Interventions to improve resilience in breast cancer patients: a systematic review

International Journal of Public Health Science (IJPHS) Vol. 14, No. 4, December 2025, pp. 1710~1719 ISSN: 2252-8806, DOI: 10.11591/ijphs.v14i4.26206  1710 Journal homepage: http://ijphs.iaescore.com Interventions to improve resilience in breast cancer patients: a systematic review Dwi Retnaningsih1, Nursalam2, Hanik Endang Nihayati2 1Nursing Study Program, Universitas Widya Husada Semarang, Semarang, Indonesia 2Department of Nursing, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia Article Info ABSTRACT Article history: Received Nov 4, 2024 Revised Aug 22, 2025 Accepted Nov 3, 2025 Breast cancer patients with low resilience may experience adverse psychological outcomes, including stress, anxiety, depression, emotional dysregulation, and difficulties in recovery. This systematic review aims to evaluate the effectiveness of various interventions in improving resilience among breast cancer patients and to provide practical guidance for healthcare practitioners in implementing these interventions. Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and PICOS framework, a comprehensive search was conducted across PubMed, Scopus, ScienceDirect, and Google Scholar for studies published between 2018–2024. Two independent reviewers screened eligible studies in two stages (title/abstract and full-text). The methodological quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Tool. A total of 20 studies met the inclusion criteria. Interventions identified include music therapy, mindfulness, family and social support programs, cognitive behavioral therapy, digital-based interventions, and psychoeducation. Most interventions demonstrated a significant positive impact on patients’ psychological resilience, coping ability, and quality of life. Evidence suggests that resilience-focused interventions can be effectively integrated into supportive care for breast cancer patients. Healthcare practitioners should consider incorporating these strategies to address psychosocial needs. Further studies are recommended to evaluate long-term impacts and costeffectiveness in diverse settings. Keywords: Breast cancer Psychological well-being Quality of life Resilience interventions Systematic review This is an open access article under the CC BY-SA license. Corresponding Author: Dwi Retnaningsih Nursing Study Program, Universitas Widya Husada Semarang Subali Raya Street, 12, Semarang, Central Java, Indonesia Email: dwi.retnaning[email protected] 1. INTRODUCTION Breast cancer is one of the most prevalent malignancies affecting women worldwide [1]. According to the World Health Organization (WHO), breast cancer is the most common type of cancer in many countries, including Indonesia, and remains a major public health concern [2]. In Indonesia, data from the Global Cancer Observatory (GLOBOCAN) 2020 reported approximately 65,858 new cases of breast cancer, accounting for 16.6% of all cancer diagnoses, with a mortality rate of 9.6% (IARC, 2021). Globally, breast cancer ranks sixth in cancer-related deaths and is the second most common cancer in terms of diagnoses [3], [4]. These statistics highlight the urgency of developing effective interventions to address the physical and psychosocial impact of the disease. Int J Public Health Sci ISSN: 2252-8806  Interventions to improve resilience in breast cancer patients: a systematic review (Dwi Retnaningsih) 1711 The diagnosis and treatment of breast cancer often result in significant psychological distress, including anxiety, depression, and heightened stress levels [5]. Patients often face challenges such as changes in body image, feelings of loneliness, and uncertainty about prognosis [6]-[8]. In addition to the disease burden, treatment modalities like chemotherapy, surgery, and radiotherapy often result in adverse effects such as fatigue, nausea, hair loss, and weight loss, further exacerbating psychological strain. In Indonesia, unique challenges include limited access to psychosocial support services, cultural stigma, and disparities in health literacy, which may influence patient outcomes. Resilience, defined as a dynamic process that enables individuals to adapt successfully to adversity, plays a crucial role in helping breast cancer patients cope with the emotional, physical, and psychological challenges of the disease [9]. The resilience model incorporates personal, social, and environmental factors that interact to promote adaptive functioning during illness [10]. Patients with high resilience are more likely to adhere to treatment, maintain hope, and achieve better psychological and clinical outcomes [11]. Conversely, low resilience can lead to increased stress, depression, and difficulty managing emotional distress [12]-[14]. Several resilience-based interventions, such as cognitive behavioral therapy, mindfulness training, social support programs, and psychoeducation, have been developed to address these challenges [15]. However, previous studies often vary in design, target population, and outcome measures, making it difficult to draw definitive conclusions about their effectiveness. There is also limited synthesis of evidence specific to breast cancer patients, particularly in lowand middle-income countries like Indonesia. Therefore, this study aims to systematically review available interventions to enhance resilience among breast cancer patients, identify the most effective approaches, and provide evidence-based guidance for healthcare practitioners. 