Background
Methods
Study design
Ethics
Setting
Participants, invitation and sampling
Data collection
1) Could you please tell us more about your general understanding of breast cancer? |
2) Would you like to share any experience of people diagnosed with breast cancer? |
3) Could you please tell us more about your concepts of treatment experience? |
4) Could you please talk about the psychological aspects of the disease and treatment? |
5) Could you elaborate on your general understanding about difficulties patients could face? |
6) Could you tell us more about your general ideas about role of women in family, role reversal, body image issues? |
7) How do you think communities could support women with breast cancer? |
8) Any further comments? |
Data analysis
Results
Participants
Variable | Number |
---|---|
Age | Range of age (in years), median |
33–81, 50 | |
Sex | Number |
Male | 10 |
Female | 35 |
Number in each groups | |
Oncologists | 05 |
Nurses | 10 |
Church members | 16 |
Community volunteers | 14 |
Education | Number |
High school | 13 |
Diploma | 06 |
Graduate level | 12 |
Post-graduate | 07 |
Not known | 07 |
Marital status | Number |
Married | 40 |
Single | 02 |
Widow | 01 |
Not known | 02 |
Religion | Number |
Hindu | 11 |
Christian | 29 |
Muslim | 04 |
Indian | 01 |
Number of years of experience for clinicians | Range in years, median |
9 to 35, 25 |
Findings
Theme | Subtheme | Quotes |
---|---|---|
Psychosocial issues related to diagnosis | Recognition of psychological distress | Quote 1 “When disease is diagnosed, instead of seeking treatment, she will decide to keep the disease a secret, also that is a private part of my body, even my husband will reject me, such a fear. All this is part of a social stigma, what people have imposed on women saying a woman should be like this. The stigma in Indian culture is a major factor in this.” ( Volunteer2;3 Age 40–50) Quote 2 “There was a lady who was behaving abnormally at home, jumped into a well. It was a cancer in the curable stage, even then patient became like that, because of incomplete information. Then finally she got admitted and was managed when she became well enough to share her story she said’ don’t laugh I will tell you the reason, I was told I will lose my hair, when the doctor said like that I thought why should I live with no hair, my husband liked my hair and married me.” (she had a lot of hair) (Nurse1 Age 50–60) Quote 3 “tend to kind of prioritise and take care of the medical aspects and leave all the rest of it thinking that it will sort out on its own” (Doctor2/Male/40–50) Quote 4 “they think these issues are a part of life, because most of them, they are alone, their family goes out to work so there is no one to talk to them, family just ensures that they are well at home when they come back but do not ask how they feel when they are alone.” (Doctor 4 /Female 40–50) Quote 5 “surgeon can only answer in one word, a detailed conversation is not possible there, so when they ask “ Will I lose my hair doctor?’ They say yes, they can only answer that. But if they add one more sentence like ‘don’t worry it will come back’ it might be more reassuring to patient.”( Nurse1 Age 50–60) Quote 6 “Then she had chemotherapy, radiation, lost all her hair and then she became very upset mentally. All these are the things they say, lot of mental stress, losing hair so much, when they have their shower and see the hair falling like water, they can’t bear it.” (Church1 Age 60–70) |
Delayed diagnosis | Quote 7 “Generally breast cancer is something which, in most, maybe western countries it is screened and detected and screening is high but in India there is no organised screening.” (Doctor1 Male/50–60) Quote 8 “Now these things like mammography, just like when health workers used to collect samples from houses for filariasis etc., in a similar manner, with the support of the social leaders, government should make it compulsory that after 35 years, all women should do mammogram”( Volunteer1; 8 Age 40–50) Quote 9 “Today’s Indian woman is of the habit of living for others. She thinks my life is meant for others. so she will hide the disease thinking other will have to suffer for me.” (Volunteer2; 3Age 40–50) Quote 10 “Initially many people hide the disease. Only after it spreads and becomes unmanageable, it is communicated and then the situation will be beyond cure.” (Volunteer2; 1 Age 50–60) Quote 11 “because of that people who live in villages don’t know we can identify or do breast self-examination or the treatment and its complications, they don’t know anything about that” (Nurse 4 Age 40–50) Quote 12 “one of the biggest problems is stigma; many people are worried that if the news gets out, it is going to