Barriers to Effective Breast Cancer Screening Programs: A Scoping Review

Breast cancer screening is one of the most effective tool for early disease detection and improved oncological outcomes. Mammography, as a gold standard is age specific recommended and international health initiatives emphasize the importance of organised, population-based approaches (1). However, programme effectiveness and real-world screening uptake vary significantly across health systems and settings. Previous reports have shown that access to screening and participation is influenced by a wide range of factors.

Regardless of widely available organized breast cancer screening programs in many countries, effective coverage rate remains a persistent challenge. European and international analyses point out that screening access and uptake are affected by a numerous constrains, such as (but not limited to) socioeconomic inequalities, geographic access, personal preferences, health system capacities (2).

The suboptimal screening participation underlying factors are multifactorial, describing multilevel barriers, identifying patient-centered determinants (fear, discomfort, cultural beliefs among others), systemic and health organizational determinants (infrastructure, costs, health care professional availability), and provider-related factors (such as communication and recommendation practices) (3). Those determinant may especially affect underserved groups, contributing to sustained disparities in screening uptake (4).

These barriers may be especially relevant for underserved, contributing to persistent inequalities in screening uptake. Although previous publications have explored screening participation determinants, current available evidence remains heterogeneous in terms of study design, context, populations under investigation, and a concise definitions of barriers. In addition, a number of published results come from high-income countries with long-established screening programmes, whereas low- and middle-income settings and vulnerable or underrepresented populations remain less thoroughly documented.

Evidence, obtained from real world data, indicate the significance of tailored interventions, such as educational approaches and screening system, to enhance breast cancer screening uptake, particularly in countries/populations without long standing, well organized screening programmes, as well as in resource-challenged systems (5).

Literature data is diverse and heterogeneous, in screening context, study design, ranging from interviews, surveys, observational analysis, mixed studies combining qualitative and qualitative approach to qualitative studies, surveys and implementation-focused work, accompanied with various definitions of barriers and screening successfulness. Additionally, quality assurance policies and standards, considering inadequate screening programme performance, emphasizing necessity for screening program and provider service redesign, as well as individualisation of approaches (6).

Given the complexity of the topic and the need for a broader mapping of the evidence, we conducted a scoping review to identify and categorize barriers affecting the effectiveness of breast cancer screening across different healthcare systems and populations.

The aim of this review was not only to summarize previously reported barriers, but also to provide findings relevant to programme improvement, policy development, and highlight potential interventions to improve screening uptake, particularly in settings where screening remains inadequate.

Breast cancer is the most frequently diagnosed malignant tumour among women worldwide (9). Trends observed over the two past decades demonstrate a consistent increase in breast cancer incidence in many regions accompanied by declining mortality rates in high-income countries (10, 11). Projections for the next two decades show a substantial rise in breast cancer incidence worldwide, with region-specific increases across continents (12).

The economic burden of breast cancer treatment varies substantially and is highly dependent on disease stage, with annual health-care costs ranging from approximately $15,600 for early stage to $137,300 for stage IV disease (13).

Breast cancer represents one of the malignancies for which a clearly defined screening strategy exists, constituting a form of secondary prevention aimed at early disease detection (14).

Mammography is a broadly available and effective imaging modality that enables visualization of breast tissue abnormalities (15) and is widely used in countries with organized screening programmes as the primary method for early detection of suspicious breast lesions (16). Countries with established breast screening programmes have experienced decline breast cancer mortality compared with those without regular screening, emphasising the impact of organised breast cancer screening (17) Most of the high-income countries in Europe, North America and Asia-Pacific region have implemented organized screening programmes (1) while, some developed countries, including Greece and Bulgaria, did not have a fully implemented national organised mammography screening programme as of 2022 (18).

Participation rates in breast cancer screening vary considerably, ranging from less than 30% in countries such as Turkey to over 80 % in countries with well organized, well-established organized screening programmes, such as Finland and Netherland (18, 19). The reasons for inadequate participation in screening mammography are multifactorial and may be related to individual-level factors, accessibility, health system organization, and other structural barriers (20). Identifying and analysing these limitations, with the aim of proposing potential strategies for improving breast cancer screening programmes, constitutes the primary objective of this narrative review.

