1. Introduction
Breast cancer is the most common malignancy, and the leading cause of cancer-related death among women. Approximately 2.1 million women have been diagnosed with breast cancer worldwide, and more than 600,000 died in 2018 [
1]. In Spain, it accounted for nearly 28% of new female carcinomas in 2015 [
2].
Cancer has its own connotations in human beings, affecting patients and their families, as well as those health professionals involved in their care, and the population in general, who wish to be free of it [
3].
In women with breast cancer, the quality of life varies according to the treatments followed [
4], their psychological characteristics [
5], and the efficacy of the psychological interventions implemented [
6,
7], among others. Despite the importance of these factors, the emotional dimension of this disease and its influence on treatment and recovery are not a priority in the existing studies. Among those psychological and social responses that cancer patients experience, anxiety, depression, lack of energy and sexual dysfunctions are frequently mentioned, as well as loneliness and problems at work [
8,
9,
10,
11,
12]. Moreover, the breast is an organ with an enormous cultural, psychological, sexual and affective influence, as it is one of the physical elements of women’s sexuality [
13]. Fatigue is also a common and distressing symptom that may influence the performance of daily life activities and persist once breast cancer has been overcome. This is a multidimensional symptom that affects physical and mental states, as well as decreases motivation in breast cancer women [
14].
To achieve a holistic approach to the treatment of breast cancer women, it is essential to work out the perceived emotions in these patients, to provide them with coping strategies. Nurses play an essential role in caring for and supporting these patients, as there is no clear support from other institutions or adequate financial support. Although several organizations or associations may be involved in the care of these patients, most of them do so on a voluntary rather than professional basis [
15]. On the other hand, it should also be noted that one of the most pressing concerns for those patients who have overcome breast cancer is their successful return to work after treatment, taking into account their difficulties related to the physical appearance and, of much more importance for them, to their psychological and emotional problems [
16].
Consequently, given the lack of information on the emotional dimension in breast cancer survivors, we have conducted a qualitative study to characterize their feelings and fears, and to evaluate if focus groups help women to cope with breast cancer. Thus, the aim of this study was to assess if taking part in focus groups and expressing emotions is useful to define the emotional state of women and to facilitate coping with the stress related to breast cancer, as well as to identify their main concerns and implications for future psychological intervention guidelines when treating them. The research question guiding this study was as follows: “Are focus groups useful for nurses both as a method to obtain information about the emotional state of women with breast cancer, and to develop coping strategies with them?”.
4. Discussion
Focus groups were chosen to carry out this study, as we were working with women in which breast cancer diagnosis and treatment had changed their routine and habits, triggering a deeply disturbing situation [
27]. Their needs’ satisfaction had been threatened, causing physical, psychological and social strains that their organism tried to delete by starting a set of physiological, cognitive, emotional and social reactions to adapt themselves to this new situation [
28]. In this sense, focus groups help people to express and clarify their feelings and points of view through group interaction that are unlikely to occur with other methods, such as questionnaires or one-to-one interview [
29]. We have observed that women had implemented defense mechanisms, such as denial, rationalization or projection [
30]. Some of them had had difficulties in coping with all the changes; others decided to face the new situation by using those resources they had previously. Finally, only a few women learned to use new coping resources, emerging stronger from their disease.
Although several factors have been extensively studied in breast cancer, such as tumor types and prognosis, risk factors, symptomatology, diagnosis or treatment possibilities, the same interest has not been shown for the emotional world, especially after diagnosis or during the time of recovery [
31,
32]. In our study, most women reported medical reviews as one of the moments of greatest uncertainty, and the longer the interval between two check-ups, the less control they felt over their own health. However, other authors [
33] described that the most stressful moment for breast cancer women was the period of time between diagnosis and the surgical intervention. Regardless of the most frustrating moment, it is clear that certain negative emotions associated with breast cancer are sustained for a long time after treatment completion (several months or even years). Many patients described having anxiety, fear of recurrence and feelings of loneliness, as well as social, physical, labor or sexual problems. They remained concerned about breast cancer even when the cancer had completely disappeared, probably because of the uncertainty of recurrence [
34]. Thus, treatment completion does not imply the end of the adaptation process, but that it continues throughout the follow-up phase. In our study, a large number of women decided not to express their emotions to avoid harming their immediate social environment [
35]. A high incidence of a potential repressive style in breast cancer survivors was also observed [
36].
Regarding coping strategies and the relationship between cognitions, behaviors and emotional answers, we have observed, as other authors [
37], that women had emotional control mechanisms to counteract the discomfort caused by an unpleasant emotion. In our study, most women carried out a repressive coping style and they tried to control each answer of a negative emotion, triggering a huge discordance among the physiological, cognitive and motor response systems. Consequently, a significant percentage of women expressed depressive or anxiety feelings. Depression and anxiety have also been reported in breast cancer women after diagnosis, as well as maladaptive reactions, affective inhibitions and high levels of psychological stress and anger [
38].
