Understanding Delays in Diagnosis and Treatment of Breast Cancer in India

描述（由申请人提供）：世界范围内，50%的乳腺癌病例和59%的乳腺癌死亡发生在低收入和中等收入国家（LMICs）。印度承担着全球7%的乳腺癌负担，每年有11.5万名女性被诊断出患有乳腺癌，其中近一半的人死于这种疾病。尽管存在这种疾病负担，但印度缺乏全国性的有组织的筛查计划。乳腺癌通常在妇女寻求治疗体征/症状的晚期才被发现。只有大约一半的印度女性在确诊后的前5年存活下来，而在美国，这一比例为90%。促进及时提供乳腺癌护理（诊断/治疗）是减轻全球乳腺癌负担和改善印度等中低收入国家癌症死亡率结果的高度优先事项。然而，很少有理论驱动的研究在中低收入国家进行，以确定促进或构成乳腺癌治疗障碍的因素。我们的研究以社会生态学的行为理论为依据，因为它适用于癌症护理连续体，我们建议通过使用混合方法研究来开发和验证一种定量工具，以检查可能促进或构成障碍的多层次背景因素之间的关联，从而解决这一差距，这些因素可能会促进或阻碍印度乳腺癌护理的及时呈现。这将为美国国立卫生研究院今后申请对这些关联进行定量研究并确定多层次干预措施以促进乳腺癌的及时诊断和治疗奠定基础。我们将在印度班加罗尔圣约翰医学院医院（SJMCH）的癌症中心进行为期2年的混合方法研究。我们将首先对女性乳腺癌患者（n=30）、家庭成员（n=20）和医疗保健提供者（n=10）进行半结构化的深入访谈。这些访谈将使我们能够了解女性如何感知、理解和体验她们的癌症症状、诊断和治疗，并探索家庭、提供者/卫生保健组织和社区如何塑造她们的癌症护理实践（目标1）。利用这些数据，我们将完善我们的乳腺癌治疗延迟的概念模型，并开发一个结构化的工具来测量多层次的背景因素。我们将有一个专家小组对该工具的内容和面效度进行审查，然后在SJMCH新登记的乳腺癌患者（n=100）中进行中试，以检验维度、收敛效度和判别效度、时间信度和内部一致性。基于这些发现，我们将改进该工具，以便在未来的定量研究中使用这些因素与印度乳腺癌诊断和治疗表现之间的关系（目标2）。总之，这项研究将为影响低收入和中等收入国家妇女乳腺癌护理的结构和过程提供急需的概念和经验见解，这是制定有效的全球癌症控制政策的关键的第一步。

DESCRIPTION (provided by applicant): Worldwide, 50% of breast cancer cases and 59% of breast cancer deaths occur in low- and middle-income countries (LMICs). India bears 7% of the global burden of breast cancer, with 115,000 women diagnosed with breast cancer annually and nearly half that many dying of the disease. Despite this disease burden, India lacks a nationwide organized screening program. Breast cancer is typically detected at an advanced stage when a woman seeks care for signs/symptoms. Only about half of Indian women survive the first 5 years post-diagnosis, compared to 90% of women in the United States. Promoting timely presentation for breast cancer care (diagnosis/treatment) is a high priority for reducing the global burden of breast cancer and improving cancer mortality outcomes in LMICs like India. However, few theory-driven studies have been conducted in LMICs to identify factors that either facilitate or pose barriers to presentation for breast cancer care. Our study, informed by the social-ecological theory of behavior as it applies to the cancer care continuum, proposes to address this gap by using mixed-methods research to develop and validate a quantitative instrument to examine the association between multilevel contextual factors that may facilitate or pose barriers to timely presentation for breast cancer care in India. This will lay the foundation for a future National Institutes of Health application to conduct a quantitative study o these associations and to identify multilevel interventions to promote timely diagnosis and treatment of breast cancer. Our 2-year mixed-methods study will be conducted at the cancer center at St. John's Medical College Hospital (SJMCH) in Bengaluru, India. We will begin by conducting semi-structured in-depth interviews with female breast cancer patients purposively selected on the basis of their stage at diagnosis (n=30), family members (n=20), and health care providers (n=10). These interviews will enable us to understand how women perceive, understand, and experience their cancer symptoms, diagnosis, and treatment, and explore how families, providers/health care organizations, and communities shape their cancer care practices (Aim 1). Using these data, we will refine our conceptual model of delays in presentation for breast cancer care and develop a structured instrument to measure multilevel contextual factors. We will have an expert panel review the instrument for content and face validity and then pilot-test it with a convenience sample of newly registered breast cancer patients (n=100) at SJMCH to examine dimensionality, convergent and discriminant validity, temporal reliability, and internal consistency. Based on the findings, we will refine the instrumen for use in a future quantitative study on the associations between these factors and presentation for breast cancer diagnosis and treatment in India (Aim 2). In conclusion, this study will provide urgently needed conceptual and empirical insights on the structures and processes that influence women's presentation for breast cancer care in an LMIC, a critical first step toward developing effective global cancer control policies.