Topic of this scoping review was addressed because barriers to breast cancer screening cannot be predominantly attributed to a single domain, such as the patient or the health care system alone. Rather, an individual’s decision to participate in screening is predominantly multifactorial, resulting from a complex interplay of personal, social, organizational, and structural determinants. Contemporary publications have largely focused on screening failure within specific populations defined by single determinant, wether young age, socioeconomic status, race, ethnicity ot other. However, although disparities across these groups are well documented, the underlying barriers to screening are inherently complex and frequently overpass and overlape beetwen categories. As a result, breast cancer screening remains insufficiently effective across a broad range of settings and populations, even in countries with established screening programmes (19). In this context, we conducted a scoping review to comprehensively map the existing evidence on barriers to breast cancer screening. A total of 103 studies, published beetwen 2000. and 2025. were included following a structured selection process involving systematic database searching, shown in PRISMA flow diagram (Figure 1).

Since eligible studies were published between 2000 and 2025, certain relevant barriers in identified earlier publications may not have been recognised. Interventions to improve screening uptake were not a primary focus of this review; therefore, studies describing such interventions were included only when detailed information was provided, and their selection was not systematic.

The most of included publications were published between 2010 and 2019, a period following the implementation and maturation of organized screening programmes in many countries. This timeframe allowed researchers sufficient data, leading to numerous evaluations of screening uptake and determinants, and subsequential publication screening effectivenes and limitation. At the same time, there was growing emphasis in public health on disparities and social determinants. Systematic reviews, analysing screening uptake show an extensive ampunt of research in these years, particularly for breast cancer screening, reflecting its global public health importance and the need to understand low participation across diverse contexts (21).

As expected, the majority of published studies comes from high-income countries with a long tradition of well-established, population-based breast cancer screening programmes, including the United States (as far as 34%), England, the Netherlands, Denmark, Sweden, Italy, and Australia. From a geographical perspective, Europe accounts for the largest share of publications – 43.7%, reflecting a large number of countries with implementation of organized screening programmes and the evaluation of long-term programme data.

Overall, the geographic distribution of the included studies demonstrates a pronounced concentration of evidence originating from countries with well-established, organized breast cancer screening systems. In contrast, there is comparatively limited data from low- and middle-income regions, where organized screening programmes are less effectively implemented or have been introduced more recent, reflecting differences in health system infrastructure and data availability. Since the data were obtained from high-income countries, the results and potential implications cannot be generalized to all countries, particularly developing and underdeveloped countries.

The included studies showed a range of methodology designs, with a clear predominance of quantitative methodologies (Table 2, Suplementary Table). while small number of studies (10.7%) were using mixed-methods designs that integrated both qualitative and quantitative approaches (Table 2), where comparison between subject perceptions and objectively measured screening participation can be evaluated. The predominance of quantitative analyses can be explained by the availability of data sources such as registry-based analyses and observational cohort designs, which were used retrospectively and could not be matched with participants’ perceptions at the time of data processing and publication. Breast cancer screening can be performed as organized (population-based), opportunistic, or risk-adapted (personalised approaches). - tend to individualize screening based on estimated risk and at the same time retaining key elements of organized programmes, but their real world practice implementation is still limited (22, 23).

In our review, the analysis showed that nearly half of the included studies focused on organized, population-based screening programmes. In contrast, studies addressing opportunistic screening accounted for 22.3% of the included literature (Table 2). In these studies, screening participation was typically assessed using data from primary health care settings and medical services (Supplementary Table), where screening uptake was largely driven by individual motivation and physician recommendation rather than systematic invitation (24). However, almost one-fifth of all included studies compared organized and opportunistic screening approaches without clearly distinguishing between these screening contexts, often drawing conclusions based on overlapping or poorly defined definitions.

The majority of included studies examined the general population of age-eligible women, accounting for 77.7% of all analysed publications. This predominance reflects the design of most organized breast cancer screening programmes, which target women within predefined age ranges and generate large, routinely collected datasets suitable for population-level analyses.

