Factors influencing the time to diagnosis and treatment of breast cancer among women in low- and middle-income countries: A systematic review

Purpose: Shorter time from symptoms recognition to diagnosis and timely treatment would be expected to improve the survival of patients with breast cancer (BC). This review identifies and summarizes evidence on time to diagnosis and treatment, and associated factors to inform an improved BC care pathways in Low- and MiddleIncome Countries (LMICs). Methods: A systematic search was conducted in electronic databases including Medline, Embase, PsycINFO and Global Health, covering publications between January 1, 2010, and November 6, 2023. Inclusion criteria encompassed studies published in English from LMICs that reported on time from symptoms recognition to diagnosis and/or from diagnosis to treatment, as well as factors influencing these timelines. Study quality was assessed independently by two reviewers using a standard checklist. Pre-contact, post-contact and treatment intervals and delays in these intervals are presented. Barriers and facilitators for shorter time to diagnosis and treatment found by individual studies after adjusting with covariates are summarized. Results: The review identified 21 studies across 14 countries and found that BC cases took a longer time to diagnosis than to treatment. However, time to treatment also exceeded the World Health Organization (WHO) recommended period for optimal survival. There was inconsistency in terminology and benchmarks for defining delays in time intervals. Low socioeconomic status and place of residence emerged as frequent barriers, while initial contact with a private health facility or specialist was commonly reported as a facilitator for shorter time to diagnosis and treatment. Conclusions: Guidelines or consensus recommendations are essential for defining the optimal time intervals to BC diagnosis and treatment. Our review supported WHO's Global Breast Cancer Initiative recommendations. Increasing public awareness, strengthening of healthcare professional's capacities, partial decentralization of diagnostic services and implementation of effective referral mechanisms are recommended to achieve a shorter time to diagnosis and treatment of BC in LMICs.