Delay in diagnosis and treatment of symptomatic breast cancer in China

Value of the NF-κB signalling pathway and the DNA repair gene PARP1 in predicting distant metastasis after breast cancer surgery

The DNA repair gene PARP1 and NF-κB signalling pathway affect the metastasis of breast cancer by influencing the drug resistance of cancer cells. Therefore, this study focused on the value of the DNA repair gene PARP1 and NF-κB pathway proteins in predicting the postoperative metastasis of breast cancer. A nested case‒control study was performed. Immunohistochemical methods were used to detect the expression of these genes in patients. ROC curves were used to analyse the predictive effect of these factors on distant metastasis. The COX model was used to evaluate the effects of PARP1 and TNF-α on distant metastasis. The results showed that the expression levels of PARP1, IKKβ, p50, p65 and TNF-α were significantly increased in the metastasis group (P < 0.001). PARP1 was correlated with IKKβ, p50, p65 and TNF-α proteins (P < 0.001). There was a correlation between IKKβ, p50, p65 and TNF-α proteins (P < 0.001). ROC curve analysis showed that immunohistochemical scores for PARP1 of > 6, IKKβ of > 4, p65 of > 4, p50 of > 2, and TNF-α of > 4 had value in predicting distant metastasis (SePARP1 = 78.35%, SpPARP1 = 79.38%, AUCPARP1 = 0.843; Sep50 = 64.95%, Spp50 = 70.10%, AUCp50 = 0.709; SeTNF-α = 60.82%, SpTNF-α = 69.07%, AUCTNF-α = 0.6884). Cox regression analysis showed that high expression levels of PARP1 and TNF-α were a risk factor for distant metastasis after breast cancer surgery (RRPARP1 = 4.092, 95% CI 2.475-6.766, P < 0.001; RRTNF-α = 1.825, 95% CI 1.189-2.799, P = 0.006). Taken together, PARP1 > 6, p50 > 2, and TNF-α > 4 have a certain value in predicting breast cancer metastasis, and the predictive value is better when they are combined for diagnosis (Secombine = 97.94%, Spcombine = 71.13%).

Patient delay in chronic kidney disease: A qualitative study

This study aimed to investigate the reasons for patient delay in chronic kidney disease (CKD) and provide a scientific basis for implementing effective interventions. With the adoption of the phenomenological method in qualitative research, semi-structured, face-to-face interviews were conducted with 14 cases, and the Colaizzi seven-step analysis method was used to analyze the interview data and refine the themes. A total of 4 themes were obtained, namely, a cognitive explanation of illness, negative psychological emotions, socioeconomic levels, and limited medical resources. The current status of patient delay in chronic kidney disease is serious, and there are various reasons for it. Health management departments and healthcare providers at all levels should pay attention to this situation and provide targeted supportive interventions and health education to help patients establish the correct awareness of medical consultation and effectively improve their quality of survival.

Unravelling the predictors of late cancer presentation and diagnosis in Jordan: a cross-sectional study of patients with lung and colorectal cancers

OBJECTIVES

Late presentation or diagnosis of cancer results in a poor clinical prognosis, negatively affects treatment and subsequently lowers one's chances of survival. This study aimed to identify the factors associated with late lung and colorectal cancer presentation and diagnosis in Jordan.

DESIGN

This correlational cross-sectional study was based on face-to-face interviews and medical chart reviews from a cancer registry database. A structured questionnaire based on a review of the literature was used.

SETTING AND PARTICIPANTS

The study participants were a representative sample of adult patients with colorectal or lung cancer who visited the outpatient clinics at King Hussein Cancer Center in Amman, Jordan, between January 2019 and December 2020, to get their first medical consultation.

RESULTS

382 study participants were surveyed, with a response rate of 82.3%. Of these, 162 (42.2%) reported a late presentation and 92 (24.1%) reported a late diagnosis of cancer. The results of backward multivariate logistic regression analyses showed that female gender and not seeking a medical advice when feeling ill combined was associated with an almost three times increased likelihood of reporting a late presentation with cancer (adjusted OR 2.97, 95% CI 1.19 to 7.43). Not having health insurance and not seeking medical advice combined was also associated with late presentation (2.5, 95% CI 1.02 to 6.12). For lung cancer, Jordanians living in rural areas were 9.29 (95% CI 2.46 to 35.1) times more likely to report late diagnosis. Jordanians who did not screen for cancer in the past were 7.02 (95% CI 1.69 to 29.18) times more likely to report late diagnosis. For colorectal cancer, those having no previous knowledge about cancers or screening programmes had increased odds of reporting late diagnosis (2.30, 95% CI 1.06 to 4.97).

CONCLUSIONS

This study highlights important factors associated with the late presentation and diagnosis of colorectal and lung cancers in Jordan. Investing in national screening and early detection programmes as well as public outreach and awareness campaigns will have a significant impact on early detection to improve treatment outcomes.

