Relationships between social support and resilience of breast cancer patients in Indonesia: A cross-sectional study

Abstract

BACKGROUND:

Breast cancer is the most common cancer among women in the world, especially in Indonesia. The incidence rate of breast cancer in Indonesia is 44.0 per 100,000 population, and the mortality rate is 17.0 per 100,000 population. Long and heavy treatment has a psychological impact that can be overcome if the patient’s resilience is good. Social support is very important to increase resilience of breast cancer patients. This study aims to determine the role of social support on the resilience of breast cancer patients.

MATERIALS AND METHODS:

A cross-sectional analytical observational study with subjects of 220 breast cancer patients who joined the Indonesian breast cancer community in 2023. The dependent variable is the resilience of breast cancer patients; the independent variable is social support; and the covariate variables are age, education, employment, marriage, financing, cancer stage, and type of treatment. The instruments used were the Psychological Resilience Questionnaire (CD-RISC-25- Connor Davidson Resilience Scale) and the Multidimensional Scale of Perceived Social Support (MSPSS). Data analysis used multiple logistic regression analysis.

RESULTS:

The characteristics of breast cancer patients aged more than 40 years old were 66.67%, 53.33% were highly educated, 52.50% were employed, 46.67% of breast cancer patients were married, 79.17% had insurance, 55.00% were in stages 3 and 4, and 54.17% were undergoing chemotherapy. The social support for breast cancer patients is mostly high at 62.50%. The study found that social support influences the resilience of cancer patients (OR = 3.6; 95% CI: 2.06–8.02) after controlling for factors such as age, education, employment, marriage, financing, cancer stage, and type of treatment.

CONCLUSION:

To increase the resilience of breast cancer patients undergoing treatment, social support is needed. The social support provided makes breast cancer patients more enthusiastic about living their lives so that they live well, and their acceptance of the condition they experience will be better.

Introduction

Breast cancer is the most cancer among women worldwide. It is estimated that the number of people with breast cancer reaches 2.1 million women every year. In 2015, people living with breast cancer reached 1,671,149 (11.9%), and in 2020, there will be an estimated increase of around 2.3 million new cases of female breast cancer (11.7%) of all new cancer cases.[1] In 2011, it was estimated that 39,520 women in the United States died from invasive breast cancer and there were about 230,480 new instances of the disease. In 2018, in the United States, the number of people with breast cancer was estimated at 231,840 invasive breast cancer in women and 60,290 additional cases of breast cancer in situ.[2]

Indonesia has the highest incidence rate of breast cancer in women, with 1.4 cases per 1000 people in 2013 and 1.79 cases per 1000 people in 2018. Breast cancer accounted for 65,858 new cases in 2020, or 16.6% of all 396,914 cancer cases in Indonesia, making it the cancer with the highest incidence rate.[3] Based on the Globogan report at 2022, the number of new cases of breast cancer reached 66,271 cases, ranking first of all types of cancer and contributing 16.2% of the total cancer cases in Indonesia. The number of deaths from breast cancer reached 22,598 deaths (ranked third of all cancers). In the past 5 years, it contributed 9.3% of total deaths from cancer. The prevalence of breast cancer in 2022 is 151.3 per 100,000 population. The cumulative risk of developing breast cancer before the age of 75 is 4.4%. The mortality risk from breast cancer before the age of 75 is 1.6%.[4]

The impact of breast cancer is all-encompassing, affecting not only physical health but also psychological, economic, and social wellbeing. The results of the study found that there were differences in the prevalence rates of resilience scores for women with breast cancer. Survival scores in breast cancer patients were found to be lower compared to the general population.[5] Long and heavy treatment has psychological implications in the form of boredom, depression, and other psychological illnesses that can be managed if the patient’s resilience is good.[6] Resilience is the ability to bounce back from adversity, such as stress, trauma, and disease, as well as the psychological characteristics that come along with it.[7]

