The Delay Factors of Early Breast Cancer Detection Patients in Indonesia

. Breast cancer is the number one death caused to women. The higher mortality rate is because the patients are diagnosed at the advanced stage. The cancer patients do not know the signs and symptoms of breast cancer and cannot do a breast self-examination (SADARI) because the cancer education in the community is insufficient. Delaying in detecting breast cancer will delay the treatment. This research aims to explore the delay factors of early breast cancer detection. It used a literature review approach with 4 electronic databases, including Google Scholar, Pubmed, Garuda, and Perpusnas, with published years of 2015-2020. The keywords are delay factors, detection, medical checkup, treatment, and breast cancer. Of 892 identified articles, only 9 articles fulfilled the inclusion criteria. The reviewed articles are the researcher and supervisor's discussion and validation using the Prisma Guideline. The 9 articles show delay factors of detecting breast cancer, including education, knowledge, income, information/mass media, husband/family support, health service center distance, health facilities, treatment cost, alternative treatment, age, pain, and fear. The research concluded that the 12 factors causing the breast cancer patients late in receiving treatment and already in advance stage cancer because they did not do breast cancer detection.


Introduction
Breast cancer or carcinoma mammae is the cell's inability to do the usual process or development, and it grows out of control in breast tissue (Depkes, 2015).World Health Organization (WHO) stated that breast cancer occurs only to women.It is estimated that 2.1 million women have breast cancer every year, and this disease causes the highest mortality rate to women (WHO, 2018).GLOBOCAN's (2018) data mentioned that the prevalence of breast cancer cases worldwide is 2,088,849, with 6.6% ending up dead (GLOBOCAN, 2018).The National Cancer Institute's Surveillance, Epidemiology and End Result Program (NCI) mentioned that in 2018 the prediction cases of breast cancer in the US is 15.3% of all various cancer cases.In comparison, Indonesia's cancer cases are 136.2cases per 100,000 people and placed 8th in Southeast Asia and 23rd in Asia.Breast cancer cases are 42.1 cases per 100,000 people, and the death rate is 17 cases per 100,000 people.Cervical cancer has 23.4 cases per 100,000 people, and the death rate is 13.9 cases per 100,000 people (WHO, 2017).
The mortality and morbidity of breast cancer increase worldwide and in Indonesia every year.It should have particular attention because it affects women's health.Not knowing the signs and symptoms of breast cancer will cause late receiving proper handling or treatment (Rahmawaty et al., 2019).The reason is that most women patients in developing countries are not aware of the signs and symptoms of cancer.They also do not know how to detect cancer because cancer education is insufficient in the community (Nasution et al., 2018).
As part of developing countries, Indonesia experiences breast cancer diagnosis and introduction delays due to some factors.They are patient delay, referral delay, and treatment delay.The patient delay means that the first consultation to another consultation is more than 3 months.The cause is a lack of self-awareness to detect cancer early.Culture and often fear of cancer diagnosis cause the patients to fear consulting even though they have had the symptoms (Stapleton et al., 2011).
Delay in examining breast cancer will cause the patients to delay examining their condition.The cancer cannot be differentiated anymore to proceed with the treatment process (Setiawan, 2012).The researcher analyzed that there is not much research exploring the factors influencing the delay of early breast cancer detection, especially using the review literature approach in Indonesia.Thus, the researcher is interested in exploring those delay factors.

Strategy for searching study
This study used PRISMA Guideline to find the relevant articles suitable with the inclusion criteria.
In searching for the articles, the researcher used 4 electronic databases, such as Google Scholar, Pubmed, Garuda, Perpusnas, with the search year of 2015-2020.The keywords split into three concepts, namely: delay factors or inactive factors or regression factors or lag factors or retaining factors or underdeveloped factors, and early detection or early detection or initial identification or initial checkup or early treatment or screening, and breast cancer or breast carcinoma or breast neoplasm.

