Journal of Community Medicine & Health Education
Open Access

Breast cancer; Cervix cancer; Delayed diagnosis; Demographic profile; Risk factors; Quality of life

According to the estimates from World Health Organisation (WHO), cancer was the second leading cause of death worldwide and the overall burden has been increasing rapidly in past decades, especially in developing countries. The estimate of the global burden of cancer based on GLOBOCAN 2020 showed approximately 19 million new cases and 10 million deaths were due to cancer. For both sexes combined, one half of all cases and 58.3% of cancer deaths were estimated to occur in Asia in 2020 followed by Europe accounting for 22.8% of the global burden and 19.6% of deaths due to cancer.

Among the top 10 cancers, female breast cancer was the most commonly diagnosed cancer (11.7% of total cases), closely followed by lung (11.4%), colorectal (10.0%), prostate (7.3%), and stomach (5.6%) cancers. Lung cancer was the leading cause of cancer death (18.0% of the total cancer deaths), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and female breast (6.9%) cancers. The most commonly diagnosed cancer in women was dominated by 2 cancer sites: Breast cancer (159 countries) and cervical cancer (23 of 26 remaining countries). The mortality profile in women was more heterogeneous, with breast and cervical cancer as the leading causes of cancer death in 110 and 36 countries, respectively, followed by lung cancer in 25 countries [1].

Globally, India ranked third in reporting cases of cancer, with approximately 1 million cases and half a million deaths every year. Of overall cancer cases, 70% of patients were women and the most common forms found in India were breast, cervical and oral cancer [2]. Epidemiological studies showed that 70%-90% of all cancers were environmental and lifestyle related factors were the most important causative factor behind them, which was preventable [3]. With regard to Tamil Nadu, the projected annual incidence of all cancer cases was 78,641 (2020) of which 56% are females and the cumulative risk of getting cancer at any site in their lifetime was 1 in 11 females [4].

Among common cancers affecting women, cancer of the breast and cervix were the most common. The highest burden of breast cancer was observed in metropolitan cities than in rural and suburban areas. Over the past few years, there had been a steady increase in the trend of incidence of breast cancer, whereas cervix cancer was on the decline [5]. This decline was attributed to either improvement in general lifestyle among women or a miscalculation.

Aside from the risk of cancer, various studies have reported the impact of the stage of diagnosis of cancer on the treatment prognosis and survival rates of patients as the survival rate was found to reduce with increasing stage of disease diagnosis. Also, involvement of either node/site had poorer survival rates for patients than those with no involvement. Thus the stage of diagnosis is highly essential to determine a better survival rate and this depends on the timely appraisal of the clinical picture of cancer by both patient and healthcare provider.

This study thus aimed to assess and understand the sociodemographic profile of women with delayed diagnosis of breast and cervix cancer in Tamil Nadu. The study also aimed to determine the potential risk factors for cancer diagnosis among patients.

Objectives

• To assess and understand the socio-demographic profile of women with delayed diagnosis of breast and cervix cancer.
• To determine the potential risk factors for cancer diagnosis among patients.

A cross-sectional study was conducted among 60 women with delayed diagnosis of breast and cervix cancer reporting at oncology OPD in two major tertiary oncology care centres in Chennai. The convenient sampling method was used where patients (both breast and cervix) who attended oncology OPD during our 2 months study period (October-November 2021) were screened for the delay in diagnosis based on the time taken between noticing their first symptom and a healthcare provider confirming the diagnosis and any time duration beyond 3 months was considered as delay (based on strong literature evidence). Based on these criteria, patients were enrolled consecutively in uniform numbers with any stage of the disease stage I (15), stage II – III (25) and stage IV (20). .

The socio-demographic profile, cancer diagnosis and treatment care of patients included in the study were collected using a standardised questionnaire. The data on sociodemographic information, clinical details, medical history, family history, menstrual history, sexual history, habits and disease related characteristics collected from patients were cross verified with their case sheets.

Quantitative data were double entered and validated using Epi data version 3.1 and analyzed using SPSS analysis (IBM SPSS statistics 17). Socio demographic, health seeking behaviour, knowledge and awareness about cancer and patients’ clinical presentation were summarized using average mean, median and cross tabulation.

