Mulugeta et al.

Archives of Public Health (2025) 83:30 Archives of Public Health

https://doi.org/10.1186/s13690-025-01514-6

RESEARCH Open Access

Predictors of survival rates among breast

cancer patients in Ethiopia: a systematic
review and meta-analysis 2024
Chalie Mulugeta1* , Tadele Emagneneh1, Getinet Kumie2, Assefa Sisay2, Nigusie Abebaw3, Mulat Ayele1 and
Abebaw Alamrew1

Abstract
Introduction Breast cancer remains the most common cancer and a leading cause of cancer-related deaths among
women worldwide. In Ethiopia, the survival rate of breast cancer patients is influenced by various socio-demographic,
clinical, and health system factors. This systematic review and meta-analysis aimed to identify and synthesize the
predictors of survival rates among breast cancer patients in Ethiopia.
Methods We conducted a systematic review of observational cohort studies. The literature search was performed
between August 1 and 30, 2024, using PubMed, Hinari, EMBASE, Google, Google Scholar, and Web of Science. The
Newcastle Ottawa 2016 Critical Appraisal Checklist assessed methodological quality. Publication bias was evaluated
using a funnel plot and Egger’s test, and heterogeneity was examined with the I-squared test. Data were extracted
with Microsoft Excel and analyzed using Stata 11.
Results A total of 15 articles with 6,375 study participants from six regions were included. We found that significant
predictors of decreased survival rate among breast cancer patients were age (aHR 1.05, 95% CI 1.02–1.08), illiteracy
(aHR 7.34, 95% CI 4.38–10.3), married (aHR 1.21, 95% CI 1.03–1.40), rural residence (aHR 1.71, 95% CI 1.06–2.36), two
or more lymph node involvement (aHR 3.57, 95% CI 1.02–6.13), histological grade two or more (aHR 1.44, 95% CI
1.12–2.77), overweight (aHR 0.56, 95% CI 0.24–0.87), and having comorbidity (aHR 1.86, 95% CI 1.04–2.68).
Conclusion This systematic review and meta-analysis identified several key predictors of reduced survival rates
among breast cancer patients in Ethiopia, including older age, illiteracy, rural residence, involvement of two or
more lymph nodes, higher histological grade, marital status, and the presence of comorbidities. Interestingly, being
overweight was associated with improved survival. Health stakeholders and policymakers emphasizing public health
education, managing comorbidities, and expanding access to early detection and treatment, especially in rural areas,
are critical.
Keywords Survival rate, Breast cancer, Predictors, Survival time, Ethiopia

2
*Correspondence: Department Of Medical Laboratory Science, College of Health Science,
Chalie Mulugeta Woldia University, Woldia City, Ethiopia
3
[email protected] Department of Midwifery, College of Medicine and Health Science,
1
Department of Midwifery, College of Health Science, Woldia University, Wollo University, Wollo, Ethiopia
Woldia City, Ethiopia

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Mulugeta et al. Archives of Public Health (2025) 83:30 Page 2 of 19

