Does delay in diagnosis of breast cancer affect survival?

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.

The effect of the number of biopsies on the delay in the time from the delivery of mammography results to breast cancer histopathological diagnosis

PURPOSE

The delay in the time (in calendar days) from the delivery of mammography results to histopathological breast cancer (BC) diagnosis could be associated with more advanced clinical stages, a worse prognosis and higher mortality. Therefore, we assessed the association between the number of biopsies and the delay in the time (in calendar days) from the delivery of mammography results to histopathological BC.

METHODS

A survey was performed on 563 women aged between 35 and 69 years with histopathologically confirmed BC who attended 11 Mexican hospitals.

RESULTS

After adjusting for potential confounders, the odds of having a delay in the time (in calendar days) from the delivery of mammography results to histopathological BC diagnosis (≥ 60 days) among women with ≥ 3 biopsies were 2.99 times the odds of those who had only one biopsy (95% CI 1.35, 6.63).

CONCLUSION

The number of biopsies should be considered as a predictor of the time delay between the delivery of the mammography result and the diagnostic result.

Tackling breast cancer in developing countries: insights from the knowledge, attitudes and practices on breast cancer and its prevention among Nigerian teenagers in secondary schools

Background

Breast cancer occurrences in developing countries are gradually matching caucasian levels. Since early detection is linked to reductions in morbidities and mortality, affordable screening techniques like breast self-examination (BSE) becomes imperative in these resource-limited economies. Ascertaining the Knowledge, Attitudes, and Practices (KAP) of breast cancers and BSE among young adult females will help provide baseline information for early and targeted interventions.

Method

A cross sectional survey involving 432 female senior secondary school students in Otuocha Educational Zone of Anambra State, Nigeria.

Results

A total of 321 (74.3%) valid questionnaires were returned. Mean age was 16.79 ± 1.48 years. Even though 84.6% and 55.2% had respectively heard about breast cancer and BSE, and the ‘General Knowledge’ of breast cancer was high (75.2%), specifics on ‘Risk Factors’ (41.5%) and ‘Symptoms’ (46.1%) were poor.

Knowledge on correct BSE ‘Techniques’ was 52.9%, but few know when to commence (43.1%), the right frequency (31.5%), or the right timing (24.6%). A large majority (73.6%) had positive attitudes, but only 6.1% practice it monthly, while 55.3% had never done it at all. No significant predictors of Knowledge and Practice of BSE was identified.

Conclusion

Health campaigns on BSE and breast cancers should provide specific details on techniques, risk factors and symptoms, while emphasizing on the right methods, timing and frequency. The positive attitudes identified raise optimism that health interventions would be effective and can have long term benefits. If possible, BSE and breast cancer teachings should be included in the secondary school academic curricula of resource-limited countries.

Effect on survival of longer intervals between confirmed diagnosis and treatment initiation among low-income women with breast cancer

PURPOSE

To determine the impact of longer periods between biopsy-confirmed breast cancer diagnosis and the initiation of treatment (Dx2Tx) on survival.

PATIENTS AND METHODS

This study was a noninterventional, retrospective analysis of adult female North Carolina Medicaid enrollees diagnosed with breast cancer from January 1, 2000, through December, 31, 2002, in the linked North Carolina Central Cancer Registry-Medicaid Claims database. Follow-up data were available through July 31, 2006. Cox proportional hazards regression models were constructed to evaluate the impact on survival of delaying treatment ≥ 60 days after a confirmed diagnosis of breast cancer.

RESULTS

The study cohort consisted of 1,786 low-income, adult women with a mean age of 61.6 years. A large proportion of the patients (44.3%) were racial minorities. Median time from biopsy-confirmed diagnosis to treatment initiation was 22 days. Adjusted Cox proportional hazards regression showed that although Dx2Tx length did not affect survival among those diagnosed at early stage, among late-stage patients, intervals between diagnosis and first treatment ≥ 60 days were associated with significantly worse overall survival (hazard ratio [HR], 1.66; 95% CI, 1.00 to 2.77; P = .05) and breast cancer-specific survival (HR, 1.85; 95% CI, 1.04 to 3.27; P = .04).

CONCLUSION

One in 10 women waited ≥ 60 days to initiate treatment after a diagnosis of breast cancer. Waiting ≥ 60 days to initiate treatment was associated with a significant 66% and 85% increased risk of overall and breast cancer-related death, respectively, among late-stage patients. Interventions designed to increase the timeliness of receiving breast cancer treatments should target late-stage patients, and clinicians should strive to promptly triage and initiate treatment for patients diagnosed at late stage.

