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Cadernos de Saúde Pública

ISSN 1678-4464

36 nº.2

Rio de Janeiro, Fevereiro 2020


ARTIGO

Fatores associados com o intervalo entre o início de sintomas e a primeira consulta médica entre mulheres com câncer de mama

Ângela Ferreira Barros, Cristiane Murta-Nascimento, Carlos Henrique de Abdon, Daniela Nunes Nogueira, Emenny Line Cardoso Lopes, Adriano Dias

http://dx.doi.org/10.1590/0102-311X00011919


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RESUMO
São comuns no Brasil os casos de mulheres com tumores de mama em estágio avançado ao diagnóstico inicial. Há pouca informação sobre os fatores que contribuem para a demora na busca de atendimento. O estudo teve como objetivo identificar os fatores associados a intervalos mais longos entre o início dos sintomas do câncer de mama e a primeira consulta médica no Distrito Federal, Brasil. A análise incluiu 444 mulheres sintomáticas com diagnóstico de câncer de mama, entrevistadas entre setembro de 2012 e setembro de 2014, durante a internação para o tratamento do câncer em nove hospitais públicos no Distrito Federal. As pacientes com doença metastática ao diagnóstico não foram incluídas no estudo. A variável de desfecho era o intervalo entre o início dos sintomas e a primeira consulta médica, sendo classificada como > 90 dias (34% das pacientes) ou ≤ 90 dias. Foi usada regressão logística para estimar os odds ratios (OR) e intervalos de 95% de confiança (IC95%). Na análise multivariada, o intervalo de > 90 dias mostrou associação significativa com a falta de mamografia e/ou de ultrassom mamário nos dois anos anteriores ao diagnóstico de câncer de mama (OR = 1,97; IC95%: 1,26-3,08), e com estágios mais avançados da doença (OR = 1,72; IC95%: 1,10-2,72). Além disso, houve probabilidade menor de demora em pacientes com maior escolaridade (OR = 0,95; IC95%: 0,91-0,99). Uma proporção relativamente alta de pacientes com câncer de mama no Distrito Federal sofreram demora na primeira consulta médica após o início dos sintomas. Uma maior conscientização sobre câncer de mama, principalmente entre mulheres com menores níveis de escolaridade e aquelas que não participam em programa de rastreamento com mamografia, pode contribuir para a redução dessa demora.

Neoplasias da Mama; Acesso aos Serviços de Saúde; Mamografia


 

Introduction

Breast cancer is the most frequent malignant tumor in women in most countries worldwide. It is the leading cause of death from cancer in women of low and medium Human Development Index countries, where it represents 14.9% of all cancer deaths 1. In Brazil, this neoplasm is the most common malignancy in women after non-melanoma skin cancer. The frequency of new cases of breast cancer is also high in the Federal District. It was estimated that 1,020 new cases of breast cancer would be detected there during 2018, which represents the fifth highest incidence rate (62.1 cases per 100,000 women) in Brazil 2.

The mortality rate of breast cancer has been increasing in Brazil 3 and actions to control this cancer, as proposed by the Brazilian National Cancer Institute (INCA), consist in improvements in both early disease detection and prompt treatment 4. For early detection, it is important to promote breast cancer screening among the target population and quick identification of breast cancer signs and symptoms by women and/or health professionals, as well as to improve access to health services for diagnosis and treatment 5. However, previous studies in Brazil have shown that women present limited knowledge about some breast cancer signs and symptoms 6,7 and many of them do not routinely undergo mammography screening 8. These weak points, besides limitations in health services access, may lead women to take longer to attend a first medical visit after identifying any breast alteration suggestive of cancer.

The interval prior to the first consultation includes the time interval between the detection or awareness of a body change defined as “appraisal time” and the time interval of perceiving a reason to talk about the symptoms with a health professional at the first consultation, defined as “help-seeking interval” 9. In the Brazilian context, it is believed that the “appraisal time” and “help-seeking interval” are more relevant than difficulty to obtain the first medical consultation given a national study showing that 97.6% of the interviewees obtained a medical appointment on their first attempt 10.

Previous studies suggested that longer time intervals between the onset of symptoms and the first health care visit were associated with older age, lower educational level and lower family income 11,12, but few of such studies were performed in Brazil 13,14, which limits the understanding of such factors regarding the breast cancer in our country.

