancer and their perceptions of management and outcomes asso- women aged 50 – 64 for mammography screening, and the ciated with the disease. Furthermore, there are currently no large uptake of invitations for screening is high (Department of sample studies examining women’s knowledge of the range of Health, 2000a). The Department of Health now plans to extend breast symptoms. Representative and up-to-date data are essential to target educational resources to the women most at need, across a broad age and socio-economic status (SES) range. The aims of *Correspondence: EA Grunfeld, Unit of Psychology, 5th Floor Thomas Guy the present study were to (1) develop this knowledge base through House, Guy’s, King’s and St Thomas’ Medical School, Guy’s Campus, the examination of women’s interpretations of potential symptoms London SE1 9RT, UK; E-mail: [email protected] of breast cancer, their beliefs about of the risks and consequences Received 11 September 2001; revised 15 February 2002; accepted 25 of breast cancer and, (2) examine these variables in relation to February 2002 age and SES. Clinical Clinical Knowledge and beliefs about breast cancer EA Grunfeld et al Table 1 The age, socio-economic status (SES) and geographical distri- MATERIALS AND METHODS butions of the sample (n=996) Sampling and data collection were conducted by the Office of Percentage National Statistics (ONS) as a module of their Omnibus survey. Group Count of sample Data collection took place during January and February 2000. Three thousand addresses were selected from the Postal Address Socio-economic classification File (PAF) and a letter sent to each household outlining the I/II Professional & Intermediate 270 27 survey. Trained interviewers visited each address and at least IIIN Skilled non manual 306 31 IIM Skilled manual 101 10 three calls were made, at different times of the day and week. IV Partly skilled 193 19 The interview schedule was specifically designed for the study, V Unskilled/never worked 126 13 and pilot testing was conducted to ensure the survey was Age group comprehensible to the target group. The questions examined 16 – 24 90 9 four issues: 25 – 34 197 20 35 – 44 159 16 (1) Knowledge of a woman’s lifetime risk of developing breast 45 – 54 137 13 cancer: Participants were first asked a knowledge question 55 – 64 145 15 and were required to choose a woman’s approximate overall 65 – 74 146 15 lifetime risk (approximately 1 in 3, 10, 100, 1000, 10 000) 75 and over 122 12 of developing breast cancer. They were then asked to Geographical region provide a general estimation of their personal risk in The North 279 28 comparison to the general population and were required to Midlands and East Anglia 260 26 state whether they perceived themselves to be more, less, or London 90 9 South East 132 13 as likely to develop breast cancer than the rest of the South West 100 10 female population as a whole. Wales 56 6 (2) Knowledge of the risk factors associated with breast cancer: Scotland 79 8 Participants were shown a list of 10 established or probable risk factors and six non-risk factors (Royak-Schaler et al, 1996). The items in the list were presented in a random order of established and non-risk factors. They were asked to choose those that they believed would increase a woman’s chance of developing breast cancer. The percentage percentages. Chi-square tests were used to analyse the categorical of respondents reporting each factor as a risk factor is and attitudinal responses according to the groups. Multivariate reported. A score was produced of the number of correct analysis of variance was used to examine group differences in risk factors identified by each respondent (range 0 – 10). response to the scale data (total risk score and total symptom (3) Knowledge of breast cancer symptoms: Participants were score). shown a card containing 12 breast changes (eight of which were potential breast cancer symptoms) and asked to RESULTS indicate which they thought could be potential symptoms of breast cancer. (The order of the breast changes was Risk estimation for developing breast cancer randomly assigned.) The percentage of respondents reporting each symptom as a potential symptom of breast cancer is Respondents were overly optimistic regarding a woman’s risk of reported. A score was produced of the number of correct developing breast cancer, with 31% reporting that a woman had potential symptoms identified by each respondent. a 1 in 1000 chance of developing breast cancer, 35% reporting (4) Perceptions of management and outcomes in breast cancer: a one in 100 risk and 23% correctly indicating a 1 in 10 risk. Participants were asked to identify methods of treatment The majority of the sample (76%) reported that they were just used for breast cancer and the responses were categorised as likely to develop breast cancer as the rest of the female according to themes. Participants rated attitudinal state- population in the UK, while 7% reported a belief that they ments about the efficacy and consequences of breast cancer were at increased risk, and 17% reported that they were less treatment on a four-point scale (strongly agree to strongly likely to develop breast cancer. However, there was a relation- disagree). The lower the score the more the participant ship between age and the perception of risk (w =54.27, df=6, agreed with the statement. P50.001) with 35% of over 65-year-olds and 30% of over 75-years-olds reporting reduced personal risk. There was also a relationship between SES and perception of risk (w =46.11, Participants df=4, P50.001), with 32% of professional and intermediate From the original 3000 randomly chosen addresses there were 1830 (non-manual, non-managerial occupation) women reporting respondents (a response rate of 67%). Nine hundred and ninety-six reduced risk compared to 10 – 15% of partly skilled and of these respondents were female (mean age 47 years, range 16 – unskilled women. The explanations for reduced risk (in response 96) and completed the breast cancer module of the survey. The to an open-ended question) provided by the women included demographic groupings of the sample can be found in Table 1. absent family history (47%), lifestyle factors, such as following Information regarding non-responders is not available due to the a healthy diet and exercise plan (12%) and not smoking nature of the data collection, however, the age, SES and geographi- (5%). Approximately 25% of the women reporting a belief that cal distributions of the data are representative of the UK they were at reduced risk believed that they were too old to population. develop breast cancer; the mean age of this sub-sample was 76 years (range 63 – 91). These participants provided explana- tions such as: ‘I think if I was going to develop it I would Statistical analysis have by now’, ‘At my age I think the danger has passed’, The data were analysed according to the age and SES groups ‘[Because] they stop mammograms at 65’ and ‘I think older shown in Table 1. Response frequencies are summarised as people are less likely to have breast cancer problems’. British Journal of Cancer (2002) 86(9), 1373 – 1378 ã 