Identifying predictors of delayed diagnoses in symptomatic breast cancer: a scoping review

Act or Wait? Presentation Delay in Symptomatic Breast Cancer in China

BACKGROUND

In Western countries, factors contributing to breast cancer presentation delay have been identified, but little is known about presentation delay in China, where culture and healthcare systems are quite different.

OBJECTIVE

To describe the delay interval among newly diagnosed breast cancer patients in China and to identify factors influencing delay, including the COVID-19 pandemic.

METHODS

Using a cross-sectional design, we recruited 154 participants within 3 months of pathological diagnosis of breast cancer. Data were collected using standardized scales and open-ended questions.

RESULTS

We found 44.8% of participants delayed ≥1 month, and 24.7% delayed ≥3 months before presentation, after self-discovery of symptoms. Logistic regression analysis showed that factors associated with longer delay (≥1 month) included preferring female physicians for breast examination, fewer negative emotions (afraid, anxious, distressed) regarding breast symptoms, more competing priorities, believing folk therapy can help treat lumps, and visiting a secondary or tertiary hospital instead of primary healthcare providers (P < .05 for all). Interaction tests showed perceived seriousness of symptoms significantly predicted delay of ≥1 month only when perceived healthcare access or trust in physicians was low. Patients (14%) reported delaying due to fear of COVID-19 infection and inability to leave home.

CONCLUSIONS

Presentation delays were substantial and multilevel barriers to timely presentation were identified, which would be expected to contribute to later-stage cancer at diagnosis.

IMPLICATIONS FOR PRACTICE

Findings suggest that nursing interventions and improved health policies are urgently needed in China, including breast cancer education to increase awareness.

Factors influencing breast cancer screening practices among women worldwide: a systematic review of observational and qualitative studies

BACKGROUND

The variation in breast cancer incidence rates across different regions may reflect disparities in breast cancer screening (BCS) practices. Understanding the factors associated with these screening behaviors is crucial for identifying modifiable elements amenable to intervention. This systematic review aims to identify common factors influencing BCS behaviors among women globally.

METHODS

Relevant papers were sourced from PubMed, Scopus, Embase, and Google Scholar. The included studies were published in English in peer-reviewed journals from January 2000 to March 2023 and investigated factors associated with BCS behaviors.

RESULTS

From an initial pool of 625 articles, 34 studies (comprising 29 observational and 5 qualitative studies) with 36,043 participants were included. Factors influencing BCS behaviors were categorized into nine groups: socio-demographic factors, health status history, knowledge, perceptions, cultural factors, cues to action, motivation, self-efficacy, and social support. The quality appraisal scores of the studies ranged from average to high.

CONCLUSIONS

This systematic review highlights factors pivotal for policy-making at various levels of breast cancer prevention and assists health promotion professionals in designing more effective interventions to enhance BCS practices among women.

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.

Are Diagnostic Delays Associated with Distress in Breast Cancer Patients?

Introduction

Receiving a new breast cancer diagnosis can cause anxiety and distress, which can lead to psychologic morbidity, decreased treatment adherence, and worse clinical outcomes. Understanding sources of distress is crucial in providing comprehensive care. This study aims to evaluate the relationship between delays in breast cancer diagnosis and patient-reported distress. Secondary outcomes include assessing patient characteristics associated with delay.

Methods

Newly diagnosed breast cancer patients who completed a distress screening tool at their initial evaluation at an academic institution between 2014 and 2019 were retrospectively evaluated. The tool captured distress levels in the emotional, social, health, and practical domains with scores of "high distress" defined by current clinical practice guidelines. Delay from mammogram to biopsy, whether diagnostic or screening mammogram, was defined as >30 days.

Result

745 newly diagnosed breast cancer patients met inclusion criteria. Median time from abnormal mammogram to core biopsy was 12 days, and 11% of patients experienced a delay in diagnosis. The non-delayed group had higher emotional (p = 0.04) and health (p = 0.03) distress than the delayed group. No statistically significant differences in social distress were found between groups. Additionally, patients with higher practical distress had longer time interval between mammogram and surgical intervention compared to those with lower practical distress. Older age, diagnoses of invasive lobular carcinoma or ductal carcinoma in situ, and clinical anatomic stages 0-I were associated with diagnostic delay.

Conclusion

Patients with higher emotional or health-related distress were more likely to have timely diagnoses of breast cancer, suggesting that patients with higher distress may seek healthcare interventions more promptly. Improved understanding of sources of distress will permit early intervention regarding the devastating impact of breast cancer diagnosis.

