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    Archive for the 'Cancer' Category

    Can technology help cancer survivors increase physical activity?

    By Moritz P Herle, on 8 August 2017

    by Anna Roberts

    Over 14 million people are diagnosed with cancer worldwide each year, and this is expected to rise to 22 million over the next two decades. Thankfully, due to improvements in early diagnosis and treatment, the number of people who are surviving longer after cancer is also increasing.

    However, many people diagnosed with cancer experience long-lasting and debilitating side effects (e.g. fatigue, pain, sleep difficulties, anxiety and depression), all of which can substantially reduce quality of life. Health behaviours, such as physical activity and diet could prolong survival, reduce the risk of cancer returning and have been shown to reduce many of these common side effects. However, it is many of these side effects which make physical activity more difficult to do following a cancer diagnosis, and the number of cancer survivors who meet the recommended 150 minutes of moderate-vigorous physical activity per week is lower than for people who have never had cancer.  Therefore, there is a need for interventions which can help support cancer survivors’ to take part in physical activity following their diagnosis.

    Digital interventions use technologies such as text messaging, email, mobile apps, social media, websites and patient portals can be used to support health behaviours such as physical activity and diet. Digital interventions have increased in popularity as they are easy to access, tend to cost less than face-to-face support and therefore have the ability to reach a large number of people. This is especially true given the ever increasing number of UK adults who access the internet and own a smartphone.

    In the last few years, the number of studies which have looked at how effective these types of technologies are at improving cancer survivors’ physical activity participation and diet quality has rapidly increased. In our new study, we reviewed all of the published literature to see how effective digital technologies are at increasing physical activity or improving dietary quality among people diagnosed with cancer. We also looked at the effect of these types of interventions on body mass index (BMI) and other cancer-relevant outcomes measured in the studies, such as fatigue, sleep quality, anxiety and depression and quality of life.

    15 studies were included in the review, all of which evaluated the effect of a digital technology on physical activity and five studies also evaluated the effect on dietary quality. By statistically combining the data from the studies (also known as a meta-analysis), we were able to estimate that digital technologies can increase cancer survivors’ moderate-vigorous physical activity by approximately 40 minutes per week. This technique also allowed us to show that digital technologies can significantly reduce BMI, however there was no evidence of an improvement in cancer survivors’ quality of life. While there was evidence for a reduction in fatigue, this was not large enough to be deemed statistically significant. Meta-analysis was not possible for all of the outcomes we were interested in (either due to the variation between studies in the way in which they were measured or because of the small number of studies which assessed these outcomes). Of the 5 studies which assessed the effect of digital interventions on diet, only 2 showed an improvement in dietary quality. There was no evidence of any improvement in anxiety or depression and while only 2 studies evaluated the effect on sleep quality, both showed a significant improvement in sleep outcomes.

    However, as this is an emerging field of research, the quality of the included studies was varied. For instance, all of the studies asked participants to report their own physical activity participation using questionnaires. These types of questionnaires are notorious for overestimating actual physical activity levels. Furthermore, the length of follow-up in these studies was relatively short which makes it difficult to understand the longer-term impact of these types of interventions. There was also large variation between the studies in terms of the types of digital interventions, the types of cancer and the way in which the outcomes were measured. This makes it very difficult to ascertain what types of intervention are most effective, for which outcomes, among which groups of cancer survivors. While the results of this review show that the use of digital technologies in this context appears promising, we also call for larger, high-quality studies with objective measures of physical activity and longer follow-up periods.

    Article link: Roberts AL, Fisher A, Smith L, Heinrich M, Potts HWW. Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis. Journal of Cancer Survivorship, 2017.

    I’ve never heard of it; I don’t want to; it’s on my list

    By Laura Marlow, on 3 July 2017

    Authors: Amanda Chorley, Laura Marlow, Jo Waller

    One of our previous blogs discussed how rates of cervical screening (aka the smear test, or pap test) have been declining in the UK. Last year, screening uptake rates fell to 72.7%, meaning that over a quarter of women had not been screened as recommended (1). A better understanding of why women are not being screened is vital. If women are making informed decisions not to attend this is perfectly acceptable, but if women do not understand cervical screening or find it difficult to attend for other reasons (e.g. inconvenient appointment times), interventions to address this are important. Treating women who do not attend screening as a single group of “non-participants” means those with very different screening experiences and intentions are considered to be the same. Unsurprisingly this means that “one size fits all” interventions to increase screening participation do not have large effects, as they are unlikely to be suited to individual women’s differing needs.

