Journal of Primeasia

1 Introduction

Gastric cancer (GC) is considered to be the most frequently seen type of cancer of the digestive system globally (Venerito et al., 2018; Bilgin & Gozum, 2018). Moreover, it is one of the most prevalent forms of cancer and the third leading cause of cancer-related death (Ferlay et al., 2015; Kim et al., 2019). In a 2018 epidemiological study, more than 1,000,000 new cases and 783,000 deaths were reported globally (Bray et al., 2018; He & Cao, 2020). Although the number of newly reported cases shows a declining trend, GC remains the second most common type of cancer after lung cancer (Bilgin & Gozum, 2018). At the early stage, GC might present with characteristic symptoms including indigestion and stomach discomfort. Additionally, affected patients may struggle with a bloated feeling after eating, mild nausea, loss of appetite, and heartburn (Cao et al., 2019). Patients in the advanced stage of GC often also suffer from blood in the stool, stomach pain, inexplicable weight loss, ascites, and vomiting (Necula et al., 2019).

The psychological burden of the disease is profound, as GC also leads to psychiatric symptoms/disorders (Takahashi et al., 2008). Here, anxiety and depression are reported as the most frequently encountered problems; therefore, the mental health of affected patients should be regarded early on and during the whole course of treatment (Xu et al., 2016). There appears to be a correlation between cancer diagnosis and an increased risk for several mental disorders in patients with GC (Mitchell et al., 2011). Considering the severity of treatments and the mostly poor prognosis, patients are at high risk of developing mental comorbidities (Baudry et al., 2019). For instance, surgery as the standard curative treatment has an enormous effect on quality of life (QOL) and might result in distress (Conroy et al., 2006). Patients who underwent gastrectomy are required to follow a specific restrictive diet, and commonly report loss of stomach storage capacity, reflux, vitamin B12 deficiency, and weight loss even after successful treatment (Coburn et al., 2018). Moreover, they may also experience the burden of stigma by family or friends possibly perceiving them to be weak and less resilient (Lee & Lim, 2019). Therefore, health-related QOL should be assessed using validated questionnaires, especially as one’s QOL plays an important role as a prognostic factor (Fayers & Hays, 2005; Conroy et al., 2006).

In the context of precision medicine, genetic and biological determinants are critical for understanding behavioral responses. Several studies reported FKBP5 as a promising gene target for anxiety and treatment response (Lekman et al., 2008). Specifically, polymorphisms of the FK506 binding protein (FKBP5) are potent predictive factors for anxiety and depression after prolonged stress exposure due to treatment of GC (Kang et al., 2012). Furthermore, the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism has been explored regarding coping mechanisms, which are known to have an enormous effect on the development of psychological distress (Koh et al., 2014; Ogden, 2000). BDNF influences neuronal proliferation and is associated with neuronal plasticity in response to stressful events (Calabrese et al., 2009). The Met allele of BDNF Val66Met may play a role in less adaptive genetic disposition toward adverse experience and is associated with decreased activity-dependent secretion of BDNF compared to the Val allele (Dincheva et al., 2012; Egan et al., 2003). Consequently, met carriers might be predisposed to an anxious coping response under conditions of GC (Koh et al., 2014).

Biological markers further inform treatment decision-making and psychological monitoring. Patients with anxiety or depression were found to have a significantly higher preoperative neutrophil-lymphocyte ratio (NLR), assuming NLR is linked with preoperative mental states (Xu et al., 2016; Shimada et al., 2010). In addition, the increase of proinflammatory cytokines is linked with the development of depression (Oliveira Miranda et al., 2014). For example, alpha-2-macroglobulin (A2M) is involved in the irreversible covalent capture of proteinases and regulates cytokine activity; elevated A2M levels have been linked to postoperative depression (Borth, 1992; Fujita et al., 2003). Nutritional markers also play a role; lower serum levels of Carnosine Dipeptidase 1 (CNDP1) are associated with higher weight loss, malnutrition, and poor QOL (Arner et al., 2015). TNF-alpha might also be specifically associated with malnutrition along with worse QOL (Correia et al., 2007; Kern & Norton, 1988). Furthermore, both serum and tissue leptin-LepRb are higher in depressive than in non-depressed patients with GC, serving as a potential predictor for depression (Pan et al., 2017; Bain et al., 2016). Oxidative stress also contributes, as ROS-activated ABL1 and oxidative imbalance may influence the onset and exacerbation of depression (Wei et al., 2009; Huang et al., 2019).

