Bridging gaps in breast cancer care: a Breast Cancer Care Quality Index to improve outcomes worldwide

Eduardo Cazap¹⁺, Benjamin O Anderson²⁺, Giuseppe Curigliano^3,4+, Sandeep Sehdev⁵⁺, Fatima Cardoso⁶⁺, Ana Rita Gonzalez⁷⁺, Emad Shash⁸⁺, Cheng-Har Yip^9,10+, André Mattar¹¹⁺, Yanin Chavarri-Guerra¹²⁺, Miriam Mutebi¹³⁺, Yongmei Yin^14,15+, João Victor Rocha^7#, Ilaria Lucibello^7# and Namita Srivastava⁷

¹Latin-American and Caribbean Society of Medical Oncology (SLACOM), Buenos Aires CP 1057, Argentina

²University of Washington, Seattle, WA 98195, USA

³Department of Oncology and Hemato-Oncology, University of Milano, Milano 20122, Italy

⁴European Institute of Oncology, IRCCS, Milano 20141, Italy

⁵Ottawa Hospital Cancer Centre, Ottawa, ON K1H 1C4, Canada

⁶Advanced Breast Cancer (ABC) Global Alliance, Lisbon 1400-038, Portugal

⁷Policy Wisdom LLC, Quebradillas 00678-2705, Puerto Rico

⁸Medical Oncology, National Cancer Institute, Cairo University, Giza 12613, Egypt

⁹Picaso Hospital, Petaling Jaya 46300, Malaysia

¹⁰University of Malaya, Kuala Lumpur 50603, Malaysia

¹¹Mastology Department, Women’s Health Hospital, São Paulo 01215-000, Brazil

¹²Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 40080, Mexico

¹³Department of Surgery, Aga Khan University, Nairobi 30270-00100, Kenya

¹⁴Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000–211300, China

¹⁵State Key Laboratory Cultivation Base of Biomarkers for Cancer Precision Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing 210029, China

# These authors contributed equally to this work.

+ These authors contributed equally to this work.

Abstract

Background: Breast cancer (BC) care faces challenges in early detection, timely diagnosis and comprehensive management. Disparities persist, with underserved populations facing the greatest barriers. Addressing these requires policies that support consistent, evidence-based practices and enhance healthcare capacity and technology advancements. This document presents the development of the Breast Cancer Care Quality Index (BCCQI), supported by evidence to promote equitable care and improve BC outcomes globally, and discusses its adoption as a strategic tool within National Cancer Control Plans.

Methods: A two-part methodology identified challenges in BC care and defined dimensions, targets and indicators for the BCCQI, aligned with the World Health Organization Global Breast Cancer Initiative. A literature review and analysis of existing United Nations (UN) frameworks informed the initial structure of the index, which was later refined through expert feedback from a multidisciplinary panel representing diverse backgrounds and geographies.

Findings: The BCCQI is organised into four dimensions, comprising 10 targets and 23 indicators to guide the development of country-specific roadmaps. It should promote progress across key domains: health equity, patient centricity, universal access, care quality and treatment effectiveness. The Index is conceived as a dynamic tool, continuously refined through real-world application and emerging evidence.

Interpretation: Despite the previous initiatives, progress has been slow, likely due to practical details and country-specific guidance remaining limited due to scarce real-world evidence. Promoting national ownership and empowering action aligned with local challenges and opportunities, a flexible, strategic framework may help address these gaps.

Keywords: breast cancer, quality index, early detection, timely diagnosis, comprehensive management, healthcare systems strengthening, health equity, patient centricity, universal access to health, healthcare quality, treatment effectiveness

Correspondence to: Ilaria Lucibello
Email: ilucibello@policywisdom.com

Published: 01/09/2025
Received: 09/06/2025

Publication costs for this article were supported by ecancer (UK Charity number 1176307).

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction

Breast cancer (BC) was the most prevalent cancer in 2022, affecting over 8.1 million individuals worldwide [1]. It has a profoundly debilitating impact on patients and imposes substantial individual, societal and economic burdens. Despite significant advancements in BC research, diagnosis and treatment, substantial challenges persist. Access to optimal care remains limited, particularly in low- and middle-income countries (LMICs) [2]. Moreover, integrated, patient-centered approaches are not broadly available, with underserved populations facing the greatest barriers. These disparities highlight that challenges in BC care endure globally, leading to inequities both between and within countries [3–5].

