Where do delays occur? A systematic review of the barriers to early breast cancer diagnosis across South Africa’s health system
TL;DR
Community awareness, culturally grounded education, streamlined referral pathways and equitable investment in diagnostic and oncology services may significantly improve timely diagnosis and breast cancer outcomes.
Abstract
Abstract Objectives Breast cancer is the most common cancer among South African women, yet the country has the lowest 5-year survival rate among the BRICS nations (Brazil, Russia, India, China, South Africa), at just 40%. Earlier diagnosis contributes to survival rates exceeding 90% in many high-income countries. We synthesised the evidence to identify barriers to early breast cancer diagnosis in South Africa and inform policy interventions. Design A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Data sources OVID MEDLINE, Global Health, Health Management Information Consortium, Scopus and Web of Science were searched for studies published between 1 January 2015 and 31 March 2025. Eligibility criteria We included English-language, peer-reviewed studies investigating patient-level, provider-level and/or health system-level barriers to early breast cancer diagnosis among adult women in South Africa. Barriers were classified using the WHO 2017 Guide to Cancer Early Diagnosis framework: (1) awareness and access to care; (2) clinical evaluation, diagnosis and staging and (3) access to treatment. Data extraction and synthesis Two reviewers independently screened studies, extracted data and assessed risk of bias. Findings were synthesised narratively using the WHO framework. Results 22 studies (n=8518 participants; 5048 women with breast cancer) were included. Step 1 barriers included limited breast cancer knowledge and poor healthcare access, particularly among rural and less educated women. Step 2 barriers included multiple prediagnosis visits and inadequate diagnostic capacity, with delays of 28 days to over 12 months. Step 3 barriers included limited surgical and oncology services, requiring many rural patients to travel for treatment. One-stop clinics were associated with shorter diagnostic intervals. Conclusions Barriers to early diagnosis occur across the breast cancer pathway in South Africa. Community awareness, culturally grounded education, streamlined referral pathways and equitable investment in diagnostic and oncology services may significantly improve timely diagnosis and breast cancer outcomes. PROSPERO registration number CRD420261297178.