Experiences of Turkish Women with Breast Cancer During the Treatment Process and Facilitating Coping Factors

Breast cancer, the most common type of cancer among women all over the world (28%), is the second leading cause of cancer-related deaths (15%) (American Cancer Society: ACS, 2010). The most frequent type of cancer among women in Turkey is breast cancer (37.6 per hundred thousand) (TC. Ministry of Health, 2006). Cancer diagnosis and treatment have a profound impact on an individual’s physical, psychological, and social life. During the process of diagnosis and treatment, women with breast cancer face many physical and psychological problems in the family, at work and in social life, and their quality of life is adversely affected (Liu et al., 2006). Breast cancer is a complex disease affecting millions of people around the world. In recent years, there have been important advances in prevention, diagnosis and treatment methods of breast cancer. Survival rates in women with breast cancer are increasing and developments in breast


Introduction
Another factor stated to help women with breast cancer cope with the disease is the social support. Women with breast cancer consider the positive support from the family and spouses important (Doumit et al., 2010). If the social support is enough, it makes it easy to cope with the disease, but if not, it has a negative effect on coping (Henderson et al., 2003).
The support women with breast cancer receive from nurses during the diagnosis and treatment within the adjustment process is important. Women with breast cancer stated that their relationships with nurses greatly contributed to meet their requirements in the diagnosis and treatment processes of the disease. Women with breast cancer expect to receive support from nurses. They want to feel valued and to receive emotional support (Remmers et al., 2010). In a study conducted to determine the support needs of women with breast cancer, it was identified that what they needed most was to get enough information, which is followed by requirements necessary in the management of daily life and emotions (Griesser et al., 2011). In a study carried out by Lei et al. (2011), it was determined that there were differences between nurses and women with breast cancer regarding their perception of information needs. While women with breast cancer care for the recurrence of the disease, metastasis, the treatment plan and the side effects of the treatment, nurses give priority to the side effects of the treatment, the duration of the disease and the impact of the disease on the patient's life. During the first interview with women with breast cancer, the areas they considered difficult should be carefully determined. However, it has been reported that the needs of women with breast cancer are often overlooked (Pigot et al., 2009). It has been determined that 53% of the women with breast cancer reported that their requirements related to patient education in the process of diagnosis and treatment are not met (von Heymann-Homan et al., 2013). In another study, women with breast cancer suffered problems in areas such as physical functioning, psychological functioning, self and body image, sexuality, relationship with the partner, relationship with others, work, returning to work and social security (Pauwels et al., 2013).
Nurses play key roles in the treatment of women with breast cancer and in their adaptation to the treatment process. Nurses provide care for patients from many different cultures in the globalizing world. To know the factors that help women with breast cancer from different cultures to cope with the disease gains importance. In parallel with the changes and developments in the diagnosis and treatment processes; experiences of women with breast cancer, their coping methods and determining whether the sources of support have changed will significantly contribute to the planning of services. In this sense, it is worth understanding the experiences of Turkish Muslim women with breast cancer have during the course of the disease and the treatment process. It is thought that the results of this study can promote the ways through which nurses provide nursing care in parallel with the needs of women with breast cancer.
The purpose of this study is to identify the experiences of women with breast cancer and the facilitating coping factors while they receive chemotherapy.

Materials and Methods
A phenomenological approach was used to explain the experiences and facilitating factors of Turkish women with breast cancer in the treatment period. The data were collected through semi-structured individual interviews.

Participants
Women over the age of 18 who were treated for breast cancer at a university hospital and were able to provide in-depth information on the research questions comprised the sample of this study. Of the breast cancer patients, those who were known to have recurrent or metastatic cancer were excluded from the study. The data collection was based on the principles of saturation (Yıldırım ve Şimşek 2006). The final sample comprised 11 breast cancer patients in the treatment period. Mean age of the patients was 48.82.

Data collection
The data were collected through semi-structured in-depth interviews. Interviews were conducted by two trained researchers and each interview was audiotaperecorded. The interviews were conducted in the chemotherapy unit. An appropriate physical environment (quiet, safe) was created for the interviews. Women with breast cancer were asked questions about experiences related to the breast cancer treatment. The research questions were: What are the changes in your life in the treatment period? How did you cope with these situations? What facilitated your coping?

