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Year : 2020  |  Volume : 16  |  Issue : 6  |  Page : 1360-1365

Women's delay in presenting breast cancer symptoms in Kurdistan-Iraq

1 Department of Nursing, Darbandikhan Technical Institute, Sulaimani Polytechnic University, Sulaimani, Iraq
2 Maternal and Neonate Nursing, College of Nursing, University of Sulaimani, Sulaimani, Iraq

Date of Submission15-Nov-2018
Date of Decision27-Dec-2018
Date of Acceptance05-Apr-2019
Date of Web Publication30-Aug-2019

Correspondence Address:
Jamal Kareem Shakor
Department of Nursing, Darbandikhan Technical Institute, Sulaimani Polytechnic University, Wrme Street 327/76 Qrga, Sulaimani
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_775_18

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 > Abstract 

Background: Women in developing countries usually delay in presenting their symptoms as a part of the early diagnosis program. This study was conducted for analyzing the reason of patient's delay and its relation with socioeconomic and health conditions, knowledge, and women's belief about breast cancer (BC).
Methodology: This study used a cross-sectional design in the early detection center in Kurdistan (North Iraq). Women were interviewed about socioeconomic and health background, knowledge, and belief about BC.
Results: The median of patient delay in the BC symptomatic women in this study was higher (30 days) as compared with developed countries. Patient delay was longer in women who were widows, had a barely self-perceived economic status, and had chronic diseases. There was a significant relationship of patient delay with women's health motivation and perceived barrier to seeking medical care.
Conclusions: Health promotion program should emphasize on the women's motivation about early diagnosis and seeking to early detection.

Keywords: Breast cancer, health belief model, Iraq, patient delay, socioeconomic variables

How to cite this article:
Shakor JK, Mohammed AK. Women's delay in presenting breast cancer symptoms in Kurdistan-Iraq. J Can Res Ther 2020;16:1360-5

How to cite this URL:
Shakor JK, Mohammed AK. Women's delay in presenting breast cancer symptoms in Kurdistan-Iraq. J Can Res Ther [serial online] 2020 [cited 2021 Nov 27];16:1360-5. Available from: https://www.cancerjournal.net/text.asp?2020/16/6/1360/265869

 > Introduction Top

Breast cancer (BC) is one among the dreaded pandemics accounting the highest rate of morbidity and mortality in women in the world including Iraq. Each year 1½ million women get diagnosed with BC and 570,000 women casualty due to BC were reported worldwide only in the year 2015.[1]

The incidence of female BC in Iraq has increased exponentially during the year 2000–2009.[2] In an another report, 539 women were diagnosed with BC during 2006–2008.[3] Most of the women were diagnosed with BC in the late clinical stage. Women diagnosed at clinical Stage 2 or Stage 3 of their disease contributed to 69.5% and 56.3%, respectively, and only 4.1% and 11.7% of patients were diagnosed at Stage 1, also known as the stage of localized tumors.[3],[4]

In Iraq, a National Program for Early Detection and Down Staging of BC were initiated in 2000.[5] Early diagnosis of the clinical stage of cancer is determined by patient delay.[6] Patient delay is defined as the period from when women felt the BC symptoms to the first medical consultation.[7] In a British study, the patient delay among BC symptomatic women was determined as a factor for its progression.[8] Furthermore, the patient delay was the reason for the late clinical cancer stage among women diagnosed with BC.[9],[10],[11] Consequently, the patient delay is a major factor for the delay in BC diagnosis and disease prognosis.[7],[12] Among BC symptomatic women, measuring patient delay and the barriers for early diagnosis would be an essential factor for downstaging of BC.[13]

