Economic Condition Affects Breast Cancer Care - A Cross Sectional Study in Bangladesh

Economic Condition Affects Breast Cancer Care - A Cross Sectional Study in Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Economic Condition Affects Breast Cancer Care - A Cross Sectional Study in Bangladesh Khursheda Akhtar, Kazi Jahangir Hossain, Khodeza Akhtar, Shamsun Nahar, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-32402/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Socio- economic condition plays a role on taking decision for cancer treatment beside this out pocket expenditure is a headache for cancer patients. For that, pattern of financial assistance for breast cancer treatment and associated factors were explored. Method: A cross sectional study was carried out with 200 samples; those were selected randomly from the listed patients who attended in the day care centre of chemotherapy. Results Maximum respondents first visited to health care provider at II and III stage with first symptom as lump on breast or axilla, no patients came at stage I. Along with family and neighbor, social welfare also play a positive role to assist finance. Donation was the major means to collect money and two or three sources were needed at a time for collecting money. In chi square (χ 2 ) test, economic condition had a significant role on care seeking. Simultaneously by ANOVA it was found that mean difference was more at age 31–40 year of age. After 50 years, care seeking time was intersect, here Main effect of age was F (1, 192) = 1.92, p = 0.162; Main effect of economic condition was F (3, 192) = 0.27, p = 0.847; Inter effect was F (2, 192) = 1.77, p = 0.154. Conclusion After knowing cancer, she and her family member become puzzled to collect money. For that necessary measure should be taken to easy availability of expenditure cost. It is recommended to launch public health insurance as soon as possible. Health Economics & Outcomes Research Infectious Diseases Health Policy socio economic condition breast cancer care seeking behavior Figures Figure 1 Figure 2 Figure 3 1. Background Cancer holds the second position among the non-communicable diseases under study of World Health organization (WHO)(Islam et al., 1970). The World Health Organization (WHO) estimates approximately 2.09 million new breast cancer cases each year, resulting in 627,000 deaths in 2018 that is approximately 15% of all cancer death among woman. (WHO,2018). Unsurprisingly, mortality rates are much higher in the developing world where women often only seek medical assistance and diagnosis in the late stages—unaware of what is wrong and reluctant to shell out on medical costs. (The Hindu.com) In Bangladesh, poor access to medical facilities, stigmatization along with lack of knowledge about the disease mean that a mere 11 percent of Bangladeshi women receive diagnosis in the early stages. Like in much of the world, breast cancer is the most common cancer amongst Bangladesh's female population, with 32.8 percent of female cancer patients suffering from this strain of the disease. The nation’s public medical services—overstretched and underfunded—simply cannot provide the care required by breast cancer sufferers(The Daily Star) . Though Bangladesh is the third quickest growth in the number of high net-worth individuals in the world in the next five years, as poor people’s residence Bangladesh is in 5th position. (The Prothom alo) 2 crore 41 lacs peoples are still in extreme poverty level. Wages in Bangladesh increased to 13258 BDT/Month in 2017 from 12897 BDT/Month in 2016. The current minimum wage of 5,300 taka (the equivalent of about 63 USD) has not been revised since 2013, and it is far below any credible living wage estimate (Clean Cloth Campaign,2018). Living Wage Family in Bangladesh remained unchanged at 15100 BDT/Month in 2018 from 15100 BDT/Month in 2017 (Trading Economics,2018) Concerns about financial burden among breast cancer patients are particularly troubling due to the costly multidisciplinary approach currently required to treat breast cancer. This multidisciplinary approach, regardless of insurance status, results in increased out-of-pocket expenses such as deductibles, and co-pays for hospitalizations and physician visits (Obeng-Gyasi S). Patients’ reasons for late presentation were fear (40%), not aware of disease severity (40%), fear of losing a breast (40%), referral problems (34%), financial problems (8%), and transportation problems (6%). Approximately 33% sought medical help from traditional healers, and 65% regularly attended clinics. (Čačala & Gilart, 2017) Maximum cost for health care is met by Out-of-pocket expenditure. Out-of-pocket healthcare expenditures of households in Bangladesh comprise 64.3% share of the total health expenditure and collectively spent approximately Taka 103.46 billion (US $ 1.49 billion) in yearly on health. Hence, Out-of - pocket expenditure for health care services have been sufficiently costly in Bangladesh. However, identified factors that are associated with higher individual out-of pocket costs include advanced disease and associated medications, hormone therapy, insurance gap payments, and greater traveling distances to the hospital (L. et al., 2007). It is reported that magnitude of cancer is increasing in a rapid pace globally. The disease poses huge burden of mortality and morbidity. Magnitude of cancer has also increased among the countries of South East Asia region. There are 13 to 15 lakh cancer patients in Bangladesh, with about two lakh patients newly diagnosed with cancer each year. About 2 lakh new cases of cancer are diagnosed each year and 13 to 15 lakh people are living with different types of cancer. (Hossain). Breast Cancer is the 3rd leading cancer in Bangladesh with overall incidence rate of 106 per 100,000 populations in Bangladesh. (Globocan 2018 ) Rising burden of cancer in Bangladesh will pose serious implications for the management and financing of the health sector. For this, health strategies may have to be reformed and activities of the health sector may have to be drastically reorganized in order to meet the challenges of the increasing burden of cancer along with other non-communicable diseases. Cancer causes serious economic damage to the households since medical care required against the disease is usually very expensive. Cancer exerts huge economic pressure both on the household economy as well as public health sector. It is imperative to estimate the disability and economic burden of cancer patients as no comprehensive and rigorous study in this regard is available at present in the context of Bangladesh. The purpose of this study is to identify the exact financial situation of the respondents; the magnitude of cancer care affected by economic which will provide data essential for formulating policies and strategies to combat this burning public health problem by determining the socio-economic condition that affects breast cancer care of Bangladeshi breast cancer patients. 