SUMMARY Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(4):187-191 187 Original Article Reasons for Delayed Presentation of Women with Breast Cancer Fatima Ayaz,1 Saeed Bin Ayaz,2 Muhammad Farrukh3 1,3Internee Surgery, Benazir Bhutto Hospital, Rawalpindi, Punjab, Pakistan 2Assistant Professor Physical Medicine and Rehabilitation, Combined Military Hospital, Institute of Medical Sciences, Quetta, Baluchistan, Pakistan Abstract Objective: The purpose of this study was to determine the reasons for late presentation of women with breast cancer in Rawalpindi and Islamabad. The influence of socio- demographic factors on the major reason for late presentation was also investigated. Subjects and Methods: It was a cross-sectional survey conducted in the surgical departments of different government hospitals of Rawalpindi and Islamabad. Through non-probability consecutive sampling, we included women diagnosed with breast cancer, who, in spite of presence of positive symptoms of breast cancer, delayed seeking medical advice for ≥ 3 months. The data was analyzed using SPSS version 20. Results: Out of 100 women (mean age: 47 years±11.2 SD), majority was married (85%), illiterate (53%), housewife by profession (93%), and belonged to rural areas (69%). The first symptom of breast cancer reported by the majority (81%) was a lump. Most of the subjects (62.3%) reported late because they did not consider the symptoms important due to lack of information about breast cancer. This factor was not significantly related to age, primary area of living, education, marital status, and profession (p=0.274, p=0.415, p=0.304, p=0.654 and p=0.533 respectively). Conclusion: Majority of women with breast cancer in our sample delayed seeking professional health care because they did not consider their first symptom of breast cancer significant. This lack of knowledge and information was not significantly related to age, primary area of living, education, marital status, and profession. Key words: Breast cancer, Delayed presentation, Socio- demographic factors, Women Introduction Breast cancer is the commonest malignancy in females all over the world, and second leading cause of death due to cancer among females. According to GLOBOCAN 2012, 14.1 million new cancer cases were identified in 2012 worldwide, out of which 1.7 million women were diagnosed with breast cancer. Since 2008 estimates, breast cancer incidence has risen by more than 20%, while mortality rate has increased by 14%.1 Pakistan has the highest rate of breast cancer amongst all other Asian countries (excluding Israel) as over 90,000 women develop breast cancer annually.2 The diagnosis of breast cancer in most cases is delayed due to various factors including lack of awareness about the symptoms of breast cancer, hesitancy of females to get themselves examined by male doctors, poverty, and shyness to discuss their problems to spouses or other members of the family. The Pakistani females, especially those belonging to rural areas prefer to go to spiritual healers for therapeutic touch or to traditional herbal medicine practitioners (Hakims), and homeopaths, rather than reporting to allopathic doctors. Ignorance, poverty, illiteracy, lack of resources, disease stigma, use of alternate medicine, and poor access to health care facilities are the key factors for delay in the diagnosis of breast cancer.3 Previously, in Pakistan, different studies have been carried out to find the causes of late presentation of women with breast cancer.3-10 This study was aimed to determine the reasons for delayed presentation in women of twin cities i.e. Rawalpindi and Islamabad, who reported to the government hospitals. The influence of socio-demographic factors on the primary cause of late presentation was also investigated. These results would further supplement the current native data to help devise better measures for earlier detection of breast cancer. Subjects and Methods This descriptive cross-sectional study was carried out in the surgical departments of different government hospitals of Rawalpindi associated with Rawalpindi Medical College namely, Holy Family Hospital, Benazir Bhutto Hospital, and District Headquarters Hospital, Rawalpindi and Nuclear Medicine, Oncology and Radiotherapy Institute (NORI), Islamabad. The delayed presentation was defined as waiting for three or more months to seek help from a physician after Corresponding Author: Dr Saeed Bin Ayaz Email: