Overall survival, poverty differentials, and mediating pathways among women with breast cancer: South African Breast Cancer and HIV Outcomes cohort
Overall survival, poverty differentials, and mediating pathways among women with breast cancer: South African Breast Cancer and HIV Outcomes cohort
Background
Breast cancer survival rates in sub-Saharan Africa are low. In a prospective, multi-center cohort study, we estimated 5-year overall survival rates, overall survival determinants, and mediating effects between socioeconomic status on overall survival among South African women diagnosed with invasive BC.
Patients and methods
Patients from 4 public hospitals were enrolled between July 1, 2015 and January 31, 2019. Survival determinants were assessed using Cox proportional hazard models adjusted for age, background mortality, and treatments. Socioeconomic pathway effects on overall survival were determined through generalized structural equation models.
Results
Of 2838 participants, 58% had advanced-stage (III/IV) disease. Five-year crude overall survival was 44.3% (95% CI 42.5-46.2). Significant mortality risks were late stage at diagnosis (hazard ratio [HR] = 2.31 [95% CI 1.99-2.69] [stage III]; 4.79 [95% CI 3.96-5.80] [stage IV]), HIV-positive status (HR = 1.45 [95% CI 1.25-1.67]), unemployment HR = 1.25 [95% CI 1.09-1.44], and low education HR 1.19 [95% CI 1.04-1.37]). Age and treatment-adjusted socioeconomic status effects on overall survival were mediated through HIV status (81.7% of the effect) and stage at diagnosis (81.7%), both P < .001. Poor breast cancer knowledge had an indirect effect on overall survival, accounting for 77.6% of the total effect (P = .001), fully mediated by late-stage presentation. Socioeconomic status had no significant direct path to mortality after accounting for these mediators.
Conclusion
Interventions should prioritize early breast cancer detection. For patients with low socioeconomic status, particularly those with comorbid HIV, we must mitigate multifaceted barriers to healthcare access, including limited awareness and knowledge of breast cancer.
South Africa, breast cancer, determinants and socioeconomic mediators, overall survival
Joffe, Maureen
3ed05269-5b6b-4f1c-a46a-df4f249280bc
Chen, Wenlong Carl
238c9d28-1cd3-49a8-9de6-6751babddc54
Craig, Ashleigh
73a7f4e1-1896-493c-83a7-a85675f6541c
O'Neil, Daniel S.
b2a52348-50c7-4572-a4e8-91655bace938
Neugut, Alfred I
78709e3f-7128-4a28-8f35-90aed0e71978
Ruff, Paul
916fe057-374c-4a7d-821c-52a54b32ffc4
Mathiba, Rofhiwa Margarent
Murugan, Nivashini
5bc46216-cf96-4128-bc64-0beb2053fd16
Cubasch, Herbert
c32933cc-390f-4351-ac45-79f6c9331763
Blanchard, Charmaine L.
6bb60456-5db4-4990-b035-ddcd5135c9ca
Nietz, Sarah
125138c5-1c1d-4801-8701-c6cd30a1219d
Buccimazza, Ines
29ed1fa1-5368-4ef1-9d0d-e6b9b29c6554
Norris, Shane A.
1d346f1b-6d5f-4bca-ac87-7589851b75a4
January 2026
Joffe, Maureen
3ed05269-5b6b-4f1c-a46a-df4f249280bc
Chen, Wenlong Carl
238c9d28-1cd3-49a8-9de6-6751babddc54
Craig, Ashleigh
73a7f4e1-1896-493c-83a7-a85675f6541c
O'Neil, Daniel S.
b2a52348-50c7-4572-a4e8-91655bace938
Neugut, Alfred I
78709e3f-7128-4a28-8f35-90aed0e71978
Ruff, Paul
916fe057-374c-4a7d-821c-52a54b32ffc4
Mathiba, Rofhiwa Margarent
Murugan, Nivashini
5bc46216-cf96-4128-bc64-0beb2053fd16
Cubasch, Herbert
c32933cc-390f-4351-ac45-79f6c9331763
Blanchard, Charmaine L.
