Stage at diagnosis and delay in seeking medical care among women with breast cancer, delhi, India

Health-related quality of life and its determinants among cancer patients: evidence from 12,148 patients of Indian database

BACKGROUND

Cancer survivors experience a decrement in health-related quality of life (HRQoL) resulting from the disease as well as adverse effects of therapy. We evaluated the HRQoL of cancer patients, stratified by primary cancer site, stage, treatment response and associated adverse events, along with its determinants.

METHODS

Data were collected from 12,148 patients, sampled from seven purposively chosen leading cancer hospitals in India, to elicit HRQoL using the EuroQol questionnaire comprising of 5-dimensions and 5-levels (EQ-5D-5L). Multiple linear regression was used to determine the association between HRQoL and various socio-demographic as well as clinical characteristics.

RESULTS

Majority outpatients (78.4%) and inpatients (81.2%) had solid cancers. The disease was found to be more prevalent among outpatients (37.5%) and inpatients (40.5%) aged 45-60 years and females (49.3-58.3%). Most patients were found to be in stage III (40-40.6%) or stage IV (29.4-37.3%) at the time of recruitment. The mean EQ-5D-5 L utility score was significantly higher among outpatients [0.630 (95% CI: 0.623, 0.637)] as compared to inpatients [0.553 (95% CI: 0.539, 0.567)]. The HRQoL decreased with advancing cancer stage among both inpatients and outpatients, respectively [stage IV: (0.516 & 0.557); stage III (0.609 & 0.689); stage II (0.677 & 0.713); stage I (0.638 & 0.748), p value < 0.001]. The outpatients on hormone therapy (B = 0.076) showed significantly better HRQoL in comparison to patients on chemotherapy. However, palliative care (B=-0.137) and surgery (B=-0.110) were found to be associated with significantly with poorer HRQoL paralleled to chemotherapy. The utility scores among outpatients ranged from 0.305 (bone cancer) to 0.782 (Leukemia). Among hospitalized cases, the utility score was lowest for multiple myeloma (0.255) and highest for testicular cancer (0.771).

CONCLUSION

Older age, lower educational status, chemotherapy, palliative care and surgery, advanced cancer stage and progressive disease were associated with poor HRQoL. Our study findings will be useful in optimising patient care, formulating individualized treatment plan, improving compliance and follow-up.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Being sick to a cancer patient: pathways of delay in help seeking and diagnosis of cancer in India

There is evidence that cancer mortality and morbidity could be reduced when the disease is diagnosed and treated at an early stage. The paper examines the pathways of delay of cancer diagnosis in an Indian setting. It draws on a qualitative study conducted among cancer survivors and family members of cancer patients in the city of Bengaluru, South India. The results show that a substantial part of the delay occurred at the stage of initial formal help seeking wherein patient and family-led, disease-related and systemic factors together played a major role. Patient-led factors included trivialisation and normalisation of symptoms as part of general fatigue and aging; unrealistic risk perceptions that linked causality of cancer merely to heredity and behavioural risk factors; fear of being diagnosed as cancer patient; gender related reasons including family's gender performance expectation, lower agency of women to seek help and lower prioratisation of women's health in the household and access related issues including financial constraints and unavailability of specialised hospitals nearby. Disease-related factors included the presence of comorbidity, cancer's mimicking of symptoms of other diseases and absence of distinguishable symptoms at the initial stage for certain types of cancers. The practitioner-led and system-led factors such as trivialisation of symptoms by general practitioners, non cancer-specific referrals, and lack of cancer screening facilities accounted for a major part of delay after the formal help seeking. The paper argues that the mere knowledge of cancer symptoms did not always lead to early diagnosis due to the interplay of these factors. The ongoing cancer prevention and control interventions in India need to be informed of these micro level factors while developing strategies to prevent avoidable delays in cancer diagnosis.

