When the World Health Organization declared Covid-19 a pandemic in March 2020, South Africa responded with one of the world’s longest national lockdowns, stretching from March 2020 to June 2022. Hospitals restricted patient movement, redeployed staff, and diverted resources toward the viral emergency. For women with suspicious breast lumps in Johannesburg’s public health system, the consequences were measurable and, in some respects, enduring. A new study published in BMC Cancer has now quantified exactly how the pandemic reshaped the journey from first symptom to cancer treatment for more than 2,500 women, and its findings reveal a health system that partially recovered but never returned to its pre-pandemic baseline.
The research team, led by Rebaone Petlele and Maureen Joffe of the University of the Witwatersrand, drew on the South African Breast Cancer and HIV Outcomes (SABCHO) cohort, a longitudinal study initiated in 2015. They analyzed data from two large academic hospitals affiliated with the university: Chris Hani Baragwanath Academic Hospital in Soweto, referred to as Site 1, and Charlotte Maxeke Johannesburg Academic Hospital in central Johannesburg, referred to as Site 2. Of 3,778 women diagnosed with invasive breast malignancies across the study windows, 2,623 consented to participate, and after excluding cases of ductal carcinoma in situ, phyllodes tumours, breast sarcoma, and patients lost to follow-up, 2,522 women with confirmed invasive breast carcinomas formed the analytical cohort, 1,641 at Site 1 and 881 at Site 2.
The investigators divided enrolment into three roughly two-year periods designed to minimize temporal spillover: a pre-Covid-19 window from April 2017 to March 2019, a pandemic window from April 2020 to March 2022, and a post-pandemic window from July 2022 to June 2024. This design captured two additional disruptions that complicate interpretation. In April 2021, a fire at Charlotte Maxeke hospital shut down treatment services for six months, while in June 2021 a new chemotherapy unit opened at Baragwanath, potentially improving treatment access there. Guided by the Model of Pathways to Treatment, the team measured three intervals: the pre-contact interval from symptom recognition to first healthcare access, the diagnostic interval from first contact to pathology-confirmed diagnosis, and the treatment interval from confirmed diagnosis to initiation of surgery, chemotherapy, or endocrine therapy.
The headline finding concerns stage at diagnosis. Late-stage disease, defined as stage III or IV, was already disturbingly common before the pandemic, affecting 50 percent of patients at Site 1 and 63 percent at Site 2. During Covid-19, those proportions climbed to 60 percent and 69 percent respectively, and then partially recovered to 53 percent and 55 percent in the post-pandemic period, differences that were statistically significant at both sites. The World Health Organization’s Global Breast Cancer Initiative, launched in 2021, calls for at least 60 percent of breast cancers to be diagnosed at stage I or II. Johannesburg’s public hospitals never came close to that benchmark in any period, meaning that even after recovery, the majority of women still arrived with advanced disease.
The timing analysis exposed where the system broke down. At Site 1, the median pre-contact interval, the time women waited after noticing symptoms before seeking care, rose from 0.8 months before the pandemic to 1.0 month during it and 2.0 months afterward, a statistically significant deterioration that never reversed. At Site 2, pre-contact intervals did not change significantly. The most commonly reported reason for delay at both hospitals was the belief that breast symptoms were not serious, cited by 75 to 89 percent of women depending on site and period, with the highest proportions during the pandemic. Fear of contracting Covid-19 on public transport and in clinics likely compounded this hesitancy. Fewer than 70 percent of women reached the health system within three months of symptom onset in any period, ranging from 45 to 58 percent at Site 2 and 58 to 64 percent at Site 1.
Diagnostic intervals, by contrast, proved relatively resilient. At Site 1 the median diagnostic interval held constant at 1.8 months across all three periods, and at Site 2 a rise to 2.0 months during the pandemic was not statistically significant. Remarkably, at Site 1 the proportion of women diagnosed within the Global Breast Cancer Initiative’s 60-day target was actually higher during the pandemic, reaching between 60 and 80 percent, because surgeons personally triaged patients for both breast and Covid-19 symptoms at the tertiary surgical breast unit, a function normally delegated to triage nurses. Still, between 27 and 41 percent of women at the two sites required more than two months from first contact to a pathology-confirmed diagnosis, and the study confirmed that delays longer than three months in the combined diagnostic journey were associated with late-stage disease.
