From symptom discovery to treatment - women's pathways to breast cancer care: a cross-sectional study

Background: Typically, women in South Africa (SA) are diagnosed with breast cancer when they self-present with symptoms to health facilities. The aim of this study was to determine the pathway that women follow to breast cancer care and factors associated with this journey. Methods: A cross-sectional study was conducted at a tertiary hospital in the Western Cape Province, SA, between May 2015 and May 2016. Newly diagnosed breast cancer patients were interviewed to determine their socio-demographic profile; knowledge of risk factors, signs and symptoms; appraisal of breast changes; clinical profile and; key time events in the journey to care. The Model of Pathways to Treatment Framework underpinned the analysis. The total time (TT) between a woman noticing the first breast change and the date of scheduled treatment was divided into 3 intervals: the patient interval (PI); the diagnostic interval (DI) and the pre-treatment interval (PTI). For the PI, DI and PTI a bivariate comparison of median time intervals by various characteristics was conducted using Wilcoxon rank-sum and Kruskal-Wallis tests. Cox Proportional-Hazards models were used to identify factors independently associated with the PI, DI and PTI. Results: The median age of the 201 participants was 54 years, and 22% presented with late stage disease. The median TT was 110 days, with median patient, diagnostic and pre-treatment intervals of 23, 28 and 37 days respectively. Factors associated with the PI were: older age (Hazard ratio (HR) 0.59, 95% CI 0.40-0.86), initial symptom denial (HR 0.43, 95% CI 0.19-0.97) and waiting for a lump to increase in size before seeking care (HR 0.51, 95% CI 0.33-0.77). Women with co-morbidities had a significantly longer DI (HR 0.67, 95% CI 0.47-0.96) as did women who mentioned denial of initial breast symptoms (HR 4.61, 95% CI 1.80-11.78). The PTI was associated with late stage disease at presentation (HR 1.78, 95% CI 1.15-2.76). Conclusion: The Model of Pathways to Treatment provides a useful framework to explore patient's journeys to care and identified opportunities for targeted interventions.