Study selection
Based on the search strategy in the data bases, a total of 1081 studies were retrieved initially. About 754 studies were remained after 327 duplicate studies were removed. 737 studies were excluded due to unrelated title and abstracts. Then, the remaining 17 studies were evaluated based on the eligibility criteria for inclusion and exclusion. Finally, ten studies met the eligibility criteria and included for final review and meta-analysis (Fig 1).
Study characteristics
A total of 10 articles which reported QOL of 2,190 breast cancer patients were analyzed. The mean age of patients was 46.97 years. From ten included articles, eight articles were cross-sectional studies and the remaining two articles were prospective observational studies. All included studies were done in Hospitals. The studies were conducted on five countries (four from Ethiopia; two from Egypt; two from Nigeria; one from Kenya and one from Morocco). The included studies collected the data through interview. To measure health related quality of life of breast cancer patients, studies were used EORTC QLQ-C30, EORTC QLQ-BR23, FACT B, FACT G and WHOQOL-BR23 questionnaires (Table 1).
Methodological quality
Based on the 14 quality assessment criteria, eight studies had high quality (attained a score of 10 or higher) whereas the remaining two studies had moderate quality (attained a score of 9). Most of (about 90%) the studies didn’t compared two groups. All of the included studies lacked information on the characteristics of non-respondents (Table 2).
Quality of life based on EORTC QLQ-C30 standard tool
Seven studies reported QOL in breast cancer patients based on EORTC QLQ-C30 questionnaires. Based on this standard tool, the pooled estimate of the mean score of GQOL was 52.77(95% CI: 42.199 to 63.345; I2=99.21%, P < 0.001) (Fig 2).
Subgroup analysis was performed based on country. The analysis showed that highest GQOL was observed in Kenya 65.48 (95% CI: 62.209 to 68.751) whereas lowest GQOL was observed in Egypt 28.38 (95% CI: 26.631 to 30.129) (Fig 3).
A leave- one-out meta-analysis was performed to show how each individual study affects the pooled estimate of the remaining studies. From the analysis, there was no change in the pooled estimate mean GQOL of breast cancer patients. There was no single study that substantially influenced the overall effect size. The pooled estimates mean GQOL was between the confidence interval of the pooled mean GQOL when one study was leaving out (Fig 4).
Functional scores in breast cancer patients based on EORTC QLQ-C30 standard tool
Six included studies reported five domains (cognitive, emotional, role, physical and social domains). The pooled score of social domain was scored highest than other domains with a mean of 72.91(95% CI: 62.14, 83.68) whereas role domain scored lowest with a mean of 56.64(95%CI: 36.42, 76.86) (table 3). In one study, QOL was dichotomized into poor and good QOL. This study showed that majority of breast cancer patients had poor emotional functioning (mean=47.61±25.83) whereas cognitive functioning was good (mean=80.06 ± 22.89) (Table 3)
Breast cancer-specific symptoms scores based on EORTC QLQ-C30
Six studies reported breast cancer specific symptoms. Based on EORTC QLQ-C30, the pooled estimate score showed that financial difficulties (mean 68.86 with 95% CI: 56.51, 81.21) and fatigue (mean 44.33with 95% CI: 32.75, 55.91) were the most cancer specific symptoms. Diarrhea (mean 14.75 with 95% CI: 6.55, 22.96) and nausea/vomiting (mean 18.81with 95% CI: (9.83, 27.79) were the least breast cancer specific symptoms (Table 4).
In one study, QOL was dichotomized into poor and good QOL. This study showed that about 79.2% of breast cancer patients faced financial difficulties whereas nausea/vomiting was least affected symptom scales of 26.6 (66%).
Breast cancer-specific functional and symptom scores based on EORTC QLQ-BR23
Five studies reported cancer specific functional and symptoms based on EORTC QLQ-BR23. The pooled estimate score of body image and future perspective were highest whereas breast and arm symptoms were lowest (Table 5). In one study, QOL was dichotomized into poor and good QOL. This study showed that about 79.2% of breast cancer patients faced financial difficulties whereas nausea/vomiting was least affected symptom scales (266 (66%)). Future perspective was less affected (mean ±SD=55±38.48) whereas sexual functioning (mean ±SD=89±21.10) was the most affected functional scale. Breast symptom (663(90.1% of participants)) was the most unbearable symptom whereas body image was the least affected (16.6% of participants)
QOL based on WHOQOL-BREF breast cancer-specific-BR23 and FACT G/FACT B
One study assessed the QOL of breast cancer patients based on WHOQOL-BR23. In this study, environmental domain (mean ± SD=93.31±19.76) was the highest mean score observed whereas social domain (mean ±SD=36.69±7.62) was the least.
Another study assessed the QOL of breast cancer patients based on fact g/fact b standard tool. In this tool QOL ranges from zero to 144. The total score of the five domains were 144 with a mean of 74.59 ± 17.72 whereas breast cancer specific symptoms were 36 with a mean of 21.10 ± 8.93.
The study which assessed QOL based on FACT-B standard tool showed that the physical domain (mean ± SD=2.22±1.1) was the most affected QOL in breast cancer patients whereas functional domain was the least.
Meta regression
To detect the source of heterogeneity Meta regression analysis was conducted. Patients mean age wasn’t significant coefficients =-2.008 (95% CI: -5.120 to 1.103; P value =0.206. Sample size was also insignificant coefficients =-0.006 (95% CI: -0.065 to 0.053; P value = 0.840. This indicated mean age and sample size did not contribute for heterogeneity.
Determinants of HRQOL of breast cancer patients in Africa
There are different factors that are associated with HRQOL in breast cancer patients (Table 6)