Delays in diagnosis and treatment of breast cancer: a multinational analysis

Impact of Low BMI and Nutritional Status on Quality of Life and Disease Outcome in Breast Cancer Patients: Insights From a Tertiary Cancer Center in India

This study investigates the impact of Body Mass Index (BMI) on Quality of Life (QoL) and treatment outcomes in breast cancer (BC) patients, particularly focusing on underweight individuals with compromised nutritional status. A nonrandomized prospective study comprising 121 newly diagnosed patients across various BMI categories utilized FACT-B & FACIT-Sp-12 questionnaires. Follow-ups occurred at baseline, during (3rd and 6th), and after (12th month) anthracycline-taxane chemotherapy, either sequentially or concomitantly. Patients with low BMI (<18.5 kg/m2; 53.7%) exhibited significantly poorer QoL, marked by compromised nutritional indicators (low MUAC and SFT). Repeated measures ANOVA identified significant correlations between BMI groups in functional, social, and emotional QoL aspects (p < 0.05), with no notable differences in other domains. A Chi-square (ꭓ2) test underscored a significant link between BMI and treatment response (p < 0.0001), showing higher rates of non-responders among underweight patients (p = 4.259e-14). The study advocates pretreatment consultation with a dietitian as standard care for Indian BC patients, offering complimentary nutritional support for improved QoL outcomes and treatment responses.

Impact of CBE-based screening program on care pathway, stage at diagnosis, nature of treatment, and overall survival among breast cancer patients in Morocco

BACKGROUND

This study aimed to indirectly examine whether the implementation of clinical breast examination-based screening program in Morocco has been successful in downstaging and improving survival rates. Breast cancer patients detected through the screening pathway were compared with those detected through self-referral over the same period in terms of cancer stage at diagnosis, tumor characteristics, care delays, and survival.

METHODS

A prospective observational study was conducted between April 2019 and August 2020 at two major public oncology centers.

RESULTS

A total of 896 women with confirmed breast cancer were recruited (483 were program-referred and 413 were self-referred). The authors did not report any significant difference between the two groups in terms of stage at diagnosis, molecular profile, or histopathological grade. Early-stage cancer (stage I-II) was detected in 55.7% of self-referred participants compared to 55.5% of program-referred participants. Median intervals between symptom recognition, pathological diagnosis, and treatment initiation were not significantly different between the two groups. Similarly, survival after treatment showed no significant difference between patients screened by the program and self-referred patients. The 3-year survival rate after treatment was 94.5% for patients referred through the program and 88.6% for patients not referred through the program (p = .16).

CONCLUSIONS

This study highlights the importance of equitable and timely access to high-quality diagnosis and treatment facilities, leading to substantial downstaging and enhanced survival rates. Continued efforts to improve quality and expand coverage to include asymptomatic women will consolidate the health infrastructure gains achieved by the Moroccan breast cancer screening program.

Caregivers' demands: caring atmosphere expected by cancer patients' caregivers-a qualitative content analysis

PURPOSE

Family caregivers play a critical role in providing care for patients with cancer. However, the quality of their caregiving can be greatly impacted if the demands and expectations they experience are not identified. Therefore, this study aimed to explore the demands and perceived expectations of caregivers while caring for cancer patients.

METHODS

This qualitative study was conducted from June 2022 to September 2023. Face-to-face and in-depth semi-structured interviews were conducted to collect the experiences of 19 Iranian family caregivers of patients with cancer. Purposive sampling was used to select the participants. The interviews were analyzed using conventional content analysis and the rigor of the study was ensured by employing Lincoln and Guba's criteria.

RESULTS

Three main themes and six subthemes were identified through data analysis. The themes that emerged from the caregivers' experiences included the following: (1) ambiguity in the healthcare system, (2) need for empathetic communication, and (3) forgotten caregivers in the healthcare system.

CONCLUSION

Caregivers often feel overlooked, resulting in unfulfilled needs and expectations. It is imperative to explore potential solutions that provide caregivers information, empathetic communication, and support. Nurses, as key members of the healthcare team, should play a significant role in addressing this problem.

Individual and area level factors associated with the breast cancer diagnostic-treatment interval in Queensland, Australia

BACKGROUND

Delays to breast cancer treatment can lead to more aggressive and extensive treatments, increased expenses, increased psychological distress, and poorer survival. We explored the individual and area level factors associated with the interval between diagnosis and first treatment in a population-based cohort in Queensland, Australia.

METHODS

Data from 3216 Queensland women aged 20 to 79, diagnosed with invasive breast cancer (ICD-O-3 C50) between March 2010 and June 2013 were analysed. Diagnostic dates were sourced from the Queensland Cancer Registry and treatment dates were collected via self-report. Diagnostics-treatment intervals were modelled using flexible parametric survival methods.

RESULTS

The median interval between breast cancer diagnosis and first treatment was 15 days, with an interquartile range of 9-26 days. Longer diagnostic-treatment intervals were associated with a lack of private health coverage, lower pre-diagnostic income, first treatments other than breast conserving surgery, and residence outside a major city. The model explained a modest 13.7% of the variance in the diagnostic-treatment interval [Formula: see text]. Sauerbrei's D was 0.82, demonstrating low to moderate discrimination performance.

CONCLUSION

Whilst this study identified several individual- and area-level factors associated with the time between breast cancer diagnosis and first treatment, much of the variation remained unexplained. Increased socioeconomic disadvantage appears to predict longer diagnostic-treatment intervals. Though some of the differences are small, many of the same factors have also been linked to screening and diagnostic delay. Given the potential for accumulation of delay at multiple stages along the diagnostic and treatment pathway, identifying and applying effective strategies address barriers to timely health care faced by socioeconomically disadvantaged women remains a priority.

Factors causing delayed presentations of breast cancer among female patients in Sulaimani Governorate, Kurdistan region, Iraq

BACKGROUND

Since breast cancer (BC) has the best chance of being effectively treated when it is tiny and has not spread, encouraging early disease detection remains a fundamental goal in improving prognosis.

OBJECTIVE

To quantify the magnitude of the delay in BC presentation as well as the contributing factors related to this delay.

PATIENTS AND METHODS

Data was collected at the Breast Diseases Treatment Clinic, Shar Teaching Hospital, Sulaimani, Iraq from January 2017 to December 2021 of 429 patients. A validated questionnaire was distributed to women about their demographics, health, and general awareness of the disease. The patient delay was calculated by collecting information on when they initially began experiencing symptoms and when they saw a doctor. We also gleaned information about the tumour's clinicopathological features from the patient's medical records.

RESULTS

The participants' ages ranged from 24 to 85 years, with a mean of 49.6 ± 11. Most women were middle-aged (53.8%), from urban areas (80.2%), illiterate (41.7%), married (86.5%), housewives (79.0%), given birth to > 4 children (34%), practised breastfeeding (78.8%), and non-smokers (91.4%). Regarding patients' health behaviours, there were highly significant correlations between early and late presentation (p < 0.001). Concerning the patient's awareness of BC symptoms, there were highly significant correlations between early and late presentation (p < 0.001). In addition, the late presentation was strongly correlated with bilateral BC, lymph node involvement, inflammatory BC, grade III BC, and T4 status.

CONCLUSIONS

Our findings shed light on possible causes of late presentation and identified those at risk of delayed consultation. Our communities need to be educated about BC, and encouraging them for early detection decreases the incidence of advanced BC.

Cancer awareness in Australian adolescents

BACKGROUND

Over one-third of cancer cases are attributable to modifiable risk factors. Because health-related behaviors are often established at adolescence, it is important that adolescents understand the risks and lifestyle decisions that may reduce their chances of developing cancer. This study aims to identify the levels of cancer awareness of adolescents in Australia.

METHODS

Paper questionnaires were used to collect information about baseline levels of cancer awareness. These questionnaires included socio-demographic questions and the Cancer Awareness Measure (CAM) with slight modifications to ensure their suitability for the Australian adolescent population. Students aged 11 to 19 years were recruited from 13 Australian high schools between 2016 and 2019.

RESULTS

A total of 766 adolescents (58% female, mean age = 14.5 years) completed the questionnaires. Adolescents' cancer awareness was low. Adolescents who knew someone with cancer recognized significantly more cancer risk factors and cancer warning signs than those who did not know someone with cancer (t (756) = 2.35, p = .019; t (747) = 5.57, p = .001). Those from high Index of Community Socio-Educational Advantage (ICSEA) schools significantly recognized more cancer risk factors than those from low ICSEA schools (t (764) = 2.42, p = .016). Females recognized significantly more warning signs than males (t (583) = 3.11, p = .002) and students from senior high school grades recognized more warning signs than those from junior grades (t (754) = 2.24, p = .02). Most adolescents (78%) were aware of skin cancer as one of the most common cancers in Australia, however half or less were aware of other common cancers. Although most adolescents would seek medical help in the presence of possible cancer symptoms as soon as possible, approximately 20% of them would not see a doctor promptly. Emotional barriers were the most common reasons to delay seeing a doctor (56%), for example "being worried about hearing bad news" (27%).

CONCLUSIONS

Australian adolescents show poor awareness of cancer risk factors and cancer warning signs. A number of demographic and experience factors were found to be related to lower cancer awareness. Education is essential to raise cancer awareness, promote healthy lifestyles from adolescence and avoid a preventable cancer diagnosis.

