Introduction
Breast cancer is the most common cancer among women worldwide and the leading cause of cancer-related deaths in this population.1 Although lung cancer is the most commonly diagnosed cancer overall when considering both sexes combined, breast cancer remains the most frequently diagnosed malignancy, specifically among females.2 In the United States, breast cancer is the most common cancer among women, with an estimated 321,910 new cases and 42,140 deaths projected in 2026.3,4 The lifetime probability of developing breast cancer for women is approximately 1 in 8 (13.0%).1,4 Breast cancer risk increases with age, with the majority of cases diagnosed in women 50 years and older; however, 17% of cases occur in women younger than 50 years.1,4 Advances in early detection and treatment have resulted in a 92% 5-year relative survival rate, exceeding 99% for localized-stage disease.1,4
Statistics have shown that breast cancer represents 32% of all diagnosed cancers among women globally in 2020 and 16.5% of all cancers registered among Palestinians, and constitutes 14% of all cancer-related deaths in 2020.2 There are 520 cases of breast cancer diagnosed annually in Palestine.2 This is equivalent to 38.4 per 100,000 women.3 According to the Palestinian Ministry of Health, the number of Palestinian women receiving a breast cancer diagnosis is rising.4
Breast cancer is considered a deadly and dangerous disease at the psychological and physical levels. Patients with breast cancer experience great pressure, depressive disorders, and anxiety that are exacerbated by thinking about the expected results of the disease, physical appearance, and body image, especially after various treatment modalities such as chemotherapy, radiotherapy, and undergoing operations, and thinking negatively about the consequences and possibility of death.5
Study data have shown that patients with cancer experience anxiety and depression more than patients with other diseases.6 The importance of body image and the effect of different treatment modalities, such as mastectomy, affects the psychological status of the patients, which justifies the high frequency of anxiety and depression.7
Throughout the treatment journey from diagnosis to survival, women with breast cancer face many challenges, making them vulnerable and in urgent need of social support. Social support refers to an individual’s perception of the availability and accessibility of help and assistance.8,9 It has long been recognized as a key factor influencing an individual’s overall quality of life, particularly regarding social, emotional, and functional well-being.10 While social support focuses on the quantity and quality of social support, perceived social support (PSS) focuses on the availability and adequacy of social support that meets the specific needs of the patient. Women’s PSS refers to the availability of friends, family members, and significant others as sources of physical, material, emotional, psychological, and overall support throughout their lives.
Social support is any perceived support, in the form of physical, emotional, or psychological help, that helps individuals feel good and in control of themselves in a difficult situation.11 Data from studies have shown that social support, felt or perceived, has a positive effect.12 In another study, findings showed that adequate social support from parents, siblings, children, friends, and significant others during periods of the disease process is associated with less anxiety and depression among women with breast cancer.12
Anxiety and depression are more than just feeling down or having a bad or rough day. When a patient experiences lasting feelings of despair and sadness, it interferes with normal daily functioning. Even milder forms of depression have detrimental effects on quality of life, adherence to cancer and anticancer treatment, risk of suicide, and possibly even the mortality rate.13,14 Experiencing feelings of discouragement, hopelessness, lack of motivation, or uninterest in life in general, as well as having a tough day, results in anxiety and depression among patients with breast cancer. Depression and anxiety are common mental illnesses because they can occur at any point from diagnosis and treatment to recovery and post recovery.15,16
Recently, more attention and focus have been paid to the rapidly increasing mental problems, such as depression and anxiety, among women with breast cancer in Palestine.17 Diagnosis and treatment of breast cancer, and all related sequelae, can cause depression and anxiety for women,18 so it is important to assess the relationship between PSS, depression, and anxiety in women with breast cancer. The results of this study may help identify the importance of PSS and its relationship with anxiety and depression, which may improve the quality of life and increase longevity and response to therapy in the long term.9
Previous studies have focused on the direct associations between social support and anxiety and depression. On the other hand, this study will focus on PSS and its relationship with anxiety and depression across demographic and clinical variables. The distinction between social support and PSS is crucial. There is no standard for all women with breast cancer. Each woman has her circumstances, needs, worries, thoughts, and challenges. This highlights the importance of not only supporting them in general but also supporting them individually. Furthermore, while extensive research has been conducted internationally, limited studies have been conducted in the Middle East, particularly in Palestine. In the Arab world, social and cultural factors shape how women experience cancer and seek support. For instance, data from studies from neighboring countries have indicated that social and cultural factors emphasizing family cohesion are bidirectional, potentially enhancing or constraining women’s access to PSS.11,18 These challenges are even more pronounced in the Palestinian context due to political instability, restrictions, and limited access to health care services for patients with cancer, which may exacerbate anxiety and depression.2,17 In conservative communities such as Palestine, women with cancer experience social stigma that may prevent them from expressing their anxiety and needs.4,15 Therefore, investigating PSS in the Palestinian context is essential for understanding how social and cultural determinants influence psychological well-being among Palestinian women with breast cancer, and for developing contextually appropriate interventions.