Patient delay in low- and middle-income countries (LMIC) is between 1.4 and 12.9 times, respectively, higher than that of high-income countries.[7] In LMIC, there is a distinct reason for this delay. Factors associated with patient delay were initially related to the socioeconomic conditions, knowledge, patients' belief, and conditional health behavior.[7],[14] Many studies reported that socioeconomic and health condition variables, such as age, education, smoking, and family income contribute to the patient delay.[15],[16] In addition, lack of knowledge on BC is another important factor for patient delay.[12] A study in Estonia reported an improved early presentation of symptoms or decreased patient delay after providing the information about BC to the population 1 year before their first symptoms.[15] Women belief and attitude toward disease also contribute to patient delay.[8] Hence, the health belief model is an important part of the early detection program.[17] According to this model, seriousness of women's perception about disease and susceptibility, benefit and barriers of the preventive actions, women's health motivation and confidence would determine early presentation and their wish to seek treatment.[18]

However, most studies found out a patient delay in women previously diagnosed with BC. Hence, the present study aimed to find out patient delay in BC symptomatic women and its relation to socioeconomic and health conditions, BC knowledge, and women's belief in Iraq.

 > Methodology Top

The study was conducted using a cross-sectional design in the Breast Diseases Treatment Center. The Breast Diseases Treatment Center has been launched since 2007 in Sulaimani Province and is the only center having the early detection program, and early diagnosis and screening. Any woman aged ≥20 years who visited the center for early diagnosis from December 13, 2016, to June 12, 2017, and was eligible to get recruited to this study. Women aged ≥20-year-old present with symptoms of BC and provided oral consent were interviewed according to the prepared questionnaire. Three hundred and twenty-three women were recruited to the study. Patients diagnosed with BC were excluded from the study. Patient delay in this study was measured by the period from when women felt the symptoms to the day when they were interviewed in the early diagnosis center.


The questionnaire addressed various variables, including socioeconomics, health conditions, knowledge, and women's belief variables. BC awareness measure tool (CAM) version 2 was used to measure the knowledge of women about BC; it is a constructed instrument used in many studies in the region.[19] This tool consisted of four subscales: screening tests (5 items), nature of BC (5 items), warning signs of BC (7 items), and risk factors and health behavior (12 items). Breast CAM version 2 is a 3 Likert scoring system. The answer of each item includes “Yes,” “No,” and “I don't know.” Only the true answer was scored, and “I don't know” was considered false and scored zero.

Women belief and attitude were measured using the Champion's Health Belief Model Scale (CHBM). CHBM is a standard instrument in many different cultures.[19],[20] This instrument consisted of six concepts: perceived seriousness of illness (5 items), perceived susceptibility to illness (3 items), health motivation (5 items), confidence in one's ability (6 items), perceived benefits of treatment (3 items), and perceived barriers of treatment (9 items).

Validation and reliability

Content validity of the questionnaire was based on the opinion and revision of 13 experts with different careers in relation to the research topic.

Reliability was obtained for subscale of Breast CAM and CHBM. We used a reliability test (Cronbach's alpha) as an internal consistency for both scales. Alpha values for the subscales were – seriousness: 0.84, susceptibility: 0.83, health motivation: 0.81, confidence: 0.83.1, treatment benefits: 0.77, and treatment barrier: 0.79. Alpha value for breast CAM was 0.78.

Scoring and measurement

Knowledge of BC was based on breast CAM; this score was based on 33 questions regarding BC, screening, risk factors, and signs and symptoms. Any true answer was scored 1, and overall knowledge was measured based on adding all scores. A higher total score of the scale (breast CAM) showed more awareness about BC.

Patient delay, as defined in the introduction, was measured based on the period of time (in days) from when women felt any warning signs of BC to the time when they visited the screening center.

Women's belief and attitude were measured using the CHBM subscales distinctively. This scale is a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Women attitude was based on the accumulation of each item score in each subscale. High score of each item indicated a strong attitude of concepts (subscale), except barriers subscale that was scored inversely. A high score, therefore, meant that women who perceived greater susceptibility to BC, perceived more seriousness of BC, more health motivation, and more confidence, perceived more benefits and higher barriers to treatment.

Data management

The data were managed and analyzed using the descriptive and inferential statistics by the SPSS 22.0 software for Windows (IBM Inc., Chicago, IL, United States). The data were analyzed through the application of descriptive statistics, frequency and percentage, and median and interquartile range (IQR). Median and IQR of patient delay were measured in socioeconomic, medical, and health variables.

