1. Introduction
Breast cancer is one of the most common causes of cancer-related deaths in women globally. It occurs when abnormal cells in the breast grow uncontrollably. It is more common among women; however, a small proportion of men also are affected by breast cancer [
1]. After diagnosis, some common treatments that Breast Cancer Survivors (BCS) receive are a lumpectomy, mastectomy, chemotherapy or hormone therapy [
2]. Due to the raised awareness and focus on early detection programs, survival is becoming increasingly likely for breast cancer patients [
3]. Within Australia, breast cancer in 2016 was the most common cancer affecting women, with 330 new cases per 100,000 people [
4]. Between 1987–1991 and 2012–2016, the five-year survival rate improved from 75% to 91%, increasing the number of survivors in the community [
4]. This is due to increased awareness campaigns and breast screening availability provided by companies, including BreastScreen Australia [
5]. BreastScreen Australia is the state and territory initiative of the Australian government to increase early detection and thus decrease illness and death. It allows women over 40 to have a free mammogram every two years [
6].
For BCS, common issues range from treatment side effects [
5], financial hardships [
7] and comorbidities [
8] to social isolation [
9]. Many studies have assessed the health related QOL of BCS [
5,
10,
11,
12]; however, there is limited research that focuses on Australian women who have survived cancer and continue to experience its detrimental effects. QOL and psychological distress are essential patient-centred outcomes, assisting with assessing cancer care delivery. BCS is a medical and social label for all who live with cancer diagnosis until death, irrespective of the cause [
13]. These BCS undergo considerable stress and trauma throughout diagnosis, treatment and post-treatment, which continues even after survival, subsequently impacting their QOL. The main factors identified in the literature as the significant causes of stress and trauma include psychological distress, financial stress and social isolation.
Studies have indicated that BCS experience mental health issues as soon as they are diagnosed with cancer, during treatment and survivorship. Two main concerns within psychological distress have been identified for BCS: mental health issues and distress surrounding cognitive function. One-fourth of breast cancer patients will develop anxiety and depression at some point in the breast cancer journey [
14]. Those aged younger than 50 years are especially likely to report psychological distress [
15,
16] compared to the older cohort aged > 50 years. However, it is also said that 12 months post-diagnosis, most BCS have returned to pre-diagnosis levels of distress [
17]. This discrepancy between studies highlights the importance of a study to outline mental health issues throughout the journey, rather than just certain checkpoints.
QOL is an individual’s perception of their position in life, in the context of the culture and value system they live within along with their goals, expectations, standards and concerns [
18]. It is clear from the review of the literature that various stressors have resulted in a reduction in QOL for BCS. Previous research on QOL has focused on understanding the QOL in the early phases of breast cancer and groups of older BCS [
10]. Most of these studies, however, focused on survivors 10 years post-diagnosis. The conclusions drawn were similar, with the participants reporting low QOL with additional sexuality, pain and psychological distress issues. This was illustrated in a quantitative study with BCS between the ages of 40 and 49, which found that the presence of breast-related symptoms at the time of survey completion had a profound impact on QOL [
5].
Within the literature, there is insufficient focus on the qualitative experience of Australian BCS from diagnosis to survivorship. Most of the literature available is based on quantitative studies, with limited research being available on the experiences of BCS. This research is an attempt to fill this gap. There has also been a focus on mental health and cognitive disorders such as struggles with depression and increased anxiety; However, there is a need for a greater understanding of the progression of these issues in Australian BCS throughout their entire BC journey.
This research aims to understand the journey undergone by BCS diagnosed with breast cancer from diagnosis to survivorship. Furthermore, it explores the challenges experienced by the BCS due to physical changes, financial hardship, emotional distress and social isolation The Australian healthcare system is unique due to the country’s cultural diversity and different demographics. Understanding the experience of specifically Australian women with breast cancer is essential, as it will allow healthcare providers to understand the experiences of BCS in greater depth within the cultural context. This, in turn, may help facilitate greater sensitivity when treating their patients and assist in developing strategies and policies for BCS.
This cross-sectional exploratory research is based on a qualitative research method. It aims to understand the journey undergone by women, diagnosed with breast cancer, from diagnosis to survivorship. Further, it explores the challenges experienced by the BCS due to physical change, financial hardship, emotional distress and social isolation.
2. Materials and Methods
Eligible participants were BCS; they were aged 35 years and above, living in Sydney and had been diagnosed for at least a year. A total of 15 women with breast cancer were recruited for the study. Participants were excluded if they had been diagnosed less than one year ago to ensure all participants had completed their treatment. Participants that were diagnosed greater than 11 years prior were also excluded as they may not clearly recollect their early experience of diagnosis. Multiple strategies were used to recruit participants including snowball and convenience sampling, social media and community organisation advertising. For example, through the assistance of the organisation Pink Hope, a preventative health charity, we acquired participants using flyers. Advertising on social media gained the most traction, with participants sharing and passing on information to other survivors. Before recruitment commenced, ethics approval was obtained from the University of Sydney Human Research Ethics Committee (25 August 2021). The participants were also presented with the “Participant Information Statement” to ensure the study had informed consent and that participation was entirely voluntary and anonymous. The data were also saved in OneDrive and password-protected, and only researchers had access. These in-depth interviews were conducted over 45 min with 15 BCS. The first author participated in two days of training prior to the interviews commencing.
