Resilience and Endocrine Therapy-Related Quality of Life and Symptom Burden in Breast Cancer Survivors

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Kelly, David O’ Reilly, Ciara O’Hanlon Brown, Sinead A Noonan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9245344/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose Resilience, the ability to adapt and recover from adversity may be particularly relevant during endocrine therapy for breast cancer which can adversely affect endocrine-related quality of life. We aimed to evaluate the association between resilience and endocrine-related quality of life in an Irish breast cancer population. Methods We performed a secondary cross-sectional analysis of a prospective dataset of patients with early-stage breast cancer receiving endocrine therapy (≥ 2 weeks). The primary outcome was endocrine-related quality of life measured by theFunctional Assessment of Cancer Therapy (FACT-ES). Resilience was measured using the BRIEF Resilience Scale (BRS). Additional variables included coping (BRIEF COPE), social support and clinicodemographic factors. Associations were analysed using multivariable linear regression. In a secondary analysis resilience was examined in relation to the FACT-ES endocrine symptom (ES23) subscale. Results The study cohort comprised 331 patients (mean age 57 years, SD 10). In multivariable regression analysis, higher resilience was associated with improved endocrine-related quality of life (ꞵ= 4.62, 95% CI 1.60-7.63, P=0.003). Older age, and lower avoidant coping were associated with improved quality of life. Domain analyses showed associations between resilience and endocrine symptoms, and social and emotional wellbeing, but not physical or functional wellbeing. In exploratory multivariable analysis resilience, age, and avoidant coping were associated with ES23 scores. Conclusion Resilience was an independent predictor of endocrine-related quality of life and symptom burden, with differences driven by emotional, social and endocrine domains. These findings may represent a target for intervention and a means of identifying patients requiring additional support. Resilience Breast Cancer Endocrine therapy-related quality of life Endocrine therapy Figures Figure 1 Introduction Breast cancer is the most common malignancy diagnosed in women worldwide [ 1 ]. Hormone receptor positive breast cancer comprises 70% of all breast cancer subtypes and endocrine therapy is the mainstay of therapy. [ 2 ] Tamoxifen and aromatase inhibitors have been used for many decades to reduce the risk of breast cancer recurrence and death [ 3 , 4 ]. Contemporary regimens particularly for women at higher risk of recurrence are increasingly complex and may incorporate cyclin D kinase 4/6 inhibitors, gonadotrophin-releasing hormone agonists for premenopausal women, poly (ADP-ribose) polymerase inhibitors for patients with BRCA mutations and bone modifying agents [ 5 – 9 ]. However, despite increasingly efficacious treatment regimens, 38–60% of patients discontinue treatment by 5 years [ 10 ]. Early discontinuation of endocrine therapy is associated with a 3-fold increased risk of recurrence and increased risk of breast cancer mortality [ 11 – 14 ]. Reasons for endocrine therapy discontinuation are complex and multifactorial, however, side effects significantly impacting quality of life are the most frequently reported cause [ 15 ]. Prolonged estrogen suppression below the normal postmenopausal estradiol range can lead to considerable life-altering toxicities such as chronic arthralgia, myalgia, debilitating vasomotor symptoms, insomnia, anxiety, and urogenital symptoms which, for some, can severely impact all aspects of daily life for the 5 to 10 years of planned treatment [ 16 , 17 ]. Multiple studies have sought to determine why some patients continue to take endocrine therapy despite side effects and others discontinue [ 15 , 18 ]. Psychosocial factors, including resilience, may contribute to variability in patients experiences of endocrine therapy and help identify those at greater risk of quality-of-life-impacting symptoms who could benefit from more intensive survivorship care.[ 19 – 21 ]. Resilience, defined as the ability to recover from stress is particularly relevant in the context of ongoing health related challenges such as endocrine therapy. Resilience has been associated with lower levels of distress, fatigue, and depressive and anxiety symptoms as well as improved physical functioning in women with breast cancer. Resilience is also inversely associated with symptom burden and the impact of cancer treatment [ 22 – 28 ]. However, its role in endocrine therapy-related quality of life and symptom burden is not well characterised. The aim of this study was to examine whether resilience, as measured using the Brief Resilience Scale (BRS), is associated with endocrine therapy-related quality of life in women receiving endocrine therapy for early-stage breast cancer. The primary outcome was endocrine-related quality of life measured using the Functional Assessment of Cancer Therapy Endocrine Subscale (FACT-ES). A secondary analysis examined the association with endocrine symptom burden using the ES23 endocrine symptom score [ 29 ]. Methods This study is a secondary analysis of data collected from a previously conducted cross-sectional observation study evaluating patient-reported outcomes in women receiving endocrine therapy for breast cancer in five cancer centres in Ireland. The original study design, eligibility criteria, and data collection procedures have been described previously [ 30 ]. Briefly, patients receiving endocrine therapy for breast cancer for ≥ 2 weeks were prospectively enrolled and completed validated patient reported outcome measures at a single time point. The original cohort included patients with early and advanced breast cancer. For the present analysis, we excluded patients with metastatic disease and restricted the study population to patients who were receiving endocrine therapy in the adjuvant setting for early-stage disease. Ethical approval was received at all hospital sites prior to patient enrolment. Outcomes Measures Endocrine symptoms were assessed using the the Functional Assessment of Cancer Therapy (FACT-ES), version 4. FACT-ES is a validated patient reported outcome measure developed to evaluate endocrine therapy related symptoms and health related quality of life in women with breast cancer (HRQOL). The instrument comprises the FACT-General (FACT-G) which includes physical, social/family, emotional, and functional well-being domains, and a 19-item endocrine symptom subscale which assesses common endocrine-related symptoms such as vasomotor, musculoskeletal, and sexual symptoms. Items are rated on a 5-point Likert scale ranging from 0 (‘not at all’) to 4 (‘very much’). Higher scores indicate better endocrine-related QOL and fewer endocrine related symptoms. A secondary analysis examined endocrine symptom burden using the ES23 endocrine symptom score which is derived from the FACT-ES instrument. ES23 is an extended endocrine subscale that adds four other endocrine-related items (sleep, fatigue, nervousness and nausea) and is scored as an additional and more extended endocrine subscale (ES23, 23 items) [ 29 ]. Resilience Psychological resilience was measured using the Brief Resilience Scale (BRS), a 6-item validated measure of the ability to recover from stress. The BRS examines the individual's inherent ability to ‘bounce back’ and does not include resilience ‘resources’ such as social supports or protective factors like coping, optimism. Questions focus on ‘self’ belief in the ability to recover with questions like “I tend to bounce back quickly after difficult times” and “I usually come through difficult times with little trouble.” Items are rated on a 5-point Likert scale and averaged to yield a total score ranging from 1 to 5, with higher scores indicating greater resilience [ 31 ]. The BRS has high internal consistency (Cronbach’s alpha 0.80–0.91) and is positively correlated with life satisfaction and mindfulness, and negatively correlates with anxiety, depression, and stress [ 32 , 33 ]. Covariates and Psychosocial Variables Coping strategies were assessed using Brief COPE, a 28-item validated instrument measuring cognitive and behavioural coping responses to stress [ 34 ]. Coping was summarised using approach and avoidant coping composites derived from BRIEF COPE subscales according to the framework described by Eisenberg et al. Avoidant coping included denial, behavioural disengagement, self-blame, and substance use, while approach coping included active coping, planning, positive reframing, acceptance, and support-seeking [ 35 ]. Items are rated on a 4-point scale, with higher scores indicating greater use of the respective coping strategy. Perceived social support was measured using the 5-item Modified Social Support Survey (MSSS-5), which provides an overall assessment of tangible support, emotional/informational support, affectionate support and positive social interaction. Items are rated on a 5-point Likert scale ranging from 1 (‘none of the time’) to 5 (‘All of the time’). Raw scores are summed and transformed to a 0-100 scale. Higher scores indicate greater perceived social support [ 36 , 37 ]. The following covariates were recorded for each patient; age, education level (third level or not), occupational status was defined as working (employed or looking after family/home) or not working (unemployed/retired/unable to work), type and duration of endocrine therapy, gonadotrophin releasing hormone agonists (GnRHa)(yes/no), cyclin D Kinase 4/6 inhibitors (yes/no), receipt of chemotherapy (yes/no). Statistical Analyses Demographic and clinical covariates were summarised by resilience category. Resilience was measured using the BRS and categorised using established thresholds as low ( 4.3) [ 31 ]. Continuous variables were summarised using mean (standard deviation, SD) and compared across resilience categories using one-way ANOVA. FACT-ES and ES23 scores across resilience categories were visualised using box-and-whisker plots. Categorical variables were compared across resilience categories using chi squared or Fisher’s exact tests as appropriate. Linear regression models were used to examine associations between resilience and endocrine-related outcomes. Univariate linear regression analyses were performed to assess the relationship between each predictor variable and the outcome measures. Variables examined included resilience score, age, social support, and coping strategy. Variables associated with the outcome at p < 0.10 in univariate analyses were entered into multivariable linear regression models. Individual FACT-ES domain scores were compared across resilience categories using one-way ANOVA. Multivariable regression models were constructed for both endocrine related quality of life measured by FACT-ES total score and endocrine symptom burden measured using the ES-23 subscale. Resilience was entered as a continuous variable in regression models. Model assumptions were assessed and multicollinearity was evaluated using variance inflation factors. As age can influence both endocrine symptom experience and psychosocial adaptation, an interaction term between resilience and age was included in the model to assess whether the association between resilience and endocrine therapy-related quality of life differed by age. Regression coefficients (β) with 95% confidence intervals (CI) were reported. Statistical significance was defined as p < 0.05. Clinical relevance was interpreted with reference to published minimally important differences for FACT measures, supported by a distribution-based estimate of 0.5 standard deviations [ 38 , 39 ]. Analyses were performed using SAS 9.4. Results A total of 331 patients with early-stage breast cancer receiving endocrine therapy were included in the analysis. Mean age was 57 years (SD = 10), 91% were Irish (n = 296), 73% were married or cohabiting (n = 235), 93% were educated beyond primary level, 60% were working (n = 193). Most patients were taking an aromatase inhibitor (65%, n = 202) and 38% were receiving tamoxifen (n = 126). The mean (SD) BRS score was 3.11 (0.91). Overall, 29% of patients were classified as low resilience (n = 96), 64% as normal (n = 212) and 7% as high resilience (n = 23). Demographic, treatment and psychosocial variables were stratified by resilience group. Age, occupational status, perceived social support and avoidant coping differed between resilience groups whereas other demographic and treatment characteristics were similar (Table 1 ). In univariable analysis examining factors associated with endocrine-related quality of life, age, occupational status, perceived social support, avoidant coping and resilience were all significantly associated with FACT-ES scores. Higher resilience (continuous) was associated with improved endocrine-related quality of life (FACT-ES ꞵ= 7.61, 95% CI 4.16–11.05, P < 0.001). In multivariable analysis adjusting for these covariates, all remained independently associated with FACT-ES scores. Higher resilience was associated with improved endocrine-related quality of life (ꞵ= 4.62, CI 1.60–7.63, P = 0.003) (Table 2 ). The distribution of FACT-ES scores by resilience category is shown in Fig. 1 . Mean FACT-ES domain scores were examined across resilience categories using one-way ANOVA. Emotional wellbeing, social wellbeing and endocrine symptoms differed significantly across resilience categories, whereas physical and functional wellbeing did not (Table 3 ). A secondary analyses using ES23 endocrine symptom score demonstrated a similar pattern. Age, perceived social support, avoidant coping and resilience were significantly associated with symptom burden in univariate analyses, whereas occupational status was not (Table 2 ). In multivariable analysis, resilience, age and avoidant coping remained significantly associated with ES23 scores, while occupational status and perceived social support were no longer statistically significant. Higher resilience was associated with lower endocrine symptom burden in multivariable analyses (ꞵ= 1.94 (95% CI 0.09–3.79), p = 0.004). There was no significant interaction between age and resilience observed for ES23 (p = 0.192) or FACT-ES (p = 0.071). These findings were consistent with those observed using the FACT-ES total score and support the robustness of the observed association between resilience and endocrine symptom experience. Variance inflation factors were examined and were all below 2, indicating no evidence of multicollinearity between predictors. The difference between mean FACT-ES scores between low and high resilience categories corresponded to 0.78 standard deviations exceeding the 0.5 standard deviation threshold for a clinically meaningful difference. A similar magnitude of difference was observed for ES23 scores (0.65 standard deviations). Discussion We observed that women with early-stage breast cancer and higher resilience had significantly higher FACT-ES scores, indicating better overall endocrine-related quality of life, and higher ES23 scores reflecting lower endocrine symptom burden. The magnitude of difference in FACT-ES and ES23 scores between the low and high resilience groups exceeded the commonly accepted 0.5 SD threshold for a clinically meaningful difference, supporting the clinical relevance of our findings. Endocrine therapies, including tamoxifen and aromatase inhibitors remain the cornerstone of treatment for early-stage breast cancer [ 3 , 4 ]. Recent advances have shown improved efficacy for a new oral selective estrogen receptor degrader and for the addition of CDK 4/6 inhibitors to endocrine therapy [ 5 , 6 , 40 ]. However, these therapeutic gains are accomplished by prolonged treatment duration and an increasing burden of treatment related toxicities [ 41 ]. As a result, optimising endocrine therapy-related quality of life and minimising symptom burden are critical to maintaining adherence and maximising benefit. In this context, we evaluated the role of resilience in shaping patients experiences of endocrine-related quality of life and symptoms. In domain-level analyses of FACT-ES, differences across resilience categories were mainly driven by emotional, social and endocrine domains, while physical and functional wellbeing did not differ significantly. These findings suggest that, even among patients with differing levels of symptom burden, resilience shapes how symptoms translate into quality-of-life outcomes particularly through emotional and social functioning. The absence of an associated between resilience and physical or functional domains, is consistent with prior work suggesting that resilience primarily influences emotional and psychosocial adaptation rather than physical symptom burden [ 19 , 25 ]. Resilience may modify interpretation and impact of symptoms, having less effect on broader physical symptoms such as fatigue or limitations in daily functioning. Instead, resilience modifies the experience and impact of endocrine symptoms on quality of life particularly through emotional well-being and social functioning. In adjusted analysis resilience remained an independent predictor of both endocrine-related quality of life and endocrine symptom burden. Older age and lower use of avoidant coping were also associated with improved outcomes. While higher perceived social