System-level barriers linked to delays and poorer survival in 1,100 women with primary breast cancer

Disparities in public health infrastructure, healthcare access, and system-level support contribute to delays in breast cancer screening, diagnosis, treatment initiation, and adherence to care, leading to advanced-stage presentation and poorer survival, particularly among rural and underserved populations. To evaluate the influence of individual, community, and health system level determinants on screening access, timeliness of diagnosis and treatment, adherence to therapy, and survival outcomes among women with breast cancer. This retrospective cohort study included 1,100 women diagnosed with primary breast cancer between January 2022 and December 2024. Data were obtained from hospital records, cancer registries, and administrative databases. Screening history, diagnostic and treatment intervals, treatment adherence, and survival were assessed. Multivariable logistic regression identified determinants of screening access, diagnostic and treatment delays, and treatment non-completion, while Cox proportional hazards models evaluated survival after adjustment for confounders. Over one-third of patients had never undergone prior screening, and 25% traveled more than 25 km to access services, indicating that geographic and access barriers may contribute to delayed diagnosis and poorer survival. Diagnostic delays exceeding 60 days occurred in nearly one-third of patients, and one-quarter experienced treatment initiation delays. Overall treatment adherence was 72.1%, with lower adherence among uninsured patients. Integrated pathway analysis identified a low-access group (28.3%) characterized by absent screening, who had prolonged delays at each stage of care and a 32.5% mortality at follow-up, and reduced survival, whereas the high-access group demonstrated >90% survival at follow-up. Geographic, financial, and system-level barriers were independently associated with delays, treatment non-completion, and poorer survival. In contrast, care at tertiary centers and patient navigation support were significantly associated with improved timeliness, adherence, and survival outcomes. Social and system-level determinants exert cumulative effects across the breast cancer care continuum. Strengthening healthcare access, expanding patient navigation, and enhancing system coordination may reduce delays, improve adherence, and improve survival.