Experiences of Patients With Breast Cancer Regarding Korean Medical Treatment Approaches: A Qualitative Study Protocol

Abstract

The importance of a complementary medical approach for patients with breast cancer is being emphasized to improve their quality of life and manage treatment-related symptoms. Korean medical treatment methods such as acupuncture, moxibustion, and herbal medicine are widely used to treat the side effects and sequelae of cancer treatment, such as pain, lymphedema, gastrointestinal disorders, and psychological issues. However, qualitative research on the perceptions of Korean patients with breast cancer regarding Korean medical treatment is lacking. This study aims to explore the how patients with breast cancer choose Korean medicine as a treatment option, patient experience regarding various therapeutic interventions, and their perception of the advantages and disadvantages of Korean medicine. A qualitative research methodology will be employed and semi-structured, in-depth interviews will be conducted with around 15 patients with breast cancer aged 19–75 years who have undergone Korean medical treatment, and each interview will last approximately 60–120 min. If necessary, interviews will be conducted up to three times. Data will be analyzed using the grounded theory methodology. This study will investigate the benefits and limitations of Korean medical treatment as a remedy for the medical needs of patients with breast cancer. These outcomes could be used as foundational data for future quantitative cancer research and serve as a basis for the development of patient-centered Korean medicine healthcare systems.

Keywords

Korean medicine breast cancer qualitative research grounded theory research

Background and Study Justification

Extended Morbidity Periods of Breast Cancer Patients

Breast cancer is among the most common malignancies, and its incidence and mortality rates are steadily increasing globally. Projections suggest that there will be approximately 2.74 million new cases annually by 2030, resulting in an estimated 857,000 deaths (Arnold et al., 2022). Breast cancer has the highest incidence rate (21.1%) among Korean females (Kang et al., 2023). Owing to early diagnosis and treatment, the survival rate of patients with breast cancer in Korea is relatively high, with reported a 5-year relative survival rate of 93.8% in 2020. Owing to these characteristics, the treatment needs of patients with breast cancer persist for the subsequent survival period, even after diagnosis and remission.

Patients with breast cancer receive different treatments, and various side and aftereffects have been observed. Patients typically undergo initial procedures such as breast-conserving surgery and radiation therapy (Harbeck & Gnant, 2017), followed by hormone therapy and chemotherapy to prevent recurrence (Hwang et al., 2015). The side effects of these treatments, including pain at the surgical site, neuropathic pain, lymphedema, fatigue, vasomotor symptoms (such as hot flashes and insomnia), and psychological symptoms (such as reduced self-esteem and depression), have been reported in various studies (Mouridsen, 2006; Muzzatti et al., 2020; Senkus-Konefka & Jassem, 2007). After being diagnosed and surviving for longer than 5 years, 17% of patients with cancer were unable to work due to health problems, and 58% reported one or more functional limitations (Hewitt et al., 2003). This indicates that cancer treatment is not only limited to combating the disease but also entails a prolonged and ongoing process for patients.

Role of Korean Medicine as a Comprehensive Treatment Strategy

The decline in physical function and subsequent psychological stress experienced by patients with breast cancer have highlighted the need for complementary and alternative medicine (CAM) (Nahleh & Tabbara, 2003). Specific CAM modalities such as acupuncture, aromatherapy, biofeedback, massage therapy, meditation, and qigong have been used to improve the quality of life of patients with breast cancer and alleviate symptoms such as fatigue, anxiety, depression, and sleep disturbances (Baum et al., 2006). Particularly, acupuncture has been reported to alleviate the adverse effects of chemotherapy and radiation therapy, including peripheral neuropathy, nausea and vomiting, lymphedema, and xerostomia (Chien et al., 2019; Zhang et al., 2021). Treatment based on Korean medicine includes various therapeutic remedies such as herbal medicine, acupuncture, moxibustion, and lifestyle modifications (Yoon et al., 2013). Korean medicine approaches for patients with breast cancer have been employed to manage symptoms resulting from chemotherapy as well as a palliative care option for patients who discontinue chemotherapy for inevitable reasons (Lee et al., 2017).

Qualitative research confirmed the perception and subjective efficacy of Korean medical treatments in patients with breast cancer. Patients with breast cancer reported that they chose integrative alternative medicine to restore health and enhance their immune system (Saibul et al., 2012) as well as to alleviate anxiety and depression by seeking novel treatment methods (Lengacher et al., 2006). Especially in Korea, 67% of patients with breast cancer receive integrative alternative medicine, and the tendency toward Korean medicine is significantly associated with cancer severity, education level, and age (Hwang et al., 2015). Patients who received acupuncture and moxibustion for lymphedema reported improved quality of life and a more positive outlook on life after treatment (de Valois et al., 2016). Further, some patients reported relief from numbness in the extremities and sleep disturbances after acupuncture treatment (Stöckigt et al., 2021).