This specific qualitative method was chosen to ensure that the full experience of BCS was explored effectively. In particular, QOL was measured subjectively rather than using established measurement tools. Quantitative measurement of QOL qualifies experience’s on a scale rather than exploring participants’ experiences which was important for this study. In the in-depth interviews, the interviewer led the BCS through a series of open-ended questions to establish the experience of breast cancer diagnosis, treatment and living with the diagnosis (
Appendix A). The interviews were conducted over 3 weeks in August and September 2021 and were recorded via Zoom. These in-depth interviews allow the participant to determine the direction of the interview and are, therefore, an effective method for an exploratory study [
19].
A thematic analysis was conducted by researchers on the interviews [
20]. Firstly, each interview was transcribed. An excel document was then prepared with each of the interview questions as titles. The responses from every participant relating to that question were then compiled for easy comparison. The first author then went through each response and highlighted common words and phrases used by the participants. These words and phrases were then grouped together to form the codes for each question. These codes were used to identify the common themes and to identify similarities between the BCS journeys.
4. Discussion
This study revealed that participants frequently reported psychological distress and a reduction in QOL. This aligns with the previous literature, where issues of financial hardships [
7], comorbidities [
8] and social isolation [
9] were reported. The most prevalent issues highlighted by these studies BCS were the harm of the side effects from post-treatment medication, anxiety around cancer recurrence and issues with health service utilisation.
Psychological distress is the emotional suffering associated with stressors and demands that are difficult to cope with daily. The results from this study illustrate that the significant points of psychological distress along the journey of BCS are receiving the diagnosis during treatment and, finally, the process of survivorship. The most commonly endorsed stressors include chemotherapy trauma (46%) and loss of identity (40%). The anxiety of reoccurrence was noted by all survivors, with three of the fifteen participants reporting that it no longer concerns them. The literature has observed that BCS levels of anxiety and depression decrease over time, which contradicts the findings of our study where it has increased [
21]. The increase in distress during the transition from active treatment aligns with qualitative and anecdotal studies [
22], whereas contradicting quantitative studies report a decrease in distress at this time [
23,
24]. There were three main events where psychological distress occurred for BCS. These included receiving the diagnosis, completing treatment and post treatment abandonment which have also been observed in other studies [
25,
26]. When diagnosed, participants went into a state of shock and experienced trauma responses. Four of the fifteen participants did, however, mention that their first instinct was to attack the problem pragmatically. The next source of distress was going through treatment, especially chemotherapy. Side effects such as losing hair and the feeling of helplessness were significant contributors to psychological distress. Finally, post-treatment feelings of abandonment by the healthcare system and the lack of direction also contributed to distress, which is supported by a growing body of evidence [
27,
28]. Here, it was evident that participants felt abandoned and struggled with not having any support networks to assist with the transition.
Participants’ QOL was explored by discussing how certain indicators, identified from the literature review, have impacted participants’ QOL. The significant concerns derived from these interviews were physical symptoms of BC, changes in support systems for BCS and poor body-image perception.
Poor body image is associated with mastectomies and breast reconstruction surgery [
11]. Although a smaller sample was used, this study supported those findings. Over half of the BCS reported a drop in self-esteem, feeling unattractive to partners and embarrassed by their breasts. There was a consensus amongst two of the BCS claiming to be unsatisfied with their reconstruction, often suggesting that they struggle with having or not having tattooed nipples. Survivors have reported sexual health concerns for up to 10 years post-treatment [
29]. In Pumo et al.’s (2012) study, sexual conditions that directly correlated to psychological disorders were prevalent in 36% of their participants [
30]. Within this study, sexual issues and complications such as dryness, pain and low libido to side effects of treatments were linked with medications rather than psychological disorders. There were also reports of participants’ embarrassment of how they look affecting their desire to be intimate with their partner.
Sleep and fatigue are both factors contributing to the reduction in QOL. Several BCS reported insomnia, trouble staying asleep and extreme fatigue throughout the day. There was a common trend of fatigue and sleep issues being more prevalent during treatment and then improving as time went on, supported in the literature [
31]. There was, however, a few BCS that reported persistent trouble sleeping and fatigue even years post-treatment. In Beck et al.’s 2010 study, this trend was also seen where some survivors continued to experience problems with sleep many years later [
32]. This constant fatigue has resulted in reducing the workability of survivors and the ability to spend time with families, which has led to a reduction in QOL.
