title: Influence of delay on survival in patients with breast cancer: a systematic review.
abstract: BACKGROUND
  Most patients with breast cancer are detected after symptoms occur rather than through screening. The impact on survival of delays between the onset of symptoms and the start of treatment is controversial and cannot be studied in randomised controlled trials. We did a systematic review of observational studies (worldwide) of duration of symptoms and survival.
  
  
  METHODS
  We identified 87 studies (101,954 patients) with direct data linking delay (including delay by patients) and survival. We classified studies for analysis by type of data in the original reports: category I studies had actual 5-year survival data (38 studies, 53,912 patients); category II used actuarial or multivariate analyses (21 studies, 25,102 patients); and category III was all other types of data (28 studies, 22,940 patients). We tested the main hypothesis that longer delays would be associated with lower survival, and a secondary hypothesis that longer delays were associated with more advanced stage, which would account for lower survival.
  
  
  RESULTS
  In category I studies, patients with delays of 3 months or more had 12% lower 5-year survival than those with shorter delays (odds ratio for death 1.47 [95% CI 1.42-1.53]) and those with delays of 3-6 months had 7% lower survival than those with shorter delays (1.24 [1.17-1.30]). In category II, 13 of 14 studies with unrestricted samples showed a significant adverse relation between longer delays and survival, whereas four of five studies of only patients with operable disease showed no significant relation. In category III, all three studies with unrestricted samples supported the primary hypothesis. The 13 informative studies showed that longer delays were associated with more advanced stage. In studies that controlled for stage, longer delay was not associated with shorter survival when the effect of stage on survival was taken into account.
  
  
  CONCLUSIONS
  Delays of 3-6 months are associated with lower survival. These effects cannot be accounted for by lead-time bias. Efforts should be made to keep delays by patients and providers to a minimum.
authors: ICRF Psychosocial Oncology Group, Guy's, King's and St Thomas's School of Medicine, St Thomas' Hospital, London, UK.
authors: M A
authors: MA
authors: Richards
authors: A M
authors: AM
authors: Westcombe
authors: S B
authors: SB
authors: Love
authors: P
authors: P
authors: Littlejohns
authors: A J
authors: AJ
authors: Ramirez
mesh_terms: D000704:Analysis of Variance; D015982:Bias; D001943:Breast Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D003627:Data Interpretation, Statistical; D005260:Female; D006801:Humans; D015993:Life Tables; D009367:Neoplasm Staging; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012044:Regression Analysis; D012107:Research Design; D016019:Survival Analysis; D013997:Time Factors