Today, we’re speaking to Dr Afrodita Marcu, a Research Fellow in Cancer Care at the University of Surrey.

Title of paper: Symptom appraisal and help- seeking before a cancer diagnosis during pregnancy: a qualitative study

Available at: https://doi.org/10.3399/BJGP.2024.0208

There is a gap in current understanding about the experiences of women diagnosed with cancer during or around pregnancy including how they appraise and seek help for cancer-related symptoms. This qualitative study found that women and healthcare professionals often interpreted symptoms through the lens of pregnancy, particularly when symptoms were vague. Health professionals need to ensure full assessment of symptoms, timely referral, and effective safety-netting for these women.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:01.040 - 00:01:04.650

Hello and welcome to BJJP Interviews. I'm Nada Khan and I'm one of the associate editors of the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.

Aphrodite Marcoux, a research fellow in Cancer care at the University of Surrey.

We're here to talk about a paper she's recently published here in the bjgp, which is titled Symptom Appraisal and Help Seeking Before a Cancer Diagnosis during Pregnancy, A Qualitative Study. So it's really lovely to meet you, Aphrodita, to talk about your research.

And I think this is a really important area and I wanted to get your thoughts on just why this area is so important to research.

But I think that most people will probably appreciate that during pregnancy, women's bodies are going through lots of changes, so it can sometimes be difficult to know what's normal and what's not. But talk us through why you wanted to do this study.

What are the challenges faced by patients and by doctors around cancer diagnosis in women who are pregnant?

Speaker B

00:01:05.050 - 00:02:32.190

It's an important area to research because the symptoms of pregnancy, the bodily changes that naturally occur during pregnancy, can mask the symptoms of cancer, both for the women experiencing them, but also for the healthcare professionals with whom they come into contact and with whom they share the symptoms.

So it's an important area to research from that point of view in terms of understanding the potential causes for delay in receiving a cancer diagnosis.

And one of the areas which we discovered was less researched was early diagnosis or timeliness of diagnosis of cancer diagnosis in the context of pregnancy.

So we conducted this research because there was a lack of research, especially in the uk, on women's pathway or other pathways to a cancer diagnosis and pregnancy.

And we wanted to get a more detailed understanding knowledge of how women make sense of their symptoms during pregnancy, how they seek help and why to whom they present, midwife, gp, other healthcare professionals and how they receive a diagnosis. What is the pathway to a cancer diagnosis and pregnancy?

We wanted to get more clarity about that, more detail, and we were also interested to find out whether delays characterize this pathway to a cancer diagnosis in pregnancy, be they patient related delays or healthcare system related delays.

Speaker A

00:02:32.830 - 00:02:44.750

And I guess you've touched on this. So does do we know if there are delays in cancer diagnosis amongst women who are pregnant?

So do they tend to have a later diagnosis than women who aren't pregnant?

Speaker B

00:02:45.540 - 00:03:15.770

International research suggests so. For example, in relation to breast cancer, which is the most frequent cancer diagnosed during pregnancy?

Women are typically diagnosed later or later stage breast cancer than women who are not pregnant of similar age groups.

So there is some indication that in the body of literature around cancer in pregnancy that women might receive a later diagnosis compared to women who are not pregnant.

Speaker A

00:03:16.570 - 00:03:56.710

And this was a qualitative research study. So your team talked to women diagnosed with cancer during or soon after pregnancy and you talked to 20 women.

And I really wanted to focus on what you found here. And you used an interesting model here.

So you map the findings of your research onto a commonly used framework in cancer diagnosis, the models of pathway to treatment. So you've talked about sort of these pathways that women experience during their cancer diagnosis journey during pregnant.

And I wanted to just talk through some of the findings. So when women were pregnant, how did they interpret their symptoms that may or may not have been related to cancer?

Speaker B

00:03:58.390 - 00:06:22.420

Well, they interpreted these symptoms in various ways and that depended on the type of cancer they had, but also the type of symptom or symptoms that they experienced.

So, for example, we had a couple of women with colon cancer, bowel cancer, one of them had abdominal pain and bloatedness, bloating, whilst the other one had blood in the stool. So obviously the symptoms were interpreted differently by the two women.