Australian women's awareness of breast cancer symptoms and responses to potential symptoms

OBJECTIVES

Poor awareness of breast cancer symptoms has been associated with patient delay in seeking help; thus reduced survival, more aggressive treatment, and fewer treatment choices. The aim of this study was to develop a representative picture of Australian women's knowledge of symptoms, experienced potential symptoms, and behavioral responses.

METHODS

A general population sample of approximately 3,000 women aged 30-69 completed a telephone survey; results were compared to previous surveys conducted in 1996 and 2003.

RESULTS

The most commonly cited potential symptom of breast cancer was a lump in the breast, identified by 86% of respondents (an increase from 75% in 2003). Other commonly mentioned symptoms were discharge from the nipple, pain/soreness, skin puckering, or dimpling; and a change in breast shape. The proportion unable to name any potential symptoms of breast cancer decreased from one in ten in 2003 to approximately one in twenty in 2007. The primary reason for not seeking medical advice in response to a potential symptom was the belief that breast cancer was not present.

CONCLUSIONS

Health promotion efforts need to continue to aim at increasing community understanding of potential breast cancer symptoms and encouraging women to act on potential symptoms by seeking medical advice.

Breast cancer survival among economically disadvantaged women: the influences of delayed diagnosis and treatment on mortality

Breast cancer affects thousands each year in the United States, and disproportionately affects certain subgroups. For example, the incidence of breast cancer in South Carolina is lower in African American compared with European American women by approximately 12% to 15%, but their mortality rate is twice as high as in European American women. The purpose of the study was to assess factors associated with breast cancer mortality between African American and European American women. Participants (n=314) in South Carolina's Breast and Cervical Cancer Early Detection Program (SCBCCEDP), which provides breast cancer screening and treatment services, during the years 1996-2004 were included in the study. Data, including tumor characteristics, delay intervals, and race, were examined using the chi(2) test and the Wilcoxon rank-sum test. Cox regression modeling was used to assess the relationship between delay intervals and other factors. No racial differences were found in age at diagnosis, tumor characteristics, or delay intervals. Time delay intervals did not explain differences and mortality rates by race. Survival, however, was affected by prognostic factors as well as by a significant interaction between hormone-receptor status and race. Despite the excellent record of the SCBCCEDP in screening and diagnostic or treatment referrals, the racial disparities in breast cancer mortality continue to exist in South Carolina. These findings highlight the need for future research into the etiology of racial differences, and their impact on breast cancer survival.

Managing the 2-week wait for breast patients

INTRODUCTION

Published data suggest that the 2-week wait system and triple assessment at one fast-track clinic visit is an out-dated method of capturing disease from a referral population. These studies report up to 32% of breast cancer coming from routine referrals. It has been recommended, therefore, that all breast referrals should be seen within 2 weeks. The sheer volume of referrals are likely to prevent this target being achieved. The aim of this study was to analyse the performance of our fast-track system.

PATIENTS AND METHODS

The Birmingham Heartlands and Solihull fast-track clinics were set up in 1999 with a prospective audit system. The data from this audit were retrospectively analysed and cross-referenced with the cancer data base to determine the referral origin of breast cancers from November 1999 to February 2005.

RESULTS

A total of 14,303 (fast-track, n = 6678; routine referral, n = 7625) patients were seen over a 5-year period. Overall, 1095 cancers (91.8% of the total) came from the fast-track clinics which had a pick-up rate of 16.4% compared with 98 cancers (8.2% of the total) and a pick-up rate of 1.3% for routine referrals (P < 0.001). The appropriateness of fast-track referral was also analysed which showed that 14.4% of cancers were detected if the referral criteria were met compared to 0.55% if they were inappropriate (P < 0.001).

CONCLUSIONS

The traditional fast-track, triple assessment breast clinic is an efficient and well-structured way of diagnosing disease. We recommend that the two system referral pattern should continue.