Ethics approval was obtained from the institutional ethics committee of all institutions where the study was conducted. Written informed consent was obtained from the participants before the commencement of the study.

Socio-demographic profile of patients

The study included patients (n=60) with delayed diagnosis of breast and cervix cancer where more patients with both breast and cervix cancer were in the age group of 51-60 years and the mean age (SD) was 51.4 (± 10.43) and 55 (± 8.68) respectively. The patients overall ranged from 28 to 72 years in both sites (Table 1).

Table 1: Socio-demographic information of participants.

Patients (both breast and cervix cancer) were mostly residing in the Northern part of Tamil Nadu and when considering the rural and urban backdrop, both breast and cervix cancer patients (60%) were mostly from rural parts of the state. Regarding educational qualifications, most patients had either not attended school or attended till primary school. The occupation status of patients and their spouses when analyzed, showed that most patients were either homemakers (57%) or daily wage workers (43%) and their spouse’s occupation was also daily wage labourers. Their monthly income was mostly between Rs. 5,000 to 15,000/- (53%).

The stage of diagnosis of patients when cross tabulated with their educational qualification, showed that most breast cancer patients who were diagnosed with stage IV of cancer were found to have attended primary school and above. Among cervix cancer patients, those who were diagnosed with stage IV of cancer had either not attended school or attended till middle school. Also, those who were daily wage workers (both breast and cervix cancers) were more commonly diagnosed with stage IV of the disease (Table 2).

The occupation of the spouse of patients was also cross tabulated with the stage of diagnosis of patients as they were the ones (in majority of cases) to accompany the patient to hospital visits. Husbands who were mostly daily wage workers were identified as the potential factor for the delay as more patients with husbands as daily wage workers were diagnosed at their stage IV of illness and the duration of delay also showed 4 to 9 months, on average.

Table 2: Education, occupation and stage of diagnosis of cancer.

With regard to their medical history, 67% of patients (both breast and cervix cancer) had no history of any underlying medical illness, and those who had, showed diabetes mellitus and hypertension to be the commonest comorbidity among 5 (out of 11) breast cancer patients and 6 (out of 9) cervix cancer patients. Their family history of cancer was also enquired, which showed that 83% of patients had no known family history of cancer. Concerning their marital status, most patients (70%) were married and with regard to consanguinity, cervix cancer patients (44%) had more consanguineous marriages than patients with breast cancer.

The body mass index of patients showed that most of both (breast and cervix) cancer patients had a normal BMI range and in correlation with their stage of disease, showed that more patients with stage IV illness had both severe thinness and normal BMI, indicating the importance of nutritious food in maintaining their physical health.

Their age of menarche on average showed patients (both breast and cervix) attained menarche between 13 to 16 years of age (73%) and very few had attained it after 17 years of age. The average number of children bore by 60% of cervix cancer patients with the delayed diagnosis was 3-5, while breast cancer had 2 or less than 2 children. No cervix cancer affected women were childless, while 4 women affected with breast cancer were childless (Table 3).

Table 3: Child and menstrual history.

The average breastfeeding duration of participants, when assessed revealed that 55% of patients had given breastfeeding for 12 to 18 months for all their children. The breastfeeding practice of patients with breast cancer when assessed showed that those who had 2 children or less (54%) had fed for an average duration of 15 to 18 months and those who had more than 3 children had fed for an average duration of 12 to 16 months.

The use of contraceptive barriers when assessed showed that most patients had no habit of contraceptive usage, be it pill or barrier and those who had used (13%) were higher among breast cancer affected women.

Delay in cancer diagnosis and care

Breast and cervix cancer patients who had their disease diagnosed beyond 3 months after noticing their first symptom, were questioned regarding their age at diagnosis, signs and symptoms they experienced before diagnosis, where, when and how did they get themselves diagnosed, the average time duration between noticing their first symptom and approaching a health care provider and factors and reasons behind their delayed diagnosis.

