“I Will Not Be Defined by This. I’m Not Going to Live Like a Victim;It Is Not Going to Define My Life”: Exploring Breast Cancer Survivors’ Experiences and Sense of Self

Abstract

A life-threatening disease such as breast cancer with its pervasive nature of uncertainty can lead to feelings of disempowerment. Nonetheless, survivors may reconstruct their identity within optimism and a celebration of a new self. In this qualitative constructionist study, we explored survivors’ experiences, meaning-making, and identity transformation. Semi-structured interviews were undertaken with 11 women who identified as breast cancer survivors. Participants were aged 35 years old or above and were in post-diagnosis for at least 3 years. Interview data were collected and analyzed using thematic techniques. We identified three master themes: Diseased Self, focused on emotional distress and the presentation of a façade; Coping Self, explored resilience and post-traumatic growth; and Transformed Self, engaged in presentations of self-image, meaning-making, and psychological ownership addressing survivorship and empowerment. The findings may be used to inform guidelines and support for cancer survivors considering the impact of diagnosis, treatment, and post-treatment experiences on self-identity.

Keywords

breast cancer cancer qualitative quality of life psychology psychological issues Australia

Introduction

Breast cancer (BC) continues to be one of the most commonly diagnosed diseases among women in Australia with over 19,000 newly diagnosed cases in 2019. The good news is that advances in biomedical technology and early detection have directly led in the last decade to a significant increase in 5-year survival rates in Australia from 72% to 90% (Australian Government, 2015; Williams & Jeanetta, 2015). However, the post-diagnosis and treatment period encompasses one’s physical and psychological well-being (Kline et al., 2018; Tindle et al., 2018), and survivors may continue to have treatment over the long term to either reduce the risk of recurrence or to manage their disease state (Ching et al., 2012).

There is still much to learn from the effects of BC, particularly in terms of psychological distress. BC survivors experience tremendous, sustained, and intrusive psychological distress (Rowland et al., 2001). Some of the negative emotional effects consist of grief and loss (Koutri & Avdi, 2016; Lechner et al., 2003), anxiety (Asiedu et al., 2014; Else-Quest et al., 2009; Min et al., 2013), and self-blame (Else-Quest et al., 2009; Phelan et al., 2013). There is also a growing body of research exploring post-traumatic growth (PTG) and coping of patients following the diagnosis of cancer (e.g., Ching et al., 2012; Williams & Jeanetta, 2015).

BC diagnosis and treatment is particularly distressing and profoundly impacts a woman’s sense of self especially when involving highly invasive surgical procedures such as a mastectomy. Women with BC under these circumstances are often confronted by a process of “identity destruction” followed by a period of transformation expressed within an “identity reconstruction” (Davis, 2008; Piot-Ziegler et al., 2010; Reynolds et al., 2020). Identity destruction starts at the point of diagnosis with feelings of loss, isolation, dissociation, and alienation (Ustjanauskas et al., 2017), and the questioning of the foundation of one’s self-identity (Sandole & Auerbach, 2013). The reconstructed self comes as a response to the known self being challenged and questioned (Park et al., 2009). This reconstructed self can adopt various personas such as being a victim, a fighter, or a thriver; but ultimately they are survivors of cancer (Park, 2013).

Persons often attempt to overcome a traumatic event in their lives by actively searching for and developing coping mechanisms (Engebretsen & Bjorbaekmo, 2020; Srivastava, 2015). Coping mechanisms may be problem-focused or emotion-focused (Lazarus & Folkman, 1984), and the former type is generally consistent with survivors of chronic disease and is associated with a better quality of life (Black et al., 2020; Shakeri et al., 2015; Srivastava, 2015). Problem-focused coping refers to a positive reframing and active reappraisal of behavior to gain control and resolve a crisis (Mehrabi et al., 2015). In contrast, the emotion-focused coping style refers to adopting avoidance behavior, self-blame, and wishful thinking (Shakeri et al., 2015).

Adopting a problem-focused coping strategy and accessing social support is integral in helping individuals cope when faced with a cancer diagnosis (Ching et al., 2012; Min et al., 2013) and facilitates a cancer survivor’s psychological well-being (Mehrabi et al., 2015). Support from family and friends provides comfort and a source of strength during treatment and post-treatment (Ching et al., 2012; Min et al., 2013; Williams & Jeanetta, 2015). Cancer patients who have strong social support have a better quality of life, are more optimistic, and can enjoy better mental and emotional health (Black et al., 2020; Caprara et al., 2016; Mahdian & Ghaffari, 2016). Therefore, it is important that the cancer patient’s social network as well as care providers are highly vigilant in providing emotional and mental support (Asiedu et al., 2014).

In addition to seeking support, a natural response to traumatic life experiences is a search for meaning (Min et al., 2013). Meaning-making involves a reorganization and reframing of thoughts to foster acceptance and a sense of control in their journey in recovery. It is directly associated with a transformation of the self to fit with the characteristics of the traumatic life experience such as a disease state and subtly different to the self previously presented to others in day-to-day life. Positive meaning-making can lead to self-growth (Ching et al., 2012; Connerty & Knott, 2013; Park et al., 2009) and PTG (Connerty & Knott, 2013; Srivastava, 2015) and is similar to PTG in that they both lead to a higher sense of awareness and acceptance as well as promoting a more insightful and reflective state that may ultimately instigate an epiphanic experience (Denzin, 2001). Epiphany is a moment of profound realization—a turning point in one’s life that is unpredictable and uncontrollable yet inspires major life changes (McDonald, 2007; Mulkins & Verhoef, 2004). An epiphany is often involuntary whereas positive meaning-making and PTG result from a conscious decision and cognitive engagement (Connerty & Knott, 2013). An epiphanic experience is a moment of rebirth, a sense of transition, and security within self, reflecting on the self and having an appreciation and gratefulness for life (Mulkins & Verhoef, 2004).

While there appears to be relatively substantial quantitative research examining coping styles (e.g., Mehrabi et al., 2015) or survivorship (e.g., Park, 2013) in BC survivors, there is limited qualitative research exploring survivors’ experiences and identity transformation in post-diagnosis. Despite the highly personal and private nature of BC as a disease state, most of this research is quantitative and therefore largely impersonal. Qualitative methods in contrast to quantitative methods are more attuned to investigating and understanding the personal and private, yet there is relatively limited qualitative research investigating the impact of BC.

Our study employs qualitative methods in an effort to more fully understand the personal and private experiences of the BC survivor following diagnosis and treatment. We also explore the transformative impact of BC on women’s sense of self. Understanding how a woman’s sense of self is affected by cancer and the strategies they employ to help them cope following diagnosis is important in developing patient-centered care that validates women’s experiences and agency. We explore BC patients’ experiences including how they coped with their diagnosis. Furthermore, we address the notion of survivorship, identity transformation, and post-treatment sense of self.