Data analysis
The researchers transcribed the audiotape-recorded interviews and combined them with notes taken during the interviews. The transcripts were read through several times to get a general sense of the information and to ensure the accuracy of the data analysis. During the coding phase, two researchers independently read all transcripts and determined codes. The codes were categorized and then themes and sub-themes. After coding was completed, the researchers discussed the codes and agreed on the thematic statements (Creswell, 2003).

Trustworthiness
To achieve trustworthiness of the data were based the strategies (credibility, transferability, dependability, confirmability) established by Lincoln and Guba (1985). For the semi-structured interview questions, two experts' opinions were received. In order to access the richer variation of phenomena, variations in sampling were provided on qualifications such as age, marital status and employment status. The research method (characteristics of the participants, data collection and analysis) were clearly defined. The interviews and data analysis were performed by two researchers. The differences between the two researchers were discussed, and then the data were organized and documented by the researchers.

Ethical considerations
Ethical approval to conduct the study was obtained from the Ethical Committee of the Dokuz Eylul University Institute of Health Sciences (decision numbered 154 and dated 03.03.2011). The patients were informed about the purpose of the study verbally and in written, and assured that they had the right to refuse to participate in the study before interview.

Results
The results about the experiences of women with breast cancer in the treatment period were classified in two main themes and six sub-themes. These two themes are adjustment and facilitating coping factors (Table 1).

Theme: adjustment
Two sub-themes (strains, and coping) were identified under the adjustment main theme.

Strains
The interviews revealed that women with breast cancer suffer physical, psychological strains and strains related to social and health systems. Physical strains experienced in the treatment process are as follows: fatigue, pain, oral and dental problems, skin / nail problems, nausea / vomiting, weight loss, loss of appetite, hair loss, and sleep problems.
"  (ÜS) "You find something to keep you busy during daytime. But nights, you're alone, the most pessimistic, negative thoughts come into your mind, you cannot go to sleep." (ÇD) Psychological strains specified by the women were uncertainty, changes in body image, loneliness, and changes in the emotional state.

One patient defined uncertainty as "I experience emotional tides; I question myself; what am I doing; what's gonna happen to me." (MÇ)
One of the areas uncertainty is experienced is about the effects of chemotherapy. A patient defined the chemotherapy-related uncertainty she experienced as "now I am having treatment, I wonder if my hair will shed, if I will suffer nausea or if I won't be able to eat? I am thinking of things like these." (SY) Women with breast cancer suffer fear of pain, metastasis, and death.
"I have fears about the next phases of the process. I do not want to be in pain. I do not want to suffer from aches." (ÇD) "I have fears. For example, when somewhere else in my body hurts, I wonder if it has metastasized." (ÜS) "Death is cold, and cancer reminds you death. Cancer leads to fear of death." (SK) During the interviews, women said that they experienced body image problems due to removal of breasts and hair loss. "

" (ÇD)
Another psychological strain is loneliness. One patient defined the loneliness she experienced as "For example, I tell someone something. Then, everyone turns back his/ her own life, and you find yourself alone." (ÜS) Interviews conducted with women with breast cancer revealed that they experienced such changes as anger, sadness, incompetence and regret in their emotional lives.
"I wasn't like this before. When there was a problem I used to talk about it calmly, in a friendly way, but now I get furious." (SK) "Dying is not a problem for me but I have regrets up behind me and hopes for the future. You say I wish I had done this or that. You cannot give up your hopes. That's my sorrow. " (HGS) "You want your kids not to be told, you want others not to worry, but you feel that you are shattered." (ÜS) Women with breast cancer regarded difficulties arising in the family or behaviors like staying away from other people as social strains.
"My skin looked terrible, some people did not come close to me, did not want to kiss me. I felt this and I did not kiss anyone. But I felt bad, of course." (ÜS) "It is just natural that everyone looks at the operated site. Has your hair or eyebrow hair shed? Are you gonna have chemotherapy? So many questions, I don't want to hear such questions so I don't talk to people." (SY) "I had my surgery and now it's over for me. But hearing people around you saying "don't eat it this or that. You're sick" annoys me." (SY) "My older son was negatively affected. For example, he doesn't study his lessons, he doesn't go to school. He cut classes for 5 or 6 days. I'm here, he's there." (MÇ) Women with breast cancer regarded topics like having difficulty reaching physicians, lack of support provided for patients and their relatives, and transportation problems as strains related to the health care system.
"Here, we are looking for the doctor, with the files in Coping It was determined that women with breast cancer employed the following methods to cope with the difficulties they encounter during the treatment: denial, suppression, crying, fatalistic approach, positive thinking, getting social support, turning to religion, taking up a hobby, setting priorities in life, acquiring information and rearranging their lifestyles.
"I sense the disease is taking things away from me. But I still haven't accepted the disease." (MÇ) "I cried a lot, but I managed to continue my life too. I was sad, but I continued." (ÜS) "Disease is something that comes from God. There exists death. We're all gonna die someday." (ŞB) "I'm reasoning the event out on my own. I say it is nothing. I'll overcome this too. I'm telling these to myself. I mean, the key to achievement, of course, is in your own hands." (MÇ) "