Over time, significant efforts have been undertaken to guide and support countries in strengthening their national BC programs and service provision to improve patient outcomes, like for example, the Breast Health Global Initiative (BHGI) [6, 7] and the BC Initiative 2.5 (BCI2.5) [8, 9]. More recently, to achieve a 2.5% annual decrease in BC mortality rates at the global level, the World Health Organization (WHO) Global Breast Cancer Initiative (GBCI) provided evidence-based recommendations for countries to follow a phased approach to implementing interventions focused on improving BC early detection, diagnosis and treatment. The GBCI, which also describes the BC patient journey, identifies three evidence-based key performance indicators (KPIs) to pinpoint country-level gaps [2].

However, recent data indicate that only a few countries have achieved or are on track to achieve-the GBCI goal [5]. This suggests that further support might be needed to help countries more effectively and rapidly scale up their efforts to improve BC care.

A comprehensive approach aimed at reducing disparities and promoting equitable care for all individuals will require bold policy change in support of consistent, evidence-based practices and a two-pronged approach focused on increasing the existing healthcare system capacity while aligning rapid advancements in health technologies. Such an undertaking calls for expanding action on BC care and engaging a more diverse and comprehensive group of stakeholders to drive collaboration and shared responsibility.

To increase clarity around the required commitment and accountability for improving the quality of BC care and outcomes for all patients, we aspire for a new Breast Cancer Care Quality Index (BCCQI) to be integrated into National Cancer Control Plans (NCCPs). Building on the GBCI, the BCCQI will provide additional guidance on essential elements to enhance national-level BC care quality. The guidance provided should allow countries to tailor their own implementation plans to their specific needs and develop context-sensitive roadmaps to adapt over time as progress is achieved. This flexible and iterative approach encourages national ownership, supports inclusive participation and should facilitate incremental progress across five key domains essential to BC care improvement: health equity, patient centricity, universal access to health, healthcare quality and treatment effectiveness.

The objective of this document is to discuss the development of the BCCQI and facilitate alignment on its adoption and implementation as a strategic tool to advance BC care globally.

Methods

A two-part methodology was developed, adapted from the consensus approach [10], in which we aimed to gather general agreement on the key components to be included in the BCCQI, in order to address the limitations of empirical data supporting the impact and expected outcomes of commonly used metrics across real-world settings.

1. Parallel reviews to inform the preliminary framework

Peer-reviewed literature

A review of global evidence explored the multidimensional impact of BC, and the challenges and priority areas for quality improvement across the BC care continuum. We used Medical Subject Headings search terms on PubMed, including ‘breast cancer’, ‘breast cancer detection’, ‘breast cancer diagnosis’ and ‘breast cancer treatment’. The search was conducted between April 14th and May 24th, 2024. Target papers were identified based on their relevance to BC burden and challenges. Relevance to the BC burden was assessed based on evidence related to: (i) the disease burden, including BC incidence, mortality and disability-adjusted life years; (ii) the socio-economic impact, encompassing direct healthcare costs, out-of-pocket expenditures and productivity losses and (iii) the impact on the well-being of individuals and caregivers, including effects on physical and mental health, as well as on personal and professional relationships. Relevance to BC challenges was evaluated based on the extent to which the evidence addressed barriers encountered across the patient journey – from early detection and diagnosis to treatment, survivorship and recovery. A total of 89 papers were considered in the preliminary literature review.

Grey literature

Policy documents from governmental and international sources were reviewed to assess existing BC strategies, guidelines and recommendations and to identify potential areas for policy improvement.

United Nations (UN) resolutions and frameworks

Relevant UN health resolutions and frameworks were reviewed to shape the BCCQI’s structure (Box 1).

Based on the analysis of the literature, the BCCQI was aligned with the three pillars of the GBCI framework – health promotion, timely diagnosis and comprehensive treatment – as well as the patient pathway outlined within the GBCI.

A fourth dimension related to healthcare systems resilience was included as supported by literature review findings.

The parallel reviews provided valuable insights into the key issues the BCCQI should address, potential indicators for assessment, areas for policy improvement and the approach used by existing BC strategies. These findings informed the development of the preliminary BCCQI framework, with evidence justifying the inclusion of each target and indicator, which was subsequently refined through expert feedback.

