INTRODUCTION
Cancer is considered a world health problem, WHO (World Health Organization) reports the cause of 1 out of 6 deaths is globally due to cancer. Data from The Global Cancer Observatory (Globocan) in 2020, breast cancer in Indonesia is among the most common cancers found in women with a proportion of 30.8% of the total cases of other cancers with 65,858 new cases [1].
The most common cancer found in women, especially in Indonesia, is breast cancer, and East Java ranked second with the highest number of cancer incidences [2]. Non-communicable disease division from the Health Department of Jember reported in a preliminary study that the number of recent breast cancer incidences in 2019 is at about 2,873 cases.
Baladhika Husada Hospital provides poly oncology services and chemotherapy units that are integrated
and cover Jember, Banyuwangi, and Lumajang regions.
This hospital is recorded as the hospital that handles most cases of breast cancer. As reported by The Jember District Health Office, about 2,712 cases in 2019 were handled by this hospital. Of the total breast cancer patients treated at the hospital, approximately 70% are at an advanced stage that is suspected to be caused by delayed diagnosis. Delays in breast diagnosing contribute to poor prognosis and a lack of therapeutic options to be done which has an impact on low life expectancy or chances of recovery [3].
Based on Farida’s 2016 research, delay in diagnosis in breast cancer patients is motivated by behavioral factors that are divided into three groups of factors, namely predisposing, enabling, and reinforcing factors [5]. The research conducted by Yuswar and Nurlilis [4]
found that the greatest effect among many factors that specifically cause delays in breast cancer patients’ early
Analysis of Dominant Factors that Effect Delayed Diagnosis in Women with Breast Cancer in Baladhika Husada Hospital Jember
Nisrina Fakhiroh Hidayati Nublah
*, Ancah Caesarina Novi Marchianti, Sugeng Winarso
Magister of Public Health Science, Jember University, Jember, Indonesia
*Corresponding author:
Nisrina Fakhiroh H. N.
Magister of Public Health science, Jember University, Jember, Indonesia [email protected]
A R T I C L E I N F O Received : 23 October 2021 Reviewed : 26 November 2021 Accepted : 21 December 2021 Keywords:
alternative treatment, breast cancer, delay in diagnosis
A B S T R A C T
Background: Delayed diagnosis will have an impact on poor prognosis and complicate the treatment of breast cancer, contributing to low life expectancy for breast cancer patients. The study aims to find the factors that play the most role in influencing the behavior of women with breast cancer as well as dig deeper into the things behind the patient in making decisions that have an impact on delayed diagnosis.
Methods: The study uses an analytical observational design with quantitative and qualitative mixed methods. Collecting data was conducted from April until June 2021 on 76 women with breast cancer at Baladhika Husada Hospital Jember based on classification into case and control groups. The sampling method used purposive sampling and the Lemeshow formula.
Results: The results showed the factor that dominates the occurrence of delayed diagnosis is alternative medicine (p = 0.013; OR 11.03). Based on the results of the study, patients who undergo alternative medicine are 11 times more at risk of delayed diagnosis of breast cancer compared to patients who do not undergo alternative treatment.
Conclusions: The patient’s background in choosing alternative medicine is supported by various reasons including concerns about medical treatment methods, concerns about nominal medical costs, and negative information from the surrounding. Thus, it can be concluded that the dominant factor affecting the delay in the diagnosis of women with breast cancer is alternative medicine.
correlations between free variables. The analysis was supported and strengthened by qualitative analysis to examine more deeply the reasons to decision making so that it has an impact on the occurrence of delayed diagnosis in women with breast cancer undergoing treatment at Baladhika Husada Jember Hospital.
RESULT
Based on the results of Table 1, among 10 variables are homogeneous data, namely ownership of health insurance and family support.
