Understanding Delays in Breast Cancer Diagnosis: Insights from Bangladesh

doi:10.21203/rs.3.rs-5283035/v1

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Research Article

Understanding Delays in Breast Cancer Diagnosis: Insights from Bangladesh

https://doi.org/10.21203/rs.3.rs-5283035/v1

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Background

This study investigates factors contributing to delays in breast cancer diagnosis in Bangladesh and their impact on cancer staging. Early detection is crucial for effective treatment, yet many women in low- and middle-income countries (LMICs) are diagnosed at advanced stages, resulting in poorer outcomes.

Methods

A cross-sectional study was conducted at two major cancer care facilities in Dhaka. Women aged 18 and older with suspected or confirmed breast cancer were included. Data were collected using a structured questionnaire on sociodemographic and clinical variables. Total delay, defined as the time from symptom recognition to treatment initiation, was categorized into patient delay (symptom recognition to first medical consultation) and provider delay (first consultation to treatment start). Logistic regression analyses identified factors associated with these delays.

Results

Among 355 participants, 55.7% experienced total delays of over four months, with the highest delays in stage III cases (51.5%). Key factors contributing to patient delay included low education (Adjusted Odds Ratio [AOR]: 1.96, 95% CI: 1.04–3.74), low monthly income (AOR: 1.45, 95% CI: 1.22–1.90), and absence of breast pain (AOR: 0.55, 95% CI: 0.32–0.94). Provider delays were significantly associated with rural residence (AOR: 3.07, 95% CI: 1.49–6.98), and presence of nipple discharge (AOR: 2.92, 95% CI: 1.04–8.06). Total delays were most prevalent among patients from the Rangpur division (AOR: 6.07, 95% CI: 1.76–8.02), rural areas (AOR: 2.04, 95% CI: 1.17–3.61), and those with lower education. Additionally, nearly 80% of patients delayed seeking medical attention due to the belief that symptoms would resolve spontaneously, while 75% cited negligence and 65.5% reported financial barriers.

Conclusions

Significant delays in breast cancer diagnosis in Bangladesh are driven by socio-economic factors and inadequate healthcare access. Increasing public awareness, especially in rural areas, and improving healthcare accessibility are essential to facilitate early detection. Expanding screening programs and training healthcare providers in early cancer detection are critical to improving patient outcomes.

Breast cancer

Clinical characteristics

Delays in diagnosis

Cancer staging

Bangladesh

Breast cancer is a significant public health concern worldwide, with its impact expected to rise. In 2020, approximately 685,000 women died from breast cancer, accounting for around 16% of all cancer-related deaths among females—equivalent to one in every six cancer fatalities [1]. While the incidence of breast cancer is lower in developing countries compared to their developed counterparts, the mortality rates are disproportionately higher in these regions [2].

Although the incidence is rising due to epidemiological transitions in low- and middle-income countries (LMICs), breast cancer mortality is projected to increase by 53.6% between 2020 and 2040 [3]. This alarming trend poses significant challenges for policymakers aiming to reduce breast cancer mortality. A critical factor contributing to the higher mortality rates is delayed diagnosis, often exacerbated by limited access to healthcare [4]. Delayed diagnosis can be more detrimental to patient survival than the disease itself, as early detection and treatment are linked to improved prognoses [5]. Additionally, delays may lead to advanced disease stages and larger tumors.

In LMICs, two specific types of delays are particularly concerning. Patient delay refers to the interval between the onset of symptoms and the decision to seek medical attention. Research indicates that this delay often results from factors such as lack of awareness, educational deficits, cultural barriers, and fear of diagnosis [6–9]. Conversely, treatment/provider delay is the period between diagnosis and the initiation of treatment, influenced by healthcare system limitations such as inadequate primary care resources and ineffective referral processes [10]. Both types of delays have been shown to negatively impact patient outcomes; a meta-analysis by Hanna T.P. et al. (2020) revealed that a four-week treatment delay post-diagnosis significantly increases mortality risk in breast cancer patients. Therefore, addressing these delays through enhanced awareness, improved healthcare access, and strengthened healthcare systems is crucial for improving survival rates.