Bridging the Gap Between Medical Approach and Patient Perspective

Korean medicine is considered a necessary treatment strategy for patients with breast cancer, as several hospitals have collaborative treatment programs for secondary symptom management (Choi et al., 2021), and patients show positive responses toward the treatment (Schapira et al., 2014). However, a gap exists between patients’ perceptions of Korean medical treatment and their actual use. Lowe et al. reported that the positive response of patients with breast cancer toward complementary therapies such as exercise therapy does not necessarily align with the actual participation rate (Lowe et al., 2015). Because Korean medicine is not a conventional treatment for managing cancer symptoms, we anticipated that there would be barriers to accessing such treatments and that there would be certain characteristics among patients who choose to use them. Furthermore, considering that patients with breast cancer undergo various changes in their physical features and interpersonal relationships during their illness (Frierson et al., 2006), we deemed it valuable to investigate how their experiences with Korean medical treatment influenced their perceptions of life and disease.

Quantitative research methods have limitations in providing an in-depth understanding of patient recognition and experiences, especially when considering the personalized and holistic characteristics of Korean medical treatments (Choy, 2014). Therefore, the introduction of a qualitative research methodology is crucial for providing a profound and comprehensive understanding of patients’ perceptions and behaviors (Renjith et al., 2021). We will conduct in-depth interviews on perceptions before treatment, the experience of the treatment itself, and the judgment and additional demands of Korean medicine after treatment.

Recently, the importance of practical data, surpassing the limitations of traditional epidemiological investigations and clinical studies, has been gaining attention (Liu & Panagiotakos, 2022). This study will provide patient-centered information on the Korean medical treatment for patients with breast cancer. This study aims to investigate the benefits and limitations of Korean medical treatment and construct an integrated medicine program model that meets the needs of patients with breast cancer.

Research Questions

1. What are the reasons and pathways for patients with breast cancer to choose Korean medical treatments?

2. What are the advantages and limitations of choosing or continuing Korean medical treatments for patients with breast cancer?

3. What changes do patients with breast cancer experience after receiving Korean medical treatment?

Explanation and Justification of Method

Study Design

To explore the motives and experiences of patients with breast cancer who chose Korean medical treatment, we utilized a qualitative research methodology. For data collection, we will conduct in-depth interviews based on semi-structured questionnaires, and for data analysis, we aim to adopt the grounded theory method proposed by Glaser and Strauss (Strauss & Corbin, 1997). According to Charmaz, grounded theory is an inductive, iterative, and interactive method that identifies symbols inherent to people’s perceptions and behaviors. The interview questions will be comprehensively designed to encompass participants’ specific experiences, and methodological flexibility will be maintained during the interview and analysis. The results will be reported in accordance with the Standards for Reporting Qualitative Research (O’Brien et al., 2014).

Study Setting

In-depth interviews will be conducted with individuals aged 19–75 years who received Korean medical treatment at least once for breast cancer or related symptoms. Currently, the patients may be undergoing treatment for breast cancer or treatment may have been completed. Prior to conducting the interviews, a brief questionnaire will be administered to gather information such as sex, age, medical history, and history of breast cancer treatment (Supplemental 1).

The study will be conducted between March 2024 and March 2025 at the Korean Medicine Hospital affiliated with Kyung Hee University and the National Medical Center. Interviews will be conducted in consultation rooms within the hospital or in spaces suitable for private conversations. Online non-face-to-face consultations are also planned only in cases where in-person interviews were not possible. Individuals who have received specialized training in qualitative research methodologies will conduct the interviews. Each interview will last approximately 60–120 min, and if the first session is deemed insufficient, additional interviews will be conducted with up to three sessions per person. We will continue data collection until theoretical saturation, and data analysis will be conducted simultaneously based on the grounded theory approach.

Inclusion Criteria

1. Individuals who received Korean medical treatment at least once for breast cancer as well as breast cancer related symptoms at a Korean medicine institution.

2. Individuals aged between 19 and 75 years old.

3. Individuals who received sufficient explanation of the study and will voluntarily agree to participate.

Exclusion Criteria

1. Patients with breast cancer unable to undergo interviews because of impairments in their mental and cognitive functions caused by cancer-related complications.