affect my daughter’s marriage, my family in general.” (Doctor 5/Male 50–60) Quote 13 “To avoid such treatment from expensive private hospitals, people take some effort and struggle but go to regional cancer centres to get treatment, even if the travel is so difficult, people tend to go like that. Because they know that expense will be too much if they go to nearby places”. (Church 5 Age 60–70) Quote 14 “her second breast was also diagnosed with the disease. So now though the doctor has told her chemotherapy was enough, she is not doing it. The single reason being, if she loses her hair again, the society will come to know of her disease again, that problem is haunting that family, she is ready to die but not ready to give up her hair…” (Volunteer2; 3 Age 40–50) |
Theme | Subtheme | Quotes |
---|---|---|
Psychosocial impact of cancer treatment | Experience of treatment | Quote 15 “The next thing is, of course surgery is usually the first line of treatment once the patient is diagnosed and I don’t think that it is either breast conservation or reconstruction is offered as often as it should be Quote 16 A lot of people are reluctant to come forward for surgery because of the fear of losing the breast. (Doctor1 Male/50–60) Quote 17 “our culture is totally different, or like somebody wearing a saree, it is not very obvious, she does not have one breast, I think it does not make much of a difference(Doctor 3/Female 50–60) Quote 18 “Most of the women feel great mental agony when breast is removed. Before surgery, all are given a psychological counselling now. That does some good. Some patients do plastic surgery after the removal surgery. But only those with money can afford that.” (Volunteer1; 8 Age 40–50) Quote 19 “I have known many who cannot reconcile with the removal of their breast. That is more prevalent among younger women around 30–35 years of age, than old women. Old women do not have that much difficulty.” (Volunteer1; 8 Age 40–50) Quote 20 “Also if it is working women financial issues also comes and job related issues so they will postpone the treatment till the job issues are sorted and settled”.” (Doctor 5/Male 50–60) Quote 21 “Post operatively patient develops lymph oedema; again this is due to lack of information. Lymphoedema is very disabling, they are free of disease for 8–10 years and they live with 15 kg of one limb”.(Nurse5 Age 60–70) Quote 22 “The society has taught all of us to consider long hair and breasts as the yardsticks of woman hood. So when you don’t have any of this, it is a very painful situation.” (Volunteer2; 3 Age 40–50) Quote 23 “If women have an illness, it is an issue from the start because that woman would have been the main person in the family, then there is a disruption of the rhythm in all aspects, taking care of children, husband, so it is very difficult.( Volunteer1; 5 Age 60–70) Quote 24 “So when they become ill, the total structure of the family is affected, they can’t do anything, so the kid’s studies will be affected, husband’s work is affected. Husband is not able to go to work, so the income of the family is affected. So the total structure of the family is getting changed. (Nurse1 Age 50–60) Quote 25 “In Kerala most women in house have an important role, right from getting up in the morning, cooking, getting kids ready for school, looking after husband, some husbands if they are lazy (laughing in background) right from getting their shirt ironed and ready to wear, feeding them, and getting their bags ready and giving it to them so that they can go for working”.(Nurse 10 Age 60–70) |
Experience of Medical care | Quote 26 “the hospital management said he is an elderly doctor, when he becomes busy with lot of patients he is not able to manage things and so gets angry.” (Church 8 Age 40–50) | |
Quote 27 “To be quiet honest this is all a business to make money. Even when doctors know that the patient is going to die soon they still give radiation, chemotherapy do all treatment and get money.” (Church 14 Age 60–70) | ||
Quote 28 “Another experience is even if patients are diagnosed with cancer the doctors don’t behave in a compassionate manner with them. I know about an experience, if we ask anything to doctor he immediately loses temper and will not explain things to us. He would say ‘The patient is 80 years old, what more do you need, how long should she be alive?’” (Church8 Age 40–50) | ||
Quote 29 “Compared to doctors from other specialities those working in palliative care shows more love and compassion People working in palliative care are very caring and I have personal experience, they have at least a bit more compassion. We need more people like that.” (Church5 Age 60–70) | ||
