Diagnosis of cancer in the south and north of Nigeria: duration and causes of delay

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We explored the durations and causes of the delay in the diagnosis of four common and treatable cancer types (breast, colorectum, head and neck, and uterine cervix) in Nigeria. Methods : Retrospective study based on interviews with cancer patients following the Aarhus framework for designing and reporting such studies. The study focused on the first two of WHO’s three main designated stages of cancer diagnosis: duration from symptom to presentation and presentation to histological diagnosis. Our hospital-based study involved 264 patients recruited from tertiary care facilities in the Northwestern (Kano) and Southwestern (Ibadan) regions of Nigeria. We obtained quantitative data to measure the duration of delay by stage, while interview data were collected to explore the causes of delay. We analysed the data by computing the median duration for the two stages of delay, and framework analysis was used to identify themes on the causes of delay. Results : The median time to receive a cancer diagnosis after noticing the first symptoms was 12 months (interquartile range 5 to 27 months), with head and neck cancer patients reporting the most prolonged (15-month) delay. Patients waited a median of 3 months (interquartile range 12 months) before presenting their first cancer symptom to a healthcare professional. The median time for patients to receive a cancer diagnosis after the first presentation of symptoms to a formal healthcare professional was 5 months (interquartile range 12 months). There was wide variance for all time intervals. Patients reported visiting a median of 3 health facilities before diagnosis in a formal hospital setting. Qualitative findings identified two main reasons patients reported delays in cancer pathway to care: patient-related factors and health system issues. Conclusion : Long delays were observed, and more than half the delay followed presentation to the local health sector. Figures Figure 1 Figure 2 Figure 3 Figure 4 BACKGROUND Cancer is responsible for about one in six deaths worldwide [ 1 ]. Low and middle-income countries (LMICs) have a growing cancer burden, with significantly higher age-adjusted cancer mortality than high-income countries [ 2 ]. The majority of people with cancer are in late stage when they receive a diagnosis and treatment in Sub-Saharan Africa [ 3 ]– for example, a median of 75% for breast cancer, according to a systematic review in 2016 [ 4 ]. Delay in treatment is associated with poor prognosis [ 5 , 6 ]. Nigeria is a LMIC in sub-Saharan Africa with a population of 224 million, larger than the population of the UK, France and Germany combined. A study of hospital case notes of urban dwellers identified from the Nigerian Cancer registry with breast, uterine cervix, colorectum or prostate cancer showed that between two-thirds and three-quarters of patients present late (stages 3 or 4), with no recent improvement [ 7 ]. Cancer incidence is rising in Nigeria as people adopt new lifestyles [ 7 ], and the overall cancer incidence is 113.6 per 100 000 persons per year whilst the overall cancer mortaliy is 74.5 per 100 000 persons per year [ 8 ].Less than 10% of Nigerians are enrolled in the National Health Insurance Scheme which provides limited coverage of healthcare services [ 9 , 10 , 11 ]. Consequently, most Nigerian patients experience financial hardship due to high out-of-pocket expenditures related to cancer care [ 11 , 12 , 13 ]. In response to the growing cancer burden, Health boards in Nigeria have invested in facilities for curative treatment for common cancers [ 14 , 15 ]. However, to realise the benefits of these investments, it will be necessary to reduce the delay between first symptoms and treatment. In this study, we explored the durations and causes of the delay to the point of histological diagnosis of cancer in health facilities in Nigeria. We focused on four cancer types: 1) breast, 2) colorectum, 3) head and neck, and 4) uterine cervix. We select these cancers because they are common, tend to present early with specific symptom groups and can be cured if treated early. METHODS Framework We conducted an observational study based on interviews with patients after they had received a diagnosis of one of the above four cancer types. The protocol for this study can be found at Protocol exchange [ 16 ]. We followed the Aarhus framework [ 17 ] for design and reporting studies on early cancer diagnosis. This statement seeks to systematise questionnaires to reconstruct a patient’s pathway from the first symptom (body change) to treatment. This pathway can be divided into stages and sub-stages. The WHO [ 18 ] designates three main stages: 1) first symptom to presentation to the formal health system (i.e. an allopathic health provider); 2) presentation to histological diagnosis, and 3) diagnosis to treatment. WHO guidelines [ 19 ] recommends that the interval from symptom onset to initiation of treatment should generally be less than 90 days to reduce delays in care and optimize treatment outcomes. We use the term ‘delay’ to indicate the time between one event and another (e.g. between first symptom and presentation to the formal health system. We could not measure the final WHO stage, diagnosis to treatment in this study (see below). We, therefore, measured the first two stages above and identified the total number of clinics each person visited on the pathway to diagnosis. Setting Two geopolitical regions of Nigeria - the Northwest (Kano) and Southwest (Ibadan) were purposively selected to sample patients of considerable ethnic, religious, and cultural diversity. Kano is the second largest city in Nigeria, with over 4 million people, who are predominantly Muslims of Hausa ethnicity. Ibadan is the third largest city in Nigeria, with a population of 3.7 million practising Christianity and Islam. Recruitment strategies Participants were recruited from the University College Hospital Ibadan, and Aminu Kano Teaching Hospital and Murtala Muhammad Specialist Hospital in Kano. These are the only hospitals providing specialist care in the study cities and, therefore, constitute the final common pathway for treatment (or the decision that treatment is not advisable) for all but a small proportion of patients who can afford and choose private care. The ideal point to recruit patients would be at the ‘critical point’ where patients either receive first-line treatment or the decision that the cancer is too advanced to treat. Attempting to recruit patients after treatment would likely miss patients who did not remain under hospital care to receive treatment. Yet, these are the very people we need to identify to avoid skewing the sample towards those with earlier presentations. To overcome this problem, we considered conducting interviews in the patients' homes, including all patients who had reached the critical point. However, we were advised by local clinicians that this would be seen as intrusive and culturally inappropriate, especially in Kano. We, therefore, recruited people at a point where the initial approach could be made in the outpatient department following histological diagnosis. Eligible participants were identified by the patient’s clinician, who requested assent (see below). Assenting patients were introduced to the non-clinical researcher, who requested consent. The study selected patients who (1) had a first histologically confirmed diagnosis of cancer of the breast, colorectum, head and neck, or uterine cervix, (2) were aged ≥ 18 years,, and (3) could provide informed consent. Participants were invited to bring any accompanying relative or friend to the interview. Ethics, consent, and permissions Ethics approvals for this study were obtained from UI/UCH Health Research Ethics Committee (Ref: UI/EC/23/0282), Aminu Kano Teaching Hospital Health Research Ethics Committee (Ref: SHREC/2023/3965) and Kano State Ministry of Health Research Ethics Committee (Ref: AKTH/EC/3562). The researchers adhered to international standards for conducting health research [ 20 ] and ensured that the rights and well-being of participants were protected during the data collection. The study approach separated ‘assent’ from ‘consent’. Assent covers the process by which the researcher clinician, a study team member, asks the patient whether they would be prepared to meet the field researcher to discuss participation in an interview and describe their journey to a point where the diagnosis has been made. After explaining and discussing the study with the patient, the field researcher requested verbal and written consent from patients who agreed to be interviewed. Patients who lacked the capacity to give informed consent, who had recurrent cancer, or who were acutely ill were not recruited into the study. Data Collection Data were collected between July 1 and December 31, 2023, across the three tertiary hospitals. The study set out to interview 60 patients per cancer type per site, (240 per site). Our sample size calculations were based on the precision with which we can estimate the quantiles of the delay (median, 75th, or 90th percentiles) for any particular group. A sample of 60 individuals will allow us to estimate the median delay to a precision of approximately +/- 5 days (95% confidence interval), and the 75th and 90th percentiles to +/- and 12 days, respectively. The instrument we developed to collect the quantitative and qualitative data is enclosed in the Supplementary File (Patient interview guide). The study collected quantitative information to measure the duration of delay by stage. If a participant could not immediately and confidently recall one of the above crucial dates, we used a ‘calendar methodology’ [ 21 ] to help recall and minimise telescoping (the tendency to perceive distant events as being more recent than they are and vice versa). We shared a calendar with the participants and asked them to provide important dates in their personal lives, such as a family member’s marriage. We then elicited a best estimate for each crucial event about these personally significant events. Qualitative data were collected to explore patients’ experiences at each step of the diagnostic pathway.All data collection was face-to-face and the sessions were audio-recorded with the permission of the participant. Data Analysis All interviews were audio recorded, anonymised, and transcribed verbatim. Interviews conducted in local languages (Yoruba or Hausa) were transcribed in the original language then back-translated to English by six culturally sensitive research assistants (2 in Ibadan and 4 in Kano). Each transcript was then read and checked by an academic member of the research team. Quantitative data analysis included: 1) computing the median and ranges for the above two stages of delay, and 2) recording the number of clinic visits made on the pathway from presentation to diagnosis. The qualitative data was analysed using framework analysis [ 22 ]. Emerging themes were identified, and a thematic framework was developed to code responses. These themes were further classified into two of the three contributing factors from the Aarhus framework: Patient Factors and Healthcare provider and system factors. The qualitative information on reasons for delays in stages in the pathway was interpreted based on discussion and consensus among the study team. Patient and Public Involvement Cancer patient advocates and healthcare professionals in the two study sites were first engaged in the research process during the planning stage. They participated in a series of stakeholder engagement meetings in Ibadan and Kano, where they identified important issues affecting the patients, forming the basis of this study's objectives. In addition, they contributed their perspectives on the study design and methodologies, particularly in contextualizing the research instruments, which informed the training of research assistants and improved the conduct of the research. RESULTS Characteristics of participants A total of 264 participants were interviewed across the selected three tertiary hospitals in Kano and Ibadan. Table 1 presents the characteristics of participants. One hundred and thirty-five patients in Ibadan and one hundred and twenty-nine in Kano participated in the study. 