The journey of cancer patients and the quest to equity: findings from Morocco

OBJECTIVES

Rapid diagnostic and assessment pathways for cancer patients provide timely and effective care. This study took place in Morocco, where the majority of patients treated in the public sector are diagnosed at an advanced stage. The aim of this study was to determine the duration of different time intervals along the cancer patient pathway and to highlight problem areas so that strategies can be implemented to make the process more equitable and effective.

STUDY DESIGN

Cross-sectional study.

METHODS

Recently diagnosed cancer patients were recruited from four major oncology centres in Morocco; namely, Marrakech, Casablanca, Rabat, and Fez. A questionnaire survey was administered, including sociodemographic and medical information and questions on access to the oncology centre, beliefs, and opinions on the medical staff. The dates of symptom recognition, assessment, diagnosis referral, biopsy, and treatment initiation were collected. Different time intervals (patient, diagnosis, biopsy, and treatment) were estimated and their determinants were investigated.

RESULTS

A total of 812 patients were interviewed. The majority of participants were breast cancer patients. In total, 60% of participants were at stage III-IV. The main facilitators of cancer diagnosis confirmation and treatment initiation were easy access to diagnosis and treatment facilities, financial resources, personal history of cancer, time availability, late stage at diagnosis, advanced age, and private health insurance. The patient interval (i.e., time from symptom recognition to initial healthcare assessment) had a median duration of 30 days. The biopsy and treatment intervals were within the current international recommendations (7 and 28 days, respectively). However, the diagnosis interval (52 days) was twice as long as the recommended timeframes from the UK, Australia, and the World Health Organization (<28 days).

CONCLUSIONS

Interval targets should be defined to encourage health systems to be more equitable and effective and to ensure that cancer patients are treated within a defined timeframe.

Time intervals and previous primary care consultations in the pathway to emergency cancer diagnosis

BACKGROUND

Time intervals and number of prior consultations in primary care (PC) are recognised metrics of diagnostic timeliness of cancer and are interrelated. However, whether and how the two measures correlate with each other in the emergency diagnostic pathway is unknown. We investigated the association between the number of prereferral consultations and the length of intervals from PC presentation to cancer diagnosis following emergency referral to hospital.

METHODS

Patients were eligible if they first consulted in PC and were diagnosed with cancer following emergency or nonemergency referral to hospital. We analysed for differences in PC and diagnostic intervals and number of consultations between emergency and nonemergency presenters and determined their associations by cancer type. Differences in presenting symptoms and stage at diagnosis between populations and according to number of consultations were also examined.

RESULTS

There were 796 emergency and 865 nonemergency presenters with comparable sociodemographic and comorbidity data. Correlation analysis in emergency presenters revealed a strong positive association between number of consultations and intervals for seven of 13 different cancers, including cancers characterised by high proportions of > 3 consultations and long intervals (pancreatic, lung, and colorectal cancer) and vice versa for others (e.g., endometrial, cervical, or oesophageal cancer). Additionally, emergency presenters with > 3 consultations were more likely than those with 1-2 to report nonspecific symptoms (60 vs. 40%, respectively) and to be diagnosed at a later stage.

CONCLUSION

System level interventions are needed to reduce unnecessary delays in the emergency diagnostic pathway, particularly in cancer patients with multiple prereferral consultations. The findings also suggest opportunities to reduce the proportion of emergency diagnoses by targeting symptomatic individuals pre-presentation.

Time intervals to care and health service use experiences of uninsured cancer patients treated under public financing in Mexico City

BACKGROUND

The present study assesses the time intervals from symptom discovery to treatment start and describes the health service use experiences of uninsured patients with cancer of the breast, cervix uteri, testicle, and prostate before their arrival to the cancer hospital.

METHODS

This cross-sectional study included 1468 patients who were diagnosed between June 2016 and May 2017 and received treatment for the selected cancers in two of the largest public cancer hospitals in Mexico City, financed through Seguro Popular. Data was collected through a survey administered via face-to-face interviews with patients and a review of their medical files.

RESULTS

The median time between detection (symptom discovery or first abnormal screening test) and treatment start was 6.6 months. For all types of cancer, the longest interval was the diagnostic interval -between the first use of healthcare services and the confirmation of cancer. Less than 20% cancer patients were diagnosed in the earliest stages that are associated with the best chances of long-term survival. The participants described a high use of private services for their first consultation, the use of several different types of health services and multiple consultations before arrival to the cancer centers, and 35% perceived being misdiagnosed by the first doctor they consulted.

