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Abstract

This study aimed to examine the factors contributing to the late-stage diagnosis of breast cancer in African American and Hispanic women. Databases were electronically searched using Academic Search Complete; Alt Health Watch; APA PsycInfo; CINAHL with Full Text; Health and Psychosocial Instruments; Health Source—Consumer Edition; Health Source: Nursing/Academic Edition; and MEDLINE. Arksey and O’Malley’s methodological framework was followed. The five levels of the socio-ecological model were used as theoretical guidelines. Social determinants of health (at the individual, interpersonal, organizational, community, and policy levels) limited the adherence to breast cancer screening and led to the late-stage diagnosis of breast cancer, which impacted the survival rates. Multi-level efforts are required to address the social determinants of health, which impede care accessibility, and improve health outcomes for women experiencing health inequalities.

Keywords

breast cancer breast cancer screening African American and Hispanic women late-stage diagnosis of breast cancer

Introduction

Currently, breast cancer affects one in eight women, with an average lifetime risk of 13%. It is the second principal cause of cancer-related death among women in the United States (American Cancer Society, 2021). There has been a recent increase in the incidence rate of breast cancer by 0.5% per year (American Cancer Society, 2021). A delay of ≥3 months in diagnosis considerably contributes to breast cancer mortality (Gullatte et al., 2010; Gwyn et al., 2004). Although the health repercussions among ethnic minority women, including migrants, are significant, remain unclear. Most racial and ethnic minority women in western societies are recent immigrants, acculturated immigrants, or offspring of immigrants.

Compared with the general population, there is a difference in the risk of breast cancer for racial and ethnic minority women. Moreover, compared with their Caucasian counterparts, African American and Hispanic females have a lower prevalence of breast cancer but a higher rate of late-stage diagnosis and mortality due to breast cancer (American Cancer Society, 2021; Bentley et al., 1998; Warner et al., 2012).

Mammography screening rates are lower than the recommended rates in patients with low socioeconomic strata, which increases the rate of late-stage breast cancer diagnosis, morbidity, and mortality rates (Bibb, 2000). Compared with White women, Hispanic/Latina American women have lower mammogram screening rates and survival rates, with an increased likelihood of late-stage breast cancer diagnosis (Castañeda et al., 2014; Hedeen & White, 2001; Mojica et al., 2007). According to the American Cancer Society, in 2018, the prevalence of up-to-date mammography screening among women aged ≥45 years was 60% and 64% in Hispanic and White women, respectively (American Cancer Society, 2021).

Between 2009 and 2018, the breast cancer incidence rate increased by approximately 0.5% per year in Hispanic women (American Cancer Society, 2021). Compared with non-Hispanic White women, Hispanic women have a lower 5-year breast cancer survival rate (88% vs. 92%), which suggests a relatively higher likelihood of late-stage diagnosis among Hispanic women (American Cancer Society, 2021). Moreover, compared with non-Hispanic White women, Hispanic women are more prone to be diagnosed with larger and hormone receptor-negative tumors, which are both more difficult to treat, and are less likely to receive prompt and appropriate breast cancer treatment (American Cancer Society, 2021; Smith-Bindman et al., 2006).

Similarly, Black women have higher population-based breast cancer mortality rates compared with White Americans. Additionally, Black women are twice as likely to be diagnosed with the biologically aggressive triple-negative phenotype breast cancer as women of other racial and ethnic groups in the US. Triple-negative breast cancer lacks estrogen receptors (ER-), progesterone receptors (PR-), and Human Epidermal growth factor Receptor 2 (HER2-); therefore, it does not respond to hormonal therapy (Bibb, 2000; Castañeda et al., 2014; Rayne et al., 2019).

There are multiple risk factors for breast cancer, including genetic and sociodemographic factors. Women with five or more risk factors have nearly a 12-fold increase in delayed breast cancer diagnosis. Genetic factors include having dense breast tissue, carrying cancer predisposing BRCA1 and BRCA2 mutations, a known family history of breast cancer, and a carcinoma pattern consistent with autosomal dominant inheritance. Furthermore, sociodemographic risk factors include race, sex, age, and reproductive history (Yedjou et al., 2017). Other risk factors include radiation exposure early in life, alcohol ingestion, smoking, obesity, sedentary lifestyle, and geographical residential area (p = .04) (F. Williams & Thompson, 2016).

Compared with White women, Black women have a 1.5-fold increased odds of late-stage breast cancer diagnosis (odds ratio [OR] = 1.50; 95% CI [1.39, 1.63]; p < .0001) (F. Williams & Thompson, 2016; Yedjou et al., 2017). Furthermore, women of color, notably Blacks and Hispanics, have differences compared with their White counterparts in the degree of the positive correlation between socioeconomic resources and cancer screening utilization (Monnat, 2014). Access to preventive care and appropriate treatment has a considerable influence on health outcomes in women with breast cancer. Social determinants of health, including marital status, education, employment, and adequate health insurance, are among the positive predictors of mammography uptake (66.8%) (Coughlin, 2019; Guo et al., 2019; Oeffinger et al., 2015; Ogunsiji et al., 2017; Patel et al., 2014; K. H. Wang et al., 2018; Zamorano-Leon et al., 2020).

Since 1990, there has been a decrease in the mortality rate of breast cancer in the United States by ≥40% due to the onset of widespread mammographic screening in the mid-1980s and evidence that mammogram screening can reliably detect breast cancer and decrease mortality (Monticciolo, 2020; Wujcik et al., 2007). Moreover, <10 years ago, disparities in diagnosis were recognized among symptomatic women, with White and Black women having a median of 36 and 53.6 days, respectively, to diagnosis. Among women with abnormal mammograms, the median time to diagnosis was 21 and 29 days for White and Black women, respectively. Black women showed the highest proportion (26%) of Stage III or IV tumors (American Joint Committee on Cancer’s Manual for Staging of Cancer; Warner et al., 2012). The issue is further complicated since compared with White women, Black women are more likely to have therapy postponed or receive suitable treatment for breast cancer.

Consistent with the Healthy People 2030 objectives of addressing disparities in breast cancer treatment in order to reach 15.3 breast cancer deaths per 100,000 females (Healthy People, 2030), this scoping review aimed to explore the current literature regarding factors contributing to the late-stage diagnosis of breast cancer in ethnic minority and/or migrant women. Further, the findings are interpreted from the perspective of the social-ecological model.

Theoretical Framework

The information presented in this review was synthesized in the context of the socio-ecological model (SEM), which is a population-based approach adopted by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) (CDC/NBCCEDP; Wu et al., 2015). Through the NBCCEDP, the Centers for Disease Control and Prevention (CDC) facilitates accessibility to timely breast and cervical cancer screening and treatments among low-income, uninsured, and medically underprivileged females (CDC/NBCCEDP; Wu et al., 2015). Furthermore, the NBCCEDP provides patient navigation services to help under-served women overcome barriers and obtain timely access to quality care (CDC/NBCCEDP; Wu et al., 2015). The SEM is an appropriate framework for elucidating the various factors influencing health and well-being. It provides a complete perspective of the factors affecting specific health behaviors, including the social determinants of health within the individual, social, organizational, and policy environments (Monticciolo, 2020; Wu et al., 2015). McLeroy et al. (1988) elaborated on the health promotion perspective of the SEM.