Breast cancer survival in Mexico between 2007 and 2016 in women without social security: a retrospective cohort study

Background

Essential indicators of health system performance for breast cancer are lacking in Mexico. We estimated survival and clinical stage distribution for women without social insurance who were treated under a health financing scheme that covered 60% of the Mexican population.

Methods

We conducted a retrospective cohort study cross-linking reimbursement claims for 56,847 women treated for breast cancer between 2007 and 2016 to a mortality registry. We estimated overall- and clinical stage-specific survival and breast cancer survival according to patient age, state of residence, marginalization, type of treatment facility, and patient volume of the treatment facility. We also explored the distribution of clinical stage according to age, year of treatment initiation, and state where the woman was treated. We used log-rank tests and estimated 95% CIs to compare differences between patient groups.

Findings

Median age was 52 years (interquartile range [IQR] 45, 61) (Sixty five percent patients (36,731/56,847) had advanced disease at treatment initiation. Five-year overall survival was 72.2% (95% CI 71.7, 72.6). For early disease (excluding stage 0), 5-year overall survival was 89.0% (95% CI 88.4, 89.5), for locally advanced disease 69.9% (95% CI 69.0, 70.2) and for metastatic 36.9% (95% CI 35.4, 38.4). Clinical stage at treatment initiation and breast cancer survival remained unchanged in the period analyzed. Clinical stage and survival differed across age groups, state of residence, and type of facility where women received treatment.

Interpretation

In the absence of population-based cancer registries, medical claims data may be efficiently leveraged to estimate essential cancer-related performance indicators.

Funding

The authors received no financial support for this research.

Breast Ultrasound Volume Sweep Imaging: A New Horizon in Expanding Imaging Access for Breast Cancer Detection

OBJECTIVE

The majority of people in the world lack basic access to breast diagnostic imaging resulting in delay to diagnosis of breast cancer. In this study, we tested a volume sweep imaging (VSI) ultrasound protocol for evaluation of palpable breast lumps that can be performed by operators after minimal training without prior ultrasound experience as a means to increase accessibility to breast ultrasound.

METHODS

Medical students without prior ultrasound experience were trained for less than 2 hours on the VSI breast ultrasound protocol. Patients presenting with palpable breast lumps for standard of care ultrasound examination were scanned by a trained medical student with the VSI protocol using a Butterfly iQ handheld ultrasound probe. Video clips of the VSI scan imaging were later interpreted by an attending breast imager. Results of VSI scan interpretation were compared to the same-day standard of care ultrasound examination.

RESULTS

Medical students scanned 170 palpable lumps with the VSI protocol. There was 97% sensitivity and 100% specificity for a breast mass on VSI corresponding to 97.6% agreement with standard of care (Cohen's κ = 0.95, P < .0001). There was a detection rate of 100% for all cancer presenting as a sonographic mass. High agreement for mass characteristics between VSI and standard of care was observed, including 87% agreement on Breast Imaging-Reporting and Data System assessments (Cohen's κ = 0.82, P < .0001).

CONCLUSIONS

Breast ultrasound VSI for palpable lumps offers a promising means to increase access to diagnostic imaging in underserved areas. This approach could decrease delay to diagnosis for breast cancer, potentially improving morbidity and mortality.

Optimized process quality in certified breast centers through adherence to stringent diagnostic and therapeutic algorithms effects of structural as well as socio-demographic factors on start of therapy

PURPOSE

An increasing incidence of breast cancer can be observed worldwide. Since a delay of therapy can have a negative impact on prognosis, timely cancer care is an important quality indicator. By receiving treatment at a certified breast cancer center, the patient has the best chance of treatment in accordance with guidelines and the best prognosis. The identification of risk factors for a delay of therapy is of central importance and should be the basis for a continuous optimization of treatment at breast cancer centers.

METHODS

This retrospective study included women with breast cancer (primary diagnosis, relapse, or secondary malignancy) at the University Hospital Würzburg in 2019 and 2020. Data were retrieved from patients' records. Correlations and regression analyses were performed to detect potential risk factors for treatment delay.

RESULTS

Patients who received the histological confirmation of breast cancer at an external institution experienced a later therapy start than those patients who received the histological confirmation at the University Hospital Würzburg itself. (35.7 vs. 32.2 days). The interval between histological confirmation and the first consultation at the University Hospital Würzburg correlated statistically significant with age, distress and distance to the hospital.

CONCLUSION

Patients with an in-house diagnosis of breast cancer are treated more quickly than those whose diagnosis was confirmed in an external institution. We identified factors such as increased age, greater distance to the hospital as well as increased distress to prolong the time until start of oncological treatment. Intensified patient care should be offered to these subgroups.

Pre- and post-intervention survey on lung cancer awareness among adults in selected communities in KwaZulu-Natal, South Africa: A quasi-experimental study

Background

Lung cancer remains the number one cause of cancer mortality estimated at 1.8 million deaths. There are limited studies in resource poor countries regarding knowledge, attitudes and practices towards lung cancer.

Objective

This study aimed to assess the effects of a lung cancer awareness intervention in selected communities in KwaZulu- Natal, South Africa.

Materials and Methods

A quasi-experimental study design was conducted in the selected communities in KwaZulu-Natal. A community intervention was administered in the communities after a baseline survey. The intervention effects were assessed a month after implementation.

Results

There were statistical differences in the mean age (p<0.001) and proportion of males and females (p<0.001) at baseline and post-intervention. There were no differences in terms of smoking status (p=0.958), however, there was a reduction in the number of cigarettes smoked per day (p<0.001) and the number of packs smoked per week (p=0.026). The mean knowledge score increased from 41.8% (95% CI 35.7 - 47.9) at baseline to 59.9 (95% CI 53.8 - 66.0) post-intervention (p<0.001). The proportion of participants who were aware that lung cancer can be detected early increased from 46.5% (95% CI 39.1 - 53.9) at baseline to 81.1% (95% CI 71.7 - 87.9) post-intervention (p<0.001). The intervention had a statistically significant effect (aOR 4.370, 95% CI 1.477-12.928) on the level of lung cancer knowledge in the selected communities (p<0.001).

Conclusions

Interventions increasing the recognition of signs and symptoms, focusing on the importance of early detection and health seeking behaviour (including screening), smoking cessation, and addressing the perceived health system barriers are required.

Exploring Youth Perceptions About Cancer Prevention and Preferences for Education: a Qualitative Study

This study aimed to characterize adolescents' perspectives on cancer and cancer prevention and to explore their preferences for cancer education. A total of 188 middle and high school students participated in 25 focus groups. Focus groups were led by study team members and included five to ten participants each. Adolescents were asked to discuss their cancer and cancer prevention knowledge, sources of cancer education, and preferences for cancer prevention education. Focus groups were audio-recorded, and professionally transcribed. Transcripts were content and thematically analyzed by two study team members using NVivo qualitative data software. Six themes were identified in focus groups: knowledge about cancer, negative perceptions of cancer, awareness of cancer prevention, engagement in cancer prevention, facilitators and barriers for action, and preferences for cancer education. Adolescents described a wide range of cancer education sources, including friends, family, healthcare professionals, school, technology, and pamphlets. Participants associated cancer with negative emotions, such as sadness and fear. Participants expressed interest in learning about cancer and cancer prevention, but also identified barriers to engaging in preventative behaviors, such as discomfort, lack of knowledge, and lack of personal connection to cancer. Adolescents preferred learning through personal presentations, online videos, school, educational games, and social situations. Adolescence is a critical period for learning and developing healthy behaviors. Awareness of cancer and cancer prevention is crucial to lowering cancer risk in the future. To be effective, cancer education for adolescents should target specific areas of cancer prevention and address barriers to engagement in preventative behaviors.

Duration of the patient interval in breast cancer and factors associated with longer delays in low-and middle-income countries: A systematic review with meta-analysis

OBJECTIVE

Breast cancer survival is lower in low- and middle-income countries (LMICs) partially due to many women being diagnosed with late-stage disease. The patient interval refers to the time elapsed between the detection of symptoms and the first consultation with a healthcare provider and is considered one of the core indicators for early diagnosis and treatment. The goal of the current research was to conduct a meta-analysis of the duration of the patient interval in LMICs and investigate the socio-demographic and socio-cultural factors related to longer delays in presentation.

METHODS

We conducted a systematic review with meta-analysis (pre-registered protocol CRD42020200752). We searched seven information sources (2009-2022) and included 50 articles reporting the duration of patient intervals for 18,014 breast cancer patients residing in LMICs.

RESULTS

The longest patient intervals were reported in studies from the Middle East (3-4 months), followed by South-East Asia (2 months), Africa (1-2 months), Latin America (1 month), and Eastern Europe (1 month). Older age, not being married, lower socio-economic status, illiteracy, low knowledge about cancer, disregarding symptoms or not attributing them to cancer, fear, negative beliefs about cancer, and low social support were related to longer delays across most regions. Longer delays were also related to use of alternative medicine in the Middle East, South-East Asia, and Africa and distrust in the healthcare system in Eastern Europe.

CONCLUSIONS

There is large variation in the duration of patient intervals across LMICs in different geographical regions. Patient intervals should be reduced and, for this purpose, it is important to explore their determinants taking into account the social, cultural, and economic context.

