Resilience in the Face of Aggression: Coping Strategies of Women With Triple Negative Breast Cancer

Abstract

Triple-negative breast cancer (TNBC) is the most aggressive breast cancer subtype, characterized by poor prognosis, lack of targeted therapies, and significant impact on younger women. Coping with a TNBC diagnosis requires extensive strategies, yet there is a dearth of literature targeting this aspect. This study contributes through an in-depth exploration of the coping strategies of adult women diagnosed with TNBC. Eleven participants aged 26–63 years were recruited through purposive sampling. Data were gathered via semi-structured interviews and analyzed using interpretative phenomenological analysis. Five themes emerged: reaching out for support; remaining present for family; searching for meaning; regaining control through lifestyle changes and distraction. Coping strategies were identified as multidimensional and synergistic, encompassing social support that provides emotional and informational resources; spirituality that offers existential meaning and resilience; lifestyle modifications that enhance physical and psychological self-regulation; and cognitive strategies, such as information seeking and distraction, that facilitate adjustment to stressors. These results underscore the need for personalized survivorship care that addresses the well-being of TNBC patients, acknowledging the interconnected nature of their coping mechanisms.

Keywords

coping strategies interpretative phenomenological analysis qualitative methods triple negative breast cancer

Introduction

Approximately 15% of all newly diagnosed cancers worldwide are breast cancers (BCF),¹ making it the most frequently diagnosed cancer in all regions of the world, except in Eastern Africa, where cervical cancer is more prevalent.² The classification of breast cancer into various subtypes is based on immunohistological markers, that are crucial for determining prognosis and treatment.^3,4 Among these, triple negative breast cancer (TNBC), is particularly aggressive due to its rapid cell proliferation, lack of targeted therapies, and frequent diagnosis in younger women at advanced stages.^5,6 Standard treatment is currently limited to chemotherapy, surgery, immunotherapy, and radiotherapy.⁷

Existing research underscores the significant psychological and practical challenges associated with a TNBC diagnosis. Compared to individuals with estrogen receptor-positive breast cancer, TNBC patients often experience more aggressive treatments and a greater care burden.⁸ The aggressive nature of the disease, coupled with limited treatment options and higher recurrence rates, contributes to heightened distress and uncertainty,⁶ while its rarity amplifies perceptions of poor survival outcomes.⁹ A persistent fear of recurrence also adversely affects their quality of life, even during the post-treatment phase.¹⁰ Consequently, TNBC patients often feel distinct from persons with other breast cancer subtypes and emphasize the need for tailored psychosocial interventions.¹¹

Despite the unique challenges faced by the TNBC population, most qualitative studies examine the coping strategies of breast cancer patients collectively together.^12,13 A notable exception is a study by Post et al¹⁰ that identified several coping strategies among TNBC patients, including information-seeking, striving for normalcy, and adopting healthy lifestyles. However, a significant gap remains in understanding the nuanced lived experiences of this specific population. Hence, this study aims to explore the coping strategies of adult women diagnosed with TNBC. This will be enabled through an in-depth qualitative approach to explore the coping strategies of adults diagnosed with TNBC, aiming to inform the development of targeted support strategies.

Method

Study Design

An Interpretative Phenomenological Approach (IPA) design was used to gain an in-depth understanding of the lived experiences of people with TNBC. This approach recognizes the active interpretative role of the researcher,¹⁴ and is based on three theoretical underpinnings: phenomenology, hermeneutics, and ideography. Phenomenology focuses on participants’ subjective first-person accounts; whilst hermeneutics emphasizes the researcher’s role to make sense of these experiences.¹⁵ Ideography involves in-depth analysis of each case individually, followed by cross-comparisons among different cases.

Participants

Inclusion criteria for this study were: (i) adults aged 18 years and over; (ii) non-metastatic for TNBC; and (iii) having completed their cancer treatment within the past year. Eleven women were recruited through purposive sampling between March 2023 and January 2024. Their ages ranged between 26 and 63 years (mean age:48.3 years). All participants were in a relationship and had children, and nine were employed. Three participants underwent a mastectomy, while eight had a lumpectomy. Table 1 presents participants’ demographic details.

Table 1.