Identification, characterization, and prognosis investigation of pivotal genes shared in different stages of breast cancer

One of the leading causes of death (20.1 per 100,000 women per year), breast cancer is the most prevalent cancer in females. Statistically, 95% of breast cancer are categorized as adenocarcinomas, and 55% of all patients may go into invasive phases; however, it can be successfully treated in approximately 70-80% of cases if diagnosed in the nascent stages. The emergence of breast tumor cells which are intensely resistant to conventional therapies, along with the high rate of metastasis occurrence, has highlighted the importance of finding novel strategies and treatments. One of the most advantageous schemes to alleviate this complication is to identify the common differentially expressed genes (DEGs) among primary and metastatic cancerous cells to use resultants for designing new therapeutic agents which are able to target both primary and metastatic breast tumor cells. In this study, the gene expression dataset with accession number GSE55715 was analyzed containing two primary tumor samples, three bone-metastatic samples, and three normal samples to distinguish the up- and down regulated genes in each stage compared to normal cells as control. In the next step, the common upregulated genes between the two experimental groups were detected by Venny online tool. Moreover, gene ontology, functions and pathways, gene-targeting microRNA, and influential metabolites were determined using EnrichR 2021 GO, KEGG pathways miRTarbase 2017, and HMDB 2021, respectively. Furthermore, elicited from STRING protein-protein interaction networks were imported to Cytoscape software to identify the hub genes. Then, identified hub genes were checked to validate the study using oncological databases. The results of the present article disclosed 1263 critical common DEGs (573 upregulated + 690 downregulated), including 35 hub genes that can be broadly used as new targets for cancer treatment and as biomarkers for cancer detection by evaluation of expression level. Besides, this study opens a new horizon to reveal unknown aspects of cancer signaling pathways by providing raw data evoked from in silico experiments. This study's outcomes can also be widely utilized in further lab research since it contains diverse information on common DEGs of varied stages and metastases of breast cancer, their functions, structures, interactions, and associations.

Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving Both Urban and Rural-Remote Communities

In response to breast cancer diagnostic regional wait times exceeding both national and provincial standards and to symptomatic patient referrals for diagnostic mammography taking longer than abnormal screening mammography referrals, the Rae Fawcett Breast Health Clinic (RFBHC) was opened in 2017 in a mid-sized Canadian hospital serving both urban and rural-remote communities. We investigated whether the RFBHC improved wait times to breast cancer diagnosis, improved compliance with national and provincial breast cancer standards, and decreased the wait time disparity associated with referral source. Statistical analyses of wait time differences were conducted between patients who were diagnosed with breast cancer prior to and after the RFBHC establishment. Study group compliance with national and provincial standards and wait time differences by referral source were also analysed. A survey was administered to assess overall patient experience with the RFBHC and clinic wait times. RFBHC patients had a shorter mean wait to breast cancer diagnosis (24.4 vs. 45.7 days, p ≤ 0.001) and a shorter mean wait to initial breast cancer treatment (49.1 vs. 78.9 days, p ≤ 0.001) than pre-RFBHC patients. After the RFBHC establishment, patients who attended the RFBHC had a shorter mean wait time to breast cancer diagnosis (24.4 vs. 36.9 days, p = 0.005) and to initial treatment (49.1 vs. 73.1 days, p ≤ 0.001) than patients who did not attend the clinic. Compliance with national and provincial breast cancer standards improved after the RFBHC establishment and the wait time disparity between screening mammography referrals and symptomatic patient referrals decreased. Survey results indicate that the RFBHC is meeting patient expectations. We concluded that the establishment of a breast health clinic in a Canadian center serving urban and rural-remote communities improved breast diagnostic services.

Factors Associated with the Breast Cancer Diagnostic Interval across Five Canadian Provinces: A CanIMPACT Retrospective Cohort Study

The cancer diagnostic process can be protracted, and it is a time of great anxiety for patients. The objective of this study was to examine inter- and intra-provincial variation in diagnostic intervals and explore factors related to the variation. This was a multi-province retrospective cohort study using linked administrative health databases. All females with a diagnosis of histologically confirmed invasive breast cancer in British Columbia (2007-2010), Manitoba (2007-2011), Ontario (2007-2010), Nova Scotia (2007-2012), and Alberta (2004-2010) were included. The start of the diagnostic interval was determined using algorithms specific to whether the patient's cancer was detected through screening. We used multivariable quantile regression analyses to assess the association between demographic, clinical and healthcare utilization factors with the diagnostic interval outcome. We found significant inter- and intra-provincial variation in the breast cancer diagnostic interval and by screen-detection status; patients who presented symptomatically had longer intervals than screen-detected patients. Interprovincial diagnostic interval variation was 17 and 16 days for screen- and symptom-detected patients, respectively, at the median, and 14 and 41 days, respectively, at the 90th percentile. There was an association of longer diagnostic intervals with increasing comorbid disease in all provinces in non-screen-detected patients but not screen-detected. Longer intervals were observed across most provinces in screen-detected patients living in rural areas. Having a regular primary care provider was not associated with a shorter diagnostic interval. Our results highlight important findings regarding the length of the breast cancer diagnostic interval, its variation within and across provinces, and its association with comorbid disease and rurality. We conclude that diagnostic processes can be context specific, and more attention should be paid to developing tailored processes so that equitable access to a timely diagnosis can be achieved.