2. Expert feedback

A multi-disciplinary group of 18 experts was consulted to provide key insights and feedback and to endorse the BCCQI through a three-phase feedback process. These experts were selected to ensure a comprehensive perspective on BC care, and with consideration for:

1. Affiliations and roles within reputable organisations dedicated to BC.
2. Diverse range of geographic locations.
3. Active engagement and participation in BC policymaking and guideline development.
4. Active involvement in patient advocacy through international and regional organisations dedicated to BC and its care.
5. Relevant publications and evidence of familiarity with the latest advancements in BC care.

The group comprised 11 experts selected for their experience as healthcare professionals, four as policymakers and public health specialists and three as patient and civil society representatives. It also included eight experts in medical and clinical oncology, with a strong focus on BC and four experts in breast surgery. A wide range of nationalities was represented, covering different regions. These included: four experts from the United States of America, two from Canada and one expert from each of the following countries: Argentina, Brazil, China, Egypt, Italy, Kenya, Malaysia, Mexico, Nigeria, Portugal, Puerto Rico and the United Arab Emirates. The expert feedback and validation process included:

• Multistep expert preliminary feedback (May–July 2024)

This phase included a variety of engagement formats, including in-person and virtual advisory boards, as well as one-on-one meetings. During these sessions, experts discussed key challenges in BC care that the BCCQI should address and reviewed and endorsed the main structure of the preliminary BCCQI.

Following this round of discussions, a more refined second iteration of the Index was developed, supported by evidence justifying the inclusion of each target and indicator.

• Pre-panel survey (October 2024)

In this pre-panel survey, experts were presented with the refined version of the BCCQI. For each indicator, they were asked to either validate it, validate it with modifications or indicate that it should not be validated. Additionally, they were encouraged to provide supporting evidence and sources as needed, addressing aspects such as the clinical and medical accuracy of the topics and the feasibility of data collection.

Following the pre-panel survey, the Index was refined and a third version was developed and supported by relevant literature.

• Two expert panels (January 2025)

The panels were held to address outstanding issues in the near-final version of the BCCQI, in which experts could provide input and suggestions for further refinement. During these sessions, all outstanding issues achieved a minimum of 80% alignment among participants.

Following the two expert panels, the final version of the BCCQI was reached.

• Manuscript development, validation and finalisation

The manuscript was developed concurrently with the expert validation process, summarising key findings from the literature review and the expert feedback process. Twelve experts who contributed to the full process for the development of the BCCQI are listed as co-authors of the manuscript.

Background and context

Breast cancer: biological, clinical, epidemiological and socioeconomic perspectives

Breast cancer is the most common cancer among women in most countries and represents an important cause of premature mortality globally [2]. It imposes a staggering burden, straining healthcare systems, impacting the quality of life for patients and their families and with a great socioeconomic cost. The International Agency for Research on Cancer (IARC) estimates nearly 2.3 million new BC cases and 700,000 deaths globally in 2022 [1, 11], with 10.7% of new cases occurring in people aged less than 40 years [12]. In the absence of bold action, the burden of BC is projected to increase to 3.19 million cases by 2040, with around 1.04 million deaths per year [11]. Globally, it has been estimated that BC had an economic cost of 1.964 trillion international dollars in 2017 [13]. Beyond the economic strain and impact on productivity, BC itself and its treatment profoundly affect patients' psychosocial well-being and physical health. BC patients have an increased risk of mental health conditions such as depression and anxiety compared to individuals without BC [14, 15]. In addition, BC is associated with social stigma, along with self-stigma and associative stigma affecting family members, due to the value placed on women’s reproductive capacity or marital status [16]

The causes of BC are poorly understood, and most identified risk factors are not amenable to change [17]; therefore, improvements in early detection, timely diagnosis and comprehensive management are crucial to reducing mortality rates, enhancing patient quality of life and alleviating the economic and social burdens associated with this disease [2].

A recent study highlighted that countries with the highest human development index (HDI) show the highest age-adjusted BC incidence rates but the lowest BC mortality rates. Conversely, the countries with lower HDI scores have the lowest incidence but the highest BC mortality rates [5]. In addition, projections indicate that, between 2022 and 2050, BC incidence and mortality will increase more sharply in regions with limited resources [5].

The disproportionately greater mortality faced by LMICs might be affected by country-specific factors, like population structure, lifestyle, genetic factors and environment [18, 19].