Applications of different machine learning approaches in prediction of breast cancer diagnosis delay

Background

The increasing rate of breast cancer (BC) incidence and mortality in Iran has turned this disease into a challenge. A delay in diagnosis leads to more advanced stages of BC and a lower chance of survival, which makes this cancer even more fatal.

Objectives

The present study was aimed at identifying the predicting factors for delayed BC diagnosis in women in Iran.

Methods

In this study, four machine learning methods, including extreme gradient boosting (XGBoost), random forest (RF), neural networks (NNs), and logistic regression (LR), were applied to analyze the data of 630 women with confirmed BC. Also, different statistical methods, including chi-square, p-value, sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC), were utilized in different steps of the survey.

Results

Thirty percent of patients had a delayed BC diagnosis. Of all the patients with delayed diagnoses, 88.5% were married, 72.1% had an urban residency, and 84.8% had health insurance. The top three important factors in the RF model were urban residency (12.04), breast disease history (11.58), and other comorbidities (10.72). In the XGBoost, urban residency (17.54), having other comorbidities (17.14), and age at first childbirth (>30) (13.13) were the top factors; in the LR model, having other comorbidities (49.41), older age at first childbirth (82.57), and being nulliparous (44.19) were the top factors. Finally, in the NN, it was found that being married (50.05), having a marriage age above 30 (18.03), and having other breast disease history (15.83) were the main predicting factors for a delayed BC diagnosis.

Conclusion

Machine learning techniques suggest that women with an urban residency who got married or had their first child at an age older than 30 and those without children are at a higher risk of diagnosis delay. It is necessary to educate them about BC risk factors, symptoms, and self-breast examination to shorten the delay in diagnosis.

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 Care Timeliness Framework: A Quality Framework for Cancer Control

PURPOSE

The aim of this study is to determine the pathway that women follow for Breast Cancer Care (BCC) and the time intervals from symptom discovery to treatment initiation and to develop a quality matrix framework.

METHODS

A retrospective cohort study was conducted at six tertiary centers in Malaysia. All women with newly diagnosed breast cancer were interviewed, and a medical records review was conducted using a structured questionnaire. The BCC timeliness framework showed that the total time between a woman discovering their first breast changes and the date of initial treatment was divided into three distinct intervals: presentation interval, diagnostic interval, and treatment interval. Four diagnosis subintervals, referral, biopsy, report, and diagnosis resolution intervals, were also looked into.

RESULTS

The BCC timeliness framework was used to capture important time points. The median total time, presentation interval, diagnostic interval, and treatment interval were 4.9 months (range, 1 month to 10 years), 2.4 months (range, 7 days to 10 years), 26 days (range, 4 days to 9.3 months), and 21 days (range, 1 day to 7.2 months), respectively. Meanwhile, the median time for the diagnosis subinterval of referral, biopsy, report, and diagnosis resolution was 8 days (range, 0 day to 8 months), 0 day (range, 0 day to 20 days), 7 days (range, 3 days to 3.5 months), and 4 days (range, 1 day to 1.8 months), respectively.

CONCLUSION

The BCC timeliness framework is based on the current sequenced trajectory of the BCC journey. Clarity in the measurement of timeliness provides a standardized language for monitoring and outcome research. It can serve as a quality indicator for community and hospital-based breast cancer programs.

The Urban-Rural Disparities and Associated Factors of Health Care Utilization Among Cancer Patients in China

Objective

This study aimed to examine the urban-rural disparities and associated factors of health care utilization among cancer patients in China.

Methods

This study used the data collected from a cross-sectional survey conducted in China. A total of 1,570 cancer survivors from three urban districts and five rural counties were selected by using a multistage stratified random sampling method. We measured health care utilization with the way of cancer diagnosis, the number of hospitals visited, and receiving alternative therapies. Chi-square test was used to examine the differences between urban and rural cancer patients. Binary logistic regression analysis was performed to explore the determinants of health care utilization.

Results

Among 1,570 participants, 84.1% were diagnosed with cancer after developing symptoms, 55.6% had visited two and above hospitals, and 5.7% had received alternative therapies. Compared with urban cancer patients, rural ones were more likely to be diagnosed with cancer after developing symptoms (χ2 = 40.04, p < 0.001), while they were less likely to visit more than one hospital (χ2 = 27.14, p < 0.001). Residence area (urban/rural), health insurance type, household income, age at diagnosis, tumor site, stage of tumor, and survival years were significantly associated with health care utilization of cancer patients (p < 0.01).

Conclusions

Health care utilization was suboptimal among cancers patients in China. Rural cancer patients had less health care utilization including screenings and treatments than urban ones. Policymakers should implement specific strategies to ensure equitable utilization of cancer care. More attention should be paid to the disadvantaged groups and rural cancer patients. Prioritizing health resources allocation is needed to prevent, screen, and treat cancers in rural areas.