2002 Cancer Research UK No/100 000 women Knowledge and beliefs about breast cancer EA Grunfeld et al dimpling of the breast skin and nipple inversion as signs of Risk factors for breast cancer breast cancer. The oldest age cohort identified fewer types of A family history of breast cancer and a personal history of breast symptoms of breast cancer than women aged between 25 and cancer were the most frequently cited risk factors, whereas less 74 (F(6, 919)=10.64 P50.001; Table 4). Women who were than one third recognised the role of advancing age (Table 2). unskilled or had never worked identified significantly fewer Table 2 shows the number of correct risk factors identified symptoms than the other socio-economic groups (F(4, 1069)= according to age group. Women over 75 correctly identified 10.43, P50.001; Table 4). fewer risk factors than women aged under 65 (F(6, 903)=13.22, P50.001). Professional women and women classified as inter- Management of breast cancer mediate (SES groups I and II) had a greater knowledge of risk factors than women who were partly skilled, skilled manual The most frequently cited treatment method for breast cancer was workers, or who had never worked (F(4, 1070)=17.50, surgery (87%), followed by chemotherapy (66%) and radiotherapy P50.001). Women aged 35 – 59 were perceived, by the sample, (49%). Only 5% of the sample spontaneously mentioned hormone to be most at risk of developing breast cancer, and those aged therapy as a treatment method. Tables 5 and 6 show the responses 75 – 90 years to be at least risk (Figure 1). to the attitudinal questions of the management of breast cancer as a function of age and SES. Eighty per cent of the women believed treatment for breast cancer to be a long process that would make a Symptoms of breast cancer patient very ill. Approximately 50% of participants thought that A painless breast lump, lump under the armpit, and nipple there were long waiting lists for tests for breast cancer, with those discharge were the most frequently identified symptoms of breast over 75 years old more likely to report this belief than participants cancer (Table 3). Less than half of the sample identified under 45 (w =13.03, df=6, P50.05). Table 2 The relative risk associated with various risk factors and the Table 3 The percentage of respondents identifying each potential percentage of respondents identifying each potential risk factor from a symptom of breast cancer (*) from a presented list (participants could presented list (participants could choose more than one) choose more than one) Percentage of Percentage Risk factor Relative risk* respondents Breast symptom of respondents Family history of breast cancer* 4290 Painless breast lump* 85 Previous breast cancer* 4471 Lump under armpit* 80 Smoking 60 Nipple discharge/bleeding* 70 Oral contraceptives* 2 35 Change in shape of breast* 64 Older age* 410 30 Lumpiness in breast* 60 Bumping or bruising breast 28 Pain in breast region* 50 High fat diet* 1.5 22 Changes in size of breast 40 Stress 22 Dimpling of breast skin* 39 Excess weight* 1 – 2 12 Breast swelling 39 First child at late age* 3 10 Inversion/pulling in of nipple* 38 Early onset of menses* 3 8 Bruising of breast 17 Alcohol* 1.3 8 Scaling/dry skin in nipple region 15 Late menopause* 2 7 Pollution 7 Large breasts 3 *Established or probable risk factors and relative risk data adapted from McPherson et al (2000). Table 4 The mean number of correct risk factors for breast cancer (range 0 – 10) and the number of correct symptoms of breast cancer (range 0 – 8) identified as a function of age and SES 80 200 Number of Number of Group correct risk factors correct symptoms 60 150 Socioeconomic group I/II Professional & Intermediate 3.2 (1.3) 5.9 (2.8) IIIN Skilled non manual 2.4 (1.1) 5.5 (2.2) 40 100 IIM Skilled manual 2.5 (1.3) 5.2 (2.2) IV Partly skilled 2.3 (1.4) 5.5 (2.0) 20 50 V Unskilled/Never worked 1.9 (1.1) 4.4 (1.8) Age group 0 0 16 – 24 2.4 (1.0) 4.6 (1.9) 20 –34 35–59 60 –74 74–90 25 – 34 2.7 (1.2) 5.8 (2.1) Age 35 – 44 2.8 (1.3) 5.6 (2.4) 45 – 54 2.7 (1.3) 6.0 (2.1) Figure 1 The percentage of respondents perceiving each of the age 55 – 64 2.6 (1.3) 5.8 (2.4) categories shown to be most at risk of developing breast cancer (bars). 65 – 74 2.0 (1.2) 5.3 (2.2) The dotted line (corresponding to the right hand axis) represents an 75 and over 1.5 (1.1) 4.0 (2.4) approximation of the incidence of breast cancer according to each age category (adapted from McPherson et al, 2000). (1 SD is shown in parentheses). ã 2002 Cancer Research UK British Journal of Cancer (2002) 86(9), 1373 – 1378 Percentage of respondents Clinical Clinical Knowledge and beliefs about breast cancer EA Grunfeld et al Table 5 Proportion of participants agreeing or agreeing strongly with statements regarding the management and outcomes of breast cancer (as a function of age) Age group All Question participants 16 – 24 25 – 34 35 – 44 45 – 54 55 – 64 65 – 74 75+ w df P Management of breast cancer % There are long waiting lists for tests for breast cancer 51 47 42 43 46 46 49 62 13.03 6 50.05 Tests for breast cancer are embarassing 17 21 19 15 15 14 16 13 7.81 6 0.252 Treatments for breast cancer work better in younger people 35 32 27 30 29 35 43 61 10.01 6 0.092 Treatment for breast cancer makes the patient very ill 70 74 63 59 67 73 76 68 6.72 6 0.284 The treatment for breast cancer is a long process 80 88 68 66 81 76 84 88 18.76 6 50.01 Treatment for breast cancer will help regardless of how advanced the disease is 50 50 46 40 45 53 65 72 29.43 6 50.01 Outcomes for breast cancer Breast cancer always results in some kind of disfigurement 32 31 23 16 34 37 44 52 31.55 6 50.001 Long term survival (more than five years) is rare 18 21 14 15 22 14 23 23 9.44 6 0.178 A woman who has had treatment for breast cancer can enjoy a good quality of life 88 92 95 92 90 92 90 84 16.75 6 50.05 Table 6 Proportion of participants agreeing or agreeing strongly with statements regarding the management and outcomes of breast cancer (as a function of socio-economic status (SES)) SES group Question I/II IIIN IIM IV V w df P Management of breast cancer % There are long waiting lists for tests for breast cancer 41 47 54 52 63 24.12 4 50.05 Tests for breast cancer are embarrassing 14 13 14 32 26 36.32 4 50.001 Treatments for breast cancer work better in younger people 34 32 33 38 43.4 6.24 4 0.903 Treatment for breast cancer makes the patient very ill 61 71 77 75 70 19.37 4 0.145 The treatment for breast cancer is a long process 76 79 82 79 83 8.49 4 0.745 Treatment for breast cancer will help regardless of how advanced the disease is 42 44 63 51 67 33.48 4 50.001 Outcomes for breast cancer Breast cancer always results in some kind of disfigurement 21 28 43 37 48 53.29 4 50.001 Long term survival (more than five years) is rare 11 18 21 22 26 25.30 4 50.01 A woman who has had treatment for breast cancer can enjoy a good quality of life 98 95 93 91 95 14.58 4 0.117 Outcomes of breast cancer Risk perception Tables 5 and 6 show the responses to the attitudinal statements Respondents were overly optimistic regarding a woman’s risk of regarding outcomes associated with breast cancer, as