2. Methodology 2.1 Methods: A cross sectional study was carried out to determine the socioeconomic status of breast cancer patients with present treatment history, pattern of financial assistance was explored, way of money collection for breast cancer treatment and compare the economic condition with care seeking time. Though total number of samples were calculated as 113 {p = 8% (7), z = 1.96, d = 0.05} but 200 samples were selected randomly from the listed patients who attended in the day care centre for chemotherapy. Randomization by lottery method and was enrolled them according to their selection criteria, but some were excluded by exclusion. Patients with mental disability, recurrence of breast cancer, treatment failure, incomplete treatment, history of metastasis, hearing impairment and who did not comply with the informed written consent were excluded from the study. To avoid recall bias newly diagnosed primary carcinoma (breast cancer) patients were selected. The questionnaire included socio demographic questions of patients, question about current treatment status of the respondents, medical care seeking time for diagnosis and treatment, pattern of sources of collect money for breast cancer treatment, way of collect money for breast cancer treatment. Clinical information such as stage of disease, type of surgical management was obtained from a review of medical records. Questionnaire was prepared by reviewing literatures of qualitative study which was done in South East Asian Region (Caroline Burgess)(Bourdeanu L1) (Norsa'adah B1) (Karbani G1) and from various models (Ní Mháthuna) (Bish A). Perspectives of the study were explained to the respondents and informed consent was taken from each respondent. Face to face interview was taken from diagnosed breast cancer patients admitted in selected hospital by pretested semi structured questionnaire. Interview was taken to 40–45 minutes in length. In total 200 patients completed the interview. The reason for non-completion included being too tired, having poor physical health, lack of interest. Generalization was assured as because patients from whole country came to this only public cancer hospital for treatment and diagnosis. 2.2 Statistical analysis Statistical analyses of the data were performed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 23.0 (SPSS Inc.; Chicago, IL, USA). Descriptive statistics like frequency distribution, mean, median, mode, range, standard deviation etc. were calculated by SPSS program. Association was seen between help seeking time and other variables by Pearson’s Chi-square (χ2) 2 × 2 table at p < 0.05 level of significance. To compare the care seeking time and other factors two way ANOVA was done. 2.3 Ethical Considerations: According to Helsinki Declaration, Ethical Clearance was taken from Institutional Review Board (IRB) of National Institution of Preventive and Social Medicine NIPSOM (NIPSOM/IRB/2016/18) and before taking interviews written permission was taken from the authority of National Institute of Cancer Research and Hospital, Dhaka Bangladesh (NICRH/Ethics/2016/204-5). Informed Written Consent was taken from each. 3. Results 3.1 Description of study population: Socio economic status of the breast cancer patients was summarized in the Table 1. Results showed that n = 90 (45%) were illiterate, n = 69 (34.5%) were in primary education (1–8 class), secondary (SSC) and above 41(20.5%). More than two third, n = 166(83%) of the respondents were house wife and rest of them n = 34(17%) were engaged in service. Majority of the respondents n = 166 (83%) had no monthly self income. In case of monthly family income n = 78(39%) respondents were in 1000-5000-taka income group, n = 85(42.5%) respondents had family income between 6000–10000 taka. 11000–15000 and above 37(18.5%). n = 156(78%) respondents were married followed by widow and separated 44(22%). results showed that n = 27(13.5%) were in 26–30 years age group, n = 29(14.5%) were in (31–35) years age group. Maximum respondents n = 43(21.5%) belongs to 36–40 years age group, n = 34(17% ) were in 41–45 age group, n = 34(17% ) were in 41–45 years age group, n = 35(17.5%) were in 46–50 years age group and rest of the respondents n = 32(16%) were more than 50 years age group, mean age was 42 years. Distributions of the stage of breast cancer patients were summarized. Results showed that no patients were found in stage I, in stage II only n = 34 (17%) respondents were suffered. Majority of patients were in advanced stage. n = 133(66.5%) were in stage III and n = 33(16.5%) respondents were categorized as stage IV. Maximum 100(50%) financial assisted by social welfare of cancer hospital, husbands 87(43.6%), relatives 54(27%), sons 44(22%), neighbors 20(10%) and only 7 (3.5%) by their daughters. According to types of monetary management maximum 117(58.5%) breast cancer patients solved their expenditure from donation. In total 76(38%) managed money by borrowing, 60 (30%) expend from self income, 57(28.5%) sold land or properly and only 7(3.5%) managed money from saving. In total 98(49%) patients use double sources and 18(9%) patients used triple source for monetary management and single source was required for 84(42%). 