60% (158/264) of participants were aged ≤ 50 years. 71% (188/264) were female; 99% (77/78) of participants with cancer of the breast were female, whilst 44% of participants with cancer of the colorectum and 29% of participants with head and neck were female. While most participants had a formal education (206 of 264), few reported working at the time of the interview (104 of 264). Just 10 of 264 participants had health insurance for cancer treatment. Table 1 Characteristics of participants Characteristics n % Location Ibadan (Southern Nigeria 135 51.1 Kano (Northern Nigeria) 129 48.9 Type of cancer Breast 78 29.5 Cervix 70 26.5 Colorectum 48 18.2 Head and Neck 68 25.8 Sex of participants Female 188 71.2 Male 76 28.8 Age group (years) 18–30 31–40 41–50 51–60 61–70 Above 70 28 48 82 54 35 17 10.6 18.2 31.1 20.5 13.3 6.4 Highest Education No Formal 55 20.8 Primary 51 19.3 Secondary 74 28.0 Tertiary 84 31.8 Currently working Yes 104 39.4 No 160 60.6 Healthcare payment plan Self 65 24.6 Family and friends 181 68.6 Health insurance 10 3.8 All of the above 1 0.4 Not sure 7 2.7 Duration of delay at different stages The median total time to receive a cancer diagnosis after noticing the first symptoms was 12 months, with an interquartile range of 5 to 27 (Fig. 1. Duration of delay between first symptom and diagnosis, by site and by cancer type). Patients with head and neck cancer experienced the most prolonged (15-month) delay (interquartile range 27 months). In contrast, colorectal cancer patients had the shortest duration, with a median of 8 months. The data were heavily skewed with patients waiting up to nearly 60 months. Patients waited a median of three months before presenting their first cancer symptom to a healthcare professional (Fig. 2. Duration of delay between first symptom and first presentation to a formal healthcare professional). This duration varied by study site and the type of cancer, with patients with cervix and head and neck cancer presenting later than those with breast and colorectum cancer. The median time for patients to receive a cancer diagnosis after the first presentation of symptoms to a formal healthcare professional was 5 months (interquartile range 12 months) (Fig. 3. Duration of delay between first presentation to a formal healthcare professional and diagnosis). Again, patients with cervical and head and neck cancer had a longer median time to diagnosis post-presentation than patients with breast and colorectal cancer. Figure 4 (Fig. 4. Number of health facilities visited between first symptom and diagnosis) provides information on the median and range number of healthcare facilities visited from the onset of symptoms to the eventual cancer diagnosis. Across all patients, the median number of health facilities visited before diagnosis in a formal hospital setting is three. Patients with breast cancer visited an average of two health facilities, whereas cervical, colorectal and head and neck cancer patients visited a median of 3 health facilities. However, the range was wide such that a quarter of patients with colorectal and cervical cancer visited four or more centres before receiving a diagnosis. Reason for delays in cancer diagnosis Reasons for delays in the cancer pathway to care consisted of patient, and health system and service provider factors. Patient factors Patient factors contributing to delayed cancer diagnosis for most study participants are presented in Box 1. These factors include financial constraints, perceived non-seriousness of symptoms, lack of knowledge and misguided advice, awaiting the outcome of alternative therapy and commitments to family and spiritual beliefs. Overall, these patient-related factors highlight the complex interplay of psychological, social, and cultural factors that can influence the timing of cancer diagnosis. i. Financial constraint The most frequently cited factor was financial constraint. While financial barriers were acknowledged in the context of initial health-seeking behaviour, they became more pronounced following referral to the specialist health sector, where significantly higher out-of-pocket expenses, such as diagnostic tests, were incurred. The expense of hospital care, rather than initial consultations, posed the greatest barrier. Patients highlighted how the high costs of diagnostic tests and treatments discouraged them from seeking timely medical attention. Covering even basic hospital tests proved difficult for those struggling with daily survival needs, such as food and transportation. Box 1: Key themes on patient factors relating to delay in cancer diagnosis Financial constraint I didn’t have enough money, that was why I chose to go that hospital first. Charges there are cheaper than the Teaching Hospital. [In the chosen health facility] He [i.e. surgeon] gave me some test to do but I didn’t do them. I stopped coming to the hospital. …I had financial problem. I came back to the hospital after four years. (Female, aged 44 with cancer of the breast, Kano) Lack of knowledge If we had the knowledge about the disease, we probably would have come earlier. The government should sensitise the community about signs and symptoms of disease and encourage people to present early to the hospital. (Male aged 22 with cancer of the colorectum, Kano) Alternative therapy I went to tell a doctor and he said it means nothing, that I had done menstruation a long time ago, but the one I saw now, he said there’s no worry about it. So that was when we came home, we came to Ogbomosho; when we got to Ogbomosho, I heard these people advertising on the radio, these people that sells medication for Haemorrhoids on the radio, Marathon! I went to complain to them, and they gave me many medications, I was taking them, taking them, but I noticed I was still bleeding. So, I called them that I was bleeding, they said I should just continue with their medicines. (Female aged 78 with cancer of the cervix, Ibadan) Fear and Denial They didn’t do anything for me but asked me to go to Murtala Specialist Hospital. When I went there, they told me to come back the following week Friday. I didn’t go back because I was afraid they will remove the breast. …That was what people keep telling me. Even the health workers at the PHC told me that my breast will be removed. So I was scared and continue using the traditional medicine. (Female aged 18 with cancer of the breast, Kano) Social responsibility and commitments I think sometimes if you have other worries whatever they might be, you just tend to neglect... …You tend to neglect your own health without actually meaning to because technically, while you are in that space, you are just focused on I need to sort this out, I need to do that and maybe even taking care of other people, you neglect yourself. (Female aged 42 with cancer of the breast, Ibadan) Role of Informal Caregiver …I have many children like you, your age. …They know, but they did not take me seriously. Then they brought me here finally. (Male aged 71 with cancer of the head and neck, Ibadan) Limited financial resources also delayed the collection of test results, with some patients spending spent significant time gathering funds from family and friends. Fluctuating costs relating to diagnostic procedures exacerbated the issue As a result, some sought care at less specialised facilities, delaying diagnosis. Only a few received external financial support for diagnostic procedures. ii. Lack of knowledge and perceived non-seriousness Many participants did not initially perceive their symptoms as serious, often viewing them as minor or common ailments that would resolve spontaneously. The absence of pain or significant discomfort further contributed to the perceived non-seriousness. For some, temporary relief from symptoms sometimes led them to postpone seeking medical help until symptoms resurfaced. Many participants sought advice from family and friends who reportedly gave false reassurance or advice to attend traditional or faith healers. Nihilism about treatment effectiveness also emerged as a reason to prevaricate. iii. Alternative therapy Some participants lost valuable time waiting for therapies such as over-the-counter medicines, traditional herbs and spiritual healing to take effect. Many participants frequently engaged in alternative treatments for conditions they believed to be infections or common illnesses, which contributed to delays in cancer diagnosis. They commonly used various symptom-relief methods, including pharmacy drugs, traditional herbs, and spiritual healing practices. Some individuals relied on home-administered injections, antibiotics, and creams, or prioritised traditional remedies over seeking formal medical care. Despite the lack of symptom improvement, several continued to use these alternative therapies, further postponing the identification of cancer symptoms. Faith healing was also sought, reflecting local beliefs in supernatural causes of illness, contributing to extended diagnosis delays. iv. Fear and Denial While some participants did not recognise the importance of serious symptoms, others recognised them all too well, resulting in fear and denial. Fears were multifaceted, ranging from concerns about poor prognosis to anxiety about surgical procedures and adverse outcomes like childlessness. Fear was a dominant theme in interviews with patients with breast cancer in particular, with most patients expressing fear of mastectomy. Also, patients reported fears related to health professionals and specific health facilities, as well as apprehension about sample collection for biopsy. v. Social roles and family commitments Participants' delayed diagnoses were influenced by their social roles and commitment to family. There were instances of distractions within their social groups, such as illness and death in the family, causing them to overlook their health concerns and miss clinic appointments. Spousal influence, particularly for women who relied on their husbands' support for medical decisions, further prolonged delays and hindered timely medical intervention. This lack of social support and alignment in the perception of the seriousness of symptoms between spouses contributed to the delayed diagnosis experienced by participants. vi. Role of informal caregivers Patients’ narratives highlighted informal caregivers' significant role in facilitating patients' diagnostic processes. Many participants reported delays in accessing medical care due to unavailability or passiveness of their caregivers, who were usually adult children of older participants. The proximity and availability of caregivers due to work commitments were also identified as contributory factors to delays in diagnosis and treatment. Despite patients being aware of their illness, diagnosis and treatment were often postponed due to caregivers not perceiving the situation with the same urgency. In some cases, caregivers delayed care by withholding consent for medical interventions. Health system and service provider factor Some participants mentioned health system and service provider factor as reasons for delayed cancer diagnosis (Box 