Diagnostic delay in moderately/poorly differentiated breast cancer types

BACKGROUND

Diagnostic delay of breast cancer related to the false-negative assessment of the healthcare provider leads to tumor progression and might worsen the outcome. Previous studies found some factors associated with provider-related diagnostic delay; however, tumor biology has tended not to be considered. The aim of our study was to find differences in diagnostic delay of poorly differentiated breast cancer types.

METHODS

Data of 970 patients with newly diagnosed moderately/poorly differentiated (G2/3) breast cancer at the age ≥40 years was retrospectively analyzed regarding breast cancer type, diagnostic delay and its consequence, clinical factors and physician's assessment. Multivariate analysis was used to evaluate associated factors with diagnostic delay.

RESULTS

We observed a diagnostic delay in 3.8% (n = 37) of all patients. Mean delay time was 128 days, and clinically relevant tumor growth was observed in 43.2% of these cases. Delay was significantly higher in the group of triple-negative breast cancer (9.9% versus 2.7, 5.3 and 1.8% in hormonal receptor (HR)+/human epidermal growth factor receptor 2 (HER2)-, HR-/Her2+ and HR+/Her2+, respectively; P value <0.001). Age, breast density and reason for presentation were not correlated to diagnostic delay.

CONCLUSION

Patients with triple-negative breast cancer are at higher risk of receiving a false-negative assessment and experiencing a diagnostic delay. Our results emphasize the importance of a detailed consideration of clinical risk factors and provider training and suggest a broad indication for a core needle biopsy.

Primary Care Continuity and Wait Times to Receiving Breast Cancer Chemotherapy: A Population-Based Retrospective Cohort Study Using CanIMPACT Data

(1) Background: Wait times to chemotherapy are associated with morbidity and mortality in breast cancer patients; however, it is unclear how primary care physician (PCP) continuity impacts these wait times, or whether this association is different in immigrants, who experience cancer care inequities. We assessed the association between PCP continuity and the contact-to-chemotherapy interval (wait time from when a patient first presents to healthcare to the first day of receiving breast cancer chemotherapy), with a specific look at the immigrant population. (2) Methods: Population-based, retrospective cohort study of women who were diagnosed with stage I–III breast cancer in Ontario who received surgery and adjuvant chemotherapy. We used quantile regression at the median and 90th percentile to quantify the effect of PCP continuity on the contact-to-chemotherapy interval, performing a separate analysis on the immigrant population. (3) Results: Among 12,781 breast cancer patients, including 1706 immigrants, the median contact-to-chemotherapy interval (126 days) was 3.21 days shorter (95% confidence interval (CI) 0.47–5.96) in symptom-detected patients with low PCP continuity, 10.68 days shorter (95% CI 5.36–16.00) in symptom-detected patients with no baseline PCP visits and 17.43 days longer (95% CI 0.90–34.76) in screen-detected immigrants with low PCP continuity compared to the same groups with high PCP continuity. (4) Conclusions: Higher PCP continuity was not associated with a change in the contact-to-chemotherapy interval for most of our study population, but was associated with a marginally longer interval in our symptom-detected population and a shorter contact-to-chemotherapy interval in screen-detected immigrants. This highlights the importance of PCP continuity among immigrants with positive screening results. Additionally, having no PCP visits at baseline was associated with a shorter contact-to-chemotherapy interval in symptom-detected patients.

An Efficient PCA-GA-HKSVM-Based Disease Diagnostic Assistant

Disease diagnosis faces challenges such as misdiagnosis, lack of diagnosis, and slow diagnosis. There are several machine learning techniques that have been applied to address these challenges, where a set of symptoms is applied to a classification model that predicts the presence or absence of a disease. To improve on the performance of these techniques, this paper presents a technique which involves feature selection using principal component analysis (PCA), a hybrid kernel-based support vector machine (HKSVM) classification model and hyperparameter optimization using genetic algorithm (GA). The HKSVM in this paper introduces a new way of combining three kernels: Radial basis function (RBF), linear, and polynomial. Combining local (RBF) and global (linear and polynomial) kernels has the effect of improved model performance. This is because the local kernels are better able to distinguish points closer to each other while the global kernels are more suited to distinguish points that are far away from each other. The PCA-GA-HKSVM is used on 7 different medical datasets, with two datasets being multiclass datasets and 5 datasets being binary. Performance evaluation metrics used were accuracy, precision, and recall. It was observed that the PCA-GA-HKSVM offered better performance than the single kernel support vector machines (SVMs).