Treatment methods significantly impact behavioral outcomes and QOL. Patients who had undergone subtotal gastrectomy show a higher QOL after operation than before surgery and 1-year postoperative compared to patients who had undergone total gastrectomy (Gockel et al., 2005; Davies et al., 1998; Goh et al., 2015). Another strand of studies has shown better QOL in patients after SG than TG due to reduced dumping and esophageal reflux, with better food intake and weight gain (Davies et al., 1998; Lehnert & Buhl, 2004). Regarding laparoscopic treatments, laparoscopy-assisted distal gastrectomy (LADG) not only leads to less pain and better recovery but also improves patients’ QOL compared to open operation (Kim et al., 2008; Misawa et al., 2015; Lee et al., 2012). However, some findings indicate that LADG patients experience lower QOL if their expectations do not align with the reality of recovery (Lee et al., 2012; Calman, 1984). Advanced techniques like the pouch-double tract method (PDT) after total gastrectomy and vagus nerve-preserving distal gastrectomy (VPG) have also been reported to improve postoperative QOL and nutritional status (Ikeguchi et al., 2011; Takase et al., 2003; Kim et al., 2016).

Behavioral determinants are further influenced by socio-economic and mental states. Factors such as residence area, income, and educational background play roles in QOL (Tian et al., 2004; Jeong & An, 2017; Wang et al., 2010). Moreover, individual personality traits, such as Type D personality or the tolerant type, are linked to overall survival and health-related QOL (Bartels et al., 2010; Zhang et al., 2016; Yamaoka et al., 1998). Successful adaptation after gastrectomy allows patients to manage physical symptoms and keep their regular roles (Lee & Lim, 2019; Naus et al., 2009). Patients with pre-existing psychological disorders or trauma are at higher risk for distress following diagnosis (Thomas et al., 1987; Nordin et al., 2001; Ben-Ezra et al., 2011). Finally, improved communication skills by nurses have been shown to lower psychological stress, and alternative treatments such as mistletoe extracts (Viscum album), Jinlongshe Granule, or nanomedicine (BCc1) can improve QOL in advanced cases (Fukui et al., 2008; Kim et al., 2012; Sun et al., 2015; Zhan et al., 2012; Hafizi et al., 2019). In summary, preventing psychosocial burden by improving patients’ QOL should be of high importance in the treatment regimen for gastric cancer (R Rupp & Stengel, 2021).

2 Methodology

This study adopts a systematic literature review approach to synthesize evidence on the behavioral determinants influencing treatment decision-making in precision medicine for gastric cancer. A comprehensive search of peer-reviewed literature was conducted across four primary electronic databases: PubMed, MedLine, PsycInfo, and Google Scholar. The search includes all relevant articles from the earliest available publication date to the present in order to capture the evolution of both behavioral and precision oncology perspectives. To identify studies relevant to gastric cancer, psychosocial determinants, and treatment decision-making, a structured keyword strategy was applied using combinations of predefined search terms. The search strategy included: (#1 Gastric cancer OR #2 Gastric neoplasm) combined with (#3 Quality of life, #4 “Depression, and #5 Anxiety), applied in multiple combinations (e.g., #1 AND #3, #2 AND #5). The detailed search structure is presented in Table 1.

The review framework was guided by the PRISMA scheme to ensure methodological rigor and relevance to treatment decision-making processes. The population of interest included adult patients (≥18 years) diagnosed with gastric cancer. The review focused on studies examining behavioral determinants, including psychosocial factors (e.g., anxiety, depression), genetic markers (such as FKBP5 and BDNF), and precision medicine-related interventions that influence treatment decisions and patient outcomes. Where applicable, comparisons were drawn between different treatment modalities, including surgical approaches (e.g., subtotal versus total gastrectomy), reconstruction techniques, and alternative therapeutic pathways. The primary outcomes of interest included the prevalence and magnitude of psychosocial burden, its association with treatment choices, and changes in health-related quality of life (QOL), which serve as critical proxies for decision-making behavior in clinical contexts. Eligible study designs included clinical trials, cohort studies, registry-based analyses, and population-based studies.

