Health Related Quality of Life Among Women with Breast Cancer in Mogadishu, Somalia

Abstract

Background

Breast cancer is a leading contributor to cancer-related illness and death among women worldwide. In Somalia, limited access to healthcare exacerbates the challenges faced by patients, making health-related quality of life (HRQoL) a vital concern.

Objective

To assess health related quality of life among women with breast cancer in Mogadishu, Somalia.

Methods

A hospital-based cross-sectional study was conducted from September to November 2024 involving 200 breast cancer patients. Data were collected using a structured questionnaire adapted from the validated European Organization for Research and Treatment of Cancer quality of life instruments (EORTC QLQ-C30 and the breast cancer-specific module EORTC QLQ-BR23). These tools were used to assess multiple domains of health-related quality of life. Data were analyzed using SPSS version 27. Descriptive statistics were used to summarize participant characteristics. Pearson’s correlation examined relationships between HRQoL domains and socio-demographic or clinical variables. Multivariable linear regression was used to identify independent predictors of HRQoL, with significance set at p < 0.05.

Results

In multivariable linear regression, advanced stage at diagnosis was associated with lower physical (β = –0.109, 95% CI: –0.202 to –0.016, p = 0.021) and emotional HRQoL (β = –1.192, 95% CI: –1.330 to –0.954, p = 0.007), and with higher financial burden (β = 1.41, 95% CI: 1.061 to 1.760, p = 0.021). Greater extent of surgery predicted lower physical HRQoL (β = –0.469, 95% CI: –0.587 to –0.351, p < 0.001). Adequate social support was positively associated with conjugal well-being (β = 0.334, 95% CI: 0.020 to 0.649, p = 0.037), and stage at diagnosis was also positively linked with conjugal HRQoL (β = 0.343, 95% CI: 0.039 to 0.647, p = 0.027).

Conclusion

Although emotional and social HRQoL were relatively preserved, physical, financial, and conjugal domains were more negatively affected especially among women with advanced cancer, extensive surgery, or longer time since diagnosis. These findings emphasize the urgent need for improved cancer care access and integrated psychosocial support in Somalia.

Introduction

Breast cancer (BC) is a malignant tumor that has the highest incidence among women of all age groups worldwide and influenced by hormonal, reproductive, and environmental factors.¹ It accounts for approximately 25% of all cancer cases and is the most frequently diagnosed type of cancer among women globally.^2,3 According to global statistics, one in six cancer-related deaths among women is attributed to this disease, making it the most commonly diagnosed cancer in many countries.⁴ The incidence of breast cancer rose to 2,002,354 cases in 2019,⁵ and it is estimated that by 2040, the number of new cases will increase by more than 40%, reaching around 3 million annually.⁴ Breast cancer incidence is significantly higher in Western European countries compared to Eastern Asian or African regions.⁶ However, survival rates are also considerably better in Western Europe than in low- and middle-income countries.⁷ Moreover, increased awareness and timely mammography screening in high-income countries have contributed to a reduction in breast cancer mortality over the past four decades.^6,8 Although only 8.3% of global breast cancer cases occurred in Africa, the continent accounted for a disproportionately higher share of breast cancer-related deaths, contributing to 12.5% of the global total.⁹ It is estimated that about one-third of Africa’s cancer cases occur in east Africa region.¹⁰

While reached advancements in breast cancer treatment and improved survival rates, a growing number of women are now experiencing ongoing symptoms associated with both the disease and its treatment.^11,12 Women diagnosed with breast cancer often endure physical symptoms and psychological distress. The most commonly reported issues include high levels of fatigue, pain, loss of appetite, and side effects associated with systemic treatments.¹³

Quality of life is a multifaceted concept that captures how emotional, social, and physical factors collectively impact an individual’s overall well-being in daily life. Health-Related Quality of Life (HRQoL) emerged in the latter half of the 20th century as a measure of individual health status, gaining broader use toward the century’s end.¹⁴ Cancer and its treatments significantly impact various aspects of a patient’s Health-Related Quality of Life.¹⁵

