Surviving cancer, managing the heart: Awareness of potential cardiovascular toxicity and barriers to cardiovascular self-management among women with breast cancer: A qualitative descriptive study

Abstract

Objective

This study aimed to explore how women with breast cancer perceived potential cardiovascular toxicity and engaged in self-management to support their cardiovascular health, monitor for symptoms, and adhere to clinical surveillance.

Methods

A qualitative descriptive design was employed. Semi-structured interviews were conducted with a purposively selected sample of 12 women with breast cancer. The interviews were audio-recorded with the participants’ consent and transcribed verbatim. NVivo 12 was used to organise the data, which were analysed using inductive thematic analysis to develop themes and subthemes.

Results

The study included 12 women aged 40–74 years. Participants reported multiple challenges in recognising and understanding potential cardiovascular toxicity, possible cardiovascular symptoms, and other treatment-related symptoms. Four themes and nine subthemes were identified: (1) overwhelming physical and functional burden of treatment; (2) fragmented knowledge and awareness of potential cardiovascular toxicity; (3) health care communication gaps and unmet informational needs; and (4) psychosocial and systemic barriers to overall well-being and health management.

Conclusions

The participants faced substantial barriers to understanding and monitoring for potential cardiovascular toxicity. These challenges highlight the need for the future development and evaluation of more proactive, patient-centred interventions. Proposed strategies, such as tailored education, symptom-reporting tools, and structured follow-up models, require future research to determine their effectiveness.

Introduction

Cancer therapy, including anthracycline- and taxane-based treatments, has been associated with adverse effects such as cardiotoxicity.¹ The absolute risk of cancer therapy-related cardiovascular toxicity (CTR-CVT) varies widely depending on the specific agent used, cumulative dose, treatment schedule, concomitant therapies, such as trastuzumab or radiotherapy, and patient-specific factors, including age, cardiovascular comorbidities, baseline left ventricular function, and genetic susceptibility.^2,3 Given that anthracycline- and taxane-based regimens are commonly used in breast cancer treatment,⁴ cardiovascular toxicity is an important survivorship concern for women with breast cancer and the health care professionals involved in their care. In a prospective study of 2625 participants, including 51% with breast cancer, the overall incidence of anthracycline-related cardiotoxicity was 9% (226 out of 2625), and 9.7% of women with breast cancer experienced cardiotoxicity, with 98% of cardiotoxicity cases occurring within the first year of follow-up.⁵

Because CTR-CVT often progresses insidiously and can be clinically silent in its early stages,⁶ patient awareness and timely symptom recognition are clinically important. Proactive cardiovascular health self-management—which includes monitoring for early warning signs, adhering to clinical surveillance, and maintaining open communication with health care providers—is an important component of early referral to cardio-oncology specialists and optimizing long-term outcomes. Therefore, health care professionals must equip women with breast cancer with clear, actionable education regarding cardiovascular risks and symptom management. Such health education should go beyond informing patients that CTR-CVT may occur; it should also provide practical guidance on symptom recognition, when and how to seek help, and ways to maintain cardiovascular health during and after cancer treatment.

Effective self-management in the context of cancer care refers primarily to strategies that support overall cardiovascular health and functional capacity—such as adopting heart-healthy lifestyles, following balanced diets, managing emotional well-being, and participating in exercise programmes—rather than interventions proven to eliminate drug-specific cardiotoxic mechanisms.^7,8 In this study, cardiovascular health self-management is understood as patients’ efforts to maintain general cardiovascular well-being, recognize possible warning signs such as unusual fatigue or shortness of breath, communicate symptoms to clinicians, and follow recommended surveillance. Self-management strategies—particularly structured, supervised aerobic and resistance training, nutritional optimization, and psychosocial support—are therefore best viewed as complementary measures that can improve fitness, symptoms, and long-term cardiovascular risk, while formal cardio-oncology surveillance and evidence-based medical therapies address drug-specific cardiotoxicity when present. It is also important to distinguish the multiple contributors to reduced cardiac health in women with breast cancer:9, 10, 11 (1) direct cardiotoxic effects of anticancer therapies, such as anthracycline-induced myocyte injury; (2) secondary deconditioning attributable to treatment-related morbidity, such as fatigue, peripheral neuropathy, which collectively limit physical activity; and (3) inactivity driven by the sequelae of the disease itself, age-related decline, and social determinants of health.

However, there is limited understanding of how women with breast cancer perceive the risk of CTR-CVT and how they manage its potential consequences in daily life, largely due to the scarcity of qualitative evidence in this area. Although cardio-oncology has received increasing attention, qualitative evidence remains limited regarding how women with breast cancer understand cardiovascular toxicity, interpret possible symptoms, communicate cardiovascular concerns with health care professionals, and incorporate cardiovascular health self-management into daily routines. This represents an important knowledge gap because survivorship care depends not only on clinical surveillance, but also on patients' awareness, confidence, and capacity to participate actively in their own care. A qualitative approach is therefore essential to deeply explore patients’ understanding of cardiovascular toxicity, their communication dynamics with care teams, and the real-world challenges they face in cardiovascular self-management. Exploring these perspectives is crucial to addressing the gaps in survivorship care and guiding the development of targeted interventions. Therefore, this study aimed to provide insights into the awareness, perceptions, and experiences of women with breast cancer regarding potential cardiovascular toxicity, as well as the self-management strategies they adopted to support their general cardiovascular health, monitor for symptoms, and adhere to clinical surveillance.

