A Systematic Review of Barriers to Breast Cancer Care in Developing Countries Resulting in Delayed Patient Presentation

Background. Within the developing world, many personal, sociocultural, and economic factors cause delayed patient presentation, a prolonged interval from initial symptom discovery to provider presentation. Understanding these barriers to care is crucial to optimizing interventions that pre-empt patient delay. Methods. A systematic review was conducted querying: PubMed, Embase, Web of Science, CINAHL, Cochrane Library, J East, CAB, African Index Medicus, and LiLACS. Of 763 unique abstracts, 122 were extracted for full review and 13 included in final analysis. Results. Studies posed variable risks of bias and produced mixed results. There is strong evidence that lower education level and lesser income status contribute to patient delay. There is weaker and, sometimes, contradictory evidence that other factors may also contribute. Discussion. Poverty emerges as the underlying common denominator preventing earlier presentation in these settings. The evidence for sociocultural variables is less strong, but may reflect current paucity of high-quality research. Conflicting results may be due to heterogeneity of the developing world itself. Conclusion. Future research is required that includes patients with and without delay, utilizes a validated questionnaire, and controls for potential confounders. Current evidence suggests that interventions should primarily increase proximal and affordable healthcare access and secondarily enhance breast cancer awareness, to productively reduce patient delay. 1. Introduction Breast cancer remains the most common cancer and most common cause of cancer-related mortality among women worldwide [1]. While incidence rates have historically been higher in the developed world, there has been a recent sharp increase in incidence and mortality in the developing world [2]. Furthermore, the case-fatality rate (or relative survival, approximated as the compliment of the mortality to incidence ratio [3]) within these nations tends to be lower, largely due to patients presenting at more advanced stages [2]. Delayed patient presentation refers to a prolonged interval between discovery of initial symptom to presentation to a provider and is typically defined as greater than 12 weeks, as periods longer than this have been associated with poorer survival [4]. In contrast, provider delay refers to an extended interval from initial patient presentation to effective oncological treatment. Nonetheless, providers and health systems may serve as primary sources of health-related education and affect patient delay as well. Patient delay has been