In Bangladesh, breast cancer represents a significant health disparity. According to the 2020 GLOBOCAN report, breast cancer is the leading cause of cancer deaths among women, responsible for 6.2% of all cancer-related fatalities and accounting for 19% of all female cancer cases. These statistics underscore the substantial burden of breast cancer on women's health and the urgent need for targeted healthcare interventions.

Women play a vital role in Bangladesh's economy and social development, particularly in sectors such as clothing and microfinance. Their health is essential for fostering healthy families and communities. However, issues related to women's health, including breast cancer, often receive insufficient attention. Alarmingly, about 90% of breast cancer patients in Bangladesh are diagnosed at advanced stages (III and IV) [11]. Delayed diagnosis significantly worsens outcomes and reduces survival rates, while early detection improves prognosis and lowers treatment costs [12, 13]. Therefore, reducing diagnostic delays is critical for improving health outcomes.

In 2014, we published the first comprehensive review of breast cancer in Bangladesh [11]. Since then, advancements in breast cancer research have been limited. Recent studies, including a 2022 investigation into university female students' knowledge and barriers to breast self-examination [14] and a 2024 study on awareness and perceived barriers to breast cancer screening, have not adequately addressed the factors contributing to diagnostic delays or their social implications[15]. Notably, no research has comprehensively examined diagnostic delays from both patient and provider perspectives. This study aims to fill that gap by investigating the socio-economic determinants and both patient- and provider-mediated factors affecting diagnostic delays in Bangladesh.

We adhered to the STROBE guidelines to ensure high-quality reporting in our observational cross-sectional study (Table S1).

Study Site

This study was conducted at the National Institute of Cancer Research and Hospital (NICRH), the only public facility in Bangladesh dedicated exclusively to cancer treatment. Public hospitals, like NICRH, primarily serve individuals from economically disadvantaged and lower-middle-class backgrounds, as the costs of treatment in private facilities are often unaffordable for most Bangladeshis [11]. Currently, Bangladesh lacks organized breast cancer screening programs, leading to almost all cases being diagnosed through clinical evaluation rather than early detection. Additionally, unlike in developed countries, there is no systematic referral system in place, and medical record-keeping is inadequate.

Patients

The study focused on women over 18 years old who presented with suspected breast cancer or had been diagnosed with the disease. Only those patients were enrolled whose initial cancer stage was documented in their medical records or, in cases where staging was unavailable, if the initial diagnosis occurred no more than six months prior to staging at our study center.

Questionnaire

We adapted a structured questionnaire from previous studies [5, 16], which is included as an additional file. The questionnaire comprised sections on sociodemographic variables, including age, education level, marital status, residence, and access to media and electronic devices. It also collected clinical history regarding breast cancer symptoms, capturing the type of initial symptoms (e.g., lump, breast pain, nipple discharge), the date of first symptom recognition, and participants’ perceptions of their symptoms’ severity.

Furthermore, the questionnaire explored barriers to seeking care, encompassing emotional factors (e.g., fear, embarrassment), practical constraints (e.g., financial limitations, time constraints), and health service-related issues (e.g., challenges in accessing healthcare, arranging transportation, or scheduling appointments). Participants were asked about their healthcare utilization, including the type of medical facility they first visited and any alternative treatments sought prior to diagnosis. The survey also assessed family support by gathering information on initial discussions about health concerns, recommendations to seek medical attention, and the level of support received after diagnosis. Knowledge and practices related to early detection were evaluated, focusing on breast self-examinations, prior clinical breast examinations, and awareness of mammography. Clinical variables, including tumor size and cancer stage classified by the tumor, node, and metastasis (TNM) system, were recorded. The data collected will be used to analyze associations between these variables and delays in diagnosis, offering insights into factors contributing to late-stage detection and their potential impact on treatment outcomes. The questionnaire was finalized for data collection after piloting it with five patients.