Method

Rationale

Qualitative methodology was used to gain insight into BC survivors’ experiences and their sense of self in post-diagnosis and treatment. Our study was informed by a constructionist epistemology which contends that there are multiple truths that can compete and be negotiated and that meaning is socially constructed rather than being objective or neutral (Orford, 2008; Willig, 2013). Knowledge is constructed from an individual’s perception and interpretations of experiences, and there are multiple possible constructions of the same experience (Galbin, 2014; Orford, 2008). This epistemology acknowledges that language is pivotal in how the world is understood and how knowledge is produced and constructed through speech (Crotty, 1998; Willig, 2013).

Phenomenology was also adopted within the methodology to gain an in-depth understanding of the BC survivor’s experiences. Phenomenology addresses feelings, thoughts, and the impact of a particular life event, which in our study encompasses the diagnosis and treatment of BC (Williams & Jeanetta, 2015). It is an in-depth interpretive (Qutoshi, 2018; Rapport & Wainwright, 2006; J. A. Smith, 2017) analysis into our survivor’s descriptions of their lived experiences and how their experiences impacted on their sense of self (Finlay, 2009; Osborn & Smith, 1998; J. A. Smith & Osborn, 2007, 2015a, 2015b).

Participants

The 11 participants were survivors who had been diagnosed and received treatment for BC. They were recruited through the first author’s extended social network as well as through Breast Cancer Network Australia and the Pink Foundation (an Australian independent charity whose mission is to provide practical support and enable a better journey through BC for patients and their families). The participants ranged in age from 40 to 86 years (M = 53); four of the 11 women were not married, seven were married, and one widowed; most (n = 8) completed a level of higher education which consisted of a university degree and in one case a PhD; others completed courses in child care, hairdressing, and/or a Technical and Further Education certificate; eight were retired; and the post-BC diagnosis period stretched from 3 to 13 years (M = 6).

Procedure

Ethics approval was gained through the Victoria University Human Research Ethics Committee. A semi-structured interview schedule was used to gain insight into the participant experiences and sense-of-self post-BC diagnosis and treatment. Semi-structured interviews are an established and commonly used procedure in qualitative research (Crotty, 1998; Laverty, 2008; Schober & Conrad, 1997; Willig, 2013). They combine formal questions with attributes of informal conversation, allowing the interviewer to develop rapport with the participant (Willig, 2013). This technique also prompts the exploration of the participant’s personal insights of a research topic (Schober & Conrad, 1997; Willig, 2013). The interview guide consisted of demographic questions and 15 open-ended questions. The questions were formulated with reference to previous research and literature relating to BC survivorship (Williams & Jeanetta, 2015). The questions explored BC survivors’ descriptions of their sense of self prior to and after their cancer diagnosis, including treatment, challenges, coping mechanisms, and social support. The length of interviews ranged from 28 to 58 minutes. All interviews were digitally recorded with the participants’ consent and transcribed verbatim.

Data Analysis

Interview data were interpreted using thematic analysis (Braun & Clarke, 2006). Thematic analysis can be used with a variety of theoretical frameworks (Braun & Clarke, 2006), including phenomenology. The analysis sought to investigate latent or underlying aspects (Braun & Clarke, 2006) of the phenomenon of BC survival. This technique involves six stages, including, first, the familiarization (reading) with the data; second, coding including generating concise labels that encapsulate items of interest relating to the research topic; third, determining themes or master themes and sub-themes; fourth, reviewing themes that include having a thematic map; fifth, defining and further refining the themes to ensure consistency and coherence in presenting the narrative; and sixth, producing the report. The major themes and sub-themes (Table 1) were constructed within a larger thematic map illustrating the essence of the phenomenological event.

Table 1.

Thematic Representations: Themes and Sub-Themes.

Sense of Self
Master theme	Diseased Self	Coping Self	Transformed Self
Sub-Theme I	Emotional distress Shock Anxiety Fear	Resilience Epiphany Post-traumatic Growth	Self-image
Sub-Theme II	Façade	Optimism	Meaning-making
Sub-Theme III		Social support	Psychological ownership Survivorship Empowerment

To help ensure rigor, all researchers were involved in the analysis process. Initial codes and emergent themes were cross-checked and discussed, which led to the refinement of themes and the final thematic map. In addition to triangulation between investigators (Patton, 2015), triangulation of methods (Merriam & Tisdell, 2016) was undertaken using related literature (Andersen et al., 2015) and associated blogs to further verify data interpretation and findings.

Findings and Discussion

Inductive thematic analysis revealed several master themes that demonstrated key topics shared among our group of survivors along with a related number of sub-themes (Braun & Clarke, 2006). The master- and sub-themes illustrated and encapsulated participants’ experiences and sense of self (Figure 1).

Figure 1.

Breast cancer sense of self conceptual map.

Sense of Self

A diagnosis of cancer is a life-changing, disturbing, and identity-altering event (Park et al., 2009). Identity transformation or negotiation is likely to occur at every stage of a patient’s life, including initial assessment to biopsy: treatment to post-treatment (Davis, 2008; Ustjanauskas et al., 2017). Some cancer survivors are inclined to restore their previous identity by upholding their preexisting values and belief systems, personal habits, and their persona in society. On the contrary, others welcome their new sense of self and use it as a catalyst for flourishing and metamorphosis (Roberts et al., 2006; Sandole & Auerbach, 2013; Sprangers et al., 2002).

This study encompasses a number of aspects in relation to sense of self. Notions of the Diseased Self, Coping Self, and Transformed Self are addressed focusing on negative emotional effects such as emotional distress, as well as positive emotional effect such as resilience and PTG, optimism, psychological ownership, social support, survivorship, and empowerment.

Diseased Self

Viewing oneself as diseased is psychologically distressing and also affects the everyday lives of family members and friends (Andersen et al., 2015). The initial diagnosis of cancer among our survivors left them feeling disempowered, shattered, overwhelmed, and broken (Sandole & Auerbach, 2013). These experiences led to emotional distress, including shock, anxiety, and fear. It also led to the need for the survivors to present a façade to others.

Emotional distress

A cancer diagnosis challenges and disrupts previously held beliefs of robustness and safety and can instigate significant emotional distress (Connerty & Knott, 2013; S. Smith et al., 2018): “I did cry because I couldn’t hold back; it was like that with my emotions. It was overwhelming, it was like flooding me. Overwhelming like a cup overflowing when you put it under the tap”. The negative emotional impact of cancer diagnosis and beyond was expressed as shock, anxiety, and fear. It was also accompanied with an effort to maintain a façade to others.