Certain groups of women may face higher risks of developing BC, or of developing it at a younger age or experience more aggressive forms of the disease. For example, Ashkenazi Jewish women are at a significantly higher risk of developing BC than other Caucasian women [20, 21]. Within this group, a family history of BC further amplifies the risk, especially for early-onset disease. Similarly, African, Asian and Hispanic/Latina women are more likely to be diagnosed with BC at younger ages compared to their White or Western counterparts [19, 22–26].

However, access to and quality of BC detection, diagnosis and treatment services [27, 28] are also significant drivers of the inequities observed, as shown for example by the striking difference in BC stage at diagnosis, with only about 5%–10% of patients with metastatic BC at initial diagnosis in high-income countries (HICs), compared to up to 50%–80% of patients diagnosed with de novo stage III/IV BC, in LMICs [16, 29–31].

Breast cancer patient journey

The GBCI framework outlines the BC patient journey through three pillars, each corresponding to sequential patient-care intervals, as illustrated in Figure 1. For each pillar, the WHO provides a detailed description of the relevant interval, including the associated processes, interventions and the desired outcomes, which serve as benchmarks for countries to aspire to in improving BC care [2].

Figure 1. Overview of the three pillars of the GBCI BC patient journey.

Challenges in BC care: findings from the literature review

Numerous challenges affect the quality of the BC care delivered at the country level. These challenges are often particularly pronounced in LMICs and among vulnerable populations that are more significantly impacted by access barriers, leading to worse patient outcomes [16, 29, 30, 32]. Table 1 presents key challenges identified along the BC patient journey in the initial literature review.

Table 1. Overview of key challenges identified in BC detection, diagnosis and care.

Based on the challenges described above, our analysis led to the identification of the following four dimensions: early detection, timely diagnosis, comprehensive management and strong and resilient healthcare systems.

Early detection and timely diagnosis are vital for reducing BC mortality; analysis of evidence from 1990 to 2020 showed that only countries detecting at least 60% of the invasive cancers at stages I or II achieved a 2% reduction in BC mortality for three consecutive years [2]. Timely diagnosed BCs are treated more effectively, with treatment being better tolerated and less costly [2]. Comprehensive care combines timely cancer therapies (surgery, radiotherapy and systemic treatments) and supportive services, following WHO guidelines and international standards, to ensure holistic BC management, improve patient outcomes and enhance quality of life. Strong, resilient healthcare systems are essential to meet the growing BC burden while ensuring quality, equity and patient-centered care across the BC patient journey [53, 62, 63].

Results

Importance of a BC care quality index

Breast cancer is a public health priority for health systems and countries worldwide, given its significant impact on patients, families, health systems and society overall. However, countries are tasked with the challenging responsibility of addressing patients’ healthcare needs while ensuring the economic sustainability of their healthcare system [64, 65]. Considering the projected growing burden of BC, this task appears even more daunting.

To support these efforts, a multitude of initiatives and organisations have focused over the years on providing guidance for countries, healthcare systems and individual healthcare institutions, on how to ensure the quality of BC services and how to develop programs and interventions to successfully improve outcomes of BC patients (Box 2).

In 2021, the WHO, in collaboration with the International Atomic Energy Agency (IAEA) and the IARC, [70] launched the GBCI which aims to provides national program managers, policymakers and multisectoral stakeholders the valuable guidance they need to assess gaps, strengthen and scale-up services for the early detection, diagnosis and management of BC [2]. The GBCI framework’s objective is to reduce BC mortality by 2.5% per year and save 2.5 million lives over a 20-year period [2]. For this purpose, the GBCI identified essential KPIs that countries should adopt to measure progress.

However, recent data show that only seven of the most developed countries are meeting, and six additional countries are close to meeting, the GBCI goal of 2.5% annual decreases in BC mortality rates [5]. This outlines a possible gap with countries requiring further support and guidance on a set of more practical and applicable essential measures to consider to more effectively and rapidly scale up action for improved BC care.

Building on the GBCI and previous global initiatives, the BCCQI proposes a unified framework that outlines essential elements for countries to prioritise in order to enhance BC care quality at the national level. By providing a structured set of targets and indicators, this framework enables countries to develop tailored implementation strategies, adapted to their specific contexts and create actionable roadmaps to address gaps in BC care.

