Life experiences of women with breast cancer in south western Turkey:
A qualitative study
Fatma Cebecia,*, Hatice Balcı Yangına, Aysel Tekelib
aAntalya School of Health, Akdeniz University, 07058 Campus/Antalya, Turkey
bMedical Oncology, Akdeniz University Hospital, 07058 Campus/Antalya, Turkey
a b s t r a c t
Purpose: This qualitative study explores the experience of women living with breast cancer.
Methods: The study was conducted among eight women with ongoing breast cancer chemotherapy
treatment, which occurred in an ambulatory unit. The data were collected using semi-structured and in-
depth individual interviews. All interviews were tape-recorded, and the results were obtained by ana-
lysing the content of the recorded data.
Results: Three major themes related to the experiences of women living with breast cancer were iden-
tified. They are as follows: (1) needs (the need for spouse and family support, the need to worship, and
the need to receive and share information), (2) living with losses (loss of the breast and of one’s hair), and
(3) changes (changes in one’s normal life, change in self-perception, changes in the perception of the
value of health, and a greater appreciation for life).
Conclusions: This study was conducted to increase awareness concerning women’s perceptions of their
care and various needs during breast cancer treatment. The results of this study challenge health care
providers and educators to be more aware of the difficulties that women face when living with breast
? 2011 Elsevier Ltd. All rights reserved.
The burden of cancer in developing countries is growing and is
likely to be associated with heavy morbidity, mortality, and
economic costs in the next fewyears (Ngoma, 2006). The numberof
global cancer deaths is projected to increase by 45% from 2007 to
2030 (from 7.9 million to 11.5 million deaths), which is partially
influenced by the increasing number of ageing adults worldwide
(World Health Organisation, 2008). Breast cancer is still the most
common type of cancer among women. InTurkey, one of every four
cancers seen in women occurs in the breast (Tuncer, 2009). The
diagnosis of breast cancer is one that not only threatens a patient’s
life but also can impact every facet of the patient’s life.
In general, cancer is perceived to be a menacing illness. For
example, in Turkey, the mere diagnosis of cancer can be over-
whelming. Therefore, it is not unusual for the families and physi-
cians of cancer patients to both avoid using the word cancer or
telling patients that they have cancer. Due to the relatively high
cure rates associated with breast cancer, this pattern is slowly
changing, although the powerful emotional responses to the
diagnosis of cancer have not changed significantly, assessed by this
author’s personal experience and personal communications with
nurses and physicians who work with this patient population as
well as Turkish families. The diagnosis and treatment of breast
cancer affects numerous dimensions of a woman’s life, including
physical, psychological, social and spiritual. Furthermore, although
breast cancer has a relatively favourable five-year survival rate
(75%) in comparison to other cancers (Çavdar, 2006), breast cancer
treatment can reduce quality of life (Hocao? glu et al., 2007;
Hacialio? glu et al., 2010).
Addressing the needs of cancer patients who have other prob-
lems that they must address while also receiving breast cancer
treatment is vitally important. Traditionally, oncology units were
among the least favoured places for nurses to work inTurkey. Many
general nurses have reported not wanting to work with cancer
patientsdue totheir negative viewof canceras a terminalcondition
in addition to the comparative lack of support in general for clinical
nurses in Turkey (Platin, 2010). Turkey is a developing country, and
new health politics are consistently being implemented. In April of
2011, the Turkish Ministry of Health published nursing regulations
that addressed the duties, powers and responsibilities of oncology
nurses (Official Gazete No: 27910). Laws in Turkey require that
* Corresponding author. Tel.: þ90 (242) 3106117; fax: þ90 (242) 2261469.
E-mail address: email@example.com (F. Cebeci).
Contents lists available at SciVerse ScienceDirect
European Journal of Oncology Nursing
journal homepage: www.elsevier.com/locate/ejon
1462-3889/$ e see front matter ? 2011 Elsevier Ltd. All rights reserved.
European Journal of Oncology Nursing 16 (2012) 406e412
nurses are to prepare and administer medications (Baykal et al.,
Perceptions of cancer, which are culturally dependent, appear to
influence psychological adjustment in a very differential manner.
People in Turkish society tend to have a fatalist approach to life
events due to their religious beliefs. An important subject is the
relative modesty of women and the view that the breast is an
intimate organ. Exploring the body (especially the breast) in
women may bring about defensive and protective thoughts and
behaviour, especially among Muslims in Turkish society. Muslim
society on the whole reinforces extreme modesty in women (Avcı,
Invarious societies as well as inTurkey, thewoman’s breast is an
essential part of a woman’s identity as it plays a crucial role in
women’s feelings concerning their femininity, their sexuality, their
aesthetic appearance, and their capacity for nurturing and moth-
erhood.. Thus, the diagnosis of breast cancer is often perceived as
a threat not only to a woman’s life but also to her sense of femi-
ninity (Çavdar, 2006; Bostancı Dastan and Buzlu, 2010). Breast
cancer creates an emotional crisis for both patients and their
families (Hocao? glu et al., 2007; Okanlı and Ekinci, 2008; Julkunen
et al., 2009). Patients and their families may first experience fear
concerning the death of their loved one after the diagnosis of breast
cancer. Fears then expand to include fear of disease metastasis and
uncertainty concerning the future (Berterö and Chamberlain
Wilmoth, 2007; Remmers et al., 2010). Breast cancer also affects
functioning of the family function because the distribution of roles
and relationships within the family are dramatically changed.