Inclusion criteria required studies to involve adult populations (≥18 years) diagnosed with gastric cancer, utilize empirical clinical or observational data, and be published in English or German. Studies were excluded if they were review articles, meta-analyses, or case reports; focused on pediatric populations; lacked full-text availability; included mixed cancer types without disaggregation; or represented highly specific early-phase (Phase I/II) drug trials with limited applicability to broader decision-making contexts.

The study selection process followed a structured screening approach. Titles and abstracts were initially reviewed to identify potentially eligible studies, followed by full-text assessment to confirm inclusion. Data were extracted using a standardized framework capturing key variables such as author, year, country, sample size, study objectives, methodological design, and principal findings related to behavioral determinants and treatment decision-making.

Quality assessment was conducted by critically evaluating study design, sampling approaches, and methodological robustness. Particular attention was given to common sources of bias in psychosocial and behavioral research. These included response bias associated with self-reported measures of quality of life and mental health, selection bias arising from non-random participant inclusion, and recall bias among patients reporting past experiences of treatment and psychological distress. Additionally, the review acknowledges heterogeneity across studies, particularly due to the use of diverse instruments for assessing QOL and mental health outcomes, which may limit direct comparability. These limitations were considered during the synthesis and interpretation of findings to ensure a balanced and context-sensitive analysis.

3 Results

3.1 Study Selection and Characteristics

The systematic literature search identified a total of 25,490 records across the four selected databases. After removing 5,425 duplicate entries, 20,065 unique records remained for title and abstract screening. At this stage, 19,720 records were excluded due to irrelevance to the review objective, involvement of pediatric populations, or a focus on highly specific early-phase clinical trials. The full texts of 345 articles were subsequently assessed for eligibility. Among these, 280 studies were excluded for failing to meet the inclusion criteria, which included factors such as inappropriate study populations, insufficient relevance of outcomes, unsuitable study designs, or a lack of extractable data. In the end, 65 non-duplicated studies were included in the final synthesis.

The included studies comprised a mix of clinical trials, cohort studies, registry-based analyses, and population-based studies, reflecting methodological diversity. Most studies were conducted in Asia and Europe, with limited representation from low-income settings, highlighting a contextual evidence gap relevant to Bangladesh. Moreover, a wide range of validated psychometric instruments were employed. The most frequently used tools included the EORTC QLQ-C30 for assessing health-related quality of life and the Hospital Anxiety and Depression Scale (HADS) for measuring psychological distress. However, variability in measurement tools contributed to heterogeneity across findings.

3.2 Classification of Behavioral Determinants

A total of 35 influencing factors affecting psychosocial burden and treatment decision-making were identified and categorized into nine thematic domains. These are:

(1) genetic condition, (2) treatment method, (3) blood markers, (4) nutritional status, (5) daily living, (6) state of health, (7) mental state, (8) supportive care, and (9) alternative treatment.

For analytical clarity and alignment with treatment decision-making behavior, these domains were synthesized into broader behavioral determinant clusters:

• Biological and genetic determinants
• Treatment-related determinants
• Psychosocial and behavioral determinants
• Socioeconomic and contextual determinants
• Health system and supportive care determinants

3.3 Biological and Genetic Determinants in Behavioral Outcomes

Biological determinants play a significant role in shaping behavioral responses and treatment decision-making within precision medicine frameworks. Genetic variations, particularly FKBP5 polymorphisms, were identified as strong predictors of anxiety and depression following prolonged treatment-related stress. These genetic factors influence the hypothalamic–pituitary–adrenal (HPA) axis, thereby affecting individual stress responsiveness.