The SEM acknowledges five interrelated domains: (1) Intrapersonal, also known as the Individual level, involves the individual’s developmental history, including knowledge, self-concept, behavior, attitudes, and skills. (2) The Interpersonal level comprises primary groups, that is, formal and informal social networks as well as social support systems involving the family, workgroup, and friendship networks. (3) The Organizational or Institutional level encompasses social institutions with organizational characteristics, formal/informal rules, and regulations for operation. (4) The Community-level involves relationships among organizations, institutions, and informal networks within defined boundaries. (5) The Policy level covers public, local, state, and national laws/policies (McLeroy et al., 1988).

Methods

This review applied the methodological framework of Arksey and O’Malley (2005). The five significant stages of this framework were used to identify literature in order to answer the research question as follows:

Stage 1, identify the research question: What are the factors contributing to the late-stage diagnosis of breast cancer in racial and ethnic minority women?

Stage 2, search for relevant studies: Articles regarding factors contributing to the late-stage diagnosis of breast cancer in racial and ethnic minority women were searched. Specifically, the EbscoHost and PubMed databases (Academic Search Complete; Alt Health Watch; APA PsycInfo; CINAHL with Full Text; Health and Psychosocial Instruments; Health Source—Consumer Edition; Health Source: Nursing/Academic Edition; MEDLINE) were searched using the terms detailed in Table 1.

Table 1.

List of Mesh Terms and Boolean/Phrases Used for the Database Search.

EbscoHost, PubMed databases
((“Delayed diagnosis” [All Fields] AND “breast neoplasms” [MeSH Terms] OR “breast cancer” [MeSH Terms] OR “breast tumor” [MeSH Terms] OR “breast carcinoma” [All Fields] AND “minority women” [All Fields] OR “women of color” [MeSH Terms] OR “black” [MeSH Terms] OR “Hispanic” [MeSH Terms] OR “African American”))

Further, the following synonyms or different keywords were used during the advanced search: Delayed diagnosis AND (breast neoplasms or breast cancer or breast tumor or breast carcinoma) AND (minority women or women of color or black or Hispanic or African American).

(3) Stage 3: Selecting appropriate studies: The inclusion criteria for peer-reviewed quantitative studies were as follows: published in English between 1980 and 2020, participants were women aged ≥18 years who were of African American or Hispanic heritage and conducted in the US.

Studies on the transgender population; institutionalized women; and women of unknown race or races other than African, African American, and Hispanic were excluded. The initial search yielded 143 articles; among them, 61 articles were excluded by removing duplicate references, screening titles and abstracts, and applying the inclusion and exclusion criteria. Finally, 38 articles were included. Figure 1 details the selection process.

Figure 1.

PRISMA diagram for inclusion of studies.

Due to the de-identified data used in this review, No Institutional Review Board was sought or required.

(4) Stage 4 charts the data on a matrix: A literature matrix was created based on the recording of data from the 38 selected articles (see Table 2).

Table 2.

Critique of the Included Studies.