A substantial proportion of studies (13.6%) focused on migrant populations (25,26,27,28,29,30,31,32,33,34,35) or ethnic minority groups (36,37,38,39,40). There are a consistent evidence emphasising lower screening participation in these populations, attributed to factors such as language barriers, limited health literacy, cultural beliefs, mistrust of health systems, and structural obstacles related to access. Migrants are less likely to participate in mammography screening programmes compared with local-born populations in Europe (30). Migrant women, born in countries with breast cancer low incidence are more likely to perceive higher risk of developing breast cancer with length of stay in developed county, with higher breast cancer incidence (30). Opposite to that, 87% of Asian immigrant to Canada had mammogram during their lifetime, at least once (organized or opportunistic) (25). A study, conducted by Kristiansen et al. using data from 1991–2008, showed that lack of contact with medical professionals and unemployment significantly affect efficacy of breast cancer screening, in negative way (27). Among ethnic minority group, greater perceived discrimination was associated with poorer health care–a results published by Gonzales et al, showed that among American Indian women, discrimination in health care settings may contribute to lower participation in breast and other cancer screening services (37).

Vulnerable populations remain insufficiently represented relative to their importance for screening equity. Minority based approach to breast cancer screening should take into account targeted culturally adapted strategies, rather than using general, population-wide approaches. Potential interventions that are derive from this results can be community based communication, multilingual education and investing efforts in strengthening connections and trust between these vulnerable groups and healthcare providers.

In contrast, only 2.9% of studies specifically addressed women of low socioeconomic status (41,42,43), despite well-documented associations between socioeconomic disadvantage and reduced screening uptake. Similarly, women residing in rural or geographically remote areas were underrepresented, with only 1.3% of studies focusing on this population, accentuating distance, transportation difficulties, and limited availability of health services as key barriers (42, 44). Fewer than 4% of the included studies examined women with disabilities or those with a previous false-positive screening result (45,46,47,48,49,50). Studies involving women with disabilities reported barriers related to physical accessibility and inadequate communication within screening services, whereas studies addressing women with prior false-positive results emphasized psychological distress, anxiety, and reduced trust in screening, which negatively affected further screening participation.

Overall, the literature highlights social, cultural, and geographic inequalities in breast cancer screening participation, indicating that these disparities remain insufficiently addressed across different health care systems and population groups. Data are presented in Table 2 and Supplementary Table. This heterogeneity is consistent with the objectives of a scoping review and enabled comprehensive mapping of the wide range of barriers affecting breast cancer screening participation across different healthcare systems and sociocultural contexts.

The multifactorial nature of barriers to effective breast cancer screening is clearly illustrated in Table 3, where substantial overlap between different limitations can be clearly observed in Table 4. Nevertheless, for the purposes of this review and in accordance with the published literature, barrier domains were categorized into the following groups (Table 3): patient-level barriers; access-related barriers; health system and organizational barriers; socioeconomic and cultural barriers; and provider-related barriers. The key barriers identified across these domains are summarized in Table 4.

Patient-level barriers were the most frequently reported, identified in 78 studies (75.7%). These barriers primarily encompassed fear of mammography-related pain, anxiety about a potential cancer diagnosis or subsequent treatment, fear from radiation exposure, and low perceived personal risk of breast cancer, particularly among asymptomatic women (51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79).

This clear predominance of patient-centered barriers should not be perceived as proof that women themselves are primary reason for screening non-participation. Number of here-defined individual barriers show substantial connection to structural and social determinants (transport limitations, competing work, low health literacy, financial insecurity, cultural marginalization, etc.). These reasons are notably significant in underserved populations, where barriers may accumulate across several domains at the same time. These findings clearly support establishing a broader interpretative framework for the reasons behind non-participation in screening, encompassing not only personal beliefs and choices, but also factors related to the healthcare system and inequalities between the groups being studied. A study conducted by Speedy and Hase, investigated influence of health beliefs—response efficacy, perceived seriousness, concern, susceptibility, and perceived barriers—on the likelihood of attending breast cancer screening. Compared with women who had not undergone mammography, screening participants were more health-conscious, more likely to have previously undergone mammography, more aware of the protective role of mammography in reducing severe breast cancer, and less concerned about the screening procedure (68). Using theory of planned behaviour, Steadman ad Rutter, included over 1600 patient planned for screening mammography in UK for a questionnaire, showing determining important association and subjective norm measures have positive prediction for screening attendance (57). When difference between organized and opportunistic screening are considering, women using opportunistic screening perceived higher breast cancer risk but expressed limited awareness and concerns regarding organized screening, whereas non-screened women showed polarized risk perceptions, questioned screening usefulness, and held negative views toward mammography (78). Multivariate analyses indicated that defensive avoidance of breast cancer screening was associated with lower perceived susceptibility and response efficacy, higher breast cancer–related fear, and breast self-examination behavior – as reported in study conducted by Ivanova and Kvalem (55).

