Person:

Meara, John

Background: Within the developing world, many personal, sociocultural, and economic factors cause delayed patient presentation, a prolonged interval from initial symptom discovery to provider presentation. Understanding these barriers to care is crucial to optimizing interventions that pre-empt patient delay. Methods: A systematic review was conducted querying: PubMed, Embase, Web of Science, CINAHL, Cochrane Library, J East, CAB, African Index Medicus, and LiLACS. Of 763 unique abstracts, 122 were extracted for full review and 13 included in final analysis. Results: Studies posed variable risks of bias and produced mixed results. There is strong evidence that lower education level and lesser income status contribute to patient delay. There is weaker and, sometimes, contradictory evidence that other factors may also contribute. Discussion. Poverty emerges as the underlying common denominator preventing earlier presentation in these settings. The evidence for sociocultural variables is less strong, but may reflect current paucity of high-quality research. Conflicting results may be due to heterogeneity of the developing world itself. Conclusion: Future research is required that includes patients with and without delay, utilizes a validated questionnaire, and controls for potential confounders. Current evidence suggests that interventions should primarily increase proximal and affordable healthcare access and secondarily enhance breast cancer awareness, to productively reduce patient delay.

Background. In Haiti, breast cancer patients present at such advanced stages that even modern therapies offer modest survival benefit. Identifying the personal, sociocultural, and economic barriers-to-care delaying patient presentation is crucial to controlling disease. Methods. Patients presenting to the Hôpital Bon Sauveur in Cange were prospectively accrued. Delay was defined as 12 weeks or longer from initial sign/symptom discovery to presentation, as durations greater than this cutoff correlate with reduced survival. A matched case-control analysis with multivariate logistic regression was used to identify factors predicting delay. Results. Of N = 123 patients accrued, 90 (73%) reported symptom-presentation duration and formed the basis of this study: 52 patients presented within 12 weeks of symptoms, while 38 patients waited longer than 12 weeks. On logistic regression, lower education status (OR = 5.6, P = 0.03), failure to initially recognize mass as important (OR = 13.0, P < 0.01), and fear of treatment cost (OR = 8.3, P = 0.03) were shown to independently predict delayed patient presentation. Conclusion. To reduce stage at presentation, future interventions must educate patients on the recognition of initial breast cancer signs and symptoms and address cost concerns by providing care free of charge and/or advertising that existing care is already free.

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.