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

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

“I want to live, but …” the desire to live and its physical, psychological, spiritual, and social factors among advanced cancer patients: evidence from the APPROACH study in India

Background

The limited access to palliative care resources along with the social stigma around cancer largely explains the poor quality of life (QoL) of Indian advanced cancer patients. As advanced cancer patients with poor QoL often harbour a desire for hastened death (DHD), it is imperative to understand factors affecting DHD, or the desire to live (DTL) among advanced cancer patients in India. We aim to examine the relationship between DTL and physical, psychological, spiritual, and social factors measuring patients’ QoL alongside their awareness of their late cancer stage.

Methods

We surveyed 200 patients from a tertiary cancer hospital in India to collect their DTL, awareness of cancer stage, demographic characteristics, and standardized measures for patients’ QoL. We used a linear probability regression model to quantify the association between these factors and patients’ DTL among the final sample of 192 patients with no missing information for the variables of interest.

Results

Among the various domains affecting cancer patients’ QoL, we found that the pain severity score (ranging from 0 to 10) and psychological distress score (ranging from 0 to 42) are negatively associated with the DTL. One point increase in each score reduced the DTL by 2.2% (p < 0.05) and 0.7% (p < 0.05), respectively. Our results also showed that patients whose perceived socio-economic status (SES) is poor have a 16% (p < 0.05) lower probability of DTL, compared to those with higher SES (lower middle class, upper middle class, and wealthy). Controlling for caste, religion, gender, age, marital status and years of education, we found psychological distress is statistically higher among patients belonging to this bottom SES.

Conclusions

We found that pain severity, psychological distress and perceived low SES are negatively associated with the desire to live in advanced cancer patients. Future research should focus on developing interventions to improve physical pain and psychological distress, particularly for patients who are socially and economically disadvantaged.

Stage at Diagnosis and Patient Delay among Breast Cancer Women in Kabul, Afghanistan

Background: Breast cancer is the commonest cause of mortality among women. According to WHO in 2012, about 7400 women died because of cancers in Afghanistan.   Aim: To obtain information about clinical stages of breast cancer of women at the time of diagnosis in Kabul, Afghanistan.   Patient and Method: This was a cross-sectional study of 240 women diagnosed with breast cancer from March 2016 to March 2019. The diagnosis of breast cancer was made by the surgeon on the basis of physical examination and Biopsy/Pathological reports. Clinical staging of the tumor was recorded according to the tumor, nodal, and metastasis (TNM) classification. The gap between knowing the problem and consulting a physician (Patient delay) was categorized: less than 3 months, 3-6 months and more than 6 months. Results: The mean age of patients was 49.31 years (SD ± 11.80) ranging from 18 to 76 years. The Patient delay was more than 6 months (65%). Infiltrating ductal carcinoma was the commonest morphological type (76.7%). Breast cancer in left breast of patients was 52.1%. Stage II was higher in left and stage III in right breast. The majority of patients were in stage II & III at the time of diagnosis. All stages were frequent in fourth decades of age group. The association between the clinical stages of breast cancer at the time of diagnosis, the age and breast R/L involvement of the patients was significant (P<0.001). The association between clinical stage and marital status was not significant (P<0.953). Conclusion: Late referrals, diagnosis delay and advanced stages of breast cancer are still a serious problem in Afghanistan. Cancer in right breast should be given more attention because higher stages of the disease are expected. Awareness and social education is great need.

Determination of the Association between Perceived Stigma and Delay in Help-Seeking Behavior of Women with Breast Cancer