Multiple Sclerosis and the Cancer Diagnosis: Diagnostic Route, Cancer Stage, and the Diagnostic Interval in Breast and Colorectal Cancer

BACKGROUND AND OBJECTIVES

The multiple sclerosis (MS) population's survival from breast cancer and colorectal cancer is compromised. Cancer screening and timely diagnoses affect cancer survival and have not been studied in the MS cancer population. We investigated whether the diagnostic route, cancer stage, or diagnostic interval differed in patients with cancer with and without MS.

METHODS

We conducted a matched population-based cross-sectional study of breast cancers (2007-2015) and colorectal cancers (2009-2012) in patients with MS from Ontario, Canada, using administrative data. Exclusion criteria included second or concurrent primary cancers, no health care coverage, and, for the patients without MS, those with any demyelinating disease. We based 1:4 matching of MS to non-MS on birth year, sex (colorectal only), postal code, and cancer diagnosis year (breast only). Cancer outcomes were diagnostic route (screen-detected vs symptomatic), stage (stage I vs all others), and diagnostic interval (time from first presentation to diagnosis). Multivariable regression analyses controlled for age, sex (colorectal only), diagnosis year, income quintile, urban/rural residence, and comorbidity.

RESULTS

We included 351 patients with MS and breast cancer, 1,404 matched patients with breast cancer without MS, 54 patients with MS and colorectal cancer, and 216 matched patients with colorectal cancer without MS. MS was associated with fewer screen-detected cancers in breast (odds ratio [OR] 0.68 [95% CI 0.52, 0.88]) and possibly colorectal (0.52 [0.21, 1.28]) cancer. MS was not associated with differences in breast cancer stage at diagnosis (stage I cancer, OR 0.81 [0.64, 1.04]). MS was associated with greater odds of stage I colorectal cancer (OR 2.11 [1.03, 4.30]). The median length of the diagnostic interval did not vary between people with and without MS in either the breast or colorectal cancer cohorts. Controlling for disability status attenuated some findings.

DISCUSSION

Breast cancers were less likely to be detected through screening and colorectal cancer more likely to be detected at early stage in people with MS than without MS. MS-related disability may prevent people from getting mammograms and colonoscopies. Understanding the pathways to earlier detection in both cancers is critical to developing and planning interventions to ameliorate outcomes for people with MS and cancer.

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.

Patient-initiated follow-up of early endometrial cancer: a potential to improve post-treatment cardiovascular risk?

Purpose

Is patient-initiated follow-up, post-surgical treatment of early endometrial cancer safe and can it be used holistically to improve cardiovascular health? What are the cost implications of this model of follow-up?

Methods

Retrospective data of 98 patients discharged to patient-initiated scheme since 2012. Service evaluation by anonymous patient feedback including physical health effects of the programme including weight loss. Financial cost was compared to traditional hospital-based follow-up over five years.

Results

No evidence of recurrence over 54 months median follow-up in low-risk endometrioid endometrial cancer. Patient feedback indicates that the exercise course helped women reduce their BMI. Over one third women felt happier and one fifth felt more confident and had a better ability to cope with stress. Total of 91% patients would recommend this model of follow-up to friends or family in the same circumstance. European Society for Medical Oncology guidance suggests the number of hospital-based follow-up appointments required for this cohort would cost £109,760. Calculations in this paper examine the cost of patient-initiated follow-up and reflect an overall saving of around 96.5%.

Conclusion

This service evaluation supports the claim that patient-initiated follow-up represents a safe alternative to the traditional hospital-based protocol. There is a potential for additional services to be offered to encourage and promote a healthy lifestyle linked to improving quality of life and cardiovascular survival following surgery for endometrial cancer.

Implications for cancer survivors

Cardiovascular morbidity is the most common cause of death in endometrial cancer survivors. Incorporating an exercise course as part of routine follow-up can help reduce this risk. The friendships formed by this communal follow-up can contribute towards emotional health and recovery. This holistic approach should be incorporated into novel follow-up strategies to help reduce patient BMI and reduce cardiovascular risk.

Public Policies and Programs for the Prevention and Control of Breast Cancer in Latin American Women: A Scoping Review (Preprint)

Background

Breast cancer has positioned itself worldwide as one of the main public health problems, especially in Latin America. In some countries, several programs for the prevention and control of breast cancer in women have been developed and implemented on a permanent basis, but there are no public reports on the policies that originated such programs.

Objective

A scoping review of scientific publications that identify the type, extent, and scope of policies and programs for the prevention and control of breast cancer in Latin American women was performed, and the main results were presented in this paper.

