Critical Thinking Exercise

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K E Y W O R D S

Breast cancer

Grounded theory

Initial chemotherapy

Psychological process

Yen-Chieh Chen, MSN

Hui-Man Huang, PhD

Chia-Chan Kao, PhD

Cheuk-Kwan Sun, MD

Chun-Ying Chiang, PhD

Fan-Ko Sun, PhD

The Psychological Process of Breast Cancer Patients Receiving Initial Chemotherapy Rising From the Ashes

Background: In Taiwan, breast cancer is the most common cancer in women.

Most breast cancer patients are willing to receive chemotherapy and experience

adverse effects and suffering during the process of chemotherapy. Objectives: The

aim of this study was to explore patients’ psychological process when receiving

initial chemotherapy for breast cancer. Methods: A qualitative grounded theory

approach was used. Data were collected through semistructured interviews of

20 patients who were from 1 district teaching hospital during 2012 to 2013.

Results: A substantive theory was generated to describe the psychological process

experienced by breast cancer patients in their initial treatment. The core category

was ‘‘rising from the ashes.’’ Four categories emerged and represented 4 stages

of the psychological process experienced by breast cancer patients. They were

(1) fear stage: patients are frightened about permanent separation from family,

chemotherapy, and the disease getting worse; (2) hardship stage: patients

experience physical suffering and mental torment; (3) adjustment stage: patients fight

against the disease, find methods for adjustment, and get assistance from supporting

systems; (4) relaxation stage: patients were released from both the physical and

mental sufferings, and patients accepted the disease-related change in their lives.

Conclusion: Each stage is closely related to the other stages, and each is likely to

occur repeatedly. It is important to help patients achieve the relaxation stage.

Author Affiliations: Department of Nursing, National Cheng Kung University The authors have no funding or conflicts of interest to disclose. Hospital (Ms Chen); and Department of Nursing, Chang Jung Christian Uni- Correspondence: Fan-Ko Sun, PhD, Department of Nursing, I-Shou versity, Tainan (Dr Huang); and Department of Healthcare Administration University, No. 8, Yida Rd, Jiaosu Village, Yanchao District, Kaohsiung City (Dr Kao), Department of Emergency Medicine, E-Da Hospital (MD Sun), 82445, Taiwan, Republic of China ([email protected]). and Department of Nursing, I-Shou University, Kaohsiung (Drs Chiang and Accepted for publication October 13, 2015. Sun), Taiwan, Republic of China. DOI: 10.1097/NCC.0000000000000331

E36 n Cancer NursingTM , Vol. 39, No. 6, 2016 Chen et al

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Implications for Practice: The results of this study may enhance nurses’

understanding of the psychological process of patients receiving initial chemotherapy

for breast cancer, thereby helping nurses to provide appropriate assistance to improve

the quality of patient care.

G lobally, cancer ranks first among the top 10 causes of death. Breast cancer is one of the most prevalent forms of cancer affecting women. In 2008, an estimated

1 380 000 women in the world had suffered from breast cancer, of which 460 000 women died of the disease.

1 In 2010,

an estimated 20 000 (n = 202 675) new breast cancer cases were diagnosed in the United States, contributing to 18% of all cancers diagnosed in the United States that year.

2 In the latest

statistical data in Taiwan, female breast cancer had the highest incidence in 2012 (n = 10 525), with the median age of pa- tients being 53 years.

3 The incidence of breast cancer in Taiwan

has increased 3-fold in the last 15 years, increasing from 3640 cases in 1997 to 10 525 cases in 2012.

3,4

A benefit arising from the recent increase of cancer screening and advancement in medical technology is that cancer survival rates have gradually risen. In particular, the survival rate of stage 0 breast cancer patients can now exceed 97%. Similarly, stage 1 survival rates can now surpass 95%, and stage 2 survival rates 89%. Stages 3 and 4 survival rates can be maintained at 70% and 25%,

5

respectively. Therefore, early diagnosis and treatment of breast cancer in women are very important for survival.

Aside from patients with stage 0 cancer, most breast cancer patients require chemotherapy.

