O atraso de paciente e atraso de sistema no tratamento do câncer de mama nos países desenvolvidos e em desenvolvimento

Freitas, Angela Gabrielly Quirino; Weller, Mathias

doi:10.1590/1413-812320152010.19692014

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Sumário

Article • Ciênc. saúde colet. 20 (10) • Out 2015 • https://doi.org/10.1590/1413-812320152010.19692014 copiar

O atraso de paciente e atraso de sistema no tratamento do câncer de mama nos países desenvolvidos e em desenvolvimento

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

O atraso no tratamento de câncer de mama foi associado com o aumento do palco da doença e a diminuição da sobrevida do paciente. O objetivo desta revisão integrativa foi a analise dos principais fatores causais e dos tipos de atraso. Sendo estes comparados entre estudos de países em desenvolvimento e desenvolvidos. Dos 53 estudos selecionados, 24 eram de países em desenvolvimento e 29 de países desenvolvidos, respectivamente. A não atribuição dos sintomas ao câncer, o medo e a menor escolaridade foram as causas mais citadas do atraso de paciente ao tratamento. Seguro menos abrangente, idade e testes diagnósticos falsos negativos foram às causas mais comuns identificadas do atraso do sistema. O efeito de vários fatores como o fator idade, dependeu principalmente do contexto social e cultural. Alguns fatores causaram tanto atraso relacionado ao paciente quanto ao sistema. Os estudos dos países em desenvolvimento identificaram mais fatores causais do atraso relacionado ao paciente, focando mais forte neste referido fator ou na combinação com o de sistema. Enquanto estudos de países desenvolvidos enfocaram com maior frequência aspectos do atraso de sistema durante o tratamento e a orientação de pacientes no sistema de saúde.

Palavras chave
Câncer de mama; Atraso; Tratamento; Países em desenvolvimento; Países desenvolvidos

Reference	Country and Language^* * English, if not differently indicated.	Sample size	Method		Type of delay
Reference		Sample size	Sampling	Analysis	Type of delay
Beattie, 2009³⁶36. Beattie A. Detecting breast cancer in a general practice - Like finding needles in a haystack? Aust Fam Physician 2009; 38(12):1003-1006.	Australia	30	Interview	Descriptive	P; S
Hansen et al., 2011³⁷37. Hansen RP, Vedsted P, Sokolowski I, Søndergaard J, Olesen F. Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients BMC Health Serv Res 2011; 11:284.	Denmark	159	Interview / Reg. Data	Univariate	P; S
Innos et al., 2013³⁸38. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, Lehtsaar J, Tekkel M. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health 2013; 13:947.	Estonia	703	Interview	Multivariate	P
Yau et al., 2010²⁴24. Yau TK, Choi CW, Ng E, Yeung R, Soong IS, Lee AWM. Delayed presentation of symptomatic breast cancers in Hong Kong: experience in a public cancer center. Hong Kong Med J 2010; 16(5):373-377.	China (Hong Kong)	158	Quest.	Univariate	P; S
Rastad et al., 2012³⁹39. Rastad H, Khanjani N, Khandani BK. Causes of Delay in Seeking Treatment in Patients with Breast Cancer in Iran: a Qualitative Content Analysis Study. Asian Pac J Cancer Prev 2012; 13(9):4511-4515.	Iran	10	In-depth-interview	Descriptive	P; S
Ermiah et al., 2012⁴⁰40. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer BMC Res Notes 2012; 21(5):452.	Libya	200	Interview	Univariate	P; S
Ukwenya et al., 2008⁴¹41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110.	Nigeria	111	Interview / Med. Rec.	Univariate	P; S
Memon et al., 2013⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.	Pakistan	100	Interview	Univariate	P
Máslach et al., 2013³⁵35. Maślach D, Krzyżak M, Szpak A, Owoc A, Magdalena Bielska-Lasota. Waiting time for treatment of women with breast cancer in Podlaskie Voivodeship (Poland) in view of place of residence. A population study. Anna Agric Environ Med 2013; 20(1)161-166.	Poland	499	Med. Rec. / Reg. Data	Univariate	S
Yun et al., 2012²⁸28. Yun YH, Kim YA, Min YH, Park S, Won YJ, Kim DY, Choi IJ, Kim YW, Park SJ, Kim JH, Lee DH, Yoon SJ, Jeong SY, Noh DY, Heo DS. The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery. Annals of Oncology 2012; 23(10):2731-2737.	South Korea	147.682	Reg. Data	Multivariate	S
Poum et al., 2014⁴³43. Poum A, Promthet S, Duffy SW, Maxwell Parkin D. Factors Associated With Delayed Diagnosis of Breast Cancer in Northeast Thailand. J Epidemiol2014; 24(2):102-108.	Thailand	180	Interview	Multivariate	P
Ozmen et al., 2014²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.	Turkey	1031	Quest.	Multivariate	P; S
Barros et al., 2013¹⁷17. Barros FA, Uemura G, Soares de Macedo JL. Tempo para acesso ao tratamento do câncer de mama no Distrito Federal, Brasil Central. Rev Bras Ginecol Obstet 2 013; 35(10):458-463.	Brazil; Portuguese	250	Interview	Univariate	P; S
Soares et al., 2012⁴⁴44. Soares PBM, Quirino Filho S, Pereira de Souza W, Gonçalves RCR, Reis B. Martelli DRB, Fagundes Silveira M, Martelli Júnior H. Characteristics of women with breast cancer seen at reference services in the North of Minas Gerais. Rev Bras Epidemiol 2012; 15(3):595-604.	Brazil	288	Med. Rec.	Multivariate	S
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Schairer et al., 2013⁴⁶46. Schairer C, Soliman AS, Omar S, Khaled H, Eissa S, Ayed FB, Khalafallah S, Ayoub WB, Kantor ED, Merajver S, Swain SM, Gail M, Morris Brown L. Assessment of diagnosis of inflammatory breast cancer cases at two cancer centers in Egypt and Tunisia. Cancer Med 2013; 2(2):178-184.	Egypt and Tunisia	74	Reg. Data	Univariate	P