Somali women face significant challenges in accessing cancer diagnosis and treatment services within their country’s healthcare system, largely due to a range of ongoing barriers.¹⁶ Somalia lacks a national cancer registry system. Based on Globocan 2020 data, around 1,900 women in Somalia were diagnosed with breast cancer. Breast cancer ranks as the fourth most common type of cancer in Somalia, following esophageal cancer, Non-Hodgkin lymphoma, and liver cancer.¹⁷ Similarly, breast cancer as a major health concern in Somalia, ranking as the leading cause of cancer-related deaths in the country.¹⁸

The aim of this study is to assess the health-related quality of life among women living with breast cancer in Mogadishu Somalia.

Methodology

Study Design and Setting

This is hospital based cross-sectional design conducted from September to November, 2024. The study was conducted at a healthcare facilities in Mogadishu, targeting women who have been diagnosed with breast cancer and are receiving treatment or follow-up care. The study was carried out in selected hospitals in Mogadishu, Somalia.

Study Population and Sampling

The study population included adult female patients diagnosed with breast cancer, who were either undergoing treatment, in pre-treatment, or in follow-up care during the data collection period. A total of 200 participants were selected using a convenient sampling method, based on their availability and willingness to participate during clinical visits.

Eligibility Criteria

Inclusion Criteria

• Female patients aged 18 years and above

• Clinically diagnosed with breast cancer

• Currently receiving or had received treatment

• Willing to provide informed consent

Exclusion Criteria

• Patients who are too ill to participate in interviews

• Those with cognitive impairments affecting recall or understanding

Sample Size Determination

The sample size for this study was determined using the single population proportion formula, assuming a 95% confidence level, an estimated proportion of 50%, and a 7% margin of error to ensure a reasonable level of precision. The required sample size is 196 participants. To account for potential non-responses, 10% non-response rate was added. This resulted in a final target sample size of 216 participants. However, a total of 200 participants were agreed to participate the study.

Data Collection

Data for this study were collected using a structured, interviewer-administered questionnaire adapted from internationally recognized health-related quality of life instruments, including the EORTC QLQ-C30¹⁹ and its breast cancer–specific module EORTC QLQ-BR23.²⁰ The questionnaire consisted of five sections: socio-demographic characteristics, clinical information, psychosocial factors, symptom profile, and health-related quality of life (HRQoL) domains, including physical, emotional, social, financial, and conjugal (Marriage) well-being.

A total of 200 eligible women diagnosed with breast cancer were recruited during routine clinical visits at selected hospitals in Mogadishu. Data were collected through face-to-face interviews conducted by trained data collectors using the structured questionnaire. This method helped ensure completeness and accuracy of the data while also accommodating participants with limited literacy.

Participants were informed about the objectives and procedures of the study prior to data collection. Written and/or verbal informed consent was obtained from all participants before participation.

Data Analysis

Data were entered and analyzed into to SPSS version 27.0. Descriptive statistics such as frequencies, percentages, means, and standard deviations were used to summarize socio-demographic, clinical, psychosocial variables, presenting symptoms and Health-Related Quality of Life Domains. Pearson’s correlation coefficients were computed to examine the relationships between HRQOL domains and socio-demographic and clinical variables. To identify factors associated with HRQoL domains, bi-variable and multivariable linear regression analyses were performed. Results were presented as beta coefficients (β) with 95% confidence intervals (CI) and standard errors. Statistical significance was defined at a p-value < 0.05. Multivariable linear regressionMultivariable linear regression. Also we used Microsoft Excel to present bar charts.

