Elsevier

The Lancet

Volume 353, Issue 9159, 3 April 1999, Pages 1127-1131
The Lancet

Fast track — Articles
Factors predicting delayed presentation of symptomatic breast cancer: a systematic review

https://doi.org/10.1016/S0140-6736(99)02142-XGet rights and content

Summary

Background

Delayed presentation of symptomatic breast cancer is associated with lower survival. Understanding of the factors that influence delay is important for the development of strategies to shorten delays. We did a systematic review to assess the quality and strength of evidence on risk factors for delays by patients and providers.

Methods

We generated hypotheses about the relation between each putative risk factor and delay, against which we tested studies. We did searches to identify papers containing original data related to risk factors for delays by patients (n=86) and providers (n=28). We critically appraised the papers for inclusion in the review according to predefined criteria. The small number of studies of adequate quality did not allow formal meta-analysis. We therefore assigned strength of evidence according to a combination of the number and size of studies supporting, not supporting, or refuting the hypotheses.

Findings

Most studies were deemed to be of poor quality and were excluded. Among 23 studies of adequate quality, however, there was strong evidence for an association between older age and delay by patients, and strong evidence that marital status was unrelated to delays by patients. Younger age and presentation with a breast symptom other than a lump were strong risk factors for delays by providers. Moderate evidence was shown for several other factors.

Interpretation

The strength of the current evidence is inadequate to inform the development of specific strategies to shorten delays by patients or providers. Clarification of the findings of this review through a major programme of primary research is urgently required.

Introduction

There is strong evidence that delayed presentation of symptomatic breast cancer is associated with lower survival.1 Patients with total delays of 3–6 months have significantly worse survival than those with delays of less than 3 months.1 The time between first symptom and treatment is longer than 3 months in at least a third of all patients, and in about a quarter the time is longer than 6 months.2 More than 50% of patients present to a family physician within 1 month of developing symptoms, but 20–30% delay more than 3 months. Family physicians refer most cases of breast cancer to hospital directly after the first consultation, but a small proportion of patients (6–16%) experience long delays (>3 months) at this step of the process. Studies over the past 20 years that have assessed delays by patients and providers suggest that the contributions of these two elements to total delay are roughly equal.2

Development of effective new strategies to shorten delays before presentation of breast cancer requires an understanding of the factors that influence the delays. Reviews have assessed research on this subject, such as those by Caplan and Helzlsouer3 and Facione,4 and have been informative, but none were done systematically. We aimed in a systematic review to assess the quality and strength of the current evidence related to factors that may predict delays by patients, providers, or both in patients with symptomatic breast cancer.

Section snippets

Selection of studies

We did the review according to established principles laid down to protect against potential bias.5, 6 Details of the methods are reported elsewhere.2 The review was started in June, 1996, and completed in March, 1998. Clear and explicit criteria for electronic searching were derived. We did extensive searches of the medical and psychological databases (eg, Medline, Embase, PsychInfo, CINAHL), as detailed elsewhere.2 The electronic searches were supplemented by manual searches of the

Results

We identified 101 original studies that included data directly linking risk factors and delay. 23 of these papers met the inclusion criteria and contributed to the findings of the review. Among the included studies, no single feature (eg, cohort vs case control) was taken by the review panel to differentiate clearly between adequate and good quality. A case-control study with clear factor definition or measurement, clear delay definition, and robust analysis was, for example, judged to be

Discussion

Our review revealed an extensive number of studies on factors purported to predict delays by patients, providers, or both. Many of the studies were, however, of insufficient quality to be included in the review. A much smaller number of studies contributed to the analysis of individual hypotheses and, in many cases, these studies involved only small numbers of patients. We were, therefore, unable to give definitive answers to many of the initial questions.

We found strong evidence for only two

References (34)

  • J Deeks et al.

    Undertaking systematic reviews of research on effectiveness: CRD guidelines for those carrying out or commissioning reviews. CRD Report 4

    (1996)
  • JM Dixon et al.

    Congenital problems and observations of normal breast development and involution

  • J Hughes et al.

    Depression and social stress among patients with benign breast disease

    Br J Surg

    (1986)
  • A Cameron et al.

    Delay in seeking treatment for mammary tumours

    Cancer

    (1968)
  • S Greer

    Psychological aspects: delay in the treatment of breast cancer

    Proc R Soc Med

    (1974)
  • S Nichols et al.

    Delay in the presentation of breast symptoms for consultant investigation

    Community Med

    (1981)
  • R Coates et al.

    Differences between black and white women with breast cancer in time from symptom recognition to medical consultation: Black/White Cancer Survival Study Group

    J Natl Cancer Inst

    (1992)
  • Cited by (375)

    View all citing articles on Scopus
    View full text