No sonographer, no radiologist: Assessing accuracy of artificial intelligence on breast ultrasound volume sweep imaging scans

Breast ultrasound provides a first-line evaluation for breast masses, but the majority of the world lacks access to any form of diagnostic imaging. In this pilot study, we assessed the combination of artificial intelligence (Samsung S-Detect for Breast) with volume sweep imaging (VSI) ultrasound scans to evaluate the possibility of inexpensive, fully automated breast ultrasound acquisition and preliminary interpretation without an experienced sonographer or radiologist. This study was conducted using examinations from a curated data set from a previously published clinical study of breast VSI. Examinations in this data set were obtained by medical students without prior ultrasound experience who performed VSI using a portable Butterfly iQ ultrasound probe. Standard of care ultrasound exams were performed concurrently by an experienced sonographer using a high-end ultrasound machine. Expert-selected VSI images and standard of care images were input into S-Detect which output mass features and classification as "possibly benign" and "possibly malignant." Subsequent comparison of the S-Detect VSI report was made between 1) the standard of care ultrasound report by an expert radiologist, 2) the standard of care ultrasound S-Detect report, 3) the VSI report by an expert radiologist, and 4) the pathological diagnosis. There were 115 masses analyzed by S-Detect from the curated data set. There was substantial agreement of the S-Detect interpretation of VSI among cancers, cysts, fibroadenomas, and lipomas to the expert standard of care ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), the standard of care ultrasound S-Detect interpretation (Cohen's κ = 0.79 (0.65-0.94 95% CI), p<0.0001), the expert VSI ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), and the pathological diagnosis (Cohen's κ = 0.80 (0.64-0.95 95% CI), p<0.0001). All pathologically proven cancers (n = 20) were designated as "possibly malignant" by S-Detect with a sensitivity of 100% and specificity of 86%. Integration of artificial intelligence and VSI could allow both acquisition and interpretation of ultrasound images without a sonographer and radiologist. This approach holds potential for increasing access to ultrasound imaging and therefore improving outcomes related to breast cancer in low- and middle- income countries.

Secondary and Quaternary Delays in the Diagnosis of Breast Cancer: Are the Physicians Responsible too?

Causes of delay in presentation of breast cancer has been categorised into 'Primary Delay' (delay by the patient or her family); 'Secondary Delay' (delay by the doctors in the first contact - family physician or quacks/alternative medicine practitioners); 'Tertiary Delay' (delay in the system in a specialist breast care unit e.g. waiting list, delayed reporting, doctors on leave, strikes); and 'Quaternary Delay' (e.g. patient hopping from one competent breast cancer specialist to another or mid-course attrition to alternative treatments). In India, many patients have blind belief and high attrition towards the quacks and alternative medicine practitioners. Our study was to assess whether these 'Secondary and Quaternary Delays', particularly the attrition towards the alternative non-modern medical practitioners, have any effect on the delayed presentation and advancement of the overall anatomical staging among the breast cancer patients. We performed a retrospective observational study, based on 'Triple Assessment' and pre-structured Questionnaire. All pathologically confirmed female breast cancer patients admitted from 02/2017 to 08/2018 in the department of General Surgery in our Institute were included. Male breast cancer, histopathologically unconfirmed/inconclusive breast lumps, patients with previous breast surgery/radiotherapy/chemotherapy were excluded. Data from 267 patients was analysed. The mean age at presentation of breast cancer was 47.54 years. The average delay between the onset of the first symptom and the histological diagnosis was 13.76 ± SD 13.08 months. About half (50.2%) of our patients visited the non-modern medical practitioners at least once during their disease. The mean delay in diagnosis was significantly higher (p < 0.0001) among them. The average 'Secondary Delay' was significantly higher among those who visited the non-modern medical practitioners (9.7 ± SD 9.38 months). The average delay between the visit to the first doctor and the histological diagnosis was also significantly higher among them (18.35 ± 14 months). Patients with attrition to non-modern medical practitioners also were diagnosed in higher cT stages: cT4a (66.67%, 2 of 3) and cT4b (60%, 33 of 55). Most (56.9%) of stage IIIB patients visited the non-modern medical practitioners before their diagnosis. Patients who visited the non-modern medical practitioners had significantly more delay in the diagnosis of breast cancer. The 'Secondary and Quaternary Delays' form the major portion in the overall delay and lead to advancement of the anatomical staging of the disease. Creating public awareness, proper training and 'continued medical education' for primary care physicians, and the AYUSH practitioners are required. Further population-based studies are advised.

Differences in breast cancer diagnosis by patient presentation in Ontario: a retrospective cohort study

BACKGROUND

In Ontario, patients with breast cancer typically receive their diagnoses through the Ontario Breast Screening Program (OBSP) after an abnormal screen, through screening initiated by a primary care provider or other referring physician, or through follow-up of symptoms by patients' primary care providers. We sought to explore the association of the route to diagnosis (screening within or outside the OBSP or via symptomatic presentation) with use of OBSP-affiliated breast assessment sites (O-BAS), wait times until diagnosis or treatment, health care use and overall survival for patients with breast cancer.

METHODS

In this retrospective cohort study, we used the Ontario Cancer Registry to identify adults (aged 18-105 yr) who received a diagnosis of breast cancer from 2013 to 2017. We excluded patients if they were not Ontario residents or had missing age or sex, or who died before diagnosis. We used logistic regression to evaluate factors associated with categorical variables (whether patients were or were not referred to an OBAS, whether patients were screened or symptomatic) and Cox proportional hazards regression to identify factors associated with all-cause mortality.

RESULTS

Of 51 460 patients with breast cancer, 42 598 (83%) received their diagnoses at an O-BAS. Patients whose cancer was first detected through the OBSP were more likely than symptomatic patients to be given a diagnosis at an O-BAS (adjusted odds ratio 1.68, 95% confidence interval [CI] 1.57 to 1.80). Patients screened by the OBSP were given their diagnoses 1 month earlier than symptomatic patients, but diagnosis at an O-BAS did not affect the time until either diagnosis or treatment. Patients referred to an O-BAS had significantly better overall survival than those who were not referred (adjusted hazard ratio 0.73, 95% CI 0.66 to 0.80).

INTERPRETATION

Patients screened through the OBSP were given their diagnoses earlier than symptomatic patients and were more likely to be referred to an O-BAS, which was associated with better survival. Our findings suggest that individuals with signs and symptoms of breast cancer would benefit from similar referral processes, oversight and standards to those used by the OBSP.

Breast Cancer Treatment Delay in SafetyNet Health Systems, Houston Versus Southeast Brazil

Background

Breast cancer outcomes among patients who use safety-net hospitals in the highly populated Harris County, Texas and Southeast Brazil are poor. It is unknown whether treatment delay contributes to these outcomes.

Methods

We conducted a retrospective cohort analysis of patients with non-metastatic breast cancer diagnosed between January 1, 2009 and December 31, 2011 at Harris Health Texas and Unicamp’s Women’s Hospital, Barretos Hospital, and Brazilian National Institute of Cancer, Brazil. We used Cox proportional hazards regression to evaluate association of time to treatment and risk of recurrence (ROR) or death.

Results

One thousand one hundred ninety-one patients were included. Women in Brazil were more frequently diagnosed with stage III disease (32.3% vs. 21.1% Texas; P = .002). Majority of patients in both populations had symptom-detected disease (63% in Brazil vs. 59% in Texas). Recurrence within 5 years from diagnosis was similar 21% versus 23%. Median time from diagnosis to first treatment defined as either systemic therapy (chemotherapy or endocrine therapy) or surgery, were comparable, 9.9 weeks versus 9.4 weeks. Treatment delay was not associated with increased ROR or death. Higher stage at diagnosis was associated with both increased ROR and death.

Conclusion

Time from symptoms to treatment was considerably long in both populations. Treatment delay did not affect outcomes.

Impact

Access to timely screening and diagnosis of breast cancer are priorities in these populations.

Breast cancer in India: Present scenario and the challenges ahead

Breast cancer is the commonest malignancy among women globally. From being fourth in the list of most common cancers in India during the 1990s, it has now become the first. In this review, we examine the available literature to understand the factors that contributed to the high burden of breast cancer in the country. We also provide the landscape of changes in the field of early diagnosis and the treatment modalities as well as the limitations of the Indian healthcare delivery systems (e.g., delayed diagnosis, human resources and funding for treatment). This review also sheds light on the newer interventions and the future of breast cancer management keeping in mind the coronavirus disease 2019 imposed limitations.

Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review

OBJECTIVES

Addressing the barriers to early breast and cervical cancer diagnosis in low and middle-income countries (LMICs) requires a sound understanding and accurate assessment of diagnostic timeliness. This review aimed to map the current evidence on the time to breast and cervical cancer diagnosis and associated factors in LMICs.

DESIGN

Scoping review.

SOURCES

MEDLINE (via PubMed), Cochrane Library, Scopus and CINAHL.

ELIGIBILITY CRITERIA

Studies describing the time to diagnosis and associated factors in the context of breast and cervical cancer in LMICs published from 1 January 2010 to 20 May 2021.

STUDY SELECTION AND DATA SYNTHESIS

Two reviewers independently screened all abstracts and full texts using predefined inclusion criteria. The review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Evidence was narratively synthesised using predefined themes.