Data Collection

Face-to-face interviews using the structured questionnaire were conducted by trained interviewers—undergraduate students—who had no involvement in the clinical management of the patients. Given the conservative societal context, all interviewers were female, working under the direct supervision of our team’s oncologist at NICRH.

For patients unable to provide specific dates for their symptoms or first medical visit, they were asked to indicate a month or a range of months and the year. If a single month was indicated, the date was estimated as the 15th; for a month range, the midpoint between the 15th of those months was used. If only the year was provided, the date was coded as June 30th of that year. Cancer staging was analyzed by the oncologist based on available health records. Out of 355 cases, determining the cancer stages was not possible due to inadequate medical records.

Outcome Variables

In this study, delay is defined as the time interval experienced by women in the diagnostic and treatment processes.

Patient delay, refers to the time between the onset of symptoms and the first medical consultation, with a commonly accepted threshold for defining this delay being three months [5].

Provider delay, or system delay, refers to the time that passes between the initial medical consultation and the final diagnosis or treatment, with a commonly accepted threshold of one month [5].

Total delay encompasses the entire duration from the patient's first recognition of symptoms to the start of definitive treatment, integrating both patient and provider delays. In our study, total delay is considered significant when it exceeds four months.

To quantify our outcome variables related to delays, we categorized each patient as "1" or "Yes" if they experienced patient delay, provider delay, or total delay that surpassed the thresholds of three months, one month, and four months, respectively. Conversely, patients who did not meet these criteria were recorded as having no delays, designated by "0" or "No."

Possible factors

To find out potential risk factors associated with various types of delays, we examined a range of socioeconomic factors and the medical history of the patients as independent variables. These included the patient's age, geographic location (division), residency (urban or rural), educational attainment (illiterate, primary, and secondary) of both the patient and their spouse, household monthly income, access to portable electronic devices, exposure to mass media, lump breast pain, nipple discharge, skin changes, bone pain, breast self-examination, and family history of breast cancer.

Statistical analyses

We conducted descriptive statistics and also differences between delays associated with other factors tested by Chi-square tests and Fisher's exact test (in case of low frequency). Univariable (unadjusted) and multivariable (adjusted) logistic regression were utilized to identify factors that are associated with patient delay, provider delay, and total delay. In the univariable analysis, variables were individually added to the logistic regression model. We used an arbitrary p-value of ≤ 0.20 as a criterion for including covariates in the multivariable models [17] from univariable model. In this study, three models were utilized to identify associated risk factors of patient delay, provider delay, and total delay, designated as Model 1, Model 2, and Model 3, respectively. Results were reported as unadjusted/crude odds ratios (COR) and adjusted odds ratios (AOR) with their respective 95% confidence intervals. We considered a p-value of less than 0.05 to be statistically significant, indicating a 5% level of significance for interpreting our results. Additionally, we assessed multicollinearity in the final model using a cut-off value of 4.00 for the variance inflation factor (VIF) analysis [18]. At this stage, all variables were incorporated into the model since the VIF values for each variable were below 4.00. All analyses were performed using R software.

Study Population

A total of 355 women participated in our study. The largest age group was 40–49 years, comprising 35.0% of participants. Most women resided in the Dhaka division (44.0%), with a significant proportion (72.8%) from rural areas. A notable majority of participants were married (82.8%). Illiteracy was prevalent, affecting 42.9% of patients, while primary education was the most common level of education among spouses (37.1%). Over a third of families reported a monthly income of less than 5,000 BDT. Access to electronic devices was high (89.9%), but 59.4% lacked access to mass media (Table 1).