Table 1. Selected characteristics of delayed diagnosis in women with breast cancer
Variable and Category Cases Control
n % n %
Knowledge
Less 14 36.8 8 21.1
Enough 14 36.8 13 43.2
Good 10 26.4 17 44.7
Fear
Yes 30 78.9 23 47.7
No 8 21.1 15 52.6
Education
Lower 30 78.9 18 47.4
Higher 8 21.1 20 52.6
Accessibility of Health Facility
Unreached 4 10.5 1 2.6
Reached 34 89.5 37 97.4
Economic Status
Lower 19 50 20 52.6
Middle 15 39.5 6 15.8
Upper 4 10.5 12 31.6
Health Insurance
Own 36 100 36 100
Family Support
Own 36 100 36 100
Alternative Medicine
Ever 29 76.3 7 18.4
Never 9 23.7 31 81.6
Pain
No 35 92.1 11 29.8
Yes 3 7.9 27 71.1
SADARI Behaviour
No 35 92.1 22 57.9
Yes 3 7.9 16 42.1
SADARI, pemeriksaan payudara sendiri (breast-self examination)
detection behaviors are SADARI (Self-Check Breast) and pain factors. Delayed diagnosis of breast cancer has an impact on the low chances of recovery for breast cancer patients. Therapy done at an advanced stage does not affect healing in breast cancer patients, so such a condition contributes to the death rate from breast cancer.
To devise appropriate and strategic policies for reducing cancer delay rates, it is necessary to identify factors that affect delays in breast cancer diagnosis [5]. The study aims to find the main and most dominant factors influencing delays in breast cancer diagnosis. It is expected that the results of this study can be considered in designing and drafting a well-targeted policy program. In addition, the final results of this effort will help the government in increasing life expectancy for breast cancer patients and reduce the mortality rate caused by breast cancer.
METHODS
This study was conducted from April until June 2021.
The research used quantitative and qualitative methods with a total sample of 76 respondents divided into 2 groups based on the clinical stage, namely 38 respondents as a control group in the early stage and 38 respondents as a case group in the advanced stage. The population in this study were women who had breast cancer and were undergoing treatment at Baladhika Husada Jember Hospital. The women who got the end of the treatment or were in the rehabilitation period become exclusion criteria of this research. Primary data collection was done using questionnaires and in-depth interviews. The questionnaire consisted of 8 sections of questions related to the variables studied including the identity of respondents, questions about general characteristics (education level, income, mileage to health services, health insurance ownership, etc.), and 10 questions about knowledge and questions about 7 steps of early detection of SADARI. A mixed method of quantitative and qualitative was used to analyze the exploration of exposure. In addition to questionnaires, as the material for qualitative analysis, the researchers conducted in-depth interviews with several breast cancer women who were undergoing treatment and a team leader of the oncology unit nurses of Baladhika Husada Jember Hospital.
Statistical analysis was conducted on the testing of free variables consisting of predisposing factors (knowledge, psychological pain, and education level), enabling factors (accessibility to health facilities, economic status, health insurance, and alternative medicine), and reinforcing factors (family and community support) with variables depending on the delayed diagnosis. Statistical analysis testing in this study was carried out in stages, ranging from univariate analysis, bivariate analysis using Chi-Square, and multivariate analysis using logistic regression to find the dominant factors that affect the delay in diagnosis of breast cancer.
A multicollinearity test was performed to identify
education, pain, and alternative medicine variables. Next, a multicollinearity analysis test was done to identify correlations or relationships between independent variables (education, pain, and alternative medicine) related to the dependent variable, namely delays in breast cancer diagnosis. The analysis found that aOR of the pain variable had a big gap between lower and upper limits because the response from the level of pain became the basis for the patients to decide to check up on their condition to health service. At the end of the analysis, it was found that pain, alternative treatment, and education were the dominant factors (Table 4).
Table 5 shows that the tolerance value of the education variable is 0.927, pain 0.942, and alternative medicine 0.912, all of which are greater than > 0.10, which means meaningful. The VIF value in the education variable is 1.079, pain 1.062, and alternative medicine 1.096, all of which are less than < 10.0 which means there is no multicollinearity in this regression model.
From the results of Table 2, there are 5 variables from 10 independent variables that have a significant influence on the delay in breast cancer diagnosis, namely education (p = 0.009), economic status (p = 0.008), alternative medicine and pain (p = < 0.001), and SADARI behavior (p = 0.001).
Multivariate analysis was performed to find potential independent variables or, in this case, the most dominant factors influencing dependent variables. The results of testing potential independent variables or dominant factors that have a significant influence on delayed breast cancer diagnosis are alternative treatment variables with p = 0.013 (Table 3).
