Southern New England cohort links self-detection and missed appointments with delayed breast cancer diagnosis

A retrospective cohort study of women diagnosed with breast cancer in a Southern New England healthcare network found that 93 of 431 diagnoses, or 22%, were delayed by at least 90 days after the first documented symptom, clinical sign or positive screening result. Self-detected cases, Medicaid insurance and multiple missed or cancelled appointments were associated with greater odds of delay, while women attending more healthcare appointments before diagnosis had lower odds.

The study, led by Kufer and colleagues, used cancer registry data to identify women newly diagnosed with breast cancer in 2024. Researchers then reviewed medical records to identify delayed diagnoses and associated patient characteristics. A delayed diagnosis was defined as pathological confirmation occurring at least 90 days after the first documented symptom, clinical sign or positive screening result.

Among the 431 new diagnoses, 67% were first detected through screening mammography. Women whose cancer was initially detected through self-examination had approximately twice the odds of delayed diagnosis compared with women whose cancer was detected through routine screening mammography. The study did not establish whether these delays arose primarily from patients delaying care, from barriers within the healthcare system or from a combination of both.

Most participants had a primary care physician: 96% did at the time of diagnosis, and delay did not differ significantly between women with and without one. The authors noted that this may partly reflect the study’s setting. Southern New England can have as many as 147 primary care physicians per 100,000 population, while some states, including Utah, have fewer than half that number. A separate study from Ontario, Canada, associated reduced access to primary care physicians with less frequent early breast cancer diagnoses and lower five-year survival rates.

Engagement with healthcare was more closely associated with delay in the Southern New England cohort. Women who attended more appointments during the six months before diagnosis had lower odds of delayed diagnosis, whereas Medicaid insurance and multiple missed or cancelled appointments were associated with increased odds. The records did not establish why appointments were missed. The authors said lower-income patients may also encounter transportation difficulties, inability to take paid leave from work, and limited access to childcare or eldercare despite having medical coverage.

The findings came against a backdrop of incomplete screening uptake. More than 25% of women aged 40 and older in the United States do not undergo routine screening mammograms, and financial barriers, including lack of insurance, are frequently reported reasons. Although the Affordable Care Act, established in 2010, requires most health insurance plans to cover screening mammography, diagnostic imaging or biopsies following an abnormal screening result may not be covered. One cited study found that out-of-pocket expenses for follow-up testing were associated with an almost 3% lower absolute probability of attending screening mammography one to two years later.

Access to diagnostic evaluation is therefore only part of the issue, and screening uptake alone does not describe the full pathway to diagnosis. A 2022 evaluation of the New York State Patient Navigation Program for Breast Cancer Screening found that delayed screening persisted despite navigation services, particularly among women in the lowest income quartiles. Reported barriers included fear of mammography, lack of transportation and inability to obtain paid leave from work. The accompanying editorial said strategies aimed at reducing diagnostic delay may need to address structural, behavioral and healthcare-system barriers, and that their effectiveness may differ across populations.

The study has important limitations. It relied on retrospective chart review, with unknown completeness and accuracy of electronic medical records. Socioeconomic status, geographic region and education level were not routinely documented and could not be evaluated, while the reasons for missed or cancelled appointments were unavailable. The relatively small sample and conduct within a single Southern New England network also limit generalizability, particularly because the region has comparatively high primary care physician density and mammography uptake.

These constraints may help explain why the cohort found no association between diagnostic delay and age, race, ethnicity or language. By contrast, a systematic review of studies from six countries, including the United States and the United Kingdom, associated older age, lower education and non-white ethnicity with delayed diagnosis. The contrasting results may reflect limited chart data, the cohort’s small sample and differences between populations. Because the Southern New England study was observational, its findings represent associations rather than causal relationships, and the absence of demographic disparities in this cohort should not be taken as evidence that such disparities do not exist elsewhere.

Subject of Research: Factors associated with delayed breast cancer diagnosis in a Southern New England retrospective cohort

Article Title: Falling Through the Cracks: Understanding Delayed Breast Cancer Diagnosis

Article References: Smith, R., Zipursky, J., & Donovan, E. (2026). Falling Through the Cracks: Understanding Delayed Breast Cancer Diagnosis. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10881-x

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10881-x

Keywords: breast cancer, diagnostic delay, self-detection, screening mammography, primary care, Medicaid, missed appointments, retrospective cohort, healthcare access, Falling, Cracks, Understanding