Dr Katriina Whitaker

Reader in Cancer Care
BSc, MSc, PhD, CPsychol
+44 (0)1483 684622
9-5pm, except Thursdays


My qualifications

PhD in Psychology (CR-UK Studentship)
University College London
MSc in Research Methods (Distinction)
University College London
BSc in Experimental Psychology (1st Class)
University of Bristol


Research interests

Research projects

Research collaborations

Indicators of esteem

  • February 2017- current. Fellow of the British Psychological Society (BPS)


  • May 2016-current. Member of the Psycho-Oncology Journal Affiliate Editorial Board

  • February 2016-current. Member of the National Cancer Research Institute (NCRI) Primary Care Clinical Study Group (CSG).

  • August 2015-current: Member of the National Cancer Research Institute (NCRI) Primary Care Early Diagnosis sub-group.

  • April 2015-current: Expert Panel Member, Early Diagnosis Panel of Population Research Committee, Cancer Research UK.

  • April 2015-current: Committee member of IPOS Communications and Publications Committee.

  • March 2015-current: Editorial Board Member, European Journal of Cancer Care.

  • November 2014-current: Honorary Senior Research Fellow, Epidemiology and Public Health, University College London.

  • November 2013-current: Scholar, Editorial Board, British Journal of Health Psychology

  • Jan 2012-current: Chartered member (CPsychol) of British Psychological Society (BPS).


My teaching

My publications



von Wagner, C., Good, A., Whitaker, K.L., Wardle, J. (2011). Psychosocial determinants of socioeconomic inequalities in cancer screening participation: A conceptual framework. Epidemiologic Reviews, 33, 135-147.


Whitaker, K.L., Scott, S., Winstanley, K., Macleod, U., Wardle, J.   (2014). Attributions of cancer ‘alarm’ symptoms in a community sample. PLOS One, 9 (12):e114028, DOI: 10.1371/journal.pone.0114028


Whitaker, K.L., Macleod, U., Winstanley, K., Scott, S., Wardle, J. (2015). Help-seeking for cancer ‘alarm’ symptoms: a qualitative interview study. British Journal of General Practice, 65(631); e96-e105.


Whitaker, K.L., Scott, S., Wardle, J.  (2015) Applying symptom appraisal models to understand socio-demographic differences in responses to possible cancer symptoms: A research agenda. British Journal of Cancer, 112, Suppl 1: S27-S34, doi: 10.1038/bjc.2015.39.


Whitaker, K.L., Friedemann Smith, C., Winstanley K., Wardle, J. (2016). What prompts help-seeking for cancer ‘alarm’ symptoms? A primary care based survey. British Journal of Cancer, 114, 334-339, doi: 10.1038/bjc.2015.445


Davies, H., Marcu, A., Vedsted, P., Whitaker, K.L (2018). Is lower symptom recognition associated with socioeconomic inequalities in help-seeking for potential breast cancer symptoms? Psycho-Oncology, 27 (2), 626-632.


