The Relationship between Cancer Fatalism and Education

Abstract

Purpose:

Fatalism is defined by feelings of pessimism, hopelessness, and powerlessness regarding cancer outcomes. Early researchers reported associations between race and cancer fatalism. Yet current evidence suggests that social determinants of health are better predictors of cancer fatalism than race. Therefore, the aim of this study was to examine the association between age, race, education, and cancer fatalism.

Methods:

Three hundred ninety (n=390) women who attended a screening mammogram at the Joanne Knight Breast Health Center, at Siteman Cancer Center at Washington University School of Medicine (St. Louis, MO) completed the Powe Fatalism Inventory (PFI), a 15-item self-report instrument used to operationalize cancer fatalism. We used Pearson’s correlation, independent samples t-tests, one-way ANOVA with post-hoc tests, and linear regression to analyze the relationships between PFI total scores and age, race, and education.

Results:

There were no differences between the mean PFI scores for Non-Hispanic Whites (1.89, SD 0.55) and African Americans (2.02, SD 0.76, p=0.092, 95%CI-0.27 to 0.02). We found significant differences between the mean PFI scores across levels of education. Women who attained a high school degree or less (n=72) reported higher PFI scores (2.24, SD 0.77) than women who attended some college or post high school vocational training (n=111; 1.95, SD 0.61) and women with a college or postgraduate degree (n=206; 1.83, SD 0.57). When PFI score was regressed onto age, race, and education, only education significantly explained fatalism (B=−0.19, p<0.001).

Conclusions:

In this study, cancer fatalism did not differ between Non-Hispanic White and African American women attending a screening mammogram. However, lower educational levels were associated with higher cancer fatalism. The previously observed associations between race and cancer fatalism may be explained by racial disparities in social determinants of health, such as education. Importantly, study findings indicate that the people with the greatest need for cancer fatalism interventions are those with lower educational levels.

Introduction

In the US, an estimated 12.4% of women will be diagnosed with breast cancer during their lifespan. Breast cancer is the most commonly diagnosed cancer in women [1]. Although breast cancer incidence rates are comparable between African American and Non-Hispanic White women, African American women have a higher mortality rate from breast cancer than Non-Hispanic Whites [2]. Moreover, African American women tend to be diagnosed with breast cancer at later stages; 9% of African American women are diagnosed with metastatic breast cancer whereas only 5–6% of women in other racial groups are diagnosed with distant-stage disease [2]. These notable health disparities are multifactorial and may be related to biological differences, disparities in access to health care, and differences in health beliefs and behavior [2].

Cancer fatalism is a health belief defined by the attitude that developing cancer is beyond one’s control [3]. Characteristics of cancer fatalistic attitudes include helplessness, pessimism, powerlessness, and the belief that almost everything causes cancer [3, 4, 5]. Those with fatalistic attitudes may therefore avoid information seeking, healthy behaviors, or cancer screening [6, 7]. Their perceptions of cancer are likely framed by having witnessed a frequent cycle of cancer diagnosis and death within their families or communities [4], thus, cancer screening and prevention efforts are seen as futile [5].

Cancer fatalism is associated with negative health outcomes including non-participation in mammography [8, 9, 10, 11, 12, 13], late presentation to healthcare providers for breast symptoms [14] and late-stage breast cancer [15], and suboptimal adherence to breast cancer chemotherapeutic regimens [16]. Moreover, interventions to reduce cancer fatalistic beliefs improve participation in cancer screening [17, 18, 19, 20]. Given its negative impact on the uptake of cancer screening, cancer fatalism represents an important area of health promotion research. Some researchers have found that cancer fatalistic attitudes are more prevalent among people from racial minority groups than Non-Hispanic Whites [3, 14, 15, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31]. Given the differences in breast cancer life expectancy and access to screening between Non-Hispanic Whites and those from racial minority groups [2, 32, 33, 34, 35, 36, 37, 38], cancer fatalism has become a prime area of interest among researchers aiming to reduce cancer screening-related health disparities. However, earlier researchers have provided limited insight into a complex construct.

