Breast cancer diagnosed before the age of forty occupies an unusual position in oncology. It arises before the recommended age for routine screening mammography, which means that in most cases neither the patient nor her clinician has an imaging-based early warning system working on her behalf. Detection instead depends on symptom recognition—typically a self-detected lump, change, or pain—and on prompt clinical follow-up. The prognosis for young-onset breast cancer is often poorer than for cancers detected later in life, in part because tumors in younger women tend to be biologically more aggressive and in part because they are frequently found at later stages. Beyond the biology, young patients face distinct treatment and psychosocial challenges, including fertility concerns, early menopause, body image, career and family disruptions, and long-term survivorship issues that span decades.

The investigators set out to understand how patient and tumor characteristics influence delays across three distinct phases of the care pathway, and to determine whether those delays affect cancer outcomes. They defined presentation delays as ninety days or more elapsing between a patient’s first reported symptom and her first presentation to a clinician. Diagnostic delays were defined as ninety days or more between the first health care visit for symptoms and the date of the biopsy that yielded the breast cancer diagnosis. Treatment delays were defined as sixty days or more between diagnosis and the first treatment. Separating the pathway into these three intervals allowed the team to see that different factors act at different points, a nuance that a single aggregate measure of delay would have obscured.

Among the 1,071 individuals analyzed, the team identified 153 presentation delays, 120 diagnostic delays, and 228 treatment delays. The numbers themselves tell a story: treatment delays were the most common of the three, affecting roughly one in five patients in the cohort, while presentation and diagnostic delays each affected more than one in ten. Every one of these intervals represents a window in which a growing malignancy is untreated, and the study’s design made it possible to ask not only who is delayed but what those delays cost in terms of disease stage at diagnosis.

After adjusting for other influencing factors, lower annual income emerged as a significant predictor of presentation delay—the interval that begins with the patient herself. Women with lower incomes had higher odds of waiting ninety days or more after first noticing symptoms before seeing a clinician. This finding points to barriers that operate before the health care system is even engaged: difficulty taking time off work, childcare obligations, transportation costs, lack of paid sick leave, and, in some cases, limited familiarity with the health care system or with the significance of breast symptoms in young women. Income-related disparities in cancer care are well documented, but this analysis pinpoints the disparity at the very first step of the journey, which is precisely the step most directly under the patient’s control and most sensitive to her material circumstances.

Several factors, by contrast, were associated with lower odds of presentation delay. Women who were pregnant at the time of diagnosis, those with a family history of breast cancer, and those whose tumors proved to be triple-negative all reached a clinician more quickly. The explanations are plausible even where the study does not fully establish them: pregnancy brings frequent contact with medical providers, a known family history heightens vigilance on both sides of the examination table, and triple-negative tumors—lacking estrogen receptors, progesterone receptors, and HER2 amplification—are often rapidly growing, so their symptoms may become conspicuous quickly. Notably, presentation delays were also associated with later-stage disease among women with certain HER2-positive tumors, a subgroup in which a slower-growing but still serious malignancy may allow a long delay before symptoms force attention.

The diagnostic phase showed its own pattern. Odds of diagnostic delay were higher for younger patients, reinforcing a concern that clinicians and researchers have voiced for years: the assumption that a woman in her twenties or thirties is too young to have breast cancer can slow the path from first visit to biopsy. Younger patients may be initially managed with reassurance, watchful waiting, or a course of antibiotics for presumed benign conditions before imaging and tissue sampling are ordered. Meanwhile, triple-negative tumor type was again associated with lower odds of diagnostic delay, consistent with aggressive biology prompting faster workup. Crucially, the analysis found that women who experienced a diagnostic delay were more likely to have late-stage disease at diagnosis, linking the interval between first visit and biopsy directly to a measure of prognostic weight.

Treatment delays followed a different logic. Patients with more aggressive tumor types were less likely to experience treatment delays, suggesting that the urgency conveyed by tumor biology and staging translates into faster mobilization of surgery, chemotherapy, or other therapy. In other words, once a diagnosis is established and its severity is clear, the system generally responds according to clinical priority. The bottleneck, the study suggests, lies upstream—in symptom recognition, in the decision to seek care, and in the decision to biopsy—rather than in the treatment apparatus itself.