2. METHOD We compiled pertinent research on boosting breast cancer patients' resilience through systematic reviews. Utilizing the Joanna Briggs Institute Guidelines and the Centre for Review and Dissemination, we employed the PRISMA checklist of questions to assess the study's quality [16], [17]. 2.1. Search strategy and inclusion criteria for systematic reviews A strategic literature search was conducted using terms such as “resilience,” “breast cancer,” “RCT,” and “stress.” Boolean operators (AND/OR) were applied to refine the search. AND RCT AND Stress; looking for pertinent publications from other references; searching articles in databases like Scopus, Science Direct, ProQuest, and Web of Science. The PICOS criteria (population, intervention, comparison, outcome, and study design) are used to define the inclusion criteria for journal articles published during the previous five years, from 2019 to 2024, as shown in Table 1. Table 1. Inclusion and exclusion criteria with PICOS Criteria Inclusion Exclusion Population breast cancer Other than breast cancer Intervention Increases resistance There are no exclusion criteria Comparisons intragroup, intergroup, in relation to the control group, or in the absence of the control group There are no exclusion criteria Outcome Patients with breast cancer have increased resistance. No pertinent relationships exist in individuals with cancer Study type RCT as well as trials Studies discussing irrelevant associations in cancer patients were excluded Type publication original studies subjected to peer review Unreviewed research studies Years 2019 sampai 2024 Pre 2019 Language English Languages besides English 795 articles from 4 sources (Scopus, Science Direct, ProQuest, and Web of Science) were found in the search results. One of the twenty-one articles that were assessed did not fit the requirements since it had nothing to do with the study's goal. Twenty papers that satisfy the inclusion criteria and the research topic have been selected for inclusion in this study. The inclusion criteria, which include: i) RCT and experiments published in English-language peer-reviewed journals between 2019 and 2024; ii) study participants with a clinical diagnosis of breast cancer; and iii) interventions promoting resilience, are used to evaluate the title and abstract manuscripts for relevance to the topic. The whole article is reviewed to evaluate if it should be included if the first review's findings do not clearly reveal its relevance. To guarantee that the original article is ultimately included in the review, the entire content is read once it has been gathered. Here, twenty articles satisfy the requirements for inclusion.  ISSN: 2252-8806 Int J Public Health Sci, Vol. 14, No. 4, December 2025: 1710-1719 1712 2.2. Study selection, data extraction, and management Determine whether crucial elements, like the research design, systematic review, clinical trials, case control, cross-sectional, case report, descriptive study, and experiment, need to be taken out of each study. Patients with breast cancer made up the sample population. The major results, analytical techniques, and conclusions pertaining to therapies aimed at enhancing patients' resilience in the face of breast cancer. Make a table to include the information gleaned from each study, along with any pertinent details and conclusions pertaining to the subject of the investigation. Make sure that all pertinent data is appropriately captured by meticulously extracting data from each chosen research project. Once the data is extracted, organize the data systematically in an accessible and manageable format, in the form of tables. Re-verify the extracted data to ensure the accuracy and completeness of the information. accurately identify inconsistencies or ambiguities in the extracted data. Analysis and interpretation of data to extract key findings and conclusions from the studies that have been analyzed. Each study's risk of bias evaluation made use of a technique developed by the Cochrane Collaboration and modified from Sterne et al. [18]. This review is limited to studies published in English, which may exclude relevant research in other languages. Additionally, the search and selection process may have missed unpublished or non-indexed studies, and the heterogeneity of study designs limited the ability to perform a meta-analysis. 3. RESULTS AND DISCUSSION 3.1. Study characteristics Twenty papers satisfy the requirements for review inclusion as shown in Figure 1. RCT studies on breast cancer patients were used to get the articles. Figure 1 shows flow diagrams for the literature selection and search process. Figure 1 illustrates the literature selection process and highlights strategies to enhance resilience among breast cancer patients. Figure 1. Flow diagram of the literature selection using PRISMA 3.2. Respondent characteristics All study respondents were breast cancer patients who received interventions aimed at enhancing their resilience. The participants’ ages ranged from 18 to 74 years. Detailed information on the respondent characteristics from each included study is presented in Table 2. 