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. Author manuscript; available in PMC: 2016 Jan 1.
Published in final edited form as: Health Psychol. 2015 Sep 21;35(1):19–28. doi: 10.1037/hea0000263

Coping with Breast Cancer: Reflections from Chinese-, Korean-, and Mexican-American Women

Patricia Gonzalez 1, Alicia Nuñez 1, Ming Wang-Letzkus 2, Jung-Won Lim 3, Katrina Flores 4, Anna María Nápoles 5
PMCID: PMC4695243  NIHMSID: NIHMS724473  PMID: 26389720

Abstract

Objective

The present study identified and compared the coping strategies of Chinese-, Korean-, and Mexican-American breast cancer survivors (BCS).

Methods

Six focus groups were conducted with Chinese- (n = 21), Korean- (n = 11), and Mexican-American (n = 9) BCS. Interviews were audio-recorded, transcribed, and translated for thematic content analysis of coping experiences and strategies.

Results

Women reported the use of eight coping strategies (religious/spiritual, benefit finding, fatalism, optimism, fighting spirit, information seeking, denial, and self-distraction). Among Chinese-American BCS, benefit finding was the most referenced coping strategy, whereas religious/spiritual coping was most frequently reported among Korean- and Mexican-American BCS. Denial and self-distraction were the least cited strategies.

Conclusions

Survivors draw upon new found inner strength to successfully integrate their cancer experience into their lives. Coping models must consider the diversity of cancer survivors and the variability in coping strategies among cultural ethnic minority BCS.

Keywords: Coping, Ethnic minority, Breast cancer survivors, qualitative

Coping with Breast Cancer: Reflections from Chinese-, Korean-, and Mexican-American Breast Cancer Survivors

Despite advances in early detection, diagnosis, and treatment, cancer remains a public health challenge in the United States (US). Among Asian-American and Latina women in the US, breast cancer is the most common cancer and the first leading cause of cancer mortality in Latinas (American Cancer Society, 2012) and the second among Asian-American women (U.S. Cancer Statistics Working Group, 2013). Reflecting the rapid growth of the US Asian-American and Latino population (U.S. Census Bureau, 2013), an increasing number of cultural ethnic minority breast cancer survivors (BCS) is expected. Given this expected increase in the prevalence of breast cancer survivorship, greater attention must be given to the experiences of cultural ethnic minority women (Yanez, Thompson, & Stanton, 2011). Advancements in medical treatment, along with increased awareness of screening guidelines, have substantially contributed to an increasing survival rate (American Cancer Society, 2012) and have brought the treatment and long-term management of cancer to the forefront of the health care agenda (Jemal et al., 2007; Stanton, Bernaards, & Ganz 2005). Therefore, research efforts are needed to improve survival and coping, particularly among cultural ethnic minority BCS.

When confronted with a breast cancer diagnosis, cultural ethnic minority BCS encounter multiple adjustment challenges. In addition to socioeconomic disparities, cultural ethnic minority women may encounter linguistic and cultural barriers (Collins, Villagran, & Sparks, 2008). These barriers are evident in the observed communication challenges between cultural ethnic minority BCS and their physician(s), and in the lack of culturally appropriate and accessible cancer coping resources.

One of the most widely accepted theoretical coping frameworks is the work by Lazarus and Folkman (Lazarus & Folkman, 1984), who define coping as cognitive and behavioral efforts used to manage external and/or internal demands appraised as stressful. Coping strategies, the intentional actions taken to address specific situations or feelings (Towsley, Beck, & Watkins, 2007), are employed by BCS with intent to alleviate breast cancer related stress. Prior studies among non-ethnic minority women have identified several coping strategies relevant across the cancer survivorship continuum, including faith, fatalism, optimism, fighting spirit, information seeking, denial, and avoidance (Towsley, et al., 2007). It is noteworthy that an inability to successfully cope with cancer may lead to significant psychosocial distress (C. Davis, Rust, & Darby, 2013), which may affect a cancer survivor’s ability to manage their post-treatment care and thus decrease quality of life in the aftermath of the diagnosis (Vachon, 2006). In this regard, the literature has indicated that approximately one-third of BCS experience significant distress and or impairment of functioning in their lives (Coyne, Palmer, Shapiro, Thompson, & DeMichel, 2004; Hegel et al., 2006).Coping strategies and breast cancer survivorship

