Table 3

Barriers and facilitators for obtaining a biopsy and initiating treatment after a high-risk telemammography result

A. The toll of getting care in major cities following referralsInsufficient financial resources and support for transportation, accommodation and food Quote #1:
They have to assume the expenses; they have to. So, often, because of the little money that they have, they don't go [to the city].(midwife, highlands)
Quote #2:
There are some shelters here where patients can stay, but they have limited access for a group of patients; first the pediatric patients and then the rest.(physician, Lima)
Quote #3:
We sold some animals. On the farm, we had sheep, cattle, and we sold everything, even the land we had to sell, to save her. If we hadn't made those efforts, my wife wouldn't be alive now. We did it to save her.(patient’s husband, highlands)
Being away from family and friends' emotional support Quote #4
Interviewer: How important do you think family support is during this time [before having the biopsy]?
Interviewee: Well, you are desperate, you feel like dying, but they talk to you, they talk with you. They give you support, psychological support. It’s as if they were saying,
‘Mom, you are not alone; you are with me’.(patient, highlands)
Quote #5
Interviewee: If they come from the provinces, they come alone. They can't come with all their family. Or they come to the first consult with a relative, and then they say things like ‘well, he is my husband, but he has to go back to my town to take care of my children. And they leave. That’s the reality of the people who come from the provinces outside of Lima.
Interviewer: How does it affect care?
Interviewee: It affects care because the patient must think twice before continuing care. Either she abandons it or comes irregularly.(physician, Lima)
Challenges adjusting to and navigating the city Quote #6
The cultural shock [of going to the city] is very strong. They feel overwhelmed; sometimes so overwhelmed that they prefer to leave care and go back to their towns.(physician, highlands)
B. Patients’ misconceptions and access to informationMisconceptions about breast cancer manifestations and progression Quote #7
I did not give it too much importance because I did not have any pain. I thought that maybe they were wrong. I didn't give it importance, so I didn't do anything.(patient, highlands)
Quote #8
Patients say that [having a biopsy] is worse, because when they prick you or take a piece of your breast that’s when the cancer awakens. And that’s why they don’t want to have the biopsy.(nurse, highlands)
Misconceptions about the treatment Quote #9
When you tell someone she has breast cancer, the first thing they think of is that it is “daño” (a sort of witchcraft), so they go first to the shamans and later, if they continue feeling sick, they come back.(program coordinator, rainforest)
Misconceptions about the prognosis Quote #10
Many times, I've heard that when you have cancer you have it until the end. You just have to wait for your death. Once you have it there is no cure.(patient, highlands)
Limited information provided about the disease Quote #11
I would have liked for them to explain it to me more thoroughly, perhaps that way I would have gone, it would have encouraged me. Because sometimes, when they explained to you well, you are conscientious and go. But if they give you a test result that only says get another test because the first test wasn't normal, you don't give it adequate importance.(…)They didn't say anything more than giving you a number, where I should go, and all of that.(patient, highlands).
C. Administrative and operational barriersDelays for obtaining appointments and tests Quote #12
Interviewer: What happened the day that you went to the hospital? How did it go?
Interviewee: I went very early, very early, but the line was already long, and as I needed to work, I got fatigued and didn't go back. So, I haven't done the test. Nothing. I left it there.(patient, highlands)
Quote #13
For these tests, they have to come one day and for these others another day. And that’s how the time passes by.(…). So sometimes when they are told to do one more test they say ‘Miss, I've been there, three months have passed, and I haven't started treatment yet’.(nurse, highlands)
Low awareness of the programme or of its guidelines among providers Quote #14
We had a patient with BI-RADS 4 who needed a biopsy, but the closest hospital didn't have biopsy services. So, we coordinated to refer her to a regional cancer center. After a lot of insistence, they could transfer her to the regional cancer center, and it happens that when she arrives at the facility, they ordered a repeat mammography.(policymaker, Lima)
Lack of standardised referral pathways Quote #15
Interviewer: Did they ask you if you wanted to go to [region X] instead of Lima?
Interviewee: No, they didn't say anything. If I had known that in [region X] they had chemotherapy, I wouldn't have gone to Lima, because I didn't have enough money or someone to help me. If I knew they had it here, I would have stayed.(patient, coast)
Inconsistent tracking of patients Quote #16
Interviewer: What type of follow-up do you do here?
Interviewee: Once they have a biopsy in the [local] hospital, and it comes back positive, they call the patient or her primary care center to inform her of the result. They talk with the patient to see what’s best: to send her to [the regional hospital] or Lima(…)
Interviewer: And what happens once they are referred?
Interviewee: We don't do further follow-up. I'd be lying if I say we do. We don't do more follow-up.(program coordinator, coast)
Quote #17
The systems are divorced; they are not integrated. So, you are taking mammography tests but there is not a structure that integrates the screening with the treatment or with the diagnosis.(policymaker, Lima)
D. FacilitatorsHaving family or a friend living in the city Quote #18
They say: ‘I don't worry much about the stay, Miss, I have family there.’ The majority that wants to go to [a major city] is because they have family there.(midwife, coast)
Collaborative and family inclusive explanation Quote #19
The psychologist has helped me a lot(…)The psychologist is part of your disease, [the psychologist] cheers you up. It is not only the doctor who helps, the psychologist too. [The psychologist] talks with you in a particular way and makes you understand.(patient, highlands)
Quote #20
Interviewer: How do you convince them [to obtain a biopsy)?
Interviewee: Taking your time and explaining kindly. Sometimes the patient accepts (undergoing biopsy), but the relative doesn't, so you need to explain it all to the family, too.(…)You need to explain to every one of them because in their way of living, all the family influences, and then they accept.(physician, highlands)
Facilitated appointments Quote #21
Interviewer: How do patients from other regions get care here?
Interviewee: They just come and get an appointment. Here in the oncology department, we have a system that we called 'unlimited appointments.' We give an appointment to everyone who arrives before 9:00 a.m.
Interviewer: What day is the appointment?
Interviewee: For the same day. So, they don't have to come back another day.(physician, highlands)