3.3. Interventions improve resilience in breast cancer patients This section presents the findings of the systematic review, organized according to the types of interventions identified across the included studies. The results summarize the characteristics of the selected articles, including study design, participant profile, and intervention components. Interventions are grouped into categories such as psychological therapies, social support programs, and digital-based approaches. The Int J Public Health Sci ISSN: 2252-8806  Interventions to improve resilience in breast cancer patients: a systematic review (Dwi Retnaningsih) 1713 discussion integrates these findings with existing literature, highlighting the effectiveness, limitations, and potential applications of each intervention in clinical and community settings. All of the study's participants were patients with breast cancer who received treatments aimed at enhancing their resilience. The research design included a mixed-method, non-randomized RCT. Table 3 lists 20 papers that address therapies aimed at enhancing the resilience of people with breast cancer. Identified interventions included family and social support programs, music therapy, mindfulness, cognitive-behavioral therapy (CBT), digital interventions, and psychoeducational programs, all of which contributed to enhancing resilience among breast cancer patients. Table 2. Respondent characteristics No Library resource Country Cancer types Age (year) No Library resource Country Cancer types Age (year) 1 [19] Spain Breast cancer ≥18 11 [29] Iran Breast cancer 35-55 2 [20] Turkey Breast cancer ≥18 12 [30] China Breast cancer ≤45 3 [21] USA Breast Urogenital Gastrointestinal Lung ≥18 13 [31] Turkey Breast cancer ≥25 4 [22] Italy Breast cancer ≥18 14 [32] China Breast cancer ≥18 5 [23] Germany Breast cancer ≥18 15 [33] Taiwan Breast cancer ≥20 6 [24] Taiwan Breast cancer ≥18 17 [34] Germany Breast cancer 25-65 7 [25] Finland Breast cancer 25-65 18 [35] China Breast cancer ≥18 8 [26] Japan Breast cancer 20–74 19 [36] United Kingdom Breast Gynecological Prostate Lung Colorectal Gastrointestinal 54.3 9 [27] USA Breast cancer <50 20 [37] USA Breast cancer ≥18 10 [28] Australia Breast cancer ≥18 21 [38] Italy Breast cancer >26 3.3.1. Family and social support Cancer patients' well-being has been demonstrated to benefit from familial, spiritual, and social support roles, which include moral, practical, and emotional care from patients' relatives [39], [40]. Social support, trust, and participation in social networking sites can also play important health-related roles [41]. The family is often the primary source of support in the patient's journey during treatment [42]-[44]. The purpose of the study was to assess resilience in cancer patients and the variables that affected it. The study emphasized the value of social support in addition to the effects of tracheotomy, anxiety, depression, and family size on resilience. Resilience was also found to be significantly influenced by formal education and its function in family decision-making [45]. For patients to improve their general health and recover from disease, spouses' emotional support and friends' informed support are crucial [46]. Husbands caring for their spouses with breast cancer may have less stress if they have greater social support, family resilience, and personal resilience [47]-[49]. Cancer patients' quality of life is significantly impacted by family resilience [14], and breast cancer patients have highlighted important information that social networks require in order to effectively assist them. Research has demonstrated a substantial positive correlation between family resilience, the quality of interpersonal communication, and the impression of support from one's spouse [50]. Family-centered lung cancer treatment is recommended, as is the development of appropriate family support networks [51], [52]. Research on the caregiving burden of families with lung cancer patients conducted in China demonstrates the significant impact that family resilience has in mitigating caregiving stress [53]. Good social support can increase family resilience, thereby reducing the burden of nursing and emphasizing the importance of family-centric care [54], [55]. For the relatives of breast cancer patients to be able to adjust and get through the difficulties, family resilience is also essential. It has been demonstrated that family resiliencefocused interventions are beneficial in lowering stress, anxiety, and depression while also enhancing social support and problem-solving skills [50]. In addition, improved communication and support between partners can increase family resilience to transitional gynecological cancers. Health services in rural areas may consider expanding transportation assistance and access to benefits to reduce nursing stress [56]. The researchers will also test the effectiveness of family resilience intervention programs that focus on breast cancer patients, including online family gatherings led by trained professionals, which are expected to improve resilience in breast cancer patient families [57]. Comprehending the interplay of psychological, social, and spiritual elements might lead to more allencompassing and efficacious approaches for addressing mental health issues in cancer patients [58]. Holistic therapy requires acknowledging the importance of spirituality in mental health and rehabilitation in addition  ISSN: 2252-8806 Int J Public Health Sci, Vol. 14, No. 4, December 2025: 1710-1719 1714 to biological, psychological, and social factors [59]-[61]. The study also covers the variables that affect the burden that Chinese caregivers of lung cancer patients perceive. It also emphasizes the significance of family-centric care and the role that family resilience plays as a mediator between the level of social support and caregiver burden [53]. Table 3. Interventions to enhance