support, and employment were all associated with better FACT-ES scores these were not significant predictors of endocrine symptoms burden as measured by ES23. This discordance likely reflects differences in constructs measured by these scales, with FACT-ES capturing broader quality of life domains, whereas ES23 more specifically reflects endocrine symptom burden indicating better endocrine-related quality of life. Consistent with prior studies, younger age was associated with a higher symptom burden, a factor previously linked to discontinuation and non-adherence to endocrine therapy [ 10 , 12 , 14 ]. Avoidant coping was independently associated with worse outcomes which is in keeping with evidence linking maladaptive coping strategies to greater distress and impaired quality of life [ 28 , 42 , 43 ]. In contrast to studies reporting resilience as a mediator in the relationship between coping strategies and quality of life our findings suggest that resilience and coping may represent distinct constructs [ 44 , 45 ]. This may relate to the use of the BRS which captures resilience as a unidimensional construct in contrast to multidimensional tools such as the Connor-Davidson Resilience Scale that incorporate coping-related resources [ 46 ]. To date most studies examining the association between resilience and breast cancer outcomes have used measures that capture resilience resources such as social supports, and coping strategies, rather than resilience as an inherent capacity [ 22 , 28 ]. By using the BRS we aimed to assess the individuals innate ability to recover from stress, while adjusting for protective personal and environmental factors [ 31 ]. In contrast to previous studies, we used FACT-ES and the ES23 subscale to specifically evaluate the independent association between resilience and endocrine-related quality of life and symptom burden. Prior studies have typically used more general quality-of-life measures or assessed the broader impact of breast cancer treatments, including surgery, radiation, and chemotherapy in heterogeneous patient populations [ 22 – 25 , 45 ]. Our study has several limitations, this was a secondary analysis of a cross-sectional study so the temporal direction of the relationship between resilience and endocrine-related quality of life cannot be determined, residual confounding by unmeasured variables may exist, and finally resilience and quality of life measures were self-reported which may have introduced reporting bias. However, the study has several strengths, our study cohort was large and comprised patients established on endocrine therapy from five cancers centres across Ireland making our findings representative and generalisable to similar clinical populations. The use of validated instruments, including the BRS to specifically capture innate resilience and the FACT-ES and ES23 to comprehensively assess endocrine-related symptoms, enabled a detailed clinically relevant evaluation of the relationship between resilience and endocrine symptom experience. As the number of breast cancer survivors increases, care is shifting toward shared-care models with primary care and patient-initiated follow-up pathways [ 47 – 51 ]. In this context, our findings suggest that assessing resilience may help identify patients at greater risk of worse endocrine-related quality of life and symptom burden, who may benefit from more tailored and intensive follow-up. Resilience-enhancing interventions including cognitive and positive psychological approaches, have shown promise in cancer populations; however, their role in patients receiving long term endocrine therapy requires further study [ 52 ]. In conclusion, targeting modifiable psychosocial factors such as resilience will be essential to optimise treatment tolerability and endocrine-related quality of life and to fully realise the benefits of increasingly effective therapeutic options. Table 1 Cohort characteristics by resilience category Low Resilience (n = 96) Normal Resilience (n = 212) High Resilience (n = 23) n (%) n (%) n (%) Demographics Age (mean years, SD) 57 (10.6) 57 (10.1) 62 (7.7) Nationality Irish 87 (30) 187 (63) 22 (7) Non-Irish 7 (24) 21 (72) 1 (3) Living Area Urban 41 (28) 96 (66) 9 (6) Town/village 32 (31) 63 (61) 9 (9) Remote 21 (28) 48 (65) 5 (7) Relationship status Married/Cohabiting 67 (29) 154 (66) 14 (6) Separated/Divorced 7 (33) 11 (52) 3 (14) Single 11 (31) 21 (60) 3 (9) Widowed 9 (28) 20 (63) 3 (9) Children Yes 79 (29) 174 (64) 19 (7) No 15 (29) 32 (63) 4 (8) Sociodemographic Education Primary 11 (48) 10 (43) 2 (9) Secondary 32 (26) 78 (64) 11 (9) Tertiary 50 (28) 117 (66) 10 (6) Occupational status Working 54 (57) 133 (64) 6 (27) Not Working 40 (43) 74 (36) 16 (73) Private Health Insurance Yes 45 (29) 100 (65) 9 (6) No 47 (29) 102 (63) 14 (9) Treatment characteristics Endocrine therapy Aromatase inhibitor 62 (31) 122 (60) 18 (9) Tamoxifen 33 (26) 88 (70) 5 (4) Time on endocrine therapy (mean months, SD) 34 (22.6) 33 (26.6) 37 (25.1) Chemotherapy ever Yes 62 (30) 128 (62) 16 (8) No 34 (27) 84 (67) 7 (6) Ovarian Function Suppression Yes 11 (33) 22 (67) 0 No 85 (29) 190 (64) 23 (8) Psychosocial Measurements Perceived social support (MSS-5) Median (IQR) 75 (45–90) 80 (55–95) 85 (60–100) Coping Avoidant 20 (16–24) 18.5 (15–22) 16 (13–19) Approach 31 (23–36) 31 (25–35) 31 (18–37) SD, standard deviation Table 2 Beta coefficients and 95% CI for the association between resilience and endocrine symptom burden (ES23 and FACT-ES) in women receiving adjuvant endocrine therapy for early-stage breast cancer: univariate (unadjusted) and multivariable (adjusted) linear regression analysis FACT-ES Univariate Linear Regression Model Multivariable Linear Regression Model ꞵ (95% CI) P value ꞵ (95% CI) P value Age 0.72 (0.42,1.03) < 0.001 0.56 (0.28, 0.84) < 0.001 Occupational status (working yes/no) -7.04 (-13.41, -0.68) 0.03 -7.30 (-12.91, -1.68) 0.011 Perceived Social Support 0.42 (0.30,0.53) < 0.001 0.26 (0.15, 0.36) < 0.001 Coping (Avoid) -2.49 (-2.99, -1.99) < 0.001 -1.79 (-2.29, -1.28) < 0.001 Resilience 7.61 (4.16, 11.05) < 0.001 4.62 (1.60–7.63) 0.003 ES23 Age 0.47 (0.30, 0.64) < 0.001 0.35 (0.18, 0.52) < 0.001 Occupational status (working yes/no) -1.78 (-5.43, 1.88) 0.340 -3.14 (-6.58, 0.29) 0.073 Perceived Social Support 0.14 (0.07, 0.21) < 0.001 0.05 (-0.02, 0.11) 0.135 Coping (Avoid) -1.36 (-1.65, -1.07) < 0.001 -1.07 (-1.38, -0.77) < 0.001 Resilience 3.19 (1.18, 5.20) 0.002 1.94 (0.09, 3.79) 0.004 ꞵ coefficients derived from linear regression models. Multivariable models adjusted for age, occupational status, perceived social support, avoidant coping and resilience score. Table 3 Mean (SD) FACT-ES domain scores by resilience categories Domain Low Resilience mean (SD) Normal Resilience mean (SD) High Resilience mean (SD) P value (ANOVA) Endocrine 50.34 (14.51) 52.00 (13.46) 59.05 (11.38) 0.028 Physical 21.13 (5.99) 21.78 (5.06) 23.12 (5.02) 0.254 Social 20.88 (5.92) 22.49 (5.32) 25.10 (3.18) 0.002 Emotional 16.29 (5.21) 17.36 (4.86) 21.04 (2.88) 0.001 Functional 19.34 (6.43) 20.41 (5.67) 22.21 (6.98) 0.092 P values derived from one-way ANOVA across resilience categories. Pairwise post hoc comparisons were not performed. Declarations Funding: This research was supported by the Mater Foundation the official fundraising body for the Mater Misericordiae University Hospital, Dublin, Ireland Author Contribution CK : concept, methodology, data curation, formal analysis, writing-original draft, review and editingDOR, COHB, SN, RC: methodology, data curation, writing- review editingKB: methodology, formal analysis, writing -review and editingCC: concept, methodology, data curation, formal analysis, writing, review and editingAll authors reviewed the manuscript Acknowledgement We thank the women who kindly gave their time and invaluable insights during this study. We also acknowledge our colleagues who helped with patient accrual and the conduct of the study. References Sung, H., et al., Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin, 2021. 71 (3): p. 209-249. 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Seltman, Psychological and physical adjustment to breast cancer over 4 years: identifying distinct trajectories of change. Health Psychol, 2004. 23 (1): p. 3-15. Karanci, A. and A. Erkam, Variables related to stress‐related growth among Turkish breast cancer patients. Stress and Health, 2007. 23 : p. 315-322. Manne, S.L., et al., Resilience, Positive Coping, and Quality of Life Among Women Newly Diagnosed With Gynecological Cancers. Cancer Nurs, 2015. 38 (5): p. 375-82. Zhou, K., et al., The mediator role of resilience between psychological predictors and health-related quality of life in breast cancer survivors: a cross-sectional study. BMC Cancer, 2022. 