RESULTS

Twenty-six studies conducted across 24 LMICs were included in the review, most (24/26) of which focused on breast cancer. Studies varied considerably in their conceptualisation and assessment of diagnostic time, events, intervals and delays, with a minority of the studies reporting the use of validated methods and tools. Patient-related intervals and delays were more frequently evaluated and reported than provider-related and health system-related intervals and delays. Across studies, there were variations in the estimated lengths of the appraisal, help-seeking, patient and diagnostic intervals for both cancers and the factors associated with them.

CONCLUSIONS

Despite the significant burden of breast and cervical cancer in LMICs, there is limited information on the timeliness of diagnosis of these cancers. Major limitations included variations in conceptualisation and assessment of diagnostic events and intervals. These underscore the need for the use of validated and standardised tools, to improve accuracy and translation of findings to better inform interventions for addressing diagnostic delays in LMICs.

Delays in the presentation and diagnosis of women with breast cancer in Yogyakarta, Indonesia: A retrospective observational study

Purpose

To investigate factors associated with delays in presentation and diagnosis of women with confirmed breast cancer (BC).

Methods

A cross-sectional study nested in an ongoing prospective cohort study of breast cancer patients at Dr Sardjito Hospital, Yogyakarta, Indonesia, was employed. Participants (n = 150) from the main study were recruited, with secondary information on demographic, clinical, and tumor variables collected from the study database. A questionnaire was used to gather data on other socioeconomic variables, herbal consumption, number of healthcare visits, knowledge-attitude-practice of BC, and open-ended questions relating to initial presentation. Presentation delay (time between initial symptom and first consultation) was defined as ≥3 months. Diagnosis delay was defined as ≥1 month between presentation and diagnosis confirmation. Impact on disease stage and determinants of both delays were examined. A Kruskal-Wallis test was used to assess the length and distribution of delays by disease stage. A multivariable logistic regression analysis was conducted to explore the association between delays, cancer stage and factors.

Results

Sixty-five (43.3%) patients had a ≥3-month presentation delay and 97 (64.7%) had a diagnosis confirmation by ≥1 month. Both presentation and diagnosis delays increased the risk of being diagnosed with cancer stage III-IV (odds ratio/OR 2.21, 95% CI 0.97–5.01, p = 0.059 and OR 3.03, 95% CI 1.28–7.19, p = 0.012). Visit to providers ≤3 times was significantly attributed to a reduced diagnosis delay (OR 0.15, 95% CI 0.06–0.37, p <0.001), while having a family history of cancer was significantly associated with increased diagnosis delay (OR 2.28, 95% CI 1.03–5.04, p = 0.042). The most frequent reasons for delaying presentation were lack of awareness of the cause of symptoms (41.5%), low perceived severity (27.7%) and fear of surgery intervention (26.2%).

Conclusions

Almost half of BC patients in our setting had a delay in presentation and 64.7% experienced a delay in diagnosis. These delays increased the likelihood of presentation with a more advanced stage of disease. Future research is required in Indonesia to explore the feasibility of evidence-based approaches to reducing delays at both levels, including educational interventions to increase awareness of BC symptoms and reducing existing complex and convoluted referral pathways for patients suspected of having cancer.

Delay in the diagnosis and treatment of breast cancer in Vietnam

BACKGROUND

Delays in diagnosis and treatment from first noticeable breast cancer symptoms are associated with poor outcomes. Understanding the reasons and barriers for patients' delay in seeking medical care is critical to mitigating the problem.

METHODS

In-person surveys were conducted among 462 women, aged 18-79, with incident breast cancer cases, recruited from two cancer hospitals in North Vietnam. Delay, defined as the time interval between symptom recognition to the diagnosis and initiation of treatment equal to or exceeding 3 months, was categorized as follows: no delay (<3 months), moderate delay (3-8 months), and serious delay (≥9 months). Multivariable multinomial logistic regression was applied in data analyses.

RESULTS

Over one-quarter patients (31.5%) experienced moderate delays, and close to one-fifth (17.5%) experienced serious delays. Adjusted odds ratios and 95% confidence intervals for moderate and serious delays were 5.60 (3.00-10.47) and 4.25 (2.05-8.85) for financial and physical barriers, respectively. Moderate delay was positively associated with psychological barriers (5.55 [1.75-17.57]) and lack of proper knowledge (3.15 [1.47-6.74]). The associations of barriers with delays in diagnosis and treatment appeared stronger among women living in rural areas. A lack of proper knowledge was significantly associated with delay among young women (<45 years old) and those with high incomes, while psychological barriers were significantly associated with delay among older women (≥45 years old).

CONCLUSION

Delays in diagnosis and treatment are common among Vietnamese breast cancer patients and are affected by several noted barriers. Proper policy needs to be developed to address this public health issue.

European trends in breast cancer mortality, 1980-2017 and predictions to 2025

BACKGROUND

Breast cancer mortality in European women has been falling for three decades. We analysed trends in mortality from breast cancer in Europe over the period 1980-2017 and predicted number of deaths and rates to 2025.

METHODS

We extracted death certification data for breast cancer in women for 35 European countries, between 1980 and 2017, from the World Health Organisation database. We computed the age-standardised (world standard population) mortality rates per 100,000 person-years, by country and calendar year. We obtained also predictions for 2025 using a joinpoint regression model and calculated the number of avoided deaths over the period 1994-2025.

RESULTS

The mortality rate declined from 15.0 in 2012 to 14.4 in 2017 per 100,000 women (-3.9%) for the European Union (EU)-27. This fall was greater in the EU-14 (-5.2%), whereas rates rose in the transitional countries during this period by 1.9%. Mortality rate predictions across Europe are expected to reach relatively uniform levels in 2025. During the studied period, favourable trends in mortality emerged in most countries, with the greatest decrease in Denmark, whereas Poland and Romania showed an upward trend. The largest predicted decrease in breast cancer mortality was estimated for the United Kingdom (12.2/100,000 women in 2025), leading to the estimated avoidance of 150,000 breast cancer deaths over the period 1994-2025 and 470,000 in the EU-27.

CONCLUSIONS

Favourable trends in breast cancer mortality were observed in most European countries, and they will continue to fall in the coming years. Less favourable patterns were still observed among the transitional countries than other European areas.

Factors associated with advanced-stage diagnosis of breast cancer in north-west Ethiopia: a cross-sectional study

Background

Breast cancer tumours are the most common malignant tumours among women in Ethiopia. Although advanced-stage diagnosis of breast cancer is a common problem, evidence-based information is lacking about the magnitude and determinants of advanced-stage presentation in north-west Ethiopia.

Methods

An institution-based, cross-sectional study was conducted at the oncology units of the University of Gondar and Felege Hiwot specialised hospitals. Stages III and IV were considered advanced stage, whereas stages I and II were considered early stages. Data were collected prospectively on newly diagnosed breast cancer patients and entered using the EPI Info version 7.2 and analysed using Statistical Package for the Social Sciences version 23. Multivariable logistic regression was used to identify the determinants of advanced-stage diagnosis of breast cancer. A p-value < 0.05 was used as the cut-off point to select the determinants of the advanced stage.

Result

About 71.2% of breast cancer patients presented with advanced-stage disease. The median age of patients was 40 years. Rural residence (adjusted odds ratio (AOR) = 1.7; 95% confidence interval (CI): 1.02, 2.96), painless breast lump/wound (AOR = 2.5; 95% CI: 1.45, 4.13), travel distance ≥5 km (AOR = 3.2; 95% CI: 1.72, 5.29), not practising breast self-examination (BSE) (AOR = 2.9; 95% CI: 1.30, 6.52), time to presentation ≥3 months (AOR = 1.4; 95% CI: 1.02, 2.37) and misdiagnosed at first visit (AOR = 1.9; 95% CI: 1.09, 3.59) were determinants of advanced-stage breast cancer.

Conclusion

Nearly three-quarters of the patients were diagnosed with advanced-stage breast cancer. Not practising BSE, travel distance ≥5 km, rural residence, painless breast wound/lump and being misdiagnosed at first visit were important determinants of advanced-stage diagnosis of breast cancer. Focused awareness creation programmes for the public and increasing cancer diagnostic centres in the country are crucial to downstage breast cancer at presentation.

Epidemiology of De Novo Metastatic Breast Cancer

Most cases of metastatic breast cancer (MBC) arise as a recurrence of a previously treated early breast cancer. Distinct from recurrent MBC is de novo MBC (dnMBC), which describes patients who present with distant sites of disease at initial diagnosis and is reviewed here. dnMBC represents approximately 3% to 6% of new breast cancer diagnoses in high-income countries. This incidence has not declined despite decades of widespread use of population-based mammography screening. Overrepresentation of both biologically aggressive tumors and patients negatively impacted by social determinants of health are characteristics of dnMBC. Survival has generally been superior for patients with dnMBC compared with those with recurrent MBC, although it is similar to that for patients with recurrent MBC with long disease-free intervals. Subgroups of patients with dnMBC who experience prolonged survival include those with human epidermal growth factor receptor-2-positive disease or hormone receptor-positive bone-only disease. Opportunities to decrease dnMBC presentation may include novel screening modalities suited for biologically aggressive breast tumors and improved access to health care. Recognizing that there will remain some women diagnosed with dnMBC, refining our ability to identify those likely to be long-term survivors could allow for appropriate escalation or de-escalation of care. Finally, evaluation of tumor genomics in robust sample sizes has the potential to advance our knowledge of the biology of dnMBC as an entity distinct from recurrent MBC.