    In our latest study published in the European Journal of Cancer last week, we used the Precaution Adoption Process Model (PAPM)(2) to try and improve our understanding of the ways in which women who do not attend screening may differ. The PAPM is a model from behavioural science which states that before carrying out a health behaviour (in this case cervical screening), a person must move through a number of stages. A person must first be aware of the health behaviour and engaged with it before they can make a decision whether or not to carry it out. If they do decide to carry out the behaviour, they must then overcome any barriers which may be in the way of this (e.g. getting to the screening appointment). Importantly, the PAPM also includes the possibility for people to make an active decision to not participate in the behaviour. By classifying women according to the PAPM we hoped to identify what the most common type of screening non-participant is, and whether women within a particular group tend to have shared characteristics.

    793 (27%) of the 3113 women we surveyed were either overdue for screening (including those who had never had a smear test) or said they did not plan to go for screening when next invited. Of these non-participating women, just over half said that they do intend to go. These women tended to be younger than women who were up to date with screening, and were more likely to be single and from less affluent backgrounds. Perhaps more surprisingly, given the fact that all should have received an invitation and leaflet about screening as part of the NHS programme, 28% of non-participating women said that they had never heard of cervical screening, smear or pap tests, even after being shown a photo of the procedure. These women were more likely to be younger and from ethnic minority and less affluent backgrounds, and to have English as a second language. Finally, 15% of non-participating women said that they had made a decision not to be screened in the future. These women tended to be older, and most had been screened before. As with the other two groups, they were also more likely to be from less affluent backgrounds.

    The differences between these groups of non-participants show how important it is to consider the different reasons for non-participation. Changes such as more flexible clinic hours or text message reminders may help women who do want to go for screening but have found it hard to get around to it. However, for women who are unaware of cervical screening, more accessible information about the programme is a vital first step towards making an informed choice about whether to participate or not. As we found that unaware women were more likely to be from ethnic minority backgrounds and less likely to speak English as their first language, it may be helpful to provide information in more languages and through TV or radio advertisements rather than just using written materials. Choosing not to be screened is a legitimate choice, and one that needs to be respected by medical professionals. However, in order for women to make an informed choice it is important that they have access to relevant information, including the benefits, risks, and limitations of screening. For some of the women who have decided not to go in the future, it may be the case that they have sought out this information. For other women the decision not to go for further screening may be due to a previous bad experience.

    Our survey goes some way to showing that there is not just one type of cervical screening non-participant, but different groups of women with different experiences, choices, and needs. In the future we hope to look further into these differences, both between and within the different groups described in this post.

    1. Screening and Immunisations team ND. Cervical screening programme: England, 2015-16. Health and Social Care Information Centre, 2016, p. 1 – 76.
    2. Weinstein N. The Precaution Adoption Process. Health Psychology. 1988; 7: 31.

    Early detection or prevention?: What is the main aim of different cancer screening programmes?

    By Moritz P Herle, on 23 May 2017

    by Amanda Chorley and Jo Waller

    Cancer screening programmes, such as breast, cervical, and bowel, are an important tool in the fight against cancer. Many people are aware of the value of early detection of cancer, which breast screening and the Faecal Occult Blood test (FOBt) part of bowel screening offer, which allows for treatment at an earlier stage when it is more likely to be effective. But are people aware that cervical screening and bowel scope screening (also known as flexible sigmoidoscopy, or FS) primarily aim to prevent cancer by identifying and removing abnormalities which may progress into cancer at a later date? This is the question we looked to answer in our recently published paper1 in the Journal of Medical Screening.

    As part of a larger survey on attitudes and behaviours surrounding cancer, we asked 1433 middle aged and older adults what they thought the main purpose of each of these screening programmes was. We found that while the majority of respondents were aware that breast screening (77.9%) and FOBt (73.2%) aimed to detect cancer early, only 17.6% knew that cervical screening primarily aimed to prevent cancer. For bowel scope screening the figure was only 13.8%. Overall only 13 people correctly identified the purpose of all four screening programmes, which is just under 1% of respondents.

    We also looked at whether people had participated in each programme in the past to see whether that had any effect on awareness of the purpose of the programme. People who had been sent a test kit, and those who had completed and returned the kit were more likely to know that FOBt is designed to detect cancer early. For breast screening, only those having participated in screening were more likely to know that it was aimed at early detection. Having received an invitation did not seem to have an effect on knowledge of the purpose of the test.