Whitaker K, Winstanley K, Macleod U, Scott S, Wardle J (2015) Low cancer suspicion following experience of a cancer ?warning sign?,European Journal of Cancer51(16)pp. 2473-2479 Elsevier
Aim Lower socioeconomic status (SES) is associated with a higher risk of late-stage cancer diagnosis. A number of explanations have been advanced for this, but one which has attracted recent attention is lower patient knowledge of cancer warning signs, leading to delay in help-seeking. However, although there is psychometric evidence of SES differences in knowledge of cancer symptoms, no studies have examined differences in ?cancer suspicion? among people who are actually experiencing a classic warning sign. Methods A ?health survey? was mailed to 9771 adults (~50 years, no cancer diagnosis) with a symptom list including 10 cancer ?warning signs?. Respondents were asked if they had experienced any of the symptoms in the past 3 months, and if so, were asked ?what do you think caused it?? Any mention of cancer was scored as ?cancer suspicion?. SES was indexed by education. Results Nearly half the respondents (1732/3756) had experienced a ?warning sign?, but only 63/1732 (3.6%) mentioned cancer as a possible cause. Lower education was associated with lower likelihood of cancer suspicion: 2.6% of respondents with school-only education versus 7.3% with university education suspected cancer as a possible cause. In multivariable analysis, low education was the only demographic variable independently associated with lower cancer suspicion (odds ratio (OR) = 0.34, confidence interval (CI): 0.20?0.59). Conclusion Levels of cancer suspicion were low overall in this community sample, and even lower in people from less educated backgrounds. This may hinder early symptomatic presentation and contribute to inequalities in stage at diagnosis.
Harvey AG, Stinson K, Whitaker KL, Moskovitz D, Virk H (2008) The subjective meaning of sleep quality: A comparison of individuals with and without insomnia, Sleep31(3)pp. 383-393
Study objectives: "Sleep quality" is poorly defined yet ubiquitously used by researchers, clinicians and patients. While poor sleep quality is a key feature of insomnia, there are few empirical investigations of sleep quality in insomnia patients. Accordingly, our aim was to investigate the subjective meaning of sleep quality among individuals with insomnia and normal sleepers. Design: Cross sectional between groups (insomnia vs. good sleeper). Analyses were conducted across three outcome variables: (1) a "Speak Freely" procedure in which participants' descriptions of good and poor sleep quality nights were analysed, (2) a "Sleep Quality Interview" in which participants judged the relative importance of variables included in previous research on sleep quality and (3) a sleep quality diary completed over seven consecutive nights. Setting: University Department of Psychiatry Participants: Individuals with insomnia (n = 25) and normal sleepers (n = 28). Interventions: N/A Results: Both the insomnia and normal sleeper groups defined sleep quality by tiredness on waking and throughout the day, feeling rested and restored on waking, and the number of awakenings they experienced in the night. The insomnia group had more requirements for judging sleep to be of good quality. Conclusion: The meaning of sleep quality among individuals with insomnia and normal sleepers was broadly similar. A comprehensive assessment of a patient's appraisal of their sleep quality may require an assessment of waking and daytime variables.
Low EL, Whitaker KL, Simon AE, Sekhon M, Waller J (2015) Women's interpretation of and responses to potential gynaecological cancer symptoms: a qualitative interview study, BMJ OPEN5(7)ARTN e008082 BMJ PUBLISHING GROUP
Whitaker KL, Scott SE, Winstanley K, Cromme S, Macleod U, Wardle J (2014) The association between normalising attributions and help-seeking for cancer alarm symptoms in the community: a cross-sectional survey, LANCET384pp. 86-86 ELSEVIER SCIENCE INC
Whitaker KL, Scott SE, Winstanley K, Macleod U, Wardle J (2014) Attributions of cancer 'alarm' symptoms in a community sample., PLoS One9(12)
BACKGROUND: Attribution of early cancer symptoms to a non-serious cause may lead to longer diagnostic intervals. We investigated attributions of potential cancer 'alarm' and non-alarm symptoms experienced in everyday life in a community sample of adults, without mention of a cancer context. METHODS: A questionnaire was mailed to 4858 adults (e50 years old, no cancer diagnosis) through primary care, asking about symptom experiences in the past 3 months. The word cancer was not mentioned. Target 'alarm' symptoms, publicised by Cancer Research UK, were embedded in a longer symptom list. For each symptom experienced, respondents were asked for their attribution ('what do you think caused it'), concern about seriousness ('not at all' to 'extremely'), and help-seeking ('did you contact a doctor about it': Yes/No). RESULTS: The response rate was 35% (n = 1724). Over half the respondents (915/1724; 53%) had experienced an 'alarm' symptom, and 20 (2%) cited cancer as a possible cause. Cancer attributions were highest for 'unexplained lump'; 7% (6/87). Cancer attributions were lowest for 'unexplained weight loss' (0/47). A higher proportion (375/1638; 23%) were concerned their symptom might be 'serious', ranging from 12% (13/112) for change in a mole to 41% (100/247) for unexplained pain. Just over half had contacted their doctor about their symptom (59%), although this varied by symptom. Alarm symptoms were appraised as more serious than non-alarm symptoms, and were more likely to trigger help-seeking. CONCLUSIONS: Consistent with retrospective reports from cancer patients, 'alarm' symptoms experienced in daily life were rarely attributed to cancer. These results have implications for understanding how people appraise and act on symptoms that could be early warning signs of cancer.
Whitaker KL, Watson M, Brewin CR (2009) Intrusive cognitions and their appraisal in anxious cancer patients., Psychooncology18(11)pp. 1147-1155
OBJECTIVE: Previous research found that anxious cancer patients experience uncontrollable negative intrusive cognitions that have an impact on coping and are associated with significant psychological distress. This is the first study to examine the appraisal of intrusive cognitions in an anxious group of cancer patients. METHODS: A sample of 139 anxious cancer patients was assessed for evidence of intrusive phenomena, including memories, images and thoughts. Patients completed the Response to Intrusions Questionnaire and the Impact of Event Scale in relation to intrusive cognitions. RESULTS: Forty-eight percent (67/139) reported frequent, uncontrollable intrusive cognitions. Intrusive thoughts and images were equally as common and images were associated with increased distress and uncontrollability. A significant positive linear relationship was found between the number of intrusions and anxiety severity (P<0.05). Negative appraisal of intrusive cognitions was associated with anxiety (P<0.01) and depression severity (P<0.01), intrusion-specific distress (P<0.01), rumination (P<0.01) and cognitive avoidance (P<0.01), after controlling for intrusion frequency. CONCLUSION: Negative appraisal of intrusive cognitions plays a significant role in psychological distress and intrusion-specific distress in anxious cancer patients. Finding similarities in the types of intrusive cognitions reported by cancer patients and other anxious populations highlights the potential applicability of psychological therapies developed to reduce the frequency and impact of intrusive cognitions.
Whitaker KL, Jarvis MJ, Beeken RJ, Boniface D, Wardle J (2010) Comparing maternal and paternal intergenerational transmission of obesity risk in a large population-based sample., Am J Clin Nutr91(6)pp. 1560-1567
BACKGROUND: Previous research showed childhood obesity to be more strongly associated with maternal weight than with paternal weight. However, confidence in this finding is limited by the lack of objectively measured data from both parents. OBJECTIVE: We quantified the individual and combined effects of maternal and paternal overweight/obesity on obesity risk in children. DESIGN: Data were pooled from the annual Health Surveys for England carried out between 2001 and 2006. Families with < or =2 children aged 2-15 y with anthropometric data available for both parents and children were included (n = 4432 families, n = 7078 children). Weights and heights were measured by a trained nurse. RESULTS: Having 2 overweight parents was associated with an increased risk of child obesity [odds ratio (OR): 2.2; 95% CI: 1.3, 3.7; P < 0.001] compared with having 2 normal-weight parents. Having 2 obese (including severely obese) parents was associated with a higher risk of child obesity (OR: 12.0; 95% CI: 7.2, 20.1; P < 0.01), and having 2 severely obese parents was associated with an even higher risk of child obesity (OR: 22.3; 95% CI: 10.3, 48.4; P < 0.01) independent of age, sex, socioeconomic status, and ethnicity. Mother-child associations (r = 0.27) for body mass index were significantly stronger than father-child associations (r = 0.23), even after adjustment for plausible levels (< or =4%) of undisclosed nonpaternity. Associations were the same for sons and daughters but increased with age. CONCLUSIONS: There is a strong and graded association between parental weight status and risk of childhood obesity, which is significantly stronger for maternal weight. Parental obesity could be used to target preventive interventions in the preschool years to avoid serious adverse effects on the future health of children.
von Wagner C, Good A, Whitaker KL, Wardle J (2011) Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework., Epidemiol Rev33pp. 135-147
Cancer screening participation shows a strong, graded association with socioeconomic status (SES) not only in countries such as the United States, where insurance status can be a barrier for lower income groups, but also in the United Kingdom, where the National Health Service provides all health care to residents, including screening, for free. Traditionally, the literature on socioeconomic inequalities has focused on upstream factors, but more proximal (downstream) influences on screening participation also need to be examined, particularly those that address the graded nature of the association rather than focusing specifically on underserved groups. This review offers a framework that links some of the components and corollaries of SES (life stress, educational opportunities, illness experience) to known psychosocial determinants of screening uptake (beliefs about the value of early detection, fatalistic beliefs about cancer, self-efficacy). The aim is to explain why individuals from lower SES backgrounds perceive cancer screening tests as more threatening, more difficult to accomplish, and less beneficial. A better understanding of the mechanisms through which lower SES causes negative attitudes toward screening could facilitate the development of intervention strategies to reduce screening inequalities.
Whitaker KL, Brewin CR, Watson M (2010) Imagery rescripting for psychological disorder following cancer: a case study., Br J Health Psychol15(Pt 1)pp. 41-50
OBJECTIVES: Intrusive memories have been identified in cancer patients and associated with psychological distress and maladaptive adjustment. Imagery rescripting is a psychological therapy that has proved successful for reducing the impact and distress associated with intrusive memories in various populations (e.g. depression). This paper describes the first application of this technique for a cancer patient reporting intrusive memories. DESIGN: A single-case design was used to assess the stand-alone therapy. RESULTS: Imagery rescripting was associated with significant reductions in the adverse impact of intrusive memories and psychological distress and these effects remained at 3- and 6-month follow-up. CONCLUSIONS: Imagery rescripting shows promise for utility in medical patients experiencing intrusive memories.
