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The influence of delay time on the survival of patients with carcinoma of the breast in British Columbia Moorehead, William P. 1978

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THE INFLUENCE OF DELAY TIME ON THE SURVIVAL OF PATIENTS WITH CARCINOMA OF THE BREAST IN BRITISH COLUMBIA by WILLIAM P. MOOREHEAD MB Bch Bao Queens U n i v e r s i t y B e l f a s t  1962  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (Dept. o f H e a l t h C a r e and Epidemiology)  We accept t h i s t h e s i s as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA September 1978  ©  W i l l i a m P. Moorehead, 1978  In p r e s e n t i n g  this  thesis  in p a r t i a l  fulfilment of  an advanced degree at the U n i v e r s i t y of B r i t i s h the L i b r a r y s h a l l I  f u r t h e r agree  for scholarly by h i s of  make i t  t h a t permission  written  thesis  for  Columbia,  reference and  f o r e x t e n s i v e copying o f  It  for financial  is understood that copying or gain s h a l l  not  Health Care  The U n i v e r s i t y o f B r i t i s h 2075 Wesbrook Place Vancouver, Canada V6T 1W5  September  15,  and E p i d e m i o l o g y  Columbia  1978  P.  that  thesis or  publication  permission.  Department of  0  this  for  study.  be allowed without my  William  Date  I agree  purposes may be granted by the Head of my Department  representatives.  this  freely available  the requirements  Moorehead  ii ABSTRACT The  q u e s t i o n asked i n t h i s t h e s i s i s , "What i s t h e  i n f l u e n c e o f d e l a y time on the s u r v i v a l o f p a t i e n t s w i t h carcinoma o f t h e b r e a s t i n B r i t i s h Columbia"? A p r e l i m i n a r y data review was c a r r i e d out on r e c o r d s of the Cancer C o n t r o l Agency o f B r i t i s h Columbia f o r t h e years I960, 1961 and 1970 t o e x p l o r e p o s s i b l e changes i n d e l a y time and the methodology o f t h e present  study.  The y e a r s 1960 t o 1964 i n c l u s i v e and t h e two d e l a y p e r i o d s , under one month and one year and over, were chosen f o r study. A t o t a l o f 456 cases from both d e l a y p e r i o d s was a v a i l a b l e f o r comparison. L i f e T a b l e s were used f o r a n a l y s i s o f the two d e l a y p e r i o d s and t h e i r s u r v i v a l from date o f d i a g n o s i s and date o f f i r s t symptom.  No s t r o n g r e l a t i o n s h i p was  between s h o r t d e l a y and s u r v i v a l .  found  In f a c t , i n the i n i t i a l  years, those who had l o n g d e l a y appeared t o do b e t t e r , although  i n the l o n g term s h o r t d e l a y appeared t o have an  advantage. A g a i n w i t h L i f e T a b l e s , the two d e l a y p e r i o d s and s u r v i v a l were e x p l o r e d i n each o f the f o u r c l i n i c a l of t h e d i s e a s e .  stages  T h i s showed t h a t i n c l i n i c a l stages I  and I I , t h e long d e l a y group s u r v i v e d l o n g e r .  The o p p o s i t e  was t r u e i n c l i n i c a l stages I I I and IV. The  i m p l i c a t i o n s f o r h e a l t h p l a n n i n g are d i s c u s s e d .  OF  CONTENTS  INTRODUCTION PRELIMINARY  DATA  LITERATURE THE  REVIEW  REVIEW  RELATIONSHIP  TO  OF  DELAY  TIME  INFLUENCING  DELAY  TIME  SURVIVAL  FACTORS  CHARACTERISTICS YEARS  AND  COURSE OTHER  AND THAN  OBJECTIVES  DELAY  IN  RECENT  INFLUENCING  SURVIVAL  OF  THE  BREAST  CANCER  TREATMENT  METHODOLOGY  DATA  OF  FACTORS  OF OF  RESEARCH STUDY  SOURCES  METHODS  OF  ANALYSIS  RESULTS THE  DISTRIBUTION  YEAR AGE  OF  GROUPS,  LOGICAL SITE  MARITAL  ECONOMIC THE OF  STAGE,  BREAST  PATHO-  INVOLVED,  HISTOLOGICAL STATUS  BY  YEAR  AND  DESCRIP-  SOCIO-  TIME  ON  OF  THE  ASSOCIATION  SURVIVAL  FROM  OF  YEAR  DIAGNOSIS  THE  ANALYSIS  DELAY OF  TIMES  FIVE  STATUS  ANALYSIS  DELAY  DELAY A G E ,  CLINICAL  STAGE,  INVOLVED,  TION,  OF  DIAGNOSIS,  TIME  FIRST  THE  OF  THE  ASSOCIATION  SURVIVAL  FROM  DATE  SYMPTOM  ANALYSIS  BETWEEN WITH  ON  DELAY  CONTROL  OF  THE  TIME FOR  ASSOCIATION AND  OTHER  SURVIVAL FACTORS  OF  iv  6.0  CONCLUSION  6.1  METHODOLOGICAL ASPECTS OF THE STUDY  6.2  DISTRIBUTION OF DELAY  6.3  ANALYSIS OF  6.4  INTERPRETATION  6.5  IMPLICATIONS FOR HEALTH  6.6  POLICIES AND PLANNING  7.0  BIBLIOGRAPHY  TIME  SURVIVAL  PLANNING  OBJECTIVES OF  HEALTH  V  L I S T OF TABLES NUMBER OF CASES WITH D I S T R I B U T I O N OF AGES DURATION OF DELAY I N MONTHS AMD NUMBER OF CASES 1960 DURATION OF DELAY I H MONTHS AND NUMBER OF CASES 1961 DURATION OF DELAY I N MONTHS AND NUMBER OF CASES 1970 PERCENTAGE OF CASES FOR EACH PERIOD OF DELAY TIME FOR AGE STRATIFICATIONS 1960 PERCENTAGE OF CASES FOR EACH PERIOD OF DELAY TIME FOR AGE STRATIFICATIONS 1 9 6 1 PERCENTAGE OF CASES FOR EACH PERIOD OP DELAY TIME FOR AGE STRATIFICATIONS 1970 A COMPARISON OP TWO DELAY PERIODS, UNDER 3 MONTHS, ONE YEAR AMD OVER WITH AGE S T R A T I F I C A T I O N S FOR 1 9 6 0 , 1961 AND 1970 COMPARISON OF TWO DELAY PERIODS, LESS THAN ONE MONTH, ONS YEAR AND OVER. WITH AGE S T R A T I F I C A T I O N S FOR 1 9 6 0 , 1 9 6 1 AND 1970 COMPARING THE TOTAL PERCENTAGES I N EACH YEAR EXAMINED FOR DELAY PERIODS LESS THAN ONE MONTH AND 01® YEAR AND OVER THE DISTRIBUTIONS OF DELAY TIMES WITHIN THE THREE AGE GROUPS FOR THE YEARS 1 9 6 0 , 1 9 6 1 AND 1970 COMBINED BY PERCENTAGES SHEET FOR COLLECTING DATA C L I N I C A L STAGING OF BREAST CARCINOMA PATHOLOGICAL STAGING OF BREAST CARCINOMA DISTRIBUTION OF DELAY BY YEAR OF DIAGNOSIS THE D I S T R I B U T I O N OF CASES I N THE DELAY PERIOD ONS YEAR AND OVER BY DELAY TIME DISTRIBUTION OF DELAY I N F I V E YEAR AGE GROUPS AGE D I S T R I B U T I O N OF CASES AND DELAY I N RELATION TO AGE C L I N I C A L STAGING I N RELATION TO DELAY TIME  vi  XX. XXI.  PATHOLOGICAL STAGING IN RELATION TO DELAY TIME THE DISTRIBUTION OF CASES BY BREAST AND DELAY TIME  XXII.  THE DISTRIBUTION OF CASES BY SITE AND DELAY TIME  XXIII.  HISTOLOGICAL DESCRIPTIVE TERM GROWTH IN RELATION TO DELAY  XXIV. XXV. XXVI.  HISTOLOGICAL DESCRIPTIVE TERM TYPE IN RELATION TO DELAY PATHOLOGICAL DESCRIPTIVE TERMS IN RELATION TO DELAY MARITAL STATUS IN RELATION TO DELAY  XXVII.  SOCIO-ECONOMIC STATUS AS DEFINED BY HUSBAND'S OCCUPATION IN RELATION TO DELAY  XXVIII.  SOCIO-ECONOMIC STATUS AS DEFINED BY PATIENT'S OCCUPATION IN RELATION TO DELAY  XXIX.  THE OUTCOME IN RELATION TO THE TWO DELAY PERIODS IN 456 CASES EXAMINED AS OF JUNE 1 9 7 7  XXX.  LIFE TABLE OF SHORT DELAY FRCM YEAR OF DIAGNOSIS NUMBERS OF DEATHS NOT INCLUDING CASES WHICH DIED OF COMPETING RISK  XXXI.  LIFE TABLE OF SHORT DELAY FROM YEAR OF DIAGNOSIS NUMBERS OF DEATHS INCLUDING CASES WHICH DIED OF COMPETING RISK  XXXII.  LIFE TABLE OF LONG DELAY FROM YEAR OF DIAGNOSIS NUMBERS OF DEATHS NOT INCLUDING CASES WHICH DIED OF COMPETING RISK  XXXIII.  LIFE TABLE OF LONG DELAY FROM YEAR OF DIAGNOSIS NUMBERS OF DEATHS INCLUDING CASES WHICH DIED OF COMPETING RISK  XXXIV. XXXV. XXXVI.  SHORT DELAY FROM DATE OF DIAGNOSIS - RELATIVE SURVIVAL RATES LONG DELAY FROM DATE OF DIAGNOSIS - RELATIVE SURVIVAL RATES COMPARISON OF RELATIVE SURVIVAL RATES FOR LONG AND SHORT DELAY FROM DATE OF DIAGNOSIS  vii  XXXVII.  XXXVIII.  XXXIX.  XXXX.  XXXXI.  XXXXII.  XXXXIII.  L I F E T A B L E OF SHORT D E L A Y FROM D A T E OF F I R S T SYMPTOM - NUMBER O F D E A T H S NOT I N C L U D I N G C A S E S WHICH D I E D OF C O M P E T I N G R I S K L I F E T A B L E OF SHORT D E L A Y FROM D A T E OF F I R S T SYMPTOM - NUMBER O F D E A T H S I N C L U D I N G C A S E S WHICH D I E D OF C O M P E T I N G R I S K L I F E T A B L E OF L O N G D E L A Y FROM D A T E OF F I R S T SYMPTOM - NUMBER O F D E A T H S NOT I N C L U D I N G C A S E S WHICH D I E D OF C O M P E T I N G R I S K L I F E T A B L E OF L O N G D E L A Y F R O M D A T E O F F I R S T SYMPTOM - NUMBER OF D E A T H S I N C L U D I N G C A S E S WHICH D I E D OF C O M P E T I N G R I S K SHORT D E L A Y FROM D A T E OF F I R S T SURVIVAL RATES L O N G D E L A Y FROM D A T E O F F I R S T SURVIVAL RATES  SYMPTOM -  SYMPTOM -  RELATIVE  RELATIVE  C O M P A R I S O N OF R E L A T I V E S U R V I V A L R A T E S F O R L O N G AND SHORT D E L A Y F R O M D A T E O F F I R S T SYMPTOM  XXXXIV.  CORRECTED OBSERVED SURVIVAL FROM F I R S T SYMPTOM  RATES  FOR LONG D E L A Y  XXXXV.  CORRECTED R E L A T I V E SURVIVAL FROM F I R S T SYMPTOM  RATES  FOR LONG D E L A Y  XXXXVI.  C O M P A R I S O N OF R E L A T I V E S U R V I V A L R A T E S F O R C L I N I C A L S T A G E I I N SHORT AND L O N G D E L A Y  XXXXVII.  C O M P A R I S O N OF R E L A T I V E S U R V I V A L R A T E S FOR C L I N I C A L S T A G E I I I N SHORT AND L O N G D E L A Y  XXXXVIII.  XXXXIX.  C O M P A R I S O N OF R E L A T I V E S U R V I V A L R A T E S F O R C L I N I C A L STAGE I I I I N SHORT AND L O N G D E L A Y C O M P A R I S O N OF R E L A T I V E S U R V I V A L R A T E S F O R C L I N I C A L S T A G E I V I N SHORT A N D L O N G D E L A Y  viii  L I S T  1.  BY  DELAY  A  A  SHORT  OF  OF  DELAY OF  CORRECTED  TIMES 1960,  WITHIN 1961  FROM  THE  AND  SHORT  IN  COMPARISON  III  OF  IN  COMPARISON STAGE  FOR  THREE  1970  THE  RELATIVE  AGE  COMBINED  YEARS  1960,  OF  OF  SURVIVAL  DATE DELAY  OF  RATES  FOR  LONG  FOR  LONG  DIAGNOSIS  F I R S T  RELATIVE  SURVIVAL  RATES  SYMPTOM SURVIVAL  RATES  RATES  FOR  LONG  RATES  FOR  CLINICAL  RATES  FOR  CLINICAL  FOR  CLINICAL  SYMPTOM  RELATIVE AND  AND  RELATIVE SHORT  SURVIVAL  LONG  RELATIVE  SHORT  IN  SURVIVAL  DATE  FROM  FIRST OF  II  RELATIVE FROM  SHORT  STAGE  I  PERCENTAGES  RELATIVE  COMPARISON  STAGE  8.  BY  DELAY  SHORT  DELAY  7.  DELAY YEARS  ILLUSTRATIONS  1970  COMPARISON AND  6.  PATTERN AND  COMPARISON  AND 5.  OF  THE  COMPARISON  AND 4.  FOR  AMD  PERCENTAGES  1961 3.  FIGURES  DISTRIBUTION GROUPS  2.  OF  AND  DELAY  SURVIVAL LONG  DELAY  SURVIVAL LONG  RATES  DELAY  AC raroWLEDGEMENT I w i s h t o a c k n o w l e d g e t h e g u i d a n c e and h e l p  given by  t h e c h a i r m a n and members o f my t h e s i s c o m m i t t e e .  Chairman:  J . M a r k E l w o o d , M.B., M.D., F.R.C.P. (C) , Head., D i v i s i o n ofEpidemiology. C a n c e r C o n t r o l Agency o f B r i t i s h C o l u m b i a J , M, R o b i n s o n , M.B., D.P.H., Assistant Professor. D e p a r t m e n t o f H e a l t h C a r e and  F.R.C.P.(C).  Epidemiology. U n i v e r s i t y o f B r i t i s h Columbia  G.. M. C r a w f o r d . M.D., F.R.C.P. (C) . Rad . l o t h e r a p i s t , C a n c e r C o n t r o l Agency o f B r i t i s h C o l u m b i a  1  1.0 The  INTRODUCTION  cornerstone o f treatment o f cancer i s e a r l y  n o s i s and t r e a t m e n t .  Carcinoma  o f t h e b r e a s t i s no e x c e p -  t i o n t o t h e r u l e a n d modern d i a g n o s t i c t e c h n i q u e s mammography (1) (2) and t h e r m o g r a p h y t h a t end.  diag-  such as  (3) h a v e b e e n u s e d t o  H e a l t h e d u c a t i o n has propagated s e l f - e x a m i n a t i o n  and e a r l y a t t e n d a n c e w i t h symptoms t o t h e d o c t o r . I n t h e p a s t , i t h a s been suggested, t h a t tumours have a " b i o l o g i c predeterminism  (4) (5) ( M a c D o n a l d  1 9 5 1 , 1958) and  that the course o f cancer o f the breast i s uninfluenced by treatment  (6) ( P a r k a n d L e e s  1951).  They p o i n t out t h a t  t u m o u r s w h i c h h a v e t h e a b i l i t y t o m e t a s t a s i z e may h a v e done so a t a v e r y e a r l y s t a g e i n t h e l i f e  o f t h e tumour, b e f o r e  d i a g n o s i s and t r e a t m e n t i s p o s s i b l e .  I n 1951 a t t h e t i m e o f  p u b l i s h i n g "Absolute C u r a b i l i t y o f Cancer  o f Breast" they  remark on t h e p a u c i t y o f r e f e r e n c e s t o t h e f u n d a m e n t a l  rela-  t i o n s h i p o f d e l a y t i m e and s u . r v i v a l a n d o f t h e a b s e n c e o f i n t e r e s t i n the matter.  T w e n t y - f i v e y e a r s l a t e r , t h e same  i n t e r e s t i s l a c k i n g and t h e r e a r e s t i l l to this relationship.  v e r y few r e f e r e n c e s  D e l a y h a s b e e n examined i n e v e r y  characteristic to a i dthe health educationist t o i t s shorte n i n g and e a r l i e r t r e a t m e n t i n t e r v e n t i o n .  Very few have  l o o k e d a t d e l a y and s u r v i v a l o f c a n c e r o f b r e a s t i n t h e l i g h t o f t h e s t a t e m e n t mace b y P a r k a n d L e e s empirical confirmation that curability" It  - " i f t h e r e i s no  "delay i n treatment lowers t h e  most o f c a n c e r t r e a t m e n t l o s e s i t s r a t i o n a l e " .  i swith this  statement  i n mind t h a t t h e q u e s t i o n i n t h i s  2  t h e s i s i s asked.  What i s t h e i n f l u e n c e o f d e l a y t i m e on  s u r v i v a l of p a t i e n t s w i t h carcinoma Columbia?  of the breast i n B r i t i s h  A s t u d y w i l l be made on t h e r e l a t i o n s h i p between  d e l a y t i m e , d e f i n e d as t h e t i m e f r o m t h e  first  i n m o s t p a t i e n t s i s d i s c o v e r y o f a lump)  (5)  ment.  the  The  f i r s t t r e a t m e n t w i l l be  biopsy/surgery.  S u r v i v a l w i l l be  the date the time  death or a given date of c o l l e c t i o n of  symptom  to f i r s t of biopsy  (which treator  from biopsy  to  data.  T h i s t h e s i s w i l l be b a s e d on a r e t r o s p e c t i v e s t u d y medical records  i n the l a r g e s t cancer treatment  facility  in  the Province.  Initially  t h e s i s w i l l be  a p r e l i m i n a r y review o f the data a v a i l a b l e i n  the c l i n i c a l  the procedure  on  f o r t e s t i n g t h e hypo-  r e c o r d s of the Cancer C o n t r o l Agency, o f  c a s e s w i t h Ccircinoma o f t h e b r e a s t .  This w i l l define  primary the  q u a l i t y of the data,  the d i s t r i b u t i o n o f p a t i e n t d e l a y times  w i t h i n a g i v e n year,  t h e number o f c a s e s  d e l a y has  changed w i t h time.  The  last  a v a i l a b l e and i f  i s e s p e c i a l l y impor-  t a n t i n t h a t i f d e l a y does change w i t h t i m e  a broader  range  o f d a t a y e a r s w i l l need r e v i e w i n g . As  well  as  r e v i e w i n g d e l a y and  v a r i a b l e s which are  be  possibly  survival,  associated  i n c l u d e d i n t h e d a t a c o l l e c t e d : - age,  the  with the  clinical  following above  will  stage,  p a t h o l o g i c a l s t a g e , p o s i t i o n o f tumour, outcome, h i s t o l o g y , m a r i t a l s t a t u s , and  socio-economic  i n d e x as d e f i n e d  by  Blishen ( 3 3 ) . The  p a t i e n t s f r o m t h e C a n c e r A g e n c y w i l l be  reasonably  representative of the t o t a l population w i t h carcinoma t h e b r e a s t as a p p r o x i m a t e l y the agency. ability  We  will  of  70% o f nev/ c a s e s a r e s e e n i n  t r y t o ensure t h a t the  i s confirmed by comparing  survivals  representfrom our s e r i e s  of  p a t i e n t s t o t h o s e r e c o r d e d by t h e P r o v i n c i a l  of  a l l cases.  registry  4 PRELXJ1IHARY DATA  2.0  A preliminary  REVIEW  d a t a r e v i e w wan  necessary t o define the  q u a l i t y o f t h e r e c o r d s i n t h e C a n c e r A g e n c y , and t o examine the g e n e r a l c h a r a c t e r i s t i c s o f t h e d a t a w i t h r e s p e c t t o age, delay time  and i t s d i s t r i b u t i o n .  Change o f d e l a y w i t h age and o v e r t i m e w e r e  t o be i m p o r t a n t occur  variables.  considered  These a r e changes t h a t  might  and c o u l d a f f e c t t h e c h o i c e a n d e x t e n t o f d a t a t o b e  collected.  The c o n c l u s i o n s t h e r e f o r e on t h a t c h o i c e o f d a t a  w i t h i t s i m p l i c a t i o n s f o r t h e f u t u r e c o u l d be c o n f i d e n t l y applied. My  breast.  i n t e r e s t w i l l be i n p r i m a r y cases o f carcinoma o f the  Primary cases  are those  defined  a s d i a g n o s e d and  t r e a t e d i n that year by the Cancer C l i n i c r e f e r r a l a f t e r treatment The  o r on i m m e d i a t e  or d i a g n o s i s elsewhere.  p r e l i m i n a r y data review w i l l help t o formulate the  m e t h o d o l o g y w h i c h w i l l answer t h e h y p o t h e s i s . tant  questions 1.  Mi at  age  a r e t o be  2.  of the primary cases  and d o e s t h i s c h a n g e w i t h t i m e ? I will  l o o k a t age i n e a c h y e a r  stratified  into  sive  65.  and >  three  levels _  To  chosen,  4 4 , 45 - 64  inclu-  time?  formulate the best comparison o f short  d e l a y and l o n g d e l a y t i m e s w i t h r e s p e c t vival .  by  facilitate  Miat i s the d i s t r i b u t i o n o f cases by delay This w i l l  impor-  answered:-  i s the distribution  this,  Three  to  sur-  5  3.  I s t h e r e a change i n t h e c h a r a c t e r o f d e l a y w i t h time?  I f t h e r e i s a c h a n g e i t w i l l be  t o s a m p l e more r e c e n t y e a r s w i t h  necessary  corresponding  r e d u c t i o n i n f o l l o w up p e r i o d f o r t h o s e T h i s could  years.  l e a d t o a b i a s i n comparing the  i n f l u e n c e o f l o n g and s h o r t d e l a y t i m e s and survival. A study o f a i l p a t i e n t s diagnosed  i n the f o l l o w i n g  years  was c h o s e n t o a n s w e r t h e s e t h r e e q u e s t i o n s a n d f o r m u l a t e t h e methodology o f f u r t h e r research?  i 9 6 0 , 1961 and 1970.  e x a m i n i n g t h e number o f p r i m a r y c a s e s ution  a n d t h e i r age d i s t r i b -  ( T a b l e I ) , I f i n d no c h a n g e i n age d i s t r i b u t i o n b e -  t w e e n 1960 and. 1 9 7 0 .  The t h r e e l e v e l s o f s t r a t i f i c a t i o n  i d e n t i c a l a v e r a g e a g e s i n 1 9 6 0 , 1961 and 1 9 7 0 . age  i s 55 y e a r s  for a l lpatients.  examining a l l p r i m a r y 1970  according t o delay time g r o u p s and. i n t o t a l .  Over h a l f o f t h e  age g r o u p i n g (45 - 64)  s i v e i n a l l t h e years examined.  seen.  inclu-  The d i s t r i b u t i o n o f p a t i e n t s  i s examined b o t h  i n the s t r a t i f i e d  These are d i s p l a y e d g r a p h i c a l l y by  t a b l e s , b a r g r a p h s and l i n e graphs f o r e a c h  for the f i r s t  The a v e r a g e  c a s e s i n 1960 ( 2 4 7 ) , 1961 (224) and.  i n t h e middle  Reviewing T a b l e s  have  T h i s i s derived, from  ( 3 6 7 ) , a t o t a l o f 333 p a t i e n t s .  p a t i e n t s occur  age  On  year.  I I , I I I a n d I V , a n i n i t i a l peak  p e r i o d o f delay time  The m o s t common r e s p o n s e s  response  ( l e s s t h a n one month) i s  from p a t i e n t s recorded  e i t h e r a f e w d a y s o r two t o t h r e e w e e k s .  were  T h e r e was a g r a d u a l  6  fall  o f f i n each delay p e r i o d until  12 months a n d we s e e a  s l i g h t r i s e t h e n a further one a t 24 m o n t h s . were o n l y t h r e e p e o p l e years  I n 1960 t h e r e  who h a d d e l a y times l o n g e r t h a n 5  (6 y e a r s , 10 y e a r s  and. 15 y e a r s ) .  Two d e l a y  times  were unknown, i n a 93 y e a r o l d woman a n d a 78 y e a r o l d woman a n d t h e s e w e r e c o u n t e d years.  a s b e i n g g r e a t e r t h a n two  These p a t i e n t s were o m i t t e d i n t h e a n a l y s i s .  1961 t h i r t e e n p e o p l e  delayed over  5 years  a n d o n l y four  t h o s e w e r e i n t h e > 65 g r o u p .  No d e l a y t i m e s w e r e  in  delayed  1961.  had  I n 1970 e i g h t p e o p l e  a delay time  o f 5 years.  t h e duration o f d e l a y . had  of  unknown  over 5 years  a n d f5.ve  Pour c a s e s h a d no s t a t e m e n t o n  I t was n o t e d  i n 1970 s i x physicians  contributed s i g n i f i c a n t l y t o the delay time.  not p r e s e n t  In  T h i s was  i n t h e 1960 a n d 1 9 6 1 f i g u r e s o r n o t commented  on.  There i s no s i g n i f i c a n c e i n t h e s e  tial  data d i s p l a y e d on Tables  the quality o f r e c o r d s respect t odelay times.  findings.  The i n i -  I I , I I I , a n d I V showed  that  i s h i g h i n t h e C a n c e r A g e n c y with I t would t h e r e f o r e b e p r o d u c t i v e  to ask t h e q u e s t i o n - "Mlat i s t h e i n f l u e n c e o f d e l a y  time  on t h e s u r v i v a l o f patients w i t h carcinoma o f t h e b r e a s t i n British  Columbia?"  T a b l e s V, V I a n d V I I d e f i n e t h e p e r c e n t a g e  o f cases f o r  e a c h d e l a y p e r i o d , s t r a t i f i e d i n t o t h r e e age g r o u p s .  The  d i s t r i b u t i o n i n t h e v a r i o u s delay p e r i o d s f o r each group has changed v e r y l i t t l e  b e t w e e n 1960 a n d 1 9 7 0 .  T h i s would r e -  assure u s t h a t p o s s i b l y any -further r e s e a r c h c o u l d be p r o -  7  jected to the present  day.  