Delays and Barriers to Cancer Care in Low- and Middle-Income Countries: A Systematic Review

Abstract

Background: Advanced stage presentation of patients with is common in low- and middle-income countries (LMICs). A comprehensive analysis of existing delays and barriers in LMICs has not been previously reported. We conducted a systematic literature review to comprehensively outline delays and barriers to identify targets for future interventions and provide recommendations for future research in this field.

Materials and methods: Multiple electronic databases were searched using a standardized search strategy. Eligible articles were of any language, from LMICs, and published between January 1, 2002, and November 27, 2017. Included studies reported cancer care intervals or barriers encountered. Intervals and associated barriers were summarized by cancer type and geographical region.

Results: This review included 316 study populations from 57 LMICs: 142 (44.9%) studies addressed time intervals, whereas 214 (67.7%) studies described barriers to cancer diagnosis. The median intervals were similar in the following three stages of early diagnosis: (a) access (1.2 months), (b) diagnostic (0.9 months), and (c) treatment (0.8 months). Studies from low-income countries had significantly longer access intervals (median, 6.5 months) compared with other country income groups. Patients with breast cancer had longer delay intervals than patients with childhood cancer. No significant variation existed between geographic regions. Low health literacy was reported most frequently in studies describing barriers to cancer diagnosis and was associated with lower education level, no formal employment, lower income, and rural residence.

Conclusion: Early diagnosis strategies should address barriers during all three intervals contributing to late presentation in LMICs. Standardization in studying and reporting delay intervals in LMICs is needed to monitor progress and facilitate comparisons across settings.

Implications for practice: This review draws the attention of cancer implementation scientists globally. The findings highlight the significant delays that occur throughout the cancer care continuum in low- and middle-income countries and describe common barriers that cause them. This review will help shape the global research agenda by proposing metrics and implementation studies. By demonstrating the importance of standardized reporting metrics, this report sets forth additional research and evidence needed to inform cancer control policies.

Keywords: Cancer; Delay interval; Early diagnosis; Low‐ and middle‐income country.

Figure 1.

Study selection flowchart. The original search returned 10,193 abstracts in total. Only 316 studies met final inclusion criteria and were analyzed in this study. Abbreviation: GIM, Global Index Medicus.

Figure 2.

Heat map of studies included in systematic review by country in which study was conducted. Colors in map represent the number of studies included in the review by country: countries in gray are high‐income countries (excluded from review); countries in white are low‐, lower‐middle, or upper‐middle income countries with no published study included in the review.