Table 1

Characteristics of women diagnosed with breast cancer and of their spouses, Bangladesh (N = 355)
Characteristics	n	%
Age at presentation (years)
< 40	114	33.24
40–49	120	34.98
50–59	79	23.03
≥ 60	30	8.75
Regions of origin
Barisal	26	7.67
Chittagong	52	15.34
Dhaka	149	43.95
Khulna	39	11.50
Mymensingh	33	9.73
Rajshahi	21	6.19
Rangpur	14	4.13
Sylhet	5	1.47
Area of residence
Rural	251	72.75
Urban	94	27.25
Current marital status
Single	59	17.25
Married	283	82.75
Patient education level
Illiterate	147	42.86
Primary	115	33.53
Secondary/higher	81	23.62
Spouse education level
Illiterate	89	27.99
Primary	118	37.11
Secondary/higher	111	34.91
Household monthly income (BDT)
< 5000	113	34.88
5000–10000	100	30.86
10001–20000	44	13.58
>20000	67	20.68
Portable electronic devices access
Yes	319	89.86
No	36	10.14
Mass media access
Yes	144	40.56
No	211	59.44

Clinical Characteristics and Associated Factors

As shown in Table 2, 88.5% of patients initially presented with a lump. Only 11.1% practiced breast self-examination, and 9.5% reported a family history of breast cancer. Patient delay (defined as a delay of more than three months) occurred in 41.0% of cases, while provider delay (more than one month) was noted in 24.3%. Total delay (more than four months) affected 55.7% of participants. Most patients sought medical help at stage II (48.8%) or stage III (44.1%).

Table 2

Medical history of the patients
Characteristics	n	%
First clinical presentations¹
Lump	314	88.45
Breast pain	93	26.20
Nipple discharge	20	5.63
Skin changes	15	4.23
Bone pain	12	3.38
Breast self-examination	37	11.11
Family history of breast cancer	32	9.52
Patient delay	139	41.00
Provider delay	82	24.33
Total delay	190	55.72
Stage of cancer
Stage I	10	3.94
Stage II	124	48.82
Stage III	112	44.09
Stage IV	8	3.15
¹multiple answer

Statistical analysis revealed significant differences in patient delay across cancer stages, with mean delays of 0.93 months for stage I, 5.23 months for stage II, 6.33 months for stage III, and 3.21 months for stage IV. Provider and total delays did not show significant variation across stages. Notably, stage III exhibited the highest patient delay (51.5%) and total delay (48.6%), while stage I had the lowest patient delay (2.0%) and total delay (1.4%). These findings underscore the urgent need for targeted interventions to reduce delays at various cancer stages (Table 3 and Fig. 1).

Table 3

Summary of patient delay, provider delay, and total delay with stage of cancer (in weeks)
	Patient delay
Stage of cancer	Mean	Standard Deviation	Median	Minimum	Maximum	P-value*
Stage I	0.93	1.89	0.07	0.00	6.00	0.022
Stage II	5.23	8.60	2.00	0.00	48.67
Stage III	6.33	10.22	3.00	0.00	60.83
Stage IV	3.21	3.80	2.50	0.00	12.17
Total	5.69	9.23	2.00	0.00	60.83
	Provider delay
Stage I	1.80	2.55	0.53	0.00	6.57	0.973
Stage II	1.75	2.50	0.53	0.00	7.20
Stage III	1.40	2.10	0.48	0.00	7.13
Stage IV	1.22	2.04	0.40	0.00	6.00
Total	1.49	2.25	0.47	0.00	7.20
	Total delay
Stage I	2.73	3.93	0.93	0.03	12.57	0.120
Stage II	6.89	8.52	5.70	0.00	48.67
Stage III	7.73	10.14	5.92	0.00	61.33
Stage IV	4.43	4.01	3.67	0.13	12.17
Total	7.13	9.22	5.40	0.00	66.83
*Kruskal-Wallis test

Figure 2 illustrates that the most common symptoms experienced by patients included breast discomfort (52.1%), followed by a lump (45.9%), arm discomfort (34.8%), itching (33.8%), changes in breast shape (31.4%), skin changes (12.7%), nipple discharge (12.1%), and ulcer or sore skin (11.5%).