Landolsi et al., 2010¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897.	Tunisia; French	160	Interview	Descriptive	P; S
Bodapati e Badu, 2013²⁷27. Chintamani, Tuteja A, Khandelwal R, Tandon M, Bamal R, Jain S, Narayan N, Srinivas S, Kumar Y. Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study. J R Soc Med Sh Rep 2011; 2:76.	India	10	In-depth-interview	Descriptive	P
Chintamani et al., 2011⁶⁷67. Wujcik D, Shyr Y, Li M, Clayton MF, Ellington L, Menon U, Mooney K. Delay in Diagnostic Testing After Abnormal Mammography in Low-Income Women. Oncol Nurs Forum 2009; 36(6):709-715.		100	Quest.	Descriptive	P; S
Ceballos-Garcia and Giraldo-Mora, 2011¹⁸18. Ceballos-García GY, Giraldo-Mora CV. "Autobarreras" de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama. Aquichán 2011; 11(2):140-157.	Colombia; Spanish	13	Interview	Descriptive	P
Piñeros et al., 2011⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485.	Colombia	1106	Interview / Med. Rec.	Univariate	S
Pineros et al., 2009⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380.		1106	Interview / Med. Rec.	Multivariate	P
Quaife et al., 2014¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18.	United Kingdom	6965	Tel. Inter.	Multivariate	P
Lim, 2011³²32. Lim JNW. Empirical Comparisons of Patient Delay and Help Seeking Models for Breast Cancer: Fitness of Models for Use and Generalisation. Asian Pacific J Cancer Prev 2011; 12(6):1589-1595.		–	–	Descriptive	P
Rajan et al., 2011⁵⁰50. Rajan SS, Lim JNW, Haq A. Late Presentation and Management of South Asian Breast Cancer Patients in West Yorkshire, United Kingdom Asian Pac J Cancer Prev 2011; 12(6):1615-1628.		36	Reg. Data	Descriptive	P
Ghazali et al., 2013⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145.	Malaysia	250	Interview / Med. Rec.	Multivariate	P
Muhamad et al., 2012⁵²52. Muhamad M, Merriam S, Suhami N. Why Breast Cancer Patients Seek Traditional Healers. Int J Breast Cancer 2012; 2012:689168.		11	In-depth-interview	Descriptive	P
Norsa'adah et al., 2012⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.		12	In-depth-interview	Descriptive	P; S
Norsa'adah et al., 2011⁵⁴54. Norsa'adah B, Rampal KG, Rahmah MA, Nyi N, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011; 11:141.		328	Interview / Med. Rec.	Multivariate	P; S
Taib et al., 2011⁵⁵55. Taib NA, Yip CH, Low WY. Recognizing Symptoms of Breast Cancer as a Reason for Delayed Presentation in Asian Women - The Psycho-sociocultural Model for Breast Symptom Appraisal: Opportunities for Intervention. Asian Pacific J Cancer Prev 2011; 12(6):1601-1608.		19	In-depth-interview	Descriptive	P
Yusoff et al., 2011⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.		16	In-depth-interview	Descriptive	P; S
Bustami et al., 2014⁵⁸58. Bustami RT, Shulkin DB, Nancy O’Donnell N, Whitman ED. Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnic background: a cohort study. JRSM Open 2014; 5(7):2042533313515863.	United States of America	3071	Reg. Data	Multivariate	S
Crowley et al., 2014⁵⁷57. Crowley MM, McCoy ME, Bak SM, Caron SE, Ko NY, Kachnic LA, Alvis F, Battaglia TA. Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital. J Oncol Pract2014; 10(2):e107-112.		113	Med. Rec. / Reg. Data	Univariate	P; S
Thind et al., 2014²⁰20. Thind A, Hoq L, Diamant A and Maly RC. Satisfaction with Care among Low-Income Women with Breast Cancer. J Womens Health (Larchmt) 2010; 19(1):77-86.		924	Tel. Inter.	Multivariate	S
Fedewa et al., 2010²⁹29. Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol2010; 28(27):4135-4141.		107.587	Reg. Data	Multivariate	S
Bourdeanu et al., 2013⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198.		40	Quest.	Descriptive	P; S
McGee et al., 2013⁶⁰60. McGee SA, Durham DD, Tse CK, Millikan RC. Determinants of breast cancer treatment delay differ for African American and White women Cancer. Epidemiol Biomarkers Prev 2013; 22(7):1227-1238.		601	Interview / Med. Rec.	Multivariate	S
Fayanju et al., 2013²⁶26. Fayanju OM, Jeffe DB, Elmore L, Ksiazek DN, Margenthaler JA. Patient and Process Factors Associated with Late-Stage Breast Cancer Diagnosis in Safety-Net Patients: A Pilot Prospective Study. Ann Surg Oncol 2013; 20(3):723-732.		52	Interview	Multivariate	P
Ramirez et al., 2013⁶¹61. Ramirez AG, Pérez-Stable EJ, Talavera GA, Penedo FJ, Carrillo JE, Fernandez EF, Muñoz E, Long Parma D, Holden AEC, San Miguel de Majors S, Nápoles A, Castañeda SF, Gallion KJ. Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study. Springerplus 2013; 2(1):84.		260	Med. Rec.	Multivariate	S
Sharma et al., 2013⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.		90	Reg. Data	Multivariate	P
Sheppard et al., 2013²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216.		359	Tel. Inter. / Med. Rec.	Multivariate	P, S
Black and Woods-Giscombé, 2012³³33. Black AR, Woods-Giscombé C. Applying the Stress and ‘Strength’ Hypothesis to Black Women's Breast Cancer Screening Delays. Stress Health2012; 28(5):389-396.		Social media	Lecture of media	Descriptive	P
Bleicher et al., 2012³⁰30. Bleicher RJ, Ruth K, Sigurdson ER, Ross E, Wong YN, Patel SA, Boraas M, Topham NS, Egleston BL. Preoperative Delays in the US Medicare Population With Breast Cancer. J Clin Oncol 2012; 30(36):4485-4492.		72.586	Reg. Data	Multivariate	S
Vandergrift et al., 2012⁶³63. Vandergrift JL, Niland JC, Theriault RL, Edge SB, Wong YN, Loftus LS, Breslin TM, Hudis CA, Javid SH, Rugo HS, SilverSM, Lepisto EM, Weeks JC. Time to Adjuvant Chemotherapy for Breast Cancer in National Comprehensive Cancer Network Institutions. J Natl Cancer Inst. 2013; 105(24):1912.		6622	Reg. Data	Multivariate	S