The one with blood in the stool saw this as incongruent with pregnancy because it's very unusual to have blood in stool during pregnancy, and looked up her symptoms online, did some reading and decided that these symptoms warrant medical attention. So she contacted her GP fairly promptly.

The other lady with more diffuse symptoms with abdominal pain and bloating repeatedly mentioned these symptoms to her midwife, but these were put down to pregnancy. And she always, when she actually engaged in information seeking online, she always added in pregnancy.

So she saw these symptoms as being part of the pregnancy, was her first child, and thought it's normal to have abdominal pain or to feel bloated during pregnancy. So she was actually diagnosed quite late with stage 4 colon cancer.

Of course, we are not drawing cause effect conclusions because this was a qualitative study, but we do find that the symptoms, which are vague, are more likely to be interpreted as being signs or symptoms of pregnancy, as being pregnancy related bodily changes.

So it depends on the type of symptom that people symptoms that people experience, but also depends on the type of cancer they have, because some cancers, such as breast cancer, are more people are more familiar with breast cancer, let's say, than with lymphoma or other types of cancer, and they're more likely to see breast lumps which are typical symptom of breast cancer as being indicative or being suggestive of breast cancer, and it makes them more worried and more inclined, speak to a healthcare professional to see their GP promptly. So for women who experience breast lumps, the pathway was in a sense clearer.

They knew who to contact and also the healthcare professional in question, the GP was more likely to make referrals to tests and secondary care, refer them to the breast clinic.

Speaker A

00:06:22.980 - 00:06:30.180

I think it was interesting in the paper you described this as people viewing their symptoms through the lens of pregnancy.

Speaker B

00:06:30.620 - 00:07:20.420

Yes.

So the pregnancy offered for the women sort of heuristic and also in competitive lens, they understood their symptoms in the context of the pregnancy.

Of course, people, women expected their bodies to change during pregnancy, such as breasts becoming larger or various lumps appearing, perhaps being related to milk ducts and things like that. So they always thought of pregnancy as being the reason for their bodily changes rather than cancer.

So again, we have different patient histories, different types of symptoms, and this leads to different ways or different pathways to cancer.

Diagnosis in pregnancy for some people can be a very straightforward pathway, for others, it's more prolonged, one more complicated one because of the types of symptoms they experience.

Speaker A

00:07:21.380 - 00:07:36.880

And I guess the flip side to this is what the healthcare professionals did with women coming to them with symptoms during their pregnancy.

And this is all from the perspective of the women you talked to in the study, but what did they feel that the healthcare professionals thought of their symptoms when they presented to them?

Speaker B

00:07:37.120 - 00:09:06.970

Well, I suppose it varied from individual to individual.

In some cases, the healthcare professionals thought that the symptoms were due to pregnancy, saying it's hormonal, just hormonal changes, nothing to worry about.

In some cases they thought that the baby was lying on a nerve, which explained why people had symptoms such as back pain or breathlessness or other symptoms, in some cases, the gps thought it is hormonal change, it's probably due to pregnancy, but I will refer the patient to a breast clinic because the system is there in place, it's better to rule it out quickly. So some women had prompt referrals to breast clinics for breast related changes, such as breast lumps.

In some cases, there were some other contextual factors which led the GPs or other healthcare professionals to interpret the symptoms.

For example, one lady had bleeding from the nipple and that was explained as being caused by her child jumping on her or just causing some sort of physical damage. So sometimes there were some other factors which helped explain the symptoms and why they occurred.

But in terms of how women reported their interactions with the, with the gps or sometimes with the midwives, I think this actually varied, but according to the symptoms and to the person they were talking to and also their personal histories as well in terms of having previous breast related changes or having a previous diagnosis of breast cancer.

Speaker A

00:09:07.210 - 00:09:43.030

So I guess I'm hearing two different things. One is that it depended if the symptoms were congruent with pregnancy or not, so that sort of affected the patient and clinician side.

And then another thing you've mentioned a few times is the ease of referrals. And for instance, like you were talking about breast lumps, there's a very recognized easy to use system for that.

So I'd imagine that that's an easier pathway to refer to with clear guidelines on what to do. So it feels like those two different areas might have affected patient presentation and also what the healthcare professionals did.