a function developing breast cancer with less than one quarter correctly indi- of age and SES. Approximately, 80% of participants believed cating a 1 in 10 risk. Although health education campaigns have long-term survival (greater than five years) to be common, and included information about the lifetime risk of breast cancer, it 70% did not believe the disease necessarily resulted in disfigure- is apparent that the majority of British women have either not ment. However, women aged over 75 were more likely to believe accessed this information or have not interpreted it correctly. that disfigurement was a frequent outcome of breast cancer However, the format of these educational campaigns may also (w =31.55, df=6, P50.001), as were manual and unskilled workers account for the poor awareness observed among these women. It (w =53.29, df=4, P50.001). Professional and intermediate women is known that leaflets produce only limited and short-lived changes (SES groups I and II) were more likely to believe that five-year in knowledge (Gatherer et al, 1979). Furthermore, many health survival following breast cancer was achievable (w =25.30, df=4, professionals believe leaflets are often not read by the target audi- P50.01). ence (Murphy and Smith, 1993). Therefore, any future campaign will need to make explicit the significant risk that breast cancer poses for women and combine the more traditional leaflet DISCUSSION approach to health education with other educational mediums The results of the survey demonstrated that although British (i.e. television and radio broadcasts) and individually tailored women have good understanding of some aspects of breast advice from health professionals. cancer there is poor awareness of other important issues, includ- The findings of this study suggest that the importance of advan- ing knowledge of non-lump breast symptoms and lifetime risk cing age as a risk factor for breast cancer is poorly understood, not of developing the disease. The survey also highlighted important only by older women in this country, but by the general female UK age and SES variations in knowledge of risk and of the range of population as a whole. This is in line with findings from USA and potential symptoms of breast cancer. These variations may help Australian populations (Breslow et al, 1997; Dolan et al, 1997; Paul to explain some of the differences in help-seeking behaviour et al, 1999). In the current sample, women aged 35 – 59 years were observed among women with breast cancer symptoms in the perceived to be most at risk of developing breast cancer. Breast UK. cancer is the single commonest cause of death among women aged British Journal of Cancer (2002) 86(9), 1373 – 1378 ã 2002 Cancer Research UK Knowledge and beliefs about breast cancer EA Grunfeld et al 40 – 50, however, in absolute terms advancing age is the greatest evidence to suggest that one of the major determinants of delay risk factor for developing breast cancer (McPherson et al, 2000); behaviour among patients is the discovery of a breast symptom approximately one-third of all breast cancers occur in women aged other than a lump (Ramirez et al, 1999). In line with previous over 70 (Office for National Statistics, 2000). work (Facione and Dodd, 1995) our results demonstrate that In our sample, a significant proportion of women aged over 65 although a breast lump is equated with a potential cancer, other perceived themselves to be at less personal risk than the general potentially serious symptoms may be misinterpreted. Detailed population, and in a significant proportion of these the explanation analysis of women’s interpretation of individual symptoms is for reduced risk related to their advanced age. In the UK, women necessary in order to determine women’s perceptions and attribu- aged 50 – 64 are routinely invited for breast cancer screening tions of breast symptoms. The summary message is that women (Department of Health, 2000a) and this may contribute to the would benefit from clear information about the variety of symp- increased risk attributed to this age group. Although not directly toms that may be indicative of a potential cancer. However, any examined in the present study, the results suggest that by stopping intervention to improve knowledge of symptoms should also aim screening at 64 a message may inadvertently be sent to women that to limit anxiety and to ensure that medical facilities are not over- they are no longer at risk, in fact one respondent explicitly stated loaded by help-seeking for benign symptoms, particularly by low this belief. This is a concern that has been expressed previously risk women. (Age Concern, 1996). The Department of Health plans to extend Knowledge of symptoms was poorer among older women and routine screening to all women up to the age of 70 by 2004 women who had never been employed. Older women were less (Department of Health, 2000b), as there is evidence that screening likely to perceive nipple eczema, changes in the shape or size of is acceptable in the age group 65 – 70 and is likely to save lives. the breast, and nipple retraction as symptoms of breast cancer. It Screening will also be available on request to women over 70. is possible that older women attribute such symptoms to the ageing The results suggest that consideration should be given to the best process, as has been reported previously for other symptoms way of communicating the need for continuing breast awareness (Leventhal and Prohaska, 1986). Furthermore, it has been argued among women over 70. that older adults, who may have a number of symptoms of other In addition to poor awareness of advancing age as a risk illnesses, should not be expected to seek help for symptoms that factor, older women demonstrated poorer knowledge of risk are not causing them pain or that have little effect on their func- factors in general. This lower level of knowledge was also appar- tioning (Ford and Taylor, 1985). The misattribution and limited ent among women in SES groups III and IV. Surveys in the USA handicap associated with early breast cancer symptoms may contri- and Australia have demonstrated that older women, particularly bute to the delay observed among this age cohort. Therefore older those classified as lower SES, have poorer knowledge of key risk women, in particular, may require further information regarding factors for various cancers (Paul et al, 1999; Breslow et al, 1997). the potential seriousness of breast changes and recommendation Additionally, professional women in the present study perceived for action if they identify such symptoms. themselves to be at reduced risk in comparison to the rest of the female population. However, there is evidence to suggest that Perceptions of treatment and consequences this group may be at increased risk of breast cancer due to a combination of lifestyle factors (Wagener and Schatzkin, 1994). The majority of participants reported that five-year survival was The results of the present study suggest therefore, that informa- a common event, which reflects the improvements in five-year tion regarding risk factors and personal risk should also be survival