A study shows that breast cancer patients with high resilience have lower levels of anxiety and stress than individuals with low resilience. Resilience helps a person reduce depression by developing positive coping mechanisms. A meta-analysis study found that breast cancer patients with high resilience have better survival rates.[8] Patients experience physical and psychological difficulties during the diagnosis process, the early phases of treatment, and the months that follow the end of treatment. During this period, adjustment is difficult for patients with low resilience. Resilience is one of the factors that influence breast cancer sufferers’ fatigue during the treatment process and affects patient survival.[9,10,11]

Long and difficult treatment requires social support for breast cancer patients. Social support is a source of coping, a factor related to psychosocial adjustment, where psychosocial adjustment increases with increasing social support.[12] Social support from family, friends, health workers, and the community plays a role in increasing the resilience of breast cancer patients. Social support in the form of emotional, tangible, and informational support will provide a sense of security, motivation, and hope for patients undergoing long treatment.[13] Social support plays an essential role in the resilience of breast cancer patients. Higher social support has predicted significantly longer survival rates in several studies. High-quality social support will increase resilience to stress and have a positive influence on resilience; that is, the higher the level of social support, the higher the level of resilience.[14]

Materials and Methods

Design study and setting

This study is an observational analytical quantitative study with a cross-sectional approach. The dependent variable (resilience), independent variable (social support), and covariates (age, education, employment status, marital status, financing, cancer stage, and type of treatment) were measured at the same time (point time approach).

Study participants and sampling

The target population of this study was all breast cancer patients who joined one of the two Indonesian breast cancer communities in 2023 and who met the inclusion and exclusion criteria of the study. The inclusion criteria of the study sample were breast cancer patients who had joined the community for the past 1 year until the study was conducted and were willing to become research respondents. The exclusion criteria of the study sample were breast cancer patients with severe conditions and severe complications, so they could not fill out the questionnaire. The research sample size was 220 breast cancer patients. The research sample size was 220 breast cancer patients. The technique for obtaining samples was by convenience sampling. Respondents were selected based on ease of access from social media. The respondents selected were patients who were members of the WhatsApp group of breast cancer patient communities in Indonesia. Data collection using an online questionnaire distributed to the target population through the WhatsApp group of breast cancer patient communities.

Data collection tools and technique

Dependent variable: Resilience

The Psychological Resilience Questionnaire (CD-RISC-25 - Connor Davidson Resilience Scale) was the tool utilized in this study to evaluate the resilience of breast cancer patients. There are 25 items in this questionnaire, and each one is rated from 0 to 4 on a Likert scale. There is a positive scoring scale. The subject with the highest score on the scale is the most resilient. The final score range of each respondent is 25–100.

Independent variable: Social support

The social support assessed is perceived support/support received from family, friends, health workers, fellow patients, and breast cancer survivors based on 4 (four) forms of support, which include emotional support, real support, information support, and friendship support. The questionnaire used was the Multidimensional Scale of Perceived Social Support (MSPSS). Modifications to the MSPSS questionnaire were carried out by adding components for Health Workers, Fellow Patients, and Breast Cancer Survivors, and the number of question items became 12 per source of social support, each consisting of three question items. About emotional support, there are three items about information, three items about reality, and three items about friendship. The final score range for each respondent after calculation is 48–192. The modified questionnaire used has undergone validity and reliability tests for accuracy and consistency of results.

Ethical considerations

Ethical clearance for this study was approved by The Ethical Committee Faculty Of Public Health University of Indonesia, Jakarta, Indonesia, under the number (617/UN2.F10D11/PPM0002/2023). All methods were conducted in accordance with the ethical committee guideline and regulations. Informed consent was obtained from all subjects.

Statistical analysis

Data analysis used univariate, bivariate, and multivariate analysis in this study. All stages of analysis were carried out using SPSS Ver software. 26. Multivariate analysis aims to test the relationship of several independent variables with one dependent variable simultaneously. This research was carried out using multiple logistic regression analysis to assess the association of social support with the resilience of breast cancer patients with α = 0.05.