Participant Demographic Details

Pseudonym	Age/yrs	Sequence of active treatment	Type of surgery	Employed (Yes/No)	In a relationship (Yes/No)	Have children (Yes/No)
Helen	53	Chemotherapy Surgery Immunotherapy	Lumpectomy	Yes	Yes	Yes
Rebecca	59	Chemotherapy Surgery Immunotherapy	Lumpectomy	Yes	Yes	Yes
Carmen	26	Chemotherapy Surgery	Mastectomy	Yes	Yes	Yes
Catherine	63	Chemotherapy Surgery Radiotherapy	Lumpectomy	No	Yes	Yes
Sarah	49	Chemotherapy Surgery Radiotherapy Immunotherapy	Lumpectomy	No	Yes	Yes
Jean	41	Chemotherapy Surgery Radiotherapy	Lumpectomy	Yes	Yes	Yes
Analise	38	Chemotherapy Surgery Radiotherapy Immunotherapy	Lumpectomy	Yes	Yes	Yes
Emily	49	Surgery Chemotherapy	Mastectomy	Yes	Yes	Yes
Lara	42	Chemotherapy Surgery Radiotherapy	Mastectomy	Yes	Yes	Yes
Brigitte	63	Surgery Chemotherapy Surgery Radiotherapy	Lumpectomy	No	Yes	Yes
Alice	48	Surgery Chemotherapy Radiotherapy	Lumpectomy	Yes	Yes	Yes

Data Collection

Data were collected through semi-structured, audio-recorded interviews conducted by the first author [JS], in a venue selected by the participant. The interviews lasted between 22 and 85 minutes (average duration:51.7 minutes). Since IPA studies are committed to the unique, inexhaustible nature of personal experience, this study prioritizes ‘evidential adequacy’ that ensures sufficient interpretive depth to represent the participants' worlds, without claiming to have ‘exhausted' the phenomenon itself.

The interview guide consisted of 6 open-ended questions that explored the impact of a TNBC diagnosis and the coping strategies adopted by the participants. The use of open-ended questions allowed the participants to elaborate on their experiences, enabling an in-depth account (Smith et al, 2009). Probing questions were also asked such as “Can you provide me with more details?” or “Can you give an example?” when additional information was required.

A reflexive journal was also utilized throughout the data collection phase where any biases, interpretations or assumptions could be listed and reflected upon. This assisted the researcher in bracketing any preconceptions that could influence the data collection process.

Data Analysis

Transcripts were analyzed using the guidelines established by Smith et al.¹⁴ The authors independently read each transcript identifying descriptive, linguistic, and conceptual insights. After coding data extracts, experiential statements were formulated. Statements with similar meanings were grouped into personal experiential themes for each case. Group experiential themes (GETs) were then developed by analyzing patterns of convergence and divergence across all cases.

Ethical Considerations

This study was approved by the relevant University Research Ethics Committee. Participants were provided with an information letter about the study from a health professional. Those interested contacted the first author and provided written informed consent for voluntary participation and publication of anonymized results. Psychological support was available but not utilized.

Trustworthiness

Trustworthiness was assessed using Yardley’s¹⁶ four principles: sensitivity to context, commitment and rigor, coherence and transparency, and impact and importance. This involved: (i) integrating relevant literature and verbatim extracts; (ii) detailing the research design, recruitment, analysis, and rationale for decisions taken; (iii) maintaining a reflexive diary to identify biases and observations; and (iv) addressing an understudied research topic. Furthermore, research triangulation was enabled by engaging researchers with varied academic expertise throughout all phases of the research. This interdisciplinary collaboration contributed to a richer and more in-depth understanding of the results.

Results

The GETs identified and corresponding subthemes are presented in Table 2.

Table 2.

Identified GETs and Corresponding Subthemes

Group experiential themes	Subthemes
Reaching out for Support	Relatives Close friends Peers having breast cancer Internet
Remaining present for family	Safeguarding my child Maintaining normalcy
Searching for meaning	Turning to religious beliefs Altruistic traits Greater appreciation of life Being mindful
Regaining control through lifestyle changes	Changes in dietary habits Physical therapy
Distraction	Employment Hobbies

Reaching out for Support

This section describes the multifaceted nature of support systems, ranging from spousal bonds and practical domestic help to peer connections and digital information-seeking, that contributed to participants’ resilience during treatment.

For many participants, spousal support was central to their ability to cope with treatment. Emotional reassurance and encouragement helped restore a sense of agency at times when participants felt helpless. Rebecca described how her husband’s unwavering presence gave her the determination to complete treatment:

“He listened to me, he let me express my feelings and then he told me, you must fight, you only have two more doses, it doesn’t make sense to leave it now… he is my rock” (Rebecca)

Future-oriented expressions of hope were particularly empowering. Emily recounted how her husband’s confidence in their shared future transformed an otherwise distressing surgical consultation into a moment of optimism:

“…the surgeon mentioned how to fix it [the breast], by getting some muscle from elsewhere, and he [husband] commented, but when you’ll be sixty or seventy, how are you gonna stand up from the chair? So, seeing him believing that I’m gonna be sixty, seventy, trying to stand up from the chair is very encouraging for me.” (Emily)

Beyond emotional reassurance, participants also emphasized the value of practical support in managing daily life demands. For Lara, assistance from her sister-in-law helped sustain a sense of order and comfort at home:

“Having a clean house means a lot to me, so my sister-in-law would come over and clean up the house.” (Lara)

Supportive networks also offered a sense of normalcy, which participants viewed as pivotal for maintaining emotional stability. Alice highlighted how her husband’s practical and emotional support, such as accompanying her to the hospital and turning chemotherapy days into small rituals, helped her experience treatment as less overwhelming.