Methods

The qualitative methodology employed in this study was “fundamental qualitative description”,¹² an approach particularly suited to exploratory research when prior knowledge of the topic is limited. As an interpretive method, qualitative description adopts a naturalistic perspective to examine phenomena, offering a detailed summary of experiences and perceptions as described by participants within their everyday contexts.^12,13

Setting and sample

This study was conducted at the First Affiliated Hospital of Jinan University in Guangzhou, China, where the Head Nurse of the breast cancer department served as a team member supporting this research. The Head Nurse's role included screening the department's clinical records to identify initially eligible participants and distributing initial information about the study to these potential participants via standardized study flyers or information sheets. To ensure patient confidentiality and prevent any sense of obligation, her role was strictly limited to these preliminary distribution activities. She did not conduct recruitment discussions, obtain informed consent, or know which patients agreed, declined, or did not respond. To minimise potential coercion and reduce the influence of clinical hierarchy, all subsequent recruitment procedures were conducted by an independent research assistant who was not involved in participants' clinical care. Specifically, the initial study information instructed interested patients to contact the independent research assistant directly if they wished to participate or learn more. Because patients initiated this secondary contact independently, the Head Nurse and the rest of the clinical team remained completely blinded to who opted in, who declined, and who simply did not respond. This separated pathway ensured that recruitment was entirely voluntary and that patients' clinical care was not influenced by their research participation status.

Purposive sampling was utilised to select eligible participants who could provide detailed insights relevant to the research question.¹⁴ Eligibility criteria included (1) patients aged 18 years or older; (2) a confirmed diagnosis of breast cancer at any stage; (3) patients currently receiving or having completed treatments with cardiotoxic cancer therapies, including anthracyclines, taxanes, and/or anti-human epidermal growth factor receptor 2 (HER2) antibodies,¹⁵ and/or had a cardiovascular condition or symptom (e.g., hypertension, arrhythmia, reduced left ventricular ejection fraction (LVEF) or chest pain or tightness) documented in their clinical records; and (4) patients able to read, write, and/or communicate in Chinese. Women with breast cancer with acute infectious diseases, severe neurological, respiratory, or renal deficiencies, or concurrent malignant diseases were excluded from the study. Participants were selected to ensure variation in age, breast cancer stage, type of potentially cardiotoxic treatment and cardiovascular issues.

Procedure

Potential participants were introduced to the study by the Head Nurse, who provided them with participant information letters outlining the study's purpose, procedures, and rights. Those expressing interest were invited to join the study by contacting the independent research assistant directly. The interviews were scheduled at times and locations that were convenient for both the participants and the research assistant. To prepare for data collection, the first author (X-L L), who possessed expertise in qualitative research methods, provided training to the research assistant in both interview techniques and data analysis. The research assistant subsequently confirmed final eligibility, explained the study in detail, answered questions, coordinated communication with interested patients, and obtained written informed consent. Patients were informed that participation was entirely voluntary, that they could decline or withdraw at any time without giving a reason, and that their decision would not affect their treatment, access to services, or relationships with health care professionals. The interviews were conducted by the research assistant, while the first author (X-L L) reviewed the interview data for accuracy and made notes.

Data collection

Semi-structured interviews were conducted. This method allowed for an in-depth understanding of both the health care and self-management contexts.¹⁶ The semi-structured interviews were guided by a predefined set of questions (Supplementary File 1) and supplemented with prompts to elicit further details, clarify responses, and allow the participants to provide additional insights.¹⁷ The interview guide was developed based on a comprehensive review of the relevant literature, the core study objectives, and the collective clinical and methodological expertise of the research team, which included specialists in oncology, cardiology, and qualitative research. The interview questions were pretested with three women who met the inclusion criteria but were not part of the final study. The pre-tests confirmed the adequacy and suitability of the interview guide, resulting in minor modifications to the phrasing of certain questions to enhance clarity for lay participants. The interviewer followed the original guide, which directly introduced the topic of cardiovascular toxicity. To accommodate participants unfamiliar with this clinical term, the interviewer adapted the wording and prompts to match their comprehension levels. While the core questions remained consistent, the interviewer facilitated discussion using broader concepts, such as “heart health” or “how some cancer treatments might affect the heart over time”, rather than listing specific symptoms.

An initial screening of clinical records by the Head Nurse identified 21 potentially eligible patients. However, study information was not distributed to all 21 patients simultaneously. Instead, during the data collection phase, the research assistant and the first author collaboratively reviewed the clinical profiles of these 21 patients to guide an iterative purposive sampling process. Based on this ongoing assessment, only 16 of the 21 patients were ultimately selected. The remaining five patients were not approached because as data collection progressed, it was determined that their specific clinical characteristics (for example, sharing highly similar clinical profiles and treatment histories with participants who had already been interviewed) were already well-represented in the sample, aligning with our purposive sampling goals. Four patients of the 16 approached declined or did not respond due to health constraints, scheduling conflicts, or personal reasons.