Results

The subjects of this study were 220 breast cancer patients. The results of the analysis showed that most of breast cancer patients were over 45 years old (66.67%), 53.33% of breast cancer patients had a high level of education, 52.50% of breast cancer patients were employed, 46.67% were married and 45.00% were divorced, 79.17% were financed by insurance, 55.00% of breast cancer were cancer stages 3 and 4, and 54.17% of breast cancer patients undergo chemotherapy treatment [Table 1].

Table 1.

Description of the characteristics of respondents

Variables		Number (n)		Percentage (%)
Aged
≥45 years old     <45 years old		130 90		66.67 33.33
Education
Low education     Higher education		106 114		46.67 53.33
Employment status
Yes     No		113 107		52.50 47.50
Marital Status
Married     Single     Divorced		89 43 88		46.67 8.33 45.00
Financing
Personal cost     Insurance		75 145		20.83 79.17
Cancer stage
Stage 1 and 2     Stage 3 and 4		104 116		45.00 55.00
Type of treatment
Surgery     Chemotherapy     Radiotherapy     Hormonotherapy     Immunotherapy		80 85 50 55 40		50.00 54.17 25.00 20.83 16.67

The average resilience score of breast cancer patients was 77.54 from 100; the median score was 69.24, with the lowest resilience score of 45 and the highest 95. The average social support score of all respondents was 142.18 from 192. The social support score received by patients was 90, and the highest score was 175. The resilience and social support measurement scores obtained a skewness index (skewness/SE skewness) <2; this indicates that resilience and social support are normally distributed [Table 2].

Table 2.

Description of Resilience and Social Support Scores for breast cancer patients

Score		Resilience		Social Support
Number of samples Mean Score Median Score Minimum Score Maximum Score Skewness/SE Skewness		220 77.54 69.24 45 95 0.052		220 142.18 135.00 90 175 0.079

The resilience of breast cancer patients in this study was measured using the Connor-Davidson Resilience Scale (CD-RISC-25). Categorization of resilience levels was based on the average score parameter (77.54). Respondents with scores below the average were categorized as having high resilience, while respondents with scores equal to or higher than the average were categorized as having low resilience. Based on this category, more than half of the respondents (55.83%) had high resilience [Table 3].

Table 3.

Description of resilience and social support for breast cancer patients

Variables		Number (n)		Percentage (%)
Resilience
Low     High		103 117		44.17 55.83
Social Support
Low     High		95 125		37.50 62.50
Form of Social Support
Emotional
Low     High		96 124		38.33 61.67
Information
Low     High		109 111		49.17 50.83
Real
Low     High		117 103		55.83 44.17
Friendship
Low     High		114 106		53.33 46.67

The forms of social support examined in this study included emotional, informational, instrumental (tangible), and friendship support. Categorization of social support was based on the average score parameter (142.18). Respondents with scores below the average were categorized as having low social support, while respondents with scores equal to or higher than the average were categorized as having high social support. Table 3 shows that social support for breast cancer patients is mostly high, which is 62.50%. Social support in this study is categorized into four forms, namely, emotional support, information support, instrumental (real) support, and friendship support. A total of 61.67% of breast cancer patients received high emotional support, 50.87% received high information support, 55.83% received high instrumental support, and 53.33% received high friendship support [Table 3].

Bivariate analysis aims to analyze the relationship between independent variables and covariables with the dependent variable. Based on bivariate analysis, factors that have a significant relationship with breast cancer patient resilience include social support (P = 0.030) with a prevalence ratio (PR) of 3.62 (95% CI: 2.34–4.65). Covariates that also have a significant relationship with resilience are age (P = 0.034, PR = 1.94; 95% CI: 1.02–3.45), education (P = 0.032, PR = 2.73; 95% CI: 1.32–4.54), financing (P = 0.032, PR = 2.57; 95% CI: 1.23–5.67), and cancer stage (P = 0.028, PR = 2.88; 95% CI: 1.23–3.56). Meanwhile, other covariables such as employment status, marital status, and type of treatment did not show a significant relationship with patient resilience [Table 4].