Ethical Consideration

Ethical clearance for the study was granted by the Research Ethics Committee of Jamhuriya University of Science and Technology, Mogadishu, Somalia (Certificate No: JUREC0113/FMHS327/052024). Participation in the study was entirely voluntary, with informed consent obtained from all participants before enrollment. Strict confidentiality of personal data was upheld throughout the research process. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Results

Socio-Demographic Characteristics of Participants and Clinical Factors

A total of 200 participants were included in the study. The age distribution revealed that the majority fell within the 25–35 years and 35–48 years age groups, each accounting for 27.5% of the sample, followed by those aged 48–62 years (22.5%). Participants aged 18–25 years represented 15.0%, while those older than 62 years comprised 7.5%. More than half of the respondents were married (52.0%), with 30.5% divorced or separated, and 17.5% single. Regarding education, 57.0% had no formal education, 17.0% completed primary school, another 17.0% completed secondary education, and only 9.0% had higher education.

In terms of employment, 34.0% were unemployed, while 32.0% were homemakers. Full-time employment was reported by 20.0% and part-time by 14.0%. More than half of the participants (54.0%) reported an average household monthly income, 32.5% had a low income, and 13.5% reported high income. The majority of participants (62.5%) were diagnosed within the past 3–8 months, followed by 30.5% diagnosed within 8 months to 1 year, and 7.0% having a diagnosis duration between 1–3 years. At the time of diagnosis, 51.5% were in early-stage (Stage I–II) and 48.5% in advanced-stage (Stage III–IV) cancer. In terms of treatment, 64.0% underwent surgery, while 36.0% received chemotherapy. No participants received hormone or radiation therapy. Regarding current treatment status, 56.0% were undergoing treatment, 35.5% were in post-treatment follow-up, and 8.5% were yet to begin treatment (Table 1).

Table 1.

Socio- Demographic and Clinical Characteristics

Variable	Frequency (N)	Percentage (%)
Age
18–25	30	15.0
25–35	55	27.5
35–48	55	27.5
48–62	45	22.5
>62	15	7.5
Marital status
Single	35	17.5
Married	104	52.0
Divorced/separated	61	30.5
Educational level
NO formal education	114	57.0
Primary school	34	17.0
Secondary school	34	17.0
Higher education	18	9.0
Employment Status
Employed (full time)	40	20.0
Employed (part time)	28	14.0
Unemployed	68	34.0
Homemaker	64	32.0
Household Monthly Income
Low	65	32.5
Average	108	54.0
High	27	13.5
Time Since Diagnosis (monthly/yrs)
>3–8 months	125	62.5
8m–1yrs	61	30.5
1–3yrs	14	7.0
Stage of cancer at Diagnosis
Early-stage (stage I–II)	103	51.5
Advanced-stage (stage III–IV)	97	48.5
Type of treatment Received
Surgery (e.g lumpectomy, mastectomy)	128	64.0
Chemotherapy	72	36.0
Hormone therapy	00	00
Radiation therapy	00	00
Current Treatment Status:
Pre-treatment	17	8.5
Undergoing treatment	112	56.0
Post-treatment\follow-up	71	35.5

Psychosocial Support, Coping, and Body Image

The findings revealed that a majority of participants reported moderate to adequate levels of support, with 45.5% indicating moderate support and 39.5% reporting adequate support. A smaller proportion (14.5%) stated they had little to no support. Regarding social contact, most participants maintained at least some regular interaction with friends or family. Nearly half (47.5%) reported monthly contact, while 26.0% had daily interactions. Weekly contact was reported by 15.0%, and only a minority (11.5%) reported rarely or never communicating with friends or family. In terms of stress coping, the responses were fairly balanced across categories. About 44.5% reported range of 8–10 on the coping scale, suggesting a high coping ability, while 44.0% fell within the 4–8 range, indicating moderate coping. Only 11.0% had low coping reported range of 1–4. When asked about body image satisfaction, the majority (64.0%) were somewhat satisfied with their body image, while 9.5% expressed being very satisfied. Meanwhile, 26.5% of participants reported dissatisfaction with their body image (Table 2).

