title: Educational differences in likelihood of attributing breast symptoms to cancer: a vignette-based study.
abstract: Stage at diagnosis of breast cancer varies by socio-economic status (SES), with lower SES associated with poorer survival. We investigated associations between SES (indexed by education), and the likelihood of attributing breast symptoms to breast cancer.
  
  
  
  We conducted an online survey with 961 women (47-92 years) with variable educational levels. Two vignettes depicted familiar and unfamiliar breast changes (axillary lump and nipple rash). Without making breast cancer explicit, women were asked 'What do you think this […..] could be?' After the attribution question, women were asked to indicate their level of agreement with a cancer avoidance statement ('I would not want to know if I have breast cancer').
  
  
  
  Women were more likely to mention cancer as a possible cause of an axillary lump (64%) compared with nipple rash (30%). In multivariable analysis, low and mid education were independently associated with being less likely to attribute a nipple rash to cancer (OR 0.51, 0.36-0.73 and OR 0.55, 0.40-0.77, respectively). For axillary lump, low education was associated with lower likelihood of mentioning cancer as a possible cause (OR 0.58, 0.41-0.83). Although cancer avoidance was also associated with lower education, the association between education and lower likelihood of making a cancer attribution was independent.
  
  
  
  Lower education was associated with lower likelihood of making cancer attributions for both symptoms, also after adjustment for cancer avoidance. Lower likelihood of considering cancer may delay symptomatic presentation and contribute to educational differences in stage at diagnosis. Copyright © 2016 John Wiley & Sons, Ltd.
authors.affiliation: School of Health Sciences, University of Surrey, Guildford, United Kingdom.
authors.forename: Afrodita
authors.initials: A
authors.lastname: Marcu
authors.affiliation: Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, United Kingdom.
authors.forename: Georgios
authors.initials: G
authors.lastname: Lyratzopoulos
authors.affiliation: Department of Applied Health Research, University College London, London, United Kingdom.
authors.forename: Georgia
authors.initials: G
authors.lastname: Black
authors.affiliation: Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Faculty of Health, Aarhus University, Denmark.
authors.forename: Peter
authors.initials: P
authors.lastname: Vedsted
authors.affiliation: School of Health Sciences, University of Surrey, Guildford, United Kingdom. k.whitaker@surrey.ac.uk.
authors.forename: Katriina L
authors.initials: KL
authors.lastname: Whitaker
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001294:Attitude to Health; D001943:Breast Neoplasms / Q000175:diagnosis; D003430:Cross-Sectional Studies; D003872:Dermatitis; D004522:Educational Status; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008875:Middle Aged; D010146:Pain; D010342:Patient Acceptance of Health Care; D036301:Qualitative Research; D012923:Social Class; D011795:Surveys and Questionnaires
keywords: Cancer; Early diagnosis; Education; Inequalities; Oncology; Symptom attribution