Speaker B

00:09:43.430 - 00:11:43.590

Yes, exactly, yes. So, I mean, our sample was quite heterogeneous.

So the majority of our sample, 13 women, had the breast cancer diagnosis, but the other participants in our study had different types of cancer, such thyroid Hodgkin lymphoma, non Hodgkin lymphoma, colon cancer, malignant melanoma. So because our sample was heterogeneous, it's difficult to think, you know, there's actually one pathway to a cancer diagnosis in pregnancy.

There are many pathways and that depends on the type of cancer, personal history, previous interaction with healthcare professionals, previous presentations for similar symptoms in the past. So there are many factors which actually influence women's and healthcare professionals interpretation of these symptoms during pregnancy.

Yeah, I would say there are many pathways rather than a pathway to cancer diagnosis.

But it's fair to say that across the sample what we saw was that women were inclined, they tended to see their symptoms as being caused by pregnancy or pregnancy was the first thing they thought of, whilst at the same time considering other potential explanations such as cancer.

So for example, women with breast lumps realized that this could be breast cancer, but at the same time wanted to believe they were linked to pregnancy.

So with some sort of kind of dual thinking or dilemmatic thinking, it's not that people thought of one cause, people thought of many causes, but also there was some sort of hope or refusal to believe this could be cancer, because it's obviously frightening time and experience for this woman, especially during pregnancy, whilst they're pregnant.

And it's not necessarily something they wanted to believe in the first place, but they ruled out that the potential explanation, seeing that the symptoms persisted or got worse, such as the breast lump getting bigger or the pain getting worse, I.

Speaker A

00:11:43.590 - 00:11:53.810

Thought it was an interesting pointer that you had in the paper for clinicians, which was the to assess the symptom, not the pregnancy. So I wonder if you could talk through that a little bit.

Speaker B

00:11:53.890 - 00:12:55.420

Yes.

I think what we recommend, based on our findings, is that GPs or other healthcare professionals that women report their symptoms to should see the think of the symptoms and not actually the pregnancy.

So should isolate the symptoms from the pregnancy and think in a person that is not pregnant, what would I think the symptom might be or what tests would I recommend?

So it's about that thinking about it outside the context of pregnancy, so that the focus should be on how that symptom should warrant further investigations and not explain everything as being pregnancy related.

So one recommendation would be for healthcare professionals, GPs to perform physical examinations, unusual blood tests and take into account the clinical history of the women presenting with these symptoms and not describe these symptoms to pregnancy. Just consider that those symptoms in their own right.

Speaker A

00:12:56.060 - 00:13:10.460

And you also talk about the importance of safety netting, I think, and you touched upon this even from the women's perspective about when things were getting worse, that acted as a bit of a nudge for them to come back or to seek medical attention in the first place as well.

Speaker B

00:13:11.350 - 00:14:05.560

Yeah.

So if GP suspect that the symptoms are not cancer, they should agree sort of management plan with the women in questions and give them an idea about how long they should expect those symptoms to last and what they should do if those symptoms persist and encourage them to return if the symptoms not go away, and also tell them what to do if the symptoms worsen.

So they should have safety netting in place for the management of the symptoms and for future help seeking on the part of these women if the symptoms persist. And women should be reassured and encouraged to return if the symptoms do not go away.

So in our study we found that some women represented multiple times to their GP and some of them actually were diagnosed only after emergency presentation.

Speaker A

00:14:06.270 - 00:14:24.110

So that's been a really interesting discussion around this paper and it's been just really interesting, I think, hearing about this research and some really clear messages for clinicians as well. But I think that's a great place to wrap things up. So I just really wanted to say thank you very much for your time. Aperita.

Speaker B

00:14:24.190 - 00:14:24.830

Thank you.

Speaker A

00:14:26.190 - 00:14:51.810

And thank you all very much for your time here and for listening to this BJGP podcast.

I hope you found today's research discussion helpful, not just for your practice, but also in thinking about other research questions coming out from this area. Aphrodita's original research article can be found on bjgp.org and the show notes and podcast audio can be [email protected] thanks again. And bye.