Reduced mortality for women with mammography-detected breast cancer in east Denmark and south Sweden

The 5-year relative survival from breast cancer in Denmark is 10 percentage points lower than in Sweden. This difference has been demonstrated previously as being caused partly by more involved lymph nodes and larger tumours in Denmark. Sweden has had nationwide mammography-screening coverage since 1991, whereas this is still in its infancy in Denmark. In the search for an explanation for the remaining survival difference, patient delay was a likely candidate. This study compared patient delay and mammography-detection between two national regions. Data on patient delay and mammography were obtained from hospital records from 1989 and 1994, and analysed using Cox proportional hazard analysis of death within the first 5 years, with the factors age, country, delay/mammography detection and established patho-anatomic variables. A comparison of patient delay and mammography detection in 1989 and 1994 showed more mammography-detected tumours in south Sweden and more women with long delay in east Denmark. Mammography detection, but not long patient delay, had a significant effect on the death hazard when adjusting for patho-anatomic risk factors. The hazard ratio was not eliminated in 1989, but in 1994, the hazard ratio between east Denmark and south Sweden was reduced from 1.3 to 1.1. In conclusion, patient delay did not appear to have any effect on 5-year survival when adjusting for patho-anatomic factors, but tumour detection by mammography affected survival favourably and partly explained the survival difference between east Denmark and south Sweden.

Knowledge, attitude and practice of Nigerian women towards breast cancer: a cross-sectional study

Background

Late presentation of patients at advanced stages when little or no benefit can be derived from any form of therapy is the hallmark of breast cancer in Nigerian women. Recent global cancer statistics indicate rising global incidence of breast cancer and the increase is occurring at a faster rate in populations of the developing countries that hitherto enjoyed low incidence of the disease. Worried by this prevailing situation and with recent data suggesting that health behavior may be influenced by level of awareness about breast cancer, a cross-sectional study was designed to assess the knowledge, attitude and practices of community-dwelling women in Nigeria towards breast cancer.

Methods

One thousand community-dwelling women from a semi-urban neighborhood in Nigeria were recruited for the study in January and February 2000 using interviewer-administered questionnaires designed to elicit sociodemographic information and knowledge, attitude and practices of these women towards breast cancer. Data analysis was carried out using Statistical Analysis Software (SAS) version 8.2.

Results

Study participants had poor knowledge of breast cancer. Mean knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer presents commonly as a painless breast lump. Practice of breast self examination (BSE) was low; only 432 participants (43.2%) admitted to carrying out the procedure in the past year. Only 91 study participants (9.1%) had clinical breast examination (CBE) in the past year. Women with higher level of education (X² = 80.66, p < 0.0001) and those employed in professional jobs (X² = 47.11, p < 0.0001) were significantly more knowledgeable about breast cancer. Participants with higher level of education were 3.6 times more likely to practice BSE (Odds ratio [OR] = 3.56, 95% Confidence interval [CI] 2.58–4.92).

Conclusion

The results of this study suggest that community-dwelling women in Nigeria have poor knowledge of breast cancer and minority practice BSE and CBE. In addition, education appears to be the major determinant of level of knowledge and health behavior among the study participants. We recommend the establishment and sustenance of institutional framework and policy guidelines that will enhance adequate and urgent dissemination of information about breast cancer to all women in Nigeria.

Waiting time for breast cancer treatment in Alberta

BACKGROUND

The present study had two research questions. First, what is the average waiting time between diagnosis and treatment for Alberta women with breast cancer relative to Canadian Society for Surgical Oncology (CSSO) recommendations? Second, does patient age, cancer stage, patient community size, and year of diagnosis have a significant relationship to waiting time?

METHODS

The sample consisted of all Alberta women diagnosed with breast cancer between 1997 and 2000. Waiting time was defined as number of days between definitive diagnosis and treatment initiation. Multiple regression examined the relative influence of the predictor variables on waiting time.

RESULTS

There were 6,418 cases of breast cancer between 1997 and 2000. Mean waiting time was 20.2 days (SD 21.6) and median waiting time was 17 days. Longer waiting time was significantly associated with year of diagnosis (progressively longer from 1997 to 2000), patients younger than 70, and Stage 1 cancer. Waiting time increase from 1997 to 2000 appears to be due to increased demand for services without corresponding increases in resources. Less treatment delay for women older than 70 is due to more of these women being treated the same day they received their diagnosis.

CONCLUSION

Only 44% of women had a waiting time of 14 days or less as recommended by the CSSO. The number of women who will have to wait longer than recommended for treatment will likely increase without a significant increase in oncological resources. The basis for differences in waiting times as a function of age needs to be further investigated to ensure equitable access to care.