Disease related factors
The participants regarded high breast cancer survival rates as a protective factor in the disease-fighting process.
"As long as you take care of yourself, no deaths from breast cancer will occur. That's why I'm telling myself I'm fine and I'll be fine." (SY)

Treatment related factors
The participants regarded breast-conserving surgery, the positive response to the treatment and the positive approach displayed by the health care team as protective factors.
"I just heard my test results are good. After getting these results, having nice talks with the doctors makes me feel better." (MC) "My breast was not completely removed. That's why I'm psychologically more comfortable." (SY)

Relationships with nurses
During the interviews, the women indicated the relationship with the nurses during the treatment period as a facilitating factor in coping with the disease. The participants expect nurses to be helpful and friendly.
"The nurses are performing our treatments; they show us where to go" (E.Ö) "Nurses are very supportive, they say you're gonna be well again, they give morale. They give us our medicines; they say "good morning; they talk to us." (FK) I expect attentiveness and a smiling face from them. I don't expect anything else." (ÇD)

Discussion
In this study, two main themes were determined: adjustment and facilitating coping factors. The adjustment theme has two sub-themes: strains and coping. The women participating in the study suffered physical, psychological, social and system-related strains. These findings account for the women's needs related to these four areas.
The participants stated that they were adversely affected due to the side effects of chemotherapy. Women with breast cancer suffer physical symptoms such as changes in taste, alopecia, nausea, vomiting, mucositis and fatigue due to chemotherapy (Stein et al., 2003). These side effects can lead to psychological problems which affect the patient's activities of daily living (Erci and Karabulut, 2007). In addition to the psychological distress caused by being diagnosed cancer, chemotherapy-related side effects cause psychological distress too. Psychological strains suffered by women with breast cancer most are uncertainty, fear of cancer recurrence, negatively affected body image, loneliness, anger and sadness. These findings are similar to the findings the literature. It has been indicated that cancer diagnosis and treatment cause the following psychological problems in women with breast cancer: anxiety, depression, anger, uncertainty about the future, fear of cancer recurrence, body image distortion, fear of losing female identity (Doumit et al., 2010;Denieffe and Gooney, 2011;Cebeci et al., 2012). In the literature, uncertainty and fear of recurrence are stated to be the most challenging experiences that women with breast cancer have in the process of diagnosis and treatment of the disease (Landmark et al., 2001;Doumit et al., 2010;Elmir et al., 2010). In our study too, women with breast cancer experienced problems such as uncertainty about the future and fear of cancer recurrence intensely. In their qualitative study of women with breast cancer, Doumit et al. (2010) determined that fear of cancer recurrence and changing body image had a negative impact on patient's coping with the disease.
This study also determined that women with breast cancer suffered social strain as well. Women with breast cancer have trouble in the family and move away from social environments. It is reported women with breast cancer are not sure how people around them would react to their illness; therefore, they do not share the disease and stay away from social environments (Brede, 1999;Louma and Hakamies-Blomqvist, 2004). In our study too, patients stay away from social environments not to hear questions of curious people or due to changes in their appearances. In Turkish society, familial and neighborly relationships are very strong. These relationships might be supporting, but on the other hand, they might lead to such problems as curiosity about and/or interfering in someone else's life. This leads to difficulties arising from the environment.
In a study of women with breast cancer conducted by Remmers et al. (2010), it was reported that especially those with small children or those who have family members who need care worried about their family members rather than about themselves. In our study too, it was determined that patients had difficulties in their family lives. In a Turkish family, women play an important role in ensuring and maintaining family functioning. Turkish women are responsible for the care of the children, all of the housework and the maintenance of intra-family relationships. Therefore, changes in the woman's health result in changes in the life of the whole family. It has been determined that women with breast cancer experience physical problems due to the disease and the treatment of the disease and that these physical problems affect them both psychologically and socially. Therefore, it is very important for health professionals to holistically evaluate women with breast cancer and to be aware of the fact that changes occurring in one area of their lives can affect the other areas of their lives as well.