CONCLUSIONS

Most cancer patients treated in the two largest public institutions available for the uninsured faced long delays to get diagnosed and started treatment at advanced stages. Strengthening quality and access for effective early cancer diagnosis and treatment is key to improve patient outcomes in low and middle-income settings.

Characteristics of human immunodeficiency virus exposure and predictors of time until access to postexposure prophylaxis: a prospective observational study

OBJECTIVES

The efficacy of postexposure prophylaxis (PEP) after human immunodeficiency virus (HIV) contact relies on administering the treatment within 4 hours of contact with the virus. This study aimed to evaluate predictors of the time that elapses between HIV exposure and emergency department arrival.

MATERIAL AND METHODS

Prospective observational study carried out at Hôpital Bichat, a university teaching hospital in Paris, France. All emergency visits for occupational or nonoccupational exposure to HIV in 2016 and 2017 were included.

RESULTS

A total of 1475 cases were studied; 598 patients responded to the follow-up survey. A delay of 4 hours or more between HIV exposure and the emergency department visit was associated with type of contact: health care occupational exposure, other occupational exposure, or sexual intercourse (P .001). We found significant differences between individuals exposed during sexual contact versus occupational exposure with respect to knowledge of the PEP program pathway (65.2% vs 46.9%, respectively), previous use of PEP (23.9% vs 13.1%), alcohol intake (36.2% vs 18.5%), drug use (34.6% vs 8.6%), and chemsex (sexualized drug use) (26.1% vs 0%) (P .001, all comparisons). Predictors of time until start of PEP among individuals exposed during sexual intercourse were knowledge and prior use of the PEP pathway (P .001), drug use (P = .03), and chemsex (P .001). Predictors among occupationally exposed individuals were prior knowledge of the PEP pathway and drug use (P .001).

CONCLUSION

Delay in seeking PEP after HIV exposure is greater among individuals exposed during sexual intercourse. Knowledge of the PEP program and prior use of it are associated with less delay. Exposure during sexual intercourse, alcohol and drug use, and chemsex are associated with longer delays, especially in men who have sex with men.

Kidney function and the prognostic value of myocardial performance index

A decreased glomerular filtration rate (GFR) is a risk factor for cardiovascular disease even after adjustment for conventional risk factors. The myocardial performance index (MPI) is defined as (isovolumetric relaxation time (IVRT) + isovolumetric contraction time (IVCT))/ejection time (ET). It has been shown to be an independent predictor of cardiovascular events. We hypothesized the MPI could prove valuable for assessing cardiac risk in subjects of the general population with decreased estimated GFR (eGFR). MPI was measured in 1915 subjects from a large general population prospective cohort study using color tissue Doppler imaging (TDI) M-mode through the mitral valve. We compared the prognostic capabilities of the MPI between subjects with eGFR ≥ 75 mL/min/1.73 m² and subjects with eGFR < 75 mL/min/1.73 m² using multivariable adjusted Cox regression models. The composite endpoint was heart failure, myocardial infarction or cardiovascular death. Mean age was 58 years (SD 16.2), 58% were women, 42% had hypertension and 8.3% diabetes. During a median follow-up time of 12.4 years [IQR 10.6-12.7 years] 269 participants reached the combined endpoint. eGFR modified the prognostic capability of MPI (p-value for interaction < 0.001): After multivariable adjustment, MPI remained an independent predictor of the composite endpoint only in participants with eGFR < 75 mL/min/1.73 m²: HR 1.18 (95% CI 1.02-1.38), p = 0.03, vs. in subjects with eGFR ≥ 75 mL/min/1.73 m²: HR 1.14 (95% CI 0.94-1.39), p = 0.17. These results suggest the MPI could be particularly valuable for identifying elevated cardiac risk in individuals from the general population with decreased eGFR.

Time intervals to diagnosis and chemotherapy do not influence survival outcome in patients with advanced pancreatic adenocarcinoma

BACKGROUND

The effect of treatment delay on survival in pancreatic ductal adenocarcinoma (PDAC) remains unclear.

AIMS

This study aimed to assess the prognostic impact of time to diagnosis and chemotherapy in advanced PDAC and factors influencing the time intervals.