OBJECTIVES: This literature review examined research into the impact of a previous 'all-clear' or non-cancer diagnosis following symptomatic presentation ('false alarm') on symptom attribution and delays in help seeking for subsequent possible cancer symptoms. DESIGN AND SETTING: The comprehensive literature review included original research based on quantitative, qualitative and mixed data collection methods. We used a combination of search strategies, including in-depth searches of electronic databases (PubMed, EMBASE, PsychInfo), searching key authors and articles listed as 'related' in PubMed, and reference lists. We performed a narrative synthesis of key themes shared across studies. PARTICIPANTS: The review included studies published after 1990 and before February 2014 reporting information on adult patients having experienced a false alarm following symptomatic presentation. We excluded false alarms in the context of screening. PRIMARY AND SECONDARY OUTCOME MEASURES: We evaluated the effect of a 'false alarm' on symptom attribution and help seeking for new or recurrent possible cancer symptoms. RESULTS: Overall, 1442 papers were screened and 121 retrieved for full-text evaluation. Among them, 19 reported on false alarms and subsequent symptom attribution or help seeking. They used qualitative (n=14), quantitative (n=3) and mixed methods (n=2). Breast (n=7), gynaecological (n=3), colorectal (n=2), testicular (n=2), and head and neck cancers (n=2) were the most studied. Two broad themes emerged underlying delays in help seeking: (1) over-reassurance from the previous 'all-clear' diagnosis leading to subsequent symptoms being interpreted as benign, and (2) unsupportive healthcare experiences in which symptoms were dismissed, leaving patients concerned about appearing hypochondriacal or uncertain about the appropriate next actions. The evidence suggested that the effect of a false alarm can persist for months and even years. CONCLUSIONS: In conclusion, over-reassurance and undersupport of patients after a false alarm can undermine help seeking in the case of new or recurrent potential cancer symptoms, highlighting the need for appropriate patient information when investigations rule out cancer.
Whitaker KL, Winstanley K, Macleod U, Scott SE, Wardle J (2015) Low cancer suspicion following experience of a cancer 'warning sign', EUROPEAN JOURNAL OF CANCER51(16)pp. 2473-2479 ELSEVIER SCI LTD
BACKGROUND: Sociodemographic inequalities in the stage of diagnosis and cancer survival may be partly due to differences in the appraisal interval (time from noticing a bodily change to perceiving a reason to discuss symptoms with a health-care professional). A number of symptom appraisal models have been developed describing the psychological factors that underlie how people make sense of symptoms, although none explicitly focus on sociodemographic characteristics. METHODS: We therefore conducted a conceptual review synthesising all symptom appraisal models, and focus on potential links with sociodemographics that could be the focus of future research. RESULTS: Common psychological elements across nine symptom appraisal models included knowledge, attention, expectation and identity, all of which could be sensitive to sociodemographic factors. For example, lower socioeconomic status (SES), male sex and older age are associated with lower health literacy generally and lower cancer symptom knowledge. Limited attentional resources, lower expectations about health and lack of social support also hamper symptom interpretation, and would be likely to be more prevalent in those from lower SES backgrounds. Symptom heuristics ('rules of thumb') may lead to symptoms being normalised because they are common within the social network, potentially disadvantaging older populations. CONCLUSIONS: A better understanding of the processes through which people interpret their symptoms, and the way these processes differ by sociodemographic factors, could help guide the development of interventions with the aim of reducing inequalities in cancer outcomes.
Whitaker KL, Smith CF, Winstanley K, Wardle J (2016) What prompts help-seeking for cancer 'alarm' symptoms? A primary care based survey,BRITISH JOURNAL OF CANCER114(3)pp. 334-339 NATURE PUBLISHING GROUP
Whitaker KL, Winstanley K, Macleod U, Scott SE, Wardle J (2015) Knowledge of cancer warning signs and reported help-seeking in a community sample, EUROPEAN JOURNAL OF CANCER CARE24pp. 9-9 WILEY-BLACKWELL
Burnet KL, Parker C, Dearnaley D, Brewin CR, Watson M (2007) Does active surveillance for men with localized prostate cancer carry psychological morbidity?, BJU International100(3)pp. 540-543
OBJECTIVES: To investigate, in a cross-sectional study, the prevalence of anxiety and depression in patients with localised prostate cancer managed by active surveillance, compared with those receiving immediate treatment, as active surveillance is a relatively new approach to managing this disease, designed to avoid 'unnecessary' treatment, but it is unclear whether the approach contributes to psychological distress, given that men are living with untreated cancer. PATIENTS AND METHODS: A consecutive series of 764 patients with prostate cancer were approached in outpatient clinics. Of these, 329 men with localized disease (cT1/2, N0/NX, M0/MX) meeting the study entry criteria, completed the Hospital Anxiety and Depression Scale (HADS); 100 were on active surveillance, 81 were currently receiving radical treatment (radiotherapy + neoadjuvant hormone therapy) and 148 had previously received radical radiotherapy. RESULTS: Overall, 16% (51/329) of patients met the HADS criteria for anxiety and 6% (20/329) for depression. Analyses indicated that higher anxiety scores were significantly associated with younger age (P < 0.01) and a longer interval since diagnosis (P < 0.01), but not with management by active surveillance (P = 0.38). Higher depression scores were significantly associated with a longer interval since diagnosis (P < 0.05), but not with management by active surveillance (P = 0.83). CONCLUSION: Active surveillance for managing localized prostate cancer was not associated with greater psychological distress than more immediate treatment for prostate cancer. © 2007 The Authors.
Whitaker KL, Simon AE, Beeken RJ, Wardle J (2012) Do the British public recognise differences in survival between three common cancers?, Br J Cancer106(12)pp. 1907-1909
BACKGROUND: The recognition that cancer is not a single entity, rather that different cancers have different causes and trajectories, has been a key development in the scientific understanding of cancer. However, little is known about the British public's awareness of differences between cancers. This study examined differences in perceived survivability for three common cancers with widely disparate survival rates (breast, colorectal and lung). METHOD: In a population-based survey, using home interviews (N=2018), respondents answered a quantitative (numeric) question on 5-year survival and a qualitative (non-numeric) question on curability, for each of the three cancers. RESULTS: British adults correctly recognised that 5-year survival for breast cancer was higher than for colorectal cancer (CRC), which in turn was recognised to be higher than for lung cancer. Similarly, curability was perceived to be higher for breast than CRC, and both were perceived to be more curable than lung cancer. Awareness of survival differences did not vary by sex, age or socioeconomic status. In terms of absolute values, there was a tendency to underestimate breast cancer survival and overestimate lung cancer survival. CONCLUSION: The British public appear to be aware that not all cancers are equally fatal.
Beeken RJ, Simon AE, von Wagner C, Whitaker KL, Wardle J (2011) Cancer fatalism: deterring early presentation and increasing social inequalities?, Cancer Epidemiol Biomarkers Prev20(10)pp. 2127-2131
BACKGROUND: Fatalistic beliefs about cancer have been implicated in low uptake of screening and delay in presentation particularly in low socioeconomic status (SES) groups, but no studies have systematically evaluated interrelationships between SES, fatalism, and early detection behaviors. We explored whether (i) fatalism is associated with negative attitudes toward early detection, (ii) lower SES groups are more fatalistic, and (iii) SES differences in fatalism partly explain SES differences in attitudes toward early detection. METHODS: In a population-representative sample of adults in Britain using computer-based interviews in the home setting, respondents (N = 2,018) answered two questions to index fatalism (expectations of cancer survival and cure) and two items on early detection attitudes (the perceived value of early detection and fear of symptom reporting). SES was indexed with a social grade classification. RESULTS: Fatalism was associated with being less positive about early detection (² = -0.40, P < 0.001) and more fearful about seeking help for a suspicious symptom (² = 0.24, P < 0.001). Lower SES groups were more fatalistic (² = -0.21, P < 0.001). Path analyses suggest that SES differences in fatalism might explain SES differences in attitudes about early detection. CONCLUSIONS: In this population sample, SES differences in fatalism partly explained SES differences in the perceived value of early detection and fear of symptom presentation. IMPACT: Fatalistic beliefs about cancer should be targeted to promote early presentation of cancer and this may be particularly important for lower SES groups.
Beck E, Burnet KL, Vosper J (2006) Birth-order effects on facets of extraversion, Personality and Individual Differences40(5)pp. 953-959
The present study investigated the reasons for inconsistent findings concerning birth-order effects and extraversion. According to Sulloway (1995, 1996), one would expect first-born siblings to rate higher on one of the facets, dominance, and later-born siblings to rate higher on the other facet, sociability. In a within-family design, 96 undergraduate and graduate students rated themselves and their siblings on a 12-item extraversion scale taken from the NEO Five-Factor Inventory. One-sample t-tests revealed, as predicted, that first-borns rated significantly higher than later-borns on the facet of dominance and later-borns rated significantly higher on the facet of sociability. Various alternative explanations of the results were ruled out and the contribution of the within-family method to the study of birth-order effects in personality was discussed. © 2005 Elsevier Ltd. All rights reserved.
Cromme SK, Whitaker KL, Winstanley K, Renzi C, Smith CF, Wardle J (2016) Worrying about wasting GP time as a barrier to help-seeking: a community-based, qualitative study, BRITISH JOURNAL OF GENERAL PRACTICE66(648)pp. E474-E482 ROYAL COLL GENERAL PRACTITIONERS
Whitaker KL, Macleod U, Winstanley K, Scott SE, Wardle J (2015) Help seeking for cancer 'alarm' symptoms: A qualitative interview study of primary care patients in the UK,British Journal of General Practice65(631)pp. e96-e105
©British Journal of General PracticeBackground: Delay in help seeking for cancer 'alarm' symptoms has been identified as a contributor to delayed diagnosis. Aim: To understand people's help-seeking decision making for cancer alarm symptoms, without imposing a cancer context. Design and setting: Community-based, qualitative interview study in the UK, using purposive sampling by sex, socioeconomic status, and prior help seeking, with framework analysis of transcripts. Method: Interviewees (n = 48) were recruited from a community-based sample (n = 1724) of adults aged e50 years who completed a health survey that included a list of symptoms. Cancer was not mentioned. Participants reporting any of 10 cancer alarm symptoms (n = 915) and who had consented to contact (n = 482) formed the potential pool from which people were invited to an interview focusing on their symptom experiences. Results: Reasons for help seeking included symptom persistence, social influence, awareness/ fear of a link with cancer, and 'just instinct'. Perceiving the symptom as trivial or 'normal' was a deterrent, as was stoicism, adopting self-management strategies, and fear of investigations. Negative attitudes to help seeking were common. Participants did not want to be seen as making a fuss, did not want to waste the doctor's time, and were sometimes not confident that the GP could help. Conclusion: Decision making about cancer alarm symptoms was complex. Recognition of cancer risk almost always motivated help seeking (more so than the fear of cancer being a deterrent), assisted by recent public-awareness campaigns. As well as symptom persistence motivating help seeking, it could also have the reverse effect. Negative attitudes to help seeking were significant deterrents.
Wardle J, Chida Y, Gibson EL, Whitaker KL, Steptoe A (2011) Stress and adiposity: a meta-analysis of longitudinal studies., Obesity (Silver Spring)19(4)pp. 771-778
