br DISCUSSION br To the authors knowledge this was
To the authors’ knowledge, this was the first population-based study in the U.S. to examine associations between recognition of potential cancer symptoms and anticipated
Table 1. Weighted Bivariate Correlates of Recognizing That a Specific Symptom Might Indicate Cancer
Note: Totals vary because of missing data. Design-adjusted F statistics were used to assess the association between care seeking for a specific symp-tom and correlate for each model. Categories reflect the specific wording of the survey item. All percentages are weighted. Boldface indicates statisti-cal significance (p<0.05).
time to seeking care. Similar to previous studies in other countries,9,10,18 the results of this study indicated that for
some, but not all, symptoms of cancer, lack of symptom recognition was associated with anticipated delay in seek-ing physician-based care. Many other factors could affect symptom recognition and rapid care seeking, including the level of public messaging for different types of cancer and cancer prevention, the impact of the symptom on daily life, or the specificity (or ambiguity) of the symptom. For example, for breast changes, there has been substan-tial public health messaging around potential warning signs and screening. Therefore, it was not surprising to see higher rates of knowledge for this symptom and lower anticipated delay.
Although rates of symptom recognition were rela-tively high across the Calcein-AM and similar to the UK,18 prevalence of anticipated delays in seeking care varied greatly depending on the symptom. Anticipated delays for rectal bleeding were the lowest across
symptoms, which partly may be driven by the functional impact on daily life, whereas delays in care seeking for persistent cough may be shaped more by the ambiguous, or seemingly trivial,23 nature of the warning sign. Coughing can indicate other health problems, such as the common cold, and may therefore not be perceived as a health issue in need of urgent physician care but rather amenable to self-management.24 In addition, although routine cancer screening for a variety of cancers is rec-ommended in the U.S.,25 many people continue to be underscreened, especially in lung cancer for which screening uptake is estimated to be <5% across the eligi-ble population.26 Regardless of the status of these other, variably influential factors, symptom identification and prompt care seeking will continue to be important. Cam-paigns and interventions to increase public awareness of symptoms and reduce barriers to rapid care are needed. Finally, similar to some studies outside the U.S.,8,27 this study found that anticipated delay was associated with
e5 Table 2. Weighted Bivariate Correlates of Anticipated Delay to Care Seeking If Experiencing Specific Symptom
Persistent Rectal Breast changes Mole Variable cough, n (%) bleeding, n (%) (females only), n (%) changes, n (%)
Note: Totals vary because of missing data. Design-adjusted F statistics were used to assess the association between care seeking for a specific symp-tom and correlate for each model. Categories reflect the specific wording of the survey item. All percentages are weighted. See Table 1 for the total sample. Boldface indicates statistical significance (p<0.05).
higher educational attainment and nonminority groups. The counterintuitive association between higher educa-tion and delay might reflect higher levels of perceived ability to interpret symptoms and seek information online before seeking medical care.28 With regard to race, other studies have shown that although minority populations might report lower levels of anticipated delay,16 this association does not necessarily remain when actual time to care is examined. Actual time to care is influenced by a range of external barriers, such as health insurance, or other cancer-related factors, such as cancer fatalism or illness perception, that may impact care seeking when actual symptoms occur.29,30
Although most people recognized mole changes as a warning sign of cancer, lack of recognition was neverthe-less associated with greater delay in care seeking, which indicates that additional public health campaigns may
be needed to further increase public knowledge. This finding aligns with studies showing skin cancer knowl-edge to be associated with greater sun protection behav-ior.31 However, even among those who did recognize the importance of mole changes, close to one third antici-pated delaying care seeking. This low level of concern about the symptom suggests that additional factors may also be important influencers of care seeking for mole changes. For instance, people may know that change in the appearance of a mole is a potential sign of cancer but may not perceive the sign as serious or needing immedi-ate attention.32,33 Moreover, structural factors may pro-mote delay, such as access to a dermatologist, which may be an out-of-pocket expense, particularly for patients without access to health insurance. Geographic density of dermatologists varies widely,34 meaning access may be more limited for those not living near many, or