Karliner et al., 2012²⁵25. Karliner LS, Hofmann M, Kerlikowske K. Language Barriers, Location of Care and Delays in Follow-up of Abnormal Mammograms. Med Care 2012; 50(2):171-178.		4027	Reg. Data / Quest.	Univariate	S
Partridge et al., 2012³¹31. Partridge AH, Hughes ME, Ottesen RA, Wong YN, Edge SB, Theriault RL, Blaney DW, Niland JC, Winer EP, Weeks JC, Tamimi RM. The Effect of Age on Delay in Diagnosis and Stage of Breast Cancer. Oncologist 2012; 17(6):775-782.		21.818	Reg. Data	Multivariate	P
Simon et al., 2012⁶⁴64. Simon MS, Lamerato L, Krajenta R, Booza JC, Ruterbusch JJ, Kunz S, Schwartz K. Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System. Int J Breast Cancer 2012; 2012:453985.		2234	Reg. Data	Multivariate	S
Heisey et al., 2011⁶⁵65. Heisey R, Clemons M, Granek L, Fergus K, Hum S, B. McCready DR, Fitzgerald B. Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians Curr Oncol 2011; 18(5):227-237.		14	In-depth-interview	Descriptive	P
Maly et al., 2011²¹21. Maly RC, Leak B, Mojica CM, Liu Y, Diamant AL, Thind A. What Influences Diagnostic Delay in Low-Income Women with Breast Cancer J Womens Health (Larchmt) 2011; 20(7):1017-1023.		921	Tel. Inter.	Multivariate	P, S
Simmons et al., 2011⁶⁶66. Simmons PS, Jayasinghe YL, Wold LE, Melton LJ. Breast Carcinoma in Young Women. Obstet Gynecol 2011; 118(3):529-536.		12	Reg. Data	Descriptive	P; S
Wujcik et al., 2009⁶⁷67. Wujcik D, Shyr Y, Li M, Clayton MF, Ellington L, Menon U, Mooney K. Delay in Diagnostic Testing After Abnormal Mammography in Low-Income Women. Oncol Nurs Forum 2009; 36(6):709-715.		4336	Reg. Data	Multivariate	S
Lobb et al., 2010⁶⁸68. Lobb R, Allen JD, Emmons KM, Ayanian JZ. Timely Care After an Abnormal Mammogram Among Low-Income Women in a Public Breast Cancer Screening Program. Arch Intern Med 2010; 170(6):521-528.		2252	Reg. Data	Univariate	S

Time interval of system delay	Reference
Time between first medical consultation and start of therapy	¹⁷17. Barros FA, Uemura G, Soares de Macedo JL. Tempo para acesso ao tratamento do câncer de mama no Distrito Federal, Brasil Central. Rev Bras Ginecol Obstet 2 013; 35(10):458-463.,²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.,²⁴24. Yau TK, Choi CW, Ng E, Yeung R, Soong IS, Lee AWM. Delayed presentation of symptomatic breast cancers in Hong Kong: experience in a public cancer center. Hong Kong Med J 2010; 16(5):373-377.,⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485.
Time between first consultation and confirmed diagnosis	⁴⁴44. Soares PBM, Quirino Filho S, Pereira de Souza W, Gonçalves RCR, Reis B. Martelli DRB, Fagundes Silveira M, Martelli Júnior H. Characteristics of women with breast cancer seen at reference services in the North of Minas Gerais. Rev Bras Epidemiol 2012; 15(3):595-604.,⁶⁶66. Simmons PS, Jayasinghe YL, Wold LE, Melton LJ. Breast Carcinoma in Young Women. Obstet Gynecol 2011; 118(3):529-536.
Time between first consultation and treatment	⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485.
Time gap from first presentation (physician visit) to surgery	³⁰30. Bleicher RJ, Ruth K, Sigurdson ER, Ross E, Wong YN, Patel SA, Boraas M, Topham NS, Egleston BL. Preoperative Delays in the US Medicare Population With Breast Cancer. J Clin Oncol 2012; 30(36):4485-4492.
Time between abnormal mammogram and confirmed diagnosis	⁶¹61. Ramirez AG, Pérez-Stable EJ, Talavera GA, Penedo FJ, Carrillo JE, Fernandez EF, Muñoz E, Long Parma D, Holden AEC, San Miguel de Majors S, Nápoles A, Castañeda SF, Gallion KJ. Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study. Springerplus 2013; 2(1):84.,⁶⁷67. Wujcik D, Shyr Y, Li M, Clayton MF, Ellington L, Menon U, Mooney K. Delay in Diagnostic Testing After Abnormal Mammography in Low-Income Women. Oncol Nurs Forum 2009; 36(6):709-715.,⁶⁸68. Lobb R, Allen JD, Emmons KM, Ayanian JZ. Timely Care After an Abnormal Mammogram Among Low-Income Women in a Public Breast Cancer Screening Program. Arch Intern Med 2010; 170(6):521-528.
Time between report of abnormal mammogram to first follow-up	²⁵25. Karliner LS, Hofmann M, Kerlikowske K. Language Barriers, Location of Care and Delays in Follow-up of Abnormal Mammograms. Med Care 2012; 50(2):171-178.
Time from abnormal mammogram to initiation of treatment	⁶⁸68. Lobb R, Allen JD, Emmons KM, Ayanian JZ. Timely Care After an Abnormal Mammogram Among Low-Income Women in a Public Breast Cancer Screening Program. Arch Intern Med 2010; 170(6):521-528.
Time between diagnosis and first treatment	³⁵35. Maślach D, Krzyżak M, Szpak A, Owoc A, Magdalena Bielska-Lasota. Waiting time for treatment of women with breast cancer in Podlaskie Voivodeship (Poland) in view of place of residence. A population study. Anna Agric Environ Med 2013; 20(1)161-166.,⁶⁰60. McGee SA, Durham DD, Tse CK, Millikan RC. Determinants of breast cancer treatment delay differ for African American and White women Cancer. Epidemiol Biomarkers Prev 2013; 22(7):1227-1238.
Time between diagnosis and definitive surgical treatment	²⁸28. Yun YH, Kim YA, Min YH, Park S, Won YJ, Kim DY, Choi IJ, Kim YW, Park SJ, Kim JH, Lee DH, Yoon SJ, Jeong SY, Noh DY, Heo DS. The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery. Annals of Oncology 2012; 23(10):2731-2737.,⁵⁸58. Bustami RT, Shulkin DB, Nancy O’Donnell N, Whitman ED. Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnic background: a cohort study. JRSM Open 2014; 5(7):2042533313515863.