Methods

This scoping review was carried out according to the method by Arksey and O’Malley based on 3 fundamental questions about breast cancer prevention and control policies in Latin America: their type, extent and scope, and reference framework. The search period was from 2000 to 2019, and the search was carried out in the following databases: MEDLINE (PubMed), MEDLINE (EbscoHost), CINAHL (EbscoHost), Academic Search Complete (EbscoHost), ISI Web of Science (Science Citation Index), and Scopus in English, Spanish, and Portuguese, and Scielo, Cochrane, and MEDES-MEDicina in Spanish and Portuguese. Of the 743 studies found, 20 (2.7%) were selected, which were analyzed using descriptive statistics and qualitative content analysis.

Results

The selected studies identified several Latin American countries that have generated policies and programs to prevent and control breast cancer in women, focusing mainly on risk communication, prevention and timely detection, effective access to health services, improvement of the screening process, and evaluation of screening programs. Evaluation criteria and greater participation of civil society in policy design and program execution are still lacking. This could undoubtedly help eliminate existing barriers to effective action.

Conclusions

Although several Latin American countries have generated public policies and action programs for the prevention and control of breast cancer, a pending issue is the evaluation of the results to analyze the effectiveness and impact of their implementation given the magnitude of the public health problem it represents and because women and civil society play an important role in its prevention and control.

International Registered Report Identifier (IRRID)

RR2-10.2196/12624

Factors associated with waiting time to breast cancer diagnosis among symptomatic breast cancer patients: a population-based study from Ontario, Canada

PURPOSE

A prolonged time from first presentation to cancer diagnosis has been associated with worse disease-related outcomes. This study evaluated potential determinants of a long diagnostic interval among symptomatic breast cancer patients.

METHODS

This was a population-based, cross-sectional study of symptomatic breast cancer patients diagnosed in Ontario, Canada from 2007 to 2015 using administrative health data. The diagnostic interval was defined as the time from the earliest breast cancer-related healthcare encounter before diagnosis to the diagnosis date. Potential determinants of the diagnostic interval included patient, disease and usual healthcare utilization characteristics. We used multivariable quantile regression to evaluate their relationship with the diagnostic interval. We also examined differences in diagnostic interval by the frequency of encounters within the interval.

RESULTS

Among 45,967 symptomatic breast cancer patients, the median diagnostic interval was 41 days (interquartile range 20-92). Longer diagnostic intervals were observed in younger patients, patients with higher burden of comorbid disease, recent immigrants to Canada, and patients with higher healthcare utilization prior to their diagnostic interval. Shorter intervals were observed in patients residing in long-term care facilities, patients with late stage disease, and patients who initially presented in an emergency department. Longer diagnostic intervals were characterized by an increased number of physician visits and breast procedures.

CONCLUSIONS

The identification of groups at risk of longer diagnostic intervals provides direction for future research aimed at better understanding and improving breast cancer diagnostic pathways. Ensuring that all women receive a timely breast cancer diagnosis could improve breast cancer outcomes.

Factors contributing to time to diagnosis in symptomatic colorectal cancer: A scoping review

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer worldwide (Ferlay et al., 2015, International Journal of Cancer, 136, E359), and delayed diagnosis is associated with mortality (Tørring et al., 2011, British Journal of Cancer, 104, 934; Tørring et al., 2012, Journal of Clinical Epidemiology, 65, 669). The purpose of this review was to determine the factors associated with time to diagnosis in symptomatic CRC using scoping review methods.

METHODS

We performed database and citation searches to identify studies which examine the length of any interval from symptom presentation to diagnosis. Study selection was conducted by two independent reviewers. Factors contributing to time to diagnosis were extracted from selected articles and mapped onto a conceptual framework consisting of four levels: patient and disease factors, provider factors, organisation/setting factors and sectors of influence.

RESULTS

From the 31 studies included in this review, we identified 138 unique factors, 17 of which were investigated by at least three studies and 11 of which had consistent results. Patient and disease factors were most commonly studied. Patient perception that their symptoms were benign, a non-urgent referral, female sex and rectal tumour location were each associated with a longer time to diagnosis.

CONCLUSION

Thus far, the literature has focused on patient or disease-related factors, while other levels of influence have been relatively understudied.

Presentation and characteristics of breast cancer in young women under age 40

PURPOSE

Although uncommon, breast cancer is the leading cause of cancer death in young women. There are limited studies on the presentation and characteristics of breast cancer in women under age 40.

METHODS

This is a retrospective study investigating patient demographics, clinical presentations, imaging findings, and cancer characteristics of a cohort of 145 women under age 40 with breast cancer.

RESULTS

Our cohort had more aggressive cancer subtypes than reported in older women; 33.1% triple negative, 80% high Ki-67, and 21.3% with stage 3+ disease. Most were referred from primary care or obstetrician/gynecologist, though 5.5% initially presented from the emergency department and another 2.1% were incidental findings. 16.6% of patients presented while pregnant or breastfeeding. Most patients presented with breast related symptoms. Of the 9.1% of patients diagnosed through our high-risk screening program, 84.6% of the cancers were identified on mammography or simultaneously with mammography and MRI. Most breast cancers presented with typically worrisome imaging (82.6%), though several cancers presented with findings that were typically benign.

