Delayed Diagnosis in Breast Cancer Patients: a Case Study of National Health Insurance in Taiwan
Shwn-Huey Shieh
1,2
1
Department of Health Services Administration, College of Public Health, China Medical University, Taichung, Taiwan
2Department of Nursing, China Medical University Hospital, Taichung, Taiwan
Table 1. Descriptive analysis of patients’ diagnostic factors (N=600)
Variables n %
Level of medical service at first visit
Medical center 321 54.7
Regional hospital 121 20.6
District hospital 95 16.2
Local clinic 44 7.5
Others 6 1.0
Number of hospitals visited before diagnosis
1 355 61.0
2 177 30.4
3 44 7.6
≥4 6 1.0
Mammography on the first visit
No 205 36.1
Yes 363 63.9
Breast ultrasound on the first visit
No 153 26.9
Yes 415 73.1
MRI on the first visit
No 547 96.3
Yes 21 3.7
Length of delay in diagnosis (days)
≤30 407 90.4
31-90 16 3.6
91-180 8 1.8
≤181 19 4.2
Mean of delay in diagnosis = 27.8±88.0 days
Table 2. Correlation between patient characteristics, various factors and delay in diagnosis
Variables Delay in diagnosis (days)
n Mean SD F-value P-value
Age at first detected symptom (y) 1.25 0.292
≤44 151 38 103 45-49 99 26 93 50-54 74 31 103 ≥55 114 17 47 Education level 0.59 0.557 Elementary or lower 117 20 66 Secondary school 194 31 98 College or higher 135 29 90 Marital status 1.66 0.175 Single 40 31 117 Married 338 27 76 Divorced/Separated 21 67 202 Widowed 50 17 59
Average family monthly income (TWDa) 0.31 0.816
≤25,000 50 23 57
25,001-45,000 87 32 98
45,001-85,000 136 29 93
>85,000 65 39 111
Level of medical service at first visit 3.32 0.011
Medical center 245 19 58
Regional hospital 93 28 89 District hospital 75 35 105
Local clinic 33 76 178
Others 4 9 8
Number of hospitals visited before diagnosis 27.57 <0.001
1 288 14 45
2 126 27 68
3 30 142 237
≥4 4 187 206
Mammography on the first visit 1.63 0.106
No 143 41 127
Yes 296 22 62
Breast ultrasound on the first visit 0.09 0.932
No 106 29 94
Yes 333 28 88
MRI on the first visit 4.51 <0.001
No 425 29 90
Yes 14 8 5
Table 3. Important predictors in delayed diagnosis with adjusted model
Variables β Std err 95% CI P-value
Lower Upper Age at first detected symptom (y)
≤44 (ref)
45-49 -19.63 13.08 -45.37 6.11 0.134
50-54 0.14 14.27 -27.95 28.23 0.992
≥55 -12.33 14.70 -41.26 16.60 0.402
Education level
Elementary or lower (ref)
Secondary school 4.84 14.60 -23.90 33.58 0.740 College or higher -3.54 15.99 -35.01 27.94 0.825 Marital status Single (ref) Married -9.40 17.24 -43.32 24.52 0.586 Divorced/Separated 37.70 28.14 -17.69 93.08 0.181 Widowed -15.55 25.65 -66.04 34.93 0.545
Average family monthly income (TWDa) ≤25,000 (ref)
25,001-45,000 9.16 16.49 -23.29 41.61 0.579 45,001-85,000 13.14 15.74 -17.84 44.12 0.404 >85,000 16.95 18.59 -19.62 53.53 0.362 Level of medical service at first visit
Medical center (ref)
Regional hospital -1.33 12.50 -25.93 23.27 0.915 District hospital 6.13 14.45 -22.31 34.57 0.672 Local clinic 18.19 19.81 -20.79 57.17 0.359
Others 1.38 44.47 -86.13 88.89 0.975
Number of hospitals visited before diagnosis 1 (ref)
2 1.41 11.23 -20.69 23.52 0.900
3 148.24 19.79 109.29 187.19 <0.001
≥4 214.16 51.08 113.64 314.68 <0.001
Mammography on the first visit No (ref)
Yes -6.08 12.04 -29.79 17.62 0.614
Breast ultrasound on the first visit No (ref)
Yes 9.11 12.77 -16.02 34.23 0.476
MRI on the first visit No (ref)
Yes -5.94 31.54 -68.00 56.13 0.851
Note: n=320; Adj R2=0.206; F-value=4.929; p<0.0001
Background
Breast cancer is the most prevalent cancer in women around the world, and it has been the leading incidence of cancer in Taiwanese females for 25 years [1]. From 2004, the Department of Health has provided free breast mammograms once every two years for women aged between 50 and 69 years old, but only 12 % of all eligible women take advantage of this screening service [2]. In comparison with other developed countries, Taiwanese women have lower awareness of the danger of breast cancer [2]; approximately 85 to 96 % of patients discovered the symptoms for breast cancer by themselves, not via breast screening [3-5].
A review of literature on delay in diagnosis finds that most studies are concerned with the delays caused by the referral system between general practices and hospitals. But contrarily, due to the implementation of the National Health Insurance system, the medical environment allows patients in Taiwan high accessibility to medical care, and people have the freedom to choose their preferred hospitals; thus delays caused by general practices or referral processes do not happen in Taiwan. The results of this study are anticipated to provide the government and medical organizations with references for developing policies to reduce the delay in the diagnosis of breast cancer, and to assist breast cancer patients in early detection and treatment.
Objective
Aims of this study, to understand the current conditions of delayed diagnosis in cases of breast cancer in Taiwan, to predict the crucial factors influencing the delay in diagnosis of breast cancer.