22 (1): p. 57. Connor, K.M. and J.R. Davidson, Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety, 2003. 18 (2): p. 76-82. Bender, J.L., et al., Virtual follow-up care among breast and prostate cancer patients during and beyond the COVID-19 pandemic: Association with distress. Cancer Med, 2024. 13 (4): p. e6948. Grunfeld, E., et al., Randomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care. Journal of Clinical Oncology. 24 (6): p. 848-855. Mayer, E.L., et al., Breast cancer survivors' perceptions of survivorship care options. J Clin Oncol, 2012. 30 (2): p. 158-63. Moore, L., et al., Optimising patient-initiated follow-up care – A qualitative analysis of women with breast cancer in the UK. European Journal of Oncology Nursing, 2022. 60 : p. 102183. Scruton, S., et al., Optimizing Virtual Follow-Up Care: Realist Evaluation of Experiences and Perspectives of Patients With Breast and Prostate Cancer. J Med Internet Res, 2025. 27 : p. e65148. Ding, X., et al., Effects of interventions for enhancing resilience in cancer patients: A systematic review and network meta-analysis. Clinical Psychology Review, 2024. 108 : p. 102381. Additional Declarations No competing interests reported. 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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-9245344","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":632197118,"identity":"83873c0c-8ecc-4ada-b133-0d0e576f86f6","order_by":0,"name":"Catherine M. Kelly","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYHACNiCWgNAPChjkgCwDhgS8OpiRtCQYMBgTq4UBriWxAaQFH+BvP3/swcc9Fnn8DGyJDxIMDqdvOH54A8ODCtxaJM4ksxvOeCZRLNnAdtgAqCV3w5m0AoaEM7i1GDAks0nzHJBI3HCAvU0CrOUGD9B5bXi08D9mk/4D1LL/AHv7D5DDDMBa/uHRIgG0hQFkCwPbMaD3DydAtDTg8cuNx2aSPUAtMw6zJQMdlm44E+iXAwnHcGvh7098JvHjQF1if3ub4YcPFdbyfMcPb3z4owa3FgRgBpPNYPIAMRpgoI4UxaNgFIyCUTBCAADrNlGC2JvNaQAAAABJRU5ErkJggg==","orcid":"","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Catherine","middleName":"M.","lastName":"Kelly","suffix":""},{"id":632197120,"identity":"fea1425d-09bc-4b44-a0eb-a7663c05e2c5","order_by":1,"name":"David O’ Reilly","email":"","orcid":"","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"O’","lastName":"Reilly","suffix":""},{"id":632197122,"identity":"22eabd34-794f-4988-a27e-9d17d69006d9","order_by":2,"name":"Ciara O’Hanlon Brown","email":"","orcid":"","institution":"HOPE Directorate, Trinity St James’s Cancer Institute","correspondingAuthor":false,"prefix":"","firstName":"Ciara","middleName":"O’Hanlon","lastName":"Brown","suffix":""},{"id":632197124,"identity":"7e324084-538c-45ea-a0ce-cf17b473ae33","order_by":3,"name":"Sinead A Noonan","email":"","orcid":"","institution":"University College Cork","correspondingAuthor":false,"prefix":"","firstName":"Sinead","middleName":"A","lastName":"Noonan","suffix":""},{"id":632197128,"identity":"1222e383-7182-48dc-ad38-8e3597ffa3d0","order_by":4,"name":"Roisin M. Connolly","email":"","orcid":"","institution":"University College Cork","correspondingAuthor":false,"prefix":"","firstName":"Roisin","middleName":"M.","lastName":"Connolly","suffix":""},{"id":632197130,"identity":"0896de06-8de4-49c1-b133-a3b433724343","order_by":5,"name":"Kathleen Bennett","email":"","orcid":"","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kathleen","middleName":"","lastName":"Bennett","suffix":""},{"id":632197132,"identity":"e9ac35c0-01ba-4eb0-acad-6cb5c7f7521a","order_by":6,"name":"Caitriona Cahir","email":"","orcid":"","institution":"RCSI University of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Caitriona","middleName":"","lastName":"Cahir","suffix":""}],"badges":[],"createdAt":"2026-03-27 13:40:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9245344/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9245344/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108947491,"identity":"6a21adab-66f2-46d7-b911-0fa2e4c2398a","added_by":"auto","created_at":"2026-05-11 06:29:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64335,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of FACT-ES (A) and ES23 (B) scores across resilience categories\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9245344/v1/581302f927fd8ebbd3061290.png"},{"id":108947562,"identity":"919153e0-0175-489b-9912-eb48b5d07c9c","added_by":"auto","created_at":"2026-05-11 06:29:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":484898,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9245344/v1/0788cc2d-bd65-4d12-9e51-fd79215dcdd7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Resilience and Endocrine Therapy-Related Quality of Life and Symptom Burden in Breast Cancer Survivors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most common malignancy diagnosed in women worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Hormone receptor positive breast cancer comprises 70% of all breast cancer subtypes and endocrine therapy is the mainstay of therapy. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Tamoxifen and aromatase inhibitors have been used for many decades to reduce the risk of breast cancer recurrence and death [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Contemporary regimens particularly for women at higher risk of recurrence are increasingly complex and may incorporate cyclin D kinase 4/6 inhibitors, gonadotrophin-releasing hormone agonists for premenopausal women, poly (ADP-ribose) polymerase inhibitors for patients with BRCA mutations and bone modifying agents [\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, despite increasingly efficacious treatment regimens, 38\u0026ndash;60% of patients discontinue treatment by 5 years [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Early discontinuation of endocrine therapy is associated with a 3-fold increased risk of recurrence and increased risk of breast cancer mortality [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Reasons for endocrine therapy discontinuation are complex and multifactorial, however, side effects significantly impacting quality of life are the most frequently reported cause [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Prolonged estrogen suppression below the normal postmenopausal estradiol range can lead to considerable life-altering toxicities such as chronic arthralgia, myalgia, debilitating vasomotor symptoms, insomnia, anxiety, and urogenital symptoms which, for some, can severely impact all aspects of daily life for the 5 to 10 years of planned treatment [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Multiple studies have sought to determine why some patients continue to take endocrine therapy despite side effects and others discontinue [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychosocial factors, including resilience, may contribute to variability in patients experiences of endocrine therapy and help identify those at greater risk of quality-of-life-impacting symptoms who could benefit from more intensive survivorship care.[\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Resilience, defined as the ability to recover from stress is particularly relevant in the context of ongoing health related challenges such as endocrine therapy. Resilience has been associated with lower levels of distress, fatigue, and depressive and anxiety symptoms as well as improved physical functioning in women with breast cancer. Resilience is also inversely associated with symptom burden and the impact of cancer treatment [\u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26 CR27\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, its role in endocrine therapy-related quality of life and symptom burden is not well characterised.