To  define the periods of  delay  t h a t might answer t h e h y p o t h e s i s , p a r t i c u l a r p e r i o d s d e l a y t i m e were examined. e i t h e r end  Delay  p e r i o d s were chosen at  o f t h e d e l a y t i m e s p e c t r u m and  V I I I , I X and  of  examined i n Tables  X.  I n Table V I I I comparing the p e r i o d of d e l a y time 3 months w i t h 1 y e a r b e t w e e n 1960  and  In Table  and  over t h e r e i s minimal  under  difference  1970.  IX, I have reduced the comparison t o t h e  p e r i o d l e s s t h a n one  month and  c o m p a r e d i t w i t h one  year  and  over.  T h e s e s u g g e s t when c o m p a r i n g 1970  slight  i n c r e a s e i n the p r o p o r t i o n i n the e a r l y delay period  ( l e s s t h a n one  month) .  provement d i s a p p e a r s . longer delay period 1961  and  I f 1961  and  year  and  over.  Again,  i s a l s o an i n c r e a s e i n t h e one Table XI  1970  l e s s t h a n one  in  month  t h e r e i s some i n c r e a s e i n one year  month p e r i o d b u t and  there  over group i n  and F i g u r e I c o m p a r e t h e d i s t r i b u t i o n s  d e l a y t i m e s w i t h i n t h e t h r e e age and  1960,  I h a v e compared t h e t o t a l p e r c e n t a g e s  the p r o p o r t i o n i n the l e s s than  1961  improvement i n t h e  over) comparing  each y e a r examined f o r d e l a y p e r i o d s one  im-  1970.  I n T a b l e X,  and  some  a l s o i s compared, t h i s  I a l s o f o u n d no  (one y e a r  w i t h 1960  delay  1970. of  groups f o r the years  combined by p e r c e n t a g e s .  The  t a b l e and  graph demonstrate t h a t there i s very l i t t l e d i f f e r e n c e b e t w e e n age  groups i n the p a t t e r n of  delay.  1960, bar  8  F i g u r e 2 compares t h e t o t a l p e r c e n t a g e of delay f o r each year little  and  f o r each p e r i o d  demonstrates again t h a t there i s  difference i n the years' d i s t r i b u t i o n of delay  I n the p r e l i m i n a r y data review the  f o l l o w i n g have been  demonstrated:- A v e r y h i g h c n i a l i t y o f data f o r delay is  available?  d e l a y l i a s not  i n c o m p a r i n g 1960  and  1970;  d e l a y times w i t h the three T h e s e f i n d i n g s w i l l be Methodology of  changed  significantly  there i s minimal l e v e l s o f age  times  times  with  difference in  stratification,  further explored i n the s e c t i o n -  Research.  time  TABLE I  NUMBER OF CASES WITH DISTRIBUTION OF AGES  I960  1961  AGE GROUPING  AVERAGE AGE  CASES (%)  < 44  38 yrs  52  yrs  132  (21%)  <  44  45-64  53  ^ 65  74 yrs  63 (26%)  > 65  yrs  247 (100$)  ALL  ALL  55  (53^)  AGE AVERAGE GROUPING AGE  45-64  1970 CASES (t)  39 yrs  60  yrs  107  54  74 yrs 55  yrs  (27$) (U&fo)  57 (?~5%) 224  (100%)  AGE GROUPING  AVERAGE AGE  <  38 yrs  44  yrs  45-64  54  -  74 yrs  65 ALL  55  yrs  CASES (%)  74 (20%) 219  (60^)  74 (20%) 367  (lOOg)  TABLE 11  DURATION OF DELAY IN MONTHS AND NUMBER OF CASES I960  -ci-  Of  13  lO  4  3  1  2  1  45-64 37 25  16  10  4  4  6  3  12  10  2  2  2  ?6  16  £44 >65  9 12  TOTAL: 58  7  6  J.O+  1  3 2  2 8  XX+  -it.. 1 2  2  1  7  1  1 2 4  1  1  7  1  1  2  17  2  Xt$+  1 1  1  1  ±V+  <iX+  ^+  1  2  1  1  7  5  1  1  5  3  10  11  TOTAL 3 Levels of Stratification Number of Cases  <44  52  45-64  132  >65  63 247  PERCENTAGE DISTRIBUTION OF CASES:  f 23.5 20 14.6 6,5 3.6 2.8 3 . 2 2.4 .81 1.2 .40 .81 6.9 0 .31 1.6 .40 .40 1.2 0 0 0 0 0 4.0 4.5 0  TABLE III  DURATION OF DELAY IN MONTHS AND NUMBER OF GASES 1961 MMMM  <1  1+ 2+ 3+ 4+ 5 + 6 + 7 + 8 +  <44 20 14 10  3  2  1  1  1  9+ 10+ 11+ 12+ 13+ 14+ 15+ 16+ 17+ 18+ 19+ 20+ 21+ 22+ 23+ 24+ 2 yr+  1  0 1  0  4  2  45-64 26 24 5 10 5 £65 1 4 8 5 2 1  2 6 1 0 4 1 1 4 5 0 1 2  0 1  7 2  1  TOTAL; 60 46 20 15  4 11  1  13  1  8  7  1  5  4  2  1  3 4  10 6  2  1  7  18  TOTAL Levels of Stratification Number of Cases  <44 . >65  60 ±  u  /  __  224 PERCENTAGE DISTRIBUTION OF CASES %  26.8 20.5 8.9  6.7 3.6 1.8 4.9 3.1  .45 2.2 1.8  .45 5.8 0  .45 0 0  0  .89 .45 0 0  0  3.1 8.0  TABLE I?  DURATION OF DELAY IN MONTHS AND NUMBER OF CASES 1970 <1 1+ 2+ 3+ 4+ 5+ 6+ 7+ 8+ 9+ 10+ 11+ 12+ 13+ 14+ 15+ 16+ 17+ 18+ 19+ 20+ 21+ 22+ 23+ 24+ 2 yr+ <44  18 20  7  5  3  1  2  0  0  8  1  45-64 71 45 17 12 6 8 9 4 3 1 1 >65 19 7 6 8 3 4 3 1 0 1 0  1  9  3  2  1 1  4  2  l  TOTAL:108 72 30 25 12 13 14  2  7  1  4  1  3  1  0  8  1  25  2  l  3  10 6  15 8  18  26  TOTAL 3 Levels of Stratification Number of Cases  <44  ,_ ^-64  4  74  „_ 219 0  36?  PERCENTAGE DISTRIBUTION OF CASES %  29.4 19.6 8.2  6.8 3.3 3.5 3.8 1.9 1.1 .82 .27 .27 6.8 0 0 1.1 0 0 .54 0 .2? .27 0 0 4.9 7.1  H M  TABLE  V  PERCENTAGE OF CASES FOR EACH PERIOD OF DELAY TIME FOR AGE STRATIFICATIONS I960  DELAY MTHS  <44  <1  1+  2  +  3  +  4  +  5  +  6  +  7  +  17.3$  25$  19.2$  7.7$  5.8$  1.9$  3.8$  1.9$  45-64  28$  18.9$  12$  7.6$  3$  3$  4.5$  2.3$  >65  19$  19$  15.9$  3.2$  3.2$  3.2$  3.2$  8  +  1.5$  9  +  10+  0.76$  3.2$  11+  0.76$  1.6$  1.6$  12  >12  3.8$  13.5$  5.3$  12$  11.1$  15.9$  TABLE VI  PERCENTAGE OF CASES FOR EACH PERIOD OF DELAY TIME FOR AGE STRATIFICATIONS  1261  DELAY MTHS  <44 45-64 >65  < 1  1+  2+  33.3$ 23.3$ 16.7$  3+  4+  5+  6+  7+  8+  5$  3.3$  1.7$  1.7$  1.7$  1.7$  0.93$ 8.8$  24.3$ 22.4$  4.7$ 9.3$  4.7$  1.9$  5.6$  24.6$ 14$  8.8$ 3.5$  1.8$  1.8$  7$  9+  10+  11+  12  >12  1.7$  6.7$  3.3$  3.7$  0.93$  6.5$  15$  1.8$  3.5$  3.5$  19.3$  1.8$  TABLE VII  PERCENTAGE OF CASES FOR EACH PERIOD OF DELAY TIME FOR AGE STRATIFICATIONS 1270  DELAY MTHS  <1  1+  2+  3+  4+  5+  6+  7+  8+  9+  24$  27%  9.5$  6.7%  4$  1.4$  2.7%  2.7%  1.4$  l.h%  45-64  32.4$  20.5$  7.8$  5.5$  2.7$  3.7$  4.1$  1.8$  1.4$  >65  25.7$  9.5$  8$  10.8$  4$  5.4$  4$  1.4$  <kk  1.4$  10+  11+  12 10.8$  >12 8$  4$  14.*  10.8$  18. c  16  TABLE  VIII  COMPARISON OF TWO DELAY PERIODS, UNDER 3 MONTHS, ONE YEAR AND OVER WITH AGE STRATIFICATIONS 1960 UNDER 3 MONTHS  DELAY PERIOD  A.  1 YEAR AND OVER  < 44  61.5%  17.3%  45-64  58.9%  17.3%  >65  53.9%  27%  1961 UNDER  DELAY PERIOD  3 MONTHS  <44 B.  73.3%  45-64  51.4%  2 65  47.4%  1 YEAR AND OVER 10% 21.5% 22.8%  1970 DELAY PERIOD < 44 C.  45-64 > 65  UNDER 3 MONTHS 60.5% 60.7% 43.2%  1 YEAR AND OVER 18.8% 18.6% 29.7%  17  TABLE  IX  COMPARISON OF TWO DELAY PERIODS, LESS THAN ONE MONTH, ONE YEAR AND OVER WITH AGE STRATIFICATIONS 1960  DELAY PERIOD  LESS THAN 1 MTH  1 YEAR AND OVER  < 44  17.3%  17.3%  45-64  28%  17.3%  >65  19%  27%  1961  DELAY PERIOD  LESS THAN 1 MTH  1 YEAR AND OVER  <44  33.3%  10%  45-64  24.3%  21.5%  >65  24.6%  22.8%  LESS THAN 1 MTH  1 YEAR AND OVER  1970  DELAY PERIOD < 44  24%  18.8%  45-64  32.4%  18.6%  > 65  25.7%  29.7%  18 TABLE  X  COMPARING THE TOTAL PERCENTAGES IN EACH YEAR EXAMINED FOR DELAY PERIODS LESS THAN ONE MONTH AND ONE YEAR AND OVER  <1 MTH  1 YEAR AND OVER  1960  23.5%  19.8%  1961  26.8%  18.75%  1970  29.4%  20.98%  DELAY PERIOD  TABLE XI  THE DISTRIBUTIONS OF DELAY TIMES WITHIN THE THREE AGE GROUPS FOR THE YEARS I960, 196l AND 1970 COMBINED BY PERCENTAGES  <1  1  2  3  4  5  6  7  8  9  10  11  12  >12 VO  £65  23.1$ 14.2$ 10.9$  5.8$  3$  3.5$  3.7$  4.5$  0$  2.1$  1.7$  1.1$  8.5$  18$  45-64  28.2$  20.6$  8.2$  7.5$  3.5$  2.9$  4.7$  1.7$  1.0$  1.5$  .3$  .2$  5.3$ 13.9$  <44  24.9$  25.1$ 15.1$  6.5$  4.4$  1.7$  2.7$  2.1$  1$  .5$  .6$  0$  7.1$  8.3$  20  FIGURE I. DISTRIBUTION OF DELAY TIMES WITHIN THE THREE AGE GROUPS FOR THE YEARS 1960, 1961 AND 1970 COMBINED BY PERCENTAGES  30 2.0 j 10  41  I  10  ll  IX  ><Z  MONTHS  %  10  ^1  J  10  II  ll  >/Z  MOUTHS  % 3o Zo io  41 MotfTKS  METRIC  22  3.0  LITERATURE REVIEW 3.1  THE RELATIONSHIP OF DELAY T I M E TO  3.2  FACTORS  3.3  CHARACTERISTICS OF DELAY I N RECENT YEARS AND FACTORS INFLUENCING THE COURSE AND SURVIVAL OF BREAST CANCER OTHER THAN TREATMENT  SURVIVAL  INFLUENCING DELAY TIME  23 3.1  THE The  RELATIONSHIP OF  literature  the breast to  the  DELAY TIME TO  on d e l a y  i s sparse  The  first  tween d e l a y  and  i n treatment  i n c o n t r a s t to the  avoidance of delay.  taken.  tries  The  t h a t i n c r e a s i n g d e l a y has  val,  and  the  this  Parle and ature of the They t r i e d of  cancer  that  of  delay.  Lees  (1951)  t o approach the  the c u r a b i l i t y  survi-  adverse  effect  on  by  of the  There i s a  defines the  individual  They found,  reviewing  few  references t o the  and  survival.  survival.  absolute  curability  by  in  f a r the  showing treatment  index  of  effec-  is a  tumour g r o w t h r a t e s . the  literature prior  to  fundamental r e l a t i o n s h i p o f the  r e l a t i o n s h i p had  They r a i s e d  liter-  t i m e and  as t h e d e l a y  T h e y r e m a r k e d on  t h e m a t t e r when t h e  various  existing  ways - f i r s t , ,  f i n d i n g how  avoided  - s u r v i v a l time or s u r v i v a l r a t e -  function of the  or small.  study  decreases  secondly,  t i v e treatment  ical  an  reviewed the  i n two  be-  assump-  r e l a t i o n s h i p between d e l a y  of the breast  increases?  relationship  are examined.  (6)  are  s e c o n d makes a p r i o r  group o f l i t e r a t u r e which simply  characteristics  of  attached  approaches  a s s u m p t i o n t h a t d e l a y must b e  factors i n f l u e n c i n g delay  third  importance  t o show a d i r e c t  survival.  o f carcinoma  Tv/o d i f f e r e n t  tion  with  SURVIVAL  the question  confirmation that delay  delay  absence o f i n t e r e s t been noted " I f there  i n treatment  treatment  1951,  t o be  i s no  lowers the  ability,  most o f c a n c e r  From t h e  l i t e r a t u r e they have reviewed they  absent  empircur-  loses i t s rationale". drew  in  these  24  inferences: "Cancer o f t h e b r e a s t has a wide range o f v a r i a b i l i t y i n behaviour, a t l e a s t i n so f a r as concerns the d u r a t i o n s between the stages o f growth and spread." They suggested t h e r e i s a b i a s i n s e l e c t i o n o f c a s e s . That good r e s u l t s seem t o appear from s t u d i e s s e l e c t e d  from  the lower grades o f malignancy. Most o f these s t u d i e s d e f i n e d "cure" as 5 years s u r v i v a l and suggested t h a t t h e f i v e year cure o r s u r v i v a l r a t e was a date chosen which m a g n i f i e s the r e s u l t s o f the above chosen cases and comparisons  tended t o be b i a s e d .  There seemed t o  be some evidence t h a t i n c r e a s e d d e l a y i n treatment may s l i g h t l y decrease The  curability.  f i n a l c o n c l u s i o n they came t o was - " I f t h e r e i s a  r e l a t i o n s h i p between d e l a y i n treatment and c u r a b i l i t y , and, s i n c e p r e s e n t day treatment o f cancer o f the b r e a s t i s based on the assumption t h a t t h i s r e l a t i o n s h i p does e x i s t , i f treatment i s e f f e c t i v e a t a l l ,  i t would be expected t h a t  t h i s r e l a t i o n s h i p would be e m p i r i c a l l y  demonstrable."  These c o n c l u s i o n s c o u l d e q u a l l y be a p p l i e d t o a p r e s e n t day review o f the l i t e r a t u r e on d e l a y .  They concluded t h a t  the i n f l u e n c e o f d e l a y i n treatment upon the c u r a b i l i t y not be g r e a t e r than 5 t o 10 p e r c e n t .  can-  I t may be l e s s o r may  not e x i s t a t a l l . I n 1958 MacDonald (5) reviewed h i s e a r l i e r t h e o r y o f  25  " B i o l o g i c Predeterminism" that  (4) , a h o s t - t u m o r  i s o f g r e a t e r p r o g n o s t i c importance  type of treatment.  He  twenty  than the time  suggested predeterminism  cancer i n d i c a t e s grouping by n a t u r a l ulated that  relationship or  i n breast  selection.  He  percent o f breast lesions w i l l  spec-  still  be  l i m i t e d t o t h e b r e a s t 3 o r more y e a r s a f t e r o n s e t ,  55  cent w i l l have developed  pre-  c l i n i c a l p h a s e and space  criteria  be  life  important.  (1950)  y e a r s 1936 available  (10)  t o 1942.  was  t o s e p a r a t e out  pessimistic  c o u l d be made, t h a t  t h e tumour was  even  i t would l e a d  to  cases o f carcinoma  Four hundred The  and  s e v e n t y c a s e s were  purpose  t o outcome.  t h e o u t l o o k was  The  The  a view  v/as t o examine  and  size  and  to these  important v a r i a b l e  younger the p a t i e n t , firmly held  of  i n re-  t h e more  serious  i n a l a r g e body o f  as o t h e r s .  of  variables.  Bloom i n h i s s e r i e s o f cases found t h a t  y o u n g e r p a t i e n t s d i d as w e l l  age  site  h i s t o l o g i c a l grade  a l s o examined i n r e l a t i o n  t o outcome.  of  at the Middlesex H o s p i t a l d u r i n g the  h a s b e e n c o n s i d e r e d an  (10).  565  delay i n seeking treatment  tumour i n r e l a t i o n  Age  reviewed  for investigation.  patient,  ature  He  groups  no  increase i n survival.  the breast treated  lation  U n f o r t u n a t e l y he gave  or proof of these b i o l o g i c  Bloom  of  saving.  the d i f f e r e n t i a t i o n  little  time-  and f o r t h e s e women prompt d i a g n o s i s and  inhere d e l a y w o u l d b e if  i n the  i n 25 p e r c e n t t h e r e i s a s e q u e n t i a l  relationship,  t r e a t m e n t may  d i s t a n t metastases  per-  literthe  A l s o the grade  of  26  tumour was  evenly d i s t r i b u t e d  discounting malignant In vivals,  suggestions that  i n younger  o v e r t h e v a r i o u s age  groups  c a n c e r o f b r e a s t was  more  patients.  r e v i e w i n g d e l a y and p r o g n o s i s u s i n g 5 y e a r a u n i f o r m s u r v i v a l r a t e was  long the h i s t o r y .  T h i s was  sur-  f o u n d no m a t t e r  c o n f i r m e d when t h e g r o u p  p a t i e n t s were e x a m i n e d f r o m t h e p o i n t o f v i e w o f s t a g i n g and h i s t o l o g i c a l g r a d i n g .  delay.  logical  There  was  a tendency  grading i n three broad  w i t h tumours o f h i g h m a l i g n a n c y w i t h tumours o f low malignancy. of  B l o o m f e e l s h e was  though,  t o appear  histo-  for patients  e a r l i e r than  T h e r e f o r e the  I t v/as s u g g e s t e d t h e c o n f l i c t i n g  t h e l i t e r a t u r e were due  groups  of cases.  l o g i c a l grade  those  distribution  to histologically  results  C o m p a r i n g d e l a y i n c a s e s o f same h i s t o -  t h e r e appeared  t o be  some a d v a n t a g e  for  l e s s t h a n 6 weeks d e l a y and  for  t h o s e d e l a y i n g s i x t o t w e l v e months. the o t h e r grades.  i n grade  ment, age In  (5-years)  72 p e r c e n t s u r v i v a l T h i s was  (5-years) not  found  Bloom t h e r e f o r e i n c o n c l u s i o n f e l t  t h a t outcome i n b r e a s t c a r c i n o m a was the h i s t o l o g i c a l  found  incomparable  1 t u m o u r s c o m i n g e a r l i e r w i t h 92 p e r c e n t s u r v i v a l  in  increas-  l o o k i n g at  d e l a y groups  not  t h e g r a d e s t e n d e d t o compensate t o some e x t e n t f o r t h e  time f a c t o r . in  of  clinical  a b l e t o show t h a t o u t l o o k becomes more gloomy w i t h ing  how  determined  largely  by  t y p e o f growth r a t h e r t h a n d e l a y i n t r e a t -  o f p a t i e n t or s i t e o f primary  s p i t e o f t h e s e c o n c l u s i o n s he  growth.  still  felt  that  27  c a m p a i g n s and e d u c a t i o n aimed a t s h o r t e n i n g d e l a y s h o u l d b e continued  f o r t h e sake o f t h o s e p a t i e n t s w i t h tumours o f  low h i s t o l o g i c a l Smithers  malignancy.  (1958)  one w i t h a d v a n c e d  (7) e x a m i n e d two g r o u p s  d i s e a s e who s u r v i v e d  a n o t h e r w i t h e a r l y d i s e a s e who d i e d The  purpose  was t o t e s t  ment h a s no e f f e c t breast  ment a l t e r s  f o r many y e a r s and  soon  after  treatment.  t h e two o p p o s i n g t h e o r i e s -  on t h e p r e d e t e r m i n e d  tumour b e h a v i o u r  of patients,  treat-  p a t t e r n o f human  and, on t h e o t h e r hand, e a r l y  i t s course.  He p o i n t e d o u t r e v i e w i n g t h e R e g i s t r a r G e n e r a l ' s ures,  t h e unchanging  age s p e c i f i c  ated t h e view o f McKinnon the f a i l u r e  treat-  of health  death  rates.  He  fig-  reiter-  (8) t h a t t h i s was e v i d e n c e o f  e d u c a t i o n and p r e s e n t t h e grade  treatment  methods.  Smithers used  lay,  site  o f t h e tumour, t h e age o f t h e p a t i e n t  atic  involvement  as i n d i c e s  and s i z e o f tumour, d e -  f o rthe benefits  and lymph-  f o r early  treatment. He d e m o n s t r a t e d and  no d i r e c t  s u r v i v a l b u t u s i n g t h e above i n d i c e s o f p r o g n o s i s  s u g g e s t s t h e r e was i n d i r e c t  evidence f o re a r l y  being b e n e f i c i a l with careful In of  r e l a t i o n s h i p between d e l a y  treatment  selection of patients.  1960 S u t h e r l a n d (9) p u b l i s h e d a b o o k u n d e r t h e t i t l e  "Cancer,  The S i g n i f i c a n c e o f Delay".  s i v e review o f the l i t e r a t u r e with He p o i n t e d o u t t h e d i f f i c u l t i e s  T h i s was an e x t e n -  an a n a l y s i s o f d e l a y .  of appraisal especially i n  28  making v a l i d  c o m p a r i s o n s b e t w e e n one  study  and  another.  O b j e c t i v e a p p r a i s a l o f t h e e f f e c t i v e n e s s o f treatment  is  difficult. S u t h e r l a n d examined t h e problems o f d e l a y under prognostic variables, teristics His  and final  tumour c h a r a c t e r i s t i c s , h o s t  own  charac-  environment. c o n c l u s i o n o f tumour c h a r a c t e r i s t i c s - " a t  a g i v e n moment o f t i m e , its  three  e a c h tumour c h a r a c t e r i s t i c  p o s i t i o n on i t s i n d i v i d u a l d e v e l o p m e n t a l  p r o b a b l y b e s t summed up  t h e c o n c l u s i o n on  the  occupies  gradient",  literature  reviewed. In the  final  chapter,  l a n d examined t h e e v i d e n c e nificance of delay. f o u n d t h a t , o f 236  He  "Duration  and P r o b l e m s "  Suther-  concerning the p r o g n o s t i c  r e c a l l e d MacDonald  (1951)  (4)  a r t i c l e s t h a t made r e f e r e n c e t o  s i g n i f i c a n c e o f e a r l y treatment,  o n l y 16  t h a t made i t p o s s i b l e t o c o r r e l a t e end  sigwho  the  contained  data  results with  early  treatment. Some d a t a a v a i l a b l e that  treatment  n o s i s and was  not  appeared  soon a f t e r onset  d e l a y makes i t w o r s e .  as c l e a r c u t and  no means i n v a r i a b l y  as d e l a y  lengthens.  delayed  a long time  the  hypothesis  o f symptoms i m p r o v e s He  t h e r e was  n o s i s by  Some l i t e r a t u r e  t o support  suggested  the  other evidence  prog-  association that  prog-  and p r o g r e s s i v e l y becomes w o r s e  showed b e t t e r s u r v i v a l o f p a t i e n t s compared t o t h o s e who  came e a r l y .  who  These  29  s u r v i v a l s were c a l c u l a t e d  f r o m the d a y  made them more r e m a r k a b l e . parable they symptoms.  s h o u l d be  Therefore  calculated  Bizarre statistics  d u r a t i o n o f s u r v i v a l o f 8.91 four years years  o r more and  appear such years  o f onset  as t h e  those  soon a f t e r onset  i n t o two  the  radically  t h a t have been asked  outcome and logical  before.  i n length of survival and  treatment?"  Sutherland  i n the  asked  the  "Does t h i s mean  (10)  i s different  that these (11)  e f f e c t s o f d e l a y on o p e r a b i l i t y , tumour r e l a t i o n s h i p s .  He  found  i n the b i o -  d i f f e r e n c e s are  un-  (12)  answered t h e q u e s t i o n by  o p e r a t i v e d e l a y was  those  that those He  -  the d e c i s i v e cause o f d i f f e r e n c e i n  type of cancer,  a f f e c t e d by  4.12  opposed groups:  o f symptoms and  S u t h e r l a n d p o i n t e d out  i n b r e a s t cancer  delayed  relationship  i n t e r m e d i a t e group have t h e worst p r o g n o s i s .  that  average  r a t e s the p a t i e n t s with  fall  questions  of  cases.  5-year s u r v i v a l  late.  com-  f o r t h o s e who  the best prognosis  treated very  truly  from date  I t w o u l d seem t h a t f r o m e x a m i n i n g  treated very  t o be  which  average d u r a t i o n o f s u r v i v a l o f  f o r short delay  b e t w e e n d e l a y and  o f treatment  l o o k i n g at  radio curability  the  and  increasing duration of  hostpre-  associated with increasing incidence of  regional  and  d i s t a n t metastases.  as e a r l y  as p o s s i b l e was  important  I t w o u l d seem a d i a g n o s i s t o a c e r t a i n y e t unknown,  number o f i n d i v i d u a l b r e a s t c a r c i n o m a p a t i e n t s . f r o m r e d u c i n g d e l a y was  moderate.  