Methods
Subjects
The research subjects were breast cancer patients of two medical centers in central Taiwan. Face-to-face interviews were conducted in clinics and breast-cancer patients’ associations during July 26th 2007 and July 31st 2008 with structured questionnaires; 615 questionnaires were retrieved, 600 of which were effective.
Data collection
The survey contents included basic personal information (age, educational level, marital status, occupation, and economic status), factors delaying the diagnosis (level of the hospital first visited, number of hospitals the patients visited before breast cancer diagnosis, items inspected on the first visit), and number of days of delayed diagnosis (defined as time elapsed between the first visit for breast cancer-related symptoms and the time of diagnosis) [5-10]. The number of days of delay in diagnosis was reported by the patients from memory.
The questionnaire was designed and developed cooperatively, and its validity was evaluated by seven medical experts specializing in breast cancer. This study plan was validated by the Institute Review of Board of China Medical University Hospital (DMR96-IRB-78).
Statistical analysis
Collected data were analyzed using a t-test and ANOVA. Finally, multiple regression analysis was used to predict the factors influencing the delay in the diagnosis of breast cancer in patients.
Results
Of the 600 breast cancer patients recruited in this study, their average age when the symptoms were discovered was 48 years old.
The first hospitals visited were medical centers for 54.7 % of the subjects, and were regional hospitals for 20.6 % of the subjects; most of the subjects (355 patients, 61 %) visited only one hospital before diagnosis were given, and 30.4% visited two hospitals; in the first clinical visit, 363 (63.9 %) subjects received a mammogram, 415 subjects received a breast ultrasound, and 21 subjects received a magnetic resonance imaging (MRI) scan. The average delay in diagnosis was approximately 28 days: 407 (90.4%) subjects had a delay in diagnosis of less than 30 days, and 43 (9.6 %) subjects experienced a delay of more than one month (Table 1).
Table 2 indicates the correlation between diagnosis delay factors and the delay in diagnosis, the correlation between the hospital level of the patient’s first visit and the delay in diagnosis was significant (p = 0.011): the average delay in diagnosis for patients who visited clinics was the longest (76 days), and was the shortest for patients who visited medical centers (19 days). The correlation between the number of hospitals visited before diagnosis and the delay in diagnosis was significant (p < 0.001): the more hospitals that were visited before correct diagnosis was given, the longer the delay in diagnosis; patients who visited three hospitals before correct diagnosis had an average delay in diagnosis as long as 142 days, and patients who visited four or more hospitals had an even longer delay in diagnosis on average (187 days). Patients who underwent an MRI as the only examination in their first hospital visit were significantly correlated with a delay in diagnosis (p < 0.001); patients who received only an MRI experienced an average diagnosis delay of 8 days; patients who received a mammogram and a breast ultrasound did not show a significant correlation with delay in diagnosis (p > 0.05), and their average delay in diagnosis was 22 days and 28 days, respectively (Table 2).
Results of multiple regression analysis show that the variations on delay in diagnosis between patients who visited three and four or more hospitals were significant (p < 0.001). In comparison to patients who visited only one hospital (the reference group), the delay in diagnosis of patients who visited three hospitals was approximately 148 days longer, and the delay in diagnosis of patients who visited four or more hospitals was approximately 214 days. Patients whose first hospital visited was a clinic had a longer delay in diagnosis as compared to patients whose first hospital visited was a medical center (reference group) of approximately 18 days (Table 4).
Conclusion
The length of delay in diagnosis for breast cancer is shorter in comparison to European countries and to the United States; the results also show effectiveness in some of the preventive health care of National Health Insurance. This study also finds that the higher the level of the hospital first visited, the shorter the delay in diagnosis; and the more hospitals visited before a breast cancer diagnosis, the longer the delay in diagnosis. Therefore, this study suggests that when a clinic or small hospital discovers that a patient is suspicious of having the symptoms of breast cancer, the hospital should take the initiative of transferring the patient to a larger hospital for further examination. This would prevent the repetitive use of medical services and subsequently shorten the delay in diagnosis.
Reference
[1] Department of Health. Hygiene Statistic Display (Sixth) Hygiene Statistic Tendency: Death Rate and Cause. Taipei, Taiwan: Department of Health; 2006.
[2] Department of Health. Phase II National Cancer Prevention and Treatment Program-Cancer Screening, 2010-2013. Taipei, Taiwan: Department of Health; 2010.
[3] Wang HH, Hou MF. Diagnostic delay and related factors in women with breast cancer. Kaohsiung J Med Sci 1993;9(2):103-12.
[4] Chie WC, Chang KJ. Factors related to tumor size of breast cancer at treatment in Taiwan. PREVENTIVE MEDICINE 1994;23(1):91-7.
[5] Lin, Y.C. Factors associated with medical-seeking delay, diagnostic delay, and therapeutic delay of women with breast cancer: in a medical center in southern Taiwan. M.S. thesis, National Cheng Kung University, Tainan, Taiwan; 2000.
[6] Caplan LS, Helzlsouer KJ, Shapiro S, Wesley MN, Edwards BK. Reasons for delay in breast cancer diagnosis. PREVENTIVE MEDICINE 1996;25(2): 218-224.
[7] Tartter PL, Pace D, Frost M, Bernstein JL. Delay in diagnosis of breast cancer. Ann SURG 1999;229(1):91-96.
[8] Gwyn K, Bondy ML, Cohen DS, Lund MJ, Liff JM, Flagg EW, et al. Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer 2004;100(8):1595-1604.
[9] Barber MD, Jack W, Dixon JM. Diagnostic delay in breast cancer. Br J Surg 2004;91(1):49-53.
[10]Unger-Saldana K, Infante-Castaneda C. Delay of medical care for symptomatic breast cancer: A literature review. Salud Publica Mex 2009;51(2S):S270-85.
