Introduction

Breast cancer (BC) is the most prevalent form of cancer among women worldwide; a total of 2.3 million diagnoses of BC were estimated in 2022, accounting for 11.6% of all cancer diagnoses1. Despite this prevalence, because of early detection programmes and advances in treatments, an increasing number of women are able to overcome the disease and thus become long-term breast cancer survivors (LT-BCSs), a term that refers to individuals who have survived five years or more following their initial diagnosis2. In fact, BC is characterized by the highest survival rate among cancers, and its survivors represent the largest group of cancer survivor3; namely, the population of breast cancer survivors (BCSs) includes more than 8.2 million individuals1.

However, in many cases, breast cancer survival is accompanied by late and long-term sequelae that can significantly impact survivors’ quality of life4,5,6. BCSs experience physical problems such as fatigue, pain and lymphedema and psychological effects such as depression and anxiety7,8,9,10,11. Some of these symptoms may improve over time, although certain late effects persist12,13,14. Accordingly, many BCSs may not live the rest of their lives in the same way as do other women of their own age who have not experienced cancer15.

In this context, self-efficacy has been identified as a key concept with respect to the adaptation of LT-BCSs. It represents a crucial influence on the ability of people with cancer to manage their symptoms both during and after treatment16. The concept of self-efficacy, which was developed by Bandura (1977), refers to an individual’s belief in their ability to perform the behaviours necessary to achieve specific performance goals. That is, this term refers to the individual’s perceived ability to engage in a specific behaviour. Self-efficacy has been identified as a fundamental component of self-care because people tend to be motivated mainly when they perceive that they can impact the results of their actions significantly17.

In the context of cancer patients, increased self-efficacy leads to relevant improvements in other health behaviours and patient-centred outcomes18. In contrast, low levels of self-efficacy are linked to negative perceptions of one’s abilities, which make it difficult to manage emotional states and elicit feelings of emptiness, sadness and increased vulnerability to the demands of daily life; in turn, these feelings negatively affect all dimensions of individuals’ quality of life. Among women with BC, low levels of self-efficacy regarding their ability to cope with symptoms predict lower levels of well-being19. On the other hand, a high level of self-efficacy is associated with an increase in healthy behaviours, greater persistence in individuals’ efforts to achieve their desired psychosocial and physical goals and, ultimately, better adaptation to stressful situations and increased quality of life20,21. In addition, among cancer survivors, a high level of self-efficacy is conducive to posttraumatic growth22.

Therefore, people who exhibit high levels of self-efficacy can set more ambitious goals, strive more diligently to achieve them, expect more positive results, and remain committed when they encounter challenges. Thus, self-efficacy is a key component of individuals’ ability to face the challenges and demands associated with cancer23. In fact, this factor has been identified as a significant predictor of improved quality of life among women with BC, as it is positively related to their general well-being and ability to develop effective coping strategies24.

The key role played by self-efficacy in the process of coping with symptoms has been observed among women undergoing adjuvant endocrine treatment for BC, thus indicating that higher levels of self-efficacy in the process of coping with symptoms are associated with increased functional, emotional and social well-being25. These results support the claim that self-efficacy can serve as a psychological resource that protects BCSs against the negative impacts of their physical symptoms on their well-being or mitigates these impacts25.

Given the lack of literature on self-efficacy among LT-BCSs, investigating this factor is crucial as it may help protect them from negative consequences and enhance their quality of life. Furthermore, although the relationship between self-efficacy and quality of life has been explored in the context of BC patients, few studies have specifically focused on long-term survivors26. Similarly, the influence of sociodemographic and clinical variables on this relationship has not yet been fully determined. Therefore, understanding these factors is essential to the design of interventions aimed at improving the quality of life of these women and the development of effective strategies that can enhance their self-efficacy in the management of their long-term health27.

Therefore, this study aimed to assess self-efficacy in the management of the long-term effects experienced by disease-free LT-BCSs living beyond five years postdiagnosis and to identify relevant sociodemographic, clinical, and lifestyle factors.