Kruskal–Wallis test was utilized to measure the difference in the median of patient delay across socioeconomic and health conditions.

Spearman's correlation coefficient was used to test the relation of knowledge (breast CAM) and women's belief and attitude about BC and seeking treatment (CHBM) with patient delay.

 > Results Top

The population studied aged 40 years and above (59%) and was married (85%), not graduated (83%), unemployed (71.5%), living in urban area (74.9), and nearly half of them perceived bare self-sufficient economic status. In general, the median of patient delay was 30 days with (IQR = 8.5–120). [Table 1] shows the significant relation of marital status (P = 0.005) and perceived economic status (P = 0.047) with patient delay. Median patient delay was significantly higher among those who were widows: 140.0 (IQR = 47–365) and perceived barely sufficient economic status: 38.0 (IQR = 14–150). Similarly, median patient delay was high in women who were uneducated: 38 (IQR = 30–135) or had a primary level of education: 37 (IQR = 7–105) and was suburban (district) residents: 45.0 (IQR = 21–120). However, none of this relation was statistically significant [Table 1].
Table 1: Socioeconomic variables versus patient delay median

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The current study found a significant relationship between chronic diseases and patient delay [P = 0.007, [Table 2]. Median patient delay was found significantly high in women who presented with chronic diseases: 45.0 (IQR = 30–180). Similarly, median patient delay was high among women who had four children: 32.0 (IQR = 7.5–90), presented with pain in the breast: 36.5 (IQR = 15–120), or pain with lump: 35.0 (IQR = 5.5–257). However, none of these relations were statistically significant [Table 2].
Table 2: Medical and health variables versus patient delay

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[Table 3] shows the relation of women awareness (CAMs) and women beliefs (CHBMs) with patient delay. The study found that the relation of patient delay was weak and negative with patient's knowledge about BC, and this correlation was not statistically significant (R = −0.013, P = 0.817).
Table 3: Spearman's rho correlation of patient delay with breast cancer awareness measure and Champion's Health Belief Model subscales

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There was a high and significant relationship between women's health motivation and patient delay (R = −0.166, P = 0.009). Health motivation was negatively associated with patient delay. Women's perception of seriousness, susceptibility, and confidence were negatively and weakly associated with patient delay, and this relation was not statistically significant.

Spearman's rho showed a significant positive correlation between perceived barrier of treatment and patient delay (R = 0.149, P = 0.02). A high perception of women to barriers of treatment was associated with longer patient delay. Perceived benefit of treatment was negatively associated with patient delay. However, this relation was statistically not significant [Table 3].

 > Discussion Top

Patient delay in women with BC and symptomatic women has not been reported in the previous studies in Iraq. The present study aimed to find out the median patient delay in women presenting with BC symptoms. This study found the median of patient delay to be 30 days with (IQR = 8.5–120), which was comparatively higher as compared to the patient delay observed in the British (13 days) and New Zealand (14 days) studies.[8],[13] The median of patient delay in women presenting with BC symptoms in this study was lower in those diagnosed when compared with findings in other LMIC; however, it was still higher than that reported in the developed countries. For instance, patient delays in diagnosed women were as follows: Morocco (6 months), Libya (4 months), Iran (3 months), Pakistan (17.2 weeks), Egypt (2.7 months), and Malaysia (2 months).[7],[11],[12],[21] However, patient delay in diagnosed women was lower in developed countries, such as Estonia and Britain: 16 days.[9],[15] Even in Thailand, it was reported to be 12 days.[14] Long patient delay in diagnosed women compared to women presenting with symptoms in LMIC may indicate that longer delay in diagnosed women led to the delayed prognosis of BC and increased the clinical stages in these women.