Table 4.

Analysis of factors associated with resilience in breast cancer patients

Variables		Resilience				P		PR (95% CL)
		Low		High
Social Support
Low     High		49 (53.33) 43 (24.00)		46 (46.67) 82 (76.00)		0.030		3.62 (2.34-4.65)
Aged
≥45 years old     <45 years old		68 (53.75) 40 (37.50)		68 (46.25) 40 (62.50)		0.034		1.94 (1.02-3.45)
Education
Low education     Higher education		66 (73.21) 57 (50.00)		15 (26.79) 32 (50.00)		0.032		2.73 (1.32-4.54)
Employment status
Yes     No		48 (36.51) 40 (26.32)		65 (63.49) 67 (73.68)		0.070		1.61 (0.20-3.45)
Marital Status
Married     Single     Divorced		39 (41.07) 22 (60.00) 51 (62.96)		50 (58.93) 21 (40.00) 37 (37.04)		0.065		0.46 (0.23-0.70)
Financing
Personal cost     Insurance		40 (60.00) 60 (36.84)		35 (40.00) 85 (63.16)		0.023		2.57 (1.23-5.67)
Cancer stage
Stage 1 and 2     Stage 3 and 4		55 (55.56) 45 (30.30)		49 (44.44) 71 (69.70)		0.028		2.88 (1.23-3.56)
Type of treatment
Surgery     Chemotherapy     Radiotherapy     Hormonotherapy     Immunotherapy		40 (50.00) 71 (83.08) 33 (66.67) 29 (52.00) 30 (75.00)		40 (50.00) 14 (16.92) 17 (33.33) 26 (48.00) 10 (25.00)		0.063		1.34 (0.23-3.32)

Multivariate analysis was carried out to analyze the role of social support on the resilience of breast cancer patients by controlling confounding variables. Based on the results of the confounder variable evaluation analysis, it was found that all variables did not meet the criteria as confounders because none of them caused a change in PR >10%. However, all covariate variables are important variables that substantially influence social support and resilience in the lives of breast cancer patients and based on the initial model, all variables have a significant relationship with quality of life with a P value < 0.05.

Table 5 presents the final model illustrating the role of social support on the resilience of breast cancer patients. Breast cancer patients with low social support are 3.6 times more likely (95% CI: (2.06–8.02) to have lower resilience than breast cancer patients with high social support after controlling for factors such as age, education, employment status, marital status, financing, cancer stage, and type of treatment [Table 5].

Table 5.

Final model of the relationship between social support and resilience in breast cancer patients after controlling covariable

Variables		B		SE		P		APR (95% CL)
Social support
Low     High		1.366 Reff		0.354		0.002		3.60 (2.06–8.02) 1
Age
≥45 years old     <45 years old		0.556 Reff		0.234		0.007		(1.01-3.23) 1
Education
Low education     Higher		0.334 Reff		0.236		0.008		2.16 (1.03-5.45) 1
Employment status
Yes     No		0.776 Reff		0.235		0.030		1.62 (1.23-4.01) 1
Marital Status
Married     Not married		0.564 Reff		0.237		0.026		0.46 (0.25-0.87) 1
Financing
Personal cost     Insurance		0.556 Reff		0.183		0.045		2.12 (1.27-3.63) 1
Cancer Stage
Stage 1 and 2     Stage 3 and 4		0.554 Reff		0.157		0.034		2.12 (1.27-3.63) 1
Type of Treatment
Operation     Chemotherapy		0.675 Reff		0.253		0.025		1.57 (1.26-3.65) 1

