Sailing toward healing. A combined group intervention to improve well-being in breast cancer survivors: a brief report study.

Introduction
Breast cancer can have a significant impact on the well-being and quality of life (QoL) of survivors (Conway, 2005). Although survival rates are improving, oncological treatments often cause long-term physical and psychological distress due to undesirable side effects (e.g. loss or deformities in the breast(s), visible scarring, hair loss, skin discoloration, alopecia, and weight fluctuation). These changes can alter the perception of body image (Yang et al., 2017; Mirandola et al., 2018). As a result, the body can be perceived as less feminine, causing difficulties in intimate relationships, particularly regarding sexuality (Cheng et al., 2016). Additionally, survivors may focus more attention on inner sensations after cancer (Sebri et al., 2023). They could tend to promote ‘checking behaviors’ to control possible bodily symptoms, increasing anxiety and distress with the risk of reframing the overall self as that of a patient (Gibson et al., 2015; McGannon et al., 2016). This particularly occurs when the social assumptions that define survivors as women who no longer align with their internal definitions of what it means to be a woman impair their self-identity and sense of self-worth (Esplen & Trachtenberg, 2020). In this regard, positive social and family relationships can be a relevant resource for promoting well-being and illness adjustment (McDonough et al., 2019). For example, being involved in positive relations with others can promote breast cancer survivors’ post-traumatic growth, which refers to the attainment of individual and social positive goals, such as the realization of new possibilities, greater appreciation for life, and enhanced personal strengths (McDonough et al., 2019). Furthermore, literature shows the relevance of implementing psychological interventions focused on emotional regulation to promote breast cancer survivors’ well-being (Sebri et al., 2024a). Generally, breast cancer survivors’ perception of needs during the transition toward survivorship is not well known. Literature suggests the efficacy of combined psychological and physical interventions to improve breast cancer survivors’ QoL (Björneklett et al., 2013). For instance, current research reported the benefits of team-based activities, such as Tai Chi and Qigong (Zeng et al., 2019; Mazzocco et al., 2023), dragon boat racing (Sabiston et al., 2007; McDonough et al., 2019), and dance practice (Mirandola et al., 2015). Interestingly, Mirandola and colleagues (2020) proposed a group intervention based on sailing, a safe and complex activity that integrates proprioceptive and exteroceptive stimuli, with benefits for physical health and anxiety symptoms in breast cancer survivors. It is worth noting that the perception of group belongingness has a positive impact on well-being, thanks to opportunities for self-disclosure, schema change, and peer social support (Eime et al., 2013). Furthermore, the literature suggests that sailing activities can enhance cognitive processes, including concentration, attention, memory, and decision-making (Olmedilla et al., 2015).
Currently, no previous studies have explored the effects of a combined program based on both sailing and psychological intervention on breast cancer survivors’ well-being, supporting the novelty of the present work. Consistent with this theoretical framework, the present pilot study examined whether a tailored physical and psychological group intervention may significantly improve overall well-being and emotions. The study aimed to assess whether breast cancer survivors reported: Hp1) improvements in their QoL, specifically referring to Hp1.1) physical well-being; Hp1.2) emotional well-being; Hp2) changes in anxiety levels.

Methods

Procedure
Ninety-two Italian women with a history of breast cancer were candidates to participate in the intervention. To be enrolled in this study, participants need to satisfy the following inclusion criteria: (1) need to be female survivors ranging from 18 to 60 years of age, with a history of breast cancer within 5 years; (2) have received any surgical intervention or concluded chemotherapy or radiotherapy treatments. Women (1) who had already attended previous projects that combined sailing courses with psychotherapy sessions, (2) with a current medical history of severe psychopathological disease, or (3) with physical limitations were excluded from this study. Women excluded from the present study did not meet one or more of the current criteria. In the study, 32 women were excluded due to their age and/or their illness history. The study adhered to the ethical principles outlined in the 1964 Declaration of Helsinki and its subsequent amendments, as well as to comparable ethical standards. Social networks (e.g. Facebook and Instagram) were used to recruit participants. Those who expressed interest in the study received a detailed project description and were asked to provide informed consent after reviewing the study information online. A battery of questionnaires and quantitative data was collected 1 week before and 1 week after the intervention through the Qualtrics platform.