Time gap from diagnosis to initiation of adjuvant chemotherapy	⁶³63. Vandergrift JL, Niland JC, Theriault RL, Edge SB, Wong YN, Loftus LS, Breslin TM, Hudis CA, Javid SH, Rugo HS, SilverSM, Lepisto EM, Weeks JC. Time to Adjuvant Chemotherapy for Breast Cancer in National Comprehensive Cancer Network Institutions. J Natl Cancer Inst. 2013; 105(24):1912.
Time between diagnosis and start of adjuvant hormone therapy	⁵⁷57. Crowley MM, McCoy ME, Bak SM, Caron SE, Ko NY, Kachnic LA, Alvis F, Battaglia TA. Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital. J Oncol Pract2014; 10(2):e107-112.
Time to start adjuvant chemotherapy after surgery	²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216.,²⁹29. Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol2010; 28(27):4135-4141.,⁶⁴64. Simon MS, Lamerato L, Krajenta R, Booza JC, Ruterbusch JJ, Kunz S, Schwartz K. Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System. Int J Breast Cancer 2012; 2012:453985.
Time gap specific for system delay was not defined	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897.,²⁰20. Thind A, Hoq L, Diamant A and Maly RC. Satisfaction with Care among Low-Income Women with Breast Cancer. J Womens Health (Larchmt) 2010; 19(1):77-86.,²⁷27. Chintamani, Tuteja A, Khandelwal R, Tandon M, Bamal R, Jain S, Narayan N, Srinivas S, Kumar Y. Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study. J R Soc Med Sh Rep 2011; 2:76.,³⁶36. Beattie A. Detecting breast cancer in a general practice - Like finding needles in a haystack? Aust Fam Physician 2009; 38(12):1003-1006.,³⁷37. Hansen RP, Vedsted P, Sokolowski I, Søndergaard J, Olesen F. Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients BMC Health Serv Res 2011; 11:284.,³⁹39. Rastad H, Khanjani N, Khandani BK. Causes of Delay in Seeking Treatment in Patients with Breast Cancer in Iran: a Qualitative Content Analysis Study. Asian Pac J Cancer Prev 2012; 13(9):4511-4515.,⁴⁰40. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer BMC Res Notes 2012; 21(5):452.,⁴⁵45. Price AJ, Ndom P, Atenguena E, Nouemssi JPM, Ryder RW. Cancer Care Challenges in Developing Countries. Cancer 2012; 118(14):3627-3635.,⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.,⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.,⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198.

Factor		Reference
Socioeconomic factors
	Lower educational level and literacy status	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897.,¹⁷17. Barros FA, Uemura G, Soares de Macedo JL. Tempo para acesso ao tratamento do câncer de mama no Distrito Federal, Brasil Central. Rev Bras Ginecol Obstet 2 013; 35(10):458-463.,¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18.,²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.,³³33. Black AR, Woods-Giscombé C. Applying the Stress and ‘Strength’ Hypothesis to Black Women's Breast Cancer Screening Delays. Stress Health2012; 28(5):389-396.,⁴⁰40. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer BMC Res Notes 2012; 21(5):452. 41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110.-⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380.,⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
	Financial costs too high or no health insurance	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897.,²⁷27. Chintamani, Tuteja A, Khandelwal R, Tandon M, Bamal R, Jain S, Narayan N, Srinivas S, Kumar Y. Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study. J R Soc Med Sh Rep 2011; 2:76.,⁴⁷47. Bodapati SL, Babu GR. Oncologist Perspectives on Breast Cancer Screening in India - Results from a Qualitative Study in Andhra Pradesh. Asian Pac J Cancer Prev 2013; 14(10):5817-5823.,⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380.,⁵⁷57. Crowley MM, McCoy ME, Bak SM, Caron SE, Ko NY, Kachnic LA, Alvis F, Battaglia TA. Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital. J Oncol Pract2014; 10(2):e107-112.,⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198.,⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
	Older age	¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18.,²⁷27. Chintamani, Tuteja A, Khandelwal R, Tandon M, Bamal R, Jain S, Narayan N, Srinivas S, Kumar Y. Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study. J R Soc Med Sh Rep 2011; 2:76.,³⁸38. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, Lehtsaar J, Tekkel M. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health 2013; 13:947.,⁴⁰40. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer BMC Res Notes 2012; 21(5):452.,⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380.,⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
	Younger age	²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.,³¹31. Partridge AH, Hughes ME, Ottesen RA, Wong YN, Edge SB, Theriault RL, Blaney DW, Niland JC, Winer EP, Weeks JC, Tamimi RM. The Effect of Age on Delay in Diagnosis and Stage of Breast Cancer. Oncologist 2012; 17(6):775-782.,⁴¹41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110.
	Martial status: Single or divorced	¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18.,²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216.,²⁶26. Fayanju OM, Jeffe DB, Elmore L, Ksiazek DN, Margenthaler JA. Patient and Process Factors Associated with Late-Stage Breast Cancer Diagnosis in Safety-Net Patients: A Pilot Prospective Study. Ann Surg Oncol 2013; 20(3):723-732.,⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145.
	No family history of breast cancer	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897.,⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁶⁶66. Simmons PS, Jayasinghe YL, Wold LE, Melton LJ. Breast Carcinoma in Young Women. Obstet Gynecol 2011; 118(3):529-536.
	Lower family income	²⁴24. Yau TK, Choi CW, Ng E, Yeung R, Soong IS, Lee AWM. Delayed presentation of symptomatic breast cancers in Hong Kong: experience in a public cancer center. Hong Kong Med J 2010; 16(5):373-377.,⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380.
	Higher family income	²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216.