Title of article	Authors	Purpose/researchquestions/hypotheses/sample	Research variables/setting/location	Design/major tools	Major findings and limitations/quality of evidence
Determinants of LS dx of breast & cervical cancer: The impact of age, race, social class & hospital type	Mandelblattet al. (1991)	Cancer Data-Tumor Registry; all cases of BC & cervical cancer among NYC residents reported bet 1980 & 1985	Age, race, marital status, hospital type (“public” for the 11 NYC municipal hospitals, “non-public”)	-Retrospective descriptive design. -LR analyses	Lower income was weakly associated with LS dx (p < .055). Age, public hospital use, marital status, & low education were linked with risks of distant disease. Limitation: Missing data regarding association with age & H origin exclusion
Delay in dx and tx of BC: Implications for education	Bedellet al. (1995)	Included 225 women from public/university hospitals/cancer centers/private practice	Times to evaluation, dx, and initiation of tx.	-Descriptive comparative design	Elapsed times for dx, tx, & combined intervals were considerably longer in public hospitals than in private hospitals
Differences in BC stage at dx bet NH W & H populations, San Diego County 1988–1993	Bentley et al. (1998)	Explored if lower number of BC was dx at ES vs. LS & if lower income is linked to LS dx at H vs. NHW	San Diego County from the California Cancer Registry	-Retrospective Descriptive comparative study	Positive correlations found bet the census tract per capita income & the rates of ES dx among NHW but not H.
Influence of SE & cultural factors on racial differences in LS	Lanninet al. (1998)	Explored factors influencing racial differences in BC stages at dx 540 of 743 newly dx BC & 414 control women fit by age/race/residence	The main outcome measures were BC stage at dx.	-Case-control study of patients diagnosed with BC from 1985 to 1992	Although a large proportion of ES cancers were diagnosed on MS or CBE, almost all patients with LS BC presented breast symptoms or distant metastases. Further, 25% of patients with LS BC had frank ulceration, which led to bleeding/infection
Access & LS dx of BC in the military system	Bibb (2000)	Analyzed noneconomic access barrier, link bet access & stage at dx of BC in W & AAW dx with BC	Variables: age, race rank of sponsor, stage at dx, mean of discovery, survival status	-Descriptive comparative design Aday/Andersen framework	LS dx of BC was more likely to occur in AAW from low SES with incidental cancers on BSE. Main predictors of LS dx were means of discovery & duration bet discovery & dx.
BC size & stage in HAW by Birthplace: 1992–1995	Hedeen andWhite (2001)	Examined whether HW with BC have tumor characteristics linked with LS dx. & birthplace SEER program	Reflecting timeliness of BC dx, tumor size, & tumor stage at dx	-Descriptive comparative design	Compared with US-born HW, HAW born in Latin America had a higher % of tumors larger >1 cm & larger >2 cm showing a relative delay in timeliness of cancer dx.
Racial differences in dx, tx, & clinical delays in a population-based study of patients with newly dx BC	Gwynet al. (2004)	Factors contributing to differences among women aged 20–54 years living in Atlanta, Georgia, who have BC dx (1990–1992): 251AAW & 580WW	Diagnosis delay, tx delay & clinical delay	-Population-based case-control study of invasive & in situ BC Polytomous LR	Compared with WW, AAW were more likely to experience delays in dx & tx. Access to care & poverty index accounted for differences in delay time. Limitations: Small study population
Latinas with Abnormal Breast Findings: Patient Predictors of Timely Diagnostic Resolution	Mojicaet al. (2007)	Effects of SES, knowledge, barriers to healthcare, communication, & clinical variables on dx resolution in Latina women with breast abnormalities at 2 Los Angeles County public hospitals. N = 714	Timely dx resolution based on medical record data & defined as receipt of a definitive dx (malignant/benign) within 6 months of the index referral	-Descriptive comparative design -Multivariate LR models	Hospital B had a higher timely dx resolution (73%) > than hospital A (56%). The odds of timely dx resolution were greater in hospital A (8%) for every point increase in the satisfaction scale score with HCP explanation of breast abnormality, but in hospital B, the increase was at 57% for every 10-year increase in age
Psychosocial factors influencing timely completion of f/u after incomplete or abnormal MS result in a medically underserved population	Wujciket al. (2007)	Women identified from medical records participated in a 30 minutes telephone interview	162 items questionnaire	-Experimental design. -Two sample t-tests and non- parametric tests -Health Belief Social Cognitive Theory	Both groups had high perceived barriers, low perceived benefits, low knowledge of BC risks & guidelines, high fatalism, & low health orientation
LS BC dx. & Health Care Access in Illinois	F. Wanget al. (2008)	Role of access to healthcare in explaining the variation of LS dx of BC. Illinois Cancer registry by zip code	The effects of spatial access, in combination with the influences of SES on LS BC dx	-Descriptive comparative design -Geographic information systems analysis	Poor geographical access to HCP increases risks of LS dx for individuals living outside of Chicago. Deprived populations endured high rates of LS dx. Poor spatial access to HCP was linked with LS dx compared with spatial access to mammography
Religious beliefs/delay in BC dx. for self-detected breast changes in AA women	Gullatteet al. (2009)	Relationship bet religious beliefs & delay in dx of BC & BC stage for self-detected breast symptoms (30 –84 years), median age of 54	Time to seek medical care & BC Stage, telling someone about the breast change	-Descriptive correlational study	Delayed seeking of medical care was linked with only talking to God about breast signs/symptoms. Telling someone about breast symptoms was significant at p = .01 for reducing delay
Misconceptions about Breast Lumps and Delayed Medical Presentation in Urban Patients with Breast Cancer	Rauscheret al. (2010)	Factors potentially related to delay in seeking health care for breast symptoms among 436 urban patients with symptomatic BC (146 W, 197 B, & 95 H)	Race/ethnicity/SES health care access, utilization, & misconceptions about breast lumps were key independent variables	-Descriptive comparative design. Andersen et al. model	About 16% reported > 3 months delay before seeking medical help about breast symptoms. Misconceptions regarding breast lumps & lacking a regular HCP, health coverage, & recent preventive care were linked with prolonged patient delay. Limitation: Self-reported passage of time
Factors Associated with Delays to Dx & tx of BC in Women in a Louisiana Urban SN Hospital	D. L. Williamset al. (2010)	Examined factors linked with delays to dx & tx of BC in W & AA women (N = 247)	Age, race, stage of disease at dx, tumor size, type of abnormality, medical care at presentation, & prior MS within the previous 2 years	-Descriptive comparative design -Chi-square ests & LR	Compared with WW, AAW experienced delays. No differences existed in distributions of cancer stage at dx bet AA & WW. Smaller tumor sizes found in women experiencing dx delays, while larger tumor sizes found in older women experiencing tx delays
Religiosity, spirituality & cancer fatalism beliefs on delay in BC Dx. in AAW	Gullatteet al. (2010)	Explored the effect of religiosity, spirituality, & cancer fatalism on delay in dx & BC stage in AAW with self-detected symptoms	Time to seek care, insurance, married, income, education, insurance, BCS, to whom breast symptoms were spoken to	-Retrospective design -Descriptive statistics 3 scales	Unmarried, less-educated females who spoke to God about breast changes were > likely to delay seeking care. While women who told a person about their symptoms were > likely to seek care sooner
Black residential segregation, disparities in spatial access to HCF, & LS dx of BC in metropolitan Detroit	Dai (2010)	Evaluated the role of B residential segregation & spatial access to health care in LS dx of BC in metropolitan Detroit	Data pertaining to BC, 1998–2002 Michigan Cancer Surveillance Program	-Retrospective study -Floating catchment area approach+ Gaussian function	Living in areas with greater B segregation & poorer mammogram access significantly increases the risk of LS dx of BC
Neighborhood Changes in Concentrated Immigration & LS BC dx.	Choet al. (2011)	Explored the link bet changes in the immigrant population & likelihood of distant metastasis stage at dx of BC in Cook County Illinois	42,714 BC cases dx bet 1994 and 2003 as well as the 1990 & 2000 Census tract data	-Descriptive design -Illinois State Cancer Registry data	An increase in immigrant populations within neighborhoods increased the risk of LS dx of BC. Despite improvement in the health indicators for immigrant populations, important health disparities in BC dx exist at the neighborhood level
BC Stage at Dx: Is Travel Time Important?	Henryet al. (2011)	Explored if patients’ travel time to MS facility impacts BC stage at dx. 10 population-based state cancer registries. (N = 161,619)	Age, race, ethnicity census tract poverty, rural/ urban residence, health insurance, & state random effects	-Comparative descriptive study -LR	Travel time to dx or nearest MS facility was not a factor of LS dx of BC & better geographic proximity did not assure more favorable stage distributions. Limited data on MS/use & transportation accessibility
Geographic disparities in LS BC dx in California.	Kuoet al. (2011)	Cancer registry data of California. 2 socio-ecological predictors were linked with the probability of LS dx of BC	Variables: Residential isolation & poverty assessed the probability of LS dx of BC	-Retrospective descriptive design -Random-intercept logistic models	Some areas had better outcomes for one group but worse outcomes for others, suggesting that interventions for improving outcomes require different strategies for different groups
