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Keywords:

  • breast cancer;
  • cervical cancer;
  • diagnostic delay;
  • therapeutic delay

Abstract

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONFLICT OF INTEREST DISCLOSURES
  7. REFERENCES

BACKGROUND:

Several publications reporting on health disparities document that ethnic minorities disproportionately experience delays in healthcare access, delivery, and treatment. However, few studies examine factors underlying access and receipt of healthcare among cancer survivors from the patient perspective. This study explores diagnostic and therapeutic care delays among a multiethnic sample of breast and cervical cancer survivors and examines contextual factors influencing diagnostic and therapeutic care delays.

METHODS:

Population-based sampling and a cross-sectional design were used to recruit 1377 survivors (breast cancer, n = 698; cervical cancer, n = 679). This multiethnic sample included 449 European American, 185 African American, 468 Latina American, and 275 Asian American survivors.

RESULTS:

Latina Americans were more likely to report diagnostic delays (P = .003), whereas African Americans were more likely to report therapeutic delays (P = .007). In terms of cancer type, cervical cancer survivors were more likely to report diagnostic (P = .004) and therapeutic delays (P = .000) compared with breast cancer survivors. “Fear of finding cancer” was the most frequently cited reason for diagnostic delays, and “medical reasons” were most frequently cited for therapeutic delays.

CONCLUSIONS:

Due in part to a higher proportion of diagnostic and therapeutic delays, ethnic minorities endure greater cancer burden, including poorer survival and survivorship outcomes. The medical community must recognize the impact of existing psychological and cultural dimensions on diagnostic care, as well as the personal and healthcare system level barriers that contribute to therapeutic delays. Cancer 2010. © 2010 American Cancer Society.

Breast and cervical cancer represent 2 of the most common cancers among women in the United States and globally.1, 2 In 2009, 192,370 women were expected to be diagnosed with breast cancer, and 11,270 were expected to be diagnosed with cervical cancer.3 Women diagnosed with early or local (stage 1) breast or cervical cancers have a 92% and 98% chance of surviving 5 years after diagnosis, respectively.3 However, these 5-year survival rates significantly decrease to 27% for breast and 17% for cervical cancer with distant cancer at diagnosis.3 Racial and ethnic disparities in breast and cervical cancer incidence, stage at diagnosis, and survival rates exist in the United States, posing preventable threats to mortality and morbidity among ethnic minority women.4, 5 For example, the incidence rate of cervical cancer is 61% higher in Latina women than in European Americans, whereas Asian Americans have lower breast and cervical cancer incidence rates than other ethnic groups. The death rates for breast and cervical cancers among African Americans are 37% and 104% higher than among European Americans, respectively.3 Differential access to healthcare and receipt of quality diagnostic and therapeutic care are primary contributors to ethnic differences in stage at diagnosis, survival rates, and mortality outcomes.6

Disparities in diagnostic and therapeutic cancer care exist according to ethnicity, geography, and socioeconomic status.7 Although patterns of diagnostic and therapeutic care are increasingly studied primarily among European Americans and African Americans,5, 8-12 these quality of care indicators are seldom examined among other ethnic populations. Furthermore, factors that contribute to delays from the patient perspective are not well understood.

Delays in the diagnosis of cancer or treatment may affect survival as well as survivorship outcomes.13 In cancer care, where prognosis is strongly associated with stage of disease at presentation, barriers in access to care may delay diagnosis and/or treatment,14 resulting in more advanced disease at time of presentation for treatment and consequently poorer prognosis. For these reasons, the ability to understand and address diagnostic and therapeutic care issues is crucial in ensuring optimal cancer care and survivorship outcomes.14

The healthcare process is complex and multidimensional, and is influenced by individual and system level factors. Healthcare delays are influenced by the interaction among several systemic factors, including insurance status, facility capacity, and physician behavior.15, 16 Patients' decision to delay may also be influenced by personal, social, and cultural factors.17