Shock. Shock was a consistent factor in response to the initial diagnosis of BC: “It was a sad moment. I wasn’t expecting it. It’s always a shock [crying]. I was just shocked.” The shock was evident in spite of the existence of cues (i.e., family history) and the results of tests such as a mammogram and/or biopsy:

The diagnosis? I was just in shock, I was sitting there and there was nothing that was going through my head actually. Because I was in shock even though I knew that it was sinister, I went and I just walked around the shops for two hours; I didn’t even do anything really, I was just walking around like a zombie.

As well as disbelief and confusion, often the newly diagnosed cancer patient felt a loss of control and balance. This occurred often as accepting a distressing diagnosis is very difficult (Baile & Beale, 2001). The sense of invincibility is suddenly terminated and the BC survivor may feel defeated and experience shock and numbness (Larner, 2005). The shock reaction also serves as an avoidance technique and a diversion to protect against the news of cancer, as well as a form of stable psychological functioning. A shock response is a protective measure (Kollberg et al., 2017) and serves to mitigate in the newly diagnosed cancer patient (Vos et al., 2011).

Anxiety. The experience of a chronic illness such as cancer and the reaction to it can trigger tremendous levels of anxiety; it alters a person’s self-concept and shifts the previously known identity to a new unknown identity (Phipps, 2018). Cancer is perceived as an invader, feared as incurable and life-threatening, impacts a woman’s physical and psychological well-being, and affects survivors’ womanhood, motherhood, femininity, and sexuality (Baglama & Atak, 2015; Black et al., 2020). During early stages of diagnosis, cancer patients often view themselves as unworthy, victimized, out of control, and at risk of dying (Contrada & Ashmore, 1999).

That first week, I just it was like the darkest part I had ever had in my life. Just thought I’m going to die . . . I thought worse case I thought I’m going to die. I got it in my head that it didn’t matter if I had BC; that my whole body had cancer. The anxiety was off the charts. It was just terrible, terrible.

Fear. As cancer is perceived as a threat to one’s mortality, it is a traumatic event that is associated with horror and trepidation (Baglama & Atak, 2015). Cancer is associated with high levels of uncertainty regarding the future and is directly aligned with death and mortality; it provokes alarming and fearful reactions regarding one’s sense of self (Koutri & Avdi, 2016):

Oh my God, It’s cancer! I was shattered. My God. I knew it was cancer. They saw me crying like a baby. I felt like it was just like endless tears. Absolutely petrified! I was like where did all these tears come from?

Fear, worry is really just scared and the worst part was the waiting from when you have a test to getting that result because it’s that unknown . . . the weekend was just horrible because it was just, “Oh my God, I’ve got, you know, cancer! I’m dying you know because I just don’t know how bad it is.” That period of not knowing, that was the hardest.

Fear is prominent and distressing, associated with the sense of uncertainty and the unknown and impacts the cancer survivors’ lives (Connerty & Knott, 2013). In reappraising their encounter with their mortality, BC survivors faced various types of fears in their cancer journey such as pain, physical mutilation and disfigurement, distorted body image, loss of hair, loss of sexuality, cancer recurrence, uncertainty about the future, and fear of death (Baglama & Atak, 2015; Black et al., 2020; S. Smith et al., 2018; Williams & Jeanetta, 2015).

It was the fear of dying that came to me was probably three times. The first time was the next day actually. I drove to work at 5:30 in the morning and on the freeway. I’ve never had an anxiety attack or anything. I started thinking about it and that fear of death came over me. That was the first time and another two times after that. But when those fear of death kind of comes over me I just usually, I prayed and it just subsided.

Cancer survivors felt out of control and not able to contain their worry and negative thoughts about their possible death, focusing on the worst-case scenarios (Asiedu et al., 2014).

Façade

Survivors presented a strong persona or façade for their loved ones and friends. However, maintenance of this façade “that everything is normal” came at an emotional cost:

I didn’t tell anybody, I kept it very hidden. Obviously my immediate family knew and a few close friends but I kept hosting retreats and teaching and everything and nobody knew. All this time I was holding in this deep dark secret so that was difficult because I wanted to have integrity. I had to really; I had to ask myself, “am I being a fraud?”; “have I failed?” From that point of view it was more difficult.

I was in this mode of let’s just keep it all normal and I know one of the doctors he said to me “we were worried about you because you were pretty a matter of fact through the whole course of treatment,” but as I said the last day that I had the radiation, the last absolute last day I was driving home and I started to cry and I couldn’t stop and I cried for about 2.5 hours.

The demonstration of the façade is often instigated by the societal expectation to demonstrate bravery and courage when confronted by negative events (Fisher et al., 2014). Often a BC survivor “playing it down” stems from the pressure they felt from family and friends to keep positive and assumed that was the only acceptable response in a crisis (Kristjansdottir et al., 2018; Sitvast et al., 2010). It was their strategy to conceal and yet display the ideal persona of a cancer survivor. The burden to stay strong, appear positive, masking their real feelings and worries, and not allowing themselves to feel vulnerable despite fear, pain, and imminent danger was extremely difficult (Montgomery et al., 2006).

Coping Self

The Coping Self is multifaceted and broadly centers on one’s perceived level of resilience, their degree of optimism concerning the disease state, and the amount of social support available to them at any point in time.

Resilience

Resilience includes an adaptive and active coping style, self-coherence, and spirituality (Min et al., 2013). The diagnosis of cancer is stressful and alters a person’s path in life; BC patients often adopt coping strategies to regulate internal and external stressors (Lazarus & Folkman, 1984). An active coping style and spirituality are present: “I think working kept my mind on the job.”

That [working] was actually a good thing for me. Yes, absolutely! It takes your mind off your sickness and then especially being a nurse it sort of; you get into the other mode of “I’m going to help you,” you know “I’m helping you; I’m your nurse.” You get into this switch off mode. I’m not the patient, I’m the nurse. . . . I am an active Christian, I don’t pray when stuff goes wrong, I am always talking to God and my faith has always been, my friends at work tell me, “Oh, it’s because you are a positive person!” and I say, “well probably a combination!” But it’s mostly my faith in God that has made me positive and gives me great outlook on life.

A coping strategy and sense of control may be expressed in turning anguish to humor and having fun with the cancer journey (Williams & Jeanetta, 2015):

I still retained roughly a sense of humor. I think I’ve always been a bit more resilient than I thought I was. I think most of the time it was just like, just get through today; just get through this week. It won’t always be like this. If I sort of held onto that, something will change soon.

Resilience more broadly encompassed the experience of an epiphany and PTG.

Epiphany. Our survivors experienced epiphanic moments expressed in their dreams and visions. These moments were a confirmation of their life’s purpose and helped foster resilience in staying strong throughout their ordeal. These moments of exaltation functioned as a constructive coping mechanism (Mahdian & Ghaffari, 2016; Miedema et al., 2007; Swinton et al., 2011):

When I went to Bali I went to a silent retreat because I’m like into meditation and yoga and I just stayed to try for myself. I was hoping for some kind of epiphany. I know for some reason all the emotions kind of started bubbling up and I just, I was just crying and you know I’ve needed that space of peace and not talking and just being with myself and then it all kind of came up and I just remember, I’m like, “this will not define me!.” That was like these are not my words they just kind of came out of nowhere; I said, “I will not be defined by this. I’m not going to live like a victim; it is not going to define my life.”