2). These factors include misdiagnosis and inconclusive results, delayed biopsy-histology results, health worker industrial strike action, attitudes of healthcare workers, administrative processing issues, infrastructural deficiencies, and distance to health facilities. Box 2: Key themes on Health system and service provider factors relating to delay in cancer diagnosis Misdiagnosis and inconclusive results When I got to general hospital, I was told to go and do abdominal scan, and after I did the abdominal scan, they said they didn’t see anything. It was where I went to do the scan that someone asked me what my complaint to the doctor was before he said I should go for abdominal scan; I said I was bleeding, he said there was nothing, I then went back home. After that my blood was taken and they said I was having infection, that was what I was treating and it wasn’t going, so I stopped going to general and went to the private hospital we were using… …Even after going, they still couldn’t get what was the issue with me…they were just telling me it was infection, but it wasn’t infection. (Female aged 50 with cancer of the cervix, Ibadan) Delayed biopsy-histology results I was examined by a Doctor. The doctor said they needed to do a test for me to know the type of sickness I have. After they did the test, I waited very long for the result and every time I called, they told me the result is not yet ready. So, I got tired and stopped asking them. (Female aged 48 with cancer of the cervix, Kano) Limited access to healthcare specialities and obstacles in the administrative process I’ve been referred since June and I’ve been coming …. and it has always been a kind of… this week we are having a meeting. Next week, there is a course we’re going for ehh there is an engagement. From that June there is … strike. So, at the end of the day, we had the surgery in September ending. Before we had the surgery, the thing has… metastasised. (Male aged 38 with cancer of the head and neck, Ibadan) Hospital equipment and infrastructure You know a lot of time, the engine in … may not be working. Sometimes we want to do a test and they tell us an engine is not working. There was a time we were asked to go and do it outside when the engine was not working. So, things like that can cause it...There was a month where for about…15 days, we were told there was no light in ... (Female aged 45 with cancer of the head and neck, Ibadan) Distance to the health facility …They told me to come and collect it [i.e. the result] in fourteen days, I’m the one that [did not go back]… The place is far from my base, so since they discharged me in the hospital, I just took time before going and, before collecting it. (Female aged 41 with cancer of the cervix, Ibadan) i. Misdiagnosis and inconclusive results Participants experienced delayed cancer diagnoses due to misdiagnosis, which was a prevalent health systems-related factor reported across all cancers and study sites. Symptoms were dismissed as "nothing" or misdiagnosed as non-cancer illnesses. Table S1 in the supplementary file lists the itemised mentions of situations where cancer symptoms were dismissed as “nothing” or misdiagnosed as non-cancer illnesses for the four cancer types. Participants in both sites reported that cancer of the cervix, breast, and head and neck cancers were often misdiagnosed as unspecified infections. Colorectal cancer was often misdiagnosed as haemorrhoids, ulcers, appendixes and typhoid. The dismissed symptoms and wrong diagnosis occurred in formal public and private health facilities. There are also a few instances of misdiagnosis from multiple health facilities undergoing various tests, each with varied and contrasting conclusions and, sometimes, receiving inconclusive results that discouraged further attendance at health facilities. ii. Delayed biopsy-histology results Participants, especially those from Southern Nigeria, frequently mentioned delayed biopsy/histology results as a major cause of delayed diagnosis. Internal human resource challenges, such as staff shortages or laboratory staff illness, further caused delays in processing biopsies and delivering results. They also mentioned that inefficient result transmission systems between health facilities contributed to prolonged waiting periods for test results. In extreme cases, delays were so severe that patients abandoned the diagnosis process altogether, leading to significant diagnostic delays. iii. Limited access to healthcare specialties and obstacles in the administrative process Participants identified several factors contributing to delays in the cancer care pathway, specifically relating to timely access and care from healthcare personnel in clinics. These factors included limited access to specialists, poor communication between patients and physicians, unprofessional attitudes of healthcare workers, and disruptions in clinic schedules. Some participants reported being unable to see their healthcare specialist and were rescheduled for later dates due to the absence of a replacement doctor. Inadequate patient-physician communication further hindered care, with participants expressing frustration over insufficient information despite their inquiries. Additionally, in both study sites, participants highlighted administrative barriers, such as difficulties in securing timely appointments, mishandling of medical files, delays in insurance processing, and inefficiencies in payment systems. iv. Hospital equipment and infrastructure As a health systems factor, delayed test results were driven by inadequate infrastructure, leading to ineffective service delivery. Participants gave examples relating to interruptions to electricity supply, faulty machines and inefficiencies in the result transmission system between health facilities. Equipment breakdown at hospitals, particularly in Ibadan, caused delays in diagnosis as patients had to seek private services due to the unavailability of diagnostic equipment, which could be costly. Issues such as poor electricity supply contributed to equipment inoperability, further prolonging the diagnostic process and impacting patients' access to timely care. v. Distance to health facilities Distance to the health facility emerged as a factor contributing to delayed diagnosis, particularly noted by participants in Ibadan. The distance between participants' residences and the health facility hindered their ability to promptly return for test results or seek diagnosis, as travelling was perceived as burdensome. Lack of familiarity with the area compounded the issue for participants who were not from the vicinity of the health facility, making it challenging to navigate and seek assistance locally. DISCUSSION Delay in seeking care. Our study confirms long delays in accessing cancer care across four common curable cancers in the second and third largest cities in Africa’s most populous country. The median time from first noticing a symptom to diagnosis was 12 months (365 days) across the four cancers. This is similar to the interval observed in Tanzania, where the median delay was 358 days [ 23 ]. The 12-month delay in our study was all the more concerning because it does not include delay from diagnosis to treatment. There was a notable difference in overall delay between different cancers, with head and neck having the largest overall delay (15.5 months) across the four cancers, followed by cervical cancer (9.5 months). Our findings are in accord with systematic and meta-analytical reviews showing the interval from first symptom to diagnosis is 1.5 to 4 times longer in low-income countries than in high-income settings [ 24 , 25 ]. The problem with the late presentation is typically ascribed to a delay in health-seeking. Remarkably, we find that delay within the formal health sector is considerably longer than delay to presentation across all four cancers. This corroborates previous findings from East Africa [ 23 , 26 ]. Whereas the median interval of three months was reported between the first notice of symptoms and presentation to a healthcare professional, the median between presentation and diagnosis was five months. Our study also showed evidence of “churning,” a situation where cancer patients move around multiple health facilities in search of solutions [ 23 ]. From symptoms to diagnosis, they visited a median of three and up to six health facilities. The reality of churning in cancer care pathways is a key driver of the out-of-pocket expenditure burden experienced by mostly poor cancer patients in poor countries. Causes of delay The study findings align with two of the Aarhus framework’s contributing factors to delay diagnostic and treatment, patient and health systems factors. Out of pocket expenditure, the role of informal caregivers, misdiagnosis and problems with histology emerged as prominent themes. Our data show that less than five percent of participants had health insurance. Therefore, it is not surprising that finance was frequently mentioned, especially after referral to the specialist system. However, finance was by no means the only barrier. We encountered many patient and service barriers reported in previous studies in high- and low-income countries. Most participants in the study had a formal education but appeared to have low health literacy concerning cancer symptoms. Such people rely on family, social and religious networks for information and support. Our data shows that such networks were often a barrier to care; the importance of symptoms was downplayed, patients were misdirected to a traditional healer or health seeking was mis-represented as a sign of insufficient religious faith. The role of traditional healers is controversial; some studies suggest they are consulted only rarely for health matters [ 27 ], while others suggest that they are consulted frequently in the context of cancer symptoms, and that such consultation is associated with worse prognosis [ 24 ]. Yet, others find that traditional healers are consulted when patients encounter delays after referral to health services [ 23 ]. There were also health system factors, which ranged from diagnostic problems to lab testing and result collection delays, attitudes of health workers, bureaucracy, and distance to health facilities. Implications of our findings Delayed cancer diagnosis results in poor outcomes [ 5 , 6 , 17 ], especially in sub-Saharan Africa, where therapies to treat advanced cancer are seldom affordable [ 28 ]. The overarching implication of our findings is that this problem cannot be ignored. Governments and donors around Africa are investing money into the development of advanced facilities, including linear accelerators [ 14 , 15 ]. In Nigeria, the federal government recently committed to such investments through the oncology initiative which seeks to enhance oncology care through strategic medical investments [ 8 ]. Yet most people cannot access these facilities because they cannot afford them. Indeed, a recent consensus statement published in Nature Medicine identified expedited presentation as the top priority for cancer care research in LMIC [ 29 ]. Our findings can help in identifying priorities. First, our finding is that most delays occur within the health service, so attention should be focused on improving service pathways. A particular barrier arises at the point of histology. We advocate first education of primary care clinicians as to where specialist services, including access to inexpensive histology, are available to avoid churn and the out-of-pocket expenses it entails. Second, histology services should be audited, and the audit results be made publicly available. Third, states in Nigeria should consider establishing centralised low-cost histology