6 There are 2 types of chemo-

therapy: adjuvant chemotherapy after a surgical operation and neoadjuvant chemotherapy before surgical operation. Adjuvant chemotherapy is aimed at reducing the chance of relapse and relocation following surgical operation. At present, the chemo- therapeutic drugs more commonly used include CEF (cyclo- phosphamide, epirubicin, 5-fluorouracil), AC (adriamycin, cyclophosphamide), and EC (epirubicin, cyclophosphamide). CEF is the most commonly used drug in adjuvant chemother- apy following surgery and in neoadjuvant chemotherapy before surgery. A course of chemotherapy requires an injection around once every 21 days for a total of 3 to 6 injections, which depend on participants’ pathology report. Therefore, a course of chemo- therapy is slow and requires approximately 4 to 5 months

7,8

The long duration of the chemotherapy process can entail multiple symptoms including (1) fatigueVapproximately 99% of breast cancer patients receiving chemotherapy report fatigue, and greater than 60% of chemotherapy patients experience mild to severe fatigue; the duration of fatigue can be several months to years, influencing patient capabilities and standard of living

9Y11 ;

(2) insomniaVapproximately 65% of patients experience a reduced quality of sleep after receiving chemotherapy; the quality of sleep is particularly worse on the first night of the chemotherapy

12 ;

(3) nausea, vomiting, and loss of appetiteVapproximately 6% to 74% of these women experience loss of appetite

13 ; and (4)

hair lossVhair loss begins 2 to 4 weeks following chemotherapy. Common psychological symptoms reported by women in

treatment with breast cancer include (1) worryVpatients were

faced with uncertainty regarding treatment results, relapse, and future living arrangements since the beginning of the disease. All breast cancer patients gave worry-related responses; of these, 28% were mildly worried, 50% moderately worried, and 22% indicated severe anxiety

14,15 ; (2) anxietyVpatients experienced

moderate to severe anxiety at the beginning of the diagnosis. Their anxiety levels were relatively lowered after their diagnosis was confirmed and decreased gradually after the first treatment

16 ;

(3) depressionVstudies have revealed that approximately 16% of breast cancer patients are mildly depressed, 11% moderately depressed, and 3% severely depressed. Those with severe de- pression reported suicidal ideations or attempts. Some patients developed severe levels of depression within the first month of diagnosis

13 ; (4) sadnessVcommonly associated with a perceived

loss such as losing their hair. 17

Much of the current breast cancerYrelated research focuses on patient fatigue after chemotherapy,

10,11,18 the adverse

effects of chemotherapy, 19,20

and quality of life during chemo- therapy.

21,22 However, studies in relation to the psychological

aspects of chemotherapy patients are rare. Therefore, in the current study, the psychological experience of breast cancer pa- tients during their first chemotherapy was explored to help generate new understanding of this experience for first-time chemotherapy breast cancer patients.

n Methods

Grounded theory (GT) focuses on describing theory or ex- plaining the stages of experience.

23 Because the current study

aimed at generating a theory to describe the psychological stages of breast cancer patients during their first chemotherapy, GT using the approach of Glaser

24 was the most suitable for this study.

Sample Breast cancer patients were recruited from a teaching hospital in southern Taiwan. The criteria for participant sampling included (1) intravenous chemotherapy patients; (2) any breast cancer stage but patients would need to have finished the first course of chemotherapy (a course has 3Y6 injections); the interview was to take place within 6 months of finishing the first course of chemo- therapy; (3) female breast cancer patients; (4) 20 years or older; (5) speaker of Mandarin or Taiwanese language; and (6) signed the agreement to participate in this study. Patients excluded from this study included those (1) experiencing a recurrence and (2) who were weak and unable to talk during the interview.

Twenty breast cancer patients were invited to participate in the study, and no one refused. Their age range was 39 to 62 years (mean, 49.8 years). Seventeen participants were married;

Psychological Process of Breast Cancer Patients Cancer NursingTM , Vol. 39, No. 6, 2016 n E37

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20 participants were religious. The religions were mostly folk religion, Taoism, and Buddhism. Eighteen participants were em- ployed, and the remaining 2 were housewives. Nine participants had stage 2 breast cancer, 7 had stage 3, 2 stage 4, and 2 had stage 1 breast cancer. Six participants received adjuvant CEF combined chemotherapy injections 3 times, 4 participants received adjuvant CEF combined chemotherapy injections 6 times, 3 participants received adjuvant CEF combined chemotherapy injections 4 times, 4 participants received AC combined chemotherapy injections 4 times, 2 participants received neoadjuvant CEF combined che- motherapy injections 4 times, and 1 participant received neo- adjuvant CEF combined chemotherapy injections 3 times (Table).