Positive meaning-making is extremely advantageous in enabling a cancer patient’s level of coping and well-being (Swinton et al., 2011). The epiphanic moments included an affirmation of the interconnectedness with God and the universe. This heightened level of spirituality and meaning-making is not uncommon (Goud, 1995):

[T]he initial plan was to remove both breasts even though the cancer was in one. But towards the end, I was determined. “No! I don’t want to go through this treatment and lose my breasts” . . . What did I do? I said to God. I stood in front of the mirror and I just said to God; I prayed in the mirror and I said, “These breasts are staying with me in Jesus’ name. These breasts will no longer bow down to cancer” . . . Anyway I went to have an MRI and C.T. scan after all the chemotherapy and the doctor said, “Why are you here?” Oh, God! Then he goes, “OK, All right. The bone scans clear.” Which was all good. My surgeon oncologist, she goes, “we can’t find a trace of cancer in your body” and she goes, “guess what? You can keep your breasts.” The Holy Spirit just led me to the mirror and said, “OK, tell me what you want, proclaim it, take authority.” That’s like the “A-ha” like OK, alright and it gave you a lot of power; I am going to overcome this. That was an “A-ha” moment for me.

While spirituality as a broad concept does not lend itself to an empirical definition or explanation (Swinton et al., 2011), the epiphanic experiences rank high among patients who consider themselves spiritual and these experiences elevated their levels of hopefulness (Asiedu et al., 2014; Mahdian & Ghaffari, 2016).

PTG. PTG is the reappraisal of one’s identity following a traumatic event (Hefferon et al., 2009). The desire to share one’s experiences and help others is an important aspect of PTG (i.e., Baglama & Atak, 2015; Connerty & Knott, 2013). Helping others became the shared code of behavior among survivors. For instance, most wished to help other women going through the same struggles as them and more specifically stated how in their personal lives they had the intrinsic need to help others also diagnosed with cancer:

I often believe you go through experiences to almost equip you to help others and I am. One of the reasons I decided to go back to study at a very late age, because I wanted to help people. I feel that that’s very fulfilling for me and that sort of is the purpose for me in my life to make a difference for people. For us to do that well, we have to experience difficulty. It’s very difficult to be empathetic, to sit in the mud with someone when you have not gone through anything; and, difficult experiences for me become almost opportunities to learn and to feel and to just know little bit more about other people. Try and use that experience to make a bit of a difference in someone else’s life. I guess that is why I became a peer advisor at Counterpart [Women Supporting Women With Cancer] and all that because there is nothing like someone who’s gone through it.

Optimism

Optimism is important in helping to cope with a cancer diagnosis and treatment (Gilbert et al., 2018). An optimist utilizes problem-focused strategies and positive reframing to help cope with adverse events (Connerty & Knott, 2013; Gilbert et al., 2018). Optimism and “staying positive” is aligned with the BC survivor’s desire to have a sense of control over their situation (Shaffaei et al., 2014): “Oh, just happier, healthier; more, more stable. Like I said, less roller coaster of emotions; just grateful for my life and in my relationships”:

happy, positive, feeling relaxed and really positive . . . staying and keep a focus and loving life. It has made me to go after my dream and love life even more. It’s funny because I’ve always been positive. I think effervescent, would be the word [laughs]! Just full of joy and full of life; positive outlook mentally, emotionally. Overall, positive and always liked who I am.

Optimism and positivity equips one to cope with their cancer diagnosis, treatments, and beyond. Hence, patients in part find meaningful activities that boost joy, gratification, and hope (Connerty & Knott, 2013).

Social support

An important aspect of the “Coping Self” was social support. Survivors received support from family and friends throughout their cancer journey. Social support contributed to a cancer patient’s sense of optimism, positive reframing, and coping (Asiedu et al., 2014; Min et al., 2013). Strong support systems, whether it be from intimate partners, friends, or a social network, were critical in enabling BC patients and survivors to endure physical, mental, and emotional distress (Hefferon et al., 2009; Williams & Jeanetta, 2015). Furthermore, social support was particularly important in fostering optimism and resilience among BC survivors (Connerty & Knott, 2013). This support gave them hope and made their lives “a little bit easier”:

Once I pulled up to school and there was the mother of my son’s best friend and she said, “you got a minute Jas?” I said, “yeah!” I had not really spoken to her but obviously my son had told his friend and she popped her boot and had like a beautiful three course meal. She said, “I’ve heard what is going on and cooked you this meal.” It was just a random act of kindness, you know and it made me, it threw me and impacted me because I thought if something were to happen to me, there were people in this world who would look after my husband and my kids; they will do things to make life a little bit easier.

A common theme among this group of women was that they had risen above their state of turmoil and despair, and revealed a positive mental change and adaptation. Acknowledging their loss and pain, the diagnosis of cancer opened the gate to coping and resilience, providing a sense of personal strength and growth as well as a re-configuration of their sense of self (Hefferon et al., 2009; Lazarus & Folkman, 1984).

Transformed Self

The Coping Self and Diseased Self directly impacted and engaged in a transformation process with the survivor a changed or altered sense of self. This Transformed Self was further engaged in the creation of a constructed and context-driven Self-Image associated with Meaning-Making and the Psychological Ownership of the disease state. The impact of trauma could be both positive and negative. The diagnosis of and living with BC can be a turning point in promoting positive meaning-making, empowerment, and control (Phipps, 2018), and may positively impact upon one’s sense of self in connection with others and in broader aspects of life (Berman, 2016):

I’ve learnt more to care about others. I just think life is too short. I try and make the most of it although that’s easier said than done. I’m a different person and maybe this will take me on a different pathway. Sometimes you have to go through your dramas or trauma in your life to make you go, “Oh, I’m gonna do this instead!” Because if your life just kind of goes along like this and then you don’t have any incentive to change it; it’s a big incentive to change.

Self-image

BC may lead to significant changes in how a woman views herself physically, intra-personally, and inter-personally (Piot-Ziegler et al, 2010; S. Smith et al., 2018). Losing a body part or losing hair is a fundamental aspect in losing a part of oneself that equates to losing part of one’s identity (Tacon, 2011). It can trigger self-disparaging thoughts and feelings of humiliation and the fear of being treated as a person with a disability, hence becoming fearful of stigmatization in public settings (Koutri & Avdi, 2016; Langellier & Sullivan, 1998).