Waiting for elective general surgery: physical, psychological and social consequences

BACKGROUND

Long surgical waiting lists are common and receive serious consideration. To evaluate the positive and negative effects of waiting lists, insight into the consequences of waiting is needed. The present study aims to assess what insight the current literature provides into the effects of delayed surgery for varicose veins, inguinal hernia in adults, gallstones, and breast cancer in terms of physical, psychological and social aspects.

METHODS

Searches of Medline and Embase, for the period January 1985-September 2003, were performed to identify articles providing direct or indirect insight into the consequences of waiting for surgery for each disorder. Reference lists of retrieved reports were examined for relevant articles.

RESULTS

Seven studies were identified with direct data on consequences of delay in elective surgery. Relevant indirect data were found in 32 reports. Results indicated that delayed varicose vein surgery or inguinal hernia repair involves marginal physical, psychological or social suffering, and that severe deterioration is unlikely. The impact of delayed cholecystectomy seems more profound by suffering on all three health aspects. Complications while waiting do occur, with a higher risk for patients with previous complications. Longer delays for breast cancer surgery seem to adversely affect prognosis, although it is unclear which interval is associated with such an effect. Moreover, having breast cancer undoubtedly affects psychological health.

CONCLUSIONS

There is a remarkable paucity of studies addressing the consequential impact of waiting for elective surgery on patients' health for each of the four studied disorders. Current literature permits merely general estimation of this consequential impact. As specific assessment of these consequences is important for daily practice and for policy, further research is required.

[Analysis of the delay in surgical treatment of adenocarcinoma of the prostate]

INTRODUCTION

The prostate cancer is an important cause of men's mortality in our society.

PURPOSE

To know the time of delay in to realise the surgical treatment of the prostate cancer.

MATERIALS AND METHODS

Analysis of 30 cases of patients treated with radical prostatectomy, cuantifying the time of delay in all the periods of the process.

RESULTS

Appointment in general practitioner-first appointment in urology: 21.7 days. First appointment in urology-biopsy: 22.8. Biopsy-diagnosis: 34.3. Diagnosis-appointment of anesthesiology: 28.5. Anesthesiology-radical prostatectomy: 25.7.

CONCLUSIONS

There are actions for to reduce the delay in to perform the diagnosis or treatment, where we can act how an improvement plan: to give poblational education in general and information to the patient in particular, to analyze the rules of medical action, to improve the coordination between level, to improve the flexibility in outpatients appointment and time waiting for diagnosis test and treatment, to correct the temporality, to create clinical units of many specialties and to improve the politics of health.

The self-reported likelihood of patient delay in breast cancer: new thoughts for early detection

BACKGROUND

Delayed presentation of self-discovered breast symptoms influences stage of cancer at diagnosis and decreases breast cancer survival.

METHODS

A total of 699 asymptomatic women (black, white, and Latino), recruited in community settings and stratified by age, income, and educational level, were surveyed for their likelihood to delay (J-Delay scale) in the event of a breast symptom discovery. Models of likelihood were tested with logistic regression analyses.

RESULTS

A total of 166 women (23.7%) reported likelihood to delay. Lower income, lower educational level, self identification as Latino or black, experienced prejudice in care delivery, perceived lack of access to health care, fatalism about breast cancer, poor health care utilization habits, self-care behavior, spouse/partner and employer perceived constraints, problem-solving style, and a lack of knowledge of breast cancer's presenting symptoms were associated with likelihood to delay. A combined sample multiple logistic regression model correctly predicted 40.6% of women reporting a likelihood to delay, 94.9% of those not likely to delay, and 82.4% (551 of 669) of cases overall.

CONCLUSIONS

Self-reported likelihood of patient delay is measurable in advance of symptom occurrence, and this measure is consistent with behavioral and knowledge variables previously linked with advanced breast cancer at diagnosis.

Perceived risk and help-seeking behavior for breast cancer. A Chinese-American perspective

Delay in the diagnosis and treatment of breast cancer diminishes a woman's chance of survival. How do women decide whether and when to seek an evaluation of breast symptoms that may signal breast cancer? Prior studies of African-American, white, and Latino women have described a number of critical factors associated with making the judgment to delay, but at this writing, there have been no studies factors influencing Chinese-American women. By means of focus group methods in English, Mandarin, and Cantonese, a sample of 45, predominantly first-generation Chinese-American women explained their understanding of breast cancer risk and their likelihood of delaying versus seeking evaluation of self-discovered breast symptoms. There was much congruence with the ideas of other American women despite the differing cultural heritage. Unique to these Chinese Americans was a sense of invulnerability to breast cancer, a linking of cancer to tragic luck, and the predominant likelihood of delay. To preserve modesty and to conserve wealth and time, many study participants favored using Chinese medicine and delaying Western therapies. This study suggests ways by which health care providers must approach guidelines for breast cancer early detection in this population.

