Delay in seeking medical attention can be divided into five stages: appraisal delay, illness delay, behavioral delay, scheduling delay, and treatment delay . The combination of these five stages is known as total patient delay, and the appraisal delay is the major stage, comprising 60% of the total delay .
Appraisal delay is the patient’s interpretation of her bodily symptoms as an illness or labeling it as serious symptoms [7, 9]. Illness delay is the number of days elapsing from the time an individual interpreted that her symptoms were concerning to the day she decided to seek medical attention, and behavioral delay is the time from her decision to the time she acted on the decision .
The first three stages, which are the appraisal, illness, and behavioral delay, are the patient-related delays. These stages comprised various factors such as the patient’s sociodemographics, previous history, interpretation of the breast symptoms, types of symptoms, knowledge, attitudes, and practices toward breast symptoms, which were analyzed in most previous studies [4, 6, 8, 9, 11, 13–15]. Lower educational level  and lack of knowledge  were associated with delayed presentation of breast cancer. In our study, the respondents’ mean age was 33.99 years, which was younger than the mean age of 47.9 years in a previous study . This younger mean age could explain why the respondents in our study presented earlier to the clinic than older patients since younger patients probably were better educated and more aware of breast cancer risks.
Our study found that 61.3% of the respondents presented within 1 month, and only 19.8% of the respondents had delayed presentation of > 3 months. This percentage was much lower than the percentage in a previous local study in Malaysia. This finding indicated the improving breast cancer awareness among the community and easily accessible health care service.
Our study was prospectively designed to avoid recall bias unlike most previous studies, which involved retrospective collection of data from medical records [4, 8, 9, 11, 15, 18, 19].
Presentation delay was operationally defined as the time elapsed between symptom self-discovery and the first presentation to a medical provider to seek evaluation . A local multicenter study published in 2011 concluded that 43.4% of the patients with breast cancer had delayed presentation times .
A delay in presentation for breast cancer examination of > 3 months was previously found to be associated with 10% lower survival rates . Another study estimated that 20–30% of women waited ≥ 3 months before seeking medical help with breast symptoms . The delayed presentation group in our study had similar perceptions that their symptoms were not dangerous. This finding is consistent with the percentage of patients who misinterpreted their symptoms as less serious than cancer, which led to delayed presentation in a study with a Western population [5, 6].
Women that delayed > 3 months were less likely to have a breast lump and had a family member previously diagnosed with breast cancer . We would expect that the respondents with a family history of breast cancer or a previous history of breast illness would present early to the clinic. Instead, we found that five (4.7%) respondents in our study with a family history of breast cancer had delayed presentations.
In our study, the most common symptom of our respondents was a breast lump (75.5%). The main reason for seeking care was that the lump was getting bigger. This finding suggests that there might be women with other breast symptoms who also do not seek medical attention. Women should understand that breast cancer symptoms are not limited to lumps and that there can be other symptoms, so early assessment is important for earlier diagnosis . In a previous study, patients with breast symptoms other than a breast lump were likely to delay in presenting to a clinic . However, in our study, we found the opposite. Our comparison of breast lumps to other breast symptoms showed that patients with breast lumps had a higher likelihood of delayed presentation (adjusted OR: 4.39, 95% CI: 0.92, 20.92; p = 0.063).
Most of the respondents informed their family members or friends about their symptoms prior to visiting a clinic. The husband can play an essential role in the decision to seek an examination when they first learn about their wife’s symptoms by encouraging them to present to a clinic as soon as possible. Nevertheless, the final decision to seek treatment was usually made by the women themselves.
Use of alternative medicine has previously been found to be associated with delayed presentation [4, 21]. In our study, only 10.4% of the respondents sought alternative treatments. A previous study in UMMC, Malaysia, found that the percentage of alternative medicine usage was 34.8% among newly diagnosed patients with breast cancer . However, in our study, we included both benign and malignant conditions. The previous study cited above also noted that most (73.1%) of the respondents did not disclose their alternative medicine use to their doctor . Our study population had a lower percentage of respondents who sought alternative treatment, which could be because they were a younger cohort that may have been less influenced by alternative health beliefs than an older cohort. However, we could only postulate this we did not explore this topic in our questionnaire. Our BESTARI clinic is a friendly service that provides walk-in consultations, examinations, and treatments without a prior appointment for new cases. This “one-stop center” service was the preferred type of facility among the respondents.
Our study found that an interpretation of symptoms as harmless was associated with presentation delay (adjusted OR: 3.051, 95%CI: 1.111, 8.378). Thus, our future breast awareness campaign should highlight that any breast symptoms have the potential to be associated with a malignant breast cancer tumor. Our respondents had a good attitude toward doctors. A few respondents were concerned about the doctors being male, but this did not contribute to their delay in seeking treatment. The highest numbers (23.8%) of respondents in the delayed group did not want to burden the doctor with small matters. This finding could be due to their earlier interpretation of the symptom as not dangerous, thus not requiring medical attention. Many of the respondents felt shy in breast exanimation; therefore, it is crucial for health care facilities to maintain an environment that puts patients at ease and comfort. It is also essential for their husbands to support the breast examination and treatments, as many women first inform their husbands about their breast symptoms before visiting the clinic.