pooled 1-year survival rate of patients with breast can-

Text box 1. Contributions to the literature cer was 0.79; 2-year survival rate was 0.70, 3-year sur-
• This study is the first systematic review and meta-analysis to synthesize vival rate0.56, 4-year survival rate was 0.54, and 5-year
predictors of breast cancer survival in Ethiopia, addressing a significant survival rate was 0.40 [15]. Previous Systematic Review
gap in public health research in low-resource settings. and meta-analysis revealed that age [14, 16], stage of dis-
• It provides evidence on how socio-demographic, clinical, and health ease [14, 16, 17], lymph node involvement [14, 17] size
system factors influence survival rates, offering critical insights for
designing targeted interventions in similar contexts.
of the tumor [14], high level of education [18], high level
• This research underscores the importance of equitable healthcare ac- of income [18], high level of socioeconomic status [18],
cess, particularly for rural and underprivileged populations, to improve positive progesterone receptor [19] and positive estrogen
breast cancer outcomes in Ethiopia and comparable regions. receptor [19] were predictors of survival rate of breast
cancer patient.
Introduction Previous primary studies done around the globe iden-
In 2020 there was an anticipated 19.3 million new cases tified overweight [20–22], married [23], higher level of
of cancer worldwide and over 10.0 million cancer-related education [23], lymph node involvement [24–26], tumor
deaths. The most prevalent cancer to be diagnosed in size [24, 26–28], stage of breast cancer [27, 29], hormone
women is breast cancer, which has overtaken lung cancer. therapy [21], comorbidities [30], distant metastasis [29,
Colon, prostate, and stomach cancers are the next most 30], lower socioeconomic status [24, 31], negative estro-
common malignancies [1]. Globally, 2.3 million women gen receptor [24], smoking [22], negative progesterone
received a breast cancer diagnosis in 2022, and 670,000 receptor [25], family history of breast cancer [32], and
people died from the disease [2]. While breast cancer age [26, 32, 33] were factors that influence the survival
mortality is highest in less developed nations, the dis- rate of breast cancer patients.
ease’s incidence is higher in more developed country [3]. Cancer accounts for 5.8% of all deaths in Ethiopia,
Sub-Saharan Africa as a whole is facing a growing cancer- with 60,000 new cases diagnosed and over 44,000 deaths
related public health burden. Currently, 4% of Ethiopian annually, the most prevalent being breast cancer (30.2%),
mortalities are related to cancer [4]. In Africa, women die cervical cancer (13.4%), and colorectal cancer (5.7%)
from breast cancer at a rate of 20% and account for 28% [34]. Research done in Ethiopia revealed that breast can-
of all cancer cases [5]. cer was the second leading neoplasm, responsible for 21
The World Health Organization (WHO) launched the (2.7%) of all deaths (95% CI 1.5–3.7%), and was among
Global Breast Cancer Initiative (GBCI) in 2021 to reduce the top five causes of non-communicable deaths [35]. The
mortality rates by 2.5% per year to 2040 through three estimated 1- and 2-year overall survival probability rates
key pillars of action on health promotion for early detec- in the rural part of Ethiopia were 78 and 53%, respec-
tion, timely diagnosis; and comprehensive breast cancer tively [36]. The majority of the cancer burden occurs in
management [6]. A systematic review and meta-analysis low- and middle-income countries where cancer has a
revealed that the average duration between recognizing profound social and economic effect on communities
symptoms and presenting them to a medical professional because of the limited access to care [37].
was less than 4 months in North Africa and between 3 WHO urges significant investments involving a broad
and 6 months in sub-Saharan Africa [7]. range of partners in comprehensive cancer control are
Evidence showed that the effects of delay on prognosis required and crucial to improving the quality of life of
have generally demonstrated that longer delays are linked vulnerable communities while at the same time strength-
to malignancies that are diagnosed at an advanced stage, ening national health systems [38]. There was previous
which lowers the likelihood of survival [8–10]. Longer primary research conducted in Ethiopia to determine the
patient delays were linked to bigger tumor sizes, positive survival rate and its predictors of breast cancer patients;
nodes, and a 24% death rate compared to shorter patient however, findings from those studies varied across
delays [11]. Longer delays were associated with lower regions. To the best of our knowledge, this topic has not
survival rates for women, both from the date of diagnosis yet been investigated by systematic review and meta-
and from the beginning of symptoms [12]. Evidence sug- analysis at the national level. In particular, this study
gests that breast cancer mortality rates are decreasing in covered a wider geographical area and provided pooled
most high-income countries, despite increasing or stable results. This information is necessary for policy planners
incidence rates [13]. and program managers to identify gaps in the predictors
A meta-analysis done in Iraq revealed that the one- of survival rate among breast cancer patients and to plan
year, three-year, five-year, and ten-year survival rates of strategies to increase the survival time of breast cancer
breast cancer were estimated to be 95.8%, 82.4%, 69.5%, patients. Early identification and prompt treatment of
and 58.1%, respectively [14]. A systematic review and breast cancer are crucial for improving maternal health.
meta-analysis done in sub-Saharan African countries the Thus, the goal of this study was to assess predictors of
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 3 of 19

