Pathways to care for patients in Pakistan experiencing signs or symptoms of breast cancer

Clinico-genomic findings, molecular docking, and mutational spectrum in an understudied population with breast cancer patients from KP, Pakistan

In this study, we report the mutational profiles, pathogenicity, and their association with different clinicopathologic and sociogenetic factors in patients with Pashtun ethnicity for the first time. A total of 19 FFPE blocks of invasive ductal carcinoma (IDC) from the Breast Cancer (BC) tissue and 6 normal FFPE blocks were analyzed by whole-exome sequencing (WES). Various somatic and germline mutations were identified in cancer-related genes, i.e., ATM, CHEK2, PALB2, and XRCC2. Among a total of 18 mutations, 14 mutations were somatic and 4 were germline. The ATM gene exhibited the maximum number of mutations (11/18), followed by CHEK2 (3/18), PALB2 (3/18), and XRCC2 (1/18). Except one frameshift deletion, all other 17 mutations were nonsynonymous single-nucleotide variants (SNVs). SIFT prediction revealed 7/18 (38.8%) mutations as deleterious. PolyPhen-2 and MutationTaster identified 5/18 (27.7%) mutations as probably damaging and 10/18 (55.5%) mutations as disease-causing, respectively. Mutations like PALB2 p.Q559R (6/19; 31.5%), XRCC2 p.R188H (5/19; 26.31%), and ATM p.D1853N (4/19; 21.05%) were recurrent mutations and proposed to have a biomarker potential. The protein network prediction was performed using GeneMANIA and STRING. ISPRED-SEQ indicated three interaction site mutations which were further used for molecular dynamic simulation. An average increase in the radius of gyration was observed in all three mutated proteins revealing their perturbed folding behavior. Obtained SNVs were further correlated with various parameters related to the clinicopathological status of the tumors. Three mutation positions (ATM p. D1853N, CHEK2 p.M314I, and PALB2 p.T1029S) were found to be highly conserved. Finally, the wild- and mutant-type proteins were screened for two drugs: elagolix (DrugBank ID: DB11979) and LTS0102038 (a triterpenoid, isolated from the anticancer medicinal plant Fagonia indica). Comparatively, a higher number of interactions were noted for normal ATM with both compounds, as compared to mutants.

Preliminary insights on the mutational spectrum of BRCA1 and BRCA2 genes in Pakhtun ethnicity breast cancer patients from Khyber Pakhtunkhwa (KP), Pakistan

Gene mutations are a source of genetic instability which fuels the progression of cancer. Mutations in BRCA1 and BRCA2 are considered as major drivers in the progression of breast cancer and their detection indispensable for devising therapeutic and management approaches. The current study aims to identify novel pathogenic and recurrent mutations in BRCA1 and BRCA2 in Pakhtun population from the Khyber Pakhtunkhwa. To determine the BRCA1 and BRCA2 pathogenic mutation prevalence in Pakhtun population from KP, whole exome sequencing of 19 patients along with 6 normal FFPE embedded blocks were performed. The pathogenicity of the mutations were determined and they were further correlated with different hormonal, sociogenetic and clinicopathological features. We obtained a total of 10 mutations (5 somatic and 5 germline) in BRCA1 while 27 mutations (24 somatic and 3 germline) for BRCA2. Five and seventeen pathogenic or deleterious mutations were identified in BRCA1 and BRCA2 respectively by examining the mutational spectrum through SIFT, PolyPhen-2 and Mutation Taster. Among the SNVs, BRCA1 p.P824L, BRCA2 p. P153Q, p.I180F, p.D559Y, p.G1529R, p.L1576F, p.E2229K were identified as mutations of the interaction sites as predicted by the deep algorithm based ISPRED-SEQ prediction tool. SAAFEQ-SEQ web-based algorithm was used to calculate the changes in free energy and effect of SNVs on protein stability. All SNVs were found to have a destabilizing effect on the protein. ConSurf database was used to determine the evolutionary conservation scores and nature of the mutated residues. Gromacs 4.5 was used for the molecular simulations. Ramachandran plots were generated using procheck server. STRING and GeneMania was used for prediction of the gene interactions. The highest number of mutations (BRCA1 7/10, 70 %) were on exon 9 and (BRCA2, 11/27; 40 %) were on exon 11. 40 % and 60 % of the BRCA2 mutations were associated Grade 2 and Grade 3 tumors respectively. The present study reveals unique BRCA1 and BRCA2 mutations in Pakhtun population. We further suggest sequencing of the large cohorts for further characterizing the pathogenic mutations.

