Journal of Family & Community Medicine
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contact us Login 

Users Online: 263 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size


 Table of Contents 
Year : 2015  |  Volume : 22  |  Issue : 2  |  Page : 96-100  

Clinical presentation and causes of the delayed diagnosis of breast cancer in patients with pregnancy associated breast cancer

Department of Internal Medicine and Oncology, College of Medicine, University of Dammam, King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia

Date of Web Publication17-Apr-2015

Correspondence Address:
Dr. Ali M Al-Amri
Department of Internal Medicine and Oncology, King Fahd Hospital of the University, Al-Khobar 31952, P.O. Box 40182
Kingdom of Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2230-8229.155383

Rights and Permissions

Objective: The objective was to assess the clinical presentation, delay of diagnosis, and the causes of delay in the diagnosis of patients with pregnancy-associated breast cancer (PABC) and patients with non-PABC. Patients and Methods: This was a face-to-face interview with women who had histologically confirmed BC. All respondents were interviewed at our hospital. Results: We interviewed 56 patients, 36 with non-PABC and 20 with PABC. Of the 20 patients with PABC, BC was diagnosed in 12 (60%) during pregnancy and 8 (40%) during postpartum. 18 of the patients (90%) with PABC presented mainly with a mass 3 (15%) with pain and ulcer, 5 (25%) with skin redness and thickening, 6 (30%) with nipple retraction and 4 (20%) with discharge 12 (60%) patients with PABC had delayed diagnosis and 8 (40%) of this delay was due to physicians' reassurance, and 2 (10%) because of fear of cancer. Similarly, 35 (97%) patients with non-PABC presented with breast mass, 3 (8.3%) with infrequent pain 4 (11.11%) with inflammation 2 (5.55%) with ulcer 2 (5.55%) with nipple discharge and4 (11.11%) with thickening of the skin compared with PABC patients. Only 4 (11.11%) in non-PABC had delayed diagnosis, and for half of them the delay was due to the fear of cancer. Two patients with PABC and non-PABC were afraid of cancer 16.66% and 5.55%, respectively. However, 8 (60%) of patients with PABC had delayed diagnosis compared to 0% of patients with non-PABC. Conclusion: In this study, the majority of patients with PABC or non-PABC presented with a breast lump. Other symptoms were more common in patients with PABC than in patients with non-PABC. An increased awareness of clinicians may help reduce delay in the diagnosis of patients with PABC.

Keywords: Breast, cancer, delay, pregnancy

How to cite this article:
Al-Amri AM. Clinical presentation and causes of the delayed diagnosis of breast cancer in patients with pregnancy associated breast cancer. J Fam Community Med 2015;22:96-100

How to cite this URL:
Al-Amri AM. Clinical presentation and causes of the delayed diagnosis of breast cancer in patients with pregnancy associated breast cancer. J Fam Community Med [serial online] 2015 [cited 2021 Nov 27];22:96-100. Available from:

   Introduction Top

Breast cancer is an important health problem in Saudi Arabia, especially in the Eastern Province. It ranks first among all newly diagnosed malignant diseases in Saudi women, accounting for 25% in year 2008. The median age at diagnosis was 47 years. [1] The Eastern Region of Saudi Arabia recorded the highest age-standardized rate of 31.8/100,000 women of all the regions in the Kingdom of Saudi Arabia. [1] Breast cancer (BC) patients in the kingdom are one decade younger than in Europe. [2]

Pregnancy-associated breast cancer (PABC) is defined as BC that is diagnosed during pregnancy or within 1-year thereafter, including any time when a woman may be lactating. It is the most frequently diagnosed cancer that co-exists with pregnancy and lactation. [3],[4],[5],[6],[7]

To improve the outcome of BC treatment, there should be increased awareness among clinicians and a better understanding of the clinical presentation, predicting factors and causes. Delay in treatment is important since smaller tumors are more likely to be treated successfully. Delayed presentation of BC is associated with larger tumors at presentation, advanced stage, and low survival. [8],[9],[10],[11],[12]

In general, delay in diagnosis and treatment of cancer is divided into two: Patient delay, provider and referral delay. Patient delay is defined as the period from the onset of symptoms to the first medical consultation. Provider and referral delay covers the period from the first consultation to definite diagnosis and commencement of treatment. [13]

We conducted this study to assess the clinical presentation, delay of diagnosis, and the causes of delayed diagnosis of patients with PABC and patients with non-PABC in our hospital.

