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Studying Delays in Breast Cancer Diagnosis and Treatment: Critical Realism as a New Foundation for Inquiry

Jan Angus
Karen-Lee Miller
Tammy Pulfer
Patricia McKeever
ONF 2006, 33(4), E62-E70 DOI: 10.1188/06.ONF.E62-E70

Purpose/Objectives: To examine how delays in breast cancer care currently are conceptualized and to introduce philosophical and theoretical tenets of critical realism as an alternative approach.

Data Sources: Health and social sciences literature.

Data Synthesis: Diagnostic and treatment delays in breast cancer most frequently are conceptualized as patient, provider, or system related. The approach has limited utility in guiding explanatory analysis because it does not acknowledge the social context in which the delays occur. The philosophical tenets of critical realism and two related theoretical approaches are an alternative. They illustrate how an individual's biologic, social, and material resources may undermine or support structural inequities in access to breast cancer care.

Conclusions: Critical realism provides a useful framework for analysis of links between social inequalities and delays in breast cancer diagnosis and treatment.

Implications for Nursing: Access to breast cancer care could be better understood and conceptualized by basing future research and theoretical endeavors on a critical realist perspective.

References 

Afzelius, P., Zedeler, K., Sommer, H., Mouridsen, H.T., & Blichert-Toft, M. (1994). Patient's and doctor's delay in primary breast cancer. Prognostic implications. <i>Acta Oncologica, 33</i>, 345-351.

Andersen, B.L., & Cacioppo, J.T. (1995). Delay in seeking a cancer diagnosis: Delay stages and psychophysiological comparison processes. <i>British Journal of Social Psychology, 34</i>(Pt. 1), 33-52.

Anglin, M.K. (1997). Working from the inside out: Implications of breast cancer activism for biomedical policies and practices. <i>Social Science and Medicine, 44</i>, 1403-1415.

Appleton, J.V., & King, L. (2002). Journeying from the philosophical contemplation of constructivism to the methodological pragmatics of health services research. <i>Journal of Advanced Nursing, 40</i>, 641-648.

Archer, M.S. (2003). <i>Structure, agency and the internal conversation</i>. Cambridge, England: Cambridge University Press.

Arndt, V., Sturmer, T., Stegmaier, C., Ziegler, H., Becker, A., & Brenner, H. (2003). Provider delay among patients with breast cancer in Germany: A population-based study. <i>Journal of Clinical Oncology, 21</i>, 1440-1446.

Arndt, V., Sturmer, T., Stegmaier, C., Ziegler, H., Dhom, G., & Brenner, H. (2001). Socio-demographic factors, health behavior and late-stage diagnosis of breast cancer in Germany: A population-based study. <i>Journal of Clinical Epidemiology, 54</i>, 719-727.

Bailey, E.J., Erwin, D.O., & Belin, P. (2000). Using cultural beliefs and patterns to improve mammography utilization among African-American women: The Witness Project. <i>Journal of the National Medical Association, 92</i>(3), 136-142.

Barber, M.D., Jack, W., & Dixon, J.M. (2004). Diagnostic delay in breast cancer. <i>British Journal of Surgery, 91</i>, 49-53.

Barry, J., & Breen, N. (2005). The importance of place of residence in predicting late-stage diagnosis of breast or cervical cancer. <i>Health and Place, 11</i>(1), 15-29.

Bartley, M. (2003). Health inequality and societal institutions. <i>Social Theory and Health, 1</i>(2), 108-129.

Baxter, N. (2001). Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? <i>CMAJ, 164</i>, 1837-1846.

Benedict, S., Williams, R.D., & Baron, P.L. (1994). Recalled anxiety: From discovery to diagnosis of a benign breast mass. <i>Oncology Nursing Forum, 21</i>, 1723-1727.

Benk, V., Ho, V., Fortin, P.R., Zhang, G., Levinton, C., & Freeman, C.R. (1998). Predictors of delay in starting radiation treatment for patients with early stage breast cancer. <i>International Journal of Radiation Oncology, Biology, Physics, 41</i>, 109-115.

Bhaskar, R. (1975). <i>A realist theory of science</i>. Boston: Brill Academic Publishers.

Bhaskar, R. (1998). General introduction. In M. Archer, R. Bhaskar, A. Collier, T. Lawson, & A. Norrie (Eds.), <i>Critical realism: Essential readings</i> (pp. ix-xxiv). New York: Routledge.

Blaikie, N. (1993). <i>Approaches to social enquiry</i>. Cambridge, England: Polity Press.