Fortunately, the analysis found that delays were not associated with differences in cancer-free survival or overall survival in this cohort. The authors caution, however, that this reassuring survival signal does not mean the delays are harmless. Later stage at diagnosis may require more extensive surgery, radiation, or systemic therapy, each of which can affect quality of life, fertility, functional outcomes, and the long-term burden of treatment. A young woman whose cancer is caught at stage one may undergo a far less punishing regimen than one whose identical tumor is caught at stage two or three because of a six-month delay, even if both are ultimately cured. Survival is the crudest of outcome measures; morbidity, disfigurement, and life disruption are not captured by it.

Senior author Kristen D. Brantley, PhD, MPH, of the Dana-Farber Cancer Institute, summarized the implications: the study reveals continued issues in care delay among patients with young-onset breast cancer and emphasizes a need to improve both patient and provider understanding of young-onset breast cancer risk factors and symptoms to decrease disease burden among these patients. The message cuts in two directions. Patients and their families need to know that breast cancer does occur in young women, that new breast symptoms deserve timely evaluation, and that income or age should never translate into months of silent waiting. Clinicians, for their part, need to resist the implicit bias of youth, maintain a low threshold for imaging and biopsy in symptomatic young patients, and recognize that the intervals between symptom, visit, biopsy, and treatment are each an opportunity to change the trajectory of a young life with breast cancer.

Subject of Research: Delays in breast cancer presentation, diagnosis, and treatment among adolescents and young adults diagnosed by age 40

Article Title: Are young women receiving delayed care for breast cancer?

Article References: Are young women receiving delayed care for breast cancer?. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: breast cancer, young women, care delays, diagnostic delay, health disparities, income, triple-negative breast cancer, HER2-positive, late-stage diagnosis, Dana-Farber Cancer Institute, CANCER journal, young-onset cancer

The research team, led by Rebaone Petlele and Maureen Joffe of the University of the Witwatersrand, drew on the South African Breast Cancer and HIV Outcomes (SABCHO) cohort, a longitudinal study initiated in 2015. They analyzed data from two large academic hospitals affiliated with the university: Chris Hani Baragwanath Academic Hospital in Soweto, referred to as Site 1, and Charlotte Maxeke Johannesburg Academic Hospital in central Johannesburg, referred to as Site 2. Of 3,778 women diagnosed with invasive breast malignancies across the study windows, 2,623 consented to participate, and after excluding cases of ductal carcinoma in situ, phyllodes tumours, breast sarcoma, and patients lost to follow-up, 2,522 women with confirmed invasive breast carcinomas formed the analytical cohort, 1,641 at Site 1 and 881 at Site 2.

The investigators divided enrolment into three roughly two-year periods designed to minimize temporal spillover: a pre-Covid-19 window from April 2017 to March 2019, a pandemic window from April 2020 to March 2022, and a post-pandemic window from July 2022 to June 2024. This design captured two additional disruptions that complicate interpretation. In April 2021, a fire at Charlotte Maxeke hospital shut down treatment services for six months, while in June 2021 a new chemotherapy unit opened at Baragwanath, potentially improving treatment access there. Guided by the Model of Pathways to Treatment, the team measured three intervals: the pre-contact interval from symptom recognition to first healthcare access, the diagnostic interval from first contact to pathology-confirmed diagnosis, and the treatment interval from confirmed diagnosis to initiation of surgery, chemotherapy, or endocrine therapy.

The headline finding concerns stage at diagnosis. Late-stage disease, defined as stage III or IV, was already disturbingly common before the pandemic, affecting 50 percent of patients at Site 1 and 63 percent at Site 2. During Covid-19, those proportions climbed to 60 percent and 69 percent respectively, and then partially recovered to 53 percent and 55 percent in the post-pandemic period, differences that were statistically significant at both sites. The World Health Organization’s Global Breast Cancer Initiative, launched in 2021, calls for at least 60 percent of breast cancers to be diagnosed at stage I or II. Johannesburg’s public hospitals never came close to that benchmark in any period, meaning that even after recovery, the majority of women still arrived with advanced disease.

The timing analysis exposed where the system broke down. At Site 1, the median pre-contact interval, the time women waited after noticing symptoms before seeking care, rose from 0.8 months before the pandemic to 1.0 month during it and 2.0 months afterward, a statistically significant deterioration that never reversed. At Site 2, pre-contact intervals did not change significantly. The most commonly reported reason for delay at both hospitals was the belief that breast symptoms were not serious, cited by 75 to 89 percent of women depending on site and period, with the highest proportions during the pandemic. Fear of contracting Covid-19 on public transport and in clinics likely compounded this hesitancy. Fewer than 70 percent of women reached the health system within three months of symptom onset in any period, ranging from 45 to 58 percent at Site 2 and 58 to 64 percent at Site 1.