Specifically, women diagnosed with breast cancer experience
changes in their family, work and social roles as well as physical
changes (Hocao? glu et al., 2007; Okanlı and Ekinci, 2008; Julkunen
et al., 2009). In addition, the intensive, long-term treatments and
therapies administered during cancer treatment can illicit aversive
side effects, including fatigue, pain, nausea and vomiting and
hormonal changes, all of which affect a woman’s daily life and can
result in various psychosocial problems (Vargens and Berterö,
2007; Erci and Karabulut, 2007).
Family is an important social support for patients coping with
problems stemming from a cancer diagnosis. The family unit is
extremely important in traditional Turkish culture; thus, Turkish
families are strongly affected by changes in family structure. In
Turkish culture, all family members support each other, both in the
has an illness (Erci and Karabulut, 2007; Hacıalio? glu et al., 2010).
Every aspect of a woman’s life is affected during breast cancer
treatment (Berterö and Chamberlain Wilmoth, 2007). The specific
impact of the diagnosis on a woman’s life can be determined using
qualitative studies, which are most appropriately used to deter-
mine individuals’ feelings, interactions, perceptions, and behav-
iours as well as to specify the particular changes that occur
(Streubert and Carpenter, 1999). There have been many published
qualitative studies in the breast cancer literature that have docu-
mented themes common to the majority of participants, including
changes in body image and sexuality (Takahashi and Kai, 2005;
Cebeci et al., 2010); sentinel experiences from the initial diag-
nosis (Gurm et al., 2008); psychological/physical impacts of cancer
(Vargens and Berterö, 2007); communication with professionals
(Gysels et al., 2004; Beaver and Witham, 2007), family and friends
(Westman et al., 2005; Wimberly et al., 2005; Howard et al., 2007;
Erci and Karabulut, 2007); and experiences of living with breast
cancer (Vargens and Berterö, 2007; Howard et al., 2007; Doumit
et al., 2010). The current study will contribute significantly to the
breast cancer literature by exploring the experiences of Turkish
women living with breast cancer. To date, there are no qualitative
studies in the Turkish literature that have explored the experiences
of women with breast cancer. Therefore, in this qualitative study,
we obtained information concerning the experiences of this pop-
ulation with the aim of using that information to assist in coun-
selling women currently receiving breast cancer treatment and
their spouses, thus enhancing their quality of life.
This study was performed qualitatively to examine the experi-
ences of women with breast cancer.
Participants, setting and sample
Participants were chosen based on purposive sampling and
saturation principles using the following inclusion criteria: 1)
ability to speak Turkish, understand questions, and express one’s
own opinions; 2) diagnosis of breast cancer for at least one year;
3) lack of metastasis or another type of cancer; 4) married status;
and 5) absence of psychiatric disease (or history of psychiatric
This study was conducted with women whose breast cancer
treatments were ongoing in the ambulatory chemotherapy unit of
the Medical Oncology Discipline at Akdeniz University Hospital.
Written permission was obtained from local authorities,
including the institutional clinical review committee, prior to
commencement of the study. In addition, the researchers obtained
informed consent from the women. Based on the right to privacy,
patients have the right to the anonymity and the right to know that
the data collected will be kept confidential. Therefore, patients
were assured that all materials collected would be handled in the
strictest of confidence and that their anonymity would be guar-
anteed. Thus, we have used pseudonyms when presenting their
comments and remarks. Following the in-depth interviews,
researchers were available to the participants to provide additional
health counselling if required.
The interview process
The data were collected using semi-structured and in-depth
individual interviews. All interviews were audiotape-recorded. In-
depth individual interviews were performed in an isolated roomfor
the participants’ comfort and safety. Data were obtained using
descriptive and semi-structured interview forms. These forms were
prepared by the researchers after completing an extensive review
of the literature (Streubert and Carpenter, 1999; Graneheim and
Lundman, 2004; Westman et al., 2005; Takahashi and Kai, 2005;
Howard et al., 2007; Vargens and Berterö, 2007; Gurm et al.,
2008; Berterö and Chamberlain Wilmoth, 2007).
The semi-structured interview form was composed of open-
ended questions in accordance with the qualitative nature of the
study. This form consisted of two parts: an introduction and the
interview. The introduction section began with questions such as
"how do you feel about yourself?”; in addition, each participant
was asked the following questions:
“What kinds of changes has your disease broughtinto your life?”
“How have breast cancer treatments affected your life?”
To avoid bias in the research methods, in-depth individual
interviews were conducted using two researchers (HBY and FC).
Probing questions were asked during the interviews to obtain
maximum variation, richness, and depth of responses. The inter-
views lasted between one and two hours. Further questions were
F. Cebeci et al. / European Journal of Oncology Nursing 16 (2012) 406e412
used to clarify or elaborate on the responses of the participants. The
descriptive questionnaire form, which asked questions concerning
the demographic information of the individuals and their past
medical background, was completed after the semi-structured
The audiotape-recorded interviews were transcribed and
subsequently combined with notes taken during the interview. The
interview transcripts were documented in Microsoft Word, and the
raw data underwent a close reading and were then categorised. All
interviews were transcribed verbatim. Data analysis of the tran-
scripts was accomplished using the process outlined below, which
was based on Graneheim and Lundman’s (2004) techniques for
extracting themes in qualitative data:
1 The interviews were read through several times to understand
their larger content.
2 The text within each content area was divided into meaning
units, each of which was comprised of several words, senten-
ces, or paragraphs containing factors related to each other via
their content and context.
3 The meaning units were condensed, while preserving their
core intent, and labelled with a code.