While much of the cancer fatalism research remains predominated by findings that highlight racial differences in cancer fatalism, there are other factors associated with cancer fatalistic attitudes. Associations between cancer fatalism and race can alternatively be explained by unequal distribution of socioeconomic disadvantages such as inequalities in access to healthcare, fewer educational opportunities, lack of health insurance, and lower incomes [39, 40, 41, 42]. Health literacy also plays a role in cancer fatalism; those with lower health literacy tend to harbor more fatalistic attitudes about cancer screening [6]. Although there is an abundance of literature regarding cancer fatalism, many of the research findings about its correlates are conflicting and the concept of cancer fatalism remains poorly understood.

Cancer fatalism has most commonly been associated with African Americans. In 1980, the American Cancer Society sponsored a landmark study to evaluate cancer fatalism among 750 African Americans. When compared to a sample of participants from the general population, African Americans in that sample were less knowledgeable about cancer and more pessimistic about its cure, factors which contribute to the disparities for some African Americans [21]. Subsequently, Powe operationally defined and developed a theoretical framework to explain cancer fatalism, which also guided this research. In the Powe Fatalism Model (PFM), demographic factors including race, age, gender, income, and education influence one’s knowledge of cancer as well as their cancer fatalistic attitudes. There is also a proposed relationship between cancer fatalism and cancer knowledge; cancer fatalism is low when cancer knowledge is high which leads to participation in cancer screening. Conversely, lower levels of cancer knowledge are related to higher cancer fatalistic attitudes impeding participation in cancer screening. Overall, cancer knowledge and cancer fatalism are interrelated intervening variables that affect the relationship between demographic variables and cancer screening [3].

Powe initially studied cancer fatalism in a group of older Non-Hispanic Whites and African Americans [3], but the majority of her research following this study was predominately conducted with African American participants [43, 44, 45, 46, 47, 48]. In fact, some researchers refer to the PFI as an instrument made for measuring cancer fatalism specifically in African Americans [49], intimating that fatalism is a construct only relevant to African Americans. Others have used the PFI to measure fatalism primarily in minority populations including African Americans, non-White Hispanics, Asian-Americans, and American Indians/Alaskan Natives [11, 12, 13, 16, 18, 20, 49, 50, 51, 52, 53, 54, 55]. The result has been an abundance of cancer fatalism research in racial minority populations with far fewer comparable studies regarding cancer fatalism in Non-Hispanic Whites or across the general population. This imbalance in the literature suggests that cancer fatalism is a cultural attribute of certain racial minority groups [41]. However, this apparent relationship between race and cancer fatalism is likely mediated by socioeconomic disadvantages, health disparities, and health literacy. A more complete conceptualization of fatalism and its demographic correlates is clearly needed given that other factors beyond race could provide better targets for interventions to reduce cancer fatalistic attitudes.

Thus, the purpose of this study was to further examine the association between cancer fatalism, racial group, level of education, and age in women presenting for screening mammography. Based on the Powe Fatalism Model, we hypothesized that 1) older age would be related to higher degrees of cancer fatalism, 2) African Americans would report higher degrees of cancer fatalism than Non-Hispanic Whites, and 3) those with lower education would report higher degrees of cancer fatalism than those with higher education.

Methods

Sample Characteristics

The sample of 400 post-menopausal women without breast cancer receiving a screening mammogram were recruited from the Joanne Knight Breast Health Center, at Siteman Cancer Center at Washington University School of Medicine St. Louis, MO between October 2017 and September 2018 for a study on mammographic breast density (R21 CA216515). Women with a history or diagnosis of breast or any other cancer were excluded from the study. Women who had used medications to reduce breast cancer risk in the previous six months and women who had any previous history of taking hormone replacement therapy were also excluded.

Women who were scheduled for screening mammography were contacted prior to their mammogram to inform them about this study. Women between the ages of 50 to 64 years were eligible to participate. We recruited post-menopausal women (ages 50–64) as the median age for breast cancer diagnosis is 62 years of age [2]. Women who agreed to participate in the mammographic breast density study completed the informed consent process. Study participants completed questionnaires designed to collect data on health belief variables including cancer fatalism. Demographic data including age, race, and level of education were also collected. Education was measured by asking respondents to choose one of seven levels. The response options ranged from less than an 8th grade education to postgraduate education. Complete data were available for 390 women. We received ethics approval from the Institutional Review Board of the Washington University School of Medicine (St. Louis, MO).