    However for both cervical screening and bowel scope screening neither those who had received an invitation nor those who had actually participated in the programme were any more likely to be aware of the preventive nature of the programme than respondents who hadn’t been invited or participated. This is despite the leaflets accompanying invitations clearly stating prevention as the main purpose.

    On the one hand it is positive that public health messages on the importance of the early detection of cancer have been so effective, and that the majority of people recognise this to be the purpose of breast screening and FOBt. However, for people to make an informed choice about whether to participate in a screening programme they need an understanding about what the screening test aims to do, as well as any risks and benefits. Our survey suggests that this is not the case for cervical screening and bowel scope. As well as this lack of awareness being an issue for informed choice, it could also have consequences for how people engage with the screening programmes. People may end up avoiding screening tests if they are afraid they might be told they have cancer2, 3. Knowing that some programmes can prevent cancer by finding and removing abnormalities may help to reduce these fears. Other studies have shown that women invited to colposcopy after having an abnormal result from their smear test sometimes mistakenly believe they have cancer4, 5. A better awareness that cervical screening mainly looks for cell abnormalities which can be removed before they have a chance to turn into cancer may help in reducing stress and worry about the abnormal result.

    If leaflets aren’t getting these messages across effectively, one of the priorities for the future will be finding different ways to communicate about cancer screening so that everyone understands what the tests are trying to do.

     

    1. Chorley AJ, Hirst Y, Vrinten C, Wagner Cv, Wardle J and Waller J. Public understanding of the purpose of cancer screening: A population-based survey. J Med Screen. 2017; 0: 0969141317699440.
    2. Vrinten C, Waller J, von Wagner C and Wardle J. Cancer fear: facilitator and deterrent to participation in colorectal cancer screening. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2015; 24: 400-5.
    3. Andersen MR, Smith R, Meischke H, Bowen D and Urban N. Breast cancer worry and mammography use by women with and without a family history in a population-based sample. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2003; 12: 314-20.
    4. Kavanagh AM and Broom DH. Women’s understanding of abnormal cervical smear test results: a qualitative interview study. BMJ (Clinical research ed). 1997; 314: 1388.
    5. Gray NM, Sharp L, Cotton SC, et al. Psychological effects of a low-grade abnormal cervical smear test result: anxiety and associated factors. British journal of cancer. 2006; 94: 1253-62.

     

    Congratulations to Dr Jo Waller

    By Alice Forster, on 7 November 2016

    Alice Forster and Laura Marlow

    Today at the NCRI Cancer Conference in Liverpool, the inaugural Jane Wardle prize was awarded to our very own Dr Jo Waller to recognise her world-leading contribution in cervical cancer prevention. The prize was set up by Cancer Research UK in memory of Professor Jane Wardle who died last year. Jo has been at the Health Behaviour Research Centre for 15 years and was herself mentored by Jane Wardle. In this blog we highlight some of Jo’s key research in cervical cancer prevention during this time.

     

    In 2005, Jo completed a PhD exploring psychosocial issues surrounding the viral aetiology of cervical cancer. These early studies explored the emotional and social consequences of a HPV diagnosis and how women make sense of a HPV positive result at cervical screening. The findings highlighted extremely low awareness of HPV and poor understanding about how cervical cancer develops. This work also showed the importance of providing good information to ensure minimal anxiety when receiving a HPV positive result at screening and to avoid stigmatising cervical cancer.

     

    Jo and her colleagues went on to explore psychosocial issues surrounding HPV vaccination before and after its introduction in 2008. This research helped identify the most appropriate age for the vaccine and contributed to the content of the information materials provided. In addition, this work offered reassurance that vaccination against a sexually transmitted infection (the HPV vaccine) did not result in changes to girls’ sexual behaviour as some media reports had suggested. Jo’s work has also explored why certain sub-groups of the population, such as young women and ethnic minority women are less likely to participate in cervical screening.

     

    In 2014, Jo was awarded a prestigious Cancer Research UK Career Development Fellowship to continue her research in cervical cancer prevention. Jo now formally manages a team of researchers and her current research activities include understanding non-participation in cervical cancer screening and HPV vaccination, developing interventions to improve uptake of these cervical cancer control interventions, and evaluating the psychological impact of primary HPV testing within cervical screening.

     

    Jo has also been involved in numerous other bodies of work over the last 10 years including development of the Cancer Awareness Measure and studies exploring informed choice about screening. She is also an informal mentor to many students and colleagues. We are all very proud of Jo’s achievement today. Well done Jo!