Similarly, the BDNF Val66Met polymorphism was found to be associated with coping mechanisms. Individuals carrying the Met allele demonstrated increased vulnerability to anxiety and maladaptive coping responses, indicating a biological predisposition influencing behavioral adaptation during cancer treatment.

In addition to genetic markers, several blood-based biomarkers were linked to psychological conditions. Elevated neutrophil-to-lymphocyte ratio (NLR) was associated with preoperative anxiety and depression, suggesting that systemic inflammation plays a role in mental health outcomes. Increased levels of alpha-2-macroglobulin (A2M) were linked to postoperative depression, particularly among patients undergoing total gastrectomy. Further evidence indicates that leptin-LepRb expression, proinflammatory cytokines (e.g., TNF-alpha), and oxidative stress pathways (e.g., ROS-ABL1 signaling) are associated with depressive symptoms. These findings demonstrate that behavioral determinants are closely intertwined with biological processes, reinforcing the relevance of precision medicine in understanding patient decision-making.

Table 1. Search Strategy of the Study

Table 2. Key Findings of Behavioral Determinants in Precision Medicine for Gastric Cancer

3.4 Treatment-Related Determinants and Quality of Life

Treatment modalities emerged as key determinants influencing both quality of life and treatment decision-making. Surgical approach, in particular, has a profound impact on postoperative outcomes. Patients undergoing subtotal gastrectomy (SG) consistently reported better quality of life compared to those undergoing total gastrectomy (TG). Improved outcomes included reduced gastrointestinal symptoms, better nutritional status, and enhanced functional capacity. In contrast, total gastrectomy was associated with greater weight loss, reflux, and long-term dietary restrictions, which negatively influenced patient perceptions of treatment.

Advancements in surgical techniques further influenced behavioral outcomes. Laparoscopy-assisted distal gastrectomy (LADG) was associated with reduced pain, faster recovery, and improved functional outcomes compared to open surgery. However, discrepancies between patient expectations and actual recovery experiences were found to negatively affect perceived quality of life, highlighting the role of expectation management in decision-making. Innovative techniques such as vagus nerve-preserving gastrectomy (VPG) and the pouch-double tract method (PDT) demonstrated improved nutritional outcomes and reduced postoperative complications. These findings indicate that treatment choices are not solely clinical decisions but are strongly influenced by anticipated quality of life outcomes.

3.5 Psychosocial and Behavioral Determinants

Psychological and behavioral factors were identified as central determinants of treatment decision-making. High prevalence rates of anxiety and depression were observed across studies, significantly affecting patient engagement, adherence, and overall well-being. Personality traits and coping mechanisms further influence behavioral responses. The Type D personality was consistently associated with poorer quality of life and increased psychological distress. In contrast, higher levels of emotional competence were linked to better coping ability and reduced anxiety and depression.

Patients’ ability to adapt to their diagnosis and treatment conditions also played a critical role. Successful adaptation was associated with improved management of physical symptoms and maintenance of social roles. Conversely, patients with prior psychological trauma or mental health conditions were more vulnerable to distress and negative treatment perceptions. Daily living challenges, including disruptions in work, social participation, and physical functioning, further contributed to psychosocial burden and influenced treatment preferences.

3.6 Socioeconomic and Contextual Determinants

Socioeconomic factors significantly influenced both quality of life and treatment decision-making. Patients residing in rural areas, as well as those with lower income and educational levels, consistently reported worse physical and psychological outcomes. Income level influenced access to treatment and supportive care, while educational status affected understanding of disease and treatment options. Nutritional status also emerged as a critical determinant, with better nutrition positively associated with improved quality of life and recovery outcomes. These findings are particularly relevant for Bangladesh, where disparities in healthcare access and socioeconomic conditions are pronounced. The interaction between economic constraints and behavioral responses is likely to play a dominant role in shaping treatment decisions.

3.7 Health System and Supportive Care Determinants

Health system factors, particularly communication and supportive care, were found to significantly influence psychological outcomes and decision-making processes. Effective communication by healthcare providers, especially nurses, reduced psychological distress and improved patient satisfaction. Unmet needs related to information, emotional support, and healthcare access were identified as major contributors to reduced quality of life. Patients who received structured education and counseling demonstrated better coping strategies and higher engagement in treatment decisions.