Reasons for Delay in Medical Care

Table 4 identifies the primary reasons for delays in seeking medical care. The most common belief was that the issue would resolve on its own (79.1%), followed by negligence (75.5%), financial constraints (65.5%), family responsibilities (54.7%), embarrassment (44.6%), busy schedules (41.0%), and fear of a cancer diagnosis (38.1%). Additional factors included transportation difficulties (27.3%), lack of information (24.5%), delays in securing appointments (21.6%), and other reasons (20.1%).

Table 4

Factors contributing to patient delay based
	Family History
	Total	Yes	No
Characteristics	n (%)	n (%)	n (%)
Thought the problem would disappear by itself	110 (79.14)	9 (8.49)	97 (91.51)
Negligence or carelessness	105 (75.54)	8 (7.92)	93 (92.08)
Financial constraints	91 (65.47)	8 (8.99)	81 (91.01)
Competing life priorities (taking care of family)	76 (54.68)	7 (9.59)	66 (90.41)
Embarrassment about having a breast examination	62 (44.60)	5 (8.06)	57 (91.94)
Too busy (other reason)	57 (41.01)	6 (11.11)	48 (88.89)
Fear of cancer diagnosis and/or treatment	53 (38.13)	5 (9.43)	48 (90.57)
Difficult to arrange transport	38 (27.34)	4 (10.53)	34 (89.47)
Lack of information	34 (24.46)	4 (11.76)	30 (88.24)
Appointment delay	30 (21.58)	4 (13.33)	26 (86.67)
Other reason	28 (20.14)	3 (10.71)	25 (89.29)

Types of Delay and Associated Factors

Table S2 highlights key risk factors for patient delay. This delay was particularly prevalent among illiterate individuals (47.7%), those with a monthly income below 5,000 BDT (50.4%), and those lacking access to electronic devices (60.0%) or mass media (43.9%). Additionally, the absence of breast pain was linked to a higher rate of delay (44.1%). Adjusted analyses revealed that illiterate patients had nearly double the odds of experiencing delay (AOR: 1.96, 95% CI: 1.04–3.74) compared to those with secondary or higher education. Patients with a monthly income of 5,000–10,000 BDT had 1.45 times higher odds of delay compared to those earning over 20,000 BDT. Conversely, those experiencing breast pain had 45% lower odds of delay (AOR: 0.55, 95% CI: 0.32–0.94) than those without pain.

Table S3 presents significant factors associated with provider delay. Patients from the Rangpur division had over four times higher odds of experiencing provider delay (AOR: 4.60, 95% CI: 1.11–7.52) compared to those from Barisal. Rural residents had three times higher odds (AOR: 3.07, 95% CI: 1.49–6.98), and those with nipple discharge had nearly three times higher odds (AOR: 2.92, 95% CI: 1.04–8.06).

Table 5 summarizes the factors associated with total delay, indicating that patients from the Rangpur division had over six times higher odds of total delay (AOR: 6.07, 95% CI: 1.76–8.02). Rural residents faced double the odds of total delay (AOR: 2.04, 95% CI: 1.17–3.61). Unmarried patients and those with lower educational attainment also exhibited higher odds of total delay, along with symptoms such as breast pain, nipple discharge, and bone pain.