What Influences Dx Delay in Low-Income Women with Breast Cancer?	Malyet al. (2011)	State-wide sample of 921 low-income women with a new dx, grouped by self or health system	Elapsed time bet knowing breast abnormality & receiving a definitive dx of BC among low-income women	-Cross-sectional study -Multivariate LR	AA had the longest intervals bet symptom detection & dx resolution; median delays: 115 & 70 days, respectively, compared to 64 & 22 days for Caucasians
Spanish As a Primary Language and Its Effect on BC Presentation	Oliveiraet al. (2011)	Examined definitive BC surgery, BC stage, & type N = 170	Ethnicity, primary language spoken, & insurance status were analyzed	-A retrospective chart review -Urban community hospital	The rate of dx at stage III or more was 10%, 16%, & 22% for the W, AA, & H populations respectively, as well as 27% for non–English-speaking H with LS disease. Limitations: SES, education, & income, were not considered
Identifying Women at Risk of Delayed Breast Cancer Diagnosis	Stuveret al. (2011)	Examined a sample of 5,464 women newly dx with BCin Boston	Delayed dx interval > 90 days bet the first breast-related problem that urged seeking care & BC dx based on biopsy	-A retrospective cohort study	The likelihood of experiencing a delayed BC dx markedly increased if a woman had multiple risk factors, with a nearly 12-fold increase among women with ≥5 risk factors
Spatial association of racial/ethnic dis-parities bet LS dx and mortality for female BC: Where to intervene?	Tianet al. (2011)	Spatial relationships of racial/ethnic disparities bet BC LS dx & mortality	Relationship bet SES/racial/ethnic disparities of LS dx & mortality for BC using the % of the population under the poverty level	-Descriptive comparative design Geographically weighted regression analysis	Census tracts with low & middle SES showed major racial disparities in BC LS dx & mortality rates. Thought values of local correlation coefficients suggested the association of these two types of racial/ ethnic disparities varied across geographic regions
Disparities in LS Dx, Tx, & BC-related Death by race, age, & rural residence among women in Georgia	Markossian andHines (2012)	Outcomes of LS BC dx, receiving first-course tx, & BC-related death by race, age, & rural/urban residence in Georgia. (N = 23,500)	Race, age, & rural/urban residence in Georgia	-Cross-sectional (1992–2007) -Multilevel modeling & Cox proportional hazard models	Increased age was linked with the odds of unknown/LS at dx, worse tx, & survival. Women in rural areas had decreased odds of receiving radiation, surgery, & receiving breast-conserving surgery compared with mastectomy
Time to dx and breast cancer stage by race/ethnicity	Warneret al. (2012)	The analytic sample includes 21,427 women diagnosed with stage I–IV BC bet 01/01/20 & 12/31/07	Differences in time to dx according to race, ethnicity, stage, & extent to which it explains differences in stage at dx.	-Descriptive comparative design -AJCC criteria	Median time to dx was 21 & 29 days for WW & BW respectively. B women had the highest proportion (26%) of Stage III or IV tumors. B & H women experienced a longer time to dx. W & B women were >likely to be diagnosed with LS tumors
Patient & Process Factors Associated with LS BC dx. in SN Patients: A Pilot Prospective Study	Fayanjuet al. (2013)	Investigated SN patients at any stage (0–IV) & NSN patients with LS dx (IIB-IV) BC from September 2008 to June 2010	Safety-Net Patients Study	-Pilot Prospective Study -LR, chi-square, & t-tests	Among the referred SN patients, 52% had LS dx of BC, >likely to be AA as well as < likely to be married, have post college education/insurance, have income <$25,000, report having a health problem, & were unable to see a doctor due to cost
Mammogram image quality as a potential contributor to disparities in BC stage at dx: an observational study	Rauscheret al. (2013)	Population-based study	Three technologist image quality indicators & four machine image quality indicators	-Descriptive design -Seven indicators of image quality on a 5-point Likert scale	Lower technologist-associated image quality indicators were subsequently linked with LS at dx, even after adjusting for multiple patient & practice factors
Neighborhood SE disadvantage & race/ethnicity as predictors of BC stage at dx	Floreset al. (2013)	Sample size of n = 7,619 for 1990 & n = 11,967 California Cancer Registry	Variables: ethnicity age, race, marital status, BCS at dx, income/education	-Retrospective design	An increase in situ cases of dx existed bet 1990–2000 among zip codes with low SES & education levels
Health Care Access & BCS Among Latinas along the California-Mexican Border	Castañedaet al. (2014)	Community-based sample of 208 Latinas aged ≥40 years in San Diego County	Psychosocial factors, health care access, & recent MS	-Descriptive design. Behavioral Model	MS adherence is linked with lower acculturation, annual physician visits/PE, & greater confidence in filling out medical forms
Rural-Urban Differences in LS BC: Do Associations Differ by Rural-Urban Classification System?	Pruittet al. (2015)	Analyzed Texas Cancer Registry data of 120,738 female patients with BC aged ≥50 years diagnosed bet 1995–2009	Variables: age, race ethnicity, year of dx, census block group-level MS capacity, census tract Poverty level, H&B	-Descriptive comparative design -Kappa statistics	Six of seven definitions revealed an adverse link bet rural residence & LS disease in unadjusted & adjusted models. Limitations: Excluded patients with BC living out of Texas. Multiple variables may be on a causal pathway
Racial/ethnic disparities in time to a BC dx: the mediating effects of healthcare facility factors	Molina et al. (2015)	Explored racial/ethnic disparities in delayed dx. of BC Illinois (N = 606)	Race/ethnicity was self-reported at the interview Dx delay	-Descriptive comparative design	Relative to NHW, minorities were more likely to experience a dx delay & involve multiple facilities in their dx. Together, facility factors accounted for 43% of the disparity in dx delay (p < .0001). Limitation: Single urban geographic area
Timeliness of abnormal screening & dx Mammography follow up at facilities serving vulnerable women	Goldman et al. (2013)	10,874 cases of abnormal MS recommended for f/u imaging. 142 facilities & 10,049 abnormal dx. Biopsy examinations across 114 facilities	Time to recommended dx breast imaging varied across facilities serving vulnerable populations	-Descriptive comparative design -BC Surveillance Consortium-linked Medicare claims	Women at facilities serving minorities with < education had lower rates of f/u imaging, lower rates of biopsy, and longer times until biopsy compared with those at facilities serving non-vulnerable. Limitations: Missing data on the capacity of the facilities
A comparative analysis of BC stage bet women enrolled in the NBCCEDP/ women not participating in the program	Wu et al. (2015)	Proportional distribution of ES & LS BC dx in years 2004–2009 among NBCCEDP enrolled & non-enrolled women	Demographic features & cancer stage distribution of women enrollees & non-enrollees	-Descriptive comparative design -LR	NBCCEDP enrollees were slightly younger & more likely to identify as AA than non-enrollees. NBCCEDP enrollees generally were diagnosed with LS BC more than those not enrolled in the NBCCEDP
Disparity in BC LS at Dx in Missouri: Does Rural Vs Urban Residence Matter?	F. Williams and Thompson (2016)	2003–2008 BC incidence data from Missouri Cancer Registry	Urban or rural using the rural–urban continuum code	-Descriptive comparative study -Chi-square test & Yates’ continuity correction	Compared with WW, BW showed a higher proportion of dx with LS BC metastasis. The stage at dx depended on the county of residence or metropolitan status
A Comparison of Compliance & Non-compliance in BCS among AAW	Davis et al. (2017)	Explored the differences in compliance with MS among AAW (N = 599)	Variables: family h/o BC, h/o MS, SBE, CBE	-Descriptive design -Bivariate analyses	Not having MS was linked with no health insurance, CBE, & previous MS. Reasons for not having a MS included: did not think to do so or were not told to do so
BC delay in Latinas: The role of cultural beliefs & acculturation	Tejeda et al. (2017)	Examined Latinas participants (age: 30–79 years) who were diagnosed with a primary BC (n = 181)	Self-reported date of symptom disco-very, date of first medical presentation, & tx	-Experimental design 15-item cultural belief scale interview -LR model	Holding ≥3 cultural beliefs as “Faith in God can protect you from BC” (48%) was linked with lower acculturation, lower SES, & less access to care (p < .01)
Identifying predictors of delayed dx in symptomatic BC: A scoping review	Webber et al. (2017)	Examined predictors of delayed presentation & dx among women with BC symptoms (1996–2015)	Time from symptom onset to first presentation to dx of BC	-Scoping Review	Among the 116 predictors, 3 were associated with less timely dx, not disclosing symptoms, non-lump breast symptoms, & AA ethnicity
Delays in Dx & Tx of BC: A Safety-Net Population Profile	Jaiswalet al. (2018)	Analyzed SN patients receiving BC care at Denver Health & Hospital Authority (N = 120)	Variables: Time from presentation to first, last imaging before dx, from dx to notification, first visit in oncology, & time to first tx.	-Retrospective review -LR	Factors associated with longer intervals than the median time included stage, presentation method, language, surgical tx, insurance, & ethnicity. Limitations: Single institution, small sample size. No theoretical framework
Multilevel Examination of Health Disparity: The Role of Policy Implementation in Neighborhood Context, in Patient Resource, & in HCF on LS of BC Dx	Warneckeet al. (2019)	411 NH black, 397 NH W, & 181 H patients diagnosed bet the ages of 30–79 years were interviewed; moreover, information was abstracted on MS & dx f/u	Neighborhood context, patient resources, facility characteristics, & mode of detecting disparity	-Cross-sectional multilevel analysis method	After adjustment for neighborhood context, mode of detection, & facility accreditation/resources, no significant disparity existed in LS BC dx bet NH black or H patients compared with NHW patients