3.2 Between group comparisons: Association of delay with socio economic status of the respondents was analyzed using Pearson’s Chi-square (χ 2 ) method and summarized in Table 2. Results showed that delay was found to be significantly (p 6 months is more there who had (2000–10000) take monthly family income (68.7%, n = 112). No significant (p > 0.05) was found with other socio demographic variable. Association between economic conditions with delay of the respondents was analyzed using Pearson’s Chi-square (χ 2 ) method and summarized in Table 2. Results showed that economic condition was found to be significant by (p < 0.05) associated with the Care seeking to the initial medical consultation and definitive treatment of the cancer (provider delay) 6.775 (p = 0.009), Woman first noticing a breast cancer symptom and receiving treatment (total delay) 8.740 (p = 0.003), economic condition was associated with family income (p = 0.002). In Table 3 cross relation was seen between family income and staging of cancer. No one come to seek treatment in stage I, one thirty-three (133) breast cancer patients came to seek treatment at stage III. Fifty-seven patients’ family income were 1000-5000-taka, fifty-four patients family income were 6000 -10,000 taka, and rest 22 patient’s family income were 11000 taka and above. 4. Discussion And Conclusion Cancer causes serious economic damage to the households since medical care required against the disease is usually very expensive. Cancer exerts huge economic pressure both on the household economy as well as public health sector (1). An expense on cancer is as like double edge sword. In Bangladesh, even after the high net worth individual will grow quickly people in this area are still regresses to seek medical care especially in cancer due to financial problem. In a study it was found that the majority of patients received assistance with costs associated with radiation therapy and approximately 70% of subjects needed financial assistance with two or more services (Obeng-Gyasi S1). Majority n = 100(50%) of respondents sought financial assistance from social welfare department of cancer hospital. Then husband, son, neighbors, relatives also assisted financially. Maximum respondents 117(58.5%) received money as donation. Others were managed money by borrowed, selling properties or land and saving as well. Maximum 49% (n = 98) respondents needed financial assistance from double source, 42% (n = 84) solved from single source; only 9% (n = 18) patients collect money from triple sources. Results of 172 patients, 50 of each had T2, T3, or T4 stages, and 22 had T1 (7). Majority of patients were in advanced stage. n = 133(66.5%) were in stage III and n = 33(16.5%) respondents were categorized as stage IV. Majority of patients n = 149 (74.5%) initially presented with a lump in breast while in a study it was found that the main presenting complaint for women with tumors was a lump (96%) and 24% presented with breast pain (7). A patient named Basanti Majumder clutching her baby and speaks of a pain in her left breast and fears her cancer may have returned. She stares briefly at the floor and giggles nervously. “I’m not going to the doctor now for financial reasons (2)”. In a study, it was found that delay of care seeking due to financial problem only 8% (7). But in this study, out of 200 sample 157(78.5%) respondents stated that due to economic problem medical care seeking was hampered and delayed. In many countries’ health insurance is a way to pay bills. But in Bangladesh most of them had no health insurance facilities along with high out pocket expenditure (Kabir and 2015). Still health system financing is regressive. High family socioeconomic status independently predicted early care seeking (AOR = 2.23, p = 0.013) and in logistic regression it is β = 1.148, odds ratio.11, p = 0.032 at 95% CI where lower value0.01 and upper value 0.83 (Tinuade A. Ogunlesi and 2010). Still the treatment of non communicable disease as well as cancer is an out-pocket expenditure. When the patients diagnosed as cancer finance is a problem to start treatment. Public health insurance is not established yet in Bangladesh. For poor patient’s social welfare department play a role in cancer hospital but it was not sufficient. Cancer patients collect money from two or three sources. Financial constrain should be overcome to start early diagnosis and treatment which will beneficial for survival time. To combat this rising burden, implementation of management and finance in health sector should be emphasized. Health strategy for communicable disease should be reformed and drastically reorganized in order to meet the challenges of the increasing burden of cancer along with other non-communicable diseases. Because this was a cross-sectional study, inference could not be done clearly. There was a chance of recall bias. A large sample size and in-depth interview could provide more reliable information. Despite of hospital-based study due to one specialized cancer hospital in Bangladesh whole cancer patients ultimately came to this hospital. That’s why the study represents the whole country. Declarations 4.1 Acknowledgements: I deeply acknowledge and express my gratitude to Director and Doctors of Surgical and Medical Oncology Department of National Institute of Cancer Research and Hospital, Mohakhali, Dhaka, Bangladesh for their kind approval and cooperation to carry out my study. I am also grateful to the physicians of Epidemiology department of NIPSOM, Dhaka for helping about analyzing the data and expressing statistical part. 4.2 Conflict of Interest: The authors have no conflicts of interest to declare . 4.2 Financial Disclosure: The author declared that this study has received no financial support. 4.4: Availability of Data and Materials : We consider our data private but the corresponding author will make it available upon reasonable request. 4.5: Ethical Declarations: 4.5.1 : Ethics approval and Consent to participate : Ethical Clearance was taken from Institutional Review Board (IRB) of National Institution of Preventive and Social Medicine NIPSOM (NIPSOM/IRB/2016/18) and before taking interviews written permission was taken from the authority of National Institute of Cancer Research and Hospital, Dhaka Bangladesh (NICRH/Ethics/2016/204-5). Informed Written Consent was taken from each. 4.5.2: Consent for Publications: Not Applicable 4.5.3: Competing Interests: The Authors declare that they have no competing Interests. 