4 The codes were interpreted and compared for differences and
similarities, and 17 tentative sub-themes were abstracted. Sub-
themes are threads of meaning running through a particular
portion of an interview. Although these descriptions point to
a linear process, it is important to remember that the analysis
process involves a back and forth movement between the
whole text and its individual parts. Using a process of reflection
and discussion, the authors agreed on a set of nine sub-themes.
5 Finally, the three themes that unified the content in the sub-
themes were determined. The sub-themes and themes
revealed during the analysis are shown in Fig. 1.
To increase the validity of the data, the statements of the
participants were encoded by the three authors separately. The
codes were compared, and the differences were discussed and re-
evaluated until shared codes and categories were created
(Graneheim and Lundman, 2004).
The sampling consisted of eight females between 30 and 47 years
old, with a mean age of 37.5 years old. Participants’ periods of
experience with breast cancer ranged from fourteen months to four
four participants had modified radical mastectomy, and two partici-
pants endured partial mastectomy of one breast. All participants had
children. The participants’ educational backgrounds varied between
illiterate (1), elementary (3), high school (3) and university (1).
The aim of this study was to reveal the experiences that women
with breast cancer experienced during treatment. Notably, the
participants experienced difficulties in using the word cancer
directly. The participants used indirect expressions, such as “it,”
“mass” “lymph,” and “this disease,” instead of using the word
“cancer. “.I am ill.It is always on my mind. There is no way to get
rid of it”. (Çi? gdem).
Moreover, in this study, we observed that women had a specific
cultural belief concerning surgical operations in general such that
when the knife touches your body, you are no longer a totally
healthy person. “You cannot perceive yourself as a complete body
after the surgery.” (Emine).
Spouse and family support
All participants reported that they received physical, emotional
and social support from their families (spouse, mother, sister(s),
daughter(s), and father) during the diagnosis and treatment of their
breast cancer. One of the participants stated that their family’s bond
even increased: “My family and I huddled together, we became
integrated after I got sick. my family fulfilled all my needs . took me
to the hospital in their arms . tried to raise my morale .” (Zeynep).
In addition, the participants stated that they needed support,
saying “. you want anyone to help you.you want everybody to take
care of you .” (Gülay).
All participants stated that they could not perform their normal
activities and received support from their families during the post-
operative period as well as during chemotherapy and radiotherapy
treatments. Participants described this support as follows: “the first
month after surgery . you fall so easily in the first ten days of
receiving chemotherapy.you cannot even move a spoon to your
mouth, your hands shake . you cannot walk . cannot even go to the
toilet. Your spouse, child, brother or mother must do everything for
you” (Nejla), and “myarm looked shortened due to the mastectomy .
I have difficulty while dressing and undressing . my daughter still
bathes me .” (Emine).
All of the participants reported that they had experienced
sadness and crying due to the hair loss related to their cancer
They also expressed that their family members supported them
during this period. Participants described the support in the
following way: “. my husband, my daughter, my mother supported
my feelings the whole night, hugged each other and cried together
.”(Çi? gdem) and “. my husband was very supportive of me . he
wiped my tears when I was crying . he came and kissed me” (Elmas).
Two participants who had a history of marital discord prior to
the diagnosis of breast cancer reported that they did not receive
emotional support from their spouses. One of the participants
stated this in the following way: “. I was thinking that my husband
would take care of me and treat me well because I had a risky disease,
but it did not happen .. my mother, my father, and my brother took
care of me instead .” (Tenzile).
All participants reported that an increase in their worshipping
needs occurred after receiving the diagnosis of breast cancer. The
Spouse and family support
Receiving and sharing of information
Living with Losses
Change in daily routine
Change in self-perception
Understanding the value of health
Greater appreciation of life
Fig. 1. Sub-themes and themes revealed during the analysis.
F. Cebeci et al. / European Journal of Oncology Nursing 16 (2012) 406e412
belief was that the disease was “something coming from God ..,”;
thus, the idea that it was their fate to develop breast cancer was
common. This situation was expressed as “the disease came from
God . the effect of treatment worked only if God allowed it, so there
was nothing else to do but pray ...” (Emine).
All of the participants in the study were Muslim, and all of the
women tried to get rid of the disease and to relax by worshipping in
accordance with the Islamic faith (e.g., praying to God, reading the
Quran, and counting beads). Participants expressed this in the
following ways: “. worshipping was good for my body, healing my
disease, and easing me .” (Gülay) and “. reading the Quran, per-
forming salaat . and counting beads gave me strength and happi-
Receiving and sharing of information
All of the participants reported that they had not been informed
to do breast self-examination (BSE). Almost half (3 females) stated
that they had actually not been informed about the diagnosis. Two
of them stated that nobody informed them about what to do in the
post-mastectomy period Participants mentioned that they had
gathered some information from other patients.
In describing this situation, the participants reported that “. if
someone had instructed me in how to do a BSE, I would have done that;
chemotherapy and radiation treatments. They said a mass was the
same thing as cancer .” (Elmas), and “I did not know what to do after
thesurgery, what to feel, how to use myarmonthe side where thelump
was removed . I learned it from people around me .” (Çi? gdem).
In addition, all of the participants stated that they did not want
anyoneelse tosuffer frombreast cancerand did their best toinform
others about the disease. One of the participants described their
desire to share information in the following way: “I hope nobody
suffers the same pain I have suffered . so I advise everyone to do
breast self-examinations and see a doctor .” (Elmas).
Living with losses
All participants described their most significant losses during
breast cancer treatment as that of losing their hair and their breast.