He  suggested  The b e n e f i t we  ought  to  30  be  modest i n o u r  a l t e r i n g the to the part  claims  situation for breast  problem.  E s s e n t i a l l y he  i n some p a t i e n t ' s  Sutherland  (1967) and  (13)  answer t o t h e v a l u e comparison o f  Epidemiologically in present be  day  untreated  times.  questioned  Grading  and  group.  suggested the  survival with treated  i s acceptable.  comparison d i f f i c u l t .  point  cancer.  necessarily other.  c a s e s o f more  The  delaying. untreated  I do  not  patients  purpose o f t h i s  thesis I  the  d i f f e r e n c e between t r e a t e d  but  questioning  the  d i r e c t r e l a t i o n s h i p between d e l a y  The  could  d e c a d e s w h i c h makes  questioning  p a t i e n t s h a v e any  the  of view of t h e i r s e l e c t i o n .  the  Does p a t i e n t d e l a y  Some  cases from  not  survival.  a  difference in survival  changed o v e r the For  requires  unsatisfactory  of untreated  importance o f not  s t a g i n g has  by  decisive  cancer  would exclude the  f o l l o w up  from the  i s espe-  patients with breast  They suggested the  this  a  assessment o f d e l a y  I would t h i n k t h i s v e r y  their  curves proves the  be  does p l a y  i t s reduction delay  approach  a group o f t r e a t e d p a t i e n t s t o  s e l e c t i n g one  contrasting  think that  He  delay  o f treatment i n breast  Authors have used the  recent  Lees.  this  i n v e s t i g a t i o n because each would  s e l e c t e d and  past  intermediate  s u r v i v a l of  group o f u n s e l e c t e d  believed  reviewed the  P a r k and  of materially  carcinoma by  s u r v i v a l and  c i a l l y warranted i n the Rubin  as t o t h e p o s s i b i l i t y  i n a spectrum o f  and  am  untreated and  treated  i n f l u e n c e i n outcome?  most t h o r o u g h and  recent  review of delay  time  has  31  been c a r r i e d  o u t b y H.J.G. B l o o m u n d e r t h e t i t l e  I n f l u e n c e o f D e l a y o n t h e N a t u r a l H i s t o r y and of  Breast Cancer".  for  five He  t o twenty  (14)  I t was  ture.  The  Both first  Prognosis  a study of cases followed  examined t h e p r e v i o u s l i t e r a t u r e ,  views.  "The  years.  been examined i n t h i s t h e s i s , ing  of  views  and  some o f w h i c h  f o u n d as I h a v e , two  are supported by  a wealth of  view which i s g e n e r a l l y the  t e a c h i n g on t h e s u b j e c t i s t h a t worse the p r o g n o s i s .  The  d i s c u s s e d under Park  oppos-  litera-  established  the g r e a t e r the d e l a y the  second  and L e e s  has  view  (1951)  i s that  previously  (6) , - t h e s u r v i v a l  a p a t i e n t does not n e c e s s a r i l y d e c r e a s e w i t h i n c r e a s i n g lay.  B l o o m drew o u r  470  cases i n which t h e 5-year  coming w i t h i n  3 months was  47 p e r c e n t , and this  after  survival  sisted  o f 1411  12 months o r more 52 p e r c e n t .  o f f o l l o w up was  On  With  o f d e l a y on  prog-  The  and  1949  study at  con-  the  London.  reviewing the t o t a l  6 months o f f i r s t  of  i n which a pro-  available.  c a s e s s e e n b e t w e e n 1936  Middlesex Hospital,  (10)  51 p e r c e n t , b e t w e e n 3 t o 6 months  o f a s e r i e s o f b r e a s t cancer cases  longed period  de-  rate for patients  i n mind Bloom i n v e s t i g a t e d t h e e f f e c t  nosis  in  attention to a previous report  of  c a s e s , 64 p e r c e n t a t t e n d e d w i t h -  symptom and  Less than h a l f the p a t i e n t s  82 p e r c e n t w i t h i n one  (45 p e r c e n t )  came * v i t h i n  months and o n l y 16 p e r c e n t w i t h i n one month; 18 d e l a y e d f o r more t h a n one  y e a r and  year.  3  percent  8 p e r c e n t f o r more t h a n  32  2 years. B l o o m compared e a c h survival  g r o u p o f 5, 10, 15 and 20 y e a r  r a t e s against the delay times,  consistent  differences with  increasing  demonstrating delay.  H.J.G. BLOOM (14)  TABLE 1 - D e l a y  5  and P r o g n o s i s  Year  10 Y e a r  Cases S u r v i v a l 0/  3 3-6 6-12 12-18 18-24 2-3 3  months H ii ii  years II  Total 3 3-6 6-12 1  months year  . . . . . . .  571 235 232 58 65 39 63  Cases Surviv; 0/  /a  . . . . . . .  % 36 29 31 29 31 37 38  .1225  .  33  . . . .  . . . .  36 29 31 33  . . . . . . .  53 44 45 52 51 49 56  . . . . . . .  .1263  .  50  . . . .  . . . .  53 44 45 52  571 235 232 225  556 231 223 55 61 38 61  556 231 223 215  no  33  15 Year-  20 Y e a r  Cases S u r v i v a l 3 3-6 6-12 12-18 18-24 2-3 3  months II II II  years II  Total 3 3-6 6-12 1  months •I  ii year He f e l t  purpose The  of  ity to  24 19 25 28 21 32 21  . . . . .  180 83 79 19 20 9 9  . . . . . . .  16 18 19 16 25 11 22  .  951  .  24  .  399  .  18  . . . .  425 191 172 163  . . . .  24 19 25 25  . . . .  180 83 79 57  . . . .  16 18 19 19  was t o show t h a t i t  q u e s t i o n s which he f e l t  advancement i m p o r t a n t  lymph node i n v o l v e m e n t ,  a limited  reflect  extent.  grade were u s e d  does n o t .  needed answering  i n d i v i d u a l tumour f a c t o r s  they  picture  such  clinical  I f clinical  t o t h e outcome? as s i z e o f p r i m a r y  s t a g e and o p e r a b i l -  tumour p o t e n t i a l  as r e g a r d s  delay.  survival  I n t h e c o n c l u s i o n Bloom  s a i d t h e i n f l u e n c e o f d e l a y o n p r o g n o s i s must t a k e  The  the i n t r i n s i c b i o l o g i c a l tumour f a c t o r s ,  g r a d e were s u r e l y (a  phrase used  just  clinical  delay  s t a g e and h i s t o l o g i c a l  t o show t h e i n f l u e n c e o f d e l a y ,  was a f f e c t e d b y i n c r e a s i n g  account  were  o f t h e b r e a s t advances d u r i n g t h e d e l a y  and, i s t h i s  and f e l t  %  . . . . . . .  h i s paper  He r e v i e w e d growth,  %  Survival  . 425 . 191 . 172 . 40 . 47 . 34 . 42  t h a t t h i s d i d not g i v e a t r u e  whether carcinoma period,  Cases  into  n a t u r e o f t h e tumour. s t a g e and h i s t o l o g i c a l  s i g n p o s t s on a " f i x e d  survival  scale"  i n h i s c o n c l u s i o n ) and do n o t r e f l e c t t h e  "intrinsic biological  nature"  o r MacDonald's  (4) t e r m  34  " b i o l o g i c predeterminism" He a d m i t t e d  that  o f t h e tumour.  a well-marked  direct  c o r r e l a t i o n be-  t w e e n d e l a y and s u r v i v a l h a d n o t b e e n t h e e x p e r i e n c e o f most investigators. In in  a more s p e c u l a t i v e f r a m e o f mind h e s u g g e s t e d  changes  t h e tumour-host r e l a t i o n s h i p w i t h time might a f f e c t  nosis. lay  He c o n c l u d e d  i n v i e w o f t h i s unanswered q u e s t i o n de-  should be continued t o be avoided.  overall reduce  improvement  paper  a direct  v i v a l has not been  He t h e n  i n survival resulting  delay alone i s l i k e l y  in this  prog-  from  t o be l i m i t e d .  admitted t h e efforts to  I t would  seem  c o r r e l a t i o n between d e l a y and s u r -  demonstrated.  S h e r i d a n e t a l (11) (1971) made a n a l y s i s o f 1,840 c a s e s seen  a t an A u s t r a l i a n t e a c h i n g h o s p i t a l b e t w e e n 1954 a n d  1965  t o examine t h e r e l a t i o n s h i p o f d e l a y i n t r e a t m e n t and  outcome and a l s o t o e x p l o r e why and where s u c h d e l a y s may occur.  He u s e d  suggested logical  clinical  t h a t t h i s was a s a f e a s s u m p t i o n  findings  The  s t a g i n g t o d e f i n e h i s cases and because h i s  substantiated the c l i n i c a l  a n a l y s i s o f delay used  patho-  findings.  stage 1 t o c a l c u l a t e  a delay  p a t t e r n t o compare w i t h t h e a c t u a l o r o b s e r v e d  case r a t e i n  the other stages.  o f t h e ex-  pected  and o b s e r v e d  delay.  T h e y compared t h e s u r v i v a l s i n each  T h e c o n c l u s i o n was made t h a t  more a d v a n c e d t h e c l i n i c a l patient.  clinical  stage l e v e l i n this  against  series the  stage, t h e worse t h e f a t e o f t h e  I do n o t t h i n k t h a t  this  i s a reasonable conclusion  35  on t h e g r a p h i c evidence, more t h a t i t shows a " b i o l o g i c a l predeterminism" a t each c l i n i c a l stage l e v e l to  irrelevant  d e l a y e s p e c i a l l y i n stage 111 and I V . The f o l l o w i n g were the f i v e y e a r s u r v i v a l r a t e s o f  stage 1 and stage 11 f o r d i f f e r e n t d e l a y p e r i o d s found i n their  analysis:Stage  1  Stage 11  Treatment i n l e s s than 4 weeks from f i r s t symptom  74%  Treatment i n 5 t o 12 weeks from f i r s t symptom  76%  Treatment i n 3 t o 6 months from f i r s t symptom  85%  Treatment i n 6 t o 9 months from f i r s t symptom  83%  Treatment begun l a t e r than 9 months from f i r s t symptom  73%  Treatment i n l e s s than 4 weeks from f i r s t symptom  65.8%  Treatment i n 5 t o 12 weeks from f i r s t symptom  55.9%  Treatment i n 3 t o 6 months from f i r s t symptom  59.5%  Treatment i n 6 t o 9 months from f i r s t symptom Treatment begun l a t e r than 9 months from f i r s t symptom  46.8%  They commented stage 1 percentages d i d not suggest d e l a y was a f a c t o r .  They suggested t h a t t h e r e may be b i a s  because the p a t i e n t s i n t h e f i r s t  few weeks c o n t a i n a number  i n whom t h e d i s e a s e was going t o develop r a p i d l y ,  presumably  36  suggesting  that  the  short  delay  f i g u r e s w o u l d be  better  t h i s would suggest a s u c c e s s r a t e f o r treatment t h a t not  exist.  S t a g e 11  f i g u r e s were d e s c r i b e d  d e t e r i o r a t i o n t h r o u g h the c l e a r that the upon, t h e  delay  e a r l i e r the  better  patient  c h a n c e she  examine t h e  first  three  rise  i n the  third  f i g u r e and  cent  as  described  T h e r e i s no  by  periods,  and  we  Lees.  f i g u r e f o r 6-9  months and  r e l a t i o n s h i p of delay  and  5-10  a per-  lead to bias any  means  s u r v i v a l c o u l d be  tothe  regarded  proven. The  delay.  paper concluded with With  age  the younger the  in relation patient  of patient's delay t h e r e had This worth  b e e n no  and  the  an  a n a l y s i s of the  to delay shorter  the  the  time brought out  change i n  i s s u r p r i s i n g and  nature  analysis  delay. the  An  " I f the  propaganda had  period,  then the  analysis  finding that  delay. t h e i r concluding  comments  been s u c c e s s f u l over  numbers o f p a t i e n t s  coming  e i t h e r because o f self-examination  because o f d e l i b e r a t e l y seeking up"  should  be  a "cancer  increasing".  i s a p t l y summarized  of  suggested  reiterating-  advice  It  we  c e r t a i n l y over  t h i n k by  not  If  (6)  wards a poor p e r c e n t a g e .  I do  appear  operated  a difference of only  P a r k and  a  a c t u a l l y see  could  as  was  would, h a v e o f s u r v i v a l .  l e v e l s of delay  does  showing  i t would  i n s t a g e 11  9 months i s a v e r y b r o a d r a n g e and  direct  as  but  in their  table-  the for  or check  are  37  METHOD OF DISCOVERY OF THE F I R S T SYMPTOM  Period  Method o f Discovery Found b y Patient  1954-1957  97.8%  1958-1961  91.2%  1961-1965  96. 1%  TOTAL  96.7%  SelfExamination  0.35%  0.54%  0.76%  0.63%  Medical Examination  1.7%  2.1%  3.0%  2.5%  38 3.2 The the To  FACTORS INFLUENCING DELAY TIME  l i t e r a t u r e I have reviewed  importance  of the  necessary  to look at f a c t o r s  d e l a y and  also  admitted  and  (16)  from  University  i t i s also motivating delay.  r e c o r d s o f 740 p a t i e n t s  mean age  of this  at t h a t time  ings r e p o r t e d by  others.  examination  percent married,  as f o l l o w s :  T h e y saw  this  the  the readequate  3 percent.  The  53.7  age was  years  and  the  consistant with  find-  (17)  of their marital status revealed,  They used  single  The  distribution 46 p e r c e n t  18 p e r c e n t were i n p r i v a t e rooms.  a p p l i c a b l e t o any a trend i n their  67 and  the p r i c e o f the h o s p i t a l  36 p e r c e n t w a r d p a t i e n t s ,  study  bed  found  was  occupied This  i n Canada.  study o f e a r l i e r r e p o r t i n g  o f symptoms w i t h i n c r e a s i n g y e a r s , w h i c h t h e y  concluded  due  to the r e s u l t o f increasing p u b l i c i t y  about c a n c e r .  was  not  (32)  a finding  re-  1951.  s e r i e s was  economic s t a t u s .  s e m i - p r i v a t e and would not be  to  and  16 p e r c e n t x^idowed, 13 p e r c e n t  3 percent divorced. to define their  1943  Only  satisfactory  obtained f o r a l l except  c o r d s were f o r t h e y e a r s  felt  of Pennsylvania.  p a t i e n t s were f o u n d  i n f o r m a t i o n was  An  survival.  c o n s e c u t i v e l y v/ith c a n c e r o f t h e b r e a s t t o  c o r d s o f 633  authors  i n f l u e n c i n g and  at  made a s t u d y o f t h e e f f e c t s o f demo-  economic f a c t o r s  H o s p i t a l o f The  The  of delay I f e e l  some o f t h e c h a r a c t e r i s t i c s o f  Waxman (1959)  looked  r e l a t i o n s h i p o f d e l a y and  complete the understanding  graphic  so f a r h a s  i n data of others.  (29)  Their  was This  find-  39  i n g s on d e l a y  suggested  the higher  t h e income t h e e a r l i e r  the p a t i e n t s consult t h e i r doctor. status affected They concluded  N e i t h e r age n o r m a r i t a l  t h e chances o f s u r v i v a l from t h e i r  i nthis  r e s u l t s the people  series.  who h a v e a  s h o r t d e l a y have a b e t t e r chance o f s u r v i v a l . Gold Diseases  (1964)  (18) i n " C a u s e s o f P a t i e n t s * D e l a y i n  o f t h eBreast"  educating  suggested  t h e p u b l i c were o f t e n n o t e f f e c t i v e ,  were c a r r i e d  having  f o r suspected  a hundred o f which subsequently cancer  Various  interviews  o u t o n 150 p a t i e n t s a t t e n d i n g t h e F r a n c i s  D e l a f i e l d H o s p i t a l , New Y o r k , breast,  t h a t c u r r e n t methods o f  diseases o f the  were d i a g n o s e d  o f the breast. reasons  were g i v e n f o r d e l a y and were summa-  r i z e d under t h e f o l l o w i n g headings,  socio-economic  pro-  blems, l a c k o f i n f o r m a t i o n and t e m p o r i z i n g m e d i c a l Seventeen percent  advice.  o f t h e women r e p o r t e d t h a t f i n a n c i a l  b l e m s d e f e r r e d them f r o m s e e k i n g e a r l y t r e a t m e n t ,  ferred  I n these  examination.  complaint  cases  f i n d i n g t h e time  pro-  some o f  t h e p a t i e n t s w e r e w o r k i n g m o t h e r s and i n some c a s e s wage e a r n e r .  as  the only  t o a t t e n d de-  L a c k o f i n f o r m a t i o n was a s u r p r i s i n g  i n view o f recent p u b l i c i t y .  Some h a d m i s c o n -  c e p t i o n s b u t one o f t e n women r a t i o n a l i z e d t h e lump away b y attributing thought pected  i t t o trauma.  Twenty-three percent  o f women  t h e lump v/as a m i n o r o r t e m p o r a r y c o n d i t i o n and e x i tt o disappear.  I t i s interesting  average s i z e o f b r e a s t cancer  i nthe series the  tumour was 6 cm. compared t o  40  n o n - c a n c e r o u s lumps w h i c h were 2.5 cm. significant not  taught  size.  Ninety-four  the proper  Seventeen percent  technique  o f t h e women were  o f breast  medical  to contribute t o delay:-  f e a r and a n x i e t y ,  their  a doctor but  f a c t o r s and b e h a v i o u r a l p a t t e r n s Of these  was c a n c e r .  examination.  advice.  examined i n t h i s p a p e r .  women i n t h e s t u d y  i s n o t an i n -  of the patients had v i s i t e d  received temporizing Psychological  percent  That  delayed  t h e f o l l o w i n g were  because they  sexual relations  sixty-one of the  f e a r e d t h a t t h e lump  especially  the p o s s i b i l i t y  i n general.  F a l s e modesty, s h y n e s s and l a c k o f t a c t i l i s m a p p e a r t o p l a y an i m p o r t a n t  and u p b r i n g i n g .  Negative  part i n influencing the delay  Women who h a v e n e v e r h a d p l e a s u r a b l e  i n their breasts  display negativistic  difficult  seeking  treatment.  Gold these  These p a t i e n t s  I n inoperable cancer  lacked pleasurable feelings  incapable  o f pafound  t o make t h e d e c i s i o n t o come f o r e x a m i n a t i o n  f r e q u e n t l y came t o o l a t e .  cent  behaviour.  a t t i t u d e s were p r o m i n e n t i n t h e b e h a v i o u r  t i e n t s who d e l a y e d  and  would  T h e s e f a c t o r s were s t r o n g l y a f f e c t e d b y f a m i l y h i s -  sensations  it  affect  i n t h o s e whom r e l a t i o n s  O t h e r f e a r s were t h e o p e r a t i o n ,  o f d e a t h and d o c t o r s  tory  found  Twenty-one f e a r e d t h a t t h e o p e r a t i o n w o u l d  were g o o d .  time.  were  i n the breast  o f even r e c o g n i z i n g changes i n t h e i r  i n summary s u g g e s t e d  f u r t h e r study  factors i n r e l a t i o n t o delay.  56 p e r -  a n d seemed breasts.  s h o u l d b e made o f  T h i s w o u l d seem a  41  priority cedures  i n view o f the p o s s i b i l i t y such  p a t i e n t s who  as mammography on  of using screening pro-  a universal basis.  delay f o r the reasons  just  more u n l i k e l y t o a t t e n d s u c h c l i n i c s . p u r p o s e would be  negated.  Fisher  (19)  (1967)  seeking treatment greatest  Therefore their  symptoms was  found  likely  i n t h o s e women \izho were i n d e p e n d e n t ,  possessed  of a clear  concerned.  sense  of identity  and  to  be  autonomous,  relatively  unonly  34 women w i t h c a n c e r  of  cervix. Cameron e t a l (1968)  mitted to Middlesex a t i o n on  the b r e a s t .  v/as p a t i e n t d e l a y .  (20)  made a s t u d y o f 83 women  H o s p i t a l , London, E n g l a n d They found Thirty-eight  f o r an  percent  more t h a n  3 months.  26 w e r e b e n i g n . malignant  tumours d e l a y e d  those with benign  longer.  ciated with  and  finding - patients with Sixty-eight  S i x p a t i e n t s (10%)  y e a r o r more.  percent  appear t o s h o r t e n d e l a y .  with  of  cancer  F a c t o r s which might be  d e l a y v/ere e x a m i n e d .  a p a i n l e s s lump.  delayed,  t u m o u r s came w i t h i n a week i n c o n t r a s t t o  25 p e r c e n t w i t h c a r c i n o m a . d e l a y e d f o r one  delay  reported within a  F i f t y - s e v e n c a s e s were m a l i g n a n t  A very i n t e r e s t i n g  ad-  oper-  the major element o f  week, 61 p e r c e n t w i t h i n a month, 20 p e r c e n t h a d  not  prime  delay i n  T h e s e c o n c l u s i o n s were made on e x a m i n i n g  28 women w i t h b r e a s t t u m o u r s and the  d i s c u s s e d are' e v e n  i n contrast to Gold  f o r cancer  Those  Symptoms s u c h  Seventy  Previous h o s p i t a l  asso-  as p a i n did.  percent presented  experience  d i d not  with have  42  any  effect  on d e l a y .  A n x i e t y d i d not d e l a y people  n i f i c a n t l y more t h a n t h o s e who thing  were c o n f i d e n t .  i t w o u l d a p p e a r t o e n c o u r a g e them t o s e e  doctor e a r l i e r .  They found t h a t  over h e a l t h laying. fell  long delays.  showed no  Examining  doctor,  felt  displaying  Age  made no  their  the reasons  Consciousness  i n t h o s e who  fear,  they had  or  concern  reason to consult  significant  summary i n t h i s  d i f f e r e n c e t o delay but  t h r e e p e r c e n t more t h a n  The  series In  series  3 months.  and K r u s h  found the o p p o s i t e p i c t u r e Cancer ing  Chemotherapy C l i n i c .  a medical breast c l i n i c  twenty-  T h e s e f i g u r e s were i n (14) whose  and t o o t h e r a u t h o r s .  i s s m a l l and t h e r e may  contrast Lynch  The  o f p a t i e n t s w i t h mammary  t o t h o s e found by Bloom  were d i s c u s s e d e a r l i e r  the  r e c e i v e d the s h o r t e r the delay.  54 p e r c e n t d e l a y e d l e s s t h a n a month and  marked c o n t r a s t  their  ignorance or a capacity to ignore.  more s c h o o l i n g t h e p a t i e n t  cancer,  they reasons  l e n g t h o f f o r m a l e d u c a t i o n d i d have a r e l a t i o n s h i p .  In  de-  delayed  v a r i o u s domestic  little  or  distributed  r e l a t i o n s h i p t o the p a t i e n t ' s  into three categories,  and t h o s e who  I f any-  i f a close relative  f r i e n d h a d b r e a s t c a n c e r t h e y were e q u a l l y amongst s h o r t a n d  sig-  be  (21)  findings (22.)  