In the following analysis tests, two stages of testing were conducted, namely multivariate selection and multicollinearity testing. Multivariate selection aims to find the dominant factor of each factor group as a candidate for multicollinearity testing. From the selection, three dominant factors were obtained, among others,
Variables Case Control OR
p-Value
n % n % (95% CI)
Knowledge
Less 14 36.8 8 21.1 2.97 (0.92–9.56) 0.118
Enough 14 36.8 13 43.2 1.83 (0.62–5.42) 0.411
Good 10 26.4 17 44.7 1
Fear
Yes 30 78.9 23 47.7 2.44 (0.88–6.75) 0.134
No 8 21.1 15 52.6 1
Education
Lower 30 78.9 18 47.4 4.16 (1.52–11.40) 0.009*
Higher 8 21.1 20 52.6 1
Accessibility of Health Insurance
Unreached 4 10.5 1 2.6 4.35 (0.46–40.89) 0.358
Reached 34 89.5 37 97.4 1
Economic Status
Lower 19 50 20 52.6 2.85 (0.78–10.39) 0.138
Middle 15 39.5 6 15.8 7.5 (1.71–32.79) 0.008*
Upper 4 10.5 12 31.6 1
Alternative Medicine
Ever 29 76.3 7 18.4 14.27 (4.70–43.29) <0.001*
Never 9 23.7 31 81.6 1
Pain
No 35 92.1 11 29.8 28.63 (7.26–112.8) <0.001*
Yes 3 7.9 27 71.1 1
SADARI behavior
No 35 92.1 22 57.9 8.48 (2.21–32.51) 0.001*
Yes 3 7.9 16 42.1 1
*p < 0.05 means significant or statistically significant; SADARI, pemeriksaan payudara sendiri (breast-self examination);
OR, odds ratio; CI, confident interval Table 2. Risk of selected
variables on delayed diagnosis in women with breast cancer
Variable aOR 95% CI
Lower limit Upper limit p
Knowledge 1.17 0.16 8.19 0.874
Fear 1.29 0.22 7.32 0.771
Education 1.79 0.24 13.17 0.565
Accessibility of Health Insurance 0.88 0.04 19.58 0.937
Economic Status 0.11 0.01 1.27 0.078
Family Support 1.1 0.05 23.64 0.949
Alternative Medicine 11.03 1.64 74.08 0.013
Pain 19.5 2.55 149.17 0.040
SADARI behavior 8.24 1.1 61.39 0.039
N observation 76
2 Log Likelihood 47.1
Nagelkerke R2 71.40%
*p < 0.05 means significant or statistically significant; SADARI, pemeriksaan payudara sendiri (breast-self examination);
aOR, adjusted odds ratio; CI, confident interval Table 3. The final
model of dominant factors delayed diagnosis in women with breast cancer
Table 4. Mapping the dominant factors of 3 groups of factors affecting delayed diagnosis in women with breast cancer
Variables aOR 95% CI
Lower limit Upper limit p Predisposing Factor
Lack of Knowledge 1.04 0.30 3.63 0.947
Enough Knowledge 1.18 0.29 4.67 0.813
Fear 2.78 0.91 8.49 0.072
Education 4.33 1.35 13.83 0.013
N observation 76
2 Log Likelihood 93.15
Nagelkerke R2 19.80%
Enabling Factor
Accessibility of Health Insurance 1.81 0.10 32.23 0.685
Lower Economic Status 0.38 0.09 1.64 0.198
Middle Economic Status 7.13 1.20 42.11 0.030
Alternative Treatment 22.85 5.55 94.11 0.000
N observation 76
2 Log Likelihood 67.10
Nagelkerke R2 52.70%
Reinforcing Factor
Pain 26.93 6.41 113.11 0.000
SADARI behavior 7.54 1.54 36.91 0.013
N observation 76
2 Log Likelihood 63.14
Nagelkerke R2 56.8%
*p < 0.05 means significant or statistically significant; SADARI, pemeriksaan payudara sendiri (breast-self examination);
OR, odds ratio; CI, confident interval
DISCUSSION
This research discusses several factors that affect delayed diagnosis in women with breast cancer who have been on treatment at the Baladhika Husada Jember Hospital. The factors are divided into three groups, namely predisposing, enabling, and reinforcing factors.