Table 5

Prevalence and associated risk factors of total delay (N = 341)
	Total delay
Characteristics	Chi-square test		Unadjusted model		Adjusted model
Characteristics		n (%)	P-value	COR (95% CI)	P-value	AOR (95% CI)	P-value
Socioeconomic characteristics
Age at presentation (years)
< 40	62 (55.36)	0.960	0.82 (0.36–1.86)	0.649
40–49	65 (54.62)		0.80 (0.35–1.80)	0.597
50–59	44 (56.41)		0.86 (0.35–2.02)	0.736
≥ 60	18 (60.00)		Reference
Geographic location
Chittagong	33 (63.46)	0.024	2.03 (1.78–5.35)	0.014	2.85 (0.99–8.39)	0.052
Dhaka	78 (52.35)		1.28 (0.56–3.00)	0.560	1.51 (0.60–3.89)	0.387
Khulna	25 (65.79)		2.24 (1.81–6.36)	0.012	2.91 (1.95–9.25)	0.044
Mymensingh	13 (39.39)		0.76 (0.27–2.15)	0.602	0.87 (0.28–2.71)	0.807
Rajshahi	10 (50.00)		1.67 (0.36–3.79)	0.796	1.51 (0.43–5.39)	0.520
Rangpur	13 (92.86)		5.17 (2.46–6.41)	0.014	6.07 (1.76–8.02)	0.030
Sylhet	3 (60.00)		1.75 (0.25–5.03)	0.573	1.47 (0.14–5.55)	0.735
Barisal	12 (46.15)		Reference		Reference
Area of residence
Rural	150 (60.48)	< 0.001	2.08 (1.28–3.40)	0.003	2.04 (1.17–3.61)	0.013
Urban	39 (42.39)		Reference		Reference
Current marital status
Single	37 (64.91)	0.011	1.60 (1.10–2.95)	0.017	1.46 (1.14–2.94)	0.027
Married	151 (53.55)		Reference		Reference
Patient education level
Illiterate	89 (60.96)	0.012	1.77 (1.02–3.09)	0.043	1.59 (1.18–3.05)	0.015
Primary	62 (54.39)		1.35 (0.76–2.41)	0.303	1.51 (1.17–2.95)	0.022
Secondary/Higher	37 (46.84)		Reference		Reference
Spouse education level
Illiterate	52 (58.43)	0.683	1.28 (0.73–2.26)	0.383
Primary	64 (55.17)		1.12 (0.67–1.90)	0.659
Secondary/Higher	58 (52.25)		Reference
Household monthly income (BDT)
< 5000	73 (64.60)	< 0.001	1.48 (0.95–2.75)	0.121	1.26 (0.59–2.68)	0.551
5000–10000	47 (47.96)		1.74 (1.40–2.39)	0.036	1.55 (0.99–2.11)	0.101
10001–20000	23 (52.27)		1.19 (0.41–1.91)	0.760	1.21 (0.35–1.87)	0.618
> 20000	37 (55.22)		Reference		Reference
Portable electronic devices
Yes	173 (54.75)	0.019	1.56 (1.23–2.32)	0.020	1.55 (1.18–2.52)	0.025
No	17 (68.00)		Reference		Reference
Mass media access
Yes	79 (55.63)	0.009	0.79 (0.94–1.12)	0.070	0.98 (0.81–1.38)	0.240
No	111 (55.78)		Reference		Reference
Medical history of the patients
Lump
Yes	174 (55.59)	0.874	0.94 (0.42–2.04)	0.874
No	16 (57.14)		Reference
Breast pain
Yes	46 (50.00)	0.019	1.73 (1.45–2.18)	0.019	1.60 (1.34–2.05)	0.016
No	144 (47.83)		Reference		Reference
Nipple discharge
Yes	14 (70.00)	0.018	1.92 (1.75–5.54)	0.018	2.19 (1.73–7.52)	0.018
No	176 (54.83)		Reference		Reference
Skin changes
Yes	9 (60.00)	0.733	1.20 (0.42–3.66)	0.733
No	181 (55.52)		Reference
Bone pain
Yes	5 (41.67)	0.031	1.56 (1.16–2.77)	0.032	1.37 (1.09–2.30)	0.012
No	185 (36.23)		Reference		Reference
Breast self-examination
Yes	20 (54.05)	0.859	0.94 (0.47–1.88)	0.859
No	164 (55.59)		Reference
Family history of breast cancer
Yes	15 (46.88)	0.306	0.68 (0.33–1.42)	0.308
No	169 (56.33)		Reference
AOR: adjusted odds ratio, CI: confidence interval, COR: crude odds ratio