saeedbinayaz@gmail.com Received: Dec 12,2016 ; Accepted January 19,2017 mailto:saeedbinayaz@gmail.com Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(4):187-191 188 identification of breast signs or symptoms.4,11,12 The permission for the study was obtained from the ethical review committees of Rawalpindi Medical College and Allied Hospitals and NORI, Islamabad. The study was carried out from March to April, 2015. We included all women suffering from breast cancer through non-probability consecutive sampling. These females in spite of presence of a lump or other positive symptoms or signs of breast cancer, delayed seeking any medical advice for at least 3 months. The women, who had breast cancer in stages 1 or 2 (early stage), were excluded.13,14 The study participants, after informed verbal consent, were interviewed using structured questionnaires, and their responses were recorded in written forms. We tried to identify the reasons for delay at two levels, i.e. at the level of the patients himself/herself, and at the level of spouse, family, friends, relatives, or peers. The reasons at both levels were suggested based on review of literature and our cultural traditions. The different reasons at the level of the patients were:1) I did not consider it important due to lack of knowledge and awareness about breast cancer, 2) I was shy of telling someone about my problem, 3) I had serious other family problems due to which I could not give due importance to my symptoms,4) I did not have enough financial resources to bear the expenses of treatment,5) I had a fear of diagnosis of serious ailment, 6) I had a fear that the treatment may cause serious side effects and make my life more difficult, 7) Other reasons. The reasons at the level of family or friends were identified from the suggestions given to the patients by their family members or friends. i.e. 1) Use home remedies for symptomatic relief, 2) Wait for some time as symptoms may disappear, 3) Go to spiritual healers for therapeutic touch, 5) Consult traditional herbal medicine practitioners “Hakims” 6) Consult homeopaths, 7) Consult doctors, 8) Other suggestions. The data also included information about age, primary area of living (rural, urban), educational status (illiterate, grade 1- 5, grade 6-10 and grade > 10), marital status (married, unmarried, divorced, widowed), professional status (house wives, working women), and the first symptom of breast cancer observed (pain, swelling, skin changes, others). The data were analyzed with the help of Statistical Package for Social Sciences V 20 (IBM Corp., Armonk, NY, USA). For all the socio-demographic factors and the responses of queries, frequencies along with percentages were calculated. To evaluate the impact of age, primary area of living, education, marital status, and profession, Pearson chi-square or Fisher’s exact tests were used where necessary. A p-value < 0.05 was considered significant. Results A sample of 168 women was initially recruited. Sixty-eight women were excluded because they had breast cancer in stages 1 or 2. The mean age of the final 100 participants was 47 ±11.2 years (median: 45.5 years) with a range of 25-75 years. Majority of them were married (85%), illiterate Table-1: Demographic properties of women with breast cancer who delayed presentation to a health care physician Variables No % Age groups ≤ 45 years > 45 years 50 50 50 50 Primary area of living Rural Urban 69 31 69 31 Marital status Married Unmarried Divorced Widowed 85 12 2 1 85 12 2 1 Reasons why patients did not inform anyone about first symptom (N=69) Did not consider it important due to lack of knowledge and information Shyness Other serious family problems were more important Fear of side effects of treatment Fear of diagnosis of serious ailment Inadequate financial resources Others Missing 43 9 6 6 2 1 2 31 62.3 13 8.7 8.7 2.9 1.4 2.9 Educational status Illiterate Grade 1- 5 Grade 6-10 Grade > 10 53 21 14 12 53 21 14 12 Professional status House wives Working women 93 7 93 7 The first symptom of breast cancer observed Pain Lump Skin changes Others 12 81 6 1 12 81 6 1 Suggestions given by spouses, family or friends Wait for some time for disappearance of symptoms Try home remedies for symptomatic relief Go to spiritual healers Consult traditional herbal medicine practitioner “Hakeem” Consult homeopaths Consult doctors Others Missing 2 1 17 1 4 65 1 9 2.2 1.1 18.7 1.1 4.4 71.4 1.1 Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(4):187-191 189 (53%), house wife by profession (93%), and belonged to the rural areas (69%). (Table 1) The first symptom of breast cancer reported by the majority was “a lump” (81%) followed by “pain” (12%). Table-2: Association of demographic factors with the different reasons for delay in presentation of women with breast cancer (n=69) Variables Did not consider it important due to lack of knowledge and information Other reasons ?? Total P-value Age groups ≤ 45 years > 45 years 17 26 13 13 30 39 0.274 Marital status Married Single (Unmarried, divorced or widowed) 38 5 23 3 61 8 0.654 Professional status House wives Working women 39 4 23 3 62 7 0.533 Primary area of living Rural Urban 29 14 19 7 48 21 0.415 Educational status Low education (Illiterate and grade 1- 5) Better education (Grade 6-10 and grade > 10) 31 12 21 5 52 17 0.304 Only 69 patients answered the question asked for the reasons for delayed presentation at the patients’ level. The bulk (62.3%) reported late because they did not consider it important due to lack of knowledge and information about breast cancer. This lack of knowledge and information was not significantly related to the age-group, primary area of living, education, marital status, and profession. (p=0.274, p=0.415, p=0.304, p=0.654 and p=0.533 respectively) (Table 2) While exploring response of family members and friends towards the complaints of patients, 91 interviewees answered the question and we found a positive attitude from them as most of them i.e. 71.4% suggested to consult doctors. (Table 1) Discussion Breast cancer, when compared to the Western population, is more common in Pakistan.5 One in every nine Pakistani women suffers from breast cancer which is one of the highest prevalence rates in Asia.6 The mean age of the patients in our study was found to be 47±11.2 years with a range of 25-75 years. This is parallel to the studies carried out in Pakistani women at Karachi and Nawabshah (mean age: 47.5±12.1 years with a range of 25- 77 years and mean age: 43.5±10.4 years with a range of 28- 80 years). Thus, our sample was a true representative of Pakistani women with breast cancer.7,8 Our study showed that majority of the women, who delayed their report of first symptoms of breast cancer, did so because they were unaware of the grave nature of those symptoms. These results are similar to other regional studies. Memon et al. reported that majority of women delayed their consultation with doctors because they considered their symptoms harmless and momentary, and because the symptoms did not affect their routine life activities.7 Malik et al. also reported lack of awareness as the key factor for delay in seeking medical attention in women with breast cancer.15 In other countries e.g. Nigeria, Germany, USA, Colombia, and Iran many studies have indicated that majority of the women with breast cancer delayed pursuing professional health care because they lacked knowledge about breast cancer or considered their symptoms harmless.16-20 Why women have a tendency to consider their symptoms of breast cancer harmless? The answers are suggested by Memon et al. and Lodhi et al.7,9 They indicated that women, especially in Pakistan, generally are considerate more towards their children, husband or other family members, and hold an overall care-free and casual approach towards their own health. They linger on with their problems unless the problems become unendurable. The second common reason for women to delay seeking medical attention was shyness of medical examination especially by male doctors. A study by Gilani et al. from the city of Rawalpindi identified that 13.1% of the study subjects showed shyness or unavailability of female doctor as the reason for delayed seeking of an appropriate medical advice.10 Another Pakistani study by Khan et al. found that 10.6% (n=13) of the studied sample from Northern Pakistan who presented late, felt shy to let their breast examined by male doctors.4 An Indian Study by Akhtar et al. found shyness as a cause of delay in 22% of the patients with locally advanced breast carcinoma.21 Altwalbeh et al. found shyness as a motive for delay in 44.6 % of the study sample in Saudi women.11 Shyness was identified as a significant cause of delay in presentation of breast cancer in many other studies.22-24 The influence of age, primary area of living, education, marital status, and profession on the