services as in parts of Kenya. Fourth, studies on methods to reduce the cost of histology should be undertaken, including using Artificial intelligence (AI) for analysis of samples. We note that failure to refer was an important source of delay in our data. This finding is consistent with the extensive literature on the quality of primary care consultations in LMIC [ 30 ]. The obvious remedy here is education, which has improved cancer referral practice in UK [ 5 ]. Education modules should be tailored to each country’s needs and follow evidence-based principles of continuing professional development, for example, using inter-active learning, enhancing motivation and re-enforcing knowledge. The modules should be evaluated and approved for continuing professional development to become scalable and sustainable. Since many people have low cancer literacy and/or considerable trepidation regarding health services, we suggest implementing navigation assistance, which has proven successful in other (non-cancer) contexts [ 31 , 32 ], to provide emotional and logistic support to those who need it. Regarding the issue of healthcare seeking, we note the importance of community networks in our data and the broader literature [ 33 , 34 ]. This suggests that public education should include a community focus to tackle some of the barriers we have documented. First, we think that education regarding cancer should be included in continuing education for Community Health Workers – a policy already enacted in Kenya. Second, many studies have shown that it is possible to engage respectfully with traditional African healers to encourage referrals for people who need allopathic care [ 35 , 36 ]. Such engagement should include awareness of serious symptoms of diseases like cancer and tuberculosis. Third, we note that faith healing was pursued, reflecting local religious beliefs in supernatural causes of illness, which can delay care, and, again, there should be respectful engagement with religious leaders to alter practice, as seen in the Ebola epidemic in West Africa [ 37 ]. Strengths and weaknesses. Our study has the strength of covering four cancers, whereas previous studies have tackled only one or two [ 38 – 42 ]. Our study has the further strength that it combines measurement of delay with qualitative data to shed light on the reasons for those delays across two culturally very different areas in Nigeria. We found similar patterns across these cities, suggesting that our findings are broadly applicable. We designed our study to maximise recruitment of participants for whom interventions with curative intent are unrealistic while complying with strictures on home visiting. However, this strength came at the cost of a limitation because we do not have data on the diagnosis to treatment interval. Another limitation arises from the strike action of the National Association of Resident Doctors during the study. Fortunately, the strike was relatively short, lasting 17 days, from July 26 to August 12, 2023. Our data collection ran for 26 weeks, as mentioned above. Thus, the strike could explain little of the 15.5-month delay observed, for example, with respect to head and neck cancer. We followed the Aarhus declaration to ensure compliance with current best practices. However, the method has limitations since it is based on recall [ 43 ]. We tried to minimise recall bias by using calendar methodology and asking participants about other life events to assist recall. We may have missed some cases, such as those who died without presenting or presented as an emergency, but again, this bias would lead to an underestimation of delay. In addition, it is possible that patients experiencing financial hardship were not captured in our study due to a lack the financial means to seek care in secondary or tertiary health facilities. CONCLUSION Addressing the challenge of delayed diagnosis is important for successful response to cancer treatment and survivorship in LMICs. We examined the duration and reasons for the delayed presentation and diagnosis of four common and treatable cancers in two regions of Nigeria. Declarations FUNDING This study is funded by Research England QR Policy Support Fund (QR Policy 22-24). RL and JS are funded by NIHR RIGHT call 1 on Leprosy, Applied Research Collaboration (ARC) West Midlands and Midlands Patient Safety Research Collaboration (PSRC). PA is funded by the NIHR Applied Research Collaboration (ARC) West Midlands. The views expressed are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care. ACKNOWLEDGEMENT We thank the study participants and stakeholders who participated in the study's inception and dissemination meetings in Kano and Ibadan including Abdulrashid Sulaiman, Ajiya Abdulrazak, Naziru Mustapha, Hajiya Rahama, Abdullahi Ibrahim, Sani Abubakar, Abdulkadir Mohammed, Sumount Thiaminu, Foluke Sarimiye, Sunday Oyerinde. Irene Pogoson, Paul Adekunle Onakoya, Temitope Ilori, Olusoji Adeyanju, Chioma Asuzu and Olufemi Olubisi DATA AVAILABILITY This study data cannot be shared publicly because of ethical requirements to protect the confidentiality of our participants. To request access to anonymised data, please contact the corresponding author at the University of Birmingham (Dr Patricia Apenteng: [email protected] ). Ethics approval and consent to participate Ethics approvals for this study were obtained from UI/UCH Health Research Ethics Committee (Ref: UI/EC/23/0282), Aminu Kano Teaching Hospital Health Research Ethics Committee (Ref: SHREC/2023/3965) and Kano State Ministry of Health Research Ethics Committee (Ref: AKTH/EC/3562). The research was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent before taking part in the study. Consent for publication Not applicable Competing interests The authors have no competing interests. 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Supplementary Files SupplementaryfileV2110325.docx Cite Share Download PDF Status: Published Journal Publication published 21 May, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Accepted 06 Apr, 2025 Reviews received at journal 04 Apr, 2025 Reviewers agreed at journal 04 Apr, 2025 Reviewers invited by journal 04 Apr, 2025 Submission checks completed at journal 27 Mar, 2025 First submitted to journal 21 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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type\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.Durationofdelaybetweenfirstsymptomanddiagnosisbysiteandbycancertype.png","url":"https://assets-eu.researchsquare.com/files/rs-5829862/v1/779ac19ca80b70fbb28d7c7c.png"},{"id":80064734,"identity":"4cf653c3-4adb-4c71-917a-5d7a9395cd29","added_by":"auto","created_at":"2025-04-07 12:59:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":429128,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDuration of delay between first symptom and first presentation to a formal healthcare professional\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.Durationofdelaybetweenfirstsymptomandfirstpresentationtoaformalhealthcareprofessional.png","url":"https://assets-eu.researchsquare.com/files/rs-5829862/v1/43651079e6b6b1c89ab9ae4b.png"},{"id":80063220,"identity":"125396f5-9cf7-4774-93ae-d0da6afd994e","added_by":"auto","created_at":"2025-04-07 12:43:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":526614,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDuration of delay between first presentation to a formal healthcare professional and diagnosis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.Durationofdelaybetweenfirstpresentationtoaformalhealthcareprofessionalanddiagnosis.png","url":"https://assets-eu.researchsquare.com/files/rs-5829862/v1/2d95a9e908bbff533a6374ee.png"},{"id":80065206,"identity":"06dded25-6cec-43af-9dc2-f640eaea8280","added_by":"auto","created_at":"2025-04-07 13:07:23","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":466567,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNumber of health facilities visited between first symptom and diagnosis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure4.Numberofhealthfacilitiesvisitedbetweenfirstsymptomanddiagnosis.png","url":"https://assets-eu.researchsquare.com/files/rs-5829862/v1/72a725c5b5b6d7217b3680e1.png"},{"id":83460090,"identity":"150c485f-3899-4623-b6fc-804bd9a1882e","added_by":"auto","created_at":"2025-05-26 16:10:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3422993,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5829862/v1/faf1964d-1381-461a-abf0-0d49716731c2.pdf"},{"id":80064101,"identity":"1f39b277-1870-4646-8a39-1bbdb94c8af5","added_by":"auto","created_at":"2025-04-07 12:51:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":110971,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfileV2110325.docx","url":"https://assets-eu.researchsquare.com/files/rs-5829862/v1/be81b9009196d528e3894638.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnosis of cancer in the south and north of Nigeria: duration and causes of delay","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eCancer is responsible for about one in six deaths worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Low and middle-income countries (LMICs) have a growing cancer burden, with significantly higher age-adjusted cancer mortality than high-income countries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The majority of people with cancer are in late stage when they receive a diagnosis and treatment in Sub-Saharan Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u0026ndash; for example, a median of 75% for breast cancer, according to a systematic review in 2016 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Delay in treatment is associated with poor prognosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNigeria is a LMIC in sub-Saharan Africa with a population of 224\u0026nbsp;million, larger than the population of the UK, France and Germany combined. A study of hospital case notes of urban dwellers identified from the Nigerian Cancer registry with breast, uterine cervix, colorectum or prostate cancer showed that between two-thirds and three-quarters of patients present late (stages 3 or 4), with no recent improvement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Cancer incidence is rising in Nigeria as people adopt new lifestyles [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and the overall cancer incidence is 113.6 per 100 000 persons per year whilst the overall cancer mortaliy is 74.5 per 100 000 persons per year [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].Less than 10% of Nigerians are enrolled in the National Health Insurance Scheme which provides limited coverage of healthcare services [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Consequently, most Nigerian patients experience financial hardship due to high out-of-pocket expenditures related to cancer care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn response to the growing cancer burden, Health boards in Nigeria have invested in facilities for curative treatment for common cancers [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, to realise the benefits of these investments, it will be necessary to reduce the delay between first symptoms and treatment. In this study, we explored the durations and causes of the delay to the point of histological diagnosis of cancer in health facilities in Nigeria. We focused on four cancer types: 1) breast, 2) colorectum, 3) head and neck, and 4) uterine cervix. We select these cancers because they are common, tend to present early with specific symptom groups and can be cured if treated early.