Predisposing factors that affect the delayed diagnosis of women with breast cancer are the level of education, belief and trust, values, and traditions in society. In this study, the results of the bivariate analysis showed that the level of education is significantly higher to the occurrence of delayed diagnosis in women with breast cancer. Women with lower levels of education are 4.16 times more likely to delayed check-ups compared to women who have a higher level of education. That is because the respondents with a higher education level can take the initiative to check with healthcare workers when they find a lump on their breast and identify the condition as a problem.
A different response is shown in the group of women with a lower level of education. They tend to ignore the problem encountered, the presence of lumps in the breast.
Women with a lower level of education consider the condition as a natural thing, so they decide not to check the condition with healthcare workers. According to Romadani [6], the lower level of education has an impact on the lack of acceptance and understanding of a particular disease that will cause respondents’ ignorance about early detection.
The other aspects of predisposing factors which have been proven that give a significant effect are belief and trust. In this study, researchers conducted in-depth interviews with some respondents. Based on the results of the interview, respondents’ beliefs and trusts influence their behavior in making decisions related to their health. These beliefs and trust related to their health behavior are based on their perception when they know there is a problem in their breasts as well as their trust in medical treatment or traditional medicine.
One of the respondents’ perceptions of a condition that occurs in their bodies is influenced by psychological changes after finding a lump or after getting the results of the examination analysis. Psychological changes are characterized by anxiety, depression, and despair, so respondents tend to perceive the condition as death. The
same thing was found in the study of Taleghani et al. [7]
that women associate their condition, in this case, breast cancer, with death. This affects the response afterward, which ultimately impacts decisions in subsequent detection and treatment.
The beliefs and trust behind their health behavior cannot be separated from the amount of distorted information about procedures or treatment of breast cancer. The patients’ beliefs and trusts in both medical and non-medical treatments directly affect their decision to undergo detection to then get diagnosed and undergo treatment so that it will have an impact on the occurrence of delayed diagnosis in breast cancer patients.
Other than belief and trust, the values and traditions in society also affect the delayed diagnosis. Based on the in-depth interview of the two groups of respondents, it was found that breast cancer patients at Baladhika Husada Hospital, mostly coming from Jember, Lumajang, and Banyuwangi, are dominated by ethnic Javanese, Osing, and Madurese tribes. People with ethnicities are very close to the traditional medicine system based on spiritual concepts and utilizing natural products. Values and traditions in society become the basis of patients in making decisions to prioritize traditional medicine without trying to undergo medical treatment, resulting in delays in diagnosis and treatment in breast cancer patients.
This is in line with the research of Yulianarista and Suaraya [8] which found that the behavior of seeking traditional medicine is done because it is considered more oriented to social and cultural factors so most women with breast cancer choose to undergo herbal treatment.
A person’s behavior in making decisions is based on the value of tradition in the community. The norms that prevail in the community will shape a person’s perception so that they will consider the value of local traditions or cultures.
In this study, it was found that the behavior of traditional society is generally based on the hereditary habits of children, offspring, and relatives, one of which is advice and suggestion in the selection of actions or treatment. This research is also in line with Martono [14], stating that traditional behavior or attitudes in society affect the way of thinking, one of which is based
Variable t Sig. Collinearity Statistic
Tolerance VIF
(Constant) 6.721 0.000
Education 1.659 0.102 0.927 1.079
Pain 0.251 0.802 0.942 1.062
Alternative Medicine -.088 0.930 0.912 1.096
VIF, variance inflation factor Table 5. Independent
variable multicollinearity testing related
to delayed diagnosis in women with breast cancer.
economic status. At the individual level, research consistently shows that individual indicators or low household incomes are associated with a higher risk of later stages of breast cancer.
The economic needs of women with breast cancer are not only medical costs also but operational costs to access health services. The unfair socialization of national health insurance services has an impact on perceptions and concerns about the high cost of treatment for breast cancer sufferers. Most new sufferers process health insurance after the first examination into the health service.
The same results were also conveyed in Rasjidi et al. [9] study that women with the lowest socioeconomic class had five times greater risk factors than women with high economy class for late treatment. Socially low economic status limits the scope of response information as well as actions that can be taken in early detection and treatment.
Other than economic status, based on the bivariate and multivariate analyses, alternative treatments significantly affect delays in breast cancer diagnosis.
