Research title: Coping Skills and its Associated Factors Among Breast Cancer Women in Iraq: A Cross-Sectional Study

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Despite improvements in early detection and treatment, breast cancer survivors continue to face long-term challenges after diagnosis. This study aims to evaluate the coping skills employed by breast cancer women in Iraq and to identify the sociodemographic, clinical, and psychological factors associated with these coping behaviours. Methods: A cross-sectional study was conducted among 244 breast cancer women in the Medical City Teaching Oncology Hospital, Baghdad, Iraq, from August 2023 to October 2023. Coping skills and psychological factors were assessed using the BRIEF COPE-28 and Hospital Anxiety Depression scale, respectively. Sociodemographic and clinical characteristics were also taken. The associations between the coping skills and associated factors were evaluated using multiple linear regression analysis. Results: The mean (SD) coping skills for active coping, passive coping, and seeking support were 5.96 (1.31), 4.00 (1.10), and 7.58 (0.84), respectively. Multiple linear regression revealed hormonal therapy, anxiety, and depression were significant factors influencing active coping. The passive coping associated factors were the type of surgery and anxiety. The seeking support was notably affected by the stage of disease, duration since surgery, and anxiety. Conclusion: This study highlights the association factors influencing the coping skills among breast cancer women in Iraq, and the need for targeted psychological and clinical interventions to improve coping skills. breast cancer coping skills association factors 1. Introduction Breast cancer (BC) remains the most common cancer among women worldwide, accounting for 18% of all female cancers. Moreover, over 100 countries report it as the leading cause of cancer-related deaths [ 1 ]. In Iraq, BC was the most prevalent cancer in 2020 [ 2 ] despite advancements in early detection and treatment [ 3 ]. BC survivors often experience long-term physical, social, emotional, and psychological challenges that persist well beyond treatment [ 4 ]. In particular, women in developing countries, including Iraq, face unique difficulties after being BC diagnosed. These challenges range from managing physical symptoms to coping with the emotional distress brought about by their diagnosis and treatment [ 5 ]. However, many women adopt coping skills to address these physical and psychological burdens. Indeed, the process of adapting to BC involves managing a wide range of stressors, including the effects of surgery, the side effects of adjuvant therapies, and changes in life circumstances [ 6 ]. Furthermore, research has shown that coping skills vary significantly among individuals, shaped by personality, prior experiences, and environmental influences [ 7 ]. According to Lazarus and Folkman's stress and coping theory, coping is defined as the cognitive and behavioural efforts people make to manage specific demands perceived as stressful. Generally, coping skills are categorized into active, passive, and seeking support [ 6 ]. Thus, coping skills are crucial in helping BC patients adapt to the challenges of their diagnosis and treatment [ 8 ]. Despite this, significant gaps remain in the literature regarding its role in BC patients at different stages of the disease [ 9 ]. Therefore, this study aims to assess coping skills and their sociodemographic, clinical, and psychological associated factors among BC women in Iraq. 2. Methods of Study 2.1 Study design. This cross-sectional survey was conducted in the Medical City Oncology Hospital in Baghdad, Iraq. Convenient sampling was applied from August 1, 2023, to the 1st of October 2023. Inclusion criteria included women aged 18 to 70 years diagnosed with BC (at least 6 to 24 months before the interview), in stages I to IV, who had undergone breast surgery and received chemotherapy and radiotherapy, proficient in reading and understanding Arabic. Written informed consent was used in this study. Participants were informed that they had the right to withdraw from the study at any time without affecting medical services. 2.2. Study Instruments The study instruments include questionnaires to collect socio-demographic and clinical data., The Hospital Anxiety and Depression Scale (HADS) was used to assess the psychological level, and the Brief COPE- 28 scale was used to determine the coping skills. The sociodemographic variable includes (age, marital status, level of education, employment status, financial perception, number of children). Clinical data were obtained from the medical records. Clinical characteristic variables include history of chronic disease, menopausal status, family history of BC, duration of BC diagnosis, stage of disease, affected breast(s), metastasis breast cancer, number of metastatic sites, duration since of surgery, mastectomy operation, breast reconstruction, Chemotherapy treatment line, hormonal therapy. The Hospital Anxiety and Depression Scale (HADS) was adapted from Zigmond & Snaith [ 10 ] to assess the psychological levels of BC women. This self-report scale comprises 14 items on a 4-point Likert scale (range 0–3), with seven items each for anxiety and depression subscales, each subscale score ranging from 0 to 21. Anxiety and depression levels were calculated using cut-off scores [ 11 ]. Studies consistently demonstrate the robust internal consistency of HADS, validating its reliability in clinical practice, including applications in the Arab population [ 12 ]. The Cronbach’s α for the HADS anxiety subscale was 0.83 at time 1 and 0.87 at time 2, while for the depression subscale, it was 0.77 at time 1 and 0.80 at time 2. These results indicate adequate internal consistency among patients for both HADS subscales at both time points. The Brief COPE-28 scale was used to assess the coping skills of BC women. Developed by Carver (1997) [ 13 ], it consists of 14 subscales, including (self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, planning, humour, acceptance, religion, and self-blame), each evaluating specific coping behaviours with scores ranging from 2 to 8. Higher scores indicate increased utilization of that particular coping skill. Responses to the items of the Brief COPE were rated on a four-point scale, with 1= ‘I have not been doing this at all, 2= ‘I have been doing this a little bit, 3= ‘I have been doing this a medium amount’ and 4= ‘I have been doing this a lot [ 14 ] The validity and the internal reliability of the Brief-COPE- 28 questionnaires for Arabic society were established in several studies, and the validity and reliability records for the Brief-COPE questionnaire were considerably adequate [ 15 ]. The Arabic version of the brief cope used in this study is characterized by a 3-factor structure incorporating adaptive and maladaptive coping methods, or ‘active’ and ‘passive’ coping, which is more appropriate; it was found to be a valid and reliable instrument among the Arab population. This makes the scale valuable in both clinical practice and clinical research. The first factor included ‘active coping,’ planning,’ ‘positive reframing,’ ‘acceptance,’ ‘humour,’ religion,’ one item from ‘self-distraction,’ and one from ‘venting.’ This factor was called ‘active coping; the second factor included all items from ‘denial,’ ‘substance use,’ behavioural disengagement,’ ‘self-blame,’ ‘venting,’ and ‘self-distraction. ‘ The third factor included all items from ‘using emotional support’ and ‘using instrumental support’ and was named ‘support-seeking[ 16 ]. 2.3. Data collection Written informed consent was obtained, and data were collected through face-to-face interviews, with clinical details extracted from medical records. The supervisor trained data collectors to ensure quality, and the principal investigator monitored the process. 2.4. Statistical Methods Data analyses were performed using SPSS version 26.0. Descriptive statistics were performed, including measures of central tendency (mean, standard deviation (SD)), frequency, and percentage of categorical variables. Simple and multiple linear regressions were conducted on all independent variables. Variables with a p-value < 0.025 were selected for inclusion in multivariate analysis. Multiple linear regression used forward selection to identify factors associated with coping skills. The basic assumptions for linear regressions, particularly the normality of residuals, were verified. The beta regression coefficient, t-value, and p-value were specified for each dependent variable. Statistical significance was set at a p-value ≤ 0.05. 