Type and design

This study followed a qualitative approach and had a reflexive thematic analysis design. The former allowed for in-depth analysis of the study subject in its natural environment, reviewing the data and determining its categories ²⁴. The design of this research allows the understanding of the information by focusing on the topics determined by the participants and explained by the researchers, associating the data according to patterns in relevant topics ²⁵.

Participants

We included sixteen women aged 35 to 65 years (Table 1) diagnosed with breast cancer who received medical care at a level-3 public hospital in Metropolitan Lima, which specializes in oncological care. We applied convenience sampling, which is used when there is little accessibility to the population ²⁶; this is the case of the present study, where the subject matter is associated with severe disease.

Patients in stages II and III were included, detected at least one year before this research. Those who presented physical comorbidity or some psychopathological alterations were excluded, due to the differences in terms of treatment, physical and psychological consequences, process of adaptation to the diagnosis, professional and family support, as well as in the care provided by the hospitals that specialize in cancer ^{5 , 13}.

Instruments for data collection

We used a semi-structured interview (Table 2) that was constructed based on the theoretical contributions about psychological coping explained from the topics of emotional, resolute and avoidant coping ¹⁸. The interview guide was evaluated by ten expert judges, health professionals knowledgeable about cancer patients, who evaluated the clarity, coherence and representativeness of the questions; their approval was obtained in order to carry out the interviews. A pilot interview was conducted by telephone call, which helped refine the questions for the final interview guide.

Procedures

First, we reached out to the president of a group of breast cancer patients from a hospital in Lima via a social network; with her approval, the patients were contacted for the first time. We contacted 37 women, 17 of whom agreed to participate in the research; however, only 16 met the inclusion criteria. Subsequently, the participants were informed about the purpose of the research. They gave their informed consent orally, which was recorded on audio files. Likewise, they were told about the confidentiality, anonymity (use of pseudonyms), beneficence and nonmaleficence principles that guided this research.

Subsequently, the interviews were scheduled and then conducted via telephone calls. During the telephone calls, we ensured that the participants were alone and in a comfortable space (usually the living room of their home). The interviews were conducted between September and October 2020, and lasted an average of 40 minutes. The interviews, as well as the verbatim transcription, were carried out by the researchers FR and PC, who worked on an equal number of interviews. No patient refused to participate or dropped out of the study. Likewise, no payment was given for participating in the interviews, which were conducted in one session (there were no repetitions) and in Spanish.

Data analysis

We followed the guidelines of reflexive thematic analysis with a hybrid method ²⁵. The process started with the familiarization with the data, through transcriptions. Sub sequently, initial codes were generated and assigned to the relevant quotations in the document; we applied a double cycle of axial and selective coding by patterns ²⁷. In parallel, we generated, reviewed, and defined the themes, which were identified by the constant comparative method, grouping the codes into categories. Finally, we prepared the results report, where the strategies of meaning generation were found ²⁸, such as the identification of patterns, which allows evidencing the saturation of the codes and/or categories; the count, which allows showing the magnitude of the codes throughout the analysis; and the density, which evidences the explanatory power of the codes, through their connections with other codes and/or categories. The categories that fulfilled at least one of the aforementioned tactics were considered as major themes. The analysis was carried out mainly by FR and PC, and they discussed and solved the discrepancies in the coding together with MS. The analysis was carried out with the support of ATLAS.ti 22 software.

Ethical and quality criteria

Permission was obtained from the ethics committee of the Graduate School of the Universidad Peruana Unión (No. 2022-CE-EPG-0000116). This article is adapted to the criteria of the Consolidated Criteria for Reporting Qualitative Research (COREQ) ²⁹.

The present study meets quality criteria such as credibility ³⁰, since the transcripts and results of the study were given to the participants to verify the information and obtain their opinions; however, there were no additional comments from them. It also complies with the confirmability criterion ³⁰, since data collection, analysis and results can be traced and verified to their origin, which generates a logical chain of evidence. Next, auditability ³¹, which implied the triangulation of researchers by auditing the interview guide through 10 expert judges.

Emotional coping

This coping strategy was the most frequently found and involves actions focused on emotions, with the aim of improving the current situation. In this regard, the patients sought social support from close people, whether from family, friends, support groups or religious groups, this was important for stage III patients.

In my case, my friends at work told me: cheer up, SN, seek another opinion. SN, 35 years old.