     

    You can read more about our current work in cervical cancer prevention on our website.

    Fifty shades of cancer fear

    By Charlotte Vrinten, on 7 October 2016

    Are you afraid of cancer? Don’t worry, you’re in good company. Surveys show that many people in the UK are afraid of cancer [1]: 35% of people fear cancer more than other serious illnesses such as heart disease or HIV [2], and 20% fear cancer more than being in debt, being in a car accident, or losing a job. [3] But although we know that lots of people find cancer frightening, we don’t really know what it is about cancer that they are afraid of. So in our latest study, we aimed to explore just that.

    You may wonder why it is important to pinpoint what it is about cancer that worries people. The answer is that the nature of the fear may determine how people behave when it comes to cancer screening or responding to suspicious symptoms. For example, a study in the US found that worry about prostate cancer motivated men to have a prostate examination, while fear of the examination put them off. Intuitively, we know that there are many different aspects to cancer that could be frightening, but until now, no one had really explored this.

    In our study, which was published today, we collated findings from 102 interview studies from 26 countries to see what people in the general population(as opposed to cancer patients) said they feared about cancer [5]. All the studies combined included more than 3,500 participants.

    We found that those who are afraid of cancer seemed to view cancer as an indestructible enemy that randomly sneaks up on people to kill them – reprising the media’s ‘war on cancer’ theme. This rogue super soldier inspired lots of fear, which could be increased or decreased by factors such as family history of cancer, symptoms, or experiences of cancer in others, as well as coping styles such as ‘checking up on the enemy’ through cancer screening, or pretending that it doesn’t exist.

    In addition, we found that there are also specific aspects of cancer that inspire fear. Many participants were fearful of the emotional upset that a cancer diagnosis would cause. Fears of cancer treatment, such as chemotherapy and surgery, were also mentioned in many studies, in addition to the fear that surgery might cause cancer to spread (a fear that is completely unfounded). Some women expressed fears about losing intimate body parts and thereby their gender identity, for example if a breast needed to be removed to treat breast cancer.

    The social implications of being a cancer patient also inspired a lot of fear. Some people feared that a cancer diagnosis would stigmatise them, or would attract blame. Many people also worried that a cancer diagnosis would have a negative effect on their family, by burdening them financially, physically, or psychologically. Some women were worried that losing a breast would mean that their partners would no longer find them attractive and might abandon them.

    Finally, we found many references to fears about dying from cancer. Some said that they were so afraid of dying from cancer that they’d rather die without knowing that they had it.

    What can we conclude from these findings? We have shown for the first time that there are many different things that people in the general population – without a cancer diagnosis – worry about when it comes to cancer. What we do not yet know is how common these worries are, and how they may influence willingness to take steps to reduce cancer risk or get it detected early. These are questions that we will be investigating further. For example, we recently completed a national survey to find out how common various cancer worries are, the results of which will be presented at the upcoming NCRI conference. Watch this space!

    References

    [1] Vrinten C, van Jaarsveld CHM, Waller J, von Wagner C, Wardle J. (2014). The structure and demographic correlates of cancer fear. BMC Cancer, 14(1), 597.

    [2] http://www.cancerresearchuk.org/about-us/cancer-news/press-release/2011-08-15-people-fear-cancer-more-than-other-serious-illness

    [3] http://www.cancerresearchuk.org/about-us/cancer-news/press-release/2010-12-08-cancer-is-biggest-fear-but-34-per-cent-put-it-down-to-fate

    [4] Consedine NS, Adjei BA, Ramirez PM, McKiernan JM. (2008). An object lesson: source determines the relations that trait anxiety, prostate cancer worry, and screening fear hold with prostate screening frequency. Cancer Epidemiology Biomarkers & Prevention, 17(7), 1631-1639.

    [5] Vrinten C, McGregor LM, Heinrich M, von Wagner C, Waller J, Wardle J, Black GB. (2016). What do people fear about cancer? A systematic review and meta-synthesis of cancer fears in the general population.  Psychooncology, Epub 6 Oct 2016.

    The importance of vaccination for everyone

    By Alice Forster, on 19 August 2016

    It’s important that most people get vaccines

    Most people get the vaccines offered to them as part of the NHS immunisation programme. They help prevent, and reduce the spread of diseases. Because of vaccines we no longer have smallpox anywhere in the world and polio is almost wiped out too.