3. Result Out of 261 eligible participants, 244 completed the questionnaires, resulting in a response rate of 93.48%. The primary reasons for dropout included time constraints, survey fatigue, lack of interest or perceived relevance, and emotional distress. Table 1 : illustrated the sociodemographic, clinical, QOL, coping skills, and psychological characteristics of BC Women, the mean (SD) age of the participants was 49.31 (9.08) years. Clinically, 53.7% had been diagnosed for over 12 months and the majority (89.8%) were in stages I and II of breast cancer. In terms of coping skills, the mean (SD) for active coping, passive coping, and seeking support scores were 5.96 (1.31), 4.00 (1.10), and 7.58 (0.84), respectively. Table 1 Descriptive of Sociodemographic, Clinical, QOL, Coping Skills, and Psychological Characteristics of BC Women (n = 244). Characteristics n (%) Mean (SD) Yes No Sociodemographic Characteristics Age (years) 49.31 (9.08) Marital status Single 43 (17.6) Married or cohabiting 201 (82.4) Education level Low education 164 (67.2) High education 80 (32.8) Employed status Employed (or retired) 57 (23.4) Unemployed 187 (76.6) Financial perception Not enough 178 (73.0) Enough 66 (27.0) Number of children 0–3 115 (47.1) >3 129 (52.9) Clinical Characteristics Duration of BC diagnosis ≤ 12 months 113 (46.3) > 12 months 131 (53.7) Menstrual status Menstrual interruption 206 (84.4) No interruption 38 (15.6) Stage of disease Stage (I and II) 219 (89.8) Stage (III and IV) 25 (10.2) Affected breast Unilateral 235 (96.3) Bilateral 9 (3.7) Family history of breast cancer Yes 108 (44.3) No 136 (55.7) History of chronic disease Yes 104 (42.6) No 140 (57.4) Type of surgery Mastectomy 221 (90.6) Lumpectomy 23 (9.4) Duration since of surgery At least six months 55 (22.5) More than six months 189 (77.5) Metastatic breast cancer Yes 39 (16.0) No 205 (84.0) Breast reconstruction Yes 11 (4.5) No 233 (95.5) Hormonal therapy Yes 129 (52.9) No 115 (47.1) Chemotherapy treatment line Chemotherapy only 118 (48.4) Chemotherapy + radiation 126 (51.6) Brief COPE-28 Active coping 5.96 (1.31) Passive coping 4.00 (1.10) Seeking support 7.58 (0.84) The Hospital Anxiety and Depression Scale (HADS) Anxiety 99 (40.6) Depression 106 (43.4) Table 2 The regression analyses identified several factors associated with the coping skills of BC women. For active coping, the absence of hormonal therapy, anxiety, and depression was negatively associated with active coping in both the simple and multiple regression analyses. In terms of passive coping was negatively associated with undergoing a mastectomy and positively associated with anxiety and depression in the simple regression; however, it was positively associated with undergoing a mastectomy and Anxiety in multiple regression. For the domain of seeking support, it was negatively associated with the stage of the disease and depression in the simple regression, and negatively associated with the stage of the disease in multiple regression. However, it was positively associated with the duration since surgery and anxiety in both the simple and multiple regression analyses. . Table 2 Regression Analysis Findings on Factors Associated with Coping Skills in BC Women (N = 244) Variable Simple linear regression Multiple linear regression b(95%CI) t-statistic P value Adjusted b(97.5%CI) t-statistic P value Factor associated with active coping among BC women Hormonal therapy Yes - - - - - - No -0.37-(-0.75, -0.00) -2.27 0.024 -0.35 (-0.68, -0.02) -2.43 0.016 Anxiety -0.09 (-0.12, -0.06) -7.35 ≤ 0.001 -0.04 (-0.08, -0.00) -2.47 0.014 Depression -0.13 (-0.16, − .009) -8.32 ≤ 0.001 -0.08 (-0.13, -0.03) -4.04 ≤ 0.001 Factor associated with passive coping among BC women Type of surgery Mastectomy -0.64 ( -1.18, -0.10) -2.70 0.007 0.60 (0.10, 1.11) 2.71 0.007 Lumpectomy - - - - - - Anxiety 0.06 (0.04, 0.09) 06.18 ≤ 0.000 0.06 (0.04, 0.09) 6.10 ≤ 0.000 Depression 0.07 (0.04, 0.11) 5.60 ≤ 0.000 - - - Factor associated with seeking support among BC women Stage of disease Stage (I &II) -0.85 (-1.05, -0.64) -9.47 ≤ 0.001 0.87 (0.71, 1.03) 12.41 ≤ 0.001 Stage (III& IV) - - - - - - Duration since of surgery < 6 months - - - - - - ≥ 6 months 0.47 (0.32, 0.63) 6.82 0.000 0.55 (0.43, 0.66) 10.63 ≤ 0.001 Anxiety 0.00 (-0.00, 0.01) 0.82 0.408 0.20 (0.14, 0.25) 7.69 ≤ 0.001 Depression -0.00 (-0.01, 0.01) -0.28 0.775 - - - *Dependent variable: Active coping skills, Passive coping skills, seeking support *Independent variable: sociodemographic, clinical characteristics, and psychological factors. *Forward multiple linear regression methods were applied. Model assumptions are fulfilled, and no multicollinearity is detected. *The coefficient of determination (R2) for Active coping skills, Passive coping skills, and seeking support were (25.7%), (22.8%), and (56.7%) 4. Discussion The mean score for active coping suggests that BC women in Iraq predominantly engage in proactive strategies, such as planning, problem-solving, and acceptance, which help foster a sense of control and reduce distress[ 16 ]. Conversely, the lower mean score for passive coping indicates that avoidance and denial are less commonly used. However, reliance on passive coping can lead to feelings of helplessness and increased psychological distress, as supported by O´smiałowska et al. (2021) and Zamanian et al. (2021), who found that passive skills often exacerbate mental health issues and symptom burden [ 7 ] [ 8 ]. The high mean score for seeking support emphasizes the critical role of social support in coping. Emotional and instrumental support from family, friends, and healthcare providers enhances emotional well-being and resilience [ 9 ]. This is consistent with other studies showing that seeking support reduces isolation and fosters psychological resilience[ 17 ] [ 18 ]. In the present study, none of the demographic variables were associated with any coping skills in patients with breast cancer. This is supported by Mohammadipour, M, who found in their study that none of the demographic variables were significantly associated with coping skills [ 9 ]. Related to active coping skills and clinical characteristics, women who did not undergo hormonal therapy experienced a decrease in active coping skills scores compared to those who did receive hormonal therapy. This decrease could be the effect of hormonal treatment on hormonal balance. Hormonal therapy may contribute to stimulating behaviours that enhance active coping, such as developing relaxation skills and changing harmful behaviours, thus potentially having a positive effect on active coping skills. This result alignment with a study conducted by Gutiérrez-Hermoso et al. (2022) They reported that women who did not undergo hormonal therapy showed a decrease in active coping skills, possibly due to the positive effects of hormonal balance on coping behaviours [ 19 ]. This interpretation is supported by Morales-Sánchez, 2021, who stated that the types of treatment to which the patient is subjected play a fundamental role in the strategy [ 20 ]. On the other side, active coping skills significantly moderate the relationship between psychological stress, anxiety, and depressive symptoms in BC women. Wang et al. (2012) reported a negative association between active coping behaviours and anxiety symptoms. Furthermore, Wang noted that combining "worrying about health" with "self-relaxation coping behaviours" significantly decreases anxiety, underscoring the importance of active coping in managing psychological distress[ 21 ]. BC Patients often engage in negative coping skills, including forgetfulness, frustration, and fear [ 7 ], where individuals attempt to escape anxiety-inducing thoughts related to their diagnosis. While this strategy may provide temporary relief, it can result in obsessive and intrusive thoughts over time, ultimately hindering survivors’ adherence to essential health behaviours, such as surveillance guidelines[ 22 ]. as in the current study identified a significant positive relationship between passive coping strategies and the type of surgery patients undergo. This finding is consistent with Ardakani (2019), who reported a positive correlation between body image and coping skills in women post-surgery. These coping skills significantly impact body image, predicting both favourable and unfavorable outcomes[ 23 ]. Moreover, the study found that increased anxiety scores were associated with a greater reliance on passive coping skills. Typically, passive coping involves avoiding or ignoring stressors rather than actively confronting them. This indicates that individuals with higher anxiety levels are more inclined to withdraw from challenges instead of addressing them directly. Supporting this, Dev et al. (2019) demonstrated that cancer patients who utilized passive coping skills such as alcohol, opioids, and other drugs experienced greater psychological distress[ 5 ]. In addition, this study found that women diagnosed with early-stage breast cancer (Stages I and II) are more likely to seek emotional or social support than those with later-stage diagnoses (Stages III and IV). Women in advanced stages may feel more hopeless, reducing their motivation to seek support, whereas early-stage patients are more likely to seek support as they adjust to their