Unlike rigid, prescriptive models or ‘one-size-fits-all’ approaches of the past, the BCCQI seeks to promote a flexible, context-sensitive approach, empowering countries to set their own short- and medium-term priorities. In doing so, countries are encouraged to leverage existing guidance from initiatives such as the GBCI and other resource-stratified frameworks. Recognising that no country has fully addressed all barriers to optimal BC care, the BCCQI helps nations identify specific areas for improvement. Some may focus on enhancing healthcare professionals knowledge and education, while others may work to improve access to supportive services that enhance patient-centered care. Because the framework is designed as a continuous, inclusive process, countries can refine their priorities and strategies iteratively, making stepwise enhancements based on local challenges and opportunities. In this way, countries with immediate limited investment capacities or differing priorities can still advance toward meaningful progress. This flexibility fosters a sense of ownership among national stakeholders, allowing each country to make strategic decisions aligned with their specific situation.

In addition, to ensure that improvements are truly impactful for patients, the BCCQI centers on five key domains essential for high-quality BC care: health equity, patient centricity, universal health access, healthcare quality and treatment effectiveness (Figure 2 and Box 3).

By emphasising the importance of national policies and strategies, the BCCQI is designed to drive bold policy reforms that establish essential national frameworks. These frameworks will empower countries to sustainably strengthen healthcare system capacity while striving to keep pace with rapid advancements in BC clinical practice.

Given the scale of the challenge, no single stakeholder can drive this transformation alone. The BCCQI is intended to serve as a catalyst for collective action by uniting key actors around a comprehensive set of actionable targets and indicators. This shared framework helps expand and clarify responsibilities, enhances accountability and fosters a sense of ownership among national stakeholders when prioritising actions and measuring progress toward the GBCI goals.

Finally, over time, by supporting the harmonisation of progress tracking, as outlined by previous initiatives [71, 72], the BCCQI is expected to facilitate the generation of comparable global evidence. This will enable intercountry comparisons, trend identification and cross-country learning – critical information for policymakers seeking to refine existing frameworks and develop targeted interventions. Ultimately, this is expected to support decision-making, increased stakeholder engagement and advocacy and enhanced accountability, ensuring continued global progress toward the highest standards of BC care.

Figure 2. Domains for BC care improvement, as prioritised by the Breast Cancer Care Quality Index index (BCCQI).

Breast Cancer Care Quality Index

The BCCQI aims to increase action and implementation of healthcare system transformation to improve BC care for all patients, highlighting key elements that each country should focus on to advance the quality of BC care. The BCCQI represents a catalyst for engagement for policymakers, the international community and multisectoral stakeholders. Box 4 provides an overview of key principles that were followed during the conception of the BCCQI to ensure its robustness and maximise the likelihood of its successful adoption.

The BCCQI is structured into dimensions, goals, targets and indicators, mirroring the structure of key outcome-driven health-related frameworks established by international organisations and their collaborators. Box 5 provides more information regarding their development.

Each target and its supporting indicators have been designed to facilitate advances in the key domains of BC care improvement: health equity, patient centricity, universal access to health, healthcare quality and effectiveness of treatment (Figure 2 and Box 3).

Table 2. Description of the categories of indicators adopted.

As discussed above, when seeking to improve BC patients’ care, every country would need to identify its medium–short term priorities to advance specific targets and indicators of the BCCQI, based on the country context, including challenges and opportunities.

Table 3 summarises the BCCQI targets and indicators by dimension, including the domains each indicator contributes to enhancing. Additional information regarding each target and indicator is provided in the Supplementary Tables S1 and S2.

Table 3. Overview of the Breast Cancer Care Quality Index (BCCQI) targets and indicators by dimension, including information regarding the domains supported by each element.

Discussion

The BCCQI provides an opportunity to promote renewed attention and focus on health care and mobilising new streams of funds for BC care. It is envisioned as a dynamic tool, subject to continuous refinement and improvement based on real-world application and evolving evidence. As a flexible and adaptable framework outlining essential elements for assessing and improving the quality of care for BC patients across the care continuum, it promotes stakeholder ownership and accountability at all levels [86], empowering countries to drive iterative improvements through context-specific roadmaps aligned with local needs, opportunities and challenges. Moving beyond the prescriptive, rigid models of the past, it encourages action through an inclusive and continuous process that recognises incremental progress. This allows countries to address public health challenges at their own pace and has the potential to serve as a replicable model for advancing care in other critical disease areas. Ultimately, this approach brings countries closer to fulfilling the three pillars of the GBCI framework, providing additional guidance and more practical and applicable details to help them reduce BC mortality and address its broader societal impact.