    For some vaccines, fewer people from some ethnic minority backgrounds get them compared to everyone else in the UK. For example, children from Nigerian, White Polish or Somali backgrounds are less likely than other groups to be vaccinated against Diphtheria in London (1). For other vaccines, more people from some ethnic minority backgrounds get them compared to everyone else. For example, one study found that children from Black and Asian backgrounds living in the London borough of Brent had higher uptake of the first dose of the MMR vaccine than children from White backgrounds (2).

    Because of the way vaccination works, it’s really important that most people get the vaccines they are offered. If enough people get vaccines, protection is given to the people who cannot get them for medical reasons or are too young. So although the vast majority of people get vaccines, it’s still useful to understand why some people do not, so we can work out how we might be able to increase the number of people who get them. Because of the differences in who is and is not getting vaccines, we decided to explore what it was that might make children from ethnic minority backgrounds more or less likely to get vaccines.

    What did we do?

    In our new review, we looked at published studies where parents from ethnic minority backgrounds have been spoken to about why they had or had not chosen to vaccinate their children. We just looked a studies that had used qualitative methods, like interviewing parents and speaking to small groups of parents all at once (called focus groups). We used a technique called Thematic Synthesis to bring all of the findings together, which involves a number of researchers labelling the things that people had said and finding common themes within these labels.

    What did we find?

    Not surprisingly we found that most of the things that had convinced parents from ethnic minority backgrounds to get vaccines for their children, or had stopped them from doing so, were the same as the things that parents in general tell us. For example, parents had said that they were happy to go along with the doctor’s recommendation; that their decision had been influenced by other people and had found that things like transport problems had stopped them getting vaccines.

    But there were also some things that had affected parents’ decisions about vaccines that were linked to ethnicity. For some parents, their religion instructed them about whether vaccines were needed for their children. Other parents were influenced by their experiences of having lived in other countries. For some, this made them appreciate the healthcare that is offered in the UK, but others felt that particular vaccines were not needed because they were not offered to them back home. Scare stories in newspapers or on the television can sometimes cause parents to worry about vaccines. We found that some parents who did not speak English had not heard these stories and so did not have the worries that other parents might. Some parents had wanted information about vaccines to be given to them in the language they speak at home. Finally, vaccines go through many years of testing and are studied in groups of people from all different ethnic backgrounds. Some parents said that they wanted to know about this testing, so that they could be reassured that their children would react to the vaccines in the same way as other children.

    We now have a better understanding of why some people do and do not get vaccines

    This research has helped us to understand why children from some ethnic minority backgrounds might be more likely to get some vaccines. It also told us the type of information that parents from ethnic minority backgrounds want to know about vaccines to be confident that giving their child a vaccine is the right thing. In some situations it might be a good idea to tailor information about vaccines to parents from particular ethnic minority backgrounds to make sure they are getting all the information they want to have.

     

    References

    1. Wagner KS, van Wijgerden JCJ, Andrews N, Goulden K, White JM: Childhood vaccination coverage by ethnicity within London between 2006/2007 and 2010/2011. Arch Dis Child 2014, 99(4):348-353. DOI: 10.1136/archdischild-2013-304388
    2. Mixer RE, Jamrozik K, Newsom D: Ethnicity as a correlate of the uptake of the first dose of mumps, measles and rubella vaccine. J Epidemiol Community Health 2007, 61(9):797-801. DOI: 10.1136/jech.2005.045633

    Cancer survivors are more dissatisfied with their sex lives – despite normal levels of sexual activity and function for their age

    By Sarah Jackson, on 17 August 2016

    Cancer survivorship rates are improving dramatically, with half of all people diagnosed with cancer in the UK now expected to survive for at least ten years. Although treatment of the cancer is the primary clinical goal, ensuring the best possible quality of life after treatment is important. Preservation of sexual function is a key component of quality of life, yet remains a commonly reported ‘unmet need’ by cancer survivors. However, sexual function declines with ageing and because the majority of cancers are diagnosed in the over-70s, it was previously unclear whether changes in sexual wellbeing reported by cancer survivors are a result of their disease or a natural by-product of ageing.