4.6: Authors Contributions: All authors has read and consented to the final draft of the manuscript. Dr. Khursheda Akhtar was involved in the Concept of study, Design study , methods and materials, Data Collection and Processing, Analysis and Interpretation, Literature Search, Writing Manuscript, Critical Review. Professor Dr. Jahangir Hossain, Dr. Khodeza Akhtar , Dr. Shamsun Nahar was involved in Concept, Supervision, Materials , Data Collection and Processing, Analysis and Interpretation , Literature Search, Writing Manuscript, Others Authors were involved in Design methods and materials , Data Collection and Processing, Literature Search , Idea sharing and help in report writing. Overall Dr. Khursheda was leading the research. References Bish A, Ramirez A, Burgess C, Hunter M, 2005. "Understanding why women delay in seeking help for breast cancer symptoms." Journal of Psychosomatic Research 58.4 (2005): 321 – 26. . Bourdeanu L1, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G.,2013. "Barriers to treatment in patients with locally advanced breast cancer." J Natl Compr Canc Netw. 11.10 (2013): 1193–8. . Caroline Burgess, Myra S Hunter,Amanda J Ramirez,2001. "A qualitative study of delay among women reporting symptoms of breast cancer." The British Journal of General Practice 51.473 (2001): 967–971. . Clean Cloth C,2018. "Full support for Bangladeshi garment workers’ demands on minimum wage." 06 July 2018. https : //cleanclothes.org/news/2018/07/06/full-support-for-bangladeshi-garment-workers2019-demands-on-minimum- wage. 06 July 2018. Globocan 2018. "50-Bangladesh Fact Sheet." GCA. WHO, 2019. . Hossain SM, Akram,2013. "Comprehensive update on cancer scenario of Bangladesh." South Asian Journal of Cancer 2.4 (2013): 279–284. Kabir, Nazmul M HuqAbul Quasem Al-AminAbul Quasem Al-AminSushil Ranjan HowladerM. A. KabirM. A.,2015. "Paying Out of Pocket for Healthcare in Bangladesh - A Burden on Poor?" Iranian Journal of Public Health 44.7 (2015): 1024-25. . Karbani G, Lim JN, Hewison J, Atkin K, Horgan K, Lansdown M, Chu CE.,2011. "Culture, attitude and knowledge about breast cancer and preventive measures: a qualitative study of South Asian breast cancer patients in the UK." Asian Pac J Cancer Prev. 12.6 (2011): 1619-26. Ní Mháthuna M. "Women's help seeking behaviour and the associated influencing factors." University College Cork (2011-11). . Norsa'adah B1, Rahmah MA, Rampal KG, Knight A.,2012. "Understanding barriers to Malaysian women with breast cancer seeking help." Asian Pac J Cancer Prev. 13.8 (2012): 3723–30. . Obeng-Gyasi S, Tolnitch L, Greenup RA, Hwang ES. The Impact of the Affordable Care Act on North Carolinian Breast Cancer Patients Seeking Financial Support for Treatment. Ann Surg Oncol. 2016 October;23(10):3412–7. Obeng-Gyasi S1, Tolnitch L2, Greenup RA1, Shelley Hwang E3.,2016. "The Impact of the Affordable Care Act on North Carolinian Breast Cancer Patients Seeking Financial Support for Treatment." Ann Surg Oncol. 23.10 (2016): 3412–7. . The Daily Star. "Beating Breast cancer in Bangladesh." 27. November 2017. https://www.thedailystar.net/women-action/beating-breast-cancer-bangladesh-1497598. 2017. The Hindu.com. Woman in Action/Beating breast cancer in Bangladesh . 28. November 2017. 27 November 2017. The Prothom alo. "economy/article/1575323/à¦࿽রিব-মানà§࿽ষà§࿽র-বসবাসà§࿽-বিশà§࿽বà§࿽-পà¦࿽à§࿽à¦࿽ম-বাà¦࿽লাদà§࿽শ." 20 January 2019. https://www.prothomalo.com/economy/article/1575323 . 20 Jnuary 2019. Tinuade A. Ogunlesi, Durotoye M. Olanrewaju and 2010. "Socio-demographic Factors and Appropriate Health Care-seeking Behavior for Childhood Illnesses." Journal of Tropical Pediatrics 56.6 (2010): 379 – 85. . Trading E,2018. "Bangladesh Living Wage Family." November 2018. https://tradingeconomics.com/bangladesh/living-wage- family. 06 April 2020. WHO,2018. "Cancer/Prevention/Diagonosis- screening/Breast Cancer." November 2018. April 2020. 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Background","content":" \u003cp\u003eCancer holds the second position among the non-communicable diseases under study of World Health organization (WHO)(Islam et al., 1970). The World Health Organization (WHO) estimates approximately 2.09\u0026nbsp;million new breast cancer cases each year, resulting in 627,000 deaths in 2018 that is approximately 15% of all cancer death among woman. (WHO,2018). Unsurprisingly, mortality rates are much higher in the developing world where women often only seek medical assistance and diagnosis in the late stages\u0026mdash;unaware of what is wrong and reluctant to shell out on medical costs. (The Hindu.com) In Bangladesh, poor access to medical facilities, stigmatization along with lack of knowledge about the disease mean that a mere 11 percent of Bangladeshi women receive diagnosis in the early stages. Like in much of the world, breast cancer is the most common cancer amongst Bangladesh's female population, with 32.8 percent of female cancer patients suffering from this strain of the disease. The nation\u0026rsquo;s public medical services\u0026mdash;overstretched and underfunded\u0026mdash;simply cannot provide the care required by breast cancer sufferers(The Daily Star) .\u003c/p\u003e \u003cp\u003eThough Bangladesh is the third quickest growth in the number of high net-worth individuals in the world in the next five years, as poor people\u0026rsquo;s residence Bangladesh is in 5th position. (The Prothom alo) 2 crore 41 lacs peoples are still in extreme poverty level. Wages in Bangladesh increased to 13258 BDT/Month in 2017 from 12897 BDT/Month in 2016. The current minimum wage of 5,300 taka (the equivalent of about 63 USD) has not been revised since 2013, and it is far below any credible living wage estimate (Clean Cloth Campaign,2018). Living Wage Family in Bangladesh remained unchanged at 15100 BDT/Month in 2018 from 15100 BDT/Month in 2017 (Trading Economics,2018)\u003c/p\u003e \u003cp\u003eConcerns about financial burden among breast cancer patients are particularly troubling due to the costly multidisciplinary approach currently required to treat breast cancer. This multidisciplinary approach, regardless of insurance status, results in increased out-of-pocket expenses such as deductibles, and co-pays for hospitalizations and physician visits (Obeng-Gyasi S).