Determinants of delay from cancer diagnosis to treatment initiation in a cohort of brazilian women with breast cancer

This objective this study was to identify the time interval between breast cancer (BC) diagnosis and treatment initiation and delay-associated factors. This is a prospective cohort study that followed breast cancer patients, enrolled and treated at the cancer center in Rio de Janeiro (RJ) - Brazil, from October 02, 2014 to April 30, 2015. Participants were interviewed at the first consultation. Treatment-related information was collected six months after recruitment. The median and interquartile range (IQR) were calculated. The interval between breast cancer diagnosis and treatment initiation of more than 60 days was considered the delay, according to the maximum term determined by Brazilian law. The association between independent variables and the outcome was performed using the crude odds ratios (OR). Variables presenting p < .20 in the univariate analysis were included in the multiple logistic regression model by the stepwise forward method, and those with p < .05 were retained in the final model. A total of 470 patients were included in the study. The median time was of 127 days (IQR: 85- 174). Delay was observed in 89.1% of the cases. After adjustment, the variables associated with delay were age ≥ 60 years (OR: 2.48; 95% CI 1.22-5.06), initial clinical staging (<2B) (OR: 2.01; 95% CI 1.05-3.86) and residence outside the city of Rio de Janeiro (OR: 2.75; 95% CI 1.38-5.51). Delays in starting treatment were associated with sociodemographic and clinical factors. Improving patient quality of care and restructuring the health service can minimise delays.

Delayed Breast Cancer Detection in an Asian Country (Taiwan) with Low COVID-19 Incidence

PURPOSE

To assess whether the COVID-19 pandemic delayed breast cancer diagnosis in Taiwan, an Asian country with a low COVID-19 incidence.

METHODS

The monthly volume of breast biopsies and breast cancers during the COVID-19 pandemic (during January 21 and July 31, 2020) was compared to the same period in 2019 (pre-COVID-19).

RESULTS

Taiwan recorded a lower COVID-19 incidence rate (20.2 cases per million population) than other Asian countries. The screen-detected lesions accounted for 55% and 36% of 2019 and 2020 total biopsied lesions, respectively. Total breast biopsy, mammography-guided, and ultrasound-guided biopsies decreased by 17%, 23%, and 14%, respectively, from pre-COVID-19 to COVID-19. Monthly differences were significant in total biopsy (p=0.03), mammography-guided biopsy (p=0.04), and a benign pathology result after breast biopsy (p<0.01). Nearly 46% decline was noted in the biopsy results of non-invasive breast cancer in 2020. The number of total breast cancers and early breast cancers (stages 0 and 1) decreased by 10% and 38%, respectively, during pandemic. Individuals with early breast cancer accounted for 71% and 49% of the total diagnosed breast cancer in the pre-COVID-19 and COVID-19 periods, respectively (p<0.001).

CONCLUSION

The pandemic significantly delayed early breast cancer detection in Taiwan despite low COVID-19 incidence.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04750018.

Treatment delay of cancer patients in Indonesia: a reflection from a national referral hospital

BACKGROUND Cancer is a complex disease requiring a multidisciplinary approach in establishing prompt diagnosis and treatment. Treatment in a timely manner is crucial for the outcomes. Hence, this study aimed to provide information on treatment delay including patient and provider delays and its associated factors. METHODS Cancer patients were recruited conveniently in the outpatient clinic of Department of Radiation Oncology, Cipto Mangunkusumo Hospital, Indonesia between May and August 2015. All patients were asked to fill a questionnaire and interviewed in this cross-sectional study. Treatment delay was explored and categorized into patient delay and provider delay. Patient delay could be happened before (patient-delay-1) or after (patient-delay-2) the patient was diagnosed with cancer. Provider delay could be due to physician, system-diagnosis, and system-treatment delays. RESULTS Among 294 patients, 86% patient had treatment delay. Patient delay was observed in 153 patients, and 43% of them had a history of alternative treatment. An older age (p = 0.047), lower educational level (p = 0.047), and history of alternative treatment (p<0.001) were associated with patient delay. Meanwhile, 214 patients had provider delay, and 9%, 36%, and 80% of them experienced physician, system-diagnosis, and system-treatment delays, respectively. All types of provider delay were associated with patient delay (p<0.001). CONCLUSIONS Most of the patient had treatment delay caused by either patient or provider.

