Breast cancer (BC) is a prevalent malignancy among women globally, with significant contributions to cancer-related morbidity and mortality (1). Beyond the physical challenges posed by the disease, BC patients often encounter severe psychological difficulties, with depression being a prominent concern (2, 3). The presence of depression in BC patients can negatively influence treatment adherence, quality of life, and overall prognosis (4).

The prevalence of depression among BC patients can be affected by a variety of factors, including demographic variables, clinical factors, and psychosocial elements. Demographic factors such as age, marital status, and socio-economic status play a crucial role, with younger patients and those lacking social support being particularly vulnerable (5, 6). Clinical aspects, including cancer stage at diagnosis, type of treatment received (e.g., chemotherapy, surgery, radiation therapy), and comorbid conditions, also significantly affect the likelihood of depression (7, 8). Moreover, psychosocial factors such as social support levels, prior mental health history, and coping mechanisms are vital determinants of mental health outcomes in these patients (9).

Despite the recognition of these influencing factors, a significant variation in the reported prevalence of depression among breast cancer patients persists across studies in Asia. Among the included Asian studies, prevalence ranged from approximately 3.71% in a Korean national cohort to 51.02% in a Jordanian study, with other countries also reporting high rates (e.g., 48% in China, 44.51% in Syria, 39.53% in Vietnam), suggesting that regional and methodological differences may jointly drive the wide dispersion of estimates (10–14). This variability may stem from differences in study design, sample characteristics, and methodological approaches to diagnosing depression (15, 16).

Breast cancer patients often face a significant psychological burden throughout diagnosis, treatment, and follow-up. Depression not only affects quality of life and treatment adherence but may also increase healthcare costs and hinder long-term recovery. Previous systematic reviews and meta-analyses indicate a considerable global pooled prevalence of depression in breast cancer patients, at approximately 30%–32% (17). Furthermore, the burden of depression shows marked regional variation. When stratified by WHO region, prevalence is approximately 49%–51% in the Eastern Mediterranean and 23%–33% in Southeast Asia (18), suggesting associations with socioeconomic development, healthcare accessibility, and cultural context.

Consequently, we systematically reviewed the existing literature on depression among breast cancer patients in Asia and conducted this meta-analysis. Our aims are to investigate regional variations and understand how various factors contribute to these differences. This comprehensive synthesis will help inform the development of targeted mental health interventions to better support breast cancer patients in Asia.

From the online databases, a total of 11,278 records were retrieved. After removing 7,955 duplicates and excluding 436 records based on title/abstract screening, 2,887 reports remained for full-text screening. Of these, 11 articles met the inclusion criteria, and one additional study was identified through citation searching, resulting in 12 studies included in the quantitative synthesis. The PRISMA flow chart diagram is presented in Figure 1.

Based on the present findings, the pooled prevalence of depression among breast cancer patients in Asia was 28%. This indicates that depression constitutes a significant and often underrecognized mental health burden in this population and should be integrated as a crucial component of comprehensive cancer care. However, subgroup analyses revealed differences in pooled prevalence rates across countries and treatment modalities, though these were not statistically significant and should be considered inconclusive due to the limited number of studies within each subgroup. This may be attributed to the limited number of relevant studies, resulting in insufficient statistical power to detect significant differences. On the other hand, it also suggests that, beyond geographical region and treatment modality, more complex socioeconomic and cultural factors collectively influence the risk of depression in breast cancer patients. Future research should consider examining patient coping mechanisms (27–29), psychosocial support systems (30–32), and economic factors (18, 29), which may play more prominent roles in patients’ psychological well-being. Furthermore, it is crucial to note the extreme heterogeneity across studies (I² = 99%). The reported prevalence ranged from 3.7% to 51%, and the 95% prediction interval was very wide. Consequently, the single pooled point estimate (28%) offers limited insight for individual patients across diverse Asian settings. Additionally, although the trim-and-fill analysis suggests robustness, the significant Egger’s test indicates that our pooled estimate may be modestly inflated—a common challenge in depression prevalence research. Therefore, interpretation should prioritize the observed range and prediction interval over the point estimate.

This study found that the pooled prevalence of depression in breast cancer patients is lower than previously reported global rates (32.2%) (17) and rates in sub-Saharan Africa (45.6%) (33), but higher than those reported in the Americas (25.1%) and Europe (27.2%) (17). These disparities may primarily stem from differences in healthcare expenditure, socio-cultural attitudes (27–29), economic status (18, 29), and accessibility of healthcare services (30–32). In regions with well-funded and accessible healthcare systems, such as South Korea (10), the prevalence of depression was notably lower (4%). It is important to note that the study by Heo et al. relied on ICD codes to identify depression, which likely captures only diagnosed or treated cases, thereby underestimating the true burden. In contrast, screening scales are more sensitive. Therefore, this low prevalence is more likely attributable to methodological differences rather than a true regional variation. This lower rate may also benefit from easier access to mental healthcare, earlier diagnosis, and more robust support systems. Consistent with this hypothesis, depression prevalence was higher in countries with lower healthcare expenditure and underdeveloped infrastructure, such as parts of West Asia (11, 25). Furthermore, socio-cultural attitudes towards mental health vary greatly across Asia, influencing the recognition and reporting of depressive symptoms. For instance, a longitudinal study among Chinese breast cancer patients indicated a significant prevalence of fear of cancer recurrence, which was positively associated with concurrent symptoms of depression and anxiety (29). This suggests that psychological distress, including depressive symptoms, is a salient and recognized experience in this cultural context, potentially influencing how distress is expressed and reported in clinical settings. In some cultural contexts, patients may tend to express psychological distress through somatic symptoms rather than emotional distress, leading to under-recognition of depression.