\u003c/p\u003e \u003cp\u003ePatients\u0026rsquo; reasons for late presentation were fear (40%), not aware of disease severity (40%), fear of losing a breast (40%), referral problems (34%), financial problems (8%), and transportation problems (6%). Approximately 33% sought medical help from traditional healers, and 65% regularly attended clinics. (Čačala \u0026amp; Gilart, 2017) Maximum cost for health care is met by Out-of-pocket expenditure. Out-of-pocket healthcare expenditures of households in Bangladesh comprise 64.3% share of the total health expenditure and collectively spent approximately Taka 103.46\u0026nbsp;billion (US\u003cspan\u003e$\u003c/span\u003e1.49\u0026nbsp;billion) in yearly on health. Hence, Out-of - pocket expenditure for health care services have been sufficiently costly in Bangladesh. However, identified factors that are associated with higher individual out-of pocket costs include advanced disease and associated medications, hormone therapy, insurance gap payments, and greater traveling distances to the hospital (L. et al., 2007).\u003c/p\u003e \u003cp\u003eIt is reported that magnitude of cancer is increasing in a rapid pace globally. The disease poses huge burden of mortality and morbidity. Magnitude of cancer has also increased among the countries of South East Asia region. There are 13 to 15 lakh cancer patients in Bangladesh, with about two lakh patients newly diagnosed with cancer each year. About 2 lakh new cases of cancer are diagnosed each year and 13 to 15 lakh people are living with different types of cancer. (Hossain). Breast Cancer is the 3rd leading cancer in Bangladesh with overall incidence rate of 106 per 100,000 populations in Bangladesh. (Globocan 2018 ) Rising burden of cancer in Bangladesh will pose serious implications for the management and financing of the health sector. For this, health strategies may have to be reformed and activities of the health sector may have to be drastically reorganized in order to meet the challenges of the increasing burden of cancer along with other non-communicable diseases. Cancer causes serious economic damage to the households since medical care required against the disease is usually very expensive. Cancer exerts huge economic pressure both on the household economy as well as public health sector. It is imperative to estimate the disability and economic burden of cancer patients as no comprehensive and rigorous study in this regard is available at present in the context of Bangladesh. The purpose of this study is to identify the exact financial situation of the respondents; the magnitude of cancer care affected by economic which will provide data essential for formulating policies and strategies to combat this burning public health problem by determining the socio-economic condition that affects breast cancer care of Bangladeshi breast cancer patients.\u003c/p\u003e "},{"header":"2. Methodology","content":" \u003ch2\u003e2.1 Methods:\u003c/h2\u003e \u003cp\u003eA cross sectional study was carried out to determine the socioeconomic status of breast cancer patients with present treatment history, pattern of financial assistance was explored, way of money collection for breast cancer treatment and compare the economic condition with care seeking time. Though total number of samples were calculated as 113 {p\u0026thinsp;=\u0026thinsp;8% (7), z\u0026thinsp;=\u0026thinsp;1.96, d\u0026thinsp;=\u0026thinsp;0.05} but 200 samples were selected randomly from the listed patients who attended in the day care centre for chemotherapy. Randomization by lottery method and was enrolled them according to their selection criteria, but some were excluded by exclusion. Patients with mental disability, recurrence of breast cancer, treatment failure, incomplete treatment, history of metastasis, hearing impairment and who did not comply with the informed written consent were excluded from the study. To avoid recall bias newly diagnosed primary carcinoma (breast cancer) patients were selected. The questionnaire included socio demographic questions of patients, question about current treatment status of the respondents, medical care seeking time for diagnosis and treatment, pattern of sources of collect money for breast cancer treatment, way of collect money for breast cancer treatment. Clinical information such as stage of disease, type of surgical management was obtained from a review of medical records. Questionnaire was prepared by reviewing literatures of qualitative study which was done in South East Asian Region (Caroline Burgess)(Bourdeanu L1) (Norsa'adah B1) (Karbani G1) and from various models (N\u0026iacute; Mh\u0026aacute;thuna) (Bish A). Perspectives of the study were explained to the respondents and informed consent was taken from each respondent. Face to face interview was taken from diagnosed breast cancer patients admitted in selected hospital by pretested semi structured questionnaire. Interview was taken to 40\u0026ndash;45 minutes in length. In total 200 patients completed the interview. The reason for non-completion included being too tired, having poor physical health, lack of interest. Generalization was assured as because patients from whole country came to this only public cancer hospital for treatment and diagnosis.\u003c/p\u003e \u003ch2\u003e2.2 Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses of the data were performed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 23.0 (SPSS Inc.; Chicago, IL, USA). Descriptive statistics like frequency distribution, mean, median, mode, range, standard deviation etc. were calculated by SPSS program. Association was seen between help seeking time and other variables by Pearson\u0026rsquo;s Chi-square (χ2) 2\u0026thinsp;\u0026times;\u0026thinsp;2 table at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level of significance. To compare the care seeking time and other factors two way ANOVA was done.\u003c/p\u003e \u003ch2\u003e2.3 Ethical Considerations:\u003c/h2\u003e \u003cp\u003eAccording to Helsinki Declaration, Ethical Clearance was taken from Institutional Review Board (IRB) of National Institution of Preventive and Social Medicine NIPSOM (NIPSOM/IRB/2016/18) and before taking interviews written permission was taken from the authority of National Institute of Cancer Research and Hospital, Dhaka Bangladesh (NICRH/Ethics/2016/204-5). Informed Written Consent was taken from each.