Factors Associated with Delay in Breast Cancer Presentation at the Only Oncology Center in North East Ethiopia: A Cross-Sectional Study

BACKGROUND

Female breast cancer is becoming an emerging public health problem which accounts for 33% of all cancers in women and 23% of all cancer cases in Ethiopia. The majority of women with breast cancer are diagnosed at later stages due to delayed presentation to seek treatment.

OBJECTIVE

To determine the prevalence and factors associated with patient delay at presentation among breast cancer patients at Dessie Referral Hospital, the only oncology center in North East Ethiopia.

METHODS

We conducted an institution-based cross-sectional study among 204 female patients with pathology-confirmed breast cancer at the only oncology center of North East Ethiopia from January to June 2020. An interviewer administered questionnaire and a medical record data extraction tool were used to address the objective of the study. Patients were said to be delayed for diagnosis if the time duration between first clinical presentations to first clinical consultation was more than 3 months. Then, bivariable and multivariable logistic regression was employed to analyze the association between dependent and independent variables.

RESULTS

Among a total of 209 eligible participants, 5 refused to participate with a response rate of 97.6%. The proportion of patients with delayed presentation was 103 (50.5%), with the median time taken to visit a healthcare provider after recognition of the first symptom was 4 months. Age above 40 years (AOR=4.81; 95% CI=1.26-18.65) P<0.024, college and above educational status (AOR=0.05; 95% CI=0.01-0.77) p<0.036, government employee (AOR=0.19, 95% CI=0.03-0.91) P<0.002, urban residence (AOR= 0.21; 95% CI=0.01-0.82) p<0.001, visit traditional healer (AOR=0.38; 95% CI=0.2-0.69) P<0.0037, and no lump in under armpit (AOR= 9.05; 95% CI=1.14-22.69) P<0.002 were associated with delayed presentation.

CONCLUSION

Delays to seek treatment is generally high in our study. Age, educational status, occupation, residence, visiting traditional healer, and absence of lump in under armpit were significant factors for delayed presentation. Intervention programs focusing on reducing delayed presentation should be employed.

Analysis of the tumor characteristics in young age breast cancer patients using collaborative stage data of the Korea Central Cancer Registry

PURPOSE

This study aimed to evaluate tumor characteristics in young age (20-39 years old) breast cancer (YABC) patients in Korea.

MATERIALS AND METHODS

We identified 10,897 breast cancer patients from 2010 to 2015. The data were collected through 10% systematic sampling of the Korea National Cancer Incidence Database (KNCI DB). Tumor size, lymph node status, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status were collected according to the Collaborative Stage version 2 (CSv2) Data Collection System.

RESULTS

Of the 10,897 patients, 1245 (11.4%) were YABC patients. They were found to have larger tumors (T2: 41.6% in 20-39 age group vs 36.4% in 40-49 age group vs 36.5% in 50-59 age group vs 38.4% in ≥ 60 age group; T3: 10.1% vs 7.3% vs 6.5% vs 6.2%, P < .0001), greater rates of lymph node involvement (41.2% vs 32.7% vs 35.7% vs 32.5%, P < .0001), higher tumor grade (High grade: 26.8% vs 19.4% vs 23.5% vs 22.1%, P < .0001), and a larger proportion of triple-negative subtype (18.2% vs 11.0% vs 12.2% vs 13.5%, P < .0001). Compared to the 40-49 age group, breast cancer-related survival (BCRS) rates were worse (91.74% vs 95.04%, P < .0001), and the characteristics of YABC patients were associated with higher risk of death from breast cancer.

CONCLUSION

YABC patients have more aggressive tumor characteristics and worse survival rates. Therefore, we need to identify high-risk groups among YABC patients and support active surveillance in them. These findings from a national cohort provide important information for establishing a national cancer care strategy to manage YABC patients.

Factors associated with delays in time to treatment initiation in Colombian women with cervical cancer: A cross-sectional analysis

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Cervical cancer is one of the leading causes of morbidity and mortality in Colombia.

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Delays in time to treatment initiation have been associated with poor prognosis.

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Only 12.41% of women were treated within the 30 days from diagnosis.

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Median time to treatment initiation was longer in women under chemotherapy.

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Social disparities were associated with delays in time to treatment initiation.

Cervical cancer (CC) is one of the leading causes of morbidity in upper-middle income countries such as Colombia. Several studies have reported poor prognosis when treatment is delayed. We aimed to describe the factors associated with delays in time to treatment initiation (TTI) in Colombian women with CC. Cross-sectional analysis including newly diagnosed cases of CC during 2018 and reported to the National Administrative Cancer Registry. TTI was defined as days from diagnosis to the first treatment (chemotherapy, radiation, or surgery). Linear and multinomial logistic regression models were estimated to analyze the association of interest. 1,249 new cases of CC were analyzed (26.98% in-situ and 40.11% locally advanced). The median age was 46 years (IQR: 36–58). Median TTI was 71 days (IQR: 42–105), varying from 70 days (IQR: 43–106) among the surgery group to 76 days (IQR: 41–118) in women under chemotherapy. Only 12.41% were treated within 30 days from diagnosis. TTI was significantly longer in women with state insurance (β = 18.95 days, 95% CI: 11.77–26.13) compared with those insured by the third payer. Women from the Pacific and Eastern regions also had a significantly longer TTI than those living in the capital of Colombia. Age, health insurance, region of residence, and stage at diagnosis were associated with TTI longer than 45 days in the multinomial model. We concluded that demographic variables (age, region of residence, and health insurance) which are proxies of social disparities and poor access to quality health care services, were associated with delays in TTI.

Does the choice of care pathways matter in timely breast cancer care in Sri Lanka?

BACKGROUND

An understanding on the use of care pathways facilitates identification of timeliness in breast cancer care. Aims of this study were to describe different breast cancer care pathways used by female breast cancer patients in Sri Lanka and to identify whether they experienced timely breast cancer care.

METHODS

We conducted a cross-sectional study among 800 female breast cancer patients with a histological/ cytological confirmation, from four state cancer treatment centers. We conceptualized five different care pathways with essential care points and in-between time intervals to be explored using an interviewer administered tool. Dates were cross-checked with the medical record. The difference of time intervals spent in different care pathways was tested for significance using one-way ANOVA test.

RESULTS

Mean (SD) age was 55.5 (10.7) years. A vast majority of 98.4 % (n = 787) self-detected the breast lesion, while only 13 had been detected through screening. Following self-detection, two thirds (n = 473, 59.1 %, 95 % CI = 55.7-62.5) had first consulted a primary healthcare physician, and a third n = 287, 35.8 %, 95 % CI = 32.6-39.3) had consulted an appropriate specialist first. Presentation interval among those who visited an Ayurvedic physician first was significantly longer than other pathways (p < 0.0001). Diagnosis interval for those who consulted an appropriate consultant was significantly shorter than other pathways (p < 0.0001).

CONCLUSIONS

Women take up numerous care paths following self-detection of a breast lesion. Empowering women on appropriate care pathways and expanding dedicated breast clinics where women to be first seen by an appropriate specialist are likely to improve timely breast cancer care in Sri Lanka.

Determinants of delay in diagnosis and end stage at presentation among breast cancer patients in Iran: a multi-center study

One of the reasons for high mortality of breast cancer (BC) is long delay in seeking medical care and end stage at presentation. This study was designed to measure the association between a wide range of socio-demographic and clinical factors with diagnostic delay in BC and stage at presentation among Iranian patients. From June 2017 to December 2019, 725 patients with newly diagnosed BC in Shiraz and Kermanshah were selected and information on BC diagnosis delay was obtained from the patient’s medical record. Data on socio-economic status was obtained via a structured interview. Our findings suggest that 45.8% of the patients were diagnosed at a late stage (stage 3 or higher). A total of 244 (34%) patients had more than 3 months delay in diagnosis. We found a significant association between stage at diagnosis and place of residence (adjusted odds ratio (aOR rural vs. urban = 1.69, 95% CI 1.49–1.97), marital status (aOR 1.61, 95% CI 1.42–1.88), family history of BC (aOR 1.46, 95% CI 1.01–2.13), and history of benign breast disease (BBD) (aOR 1.94, 95% CI 1.39–2.72) or unaware of breast self-examination (BSE) (aOR 1.42, 95% CI 1.42–1.85), delay time (aOR 3.25, 95% CI 1.04–5.21), and left breast tumor (aOR right vs. left 2.64, 95% CI 1.88–3.71) and smoking (aOR no vs. yes 1.59, 95% CI 1.36–1.97). Also, delay in diagnosis was associated with age, family income, health insurance, place of residence, marital status, menopausal status, history of BBD, awareness of breast self-examination, type of first symptoms, tumor histology type, BMI and comorbidity (p < 0.05 for all). Factors including history of BBD, awareness of BSE, and suffering from chronic diseases were factors associated with both delay in diagnosis and end stage of disease. These mainly modifiable factors are associated with the progression of the disease.

