Health System and Socioeconomic Barriers to Early Detection of Breast Cancer: Why do Patients Still Present Late?

A BSTRACT Background: Delayed breast cancer diagnosis remains a critical public health challenge, particularly in low- and middle-income countries (LMICs) where advanced-stage presentation is prevalent. The multifactorial nature of diagnostic delays – encompassing health system limitations, socioeconomic disparities, and patient-level factors – necessitates comprehensive evidence synthesis to identify key determinants and inform targeted interventions. Objective: This narrative review aimed to analyze the determinants of delayed breast cancer diagnosis and to identify key patterns across health system, socioeconomic, and patient-level factors. Methods: A comprehensive literature search was conducted across PubMed, Scopus, and Web of Science databases to identify original research articles and systematic reviews published between 2021 and 2026. Studies reporting determinants, barriers, or factors associated with delayed or late-stage breast cancer diagnosis in human populations were included. A total of 12 studies met the inclusion criteria, representing diverse geographical settings including Tanzania, Kenya, Ethiopia, Bangladesh, India, and China. Data were synthesized narratively, with barriers categorized into health system, socioeconomic, and patient-level domains based on the predominant focus of each study. An evidence matrix was constructed to visualize the presence or absence of each barrier type across the included countries. Results: Health system barriers were the most frequently reported (41.7%, n = 5/12), consistently identified across nearly all included countries, highlighting systemic limitations in diagnostic infrastructure and referral pathways. Socioeconomic barriers accounted for 33.3% ( n = 4/12) of studies, with income inequality, low educational attainment, and geographic disparities limiting access to timely care. Patient-level barriers, including low symptom awareness, fear of diagnosis, cultural stigma, and delayed help-seeking behavior, were reported in 25.0% ( n = 3/12) of studies. The evidence matrix demonstrated that while health system barriers were universally present, socioeconomic and patient-level barriers showed greater regional variability, indicating context-dependent interactions between structural and individual factors. Conclusion: Delayed breast cancer diagnosis is predominantly driven by structural and systemic barriers, with health system limitations representing the most consistent determinant across diverse settings. These findings underscore the need for comprehensive, multilevel interventions that integrate health system strengthening, reduction of socioeconomic inequities, and community-based awareness programs. Future research should prioritize implementation science approaches to evaluate the effectiveness of integrated strategies in reducing diagnostic delays and improving early detection outcomes.