The interviews were conducted until “data saturation” (where no new themes or ideas were identified) was achieved.¹⁸ The assessment of data saturation was treated as an ongoing, iterative process. Interviews were transcribed and coded concurrently with data collection. The research team collectively reviewed the emerging codes and preliminary themes after every batch of interviews to evaluate whether new information was still being generated. By the 10th interview, the research team reached a consensus that thematic saturation had been achieved. At this point, the conceptual categories were densely populated, and no new codes or themes were emerging from the transcripts. To confirm this judgment and ensure that no nuanced perspectives were overlooked, two additional participant interviews were conducted.

Data collection took place over a four-month period, from June 2025 to September 2025, during which participant recruitment and interviews were conducted. The interviews took place either during or after the participants had completed their chemotherapy cycles. Interviews were conducted in a private and quiet room at the hospital or another mutually agreed private location to ensure confidentiality and participant comfort. No other persons were present during the interviews. Interviews lasted between 26 and 78 minutes. Participants were interviewed in Chinese, including Mandarin, Cantonese or hometown dialect, according to their preference and usual mode of communication. One participant (P10) was interviewed in her hometown dialect by a research assistant who spoke the dialect fluently, with no interpreter or family member present. Background and clinical information were requested at the end of the interviews.

Data analysis

With the permission of the participants, the interviews were audio-recorded and subsequently transcribed into Chinese. To preserve the original meaning and cultural context, the entire analytic process was conducted in Chinese. The interview data were analysed using an inductive thematic analysis approach.^19,20 The codes and themes were driven directly by the participants’ narratives rather than being fitted into a pre-existing theoretical framework.

The transcriptions were organised using NVivo 12 software.²¹ The first author (X-L L) conducted the primary coding of the transcripts, while the broader analytical process was collaborative and involved regular team discussion, peer checking, and consensus-based refinement. No other researchers independently coded or analysed the full transcripts; however, members of the research team reviewed the coding framework, sub-themes, and themes developed by the first author to enhance analytic credibility and consistency. The first author read the transcripts multiple times to gain a comprehensive understanding of the data, and reflective notes were made during this process. The analysis began by identifying significant sentences, which were defined as meaningful data segments. In the next step, these segments were condensed and assigned short descriptive codes. Subsequently, the codes were compared to identify patterns, similarities, and differences. Based on the codes, initial sub-themes were developed to reflect the manifest content of the data. The emerging themes were then tested and revised through further analysis of the interview transcripts.

The first author presented the initial codes and proposed thematic structure to all team members during regular meetings. Through these collaborative discussions, the coding framework was reviewed and refined. Because the rest of the team did not independently code the transcripts, any differing perspectives regarding the categorization of codes or thematic definitions were resolved through iterative peer discussions until a consensus was reached. Once the themes were finalized, representative quotations were purposefully selected by the research team based on their richness, clarity, and ability to vividly illustrate the core meaning of each theme. Finally, to ensure accuracy for publication, the finalized themes and selected quotations were translated into English by experienced qualitative researchers (XL L and MB Y) fluent in Chinese and English. These researchers carefully reviewed the translations to ensure that the data extracts and themes accurately reflected the original data.

Strategies for rigor

To ensure methodological rigor, trustworthiness was established through the criteria of credibility, confirmability, dependability, and transferability.²² Credibility was enhanced by including participants with diverse characteristics, such as variations in age, cancer stage and treatment history. Credibility was further supported through peer checking, team-based review of the coding framework, validation of sub-themes and themes, and debriefing with an expert in qualitative methods and the subject area. These procedures were integrated into the collaborative analytic process described above, whereby research team members reviewed the identified codes, sub-themes, and themes and provided feedback to strengthen the consistency and credibility of the findings. Confirmability was enhanced by involving researchers with expertise in qualitative methods and conducting member checking. Specifically, a summary of their individual interview and the preliminary themes was returned to all 12 participants via their preferred communication method (e.g., WeChat or email), and the research assistant asked them to verify whether these documents accurately reflected their experiences and to provide any additional comments or clarifications. Of the 12 participants invited, seven responded. All seven participants who responded confirmed the accuracy of the summaries. Although some participants provided brief, affirming comments that agreed with the findings, they did not offer any further clarifications or corrections; no changes to the coding or themes were required based on their feedback. An audit trail was also maintained, including field notes, reflexive memos, coding decisions, and records of team discussions, to support transparency in the analytic process. Dependability was strengthened by using pretested interview guides, detailed field notes, reflexive documentation, and a clearly documented analytic process involving primary coding by the first author, peer checking, team discussion, and consensus-based theme refinement. Transferability was supported by providing comprehensive descriptions of the study's methodology and context, enabling others to assess the applicability of the findings to different contexts.

Reflexivity

Reflexivity was maintained by explicitly addressing the researchers' positionalities and potential influence on data collection and interpretation. All interviews were conducted face-to-face by an independent female research assistant who was not involved in participants' clinical care. She had prior training in qualitative interviewing and received additional study-specific training from the first author, who has expertise in qualitative methods. Before each interview, the research assistant built rapport by explaining the study purpose, voluntary nature of participation, confidentiality, and the right to withdraw. She also maintained field notes and a reflexive journal to document contextual observations, emerging impressions, and potential preconceptions during data collection. Because the lead researcher, X-L L, is an Associate Professor specializing in cardio-oncology nursing and qualitative methods, the research team held regular reflexive discussions to distinguish professional clinical assumptions from participants' accounts. The multidisciplinary composition of the team, including a veteran breast cancer nurse and academics in cardiovascular nursing, further supported balanced interpretation and reduced the risk of a singular disciplinary perspective. Throughout the analysis, coding decisions and thematic interpretations were reviewed collaboratively, and any questions regarding interpretation were resolved by returning to the raw transcripts to preserve a data-driven, low-inference approach and maintain participants’ intended meanings.

