Secondary and Quaternary Delays in the Diagnosis of Breast Cancer: Are the Physicians Responsible too?

Causes of delay in presentation of breast cancer has been categorised into 'Primary Delay' (delay by the patient or her family); 'Secondary Delay' (delay by the doctors in the first contact - family physician or quacks/alternative medicine practitioners); 'Tertiary Delay' (delay in the system in a specialist breast care unit e.g. waiting list, delayed reporting, doctors on leave, strikes); and 'Quaternary Delay' (e.g. patient hopping from one competent breast cancer specialist to another or mid-course attrition to alternative treatments). In India, many patients have blind belief and high attrition towards the quacks and alternative medicine practitioners. Our study was to assess whether these 'Secondary and Quaternary Delays', particularly the attrition towards the alternative non-modern medical practitioners, have any effect on the delayed presentation and advancement of the overall anatomical staging among the breast cancer patients. We performed a retrospective observational study, based on 'Triple Assessment' and pre-structured Questionnaire. All pathologically confirmed female breast cancer patients admitted from 02/2017 to 08/2018 in the department of General Surgery in our Institute were included. Male breast cancer, histopathologically unconfirmed/inconclusive breast lumps, patients with previous breast surgery/radiotherapy/chemotherapy were excluded. Data from 267 patients was analysed. The mean age at presentation of breast cancer was 47.54 years. The average delay between the onset of the first symptom and the histological diagnosis was 13.76 ± SD 13.08 months. About half (50.2%) of our patients visited the non-modern medical practitioners at least once during their disease. The mean delay in diagnosis was significantly higher (p < 0.0001) among them. The average 'Secondary Delay' was significantly higher among those who visited the non-modern medical practitioners (9.7 ± SD 9.38 months). The average delay between the visit to the first doctor and the histological diagnosis was also significantly higher among them (18.35 ± 14 months). Patients with attrition to non-modern medical practitioners also were diagnosed in higher cT stages: cT4a (66.67%, 2 of 3) and cT4b (60%, 33 of 55). Most (56.9%) of stage IIIB patients visited the non-modern medical practitioners before their diagnosis. Patients who visited the non-modern medical practitioners had significantly more delay in the diagnosis of breast cancer. The 'Secondary and Quaternary Delays' form the major portion in the overall delay and lead to advancement of the anatomical staging of the disease. Creating public awareness, proper training and 'continued medical education' for primary care physicians, and the AYUSH practitioners are required. Further population-based studies are advised.