Living with the loss of breast
All of the women in this study described the breast as “very
important for women and one of the most essential features of being
a woman.” One participant reported that “. when it (the breast) is
gone, you feel that your femininity is gone and that you are useless as
a woman .” (Elmas). Thus, the loss of a breast was the most
demoralising and destructive loss for women (i.e., participants
reported that the most demoralising and devastating loss was the
Participants reported that after breast surgery, “when the sutures
were removed, I touched my breast . it was as smooth as wood . I
felt such a bad loss that. it felt very big, very bad ." (Emine) and
"when I went home after the surgery . I did not want to see my breast
. I broke all the mirrors . I did not go out of the house . the world
did not mean anything to me” (Çi? gdem).
All of the participants who underwent total mastectomy and
modified radical mastectomy observed that they wanted to hide/
cover their breast loss. They decided on their covering preferences
according to their own understanding and economic conditions.
Participants described how they covered it in the following ways:
“. I placed a piece of cotton in my bra” (Çi? gdem), “. in place of the
removed breast, I wore a prosthesis for 2e3 months after the surgery
.” (Zeynep), and “I would like to have a reconstruction of my breast
. but I place a piece of cloth there instead .” (Elmas).
The participants who underwent partial mastectomy of one
breast described their worries about complete removal of the
cancerasfollows: “. I always have doubts in me because they did not
remove the whole breast” (Gülay) and “. my mother laments that the
disease will jump somewhere else” (Elmas).
Two of the participants stated that they felt as if the breasts they
had removed were still there (e.g., phantom sensations and
phantom pains), stating “. I feel pain; I forget that it has been
removed . I touch there, and there is no breast .. this makes me sad
.” (Elmas) and “sometimes when I touch my chest, it feels like it was
there; I want to scratch it, and then I say ‘what am I doing? Am I
crazy?’” (Çi? gdem).
Living with hair loss
Because the hair loss experienced by participants was not
permanent, it did not affect the participants as much as their breast
loss. All participants stated that they felt sad when their hair began
falling out as a result of chemotherapy, that they cried and their
families were affected by the situation.
Participants described the situation in the following ways: “. I
loved my hair, and I cried a lot when I lost it .” (Tenzile H.) and “.
when I lost my hair, I hated my appearance. I couldn’t stand looking at
the mirror. I felt ashamed before my husband, children and family . I
did not want anyone to see me that way” (Emine). One of the
participants described her child’s reaction to her hair loss as
follows: “. ‘mom, you look like a bald and scary character in the Lord
of the Rings movie when you have no hair’” (Gülay).
All of the participants tried to cover the hair loss during
chemotherapy. They developed covering preferences in line with
their own conceptions, and the participants described their expe-
riences on the matter as follows: “. I did not think of using anything
other than a headscarf” (Çi? gdem), “. I had a very nice wig .”
(Zeynep), and“. I didn’t think the wig suited me . I felt like it was an
image of bad women (such as sex workers) . so I used a scarf .”
One of the important themes of the study was change, which
was evidenced in the four sub-themes of changes in everyday life,
changes in self-perception, a greater appreciation of life, and an
understanding of the value of health.
Changes in everyday life
All participants stated that the process of diagnosis and treat-
ment of breast cancer changed both their own and their family’s
“. this disease affected our life . you constantly go to the hospital
. after the treatments (surgery, chemotherapy and radiotherapy)
you cannot do any jobs . you can’t give enough care to your child
. and now you can’t use your arm as you want .” (Tenzile), and
“this disease changes everything . everything . I want to go back
to my routines. I want to continue my normal life now . (crying)”
Changes in self-perception
All of the participants reported that theyexperienced changes in
their self-perception from the effects of the treatments and disease.
Participants reported the effects of breast cancer on their self-
perception as follows: “. I thought nothing would happen to me
. when I heard that I had cancer, I was ruined . it could happen to
me .” (Tenzile), “. you see yourselfas half a person after the surgery
.” (Emine), “. no breasts, no hair, no eyebrows; I was at peace with
myself before; I was beautiful . now nobody can recognise me .”
F. Cebeci et al. / European Journal of Oncology Nursing 16 (2012) 406e412
(Çi? gdem), “. you become dependent on others after treatments .
too bad you can’t fulfil your own needs .” (Nejla), and “. to not
show the absence of the breast, you can’t wear low-cut dresses.you
have to change the way you dress . you wear loose fitting clothes .
people look at you in a different way .” (Çi? gdem).
Changes in understanding the value of health
All of the participants stated that health was very important but
did not appreciate the value of being healthy before they had
cancer. They explained this situation as follows: “. we did not
appreciate the value of being healthy before we got ill .” (Çi? gdem)
and “. to be able to breathe comfortably, to eat, to drink, to feel the
taste of things, do your own things was a very beautiful thing .”
Almost all of the participants reported that they developed
healthy lifestyle behaviours after their breast cancer diagnosis. One
of the participants explained this situation as follows: “you under-
stand the value of health when you lose it . now, I have to pay a lot of
attention to my health . I used to smoke, but now I quit . I have
changed my diet . I’m going for walks . I try not to worry about
everything .” (Gülay).
Greater appreciation of life
One of the most important sub-themes from a greater appreci-
ationoflifewasthepositive change inthepatients’ worldview. All of
the participants indicated that they felt more connected to life after
their diagnosis and treatment. In addition, most indicated they now
realised the beauty of life and derived more pleasure from it. All of
the participants stated that to be alive despite everything was
amazing, saying, “it’s great to be alive.” A participant explained this
situation as follows: “. it is very important to be alive, to be living in
this world .” (Çi? gdem). Another participant stated, “life is worth
living. I started to hold lifetightly.” (Elmas). In comparing her new
life to her past life when she had breasts, one participant said “. I
lack a breast, but this is not the end of life, I am alive .” (Keriman).
