!Volume 3, No. 3, January 2022

p- ISSN 2777-0915 | e-ISSN 2797-6068

!

175 http://devotion.greenvest.co.id

THE$ANALYSIS$OF$FACTORS$AFFECTING$STAGE$LEVEL$OF$

BREAST$CANCER$PATIENTS$AT$RSUD$DR.$SOETOMO$

SURABAYA$

Destri Susilaningrum

1

, Nur Azizah

2

, Mutiah S

3

and Mukti Ratna D

4

Sepuluh Nopember Institute of Technology, Indonesia

1,2,3 and 4

Email: [email protected]

1

, [email protected]

2

,

[email protected]om

3

and [email protected]

4

Introduction*

Cancer is one of the main causes of morbidity and mortality in the world.

According to the World Health Organization (WHO) in 2020 (Bray, Laversanne,

Weiderpass, & Soerjomataram, 2021), breast cancer is the first cancer with the highest

number in the world (Cao, Chen, Yu, Li, & Chen, 2021). Followed by lung cancer, colon

cancer, prostate cancer, and stomach cancer (Cho, Park, & Kim, 2021). A survey

conducted by WHO states that 45% of breast cancer incidences are in Asia (Sohn, Chang,

& Miles, 2021).

Breast cancer also known as Carcinoma Mammae (Ca Mammae) is a malignant

tumor that grows in breast tissue (Hwang, Peregrina, Maglalang, & Yoo, 2021). This

cancer grows because of the abnormal growth of breast cells (Shaikh, Krishnan, &

Thanki, 2021a). The cause of breast cancer is not known with certainty. So far it has been

associated with female reproductive hormones (Bonfiglio & Di Pietro, 2021). This

hormone is estrogen which plays a role in the growth and development of female

reproductive organs, including breasts (Kumar et al., 2021). Breast cancer can spread or

move to surrounding tissues, spread to lymph nodes (Shaikh, Krishnan, & Thanki,

2021b), enter blood vessels to other organs such as bones, lungs, liver, even the brain and

cause malfunction of these organs which can lead to death (Mortezaee, 2021). The stage

Keywords

!!

Binary Logistic

Regression, Breast

Cancer, Stage

Article*Info*

Accepted:

December, 23

th

2021

Revised:

January, 4

th

2022

Approved:

January, 14

th

2022

Abstract!

Breast cancer is the cancer with the largest number in the world,

and ranks as the fifth largest cause of death, which is 6.9% of

the total 9,958,133 million cases of cancer deaths. Breast cancer

is one of the main killers of women in the world and in

Indonesia. Breast and cervical cancer dominate cancer cases in

East Java. Throughout 2019, RSUD Dr. Soetomo Surabaya

received 167,000 cancer patients, and the highest case was

breast cancer. Binary logistic regression is a method of analysis

that used to find out the relationship between the response

variables (Binary or dichotomous) with the predictor variables

that are polychotomous. The high number of breast cancer

sufferers makes this disease requires special attention. The

cancer staging or staging system is based on whether the cancer

has spread from the breast to other parts of the body. Cancer

stage is divided into two categories, namely early stage (stages 0

to III A) and late stage (stages III B to IV). This study will

examine the factors that affect the level of cancer stage in breast

cancer patients at RSUD Dr. Soetomo Surabaya in 2019. Using

the binary logistic regression analysis method, it was found that

the factors that significantly influence the stage of breast cancer

are Grade and Obesity with a classification correctness level of

82.5%.

Destri Susilaningrum

1

, Nur Azizah

2

, Mutiah S

3

and Mukti Ratna D

4

The Analysis of Factors Affecting Stage Level of Breast Cancer Patients at RSUD

dr. Soetomo Surabaya 176

of breast cancer must be confirmed before the diagnosis is completed and treatment is

selected (Metzger Filho et al., 2021). This process can determine whether the cancer has

spread from the breast to other parts of the body. Cancer stages can be categorized into

two, namely the Early stage which includes stages 0 to III A and the Last stage which

consists of stages III B to IV.