Symptomatology experience
	Non-attribution of symptoms to cancer	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897., ¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18., ²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14., ³⁴34. Ngowa JDK, Yomi J, Kasia JM, Mawamba Y, Ekortarh AC, Vlastos G. Breast Cancer Profile in a Group of Patients Followed up at the Radiation Therapy Unit of the Yaounde General Hospital, Cameroon. Obstet Gynecol Int 2011; 2011:143506., ³⁶36. Beattie A. Detecting breast cancer in a general practice - Like finding needles in a haystack? Aust Fam Physician 2009; 38(12):1003-1006., ³⁹39. Rastad H, Khanjani N, Khandani BK. Causes of Delay in Seeking Treatment in Patients with Breast Cancer in Iran: a Qualitative Content Analysis Study. Asian Pac J Cancer Prev 2012; 13(9):4511-4515., ⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414., ⁴⁷47. Bodapati SL, Babu GR. Oncologist Perspectives on Breast Cancer Screening in India - Results from a Qualitative Study in Andhra Pradesh. Asian Pac J Cancer Prev 2013; 14(10):5817-5823., ⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380., ⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145., ⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730., ⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198., ⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367., ⁶⁶66. Simmons PS, Jayasinghe YL, Wold LE, Melton LJ. Breast Carcinoma in Young Women. Obstet Gynecol 2011; 118(3):529-536.
	Ignorance or negligence of symptoms	¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18.,³⁹39. Rastad H, Khanjani N, Khandani BK. Causes of Delay in Seeking Treatment in Patients with Breast Cancer in Iran: a Qualitative Content Analysis Study. Asian Pac J Cancer Prev 2012; 13(9):4511-4515.,⁴⁵45. Price AJ, Ndom P, Atenguena E, Nouemssi JPM, Ryder RW. Cancer Care Challenges in Developing Countries. Cancer 2012; 118(14):3627-3635.,⁴⁷47. Bodapati SL, Babu GR. Oncologist Perspectives on Breast Cancer Screening in India - Results from a Qualitative Study in Andhra Pradesh. Asian Pac J Cancer Prev 2013; 14(10):5817-5823.,⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.,⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198.
	Other symptoms than breast lump or breast pain	²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.,³⁸38. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, Lehtsaar J, Tekkel M. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health 2013; 13:947.,⁴⁰40. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer BMC Res Notes 2012; 21(5):452.,⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.,⁶⁵65. Heisey R, Clemons M, Granek L, Fergus K, Hum S, B. McCready DR, Fitzgerald B. Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians Curr Oncol 2011; 18(5):227-237.
	Previous benign or harmless breast complaint	³⁸38. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, Lehtsaar J, Tekkel M. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health 2013; 13:947.,⁴⁰40. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer BMC Res Notes 2012; 21(5):452.,⁶⁵65. Heisey R, Clemons M, Granek L, Fergus K, Hum S, B. McCready DR, Fitzgerald B. Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians Curr Oncol 2011; 18(5):227-237.
	Painless breast lump vs. other symptoms	⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.
Attitudes of patients
	Fear of disease, treatment adverse effects, examination and chemotherapy	¹⁸18. Ceballos-García GY, Giraldo-Mora CV. "Autobarreras" de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama. Aquichán 2011; 11(2):140-157.,³⁸38. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, Lehtsaar J, Tekkel M. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health 2013; 13:947.,³⁹39. Rastad H, Khanjani N, Khandani BK. Causes of Delay in Seeking Treatment in Patients with Breast Cancer in Iran: a Qualitative Content Analysis Study. Asian Pac J Cancer Prev 2012; 13(9):4511-4515.,⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁴⁷47. Bodapati SL, Babu GR. Oncologist Perspectives on Breast Cancer Screening in India - Results from a Qualitative Study in Andhra Pradesh. Asian Pac J Cancer Prev 2013; 14(10):5817-5823.,⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.,⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.,⁵⁷57. Crowley MM, McCoy ME, Bak SM, Caron SE, Ko NY, Kachnic LA, Alvis F, Battaglia TA. Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital. J Oncol Pract2014; 10(2):e107-112.,⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198.,⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
	Family and career commitments and no support from family and friends	¹⁸18. Ceballos-García GY, Giraldo-Mora CV. "Autobarreras" de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama. Aquichán 2011; 11(2):140-157.,²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.,³⁹39. Rastad H, Khanjani N, Khandani BK. Causes of Delay in Seeking Treatment in Patients with Breast Cancer in Iran: a Qualitative Content Analysis Study. Asian Pac J Cancer Prev 2012; 13(9):4511-4515.,⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.,⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198.,⁶⁵65. Heisey R, Clemons M, Granek L, Fergus K, Hum S, B. McCready DR, Fitzgerald B. Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians Curr Oncol 2011; 18(5):227-237.
	Reliance on traditional healers or preference for alternative treatment	²⁷27. Chintamani, Tuteja A, Khandelwal R, Tandon M, Bamal R, Jain S, Narayan N, Srinivas S, Kumar Y. Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study. J R Soc Med Sh Rep 2011; 2:76.,³⁴34. Ngowa JDK, Yomi J, Kasia JM, Mawamba Y, Ekortarh AC, Vlastos G. Breast Cancer Profile in a Group of Patients Followed up at the Radiation Therapy Unit of the Yaounde General Hospital, Cameroon. Obstet Gynecol Int 2011; 2011:143506.,⁴¹41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110.,⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁴⁵45. Price AJ, Ndom P, Atenguena E, Nouemssi JPM, Ryder RW. Cancer Care Challenges in Developing Countries. Cancer 2012; 118(14):3627-3635.,⁵⁴54. Norsa'adah B, Rampal KG, Rahmah MA, Nyi N, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011; 11:141.,⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.
	No breast self examination	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897.,¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18.,⁴⁰40. Ermiah E, Abdalla F, Buhmeida A, Larbesh E, Pyrhönen S, Collan Y. Diagnosis delay in Libyan female breast cancer BMC Res Notes 2012; 21(5):452.,⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145.
	No participation on mammography screening program	²¹21. Maly RC, Leak B, Mojica CM, Liu Y, Diamant AL, Thind A. What Influences Diagnostic Delay in Low-Income Women with Breast Cancer J Womens Health (Larchmt) 2011; 20(7):1017-1023.,³¹31. Partridge AH, Hughes ME, Ottesen RA, Wong YN, Edge SB, Theriault RL, Blaney DW, Niland JC, Winer EP, Weeks JC, Tamimi RM. The Effect of Age on Delay in Diagnosis and Stage of Breast Cancer. Oncologist 2012; 17(6):775-782.,³²32. Lim JNW. Empirical Comparisons of Patient Delay and Help Seeking Models for Breast Cancer: Fitness of Models for Use and Generalisation. Asian Pacific J Cancer Prev 2011; 12(6):1589-1595.,³⁶36. Beattie A. Detecting breast cancer in a general practice - Like finding needles in a haystack? Aust Fam Physician 2009; 38(12):1003-1006.,³⁸38. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, Lehtsaar J, Tekkel M. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health 2013; 13:947.,⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485.