Intervention
The intervention occurred between May 2021 and October 2022, involving eight teams of women (with 7–12 participants for each group). All participants were volunteers, not compensated, and were free to withdraw from the study without needing to justify their decision. Women participated in a 1-week psychological intervention that combined daily group psychotherapy sessions and daily sailing activities in a crew. Specifically, women were enrolled in 2-hour daily group psychological sessions with two psycho-oncologists with extensive professional experience in the oncological field. The psychological program followed the structure and contents of a published study and was based on relevant psychological constructs related to breast cancer issues (Sebri et al., 2023b). Notably, the sessions aimed to manage breast cancer psychosocial issues by improving social and intimate relationships and emotions towards the self, sustained by the perception of group belongingness. The psychological sessions also focused on the role of caregivers and the related perceptions of breast cancer survivors regarding emotions and cognitions. Previous studies showed that the caregiver role within the cancer journey is fundamental, encompassing emotional support and shared decision-making (Sebri et al., 2024b). Therefore, the present intervention also focused on women’s perceptions of caregiver involvement in their care process, specifically exploring the quality of their support as well as any possible limitations.
In-group activities and individual tasks were used to elucidate individual experiences and manage personal emotions. Furthermore, women experienced daily navigation practice in the open sea aboard the cabin cruisers from 10 a.m. to 4 p.m. Lastly, theory lessons (e.g. essential right-of-way sailing rules, sailing knots, and wind direction) were conducted by a sailing trainer in the evening. During the 1-week intervention, participants shared common spaces for sleeping and eating.

Measures
Participants were asked to complete a sociodemographic questionnaire that included items on: age, nationality, educational level (rated on a five-point scale: elementary school, middle school, high school, university degree, PhD/Master’s degree), occupation, marital status (single, married, divorced, or widowed), motherhood (yes/no), residence, engagement in physical activity (currently active/formerly active/never active), and participation in psychotherapy sessions (yes/no). Additionally, two self-reported questionnaires have been administered as described below.
The Functional Assessment of Cancer Therapy–Breast (FACT-B) (Cella et al., 1993; Di Bella et al., 2018) is a 37-item questionnaire with items rated on a 5-point Likert scale from 0 (not at all) to 4 (very much), designed to assess QoL in breast cancer patients. FACT-B aims to assess different domains of QoL, such as physical, emotional, and relational characteristics. In this regard, it comprises two sections. The first one, FACT-general, includes four domains: physical well-being (PWB; seven items, for example, fatigue, nausea, pain, treatment-related symptoms, and family care), social/family well-being (SWB; seven items, for example, acceptance and support from family and friends), emotional well-being (EWB; six items, for example, feelings about the disease and its course), and functional well-being (FWB; seven items, for example, professional and personal activities and sleep quality). The second section, the breast cancer domain (BCS; 10 items), includes additional specific items about breast cancer: physical, psychological, and aesthetic concerns related to breast cancer and its treatments (Di Bella et al., 2018). When single questions are skipped, scores are prorated using the average of the other answers in the scale and counted in the results (Webster et al., 2003). Final scores (FACT-B-Total) of all subscales range from 0 to 148, where 148 represents the highest QoL. In this study, the reliability of the FACT-B questionnaire was assessed using Cronbach’s alpha for each subscale at both time points. At T0, internal consistency was good across all subscales (FACT-B total α = 0.81; PWB α = 0.81, SWB α = 0.83, EWB α = 0.69, FWB α = 0.75; BCS α = 0.55). At T1, reliability remained adequate (FACT-B total α = 0.78; PWB α = 0.80, SWB α = 0.71, EWB α = 0.52, FWB α = 0.74, and BCS α = 0.57).
The State-Trait Anxiety (STAI-Y) scale, used to assess anxiety levels, consists of 40 items divided into two subscales: State Anxiety (STAI-Y1; 20 items) and Trait Anxiety (STAI-Y2; 20 items) (Spielberger et al., 1971). For this study, the STAI-Y1 has been used, which measures state anxiety, a temporary emotional condition experienced in specific situations. All 20 items are rated on a four-point Likert scale, ranging from 1 (not at all) to 4 (very much so). The total score ranges from 20 to 80, with higher scores indicating greater levels of state anxiety. In line with the literature, an established cutoff of 45 or greater to indicate high state anxiety was proposed (Cohen, 1994; Masaud et al., 2024). The STAI-Y1 has demonstrated high reliability and validity across diverse populations, making it a robust tool for assessing situational anxiety in research settings. In this study, the internal consistency of the STAI-Y1 scale, as measured by Cronbach’s alpha, was 0.95 at T0 and 0.86 at T1, indicating very good internal consistency across both time points.