The essential domains that guided development of the BCCQI serve to enhance alignment of the framework with the international community’s global health priorities, like as example, the 2030 Agenda for Sustainable Development. Additionally, in the lead up to the fourth UN high-level meeting on noncommunicable diseases (NCDs), the BCCQI presents an opportunity for the cancer and BC communities to push for reprioritisation of an unfinished agenda. The marked alignment of the BCCQI with other global health priorities, such as universal health coverage and non-communicable disease management, guarantees that policymakers can more easily secure the necessary political and financial support due to this synergy with ongoing efforts at the country and global level.

As seen in previous disease-specific programs, foundational frameworks can often serve as a platform for broader service integration, yielding benefits that extend beyond their original scope [86–88]. Similarly, the BCCQI framework has the potential to generate positive spillover effects that enhance the overall strength and resilience of national healthcare systems. This is particularly relevant for the BCCQI, which directly focuses on overall healthcare system strengthening by dedicating a full dimension to integral healthcare system components.

By incorporating metrics related to governance, financing, resource allocation, service organisation and results, this framework is fully geared towards ensuring that impact and advances in overall healthcare system capacity can be systematically recorded and monitored. Monitoring and evaluation should indeed become a pivotal component of any BC planning and implementation effort, as outlined by previous initiatives [71, 72]. The fact that the BCCQI already provides a general reference aids countries in setting a starting point to begin recording the baseline, in support of BC and healthcare system performance assessment and improvement over time.

Yet, several challenges must be understood and mitigated to ensure the successful adoption of the BCCQI. First and foremost, the perception that BC is an already addressed need might reduce the willingness of policymakers to continue working on it.

In addition, the inadequate public awareness and the lack of robust advocacy movements further hinder the prioritisation of BC as a key health issue. There is also a lack of comprehensive data, as many countries face gaps in national cancer staging, timely diagnosis and treatment completion data, which leads to a lack of agreement on critical aspects of BC care. More specifically, for example, in LMICs, there are critical evidence gaps in building the case for comprehensive BC management services, especially when considering the full spectrum of the desirable supportive services to be offered. These gaps pose remarkable challenges for countries with limited capacity to invest in data infrastructure development in the short-medium term but, on the other hand, offer them the opportunity to leverage the index as a tool for broader awareness creation, resource mobilisation and collaborative action for iterative progress.

Finally, financial, infrastructural and human resource constraints, along with competing priorities within and beyond healthcare systems, pose substantial barriers to the adoption of the BCCQI.

As we look ahead, sustained collaboration among governments, the international community and multisectoral stakeholders will be essential to driving continuous progress in addressing growing healthcare needs worldwide. By offering a unified framework for action and fostering inclusivity and adaptability to support decision making, the index empowers countries and multisectoral stakeholders to develop and advance tailored efforts to bridge gaps in BC care. Collaboration will be especially valuable in advancing data infrastructure needs and pilot programs to field test and further refine the BCCQI, which is conceived as a dynamic tool that, once adopted, will be subject to ongoing refinement and future improvements based on real-world application and evolving evidence. In this regard, key opportunities for immediate action, which are ultimately expected to have positive repercussions on the broader healthcare system and global health, have been pinpointed in the recommendations.

Limitations

The methodology used in this study, which includes a review of peer-reviewed literature, grey literature, UN resolutions and frameworks and an expert feedback process, guided the development of the BCCQI as an expert-endorsed tool designed to drive actionable, systematic healthcare transformation and improve the quality of BC care for all patients. However, the HIC-bias of grey literature and CPGs may represent a limitation of the tool.

This geographic concentration may not fully capture the unique challenges and resource constraints faced by LMICs. However, the inclusion of peer-reviewed literature from countries across diverse regions and development levels helps mitigate this limitation by incorporating a broader range of perspectives. Future iterations of the BCCQI could further enhance its comprehensiveness and generalisability through a systematic review of the existing evidence.

The expert feedback process, although robust and multidisciplinary, reflects the perspectives of a selected group of professionals. While this could potentially limit the generalisability of findings, the experts consulted for this study were carefully chosen based on their affiliations and roles within reputable organisations dedicated to BC, extensive experience in oncology and related fields and active engagement and participation in BC policymaking and guideline development.

Moreover, their representation from a diverse range of geographic locations and healthcare systems reinforces the global applicability of the BCCQI.