different causes of delay was also evaluated, but, we could not find any significant correlation. Bhosai et al., in a Thai study, abstracted that patient’s socio-demographic factors were not significantly associated with delay in care-seeking of patients with cancer (p>0.05).25Another study by Ramirez et Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(4):187-191 190 al. suggested no significant association (p>0.05) between marital status and patient delays.13 On the contrary, many studies have concluded different results. Khan and colleagues discovered that advanced age, low education and low socioeconomic status were significantly associated with a delay in presentation for women with breast cancer (p<0.05 and OR of 2.26, 2.29 with 95% CI: 1.25-4.10 and 1.06-4.94 respectively).4 Memon et al. also found that marital status and decreased level of education (p<0.001 and p=0.002 respectively) was associated with more prolonged delays.7 Harirchi et al. suggested that delay among Iranian women with breast cancer was associated with older age, being married, lower income, less education, and residence in small cities.26 Other studies have identified higher age groups, negative family history, low education, and low socioeconomic status as demographic factors associated with delayed presentation.27- 38 The findings of this study, and review of related literature endorses the view that women in Pakistan have an alarmingly poor knowledge about breast cancer. Resultantly, they fail to report to the appropriate health professional in the desired time. Thus, they need to be educated about the earliest symptoms of breast cancer so that timely evaluation and intervention be commenced, and mortality related to breast cancer can be reduced. Public health department need to do an enormous job to create awareness among the masses by the help of press and media in this regard. Conclusion Majority of women with breast cancer in our study delayed seeking professional health care because they did not consider their first symptom of breast cancer significant. This lack of knowledge and information was not significantly related to age, primary area of living, education, marital status, and profession. Conflict of Interest This study has no conflict of interest as declared by authors References 1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer.2013. Available from: http://globocan.iarc.fr. 2. Liede A, Malik IA, Aziz Z, Rios Pd Pde L, Kwan E, Narod SA. Contribution of BRCA1 and BRCA2 mutations to breast and ovarian cancer in Pakistan. Am J Hum Genet. 2002;60(9):721-5. 3. Iqbal J, Bano K, Saeed A, Akram M, Aziz Z. Survival of women with locally advanced breast cancer at a teaching hospital in Lahore. J Pak Med Assoc. 2010;60(9):721-5. 4. Khan MA, Hanif S, Iqbal S, Shahzad MF, Shafique S, Khan MT. Presentation delay in breast cancer patients and its association with sociodemographic factors in North Pakistan. Chin J Cancer Res. 2015;27(3):288-93. 5. Mahmood S, Rana TF, Ahmad M. Common determinants of Ca breast - a case control study in Lahore. Ann King Edward Med Uni. 2006;12(2):227-8. 6. Sohail S, Alam SN. Breast cancer in Pakistan - awareness and early detection. J Coll Physicians Surg Pak. 2007;17(12):711-2. 7. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for patient's delay in diagnosis of breast carcinoma in Pakistan. Asian Pac J Cancer Prev. 2013;14(12):7409-14. 8. Talpur AA, Surahio AR, Ansari A, Ghumro AA. Late presentation of breast cancer: a dilemma. J Pak Med Assoc. 2011;61(7):662-6. 9. Lodhi FB, Ahmad B, Shah SIH, Naeem M, Dab RH, Ali N, et al. Determinants of delayed presentation in breast cancer. APMC. 2010;4(2), 9-16. 10. Gilani SI, Khurram M, Mazhar T, Mir ST, Ali S, Tariq S, Malik AZ. Knowledge, attitude and practice of a Pakistani female cohort towards breast cancer. J Pak Med Assoc. 2010;60(3):205-8. 11. Elobaid Y, Aw T-C, Lim JN, Hamid S, Grivna M. Breast cancer presentation delays among Arab and national women in the UAE: a qualitative study. SSM-Population Health. 2016;2:155-63. 12. Altwalbeh D, El Dahshan ME, Yaseen R. Factors influencing delayed presentation of breast cancer among Saudi women. Int J Sci Res. 2015; 4(1):967-74. 13. Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Littlejohns P, Richards MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet. 1999;353(9159):1127-31. 