In-hospital delay in the diagnosis of breast cancer

BACKGROUND

There is evidence that delay in the diagnosis of breast cancer may prejudice survival. The aim of this study was to determine the incidence, time trends and causes of delay in a dedicated breast clinic.

METHODS

The interval between first breast clinic visit and a definitive diagnosis was recorded in all patients with invasive breast cancer between 1988 and 1997. In all patients with a delay of 3 months or more, the case notes were reviewed for evidence of a triple assessment (clinical examination, imaging and needle biopsy). The principal cause of delay was identified.

RESULTS

Of 1004 patients with invasive breast cancer, there was a delay in diagnosis of 3 months or more in 42 patients between 1988 and 1997, an incidence of 4.2 per cent. The median delay was 6 months and the median age at diagnosis was 53 (range 27-89) years. Triple assessment was undertaken in 30 patients; ten did not have a needle biopsy performed and three patients had no mammography. The principal cause of delay was: false-negative or inadequate fine-needle aspiration cytology (FNAC) in 19 patients, failure of follow-up in eight, clinical signs did not impress in five, FNAC not carried out in four, false-negative mammogram in three, failure of needle localization in two and one patient did not accept clinical advice. The annual incidence of delay in diagnosis did not change significantly over the 10-year interval.

CONCLUSION

Triple assessment is not sufficiently sensitive to detect every breast cancer and a small incidence of diagnostic delay is therefore inevitable with current techniques.

Diagnosis and treatment delay in gynecological malignancies. Does it affect outcome?

Delay of diagnosis and treatment of malignant tumors is perceived as unfavorably affecting outcome. However, tumor behavior may be determined early in the histogenesis process and the outcome may be more a function of the biologic properties of the tumor than of our ability to make an early diagnosis. The objective of the present review is to evaluate data concerning the effect of diagnosis and treatment delay on outcome in gynecological malignancies. A medline search including the terms diagnosis delay, treatment delay, outcome, vulvar carcinoma, cervical carcinoma, endometrial carcinoma and ovarian carcinoma was conducted and all pertinent articles in the English language were included. Relatively few investigations deal with the effect of diagnosis and treatment delay on prognostic factors and on outcome in invasive gynecological malignancies. The reviewed data do not seem to indicate an unequivocal deleterious effect of a delay of several weeks or even several months in patients with some gynecological malignancies. Intentional delay of diagnosis or treatment of gynecologic malignancies is unjustified; however, the data presented should encourage a closer scrutiny and possibly a revision of the concept of "early" diagnosis and of the notion that delay of any duration has a definite, unfavorable effect on outcome.

Influence of delay on survival in patients with breast cancer: a systematic review

BACKGROUND

Most patients with breast cancer are detected after symptoms occur rather than through screening. The impact on survival of delays between the onset of symptoms and the start of treatment is controversial and cannot be studied in randomised controlled trials. We did a systematic review of observational studies (worldwide) of duration of symptoms and survival.

METHODS

We identified 87 studies (101,954 patients) with direct data linking delay (including delay by patients) and survival. We classified studies for analysis by type of data in the original reports: category I studies had actual 5-year survival data (38 studies, 53,912 patients); category II used actuarial or multivariate analyses (21 studies, 25,102 patients); and category III was all other types of data (28 studies, 22,940 patients). We tested the main hypothesis that longer delays would be associated with lower survival, and a secondary hypothesis that longer delays were associated with more advanced stage, which would account for lower survival.

FINDINGS

In category I studies, patients with delays of 3 months or more had 12% lower 5-year survival than those with shorter delays (odds ratio for death 1.47 [95% CI 1.42-1.53]) and those with delays of 3-6 months had 7% lower survival than those with shorter delays (1.24 [1.17-1.30]). In category II, 13 of 14 studies with unrestricted samples showed a significant adverse relation between longer delays and survival, whereas four of five studies of only patients with operable disease showed no significant relation. In category III, all three studies with unrestricted samples supported the primary hypothesis. The 13 informative studies showed that longer delays were associated with more advanced stage. In studies that controlled for stage, longer delay was not associated with shorter survival when the effect of stage on survival was taken into account.