The existing literature on coping with breast cancer has documented that positive coping strategies are associated with enhanced quality of life among BCS (Aziz 2002). For example, fighting spirit (the willingness to fight and recover from breast cancer) and optimism (positive outlook of the future) are associated with improved disease outcomes and psychological adjustment (Matthews & Cook, 2009). Alternatively, BCS who hold fatalistic beliefs, that is, pessimistic beliefs that one cannot control illness outcomes, exhibit more stress-related problems (Im, Chee, Tsai, Lin, & Cheng, 2005). Most cancer fatalism research has been examined within the context of preventive cancer screening as opposed to within the context of coping during the survivorship period and has failed to provide a close analysis of fatalism beyond its simplistic depiction as a passive life outlook.

While the manner in which non-ethnic minority women cope with breast cancer during the cancer diagnosis and treatment phase has received much attention, less attention has focused on coping strategies among cultural ethnic minority BCS. It is salient that conceptualizations of coping are based largely on research with the general population and/or non-Hispanic Whites (Yoo, Levine, & Pasick, 2014) and has also largely ignored the post-treatment survivorship experience (Towsley, et al., 2007). Therefore, findings from such research may not capture the unique experiences and needs of cultural ethnic minority BCS, being largely devoid of consideration of cultural preferences. Yet, it is known that culture, set of enduring characteristics shared by a large group of people such as language, behaviors, beliefs, and traditions (Myers, 2002), exerts a significant influence over coping processes (Graves et al., 2012).

Few studies have examined the coping experiences of cultural ethnic minority women. A study that conducted a systematic review of the literature on breast cancer coping found that spirituality and religious faith may be coping strategies particularly relevant for women of color (Levine, Aviv, Yoo, Ewing, & Au, 2009; Yoo, et al., 2014). Relatedly, Culver et al. (Culver, Arena, & Wimberly, 2004) found that cultural ethnic minority breast cancer patients are less likely to use humor and engage in more religious coping than non-Hispanic Whites. Nevertheless, most studies addressing religion/spirituality and coping have been conducted predominantly with African-American women and limited research is available on women from other underrepresented groups who are breast cancer survivors, such as Asian-Americans and Latinas (Yoo, et al., 2014). Additional research suggests that cultural ethnic minority BCS are more likely to engage in coping that involves benefit finding, or meaning making, compared to non-Hispanic Whites (Helgeson, 2010). Thus, existing research suggests differences in coping with breast cancer among cultural ethnic minority women and highlights the need to identify culturally relevant coping strategies that may help cultural ethnic minority women cope with the stress surrounding the breast cancer experience.

Study purpose

The majority of the existing empirical evidence on the notions of breast cancer coping reflects the lived experiences of non-ethnic minority women. There has been limited research in women from underrepresented groups who are breast cancer survivors and there is a paucity of information regarding the important influence of culture of origin in coping with breast cancer. Therefore, a qualitative research approach may help address this gap in the literature by providing detailed information on this topic and contribute to our understanding of breast cancer survivorship in cultural ethnic minority women, a population that persist to be underrepresented in research. The aim of the present study was to describe and explore the culturally-relevant coping strategies of Chinese-, Korean-, and Mexican-American BCS.

Methods

This study used a qualitative ethnographic approach to inductively derive insights about the role of culture in coping with breast cancer survivorship. We conducted focus groups to gather in-depth qualitative information on the coping strategies employed by BCS until data reached saturation. Focus groups provide an efficient way to gain richer understanding of the research question by facilitating the expression of ideas (J. Kitzinger, 1995; Kruegar, 1998; Krueger & Casey, 2000). The dynamic nature of the focus group interview allows participants to explore the research question by building on each other’s ideas through dialogue exchange (J. Kitzinger, 1995); group interaction is appropriate and useful for exploring people’s experiences about a given topic (J. Kitzinger, 1994). A central aim of ethnography is to describe and provide cultural interpretation of people’s views and practices (Creswell, 1998). This study describes the coping experiences of cultural ethnic minority BCS through their cultural lens.