Psychosocial stress has been strongly implicated in the biology of adiposity but epidemiological studies have produced inconsistent results. The aim of this analysis was to bring together results from published, longitudinal, prospective studies examining associations between psychosocial stress and objectively measured adiposity in a meta-analysis. Searches were conducted on Medline, PsycINFO, Web of Science, and PubMed (to January 2009) and reference lists from relevant articles were examined. Prospective studies relating psychosocial stress (general life stress (including caregiver stress), work stress) to BMI, body fat, body weight, waist circumference, or waist-to-hip ratio were included. Analyses from 14 cohorts were collated and evaluated. There was no significant heterogeneity, no evidence of publication bias, and no association between study quality and outcomes. The majority of analyses found no significant relationship between stress and adiposity (69%), but among those with significant effects, more found positive than negative associations (25 vs. 6%). Combining results in a meta-analysis showed that stress was associated with increasing adiposity (r = 0.014; confidence interval (CI) = 0.002-0.025, P < 0.05). Effects were stronger for men than women, in analyses with longer rather than shorter follow-ups, and in better quality studies. We conclude that psychosocial stress is a risk factor for weight gain but effects are very small. Variability across studies indicates there are moderating variables to be elucidated.
Renzi C, Whitaker KL, Winstanley K, Cromme S, Wardle J (2016) Unintended consequences of an 'all-clear' diagnosis for potential cancer symptoms: a nested qualitative interview study with primary care patients.,The British journal of general practice : the journal of the Royal College of General Practitioners Royal College of General Practitioners
Nine out of 10 patients undergoing urgent cancer investigations receive an 'all-clear' diagnosis.A qualitative approach was used to evaluate the impact of investigations that did not result in cancer diagnosis on subsequent symptom attribution and help seeking for recurrent or new possible cancer symptoms.A survey of symptoms, help seeking, and past investigations was sent to 4913 individuals aged e50 years from four UK general practices. Of 2042 responders, 62 participants were recruited still reporting at least one cancer 'alarm' symptom in a 3-month follow-up survey for a nested in-depth interview study (ensuring variation in sociodemographic characteristics).Framework analysis was used to examine the in-depth semi-structured interviews and identify themes related to previous health investigations.Interviewees were on average 65 years old, and 90% reported investigations within the previous 2 years. Most often they reported gastrointestinal, urinary, and respiratory symptoms, and 42% had waited e3 months before help seeking. Reassurance from a previous non-cancer diagnosis explained delays in help seeking even if symptoms persisted or new symptoms developed months or years later. Others were worried about appearing hypochondriacal or that they would not be taken seriously if they returned to the doctor.An all-clear diagnosis can influence help seeking for months or even years in case of new or recurrent alarm symptoms. Considering the increasing number of people undergoing investigations and receiving an all-clear, it is paramount to limit unintended consequences by providing appropriate information and support. Specific issues are identified that could be addressed.
Whitaker KL, Brewin CR, Watson M (2008) Intrusive cognitions and anxiety in cancer patients, Journal of Psychosomatic Research64(5)pp. 509-517
Objective: The study aimed to provide information on intrusive cognitions reported by cancer patients and to investigate for the first time whether intrusive imagery is a factor in psychological morbidity. Methods: Matched samples of anxious (n=65) and nonanxious (n=65) patients were assessed for evidence of intrusive cognitions, including memories, images, and thoughts. Patients also completed the Mini-Mental Adjustment to Cancer Scale. Results: Twenty-three percent of patients reported intrusive cognitions. Cognitions were frequent, uncontrollable, and associated with significant distress. Anxious patients reported significantly more of each intrusion type than nonanxious patients, and the presence of intrusive cognitions was significantly associated with maladaptive adjustment, including anxious preoccupation and helplessness-hopelessness. Conclusion: Intrusive cognitions play a significant role in anxiety and adaptation to the experience of cancer. Advancing knowledge in relation to the phenomenology of intrusions and to the manner in which intrusions can be targeted with psychological treatments is an important next stage of research. © 2008 Elsevier Inc. All rights reserved.
Whitaker KL, Jarvis MJ, Boniface D, Wardle J (2011) The intergenerational transmission of thinness., Arch Pediatr Adolesc Med165(10)pp. 900-905
OBJECTIVES: To examine intergenerational associations for thinness and to compare maternal and paternal effects. DESIGN: Population-based, cross-sectional design using data from the Health Survey for England from January 1, 2001, through December 31, 2006. SETTING: The Health Survey for England, an annual, national survey representative of the population living in private households in England. PARTICIPANTS: Families with children and adolescents aged 2 to 15 years with anthropometric data available for children and adolescents and 2 parents (N = 4423 families, N = 7078 children and adolescents). MAIN EXPOSURE: Trained interviewers collected height and weight measurements. MAIN OUTCOME MEASURE: Child/adolescent thinness, categorized using International Obesity Task Force criteria. RESULTS: Of 7078 children and adolescents, 402 (5.7%) were categorized as being thin. Thinness was more common in 2- to 5-year-olds (odds ratio, 1.61; 95% confidence interval, 1.22-2.13) than in 11- to 15-year-olds and in children and adolescents from ethnic minority (black: 2.28; 1.22-4.26; and Asian: 3.65; 2.76-4.83) than white backgrounds, but no differences were observed by sex or socioeconomic status. The strongest predictor of child/adolescent thinness was parental weight status. The prevalence of thinness was highest (16.2%) when both parents were thinner and progressively lower when both parents were in the upper half of the healthy-weight range (7.8%) or were overweight (5.3%) or obese (2.5%), with no differences in the magnitude of maternal and paternal influences. CONCLUSIONS: These results are consistent with the idea that many cases of thinness are likely to represent the low end of the healthy distribution of weight and, as such, are likely to have a primarily genetic origin.
Waller J, Whitaker KL, Winstanley K, Power E, Wardle J (2014) A survey study of women's responses to information about overdiagnosis in breast cancer screening in Britain., Br J Cancer111(9)pp. 1831-1835
BACKGROUND: There is concern about public understanding of overdiagnosis in breast cancer screening, and uncertainty about the likely impact on screening participation. METHODS: In a population-based survey of 2272 women, we assessed understanding of overdiagnosis and screening intentions before and after exposure to an explanation of overdiagnosis, and one of the three information formats providing an estimate of the rate of overdiagnosis based on the findings of the UK Independent Review. RESULTS: Subjective and objective comprehension of overdiagnosis was moderate across information formats (64% and 57%, respectively). Following overdiagnosis information, 7% of women showed a decrease in screening intention, with a stronger effect among women below screening age (<47 years), and receiving the estimate of the rate of overdiagnosis in a simple ratio format (one life saved to three overdiagnoses). CONCLUSIONS: Brief written information on overdiagnosis was incompletely understood, but reduced breast screening intentions in a proportion of women, regardless of comprehension. Subjective comprehension was lower among women who had not yet reached screening age but the deterrent effect was higher.
Whitaker KL, Good A, Miles A, Robb K, Wardle J, von Wagner C (2011) Socioeconomic inequalities in colorectal cancer screening uptake: does time perspective play a role?, Health Psychol30(6)pp. 702-709
OBJECTIVE: This study examined the role of time perspective in explaining inequalities in colorectal cancer screening attendance. We tested a path model predicting that (a) socioeconomic status (SES) would be associated with consideration of future consequences (CFC), (b) CFC would be associated with perceived benefits/barriers, and (c) barriers and benefits would be associated longitudinally with screening attendance. METHOD: Data for these analyses came from the control arm (n = 809) of an intervention to increase screening uptake. Participants between 55 and 64 years were offered screening as part of the U.K. Flexible Sigmoidoscopy (FS) Trial. They completed a questionnaire that included demographic and psychological variables. Subsequent screening attendance was recorded. RESULTS: There was clear evidence of SES differences in attendance, with 56% in the most deprived tertile attending their FS appointment, compared with 68% in the middle tertile and 71% in the least deprived tertile (p < .01). Lower SES was associated with lower CFC, higher perceived barriers, and lower perceived benefits (p < .05 for all). Higher CFC, higher perceived benefits, and lower perceived barriers were associated with attendance (p < .01 for all). CFC mediated the association between SES and perceived benefits/barriers, while perceived benefits/barriers mediated the association between CFC and attendance. CONCLUSION: SES differences in CFC contribute to SES differences in the perceived barriers and benefits of screening, which, in turn, contribute to differences in attendance. Interventions that take CFC into account, for example, by emphasizing short-term benefits, could promote equality in screening participation.
Croker H, Whitaker KL, Cooke L, Wardle J (2009) Do social norms affect intended food choice?, Prev Med49(2-3)pp. 190-193
OBJECTIVE: To evaluate the effect of social norms on intended fruit and vegetable intake. METHODS: A two-stage design to i) compare the perceived importance of normative influences vs cost and health on dietary choices, and ii) test the prediction that providing information on social norms will increase intended fruit and vegetable consumption in an experimental study. Home-based interviews (N=1083; 46% men, 54% women) were carried out as part of the Office for National Statistics Omnibus Survey in November 2008. RESULTS: The public's perception of the importance of social norms was lower (M=2.1) than the perceived importance of cost (M=2.7) or health (M=3.4) (all p's<0.001) on a scale from 1 (not at all important) to 4 (very important). In contrast, results from the experimental study showed that intentions to eat fruit and vegetables were positively influenced by normative information (p=0.011) in men but not by health or cost information; none of the interventions affected women's intentions. CONCLUSIONS: People have little awareness of the influence of social norms but normative information can have a demonstrable impact on dietary intentions. Health promotion might profit from emphasising how many people are attempting to adopt healthy lifestyles rather than how many have poor diets.
Renzi C, Whitaker KL, Wardle J (2015) Symptom attribution and help-seeking after an 'all clear' diagnosis: a systematic review of the literature, EUROPEAN JOURNAL OF CANCER CARE24pp. 3-3 WILEY-BLACKWELL
Waller J, Douglas E, Whitaker KL, Wardle J (2013) Women's responses to information about overdiagnosis in the UK breast cancer screening programme: a qualitative study., BMJ Open3(4)
OBJECTIVES: To explore the influence of overdiagnosis information on women's decisions about mammography. DESIGN: A qualitative focus group study with purposive sampling and thematic analysis, in which overdiagnosis information was presented. SETTING: Community and university settings in London. PARTICIPANTS: 40 women within the breast screening age range (50-71 years) including attenders and non-attenders were recruited using a recruitment agency as well as convenience sampling methods. RESULTS: Women expressed surprise at the possible extent of overdiagnosis and recognised the information as important, although many struggled to interpret the numerical data. Overdiagnosis was viewed as less-personally relevant than the possibility of 'under diagnosis' (false negatives), and often considered to be an issue for follow-up care decisions rather than screening participation. Women also expressed concern that information on overdiagnosis could deter others from attending screening, although they rarely saw it as a deterrent. After discussing overdiagnosis, few women felt that they would make different decisions about breast screening in the future. CONCLUSIONS: Women regard it as important to be informed about overdiagnosis to get a complete picture of the risks and benefits of mammography, but the results of this study indicate that understanding overdiagnosis may not always influence women's attitudes towards participation in breast screening. The results also highlight the challenge of communicating the individual significance of information derived from population-level modelling.