Results

Participants’ characteristics.

The study recruited 12 female participants (age range: 40–74 years), with diverse timelines post-breast cancer diagnosis (from 3 months to 8.5 years). Cancer stages ranged from I to IV, with the majority in stages II, III, and IV. All participants had received anthracycline-based and/or taxane-based chemotherapy, some had also received endocrine therapy. Table 1 provides relevant characteristics of the participants.

Table 1.

Demographic characteristics of participants (N = 12).

Participants' number	Gender	Age (years)	Time since diagnosis	Cancer stage	Potentially cardiotoxic therapies received (obtained from clinical records)	Cardiovascular issues (obtained from clinical records)
P1	Female	74	6 months	II	Anthracycline-based, taxane-based, endocrine therapy	Hypertension; unable to determine if pre-existing or secondary to cancer treatment
P2	Female	68	5 years	IV	Anthracycline-based, taxane-based, targeted therapy	Pre-existing hypertension before chemotherapy treatment
P3	Female	54	6 months	III	Anthracycline-based, taxane-based	Hypertension; unable to determine if pre-existing or secondary to cancer treatment
P4	Female	59	8.5 years	IV	Anthracycline-based, taxane-based, endocrine therapy	LVEF recorded as 60%; baseline value, precise measurement timing, and causal attribution unknown
P5	Female	74	1.5 years	III	Taxane-based	LVEF recorded as 60%; baseline value, precise measurement timing, and causal attribution unknown
P6	Female	58	3 months	I	Anthracycline-based	Arrhythmia after chemotherapy; precise onset timing relative to treatment and causal attribution unknown
P7	Female	41	5 months	III	Anthracycline-based, taxane-based	LVEF recorded as 49%; baseline value, precise measurement timing, and causal attribution unknown
P8	Female	48	8 months	IV	Anthracycline-based, taxane-based	LVEF recorded as 48%; baseline value, precise measurement timing, and causal attribution unknown
P9	Female	59	2 years	II	Anthracycline-based, taxane-based	LVEF recorded as 54%; baseline value, precise measurement timing, and causal attribution unknown
P10	Female	68	9 months	II	Anthracycline-based	Hypertension; unable to determine if pre-existing or secondary to cancer treatment
P11	Female	40	10 months	II	Anthracycline-based, taxane-based	Chest pain and tightness after chemotherapy, precise onset timing, and causal attribution not available
P12	Female	62	1 year	IV	Anthracycline-based, taxane-based, endocrine therapy	Hypertension, arrhythmia after chemotherapy, precise measurement timing, and causal attribution unknown

LVEF, left ventricular ejection fraction.

Thematic Analysis.

Four themes and nine subthemes were identified (Table 2).

Table 2.

Themes and subthemes.

Themes	Sub-themes
Theme 1: Overwhelming physical and functional burden of treatment	Subtheme 1.1: Debilitating neuropathy and mobility challenges limiting general physical function.
	Subtheme 1.2: Gastrointestinal distress and nutritional deficits compounding functional decline
Theme 2: Fragmented knowledge and awareness of potential cardiovascular toxicity	Subtheme 2.1: Disconnect between symptoms and cardiac health literacy
	Subtheme 2.2: Medication-centred management amid limited lifestyle guidance
Theme 3: Health care communication gaps and unmet informational needs	Subtheme 3.1: Brief or non-specific guidance on symptom management
	Subtheme 3.2: Limited or inconsistently understood information about potential cardiovascular toxicity
Theme 4: Psychosocial and systemic barriers to overall well-being and health management	Subtheme 4.1: Emotional distress and mental health burden
	Subtheme 4.2: Financial burden
	Subtheme 4.3: Loss of independence, diminished social participation, and communication barriers

Theme 1: Overwhelming physical and functional burden of treatment.

Participants reported experiencing profound physical challenges to their functional independence during the course of their treatment. These debilitating general cancer treatment-related adverse effects—such as neuropathy, gastrointestinal distress, and fatigue—dominated the participants’ attention, leaving them with limited physical and cognitive capacity.

Subtheme 1.1 Debilitating neuropathy and mobility challenges limiting general physical function. The participants frequently described chemotherapy-induced peripheral neuropathy, characterised by numbness, tingling, and weakness in the extremities. These symptoms restricted daily activities, reduced mobility, and heightened fall risks, which severely limited their capacity to engage in routine physical activity and manage their general health. For instance, P8, a 48-year-old participant, mentioned that health care professionals had advised her not to walk too much because her condition was different from others—she had a low platelet count. She described her progressive deterioration in mobility after the seventh and eighth chemotherapy cycles:

“I couldn’t even walk – how could I exercise? […] Just couldn’t move. […] making it very hard for me to take care of myself … When I walked, I’d wobble. […] Around the seventh or eighth round of treatment, my hands and feet started going numb.” (P8)