that have recently been reported (Welch et al, 2000). targeted across SES groups. The majority of respondents, however, reported negative percep- One risk factor that the majority of women recalled was a family tions regarding the length of treatment and the accompanying history of the disease, and this finding is in agreement with side effects. It is probable that their perceptions related to surgi- previous research (Paul et al, 1999). Although women with a strong cal and chemotherapeutic treatment modalities, as these were the family history of breast cancer have a higher risk, a larger percen- methods most frequently mentioned. This emphasis on surgery tage of cases occur in women without a positive family history has been reported previously (Roberts et al, 1984). Hormone (McPherson et al, 2000). This emphasis on family history as a risk therapy was cited by only 5% of respondents, yet this is one factor for breast cancer could potentially lead to a state of compla- of the most common post-operative treatments prescribed for cency among women for whom there is no known family history. older women (Bellet et al, 1995). Older women were more likely It was outside the scope of the present study to examine this to perceive that treatments would work better in younger hypothesis, however, previous research has demonstrated that patients. However, there is no evidence of this and it is recom- women with a family history may overestimate their risk of devel- mended that older women be treated with a similar protocol to oping disease (Evans et al, 1993; Neise et al, 2001). Furthermore, younger patients (Dixon et al, 1994). Older patients may be increased personal risk perception may have a negative effect on excluded from treatment on the grounds of co-morbidity or participation in breast screening (Neise et al, 2001), suggesting that functional disability, furthermore, there may also be problems consideration should be given to the way that information is with treatment due to difficulties accessing transport and poor presented even to women at increased risk. compliance (Bellet et al, 1995). It is these factors that may influ- ence perceptions of the efficacy of treatment among older women. The older group were also more likely to report that Knowledge of breast cancer symptoms breast cancer would result in disfigurement, which may reflect The majority of the women surveyed recognised a painless breast this cohort’s experience of peers who may have been treated at lump as a symptom of breast cancer. In line with previous findings a time when methods were less effective and associated with (Facione, 1993), less than half the sample recognised dimpling of poor aesthetic outcomes. Further research would be required to the breast skin, nipple retraction or nipple eczema as symptoms confirm the reasons why older women may hold more negative of breast cancer. All of these conditions, however, are considered perceptions of the outcomes associated with breast cancer. to warrant hospital referral in a significant proportion of women Women generally reported positive beliefs about breast cancer (Dixon and Mansel, 1994; Fentiman and Hamed, 2001). These outcomes, however there were aspects of symptomatology and risk findings confirm previous qualitative research with women with that were poorly understood. This poor level of knowledge could breast cancer, which has demonstrated that non-lump breast symp- potentially contribute to delay in seeking medical help. This is toms are less likely to be attributed to breast cancer (Burgess et al, especially true for older women, who have a poor awareness both 1998, 2001). The results are important, as there is moderate of the risk factors and of the range of symptoms associated with ã 2002 Cancer Research UK British Journal of Cancer (2002) 86(9), 1373 – 1378 Clinical Clinical Knowledge and beliefs about breast cancer EA Grunfeld et al breast cancer. This poor level of knowledge is of particular concern, of women who have recently sought medical help for breast cancer given the increased risk of developing breast cancer with advancing symptoms, with the aim of developing a health promotion inter- age, and may partly explain the increased delay behaviour observed vention. among older women. However, further research is necessary to confirm this. The current study forms part of a larger programme of research examining delay behaviour for breast cancer. 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Women's knowledge and beliefs regarding breast cancer

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Publisher
Springer Journals
Copyright
Copyright © 2002 by The Author(s)
Subject
Biomedicine; Biomedicine, general; Cancer Research; Epidemiology; Molecular Medicine; Oncology; Drug Resistance
ISSN
0007-0920
eISSN
1532-1827
DOI
10.1038/sj.bjc.6600260
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Abstract

British Journal of Cancer (2002) 86, 1373 – 1378 ã 2002 Cancer Research UK All rights reserved 0007 – 0920/02 $25.00 www.bjcancer.com ,1 2 2 2 EA Grunfeld* , AJ Ramirez , MS Hunter and MA Richards 1 2 Psychology Unit, Guy’s, King’s and St Thomas’ Medical School, Guy’s Campus, London SE1 9RT, UK ; Section of Liaison Psychiatry and ICRF Psychosocial Oncology Group, Guy’s, King’s and St Thomas’ Medical School, St Thomas’ Hospital, London SE1 7EH, UK Approximately 20 – 30% of women delay for 12 weeks or more from self-discovery of a breast symptom to presentation to a health care provider, and such delay intervals are associated with poorer survival. Understanding the factors that influence patient delay is important for the development of an effective, targeted health intervention programme to shorten patient delay. The aim of the study was to elicit knowledge and beliefs about breast cancer among a sample of the general female population, and examine age and socio-economic variations in responses. Participants were randomly selected through the Postal Address File, and data were collected through the Office of National Statistics. Geographically distributed throughout the UK, 996 women participated in a short structured interview to elicit their knowledge of breast cancer risk, breast cancer symptoms, and their perceptions of the management and outcomes associated with breast cancer. Women had limited knowledge of their relative risk of developing breast cancer, of associated risk factors and of the diversity of potential breast cancer-related symptoms. Older women were particularly poor at identifying symptoms of breast cancer, risk factors associated with breast cancer and their personal risk of developing the disease. Poorer knowledge of symptoms and risks among older women may help to explain the strong association between older age and delay in help-seeking. If these findings are confirmed they suggest that any intervention programme should target older women in particular, given that advancing age is a risk factor for both developing breast cancer and for subsequent delayed presentation. British Journal of Cancer (2002) 86, 1373 – 1378. DOI: 10.1038/sj/bjc/6600260 www.bjcancer.com ã 2002 Cancer Research UK Keywords: breast cancer ; symptoms; risk factors; age Delayed presentation of symptomatic breast cancer of three months routine breast screening to women up to the age of 70, and the or more is associated with lower survival rates (Richards et al, procedure will be available on request to women over 70 1999a). While some of this delay is health-provider related, an esti- (Department of Health, 2000b). It has been estimated that an mated 20 – 30% of women wait at least three months before effective screening programme may reduce mortality in the seeking medical help for breast symptoms (Richards et al, screening age group by up to 25% (Blamey et al, 2000). 