RSUD Dr. Soetomo is a General hospital owned by the government of East Java

Province, which is the largest hospital in East Java as well as a referral hospital for East

Java and Eastern Indonesia. There is a poly that handles cancer, namely Poly Oncology

where cancer treatment is carried out in an integrated manner and focused on organs, one

of which is breast cancer. In 2019 , Dr Soetomo Hospital was recorded 167,000 cancer

patients, and the highest case was breast cancer. Cancer is also a high cause of death in Dr

Soetomo Hospital Surabaya, from the 10 cancer cases hospitalized the highest are breast

cancer patients, followed by cervical cancer and blood cancer.

This study aims to determine the factors that are thought to affect the level of

breast cancer stage in breast cancer patients at Dr. Soetomo Hospital Surabaya in 2019.

The analysis used was binary logistic regression. The benefit of this research is that

knowing these causative factors, the patient can control these factors so that the

development of staging can be controlled.

Research*Method****

Binary Logistic Regression

Binary logistic regression is a method of analysis that used to find out the

relationship between the response variables (Binary or dichotomous) with the predictor

variables that are polychotomous .The response variable (y) consists of two categories:

"success" (y =1) and "failure" (y = 0). The model logistic regression given as

(1)

The Equation 2.1 can be explained as a logit model: by logit transformation of π(x

i

) as:

(2)

The test is conducted to get the best model which was built by the significant parameters.

Parameters were first tested simultaneously and then tested partially to get the significant

parameters.

Simultaneously Test of Parameters

Hypothesis:

Test Statistic:

)exp(1

)exp(

)(

110

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i

xxx

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p

++++++

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=

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x

÷

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=+++++=

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0

110

)(

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!!x

01 2

1

:0

: at least one of 0 ; j = 1, 2, ..., p

p

j

H

bb b

b

====

¹

!

Volume 3, No. 3, January 2022, pp. 175-183

177 http://devotion.greenvest.co.id

(3)

With ; ;

Reject H

0

if G > χ

2

(α; df)

Partial Test of Parameters

Hypothesis:

Test Statistic:

(4)

Reject H

0

if

Goodness of Fit Model

The test for overall fit of a Binary logistic regression model with the hypothesis:

H

0

: Model Fit

H

1

: Model Not Fit

Test Statistic:

(5)

y

ij

: the Binary outcome for observation j in group i of the partition; i = 1, . . ., g; j = 1, . .

., n

i

: the corresponding fitted probability for the model fitted to the ungrouped data.

Reject H

0

if or P-value < α or P-value < α

Classification Procedure

This procedure was used to evaluate the result of prediction value given by the best

model to compare with the observation value, give an evaluation on classification

procedure to see the probability of miss classification. It is measured by apparent error

rate (APER). APER value stated the proportion value of miss classification sample by the

function of classification. If the subject only classified as two groups, y

1

and y

2

, then

determination of classification errors can be known through the classification table

described in Table 1.

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Destri Susilaningrum

1

, Nur Azizah

2

, Mutiah S

3

and Mukti Ratna D

4

!

The Analysis of Factors Affecting Stage Level of Breast Cancer Patients at RSUD

dr. Soetomo Surabaya 178

Table 1. Classification Table.

Observation

Prediction

y

1

y

2

y

1

n

11

n

12

y

2

n

21

n

22

Description :

n

11

: The number of the subject of y1 on the correct classified as y

1

n

12

: The number of the subject of y1 on the miss classified as y

2

n

21

: The number of the subject of y2 on the miss classified as y1

n

22

: The number of the subject of y2 on the correct classified as y

2

(6)

And the proportion of the correct classification = 1-APER (%) =

Source of Data and Research Variables

This research used secondary data from the medical records of patients suffering

breast cancer at RSUD Dr. Soetomo Surabaya in 2019 as many as 217 patients. The

variables used consist of two kind variables: Respond variable, and Predictor variable.

Respond Variable

Respond Variable (Y) in this research is the level stage as given in Table 2.

Table 2. Respond Variable.