These findings direct system toward potential practical implication, that screening uptake improvements must extend beyond patient knowledge and basic health education and therefore adopt a multilevel approach, taking into account individual and structural determinants of non-participation. Potential measures here can include concern adapted education, organized transportation and reminder system as well as patient navigation, which can be especially effective in vulnerable populations, where barriers often cross over multiple domains simultaneously.

Patient-related barriers are deeply connected with social determinants of health - they interact synergistically, affecting screening participation. Across the reviewed literature, the most frequently reported limitations included low income, lack of health insurance or underinsurance, and indirect costs such as transportation expenses and loss of income due to time off work. These financial constraints were further accompanied often by low educational attainment, limited health literacy, and social deprivation, which collectively reduced awareness of screening potential usefulness. Notably, financial insecurity persisted as a significant barrier even in settings where breast cancer screening was provided at no direct cost (80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95).

Here, in must be noted that a majority of available evidence in high-income countries with long-established organized screening programmes. On the other side, evidence from low- and middle-income countries and/or settings with less developed screening infrastructure is quite limited or non-existing. This imbalance, as noted before, limits the generalizability of the available evidence and suggests that important barriers in resource-constrained settings may remain overlocked.

Deficits in health literacy and social deprivation, together with financial barriers, have been consistently reported across the globe, irrespective of countries’ income level. These barriers persist across diverse health-care systems and screening models, suggesting that economic development alone is insufficient to ensure equitable screening participation (80, 81, 87, 90, 95). A cross-sectional study conducted in 2017. showed that participation in breast cancer screening programs was associated with woman health insurance, while breast cancer awareness was associated with lack of social deprivation and woman occupation (85). A Flanders study showed that patient with crowded households, population densities and employment status will more likely to undergo outside organized screening system, that has more coverage rate (86). A study by Zhao et al, published in 2025. showed that Gross Domestic Product (GDP) per capita has negative influence on mammography nonattendance, while urbanization showed positive correlation (90).

Access-related barriers are encompassing geographic and service-related constraints. Key barriers included long distances to screening facilities, transportation difficulties, inconvenient appointment times, limited availability of screening services, and prolonged waiting times. These challenges were particularly pronounced in rural and remote areas, contributing to difference in urban/rural disparities (89). In addition, inadequate accessibility of screening and/or facilities is a significant barrier for women with disabilities, further accentuating inequities in screening participation (50). Access-related barriers are wide term, overlapping with health system and provider barriers (95,96,97,98,99,100).

Among previously unscreened women from disadvantaged areas, screening uptake was higher among those living closer to screening clinics (95), while women with private vehicle would not ephasise time as a barier to further mamography facility (97). In favour to acessibility, speaks a large study in Denmark, on almost 150.000 participants, stating that a long travel distance is associated with an increased risk of non-participation (100).

Literature findings emphasize that improving screening participation should prioritize accessibility and social equity, together with advances in healthcare infrastructure, such as mobile screening services, shorter waiting lists, adapted facilities, thus reducing structural disadvantages across healthcare settings.

Health system and organizational barriers reflected structural inefficiencies within screening programmes, including delayed or failed invitation processes, registry inaccuracy, and the absence of effective, well established reminder system. Additional obstacles included insufficiently defined care pathways, lack of individual approach, insufficient screening capacity causing prolonged intervals, and administrative complexity and errors, all of which collectively undermined adequate access to screening participation, as shown in included studies (101,102,103,104,105,106,107,108,109,110,111).

Several studies highlighted deficiencies in reminder systems—including inadequate, delayed, or absent reminders—as a key organizational barrier, emphasizing their critical role in sustaining engagement and continuity in breast cancer screening participation (101, 106, 109, 110). Confirmation requirements constitute an obstacle mainly for women invited for the first time, while having little influence on participation among those with previous screening experience (108).