   Patients and Methods Top

Structured face-to-face interview was conducted after histological diagnosis of BC was confirmed at our hospital. The study was conducted at King Fahd Hospital of the University at Al-Khobar, KSA from 2007 to 2013.

The interview consisted of detailed questions on demographic characteristics of our patients, clinical presentation including breast mass, pain, redness, ulcers, nipple discharge, and thickening of the skin of the breast. The phases of delay were defined as follows:

  • Patient delay was defined as the interval between first detection of a symptom and the time of first presentation to a general practitioner, or any health professional
  • Physicians delay was defined as the interval between the time of first presentation to the general practitioner or health care providers and onward referral to a hospital
  • Referral delay was defined as the interval between the time of presentation at a general practitioner's or health care provider and the time of commencement of investigation and therapy at special care center. Delay of <3 months was not considered for this study.

The patients were asked to recall the time they first noticed their symptoms and when they decided to seek medical advice. In addition, they were asked to recall the time it took for a referral to be made to the special care center. Any radiological, laboratory, and referral reports available with the patients were examined and considered as part of the interview as these data helped to resolve any conflicting dates of events. Detailed questions concerning the causes of delay of the diagnosis of BC were asked as well. In addition, the patients were informed of the aim of the study prior to the interview. The outcomes of these questions were then reported.

The data were collected for this study during the time of admission to our hospital as part of the review of patients' history and clinical examination, or during follow-up of patients at our oncology outpatients department. All patients in this study gave verbal consent. None of the patients refused to participate in the interview.

Fisher's exact test was performed to examine whether there was a significant difference between PABC and non-PABC symptoms and signs at the time of presentation, as well as reasons for the delay in the diagnosis of BC. The significant level was determined at 5%.

   Results Top

The demographic characteristics of the study population (n = 20 PABC and n = 36 non-PABC) are shown in [Table 1]. Eighty percent of patients with PABC and 83% of patients with non-PABC were Saudi. Of the patients with PABC, 60% had breast carcinoma during pregnancy, and 40% had BC postpartum. The main symptom of patients with PABC and non-PABC was the discovery of the breast lump, 90% and 97%, respectively, as shown in [Table 2]. The rest of the symptoms like pain, skin redness, ulcer, nipple retraction, nipple discharge, and skin thickening were more common in patients with PABC compared with patients with non-PABC; (15% vs. 8.3%, 25% vs. 11.11%, 15% vs. 5.5%, 30% vs. 19.44%, 20% vs. 5.5%, and 25% vs. 11.11%, respectively). Sixty percent of patients with PABC had delayed diagnosis compared with only 11.11% of patients with non-PABC.
Table 1: Demographic characteristics of PABC and BC without pregnancy

Click here to view
Table 2: Clinical presentation of PABC and breast carcinoma without pregnancy

Click here to view

The questions and the responses of BC patients regarding the delay of diagnosis and the causes of the delay during the interview are shown in [Table 3].
Table 3: Questions to be answered by BC patients during interview

Click here to view

Of the patients with PABC, who had delayed diagnosis, 40% of the delay was due to the reassurance by physicians. No delay of diagnosis was reported by patients with non-PABC. Furthermore, the other causes of delayed diagnosis like fear of cancer, family issues, and long delay in getting an appointment were more common in patients with PABC compared to non-PABC patients, 10% versus 5.55%, 5% versus. 2.77% and 5% versus 0%, respectively. Problems with transportation were more common with patients with non-PABC than patients with PABC, 2.77% versus 0% as shown in [Table 4].
Table 4: Reasons of BC diagnosis delay

Click here to view

   Discussion Top

Our study found that the main presenting symptom of patients with BC was breast mass (lump), and 90% or more of PABC and non-PABC had a breast lump either by itself or in association with other symptoms. According to the Merck Manual of diagnosis and therapy, >80% of BC are discovered when a woman feels a lump herself. Furthermore, most patients with PABC present with painless masses, 90% of which are detected by self-examination. [14]

The physiologic changes that occur in the breast during pregnancy and lactation leading to ductal and lobular proliferation, which alter breast structure resulting in enlargement, increased nodularity and temperature, firmness, nearly doubled breast size, and increased susceptibility to infections can partly obscure the symptoms of BC. [15],[16]

In our study, pain, skin thickness, ulcer, nipple retraction and discharge, and skin redness were more than double in patients with PABC compared to non-PABC patients, which can partly be explained by the physiologic changes that occur during pregnancy and lactation.