Participants and recruitment

Eligible participants included women who were breast cancer survivors (one to five years post diagnosis), were free from disabling medical or psychiatric conditions, at least 18 years of age, and who self-identified as Chinese-, Korean-, or Mexican-American. We used purposive sampling strategies to recruit information rich-cases and elucidate greater understanding of the research questions (Patton, 1990). Participants were recruited through community- and hospital-based support groups and hospital cancer registries in Los Angeles, California; we also contacted participants from previous studies who had expressed interest in participating in future research. Recruitment letters—available in English, Chinese, Korean, and Spanish—describing the study were mailed to potential participants and flyers were distributed to community agencies and support groups. Additional details concerning the study sample have previously been described (Lim, Gonzalez, Wang-Letzkus, Baik, & Ashing-Giwa, 2013). The study received Institutional Review Board approval from City of Hope and California State University, Los Angeles. Informed consent was obtained from all participants.

Data collection procedures

Six focus groups, two per cultural ethnic group, were conducted at local hospitals or community centers with 42 BCS [Chinese- (n = 21), Korean- (n = 11), and Mexican-American (n = 10)]. The focus groups were held within the community with the intent of eliciting participants’ narratives of the breast cancer experience in a familiar setting as opposed to a research laboratory. To minimize social desirability bias, focus groups were facilitated by the principal investigators who were matched to participants linguistically and ethnically. Graduate students trained in qualitative methodology assisted the facilitators by arranging the room (e.g., seating) and taking notes of major ideas discussed. The focus group discussions were held in participants’ native language (i.e., participants’ preferred language). Focus groups were audio-recorded and ranged from 90 to 120 minutes in duration. Participants were asked to discuss their breast cancer experience from the time of initial diagnosis to survivorship using a semi-structured interview approach. Specifically, women were asked about the influence of ethnicity and culture (both ethnic background and American culture) in their illness experience, breast cancer causal beliefs, and lifestyle changes, with notions of coping strategies emerging throughout the narratives of the survivorship trajectory. For example, women were asked: “How does your ethnic and cultural background influence your breast cancer experience?” “Are there any health or lifestyle changes after breast cancer diagnosis and treatment?” “How do you manage your stress?” Facilitators used probing techniques to promote participant interaction and encourage in-depth description of the breast cancer experience (e.g., “I welcome you to share your views…” “How…?” “What do you mean…?”). At the beginning of each focus group session, participants completed a questionnaire assessing demographic characteristics, medical information, and health behaviors. All participants received a $20 gift certificate as compensation for their participation in the study.

Data analysis

Focus groups were audio-recorded, transcribed verbatim in their original language, and translated to English by bilingual bicultural research assistants using forward and back translation techniques (Brislin, 1970; Liamputtong, 2010). These techniques enabled the research team to assess the appropriateness of the translations and ensure that they maintained semantic and conceptual equivalence across languages. The completed translated transcripts were analyzed using NVivo (QSR NVivo 9, Copyright© 2010), a qualitative data storage and coding software. Qualitative content analysis, a method that enables the interpretation of context through the systematic classification of open coding and identification of emerging themes (H.-F. Hsieh & S. E. Shannon, 2005), was used. Two research assistants independently reviewed the content of each transcript using an open coding process in which data was analyzed line by line to identify words or phrases narrating coping experiences; they created and assigned codes that exemplified the data content. These codes were used to identify patterns and recurrent themes.

The coding process was iterative, and categories and themes evolved as re-readings were completed and analysis progressed (Bradley, Curry, & Devers, 2007; H. F. Hsieh & S. E. Shannon, 2005). It involved comparing findings, discussing divergent coding, and resolving differences of interpretation (Miles & Huberman, 1994). Clusters addressing similar content were respectively grouped into themes and subthemes (see Table 2). To add methodological rigor and to reduce researcher bias, all transcripts were coded with a minimum of 80% or greater reliability between coders (Morse, Barett, Mayan, Olson, & Spiers, 2002); thus meeting the recommended criteria for inter-rater reliability and ensuring consistency in the coding process.

Table 2.

