Factors Driving Low Rates of Post-Mastectomy Breast Reconstruction in Low- and Middle-Income Countries: A Systematic Review

Breast cancer remains a leading public health issue in low- and middle-income countries (LMICs), where 5-year survival rates range from 12% to 53%. Although post-mastectomy breast reconstruction is a key part of cancer care, its uptake remains low in LMICs. This review identifies the main barriers limiting reconstruction access to inform potential interventions. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were searched for English-language, peer-reviewed articles published between January 2013 and October 2023 on challenges to post-mastectomy breast reconstruction. Eligible studies were original research. Two reviewers extracted and categorized findings into socio-cultural, structural, and financial themes, summarized through descriptive analysis. The search identified 15 papers from 11 countries across four continents. Of the included studies, 73% (n = 11) mentioned barriers under two or more categories; 20% (n = 3) mentioned only structural barriers, and 7% (n = 1) mentioned only socio-cultural factors. Ten studies (67%) described socio-cultural barriers, with the most prevalent themes being the perception of reconstruction as purely aesthetic (47%), fear of anesthesia and recovery time (33%). Thirteen studies (87%) described structural barriers, with the most prevalent structural barrier being a lack of patient awareness, especially before mastectomy (47%). Limited numbers of practicing plastic surgeons (40%), urban-clustered tertiary treatment facilities (33%), and low surgeon referral rates (27%) reduced reconstruction utilization. Twelve studies (80%) described financial barriers with self-payment cited as the most significant limitation to reconstruction and the most significant barrier overall (60%). Reconstruction in LMICs faces intertwined socio-cultural, structural, and financial barriers that limit access and patient willingness.