Because her focus was entirely on her neuropathy and hematological issues, her severe inability to move represented a profound functional decline that precluded any engagement in basic physical activities or proactive health self-care. P3, a 54-year-old with stage III breast cancer, and P9 shared similar struggles after anthracycline-based chemotherapy. The loss of mobility often led to reduced physical activity, contributing to general physical deconditioning and acting as a major barrier to maintaining everyday functional independence:

“But I still can’t walk too far. Even now, I can’t go far. I walk until I feel like I’m not too tired, then I turn back. […] I’m not as good at walking as before. In the past, I could walk two or three thousand steps a day, but now, after about a thousand steps, I just can’t do it anymore … [I do this] to manage my health” (P3)

“My white blood cell count was low. My head felt weak and dizzy. They did a blood test – turns out I had a bit of anaemia. I didn’t have it in the earlier rounds, but in these last two, I did. Eight rounds of chemo were just too much. After those two rounds, I had some anaemia, so I’ve been taking medicine for it ever since … …When you feel that weak all the time, keeping up with anything for your health feels impossible” (P9)

Subtheme 1.2: Gastrointestinal distress and nutritional deficits compounding functional decline. Chemotherapy-induced nausea, loss of appetite, and bowel dysfunction were nearly universal, leading to malnutrition, fatigue, and metabolic imbalances. The participants received medication-centred management (e.g., antiemetics, laxatives) but were given minimal guidance on lifestyle and dietary adaptations to support their general health and cope with these side effects. P8 highlighted her struggles with malnutrition and having to rely on antiemetics and intravenous nutrition due to severe intolerance:

“It’s just that sometimes I can eat, and sometimes I just can’t. My mouth sometimes feels bitter and dry. […] They [the doctors] just said it’s something wrong with my gut. They gave me medicine for it, and now I’m getting nutrition injections too, just getting nutrition shots.” (P8)

The participants with advanced cancer (e.g., P2, P12) reported similar challenges, emphasising how malnutrition compounded their fatigue. This profound functional decline and exhaustion were viewed by participants primarily through the lens of nutritional deficits and the general toxicity of treatment, which severely limited their physical capacity. P12 mentioned that she had spent most of her time in the hospital and had been admitted to the ICU several times. She recalled an occasion when she hired a carer to look after her during treatment, who helped with daily needs such as buying rice porridge:

“I couldn’t even handle a little bit of rice porridge. I had to rely completely on that white kind of nutrition drink every day. […] Now when I walk, I feel like an old woman. My knees hurt just going up and down stairs. It’s really painful, just going up and down stairs. I can’t even climb one floor without having to stop and rest for a while. […]” (P12)

Theme 2: Fragmented knowledge and awareness of potential cardiovascular toxicity.

This theme described the critical gap in the participants’ understanding of the cardiovascular risks associated with cancer treatments. While some participants reported symptoms indicative of cardiac strain, such as tachycardia or arrhythmia, these symptoms were not universally experienced, and there was variability in their awareness of the link between these cardiovascular symptoms, chemotherapy, targeted therapies, and potential heart damage.

Subtheme 2.1: Disconnect between symptoms and cardiac health literacy. Many of the participants experienced tachycardia, hypertension, or arrhythmia but did not associate these conditions and symptoms with cardiovascular comorbidity, and the health care professionals rarely explained these risks. P8, despite experiencing tachycardia (“rapid heartbeat”), did not associate it with potential cardiovascular toxicity:

“After the chemotherapy, my hands and feet went numb. And now, this part here keeps trembling, and my heartbeat gets really strong. […] Side effects from the cancer treatment? There’s definitely a bit. […] But the heart? It doesn’t really affect it.” (P8)

P2, a 68-year-old who had lived with hypertension for about 20 years, mentioned that she was reluctant to learn more about the treatment's side effects, as such information tended to affect her mood. She attributed her health conditions and symptoms to aging:

“I don’t really feel any side effects myself. Of course, I’m definitely taking more and more medication for blood pressure now – but whether that’s from the chemo or just getting older, I really don’t know. […] When the high blood pressure first started, it was pretty mild. But over time, as I’ve gotten older, it’s gotten higher and higher. It’s hard to say, and I don’t really feel much either.” (P2)

Most of the participants did not understand the potential cardiovascular toxicity of cancer treatment. This gap persisted even among the participants who had received cardiotoxic regimens (e.g., anthracyclines). As P2 described it:

“God knows – I really don’t know. The doctor said targeted therapy could have side effects on the heart, but I honestly don’t know whether it’s because of my own condition or the medication. I just can’t tell.” (P2)

Subtheme 2.2: Medication-centred management amid limited lifestyle guidance. The participants overwhelmingly depended on medication, rather than lifestyle interventions, to manage their symptoms. While their health care providers prescribed antihypertensives, antiemetics, and laxatives, they rarely discussed lifestyle modifications or long-term cardiac surveillance. P9 described how she relied on medication to protect her heart during each chemotherapy session:

“That started during the first few rounds of chemo – I had this uncomfortable feeling in my heart ….They [the doctors] give me medicine with each chemo. The medicine protects the heart and the stomach, but I still get those symptoms anyway.” (P9)

Similarly, those with hypertension (e.g., P1, P10) prioritised antihypertensives over lifestyle modifications for several reasons, including physical limitations. P10 described her dilemma: she was uncertain about the appropriate exercise instructions, and her health conditions restricted her to only simple activities such as walking after treatment.

