Social Equity, Strong Health Care Systems Can Improve Advanced Breast Cancer Outcomes Globally


Disparities in health care systems around the world limit access to effective treatments for advanced breast cancer, especially for people in low- and middle-income countries and marginalized communities. Stronger health systems and social education efforts are necessary to improve outcomes for all patients.

Breast cancer costs. | Image Credit: Cozine -

Breast cancer costs. | Image Credit: Cozine -

Advanced breast cancer can be improved and resolved through more robust health systems or pathways, as well as social education, that must be developed across the cancer continuum.

Breast cancer, a heterogenous disease, is often defined based on the hormone receptor expression pattern (estrogen/progesterone receptors and HER2). When breast cancer spreads, it develops into advanced breast cancer, a highly incurable disease.

Advanced breast cancer has a high prevalence rate in low- and middle- income countries, but accurate reports of patients are unlikely because national registries are underreported, and histologic diagnosis required for registry confirmation tend to create difficulties.1

The current approach for treatment includes systemic anticancer therapy, which is incredibly important in the treatment of advanced breast cancer. Endocrine therapy (ET) in conjunction with cyclin-dependent kinase 4/6 inhibitors are the first line standard for HR+ and HER2– breast cancer.

Alternatively, in HER2+ disease, anti–HER2-targeted therapy combines with taxane-based chemotherapy throughout 6 or more cycles. If the disease is HR+, it is typically followed by anti–HER2-targeted therapy up until disease progression or combines with anti-HER2+ ET until disease progression. In cases where the disease is HR+, it will combine with the anti-HER2+ ET until disease progression.

Standard of care for germline BRCA mutation and PD-L1 testing in the triple-negative breast cancer setting is only considered when available. Polymerase inhibitors have gained popularity recently, but access is limited in many low- and middle-income countries, as well as several populations within high income countries.

Disparities within health care systems are prevalent throughout society and patients with advanced breast cancer are not exempt from these prejudices. Later stage diagnosis was found to be more common among marginalized communities, socioeconomically deprived areas, and older women.

A retrospective, multi-institutional cohort study, enrolled patients with stage I to IV breast cancer and evaluated them based on neighborhood disadvantages relating to cancer specific survival using individual sociodemographic, comorbidities, risk factors, access to care, and tumor type. Results found women living under the most disadvantaged conditions were less likely to survive compared with patients living in the most advantaged neighborhoods.2

The study supports the argument that access to preventative medicine is not universal, which can further be proven through the lack of routine funding for medications. For example, tamoxifen, a primary treatment option for advanced breast cancer with an overall response rate of 34%, failed to receive proper funding from clinical commissioning groups for postmenopausal women with a high risk of recurrence.1

In 2019, the advanced breast cancer Global Alliance Meeting in Portugal, a representation of 27 countries, identified unmet needs and gaps in advanced breast cancer care. Patient knowledge gaps surrounded diagnosis and management of advanced breast cancer, the role of patients in shared decision making with physicians, coordination of multidisciplinary care endeavors, access to advanced breast cancer clinical trials, and lack of guidance for friends, family, and caregivers in supporting patients living with advanced breast cancer.

An integral component of the management of advanced breast cancer is palliative care, which focuses on quality of life and symptom control. Patients with advanced breast cancer have benefitted extensively from support groups, navigation programs, and psychosocial interventions. Resources and awareness campaigns have educated an average of 1,176,000 people. Continued training on palliative care and advocacy amongst health care professionals has allowed about 2600 of them to gain new knowledge.

Studies show advanced breast cancer patients benefit from emotional support, clear information, and consistent care. However, low- and middle-income countries face hurdles in training specialist nurses due to workforce shortages, low pay, cultural stigmas, and limited educational resources. Breast cancer care itself can be difficult due to lack of knowledge, cultural barriers, and limited resources.

Global data from the National Cancer Database analyzed records of palliative care used over time between 2004 to 2020.3 While significant increases were evident, underserved populations were the least likely to receive palliative care. Non-Hispanic Black, Asian, or Pacific Islander, and Hispanic patients were 13%, 26%, and 35% less likely to have the option for palliative treatment compared with non-Hispanic White patients and those who identified as American Indian, Alaska Native, or another ethnicity.

Specialist nurses with expertise in oncology and palliative care help improve patient satisfaction and overall care. Advanced breast cancer education focuses on disease background, treatment options, supportive care, communication, cultural competency, emotional intelligence, teamwork, leadership, and self-care for nurses.

However, research found there are unmet needs in establishing a comprehensive, accessible advanced breast cancer education and specialized training programs overcoming geographic and linguistic disparities. Currently, there is an international online education program directed for nurses that includes translations from 15 different languages, acting as a potential solution to the inequalities existing within the health care system.

To improve breast cancer outcomes globally, countries need stronger health systems, public education, and research focused on specific populations. Funding and addressing social factors are crucial to ensure equitable access to care throughout the entire cancer journey, keeping the patient at the core.


1. Ghose A, Stanway S, Bhawna Sirohi, Mutebi M, Adomah S. Advanced breast cancer care: The current situation and global disparities. Semin Oncol Nurs. 2024;40(1):1-5.doi:10.1016/j.soncn.2023.151551

2. Goel N, Hernandez A, Thompson C, et al. Neighborhood disadvantage and breast cancer–specific survival. JAMA Netw Open. 2023;6(4):e238908. doi:10.1001/jamanetworkopen.2023.8908

3. Racial/ethnic minority patients may be less likely than white patients to receive palliative care during breast cancer treatment. American Association for Cancer Research (AACR). September 29, 2023. Accessed April 30, 2024.

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