The impact of socioeconomic status (SES) and health insurance coverage on healthcare access and delivery are well documented.18 For example, uninsured status often functions as a barrier to receiving optimal cancer care.19 National reports indicate that lower SES negatively impacts access to quality care and is associated with poorer health outcomes.18, 20, 21 Furthermore, the literature documents that ethnic minorities receive inferior care, and that the existing healthcare system is plagued with discrimination in terms of care delivery, leading to disparate health outcomes among ethnic groups and those most vulnerable.22, 23

Cultural and linguistic factors may also contribute to healthcare disparities.18, 24, 25 In fact, many ethnic minorities with limited English skills encounter difficulties in communicating with their health providers and receiving quality carec.25 The provision of culturally competent care is further hindered by lack of provider training on cultural dimensions, such as spiritual practices and family involvement in the healthcare process.24, 26

The purpose of this study was to: 1) examine demographic factors that may contribute to diagnostic and therapeutic delays among a multiethnic, population-based sample of breast or cervical cancer survivors; and 2) explore from the patient perspective the level of and reasons for diagnostic and therapeutic delays. Specifically, this study investigated diagnostic and therapeutic care delays based on cancer type and ethnicity, as well as by delay reasons. On the basis of the literature the following research questions were developed:

  • Are there significant differences in diagnostic (symptoms to first medical diagnostic consultation) and therapeutic delays (medical diagnosis to treatment initiation) by demographic factors?

  • What are the most frequent reasons for diagnostic and therapeutic delays by cancer type and ethnicity?

  • Are there significant differences in diagnostic and therapeutic delays by cancer type, ethnicity, and cited reasons for such delays, after controlling for demographic and medical characteristics?

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONFLICT OF INTEREST DISCLOSURES
  7. REFERENCES

The current study is based on data from a breast27 and a cervical cancer survivor study.28 These 2 studies used a multiethnic, population-based sampling and cross-sectional design, and the recruitment period and procedures, survey administration, and measures (except for the Functional Assessment of Cancer Therapy additional items) were almost identical, such that these 2 studies are comparable. Details regarding the study protocols, measures, and survivorship outcomes have been described elsewhere.29, 30 Briefly, recruitment strategies included: 1) sending out letters to survivors identified from the California Cancer Surveillance Program; 2) referrals from local oncologists; and 3) community outreach (distributing study flyers). Active recruitment and enrollment occurred between 2000 and 2004. The participation rates for the breast and cervical cancer studies were 58% and 64%, respectively. Questionnaires were translated and back-translated into Spanish, Chinese, and Korean; other Asian ethnic groups such as Japanese, Filipinos, and Vietnamese participants completed the survey in English because of their English proficiency and limited study resources. Internal consistency for the scales was assessed using Cronbach alpha (α), and no language differences were found. The studies were approved by the University of California, Los Angeles Institutional Review Board.

Participants

Eligible participants included women within 1 to 5 years of a diagnosis with either breast or cervical cancer and diagnosed with stages 0 to III. Sample characteristics included European, African, Latina, and Asian ethnic groups. Specifically, Asian subgroup membership included Chinese, Filipino, Korean, Japanese, and other Asian groups. Exclusion criteria included participants younger than 18 years and participants experiencing any other cancers, or major psychological or other major medical conditions.

Measures

Sociodemographic and cancer-related medical factors

Sociodemographic questions assessed participants' age, income, education, health insurance coverage, ethnicity, and language. Cancer-related factors included cancer type, stage, and years since diagnosis.