Background:One of the leading causes of death in patients with breast cancer is delays in help-seeking, which is influenced by various factors, including social factors such as cancer stigma. Objectives:This study aimed to determine the relationship between perceived stigma and delay in seeking help for women with breast cancer. Methods:In this cross-sectional study, 140 women with breast cancer referred to Besat Clinic in Rasht, Iran, were included. The data gathering tools included a demographic questionnaire, a cancer stigma questionnaire and a delay questionnaire completed through interviews with patients. Data analysis was performed using SPSS software V.21 and the descriptive and inferential statistics were performed using correlation coefficient, chi-square test, logistic regression, Mann-Whitney U-test, and Kruskal-Wallis test. Results:In this study, 72.1% of patients were aged between 39 and 57 years, with a mean age of 47.99±8.03 years; 34.3% and 16.4% of patients delayed seeking help between 30 and 90 days, and more than 90 days (with mean±SD of 75.35±165.19), respectively. Breast cancer stigma was present in 45% of patients. Delay in seeking help based on stigma was significant (P <0.001). Due to multiple logistic regression, the association between stigma and delayed relief was significant (P <0.01), so that in women suffering from breast cancer with stigma, the chance of delaying seeking help was 5.7 times (OR 5/706, Cl 95% 1.381-23.572) higher than women without stigma. Conclusion:Stigma may be a factor in delaying the screening of women with breast cancer. Therefore, it is recommended that the health care team considers stigma as one of the most important psychological aspects of breast cancer, which may have an impact on patients' delay in seeking help. It should also be considered in the process of diagnosis, treatment counseling, and patient follow-up.

[Association between delayed diagnosis and breast cancer in advanced clinical stage at the time of consultation in four oncology centers in Medellin- Colombia, 2017. Cross-sectional study]

OBJECTIVE

To determine the association between delayed diagnosis and advanced clinical stage breast cancer, and to explore the factors that influence this delay.

METHODS

Cross-sectional study of women over 18 years of age with breast cancer who attended 4 oncology centers in Medellín, Colombia, in 2017. The "Breast Cancer Delay Questionnaire" which includes sociodemographic and clinical variables as well as time intervals was used. Crude and adjusted odds ratio (OR) were estimated, using advanced clinical stage as outcome and delayed diagnosis as exposure.

RESULTS

42 patients were included. The median time interval between the identification of the problem and the diagnostic biopsy was 104.5 days; between the identification of the problem and the first medical visit, 20 days; and between the first visit and the diagnostic biopsy, 53 days. Of all the cases, 52.1 % were diagnosed at an advanced stage. An association was found between delayed diagnosis and advanced clinical stage (OR = 2.15 95 % CI 1.21-3.79). Age above 40 was found to be a protective factor against having an advanced-stage lesion (OR = 0.35; 95 % CI: 0.14-0.83). Delayed diagnosis was associated with affiliation to the government subsidized health system (OR = 9.67; 95 % CI 2.76- 33.9) and age over 40 years (OR = 2.75; 95 % CI1.16-6.53).

CONCLUSIONS

Patient education is required in order to ensure adherence to early screening programs or timely consultation whenever a sign or symptom is identified, thus allowing diagnosis at an early stage of the disease. Moreover, prospective studies are needed in order to identify factors associated with delays in treatment after the diagnosis of breast cancer, and to assess interventions designed to reduce delays in the care of this form of cancer.

Time Interval between Self-Detection of Symptoms to Treatment of Breast Cancer

Background:

In India breast cancer is the number one cancer among females with an incidence rate of 25.8 per 100,000 women and mortality of 12.7 per 100,000 women. India continues to have a low 5-year survival rate of breast cancer with only 66.1% as compared to 90% in developed countries. The major reason for low survival is that patients are diagnosed with cancer at high stage. The present study attempts to delineate the time interval between self-detection of breast cancer symptoms and seeking care and to find the main reasons for delay in seeking care.

Methods:

A cross sectional study was undertaken from October 2016 to March 2017 in a population based cancer registry (PBCR) and hospital based cancer registry (HBCR) located in south of India. Histologically confirmed breast cancer patients (N=181) were interviewed at hospital using a pre-tested semi structured questionnaire.

Results:

The median time interval between the self-detection of breast cancer symptoms and first contact with general physician was 60 [IQR 30-180] days. The median time to diagnosis from the first contact was 30 [IQR 10 - 60] days and the overall median time span from self-detection of symptoms to treatment was 150 [IQR 95-265] days. The major reason given for not seeking medical care in time was lack of awareness in identifying the cancer symptoms both among patients and primary care providers.