some s e l e c t i o n  (1969)  (23)  (24)  bias.  (25)  at the U n i v e r s i t y o f Nebraska Of  eighty-five patients attend-  f i f t y - f o u r percent delayed  y e a r o r l o n g e r , and  of eighty-five patients  gical breast c l i n i c  24 p e r c e n t d e l a y e d one  seen  one  at a sur-  year or longer.  43  P a t i e n t s i n these groups delayed because o f misconceptions and  f a i l u r e t o recognize serious  patients family  from e a r l y treatment  illness  Greer  and  (1974)  financial (26)  symptoms.  and  o t h e r r e a s o n s were  problems.  reviewed  a t o t a l o f 160  admitted t o Kings C o l l e g e H o s p i t a l comprising breast. patient  69 w i t h c a n c e r and  The  following table  Fear deterred  patients  f o r b r e a s t tumour b i o p s y ,  91 w i t h b e n i g n t u m o u r s o f from t h e i r  report  the  displays  delay time.  INTERVAL BETWEEN F I R S T SYMPTOM AND F I R S T MEDICAL EXAMINATION (MONTHS)  DIAGNOSIS  <1  1-2  3-12  > 12  TOTAL  BENIGN  67(74%)  5(6%)  13(14%)  5(6%)  90  CANCER  33(49%)  12(18%)  18(27%)  4(6%)  67  We  see  and H i n t o n times  in this, (20) who  findings  similar  demonstrated  significantly  i n p a t i e n t s w i t h a malignant  tumour.  In this  disfigurement delay.  s e r i e s Greer  felt  longer delay  tumour t h a n a b e n i g n that  fear of cancer  f r o m o p e r a t i o n were p r o m i n e n t  o f t h e lump i n d e l a y e r s was  in previous discussed l i t e r a t u r e . a d e n i a l r a t h e r than crisis  This,  small,  lives.  a  The  finding  suggests Greer, i s  an i g n o r a n c e ; an i n a b i l i t y  in their  and  reasons f o r  D o m e s t i c problems were a l s o r e a s o n s f o r d e l a y .  significance  possible  t o t h o s e o f Cameron  In t h i s paper  to face a i t v/as  found  44  that medical cancer  d e l a y h a d c o n t r i b u t e d i n a s many a s 1 9 % o f t h e  patients.  "doctors  delay"  breast cancer  Rimsten and S t e n k v i s t o f 17 p e r c e n t  (1975)  (27) f o u n d  o n e x a m i n i n g 115 p a t i e n t s  a  with  i n t h e C o u n t y o f U p p s a l a d u r i n g a 15 month  period. Fink cancer two  (1976)  (28) e x a m i n e d d e l a y b e h a v i o u r  s c r e e n i n g o f about  stratified  reasonably  31,000 women aged 40-64,  random s a m p l e s , o n e d e s i g n a t e d  group and t h e other high  as t h e c o n t r o l group.  blance  c a l l y presenting cases. sample b o t h  percent  They were l a b e l l e d  i n carcinoma o f b r e a s t  various  according resemin clini-  Among a l l t h e women i n t h e s t u d y  g r o u p " , 7% i n t h e " s e c o n d a r y e f f o r t  i n t h e "repeated  participants. selection  group  e x a m i n e d a n d n o t e x a m i n e d , 4 7 % were i n t h e  "minority effort 10  as t h e study  n e e d e d and t h e r e s u l t s b e a r a r e m a r k a b l e  t o the delay p i c t u r e  using  In achieving a  r a t e o f response f o r t h e study  l e v e l s o f l o b b y i n g were u s e d . to effort  i n breast  effort  g r o u p " , a n d 35% were n o n -  I t w o u l d a p p e a r t h e r e was c o n s i d e r a b l e  i n mammography  screening.  group",  self  45 3.3  CHARACTERISTICS OF DELAY IN RECENT YEARS AND FACTORS INFLUENCING THE COURSE AND SURVIVAL OF BREAST CANCER OTHER THAN TREATMENT Before  in  concluding a review  carcinoma o f the b r e a s t  at delay c h a r a c t e r i s t i c s f l u e n c i n g t h e course Hackett cancer  of the l i t e r a t u r e  on d e l a y  i t w o u l d seem o p p o r t u n e t o l o o k  i n recent years,  and f a c t o r s i n -  and s u r v i v a l o f b r e a s t c a n c e r p a t i e n t s .  e t a l (1973) (29) e x a m i n e d p a t i e n t d e l a y i n  and f a c t o r s t h a t m i g h t c o n t r i b u t e t o d e l a y .  s u r v e y was c o n d u c t e d  Their  b e t w e e n 1968 a n d 1970 a t t h e M a s s a -  c h u s e t t s G e n e r a l H o s p i t a l and c o n t a i n e d  563 p a t i e n t s o f  w h i c h 88 were c a r c i n o m a o f t h e b r e a s t .  The l e n g t h o f d e l a y  was n o t r e l a t e d t o age o r s e x . percent  came w i t h i n one month and. 61 p e r c e n t w i t h i n 3 months.  F i f t e e n point s i x percent Using  results  suggest  Hollingshead  occupation  weighted. idly  l o n g e r t h a n one y e a r . d e r i v e d from H o l l i n g s -  a r e l a t i o n s h i p between s o c i a l  and d e l a y ; t h e h i g h e r t h e c l a s s , The  both  delayed  the index o f s o c i a l p o s i t i o n ,  head t h e i r class  Thirty-three point eight  index  of social position  and e d u c a t i o n , w i t h  a b l e a s 80 p e r c e n t w i t h a lump.  h a v e any a f f e c t  other cancers.  (30) (31) o f c a n c e r s  Anxiety  r e s p o n d e d most  of breast  present  o r f a m i l y h i s t o r y o f cancer  d i d not  on d e l a y .  r a t h e r than  information without  rap-  T h i s i s understand-  Worry o r f e a r c o u l d be  p r o d u c t i v e and p r o d u c e a d e n i a l and f a t a l i s m Longer,  includes  t h e f o r m e r more h e a v i l y  P a t i e n t s with breast cancer  i n comparison with  the l e s s the delay.  i n patients.  s h o r t e r delay could occur with t h e assurance  that cancer  counter  more  i s curable.  46  It  i s notable  medical ly. the  i n this  help u n t i l  The authors  s e r i e s o f p a t i e n t s 8 percent  they  could  population These pa-  and do n o t r e s p o n d t o a n y f o r m  o r i n f o r m a t i o n program.  Delay i n fact  is a  and d e l i b e r a t e a c t i n s p i t e o f a w a r e n e s s and t h e  information clusions  independent-  a s 10 t o 20 p e r c e n t .  t i e n t s may n e v e r s e e a d o c t o r  conscious  operate  suggested that i n the general  f i g u r e may b e a s h i g h  of education  no l o n g e r  avoided  supplied.  These a r e c e r t a i n l y  f o r anyone who  educational  interesting  con-  i s c o n s i d e r i n g e m b a r k i n g o n an  campaign.  D e n n i s e t a l (1975)  (32) r e v i e w e d 237 p a t i e n t s who h a d  undergone r a d i c a l mastectomies f o r carcinoma o f t h e b r e a s t during  a f i v e year  p e r i o d f r o m J a n u a r y 1965 t o December 1970,  at t h e S t a t e U n i v e r s i t y H o s p i t a l - Kings County H o s p i t a l Center,  New Y o r k . <1 1 2 3 4-8 8-12 >12  T h e f o l l o w i n g p a t i e n t d e l a y was month month months months months months months  16.8% 16.4% 9.2% 10.5% 23.2% 16.4% 7.5%  The  a v e r a g e age o f t h e p a t i e n t s was 52.3 y e a r s  age  p a t i e n t ' s d e l a y was 4.8 months.  little  periods  comparable p i c t u r e . pared with  and t h e a v e r -  T h e 4.8 months i s o f  s i g n i f i c a n c e i n comparison with  various delay  found:-  the percentages f o r  (above) w h i c h g i v e  a c o m p l e t e and  I t i s i n t e r e s t i n g t h o u g h , when com-  f i g u r e s i n the i n t r o d u c t i o n t o Hackett  e t a l (29)  47  w h i c h showed t h e p a t i e n t s w i t h General  H o s p i t a l had  b e t w e e n 1917 age of  and  1918  o f 4 months 1921 4.8  months.  the  The  and  recurrence  b e t w e e n d e l a y and  t o 1922  location  and  found  not  no  significant  metastases.  n e c e s s a r i l y mean e a r l y t r e a t m e n t  not  synonymous w i t h  s u c h as t u m o u r - h o s t part  d e l a y had logical  (5)  to  sur-  the  to rate  and  vessel invasion  and  though t h a t  treatment  without  did  l i f e h i s t o r y o f the  a more  (9)  and  Bloom.  an  educational or  factors  been  (14)  n o t b e e n w e l l enough d e f i n e d i n t e r m s o f  f a c t o r s t o develop  tumour  important  a p o i n t which had  Sutherland  not  value.  t h e d u r a t i o n o f symptoms and  T h i s was  of  number  and  relationship played  i n t h e outcome.  ed b y M a c D o n a l d ,  t h a t the  years.  relationship  They f e l t  was  aver-  delay  the  S u r v i v a l v/as r e l a t e d  lymph node i n v o l v e m e n t ,  c o n c l u s i o n was  average  in relation  o f lymph n o d e s i n v o l v e d , b l o o d  The  an  months,  changed o v e r  l a c k o f c o r r e l a t i o n between d e l a y  was  o f 5.4  i n 1930  examined d e l a y  the presence of systemic the  and  p i c t u r e has  survival.  g r o w t h , tumour s i z e ,  Massachusetts  f o l l o w i n g d e l a y : - p a t i e n t s seen  an a v e r a g e d e l a y  D e n n i s e t a l (32) vival  a tumour a t t h e  stressPatient  psycho-  information  programme w h i c h w o u l d i n f l u e n c e d e l a y . Our  a t t e n t i o n has  course  and  tainly  the stage  to  survival other  delay.  than  the treatment  given.  o f advancement, r a t e o f g r o w t h ,  d i s s e m i n a t i o n may  than  b e e n drawn t o f a c t o r s i n f l u e n c i n g  be  liability  o f more i m p o r t a n c e t o t h e  T h e r e i s no d o u b t o f t h e  Cer-  significance  individual for  48  survival,  o f s i t e o f o r i g i n o f t h e tumour w i t h i n t h e b r e a s t .  (12)  The l i t e r a t u r e  i s e x t e n s i v e on c o n f i r m i n g t h e impor-  tance  o f these  factors.  other  Williams with  e t a l (1976)  (34, 35, 36)  (30) made a s t u d y  p o s s i b l e d i s e a s e o f t h e b r e a s t a t t h e U n i v e r s i t y Hos-  pital  o f Wales B r e a s t C l i n i c .  T h e p r e s e n t i n g symptom i n  81 p e r c e n t was a p a l p a b l e lump. these  lumps were f o u n d  seemed t o r e g a r d t h i s  Twenty-five  found  attended  35 y e a r s  more t h a n  expressed  ferent  women w i t h  domestic  (18) G r e e r  women w i t h response  children  8 percent  interest delayed  i n the rest  (26) a n d Cameron  (20) h a v e  and f i n a n c i a l problems as causes o f de-  T h i s may b e t h e r e a s o n  married  o f age. A l s o , o f g r e a t  o f married  Gold,  reviews  o f symptoms i n c o m p a r i s o n  3 months i n c o m p a r i s o n w i t h  o f t h e group.  i n earlier  o f women u n d e r 35 y e a r s  w i t h i n o n e week o f o n s e t over  They  d i f f e r e n c e i n d e l a y a c c o r d i n g t o age  t h a t 30 p e r c e n t  lay.  I t may b e t h e way i n w h i c h t h e q u e s -  Forty-three percent  19 p e r c e n t  was  e t a l (15) i t i s q u i t e  T h i s was n o t a p r o m i n e n t f i n d i n g  of delay.  again  a n d t h e s t r e s s t h a t was p u t o n r o u t i n e .  a significant  groups.  They  a s a l o w f i g u r e b u t i f one l o o k s  a remarkable response. t i o n was a s k e d  percent o f  by r o u t i n e s e l f - e x a m i n a t i o n .  at t h e t a b l e a b s t r a c t e d from Sheridan  to  o f 158 women  children.  f o r t h i s delay s t a t i s t i c The p o s s i b l e reason  for  for dif-  i n t h e two age g r o u p s i s t h a t t h e s e women  were p r e s e n t i n g w i t h  p o s s i b l e breast disease, not diagnosed  carcinoma o f t h e b r e a s t .  A s we h a v e s e e n i n G r e e r  (26)  the  49  d e l a y p a t t e r n between t h e b e n i g n with carcinoma will  i s somewhat  contain predominantly  g r o u p o f p a t i e n t s and t h o s e  different. benign  T h e y o u n g e r age g r o u p  disease  (see Gold's  Table below).  Thus, g i v e n t h a t e a r l y response  see  (26) r e s u l t s w i t h b e n i g n  i n Greer's  t o delay  we  d i s e a s e t h a t any  c o n c l u s i o n s o n c h a n g e o f d e l a y w i t h age i n c a r c i n o m a b r e a s t c o u l d be  (18)  o f the  questioned.  AGE DISTRIBUTION OF WOMEN IN STUDY Age G r o u p  No. o f P a t i e n t s Without Cancer  No. o f P a t i e n t s Ttfith C a n c e r  <30 30-39 40-49 50-59 60-69 70>  11 7 18 8 3 __3  0 7 25 24 20 24  TOTAL  50  100 Gold  The little of  level  impact  Hackett  of education on d e l a y .  i n this  study  1964 (18)  seemed t o h a v e  T h i s i s i n c o n t r a s t t o the s t u d i e s  e t a l , (29) and Cameron and H i n t o n .  f o l l o w i n g was t h e d i s t r i b u t i o n o f d e l a y i n t h i s patients%< 1 week 1 week - 1 month 1- 2 months 2- 3 months > 3 months Sixty-seven percent delayed  less  20% 26% 15% 6% 23% than  3 months.  (20)  The  series of  50  A  response  which i s very  of p a t i e n t s admitted the  ately  series, and Gold  80 p e r c e n t  92  percent  (18)  i s t h a t 77  deliberately delaying after  lump i n t h e b r e a s t .  this  interesting  T h e r e was  noticing  no undue d o c t o r  of patients being  percent  delay i n  referred  immedi-  w i t h i n a month.  i n reviewing psychological factors  and  be-  h a v i o u r a l p a t t e r n s i n d e l a y d i s c u s s e d the p l a c e o f modesty, s h y n e s s and  lack of t a c t i l i s m  i n r e l a t i o n to delay.  therefore notable that i n t h i s  p a p e r 30 p e r c e n t  e m b a r r a s s m e n t when e x a m i n e d b y  a male d o c t o r  would have p r e f e r r e d t o have seen a female In c o n c l u s i o n they largely  ineffective.  the p o s s i b i l i t y s c h o o l may  be  found  of educating  the  answer.  Krush  admitted  and  50  to  percent  doctor.  that education  L i k e L y n c h and  It is  so f a r has  (23)  g i r l s while they  they  are  been  suggest  still  at  51  4.0  METHODOLOGY OF RESEARCH  4.1  OBJECTIVES OF STUDY  4.2  DATA SOURCES  4.3  METHODS OF ANALYSIS  52  4.1 The the  is felt  short delay e n a b l e me The the  STUDY  methodology w i l l have t h e o b j e c t i v e o f  r e l a t i o n s h i p betxireen d e l a y It  in  OBJECTIVES OF  and  exploring  survival.  t h a t comparing those p a t i e n t s with  t i m e s and  to test  the  their  respective survivals w i l l  age,  best  c l i n i c a l stage,  e x a m i n e d as t h e y pathological  appear  stage,  p o s i t i o n o f tumour, outcome, h i s t o l o g y , m a r i t a l s t a t u s socio-economic variables  are  ated both with ing  the  other  i n d e x as d e f i n e d b y B l i s h e n chosen because they are delay  t i m e and  with  I will  be  to  import  to influencing delay  (33).  and  These  likely  t o be  associ-  survival.  Also  review-  v a r i a b l e s associated with  more l i k e l y  and  hypothesis.  f o l l o w i n g v a r i a b l e s w i l l be  records:-  long  delay  and  show d i f f e r e n c e s t h a t may i n future  planning.  survival, be  of  53  4.2  DATA SOURCES  From t h e p r e l i m i n a r y r e v i e w o f t h e d a t a a v a i l a b l e i n the c l i n i c a l r e c o r d s o f t h e Cancer C o n t r o l Agency, t h e q u a l i t y o f t h e d a t a c a n b e judged as good. The  r e v i e w o f d e l a y i n t h e y e a r s 1960,  1961 and 1970  shows t h a t d e l a y has n o t a p p r e c i a b l y changed i n a decade. In  f a c t i t i s remarkable how c l o s e l y t h e p a t t e r n s o f d e l a y  f o l l o w each o t h e r from y e a r t o y e a r .  There a r e changes w i t h  t h e t h r e e l e v e l s o f age s t r a t i f i c a t i o n b u t t h e y a r e m i n i m a l and n o t c o n s i s t e n t . The y e a r s 1960 t o 1964 i n c l u s i v e a r e chosen f o r examination.  T h i s f i v e y e a r s ' p e r i o d w i l l produce a l a r g e  sample f o r a p e r i o d o f time between t h e n and t h e p r e s e n t , t o g i v e l e n g t h y f o l l o w up p e r i o d s f o r  comparison.  Two groups o f women, t h o s e w i t h d e l a y p e r i o d s l e s s t h a n a month, and 12 months and o v e r , a r e chosen t o compare w i t h respect t o s u r v i v a l .  These two d e l a y p e r i o d s w i l l g i v e a  b a l a n c e d number o f cases and a l l o w s comparison o f two extremes o f d e l a y t i m e . The f o l l o w i n g pages g i v e a d a t a l i s t r e v i e w w i t h d e f i nitions o f the various variables.  The column numbers g i v e n  at t h e r i g h t o f t h e page i n r e l a t i o n t o each v a r i a b l e , r e p r e sent c o d i n g f o r t r a n s c r i p t i o n t o punch c a r d s . shows t h e d a t a c o l l e c t i o n  Table  (XII)  sheet.  E a c h y e a r i s d e f i n e d and each p a t i e n t i s g i v e n an i d e n t i f i c a t i o n number f o r r e c a l l . by s t a g e number as d e f i n e d i n T a b l e  C l i n i c a l s t a g e i s coded (XIII).  Pathological  54  staging  i s n o t e d i n a s i m i l a r manner, z e r o  absence o f the d a t a . Table  (XIV) .  Histology  w h i c h were f o u n d on entiation, nology.  The  by  according  u s i n g the  education t o the  and  the T h i r t i e t h  35.00 a b o v e and S c o r e s o f 40,  occupation  60  the  and  the  i s rated and  into class levels  income i s done  from each  70  lowest,  and  Zero w i l l  other."  f o r t h i s p u r p o s e f r o m one  d e c i l e w i l l be  7 respectively.  mation.  An  i s produced u s i n g  scores  f r o m 20.00 t o  divided arbitrarily  34.99 b e l o w i n t o c l a s s e s two  50,  and  occupation.  n o t much d i f f e r  defined  being  ways,  " t h e p i c t u r e s w h i c h emerge u s i n g  c u t t i n g p o i n t s do  C l a s s one  differ-  i s u s e d i n two  l e v e l s o f education  division  Seven c l a s s e s are  seven.  and  income.  a r b i t r a r y b a s i s and  different  6  The  review,  t h e husband's o c c u p a t i o n 1  and  four variables  descriptive pathological termi-  patient s  prevailing  o f i t s incumbents.  99  and  B l i s h e n Socio-Economic index  variables,  (33)  the  the p r e l i m i n a r y data  to give a l e v e l using  secondly,  an  i s d e f i n e d by  growth, type  the  method o f s t a g i n g i s o u t l i n e d i n  B l i s h e n ' s Socio-Economic index  firstly  on  The  recording  above w i l l be  and  to 29.  at  three.  c l a s s e s 4,  denote absence o f  infor-  5,  55 4.3  METHODS OF  ANALYSIS  The r e s u l t s w i l l be reviewed i n t a b l e s long  and s h o r t d e l a y p e r i o d s w i t h each v a r i a b l e .  sguare a n a l y s i s the  a f t e r Armitage  tables  (37) w i l l b e u s e d t o e x a m i n e  (38) (39) w i l l b e u s e d t o compare  for both delay periods. be c a l c u l a t e d  The r e l a t i v e s u r v i v a l  from these t a b l e s .  survival  rates  will  The r e l a t i v e s u r v i v a l  t h e r a t i o o f t h e observed t o t h e expected s u r v i v a l .  expected the  Achi-  results. Life  is  comparing t h e  survival  display  1968 - 1972. S u r v i v a l  these  The  r a t e s w i l l b e t h o s e o f a g r o u p o f women o f  same a g e , b a s e d o n t h e v i t a l  Columbia,  rate  figures.  statistics  for British  g r a p h s w i l l b e drawn t o  56 DATA L I S T AND  1. YEAR  REVIEW  PRIMARY c a s e s a r e c o n s i d e r e d f r o m e a c h y e a r 1960-1964 inclusive. Primary cases a r e those def i n e d a s d i a g n o s e d and t r e a t ment i n t h a t y e a r b y t h e c a n c e r c l i n i c o r on immediate r e f e r r a l a f t e r treatment o r d i a g n o s i s elsexvhere.  Cols  1-2  2. IDENTIFICATION NUMBER  Cols  3-8  3. AGE  Cols  9-10  4. C L I N I C A L STAGE  5. PATHOLOGICAL STAGE  6. BREAST  7. S I T E  C o d e d b y s t a g e number as in table S t a g e 1, 2, 3, 4  Cols  11  C o d e d b y s t a g e number as defined i n table S t a g e 1, 2, 3, 4  Cols  12  Left or right Coded L e f t 1 Right 2  Cols  13  Cols  14  Location  i n breast  INNER  OUTER 4  1  3  2  5 - Whole b r e a s t 6 - Nipple  area  57  8.  BIOPSY DATE  cols 15  •  cols 16  MONTH  DELAY TIME  cols 17  cols 18  • •  YEAR  •  C o l s 15-18  T h i s i s d e f i n e d as t h e t i m e f r o m t h e f i r s t symptom t h e p a t i e n t complains o f , t o t h e date o f b i o p s y o r biopsysurgery G i v e n i n months. col 19  col 20  •  •  col 21  •  MONTHS 10.  SURVIVAL  I s d e f i n e d as t h e time from biopsy t o death o r l a t e s t date o f f o l l o w up col 22  •  col 23  OUTCOME  col 24  • •  YEARS 11.  C o l s 19-21  col 25  •  MONTHS  Cols  22-25  Coded a s : 0 - alive 1 - dead  from b r e a s t  cancer  2 - dead  from o t h e r causes  3 - dead  f r o m unknown  4 - lost  t o f o l l o w up  causes C o l s 26  58  12. LENGTH OF SURVIVAL OR FOLLOW UP  Similarly Survival Col 27  defined as:  Col 28  Col Col 29 30  • ••• YEARS  HISTOLOGY 13. DIFFERENTIATION  14. GROWTH  15. TYPE  16. DESCRIPTIVE  MONTHS  Cols  27-30  IS DEFINED BY FOUR VARIABLES Coded Well  = 1  Moderately o r fairly well  = 2  Poor  = 3  Insitu  = 1  Infiltrating  = 2  Ductal  = 01  Lubular  = 02  Medullary  = 03  Tubular  = 04  Papillary  = 05  Colloid or Mucoid  = 06  Adenocystic  = 07  Scirrhous Carcinoma  = 08  Adenocarcinoma  = 09  Scirrhous Adenocarcinoma  = 10  Carcinoma  = 11  C o l s 31  C o l s 32  Cols  33-34  59  Comedo Carcinoma = 12 C a r c i n o m a S i m p l e x = 13 Malignant Cystosarcoma  17.  