Lewis Liane, Marcu Afrodita, Whitaker Katriina, Maguire Roma (2017) Patient factors influencing symptom appraisal and subsequent adjustment to oesophageal cancer: A qualitative interview study,European Journal of Cancer Care27(1)e12745 Wiley
Oesophageal cancer (EC) is characterized by vague symptoms and is often diagnosed at an advanced stage, leading to poor outcomes. Therefore, we aimed to investigate whether there might be any patient factors contributing to delay in EC diagnosis, and focused on the symptom appraisal and help-seeking strategies of people diagnosed with EC in the UK. Semi-structured interviews were conducted with 14 patients aged >18 years with localised EC at point of diagnosis. Purposive sampling was used to include patients from one to nine months post-diagnosis. Analysis of the interviews identified three main themes: Interpreting symptoms, Triggers to seeking help, and Making sense of an unfamiliar cancer. Findings suggested that participants normalised symptoms or used previous health experiences as a means to interpret their symptoms. The majority of participants were not alarmed by their symptoms, mainly because they had very little knowledge of EC specific symptoms. Lack of knowledge also influenced participants? sense-making of their diagnosis. The findings highlight that the process of symptom appraisal in EC is likely to be inaccurate, which may hinder early presentation and thus diagnosis. Public health campaigns communicating EC specific symptoms, however, could shorten the appraisal period and lead to earlier diagnosis.
Winstanley K, Renzi C, Friedemann Smith C, Wardle J, Whitaker K (2016) The impact of body vigilance on help-seeking for cancer 'alarm' symptoms: a community-based survey.,BMC Public Health161172 BioMed Central
Background: The act of detecting bodily changes is a pre-requisite for subsequent responses to symptoms, such as seeking medical help. This is the first study to explore associations between self-reported body vigilance and help-seeking in a community sample currently experiencing cancer ?alarm? symptoms. Methods: Using a cross-sectional study design, a ?health survey? was mailed through primary care practices to 4,913 UK adults (age e50 years, no cancer diagnosis), asking about symptom experiences and medical help-seeking over the previous three months. Body vigilance, cancer worry and current illness were assessed with a small number of self-report items derived from existing measures. Results: The response rate was 42% (N=2,042). Almost half the respondents (936/2,042; 46%) experienced at least one cancer alarm symptom. Results from logistic regression analysis revealed that paying more attention to bodily changes was significantly associated with help-seeking for cancer symptoms (OR=1.44; 1.06-1.97), after controlling for socio-demographics, current illness and cancer worry. Being more sensitive to bodily changes was not significantly associated with help-seeking. Conclusions: Respondents who paid attention to their bodily changes were more likely to seek help for their symptoms. Although the use of a cross-sectional study design and the limited assessment of key variables preclude any firm conclusions, encouraging people to be body vigilant may contribute towards earlier cancer diagnosis. More needs to be understood about the impact this might have on cancer-related anxiety.
Whitaker Katriina, Ghanouni A, Zhou Y, Lyratzopoulos G, Morris S (2017) Patients' preferences for GP consultation for perceived cancer risk in primary care: a discrete choice experiment.,British Journal of General Practice67(659)pp. e388-e395 Royal College of General Practitioners
Background: Contacting a doctor for advice when experiencing a potential cancer symptom is an important step in earlier diagnosis, but barriers to consultation are commonly reported. Aim: To investigate patients? GP consultation preferences when presented with a potential cancer symptom, and to describe whether these preferences are mediated by variable levels of cancer risk. Design and setting: UK-wide online survey of adults over 50 years old, using quota sampling to reflect general population characteristics. Method: A discrete choice experiment examined preferences for primary care consultation for three cancer symptom scenarios (risk level not mentioned, risk designated as either ?low? or ?high?). Scenarios based on length of consultation, time to getting an appointment, convenience, choice of GP and GP listening skills were presented in a self-completed online questionnaire. Results: We obtained 9616 observations from 601 participants. Participants expressed preferences for doctors with better listening skills, for ability to see a GP of their choice and for shorter waiting times. These findings were the same across risk conditions and demographic groups. Participants were willing to wait an extra 3.5 weeks for an appointment with a doctor with good/very good listening skills (vs very poor listening skills) and an extra 1 week for an appointment with a GP of their choice (vs any GP). Conclusion: Patient decisions about help-seeking seem to be particularly influenced by the anticipated listening skills of doctors. Improving doctor?s communication skills may in the longer term encourage people to seek prompt medical help when they experience a cancer symptom.
Marcu AM, Lyratzopoulos G, Black G, Vedsted P, Whitaker K (2016) Educational differences in likelihood of attributing breast symptoms to cancer: a vignette-based study,Psycho-Oncology25(10)pp. 1191-1197 Wiley
Background Stage at diagnosis of breast cancer varies by socio-economic status (SES), with lower SES associated with poorer survival. We investigated associations between SES (indexed by education), and the likelihood of attributing breast symptoms to breast cancer. Method We conducted an online survey with 961 women (47-92 years) with variable educational levels. Two vignettes depicted familiar and unfamiliar breast changes (axillary lump and nipple rash). Without making breast cancer explicit, women were asked ?What do you think this [&..] could be?? After the attribution question, women were asked to indicate their level of agreement with a cancer avoidance statement (?I would not want to know if I have breast cancer?). Results Women were more likely to mention cancer as a possible cause of an axillary lump (64%) compared with nipple rash (30%). In multivariable analysis, low and mid education were independently associated with being less likely to attribute a nipple rash to cancer (OR 0.51, 0.36-0.73 and OR 0.55, 0.40-0.77, respectively). For axillary lump, low education was associated with lower likelihood of mentioning cancer as a possible cause (OR 0.58, 0.41-0.83). Although cancer avoidance was also associated with lower education, the association between education and lower likelihood of making a cancer attribution was independent. Conclusion Lower education was associated with lower likelihood of making cancer attributions for both symptoms, also after adjustment for cancer avoidance. Lower likelihood of considering cancer may delay symptomatic presentation and contribute to educational differences in stage at diagnosis.
Salika T, Lyratzopoulos G, Whitaker K, Waller J, Renzi C (2017) Do comorbidities influence help-seeking for cancer alarm symptoms? A population-based survey in England,Journal of Public Healthpp. 1-10 Oxford University Press
Background We examined associations between different chronic morbidities and help-seeking for possible cancer symptoms. Methods Postal survey of individuals aged>50 years in England. Participants could report prior morbidities in respect of 12 pre-defined conditions. Among patients experiencing possible cancer symptoms we examined associations between specific morbidities and self-reported help-seeking (i.e. contacted versus not contacted a GP) for each alarm symptom using regression analyses. Results Among 2042 respondents (42% response rate), 936 (46%) recently experienced one of 14 possible cancer symptoms considered in our analysis. Of them, 80% reported one or more morbidities, most frequently hypertension/hypercholesterolemia (40%), osteomuscular (36%) and heart diseases (21%). After adjustment for socio-demographic characteristics, patients with hypertension/hypercholesterolemia were more likely to report help-seeking for possible cancer symptoms, such as unexplained cough (OR=2.0; 95%CI 1.1-3.5), pain (OR=2.2; 95%CI 1.0-4.5) and abdominal bloating (OR=2.3; 95%CI 1.1-4.8). Urinary morbidity was associated with increased help-seeking for abdominal bloating (OR=5.4; 95%CI 1.2-23.7) or rectal bleeding (OR=5.8; 95%CI 1.4-23.8). In contrast, heart problems reduced help-seeking for change in bowel habits (OR=0.4; 95%CI 0.2-1.0). Conclusions Comorbidities are common and may facilitate help-seeking for possible cancer symptoms, but associations vary for specific symptom-comorbidity pairs. The findings can contribute to the design of future cancer symptom awareness campaigns.
Walabyeki J, Adamson J, Buckley H, Sinclair H, Atkin K, Graham H, Whitaker K, Wardle J, Macleod U (2017) Experience of, awareness of and help-seeking for potential cancer symptoms in smokers and non-smokers: a cross-sectional study,PLoS ONE Public Library of Science
Abstract Background: Presenting to primary care with potential cancer symptoms is contingent on one?s ability to recognize potentially serious symptoms. We investigated differences between smokers and non-smokers in symptoms experienced, awareness and consulting of potential respiratory, head and neck cancer symptoms. Methods: Smokers and non-smokers aged over 50 from Yorkshire general practice lists were sent a postal questionnaire asking about symptoms, consulting and awareness of cancer symptoms. Data were analysed using STATA14. Results: Response rate after one reminder was 30.5% (1205/3954). Smoking status was associated with experience of cough (p<0.001), breathlessness (p=0.002) and tiredness (p=0.004) with smokers (25.8% of population) more likely than never-smokers (53.6% of population) to experience all three symptoms (cough OR=2.56;95%CI[1.75-3.75], breathlessness OR=2.39;95%CI[1.43-4.00], tiredness OR=1.57;95%CI[1.12-2.19]). Smoking status was associated with awareness of breathlessness as a potential cancer symptom (p=0.035) and consulting for cough (p=0.011) with smokers less likely to consult than never-smokers (OR=0.37;95% CI[0.17-0.80]). Conclusion: Our findings suggest that current smokers are more likely to experience cough, breathlessness and tiredness, but are less likely to consult for cough than never-smokers. To increase cancer awareness and promote consulting among smokers, innovative interventions improving symptom recognition and empowering smokers to seek help are required.
Whitaker K, Cromme S, Winstanley K, Renzi C, Wardle J (2015) Emotional responses to the experience of cancer 'alarm' symptoms,Psycho-Oncology24pp. 29-29 WILEY-BLACKWELL
Objective: To qualitatively explore associations between emotional responses to experience of cancer 'alarm' symptoms and help-seeking in a community sample of adults. Method: Interviewees (n=62) were recruited from a community sample (n=2042) of adults aged e50 years, who had completed a health survey that included a list of cancer alarm symptoms. Participants who had reported an alarm symptom both at baseline and 3-month follow-up (n=271), and who had consented to contact (n=215), constituted the pool for invitations to interview. Results: Over a third of participants (37%) described an emotional response to their symptom experience. In all these cases, there was evidence of awareness of the risk of cancer. Emotional responses were usually either classified as mild ('worry') or severe ('fear'). Worry was often described in the context of a desire to seek medical help, either to rule out cancer or to minimise patient delay. In contrast, the 'fear' group described associations with death, the perceived incurability of cancer, and the consequence of a cancer diagnosis. Where the emotional reaction was fear, medical contact was seen as something to be avoided either because it had no value or because it was preferable not to be told a diagnosis. Conclusion: In this community sample, worry about the possibility of cancer was associated with help-seeking, either for reassurance or as part of a 'sensible' strategy to deal with the risk. In contrast, fear was associated with avoiding help-seeking or even thinking about cancer, which could lead to prolonged help-seeking intervals.
Davies Hilary, Marcu Afrodita, Vedsted P, Whitaker Katriina (2017) Is lower symptom recognition associated with socioeconomic inequalities in help-seeking for potential breast cancer symptoms?,Psycho-Oncology27(2)pp. 626-632 Wiley

