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.
Delayed diagnosis and treatment contribute to high mortality among women with breast cancer in low- and middle-income countries (LMICs) like India. However, few theory-driven studies have been conducted in LMICs to identify factors that either facilitate or pose barriers to timely diagnosis and treatment of breast cancer. Our study, informed by the social-ecological theory of behavior as it applies to the cancer care continuum, proposes to develop and validate a quantitative instrument to examine the association between multilevel facilitators of and barriers to timely presentation for breast cancer care in India.