    In a new study published today in Cancer we explored differences in sexual activity, function and concerns between cancer survivors and people who had never received a cancer diagnosis. The findings revealed that a diagnosis of cancer does not seem to affect whether or not people have sex, how often they have sex, what they do when they have sex, and (in the case of men) their sexual function.  Compared with women of a similar age, women who had been diagnosed with cancer within the past five years were just as likely to be sexually active, although they were more likely to report problems with arousal.  Following the five years post-diagnosis the only difference was greater dissatisfaction with their sex lives, with 18% of women with a history of cancer reporting dissatisfaction compared to 12% of cancer-free women.  Male cancer survivors did not report any more sexual problems than their age-matched counterparts, but they were more dissatisfied with their sex lives (31% of men with cancer compared to 20% of men with no history of cancer).

    The research involved 2982 men and 3708 women aged 50 years and older taking part in the English Longitudinal Study of Ageing (ELSA), a large population-based cohort of middle-aged and older adults living in England.  Participants reported whether they had ever been diagnosed with cancer, and completed the Sexual Relationships and Activities Questionnaire, a comprehensive measure that includes questions on the frequency of sexual behaviours, problems with sexual activities and function, and concerns and worries about sexual activities, function and relationships.  It is the first study to compare sexual behaviour and concerns between cancer survivors and controls from the same population-based study using a standardised measure.

    The results of this study are generally encouraging in showing that older people with cancer do not experience greater problems with sexual activity or functioning than people of the same age without a history of cancer.  However, with more than one in five men and one in nine women reporting that they were dissatisfied with their sex lives, it is clear that there is a need to identify interventions to enhance sexual health in ageing men and women.  In the meantime, better advice on the normal changes in sexual activity and functioning that occur with ageing could help to address the mismatch between the normal sexual behaviour and lower sexual satisfaction seen in cancer survivors.

     

    Article link:

    Jackson SE, Wardle J, Steptoe A, Fisher A. Sexuality after a cancer diagnosis: a population-based study. Cancer. First published ahead of print 17 August 2016. doi:10.1002/cncr.30263

    http://onlinelibrary.wiley.com/doi/10.1002/cncr.30263/full

    A new jab to prevent cancer

    By Alice Forster, on 26 May 2016

    What is HPV and how is it linked to cancer?

    Around 5% of all cancers worldwide are caused by the human papillomavirus (“papi-lo-ma-virus”) or HPV. More and more people are aware that HPV causes cancer of the cervix (the neck of the womb) in women, but HPV can also cause cancers of the penis, anus, vagina, vulva and mouth and throat. The virus is spread by skin to skin contact, including sexual contact. There are many different types of HPV. Some types cause cancer, while others cause warts that people get on their hands, feet or genitals and these types do not cause cancer. The types of HPV that cause cancer are so common that HPV is the most frequent sexually transmitted infection in the UK. In most people the cancer causing types of HPV cause no problems and the virus goes away on its own. However, some people do not get rid of the infection. If the infection stays for many years it can turn into cancer.

    HPV vaccines

    In the late 1990s and early 2000s two vaccines were developed that protect against the two types of HPV that cause around 80% of cervical cancers. Girls who are aged 12-13 years old in Year 8 at school are now offered one of these vaccines as part of the childhood immunisation programme. The vaccine that is used as part of the UK programme also protects against two types of HPV that cause genital warts. Recently, a third HPV vaccine called the nonavalent or 9-valent vaccine has been licenced for use in the UK, as well as in the USA and elsewhere in Europe.

    The new 9-valent vaccine

    The 9-valent vaccine, as the name suggests, protects against 9 types of HPV – that means protection against an extra 5 HPV types compared with the other two vaccines. These 9 HPV types cause up to 90% of cervical cancers, so an additional 10 in every 100 cervical cancers could be prevented.

    Where does behavioural science fit in?

    The invention of these vaccines is a fantastic step forward towards wiping out cervical cancer, but this can only happen if people get the vaccine and we know that many people are not doing so for a variety of reasons. The benefits of the HPV vaccine will be greatest if most people get the vaccine, however as with all healthcare decisions, the decision to get the HPV vaccine should be an individual informed choice. In our new paper, we look at how we can use our understanding of why people don’t get vaccines, specifically the HPV vaccine, to try to increase uptake of the 9-valent vaccine.

    Reason 1: Will the 9-valent vaccine overload the immune system?

    Some parents worry that vaccines overload the immune system and others worry that particular ingredients make vaccines risky for their children. Parents consider combination vaccines to be risky for both of these reasons as they are seen as containing a greater number of ingredients. The 9-valent vaccine is not a combination vaccine, but it protects against 9 types of HPV compared to 2 or 4 types of HPV with older HPV vaccines and might be seen as more dangerous. However, parents should be reassured that the 9-valent vaccine is safe and has been licensed for use in the UK, USA and the rest of Europe. There is also no evidence that vaccines overload the immune system.