\u003c/p\u003e \u003cp\u003eThe aim of this study was to examine whether resilience, as measured using the Brief Resilience Scale (BRS), is associated with endocrine therapy-related quality of life in women receiving endocrine therapy for early-stage breast cancer. The primary outcome was endocrine-related quality of life measured using the Functional Assessment of Cancer Therapy Endocrine Subscale (FACT-ES). A secondary analysis examined the association with endocrine symptom burden using the ES23 endocrine symptom score [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is a secondary analysis of data collected from a previously conducted cross-sectional observation study evaluating patient-reported outcomes in women receiving endocrine therapy for breast cancer in five cancer centres in Ireland. The original study design, eligibility criteria, and data collection procedures have been described previously [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Briefly, patients receiving endocrine therapy for breast cancer for \u0026ge;\u0026thinsp;2 weeks were prospectively enrolled and completed validated patient reported outcome measures at a single time point. The original cohort included patients with early and advanced breast cancer. For the present analysis, we excluded patients with metastatic disease and restricted the study population to patients who were receiving endocrine therapy in the adjuvant setting for early-stage disease. Ethical approval was received at all hospital sites prior to patient enrolment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes Measures\u003c/h2\u003e \u003cp\u003eEndocrine symptoms were assessed using the the Functional Assessment of Cancer Therapy (FACT-ES), version 4. FACT-ES is a validated patient reported outcome measure developed to evaluate endocrine therapy related symptoms and health related quality of life in women with breast cancer (HRQOL). The instrument comprises the FACT-General (FACT-G) which includes physical, social/family, emotional, and functional well-being domains, and a 19-item endocrine symptom subscale which assesses common endocrine-related symptoms such as vasomotor, musculoskeletal, and sexual symptoms. Items are rated on a 5-point Likert scale ranging from 0 (\u0026lsquo;not at all\u0026rsquo;) to 4 (\u0026lsquo;very much\u0026rsquo;). Higher scores indicate better endocrine-related QOL and fewer endocrine related symptoms. A secondary analysis examined endocrine symptom burden using the ES23 endocrine symptom score which is derived from the FACT-ES instrument. ES23 is an extended endocrine subscale that adds four other endocrine-related items (sleep, fatigue, nervousness and nausea) and is scored as an additional and more extended endocrine subscale (ES23, 23 items) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResilience\u003c/h3\u003e\n\u003cp\u003ePsychological resilience was measured using the Brief Resilience Scale (BRS), a 6-item validated measure of the ability to recover from stress. The BRS examines the individual's inherent ability to \u0026lsquo;bounce back\u0026rsquo; and does not include resilience \u0026lsquo;resources\u0026rsquo; such as social supports or protective factors like coping, optimism. Questions focus on \u0026lsquo;self\u0026rsquo; belief in the ability to recover with questions like \u0026ldquo;I tend to bounce back quickly after difficult times\u0026rdquo; and \u0026ldquo;I usually come through difficult times with little trouble.\u0026rdquo; Items are rated on a 5-point Likert scale and averaged to yield a total score ranging from 1 to 5, with higher scores indicating greater resilience [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The BRS has high internal consistency (Cronbach\u0026rsquo;s alpha 0.80\u0026ndash;0.91) and is positively correlated with life satisfaction and mindfulness, and negatively correlates with anxiety, depression, and stress [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eCovariates and Psychosocial Variables\u003c/h3\u003e\n\u003cp\u003eCoping strategies were assessed using Brief COPE, a 28-item validated instrument measuring cognitive and behavioural coping responses to stress [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Coping was summarised using approach and avoidant coping composites derived from BRIEF COPE subscales according to the framework described by Eisenberg et al. Avoidant coping included denial, behavioural disengagement, self-blame, and substance use, while approach coping included active coping, planning, positive reframing, acceptance, and support-seeking [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Items are rated on a 4-point scale, with higher scores indicating greater use of the respective coping strategy.\u003c/p\u003e \u003cp\u003ePerceived social support was measured using the 5-item Modified Social Support Survey (MSSS-5), which provides an overall assessment of tangible support, emotional/informational support, affectionate support and positive social interaction. Items are rated on a 5-point Likert scale ranging from 1 (\u0026lsquo;none of the time\u0026rsquo;) to 5 (\u0026lsquo;All of the time\u0026rsquo;). Raw scores are summed and transformed to a 0-100 scale. Higher scores indicate greater perceived social support [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe following covariates were recorded for each patient; age, education level (third level or not), occupational status was defined as working (employed or looking after family/home) or not working (unemployed/retired/unable to work), type and duration of endocrine therapy, gonadotrophin releasing hormone agonists (GnRHa)(yes/no), cyclin D Kinase 4/6 inhibitors (yes/no), receipt of chemotherapy (yes/no).\u003c/p\u003e\n\u003ch3\u003eStatistical Analyses\u003c/h3\u003e\n\u003cp\u003eDemographic and clinical covariates were summarised by resilience category. Resilience was measured using the BRS and categorised using established thresholds as low (\u0026lt;\u0026thinsp;3), normal (3-4.3) and high (\u0026gt;\u0026thinsp;4.3) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Continuous variables were summarised using mean (standard deviation, SD) and compared across resilience categories using one-way ANOVA. FACT-ES and ES23 scores across resilience categories were visualised using box-and-whisker plots. Categorical variables were compared across resilience categories using chi squared or Fisher\u0026rsquo;s exact tests as appropriate.\u003c/p\u003e \u003cp\u003eLinear regression models were used to examine associations between resilience and endocrine-related outcomes. Univariate linear regression analyses were performed to assess the relationship between each predictor variable and the outcome measures. Variables examined included resilience score, age, social support, and coping strategy. Variables associated with the outcome at p\u0026thinsp;\u0026lt;\u0026thinsp;0.10 in univariate analyses were entered into multivariable linear regression models. Individual FACT-ES domain scores were compared across resilience categories using one-way ANOVA. Multivariable regression models were constructed for both endocrine related quality of life measured by FACT-ES total score and endocrine symptom burden measured using the ES-23 subscale. Resilience was entered as a continuous variable in regression models. Model assumptions were assessed and multicollinearity was evaluated using variance inflation factors. As age can influence both endocrine symptom experience and psychosocial adaptation, an interaction term between resilience and age was included in the model to assess whether the association between resilience and endocrine therapy-related quality of life differed by age. Regression coefficients (β) with 95% confidence intervals (CI) were reported. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Clinical relevance was interpreted with reference to published minimally important differences for FACT measures, supported by a distribution-based estimate of 0.5 standard deviations [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Analyses were performed using SAS 9.4.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 331 patients with early-stage breast cancer receiving endocrine therapy were included in the analysis. Mean age was 57 years (SD\u0026thinsp;=\u0026thinsp;10), 91% were Irish (n\u0026thinsp;=\u0026thinsp;296), 73% were married or cohabiting (n\u0026thinsp;=\u0026thinsp;235), 93% were educated beyond primary level, 60% were working (n\u0026thinsp;=\u0026thinsp;193). Most patients were taking an aromatase inhibitor (65%, n\u0026thinsp;=\u0026thinsp;202) and 38% were receiving tamoxifen (n\u0026thinsp;=\u0026thinsp;126). The mean (SD) BRS score was 3.11 (0.91). Overall, 29% of patients were classified as low resilience (n\u0026thinsp;=\u0026thinsp;96), 64% as normal (n\u0026thinsp;=\u0026thinsp;212) and 7% as high resilience (n\u0026thinsp;=\u0026thinsp;23). Demographic, treatment and psychosocial variables were stratified by resilience group. Age, occupational status, perceived social support and avoidant coping differed between resilience groups whereas other demographic and treatment characteristics were similar (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn univariable analysis examining factors associated with endocrine-related quality of life, age, occupational status, perceived social support, avoidant coping and resilience were all significantly associated with FACT-ES scores. Higher resilience (continuous) was associated with improved endocrine-related quality of life (FACT-ES ꞵ= 7.61, 95% CI 4.16\u0026ndash;11.05, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In multivariable analysis adjusting for these covariates, all remained independently associated with FACT-ES scores. Higher