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Module 2 - Population awareness and beliefs about cancer

Module 2

Module 2 is exploring the attitudes and beliefs the general public have towards cancer. Populations with lower cancer awareness and more negative beliefs about cancer outcomes may be more likely to delay seeing their doctor about any suspicious symptoms they may have. This in turn may lead to more advanced stage at cancer diagnosis and poorer survival.

Professors Amanda Ramirez (King’s College London) and Jane Wardle (University College London) co-chair and lead the work in this module. They work in close collaboration with scientists from all ICBP partner jurisdictions, forming an international research team.
Module 2 has recently provided the first robust international comparison of population awareness and beliefs about cancer. It tested the hypothesis that differences in the levels of cancer awareness and beliefs contribute to observed international differences in cancer survival. These results could potentially be used to identify target for interventions to address low cancer awareness and negative beliefs. Such interventions could include cancer awareness campaigns.

The international Module 2 team has developed the Awareness and Beliefs about Cancer (ABC) survey instrument to assess the general public’s attitudes and beliefs about cancer.

The ABC is an international survey instrument which includes questions designed to find out more about:

  • what individual people know about the signs and symptoms of cancer
  • what their beliefs towards cancer treatment and outcomes are
  • what might put people off from seeing their doctor
  • The questionnaire was first developed and tested in UK English. This process included in-depth interviews with a sample from the general public to probe whether the questions were easily understood and clear. Following the testing process in the UK, the team then developed a different version of the ABC for each ICBP partner jurisdiction. Each version has the same core questions but these have been translated, adapted and harmonised to make sure that they are relevant locally
  • A paper written by the Module 2 central team, describing the development and testing of the ABC measure, was published in the BMJ Open. You can find more information about this paper and access it free of charge here

Data collection

The international market research provider Ipsos MORI conducted computer-assisted telephone interviews using the ABC instruments in each ICBP partner jurisdiction. They surveyed over 19,000 men and women aged 50 or over in Australia (New South Wales and Victoria), Canada, England, Northern Ireland, Denmark, Norway, Sweden and Wales.

This fieldwork took place over a five month period from May – September 2011. In addition, some jurisdictions also surveyed younger people (men and women aged 35-43) or asked questions from three optional survey elements developed by the international team. These optional modules focused on (1) awareness of cancer risk factors (2) awareness and beliefs about cancer screening (3) awareness and beliefs about ovarian cancer. Northern Ireland participated in the additional risk factor awareness module along with Denmark, Norway and Sweden.

Progress to July 2015

Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? British Journal of Cancer advance online publication 31 January 2013; doi: 10.1038/bjc.2012.542

This study looked at whether differences between countries in what people know about cancer and what people believe about cancer outcomes could help explain differences in their cancer survival rates. The study asked people about things like what increases the risk of cancer, whether a symptom could be caused by cancer, how likely they are to visit the doctor with a symptom and what might put them off and how they feel about the chances of surviving cancer. Countries with populations that have lower cancer awareness and more negative beliefs about cancer outcomes may be more likely to delay seeing their doctor about any symptoms they may have. This may lead to more cancers being diagnosed at a later stage and, in turn, poorer survival.
ICBP researchers developed and used a new research tool, the Awareness and Beliefs about Cancer (ABC) measure, to study people’s awareness and beliefs. Nearly 20,000 men and women aged 50 and older were interviewed in Australia, Canada, Denmark, Norway, Sweden and the UK – resulting in the strongest international comparison of awareness and beliefs about cancer in the general population yet.

The study suggested that international differences in cancer survival, as highlighted in previous ICBP research, are not likely to be explained by differences in awareness and beliefs about cancer and cancer outcomes. The results showed that the public awareness of cancer symptoms and beliefs about cancer outcomes was similar internationally. All of the countries reported that around eight out of eleven cancer symptoms were recognised by members of the public. In all of the countries, people had positive beliefs about cancer with around nine out of ten people agreeing that ‘cancer can often be cured’ and seven out of ten disagreeing that ‘a diagnosis of cancer is a death sentence’.

More people in the UK than in other countries said that there were specific reasons they wouldn’t go to their GP, even with a symptom that worried them. People in the UK mentioned that embarrassment and not wanting to waste the doctor’s time would put them off seeing their doctor. Across all countries, the knowledge that the risk of cancer increases with age was low, particularly in the UK. Low one year cancer survival in the UK and Denmark does not seem to be explained by poor awareness and negative beliefs about cancer. This paper calls for continued research into why international cancer survival differences exist.

Quaife SL, Forbes LJ, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer. 2013 Oct 31. doi: 10.1038/bjc.2013.684.

This study investigated the relationship between symptom awareness and anticipated delay as reported by respondents to the ABC survey. Not recognising a symptom as suspicious is a common reason given by cancer patients for delayed help-seeking; but inevitably this is with the benefit of hindsight. This study therefore investigated associations between recognition of warning signs for breast, colorectal and lung cancer and anticipated time to help-seeking for symptoms of each cancer. The researchers used the data collected the data collected for Module 2 on UK adults age >=50 years (N=6965). Time to help-seeking for persistent cough, rectal bleeding and breast changes was categorised as >2 vs <2 weeks. Recognition of persistent cough, unexplained bleeding and unexplained lump as cancer warning signs was assessed (yes/no). Associations between recognition and help-seeking were examined for each symptom taking demographics and perceived ease of health-care access into account. For each symptom, the odds of waiting for >2 weeks were significantly increased in those who did not recognise the related warning sign: breast changes: OR=2.45, 95% CI 1.47-4.08; rectal bleeding: OR=1.77, 1.36-2.30; persistent cough: OR=1.30, 1.17-1.46, independent of demographics and health-care access suggesting that recognition of warning signs was associated with anticipating faster help-seeking for potential symptoms of cancer. Strategies to improve recognition are likely to facilitate earlier diagnosis