title: A grounded explanation of why women present with advanced breast cancer.
abstract: BACKGROUND
  Advanced breast cancer presentation remains a large obstacle in lowering mortality rates in low- and middle-resource countries. This study aims to explore the reasons why women present with breast cancer at an advanced stage.
  
  
  METHODS
  Purposive sampling of 19 breast cancer patients presenting with advanced cancer that were diagnosed within 2 years at the University Malaya Medical Centre, Kuala Lumpur, Malaysia. In-depth interviews were conducted, and audio-recordings were transcribed. Sample size was determined by theoretic sufficiency, and the constructivist grounded theory method was used.
  
  
  RESULTS
  The reasons for delayed presentation can be displayed in two models. The total breast cancer delay (TBCD) model was derived from the journey of the patients. Four concepts emerged: (1) pluralistic health systems; (2) points of delay; (3) presence of patient or system delays, and (4) patient decision-making at each stage. Eight points of delay were found. At each point, evidence of a patient decision-making model emerged: the breast cancer delay explanatory (BCDE) model, which was the process of assessing severity and knowing and choosing options. The four main operational constructs were (1) knowledge on disease and disease outcomes, (2) knowledge of treatment and treatment outcomes, (3) psychological and physical resources and support; and (4) roles in decision-making.
  
  
  CONCLUSIONS
  The phenomenon is explained by the TBCD and BCDE models. Deconstructing why women present with advanced breast cancer and resist treatment provides clarity of the issues and opportunities for intervention.
authors.affiliation: Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, naisha@um.edu.my.
authors.forename: Nur Aishah
authors.initials: NA
authors.lastname: Taib
authors.forename: Cheng Har
authors.initials: CH
authors.lastname: Yip
authors.forename: Wah Yun
authors.initials: WY
authors.lastname: Low
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000473:pathology* / Q000523:psychology / Q000628:therapy; D003657:Decision Making; D057210:Delayed Diagnosis / Q000523:psychology*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008296:Malaysia; D008875:Middle Aged; D008962:Models, Theoretical; D010342:Patient Acceptance of Health Care; D036301:Qualitative Research; D012017:Referral and Consultation; D016896:Treatment Outcome; D055815:Young Adult