Quote 30 “Here (public hospital) the treatment is very good. We do not have anything to complain. All the doctors and nurses, attenders, chemo ward staff, volunteers, are very good. I had gone to a private hospital before coming here. What I feel is, here we have better treatment than even that. All patients get equally good treatment. That government is doing all these things. Many people do not know. (Volunteer1; 8 Age 40–50) | ||
Solutions | Quote 31 “similarly, government should ensure adequate screening services for asymptomatic people then it will be more useful in detecting the disease.” ( Volunteer2; 1 Age 50–60) Quote 32 “I think what’s best you could do is probably just have people to provide inputs, have somebody who is always available on call to support, because all that they, I realize,, most of the time, twenty people who call, about ten or twelve of them just call for reassurance like this is nothing wrong, this is alright,” D5: (Doctor/Male 50–60) Quote 33 “How they are going to face the treatment, few days ahead, how you will face, what changes will happen to patient and what should you do?” (Nurse4 Age 40–50) Quote 34 “I still feel the best way to address it is to get people who have gone through it, show them the photograph, talk to them and make them talk. ‘I have also gone through this hair loss and my hair is grown back’. That confidence cannot come from any amount of preaching, it has to be actually talked to with the person who has gone through it.” (Doctor 5/Male 50–60) Quote 35 ‘Will I lose my hair doctor?’ They say yes, they can only answer that. But if they add one more sentence like ‘don’t worry it will come back’ it might be more reassuring to patient’. (Nurse 7 Age 40–50) |
Theme | Subtheme | Quotes |
---|---|---|
Coping with diagnosis and treatment | Response to illness | Quote 36 “encourage and support the patient to face the treatment bravely and help them to go through the illness.” They should create a supportive environment for the patient; all these are needed for the patient”. (Church 1 Age 60–70) Quote 37 “Also after staring chemotherapy we will really be fatigued, then we have to take rest and the whole family needs to support them, else they the patient would be low in mood and lose all hope. Also because of the mental strain they will continue to go downhill. If the family are very supportive then the patient would get better quickly”. (Church 9 Age70-80) Quote 38 “they don’t want to tell others they are cancer patients. ‘ how will public see me?’ I will lose all my hair’. (Nurse 5 Age 60–70) Quote 39 “There was an author and college lecturer who used to go to college and say, I am a cancer patient, keep an eye in newspaper for my obituary. So the students only knew about it when she spoke about that. Else she was not looking like a cancer patient.” (Nurse1 Age 50–60) Quote 40 “there was a patient who had breast cancer and had surgery, but her main concern was whether her husband would abandon her. As one of her breasts is removed she was concern that her husband would leave her. The patient used to talk to me about it and cry about that”. (Nurse 7 Age 40–50) Quote 41 “they become better, get their hair back, wear breast supports such things are available now, then they become better and cope.” (Church 1 Age 60–70) Quote 42 “Whereas there is another lady who is nearby, she after radiation, with no issues, went to temple with her husband daily, showing her power, for them, it will not come back again” (Volunteer1; 4 Age 40–50): |
Sources of support | Quote 43 “it is good for her children’s sake point of view”. Or “if she becomes depressed, same thing is going to affect children when they grow up if they ever have to face this again”.(Doctor 1 Male/50–60) Quote 44 “automatically become more religious, pray to God more” (Nurse 10 Age 60–70) Quote 45 “then socially like neighbours, people whom we interact with are all very compassionate to cancer patients, they provide them with whatever assistance they can. With all that these patients cope. Then they all have acceptance and they accept it as their fate.” (Nurse 3 Age 30–40) Quote 46 “Generally the Indian women sacrifice a lot for the family and they always keep their priorities the last. I had a lady whose husband had rectal cancer, she actually did not reveal about her breast lump till her husband completed his full treatment, only after that she told me that doctor I want you to look at my breast lump, then I realised that it was a large lump and we have lost almost 4–5 months.” (Doctor 4 /Female 40–50) Quote 47 “Sometimes they are worried if their husbands will leave them and go away they have to spend a lot of money for their treatment, or they are worried about their kids and them wasting a lot of