Diagnostic and therapeutic care delays

Delays were assessed by asking respondents how long (number of days) they waited to obtain medical care from the time they first noticed “something was wrong,” and how long (number of days) they waited for their physicians to begin treatment. “Diagnostic delay” was defined as the time interval (days) between the first symptom and medical diagnosis. “Therapeutic delay” was defined as the time interval (days) between receiving a medical diagnosis and treatment. Delay reasons were assessed by asking respondents the basis for diagnostic delays, which included financial reasons (could not pay for medical care/no medical insurance), work reasons (could not get time off from work), fear of a cancer diagnosis, or other reasons. Reasons for therapeutic delays were assessed by asking participants the basis for their delay and included treatment effects (afraid the treatment would make the cancer get worse), lack of physician trust (did not trust the physicians), financial reasons (did not have the money or health insurance), competing medical reasons (comorbidities), physician's delay (physician was too busy), or other reasons (time, competing life demands, not knowing the next steps to take to access further medical care). The delay items were informed by Dr. Ashing-Giwa's preliminary quantitative and qualitative studies with multiethnic breast and cervical cancer survivors.25, 31-34

Data Analysis

Exploratory data analyses such as mean, standard deviation, and range were conducted to elicit information on the main study variables. Chi-square tests were computed to investigate the relationships of demographic and medical variables according to cancer type and ethnicity. Independent sample t tests and analyses of variance were conducted to investigate differences in delays according to demographic information. Delay reasons according to cancer type and ethnicity were explored using the chi-square tests. In addition, univariate general linear models were conducted to investigate differences in diagnostic and therapeutic delays by cancer type, ethnicity, and cited reasons for such delays, after controlling for demographic and medical characteristics. Statistical analyses were performed with SPSS 15.0 (SPSS Inc., Chicago, Ill), with the level of significance set at .05. A total of 8 participants who reported extreme diagnostic delays (>2 years) and/or therapeutic delays (>1 year) were excluded from the analyses.

RESULTS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONFLICT OF INTEREST DISCLOSURES
  7. REFERENCES

A total of 1377 cancer survivors including, 449 European Americans, 185 African Americans, 468 Latina Americans, and 275 Asian Americans comprised the final sample. A total of 698 participants were diagnosed with breast cancer, and 679 were diagnosed with cervical cancer. Breast cancer survivors were relatively older, with a mean age of 55 years (standard deviation [SD], 11.3), compared with cervical cancer survivors (mean, 50; SD, 12.3), P = .000. Breast cancer survivors reported higher income levels and higher education levels, and were more likely to report English proficiency, compared with cervical cancer survivors (see Table 1). Survivors' demographic and medical characteristics according to cancer type are also illustrated in Table 1. Overall, European Americans reported higher income and education levels.

Table 1. Demographic and Medical Characteristics for Breast and Cervical Cancer Survivors
VariablesBreast Cancer (n=698)Cervical Cancer (n=679)Chi- Squarea
TotalEuropeanAfricanLatinaAsianTotalEuropeanAfricanLatinaAsian
  • Dx indicates diagnosis; SD, standard deviation.

  • a

    The relationships between demographic and medical variables and cancer type (breast vs cervical cancer) without considering ethnic differences were examined using the chi-square.

  • b

    P < .001.

  • c

    The relationships between demographic and medical variables and ethnicity according to the cancer type were examined.

  • d

    P < .01.