METHODS

advanced PDAC patients receiving chemotherapy in five centers in the decade 2007-2016 were included. Key time points during care pathway from clinical presentation to beginning of chemotherapy were retrospectively collected. Multivariate Cox proportional hazard model was performed.

RESULTS

A total of 409 patients were included (mean age 66.1 ± 10.3 years; 250 metastatic (61%); 139 received FOLFIRINOX chemotherapy (34%). The median overall survival (OS) was 7.2 months. The median times from first symptoms and from first specialist visit to the beginning of chemotherapy were respectively 100 days and 47 days. None of time intervals was significantly associated with OS. Significant prognostic factors were FOLFIRINOX chemotherapy (HR 0.6 [0.5-0.8]; P < 0.001), metastasis (HR 1.6 [1.3-2.0]; P = 0.001), WHO PS ≥ 2 (HR 1.6 [1.2-2.1]; P < 0.001) and acute pancreatitis as first symptom (HR 2.9 [1.7-4.9]; P < 0.001). Jaundice shortened time to diagnosis (P < 0.001). Acute pancreatitis (P < 0.001) and diabetes (P = 0.01) increased time to treatment.

CONCLUSION

Wait times from clinical presentation to beginning of chemotherapy do not influence survival in advanced PDAC.

Factors Associated with Time Intervals for Diagnosis of Colorectal Cancer: A Hospital Based Study in Khon Kaen, Thailand

Background:

Colorectal cancer (CRC) is among the five-leading cancers in Thailand. Delayed diagnosis is crucial for undermining the prognosis of the patients. This study aims to evaluate the factors associated with the time interval for diagnosis (TID).

Methods:

A cross-sectional analytical study of 191 CRC patients with histological confirmation who were undergoing treatment in the tertiary hospital in Khon Kaen Province was conducted. The data were obtained by interview and retrieving from medical records. The time interval in each diagnostic process is reported in geometric mean. The geometric mean ratio (GMR) used to interpret the results from multiple linear regressions that analyze the relationship between factors and log-transformed TID.

Results:

Most patients were males (61.78%) with mean age of 61.28±10.2 years old. The geometric mean of TID was 263.48 days. Two factors were significantly associated with longer TID: first visit at a tertiary hospital (GMR=7.77 relative to secondary hospital; 95%CI=1.95 to 30.57) and distance to tertiary healthcare. Two factors were significantly associated with shorter TID: officer/ state enterprise (GMR=0.53 relative to agriculture; 95%CI=0.28 to 0.98) and cost of traveling to secondary healthcare.

Conclusions:

The results showed the occupation, first health care visit, distance and cost were factors associated with TID. Improving the facilities at the secondary healthcare units for diagnosing CRC would be likely to help to reduce the wasted time in the healthcare system.

Pathways to care for patients in Pakistan experiencing signs or symptoms of breast cancer

Multiple social and financial barriers exist to breast cancer detection in Pakistan, which may cause a delay in seeking care and the final diagnosis. This analytical study documents the pathways and time courses associated with referral to diagnostic centres to evaluate the clinical signs and symptoms of breast cancer. This report also verifies the association between socio-demographic and clinical indicators concerning the length of time spent before reaching diagnostic facilities. A purposive sample of 200 patients was selected from two tertiary care hospitals in Lahore, Pakistan, for the interviews. Descriptive statistics (that is, percentages, frequencies, and measures of central tendencies) and a multiple linear regression model were used to achieve the study objectives. The descriptive model showed 31-128 days interval between a patient's awareness of a clinical sign or symptom and receiving care. The healthcare system, including traditional healers, took from 7 to 194 days, and the time to diagnosis ranged from 15 to 30 days. Pain severity, larger tumour size, lack of clinical improvement, and the desire to obtain better treatment were reasons given for seeking care, but lack of awareness and fear of financial burden related to accessing healthcare facilities were identified as barriers. Moreover, socio-demographic and other predictive clinical factors were potentially associated with and substantially influenced the likelihood of the increased length of breast cancer patients' time to reach diagnostic centres. In conclusion, referrals by multiple healthcare providers, especially traditional healers and general practitioners, was a significant predictor for delay in diagnosis. Therefore, increased awareness and a responsive healthcare system may reduce the time from the recognition of symptoms to the early detection of breast cancer among women, thus improving outcomes in a developing country.