Based on the above considerations, the aim of this study was to investigate the time interval between the onset of suggestive symptoms of breast cancer and the first medical visit. We further investigated which factors were associated to longer intervals.

Material and methods

This cross-sectional study started with 600 incident breast cancer patients hospitalized for breast cancer treatment in nine public hospitals of the Federal District, Brazil. Patients with metastatic disease identified before treatment were not included in the study. Data collection was carried out between September 2012 and September 2014. All women were interviewed using a structured questionnaire. Clinical data was retrieved from hospital records and a total of 444 (74%) consecutive symptomatic women at the first medical visit were included in the analysis, disregarding refusals.

Sample size calculation was based on the estimation that 1,800 new breast cancer cases would be diagnosed in the Federal District during the period of data collection 15. We considered that 40% of these cases would be treated in private services (Brazilian National Agency for Supplementary Health. http://www.ans.gov.br/anstabnet/cgi-bin/dh?dados/tabnet_tx.def, accessed on 04/Dec/2014) and the time interval between the onset of symptoms and the first medical consultation would exceed 90 days in 30% of cases 14.

The variable of interest was the self-referred time interval between the onset of the suggestive symptom of breast cancer and the date of the first medical visit. This variable was dichotomized - ≤ 90 days and > 90 days - as this was the cut-off point used in other studies 11,16,17,18. The presence of a palpable lump, skin and/or nipple retraction, hyperemia, bulging, abscess or pain in the breast, ulceration, nipple discharge, change in breast size, and the presence of axillary nodules were considered signs/symptoms. The first medical visit was defined as the moment when the patient was first examined due to her complaint regarding the breast.

Other variables were considered, such as patient sociodemographic characteristics (age, marital status, place of residence, educational level, and average family income), family history of breast cancer, periodicity of breast self-examination, date of last mammography and/or breast ultrasound before diagnosis, date of last clinical breast examination before diagnosis, and stages grouped according to the sixth edition of the TNM Classification of Malignant Tumors19. Family income per month was expressed in US dollars (1 USD = 2.7 BRL on December 31, 2014).

The descriptive analysis estimates frequencies for categorical variables and measuring central tendency and dispersion for continuous variables - mean and standard deviation (SD) or median and range. Some variable categories were abandoned for the few cases. Bivariate and multiple logistic regression models were performed. Variables that showed p-value ≤ 0.25 in the bivariate analysis were tested in the multiple model 20 by a stepwise forward method, and remained in the model when p-value < 0.05. The IBM SPSS Statistics v.20.0 software (https://www.ibm.com/) was used for the analysis.

This study was approved by the Ethics Research Committee of the Health Sciences Teaching and Research Foundation, Federal District Health State Department (Ethics Approval n. 99,313) as recommended by Resolution n. 196/1996 of the Brazilian National Health Council. All participants signed an informed consent form before the interview.

Results

Out of the 444 women included in this analysis, the mean age at diagnosis was 52.3 years (± 12.8) and the most frequent age group was 50 to 69 years Table 1. The following characteristics were more prevalent: being married or living in a stable union and dwelling in the Federal District. The mean number of schooling time was 7.8 years (± 4.7) and the average family income was USD 502.22 (ranging between USD 25.90 and 12,963.00).

 

Tab.: 1
Table 1 Characteristics of 444 symptomatic women with breast cancer treated at public hospitals in the Brazilian Federal District between September 2012 and September 2014.

 

The time interval between the onset of suggestive signs/symptoms of breast cancer and the first medical visit showed a median of 39 days (ranging between 0 and 1,857 days), with 34% occurring up to 90 days.

In both bivariate Table 2 and multiple regression Table 3 analyses, the variables that showed a statistically significant association with a longer interval (> 90 days) were patients not performing mammography and/or breast ultrasound in the two years prior to breast cancer diagnosis (OR = 1.97; 95%CI: 1.26-3.08), and with more advanced stages (OR = 1.72; 95%CI: 1.10-2.72). Furthermore, there was a lower chance of delay in patients with higher levels of education (OR = 0.95; 95%CI: 0.91-0.99).

 

Tab.: 2
Table 2 Bivariate analysis. Factors associated with longer time interval (> 90 days) between onset of breast cancer symptoms and first medical visit and associated factors.

