Economic Condition Affects Breast Cancer Care- A Cross Sectional Study in Bangladesh.

Background: Socio- economic condition plays a role on taking decision for cancer treatment beside this out pocket expenditure is a headache for cancer patients. For that, pattern of nancial assistance for breast cancer treatment and associated factors were explored. Method: A cross sectional study was carried out with 200 samples; those were selected randomly from the listed patients who attended in the day care centre of chemotherapy. Results: Maximum respondents rst visited to health care provider at II and III stage with rst symptom as lump on breast or axilla, no patients came at stage I. Along with family and neighbor, social welfare also play a positive role to assist nance . Donation was the major means to collect money and two or three sources were needed at a time for collecting money. In chi square (χ 2 ) test, economic condition had a signicant role on care seeking. Simultaneously by ANOVA it was found that mean difference was more at age 31-40 year of age. After 50 years, care seeking time was intersect, here Main effect of age was F (1, 192) = 1.92, p=0.162; Main effect of economic condition was F (3, 192) =0.27, p=0.847; Inter effect was F (2, 192) = 1.77, p=0.154. Conclusion: After knowing cancer, she and her family member become puzzled to collect money. For that necessary measure should be taken to easy availability of expenditure cost. It is recommended to launch public health insurance as soon as possible. oor and giggles nervously. “I’m not going to the doctor now for nancial reasons (2)”. In a study, it was found that delay of care seeking due to nancial problem only 8% (7). But in this study, out of 200 sample 157(78.5%) respondents stated that due to economic problem medical care seeking was hampered and delayed. In many countries’ health insurance is a way to pay bills. But in Bangladesh most of them had no health insurance facilities along with high out pocket expenditure (16). Still health system nancing is regressive. High family socioeconomic status independently predicted early care seeking (AOR = 2.23, p = 0.013) and in logistic regression it is β = 1.148, odds ratio.11, p = 0.032 at 95% CI where lower value0.01 and upper value 0.83(17).


Background:
Cancer holds the second position among the non-communicable diseases under study of World Health organization (WHO) (1). The World Health Organization (WHO) estimates approximately 1.38 million new breast cancer cases each year, resulting in 458,000 deaths annually.
Unsurprisingly, mortality rates are much higher in the developing world where women often only seek medical assistance and diagnosis in the late stages-unaware of what is wrong and reluctant to shell out on medical costs. In Bangladesh, poor access to medical facilities, stigmatization along with lack of knowledge about the disease mean that a mere 11 percent of Bangladeshi women receive diagnosis in the early stages. Like in much of the world, breast cancer is the most common cancer amongst Bangladesh's female population, with 32. 8  Concerns about nancial burden among breast cancer patients are particularly troubling due to the costly multidisciplinary approach currently required to treat breast cancer. This multidisciplinary approach, regardless of insurance status, results in increased out-of-pocket expenses such as deductibles, and co-pays for hospitalizations and physician visits (6).
Perspectives of the study were explained to the respondents and informed consent was taken from each respondent. Face to face interview was taken from diagnosed breast cancer patients admitted in selected hospital by pretested semi structured questionnaire. Interview was taken to 40-45 minutes in length. In total 200 patients completed the interview. The reason for non completion included being too tired, having poor physical health, lack of interest. Generalization was assured as because patients from whole country came to this only public cancer hospital for treatment and diagnosis.
breast cancer patients came to seek treatment at stage III. Fifty-seven patients' family income were 1000-5000-taka, fty-four patients family income were 6000 -10,000 taka, and rest 22 patient's family income were 11000 taka and above.