Because of these changes both the physicians and patients sometimes assume that the density, nipple retraction, redness, skin thickness, discharge or even breast mass are a normal part of pregnancy and lactation. This unfortunately leads to misapprehension of the situation and the reluctance on the part of the physicians to undertake invasive diagnostic procedures.

It is very important that all breast complaints and symptoms, especially those not resolving within 4 weeks, whether associated with gestation or not, are evaluated aggressively to document the nature of the symptoms so that BC can be excluded or treated. [17],[18],[19]

The strength of our study was the direct personal interviews with our BC patients regarding the date of the onset of symptoms and the date of the first consultation. The use of radiological, laboratory and referral report, when available, were probably more reliable and made our findings more accurate than data-based hospital records. In addition, a delay of <3 months was not considered for this study to minimize the estimates of duration of symptoms, and avoid false reporting or faulty recall by the BC patients. However, the retrospective nature of the data collection on the duration of symptoms poses a potential bias to the validity of these findings. Besides, the sample size of our study was small.

Delay in diagnosing BC is common. [20],[21],[22] Many studies in developed countries have reported 4-54% frequency in the delay of BC diagnosis of >3 months prior to the initiation of investigation and therapy of women with BC in hospital. [14],[23],[24],[25] In developing countries, the reported frequency of diagnosis delay of >3 months was 72.6% of patients with BC. [26]

Often the diagnosis of PABC is delayed because neither the patient nor the physician suspects malignancy. [27],[28]

In our study, 60% of the delay in the diagnosis of patients with PABC was due to false assurance. However, in comparison, non-PABC patients did not report any diagnosis delay. Two patients in each group were afraid of cancer, so they did not seek medical advice themselves. This accounts for 10% of PABC patients and 5.55% of non-PABC patients whose diagnoses were delayed. One patient, 5% of PABC was not able to go to the hospital and seek medical advice because she had to take care of her children attending school. One patient, 2.77% of the non-PABC patients were unable to go to the hospital because of the lack of transportation and inability to pay for it. Whether the pregnancy itself negatively affects survival remains debatable. However, the results of a recent study showed similar overall survival for patients diagnosed with PABC compared with nonpregnant patients. [29] In our study, the fear of cancer, distance to the hospital and family issues still played a role in delaying the diagnosis of BC. Other studies have reported similar findings. [30],[31]

In summary, this study showed that >90% of both patients with PABC and non-PABC presenting with a breast mass discovered it themselves. However, in patients with PABC, other symptoms of BC were more common, which could have obscured and delayed the diagnosis. Therefore, the delayed diagnosis of BC is common in patients with PABC compared to patients with non-PABC. The delays are mainly caused by an underestimation of BC symptoms during pregnancy and lactation. Therefore, an increased awareness of clinicians may help reduce the delay in the diagnosis of women with PABC. This would help to reduce the misreading of symptoms and assurance of patients complaining of breast symptoms and the consequent delays in diagnosis and treatment.

   Acknowledgment Top

We would like to extend our sincere gratitude to our statistician, Nithya Jayaseeli, MSc, for her valuable contribution and revision of the statistical analysis.

