BackgroundBreast cancer is the most commonly diagnosed cancer affecting Australian women, and the second largest cause of cancer death in Australian women. While the incidence of breast cancer is lower in Aboriginal women than non-Aboriginal women, the mortality rate for Aboriginal women is higher. There are a number of factors impacted by whether patient engagement and services are delivered in culturally safe manner that may contribute to this higher mortality rate.Objectives To systematically assess the evidence on whether cultural safety affects breast cancer outcomes with regards to screening, diagnosis, treatment and follow up care for Indigenous women in high income countries. Methods We conducted a systematic review in accordance with PRISMA guidelines of peer-reviewed articles in Medline, EMBASE, CINAHL, Scopus, Web of Science, Proquest Sociology and Informit Rural health database and Indigenous collection databases. Key inclusion criteria were: adult female patients with breast cancer; high income country setting; outcome measure was uptake and level of satisfaction for women, including screening, diagnosis, treatment and follow up care. We developed a Community Engagement assessment tool in consultation with aboriginal researchers, based on the National Health and Medical Research Councils’ community engagement guidelines, against which studies were appraised. Thematic analysis of all 15 studies was also undertaken. ResultsA total of 15 were selected assessment of community engagement and the final 15 studies also underwent a thematic analysis. ConclusionThe literature provides evidence-based strategies that are likely to improve outcomes for Indigenous women with breast cancer in wealthy countries and clearly indicates that culture makes a positive difference. It is also clear that strong Indigenous community leadership and governance at all stages of the research including design is an imperative for feasibility. Prospero registration number: CRD42020193019