The qualitative data obtained in this study provide preliminary
insights into understanding the experiences of Turkish women
with breast cancer. As the results revealed, breast cancer affects
women’s health in multiple dimensions. Physical and mental
problems resulting from surgery, chemotherapy, radiotherapy and
hormonal therapy as well as problems with family and work life,
future uncertainties, and social and spiritual problems affect the
well-being of patients with breast cancer (Hocao? glu et al., 2007;
Julkunen et al., 2009).
In the study, the participants did not use the word cancer,
expressing this concept as “. both its name . and itself are bad.” In
fact, in the literature, cancer is perceived as a significant source of
stress because it symbolises death and intensive treatment
processes, both of which are difficult for patients and their families
to accept (Hocao? glu et al., 2007; Vargens and Berterö, 2007; Gurm
et al., 2008; Remmers et al., 2010; Doumit et al., 2010).
In our study, all of the participants were unable to fulfil their
domestic roles during surgery, chemotherapy and radiotherapy
treatments. However, most women were supported by their family
members during this phase. Similarly, the study by Vargens and
Berterö (2007) found that women with breast cancer experienced
restrictions on their domestic activities due to breast cancer treat-
ment. Particularly, in Turkish society, family dynamics are adversely
affected when the health of one of the family members, especially
a woman, deteriorates. Turkish women are responsible for all of the
housework, the care of the children and husband, and fulfilment of
any work responsibilities if employed outside the home, which is
considered a normal duty of women in traditional Turkish culture.
Additionally, women take the responsibility for organising activities
and relations within the family (Hacialioglu et al., 2010).
In our study, participants emphasised the importance of family
support in the process of breast cancer diagnosis and treatment and
reported that they were physically, emotionally and socially sup-
ported by their family members. In addition, the majority of family
members giving support, except spouses, were women. This is not
surprising because in Turkish culture, women are generally the
In Turkish society, family members play a major role in the
obligations. Family and friends, especially women, tend to strongly
support women with breast cancer (Raupach and Hiller, 2002;
Westman et al., 2005, Howard et al., 2007; Erci and Karabulut,
2007; Berterö and Chamberlain Wilmoth, 2007). For example, in
the study by Erci and Karabulut (2007), Turkish women with breast
cancer fulfilled their support needs via family and friends. This is
important as family support, especially spouse support, is critical for
cancer patients to best cope with their disease (Raupach and Hiller,
2002; Julkunen et al., 2009). Furthermore, Gurm et al. (2008)
showed that the social support and assistance provided to women
with breast cancer improved their coping behaviours, strengthened
them, and decreased their distress, thus increasing their quality of
life. Psychosocial interventions that provided social support and
were also shown to reduce distress and improve the quality of life of
women with breast cancer. Westman et al. (2005) found that some
patients had wanted existential support from nurses, while others
received the support that they needed from family and friends.
However, in our study, women reported that they did not receive
from nurses during chemotherapy.
In our study, the relationship between the majority of women
diagnosed with cancer and their spouses gradually improved after
receiving a cancer diagnosis and during the treatment process. The
relationships of couples who already had problems prior to diag-
nosis of the disease gradually worsened during treatment. In the
study by Hocao? glu et al. (2007), the authors found that marriages
that were already strong before the cancer diagnosis resulted in
improvement over the course of coping with disease, whereas
marriages that were weak before were more likely to be affected
negatively by the diagnosis. Moreover, Wimberly et al. (2005)
showed that a good marital relationship was very important for
emotional coping with cancer and its outcome.
In this study, all of the participants stated that they needed
information, while half of them stated they were not informed
about their disease or its treatment. The study of Raupach and
Hiller (2002) concluded that women require more information on
the various problems encountered following breast cancer treat-
ment. Therefore, it is important that healthcare personnel, espe-
cially doctors and nurses, provide information to patients.
Otherwise, patients may become misinformed concerning their
diseaseand treatments. Therefore,
between healthcare professionals and people with cancer is an
important objective for cancer care internationally (Gysels et al.,
2004; Beaver and Witham, 2007). Moreover, providing informa-
tion to women with breast cancer can reduce anxiety and fear
(Raupach and Hiller, 2002).
All of the participants in this study believed that their disease
was created by God; thus, their “faith in God” increased after their
breast cancer diagnosis. In addition, all of the participants engaged
in worship practices to reduce their fears and stress. The religious
beliefs of patients can increase aftera diagnosis of cancer, measured
by increases in prayer and religious study (Bussing et al., 2007;
F. Cebeci et al. / European Journal of Oncology Nursing 16 (2012) 406e412
Choumanova et al., 2006; Howard et al., 2007; Tam Ashing et al.,
2003; Tokgöz et al., 2008; Harandy et al., 2010). Moreover, spiri-
tuality can prevent cancer patients from falling into desperation
(McClain et al., 2003).
