Who and what influences delayed presentation in breast cancer?

Abstract

Summary This study aimed to examine the extent and determinants of patient and general practitioner delay in the presentation of breast cancer. One hundred and eighty-five cancer patients attending a breast unit were interviewed 2 months after diagnosis. The main outcome measures were patient delay in presentation to the general practitioner and non-referral by the general practitioner to hospital after the patient's first visit. Nineteen per cent of patients delayed 2 12 weeks. Patient delay was related to clinical tumour size > 4 cm (P = 0.0002) and with a higher incidence of locally advanced and metastatic disease (P = 0.01). A number of factors predicted patient delay: initial breast symptom(s) that did not include a lump (OR 4.5, P= 0.003), not disclosing discovery of the breast symptom immediately to someone else (OR 6.0, P < 0.001), seeking help only after being prompted by others (OR 4.4, P = 0.007) and presenting to the general practitioner with a nonbreast problem (OR 3.5, P = 0.03). Eighty-three per cent of patients were referred to hospital directly after their first general practitioner visit. Presenting to the GP with a breast symptom that did not include a lump independently predicted general practitioner delay (OR 3.6, P = 0.002). In view of the increasing evidence that delay adversely affects survival, a large multicentre study is now warranted to confirm these findings that may have implications for public and medical education.Keywords: patient delay; GP delay; breast cancer; psychological response; type of symptom For women who present with symptomatic breast cancer there is, by definition, an interval between first detection of symptoms (either by the woman herself or by another) and the time of diagnosis and treatment. Prolonged delays, usually defined arbitrarily as intervals greater than 12 weeks, occurring during this period have been shown to be associated with increased tumour size (Fisher et al, 1977;Pilipshen et al, 1984; GIVIO, 1986;Neave et al, 1990;Rossi et al, 1990) and more advanced stage of disease (Elwood and Moorehead, 1980;Gould-Martin et al, 1982;Robinson et al, 1984; GIVIO, 1986;Machiavelli et al, 1989;Rossi et al, 1990) and with poor long-term survival (Neave et al, 1990;Afzelius et al, 1994).Given this relationship between delay, stage and survival, it is important to assess in detail the different phases of delay between first detection of a symptom and treatment being commenced. For each of these phases, factors need to be identified that are associated with prolonged delays, so that effective strategies can be planned to reduce the overall interval between first symptom and treatment.The phases of delay can be considered as follows:1. Patient delay. The interval between first detection of a symptom and first presentation to a health professional, usually a general practitioner (GP). 2. GP delay. The interval between first presentation to a GP and onward referral to a hospital. This study examines patient and GP delay in a prospective cohort of women presenting to the ...

Patient delay and stage of diagnosis among breast cancer patients in Germany – a population based study

“…This is in agreement with findings from pertinent studies published during the last decade (Coates et al, 1992;Afzelius et al, 1994;Burgess et al, 1998) and is further evidence of a favourable trend towards shorter delay during the last two decades when compared with earlier studies (Cameron and Hinton, 1968;Dennis et al, 1975;Fisher et al, 1977;Elwood and Moorehead, 1980;MacArthur and Smith, 1981;Dohrmann et al, 1982;Vernon et al, 1985;Neale et al, 1986). This trend might be attributable to an increasing health awareness among women due to extensive information campaigns which address breast cancer warning signs in many developed countries.…”

“…Although women who undergo breast cancer screening tend to be more health conscious, they might feel less worried about some vague alterations of the breast if the last mammography or clinical examination had been normal. Other studies show no clear evidence of an association between lack of breast self examination and patient delay (Huguley et al, 1988;Coates et al, 1992;Burgess et al, 1998).…”

Psychosocial and cultural reasons for delay in seeking help and nonadherence to treatment in Indonesian women with breast cancer: A qualitative study.

“…To determine the delay in seeking help and uptake of treatment we adopted a 3-month interval as our gold standard, because there is strong evidence that a delay in presentation of symptomatic breast cancer of 3 months or more is associated with lower survival (Burgess, Ramirez, Richards, & Love, 1998;Richards, Westcombe, Love, Littlejohns, & Ramirez, 1999). We defined delay in seeking help if the period from the first breast symptom to the first medical consultation was Ͼ 3 months; and delay in uptake of treatment if the period between the first diagnosis and the first admission at HSH was Ͼ 3 months.…”

Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer

“…patient-mediated delay, which is the period from first onset of symptoms to first medical consultation; and provider delay (Facione, 1993;MacLeod et al, 2009), the period from first consultation to definite diagnosis or treatment and practitioner or hospital delay, or the interval between referral and initiation of treatment (Burgess et al, 1998). Presentation of breast cancer at late stages may be due to the patient delaying seeking medical attention for self-detected symptoms.…”

“…Presentation of breast cancer at late stages may be due to the patient delaying seeking medical attention for self-detected symptoms. The length of symptom duration commonly used to indicate this delay is more than 3 months (Burgess et al, 1998;Montazeri et al, 2003;Friedman et al, 2006). This categorisation is based on the evidence that patients who delay presentation for 3 months or more have lower 5-year survival rates than those with less delay (Richards et al, 1999).…”