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eFramework\u003c/h2\u003e\n\u003cp\u003eWe conducted an observational study based on interviews with patients after they had received a diagnosis of one of the above four cancer types. The protocol for this study can be found at Protocol exchange [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. We followed the Aarhus framework [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e] for design and reporting studies on early cancer diagnosis. This statement seeks to systematise questionnaires to reconstruct a patient\u0026rsquo;s pathway from the first symptom (body change) to treatment. This pathway can be divided into stages and sub-stages. The WHO [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e] designates three main stages: 1) first symptom to presentation to the formal health system (i.e. an allopathic health provider); 2) presentation to histological diagnosis, and 3) diagnosis to treatment. WHO guidelines [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] recommends that the interval from symptom onset to initiation of treatment should generally be less than 90 days to reduce delays in care and optimize treatment outcomes. We use the term \u0026lsquo;delay\u0026rsquo; to indicate the time between one event and another (e.g. between first symptom and presentation to the formal health system. We could not measure the final WHO stage, diagnosis to treatment in this study (see below). We, therefore, measured the first two stages above and identified the total number of clinics each person visited on the pathway to diagnosis.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eTwo geopolitical regions of Nigeria - the Northwest (Kano) and Southwest (Ibadan) were purposively selected to sample patients of considerable ethnic, religious, and cultural diversity. Kano is the second largest city in Nigeria, with over 4\u0026nbsp;million people, who are predominantly Muslims of Hausa ethnicity. Ibadan is the third largest city in Nigeria, with a population of 3.7\u0026nbsp;million practising Christianity and Islam.\u003c/p\u003e\n\u003ch3\u003eRecruitment strategies\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited from the University College Hospital Ibadan, and Aminu Kano Teaching Hospital and Murtala Muhammad Specialist Hospital in Kano. These are the only hospitals providing specialist care in the study cities and, therefore, constitute the final common pathway for treatment (or the decision that treatment is not advisable) for all but a small proportion of patients who can afford and choose private care.\u003c/p\u003e\n\u003cp\u003eThe ideal point to recruit patients would be at the \u0026lsquo;critical point\u0026rsquo; where patients either receive first-line treatment or the decision that the cancer is too advanced to treat. Attempting to recruit patients after treatment would likely miss patients who did not remain under hospital care to receive treatment. Yet, these are the very people we need to identify to avoid skewing the sample towards those with earlier presentations. To overcome this problem, we considered conducting interviews in the patients' homes, including all patients who had reached the critical point. However, we were advised by local clinicians that this would be seen as intrusive and culturally inappropriate, especially in Kano. We, therefore, recruited people at a point where the initial approach could be made in the outpatient department following histological diagnosis.\u003c/p\u003e\n\u003cp\u003eEligible participants were identified by the patient\u0026rsquo;s clinician, who requested assent (see below). Assenting patients were introduced to the non-clinical researcher, who requested consent. The study selected patients who (1) had a first histologically confirmed diagnosis of cancer of the breast, colorectum, head and neck, or uterine cervix, (2) were aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years,, and (3) could provide informed consent. Participants were invited to bring any accompanying relative or friend to the interview.\u003c/p\u003e\n\u003ch3\u003eEthics, consent, and permissions\u003c/h3\u003e\n\u003cp\u003eEthics approvals\u0026nbsp;for this study were obtained from UI/UCH Health Research Ethics Committee (Ref: UI/EC/23/0282), Aminu Kano Teaching Hospital Health Research Ethics Committee (Ref: SHREC/2023/3965) and Kano State Ministry of Health Research Ethics Committee (Ref: AKTH/EC/3562). The researchers adhered to international standards for conducting health research [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e] and ensured that the rights and well-being of participants were protected during the data collection. The study approach separated \u0026lsquo;assent\u0026rsquo; from \u0026lsquo;consent\u0026rsquo;. Assent covers the process by which the researcher clinician, a study team member, asks the patient whether they would be prepared to meet the field researcher to discuss participation in an interview and describe their journey to a point where the diagnosis has been made. After explaining and discussing the study with the patient, the field researcher requested verbal and written consent from patients who agreed to be interviewed. Patients who lacked the capacity to give informed consent, who had recurrent cancer, or who were acutely ill were not recruited into the study.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected between July 1 and December 31, 2023, across the three tertiary hospitals. The study set out to interview 60 patients per cancer type per site, (240 per site). Our sample size calculations were based on the precision with which we can estimate the quantiles of the delay (median, 75th, or 90th percentiles) for any particular group. A sample of 60 individuals will allow us to estimate the median delay to a precision of approximately +/- 5 days (95% confidence interval), and the 75th and 90th percentiles to +/- and 12 days, respectively. The instrument we developed to collect the quantitative and qualitative data is enclosed in the Supplementary File (Patient interview guide).\u003c/p\u003e\n\u003cp\u003eThe study collected quantitative information to measure the duration of delay by stage. If a participant could not immediately and confidently recall one of the above crucial dates, we used a \u0026lsquo;calendar methodology\u0026rsquo; [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] to help recall and minimise telescoping (the tendency to perceive distant events as being more recent than they are and vice versa). We shared a calendar with the participants and asked them to provide important dates in their personal lives, such as a family member\u0026rsquo;s marriage. We then elicited a best estimate for each crucial event about these personally significant events. Qualitative data were collected to explore patients\u0026rsquo; experiences at each step of the diagnostic pathway.All data collection was face-to-face and the sessions were audio-recorded with the permission of the participant.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003eAll interviews were audio recorded, anonymised, and transcribed verbatim. Interviews conducted in local languages (Yoruba or Hausa) were transcribed in the original language then back-translated to English by six culturally sensitive research assistants (2 in Ibadan and 4 in Kano). Each transcript was then read and checked by an academic member of the research team.\u003c/p\u003e\n\u003cp\u003eQuantitative data analysis included: 1) computing the median and ranges for the above two stages of delay, and 2) recording the number of clinic visits made on the pathway from presentation to diagnosis. The qualitative data was analysed using framework analysis [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Emerging themes were identified, and a thematic framework was developed to code responses. These themes were further classified into two of the three contributing factors from the Aarhus framework: Patient Factors and Healthcare provider and system factors. The qualitative information on reasons for delays in stages in the pathway was interpreted based on discussion and consensus among the study team.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePatient and Public Involvement\u003c/h3\u003e\n\u003cp\u003eCancer patient advocates and healthcare professionals in the two study sites were first engaged in the research process during the planning stage. They participated in a series of stakeholder engagement meetings in Ibadan and Kano, where they identified important issues affecting the patients, forming the basis of this study's objectives. In addition, they contributed their perspectives on the study design and methodologies, particularly in contextualizing the research instruments, which informed the training of research assistants and improved the conduct of the research.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eCharacteristics of participants\u003c/h2\u003e\n \u003cp\u003eA total of 264 participants were interviewed across the selected three tertiary hospitals in Kano and Ibadan. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the characteristics of participants. One hundred and thirty-five patients in Ibadan and one hundred and twenty-nine in Kano participated in the study. 60% (158/264) of participants were aged\u0026thinsp;\u0026le;\u0026thinsp;50 years. 71% (188/264) were female; 99% (77/78) of participants with cancer of the breast were female, whilst 44% of participants with cancer of the colorectum and 29% of participants with head and neck were female. While most participants had a formal education (206 of 264), few reported working at the time of the interview (104 of 264). Just 10 of 264 participants had health insurance for cancer treatment.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIbadan (Southern Nigeria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKano (Northern Nigeria)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of cancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCervix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eColorectum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHead and Neck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex of participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge group (years)\u003c/p\u003e\n \u003cp\u003e18\u0026ndash;30\u003c/p\u003e\n \u003cp\u003e31\u0026ndash;40\u003c/p\u003e\n \u003cp\u003e41\u0026ndash;50\u003c/p\u003e\n \u003cp\u003e51\u0026ndash;60\u003c/p\u003e\n \u003cp\u003e61\u0026ndash;70\u003c/p\u003e\n \u003cp\u003eAbove 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003cp\u003e31.1\u003c/p\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Formal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrently working\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare payment plan\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily and friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll of the above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eDuration of delay at different stages\u003c/h2\u003e\n \u003cp\u003eThe median total time to receive a cancer diagnosis after noticing the first symptoms was 12 months, with an interquartile range of 5 to 27 \u003cstrong\u003e(Fig.\u0026nbsp;1. Duration of delay between first symptom and diagnosis, by site and by cancer type).\u003c/strong\u003e Patients with head and neck cancer experienced the most prolonged (15-month) delay (interquartile range 27 months). In contrast, colorectal cancer patients had the shortest duration, with a median of 8 months. The data were heavily skewed with patients waiting up to nearly 60 months.\u003c/p\u003e\n \u003cp\u003ePatients waited a median of three months before presenting their first cancer symptom to a healthcare professional \u003cstrong\u003e(Fig.