1999b). A recent fall in deaths from breast cancer has been However women still need to be ‘breast aware’ and to accurately reported due to improved survival from a combination of earlier identify breast symptoms in order to receive treatment as quickly diagnosis, breast screening and improvement in treatment methods as possible (as symptoms may develop between screening (Richards et al, 2000; Peto et al, 2000). The relative contribution of appointments). Furthermore, approximately 44% of breast cancer these factors remains to be clarified. In the meantime, breast cancer cases occur in women within the screening age range; 21% of continues to represent a major public health problem, and further cases occur in women under the age of 50 and a further 35% gains in survival might be achieved by encouraging women to seek of cases occur in women aged over 70 years (Office for National help more promptly. Understanding the factors that influence Statistics, 2000). Therefore, women outside of the routine screen- patient delay is a prerequisite for the development of strategies ing age group will still need to be informed of the risks and to shorten delays. Strong evidence suggests that older women are symptoms of breast cancer. more likely to delay their presentation with breast cancer, although Women’s knowledge of breast cancer risk factors and of survival the strength of evidence for other risk factors for delay is inade- have been studied in Scottish, American and Australian popula- quate to inform any intervention (Ramirez et al, 1999). Such tions (Roberts et al, 1984; Breslow et al, 1997; Paul et al, 1999). factors are likely to relate to women’s knowledge and beliefs about No studies, however, have employed a UK national perspective breast cancer and its management. to examine women’s knowledge of the risks associated with breast The NHS Breast Screening Programme aims to invite all cancer and their perceptions of management and outcomes asso- women aged 50 – 64 for mammography screening, and the ciated with the disease. Furthermore, there are currently no large uptake of invitations for screening is high (Department of sample studies examining women’s knowledge of the range of Health, 2000a). The Department of Health now plans to extend breast symptoms. Representative and up-to-date data are essential to target educational resources to the women most at need, across a broad age and socio-economic status (SES) range. The aims of *Correspondence: EA Grunfeld, Unit of Psychology, 5th Floor Thomas Guy the present study were to (1) develop this knowledge base through House, Guy’s, King’s and St Thomas’ Medical School, Guy’s Campus, the examination of women’s interpretations of potential symptoms London SE1 9RT, UK; E-mail: [email protected] of breast cancer, their beliefs about of the risks and consequences Received 11 September 2001; revised 15 February 2002; accepted 25 of breast cancer and, (2) examine these variables in relation to February 2002 age and SES. Clinical Clinical Knowledge and beliefs about breast cancer EA Grunfeld et al Table 1 The age, socio-economic status (SES) and geographical distri- MATERIALS AND METHODS butions of the sample (n=996) Sampling and data collection were conducted by the Office of Percentage National Statistics (ONS) as a module of their Omnibus survey. Group Count of sample Data collection took place during January and February 2000. Three thousand addresses were selected from the Postal Address Socio-economic classification File (PAF) and a letter sent to each household outlining the I/II Professional & Intermediate 270 27 survey. Trained interviewers visited each address and at least IIIN Skilled non manual 306 31 IIM Skilled manual 101 10 three calls were made, at different times of the day and week. IV Partly skilled 193 19 The interview schedule was specifically designed for the study, V Unskilled/never worked 126 13 and pilot testing was conducted to ensure the survey was Age group comprehensible to the target group. The questions examined 16 – 24 90 9 four issues: 25 – 34 197 20 35 – 44 159 16 (1) Knowledge of a woman’s lifetime risk of developing breast 45 – 54 137 13 cancer: Participants were first asked a knowledge question 55 – 64 145 15 and were required to choose a woman’s approximate overall 65 – 74 146 15 lifetime risk (approximately 1 in 3, 10, 100, 1000, 10 000) 75 and over 122 12 of developing breast cancer. They were then asked to Geographical region provide a general estimation of their personal risk in The North 279 28 comparison to the general population and were required to Midlands and East Anglia 260 26 state whether they perceived themselves to be more, less, or London 90 9 South East 132 13 as likely to develop breast cancer than the rest of the South West 100 10 female population as a whole. Wales 56 6 (2) Knowledge of the risk factors associated with breast cancer: Scotland 79 8 Participants were shown a list of 10 established or probable risk factors and six non-risk factors (Royak-Schaler et al, 1996). The items in the list were presented in a random order of established and non-risk factors. They were asked to choose those that they believed would increase a woman’s chance of developing breast cancer. The percentage percentages. Chi-square tests were used to analyse the categorical of respondents reporting each factor as a risk factor is and attitudinal responses according to the groups. Multivariate reported. A score was produced of the number of correct analysis of variance was used to examine group differences in risk factors identified by each respondent (range 0 – 10). response to the scale data (total risk score and total symptom (3) Knowledge of breast cancer symptoms: Participants were score). shown a card containing 12 breast changes (eight of which were potential breast cancer symptoms) and asked to RESULTS indicate which they thought could be potential symptoms of breast cancer. (The order of the breast changes was Risk estimation for developing breast cancer randomly assigned.) The percentage of respondents reporting each symptom as a potential symptom of breast cancer is Respondents were overly optimistic regarding a woman’s risk of reported. A score was produced of the number of correct developing breast cancer, with 31% reporting that a woman had potential symptoms identified by each respondent. a 1 in 1000 chance of developing breast cancer, 35% reporting (4) Perceptions of management and outcomes in breast cancer: a one in 100 risk and 23% correctly