Finally, while the metrics outlined in the BCCQI are derived from evidence, they have not been field-tested. The primary goal of this study is to initiate meaningful discussions on the development of the BCCQI as a global tool to be adopted in NCCPs. It is intended to represent, despite its limitations, a first attempt at developing such a framework at the global level and to lay the foundation for following iterations as more evidence becomes available. However, it is important to recognise that incorporating the BCCQI into NCCPs does not guarantee better patient outcomes and higher quality care delivery, as clear evidence of the impact of similar frameworks in key governance documents at the national level is still missing.

Recommendations

The BCCQI serves as a catalyst for unifying stakeholder efforts and accelerating global progress in BC care by building on existing initiatives and maximising the impact of prior investments. It offers a clear, actionable and adaptable framework focused on key dimensions, including early detection, timely diagnosis, comprehensive management and healthcare system resilience. However, while adopting as part of NCCPs and implementing the BCCQI stands as a key recommendation, existing challenges may hinder global commitment to its success. To this end, policymakers, international organisations and stakeholders across sectors play a critical role in building momentum and fostering broad engagement toward a strong global partnership striving to guarantee that the BCCQI becomes a pivotal tool to ensure that all BC patients have access to the highest standards of care.

To advance this objective, the following recommendations are proposed (Box 6).

Conclusion

Significant disparities in BC access and quality of care persist globally, including within HICs, highlighting the urgent need for a unified framework that supports all countries in advancing BC care, regardless of their context, resources, infrastructure or specific challenges. The Breast Cancer Care Quality Index (BCCQI) offers countries the guidance they need to design results-driven approaches supported by evidence to tackle their respective challenges at their own pace.

The global action to combat BC calls for coordinated and effective measures that streamline efforts, reduce unnecessary duplication and address existing gaps in care. In this spirit, it is important to emphasise that the BCCQI has been thoughtfully designed to further support and strengthen action under the GBCI and other relevant initiatives by providing more detailed metrics that countries can adopt in a context-specific manner. Rather than competing, it acts as a valuable tool to help operationalise the general guidance applicable to broad country groups provided by existing initiatives such as the GBCI framework, deepening their impact by empowering countries to develop their own tailored roadmaps for implementation.

In the lead-up to the UN high-level meeting on NCDs in September 2025, this framework presents an opportunity to drive renewed attention to BC care and mobilise new funding streams to enhance its quality at the global level. However, the successful adoption and implementation of the BCCQI requires multisectoral collaboration and coordinated action to overcome multiple barriers. It is envisioned that, by establishing clear benchmarks to be tracked through regular audits for the refinement of its implementation, integration of the BCCQI into NCCPs can enable more systematic efforts towards strong governance, sustainable financing and robust data collection and analysis systems.

Future studies can explore the implementation process of the BCCQI, and field-test the index to refine it, validate its metrics and ensure its relevance and reliability across different contexts. This will help make the BCCQI more evidence-based and context-validated.

By providing a tool for coordinated action at the global, national and regional levels, the BCCQI has the potential to serve as a catalyst for enhanced efforts towards more equitable and sustainable BC care worldwide. Its adoption and effective implementation are expected to lead to higher quality, patient-centered services globally, ultimately improving BC care for all patients, regardless of geographic or economic barriers.

Acknowledgments

We thank the group of experts that participated and provided invaluable feedback during the Global Breast Cancer Care Council held in March 2024: Mary Ajango, Maira Caleffi, Andrea Feigl, Victoria Harmer, Thomas Hofmarcher and Naveena Nekkalapudi. We thank the group of experts that participated and provided invaluable feedback during the in-person and virtual Advisory Boards and one-on-one meetings held in May to July 2024: Aydah Al Awadhi, Jenn Gordon, Ricki Fairley, H.E. Toyin Saraki and Victoria Wolodzko Smart.

Conflicts of interest

BOA declares consulting fees from AstraZeneca as Global Oncology Consultant (2024–25).

GC declares consulting fees from BMS, Roche, Pfizer, Novartis, Lilly, AstraZeneca, Daiichi Sankyo, Merck, Seagen, Ellipsis, Gilead and Menarini; is a speakers’ bureau member for Lilly, Pfizer, Relay, Gilead, Novartis and Menarini; and received support for attending meetings/travel from Daiichi Sankyo.