Measures

Women completed the 15-item Powe Fatalism Inventory (PFI) [3] to measure cancer fatalism that had been included as part of one specific aim of the breast density study. The instrument contains items pertaining to fear, predetermination, pessimism, and the inevitability of death. Powe developed this instrument through a process of conducting qualitative interviews with target participants, a literature review, a concept analysis, expert evaluation, pilot testing of the instrument, and multiple revisions [3]. Psychometric evaluation of the PFI yielded an alpha of 0.87 and a unidimensional factor structure [3]. Other researchers have used this scale to assess breast cancer fatalism [11, 22]. Whereas, Powe’s original PFI uses dichotomous yes/no answers, we scored the items on a 5-point Likert scale from Strongly Agree (5) to Strongly Disagree (1) with statements such as: If someone is meant to get a serious disease, they will get it no matter what they do. Other researchers have used and validated PFI adaptations with 5-point Likert scale scoring [50, 55, 56]. With this scoring method, possible scores range from 15 to 75 with higher scores indicating higher degrees of cancer fatalism.

Data Analysis

All data were initially checked to ensure that they met the assumptions for conducting statistical analyses. Thus, we determined that frequencies of missing data were low (1–5%), ensured that continuous variables were normally distributed, checked cell frequencies of ordinal variables to ensure that none were too low, and checked collinearity and autocorrelation diagnostics. To examine the relationship between age and cancer fatalism (hypothesis 1), we used Pearson’s correlations. We used an independent samples t-test to determine the difference in PFI total scores across race (Non-Hispanic Whites vs. African American, (hypothesis 2). To analyze PFI scores across levels of education (hypothesis 3), we used a one-way ANOVA. Participants had indicated one of seven levels of education which we recoded into three levels of education (high school degree or less, some college or post-high school vocational training, and college or postgraduate degree). Tukey’s post-hoc test was requested to further analyze the differences between these levels of education. We used two-sided statistical tests with alpha level set to 0.05 for all analyses. Finally, to explain fatalism using age, racial group, and level of education combined, we regressed PFI total scores (dependent variable) on age, race, and education level (independent variables) using linear regression. We used SPSS version 26 to conduct all analyses.

Results

The mean age of study participants (N=390) was 57.4 (SD 4.8) years old. Non-Hispanic White women made up 63% of the sample (n=244) while 37% self-identified as Black or African American (n=146). The majority, 206 (53%), reported having graduated from college and 323 (83%) had ever had a child (Table 1). We did not find a significant correlation between age and mean PFI scores neither for the overall study population (r=0.004, p=0.943), nor within the subgroups of African Americans (r=0.15, p=0.074) or Non-Hispanic Whites (r=−0.10, p=0.122; Table 2). In addition, we found no differences between the mean PFI scores for Non-Hispanic Whites (1.89, SD 0.55) and African Americans (2.02, SD 0.76; t=−1.69, p=0.092, 95%CI −0.266 to 0.02). We found significant differences between the mean PFI scores across levels of education (F=11.29, p<0.001, 95%CI = 1.87 to 2; Table 3). Women who attained a high school degree or less (n=72) reported higher PFI scores (2.24, SD 0.77) than women who attended some college or post high school vocational training (n=111, 1.95, SD 0.61) and women with a college or postgraduate degree (n= 206, 1.83, SD 0.57; Table 3). Post-hoc analyses demonstrated significantly higher mean PFI scores for women with a high school education or less than for women who had some college or post high school education (p=0.007, 95%CI 0.512 to .066) and women with college and post graduate education (p<0.001, 95%CI 0.61 to 0.21; Table 4). However, there was no significant difference in the mean PFI scores between women with some college or vocational training and women with a college degree or higher. Of importance, we also found a significant difference in education between Non-Hispanic Whites and African Americans; more Non-Hispanic Whites reported greater educational attainment (p<0.001; Table 3).

Table 1.