Materials and methods

Design

A cross-sectional study involving female LT-BCSs was conducted to evaluate their self-efficacy in the management of the late and long-term effects of BC treatment. To ensure the rigor of this study, the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist was used to ensure the accuracy of the items that should be included in reports of cross-sectional studies28.

Participants and settings

The study was conducted in Navarre, a region in northern Spain that features a total population of 683,525 inhabitants.

The study population consisted of women LT-BCSs. The sample was recruited via an intentional sampling approach. The inclusion criteria were as follows: (1) being a woman, (2) being older than 18 years, (3) having been diagnosed with BC, (4) having completed oncological treatments (i.e., chemotherapy, radiotherapy and/or immunotherapy) longer than five years ago, and (5) being free of disease at the time of data collection. The corresponding exclusion criteria were as follows: (1) receiving a diagnosis of cancer other than BC, (2) having experienced a recurrence of cancer or metastasis resulting in new treatment, and (3) being in active treatment (hormone therapy, which is common among LT-BCSs, was not considered an exclusion criterion as it is an adjuvant treatment).

Variables and measurements

An ad hoc questionnaire was used to collect sociodemographic data (i.e., age, sex, marital status, level of education and employment status), clinical data (i.e., type of BC, treatment(s) received, time elapsed since the end of active cancer treatment, relapses and comorbidities) and lifestyle data (i.e., tobacco use, alcohol consumption and physical activity).

The main variable included in this research was self-efficacy in the management of cancer sequelae, which was analysed via the Spanish version of the 6-item Self-Efficacy for Managing Chronic Disease (SEMCD-S) scale29. This scale was used to assess self-efficacy in the management of the long-term effects of cancer and the promotion of healthy lifestyles. Although the SEMCD-S is not disease-specific, it was considered appropriate because LT-BCSs experience persistent sequelae that resemble chronic health conditions, for which this scale was originally developed. In this study, the Spanish version of the SEMCD-S was used; this version of the scale consists of 4 items, in contrast to the 6 items that are included in the English version29. These scales have exhibited high levels of internal consistency reliability (in terms of Cronbach’s alpha coefficient) in multiple studies. The internal consistency of the SEMCD for each sample ranged from 0.88 to 0.91. The mean score on the four-item SEMCD-S was slightly higher at 6.2 in the two relevant Spanish studies. The reliability of the SEMCD-S was 0.95 and 0.94 with respect to these two samples29.

Sample size

The sample size required for this research was estimated on the basis of a minimum desirable effect of 0.195 (standardized difference in quality of life-correlation coefficient of 0.2), with a standard deviation of 1.3530.Given that this effect was classified as low intensity (0.1 ≤ d < 0.3) and that the desired power was 80%, the number of subjects to be recruited was 176. The Granmo sample size calculator was used in this context31.

Data procedure

Invitations to participate in the study were extended based on a dissemination strategy that involved social networks, print and digital media, and radio and television. In addition, the researchers collaborated with regional patient associations, such as the Navarre Breast Cancer Association (SARAY) and the Spanish Association Against Cancer (AECC) (Navarre), which disseminated information regarding the study via their own communication channels. Recruitment was conducted over a period of 12 months, with successive dissemination phases due to the gradual recruitment rate.

The participants were invited to an informative session at which the objectives of this research, its methodology and the importance of their participation were explained in detail. These sessions were held in health centres, at the Public University of Navarre (UPNA) and in different cities within the region. At this session, doubts were resolved, the participants were informed of the confidentiality of their data and their rights with respect to this research, and informed consent forms were signed. The participants subsequently completed an electronic questionnaire that was designed with the assistance of Microsoft Forms tool and used for data collection. This questionnaire contained questions pertaining to sociodemographic, clinical and lifestyle data and included the SEMCD-S scale.