Data analysis
Descriptive statistics (means, standard deviations, and frequencies) were first computed to summarize participant characteristics and scores on FACT-B and STAI-Y measures. Linear mixed-effects models were used to examine changes over time in QoL (FACT-B total score and subscales: PWB, EWB, SWB, FWB, and BCS) and anxiety (STAI-Y). Time was included as a fixed effect, with participants modeled as a random intercept to account for within-subject correlations. Separate models were run to test whether previous psychotherapy and levels of physical activity influenced changes over time. Fixed effects included time, psychotherapy, physical activity, and their interactions with time, with random intercepts specified for participants. Analyses were conducted using SPSS (version 29.0), and significance was set at P < 0.05.

Results
The study included 60 breast cancer patients (Mage = 51.0; I = 5.5; range: 33–60). The majority of participants had obtained a university degree or completed advanced training (56.7%) and were employed in white-collar occupations (88.3%). Most participants were from Northern Italy (75.0%) and identified as Caucasian. A substantial proportion had one or more children (63.3%) and were in a sentimental relationship (65.0%). Approximately 56.7% reported engaging in regular physical activity, and 38.3% were currently undergoing individual psychotherapy. Detailed sociodemographic and clinical characteristics of the sample are presented in Table 1.
Linear mixed-effects models were used to examine changes over time in QoL and anxiety. Descriptive statistics for all outcomes are reported in Table 2. Overall QoL, assessed with the FACT-B total score, increased significantly over time (F(1,59) = 8.85, P = 0.004), indicating an improvement in perceived well-being (M(T0) = 93.14; M(T1) = 97.26). These findings support results present in the literature that show an increase of general well-being in the intervention groups compared with the control groups that maintained stable scores in the FACT-B general well-being (Palesh et al., 2019; Ramirez et al., 2020).
Analyses of the FACT-B subscales revealed significant improvements in PWB (F(1,59) = 16.22, P < 0.001) and EWB (F(1,61) = 21.62, P < 0.001). The BCS subscale showed a small but significant increase (F(1,59) = 5.96, P = 0.018). In contrast, no significant changes over time were observed for SWB (F(1,59) = 0.60, P = 0.443) or FWB (F(1,61) = 0.06, P = 0.814).
Regarding anxiety, assessed with the STAI-Y, participants reported moderate levels across both time points, with mean scores marginally approaching the clinical cutoff, and no significant change over time was found (F(1,60) = 1.35, P = 0.250).
We then examined whether previous psychotherapy or physical activity influenced changes in QoL outcomes (PWB, EWB, BCS, and FACT-B total scores). There were no significant main effects of psychotherapy (PWB: F(1,58) = 1.54, P = 0.22; EWB: F(1,58) = 3.22, P = 0.08; BCS: F(1,58) = 1.04, P = 0.31; FACT-B: F(1,58) = 2.54, P = 0.12) and no significant interactions with time (PWB: F(1,58) = 1.46, P = 0.23; EWB: F(1,58) = 2.14, P = 0.15; BCS: F(1,58) = 0.14, P = 0.71; FACT-B: F(1,58) = 0.75, P = 0.39). Similarly, no significant main effects of physical activity (PWB: F(2,57) = 0.79, P = 0.46; EWB: F(2,57) = 0.89, P = 0.42; BCS: F(2,57) = 1.01, P = 0.37; FACT-B: F(2,57) = 0.42, P = 0.66) or interactions with time (PWB: F(2,57) = 0.21, P = 0.81; EWB: F(2,57) = 0.40, P = 0.68; BCS: F(2,57) = 1.03, P = 0.36; FACT-B: F(2,57) = 1.21, P = 0.31) were observed. These findings indicate that changes in QoL over time occurred independently of participants’ previous psychotherapy or levels of physical activity.