survival rates among breast cancer patients in Ethiopia. also excluded studies focusing on specific factors and
The literature search was conducted over one month, frequency with descriptive studies. Since there was no
from August 1 to 30, 2024, to identify relevant studies. concrete data to take from this research, they were elimi-
nated (Table 1).
Methods and materials
Study protocol and reporting Operational definition
This systematic review and meta-analysis was carried out Survival time: The duration a patient remains free from
per the Preferred Reporting Items for Systematic Reviews the outcome following their diagnosis [41–43]. Individu-
and Meta-Analyses (PRISMA) criteria [39] (supplemen- als who were lost to follow-up, still alive, or transferred
tary S1 file ). The eligibility criteria were adapted from the out by the end of the study period were considered cen-
Newcastle Ottawa 2016 review guidelines [40]. We used sored [44].
Endnote (version X7) reference management software The place of residence was classified as rural or urban
to download, organize, and review and Zotero to cite and educational status was classified as literate and illiter-
related articles. ate, comorbidities were categorized as yes or not having
comorbidities, having a family history of breast cancer
Inclusion criteria was categorized as having a history of breast cancer or
We searched our studies on human studies published in not, tumor size is grouped into < 5 cm or = > 5 cm. Mari-
English language. Participants were all quantitative stud- tal status is grouped into married or not married. Age is
ies with variables or indicators indicating predictor of a continuous variable and is expressed in a unit. About
survival rate among breast cancer patients were included histological grade of breast cancer was grouped into < 2
in the systematic review and meta -analysis. or = > 2. Lymph node involvement is grouped as < 2 or
The review considered all observational cohort stud- = > 2 lymph involved. Lymph nodal status was grouped
ies written in English, and conducted in Ethiopia. We into positive or negative. Weight of patients classified as
searched literatures included for the review for one- underweight or overweight. Treatment taken is grouped
month duration August 1 to 30, 2024.All published arti- into combined chemotherapy taken or single treatment
cles were included in the form of journal articles without taken.
time limit. Results of interest: The main investigations
revealed predictor of survival rate among breast cancer Search strategy
patients. A systematic search of peer-reviewed, published lit-
erature in English was conducted to identify the factors
Exclusion criteria contributing to the survival rate among breast cancer
Excluded from the study were anonymous reports, dupli- patients in Ethiopia (supplementary S2 file). We looked
cate research, articles lacking an abstract or full text, through the databases at PubMed, Hinari, EMBASE,
and qualitative investigations. We excluded systematic Google, Google Scholar, and Web Science to find per-
reviews, case reports, and retrospective reviews. We tinent research. To find pertinent key phrases, we first
searched by article title in PubMed, Google, and Google
Table 1 Inclusion and exclusion criteria predictor of survival rate Scholar. Secondly, we discovered related ideal key-
among breast cancer patients in Ethiopia: systematic review and words. Third, we conducted a second search using these
meta -analysis 2024 phrases in the databases after looking for more research
Study Inclusion criteria Exclusion criteria in the reference lists of all the recognized papers and
characteristics publications. Terms like “breast cancer,” “associated fac-
Design observational stud- Clinical trials, qualitative tors,” “predictors,” “determinants,” “contributing fac-
ies cohort studies studies, editorial letters, case
reports/series
tors,” “survival time,” “survival rate,” “survival analysis,”
Population Breast cancer Studies not involving the tar- “determinant of breast cancer mortality,” “survival time
patients get population or focused on of breast cancer patient,” “survival analysis of breast can-
different health conditions cer patient,” “survival rate of a breast cancer patient,”
Condition Predictors of survival Unclear to articles with the “Ethiopia,“. We experimented and improved utilizing
rate among breast outcome variable of breast several test searches, combining related search phrases
cancer patients cancer patient, articles only
with Boolean operators like OR and combining distinct
reviews and descriptive
static’s notions using the Boolean operator AND.
Context Studies conducted Studies outside Ethiopia
in Ethiopia Data extraction
Language Articles published in Articles published in other The data was extracted using Microsoft Excel. Two dis-
English languages tinct data extraction formats were utilized to collect the
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 4 of 19

information needed for analysis. In the extraction form, screening. 100 articles were further excluded for vari-
we included the author’s last name, the year the work ous reasons, leaving only 50 studies assessed for eligi-
was published, the study country, the study design, sam- bility. Finally,15 reports of articles were included for the
ple size, associated factor, study area, the hazard rate of final systematic review and meta-analysis. 35 articles
predictors and its confidence interval, and the quality were excluded for various reasons different outcome
score of each study. The author’s last name and the year definitions, overlapping of participants, and lack of full
of publication were also included in the data extraction data = 10 (Fig. 1).
format for contributing factors. Every necessary piece
of information was separately collected by two writers, Study characteristics
who then cross-checked their findings and agreed on any Fifteen studies were included in this analysis [41–44,
discrepancies. 46–56]. Six articles were included from Amhara, three
articles were from AdisAbeba, two articles were from
Quality assessment/critical appraisal Tigray, two articles were from Oromia, one article was
The article was manually transferred to EndNote and from Sidama and one article was included in south
checked for duplicates. The inclusion and exclusion cri- nation nationalities of people Ethiopia region (SNNPE).
teria were applied to review the remaining articles, focus- From the included articles 6,375 breast cancer patients
ing on patient predictors of survival rate among breast participated in the determinant of survival rate among
cancer patients in Ethiopia. The Newcastle-Ottawa qual- breast cancer. The included articles were published. All
ity appraisal checklist was used to evaluate the quality of the included studies were facility-based cohorts by design
individual studies [40] (Supplementary S3 file). and reported survival rate predictors among breast can-
Two reviewers evaluated each primary study individu- cer patients. The sample sizes across the studies ranged
ally, and a decision was made to accept or reject based from 86 [56] to 819 [55] (Table 2).
on specific criteria. In case of disagreement, the average
score of both reviewers was taken. A study was catego- Publication bias
rized as good quality if it scored more than 50% on qual- The Egger’s test yielded non-significant results, indicating
ity assessment indicators. Each cohort study was assessed no evidence of publication bias across the included stud-
using eight criteria: inclusion criteria, study subject and ies. Additionally, the funnel plot appeared symmetrical,
setting description, valid measurement of exposure, and further supporting the absence of significant publication
identification of confounders using objective criteria, bias. The funnel plot for each predictor is provided in
confounder handling strategies, outcome measurement, Supplementary File S4 for detailed reference.
and statistical analysis. Fifteen cohort studies met quality
criteria and were included in the analysis. Predictors of survival rate among breast cancer patients in
Ethiopia: a systematic review 2024
Statistical analysis We included 12 selected variables to identify relation-
Meta-analysis was conducted using STATA version 11. ships with the survival rate of breast cancer patients in
Hazard ratios (HRs) with 95% confidence intervals (CIs) Ethiopia. Of these, eight variables, namely age years,
were extracted or calculated to summarize the predictors illiterate educational level, rural residence, lymph node
of survival. Heterogeneity among studies was assessed involvement, histological grade = > 2, overweight, hav-
using the I² statistic, with values > 50% indicating sub- ing comorbidity, and married women were significantly
stantial heterogeneity. A random-effects model was used associated with the survival rate of breast cancer patients
to account for variability among studies. (Table 3). The review also demonstrated that family his-
tory of breast cancer, treatment taken, tumor stage,
Publication bias tumor size, and nodal status had no statistically signifi-
Publication bias was assessed using a funnel plot and cant association with predictors of survival rate among
Egger’s test, with a p-value < 0.05 indicating significant breast cancer patients.
bias [45].
Histological grade
Result In the overall analysis of this study, histological grades
A total of 800 published studies (PubMed = 100, of breast cancer patients were significantly associated
Hinari = 10, Google = 85, EMBASE = 10, Google with survival rates. Patients with histological grade two
Scholar = 585, Web science = 10) were identified. 100 and above were 1.44 times more likely to short survival
duplicates were removed, leaving 700 abstracts for rate than their counterparts (aHR, 1.44; 95% CI: 1.12,
evaluation. 550 articles were excluded based on differ- 2.77). This means that breast cancer patients with grade
ent. Resulting in 150 articles was retained for full-text two histological involvement have a 44% higher risk of
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 5 of 19