Why women with breast cancer presented late to health care facility in North-west Ethiopia? A qualitative study

BACKGROUND

Although early diagnosis is a key determinant factor for breast cancer survival, delay in presentation and advanced stage diagnosis are common challenges in low and middle income countries including Ethiopia. Long patient delays in presentation to health facility and advanced stage diagnosis are common features in breast cancer care in Ethiopia but the reasons for patient delays are not well explored in the country. Therefore we aimed to explore the reasons for patient delay in seeking early medical care for breast cancer in North-west Ethiopia.

METHODS

A qualitative study was conducted from November to December 2019 using in-depth interviews from newly diagnosed breast cancer patients in the two comprehensive specialized hospitals in North West Ethiopia. Verbal informed consent was taken from each participant before interviews. A thematic content analysis was performed using Open Code software version 4.02.

RESULTS

Lack of knowledge and awareness about breast cancer, cultural and religious beliefs, economic hardships, lack of health care and transportation access, fear of surgical procedures and lack of trusts on medical care were the major reasons for late presentation of breast cancer identified from the patient's narratives.

CONCLUSIONS

The reasons for late presentation of patients to seek early medical care for breast cancer had multidimensional nature in Northwest Ethiopia. Health education and promotion programs about breast cancer should be designed to increase public awareness to facilitate early detection of cases before advancement on the existing health care delivery system.

Variations in intrinsic breast cancer characteristics in screen-detected breast cancer patients aged between 45 and 69 and above the age of 70

BACKGROUND

Increasing age is a well-recognized risk factor for breast cancer. With an increase in life expectancy of women, more older patients are diagnosed with breast cancer. This study aimed to identify the variations in breast cancer attributes and mortality in different age groups in New Zealand.

METHODS

This was a retrospective study of data from the Auckland Breast Cancer Register between 1 June 2000 and 28 February 2017. Patients who were diagnosed through Breast Screen were included. Group A included those aged between 45 and 69 years. Group B included individuals with an age of 70 years or above.

RESULTS

From June 2000 to February 2017, a total of 6304 new cases of new breast cancer were diagnosed through Auckland Breast Screen, with 5788 patients in group A and 516 patients in group B. Group B was more likely to have the lower grade invasive cancers, with fewer grade 3 cancers. Oestrogen receptor positivity was more pronounced in group B, along with progesterone receptor positivity. Conversely, HER-2 receptor was less likely to be positive in group B. There was a significantly higher breast cancer-related mortality in group B (6.0% versus 2.7%). Mortality related to other causes was also much higher in group B as compared to that in group A (12.8% versus 2.5%).

CONCLUSION

Women aged 70 years or above generally tend to have a more favourable type of breast cancer, with a lower tumour grade, oestrogen and progesterone receptor positivity, and lower rate of HER-2 overexpression.

Impact of Time to Initiation of Treatment on the Quality of Life of Women with Breast Cancer

Introduction: Breast cancer is the most common malignancy in women. Due to the large number of women living with breast cancer and the increasing incidence of this cancer, it is very important to understand the factors determining the quality of life (QOL) of patients. The aim of the study. The aim of the study was to determine the impact of time to initiation of treatment on the quality of life of women with breast cancer. Materials and methods. The study involved 324 women with breast cancer, treated at the Podkarpackie Oncology Centre in Brzozów, Poland. The study was conducted using a diagnostic survey, using a standardised questionnaire to measure the quality of life of women treated for breast cancer, i.e., the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC) QLQ-C30 and the QLQ-BR23 module, as well as a proprietary survey questionnaire. Statistical analysis was performed using the Statistica 10.0 software (StatSoft Inc., 2011). A p value of <0.05 was considered statistically significant. Results: The examined women had a reduced overall quality of life and health (M = 53.88). The quality of life was higher in women who consulted a doctor the earliest after noticing initial symptoms of the disease, i.e., up to one week (M = 57.58), compared to patients who delayed the decision (over four weeks; M = 47.8) (p = 0.002). The quality of life was also considered higher by women who received treatment within two weeks of diagnosis (M = 56.79) and was lower for patients who waited for treatment for more than two months (M = 43.68). Statistically significant relationships were demonstrated for functional scales and disease intensity. Conclusions: Women diagnosed with breast cancer had a considerably lower overall quality of life. A relatively higher quality of life was experienced by patients who consulted a doctor the earliest after discovering symptoms of the disease and those whose waiting time for treatment was shorter. In a systematic manner, the individual stages of diagnosis should be maximally reduced and breast cancer treatment initiated without delay.

Patient Delay and Contributing Factors Among Breast Cancer Patients at Two Cancer Referral Centres in Ethiopia: A Cross-Sectional Study

Background

Unlike developed countries, there is high mortality of breast cancer in low- and middle-income countries associated with prolonged patient delays and advanced stage presentations. However, evidence-based information about patient delay in presentation and contributing factors to diagnosis of breast cancer in Ethiopia is scarce.

Methods

Institution-based cross-sectional study was conducted at oncology units of the University of Gondar and Felege Hiwot specialized hospitals. A total of 371 female breast cancer patients who were newly diagnosed from September 2019 to April 30, 2020 were included. Data were entered using EPI info version 7.2 and analyzed in SPSS version 23. Descriptive statistics was used to summarize socio-demographic and clinical characteristic of the patients. Multivariable logistic regression at a P-value<0.05 significance level was used to identify predictors of patient delay.

Results

A total of 281 (75.7%) patients had long patient delay of ≥90 days (3 months) with the average patient delay time of 8 months, and advanced stage diagnosis was found on 264 (71.2%) of patients. The median age of patients was 40 years. Rural residence (AOR=3.72; 95% CI=1.82–7.61), illiterate (AOR=3.8; 95% CI=1.71–8.64), having a painless wound (AOR=3.32; 95% CI=1.93, 5.72), travel distance ≥5 km (AOR=1.66; 95% CI=1.09–3.00), having no lump/swelling in the armpit (AOR=6.16; 95% CI=2.80–13.54), and no history of any breast problem before (AOR=2.46; 95% CI=(1.43–4.22) were predictors for long patient delay.

Conclusion

Long patient delay and advanced stage diagnosis of breast cancer are higher in our study. Travel distance ≥5 km, rural residence, no history of any breast problem before, having no lump/swelling in the arm pit, a painless lump in the breast, and being illiterate were important predictors for patient delay. Therefore, public awareness programs about breast cancer should be designed to prevent patient delay in presentation and to promote early detection of cases before advancement.

Factors Contributing to Delay in Specialist Care After Colorectal Cancer Diagnosis in Kentucky

BACKGROUND

Abundant studies have associated colorectal cancer (CRC) treatment delay with advanced diagnosis and worse mortality. Delay in seeking specialist is a contributor to CRC treatment delay. The goal of this study is to investigate contributing factors to 14-d delay from diagnosis of CRC on colonoscopy to the first specialist visit in the state of Kentucky.

METHODS

The Kentucky Cancer Registry (KCR) database linked with health administrative claims data was queried to include adult patients diagnosed with stage I-IV CRC from January 2007 to December 2012. The dates of the last colonoscopy and the first specialist visit were identified through the claims. Bivariate and logistic regression analysis was performed to identify factors associated with delay to CRC specialist visit.

RESULTS

A total of 3927 patients from 100 hospitals in Kentucky were included. Approximately, 19% of patients with CRC visited a specialist more than 14 d after CRC detection on colonoscopy. Delay to specialist (DTS) was found more likely in patients with Medicaid insurance (OR 3.1, P < 0.0001), low and moderate education level (OR 1.4 and 1.3, respectively, P = 0.0127), and stage I CRC (OR 1.5, P < 0.0001). There was a higher percentage of delay to specialist among Medicaid patients (44.0%) than Medicare (18.0%) and privately insured patients (18.8%).

CONCLUSIONS

We identified Medicaid insurance, low education attainment, and early stage CRC diagnosis as independent risk factors associated with 14-d delay in seeking specialist care after CRC detection on colonoscopy.

Breast Cancer Diagnostic Delays Among Young Mexican Women Are Associated With a Lack of Suspicion by Health Care Providers at First Presentation

PURPOSE

There is insufficient evidence in the literature regarding the association between young age and diagnostic delay of breast cancer (BC). This study aimed to determine whether young age increases the risk of diagnostic delays among patients with BC and also to identify the mechanisms through which young age affects diagnostic delay.

PATIENTS AND METHODS

This was a cross-sectional study of 592 patients with symptomatic BC treated at two of the largest public cancer hospitals in Mexico City available for the uninsured and those covered by Seguro Popular. A validated questionnaire was administered via face-to-face interviews with the patients, and their medical files were reviewed. Path analyses, using multivariable logistic regression models, were conducted to assess the relationship between age and diagnostic delay, as well as the role of potential confounders.

RESULTS

Younger participants (40 years of age or younger) had significantly longer diagnostic intervals and presented with more advanced cancer stage than did their older counterparts. Younger participants more often sought initial health care in private services led by gynecologists, more frequently experienced a lack of cancer suspicion by the first physician they consulted, used a higher number of different health services, and had more medical consultations before arrival to a cancer care center. Younger age was significantly associated with longer diagnostic delays after controlling for education, occupation, lack of health insurance, history of benign breast conditions, type of first health service used, specialty of the first physician consulted, first symptom presented, and benign interpretation of the first breast image study.

CONCLUSION

Young age increased the risk of diagnostic delays, which seems to be a result of an increased risk of lack of cancer suspicion at the first health care service consulted.