“The doctor probably told me I had to take blood pressure medicine in case my blood pressure got too high, which would cause discomfort. So, these two years, I have gone out and bought the medicine myself. […] I bought it all on my own and started taking it – been taking it for about two years now. But these days, it’s tough. Maybe I am lazy and don’t want to exercise, probably like this. And when I do exercise, it really hurts – a lot – so I don’t want to move around. That’s how it is.” (P10)

Theme 3: Health care communication gaps and unmet informational needs.

Participants reported gaps in communication with health care professionals that limited their ability to recognize and manage potential cardiovascular toxicity. The guidance was experienced as fragmented and oriented toward short-term symptom control rather than comprehensive, longitudinal strategies for cardiovascular risk mitigation and preservation.

Subtheme 3.1: Brief or non-specific guidance on symptom management. While the health care providers occasionally advised dietary adjustments (e.g., “eat lighter”) or activity restrictions (e.g., “limit movement”), their instructions were rarely tailored or actionable. Some of the participants described that the oncology department primarily concentrated on cancer treatment, rather than on cardiovascular diseases. For instance, P2 expressed this concern:

“I don’t even bring it up anymore. I just feel like the heart isn’t his [the doctor’s] concern – he’s focused on treating the tumour. Of course, if you ask, he’ll answer your questions. But if you don’t ask, he definitely won’t bring up anything about the heart – it’s all about the cancer treatment. That’s just how hospitals are. The oncology department focuses only on cancer, orthopaedics focuses only on bones – they don’t really deal with anything outside their specialty. Unless you start feeling unwell, then they’ll tell you to go see a specialist.” (P2)

P9, a 59-year-old with Stage II breast cancer, stated that side effects were normal:

“He [the doctor] said [the side effects] were all normal. Those are all normal symptoms. Generally, some people get numbness in their hands. For example, others get numbness in their hands, but I didn’t have that. Everyone’s symptoms are different. Some say they had numbness after chemo, or after surgery, but I didn’t have that. For me, the main thing was feeling nauseous.” (P9)

P2 mentioned that the cancer treatments were not associated with her hypertension:

“There’s been no improvement [with the blood pressure] – only getting worse. The dosage keeps increasing. The [cancer] treatment has nothing to do with the high blood pressure.” (P2)

Subtheme 3.2: Limited or inconsistently understood information about potential cardiovascular toxicity. While some participants recalled brief warnings, the majority of the participants did not recall receiving detailed pre-treatment counselling about potential cardiovascular toxicity, even those prescribed high-risk therapies like anthracyclines. Furthermore, although routine cardiac monitoring was frequently conducted, its purpose, findings, and implications for long-term health were not consistently explained or understood. P11's confusion about the rationale behind her repeated examinations highlighted this gap:

“Probably not [did the doctors say that heart problems were one of the side effects], but they do an ECG every time. Every time I go, they do a colour Doppler ECG [echocardiography]. Then, they also run blood tests and other related checks.” (P11)

Similarly, P2 expressed that although a doctor had mentioned cardiovascular side effects of targeted therapy, she did not understand the nature of the treatment-related potential cardiovascular toxicity because the doctor was too busy to discuss this in detail:

“The doctor said that targeted therapy could have side effects on the heart, but I really don’t know whether it’s from my own condition or the medication – I just can’t tell. […] The doctors don’t have time anyway. They have to run outpatient clinics and perform surgeries. And the interns who come – every time it’s a new face, so there’s no way they’d really explain anything to you. That’s just not possible.” (P2)

P10 mentioned the language barrier, stating that she could not communicate directly with her doctors:

“Communication has to go through my children. I can’t really speak that – I don’t even speak Mandarin properly. My hometown dialect, I just speak my hometown dialect. I can’t speak [Mandarin] comfortably. I can only speak a little bit of Mandarin. I never had any schooling, so that’s just how it is. Speak a little Cantonese, or whatever, I don’t speak [any other dialects]. Just don’t know how to speak. That’s it.” (P10)

Theme 4: Psychosocial and systemic barriers to overall well-being and health management.

Psychosocial challenges emerged as significant barriers to effective self-management during cancer recovery. The participants described their emotional distress, financial burden, and limitations in social and health care interactions as compounding factors that hindered their ability to prioritise broader health strategies, including cardiovascular care.

Subtheme 4.1: Emotional distress and mental health burden. The psychological toll of the participants’ cancer diagnosis and treatment often overshadowed other health concerns. Several of the participants reported persistent anxiety about cancer recurrence and general survival, which diminished their capacity to focus on managing additional health risks. As P2 described it:

“There are definitely challenges. This cancer is already a big challenge for me, but I don’t care. I feel like – at my age – it is what it is. And then there’s the financial burden. Every month, I have to spend a lot out of pocket – quite a lot on my own.” (P2)

P4 had undergone multiple rounds of chemotherapy. Sleep disturbances linked to stress further exacerbated her emotional strain. She described her experience during treatment as follows:

“It’s just poor sleep – really bad. Every night, I can’t sleep at all. Like last night, it felt like I didn’t sleep at all. Yeah, it’s just insomnia. That’s what I have.” (P4)

