A study of young women with breast cancer found persistent delays in care, particularly among those with lower incomes, as well as a survival paradox that experts cautioned should not diminish the urgency of treatment.

Women with annual household incomes below $50,000 had nearly twice the odds of waiting at least 90 days after first noticing breast cancer symptoms before seeking medical attention compared with those with higher incomes. Younger patients were also more likely to experience delays between seeking medical care and receiving a diagnosis, the researchers found.

“Given the rising rates of young-onset breast cancer, it is important for clinicians to recognize symptoms indicative of breast cancer in these younger women so that diagnostic workup can be done in a timely fashion. Assumptions that a patient is too young to have breast cancer can be detrimental, as this may lead to delays in care,” senior author Kristen Brantley, PhD, MPH, of Dana-Farber Cancer Institute in Boston, told Medscape Medical News.

Regarding financial barriers, Brantley said, “the onus falls on our healthcare system to enhance access to care for individuals of all socioeconomic backgrounds.”

The study, published online on October 12 in Cancer, also yielded some counterintuitive findings. Presentation and diagnostic delays were not significantly associated with worse survival, while treatment delays were paradoxically linked to longer disease-free survival (DFS) in some analyses. In addition, women with a first-degree family history of breast cancer were less likely to delay seeking care, but among those with self-detected cancers, family history was associated with greater odds of diagnostic delay.

Jasmine Sukumar, MD, a breast medical oncologist at The University of Texas MD Anderson Cancer Center in Houston, who wasn’t involved in the study, cautioned that the absence of a statistically significant association with care delay and overall survival (OS) should not be interpreted as evidence that delays are harmless. “Timely diagnosis and treatment remain the clinical priority," Sukumar told Medscape Medical News.

Sukumar also noted that the impact of family history on diagnostic delays is nuanced and complex.

“Having a close relative with breast cancer can shape a woman’s response to breast symptoms in different ways depending on the individual. That experience may make an individual more alert to changes and more likely to seek medical attention promptly, but, on the other hand, it could also bring greater anxiety about what those changes might mean,” she explained.

Delays at Multiple Points in Care

Brantley and colleagues analyzed 1071 women aged 40 years or younger diagnosed with stage 0-IV breast cancer between 2006 and 2016 who participated in the prospective Young Women’s Breast Cancer Study at 13 sites in the US and Canada. The median age at diagnosis was 36 years, and most cancers (78%) were self-detected.

The investigators examined three types of delays: presentation delay, defined as 90 days or longer between first symptoms and seeking medical care; diagnostic delay, defined as 90 days or longer between presentation and confirmed diagnosis; and treatment delay, defined as 60 days or longer between diagnosis and initial treatment.

Overall, 14% of patients experienced a presentation delay, 11% a diagnostic delay, and 22% a treatment delay. Median times were 14 days from symptom recognition to presentation, 14 days from presentation to diagnosis, and 41 days from diagnosis to treatment.

After adjustment for patient and tumor characteristics, women with annual household incomes below $50,000 had nearly double the odds of presentation delay compared with those with higher incomes (odds ratio [OR], 1.98). This finding provides “needed evidence that addressing socioeconomic disparities in health access and education may be instrumental in reducing delays in BC [breast cancer] care,” Brantley said.

Plus, each additional year of age was associated with a 6% reduction in the odds of diagnostic delay (OR, 0.94), suggesting that the youngest patients faced greater barriers to timely diagnosis. Possible explanations include lower cancer awareness among very young women, attributing symptoms to lifestyle factors, fear of a cancer diagnosis, and clinician assumptions that younger women are unlikely to develop breast cancer.

Tumor subtype also mattered. Compared with women with luminal A cancers, those with triple-negative breast cancer had lower odds of presentation delay (OR, 0.29), diagnostic delay (OR, 0.35), and treatment delay (OR, 0.26). The authors suggested that larger, more readily detectable triple-negative tumors and the urgency of treating aggressive disease may help explain the shorter delays. Presentation delays were also associated with higher odds of stage III-IV rather than stage I-II disease among women with hormone receptor-positive, HER2-positive (luminal B) tumors (OR, 3.19).