Data Collection This study primarily used semistructured interviews to collect data during 2012 to 2013. The actual answers provided by the participants during the interviews were used to guide the in- terview into a deeper exploration of the psychological processes of breast cancer patients during their first chemotherapy. The interviewer had worked as a specialized nurse in a surgical ward for 7 years and had extensive knowledge regarding breast cancer chemotherapy. Interviews were conducted in an interview room in the hospital, which provided a comfortable, quiet, and un- disturbed environment. Each participant was interviewed once, and each interview lasted 30 to 60 minutes.

Three breast cancer patients who had undergone their first chemotherapy with at least 3 injections were selected to partic- ipate in a pilot study that was aimed at learning of problems that could arise during the interviewing process and details that required attending to and if interview guidelines needed to be

Table & Demographic Details of the Sample

refined based on the interviewee’s answers. After the pilot study, the open-ended grand tour interview questions became as follows: (1) What was on your mind before receiving chemo- therapy? How were your mood and feelings? (2) During chemo- therapy, what was on your mind? How were your mood and feelings? (3) After chemotherapy, what was on your mind? How were your mood and feelings? (4) How did the chemotherapy affect your life? (5) During chemotherapy, did you encounter any problems or difficulties? How did you adjust? Guided by participants’ interview content, the researcher would ask ques- tions linking to emergent concepts, subcategories, or categories in order to contribute to theoretical sampling and to reach the- oretical saturation. For example, the participant would be asked a question concerning physical suffering experienced as a result of receiving chemotherapy.

Ethical Considerations This study was approved by the institutional review board in a hospital (EMRP-101-030). Prior to participant enrollment, the interviewer explained in detail to the participants the aim of the study, the methods to be used, and the rights that the partic- ipants had. An agreement to participate in the study was signed only if the participant wished to join the study following the detailed disclosure about the study. Even after the agreement was signed, participants could request to opt out of the study at any time without providing reasons. During the interviews, in- terviewees had the right to decide on the details of the infor- mation shared. After the interviews were conducted, interviewees still could ask to delete any information provided. All interview data were processed based on anonymity; thus, privacy of the

Patient Age, y Marital Status Religion Occupation Breast Cancer Staging Chemotherapy

1 48 Married Folk religion a

Businesswoman T2 N3 M0 IIIC CEF � 6 2 57 Married Folk religion

a Service industry T1 N1 M0 IIA AC � 4

3 50 Married Taoism Construction worker T1c N1 M1 IIA AC � 4 4 45 Married Taoism Labor T2 N2 M0 IIIA CEF � 3 5 49 Married Folk religion

a Labor T1c N0 M0 I CEF � 6

6 41 Married Folk religion a

Labor T2 N2 M0 IIIA CEF � 4 7 47 Married Taoism Labor T1c N0 M0 I CEF

b � 3 8 62 Widow Buddhism Farmer T4 N3 M1 IV CEF � 3 9 51 Married Folk religion

a Self employed T1c N1 M0 IIA AC � 4

10 59 Married Other Insurance Saleswoman T2 N2 M0 IIIA CEF � 3 11 43 Divorce Buddhism Businesswoman T2 N0 M0 IIA CEF � 6 12 52 Married Taoism Labor T2 N3 M0 IIIC CEF

b � 4 13 50 Divorce Taoism Construction worker T2 N0 M0 IIA CEF � 6 14 39 Married Buddhism Service industry T3 N1 M0 IIIA CEF � 3 15 47 Married Catholicism Government employee T1b N1 M0 IIA CEF � 4 16 59 Married Other Government employee T1c N2 M0 IIIA CEF � 3 17 45 Married Buddhism Service industry T2 N1 M0 IIB CEF � 3 18 46 Married Folk religion

