Pathways to Care, Out- of- Pocket Expenditure, and Associated Factors Among Breast Cancer Patients in Kerala, India: A Hospital-Based Cross- Sectional Study

BACKGROUND: Breast cancer, the most common cancer among women in India, poses a significant public health challenge. However, data on pathways to care and out-of-pocket expenditure (OOPE) among breast cancer patients are limited in India. Kerala, despite its high literacy rates and excellent healthcare access, continues to experience significant delays in cancer care, making it an important setting for this study. Therefore, we aimed to study the pathways to care, estimate OOPE, and identify factors associated with OOPE among breast cancer patients in the Indian state of Kerala. METHODS: We conducted a hospital-based cross-sectional study among 216 breast cancer patients (mean age: 57 years) from one private and one public tertiary cancer care centre (TCCC) in Kerala. A structured interview schedule was used to collect socio-demographic, clinical, and expenditure-related data. Descriptive statistics, Mann-Whitney U tests, and median regression analysis were performed. The duration of the study was from October 2024 to May 2025. RESULTS: Most participants were diagnosed at early stages (n=152, 70.4%), and 42.5% (n=92) had health insurance coverage. In the study, 168 (77.8%: 95% CI: 71.6-83.1%) participants followed indirect pathways, initially consulting traditional healers (25, 11.57%) or other healthcare providers (143, 66.20%) before reaching TCCCs. OOPE was significantly higher among patients treated in private TCCCs compared to those in public TCCCs (median INR 2,26,395 vs 1,93,290; p = 0.015). Residence ≥82 km from the centre (coefficient:28470; p=0.044), treatment at private TCCC (coefficient:50010; p=0.001) and indirect pathway to TCCC (coefficient:46180; p=0.015) were significantly associated with higher OOPE. CONCLUSION: The majority of breast cancer patients in Kerala accessed tertiary care through indirect pathways, with substantially higher out-of-pocket expenditure (OOPE) among those treated in private centres. Targeted policy interventions, such as strengthening primary care linkages and improving referral coordination, are essential to reduce delays in care pathways and alleviate the financial burden on breast cancer patients.