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

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

3.0 T Magnetic Resonance Functional Imaging Quantitative Parameters for Differential Diagnosis of Benign and Malignant Lesions of the Breast

Objective: To investigate value of quantitative dynamic contrast-enhanced magnetic resonance imaging (MRI) parameters and apparent diffusion coefficient (ADC) value in differential diagnosis of breast benign and malignant lesions, and their correlation with prognostic factors of breast cancer. Methods: The study collected MRI images and clinical data from 232 female patients suspected of breast cancer. Philips INGENIA 3.0T superconducting magnetic resonance scanner was used for imaging examination. Complete pathological data of patients were collected, and the expression of ER, PR, HER-2, and Ki-67 were further investigated. Results: K_ep was higher in malignant breast lesion group than that in benign breast lesion group, and ADC value was lower in the former group than that in the latter group (both p < 0.05). The areas under the receiver operating characteristic curves for K_ep, ADC, and extravascular volume fraction (V_e) were 0.904 (95% confidence interval [CI]: 0.863-0.945), 0.813 (95% CI: 0.752-0.875), and 0.774 (95% CI: 0.707-0.841), respectively. Furthermore, according to the maximum Youden index, the specificity of K_ep and the sensitivity of ADC were high, which were 97.20% and 96.00%, respectively, with a cutoff value of 0.314 and 0.151, respectively. K_ep value in ER-positive expression group was significantly higher than that in ER-negative expression group (p < 0.05). K_ep value in PR-positive expression group was significantly higher than that in PR-negative expression group (p < 0.05). There was positive correlation between K_ep and expression of Ki-67 (p < 0.05). ADC value was negatively correlated with Ki-67 expression (p < 0.05). Conclusion: Quantitative parameters K_ep and ADC of 3.0 T MR functional imaging can be used as reference indexes for differential diagnosis of benign and malignant breast lesions and for biological behavior evaluation, indicating potential clinical value for noninvasive preoperative evaluation of breast cancer.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Geographical Differences in Intracranial Meningioma Management: Examining 65,973 Patients across the United States

Background  Age, tumor size and location, overall health, and patient preference are primary considerations driving treatment decision-making for intracranial meningiomas. However, even for the same individual patient, treatment recommendations may vary between centers and providers. Objective  To study associations between geography, disease presentation, and management of intracranial meningioma in the United States. Methods  The population-based Surveillance, Epidemiology, and End Results(SEER) data were queried between 2004 and 2014 for cases of intracranial meningioma. Results  A total of 65,808 patients with intracranial meningioma were identified. Univariate analyses demonstrated strong associations between geographic location, age, and size of tumor at presentation. The mean age for all registries was 64.2 years, with a range from 62.0 (Utah registry) to 66.6 (Detroit registry). The greatest proportion of small tumors (<1 cm) were identified in the Utah registry (13.9% of tumors), while the greatest proportion of large tumors (> 4cm) were noted in the Hawaii registry (30.7% of tumors). Multivariable analysis demonstrated that the impact of geography on treatment selection was just as important as other established variables. For example, the distribution in tumor size between New Mexico and Greater California registries is nearly identical; however, the odds ratio for surgery was 1.5 times greater for the New Mexico population. Conclusion  These data suggest that disease presentation and treatment are significantly influenced by regional referral patterns, provider or institutional treatment preferences, and regional availability of subspecialty expertise. Understanding such biases is important for patients, referring physicians, and treatment providers in an effort to provide balanced counseling and treatment.

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.

Work and income changes after cancer in rural China: A cross-sectional survey

Background

The present study aimed to first describe the work‐related outcomes of cancer survivors and to then identify those characteristics that influenced the decision to stop working in rural China.

Methods

We assessed 752 cancer survivors (residents of rural areas, working at the time of diagnosis, >1 year since completing treatment) from the cross‐sectional study “China Survey of Experiences with Cancer”. Participants reported changes in employment status, income, and the ability to perform physical jobs due to cancer, as well as the work‐related outcomes of their informal caregivers. Logistic regression analyses were used to examine the association between sociodemographic characteristics, cancer characteristics, and changes in work (ie, continue to work vs not working).

Results

The participants were largely farmers (96%), women (56%), younger than 65 years old (69%), and diagnosed with colorectal (31%) and breast cancer (31%). Thirty‐nine percent reported reducing working hours, and 40% reported stopping work altogether. Approximately 7% of informal caregivers also stopped working in order to take care of those diagnosed with cancer. Thirty‐three percent of cancer survivors and 5% of their informal caregivers had no source of income following treatment. Controlling for other variables, lower educational attainment, physical limitations in work, and different cancer sites were significantly associated with ending employment in both men and women, while among men specifically, we observed that older age, being unmarried, and being diagnosed at later stages were significantly associated with an end to working.

Conclusion

Rural cancer survivors are at a high risk for stopping work after completing treatment, and many survivors and their caregivers experience poor work‐related outcomes and economic hardship. These results highlight the importance of paying attention to the work experiences of cancer survivors in rural China.

