Breast cancer treatment pathways
Breast cancer is an exceptionally prevalent chronic illness among women worldwide. Although overall mortality has decreased since the 1980s thanks to preventive and therapeutic interventions, the availability of diagnosis and treatment services varies substantially across countries. Clinical guidelines for treatment are, for the most part, comparable across countries and providers; treatment pathways, however, often vary, even within a single country. Not all differences in treatment pathways imply a disparity in access to treatment and patient outcomes, but some do point in that direction and therefore deserve further empirical investigation. This is particularly the case if the difference implies a delay in treatment, which is found to increase mortality [
1].
Patient pathways to treatment represent a relatively new agenda in research on healthcare systems and services. The term ‘treatment pathway’ refers to how patients navigate the healthcare system during treatment for their illness [
2]. ‘Treatment pathway’ is used interchangeably in the literature with ‘patient pathway,’ ‘patient journey’ and ‘cancer journey’ [
3]. The present study adopts Richter and Schlieter’s view that patient pathways should not be reduced to a set of standardised procedures; rather, they should be characterized as an ‘unplanned journey’ [2, p. 993]. Similar to several previous studies [
4‐
6], this article takes a bottom-up approach to examining patient pathways, that is, by starting with individual patient experiences and assembling them into specific pathway patterns.
Research into healthcare system influences on breast cancer treatment pathways is growing, but it focuses primarily on lower and middle-income countries (LMICs) [
7‐
9]. A systematic review of studies on sub-Saharan African countries [
8] identified several healthcare system factors such as diagnostic process failures, cost, and provider attitudes, all of which can erect barriers to access that result in a delay in the diagnosis and treatment of breast cancer patients. ‘Provider attitude’ in that review refers specifically to the pervasive prevalence of corruption, bribery, and nepotism within the medical staff. Another systematic review [
7] —this one on healthcare system barriers to breast cancer diagnosis and treatment in LMICs in Asia—arrives at conclusions similar to those of Gbenonsi et al.’s review [
8]. This review on Asia reveals that the most important barriers are low-quality healthcare, shortages of health personnel, medicines and medical technologies, and a lack of insurance, which has implications for out-of-pocket payments.
Studies on how healthcare system factors influence breast cancer treatment pathways in upper-middle-income countries (UMICs) and high-income countries are limited in number. A rare study in Thailand [
10], a UMIC, finds that it is patient beliefs, not healthcare system factors, that explain delays in cancer treatment. In a Canadian study [
11], the researchers observed a negative relationship between physical distance from radiotherapy centres and cancer outcomes. Studies in the United States [
12,
13] mention underinsurance as a healthcare system factor that impedes access to breast cancer diagnosis and treatment. Finally, a systematic review of financial distress reported by cancer patients in universal healthcare systems [
14, p. 14] concludes that ‘the design of healthcare and social security systems might also shape the extent of not only objective financial burden but also protection of vulnerable cancer patients at risk of financial distress.’
To explore the influence of healthcare system factors on breast cancer treatment pathways, we combined a bottom-up approach to patient pathways with a context-sensitive approach. This is important, as patient experiences do not occur in a social and historical vacuum. We interpreted individual patient experiences in the light of the healthcare system context. This helped us ascertain whether differences in treatment pathways were caused by healthcare system factors and if, in turn, these differences created inequalities in healthcare.
Breast cancer treatment in Türkiye offers an interesting case to examine the role of healthcare system factors in shaping these treatment pathways, first of all because breast cancer is highly prevalent [
15]; its incidence reached 56.6 per 100,000 in 2020 [
16,
17] and continues to rise. Late diagnosis is also frequent [
16]; Turkish breast cancer is often diagnosed only when the patient presents to the hospital with symptoms. Importantly, Türkiye is a UMIC with a universal healthcare system where the state’s social health insurance (SHI) pays for all breast cancer treatment, whether it is from a public or private hospital.
Theoretically, the Turkish healthcare system is a publicly-funded internal market, as defined elsewhere [
18] that brings together SHI for all with fully comprehensive coverage and gives patients the right to choose their treatment provider. Patients in Türkiye are charged a flat fee (a co-payment) for outpatient visits and prescribed medications, and they pay variable rates of co-insurance for outpatient visits to private hospitals only [
19]. Co-payments are modest, but the charges for co-insurance can be considerable. Although co-insurance is required for most private services, breast cancer treatment is exempt; it is completely free of charge at the point of service [
20]. Türkiye has witnessed an upsurge in the number of its citizens who hold private health insurance (PHI) in the last decade, which is an intriguing trend in a universal healthcare system, up from less than a million in 2010 to more than 6.5 million (out of a population of almost 85 million) by the end of 2021 [
21].
In the context of the Turkish healthcare system described above, we would not have expected to observe insurance-based differences in breast cancer treatment pathways. Two assumptions underlie our expectation: (1) the SHI should be providing the same comprehensive coverage to all patients, and (2) breast cancer treatment is exempt from co-insurance payments. Nevertheless, we observed considerable insurance-based differences in treatment pathways for breast cancer. We argue that these differences can be explained by factors that are specific to the Turkish healthcare system.
Finally, this study on Türkiye also speaks to the literature on patient choice and equity in access in UMICs with universal healthcare systems. Data is also scarce on how patients view and experience choice in healthcare in UMICs that have undertaken patient choice reforms (Thailand and Türkiye, for instance), and most existing studies have been conducted in the Global North [
22]. In the countries of the Global North, scholars have observed a disharmony between choice and equity in healthcare systems [
23‐
26]. Whether a similar tension exists between choice and equity in UMICs with universal healthcare systems is still an open question.