indicating a 1 in 10 risk. Participants were asked to identify methods of treatment The majority of the sample (76%) reported that they were just used for breast cancer and the responses were categorised as likely to develop breast cancer as the rest of the female according to themes. Participants rated attitudinal state- population in the UK, while 7% reported a belief that they ments about the efficacy and consequences of breast cancer were at increased risk, and 17% reported that they were less treatment on a four-point scale (strongly agree to strongly likely to develop breast cancer. However, there was a relation- disagree). The lower the score the more the participant ship between age and the perception of risk (w =54.27, df=6, agreed with the statement. P50.001) with 35% of over 65-year-olds and 30% of over 75-years-olds reporting reduced personal risk. There was also a relationship between SES and perception of risk (w =46.11, Participants df=4, P50.001), with 32% of professional and intermediate From the original 3000 randomly chosen addresses there were 1830 (non-manual, non-managerial occupation) women reporting respondents (a response rate of 67%). Nine hundred and ninety-six reduced risk compared to 10 – 15% of partly skilled and of these respondents were female (mean age 47 years, range 16 – unskilled women. The explanations for reduced risk (in response 96) and completed the breast cancer module of the survey. The to an open-ended question) provided by the women included demographic groupings of the sample can be found in Table 1. absent family history (47%), lifestyle factors, such as following Information regarding non-responders is not available due to the a healthy diet and exercise plan (12%) and not smoking nature of the data collection, however, the age, SES and geographi- (5%). Approximately 25% of the women reporting a belief that cal distributions of the data are representative of the UK they were at reduced risk believed that they were too old to population. develop breast cancer; the mean age of this sub-sample was 76 years (range 63 – 91). These participants provided explana- tions such as: ‘I think if I was going to develop it I would Statistical analysis have by now’, ‘At my age I think the danger has passed’, The data were analysed according to the age and SES groups ‘[Because] they stop mammograms at 65’ and ‘I think older shown in Table 1. Response frequencies are summarised as people are less likely to have breast cancer problems’. British Journal of Cancer (2002) 86(9), 1373 – 1378 ã 2002 Cancer Research UK No/100 000 women Knowledge and beliefs about breast cancer EA Grunfeld et al dimpling of the breast skin and nipple inversion as signs of Risk factors for breast cancer breast cancer. The oldest age cohort identified fewer types of A family history of breast cancer and a personal history of breast symptoms of breast cancer than women aged between 25 and cancer were the most frequently cited risk factors, whereas less 74 (F(6, 919)=10.64 P50.001; Table 4). Women who were than one third recognised the role of advancing age (Table 2). unskilled or had never worked identified significantly fewer Table 2 shows the number of correct risk factors identified symptoms than the other socio-economic groups (F(4, 1069)= according to age group. Women over 75 correctly identified 10.43, P50.001; Table 4). fewer risk factors than women aged under 65 (F(6, 903)=13.22, P50.001). Professional women and women classified as inter- Management of breast cancer mediate (SES groups I and II) had a greater knowledge of risk factors than women who were partly skilled, skilled manual The most frequently cited treatment method for breast cancer was workers, or who had never worked (F(4, 1070)=17.50, surgery (87%), followed by chemotherapy (66%) and radiotherapy P50.001). Women aged 35 – 59 were perceived, by the sample, (49%). Only 5% of the sample spontaneously mentioned hormone to be most at risk of developing breast cancer, and those aged therapy as a treatment method. Tables 5 and 6 show the responses 75 – 90 years to be at least risk (Figure 1). to the attitudinal questions of the management of breast cancer as a function of age and SES. Eighty per cent of the women believed treatment for breast cancer to be a long process that would make a Symptoms of breast cancer patient very ill. Approximately 50% of participants thought that A painless breast lump, lump under the armpit, and nipple there were long waiting lists for tests for breast cancer, with those discharge were the most frequently identified symptoms of breast over 75 years old more likely to report this belief than participants cancer (Table 3). Less than half of the sample identified under 45 (w =13.03, df=6, P50.05). Table 2 The relative risk associated with various risk factors and the Table 3 The percentage of respondents identifying each potential percentage of respondents identifying each potential risk factor from a symptom of breast cancer (*) from a presented list (participants could presented list (participants could choose more than one) choose more than one) Percentage of Percentage Risk factor Relative risk* respondents Breast symptom of respondents Family history of breast cancer* 4290 Painless breast lump* 85 Previous breast cancer* 4471 Lump under armpit* 80 Smoking 60 Nipple discharge/bleeding* 70 Oral contraceptives* 2 35 Change in shape of breast* 64 Older age* 410 30 Lumpiness in breast* 60 Bumping or bruising breast 28 Pain in breast region* 50 High fat diet* 1.5 22 Changes in size of breast 40 Stress 22 Dimpling of breast skin* 39 Excess weight* 1 – 2 12 Breast swelling 39 First child at late age* 3 10 Inversion/pulling in of nipple* 38 Early onset of menses* 3 8 Bruising of breast 17 Alcohol* 1.3 8 Scaling/dry skin in nipple region 15 Late menopause* 2 7 Pollution 7 Large breasts 3 *Established or probable risk factors and relative risk data adapted from McPherson et al (2000). Table 4 The mean number of correct risk factors for breast cancer (range 0 – 10) and the number of correct symptoms of breast cancer (range 0 – 8) identified as a function of age and SES 80 200 Number of Number of Group correct risk factors correct symptoms 60 150 Socioeconomic group I/II Professional & Intermediate 3.2 (1.3) 5.9 (2.8) IIIN Skilled non manual 2.4 (1.1) 5.5 (2.2) 40 100 IIM Skilled manual 2.5 (1.3) 5.2 (2.2) IV Partly skilled 2.3 (1.4) 5.5 (2.0) 20 50 V Unskilled/Never worked 1.9 (1.1) 4.4 (1.8) Age group 0 0 16 – 24 2.4 (1.0) 4.6 (1.9) 20 –34 35–59 60 –74 74–90 25 – 34 2.7 (1.2) 5.8 (2.1) Age 35 – 44 2.8 (1.3) 5.6 (2.4) 45 – 54 2.7 (1.3) 6.0 (2.1) Figure 1 The percentage of respondents perceiving each of the age 55 – 64 2.6 (1.3) 5.8 (2.4) categories shown to be most at risk of developing breast cancer (bars). 