The commonest age of patients during diagnosis of breast cancer was reported to be 49 (± 9.98) and for cervix cancer patients was reported to be 54 (± 8.81) (Table 4). The first symptom noticed before the diagnosis of cancer was a lump in the breast (88%) followed by pain for breast cancer patients and bleeding per vaginum (60%) followed by lower abdominal pain and leucorrhoea for cervix cancer patients.

Table 4: Delay in cancer diagnosis and care.

Factors for delay

The delay was categorized as factors that caused the delay, the average time duration of delay and reasons behind the delay in diagnosis, and our study reported patient to be the most common factor for the delay. 32 (out of 35) breast cancer patients and 23 (out of 25) cervix cancer patients reported themselves (patient) to be the factor behind the delay and 5 patients (breast and cervix both included) reported healthcare to be the factor for their delay. Though both patient (presentation) and healthcare (treatment) delays were reported in the study, presentation delay was more predominant in all cases.

Time duration of the delay

The average time duration of overall delay was calculated from the time interval between the date of noticing their first symptom, the date of approaching the first healthcare provider, and the date when their diagnosis was confirmed. The average time duration of delay was categorized into three-time intervals between 3.1 to 6 months, 6.1 to 9 months and above 9 months and the median duration of delay among both breast and cervix cancer patients was 6 months. 54% (19) of breast cancer patients had an average time delay between 3.1 to 6 months and their overall median (Interquartile Range, IQR) duration was 180 (68-263) days. Among the cervix cancer patients, 52% (13) had an average time delay of more than 9 months since noticing their first symptom and their median (IQR) duration of delay was 150 (30-360) days. When cross tabulated with their stage of diagnosis, more breast cancer patients who were in late stages (stage III and IV) during diagnosis, were diagnosed between 3 to 6 months of noticing their first symptom, while most cervix cancer patients were found to be diagnosed after 9 months of noticing their first symptom.

In our study, we also attempted to find out the significant time interval that increases the risk of advancing the stage of disease by assessing the average duration taken by our patients between noticing the first symptom and diagnosis of cancer. The average time interval that can be considered as a delay in diagnosis and increased the risk of advancing stage of disease showed different time duration for breast and cervix cancer.

For breast cancer diagnosis, a time interval of more than 2 months or (95% CI): 5.58 (1.07-29.19); p<0.05) after noticing the first symptom increased the risk of late stage of diagnosis while for cervix cancer diagnosis, a time interval of more than 5 months or (95% CI): 3.91 (1.02-14.87); p<0.05) after noticing the first symptom increased the risk of advancing stage of the disease.

Reasons for the delay

Both breast and cervix cancer patients who reported delays in their diagnosis of cancer stated their poor awareness about the disease and its signs and symptoms (76%) were the main reasons behind their delay. However, those patients who had reported healthcare to be the causative factor for their delay stated misdiagnosis and delayed investigations reports to be the predominant reasons for their diagnostic delay.

Potential risk factors for cancer diagnosis

Logistic regression was performed to ascertain the impact of various socio-demographic and behavioural factors of patients on the likelihood that they are the potential factors that would increase the risk of breast and cervix cancer and in delaying their diagnosis. The patients who had an average time interval of more than 6 months (based on median duration) in both cases were only considered.

The key factors considered for breast cancer patients were age, education, monthly income, marital status, family history of cancer and average breastfeeding duration. However, the factors which showed higher significance in Hosmer and Lemeshow test (p=0.761) were only taken up for analysis and displayed in Table 5.

Table 5: Potential risk factors for delay in seeking care, diagnosis and treatment among breast cancer patients.

The logistic regression model was statistically significant, χ² (6)=13.748, p<0.05. The model showed 33% (Nagelkerke R²) variance in the time duration of the delay and correctly classified 77% of cases. The increasing age of patients (OR: 1.36) was found to be associated with an increasing duration of delay in cancer diagnosis followed by the monthly income of patients (OR: 1.2).

Similarly, among cervix cancer patients, the key factors considered were age, education, monthly income, marital status, residing area (rural or urban), the average number of children they had and their family history of cancer. However, the factors which showed higher significance in Hosmer and Leme show test (p=0.41) were only taken up for analysis and displayed in Table 6.

Table 6: Potential risk factors for delay in seeking care, diagnosis and treatment among cervix cancer patients.