Data analysis

A descriptive analysis of the quantitative variables (in terms of means and standard deviations) and qualitative variables (in terms of frequencies and percentages) included in this research was carried out. To verify the normal distribution of the quantitative variables, the Kolmogorov–Smirnov test was performed, considering the sample size (i.e., > 30–50). Bivariate analyses were subsequently conducted with respect to the relationships between the self-efficacy variable and the sociodemographic, clinical and lifestyle variables, in which context the nonparametric Mann‒Whitney and Kruskal‒Wallis statistical methods as well as the Spearman correlation coefficient were used.

A multiple regression analysis was conducted via backwards elimination to identify the explanatory variables that contributed to self-efficacy and to identify possible predictors of their scores. All variables of interest were included, and variables that exhibited the highest p value were removed one by one until the remaining variables were statistically significant (p < 0.05). This analysis featured a level of statistical significance of p < 0.05. The data were analysed with the assistance of SPSS V27.0 software (SPSS Inc., Chicago, IL, USA).

Ethical considerations

The Navarre Ethics Committee for Research with Medicinal Products (CEIm) approved this study (reference PI-2021/18), which was conducted in line with the ethical principles of the Declaration of Helsinki. The participants received an information sheet and details concerning the study before they voluntarily signed the informed consent form. The data collected as part of this research were processed anonymously and were accessible only to the research team; in particular, they were protected by a password.

Results

A total of 188 LT-BCSs participated in this research. Sociodemographic and lifestyle characteristics of the sample are summarized in Table 1. The mean age of the participants was 57.55 years (SD 8.968), with a range of 32 to 78 years.

Table 1 Demographic characteristics and health behaviours of the participants.
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Clinical characteristics are presented in Table 2. The mean survival time from the completion of the primary treatments was 10.22 years (SD 8,968), with a minimum of 5 years of survival and a maximum of 38 years.

Table 2 Clinical characteristics of the participants.
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A total of 48.4% (n = 91) of the participants did not remember the stage of their cancer at diagnosis, and 37.2% (n = 100) were diagnosed at stage 0, I or II. Mastectomy had been performed in 58.5% of the women (n = 110), and 17.6% (n = 33) reported no lymph node removal. The most frequent combination of treatment was chemotherapy with radiotherapy, (46.8%, n = 88); and 75.5% of the participants (n = 142), also received hormonal therapy.

Regarding the main outcome, perceived self-efficacy in managing chronic disease sequelae, the mean SEMCD-S score was 6.40 (SD = 2.10) on a scale ranging from 0 to 10, indicating a moderate level of self-efficacy. Scores were consistent across the four items of the scale, suggesting balanced confidence in managing different aspects of chronic disease-related challenges (Table 3).

Table 3 SEMCD-S (ítems).
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Bivariate analyses examining the association between SEMCD-S scores and sociodemographic, clinical, and lifestyle variables are shown in Table 4. A statistically significant association was observed with tobacco consumption, with higher self-efficacy scores among non-smokers (p < 0.05). Similarly, participants with other pathologies obtained lower scores on the instrument (p = 0.013). No statistically significant associations were found for the remaining variables (Table 5).

Table 4 Bivariate comparison of the SEMCD-S and the sociodemographic and clinic variables in the study sample (n = 188).
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Table 5 Bivariate comparison of the SEMCD-S and the sociodemographic and clinic variables in the study sample (n = 188).
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Table 6 Lineal regression models for the SEMCD-S instrument according to the variables included in the study sample (n = 188).
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To further explore potential predictors of self-efficacy, a multiple regression analysis was conducted (Table 6). Self-efficacy was included as the dependent variable, and. all relevant sociodemographic, clinical and lifestyle variables were entered as the independent variables.

Using a backward elimination approach, the final model retained only the variable “other pathologies/comorbidities”. This variable showed a significant negative association with self-efficacy (− 0.7616; p = 0.0166), explaining 2.53% of the total variance in SEMCD-S scores.

Discussion

This study examined the self-efficacy in the management of BC sequelae exhibited by disease-free LT-BCS women who were between 5 and 38 years of survival and explored its associations with sociodemographic characteristics. Self-efficacy, as measured by the SEMCD-S, attained an overall mean score of 6.40 (scale from 010), thus indicating a moderate level of self-efficacy. The four items showed similar values, suggesting a consistent perception of moderate self-efficacy across different self-management contexts.

