Demoralization syndrome among women exposed to war: comparing breast cancer survivors and those with no breast cancer history.

INTRODUCTION: Demoralization syndrome, characterized by distress and subjective incompetence, is prevalent among cancer survivors and particularly salient among breast cancer survivors (BCS). Collective trauma may exacerbate existential vulnerability and heighten demoralization syndrome. However, no study has compared demoralization syndrome among BCS and non-BCS women exposed to the same war-related context, nor examined age as a moderator of this relationship. Therefore, this study aimed to: (a) compare levels and clinically significant prevalence of demoralization syndrome between BCS and non-BCS women exposed to the October 7 war; (b) examine the association between war exposure and demoralization syndrome in both groups; and (c) test whether this association was moderated by breast cancer survivorship status and age. MATERIALS AND METHODS: This secondary analysis combined data from two parallel Israeli studies conducted during April-July 2024, following the October 7 war. The sample comprised 350 women: 190 BCS (diagnosed 1-2 years prior, post-active treatment) and 160 non-BCS participants. Measures included the War Exposure Index and Demoralization Scale-II. Group differences were examined using t-tests and chi-square analyses. Moderation analyses (PROCESS Model 1, 5,000 bootstrap samples) tested whether group and age moderated the association between war exposure and demoralization syndrome, controlling for age and ethnicity where appropriate. RESULTS: BCS reported significantly higher demoralization than non-BCS participants, with 47.9% meeting criteria for demoralization syndrome versus 33.1% of non-BCS women. War exposure was positively associated with demoralization syndrome in both groups, but this association was significantly stronger among BCS. Moderation analyses indicated that war exposure predicted demoralization only among BCS. Age moderated this association in BCS: war exposure and demoralization syndrome were significantly associated among median and older participants, but not among younger women. Johnson-Neyman analysis identified age 46.22 years as the threshold above which war exposure was significantly associated with higher demoralization syndrome. DISCUSSION: Findings suggest compounded vulnerability among BCS exposed to war stress, consistent with cumulative stress and resource-depletion frameworks. Older BCS appear particularly susceptible under dual health and societal threat. These results underscore targeted screening and psychosocial interventions addressing loss of meaning, helplessness, and existential distress among cancer survivors during armed conflict.