Elsevier

Clinical Oncology

Volume 34, Issue 9, September 2022, Pages 598-607
Clinical Oncology

Original Article
Presentation, Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country

https://doi.org/10.1016/j.clon.2022.05.007Get rights and content

Highlights

  • Most breast cancer patients in Sri Lanka detect breast lesions by themselves.

  • Delays in breast cancer care in Sri Lanka are much less than in other lower-middle income countries.

  • However, there is significant room for improvement in the quality of care.

  • Periodical delay estimations are encouraged to direct improvements in care.

Abstract

Aims

Delays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation.

Materials and methods

We interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance.

Results

Nearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9–66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4–40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8–15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2–9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8–3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1–2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6–11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2–0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3–0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7–32.7) reduced the likelihood of treatment delays.

Conclusions

Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.

Introduction

One of the important factors affecting breast cancer survival is timely diagnosis and initiation of treatment [[1], [2], [3], [4]]. Despite having higher incidence rates, developed countries have been able to lower the mortality rates in breast cancer by ensuring early detection and timely care [4,5]. On the other hand, low-resourced countries report much higher breast cancer-specific mortality rates, although the incidence is not as high as in developed countries [6]. According to the world's largest study on disease burden, the global burden of disease study, during the period of 1990–2017, South Asia reported the highest total number of breast cancer deaths with an increasing trend, while age-specific death rates declined over this time period in high income regions such as North America, Western Europe and Australasia [7]. Despite this greater burden, there is limited evidence on delays along the breast cancer diagnostic and therapeutic pathway in lower–middle income countries [8].

Studies report that 30–80% of breast cancer patients in low-resourced countries present with metastatic or locally advanced disease [9]. In Sri Lanka, a large retrospective study of over 2000 patients showed that almost half of all cases (47%) were diagnosed at stage III or IV [10].

Poor care-seeking behaviour, restricted access and resource limitations have been identified as challenges in the early diagnosis and treatment of breast cancer in low-resourced countries and most of these factors are modifiable and their identification will pave the way for more effective early detection strategies [2,9,[11], [12], [13], [14], [15], [16]].

Delays in breast cancer care are commonly defined using cut-off times to dichotomise intervals between important care points along the care pathway. The care pathway for breast cancer typically starts at the point where a suspicious breast lesion is detected, either by the woman herself or by a healthcare provider, and ends at the point of treatment completion. However, the time spent in between these two points varies widely depending on many factors, such as the health system structure, awareness, knowledge and beliefs of the public about the disease itself. We have previously published our work on the breast cancer care pathways in Sri Lanka [17]. Here we report delays in presentation, diagnosis and treatment along the care pathway while identifying factors associated with them.

Section snippets

Study Design, Population and Sample Size

We carried out a cross-sectional study to determine the magnitude of different types of delay in Sri Lanka. Female patients with pathologically confirmed breast cancer, diagnosed within the past 12 months and who have received their definitive primary treatment for breast cancer were considered as our eligible study population. We excluded male patients due to their limited numbers as well as the difference in tumour behaviour and care-seeking patterns. To minimise recall bias, we included

Results

We interviewed 865 patients to achieve the calculated sample size of 800, with a response rate of 92.5%. The mean age (standard deviation) of the study sample at confirmation of the breast cancer was 55.5 years (±10.7) and the range was 28–79 years. Nearly two-thirds of patients were from the rural sector (n = 610; 76.3%) and many participants (n = 721; 90.2%) did not possess any health insurance at the time of symptom detection (Table 2).

Table 3 displays some of the breast cancer-related

Discussion

Among other cancers, breast cancer provides a unique opportunity for detection at early stages through screening. Disease-free survival for those treated at early stages is recorded to be about 90% [29]. Despite this fortuity, breast cancer remains a leading cause of death among women in developing countries, including Sri Lanka. The higher breast cancer mortality rates in lower–middle income countries, despite their low incidence rates compared with high income countries, is attributed to late

Conclusions

Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those from other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Although the delays are lower, our study confirms that socioeconomically disadvantaged women are at a higher risk of experiencing presentation delays, which indicate the importance of focusing

Conflicts of Interest

S.A. Hewage reports a relationship with National Cancer Control Program, Sri Lanka that includes: employment. S. Samaraweera reports a relationship with National Cancer Control Program, Sri Lanka that includes: employment.

Funding

This work was supported by the National Cancer Control Program, Sri Lanka [project grant numbers 111-02-14-21-2509 (11), 2018].

Author Contributions

S. Hewage was responsible for conceptualisation, methodology, validation, formal analysis, investigation, resources, data curation, writing - original draft, project administration, funding acquisition. S. Samaraweera was responsible for methodology, validation, resources, writing - review and editing, supervision, funding acquisition. N. Joseph was responsible for methodology, validation, resources, writing - review and editing. S. Kularatna was responsible for methodology, validation, writing

Acknowledgements

We would like to acknowledge the independent reviewers who provided their insightful comments in improving this paper. We also acknowledge Professor R. Wickramasinghe for his technical inputs to improve the quality of the study and Dr N. Seneviratne at the National Cancer Control Programme for her support in providing resources during the study implementation. Doctors M. Herath, K.M. Sanchana, N. Herath, R. Cader, K. Ovitigala, J. Atapattu and M. Kumari are acknowledged for their involvement in

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