The influence on survival of delay in the treatment initiation of screening detected non-symptomatic breast cancer

We aimed to determine whether the detection-to-treatment interval of non-symptomatic breast cancer is associated with factors that can predict survival outcomes. A retrospective review of the Breast Surgery Department Database at Peking Union Medical College Hospital (PUMCH) was performed, and a total of 1084 non-symptomatic invasive breast cancer patients were included. The findings revealed that detection-to-treatment interval was significantly longer for women who were older (p = 0.001), lived in rural areas (p = 0.024), had lower education (p = 0.024), and had detection in other institutions (p = 0.006). Other sociodemographic and clinicopathological characteristics were not associated to longer interval. A median follow-up of 35 months (range: 6–60 months) was carried out and a long delay at more than 90 days did not significantly decrease the DFS (univariate, P = 0.232; multivariate, P = 0.088). For triple negative breast cancer, there was a worse DFS if the interval was longer than 90 days both in multivariate analysis (hazard ratio [HR] = 3.40; 95% CI, 1.12–10.35; P = 0.031) and univariate analysis (HR = 2.86; 95% CI, 1.03–7.91; P = 0.042). Further studies on care before initial treatment of non-symptomatic breast cancers are warranted.

Locally advanced breast cancer in young women in Latin America

The purpose of this review is to organise, summarise and critically assess existing knowledge on locally advanced breast cancer (LABC) among young women in Latin America. We discuss the most relevant findings in six sections: 1) epidemiology of breast cancer in young women in Latin America; 2) being young as a factor for worse prognosis; 3) LABC in young women in the region; 4) aggressive tumour behaviour among young women; 5) delays in diagnosis and treatment and 6) burden of advanced disease. We point out the need to dedicate resources to enhance earlier diagnosis and prompt referrals of young women with breast cancer; promote research regarding prevalence, biologic characteristics, outcomes and reasons for diagnosis and treatment delays for this age group; and finally, implement supportive care programmes as a means of improving patients and their families’ well-being. The recognition of the current standpoint of breast cancer in young patients across the continent should shed some light on the importance of this pressing matter.

Adherence in the Cancer Care Setting: a Systematic Review of Patient Navigation to Traverse Barriers

Patient navigation is an evidence-based intervention involving trained healthcare workers who assist patients in assessing and mitigating personal and environmental factors to promote healthy behaviors. The purpose of this research is to systematically assess the efficacy of patient navigation and similar programs to improve diagnosis and treatment of diseases affecting medically underserved populations. A systematic review was performed by searching PubMed, MEDLINE, PsychINFO, and CINAHL to identify potential studies. Eligible studies were those containing original peer-reviewed research reports in English on patient navigation, community health workers, vulnerable and underserved populations, and healthcare disparity. Specific outcomes regarding patient navigator including the effect of the intervention on definitive diagnosis and effect on initiation of treatment were extracted from each study. The search produced 1428 articles, and 16 were included for review. All studies involved patient navigation in the field of oncology in underserved populations. Timing of initial contact with a patient navigator after diagnostic or screening testing is correlated to the effectiveness of the navigator intervention. The majority of the studies reported significantly shorter time intervals to diagnosis and to treatment with patient navigation. Patient navigation expedites oncologic diagnosis and treatment of patients in underserved populations. This intervention is more efficacious when utilized shortly after screening or diagnostic testing.

Patient and Care Delays of Breast Cancer in China

Purpose

This study differentiates patient and care delays of breast cancer and explores the related factors as well as the associations with the prognosis in Guangzhou, a southern city of China.

Methods

A cohort of female incident breast cancer patients (n=1,551) was recruited from October 2008 to March 2012 and followed up until January 1, 2016 (n=1,374) in the affiliated hospitals of Sun Yat-sen University. The factors associated with patient and care delays were analyzed with multivariable logistic models. Cox proportional hazards regression models were constructed to estimate the impacts of the delays on the prognosis.

Results

There were 40.4% patient delay (≥3 months) and 15.5% care delay (≥1 month). The patient delay, but not the care delay, was significantly related to the clinical stage and consequently worsened the prognosis of breast cancer (hazard ratio, 1.45; 95% confidence interval, 1.09 to 1.91 for progression-free survival). The factors related to an increased patient delay included premenopausal status, history of benign breast disease, and less physical examination.

Conclusion

Patient delay was the main type of delay in Guangzhou and resulted in higher clinical stage and poor prognosis of breast cancer. Screening for breast cancer among premenopausal women may be an effective way to reduce this delay.

Barriers and Explanatory Mechanisms of Delays in the Patient and Diagnosis Intervals of Care for Breast Cancer in Mexico

BACKGROUND

Most breast cancer patients in low- and middle-income settings are diagnosed at advanced stages due to lengthy intervals of care. This study aimed to understand the mechanisms through which delays occur in the patient interval and diagnosis interval of care.

MATERIALS AND METHODS

We conducted a cross-sectional survey including 886 patients referred to four major public cancer hospitals in Mexico City. Based in a conceptual model of help-seeking behavior, a path analysis strategy was used to identify the relationships between explanatory factors of patient delay and diagnosis delay.