Coping strategies of Chinese-, Korean-, and Mexican-American Breast Cancer Survivors

Themes
Coping Strategy		 Subthemes Definition Total
Frequency		 Chinese-
American		 Korean-
American		 Mexican-
American
Religion/spirituality --- Endorsing religious or spiritual aspects to cope with breast cancer. 45 2 26 17
Benefit finding Positive meaning making and beneficial life changes resulting from the breast cancer experience, such as: 43 13 14 16
• Religious/spiritual growth • greater religiosity and/or spirituality 10 2 6 2
• Prioritization • changes in life priorities 19 7 4 8
• Finding inner strength • personal growth/maximizing life potential 14 4 4 6
Fatalism Coping with cancer fatalism (i.e., feelings of powerlessness based on the belief that cancer leads to death) characterized by: 31 8 9 14
• Active fatalistic coping • addressing cancer fatalistic thought through active reframing 12 5 3 4
• Passive fatalistic coping • passive view of cancer fatalism or not engaging in reframing of fatalistic thought 7 2 3 2
• Religious-oriented fatalism • intertwining fatalism with religiosity 12 1 3 8
Optimism --- Positive mental and life outlook 26 8 9 9
Fighting spirit --- Attitudinal disposition that includes believing in the ability to fight back, conquer, and recover from cancer. 18 7 2 9
Information seeking --- Seeking breast cancer-related information and resources. 16 6 5 5
Denial --- Negating having breast cancer or engaging in conscious efforts to forget existence of breast cancer diagnosis. 9 1 5 3
Self-distraction --- Engaging in something to remove attention from breast cancer thoughts. 6 1 1 4
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Note. The total frequency count represents the number of times participants’ made references to each theme. The total frequency for each subtheme is presented in italics.

Results

Sample characteristics

Among the 42 participants, 30 were married, about a third reported less than a high school education, and reported a mean age of 53 years (SD = 9; see Table 1). Participants’ mean number of years living in the US was 20 years (SD = 10). Most women reported undergoing mastectomies (76%) and adjuvant chemotherapy (62%). Compared with Korean- and Mexican-American BCS, Chinese-American women reported higher education levels and private health insurance coverage.

Table 1.

Participants’ Demographic and Medical Characteristics

Variables N (%)
Overall
(N = 42)		 Chinese
(n = 21)		 Korean
(n = 11)		 Mexican
(n = 10)
Educationa
< High school 8 (19.5) 0 (0.0) 1 (9.1) 7 (70.0)
  High school graduated 6 (14.6) 1 (5.0) 3 (27.3) 2 (22.2)
> High school 27 (65.9) 19 (95.0) 7 (63.6) 1 (11.1)
Health insuranceb
  No insurance 6 (14.3) 2 (9.5) 3 (27.3) 1 (11.1)
  Public (Medicare/Medicaid) 24 (57.1) 7 (30) 10 (76.9) 7 (64.0)
  Private 17 (40.5) 14 (61) 0 (0) 3 (27.0)
Employment statusa
  Employed 13 (31.7) 9 (45.0) 2 (18.2) 2 (22.2)
  Homemaker 18 (43.9) 5 (25.0) 8 (72.7) 5 (50)
  Other 10 (24.4) 6 (30.0) 1 (9.1) 3 (30.0)
Marital status
  Single 3 (7.3) 2 (9.5) 1 (9.1) 0 (0)
  Married 30 (73.2) 14 (66.7) 9 (81.8) 8 (80)
  Other 8 (19.5) 5 (23.8) 1 (9.1) 2 (20)
Age (yrs) (M, SD) 53.39 (9.23) 53.52 (10.69) 53.82 (8.92) 52.56 (6.25)
Years living in US (M, SD) 19.85 (9.77) 18.75 (9.71) 17.36 (9.19) 27.33 (8.62)
Cancer stagea
  I 8 (20.0) 5 (23.8) 2 (18.2) 2 (12.5)
  II 23 (57.5) 11 (52.4) 6 (54.6) 6 (62.5)
  III 9 (22.5) 5 (23.8) 3 (27.3) 1 (12.5)
Type of surgerya
  Lumpectomy 6 (14.6) 4 (19.0) 2 (20.0) 0 (0.0)
  Mastectomy 31(75.6) 17 (81.0) 8 (80.0) 6 (55.6)
  Mastectomy+ reconstruction 1 (0.24) 0 (0) 0 (0.0) 1 (14.0)
Cancer treatment (Yes)
  Chemotherapy 25 (60.9) 13 (61.9) 6 (54.5) 7 (66.7)
  Radiation therapy 17 (41.4) 7 (33.3) 5 (45.5) 6 (55.6)
  Hormonal therapy 12 (29.3) 7 (33.3) 3 (27.3) 2 (22.2)
Years since diagnosis (M, SD) 2.5 (1.86) 2.03 (1.96) 2.26 (0.98) 3.92 (1.86)
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Note.

a

Numbers do not add to total sample size because of the missing values.

b

Multiple responses.