	No acceptance of hospital treatment or distrust in success of therapy and medical system	²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216.,²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.,⁴¹41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110.,⁵⁴54. Norsa'adah B, Rampal KG, Rahmah MA, Nyi N, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011; 11:141.
	Poor knowledge of the disease and its outcomes	⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁴⁷47. Bodapati SL, Babu GR. Oncologist Perspectives on Breast Cancer Screening in India - Results from a Qualitative Study in Andhra Pradesh. Asian Pac J Cancer Prev 2013; 14(10):5817-5823.,⁵⁵55. Taib NA, Yip CH, Low WY. Recognizing Symptoms of Breast Cancer as a Reason for Delayed Presentation in Asian Women - The Psycho-sociocultural Model for Breast Symptom Appraisal: Opportunities for Intervention. Asian Pacific J Cancer Prev 2011; 12(6):1601-1608.
	No information about breast cancer from affected women, family members or other sources	³⁴34. Ngowa JDK, Yomi J, Kasia JM, Mawamba Y, Ekortarh AC, Vlastos G. Breast Cancer Profile in a Group of Patients Followed up at the Radiation Therapy Unit of the Yaounde General Hospital, Cameroon. Obstet Gynecol Int 2011; 2011:143506.,³⁸38. Innos K, Padrik P, Valvere V, Eelma E, Kütner R, Lehtsaar J, Tekkel M. Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia. BMC Public Health 2013; 13:947.,⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.
	A comorbid condition	²⁹29. Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol2010; 28(27):4135-4141.,⁵⁷57. Crowley MM, McCoy ME, Bak SM, Caron SE, Ko NY, Kachnic LA, Alvis F, Battaglia TA. Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital. J Oncol Pract2014; 10(2):e107-112.,⁶⁵65. Heisey R, Clemons M, Granek L, Fergus K, Hum S, B. McCready DR, Fitzgerald B. Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians Curr Oncol 2011; 18(5):227-237.
	Previous negative health care experience	¹⁸18. Ceballos-García GY, Giraldo-Mora CV. "Autobarreras" de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama. Aquichán 2011; 11(2):140-157.,⁶⁵65. Heisey R, Clemons M, Granek L, Fergus K, Hum S, B. McCready DR, Fitzgerald B. Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians Curr Oncol 2011; 18(5):227-237.
	Fear of social isolation and sanctions by relatives	⁴²42. Memon ZA, Shaikh AN, Rizwan S, Sardar MB. Reasons for Patient's Delay in Diagnosis of Breast Carcinoma in Pakistan. Asian Pac J Cancer Prev 2013; 14(12):7409-7414.,⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.
	Strong religious beliefs or religious fatalism	²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216.,⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.
Ethnic differences
	Afro Americans, Latin American and Asian versus Caucasian ethnicity or Chinese versus Malay and Indian ethnicity	¹⁹19. Quaife SL, Forbes LJL, Ramirez AJ, Brain KE, Donnelly C, Simon AE, Wardle J. Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK. Br J Cancer 2014; 110(1):12-18.,⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380.,⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145.,⁵⁷57. Crowley MM, McCoy ME, Bak SM, Caron SE, Ko NY, Kachnic LA, Alvis F, Battaglia TA. Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital. J Oncol Pract2014; 10(2):e107-112.

Factor		Reference
Socioeconomic factors
	Worse insurance status and insurance authorization delays	²⁹29. Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol2010; 28(27):4135-4141., ⁴³43. Poum A, Promthet S, Duffy SW, Maxwell Parkin D. Factors Associated With Delayed Diagnosis of Breast Cancer in Northeast Thailand. J Epidemiol2014; 24(2):102-108., ⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485., ⁵⁸58. Bustami RT, Shulkin DB, Nancy O’Donnell N, Whitman ED. Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnic background: a cohort study. JRSM Open 2014; 5(7):2042533313515863., ⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198., ⁶¹61. Ramirez AG, Pérez-Stable EJ, Talavera GA, Penedo FJ, Carrillo JE, Fernandez EF, Muñoz E, Long Parma D, Holden AEC, San Miguel de Majors S, Nápoles A, Castañeda SF, Gallion KJ. Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study. Springerplus 2013; 2(1):84., ⁶³63. Vandergrift JL, Niland JC, Theriault RL, Edge SB, Wong YN, Loftus LS, Breslin TM, Hudis CA, Javid SH, Rugo HS, SilverSM, Lepisto EM, Weeks JC. Time to Adjuvant Chemotherapy for Breast Cancer in National Comprehensive Cancer Network Institutions. J Natl Cancer Inst. 2013; 105(24):1912.
	Older age	²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216., ²⁸28. Yun YH, Kim YA, Min YH, Park S, Won YJ, Kim DY, Choi IJ, Kim YW, Park SJ, Kim JH, Lee DH, Yoon SJ, Jeong SY, Noh DY, Heo DS. The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery. Annals of Oncology 2012; 23(10):2731-2737., ²⁹29. Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol2010; 28(27):4135-4141., ⁶³63. Vandergrift JL, Niland JC, Theriault RL, Edge SB, Wong YN, Loftus LS, Breslin TM, Hudis CA, Javid SH, Rugo HS, SilverSM, Lepisto EM, Weeks JC. Time to Adjuvant Chemotherapy for Breast Cancer in National Comprehensive Cancer Network Institutions. J Natl Cancer Inst. 2013; 105(24):1912.
	Younger age	²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14.,³⁰30. Bleicher RJ, Ruth K, Sigurdson ER, Ross E, Wong YN, Patel SA, Boraas M, Topham NS, Egleston BL. Preoperative Delays in the US Medicare Population With Breast Cancer. J Clin Oncol 2012; 30(36):4485-4492.,⁴³43. Poum A, Promthet S, Duffy SW, Maxwell Parkin D. Factors Associated With Delayed Diagnosis of Breast Cancer in Northeast Thailand. J Epidemiol2014; 24(2):102-108.