Difficulties experienced by women with breast cancer are not limited to disease-and treatment-related difficulties. Patients have problems such as obtaining treatment, reaching physicians and struggling with bureaucratic barriers. According to the results of a review regarding women living in rural regions by Bettencourt et al. (2007), women with breast cancer experience problems of transportation and accommodation. In addition, patients are negatively affected because they cannot adequately communicate with physicians and have to wait for a long time to receive the test results. In a study of women with breast cancer by Remmers et al. (2010), patients stated that they needed a friendly environment all over the hospital so that they could feel comfortable. System-related problems increase stressors in women with breast cancer who have already been suffering from depressive experiences, which affects them physiologically and psychologically too.
Another sub-theme of the adjustment main theme of the study is coping. Women with breast cancer struggle to cope with the strains they suffer. It was determined that patients resort to positive thinking, social support, turning to religion, taking up a hobby, setting priorities in life, acquiring information and rearranging their lifestyles for coping. It has been determined that Iranian Muslim women tend to involve in religious activities such as reading the Qur'an more after being diagnosed breast cancer. In addition, women with breast cancer reported that believing in that "diseases come from God" relieved them (Taleghani et al., 2008). In a study conducted by Cebeci et al. (2012), it was found that after having cancer, women experienced positive changes in their lives and their perspectives of the world changed. Women with breast cancer reported that they clung to life more than they did before the diagnosis and treatment process and that life became more valuable for them. The process of diagnosis and treatment of breast cancer causes a traumatic effect on individuals. After this experience, many changes occur in individuals. The meaning they attribute to life and priorities in their lives may change (Landmark et al., 2001). Tedeschi and Calhoun (2004) define this as post-traumatic growth. Post-traumatic growth can be defined as "positive psychological changes experienced as a result of struggle with highly challenging life circumstances" (Tedeschi and Calhoun, 2004). Major domains of posttraumatic growth are: greater appreciation of life and changed sense of priorities, warmer, more intimate relationship with others, a greater sense of personal strength, recognition of new possibilities or paths for one's life and spiritual development (Tedeschi and Calhoun, 2004). Women with breast cancer tend to consider materialistic factors less important after experiencing the disease. While the importance attributed to the demands of everyday life diminishes, developing better relationships with their relatives and friends becomes more and more important.
Another main theme of the study is the factors affecting coping. This main theme has four sub-themes: social support, disease-related factors, treatment-related factors and relationships with nurses. The majority of women with breast cancer participating in the study indicated that social support was the most important factor for their coping with the disease. While those who had adequate social support stated that they were able to cope with the disease better, those who did not have adequate social support stated that this lack of social support made their coping harder. The participants of the study stated that they wanted to survive for the sake of their children and that having children motivated them to fight the disease. These findings support the findings of other studies indicating that the positive family support plays an important role in coping with breast cancer. In the literature too, it is indicated that social support received from the family and friends during the healing process is of great importance for women with breast cancer. It is stated that social support is an important factor that facilitates coping (Connell et al., 2006). In a study evaluating hopelessness levels of women with breast cancer, it was determined that women receiving social support had a lower level of hopelessness (Öztunç et. al., 2013). In a study carried out by Doumit et al. (2010), positive support from family and colleagues was indicated to be one of the factors that help women with breast cancer to cope with the disease better. In their study of women with breast cancer, Henderson et al. (2003) pointed out that support from the family and/or spouse was a facilitating coping factor, but not in all cases. In their study investigating the experiences of women with breast cancer, Cebeci et al. (2012) stated that all the participants of their study received physical, psychological and social support from their families and emphasized the importance of the family in Turkish society. In Turkish family structure, social support is of great importance. A patient's needs are met by the other family members. On the other hand, some participants, though not many, stated that they did not receive adequate social support. However, most of the women stated that the other members of the family fulfilled the responsibilities they were not able to do due to the disease. Families support the women with breast cancer not only by performing their roles but also by motivating them psychologically, which makes it easier for the women with breast cancer to cope with the disease better.