18.  19*  MARITAL  SOCIOECONOMIC  STATUS  Phyllodes  = 14  C a r c i n o Sarcoma  = 15  Pagets Disease  = 16  Cols  35  Cols  36  Cols  37  Cols  38  Coded: Married  1  Single  2  Widowed  3  Separated/ Divorced  4  B l i s h e n s Socio-Economic as d e f i n e d b y h u s b a n d ' s occupation. Coded: 7,6,5,4,3,2,1,0  Index  B l i s h e n s Socio-Economic as d e f i n e d b y p a t i e n t ' s occupation. Coded: 7,6,5,4,3,2,1,0  Index  TABLE XII  SHEET FOR COLLECTING DATA YEAR  on  Cols 1-2  CLINICAL STAGE Stage 1 2 3 4  •••••• •• •  Col  11  PATHOLOGICAL Stage 1 2 3 4  •  Col  12  Col Col  13 14  IDENTIFICATION NO, AGE  Cols 3-8 Cols 9-10  SITE Left 1 Right 2  Inner 4 1 Outer 3 2  OUTCOME 0 1 2 3 4 (See Code)  •••• ••• •••• •  Col  LENGTH OF SURVIVAL OR FOLLOW UP  ••••  Cols 27-30  DATE OF BIOPSY DELAY TIME SURVIVAL  Cols 15-18 Cols 19-21 Cols 22-25 26  HISTOLOGY Differentiation 12 3  Insitu/lnfiltrating Type Descriptive (See Code) MARITAL STATUS SOCIO-ECONOMIC STATUS By Husband By Patient •Coding appears in data l i s t review  • •  •n •  Col Col Cols Cols  31  Col  36  Col Col  37  32 33-34 34-35  38  61  TABLE  XIII  CLINICAL STAGING OF CARCINOMA BREAST Paterson  Stages 1 and 11 conform t o B r i t i s h d e f i n i t i o n of Early STAGE 1  The primary tumour i s f r e e l y movable on the pectoral muscle (with muscle contracted) or, i f l a t e r a l t o the pectoral muscle, movable on the chest w a l l . Skin involvement, including u l c e r a t i o n , may be present, but such involvement must be i n d i r e c t continuity with the tumour and there must not be any extension i n t o the s k i n wide of the tumour i t s e l f .  STAGE 11  As Stage 1 but there are palpable mobile lymph nodes i n the a x i l l a of the same side.  STAGE 111  The primary growth i s more extensive than Stage 1 as shown by: (a)  The skin invaded or fixed over an area wide of the tumour i t s e l f , but s t i l l l i m i t e d t o the breast.  (b)  The tumour f i x e d t o underlying muscle but not t o chest w a l l . A x i l l a r y lymph nodes may or may not be palpable, but i f lymph nodes are present, they must be mobile.  STAGE 17  The growth has extended beyond the breast area, as shown by: (a)  F i x a t i o n of a x i l l a r y lymph nodes i n d i c a t i n g extension outside the capsule.  (D)  Tumour f i x e d t o the chest w a l l .  (c)  Secondary growth i n supraclavicular lymph nodes.  (d)  Secondary involvement  (e)  Secondary growth i n opposite breast.  (f)  Distant metastases, e.g. bone, l i v e r , lung, e t c .  i n skin wide of the breast.  Inflammatory carcinoma i n Stage I? NOTE:  Paget*s Disease of the nipple i s accepted as a primary carcinoma, and Stages 1 unless palpable lymph nodes are present.  62 TABLE  XIV  PATHOLOGICAL STAGING OF BREAST CARCINOMA  STAGE I  Disease confined t o the breast.  STAGE 1-0  Where t h e d i s e a s e i s i n s i t u carcinoma o n l y they w i l l be l i s t e d as Stage 1-0.  STAGE I I  As i n one, p l u s m e t a s t a t i c d i s e a s e c o n f i n e d t o a x i l l a r y lymph nodes below t h e l e v e l o f t h e apex.  II? STAGE I I I  STAGE IV  L e v e l o f involvement  unknown.  D i r e c t l o c a l spread from b r e a s t primary t o : (a)  s k i n wide o f tumour  (b)  underlying f a s c i a  (c)  u n d e r l y i n g muscle  (a) D i r e c t e x t e n s i o n from b r e a s t primary t o r i b o r c a r t i l a g e o f chest w a l l . (b)  E x t e n s i o n o f d i s e a s e beyond t h e capsule o f an a x i l l a r y lymph node.  (c)  Involvement o f a p i c a l o r i n t e r n a l mammary lymph nodes o r t i s s u e s .  (d)  Involvement o f an a x i l l a r y lymph node a t any l e v e l which i s found p a t h o l o g i c a l l y t o be 2.5 cm. i n s i z e o r l a r g e r .  (e)  D i s t a n t metastases ( i n c l u d i n g s u p r a c l a v i c u l a r lymph nodes).  63  5.0  RESULTS  5.1  THE DISTRIBUTION OF DELAY TIMES BY YEAR OF DIAGNOSIS, AGE, FIVE YEAR AGE GROUPS, CLINICAL STAGE, PATHOLOGICAL STAGE, BREAST INVOLVED, SITE INVOLVED, HISTOLOGICAL DESCRIPTION, MARITAL STATUS AND SOCIOECONOMIC STATUS  5.2  THE ANALYSIS OF THE ASSOCIATION OF DELAY TIME ON SURVIVAL FROM YEAR OF DIAGNOSIS  5.3  THE ANALYSIS OF THE ASSOCIATION OF DELAY TIME ON SURVIVAL FROM DATE OF FIRST SYMPTOM  5.4  THE ANALYSIS OF THE ASSOCIATION BETWEEN DELAY TIME AND SURVIVAL WITH CONTROL FOR OTHER FACTORS  64 5.1  THE DISTRIBUTION OF DELAY TIMES BY YEAR OF. DIAGNOSIS, AGE, F I V E YEAR AGE GROUPS, C L I N I C A L STAGE, PATHOLOGICAL STAGE, BREAST INVOLVED, S I T E INVOLVED, HISTOLOGICAL DESCRIPTION, MARITAL STATUS AND SOCIO-ECONOMIC STATUS The  defined sed  records o f a l l the p a t i e n t s i n both delay as l e s s  groups,  t h a n one month and 12 o r more months  diagno-  i n 1960, 1961, 1962, 1963 and 1964, were e x a m i n e d .  total  number o f p a t i e n t s was 456.  every case  D a t a was n o t c o m p l e t e  and t h e number a v a i l a b l e  noted w i t h each  d i s t r i b u t i o n o f delay by year. o f numbers o f c a s e s t h r o u g h o u t  test.  c a s e s were e x a m i n e d f o r t h e i r There  i s an e v e n  the years.  distribution  This applies to  b o t h d e l a y p e r i o d s and i t i s n o t e d t h a t p e r c e n t a g e b u t i o n and numbers o f c a s e s v a r i e s This confirms the e a r l i e r Review t h a t strated  finding  little  from  one y e a r  occurring cluded  and o v e r b y d e l a y t i m e .  i n the l e s s than  y e a r age g r o u p s .  cases  I t i s inter-  i n t h e l o n g d e l a y group i s  One hundred, and t h r e e c a s e s h a v e d e -  l a y e d two y e a r s and o v e r . (224) i n t h i s  i n the delay  The t o t a l  f o r comparison.  the delay time  quite considerable.  T a b l e XVII  T h i s i s demon-  one month p e r i o d o f 232 a r e i n -  at the top of the table  e s t i n g t o see that  cases  1960 t o 1964.  XV.  T a b l e X V I shows t h e d i s t r i b u t i o n o f c a s e s period  distri-  i n the P r e l i m i n a r y Data  d e l a y has n o t changed w i t h t i m e .  i n Table  in  f o r each v a r i a b l e i s  table or s t a t i s t i c a l  F o u r h u n d r e d and f i f t y - s i x  The  T h i s i s almost h a l f  of the t o t a l  group.  shows t h e d i s t r i b u t i o n From t h i s t a b l e  of delay i n five  i t can be seen t h a t  cases  65  in  the  not to  s h o r t d e l a y group are younger.  a remarkable be  one.  On  statistical  i n r e l a t i o n t o age  Information i s available  statistical  clinical  stage  Almost over  70%  see t h a t o f cases  i n 456  50%  reviews  cases.  stage  that  and  this  in relation  t o s h o r t and  of the t o t a l  in clinical  fall  stages  1 and  within clinical  11.  There  11.  clinical  of cases  in clinical  a marked c o n t r a s t b y  clinical  It  therefore, that  better of  tical and  stage 1 cases.  difference both  long delay with  almost  While  stage  There  in total X  in  clinifigures  stage would  i n the l e s s clinical  These f i g u r e s i n t h e two  be  than  stage  suggest  delay periods.  outcome s h o u l d be  i n the e a r l y d e l a y group because o f the  clinical  month 11.  t o 30.4%  over p e r i o d .  1  I n c o n t r a s t we  stage IV  month d e l a y p e r i o d i n c o m p a r i s o n  expected  stage  suggestion i n these  find  i n t h e 12 months and  times.  o v e r o n l y 52% were i n  i s no  by  I t i s interesting  s t a g e 1 and  cases o f a p o o r e r p r o g n o s i s by  o n l y 3.8%  (449)  c a s e s were i n c l i n i c a l  f o r t h e d e l a y p e r i o d l e s s t h a n one  1 and  c o u l d be  suggest  i s c o n f i r m e d on °  long delay  i n the e a r l y delay period.  IV  XVIII.  figures  of cases  more p r o m i n e n t  one  i n Table  The  the d i s t r i b u t i o n  t h e d e l a y p e r i o d 12 months and cal  i t i s found  analysis.  T a b l e XIX  90%  analysis  i s examined  t h a t the young t e n d t o d e l a y l e s s  to  t r e n d though i s  significant. Delay  and  The  much  preponderance  i s a considerable s t a t i s and  analysis of Table  m  t r e n d between s h o r t  XIX.  66  Unfortunately  the data  available for distribution of  cases by p a t h o l o g i c a l staging  i s poor.  Only information  168 c a s e s i s a v a i l a b l e o u t o f t h e 456 c a s e s e x a m i n e d . XX  shows t h e d i s t r i b u t i o n o f t o t a l  staging,  different clinical  from T a b l e XIX w i t h stage.  The t r e n d  the  pathological staging  lay  period.  to c l i n i c a l months  This  1 and 11 b u t o v e r i s a trend which i s  the d i s t r i b u t i o n  staging  i s n o t as marked.  Thus t h e s h o r t  the  d i f f e r e n c e b e t w e e n them and t h e l o n g d e l a y  staging and  to staging by pathology.  shows t h e d i s t r i b u t i o n  l e f t breast  t i o n by delay  i s not as  d i f f e r e n c e between t h e s h o r t  i n respect  F o u r h u n d r e d and f i f t y - s i x the  o f cases by  breast.  c a s e s w e r e e x a m i n e d , 204 w e r e i n  and 252 i n t h e r i g h t b r e a s t .  The  distribu-  d e m o n s t r a t e d no s i g n i f i c a n t r e l a t i o n s h i p .  T h e p o s i t i o n o f t h e tumour i n t h e b r e a s t w i t h to delay  although  analysis of the table of pathological  periods  T a b l e XXI  pathological staging,  de-  staging.  shows no s i g n i f i c a n t  long delay  more  T h e d i f f e r e n c e i n t h e 12  c a s e s h a v e more f a v o u r a b l e  Statistical  period  as p a t h o l o g i c a l s t a g e I V i n c o n t r a s t  lay  marked a s f o r c l i n i c a l  examine  i n t h e 168 c a s e s i n r e l a t i o n t o d e -  of cases.  and o v e r p e r i o d  o f cases by  i s more n o t i c e a b l e when we  I n t h e l e s s t h a n one month d e l a y  c a s e s were c l a s s i f i e d  Table  cases by p a t h o l o g i c a l  23.3% i n p a t h o l o g i c a l s t a g e s  13.2% i n p a t h o l o g i c a l s t a g e I V .  on  periods  i s shown i n T a b l e X X I I .  o f t h e tumours i n b o t h d e l a y  periods  respect  Approximately h a l f  are i n the outer  upper  67  quadrant 24.1% and  of the b r e a s t .  The  i n n e r upper  o f tumours i n t h e d e l a y p e r i o d  17.4%  i n t h e one  quadrant  contained  l e s s t h a n one  y e a r and more p e r i o d .  A  month  significant  d i f f e r e n c e o c c u r r e d w i t h t u m o u r s d e s c r i b e d as o c c u p y i n g whole b r e a s t . t h e one ing  Fourteen point  less  t h a n one  described that  T h i s i s i n marked c o m p a r i s o n  month d e l a y p e r i o d where we  histology  thus p o s s i b l y  to  only  the  2.6%  T h i s would  indicate  logical  i n the p r e l i m i n a r y data  descriptive  well,  as i n s i t u  and  review.  growth, t y p e  i s d e s c r i b e d as w e l l ,  poorly differentiated.  or i n f i l t r a t i n g .  ductal or lobular.  are  found  With  i n T a b l e XXV.  With  available  further  information.  Only  i n one  patho-  moderately  terms are  A  list  differentiation  so t h i s  or  used terms  of these  only, data i n  i n f o r m a t i o n has been  dis-  discussion.  t h e v a r i a b l e growth,  this  a  Fourteen pathological descriptive  found t o d e s c r i b e d e t a i l e d h i s t o l o g y .  carded from  and  Growth i s r e f e r r e d  I n t y p e two  are  c a s e s was  in relation  term.  Differentiation fairly  a worse p r o g n o s i s .  f o u r t e r m s were f o u n d t o b e u s e d  These are d i f f e r e n t i a t i o n ,  five  occupy-  tumours i n t h e one y e a r and o v e r g r o u p h a v e much more  Generally  to  find  as o c c u p y i n g t h e w h o l e b r e a s t .  e x t e n s i v e d i s e a s e and  to  t h r e e p e r c e n t o f tumours i n  y e a r and more d e l a y p e r i o d were d e s c r i b e d as  t h e whole b r e a s t .  the  The  c a s e was  results  the term  185  c a s e s were f o u n d  are displayed insitu  used.  with  i n Table XXIII. Infiltrating  was  68  u s e d i n an e q u a l number o f cases i n b o t h d e l a y p e r i o d s . I n t y p e , d u c t a l and l o b u l a r are used e q u a l l y between t h e two d e l a y p e r i o d s .  I n f o r m a t i o n was  a v a i l a b l e on  c a s e s , over 90% b e i n g d e s c r i b e d as d u c t a l .  The  153  f i g u r e s are  shown i n T a b l e XXIV. T a b l e XXV  d i s p l a y s the p a t h o l o g i c a l d e s c r i p t i v e terms  i n r e l a t i o n to both delay periods.  I n f o r m a t i o n was  a b l e on 453 c a s e s .  a r e prominent,  carcinoma,  Three d i a g n o s e s  adenocarcinoma and carcinoma.  The  availscirrhous  s u g g e s t i o n from  these f i g u r e s i s t h a t the d i a g n o s i s f o r the short delay i s more l i k e l y t o be s c i r r h o u s carcinoma carcinoma, b u t t h e p e r c e n t a g e adeno carcinoma  and f o r l o n g d e l a y  d i f f e r e n c e s are s m a l l .  the d i f f e r e n c e i s very s m a l l .  The  In  diagnosis  o f Paget's d i s e a s e o c c u r r e d i n t h e 1 y e a r o r more group, i n f o u r cases but not i n t h e l e s s t h a n one month group. I n T a b l e XXVI m a r i t a l s t a t u s i s examined w i t h r e g a r d t o t h e two d e l a y p e r i o d s . cases.  I n f o r m a t i o n was  S i x t y - n i n e p e r c e n t o f m a r r i e d women appeared i n t h e  s h o r t d e l a y i n comparison t o 54.9% The  a v a i l a b l e i n 455  i n t h e l o n g d e l a y group.  s i n g l e and widowed t e n d more t o t h e one y e a r o r more  delay period. percent.  The d i f f e r e n c e i n t h e widowed i s over t e n  The numbers f o r t h e s e p a r a t e d o r d i v o r c e d are  small. Socio-economic s t a t u s and d e l a y are examined i n T a b l e s X X V I I and X X V I I I by husband's and then t h e w i f e ' s o c c u p a t i o n . T a k i n g i n t o c o n s i d e r a t i o n t h e l a r g e number o f cases v/ithout  69  information, using the husband's occupation there appears to be l i t t l e difference between the delay periods and status l e v e l s .  The figures suggest the lower income groups  tend to delay l e s s .  With the patient's occupation  the  opposite i s true though very l i t t l e information i s a v a i l able (less than 20%).  Maybe t h i s trend i s seen because  information i s available on single and widowed women, who in Table 31 appear to delay longer.  70 TABLE  XV  DISTRIBUTION OP DELAY BY YEAR OF DIAGNOSIS  YEAR  SHORT  1960  44  LONG  TOTAL  (19%)  49 (21.9%)  93 (20.4°/  1961  46 (19.8%)  40 (17.9%)  86 (18.9%)  1962  42 (18.1%)  44 (19.6%  86 (18.9%)  1963  56 (24.1%)  47 (21%)  103 (22.6%  1964  43 (18.5%)  44 (19.6%  87 (19.1%  UNKNOWN  1 (0.4%  0 (0%)  1 (0.2%)  TOTAL  232 (100%)  224 (100%)  456 (100%)  %2  TOTAL  =  1.42  d f 4  N.S.  71 TABLE  XVI  TABLE DISTRIBUTION OF CASES IN THE DELAY PERIOD ONE YEAR AND OVER BY DELAY TIME  DELAY TIME Less than 1 Month 12 Months  NUMBER 2  3, 2  8 7  tt  3  15 16  5  k  17  18 19 21 24 30 36 42  48 54 60 66 72 84 96 120  1  1 8  2  1  3 3  5  1  8  3 9  1  9  1  6  5  k  4  132  150  1  1  168  180  2  1  72 TABLE  XVII  DISTRIBUTION OF DELAY IN F I V E YEAR AGE GROUPS MEAN 54.8 AGE  MEAN 59.6  SHORT  LONG  TOTAL  20-24  1 (0.4%)  0  1 (0.2%)  25-29  3 (1.3%)  0  3 (0.7%)  30-34  9 (3.9%)  1 (.4%)  10 (2.2%)  35-39  14 (6%)  17 (7.6%)  31 (6.8%)  40-44  39 (16.8%)  21 (9.4%)  60 (13.2%)  45-49  35 (15.1%)  33 (14.7%)  68 (14.9%)  50-54  24 (10.3%)  23 (10.3%)  47 (10.3%)  55-59  24 (10.3%)  28 (12.5%)  52  (11.4%)  60-64  23 (9.9%)  22 (9.8%)  45  (9.9%)  65-69  26 (11.2%)  12  38 (8.3%)  70-74  12  (5.2%)  25 (11.2%)  37 (8.1%)  75-79  12 (5.2%)  23 (10.3%)  35 (7.7%)  80-84  9 (3.9%)  12 (5.4%)  21 (4.6%)  85-89  1 (0.4%)  3 (1.3%)  4 (0.9%)  90-94  0  4 (1.8%)  4 (0.9%)  UNKNOWN  0  0  0  TOTAL  232 (100%) %2 *2 X 2  TOTAL TREND RESIDUAL  (5.4%)  224 (100%) 34.98 13.08 21.90  cl f  456 (100%) 14  P<0.05  73 TABLE  XVIII  AGE DISTRIBUTION OP CASES AND DELAY IN RELATION TO AGE  AGE  SHORT  <44  66 (28.4%  39 (17.4%)  105 (23%)  45-64  106 (45.7%)  106 (47.3%)  212 (46.5%)  65-99  60 (25.9%)  79 (35.3%)  139 (30.5%)  0  0  UNKNOWN TOTAL  232 (100%)  X X  2  TOTAL  9.40  2  TREND  8.99  LONG  TOTAL  224 (100%)  a f  456 (100%)  2  p  <0.01  74 TABLE  CLINICAL  CLINICAL STAGE  XIX  STAGING I N RELATION TO D E L A Y T I M E  SHORT  LONG  149 (64.2%)  TOTAL  70 (31.3%)  219 (48.0%)  (24.151  44 (19.6%)  100 (21.9%)  16 (6.9%)  37 (16.5%)  53 (11.6%  9 (3.8%)  68 (30.4%  77 (16.9%)  UNKNOWN  2 (0.9%)  5 (2.2%)  7 (1.59  TOTAL  232 (100%)  224 (100%)  456 (100%)  56  X  2  X  2  TOTAL  =  83.25  d f 3  P <0.001  TREND  =  81.81  d  P <0.001  f 1  75  TABLE  XX  PATHOLOGICAL STAGING IN RELATION TO DELAY TIME  PATHOLOGICAL STAGE  SHORT  LONG  41 (17.7%)  19 (8.5%)  23 (9.9%)  23 (10.3%)  2 (0.9%) 4  0 (0%)  32 (13.8%)  28 (12.5%)  UNKNOWN  134 (57.8%)  154 (68.8%)  TOTAL  232 (100%)  224 (100%)  X  TOTAL  5.83  d f 3  76 TABLE  XXI  DISTRIBUTION OF CASES BY BREAST AND DELAY TIME  BREAST  SHORT  LONG  TOTAL  LEFT  100 (43.1%)  104 (46.4%)  204 (44.7%)  RIGHT  132 (56.9%)  120 (53.6%)  252 (55.3%)  0  0  0  UNKNOWN  TOTAL  232 (100%) %  2  TOTAL  0.51  224 (100%) d f 1  456 (100%) N.S.  77 TABLE  XXII  DISTRIBUTION OF CASES BY S I T E AND DELAY TIME  SITE  SHORT  LONG  TOTAL  OUTER UPPER  119 (51.3%)  98 (43.8%)  217 (47.6%)  OUTER LOWER  19 (8.2%)  17 (7.6%)  36 (7.9%)  INNER LOWER  15 (6.5°/  20 (8.9%)  35 (7.7%)  INNER UPPER  56 (24.1%)  39 (17.4%)  95 (20.8%)  WHOLE BREAST  6 (2.6%)  32 (14.3%)  38 (8.3%)  NIPPLE  17 (7.3%)  UNKNOWN  18 (8%)  0  TOTAL  0  232 (100%) X X  2  2  TOTAL RESIDUAL  35 (7.7%)  224 (100%) 23.58  19.12  456 (100%) d f 5  P <0.001  78  TABLE  XXIII  HISTOLOGICAL DESCRIPTIVE TERM GROWTH IN RELATION TO DELAY  GROWTH  SHORT  LONG  TOTAL  INSITU  1 (0.49  0 (0%)  1 (0.2%)  INFILTRATING  90 (38.8%)  94 (42%)  184 (40.4%)  UNKNOWN  141 (60.8%)  130 (58%)  271 (59.4%)  TOTAL  232 (100%)  224 (100%)  456 (100%)  79 TABLE  XXIV  HISTOLOGICAL DESCRIPTIVE TERM TYPE IN RELATION TO DELAY  TYPE DUCTAL  LOBULAR  SHORT 71 (30.6%) 7 (3%)  LONG  TOTAL  69 (30.8%)  140 (30.7%)  6 (2.8%)  13 (2.9%)  UNKNOWN  154 (66.4%)  149 (66.5%)  303 (66.4%)  TOTAL  232 (100%)  224 (100%)  456 (100%)  80  TABLE  XXV  PATHOLOGICAL DESCRIPTIVE TERMS IN RELATION TO DELAY DESCRIPTIVE MEDULLARY  SHORT 11  (4.7%)  LONG  TOTAL  3 (1.3%)  14 (3.1%)  TUBULAR  0 (0%)  0 (0%)  0 (0%)  PAPILLARY  3 (1.3%)  1 (0.4%)  4 (0.9%)  COLLOID OR MUCOID  5 (2.2%)  3 (1.3%)  8 (1.8%)  ADENOCYSTIC  0 (0%)  0 (0%)  0 (0%)  SCIRRHOUS CARCINOMA  90 (38.8%)  71  (31.7%)  ADENO CARCINOMA  27 (11.6%)  33  (14.7%)  SCIRRHOUS ADENOCARCINOMA  161  (35.3%)  60 (13.2%)  1 (0.4%)  6 (2.7%)  CARCINOMA  82 (35.3%)  98 (43.8%)  COMEDO CARCINOMA  1 (0.4%)  1 (0.4%)  2 (0.4%)  CARCINOMA SIMPLEX  7 (3%)  2 (0.9%)  9 (2.0%)  MALIGNANT CYSTOSARCOMA PHYLLODES  1 (0.4%)  1 (0.4%)  2 (0.4%)  CARCINO  1 (0.4%)  1 (0.4%)  2 (0.4%)  PAGETS DISEASE  0 (0%)  4 (1.8%)  4 (0.9%)  UNKNOWN  3 (1.3%)  0  3 (0.7%)  TOTAL  SARCOMA  232 (100%)  224 (100%)  7 (1.5%) 180  456  (39.5%)  (100%)  81  TABLE  MARITAL  STATUS  IN  XXVI  RELATION  TO  DELAY  MARITAL STATUS  SHORT  MARRIED  160  WIDOWED  TOTAL  123  (69%) SINGLE  LONG  283  (54.9%)  (62.1%)  19  26  45  (8.2%)  (11.6%  (9.9%)  44  66  (19%)  110  (29.5%)  (24.1%)  SEPARATED/ DIVORCED  8 (3.9%)  UNKNOWN  17  (3.5°/  0  (3.7%)  1  1  (0.4%  TOTAL  232  224  (100%)  X  (0.2%)  456  (100%)  2  TOTAL  10.21  X  2  TREND  7.03  X  2  RESIDUAL  3.18  (100%)  d f  3  P  <0.05  82 TABLE  XXVII  SOCIO-ECONOMIC STATUS AS DEFINED BY HUSBAND'S OCCUPATION I N RELATION TO DELAY  STATUS LEVEL  SHORT 13 (5.6%  LONG 6 (2.7%)  17 (7.3%)  TOTAL 19 (4.2%) 26 (5.7%)  13 (5.6%)  13 (5.8%)  26 (5.7%)  29 (12.5%  29 (12.9%)  58 (12.7%)  21 (9.1%  22 (9.8%)  43 (9.5%)  29 (12.5%  23 (10.3%)  52 (11.4%  39 (16.8%)  19 (8.5%)  58 (12.7%) 174 (38.2%)  UNKNOWN  71 (30.6%  103 (46%)  TOTAL  232 (100%)  224 (100%)  456 (100%)  83  TABLE  XXVIII  SOCIO-ECONOMIC STATUS AS DEFINED BY PATIENT'S OCCUPATION I N RELATION TO DELAY  STATUS LEVEL  SHORT  LONG  TOTAL  4 (1.7%)  4 (1.8%)  8 (1.8%)  1 (0.4%)  0 (0%)  1 (0.2%)  5 (2.2%)  5 (2.2%)  10 (2.2%)  12 (5.2%)  9 (4%)  21 (4.6%)  4 (1.7%)  8 (3.6%  12 (2.6%)  1 (0.4%  7 (3.1%  8 (1.8%)  4 (1.7%)  6 (2.7%)  10 (2.2%)  UNKNOWN  201 (86.6°/  185 (82.6%)  386 (84.6%)  TOTAL  232 (100%)  224 (100%)  456 (100%)  84  5.2  THE ANALYSIS OF THE ASSOCIATION OF DELAY TIME ON SURVIVAL FROM YEAR OF DIAGNOSIS  The in  outcome i n t h e 456  T a b l e XXIX.  alive,  almost  One  hundred  cases  and one  p a t i e n t s had  3%  In to  (54)  relation  Two  Twelve percent d i e d  f r o m unknown c a u s e s .  