Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserv.docx

Copyright B 2016 Wolters Kluwer Health, Inc. All rights
reserved.
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
Copyright © 2016 Wolters Kluwer Health, Inc. All rights
reserved.
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
reserved.
https://experience.23
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
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
a
Labor T1c N0 M0 I CEF � 6
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
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
a
Labor T2 N1 M0 IIB AC � 4
19 56 Married Taoism Housewife T4 N2 M1 IV CEF
b � 4
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).
reserved.
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.

reserved.
https://study.29
https://saturated.28
https://analysis.25
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)
reserved.
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.

reserved.
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
reserved.
https://relapse.34
https://therapy.33
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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