resilience was associated with improved endocrine-related quality of life (ꞵ= 4.62, CI 1.60\u0026ndash;7.63, P\u0026thinsp;=\u0026thinsp;0.003) (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The distribution of FACT-ES scores by resilience category is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eMean FACT-ES domain scores were examined across resilience categories using one-way ANOVA. Emotional wellbeing, social wellbeing and endocrine symptoms differed significantly across resilience categories, whereas physical and functional wellbeing did not (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA secondary analyses using ES23 endocrine symptom score demonstrated a similar pattern. Age, perceived social support, avoidant coping and resilience were significantly associated with symptom burden in univariate analyses, whereas occupational status was not (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In multivariable analysis, resilience, age and avoidant coping remained significantly associated with ES23 scores, while occupational status and perceived social support were no longer statistically significant. Higher resilience was associated with lower endocrine symptom burden in multivariable analyses (ꞵ= 1.94 (95% CI 0.09\u0026ndash;3.79), p\u0026thinsp;=\u0026thinsp;0.004). There was no significant interaction between age and resilience observed for ES23 (p\u0026thinsp;=\u0026thinsp;0.192) or FACT-ES (p\u0026thinsp;=\u0026thinsp;0.071). These findings were consistent with those observed using the FACT-ES total score and support the robustness of the observed association between resilience and endocrine symptom experience. Variance inflation factors were examined and were all below 2, indicating no evidence of multicollinearity between predictors.\u003c/p\u003e \u003cp\u003eThe difference between mean FACT-ES scores between low and high resilience categories corresponded to 0.78 standard deviations exceeding the 0.5 standard deviation threshold for a clinically meaningful difference. A similar magnitude of difference was observed for ES23 scores (0.65 standard deviations).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe observed that women with early-stage breast cancer and higher resilience had significantly higher FACT-ES scores, indicating better overall endocrine-related quality of life, and higher ES23 scores reflecting lower endocrine symptom burden. The magnitude of difference in FACT-ES and ES23 scores between the low and high resilience groups exceeded the commonly accepted 0.5 SD threshold for a clinically meaningful difference, supporting the clinical relevance of our findings. Endocrine therapies, including tamoxifen and aromatase inhibitors remain the cornerstone of treatment for early-stage breast cancer [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Recent advances have shown improved efficacy for a new oral selective estrogen receptor degrader and for the addition of CDK 4/6 inhibitors to endocrine therapy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, these therapeutic gains are accomplished by prolonged treatment duration and an increasing burden of treatment related toxicities [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. As a result, optimising endocrine therapy-related quality of life and minimising symptom burden are critical to maintaining adherence and maximising benefit. In this context, we evaluated the role of resilience in shaping patients experiences of endocrine-related quality of life and symptoms.\u003c/p\u003e \u003cp\u003eIn domain-level analyses of FACT-ES, differences across resilience categories were mainly driven by emotional, social and endocrine domains, while physical and functional wellbeing did not differ significantly. These findings suggest that, even among patients with differing levels of symptom burden, resilience shapes how symptoms translate into quality-of-life outcomes particularly through emotional and social functioning. The absence of an associated between resilience and physical or functional domains, is consistent with prior work suggesting that resilience primarily influences emotional and psychosocial adaptation rather than physical symptom burden [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Resilience may modify interpretation and impact of symptoms, having less effect on broader physical symptoms such as fatigue or limitations in daily functioning. Instead, resilience modifies the experience and impact of endocrine symptoms on quality of life particularly through emotional well-being and social functioning.\u003c/p\u003e \u003cp\u003eIn adjusted analysis resilience remained an independent predictor of both endocrine-related quality of life and endocrine symptom burden. Older age and lower use of avoidant coping were also associated with improved outcomes. While higher perceived social support, and employment were all associated with better FACT-ES scores these were not significant predictors of endocrine symptoms burden as measured by ES23. This discordance likely reflects differences in constructs measured by these scales, with FACT-ES capturing broader quality of life domains, whereas ES23 more specifically reflects endocrine symptom burden indicating better endocrine-related quality of life. Consistent with prior studies, younger age was associated with a higher symptom burden, a factor previously linked to discontinuation and non-adherence to endocrine therapy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Avoidant coping was independently associated with worse outcomes which is in keeping with evidence linking maladaptive coping strategies to greater distress and impaired quality of life [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In contrast to studies reporting resilience as a mediator in the relationship between coping strategies and quality of life our findings suggest that resilience and coping may represent distinct constructs [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This may relate to the use of the BRS which captures resilience as a unidimensional construct in contrast to multidimensional tools such as the Connor-Davidson Resilience Scale that incorporate coping-related resources [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date most studies examining the association between resilience and breast cancer outcomes have used measures that capture resilience resources such as social supports, and coping strategies, rather than resilience as an inherent capacity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. By using the BRS we aimed to assess the individuals innate ability to recover from stress, while adjusting for protective personal and environmental factors [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In contrast to previous studies, we used FACT-ES and the ES23 subscale to specifically evaluate the independent association between resilience and endocrine-related quality of life and symptom burden. Prior studies have typically used more general quality-of-life measures or assessed the broader impact of breast cancer treatments, including surgery, radiation, and chemotherapy in heterogeneous patient populations [\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study has several limitations, this was a secondary analysis of a cross-sectional study so the temporal direction of the relationship between resilience and endocrine-related quality of life cannot be determined, residual confounding by unmeasured variables may exist, and finally resilience and quality of life measures were self-reported which may have introduced reporting bias. However, the study has several strengths, our study cohort was large and comprised patients established on endocrine therapy from five cancers centres across Ireland making our findings representative and generalisable to similar clinical populations. The use of validated instruments, including the BRS to specifically capture innate resilience and the FACT-ES and ES23 to comprehensively assess endocrine-related symptoms, enabled a detailed clinically relevant evaluation of the relationship between resilience and endocrine symptom experience.\u003c/p\u003e \u003cp\u003eAs the number of breast cancer survivors increases, care is shifting toward shared-care models with primary care and patient-initiated follow-up pathways [\u003cspan additionalcitationids=\"CR48 CR49 CR50\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In this context, our findings suggest that assessing resilience may help identify patients at greater risk of worse endocrine-related quality of life and symptom burden, who may benefit from more tailored and intensive follow-up. Resilience-enhancing interventions including cognitive and positive psychological approaches, have shown promise in cancer populations; however, their role in patients receiving long term endocrine therapy requires further study [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn conclusion, targeting modifiable psychosocial factors such as resilience will be essential to optimise treatment tolerability and endocrine-related quality of life and to fully realise the benefits of increasingly effective therapeutic options.