Abstract
Background: Immediate breast reconstruction (IBR) contributes to comprehensive breast cancer care. Rural patients often face barriers to healthcare access and worse health outcomes versus urban counterparts. We sought to (1) compare rates of IBR among rural and urban residents; (2) identify sociodemographic and economic factors associated with breast reconstruction rates. Methods: In this systematic review and meta-analysis, MEDLINE, Embase, Web of Science, and CENTRAL were searched from inception to May 15, 2025, for studies comparing IBR rates among rural versus urban individuals globally. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies - of Exposures tool. The primary outcome was the literature-pooled odds ratio (OR) of rural patients receiving IBR versus urban patients, evaluated with a random-effects meta-analysis, followed by sensitivity and leave-one-out analyses. Univariate meta-regression was conducted to explore whether mean age, socioeconomic status (SES), and data collection year explain heterogeneity and rural-urban IBR disparities. Results: Fifteen studies were included, encompassing 46 986 rural and 1 833 906 urban mastectomy patients. Rural patients were significantly less likely to undergo IBR (OR 0.67; 95% confidence interval [0.57-0.79], I (2) = 97%). There was no temporal trend suggesting changes in geographic disparities in IBR rates. Mean age, SES, and midpoint data collection year did not significantly explain heterogeneity nor rural-urban IBR disparities. Conclusions: Rural patients were approximately 33% less likely to receive IBR versus urban patients. However, considerable heterogeneity suggested the need for research on moderators to explain this association and inform strategies to promote equitable IBR access, including ride-share programs and increased plastic surgeon density in rural communities.