Table 2.

Psychological and Social Support Factors

Variable	Category	Frequency	Percentage (%)
Access to Support	Adequate support	79	39.5
	Moderate support	91	45.5
	Little to no support	29	14.5
	Other/Invalid	1	0.5
Frequency of Contact with Friends/Family	Daily	52	26.0
	Weekly	30	15.0
	Monthly	95	47.5
	Rarely/Never	23	11.5
Coping with Stress	Score 1–4	22	11.0
	Score 4–8	88	44.0
	Score 8–10	89	44.5
	Other/Invalid	1	0.5
Body Image Satisfaction	Very satisfied	19	9.5
	Somewhat satisfied	128	64.0
	Dissatisfied	53	26.5

Health-Related Quality of Life (HRQoL) Domain Scores

This table presents the mean scores, standard deviations (SD), and 95% confidence intervals (CI) for five HRQoL domains among breast cancer patients. The emotional domain had the highest average score (Mean = 5.01, SD = 0.44), followed closely by the social, financial, and conjugal domains (each with a mean of 5.00). The physical domain had the lowest mean score (Mean = 4.85, SD = 0.36), indicating comparatively lower physical well-being (Table 3).

Table 3.

Health Related Quality of Life Domain Score of Breast Cancer

HRQoL Domains	Mean (SD)	95% CI
Physical domain	4.85(0.36)	4.80–4.90
Emotional domain	5.01(0.44)	4.95–5.07
Social domain	5.00(0.43)	4.94–5.06
Financial domain	5.00(1.08)	4.84–5.15
Conjugal domain	5.00(1.11)	4.83–5.15

Common Reported Symptoms Among Study Participants

Pain or discomfort in the affected breast was the most commonly reported symptom, with nearly 59% of patients experiencing it frequently. Fatigue followed closely, affecting 46% of participants on a frequent basis. While pain and fatigue were most prevalent, a significant portion of patients also reported difficulty sleeping (45.5%) and swelling/lymphedema (48.5%) as frequent concerns. Interestingly, nausea or vomiting showed a more even distribution, with 37% experiencing it either occasionally or frequently (Table 4).

Table 4.

Commonly Reported Symptoms Among Study Participants

Symptoms	Response	Frequency	Percentage (%)
Pain or discomfort in the affected breast	Never	25	12.5
	Occasionally	58	29.0
	Frequently	117	58.5
Fatigue	Never	32	16.0
	Occasionally	76	38.0
	Frequently	92	46.0
Nausea or vomiting	Never	52	26.0
	Occasionally	74	37.0
	Frequently	74	37.0
Swelling/lymphedema (arms or shoulders)	Never	40	20.0
	Occasionally	63	31.5
	Frequently	97	48.5
Difficulty sleeping	Never	34	17.0
	Occasionally	75	37.5
	Frequently	91	45.5

Pearson’s Correlation Matrix Between HRQOL Domains and Socio-Demographic Variables and Clinical Factors