INTERPRETATION

Delays of 3-6 months are associated with lower survival. These effects cannot be accounted for by lead-time bias. Efforts should be made to keep delays by patients and providers to a minimum.

The influence on survival of delay in the presentation and treatment of symptomatic breast cancer

The aim of this study was to examine the possible influence on survival of delays prior to presentation and/or treatment among women with breast cancer. Duration of symptoms prior to hospital referral was recorded for 2964 women who presented with any stage of breast cancer to Guy's Hospital between 1975 and 1990. Median follow-up is 12.5 years. The impact of delay (defined as having symptoms for 12 or more weeks) on survival was measured from the date of diagnosis and from the date when the patient first noticed symptoms to control for lead-time bias. Thirty-two per cent (942/2964) of patients had symptoms for 12 or more weeks before their first hospital visit and 32% (302/942) of patients with delays of 12 or more weeks had locally advanced or metastatic disease, compared with only 10% (210/2022) of those with delays of less than 12 weeks (P < 0.0001). Survival measured both from the date of diagnosis (P < 0.001) and from the onset of the patient's symptoms (P = 0.003) was worse among women with longer delays. Ten years after the onset of symptoms, survival was 52% for women with delays less than 12 weeks and 47% for those with longer delays. At 20 years the survival rates were 34% and 24% respectively. Furthermore, patients with delays of 12-26 weeks had significantly worse survival rates than those with delays of less than 12 weeks. Multivariate analyses indicated that the adverse impact of delay in presentation on survival was attributable to an association between longer delays and more advanced stage. However, within individual stages, longer delay had no adverse impact on survival. Analyses based on 'total delay (i.e. the interval between a patient first noticing symptoms and starting treatment) yielded very similar results in terms of survival to those based on delay to first hospital visit (delay in presentation).

Who and what influences delayed presentation in breast cancer?

This study aimed to examine the extent and determinants of patient and general practitioner delay in the presentation of breast cancer. One hundred and eighty-five cancer patients attending a breast unit were interviewed 2 months after diagnosis. The main outcome measures were patient delay in presentation to the general practitioner and non-referral by the general practitioner to hospital after the patient's first visit. Nineteen per cent of patients delayed > or = 12 weeks. Patient delay was related to clinical tumour size > or = 4 cm (P = 0.0002) and with a higher incidence of locally advanced and metastatic disease (P = 0.01). A number of factors predicted patient delay: initial breast symptom(s) that did not include a lump (OR 4.5, P = 0.003), not disclosing discovery of the breast symptom immediately to someone else (OR 6.0, P < 0.001), seeking help only after being prompted by others (OR 4.4, P = 0.007) and presenting to the general practitioner with a non-breast problem (OR 3.5, P = 0.03). Eighty-three per cent of patients were referred to hospital directly after their first general practitioner visit. Presenting to the GP with a breast symptom that did not include a lump independently predicted general practitioner delay (OR 3.6, P = 0.002). In view of the increasing evidence that delay adversely affects survival, a large multicentre study is now warranted to confirm these findings that may have implications for public and medical education.

Timeliness of follow-up after abnormal screening mammography

Little information has been published concerning the timeliness of follow-up after abnormal mammography. This article presents data on follow-up after abnormal mammography, including differences in follow-up by age, race, mammographic interpretation, and type of tracking system. From unpublished data, the rate of timely follow-up 8 to 12 weeks after index abnormal mammography ranges from 69% to 99%. Women aged 65 and older, those of lower socioeconomic status, and those who are instructed to have repeat evaluations in four to six months have the highest proportion of untimely follow-up. With use of computer-based tracking systems, timely follow-up ranges from 89% to 99%. Computer-based tracking systems should be encouraged to promote timely follow-up of abnormal mammography. Further research is needed to better delineate those at risk for untimely follow-up after abnormal mammography, causes of untimely follow-up, the impact of untimely follow-up on breast cancer stage and mortality, and interventions that maximize timely follow-up.

The effect of diagnosis and treatment delay on prognostic factors and survival in endometrial carcinoma

OBJECTIVE

The aim of this study was to assess the association of diagnosis and treatment delay with established prognostic factors and survival.