Determinants of total ischemic time in primary percutaneous coronary interventions: A prospective analysis

OBJECTIVE

To assess the factors contributing to longer total ischemic times in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI).

METHODS

Three hundred forty-six patients who underwent PPCI from July 2016 to June 2017 were studied. From time for the patient to recognize the symptoms, time was divided into 11 stages, any reason for delay was observed.

RESULTS

Mean window period was 6.7 ± 9.8 hours. Mean time to recognize the symptoms, reach first medical contact and prehospital management were 150.2 ± 140.5 min, 58.5 ± 57.0 min and 36.3 ± 38.0 min, respectively. Mean time for the patients brought in ambulance was 82.4 ± 59.8 min whereas for those transported in other vehicles was 130.4 ± 59.7 min (p = < 0.0001). Mean door to electrocardiogram (ECG) time, decision for PPCI, consent time and STEMI team activation time were 6.2 ± 3.1 min, 8.3 ± 4.5 min, 12.6 ± 16.2 min and 10.7 ± 8.2 min, respectively. Mean time for financial process and mean sheath to balloon time were 9.1 ± 6.9 min and 21.8 ± 11.7 min, respectively. Door to balloon time (DTB) was <90 min in 81% of the patients, mean DTB was 72.0 ± 33.0 min. Mean DTB for cases performed during night was 72.6 ± 32.9 min, whereas for those performed during day was 60.3 ± 30.2 min (p < 0.05). Total 30 day mortality was 2.9%. Mortality among DTB <90 min was 1.4%, mortality among DTB > 90 min was 9% (p < 0.05).

CONCLUSIONS

The main contributor for longer total ischemic time was the time taken for the patient to recognize the symptoms. DTB of <90 min can be achieved with effective hospital strategies.

Mechanical Thrombectomy for Acute Ischemic Stroke in Czech Republic: Technical Results from the Year 2016

BACKGROUND AND PURPOSE

Experienced multidisciplinary stroke team and well-organized hospital management are considered necessary to achieve good results after mechanical thrombectomy (MT) in acute ischemic stroke patients. We analyzed the technical results of MT performed in the Czech Republic in the year 2016 to provide relevant data for further quality improvement.

MATERIAL AND METHODS

All centers performing MT in the CR were called for detailed technical and clinical data from year 2016, which were anonymously analyzed and relevant technical key time intervals were compared. Clinical outcomes were assessed according to the HERMES meta-analysis.

RESULTS

In the 2016, 1053 MTs were performed in the CR. Of 15 dedicated centers, the data from 12 centers and from 886 (84%) patients (49.2% males, mean age 69.8 ± 12.3 years) were analyzed. The overall median of time from hospital arrival to groin puncture (GP) was 77 min with a range from 40 to 109 min among individual hospitals, from GP to first passage of stent retriever 20 (15-40) min and from GP to maximal reached recanalization 42 (33-80) min. The median of recanalization time was 240 (219-320) min. The recanalization (TICI 2b-3) was achieved in 81.7% of patients, 44.1% of patients had a good 3-month clinical outcome and 6.3% suffered from symptomatic intracerebral hemorrhage. Peri-procedural complications were recorded in 89 (10%) patients.

CONCLUSION

Despite achieved good overall results, a great variability in some of the analyzed key time intervals among individual centers performing MT warrants further quality improvement.

Alerta Rosa: Novel Alert and Navigation Breast Cancer Program in Nuevo Leon, Mexico, for Reducing Health System Interval Delays

BACKGROUND

In Mexico, the median time between breast cancer (BC) symptom detection and treatment initiation is approximately 7 months. Alerta Rosa is a program that was developed with the intent of breaking down medical care barriers and reduce delays.

PATIENTS AND METHODS

Through several media campaigns, we reached out to patients with breast symptoms or abnormal imaging studies. Patients contacted our call center or Facebook page. A navigator recorded their main complaint and scheduled a medical consultation with a specialist. We prioritized patients according to clinical risk. Those diagnosed with BC were referred to their health affiliation unit for care.

RESULTS

To date, 656 patients have contacted our program. Median age was 44 years (range, 7-82). Patients reported becoming aware of Alerta Rosa mainly by word of mouth and TV. A total of 446 medical consultations were scheduled, and 309 patients attended their appointments. A biopsy procedure was solicited for 39 patients, and 22 were diagnosed with BC. Most patients had stage II (45%) or stage III (32%) disease. The median time from alert activation to treatment initiation was 33 days (range, 19-56) and from first medical evaluation to treatment initiation was 28 days (range, 16-48).