Other studies have reported higher self-efficacy values among BCSs when the Cancer Behaviour Inventory-Breast Cancer (CBI-B) has been used, in which context a self-efficacy of 3.43 was obtained (on a scale ranging from 0 to 4)32. Similarly, in a study of BC patients undergoing chemotherapy, intermediate levels of self-efficacy were reported, as indicated by SEMCD-S scores of 30.0 5 ± 15.18 (on a scale ranging from 0 to 40)33. The differences that emerge when the results pertaining to BC undergoing active treatment are compared with those pertaining to the LT-BCSs on which our study focuses can be attributed both to the different sociocultural contexts in which the studies were conducted and to the specific characteristics of each sample.

Self-efficacy among women diagnosed with BC has been widely studied34,35,36. However, self-efficacy among BCSs has rarely been addressed, and research on LT-BSCs is practically non-existent. With respect to BCSs, self-efficacy has been reported to influence survivors’ commitment to physical activity37,38, fatigue39, degree of benefit from participating in BC support group discussions40, digital literacy41, adherence to treatment41,42 and sexual self-efficacy43.

A key contribution of this study is the identification of comorbidities as a significant predictor of self-efficacy, with women reporting additional health conditions showing lower SEMCD-S scores. This pattern is consistent with studies in other chronic illness populations, in which greater disease burden is associated with reduced confidence in self-management44. Several mechanisms may explain this relationship: comorbidities can increase symptom load, generate competing health demands, complicate care routines, and heighten perceived vulnerability, all of which may undermine individuals’ confidence in navigating cancer-related sequelae. Self-efficacy is multifactorial; however, the consistent association with comorbidities highlights a clinically meaningful subgroup that may require additional support.

In contrast to prior literature linking self-efficacy with age, education, income, and treatment-related variables, our study did not identify associations between self-efficacy and sociodemographic factors20,35. Although younger women have been reported to exhibit lower self-efficacy due to different coping demands and life-stage expectations, the mean age of our sample (57.5 years) and its relatively narrow age distribution may have limited our ability to detect such differences. Likewise, the absence of associations with survivorship duration suggests that time since diagnosis alone may not determine self-efficacy among LT-BCSs once women have transitioned beyond the acute phase of survivorship.

In the transition to the phase of BC survival, the self-efficacy has been identified as a key factor with regard to a successful transition to the survival phase45; as it can mitigate the negative impacts of the physical manifestations of the disease and its treatments and contribute significantly to the well-being of BCSs25. In addition, self-efficacy is a key factor in the management of the disease and significantly influences the adaptation and recovery of LT-BCSs46. This factor has been identified as a key protective factor that can improve survivors’ quality of life and encourage them to adopt healthy habits47,48.

In light of the decreased self-efficacy exhibited by women with BC, it is necessary to implement interventions that view cancer-related self-efficacy as a potential goal for improvement23.

The findings of previous studies on interventions targeting women with BC have generally been inconclusive, thus highlighting the need for further investigation49,50,51,52.

In any case, further research using robust methodological designs is needed to determine the effectiveness of different interventions aimed at improving self-efficacy. Although some studies have reported promising results with counselling, educational, and technology-based interventions, these findings are subject to important methodological limitations, including pilot study designs, small sample sizes, and culturally specific contexts45,53.

Therefore, it is necessary to conduct further research to validate and generalize these results in other cultural contexts.

Moreover, evidence from BCSs receiving adjuvant endocrine therapy highlighted the need for further research to determine whether psychosocial interventions targeting self-efficacy in symptom management can improve adaptation to treatment side effects and quality of life25.