There was a statistically significant positive correlation between age and the emotional domain of HRQOL (r = 0.264, p < 0.01), indicating that emotional well-being tended to improve with age. Marital status was also significantly and positively associated with the emotional domain (r = 0.231, p < 0.01). Conversely, educational level demonstrated a significant negative correlation with both the physical domain (r = –0.172, p < 0.05) and the emotional domain (r = –0.207, p < 0.01), suggesting that individuals with higher education perceived lower physical and emotional well-being. Employment status showed a significant positive correlation with the physical domain (r = 0.196, p < 0.01) and the emotional domain (r = 0.157, p < 0.05), indicating better outcomes among employed individuals. Notably, household income was negatively correlated with the physical domain (r = –0.273, p < 0.01), suggesting that individuals with higher income levels reported slightly lower physical HRQOL scoresStage of cancer at diagnosis showed a significant positive association with both the physical domain (r = 0.318, p < 0.01) and the emotional domain (r = 0.246, p < 0.01), suggesting better physical and emotional well-being among those diagnosed at later stages. However, stage at diagnosis was negatively correlated with the financial domain (r = –0.202, p < 0.01) and the conjugal domain (r = –0.222, p < 0.01), indicating financial and interpersonal strain associated with advanced cancer stages. The type of treatment received showed a significant positive correlation with both the physical domain (r = 0.198, p < 0.01) and emotional domain (r = 0.227, p < 0.01), indicating better physical and emotional outcomes among those who received treatment. The extent of surgery was positively correlated with the physical domain (r = 0.197, p < 0.01) and the emotional domain (r = 0.272, p < 0.01), further highlighting the benefit of surgical intervention on quality of life. Time since diagnosis exhibited significant negative correlations with the social domain (r = –0.227, p < 0.01), financial domain (r = –0.425, p < 0.01), and conjugal domain (r = –0.413, p < 0.01), indicating a decline in social and financial well-being, as well as intimate relationships, over time. Current treatment status also showed a significant negative association with the financial (r = –0.199, p < 0.01) and conjugal domains (r = –0.193, p < 0.01), suggesting that patients in active treatment phases may experience more financial burden and relationship difficulties (Table 5).

Table 5.

Pearson’s Correlation Matrix Between Quality of Life Domains and Socio-Demographic and Clinical Factors

Variables	Physical Domain	Emotional Domain	Social Domain	Financial Domain	Conjugal Domain
Age	0.108	0.264**	0.101	–0.064	–0.066
Marital Status	0.080	0.231**	0.087	0.020	0.026
Educational Level	–0.172*	–0.207**	–0.103	–0.054	–0.066
Employment Status	0.196**	0.157*	–0.011	–0.122	–0.119
Household Income	–0.273**	–0.136	–0.054	–0.029	–0.035
Stage at Diagnosis	0.318**	0.246**	0.022	–0.202**	–0.222**
Type of Treatment Received	0.198**	0.227**	0.098	–0.077	–0.075
Time Since Diagnosis	–0.015	–0.081	–0.227**	–0.425**	–0.413**
Current Treatment Status	0.025	–0.061	–0.058	–0.199**	–0.193**
Extent of Surgery	0.197**	0.272**	0.069	–0.075	–0.066

Notes: p < 0.05 (*); p < 0.01 (**).

Self- Rating of Health-Related Quality of Life of Breast Cancer Patients

According the patients’ self-assessment of their overall health-related quality of life. 50.5% of participants rated their HRQoL as fair, 41% as poor and 8.5% for good HRQoL (Figure 1).

Figure 1.

Self-rating of health related quality of life of breast cancer patients.

Self-Reported Life Satisfaction of Breast Cancer Patients

Low satisfaction was the most prevalent among participants (48%), followed by moderate satisfaction (40%), while only 12% reported high satisfaction, indicating an overall low level of life satisfaction (Figure 2).

Figure 2.

Self-reported life satisfaction of breast cancer patients.

Regression Analysis of Factors Associated with HRQoL Domains

In the multivariable model, both stage of cancer and extent of surgery were significantly associated with the physical HRQoL domain. Patients with advanced-stage cancer reported lower physical functioning (β = –0.109, 95% CI: –0.202 to –0.016, p = 0.021). Similarly, those who underwent more extensive breast surgery had significantly lower physical scores (β = –0.469, 95% CI: –0.587 to –0.351, p < 0.001). The stage of cancer was also significantly associated with emotional well-being. Patients with advanced-stage disease had lower emotional domain scores (β = –1.192, 95% CI: –1.330 to –0.954, p = 0.007), indicating worse emotional health outcomes. A significant association was observed between stage of cancer and financial HRQoL. Advanced-stage cancer was linked to higher reported financial domain (β = 1.41, 95% CI: 1.061 to 1.760, p = 0.021). Both social support and stage of cancer were significant predictors in the conjugal domain. Adequate social support was associated with better conjugal quality of life (β = 0.334, 95% CI: 0.020 to 0.649, p = 0.037). Similarly, advanced-stage cancer was positively associated with conjugal scores (β = 0.343, 95% CI: 0.039 to 0.647, p = 0.027). No variable showed a statistically significant association with the social domain in the multivariable model (p > 0.05).