Demographic Characteristics of Sample

	Total Sample (N=390)	White (n=244)	African American (n=146)
Mean Age (Standard Deviation)	57.4 (3.8)	57.6 (3.9)	57.2 (3.6)
Mean Fatalism (SD)	1.94 (.64)	1.89 (.55)	2.02 (.76)
	N (%)	n (%)	n (%)
Children
Yes	323 (82.8)	196 (80.3)	127 (87.0)
No	67 (17.2)	48 (19.7)	19 (13.0)
Highest Level of Education
Less than 8th grade	1 (0.3)	0 (0)	1 (0.7)
8–11th grade	15 (3.8)	1 (0.4)	14 (9.6)
High school	56 (14.4)	18 (7.4)	38 (26.0)
Post-high school training	21 (5.4)	12 (4.9)	9 (6.2)
Some college	90 (23.1)	50 (20.5)	40 (27.4)
College graduate	114 (29.2)	82 (33.6)	32 (21.9)
Postgraduate	92 (23.6)	80 (32.8)	12 (8.2)

Note: Numbers do not add up because of missing data.

Table 2.

Correlation Between Age and Fatalism Scores by Race (N=390)

	Pearson’s r	p value
All participants (N=384)	0.004	0.943
Non-Hispanic Whites (n=239)	−0.10	0.122
African Americans (n=145)	0.15	0.074

Table 3.

Mean fatalism scores by level of education and race (N=389)

				Fatalism
Level of Education	White	AA	Total	Mean (SD)	Range
Completed high school or less	19	53	72	2.24 (0.77)	1–5
Some college or vocational training	62	49	111	1.95 (0.61)	1–3.64	F=11.29; 95%CI=1.87 to 2.0*
College & post-graduate degree	162	44	206	1.83 (0.57)	1–5
Total	243	146	389	1.94 (0.64)	1–5
	χ2=65.03; (p<0.001)*

Table 4.

Post-Hoc Comparisons between Level of Education and Fatalism Scores

Level of Education		Mean Difference in Mean PFI scores	p	95% Confidence Interval
				Lower Bound	Upper Bound
Completed high school or less	Some college or vocational	.29*	.007*	.07	.51
	College & post-graduate degree	.41*	.000*	.21	.61
Some college or vocational	Completed high school or less	−.29*	.007*	−.51	−.07
	College & post-graduate degree	.12	.240	−.05	.29
College & post-graduate degree	Completed high school or less	−.41*	.000*	−.61	−.21
	Some college or vocational	−.12	.240	−.29	.05

Finally, we regressed PFI scores on age, race, and education. The regression model was significant (F=7.12, adjusted R²=0.046, p<0.001, Table 5). Education was the only variable that explained a significant proportion of the variance in PFI scores (B=−0.19; p<0.001, 95%CI −0.10 to −0.28; Table 5). Neither race nor age significantly explained PFI total scores.

Table 5.

Linear regression between Race, Age, and Level of Education on Fatalism

	Unstandardized Coefficients				95% Confidence Interval for B
	B	Standard Error	Beta	p	Lower Bound	Upper Bound
Age	.003	.008	.017	.732	−.014	.020
Race	.006	.072	.004	.935	−.136	.147
Education	−.191	.045	−.231	.000*	−.280	−.102

F= 7.12, adjusted R²=0.046, p<0.001

Discussion

Overall we found no association between race and cancer fatalism. Instead, we found that education was the main predictor of cancer fatalism. Our findings suggest that providers who care for women between the ages of 50 to 64 years with lower educational attainment should be concerned about cancer fatalism. Interventions to decrease cancer fatalism should be targeted toward the less educated. Cancer is a complex disease process with varied presentations, screening modalities, treatments, and prognoses. Thus, providers must educate patients about cancer and the role of cancer screening in prevention to enhance buy-in from patients, particularly those who have a high school education or less.

Other researchers have reported associations between educational attainment and cancer fatalism [3, 7, 8, 22, 56, 57, 58, 59, 60]. For example, Powe, Daniels, and Finnie [59] found a significant negative correlation between educational level and cancer fatalism scores (r=−0.4, p=0.008). Moreover, using the Health Information National Trends Survey (HINTS) dataset with 7,674 participants, Befort and colleagues [58] found that those with a high school education or less were twice as likely to agree with the statement there is not much you can do to lower your chances of getting cancer when compared to those with a college education (OR=2.07, 95% CI 1.46 to 2.94). Thus, education is salient to the development of cancer fatalism.