For others, such as P1, the unpredictability of post-surgical recovery and unfamiliar physical sensations caused unresolved anxiety about their physical state:

“Sometimes – even though it’s been a long time [since the surgery] – it still feels like there’s a bit of pulling here, a bit of pulling there. Is that a big problem?” (P1)

Subtheme 4.2: Financial burden. The economic burden of cancer care directly impacted the participants’ ability to prioritise cardiovascular health. Out-of-pocket costs for treatments and medications forced difficult trade-offs, as described by P4:

“Finance. […] No, it’s tough. There’s no. […] No money for medication. One round costs over twenty thousand. It’s just money – there’s not enough. Been seeing doctors for so long, right? […] As for ECGs, they do it every time. And every three months they do a colour Doppler echocardiography, right? But we patients – having been sick for so many years – where are we supposed to find that kind of money? They check every time, don’t they? It all costs money.” (P4)

P12 highlighted her long-term financial strain. These financial pressures left little motivation for proactive cardiac monitoring or lifestyle modifications:

“For me, I don’t have any commercial insurance. Other people bought commercial insurance. Those critical illness plans [of commercial insurance], I couldn’t get them. […] So, I don’t have any commercial insurance. I don’t have any commercial insurance, just the basic social insurance. I’ve paid more out of pocket than what social insurance covered. I don’t even know how much I’ve spent.…I don’t tell others. […] Including hiring help and everything, I’ve spent around 300,000 yuan.” (P12)

Subtheme 4.3: Loss of independence, diminished social participation, and communication barriers. Diminished social networks due to physical limitations and a perceived lack of adequate communication with health care providers created barriers to sustaining health-promoting routines. P1 used to dance with others in the square every night before her third operation. She described how mobility issues and physical discomfort compounded her isolation and limited her community engagement:

“Sitting here all day makes me feel kind of stuffy. So, I need to get some exercise. If I feel a bit better – if my back doesn’t hurt so much – then I’ll go out for a walk at night, or maybe slowly start interacting with others. […]” (P1)

Other participants, such as P2, felt unsupported by the health care system in navigating their ongoing health concerns, pointing to time constraints and communication barriers during medical consultations:

“The doctors don’t have time anyway. No time.” (P2)

P10, who had experienced severe treatment complications, recalled how physical debilitation had eroded her independence and social engagement:

“What’s the most miserable for me now are these two legs. […] If I squat down, I can’t get back up. It takes two nurses to come and lift me up.” (P10)

Discussion

Main findings

This study identified a multidimensional cluster of barriers that shaped how the participants perceived and enacted self-management behaviors to support their cardiovascular health and monitor for symptoms of potential cardiovascular toxicity. Based on the present interviews, cancer treatment can lead to significant physical complications, including peripheral neuropathy, gastrointestinal issues, and exhaustion, which reduce functional independence and increase the risk of cardiovascular deconditioning. The participants showed a lack of understanding regarding the cardiotoxic effects of anthracyclines and trastuzumab, often attributing palpitations or hypertension to aging or “normal” treatment effects, although their causes were not established. This medication-centred management amid limited lifestyle guidance was exacerbated by suboptimal patient-provider communication, as oncology consultations focused primarily on tumour treatment and provided minimal advice regarding cardiovascular health. Additionally, psychosocial stressors such as cancer-related anxiety and financial burdens were described as barriers to prioritising cardiovascular self-management. These barriers underscore the need to integrate culturally sensitive oncological care that includes education, cardiac monitoring, and psychosocial support throughout survivorship, with family involvement considered as a potential supportive component.

Implications for nursing practice and research

Among the barriers to effective self-management, reduced physical function was frequently mentioned by participants, while emotional distress also emerged as an important factor affecting self-management. The interviews in the current study revealed that financial strain contributed to the participants’ emotional stress. To improve and maintain mental well-being, family support may provide emotional reinforcement and help support psychological well-being.²³ Despite having relatively stable physical conditions, some patients do not proactively engage in self-management, largely due to a lack of understanding of potential cardiovascular toxicity. This study indicated a general lack of awareness about cardiovascular toxicity, even among those with documented cardiovascular conditions or findings. To address this gap, future interventions could be developed and evaluated to incorporate structured, pre-treatment education specifically focused on improving cardiovascular risk awareness, ensuring patients understand the potential cardiovascular impact of their specific regimens before therapy begins. Second, the participants and their families frequently struggled to fully understand medical explanations. They expressed fear of receiving bad news—such as information about mortality or treatment side effects—particularly when these were related to their pre-existing conditions. Consequently, the participants may have downplayed their side effects, viewing them as normal. As a potential practice implication informed by these findings, straightforward, standardized symptom checklists could be developed and evaluated as a potential intervention component to support patients in monitoring and reporting warning signs. Because fatigue, weakness, dyspnoea, dizziness, and palpitations are non-specific symptoms and cannot establish cardiac dysfunction, a more appropriate implication is that structured guidance may help patients recognise symptoms that warrant timely reporting and clinical assessment.²⁴

Our findings align with qualitative evidence indicating that clear informational guidance and robust social support may support patients' understanding of treatment-related risks and their confidence in seeking help, particularly when information is tailored to their health literacy, symptom burden, and functional capacity.^25,26 These findings were generated from participants’ accounts and show that patients often struggled to distinguish treatment-related symptoms, such as fatigue, weakness, dizziness, neuropathy, and reduced mobility, from possible cardiovascular warning signs. The findings also suggest that patients may need clearer, more practical information about which symptoms require reporting, whom to contact, and when to seek urgent assessment. However, this qualitative study did not test the effectiveness of specific interventions.