\u003c/p\u003e "},{"header":"3. Results","content":" \u003ch2\u003e3.1 Description of study population:\u003c/h2\u003e \u003cp\u003eSocio economic status of the breast cancer patients was summarized in the Table\u0026nbsp;1. Results showed that n\u0026thinsp;=\u0026thinsp;90 (45%) were illiterate, n\u0026thinsp;=\u0026thinsp;69 (34.5%) were in primary education (1\u0026ndash;8 class), secondary (SSC) and above 41(20.5%). More than two third, n\u0026thinsp;=\u0026thinsp;166(83%) of the respondents were house wife and rest of them n\u0026thinsp;=\u0026thinsp;34(17%) were engaged in service. Majority of the respondents n\u0026thinsp;=\u0026thinsp;166 (83%) had no monthly self income. In case of monthly family income n\u0026thinsp;=\u0026thinsp;78(39%) respondents were in 1000-5000-taka income group, n\u0026thinsp;=\u0026thinsp;85(42.5%) respondents had family income between 6000\u0026ndash;10000 taka. 11000\u0026ndash;15000 and above 37(18.5%). n\u0026thinsp;=\u0026thinsp;156(78%) respondents were married followed by widow and separated 44(22%). results showed that n\u0026thinsp;=\u0026thinsp;27(13.5%) were in 26\u0026ndash;30\u0026nbsp;years age group, n\u0026thinsp;=\u0026thinsp;29(14.5%) were in (31\u0026ndash;35) years age group. Maximum respondents n\u0026thinsp;=\u0026thinsp;43(21.5%) belongs to 36\u0026ndash;40\u0026nbsp;years age group, n\u0026thinsp;=\u0026thinsp;34(17% ) were in 41\u0026ndash;45 age group, n\u0026thinsp;=\u0026thinsp;34(17% ) were in 41\u0026ndash;45\u0026nbsp;years age group, n\u0026thinsp;=\u0026thinsp;35(17.5%) were in 46\u0026ndash;50\u0026nbsp;years age group and rest of the respondents n\u0026thinsp;=\u0026thinsp;32(16%) were more than 50\u0026nbsp;years age group, mean age was 42\u0026nbsp;years. Distributions of the stage of breast cancer patients were summarized. Results showed that no patients were found in stage I, in stage II only n\u0026thinsp;=\u0026thinsp;34 (17%) respondents were suffered. Majority of patients were in advanced stage. n\u0026thinsp;=\u0026thinsp;133(66.5%) were in stage III and n\u0026thinsp;=\u0026thinsp;33(16.5%) respondents were categorized as stage IV. Maximum 100(50%) financial assisted by social welfare of cancer hospital, husbands 87(43.6%), relatives 54(27%), sons 44(22%), neighbors 20(10%) and only 7 (3.5%) by their daughters. According to types of monetary management maximum 117(58.5%) breast cancer patients solved their expenditure from donation. In total 76(38%) managed money by borrowing, 60 (30%) expend from self income, 57(28.5%) sold land or properly and only 7(3.5%) managed money from saving. In total 98(49%) patients use double sources and 18(9%) patients used triple source for monetary management and single source was required for 84(42%).\u003c/p\u003e \u003ch2\u003e3.2 Between group comparisons:\u003c/h2\u003e \u003cp\u003eAssociation of delay with socio economic status of the respondents was analyzed using Pearson\u0026rsquo;s Chi-square (χ\u003csup\u003e2\u003c/sup\u003e) method and summarized in Table\u0026nbsp;2. Results showed that delay was found to be significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) associated with family income of the respondents. Delay\u0026thinsp;\u0026gt;\u0026thinsp;6 months is more there who had (2000\u0026ndash;10000) take monthly family income (68.7%, n\u0026thinsp;=\u0026thinsp;112). No significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) was found with other socio demographic variable. Association between economic conditions with delay of the respondents was analyzed using Pearson\u0026rsquo;s Chi-square (χ\u003csup\u003e2\u003c/sup\u003e) method and summarized in Table\u0026nbsp;2. Results showed that economic condition was found to be significant by (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) associated with the Care seeking to the initial medical consultation and definitive treatment of the cancer (provider delay) 6.775 (p\u0026thinsp;=\u0026thinsp;0.009), Woman first noticing a breast cancer symptom and receiving treatment (total delay) 8.740 (p\u0026thinsp;=\u0026thinsp;0.003), economic condition was associated with family income (p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;3 cross relation was seen between family income and staging of cancer. No one come to seek treatment in stage I, one thirty-three (133) breast cancer patients came to seek treatment at stage III. Fifty-seven patients\u0026rsquo; family income were 1000-5000-taka, fifty-four patients family income were 6000 -10,000 taka, and rest 22 patient\u0026rsquo;s family income were 11000 taka and above.\u003c/p\u003e "},{"header":"4. Discussion And Conclusion","content":" \u003cp\u003eCancer causes serious economic damage to the households since medical care required against the disease is usually very expensive. Cancer exerts huge economic pressure both on the household economy as well as public health sector (1). An expense on cancer is as like double edge sword. In Bangladesh, even after the high net worth individual will grow quickly people in this area are still regresses to seek medical care especially in cancer due to financial problem. In a study it was found that the majority of patients received assistance with costs associated with radiation therapy and approximately 70% of subjects needed financial assistance with two or more services (Obeng-Gyasi S1). Majority n\u0026thinsp;=\u0026thinsp;100(50%) of respondents sought financial assistance from social welfare department of cancer hospital. Then husband, son, neighbors, relatives also assisted financially. Maximum respondents 117(58.5%) received money as donation. Others were managed money by borrowed, selling properties or land and saving as well. Maximum 49% (n\u0026thinsp;=\u0026thinsp;98) respondents needed financial assistance from double source, 42% (n\u0026thinsp;=\u0026thinsp;84) solved from single source; only 9% (n\u0026thinsp;=\u0026thinsp;18) patients collect money from triple sources.\u003c/p\u003e \u003cp\u003eResults of 172 patients, 50 of each had T2, T3, or T4 stages, and 22 had T1 (7). Majority of patients were in advanced stage. n\u0026thinsp;=\u0026thinsp;133(66.5%) were in stage III and n\u0026thinsp;=\u0026thinsp;33(16.5%) respondents were categorized as stage IV. Majority of patients n\u0026thinsp;=\u0026thinsp;149 (74.5%) initially presented with a lump in breast while in a study it was found that the main presenting complaint for women with tumors was a lump (96%) and 24% presented with breast pain (7).