Referral delays in metastatic breast cancer care: barriers and facilitators across a fragmented pathway.

BACKGROUND: The proportion of women diagnosed with metastatic breast cancer (mBC) in Southern Thailand has remained stable at 10.5-11.7% over the past decade. Healthcare system-level and provider-level barriers contributing to these delays remain poorly understood. OBJECTIVES: To identify patient-related and healthcare system-related factors influencing referral delays for mBC in Southern Thailand, and to co-design implementation strategies with stakeholders to address these barriers. METHODS: This co-produced qualitative study, developed in partnership with a breast cancer survivor support group, employed Force Field Analysis to identify barriers and facilitators influencing mBC referral in Health Region 12. Data were generated through semi-structured interviews with 8 women living with mBC and 13 medical interns, documentary analysis of 3 national policy documents and a stakeholder co-design workshop. Reflexive thematic analysis was undertaken, with findings synthesised across macro, organisational and micro levels. RESULTS: Four barriers and three facilitators were identified. At the macro level, inequities in insurance scheme restrictions and the incomplete implementation of national guidelines created structural filters that delayed access to specialist care. At the organisational level, limited diagnostic resources, fragmented medical information systems and a culture of caution surrounding referral further compounded delays. At the micro level, socioeconomic constraints and reliance on traditional medicine interacted with system-level barriers, indicating that late presentation is more reflective of systemic dysfunction than of individual health literacy deficits. Facilitators were informal, fragile and largely dependent on individual clinician initiative. CONCLUSIONS: Referral delays are driven by cumulative and reinforcing structural barriers rather than patient-level factors alone. Through co-design, stakeholders prioritised two key interventions: a regional integrated queue system to enable urgency-based access, and a digital health platform to enhance care coordination. Future research should focus on feasibility testing and pilot implementation of these interventions to evaluate improvements in timeliness, equity and sustainability of cancer care.