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Background: Armenia, an Upper-Middle Income Country (UMIC) in the Southern Caucasus, has one of the world’s highest breast cancer mortality-to-incidence ratios (0.41 vs. 0.23 for peer countries), yet drivers of this excess mortality remain poorly characterized and the country lacks a National Cancer Registry. Armenia's experience reflects challenges common to post-soviet UMICs transitioning health infrastructure toward modern, equity-focused systems. No prior study has comprehensively evaluated breast cancer care across all levels of Armenia's health system. Armenia is now at a pivotal inflection point with a phased transition to Universal Health Coverage (UHC), alongside efforts to expand mobile mammography and organized screening. A pre-reform baseline is essential to evaluate whether reforms translate into earlier detection and improved outcomes, and to construct policy recommendations applicable to other UMICs undertaking similar transitions.

Methods: This mixed-methods research comprises four components: (1) a retrospective, population-level analysis of Armenia's National Institute of Health yearbook data (2010-2024) examining incidence, staging, and mortality; (2) a cross-sectional capacity assessment, culturally adapted from validated instruments (Tanzania 2017, Sergipe 2018), administered at the highest-volume tertiary/national centers and secondary facilities in Yerevan and provincial/rural regions; (3) a primary-care level survey on screening, referral, and resource availability; and (4) a translated and validated patient survey on pathways to screening, diagnosis, and treatment-seeking. Analyses used negative binomial regression, multinomial logistic regression, and non-parametric trend testing.

Results: Breast cancer incidence rose from 32 to 54 per 100,000 between 2010-2024 (APC+2.88%,p<0.001), while mortality remained stable. Stage I/II diagnoses declined 1.8 percentage points/year (p=0.049), while Stage III rose 2.4 percentage points/year (p=0.003), indicating worsening stage migration. At the four tertiary/national centers, diagnostic imaging technology (ultrasound/mammogram/CT/MRI) was universally available; only one LINAC and one PET scanner existed across sites, and no site reported a Cobalt-60 unit. All performed breast surgery and had most standard antineoplastics, radiation was available at two, immunotherapy at three, and gene profiling and BRCA1/2 testing at two. Palliative care, financial coverage, and longitudinal follow-up infrastructure remained widely deficient. 

Among four assessed secondary facilities, none provided radiation or palliative care; the provincial sites additionally lacked mammography, systemic therapy, and surgery, functioning as a referral-only node. No facility implemented organized clinical-breast-examination screening, and all reported symptomatic presentation with palpable lumps. Reported Stage III/IV presentation was 55-65%. All three secondary sites providing chemotherapy reported that patients routinely fail to initiate or complete treatment due to cost, with out-of-pocket drug payment. 

Preliminary primary-care and patient survey data highlight further disparities in screening reach, referral coordination, and awareness as contributors to delayed diagnosis.

Conclusion: Armenia possesses substantial tertiary capacity, yet absent population-based screening, geographic concentration of services in Yerevan, fragmented follow-up, and high patient financial burden prevent this capacity from translating into outcomes. These findings establish the first comprehensive pre-reform baseline for evaluating Armenia's UHC, mammography, and screening reforms, and offer a replicable framework for other UMICs where technological capacity outpaces systemic organization.