الفهرس 
Introduction and Aim of the StudyOnly 14 pages are availabe for public view
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Abstract
Breast cancer constitutes a major health problem for women worldwide. The increased burden of breast cancer among Egyptian females, as well as the economic impact of the disease in limited resources setting, put breast cancer on the top of public health issues in Egypt.
Tumor Stage of BC at diagnosis crucially determines its prognosis. Previous studies have shown most of women with breast cancer in Egypt and similar developing countries present for the first time at late stages, indicating the need for increased community awareness and early detection of the disease.
Late-stage diagnosis of BC means that the tumor has already progressed to late stages (III & IV) at the time of initial diagnosis which results in unfavorable outcomes and the escalating mortality rates from the disease.
The aim of the study was to develop a statistical model for the factors associated with late-stage diagnosis of BC. The specific objectives were to describe the proportion of women diagnosed at late stage among the studied females, to determine the relation between diagnosis delay and the tumor stage at diagnosis, and further to identify different risk factors related to delay by patients, providers or health system barriers.
A cross-sectional design was used for the implementation of the study. A predesigned questionnaire was used in face-to-face interview to collect data about sociodemographic characterestics, medical history, clinical characteristics of the tumor, knowledge about BC and its screening methods, preventative health behavior of participants, illness behavior, and the pathway followed by the sampled women until reaching definite diagnosis.
Data entry and statistical analysis were done using SPSS version 23 software, two-tailed tests were used for the whole analysis and alpha error 0.05.
The study revealed the following main results:
A total of 400 newly diagnosed women with BC are enrolled in this study, (47.5%) were diagnosed at late stages (40% at stage III/ 7.5% at stage IV), while (52.5%) were diagnosed at early stages (6.5% at stage I/ 46% at stage II).
The risk of late-stage diagnosis of BC among women with non-luminal subtypes of the tumor is 2.015 times relative to women with luminal tumor subtypes, and this was very high statistically significant (p=0.001).
The risk of late-stage diagnosis of BC among women who never sought mammographic screening before their condition is 4.113 times relative to women who were compliant mammogram screening before their condition, and this was statistically significant (p=0.029).
The risk of late-stage diagnosis of BC among women who experienced total diagnosis delay longer than three month is 8.389 times relative to women who were not delayed, and this was very high statistically significant (p<0.001).
The risk of late-stage diagnosis of BC is significantly increased among women who delayed to first presentation longer than 3 months (OR=2.451, p=0.042), equal or longer than 6 month (OR=6.038, p<0.001), and equal or longer than 12 month (OR=9.628, p<0.001) compared with women who not delayed to first presentation.
The risk of late-stage diagnosis of BC is significantly increased among women who delayed by providers or because of health system barriers more than 1 month (OR=9.353, p<0.001) and more that 3 month (OR=7.118, p<0.001) compared with women who definitely diagnosed within 1 month after the first presentation.
Living in rural areas (OR=2.028, p=0.015), not performing BSE (OR=2.342, p=0.043), having financial constraints as a barrier to help seeking (OR=6.696, p<0.001), having time constraints as a barrier to help seeking (OR=4.731, p<0.001), fear from cancer (OR=4.112, p=0.002), and embarrassment to have breast examination (OR= 24.939, p<0.001) were significant risk factors of delay by patients to first presentation.
Presentation to the first facility with non-breast or mixed symptoms (OR=2.442, p=0.048), misdiagnosed or not correctly referred by the first doctor consulted (OR= 31.744, p<0.001), and experience with long waiting till medical appointments or other health system barriers (OR=24.755, p<0.001) were found as significant risk factors of diagnostic delay by providers or because of health system.
Lack of knowledge about BC and screening methods (OR= 4.319, p=0.003), non-breast symptoms as the first discovered symptoms (OR= 4.737, p< 0.001) and unmarried women (OR= 1.68, p=0.28) were significantly associated with late-stage diagnosis regardless diagnosis delay.
The multivariate logistic regression analysis was adopted to determine the significant predictors of late-stage diagnosis of BC, which were unmarried, non-luminal subtype, no mammogram screening, the first symptom is breast changes without lump, the first symptom is non-breast symptoms, patient delay > 3 months, provider or system delay > 1 month.
Conclusion:
Based on the results of the current study, the following can be concluded:
1. Breast cancer is still diagnosed at a late stage, with a high rate in Egypt, therefore downstaging should be assigned as a public health priority.
2. Promoting early detection of breast cancer can save lives.
3. Mammographic screening is the gold standard approach for detecting asymptomatic women, and early diagnosis is a cost-effective alternative for better management of the symptomatic women.
4. Women with non-luminal subtypes of BC are at high risk of latestage disease at diagnosis.
5. Diagnosis time is a significant mediator for the tumor stage at diagnosis.
6. Lack of knowledge and misconception about BC are very important controllable risk factor for the delay in presentation by patients for seeking medical advice.
7. Financial constrains contributed a significant barrier to help seeking.
8. Lack of awareness among health care providers for detecting early signs and symptom of BC is responsible for longer delay to reach definite diagnosis, and in turn later stage of BC at diagnosis.
9. Lack of proper navigation and adequate referral system in Egypt is an important barrier to timely diagnosis.
10. Long waiting till medical appointments or during the diagnostic process results in unnecessary delay to diagnosis.