In a previous study [
39], we have observed, on the one hand, that breast cancer survivors show different patterns of long-term emotional needs and, on the other one, that psychological therapeutic interventions should be maintained in many patients over time, even after treatment completion. In the current study, we have tried to apply our results to women’s recovery. Other authors [
40,
41] have assessed the repressive coping style, or the existence of depression or anxiety, and their influence in the development of cancer, but they did not evaluate how these coping styles affect patient recovery. Focus groups have allowed us to verify that the coping style chosen by each woman may determine the recovery from their disease; if women choose a positive coping style, they may develop their emotional abilities to overcome breast cancer. By contrast, if a repressive coping style is carried out, women greatly limit their emotional tools, becoming dependent on external actions, and preventing their body from evolving towards full recovery.
Our final aim was to establish the most appropriate psychological intervention guidelines when treating these women. They do not only need treatment at a medical level, but also at a psychological one, taking into account the emotional state in which they are at a certain moment [
42]. Several factors, such as genetic background, initial general condition or previous relationship with cancer, can alter their emotional answers to breast cancer. Thus, any psychological intervention may be individualized [
43]. As Levkovich
et al. reported [
44], we have observed that diagnosis and treatment are accompanied by psychosocial problems in a large number of patients. In addition, healthcare systems overestimate technical procedures instead of using empathy, which should be present in any healthcare professional [
45]. Although a multidisciplinary team should treat these women (doctors, psycho-oncologists, psychologists, nurses and nursing assistants), nurses play an essential supporting role for these women, as they are those healthcare professionals who spend more time with these patients. On the other hand, the nursing task should be addressed not only to patients but also to their relatives, trying to recognize their particular needs [
46]. Thus, these tasks can be summarized by the following three points:
Providing care to patients from a more humanistic point of view, also including their relatives.
Ensuring that they have a high quality of life, in spite of breast cancer.
Reducing the impact of hospital dynamics on people that are not used to health services.
Any breast cancer patient is susceptible to receive emotional supportive therapy by nurses, facilitating the expression of emotions and teaching the patient how to handle the problems associated with cancer [
42]. Once emotional needs are identified, interventions should include the following [
28]:
Providing information to patients and families about their emotional state.
Explaining them the best ways to share and show feelings within the family sphere.
Teaching the patient how to detect negative feelings and handle them through emotional self-control techniques.
To be effective, these interventions should be carried out within a dynamic and progressive training program, from the most basic behaviors to the expression of feelings [
6]. Regarding coping strategies and adaptation, a new assessment should be carried out, which should include the following [
12]:
Patient perception about themselves, their disease and mood.
Coping resources, such as health resources, social and problem-solving skills, social support, economic and personal resources, and their relationship with healthcare personnel.
Patient’s ability to overcome breast cancer.
Physical and emotional signs of stress.
Healthcare professionals may help survivors to identify all those reactions they have in certain situations of their disease. Once aware of them, women will be able to recognize these stressful stimuli. The second intervention may be aimed at managing these negative stimuli. Then, women should learn how to correct or adapt themselves to these stimuli as healthy as possible. Patients should be taught that stressful stimuli can be controlled, but not eliminated in a radical way. Once addressed these objectives, health professionals can talk about the adaptive responses, as survivors have to learn and develop effective mechanisms for any situation triggered by the disease.
Breast cancer diagnosis and treatment are an important source of stress that triggers a wide variety of adaptation problems. Medical success is also related to the affective characteristics of patients, and the confidence generated by healthcare professionals is a powerful predictor for the evolution of the disease. Nurses are optimally positioned to address survivor specific emotional needs in order to develop proper emotional support programs. Focus groups may be a valuable tool for guiding the development of interventions by nurses. They may help women to express emotions and, subsequently, implement optimal coping strategies to improve their recovery.
The results of this study have implications for nursing practice. Therapeutic interventions performed by nurses should be carried out from the very moment of diagnosis and maintained and prolonged in time, in order to consolidate adaptive responses of a lasting nature. Health professionals cannot neglect that learning to handle emotions is essential to maintain and recover the quality of life in these patients [
6]. The current specialization of healthcare professionals has, as a disadvantage, the possibility of compromising care due to the emphasis given to the disease and not to the person. It is crucial that nursing protects, improves and preserves humanity in care. Focus groups are one of the most appropriate approaches to establish an effective professional–patient relationship, as they can provide major insights into patient opinions, attitudes and beliefs. The final goal would be to reduce negative emotions and achieve comprehensive and holistic care for breast cancer survivors.
Limitations
Our study has several limitations. As any qualitative study, the findings may be affected by the experience and perception of the research team, as well as the characteristics of the participants. Moreover, although focus groups yielded in-depth data that would not have been easily obtained by other methods, there may have been variations in the way that they were conducted by the researchers. On the other hand, self-reported data obtained through focus groups can rarely be verified, and may contain potential sources of bias. Finally, attribution or exaggeration bias may have occurred during the study.