Study selection
The article selection process is to identify the articles in the four electronic databases using specific keywords which have been adjusted to MeSH.The researchers obtained 829 articles.
After conducting a duplication check, 59 articles were excluded, leaving the researcher with 833 articles.The remaining articles were screened by reading the article's title or abstract in detail according to the specific criteria.Eight hundred four articles were excluded because they did not fulfill the inclusion criteria.Those articles include General discussion (346), Thesis (150), Exclusive breastfeeding (33), Cervical cancer (74), Breast self-examination (sadari) counseling (60), Chemotherapy (25), Pregnant mothers (38), Adolescent menarche (25), Hypertension (15).
After the researcher checked and discussed with the supervisor, it was decided that 9 articles would be reviewed.After reviewing the nine articles, 2 used the case-control study method, 4 used the cross-sectional method, and the other 3 used the longitudinal descriptive method, qualitative descriptive method, and analytical observational study method.All articles were researched in Indonesia.There are 12 delay factors of early breast cancer detection from the nine articles.

a. Education
The reviewed articles (1,7,8) show that the respondents' low-level education affects the late detection of breast cancer.Respondents with education (Not attending school/Elementary school/Junior high school) have a risk of 5.67.Notoatmodjo (2012) mentioned that the higher one's education is, they are easier to obtain information, causing an abundance of knowledge.An individual with lots of knowledge tends to behave by his knowledge-Vice versa.
The lower one's education is they cannot obtain information causing lack of knowledge.An individual who lacks knowledge tends to behave as not expected.As a result, one will not have enough motivation to perform early breast cancer detection (Notoatmodjo, 2012).

b. Knowledge
The reviewed articles (1,2,4,7,8,9) show that the respondent's low-level education affects the late detection of breast cancer.Most low-level educated women are late in performing breast cancer detection due to having a lack of knowledge.According to Notoatmodjo (2012), knowledge is acquired after one senses a certain object.Sensing happens through the human five senses: sight, hearing, smell, taste, and touch.Mostly, humans obtain knowledge through eyes and ears.Also, knowledge or cognition is crucial in shaping one's behavior (overt behavior) (Notoatmodjo, 2012).Ministry of Health (Depkes) (2016) stated that people still lack knowledge on breast cancer.Thus, it is crucial to be aware of early breast cancer detection to control breast cancer cases (Depkes, 2015).If breast cancer can be early detected and diagnosed and receive proper treatment, there is still a chance to survive cancer.The statement aligns with Antriana's (2014) research stating that knowledge affects a person as motivation to behave (Antriana, 2014).

c. Income
The reviewed articles (1,2,7) show that income affects late breast cancer detection.Low-income women are three times riskier to have a late breast cancer detection than better-income women.
According to Bastable (2016), social and economic status significantly affect health status and health behavior.The higher the income aligns with, the higher usage of health services.Lowerincome people are less likely to use health services and maintain their health due to their inability to buy medicines and the high transportation cost to health service centers (Bastable, 2016).This statement aligns with Sobani et al.'s (2012) research stating that family income is related to the awareness of performing breast cancer screening (Sobani et al., 2012).

d. Information/mass media
The reviewed article (1) shows that information/mass media affect late breast cancer detection.
According to Notoatmodjo (2012), the source of information is the perceived information by reading books and other people's research along with one experiencing directly (Notoatmodjo, 2012).One can obtain information from various sources such as media that will affect their knowledge level.This statement aligns with Ompusunggu (2012) research stating that lack of knowledge is why people do not conduct medical checkups (Ompusunggu, 2012).A good delivered and perceived information will contribute directly to improving one's knowledge of breast cancer.They will conduct early breast detection in health services by explaining the symptoms they have in their breasts.

e. Husband/family support
The reviewed article (1) shows that husband/family support affects late breast cancer detection.
According to Friedman (2012), family support is family acts and behavior as responses in information, appraisement, instrumental, and emotional supports.Family support is an act of caring from one family member to another in the form of verbal information, advice, direct help, attitude, and emotional support to uplift other family members' morale.It affects the quality of life of breast cancer patients.The more support family provides the better the patient's life quality.
The less support family provides, the patient's life quality will decrease (Friedman & Marylin, 2012).This statement aligns with Husni's (2015) research stating that family support has a significant role in improving patients' health and self-esteem.The more family supports the patient, the patient's anxiety will decrease.This happens because family support is an important factor in providing positive motivation and minimizing patients' anxiety (Husni et al., 2015).