65 – 74 2.0 (1.2) 5.3 (2.2) The dotted line (corresponding to the right hand axis) represents an 75 and over 1.5 (1.1) 4.0 (2.4) approximation of the incidence of breast cancer according to each age category (adapted from McPherson et al, 2000). (1 SD is shown in parentheses). ã 2002 Cancer Research UK British Journal of Cancer (2002) 86(9), 1373 – 1378 Percentage of respondents Clinical Clinical Knowledge and beliefs about breast cancer EA Grunfeld et al Table 5 Proportion of participants agreeing or agreeing strongly with statements regarding the management and outcomes of breast cancer (as a function of age) Age group All Question participants 16 – 24 25 – 34 35 – 44 45 – 54 55 – 64 65 – 74 75+ w df P Management of breast cancer % There are long waiting lists for tests for breast cancer 51 47 42 43 46 46 49 62 13.03 6 50.05 Tests for breast cancer are embarassing 17 21 19 15 15 14 16 13 7.81 6 0.252 Treatments for breast cancer work better in younger people 35 32 27 30 29 35 43 61 10.01 6 0.092 Treatment for breast cancer makes the patient very ill 70 74 63 59 67 73 76 68 6.72 6 0.284 The treatment for breast cancer is a long process 80 88 68 66 81 76 84 88 18.76 6 50.01 Treatment for breast cancer will help regardless of how advanced the disease is 50 50 46 40 45 53 65 72 29.43 6 50.01 Outcomes for breast cancer Breast cancer always results in some kind of disfigurement 32 31 23 16 34 37 44 52 31.55 6 50.001 Long term survival (more than five years) is rare 18 21 14 15 22 14 23 23 9.44 6 0.178 A woman who has had treatment for breast cancer can enjoy a good quality of life 88 92 95 92 90 92 90 84 16.75 6 50.05 Table 6 Proportion of participants agreeing or agreeing strongly with statements regarding the management and outcomes of breast cancer (as a function of socio-economic status (SES)) SES group Question I/II IIIN IIM IV V w df P Management of breast cancer % There are long waiting lists for tests for breast cancer 41 47 54 52 63 24.12 4 50.05 Tests for breast cancer are embarrassing 14 13 14 32 26 36.32 4 50.001 Treatments for breast cancer work better in younger people 34 32 33 38 43.4 6.24 4 0.903 Treatment for breast cancer makes the patient very ill 61 71 77 75 70 19.37 4 0.145 The treatment for breast cancer is a long process 76 79 82 79 83 8.49 4 0.745 Treatment for breast cancer will help regardless of how advanced the disease is 42 44 63 51 67 33.48 4 50.001 Outcomes for breast cancer Breast cancer always results in some kind of disfigurement 21 28 43 37 48 53.29 4 50.001 Long term survival (more than five years) is rare 11 18 21 22 26 25.30 4 50.01 A woman who has had treatment for breast cancer can enjoy a good quality of life 98 95 93 91 95 14.58 4 0.117 Outcomes of breast cancer Risk perception Tables 5 and 6 show the responses to the attitudinal statements Respondents were overly optimistic regarding a woman’s risk of regarding outcomes associated with breast cancer, as a function developing breast cancer with less than one quarter correctly indi- of age and SES. Approximately, 80% of participants believed cating a 1 in 10 risk. Although health education campaigns have long-term survival (greater than five years) to be common, and included information about the lifetime risk of breast cancer, it 70% did not believe the disease necessarily resulted in disfigure- is apparent that the majority of British women have either not ment. However, women aged over 75 were more likely to believe accessed this information or have not interpreted it correctly. that disfigurement was a frequent outcome of breast cancer However, the format of these educational campaigns may also (w =31.55, df=6, P50.001), as were manual and unskilled workers account for the poor awareness observed among these women. It (w =53.29, df=4, P50.001). Professional and intermediate women is known that leaflets produce only limited and short-lived changes (SES groups I and II) were more likely to believe that five-year in knowledge (Gatherer et al, 1979). Furthermore, many health survival following breast cancer was achievable (w =25.30, df=4, professionals believe leaflets are often not read by the target audi- P50.01). ence (Murphy and Smith, 1993). Therefore, any future campaign will need to make explicit the significant risk that breast cancer poses for women and combine the more traditional leaflet DISCUSSION approach to health education with other educational mediums The results of the survey demonstrated that although British (i.e. television and radio broadcasts) and individually tailored women have good understanding of some aspects of breast advice from health professionals. cancer there is poor awareness of other important issues, includ- The findings of this study suggest that the importance of advan- ing knowledge of non-lump breast symptoms and lifetime risk cing age as a risk factor for breast cancer is poorly understood, not of developing the disease. The survey also highlighted important only by older women in this country, but by the general female UK age and SES variations in knowledge of risk and of the range of population as a whole. This is in line with findings from USA and potential symptoms of breast cancer. These variations may help Australian populations (Breslow et al, 1997; Dolan et al, 1997; Paul to explain some of the differences in help-seeking behaviour et al, 1999). In the current sample, women aged 35 – 59 years were observed among women with breast cancer symptoms in the perceived to be most at risk of developing breast cancer. Breast UK. cancer is the single commonest cause of death among women aged British Journal of Cancer (2002) 86(9), 1373 – 1378 ã 2002 Cancer Research UK Knowledge and beliefs about breast cancer EA Grunfeld et al 40 – 50, however, in absolute terms advancing age is the greatest evidence to suggest that one of the major determinants of delay risk factor for developing breast cancer (McPherson et al, 2000); behaviour among patients is the discovery of a breast symptom approximately one-third of all breast cancers occur in women aged other than a lump (Ramirez et al, 1999). In line with previous over 70 (Office for National Statistics, 2000). work (Facione and Dodd, 1995) our results demonstrate that In our sample, a significant proportion of women aged over 65 although a breast lump is equated with a potential cancer, other perceived themselves to be at less personal risk than the general potentially serious symptoms may be misinterpreted. Detailed population, and in a significant proportion of these the explanation analysis of women’s interpretation of individual symptoms is for reduced risk related to their advanced age. In the UK, women necessary in order to determine women’s perceptions and attribu- aged 50 – 64 are routinely invited for breast cancer screening tions of breast symptoms. The summary message is that women (Department of Health, 2000a) and this may contribute to the would benefit from clear information about the variety of symp- increased risk attributed to this age group. Although not directly toms that may be indicative of a potential cancer. However, any examined in the present study, the results suggest that by stopping intervention to improve knowledge of symptoms should also aim screening at 64 a message may inadvertently be sent to women that to limit anxiety and to ensure that medical facilities are not over- they are no longer at risk, in fact one respondent explicitly stated loaded by help-seeking for benign symptoms, particularly by low this belief. This is a concern that has