This study highlights several key factors contributing to diagnostic delays in breast cancer care in Bangladesh, including self-perceived beliefs and negligence, fear, embarrassment, economic and educational barriers, and geographic disparities. Understanding these factors is critical for developing effective interventions to reduce delays and improve outcomes for breast cancer patients.

A significant portion of patients (79.1%) delayed seeking medical attention due to the belief that their symptoms would resolve on their own. This suggests a pervasive lack of awareness about the severity of breast cancer symptoms, such as lumps or nipple discharge, which often leads to advanced-stage diagnoses. This self-perceived belief is dangerous as it allows the disease to progress unchecked, increasing the risk of mortality. Negligence or carelessness was also cited by 75.5% of participants, indicating that even when symptoms are acknowledged, there is a tendency to delay seeking care due to underestimating the potential severity of the symptoms. This finding aligns with similar studies conducted in Tunisia and Libya, where a significant percentage of women delayed seeking medical help due to the perception that their symptoms were not serious [7, 19]. Improving awareness and education about the early warning signs of breast cancer is essential to encourage prompt medical consultation and reduce patient delay.

Fear of a cancer diagnosis or treatment emerged as a critical factor in delaying medical consultation, reported by 38.1% of participants. This fear is often compounded by a lack of knowledge and misconceptions about the disease and its treatment. Negative perceptions about the toxicity of cancer treatments, such as chemotherapy, can deter patients from seeking help. This is particularly evident in developing countries where fear of diagnosis is more prevalent among those with a family history of breast cancer [7, 20]. In contrast, in the UK, only 4.9% of delays are attributed to fear, highlighting a significant difference in perception between developed and developing nations [21]. Disseminating positive information about cancer survivorship and organizing awareness campaigns can help alleviate this fear. Furthermore, encouraging cancer survivors to share their experiences could normalize discussions about the disease and reduce the stigma associated with cancer diagnosis and treatment.

Embarrassment related to breast examinations and discussing reproductive health is another significant barrier, particularly in societies with conservative norms. In Bangladesh, where concepts like 'Purdah' promote modesty, women may feel uncomfortable undergoing breast examinations or discussing their symptoms with healthcare providers. This cultural barrier is evident in our study, where 44.6% of participants reported embarrassment as a reason for delay Similar trends are observed among South Asian women residing in developed countries, indicating that cultural influences on health-seeking behavior persist even outside their native contexts [22, 23]. Efforts to increase awareness and normalize breast health discussions are crucial. Training healthcare providers, particularly female staff, to handle these situations sensitively can also reduce patient discomfort and encourage timely medical consultations.

Socio-economic factors, including education level and household income, significantly impact patient delays. Our study found that patients with a monthly income of 5,000–10,000 BDT had 1.45 times higher odds of experiencing delays compared to those with incomes over 20,000 BDT Financial constraints often prevent patients from seeking timely medical care, as many may prioritize other family needs over personal health. Moreover, education plays a crucial role in health-seeking behavior. Illiterate patients were found to delay diagnosis at twice the rate of those with secondary education or higher. Educated women are more likely to recognize symptoms and seek medical attention promptly, which is consistent with findings from other studies [24, 25]. Lack of access to electronic devices and mass media further exacerbates this issue, as these are primary sources of health information. Women without access to these resources are less likely to be aware of breast cancer symptoms and the importance of early detection [26, 27]. Targeted interventions, such as community-based educational programs and mass media campaigns, are needed to address these barriers.