\u0026nbsp;2. Duration of delay between first symptom and first presentation to a formal healthcare professional).\u003c/strong\u003e This duration varied by study site and the type of cancer, with patients with cervix and head and neck cancer presenting later than those with breast and colorectum cancer.\u003c/p\u003e\n \u003cp\u003eThe median time for patients to receive a cancer diagnosis after the first presentation of symptoms to a formal healthcare professional was 5 months (interquartile range 12 months) \u003cstrong\u003e(Fig.\u0026nbsp;3. Duration of delay between first presentation to a formal healthcare professional and diagnosis).\u003c/strong\u003e Again, patients with cervical and head and neck cancer had a longer median time to diagnosis post-presentation than patients with breast and colorectal cancer.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFigure 4 (Fig.\u0026nbsp;4. Number of health facilities visited between first symptom and diagnosis)\u003c/strong\u003e provides information on the median and range number of healthcare facilities visited from the onset of symptoms to the eventual cancer diagnosis. Across all patients, the median number of health facilities visited before diagnosis in a formal hospital setting is three. Patients with breast cancer visited an average of two health facilities, whereas cervical, colorectal and head and neck cancer patients visited a median of 3 health facilities. However, the range was wide such that a quarter of patients with colorectal and cervical cancer visited four or more centres before receiving a diagnosis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eReason for delays in cancer diagnosis\u003c/h2\u003e\n \u003cp\u003eReasons for delays in the cancer pathway to care consisted of patient, and health system and service provider factors.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient factors\u003c/h2\u003e\n \u003cp\u003ePatient factors contributing to delayed cancer diagnosis for most study participants are presented in Box 1. These factors include financial constraints, perceived non-seriousness of symptoms, lack of knowledge and misguided advice, awaiting the outcome of alternative therapy and commitments to family and spiritual beliefs. Overall, these patient-related factors highlight the complex interplay of psychological, social, and cultural factors that can influence the timing of cancer diagnosis.\u003c/p\u003e\n \u003cp\u003ei. Financial constraint\u003c/p\u003e\n \u003cp\u003eThe most frequently cited factor was financial constraint. While financial barriers were acknowledged in the context of initial health-seeking behaviour, they became more pronounced following referral to the specialist health sector, where significantly higher out-of-pocket expenses, such as diagnostic tests, were incurred. The expense of hospital care, rather than initial consultations, posed the greatest barrier. Patients highlighted how the high costs of diagnostic tests and treatments discouraged them from seeking timely medical attention. Covering even basic hospital tests proved difficult for those struggling with daily survival needs, such as food and transportation.\u003c/p\u003e\n \u003cp\u003eBox 1: Key themes on patient factors relating to delay in cancer diagnosis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFinancial constraint\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI didn\u0026rsquo;t have enough money, that was why I chose to go that hospital first. Charges there are cheaper than the Teaching Hospital. [In the chosen health facility] He [i.e. surgeon] gave me some test to do but I didn\u0026rsquo;t do them. I stopped coming to the hospital. \u0026hellip;I had financial problem. I came back to the hospital after four years. (Female, aged 44 with cancer of the breast, Kano)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIf we had the knowledge about the disease, we probably would have come earlier. The government should sensitise the community about signs and symptoms of disease and encourage people to present early to the hospital. (Male aged 22 with cancer of the colorectum, Kano)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlternative therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI went to tell a doctor and he said it means nothing, that I had done menstruation a long time ago, but the one I saw now, he said there\u0026rsquo;s no worry about it. So that was when we came home, we came to Ogbomosho; when we got to Ogbomosho, I heard these people advertising on the radio, these people that sells medication for Haemorrhoids on the radio, Marathon! I went to complain to them, and they gave me many medications, I was taking them, taking them, but I noticed I was still bleeding. So, I called them that I was bleeding, they said I should just continue with their medicines. (Female aged 78 with cancer of the cervix, Ibadan)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFear and Denial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThey didn\u0026rsquo;t do anything for me but asked me to go to Murtala Specialist Hospital. When I went there, they told me to come back the following week Friday. I didn\u0026rsquo;t go back because I was afraid they will remove the breast. \u0026hellip;That was what people keep telling me. Even the health workers at the PHC told me that my breast will be removed. So I was scared and continue using the traditional medicine. (Female aged 18 with cancer of the breast, Kano)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial responsibility and commitments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI think sometimes if you have other worries whatever they might be, you just tend to neglect... \u0026hellip;You tend to neglect your own health without actually meaning to because technically, while you are in that space, you are just focused on I need to sort this out, I need to do that and maybe even taking care of other people, you neglect yourself. (Female aged 42 with cancer of the breast, Ibadan)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRole of Informal Caregiver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026hellip;I have many children like you, your age. \u0026hellip;They know, but they did not take me seriously. Then they brought me here finally. (Male aged 71 with cancer of the head and neck, Ibadan)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eLimited financial resources also delayed the collection of test results, with some patients spending spent significant time gathering funds from family and friends. Fluctuating costs relating to diagnostic procedures exacerbated the issue As a result, some sought care at less specialised facilities, delaying diagnosis. Only a few received external financial support for diagnostic procedures.\u003c/p\u003e\n \u003cp\u003eii. Lack of knowledge and perceived non-seriousness\u003c/p\u003e\n \u003cp\u003eMany participants did not initially perceive their symptoms as serious, often viewing them as minor or common ailments that would resolve spontaneously. The absence of pain or significant discomfort further contributed to the perceived non-seriousness. For some, temporary relief from symptoms sometimes led them to postpone seeking medical help until symptoms resurfaced. Many participants sought advice from family and friends who reportedly gave false reassurance or advice to attend traditional or faith healers. Nihilism about treatment effectiveness also emerged as a reason to prevaricate.\u003c/p\u003e\n \u003cp\u003eiii. Alternative therapy\u003c/p\u003e\n \u003cp\u003eSome participants lost valuable time waiting for therapies such as over-the-counter medicines, traditional herbs and spiritual healing to take effect. Many participants frequently engaged in alternative treatments for conditions they believed to be infections or common illnesses, which contributed to delays in cancer diagnosis. They commonly used various symptom-relief methods, including pharmacy drugs, traditional herbs, and spiritual healing practices. Some individuals relied on home-administered injections, antibiotics, and creams, or prioritised traditional remedies over seeking formal medical care. Despite the lack of symptom improvement, several continued to use these alternative therapies, further postponing the identification of cancer symptoms. Faith healing was also sought, reflecting local beliefs in supernatural causes of illness, contributing to extended diagnosis delays.\u003c/p\u003e\n \u003cp\u003eiv. Fear and Denial\u003c/p\u003e\n \u003cp\u003eWhile some participants did not recognise the importance of serious symptoms, others recognised them all too well, resulting in fear and denial. Fears were multifaceted, ranging from concerns about poor prognosis to anxiety about surgical procedures and adverse outcomes like childlessness.\u003c/p\u003e\n \u003cp\u003eFear was a dominant theme in interviews with patients with breast cancer in particular, with most patients expressing fear of mastectomy. Also, patients reported fears related to health professionals and specific health facilities, as well as apprehension about sample collection for biopsy.\u003c/p\u003e\n \u003cp\u003ev. Social roles and family commitments\u003c/p\u003e\n \u003cp\u003eParticipants\u0026apos; delayed diagnoses were influenced by their social roles and commitment to family. There were instances of distractions within their social groups, such as illness and death in the family, causing them to overlook their health concerns and miss clinic appointments. Spousal influence, particularly for women who relied on their husbands\u0026apos; support for medical decisions, further prolonged delays and hindered timely medical intervention. This lack of social support and alignment in the perception of the seriousness of symptoms between spouses contributed to the delayed diagnosis experienced by participants.\u003c/p\u003e\n \u003cp\u003evi. Role of informal caregivers\u003c/p\u003e\n \u003cp\u003ePatients\u0026rsquo; narratives highlighted informal caregivers\u0026apos; significant role in facilitating patients\u0026apos; diagnostic processes. Many participants reported delays in accessing medical care due to unavailability or passiveness of their caregivers, who were usually adult children of older participants. The proximity and availability of caregivers due to work commitments were also identified as contributory factors to delays in diagnosis and treatment. Despite patients being aware of their illness, diagnosis and treatment were often postponed due to caregivers not perceiving the situation with the same urgency. In some cases, caregivers delayed care by withholding consent for medical interventions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eHealth system and service provider factor\u003c/h2\u003e\n \u003cp\u003eSome participants mentioned health system and service provider factor as reasons for delayed cancer diagnosis (Box 2). These factors include misdiagnosis and inconclusive results, delayed biopsy-histology results, health worker industrial strike action, attitudes of healthcare workers, administrative processing issues, infrastructural deficiencies, and distance to health facilities.