Young Women With Breast Cancer in Mexico: Results of the Pilot Phase of the Joven & Fuerte Prospective Cohort

PURPOSE

The pilot-phase report of the Joven & Fuerte prospective cohort broadly characterizes and assesses the needs of Mexican young women with breast cancer (YWBC).

PATIENTS AND METHODS

Women age ≤ 40 years with nonmetastatic primary breast cancer were consecutively accrued from 2 hospitals. Data were collected at the first/baseline oncology visit and 2 years later using a sociodemographic survey, European Organisation for Research and Treatment of Cancer Quality-of-Life (QOL) Questionnaire Core 30 (QLQ-C30) and Breast Cancer-Specific QOL Questionnaire (QLQ-BR23), Hospital Anxiety and Depression Scale (HADS), Female Sexual Functioning Index (FSFI), Sexual Satisfaction Inventory, and patients' medical records. Pearson χ2 and 2-sided t tests were used for statistical analysis. An unadjusted P value < .05 was considered significant.

RESULTS

Ninety patients were included, all with government health care coverage. Most had low monthly household incomes (98%) and at least a high school education (59%). There was a considerable prevalence of unpartnered patients (36%) and unmet parity (25%). Patients' most common initial symptom was a palpable mass (84%), and they were most frequently diagnosed with stage III disease (48%), with 51% having had a physician visit ≤ 3 months since detection but 39% receiving diagnosis > 12 months later. At baseline, 66% of patients were overweight/obese, and this proportion had significantly increased by 2 years (P < .001). Compared with baseline, global QLQ-C30 had improved significantly by 2 years (P = .004), as had HADS-Anxiety (P < .001). However, both at baseline and at 2 years, nearly half of patients exhibited FSFI sexual dysfunction.

CONCLUSION

These preliminary findings demonstrate that YWBC in Mexico have particular sociodemographic and clinicopathologic characteristics, reinforcing the necessity to further describe and explore the needs of these young patients, because they may better represent the understudied and economically vulnerable population of YWBC in limited-resource settings.

Perceived barriers to early diagnosis of breast Cancer in south and southwestern Ethiopia: a qualitative study

Background

Early diagnosis is a key determinant of breast cancer prognosis and survival. More than half of breast cancer cases are diagnosed at an advanced stage in Ethiopia, and the barriers to early diagnosis in this country are not well understood. We aimed to identify the perceived barriers to early diagnosis of breast cancer from the perspective of patients and health care providers in south and southwestern Ethiopia.

Methods

A qualitative study was conducted from March to April 2018 using in-depth interviews of breast cancer patients and breast cancer health care providers from six public hospitals located in urban and rural areas of south and southwestern Ethiopia. All participants provided verbal consent before participating. A thematic analysis was performed using Open Code 4.02.

Results

Twelve breast cancer patients and thirteen health care providers were included in the study. Patient and health-system related barriers to early diagnosis of breast cancer were identified. Patient-related barriers were lack of knowledge and awareness of breast cancer, belief in traditional medicine and religious practices for treatment, and lack of social and financial support to seek care at a medical facility. Health-system related barriers were misdiagnosis of breast cancer, long distance to referral facilities, high cost of diagnostic services, long waiting time for diagnostic tests, and lack of screening and diagnostic tests in local facilities.

Conclusions

Early diagnosis of breast cancer is affected by multiple barriers in south and southwestern Ethiopia. Awareness campaigns and education about the disease, prevention, and early detection are needed to increase early diagnosis of breast cancer. Opportunities exist to improve early diagnosis and timely treatment in rural areas.

Factors associated with time interval between the onset of symptoms and first medical visit in women with breast cancer

Women presenting with advanced breast cancer tumors are common in Brazil. Little is known about factors contributing to the delay in seeking care. The aim of this study was to identify factors associated with longer time intervals between the onset of breast cancer symptoms and the first medical visit in the Federal District, Brazil. The analysis included 444 symptomatic women with incident breast cancer, interviewed between September, 2012 and September, 2014, during their admission for breast cancer treatment in nine public hospitals in the Federal District. Patients with metastatic disease at diagnosis were not included in this study. The outcome was time interval between symptom onset and the first medical visit, whether > 90 (34% of patients) or ≤ 90 days. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95%CI). In the multivariate analysis, the > 90 day interval was significantly associated with patients not performing mammography and/or breast ultrasound in the two years prior to breast cancer diagnosis (OR = 1.97; 95%CI: 1.26-3.08), and with more advanced stages (OR = 1.72; 95%CI: 1.10-2.72). Furthermore, there was a lower chance of delay in patients with higher levels of education (OR = 0.95; 95%CI: 0.91-0.99). A relatively high proportion of breast cancer patients in the Brazilian Federal District experienced delay to attend the first medical consultation after the symptoms onset. Increasing breast cancer awareness, especially among women with low educational levels and those not participating in mammography screening programs could contribute to reduce this delay.

Timeliness of Treatment Initiation in Newly Diagnosed Patients With Breast Cancer

BACKGROUND

Evidence-based timeliness benchmarks have been established to assess quality of breast cancer care, as delays in treatment are associated with poor clinical outcomes. However, few studies have evaluated how current breast cancer care meets these benchmarks and what factors may delay the timely initiation of treatment.

PATIENTS AND METHODS

Demographic and disease characteristics of 377 newly diagnosed patients with breast cancer who initiated treatment at Tufts Medical Center (2009-2015) were extracted from electronic medical records. Time from diagnosis to initial surgery and time from diagnosis to initiation of hormone therapy were estimated with Kaplan-Meier curves. Multivariable regression analysis was used to identify factors associated with treatment delays. Thematic analysis was performed to categorize reasons for delay.

RESULTS

Of 319 patients who had surgery recommended as the first treatment, 248 (78%) met the 45-day benchmark (median, 28 days; 25th-75th %, 19-43). After adjusting for potential confounders, multivariable regression analysis revealed that negative hormone receptor status (odds ratio, 3.48; 95% confidence interval, 1.44-8.43) and mastectomy (odds ratio, 4.07; 95% confidence interval, 2.10-8.06) were significantly associated with delays in surgery. Delays were mostly owing to clinical complexity or logistical/financial reasons. Of 241 patients eligible for hormone therapy initiation, 232 (96%) met the 1-year benchmark (median, 147 days; 25th-75th %, 79-217).

CONCLUSION

Most patients met timeliness guidelines for surgery and initiation of hormone therapy, although risk factors for delay were identified. Knowledge of reasons for breast cancer treatment delay, including clinical complexity and logistical/financial issues, may allow targeting interventions for patients at greatest risk of care delays.

Breast cancer mortality trends in Europe among women in perimenopausal and postmenopausal age (45+)

INTRODUCTION

The aim of the study was to analyze breast cancer (BC) mortality trends among women at the age of 45 years old and older (45+) in the 28 European Union (EU) countries, as well as in 3 non-EU countries - Norway, Switzerland and the Russian Federation (control group) within the period 1959-2017.

MATERIAL AND METHODS

Mortality and population data were sourced from the World Health Organization (WHO) database, and age-standardized mortality rates were calculated using the standard world population. Changes in mortality trends were analyzed using Joinpoint Trend Analysis Software.

RESULTS

The majority of analyzed countries showed a meaningful decrease in BC mortality among women aged 45+. However, the results of our study suggest that there are 4 EU countries - Croatia, Poland, Romania and Slovakia - where increasing BC mortality trends started to be visible in the analyzed age group. Currently, the observed increase is still not significant, but the obtained data suggest the possibility of further continuation of the observed trend in the future. Moreover, in Bulgaria we also noted continuation of the increase in BC mortality (statistically significant).

CONCLUSIONS

Due to the availability of better treatment options, as well as presence of effective tools for detecting BC at the early stages of progression, BC mortality is falling in most analyzed European countries. To maintain this situation and to stop BC mortality increase in the analyzed age group in Bulgaria, Croatia, Poland, Romania and Slovakia, immediate actions for improvement of BC management in the European health care systems should be considered.

Health and health belief factors associated with screening and help-seeking behaviours for breast cancer: A systematic review and meta-analysis of the European evidence

PURPOSE

The aim of this systematic review was to identify health or health belief factors associated with mammography attendance or with self-initiated medical help-seeking for breast cancer symptoms among women in Europe.

METHODS

Five databases were searched for articles published between 2005 and 2018. Meta-analyses were conducted for 13 factors related to screening attendance and two factors associated with help-seeking behaviour. Where there were too few studies to include in the meta-analysis, a narrative synthesis was undertaken.

RESULTS

Sixty-five studies were included. Never having had cervical screening (d = -.72, p < .001) and higher perceived barriers to mammography (d = -.40, p < .001) were associated with lower levels of screening attendance. Possessing health insurance (d = .49, p < .001), greater perceived benefits (d = .31, p < .001) and motivation (d = .36, p = .003) towards screening, and higher perceived seriousness (d = .24, p = .019) and susceptibility (d = .20, p = .024) towards breast cancer were associated with a higher level of screening attendance. Presenting with a non-lump symptom was associated with a longer time to presentation (d = .32, p < .001). The narrative synthesis revealed that previous benign breast disease was associated with a higher level of screening attendance but with a longer time to presentation.