been expressed previously risk women. (Age Concern, 1996). The Department of Health plans to extend Knowledge of symptoms was poorer among older women and routine screening to all women up to the age of 70 by 2004 women who had never been employed. Older women were less (Department of Health, 2000b), as there is evidence that screening likely to perceive nipple eczema, changes in the shape or size of is acceptable in the age group 65 – 70 and is likely to save lives. the breast, and nipple retraction as symptoms of breast cancer. It Screening will also be available on request to women over 70. is possible that older women attribute such symptoms to the ageing The results suggest that consideration should be given to the best process, as has been reported previously for other symptoms way of communicating the need for continuing breast awareness (Leventhal and Prohaska, 1986). Furthermore, it has been argued among women over 70. that older adults, who may have a number of symptoms of other In addition to poor awareness of advancing age as a risk illnesses, should not be expected to seek help for symptoms that factor, older women demonstrated poorer knowledge of risk are not causing them pain or that have little effect on their func- factors in general. This lower level of knowledge was also appar- tioning (Ford and Taylor, 1985). The misattribution and limited ent among women in SES groups III and IV. Surveys in the USA handicap associated with early breast cancer symptoms may contri- and Australia have demonstrated that older women, particularly bute to the delay observed among this age cohort. Therefore older those classified as lower SES, have poorer knowledge of key risk women, in particular, may require further information regarding factors for various cancers (Paul et al, 1999; Breslow et al, 1997). the potential seriousness of breast changes and recommendation Additionally, professional women in the present study perceived for action if they identify such symptoms. themselves to be at reduced risk in comparison to the rest of the female population. However, there is evidence to suggest that Perceptions of treatment and consequences this group may be at increased risk of breast cancer due to a combination of lifestyle factors (Wagener and Schatzkin, 1994). The majority of participants reported that five-year survival was The results of the present study suggest therefore, that informa- a common event, which reflects the improvements in five-year tion regarding risk factors and personal risk should also be survival that have recently been reported (Welch et al, 2000). targeted across SES groups. The majority of respondents, however, reported negative percep- One risk factor that the majority of women recalled was a family tions regarding the length of treatment and the accompanying history of the disease, and this finding is in agreement with side effects. It is probable that their perceptions related to surgi- previous research (Paul et al, 1999). Although women with a strong cal and chemotherapeutic treatment modalities, as these were the family history of breast cancer have a higher risk, a larger percen- methods most frequently mentioned. This emphasis on surgery tage of cases occur in women without a positive family history has been reported previously (Roberts et al, 1984). Hormone (McPherson et al, 2000). This emphasis on family history as a risk therapy was cited by only 5% of respondents, yet this is one factor for breast cancer could potentially lead to a state of compla- of the most common post-operative treatments prescribed for cency among women for whom there is no known family history. older women (Bellet et al, 1995). Older women were more likely It was outside the scope of the present study to examine this to perceive that treatments would work better in younger hypothesis, however, previous research has demonstrated that patients. However, there is no evidence of this and it is recom- women with a family history may overestimate their risk of devel- mended that older women be treated with a similar protocol to oping disease (Evans et al, 1993; Neise et al, 2001). Furthermore, younger patients (Dixon et al, 1994). Older patients may be increased personal risk perception may have a negative effect on excluded from treatment on the grounds of co-morbidity or participation in breast screening (Neise et al, 2001), suggesting that functional disability, furthermore, there may also be problems consideration should be given to the way that information is with treatment due to difficulties accessing transport and poor presented even to women at increased risk. compliance (Bellet et al, 1995). It is these factors that may influ- ence perceptions of the efficacy of treatment among older women. The older group were also more likely to report that Knowledge of breast cancer symptoms breast cancer would result in disfigurement, which may reflect The majority of the women surveyed recognised a painless breast this cohort’s experience of peers who may have been treated at lump as a symptom of breast cancer. In line with previous findings a time when methods were less effective and associated with (Facione, 1993), less than half the sample recognised dimpling of poor aesthetic outcomes. Further research would be required to the breast skin, nipple retraction or nipple eczema as symptoms confirm the reasons why older women may hold more negative of breast cancer. All of these conditions, however, are considered perceptions of the outcomes associated with breast cancer. to warrant hospital referral in a significant proportion of women Women generally reported positive beliefs about breast cancer (Dixon and Mansel, 1994; Fentiman and Hamed, 2001). These outcomes, however there were aspects of symptomatology and risk findings confirm previous qualitative research with women with that were poorly understood. This poor level of knowledge could breast cancer, which has demonstrated that non-lump breast symp- potentially contribute to delay in seeking medical help. This is toms are less likely to be attributed to breast cancer (Burgess et al, especially true for older women, who have a poor awareness both 1998, 2001). The results are important, as there is moderate of the risk factors and of the range of symptoms associated with ã 2002 Cancer Research UK British Journal of Cancer (2002) 86(9), 1373 – 1378 Clinical Clinical Knowledge and beliefs about breast cancer EA Grunfeld et al breast cancer. This poor level of knowledge is of particular concern, of women who have recently sought medical help for breast cancer given the increased risk of developing breast cancer with advancing symptoms, with the aim of developing a health promotion inter- age, and may partly explain the increased delay behaviour observed vention. among older women. However, further research is necessary to confirm this. The current study forms part of a larger programme of research examining delay behaviour for breast cancer. 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British Journal of Cancer – Springer Journals

Published: May 7, 2002

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