The purpose of this study was to evaluate the association between PSS and depression and anxiety in Palestinian women with breast cancer. The study aimed to assess PSS, depression, and anxiety levels in these women; examine differences in PSS, depression, and anxiety based on personal characteristics; and analyze the relationship between clinical characteristics and PSS, depression, and anxiety.
Methodology
Study Design
A cross-sectional, descriptive approach was used to evaluate the association between PSS, anxiety, and depression in Palestinian women with breast cancer.
Participants and Setting
This study enrolled 257 women with a confirmed medical diagnosis of breast cancer. All participants were older than 18 years, had no concomitant conditions, and were able to read and write in Arabic. Individuals with psychological illnesses or confirmed metastases at the time of data collection were excluded. The sample size was determined using G*Power 3.1, based on a modest effect size, a power of 0.80, and an α of 0.05. Based on these parameters, the minimum required sample size was 150, but to account for an attrition or refusal rate, an overrecruitment strategy was applied. Therefore, 300 surveys were distributed to eligible participants, and 257 completed questionnaires were collected. The response rate exceeded the minimum required, thereby enhancing the statistical power and the representativeness of the findings. The study was conducted in a referral hospital specializing in the treatment of women with breast cancer. Potential participants were recruited to the study and informed about its purpose, significance, and related information. The sample was nonprobability convenience sampling.
Ethical Considerations
The research ethics committee of Birzeit University’s Faculty of Pharmacy, Nursing, and Health Professions approved the study. All data were kept confidential and used solely for scientific purposes. The cover page clearly outlined the research title, objectives, and research team members and their contact details. Participants’ names were not required, and they could ask questions, decline to participate, or withdraw from the study at any time without consequences.
Instrument
Perceived Social Support
The Medical Outcomes Study Social Support Survey was used to measure the support received, if needed, in 4 domains. It is a self-administered, multidimensional instrument containing 19 items. Each item is rated on a 5-point Likert scale. The scores for each subscale and for the total PSS were computed by averaging item responses, with higher scores indicating greater PSS. This survey is comprehensive in its coverage of perspectives on different aspects of social support. The survey results indicated that informational and emotional support should be assessed together. Consequently, 4 functional subscales were developed: tangible support (4 items), affectionate support (3 items), positive social interaction (3 items), and emotional/informational support (8 items). Item 13 is not classified under any specific subscale but contributes to the overall PSS scores.19
Anxiety and Depression
The Hospital Anxiety and Depression Scale (HADS) was developed by Zigmond and Snaith in 1983 to assess patients’ levels of anxiety and depression in nonpsychiatric hospitals.20 The HADS includes 14 items with 2 subscales assessing anxiety (7 items) and depression (7 items), which are rated on a Likert scale (range, 0-3). Each subscale’s scores are calculated by summing the relevant items. The maximum score for each subscale is 21. A score ranging from 0 to 7 is classified as normal, 8 to 10 is considered borderline, and 11 to 21 indicates anxiety and depression.
Data Collection
After ethical approval, participants were recruited to the study and informed about the objectives, benefits, risks, and ethical considerations at a referral oncology hospital in the West Bank. The participants who were willing to participate and met the eligibility criteria were given the questionnaire. The authors were available to answer any related questions. The data were then collected and entered into an SPSS file, which was stored on a personal computer protected by a strong password.
Variables
The independent variables in the current study were sociodemographic, including marital status, education, occupation, age, and PSS. The dependent variables were anxiety and depression. The researchers controlled bias by increasing the sample size, applying inclusion and exclusion criteria, developing a detailed, planned data collection procedure, and using appropriate SPSS tests to meet the study’s objectives.