Religious activities and intrinsic religiosity were both positively
associated with growth (Linley and Joseph, 2004). Specifically,
numerous researchers have demonstrated that spirituality and
religious practice are associated with better coping and psycho-
logical well-being among breast cancer patients (Bussing, et al.,
2007; Choumanova et al., 2006; Howard et al., 2007; Tam Ashing
et al., 2003; Tokgöz et al., 2008; Harandy et al., 2010). In the
study by Doumit et al. (2007), a belief in God and religion were
important factors for coping with the diagnosis of cancer. However,
the belief that the disease is a result of fate might cause some
patients to believe that “the disease comes from God; we cannot
prevent it no matter what we do.” This belief may prevent patients
from participating in efforts to prevent breast cancer, to diagnose it
early and may delay the initiation of appropriate treatment
(Doumit et al., 2010; Harandy et al., 2010). Therefore, it is important
that healthcare personnel be aware of these beliefs.
Conversely, the negative influences of spirituality and religiosity
can produce a sense of fatalism, a belief that the outcome of one’s
health is controlled by fate or a god. This appears to be a significant
barrier to participation in breast cancer screening and treatment
(Kwok and Sullivan, 2006; Mohamed, et al. 2005; Harandy et al.,
2010) in many parts of the world.
In our study, all participants stated that they saw breast loss as
a loss of womanhood. The breast is a symbol of femininity and
sexuality in Turkish society as well as in many other societies. Thus,
the loss of a breast was a traumatic life experience for many of the
participants, damaging their sense of attraction and sexuality
(Özkan and Açlalar, 2009). This sense of loss is found to be common
across many different cultural and ethnic groups in a variety of
studies (Howard et al., 2007; Doumit et al., 2010).
In this study, women reported that they were not affected by
temporary hair loss as much as the loss of a breast. Doumit et al.
(2010) found that the most demoralising and devastating loss
was hair loss. This situation may be because the studies were
conducted in different ethno-cultural contexts. Many women in
traditional Turkish society wear scarves; thus, many of the partic-
ipants in this study simply wore a scarf to cover up their hair loss.
This covering of the head may explain the decreased impact that
hair loss had on the study participants.
whentheemotions of patients andtheir familiesintensified,leading
to difficulty in coping with the disease. In our study, all of the
participants eventually learned to live with breast and hair loss,
which initially made them very upset. While the absence of a breast
was perceived to be very important by women, life soon became far
more valuable than a breast for the participants. This result is in
agreement with studies that showed that people who had various
traumatic experiences tended to adapt in response to the sources of
In our study, two participants felt as though the breasts that had
been removed were still there. Previous studies have reported
a prevalence of “phantom breast” (PB) ranging from10% to 66%. The
PB can appear as PB sensations, PB pain, or both. PB pain has been
described as shooting, knife-like, pressing, and burning, while PB
sensations have been described as swarming, itching, numbness,
tension, and pounding. Our study found results that were compa-
rable with that of previously conducted studies (Dijkstra et al.,
2007; Björkman et al., 2008).
Participants who had partial mastectomies experienced fear of
metastasis. According to the research literature, the diagnosis of
breast cancer can cause fear of the disease spreading and leading to
death (Berterö and Chamberlain Wilmoth, 2007; Kaiser, 2008;
Remmers, et al., 2010; Doumit et al., 2010). Thus, these studies
were consistent with our findings.
changes in self-perception and everyday life as negative and
perceived the changes related to understanding the value of health
anddevelopingagreaterappreciationof life aspositive.Specifically,
participants stated that loss of hair and the other side effects of
cancer treatment as well as the dependence on others for self-care
and household chores during the acute phases of treatment had
a negative impact on their self-perception. In addition, they
desperatelywanted toreturn to their normal lives. These results are
not surprising because individuals typically experience negative
changes in self-perception after traumatic experiences (Pinquart
et al., 2007; Erci & Karabulut, 2007; Tokgöz et al., 2008).
In an exploratory study by Küçükkaya (2010) on positive life
changes among Turkish women diagnosed with breast cancer, 50%
of women experienced positive life changes. The findings of this
study are similar to the greater appreciation of life found in our
study. In the study by Pinquart et al. (2009), an understanding of
human life became more important forcancer patients. This finding
also coincided with the theme “gaining a positive attitude for life”,
found in the study by Vargens and Berterö (2007). In this study,
participants stated that they understood that health was a value
that could not be purchased, and they realised the importance of
fulfilling daily physiological needs (e.g., breathing easily, eating,
and drinking water). In addition, changing previous bad habits that
threatened their health and developing behaviours to protect their
health were noted as positive changes in our study. After the cancer
diagnosis, some aspects of life became more important than before,
as reported in a study by Westman et al. (2005). The results of
previous studies on this subject are consistent with the results
reported here (Berterö and Chamberlain Wilmoth, 2007; Kaiser,
2008; Pinquart et al., 2009; Küçükkaya 2010).
Furthermore, the belief that “when you undergo surgery, you
feel like half a person” appears to be an original finding in Turkish
culture. The present authors came across this belief during this
study; however, no other information on this subject has been
found in the literature. Thus, this qualitative study is the first to
demonstrate this belief.
This study has several limitations. First, the data were gathered
in a single university hospital with a limited number of patients;
therefore,ourresultsmay not begeneralisable toalargerpopulation
base. Future studies should focus on a larger group of patients
treated at different institutions. Second, it is commonly accepted
that interviewing is the best method by which to gain deeper
understanding of participants. Therefore, using interviews may lead
to more substantial data on a given topic. New studies employing
a standardised and more comprehensive measurement method
would improve the reliability of the data collected. Third, the
present study included only breast cancer patients. Different cancer
types may lead to different impacts on life experience. Despite these
limitations, the results should be seen as a contribution to an
ongoing effort to fill the gap in the literature and to comprehend the
experience of Turkish women living with breast cancer.
