Aetiology

In a review of the preventable causes of cancer, behavioural factors were implicated in the majority of cancers (Doll & Peto, 1981): smoking (involved in 30% of cancers); diet (35%); reproductive and sexual behaviour (7%); and alcohol use (3%). Thirty-five per cent of the 7 million global deaths from cancer in 2001 have been attributed to nine behavioural or environmental risk factors. The lead risk factors were smoking (596 000 deaths), alcohol use (88 000), overweight and obesity (69 000), low fruit and vegetable intake (64 000) and physical inactivity (51 000 deaths) (Danaei et al., 2005).

Communication about cancer

Cancer is associated with many social and clinical taboos. In popular language and in medical settings euphemisms such as ‘growth’, ‘tumour’, ‘lump’, ‘shadow’ and ‘the big C’ are used to avoid the word ‘cancer’ (see pp. 98–99). These communications may arise from the fears and misconceptions surrounding cancer, but in turn they also give rise to such fears. Thus patients with benign disease sometimes suspect that they have malignant disease but that their doctor is withholding the information. On the other hand, such language may lead patients who do have a malignant cancer to misunderstand the full implications of their condition.

Research shows that members of the general public are much more likely to say that they want to be informed of a terminal diagnosis than doctors estimated they would (Jenkins et al., 2001) and want to be told personally, rather than have other people (such as relatives) told first.

Health care staff sometimes worry that giving patients with cancer information about their condition or treatment may increase anxiety. However, a systematic review of interventions to improve information given to advanced cancer patients found positive results (e.g. improved satisfaction with communication) in six of eight trials. The other two trials showed no difference between groups (Gaston & Mitchell, 2005).

Communications about cancer are fraught with problems due to negative attitudes of patients, their families, health professionals (including doctors and nurses), other hospital personnel and the wider lay community. Doctors rate the quality of life of cancer patients significantly worse than the patients’ own ratings.

Providing patients with information enables them to decide whether or not they would like to participate in decision-making (rather than leave the decision-making to medical professionals) and, if they wish to be involved in decision-making, helps them to arrive at the optimal decision for their personal situation.

Delay

People may not seek medical help when they experience potential cancer symptoms and may not choose to participate in cancer screening programmes. Screening for the detection of precancerous cells or for the early diagnosis of treatable cancers has often had poor uptake rates (see pp. 68–60).

Patient delay in seeking help when a symptom is noticed has four components: (1) appraisal delay (deciding the symptom indicates an illness); (2) illness delay (deciding that the illness merits a consultation with a doctor); (3) behavioural delay (making the appointment); and (4) scheduling delay (the time between making the appointment and actually seeing the doctor) (Andersen et al., 1995; Fig. 1

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