\u003c/p\u003e\n \u003cp\u003eBox 2: Key themes on Health system and service provider factors relating to delay in cancer diagnosis\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMisdiagnosis and inconclusive results\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eWhen I got to general hospital, I was told to go and do abdominal scan, and after I did the abdominal scan, they said they didn\u0026rsquo;t see anything. It was where I went to do the scan that someone asked me what my complaint to the doctor was before he said I should go for abdominal scan; I said I was bleeding, he said there was nothing, I then went back home. After that my blood was taken and they said I was having infection, that was what I was treating and it wasn\u0026rsquo;t going, so I stopped going to general and went to the private hospital we were using\u0026hellip; \u0026hellip;Even after going, they still couldn\u0026rsquo;t get what was the issue with me\u0026hellip;they were just telling me it was infection, but it wasn\u0026rsquo;t infection. (Female aged 50 with cancer of the cervix, Ibadan)\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDelayed biopsy-histology results\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI was examined by a Doctor. The doctor said they needed to do a test for me to know the type of sickness I have. After they did the test, I waited very long for the result and every time I called, they told me the result is not yet ready. So, I got tired and stopped asking them. (Female aged 48 with cancer of the cervix, Kano)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited access to healthcare specialities and obstacles in the administrative process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI\u0026rsquo;ve been referred since June and I\u0026rsquo;ve been coming \u0026hellip;. and it has always been a kind of\u0026hellip; this week we are having a meeting. Next week, there is a course we\u0026rsquo;re going for ehh there is an engagement. From that June there is \u0026hellip; strike. So, at the end of the day, we had the surgery in September ending. Before we had the surgery, the thing has\u0026hellip; metastasised. (Male aged 38 with cancer of the head and neck, Ibadan)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital equipment and infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eYou know a lot of time, the engine in \u0026hellip; may not be working. Sometimes we want to do a test and they tell us an engine is not working. There was a time we were asked to go and do it outside when the engine was not working. So, things like that can cause it...There was a month where for about\u0026hellip;15 days, we were told there was no light in ... (Female aged 45 with cancer of the head and neck, Ibadan)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistance to the health facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026hellip;They told me to come and collect it [i.e. the result] in fourteen days, I\u0026rsquo;m the one that [did not go back]\u0026hellip; The place is far from my base, so since they discharged me in the hospital, I just took time before going and, before collecting it. (Female aged 41 with cancer of the cervix, Ibadan)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003ei. Misdiagnosis and inconclusive results\u003c/p\u003e\n \u003cp\u003eParticipants experienced delayed cancer diagnoses due to misdiagnosis, which was a prevalent health systems-related factor reported across all cancers and study sites. Symptoms were dismissed as \u0026quot;nothing\u0026quot; or misdiagnosed as non-cancer illnesses. Table \u003cspan class=\"InternalRef\"\u003eS1\u003c/span\u003e in the supplementary file lists the itemised mentions of situations where cancer symptoms were dismissed as \u0026ldquo;nothing\u0026rdquo; or misdiagnosed as non-cancer illnesses for the four cancer types. Participants in both sites reported that cancer of the cervix, breast, and head and neck cancers were often misdiagnosed as unspecified infections. Colorectal cancer was often misdiagnosed as haemorrhoids, ulcers, appendixes and typhoid. The dismissed symptoms and wrong diagnosis occurred in formal public and private health facilities. There are also a few instances of misdiagnosis from multiple health facilities undergoing various tests, each with varied and contrasting conclusions and, sometimes, receiving inconclusive results that discouraged further attendance at health facilities.\u003c/p\u003e\n \u003cp\u003eii. Delayed biopsy-histology results\u003c/p\u003e\n \u003cp\u003eParticipants, especially those from Southern Nigeria, frequently mentioned delayed biopsy/histology results as a major cause of delayed diagnosis. Internal human resource challenges, such as staff shortages or laboratory staff illness, further caused delays in processing biopsies and delivering results. They also mentioned that inefficient result transmission systems between health facilities contributed to prolonged waiting periods for test results. In extreme cases, delays were so severe that patients abandoned the diagnosis process altogether, leading to significant diagnostic delays.\u003c/p\u003e\n \u003cp\u003eiii. Limited access to healthcare specialties and obstacles in the administrative process\u003c/p\u003e\n \u003cp\u003eParticipants identified several factors contributing to delays in the cancer care pathway, specifically relating to timely access and care from healthcare personnel in clinics. These factors included limited access to specialists, poor communication between patients and physicians, unprofessional attitudes of healthcare workers, and disruptions in clinic schedules. Some participants reported being unable to see their healthcare specialist and were rescheduled for later dates due to the absence of a replacement doctor. Inadequate patient-physician communication further hindered care, with participants expressing frustration over insufficient information despite their inquiries. Additionally, in both study sites, participants highlighted administrative barriers, such as difficulties in securing timely appointments, mishandling of medical files, delays in insurance processing, and inefficiencies in payment systems.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003cp\u003eiv. Hospital equipment and infrastructure\u003c/p\u003e\n \u003cp\u003eAs a health systems factor, delayed test results were driven by inadequate infrastructure, leading to ineffective service delivery. Participants gave examples relating to interruptions to electricity supply, faulty machines and inefficiencies in the result transmission system between health facilities. Equipment breakdown at hospitals, particularly in Ibadan, caused delays in diagnosis as patients had to seek private services due to the unavailability of diagnostic equipment, which could be costly. Issues such as poor electricity supply contributed to equipment inoperability, further prolonging the diagnostic process and impacting patients\u0026apos; access to timely care.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003cp\u003ev. Distance to health facilities\u003c/p\u003e\n \u003cp\u003eDistance to the health facility emerged as a factor contributing to delayed diagnosis, particularly noted by participants in Ibadan. The distance between participants\u0026apos; residences and the health facility hindered their ability to promptly return for test results or seek diagnosis, as travelling was perceived as burdensome. Lack of familiarity with the area compounded the issue for participants who were not from the vicinity of the health facility, making it challenging to navigate and seek assistance locally.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e \u003cem\u003eDelay in seeking care.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOur study confirms long delays in accessing cancer care across four common curable cancers in the second and third largest cities in Africa\u0026rsquo;s most populous country. The median time from first noticing a symptom to diagnosis was 12 months (365 days) across the four cancers. This is similar to the interval observed in Tanzania, where the median delay was 358 days [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The 12-month delay in our study was all the more concerning because it does not include delay from diagnosis to treatment. There was a notable difference in overall delay between different cancers, with head and neck having the largest overall delay (15.5 months) across the four cancers, followed by cervical cancer (9.5 months). Our findings are in accord with systematic and meta-analytical reviews showing the interval from first symptom to diagnosis is 1.5 to 4 times longer in low-income countries than in high-income settings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe problem with the late presentation is typically ascribed to a delay in health-seeking. Remarkably, we find that delay within the formal health sector is considerably longer than delay to presentation across all four cancers. This corroborates previous findings from East Africa [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Whereas the median interval of three months was reported between the first notice of symptoms and presentation to a healthcare professional, the median between presentation and diagnosis was five months.\u003c/p\u003e \u003cp\u003eOur study also showed evidence of \u0026ldquo;churning,\u0026rdquo; a situation where cancer patients move around multiple health facilities in search of solutions [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. From symptoms to diagnosis, they visited a median of three and up to six health facilities. The reality of churning in cancer care pathways is a key driver of the out-of-pocket expenditure burden experienced by mostly poor cancer patients in poor countries.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCauses of delay\u003c/h2\u003e \u003cp\u003eThe study findings align with two of the Aarhus framework\u0026rsquo;s contributing factors to delay diagnostic and treatment, patient and health systems factors. Out of pocket expenditure, the role of informal caregivers, misdiagnosis and problems with histology emerged as prominent themes. Our data show that less than five percent of participants had health insurance. Therefore, it is not surprising that finance was frequently mentioned, especially after referral to the specialist system. However, finance was by no means the only barrier. We encountered many patient and service barriers reported in previous studies in high- and low-income countries. Most participants in the study had a formal education but appeared to have low health literacy concerning cancer symptoms. Such people rely on family, social and religious networks for information and support. Our data shows that such networks were often a barrier to care; the importance of symptoms was downplayed, patients were misdirected to a traditional healer or health seeking was mis-represented as a sign of insufficient religious faith. The role of traditional healers is controversial; some studies suggest they are consulted only rarely for health matters [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], while others suggest that they are consulted frequently in the context of cancer symptoms, and that such consultation is associated with worse prognosis [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Yet, others find that traditional healers are consulted when patients encounter delays \u003cem\u003eafter\u003c/em\u003e referral to health services [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. There were also health system factors, which ranged from diagnostic problems to lab testing and result collection delays, attitudes of health workers, bureaucracy, and distance to health facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplications of our findings\u003c/h2\u003e \u003cp\u003eDelayed cancer diagnosis results in poor outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], especially in sub-Saharan Africa, where therapies to treat advanced cancer are seldom affordable [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The overarching implication of our findings is that this problem cannot be ignored. Governments and donors around Africa are investing money into the development of advanced facilities, including linear accelerators [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In Nigeria, the federal government recently committed to such investments through the oncology initiative which seeks to enhance oncology care through strategic medical investments [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Yet most people cannot access these facilities because they cannot afford them. Indeed, a recent consensus statement published in \u003cem\u003eNature Medicine\u003c/em\u003e identified expedited presentation as the top priority for cancer care research in LMIC [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings can help in identifying priorities. First, our finding is that most delays occur within the health service, so attention should be focused on improving service pathways. A particular barrier arises at the point of histology. We advocate first education of primary care clinicians as to where specialist services, including access to inexpensive histology, are available to avoid churn and the out-of-pocket expenses it entails. Second, histology services should be audited, and the audit results be made publicly available. Third, states in Nigeria should consider establishing centralised low-cost histology services as in parts of Kenya. Fourth, studies on methods to reduce the cost of histology should be undertaken, including using Artificial intelligence (AI) for analysis of samples.