The logistic regression model was not statistically significant, χ² (8)=13.31, p=0.1. The model showed 37% (Nagelkerke R²) variance in the time duration of the delay and correctly classified 63% of cases. More number of children bore by a woman (OR: 3.5) was found to be associated with an increasing duration of delay in cancer diagnosis followed by family history of cancer (OR: 3.11) and their increasing age.

The socio-demographic and behavioural characteristics of patients (breast and cervix cancer) showed that most patients belong to the age group of 51 to 60 years with a mean age of 51 and 55 years for breast and cervix cancer respectively. As per various literature evidence, it is strongly reported that women above 50 years of age are highly vulnerable to acquiring breast and cervix cancer and our study reports show strong agreement with them. The educational qualification of participants in our study was reported to be at a low level with more numbers either not attended school or attended till middle school. This is similar to various study reports suggesting that lower educational qualification is a high risk for delayed diagnosis of cancer. The occupational levels of patients (before their diagnosis) when assessed showed that most patients were either homemakers or daily wage workers and those who were diagnosed in their later stages of disease were mostly daily wage workers.

Also, those women who were homemakers still faced a delay in their diagnosis as they were hesitant to visit a healthcare facility on their own and their husbands who were daily wage workers couldn’t afford to take leave for a day for their check-ups. This shows the need for women to step themselves up to visit a healthcare facility for their good is still existent and insists on the need to build their health seeking behaviour for their betterment. Also, most patients in our study belonged to low and lower middle income households and that has been a hindrance to a majority of people to approach a healthcare facility for a screening or diagnostic test or a master health check-up as a means of prevention.

Concerning the marital status of our patients, most women in both the groups considered were married and yet few affected with breast cancer were unmarried. As various literature studies suggest that staying unmarried or nulliparous women are at high risk of acquiring breast cancer and our study also confirms the facts. Also, the number of children bared by a woman, on average, was higher among cervix cancer women than breast cancer women, confirming the fact that multiparous women are more exposed to the risk of cervix cancer. With regard to breastfeeding, the average breastfeeding duration of our study participants was between 12 to 18 months which is the normal advised duration. However, poor breastfeeding duration is a risk factor for breastfeeding and our study contradicts this fact stating that normal duration of breastfeeding is not a protective factor against breast cancer and those women are also exposed, though in a lesser proportion [6].

The family history of cancer is a major risk factor as cancer is a hereditary disease and our study participants also reported that few of them had a family history of various cancers. This when compared with their stage of diagnosis, to test whether their family history probed them to be more aware of the clinical signs of cancer, more women who had family history were diagnosed in the early stages of the disease. This shows the importance and impact of first-hand information regarding diseases like cancer in early detection and diagnosis. Another interesting finding was those women with a family history of cancer and who had increased time duration of delay in their cancer diagnosis were found to be their factor behind the delay. This shows the lack of understanding about the disease. Also, strong literature findings suggest that the presence of comorbidities might be a triggering factor for cancer and our study partially lines with the fact as 25% of patients only had some underlying medical conditions, predominantly diabetes and hypertension [7].

The prime factor behind the delay in cancer diagnosis was patients themselves (91%) followed by healthcare delay. The patient delay was attributed to various reasons, predominantly due to their poor knowledge or awareness about the signs and symptoms of cancer and the healthcare reasons for the delay were misdiagnosis and delayed diagnostic reports.

Regarding the time duration of delay, most breast cancer patients were diagnosed between 3 to 6 months after noticing their first symptom while most cervix cancer patients were diagnosed beyond 9 months after noticing their first symptom. The key factors considered to be potential risk factors for diagnostic delay in breast cancer were age, education, monthly income and family history of cancer. The regression results showed that increasing age was a predominant risk factor for delay in diagnosis. This is similar to the systematic review conducted by Rivera-Franco and Leon Rodriguez, which explored the association of socio-demographic factors such as age, education, marital status, occupational status, and socioeconomic status with Presentation Delay (PD) in breast cancer patients. The advanced age of patients was the only socio-demographic factor that seemed to be strongly associated with PD [8].