	Lower family income	²⁴24. Yau TK, Choi CW, Ng E, Yeung R, Soong IS, Lee AWM. Delayed presentation of symptomatic breast cancers in Hong Kong: experience in a public cancer center. Hong Kong Med J 2010; 16(5):373-377.,⁴³43. Poum A, Promthet S, Duffy SW, Maxwell Parkin D. Factors Associated With Delayed Diagnosis of Breast Cancer in Northeast Thailand. J Epidemiol2014; 24(2):102-108.,⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485.,⁶⁴64. Simon MS, Lamerato L, Krajenta R, Booza JC, Ruterbusch JJ, Kunz S, Schwartz K. Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System. Int J Breast Cancer 2012; 2012:453985.
	Lower educational level	²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216., ²⁹29. Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol2010; 28(27):4135-4141., ⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485.
Diagnostic factors
	False negative diagnostic test	²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14., ³⁶36. Beattie A. Detecting breast cancer in a general practice - Like finding needles in a haystack? Aust Fam Physician 2009; 38(12):1003-1006., ⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485., ⁵⁴54. Norsa'adah B, Rampal KG, Rahmah MA, Nyi N, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011; 11:141., ⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198., ⁶⁶66. Simmons PS, Jayasinghe YL, Wold LE, Melton LJ. Breast Carcinoma in Young Women. Obstet Gynecol 2011; 118(3):529-536.
	Delay in scheduling or getting diagnostic test results	⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730., ⁵⁷57. Crowley MM, McCoy ME, Bak SM, Caron SE, Ko NY, Kachnic LA, Alvis F, Battaglia TA. Challenges in the Delivery of Quality Breast Cancer Care: Initiation of Adjuvant Hormone Therapy at an Urban Safety Net Hospital. J Oncol Pract2014; 10(2):e107-112., ⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198.
Factors that affect decisions of physicians
	Having no mammogram or no participation in periodic mammography screening program	²¹21. Maly RC, Leak B, Mojica CM, Liu Y, Diamant AL, Thind A. What Influences Diagnostic Delay in Low-Income Women with Breast Cancer J Womens Health (Larchmt) 2011; 20(7):1017-1023., ²³23. Ozmen V, Boylu S, Ok E, Canturk NZ, Celik V, Kapkac M, Girgin S, Tireli M, Ihtiyar E, Demircan O, Baskan MS, Koyuncu A, Tasdelen I, Dumanli E, Ozdener F, Zaborek P. Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies. Eur J Public Health 2014; 25(1):9-14., ⁴⁴44. Soares PBM, Quirino Filho S, Pereira de Souza W, Gonçalves RCR, Reis B. Martelli DRB, Fagundes Silveira M, Martelli Júnior H. Characteristics of women with breast cancer seen at reference services in the North of Minas Gerais. Rev Bras Epidemiol 2012; 15(3):595-604., ⁶⁷67. Wujcik D, Shyr Y, Li M, Clayton MF, Ellington L, Menon U, Mooney K. Delay in Diagnostic Testing After Abnormal Mammography in Low-Income Women. Oncol Nurs Forum 2009; 36(6):709-715.
	More comorbidities	²²22. Sheppard VB, Isaacs C, Luta G, Willey SC, Boisvert M, Harper FWK, Smith K, Horton S, Liu MC, Jennings Y, Hirpa F, Snead F, Mandelblatt JS. Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship. Breast Cancer Res Treat 2013; 139(1):207-216., ⁶³63. Vandergrift JL, Niland JC, Theriault RL, Edge SB, Wong YN, Loftus LS, Breslin TM, Hudis CA, Javid SH, Rugo HS, SilverSM, Lepisto EM, Weeks JC. Time to Adjuvant Chemotherapy for Breast Cancer in National Comprehensive Cancer Network Institutions. J Natl Cancer Inst. 2013; 105(24):1912.
	Fewer comorbidities	²⁸28. Yun YH, Kim YA, Min YH, Park S, Won YJ, Kim DY, Choi IJ, Kim YW, Park SJ, Kim JH, Lee DH, Yoon SJ, Jeong SY, Noh DY, Heo DS. The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery. Annals of Oncology 2012; 23(10):2731-2737.
Access barriers
	Longer distance to health care centre	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897., ²⁷27. Chintamani, Tuteja A, Khandelwal R, Tandon M, Bamal R, Jain S, Narayan N, Srinivas S, Kumar Y. Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study. J R Soc Med Sh Rep 2011; 2:76., ⁴¹41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110., ⁴³43. Poum A, Promthet S, Duffy SW, Maxwell Parkin D. Factors Associated With Delayed Diagnosis of Breast Cancer in Northeast Thailand. J Epidemiol2014; 24(2):102-108., ⁴⁵45. Price AJ, Ndom P, Atenguena E, Nouemssi JPM, Ryder RW. Cancer Care Challenges in Developing Countries. Cancer 2012; 118(14):3627-3635., ⁶³63. Vandergrift JL, Niland JC, Theriault RL, Edge SB, Wong YN, Loftus LS, Breslin TM, Hudis CA, Javid SH, Rugo HS, SilverSM, Lepisto EM, Weeks JC. Time to Adjuvant Chemotherapy for Breast Cancer in National Comprehensive Cancer Network Institutions. J Natl Cancer Inst. 2013; 105(24):1912.
	Rural versus urbanized living place	²⁷27. Chintamani, Tuteja A, Khandelwal R, Tandon M, Bamal R, Jain S, Narayan N, Srinivas S, Kumar Y. Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study. J R Soc Med Sh Rep 2011; 2:76., ⁴¹41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110.
	Urbanized versus rural living place	³⁵35. Maślach D, Krzyżak M, Szpak A, Owoc A, Magdalena Bielska-Lasota. Waiting time for treatment of women with breast cancer in Podlaskie Voivodeship (Poland) in view of place of residence. A population study. Anna Agric Environ Med 2013; 20(1)161-166.
Communication between patient and physician
	Poor communication	⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570., ⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
	Good communication	⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
Disease Management
	Other hospital versus teaching hospital or specialized cancer centre, respectively	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897., ⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730., ⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570.
	High volume or public hospital versus smaller or private hospital, respectively	⁴¹41. Ukwenya AY, Yusufu LMD, Nmadu PT, Garbaa ES, Ahmed A. Delayed treatment of symptomatic breast cancer: The experience from Kaduna, Nigeria. S Afr Surg 2008; 46(4):106-110., ⁴⁹49. Piñeros M, Sánchez R, Cendales R, Perry F, Ocampo R. Patient delay among Colombian women with breast cancer. Salud Publica Mex 2009; 51(5):372-380.