c a s e s examined  were l o s t  to follow  i n t h e s e c a s e s t h e r e f o r e was f o l l o w up.  both groups.  number l o s t  of  T a b l e XXV  the  examines  delay periods.  we lay  alive  t o f o l l o w up was  and  equivalent i n  F o u r p e r c e n t were d e a d f r o m unknown c a u s e s  in this  category.  s e e a d i f f e r e n c e o f 8.4% group  Twenty-six  t o 18% o f t h e one y e a r  t h e l o n g d e l a y c a s e s w h i l e o n l y 1.7% cases f e l l  Sur-  measured from d a t e  t h a n one month g r o u p were s t i l l  The  lost  seen.  percent o f the l e s s  over group.  the  those cases  t o t h e two  i n comparison  other  up.  outcome i n r e l a t i o n  as o f J u n e 1977  over  Twelve percent o f  t o measurement o f s u r v i v a l  biopsy t o date o f l a s t  hundred  from  f o l l o w up were c o n s i d e r e d a s o f t h e d a t e l a s t  vival  still  died of b r e a s t cancer,  h a l f o f t h e c a s e s examined. and  i s shown  p a t i e n t s were  a q u a r t e r o f the cases reviewed.  and t h i r t y - f i v e  causes  as o f J u n e 1977  of the short delay  T h e r e f o r e , examining i n cases a l i v e  from t h e l o n g d e l a y group.  in  outcome  i n the short  T h e r e was  no  de-  differ-  e n c e i n t h e c a s e s when d e a t h f r o m o t h e r c a u s e s w e r e e x a m i n e d . T h i s would c o n f i r m t h e s i m i l a r i t i e s have seen e a r l i e r Life  tables  b e t w e e n t h e two are used  i n age  distribution  we  groups.  t o d i s p l a y the s u r v i v a l  rate  of  85  the  short  and l o n g  delay  groups.  T a b l e s XXX  and X X X I I  show t h e s u r v i v a l r a t e s n o t i n c l u d i n g c a s e s w h i c h d i e d o f competing r i s k .  Tables  d i e d o f competing r i s k served  XXXI and X X X I I I  i n c l u d e cases which  and f r o m t h e s e t h e r e s p e c t i v e ob-  survival rates are calculated.  T a b l e s XXXIV a n d XXXV  show t h e o b s e r v e d and e x p e c t e d s u r v i v a l r a t e s culated relative  s u r v i v a l rates f o r short  T a b l e XXXVI compares t h e r e l a t i v e long  and s h o r t  delay  and t h e c a l -  and l o n g  delay.  survival rates f o r  from date o f d i a g n o s i s .  We  see i n  t h i s t a b l e and i n f i g u r e s 3 a c o n s i s t e n t d i f f e r e n c e i n s u r vival  o f the short  delay  over long delay  g r o u p when  vival  i s c a l c u l a t e d from t h e date o f d i a g n o s i s .  sur-  86  TABLE  XXIX  THE OUTCOME I N RELATION TO THE TWO DELAY PERIODS I N 456 CASES EXAMINED AS OF JUNE 1977  OUTCOME  SHORT  LONG  TOTAL  ALIVE  61 (26.3%)  40 (17.9%)  101 (22.1%  DEAD FROM BREAST CANCER  110 (47.49  125 (55.8%)  235 (51.5%  DEAD FROM OTHER CAUSES  27 (11.6%)  26 (11.6°/  53 (11.6%  DEAD FROM UNKNOWN CAUSES  4 (1.7%)  LOST TO FOLLOW UP  30 (12.9%)  9 (4%)  13 (2.9%)  24 (10.7%)  54 (11.896)  UNKNOWN  Q_  TOTAL  232 (100%)  X  TOTAL  7.79  X  2  TREND  0.32  X  2  RESIDUAL  7.47  2  224 (100%) d f 4,  456 (100%) N.S.  TABLE XXX LIFE TABLE OF SHORT DELAY FROM YEAR OF DIAGNOSIS NUMBER OF DEATHS NOT INCLUDING CASES WHICH DIED OF COMPETING RISK YEARS AFTER DIAGNOSIS  ALIVE AT BEGINNING OF INTERVAL  DIE DURING INTERVAL  DIE OF COMPETING RISK  WITHDRAWN ALIVE DURING INTERVAL  EFFECTIVE NBR EXPOSED TO RISK OF DYING  PROPORTION DYING  PROPORTION SURVIVING  SURVIVAL RATE  0-1  235  8  3  0  233.5  0.03  0.966  0.966  1-2  224  2  0  223.0  0.09  203 181  4  0  201.0  0.09  0.915 0.910  0.883  2-3  19 18 11  5  1  178.0  0.06  0.938  0.755  H  0.804  4-5  164  13  0  0  164.0  0.08  0.921  0.695  5-6  151  9  1  5  148.0  0.06  0.939  0.653  6-7  136  4  3  11  129.0  0.03  0.969  0.632  7-8  118  8  3  4  114.5  0.07  0.930  0.588  8-9  103  5  1  5  100.0  0.05  0.950  0.559  9-10  92  4  4  0  90.0  0.04  0.956  0.534  10-11  84  3  1  3  82.0  0.04  0.963  0.514  11-12  77  3  2  6  73.0  0.04  0.959  0.493  12-13  66  0  2  5  62.5  0.0  1.000  0.493  13-14  59  2  0  15  51.5  0.04  0.961  0.474  14-15  42  2  0  16  34.0  0.06  0.941  0.446  15-16  24  1  1  14  16.5  0.06  0.939  0.419  16-17  8  0  0  0.0  1.000  0.419  7  TABLE XXXI LIFE TABLE OF SHORT DELAY FROM YEAR OF DIAGNOSIS NUMBER OF DEATHS INCLUDING CASES WHICH DIED OF COMPETING RISK YEARS AFTER DIAGNOSIS 0-1 1-2 2-3 3-4 4-5 5^ 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17  ALIVE AT BEGINNING OF INTERVAL 235 224 203 181  DIE DURING INTERVAL 8 19 18 11  164 151 136 118  13  103  5 4  92  84  9 4 8  59 42  3 3 0 2 2  24 8  1 0  77 66  DIE OF COMPETING RISK 3 2  WITHDRAWN ALIVE DURING INTERVAL 0 0  4  0  5 0  1 0  180.5 164.0  0.09 0.08  1  5 11  148.5  0.07  130.5 116.0 100.5  0.05 0.09 0.06  92.0  0.09  3 6  82.5 74.0  0.05  5  63.5  15 16  51.5 34.0  0.04  14  17.0  0.12  0.941 0.882  4.5  0.0  1.000  3 3 1 4 1 2 2 0 0 1 0  4 5 0 .  7  EFFECTIVE NBR EXPOSED TO RISK OF DYING 235.0 224.0 203.0  PROPORTION DYING  PROPORTION SURVIVING  OBSERVED SURVIVAL RATE  0.05 0.09 0.11  0.953 0.906 0.892 0.911  0.953 0.864 0.770 0.702 0.646  0.07 0.03 0.06  0.921  0.933 0.946 0.905 0.940 0.913 0.952 0.932 0.969 0.961  0.603 0.570 0.516 0.486 0.443 0.422 0.393 0.381 0.366 0.345 0.304 0.304  TABLE  XXXII  LIFE TABLE OF LONG DELAY FROM YEAR OF DIAGNOSIS NUMBER OF DEATHS NOT INCLUDING CASES WHICH DIED OF COMPETING RISK YEARS AFTER DIAGNOSIS  ALIVE AT BEGINNING OF INTERVAL  DIE DURING INTERVAL  DIE OF COMPETING . RISK  WITHDRAWN ALIVE DURING INTERVAL  EFFECTIVE NBR EXPOSED TO RISK OF DYING  PROPORTION DYING  PROPORTION SURVIVING  SURVIVAL RATE  0-1  228  25  3  0  226.5  0.11  0.890  0.890  1-2  200  23  7  1  196.0  0.12  0.883  0.785  2-3  169  12  3  0  167.5  0.07  0.928  0.729  3-4  154  13  6  1  150.5  0.09  0.914  0.666  4-5  134  11  0  0  134.0  0.08  0.918  0.611  5-6  123  6  3  5  119.0  0.05  0.950  0.581  6-7  109  12  3  8  103.5  0.12  0.884  0.513  7-8  86  5  2  0  85.0  0.06  0.941  0.483  8-9  79  7  0  4  77.0  0.09  0.909  0.439  68  1  0  2  67.0  0.01  0.985  0.433  10-11  65  5  2  2  63.0  0.08  0.921  0.398  11-12  56  3  2  3  53.5  0.06  0.944  0.376  12-13  48  0  3  9  42.0  0.0  1.000  0.376  13-14  36  1  0  29.0  0.Q3  0.966  0.363  14-15  21  2  1  7  17.0  0.12  0.882  0.320  15-16  11  0  1  6  7.5  0.0  1.000  0.320  16-17  4  0  0  ?  t?  0.0  1.000  0.320  9-10  1  U  2  TABLE XXXIII LIFE TABLE OF LONG DELAY FROM YEAR OF DIAGNOSIS NUMBER OF DEATHS INCLUDING CASES WHICH DIED OF COMPETING RISK YEARS AFTER DIAGNOSIS  ALIVE AT BEGINNING OF INTERVAL  DIE DURING INTERVAL  0-1 1-2  228 200  2-3  169 154 134 123  25 23 12  3-k  4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17  109 86  13 11 6 12 5  79 68  7 1  65 56 48 36 21  5 3 0 1 2 0 0  11 4  DIE OF COMPETING RISK 3 7 3 6 0 3 3 2 0 0 2 2 3 0 1 1 0  WITHDRAWN ALIVE DURING INTERVAL 0 1 0 1 0  EFFECTIVE NBR EXPOSED TO RISK OF DYING 228.0 199.5 169.0 153.5 134.0  PROPORTION DYING  PROPORTION SURVIVING  OBSERVED SURVIVAL RATE  0.12  0.877 0.850  0.877 0.745 0.679 0.595 0.546  0.15 0.09 0.12 0.08 0.07 0.14 0.08  4 2 2  120.5 105.0 86.0 77.0 67.0 64.0  3 9 14  54.5 43.5 29.0  0.09 0.07 0.03  7 6  17.5 8.0  ?  2.5  0.17 0.13 0.0  5 8 0  0.09 0.01 0.11  0.911 0.876 0.918  0.925 0.857 0.919 0.909 0.985 0.891 0.908 0.931 O.966 0.829 0.875 1.000  0.505 0.433 0.398 0.362 0.356 0.317 0.288 0.268  0.259 0.215 0.188 0.188  91 TABLE XXXIV  SHORT DELAY FROM DATE OF DIAGNOSIS RELATIVE SURVIVAL RATES  YEARS AFTER DIAGNOSIS  OBSERVED SURVIVAL RATES  EXPECTED SURVIVAL RATES  RELATIVE SURVIVAL RATES  1  0.953  0.988  0.964  2  0.864  0.975  0.886  3  0.770  0.961  0.801  4  0.702  0.947  0.741  5  0.646  0.932  0.693  6  0.603  0.916  0.658  7  0.570  0.900  0.633  8  0.516  0.883  0.584  9  0.486  0.866  0.561  10  0.443  0.848  0.522  11  0.422  0.830  0.508  12  0.393  0.811  0.484  13  0.381  0.792  0.481  14  0.366  0.773  0.473  15  0.345  0.753  0.458  16  0.304  0.733  0.414  17  0.304  0.713  0.426  92 TABLE XXXV  LONG DELAY FROM DATE OF DIAGNOSIS RELATIVE SURVIVAL RATES  YEARS AFTER DIAGNOSIS  OBSERVED SURVIVAL RATES  EXPECTED SURVIVAL RATES  RELATIVE SURVIVAL RATES  1  0.877  0.980  0.895  2  0.745  0.959  0.777  3  0.679  0.939  0.723  4  0.595  0.918  0.648  5  0.546  0.896  0.609  6  0.505  0.874  0.578  7  0.433  0.852  0.508  8  0.398  0.829  0.480  9  0.362  0.806  0.449  10  0.356  0.783  0.454  11  0.317  0.760  0.417  12  0.288  0.737  0.391  13  0.268  0.713  0.376  14  0.259  0.690  0.375  15  0.215  0.667  0.322  16  0.188  0.644  0.292  17  0.188  0.621  0.303  93 TABLE  XXXVI  COMPARISON OF RELATIVE SURVIVAL RATES FOR LONG AND SHORT DELAY FROM DATE OF DIAGNOSIS  YEARS AFTER DIAGNOSIS  SHORT DELAY  LONG DELAY  1  0.964  0.895  2  0.886  0.777  3  0.801  0.723  4  0.741  0.648  5  0.693  0.609  6  0.658  0.578  7  0.633  0.508  8  0.584  0.480  9  0.561  0.449  10  0.522  0.454  11  0.508  0.417  12  0.484  0.391  13  0.481  0.376  14  0.473  0.375  15  0.458  0.322  16  0.414  0.292  17  0.426  0.303  94  FIGURE 3 A COMPARISON OF RELATIVE SURVIVAL RATES FOR LONG AND SHORT DELAY FROM DATE OF DIAGNOSIS  z  i  *  S  6  r  ,  1  n  95  5.3  THE ANALYSIS OF THE ASSOCIATION OF DELAY TIME ON SURVIVAL FROM DATE OF FIRST SYMPTOM  In t h i s the date  s e c t i o n s h o r t and l o n g d e l a y  of first  symptom.  Life  a r e examined  from  tables are displayed i n  T a b l e s X X X V I I , X X X V T I I , XXXIX and XXXX. The from date  relative of first  X X X X I I and t h e n The  survival  rates f o r short  i n T a b l e X X X X I I I and f i g u r e  advantage o f s h o r t d e l a y d i s a p p e a r s i n l o n g d e l a y do b e t t e r  In calculating  the l i f e  and i t would  initially.  months.  With  mind t h r e e p o s s i b l e c o r r e c t i o n s a r e made i n t h e  corrected  rates.  4.  t a b l e s f o r long delay the pa-  t i e n t s have a l r e a d y s u r v i v e d f o r e i g h t e e n  survival  delay  symptom a r e c a l c u l a t e d i n T a b l e s XXXXI and  compared  appear t h a t those  in  and l o n g  observed  T h e s e a r e d i s p l a y e d i n T a b l e XXXXIV.  relative  survival  rates f o r long delay  this  from  The first  symptom a r e shown i n T a b l e XXXXV and d i s p l a y e d g r a p h i c a l l y in and  f i g u r e s 5. suggest  These modify t h e p i c t u r e given  that there  i s very  b e t w e e n l o n g and s h o r t d e l a y  little,  from date  4  i f any d i f f e r e n c e of first  Using  c o r r e c t i o n 2 which gives the poorest  delay  suggests  term.  i n figure  symptom.  survival  f o r long  an a d v a n t a g e t o s h o r t d e l a y o n l y i n t h e l o n g  TABLE XXXVII LIFE TABLE OF SHORT DELAY FROM DATE OF FIRST SYMPTOM NUMBER OF DEATHS NOT INCLUDING CASES WHICH DIED OF COMPETING RISK YEARS AFTER FIRST SYMPTOM  ALIVE AT BEGINNING OF INTERVAL  DTE DURING INTERVAL  DIE OF COMPETING RISK  WITHDRAWN ALIVE DURING INTERVAL  0-1  235  8  3  0  1-2  224  18  1  2-3  205  19  3-4  181  EFFECTIVE NBR EXPOSED TO RISK OF DYING  PROPORTION DYING  PROPORTION SURVIVING  SURVIVAL RATE  233.5  0.03  O.966  O.966  0  223.5  0.08  0.919  0.888  5  0  202.5  0.09  0.906  0.805  11  4  1  178.5  0.06  0.938  0.755  4-5  165  13  1  0  164.5  0.08  0.921  0.695  5-6  151  9  1  5  148.0  0.06  0.939  0.653  6-7  136  3  0  11  130.5  0.02  0.977  0.638  7-8  122  8  6  4  117.0  0.07  0.932  0.594  8-9  104  5  0  5  101.5  0.05  0.951  O.565  9-10  94  5  4  0  92.0  0.05  0.946  0.534  10-11  85  3  1  3  83.0  0.04  0.964  0.515  11-12  78  3  3  6  73.5  0.04  0.959  0.494  12-13  66  0  2  5  62.5  0.0  1.000  0.494  13-14  59  2  0  15  51.5  0.04  0.961  0.475  14-15  42  2  0  16  34.0  0.06  0.941  0,447  15-16  24  1  1  14  16.5  0.06  0.939  0.420  16-17  8  0  0  7  4.5  0.0  1.000  0.420  TABLE  XXXVIII  LIFE TABLE OF SHORT DELAY FROM DATE OF FIRST SYMPTOM NUMBER OF DEATHS INCLUDING CASES WHICH DIED OF COMPLETING RISK YEARS AbTER FIRST SYMPTOM  ALIVE AT BEGINNING OF INTERVAL  DIE DURING INTERVAL  0-1  235  8  1-2  224  18  2-3  205  3^  DIE OF COMPETING RISK  WITHDRAWN ALIVE DURING INTERVAL  EFFECTIVE NBR EXPOSED TO RISK OF DYING  PROPORTION DYING  PROPORTION SURVIVING  OBSERVED SURVIVAL RATE  0  235.0  0.05  0.953  0.953  1  0  224.0  0.08  0.915  0.872  19  5  n  205.0  0.12  0.883  0.770  181  11  4  1  180.5  0.08  0.917  0.706  4-5  165  13  1  0  165.0  0.08  0.915  0.646  5-6  151  9  1  5  148.5  0.07  0.933  0.603  6-7  136  3  0  11  130.5  0.02  0.977  0.589  7-8  122  8  6  4  120.0  0.12  0.883  0.520  8-9  104  5  0  5  101.5  0.05  0.951  0.495  9-10  94  5  4  0  94.0  0.10  0.904  0.447  10-11  85  3  1  3  83.5  0.05  0.952  0.426  11-12  78  3  3  6  75.0  0.08  0.920  0.392  12-13  66  0  2  5  63.5  0.03  0.969  0.379  13-14  59  2  0  15  51.5  0.04  0.961  0.365  14-15  42  2  0  16  34.0  0.06  0.941  0.343  15-16  24  1  1  14  17.0  0.12  0.882  0.303  16-17  8  0  0  7  4.5  0.0  1.000  0.303  TABLE XXXIX LIFE TABLE OF LONG DELAY FROM DATE OF FIRST SYMPTOM NUMBER OF DEATHS NOT INCLUDING CASES WHICH DIED OF COMPETING RISK YEARS AFTER FIRST SYMPTOM  ALIVE AT BEGINNING OF INTERVAL  DIE DURING INTERVAL  DIE OF COMPETING RISK  WITHDRAWN ALIVE DURING INTERVAL  EFFECTIVE NBR EXPOSED TO RISK OF DYING  PROPORTION DYING  PROPORTION SURVIVING  SURVIVAL RATE  0-1  228  0  0  0  228.0  0.0  1.000  1.000  1-2  228  13  2  0  227.0  0.06  0.943  0.943  2-3  213  16  1  0  212.5  0.08  0.925  0.872  3-4  196  13  2  0  195.0  0.07  0.933  0.814  4-5  181  13  5  1  178.0  0.07  0.927  0.754  5-h  162  7  2  0  161.0  0.04  0.957  0.721  6-7  153  9  1  5  150.0  0.06  0.940  0.678  7-8  138  10  6  5  132.5  0.08  0.925  0.627  8-9  117  9  3  1  115.0  0.08  0.922  0.578  9-10  104  11  1  3  102.0  0.11  0.892  0.516  10-11  89  5  1  1  88.0  0.06  0.943  0.486  11-12  82  3  0  2  81.0  0.04  0.963  0.468  12-13  77  7  3  4  73.5  0.10  0.905  0.424  13-14  63  2  3  5  59.0  0.03  0.966  0.409  14-15  53  2  1  10  47.5  0.04  0.958  0.392  15-16  40  1  0  9  35.5  0.03  0.972  0.381  16-17  30  2  1  ?  27.0  Of°7  0.926  0.353  TABLE  XXXX  LIFE TABLE OF LONG DELAY FROM DATE OF FIRST SYMPTOM NUMBER OF DEATHS INCLUDING CASES WHICH DIED OF COMPETING RISK YEARS AFTER FIRST SYMPTOM  ALIVE AT BEGINNING OF INTERVAL  DIE DURING INTERVAL  DIE OF COMPETING RISK  WITHDRAWN ALIVE DURING INTERVAL  EFFECTIVE NBR EXPOSED TO RISK OF DYING  PROPORTION DYING  PROPORTION SURVIVING  OSBSERVED SURVIVAL RATE  0-1  228  0  0  0  228.0  0.0  1.000  1.000  1-2  228  13  2  0  228.0  0.07  0.934  0.934  2-3  213  16  1  0  213.0  0.08  0.920  0.860  M  196  2  0  196.0  0.08  0.923  0.794  180.5  0.10  0.900  0.715  5-6  181  13  5  1  162  7  2  0  162.0  0.06  0.944  0.675  9  1  5  150.5  0.07  0.934  0.630  6-7 7-8  138  10  6  5  135.5  0.12  0.882  0.556  8-9  117  9  3  1  116.5  0.10  0.897  0.498  9-10  104  11  1  3  102.5  0.12  0.883  0.440  10-11  89  5  1  1  88.5  0.07  0.932  0.410  11-12  82  3  0  2  81.0  0.04  0.963  0.395  12-13  77  7  3  4  75.0  0.13  0.867  0.342  13-14  63  2  3  5  60.5  0.08  0.917  0.314  14-15  53  2  1  10  48.0  0.06  0.938  0.294  15-16  40  1  0  9  35.5  0.03  0.972  0.286  16-17  30  2  1  ?  27.5  0.11  0.891  0.255  100 TABLE  XXXXI  SHORT DELAY PROM DATE OF F I R S T SYMPTOM RELATIVE SURVIVAL RATES  YEARS AFTER F I R S T SYMPTOM  OBSERVED SURVIVAL RATES  EXPECTED SURVIVAL RATES  RELATIVE SURVIVAL RATES  1  0.953  0.988  0.964  2  0.872  0.975  0.894  3  0.770  0.961  0.801  4  0.706  0.947  0.745  5  0.646  0.932  0.693  6  0.603  0.916  0.658  7  0.589  0.900  0.654  8  0.520  0.883  0.589  9  0.495  0.866  0.571  10  0.447  0.848  0.527  11  0.426  0.830  0.513  12  0.392  0.811  0.483  13  0.379  0.792  0.478  14  0.365  0.773  0.472  15  0.343  0.753  0.455  16  0.303  0.733  0.413  17  0.303  0.713  0.425  101 TABLE  XXXXII  LONG DELAY FROM DATE OF F I R S T SYMPTOM RELATIVE SURVIVAL RATES  YEARS AFTER FIRST S Y M P T O M  OBSERVED SURVIVAL RATES  EXPECTED SURVIVAL RATES  RELATIVE SURVIVAL RATES  1  1.000  0.980  1.020  2  0.934  0.959  0.974  3  0.860  0.939  0,916  4  0.794  0.918  0.865  5  0.715  0.896  0.798  6  0.675  0.874  0.772  7  0.630  0.852  0.739  8  0.556  0.829  0.671  9  0.498  0.806  0.618  10  0.440  0.783  0.562  11  0.410  0.760  0.539  12  0.395  0.737  0.536  13  0.342  0.713  0.480  14  0.314  0.690  0.455  15  0.294  0.667  0.441  16  0.286  0. 644  0.444  17  0.255  0.621  0.411  102  TABLE  XXXXIII  COMPARISON OF RELATIVE SURVIVAL RATES FOR LONG AND SHORT DELAY FROM DATE OF F I R S T SYMPTOM  YEARS AFTER F I R S T SYMPTOM  SHORT DELAY  LONG DELAY  1  0.964  1.020  2  0.894  0.974  3  0.801  0.916  4  0.745  0.865  5  0.693  0.798  6  0.658  0.772  7  0.654  0.739  8  0.589  0.671  9  0.571  0.618  10  0.527  0.562  11  0.513  0.539  12  0.483  0.536  13  0.478  0.480  14  0.472  0.455  15  0.455  0.441  16  0.413  0.444  17  0.425  0.411  TABLE XXXXIV CORRECTED OBSERVED SURVIVAL RATES FOR LONG DELAY FROM FIRST SYMPTOM YEARS AFTER FIRST SYMPTOM  OBSERVED SURVIVAL FROM FIRST SYMPTOM YEAR 0  CORRECTION ( l ) ASSUMING 18 MTHS SURVIVAL = 0.925 BASED ON SHORT DELAY  CORRECTION (2) ASSUMING 18 MTHS SURVIVAL » 0.830 BASED ON LONG DELAY FROM DIAGNOSIS  CORRECTION (3) ASSUMING 1 YR. SURVIVAL =0.980 FOR NORMAL POPULATION  EXPECTED SURVIVAL  1  1.00  0.925  0.830  0.980  0.980  2  0.934  0.864  0.775  0.915  0.959  3  0.860  0.796  0.714  0.843  0.939  4  0.794  0.734  0.659  0.778  0.918  5  0.715  0.661  0.593  0.701  O.896  6  0.675  0.624  0.560  0.662  0.874  7  0.630  0.583  0.523  0.617  0.852  8  0.556  0.514  0.461  0.545  0.829  9  0.498  0.461  0.413  0.488  0.806  10  0.440  0.407  0.365  0.431  0.783  11  0.410  0.379  0.340  0.402  0.760  12  0.395  0.365  0.328  0.387  0.737  13  0.342  0.316  0.284  0.335  0.713  14  0.314  0.290  0.261  0.308  0.690  15  0.294  0.272  0.244  0.288  0.667  16  0.286  0.265  0.237  0.280  0.644  17  0.255  0.236  0.212  0.250  0.621  104  TABLE  XXXXV  CORRECTED RELATIVE SURVIVAL RATES FOR LONG DELAY FROM F I R S T SYMPTOM  YEARS AFTER F I R S T SYMPTOM  CORRECTION (1)  CORRECTION (2)  CORRECTION (3)  1  0. 944  0.847  1.000  2  0.901  0.808  0.954  3  0.847  0.760  0.898  4  0.800  0.718  0.848  5  0.738  0.662  0.782  6  0.714  0.641  0.757  7  0.684  0.614  0.725  8  0.620  0.557  0.657  9  0.572  0.513  0.606  10  0.520  0.466  0.551  11  0.499  0.448  0.529  12  0.496  0.445  0.525  13  0.444  0.398  0.470  14  0.421  0.378  0.446  15  0.408  0.366  0.432  16  0.411  0.369  0.435  17  0.380  0.341  0.402  105  106  107 5.4  THE ANALYSIS OF THE ASSOCIATION BETWEEN DELAY TIME AND SURVIVAL WITH CONTROL FOR OTHER FACTORS  In this relation tables  section delay  t o the four c l i n i c a l  f o rsurvival  clinical  and s u r v i v a l a r e e x p l o r e d i n  stage  i n both  stages  o f the disease.  s h o r t and l o n g d e l a y  are used t o c a l c u l a t e r e l a t i v e  Life  f o r each  survival  rates. T h e s e a r e compared i n T a b l e s XXXXVI, XXXXVII, X X X X V I I I and XXXXIX and d i s p l a y e d g r a p h i c a l l y i n F i g u r e s The  6, 7 and 8.  s u r v i v a l o f t h e l o n g d e l a y group i n c l i n i c a l  1 a n d 11 w o u l d a p p e a r t o b e b e t t e r w h i l e 111 and I V t h e r e v e r s e  i s true.  in clinical  stages stages  108  TABLE  XXXXVI  COMPARISON OF RELATIVE SURVIVAL RATES FOR C L I N I C A L STAGE I I N SHORT AND LONG DELAY  YEARS AFTER DIAGNOSIS  RELATIVE SURVIVAL RATE SHORT DELAY  RELATIVE SURVIVAL RATE LONG DELAY  0  1.000  1.000  1  0.992  1.000  2  0.916  0.929  3  0.847  0.915  4  0.796  0.841  5  0.751  0.857  6  0.716  0.804  7  0.678  0.766  8  0.629  0.725  9  0.622  0.702  10  0.569  0.718  11  0.562  0.694  12  0.543  0.598  13  0.555  0.559  14  0.535  0.536  15  0.462  0.489  16  0.474  0.502  17  0.488  0.516  109 TABLE  XXXXVII  COMPARISON OF RELATIVE SURVIVAL RATES FOR C L I N I C A L STAGE I I IN SHORT AND LONG DELAY  YEARS AFTER DIAGNOSIS  RELATIVE SURVIVAL RATE SHORT DELAY  RELATIVE SURVIVAL RATE LONG DELAY  0  1.000  1.000  1  0.956  0.990  2  0.874  0.980  3  0.737  0.875  4  0.690  0.792  5  0.622  0.730  6  0.591  0.689  7  0.577  0.645  8  0.563  0.598  9  0.472  0.578  10  0.455  0.589  11  0.437  0.568  12  0.388  0.579  13  0.333  0.591  14  0.340  0.603  15  0.347  0.616  16  0.355  0.315  110  TABLE  XXXXVTII  COMPARISON OF RELATIVE SURVIVAL RATES FOR C L I N I C A L STAGE I I I I N SHORT AND LONG DELAY  YEARS AFTER DIAGNOSIS  RELATIVE SURVIVAL RATE SHORT DELAY  RELATIVE SURVIVAL RATE LONG DELAY  0  1.000  1.000  1  0.888  0.971  2  0.837  0.798  3  0.783  0.762  4  0.653  0.605  5  0.665  0.562  6  0.604  0.547  7  0.540  0.454  8  0.461  0.430  9  0.472  0.403  10  0.485  0.370  11  0.356  0.208  12  0.367  0.218  13  0.379  0. 