The major strength of this study was that it was carried out on
an individual basis and included the experiences of women at all
F. Cebeci et al. / European Journal of Oncology Nursing 16 (2012) 406e412
stages of breast cancer. This study provided preliminary insights Download full-text
into the experiences of Turkish and Muslim women with breast
cancer. Identification of such experiences may provide healthcare
professionals with a better understanding of patients’ needs and
concerns during diagnosis and treatment and may help clinicians
provide appropriate counselling services to patients and their
families. The results of this study also challenge health care
providers and educators to be aware of the difficulties that Turkish
women face when living with breast cancer because we strongly
believe that understanding should be the basis of our caring
process. This research may also provide an opportunity for further
investigation that would facilitate designing culturally sensitive
interventions that use religious beliefs and Islamic teachings in
Muslim societies to further promote both breast cancer screening
and adherence to breast cancer health care-seeking behaviour as
well as coping strategies. Future research should concentrate on
breast cancer patients from different sociocultural and socioeco-
Conflict of interest
The authors declare that there is no conflict of interest.
We are grateful tothe participants who shared theirexperiences
with us. This study received external funding from Akdeniz
University Scientific Research Projects Unit.
Avcı, I.A., 2008. Factors associated with breast self-examination practices and beliefs
in female workers at a Muslim community. European Journal of Oncology
Nursing 12, 127e133.
Baykal, U., Seren, S., Somken, S., 2009. A description of oncology nurses’ working
conditions in Turkey. European Journal of Oncology Nursing 13, 368e375.
Beaver, K., Witham, G., 2007. Information needs of the informal carers of women
treated for breast cancer. European Journal of Oncology Nursing 11, 16e25.
Berterö, C., Chamberlain Wilmoth, M.C., 2007. Breast cancer diagnosis and its
treatment affecting the self: a meta synthesis. Cancer Nursing 30, 194e202.
Björkman, B., Arnér, S., Hydén, L.C., 2008. Phantom breast and other syndromes
after mastectomy: eight breast cancer patients describe their experiences over
time: a 2-year follow-up study. The Journal of Pain 9 (11), 1018e1025.
Bostancı Dastan, N., Buzlu, S., 2010. Meme Kanseri Hastalarında Maneviyatın Etki-
leri ve Manevi Bakım. (The effects of spirituality in breast cancer patients and
spiritual care). Maltepe Üniversitesi Hemsirelik Bilim ve Sanatı Dergisi. (Mar-
mara University Nursing Science and Art E- Journal) 3 (1), 73e78.
Bussing, A., Abu-Hassan, W.M., Matthiessen, P.F., Ostermann, T., 2007. Spirituality,
religiosity, and dealing with illness in Arabic and German patients. Saudi
Medical Journal 28, 933e942.
Cebeci, F., Balci Yangin, H., Tekeli, A., 2010. Determination of changes in the sexual
lives of young women receiving breast cancer treatment: a qualitative study.
Sexuality and Disability 28, 255e264.
Choumanova, I., Wanat, S., Barrett, R., Koopman, C., 2006. Religion and spirituality
in coping with breast cancer: perspectives of Chilean women. The Breast
Journal 12, 349e352.
Çavdar,_I, 2006. Meme kanserli hastalarda cinsel sorunlar. (Sexual problems at
women with breast cancer). Meme Sa? glı? gı Dergisi. (The Journal of Breast
Health) 2, 64e66.
Dijkstra, P.U., Rietman, J.S., Geertzen, J.H.B., 2007. Phantom breast sensations and
phantom breast pain: a 2-year prospective study and a methodological analysis
of literature. The European Journal of Pain 11, 99e108.
Doumit, A.A.M., Abu-Saad HuijerKelley, J.H., 2007. The lived experience of Lebanese
oncology patients receiving palliative care. European Journal of Oncology
Nursing 11, 309e319.
Doumit, M.A.A., El Saghir, N., Huijer, A.S., Kelley, J.H., Nassar, N., 2010. Living with
breast cancer, a Lebanese experience. European Journal of Oncology Nursing 14,
Erci, B., Karabulut, N., 2007. Appraising the self-assessed support needs of Turkish
women with breast cancer. European Journal of Cancer Care 16, 137e143.
Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing
research: concepts, procedures and measures to achieve trustworthiness. Nurse
Education Today 24, 105e112.
Gurm, B.K., Stephen, J., Mackenzie, G., Doll, R., Barroetavena, M.C., Candell, S., 2008.
Understanding Canadian Punjabi-speaking South Asian women’s experience of
breast cancer: a qualitative study. International Journal of Nursing Studies 45,
Gysels, M., Richardson, A., Higginson, I., 2004. Communication training for health
professionals who care for patients with cancer: a systematic review of effec-
tiveness. Supportive Care in Cancer 12 (10), 692e700.
Hacialio? glu, N., Özer, N., Yilmaz Karabulutlu, E., Erdem, N., Erci, B., 2010. The quality
of life of family caregivers of cancer patients in the East of Turkey. European
Journal of Oncology Nursing 14, 211e217.
Harandy, T.F., Ghofranipour, F., Montazeri, A., Anoosheh, M., Bazargan, M.,
Mohammadi, E., Ahmadi, F., Niknamia, S., 2010. Muslim breast cancer survivor
spirituality: coping strategy or health seeking behavior hindrance? Health Care
for Women International 31, 88e98.
Hocao? glu, Ç., Kandemir, G., Civil, F., 2007. Meme kanserinin aile ilis ¸kilerine etkileri.
(The influence of breast cancer to family relationships). Meme Sa? glı? gı Dergisi.