Note. BC = breast cancer; IBC = invasive breast cancer; BCS = breast cancer screening; BSE = breast self-examination; MS = mammogram screening; BI = breast imaging; CBE = clinical breast examination; dx = diagnosis; PE = physical examination; ES = early stage; LS = late stage; LABC = locally advanced breast cancer; IDC = invasive ductal cancer; SN = safety-net; NSN = non-safety-net; Tx = treatment; A = African; AA = African American; AAW = African American Women; B = Black; BW = Black women; EMW = ethnic minority women; H = Hispanic; HW = Hispanic Women; HAW = Hispanic American Women; NHW = Non-Hispanic White; WW = White Women; F/u = follow up; bet = between; &, and; LR = logistic; SR = systematic review; SES = socio-economic status; CE = center of excellence; HCP = health care providers; HCF = health care facilities.

The information obtained from the studies was classified by year of publication, title of article, authors, purpose/research question/hypotheses/sample, research variable/setting/location, design/major tools, and major finding/limitations/quality of evidence.

(5) Stage 5 collate, summarize, and report the results: Thorough summary and synthesis of the evidence from the selected articles were conducted. Additionally, national agencies such as the American Cancer Society, American College of Radiology, Centers for Disease Control and Prevention (CDC), NBCCEDP, Healthy People (2030), and Yedjou et al.’s article on “Assessing the racial and ethnic disparities in breast cancer mortality in the United States” were consulted for supplemental pieces of evidence, recommendations, and appropriate interventions applicable to the studied population (American Cancer Society, 2021; Healthy People, 2030; Monticciolo, 2020; Wu et al., 2015; Yedjou et al., 2017).

Results

The included studies had differences in design and methodology. This review included nine descriptive retrospective studies, one population-based case-control study, one prospective observational cohort study, two quasi-experimental studies, one scoping review, four cross-sectional studies, and twenty descriptive comparative and longitudinal studies. Additionally, the included studies were geographically diverse and were conducted in various US states, including California (Los Angeles), Illinois (Chicago), Michigan (Detroit), Georgia (Atlanta), Colorado (Denver,) Massachusetts (Boston), Louisiana, and Texas, as well as a multistate dataset from Arkansas, Missouri, Iowa, Idaho, Kentucky, North Carolina, New Hampshire, New Jersey, New York, and Oregon.

Taken together, the studies demonstrated the principal causative factors for advanced-stage diagnosis of breast cancer in racial and ethnic minority women. All studies focused on one or more preventive measures, including screening, barriers to early screening as well as healthcare inaccessibility, lack of health insurance, or disparities in breast cancer survivorship care. Further, issues regarding immigrants, including cultural beliefs, generational differences, acculturation, and language barriers were tackled. The literature is synthesized and presented based on the interconnected multiple levels of the SEM.

Individual/Intrapersonal Level

Overall, the 38 studies focused on the importance of individual-level factors in health care accessibility and health promotion behaviors, including Knowledge Base (body of knowledge), Education and Health Literacy (the act of receiving knowledge and/or health literacy), Psychological Factors (worry, lack of motivation, anxiety, and fear of the unknown), Language Barrier (inability to speak a common language, which impedes proper communication), Ethnicity (the state of belonging to a social group with common cultural tradition), Age (how long someone has lived), Absence of Pain (the state of being free from pain, asymptomatic), Unawareness of the Presence of a Lump in the Breast (not being aware of breast symptoms), Religiosity/Spirituality (strong religious/spiritual feelings), attitudes and practices (a settled way of thinking/feeling about someone/something that is reflected in a person’s behavior), having a chronic condition (a health condition that lasts ≥3 months), Socioeconomic Factors (the social standing of an individual, which is often measured as a combination of education, income, and occupation).

Knowledge base, education, and health literacy

Among the included studies, three found that education, health literacy, and breast cancer awareness were strongly associated with the desire to be screened and adherence to early detection approaches (p < .05) (Davis et al., 2017; Gullatte et al., 2009; Rauscher et al., 2010). The lack of breast cancer knowledge was related to compliance with early detection. Less-educated women or racial/ethnic minority women had lower rates of follow-up on their breast imaging (4%–5% difference) (Davis et al., 2017). Less-educated women who were unmarried and spoke to God about their breast symptoms were considerably more likely to postpone looking for medical care (Gullatte et al., 2009).

Misconceptions about breast lumps were frequently noted among ethnic minorities and women with low socioeconomic standing. Specifically, 16% of patients showed a >3-month delay before obtaining medical guidance regarding breast symptoms (Rauscher et al., 2010). Furthermore, the most common reasons for not having a mammogram within the previous year included not considering it or their provider not asking them to do so. Additionally, compared with White women, Black women were slightly less likely to identify five or more non-lump indicators of breast cancer, and thus had lower breast cancer awareness (Davis et al., 2017; Rauscher et al., 2010).

Psychological factors (worry, lack of motivation, anxiety, and fear of the unknown)

The common barriers to seeking medical assistance include fear or concerns regarding an eventual abnormal finding in the breast, embarrassment, concerns about wasting the provider’s time, worrisome or anxiety related to seeing a doctor, and lack of motivation to seek health services (Gullatte et al., 2010; Rauscher et al., 2012; Webber et al., 2017).

Language barrier

Women who are not fluent in English may face language barriers. Jaiswal et al. (2018) discovered that patients who spoke English as their primary language (OR, 0.20; 95% CI [0.07–0.61]) experienced a relatively shorter time from diagnosis to first treatment. Contrastingly, patients who spoke Spanish as their primary language were at an increased risk of late-stage breast cancer diagnosis (Oliveira et al., 2011). The diagnostic centers with the shortest deferment in radiographic follow-up and the lowest percentage of non-fluent English participants were twice as likely to be >30 days late in following up with patients (Jaiswal et al., 2018; Markossian & Hines, 2012; Oliveira et al., 2011).