Overview of qualitative findings

Eight main coping themes were identified: 1) religion/spirituality, 2) benefit finding, 3) fatalism, 4) optimism, 5) fighting spirit, 6) information seeking, 7) denial, and 8) self-distraction. Three corresponding sub-themes emerged for benefit finding (religious or spiritual growth, prioritization, and finding inner strength) and fatalism (active fatalistic coping, passive fatalistic coping, and religious-oriented fantastic coping). Although all themes were mentioned by all groups, ethnic differences were observed in the degree to which BCS employed the coping strategies (See Table 2).

Breast cancer coping themes

1) Religion/spirituality: prayer and faith influencing ability to cope with breast cancer

Of the eight coping themes that emerged, religion/spirituality (i.e., endorsing religious or spiritual aspects) was identified as an important strategy to cope with breast cancer; this was particularly true for Korean- and Mexican-American BCS. Participant narratives emphasized religious prayers as a source of emotional and spiritual healing, particularly during times of illness. Likewise, Korean-American BCS indicated that reading the bible and religious hymns was a source of comfort, or in the case of one respondent: “…singing Christian hymns helps.” Religious faith and God provided BCS with comforting reassurance as illustrated by the following:

Chinese: “I pray every day; I don’t want to go astray from my Lord. The Bible holds so much wisdom, it is a great help. I recite the Lord’s prayer in my sick bed.”

Korean: “While I was ill, my sincere prayers spilled out from the heart.”

Mexican: “You have God who will help you see it through.”

2) Benefit finding: Meaning making from breast cancer experience

Benefit finding, positive meaning making in the face of adversity, was the second most used coping strategy. Participants reported that their cancer provided them an opportunity for making beneficial and positive life changes. As seen in Table 2, three subthemes describing the benefit finding resulting from the breast cancer experience emerged: a) religious or spiritual growth (i.e., greater religiosity and/or spirituality resulting from the breast cancer experience), b) prioritization (i.e., changes in life priorities resulting from the breast cancer experience), and c) personal/inner strength (i.e., personal growth resulting from the breast cancer experience). The total number of benefit-finding references was similar across groups. However, differences were noted with regard to which subtheme BCS identified as being a beneficial life change. While religious or spiritual growth was the most frequently referenced manifestation of benefit finding in Korean-American BCS, prioritization was the most referenced subtheme in Chinese- and Mexican-American BCS.

Religious or spiritual growth

Participants’ narratives showed that religious and/or spiritual growth was a dimension of the benefit finding coping process of their breast cancer experience, particularly for Korean-American BCS. Some participants reported a greater sense of religiosity and a new-found importance to spirituality. For example, several BCS mentioned that they began actively practicing a religious life:

Chinese: “After I was diagnosed with breast cancer, I became a Christian.”

Korean: “As for me, to be honest I didn’t even go to church. I started believing strongly after surgery.”

Mexican: “I have given importance to emotional spiritual health”

Prioritization

Most participants reported that benefit finding-related coping involved evaluating life’s priorities and making corresponding life changes. Specifically, participants expressed that their breast cancer experience contributed to their realization of the importance of their own needs; not surprisingly, several BCS became more cognizant of their personal health. Additionally, BCS viewed breast cancer as an opportunity to reflect and reevaluate their lives:

Chinese: “I used to go along with the needs of my family, do the things my husband wanted. Now I exercise first. Only with good health will I be able to prepare food for my family; otherwise nothing is prepared.”

Korean: “My attitude changed; from now on I am taking care of myself.”

Mexican: “As I told my sister cancer is an opportunity to stop and restructure your life.”

Finding inner strength

Participants across groups claimed that their struggle with breast cancer was accompanied by personal growth. Some BCS described their illness as a motivating factor for personal development and finding inner strength. For example, some women stated that overcoming the difficulties associated with having breast cancer made them stronger by bringing personal enlightenment and the important realization of reaching one’s full potential in life, which included making life changes (decisions) that correspond with this new found strength. This inner strength was evident in expressions of gratitude for all that life offers, including challenges:

Chinese: “Gradually I found all these difficulties made me stronger.”