Income          26.171b
 <25K196 (29)24 (14)39 (30)86 (50)47 (24)284 (43)38 (14)21 (44)199 (37)26 (37) 
 25K-45K147 (22)38 (22)36 (27)36 (21)37 (19)120 (18)41 (15)14 (29)17 (24)17 (24) 
 >45K-75K145 (22)42 (24)27 (21)27 (16)49 (25)110 (17)70 (26)8 (17)11 (16)11 (16) 
 >75K181 (27)68 (40)30 (23)22 (13)61 (31)153 (23)119 (44)5 (10)16 (23)16 (23) 
 Chi-squarec73.24b    237.12b     
Education          63.913b
 <High school100 (14)5 (3)9 (7)69 (38)17 (8)204 (31)9 (3)6 (12)179 (64)10 (14) 
 High school76 (11)13 (7)17 (13)27 (15)19 (9)97 (15)46 (17)10 (20)28 (10)13 (18) 
 >High school520 (75)160 (90)108 (81)84 (47)168 (82)368 (55)214 (80)34 (68)72 (26)48 (68) 
 Chi-squarec131.53b    263.72b     
Health insurance          36.720b
 No insurance52 (8)12 (7)8 (6)16 (9)16 (8)105 (16)7 (3)7 (14)84 (30)7 (10) 
 Public68 (10)4 (2)14 (11)32 (19)18 (9)113 (17)21 (8)8 (16)73 (26)11 (16) 
 Private545 (82)150 (90)107 (83)121 (72)167 (83)458 (68)243 (90)34 (69)128 (45)53 (75) 
 Chi-squarec27.61b    134.72b     
Language          17.877b
 English547 (78)178 (100)135 (100)96 (53)138 (68)464 (68)271 (100)50 (100)88 (31)55 (78) 
 Other151 (22)85 (47)66 (32)215 (32)199 (69)16 (23) 
 Chi-squarec167.88b    339.73b     
Cancer stage          95.358b
 076 (11)16 (9)6 (5)18 (10)36 (18)1 (0.1)01 (2)00 
 1254 (37)61 (34)54 (41)59 (33)80 (40)348 (52)149 (56)29 (58)129 (45)41 (58) 
 2264 (38)71 (40)51 (39)73 (41)69 (34)213 (32)69 (26)14 (28)113 (40)17 (24) 
 395 (14)30 (17)20 (15)28 (16)17 (8)110 (16)45 (17)6 (12.0)43 (15)13 (18) 
 Chi-squarec26.55d    38.96b    7.322b
Age, mean y (SD)55.1 (11)57.2 (11)55.8 (11)53.6 (11)54.0 (11)50.4 (12)49.5 (12)51.1 (10)49.4 (12)56.8 (13) 
 Fc4.24d    7.70b    −3.342d
Years since Dx, mean (SD)3.0 (1.7)2.7 (1.4)3.6 (2.2)2.9 (1.6)2.9 (1.5)3.3 (1.6)3.3 (1.7)3.2 (1.6)3.3 (1.4)3.3 (2.2) 
 Fc8.18b    0.02     

In terms of how the cancer was first detected, approximately half of breast cancer survivors (51%) indicated finding an abnormality on their own, and 36% reported that an abnormality was detected during a routine mammogram. For cervical cancer survivors, 26% experienced abnormal symptoms before diagnostic screening, and 59% reported that an abnormality was detected during a routine examination.

Table 2 illustrates diagnostic and therapeutic delay differences by demographic characteristics by cancer type. For breast cancer survivors, economically challenged survivors (P = .001) and those with public/government-assisted healthcare (P = .05) were more likely to report diagnostic delays. However, no demographic variable was associated with diagnostic delays for cervical cancer survivors.

Table 2. Associations Between Demographic Information and Diagnostic and Therapeutic Care Delays
VariableSymptoms to Diagnosis, Mean d (SD)Diagnosis to Cancer Treatment, Mean d (SD)
Breast (n=698)Cervical (n=679)Breast (n=698)Cervical (n=679)
  • a

    P < .01.

  • b

    P < .05.