money. “They have just started their life and they are spending a lot of money for my treatment”. “it is better to die’. There are people who say like that. (Nurse 4 Age 40–50) Quote 48 “Probably it is so much easier in western countries to voice out your love or concern which is probably still a taboo in our country. I don’t think there are too many husbands who go around saying, “no, don’t worry. I love you, I am still here.” I don’t do it, so I don’t know how the patient’s might be doing it”. (Doctor 2/Male/40–50) Quote 49 “People find solace in religion and spirituality. They look for prayer groups and attend that, they are consoled by people praying together. That will give them happiness. They will pray more.” (Church 8 Age 40–50) Quote 50 “I have a cousin, he wouldn’t even go to church but once the wife developed this condition, he started going to church, started praying for her, asked everyone to pray for his wife. Such husbands are also there”. (Church 5 Age 60–70) Quote 51 “Even if somehow the treatment is done and it is successful, she thinks, this organ is given to me by God, I should not allow the God given body to be cut and parts removed. That is a religious view” (Volunteer2; 3 Age 40–50): |
Theme 1: Psychosocial issues related to diagnosis (Table 3)
Theme 2: Psychosocial impact of cancer treatment (Table 4)
Theme 3: Coping with diagnosis and treatment (Table 5)
Congruence and dissonance between professional and lay groups (Table 6)
Subtheme | Doctors | Nurse | Community volunteers | Church members |
---|---|---|---|---|
Recognition of psychological distress | Agreement | |||
All groups recognised psychological distress, and identified similar causes | ||||
Delayed diagnosis | Agreement | |||
All groups felt delayed diagnosis aggravated distress around diagnosis and fed erroneous public understanding about cancer, including surrounding stigma, which led to a vicious cycle of late presentation | ||||
Experience of treatment | Disagreement | |||
Acknowledged side effects could be distressing and sub-optimally managed Concerns about financial “toxicity” of treatment Suspicions that treatment options were driven by hospital profit and pharmaceutical companies rather than patient benefit Lack of national guidelines leading to variable treatment | ||||
Experience of medical care | Agreement | |||
There were uniform agreement about the care provided by palliative care team for symptom control, empathy and psychological support | ||||
Disagreement | ||||
Recognised care was disease focused and felt lacked skills and time to manage mental health | Doctors communicated poorly and could do better especially around expressing empathy regarding hair loss | Poor opinion of medical (doctor) care, particularly with regard to communication skills, information giving and being open to questions | ||
Solutions | Disagreement | |||
More resources, healthcare workers with mental health training, e.g. social workers Better training and time in clinic | Better communication skills for the doctors even within resources, although agreed more resources and a system which valued person-centred care would be helpful | Further research is needed regarding the cause of the cancer, e.g. dietary issues | Cancer treatment should be free, which may also encourage early presentation | |
Agreement | ||||
National screening programmes for all; national public education programmes; national clinical guidelines to manage the cancers; cancer should be a government priority | ||||
Response to illness | Agreement | |||
All groups agreed that the distress caused by the cancer of a female organ in relation to body image and disfigurement had profound effects on the relationship with spouse, sense of self and role. This was especially because of the importance placed on women as wife, lover, home-maker, mother and carer of the elderly in the Indian culture | ||||
Disagreement | ||||
Doctors felt that the impact of loss of breast, etc. was less of an issue for Indian women because of national dress | Nurses highlighted the impact of lymphoedema especially, which is not hidden by national dress | Lay groups both felt that loss of the breast was felt as keenly as in Western cultures, if not more so, by Indian women, given the importance of her almost sole role in the family | ||
Sources of support | Agreement | |||
Family and faith were considered as strong sources of support by all groups However, all also could see that the family and faith centred society was a cause of distress in some, particularly when faith practices were disrupted, and family expectations not met and families did not accept the women’s needs, or where interpretations of faith fed into erroneous health beliefs and stigma |