Data Analysis
The data were analyzed by using SPSS version 27 and inserted and coded. The data were screened for missing and outlier variables. No outliers were found. If the questionnaire had more than 3 missing data points, it was excluded. No outliers were found. If the questionnaire had more than 3 missing data points, it was excluded. However, the questionnaires with fewer than 3 missing data points were replaced by the mean. Then a descriptive analysis was run to illustrate the frequency, percentages, mean, standard deviation, and variance. Finally, inferential statistics were run to assess the relationship between PSS, anxiety, and depression, and demographic and clinical variables. Differences in PSS, anxiety, and depression according to sociodemographic characteristics of the participants were analyzed using a t-test and ANOVA. P < .05 was considered significant.
Results
A total of 257 women with established diagnoses of breast cancer were included in the study. Most women (95%) were married (n = 245), with a mean age of 51 ± 9.8 years. The maximum age was 68 years, and the minimum age was 26 years (Table 1). Most of the sample had completed only primary school (59.5%, n = 153). Most of the (95.2%) study respondents were housewives (n = 244). Regarding PSS, the results show the mean total scores for each subclass and the total PSS. Tangible support was moderately high; it was the highest subclass of PSS (mean; M = 85.9), whereas the lowest was emotional/informational support (M = 60.5). These results indicated that perceived tangible support is much better than perceived emotional support. Regarding anxiety and depression, the results indicated that participants experienced mild levels of both conditions. The mean anxiety score was 7.8 (SD = 3.3), and the mean depression score was 8.3 (SD = 3.6), as presented in Table 2.
As shown in Table 3, all subclasses of PSS were significantly negatively correlated with anxiety and depression. The correlation coefficients ranged from r = –0.124 (P = .048) between emotional/informational support and anxiety to r = –0.428 (P < .001). Depression had the lowest correlation with tangible support (r = –0.272; P < .001), and the highest with emotional/informational support (r = –0.373; P < .001). It is worth noting that depression has a strong correlation with the overall PSS (r = –0.462; P < .001). Age was significantly positively correlated with tangible support (r = 0.171) and negatively correlated with positive social interaction (r = –0.349).
An independent sample t-test was run to assess the differences between patients who were single and married and between workers and housewives. The results showed that there were significant differences between patients who were single or married regarding emotional support (t = –2.5; P = .028), positive support interaction (t = 4.71; P < .001), and total PSS (t = –2.72; P = .019). There were no significant differences in anxiety and depression between single and married patients. The mean of the data showed that single patients have more support than married patients. Moreover, significant differences were found between employed and housewife patients for tangible support (t = –3.08; P = .009), affectionate support (t = –3.36; P = .001), and positive support interaction (t = 2.88; P = .013). There are also significant differences between employed and housewife patients in anxiety (t = –3.65; P < .001) and depression (t = –18.75; P < .001). The results showed that housewives experienced more support than employed patients (Table 4).
However, they have more anxiety and depression. With education levels, significant differences were found in tangible support (F = 8.02; P < .001), positive support interaction (F = 24.29; P < .001), anxiety (F = 12.36; P < .001), and depression (F = 16.68; P < .001). A post hoc analysis (Table 5) run by the Scheffé test, a post hoc test known for its conservative approach in controlling Type I error, was used for multiple comparisons and showed that the differences were mainly accounted for in highly educated women (P < .05).
Discussion
This study aimed to highlight the PSS for women with breast cancer, recognizing that social support is experienced differently by everyone. Therefore, understanding the domains of social support is paramount for detecting its aspects. Social support is highly correlated with the success and prognosis of breast cancer treatment, and its correlation with anxiety and depression highlights the importance of providing social support. Tangible support is moderately highly perceived by women with cancer. This is important, but it is not enough because the emotional/informational support is mild (M = 60.5). Each patient needs support that encompasses all aspects and is genuinely perceived by patients.