Pakistani healthcare professionals' perceptions of communication with patients and their relatives about hereditary breast cancer: a qualitative study in a LMIC

Pakistan has the highest incidence and mortality rates of breast cancer in Asia, with high numbers of patients diagnosed at a young age suggesting the possibility of an inherited cancer syndrome. Communication of hereditary breast cancer (HBC) risk information with patients could enable earlier detection of the condition in relatives and reduce mortality rates. This study aimed to explore perceptions of healthcare professionals (HCPs) in Pakistan about communication with patients and their relatives about HBC. Semi-structured qualitative interviews were conducted with eighteen HCPs during March to May 2020 in Lahore. Thematic analysis shows the HCPs were generally supportive of informing patients themselves about HBC, but believed it was the patients' role to inform their relatives. HCPs also highlighted important barriers to communication with patients about HBC, including (i) patients' low socioeconomic status and educational attainment; (ii) high prevalence of the social stigma of breast cancer; and (iii) lack of health resources and facilities to provide genetic testing for HBC. In conclusion, HCPs would value the development of interventions to support communication between HCPs and patients. They also highlighted the need for interventions to support intrafamilial communication about HBC. Much research and political support are needed to address patient, social, and systemic-level barriers to facilitate communication about HBC.

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.

Health system barriers influencing timely breast cancer diagnosis and treatment among women in low and middle-income Asian countries: evidence from a mixed-methods systematic review

BACKGROUND

Globally, breast cancer is the most common cancer type and the leading cause of cancer mortality among women in developing countries. A high prevalence of late breast cancer diagnosis and treatment has been reported predominantly in Low- and Middle-Income Countries (LMICs), including those in Asia. Thus, this study utilized a mixed-methods systematic review to synthesize the health system barriers influencing timely breast cancer diagnosis and treatment among women in Asian countries.

METHODS

We systematically searched five electronic databases for studies published in English from 2012 to 2022 on health system barriers that influence timely breast cancer diagnosis and treatment among women in Asian countries. The review was conducted per the methodology for systematic reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, while health system barriers were extracted and classified based on the World Health Organization (WHO)'s Health Systems Framework. The mixed-methods appraisal tool was used to assess the methodological quality of the included studies.

RESULTS

Twenty-six studies were included in this review. Fifteen studies were quantitative, nine studies were qualitative, and two studies used a mixed-methods approach. These studies were conducted across ten countries in Asia. This review identified health systems barriers that influence timely breast cancer diagnosis and treatment. The factors were categorized under the following: (1) delivery of health services (2) health workforce (3) financing for health (4) health information system and (5) essential medicines and technology. Delivery of health care (low quality of health care) was the most occurring barrier followed by the health workforce (unavailability of physicians), whilst health information systems were identified as the least barrier.

CONCLUSION

This study concluded that health system factors such as geographical accessibility to treatment, misdiagnosis, and long waiting times at health facilities were major barriers to early breast cancer diagnosis and treatment among Asian women in LMICs. Eliminating these barriers will require deliberate health system strengthening, such as improving training for the health workforce and establishing more healthcare facilities.

Breast cancer in a teenage girl with BRCA mutation: A case report from a low middle-income country

Introduction

Case history

Discussion

Conclusion

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The case of the youngest known breast cancer patient in Pakistan.

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Genetic counseling should be readily offered in low middle-income countries.

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Triple assessment is a mandatory tool to diagnose a breast lump in any age group.

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Up-to-date guidelines should be followed for managing breast lumps,

Invasive Lobular Carcinoma in Premenopausal Woman: A Delayed Diagnosis Due to Socio-Cultural Factors Prevalent in Pakistan

A 41-year-old premenopausal woman presented to the outpatient department with a diagnosis of invasive lobular carcinoma. She noticed a lump a year back but did not seek medical attention due to many socio-cultural factors prevalent in Pakistan that prevent her from seeking medical attention earlier. She came in for a check-up after increasing in size of the lump. The bilateral mammogram showed large areas of asymmetrical density in the left upper quadrant. It was followed by an ultrasound-guided biopsy which confirmed the diagnosis of invasive lobular carcinoma. Due to stage 3, it was recommended to have CT and an MRI of the breast to assess the extent of the disease. Tissue immunohistochemistry was also requested, which came back as ER-positive, PR-positive, and HER2/neu negative. MRI of the breast revealed a 4.2 x 3.3cm heterogeneously enhancing asymmetric mass-like enhancement area within the left breast outer quadrant with an adjacent spiculated nodular lesion measuring 2.2 cm. CT chest/abdomen/pelvis with contrast showed left breast with minimal parenchymal asymmetry and a small 9 mm node seen in the left axilla. There was no evidence of metastasis. The patient was started on neoadjuvant therapy to minimize systemic disease, followed by mastectomy. This case highlights socio-cultural factors prevalent in Pakistan that lead to delays in the diagnosis and treatment of invasive lobular carcinoma. The outcome had been better if the patient sought medical attention sooner at an earlier stage. We also propose strategies to raise awareness in Pakistan for the timely diagnosis and treatment of breast cancer.