\u003c/p\u003e \u003cp\u003eA patient named Basanti Majumder clutching her baby and speaks of a pain in her left breast and fears her cancer may have returned. She stares briefly at the floor and giggles nervously. \u0026ldquo;I\u0026rsquo;m not going to the doctor now for financial reasons (2)\u0026rdquo;. In a study, it was found that delay of care seeking due to financial problem only 8% (7). But in this study, out of 200 sample 157(78.5%) respondents stated that due to economic problem medical care seeking was hampered and delayed. In many countries\u0026rsquo; health insurance is a way to pay bills. But in Bangladesh most of them had no health insurance facilities along with high out pocket expenditure (Kabir and 2015). Still health system financing is regressive.\u003c/p\u003e \u003cp\u003eHigh family socioeconomic status independently predicted early care seeking (AOR\u0026thinsp;=\u0026thinsp;2.23, p\u0026thinsp;=\u0026thinsp;0.013) and in logistic regression it is β\u0026thinsp;=\u0026thinsp;1.148, odds ratio.11, p\u0026thinsp;=\u0026thinsp;0.032\u0026nbsp;at 95% CI where lower value0.01 and upper value 0.83 (Tinuade A. Ogunlesi and 2010).\u003c/p\u003e \u003cp\u003eStill the treatment of non communicable disease as well as cancer is an out-pocket expenditure. When the patients diagnosed as cancer finance is a problem to start treatment. Public health insurance is not established yet in Bangladesh. For poor patient\u0026rsquo;s social welfare department play a role in cancer hospital but it was not sufficient. Cancer patients collect money from two or three sources. Financial constrain should be overcome to start early diagnosis and treatment which will beneficial for survival time. To combat this rising burden, implementation of management and finance in health sector should be emphasized. Health strategy for communicable disease should be reformed and drastically reorganized in order to meet the challenges of the increasing burden of cancer along with other non-communicable diseases. Because this was a cross-sectional study, inference could not be done clearly. There was a chance of recall bias. A large sample size and in-depth interview could provide more reliable information. Despite of hospital-based study due to one specialized cancer hospital in Bangladesh whole cancer patients ultimately came to this hospital. That\u0026rsquo;s why the study represents the whole country.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e4.1 Acknowledgements:\u003c/h2\u003e\n\u003cp\u003eI deeply acknowledge and express my gratitude to Director and Doctors of Surgical and Medical Oncology Department of National Institute of Cancer Research and Hospital, Mohakhali, Dhaka, Bangladesh for their kind approval and cooperation to carry out my study. I am also grateful to the physicians of Epidemiology department of NIPSOM, Dhaka for helping about analyzing the data and expressing statistical part.\u003c/p\u003e\n\u003ch2\u003e4.2 \u003cstrong\u003eConflict of Interest:\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e4.2 Financial Disclosure:\u003c/h2\u003e\n\u003cp\u003eThe author declared that this study has received no financial support.\u003c/p\u003e\n\u003ch2\u003e4.4: \u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e:\u003c/h2\u003e\n\u003cp\u003eWe consider our data private but the corresponding author will make it available upon reasonable request.\u003c/p\u003e\n\u003ch2\u003e4.5: \u003cstrong\u003eEthical Declarations:\u003c/strong\u003e\u003c/h2\u003e\n\u003ch2\u003e4.5.1 : \u003cstrong\u003eEthics approval and Consent to participate\u003c/strong\u003e:\u003c/h2\u003e\n\u003cp\u003eEthical Clearance was taken from Institutional Review Board (IRB) of National Institution of Preventive and Social Medicine NIPSOM (NIPSOM/IRB/2016/18) and before taking interviews written permission was taken from the authority of National Institute of Cancer Research and Hospital, Dhaka Bangladesh (NICRH/Ethics/2016/204-5). Informed Written Consent was taken from each.\u003c/p\u003e\n\u003ch2\u003e4.5.2: Consent for Publications:\u003c/h2\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003ch2\u003e4.5.3: Competing Interests:\u003c/h2\u003e\n\u003cp\u003eThe Authors declare that they have no competing Interests.\u003c/p\u003e\n\u003ch2\u003e4.6: Authors Contributions:\u003c/h2\u003e\n\u003cp\u003eAll authors has read and consented to the final draft of the manuscript. Dr. Khursheda Akhtar was involved in the Concept of study, Design study ,\u0026nbsp; methods and materials, Data Collection \u0026nbsp;and Processing, Analysis and Interpretation, Literature Search,\u0026nbsp; Writing Manuscript,\u0026nbsp; Critical Review.\u0026nbsp;\u0026nbsp; Professor Dr. Jahangir Hossain, Dr. Khodeza Akhtar , Dr. Shamsun Nahar was involved in Concept, Supervision, Materials , Data Collection and Processing, Analysis and Interpretation , Literature Search, Writing Manuscript, Others Authors were involved in Design methods and materials , Data Collection and Processing, Literature Search , Idea sharing and help in report writing. Overall Dr. Khursheda was leading the research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e \u003cli\u003e \u003cspan\u003eBish A, Ramirez A, Burgess C, Hunter M, 2005. \"Understanding why women delay in seeking help for breast cancer symptoms.\" \u003cem\u003eJournal of Psychosomatic Research\u003c/em\u003e 58.4 (2005): 321 \u0026ndash; 26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u0026lt;https://europepmc.org/article/med/15992567\u0026gt;\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eBourdeanu L1, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G.,2013. \"Barriers to treatment in patients with locally advanced breast cancer.\" \u003cem\u003eJ Natl Compr Canc Netw.\u003c/em\u003e 11.10 (2013): 1193\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u0026lt;https://www.ncbi.nlm.nih.gov/pubmed/24142820\u0026gt;\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eCaroline Burgess, Myra S Hunter,Amanda J Ramirez,2001. \"A qualitative study of delay among women reporting symptoms of breast cancer.\" \u003cem\u003eThe British Journal of General Practice\u003c/em\u003e 51.473 (2001): 967\u0026ndash;971. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u0026lt;https://www.ncbi.nlm.nih.gov/pubmed/11766868\u0026gt;\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eClean Cloth C,2018. \"Full support for Bangladeshi garment workers\u0026rsquo; demands on minimum wage.