Blaxter, M. (1997). Whose fault is it? People's own conceptions of the reasons for health inequalities. <i>Social Science and Medicine, 44</i>, 747-756.

Borrayo, E.A., Buki, L.P., & Feigal, B.M. (2005). Breast cancer detection among older Latinas: Is it worth the risk? <i>Qualitative Health Research, 15</i>, 1244-1263.

Borrayo, E.A., & Jenkins, S.R. (2001). Feeling healthy: So why should Mexican-descent women screen for breast cancer? <i>Qualitative Health Research, 11</i>, 812-823.

Bottorff, J.L., Johnson, J.L., Bhagat, R., Grewal, S., Balneaves, L.G., Clarke, H., et al. (1998). Beliefs related to breast health practices: The perceptions of South Asian women living in Canada. <i>Social Science and Medicine, 47</i>, 2075-2085.

Bourdieu, P. (1990). <i>The logic of practice</i>. Cambridge, England: Polity Press.

Bradley, C.J., Given, C.W., & Roberts, C. (2002). Race, socioeconomic status, and breast cancer treatment and survival. <i>Journal of the National Cancer Institute, 94</i>, 490-496.

Burgess, C., Hunter, M.S., & Ramirez, A.J. (2001). A qualitative study of delay among women reporting symptoms of breast cancer. <i>British Journal of General Practice, 51</i>, 967-971.

Burgess, C.C., Ramirez, A.J., Richards, M.A., & Love, S.B. (1998). Who and what influences delayed presentation in breast cancer? <i>British Journal of Cancer, 77</i>, 1343-1348.

Burgess, C.C., Ramirez, A.J., Smith, P., & Richards, M.A. (2000). Do adverse life events and mood disorders influence delayed presentation of breast cancer? <i>Journal of Psychosomatic Research, 48</i>, 171-175.

Canadian Cancer Society/National Cancer Institute of Canada. (2006). <i>Canadian cancer statistics 2006</i>. Toronto, Canada: Author.

Caplan, L.S., & Helzlsouer, K.J. (1992). Delay in breast cancer: A review of the literature. <i>Public Health Reviews, 20</i>(3-4), 187-214.

Charatan, F. (2002). The great American mammography debate. <i>BMJ, 324</i>, 432.

Charles, C., Whelan, T., Gafni, A., Reyno, L., & Redko, C. (1998). Doing nothing is no choice: Lay constructions of treatment decision-making among women with early-stage breast cancer. <i>Sociology of Health and Illness, 20</i>(1), 71-95.

Clark, A.M. (2003). "It's like an explosion in your life": Lay perspectives on stress and myocardial infarction. <i>Journal of Clinical Nursing, 12</i>, 544-553.

Clement, W., & Myles, J. (1994). <i>Relations of ruling: Class and gender in postindustrial societies</i>. Montreal, Canada: McGill-Queen's University Press.

Coburn, D. (2004). Beyond the income inequality hypothesis: Class, neoliberalism, and health inequalities. <i>Social Science and Medicine, 58</i>, 41-56.

Crooks, D.L. (2001). Older women with breast cancer: New understandings through grounded theory research. <i>Health Care for Women International, 22</i>, 99-114.

Deane, K.A., & Degner, L.F. (1998). Information needs, uncertainty, and anxiety in women who had a breast biopsy with benign outcome. <i>Cancer Nursing, 21</i>, 117-126.

Desai, M.M., Bruce, M.L., & Kasl, S.V. (1999). The effects of major depression and phobia on stage at diagnosis of breast cancer. <i>International Journal of Psychiatry in Medicine, 29</i>, 29-45.

Facione, N.C. (1993). Delay versus help seeking for breast cancer symptoms: A critical review of the literature on patient and provider delay. <i>Social Science and Medicine, 36</i>, 1521-1534.

Facione, N.C., Miaskowski, C., Dodd, M.J., & Paul, S.M. (2002). The selfreported likelihood of patient delay in breast cancer: New thoughts for early detection. <i>Preventive Medicine, 34</i>, 397-407.

Glazier, R.H., Creatore, M.I., Gozdyra, P., Matheson, F.I., Steele, L.S., Boyle, E., et al. (2004). Geographic methods for understanding and responding to disparities in mammography use in Toronto, Canada. <i>Journal of General Internal Medicine, 19</i>, 952-961.

Goodson, W.H., III, & Moore, D.H., II. (2002). Causes of physician delay in the diagnosis of breast cancer. <i>Archives of Internal Medicine, 162</i>, 1343-1348.