Fig. 1 PRISMA flowchart diagram of the study selection process for predictors of survival rates among breast cancer patients in ethiopia 2024

decreased survival compared to their counterparts. A among the included studies for this factor analysis
random effects model was assumed for the analysis as I2 (Fig. 3).
(98.1%) and Egger test 0.517 with a p-value of (< 0.001)
showed statistically significant heterogeneity among the Educational status
included studies for this factor analysis (Fig. 2). In this meta-analysis educational status was significantly
associated with the survival rate of breast cancer patients.
Having comorbidity Patients with illiterate educational levels were 7.34 times
In the overall analysis of this study having comorbidity of reduced the survival rate than that of educated one (aHR,
breast cancer patients was significantly associated with 7.34; 95% CI: 4.38, 10.30). This means that breast can-
survival rate. Patients with comorbidity were 1.86 times cer patients illiterate have a 34% higher risk of reduced
more likely to reduced survival rate than their counter- survival compared to those educated ones. The random
parts (aHR, 1.86; 95% CI: 1.04, 2.68). This means that effect model was used for the analysis as I2 = 99.8% and
breast cancer patients having comorbidity have a 68% Egger test 0.020 showed statically significant heterogene-
higher risk of reduced survival compared to their coun- ity among the included studies (Fig. 4).
terparts. A random effects model was assumed for the
analysis as I2 (99.2%) and Egger test 0.090 with a p-value
of (< 0.001) showed statistically significant heterogeneity
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 6 of 19

Table 2 Study characteristics of systematic review and meta-analysis on breast cancer survival predictors in Ethiopia 2024
Author Region Study period Study design Sample size Predictors Adjusted HR LCI UCI
Wondimu AD, et al. Addis Abeba 2019 Cohort 408 Family history of breast cancer 0.7959 0.074 1.517
Tx taken 0.5726 0.204 1.349
Tumor size 1.1365 0.331 1.94
Age 0.0834 0.055 0.112
Feleke B, et al. Amhara 2022 Cohort 322 Family hx 1.86 1.096 3.158
Tx taken 1.274 0.91 1.783
Tumor stage 0.258 0.088 0.752
Having comorbidity 4.569 2.104 9.921
Age 1.028 0.975 0.999
Lymph node involvement 0.726 0.56 0.997
Tesfay B, et al. Tigray 2021 Cohort 186 Tx taken 0.132 0.01577 1.16
Tumor size 1.17 1.06 1.29
Educational status 30.3 1.11 833
Residence 4.69 1.08 20
Age 1.012 0.0036 0.02
Hagos BT, et al. Tigray 2024 Cohort 146 Tx taken 0.84 0.6 1.179
Tumor size 0.98 0.968 0.996
Tumor stage 0.48 0.297 0.789
Educational status 0.52 0.325 0.823
Residence 0.68 0.516 0.904
Marital status 1.1 0.546 2.031
Age 0.98 0.968 0.997
Lymph node involvement 0.52 0.341 0.787
Tasfa Marine B, et al. Oromia 2023 Cohort 552 Tx taken 0.53 0.16 1.12
Tumor size 0.4 0.39 1.44
Tumor stage 0.4 0.34 1.47
Histological grade 1.17 0.26 0.56
Having comorbidity 2.46 0.39 1.41
Educational status 2.32 0.79 2.43
Residence 0.84 0.0001 0.35
Marital status 1.3 0.05 0.47
Overweight 0.05 1.57 4.41
Age 2.54 3.95 7.13
Nodal status 0.04 1.88 4.45
Gashu C, et al. Amhara 2024 Cohort 382 Tumor size 0.43 0.05 0.46
Having comorbidity 0.42 0.16 0.51
Educational status 0.28 0.32 1.13
Overweight 0.21 0.15 0.62
Lymph node involvement 0.53 0.26 0.81
Nodal status 0.32 0.26 0.81
Yismaw D, et al. Amhara 2022 Cohort 392 Family hx 0.643 0.579 0.714
Tumor size 0.595 0.541 0.655
Tumor stage 0.33 0.198 0.548
Residence 1.806 1.27 2.564
Overweight 0.971 0.97 0.988
Age 0.98 0.968 0.994
Areri HA, et al. Addis Abeba 2019 Cohort 627 Tx taken 0.67 0.451 0.989
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 7 of 19