Ethnicity

Ethnicity is an individual-level barrier. Hispanic ethnicity (OR, 3.38; 95% CI [1.41–8.12]) greatly increased the likelihood of a woman showing longer intervals between disease presentation and receiving initial treatment (Jaiswal et al., 2018). Additionally, compared with US-born Hispanic women, Hispanic American women born in Latin America had more tumors larger than 1 cm (82.2% vs. 75.2%) and 2 cm (54.1% vs. 41.7%), which suggests a relative delay in the timeliness of cancer diagnosis in first-generation Hispanic American women (Henry et al., 2011; Mojica et al., 2007). Factors significantly linked with extended intervals compared with the median duration included stage, method of presentation, language, surgical treatment, insurance, and ethnicity (Flores et al., 2013; Jaiswal et al., 2018; Markossian & Hines, 2012; Oliveira et al., 2011).

Age

Studies using person-level models as the SEM have demonstrated that racial and ethnic minority women aged >50 years had an increased likelihood of being diagnosed with advanced breast cancer, which was decreased in patients aged <50 years. Moreover, increased age was significantly related to the likelihood of late/unknown stage at diagnosis, worse treatment, and survival. Likewise, older age significantly contributed to treatment delays, which suggests that comorbidities were other possible barriers to treatment (Henry et al., 2011; Mandelblatt et al., 1991; Markossian & Hines, 2012; Mojica et al., 2007; D. L. Williams et al., 2010).

The absence of pain and unawareness of the presence of a lump in the breast

The lack of pain and unawareness of a lump in the breast were limiting factors among Black African females. Failure to experience any symptoms was among the major factors that contributed to delayed breast cancer diagnosis. Taken together, women considered themselves as having a minimal risk of being diagnosed with breast cancer. They reported uncertainty over the signs and symptoms to be aware of. Additionally, 16% of patients reported a 3-month delay before seeking medical advice regarding breast symptoms. The average delay between self-detection of a breast symptom to seeking medical care was 5.5 months (Gullatte et al., 2010). Misconceptions regarding symptoms, including the presence of lumps or masses in the breast, were associated with extended delays in receiving care (p < .005) (Rauscher et al., 2012; Webber et al., 2017).

Religiosity/spirituality/fatalistic beliefs

There was an association between revealing the breast symptom to God only and delayed seeking of medical care. Contrastingly, women who had disclosed their breast symptoms to a person were likely to promptly request medical care (Gullatte et al., 2009). The belief most generally held was that “Faith in God can safeguard you from breast cancer” (48%). Only speaking to God about the breast change was considerably associated with delayed seeking of healthcare assistance (p = .02) (Gullatte et al., 2009).

Cultural beliefs

Consistent with these findings, having three or more cultural beliefs was associated with lower acculturation, lower socioeconomic rank, and less access to care (p < .01). After adjusting for age, education, income, acculturation, trust, and insurance, the probability of prolonged total delay was 21% greater in women with a higher number of cultural beliefs (p = .02) (Tejeda et al., 2017). Women from various ethnicities, including first-generation Black African, and elderly White women aged ≥70 years had similar archaic approaches and taboos regarding their breast health (Tejeda et al., 2017; Wujcik et al., 2007). Therefore, cultural beliefs (e.g., skepticism, mistaken beliefs regarding the illness or treatment, and fear) and socio-circumstantial factors (e.g., surrounding atmosphere, level of societal assistance) are intervention targets for reducing delays and promoting timely diagnosis/treatment of breast symptoms among women.

Socioeconomic factors

Factors contributing to significantly delayed presentation and diagnosis of breast cancer included patient-mediated factors (e.g., socioeconomic factors) (Espina et al., 2017). Safety-net hospitals deliver care to low-income and vulnerable populations, including individuals with Medicaid and/or without health insurance. Additionally, non-safety-net hospitals are those where the percentage of Medicaid-dependent discharges was less than or equivalent to the median level for all hospitals (Fayanju et al., 2013). Compared with non-Safety-Net advanced-stage patients, Safety-Net advanced-stage patients were more prone to be African American (83% vs. 21%, p < .001), have a yearly household revenue <$25,000 (89% vs. 38%, p < .001), and report a health-related concern in the previous year but could not visit a doctor due to expenses (67% vs. 25%, p = .012); moreover, they were unlikely to be married/partnered (22% vs. 79%, p < .001), unlikely to have post-college education (0% vs. 25%, p < .03), lack health coverage (61% vs. 96%, p < .005), and were unlikely to seek healthcare assistance within 1 week of being aware of breast symptoms (50% vs. 79%, p = .047) (Espina et al., 2017; Fayanju et al., 2013; Gwyn et al., 2004). Socioeconomic factors could not sufficiently account for the dramatic effect of race on the breast cancer stage since cultural beliefs and attitudes could largely account for the perceived effect (Lannin et al., 1998; Rauscher et al., 2013).

Interpersonal Level

The second level of the SEM addresses the interpersonal level, which emphasizes the relationships among people; ordinary and extraordinary communal structures; and societal support systems such as biological descendants, workgroups, and relationship networks. For instance, natural dynamics (individuals’ well-being, their state of mind, perception, apprehension) and social circumstantial resources (the surrounding atmosphere, the level of societal assistance) are all instrumental factors in determining a woman’s practical involvement in her regular breast care.

While individuals’ well-being, either physiological or psychological can be categorized at the intrapersonal level, it might be impacted by their surroundings and social determinants of health, which significantly affect health outcomes. Having comparable obsolete viewpoints and superstitions was a consistent finding for women from African American and Hispanic origins. Accordingly, women’s motivation to be actively involved in their breast health was prompted by their knowledge of breast cancer, their connection with their communities, the availability of social support systems, and practical assistance when needed (Coughlin, 2019; Talley et al., 2017; Tompkins et al., 2016; K. H. Wang et al., 2018; Wujcik et al., 2007).

Data indicate a lower compliance rate with breast cancer screening recommendations in African American and Hispanic females, leading to the disparity in late diagnosis and cancer mortality in this population (Monticciolo, 2020; Talley et al., 2017). Through interpersonal communication, women can gain knowledge and awareness of the life-saving benefits of screening mammography, the value of early detection, and its impact on breast cancer treatment options. Therefore, interpersonal interaction enables exposure to information on breast cancer prevention, hence influencing the degree to which women perform protective breast cancer activities. Breast cancer awareness, adherence to breast cancer screening measures, access to diagnostic studies, and high-quality treatment are all essential factors in improving breast cancer survival (Coughlin, 2019; Monticciolo, 2020; Talley et al., 2017; Tompkins et al., 2016; K. H. Wang et al., 2018; Wujcik et al., 2007).

Consequently, for breast cancer screening interventions involving African American and Hispanic women to be successful, it is important to consider the women’s functional breast cancer literacy, their motivation to be willingly involved in their breast health, their social and circumstantial dynamics concomitant with their screening behaviors.