Racial Disparities: An Incomplete Picture

The study found no statistically significant racial differences in delays, although the predominantly White, well-insured cohort limited the ability to detect disparities. Nearly 88% of participants were White, only 3.5% were Black, and fewer than 5% were Hispanic. Most had commercial or managed care insurance (85%), and nearly half reported annual household incomes exceeding $100,000.

In unadjusted analyses, non-White women had numerically higher odds of presentation delay (OR, 1.48), diagnostic delay (OR, 1.34), and treatment delay (OR, 1.10), but none of these associations was statistically significant. Hispanic women also had numerically higher odds of diagnostic delay, although the association did not reach statistical significance.

Evidence from larger, more diverse populations has documented disparities. A 2022 study involving more than 74,000 women younger than 40 years with nonmetastatic breast cancer found that Black women had nearly twice the adjusted odds of delayed upfront surgery compared with White women (adjusted OR, 1.93).

Similarly, a population-based analysis of nearly 3000 women in the Carolina Breast Cancer Study, roughly half of whom were Black, found that Black women were more likely than non-Black women to be diagnosed with stage III-IV disease (22% vs 15%) and to experience delays of more than 30 days before starting treatment (39% vs 31%).

Impact of Family History?

Brantley and colleagues also saw that, overall, women with a first-degree family history of breast cancer had significantly lower odds of presentation delay (OR, 0.40). However, among women whose cancers were self-detected, family history was associated with more than twice the odds of diagnostic delay (OR, 2.08).

This finding supports an earlier analysis of 585 women from the same cohort, which found that women with a family history of breast or ovarian cancer were more likely to experience diagnostic delays. The earlier analysis also linked financial disadvantages to longer delays in seeking medical attention.

Brantley said the updated analysis nearly doubled the cohort size, allowing for “a more robust statistical analysis” and greater confidence in the persistent findings. Unlike the earlier study, the new analysis included annual income, examined delays by tumor subtype, and assessed long-term survival.

A Survival Paradox?

During a median follow-up of 12.3 years, presentation and diagnostic delays were not significantly associated with DFS or OS. However, treatment delays of 60 days or longer were associated with longer DFS among women with stage I-III disease, even after adjustment for age, tumor subtype, stage, and treatment (hazard ratio, 0.50).

The association was particularly evident among women with stage II disease and those with luminal A or HER2-negative luminal B tumors. Although treatment delays were associated with improved OS in less-adjusted models, the association was no longer statistically significant after accounting for treatment and stage.

Both Brantley and Richard J. Bleicher, MD, chief of the Division of Breast Surgery at Fox Chase Cancer Center, Philadelphia, who was not involved in the study, attributed the association to tumor biology and other factors, rather than suggesting that delaying treatment is beneficial or inconsequential.

The “seemingly paradoxical findings” largely reflect tumor biology and differences in treatment urgency. Less aggressive tumors are more likely to have a greater time between diagnosis and treatment initiation and are associated with better outcomes and lower recurrence rates, Brantley said.

A patient’s ability to survival longer delays can also be attributed to having less aggressive disease or beneficial confounding characteristics that cannot be identified, “creating the appearance of an association between delay and longer survival,” Bleicher explained.

Bleicher, whose research has linked longer time to breast cancer surgery with worse survival, noted that large national studies have detected adverse effects of treatment delays that smaller cohorts may lack sufficient statistical power to identify.

Bleicher also pointed to the study’s heterogeneous population and selection of participants who completed baseline surveys as possibly limiting its ability to detect differences and generalize findings. He added that methodological limitations of the new study included its use of fixed thresholds to define delays in the categorical analyses. For example, a 45-day interval and an 89-day interval would both fall into the “no delay” category, potentially obscuring meaningful differences in timing.

The study was supported by the Breast Cancer Research Foundation, Susan G. Komen, and the American Cancer Society. Author disclosures are available with the original study publication. Sukumar and Bleicher had no relevant disclosures.