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