JMIR Publications

ABSTRACT

Background:

Breast cancer is the most commonly diagnosed cancer worldwide and the leading cause of cancer death among women in low- and middle-income countries (LMICs) (Sung et al., 2021). Survival disparities between high-income and LMICs are largely attributable to late-stage presentation and failure to receive timely, definitive surgery (World Health Organization [WHO], 2023). Health-system barriers—including shortages of trained surgical teams, weak referral pathways, affordability constraints, and limited theatre availability—prevent many eligible patients from accessing mastectomy or breast-conserving surgery. While a range of health policy and system-level interventions have been implemented, the evidence base remains fragmented and unsynthesised.

Objective:

To identify and synthesise evidence on health policy and health-system interventions implemented and evaluated in LMICs to improve access to definitive breast cancer surgery, and to assess their effects on: (1) receipt/coverage of indicated surgery; (2) timeliness of surgery; and (3) surgical service availability/capacity, including implementation and equity considerations where reported

Methods:

This is a pre-registered systematic review protocol (PROSPERO CRD420261333028). We will search CENTRAL, Embase, PubMed, Scopus, LILACS, Web of Science, and grey literature sources from January 2000 to March 2026 with no language restrictions. Evaluative quantitative, qualitative, and mixed-methods studies of implemented interventions will be included. Risk of bias will be assessed using RoB 2 (Sterne et al., 2019), ROBINS-I (Sterne et al., 2016), CASP, and MMAT 2018. Synthesis will follow a structured narrative approach using the WHO Health System Building Blocks framework, with meta-analysis where feasible. Certainty of evidence will be rated using a GRADE-informed approach.

Results:

This section will be completed upon review completion (target: 15 June 2026). Results will be presented in accordance with PRISMA 2020 guidelines and will include: a PRISMA flow diagram documenting records identified, screened, and included; a summary of included study characteristics; risk of bias assessments across all included studies; and a structured narrative synthesis of intervention effects, organised by the WHO Health System Building Blocks framework. Where sufficient homogeneity permits (≥3 comparable studies), meta-analytic results will be reported with pooled effect estimates, confidence intervals, and heterogeneity statistics (I², Cochran's Q). GRADE evidence profiles will be presented for primary outcomes.

Conclusions:

This systematic review will provide the first comprehensive synthesis of health policy and health-system interventions targeting access to definitive breast cancer surgery in LMICs. By mapping the evidence base across all three primary outcome domains — receipt of surgery, timeliness, and service availability — and situating findings within the WHO Health System Building Blocks framework, the review is designed to produce actionable intelligence for policymakers, health system planners, and international funders. Findings will be disseminated through peer-reviewed publication in English and will be aligned with the WHO Global Breast Cancer Initiative implementation framework. The review addresses a critical accountability gap: as international investment in LMIC breast cancer surgical programmes grows, there is an urgent need for rigorous evidence on what works, for whom, and under what contextual conditions. Results are expected to directly inform programme design, resource allocation decisions, and future research priorities in global cancer surgery. Clinical Trial: PROSPERO (CRD420261333028)