2. Individuals deemed unable to undergo interviews due to hearing or language impairments.

Recruitment and Sample Size

Interview participants will be selected from individuals who can provide abundant information on breast cancer and Korean medical treatment. Extreme and snowball sampling methods will be used for the recruitment. Additionally, patients who visited Kyung Hee University Korean Medicine Hospital for Korean medical treatment, met the inclusion criteria, and signed the consent form for research participation will be eligible to participate in the study. All participants will receive information about the purpose, process, and methods of the research prior to the initiation of the study and will receive documented consent forms. After obtaining consent, the interview schedule will be adjusted according to the participants’ availability.

The number of research subjects is set at 15, as recommended by Gutterman for phenomenological studies on experiences (Guetterman, 2015). However, if data saturation is not achieved, additional interviews may be conducted, even after interviewing 15 patients.

Data Collection

This study will be conducted through one-on-one in-depth interviews using semi-structured questionnaires. The interview questions have been developed by a research team comprising professionals with sufficient experience in qualitative research and possessing licenses as Korean medicine doctors. Table 1 Interview will be conducted by female Korean medicine doctors (SN and IA) who have experience in qualitative research, and have a Master’s Degree and Bachelor’s Degree in Korean medicine respectively. These questions aim to explore the perceptions of patients with breast cancer before, during, and after receiving treatment with Korean medicine. Specifically, the questions will inquire about the motives behind treatment choices, specific experiences, and perceptions of Korean medical treatment.

Table 1.

Interview Guide.

Motivation behind choosing Korean medical treatment as a patient with breast cancer

· How did you come to receive Korean medical treatment?

· What did you expect before receiving Korean medical treatment?

The experience of receiving Korean medical treatment

· What type of Korean medical treatment did you receive?

· What aspects of the treatment did you find beneficial?

· What aspects of the treatment did you find uncomfortable or inconvenient?

· How did individuals close to you react to your decision to receive Korean medical treatment?

The significance of receiving Korean medical treatment for breast cancer patients

· Have there been any changes since receiving Korean medical treatment?

· Do you plan to continue receiving Korean medical treatment in the future?

Data Analysis

All interviews will be recorded and transcribed and nonverbal expressions and pauses will be documented by the researchers. The researchers will be required to read the transcribed documents multiple times, extract meanings, and gather similar content. MAXQDA software will be used for data analysis.

Following completion of the first interview, the initial analysis will commence based on the transcribed content. We will use an open coding method to understand and classify the collected data according to themes. Subsequently, additional data collection and categorization directions will be proposed based on theoretical sampling. This process will be iteratively repeated as new interview data from additional participants are generated. With the accumulation of data from interviews with additional participants, intermediate coding was conducted to create core categories and relationships between the concepts. Advanced coding will then conceptualize the core categories, ultimately deriving a grounded theory on the experience of patients with breast cancer with Korean medical treatment (Chun Tie et al., 2019).

Data analysis will be conducted by the same researchers who conducted the interviews to maintain objectivity in the analysis process and results. The analytical content will be shared with the researchers licensed as Korean medicine doctors with sufficient qualitative research experience. Patient information and CRFs will not be disclosed to the reviewing researchers; only anonymized transcribed data and analysis results will be shared.

Techniques to Enhance Trustworthiness

To ensure the validity and reliability of the research, participant review and data triangulation will be employed, and two or more researchers will be involved in the in-depth interviews and analysis. The analysis results will be reviewed multiple times and a joint analysis will be conducted. In addition, consultations with experts with qualitative research experience will be discussed and revised as necessary. The aim is to enhance the quality of the research report based on the COREQ (Consolidated criteria for Reporting Qualitative research) guidelines. (Tong et al., 2007).

Ethics and Dissemination

This study will adhere to the Declaration of Helsinki (64th WMA General Assembly, Fortaleza, Brazil, October 2013). As this research is qualitative and is based on interviews, it is deemed to involve no risks related to the research; however, if a research participant expresses discomfort during the interview, the interview will be temporarily paused, and if a participant wishes to withdraw from the research, the research will be immediately discontinued. Vulnerable participants will be excluded from the study. This study will be conducted after approval from the Institutional Review Board (IRB) and will adhere to relevant regulations regarding any changes that may occur during the research process.

All documents related to the research, such as case report forms, will be recorded and distinguished by the research subject identification code instead of the participant’s name. No identifiable information (such as name, resident registration number, address, or phone number) of the participants will be recorded. Maximum effort will be made to protect personal information. Records that can identify the identity of the research subject will be maintained confidential.

Research data will be stored in cabinets with locks and only authorized researchers will have access to it. All documents containing research data will be stored on computer storage devices in locked research rooms with security settings that allow access only through separate passwords, ensuring the protection of records from unauthorized access.

The research protocol has been submitted to the Institutional Review Boards of NMC and KHMC and has been approved in January 2024 and February 2024, respectively. (IRB No. NMC-2024-02-019, KHMC-2024-01-003).