Age, y    
 <5046.3 (82.8)61.5 (107.7)27.3 (35.5)40.5 (53.7)
 50-7042.9 (96.5)52.9 (92.1)28.0 (34.8)35.8 (43.4)
 >7028.0 (53.9)47.5 (75.9)21.8 (20.8)43.1 (61.2)
 F value1.1460.8130.9620.801
Income    
 <25K59.7 (108.0)62.9 (105.6)29.4 (34.9)42.1 (54.1)
 25K-45K42.1 (77.6)64.0 (115.3)32.7 (49.0)38.5 (50.0)
 >45K-75K34.5 (83.6)51.3 (83.6)26.1 (27.4)34.4 (43.9)
 >75K29.0 (57.7)44.0 (84.7)20.7 (20.2)37.3 (50.2)
 F value4.531a1.4643.753b0.696
Education    
 <High school55.1 (118.7)62.0 (92.2)32.0 (32.7)44.6 (54.1)
 High school34.9 (63.5)65.1 (112.3)33.7 (50.2)39.9 (55.9)
 >High school41.8 (84.)54.0 (102.0)25.3 (31.0)36.2 (47.5)
 F value1.2870.6743.154b1.789
Health insurance    
 No insurance52.8 (91.3)53.8 (87.9)22.7 (20.0)36.2 (38.2)
 Public64.1 (116.3)73.3 (117.8)32.2 (35.1)49.7 (58.3)
 Private38.9 (79.9)54.8 (98.1)26.1 (34.4)36.5 (49.8)
 F value2.996b1.5591.3603.300b
Ethnicity    
 European32.7 (76.8)44.8 (84.1)23.1 (25.3)36.9 (53.5)
 African45.6 (91.0)69.0 (106.3)36.2 (53.3)47.6 (67.1)
 Latina56.6 (107.1)66.3 (112.0)27.3 (30.9)40.9 (48.0)
 Asian37.7 (74.6)61.8 (97.5)24.5 (24.5)32.5 (34.2)
 F value2.4902.3924.471a1.133
Language    
 English42.0 (88.3)52.7 (94.0)26.6 (34.7)37.8 (50.2)
 Other45.6 (87.5)67.8 (111.7)29.2 (31.2)41.3 (51.6)
 T value0.1843.2540.6840.653

In terms of therapeutic care, income, education, and ethnicity were significantly related to treatment delays for breast cancer survivors, whereas health insurance coverage was related for cervical cancer survivors. More specifically, breast cancer survivors who reported less income (P = .011) and less education (P = .043) were more likely to report therapeutic delays. As well, of the 4 ethnic groups, African American breast cancer survivors were more likely to report longer treatment delays, whereas European American and Asian American breast cancer survivors reported the least delays (P = .004). Meanwhile, for cervical cancer survivors, women who reported publically assisted health coverage experienced the greatest treatment delays (P = .037).

Table 3 also illustrates reasons for diagnostic and therapeutic delays by cancer type and ethnicity. Overall, 248 (36%) breast cancer survivors reported that they waited to seek medical attention after self-detecting an abnormality. Of these respondents, 84 (34%) indicated that they waited because of fear of finding cancer. For cervical cancer, 220 (48%) survivors reported waiting to obtain diagnostic care, and of these 105 (38%) waited because of fear of finding cancer. Differences in reasons for waiting were also noted according to ethnicity. Latinas were more likely to delay because of fear of a cancer diagnosis (45%) and financial issues (29%), compared with other ethnic groups. However, the most commonly cited reason for delay among all ethnic groups was “fear of a cancer diagnosis.” In terms of reasons for therapeutic delays, cervical cancer survivors were more likely to delay because of financial issues (23.9%) and medical reasons (20.2%), compared with breast cancer survivors.

Table 3. Reasons for Diagnostic and Therapeutic Care Delays by Cancer Type and Ethnicity
DelayCancer Type, No. (%)Ethnicity, No. (%)
Breast (n=698)Cervical (n=679)Chi- squareEuropean (n=449)African (n=185)Latina (n=468)Asian (n=275)Chi- Square
  • “Treatment effects” refers to “they were afraid the treatment would make the cancer get worse”; “physician trust” refers to “they did not trust the physicians.”

  • a

    P < .001.

  • b

    P < .05.

  • c

    P < .01.