Geographic location and area of residence significantly contribute to provider delays. Patients from rural areas and the Rangpur division experienced longer diagnosis times due to limited access to healthcare resources, long waiting times, and a scarcity of specialized medical professionals. In Bangladesh, there are approximately two nurses and five physicians per 10,000 people, which severely limits the capacity to provide timely care, particularly in rural areas [11]. A systematic review identified deficiencies in primary healthcare and referral processes as major factors influencing provider delays in breast cancer diagnosis [10]. Moreover, most specialized healthcare facilities are located in urban areas, forcing rural patients to rely on primary healthcare centers that may not be equipped for early cancer detection [28]. Training healthcare providers in early detection and improving referral systems are essential for reducing provider delays.

There are several limitations to this study. First, the study was conducted in two public hospitals in Dhaka, without including private healthcare facilities. This limits the generalizability of the findings to the broader population, as private hospitals may have different patient demographics and healthcare delivery models. Second, the lack of a systematic referral system and organized cancer screening programs in Bangladesh hampers early detection efforts, and cancer staging data were not comprehensively available for all patients, limiting the analysis of the impact of delays on cancer progression. Additionally, the use of a non-random convenience sampling method may introduce selection bias, and recall bias may affect the accuracy of self-reported data on symptom onset and first medical consultation.

The study underscores the urgent need for targeted interventions to reduce delays in breast cancer diagnosis in Bangladesh. Public awareness campaigns, especially in rural areas, are essential to educate women about the early signs and symptoms of breast cancer and the importance of early medical consultation. Expanding organized screening programs and training healthcare providers in early detection are crucial steps to improve early diagnosis and treatment outcomes. Efforts should also be made to improve healthcare accessibility, particularly in underserved areas, and to address socio-economic barriers that prevent women from seeking timely medical care.

Policymakers should prioritize the development of a robust referral system to streamline patient management and reduce provider delays. Collaborations with non-governmental organizations (NGOs) and community health workers to disseminate information and support women in accessing healthcare can further enhance the effectiveness of these interventions. Implementing educational programs targeting both patients and healthcare providers, and ensuring the availability of affordable healthcare services, will be essential to mitigate the impact of delayed breast cancer diagnosis in Bangladesh.

These findings provide a baseline for future research and policy-making aimed at improving breast cancer outcomes in Bangladesh. Addressing the identified barriers holistically will be key to reducing diagnostic delays and enhancing the quality of life for breast cancer patients in the country.

LMICs Low- and middle-income countries

AOR Adjusted Odds Ratio

COR Crude Odds Ratio

NICRH National Institute of Cancer Research and Hospital

NGOs non-governmental organizations

TNM Tumor, node, and metastasis

VIF Variance inflation factor

CI Confidence Interval

Acknowledgements

We would like to extend our gratitude to Maliha Nuzhat Munir, Nazam Laila, Ishrat Binte Aftab, Akash Ahmed and SM Abdullah Al Mamun for their invaluable contributions to data collection.

Author contributions

MSH conceived the study concept. MSH and WH designed the study and oversaw data collection, while MNH and HKK handled data curation and formal analysis. The manuscript was drafted by MSH, SKS, MNH, and HKK. All authors critically reviewed the manuscript and fully endorse its results and conclusions.

Funding

None

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request

Ethics approval and consent to participate

This study protocol was approved by the Ethical Review Board of the National Institute of Cancer Research and Health (NICRH/Ethics/2017/29). Informed written consent was taken from each patient.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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No competing interests reported.

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Understanding Delays in Breast Cancer Diagnosis: Insights from Bangladesh

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Abstract

Background

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Background

Methods

Study Site

Patients

Questionnaire

Data Collection

Outcome Variables

Possible factors

Statistical analyses

Results

Study Population

Clinical Characteristics and Associated Factors

Reasons for Delay in Medical Care

Types of Delay and Associated Factors

Discussion

Conclusions

Abbreviations

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References

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