In bivariate analysis, stage of cancer (β = –0.230, 95% CI: –0.360 to –0.134, p < 0.001), extent of surgery (β = –0.163, 95% CI: –0.260 to –0.066, p < 0.001), and difficulty sleeping (β = –0.528, 95% CI: –0.639 to –0.417, p < 0.001) were significantly associated with lower physical domain scores. Age was not significantly associated (p = 0.197). None of the variables examined social support, stage of cancer, or employment status showed statistically significant associations with the social HRQoL domain (p > 0.05). Both social support (β = –0.176, 95% CI: –0.300 to –0.051, p = 0.006) and stage of cancer (β = –0.234, 95% CI: –0.356 to –0.113, p < 0.001) showed significant negative associations with emotional HRQoL. Marital status showed a marginal association (β = –0.145, 95% CI: –0.360 to 0.017, p = 0.079). In the financial domain, none of the bivariate associations with education, marital status, or stage of cancer were statistically significant (p > 0.05), though stage of cancer showed a borderline trend (β = 0.282, 95% CI: –0.014 to 0.578, p = 0.062). Significant positive associations were found for both social support (β = 0.334, 95% CI: 0.020 to 0.649, p = 0.037) and stage of cancer (β = 0.343, 95% CI: 0.039 to 0.647, p = 0.027), suggesting better conjugal domain scores among those with support and at advanced stages (Table 6).

Table 6.

Regression Analysis of Factors Associated with HRQoL Domains

Variable	Domains
	Bi-variable Linear Regression		Multiple Linear Regression
	β (95% CI)	p-value	Β (95% CI)	Standard Error	p-value
	Physical Domain
Age
45 and above (Ref)	0.07 (−0.037, 0.180)	0.197
Stage of Cancer
Early stage (Ref)	−0.230 (−0.360, −0.134)	< 0.001	−0.109 (−0.202,-0.016)	0.047	0.021
Extent of Surgery
Part of one breast (Ref)	−0.163 (−0.260,-0.066)	< 0.001	−0.469 (−0.587,-0.351)	0.060	< 0.001
Difficulty of Sleeping
Never (Ref)	−0.528 (−0.639,-0.417)	< 0.001
	Emotional Domains
Social Support
Adequate (Ref)	−0.176 (−0.300,-0.051)	0.006
Stage of Cancer
Early stage (Ref)	−0.234 (−0.356,-0.113)	< 0.001	−1.192 (−1.330, −0.954)	0.070	0.007
Marital status
Single (Ref)	−0.145 (−0.360, 0.017)	0.079
	Social Domains
Social support
Adequate (Ref)	−0.084 (−0.205, 0.037)	0.174
Stage of Cancer
Early stage (Ref)	−0.051 (−0.170, 0.068)	0.396
Employment
Housewife (Ref)	0.022 (−0.103, 0.148)	0.727
	Financial Domains
Educational level
No formal education (Ref)	0.041 (−0.264, 0.346)
Marital status
Single (Ref)	0.208 (−0.188, 0.604)	0.302
Stage of Cancer
Early stage (Ref)	0.282 (−0.014, 0.578)	0.062	1.41 (1.061,1. 760)	0.177	0.021
	Conjugal Domains
Social support
Adequate (Ref)	0.334 (0.020, 0.649)	0.037
Stage of Cancer
Early stage (Ref)	0.343 (0.039, 0.647)	0.027

Notes: β = regression coefficient. Statistical significance set at p < 0.05.

