[Accepted Manuscript] Delayed presentation and diagnosis of breast cancer in African women: a systematic review.

Africa has low breast cancer incidence rates but high mortality rates from this disease due to poor survival. Delays in presentation and diagnosis are major determinants of breast cancer survival, but these have not been comprehensively investigated in Africa. MEDLINE, Embase, and Global Health were searched to identify studies reporting on delays in presentation and/or diagnosis of breast cancer published between January 1, 2000 and May 31, 2016. Data were synthesized in narrative, tabular, and graphical forms. Meta-analyses were not possible due to between-study differences in the way delays were reported. Twenty-one studies were included in the review. Study-specific average times between symptom recognition and presentation to a health care provider ranged from less than 1 to 4 months in North Africa and from less than 3 to greater than 6 months in sub-Saharan Africa. Study-specific average times from presentation to diagnosis were less than 1 month in North Africa but ranged from less than 3 to greater than 6 months in sub-Saharan Africa. Reported reasons for these delays included patient-mediated (e.g., socioeconomic factors) and health system-mediated factors (e.g., referral pathways). This systematic review revealed marked delays in presentation and diagnosis of breast cancer in Africa. Identification of their drivers is crucial to the development of appropriate control strategies in the continent