Conclusion:

There was considerable delay from self-detection of symptoms to cancer specific primary treatment of breast cancer. We found lack of awareness among patients as well as in primary care providers to be the major concern for delay. Awareness among the target population and health care professionals would have to be improved for early diagnostics and access to care.

Health-related quality of life and its socio-economic and cultural predictors among advanced cancer patients: evidence from the APPROACH cross-sectional survey in Hyderabad-India

Background

Patients with advanced cancer often experience poor health-related quality-of-life (HRQoL) due to cancer and treatment-related side-effects. With India’s palliative care landscape in its infancy, there is a concern that advanced cancer patients, especially individuals who are from disadvantaged populations experience poor HRQoL outcomes. We aim to assess HRQoL of advanced cancer patients in terms of general well-being (physical, functional, emotional, and social/family well-being), pain experiences, psychological state, and spiritual well-being, and determine the relationship between belonging to a disadvantaged group and HRQoL outcomes. We hypothesize that patients from disadvantaged or minority backgrounds, identified in this paper as financially distressed, female, lower years of education, lower social/family support, minority religions, and Non-General Castes, would be associated with worse HRQoL outcomes compared to those who are not from a disadvantaged group.

Methods

We administered a cross-sectional survey to 210 advanced cancer patients in a regional cancer center in India. The questionnaire included standardized instruments for general well-being (FACT-G), pain experiences (BPI), psychological state (HADS), spiritual well-being (FACT-SP); socio-economic and demographic characteristics.

Results

Participants reported significantly lower general well-being (mean ± SD) (FACT-G = 62.4 ± 10.0) and spiritual well-being (FACT-SP = 32.7 ± 5.5) compared to a reference population of cancer patients in the U.S. Patients reported mild to moderate pain severity (3.2 ± 1.8) and interference (4.0 ± 1.6), normal anxiety (5.6 ± 3.1) and borderline depressive symptoms (9.7 ± 3.3). Higher financial difficulty scores predicted most of the HRQoL domains (p ≤ 0.01), and being from a minority religion predicted lower physical well-being (p ≤ 0.05) and higher pain severity (p ≤ 0.05). Married women reported lower social/family well-being (p ≤ 0.05). Pain severity and interference were significant predictors of most HRQoL domains.

Conclusions

Advanced cancer patients, especially those with lower financial well-being and belonging to minority religions, reported low physical, functional, emotional, social/family, and spiritual well-being, and borderline depressive symptoms. Future studies should be directed at developing effective interventions supporting vulnerable groups such as those with financial distress, and those belonging to minority religions.

Factors influencing delayed presentation of breast cancer at a tertiary care hospital in Pakistan

BACKGROUND

Breast cancer is the leading cause of death despite the continuous development of newer and more effective modalities of treatment for breast cancer. In Asia, Pakistan has the highest rate of breast cancer. Breast cancer treatment shows better prognosis when it is diagnosed at an early stage, but mortality increases significantly with delayed diagnosis and advanced stage of disease. Delay in diagnosis and nonavailability of treatment are the major factors responsible for advanced stage and low survival.

AIMS

The objective of our study was to identify the factors responsible for delayed presentation of patients with breast carcinoma.

METHODS AND RESULTS

A cross-sectional study using a questionnaire method was conducted at the Foundation University Medical College from January 2015 to December 2016. A total of 89 patients gave consent and were interviewed using a prestructured questionnaire during the study. Age ranged from 25 to 64 years. Majority of patients were in stage T3N1M0 (31.5%). Second most common stage was T4N0M0 (14.6%). Thirteen patients (12.4%) were in stage T3N0M0, and 10 patients (11.2%) were in T3N2M0. Delay ranged from 3 months to more than 1 year; 43.8% presented with delay of 3 to 6 months. The reasons for delay were lack of knowledge about breast cancer (41%), lack of availability of health care services (32.6%), purdah and religious reasons (6.7%), and fear of being diagnosed with cancer (10.1%).