Abbreviations: CI, confidence interval; Ref, reference category.

Discussion

This study assessed the health-related quality of life (HRQoL) among women diagnosed with breast cancer in Mogadishu, Somalia. Overall, participants showed relatively high average scores across all HRQoL domains, with emotional and social well-being rated the highest. In contrast, the physical domain scored slightly lower, indicating some limitations in physical functioning. Consistent with these findings, previous research has shown that breast cancer patients often retain strong emotional health, particularly when supported by family or social networks.²¹ Similarly, other study have identified the physical domain as receiving the lowest ratings among the various functional health dimensions.¹³

In this study, the majority of breast cancer patients self-rated their general health-related quality of life (HRQoL) as fair (50.5%), while a substantial portion (41%) reported it as poor, indicating an overall cautious or negative perception of their well-being. This is in contrast with the relatively high scores reported in specific HRQoL domains. Indicating overall moderate to poor quality of health of life. Also a study in Sweden reported poor of HRQoL.²²

Participants most commonly reported pain in the affected breast, with over half experiencing it frequently. Other frequently reported symptoms included fatigue, swelling or lymphedema, and difficulty sleeping. Nausea or vomiting was less pronounced, with responses more evenly divided between occasional and frequent occurrences. Similarly, previous studies have identified the same symptoms including pain, fatigue, and sleep disturbances as common concerns.^23–26 We made Pearson’s correlation matrix between Quality of Life domains and socio-demographic factors and clinical factors. Age was positively associated with emotional wellbeing in our study, echoing findings from studies in Egypt, where older women showed more emotional stability and acceptance of illness with the participants aged 50 and above had significantly higher scores on the breast cancer subscale compared to those under 50 years old.²⁷ Several studies also reported the association of age on HRQoL in breast cancer patients^28–31 with studies reported that older patients experienced better HRQoL26, 28, while other study found the opposite.²⁹ These symptoms were consistently reported in four studies that examined symptom clusters among patients prior to initiating treatment. In our study marital status showed a significant positive relationship with the emotional domain suggesting that married women may benefit from spousal support during illness. However, marital status did not significantly influence physical, social, financial, or conjugal domain. Consistently a study conducted at Jaen University Hospital in Spain revealed that cancer patients with higher-quality marital relationships experienced significantly lower levels of depression, anxiety, sleep problems, and suicidal thought.³²

Surprisingly, education level in our findings had a negative association with both physical and emotional wellbeing. Likewise, research conducted among breast cancer patients in Malaysia revealed that those with only primary education or less reported higher HRQoL than patients with more advanced levels of education.³³ In contrast to our findings, several studies have examined the relationship between educational level and HRQoL among breast cancer patients, and reported a positive association—indicating that higher educational attainment was linked to better health-related quality of life.^{29–31,34,35} Our result may indicate increased anxiety or critical awareness among educated women in a context with limited treatment options, highlighting a unique socio-psychological dynamic.

Employment status was positively associated with physical and emotional domains indicating that employed women (both full- and part-time) experienced better functioning and emotional resilience. Consistently similar studies shown that employed patients tended to have better HRQoL compared to those who were unemployed 27, 29. However, another study found contrasting results, reporting that patients who were unemployed exhibited better HRQoL than their employed counterparts.³⁶ Household income is negatively correlated with the physical domain in the current study, suggesting that higher income is associated with lower physical HRQoL. In contrast, two studies reported that income positively influenced the HRQoL of breast cancer patients.^35,37 This unexpected association may be due to wealthier women being more aware or critical of their physical health, or it might justified that greater reporting of treatment-related side effects among those accessing more intensive care options. No other domain showed a significant relationship with income.