   References Top

Bazarbashi S, Al-Zahrani A. Cancer Incidence Report Saudi Arabia. Saudi Cancer Registry: Riyadh; 2008.  Back to cited text no. 1
Najjar H, Easson A. Age at diagnosis of breast cancer in Arab nations. Int J Surg 2010;8:448-52.  Back to cited text no. 2
Donegan WL. Cancer and pregnancy. CA Cancer J Clin 1983;33:194-214.  Back to cited text no. 3
Fiorica JV. Special problems. Breast cancer and pregnancy. Obstet Gynecol Clin North Am 1994;21:721-32.  Back to cited text no. 4
Meshikhes AW, Al-Mubarek MA, Al-Tufaif AA. Breast cancer during pregnancy and lactation. Saudi Med J 2004;25:531-2.  Back to cited text no. 5
Antonelli NM, Dotters DJ, Katz VL, Kuller JA. Cancer in pregnancy: A review of the literature. Part I. Obstet Gynecol Surv 1996;51:125-34.  Back to cited text no. 6
Gemignani ML, Petrek JA. Breast cancer during pregnancy: Diagnostic and therapeutic dilemmas. Adv Surg 2000;34:273-86.  Back to cited text no. 7
Woo JC, Yu T, Hurd TC. Breast cancer in pregnancy: A literature review. Arch Surg 2003;138:91-8.  Back to cited text no. 8
Borges VF, Schedin PJ. Pregnancy-associated breast cancer: An entity needing refinement of the definition. Cancer 2012;118:3226-8.  Back to cited text no. 9
Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. Influence of delay on survival in patients with breast cancer: A systematic review. Lancet 1999;353:1119-26.  Back to cited text no. 10
Burgess CC, Ramirez AJ, Richards MA, Love SB. Who and what influences delayed presentation in breast cancer? Br J Cancer 1998;77:1343-8.  Back to cited text no. 11
Eedarapalli P, Jain S. Breast cancer in pregnancy. J Obstet Gynaecol 2006;26:1-4.  Back to cited text no. 12
Facione NC. Delay versus help seeking for breast cancer symptoms: A critical review of the literature on patient and provider delay. Soc Sci Med 1993;36:1521-34.  Back to cited text no. 13
Pavlidis NA. Coexistence of pregnancy and malignancy. Oncologist 2002;7:279-87.  Back to cited text no. 14
Moore HC, Foster RS Jr. Breast cancer and pregnancy. Semin Oncol 2000;27:646-53.  Back to cited text no. 15
Tabbarah HJ. Cancer and pregnancy. In: Haskell CM, editor. Cancer Treatment. Philadelphia: WB Saunders; 2001. p. 425-34.  Back to cited text no. 16
Taylor D, Lazberger J, Ives A, Wylie E, Saunders C. Reducing delay in the diagnosis of pregnancy-associated breast cancer: How imaging can help us. J Med Imaging Radiat Oncol 2011;55:33-42.  Back to cited text no. 17
Ulery M, Carter L, McFarlin BL, Giurgescu C. Pregnancy-associated breast cancer: Significance of early detection. J Midwifery Womens Health 2009;54:357-63.  Back to cited text no. 18
Litton JK, Theriault RL, Gonzalez-Angulo AM. Breast cancer diagnosis during pregnancy. Womens Health (Lond Engl) 2009;5:243-9.  Back to cited text no. 19
Tartter PI, Pace D, Frost M, Bernstein JL. Delay in diagnosis of breast cancer. Ann Surg 1999;229:91-6.  Back to cited text no. 20
Azim HA Jr, Santoro L, Russell-Edu W, Pentheroudakis G, Pavlidis N, Peccatori FA. Prognosis of pregnancy-associated breast cancer: A meta-analysis of 30 studies. Cancer Treat Rev 2012;38:834-42.  Back to cited text no. 21
Loibl S, Han SN, von Minckwitz G, Bontenbal M, Ring A, Giermek J, et al. Treatment of breast cancer during pregnancy: An observational study. Lancet Oncol 2012;13:887-96.  Back to cited text no. 22
Arndt V, Stürmer T, Stegmaier C, Ziegler H, Dhom G, Brenner H. Patient delay and stage of diagnosis among breast cancer patients in Germany-A population based study. Br J Cancer 2002;86:1034-40.  Back to cited text no. 23
Velikova G, Booth L, Johnston C, Forman D, Selby P. Breast cancer outcomes in South Asian population of West Yorkshire. Br J Cancer 2004;90:1926-32.  Back to cited text no. 24
Montella M, Crispo A, D'Aiuto G, De Marco M, de Bellis G, Fabbrocini G, et al. Determinant factors for diagnostic delay in operable breast cancer patients. Eur J Cancer Prev 2001;10:53-9.  Back to cited text no. 25
Norsa'adah B, Rampal KG, Rahmah MA, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011;11:141.  Back to cited text no. 26
Jenner DC, Middleton A, Webb WM, Oommen R, Bates T. In-hospital delay in the diagnosis of breast cancer. Br J Surg 2000;87:914-9.  Back to cited text no. 27
Goodson WH 3 rd , Moore DH 2 nd . Causes of physician delay in the diagnosis of breast cancer. Arch Intern Med 2002;162:1343-8.  Back to cited text no. 28
Amant F, von Minckwitz G, Han SN, Bontenbal M, Ring AE, Giermek J, et al. Prognosis of women with primary breast cancer diagnosed during pregnancy: Results from an international collaborative study. J Clin Oncol 2013;31:2532-9.  Back to cited text no. 29
Richardson JL, Langholz B, Bernstein L, Burciaga C, Danley K, Ross RK. Stage and delay in breast cancer diagnosis by race, socioeconomic status, age and year. Br J Cancer 1992;65:922-6.  Back to cited text no. 30
Bish A, Ramirez A, Burgess C, Hunter M. Understanding why women delay in seeking help for breast cancer symptoms. J Psychosom Res 2005;58:321-6.  Back to cited text no. 31