Socioeconomic inequalities in recognising signs and symptoms of cancer may result in inequalities in timely help-seeking and subsequent prognosis of breast cancer. We explored the mediating role of symptom attribution and concern on the relationship between level of education and help-seeking for potential breast cancer symptoms.


Women aged e47 years (n=961) were purposively recruited (by education) to complete an online vignette-based survey that included nipple rash and axillary lump (in separate vignettes) as potential symptoms of breast cancer. Women completed questions relating to medical help-seeking (Yes/No), cancer attribution, symptom concern, cancer avoidance, family history and demographics.


Women with low education and mid-education attributed nipple rash less often to cancer (26% and 27% mentioned cancer) than women with a degree or higher (40%). However, women with a degree or higher (63%) or mid-education (64%) were less likely to anticipate seeking help for the nipple rash than women with no formal qualifications (73%). This association was statistically significant in the 60-69 year old age group. There was no significant association between education and help-seeking for axillary lump. Mediation analysis adjusting for potential confounders confirmed that the association between education and help-seeking for nipple rash was fully mediated by symptom concern.


Socioeconomic inequalities in stage at diagnosis and survival of breast cancer may not always be explained by lower likelihood of suspecting cancer and subsequent impact on help-seeking. Reducing inequalities in stage at diagnosis will involve understanding a broader range of bio-psycho-social factors (e.g. comorbidities, healthcare system factors).

Marcu A, Black G, Vedsted P, Lyratzopoulos G, Whitaker K (2016) Educational differences in responses to breast cancer symptoms: A qualitative comparative study,British Journal of Health Psychology22(1)pp. 26-41 Wiley
Objective. Advanced stage at diagnosis for breast cancer is associated with lower socio-economic status (SES). We explored what factors in the patient interval (time from noticing a bodily change to ?rst consultation with a health care professional) may contribute to this inequality.Design. Qualitative comparative study.Methods. Semi-structured interviews with a sample of women (e47 years) from higher(n = 15) and lower (n = 15) educational backgrounds, who had experienced at least one potential breast cancer symptom. Half the participants ( n = 15) had sought medical help,half had not (n = 15). Without making breast cancer explicit, we elicited women?s sense-making around their symptoms and help-seeking decisions.Results. Containment of symptoms and con?dence in acting upon symptoms emerged as two broad themes that differentiated lower and higher educational groups. Women from lower educational backgrounds tended to attribute their breast symptoms to trivial factors and were reticent in using the word ?cancer?. Despite ?knowing? that symptoms could be related to cancer, women with lower education invoked lack of medical knowledge ? ?I am not a doctor? ? to express uncertainty about interpreting symptoms and accessing help. Women with higher education were con?dent about interpreting symptoms, seeking information online, and seeking medical help.Conclusions. Our ?ndings suggest that knowledge of breast cancer alone may not explain socio-economic differences in how women respond to breast cancer symptoms as women with lower education had ?reasons? not to react. Research is needed on how to overcome a wider spectrum of psycho-social factors to reduce future inequality.
Marcu Afrodita, Black Georgia, Whitaker Katriina (2018) Variations in trust in Dr Google when experiencing potential breast cancer symptoms: Exploring motivations to seek health information online,Health, Risk & Society20(7-8)pp. 325-341 Taylor & Francis
How people trust the internet and seek health information online when experiencing and interpreting potential cancer symptoms is not well understood. We interviewed twenty-seven women who had recently experienced at least one potential breast cancer symptom, and explored their symptom experience, help-seeking strategies, and whether they consulted the internet in relation to their symptoms. We conducted a thematic analysis and constructed a typology of attitudes towards, and experiences of, consulting the internet about the symptoms: i) confident; ii) neutral; iii) hesitant; and iv) avoidant. ?Hesitant? and ?avoidant? participants rarely mentioned cancer explicitly, doubted being able to interpret the information found online, and expressed concerns over finding ?scaremongering? information or making incorrect self-diagnosis. The ?avoiders? and the ?hesitant? participants perceived online information-seeking as being inherently risky, partly because online health content is likely to be inaccurate or exaggerated, and partly because the process of lay interpretation is likely to be flawed by lack of medical expertise. The findings suggest that not all women experiencing potential breast cancer symptoms seek health information online spontaneously or trust the internet as a legitimate source of health information. The women who did engage in online information seeking, particularly those with lower education, felt unsure about how to appraise online health sources to interpret their symptoms
Tookey Sara, Renzi Cristina, Waller Jo, von Wagner Christian, Whitaker Katriina (2018) Using the Candidacy Framework to understand how doctor-patient interactions influence perceived eligibility to seek help for cancer alarm symptoms: a qualitative interview study,BMC Health Services Research18937 BMC

?Candidacy? is concerned with the way people consider their eligibility for accessing health services. We used the Candidacy Framework to explore how the doctor-patient relationship can influence perceived eligibility to visit their General Practitioner (GP) among people experiencing cancer alarm symptoms.


We carried out a secondary analysis of qualitative interviews with 29 women and 33 men, aged e50 years experiencing cancer alarm symptoms, recruited through primary care. Interviews focused on symptom experience, help-seeking and primary care use. Framework analysis was used to analyse transcripts with a focus on GP-patient interactions.


Perceived (im)permeability of services acted as a barrier to help-seeking, due to limited availability of appointments, time-limited communication and difficulties asserting candidacy. There was also a focal role of communication in building a positive doctor-patient relationship, with some participants describing resisting offers of appointments as a result of previous negative GP adjudication. These factors not only influenced the current consultation but had longer-term consequences for future consultation.


Candidacy provides a valuable theoretical framework to understand the interactional factors of the doctor-patient relationship which influence perceived eligibility to seek help for possible cancer alarm symptoms. We have highlighted areas for targeted interventions to improve patient-centred care and improve earlier diagnosis.