\" 06 July 2018. \u003cem\u003ehttps\u003c/em\u003e:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e//cleanclothes.org/news/2018/07/06/full-support-for-bangladeshi-garment-workers2019-demands-on-minimum-\u003c/span\u003e\u003c/span\u003e\u003cem\u003ewage.\u003c/em\u003e 06 July 2018.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eGlobocan 2018. \"50-Bangladesh Fact Sheet.\" GCA. 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November 2017. 27 November 2017.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eThe Prothom alo. \"economy/article/1575323/\u0026agrave;\u0026brvbar;࿽\u0026agrave;\u0026brvbar;\u0026deg;\u0026agrave;\u0026brvbar;\u0026iquest;\u0026agrave;\u0026brvbar;\u0026not;-\u0026agrave;\u0026brvbar;\u0026reg;\u0026agrave;\u0026brvbar;\u0026frac34;\u0026agrave;\u0026brvbar;\u0026uml;\u0026agrave;\u0026sect;࿽\u0026agrave;\u0026brvbar;\u0026middot;\u0026agrave;\u0026sect;࿽\u0026agrave;\u0026brvbar;\u0026deg;-\u0026agrave;\u0026brvbar;\u0026not;\u0026agrave;\u0026brvbar;\u0026cedil;\u0026agrave;\u0026brvbar;\u0026not;\u0026agrave;\u0026brvbar;\u0026frac34;\u0026agrave;\u0026brvbar;\u0026cedil;\u0026agrave;\u0026sect;࿽-\u0026agrave;\u0026brvbar;\u0026not;\u0026agrave;\u0026brvbar;\u0026iquest;\u0026agrave;\u0026brvbar;\u0026para;\u0026agrave;\u0026sect;࿽\u0026agrave;\u0026brvbar;\u0026not;\u0026agrave;\u0026sect;࿽-\u0026agrave;\u0026brvbar;\u0026ordf;\u0026agrave;\u0026brvbar;࿽\u0026agrave;\u0026sect;࿽\u0026agrave;\u0026brvbar;࿽\u0026agrave;\u0026brvbar;\u0026reg;-\u0026agrave;\u0026brvbar;\u0026not;\u0026agrave;\u0026brvbar;\u0026frac34;\u0026agrave;\u0026brvbar;࿽\u0026agrave;\u0026brvbar;\u0026sup2;\u0026agrave;\u0026brvbar;\u0026frac34;\u0026agrave;\u0026brvbar;\u0026brvbar;\u0026agrave;\u0026sect;࿽\u0026agrave;\u0026brvbar;\u0026para;.\" 20 January 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.prothomalo.com/economy/article/1575323\u003c/span\u003e\u003c/span\u003e. 20 Jnuary 2019.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eTinuade A. Ogunlesi, Durotoye M. Olanrewaju and 2010. \"Socio-demographic Factors and Appropriate Health Care-seeking Behavior for Childhood Illnesses.\" \u003cem\u003eJournal of Tropical Pediatrics\u003c/em\u003e 56.6 (2010): 379 \u0026ndash; 85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u0026lt;https://academic.oup.com/tropej/article/56/6/379/1664451\u0026gt;\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eTrading E,2018. \"Bangladesh Living Wage Family.\" November 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://tradingeconomics.com/bangladesh/living-wage-\u003c/span\u003e\u003c/span\u003e\u003cem\u003efamily.\u003c/em\u003e 06 April 2020.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eWHO,2018. \"Cancer/Prevention/Diagonosis- screening/Breast Cancer.\" November 2018. April 2020.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"socio economic condition, breast cancer, care seeking behavior","lastPublishedDoi":"10.21203/rs.3.rs-32402/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-32402/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSocio- economic condition plays a role on taking decision for cancer treatment beside this out pocket expenditure is a headache for cancer patients. For that, pattern of financial assistance for breast cancer treatment and associated factors were explored.\u003c/p\u003e\u003ch2\u003eMethod:\u003c/h2\u003e \u003cp\u003eA cross sectional study was carried out with 200 samples; those were selected randomly from the listed patients who attended in the day care centre of chemotherapy.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMaximum respondents first visited to health care provider at II and III stage with first symptom as lump on breast or axilla, no patients came at stage I. Along with family and neighbor, social welfare also play a positive role to assist finance. Donation was the major means to collect money and two or three sources were needed at a time for collecting money. In chi square (χ \u003csup\u003e2\u003c/sup\u003e) test, economic condition had a significant role on care seeking. Simultaneously by ANOVA it was found that mean difference was more at age 31\u0026ndash;40\u0026nbsp;year of age. After 50 years, care seeking time was intersect, here Main effect of age was F (1, 192)\u0026thinsp;=\u0026thinsp;1.92, p\u0026thinsp;=\u0026thinsp;0.162; Main effect of economic condition was F (3, 192)\u0026thinsp;=\u0026thinsp;0.27, p\u0026thinsp;=\u0026thinsp;0.847; Inter effect was F (2, 192)\u0026thinsp;=\u0026thinsp;1.77, p\u0026thinsp;=\u0026thinsp;0.154.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAfter knowing cancer, she and her family member become puzzled to collect money. For that necessary measure should be taken to easy availability of expenditure cost. It is recommended to launch public health insurance as soon as possible.\u003c/p\u003e","manuscriptTitle":"Economic Condition Affects Breast Cancer Care - A Cross Sectional Study in Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-06-04 16:37:25","doi":"10.21203/rs.3.rs-32402/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-07-06T12:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"editorInvitedReview","content":"","date":"2020-06-26T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2020-06-15T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-06-14T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-06-14T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-06-01T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-05-31T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-05-31T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-05-27T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6c266daa-2b33-4a62-b164-1797e273e0ca","owner":[],"postedDate":"June 4th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":113470,"name":"Health Economics \u0026 Outcomes Research"},{"id":113471,"name":"Infectious Diseases"},{"id":113472,"name":"Health Policy"}],"tags":[],"updatedAt":"2020-06-04T16:37:25+00:00","versionOfRecord":[],"versionCreatedAt":"2020-06-04 16:37:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-32402","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-32402","identity":"rs-32402","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}