6bb60456-5db4-4990-b035-ddcd5135c9ca
Nietz, Sarah
125138c5-1c1d-4801-8701-c6cd30a1219d
Buccimazza, Ines
29ed1fa1-5368-4ef1-9d0d-e6b9b29c6554
Norris, Shane A.
1d346f1b-6d5f-4bca-ac87-7589851b75a4
Joffe, Maureen, Chen, Wenlong Carl, Craig, Ashleigh, O'Neil, Daniel S., Neugut, Alfred I, Jacobson, Judith, Ruff, Paul, Mathiba, Rofhiwa Margarent, Murugan, Nivashini, Cubasch, Herbert, Blanchard, Charmaine L., Nietz, Sarah, Edge, Jennifer, Buccimazza, Ines, Cacala, Sharon, McCormack, Valerie A., Pumpalova, Yoanna and Norris, Shane A.
(2026)
Overall survival, poverty differentials, and mediating pathways among women with breast cancer: South African Breast Cancer and HIV Outcomes cohort.
The Oncologist, 31 (1), [oyaf408].
(doi:10.1093/oncolo/oyaf408).
Abstract
Background
Breast cancer survival rates in sub-Saharan Africa are low. In a prospective, multi-center cohort study, we estimated 5-year overall survival rates, overall survival determinants, and mediating effects between socioeconomic status on overall survival among South African women diagnosed with invasive BC.
Patients and methods
Patients from 4 public hospitals were enrolled between July 1, 2015 and January 31, 2019. Survival determinants were assessed using Cox proportional hazard models adjusted for age, background mortality, and treatments. Socioeconomic pathway effects on overall survival were determined through generalized structural equation models.
Results
Of 2838 participants, 58% had advanced-stage (III/IV) disease. Five-year crude overall survival was 44.3% (95% CI 42.5-46.2). Significant mortality risks were late stage at diagnosis (hazard ratio [HR] = 2.31 [95% CI 1.99-2.69] [stage III]; 4.79 [95% CI 3.96-5.80] [stage IV]), HIV-positive status (HR = 1.45 [95% CI 1.25-1.67]), unemployment HR = 1.25 [95% CI 1.09-1.44], and low education HR 1.19 [95% CI 1.04-1.37]). Age and treatment-adjusted socioeconomic status effects on overall survival were mediated through HIV status (81.7% of the effect) and stage at diagnosis (81.7%), both P < .001. Poor breast cancer knowledge had an indirect effect on overall survival, accounting for 77.6% of the total effect (P = .001), fully mediated by late-stage presentation. Socioeconomic status had no significant direct path to mortality after accounting for these mediators.
Conclusion
Interventions should prioritize early breast cancer detection. For patients with low socioeconomic status, particularly those with comorbid HIV, we must mitigate multifaceted barriers to healthcare access, including limited awareness and knowledge of breast cancer.
Text
Joffe M et al
- Accepted Manuscript
More information
Submitted date: 12 August 2025
Accepted/In Press date: 7 December 2025
e-pub ahead of print date: 13 December 2025
Published date: January 2026
Keywords:
South Africa, breast cancer, determinants and socioeconomic mediators, overall survival
Identifiers
Local EPrints ID: 511263
URI: http://eprints.soton.ac.uk/id/eprint/511263
ISSN: 1083-7159
PURE UUID: 2c7df9b5-1cdf-4ebd-a72c-d072635d3113
Catalogue record
Date deposited: 11 May 2026 16:33
Last modified: 12 May 2026 02:00
Export record
Altmetrics
Contributors
Author:
Maureen Joffe
Author:
Wenlong Carl Chen
Author:
Ashleigh Craig
Author:
Daniel S. O'Neil
Author:
Alfred I Neugut
Author:
Judith Jacobson
Author:
Paul Ruff
Author:
Rofhiwa Margarent Mathiba
Author:
Nivashini Murugan
Author:
Herbert Cubasch
Author:
Charmaine L. Blanchard
Author:
Sarah Nietz
Author:
Jennifer Edge
Author:
Ines Buccimazza
Author:
Sharon Cacala
Author:
Valerie A. McCormack
Author:
Yoanna Pumpalova
Download statistics
Downloads from ePrints over the past year. Other digital versions may also be available to download e.g. from the publisher's website.
View more statistics