Cognitive changes were linked to memory loss and reduced capacity for work for the majority of the study participants. Similar findings were reported in previous studies, where participants noticed language, memory, spatial ability and motor function changes [
33]. However, there was some discrepancy among participants regarding whether the medication, treatment or effects of ageing were causing the changes in cognition. Collins et al. (2009) discussed this phenomenon concerning hormonal therapies such as tamoxifen and anastrozole [
34]. It was concluded that hormonal therapies subtly have a negative influence on cognition. This aligned with our findings as the negative side effects of tamoxifen were mentioned by four of the fifteen participants and linked to their cognitive changes and other physical symptoms. There were also conversations linking these cognitive changes to stressors in the workplace, with BCS worrying that it would affect their performance. Similar findings were cited in Nelson and Sul’s (2013) study, which noted that the detrimental effects of reduced memory and learning impacted the workplace and function roles [
35].
The majority of participants were married and had children. This resulted in extensive conversations about relationship changes and social isolation. Most BCS reported that their husbands were highly supportive and a great help during this time. Only a minority mentioned relationship breakdowns and increased stress due to their partners. Multiple studies have illustrated the positive effect of supportive spousal relationships [
36,
37], which our study supports. Even with this support, many BCS still feel isolated post-treatment due to a lack of continued understanding of their experience from family and friends [
38] and continued side effects of medications. Perz et al. (2013) explored that the heightened fear of rejection experienced by BCS with potential partners causes survivors to isolate themselves even further [
39]. The single woman who participated in this study reported that they felt embarrassed by their breast appearance; however, this fear of rejection was not explicitly mentioned. There was also no mention of participants further isolating themselves as they sought out more connections via social networks, support groups and their own families. Those who had better support networks of friends, family and communities mentioned that going through treatment was easier with all the extra help, and thus they felt less isolated. When this community was not present, there were often reports of feeling helpless and overwhelmed by tasks. This is supported in the literature, where those who have strong relationships and communities to assist them felt protected from negative feelings such as depression, anxiety and the stigma of BC [
9,
36,
38].
The experience of using and accessing healthcare services was identified as a significant factor contributing to QOL. Within Australia, Medicare is the publicly funded universal health care insurance scheme that all Australians can access. In addition to this, private health coverage is also available to paying customers to cover the gaps in Medicare. These two services however still do not alleviate the entire financial burden of Breast Cancer treatments and services. Financial distress acted as a significant barrier to healthcare services for BCS [
40]. This result was expected because various studies outlined expensive costs and lack of coverage via Medicare and private health [
40]. The previous literature also outlined that breast cancer comorbidities would also be a barrier to returning to work [
41], which was also seen in this study. One central area discussed was the difficulties affording services post-treatment. Through the public and private health sectors, most women received some financial support.
In some cases, participants had to pick and choose the most needed services at a specific time rather than having access to all services that may improve their QOL. Although the majority did report that financially they were stable, all acknowledge the exorbitant costs of life-saving and life-enhancing treatments during survivorship. Breast reconstruction was a significant source of financial strain. It is not covered under Medicare, and as it is not considered a life-saving surgery, private health services often do not cover it.
Treatment and communication by staff within the healthcare system had a significant impact on survivors’ experience and distress. Four of the fifteen BCS reported at least one issue of switching practitioners or feeling like they were not being heard. One of the most considerable contributions to distress during diagnosis was the communication of medical staff about the severity and course of action for treatments. Participants also highlighted how their health was now in their own hands after treatment, and there was no transition phase. Many felt abandoned and isolated by the shift in control as well as being at a loss as to how to manage their symptoms into the future. Most participants continued to take medication after their treatments to prevent cancer recurrence. These medications, however, had harmful side effects that BCS have had to learn how to manage by themselves. This, paired with financial restrictions, has resulted in a reduction in QOL.
However, there are a few limitations of the study. The limitations of this study include social media and readiness bias. The effectiveness of social media recruitment resulted in a biased sample toward BCS who do not use or do not have access to social media. In addition, it also eliminates participants who are not yet ready to share their experiences as they are still dealing with the consequences of their disease.
5. Summary and Conclusions
Fifteen BCS were interviewed to understand their journey from pre-diagnosis to survivorship. The average participants were aged 35–45, had at least one child, were married and were Australian. The most common issues mentioned throughout this study were the lack of interventions for medication side effects, changes in their body image and anxiety around cancer reoccurrence. There were also many accounts of how physical side effects from treatments have impacted their work and social and sexual lives.
These findings are based on a qualitative study, with a small sample of 15 in-depth interviews; therefore, a generalisation of the study cannot be made. Due to the small number of participants and sampling error, there was also a lack of older participants from diverse backgrounds.
This study has provided a preliminary basis for the experience of BCS and can expanded on in a larger study using quantitative methods to assess QOL and psychological distress. These findings have implications for policymakers and for the healthcare industry along with the importance of a survivor’s relationship with their healthcare team and their ability to access services, which was especially highlighted. It would be our recommendation to focus future studies on the experience of BCS from ages 35 to 45 including their diagnosis. Future studies should also include BCS of culturally diverse groups and older age cohorts.
From this research, it is also clear that younger women should have access to free and convenient mammograms. Additionally, the experience of sexuality and early menopause is an area that needs to be examined to provide better services and support for survivors. Access to post-care services, links to support groups and information about medication side effects should be prioritised in order to increase survivors’ QOL.