diagnosis and treatment. The study by Sørensen et al. , (2020) showed the role of social support in managing fatigue among early-stage breast cancer patients in alleviating fatigue symptoms and overall recovery[ 24 ]. Additionally, this study found that cancer patients' use of coping skills tends to decline as treatment duration increases. Initially, patients feel optimistic about dealing with their diagnosis, but this positivity wanes after several treatments. This finding aligns with a previous study indicating that cancer patients often experience loneliness, which negatively impacts their coping abilities[ 25 ]. The diagnosis requires women to transition from being healthy to facing a life-threatening disease, with coping styles and illness perception playing crucial roles in this adjustment. Psychological stress often accompanies diagnosis and treatment, and supportive coping styles and social support can mitigate this distress [ 26 ]. There is a positive correlation between anxiety and seeking support; as anxiety levels rise, so does the tendency to seek support. This relationship was confirmed by multivariate analysis, showing that anxiety and depression are significant predictors of coping styles [ 27 ]. Therefore, Psychological disorders in people with cancer are significantly affected by social support. Patients with good social support have fewer emotional and psychosocial problems and can better cope with their illness [ 28 ]. BC women often face significant disruptions in both personal and family life, primarily due to cancer-related uncertainty and fear of recurrence. These psychological stressors tend to increase reliance on emotion-focused coping skills, which are associated with heightened anxiety [ 23 ]. Similarly, social support plays a critical role in mitigating these effects, as it promotes functional coping skills and helps reduce symptoms of depression and anxiety[ 29 ]. Adequate perceived social support encourages individuals to seek reassurance from others regarding their health concerns, whereas insufficient support is linked to greater levels of health anxiety [ 30 ]. 5. Conclusion and recommendations The cross-sectional design of this study captures a momentary view of the participants' adaptation experiences, restricting the ability to evaluate how their coping skills evolve or the causal relationships between various factors and their adaptation outcomes. Furthermore, the reliance on convenience sampling may have introduced selection bias, potentially influencing the sample's representativeness. Therefore, additional research, including longitudinal studies and qualitative approaches, is essential to overcome these limitations and to gain a more comprehensive understanding of the adaptation processes among BC women in Iraq. 6. Limitations of study The study's cross-sectional nature provides only a snapshot of the participants' experiences, limiting the ability to assess changes over time or causality between factors and quality of life. Additionally, the use of convenience sampling may have introduced selection bias, potentially affecting the representativeness of the sample. Therefore, further research, including qualitative methods, is needed to address these limitations and gain deeper insights into the quality of life and coping skills of breast cancer patients in Iraq. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of The Universiti Sains Malaysia Research Human Research and Ethics Committee (USM/JEPeM/KK/23030229), and the Iraqi Ministry of Health have approved the study. Informed consent was obtained from all subjects involved in the study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This research was funded by Universiti Sains Malaysia, which provided the necessary support for conducting and completing this study. Author Contribution A prepared the main manuscript text, B provided primary supervision, while C and D contributed as additional supervisors. All authors reviewed and approved the final manuscript. Acknowledgement I thank all the breast cancer survivors who participated in this study. I want to thank the staff of the Teaching Oncology Hospital) in Baghdad- Iraq, for their support. Data availability The datasets analyzed during the current study are not publicly available due to ethical restrictions. but are available from the corresponding author on reasonable request. References Mustafa IJ, Abdullah OR, Al-Saffar N, Ahmed RF, Fouad M. Quality of Life Assessment in Women With Breast Cancer in Nineveh, Iraq. Cureus 2023, 16 , 1–8, 10.7759/cureus.51589 Sung H, Global Cancer. Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. cancer J Clin 2021, 71 . Rashid AA, Abdulzahra R, Hussein M, Hashim W. Assessing the Quality of Life in Breast Cancer Women: A Cross Sectional Descriptive Study. 2022, 23 , 2299–307, 10.31557/APJCP.2022.23.7.2299 Maurer T, Thöne K, Obi N, Jung AY, Behrens S, Becher H, Chang-Claude J. Health-Related Quality of Life in a Cohort of Breast Cancer Survivors over More Than 10 Years Post-Diagnosis and in Comparison to a Control Cohort. Cancers (Basel). 2021;13. 10.3390/cancers13081854 . Mohammed Al-Azri M. Coping With a Diagnosis of Breast Cancer-Literature Review and Implications for Developing Countries. Breast J. 2019;5:615. Nezamodini ZS, Rezvani Z, Kian K. Coping Response Following a Diagnosis of Breast Cancer: A Systematic Review Esmat. Electron Physician. 2017;9:3592–7. Zamanian H, Amini-Tehrani M, Jalali Z, Daryaafzoon M, Ala S, Tabrizian S, Foroozanfar S. Perceived Social Support, Coping Strategies, Anxiety and Depression among Women with Breast Cancer: Evaluation of a Mediation Model. Eur J Oncol Nurs. 2021;50:101892. 10.1016/j.ejon.2020.101892 . O´smiałowska E, ˛ag WM, Chabowski M, ´nska BJ-P. Coping Strategies, Pain, and Quality of Life in Patients with Breast Cancer. Clin Med Artic. 2021;10:2–16. Mohammadipour M, Pidad F, Coping Strategies. Locus of Control, and Quality of Life in Patients with Early-Stage Breast Cancer. J Psychol. 2021;155:375–86. 10.1080/00223980.2020.1816873 . Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Occup Med (Chic Ill). 1983;64:393–4. 10.1093/occmed/kqu024 . Salvetti M, de Machado G, Donato CSP, da Silva SCT. Prevalence of Symptoms and Quality of Life of Cancer Patients. Rev Bras Enferm. 2020;73:1–7. 10.1590/0034-7167-2018-0287 . Awad MA, Denic S, El Taji H. Validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires for Arabic-Speaking Populations. Ann N Y Acad Sci. 2008;1138:146–54. 10.1196/annals.1414.021 . Terkaw AS, Tsang S. Development and Validation of Arabic Version of the Hospital Anxiety and Depression Scale. Saudi J Gastroenterol ·. 2017;11:11. Carver CS. You Want to Measure Coping but Your Protocol’s Too Long: Consider the Brief COPE. Int J Behav Med. 1997;4:92–100. 10.1207/s15327558ijbm0401_6 . DeDios-Stern S, Lee EJ, Nitsch K. Clinical Utility and Psychometric Properties of the Brief: Coping With Problems Experienced with Caregivers. Rehabil Psychol. 2017;62:609–10. 10.1037/rep0000188 . Alghamdi M. Cross-Cultural Validation and Psychometric Properties of the Arabic Brief COPE in Saudi Population. Med J Malaysia. 2020;75:502. Harandy TF, Ghofranipour F, Montazeri A, Anoosheh M, Mohammadi E, Ahmadi F, Shokravi FA, Niknami S. Health-Related Quality of Life in Iranian Breast Cancer Survivors: A Qualitative Study. Appl Res Qual Life. 2010;5:121–32. 10.1007/s11482-010-9097-3 . Khalili N, Farajzadegan Z, Mokarian F, Bahrami F. Coping Strategies, Quality of Life and Pain in Women with Breast Cancer. Iran J Nurs Midwifery Res. 2013;18:105–11. Gutiérrez-Hermoso L, Velasco-Furlong L, Sánchez-Román S, Berzal-Pérez E, Alcocer-Castillejos N, Quiroz-Friedman P. The Effect of Treatment and Coping on the Quality of Life in Breast Cancer Patients: A Moderated Mediation Model. Qual Life Res. 2022;31:147–58. 10.1007/s11136-021-02885-3 . Morales-Sánchez L, Luque-Ribelles V, Gil-Olarte P, Ruiz-González P, Guil R. Enhancing Self-Esteem and Body Image of Breast Cancer Women through Interventions: A Systematic Review. Int J Environ Res Public Health. 2021;18:1–20. 10.3390/ijerph18041640 . Wang X, Wang SS, Peng RJ, Qin T, Shi YX, Teng XY, Liu DG, Chen WQ, Yuan ZY. Interaction of Coping Styles and Psychological Stress on Anxious and Depressive Symptoms in Chinese Breast Cancer Patients. Asian Pac J Cancer Prev. 2012;13:1645–9. 10.7314/APJCP.2012.13.4.1645 . Crosthwaite K, Advisor F, Lester J. The Mediating Role of Avoidant Coping in the Relationships between Physical, Psychological, and Social Wellbeing and Distress in Breast Cancer Survivors Andrea. 2021, 30 , 1–37, 10.1002/pon.5663.The Ardakani BY. Body Image and Its Relationship with Coping Strategies: The Views of Iranian Breast Cancer Women Following Surgery. Eur lournal cancer care. 2019;1:5–12. 10.1111/ecc.13191 . Sørensen HL, Schjølberg TK, Småstuen MC, Utne I. Social Support in Early-Stage Breast Cancer Patients with Fatigue. BMC Womens Health. 2020;20:243. 