Respondents who underwent alternative medicine 11 times were at risk of delaying their diagnosis of breast cancer. Generally, respondents decide to prioritize alternative medicine when they find a lump in their breasts. The decision is based on the information obtained either from relatives or from the media related to treatment testimonials. In addition, the respondents have a negative perception of medical treatment as well as the perception that alternative medicine is considered more effective and has minimal side effects.
Alternative medicine is much in demand. A person suffering from an early illness initially gets information from advertisements, neighbors, friends, or other sources that the pain she/he suffers can be restored through alternative medicine. People are interested in such information and will propose to be cured by alternative medicine practicians. The time, location, and type of alternative treatment selected by respondents are various;
some claim to come to alternative treatments such as herbal medicine, spiritual, or massage therapy after getting a diagnosis of tumors and the like. This is done to avoid chemical treatment methods (chemotherapy) and surgery. (Statement of case group respondents 3)
Others decided to visit alternative medicine practicians before getting examination. The length of treatment time in the respondents varied, and the longest is recorded at approximately 4 years. The perceptions and expectations of respondents to the results of alternative medicines that are considered more effective than medical treatment do not have a good effect but worsen the condition. In the end, after learning that alternative methods did not produce the expected results, the respondents seek medical treatment for chronic conditions or advanced stages. This makes it more on the experience or habits where one can judge what
is profitable and what is not.
Based on the bivariate analysis, it was found that knowledge and psychological fear do not give a significant effect on the delayed diagnosis of breast cancer. However, based on the level of risk, women with less knowledge are 3 times at risk to delay checking their condition to the health service. In this study, data collection was done while respondents were undergoing treatment so that their level of knowledge related to breast cancer was better than before the examination.
This is because they have independently sought information after getting a diagnosis. (As in the following statement of control group respondents 2)
The results of these findings will be more maximal if the study is carried out when respondents have not done an examination or have not received a diagnosis.
Knowledge is the result of “knowing” that occurs after a person uses his five human senses to a particular object. Knowledge is the primary domain that determines how a person makes decisions and performs actions.
Psychologically, the fear factor based on the bivariate analysis was not found significantly affected because both the control group and the case group had fear.
The thing that distinguishes between the two is the response in perceiving the psychological condition of the fear experienced. Some respondents claimed to feel afraid of the possible operation undergone after getting a diagnosis; the fear causes respondents to choose to delay checking their condition to the health service.
Meanwhile, in the control group of respondents, the fear experienced was not much different; they feared surgery and the cost of treatment. In the control group respondents, they responded to these concerns by checking their condition and consulting with healthcare workers (Statement of control group respondents 1).
This is done to dig up more information about the treatment procedures to be faced including surgery.
The difference is evident in the following statement of control group respondents 3. They decided to delay checking up as a response to their psychological fear.
The same psychological fear condition is thought to have led to statistical analysis showing that there was no significant influence between fear and delay in diagnosis. This study is in line with Yuswar and Nurilis [4] study which showed that there was no influence between fear and delayed treatment.
Enabling factors that affect the delayed diagnosis of women with breast cancer are economic status and alternative medicine. This study found that economic status significantly affects delayed diagnosis in women with breast cancer at Baladhika Husada Jember Hospital.
Women with lower economic status are 7 times more likely to experience delays than women with higher
difficult for healthcare workers in managing breast cancer to minimize the number of patients to heal.
(Statement of case group respondents 2)
The results in this study are in line with Farida [5]
who states that alternative medicines have a significant influence on the delay of breast cancer patients in checking themselves into health care facilities.
In this study, accessibility of health facilities and ownership of health insurance did not significantly affect delays in breast cancer diagnosis. The accessibility of health facilities is reviewed based on the distance from where respondents live to related health facilities and the public transportation access. It had no effect because most breast cancer patients, 93.42% of respondents, can reach the health facility that provides treatment for breast cancer patients.
Based on the results of interviews with respondents, even though the distance between residences and health facilities is more than 3 km with no transportation access, there are ambulances available in the village or local area to facilitate access to residents. (Statement of control group respondents 1)
The availability of facilities in the form of village ambulances or local health centers is felt to greatly help the limitations of patients in accessing desired health facilities so that the accessibility of health facilities is not associated with delayed diagnoses in breast cancer patients.