Changes in physical appearance after BC treatment transformed BC survivors’ sense of self and they constantly dwelled on their pre-cancer intact body or hair (Koutri & Avdi, 2016). Our survivors consistently commented on losing a body part or hair as a constant reminder of the impact of the illness and its effect on their life (Langellier & Sullivan, 1998; S. Smith et al., 2018; Thomas-MacLean, 2005). They became emotional when speaking about the loss of their breasts or their hair expressed as a feeling of shame, loss of confidence, and profound altered sense of self:

When I look in the mirror after I was sort of recovering and having to get to know the new me and looking and remembering what I had and then looking at this person that was covered with scars [crying] and things. I think even now when I look in the mirror, it’s a bit of a shock. I had beautiful breasts and I was proud of my body shape and you know, I always felt and looked good in bathers and clothes; and then, to have the surgery and I felt sort of deformed! I don’t like it. You wish it was different. You know you can’t take back the time [crying] because I was a very confident person. I just don’t feel relaxed. Just not the same so, yes, sort of hard. I still feel like I am learning to like the new me. It’s reminding you over and over again what you have been through.

The new embodied experience is expressed as a lack of body integrity and a reduced confidence from losing one’s previous physical appearance. This is directly associated with an adjustment to a new embodied self:

The first week that I lost all my hair and I was sitting in the bathroom and I was just crying and crying and I learnt a lot in that, losing hair. I mean you wouldn’t think much about hair but my daughter came in and she said to me and she was only about 14 at the time, she goes, “mum, hair is overrated!” She went and shaved her hair. That really helped me. That was like, “wow!,” because I was having a hard time with that. It was huge, because I had self-image issues and other issues connected to that. That was a massive learning curve for me.

BC treatment challenged the previously known self-image due to the impact of the loss of breast(s) or hair. Cancer was an invader and an intrusion on their body integrity (Piot-Ziegler et al., 2010). The extreme psychological distress and associated emotions signify the importance of self-image and the sense of loss and grief experienced once confronted with losing part of their physical appearance and femininity (Langellier & Sullivan, 1998; S. Smith et al., 2018).

Meaning-making

Although the initial diagnosis comes as a shock, meaning-making provides patients with a sense of normalcy, positive reframing, and positive thinking that then renders itself to gaining a stronger coping mechanism (Asiedu et al., 2014; Ching et al., 2012). Meaning-making is a significant factor in reframing and reorganizing thoughts and is vital in accepting the diagnosis (Ching et al., 2012). Being at peace with the situation leads to surrendering and ultimately promotes embracing oneself, adaptation, and acceptance (Mulkins & Verhoef, 2004; Park et al., 2009). Furthermore, acceptance is a foundation for positive thinking and positive emotions and is quintessential in hopefulness in an intense situation such as cancer diagnosis (Min et al., 2013):

It was just a wakeup call to say, “hey, it’s time to slow down; it’s time to do things differently. Because you keep doing things you always done, you’re going to get the same results, right?” It’s not just getting rid of the lump or the bump; it’s about the transformation of your life. You can cut out the tumor but if you don’t change how you live your life, you’re not going to heal.

Meaning-making and the new sense of self is a moment of change in the face of the adversity by taking control and/or making emotional peace with their diseased state (Engebretsen & Bjorbaekmo, 2020; Goud, 1995).

Psychological ownership

Psychological ownership refers to sense of self and the perception of control over the distressful cancer diagnosis (Karnilowicz, 2011). Psychological ownership is vital to some as cancer patients recognize their desire to maintain good health, their pervasive fear of the uncertainty about the future, and their relationship and support from family and health care providers (Ustjanauskas et al., 2017). This identity shift becomes a catalyst to survivorship. The internal dialogue, the transition, the adjustment, attitudes, and beliefs contribute to promoting optimal health (Coyne et al., 2010).

Survivorship. Survivorship correlates with psychological ownership, control, and self-care, as well as directly fostering empowerment (Park, 2013). An element of sense of survivorship is control. It provides a relational consolation and security within which women felt they were in charge of what may transpire in the future (Swinton et al., 2011). Recognition of the sense of control facilitated confidence and assurance dealing with their situation (Asiedu et al., 2014). Having a sense of control gave the BC survivor power and authority and helped them cope with their diagnosis (Miedema et al., 2007):

What was I thinking? “I can beat this; I am going to beat this!” That was the main thing! That was the motivation that gave me strength to just keep going on and do what I have to do. In that mode I was like really didn’t give my emotions a chance too much. My emotions caught up down the track.

BC survivors engage in activities that optimize their health and well-being such as complementary therapies, systematic diet change, and physical activities such as yoga and meditation (Park, 2013). Self-care was another shared code of behavior. Self-care is a facet of gaining control over one’s life (Connerty & Knott, 2013). At the end of their treatment regime, the women had to assume control and take full responsibility for their well-being (Mulkins & Verhoef, 2004). These self-care activities helped them work on their inner self and alleviated anxiety and fear:

It’s like there’s nothing else to do except get on this treadmill. That defines everything for nine months, ten months. After that you start putting life back in again. I feel like you almost just had to put your emotions aside to get through it. You have to sort of like going through treatment you are so busy.

Empowerment. When confronted with the life-changing diagnosis of cancer, our survivors with others overcame their diseased state, felt inspired, and ultimately became empowered (Lechner et al., 2003): “I became outspoken. So that’s probably the biggest change. The new me is just more forthright, I stand up for myself. I probably know myself little bit better. I guess I look at problems little bit differently.”

I feel like it really surprises me how strong I am, I felt really empowered by the fact that the strength and the courage of what I’ve been through basically nothing scares me anymore [laughs]. I was actually surprised I’ve been through this sickness that my body is actually really strong. While I was diagnosed and going through my treatment, I was going to court for custody arrangements over the children. That was taking a massive mental and physical toll on me. Because I was trying to recover and I had that to deal with that as well so I’m proud of myself. I feel like it’s a real pride there. I survived cancer and I had all that to deal with, I feel like now I am really on the other side with some really dark times behind me those tiny dark clouds are gone now. I feel like, “Wow! Look at me; look at what I achieved, what I went through” and I feel like I am a real fighter [laughs]. Like I have been through so much in my life and I keep bouncing back and I can overcome anything really.

Conclusion

This study provided a detailed, in-depth exploration of BC survivors’ experiences and their identity transformation following BC diagnosis. Survivors faced tremendous psychological distress following their cancer diagnosis while also experiencing psychological growth in coming to terms with BC. They decided to take control and felt empowered in trying to combat their chronic illness. The findings are important in terms of documenting the transformative experience of coping with BC and its effect of one’s sense of self. Three master themes Diseased Self, Coping Self, and the Transformed Self encapsulate this transformative experience. Diseased Self focuses on emotional distress (shock, anxiety, and fear) and the presentation of a façade. The Coping Self explored resilience within an epiphanic experience and PTG. The prominent theme, the Transformed Self, engaged in presentations of self-image, meaning-making, and psychological ownership addressing survivorship and empowerment. The survivors in this study experienced a transformed sense of self and felt an incredible sense of strength and empowerment in the face of a traumatic life event—their diagnosis of cancer. Facing cancer became a catalyst for higher personal, emotional, and spiritual growth (Mulkins & Verhoef, 2004; Stephens et al., 2018).