CONCLUSIONS

The review identified key similarities in factors associated with screening and help-seeking behaviours which offer scope for combined interventions aimed at women that target both behaviours. Furthermore, the review highlighted that fewer studies have focused on help-seeking behaviour, despite two thirds of breast cancer cases being self-detected. Future research should further examine predictors of help-seeking behaviour including a focus on modifiable factors, such as BMI, and physical activity.

Knowledge of Cancer Risk Factors, Symptoms, and Barriers to Seeking Medical Help among Omani Adolescents

Objective:

Raising cancer awareness among adolescents should lead to early diagnosis and improve their survival rate into adulthood. This study aims to identify knowledge of cancer risk factors, symptoms and barriers to seek medical help among Omani adolescents.

Methods:

A cross-sectional study with Omani adolescents (aged 15-17 years) has been conducted in six schools in Muscat, the capital of Oman. The general Cancer Awareness Measure questionnaire was used to collect the data.

Results:

A total of 481 adolescents participated. The average recognition of cancer risk factors and symptoms was low (36.8% and 39.6%, respectively). Cancer risk factors and/or symptoms significantly recognised more in girls compared to boys (χ² = 10.136; Odds ratio [OR] = 2.13 ; 95% confidence interval [CI]= 0.33-3.41; P = 0.001); older (age 17 year) versus younger (aged 15 and 16 years) (χ² = 6.075; OR = 11.68; 95% CI: 1.11-2.53; P = 0.014); those with existing co-morbidities compared to those without (χ² = 4.955; OR = 0.41; 95% CI: 0.18-0.92; P = 0.026); and those who knew someone with cancer compared to those who did not (χ² = 15.285; OR 2.70; 95% CI: 1.62-4.49; P <0.001). The majority of adolescents (88.8%) would seek medical help within the first two weeks of noting cancer symptoms. The most notable barriers to seek medical help were “emotional”. Girls were experienced “emotional barriers” significantly more than the boys (χ² = 11.617; OR = 1.89; 95% CI: 1.31-2.72; P = <0.001).

Conclusion:

Adolescents in Oman showed poor cancer awareness with several “emotional” barriers. There is a need to establish and integrate effective cancer educational programs in school curriculums to raise the cancer awareness, address emotional barriers and encourage seeking early medical help. The program could potentially have a life-long impact on encouraging early cancer diagnosis and improving the cancer survival rate.

Factors influencing delay in symptomatic presentation of breast cancer in Brazilian women

The aim of this study was to evaluate delays in the presentation of symptomatic breast cancer in women (time interval between the perception of their first sign or symptom until the first medical appointment) and its risk factors. A cohort study composed of patients with breast cancer (symptomatic) admitted to an oncological centre in the city of Rio de Janeiro, Brazil was performed. The patients were interviewed during their first hospital visit. To assess time interval as a continuous variable, the median and interquartile ranges (IQR) were calculated. The outcome comprised delay in breast cancer presentation when time from the first sign or symptom perception to the first medical appointment was ≥90 days. A descriptive analysis was performed. The association between independent variables (epidemiological, social and demographic data, related to individual healthcare, clinical and current disease) and the outcome (delay in symptomatic presentation) was assessed by a univariate analysis applying odds ratios (OR). Associations with p < .20 in the univariate analysis were included in the multiple logistic regression model. Variables with a p < .05 were retained in the final model. A total of 388 women were included. The median time was of 41 days (interquartile range - IQR: 13.2-130.0); 34.3% delayed presentation at ≥ 90 days. After adjustment, the variables associated with a delay in presentation were frequency of gynaecological examination of over than 1 year (OR: 2.59, 95% CI: 1.67-4.05), no family history of breast cancer (OR: 1.96, 95% CI: 1.15-3.35), and income lower than the minimum wage (OR: 1.62, 95% CI: 1.03-2.55). A higher score in tangible support (OR: 0.98; 95% CI: 0.96-0.99) was associated with a lesser chance of delay in presentation. Thus, delay in presentation was associated with social barriers, access to health service, health information and individual factors.

Effect of time interval from diagnosis to treatment for cervical cancer on survival: A nationwide cohort study

Objectives

Despite the ease of health care access and the waiver of copayments for cancer patients, treatment is delayed in a small proportion of Taiwanese patients diagnosed with cervical cancer. In this study, we explored the relationship between the time interval from diagnosis to treatment and survival in cervical cancer patients.

Material and methods

The study was a retrospective population-based observational study conducted between 2004 and 2010. In Taiwan, 12,020 patients were newly diagnosed with cervical cancer from 2004 to 2010, and 9,693 patients (80.6%) were enrolled in our final analysis.

Results

Most of the patients received treatment within 90 days of diagnosis (n = 9,341, 96.37%). After adjustment for other variables, patients who received treatment between 90 and 180 days and >180 days after diagnosis had a 1.33 (95% CI: 1.02–1.72, P < 0.05) and 1.36 (95% CI: 1.12–1.65, P < 0.05) times higher risk of death, respectively, than those who received treatment within 90 days. Kaplan–Meier analysis showed that the patients treated after 90 days from diagnosis had a lower overall survival rate than those treated within 90 days. In analysis stratifying the patients according to their initial tumor stage, namely stages I and II and stage III and IV, the time interval from diagnosis to treatment remained a significant prognosticator in those who received treatment >180 days after diagnosis.

Conclusion

A longer interval between diagnosis and treatment is associated with poorer prognosis among cervical cancer patients.

Caregiver Well-being and the Quality of Cancer Care

OBJECTIVES

To conceptualize the pathways and assess current evidence for the relationship between caregiver well-being and the quality of the cancer patient's care.

DATA SOURCES

Qualitative, quantitative, and theoretical literature and official reports.

CONCLUSION

Caregiver well-being has both direct and indirect effects on the quality of cancer care, including care received from the health care team, from the caregiver themselves, and in relation to patients' own self-management.

IMPLICATIONS FOR NURSING PRACTICE

Supporting caregivers has tangible consequences with regard to the quality of cancer care on multiple levels, with direct implications for patient outcomes. Nurses have a key role in providing psychosocial care to patients and their caregivers, and in supporting system-level change.

Inequality in breast cancer care in a Brazilian capital city: a comparative analysis of narratives

Introduction

Breast cancer is the leading cause of death by cancer in women in Brazil. Timely access to treatment is a priority for health policy in the country. However, indicators of the disease are not equally distributed between women. Poverty and low levels of schooling associate with late diagnosis, worse prognosis and lower survival.

Objective

To investigate differences between women from different socio-demographic profiles in the breast cancer care trajectory in Belo Horizonte, Brazil.

Method

This is a hermeneutic study through narrative analysis. The selection of the participants was based on data from hospital records of four public and private oncology services in Belo Horizonte, Brazil, according to the following variables: age, levels of schooling, and treatment cost source (Proxy of income): In-depth interviews were performed with 35 women characterized in three profiles: Profile 1 (n = 7), age range 51–69 years, schooling ≥15 years and private treatment cost; Profile 2 (n = 13), age range 35–58 years, schooling = 11 years and predominantly public treatment costing; Profile 3 (n = 15), age range 43–79 years, schooling ≤ 8 years and public treatment cost.

Results

The analysis of the narratives allowed the identification of three main themes (preventive care and first signs/symptoms; search for care and diagnosis of cancer; treatment and perceptions about care received) that highlighted differences between the trajectories, with prejudice to women with characteristics of greater vulnerability (Profile 3).

Conclusion

Although in Brazil the attention to women with breast cancer is guided by principles of equality and equity of care, it is necessary to develop mechanisms to prevent discriminatory practices and that guarantee equality of access to diagnosis and treatment.

Time from Symptom Onset to Diagnosis and Treatment among Haematological Malignancies: Influencing Factors and Associated Negative Outcomes

Background and objectives: Diagnostic delay causes unfavorable outcomes among cancer patients. It has been widely analyzed in solid tumors. However, data regarding hematological malignancies diagnostic delay are scarce. We aimed to evaluate diagnostic intervals, their influencing factors, and the negative effect on clinical outcomes among multiple myeloma and lymphoma patients. Materials and methods: One hundred patients diagnosed with multiple myeloma (n = 53) or lymphoma (n = 47) (ICD codes-C90, C81-C84) were asked to participate during their scheduled hematology consultations. Interval durations and the majority of influencing factors were assessed based on a face-to-face questionnaire. Data of disease characteristics were collected from medical records. Results: The median interval from symptom onset to registration for medical consultation was 30 (0-730) days, from registration to consultation 2 (0-30) days, from first consultation to diagnosis 73 (6-1779) days, and from diagnosis to treatment 5 (0-97) days. Overall time to diagnosis median was 151 (23-1800) days. Factors significantly prolonging diagnostic intervals in multivariate linear regression were living in big cities (p = 0.008), anxiety and depression (p = 0.002), self-medication (p = 0.019), and more specialists seen before diagnosis (p = 0.022). Longer diagnostic intervals resulted in higher incidences of multiple myeloma complications (p = 0.024) and more advanced Durie-Salmon stage (p = 0.049), but not ISS stage and Ann-Arbor staging systems for lymphomas. Conclusion: Median overall diagnostic delay was nearly 5 months, indicating that there is room for improvement. The most important factors causing delays were living in big cities, anxiety and depression, self-medication, and more specialists seen before diagnosis. Diagnostic delay may have a negative influence on clinical outcomes for multiple myeloma patients.