Health insurance ownership did not affect the delay of breast cancer diagnoses because most respondents undergoing breast cancer treatment at Baladhika Husada Hospital had been registered with national health insurance (BPJS). Some respondents stated in the interview that the registration process was finally carried out after they were informed about services supported by the BPJS program by both post-diagnosis healthcare workers and local village employees (Statement of case group respondents 1). The statement was justified by the information of the head nurse of the oncology clinic of Baladhika Husada Hospital that almost 98% of new patients have BPJS after getting advice or recommendations from healthcare workers.
The results of this study are in line with Farida [5], that there is no influence between health insurance and delayed treatment in breast cancer patients. In the literature review conducted by Saldana and Castaneda [10], the relationship between socioeconomic status and delay has not been proven definitively.
Reinforcing factors that affect the delayed diagnosis of women with breast cancer are pain and early detection of SADARI. The second reinforcing factor that affects the delayed diagnosis is pain. This found that pain affects the occurrence of delayed diagnosis in women with breast cancer. This finding is in line with that of Maghouse et al. [11] who stated that pain contributes to delayed diagnosis. From the interviews
conducted on patients, it was found that the respondents claimed at the diagnosis, that they did not feel the pain of the lump in the breast. They tend to ignore it because it is considered not to interfere with daily activities. They also assume that if there is no pain, the lump will shrink and disappear by itself. (Statement of case group respondents 2)
According to Notoatmodjo [15], a person acts to check themselves or treat her/his illness driven by the seriousness of the disease and the threats seen regarding symptoms and diseases against him/her.
In some cases, pain also influences respondents’
decision-making regarding early detection. The respondent who does not feel pain does not have the initiative to do the early detection, especially SADARI (breast self- examination). The results of statistical analysis in this study found that early detection behavior (breast self- examination) significantly affects the occurrence of delayed diagnosis in women with breast cancer. Women who do not apply early detection behaviors realize that they are at risk 8 times to experience delays in breast cancer diagnosis. This is due to the symptoms of breast cancer that are sometimes invisible and, in some cases, are not accompanied by pain; they are generally not aware.
The SADARI early detection behavior referred to in the study is based on testing on 7 screening steps whether in periods or menstrual cycles (for women of productive age). The sufferers have done some or seven steps of early detection of SADARI. Early detection plays an important role in the process of the breast cancer experience. According to Despitasari and Nofrianti [16], breast cancer is a type of cancer that is quite easily characterized by risk factors, the appearance of symptoms, and tends to be found through early detection such as Breast Self-Examination or SADARI.
Based on the findings in this study, there are two different behavioral images between the respondents of the case group and the control group on the early detection behavior of SADARI. For the case group, the respondents generally implement the conscious behavior only in the fifth step (making a touch to the breast to detect the presence of lumps) which is done accidentally while bathing. Limited knowledge and information about early detection have caused the steps taken to not continue to the next step repeatedly. Respondents tend to ignore it because they do not feel any effect or change.
Different behavioral images are shown in the respondents of the control group who generally perform their breast examination more than one step including reflecting with a standing position while observing the shape, size, and color of the breast (step 1) and touching on both sides of the breast (steps 5 and 6). After finding a problem or lump in her breast, the respondents will do their examination periodically adjusting their menstrual
diagnosis is hard to be explored. Therefore, the result of the knowledge analysis has not shown a significant effect. Other than that, the older age and lower education greatly complicated filling out the questionnaire.
CONCLUSIONS
Factors that affect delays in breast cancer diagnosis based on patient delays are divided into three factors (predisposing, enabling, and reinforcing factors). Among them, the analysis test was conducted with multivariate analysis.
It was found that the dominant factor that affects delayed diagnosis in women with breast cancer at Baladhika Husada Jember Hospital in 2021 is enabling factor which, in this case, is alternative medicine (p = 0.013 and OR 11.03). Therefore, patients who prioritize alternative medicine before medical treatment have an 11 times greater risk of experiencing a delay in breast cancer diagnosis than patients who never took alternative medicine.
DECLARATIONS
Ethics ApprovalThis research was approved by KEPK (Health Research Ethics Commission), Faculty of Dentistry, University of Jember (The Ethical Committee of Medical Research Faculty of Dentistry University of Jember) with ethical number 1237/UN25.8/KEPK/DL/2020.
Competing of Interest
The authors declare no competing interest in this study.
Acknowledgment Not applicable.
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