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Ukw Pub H. 2024; 24(10): 1-18. Published Online 2024 October 18
UkwSciID: USPH5
A SYSTEMATIC REVIEW OF BARRIERS TO EARLY PRESENTATION AND BREAST CANCER DIAGNOSIS IN THE UNITED KINGDOM
Edmund Ikpechi Ukwuru, and Ukwuru Science Study Group
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Ukwuru, E.I. and Ukwuru Science Study Group. (2024). A systematic review of Barriers to early presentation and breast cancer diagnosis in the United Kingdom. Ukwuru Public Health, 24(10): 1-18.
Abstract
Background
Breast cancer is still a disease of concern apparently because of failure to go for early diagnosis. Even in the United Kingdom, there are several cases of late diagnosis due to several factors. This systematic review was conducted to identify the barriers to early presentation and diagnosis of breast cancer in the United Kingdom.
Method
A quantitative systematic review was conducted. A total of seventy-eight studies were identified from three databases; PubMed, SCOPUS, and MEDLINE. The studies were then screened, and nine were included in the final synthesis.
Findings
There were 14,171,123 pooled study participants from the nine studies included in the final review. The findings showed that prevalence of breast cancer is associated with the cancer database because arrival for testing varies. The barriers to early presentation and diagnosis of breast cancer are; lack of knowledge of symptoms of breast cancer, educational status, sociodemographic factors, personal affects/ perceptions, and health related factors. The availability of health infrastructure in the UK in terms of deprivation status showed that majority of breast cancer patients are within the 2nd, 3rd, and 4th index of deprivation.
Conclusion
The study concludes that the lack of knowledge of the symptoms and signs of breast cancer is the main barrier to early presentation and diagnosis and it is strongly decided by educational level and socioeconomic status.
Recommendations
Health education and health promotion are required to facilitate early intervention for diagnosis of breast cancer.
Keywords: Breast cancer, barriers, early presentation, early diagnosis, prevention
Introduction
Sung et al. (2021) confirmed that among all cancers diagnosed among women, breast cancer is the most frequent. Lei et al. (2021a;2021b) stated that breast cancer ranks in fifth place for the most prevalence cause of cancer associated mortality (685,000 deaths in 2.3 million cases as of 2020). It is estimated that by 2070, there would be 4.4 million breast cancer cases if efforts are not committed towards prevention (Soerjomataram and Bray, 2021). In developing countries, breast cancer accounts for 15.4% of cancer associated mortality, out of the 24.5% prevalence of breast cancer recorded (Sung et al., 2021). The World Cancer Report, (2014) noted that breast cancer cases were expected to increase by 70% over a 2-year period; and among black women, evidences have shown that there is high predilection of breast cancer (Vrinten et al., 2016; Marcu et al., 2022).
In light of high prevalence of cancer, the solution is to present for diagnosis early on (Sobri et al., 2021). Findings suggest that curbing breast cancer in its early stages can result in an arrest of progression and lead to improvements in health outcomes (Hutajulu et al., 2022). Despite the positive potentials of early diagnosis, observations from Zhang et al. (2019) and Hutajulu et al. (2022) suggest that sociodemographic factors such as age, marital status, and socioeconomic status impeded early presentation of women for diagnosis. Health status such as type of tumour, history of benign breast diseases, and menopause have negative effects on the likelihood of presenting for diagnosis (Brennan, 2017; Gathani et al., 2021a,b,c). Overall, lack of awareness tends to be a key unifying factor between these social and health states factors. This can be explained using Rosenstock, (1966); Rosenstock, (1974); Janz and Becker, (1984) health belief model and health seeking behaviour as explained by Pushpalata and Chandrika, (2017). According to these models individuals would seek out health services if they are aware of the benefits of the health services.
In this systematic review, we examine the evidence on barriers to early presentation and diagnosis of breast cancer among women in the United Kingdom. We intend to devise findings that can contribute towards addressing a health problem that is responsible for high cases of morbidity, reduced quality of life, and mortality. We hope that our findings can influence willingness to present for early diagnosis.
Method
Search Strategy and Sources of Information
Study search lasted for a period of 30 days. We used the PCO/PIO framework (Population, Concept/Interest, Outcome) framework. Hence, the population of interest was women living in the United Kingdom, the concept of interest was breast cancer, while the outcome was barriers to presentation for early diagnosis. We devised keywords from the research question and formulated search strings for the study search in line with the PRISMA flowchart (Figure I).
We searched the PubMed, SCOPUS, EMBASE, and MEDLINE databases to identify studies. We then screened the studies based on their titles and abstracts to remove duplicates and those studies that did not align with the research question. We also used the eligibility criteria that we developed to screen the studies. Those studies that passed the eligibility assessment were then subjected to methodological quality assessment. We applied the CASP tool to evaluate the quality of included studies.
