Abstract P6-11-22: Reasons for advanced presentation of breast cancer: Results from a referral center in India
Authors: Mishra Anand K , Ramakant Pooja , Singh Kul Ranjan , Rana Chanchal , Manjunath Shreyamsa 
Published: March 2020

Abstract
Introduction: Breast cancer (BC) is the commonest malignancy with increasing incidence rates amongst women worldwide. Morbidity and mortality from BC remains high due to presentation at an advanced stage. A period of more than 3 months between noticing the first symptom and &gt;1 month between presentation at a health facility and initiation of treatment is considered a delay in BC management. This study aims to study the perceived reasons for advanced stage of breast cancer (stage 2b and beyond) at initiation of treatment as per standard of care.
Materials and Methods
A self designed structured questionnaire was administered to 625 BC patients at initiation of treatment between January 2016 and June 2019 at a tertiary referral center catering to all strata of society in north India. The questionnaire contained questions pertaining to socio demographic profile, knowledge and awareness of BC, clinical parameters and perceived reasons for delay. Previous medical records were reviewed to reduce recall bias. Patient staged with BC stage 2b and beyond were analyzed. Statistical analysis was done using SPSS software (ver 23)
Results: The mean age of cohort was - 44 years, Females comprised 98.8%. Stage at presentation -(Stage 1 - 4%, 2a- 14%, 2b- 16%, 3 - 51%, 4- 15%). 36% of patients were &lt;40 years at presentation. 82% patients presented at stages 2b and beyond. 70% of the patient presenting at stages 2B and beyond had a delay in presentation. 30 % of the patient had no delay yet presented at a advanced stage. This may be attributed to the biology of the disease.
On further analyzing cohort of patients who had delay in presentation - 73% were illiterate(47%)or did not receive education beyond school. 88% belonged to lower middle, upper lower or lower socio economic class. 84% had a rural background.Married women were more likely to have delay compared to unmarked women (65% vs. 45%). 40% of the patient were not aware about BC. Only 64% of those aware of BC had breast self examination awareness (BSE) and of these only 14 % routinely performed BSE. 60% patients thought that complaint would be self limiting. 77% of patients sought medical consultation for worsening or persistence of symptoms. 76% approached a local practioner. 19% sought their first consultation from a quack and 25% from alternative medicine practioner.10% patient presented directly to our hospital. 60% were not offered any investigation at first consultation and 12% underwent triple assessment. Multiple consultations was sought in 2/3rds of the patient before start of definitive treatment. 57% of patient sought alternative treatment at some stage. In more than 80% of the patents the diagnosis of benign etiology was made at the first consultation. 38% had a diagnosis of BC at the time of referral to our hospital. Misdiagnosis at first consultation was the most frequent perceived barrier observation from patients’ perspective (41.4%). About 14% opined that delays in specialist referral from first contact practitioner resulted in delay, followed by distance travelled to avail expert services (15%), lack of information about available health facilities (11.3%). Financial issues, waiting periods at hospitals and absence of female doctors were other observed barriers.
Conclusions: The perceived reasons for delay and advanced presentation were found to be.
1. Poor awareness of Breast Cancer amongst general population.
2. Illitracy, remoteness for health care facilities from residence, poor social support contribute to late presentation.
3. Quacks and practioners of alternative medicine are the point of first contact for a segment of the population and may contribute to delay in initiation of optimum treatment.
4. Treatment protocols as per standard of care is not universal amongst practioners of modern medicine.
Citation Format: Anand K Mishra, Pooja Ramakant, Kul Ranjan Singh, Chanchal Rana, Shreyamsa Manjunath. Reasons for advanced presentation of breast cancer: Results from a referral center in India [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-22.