Table 2 (continued)
Author Region Study period Study design Sample size Predictors Adjusted HR LCI UCI
Tumor size 2.31 0.891 4.123
Tumor stage 1.86 1.127 3.08
Histological grade 3.12 1.16 8.36
Having comorbidity 1.49 0.98 2.29
Residence 1.48 0.999 2.195
Marital status 1.44 0.81 2.5
Lymph node involvement 0.79 0.517 1.205
Nodal status 1.83 1.217 2.736
Sharma MK, et al. Addis Abeba 2019 Cohort 819 Tumor size 0.906 0.824 0.995
Tumor stage 0.397 0.307 0.513
Histological grade 1.154 1.05 1,26
Misganaw M, et al. Amhara 2023 Cohort 410 Tumor stage 9.43 6.3 11.03
Histological grade 2.12 1.26 3.55
Having comorbidity 1.5 1.01 2.21
Residence 1.25 0.88 1.78
Lymph node involvement 12.58 5.19 30.46
Nodal status 1.68 0.56 5.05
Tiruneh M, et al. Amhara 2021 Cohort 482 Tumor stage 1.82 1.52 3.62
Marital status 1.1 0.8 1.53
Lymph node involvement 0.85 0.62 1.05
Bacha RH, et al. Oromia 2021 Cohort 642 Family history of breast cancer 0.99 0.82 1.21
Tx taken 0.56 0.37 0.85
Tumor size 0.59 0.46 0.75
Tumor stage 0.32 0.22 0.46
Histological grade 0.64 0.5 0.83
Residence 0.14 0.11 0.17
Overweight 0.87 0.68 1.1
Age 0.99 0.98 0.99
Fentaw S, et al. Amhara 2024 Cohort 632 Tumor size 0.853 0.82 0.899
Tumor stage 0.637 0.578 0.745
Histological grade 0.866 0.612 0.926
Having comorbidity 0.782 0.634 0.867
Lymph node involvement 0.883 0.645 0.996
Shita A, et al. Sidama 2020 Cohort 289 Tx taken 6.69 2.2 20.3
Tumor stage 3.01 1.05 8.59
Residence 2.71 1.44 5.09
Tekle G, et al. SNNPE 2019 Cohort 86 Educational status 4.306 1.085 4.966
Age 1.06 0.896 0.992

Residence Marital status

In the overall analysis of this study residence of breast In the overall analysis of this study marital status of breast
cancer patients was significantly associated with sur- cancer patients was significantly associated with survival
vival rate. Patients with rural residence were 1.71 times rate. Patients with married were 1.21 times more likely to
more likely to reduced survival rate than their counter- reduced survival rate than their counterparts (aHR, 1.21;
parts (aHR, 1.71 95% CI: 1.06, 2.36). This means that 95% CI: 1.03, 1.40). A random effects model was assumed
breast cancer patients residing in rural areas have a 71% for the analysis as I2 (50.9%) and Egger test 0.512 showed
higher risk of decreased survival compared to those liv- statistically moderate heterogeneity among the included
ing in urban areas. A random effects model was assumed studies for this factor analysis (Fig. 6).
for the analysis as I2 (99.1%) and Egger test 0.070 with a
p-value of (< 0.001) showed statistically significant het- Weight
erogeneity among the included studies for this factor In the overall analysis of this study weight of breast
analysis (Fig. 5). cancer patients was significantly associated with sur-
vival rate. Patients with overweight were 44% increased
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 8 of 19

