**Background:** Breast cancer and cervical cancer are the first and second most common cancers in women in sub-Saharan Africa (SSA), respectively. Five-year overall survival for breast cancer in SSA is below 50%, far lower than in high-income countries (90%) or middle-income countries (66%). Radiation therapy (RT) is a standard component of curative treatment for locally advanced breast and cervical cancer, but access across SSA is severely limited. This systematic review aimed to comprehensively characterize barriers to RT access and their impact on clinical outcomes.
**Methods:** A comprehensive literature search was developed with a medical librarian and conducted on December 30, 2021, in MEDLINE (Ovid), Scopus, Web of Science, and African Index Medicus. Searches were limited to English-language articles published from 2016 onward. Articles were screened by two independent reviewers at title, abstract, and full-text levels. Included studies were original studies or summaries of national/regional interventions assessing RT use or RT-related outcomes (survival, toxicities, mental health, palliation, quality of life) for breast or cervical cancer in SSA. Data were extracted on financial, geographic, staffing, technology, and patient-level barriers, and outcomes were graded as poor, intermediate, or good according to predefined criteria. No randomized controlled trials were identified; most studies were retrospective or qualitative.
**Key Results:** A total of 96 articles were included: 37 on breast cancer, 51 on cervical cancer, and 8 on both. Financial barriers were pervasive: out-of-pocket payment models were most common. In Kenya, RT cost 1,200 USD while patients lived on approximately 1 USD per day; in Ethiopia, costs were 1.5–25 USD. In Nigeria, only 5 of 66 patients for whom breast RT was recommended completed treatment due to financial constraints. Treatment initiation rates ranged from 38%–82% in facilities with largely out-of-pocket payments compared with 98.7%–100% in a free center. Geographic access was severely limited: approximately 90% of African RT capacity is concentrated in Northern and Southern Africa, with nearly 60% in Egypt and South Africa alone. As of publication, 26 of 54 African countries had no RT. In countries with RT, single national centers were common (Zimbabwe, Zambia, Uganda, Ethiopia), leading to delays—an Ethiopian cohort reported 16 deaths and 44.4% progression to higher stage while awaiting RT for >60 days. Staffing shortages were critical: Kenya had only 4 practicing radiation oncologists for approximately 82,000 new cancer cases annually. SSA has just 0.115 radiation machines per million people versus a recommended 4. Technology access was further limited by unreliable power grids, broken-down equipment, and lack of brachytherapy—44.8% of surveyed facilities lacked EBRT and 52.5% lacked brachytherapy. Patient factors including fear, stigma, and low health literacy decreased care-seeking; 83% of respondents in one survey believed RT would decrease their lifespan. Survival outcomes were poor: breast cancer 5-year OS ranged from 38% to 79%. Cervical cancer survival varied from 3.4% for palliative cases to 86.7% for localized disease. Only 5.2% of patients received guideline-compliant curative-intent treatment. Wait times >180 days were associated with 5.8 times higher all-cause mortality compared with waits <60 days. Side effects were similar to other regions but limited by poor documentation. Palliative RT had shorter wait times (0–15 days) versus definitive treatment (median 150 days).
**Clinical Implications:** This review demonstrates that RT access barriers across SSA are multifactorial and interconnected, leading to substantially worse survival outcomes than in high- and middle-income countries. Long-term solutions require increased technology, staffing, and rural treatment centers. Short-term strategies include interim housing for traveling patients (building on a Botswana model), adoption of hypofractionated regimens to reduce treatment burden, telehealth and virtual multidisciplinary clinics to reduce travel, and community education to combat stigma and improve early presentation. Country-specific solutions are needed given the tremendous diversity across SSA nations in RT capacity, funding models, and outcomes.