  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Postpartum breast cancer: mechanisms underlying its worse prognosis, treatment implications, and fertility preservation
Hanne Lefrère,Liesbeth Lenaerts,Virginia F Borges,Pepper Schedin,Patrick Neven,Frédéric Amant
International Journal of Gynecologic Cancer. 2021; 31(3): 412
[Pubmed] | [DOI]
2 Clinical Study of Ultrasound Elastography in Qualitative Diagnosis of Breast Masses
Qing Duan,Na Zhuo,Tong Sun,Xuening Zhang
Journal of Medical Imaging and Health Informatics. 2021; 11(3): 1020
[Pubmed] | [DOI]
3 Breast cancer and pregnancy: Why special considerations prior to treatment are needed in multidisciplinary care
Mingdi Zhang,Jing Zhou,Ling Wang
BioScience Trends. 2021;
[Pubmed] | [DOI]
4 Factors Associated With Treatment Delay in Breast Cancer: A Prospective Study
Raja Rahool,Ghulam Haider,Muhammad Hayat,Mehwish R Shaikh,Paras Memon,Bhunisha Pawan,Kiran Abbas
Cureus. 2021;
[Pubmed] | [DOI]
5 Breast Cancer During Pregnancy: A Marked Propensity to Triple-Negative Phenotype
Soumaya Allouch,Ishita Gupta,Shaza Malik,Halema F. Al Farsi,Semir Vranic,Ala-Eddin Al Moustafa
Frontiers in Oncology. 2020; 10
[Pubmed] | [DOI]
6 Identification of core genes and clinical roles in pregnancy-associated breast cancer based on integrated analysis of different microarray profile datasets
Jiao Zhang,Yan-Jun Zhou,Zhi-Hao Yu,Ao-Xiang Chen,Yue Yu,Xin Wang,Xu-Chen Cao
Bioscience Reports. 2019; 39(6)
[Pubmed] | [DOI]
7 Pregnancy-associated breast cancer in rural Rwanda: the experience of the Butaro Cancer Center of Excellence
Jean Marie Vianney Dusengimana,Vedaste Hategekimana,Ryan Borg,Bethany Hedt-Gauthier,Neil Gupta,Susan Troyan,Lawrence N. Shulman,Ignace Nzayisenga,Temidayo Fadelu,Tharcisse Mpunga,Lydia E. Pace
BMC Cancer. 2018; 18(1)
[Pubmed] | [DOI]
8 Diagnostic pathways and management in women with pregnancy-associated breast cancer (PABC): no evidence of treatment delays following a first healthcare contact
Anna L. V. Johansson,Caroline E. Weibull,Irma Fredriksson,Mats Lambe
Breast Cancer Research and Treatment. 2018;
[Pubmed] | [DOI]
9 Breast imaging after dark: patient outcomes following evaluation for breast abscess in the emergency department after hours
Melissa S. Bosma,Kasey L. Morden,Katherine A. Klein,Colleen H. Neal,Ursula S. Knoepp,Stephanie K. Patterson
Emergency Radiology. 2016; 23(1): 29
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
   Patients and Methods
    Article Tables

 Article Access Statistics
    PDF Downloaded452    
    Comments [Add]    
    Cited by others 9    

Recommend this journal

Advertise | Sitemap | What's New | Feedback | Disclaimer
© Journal of Family and Community Medicine | Published by Wolters Kluwer - Medknow
Online since 05th September, 2010