a Labor T2 N1 M0 IIB AC � 4

19 56 Married Taoism Housewife T4 N2 M1 IV CEF b � 4

20 50 Married Folk religion a

Housewife T1c N1 M0 IIA CEF � 4

Abbreviations: AC, adriamycin (doxorubicin), Cytoxan (cyclophosphamide); CEF, Adjuvant chemotherapy, Cytoxan (cyclophosphamide), Ellence (epirubicin), 5-FU (5-fluorouracil). a A mix of Taoism and Buddhism

b CEF, neoadjuvant chemotherapy, Cytoxan (cyclophosphamide), Ellence (epirubicin), 5-FU (5-fluorouracil).

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participants was protected. Participants who exhibited intense emo- tional reactions during the interviews were comforted by the inter- viewer. In this study, only 1 participant required comfort from the interviewer, but no participant required a referral to a psychiatrist.

Data Analysis Data analysis involved open and theoretical coding processes to achieve data conceptualization. Coding involves analyzing every word and sentence in the text data and identifying important, outstanding, and repetitive messages during data analysis.

25 Each

interview was recorded using audio tape, and the interview verbatim was prepared within 3 days. Every word and sentence was then analyzed immediately to seek out important and re- petitive message code to form concepts. Similar concepts were then grouped into subcategories using the constant comparative method. Similar subcategories were grouped into categories. Software package NVivo 10 (QSR International Pty Ltd, Australia) was used to assist in the grouping of concepts, subcategories, and categories.

26,27 A purposive sampling was used initially for emerg-

ing concepts, and then theoretical sampling was used to select additional participants until categories were saturated.

28 For

example, when the category of ‘‘relaxation stage’’ began to emerge from the data, an additional 3 breast cancer patients were selected to elicit more data about relevant properties (subcategories) and to reach saturation of this category. Analysis became saturated with concepts after the number of participants reached 20. At this point, no new concepts were discovered, and consequently, participant

recruitment was terminated. At the end of the analysis, 4 categories and 10 subcategories and a core category were derived from the data; the process of ‘‘coding family’’ was used to link each category with the core category,

24 which led to the theory

generation of describing the psychological process of breast cancer patients in their initial treatment (Figure).

Rigor Five methods were used to enhance the credibility of the current study.

29 They were (1) prolonged engagementVthe researcher

would participate in the care of the participants during their hospitalization and the continuing care of the patients during their follow-up visits to establish a good therapeutic relationship; (2) persistent observationVthe researcher continued to observe the verbal and nonverbal expressions of participants during their follow-up visits to understand their actual situation; (3) peer briefingV3 breast cancer psychological experts with experience in qualitative research were invited to collaborate in reviewing and discussing the categories, subcategories, and concepts obtained from the analysis. This was to ensure that the results would be consistent; (4) member checkV2 participants were invited to check the categories, subcategories, and concepts obtained by the researcher in order to determine if the results represented their actual situation; (5) use of a reflective journalVthe researcher used the reflective journal to help with self-awareness for cor- recting interview techniques. This enabled more detail and actual research data to be obtained.

Figure n A theory to describe the psychological process of breast cancer patients in their initial treatment.

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n Results

Four categories and a core category resulted. Using these 4 cate- gories, ‘‘the psychological process of breast cancer patients re- ceiving initial chemotherapy’’ was concluded. Four psychological processes were identified: the fear stage, hardship stage, adjust- ment stage, and relaxation stage. The core category was ‘‘rising from the ashes’’ (Figure). The 4 stages are described in the following sections, followed by a description of the GT con- structed around the core category.

Stage 1: Fear Stage In the first stage, breast cancer chemotherapy patients experienced the fear stage. The participants worried that the disease would be incurable and that they could no longer live with their family. They expressed fear at the thought of suffering adverse effects from the chemotherapy, cancer cell metastasis, and disease dete- rioration. Therefore, this category was classified into 3 subcategories.

