Delayed Presentation of Symptomatic Breast Cancer in Chinese Women

The Plan for Healthy China 2030 has made early detection and treatment of cancers a priority. Delay before treatment initiation increases the likelihood of a later-stage diagnosis of breast cancer and reduces survival. This delay is a complex and multifactorial phenomenon, and the factors contributing to delay among Chinese women are unclear. This dissertation aimed to deepen our understanding of delay and provide evidence to inform the development of strategies to reduce delay. Chapter 1 is an integrative review that aimed to characterize delay intervals among Chinese women living in mainland China, Hong Kong, and Taiwan; to identify factors contributing to delay; and to develop a conceptual model of these factors. Using Whittemore and Knafl’s methodology for integrative reviews, PubMed, CINAHL, Web of Science, SCOPUS, PsycINFO, and China National Knowledge Infrastructure were searched for primary research articles. For the 15 selected studies, quality evaluation was performed employing the Crowe Critical Appraisal Tool. A narrative synthesis was developed to summarize and explain the findings. I found that total delay intervals (from the first discovery of breast symptoms to treatment initiation) exceeded 3 months for 50.2%-52% of breast cancer patients. The greatest delay occurred between symptom discovery and the first presentation of symptoms to healthcare providers. I identified eight categories of factors that affect delay in presentation, diagnosis, and treatment, including symptom appraisal, Chinese culture, knowledge of breast cancer symptoms and breast cancer screening, health history, personality, social factors, healthcare factors, and background factors. I concluded that half of Chinese breast cancer patients delayed long enough to lower their chances of survival. Factors identified in this review can inform nursing interventions to raise breast cancer awareness and promote timely diagnosis and treatment among Chinese women. As revealed in Chapter 1, a high-quality study about delay in seeking breast evaluation in mainland China is needed. Most breast cancers in China are diagnosed when women present their self-discovered symptoms to healthcare providers rather than through screening. Thus, Chapter 2 presents a cross-sectional study that aimed to identify the time intervals of presentation delay among women with symptomatic breast cancer, describe the impact of the COVID-19 pandemic on delay, identify factors contributing to delay, and examine the potential moderation effects of healthcare factors on delay. In the study, 154 Chinese women with symptomatic breast cancer were surveyed and interviewed. Up to 24.7% of the subjects delayed ≥ 3 months before presentation, which is long enough to lower the chance of survival and is longer than in western countries (14-18% in previous research). The COVID-19 pandemic contributed to delay for 13.8% of the subjects, but the impact appeared to be limited, as the delay intervals were comparable with pre-pandemic data in China. Factors contributing to delay ≥ 1 month included preferring female physicians for clinical breast examination, less negative emotional response to symptoms, more competing role demands, believing folk therapy can help treat lumps, not knowing someone with breast cancer, and visiting a secondary or tertiary hospital rather than a primary healthcare provider. For women with lower perceived healthcare access and lower trust in physicians, the effects of perceived seriousness of symptoms on presentation delay were significant: the higher their perceived seriousness of symptoms, the less likely they were to delay seeking breast evaluation ≥ 1 month. In addition, awareness of breast cancer screening should be promoted among Chinese women, and access to screening urgently needs to be increased. The study findings demonstrated the impact of the COVID-19 pandemic on Chinese women’s help-seeking and can inform the development of programs to reduce delay. Furthermore, the findings provide insights that other low- and middle-income countries can consider to improve early detection of breast cancer. These study contributions could ultimately improve the survival rates and quality of life of breast cancer patients.