Disease-and treatment-related factors make it easier for women with breast cancer to cope with the disease too. In this study, it was determined that women with breast cancer perceived breast cancer more positively than they did other types of cancer. Although the incidence of breast cancer is high, women's survival time has prolonged in recent years thanks to effective treatment methods. A review of survival rates of different cancer types unique to women reveals that the highest survival rate (40%) is among women with breast cancer (Knobf, 2007). This situation has widespread media coverage and the survival rate is known to be high, which reduce women's negative perceptions of breast cancer diagnosis. The participants considered undergoing breast-conserving surgery or removal of their breasts as a facilitating coping factor. In their study conducted to evaluate the impact of the type of the breast surgery on women with breast cancer, Önen-Sertöz et al. (2004) determined that total mastectomy affected the women's perception of breast and self-esteem negatively. Furthermore, half of the women who underwent total mastectomy said that they would have preferred breast-conserving surgery if they had had another opportunity. Changes in the body image occurring after mastectomy may be an additional stressor for the patient in the treatment of the disease, which itself is already difficult. Therefore, it is thought that surgeries like breast-conserving surgery do not create stressors for women and facilitate their coping with the disease. These results suggest that recent developments in breast cancer treatment have changed breast cancer women's perception of the disease.
The relationship between nurses and women with breast cancer was determined to be one of the factors that facilitate these women's coping with cancer. Women with breast cancer expect to get sympathy and a smiling face from nurses. These results are similar to those of the studies carried out in Turkey. However, studies conducted especially in Western countries indicate that breast cancer women's expectations of nurses have increased. According to women in Turkey, if nurses are smiling this would be enough, but in western countries, nurses are expected to be professionally competent too. In a study of women with breast cancer by Remmers et al. (2010), patients expected nurses to stand by them in their hard times, to give them emotional support and to have professional competence. Gilbert et al. (2010) evaluated positive and negative interactions between health professionals and relatives of cancer patients. As a result, of the health personnel, those who are warm, courteous, accessible and approachable and make patients feel relaxed are considered to interact with patients positively. On the other hand, patients do not have good perception of health personnel who do not empathize with them well enough or do not give enough information on the management of cancer. In our study too, patients indicated that nurses' friendly approaches relieved them. In order for women with breast cancer to talk about their needs freely, nurses are required to establish a friendly and reliable environment. Unless this environment is established, patients will not share their fears and sex-related problems with nurses. Özsoy and Özgür (2007) reviewed the literature in order to investigate the studies carried out in Turkey on women's expectations of nurses. As a result, they determined that women expect nurses to be smiling, understanding, affectionate, courteous, and helpful. On the other hand, it was determined that nurses' professional competence was not among the women's expectations of nurses. This suggests that if nurses establish a positive relationship with women this would content women. However, this fact, in other words, Turkish people's only expectation of nurses is their establishing a positive relationship with patients but no professional effort, is worrisome. For women, nurses' displaying a humanistic approach is good enough. This may be related to the society's perception of the nursing profession.Since women do not know much about roles and functions of nurses, they do not have any expectations regarding care.
The results of this study are expected to shed light both on giving effective culture-specific nursing care and on cross-cultural comparison studies. Although there are changes in the treatment of breast cancer, women with breast cancer still have difficulty in every area of their lives over the course of the disease and treatment. Therefore, nurses should provide holistic care and be aware of patients' strains. Besides being supportive, nurses should have enough knowledge about how to teach ways of coping with the disease and how to spiritually (psychologically) strengthen women with breast cancer. Nurses should be aware of the importance of information for women with breast cancer, should give them the opportunity to ask questions freely and should plan the training programs in line with the information needs of women with breast cancer. Nurses should also provide information, skills, and support that the other family members need.
Since family support is very important in Turkish culture, patients' relatives should be informed and supported at every stage of the treatment. The results of this study demonstrated once again the importance of dealing with women and their family together. It is considered that conducting studies on the experiences of relatives of women with breast cancer in the future would be beneficial.