    Reason 2: ‘I’ll wait to decide until there’s more evidence that it will protect my daughter in her twenties’

    Many parents have said that rather than giving their 12 or 13 year old daughter the vaccine (as recommended) they would rather wait until their daughter became sexually active so that she may be protected when she ‘really needs it’. However, the HPV vaccine is likely to give protection against HPV for decades and works better if it is given at a younger age. Parents may also find it difficult to get the vaccine for their daughter outside of the routine immunisation programme. Parents should be reassured that 12 to 13 is the right age for their daughter to get the 9-valent vaccine.

    Reason 3: ‘It’s so new, the government can’t know about the long-term side effects’

    Because the vaccine is relatively new, some parents say that they are worried that the vaccine has not been monitored for long enough. However, vaccines go through many years of testing before they become available to the public. There is no evidence that the HPV vaccines are unsafe or cause side-effects other than temporary mild/moderate pain, swelling, redness and itching.

    What else can be done to increase uptake of the 9-valent vaccine?

    Scientists have looked at all of the published research studies that have tried to improve uptake of HPV vaccines. These show that uptake can be improved by doing things like sending reminders to parents and running school-based immunisation programmes like we have in the UK. In the USA, where the vaccine is given in a clinic setting, parents are most likely to get their daughter vaccinated if a doctor recommends that she has it. The language that the doctor uses to make that recommendation is also important.

     

    The 9-valent HPV vaccine is a fantastic opportunity to prevent even more cancers that are caused by HPV. Parents can be reassured that the HPV vaccines are safe and will provide protection for their children against a number of cancers for many many years.

    Could a leaflet help catch cancer earlier?

    By Jo Waller, on 4 May 2016

    We’ve written here before about the difficulty of recognising symptoms that could be signs of cancer, and knowing when it’s appropriate to go to the doctor about them. There’s lots of evidence that cancer is more treatable if it’s found at an earlier stage, but we know less about effective ways of encouraging people to seek help appropriately.

    Encouraging people to seek help

    Our new study tried to do just this. We focused on gynaecological cancers – that is ovarian, cervical, endometrial (womb/uterine), vaginal and vulval cancers which together affect over 20,000 women a year in the UK. We know from previous research that some of the things that stop people going to the doctor with symptoms are:

    1) Not knowing that the symptom could be a sign of something serious
    2) Worry about wasting the doctor’s time
    3) Embarrassment about discussing or exposing intimate parts of the body
    4) Worry about what the doctor might find

    So we designed an information leaflet that addressed some of these issues. It provided details about possible symptoms of gynaecological cancer and a checklist to help women record their symptoms and make a plan to visit their GP. It reassured women that their doctor would be happy to see them, and that the symptoms were unlikely to be serious. It addressed the issue of embarrassment and reminded women they could ask to see a female doctor.

     

    In this study Leaflet 1, we uLeaflet 2sed questionnaires to measure the impact of the leaflet in the short-term. We asked 464 women about their symptom knowledge, the things that might put them off going to the doctor if they had gynaecological symptoms, and how quickly they thought they would seek help for a range of symptoms. We also asked about how anxious they were feeling right now, so we could see if the leaflet raised anxiety levels. Women then spent some time reading the leaflet before filling in another questionnaire.

    What did we find?

    After reading the leaflet, most women said they would seek help more quickly if they noticed one of the symptoms. In particular, we reduced the number of women who said they would never seek help for vague symptoms like bloating and feeling full quickly, which can be signs of ovarian cancer. Women reported fewer barriers to visiting their GP, and greater knowledge about possible symptoms of gynaecological cancer. There was no evidence that the leaflet made women feel anxious.

    What next?

    These findings are very encouraging, and suggest that a leaflet may be an effective way of promoting prompt help-seeking for these symptoms. But it’s also important to remember that it was an experimental study – women read the leaflet under controlled conditions, so it doesn’t tell us what impact the leaflet would have in a real-world setting where women might be sent it in the post, or handed it at their GP surgery. Under these circumstances, they might not even read it.

    In addition, we could only measure women’s anticipated help-seeking, and we can’t be sure what they would really do if they had these symptoms. Even when people intend to seek help, life often gets in the way, other things take priority, and people don’t get round to making an appointment.