	Low volume versus larger hospital	⁵⁰50. Rajan SS, Lim JNW, Haq A. Late Presentation and Management of South Asian Breast Cancer Patients in West Yorkshire, United Kingdom Asian Pac J Cancer Prev 2011; 12(6):1615-1628.
	Inappropriate surgery and biopsy management	¹⁶16. Landolsi A, Gahbiche S, Chaafii R, Chabchoub I, Ben Fatma L, Hochlef M, Gharbi O, Ahmed SB. Reasons of diagnosis delay of breast cancer in Tunisian women (160 patients in central region of Tunisia). Tunis Med 2010; 88(12):894-897., ²⁹29. Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006. J Clin Oncol2010; 28(27):4135-4141.
	Preoperative components (imaging, biopsy, clinical visits)	⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145., ⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.
	Comparison of different disease management programs or imaging and reporting data systems	³⁴34. Ngowa JDK, Yomi J, Kasia JM, Mawamba Y, Ekortarh AC, Vlastos G. Breast Cancer Profile in a Group of Patients Followed up at the Radiation Therapy Unit of the Yaounde General Hospital, Cameroon. Obstet Gynecol Int 2011; 2011:143506., ⁵⁸58. Bustami RT, Shulkin DB, Nancy O’Donnell N, Whitman ED. Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnic background: a cohort study. JRSM Open 2014; 5(7):2042533313515863.
	Limited knowledge about cancer by health care professionals	³³33. Black AR, Woods-Giscombé C. Applying the Stress and ‘Strength’ Hypothesis to Black Women's Breast Cancer Screening Delays. Stress Health2012; 28(5):389-396., ⁵²52. Muhamad M, Merriam S, Suhami N. Why Breast Cancer Patients Seek Traditional Healers. Int J Breast Cancer 2012; 2012:689168.
Histopathological characteristics
	Higher staged tumor	¹⁸18. Ceballos-García GY, Giraldo-Mora CV. "Autobarreras" de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama. Aquichán 2011; 11(2):140-157., ⁵²52. Muhamad M, Merriam S, Suhami N. Why Breast Cancer Patients Seek Traditional Healers. Int J Breast Cancer 2012; 2012:689168., ⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.
	Lower staged tumor	⁵⁰50. Rajan SS, Lim JNW, Haq A. Late Presentation and Management of South Asian Breast Cancer Patients in West Yorkshire, United Kingdom Asian Pac J Cancer Prev 2011; 12(6):1615-1628., ⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145.
	Positive lymph node state, lymphovascular invasion, overweight, smaller tumor and invasive versus in situ tumor	⁴⁸48. Piñeros M, Sánchez RM, Perry F, García OA, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011; 53(6):478-485., ⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
	Negative hormone receptor status	⁵⁰50. Rajan SS, Lim JNW, Haq A. Late Presentation and Management of South Asian Breast Cancer Patients in West Yorkshire, United Kingdom Asian Pac J Cancer Prev 2011; 12(6):1615-1628., ⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367.
	Positive hormone receptor status	⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730.
Ethnic differences
	Afro Americans, Latin American and/or Asian versus Caucasian ethnicity	¹⁸18. Ceballos-García GY, Giraldo-Mora CV. "Autobarreras" de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama. Aquichán 2011; 11(2):140-157., ³⁴34. Ngowa JDK, Yomi J, Kasia JM, Mawamba Y, Ekortarh AC, Vlastos G. Breast Cancer Profile in a Group of Patients Followed up at the Radiation Therapy Unit of the Yaounde General Hospital, Cameroon. Obstet Gynecol Int 2011; 2011:143506., ⁵⁰50. Rajan SS, Lim JNW, Haq A. Late Presentation and Management of South Asian Breast Cancer Patients in West Yorkshire, United Kingdom Asian Pac J Cancer Prev 2011; 12(6):1615-1628., ⁵¹51. Ghazali SM, Othman Z, Cheong KC, Hock LK, Rozita W, Mahiyuddin W, Kamaluddin MA, Yusoff AF, Mustafa AN. Non-Practice of Breast Self Examination and Marital Status are Associated with Delayed Presentation with Breast Cancer Asian Pacific J Cancer Prev 2013; 14(2):1141-1145., ⁵³53. Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding Barriers to Malaysian Women with Breast Cancer Seeking Help. Asian Pac J Cancer Prev2012; 13(8):3723-3730., ⁵⁴54. Norsa'adah B, Rampal KG, Rahmah MA, Nyi N, Naing NN, Biswal BM. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011; 11:141., ⁵⁶56. Yusoff N, Taib NAM, Ahmad A. The Health Seeking Trajectories of Malaysian Women and their Husbands in Delay Cases of Breast Cancer: A Qualitative Study Asian Pac J Cancer Prev 2011; 12(10):2563-2570., ⁵⁹59. Bourdeanu L, Luu T, Baker N, Swain-Cabriales S, Chung CT, Mortimer J, Hurria A, Helton S, Smith D, Ferrell B, Juarez G, Somlo G. Barriers to Treatment in Patients With Locally Advanced Breast Cancer. J Natl Compr Canc Netw2013; 11(10):1193-1198., ⁶¹61. Ramirez AG, Pérez-Stable EJ, Talavera GA, Penedo FJ, Carrillo JE, Fernandez EF, Muñoz E, Long Parma D, Holden AEC, San Miguel de Majors S, Nápoles A, Castañeda SF, Gallion KJ. Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study. Springerplus 2013; 2(1):84., ⁶²62. Sharma K, Costas A, Damuse R, Hamiltong-Pierre J, Pyda J, Ong CT, Shulman LN and Meara JG. The Haiti Breast Cancer Initiative: Initial Findings and Analysis of Barriers-to-Care Delaying Patient Presentation. J Oncol 2013; 2013:206367., ⁶⁵65. Heisey R, Clemons M, Granek L, Fergus K, Hum S, B. McCready DR, Fitzgerald B. Health care strategies to promote earlier presentation of symptomatic breast cancer: perspectives of women and family physicians Curr Oncol 2011; 18(5):227-237.

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[1] Collaborations

AGQ Freitas contributed to the selection process of literature. M Weller contributed to the selection process of literature and was responsible for study design and manuscript draft.