Discussion And Conclusion:
Cancer causes serious economic damage to the households since medical care required against the disease is usually very expensive. Cancer exerts huge economic pressure both on the household economy as well as public health sector (1). An expense on cancer is as like double edge sword. In Bangladesh, even after the high net worth individual will grow quickly people in this area are still regresses to seek medical care especially in cancer due to nancial problem. In a study it was found that the majority of patients received assistance with costs associated with radiation therapy and approximately 70% of subjects needed nancial assistance with two or more services (15). Majority n = 100(50%) of respondents sought nancial assistance from social welfare department of cancer hospital. Then husband, son, neighbors, relatives also assisted nancially. Maximum respondents 117(58.5%) received money as donation. Others were managed money by borrowed, selling properties or land and saving as well. Maximum 49% (n = 98) respondents needed nancial assistance from double source, 42% (n = 84) solved from single source; only 9% (n = 18) patients collect money from triple sources.
Results of 172 patients, 50 of each had T2, T3, or T4 stages, and 22 had T1 (7). Majority of patients were in advanced stage. n = 133(66.5%) were in stage III and n = 33(16.5%) respondents were categorized as stage IV. Majority of patients n = 149 (74.5%) initially presented with a lump in breast while in a study it was found that the main presenting complaint for women with tumors was a lump (96%) and 24% presented with breast pain (7).
A patient named Basanti Majumder clutching her baby and speaks of a pain in her left breast and fears her cancer may have returned. She stares brie y at the oor and giggles nervously. "I'm not going to the doctor now for nancial reasons (2)". In a study, it was found that delay of care seeking due to nancial problem only 8% (7). But in this study, out of 200 sample 157(78.5%) respondents stated that due to economic problem medical care seeking was hampered and delayed. In many countries' health insurance is a way to pay bills. But in Bangladesh most of them had no health insurance facilities along with high out pocket expenditure (16). Still health system nancing is regressive.
Still the treatment of non communicable disease as well as cancer is an out-pocket expenditure. When the patients diagnosed as cancer nance is a problem to start treatment. Public health insurance is not established yet in Bangladesh. For poor patient's social welfare department play a role in cancer hospital but it was not su cient. Cancer patients collect money from two or three sources. Financial constrain should be overcome to start early diagnosis and treatment which will bene cial for survival time. To combat this rising burden, implementation of management and nance in health sector should be emphasized. Health strategy for communicable disease should be reformed and drastically reorganized in order to meet the challenges of the increasing burden of cancer along with other non-communicable diseases. Because this was a cross-sectional study, inference could not be done clearly. There was a chance of recall bias. A large sample size and in-depth interview could provide more reliable information. Despite of hospital-based study due to one specialized cancer hospital in Bangladesh whole cancer patients ultimately came to this hospital. That's why the study represents the whole country.      Figure 1 Two-way analysis of variance (Two-way ANOVA) among care seeking time, family income and economic condition (n=200) Relationship among care seeking time, family income and economic condition was summarized. Care seeking time was more than 6 months those who had economic problem (1000-5000-11 vs.12; 6000-10000-10 vs. 10; 11000-15000-4 vs. 12; 16000-30000-7 vs. 9). Maximum care seeking time was those who had monthly family income1000-5000 taka and 11000-15000 taka. Economic problem at 11000-15000 taka caused the highest care seeking time (Mean 12). Here Main effect of family income was F (3, 192) = 0.0608, p=0.611; Main effect of economic condition was F (1, 192) = 2.31, p=0.130; Inter effect was F (3, 192) = 0.96, p=0.410.

Figure 2
Two-way analysis of variance (Two-way ANOVA) among care seeking time with age in years and economic condition (n=200) Relationship among care seeking time, age in years and economic condition was summarized. At age 26-30 years, those who had no economic problem had less care seeking time (7vs.12). At age 31-40 years, those who had no economic problem care seeking time mean became sharply low and those who had economic problem to manage the money care seeking time mean sharply rise, but at age >50 years care seeking time mean was reversed (12 vs. 10  Two-way analysis of variance (Two-way ANOVA) on delay with rst diagnostic institution and economic condition (n=200) Relationship among care seeking time, rst diagnostic institution and economic condition was summarized in Figure 3. Care seeking time mean was higher for those who face economic problem than another group. Those who had no economic problem to consult at private hospital, was care seeking time less (Mean=9 vs.11) than the patients had economic problem. Those who had no economic problem, consulted at cancer hospital had care seeking time less. Those who had economic problem, consulted at cancer hospital care seeking time most (Mean=17