FEAR OF PERMANENT SEPARATION FROM FAMILY

Many participants expressed fear about any possible, unfortu- nate event that could happen because of their breast cancer because their children were still minors or still required parental support. They also feared that their own parents would be worried when they were eventually informed about the cancer. Furthermore, the participants feared that their parents would think they were ill fated and worry that they would have to experience their child’s death before their own. Two participants had this to say:

I would think that if I really passed away, how would my child cope? I was the one who managed everything at home such as the child’s education. If I really passed away, my child and husband do not have a close relationship compared to me. I fear my child would not have anyone to talk to anymore. (Participant 1)

Since I am the only daughter at home, my father favors me the most. Therefore, I know he would be the one feeling hurt the most because of my cancer. I dare not to tell him about my cancer. I fear he would worry. (Participant 6)

FEAR OF CHEMOTHERAPY

Many participants knew there might be multiple adverse effects associated with the chemotherapy that could cause discomfort. Therefore, they were fearful of chemotherapy and wanted to look for alternative therapy. They also feared that chemotherapy would affect their body, and they would be unable to work. Three participants expressed their experiences as follows:

I am afraid when I hear about chemotherapy! This is my first time, I have heard from others that I may vomit. (Participant 18)

Before receiving chemotherapy, my husband suggested that I take herbal medicine to treat the breast cancer. (Participant 7)

Before receiving chemotherapy, I was very worried because I really wanted that job and would like to have

kept working. I worried that my body would become weak and be unable to work. I still need to earn money to support my family. (Participant 11)

FEAR OF THE DISEASE GETTING WORSE

Many participants received chemotherapy to kill off the cancer cells because they wanted to be completely cured from breast cancer, but they also feared that if the chemotherapy was un- successful, the cancer cells could spread, their lives could be cut short, and the disease could become incurable. Therefore, they were very worried about a possible relapse and their cancer metastasizing:

I fear of the possibility of cancer metastasis. I have heard others say that even if it is confirmed you have breast cancer, other cancers such as lung adenocarcinoma can arise. I am worried. (Participant 11)

During the chemotherapy treatment period, if I do not have to work and am lying on bed the whole day, I would think about anything, and they would usually be the negative side of things. I would worry about having a relapse or something similar. (Participant 18)

Stage 2: Hardship Stage After the participants began to receive chemotherapy, adverse effects began, and their bodies started to feel the strain. Their capability of performing daily chores was affected; they would start to feel the psychological strain as well. When both types of hardship combined, it became hard for the participants to withstand the suffering. This category was classified into 2 subcategories.

PHYSICAL SUFFERING

All participants complained about the various adverse effects of the chemotherapy, including hair loss and the worry that others would perceive them differently. Many participants expressed that after the chemotherapy they had symptoms such as nausea, vomiting, loss of appetite, insomnia, and inactivity due to fatigue. Some reported numbness in their limbs, a higher rate of infection due to weaker immunity, and poor memory. The following 5 par- ticipants shared their experiences:

After the chemotherapy, all my hair had fallen out; I locked myself at home because I was afraid of going out. This included when I needed to get some food for lunch, my husband had to manage that for me. When my husband was really tired, I would wear a wig out. I would consistently stare at people to see if anyone noticed that I was wearing a wig! (Participant 14)

After the chemotherapy, it made me lazy, and I did not want to move because I was so tired. Then, I had no appetite because my sense of taste changed. It was so different that I couldn’t taste the food. Everything was different in my body. (Participant 15)

I can usually fall asleep very easily, as in whenever I want to sleep, I can just go to bed and sleep. During chemotherapy, I felt very uncomfortable, tired, and sleepy, but I couldn’t fall asleep no matter what! (Participant 17)

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Because of the adverse effects of chemotherapy, my fingertips felt very numb. I went to do electrotherapy rehabilitation for a couple of weeks. My skin became red and itchy, and this led to infection. Because of this, I needed to get my own electrotherapy stickers. (Participant 12)

During the chemotherapy period, my memory wasn’t as good, and I often forgot things. I often forgot I had already gotten the things I wanted. (Participant 17)

MENTAL TORMENT

Many participants described feeling depressed when it was close to the next chemotherapy injection session because they did not want to suffer the adverse effects from chemotherapy. They felt that it was too hard to live and contemplated suicide. Some participants even blamed themselves for having done something wrong that caused the cancer. Two participants expressed:

