Time to treatment initiation delays in cervical cancer worldwide: A systematic review and meta-analysis

Cervical cancer disproportionately affects women in LMICs, with treatment delays worsening outcomes. Despite WHO's 90-70-90 elimination goal, global disparities persist. This study systematically reviews worldwide delays from diagnosis to treatment, identifying contributing factors across income levels, healthcare systems, and treatment approaches.

We conducted a systematic review and meta-analysis following PRISMA 2020 guidelines. Observational studies reporting the interval between histopathological diagnosis of cervical cancer and initiation of first-line definitive treatment (surgery, chemotherapy, radiotherapy, or combination therapy) were eligible. Search was performed in PubMed, Embase, Web of Science, and Scopus up to October 30, 2025. Two reviewers independently screened records, extracted data, and assessed study quality using the JBI Critical Appraisal Checklist. Pooled mean delays were estimated using random-effects models in STATA 19.5. Subgroup analyses and meta-regression explored heterogeneity by income level, data source, and treatment modality. Sensitivity analyses and publication bias assessments were performed using Galbraith plots, leave-one-out methods, Egger's test, and trim-and-fill procedures.

The pooled mean delay from diagnosis to treatment initiation was 71.42 days (95% CI: 47.96-94.88), exceeding recommended benchmarks of 30-60 days. Across studies, 59% of patients experienced treatment initiation delays exceeding 30 days, 54% exceeded 45 days, and 33% exceeded 90 days. Subgroup analysis revealed that high-income countries experienced shorter delays (40.50 days), while upper-middle-income countries faced significantly longer waits (94.63 days). Among treatment types, radiotherapy had the longest delay (79.90 days). The causes of delay were multifaceted, involving patient-level challenges such as stigma and financial constraints, systemic issues like inefficient referral processes and limited radiotherapy access, and disease-related factors. Despite substantial heterogeneity across studies (I² = 99.98%), sensitivity analyses validated the consistency and reliability of the pooled estimates.

This study provides the most comprehensive global estimate of cervical cancer treatment delays to date. The findings highlight critical disparities across income settings and healthcare systems, with actionable insights for policy and practice. Addressing these delays is essential to improving survival outcomes and achieving WHO's cervical cancer elimination targets. Strengthening referral systems, expanding radiotherapy infrastructure, and tailoring interventions to local barriers are key priorities.