CONCLUSIONS

We recommend prompt breast imaging for young women presenting with breast-related symptoms or an incidental breast finding, as younger patients have more aggressive cancer subtypes and are of a higher grade at presentation compared to older women. We also recommend vigilance when distinguishing suspicious symptoms from pregnancy-related breast changes to minimize delays in diagnosis. Additionally, it is important to identify patients who qualify for high risk screening, since cancers in screening patients were found at a lower grade than those presenting with symptoms.

Psychological factors related to time to help-seeking for cancer symptoms: a meta-analysis across cancer sites

The time patients wait before seeking help for cancer symptoms is among the most important factors contributing to diagnostic delays in cancer. We reviewed the association between time to help-seeking and three psychological factors: symptom knowledge, symptom interpretation, and beliefs about cancer. Forty-seven studies met the inclusion criteria, providing data from 22 countries concerning seven cancer sites. Better symptom knowledge was related to lower odds of a long help-seeking interval in both studies with healthy populations (OR = .73, 95% CI [.63, .84], k = 19) and patients (OR = .40, 95% CI [.23, .69], k = 12), and so was interpreting experienced symptoms as cancer-related (OR = .52, 95% CI [.36, .75], k = 13 studies with patients). More positive beliefs about cancer (i.e., that cancer is treatable) were associated with lower odds of a long help-seeking interval in both studies with healthy populations (OR = .70, 95% CI [.52, .92], k = 11) and with patients (OR = .51, 95% CI [.32, .82], k = 7). Symptom knowledge, interpretation, and beliefs about cancer are likely to be universal predictors of help-seeking and should be incorporated into theoretical models of patient help-seeking and interventions aiming to reduce delays.

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.

Time intervals experienced between first symptom recognition and pathologic diagnosis of breast cancer in Addis Ababa, Ethiopia: a cross-sectional study

OBJECTIVES

This study aimed to estimate the magnitude of patient and diagnostic delays and associated factors among women with breast cancer in Addis Ababa.

DESIGN

This is a cross-sectional study.

SETTINGS AND PARTICIPANTS

All women newly diagnosed with breast cancer in seven major healthcare facilities in Addis Ababa (n=441) were included in the study.

MAIN OUTCOMES AND MEASURES

Patient interval (time from recognition of first symptom to medical consultation) and diagnostic interval (time from first consultation to diagnosis). Patient intervals >90 days and diagnostic intervals >30 days were considered delays, and associated factors were determined using multivariable Poisson regressions with robust variance.

RESULTS

Thirty-six percent (95% CI [31.1%, 40.3%]) of the patients had patient intervals of >90 days, and 69% (95% CI [64.6%, 73.3%]) of the patients had diagnostic intervals of >30 days. Diagnostic interval exceeded 1 year for 18% of patients. Ninety-five percent of the patients detected the first symptoms of breast cancer by themselves, with breast lump (78.0%) as the most common first symptom. Only 8.0% were concerned about cancer initially, with most attributing their symptoms to other factors. In the multivariable analysis, using traditional medicine before consultation was significantly associated with increased prevalence of patient delay (adjusted prevalence ratio (PR) = 2.13, 95% CI [1.68, 2.71]). First consultation at health centres (adjusted PR = 1.19, 95% CI [1.02, 1.39]) and visiting ≥4 facilities (adjusted PR = 1.24, 95% CI [1.10, 1.40]) were associated with higher prevalence of diagnostic delay. However, progression of symptoms before consultation (adjusted PR = 0.73, 95% CI [0.60, 0.90]) was associated with decreased prevalence of diagnostic delay.

CONCLUSIONS

Patients with breast cancer in Addis Ababa have prolonged patient and diagnostic intervals. These underscore the need for public health programme to increase knowledge about breast cancer symptoms and the importance of early presentation and early diagnosis among the general public and healthcare providers.

Policies and Programs for the Prevention and Control of Breast Cancer in Mexican and Latin American Women: Protocol for a Scoping Review

Background

Breast cancer has become a major public health problem around the world, especially in Mexico and Latin America. Screening for breast cancer, which involves self-examination, mammography, and clinical breast examination, is crucial for early diagnosis, which in turn is associated with improved outcomes and survival rates. Although breast cancer prevention and control activities are being implemented in Mexico and Latin America, as in many other countries, there are no comprehensive public reports that provide information on the number, type, and scope of these activities; the impact of the programs and actions implemented; and the policies that form the basis of these programs.

Objective

This study aims to present the design of a protocol for a scoping review on the policies and action programs for breast cancer care in Mexico and Latin America, as well as their objectives and implementation plans.

Methods

This scoping review is guided by the methodological reference framework proposed by Arksey and O’Malley. A systematic search of the following electronic databases will be performed: MEDLINE (PubMed), MEDLINE (EBSCOHost), CINAHL (EBSCOHost), Academic Search Complete (EBSCOHost), ERIC, ISI Web of Science (Science Citation Index) in English and Cochrane and MEDES-MEDicina in Spanish. A search will be conducted to identify relevant studies published between 2000 and 2018. Data will be analyzed and presented in descriptive statistics and qualitative content analyses with analysis matrices and semantic networks. The selected studies will be arranged according to the Specific Action Program, Prevention and Control of Female Cancer 2013-2018.