The study’s limitations centered on the characteristics of the participant group, including the wide range of ages (40–86 years) and number of years post-diagnosis (3–13 years). The age at which the women were diagnosed varied widely. Their stage of life and concomitant work and family responsibilities impacted upon how they coped with their diagnosis. Future studies could be conducted with women at different life stages and an emphasis on a greater number of survivors of a specific age group and stage of diagnosis to further explore the possible impact on sense of self (Willig, 2013). Nonetheless, we do not posit that our participants’ experiences were universal or that all women need to report that their experiences have empowered them. We contend that the lived experiences of a group of survivors and coping with BC had a profound transformative impact on their sense of self. It is important to acknowledge the variety of responses that women experience in their ongoing survivor journey. In addition, this journey is not linear and women who feel empowered may also still have moments of despair or anger.

The valuable information from our group of BC survivors has practical applications. The study’s findings highlight the varied responses of women in their survivor journeys. Tailored patient-centered care and counseling support is important in helping women cope with the emotional, social, and physical impact of their BC diagnosis and treatment. The sharing of experiences in counseling and support groups provides an important source of consensual validation for BC survivors’ feelings and ways of coping, which in turn can promote positive transformative change and growth. This study’s findings may help health care professionals provide care for women with BC in that it highlights the process of identity reconstruction that some women undergo in the survivor journey and how this may impact on psychosocial well-being (Emslie et al., 2017; Reynolds et al., 2020). The telling of our survivor’s experiences also contributes to further knowledge in embodying care physically, emotionally, and mentally for patients and survivors’ support networks; to reduce distress and fear; and to facilitate a higher rate of survivorship (Ustjanauskas et al., 2017).

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Elly Rashidi

Wally Karnilowicz

Author Biographies

Elly Rashidi is a major research focus in Psychological investigations of identity related to disease state (i.e., Breast Cancer).

Romana Morda is a senior lecturer Psychology and Registered Psychologist. Major research focus in Developmental and Organizational Psychology.

Wally Karnilowicz is a Research focus in Social Psychology with a particular emphasis on disease state (i.e., Cancer).

References

Andersen

L. S.

Larsen

B. H.

Birkelund

(2015). A companionship between strangers—Learning from fellow people with cancer in oncology wards. Journal of Advanced Nursing, 71(2), 271–280. https://doi.org/10.1111/jan.12490

Asiedu

G. B.

Eustace

R. W.

Eton

D. T.

Breitkopf

C. R.

(2014). Coping with colorectal cancer: A qualitative exploration with patients and their family members. Family Practice, 31(5), 598–606. https://doi.org/10.1093/fampra/cmu040

Australian Government. (2015, December 17). Breast cancer statistics. http://breast-cancer.canceraustralia.gov.au/statistics

Baglama

Atak

I. E.

(2015). Posttraumatic growth and related factors among postoperative breast cancer patients. Social and Behavioral Sciences, 190, 448–454. https://doi.org/10.1016/j.sbspro.2015.05.024

Baile

W. F.

Beale

E. A.

(2001). Giving bad news to cancer patients: Matching process and content. Journal of Clinical Oncology, 19(9), 2575–2577. https://doi.org/10.1634/theoncologist.2015-0250

Berman

S. L.

(2016). Identity and trauma. Journal of Traumatic Stress Disorders and Treatment, 5(2), 1–3. https://doi.org/10.4172/2324-8947.1000e108

Black

K. Z.

Eng

Schaal

J. C.

Johnson

Nichols

H. B.

Ellis

K. R.

Rowley

D. L.

(2020). The other side of through: Young breast cancer survivors’ spectrum of sexual and reproductive health needs. Qualitative Health Research, 17(3), 1–14. https://doi.org/10.1177/1049732320929649

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. http://doi.org/10.1191/1478088706qp063oa

Caprara

G. V.

Castellani

Alessandri

Mazzuca

La Torre

Barbaranelli

Ziparo

(2016). Being positive despite illness: The contribution of positivity to the quality of life of cancer patients. Psychology and Health, 31(5), 524–534. https://doi.org/10.1080/08870446.2015.1117081

10.

Ching

S. S.

Martinson

I. M.

Wong

T. K.

(2012). Meaning making: Psychological adjustment to breast cancer by Chinese women. Qualitative Health Research, 22(2), 250–262. https://doi.org/10.11717/049732311421679

11.

Connerty

T. J.

Knott

(2013). Promoting positive change in the face of adversity: Experiences of cancer and post-traumatic growth. European Journal of Cancer Care, 22(3), 334–344. https://doi.org/10.1111/ecc.12036

12.

Contrada

R. J.

Ashmore

R. D.

(1999). Self, social identity and physical health: Interdisciplinary exploration. Oxford University Press.

13.

Coyne

J. C.

Tennen

Ranchor

A. V.

(2010). Positive psychology in cancer care: A storyline resistant to evidence. Annals of Behavioral Medicine, 39(1), 35–42. https://doi.org/10.1007/s12160-010-9157-9

14.

Crotty

(1998). The foundation of social research: Meaning and perspective in research process. Sage.

15.

Davis

E. M.

(2008). Risky business: Medical discourse, breast cancer, and narratives. Qualitative Health Research, 18(1), 65–76. https://doi.org/10.1177/1049732307309002

16.

Denzin

N. K.

(2001). Interpretive interactionism (2nd ed.). Sage.

17.

Else-Quest

N. M.

LoConte

N. K.

Schiller

J. H.

Hyde

J. S.

(2009). Perceived stigma, self-blame, and adjustment among lung, breast and prostate cancer patients. Psychology and Health, 24(8), 949–964. https://doi.org/10.1080/08870440802074664

18.

Emslie

Lennox

Ireland

(2017). The role of alcohol in identity construction among LGBT people: A qualitative study. Sociology of Health & Illness, 39(8), 1465–1476. https://doi.org/10.1111/1467-9566.12605

19.

Engebretsen

K. M.

Bjorbaekmo

W. S.

(2020). Out of chaos—Meaning arises: The live experience of re-habituating the habitual body when suffering from burnout. Qualitative Health Research, 30(10), 1468–1479. https://doi.org/10.1177/1049732320914584

20.

Finlay

(2009). Debating phenomenological research methods. Phenomenology and Practice, 3(1), 6–25. http://doi.org/10.29173/pandpr19818

21.