In low-income regions, breast cancer patients often face a heavy economic burden, which not only affects their treatment outcomes but also significantly increases their risk of developing depression (23). Breast cancer treatment typically requires long-term medical interventions, including surgery, radiotherapy, chemotherapy, and prolonged medication, all of which can be prohibitively expensive in low-income countries (34, 35). Due to limited healthcare expenditure and underdeveloped public health infrastructure in these regions, many patients struggle to access necessary treatments, leading to disease progression and exacerbated psychological distress (36, 37). Additionally, patients in low-income areas often bear high costs related to transportation and accommodation, further intensifying their financial pressure (17, 31). The lack of a robust social security system prevents patients from receiving adequate financial support, which is another reason for the observed higher prevalence of depression in these populations.

To address these challenges, governments and non-governmental organizations must collaborate to establish and expand financial assistance programs to help breast cancer patients cover treatment costs. Strengthening primary healthcare systems to improve early diagnosis and treatment accessibility is also crucial, as this can reduce the overall cost burden associated with late-stage cancer treatment (38). In resource-limited settings, priority can be given to low-cost, scalable interventions, such as psychological screening, brief psychological interventions, peer support programs, or community-based support networks implemented by primary healthcare workers. Furthermore, increasing public awareness and education about breast cancer and its psychological impact can help reduce the stigma associated with the disease and mental health issues. Establishing patient support groups and providing psychological counseling services are essential for offering the emotional support patients need to cope with the challenges of the disease. Secondly, psycho-oncology services have not been systematically integrated into standard oncology care pathways in many Asian countries. The shortage of dedicated mental health professionals and unclear referral pathways may further limit the identification and intervention of depression in breast cancer patients. In summary, comprehensive intervention strategies targeting the economic burden on breast cancer patients in low-income regions, and integrating mental health assessment and intervention throughout the breast cancer care pathway (e.g., at diagnosis, during treatment, and at follow-up), are crucial for achieving a patient-centered comprehensive oncology care model and for improving their quality of life and mental health outcomes.

From a clinical practice perspective, the findings of this study suggest that the focus of integrating psychological care lies not merely in whether depression screening is conducted, but in how it is conducted and the subsequent linkage to care pathways. Given the limited and uneven distribution of mental health resources in many Asian countries, relying solely on referrals to psychiatric specialists may be impractical. In contrast, embedding brief psychosocial assessment tools into routine oncology workflows (e.g., at initial diagnosis, treatment transition points, or follow-up) and training oncology nurses or primary healthcare workers to recognize psychological distress may be a more feasible strategy. Particularly in regions with heavy economic burdens or fragmented support systems, ensuring that positive screening results are linked to accessible support resources (such as peer support, basic psychological interventions, or community-based projects) may improve patient mental health outcomes more effectively than simply increasing the screening rate.

Although this study is one of the earliest systematic assessments of the prevalence of depression among breast cancer patients in Asia, it is not without limitations. First, our search strategy was restricted to literature in English and Chinese, which may have led to the omission of relevant studies published in other local Asian languages (e.g., Korean, Japanese, Arabic), thereby introducing language bias. Considering that significant research findings in resource-limited settings are often published in local languages, this bias may create uncertainty in our overall prevalence estimate. Second, the sample size was relatively limited, and the geographical distribution was uneven, particularly due to a lack of data from countries with less developed healthcare systems (Figure 7). This limitation may restrict the generalizability of our findings to the broader Asian context. Furthermore, the sample was primarily drawn from countries with more advanced medical infrastructure, which may have led to an overestimation of the prevalence, as these countries typically offer more extensive mental health support services. Moreover, this study did not account for breast cancer stage. Given the established link between disease severity and mental health outcomes, stage likely significantly influences depression prevalence. Additionally, due to missing data, we were unable to perform subgroup analyses based on age, income level, or education level, which limits our ability to fully explore the impact of these socioeconomic factors on depression prevalence. Future research should consider including larger, more homogeneous samples within each treatment category and explore other factors that may more profoundly influence depression outcomes, such as socioeconomic status, mental health service accessibility, and cultural differences. Furthermore, based on the relatively high prevalence of depression found in this study, it is recommended to implement routine depression screening for breast cancer patients in Asia. Priority can be given to tools already validated in Asian populations, such as the PHQ-9, HADS, or CES-D, using culturally validated cut-off values to improve the accuracy of depression identification.