Diagnostic intervals, by contrast, proved relatively resilient. At Site 1 the median diagnostic interval held constant at 1.8 months across all three periods, and at Site 2 a rise to 2.0 months during the pandemic was not statistically significant. Remarkably, at Site 1 the proportion of women diagnosed within the Global Breast Cancer Initiative’s 60-day target was actually higher during the pandemic, reaching between 60 and 80 percent, because surgeons personally triaged patients for both breast and Covid-19 symptoms at the tertiary surgical breast unit, a function normally delegated to triage nurses. Still, between 27 and 41 percent of women at the two sites required more than two months from first contact to a pathology-confirmed diagnosis, and the study confirmed that delays longer than three months in the combined diagnostic journey were associated with late-stage disease.

Treatment initiation told a grimmer story. At Site 1, the median treatment interval lengthened from 1.6 months before the pandemic to 2.0 months during it and remained at 2.0 months afterward. The national suspension of elective surgical procedures and restricted theatre availability slashed the proportion of women receiving surgery, a decline that worsened in the post-pandemic period regardless of disease stage. At no point did either hospital meet the European Society of Breast Cancer Specialists benchmark of initiating first treatment within eight weeks of diagnostic workup in 80 percent of patients. The pandemic also accelerated a therapeutic shift: neoadjuvant chemotherapy rose from 35 percent of patients before Covid-19 to 54 percent afterward at Site 1, and from 52 to 62 percent at Site 2, while endocrine therapy served as a bridging strategy for hormone-responsive tumours when operating theatres were unavailable.

The stakes of these delays are not abstract. Prior analyses of the same SABCHO cohort showed that women who underwent surgery within three months of diagnosis had three-year overall survival of 85 percent, compared with 79 percent for those delayed beyond three months, with mortality risk climbing 11 percent for every additional month of delay. The authors also note that patient volumes at both hospitals increased by more than 20 percent after the pandemic compared with pre-pandemic levels, without any corresponding increase in staff or infrastructure, meaning the system is now treating more women with fewer resources per patient. Simulation-based sensitivity analyses supported the robustness of the pre-contact and treatment interval findings, though the study relied on self-reported recall for the pre-contact interval, an unavoidable source of bias.

The authors argue that their findings point to interventions at two levels. In communities, aggressive education campaigns are needed to encourage breast self-examination and dispel the perception that small or painless lumps can be ignored, since pre-contact delays were long and never recovered after the pandemic. Within the health system, they recommend streamlining referrals so that suspected breast cancer cases bypass secondary hospitals, a route previously linked to later-stage diagnosis, and they call for public-private partnerships to finance expanded surgical and chemotherapy capacity. Without substantial investment in human resources and infrastructure, they conclude, neither Johannesburg hospital is likely to meet international standards or cope with the steadily rising burden of breast cancer in South Africa, a country where no formal public screening programme exists and mammography remains reserved for symptomatic women.

Subject of Research: The impact of and recovery after the Covid-19 pandemic on breast cancer stage at diagnosis, diagnostic intervals, and treatment initiation at two public academic hospitals in Johannesburg, South Africa.

Article Title: Impact of and recovery after Covid-19 on breast cancer diagnosis and care in Johannesburg, South Africa

Article References: Petlele, R., Chikwati, R. P., Ojoniyi, O. O., Akokuwebe, M. E., Chen, W. C., Murugan, N., Ndwambi, P., Kumirayi, L., Jassat, F., Nietz, S., Mathiba, R. M., Singh, K., Ohene-Agyei, P., McCormack, V., Norris, S. A., & Joffe, M. (2026). Impact of and recovery after Covid-19 on breast cancer diagnosis and care in Johannesburg, South Africa. BMC Cancer, 26(1), Article 1182. https://doi.org/10.1186/s12885-026-17068-x

Image Credits: AI Generated

DOI: 10.1186/s12885-026-17068-x

Keywords: breast cancer, Covid-19, South Africa, Johannesburg, late-stage diagnosis, diagnostic delays, treatment delays, Global Breast Cancer Initiative, EUSOMA, public health system, neoadjuvant chemotherapy, health services research