10.1186/s12905-020-01106-2 . Jabbarian LJ, Korfage IJ, Červ B, van Delden JJM, Deliens L, Miccinesi G, Payne S, Thit Johnsen A, Verkissen MN, Wilcock A, et al. Coping Strategies of Patients with Advanced Lung or Colorectal Cancer in Six European Countries: Insights from the ACTION Study. Psychooncology. 2020;29:347–55. 10.1002/pon.5259 . Alcalar N, Ozkan S, Kucucuk S, Aslay I, Ozkan M. Association of Coping Style, Cognitive Errors and Cancer-Related Variables with Depression in Women Treated for Breast Cancer. Jpn J Clin Oncol. 2012;42:940–7. 10.1093/jjco/hys119 . Okati-Aliabad H, Ansari-Moghadam A, Mohammadi M, Kargar S, Shahraki-Sanavi F. The Prevalence of Anxiety and Depression and Its Association with Coping Strategies, Supportive Care Needs, and Social Support among Women with Breast Cancer. Support Care Cancer. 2022;30:703–10. 10.1007/s00520-021-06477-2 . Kavitha R, Jayan C, Jayan C. 2014, 2 , 247–51. Refaee Saeedi N, Aghamohammadian Sharbaf H, Asghari Ebrahimabad MJ, Kareshki H. Psychological Consequences of Breast Cancer in Iran: A Meta-Analysis. Iran J Public Health. 2019;48:816–24. 10.18502/ijph.v48i5.1796 . Mayouf MM, Yasir AA. Social Support and Its Relationship to Self Hardiness among Breast Cancer Women. Int J Heal Sci. 2022;6:11886–94. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 May, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 10 Feb, 2025 Reviews received at journal 10 Feb, 2025 Reviewers agreed at journal 26 Jan, 2025 Reviewers agreed at journal 20 Dec, 2024 Reviews received at journal 17 Dec, 2024 Reviewers agreed at journal 17 Dec, 2024 Reviewers invited by journal 23 Nov, 2024 Editor invited by journal 22 Nov, 2024 Editor assigned by journal 22 Nov, 2024 Submission checks completed at journal 14 Nov, 2024 First submitted to journal 05 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5399540","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":384651397,"identity":"415498c6-04de-433e-955b-f1ba20f7dd46","order_by":0,"name":"Rasha Mohammed Alsdfan","email":"","orcid":"","institution":"Universiti Sains Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Rasha","middleName":"Mohammed","lastName":"Alsdfan","suffix":""},{"id":384651398,"identity":"f49d22eb-2be2-49cf-9463-18b664727154","order_by":1,"name":"Azidah Abdul Kadir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYFACxgYJxoaEBH7StUg2kGIPWIvBAWKV8/cfbrzxc0danvGN9KcbGHMOE2HDgYPNlr1ncorNbuSY3WDcRoQWhoONbRK8bRWJ227ksBGnRf4wY5vkX6CWzTPSnxGnxeAYY5s0b1tO4gaJBCIdZniGsdlati2tWOLMG7MbidvSCWuRO3/84c23bcl5/O1Ah33cZk1YCypIYGgmVQsDQx3pWkbBKBgFo2DYAwB/G0L9C9t0ugAAAABJRU5ErkJggg==","orcid":"","institution":"Universiti Sains Malaysia","correspondingAuthor":true,"prefix":"","firstName":"Azidah","middleName":"Abdul","lastName":"Kadir","suffix":""},{"id":384651400,"identity":"bd9f9134-777e-46dd-b89d-83195115cd44","order_by":2,"name":"Norhayati Mohd Noor","email":"","orcid":"","institution":"Universiti Sains Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Norhayati","middleName":"Mohd","lastName":"Noor","suffix":""},{"id":384651401,"identity":"56f6aea4-efe6-4502-9c68-e90dc6194738","order_by":3,"name":"Mohammed Baqer Abbas Al-jubour","email":"","orcid":"","institution":"Baghdad University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Baqer Abbas","lastName":"Al-jubour","suffix":""}],"badges":[],"createdAt":"2024-11-06 05:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5399540/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5399540/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-23243-9","type":"published","date":"2025-05-29T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83782991,"identity":"efa579dc-d2e9-4359-a8c7-975ae5e75465","added_by":"auto","created_at":"2025-06-02 16:09:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1124873,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5399540/v1/745e4101-a353-4a14-a374-55351ac0ce02.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Research title: Coping Skills and its Associated Factors Among Breast Cancer Women in Iraq: A Cross-Sectional Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBreast cancer (BC) remains the most common cancer among women worldwide, accounting for 18% of all female cancers. Moreover, over 100 countries report it as the leading cause of cancer-related deaths [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Iraq, BC was the most prevalent cancer in 2020 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] despite advancements in early detection and treatment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. BC survivors often experience long-term physical, social, emotional, and psychological challenges that persist well beyond treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn particular, women in developing countries, including Iraq, face unique difficulties after being BC diagnosed. These challenges range from managing physical symptoms to coping with the emotional distress brought about by their diagnosis and treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, many women adopt coping skills to address these physical and psychological burdens. Indeed, the process of adapting to BC involves managing a wide range of stressors, including the effects of surgery, the side effects of adjuvant therapies, and changes in life circumstances [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, research has shown that coping skills vary significantly among individuals, shaped by personality, prior experiences, and environmental influences [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. According to Lazarus and Folkman's stress and coping theory, coping is defined as the cognitive and behavioural efforts people make to manage specific demands perceived as stressful. Generally, coping skills are categorized into active, passive, and seeking support [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, coping skills are crucial in helping BC patients adapt to the challenges of their diagnosis and treatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite this, significant gaps remain in the literature regarding its role in BC patients at different stages of the disease [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, this study aims to assess coping skills and their sociodemographic, clinical, and psychological associated factors among BC women in Iraq.\u003c/p\u003e"},{"header":"2. Methods of Study","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design.\u003c/h2\u003e \u003cp\u003eThis cross-sectional survey was conducted in the Medical City Oncology Hospital in Baghdad, Iraq. Convenient sampling was applied from August 1, 2023, to the 1st of October 2023. Inclusion criteria included women aged 18 to 70 years diagnosed with BC (at least 6 to 24 months before the interview), in stages I to IV, who had undergone breast surgery and received chemotherapy and radiotherapy, proficient in reading and understanding Arabic. Written informed consent was used in this study. Participants were informed that they had the right to withdraw from the study at any time without affecting medical services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Study Instruments\u003c/h2\u003e \u003cp\u003eThe study instruments include questionnaires to collect socio-demographic and clinical data., The Hospital Anxiety and Depression Scale (HADS) was used to assess the psychological level, and the Brief COPE- 28 scale was used to determine the coping skills.\u003c/p\u003e \u003cp\u003eThe sociodemographic variable includes (age, marital status, level of education, employment status, financial perception, number of children). Clinical data were obtained from the medical records. Clinical characteristic variables include history of chronic disease, menopausal status, family history of BC, duration of BC diagnosis, stage of disease, affected breast(s), metastasis breast cancer, number of metastatic sites, duration since of surgery, mastectomy operation, breast reconstruction, Chemotherapy treatment line, hormonal therapy.\u003c/p\u003e \u003cp\u003eThe Hospital Anxiety and Depression Scale (HADS) was adapted from Zigmond \u0026amp; Snaith [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] to assess the psychological levels of BC women. This self-report scale comprises 14 items on a 4-point Likert scale (range 0\u0026ndash;3), with seven items each for anxiety and depression subscales, each subscale score ranging from 0 to 21. Anxiety and depression levels were calculated using cut-off scores [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Studies consistently demonstrate the robust internal consistency of HADS, validating its reliability in clinical practice, including applications in the Arab population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The Cronbach\u0026rsquo;s α for the HADS anxiety subscale was 0.83 at time 1 and 0.87 at time 2, while for the depression subscale, it was 0.77 at time 1 and 0.80 at time 2. These results indicate adequate internal consistency among patients for both HADS subscales at both time points.