Balancing - Cancer from a primary care perspective. Diagnosis, posttraumatic stress, and end-of-life care.

Research output: ThesisDoctoral Thesis (compilation)


This thesis explores cancer from a primary care perspective covering three areas: diagnosis, posttraumatic stress disorder (PTSD), and end-of-life care.

We analyzed patient records of every child diagnosed with a malignancy in a defined area. During 12 years 68 children were diagnosed (incidence 14/100,000). For 68% the diagnosis was initiated in primary care. There were 25 children with leukemia, and 22 with brain tumors. Median parent’s and doctor’s delay were 1 and 0 weeks for the former, and 5 and 3 weeks for the latter group.

We found that diagnosis for 135 women with breast cancer, and 99 women with ovarian cancer was initiated in primary care for more than 50%. Median patient’s delay was 1 week for breast cancer, and 3.5 weeks for ovarian cancer patients, and provider delay 3 weeks for both groups. Crude and relative 5-year survival was 73% and 91% in breast cancer, and 40% and 49% in ovarian cancer.

We found a possible PTSD prevalence of 6.5% (n=72) in 1113 primary care attenders. DSM-IV trauma criteria, and >35 for the Impact of Event Scale combined with >5 for the Posttraumatic Symptom Scale. Cancer was a triggering trauma for 20% of those with possible PTSD. Low well-being had the strongest association with possible PTSD followed by sexual assault, and female gender.

We designed an attitude questionnaire to evaluate a learner-centered education in end-of-life care for home care staff. The Hospital Anxiety and Depression scale was used to measure well-being. Attitudes towards end-of-life care improved, and mental well-being increased in the intervention group, while no positive changes were seen in the control group.

We did a grounded theory analysis and found that the basic process balancing explains the problem-solving in end-of-life cancer care. Four main balancing stages emerged. Weighing by sensing needs and wishes, and gauging against resources in diagnosing and care planning. Shifting by breaking bad news, changing careplaces and treatments. Compensating by controlling symptoms, educating, team-working, prioritizing and "stretching" time, innovating, improvising, and upholding the "homeostasis of hope". Compromising, the resulting stage, was a "walk on a fine line", between optimizing the care and deceiving the patient.

Balancing was also used to conceptualize cancer care in general using data from all of the studies.


Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Public Health, Global Health, Social Medicine and Epidemiology


  • medicinsk utbildning, Cytology, grounded theory, brain tumor, leukemia, child, ovarian cancer, breast cancer, prognosis, end-of-life care, screening, posttraumatic stress, diagnosis, primary care, Cancer, family practice, oncology, cancerology, Cytologi, onkologi, cancer, General practice, medical training, Allmän medicinsk utövning
Original languageEnglish
Awarding Institution
Supervisors/Assistant supervisor
  • [unknown], [unknown], Supervisor, External person
Award date2003 Jan 8
  • Hans Thulesius, FoU-centrum, Box 1223, SE-35112 Växjö, Sweden, or Department of Community Medicine, Malmö University Hospital, SE-205 02 Malmö, Sweden.,
Print ISBNs91-628-5501-8
Publication statusPublished - 2002
Publication categoryResearch

Bibliographic note

Defence details Date: 2003-01-08 Time: 10:15 Place: Jubileumsaulan, entrance 59, Carl Gustavs väg 33, Universitetssjukhuset MAS, Malmö External reviewer(s) Name: Mattsson, Bengt Title: Professor Affiliation: [unknown] --- Article: I. Thulesius H, Pola J, Håkansson A. Diagnostic delay in pediatric malignancies – a population-based study. Acta Oncologica 2000; 39:873–6. Article: II. Thulesius H, Lindgren A, Olsson H, Håkansson A. Diagnosis and prognosis of breast and ovarian cancer – a population based study of 234 women. Submitted. Article: III. Thulesius H, Alveblom A-K, Håkansson A. Posttraumatic stress and impaired well-being in primary care patients. Submitted. Article: IV. Thulesius H, Petersson C, Petersson K, Håkansson A. Learner centred education in end-of-life care improved well-being in home care staff. A prospective controlled study. Palliative Medicine 2002; 16:347–354. Article: V. Thulesius H, Håkansson A, Petersson K. Balancing – a basic social process in end-of-life cancer care. Qualitative Health Research. In press.