Diagnostic delay  1.5    29.3a
 No450 (64)459 (68) 339 (76)117 (63)276 (59)177 (64) 
 Yes248 (36)220 (32) 110 (25)68 (37)192 (41)98 (36)
Diagnostic delay reasons        
 Financial  17.6a    30.6a
  Yes28 (4)66 (10) 15 (3)8 (4)56 (12)15 (6) 
  No670 (96)613 (90) 434 (97)177 (96)412 (88)260 (95)
 Work  1.2    6.5
  Yes15 (2)21 (3) 8 (2)5 (3)10 (2)13 (5) 
  No683 (98)658 (97) 441 (98)180 (97)458 (98)262 (95)
 Emotional (fear)  3.4b    19.0a
  Yes84 (12)105 (16) 39 (9)29 (16)86 (18)35 (13) 
  No614 (88)574 (85) 410 (91)156 (84)382 (82)240 (87)
 Other  42.9a    4.4
  Yes140 (20)53 (8) 60 (13)28 (15)57 (12)48 (18) 
  No558 (80)626 (92) 389 (87)157 (85)411 (88)227 (83)
Therapeutic Delay  80.1a    17.5c
 No625 (90)477 (70) 115 (26)31 (17)92 (20)37 (14) 
 Yes73 (10)202 (30) 334 (74)154 (83)376 (80)238 (86)
Therapeutic delay reasons        
 Treatment effects  0.70    7.7
  Yes12 (2)8 (1) 1 (0.2)3 (2)11 (2)5 (2) 
  No686 (98)671 (99) 448 (99.8)182 (98)457 (98)270 (98)
 Physician trust  0.24    1.4
  Yes8 (1)6 (1) 5 (1)3 (2)3 (1)3 (1) 
  No690 (99)673 (99) 444 (99)182 (98)465 (99)272 (99)
 Financial  18.1a    5.6
  Yes6 (1)31(5) 8 (2)3 (2)19 (4)7 (3) 
  No692 (99)648 (95) 441 (98)182 (98)449 (96)268 (98)
 Medical reasons  37.6a    3.3
  Yes2 (0.3)41(6) 17 (4)6 (3)16 (3)4 (2) 
  No696 (99.7)638 (94) 432 (96)179 (97)452 (97)271 (99)
 Physician's delay  3.7b    7.0
  Yes45 (6)28 (4) 28 (6)10 (5)15 (3)20 (7) 
  No653 (94)651(96) 421 (94)175 (95)453 (97)255 (93)
 Other  37.7a    19.8a
  Yes33 (5)98 (14) 63 (14)16 (9)40 (9)12 (4) 
  No665 (95)581 (86) 386 (86)169 (91)428 (91)263 (96)

We further investigated diagnostic and therapeutic delay by cancer type, ethnicity, and delay reasons, after controlling for demographic and medical characteristics (Table 4). Overall, the mean number of days from time of discovery of an abnormality to obtaining medical care (diagnostic delay) was 50 days (SD, 94.4; range, 0-720; median, 14 days), and the mean number of days from obtaining a diagnosis to cancer treatment (therapeutic delay) was 32.9 days (SD, 43.4; range, 0-360; median, 21 days). In terms of diagnostic delay, neither cancer type nor ethnicity was related to the number of days to diagnostic care. However, cancer type was found to be a significant predictor of therapeutic care, indicating that cervical cancer survivors were more likely to report treatment delays compared with breast cancer survivors, P < .001.

Table 4. Differences in Diagnostic and Therapeutic Care Delays
VariablesNo.Mean (SD)F
  • a

    A univariate general linear model was constructed, after controlling for demographic and medical variables such as ethnicity, income, education, health insurance, language, cancer stage, age, and years since diagnosis.

  • b

    Cancer type and demographic and medical variables were controlled.

  • c

    All demographic and medical variables such as cancer type, ethnicity, income, education, health insurance, language, cancer stage, age, and years since diagnosis were controlled.

  • d

    P < .001;

  • e

    P < .01.