Korean: “I am thankful for each day. Before [breast cancer], when my life would get difficult, I would be irritable. I did not understand that being given a day is cause for gratitude”

Mexican: “The only thing that changes is your character- you become a stronger person- you learn to make stronger decisions.”

3) Fatalism: Coping with thoughts that death is inevitable

Fatalism often describes the belief that life events are predetermined and out of one’s control. In cancer research, cancer fatalism refers to the belief that death is inevitable after a cancer diagnosis. Such views of powerlessness have been associated with adopting a passive attitude (Powe & Finnie, 2003). Therefore, in this study, fatalism referred to feelings of powerlessness based on the beliefs that cancer leads to death. Although a few women reported passive fatalistic attitudes, the cognitive reappraisal of fatalism was mostly characterized by an active coping style of fatalistic beliefs and by intertwining fatalism with religiosity. Three subthemes related to fatalism were identified: a) active fatalistic coping (i.e., addressing cancer fatalistic thought through active cognitive reframing), b) passive fatalistic coping (i.e., passive view of cancer and not engaging in reframing of fatalistic thought), and c) religious-oriented fatalistic coping (i.e., interviewing fatalism with religiosity). Fatalism was the third most common coping theme, with active and religious-oriented fatalistic coping being the prominent fatalism-related subthemes. Of the three groups, Mexican-American BCS reported more fatalistic coping, particularly religious-oriented fatalism.

Active fatalistic coping

BCS who adopted an active fatalistic approach reinterpreted their view of feeling powerless in the face of cancer through positive reframing and/or engaged in other coping strategies. A key component of the reframing process was benefit finding (or meaning making) and the adoption of a positive outlook towards cancer survivorship transitions. For instance, participants’ initial views of breast cancer as a life threatening experience were reframed as an opportunity for making meaningful life changes and gaining inner strength, namely, benefit finding. BCS’ narratives reflected the reframing of the threat of death as an opportunity to consciously embrace a positive outlook on life:

Chinese: “Now I realize that although my physical health is out of my hands I still have power over my mental health. None of us are able to control our physical conditions, but we are able to change our mental state, and reach our goals”

Korean: “Even if I were to die tomorrow, I want to rejoice in my present life”

Mexican: “We are not going to die right now but we know our time is limited and we live one day at a time.”

Passive fatalistic coping

Irrespective of ethnicity, passive fatalistic coping was the least referenced fatalism subtheme. BCS with a passive fatalistic approach did not engage in active reframing of fatalistic thoughts pertaining to feeling powerless. Instead, participants associated the breast cancer diagnosis with death and adopted a passive attitude:

Chinese: “I don’t know how many more days I have in this world.”

Korean: “I didn’t care about getting a checkup no matter how much people told me to do it. I thought it would be okay to just die if I got it [breast cancer].”

Mexican: “I was going to die over a breast.”

Religious-oriented fatalistic coping

In religious-oriented fatalism, BCS intertwined religious beliefs with fatalism as a coping mechanism that is distinct from fatalistic or religious/spiritual coping. Women who employed religious-oriented fatalism strategies believed that it was best to leave to God the uncertainty around their breast cancer prognosis. For example, a BCS mentioned that prior to having a mastectomy, entrusting herself to God granted her serenity to accept the unknown outcomes, “I was not afraid. I felt that everything goes well if I leave it up to God. I went with the mindset that if I die, I die.” Although not always explicitly stated, participants’ depictions of their breast cancer experience suggest that the interconnection of beliefs in God and cancer fatalism facilitate acceptance and emotional adjustment to their illness experience:

Chinese: “I had done my best and what happens later is up to God.”

Korean: “If God chooses to take me, then so be it.”

Mexican: “I began making preparations. I went to a cemetery to search for information. I wanted to prepare myself so my family would not take all of this so hard. But then I thought God has a plan for me and I am going to leave it in his hands. If this was his plan and my time of serving others has ended, then I will accept it.”

4) Optimism: Positive life outlook

Optimistic coping, having a positive mental and life outlook, was the fourth most cited coping strategy and was similar across the groups. Participants who adopted an optimistic approach valued having a general positive disposition towards life, which seemed to reassure them that good things would come.

Chinese: “I seemed to have an optimistic outlook toward breast cancer.”