Guerra, C.E., Krumholz, M., & Shea, J.A. (2005). Literacy and knowledge, attitudes and behavior about mammography in Latinas. <i>Journal of Health Care for the Poor and Underserved, 16</i>, 152-166.

Gulitz, E., Hernandez, M.B., & Kent, E.B. (1998). Missed cancer screening opportunities among older women: A review. <i>Cancer Practice, 6</i>, 289-295.

Haas, J.S., Cook, E.F., Puopolo, A.L., Burstin, H.R., & Brennan, T.A. (2000). Differences in the quality of care for women with an abnormal mammogram or breast complaint. <i>Journal of General Internal Medicine, 15</i>, 321-328.

Harris, S.R., & Templeton, E. (2001). Who's listening? Experiences of women with breast cancer in communicating with physicians. <i>Breast Journal, 7</i>, 444-449.

Iezzoni, L.I., McCarthy, E.P., Davis, R.B., & Siebens, H. (2000). Mobility impairments and use of screening and preventive services. <i>American Journal of Public Health, 90</i>, 955-961.

Jenner, D.C., Middleton, A., Webb, W.M., Oommen, R., & Bates, T. (2000). In-hospital delay in the diagnosis of breast cancer. <i>British Journal of Surgery, 87</i>, 914-919.

Johnson, J.L., Bottorff, J.L., Balneaves, L.G., Grewal, S., Bhagat, R., Hilton, B.A., et al. (1999). South Asian women's views on the causes of breast cancer: Images and explanations. <i>Patient Education and Counseling, 37</i>, 243-254.

Kasper, A.S. (2000). Barriers and burdens: Poor women face breast cancer. In A.S. Kasper & S.J. Ferguson (Eds.), <i>Breast cancer: Society shapes an epidemic</i> (pp. 183-212). New York: St. Martin's Press.

Katapodi, M.C., Facione, N.C., Humphreys, J.C., & Dodd, M.J. (2005). Perceived breast cancer risk: Heuristic reasoning and search for a dominance structure. <i>Social Science and Medicine, 60</i>, 421-432.

Katz, S.J., Zemencuk, J.K., & Hofer, T.P. (2000). Breast cancer screening in the United States and Canada, 1994: Socioeconomic gradients persist. <i>American Journal of Public Health, 90</i>, 799-803.

Kickbusch, I.S. (2001). Health literacy: Addressing the health and education divide. <i>Health Promotion International, 16</i>, 289-297.

Kroman, N., Jensen, M.B., Wohlfahrt, J., Mouridsen, H.T., Andersen, P.K., & Melbye, M. (2000). Factors influencing the effect of age on prognosis in breast cancer: Population based study [Comment]. <i>BMJ, 320</i>, 474-478.

Langellier, K.M., & Sullivan, C.F. (1998). Breast talk in breast cancer narratives. <i>Qualitative Health Research, 8</i>, 76-94.

Lauver, D., Coyle, M., & Panchmatia, B. (1995). Women's reasons for and barriers to seeking care for breast cancer symptoms. <i>Women's Health Issues, 5</i>, 27-35.

Lawson, T. (1998). Economic science without experimentation. In M. Archer, R. Bhaskar, A. Collier, T. Lawson, & A. Norrie (Eds.), <i>Critical realism: Essential readings</i> (pp. 144-169). New York: Routledge.

Lerman, C., Trock, B., Rimer, B.K., Boyce, A., Jepson, C., & Engstrom, P.F. (1991). Psychological and behavioral implications of abnormal mammograms. <i>Annals of Internal Medicine, 114</i>, 657-661.

Li, C.I., Malone, K.E., & Daling, J.R. (2003). Differences in breast cancer stage, treatment, and survival by race and ethnicity. <i>Archives of Internal Medicine, 163</i>, 49-56.

Libstug, A.R., Moravan, V., & Aitken, S.E. (1998). Results from the Ontario breast screening program, 1990-1995. <i>Journal of Medical Screening, 5</i>(2), 73-80.

Mackillop, W.J., Fu, H., Quirt, C.F., Dixon, P., Brundage, M., & Zhou, Y. (1994). Waiting for radiotherapy in Ontario. <i>International Journal of Radiation Oncology, Biology, Physics, 30</i>, 221-228.

Mayo, N.E., Scott, S.C., Shen, N., Hanley, J., Goldberg, M.S., & MacDonald, N. (2001). Waiting time for breast cancer surgery in Quebec. <i>CMAJ, 164</i>, 1133-1138.