CONCLUSION

In low- or middle-income countries, where BC screening programs do not effectively reach the target population, it is crucial to focus efforts in identifying and prioritizing symptomatic patients or those with abnormal imaging studies to ultimately downstage BC. Alerta Rosa proved to be successful in reducing health system intervals and could be replicated and adapted for other limited resource settings.

IMPLICATIONS FOR PRACTICE

In countries such as Mexico, infrastructure and financial drawbacks limit the implementation of effective screening mammography programs. This article presents a novel and effective alternative to optimize resources and reduce health system intervals, so that patients in limited-resource settings can have access to prompt quality care. This strategy for early breast cancer detection focused efforts in prioritizing symptomatic women and those with abnormal breast imaging studies. This article presents novel information that will be useful for the development of effective early breast cancer detection with a focus on opportunistic rather than population-screening mammography in low-resource settings.

The LEAD study protocol: a mixed-method cohort study evaluating the lung cancer diagnostic and pre-treatment pathways of patients from Culturally and Linguistically Diverse (CALD) backgrounds compared to patients from Anglo-Australian backgrounds

Background

Lung cancer is the leading cause of cancer mortality worldwide. Early diagnosis and treatment is a key factor in reducing mortality and improving patient outcomes. To achieve this, it is important to understand the diagnostic pathways of cancer patients. Patients from Culturally and Linguistically Diverse (CALD) are a vulnerable group for lung cancer with higher mortality rates than Caucasian patients. The aim of this study is to explore differences in the lung cancer diagnostic pathways between CALD and Anglo-Australian patients and factors underlying these differences.

Methods

This is a prospective, observational cohort study using a mixed-method approach. Quantitative data regarding time intervals in the lung cancer diagnostic pathways will be gathered via patient surveys, General practitioner (GP) review of general practice records, and case-note analysis of hospital records. Qualitative data will be gathered via structured interviews with lung cancer patients, GPs, and hospital specialists. The study will be conducted in five study sites across three states in Australia. Anglo-Australian patients and patients from five CALD groups (i.e., Arabic, Chinese, Greek, Italian and Vietnamese communities) will mainly be identified through the list of new cases presented at lung multidisciplinary team meetings. For the quantitative component, it is anticipated that 724 patients (362 Anglo-Australian and 362 CALD patients) will be recruited to obtain a final sample of 290 (145 per group) assuming a 50% patient survey completion rate and a 80% GP record review completion rate. For the qualitative component, 60 interviews with lung cancer patients (10 Anglo-Australian and 10 patients per CALD group), 20 interviews with GPs, and 20 interviews with specialists will be conducted.

Discussion

This is the first Australian study to compare the time intervals along the lung cancer diagnostic pathway between CALD and Anglo-Australian patients. The study will also explore the underlying patient, healthcare provider, and health system factors that influence the time intervals in the two groups. This information will improve our understanding of the effect of ethnicity on health outcomes among lung cancer patients and will inform future interventions aimed at early diagnosis and treatment for lung cancer, particularly patients from CALD backgrounds.

Trial registration

The project was retrospectively registered with Australian New Zealand Clinical Trials Registry (registration number: ACTRN12617000957392, date registered: 4th July 2017).

Resting Heart Rate Variability (HRV) in Adolescents and Young Adults from a Genetically-Informed Perspective

Reduced heart rate variability (HRV) is associated with cardiac morbidity, mortality, and negative psychopathology. Most research concerning genetic influences on HRV has focused on adult populations, with fewer studies investigating the developmental period of adolescence and emerging adulthood. The current study estimated the genetic and environmental contributions to resting HRV in a sample of twins using various HRV time domain metrics to assess autonomic function across two different time measurement intervals (2.5- and 10-min). Five metrics of resting HRV [mean interbeat interval (IBI), the standard deviation of normal IBIs (SDNN), root square mean of successive differences between IBIs (RMSSD), cardiac vagal index (CVI), and cardiac sympathetic index (CSI)] were assessed in 421 twin pairs aged 14-20 during a baseline electrocardiogram. This was done for four successive 2.5-min intervals as well as the overall 10-min interval. Heritability (h²) appeared consistent across intervals within each metric with the following estimates (collapsed across time intervals): mean IBI (h² = 0.36-0.46), SDNN (h² = 0.23-0.30), RMSSD (h² = 0.36-0.39), CVI (h² = 0.37-0.42), CSI (h² = 0.33-0.46). Beyond additive genetic contributions, unique environment also was an important influence on HRV. Within each metric, a multivariate Cholesky decomposition further revealed evidence of genetic stability across the four successive 2.5-min intervals. The same models showed evidence for both genetic and environmental stability with some environmental attenuation and innovation. All measures of HRV were moderately heritable across time, with further analyses revealing consistent patterns of genetic and environmental influences over time. This study confirms that in an adolescent sample, the time interval used (2.5- vs. 10-min) to measure HRV time domain metrics does not affect the relative proportions of genetic and environmental influences.

