Delays to diagnosis and barriers to care for breast cancer in Mexico and Peru: a cross sectional study

Background
Delays to breast cancer diagnosis and treatment initiation are associated with worsened outcomes. However, population-based screening is impractical in many low-income and middle-income countries (LMICs) because of resource constraints and a lack of capacity to effectively diagnose and treat screen-detected disease. Mexico and Peru have similar mortality-to-incidence ratios for breast cancer. Unlike Peru, Mexico has attempted to implement mammography screening, although it remains opportunistic with low (20%) national coverage rates. The aim of this study was to compare delays and describe barriers to care among breast cancer patients in Mexico and Peru.

Methods
This international cross-sectional study included breast cancer patients interviewed at four public cancer hospitals in Mexico City between 2009 and 2011, and a federally-funded regional cancer institute in Trujillo, Peru in 2015. A Breast Cancer Delays Questionnaire, developed and validated in Mexico and modified for Peru, was administered to breast cancer patients during routine hospital visits at each location. Patient-related, diagnostic, and treatment delays were quantified, and barriers to care identified.

Findings
We included data from 597 Mexican women and 113 Peruvian women. Age at diagnosis did not differ between countries (53 years [Mexico] vs 54 years [Peru], p=0·266). Most women in both countries had breast cancer detected by symptoms (84% [Mexico] vs 93% [Peru]; p<0·001), although more women in Mexico were diagnosed by mammography screening (12% vs 6%) and screening clinical breast examination (4% vs 1%). Of patients with available stage information, the majority of disease was AJCC stage II or III at diagnosis (76% [n=597, Mexico] vs 91% [93, Peru]; p=0·014). More women in Mexico were diagnosed at an early stage (AJCC stage 0 or I) (14% [Mexico] vs 4% [Peru]). Total delay (symptom discovery or screening to initiation of treatment) did not differ between the two countries (median 210 days [IQR 128–415; n=597] Mexico vs 201 days [82–442; n=74] Peru; [p=0·71]). Diagnostic delay (first medical consultation to diagnosis) was the greatest contributor to overall delay (113 days [59–250; n=597, Mexico] vs 174 days [40–396; n=95, Peru]; p=0·105). Approximately 60% of all patients had diagnostic delays greater than 3 months. Less than half (44%) of Mexican patients visited more than two health-care facilities before the cancer centre, compared with 71% of Peruvian patients (p<0·001). Patients in both countries reported that barriers to prompt arrival at the cancer centre were: not knowing where to go, lack of money, spread out appointments, and diagnostic errors.

Interpretation
Improved diagnostic and referral systems are necessary to reduce delays to breast cancer care in Mexico and Peru. Such improvements are prerequisites to the establishment of maximally effective mammography screening programmes in LMICs.

Surgical Site Infections Rates in More Than 13,000 Surgical Procedures in Three Cities in Peru: Findings of the International Nosocomial Infection Control Consortium

BACKGROUND: Surgical site infections (SSIs) are a threat to patient safety. However, there are not available data on SSI rates stratified by surgical procedure (SP) in Peru.

METHODS: From January 2005 to December 2010, a cohort prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in four hospitals in three cities of Peru. Data were recorded from hospitalized patients using the U.S. Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) methods and definitions for SSI. Surgical procedures (SPs) were classified into 4 types, according to ICD-9 criteria.

RESULTS: We recorded 352 SSIs, associated to 13,904 SPs (2.5%; CI, 2.3-2.8) SSI rates per type of SP were the following for this study’s Peruvian hospitals, compared with rates of the INICC and CDC-NHSN reports, respectively: 2.9% for appendix surgery (vs. 2.9% vs. 1.4%); 2.8% for gallbladder surgery (vs. 2.5% vs. 0.6%); 2.2% for cesarean section (vs. 0.7% vs. 1.8%); 2.8% for vaginal hysterectomy (vs. 2.0% vs. 0.9%).

CONCLUSIONS: Our SSIs rates were higher in all of the four analyzed types of SPs compared with CDC-NHSN, whereas compared with INICC, most rates were similar. This study represents an important advance in the knowledge of SSI epidemiology in Peru that will allow us to introduce targeted interventions.