Table 3 Predictors of survival rate among breast Cancer patients rate. Patients with two or more lymph node involve-
in Ethiopia– a systematic review and Meta-analysis 2024 ment were 1.86 times more likely to reduced survival rate
Variable Exposed Comparator aHR (95% I2 than their counterparts (aHR, 3.57; 95% CI:1.02, 6.13).
CI)
This means that Patients with two or more lymph node
Marital status Yes No 1.21;(1.03, 50.9%
1.40) involvement were an 86% reduced survival rate than
Age A unit - 1.05;(1.02, 99.3% their counterparts A random effects model was assumed
increase 1.08) for the analysis as I2 (99.9%) and Egger test 0.073 with a
Educational Illiterate Literate 7.34;(4.38, 99.8% p-value of (< 0.001) showed statistically significant het-
status 10.30) erogeneity among the included studies for this factor
Residence Rural Urban 1.71(1.06, 99.1% analysis (Fig. 8).
2.36)
Lymph node =>2 <2 3.57(1.02, 99.8% Age
involvement 6.13).
In this meta-analysis age of breast cancer patients
Histological =>2 <2 1.44;(1.12, 98.1%
grade Overweight Normal 2.77) 96.7%
was significantly associated with survival rate. As age
Weight 0.56;( 0.24, increased by one unit the survival rate of breast cancer
0.87) patients was reduced by by1.05 times (aHR, 1.05; 95%
Having Yes No 1.86;(1.04, 99.2% CI:1.02, 1.08). A random effects model was assumed for
comorbidity 2.68) the analysis as I2 (99.3%) with a p-value of (< 0.001) and
the Egger test 0.472 showed statistically significant het-
survival rate than their counterparts (aHR, 0.56; 95% CI: erogeneity among the included studies for this factor
0.24, 0.87). A random effects model was assumed for the analysis (Fig. 9).
analysis as I2 (96.7%) and Egger test 0.105 with a p-value
of (< 0.001) showed statistically significant heterogene- Predictors not associated with survival rate among
ity among the included studies for this factor analysis breast cancer patients– a systematic review in
(Fig. 7). Ethiopia 2024
Family history of breast cancer
Lymph node involvement Family history of breast cancer patients was not associ-
In this meta-analysis lymph node involvement of breast ated with survival rate. The overall Adjusted Hazard
cancer patients was significantly associated with survival Ratio of married women is 1.09(0.69–1.49). Random

Fig. 2 The pooled adjusted hazard ratio (aHR) for the association between histological grade of breast cancer and survival rate– a systematic review in
Ethiopia 2024
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 9 of 19

Fig. 3 The pooled adjusted hazard ratio (aHR) for the association between comorbidities and survival rate among breast cancer patients– a systematic
review in Ethiopia 2024

Fig. 4 The pooled adjusted hazard ratio (aHR) for the association between educational status and survival rate among breast cancer patients– a system-
atic review in Ethiopia 2024
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 10 of 19

Fig. 5 The pooled adjusted hazard ratio (aHR) for the association between residence and survival rate among breast cancer patients– a systematic review
in Ethiopia 2024

Fig. 6 The pooled adjusted hazard ratio (aHR) for the association between marital status and survival rate among breast cancer patients– a systematic
review in Ethiopia 2024
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 11 of 19

Fig. 7 The pooled adjusted hazard ratio (aHR) for the association between weight and survival rate among breast cancer patients– a systematic review
in Ethiopia 2024

Fig. 8 The pooled adjusted hazard ratio (aHR) for the association between lymph node involvement and survival rate among breast cancer patients– a
systematic review in Ethiopia 2024

effect model was used I2,97.9%) with p-value < 0.001 and breast cancer patients. The overall Adjusted Hazard Ratio
Egger test 0.314 with significant heterogeneity for this of treatment taken is 1.41(0.66–2.16). Random effect
analysis (Fig. 10). model was used I2,98.8%) as p-value,0.001and Egger
test 0.441 with significant heterogeneity for this analysis
Treatment taken (Fig. 11).
Treatment taken (radiotherapy, chemotherapy, and com-
bined) was a significance difference in survival rate of
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 12 of 19

Fig. 9 The pooled adjusted hazard ratio (aHR) for the association between age and survival rate among breast cancer patients– a systematic review in
Ethiopia 2024

Fig. 10 The pooled adjusted hazard ratio (aHR) for the association between family history of breast cancer and survival rate among breast cancer pa-
tients– a systematic review in Ethiopia 2024

Tumor stage p-value < 0.001 and Egger test 0.749 with significant het-
The tumor stage was not associated with the survival erogeneity for this analysis (Fig. 12).
rate of breast cancer patients. The overall Adjusted Haz-
ard Ratio of tumor stage two and above is 1.72 (-0.24- Tumor size
3.68). Random effect model was used I2,99.9%) as Tumor size was not associated with survival rate of breast
cancer patients. The overall Adjusted Hazard Ratio of
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 13 of 19

Fig. 11 The pooled adjusted hazard ratio (aHR) for the association between treatment received and survival rate among breast cancer patients: a sys-
tematic review in Ethiopia 2024