3.8 Role of Alternative and Adjunct Treatments

Several studies reported positive effects of alternative and adjunct therapies on quality of life and psychological well-being. Treatments such as mistletoe extracts (Viscum album), Jinlongshe Granule, and BCc1 nanomedicine were associated with improvements in emotional function, symptom management, and overall survival in advanced gastric cancer. While these interventions are not part of standard precision medicine protocols, they influence patient perceptions of treatment effectiveness and may shape decision-making behavior, particularly in contexts where conventional treatment options are limited or financially inaccessible.

3.9 Synthesis: Behavioral Determinants Model (Bangladesh Relevance)

The findings indicate that treatment decision-making in gastric cancer is shaped by a multidimensional interaction of biological, psychological, socioeconomic, and health system factors. These determinants operate dynamically, influencing patient perceptions, preferences, and behavioral responses. In the context of Bangladesh, where healthcare access is constrained and socio-cultural influences are strong, these behavioral determinants are likely to have an amplified effect. Financial barriers, family-centered decision-making, and limited access to precision medicine technologies further reinforce the importance of behavioral factors in shaping treatment pathways.

Existing infrastructure

The relevance of the behavioral determinant model in Bangladesh becomes clearer when patient decision making is read alongside the country’s present cancer care capacity. Bangladesh had an estimated 167,256 new cancer cases and 116,598 cancer deaths in 2022, and stomach cancer accounted for 8,365 new cases and 7,359 deaths, which makes treatment choice and continuity of care highly relevant in this setting (International Agency for Research on Cancer [IARC], 2024). At the service delivery level, cancer care remains centered in Dhaka, especially through the National Institute of Cancer Research and Hospital (NICRH), which provides surgery, chemotherapy, radiotherapy, palliative care, telemedicine, and hospital-based registry functions. NICRH also reports a relatively broad institutional base, including more than 160 doctors, 23 departments, and facilities such as a linear accelerator and contouring laboratory services (NICRH, 2026). In addition, molecular capacity is beginning to emerge, as shown by the launch of next-generation sequencing-based cancer diagnostics at icddr,b in 2025 (icddr,b, 2025).

Challenges and barriers

Despite this growing infrastructure, behavioral determinants are likely to carry greater weight in Bangladesh because treatment decisions are filtered through cost, distance, limited literacy, and family dependence. Cancer care is still concentrated in major urban centers, and the country does not yet have a unified national cancer registry, which weakens coordinated planning, referral pathways, and outcome tracking (Islam et al., 2025). Financial hardship is another major barrier. Evidence from Bangladesh shows that the average annual out-of-pocket cost for cancer care was about US$6,504, and 90% of affected households reported financial distress (Sarker et al., 2025). This burden is reinforced by the broader financing structure of the health system, where out-of-pocket expenditure remains a dominant share of current health expenditure in Bangladesh (World Bank, 2025). In practical terms, these structural constraints can intensify fear of treatment burden, hesitation about expensive interventions, and preference for delayed or simplified care, even when clinically beneficial options exist.

Ideal roadmap for Bangladesh

An ideal roadmap for Bangladesh should connect behavioral determinants with phased health system reform. First, behavioral screening, counseling, and shared decision support should be incorporated into routine oncology care, especially for high-burden cancers. Second, pathology and molecular testing should expand beyond Dhaka through referral-linked hub and spoke arrangements. Third, financial protection for diagnosis, surgery, medicines, and follow-up should be strengthened to reduce treatment refusal and discontinuation. Fourth, a national cancer registry should be established to improve planning, referral coordination, and monitoring of outcomes (Islam et al., 2025). Finally, workforce development in oncology nursing, psycho oncology, pathology, and patient communication should be treated as a core requirement for equitable precision medicine rather than an additional service layer.

