Delayed presentation and diagnosis of breast cancer in African women: a systematic review

Abstract

Purpose: Africa has low breast cancer incidence rates but high mortality rates from this disease due to poor survival. Delays in presentation and diagnosis are major determinants of breast cancer survival, but these have not been comprehensively investigated in Africa.

Methods: MEDLINE, Embase, and Global Health were searched to identify studies reporting on delays in presentation and/or diagnosis of breast cancer published between January 1, 2000 and May 31, 2016. Data were synthesized in narrative, tabular, and graphical forms. Meta-analyses were not possible due to between-study differences in the way delays were reported.

Results: Twenty-one studies were included in the review. Study-specific average times between symptom recognition and presentation to a health care provider ranged from less than 1 to 4 months in North Africa and from less than 3 to greater than 6 months in sub-Saharan Africa. Study-specific average times from presentation to diagnosis were less than 1 month in North Africa but ranged from less than 3 to greater than 6 months in sub-Saharan Africa. Reported reasons for these delays included patient-mediated (e.g., socioeconomic factors) and health system-mediated factors (e.g., referral pathways).

Conclusions: This systematic review revealed marked delays in presentation and diagnosis of breast cancer in Africa. Identification of their drivers is crucial to the development of appropriate control strategies in the continent.

Keywords: Africa; Breast cancer; Delayed diagnosis; Delayed presentation; Late-stage breast cancer.

Fig. 1

Presentation, diagnostic, and treatment delays in breast cancer. BC = breast cancer; HCP = health care provider.

Fig. 2

Literature search and study selection.

Fig. 3

Study-specific delays in breast cancer: (A) from symptom recognition by the patient to her presentation to the first health care provider; (B) from presentation to breast cancer diagnosis or start of cancer treatment; and (C) from symptom recognition to diagnosis or start of treatment. ^aStudy eligibility restricted to advanced BC. See Table 2 for more detailed information on study-specific estimates of delay. A dashed line indicates that the delay estimate shown in the figure is an underestimation of the median value (the latter could not be calculated from the data provided in the original article). No delay estimates for Otieno et al. are shown because average time from symptoms to diagnosis could not be estimated (>3 months for 73% of patients—all with advanced BC—with no further information provided; see Table 1, Table 2). BC = breast cancer; HCP = health care provider; IQR = interquartile range; Md = median; Me = mean; SSA = sub-Saharan Africa; wMe = weighted mean.

Fig. 3

Study-specific delays in breast cancer: (A) from symptom recognition by the patient to her presentation to the first health care provider; (B) from presentation to breast cancer diagnosis or start of cancer treatment; and (C) from symptom recognition to diagnosis or start of treatment. ^aStudy eligibility restricted to advanced BC. See Table 2 for more detailed information on study-specific estimates of delay. A dashed line indicates that the delay estimate shown in the figure is an underestimation of the median value (the latter could not be calculated from the data provided in the original article). No delay estimates for Otieno et al. are shown because average time from symptoms to diagnosis could not be estimated (>3 months for 73% of patients—all with advanced BC—with no further information provided; see Table 1, Table 2). BC = breast cancer; HCP = health care provider; IQR = interquartile range; Md = median; Me = mean; SSA = sub-Saharan Africa; wMe = weighted mean.