Fig. 12 The pooled adjusted hazard ratio (aHR) for the association between tumor stage and survival rate among breast cancer patients– a systematic
review in Ethiopia 2024
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 14 of 19

tumor size = > 5 cm is 0.91(0.80–1.01). Random effect finding is similar to earlier studies in Iran [14, 58, 59], in
model was used I2,98.7%) as p-value < 0.001 and Egger France [60]. The possible explanation is older breast can-
test 0.408 with significant heterogeneity for this analysis cer patients are less likely to undergo screening leading to
(Fig. 13). late-stage diagnosis [61, 62]. They may have comorbidi-
ties that complicate breast cancer treatment and recov-
Nodal status ery, reducing the overall survival [63–66]. They may have
Nodal status was not associated with the survival rate a reduced ability to tolerate aggressive cancer treatments
of breast cancer patients. The overall Adjusted Hazard like chemotherapy or surgery and also a weak immune
Ratio of a positive node is 0.92(0.48–1.36). Random effect system.
model was used I2,97.7%) as p-value < 0.001 and Egger The meta-analysis found that two or more histologi-
test 0.959 with significant heterogeneity for this analysis cal grades of breast cancer patient had 1.44 times short
(Fig. 14). survival rate than that of their counterparts. This is con-
gruent with a study done in Denmark [67], in Malaysia
Discussion [68], in France [59, 60, 69], in Italy [70], in Saudi [71], in
Breast cancer survival five years after diagnosis now Iran [14], United Arab Emirates [72], and in Nigeria [73].
exceeds 80% in most high-income countries, compared The reason might be high-grade tumor tend to grow
with 66% in India and just 40% in South Africa [57]. The and spread rapidly making them more difficult to con-
premature deaths and high out-of-pocket expenditure trol. High-grade tumor less responsive to treatment [74],
that arise when breast cancer services are unavailable advanced histological grade is associated with a higher
or unaffordable result in social disruption, impoverish- proliferation rate, meaning the cancer cells divide more
ment, family instability, and orphaned children and also quickly and they may have complex genetic mutations.
threaten economic growth. We found that age, illiterate, It was found that illiterate breast cancer patients had
rural residence, two or more lymph node involvement, 7.34 times reduced survival rate than educated ones. This
married patients, overweight, histological grade two or is congruent with study done in Vietnam [23], in India
more, and having comorbidity were predictors of short [75], in USA [76], in Egypt [77] and in Nigeria [73]. The
survival rate among breast cancer patients in Ethiopia. In possible explanations illiterate individuals may have less
this meta- analysis as age increases by one unit the sur- access to information about breast cancer symptoms, the
vival rate of breast cancer decreases by 1.05 times. This importance of early detection, and available treatment

Fig. 13 The pooled adjusted hazard ratio (aHR) for the association between tumor size and survival rate among breast cancer patients– a systematic
review in Ethiopia 2024
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 15 of 19

Fig. 14 The pooled adjusted hazard ratio (aHR) for the association between nodal status and survival rate among breast cancer patients– a systematic
review in Ethiopia 2024

options. They may not understand health education and they may have high cancer cell in the body. Patients
materials, screening options and leading to delayed diag- with lymph node involvement the cancer cell were more
nosis. Illiteracy might be associated with cultural or spread rapidly and difficult to control by treatment, sur-
social barriers that discourage individuals from seeking gery and radiography. When cancer has spread to the
timely medical care, particularly for women [78]. Illit- more lymph nodes, more extensive treatment is often
erate breast cancer patients may have poor adherence, required, such as a combination of surgery, radiation,
missed appointment, misunderstanding about medica- and chemotherapy. These treatments can be more toxic,
tions and lead short survival rate [79]. and the cancer may still be more likely to recur despite
The meta-analysis found that rural residence breast aggressive treatment, contributing to a lower overall sur-
cancer patients were 1.71times reduced survival rate than vival rate.
that of urban residence. This is similar with study done Married breast cancer patients were 1.21 times short
in Egypt [77], in Poland [80] and New Zealand [81]. The survival rate than that of unmarried women. It was simi-
explanation were rural areas have fewer health care facili- lar with earlier study done in Vietnam [23]. The justifi-
ties, access to advanced cancer treatment and travel long cation might be married women delay seeking medical
distance to access treatment [82, 83]. Rural residents may help due to family responsibilities, prioterizing the health
have finical challenges including lower income and high and needs of their family member.Insome cases, finicial
cost for traveling for treatment [84]. rural populations dependence on spouse, married women in rural area
might have lower health literacy levels, making it harder might have limited access to health care facilities, the
for them to understand the importance of early detec- health care decision made by husbands which may delay
tion, follow complex treatment plans, or seek out special- treatment.
ized care. This can contribute to delays in treatment and However, it was contrasts earlier research conducted in
lower adherence to recommended therapies [85]. India [88], in Saudi [71], in china [89, 90], and in Califor-
Moreover, this meta-analysis found that two or more nia [91]. The reason might be unmarried women might
lymph node involvement of breast cancer patients were lack of social support, might delay medical consultation
2.4 times short survival rate than that of the counter- because they are more focused on other responsibilities
parts.it was similar with previous studies done in France or lack encouragement from their partner to seek early.
[69], in Japan [86], China [87], in Iran [14], and in Egypt Unmarried women may face barriers to accessing health
[77]. The possible explanation were patients present care, lack of someone to assist them for transportation
with lymph node involvement suggests the indication or accompanying them to appointments and unmarried
of advanced disease and metastasis other body parts women might be less likely to engage in regular health
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 16 of 19