Diagnostic Delay: Symptoms to Diagnosis, d
 Cancer typea  3.26
  Breast61641.9 (82.5) 
  Cervical62455.9 (98.6) 
 Ethnicityb  1.05
  European40639.5 (80.4) 
  African16951.4 (95.7) 
  Latina41461.2 (103.2) 
  Asian25142.1 (80.9) 
 The presence of diagnostic delayc  227.95d
  No delay82522.4 (51.1) 
  Delay415101.7 (124.5) 
 Differences in delay days according to diagnostic delay reasonsc   
  Financial  31.64d
   Yes83113.4 (141.3) 
   No115744.3 (84.7) 
  Work  3.17
   Yes3279.8 (102.6) 
   No120848.1 (90.8) 
  Emotional (fear)  90.53d
   Yes172112.7 (128.5) 
   No106838.6 (79.1) 
  Other  82.28d
   Yes170102.1 (124.8) 
   No107040.4 (81.6) 
Therapeutic Delay: Diagnosis to Cancer Treatment, d
 Cancer typea  16.44d
  Breast62026.0 (33.3) 
  Cervical62938.3 (48.6) 
 Ethnicityb  2.29
  European40730.8 (43.0) 
  African16636.7 (55.5) 
  Latina41935.3 (42.2) 
  Asian25726.3 (27.8) 
 The presence of therapeutic delayc  128.59d
  No delay99825.4 (34.5) 
  Delay25059.2 (56.9) 
 Differences in delay days according to therapeutic delay reasonsc   
  Treatment effects  8.51e
   Yes1859.1 (58.6) 
   No123031.8 (41.8) 
  Physician trust  7.82e
   Yes1363.8 (60.0) 
   No123531.8 (41.9) 
  Financial  9.48e
   Yes3460.1 (54.4) 
   No121431.4 (41.5) 
  Medical reasons  30.62d
   Yes4073.2 (80.2) 
   No120830.8 (39.6) 
  Physician's delay  58.93d
   Yes6768.4 (68.5) 
   No118130.1 (39.2) 
  Other  26.44d
   Yes11652.1 (47.0) 
   No113230.1 (41.1) 

In diagnostic and therapeutic delay by delay reasons, overall, a significant difference was found in mean number of days to diagnostic and therapeutic care according to whether survivors reported they delayed (yes, no). Mean number of days to diagnostic care among survivors who reported they delayed was 101.7 (SD, 124.5), whereas the mean days among survivors who reported that they did not delay was 22.4 (SD, 51.1). Fear was the most cited reason for diagnostic delays. Mean number of days delayed was 113 (SD, 128.5) among those who cited fear, compared with 39 days (SD, 79.1) for those who did not cite fear. Meanwhile, the mean number of days to therapeutic care among survivors who reported they delayed was 59 (SD, 56.9), whereas the mean number of days among survivors who reported that they did not delay was 25 (SD, 34.5). In therapeutic care, women who cited “medical reasons” and “physician's delay” reported the greatest delays, with a mean of 73 days (SD, 80.2) and 68 days (SD, 68.5), respectively. In addition, women who cited “financial issues” in diagnostic and therapeutic care showed significant differences in length of delay compared with women who did not.

DISCUSSION

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONFLICT OF INTEREST DISCLOSURES
  7. REFERENCES

Several important reports document that ethnic minorities bear an unequal burden in accessing cancer care.35 The current study attempted to identify barriers that contribute to inequities of cancer care, by examining diagnostic and therapeutic delays among a population-based, multiethnic sample of breast cancer survivors and cervical cancer survivors. Several important findings were observed. First, in terms of diagnostic delays, low income survivors on public or private assisted medical coverage reported greater diagnostic delays. Consistent with previous research,9 SES and health insurance coverage were influential factors in both diagnostic and therapeutic delays. Also, Latina breast cancer survivors reported greater diagnostic delays compared with the other groups. In terms of therapeutic delays, findings revealed that breast cancer survivors were significantly less likely to delay treatment compared with cervical cancer survivors. One explanation for greater delays among cervical cancer survivors is that cervical cancer survivors tended to report lower education and income levels, thus making it more challenging to navigate the public healthcare system and obtain timely treatment. Furthermore, women with private insurance may have additional resources compared with women without insurance and may be more assertive in obtaining a timely diagnosis.36

Third, consistent with previous research,10, 37 fear of finding cancer was mentioned by both breast cancer survivors and cervical cancer survivors as a significant barrier to seeking diagnostic care. In terms of therapeutic delay, physician delay was cited among women who reported the greatest delays. This finding indicates that physicians serve a role in therapeutic delays, and greater exploration into this association is needed. Furthermore, ethnicity played a role in delays. Specifically, African American breast cancer survivors were more likely to report therapeutic delays, compared with other breast cancer survivors.