Figure I: PRISMA Flowchart
Figure I: We identified a total of seventy-eight (78) studies from the databases; PubMed (22), SCOPUS (45), and MEDLINE (11). Ten (10) of the studies occurred as duplicates, another forty-six (46) were excluded because their titles and abstract did not align with our research question. The remaining 22 studies were then subjected to eligibility assessment. Thirteen (13) of the 22 studied did not present findings that answered the research question. The remaining 9 studies were included in the final synthesis.
Data Extraction and Data Analysis
Data was extracted from the 9 included studies by using the PCO/PIO framework. The quantitative data was outlined and summarized into charts and tables. Narrative synthesis was used to demonstrate the relationship between the data.
Results
Characteristics of Included Studies
All nine (9) included studies; Al-Ajmi et al (2018); Clift et al (2023); Green et al (2023); Hardy et al (2020); Jani et al (2021); Moriarty et al (2021); Palmieri et al (2022); Sun et al (2020); Taylor et al (2023). Were conducted using quantitative research method. The research strategies varied from survey strategy Clift et al (2023); Green et al (2023); Hardy et al (2020) to archival (retrospective) strategy Al-Ajmi et al (2018); Jani et al (2021); Sun et al (2020); Taylor et al (2023). Moriarty et al (2021) was a randomized controlled trial while Palmieri et al (2022) was a case series study. The study period ranged between 200 0 and 2021. The full description of studies is presented on table I.
Table I: Characteristics and summary of included studies
Table I: The study with the highest population (11,626,969) is Clift et al. (2023) while the study with the lowest population (246) is Moriarty et al. (2021).
The prevalence of breast cancer across the United Kingdom
Evidences from Sun et al. (2020); Palmieri et al. (2022); and Taylor et al. (2023) confirms that they studied participants who were living with breast cancer; the total pooled population between the three studies is over 700,000 participants which is a lot larger than the combined sample sizes from the other 6 studies. This is can be seen in figure II. The differences in prevalence is associated with the databases and sample sizes from which the authors drew their sample population.
Figure II: Prevalence of Breast Cancer in the United Kingdom
Figure II shows a 100% prevalence for Palmieri et al. (2022); Sun et al. (2020); and Taylor et al. (2023); this is because the study population groups that had been diagnosed positive for BC.
Findings from Hardy et al. (2020) indicated that there were more participants between ages 30 to 39 years (75%) who presented with cases of breast cancer than any other age group. A combined prevalence of 70% is obtained for age 60 to 69 years from Sun et al. (2020) and Taylor et al. (2023). The finding implies that across the UK, women who are between ages 30 and 39, and 60 and 69 had the highest prevalence of breast cancer (figure III).
Figure III: Age Prevalence of Breast Cancer
Figure III: The prevalence of breast cancer is presented based on each study
Prevalence of breast cancer within each study can be identified on table II. In addition, other types of prevalence data are captured. For example, Al-Ajmi et al. (2018) showed that post-menopausal prevalence of breast cancer is higher than pre-menopausal prevalence of breast cancer. This is associated with the earlier evidence that suggests, more women between he ages of 60 to 69 years are more likely to present with breast cancer. Findings from Sun et al. (2020) and Taylor et al. (2023) also suggested that women above the age of 50 years account for the high prevalence of breast cancer.
Table II: Prevalence of Breast Cancer in studies across the United Kingdom
Barriers to early presentation and diagnosis of breast cancer among women in the United Kingdom.
Two studies; Moriarty et al. (2021) and Green et al. (2023) contributed to the development of themes pertaining to barriers affecting early presentation for diagnosis of breast cancer. These themes include; lack of awareness of symptoms, educational status, personal feelings/perceptions, Health-related barrier/Delay in Help Seeking, Social and Economic, Knowledge of Symptoms. The associated quantitative percentages are presented alongside the themes on table III. Figure IV also shows the themes and their sub-themes.
Table III: Barriers to early diagnosis of breast Cancer
Figure IV: Summary of Themes describing Barriers to early presentation and diagnosis of breast cancer
The availability of health infrastructure for breast cancer diagnosis across the United Kingdom.
Four of the included studies Al-Ajmi et al. (2018); Sun et al. (2020); Clift et al. (2023); and Taylor et al. (2023) indicated evidence of deprivation that affects availability and access to health care resources (table IV). The issue of proximity to health care resources has implications on health seeking behaviour. The scales used for indicating deprivation varied between studies. For example, Clift et al. (2023) used the Townsend Deprivation mean, while Sun et al. (2023) used the index of multiple deprivation.
Table IV: Health Infrastructure Deprivation
The prevalence of deprivation in line with Sun et al. (2020) and Taylor et al. (2023) is represented using bar charts in figure V. The highest level of deprivation (42%) pooled from both Sun et al. (2020) and Taylor et al. (2023) is at a score of 3(40-59%).