Overall, we found that race was not significantly associated with cancer fatalism. While many researchers have demonstrated differences in cancer fatalism between racial groups, it is important to note that there are some researchers who, like us, have also found no racial differences in cancer fatalism [56, 57, 61] and others who report inconsistent associations between race and cancer fatalistic beliefs [6, 7, 30, 58]. For example, Shen and colleagues found in their sample (N=1218) that the mean PFI scores between those who self-identified as non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic more than two races were not significantly different [56]. Moreover, many researchers studying specific racial minority groups reported generally low cancer fatalism scores among African Americans [29, 50, 51, 59, 62] and non-White Hispanics [26, 63, 64, 65]. Among a sample of exclusively African American women with breast cancer (N=129), Gullatte and colleagues [51] found a mean fatalism score of 2.8 on a revised version of the PFI specific to breast cancer in which scores above 5 are qualified as high fatalism [22]. Thus, breast cancer fatalism in that sample was quite low. Moreover, 98% of the women disagreed with the item stating I believe if someone gets breast cancer it is already too late to do anything about it, they will die. [51]. Findings such as these provide evidence indicating that racial grouping is not a reliable predictor of cancer fatalism.

Further, other cancer fatalism researchers have found high degrees of cancer fatalism among predominately rural-dwelling non-Hispanic Whites [58, 66]. For example, Vanderpool and colleagues found that 60% of a large sample (N=1,891) of underserved, low-income, Appalachian non-Hispanic Whites with less than a high school education reported high cancer fatalistic attitudes. They were significantly more likely to agree that everything causes cancer (p=0.003) and that cancer makes them think about death (p=0.008) when compared to respondents from a nationally representative sample [66]. Conversely, in a sample of Non-Hispanic Whites with high educational attainment, high annual incomes, and health insurance (N=1295), only 5.3% agreed with a cancer fatalistic statement [67]. Educational level which is related to other social determinants of health is a key factor in the development of cancer fatalism even within samples of non-Hispanic White participants.

Similarly, in samples of well-educated African Americans, fatalism scores tend to be low. Powe and colleagues reported low cancer fatalism scores (mean=4.46, possible range 0–15) among African American college students (N=190) regarding testicular cancer [68]. Additionally, in a sample of African American men (N=264) in which 73% had at least some college education, the mean fatalism scores were quite low (mean=2.91, possible range 0–15) [62]. Taken together, these findings suggest that, while race and education are intertwined due to racial disparities in education level, education better explains variations in cancer fatalism scores than race. Racial educational disparities are marked in the United States. A higher percentage of non-Hispanic Whites compared to African Americans have bachelor’s degrees (36.2% vs. 22.5%) [69]. Likewise, we found a significant difference in education levels between African Americans and non-Hispanic Whites in our study participants. Thus, previously observed differences in cancer fatalism between African Americans and non-Hispanic Whites could have been explained by educational disparities.

Educational disparities are related to other salient social and health variables. Evidence is mounting that income [11, 51, 56], health literacy [6, 57, 70], access to quality healthcare [25, 67, 71], and mistrust or fear of the medical system [27, 72, 73] are related to the development of cancer fatalism. Moreover, low cancer fatalism is linked to having access to a consistent care provider and having health insurance [67]. Mayo and colleagues reported significant differences in cancer fatalism scores based on race, education, and health insurance [22]. Powe, in her first study, also reported that income, education, and race were all significant predictors of cancer fatalism [3]. Interestingly, both researchers also noted that African Americans in their samples had less education [3, 22], lower annual incomes [3] and less insurance coverage [22] than non-Hispanic White participants. Given presumed relationships between higher education levels, likelihood of employment, access to health insurance, and health literacy levels, it is likely that many socioeconomic variables (income, employment) mediate the relationship between education level and cancer fatalism.