RESULTS

The patient and the diagnosis intervals were greater than 3 months in 20% and 65% of participants, respectively. We present explanatory models for each interval and the interrelationship between the associated factors. The patient interval was longer among women who were single, interpreted their symptoms as not worrisome, concealed symptoms, and perceived a lack of financial resources and the difficulty of missing a day of work as barriers to seek care. These barriers were more commonly perceived among patients who were younger, had lower socioeconomic status, and lived outside of Mexico City. The diagnosis interval was longer among those who used several different health services prior to the cancer hospital and perceived medical errors in these services. More health services were used among those who perceived errors and long waiting times for appointments, and who first consulted private services.

CONCLUSION

Our findings support the relevance of strengthening early cancer diagnosis strategies, especially the improvement of quality of primary care and expedited referral routes to cancer services.

IMPLICATIONS FOR PRACTICE

This study's findings suggest that policy in low- and middle-income countries (LMICs) should be directed toward reducing delays in diagnosis, before the implementation of mammography screening programs. The results suggest several factors susceptible to early diagnosis interventions. To reduce patient delays, the usually proposed intervention of awareness promotion could better work in LMIC contexts if the message goes beyond the advertising of screening mammography to encourage the recognition of potential cancer symptoms and sharing of symptoms with significant others. To reduce diagnosis delay, efforts should focus on strengthening the quality of public primary care services and improving referral routes to cancer care centers.

Complementary and alternative medicine (CAM) use and delays in presentation and diagnosis of breast cancer patients in public hospitals in Malaysia

Complementary and alternative medicine (CAM) is widely used among the breast cancer patients in Malaysia. Delays in presentation, diagnosis and treatment have been shown to impact the disease prognosis. There is considerable use of CAM amongst breast cancer patients. CAM use has been cited as a cause of delay in diagnosis and treatments in qualitative studies, however there had not been any confirmatory study that confirms its impact on delays. The purpose of this study was to evaluate whether the use of CAM among newly diagnosed breast cancer patients was associated with delays in presentation, diagnosis or treatment of breast cancer. This multi-centre cross-sectional study evaluating the time points of the individual breast cancer patients' journey from first visit, resolution of diagnosis and treatments was conducted in six public hospitals in Malaysia. All newly diagnosed breast cancer patients from 1st January to 31st December 2012 were recruited. Data were collected through medical records review and patient interview by using a structured questionnaire. Complementary and alternative medicine (CAM) was defined as the use of any methods and products not included in conventional allopathic medicine before commencement of treatments. Presentation delay was defined as time taken from symptom discovery to first presentation of more than 3 months. The time points were categorised to diagnosis delay was defined as time taken from first presentation to diagnosis of more than 1 month and treatment delay was defined as time taken from diagnosis to initial treatment of more than 1 month. Multiple logistic regression was used for analysis. A total number of 340 patients participated in this study. The prevalence of CAM use was 46.5% (n = 158). Malay ethnicity (OR 3.32; 95% CI: 1.85, 5.97) and not interpreting symptom as cancerous (OR 1.79; 95% CI: 1.10, 2.92) were significantly associated with CAM use. The use of CAM was associated with delays in presentation (OR 1.65; 95% CI: 1.05, 2.59), diagnosis (OR 2.42; 95% CI: 1.56, 3.77) and treatment of breast cancer (OR 1.74; 95% CI: 1.11, 2.72) on univariate analyses. However, after adjusting with other covariates, CAM use was associated with delays in presentation (OR 1.71; 95% CI: 1.05, 2.78) and diagnosis (OR 2.58; 95% CI: 1.59, 4.17) but not for treatment of breast cancer (OR 1.58; 95% CI: 0.98, 2.55). The prevalence of CAM use among the breast cancer patients was high. Women of Malay ethnicity and not interpreting symptom as cancerous were significantly associated with CAM use. The use of CAM is significantly associated with delay in presentation and resolution of diagnosis. This study suggests further evaluation of access to breast cancer care is needed as poor access may cause the use of CAM. However, since public hospitals in Malaysia are heavily subsidized and readily available to the population, CAM use may impact delays in presentation and diagnosis.

A protocol for a cluster-randomized controlled trial of a self-help psycho-education programme to reduce diagnosis delay in women with breast cancer symptoms in Indonesia

Background

Breast cancer (BC) is the most frequent cancer occurring in women across the world. Its mortality rate in low-middle income countries (LMICs) is higher than in high-income countries (HICs), and in Indonesia BC is the leading cause of cancer deaths among women. Delay in breast cancer diagnosis negatively impacts cancer prognosis. Only about 30% of patients who come to the hospital to check on their breast abnormalities, continue thorough examination to biopsy to get a diagnosis based on the results of anatomical pathology. Many Indonesian women with breast cancer were already in an advanced stage when starting treatment. Therefore, delay in diagnosis is a serious problem that needs to be addressed. The present study will investigate whether our newly developed self-help psycho-educational programme, “PERANTARA”, for women with breast cancer symptoms is effective to reduce patient diagnosis delay in Indonesia.

