How social class shapes breast cancer risk perspectives and prevention practices of Australian midlife women: a qualitative study using the concept of 'breast cancer candidacy'.

Background: The increasing incidence of breast cancer and disease burden is a significant public health concern. While 30% of breast cancers could be prevented through addressing modifiable risk factors, misconceptions among women about breast cancer risks hamper primary prevention. In the absence of primary prevention, secondary prevention such as mammography increases the early detection of breast cancer and improves health outcomes. However, current population-level screening rates indicate secondary prevention is suboptimal. More effective public health efforts to improve breast cancer prevention are required. Given breast cancer is socially patterned, this work explores how social class impacts women's breast cancer prevention practices. This study uses the concepts of lay epidemiology and candidacy as a mechanism to understand women's breast cancer risk perspectives. It engages Bourdieu's relational social class theory to unpack how women's social, cultural, and structured life contexts shape these perspectives and their considerations regarding primary and secondary prevention.

Methods: In this qualitative study 43 Australian midlife women (aged 45-64 years), were interviewed to explore their understandings of breast cancer risks, how they perceived their own risk, and how this shaped their prevention behaviours. A theory-informed thematic analysis applying Bourdieu's concepts of habitus, capital, and fields to understand how women's social class positions shapes risk perspectives and prevention practices was conducted.

Results: This social class analysis showed differences in how women engage in breast cancer discourse, consider risks, and participate in breast cancer prevention. Middle-class women prioritise health promoting practices and were more likely than working-class and affluent women to attend mammography screening. Working-class women experience structural factors, like low income, stress and difficult life circumstances, which hamper primary prevention practices and for some screening is not considered or prioritised, and their decisions not to screen are less active. Affluent women often do not consider themselves at-risk due to their healthier 'lifestyles. 'They suggest that this, and their knowledge of screening benefits and harms allows them to make informed decisions not to screen.

Conclusions: Women interpret and understand breast cancer risks differently and enact prevention practices within the parameters afforded by their social class positions. These findings are useful to inform improved public health approaches regarding both modifiable breast cancer risks and increasing mammography screening. To improve equity in breast cancer prevention efforts, such approaches must respond to limitations based on social class and address structural factors that impact prevention practices.