Table 1 Main characteristics of the included studies
Title | Authors | Year of publication | Country | Study design | Research method | Age group (Years. Median/Mean) | Participants | Sample size | Diagnostic interval | Treatment interval | Diagnostic and treatment intervals | Cited limits | WHO building blocks addressed |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
(1) Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda | Lydia E. Pace et al | 2015 | Rwanda | Cross-sectional study | Quantitative and qualitative | 49 | - Women with pathologically confirmed breast cancer | 144 | 5 Months | NA* | NA | - Doubt about the accuracy of the delays noted by patients - Likelihood to not assess all the important contributors to delay - -Included patients might not be representative of all patients with breast cancer in Rwanda - Limited power to detect small differences in patient or system factors that might have been associated with delays | - Service delivery - Health workforce - Information systems |
(2) Barriers to early presentation of breast cancer among women in Soweto, South Africa | Maureen Joffe et al | 2018 | South Africa | Cross-sectional survey | Quantitative and qualitative | > 18 | - Female patients who were newly diagnosed with stage 0-IV breast carcinoma | 499 | NA | NA | NA | - Information about delays in care seeking and numbers and types of healthcare visits is based on patient survey responses. Rather than administrative data. Which may be biased or less accurate - Limited generalizability | - Service delivery - Health workforce |
(3) Access to Breast Cancer Treatment Services in Mombasa County. Kenya: A Quality of Care Analysis of Patient and Survivor Experiences | Sultane Sherman and Vincent Okungu | 2018 | Kenya | Cross-sectional descriptive study | Quantitative and qualitative | 36–55 | - Breast cancer patients and survivors | 72 | NA | NA | NA | - The study was conducted in an organized group of cancer survivors and patients and their level of access to services may not entirely reflect the realities of the county where other patients survive without support systems | - Service delivery - Health workforce - Health financing |
(4) Factors associated with time to first healthcare visit. Diagnosis and treatment, and their impact on survival among breast cancer patients in Mali | Grosse Frie K et al | 2018 | Mali | Prospective cohort study | Quantitative and qualitative | 45 (Mean) | - Female patients with Breast Cancer | 64 | 6.4 months (mean) | 2.5 months (mean) | NA | - Relatively small sample size - This study did not include breast cancer patients who did not go to the hospital for diagnostic services - Women who were lost after the first healthcare visit or never sought healthcare were unknown - These limitations effect the generalizability of the results | - Service delivery - Health workforce |
(5) Financial barriers related to breast cancer screening and treatment: A cross-sectional survey of women in Kenya | Subramanian S et al | 2019 | Kenya | Cross-sectional survey | Quantitative and qualitative | 46.1 (Mean) | - 400 Women with breast cancer - 400 Women without a diagnosis of breast cancer | 800 | NA | NA | NA | - Women were interviewed by research assistants. Which could have also introduced bias - The analysis was based on responses provided by the women themselves. Which may be subject to recall or other biases - All women who participated in this cohort study were identified from the regions within or in close proximity to Nairobi County therefore our findings might not be generalizable - Non-random selection process could have introduced selection bias - Small sample of women with private insurance limited the ability to conduct a stratified analysis to evaluate potential differences by type of insurance coverage | - Health financing - Medication access |
(6) Factors linked to late diagnosis in breast cancer in sub-Saharan Africa: Case of Côte d’Ivoire | M. Toure et al | 2013 | Ivory Coast | Retrospective study | Quantitative | 42 (Median) | - Female patients with breast adenocarcinoma | 350 | < 6–14 Months | NA | NA | NA | - Service delivery - Health workforce - Health Financing |
(7) Financial barriers to utilization of screening and treatment services for breast cancer: an equity analysis in Nigeria | Okoronkwo IL et al | 2015 | Nigeria | Descriptive study | Quantitative | 34.69 (Mean) | - women with breast cancer | 270 | NA | NA | NA | - The respondents were recruited from one hospital only and therefore the study cannot be generalized | - Health Financing |
(8) From symptom discovery to treatment - women’s pathways to breast cancer care: a cross-sectional study | Moodley J. et al | 2018 | South Africa | Cross-sectional study | Quantitative | 54 | - Women with breast cancer | 201 | 28 days (median) | 37 days (median) | NA | - Low recruitment of population targets due to logistic constraints - The timing of interviews could have resulted in difficulty in putting the journey into perspective if women were not emotionally prepared - Interviews conducted in a hospital setting could have resulted in a social desirability bias with under-reporting of time delays - Time intervals reported are unlikely to be representative of intervals seen in public sector settings in SA without a tertiary centre based one-stop breast clinic - Retrospective recall could have affected accurate reporting of symptoms and health seeking behaviours in this study | - Service delivery |