Discussion

A person’s age affects a person’s resilience, especially for breast cancer patients. The process of maturation, emotional maturity, and acceptance of something difficult for oneself are all related to age. Breast cancer patients’ resilience tends to increase with age due to factors of life experience and better self-acceptance. One of the factors that influence the resilience of breast cancer patients based on age is social support, where young patients tend to be more active in seeking support through online communities, while older patients rely more on support from family.[15] Therefore, based on several studies, respondents aged >45 have a better proportion regarding resilience. Studies in Malaysia show that age is an important factor contributing to survival and good quality of life among adult female breast cancer patients, as well as a significant predictor for Global Health Status (GHS), where age >55 years contributes to good quality of life.[16,17]

The sociodemographic factor that has the biggest impact on determining resilience and health status is education. The respondents with the least amount of schooling frequently displayed signs of illness-related issues. Women with secondary and higher education scored higher than women with vocational education in a broad analysis of the health status and resilience of women diagnosed with breast cancer. Additional research findings indicate that women with higher education attainment are substantially more successful than women with vocational education in the areas of physical, emotional, cognitive, and sexual functioning.[16,18] Other study results showed a relationship between women’s education level and knowledge of breast cancer risk factors. Better knowledge can help patients develop effective coping strategies, increasing their resilience.[19]

Employment status will affect the patient’s financial situation and the relationships of breast cancer patients. Respondents’ excellent financial situation was associated with higher resilience globally and expressed in the form of functional scales and individual symptoms. Women who report having superior financial conditions perform better physically, fulfill social tasks, and exhibit higher levels of emotional and religious functioning.[18,20] Yan et al. (2016)[21] and Huang et al. (2017)[22] also found similar outcomes. According to their research, breast cancer patients with greater earnings had better quality of life. Higher family income has been linked to improved women’s quality of life and general health, according to other studies.[22]

The patient’s marital status will impact the support provided to the patient. The majority of married women, particularly those who marry young, experience the worst effects of mastectomy on their body image. Regardless of age, married women who get breast conservation typically have an idealized body image. Among single women, the benefits of breast conservation were seen only in the middle age gap: Older unmarried women had good body image, while younger unmarried women had poor body image, regardless of the type of surgery.[18,23] Breast cancer patients’ quality of life is predicted by their current marital status.[22] Social support, often from a partner, has been shown to have a positive relationship with resilience in breast cancer patients. This support can take the form of encouragement, attention, care, information, affection, and moral support, all of which contribute to increasing patient resilience.[24]

Financing related to the quality of life of breast cancer patients includes insurance ownership and the type of health insurance they have. The type of health insurance is directly related to a patient’s financial stress after a cancer diagnosis. The research results in China show that private insurance coverage of medical costs is higher than that of the government, where patients with private insurance financing have better resilience compared to those who have government insurance and do not have insurance.[21] The differences may be related to the different financial risks and cost burden of medical care due to breast cancer under various health insurance plans. The results of related studies show that stable financial conditions can reduce stress related to medical costs, thus potentially increasing breast cancer patient resilience.[25]

Diagnosis at a certain stage affects the quality of life and the type of treatment that breast cancer patients will undergo. According to other research, chemotherapy and tumor stage are reliable indicators of high levels of anxiety of progression. Patients with stages 0 and 1 have a better quality of life than those with stages 2, 3, and 4. Patients with breast cancer have much higher quality of life across the board depending on their stage of the disease.[26]

Breast cancer treatment often has significant short-term and long-term impacts on breast cancer resilience, with varying results for different types of treatment. Acute and chronic pain, scarring, structural alterations, breast asymmetry, loss of feeling, nerve damage, and diminished sexual function are a few outcomes of surgical treatments that can have varying effects on an individual’s quality of life. Relationships among many subgroups of breast cancer patients, such as younger women, survivors, those with advanced disease, and various therapy groups, have been found between resilience, body image, and quality of life.[18,27] Research on the relationship between treatment type and resilience in breast cancer patients shows that social support and patients’ understanding of treatment play an important role in increasing their resilience. A study examining the relationship between resilience and anxiety levels in breast cancer patients undergoing chemotherapy found that the higher the patient’s resilience, the lower the level of anxiety they experienced.[28]

Based on the research results, social support has a strong influence on the resilience of breast cancer patients after controlling for factors such as age, education, employment status, marriage, financing, stage of cancer, and type of treatment. Breast cancer patients with supportive social support are 3.6 times more likely to have low resilience than breast cancer patients with supportive social support. The large PR results between social support and the resilience of breast cancer patients show that there is a strong association between social support and the resilience of breast cancer patients. The results of this study are consistent with previous studies.

Positive treatment outcomes have been linked to social support for a number of chronic illnesses, including breast cancer. When someone is diagnosed with cancer, their stress level drops dramatically, and their emotional health also improves. Numerous studies have demonstrated the critical impact that social support plays in improving the psychological wellbeing of breast cancer patients.[13,29]

It is commonly recognized that social support plays a critical role in enhancing the effectiveness of treatment for those with chronic illnesses and conditions. Numerous studies demonstrate that people with breast cancer can receive and utilize a range of social supports, including material, financial, emotional, and informational support. Informational support, mainly from medical professionals, was the most common type of support that breast cancer patients received. Most participants found this type of support to be beneficial for understanding breast cancer treatment procedures, maintaining a healthy diet, and raising awareness about understanding of breast cancer.[13,30]

Emotional and financial support was also the main type of support received by participants in this study. This is in line with recent research showing that family and close friends provide the majority of the material and emotional support. The majority of informational support comes from health professionals, along with genuine emotional support primarily from family members. For women diagnosed with breast cancer, family and medical professionals are the key sources of social support; this may also be the case for individuals with other chronic illnesses.[31,32] Having emotional support is also very important during treatment. Various social supports are essential at different points throughout a person’s sickness trajectory and can be acquired from various sources. According to additional studies, a person may typically receive support from peers, family, close friends, and medical experts. They offer varying levels of needed social support.[17,29,33]

Social support plays a key role in easing the suffering experienced by those coping with breast cancer. When someone is helped in a tough situation, they can get a variety of forms of social support. Social assistance makes it easier for those going through a crisis to cope and better manage their challenging lives. Social support improves human functioning and, therefore, improves quality of life. In treating breast cancer patients, medical personnel need to consider psychosocial aspects, not just medical aspects. The social implications of forming a community of breast cancer patients can provide a space for them to share experiences and obtain broader emotional support. Hospitals and cancer centers can develop social support-based programs, such as patient support groups or psychological counseling.

Limitations and recommendations

Data were collected cross-sectionally, limiting the ability to draw causal conclusions. This study did not analyze the influence of social support on patient resilience based on time so that there is a possibility of temporal ambiguity. Selection bias may have occurred because the data were collected through an online survey distributed through digital channels and are therefore not fully representative of the general population. Another limitation is that it did not analyze social support with a qualitative study, thus not exploring the social support provided to breast cancer patients.

Conclusion

This research found that social support has a strong influence on the resilience of breast cancer patients after controlling for factors such as age, education, employment status, marriage, financing, stage of cancer, and type of treatment. Patients with high social support have higher resilience than those with low social support. Therefore, increasing social support for breast cancer patients can help improve their psychological resilience and improve quality of life. Further longitudinal studies are needed to verify this. The practical implication for clinical work is that when family members or medical professionals wish to provide support to breast cancer patients, they should pay more attention to the form of support provided and focus on the extent of support utilization. Further research could explore other factors that may moderate or mediate the relationship between social support and resilience, such as patient personality, cultural factors, or economic status.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Financial support was from Directorate of Research and Development, University of Indonesia under Hibah PUTI 2023 (Grant No. NKB-209/UN2.RST/HKP. 05.00/2023)