\u003c/p\u003e \u003cp\u003eWe note that failure to refer was an important source of delay in our data. This finding is consistent with the extensive literature on the quality of primary care consultations in LMIC [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The obvious remedy here is education, which has improved cancer referral practice in UK [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Education modules should be tailored to each country\u0026rsquo;s needs and follow evidence-based principles of continuing professional development, for example, using inter-active learning, enhancing motivation and re-enforcing knowledge. The modules should be evaluated and approved for continuing professional development to become scalable and sustainable. Since many people have low cancer literacy and/or considerable trepidation regarding health services, we suggest implementing navigation assistance, which has proven successful in other (non-cancer) contexts [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], to provide emotional and logistic support to those who need it.\u003c/p\u003e \u003cp\u003eRegarding the issue of healthcare seeking, we note the importance of community networks in our data and the broader literature [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This suggests that public education should include a community focus to tackle some of the barriers we have documented. First, we think that education regarding cancer should be included in continuing education for Community Health Workers \u0026ndash; a policy already enacted in Kenya. Second, many studies have shown that it is possible to engage respectfully with traditional African healers to encourage referrals for people who need allopathic care [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Such engagement should include awareness of serious symptoms of diseases like cancer and tuberculosis. Third, we note that faith healing was pursued, reflecting local religious beliefs in supernatural causes of illness, which can delay care, and, again, there should be respectful engagement with religious leaders to alter practice, as seen in the Ebola epidemic in West Africa [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eStrengths and weaknesses.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOur study has the strength of covering four cancers, whereas previous studies have tackled only one or two [\u003cspan additionalcitationids=\"CR39 CR40 CR41\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Our study has the further strength that it combines measurement of delay with qualitative data to shed light on the reasons for those delays across two culturally very different areas in Nigeria. We found similar patterns across these cities, suggesting that our findings are broadly applicable. We designed our study to maximise recruitment of participants for whom interventions with curative intent are unrealistic while complying with strictures on home visiting. However, this strength came at the cost of a limitation because we do not have data on the diagnosis to treatment interval. Another limitation arises from the strike action of the National Association of Resident Doctors during the study. Fortunately, the strike was relatively short, lasting 17 days, from July 26 to August 12, 2023. Our data collection ran for 26 weeks, as mentioned above. Thus, the strike could explain little of the 15.5-month delay observed, for example, with respect to head and neck cancer. We followed the Aarhus declaration to ensure compliance with current best practices. However, the method has limitations since it is based on recall [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. We tried to minimise recall bias by using calendar methodology and asking participants about other life events to assist recall. We may have missed some cases, such as those who died without presenting or presented as an emergency, but again, this bias would lead to an underestimation of delay. In addition, it is possible that patients experiencing financial hardship were not captured in our study due to a lack the financial means to seek care in secondary or tertiary health facilities.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAddressing the challenge of delayed diagnosis is important for successful response to cancer treatment and survivorship in LMICs. We examined the duration and reasons for the delayed presentation and diagnosis of four common and treatable cancers in two regions of Nigeria.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by Research England QR Policy Support Fund (QR Policy 22-24). \u0026nbsp;RL and JS are funded by NIHR RIGHT call 1 on Leprosy, Applied Research Collaboration (ARC) West Midlands and Midlands Patient Safety Research Collaboration (PSRC). \u0026nbsp; \u0026nbsp; PA is funded by the NIHR Applied Research Collaboration (ARC) West Midlands. \u0026nbsp; The views expressed are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the study participants and stakeholders who participated in the study\u0026apos;s inception and dissemination meetings in Kano and Ibadan including Abdulrashid Sulaiman, Ajiya Abdulrazak, Naziru Mustapha, Hajiya Rahama, Abdullahi Ibrahim, Sani Abubakar, Abdulkadir Mohammed, Sumount Thiaminu, Foluke Sarimiye, \u0026nbsp;Sunday Oyerinde. Irene Pogoson, Paul Adekunle Onakoya, Temitope Ilori, Olusoji Adeyanju, Chioma Asuzu and Olufemi Olubisi\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study data cannot be shared publicly because of ethical requirements to protect the confidentiality of our participants. To request access to anonymised data, please contact the corresponding author at the University of Birmingham (Dr Patricia Apenteng: [email protected]).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthics approvals for this study were obtained from UI/UCH Health Research Ethics Committee (Ref: UI/EC/23/0282), Aminu Kano Teaching Hospital Health Research Ethics Committee (Ref: SHREC/2023/3965) and Kano State Ministry of Health Research Ethics Committee (Ref: AKTH/EC/3562). \u0026nbsp;The research was conducted in accordance with the Declaration of Helsinki. \u0026nbsp; All participants provided written informed consent before taking part in the study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerlay J, Colombet M, Soerjomataram I, Parkin DM, Pi\u0026ntilde;eros M, Znaor A, et al. 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BMC Health Serv Res. 2018;18:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5829862/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5829862/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Nigeria has a growing cancer burden, with late presentation and delayed diagnosis contributing to poor outcomes. We explored the durations and causes of the delay in the diagnosis of four common and treatable cancer types (breast, colorectum, head and neck, and uterine cervix) in Nigeria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Retrospective study based on interviews with cancer patients following the Aarhus framework for designing and reporting such studies. The study focused on the first two of WHO’s three main designated stages of cancer diagnosis: duration from symptom to presentation and presentation to histological diagnosis. Our hospital-based study involved 264 patients recruited from tertiary care facilities in the Northwestern (Kano) and Southwestern (Ibadan) regions of Nigeria. We obtained quantitative data to measure the duration of delay by stage, while interview data were collected to explore the causes of delay. We analysed the data by computing the median duration for the two stages of delay, and framework analysis was used to identify themes on the causes of delay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The median time to receive a cancer diagnosis after noticing the first symptoms was 12 months (interquartile range 5 to 27 months), with head and neck cancer patients reporting the most prolonged (15-month) delay. Patients waited a median of 3 months (interquartile range 12 months) before presenting their first cancer symptom to a healthcare professional. The median time for patients to receive a cancer diagnosis after the first presentation of symptoms to a formal healthcare professional was 5 months (interquartile range \u0026nbsp;\u0026nbsp;12 months). There was wide variance for all time intervals. Patients reported visiting a median of 3 health facilities before diagnosis in a formal hospital setting. Qualitative findings identified two main reasons patients reported delays in cancer pathway to care: patient-related factors and health system issues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Long delays were observed, and more than half the delay followed presentation to the local health sector.\u003c/p\u003e","manuscriptTitle":"Diagnosis of cancer in the south and north of Nigeria: duration and causes of delay","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-07 12:43:18","doi":"10.21203/rs.3.rs-5829862/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-07T03:58:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-04T10:32:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310656718760133591348701134471640565224","date":"2025-04-04T09:51:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-04T08:26:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-27T09:27:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-03-21T20:17:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91a7ebdc-8a57-496f-a83d-90d0d9851557","owner":[],"postedDate":"April 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:03:49+00:00","versionOfRecord":{"articleIdentity":"rs-5829862","link":"https://doi.org/10.1186/s12913-025-12707-8","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-05-21 15:57:16","publishedOnDateReadable":"May 21st, 2025"},"versionCreatedAt":"2025-04-07 12:43:18","video":"","vorDoi":"10.1186/s12913-025-12707-8","vorDoiUrl":"https://doi.org/10.1186/s12913-025-12707-8","workflowStages":[]},"version":"v1","identity":"rs-5829862","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5829862","identity":"rs-5829862","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}