The reason and barrier for patient delay vary among countries. In this study, socioeconomic characteristics indicated the patient delay. Median patient delay was significantly higher among those who were widows: 140.0 (IQR = 47–365). This study could be supported by a study in Pakistan.[22] Meanwhile, in the LMICs, many studies confirmed that married women, owing to fear of losing the husband, had a long patient delay.[12],[23] Median patient delay was also significantly higher among those who perceived barely self-sufficient economic status: 38.0 (IQR = 14–150). The same finding was reported in a Thailand study.[14]

However, in the current study, median patient delay was higher in women who were not educated well, suburban residents. However, none of this relation was statistically significant. Among socioeconomic factors, education has been confirmed as an indicator of early presentation; conversely, illiteracy significantly increased the risk of delay.[10],[12],[15] Regarding the place of residence, in Morocco, living in rural areas was associated with ≥6 months of delay, because they lived far away from specialized care centers.[21] In a Thailand study, both distances from and time to the hospital were significantly associated with patient delay.[14]

Among health condition variables, this study found that having chronic diseases (comorbidity) was significantly accompanied by a longer median patient delay of 45.0 (IQR = 30–180). Long delay in women presenting with chronic diseases may be related to the decreased wish to seek early breast care due to their other health conditions. However, comorbidity in the British study was not a barrier to an early presentation but age ≥65 years was the cause for patient delay.[9] Regarding awareness signs, the present study reported that ≥65% of women presented with pain (tenderness) and lump with pain, and patient delay was longer in these two presentations. However, statistical significance was not observed, but the same finding was statistically confirmed in the study conducted in Pakistan.[22] This may indicate that women did not care much about these two signs. Similarly, median patient delay was higher among women who had four children: 32.0 (IQR = 7.5–90). The same outcome was approved in a study in Poland.[24] This finding may indicate that women's childcare could intervene with patient delay by giving more priority to homecare and children instead of their own health.

Concerning knowledge about BC, this study found that low patient knowledge was related to more patient delay, but the relationship was weak and not statistically significant (R = −0.013, P = 0.817). The significant relation of knowledge with patient delay has been approved in many studies. A study confirmed that knowledge decreased patient delay by an odd of 2.5.[25] Specifically, some studies have determined low knowledge about warning signs for a longer patient delay.[21],[26]

The present study showed that among health belief model constructs, women's health motivation (R = −0.166, P = 0.009) and perceived barriers to medical care (treatment; R = 0.149, P = 0.02) were significantly related with patient delay or not seeking treatment. Same finding was observed in the Iranian study; while in the Iranian study, all constructs of health belief model, such as perceived barrier and benefit to treatment, confidence, perceived seriousness, and susceptibility, significantly determined the patient delay;[27] this model explained that how women belief and attitude contributed to making decisions to prevent diseases.[18] In this study, women who reported a lower health motivation and more perception to treatment barrier were more likely to delay in presenting symptoms.

In the current study, women's perceived seriousness of BC and perceived susceptibility were associated with patient delay, while these were statistically not significant. Women who perceived less seriousness (fear about BC) and susceptibility (perceived to get BC) reported a longer delay in presentation and not seeking treatment. This finding was controversial with the studies in LMICs, which indicated the fear from diagnosis was the barrier for early presentation.[23],[26] Similarly, in a Poland study, fear of being diagnosed with cancer was observed for (48%) causes of patient delay.[24]

Logistic regression analysis was used to predict the factors related to patient delay ≥3 months. The model was accounted for 70% of the variance in patient delay. Aged women, unemployed, those who live out of the city, widow, those who perceived barely self-sufficient economic state, women with long lactation period, confident, those who experienced more barrier for treatment, and were more likely to be delay for presentation (≥3 months) [Table 4].
Table 4: Variables in binary logistic regressions analysis of predicting 3 months delay

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 > Conclusions Top

The patient delay in this study was higher compared to the British study which reported a delay of 30 days. Socioeconomic and health conditions, such as marital status, insufficient economic status, and associated comorbidities, were significantly associated with a longer patient delay. In addition to this, among health belief model constructs, women's health motivation and perceived barriers to medical care contribute to the patient delay. Aged women, unemployed women, women those who live out of city, widow, and women with long lactation period tend to have higher patient delay. This is due to lack of education and awareness among people for early diagnosis. For early diagnosis program, measuring patient delay for symptomatic BC women is more crucial. Educating women on BC and motivation for seeking early health checkup would improve the BC prognosis in women.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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