The results will be disseminated in newspaper and journal articles.

Rigor

The reliability of this study is based on the trustworthiness criteria proposed by Guba and Lincoln (Lincoln & Guba, 2004). Trustworthiness is guided by four principles of credibility, transferability, dependability, and conformability. For credibility, interviews will be conducted with participants for an adequate period and the interview content will be transcribed verbatim. Peer reviews by researchers will be conducted to review the data. Regarding transferability, we will conduct a thorough demographic investigation of the participants. To ensure the conformability of the study, interviews will be conducted in comfortable and private spaces using open-ended questions to encourage active participation. The research data will be anonymized to maintain confidentiality during the data analysis. To ensure the dependability of the results, researchers will closely observe the participants’ responses and maintain records via audio recordings and transcription.

Discussion

This qualitative study aims to provide a profound understanding of how patients with breast cancer perceive Korean medicine as a treatment option. Research on Korean medical treatment for patients with cancer in Korea is limited, and existing qualitative studies have mainly focused on specific interventions (such as acupuncture alone) or specific patient groups (such as lymphedema patients) (Kim et al., 2018). This study aims to gain insights into the motivations of Korean medicine and understand its role and limitations in the treatment of breast cancer-related symptoms.

Breast cancer has a high survival rate, and patients undergo several cycles of chemotherapy treatment and a significant period of follow-ups even after surgical treatment. Accordingly, patients with breast cancer experience various treatment-related symptoms (Pinto & de Azambuja, 2011), and the need for a more holistic and comprehensive treatment approach has been emphasized (Greenlee et al., 2017). In the clinical field, Korean medical treatment methods, such as acupuncture (Han et al., 2022), moxibustion (Ji et al., 2021), and cupping therapy (Wang et al., 2018) are being used to control the symptoms of cancer (including pain, nausea and vomiting, and vasomotor symptoms) (Bao et al., 2018; Li et al., 2020; Pan et al., 2018). Moreover, Schapira et al. reported that patients with breast cancer expressed positive views of Korean medical treatment and desired further treatment (Schapira et al., 2014). However, the research exploring the treatment experiences and perceptions of patients with breast cancer from a multifaceted perspective is lacking. Consequently, evidence regarding the role of Korean medicine in treating breast cancer symptoms is lacking. The actual treatment effects on patients are influenced by various social contexts, such as national policies, healthcare systems, and environments (Davies, 2003), and integrative alternative medicine is particularly susceptible to these factors (Shim, 2015). Hence, we expect that this qualitative study will provide an opportunity to contemplate the needs of patients with breast cancer in Korean medical treatment.

This proposed study has several limitations. First, due to the interview-centered nature of the study, it remains challenging to provide objective evidence of treatment efficacy. Additionally, because the study focused on Korean patients, there are limitations in generalizing the results. Second, this study targets patients who have already received treatment with Korean medicine; hence, it provides a limited perspective on the total population of patients with breast cancer. Obtaining a fair perspective may be challenging because the perspectives of patients who have chosen not to undergo Korean medical treatment or have not yet received treatment cannot be documented. Additionally, as all researchers are qualified Korean medicine doctors, there is a high likelihood of positive underlying consciousness regarding Korean medicine. Consequently, maintaining objectivity in the data interpretation process may be challenging, making it difficult to represent the perspectives of patients and other medical professionals.

Nevertheless, this study is expected to provide practical data from patients to interpret the significance of Korean medicine for patients with cancer and obtain more realistic information about the role of Korean medicine in treatment. The results of this study can serve as foundational data for quantitative research on Korean medical treatment for breast cancer and can be used as evidence for developing Korean medical treatment models for patients with breast cancer.

Supplemental Material

Supplemental Material - Experiences of Patients With Breast Cancer Regarding Korean Medical Treatment Approaches: A Qualitative Study Protocol

Supplemental Material for Experiences of Patients With Breast Cancer Regarding Korean Medical Treatment Approaches: A Qualitative Study Protocol by Seungjin Noh, Yejin Hong, Jisu Ha, Sunjoong Kim, Inae Youn, and Dongwoo Nam in International Journal of Qualitative Methods

Footnotes

Acknowledgments

This research is supported by the Korean Medicine Hospital affiliated with Kyung Hee University and the National Medical Center, Republic of Korea. We express our gratitude to all of the potential participants of the study.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the National Medical Center, Republic of Korea. (Grant number: I_2024_015).

ORCID iDs

Seungjin Noh

Yejin Hong

Sunjoong Kim

Inae Youn

Dongwoo Nam

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Supplemental Material

Supplemental material for this article is available online.

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