McEvoy, P., & Richards, D. (2003). Critical realism: A way forward for evaluation research in nursing? <i>Journal of Advanced Nursing, 43</i>, 411-420.

McGuire, W.L. (2005). Beyond EBM: New directions for evidence-based public health. <i>Perspectives in Biology and Medicine, 48</i>, 557-569.

McVea, K., Minier, W., & Palensky, J. (2001). Low-income women with early-stage breast cancer: Physician and patient decision-making styles. <i>Psycho-Oncology, 10</i>, 137-146.

Meana, M., Bunston, T., George, U., Wells, L., & Rosser, W. (2001). Influences on breast cancer screening behaviors in Tamil immigrant women 50 years old and over. <i>Ethnicity and Health, 6</i>, 179-188.

Miller, A., Benk, V., Rajan, R., & Dobkin, P. (1999). The burden of waiting. <i>Current Oncology, 3</i>(6), 188.

Montella, M., Crispo, A., Botti, G., De Marco, M., de Bellis, G., Fabbrocini, G., et al. (2001). An assessment of delays in obtaining definitive breast cancer treatment in southern Italy. <i>Breast Cancer Research and Treatment, 66</i>, 209-215.

Montella, M., Crispo, A., D'Aiuto, G., De Marco, M., de Bellis, G., Fabbrocini, G., et al. (2001). Determinant factors for diagnostic delay in operable breast cancer patients. <i>European Journal of Cancer Prevention, 10</i>, 53-59.

Moren, S., & Blom, B. (2003). Explaining human change: On generative mechanisms in social work practice. <i>Journal of Critical Realism, 2</i>(1), 37-60.

Muntaner, C., Lynch, J., & Oates, G.L. (1999). The social class determinants of income inequality and social cohesion. <i>International Journal of Health Services, 29</i>, 699-732.

Naish, J., Brown, J., & Denton, B. (1994). Intercultural consultations: Investigation of factors that deter non-English speaking women from attending their general practitioners for cervical screening. <i>BMJ, 309</i>, 1126-1128.

Nash, R. (1999). What is real and what is realism in sociology? <i>Journal for the Theory of Social Behaviour, 29</i>, 445-466.

Nekhlyudov, L., & Fletcher, S.W. (2001). Is it time to stop teaching breast self examination [Commentary]? <i>CMAJ, 164</i>, 1851-1852.

Nosarti, C., Crayford, T., Roberts, J.V., Elias, E., McKenzie, K., & David, A.S. (2000). Delay in presentation of symptomatic referrals to a breast clinic: Patient and system factors. <i>British Journal of Cancer, 82</i>, 742-748.

Nutbeam, D. (2001). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. <i>Health Promotion International, 15</i>, 259-267.

Oliveria, S.A., Christos, P.J., Halpern, A.C., Fine, J.A., Barnhill, R.L., & Berwick, M. (1999). Patient knowledge, awareness, and delay in seeking medical attention for malignant melanoma. <i>Journal of Clinical Epidemiology, 52</i>, 1111-1116.

Olivotto, I.A., Bancej, C., Goel, V., Snider, J., McAuley, R.G., Irvine, B., et al. (2001). Waiting times from abnormal breast screen to diagnosis in 7 Canadian provinces [Comment]. <i>CMAJ, 165</i>, 277-283.

Peek, M.E. (2003). Screening mammography in the elderly: A review of the issues. <i>Journal of the American Medical Women's Association, 58</i>, 191-198.

Phillips, J.M., Cohen, M.Z., & Moses, G. (1999). Breast cancer screening and African American women: Fear, fatalism, and silence. <i>Oncology Nursing Forum, 26</i>, 561-571.

Popay, J., Bennett, S., Thomas, C., Williams, G., Gatrell, A., Bostock, L. (2003). Beyond ‘beer, fags, egg and chips?’ Exploring lay understandings of social inequalities in health. <i>Sociology of Health and Illness, 25</i>, 1-23.

Popay, J., Williams, G., Thomas, C., & Gatrell, A. (1998). Theorising inequalities in health: The place of lay knowledge. <i>Sociology of Health and Illness, 20</i>, 619-644.

Rajaram, S.S., & Rashidi, A. (1999). Asian-Islamic women and breast cancer screening: A socio-cultural analysis. <i>Women and Health, 28</i>(3), 45-58.

Ramirez, A.J., Westcombe, A.M., Burgess, C.C., Sutton, S., Littlejohns, P., & Richards, M.A. (1999). Factors predicting delayed presentation of symptomatic breast cancer: A systematic review [Comment]. <i>Lancet, 353</i>, 1127-1131.