I didn’t feel much from the first injection. In the second one, I felt very depressed. The discomfort could last for 4 to 5 days. I was thinking that if I had to suffer this much, I would rather not have had the chemotherapy. But my husband told me to be patient for a bit. In my third injection, I got even more depressed and uncomfortable. I was thinking that if I had to suffer this much to live, I would rather not live! (Participant 9)

My daughter had just given birth, so I made sesame oil chicken and fish soup for her. But she didn’t eat much, so I helped her eat it. I suspect that I ate too much and that it made me ill. My whole armpit was swollen, so I went to see the doctor. (Participant 12)

Stage 3: Adjustment Stage The psychological process of breast cancer patients during che- motherapy entailed both physical and mental suffering. They needed to adjust their mindset toward cancer using different positive coping methods such as exercise to surpass the suffering caused by chemotherapy. They also required help from friends, medical professionals, and religion to adjust themselves to with- stand the cancer treatment. This category was classified into 3 subcategories:

FIGHT AGAINST THE DISEASE

Most of the participants expressed that they had to live for their families and thus had to be brave in facing their disease. They had to adhere to the medical professionals’ instructions on how to treat their disease. Moreover, they had to fight for their lives by forcing themselves to eat, even when they were unable to eat. They had a desire to surpass their disease so that they could continue living. Two participants had this to say:

During chemotherapy, I felt that I had to fight this disease. I thought that I might as well try to fight it to see if I could live for a few more years! Besides taking the advice from doctors, I needed to depend on my own mental strength. After that, I tried to do as much exercise as possible and eat normally to help my body heal. (Participant 8)

After having chemotherapy, I couldn’t eat when I got home. But, I would think of some ways to eat something more nutritious. For example, when I cooked fish, I would add an egg in it. I would try to eat as much as I could. But if I couldn’t eat, I would make some fruit juice to drink. I don’t want to leave my child and his father behind! I will be brave and keep on living! (Participant 2)

ADJUSTMENT METHODS

Participants used different adjustment methods to reduce their suffering during chemotherapy. For example, they exercised more to be more energetic, cried to release sad emotions, and kept themselves busy so as not to focus on the discomfort their body was experiencing. Three participants shared their experiences:

In order to feel more comfortable during chemotherapy, exercise is very important. During my chemotherapy period, I exercised for an hour daily by walking, such as walking to the park or school. Running is too difficult, but walking is good. (Participant 7)

I couldn’t accept losing my hair during chemotherapy. I used to have really good hair! I decided to cut all my hair off, so I lost my hair all at once, which made me cry. I cried so much in the beauty salon. Crying made me feel better! (Participant 2)

Because I have to work, I would return to work after the injection. I was in a very good mood when I still had a job! If I had no job, I would just feel dizzy. A job could transfer my attention! (Participant 11)

ASSISTANCE FROM SUPPORT SYSTEMS

Almost all the participants expressed that besides having to be brave to accept and face the therapy, it was essential that they received support from others, for example, care from family and medical professionals, encouragement from friends, and spiri- tual comfort from religion. These were all sources of support that helped them continue with the therapy. Four participants expressed their experiences:

My husband and child are the closest people to me. My sisters also know about my disease. My sisters also care about me and encourage me. My mood became better, and I wouldn’t have silly thoughts because of the care and encouragement from the people closest to me. (Participant 7)

Medical professionals would ask me about my response to the chemotherapy each time before the injection. I would tell them about my response, and they in turn would tell me about their other patients’ situation. They would tell me more about the usual responses from chemotherapy. This made me feel cared for. (Participant 2)

My friends would tell me about other people they knew that also got sick. They would encourage me to say, ‘‘It doesn’t matter! People who have had breast cancer also overcome their disease. It is not a problem!’’ (Participant 10)

It may be because of my religion. I do not care much about my breast cancer because my religion leads me to think that everything Jesus gave me is a good thing.