Fisher

R. L.

Fisher

(2014). The psychology of adaptation to absurdity: Tactics of Make-Believe. Psychology Press.

22.

Galbin

(2014). An introduction to social constructionism. Social Research Reports, 26, 82–92. https://www.researchgate.net/publication/283547838

23.

Gilbert

Savard

Gagnon

Savard

M. H.

Ivers

Foldes-Busque

(2018). To be or not to be positive: Development of a tool to assess the relationship of negative, positive, and realistic thinking with psychological distress in breast cancer. Journal of Health Psychology, 23(5), 731–742. https://doi.org/10.1177/1359105316681062

24.

Goud

N. H.

(1995). Vital moments. Journal of Humanistic Education and Development, 34(1), 24–34. https://doi.org/10.1002/j.2164-4683.1995.tb00108.x

25.

Hefferon

Grealy

Mutrie

(2009). Post-traumatic growth and life threatening physical illness: A systematic review of the qualitative literature. The British Journal of Health Psychology, 14, 343–378. https://doi.org/10.1348/135910708X332936

26.

Karnilowicz

(2011). Identity and psychological ownership in chronic illness and disease state. European Journal of Cancer Care, 20(2), 276–282. https://doi.org/10.1111/j.1365-2354.2010.01220.x

27.

Kline

R. M.

Arora

N. K.

Bradley

C. J.

Brauer

E. R.

Graves

D. L.

Buchanan Lunsford

McCabe

M. S.

Fuld-Nasso

Nekhlyudov

Rowland

J. H. R. M.

Ganz

P. A.

(2018). Long-term survivorship care after cancer treatment—Summary of a 2017 National cancer policy forum workshop. Journal of National Cancer Institute, 110(12), 1300–1310. https://doi.org/10.1093/jnci/djy176

28.

Kollberg

K. S.

Wilderang

Thorsteinsdottir

Hugosson

Wiklund

Bjartell

Steineck

(2017). How badly did it hit? Self-assessed emotional shock upon prostate cancer diagnosis and psychological well-being: A follow-up at 3, 12, and 24 months after surgery. Acta Oncologica, 56(7), 984–990. https://doi.org/10.1080/0284186.2017.1300320

29.

Koutri

Avdi

(2016). The suspended self: Liminality in breast cancer narratives and implications for counselling. The European Journal of Counselling Psychology, 5(1), 78–96. https://doi.org/10.5964/ejcop.v5i1.92

30.

Kristjansdottir

O. B.

Mirkovic

Krogseth

Marte Ljosa

Stange

K. C.

Ruland

C. M.

(2018). Personal strengths reported by people with chronic illness: A qualitative study. Health Expectations, 21(4), 787–795. https://doi.org/10.1111/hex.12674

31.

Langellier

K. M.

Sullivan

C. F.

(1998). Breast talk in breast cancer narratives. Qualitative Health Research, 8(1), 76–94. https://doi.org/10.1177/104973239800800106

32.

Larner

(2005). Common psychological challenges for patients with newly acquired disability. Nursing Standard, 19(28), 33–39. http://doi.org/10.7748/ns.19.28.33.s55

33.

Laverty

S. M.

(2008). Hermeneutic phenomenology and phenomenology: A comparison of historical and methodological consideration. International Journal of Qualitative Methods, 2(3), 21–35. https://doi.org/10.1177/160940690300200303

34.

Lazarus

R. S.

Folkman

S. S.

(1984). Stress, appraisal and coping. Springer.

35.

Lechner

S. C.

Zakowski

S. G.

Antoni

M. H.

Greenhawt

Block

(2003). Do sociodemographic and disease-related variables influence benefit-finding in cancer patients? Psycho-Oncology, 12, 491–499. https://doi.org/10.1002/pon.671

36.

Mahdian

Ghaffari

(2016). The mediating role of psychological resilience, and social support on the relationship between spiritual well-being and hope in cancer patients. Journal of Fundamentals of Mental Health, 18(72), 130–138.

37.

McDonald

M. G.

(2007). Epiphanies: An existential inquiry. Existential Analysis, 18(1), 17–30.

38.

Mehrabi

Hajian

Simbar

Hoshyari

Zayeri

(2015). Coping response following a diagnosis of breast cancer: A systematic review. Electron Physician, 7(8), 1575–1583. https://doi.org/10.19082/1575

39.

Merriam

S. B.

Tisdell

E. J.

(2016). Qualitative research: A guide to design and implementation (4th ed.). Jossey-Bass.

40.

Miedema

Hamilton

Easley

(2007). From “invincibility” to “normalcy”: Coping strategies of young adults during the cancer journey. Palliative and Supportive Care, 5(1), 41–49. https://doi.org/10.1017/S147895150707006X

41.

Min

J. A.

Yoon

Lee

C. U.

Song

K. Y.

Kim

T. S.

(2013). Psychological resilience contributes to low emotional distress in cancer patients. Support Care Cancer, 21(9), 2469–2476. https://doi.org/10.1007/s00520-013-1807-6

42.

Montgomery

Tompkins

Forchuk

French

(2006). Keeping close: Mothering with a serious mental illness. Issues and Innovations in Nursing Practice, 54(1), 20–28. https://doi.org/10.1111/j.1365-2648.2006.03785

43.

Mulkins

A. L.

Verhoef

M. J.

(2004). Supporting the transformative process: Experiences of cancer patients receiving integrative care. Integrative Cancer Therapies, 3(3), 230–237. https://doi.org/10.1177/1534735404268054

44.

Orford

(2008). Community psychology: Challenges, controversies and emerging consensus. John Wiley.

45.

Osborn

Smith

J. A.

(1998). The personal experience of chronic benign lower back pain: An interpretative phenomenological analysis. British Journal of Health Psychology, 3(1), 65–83. https://doi.org/10.1111/j.2044-8287.1998.tb00556.x

46.

Park

C. L.

(2013). The meaning making model: A framework for understanding meaning, spirituality, and stress-related growth in health psychology. The European Health Psychologist, 15(2), 40–47. https://www.ehps.net/ehp/index.php/contents/article/view/ehp.v15.i2.p40/1041

47.

Park

C. L.

Zlateva

Blank

T. O.

(2009). Self-identity after cancer: Survivor, victim, patient and person with cancer. Journal of General Internal Medicine, 24(2), 430–435. https://doi.org/10.1007/s11606-009-0993-x

48.

Patton

(2015). Qualitative research and evaluation methods (4th ed.). Sage.

49.

Phelan

S. M.

Griffin

J. M.

Jackson

G. L.

Zafar

S. Y.

Hellerstedt

Stahr

Van Ryn

(2013). Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer. Psycho-Oncology, 22(1), 65–73. https://doi.org/10.1002/pon.2048

50.