 

 

Tab.: 3
Table 3 Multivariate analysis. Factors associated with longer time interval (> 90 days) between onset of breast cancer symptoms and first medical visit and associated factors.

Discussion

Our results reveal that one third of the sample (34%) had a considerable time interval between the onset of symptoms and the first medical consultation. Three variables were associated with this delay: lower educational level, not undergoing mammography and/or breast ultrasound in the two years prior to the diagnosis, and cases diagnosed at more advanced stages.

The median interval between the onset of signs/symptoms and the first medical visit observed - i.e., 39 days - was higher than reported in previous studies in Brazil 13,14. Over one-third showed an interval exceeding 90 days, which is longer than in other countries 16,21,22,23. Although methodological differences between studies and different characteristics of health services among countries hinder the results comparison, we consider that devising actions to reduce this interval in the Brazilian scenario should be a priority, given that longer intervals are associated with lower survival rates of breast cancer 24.

To reduce this interval, it would be important to remember that women with lower educational levels were more susceptible to have longer intervals, which is consistent with results from other studies 21,25,26. Lower educational levels are also associated with lower levels of awareness and recognition of breast cancer warning signs 27,28.

Furthermore, knowledge about breast cancer signs/symptoms among the Brazilian population is limited. A recent study including 478 women aged 40 or older in the city of Rio Branco, in Northern Brazil, reported that women were aware of some signs/symptoms such as lumps, nipple discharge, and breast discomfort. However, most of the sample did not identify nipple retraction, redness of breast skin and/or nipple discharge as breast cancer signs/symptoms 7. The difficulty in recognizing breast cancer warning signs may have resulted in longer intervals prior to the first consultation.

Moreover, note that the perceived barriers regarding access to health services are more frequently observed among people with worse socioeconomic conditions, in addition to previous experience and judgment regarding health services that may lead to avoidable delays and late diagnosis 29,30.

Access to outpatient secondary services such as mammography is limited in Brazil 31. An increase in the rate of mammography screening coverage among the target population should contribute to an earlier diagnosis. Although the INCA advises biennial mammography screening for women between 50 and 69 years 4, there is no population-based breast cancer screening program in the country and women only have access to screening strategies opportunistically 8. Besides, there is a reason to believe that mammography performance contributes to breast cancer awareness among patients and health professionals. An association was observed in other studies between delay at attending and patients not undergoing mammography or breast ultrasound 17,21,23,32.

Breast self-examination and clinical breast examination periodicity were not associated with a longer time interval to attend the first medical visit constrasting with previous studies 21,32,33. Moreover, these practices are not recommended for breast cancer screening on recent national directive 4.

Finally, there was an association of more advanced stages with delay to attend the first medical consultation as in other studies 13,16,34. This association was found in both bivariate and multivariable analyses, which points to the importance of this delay regarding the disease outcome. Women with advanced breast cancer tumors at medical appointment are common in Brazil, with more than 70% of the tumors diagnosed at stage II or higher 35. This highlights the importance of speeding up the first medical visit after the onset of symptoms by improving breast cancer awareness to detect the disease at earlier stages 36.

No association was observed between the delay to attend the first medical visit after the onset of symptoms and age, marital status, family history of cancer, income, or distance between place of residence and health care facilities, unlike what was previously reported 16,18,21,37. This inconsistency may result of various circumstances: methodological differences; the fact that these events depend on the sociocultural context 38; insufficient research about these aspects related with delay 39.

This is one of the largest studies performed in Brazil focusing on this issue, but it has some limitations. Patients with metastatic disease at diagnosis were not included in our study and this may have decreased the delay interval. Moreover, patients might not accurately remember when certain events occurred in their lives, which might translate into some memory bias; to minimize this risk, this study included only incident breast cancer cases. Furthermore, there is a possibility that some patients did not report the real time interval to avoid shame or embarrassment, as previously reported 24.

In conclusion, in a relatively high proportion of breast cancer patients in the Federal District, the first medical visit occurs long after the onset of symptoms. Thus, increasing breast cancer awareness, especially among women with low educational levels and those not participating in mammography screening programs could contribute to reduce this delay.

Acknowledgments

We would like to thank Mastology Unit of the Brasília University Hospital, Federal District Base Hospital, and the Oncology Service of the Taguatinga Regional Hospital, Brasília (Federal District, Brazil). This study was supported by the Higher Education School of Health Sciences (ESCS).

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