STUDY DESIGN

The study group comprised 181 consecutive patients with endometrial carcinoma diagnosed between 1970 and 1986, whose records contained details with regard to diagnosis delay; 174 of them also contained details with regard to treatment delay.

RESULTS

The significant prognostic factors that we found, namely, age, clinical stage, grade, depth of myometrial invasion, and histologic type, are in line with those of other studies. However, no significant correlation was found between the duration of delay and these prognostic factors or with survival.

CONCLUSION

We conclude that delay of diagnosis (< 1 year) and of treatment of < 4 months do not compromise survival of patients with endometrial cancer.

Patient's and doctor's delay in primary breast cancer. Prognostic implications

In a study of 7,608 patients with primary breast cancer patient's and doctor's delay were examined in relation to age, tumour size, grade of anaplasia, and number of positive lymph nodes. The delays were arbitrarily divided into the following intervals: Short (0-14 days), intermediate (15-60 days) and long (> 60 days). The well-established patient and tumour characteristics were shown to have prognostic significance. Similarly the delays showed significant influence on survival. A long patient's delay was associated with an unfavourable outcome, as compared with a short delay. On the contrary, the prognosis was superior for patients with a long doctor's delay compared to those with a short doctor's delay. Overall, when corrected for age, the prognostic value of delay in terms of mortality increased by 24% for a long patient's delay compared to a shorter and by 13% for a short doctor's delay compared to a longer. This indicates that doctors are capable of distinguishing between more and less aggressive malignancies. The study also suggests that all sources of delays should be kept at a minimum.

Delay versus help seeking for breast cancer symptoms: a critical review of the literature on patient and provider delay

Patient delay in seeking help for breast cancer symptoms and provider delay in treating those symptoms combine to decrease a woman's potential for breast cancer survival. This paper reviews the literature on patient and provider delay published since 1975. Meta-analysis of 12 studies using common definitions of patient delay estimates that 34% of women with breast cancer symptoms delay help seeking for 3 or more months. Provider delay appears to be both under researched and underestimated. This review identifies the factors that have been advanced as contributing to patient and provider delay, evaluating the support for each of these reported findings. Theory-based hypotheses emerging from the reviewed studies highlight foci for future investigations.

A New Approach to Tumour Marker Assessment by Perioperative Determination in Breast and Colorectal Cancer

Preoperative serum tumour markers are currently classified as positive or negative according to a predetermined cut-off point. In the present study we examined the dynamic variation of marker levels after radical surgery of breast and colorectal cancer. CEA and CA15.3 were measured in 93 patients with breast cancer, CEA and CA19.9 in 97 patients with colorectal carcinoma before and 30 days after radical surgery. Any variation higher than 3-fold the analytical coefficient of variation of the assay was considered significant. In patients with negative preoperative marker levels a significant decrease was noted after surgery in 15.6% of cases for CEA and 27.8% for CA15.3 in breast cancer and in 46.8% for CEA and 25.7% for CA19.9 in colorectal cancer. Using both cut-off-based and dynamic criteria, we found an overall positivity rate of 19.6% for CEA and 33.3% for CA15.3 in breast cancer; 60.0% for CEA and 37.1% for CA19.9 in colorectal cancer.

From the present findings we conclude that the dynamic study of perioperative variations of tumour markers is a sensitive method additional to cut-off-based criteria for the assessment of the phenotypic expression of the marker by the tumour.

Association between the month of diagnosis and prognosis in breast carcinoma

The effect of the month of diagnosis on survival was investigated in two series of unilateral invasive breast cancer, of which one comprised 95% of all such histologically diagnosed breast carcinomas in the city of Turku, Finland, in 1945 to 1965 (n = 401), and the other 94% of all such carcinomas diagnosed in 1980 to 1984 (n = 337). If the histological diagnosis was made in January, February, or August to October in 1945-65, or in July to September in 1980-84, mortality in breast cancer was greater than if the diagnosis was made during the rest of the year (P = 0.03 and 0.009, respectively). Cancers diagnosed during the unfavourable months had more tumour necrosis in both series, and higher mitotic count and larger tumour size in the 1945-65 series. The number of diagnosed cases was usually less than the median during the months associated with unfavourable prognosis. Hypotheses to explain the altering prognosis by the month of diagnosis include seasonal hormonal changes and social factors.