CONCLUSION

The main reasons for delay identified in our study were lack of knowledge and availability of appropriate health care facilities. In order to improve outcome of breast cancer, more focus is needed on spreading awareness and improving health care services in rural areas.

Treatment Experiences of Women with Reproductive Cancers in Odisha, India: A Qualitative Exploration of Enablers and Barriers

Introduction: Cancer continues to be a major menace to our Indian society notwithstanding significant progress in diagnosis and treatment. In India cancer mortality rates in women are high compared to other countries, despite efforts to improve survival through the development of effective detection techniques and increased numbers of viable treatment options. Indian women’s advanced stage of disease at diagnosis is largely attributable to delay in seeking treatment. The present qualitative inquiry was conducted with the aim of capturing the treatment experiences of patients with gynecology cancer at a tertiary care hospital and understanding the barriers, enablers, stress and apprehension they experience during the treatment phases. Methods: Twenty-one in-depth interviews were conducted with women diagnosed with gynecological cancers and undergoing at least one treatment intervention in the Inpatient Department (IPD). Theme guides were developed with a review of the literature and consultation with experts in the field. Data were collected by trained investigators who were well versed with the local language and analyzed using an inductive approach. Results are presented in the form of core- and sub-themes evolved during this process. Results: Out of the 21 respondents, 19 were married and 2 were widows. Nineteen had attained more than secondary qualifications. Nearly all women described themselves as ‘housewives’. Amongst participants, 13 were diagnosed with breast cancer, 5 with ovarian cancer and 3 with cervical cancer. Thematic framework analysis of the transcripts yielded six key themes: 1) best and worst experiences during the treatment process; 2) financial and emotional stress; 3) care giving and social support; 4) satisfaction with the medical staff; 5) preferences for a female gynecologist and female gynecology ward; and 6) prompt and free treatment. Quotable quotes were presented in the table against every theme. Conclusion: Strengths in the Indian health care delivery system need to be built upon, while attention should be paid to developing effective psychosocial interventions, with a robust financial protection plan for patients and their involvement in decision making. Counselling of patients should be made part of a routine protocol.

Identifying the Factors Causing Delayed Presentation of Cancer Patients to a Government Medical College of Central India

BACKGROUND

The incidence of cancer is increasing throughout the world. One of the prime aims of its management is early diagnosis and therapeutic intervention. Factors causing delay to either of these goals should be identified and rectified.

AIM

To identify the factors causing delayed initial diagnosis and subsequent management in patients presenting to the Oncology department.

MATERIALS AND METHODS

Three hundred proven cancer patients were prospectively evaluated for the pattern of presentation to the outpatient Department of Radiation Oncology of a Government Medical College (MC) in Central India.

RESULTS

The mean age of presentation was 51.05 years (range 7 months-77 years). The number of male patients was 168 while females were 132. The duration of symptoms ranged from 20 days to 3 years. The number of patients with little/no education presented mainly in advanced stages as compared to their educated counterpart and this difference was statistically significant (p<0.001). The number of patients presenting directly to the department was 108, those diagnosed outside and referred to us was 84 while those diagnosed and received some form of oncologic treatment outside and referred thereafter was 108. The difference in the primary delay between patients presenting directly to the MC versus those diagnosed outside was significant (p=0.0126). The mean duration of starting definitive treatment after presentation to the outpatient was 4.68 days (range 0-22 days) and was very significantly (p< 0.001) less than the secondary delays caused to the other two subsets of patients.

CONCLUSION

Factors causing delayed presentation are both patient and system related. It is imperative to educate the common people regarding the early signs and symptoms of cancer. At the same time, the system needs to overhaul its efficiency to avoid secondary delays that adversely affect the treatment outcome. An upgradation of the existing oncology facilities in the public sector can achieve this target efficiently.