Results

The intention is to perform this review during the first and second quarters of 2019 and present the results to health authorities by the first quarter of 2020. Results will also be sent for publication to an indexed journal by the second quarter of 2020.

Conclusions

We present a protocol for a scoping review–type literature revision based on the Arksey and O’Malley methodology to be performed during the first quarter of 2019. According to this 6-stage methodology, we will identify the scientific publications that present or analyze first-level action policies and programs for breast cancer care in Mexican women, as well as the results of these policies and programs, if any. The outcome of this review will be used to define the basis of a research project intended to design an educational intervention strategy for the general public in Mexico to enable them to deal with this public health problem.

International Registered Report Identifier (IRRID)

PRR1-10.2196/12624

Online Information-Seeking About Potential Breast Cancer Symptoms: Capturing Online Behavior With an Internet Browsing Tracking Tool

Background

People engage in health information-seeking online when experiencing unusual or unfamiliar bodily changes. It is not well understood how people consult the internet for health information after the onset of unfamiliar symptoms and before receiving a potential diagnosis and how online information-seeking can help people appraise their symptoms. This lack of evidence may be partly due to methodological limitations in capturing in real time the online information-seeking process.

Objective

We explored women’s symptom attribution and online health information-seeking in response to a hypothetical and unfamiliar breast change suggestive of cancer (nipple rash). We also aimed to establish the feasibility of capturing in real time the online information-seeking process with a tool designed to track participant online searches and visited websites, the Vizzata browser tracker.

Methods

An online survey was completed by 56 cancer-free women (mean age 60.34 [SD 7.73] years) responding to a scenario asking them to imagine noticing a red scaly rash on the nipple. Participants were asked to make symptom attributions when presented with the scenario (T1) and again after seeking information online (T2). The online tracking tool, embedded in the survey, was used to capture in real time participant search terms and accessed websites.

Results

The tracking tool captured the search terms and accessed websites of most of the participants (46/56, 82%). For the rest (10/56, 18%), there was evidence of engagement in online information-seeking (eg, medical terminology and cancer attribution at T2) despite their searching activity not being recorded. A total of 25 participants considered cancer as a potential cause for the nipple rash at T1, yet only one of these used cancer as a search term. Most participants (40/46, 87%) used rash-related search terms, particularly nipple rash and rash on nipple. The majority (41/46, 89%) accessed websites containing breast cancer information, with the National Health Service webpage “Paget disease of the nipple” being the most visited one. At T2, after engaging in the internet search task, more participants attributed the nipple rash to breast cancer than at T1 (37/46, 66% vs 25/46, 45%), although a small number of participants (6/46) changed from making a cancer attribution at T1 to a noncancer one at T2.

Conclusions

Making a cancer attribution for an unfamiliar breast change did not necessarily translate into cancer-termed searches. Equally, not all internet searches led to a cancer attribution. The findings suggest that online information-seeking may not necessarily help women who experience unfamiliar breast cancer symptoms understand their condition. Despite some technical issues, this study showed that it is feasible to use an online browser tracking tool to capture in real time information-seeking about unfamiliar symptoms.

Disparities in breast cancer diagnosis for immigrant women in Ontario and BC: results from the CanIMPACT study

BACKGROUND

In Canada, clinical practice guidelines recommend breast cancer screening, but there are gaps in adherence to recommendations for screening, particularly among certain hard-to-reach populations, that may differ by province. We compared stage of diagnosis, proportion of screen-detected breast cancers, and length of diagnostic interval for immigrant women versus long-term residents of BC and Ontario.

METHODS

We conducted a retrospective cohort study using linked administrative databases in BC and Ontario. We identified all women residing in either province who were diagnosed with incident invasive breast cancer between 2007 and 2011, and determined who was foreign-born using the Immigration Refugee and Citizenship Canada database. We used descriptive statistics and bivariate analyses to describe the sample and study outcomes. We conducted multivariate analyses (modified Poisson regression and quantile regression) to control for potential confounders.

RESULTS

There were 14,198 BC women and 46,952 Ontario women included in the study population, of which 11.8 and 11.7% were foreign-born respectively. In both provinces, immigrants and long-term residents had similar primary care access. In both provinces, immigrant women were significantly less likely to have a screen-detected breast cancer (adjusted relative risk 0.88 [0.79-0.96] in BC, 0.88 [0.84-0.93] in Ontario) and had a significantly longer median diagnostic interval (2 [0.2-3.8] days in BC, 5.5 [4.4-6.6] days in Ontario) than long-term residents. Women from East Asia and the Pacific were less likely to have a screen-detected cancer and had a longer diagnostic interval, but were diagnosed at an earlier stage than long-term residents. In Ontario, women from Latin America and the Caribbean and from South Asia were less likely to have a screen-detected cancer, had a longer median diagnostic interval, and were diagnosed at a later stage than long-term residents. These findings were not explained by access to primary care.