Marcu Afrodita, Muller Cecile, Ream Emma, Whitaker Katriina L (2019) Online information-seeking about potential breast cancer symptoms Capturing online behaviour with an Internet browsing tracking tool,Journal of Medical Internet Research Journal of Medical Internet Research


People engage in health information-seeking online when experiencing unusual or unfamiliar bodily changes. It is not well understood how people consult the Internet for health information after the onset of unfamiliar symptoms and before receiving a potential diagnosis, and how online information-seeking can help people appraise their symptoms. This lack of evidence may be partly due to methodological limitations in capturing in real time the online information-seeking process.


We explored women?s symptom attribution and online health information-seeking in response to a hypothetical and unfamiliar breast change suggestive of cancer (nipple rash). We also aimed to establish the feasibility of capturing in real time the online information-seeking process with a tool designed to track participants? online searches and visited websites, the VIZZATATM browser tracker.


An online survey was completed by 56 cancer-free women (Mage = 60.34 years, SD = 7.73 years) responding to a scenario asking them to imagine noticing a red scaly rash on the nipple. Participants were asked to make symptom attributions when presented with the scenario (Time1) and again after seeking information online (Time2). The online tracking tool, embedded in the survey, was used to capture in real time participants? search terms and accessed websites.


The tracking tool captured the search terms and accessed websites of most of the participants (46/56, 82%). For the rest (n=10, 18%), there was evidence of engagement in online information-seeking, e.g. medical terminology and cancer attribution at Time2, despite their searching activity not being recorded. Twenty five participants considered cancer as a potential cause for the nipple rash at Time1, yet only one of these used ?cancer? as a search term. Most participants (n=40, 87%) used rash-related search terms, particularly ?nipple rash? and ?rash on nipple?. The majority (41/46, 89%) accessed websites containing breast cancer information, with the NHS webpage ?Paget?s disease of the nipple? being the most visited one. At Time2, after engaging in the Internet search task, more participants attributed the nipple rash to breast cancer than at Time1, n=37 (66.1%) vs. n=25 (44.6%), although a small number of participants (n=6) changed from making a cancer attribution at Time1 to a non-cancer one at Time2.


Making a cancer attribution for an unfamiliar breast change did not necessarily translate into cancer-termed searches. Equally, not all Internet searches led to a cancer attribution. The findings suggest that online information-seeking may not necessarily help women who experience unfamiliar breast cancer symptoms understand their condition. Despite some technical issues, this study showed that it is feasible to use an online browser tracking tool to capture in real time information-seeking about unfamiliar symptoms.



Cunningham Yvonne, Wyke Sally, Blyth Kevin G., Rigg Douglas, Macdonald Sara, Macleod Una, Harrow Stephen, Robb Kathryn A., Whitaker Katriina L. (2019) Lung cancer symptom appraisal among people with Chronic Obstructive Pulmonary Disease: A qualitative interview study,PSYCHO-ONCOLOGY28(4)pp. 718-725 JOHN WILEY & SONS LTD
Objective The incidence of lung cancer is four?times higher in people with Chronic Obstructive Pulmonary Disease (COPD) compared to the general population. Promotion of a shorter time from symptom onset to presentation is one potential strategy for earlier lung cancer diagnosis but distinguishing respiratory symptoms can be difficult. We investigated how the experience of COPD influences symptom appraisal and help?seeking for potential lung cancer symptoms. Methods We conducted qualitative interviews with men (n=17) and women (n=23) aged 40?83 with COPD. Topic guides drew on the Integrated Symptom?Response Framework and covered symptom experience, interpretation, action, recognition, help?seeking, evaluation and re?evaluation. We used the Framework Method to analyse the data. Results Participants said they attributed chest symptoms to their COPD; no other cause was considered. Participants said that family/friends noticed changes in their symptoms and encouraged help?seeking. Others felt isolated by their COPD because they could not get out, were fatigued, or were embarrassed. Participants visited health professionals frequently but increased risk of lung cancer was not discussed. Conclusions Our study provides insight into different levels of influence on symptom appraisal and targets for intervention. Greater awareness of increased lung cancer risk and support to act on symptom changes is essential and could be achieved through a concerted information campaign. Health professionals working with people with COPD could also optimise appointments to support symptom appraisal of potential lung cancer symptoms.
Piano Marianne, Black Georgia, Amelung Dorothee, Power Emily, Whitaker Katriina L (2019) Exploring public attitudes towards the new Faster Diagnosis Standard for cancer: a focus group study with the UK public,British Journal of General Practicebjgp19X702pp. 1-9 Royal College of General Practitioners

Background The Faster Diagnosis Standard (FDS) is to be introduced in England in 2020. This standard is a new policy in which patients should have cancer ruled out or diagnosed within 28 days of referral.

Aim To explore public attitudes towards the FDS within the context of their recent referral experiences.

Design and setting Four 90-minute focus groups (two in Guildford, two in Bradford).

Method Participants aged >50 years without a current cancer diagnosis (N = 29), who had completed certain diagnostic tests, for example, ultrasound, and received results within the last 6 months were recruited. Age, education, and sex were evenly distributed across groups through purposive sampling.

Results The largest cause of concern was the waiting process for obtaining test results. Most had experienced swift referral, and it was difficult for participants to understand how the new standard could impact upon time progressing through the system. Responsibility for meeting the standard was also a concern: participants did not see their own behaviours as a form of involvement. The GP?s role was conceptualised by patients as communicating about their referral, establishing patients? preferences for information, and continued involvement at each stage of the referral process. The standard legitimised chasing for test results, but 28 days was considered too long.

Conclusion Patients should be asked what they would like to know about their referral. GPs should be more transparent about the referral process and the potential for a lack of clarity around next steps.

Skrobanski Hanna, Ream Emma, Poole Karen, Whitaker Katriina (2019) Understanding primary care nurses? contribution to cancer early diagnosis: A systematic review,European Journal of Oncology Nursing41pp. 149-164 Elsevier

Purpose: Primary care nurses can contribute to cancer early diagnosis. The objective of this systematic review was to identify, appraise and synthesise evidence on primary care nurses? contribution towards cancer early diagnosis in developed countries.

Method: The following databases were searched in September 2017: MEDLINE, PsychINFO, CINAHL, SCOPUS, and EMBASE. Data were extracted on nurses?: knowledge of cancer; frequency of 'cancer early diagnosis-related discussions' with patients; and perceived factors influencing these discussions. Studies were appraised using the Mixed Methods Appraisal Tool.

Results: Twenty-one studies were included from: United States, United Kingdom, Ireland, Spain, Turkey, Australia, Brazil and Middle East. Studies were mostly of low quality (one did not meet any appraisal criteria, 15 met one, four met two, and one met three). Nurses? knowledge of cancer, and their frequency of ?cancer early diagnosis-related discussions?, varied across countries. This may be due to measurement bias or nurses? divergent roles across healthcare systems. Commonly perceived barriers to having screening discussions included: lack of time, insufficient knowledge and communication skills, and believing that patients react negatively to this topic being raised

Conclusions: Findings suggest a need for nurses to be adequately informed about, and have the confidence and skills to discuss, the topic of cancer early diagnosis. Further high-quality research is required to understand international variation in primary care nurses? contribution to this field, and to develop and evaluate optimal methods for preparing them for, and supporting them in, this.

Amelung D, Whitaker KL, Lennard D, Ogden M, Sheringham J, Zhou Y, Walter FM, Singh H, Vincent C, Black G (2019) The influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study,BMJ Quality & Safety BMJ Publishing Group

Background: Most cancers are diagnosed following contact with primary care. Patients diagnosed with cancer often see their doctor multiple times with potentially relevant symptoms before being referred to see a specialist, suggesting missed opportunities during doctor-patient conversations.

Objective: To understand doctor-patient communication around the significance of persistent or new presenting problems and its potential impact on timely cancer diagnosis.

Research design: Qualitative thematic analysis based on video recordings of doctor-patient consultations in primary care and follow-up interviews with patients and doctors.

Subjects: 80 video observations, 20 patient interviews and 7 doctor interviews across 7 general practices in England.

Results: We found that timeliness of diagnosis may be adversely affected if doctors and patients do not come to an agreement about the presenting problem?s significance. ?Disagreements? may involve misaligned cognitive factors such as differences in medical knowledge between doctor and patient, or misaligned emotional factors such as patients? unexpressed fear of diagnostic procedures. Interviews suggested that conversations where the difference in views is either not recognised or stays unresolved may lead to unhelpful patient behaviour after the consultation (e.g. non-attendance at specialist appointments), creating potential for diagnostic delay and patient harm.

Conclusions: Our findings highlight how doctor-patient consultations can impact timely diagnosis when patients present with persistent or new problems. Misalignments were common and could go unnoticed, leaving gaps for potential to cause patient harm. These findings have implications for timely diagnosis of cancer and other serious disease because they highlight the complexity and fluidity of the consultation, and the subsequent impact on the diagnostic process.

