‘I am not someone who gets skin cancer’: risk, time and malignant melanoma

Abstract

ABSTRACT'Delay' is a term used in the cancer literature since the 1930s to describe the period between self-detection of a concerning sign of possible disease and presentation to a health professional. This linguistic choice carries an implication of blame for apparent failure to manage a risk appropriately, drawing attention away from the contemporaneous perspectives of those who respond to suspicious indicators more or less quickly. We present findings from a grounded theory study of accounts given by 45 patients about their slower or quicker journeys to a diagnosis of cutaneous 2 malignant melanoma, a cancer which can 'hide in plain sight'. There has been little research exploring in qualitative detail patients' perspectives on their decision-making about what subsequently turn out to have been signs of this most risky of skin cancers.The findings frame referral time-lapses in terms of normalisation of symptoms, sometimes buttressed by reassurance derived from health promotion messages, disconfirmation of patients' concerns by their general practitioners and prioritisation of other life concerns. We argue that a shared sense of urgency surrounding melanoma self-referral derives from a clinical representation of current knowledge which conceals numerous evidential uncertainties.

The sociology of cancer: a decade of research

“…Hill and Hayes () applied similar analysis to public health initiatives and associated campaigns encouraging patient ‘awareness’ of symptoms of cancer, and Topping et al . () explored how these practices locate the responsibility for late diagnosis with patients. A similar theme was taken up in other analyses of how cancer prevention approaches based around evidence‐based medicine (Bell and Ristovski‐Slijepcevic ), mathematical models to determine risk estimations for individuals (Holmberg and Parascandola ), or linking the risk of cancer to particular behaviours (Hooker et al .…”

Which symptoms are linked to a delayed presentation among melanoma patients? A retrospective study

“…A greater proportion of patients with this symptom presented within 3 months although the odds ratio for delay was not statistically significant. Bleeding is known to occur more frequently in thicker tumours [20] and appears to be a more recognisable symptom by patients [11]. In other cancers, bleeding is perceived as an alarm symptom and is associated with a more prompt presentation when the source is urinary but not rectal [4].…”

“…Some patients have perceived themselves to be “low-risk” [11] and have reported a lack of general malaise, which might have contributed to delay [12]. Patients have also noted that they worry about attending their general practitioner (GP) for fear of creating a “fuss” [13].…”

“…Urgent referral to specialist care is indicated in cases of suspected melanoma and the 2-week wait system is designed to limit healthcare-associated delay. Patient factors, however, crucially influence the timing of presentation [3–11]. It has previously been shown that changing moles may not cause patient concern or even be recognised as a feature of skin cancer [12] and the reasons for delay are complex, including a lack of recognition of the symptoms as significant and not wanting to “waste” the doctor’s time [8, 10, 11, 13].…”

Health care through the ‘lens of risk’: reflections on the recent series of four special issues

“…However, we ended up with sufficient material for a double special issue. The published papers covered: home drinking in relation to concerns about the present and future (Foster and Heyman, 2013); the decision-making of older women about when to become pregnant (Locke and Budds, 2013); constructions of their futures by patients with advanced cancer (Brown and De Graaf, 2013); the temporal considerations of individuals who self-harm (West, Newton and Barton-Breck, 2013); and accounts of their time management given by patients who develop malignant melanoma (Topping, Nkosana-Nyawata and Heyman, 2013). The original call for papers referred to 'time-framing', drawing attention to the propensity of policy-makers, healthcare professionals and public to set temporal horizons beyond which risk assessment is not considered, as with the convention of assessing five-year survival for cancer treatments.…”