Dr Rebecca Spencer

People with type 2 diabetes (T2DM) are more likely to develop cancer and experience poorer cancer-related outcomes. Despite this, women with diabetes are less likely to participate in cancer screening than women without diabetes. Previous research suggests there are diabetes-related barriers to cancer screening, but very few studies have sought to identify and characterise these barriers. The current PhD aimed to address this research gap, by advancing knowledge and understanding of diabetes-related barriers to cancer screening and potential intervention strategies. Study one undertook a novel, comprehensive systematic review of qualitative research, exploring barriers and facilitators to cancer screening among people living with any type of chronic illness or disability (n = 70 articles). The review revealed a paucity of studies examining bowel cancer screening, and which have been conducted outside the USA. Only one study exclusively examined cancer screening among people with diabetes. Consequently, study two conducted, for the first time, in-depth qualitative interviews examining views and experiences of cervical, breast and bowel cancer screening among women with T2DM in England (n = 25). Interviews identified several diabetes-related barriers and facilitators to cancer screening and potential ways to address and promote these, respectively. Study three developed a novel, brief written intervention (containing a threat and/or coping message), based on Protection Motivation Theory, to address lack of awareness of the T2DM-increased risk of bowel cancer (a key diabetes-related barrier identified in the interviews). An online randomised controlled experiment (n = 349) found no effects of the intervention on cancer screening intentions, likely due in part to a ceiling effect. However, the coping message significantly increased self-efficacy, and decreased response costs and perceived severity. Overall, the thesis findings elucidate how having diabetes can both heighten and add barriers to cancer screening and indicate multifaceted potential intervention targets and strategies to address these.

Objectives People with type 2 diabetes (T2DM) are more likely to develop breast and bowel cancers. Despite this, cancer screening participation is lower among women with diabetes than among women without diabetes, indicating diabetes-related barriers to screening, but little research has examined this. This study aimed to identify and understand diabetes-related barriers to cancer screening, and potential ways to address these, among women with T2DM. Design In-depth qualitative interviews. Methods Semi-structured interviews with 25 women with T2DM, aged 50 to 74 years, living in England. Participants were recruited via diabetic eye screening clinics and community advertisement. Data were analysed to develop themes, using the framework method. Results Women with T2DM were often living with an accumulated high burden of illness and its treatment, due to diabetes and comorbidities, which reduced their capacity to participate in cancer screening (e.g. physical and psychological capacities; practical resources). Having diabetes could complicate taking part in screening tests for some people (e.g. physical difficulties during screening related to diabetes, its treatment, complications or comorbidities; having to consider glycaemic control during appointments). There appeared to be underappreciation of the T2DM-increased risk of cancer, and limited cancer screening promotion within diabetes care. Conclusions Despite self-reported cancer screening uptake being high among study participants, having diabetes appeared to heighten common barriers to cancer screening (e.g. travel-related, logistical and scheduling barriers), whilst also posing additional unique barriers (e.g. diabetes-related stigma and embarrassment). Several potential strategies are suggested to improve cancer screening informed decision-making and participation among people with T2DM.

Background: Individuals with chronic illnesses and disabilities are less likely to participate in cancer screening than people without, with some research indicating that cancer screening participation rates decline as levels of morbidity or disability increase. Aims: This systematic review aimed to: (1) better understand the illness and disability-related barriers and facilitators to cancer screening participation experienced by people with chronic illnesses and disabilities; (2) understand how clinical and sociodemographic characteristics influence these barriers/facilitators; and (3) identify limitations and gaps in this literature to date. Methods: CINAHL, Medline and PsycInfo were searched, using a search strategy developed based on the Adult CoMorbidity Evaluation-27. Citation searching (backward and forward) was conducted. Studies containing qualitative data about experiences of/perspectives on cancer screening, from people with one or more chronic illnesses (physical or mental) and/or disabilities (physical or intellectual) were included. All screening (title, abstract and full-text) was 100% conducted by two independent reviewers. 20% of data extraction and quality appraisal (using the Mixed Methods Appraisal Tool) was double-checked. Thematic synthesis was conducted, with 10% of articles double-coded. Results/Conclusions: Seventy articles were included, covering a range of chronic illnesses and disabilities. Most studies focussed on cervical and/or breast cancer screening. Having a chronic illness or disability exacerbated existing barriers to screening (e.g. pain/discomfort; anxiety) and added additional barriers. Individuals frequently experienced reduced physical and/or psychological capability to participate, which was often compounded by having additional work to perform (e.g. arranging medical transport; self-advocating). Barriers beyond the individual’s control (e.g. inaccessible screening facilities), sometimes proved insurmountable. Occasionally, individuals were advised against screening, due to increased risks and/or reduced benefits. This is the first systematic review to synthesise qualitative evidence about cancer screening, from people with any type of chronic illness or disability. The findings will identify areas for further research and may inform future interventions.

Background: People with type 2 diabetes (T2DM) are more likely to develop breast and bowel cancers. Despite this, cancer screening participation is lower among women with diabetes than among women without diabetes, indicating there are diabetes-related barriers to screening, but little research has examined this. Two interlinked studies aimed to advance knowledge and understanding of diabetes-related barriers to cancer screening and potential intervention strategies. Methods: Study-1: Semi-structured interviews examining cancer screening views and experiences were conducted with 25 women with T2DM in England. Data were analysed to develop themes, using the framework method. Study-2: A brief written intervention (containing a threat and/or coping message) was developed, based on Protection Motivation Theory (PMT), to address low awareness of the T2DM-increased risk of bowel cancer (a key diabetes-related barrier identified in the interviews). An online randomised controlled experiment (N = 349) with people with T2DM assessed the effect of the intervention on PMT constructs and bowel screening intentions, using between-subjects MANOVA and binary logistic regression. Results: Interviews identified several diabetes-related barriers to cancer screening (e.g. having a high burden of illness and its treatment consumes personal resources; diabetes-related stigma and embarrassment; low promotion of cancer risk/screening within diabetes care) and potential ways to address these. The novel intervention had no significant effects on screening intentions, likely due in part to a ceiling effect. However, the coping message significantly increased self-efficacy (F(1, 345) = 12.65, p <.001, ηp2 = .04), and decreased response costs (F(1, 345) = 19.15, p <.001, ηp2 = .05) and perceived severity (F(1, 345) = 7.36, p = .007, ηp2 = .02). Conclusions and implications: Having diabetes can both heighten and add barriers to cancer screening. Findings suggest multifaceted potential intervention targets and strategies to address these barriers, including providing cancer risk and screening information on diabetes websites.