Smith Sarah M., Whitaker Katriina L., Cardy Amanda H., Elliott Alison M., Hannaford Phil C., Murchie Peter (2019) Validation of self-reported help-seeking, and measurement of the patient interval, for cancer symptoms: an observational study to inform methodological challenges in symptomatic presentation research,Family Practice Oxford University Press (OUP)


To improve earlier presentation with potential symptoms of cancer accurate data is needed on how people respond to these symptoms. It is currently unclear how self-reported medical help-seeking for symptoms associated with cancer by people from the community correspond to what is recorded in their general practice records, or how well the patient interval (time from symptom onset to first presentation to a health-professional) can be estimated from patient records.


Data from two studies that reviewed general practice electronic records of residents in Scotland, 1) the ?Useful Study?: respondents to a general population survey who reported experiencing symptoms potentially associated with one of four common cancers (breast, colorectal, lung, and upper gastro-intestinal) 2) the ?Detect Cancer Early? programme: cancer patients with one of the same four cancers. Survey respondents? self-reported help-seeking (yes/no) was corroborated; Cohen?s Kappa assessed level of agreement. Combined data on the patient interval was evaluated using descriptive analysis.


?Useful Study? respondents? self-report of help-seeking showed exact correspondence with general practice electronic records in 72% of cases (n=136, kappa 0.453, moderate agreement). Between both studies, 1269 patient records from 35 general practices were reviewed. The patient interval could not be determined in 44% (N=809) of symptoms presented by these individuals.


Patient self-report of help-seeking for symptoms potentially associated with cancer offer a reasonably accurate method to research responses to these symptoms. Incomplete patient interval data suggests routine general practice records are unreliable for measuring this important part of the patient?s symptom journey.

Williams Emily D., Whitaker Katriina L., Piano Marianne, Marlow Laura A.V. (2019) Ethnic differences in barriers to symptomatic presentation in primary care: A survey of women in England,Psycho-Oncology Wiley


The majority of cancers are diagnosed following a decision to access medical help for symptoms. People from ethnic minority backgrounds have longer patient intervals following identification of cancer symptoms. This study quantified ethnic differences in barriers to symptomatic presentation including culturally?specific barriers. Correlates of barriers (e.g. migration status, health literacy and fatalism) were also explored.


A cross?sectional survey of 720 White British, Caribbean, African, Indian, Pakistani and Bangladeshi women aged 30?60 (n=120/group) was carried out in England. Barrier items were taken from the widely?used Cancer Awareness Measure; additional culturally?specific barriers to symptomatic presentation were included following qualitative work (11 in total). Migration status, health literacy and fatalism were included as correlates to help?seeking barriers.


Ethnic minority women reported a higher number of barriers (pÂ0.001, 2.6?3.8 more than White British women). Emotional barriers were particularly prominent. Women from ethnic minority groups were more likely to report 'praying about a symptom' (pÂ0.001, except Bangladeshi women) and 'using traditional remedies' (pÂ0.001,except Caribbean women). Among ethnic minority women, adult migration to the UK, low health literacy and high fatalistic beliefs increased likelihood of reporting barriers to symptomatic presentation. For example, women who migrated as adults were more likely to be embarrassed (OR=1.83,CI:1.06?3.15), worry what GP might find (OR=1.91,CI:1.12?3.26) and be low on body vigilance (OR=4.44,CI:2.72?7.23).


Campaigns addressing barriers to symptomatic presentation among ethnic minority women should be designed to reach low health literacy populations and include messages challenging fatalistic views. These would be valuable for reducing ethnic inequalities in cancer outcomes.

Hannaford Philip C., Thornton Alison J., Murchie Peter, Whitaker Katriina, Adam Rosalind, Elliott Alison M. (2020) Patterns of symptoms possibly indicative of cancer and associated help-seeking behaviour in a large sample of United Kingdom residents - the USEFUL study,PLOS One Public Library of Science
Background. Cancer awareness campaigns aim to increase awareness of the potential seriousness of signs and symptoms of cancer, and encourage their timely presentation to healthcare services. Enhanced understanding of the prevalence of symptoms possibly indicative of cancer in different population subgroups, and associated general practitioner (GP) help-seeking behaviour, will help to target cancer awareness campaigns more effectively. Aim. To determine: i) the prevalence of 21 symptoms possibly indicative of breast, colorectal, lung or upper gastrointestinal cancer in the United Kingdom (UK), including six ?red flag? symptoms; ii) whether the prevalence varies among population subgroups; iii) the proportion of symptoms self-reported as presented to GPs; iv) whether GP help-seeking behaviour varies within population subgroups. Methods. Self-completed questionnaire about experience of, and response to, 25 symptoms (including 21 possibly indicative of the four cancers of interest) in the previous month and year; sent to 50,000 adults aged 50 years or more and registered with 21 general practices in Staffordshire, England or across Scotland. Results. Completed questionnaires were received from 16,778 respondents (corrected response rate 34.2%). Almost half (45.8%) of respondents had experienced at least one symptom possibly indicative of cancer in the last month, and 58.5% in the last year. The prevalence of individual symptoms varied widely (e.g. in the last year between near zero% (vomiting up blood) and 15.0% (tired all the time). Red flag symptoms were uncommon. Female gender, inability to work because of illness, smoking, a history of a specified medical diagnosis, low social support and lower household income were consistently associated with experiencing at least one symptom possibly indicative of cancer in both the last month and year. The proportion of people who had contacted their GP about a symptom experienced in the last month varied between 8.1% (persistent cough) and 39.9% (unexplained weight loss); in the last year between 32.8% (hoarseness) and 85.4% (lump in breast). Nearly half of respondents experiencing at least one red flag symptom in the last year did not contact their GP about it. Females, those aged 80+ years, those unable to work because of illness, ex-smokers and those previously diagnosed with a specified condition were more likely to report a symptom possibly indicative of cancer to their GP; and those on high household income less likely. Conclusion. Symptoms possibly indicative of cancer are common among adults aged 50+ years in the UK, although they are not evenly distributed. Help-seeking responses to different symptoms also vary. Our results suggest important opportunities to provide more nuanced messaging and targeting of symptom-based cancer awareness campaigns.
Whitaker Katriina (2019) Earlier diagnosis: the importance of cancer symptoms,LANCET ONCOLOGY21(1)pp. 6-8 ELSEVIER SCIENCE INC
Kaushal Aradhna, Waller Jo, von Wagner Christian, Kummer Sonja, Whitaker Katriina, Puri Aishwarya, Lyratzopoulos Georgios, Renzi Christina (2020) The role of chronic conditions in influencing symptom attribution and anticipated help-seeking for potential lung cancer symptoms: a vignette-based study,British Journal of General Practice Royal College of General Practicioners
Background: Very little is known about the influence of chronic conditions on symptom attribution and help-seeking for potential cancer symptoms. Aim: We aimed to determine if symptom attribution and anticipated help-seeking for potential lung cancer symptoms is influenced by pre-existing respiratory conditions (often referred to as comorbidity) such as asthma or chronic obstructive pulmonary disease (COPD). Design and Setting: 2 143 adults (1081 with and 1062 without a respiratory condition) took part in an online vignette survey. Method: The vignette described potential lung cancer symptoms (persistent cough and breathlessness) after which questions were asked on symptom attribution and anticipated help-seeking. Results: Attribution of symptoms to cancer was similar in participants with and without respiratory conditions (22%). Participants with respiratory conditions, compared to those without, were more likely to attribute the new or changing cough and breathlessness to asthma or COPD (adjusted odds ratio=3.64, 95% CI=3.02,4.39). Overall, 56.5% of participants reported intention to seek help from a GP within 3 weeks if experiencing the potential lung cancer symptoms. Having a respiratory condition increased the odds of prompt help-seeking (OR=1.25, 95% CI=1.04,1.49). Regular healthcare appointments was associated with higher odds of anticipated help-seeking. Conclusions: Only 1 in 5 participants identified persistent cough and breathlessness as potential cancer symptoms, and half said they would promptly seek help from a GP, indicating scope for promoting help-seeking for new or changing symptoms. Chronic respiratory conditions did not appear to interfere with anticipated help-seeking, which might be explained by regular appointments to manage chronic conditions.
Jones Daniel, Neal Richard D, Duffy Sean R G, Scott Suzanne E, Whitaker Katriina L, Brain Kate (2020) Impact of the COVID-19 pandemic on the symptomatic diagnosis of cancer: the view from primary care,The Lancet Oncology Elsevier
The entire landscape of cancer management in primary care, from case identification to the management of people living with and beyond cancer, is evolving rapidly in the face of the coronavirus disease 2019 (COVID-19) pandemic.1 In a climate of fear and mandated avoidance of all but essential clinical services, delays in patient, population, and health-care system responses to suspected cancer symptoms seem inevitable.