Rees, G., Fry, A., & Cull, A. (2001). A family history of breast cancer: Women's experiences from a theoretical perspective. <i>Social Science and Medicine, 52</i>, 1433-1440.

Richards, M.A., Smith, P., Ramirez, A.J., Fentiman, I.S., & Rubens, R.D. (1999). The influence on survival of delay in the presentation and treatment of symptomatic breast cancer. <i>British Journal of Cancer, 79</i>, 858-864.

Richardson, J.L., Langholz, B., Bernstein, L., Burciaga, C., Danley, K., & Ross, R.K. (1992). Stage and delay in breast cancer diagnosis by race, socioeconomic status, age and year. <i>British Journal of Cancer, 65</i>, 922-926.

Safer, M.A., Tharps, Q.J., Jackson, T.C., & Leventhal, H. (1979). Determinants of three stages of delay in seeking care at a medical clinic. <i>Medical Care, 17</i>, 11-29.

Sainsbury, R., Johnston, C., & Haward, B. (1999). Effect on survival of delays in referral of patients with breast-cancer symptoms: A retrospective analysis. <i>Lancet, 353</i>, 1132-1135.

Savage, S.A., & Clarke, V.A. (1998). Older women's illness representations of cancer: A qualitative study. <i>Health Education Research, 13</i>, 529-544.

Scambler, G. (2001). Critical realism, sociology and health inequalities: Social class as a generative mechanism and its media of enactment. <i>Journal of Critical Realism, 4</i>(1), 35-42.

Selvin, E., & Brett, K.M. (2003). Breast and cervical cancer screening: Sociodemographic predictors among white, black, and Hispanic women. <i>American Journal of Public Health, 93</i>, 618-623.

Sen, A. (1993). The economics of life and death. <i>Scientific American, 268</i>(5), 40-47.

Smith, D. (1987). <i>The everyday world as problematic: A feminist sociology</i>. Toronto, Canada: University of Toronto Press.

Smith, D. (1990). <i>The conceptual practices of power</i>. Toronto, Canada: University of Toronto Press.

Smith, D. (1999). <i>Writing the social: Critique, theory, and investigations</i>. Toronto, Canada: University of Toronto Press.

Tartter, P.I., Pace, D., Frost, M., & Bernstein, J.L. (1999). Delay in diagnosis of breast cancer. <i>Annals of Surgery, 229</i>, 91-96.

Tatla, R.K., Paszat, L.F., Bondy, S.J., Chen, Z., Chiarelli, A.M., & Mai, V. (2003). Socioeconomic status and returning for a second screen in the Ontario breast screening program. <i>Breast, 12</i>, 237-246.

Thompson, B., Montano, D.E., Mahloch, J., Mullen, M., & Taylor, V. (1997). Attitudes and beliefs toward mammography among women using an urban public hospital. <i>Journal of Health Care for the Poor and Underserved, 8</i>, 186-201.

Tjemsland, L., & Soreide, J.A. (2004). Operable breast cancer patients with diagnostic delay—Oncological and emotional characteristics. <i>European Journal of Surgical Oncology, 30</i>, 721-727.

Underwood, S.M., Shaikha, L., & Bakr, D. (1999). Veiled yet vulnerable. Breast cancer screening and the Muslim way of life. <i>Cancer Practice, 7</i>, 285-290.

Vahabi, M., & Gastaldo, D. (2003). Rational choice(s)? Rethinking decision-making on breast cancer risk and screening mammography. <i>Nursing Inquiry, 10</i>, 245-256.

Waitzkin, H. (1989). A critical theory of medical discourse: Ideology, social control, and the processing of social context in medical encounters. <i>Journal of Health and Social Behavior, 30</i>, 220-239.

Wilkinson, R.G. (1999). Income inequality, social cohesion, and health: Clarifying the theory—A reply to Muntaner and Lynch. <i>International Journal of Health Services, 29</i>, 525-543.

Williams, S.J. (1999). Is anybody there? Critical realism, chronic illness and the disability debate. <i>Sociology of Health and Illness, 21</i>, 797-819.

Williams, S.J. (2003). Beyond meaning, discourse and the empirical world: Critical realist reflections on health. <i>Social Theory and Health, 1</i>(1), 42-71.

Yabroff, K.R., & Gordis, L. (2003). Does stage at diagnosis influence the observed relationship between socioeconomic status and breast cancer incidence, case-fatality, and mortality? <i>Social Science and Medicine, 57</i>, 2265-2279.