\u003c/p\u003e \u003cp\u003eThe Brief COPE-28 scale was used to assess the coping skills of BC women. Developed by Carver (1997) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], it consists of 14 subscales, including (self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, planning, humour, acceptance, religion, and self-blame), each evaluating specific coping behaviours with scores ranging from 2 to 8. Higher scores indicate increased utilization of that particular coping skill. Responses to the items of the Brief COPE were rated on a four-point scale, with 1= \u0026lsquo;I have not been doing this at all, 2= \u0026lsquo;I have been doing this a little bit, 3= \u0026lsquo;I have been doing this a medium amount\u0026rsquo; and 4= \u0026lsquo;I have been doing this a lot [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe validity and the internal reliability of the Brief-COPE- 28 questionnaires for Arabic society were established in several studies, and the validity and reliability records for the Brief-COPE questionnaire were considerably adequate [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The Arabic version of the brief cope used in this study is characterized by a 3-factor structure incorporating adaptive and maladaptive coping methods, or \u0026lsquo;active\u0026rsquo; and \u0026lsquo;passive\u0026rsquo; coping, which is more appropriate; it was found to be a valid and reliable instrument among the Arab population. This makes the scale valuable in both clinical practice and clinical research. The first factor included \u0026lsquo;active coping,\u0026rsquo; planning,\u0026rsquo; \u0026lsquo;positive reframing,\u0026rsquo; \u0026lsquo;acceptance,\u0026rsquo; \u0026lsquo;humour,\u0026rsquo; religion,\u0026rsquo; one item from \u0026lsquo;self-distraction,\u0026rsquo; and one from \u0026lsquo;venting.\u0026rsquo; This factor was called \u0026lsquo;active coping; the second factor included all items from \u0026lsquo;denial,\u0026rsquo; \u0026lsquo;substance use,\u0026rsquo; behavioural disengagement,\u0026rsquo; \u0026lsquo;self-blame,\u0026rsquo; \u0026lsquo;venting,\u0026rsquo; and \u0026lsquo;self-distraction. \u0026lsquo; The third factor included all items from \u0026lsquo;using emotional support\u0026rsquo; and \u0026lsquo;using instrumental support\u0026rsquo; and was named \u0026lsquo;support-seeking[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data collection\u003c/h2\u003e \u003cp\u003e Written informed consent was obtained, and data were collected through face-to-face interviews, with clinical details extracted from medical records. The supervisor trained data collectors to ensure quality, and the principal investigator monitored the process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical Methods\u003c/h2\u003e \u003cp\u003eData analyses were performed using SPSS version 26.0. Descriptive statistics were performed, including measures of central tendency (mean, standard deviation (SD)), frequency, and percentage of categorical variables. Simple and multiple linear regressions were conducted on all independent variables. Variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.025 were selected for inclusion in multivariate analysis. Multiple linear regression used forward selection to identify factors associated with coping skills. The basic assumptions for linear regressions, particularly the normality of residuals, were verified. The beta regression coefficient, t-value, and p-value were specified for each dependent variable. Statistical significance was set at a p-value\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Result","content":"\u003cp\u003eOut of 261 eligible participants, 244 completed the questionnaires, resulting in a response rate of 93.48%. The primary reasons for dropout included time constraints, survey fatigue, lack of interest or perceived relevance, and emotional distress.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: illustrated the sociodemographic, clinical, QOL, coping skills, and psychological characteristics of BC Women, the mean (SD) age of the participants was 49.31 (9.08) years. Clinically, 53.7% had been diagnosed for over 12 months and the majority (89.8%) were in stages I and II of breast cancer. In terms of coping skills, the mean (SD) for active coping, passive coping, and seeking support scores were 5.96 (1.31), 4.00 (1.10), and 7.58 (0.84), respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive of Sociodemographic, Clinical, QOL, Coping Skills, and Psychological Characteristics of BC Women (n\u0026thinsp;=\u0026thinsp;244).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSociodemographic Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.31 (9.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried or cohabiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e201 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e164 (67.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80 (32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployed status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed (or retired)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e187 (76.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFinancial perception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot enough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178 (73.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66 (27.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e115 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of BC diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le; 12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMenstrual status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual interruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e206 (84.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo interruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage of disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage (I and II)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e219 (89.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage (III and IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAffected breast\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e235 (96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily history of breast cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e136 (55.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of chronic disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e221 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumpectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration since of surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least six months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than six months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189 (77.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMetastatic breast cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e205 (84.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBreast reconstruction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e233 (95.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHormonal therapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e115 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChemotherapy treatment line\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e118 (48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u0026thinsp;+\u0026thinsp;radiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e126 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBrief COPE-28\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.96 (1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePassive coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.00 (1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeeking support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.58 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe Hospital Anxiety and Depression Scale (HADS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e99 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106 (43.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e The regression analyses identified several factors associated with the coping skills of BC women. For active coping, the absence of hormonal therapy, anxiety, and depression was negatively associated with active coping in both the simple and multiple regression analyses.\u003c/p\u003e \u003cp\u003eIn terms of passive coping was negatively associated with undergoing a mastectomy and positively associated with anxiety and depression in the simple regression; however, it was positively associated with undergoing a mastectomy and Anxiety in multiple regression.\u003c/p\u003e \u003cp\u003eFor the domain of seeking support, it was negatively associated with the stage of the disease and depression in the simple regression, and negatively associated with the stage of the disease in multiple regression. However, it was positively associated with the duration since surgery and anxiety in both the simple and multiple regression analyses.