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There is no reason for me not to accept this situation. Therefore, I was at peace. (Participant 15)

Stage 4: Relaxation Stage During the initial chemotherapy, after experiencing the fear stage, hardship stage, and adjustment stage, participants would transition into the relaxation stage. At the completion of che- motherapy, the adverse effects gradually lightened, and the participants’ body and mind would start to relax. In addition, the participants gradually accepted the reality that they were sick and the influence that their illness had on their lives. Therefore, this category was classified into 2 subcategories.

RELAXATION OF BODY AND MIND

Many participants expressed that it felt like they had crossed a deep-water channel when the chemotherapy was completed. They felt like they had released a heavy burden and became very relaxed because they no longer needed to suffer the strain of the chemotherapy, and they could resume their normal standard of living. Some participants expressed that the adverse effects from chemotherapy had slowly alleviated. For example, their hair would slowly grow back, their taste sensation improved, numb- ness of the limbs lessened, and their memory improved. Two participants had this to say:

My mood was rather good after the chemotherapy! I no longer need to suffer from the chemotherapy! The treatment is finished! I can be normal again! My life can be normal again! (Participant 11)

After the chemotherapy, I felt that I became weaker and would not like to move. I had a long chemotherapy treatment period; my limbs are numb. They are still numb after 6 months, but the symptoms are getting less intense! I am less numb than before! (Participant 18)

ACCEPTING CHANGES IN THEIR LIVES

Some participants expressed that after experiencing breast cancer and the suffering from chemotherapy, they realized that human life lasted for only several decades and that if they had reached the end of their lives it did not matter much. They thought they should use their remaining days to help other people. Anything could happen in life, and only knowing how to be satisfied could help an indi- vidual live a better life. Two participants shared their experiences:

I want to say that anything could happen in our lives; nothing is guaranteed. Therefore, there is no need to try so hard or care about anything so much. It is good enough to be able to eat. There is no need to worry about this and that! (Participant 18)

After getting the disease, I changed my view toward life. If there is an opportunity to help others, we should help. There is not much time to wait. (Participant 16)

A Theory to Describe the Psychological Process of Breast Cancer Patients in Their Initial Treatment The psychological process of breast cancer patients receiving initial chemotherapy is like the process of rising from the ashes

E42 n Cancer NursingTM , Vol. 39, No. 6, 2016

(core category). This study defines ‘‘rising from the ashes’’ as participants felt they regained their life after they experienced and overcame huge suffering from breast cancer and the adverse effects of chemotherapy. That is, when participants were in the fear stage and hardship stage, their tolerance for pain and suf- fering was tested by destructive effects, both physically and emotionally, in their lives. However, when they were in the adjustment stage and relaxation stage, they felt relieved and were able to regain a positive outlook, a constructive element to re- storing their normal lives. Participants expressed when they were diagnosed with breast cancer, they were fearful that their illness could not be cured, and that they would leave their family forever (fear stage). Thus, they decided to accept chemotherapy in order to keep life for their family. However, the adverse effects of chemotherapy caused them great physical and mental suf- fering (hardship stage). This suffering was difficult to tolerate, and for some, unbearable. Therefore, they used different methods to adjust the suffering in order to live (adjustment stage). If breast cancer patients were persistent and confident in facing their disease and completing the chemotherapy process, they would achieve the relaxation stage faster (relaxation stage). Inversely, if they lost their confidence, or there was a delay in chemotherapy because of adverse effects, this could prolong the treatment process and delay achieving the relaxation stage. That is, the 4 stages experi- enced by participants were related to one another, and each stage could occur repetitively. In addition, participants might move backward and forward through the stages, depending on par- ticipants’ chemotherapy condition and coping ability (Figure).

n Discussion

The results of this study describe the psychological process of breast cancer patients during their initial chemotherapy that begins with fear. When the participants realized that they had cancer, they feared dying (n = 11) because the participants were middle aged

30 and were still responsible for supporting their

children and caring for their parents. Therefore, they would worry about the future arrangements of their children if they were gone and could not be with them. This result is similar to pre- vious studies, in which female breast cancer patients reported being worried, sad, depressed, and blaming self because they could not take care of their children or participate in their children’s activities and became a burden on their families.

31,32

In addition, this study revealed that many participants feared the adverse effects of chemotherapy (n = 12) and that their fear led some to seek alternative therapy (n = 6). This is consistent with other studies that documented at the initial treatment breast cancer patients did not have enough information or knowledge about chemotherapy and its efficacy, leading participants to seek alternative therapy.