CONCLUSIONS

There are inequalities in breast cancer diagnosis for Canadian immigrant women. We have identified particular immigrant groups (women from Latin America and the Caribbean and from South Asia) that appear to be subject to disparities in the diagnostic process that need to be addressed in order to effectively reduce gaps in care.

The fluctuating incidence, improved survival of patients with breast cancer, and disparities by age, race, and socioeconomic status by decade, 1981-2010

Purpose

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related deaths among women worldwide. However, the data on breast cancer incidence and survival over a long period, especially the dynamic changes in the role of race and socioeconomic status (SES), are scant.

Materials and methods

To evaluate treatment outcomes of patients with breast cancer over the past 3 decades, the data from the Surveillance, Epidemiology, and End Results (SEER) registries were used to assess the survival of patients with breast cancer. Period analysis was used to analyze the incidence and survival trend; survival was evaluated by the relative survival rates (RSRs) and Kaplan-Meier analyses. The HRs for age, race, stage, and SES were assessed by Cox regression.

Results

A total of 433,366 patients diagnosed with breast cancer between 1981 and 2010 were identified from the original nine SEER registries. The incidences of breast cancer in each decade were 107.1 per 100,000, 117.5 per 100,000, and 109.8 per 100,000. The 10-year RSRs improved each decade, from 70.8% to 81.5% to 85.6% (P<0.0001). The lower survival in black race and high-poverty group is confirmed by Kaplan-Meier analyses and RSRs. Furthermore, Cox regression analyses demonstrated that age, race, SES, and stage are independent risk factors for patients with breast cancer in each decade.

Conclusion

The current data demonstrated a fluctuating incidence trend with improving survival rates of patients with breast cancer over the past 3 decades. In addition, the survival disparity exists among different races, ages, SESs, and stages.

Patient-initiated follow up affects fear of recurrence and healthcare use: a randomised trial in early-stage endometrial cancer

OBJECTIVE

To test the hypothesis that patient-initiated follow up reduces the fear of cancer recurrence (FCR) and healthcare use when compared with traditional hospital-based follow up.

DESIGN

Pragmatic, multicentre randomised trial.

SETTING

Four Danish departments of gynaecology between May 2013 and May 2016.

POPULATION

One hundred and fifty-six women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I low-intermediate risk endometrial carcinoma.

METHODS

Women allocated to the control group attended hospital-based follow up consisting of regular outpatient visits for 3 years after primary treatment. Women in the intervention group were instructed in patient-initiated follow up, which included careful instruction in alarm symptoms and options for self-referral rather than a schedule of examinations.

MAIN OUTCOME MEASURES

The primary end point was FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) after 10 months of follow up. Secondary end points included cancer-related use of primary and secondary health care during the first 10 months after treatment.

RESULTS

In the primary analysis, FCR decreased significantly more in the control group from baseline to 10 months of follow up (difference -5.9, 95% CI -10.9 to -0.9). The majority of this improvement happened after only 3 months of follow up. Women receiving the intervention had fewer examinations at the department compared with the control group (0 versus 2 median visits, P < 0.01) and 58% of these examinations were scheduled because of vaginal bleeding.

CONCLUSIONS

Hospital-based follow up alleviates FCR significantly more than patient-initiated follow up, though the estimated difference was small. Patient-initiated follow up is a feasible, potentially cost-reducing follow-up approach in a population of endometrial cancer survivors with low risk of recurrence. The decision to use patient-initiated follow up should balance these benefits and harms.

TWEETABLE ABSTRACT

Patient-initiated follow up reduces healthcare use but maintains fear of recurrence in endometrial cancer.

PLAIN LANGUAGE SUMMARY

Why and how was the study carried out? Follow up of women with endometrial cancer is resource consuming and previous research suggests that it is not effective. Even though the women benefit from reassurance at follow up, routine examinations may also remind the women of the disease and induce fear of cancer recurrence. Furthermore, routine follow up may delay recurrence diagnosis, because the women do not report their symptoms until the next scheduled visit. In the research explained in this article, patient-initiated follow up was evaluated as an alternative to traditional follow up. The women were randomly assigned to one of two follow-up programmes: regular gynaecological examinations at the department of gynaecology or self-referral with careful instruction in alarm symptoms, that is, patient-initiated follow up. The level of fear of cancer recurrence in the two groups was obtained by questionnaires. Information on healthcare use was obtained by questionnaires and a chart review. What were the main findings? Regular examinations at the department of gynaecology reduced the fear of cancer recurrence significantly more than patient-initiated follow up, though the difference was small. Women who were instructed in alarm symptoms, under self-referral, were able to monitor their symptoms, and this approach significantly reduced the number of examinations at the department of gynaecology. What are the limitations of the work? Participants in the self-referral group knew that they were examined less than other women, and this may have induced fear of cancer recurrence. Similarly, the regular completion of questionnaires regarding fear of cancer recurrence may have reminded the women of the disease and diminished the difference between the two groups. What are the implications for patients Patient-initiated follow up reduced healthcare use but maintained fear of cancer recurrence in women who had survived early-stage endometrial cancer. Future analyses on quality of life and cost-effectiveness are needed to balance the benefits and harms of patient-initiated follow up.