\u003c/p\u003e \u003cp\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression Analysis Findings on Factors Associated with Coping Skills in BC Women (N\u0026thinsp;=\u0026thinsp;244)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSimple linear regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultiple linear regression\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eb(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003et-statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdjusted b(97.5%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003et-statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eFactor associated with active coping among BC women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eHormonal therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.37-(-0.75, -0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.35 (-0.68, -0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.09 (-0.12, -0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-7.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.04 (-0.08, -0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.13 (-0.16, \u0026minus;\u0026thinsp;.009)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-8.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.08 (-0.13, -0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-4.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor associated with passive coping among BC women\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.64 ( -1.18, -0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60 (0.10, 1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumpectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e-\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.06 (0.04, 0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e06.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06 (0.04, 0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.07 (0.04, 0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactor associated with seeking support among BC women\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eStage of disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage (I \u0026amp;II)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.85 (-1.05, -0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-9.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.87 (0.71, 1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage (III\u0026amp; IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eDuration since of surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.47 (0.32, 0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55 (0.43, 0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00 (-0.00, 0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.20 (0.14, 0.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.00 (-0.01, 0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*Dependent variable: Active coping skills, Passive coping skills, seeking support\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Independent variable: sociodemographic, clinical characteristics, and psychological factors.\u003c/p\u003e \u003cp\u003e*Forward multiple linear regression methods were applied. Model assumptions are fulfilled, and no multicollinearity is detected.\u003c/p\u003e \u003cp\u003e*The coefficient of determination (R2) for Active coping skills, Passive coping skills, and seeking support were (25.7%), (22.8%), and (56.7%)\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe mean score for active coping suggests that BC women in Iraq predominantly engage in proactive strategies, such as planning, problem-solving, and acceptance, which help foster a sense of control and reduce distress[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Conversely, the lower mean score for passive coping indicates that avoidance and denial are less commonly used. However, reliance on passive coping can lead to feelings of helplessness and increased psychological distress, as supported by O\u0026acute;smiałowska et al. (2021) and Zamanian et al. (2021), who found that passive skills often exacerbate mental health issues and symptom burden [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe high mean score for seeking support emphasizes the critical role of social support in coping. Emotional and instrumental support from family, friends, and healthcare providers enhances emotional well-being and resilience [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This is consistent with other studies showing that seeking support reduces isolation and fosters psychological resilience[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, none of the demographic variables were associated with any coping skills in patients with breast cancer. This is supported by Mohammadipour, M, who found in their study that none of the demographic variables were significantly associated with coping skills [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRelated to active coping skills and clinical characteristics, women who did not undergo hormonal therapy experienced a decrease in active coping skills scores compared to those who did receive hormonal therapy. This decrease could be the effect of hormonal treatment on hormonal balance. Hormonal therapy may contribute to stimulating behaviours that enhance active coping, such as developing relaxation skills and changing harmful behaviours, thus potentially having a positive effect on active coping skills. This result alignment with a study conducted by Guti\u0026eacute;rrez-Hermoso \u003cem\u003eet al.\u003c/em\u003e (2022) They reported that women who did not undergo hormonal therapy showed a decrease in active coping skills, possibly due to the positive effects of hormonal balance on coping behaviours [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This interpretation is supported by Morales-S\u0026aacute;nchez, 2021, who stated that the types of treatment to which the patient is subjected play a fundamental role in the strategy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other side, active coping skills significantly moderate the relationship between psychological stress, anxiety, and depressive symptoms in BC women. Wang et al. (2012) reported a negative association between active coping behaviours and anxiety symptoms. Furthermore, Wang noted that combining \"worrying about health\" with \"self-relaxation coping behaviours\" significantly decreases anxiety, underscoring the importance of active coping in managing psychological distress[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBC Patients often engage in negative coping skills, including forgetfulness, frustration, and fear [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], where individuals attempt to escape anxiety-inducing thoughts related to their diagnosis. While this strategy may provide temporary relief, it can result in obsessive and intrusive thoughts over time, ultimately hindering survivors\u0026rsquo; adherence to essential health behaviours, such as surveillance guidelines[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. as in the current study identified a significant positive relationship between passive coping strategies and the type of surgery patients undergo. This finding is consistent with Ardakani (2019), who reported a positive correlation between body image and coping skills in women post-surgery. These coping skills significantly impact body image, predicting both favourable and unfavorable outcomes[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, the study found that increased anxiety scores were associated with a greater reliance on passive coping skills. Typically, passive coping involves avoiding or ignoring stressors rather than actively confronting them. This indicates that individuals with higher anxiety levels are more inclined to withdraw from challenges instead of addressing them directly. Supporting this, Dev et al. (2019) demonstrated that cancer patients who utilized passive coping skills such as alcohol, opioids, and other drugs experienced greater psychological distress[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, this study found that women diagnosed with early-stage breast cancer (Stages I and II) are more likely to seek emotional or social support than those with later-stage diagnoses (Stages III and IV). Women in advanced stages may feel more hopeless, reducing their motivation to seek support, whereas early-stage patients are more likely to seek support as they adjust to their diagnosis and treatment. The study by S\u0026oslash;rensen \u003cem\u003eet al.