the resilience of cancer patients No Research Type of research Intervention Clustering intervention 1 [19] RCT Peer support program Family and social support 2 [20] Pretests and posttests, and a control group support group intervention 3 [21] RCT Music psychotherapy Music therapy 4 [22] RCT Music intervention 5 [23] RCT Mindful walking Mindfulness 6 [24] RCT Mindfulness-based fitness training program 7 [25] A single-group pretest and repeated midand post-test Mindfulness-based Stress reduction 8 [26] RCT Mindfulness-based cognitive therapy intervention 9 [27] Nonrandomized Mindfulness-based Stress reduction 10 [28] Mixed-methods uncontrolled study Cognitive behavioural therapy, acceptance and commitment therapy, mindfulness, and positive psychology 11 [29] RCT Educate the fredrickson positive emotions 12 [30] RCT Psychological intervention 13 [31] RCT Psychosocial intervention 14 [32] RCT Family centered positive psychological intervention 15 [33] RCT Cognitive behavioral Therapy Cognitive behavioral therapy 16 [34] RCT Cognitive behavioral therapy 17 [35] RCT Cyclic adjustment training (CAT) using WeChat for women with breast cancer Digital-based interventions 18 [36] RCT Digital HOPE program 19 [37] RCT Psychoeducational intervention Psychoeducational intervention 20 [38] A Mixed Methods Study Psychoeducational intervention 3.3.2. Music therapy Patients with breast cancer frequently have clinically substantial depression and mild anxiety. Following an art-based mandala intervention, they experienced a marked reduction in fear. Nonetheless, their anxiety did not go down, most likely as a result of outside influences like the COVID-19 epidemic. The study's findings showed that although art-based mandala treatments were effective in reducing patients' fear, they were less effective in reducing their anxiety, possibly due to outside factors [62]. Numerous elements, including how optimism, resilience, and social support affect one's well-being, have an impact on the quality of life experienced by cancer patients. These elements are crucial for the flexibility and overall health of patients, and they may be used to develop new therapeutic approaches [46]. In addition, the research highlights the significance of family resilience interventions as a means of assisting relatives of breast cancer patients in better managing their challenges [54]. The report's other papers emphasize the need to identify the emergency profile of patients with gynecological cancer receiving chemotherapy, comprehend their risk factors, and offer suitable psychosocial support services [63]. 3.3.3. Mindfulness Mindfulness is a practice of full consciousness involving attention to current experiences without judgment. Mindfulness is useful in reducing stress, anxiety, and depression, as well as improving emotional and mental well-being. In breast cancer patients, mindfulness helps manage the physical and emotional symptoms associated with the disease and its treatment. Various techniques, such as meditation and yoga, are frequently used, and research shows that mindfulness is effective in improving the quality of life of patients. This section also recommends integrating mindfulness into cancer patient care programs and training medical staff to support these practices. Mindfulness-based stress reduction (MBSR) is an intervention that enhances suffering tolerance and endurance by promoting changes in mindfulness. Resilience is defined as the ability to get back and recover quickly from stress, and mindfulness training has been shown to enhance self-esteem, which shows resilience. However, no research has directly explored the effects of MBSR on suffering tolerance and resilience. MBSR has the potential to equip individuals with protective abilities that strengthen psychological health and reduce the risk of developing future psychopathologies [64]-[66]. Increasing the number of evidence-based psychosocial treatments included in mental health care can help patients gain new skills, become more independent, and be more motivated to recover [67]. The study emphasizes the importance of giving patients a choice and enhancing dialogue between patients and Int J Public Health Sci ISSN: 2252-8806  Interventions to improve resilience in breast cancer patients: a systematic review (Dwi Retnaningsih) 1715 therapists in mental health care. Evaluation of the effectiveness of interventions is crucial to perfecting and optimizing future resilience programs [68], [69]. The article also discusses different anxiety profiles in patients with gynecological cancer undergoing chemotherapy, emphasizing the importance of assessing anxieties, understanding risk factors, and providing appropriate psychosocial support services [63]. 