Among cervix cancer patients, the residence of patients and the total number of children they had borne were also considered in addition to other socio-demographic factors and the increased number of children turned out to be the predominant risk factor for delay followed by their family history of cancer.

Also, when assessing the significant time interval that increased the risk of advancing the stage of disease, the average time interval that can be considered as a delay in diagnosis and that increased the risk of advancing stage of disease showed different time duration for breast and cervix cancer. For breast cancer diagnosis, a time interval of more than 2 months (OR: 5.58 (1.07-29.19); p<0.05) after noticing the first symptom increased the risk of late-stage of diagnosis while for cervix cancer diagnosis, a time interval of more than 5 months (OR: 3.91 (1.02–14.87); p<0.05) after noticing the first symptom increased the risk of advancing stage of the disease. This finding differed from major studies which suggested a 3 months delay to be a significant time interval for advancing disease [9]. This indicates that patients’ appraisal of symptoms in breast cancer is quite delayed and any delay beyond 2 months poses the risk of advancing stage of the disease. Also, among cervix cancer patients, appraisal of symptoms needs to be earlier for detection for cancer within 5 months, as any delay beyond that duration, poses a risk of advancing stage.

Thus, our study on assessing the socio-demographic profile of patients with delayed diagnosis (based on time duration) of breast and cervix cancer, showed that more patients were above 50 years of age with lower educational qualifications and no/daily wage occupation. Both Breast and cervix cancer patients had on average, two or more children with normal breastfeeding duration and a very less yet considerable number of breast cancer patients were unmarried and nulliparous. Patients with a family history of cancer still had delayed diagnoses suggesting the need for better awareness and education. The factors and reasons for delay mainly involved patients and their incomprehensiveness about the disease. Also, concerning the potential factors that may increase the risk of cancer or its delay in diagnosis includes age (in both cancers) followed by increased childbearing and family history of cancer. This indicates the need for proper education and awareness on common cancers affecting women among general people to improve their understanding of the clinical picture of disease and enhance early disease diagnosis for better prognosis, survival rate and quality of life.

1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, et al. (2022) Global cancer statistics 2020: GLOBOCAN Estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71: 209-249.

   [Crossref] [Google Scholar] [PubMed]

2. Woodhead C, Cunningham R, Ashworth M, Barley E, Stewart RJ, et al. (2016) Cervical and breast cancer screening uptake among women with serious mental illness: A data linkage study. BMC Cancer 16: 1-9.

   [Crossref] [Google Scholar] [PubMed]

3. Varghese C (2001) Cancer prevention and control in India. Fifty Years Cancer Control India. 48-59.

   [Google Scholar]

4. Gyenwali D, Pariyar J, Onta SR (2013) Factors associated with late diagnosis of cervical cancer in Nepal. Asian Pac J Cancer Prev 14: 4373-4377.

   [Crossref] [Google Scholar] [PubMed]

5. Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL, et al. (2020) Cancer statistics, 2020: Report from national cancer registry programme, India. JCO Glob Oncol 6: 1063-1175.

   [Crossref] [Google Scholar] [PubMed]

6. Jassem J, Ozmen V, Bacanu F, Drobniene M, Eglitis J, et al. (2014) Delays in diagnosis and treatment of breast cancer: A multinational analysis. Eur J Public Health 24: 761-767.

   [Crossref] [Google Scholar] [PubMed]

7. Shahid S, Teng KHK, Bessarab D, Aoun S, Baxi S, et al. (2016) Factors contributing to delayed diagnosis of cancer among Aboriginal people in Australia: A qualitative study. BMJ Open 6: e010909.

   [Crossref] [Google Scholar] [PubMed]

8. Franco MMR, Rodriguez EL (2018) Delays in breast cancer detection and treatment in developing countries. Breast Cancer 12.

   [Crossref] [Google Scholar] [PubMed]

9. Kumar A, Bhagabaty SM, Tripathy JP, Selvaraj K, Purkayastha J, et al. (2019) Delays in diagnosis and treatment of breast cancer and the pathways of care: A mixed methods study from a tertiary cancer centre in North East India. Asian Pac J Cancer Prev APJCP 20: 3711-3721.

   [Crossref] [Google Scholar] [PubMed]