    The next step will be to see what happens when we actually send the leaflet to women – will more of them seek help and, ultimately, will more cancers be diagnosed at an earlier stage when treatment is more effective? We hope to answer these questions in our future work.

    Putting screening non-attendance under the microscope – understanding why some women don’t go for smear tests

    By Jo Waller, on 26 April 2016

    Authors: Amanda Chorley and Jo Waller

    If you are a woman aged 25 or over, there is a good chance you have attended cervical screening (the smear or Pap test) at least once. In England last year, just under three quarters of women were ‘up to date’ with cervical screening [1], meaning that over a quarter of women are not up to date. As cervical screening, in addition to HPV vaccination, is one of the best ways to protect yourself from cervical cancer it is important to understand why some women do not attend.

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    Many studies have asked women about their feelings towards and experiences of cervical screening. We carried out a review of studies [2] from the UK, Australia, Sweden and South Korea – countries where women are automatically invited for screening on a regular basis.

    By pulling together findings from across 39 studies, we identified two main themes. Firstly women considered whether they should go for screening – were they at risk of cervical cancer? How serious was the outcome? And is screening a useful way of dealing with that threat? Secondly, women who had previously been for screening recounted their experiences, and how this made them feel about going again.

    Should I go for screening?
    In deciding whether they should go for cervical screening or not, women considered whether they were at risk of cervical cancer, and therefore if screening was relevant to them. Their decisions were often based on ideas of the causes of cervical cancer, such as number of sexual partners. Women also considered their current life stage (both biological such as menopause, and social such as being the mother of young children), and their family history of cervical (and other) cancer.

    Women differed in whether they thought cervical screening was worthwhile. Some talked about the benefits of early detection of cancer (e.g. better survival or ‘peace of mind’). Others believed that they would know if they had an illness as serious as cancer, without screening, or were cynical about the motives of screening programmes. The final group were aware of screening, but were unsure of its importance. These women were often from more deprived backgrounds, or were from ethnic minority groups.

    Screening is a big deal
    It was clear from women’s accounts that one bad experience of screening could make them avoid screening in the future. However it is important to remember that it is possible that women who have had bad experiences are perhaps more likely to take part in studies about screening than women who do not view screening as a big deal.

    Some women found the prospect of screening threatening, either through the risk of being given a diagnosis of cervical cancer, the belief that you might get an infection from unclean instruments, or through the anxiety screening and the wait for results could cause. Some women reported a different kind of threat. It was believed that a positive result could mark you as “promiscuous”, and for some women (especially those from ethnic minority groups) simply attending screening could suggest to other people that you were sexually active.

    Cervical screening was also seen as a big deal because of physical aspects, such as pain, or disliking the speculum. For others emotional aspects were more important. In particular, some women reported feelings of embarrassment, shame, and a loss of control during screening, due to the unusual situation in which you are expected to expose your genitals to a relative stranger.

    Because of this, women across studies had a strong preference for female nurse or doctor for cervical screening.

    Other factors
    These are not the only reasons women do not attend screening. Some women talked about how they would like to go for screening, but competing priorities, such as childcare and work, or inconvenient appointment times or clinic locations meant that they could not easily attend. Women from ethnic minority groups also reported specific problems, such as racist treatment from health professionals, and difficulty in accessing information about screening due to a lack of translated material.

    What does this mean?
    Our findings show that women are not all alike in their reasons for not attending screening. Some do not think screening is relevant for them and have made a conscious decision not to go. Others have had a bad experience and wish to avoid that happening again. Yet other women would like to attend screening, but life gets in the way. And of course cervical screening is not a one-off event. Women will continue to be invited over a period of decades, and factors that were important at one stage of a woman’s life may be more or less important in the future.

    Knowing this allows us to develop different kinds of information and support for women depending on which factors are most important to them. We are now also able to carry out further research to try and find out whether certain factors are more likely to be considered important by certain groups of women. Our review also made it clear that the opinions of women who have never attended, or even heard of screening, have hardly been explored. We hope to interview women from these groups in the coming months, and find out more about their barriers to cervical screening.

    [1] Screening and Immunisations team HaSCIC. Cervical Screening Programme, England. Statistics for 2014-15. 2015.

    [2] Chorley AJ, Marlow LAV, Forster AS, Haddrell JB, Waller J. Experiences of cervical screening and barriers to participation in the context of an organised programme: a systematic review and thematic synthesis. Psycho-Oncol. 2016.