f. Health service center distance
The reviewed articles (2,3) show that if the distance of health service centers with patient's house is too far, the patients will be 2.5 times riskier to be late in detecting breast cancer.According to Notoatmodjo (2012), the long time it takes to reach the health service center affects an individual to utilize the health services to cure his/her disease (Notoatmodjo, 2012).This aligns with Chisbuldin's (2013) research stating that there is a significant correlation between the distance of health service centers with the late treatment of breast cancer patients.He argued that if the distance of health service is too far, it will affect the patients late receiving examination in the health service center (Chisbuldin, 2013).

g. Pain
One reviewed article (2) explained the pain.The article stated that pain affects late breast cancer detection.Women who do not feel breast cancer pain will be two times riskier to have late breast cancer detection than those who feel pain.According to Notoatmodjo (2012), pain severity and the threat of disease that people have will drive them to check up or treat their diseases (Notoatmodjo, 2012).This aligns with Mardiana's (2015) research.For a long time, breast cancer patients will know they have cancer once their breast is painful, along with a lump growing bigger in their breast tissue (Mardiana et al., 2015).

h. Health facility
The two reviewed articles (3,8) show that health facilities affect late breast cancer detection.The insufficient health facility urged the informant to receive treatment in another hospital with sufficient health facilities outside her living area.According to the Government of the Republic of Indonesia (2016), Health Service Facility is equipment or places used for carrying out health service means such as promotion, prevention, curation, and rehabilitation performed by the Government, Regional Government, and community (Depkes, 2015).This statement aligns with Pratama's (2016) research stating that one of the factors causing late breast cancer management is the insufficient treatment facility in hospitals.Thus, it becomes the obstruction factor causing cancer patients to receive hospital treatment (Pratama, 2016).

i. Treatment cost
The reviewed article (3) shows that treatment cost has a significant role in the late finding of health services for breast cancer patients.According to Notoatmodjo (2010), expensive treatment cost causes the patient to postpone finding health services, especially poor people who cannot afford them.The patients assume that their symptoms are not that severe, making it to cover the expensive treatment cost (Notoatmodjo, 2010).This aligns with Elvira's (2010) research stating that patients took a long time to receive therapy because they did not want to undergo a mastectomy and assumed that the treatment was expensive (Elvira, 2010).

j. Alternative treatment
The five reviewed articles (4,5,7,8,9) show that patients who underwent alternative treatment are 4.081 times riskier to late breast cancer detection.According to Notoatmodjo (2010), faith in the success of treatment selection (specifically traditional treatment) affects one late in looking for a health facility center (Notoatmodjo, 2010).This aligns with Hikmanti & Adriani's (2016) research that breast cancer patients did not want to receive treatment because they fear cancer therapies, including operation procedures, chemotherapy, and radiation treatment (Hikmanti & Adriani, 2016).

k. Age
The reviewed article (6) shows that old women patients tend to have late breast cancer detection.
According to Notoatmodjo (2010), the older the people, they are more mature and have more power to think and work.Also, age is related to one's mind maturity in accepting, relishing, and overcoming a problem (Notoatmodjo, 2010).This aligns with Saika and Sobue (2009) research that age is a significant factor in breast cancer cases because breast cancer will multiply in productive age and grow slower as one gets older (SAIKA & SOBUE, 2009).

l. Fear
The three reviewed articles (4,7,9) show that fear affects late breast cancer detection patients.
The patients fear receiving medical treatment.According to Kurniati et al. (2010), fear is a natural psychological response towards certain stimuli.It is a reaction towards a real threat that potentially harms an individual (Kurniati et al., 2010).This aligns with Frida's (2012) research stating that the postponing of detecting breast cancer for the patients is due to their anxiety and fear of undergoing a mastectomy procedure (a procedure to remove a breast) even though the patients can early detect the symptoms of breast cancer (Setiawan, 2012).

Conclusion and Suggestion
Based on the 9 analyzed articles, it can be concluded that the delay factors of breast cancer detection are education, knowledge, income, information/mass media, husband/family support, health service center distance, health facilities, treatment cost, alternative treatment, age, pain, and fear.
The research of Djatmiko et al. (2013) and Dyanti and Suariyani (2016) mentioned that there is a correlation in the delay factors of breast cancer treatment on medical personnel.The factors include age, education, knowledge, treatment cost, exposure to information or mass media, husband and family support, and early cancer detection (Djatmiko et al., 2013; Dyanti & Suariyani, 2016).

3. Research Result Table 1
Result for literature review search