1.82 <0.001 Adj. HR* 95 CI P valueOther catastrophic illnesses or injuries(Continued)PLOS ONE | DOI:10.1371/journal.pone.0131305 June 26,9 /Delayed or Refusal Therapy in Breast Cancer PatientsTable 3. (Continued) Variables Total N Stage III Stage IV 3502 2182 9.98 6.22 N 49 126 Delay or untreated Alive 1.40 5.77 N 70 438 Death 2.00 20.07 N 2222 497 Alive 63.45 22.78 N 1161 1121 Treated Death 33.15 51.37 qhw.v5i4.5120 1.83 1.51 1.43 1.35 2.34 1.69 <0.001 <0.001 Adj. HR* 95 CI P valueNote: * Treated patients as the references group doi:10.1371/journal.pone.0131305.tdefinite diagnosis with cancer staging. Therefore, some patients who delayed or refused therapy did not have cancer staging confirmed [43]. Delay therapy can be divided fpsyg.2014.00726 into three phases: primary delay (patient delay: from the onset of symptoms to visit the doctor), Olumacostat glasaretil site secondary delay (from the first visit to the confirmed diagnosis), and tertiary delay (from the diagnosis to start therapy) [36]. Among them, the clinician delay Isovaleryl-Val-Val-Sta-Ala-Sta-OH web belongs to secondary delay and tertiary delay. Delay in any phase or no treatment would cause cancer progression to advanced stages, and significantly affects the treatment outcome [44, 45]. Phases and characteristics of delay or refusal of therapy are different among different cancers and stages. For breast cancer, the major type of delay or no treatment was tertiary delay, and followed by primary delay[45]. Furthermore, phases of therapy delay also depend on region and country (cancer care system), patient characteristics, age as well as cancer staging. Study by Wagner et al. has shown that breast cancer patients delayed surgeries after diagnosis in relation to types of surgeries. There were more delay of surgeries for patients with total mastectomy than those with breast-conserving surgery and reconstructive surgery [33]. Moreover, Jassem et al. showed that the total delay time was about 14.4 (range: 11.5?9.4) weeks in breast cancer patients from 12 different countries surveyed; the duration of primary delay (patient delay) was 4.7 (range: 3.4?.2) weeks. Longer patient delay happened for patients who distrusted and disregarded medicine. The patients who took routine self-examination, were fear, had higher education, were employed and lived in high urbanization area had shorter delay in therapy [11].The current study focused on the tertiary delay that was at least 120 days between diagnosis and start of therapy. It was also found that patients with employment had lower ratio to delay or refuse therapy. However, our data did not show differences in proportion of delay or refusal of therapy between urbanization levels of residential areas. The study conducted by Tsai et al. collected 109 valid semi-structured questionnaire to investigate the reasons of untreated or interrupted treatment within 4 months among oral, colon, breast and cervical cancer patients [30]. The major factors of refusing treatment in breast cancer patients including the fear of surgery, poor response to therapy and poor life quality following therapy accounted for 33.33 ; fear of adverse effects of chemotherapy or radiotherapy, economic burden of household or busy job, and feeling guilty accounted for 22.22 ; fear of outlook change following therapy, increased family burden, and fear of others’ knowing of disease accounted for 11.11 [30]. In clinical observation, physical suffering was the most primary care in advanced cancer patients, and almost needed to use the sedation to relieve pat.1.82 <0.001 Adj. HR* 95 CI P valueOther catastrophic illnesses or injuries(Continued)PLOS ONE | DOI:10.1371/journal.pone.0131305 June 26,9 /Delayed or Refusal Therapy in Breast Cancer PatientsTable 3. (Continued) Variables Total N Stage III Stage IV 3502 2182 9.98 6.22 N 49 126 Delay or untreated Alive 1.40 5.77 N 70 438 Death 2.00 20.07 N 2222 497 Alive 63.45 22.78 N 1161 1121 Treated Death 33.15 51.37 qhw.v5i4.5120 1.83 1.51 1.43 1.35 2.34 1.69 <0.001 <0.001 Adj. HR* 95 CI P valueNote: * Treated patients as the references group doi:10.1371/journal.pone.0131305.tdefinite diagnosis with cancer staging. Therefore, some patients who delayed or refused therapy did not have cancer staging confirmed [43]. Delay therapy can be divided fpsyg.2014.00726 into three phases: primary delay (patient delay: from the onset of symptoms to visit the doctor), secondary delay (from the first visit to the confirmed diagnosis), and tertiary delay (from the diagnosis to start therapy) [36]. Among them, the clinician delay belongs to secondary delay and tertiary delay. Delay in any phase or no treatment would cause cancer progression to advanced stages, and significantly affects the treatment outcome [44, 45]. Phases and characteristics of delay or refusal of therapy are different among different cancers and stages. For breast cancer, the major type of delay or no treatment was tertiary delay, and followed by primary delay[45]. Furthermore, phases of therapy delay also depend on region and country (cancer care system), patient characteristics, age as well as cancer staging. Study by Wagner et al. has shown that breast cancer patients delayed surgeries after diagnosis in relation to types of surgeries. There were more delay of surgeries for patients with total mastectomy than those with breast-conserving surgery and reconstructive surgery [33]. Moreover, Jassem et al. showed that the total delay time was about 14.4 (range: 11.5?9.4) weeks in breast cancer patients from 12 different countries surveyed; the duration of primary delay (patient delay) was 4.7 (range: 3.4?.2) weeks. Longer patient delay happened for patients who distrusted and disregarded medicine. The patients who took routine self-examination, were fear, had higher education, were employed and lived in high urbanization area had shorter delay in therapy [11].The current study focused on the tertiary delay that was at least 120 days between diagnosis and start of therapy. It was also found that patients with employment had lower ratio to delay or refuse therapy. However, our data did not show differences in proportion of delay or refusal of therapy between urbanization levels of residential areas. The study conducted by Tsai et al. collected 109 valid semi-structured questionnaire to investigate the reasons of untreated or interrupted treatment within 4 months among oral, colon, breast and cervical cancer patients [30]. The major factors of refusing treatment in breast cancer patients including the fear of surgery, poor response to therapy and poor life quality following therapy accounted for 33.33 ; fear of adverse effects of chemotherapy or radiotherapy, economic burden of household or busy job, and feeling guilty accounted for 22.22 ; fear of outlook change following therapy, increased family burden, and fear of others’ knowing of disease accounted for 11.11 [30]. In clinical observation, physical suffering was the most primary care in advanced cancer patients, and almost needed to use the sedation to relieve pat.