\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\u003eCohort characteristics by resilience category\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow Resilience (n\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal Resilience\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;212)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh Resilience\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDemographics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean years, SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNationality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Irish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving Area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTown/village\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemote\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/Cohabiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated/Divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e174 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (7)\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\u003e15 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSociodemographic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate Health Insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6)\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\u003e47 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndocrine therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAromatase inhibitor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTamoxifen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime on endocrine therapy (mean months, SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (25.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy ever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (8)\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\u003e34 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian Function Suppression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\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\u003e85 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e190 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychosocial Measurements\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived social support (MSS-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (45\u0026ndash;90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (55\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85 (60\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoidant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (16\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5 (15\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (13\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (23\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (25\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (18\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\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\u003eBeta coefficients and 95% CI for the association between resilience and endocrine symptom burden (ES23 and FACT-ES) in women receiving adjuvant endocrine therapy for early-stage breast cancer: univariate (unadjusted) and multivariable (adjusted) linear regression analysis\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFACT-ES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariate Linear Regression Model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariable Linear Regression Model\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eꞵ (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eꞵ (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.42,1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.56 (0.28, 0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational status (working yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-7.04 (-13.41, -0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.30 (-12.91, -1.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived Social Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.42 (0.30,0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.26 (0.15, 0.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoping (Avoid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.49 (-2.99, -1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.79 (-2.29, -1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.61 (4.16, 11.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.62 (1.60\u0026ndash;7.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eES23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.47 (0.30, 0.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35 (0.18, 0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational status (working yes/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.78 (-5.43, 1.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.14 (-6.58, 0.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived Social Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.14 (0.07, 0.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.05 (-0.02, 0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoping (Avoid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.36 (-1.65, -1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.07 (-1.38, -0.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.19 (1.18, 5.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.94 (0.09, 3.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eꞵ coefficients derived from linear regression models. Multivariable models adjusted for age, occupational status, perceived social support, avoidant coping and resilience score.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean (SD) FACT-ES domain scores by resilience categories\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow Resilience\u003c/p\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal Resilience\u003c/p\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh Resilience\u003c/p\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value (ANOVA)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndocrine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.34 (14.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.00 (13.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59.05 (11.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.13 (5.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.78 (5.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.12 (5.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20.88 (5.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.49 (5.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.10 (3.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.29 (5.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.36 (4.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.04 (2.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.34 (6.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.41 (5.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.21 (6.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eP values derived from one-way ANOVA across resilience categories. Pairwise post hoc comparisons were not performed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research was supported by the Mater Foundation the official fundraising body for the Mater Misericordiae University Hospital, Dublin, Ireland\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCK : concept, methodology, data curation, formal analysis, writing-original draft, review and editingDOR, COHB, SN, RC: methodology, data curation, writing- review editingKB: methodology, formal analysis, writing -review and editingCC: concept, methodology, data curation, formal analysis, writing, review and editingAll authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the women who kindly gave their time and invaluable insights during this study. We also acknowledge our colleagues who helped with patient accrual and the conduct of the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSung, H., et al., \u003cem\u003eGlobal Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries.\u003c/em\u003e CA Cancer J Clin, 2021. \u003cstrong\u003e71\u003c/strong\u003e(3): p. 209-249.\u003c/li\u003e\n \u003cli\u003eSt Gallen Consensus Conference, P., et al., \u003cem\u003eUnderstanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023.