Relationship of Muslim Religiosity and Death Anxiety with the Mediating Effect of Optimism and Depression Among Cancer Patients in Pakistan

Optimism and the practice of any religion are known to reduce depression and anxiety in cancer patients. In the present study, the specific role of Muslim religiosity, optimism, depression, and death anxiety in cancer patients has been explored. The sample of this study consisted of 200 cancer patients from different hospitals of the districts Faisalabad and Lahore (Pakistan). The sample's average age was 26.6 years. Parallel mediation findings show that optimism and depression are significant mediators between Muslim religiosity and death anxiety among cancer patients. Muslim religiosity is positively associated with optimism, and it helps to decrease the level of death anxiety, while depression is negatively associated with Muslim religiosity, and high depression increases the death anxiety level of cancer patients. In conclusion, Muslim religiosity and optimism play significant roles in managing depressive symptoms and death anxiety among cancer patients.

A national survey to assess breast cancer awareness among the female university students of Pakistan

The incidence of breast cancer is increasing in Pakistan as well as globally. Awareness of women about breast cancer plays a cornerstone role in its early detection, better management, and prevention. Keeping this in mind, a cross-sectional study was carried out to assess the awareness of female university students about breast cancer’s risk factors, signs and symptoms, and breast cancer examination. The data was collected from female university students studying in Pakistan. A total of 774 participants completed the survey and recorded their responses on an online pre-tested self-administered questionnaire. Only 29.8% of the participants have identified breast cancer history in their first-degree relatives as a risk factor. Moreover, 14.1% of the participant considered that the use of oral contraceptives for more than 5 years can increase the risk of developing breast cancer. In addition, inward pulled nipple, wounds around the nipple, and abrupt changes in the breast size were considered as the sign and symptoms of breast cancer by 25.2%, 25.7%, and 31.7% of the participants, respectively. Moreover, only 20.9% of the participants identified the correct year for starting breast cancer examination and 44.4% of the respondents marked that mammography should be initiated after 40 years. Overall, the university female students of Pakistan were poorly aware of breast cancer’s risk factors, signs and symptoms, and breast examination. This study has highlighted the need for initiation of aggressive strategies regarding breast cancer awareness in both the literate and illiterate female population of Pakistan.

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.

Perceptions of oncology as a career choice among the early career doctors in Pakistan

BACKGROUND

Lack of oncologists is a growing global concern. With the rise in cancer burden across the world, the supply-demand mismatch of the oncology workforce is projected to increase. Furthermore, oncology is a low-ranked field of choice among medical students, and without understanding the perceptions and concerns of early-career doctors regarding oncology, any investments made in cancer care will be futile. This study aims to determine the opinions of young doctors and the factors most affecting their preferences in order to devise focused strategies to attract more doctors into oncology.

METHODS

A cross-sectional study was conducted on 300 early-career doctors across various public and private hospitals in Pakistan, from March to November 2019. A close-ended, self-administered questionnaire was used to assess their opinions in terms of the workplace environment, scope, and the emotional and financial aspects of oncology. Data was analyzed using SPSS version 23 and the influence (positive or negative) of the perceptions on the choice of oncology as a career was determined by binary logistic regression analysis.

RESULTS

Almost three-quarters of the participants did not want a career in oncology. The top positive perceptions about oncology in descending order were: progressive field, gender-neutral, stable working hours, financially healthy, and work-family balance. Top negative perceptions were: lack of oncologic facilities in hospitals, radiation exposure, need for private practice, poor patient prognosis, high patient load, and depressing environment. Participants who attended private medical school (p < 0.10), planned to live abroad (p < 0.10), had an oncologist (p < 0.05), cancer survivor or death due to cancer in the family (p < 0.05), were more likely to adopt oncology as a career. Those who believed that poor patient prognosis can have an impact on career choice were less likely to prefer oncology (p < 0.05).