“…he [husband] would take me to hospital and pick me up. Then after each chemo, we would go for coffee… it was like an outing at the same time and then I’d go home and just relax on the sofa and he would pick up the children in the evening.” (Alice)

While spousal support was a cornerstone for many, friendships also emerged as crucial. Brigitte recalled how receiving inspirational quotes from a friend became a source of strength, underscoring how consistent, thoughtful gestures could enhance well-being and resilience.

“A friend of mine made it her mission to send me these motivational quotes every morning… she was always telling me I wish I could be of greater help, but I used to tell her that these quotes make my day” (Brigitte)

Peer relationships with other breast cancer patients also served as meaningful support systems. Lara described how connecting with another patient created a reciprocal bond of understanding, guidance and encouragement:

“There was one woman next to me [during treatment], we became friends. We’re constantly messaging and supporting each other. When she complains of certain ailments, I advise her, because I have a longer experience with the disease” (Lara)

Participants reported a mixed experience with online searching, noting it could cause increased anxiety, while also providing a sense of hope and control.

“I used to search the internet for information. It sometimes made me anxious, but it also helped-especially reading survivor stories of persons with TNBC, learning about new treatments, and finding tips for managing related issues” (Catherine)

However, not all participants perceived online engagement as necessary. Sarah explained that her confidence in healthcare professionals and scientific expertise provided sufficient reassurance, reducing the need to conduct her own research:

“I have faith in science, in the treatment and the team of professionals. They are so caring, so encouraging and attentive to our needs…it makes a difference. So, I didn’t do any research on TNBC. However, I did use the internet to search about my granddaughter’s autism, we don’t know much about it, and I need to support them. (Sarah)

Remaining Present for Family

The theme ‘remaining present for family’ demonstrates that the desire to maintain a presence within the family unit (both as a caregiver and a source of stability), serves as a primary catalyst for psychological resilience in the participants.

Family relationships, particularly parental roles, emerged as powerful motivators for resilience. Carmen described how her daughter inspired her determination to endure treatment:

“Because she [my daughter] makes me strong. I need to be strong, because who will take care of her if I am gone? (Carmen)

Others emphasized the importance of maintaining a sense of normalcy. Helen reflected that sustaining daily routines, even when physically exhausted, not only shielded her family from worry but also motivated her to keep going:

“During chemotherapy, I forced myself to get out of bed, get dressed, and go downstairs, even if I spent the day on the sofa. It was important that my husband and daughter don’t see me in bed…” (Helen)

Searching for Meaning

The GET ‘searching for meaning’ explores the spiritual and philosophical frameworks, specifically faith, altruistic purpose, and mindfulness, that enabled participants to transcend their suffering and reframe their illness through a lens of gratitude and presence.

Faith emerged as a vital coping mechanism, providing participants with strength and a sense of understanding amid struggles. Catherine described finding comfort through prayer, drawing solace from Christ’s suffering and feeling less alone:

“Throughout all this experience I resorted to prayer. I felt that Jesus Christ had suffered and could understand what I was going through.” (Catherine)

For some participants, finding meaning in adversity was also derived through altruism and gratitude. Participants expressed a desire to help others facing similar experiences.

“I would like to be there for others, for them to speak with someone when the need arises” (Helen)

Several participants also expressed gratitude at being given additional time to live, describing a renewed appreciation of what truly matters in life.

“I think of other positive things, of good things… I thought this is the time to rest and spend more time with my family. This is all time which has been given to me, and I want to try and make the best of it” (Jean)

The importance of mindfulness also emerged. While acknowledging their fears and distress, participants emphasized the value of focusing on the present and consciously redirecting attention toward positive and meaningful thoughts.

“I believe that living and appreciating the moment is important for your well-being. It’s useless worrying about the future. If negative thoughts come to mind, I try to think of something beautiful or something that makes me happy.” (Sarah)

Regaining Control Through Lifestyle Changes

This section examines how participants reclaimed a sense of agency and physical control through proactive lifestyle modifications, specifically targeting dietary choices and structured physical activity, to mitigate the side effects of treatment.