screenings or preventive care, leading to later-stage diag- However, it was opposed to earlier research conducted
noses and poorer outcomes. in Taiwan [113]. The potential reason might be patients
This meta-analysis also found that the survival rate of with comorbidity have regular check-ups and more fre-
overweight breast cancer patients increases by 44% than quent interaction with health care providers, close moni-
that of their counterparts. The possible reason might be toring of side effects, and may experience engagement in
overweight individuals are better to engage in the health a healthier lifestyle positively impacts survival and over-
care systems for the management of comorbid condi- all health. Patients with chronic conditions often have an
tions, and might receive more comprehensive and coor- awareness of their health and are more likely to engage in
dinated care. Overweight patients may have more fat preventive care, which can lead to earlier detection and
reserves, which can provide additional energy during the treatment of recurrent cancer.
physically taxing periods of cancer treatment, such as
chemotherapy or radiation therapy. This can help them Limitations of the study
maintain better overall health during treatment. Heterogeneity Among Studies: Variations in study
However, this finding contrasts with earlier research designs, sample sizes, and methodologies of included
conducted in Italy [92], in Germany [93], in USA [94, 95], articles may have contributed to heterogeneity, even
in UK [21, 96] in California [20] and Australia [97] which though efforts were made to address this using statistical
found that obese breast cancer patients were at higher tools. Publication Bias: While a funnel plot and Egger’s
risk for death and had reduced survival rates. A possible test were used to assess publication bias, unpublished
explanation might be excess body fat increases the level data, and gray literature were not included, which might
of estrogen [98, 99] and other hormones that can fuel have led to an overestimation or underestimation of the
the growth of hormone receptor-positive breast can- reported associations.
cer. Overweight individuals often have higher levels of
inflammation [100], which can promote cancer progres- Conclusion
sion and resistance to treatment. Overweight patients This systematic review and meta-analysis identified sev-
are more likely to have other health conditions such as eral key predictors of decreased survival rates among
diabetes, hypertension, and cardiovascular disease [101, breast cancer patients in Ethiopia, including older age,
102]. These comorbidities can complicate cancer treat- illiteracy, rural residence, involvement of two or more
ment and reduce overall survival. They may also be more lymph nodes, higher histological grade, marital status,
likely to lead a sedentary lifestyle which is associated with and the presence of comorbidities. Interestingly, being
poorer health outcomes and short survival rate. Over- overweight was associated with improved survival.
weight individuals often have insulin resistance, leading Health stakeholders and policy makers emphasizing
to higher levels of insulin and insulin-like growth fac- providing public health education to improve awareness
tors, which can promote tumor growth and metastasis among women of the signs and symptoms of breast can-
[103, 104]. The efficacy of chemotherapy is influenced by cer, should focus on managing comorbidities in breast
body weight, overweight patients are complicated during cancer patients, understand the importance of early
surgery and excess body fat can make it more difficult to detection and treatment, and expand access to cancer
detect breast tumors early through physical examination. treatment centers, particularly in primary and general
Having comorbidity of breast cancer patients was 1.86 hospitals.
times short survival rate than their counterparts. This
is similar to a study done in Ontario [105], in California Supplementary Information
[106], in China [107], and in Sweden [108]. The possible The online version contains supplementary material available at ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​
g​/​1​0​.​1​1​8​6​/​s​1​3​6​9​0​-​0​2​5​-​0​1​5​1​4​-​6​​​​.​ ​​
explanation might be patients with comorbidities like
heart disease, diabetes or chronic respiratory disease Supplementary Material 1
may not eligible for certain aggressive cancer treatments
Supplementary Material 2
of high-dose chemotherapy due to toxicity, and chronic
Supplementary Material 3
conditions may be prone to infection leading to hos-
pitalization and disrupting treatment follow-up. Some Supplementary Material 4
comorbidities like obesity and diabetes can create an
environment that promotes tumor growth and metasta- Acknowledgements
sis and hormonal imbalance [109–111]. Comorbidities We would like to thank Woldia University for providing access to the Internet
to conduct this study.
might weaken the immune system and reduce body’s
ability to fight cancer cells [112] and the cost of managing Author contributions
multiple health conditions can lead to financial strains, CM and AA were the formulation or evolution of overarching research goals
and aims and writing the research drafting. TE wrote the development or
potentially limited to access cancer treatment.
Mulugeta et al. Archives of Public Health (2025) 83:30 Page 17 of 19

design of the methodology.GK &AS facilitates the work by supervision and 17. Li Y, Ma X, Wu X, Liu X, Liu L. Prognostic significance of survivin in breast
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Funding socio economic status, income, and education with the survival rate of breast
The authors received no specific funding for this work from any funding cancer: a meta-analysis. Iran J Public Health. 2019;48(8):1428.
agency in the public, commercial, or not-for-profit sectors. 19. Ssentongo P, Lewcun JA, Candela X, Ssentongo AE, Kwon EG, Ba DM, et
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