\u003c/em\u003e Annals of Oncology, 2023. \u003cstrong\u003e34\u003c/strong\u003e(11): p. 970-986.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eAromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials.\u003c/em\u003e The Lancet, 2015. \u003cstrong\u003e386\u003c/strong\u003e(10001): p. 1341-1352.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eAromatase inhibitors versus tamoxifen in premenopausal women with oestrogen receptor-positive early-stage breast cancer treated with ovarian suppression: a patient-level meta-analysis of 7030 women from four randomised trials.\u003c/em\u003e Lancet Oncol, 2022. \u003cstrong\u003e23\u003c/strong\u003e(3): p. 382-392.\u003c/li\u003e\n \u003cli\u003eSlamon, D.J., et al., \u003cem\u003eRationale and trial design of NATALEE: a Phase III trial of adjuvant ribociclib + endocrine therapy versus endocrine therapy alone in patients with HR+/HER2- early breast cancer.\u003c/em\u003e Ther Adv Med Oncol, 2023. \u003cstrong\u003e15\u003c/strong\u003e: p. 17588359231178125.\u003c/li\u003e\n \u003cli\u003eJohnston, S.R.D., et al., \u003cem\u003eAbemaciclib plus endocrine therapy for hormone receptor-positive, HER2-negative, node-positive, high-risk early breast cancer (monarchE): results from a preplanned interim analysis of a randomised, open-label, phase 3 trial.\u003c/em\u003e Lancet Oncol, 2023. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 77-90.\u003c/li\u003e\n \u003cli\u003eGeyer, C.E., Jr., et al., \u003cem\u003eOverall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and high-risk, early breast cancer.\u003c/em\u003e Ann Oncol, 2022. \u003cstrong\u003e33\u003c/strong\u003e(12): p. 1250-1268.\u003c/li\u003e\n \u003cli\u003eColeman, R.E., et al., \u003cem\u003eBenefits and risks of adjuvant treatment with zoledronic acid in stage II/III breast cancer. 10 years follow-up of the AZURE randomized clinical trial (BIG 01/04).\u003c/em\u003e J Bone Oncol, 2018. \u003cstrong\u003e13\u003c/strong\u003e: p. 123-135.\u003c/li\u003e\n \u003cli\u003eFrancis, P.A., et al., \u003cem\u003e15-year outcomes for women with premenopausal hormone receptor-positive early breast cancer (BC) in the SOFT and TEXT trials assessing benefits from adjuvant exemestane (E) + ovarian function suppression (OFS) or tamoxifen (T)+OFS.\u003c/em\u003e Journal of Clinical Oncology, 2025. \u003cstrong\u003e43\u003c/strong\u003e(16_suppl): p. 505-505.\u003c/li\u003e\n \u003cli\u003eMurphy, C.C., et al., \u003cem\u003eAdherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review.\u003c/em\u003e Breast Cancer Res Treat, 2012. \u003cstrong\u003e134\u003c/strong\u003e(2): p. 459-78.\u003c/li\u003e\n \u003cli\u003eWinn, A.N. and S.B. 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Davidson, \u003cem\u003eDevelopment of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC).\u003c/em\u003e Depress Anxiety, 2003. \u003cstrong\u003e18\u003c/strong\u003e(2): p. 76-82.\u003c/li\u003e\n \u003cli\u003eBender, J.L., et al., \u003cem\u003eVirtual follow-up care among breast and prostate cancer patients during and beyond the COVID-19 pandemic: Association with distress.\u003c/em\u003e Cancer Med, 2024. \u003cstrong\u003e13\u003c/strong\u003e(4): p. e6948.\u003c/li\u003e\n \u003cli\u003eGrunfeld, E., et al., \u003cem\u003eRandomized Trial of Long-Term Follow-Up for Early-Stage Breast Cancer: A Comparison of Family Physician Versus Specialist Care.\u003c/em\u003e Journal of Clinical Oncology. \u003cstrong\u003e24\u003c/strong\u003e(6): p. 848-855.\u003c/li\u003e\n \u003cli\u003eMayer, E.L., et al., \u003cem\u003eBreast cancer survivors\u0026apos; perceptions of survivorship care options.\u003c/em\u003e J Clin Oncol, 2012. \u003cstrong\u003e30\u003c/strong\u003e(2): p. 158-63.\u003c/li\u003e\n \u003cli\u003eMoore, L., et al., \u003cem\u003eOptimising patient-initiated follow-up care \u0026ndash; A qualitative analysis of women with breast cancer in the UK.\u003c/em\u003e European Journal of Oncology Nursing, 2022. \u003cstrong\u003e60\u003c/strong\u003e: p. 102183.\u003c/li\u003e\n \u003cli\u003eScruton, S., et al., \u003cem\u003eOptimizing Virtual Follow-Up Care: Realist Evaluation of Experiences and Perspectives of Patients With Breast and Prostate Cancer.\u003c/em\u003e J Med Internet Res, 2025. \u003cstrong\u003e27\u003c/strong\u003e: p. e65148.\u003c/li\u003e\n \u003cli\u003eDing, X., et al., \u003cem\u003eEffects of interventions for enhancing resilience in cancer patients: A systematic review and network meta-analysis.\u003c/em\u003e Clinical Psychology Review, 2024. \u003cstrong\u003e108\u003c/strong\u003e: p. 102381.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"breast-cancer-research-and-treatment","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brea","sideBox":"Learn more about [Breast Cancer Research and Treatment](https://www.springer.com/journal/10549)","snPcode":"10549","submissionUrl":"https://submission.nature.com/new-submission/10549/3","title":"Breast Cancer Research and Treatment","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Resilience, Breast Cancer, Endocrine therapy-related quality of life, Endocrine therapy ","lastPublishedDoi":"10.21203/rs.3.rs-9245344/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9245344/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResilience, the ability to adapt and recover from adversity may be particularly relevant during endocrine therapy for breast cancer which can adversely affect endocrine-related quality of life. We aimed to evaluate the association between resilience and endocrine-related quality of life in an Irish breast cancer population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe performed a secondary cross-sectional analysis of a prospective dataset of patients with early-stage breast cancer receiving endocrine therapy (≥ 2 weeks). The primary outcome was endocrine-related quality of life measured by theFunctional Assessment of Cancer Therapy (FACT-ES). Resilience was measured using the BRIEF Resilience Scale (BRS). Additional variables included coping (BRIEF COPE), social support and clinicodemographic factors. Associations were analysed using multivariable linear regression. In a secondary analysis resilience was examined in relation to the FACT-ES endocrine symptom (ES23) subscale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study cohort comprised 331 patients (mean age 57 years, SD 10). In multivariable regression analysis, higher resilience was associated with improved endocrine-related quality of life (ꞵ= 4.62, 95% CI 1.60-7.63, P=0.003). Older age, and lower avoidant coping were associated with improved quality of life. Domain analyses showed associations between resilience and endocrine symptoms, and social and emotional wellbeing, but not physical or functional wellbeing. In exploratory multivariable analysis resilience, age, and avoidant coping were associated with ES23 scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResilience was an independent predictor of endocrine-related quality of life and symptom burden, with differences driven by emotional, social and endocrine domains. These findings may represent a target for intervention and a means of identifying patients requiring additional support.\u003c/p\u003e","manuscriptTitle":"Resilience and Endocrine Therapy-Related Quality of Life and Symptom Burden in Breast Cancer Survivors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 06:27:05","doi":"10.21203/rs.3.rs-9245344/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"43882082753443375064829732436882840014","date":"2026-04-29T14:58:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-29T14:14:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-28T07:02:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-28T07:02:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer Research and Treatment","date":"2026-03-27T13:27:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"breast-cancer-research-and-treatment","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brea","sideBox":"Learn more about [Breast Cancer Research and Treatment](https://www.springer.com/journal/10549)","snPcode":"10549","submissionUrl":"https://submission.nature.com/new-submission/10549/3","title":"Breast Cancer Research and Treatment","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4f2a486d-e88b-4732-820c-2b07e0d34ce4","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T06:27:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 06:27:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9245344","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9245344","identity":"rs-9245344","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}