Through these lifestyle adjustments participants strived to regain a sense of control. Dietary changes were particularly important during treatment, with participants carefully selecting foods that supported their physical wellbeing.

“During chemo, I ate food that helped to maintain my blood cells at the proper level. It was not a question of simply eating, but obtaining nourishment” (Catherine)

Physical activity also played a role in recovery. Helen described seeking professional advice before treatment and undertaking prescribed exercises to prevent lymphoedema. This reflects her sense of agency and responsibility in managing her health

“I went to the physiotherapists and asked for exercises to prevent lymphoedema…and I did them” (Helen)

Distraction

The final GET ‘distraction’, highlights how professional engagement and leisure activities are strategic tools for maintaining self-esteem and mitigating the psychological burden of illness.

Through distraction participants could shift their focus away from their illness and minimize rumination. For some, engaging in work provided structure, reinforced self-esteem, and fostered a sense of productivity.

“Work helped me from ruminating whilst protecting my self-esteem, as I still felt that I was productive” (Catherine).

Some participants adapted their routines to balance health needs with professional commitments:

“I still worked, obviously… we work remotely as well, so that helped obviously” (Alice)

Rebecca highlighted the importance of a balanced attitude toward work, showing willingness to contribute while also acknowledging her limits and asking for support when necessary.

“I expect that they provide me with my usual work commitments, if I manage to do them, I’ll do them, if not I will ask them to help me.” (Rebecca)

Other participants turned to leisure activities such as reading and watching television as distractions to foster a positive mindset.

“To keep my mind healthy ... I was watching movies; I was reading books” (Rebecca)

Discussion

This study addressed a critical gap in the literature by exploring in-depth the coping strategies of women diagnosed with TNBC. Participant narratives underscored that coping with TNBC is shaped not only by individual efforts, but also by relational, cultural, and systemic contexts.

Support

Consistent with existing research,^13,17 support networks emerged as central to coping with TNBC. These networks were multifaceted, extending from intimate family relationships to the shared understanding of peers with similar experiences. Such support is particularly important, as individuals who perceive stronger support systems are more likely to adopt active coping strategies.¹⁷ These findings align with the Social Support Theory,¹⁸ which posits that perceived support buffers stress and enhances wellbeing.

Spouses frequently served as emotional anchors and practical supporters, helping to maintain daily routines, foster hope, and preserve a sense of normalcy. This “safe haven” enabled participants to adapt and thrive amid adversity, reflecting Feeney and Collins’¹⁹ conceptualization of relational support as a foundation for thriving. Beyond intimate partnerships, friends and fellow cancer survivors provided encouragement, practical assistance, experiential guidance, and survivorship narratives that reinforced resilience.

Some participants also described turning to digital means of support in response to distress and uncertainty. This provided them with online information that addressed knowledge gaps and re-established a sense of control.²⁰ However, online support presents an information paradox: that while potentially empowering, it may also expose participants to distressing or unreliable content that exacerbates anxiety—a phenomenon observed in other cancer-related information-seeking contexts.²¹ These findings underscore the importance of healthcare professionals guiding patients toward credible, curated information sources and providing timely psychosocial support that mitigates emerging fears and uncertainties.

Remaining Present

Participants frequently described a strong motivation to maintain family roles, especially parenting. This need to remain emotionally and physically present for their children emerged as a powerful source of resilience—a finding that is particularly salient given the higher prevalence of TNBC among younger women. This aligns with coping literature on role centrality, which posits that preserving valued identities (e.g., “mother,” “wife”) bolsters self-concept and adaptive functioning.²² These findings align with those of Post et al¹⁰ who reported similar patterns among individuals with early-stage TNBC.

However, although role preservation can bolster resilience, it sometimes limits opportunities for shared vulnerability within families,²³ particularly when participants are managing both illness and demanding caregiving responsibilities. This dynamic could exacerbate psychological distress,²⁴ implying that parental responsibility may serve both as a vital coping mechanism and a significant source of emotional strain.

The deliberate efforts to conceal visible signs of illness further illustrate participants’ determination to sustain a sense of normalcy. Although such strategies are empowering, they could also impose additional psychological and physical burdens by discouraging rest and emotional openness.