CONCLUSION

Despite the rising cancer burden, early career doctors are reluctant to join oncology. Curricular, infrastructural and policy changes are needed at the level of medical school, oncology training and practice to recruit more young doctors and minimize the existing paucity of the oncologic workforce.

Evaluation of potential drug-drug interactions in cancer patients at a tertiary care hospital in Pakistan

BACKGROUND

Despite harboring a high burden of cancer patients who are at high risk of potential drug-drug interactions (pDDIs), there is scarcity of published information about pDDIs in cancer patients from Pakistan.

OBJECTIVE

To evaluate frequency, pattern, mechanism and factors associated with pDDIs in cancer patients treated at a tertiary care hospital in Pakistan.

METHODS

In this cross-sectional analytical study, a total of 253 eligible ambulatory cancer patients treated at Center for Nuclear Medicine and Radiotherapy Hospital Quetta were evaluated for pDDIs using IBM Micromedex® Drug Interactions. SPSS (version 26) was used for conducting multivariate analysis to find factors associated with the presence pDDIs. A p-value <0.05 was considered statistically significant.

RESULTS

A total of 141/253 (55.7%) patients were exposed to at-least one pDDI. A total of 251 pDDIs were noted with a median of one pDDI/per patient (interquartile range:1-2) Majority interactions were of major severity (72.9%), pharmacodynamic (49.8%) and had fair documentation level (64.1%). Anti-cancer drugs were involved in 73.0% pDDIs with doxorubicin as the most commonly involved (40.0%) anti-cancer followed by cyclophosphamide (27.6%) and cisplatin (13.5%). Potential cardiac adverse events made the bulk (33.8%) of predicted events. Receiving >2 anti-cancer (OR = 5.19, p-value = 0.001) and >6 ancillary drugs (OR = 4.16, p-value = 0.033) emerged as the risk factors of pDDIs.

CONCLUSIONS

The prevalence of pDDIs was within the range reported in published literature. Solid medication review, availability of DDI detecting tools and clinical pharmacist, and paying special attention to the high-risk patients may reduce the frequency of pDDIs at the study site.

Psychosocial influences on help-seeking behaviour for cancer in low-income and lower middle-income countries: a mixed-methods systematic review

Introduction

Starting cancer treatment early can improve outcomes. Psychosocial factors influencing patients’ medical help-seeking decisions may be particularly important in low and lower middle-income countries (LMIC) where cancer outcomes are poor. Comprehensive review evidence is needed to understand the psychosocial influences on medical help-seeking for cancer symptoms, attendance for diagnosis and starting cancer treatment.

Methods

Mixed-methods systematic review registered on PROSPERO (CRD42018099057). Peer-reviewed databases were searched until April 2020 for studies assessing patient-related barriers and facilitators to medical help-seeking for cancer symptoms, diagnosis and treatment in adults (18+ years) living in LMICs. Quality of included studies was assessed using the Critical Appraisal Skills Programme tool. Data were synthesised using meta-analytic techniques, meta-ethnography or narrative synthesis as appropriate.

Results

Of 3963 studies identified, 64 were included. In quantitative studies, use of traditional, complementary and alternative medicine (TCAM) was associated with 3.60 higher odds of prolonged medical help-seeking (95% CI 2.06 to 5.14). Qualitative studies suggested that use of TCAM was a key barrier to medical help-seeking in LMICs, and was influenced by causal beliefs, cultural norms and a preference to avoid biomedical treatment. Women face particular barriers, such as needing family permission for help-seeking, and higher stigma for cancer treatment. Additional psychosocial barriers included: shame and stigma associated with cancer such as fear of social rejection (eg, divorce/disownment); limited knowledge of cancer and associated symptoms; and financial and access barriers associated with travel and appointments.

Conclusion

Due to variable quality of studies, future evaluations would benefit from using validated measures and robust study designs. The use of TCAM and gender influences appear to be important barriers to help-seeking in LMIC. Cancer awareness campaigns developed with LMIC communities need to address cultural influences on medical help-seeking behaviour.

Fears and barriers: problems in breast cancer diagnosis and treatment in Pakistan

Background

Women in Pakistan lack appropriate awareness about diagnosis and treatment for breast cancer due to a range of multifaceted barriers. There is a dearth of literature examining the socio-cultural factors that inhibit women from breast cancer screening, diagnosis and treatment in Punjab, Pakistan. Addressing this gap, this qualitative study sought to identify and explore the barriers that hinder women from seeking timely screening and treatment.