228  14  0.196  0.239  Ill TABLE  XXXXIX  COMPARISON OF RELATIVE SURVIVAL RATES FOR C L I N I C A L STAGE I V I N SHORT AND LONG DELAY  YEARS AFTER DIAGNOSIS  RELATIVE SURVIVAL RATES SHORT DELAY  R E L A T I V E SURVIVAL RATE^ LONG DELAY  0  1.000  1.000  1  0.694  0.611  2  0.483  0.399  3  0.380  0.346  4  0.133  0.305  5  0.141  0.262  6  0.150  0.252  7  0.160  0.130  1 1 2  113  114  115  6.0  CONCLUSION  6.1  METHODOLOGICAL ASPECTS OP THE STUDY  6.2  DISTRIBUTION OF DELAY  6.3  ANALYSIS OF  6.4  INTERPRETATION  6.5  IMPLICATIONS FOR HEALTH  6.6  POLICIES AND  TIME  SURVIVAL  PLANNING  OBJECTIVES OF HEALTH  PLANNING  116 6.1  METHODOLOGICAL ASPECTS OF THE STUDY  The  objective of the current  s u r v i v a l experience those one  defined  those to one  a f t e r they  diagnosis  cancer  patients,  who came t o c l i n i c a l  noticed their  p a t i e n t s who h a d " l o n g d e l a y " ,  clinical  was t o compare t h e  o f two g r o u p s o f b r e a s t  as " s h o r t d e l a y " ,  month o r l e s s  study  after having  first  defined  diagnosis  symptom, and  as t h o s e  h a d symptoms  who  f o r more  came than  year. It  i s a r e t r o s p e c t i v e s t u d y b a s e d on t h e r o u t i n e  of p a t i e n t s admitted Columbia.  t o the Cancer C o n t r o l Agency o f B r i t i s h  T h e r e a r e some p o s s i b l e l i m i t a t i o n s  b a s e d on t h i s  a n a l y s i s w h i c h may r e s t r i c t  of the r e s u l t s .  records  t o conclusions  the i n t e r p r e t a t i o n  The q u a l i t y o f t h e r e c o r d s  i n respect t o the  two m a j o r v a r i a b l e s , d e l a y t i m e and s u r v i v a l t i m e , may be s o p o o r t h a t no v a l i d The stract staff  conclusions  subjective impression  cards  prepared  are p o s s i b l e . from r e a d i n g  from these  t h e c h a r t s , ab-  and t a l k i n g t o members o f  a t t h e Cancer C o n t r o l Agency i s t h a t t h e r e c o r d s a r e  of very high The  q u a l i t y with  date o f f i r s t  respect  t o these  two v a r i a b l e s .  symptom n o t i c e d b y t h e p a t i e n t h a s  b e e n an i n t e g r a l p a r t o f t h e h i s t o r y w h i c h i s t a k e n on  every  new p a t i e n t s e e n a t t h e C a n c e r C o n t r o l A g e n c y s i n c e i t s i n stitution stract  i n 1938.  cards  clinical  F o r the purposes o f t h i s  are used.  records  These are a b r i e f  summary  f o r e a c h p a t i e n t and i n c l u d e s a  space f o r t h e i n t e r v a l between f i r s t In the i n i t i a l  study  data  survey  t h e abo f the designated  symptom and d i a g n o s i s .  f o r the study,  I examined t h e  117  abstract  cards  for a l l patients with breast  the Cancer C o n t r o l Agency i n the years This  i n v o l v e d the  7 of these  was  there  Though t h e m i g h t be  r e v i e w o f 838 no  questioned.  c o n t r o l o f the memory o r on  1960,  recorded  i s very  on  due  a deliberate giving of  f e e l i n g s because of i n c r e a s i n g education  years  on  d u r i n g the study,  10 y e a r  delay.  i t w o u l d show as  patients  an  was  s e e n b e t w e e n 1960,  w o u l d n o t be  confidence.  For  f o l l o w e d by  For  the  A l l breast  clinical  family doctor follow-up  contact with  occurred  part  of  proportion trend  the of  i n the  long delay  Therefore,  pro-  times  such a b i a s  s u r v i v a l t i m e s can  cancer  p a t i e n t s seen at on  an  of patients, t h i s e x a m i n a t i o n s on  p a t i e n t s whose f o l l o w - u p  province,  first  No  1970.  i n f o r m a t i o n on  the m a j o r i t y  are  their  misinformation.  reason  i n the  Cancer C o n t r o l Agency are maintained system.  1  likely.  S i m i l a r l y the with  patient s  is possibly a  e i t h e r short or and  the  recent  i n c r e a s e i n the  1961  time.  over  r e p o r t i n g a short delay time.  portion of patients with  i n only  accuracy  However, i f t h a t h a s  p e r i o d covered  1970.  delay  t o the  Guilt  for underestimating  and  at  have been beyond  r e c o r d i n g p h y s i c i a n and  the need f o r e a r l y d i a g n o s i s  seen  and  complete the  T h e s e e r r o r s may  occasions  1961  abstract cards,  information  information  cancer  care  active  be the  follow-up  i s because  recall  used  t o the  they clinic.  i s handled e n t i r e l y  or s p e c i a l i s t  o r who  i s maintained  by  move o u t s i d e  letter  o r phone  the p h y s i c i a n or even d i r e c t l y w i t h  the  by  the call patient  118  on at l e a s t an annual b a s i s .  T h i s follow-up  dated from t h e e a r l i e s t days o f the c l i n i c ,  system has and thus t h e  p r o p o r t i o n o f cases who were l o s t t o follow-up was not h i g h . In the major p a r t o f t h e study, r e l a t e d t o the 456 cases o f b r e a s t cancer seen i n the c l i n i c between 1960 and 1964, o n l y 12%  (54) o f these were l o s t t o follow-up b e f o r e the end  p o i n t o f the study i n June 1977.  The r e s t were e i t h e r s t i l l  on a c t i v e follow-up w i t h i n a year a t t h a t time, o r have been f o l l o w e d up u n t i l  death.  T h i s 12% l o s s i s r e a s s u r i n g l y s m a l l , although i t i s s t i l l s u f f i c i e n t t o cause some e r r o r i f t h e method o f a n a l y s i s d i d not take account o f i t . However i n the s u r v i v a l a n a l y s i s performed, an a c t u a r i a l method was used i n which a p a t i e n t l o s t t o follow-up  o n l y c o n t r i b u t e s t o the a n a l y s i s f o r t h a t  p e r i o d d u r i n g which t h e i r s t a t u s i s known. o f l o s s o f follow-up and  The d i s t r i b u t i o n  i s 30 p a t i e n t s (12.9%) i n s h o r t  24 (10.7%) i n l o n g delay,  and i t i s t h e r e f o r e v e r y un-  l i k e l y t h a t any b i a s i n the r e s u l t s would thus The  delay,  occur.  data was incomplete f o r some o f the v a r i a b l e s which  are p o s s i b l y a s s o c i a t e d w i t h d e l a y and s u r v i v a l .  The m i s s i n g  i n f o r m a t i o n has r e s u l t e d i n some l i m i t a t i o n o f t h e analyses which c o u l d be done.  F o r example, t h e p a t h o l o g i c a l grade o f  the tumour v/as not a v a i l a b l e i n most cases, o n l y a v a i l a b l e i n 168 (37%).  information  being  I n f a c t the m e d i c a l records do  c o n t a i n t h i s i n f o r m a t i o n f o r most p a t i e n t s , b u t i t v/as not r o u t i n e l y put on t o the a b s t r a c t c a r d s .  To e x t r a c t t h i s one  119  p i e c e of i n f o r m a t i o n would t h e r e f o r e have r e q u i r e d a veryl a r g e i n c r e a s e i n the time needed f o r data e x t r a c t i o n , and i t v/as not thought e s s e n t i a l t o do t h i s .  The most  important  f a c t o r which has been shown i n other work (14) t o be r e l a t e d t o the s u r v i v a l of b r e a s t cancer the d i s e a s e .  Information  7 o f the cases.  i s the c l i n i c a l stage  of  oh t h i s v/as a v a i l a b l e f o r a l l but  In socio-economic s t a t u s heavy r e l i a n c e i s  p l a c e d on the husband's occupation data i s m i s s i n g i n 174  (38%)  cases.  for classification Only i n 15%  and  (70)  i s the  p a t i e n t ' s o c c u p a t i o n taiown. D u r i n g the p e r i o d s t u d i e d , approximately t o t a l number o f b r e a s t cancer  cases  70% o f the  seen i n the P r o v i n c e  of  B r i t i s h Columbia were seen by the Cancer C o n t r o l Agency. The  number seen at the Cancer C o n t r o l Agency v / i l l  not  be r e p r e s e n t a t i v e i n a l l r e s p e c t s t o the t o t a l scene i n the province.  F o r example, amongst the group not seen at the  Cancer C o n t r o l Agency would be a number o f cases  diagnosed  o n l y on autopsy, a number o f l e s i o n s perhaps i n e l d e r l y o r otherwise  d e b i l i t a t e d p a t i e n t s which would not r e c e i v e  any  treatment, and p o s s i b l y a group o f v e r y e a r l y l o c a l i z e d tumours which would be t r e a t e d by surgery alone, and because r a d i o t h e r a p y or other treatment was  not advised, would not  n e c e s s a r i l y be r e f e r r e d t o the Cancer C o n t r o l Agency. ever, t h e r e i s l i t t l e ground t o conclude t h a t the o f the study t o the cases  How-  restriction  seen at the Cancer C o n t r o l Agency  should change the r e l a t i o n s h i p between s u r v i v a l time  and  120  delay  time. All  except  possibly  associated  f o r the size  literature  (10)  particularly  (17)  variables  have been c o n s i d e r e d  o f tumour and i t w o u l d a p p e a r f r o m t h e that  important.  this  variable  in itself  i s not  121  6.2  THE  DISTRIBUTION OF DELAY TIME  I n t h e f i r s t p a r t o f t h e s t u d y , the d e l a y t i m e s on a l l p a t i e n t s seen a t t h e Cancer C o n t r o l Agency i n the y e a r s 1961  and 1970 were s t u d i e d .  1960,  T h i s demonstrated t h a t 26%  of  the p a t i e n t s seen i n t h o s e y e a r s showed a s h o r t d e l a y t i m e , d e f i n e d as l e s s t h a n one month, whereas 20% o f them showed a l o n g d e l a y t i m e , d e f i n e d as one y e a r o r o v e r . The p a t t e r n s o f d e l a y t i m e have not changed f o r p a t i e n t s w i t h b r e a s t c a n c e r i n B r i t i s h C o l u m b i a i n t h e decade from 1960  t o 1970.  T h i s i s s u r p r i s i n g when one c o n s i d e r s t h e  h e a l t h i n f o r m a t i o n t h a t has been a v a i l a b l e and t h e changes t h a t have o c c u r r e d i n a t t i t u d e s i n t h o s e t e n y e a r s .  I t would  have been a n t i c i p a t e d t h a t d u r i n g t h i s decade t h e r e would be a s h i f t toward e a r l i e r d i a g n o s i s w h i c h would be showed by i n c r e a s e i n t h e p r o p o r t i o n i n t h e s h o r t d e l a y group and  an  a  d e c r e a s e i n t h e p r o p o r t i o n i n t h e l o n g d e l a y group when comp a r i n g 1970  t o 1960  data.  The  s t a b i l i t y of these p a t t e r n s  has been a l s o shown b y H a c k e t t e t a l (29) i n a s t u d y o f  563  p a t i e n t s w i t h d i f f e r e n t t y p e s o f c a n c e r and by Dennis e t a l i n 237 p a t i e n t s w i t h r a d i c a l m a s t e c t o m i e s .  I t would be  inter-  e s t i n g t o e x p l o r e a more r e c e n t y e a r t o determine i f t h e b i l i t y i n d e l a y p a t t e r n s has c o n t i n u e d . 1970  sta-  Certainly, since  t h e r e has been an i n c r e a s i n g amount o f i n f o r m a t i o n from  Cancer S o c i e t i e s , p o p u l a r magazines and news media and occurrence  the  o f b r e a s t cancer i n well-known N o r t h A m e r i c a n  women has drawn a t t e n t i o n t o a p e r s o n a l r e s p o n s i b i l i t y f o r early diagnosis.  However, t h e p r e s e n t r e s u l t s suggest t h a t  122  it  i s very  lation  likely  t h a t the patterns  a r e r e m a r k a b l y s t a b l e and  influences.  t h e two  456  cases  out  tween age  and  i n the  (23)  two  delay.  be  implications for now  and  i n the evenly  between  delay time i n the One  and  h u n d r e d and  long  three  over.  significant  relationship  The  younger p a t i e n t tended to  the  f i n d i n g of Sheridan  due  future.  be-  delay  e t a l (15)  t o f a c t o r s " s u c h as g r e a t e r  who  ignorance  p e r h a p s a more p h i l o s o p h i c a t t i t u d e i n t h e  groups".  There i s considerable l i t e r a t u r e  concerning  and H i n t o n  and  years  a statistically  the p s y c h o l o g i c a l aspects  f i r m c o n c l u s i o n s were f o u n d  "the  The  such  o l d e r group, a g r e a t e r sense o f f a m i l y needs i n t h e  y o u n g e r , and age  examined.  delayed  i t may  responded t o  e x a m i n e d were d i s t r i b u t e d  This confirmed  suggested  f o r both  quite considerable.  o f 224  T h e r e was  less.  planning  delay periods  d e l a y g r o u p was cases  have not  T h i s v/ould h a v e i m p o r t a n t  h e a l t h p r o g r a m s and The  o f d e l a y t i m e i n a popu-  (20)  literature  above.  various  i n d i f f e r e n c e t o cancer  s t u d i e s r e v e a l no  readiness  to report with  c e r t a i n way cancer  T h e r e v/as a s t a t i s t i c a l l y t h e two  1.  Ninety  saying  denial,  i s c o m p l e x and  anxiety these  of p r e d i c t i n g people's  significant  d e l a y p e r i o d s v/ith r e g a r d  stage  no  symptoms".  s h o r t d e l a y g r o u p were more l i k e l y clinical  (21)  Cameron  a p t l y by  i n t e r r e l a t i o n s h i p b e t w e e n k n o w l e d g e and professed  (19)  of delay but  t o confirm the  summarized t h e  (18)  older  percent  d i f f e r e n c e between  to c l i n i c a l staging. t o be  classified  of cases  i n the  The  as  short  delay  123  were i n c l i n i c a l d e l a y group. peared  stage  Conversely  i n grade IV  would suggest  compared t o 52%  o n l y 3.8%  of the  of the  i n the  short delay  long delay.  apThis  t h a t t h e s h o r t d e l a y group should have T h e r e i s no  long  a  d i f f e r e n c e seen i n the  patho-  staging.  T h e r e was married  tended  a relationship to marital status. to delay less while  f o u n d more i n t h e one and  11  a g a i n s t 30.4%  better prognosis. logical  1 and  concern  year  single  or over  and widowed were  d e l a y group.  w i t h i n a f a m i l y g r o u p may  Those  account  The  for  support  this  difference. No  d i f f e r e n c e v/as f o u n d  i n socio-economic  tween t h e d e l a y g r o u p s , a s s e s s e d b y Index  (33)  Sv/an and study.  v/hich i s b a s e d on  Paterson  (21)  that the higher the study  reviewed  education  class,  found  and  status  The  delay i n a l l types  i s not  present a factor  results  Aitken-  association in their  the delay.  suggest  However  this  i n breast cancer  that  is  socio-economic  i n d e l a y i n B r i t i s h Columbia,  f u r t h e r s t u d y u s i n g a more r e f i n e d  Index)  o f c a n c e r w h i c h h a v e many  v a r i e d p r e s e n t a t i o n s so i t s s i g n i f i c a n c e limited.  income.  (using Hollingshead's  the l e s s  be-  the B l i s h e n Socio-Economic  a l s o showed no  H a c k e t e t a l (29)  status  i n d e x v/ould be  although  useful.  124 6.3 Of  the  of breast  the  53  alive,  rates  and  and  r a t i o of the  the  age  c a r r i e d out  also relative  d i s t r i b u t i o n of  patients  i s not  n e c e s s a r i l y simple t o  the  XXXVI) show t h a t  s u r v i v a l time from the  within  This  clinical  date  of  date  of  stage.  patients with short  d i f f e r e n c e i s shown b y  long  These r e s u l t s are  tients with  delay  can  short  rela(Table better  differ-  (69.3% s h o r t  and  c o n s i s t e n t w i t h those o f Park  t i m e do  that  de-  difference  r e s p e c t i v e l y 6.8%  conclude from t h i s , delay  a 8.4%  p a t i e n t s ) , the  year survivals being  We  The  d e l a y have a  f i v e year s u r v i v a l rates  compared t o 60.9%  (6).  I  diagnosis.  e s t i m a t e d from date of d i a g n o s i s  the  e n c e shown i n t h e  Lees  date of  S u r v i v a l Time From Date o f D i a g n o s i s .  survival rates  13.6%.  short  interpret.  s u r v i v a l time from the  the  diagnosis,  15  and  symptom.  B a s e d on  and  adjusts  ways:  B a s e d on  10  expected s u r v i v a l ,  patients).  (2)  survival rate.  (that i s ,  t a b l e s , which thus  s u r v i v a l time from the  (1)  ;  patients  survival rates  the  died  computing a c t u a r i a l  B a s e d on  (3)  in  by  101  had  follow-up.  (1)  first  lay  to  235  s u r v i v a l experience of long  compared s u r v i v a l i n t h r e e  tive  causes,  observed s u r v i v a l t o the  Comparison o f the delay  J u n e 1977,  54 w e r e l o s t  b a s e d on B r i t i s h C o l u m b i a l i f e for  by  died of other  a n a l y s i s was  survival  SURVIVAL  cases studied,  cancer,  were s t i l l The  456  ANALYSIS OF  a group o f  and  pa-  have a b e t t e r prognosis,  as  125  estimated delay  from t h e d a t e o f d i a g n o s i s , t h a n t h o s e w i t h a l o n g  time. (2)  S u r v i v a l Time From Date o f D i a g n o s i s .  I n terms o f  the s u r v i v a l t i m e as seen from t h e p a t i e n t ' s p o i n t o f v i e w r a t h e r t h a n from t h e p h y s i c i a n ' s p o i n t o f v i e w , i t i s more l o g i c a l t o estimate  s u r v i v a l from t h e t i m e o f f i r s t  symptom.  A n a l y s i s ( F i g u r e 4) u s i n g s u r v i v a l from t h e d a t e o f f i r s t symptom d i d n o t show b e t t e r s u r v i v a l r a t e f o r t h e s h o r t d e l a y group, and i n f a c t t h e p a t i e n t s who d e l a y f o r a l o n g t i m e i n i t i a l l y appear t o do b e t t e r .  After fifteen  y e a r s , t h e r e would appear t o be no advantage t o e i t h e r group. U s i n g t h e l o n g d e l a y group and e s t i m a t i n g s u r v i v a l from date o f f i r s t symptom, I am i g n o r i n g any m o r t a l i t y has o c c u r r e d  which  i n t h e f i r s t months a f t e r t h e symptom d e v e l o p e d .  I n e x a m i n i n g t h e s e p a t i e n t s i n t h i s way I may have produced a b i a s i n f a v o u r o f t h e l o n g d e l a y group. c o r r e c t i o n s f o r t h i s b i a s are considered  These p o s s i b l e valid f o r further  comparison. The f i r s t , w h i c h would be t h e one g i v i n g t h e l o w e s t reasonable estimate  of the m o r t a l i t y during that period,  would be t o assume t h a t from t h e d a t e o f f i r s t symptom t o t h e d a t e o f d i a g n o s i s t h e s e women e x p e r i e n c e t h e same mort a l i t y r a t e as a l l women i n t h e i r age group i n t h e p r o v i n c e . Thus we t a k e t h e e x p e c t e d number o f deaths f o r women o f t h a t age group o v e r an 18 month p e r i o d and a d j u s t t h e s u r v i v a l rates accordingly  ( T a b l e s XXXXIV and XXXXV) .  The second  126  a p p r o a c h w o u l d b e t o assume t h a t t h e r a t e o f d e a t h i n t h e first the  18 months a f t e r  symptoms  f o r the long delay  same a s t h a t r a t e o f d e a t h f o r t h i s g r o u p i n t h e 18  months a f t e r d i a g n o s i s , w h i c h i s t h e e a r l i e s t w h i c h we h a v e i n f o r m a t i o n . this is  quite high,  proach, which g i v e s survival  that  18 months a f t e r  Using nine  these  date o f f i r s t  those  t h o u g h i s no more t h a n 5 - 10%.  somewhat  l e s s than that,  with  seem  l o n g d e l a y do I n the long  survival.  patients  term  from  The advantage  In a retrospective  answer c a n b e p r o d u c e d .  study  T h e most  as b a s e d on t h e i n t e r m e d i a t e  above, a l t h o u g h  t h e improvement  a r o u n d 15 y e a r s  be  after  i n t e r p r e t a t i o n would be t h a t t h e advantage i s  rection described  study  18 months  and s h o r t d e l a y  symptom h a v e a l o n g e r  no d e f i n i t e  first  i s no d i f f e r e n c e .  though, t h e p a t t e r n r e v e r s e s  reasonable  i s t o assume t h a t  c o r r e c t i o n s ( F i g u r e 5) i t w o u l d  t o t e nyears  s l i g h t l y better or there  such as t h i s  A t h i r d ap-  r a t e o f t h e l o n g d e l a y p a t i e n t s i s t h e same a s  the f i r s t  that  result  o f t h e s h o r t d e l a y women i n t h e i r  treatment.  the use o f t h i s  a pessimistic limit.  an i n t e r m e d i a t e  diagnosis  than that o f the  I t seems c l e a r t h a t  give  p e r i o d on  t h e r a t e o f death i n  and i s c o n s i d e r a b l y h i g h e r  approximation w i l l  the  In fact  g r o u p o f women i n t h e f i r s t  short delay patients.  in  group i s  i sbeginning  after the f i r s t  t o consider  there  i s an i n d i c a t i o n '  t o be n o t i c e a b l e at  symptom.  p e r h a p s 20 y e a r s  cor-  Extension  follow-up  u s e f u l , a s a n y t r e n d may become more  would  obvious.  of the therefore  127  Therefore, of the breast over  p a t i e n t s i n B r i t i s h Columbia with  i n my s h o r t d e l a y g r o u p a p p e a r t o g a i n  the long delay  g r o u p i n t h e way o f s u r v i v a l .  a c o n c l u s i o n which confirms and  Bloom's  i s a l s o a c o n c l u s i o n confirmed  (40).  (14) e a r l i e r i n recent  chosen.  Sutherland  worst prognosis tially  selective  This i s findings  literature  (9) i n h i s reviexv o f d e l a y  i s i n an i n t e r m e d i a t e  "tumour d e t e r m i n e d " .  i s e s p e c i a l l y t r u e o f my one y e a r  land's  chosen i n t h i s do e q u a l l y w e l l . g r o u p who  "tumour d e t e r m i n e d "  as a l r e a d y d i s c u s s e d e a r l i e r .  of "natural selection"  delay.  