Provider-related barriers primarily reflected limitations in provider (medical staff)-subject interactions and communication processes. These included the lack of sufficient physician recommendations for screening, short counseling time, and inadequate communication regarding the benefits, risks, and procedures of mammography. In addition, unclear screening guidelines, limited cultural competence, and language barriers during clinical encounters further hindered informed decision-making and reduced screening participation, particularly among socioeconomically and culturally diverse populations, especially the ones with language barriers (112,113,114,115,116,117,118,119,120,121,122,123,124).

Women who had undergone mammography were more likely to report receiving a recommendation for screening, having an established primary care provider, and being cared for by a female primary care provider (113). A brief, qualitative study, conducted by Sterlingova and Lunden identified non-personalization of the screening system as a dominant theme, reflecting participants’ perceptions of limited individualization (115).

In a twenty-year-old study and with still actual barriers, published by Aro et al, the most common reason for non-attendance was having undergone mammography outside the organized programme. Other reported reasons included logistical barriers, fear and anxiety, limited screening knowledge, and organizational issues. Non-attenders could be broadly classified into two groups; women screened elsewhere were typically urban, socioeconomically advantaged, health-proactive, perceived themselves at higher risk of breast cancer, and expected the examination to be painful (117).

These findings clearly illustrate the complexity and interrelated nature of barriers influencing decisions to participate in screening. Simplified classification models may be insufficient to identify the true constraints of non-attendance, with important implications for the design and optimization of screening programmes.

From a practical perspective, the findings indicate that isolated interventions are unlikely to substantially improve screening uptake. More effective strategies are likely to require coordinated, multilevel approaches that combine public education, culturally and linguistically appropriate communication, improved invitation and reminder systems, easier appointment scheduling, better physical and geographic access to services, and stronger provider engagement in screening recommendation and counseling. In organized screening programmes, particular attention should be given to registry quality, invitation accuracy, recall systems, and continuity of follow-up. In underserved populations, tailored outreach strategies and more flexible service delivery models may be especially important.

A small number of studies (n = 3) did not provide sufficiently precise definitions of screening barriers; however, their research focus was considered methodologically relevant and aligned with the objectives of this review (124,125,126,127).

Although the analyzed data from the included studies provided valuable insight into breast cancer screening programs and identified key target domains in which major barriers to effective screening implementation can be recognized—potentially serving as a framework for future guidance and for the development of efficient, organized screening systems—several limitations should be acknowledged to inform further actions aimed at improving screening. First, this scoping review included studies published between 2000 and 2025; consequently, some barriers identified earlier may not have been captured. However, given the extended period evaluated, it can be reasonably assumed that such barriers have by now been clearly identified and, in many cases, appropriately addressed. Nevertheless, despite the fact that breast cancer screening remains insufficiently effective in many countries, there is a notable lack of data from the past five years—particularly studies that would identify emerging barriers to successful screening, as well as those indicating whether barriers reported in earlier studies have been successfully resolved.

In addition to that, grey literature was not systematically searched, and intervention studies were not the primary focus of this review; therefore, some potentially relevant implementation evidence may not have been captured.

The included studies were methodologically heterogeneous in terms of design, populations, screening settings, and reported outcomes, which precluded quantitative synthesis.

Finally, the predominance of evidence from high-income countries limits the transferability of the findings to low-resource settings. Despite these limitations, the scoping approach allowed broad mapping of the literature and identification of recurring domains that may inform future research and programme redesign.

This scoping review defined key domains encompassing participant- or population-level factors, access and health system organization, cultural and socioeconomic domains, as well as factors related to healthcare providers and the health system. Most of the available evidence originates from high-income regions with well-organized screening systems and high population coverage, whereas data from low- and middle-income countries, where breast cancer screening remains less effective, are scarce. Disadvantaged populations, as previously defined, have been insufficiently represented in research, despite a growing emphasis in recent years on equity-sensitive and vulnerable populations. The findings of this review may help support future screening improvement efforts by emphasizing the need for coordinated action across multiple domains, rather than isolated interventions targeting a single barrier.