SS received speaking fees and participated in advisory boards for Novartis, Gilead, Lilly, Roche, AstraZeneca, Daiichi Sankyo, Knight, Merck, Bristol Myers Squibb, Incyte and Sandoz.

FC holds consultancy roles with Amgen, Astellas/Medivation, AstraZeneca, Bayer, Celgene, Daiichi Sankyo, Eisai, GE Oncology, Genentech, Gilead, GlaxoSmithKline, IQVIA, MacroGenics, Medscape, Merck Sharp & Dohme, Merus BV, Mylan, Mundipharma, Novartis, Pfizer, Pierre Fabre, prIME Oncology, Roche, Sanofi, Samsung Bioepis, Seagen, Teva and TouchIME; is the President of the ABC Global Alliance, Chair of the ABC Consensus Conference and Guidelines, and a Fellow of the European Academy of Cancer Sciences; and is a member or committee member of ESMO, ESO, ASCO, AACR, ECO, AORTIC, UICC, EORTC, IBCSG, SOLTI, EACR, SIS, ASPIC, SPO and EVITA.

ARG reports being the CEO of Policy Wisdom LLC.

ES received travel grants from Boehringer Ingelheim, Hikma, Janssen, Lilly, Merck Sharp & Dohme, Mundipharma, Novartis, Pfizer and Roche; participated in advisory board meetings, consultancy and/or speakers’ bureaus for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Clinart MENA, Genomics Genetics, GSK, Hikma, EVA Pharma, Janssen, Lilly, Merck Sharp & Dohme, Mundipharma, Nebridge Pharmaceutical, Novartis, Pfizer, Pierre Fabre, Roche and Sandoz; and has been involved in clinical trials for AstraZeneca, Boehringer Ingelheim, Novartis, Pfizer and Roche.

CHY declares payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing or educational events from Novartis; and participation on a Data Safety Monitoring Board or advisory board for AstraZeneca.

AM declares consulting fees from Roche and Eli Lilly; payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing or educational events from Merck, Roche, Eli Lilly and AstraZeneca; and received support for attending meetings and/or travel from Roche.

YCG received research support from Roche and Pfizer; participated in speakers’ bureaus for Gilead, AstraZeneca, Lilly and Merck Sharp & Dohme; received support for travel expenses from Novartis, Pfizer, Gilead and Lilly; and holds an advisory role with AstraZeneca.

EC, MM, YY, JVR, IL and NS declare no competing interests.

EC, BOA, GC, SS, FC, ES, AM, YCG and YY received honoraria for their involvement as expert panel members. MM’s honorarium was allocated in support of the Kenya Society of Hematology and Oncology (KESHO). The participation of JVR, IL and NS was covered through their regular roles at Policy Wisdom LLC.

Funding

The authors disclose receipt of financial support from AstraZeneca for the research and the discussion process that was part of developing this document. AstraZeneca had no role in the conceptualisation, planning and execution of the research, investigation; in the drafting of the document or in the findings presented and discussed, at any point. The authors independently drafted the manuscript’s contents and the index, and this manuscript is their product.

Author contributions

• Conceptualisation- Formulation: IL, NS.
• Conceptualisation- Evolution: EC, BOA, GC, SS, FC, ARG, ES, CHY, AM, YCG, MM, YY.
• Data curation: JVR, IL.
• Formal analysis, data adaption to real world experience, data interpretation: EC, BOA, GC, SS, FC, ARG, ES, CHY, AM, YCG, MM, YY, JVR, IL, NS.
• Investigation: EC, BOA, GC, SS, FC, ARG, ES, CHY, AM, YCG, MM, YY, JVR, IL, NS.
• Methodology- Original: JVR, IL, NS.
• Methodology- Refinement and adaptation: EC, BOA, GC, SS, FC, ARG, ES, CHY, AM, YCG, MM, YY.
• Index Endorsement: EC, BOA, GC, SS, FC, ARG, ES, CHY, AM, YCG, MM, YY.
• Project administration: NS.
• Supervision: NS.
• Writing – original draft: JVR, IL.
• Writing – review & editing: EC, BOA, GC, SS, FC, ARG, ES, CHY, AM, YCG, MM, YY, NS.

Data sharing statement

Not applicable.

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Supplementary Material

Table S1. The Breast Cancer Care Quality Index (BCCQI) – description of targets.

Table S2. The Breast Cancer Care Quality Index (BCCQI) – description of indicators.

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