Emergency management of patients with ST-segment elevation myocardial infarction in Eastern Austria: a descriptive quality control study

Background

Myocardial infarction is a time-critical condition and its outcome is determined by appropriate emergency care. Thus we assessed the efficacy of a supra-regional ST-segment elevation myocardial infarction (STEMI) network in Easternern Austria.

Methods

The Eastern Austrian STEMI network serves a population of approx. 766.000 inhabitants within a region of 4186 km². Established in 2007, it now comprises 20 pre-hospital emergency medical service (EMS) units (10 of these physician-staffed), 4 hospitals and 3 cardiac intervention centres. Treatment guidelines were updated in 2012 and documentation within a web-based STEMI registry became mandatory. For this retrospective qualitative control study, data from February 2012–April 2015 was assessed.

Results

A total of 416 STEMI cases were documented, and 99% were identified by EMS within 6 (4.0–8.0) minutes after arrival. Median time loss between onset of pain and EMS call was 54 (20–135) minutes; response, pre-hospital and door-to-balloon times were 14 (10–20), 46 (37–59) and 45 (32–66) minutes, respectively. When general practitioners were involved, time between onset of pain and balloon inflation significantly increased from 180 (135–254) to 218 (155–348) minutes (p < .001). A pre-hospital time < 30 min was achieved in 25.8% of all patients during the day vs. 11.6% during the night (p < .001). Three hundred forty-five patients (83%) were subjected to primary percutaneous coronary intervention (PPCI), and 6.5% were thrombolysed by EMS. Pre-hospital complication rate was 18% (witnessed cardiac arrest 7%, threatening arrhythmias 6%, cardiogenic shock 5%). Twenty-four hours and hospital mortality rate were 1.2 and 2.8%, respectively.

Discussion

Optimal patient care and subsequently outcome of STEMI is strongly determined by a short patient-decision time to call EMS and by the first medical contact to balloon time (FMCBT). Supra-regional networks are key in order to increase the efficacy and efficiency of health care. The goal of 120 min FMCBT was achieved in 78% of our patients immediately managed by EMS, thus indicating room for improvement.

Conclusion

In conclusion, results from the Eastern Austrian STEMI network shed light on the necessity of increasing patient awareness in order to minimize any time loss derived by delayed EMS calls. Involvement of family physicians resulted in prolonged FMCBT. A stronger utilization of rescue helicopters could further improve the efficacy of this supra-regional network. Nevertheless PPCI rates, time intervals and outcome rates compare well with international benchmarks.

Challenges to the early diagnosis and treatment of breast cancer in developing countries

This critical review of the literature assembles and compares available data on breast cancer clinical stage, time intervals to care, and access barriers in different countries. It provides evidence that while more than 70% of breast cancer patients in most high-income countries are diagnosed in stages I and II, only 20%-50% patients in the majority of low- and middle-income countries are diagnosed in these earlier stages. Most studies in the developed world show an association between an advanced clinical stage of breast cancer and delays greater than three months between symptom discovery and treatment start. The evidence assembled in this review shows that the median of this interval is 30-48 d in high-income countries but 3-8 mo in low- and middle-income countries. The longest delays occur between the first medical consultation and the beginning of treatment, known as the provider interval. The little available evidence suggests that access barriers and quality deficiencies in cancer care are determinants of provider delay in low- and middle-income countries. Research on specific access barriers and deficiencies in quality of care for the early diagnosis and treatment of breast cancer is practically non-existent in these countries, where it is the most needed for the design of cost-effective public policies that strengthen health systems to tackle this expensive and deadly disease.