4 Discussion

This review synthesizes global evidence on behavioral determinants influencing treatment decision-making in precision medicine for gastric cancer and contextualizes these findings within the healthcare realities of Bangladesh. The findings demonstrate that treatment decisions are not solely driven by clinical or biological considerations but are shaped by a complex interaction of behavioral, psychosocial, socioeconomic, and health system factors. A key contribution of this review is the identification of multi-level determinants that collectively influence patient behavior. These determinants operate across biological, individual, and structural dimensions, reinforcing the notion that precision medicine must extend beyond molecular targeting to incorporate behavioral and contextual realities. Consistent with prior systematic evidence, the interplay between psychological distress, treatment burden, and quality of life emerges as central to decision-making processes.

4.1 Integration of Behavioral and Biological Determinants in Decision-Making

The findings highlight a critical intersection between biological mechanisms and behavioral responses. Genetic polymorphisms such as FKBP5 and BDNF Val66Met influence stress reactivity, coping capacity, and vulnerability to anxiety and depression. These biological predispositions shape how patients perceive treatment risks and benefits, thereby influencing decision-making pathways. Similarly, biomarkers such as NLR, A2M, and inflammatory cytokines are associated with psychological distress, suggesting that physiological and emotional states are deeply interconnected. This reinforces the importance of integrating psychosocial assessment into precision oncology frameworks. In the context of Bangladesh, where access to genetic testing remains limited, these biological-behavioral interactions are often unrecognized, potentially leading to suboptimal treatment engagement.

4.2 Psychosocial Determinants and Behavioral Responses

Psychological distress, particularly anxiety and depression, plays a decisive role in shaping treatment decisions. Patients experiencing higher levels of distress are more likely to delay treatment, disengage from care, or make decisions based on fear rather than clinical evidence. Personality traits, such as Type D personality, further exacerbate vulnerability to poor quality of life and adverse outcomes. Coping mechanisms and emotional competence emerge as protective factors. Patients with stronger adaptive capacities demonstrate better engagement with treatment and improved outcomes. These findings underscore the importance of integrating mental health services into cancer care, particularly in resource-constrained settings like Bangladesh, where psycho-oncology services are limited.

4.3 Socioeconomic Inequalities and Structural Constraints

Socioeconomic disparities significantly shape treatment decision-making. Evidence indicates that patients from rural areas and lower socioeconomic backgrounds experience poorer quality of life and higher psychological burden. These disparities are particularly relevant for Bangladesh, where healthcare access is uneven and out-of-pocket expenditure is high. Moreover, economic constraints often force patients to prioritize affordability over optimal treatment options, limiting access to precision medicine interventions. Educational disparities further influence health literacy, affecting patients’ ability to understand complex treatment pathways. These findings highlight that treatment decisions in Bangladesh are often constrained by structural limitations rather than individual preferences.

4.4 Treatment Experience, Expectations, and Quality of Life

Treatment-related factors, particularly surgical interventions, significantly influence behavioral responses. Patients undergoing fewer invasive procedures generally report better quality of life, which positively reinforces treatment adherence. However, discrepancies between patient expectations and actual recovery experiences can negatively affect perceived outcomes and future decision-making. This expectation-reality gap is particularly important in Bangladesh, where limited patient counseling and information dissemination may lead to unrealistic expectations. Improving pre-treatment communication and expectation management is therefore essential to enhance patient satisfaction and engagement.

4.5 Role of Health System and Supportive Care

Health system factors, including provider-patient communication and supportive care, play a crucial role in shaping behavioral outcomes. Effective communication has been shown to reduce psychological distress and improve treatment satisfaction. Conversely, unmet informational and emotional needs contribute to uncertainty and poor decision-making. In Bangladesh, systemic challenges such as limited oncology infrastructure, fragmented referral systems, and insufficient counseling services further complicate treatment pathways. Strengthening communication strategies and integrating patient-centered care models are therefore critical for improving decision-making processes.

4.6 Relevance of Global Evidence to Bangladesh: Contextual Interpretation

The sources provided focus on a systematic review of international studies and do not contain specific data or studies conducted in Bangladesh. However, the behavioral determinants identified, such as socio-economic disparities (rural vs. urban), genetic markers, and nutritional status, provide a critical non-Bangladesh context that can be directly applied to the clinical and behavioral landscape of precision medicine for gastric cancer in Bangladesh.

