The delay of breast cancer diagnosis and management during the Syrian war

1Introduction

Breast Cancer (BC) is the most commonly diagnosed cancer among women. It is responsible for one in four cancer cases and one in six cancer deaths worldwide [37] . Significant delays in BC diagnosis and treatment occurs three times more in low- and middle-income countries (LMICs) than high-income countries (HICs). Late diagnosis and poor access to healthcare in the former, represent major determinants of higher mortality rates, as cancer is more likely to be treated in its early stages [2432388] . Similarly, treatment delayed for as short as four weeks can also associate with lower survival rates [1416] and more invasive surgical procedures [26] .

These prolonged time intervals between symptoms appearance, diagnosis, and treatment were linked to poor awareness of the signs and symptoms, limited access to primary healthcare, inadequacy of screening programs, lack of standardized treatment plans, poor financial status, cancer stigma, and sociocultural factors [202723] . They are also categorized into patient delay (PD) and healthcare system delay (SD) [12] ; the former is defined as the delay between noticing symptoms and seeking medical care, and it is related to patient’s beliefs and cultural background [30] , attitudes [11] , absence of social support [25] , economic status [30] , and age [1541] . SD, on the other hand, is defined as the delays within healthcare systems, which are related to several factors including the availability of screening tests [8] and accessibility to healthcare facilities [39] . Additionally, the minimized availability of healthcare professionals and misjudgment of the disease leads to late diagnosis [28] and represents a significant component of SD [12] .

In Syria, the healthcare system suffered from a dramatic collapse since the armed conflict started in 2011. Over half of healthcare facilities in Syria went out of service by 2016, and more followed due to the repeated attacks. The healthcare system additionally experienced shortage in essential medicines and equipment, lack of professionals, and insufficient screening and follow up especially in besieged areas [34] . These factors as well as the dire humanitarian situation challenged the country preparedness for the burden of severe chronic diseases including cancers [6] , leading to late diagnosis, inadequate management of cancers, and as a result poorer survival rate [33] . BC screening during the Syrian war was also found to be less commonly practiced compared to other surrounding populations, especially in rural and war-affected regions [17] . Therefore, as early detection improves the survival rate, minimizing delay intervals can be the most feasible and approachable means of improving BC prognosis and treatment costs in our limited-resources country. This study aims for the first time to assess the prevalence of the different delays in BC diagnosis and management, as well as their predisposing characteristics and impact on disease staging during the Syrian armed conflict.