Variable

Level stage statue

Y

Y = 1 = Early stage or

Y = 0 = Last stage

Predictors Variable (X)

Predictor variable (X) gives in Table 3.

Table 3. Research Variable.

Indicator

Variable

Categorical

Data Scale

X1

Grade

1= Grade 3

2= Grade 2

3= Grade 1

Ordinal

X2

Age

-

Ratio

X3

Obesity History

1= Obesity

2= No obesity

Nominal

X4

Comfort Level

1= Pain

2= No Pain

Nominal

X5

Patient’s Psyche

1= Anxiety / Depression

2= Surrender

Nominal

X6

History of Anemia

1= Yes

2= No

Nominal

X7

Treatment

1= Operation (MRM, BCS)

2= Chemotherapy

Nominal

X8

Family History of Breast Cancer

1= Yes

2= No

Nominal

X9

Metastasis

1= Yes

2= No

Nominal

%100

nnnn

nn

(%)

22211211

2112

´

+++

+

=APER

11 22

11 12 21 22

100%

nn

nnnn

æö

+

ç÷

+++

èø

Volume 3, No. 3, January 2022, pp. 175-183

179 http://devotion.greenvest.co.id

The operational definition of each variable is as follows.

A. Grade Breast cancer

The WHO using criteria, namely the Nottingham Grading system (also called Elston-

Ellis modification of the Scarff-Bloom Richardson grading system). This rating scale

looks at 3 different cell images and is classified each score from 1-3. The classifications

are:

Table 4. Breast Cancer Grade

Grade

Score

Information

Grade

I

Score 3-5

Low grade with well differentiated cancer (well

differentiated) where the cancer cells do not grow quickly

and do not appear to spread.

Grade

II

Score 6-7

Cancer with moderate differentiation

(moderately/intermediate differentiated) which has a

picture between grades 1 and 3.

Grade

III

Score 8-9

Cancer that is poorly differentiated (poorly differentiated

or undifferentiated) in which cancer cells grow rapidly

and are more likely to spread.

Another benefit of determining the grading is to determine the response to therapy

that will be given (Crotty et al., 2021). At a poor degree of differentiation, where cell

growth and spread is considered to be more rapid or aggressive (Redmond, McCarthy,

Buchanan, Levingstone, & Dunne, 2021), additional therapy is needed besides definitive,

namely by administering chemoradiation. The relationship between stage and grade of

breast cancer is that the stage in breast cancer serves to describe the condition of the

cancer, namely the location and spread of cancer cells and how far it affects other body

organs.

B. Comfort Level

Pain is a common complaint after treatment of breast cancer patients, even years

after treatment (De Baets et al., 2021). Cancer pain is often found in patients who first

come for treatment (Drewes, Kuhlman, Andresen, & Olesen, 2021).

C. Patient’s Psyche

Reactions in some people with cancer vary widely, such as shock, fear, anxiety,

feelings of grief, anger, sadness, and even withdrawal. Anxiety is a mental condition

filled with worry and fear of what might happen, both related to limited problems and

strange things.

D. Anemia

Anemia in cancer patients can cause fatigue and decreased quality of life and

increased mortality. In general, the presence of anemia in cancer patients can increase

mortality by up to 65%. Patients are said to be anemic if they have hemoglobin < 12

g/dL.

E. Family History of Breast Cancer

Family history of inherited breast cancer is a risk factor for breast cancer. Family

history of breast cancer will increase the development of breast cancer at a young age.

F. Treatment

Breast cancer treatment consists of surgery, radiation therapy, chemotherapy and

hormone blocking drugs.

Destri Susilaningrum

1

, Nur Azizah

2

, Mutiah S

3

and Mukti Ratna D

4

The Analysis of Factors Affecting Stage Level of Breast Cancer Patients at RSUD

dr. Soetomo Surabaya 180

G. Metastases

Cancer cells can infiltrate the surrounding tissues and spread (metastasize) through

blood vessels and lymph vessels. Metastases are cancer cells that have spread beyond the

organs or tissues from where the cancer first appeared. Spread of cancer cells to other

parts of the body is affected by many things, such as the type of cancer, the severity of

cancer stage, and the location of the cancer originating [15].