Limitations

This study has several limitations. First, the study relied on a small and heterogeneous sample recruited from a single clinical site, which inherently limits the transferability of the findings to other health care systems or populations. Crucially, this heterogeneous sample limits the interpretation of a single shared experience of potential cardiovascular toxicity. Furthermore, because participants were identified and approached through staff-mediated recruitment, there is a possible recruitment bias; health care professionals may have inadvertently selected patients who were more communicative, compliant, or engaged in their care. Second, clinically confirmed diagnoses of CTR-CVT or cancer therapy-related cardiac dysfunction were unknown for all participants, and the timing and cause of several cardiovascular conditions were uncertain. For example, clinical records indicated that five participants had hypertension; however, the documentation for four of these cases lacked sufficient detail to determine whether the condition was pre-existing or if it emerged during or after cancer treatment. Furthermore, although our sample included patients with stage I–IV breast cancer, we did not systematically collect detailed clinical data regarding specific treatment combinations, cumulative treatment exposure, or precise treatment status at the time of the interview. Because cardiovascular risk is driven more directly by these treatment-specific factors and pre-existing conditions rather than by cancer stage alone, the absence of this granular clinical context limits our ability to precisely map patients' perceptions to their actual objective cardiotoxic risk. Additionally, the patients' reported symptoms could have multiple competing explanations (such as general treatment fatigue or age-related changes), which limits our ability to fully contextualize the exact cardiovascular impact of their therapies. Moreover, because the interview guide directly introduced the concepts of cardiotoxicity and heart-related effects, this framing may have influenced participants’ responses, particularly regarding their reported awareness and the attribution of their symptoms to cardiovascular causes. Third, participants were interviewed at different treatment and survivorship stages. Because participants were asked to reflect on past events—with most diagnosed within the last five years and one as recently as three months prior—the data are subject to possible recall bias and reflect varying phases of the cancer care continuum. Moreover, the use of multiple languages during the interviews, including Mandarin and Cantonese, posed challenges in ensuring the consistency of data interpretation. Furthermore, some of the participants had a limited education, which may have influenced their ability to fully articulate their experiences and perceptions. Finally, because the purposive sample included only women with breast cancer, the findings have limited transferability to people with other types of cancer who may receive different potentially cardiotoxic regimens and experience distinct clinical trajectories.

Conclusions

The participants in this study faced challenges in recognizing early warning signs of potential cardiovascular toxicity during and after therapy. These challenges may indicate the need for further development and evaluation of coordinated partnerships between patients and health care professionals, combining clinician-led surveillance with proactive, patient-centered education and support. Specifically, future interventions could explore how oncology and cardio-oncology nurses may be well positioned to support patients through structured pre-treatment education about specific cardiac risks and the involvement of family members to reinforce this knowledge. Furthermore, nurses may help facilitate timely symptom reporting by equipping patients with practical symptom checklists for the at-home monitoring of warning signs, although the effectiveness of such tools requires further evaluation. This single-site qualitative descriptive study involving 12 participants highlighted barriers to understanding and responding to cardiovascular risk in this purposively selected sample and highlights the need for the future development and evaluation of patient-centered, culturally sensitive interventions that include robust, structured follow-up care during survivorship. Future research should evaluate integrated models that combine structured cardiac surveillance, timely pharmacologic management, and tailored lifestyle interventions, with particular attention to long-term outcomes and the needs of vulnerable groups.

CRediT authorship contribution statement

Conceptualization: XLL, YHM, MBY, QYL, YHZ, WMW, QHY. Methodology: XLL, YHM, MBY, QYL, YHZ, WMW, QHY. Investigation: MBY, YHM, XLL. Formal analysis: XLL, YHM, MBY, QHY. Writing – original draft: XLL, YHM, MBY, QYL, YHZ, WMW, QHY. Writing – review & editing: XLL, YHM, MBY, QYL, YHZ, WMW, QHY.

Ethics statement

This study was approved by the Hong Kong Metropolitan University Research Ethics Committee (Approval Reference No. HE-FRSF/2024/01) and the First Affiliated Hospital of Jinan University human research ethics committee (Approval Reference No. KY-2025-097), and was conducted in accordance with the Declaration of Helsinki and its subsequent amendment. All participants provided written informed consent.

Data availability

The data supporting the findings of this study are not publicly available because they contain potentially identifiable and sensitive participant information. De-identified data may be available from the corresponding author upon reasonable request, subject to ethical and data protection requirements.

Declaration of generative AI and AI-assisted technologies in the writing process

No generative AI or AI-assisted technologies were used in the preparation of this work.

Funding

This work is supported by the Hong Kong Metropolitan University Faculty Research Startup Fund (Ref. No. FRSF/2024/01). The funders had no role in the study design; data collection, analysis, or interpretation; preparation of the manuscript; or the decision to submit the article for publication.

Declaration of conflicting interests

The authors declare no conflict of interest.

Appendix. Supplementary materials

The following is the Supplementary data to this article.