Methods

A cluster-randomized controlled trial will be conducted in 106 patients in four hospitals in Bandung, West Java, Indonesia. Data will be collected at baseline (pre-assessment), 7 days after the intervention (post-assessment), and at 3 months (follow-up assessments). The primary outcome is delay in diagnosis and treatment. Secondary outcomes are breast cancer knowledge, anxiety and depression, and quality of life. Exploratively, adherence with treatment will be measured too. Data will be analysed by hierarchical linear modelling (HLM) to assess differential change over time.

Discussion

If proven effective, PERANTARA will be evaluated and implemented in a diversity of settings for local cares (such as in POSYANDU, PUSKESMAS) that provide health education/psycho-education for women with breast symptoms.

Trial registration

ISRCTN12570738. Date: November 19th, 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3268-7) contains supplementary material, which is available to authorized users.

Influence of time interval from diagnosis to treatment on survival for oral cavity cancer: A nationwide cohort study

OBJECTIVES

We aimed to explore the relationship between the time interval from diagnosis to treatment and survival of oral cavity squamous cell carcinoma patients.

MATERIALS AND METHODS

A population-based study was conducted between 2004 and 2010. Claims data of oral squamous cell carcinoma patients were retrieved from the Taiwan Cancer Registry Database. Secondary data were obtained from Taiwan's National Health Insurance Research Database.

RESULTS

A total of 21,263 patients were included in the final analysis. The majority of the patients received treatment within 30 days of diagnosis (n = 18,193, 85.5%), while 572 patients (2.7%) underwent treatment after 120 days. The patients who were treated after 120 days had a higher risk of death when compared to those treated within 30 days (Hazard ratio: 1.32, 95% Confidence intervals: 1.19 to 1.47).

CONCLUSION

A longer time interval from diagnosis to treatment was found to be associated with a poorer prognosis among patients suffering from oral squamous cell carcinoma.

Delay in Presentation, Diagnosis, and Treatment for Breast Cancer Patients in Jordan

Breast cancer is the most common cancer, and one of the leading causes of death for females in Jordan and many countries in the world. Studies have shown that delay in symptoms presentation, diagnosis or treatment would result in poor prognosis. There has been no published study from Jordan on delays in patient presentation, delays in diagnosis, or delays in treatment. Therefore, we conducted this study to assess these important quality indicators aiming to improve prognosis for breast cancer patients in Jordan. This project was a cross-sectional study on female breast cancer patients in Jordan. The total number of participants was 327. The proportion of patients with presentation delay, diagnosis delay, and treatment delay was 32.2%, 49.1%, or 32.4%, respectively. The main reported reasons for delay in presentation were ignorance of the nature of the problem (65.6%), limited/lack of knowledge that symptoms were suggestive of cancer diagnosis (16.7%), and misdiagnosis (16.7%). Predictors of delay and mean time for presentation, diagnosis, and treatment were identified. Our results reveal that breast cancer patients in Jordan are experiencing delays in presentation, diagnosis, and treatment. This could justify the advanced stages at diagnosis and poor outcomes for breast cancer patients in Jordan. We recommend revising the current early detection and down-staging programs in Jordan.

Estudo do tempo entre o diagnóstico e início do tratamento do câncer de mama em idosas de um hospital de referência em São Paulo, Brasil

Resumo Objetivou-se analisar o tempo entre o diagnóstico e o início do tratamento e conhecer o perfil sociodemográfico e clínico de mulheres com 60 ou mais anos de idade, diagnosticadas com câncer de mama entre os anos de 2001 a 2006, no Hospital Pérola Byington, São Paulo. Trata-se de um estudo descritivo, com dados secundários e amostra de 1299 casos. Coletou-se variáveis sociodemográficas, clínicas e temporais. Formou-se dois grupos de mulheres utilizando a variável tempo, sendo o tempo entre o diagnóstico e o início do tratamento: “até e maior que 60 dias”. A média do tempo entre o diagnóstico e o início do tratamento foi de 74,7 dias (DP = 212,6), e o tempo mediano de 45 dias. As idosas sem o diagnóstico e sem o tratamento anterior levaram menos tempo para dar início ao tratamento (p = 0,001), bem como as mulheres com estadiamento do tumor na fase inicial, in situ e I (p = 0,001). O tempo foi significante para os desfechos de recidiva (p = 0,004) e metástase (p = 0,038). O diagnóstico e o tratamento estabelecidos garantiu às idosas menor tempo para o início da assistência devida. Melhorar a estruturação e o funcionamento dos serviços de saúde constitui fator imprescindível para o atendimento dos casos da doença de forma eficiente, um importante desafio para o Sistema Único de Saúde.