Social Determinants of Inequities in Breast Cancer Care Across the Care Continuum in Low- and Middle-Income Countries: A Systematic Review

Abstract

Introduction: Breast cancer is the most frequently diagnosed cancer among women worldwide, yet mortality remains disproportionately high in low- and middle-income countries (LMICs). Social determinants of health (SDoH), including socioeconomic status, education, geographic access, gender norms, and health system capacity, contribute substantially to inequities across the breast cancer care continuum. This systematic review synthesized evidence on the impact of SDoH on breast cancer care and outcomes in LMICs.

Methods: PubMed/MEDLINE, Scopus, Web of Science, and Embase were searched for eligible observational and intervention studies examining associations between SDoH and breast cancer care outcomes in LMICs. Outcomes included screening, diagnostic delay, stage at diagnosis, treatment access, adherence, and survival. Two reviewers independently screened studies, extracted data, and assessed study quality. Owing to substantial heterogeneity, findings were synthesized narratively.

Results: A total of 221 studies were included. Socioeconomic disadvantage was consistently associated with delayed diagnosis, advanced-stage presentation, limited access to guideline-concordant treatment, and poorer survival. Rural populations experienced reduced access to oncology services and lower treatment completion rates. Health system constraints, including inadequate pathology services, workforce shortages, weak referral systems, and limited access to radiotherapy and systemic therapies, further exacerbated inequities. Financial hardship frequently caused treatment interruption, while low health literacy, stigma, fear of mastectomy, and gender-related barriers delayed healthcare seeking. Community-based interventions, task-shifting, and resource-stratified care models showed promise, although evidence supporting their long-term effectiveness remains limited.

Conclusions: Breast cancer care inequities in LMICs result from interacting socioeconomic, geographic, sociocultural, and health system factors. Addressing these disparities requires equity-focused policies that strengthen primary healthcare, expand financial protection, decentralize oncology services, and target upstream social determinants. Future research should prioritize evaluating interventions that effectively reduce inequities.