(9) Prevalence and Factors Contributing to Late Diagnosis of Breast Cancer among Women Attending Tikur Anbessa Specialized Hospital. Oncology Unit, Addis Ababa, Ethiopia. 2017 | Bedada T et al | 2018 | Ethiopia | Cross-sectional study | Quantitative | 41.6 | - Newly diagnosed and on-follow-up female breast cancer patient | 215 | NA | NA | NA | NA | - Service delivery - Health workforce |
(10) Educational Opportunities for Down-Staging Breast Cancer in Low-Income Countries: An Example from Tanzania | Yang K et al | 2019 | Tanzania | Cross- sectional study | Quantitative | 51.6 | - Female breast cancer patients. 18 years of age and older. Newly referred to Ocean Road Cancer Institute (ORCI) for treatment | 196 | NA | NA | NA | - Possible recall bias - The medical records did not contain information regarding the previous primary care visits that may have been made | - Service delivery - Health workforce |
(11) Time intervals experienced between first symptom recognition and pathologic diagnosis of breast cancer in Addis Ababa. Ethiopia: a cross-sectional study | Gebremariam A. et al | 2019 | Ethiopia | Cross-sectional study | Quantitative | 44.4 (Mean) | - women newly diagnosed with breast cancer | 441 | 2.3 (median) | NA | NA | - The retrospective nature of collecting information about dates of symptom recognition and medical consultations is prone to recall bias - The interviews were conducted in a hospital setting. Which could have resulted in a social desirability bias leading to under-reporting of time interval before medical consultation and over-reporting of desirable behaviours such as self-breast examination | - Service delivery - Health workforce |
(12) Impact of Primary Care Delay on Progression of Breast Cancer in a Black African Population: A Multicentered Survey | Agodirin O. et al | 2019 | Nigeria | Cross-sectional study | Quantitative | 48.35 (Mean) | - Breast cancer patients | 237 | NA | NA | NA | - Although measures were taken to reduce recall bias in the study design. This survey was still limited in that triangulation with the primary care records was impossible because of poor record keeping. | - Service delivery - Health workforce |
(13) Inequities in Breast Cancer Treatment in sub-Saharan Africa: Findings from a Prospective Multi-Country Observational Study | Foerster M. et al | 2019 | -Namibia -Nigeria -Uganda | Prospective Multi-Country Observational Study | Quantitative | 50.7 (Mean) | - Women newly diagnosed with breast cancer | 1335 | NA | NA | NA | - Difficult to disentangle whether untreated proportions were attributable to the country or the specific hospital setting in this specific country - Breast cancer patients who do not reach this level of the health system. and may be more likely to go untreated were not included | - Service delivery - Health financing - Medication access and technologies |
(14) Barriers to timely surgery and early surgical outcomes for breast cancer patients in a setting with limited resources | F. Ntirenganya | 2019 | Rwanda | Cross-sectional study | Quantitative | 48 (Median) | Patients who underwent surgery for breast cancer | 69 | NA | NA | 3 months (Mean) | -All patients received standard and adequate therapy according to their diagnosis and staging -The study was conducted in 2 hospitals. With 2 different surgical teams. This can constitute a bias and influence the outcomes | - Service delivery |
(15) Presentation Intervals and the Impact of Delay on Breast Cancer Progression in a Black African Population | Agodirin O et al | 2020 | Nigeria | multicentred survey | Quantitative | 50.6 (Mean) | Female breast cancer patients who were newly diagnosed | 420 | NA | NA | NA | -This Study was limited in that the primary outcome was patient-reported; hence it might be influenced by recall bias | - Service delivery - Health workforce |
(16) Dissecting the journey to breast cancer diagnosis in sub-Saharan Africa: Findings from the multicountry ABC-DO cohort study | Foerster M et al | 2020 | -Namibia -Nigeria -Uganda -Zambia | Prospective multi-country observational study | Quantitative | 50.1 (Mean) | women aged ≥18 years with histologically confirmed or suspected breast cancer | 1429 | NA | NA | NA | -Weaknesses include the fact that participants were recruited in public tertiary referral centres and. Thus. might be unrepresentative as not all breast cancer patients are referred to these hospitals or can reach them -The self-reported length of the diagnostic journey might have been affected by between-woman variation in the ability to recognize symptoms across settings | - Health financing - Health workforce - Service delivery |
(17) Social barriers to diagnosis and treatment of breast cancer in patients presenting at a teaching hospital in Ibadan, Nigeria | Pruitt L et al | 2014 | Nigeria | Qualitative study | Qualitative | 51 (Median) | 31 women with a diagnosis of breast cancer 5 physicians | 36 | NA | NA | NA | -This study did not capture the experiences of patients who never made it to tertiary care for breast cancer treatment -The medical setting may also have reduced willingness to speak about complementary and alternative medicine for fear of being judged by their physicians or the belief that such an admission might affect their treatment -Follow-up questions were limited by the use of a translator | - Service delivery - Health workforce - Health financing - Medication access and technologies |
(18) Breast Cancer Diagnosis and Factors Influencing Treatment Decisions in Ghana | Aziato. L. and Clegg-Lamptey | 2014 | Ghana | Qualitative descriptive | Qualitative | 31–60 years | Women diagnosed with breast cancer who had undergone a single or bilateral mastectomy | 12 | NA | NA | NA | NA | - Health workforce - Service delivery |