Factors associated with insufficient awareness of breast cancer among women in Northern and Eastern China: a case-control study

OBJECTIVES

To investigate the awareness and knowledge level of breast cancer among Chinese participants.

DESIGN

Case-control study.

SETTINGS

This study was based on the database of the minister-affiliated hospital key project of the Ministry of Health of the People's Republic of China that included 21 Chinese hospitals between April 2012 and April 2013.

PARTICIPANTS

Matched study was designed among 2978 participants with Han ethnicity aged between 25 and 70.

PRIMARY AND SECONDARY OUTCOME MEASURES

Student's t-test, Pearson's χ² test, reliability analysis, exploratory factor analysis, and univariate and multivariate logistic regression analyses were performed to know the level of breast cancer knowledge and find the breast cancer awareness-associated factors.

RESULTS

80.0% (2383/2978) of the participants had poor awareness level of breast cancer. In-depth knowledge of breast cancer such as early symptoms and risk factors was poorly found among them. Television broadcast and relatives or friends with breast cancers were the main sources of information about breast cancer. Of all participants, 72.8% (2167/2978) had heard about breast cancer as a frequent cancer affecting women, and 63.3% (1884/2978) knew that family history of breast cancer was a risk factor for breast cancer. Over half of them were aware that a breast lump could be a symptom of breast cancer. Multivariate analysis identified the following variables that predicted awareness of breast cancer: young age (OR=0.843, 95% CI 0.740 to 0.961), occupation (agricultural worker) (OR=12.831, 95% CI 6.998 to 23.523), high household social status (OR=0.644, 95% CI 0.531 to 0.780), breast hyperplasia history (OR=1.684, 95% CI 1.273 to 2.228), high behavioural prevention score (OR=4.407, 95% CI 3.433 to 5.657).

CONCLUSION

Most women were aware of breast cancer as a disease, but their in-depth knowledge of it was poor. More publicity and education programmes to increase breast cancer awareness are necessary and urgent, especially for the ageing women and agricultural workers.

Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.

Increasing Routine Cancer Screening Among Underserved Populations Through Effective Communication Strategies: Application of a Health Literacy Framework

Cancer prevention and control efforts serve as national priorities, as cancer is the second leading cause of death in the USA. In addition, cancer disparities exist, with racial/ethnic minority, low-income, and uninsured populations suffering the greatest burden. The goal of this paper is to describe the role that effective health communication can play in increasing routine cancer screening among medically underserved populations, thus decreasing persistent health disparities. For this paper, we applied Sorenson's integrated model of health literacy as a framework for identifying communication gaps and opportunities that can help improve cancer screening specifically at federally qualified health centers (FQHCs). This integrated model consists of four interrelated dimensions: access, understand, appraise, and apply. Employing communication strategies across this health literacy framework has the potential to facilitate improved decision making and cancer screening outcomes among the most underserved populations.

Typical and atypical presenting symptoms of breast cancer and their associations with diagnostic intervals: Evidence from a national audit of cancer diagnosis

INTRODUCTION

Most symptomatic women with breast cancer have relatively short diagnostic intervals but a substantial minority experience prolonged journeys to diagnosis. Atypical presentations (with symptoms other than breast lump) may be responsible.

METHODS

We examined the presenting symptoms of breast cancer in women using data from a national audit initiative (n=2316). Symptoms were categorised topographically. We investigated variation in the length of the patient interval (time from symptom onset to presentation) and the primary care interval (time from presentation to specialist referral) across symptom groups using descriptive analyses and quantile regression.

RESULTS

A total of 56 presenting symptoms were described: breast lump was the most frequent (83%) followed by non-lump breast symptoms, (e.g. nipple abnormalities (7%) and breast pain (6%)); and non-breast symptoms (e.g. back pain (1%) and weight loss (0.3%)). Greater proportions of women with 'non-lump only' and 'both lump and non-lump' symptoms waited 90days or longer before seeking help compared to those with 'breast lump only' (15% and 20% vs. 7% respectively). Quantile regression indicated that the differences in the patient interval persisted after adjusting for age and ethnicity, but there was little variation in primary care interval for the majority of women.

CONCLUSIONS

About 1 in 6 women with breast cancer present with a large spectrum of symptoms other than breast lump. Women who present with non-lump breast symptoms tend to delay seeking help. Further emphasis of breast symptoms other than breast lump in symptom awareness campaigns is warranted.