3.3.4. Cognitive behavioral therapy (CBT) A broad technique called cognitive-behavioral therapy (CBT) reduces negative thought patterns, encourages joyful activities, and improves social and problem-solving skills [70], [71]. Support-expressive group therapy, mindfulness, positive psychology, and attention-based psychotherapy are further therapies. The goals of all these interventions are to improve the ability to solve problems, be self-sufficient, optimistic, and tolerate bad circumstances and emotions. Resistance training has demonstrated benefits for cancer patients' development and post-traumatic endurance, particularly following diagnosis and as the intervention's length increases [72]. Research on patients with breast cancer who underwent CBT revealed reduced feelings of anxiety and sadness and enhanced resilience [73]. This implies that CBT may be a useful strategy for raising breast cancer patients' quality of life. It's normal for women who get a breast cancer diagnosis to have feelings of desperation and anxiety about the future. Having received CBT, though, individuals are able to get over negative ideas and muster the will to battle the illness. They learn how to control their stress and anxiety with the use of CBT, which enhances their quality of life and quickens the healing process. By using this strategy, kids can become more resilient and feel more powerful when faced with obstacles [74]. In chronic pain disorders, CBT is a dominant psychological intervention aimed at helping patients cope with their condition, while MBSR focuses on increasing awareness and experiencing acceptance. In a number of chronic pain problems, attention treatments have demonstrated benefits over traditional treatment; however, further study is required to evaluate their efficacy with CBT [75]. Cancer patients' resilience has been proven to be greatly increased by psychological therapies, including CBT, which has been linked to enhanced quality of life and post-traumatic growth [76], [77]. Furthermore, resilience and psychological treatments have been connected, indicating that a decrease in chronic stress in breast cancer patients may have an effect on the disease's progression [78]. In order to help breast cancer families better adapt and manage the obstacles given by the disease, family resilience interventions have also been recommended [79], underscoring the significance of a comprehensive approach to resilience in the context of breast cancer therapy and care. 3.3.5. Intervention through digital It has been demonstrated that cyclical adaptation training (CAT) on WeChat enhances psychological resilience and lowers anxiety and despair in breast cancer survivors who have had surgery. CAT improves mental health and general well-being by assisting patients in overcoming the psychological and physical strain of cancer therapy [9]. Rehabilitation institutions may offer patients comprehensive care by integrating physical activity, diet, and CAT through platforms like WeChat. By facilitating simple access and communication, WeChat fosters a sense of support and unity between patients and healthcare professionals. The platform also makes it easy for patients to track their progress, set goals, and receive guidance from their care team. Overall, integrating CAT through WeChat into breast cancer rehabilitation programs can improve patient endurance and quality of life [80]. In conclusion, WeChat’s integration into breast rehabilitation can greatly improve patient experience and recovery outcomes [81]. 3.3.6. Psychoeducational intervention Psychoeducational treatments can benefit cancer patients' physical health in the long run, as well as their quality of life and confidence in the short term. They can also reduce stress, anxiety, and sadness [82]. There are indications that these approaches may be able to address the insomnia issue, even when there have been no appreciable changes in the patient's general quality of life or ability to perform physically. Future studies should look at these findings in more detail [82]. 4. CONCLUSION This systematic review demonstrates that interventions such as mindfulness-based programs, cognitive behavioral therapy, music therapy, psychoeducation, and digital health applications are effective in enhancing resilience, psychological well-being, and quality of life among breast cancer patients. These findings provide strong evidence for integrating resilience-focused strategies into supportive care, thereby enabling healthcare practitioners to address both physical and psychosocial needs in a comprehensive and holistic manner.  ISSN: 2252-8806 Int J Public Health Sci, Vol. 14, No. 4, December 2025: 1710-1719 1716 However, this review is limited by the inclusion of only English-language studies, potential publication bias, and heterogeneity in study designs and outcome measures. Future research should focus on conducting long-term randomized controlled trials, assessing cost-effectiveness, and adapting interventions to different cultural and healthcare contexts to maximize impact and sustainability. The findings of this review may assist healthcare providers in selecting appropriate resilience-enhancing strategies and support the development of evidence-based psychosocial programs for breast cancer care. FUNDING INFORMATION The researcher declares that this study was conducted without any financial support from external funding agencies. AUTHOR CONTRIBUTIONS STATEMENT This journal uses the Contributor Roles Taxonomy (CRediT) to recognize individual author contributions, reduce authorship disputes, and facilitate collaboration. Name of Author C M So Va Fo I R D O E Vi Su P Fu Dwi Retnaningsih ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Nursalam ✓ ✓ ✓ ✓ ✓ ✓ ✓ Hanik Endang Nihayati ✓ ✓ ✓ ✓ ✓ ✓ C : Conceptualization M : Methodology So : Software Va : Validation Fo: Formal analysis I : Investigation R : Resources D : Data Curation O : Writing - Original Draft E : Writing - Review & Editing Vi : Visualization Su : Supervision P : Project administration Fu : Funding acquisition CONFLICT OF INTEREST STATEMENT The authors declare no conflict of interest. DATA AVAILABILITY The data that support the findings of this study are available from the corresponding author, DR, upon reasonable request. 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