(19) “My experience has been a terrible one. Something I could not run away from”: Zambian women’s experiences of advanced breast cancer | ‘Johanna E. Maree And J. Mulonda | 2015 | Zambia | Qualitative descriptive | Qualitative | 48.2 (Mean) | Women living with advanced breast cancer | 10 | NA | NA | NA | -This was a qualitative study, and no other study reflects on the only true meaning of the narratives, as there could be more than one interpretation -Women who were recruited received treatment at the same hospital | - Health workforce |
(20) Understanding pathways to breast cancer diagnosis among women in the Western Cape Province. South Africa: a qualitative study | Jennifer Moodley et al | 2016 | South Africa | Qualitative | Qualitative | 52 (Mean) | Patients with newly diagnosed breast cancer | 20 | 3 Months (Average) | NA | NA | -This study was conducted at one clinic in the Western Cape Province and this limits its generalizability -Women who did not access tertiary healthcare were not included | - Health workforce |
(21) A framework for improving early detection of breast cancer in sub-Saharan Africa: A qualitative study of help-seeking behaviors among Malawian women | Kohler Racquel E. et al | 2017 | Malawi | Qualitative | Qualitative | 47 (Median) | Female breast cancer patients | 20 | NA | NA | NA | -Many Malawian women with breast cancer may never reach a referral hospital (where patients were recruited) -Some women initially experienced symptoms or were diagnosed a few years prior to being interviewed. Therefore, their recollection of events may not be as sharp | - Service delivery - Health workforce - Medication access and technologies |
(22) Why Do Women with Breast Cancer Get Diagnosed and Treated Late in Sub-Saharan Africa? Perspectives from Women and Patients in Bamako. Mali | Grosse Frie K et al | 2018 | Mali | Qualitative study | Qualitative | 48 (Mean) | 8 women with breast cancer 17 women without breast cancer | 25 | NA | NA | NA | -Only a small number of women were analysed -There might be further barriers. Particularly for women living outside the capital city. Bamako -Furthermore. experiences and opinions of healthcare personnel and doctors should be researched. as they might balance the views of patients and women | - Service delivery - Health workforce - Medication access |
(23) Understanding the causes of breast cancer treatment delays at a teaching hospital in Ghana | Sanuade OA et al | 2018 | Ghana | Qualitative study | Qualitative | 40–49 (modal age range) | Female breast cancer patients | 20 | NA | NA | < 1–3+ (Min-Max) | - The main limitation of this study was that the number of participants included in the focus groups was very limited | - Service delivery - Health workforce - Health financing |
(24) Perceived Barriers to Early Detection of Breast Cancer in Wakiso District. Uganda Using a Socioecological Approach | Ilaboya D et AL | 2018 | Uganda | Qualitative study | Qualitative | NA | -Woman who have experience in healthcare delivery or health research in relation to cancer care -Community health workers -Key informants | 24 | NA | NA | NA | -This study involved only one sub-county; therefore, the results may not necessarily be generalizable | - Governance/Leadership - Service delivery - Health workforce |
(25) Fear of Mastectomy Associated with Delayed Breast Cancer Presentation Among Ghanaian Women | Martei YM et al | 2018 | Ghana | Qualitative Study | Qualitative | 47.12 (Mean) | Women with a confirmed breast cancer diagnosis | 31 | NA | NA | NA | - Purposive sampling Only women seen at study site were interviewed - Most of the women seen in the public sector are of lower socioeconomic status, therefore the information may not be generalizable - Financial barriers to presentation and management could be even more significant than those reported in this study | - Health financing - Medication access |
(26) Identifying Barriers and Facilitators to Breast Cancer Early Detection and Subsequent Treatment Engagement in Kenya: A Qualitative Approach | Robai Gakunka et al | 2019 | Kenya | Qualitative | Qualitative | 30–60 years | 6–11 women with breast cancer 6–11 women without breast cancer | 2 Focus groups (6–11 per group) | NA | NA | NA | -Study was carried out in Nairobi and its environs where most of the cancer care services in Kenya are found and, Therefore, it may not be generalizable | - Health financing - Service delivery - Health workforce - Medication access |
(27) Perspectives of patients, family members, and health care providers on late diagnosis of breast cancer in Ethiopia: A qualitative study | Gebremariam A et al | 2019 | Ethiopia | Qualitative study | Qualitative study | < 40 (Modal age range) | 13 breast cancer patients 5 family members 5 health workers | 23 | NA | NA | NA | Recall of past events with the foresight of experience may unconsciously make the stories of these women biased and inaccurate explanations of their experience | - Service delivery - Health workforce - Health financing - Medication access and technologies |
(28) Perceived barriers to early diagnosis of breast Cancer in south and southwestern Ethiopia: a qualitative study | Getachaw S et al | 2020 | Ethiopia | Qualitative study | Qualitative study | 26–65 (Modal age range) | 12 Breast cancer patients 13 care providers | 25 | NA | NA | NA | This study used only in-depth interviews for data collection with a limited number of participants | - Governance/Leadership - Service delivery - Health workforce - Health financing - Medication access and technologies |