Discussion
The present study highlights the impact of a tailored and combined intervention to foster emotional and physical well-being in breast cancer survivors, regardless of their prior individual psychotherapy experiences. In particular, emotions and physical well-being were assessed after a 1-week psychological intervention with peculiar characteristics. First, the group intervention took place in a naturalistic outdoor place far from the town. Second, the proposed activities were facilitated by a multidisciplinary team, from psycho-oncologists to sailing instructors. Additionally, sailing is a high-emotional-impact adventure sport. Given all these features, we can speculate that sailing, as a guided activity facilitated by trained instructors, plays a significant role in enhancing the emotional and physical well-being of breast cancer survivors.
Regarding Hp.1, results confirmed Hp. 1.1 and 1.2, which are related to both emotional and physical well-being. Our study supports that sailing can be considered a meaningful experience, offering materials and metaphors that are effectively integrated into psychological sessions to promote self-reflection, emotional processing, and relationship dynamics (Finlay, 2015). These metaphors enable women to reframe their illness experiences, fostering the development of new, healing narratives. Additionally, the physical aspects of sailing encourage participants to respect roles, rules, and personal boundaries within the group, key elements in the process of illness elaboration. In line with our findings, Mirandola and colleagues (2020) demonstrated the effectiveness of sailing in enhancing the QoL of breast cancer survivors. Considering previous interventions that incorporated sports and physical activities for cancer patients (e.g. dragon boat), the authors provided direct evidence that a 1-week sailing experience can significantly improve the QoL in breast cancer survivors. Additionally, psychological intervention obtained significant and positive results in enhancing emotions in breast cancer survivors, as supported by many studies (LeRoy et al., 2018). It is also supported by small, significant decreases in breast cancer-related issues in the present study, highlighting the relevant role of tailored intervention for breast cancer survivors to improve their QoL (Ferrier et al., 2025). Considering that no control group was considered in the present study, one might think that the found effects were not attributable to the intervention and were just time or placebo effects. Nevertheless, previous randomized control trials investigating behavioral, psychological interventions on breast cancer patients and survivors showed stable scores in QoL over time in the control group, supporting our findings (e.g. Palesh et al., 2019; Ramirez et al., 2020; Heiman et al., 2022; Hao et al., 2024).
Starting from the aforementioned considerations, the novelty of the present study was to propose a combined approach to address physician and emotional well-being in breast cancer survivors. This was supported by current studies that have demonstrated the effectiveness of mixed-method interventions, which propose different psychological approaches (e.g. cognitive-behavioral/existential, psychosocial, and educational programs) to promote overall well-being (Blanco et al., 2014; Xu et al., 2023). Thus, benefits depended on addressing women’s needs, rather than the intervention modalities.
However, anxiety has not significantly changed over time (Hp. 2). Anxiety is one of the primary emotional challenges faced by breast cancer survivors (Ryan, 2020; Saevarsdottir and Gudmundsdottir, 2023). However, it is important to note that the intervention did not specifically target anxiety management strategies, which may explain the lack of significant results in this domain. The present intervention was indeed focused on improving overall well-being, without the implementation of specific strategies aimed at decreasing anxiety. As affirmed in a systematic review published by Lei et al. (2023), anxiety should be addressed by considering the mode of contact, specifically whether the intervention is delivered in a group or individual setting, and the type of intervention. Accordingly, the American Society for Clinical Oncology (ASCO) guidelines recommend following a stepped-care model to provide the most effective intervention for anxiety symptoms in oncology. For example, patients with moderate anxiety should be offered cognitive behavior or acceptance therapy, behavioral activation, structured physical activity, and psychosocial interventions (Andersen et al., 2023). Additionally, anxiety levels were not clinically significant, neither before nor after the intervention, suggesting that there was no urgent need for anxiety reduction within this group. Moreover, given its complex and persistent nature, achieving significant improvements with a single intervention may be difficult. The brief duration of the intervention might also have been insufficient to generate meaningful changes in anxiety levels, particularly when preexisting emotional issues were already present.