33 The efficacy of alternative therapy methods

is not proven, but some can be used in conjunction with certain conventional therapy to supplement effects, improve immunity, and reduce the chance of relapse.

34 During this critical stage, cli-

nicians can educate women about chemotherapy to enhance their confidence toward the treatment and their future.

The second stage is the hardship stage. Participants in this study complained that the adverse effects of chemotherapy led

Chen et al

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both their body and mind to suffer. The most common adverse effect was hair loss (n = 20), which led them to fear going out and to be seen. This result is similar to the results obtained from a study researching the effects of chemotherapy on Syrian women, which revealed that the effect on hair loss was the strongest effect on their body image.

35 The second most common adverse effect

was being too fatigued to move (n = 11); because of loss of appetite, insomnia, anemia, difficulty in breathing, metabolic disorder, hormone imbalance, loss of body weight, and loss of muscle strength, patients experienced cancer-related fatigue.

11,36Y39

Close to half of the participants in this study had contemplated suicide (n = 9) because of the suffering. The risk of cancer patients committing suicide is 2 to 4 times higher than healthy people.

40,41 Therefore, clinicians who take care of breast cancer

patients should screen patients for depression and suicidal ideation. Early intervention could prevent patients from committing suicide.

42

The third stage is the adjustment stage. Participants in this stage were able to gradually adjust themselves to their disease (n = 20). Participants would cooperate with clinicians during their treatment and care. The cooperation from patients affects the progression of their disease, the easing of their symptoms, and their prognosis.

43 Participants also had their own adjust-

ment methods. The most common method was exercise-related adjustment, such as walking (n = 9), yoga, and cycling. Previous research also indicates that moderate and regular exercise can improve cancer patients’ body functional performance and mood, reduce treatment-related adverse effects, and improve quality of life.

36,44,45 Participants indicated that help from support

systems also helped them respond to the illness and its related physical and emotional stress from the chemotherapy. The main support system was family including parents, spouse, siblings, and children (n = 13) and clinicians (n = 13). Previous literature also indicated that care and support from family were the strongest support system for breast cancer patients.

31 Clinicians contribute

to supporting patients by listening to them, spending time with them, and encouraging them to face their disease positively and

46Y48 accept the treatment.

The fourth stage is the relaxation stage. Participants (n = 12) in this study expressed that they felt much more relaxed when the treatment was complete because they had passed the challenge. In addition, adverse effects of the chemotherapy had gradually reduced and disappeared after the chemotherapy. Bodily func- tions also gradually returned, and participants were more com- fortable. Moreover, some participants (n = 7) in this study realized that life is limited in general. They expressed that they would like to treasure their remaining time and to help people as much as they could. Experiencing the possibility of death can bring a realization that there is only certain time to achieve goals and plans and to value time and lives.

49

This study had 4 limitations. First, this study focused only on breast cancer patients who received initial chemotherapy intra- venously and did not study those who received oral chemother- apy and radiotherapy or more courses of chemotherapy. Second, this study was limited in knowledge regarding breast cancer pa- tients with relapse. Third, this study did not separately investi- gate patients with different cancer stages. Therefore, it was

impossible to compare the psychological process of breast cancer patients in different cancer stages. Fourth, participants were interviewed within 6 months of finishing the first course of chemotherapy, a design point selected because adverse effects of chemotherapy tend to gradually reduce 6 months after the completion of chemotherapy.

50 In future studies, the effect of

different treatment methods on patients’ psychological process could be investigated. Furthermore, the effect of chemotherapy on relapsing breast cancer patients’ psychological process and the psychological process of patients in different cancer stages could be investigated.

n Conclusion

This study generated ‘‘a theory to describe the psychological process of breast cancer patients in their initial treatment.’’ It revealed that the psychological process of breast cancer patients during initial chemotherapy can be classified in 4 stages: fear, hardship, adjustment, and relaxation. The results of this study may enhance clinicians’ understanding of the psychological process of breast cancer patients receiving initial chemotherapy so that they can provide appropriate help in the 4 different stages.

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