There are various explanations for previously observed relationships between race and cancer fatalism. It could be that the U.S. regions where studies were conducted has some bearing on the degree of cancer fatalism observed among the participants. Many researchers of cancer fatalism conducted their studies in Southeastern states, likely because of the larger population of African Americans who reside in this region [74]. In these studies, significant differences in cancer fatalism scores were reported between non-Hispanic Whites and African Americans [3, 22, 68]. Yet when interpreting these findings, we must consider structural barriers to health care in the Southeast; 9% to 12% of the general population in Southeastern states are uninsured [75]. Moreover, all southern states have less than the national average of physicians per capita. In the U.S. the average number of physicians per 100,000 is 46, but Georgia and Mississippi have 31 and 26.5 physicians per 100,000, respectively, which are among the lowest in the nation [76]. Additionally, educational attainment and income levels are lower than the national averages in all Southeastern states [77, 78]. Access to healthcare, insurance, and education, as well as low income all represent barriers to good health in the Southeastern states where the majority of African Americans reside making it difficult to separate the independent effects of these variables on cancer fatalism. Still other researchers in the Southeastern Bible belt states have suggested that fatalism is related to religion or the belief in God [22]. Again, this might be related to education in that, college graduates have been shown to be less likely to believe in God and to pray and more likely to identify as atheist or agnostic [79].

Conversely, when researchers analyzed nationally representative data, such as the HINTS data, they were unable to find significant associations between race and cancer fatalism. However, many researchers using HINTS data have reported that lower education, lower income, and lower health literacy, were associated with increased cancer fatalistic attitudes [6, 7, 30, 56, 57, 73]. As our study was conducted in a Midwestern state and there are no other studies in which researchers have measured breast cancer fatalism in exclusively Midwestern women it is possible that women in Southeastern states have a tendency to demonstrate higher degrees of breast cancer fatalism than women in other regions of the U.S. Given the diversity spanning the U.S., it is likely that cancer fatalism varies by region. However, to our knowledge, no research has been conducted to describe differences in cancer fatalism across different regions of the U.S. (Midwest, Pacific Northwest, Southeast, Northeast, etc.)

Perhaps cancer fatalism is bound to structural barriers; cancer fatalism develops in response to a multitude of social and economic conditions that constrain individuals’ ability to seek health care [39, 41]. Education is a social determinant of health and people with less education tend to experience more structural barriers to healthcare. Individuals’ level of education impacts their employment opportunities which affects their health insurance, which in turn affects their access to quality health care. Moreover, level of education affects health literacy. Additionally, health beliefs such as self-efficacy, cancer fear, perceived susceptibility to cancer, benefits of screening, barriers to screening, and locus of control are all likely related to cancer fatalism. These variables have a complex relationship which eludes a simple explanation; however, it remains clear that they are all salient factors in determining the motivation to seek cancer screening. Given that structural barriers to healthcare disproportionately impact those with limited educational attainment, cancer fatalism may result from a realistic assessment of the challenges that prevent individuals from participating in cancer screening [39,41].

Reframing our current understanding of cancer fatalism has important health implications. Cancer fatalism, when framed as a faulty belief system of African Americans rather than as the result of structural barriers to healthcare, may increase racial health disparities [39, 41]. For example, in a sample of predominately African American patients, Powe and colleagues found that self-rated cancer fatalism scores were low (4.6, SD 2.95; possible range 0–15) [59]. However, when they also asked health care providers in the same medical system to report the cancer fatalism scores they believed their patients would have, providers perceived these scores to be significantly higher (10.17, SD 3.85). To summarize, physicians and nurses perceived fatalism among their patients to be quite high while patients themselves reported relatively low cancer fatalism scores indicating implicit bias. Health care providers who believe their patients to be highly cancer fatalistic may be hesitant to recommend screening [59] thereby impeding patients’ self-determination. Cancer fatalism is typically understood as a negative health belief. It is characterized by pessimism, helplessness, and powerlessness, none of which are words that when associated with a specific racial group serve to elevate or empower those people. Thus, framing cancer fatalism as a problem for the African American community, has negative consequences; it perpetuates a false impression of African Americans among healthcare providers which ultimately negatively impacts their care [39].