Anxiety and depression are common problems among patients with cancer. Park et al21 conducted a study about anxiety and depression among young women with breast cancer and found that anxiety and depression were prevalent among a considerable proportion. Findings from another study found that 15% and 20.4% of patients with breast cancer were experiencing anxiety and depression, respectively. The higher prevalence of depression vs anxiety found in this study is consistent with the literature.22
PSS was negatively correlated with anxiety and depression (r = –0.351, P <.001; r = –0.462, P <.001). This means that if PSS increases, anxiety will decrease. This is the same for depression: the more PSS, the less the depression. This is consistent with data from a study conducted in Iran. The authors found that PSS was negatively correlated with anxiety and depression.8
Political instability, restricted mobility, and a conservative community play a crucial role in shaping the PSS among Palestinian women with breast cancer. These factors reinforce traditional family cohesion but may also conceal emotional distress. Moreover, barriers to accessing health care services and limited psychosocial services in government hospitals constrain access to professional support. Therefore, the perceptions of social support among Palestinian women with breast cancer are more connected to informal familial and communal solidarity. Thus, interventions to improve PSS in Palestine may include, but are not limited to, strengthening community-based initiatives, empowering family members with psychosocial skills, and advocating for greater access to health care services.
Educational level, occupation, and marital status were correlated with PSS, anxiety, and depression. The results showed that highly educated women tend to receive and experience less support but also experience less anxiety and depression. This may be because family and friends expect that a woman with breast cancer has the required information, strengths, and power to fight the disease. Housewives experience more support but more anxiety and depression. This could be due to their financial needs throughout their treatment journeys. Unexpectedly, single women experience more PSS than married women. Although this finding appears counterintuitive, it can be better understood within the sociocultural context of Palestine. Single women with breast cancer may receive social support from their parents and siblings. The families of women with breast cancer assume primary caregiving roles during the disease journey. In contrast, married women with breast cancer, especially with children, may have household and caregiving responsibilities that may limit the PSS. Age was significantly correlated with PSS, anxiety and depression. The results showed positive correlations with anxiety, depression, and a negative association with PSS. This means that the older the women with cancer, the more anxiety and depression, and less PSS. These results are partially consistent with previous studies. Anxiety and depression levels are significantly correlated with educational level and employed women.23 Housewives had a higher level of depression than working women. Data also showed that anxiety and depression levels are not correlated with age or marital status.24
Conclusion
In conclusion, our study data found that women with breast cancer had lower levels of depression and anxiety than results from other studies showed. The findings reflect the importance of providing social support at all levels and in an individualized way. Although women with breast cancer have mild to moderate levels of PSS, they also have borderline anxiety and depression. The PSS, especially at emotional/informational levels, should be enhanced. Women with breast cancer need not only tangible support but also someone trustworthy who can provide active listening, information, and advice throughout the treatment journey. Special consideration should be provided for unemployed, older, and less educated women.
Ensuring adequate PSS, especially to housewives, providing adequate information to patients about their illness, informing them about the importance of taking care of the psychological aspect and providing information to their families about the necessity of that, and providing them with PSS at all levels to improve treatment and enhance quality of life may alleviate the perceived anxiety and depression.
Limitations and Recommendations
This study was conducted in a referral hospital for cancer treatment, but the results cannot be generalized to all Palestinian women with breast cancer. The cross-sectional design hindered the causal inference between PSS and anxiety and depression. Moreover, the sample was overwhelmingly homogeneous in terms of marital and occupational status. This homogeneity, in addition to the limitations in the statistical power resulting from small subgroup sizes, restricts the generalizability of the findings to unmarried and employed women with breast cancer. The results should be considered with caution. Multisite, longitudinal studies are recommended to make the results more generalizable and to assess the effect of time on the PSS. Furthermore, the absence of a disease stage is another limitation of this study. Disease stage is a determinant for psychological status for women with breast cancer. Women who are diagnosed at an early stage may experience less anxiety, depression, and dependency on social support compared with those diagnosed at an advanced stage. Lack of these data limited the ability to control for the stage as a confounding variable on the relationships between PSS, depression, and anxiety.
Conflicts of Interest/Competing Interests
No researchers in this study reported any conflicts of interest.
Data Availability Statement
The data sets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Authors’ Contributions
IA, MD, and MA were responsible for conceptualization, methodology, software, formal analysis, writing (original draft), writing (review and editing), and supervision.
Ethics Approval
The research ethics committee of Birzeit University’s Faculty of Pharmacy, Nursing, and Health Professions approved the study.
Consent to Participate
All data were kept confidential and used solely for scientific purposes. Participants’ names were not required, and they were free to ask questions, decline participation, or withdraw from the study at any time without consequences.
Acknowledgments
The authors wishes to extend sincere appreciation to women with a confirmed medical diagnosis of breast cancer who took part in the study.
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