Searching for Meaning

A key finding that extends existing TNBC literature is the role of spirituality and meaning making as a coping strategy. Many participants drew on spiritual beliefs to interpret their experiences, finding comfort, strength, and personal growth, while fostering acceptance, adjustment, and resilience.^25,26 Religious frameworks also enabled cognitive reframing, situating personal suffering within a broader spiritual narrative. This aligns with Costa et al.’s²⁵ observation that life-threatening illness often prompts existential reflection. In some cases, spiritual coping extended to altruistic acts toward others facing similar experiences, echoing Bosankic et al.’s¹² findings. However, reliance on religious meaning-making may be culturally contingent and less relevant in secular contexts.

Many participants also expressed living in the present and appreciating everyday experiences, a practice shown to mitigate perceived distress.²⁷ Given that gratitude-based interventions are also particularly beneficial for people with high distress,²⁸ combining mindfulness and gratitude practices may represent effective coping strategies for individuals with TNBC.

Lifestyle Changes

Altering dietary habits was a primary coping strategy, with participants focusing on foods perceived to enhance their physical wellbeing and support their treatment, a finding that aligns with established research on coping with patients having TNBC.¹⁰ This proactive approach to physical health was also evident in participants' engagement with physical therapy, sometimes even before it was medically recommended. This highlights a powerful drive to regain a sense of control over their bodies and their circumstances. As Gibbons and Groarke²⁹ note, such proactive health behaviors can empower patients, increase their self-efficacy, and improve adherence to demanding treatment schedules.

Distraction

Distraction served as a temporary respite from rumination, helping individuals preserve their sense of identity and purpose.³⁰ For instance, employment provided structure, fostered self-worth, and promoted productivity, reinforcing both self-esteem and a sense of normalcy.³¹ Participants emphasized the importance of workplace understanding of the realities of a cancer diagnosis and the need for flexible policies that support individuals in remaining employed.³¹ For those unable to work, psychological support is critical to address a potential loss of professional identity.

Some participants turned to recreational activities, such as reading or watching films, as mental reprieves, suggesting that engaging in enjoyable or absorbing pastimes can serve as a sustainable coping mechanism.³² Yet whilst distraction can be beneficial as a temporary coping mechanism in situations of uncertainty and longevity, it can also increase psychological distress when its use is prolonged.³³

Limitations and Future Research

While this study’s cross-sectional design and reliance on retrospective accounts provide a valuable snapshot of participant experiences, the findings specifically reflect the experiences of women living with a spouse and children. Consequently, there is a critical need for longitudinal research to capture how coping strategies evolve across the entire illness trajectory. Future studies should also prioritize single women and those not having children, as their experiences may differ significantly from this cohort. Furthermore, research should focus on developing targeted interventions based on the coping themes identified in the present study, such as structured information-seeking support, mindfulness, gratitude-based programmes and attentional redirection strategies to potentially mitigate distress.

Conclusion

This study provides a nuanced understanding of the coping mechanisms used by women living with Triple-Negative Breast Cancer (TNBC). The findings underscore the necessity of integrated, person-centered care that addresses physical, psychological, social, and existential needs to promote overall well-being and restore patient agency. Care models should move beyond clinical treatment to include the strengthening of relational networks and the provision of culturally sensitive psychosocial and spiritual support. Furthermore, proactive lifestyle interventions, such as nutritional counseling and prehabilitation services are essential to helping patients regain their physical health.

Footnotes

Acknowledgements

We would like to thank Ms Alexis Borg Sapiano and Dr Kristel von Brockdorff, Europa Donna and Action for Breast Cancer for their assistance in the recruitment process and the study participants who shared their experiences. We would also like to thank Prof Carmel Cefai for assistance in funding acquisition.

ORCID iD

Josianne Scerri

Ethical Considerations

All procedures in this study were conducted in accordance with the Faculty of Health Sciences Research Ethics Committee, University of Malta (Approval number: FHS2022-00338) approved protocols.

Consent for Publication

Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.

Author Contributions

JS, JA, and MG: study concept and methodology; JS and JA: formal analysis; JS: data collection; JS and JA: writing—original draft; JS, JA, and MG: writing—review and editing; JS and MG—funding acquisition. All authors have read and agreed to the published version of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a peer-reviewed grant from the Alive Charity Foundation through the Research, Innovation, Development and Trust fund University of Malta. The funders did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

As indicated, this study was conducted in Malta with the availability of one oncology hospital. Being a rarer sub-type of breast cancer (affecting 15-20% of breast cancer patients), it is possible that participants could be identified from the data collected. Hence, to mitigate this risk, participants were informed during the ethics and data protection approval process that their data would only be accessible to the research team. This concern is heightened by the use of an Interpretative Phenomenological Analysis (IPA) design, which involved in-depth interviews and extensive textual data for each participant. When submitting this qualitative research to various journals, I have explained the uniqueness of our context, and editors have been understanding of this challenge.*

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