o r i n some  o b s e r v a t i o n may w e l l a p p l y t o t h i s  a process  suggests the  and o v e r  T h e y h a v e a l r e a d y s u r v i v e d f o r one y e a r much l o n g e r  research.  t i o n a t e number w i t h  t u m o u r s o f low, o r c o m p a r a t i v e l y  o r two w i l l  "Thus,  low,  Consequently, the m o r t a l i t y rates o f the long-  intermediate-delay  groups,  those  o f the short  unfavourably."  (3) S u r v i v a l T i m e F r o m D a t e o f D i a g n o s i s W i t h i n The r o l e o f d e l a y t i m e as a p r o g n o s t i c  can be used b y t h e c l i n i c i a n predict  those  include a dispropor-  d e l a y group w i l l be weighted f a v o u r a b l y ;  Stage.  Suther-  (MacDonald, 1 9 4 2 ) ,  a year  and  cases  Therefore,  who d e l a y more t h a n  malignancy.  groups  g r o u p who a r e e s s e n -  I have i n f a c t  c o u l d be d e s c r i b e d as h a v i n g  now  i n t h e two d e l a y  r e s e a r c h p o s s i b l y t h e two g r o u p s t h a t w i l l  by  little  I t h i n k t h o u g h l o o k i n g b a c k on t h e r e s u l t s we  know, I may h a v e b e e n v e r y  This  carcinoma  prognosis,  factor  Clinical which  a t the time o f diagnosis t o  might be deduced from t h i s a n a l y s i s .  128  These r e s u l t s  ( F i g u r e s 6 and  7)  shew t h a t f o r p a t i e n t s i n  Stage I or Stage I I , those w i t h than those with  a l o n g d e l a y time  a short delay time.  l o n g d e l a y g r o u p i n S t a g e I and t e r t h a n t h e p h y s i c i a n may  The  prognosis  the  and  suspect.  Sutherland  i n t h i s d e s c r i p t i o n may  above r e s u l t s .  t o show t h e i r  (9) h a s  true colours while  less  a year,  (4)  are s t i l l  i n Stages  I and an  contention of "Biological I I I and  P a t i e n t s i n these  IV,  the  II  tumour g r o w t h to  month o r 18 months a f t e r ease,  and  earlier  t h e r e f o r e the  reach t h i s  Mac-  long delay patients  stages have e i t h e r  t h a t p a t i e n t s who  a very  stage  One  argument w h i c h may I t s h o u l d be  in either  apply to  isolated metastatic lesion,  w h i c h may  resistant  t o any  treatment.  dis-  though  they  be t r e a t a b l e ,  o r h a v e l a r g e e x t e n s i v e and m u l t i p l e m e t a s t a s e s , be  1  the  remembered  a p a t i e n t i s c l a s s e d f o r example i n S t a g e I V w h e t h e r h a v e one  excould  symptoms b o t h h a v e a g g r e s s i v e  s t a g e s does not h o l d .  inhi-  Predeterminism".  t e n s i v e l o c a l d i s e a s e o r have d i s t a n t metastases. hypothesize  after  intrinsically  T h i s p o s s i b l y gives support  However, i n S t a g e s do w o r s e .  for  the l o n g d e l a y group which  a g g r e s s i v e tumour, o r more e f f i c i e n t  Donald's  "tumour  l i e the reason  i n d i c a t i n g they have e i t h e r  b i t i o n mechanisms.  and  de-  S t a g e I tumours o f e a r l y d e l a y have y e t  a r e "tumour d e t e r m i n e d " at l e a s t  f o r the  I I i s s u r p r i s i n g l y much b e t -  s c r i b e d d e l a y g r o u p s as " p e r s o n a l i t y d e t e r m i n e d " determined"  do b e t t e r  which would  129 6.4 It two  INTERPRETATION  appears f a c t o r s which i n f l u e n c e  large  fall  into  g r o u p s when d e t e r m i n i n g how e a r l y t h e y w i l l r e -  spond t o t h e i r d i s e a s e . are  patients  Firstly,  r e l a t e d t o t h e tumour.  there are factors  which  T h e most i m p o r t a n t o f w h i c h i s  s p e e d o f g r o w t h , w h i c h may b e r e f l e c t e d b y i t s d e g r e e o f differentiation  or other pathological  Secondly, there are f a c t o r s ularly personality the  disease.  related t o the patient,  spect in  partic-  f a c t o r s which determine h e r response t o  I t i s t h e i n t e r a c t i o n o f t h e s e two g r o u p s o f  f a c t o r s which leads t o t h e patterns of the breast.  characteristics.  o f delay i n carcinoma  T h e i n t e r p r e t a t i o n o f my r e s u l t s w i t h r e -  t o survival i s therefore  s u r v i v a l between l o n g  delay  d i f f i c u l t as t h e d i f f e r e n c e and s h o r t  delay patients  will  r e f l e c t b o t h c h a r a c t e r i s t i c s o f t h e tumour and c h a r a c t e r i s tics  o f the patients. There are several  study. status  approaches t o t h e f i n d i n g s  Characteristics o f patients  of this  s u c h a s age a n d m a r i t a l  i n t h e two d e l a y g r o u p s c a n b e i n t e r p r e t e d .  I have  shown t h a t women who a r e m a r r i e d t e n d t o h a v e s h o r t e r t i m e s t h a n t h o s e who a r e e i t h e r might  s i n g l e o r widowed.  delay  This  s u g g e s t t h a t women who h a v e a s p o u s e t o whom t h e y c a n  r e l a t e o n p e r s o n a l m a t t e r s a n d i n whom t h e y c a n c o n f i d e t h e i r worries,  a r e more l i k e l y  t o receive  agement t o s e e k e a r l y t r e a t m e n t .  I t could  support  be because  women h a v e a h u s b a n d a n d p r o b a b l y d e p e n d e n t s , t h a t more c o n c e r n e d t o r e c e i v e  a n d encourthese  they are  optimum t r e a t m e n t , w h e r e a s women  130  without such r e s p o n s i b i l i t i e s may be able t o j u s t i f y more e a s i l y .  delay  A much l e s s l i k e l y a l t e r n a t i v e i s t h a t t h e  type o f tumour which occurs  i n married  women i s d i f f e r e n t  i n terms o f i t s speed o f growth o r i t s symptomatology from t h a t o c c u r r i n g i n s i n g l e o r widowed women. age,  With r e s p e c t t o  the younger t h e p a t i e n t the l e s s l i k e l y they a r e t o  delay.  T h i s c o u l d be due t o p e r s o n a l i t y f a c t o r s e s p e c i a l l y  those a s s o c i a t e d w i t h a t t i t u d e t o the body i t s e l f ,  as we  have seen g r e a t changes i n t h i s area i n t h e l a s t decade. Increase  i n education by s c h o o l s and news media may a l s o  play a part.  C e r t a i n l y , we may be s e e i n g p o s s i b l e e a r l y  changes i n t h e p a t t e r n o f d e l a y and a review o f l a t e r as s t a t e d e a r l i e r might be o f v a l u e . c h a r a c t e r i s t i c s t h e r e i s no support  years  With r e s p e c t to tumour f o r t h e view t h a t tumours  o f younger women, apart from those a s s o c i a t e d with  pregnancy  and l a c t a t i o n are more r a p i d l y growing. A second type o f i n t e r p r e t a t i o n i s t o review d e l a y time as a p r o g n o s t i c  f a c t o r , l o o k i n g a t t h e d i s e a s e from t h e  p h y s i c i a n ' s r a t h e r than from the p a t i e n t ' s p o i n t o f view. T h i s would be u s i n g t h e accepted  c l i n i c a l d e f i n i t i o n that  d i s e a s e i s measured from the date o f c l i n i c a l  diagnosis.  My r e s u l t s suggest t h a t the short d e l a y group i n t h e long term d i d b e t t e r and t h e r e f o r e t h e r e i s some s u b s t a n t i a t i o n i n shortening delay.  A g a i n my r e s u l t s agreed w i t h  Suther-  land' s (9) c o n c l u s i o n t h a t t h e b e n e f i t i s s t a t i s t i c a l l y moderate and c l a i m s should be modest.  As a p r o g n o s t i c  131  f a c t o r my by  analyses  clinical  tified  stage  i s t h e most i n t e r e s t i n g .  a group o f p a t i e n t s , those  are c l a s s i f i e d is  of d e l a y time w i t h i n groups  g o o d and  in clinical  who  I have  S t a g e s I and  I I whose  given these  on  I t would appear those  lay  times  have a l e s s  aggressive  b i o l o g y o f t h e tumour, d e l a y these  results,  MacDonald to  see  (4)  outcome a r e  I t would be h e l p f u l  not  only c l i n i c a l  m a t i o n on  the  extent  stage,  ses) , and  another  but  o f the d i s e a s e  n o d e s i n v o l v e d , o r t h e number and  long  de-  relationship  of  suggested  in  suggested  by  i n further studies  characteristic  more d e t a i l e d  (such  sites  infor-  as number o f  lymph  of d i s t a n t metasta-  s u c h as p a t h o l o g i c a l g r a d e  included. The  third  difficult.  approach t o i n t e r p r e t i n g the data  T h e r e i s no  doubt w i t h  p r o g r a m s , c o m p a r i s o n s o f l o n g and useful.  I have taken  the p u b l i c education six  percent  fit  by  as  with  based  i f delay time i s a u s e f u l p r o g n o s t i c a t o r i f i n f o r -  m a t i o n on  are  A  "the b i o l o g i c predeterminism" (5).  delay.  p a t i e n t s s h o u l d be  tumour.  and  and  prognosis  would p o s s i b l y b e n e f i t from s h o r t e n i n g  consideration.  iden-  have long d e l a y  C e r t a i n l y the treatment this  classified  20%  any  respect to p u b l i c health short delay patients  a t i m e p e r i o d i n w h i c h we m e a s u r e s as b e i n g  of patients presented  health education  long delay  and  can  will  are  regard  f a i r l y modest.  p r o m p t l y and  e d u c a t i o n a l programs w i t h  showed a v e r y  i s t h e most  Twenty-  not  respect to delay. the  rationale of  p r o g r a m t h e r e f o r e w o u l d be  to  any  encourage  beneWhere-  132  these patients to present with t h e i r symptoms much e a r l i e r . The question i s , "does a benefit i n terms of the outcome from the disease occur"?  The present study cannot d i r e c t l y  answer that question, although the findings demonstrated here v/ould suggest that the possible improvement which could result from e a r l i e r diagnosis would be very small.  The  optimum method of v a l i d l y assessing the impact of educational programs on early diagnosis would be a prospective randomized trial,  i n which a large number of women i n the breast cancer  r i s k age groups for example from 40 to 65, were randomized into one group who would receive e f f o r t s aimed at early diagnosis and another group who would not receive such e f f o r t s .  133 6.5  DUPLICATIONS FOR  Health planning directed  i n the  HEALTH PLANNING last  twenty y e a r s has  at e a r l y i d e n t i f i c a t i o n  of disease  and  been  prompt  treatment. In cancer,  d e l a y has  b e e n s o m e t h i n g t o be  c a r c i n o m a o f the b r e a s t has  b e e n no  avoided,  exception.  Various  methods o f s c r e e n i n g , mammography, t h e r m o g r a p h y and  breast  s e l f - e x a m i n a t i o n , have been propagated t o o b t a i n the est we  d i a g n o s i s , and  encourage people  have seen i n the  literature  d e n c e t o show t h a t d e l a y this oma  to avoid delay.  review  We  in British  see t h a t d e l a y has  t i o n a l methods.  We  i s no  earliYet  firm  i s related to survival.  i n m i n d t h a t d e l a y v/as e x p l o r e d o f the b r e a s t  there  and  as evi-  I t was  i n patients with  with  carcin-  Columbia.  not  changed w i t h p r e s e n t  must c o n c l u d e  t h a t e i t h e r the  educa-  wrong  methods h a v e b e e n u s e d o r d e l a y  i s u n a l t e r a b l e , a psycho-  logical trait  t o any  Certainly The (41)  form o f  propaganda.  a r e - e v a l u a t i o n o f e d u c a t i o n a l methods  p a t t e r n we has  that i s resistant  see  w o u l d c o n f i r m what " t h e W a l t o n R e p o r t "  pointed out.  are s e l f - s e l e c t e d  and  The  problem i s t h a t program  they  come f r o m t h e  u l a t i o n t h a t i s most h e a l t h c o n s c i o u s . see  the  l o n g d e l a y g r o u p , d e f i n e d as  had  a better survival  markedly improved changed t o the  is-indicated.  rate.  i f this  pop-  F r o m t h e r e s u l t s v/e stage  Would t h a t s u r v i v a l  s h o r t d e l a y group?  i n t e n s i f i c a t i o n of research  segment o f t h e  clinical  g r o u p o f one  attenders  year  and  1 and  rate over  of  be patients  T h i s v/ould i n v o l v e  i n t o the motivations  11,  an  this  134  group. with  Previous  r e s e a r c h h a s i n v o l v e d s m a l l numbers, d e a l t  i n d i v i d u a l experiences,  depth understanding icant  insufficient  o f motivations  f i g u r e s on w h i c h t o a c t .  survival rate i n c l i n i c a l  stage  short d e l a y group c e r t a i n l y improve s u r v i v a l  to give  an i n -  or s t a t i s t i c a l l y  signif-  T h i s group i n i t s b e t t e r I and I I c a s e s  than the  shows a p o s s i b l e p o t e n t i a l t o  i n carcinoma o f the breast  C e r t a i n l y f o r health planning  i f delay  could  t o lend  support  be  improved.  to  v a r i o u s e d u c a t i o n a l p r o g r a m s and s c r e e n i n g p r o c e d u r e s  greater understanding variables  A  and a s s o c i a t e d  s t u d i e s s h o u l d b e made o f t h e p s y c h o -  characteristics  o f delay.  s h o u l d be s t u d i e d a l o n g w i t h those  and s u r v i v a l  i s essential.  More d e f i n i t i v e logical  o f delay  Various  delay  d e t a i l e d pathology  periods t o define  who m i g h t b e n e f i t f r o m s h o r t e n i n g t h e d e l a y  period.  r e - e v a l u a t i o n o f e d u c a t i o n a l methods i n t h e l i g h t  changing delay patterns and of  i s necessary.  p h y s i c a l examination breast  a  i n women l e s s  self-examination are c a l l e d  Studies than  o f un-  o f mammography  fifty  and a  trial  for.  I n t h e f u t u r e , h e a l t h p l a n n i n g must t r a v e l more d e f i n e d paths has  s o t h a t p r o g r a m s a r e more e f f e c t i v e .  I n the past  there  b e e n p o s s i b l y a w a s t a g e o f f u n d s due t o p r o g r a m s and  policies  i n w h i c h t h e o r i g i n a l t h e s i s was p o o r l y  o r o n g o i n g e v a l u a t i o n was  supported  absent.  I n f u t u r e , h e a l t h p l a n n i n g must answer C o c h r a n e ' s a n d Holland's  (42) q u e s t i o n :  "Is the test  (various breast  135  s c r e e n i n g programs) j u s t i f i e d , cially,  scientifically  by the r e s u l t i n g b e n e f i t  and  finan-  t o t h e Community?".  136 6.6  POLICIES AND  OBJECTIVES OF  HEALTH PLANNING  I n t h e p a s t h e a l t h p l a n n i n g programs have been cerned with d i s t r i b u t i o n  of resources,  and u n i v e r s a l i t y o f s e r v i c e . been accomplished being Yet  formulated  access  These g o a l s have  i n B r i t i s h Columbia. and  New  psychology  are p o o r l y researched.  of delay  and  a re-examination  and  s h o u l d be altered,  d i s c o v e r y may  and  The  In the  lack of delay  a d v a n t a g e o u s as  should  n e v e r be  partic-  believed.  There-  i n f o r m a t i o n needs  regarded  throughout  research  i n one  first  and  as e s t a b l i s h e d .  i t s application  m o d i f i e d o r c a n c e l l e d as i t i s e v a l u a t e d . a process  and b r o a d take the  a statement  goals  of discovery before i s made.  The  a  process  f o r m o f a p r e l i m i n a r y p l a n and  of information available  q u a l i t y o f i n f o r m a t i o n s h o u l d be  l i m i t a t i o n s o f any is  the  p o s s i b l y on t r i a l  ment o f p o l i c y  The  see  as  T h e r e s h o u l d be  contain  o f c o u n t i n g numbers  p l a n n i n g o r p r o g r a m b a s e d on t h i s  continual review It  not  interim objec-  of basic principles.  o u t we  u l a r d i s e a s e i s not f o r e any  patient moti-  formulated.  Evaluation often i s a process  I have c a r r i e d  understood,  or inappropriate.  o b j e c t i v e f o r t h e p o l i c y o f p r e v e n t i o n and  not  are  I f these parameters are  well defined, evaluation i s worthless  cannot be  essentially  the p o l i c y of p r e v e n t i o n i s prominent.  screening procedures,  tives  treatment  directions  the b a s i c science of prevention i s p o o r l y  vation  to  con-  given procedure  e s p e c i a l l y t r u e o f any  closely  s h o u l d be  and  of must  required.  studied. known.  program proceeded w i t h  state-  and  The This whose  137  e x p e c t a t i o n s may  be  set too high.  the m o t i v a t i o n o f delay, cancer  U n t i l we  know more a b o u t  f o r example i n r e l a t i o n t o b r e a s t  an i n c r e a s e i n t h e m a r g i n a l b e n e f i t s o f  d e l a y w i l l not be  made.  h e a l t h e d u c a t i o n may  be  shortening  Such o t h e r r e l a t e d programs very wasteful  and  as  ineffectual.  T h e r e f o r e w i t h o t i t b a s i c r e s e a r c h as a p r e l i m i n a r y t o planning process  and  a f i r m knowledge o f the r e s u l t i n g  t a t i o n s of that research, popular l i s h e d which give r i s e t o l i t t l e i c a l l y may has  be  a l s o now  p r o g r a m s may  d i f f i c u l t t o remove.  In view o f t h i s  t o l o o k a t the economic aspect  i s necessary.  more h e a v i l y now  The  An  We  the understanding  d e p e n d more on  t o r y o f a d i s e a s e and  icies in  can be  marginal  given alter-  In the  past  defined.  o f the n a t u r a l h i s -  Any  spent  on  re-  and  pol-  prospective health care  plan  e x p e n s i v e and  b e n e f i t at l e a s t  to  priorities.  of information before plans  formulated.  f u t u r e w i l l be  planning  needs were e a s i l y  d o u b t more r e s o u r c e s must be  collection  polit-  a t e c h n i c a l knowledge i s n e c e s s a r y  d i s c r i m i n a t e between t h e v a r i o u s  s e a r c h and  estab-  exploration of  t h a n e v e r b e f o r e on p l a n n e r s . t h e g o a l and  T h e r e i s no  o f any  limi-  responsibility of decision rests  b a s i c h e a l t h c a r e was now  become  g a i n t o s o c i e t y but  p r o g r a m b e f o r e i t i s embarked u p o n . natives  the  equals  we  must e n s u r e t h a t  the marginal  the  cost.  Only  research can d e f i n e those b e n e f i t s f o r us. I n c o n c l u s i o n t h i s t h e s i s has planner the  p o i n t e d out  importance o f adequate r e s e a r c h  to  the  i n t o the n a t u r a l  138  history of a disease before  any p r o g r a m s a r e embarked  on.  139  7.0  1.  BIBLIOGRAPHY  SHAPIRO, S., S t r a x , P., V e n e t , L . P e r i o d i c Breast Cancer Screening i n Reducing from B r e a s t Cancer.  Mortality  J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n , 215: 1777-1785, 1971. 2.  EGAN, R. L . , E x p e r i e n c e w i t h Mammography i n a Tumour I n s t i t u t i o n : E v a l u a t i o n o f 1,000 s t u d i e s . R a d i o l o g y , 15, 894-900.  3.  DAVEY, J . B . , P e n t n e y , B.H., R i c h t e r , A.M., The E a r l y D i a g n o s i s o f B r e a s t C a n c e r : A further f r o m a Women's S c r e e n i n g U n i t . T h e P r a c t i t i o n e r , 213, 365-369, 1974.  report  4.  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SUTHERLAND, R., Cancer; The S i g n i f i c a n c e o f D e l a y . London, E n g l a n d . B u t t e r w o r t h a n d Company L t d . 1960.  10.  (Publishers)  BLOOM, H.J.G., F u r t h e r S t u d i e s on Prognosis i n Carcinoma o f t h e B r e a s t . B r i t i s h J o u r n a l o f C a n c e r , .4:4, 347-367, 1950.  140  11.  McKENNON, N.E., Cancer M o r t a l i t y ; The F a i l u r e o f C o n t r o l Through Case F i n d i n g Programmes (A Summary). S u r g e r y , G y n a e c o l o g y a n d O b s t e t r i c s , 94, 173-178, 1952  12.  SMTTHERS, D.W. , R i g b y - J o n e s , P., G a l t o n , D.A.G., Payne, P.M.,, C a n c e r o f the B r e a s t : A Review. B r i t i s h J o u r n a l R a d i o l o g y , S u p p l . No. 4,  1952.  13.  RUBIN, P h i l i p Comment: T h e E f f e c t o f D e l a y i n T r e a t m e n t o n P r o g n o s i s . J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n , 200:7, 136-138, 1967.  14.  BLOOM, H.J.G., The I n f l u e n c e o f D e l a y o n t h e N a t u r a l H i s t o r y and Prognosis o f Breast Cancer. B r i t i s h J o u r n a l o f C a n c e r , JL9:2, 228-262, 1965.  15.  SHERIDAN, B., F l e m i n g , J . , A t k i n s o n , L . , S c o t t , G., The E f f e c t s o f D e l a y i n T r e a t m e n t o n S u r v i v a l R a t e s i n Carcinoma o f the B r e a s t . T h e M e d i c a l J o u r n a l o f A u s t r a l i a , .1(5) , 262-267, 1971.  16.  WAXMAN, B.D., S u r v i v a l o f Female P a t i e n t s w i t h Cancer o f the B r e a s t : A S t u d y o f t h e E f f e c t s o f D e m o g r a p h i c and E c o n o m i c Factors. A m e r i c a n J o u r n a l o f S u r g e r y , _97, 31-35, 1959.  17.  HAAGENSEN, C D . , S t o u t , A. P., Carcinoma o f the B r e a s t . A n n a l s o f S u r g e r y , 134, 162, 1951.  18.  GOLD, M.A., Causes o f P a t i e n t s ' Delay i n D i s e a s e s o f the B r e a s t . C a n c e r , 17, 564-577, 1964.  19.  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