"Breast cancer survival rates have greatly improved in recent decades. However, they are still relatively lower for women with disabilities, particularly those with a severe degree of disability, as highlighted by the study by Choi et al.¹ The authors linked data for patients with breast cancer for 2012 to 2019 from a major national database, including Korea’s national cancer registry, the Cancer Public Library Database, and National Disability Registry database. The linked data yielded a cohort of 150 412 patients with cancer, of whom 142 969 were women without disabilities and 7443 were women with disabilities. The latter group included patients with cancer with different disabilities, ranging from physical, sensory, traumatic brain injury, and other categories comprising cognitive impairment and serious mental health disorders. The study assessed stage at diagnosis, treatment uptake, survival rates, and mortality after adjusting for a range of potential confounders (ie, age, income, residence, comorbidities, and treatment type, including surgery, chemotherapy, radiotherapy, and hormone therapy).

The findings of the study by Choi et al¹ are concerning. Notably, women with disabilities had higher overall and breast cancer–related mortality compared with women without disability. Women with disability were more likely to be older (>65 years), have income in the lower quintiles, live in nonurban settings, have more comorbidities, and present with an advanced stage of breast cancer with lower treatment uptake. Furthermore, even among women with localized breast cancer at diagnosis, a potentially curable condition, higher mortality rates were found for women with disabilities. The study by Choi et al¹ adds to the existing evidence base of similar underlying issues for adverse breast cancer outcomes for women with disability in many other countries.^2,3 Together, these findings and results of other studies highlight the need for targeted health care interventions to address disparities in health care systems that manifest in the form of poor outcomes for vulnerable populations like women with disabilities.

However, there is a need for a nuanced understanding of how disparities are linked to inherent problems within health care systems and broader societal disadvantages. Therefore, it is important to highlight the wider context of lifelong disparities in health for people with disability compared with people without disability. The underlying factors are a complex mix of interconnected components of personal and larger systems-level issues.² At the individual level, for people with disability, particularly women, there are substantial disadvantages in socioeconomic status that contribute to poor health. For distinct types of disabilities, the stigma associated with disability, which is experienced in various health care encounters, adds another dimension of distrust about health systems. A similar dynamic is at play for women with disabilities, in terms of preventive and clinical care regarding breast cancer, who often have difficulties in access to and uptake of breast cancer screening due to comprehension and/or access issues. Apart from locational access issues (such as limited screening options in smaller towns and rural regions), there are often also personal access–level barriers, such as fear of equipment and procedures involved in breast cancer screening due to lack of adequate information materials that are appropriate to the type of disability.³

As part of enhancing health care systems, there is a need for developing more inclusive and comprehensive policies for cancer screening for people with disabilities—in particular, women with disabilities. In settings where such policies exist, there are gaps in the implementation, ranging from a lack of regular health checks to irregular or incomplete implementation of health checks and preventive screening for early diagnosis of cancers.⁴ Undertaking health checks for people with disability requires additional time and expertise and, therefore, needs adequate incentivizing. Given the relatively small number of people who fall in this category, health budgets should be able to absorb these costs, especially in countries where disability insurance schemes are operational. Beyond the issues outlined above, there are also deficiencies in health care provision due to practitioner-level issues ranging from ableist attitudes, inadequate training of health care professionals and more conservative approaches to treatment on the basis of implicit notions of quality of life and longevity of women with disability.⁵

The study by Choi et al¹ offers a useful roadmap for improving breast cancer care for women with disabilities. By highlighting the intersectional factors that contribute to disparities in care, this study calls for greater awareness and systemic change to address the needs of this underserved group, and, by extension, for enhancing care services for cancers in women with disabilities. For a systems-level change for inclusive cancer care, there is a need for multidimensional strategies encompassing preventive to clinical care. Codesign of health promotion materials with women with disabilities can improve their comprehension of risk for breast cancer as well as other cancers. Within health systems, as mentioned previously, policies need to be developed or implemented more rigorously for regular health checks by primary care physicians, including ensuring timely uptake of preventive and curative services.^4,6 However, enhancing inclusive cancer care goes beyond good policies and program implementation to also directing attention to care practitioners. There is an urgent need to focus on the training needs of health practitioners, which is extremely limited for people with disability, particularly for women with disability. Hence, a vital component of strengthening health systems is adequate training of primary care physicians and specialists regarding the complex health care needs of women with disabilities including cancers. Various training strategies have been suggested, but the most effective include a mix of approaches. Structured education programs, clinical rotations, interprofessional curricula, and specialty training initiatives are all useful strategies to bridge the knowledge and skills gap and enhance equitable access to care for women with disabilities.⁷

Our concluding comments, therefore, relate to foundational principles of equity in health care systems. We recommend an integrated approach to strengthening the capacity of health systems to ensure they adequately address the health needs of women with disabilities. With increasing use of digital health records, implementation of such an approach has the potential to highlight care gaps and appropriate follow-up. Furthermore, such changes would be beneficial not just for embedding inclusive care services for cancers but also for other complex comorbid conditions. Although systems-level changes in health care take time and resources, they are more sustainable and cost-effective in the long run, with improvements in clinical outcomes through early detection and appropriate management of these conditions."