Figure V: Prevalence of Deprivation in the United Kingdom
Discussion
Prevalence of Breast Cancer among women in the United Kingdom
The prevalence of breast cancer in the United Kingdom is high. One of the included studies, Clift et al. (2023) studied analysed data from 11 million individuals and determined a 1.2% prevalence. Large studies such as Taylor et al. (2023) which studied dataset of over five hundred thousand participants was based on a 100% prevalence because the data was for women who had attended a breast cancer clinic and were diagnosed positive for breast cancer. A review carried out by Srinath et al. (2023) noted that the situation is worse in developing countries; the prevalence of breast cancer is usually higher. In Asian countries, Lei et al. (2021a; 2021b) also identified high prevalence of breast cancer. Similarly, Foroozani et al. (2020) revealed a 70% prevalence of breast cancer among 100,000 women in a developing country. The UK is a developed country and it reflects access to opportunities that could limit the prevalence of breast cancer.
Barriers to early presentation and Diagnosis
The findings showed that there are various barriers to breast cancer. Although the findings differ from the findings in Beltran Ponce et al. (2023) which revealed that women were less willing to present for diagnosis because of the nature of treatment to be used. Nonetheless, they align on the basis of being a health related factor that could interfere with willingness to present for early diagnosis. Findings from Gathani et al. (2021a) suggested that there have been improvements to diagnosis of breast cancer in recent years; however, this is higher in developed countries where access to advanced diagnostic resources and increased educational awareness has been on the rise. In contrast, Anderson de Cuevas et al. (2018) noted that in South Asia, various social, structural, and behavioral factors have negative effects on willingness to present for early diagnosis. Afaya et al. (2022) and Srinath et al. (2023) also revealed that various barriers interfered with early presentation for diagnosis. Particularly, Afaya et al. (2022) indicated health information system, health services financing, and availability of essential medicines as key barriers affecting access to early diagnosis. Issues related to level of knowledge were also pointed out by Anastasi and Lusher, (2017), and Joe et al. (2023). Continuous education is required to encourage women to undertake tests as frequently as possible.
Availability of health infrastructure for breast cancer diagnosis
Four of the nine included studies revealed evidence of deprivation in the areas where the studies were conducted. The implication is that women may not have been able to visit breast cancer diagnostic centres because of the area where they were living. Although, a combined prevalence from two of the four studies revealed that the highest score on the index was 3. This implies an average level of deprivation in which the women could potentially visit diagnostic centres at their own convenience. According to Gathani et al. (2021b) there were no health inequalities that could have affected access to early diagnosis of breast cancer; this contrasts with the findings obtained in this study. Going by the distribution of the prevalence data, ethnic disparities may have influenced access to health care or willingness to present for early diagnosis and treatment.
Conclusion
Breast cancer is an issue of public health concern. The evidence from this systematic review showed that women between the ages of 30 to 39 are likely to present with breast cancer, and there is also a high prevalence of breast cancer among menopausal women. Women from other ethnicities who are living in the UK are highly likely to present with breast cancer. There are various barriers to presentation for early diagnosis of breast cancer in the UK; these barriers include, lack of awareness of symptoms, educational status, personal feelings/perceptions, Health-related barrier/Delay in Help Seeking, Social and Economic, Knowledge of Symptoms. There is also the issue of social deprivation that could potentially influence presentation for early diagnosis. In general, health promotion should be used to encourage early presentation for diagnosis of breast cancer status.
Limitations
Most of the included studies were based on retrospective research strategy. This reflects the collective prevalence of breast cancer across the years; hence, interfering with evidence of more current prevalence of breast cancer.
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Acknowledgements
We acknowledge the efforts of Ukwuru Science Management team and Ukwuru Science Study Group in bringing this study to reality.
Funding
Funding was provided by Ukwuru Science.
Author Information
Edmund Ikpechi, Ukwuru is the research director at Ukwuru Science Lagos. He works with a number of private organisations and individuals, consulting on public health and biomedical science research. He is also a Management Consultant and holds a Honorary Doctor of Business Administration (DBA) for his expertise in business practices.
Corresponding Author
Edmund Ikpechi, Ukwuru
Competing Interests
There are no competing interests for this study.
Rights
The publication is open for public use; credits must be provided by acknowledging the authors of the study.
Cite as
Ukwuru, E.I. and Ukwuru Science Study Group. (2024). A systematic review of Barriers to early presentation and breast cancer diagnosis in the United Kingdom. Ukwuru Public Health, 24(10): 1-18.
Received: 1 August 2024
Accepted: 1 October 2024
Published: 19 October, 2024
Keywords: FLT3, dual therapy, monotherapy, inhibitors, resistance.