\u003c/em\u003e, (2020) showed the role of social support in managing fatigue among early-stage breast cancer patients in alleviating fatigue symptoms and overall recovery[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, this study found that cancer patients' use of coping skills tends to decline as treatment duration increases. Initially, patients feel optimistic about dealing with their diagnosis, but this positivity wanes after several treatments. This finding aligns with a previous study indicating that cancer patients often experience loneliness, which negatively impacts their coping abilities[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnosis requires women to transition from being healthy to facing a life-threatening disease, with coping styles and illness perception playing crucial roles in this adjustment. Psychological stress often accompanies diagnosis and treatment, and supportive coping styles and social support can mitigate this distress [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. There is a positive correlation between anxiety and seeking support; as anxiety levels rise, so does the tendency to seek support. This relationship was confirmed by multivariate analysis, showing that anxiety and depression are significant predictors of coping styles [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Therefore, Psychological disorders in people with cancer are significantly affected by social support. Patients with good social support have fewer emotional and psychosocial problems and can better cope with their illness [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBC women often face significant disruptions in both personal and family life, primarily due to cancer-related uncertainty and fear of recurrence. These psychological stressors tend to increase reliance on emotion-focused coping skills, which are associated with heightened anxiety [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Similarly, social support plays a critical role in mitigating these effects, as it promotes functional coping skills and helps reduce symptoms of depression and anxiety[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Adequate perceived social support encourages individuals to seek reassurance from others regarding their health concerns, whereas insufficient support is linked to greater levels of health anxiety [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Conclusion and recommendations","content":"\u003cp\u003eThe cross-sectional design of this study captures a momentary view of the participants' adaptation experiences, restricting the ability to evaluate how their coping skills evolve or the causal relationships between various factors and their adaptation outcomes. Furthermore, the reliance on convenience sampling may have introduced selection bias, potentially influencing the sample's representativeness. Therefore, additional research, including longitudinal studies and qualitative approaches, is essential to overcome these limitations and to gain a more comprehensive understanding of the adaptation processes among BC women in Iraq.\u003c/p\u003e"},{"header":"6. Limitations of study","content":"\u003cp\u003eThe study's cross-sectional nature provides only a snapshot of the participants' experiences, limiting the ability to assess changes over time or causality between factors and quality of life. Additionally, the use of convenience sampling may have introduced selection bias, potentially affecting the representativeness of the sample. Therefore, further research, including qualitative methods, is needed to address these limitations and gain deeper insights into the quality of life and coping skills of breast cancer patients in Iraq.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was approved by the Ethics Committee of The Universiti Sains Malaysia Research Human Research and Ethics Committee (USM/JEPeM/KK/23030229), and the Iraqi Ministry of Health have approved the study. Informed consent was obtained from all subjects involved in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was funded by Universiti Sains Malaysia, which provided the necessary support for conducting and completing this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA prepared the main manuscript text, B provided primary supervision, while C and D contributed as additional supervisors. All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI thank all the breast cancer survivors who participated in this study. I want to thank the staff of the Teaching Oncology Hospital) in Baghdad- Iraq, for their support.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eThe datasets analyzed during the current study are not publicly available due to ethical restrictions. but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMustafa IJ, Abdullah OR, Al-Saffar N, Ahmed RF, Fouad M. Quality of Life Assessment in Women With Breast Cancer in Nineveh, Iraq. \u003cem\u003eCureus\u003c/em\u003e 2023, \u003cem\u003e16\u003c/em\u003e, 1\u0026ndash;8, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.51589\u003c/span\u003e\u003cspan address=\"10.7759/cureus.51589\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSung H, Global Cancer. Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. cancer J Clin 2021, \u003cem\u003e71\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRashid AA, Abdulzahra R, Hussein M, Hashim W. Assessing the Quality of Life in Breast Cancer Women: A Cross Sectional Descriptive Study. 2022, \u003cem\u003e23\u003c/em\u003e, 2299\u0026ndash;307, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.31557/APJCP.2022.23.7.2299\u003c/span\u003e\u003cspan address=\"10.31557/APJCP.2022.23.7.2299\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaurer T, Th\u0026ouml;ne K, Obi N, Jung AY, Behrens S, Becher H, Chang-Claude J. Health-Related Quality of Life in a Cohort of Breast Cancer Survivors over More Than 10 Years Post-Diagnosis and in Comparison to a Control Cohort. Cancers (Basel). 2021;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cancers13081854\u003c/span\u003e\u003cspan address=\"10.3390/cancers13081854\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammed Al-Azri M. Coping With a Diagnosis of Breast Cancer-Literature Review and Implications for Developing Countries. Breast J. 2019;5:615.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNezamodini ZS, Rezvani Z, Kian K. Coping Response Following a Diagnosis of Breast Cancer: A Systematic Review Esmat. Electron Physician. 2017;9:3592\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZamanian H, Amini-Tehrani M, Jalali Z, Daryaafzoon M, Ala S, Tabrizian S, Foroozanfar S. Perceived Social Support, Coping Strategies, Anxiety and Depression among Women with Breast Cancer: Evaluation of a Mediation Model. Eur J Oncol Nurs. 2021;50:101892. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejon.2020.101892\u003c/span\u003e\u003cspan address=\"10.1016/j.ejon.2020.101892\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026acute;smiałowska E, ˛ag WM, Chabowski M, \u0026acute;nska BJ-P. Coping Strategies, Pain, and Quality of Life in Patients with Breast Cancer. Clin Med Artic. 2021;10:2\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammadipour M, Pidad F, Coping Strategies. Locus of Control, and Quality of Life in Patients with Early-Stage Breast Cancer. J Psychol. 2021;155:375\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/00223980.2020.1816873\u003c/span\u003e\u003cspan address=\"10.1080/00223980.2020.1816873\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Occup Med (Chic Ill). 1983;64:393\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/occmed/kqu024\u003c/span\u003e\u003cspan address=\"10.1093/occmed/kqu024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalvetti M, de Machado G, Donato CSP, da Silva SCT. Prevalence of Symptoms and Quality of Life of Cancer Patients. Rev Bras Enferm. 2020;73:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/0034-7167-2018-0287\u003c/span\u003e\u003cspan address=\"10.1590/0034-7167-2018-0287\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAwad MA, Denic S, El Taji H. Validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires for Arabic-Speaking Populations. Ann N Y Acad Sci. 2008;1138:146\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1196/annals.1414.021\u003c/span\u003e\u003cspan address=\"10.1196/annals.1414.021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerkaw AS, Tsang S. Development and Validation of Arabic Version of the Hospital Anxiety and Depression Scale. Saudi J Gastroenterol \u0026middot;. 2017;11:11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarver CS. You Want to Measure Coping but Your Protocol\u0026rsquo;s Too Long: Consider the Brief COPE. Int J Behav Med. 1997;4:92\u0026ndash;100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1207/s15327558ijbm0401_6\u003c/span\u003e\u003cspan address=\"10.1207/s15327558ijbm0401_6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeDios-Stern S, Lee EJ, Nitsch K. Clinical Utility and Psychometric Properties of the Brief: Coping With Problems Experienced with Caregivers. Rehabil Psychol. 