Among the clinical factors, Stage at diagnosis showed a positive association with physical and emotional well-being. Aligning the current study, one study found similar association indicating that breast cancer patients diagnosed at an advanced stage (stage III–IV) reported better HRQoL than those diagnosed at earlier stages (stage I–II).³⁸ Several factors may explain this discrepancy. First, correlation analyses do not account for potential confounding variables, which may influence the observed relationships. Second, psychological adaptation to illness may occur over time, where some patients develop coping mechanisms that help maintain aspects of emotional or social well-being despite disease severity.

In terms of type of treatment received in this study, primarily surgery and chemotherapy, was positively associated with physical and emotional wellbeing. Similar finding was reported in two studies conducted in Malaysia and China.^33,37 Time since diagnosis is significantly negatively correlated with the social, financial, and conjugal domains, indicating that longer time since diagnosis is associated with poorer HRQoL in these areas. Like a study in china revealed Patients who had been diagnosed with breast cancer for a year or longer prior to the survey reported better HRQoL compared to those diagnosed within the past year.³⁷

Current Treatment Status has a significant negative correlation with the financial and conjugal domains, suggesting that being currently under treatment is linked to lower HRQoL in financial and conjugal aspect. A study conducted in Malaysia also reported patients who had either completed treatment or had not yet started it reported better HRQoL compared to those currently undergoing breast cancer treatment.³³

According to the extent of surgery showed a positive correlation with physical and emotional well-being. In contrast, since Halsted first introduced the standard radical mastectomy for breast cancer, the scope of surgical intervention has gradually diminished. As life expectancy has improved and surgical procedures have become less invasive, the concept of quality of life has gained growing attention and significance.³⁹ In the multivariable regression analysis, stage of cancer was significantly linked to poorer emotional well-being. This finding aligns with a study conducted in Spain, which also reported that patients with advanced-stage cancer experienced higher levels of emotional distress, including symptoms such as anxiety, depression, and fear of disease recurrence.⁴⁰ The current study, advanced-stage breast cancer was associated with a higher financial burden, which is consistent with findings from previous research showing that metastatic breast cancer incurs greater healthcare costs compared to earlier stages of the disease.^41–43 In this study, both social support and cancer stage were positively associated with the conjugal domain. Similarly, other studies have shown that support from family and partners plays a significant role in strengthening marital and intimate relationships.^44–46 Advanced stage of breast cancer and extent of surgery linked to lower physical HRQoL. Which is aligns in these studies similar associations.^47–49

This study has limitations. First, the cross-sectional design limits the ability to infer causal or temporal relationships between socio-demographic or clinical factors and HRQoL domains. The associations identified in this study should therefore be interpreted cautiously, as the direction of these relationships cannot be determined. Additionally, the study relied on self-reported responses, which may be subject to recall or reporting bias.

Conclusion

This study indicates that women with breast cancer in Mogadishu experience a mixed health-related quality of life, with relatively higher emotional and social functioning but lower physical and financial well-being. Clinical factors such as advanced disease stage, extensive surgery, and ongoing treatment were associated with variations in several HRQoL domains. In addition, psychosocial support showed a positive relationship with emotional and conjugal well-being. However, some observed associations should be interpreted with caution due to the cross-sectional design and the presence of unexpected patterns in certain findings. Future studies using longitudinal designs and standardized HRQoL measurement instruments are recommended to better understand these relationships and inform comprehensive cancer care strategies in Somalia.

Funding Statement

There is no funding to report.

Open Access

This article is distributed under an open access license and can be freely accessed in line with the provisions of the Creative Commons license.

Data Sharing Statement

This data can be accessed through corresponding author upon reasonable request.

Ethical Approval

Ethical approval for this study was obtained from the Research Ethics Committee of Jamhuriya University of Science and Technology, Mogadishu, Somalia (Certificate Number: JUREC0113/FMHS327/052024).

Informed Consent

Written informed consent was obtained from all participants prior to their inclusion in the study. Participation was voluntary, and confidentiality of personal information was maintained throughout the research process.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no conflict of interest.