Our findings have important public health implications. Implementing interventions to increase health literacy have shown promise in increasing engagement in cancer screening [17, 19, 20]. For example, Powe and Weinrich designed a video intervention to decrease cancer fatalism targeting rural-dwelling older adults. They watched the educational video and were given fecal-occult blood testing kits to be used as a screening tool for colorectal cancer. Participants in the intervention group had a post-test decrease in cancer fatalism scores and increased colorectal cancer knowledge compared to those in the control group [19]. Thus, well designed interventions to enhance health literacy and reduce structural barriers to screening stand to increase engagement in cancer screening behaviors across a broad spectrum of patients who may otherwise be reluctant to engage in screening. Few other interventions to reduce cancer fatalism have been tested. Further research is needed to develop and test well-designed interventions to decrease cancer fatalism with the ultimate goal of increasing uptake of cancer screening as this has far reaching public health implications.

Moreover, healthcare providers can remain aware that patients with lower educational attainment, especially those who have a high school education or less, are more vulnerable to cancer fatalism. Educational interventions may improve health literacy and decrease mistrust of the medical system [19], thereby, indirectly reducing cancer fatalism. Health care providers can ensure that when they are meeting with patients with a high school education or less that they take time to educate patients about cancer screening and increase their understanding about cancer early detection using lay language so patients understand [19]. Moreover, patients with less educational attainment could be paired with a case manager or social worker who could help patients navigate the health care system to attain the appropriate cancer screening tests. These are interventions that can be completed at the point of care to reduce structural barriers to health care, increase health literacy, and, ultimately, increase the uptake of cancer screening among patients who may be at risk for high degrees of cancer fatalism.

Our findings should be interpreted within the context of relevant limitations. First, our findings regarding age should be interpreted with caution. The age range of our sample was limited to 50 to 64 years. If we had surveyed women from a broader age range, we may have found an association between age and cancer fatalism. Moreover, in our sample, there were too few participants who self-identified as Hispanic (n=5) or Asian (n=1) to conduct subgroup analyses to examine cancer fatalism in other racial minority groups of women. It is also important to note that the mean cancer fatalism score of our entire sample was low. This could be expected because this study was done in a group of women who were already scheduled for mammography. They may have been women with positive views of mammography who were already highly motivated to engage in screening, therefore, less likely to have cancer fatalistic attitudes. Because these data were from a study that was not specifically focused on fatalism, we did not have data for variables that might influence fatalism such as mammogram history and health care literacy.

Another limitation is that we used the original PFI to measure cancer fatalism, however, there are researchers who have used revised scales which include items that specifically measure breast cancer fatalism [22]. Our study may have been strengthened by administering the revised PFI as our study participants were specifically being screened for breast cancer. Additionally, we studied a convenience sample of women so the generalizability of our results is limited. The women in our sample tended to be well-educated; 53.3% had a college degree or post-graduate education, which may, in part, explain the generally low fatalism scores that we found. Future researchers might examine the impetus behind cancer fatalism, which may reveal potential intervention targets to reduce cancer fatalistic attitudes in an effort to increase cancer screening and perhaps other health behaviors, such as smoking, poor dietary habits, and a sedentary lifestyle. Moreover, we did not measure variables related to health literacy, annual income, access to healthcare, or mistrust of the medical system in our sample. Evidence is mounting that these social determinants of health are salient to the development of cancer fatalistic attitudes. Thus, future researchers may seek to better understand the complex relationships between race, level of education, socioeconomic status, and cancer fatalism.

Conclusion

We observed that educational attainment is inversely associated with cancer fatalism. The previously observed relationships between race and cancer fatalism may be explained by racial disparities in education and other social determinants of health. Efforts to reframe the construct of cancer fatalism are clearly warranted; healthcare providers who are able to provide high-quality educational interventions and help patients navigate the healthcare system to access screening tests can improve cancer screening uptake. Interventions to reduce cancer fatalism in people with lower educational levels are needed to enhance the uptake of mammography which will ultimately improve breast cancer-related outcomes for less educated patients. Targeting groups of people with less than a college education to improve their understanding of breast cancer and increase their perception that screening is beneficial stands to improve breast cancer-related health disparities within the US healthcare system.