2017;62:609\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/rep0000188\u003c/span\u003e\u003cspan address=\"10.1037/rep0000188\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlghamdi M. Cross-Cultural Validation and Psychometric Properties of the Arabic Brief COPE in Saudi Population. Med J Malaysia. 2020;75:502.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarandy TF, Ghofranipour F, Montazeri A, Anoosheh M, Mohammadi E, Ahmadi F, Shokravi FA, Niknami S. Health-Related Quality of Life in Iranian Breast Cancer Survivors: A Qualitative Study. Appl Res Qual Life. 2010;5:121\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11482-010-9097-3\u003c/span\u003e\u003cspan address=\"10.1007/s11482-010-9097-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhalili N, Farajzadegan Z, Mokarian F, Bahrami F. Coping Strategies, Quality of Life and Pain in Women with Breast Cancer. Iran J Nurs Midwifery Res. 2013;18:105\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuti\u0026eacute;rrez-Hermoso L, Velasco-Furlong L, S\u0026aacute;nchez-Rom\u0026aacute;n S, Berzal-P\u0026eacute;rez E, Alcocer-Castillejos N, Quiroz-Friedman P. The Effect of Treatment and Coping on the Quality of Life in Breast Cancer Patients: A Moderated Mediation Model. Qual Life Res. 2022;31:147\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11136-021-02885-3\u003c/span\u003e\u003cspan address=\"10.1007/s11136-021-02885-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorales-S\u0026aacute;nchez L, Luque-Ribelles V, Gil-Olarte P, Ruiz-Gonz\u0026aacute;lez P, Guil R. Enhancing Self-Esteem and Body Image of Breast Cancer Women through Interventions: A Systematic Review. Int J Environ Res Public Health. 2021;18:1\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph18041640\u003c/span\u003e\u003cspan address=\"10.3390/ijerph18041640\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Wang SS, Peng RJ, Qin T, Shi YX, Teng XY, Liu DG, Chen WQ, Yuan ZY. Interaction of Coping Styles and Psychological Stress on Anxious and Depressive Symptoms in Chinese Breast Cancer Patients. Asian Pac J Cancer Prev. 2012;13:1645\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7314/APJCP.2012.13.4.1645\u003c/span\u003e\u003cspan address=\"10.7314/APJCP.2012.13.4.1645\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrosthwaite K, Advisor F, Lester J. The Mediating Role of Avoidant Coping in the Relationships between Physical, Psychological, and Social Wellbeing and Distress in Breast Cancer Survivors Andrea. 2021, \u003cem\u003e30\u003c/em\u003e, 1\u0026ndash;37, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/pon.5663.The\u003c/span\u003e\u003cspan address=\"10.1002/pon.5663.The\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArdakani BY. Body Image and Its Relationship with Coping Strategies: The Views of Iranian Breast Cancer Women Following Surgery. Eur lournal cancer care. 2019;1:5\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ecc.13191\u003c/span\u003e\u003cspan address=\"10.1111/ecc.13191\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026oslash;rensen HL, Schj\u0026oslash;lberg TK, Sm\u0026aring;stuen MC, Utne I. Social Support in Early-Stage Breast Cancer Patients with Fatigue. BMC Womens Health. 2020;20:243. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12905-020-01106-2\u003c/span\u003e\u003cspan address=\"10.1186/s12905-020-01106-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJabbarian LJ, Korfage IJ, Červ B, van Delden JJM, Deliens L, Miccinesi G, Payne S, Thit Johnsen A, Verkissen MN, Wilcock A, et al. Coping Strategies of Patients with Advanced Lung or Colorectal Cancer in Six European Countries: Insights from the ACTION Study. Psychooncology. 2020;29:347\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/pon.5259\u003c/span\u003e\u003cspan address=\"10.1002/pon.5259\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlcalar N, Ozkan S, Kucucuk S, Aslay I, Ozkan M. Association of Coping Style, Cognitive Errors and Cancer-Related Variables with Depression in Women Treated for Breast Cancer. Jpn J Clin Oncol. 2012;42:940\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jjco/hys119\u003c/span\u003e\u003cspan address=\"10.1093/jjco/hys119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkati-Aliabad H, Ansari-Moghadam A, Mohammadi M, Kargar S, Shahraki-Sanavi F. The Prevalence of Anxiety and Depression and Its Association with Coping Strategies, Supportive Care Needs, and Social Support among Women with Breast Cancer. Support Care Cancer. 2022;30:703\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00520-021-06477-2\u003c/span\u003e\u003cspan address=\"10.1007/s00520-021-06477-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKavitha R, Jayan C, Jayan C. 2014, \u003cem\u003e2\u003c/em\u003e, 247\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRefaee Saeedi N, Aghamohammadian Sharbaf H, Asghari Ebrahimabad MJ, Kareshki H. Psychological Consequences of Breast Cancer in Iran: A Meta-Analysis. Iran J Public Health. 2019;48:816\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18502/ijph.v48i5.1796\u003c/span\u003e\u003cspan address=\"10.18502/ijph.v48i5.1796\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayouf MM, Yasir AA. Social Support and Its Relationship to Self Hardiness among Breast Cancer Women. Int J Heal Sci. 2022;6:11886\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"breast cancer, coping skills, association factors","lastPublishedDoi":"10.21203/rs.3.rs-5399540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5399540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCoping skills play a vital role in managing the physical and psychological effects of breast cancer. Despite improvements in early detection and treatment, breast cancer survivors continue to face long-term challenges after diagnosis. This study aims to evaluate the coping skills employed by breast cancer women in Iraq and to identify the sociodemographic, clinical, and psychological factors associated with these coping behaviours.\u003c/p\u003e \u003cp\u003eMethods: A cross-sectional study was conducted among 244 breast cancer women in the Medical City Teaching Oncology Hospital, Baghdad, Iraq, from August 2023 to October 2023. Coping skills and psychological factors were assessed using the BRIEF COPE-28 and Hospital Anxiety Depression scale, respectively. Sociodemographic and clinical characteristics were also taken. The associations between the coping skills and associated factors were evaluated using multiple linear regression analysis.\u003c/p\u003e \u003cp\u003eResults: The mean (SD) coping skills for active coping, passive coping, and seeking support were 5.96 (1.31), 4.00 (1.10), and 7.58 (0.84), respectively. Multiple linear regression revealed hormonal therapy, anxiety, and depression were significant factors influencing active coping. The passive coping associated factors were the type of surgery and anxiety. The seeking support was notably affected by the stage of disease, duration since surgery, and anxiety.\u003c/p\u003e \u003cp\u003eConclusion: This study highlights the association factors influencing the coping skills among breast cancer women in Iraq, and the need for targeted psychological and clinical interventions to improve coping skills.\u003c/p\u003e","manuscriptTitle":"Research title: Coping Skills and its Associated Factors Among Breast Cancer Women in Iraq: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-02 05:34:19","doi":"10.21203/rs.3.rs-5399540/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-11T04:48:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-10T13:44:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58882662097070283898630988757183675503","date":"2025-01-26T05:16:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318703208678441945164798532547881535925","date":"2024-12-20T16:03:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-17T09:48:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"215159471268828569965828820908119012430","date":"2024-12-17T05:55:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-23T11:59:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-22T11:47:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-22T11:26:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-14T13:21:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-11-06T04:52:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99e3751e-a5d5-45d0-909c-00296806da12","owner":[],"postedDate":"December 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T16:04:22+00:00","versionOfRecord":{"articleIdentity":"rs-5399540","link":"https://doi.org/10.1186/s12889-025-23243-9","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-05-29 15:57:14","publishedOnDateReadable":"May 29th, 2025"},"versionCreatedAt":"2024-12-02 05:34:19","video":"","vorDoi":"10.1186/s12889-025-23243-9","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23243-9","workflowStages":[]},"version":"v1","identity":"rs-5399540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5399540","identity":"rs-5399540","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}