Treatment initiation told a grimmer story. At Site 1, the median treatment interval lengthened from 1.6 months before the pandemic to 2.0 months during it and remained at 2.0 months afterward. The national suspension of elective surgical procedures and restricted theatre availability slashed the proportion of women receiving surgery, a decline that worsened in the post-pandemic period regardless of disease stage. At no point did either hospital meet the European Society of Breast Cancer Specialists benchmark of initiating first treatment within eight weeks of diagnostic workup in 80 percent of patients. The pandemic also accelerated a therapeutic shift: neoadjuvant chemotherapy rose from 35 percent of patients before Covid-19 to 54 percent afterward at Site 1, and from 52 to 62 percent at Site 2, while endocrine therapy served as a bridging strategy for hormone-responsive tumours when operating theatres were unavailable.
The stakes of these delays are not abstract. Prior analyses of the same SABCHO cohort showed that women who underwent surgery within three months of diagnosis had three-year overall survival of 85 percent, compared with 79 percent for those delayed beyond three months, with mortality risk climbing 11 percent for every additional month of delay. The authors also note that patient volumes at both hospitals increased by more than 20 percent after the pandemic compared with pre-pandemic levels, without any corresponding increase in staff or infrastructure, meaning the system is now treating more women with fewer resources per patient. Simulation-based sensitivity analyses supported the robustness of the pre-contact and treatment interval findings, though the study relied on self-reported recall for the pre-contact interval, an unavoidable source of bias.
The authors argue that their findings point to interventions at two levels. In communities, aggressive education campaigns are needed to encourage breast self-examination and dispel the perception that small or painless lumps can be ignored, since pre-contact delays were long and never recovered after the pandemic. Within the health system, they recommend streamlining referrals so that suspected breast cancer cases bypass secondary hospitals, a route previously linked to later-stage diagnosis, and they call for public-private partnerships to finance expanded surgical and chemotherapy capacity. Without substantial investment in human resources and infrastructure, they conclude, neither Johannesburg hospital is likely to meet international standards or cope with the steadily rising burden of breast cancer in South Africa, a country where no formal public screening programme exists and mammography remains reserved for symptomatic women.
Subject of Research: The impact of and recovery after the Covid-19 pandemic on breast cancer stage at diagnosis, diagnostic intervals, and treatment initiation at two public academic hospitals in Johannesburg, South Africa.
Article Title: Impact of and recovery after Covid-19 on breast cancer diagnosis and care in Johannesburg, South Africa
Article References: Petlele, R., Chikwati, R. P., Ojoniyi, O. O., Akokuwebe, M. E., Chen, W. C., Murugan, N., Ndwambi, P., Kumirayi, L., Jassat, F., Nietz, S., Mathiba, R. M., Singh, K., Ohene-Agyei, P., McCormack, V., Norris, S. A., & Joffe, M. (2026). Impact of and recovery after Covid-19 on breast cancer diagnosis and care in Johannesburg, South Africa. BMC Cancer, 26(1), Article 1182. https://doi.org/10.1186/s12885-026-17068-x
Image Credits: AI Generated
DOI: 10.1186/s12885-026-17068-x
Keywords: breast cancer, Covid-19, South Africa, Johannesburg, late-stage diagnosis, diagnostic delays, treatment delays, Global Breast Cancer Initiative, EUSOMA, public health system, neoadjuvant chemotherapy, health services research
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Nathaniel Bowman. (October 3, 2026). Covid-19 Left Lasting Delays in Breast Cancer Care in Johannesburg. Scienmag. https://scienmag.com/covid-19-left-lasting-delays-in-breast-cancer-care-in-johannesburg/
Nathaniel Bowman. “Covid-19 Left Lasting Delays in Breast Cancer Care in Johannesburg.” Scienmag, 3 October 2026, https://scienmag.com/covid-19-left-lasting-delays-in-breast-cancer-care-in-johannesburg/. Accessed 3 October 2026.
Nathaniel Bowman. “Covid-19 Left Lasting Delays in Breast Cancer Care in Johannesburg.” Scienmag. October 3, 2026. https://scienmag.com/covid-19-left-lasting-delays-in-breast-cancer-care-in-johannesburg/
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