Overall, SES factors are important in understanding therapeutic delays, particularly among cervical cancer survivors. Evidence that diagnostic and therapeutic delays are linked to income and ethnicity serve as rationale for developing better methods to deliver quality cancer care to underserved socioeconomic and ethnic minority populations. Furthermore, a greater understanding of the impact of cancer-related fear, its meaning among diverse groups, and the influence of these belief systems on health behaviors is needed. In light of the current study's findings, an important aspect of community health education will be dissemination of the knowledge that many cancers are highly treatable and potentially curable, if diagnosed early and promptly treated. Early detection and screening behaviors are important for increasing survival rates,19 more likely to result in better prognosis, and associated with treatments that are more affordable and less resource intensive to provide. Thus, early detection and prevention strategies secure the greatest human and economic benefit. Our findings suggest the possibility of other unexplained factors that contribute to delays, including family history of the disease (eg, family history of cancer, prognosis of the relative's cancer, and positive or negative experience of cancer in the family), systemic factors (eg, hospital distance, appointment availability, and hospital type [cancer center, public/county facility]), and specific medical factors (eg, tumor histology and comorbidities), as well as psychosocial (emotional and practical support) and cultural (eg, religiosity/spirituality) factors. These factors were not measured in this study, but should be incorporated in future investigations. In addition, this study proposes that existing health/cancer education, cancer prevention, and control policy should be changed to facilitate access to healthcare systems, particularly among ethnic minorities and underserved populations to optimize timely and quality care, improve outcomes, and reduce the economic and human costs associated with the treatment of advanced disease and premature morbidity and mortality. To address timely preventative, diagnostic, and therapeutic cancer care, our cancer control program may benefit from adopting strategies through a public health approach that includes a multidimensional approach including media campaign, public-private prevention, and treatment partnerships (where companies that produce cancer therapeutics are required to contribute to cancer prevention and treatment access programs) and locally devised, culturally and linguistically oriented cancer control activities that draws on the wisdom from all stakeholders (medical professionals, policy makers, providers, advocates, and researchers) of that community. The findings suggest that culturally and socioeconomically informed health education, cancer screening promotion, and medical care navigational services may be necessary for the delivery of comprehensive cancer care. Moreover, to provide patients with the best opportunity for survival, it is imperative to address the personal, cultural, financial, and systemic barriers to diagnosis and treatment.

Despite some limitations, this research represents 1 of the first attempts to understand the causes of diagnostic and therapeutic cancer care delays from the patient perspective. The large population-based sample and the inclusion of an ethnically and linguistically diverse population are major strengths of this study. The first limitation is that the current data consist of retrospective self-reports, and thus may be subjected to recall accuracy influenced by the emotional crisis that surrounded a cancer diagnosis, as well as other recall factors.38 Specifically, participants may have encountered difficulty recalling the exact moment of symptom onset and diagnostic consultation. Second, breast cancer survivors and cervical cancer survivors diagnosed with stage IV disease were excluded from the study, which limits the generalizability of the results. Lastly, the theoretical, methodological, and measurement foundations for investigations on diagnostic and therapeutic care delay are still under development and lack standardization. Future studies are needed to better inform the scientific, healthcare system, and policy approaches to comprehensively understand and effectively address delays in cancer care at all phases of the cancer care continuum.

CONFLICT OF INTEREST DISCLOSURES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONFLICT OF INTEREST DISCLOSURES
  7. REFERENCES

This work was supported by the Department of Defense (17-99-1-9106); and the California Cancer Research Program (#2110008).

REFERENCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONFLICT OF INTEREST DISCLOSURES
  7. REFERENCES