Research on this topic should focus on the development of social support programmes, health education and psychological interventions that can strengthen individuals’ perceptions of self-efficacy. These findings highlight the importance of strengthening prevention and health promotion strategies for BCSs, especially in the context of nursing, with the goal of improving the self-efficacy of LT-BCSs54. When patients participate in the process of making decisions concerning their cancer treatment, their level of self-efficacy with respect to BC increases20. This approach can thus help individuals recognize the active involvement of BCSs in their own self-care, as well as the role that they may play in this stage of survival.

Finally, the present study revealed moderate levels of self-efficacy among LT-BCSs, thus highlighting the importance of implementing specific intervention programmes aimed at promoting quality of life among members of this population, thereby increasing their self-efficacy in the long-term stage of cancer survivorship. The provision of sufficient information concerning the disease and treatment options, which must be adapted to the level of education attained by each survivor, can strengthen their sense of control and confidence, thus promoting higher levels of self-efficacy20. In addition, in cancer follow-up programmes, the physical sequelae resulting from the treatment must be addressed, as must the psychological, social and work challenges that LT-BCSs face, thereby increasing the levels of self-efficacy exhibited by these survivors. This approach can result in improved quality of life among this population.

The level of self-efficacy exhibited by LT-BCSs is moderate. Given that many of these individuals experience secondary and late effects of cancer and its treatments that impact their physical, psychological, social and spiritual well-being, these results highlight the importance of implementing interventions aimed at improving the self-efficacy that enables them to address and manage these sequelae.

Furthermore, the increase observed in the number of BCSs poses a significant challenge for health systems55,56 with regard to the design and implementation of strategies that include rehabilitation, psychosocial support and health promotion57. In recent decades, the importance of supportive care and rehabilitation has increased in many countries, especially for LT-BCSs11. This situation has highlighted the need for strategies such as survivorship care plans (SCPs), which can facilitate the provision of more structured, coordinated care that is adapted to the needs of these patients58.

At the level of health care, evaluations of self-efficacy can provide health professionals with valuable information concerning patients’ perceptions of their own ability to manage their lives following BC15 or the transition to the stage of BC survival. In addition, such evaluations can help support these patients in terms of self-management, and they can facilitate the development, implementation and evaluation of specific interventions targeting BCSs with the aim of improving their health outcomes.

This study provides relevant evidence concerning self-efficacy among LT-BCSs, a group that has received little attention in the scientific literature. Thus, the present study contributes to a better understanding of the long-term challenges faced by these women and their impact on self-efficacy. In addition, this study can serve as a model for future research on this subject since it is characterized by methodological rigor, as supported by the STROBE checklist.

However, one primary limitation of this study pertains to the small sample size, as well as the methodology used to collect the data, since, depending on the self-reported responses provided by the participants, memory bias could have been introduced, thereby impacting the generalizability of the results. Another limitation concerns the choice of the measurement instrument. Although the SEMCD-S was considered appropriate due to the chronic nature of breast cancer sequelae and its previous use in cancer survivorship research, it is a generic measure of self-efficacy and not disease-specific. As such, it may not have been sufficiently sensitive to capture cancer-related nuances or subtle changes in self-efficacy specific to breast cancer survivorship, as previously noted in the literature53. Future studies could benefit from incorporating cancer- or breast cancer–specific self-efficacy instruments, or from combining generic and disease-specific measures to assess more comprehensively this construct.

Conclusions

This study provides new evidence regarding self-efficacy among LT-BCSs, highlighting moderate self-efficacy levels and reduced self-efficacy among those with comorbid conditions.

Overall, these findings highlight the need for comprehensive follow-up strategies for LT-BCSs, addressing not only the sequelae of cancer and its treatment but also the management of concomitant conditions. In addition, it is essential to promote specific interventions aimed at increasing self-efficacy, which could have positive impacts on quality of life among these women.

The present study advanced current knowledge by offering an updated and contextualized assessment of the level of self-efficacy among LT-BCSs, an underexplored area of research, especially in relation to the burden of comorbidities. It is essential to ensure that health policies and care models recognize self-efficacy as a key component of well-being among LT-BCSs and seek to strengthen this factor as an essential component of comprehensive care in the long-term cancer survival stage.