(The Journal of Breast Health) 3 (3), 163e165.
Howard, A.F., Balneaves, L.G., Bottorff, J.L., 2007. Ethnocultural women’s experiences
of breast cancer: a qualitative meta-study. Cancer Nursing 30, 27e35.
Julkunen, J., Lilius, M.G., Hietanen, P., 2009. Anger expression, partner support, and
quality of life in cancer patients. Journal of Psychosomatic Research 66, 235e244.
Kaiser, K., 2008. The meaning of the survivor identity for womenwith breast cancer.
Social Science & Medicine 67, 79e87.
Küçükkaya, P.G., 2010. An exploratory study of positive life changes in Turkish
women diagnosed with breast cancer. European Journal of Oncology Nursing
Kwok, C., Sullivan, G., 2006. Influence of traditional Chinese beliefs on cancer
screening behaviour among Chinese-Australian women. Journal of Advanced
Nursing 54 (6), 691e699.
Linley, P.A., Joseph, S., 2004. Positive change following trauma and adversity:
a review. Journal of Traumatic Stress 17, 11e21.
McClain, C.S., Rosenfeld, B., Breitbart, W., 2003. Effect of spiritual well-being on end-
of-life despair in terminally ill cancer patients. Lancet 361, 1603e1607.
Mohamed, I.E., Skeel Williams, K., Tamburrino, M., Wryobeck, J., Carter, S., 2005.
Understanding locally advanced breast cancer: what influences a woman’s
decision to delay treatment? Preventive Medicine 41, 399e405.
Ngoma, T., 2006. World health organization cancer priorities in developing coun-
tries. Annals of Oncology 17 (Suppl. 8), viii9eviii14.
Okanlı, A., Ekinci, M., 2008. Meme kanserli hasta ve es ¸lerinin yas ¸am doyumları
duygu kontrol düzeyleri ve evlilik uyumlarının mastektomi öncesi ve sonrası
kars ¸ılas ¸tırılması. New Symposium Journal 46 (1), 9e14.
Özkan, S., Açlalar, N., 2009. Meme Kanserinin Cerrahi Tedavisine Psikolojik Tepkiler.
(Psychologıcal reactions to surgical treatment in breast cancer). Meme Sa? glı? gı
Dergisi. (The Journal of Breast Health) 5 (2), 60e64.
Pınquart, M., Fröhlıch, C., Sılbereısen, R.K., 2007. Cancer patients’ perceptions of
positive and negative illness-related changes. Journal of Health Psychology 12
Pinquart, M., Silbereisen, R.K., Fröhlich, C., 2009. Life goals and purpose in life in
cancer patients. Supportive Care in Cancer 17, 253e259.
Platin, N., Retrieved April 20, 2010. from http://www.cancernurse.eu/documents/
Raupach, J.C.A., Hiller, J.E., 2002. Information and support for women following the
primary treatment of breast cancer. Health Expectations 5 (4), 289e301.
Remmers, H., Holtgräwe, M., Pinkert, C., 2010. Stress and nursing care needs of
women with breast cancer during primary treatment: a qualitative study.
European Journal of Oncology Nursing 14, 11e16.
Resmî Gazete (Official Gazette). Sayı (No): 27910. Retrieved April 20, 2010. from
Streubert, H.J., Carpenter, D.R., 1999. Qualitative Research in Nursing: Advancing
The Humanistic Imperative, second ed. Lippincott, Philadelphia.
Takahashi, M., Kai, I., 2005. Sexuality after breast cancer treatment: changes and
coping strategies among Japanese survivors. Social Science & Medicine 61 (6),
Tam Ashing, K., Padilla, G., Tejero, J., Kagawa-Singer, M., 2003. Understanding the
breast cancer experience of Asian American women. Psycho-Oncology 12 (1),
Tokgöz, G., Yalu? g, I., Özdemir, S., Yazıcı, A., Uygun, K., Aker, T., 2008. Kanserli has-
talarda travma sonrası stres bozuklu? gunun yaygınlı? gı ve ruhsal gelis ¸im. (The
prevalence of post traumatic stress disorder in patients with cancer and post-
traumatic growth). New Symposium Journal 46 (2), 51e61.
Tuncer, M. (Ed.), 2009. T.C. Sa? glık Bakanlı? gı Kanserle Savas ¸ Dairesi Bas ¸kanlı? gı Ulusal
Kanser Programı (National Cancer Program) 2009-2015 Bakanlık Yayın (Health
Ministry Pub.) No:760. Ankara.
Vargens, O.M.C., Berterö, C., 2007. Living with breast cancer: its effect on the life situ-
ation and the close relationship of women in Brazil. Cancer Nursing 30, 471e478.
Westman, B., Bergenmar, M., Andersson, L., 2005. Life, illness and deathV -exis-
tential reflections of a Swedish sample of patients who have undergone cura-
tive treatment for breast or prostatic cancer. European Journal of Oncology
Nursing 10, 169e176.
Wimberly, S.R., Carver, C.S., Laurenceau, J.P., Haris, S.D., Antoni, M.H., 2005.
Perceived partner reactions to diagnosis and treatment of breast cancer: impact
on psychosocial and psychosexual adjustment. Journal of Consulting and Clin-
ical Psychology 73 (2), 300e311.
World Health Organization, 2008. Are the numbers of cancer cases increasing or
decreasing in the world?. Retrieved June 11, 2010. From. http://www.who.int/
F. Cebeci et al. / European Journal of Oncology Nursing 16 (2012) 406e412