Result*and*Discussion*

The Characteristics of Breast Cancer Patient at RSUD Dr Soetomo

(a)

(b)

(c)

Picture 1. the characteristic of (a) The Age, (b) The Stage Level, and (c) The Grade

Level.

Picture 1. a) show that the Age with high percentage of sufferer breast cancer at

RSUD Dr. Soetomo Surabaya are the ages between 45 to 60 years old about 50% of the

breast cancer patients, while between the ages of 27 - 44 and more than 60 years each

with almost the same percentage, namely 26% and 25%.

Picture 1. b) show that majority the breast cancer patients at RSUD Dr. Soetomo

Surabaya in Last stage condition about 75%. And figure 1 c) show that the greater Grade

is Grade 3 (Cancer that is poorly differentiated) about 56%, than Grade 2 with 37% and

the rest are Grade 1 (7%).

The Factors That Affect the Stage Level of Breast Cancer

The result of the binary logistic regression analysis, with the full logit model which

include all variables gives as below.

Simultaneously Test of Parameter

To find out which parameters are significant, the simultaneously test with the hypothesis

as in subsubsection 2.1.1 had done and give the result on Table 5.

Table 5. Simultaneous Test Results.

Df

P-value

85.615

9

0.000

For , it showed that P-value = 0.000 less than α indicated that reject H

0

, the

partial test was then conducted to find out the variables that significant in the model.

å

=

=++++=

9

1

9922110

)(

j

ijjiiii

xxxxxg

bbbbb

!

2

c

100.=

a

Volume 3, No. 3, January 2022, pp. 175-183

!

181 http://devotion.greenvest.co.id

Partially Test of Parameter

The partial test with the hypothesis as in subsubsection 2.1.2, with the significant level

10%, give the result of the significant variables as shown in Table 6.

Table 6. Partial Test Results.

Variables

B

Wald

Df

P-value

X

1

: Grade

1.303

14.877

1

0.000

X

3

: Obesity History

-0.760

3.244

1

0.072

Constant

-1.428

5.285

1

.022

Table 6 shows that the P-value less than α = 0.10, this indicate the variables are

significant to the model, and the variables are: Grade and Obesity History. The logit

Binary logistics Regression model gives as below.

3.2.3 Goodness of fit model

The hypothesis of goodness of fit model as in subsubsections 2.1.3, shown in Table 7.

Table 7. Goodness Fit of Model Results.

Df

P-value

5.935

8

0.654

Table 7. showed that P-value is more than α = 0.10, indicated the test cannot reject H

0

,

and so the model fit.

Classification Procedure

The subject only classified as two groups, with Y

1

: Secure

and Y

2

: Insecure. The

determination of classification errors can be known through the classification table

described in Table 8.

Table 8. Classification Table.

Observed

Prediction

Percentage

Corrected

Early

Stage

Last Stage

Early Stage

25

30

45.5

Last Stage

8

154

95.1

Overall Percentage

82.5

Based on the results above, the factors affecting stage level of breast cancer patients at

RSUD Dr. Soetomo Surabaya are Grade and Obesity history with the correct

classification between predicted and observation 82.5%.

Conclusion*

The factors that affect the level stage of breast cancer patients at RSUD Dr.

Soetomo Surabaya are Grade and Obesity History.

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76.0

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303.1428.1)( xxxg -+-=

2

c

Destri Susilaningrum

1

, Nur Azizah

2

, Mutiah S

3

and Mukti Ratna D

4

The Analysis of Factors Affecting Stage Level of Breast Cancer Patients at RSUD

dr. Soetomo Surabaya 182

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Volume 3, No. 3, January 2022, pp. 175-183

183 http://devotion.greenvest.co.id

Copyright*holder*:*

Destri$Susilaningrum

1

,$Nur$Azizah

2

,$Mutiah$S

3

,$Mukti$Ratna$

D

4

$(2021)

%

First*publication*right*:*

Devotion$:$Journal$of$Research$and$Community$Service$

This*article*is*licensed*under: