Breast cancer is one of the most common diseases among women. [1] According to the World Health Organization (WHO) reported in 2022, new cases of breast cancer and a mortality rate were 2.26 and 0.68 million per year, respectively. [2] In Thailand, breast cancer is the most common cancer occurring among women with 22,158 new cases and 8,266 deaths annually. Moreover, new breast cancer cases have increasingly been diagnosed and reported globally, revealing breast cancer as a significant public health issue for Asian women worldwide. [3] Even though cancer deaths are prevalent, early diagnosis through detecting cancer by screening provides asymptomatic patients a greater chance of recovery.
Cancer survivor refers to patients diagnosed with cancer from their first diagnosis throughout their life as cancer patients. Most survivors face a variety of cancer-related effects, including physical, mental, and social impacts. After receiving treatments, patients experienced physical symptoms such as chronic pain, [4] dizziness, fatigue, insomnia, forgetfulness, [5] and discomfort. [6] Mental symptoms encompassed stress, anxiety, and depression. [7] Such stress may contribute to anxiety and depression, leading to an increased risk of suicide. Social impacts entail incompatibility with other family, friends, and colleagues; inability to maintain their family and social roles; and risk of working problems due to frequent sick leave and compromised work performance.[8] Such problems may cause an imbalance in the psychological well-being of breast cancer survivors. However, some of them reported good psychological well-being without mental health problems, felt happy, had satisfaction in life, and handled both disease conditions and lifestyle changes.
Psychological well-being (PWB) is a condition without any mental health problems and a vital indicator of personal mental health, mental strength, optimism, and the ability to live everyday life. [9] PWB has six dimensions: living with self-competence, autonomy, purpose, self-acceptance, personal growth, positive relationships with others, and environmental mastery. [9] For breast cancer survivors, PWB is linked with lifestyle changes, good mental health conditions, self-acceptance, self-confidence, self-improvement, goal setting, building healthy relationships, and handling confrontations with confidence. Those who adapted their lifestyle could recover quicker after receiving the treatments. [10, 11] Studies examined factors influencing breast cancer survivors’ PWB, including stress, [12, 13] self-efficacy, [14, 15] social support, [16, 17] and resilience. [14, 18]
Stress is a personal perception reacting to stimuli, which causes physical changes and physiological imbalance between biology and biochemistry in response to those stimuli. [19] Breast cancer is considered a life-threatening condition leading to stress, which causes lifestyle changes, worsen mental health, [20, 21] emotional adjustment, and lower quality of life. [22, 23] Breast cancer patients evaluated their illness as a threat affecting their perceptions and raising stress levels and psychological disruptions. [24] However, factors like recognition of social support, self-efficacy, and resilience provided positive PWB enabling patients to survive breast cancer.
Social support is a key factor related to PWB, [18] perceived interactions and support, [25] and illness management for breast cancer survivors. Social support helps promote an appropriate adaptation, leading to good mental health conditions. Optimal social support facilitates self-adaptation and promotes self-acceptance of the illness condition. [26]
Self-efficacy refers to a personal belief in their capability to do something that urges how they live. Self-efficacy is personal feelings, thoughts, motivations, and behaviors. [27] Studies demonstrated that self-efficacy is an essential characteristic of successful self-management for the effects of cancer and its treatments. On contrary, cancer patients with low self-efficacy were more like to experience depression. [28] Generally, cancer patients aim to be successful in their self-management, which is one of the components of mental health. Additionally, a lack of/low levels of depression would be an ideal. Therefore, self-efficacy is correlated with PWB in cancer patients.
In addition, resilience is associated with PWB, perceived growth and quality of life in breast cancer survivors. Perception of Growth is a component of PWB, while PWB is an essential factor in the quality of life. Hence, patients with positive perceptions of growth are more likely to report greater PWB and better quality of life. [29] Resilience is a personality that individuals apply to protect themselves from undesirable events and to overcome negative experiences happening in their life [30], such as being diagnosed with cancer. [31] Although the above-mentioned factors were examined among patients with cancer and other chronic diseases, [16, 32, 33]; however, limited research simultaneously tested all factors in the same study. Thus, it is inclusive on the magnitude of the effect of each factor. Moreover, most studies focused on promoting the quality of a patient's life rather than PWB. It is unclear which factors predict PWB among breast cancer survivors.
Accordingly, this study aimed to examine the factors that predict PWB in breast cancer survivors in Thailand. It is hypothesized that stress, perceived social support, mindfulness, self-efficacy, and resilience would significantly predict PWB among breast cancer survivors in Thailand. Findings from this study would increase the awareness of healthcare providers on PWB and It should result in self-acceptance and the ability to live happily as a cancer survivor, maintaining good PWB.
Theoretical framework
This research was guided by the Kumpfer’s resilience framework [34], comprising six core concepts; stressors and challenges, external environmental context, person-environment transactional processes, internal resilience factors, resilience processes, and positive outcomes.
Considering the Kumpfer's framework and the factors relating to PWB, one recognizes that the breast cancer survivors need surveillance for a recurrence, requiring continuous monitoring of treatment results. Cancer-related stress may lead to poor mental health. However, environmental contexts (such as social support from family, friends, and significant people) can minimise the effects of stress. The internal resilience factor and resilience process can lead to good adaptation. Self-efficacy and well-resilience grounds the ability to deal with stress and threats and reduce the chances of problems in adapting to the stress of being a breast cancer survivor. These enabling factors result in a positive outcome of effective adaptation to mental health problems and allow for PWB.
Breast cancer survivors are a group with life goals. They have self-acceptance and good relationships with others, can adapt to threats, have the potential for self-improvement, and can make choices themselves. Besides, they have a purposeful life, take good care of their health, work to reduce relapse, and achieve long-term survivorship. This determination to survive is consistent with the Ryff and Keyes [35] PWB concept that recognizes PWB as a personal commitment to a positive lifestyle. Its six dimensions consist of; autonomy, self-acceptance, positive relationships with others, purpose in life, environmental mastery, and personal growth, as shown in Fig. 1.