Phipps

C. B.

(2018). Metamorphosis: An autoethnographic journey through loss, grief, and perceived identity changes. Journal of Loss and Trauma, 23(6), 458–467. https://doi.org/10.1080/15325024.2018.1475138

51.

Piot-Ziegler

Sassi

M. L.

Raffoul

Delaloye

J. F.

(2010). Mastectomy, body deconstruction, and impact on identity: A qualitative study. British Journal of Health Psychology, 15(Pt 3), 479–510. https://doi.org/10.1348/135910709X472174

52.

Qutoshi

S. B.

(2018). Phenomenology: A philosophy and method of inquiry. Journal of Education and Education Development, 5(1), 215–222. http://doi.org/10.22555/joeed.v5i1.2154

53.

Rapport

Wainwright

(2006). Phenomenology as a paradigm of movement. Nursing Inquiry, 13(3), 228–236. https://doi.org/10.1111/j.1440-1800.2006.00325.x

54.

Reynolds

Medved

Mackenzie

C. S.

Funk

L. M.

Koven

(2020). Older adults’ narratives of seeking mental health treatment: Making sense of mental health challenges and “muddling through” to care. Qualitative Health Research, 30(10), 1517–1528. https://doi.org/10.1177/1049732320919094

55.

Roberts

Morden

MacMath

Massie

Olivotto

I. A.

Parker

Hayashi

(2006). The quality of life of elderly women who underwent radiofrequency ablation to treat breast cancer. Qualitative Health Research, 16(6), 762–772. http://doi.org/10.1177/1049732306288541

56.

Rowland

Aziz

Tesauro

Feuer

(2001). The changing face of cancer survivorship. Seminars Oncology Nursing, 17(4), 236–240. https://doi.org/10.1053/sonu.2001.27912

57.

Sandole

D. H.

Auerbach

C. F.

(2013). Dissociation and identity transformation in female survivors of the genocide against the Tutsi in Rwanda: A qualitative research study. Journal of Trauma and Dissociation, 14(2), 127–137. https://doi.org/10.1080/15299732.2013.724345

58.

Schober

M. F.

Conrad

F. G.

(1997). Does conversational interviewing reduce survey measurement error? The Public Opinion Quarterly, 61(4), 576–602. https://doi.org/10.1086/297818

59.

Shaffaei

Saadati

Sabetkhah

Mirzaei

(2014). The relationship between optimism, self-actualization, religious orientation and psychological well-being on active and non-active olders. Indian Journal of Fundamental and Applied Life Sciences, 4(S4), 2121–2126. https://www.cibtech.org/sp.ed/jls/2014/04/JLS-244-S4-255.pdf

60.

Shakeri

Kamangar

Ebrahimi

Aznab

Shakeri

Arman

(2015). Association of coping styles with quality of life in cancer patients. Indian Journal of Palliative Care, 21(3), 298–304. http://doi.org/10.4103/0973-1075.164890

61.

Sitvast

J. E.

Abma

T. A.

Widdershoven

G. A.

(2010). Facades of suffering: Clients’ photo stories about mental illness. Archives of Psychiatric Nursing, 24(5), 349–361. https://doi.org/10.1016/j.apnu.2010.02.004

62.

Smith

J. A.

(2017). Interpretive phenomenological analysis: Getting at lived experience. The Journal of Positive Psychology, 12(3), 303–304. https://doi.org/10.1080/17439760.2016.1262622

63.

Smith

J. A.

Osborn

(2007). Interpretive phenomenological analysis. Sage.

64.

Smith

J. A.

Osborn

(2015a). Interpretive phenomenological analysis: A practical guide to methods. Qualitative Psychology, 3, 53–80. http://doi.org/10.14691/CPPJ.20.1.7

65.

Smith

J. A.

Osborn

(2015b). Interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain. British Journal of Pain, 9(1), 41–42. https://doi.org/10.1177%2F2049463714541642

66.

Smith

Eatough

Smith

Mihai

Weaver

Sadler

G. P.

(2018). “I know I’m not invincible”: An interpretative phenomenological analysis of thyroid cancer in young people. The British Journal of Health Psychology, 23(2), 352–370. https://doi.org/10.1111/bjhp.12292

67.

Sprangers

M. A.

Tempelaar

Van Den Heuvel

W. J.

De Haes

H. C.

(2002). Explaining quality of life with crisis theory. Psycho-Oncology, 11(5), 419–426. https://doi.org/10.1002/pon.601

68.

Srivastava

(2015). Trauma, trust and hope among women: A qualitative study. Psychological Studies, 60(2), 170–184. https://doi.org/10.1007/s12646-015-0307-9

69.

Stephens

Halcomb

Dewing

(2018). Living on: An exploration of healthful cancer survivorship among grey nomads. The Australian Journal of Cancer Nursing, 19(1), 19–24.

70.

Swinton

B. J.

Ingram

Heys

S. D.

(2011). Moving inwards, moving outwards, moving upwards: The role of spirituality during the early stages of breast cancer. European Journal of Cancer Care, 20(5), 640–652. https://doi.org/10.1111/j.1365-2354.2011.01260.x

71.

Tacon

A. M.

(2011). Mindfulness: Existential, loss, and grief factors in women with breast cancer. Journal of Psychosocial Oncology, 29(6), 643–656. https://doi.org/10.1080/07347332.2011.615382

72.

Thomas-Maclean

(2005). Beyond dichotomies of health and illness: Life after breast cancer. Nursing Inquiry, 12(3), 200–209. https://doi.org/10.1111/j.1440-1800.2005.00268.x

73.

Tindle

Windsor

Yates

(2018). Centralizing temporality in adolescent and young adults cancer survivorship. Qualitative Health Research, 29(2), 173–183. https://doi.org/10.1177%2F1049732318797087

74.

Ustjanauskas

A. E.

Quinn

G. P.

Pan

T. M.

Rivera

Vázquez-Otero

Ung

Roetzheim

R. G.

Laronga

Johnson

Norton

Carrizosa

Muñoz

Goldenstein

Nuhaily

Wells

K. J.

(2017). Facilitators of survivorship care among underserved breast cancer survivors: A qualitative study. Journal Cancer Education, 32(4), 756–763. https://doi.org/10.1177%2F1049732318797087

75.

Vos

M. S.

Putter

Van Houwelingen

H. C.

De Haes

H. C.

(2011). Denial and social and emotional outcomes in lung cancer patients: The protective effect of denial. Lung Cancer, 72(1), 119–124. https://doi.org/10.1016/j.lungcan.2010.07.007

76.

Williams

Jeanetta

S. C.

(2015). Lived experiences of breast cancer survivors after diagnosis, treatment and beyond: Qualitative study. Health Expectations, 19(3), 631–642. https://doi.org/10.1111/hex.12372

77.

Willig

(2013). Introducing qualitative research in psychology (3rd ed.). Open University Press.