Conclusions
The present study revealed improved well-being in breast cancer survivors following a 1-week sailing experience, referring to both emotions and the body, highlighting the effective impact of combined and tailored interventions that integrate sailing and psychotherapy in breast cancer survivors. These findings provide a foundation for designing interventions more closely tailored to patients’ needs. However, some limitations must be acknowledged. The study relied exclusively on self-reported assessments, a common approach in health psychology research (Santa Mina et al., 2018; Mirandola et al., 2019). Additionally, the self-selection of participants (breast cancer survivors who voluntarily joined the program) may have influenced the results by favoring motivated individuals, thereby facilitating positive outcomes. In this regard, women who were recruited had different cancer histories, for example, in terms of time elapsed since cancer treatments and surgery. It was chosen as a group characteristic to increase the sharing of new insights and diverse points of view among participants. However, it would be interesting to make a more homogeneous group in future research, proposing groups in which participants discuss their emotional reaction after similar cancer experiences. Another significant limitation is the absence of a control group, which prevents us from conclusively attributing the observed improvements solely to the intervention. For instance, the supportive environment and sense of group belonging contributed substantially to the psychosocial benefits reported. Moreover, the lack of a control group could increase a placebo effect due to the absence of a comparison, as well as the positive outcomes, thanks to the idea of being involved in a beneficial intervention. Additionally, we acknowledge the absence of a control group as a limitation, as well as the inability to test for potential combined effects. Future research should include larger samples, control groups, and longer follow-up periods to confirm and expand these findings. Longitudinal studies across different phases of cancer survivorship could help map the trajectory of improvements, assessing the obtained outcomes over time. Accordingly, extending this intervention to other individuals with other types of cancer (such as men with prostate cancer) could provide valuable insights. Lastly, potential clustering at the team level was not accounted for in this study. Future research should address the hierarchical structure of similar study designs to avoid this risk. Despite some limitations, this study encourages the proposal of future interventions in which the body-and-mind connection would be the focus of interest, also providing new approaches that could be helpful to promote even more tailored interventions (Sebri et al., 2020). Such knowledge is fundamental to developing increasingly effective interventions involving a multidisciplinary team of professionals to improve overall well-being after breast cancer. In this regard, future interventions should be tailored to anxiety symptoms to address them and provide improvements in participants’ abilities to manage them.

Acknowledgements
This work was partially supported by the Italian Ministry of Health with Ricerca Corrente and 5 × 1000 funds.
The data that support the findings of this study are available from the corresponding author upon reasonable request.
All procedures performed in this study involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All subjects gave consent to participation after reviewing the study information online.
V.S.: conception of the study design; recruitment and data collection; data coding; statistical analysis plan and data analyses; manuscript draft, revisions, and approval. G.O.: recruitment and data collection; data coding; statistical analysis plan and data analyses; manuscript draft, revisions, and approval. A.G.: recruitment and data collection; manuscript revisions and approval. K.M.: recruitment and data collection; manuscript revisions and approval. G.P.: conceptualization of the research; manuscript revisions and approval.

Conflicts of interest
There are no conflicts of interest.