This is a direct way of coping, with the aim of seeking understanding, trust and empathy. They also showed religious coping, which helped them become closer and strengthened their beliefs.

I am a believer, that was my support [... ] I believed that God’s will was being clear with the relapses and I had to accept it [... ] I am moving forward for my healing. CR, 51 years old.

On the other hand, participants also showed that they focus on the positive consequences of the disease, which leads them to generate a positive reinterpretation, as they recognize beneficial experiences in the face of what they have lived; at this point, they point out to carry out new activities and revalue daily activities (spending time with the family and improving self-care).

But as a result of this diagnosis, I have decided to do things that I was always thought of doing later. So, now I have dedicated myself to music, I plan to teach, it fills my soul, my life and everything. It’s something I enjoy. TC, 56 years old.

An element that emerges from the positive reinterpretation is the progressive acceptance of the disease, thus, although they had feelings of fear and worry at the beginning, they later experienced surprise and tranquility, and came to accept the disease.

One has to live with it, there is nothing else to do, although you still miss your life before, the things you used to do. JN, 58 years old.

In this sense, women sought support from close personal environment, in search of understanding, trust and empathy, which made them feel accompanied in order to control the emotions caused by the disease.

Likewise, approaching religion made them feel that the disease is an obstacle to overcome, which gave them faith and strength, making them feel comforted while they focused on the positive consequences, either to avoid increasing negative emotions or because they had a more optimistic perspective of life situations in accordance with their personality, so they could have a positive reinterpretation, achieving a progressive acceptance of the disease.

Resolute coping

The patients, during their first experiences with the diagnosis, took diligent actions to intervene directly in the face of suspicions about their condition, especially when seeking a medical opinion to confirm their diagnosis and learn about the possible treatments they would have to undergo. In the face of this, they focused on following medical indications.

Just following what the doctors told me, right? They are the ones who tell you, first the surgery, the mastectomy, radiation, biopsy, an appointment for this, for that, they are the ones you have to follow. SF, 51 years old.

Therefore, the patients sought professional support, both physical and psychological, in order to reduce the adverse effects of the disease, which is representative of women in stage II.

When I went to the psychologist, he helped me a lot because I felt that this person made me feel calmer, I felt the hugs from the doctor who supported me, he always tells me: You are getting over it, you are doing fine. DN, 52 years old.

On the other hand, participants stated that they omitted daily activities, whether work, academic or home activities that they carried out before learning of their diagnosis, in order to focus all their temporal, mental and physical efforts to carry out the treatment and its implications.

Before, everything was normal, but when I found out, since then, I have been almost a year without working, since the treatment, the operations, the chemotherapy and now the radiotherapy take too much time [... ] so, it is practically dedicating all that time to just cure yourself. TC, 56 years old.

Thus, the suspicion of breast cancer produces uncertainty, so in order to reduce it, patients seek medical attention to learn about their condition. When they already know about it, they focus on complying with medical indications, due to hasty decision making to avoid aggravation of their health. Thus, they seek professional support to improve their physical and mental condition; likewise, they are committed to set aside routine activities, studies and work, due to lack of time, motivation and physical limitations.

Avoidant coping

Some participants focused on the negative elements of their diagnosis (limitations regarding work, physical, emotional aspects, etc.), which made it difficult for them to continue with their daily activities. Therefore, they avoided these tasks, which caused them to postpone coping at a certain point, which implied an immobilizing reflection on the fact, hiding the diagnosis from those close to them and seeking different medical opinions before starting any treatment.

Well, to get closer, to verify, to have other opinions, until I rectified that, if it really was cancer, and to start with the treatment, right? TC, 56 years old.

Participants also reported focusing on other thoughts and activities in order not to focus on the disease, thus seeking cognitive and behavioral distraction, including family activities, helping others and having behaviors related to the improvement of their health. It is relevant to point out that although these distractors reorganize the patients’ activities, they are also necessary to balance their daily tasks. This was more significant in stage III patients.

Yes, to avoid thinking about my illness, I look for more things to do, if I finish cooking, washing the dishes, sewing, I give myself more work to do. It helps me to clear my mind and not have negative thoughts. MR, 48 years old.

In general, women who use avoidant coping are indifferent to the condition, so that, when they consider the negative elements, they prefer to postpone coping, either by avoiding prioritizing the diagnosis or by increasing the time dedicated to other activities in order to reduce the stress they are experiencing. In this way, thoughts related to worsening physical and emotional health will decrease.