Organizational Level

The third level of the SEM represents the organizational level, which involves social institutions with organizational features, formal and informal guidelines, and a code of operation. Disorganized structural healthcare systems negatively affected the satisfaction and health outcomes of patients with breast cancer based on care efficacy and assistance received during their treatment course. Obstacles experienced by the participants included challenges in scheduling appointments, collaborating with the healthcare team, accessing necessary information, and navigating the healthcare system, as well as unaffordability of resources to meet healthcare necessities (Gullatte et al., 2010; Rauscher et al., 2012; Webber et al., 2017). Bedell et al. (1995) reported that the elapsed times for diagnosis, treatment, and combined intervals were significantly longer among women receiving care in public hospitals than those in private hospitals (25 and 14 days, p = .008, for the diagnosis interval; 15 and 10 days, p = .007 for the treatment interval, and 43 and 24 days, p = .001 for the combined intervals) (Bedell et al., 1995).

Taken together, facility factors accounted for 43% of the diagnostic delay (p < .0001) (Goldman et al., 2013; Molina et al., 2015). Health system-related factors (e.g., referral pathways) contributed to substantial delays in presenting and diagnosing breast cancer (Espina et al., 2017). Among English-speaking Latinas, undergoing an annual physical exam was the strongest predictor of breast cancer screening. Women who did not undergo a mammogram during the previous year were less likely to be insured, have a clinical breast exam at their last checkup, have their breasts examined by their doctor at least once annually, or have undergone a mammogram previously.

Furthermore, delayed seeking of medical attention was associated with misinformation regarding the requirement of a consistent health care provider, a source of health coverage, and recent preventive care (p < .005) (Rauscher et al., 2010). Moreover, the proportion of women who underwent imaging and biopsy within 11 and 3 months, respectively, varied across facilities (interquartile range: 85.5%–96.5% for imaging and 79.4%–87.3% for biopsy) (Oliveira et al., 2011). Uninsured ethnic minority women who could not obtain adequate healthcare services were at an increased risk of late-stage breast cancer diagnosis (Castañeda et al., 2014; Espina et al., 2017; Oliveira et al., 2011).

Community Level

The fourth level of the SEM addresses community factors, including affiliations among organizations, institutions, and informal networks within defined limits. Being enrolled in a secure health insurance plan and living in certain communities that allow easy access to health care providers were associated with compliance with recommended mammography screening and follow-up (p < .05) (Pruitt et al., 2015). There was a positive correlation of the concentration and immigrant populations within neighborhoods with the risk of a late-stage breast cancer diagnosis. Furthermore, living in rural areas was a deterrent to seeking needed care such as undergoing radiation and surgery with radiation (OR = 0.59, p = .0001) as well as breast-conserving surgery compared with mastectomy (OR = 0.73, p = .005) (Markossian & Hines, 2012; Pruitt et al., 2015). There was a significant spatial (residential or geographical locations) relationship of racial inequalities between late-stage diagnosis and breast cancer mortality after adjusting for a socio-economic status cofounder with an OR of 18.39 (CI: 12.79–26.44) and 11.64 (CI: 8.29–16.34) for African American and Hispanic women, respectively (Tian et al., 2011). Living in isolated geographical settings or areas with limited access to primary health care is related to late diagnosis, which demonstrates the importance of accessibility to primary care services in early breast cancer detection (Dai, 2010; F. Williams & Thompson, 2016).

Policy Level

The Policy Level of the SEM considers local, state, and national regulations and guidelines. Among the 38 reported articles, only 2 articles tackled the policy level (Warnecke et al., 2019; Wu et al. (2015). The study conducted by Wu et al. examined how the NBCCEDP has efficiently assisted uninsured and underserved women of low socioeconomic status by facilitating access to lifesaving screening programs for early diagnosis of breast and cervical cancers. Wu et al. revealed that NBCCEDP enrollees were more likely to be diagnosed at a late stage of breast cancer than those not enrolled in the NBCCEDP. Therefore, it is important to highlight the need to expand breast cancer control efforts in the low-income deprived populations (Wu et al., 2015). After adjusting for covariates, there were no substantial dissimilarities in the advanced-stage breast cancer diagnosis between Non-Hispanic Black/Hispanic and Non-Hispanic White patients. Warnecke et al. attributed the disparity in the stage at diagnosis to racial and ethnic variances in the detection mode, availability of resources, suitable policy, and facility accreditation by the American College of Radiology. Therefore, it highlights access to accredited screening amenities as a means of preventing disparity in the diagnosis of breast cancer (Warnecke et al., 2019).

Discussion

The 38 studies included in the current review were evaluated within the context of the SEM. The SEM places the individual in the center of the model and all other levels around the individual, which indicates that the individual is the central focus of the interventions. There were several gaps in health care accessibility and coverage at the policy level; provision of culturally sensitive approaches to care at the organizational level; system and structural barriers at the community level; and the lack of empowerment, including knowledge deficits, and awareness at the individual level. Numerous factors identified among African American and Hispanic women were congruent with their White counterparts, while others were not. Knowledge deficits at the individual level can be addressed by teaching health care providers to educate women in their communities (including schools and colleges) and eradicate misapprehensions associated with breast cancer ignorance. Improving the understanding of screening measures may inform choices and improve compliance with recommended screening/treatment regimens. Additionally, improved knowledge regarding a woman’s illness may improve trust, confidence, communication, and satisfaction with her treatment team (Freedman et al., 2015; Rauscher et al., 2010, 2013; Rayne et al., 2019). Behavior alteration is burdensome, especially in a setting that does not eagerly support change. Therefore, prevention interventions such as cancer screening and educational campaigns for increasing awareness can only be successful if the individual recognizes the necessity and the health advantages of seeking appropriate medical assistance (Talley et al., 2017; Tejeda et al., 2017; Tian et al., 2011; F. Wang et al., 2008; F. Williams & Thompson, 2016).

A comparison of breast cancer screening among racial and ethnic minority women indicated that Latina females were aware of very little basic information regarding breast cancer. The lack of knowledge could be associated with inadequate language proficiency, especially in less assimilated individuals. Therefore, it is important to include cultural and circumstantial dynamics in educational activities intended to attract this population. Although there was a limited number of Latina women, our findings could inform future breast cancer screening interventions for other ethnic minority women (Talley et al., 2017).

Additionally, implementing patients’ navigation systems in healthcare facilities could improve health outcomes by reducing structural barriers, which could empower patients as well as improve their experience and health outcomes. Language interpreters could minimize language barriers by allowing effective communication and reducing delays in care delivery (Karliner et al., 2012). Even with access to adjuvant therapies, Black females still had an increased likelihood of breast cancer recurrence compared with their White counterparts. This suggests that being Black is a significant indicator of an unfavorable outcome and that existing treatment may be less effective in this population. Therefore, further research is warranted to improve health outcomes in this younger population (Karliner et al., 2012).