Methods

In this process 45 women (age = 18–50 years) with breast cancer were purposively sampled and interviewed from the Punjab Institute of Nuclear Medicine (PINUM) hospital, Faisalabad, Pakistan.

Results

An inductive approach was used to analyze the data which resulted in the emergence of eight subthemes under the umbrella of three major themes that delineate individual, socio-cultural and structural barriers to seek screening and treatment of breast cancer in Punjab. Individual barriers included lack of awareness, hesitance in accepting social support, and spiritual healing. The identified socio-cultural factors included feminine sensitivity, stigmatization, and aversion to male doctors. Lack of financial resources and apathetic medical services were structural barriers that hinder screening and treatment.

Conclusions

These barriers can be addressed through raising awareness and community mobilization about breast-self exam and treatment. The healthcare system should also pay attention to socio-psychological and cultural factors impeding women's access to available health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01293-6.

Factors affecting mothers' intentions to visit healthcare facilities before hospitalisation of children with pneumonia in Biliran province, Philippines: a qualitative study

BACKGROUND AND OBJECTIVES

Despite a substantial reduction in the mortality rate of children under 5 years in the past 25 years, pneumonia remains the single-largest infectious cause of child deaths worldwide. This study explored the chronological order of visited healthcare facilities and practitioners, and the factors affecting mothers' intention to seek care before the hospitalisation of children with pneumonia.

METHODS AND ANALYSIS

A qualitative research design was employed using theory of planned behaviour as a framework for the analysis. Using purposive sampling technique, 11 mothers, whose children under 5 years old were hospitalised with severe pneumonia, were recruited for individual semi-structured interviews. Their socio-demographic information was analysed using descriptive statistics.

RESULTS

Mothers brought their sick children to multiple facilities, and 1 to 19 days had passed before hospitalisation. We identified four major factors determining mothers' intentions: (1) doing something useful for the sick child, (2) expecting the child to receive the necessary assessment and treatment, (3) accepting advice to visit a healthcare facility and be referred to a hospital and (4) considering issues and benefits associated with hospitalisation. Mothers noticed their children's unusual symptoms and monitored them while applying home remedies. They also took their children to traditional healers despite knowing that the treatments were not necessarily effective. Mothers expected children to be checked by health professionals and listened to advice from family members regarding the facilities to visit, and from healthcare staff to be referred to a hospital. Financial issues and the double burden of housework and caring for the hospitalised child were mothers' major concerns about hospitalisation.

CONCLUSION

Children were hospitalised after several days because they visited multiple healthcare facilities, including traditional healers. Improving care quality at healthcare facilities and reducing financial and mothers' burden may reduce the hospitalisation delay for children with pneumonia.

Health seeking behaviour, delayed presentation and its impact among oral cancer patients in Pakistan: a retrospective qualitative study

Background

Delayed diagnosis of Oral Cancer (OC) can mean a difference in quality and expectancy of life for the patient. This delay could be from the healthcare side, or more importantly from the patient’s side. Globally, there are studies enumerating the causes for delays from the patients’ side in seeking healthcare for Oral Cancer; however, no similar research is found in the context of Pakistan. This study endeavoured to understand the health seeking behaviour, reasons for delay in consultation and the impact on OC patients’ lives.

Methods

In-depth interviews were conducted with randomly selected OC patients at a private sector tertiary care facility in Islamabad (who met the inclusion criteria of having successfully been treated for Oral Cancer) which caters to the most diverse population for the treatment of Oral Cancer. Theoretical saturation was achieved at 14 interviews. All participants gave verbal consent for participation, which was recorded prior to the interviews.

Results

Patients (age range 43–68 years) had received the surgical treatment and radiation. The reported delay before seeking a proper medical advice ranged from 1 month to 2 years. Lack of awareness about OC risk factors, symptoms, and whom to approach for treatment were the main reasons. Most respondents relied on self-treatment considering the non-healing wound/ulcer to be a minor issue until they were advised a consultation with a specialist. Treatment started within 1–3 months after a confirmed diagnosis on biopsy. The reported average expenditure on treatment was US$5000-10,000, mostly covered through a private health insurance and others borrowed the money.

Conclusion

A socio-behavioural change campaign for the general population can result in earlier presentation of the OC, minimizing the financial burden on the patient as well as the health system, and improving the quality of life of the patients.