14. Stapleton JM, Mullan PB, Dey S, Hablas A, Gaafar R, Seifeldin IA, et al. Patient‐mediated factors predicting early‐and late‐stage presentation of breast cancer in Egypt. Psychooncology. 2011;20(5):532-7. 15. Malik IA, Gopalan S. Use of CAM results in delay in seeking medical advice for breast cancer. Eur J Epidemiol. 2003;18(8):817-22. 16. Ukwenya AY, Yusufu LM, Nmadu PT, Garba ES, Ahmed A. Delayed treatment of symptomatic breast cancer: the experience from Kaduna, Nigeria. S Afr J Surg. 2008;46(4):106-10. 17. Arndt V, Stürmer T, Stegmaier C, Ziegler H, Becker A, Brenner H. Provider delay among patients with breast cancer in Germany: a population-based study. J Clin Oncol. 2003;21(8):1440-6. 18. Gullatte MM, Phillips JM, Gibson LM. Factors associated with delays in screening of self-detected breast changes in African-American women. J Natl Black Nurses Assoc. 2006;17(1):45-50. 19. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex. 2009;51(5):372-80. 20. Rastad H, Khanjani N, Khandani BK. Causes of delay in seeking treatment in patients with breast cancer in Iran: a qualitative content analysis study. Asian Pac J Cancer Prev. 2012;13(9):4511-5. 15. 21. Akhtar M, Akulwar V, Gandhi D, Chandak K. Is locally advanced breast cancer a neglected disease? Indian J Cancer. 2011;48(4):403-5. 22. Salih AM, Alfaki MM, Alam-Elhuda DM, Nouradyem MM. Factors delaying Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(4):187-191 191 presentation of Sudanese breast cancer patients: an analysis using andersen's aodel. Asian Pac J Cancer Prev. 2016;17(4):2105-10. 23. Gold MA. Causes of patients' delay in diseases of the breast cancer. 1964;17:564-77. 24. Facione NC, Giancarlo CA. Narratives of breast symptom discovery and cancer diagnosis: psychologic risk for advanced cancer at diagnosis. Cancer Nurs. 1998;21(6):430-40. 25. Bhosai SJ, Sinthusake T, Miwa S, Bradley E. Factors affecting patient access in Thailand: understanding delay in care seeking for patients with cancer. Glob Public Health. 2011;6(4):385-97. 26. Harirchi I, Ghaemmaghami F, Karbakhsh M, Moghimi R, Mazaherie H. Patient delay in women presenting with advanced breast cancer: an Iranian study. Public Health. 2005;119(10):885-91. 27. Brzozowska A, Duma D, Mazurkiewicz T, Brzozowski W, Mazurkiewicz M. Reasons for delay in treatment of breast cancer detected due to breast self-examination in women from the Lubelskie region. Ginekol Pol. 2014;85(1):14-7. 28. Jones CE, Maben J, Jack RH, Davies EA, Forbes LJL, Lucas G, et al. A systematic review of barriers to early presentation and diagnosis with breast cancer among black women. BMJ Open. 2014;4:e004076. 29. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer. BMC Res Notes. 2012;5:452. 30. Norsa'adah B, Rampal KG, Rahmah MA, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer. 2011;11:141. 31. Ali R, Mathew A, Rajan B. Effects of socio-economic and demographic factors in delayed reporting and late-stage presentation among patients with breast cancer in a major cancer hospital in South India. Asian Pac J Cancer Prev. 2008;9(4):703-7. 32. Poum A, Promthet S, Duffy SW, Parkin DM. Factors associated with delayed diagnosis of breast cancer in northeast Thailand. J Epidemiol. 2014(2);24: 102-8. 33. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, et al. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health. 2013;13:947. 34. Gullatte MM, Brawley O, Kinney A, Powe B, Mooney K. Religiosity, spirituality and cancer fatalism beliefs on delay in breast cancer diagnosis in African American women. J Relig Health. 2010;49(1):62-72. 35. O'Mahony M, McCarthy G, Corcoran P, Hegarty J. Shedding light on women's help seeking behaviour for self-discovered breast symptoms. Eur J Oncol Nurs. 2013;17(5):632-9. 36. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding barriers to Malaysian women with breast cancer seeking help. Asian Pac J Cancer Prev. 2012;13(8):3723-30.32. 37. Li YWW, Lam WWT, Wong JHF, Chiu A, Chan M, Or A, et al. Waiting to see the doctor: understanding appraisal and utilization components of consultation delay for new breast symptoms in Chinese women. Psycho-Oncology. 2012;21(12):1316-23. 38. O'Mahony M, Hegarty J, McCarthy G. Women's help seeking behavior for self-discovered breast cancer symptoms. Eur J Oncol Nurs. 2011;15(5):410-8. Authorship Contribution: Author 1: Conception, Synthesis and Planning of the research, Active participation in active methodology Author 2: Interpretation, analysis and discussion Author 3 Active participation in active methodology,