As described by the NBCCEDP, interventions at the individual level can reinforce knowledge and influence perspectives regarding health literacy, which can be achieved by delivering health education regarding the risks and benefits of breast cancer screening. For example, the NBCCEDP emphasized the need for appropriate screening and surveillance to facilitate treatment initiation for newly diagnosed women with cancer (Wu et al., 2015; Yedjou et al., 2017).

Additionally, at the interpersonal level, the NBCCEDP suggests that providers offer screening recommendations to their patients. Patients should be informed of the need for screening and follow-up compliance with scheduled appointments. Finally, patient navigators should eliminate logistical and other obstacles to screening (CDC/NBCCEDP; Karliner et al., 2012; Wu et al., 2015).

Furthermore, interventions proposed by the NBCCEDP at the interpersonal level included encouraging providers to adopt reminder systems for prompting patients (eventually minimizing delays in treatment). Other interventions included evaluating and criticizing providers’ performance, encouraging the coverage/expansion of benefits allocated to screening, and implementing workplace regulations that support preventive care (CDC/NBCCEDP; Wu et al., 2015). Having a familiar and consistent source of care can promote cancer screening and preventive health education. Counseling and suggestions by healthcare providers regarding mammogram screening provide a primary point for exploring the socio-demographic, health-related, and circumstantial characteristics that obstruct timely screening mammography in geographically isolated regions. Furthermore, it is important to consider between the person-centered and place-centered approaches when providing health teaching to patients living in remote settings. At the community level, residing in a location that permit access to expert providers was, to some extent, associated with a decreased likelihood of being diagnosed with late-stage breast cancer. Therefore, geographic factors influence the probability of late-stage breast cancer diagnosis, which significantly differ across the United States (Mobley et al., 2017; Tejeda et al., 2017; Tian et al., 2011; F. Williams & Thompson, 2016). Although there have been recent improvements in the health guidelines for immigrant populations, there remain significant health inequalities in breast cancer diagnosis at the neighborhood or community level. Moreover, regarding interventions for improving outcomes, it is important to consider geographic risk factors and multilevel modeling assessment, as well as different approaches for different groups within the same areas (Cho et al., 2011; Dai, 2010; Flores et al., 2013; Hedeen & White, 2001; Kuo et al., 2011). At the community and organizational levels, the NBCCEDP highlights numerous interventions, including collaborating with alliances to increase funds, raising public consciousness through educational campaigns, and collaborating with tribal health departments to expand breast and cervical cancer screening (CDC/NBCCEDP; Wu et al., 2015).

Although there remain no adequate interventions at the policy level, the NBCCEDP shows that prevention interventions at the policy level promote and apply existing policies. Federal, state, local, and tribal government agencies assist clinicians seeking to implement guidelines that support healthy behavior. These interventions include collaboration with organizations to divulge policy decisions to the public (e.g., insurance mandates for screening), translating local guidelines for community members, and organizing screening during the breast cancer awareness month. Suitable public health activities can be implemented at each level, regardless of related factors, and therefore increase collaborations among interventions for improving the overall health outcomes of individuals (CDC/NBCCEDP; Monticciolo, 2020; Newman, 2017; Rayne et al., 2019; Wu et al., 2015).

Future Research Implications

A family history of breast cancer means having a first-degree relative known to have breast cancer (F. Williams & Thompson, 2016; Yedjou et al., 2017). With the considerable number of patients not knowing their family health history, it is important to address the factor of unknown family health history since some patients may have been adopted or have lost their entire family. Other patients from developing countries, where cancer screening and diagnosis are unaffordable, might have had family members who died of the disease without being correctly diagnosed.

The increasing number of newly diagnosed breast cancer cases with unknown family history suggests that these patients probably had a first-degree relative who had the disease but was unaware of it. Therefore, to address compositional and contextual inequalities evident in the breast cancer stage at diagnosis, cancer screening, and follow-up, resources should focus on communities with rapidly increasing immigrant populations. Furthermore, when planning breast cancer screening campaigns for racial and ethnic minority women, it is necessary to consider incentivized learning activities for increasing practical knowledge regarding breast cancer (Davis et al., 2017). It is important to improve access to care in this community and address health literacy issues in order to promote breast cancer screening utilization.

Limitations

This study has several limitations, including the low methodological quality of several small-scale studies, which might limit the generalizability of the findings. Some studies prospectively recruited women; moreover, some participants were asked to remember the time from first symptoms to presentation, which could result in recall errors and even biases. Moreover, our findings might not be generalized to populations outside the African/American and Hispanic populations. The study didn’t mention that participants’ undocumented status might have an impact on late-stage diagnoses of breast cancer as the fear of being deported might discourage some women from seeking much-needed medical care. Though participants’ documentation status will most likely impact their accessibility to testing and treatment for breast cancer, it was not explored due to the unavailability of data. The review mainly focused on information available from the included studies and therefore didn’t mention participants’ immigration status. The major strengths of this study include the use of standardized methods for data extraction and synthesis (PRISMA, and the methodological framework of Arksey and O’Malley) in order to reinforce the rigidity and reproducibility of our findings. Further, the literature was synthesized and presented based on the interconnecting multiple levels of the SEM.

Conclusion

The factors contributing to the advanced diagnosis of breast cancer are associated with social determinants of health and their impact on healthcare utilization. There is an urgent need for evidence-based breast cancer interventions that are culturally suitable for impoverished and uninsured/underserved patients in deprived communities. With the persistent disparity in breast cancer survival rate and an increasing awareness of the harmful consequences of the disease, there is a need for multilevel efforts at the individual, intrapersonal, organizational, community, and policy levels to attain health equity. Multilevel efforts are required to mitigate the late diagnosis of breast cancer by restructuring existing health promotion programs to promote and support greater health literacy; increase cultural sensitivity through breast health awareness campaigns and increase accessibility to early screening mammography.

Footnotes

Authors Contributions

(SY and LAT) confirm contribution to the paper as follows: SY wrote the main manuscript text and substantially contributed through the acquisition and analysis of the data. SY and LAT substantially contributed to the study design and drafting of the manuscript. SY and LAT substantially contributed in the interpretation of the results. LAT edited and revised the article critically for important intellectual content and approved the version to be published.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Salamata Yoda

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A Scoping Review of Factors Contributing to Late-Stage Diagnosis of Breast Cancer in Racial and Ethnic Minority (African American and Hispanic) Women

Abstract

Keywords

Introduction

Theoretical Framework

Methods

Results

Individual/Intrapersonal Level

Knowledge base, education, and health literacy

Psychological factors (worry, lack of motivation, anxiety, and fear of the unknown)

Language barrier

Ethnicity

Age

The absence of pain and unawareness of the presence of a lump in the breast

Religiosity/spirituality/fatalistic beliefs

Cultural beliefs

Socioeconomic factors

Interpersonal Level

Organizational Level

Community Level

Policy Level

Discussion

Future Research Implications

Limitations

Conclusion

Footnotes

Authors Contributions

Declaration of Conflicting Interests

Funding

ORCID iD

References