Following the analytical framework of this review, Table 2 summarizes the key behavioral determinants that are most relevant to the Bangladeshi healthcare setting.

4.7 Implications for Precision Medicine in Bangladesh

The integration of behavioral determinants into precision medicine is essential for improving treatment outcomes in Bangladesh. While precision oncology emphasizes genetic and molecular profiling, this review demonstrates that behavioral and contextual factors are equally critical in determining treatment pathways.

For Bangladesh, this implies:

• The need to integrate behavioral assessment into clinical decision-making
• Strengthening patient counseling and communication systems
• Addressing financial barriers to treatment access
• Promoting equitable access to diagnostic and treatment technologies

Without addressing these behavioral and structural dimensions, the benefits of precision medicine are unlikely to be fully realized in low-resource settings.

4.8 Limitations and Future Research Directions

This review provides a comprehensive synthesis of behavioral determinants influencing treatment decision-making, integrating biological, psychological, and socioeconomic perspectives. However, several limitations should be acknowledged. First, the absence of primary studies from Bangladesh limits the ability to draw context-specific conclusions. Second, heterogeneity in study designs and measurement tools reduces comparability across studies. Third, potential biases, including response bias and selection bias, may affect the interpretation of findings. Despite these limitations, the review provides a robust conceptual foundation for understanding treatment decision-making in gastric cancer within LMIC contexts.

Future research should focus on generating empirical evidence from Bangladesh to validate and expand upon the findings of this review. Mixed-method studies exploring behavioral, cultural, and economic determinants are particularly needed. Additionally, research integrating genomic data with behavioral insights would provide a more comprehensive understanding of precision medicine in low-resource settings. The development of decision-support tools and digital health interventions may further enhance patient-centered care.

5 Conclusion

This review demonstrates that treatment decision-making in precision medicine for gastric cancer is shaped by a complex and dynamic interaction of behavioral, biological, and structural determinants. While precision oncology traditionally emphasizes genetic and molecular profiling, the findings clearly indicate that psychological conditions, socioeconomic realities, treatment experiences, and health system factors play equally critical roles in influencing patient choices and treatment pathways. The synthesis of global evidence reveals that mental health status, coping capacity, and personality traits significantly affect treatment engagement and adherence. At the same time, biological markers such as FKBP5, BDNF, and inflammatory indicators highlight the interconnected nature of physiological and behavioral responses. Treatment modalities and their impact on quality of life also influence patient perceptions and treatment-related decisions, underscoring the importance of patient-centered care approaches.

In the context of Bangladesh, these determinants are amplified by structural constraints, including high out-of-pocket healthcare expenditure, limited access to precision diagnostic technologies, and strong socio-cultural influences on decision-making. Family-centered decision processes, disparities between rural and urban populations, and gaps in healthcare communication systems further complicate treatment pathways. As a result, treatment decisions are often driven not only by clinical considerations but also by financial feasibility, social norms, and perceived quality of life. These findings underscore the need to move beyond a purely biomedical model of precision medicine toward an integrated framework that incorporates behavioral and contextual dimensions. For Bangladesh and similar low- and middle-income settings, this requires strengthening patient counseling, integrating psychosocial support into oncology care, improving provider–patient communication, and ensuring more equitable access to diagnostic and treatment services.

Author Contributions

M.N.I. Conceptualization, methodological supervision, interpretation of findings, and critical revision of the manuscript for important intellectual content. S.S. Conceptualization, literature search, study screening, data extraction, data synthesis, original draft preparation, manuscript organization, and corresponding author responsibilities. D.B. Literature screening, data extraction, review of treatment-related and pharmacological evidence, preparation of summary findings, and manuscript review. M.H. Public health interpretation, contextualization of findings within the Bangladesh health system, review of health system barriers and policy implications, and manuscript editing. All authors contributed to the development of the manuscript, reviewed and approved the final version, and agreed to be accountable for the accuracy and integrity of the work.

Competing Financial Interests

The authors M.N.I. et al., declare that they have no competing interests.

References