Korean: “I am trying to be optimistic. I try to live that way always.”

Mexican: “I value my message to be happy-you only have one opportunity in life.”

5) Fighting spirit: Refusing to give up

Fighting spirit, the willingness to surpass breast cancer, was yet another coping strategy employed by BCS. There was greater use of fighting spirit among Chinese- and Mexican-American BCS. Fighting spirit was characterized as an attitudinal disposition (e.g., hardiness) to fight back, conquer, and/or recover from cancer. Women who described having a fighting spirit described their willingness to live and capacity to fight and recover from cancer. As one participant described, “you will be able to face the disease, head on, and surpass it.” Despite the physical and emotional demands of breast cancer, women felt they were capable of recovering and conquering their illness:

Chinese: “I found I was quite lucky, removed the tumor, went through chemo and I was as good as new.”

Korean: “I feel very healthy, I will recover.”

Mexican: “We have to face the disease and we have to show others, that there is strength. Others need to see our will to survive.”

6) Information seeking: Searching for breast cancer information as a form of empowerment

Information seeking, or searching for breast cancer related information and resources, was another theme that emerged across all groups. After their breast cancer diagnosis, some participants noted the need to engage in breast cancer information seeking related to survival and quality of life (e.g., healthy lifestyle choices). Chinese- and Korean-American BCS referred to searching for information that promoted acquiring breast cancer knowledge and enhancing quality of life, whereas Mexican-American women mentioned seeking general information pertaining to their breast cancer diagnosis:

Chinese: “I found a breast cancer support group, Jaosheng, in my neighborhood in the Yellow Pages.”

Korean: “Since it is not healthy to eat products with hormones in them, I research these things on the internet.”

Mexican: “If I have a doubt I ask first and I also do my research on the topic [breast cancer].”

7) Denial: Refusing to accept breast cancer diagnosis

Denial was defined as negating having breast cancer or engaging in conscious efforts to forget the existence of breast cancer. Compared with the above strategies, denial was less prominent but still relevant for some participants. Among participants who engaged in denial, it emerged as part of their initial reaction to their breast cancer diagnosis. As shown for one Chinese-American BCS, denial-based coping involved negating the cancer diagnosis or trying to engage in conscious efforts to forget about it. For Korean- and Mexican-American BCS, denial was mostly characterized by wanting to forget having cancer:

Chinese: “As for me I didn't even think it was cancer. They said that there was nothing wrong with me. And when they said that they felt something, I was in disbelief, oh, cancer what cancer? I said it wasn't so; I looked at my son and said it wasn't cancer.”

Korean: “I followed through the follow-up course, and I came to forget [breast cancer].”

Mexican: “I do not even want to remember that I have it [breast cancer]. You don’t remember that you have cancer until you undress and see that you’re not complete.”

8) Self-distraction: Distracting oneself away from breast cancer

Self-distraction referred to engaging in something to remove attention from breast cancer related thoughts. Compared to other coping strategies, self-distraction coping was the least mentioned among Chinese- and Korean-American BCS and next to last among Mexican-American BCS. Women who used self-distraction opted to divert their attention from cancer and its negative emotional effects. They mentioned engaging in diverse behavioral activities including work, household chores, and walking to take their minds off of cancer. In the words of one woman, “it distracts me to go out for a walk.” Below are some references to distraction:

Chinese: “I tried not to think about stress. I turned to TV soap operas.”

Korean: “I clean when my mood isn’t good.”

Mexican: “Work helps you not think about the cancer”

Discussion

Research on coping strategies among cultural ethnic minority BCS is sparse. To address this gap, the present study sought to identify coping strategies used by Chinese-, Korean- and Mexican-American BCS through the use of qualitative narratives, which highlighted the potential impact culture can play in breast cancer coping. Eight coping strategies were identified including, religion/spirituality, benefit finding, fatalism, optimism, fighting spirit, information seeking, denial, and self-distraction to manage their breast cancer diagnosis. Findings are consistent with previous research that have identified similar strategies among non-ethnic minority BCS (Danhauer et al., 2009; Matthews & Cook, 2009). However, our study was unique in that it explored and identified cultural preferences in the relative use of these coping strategies among cultural ethnic minority BCS. Through their unique cultural lens, most participants in this study referenced positive coping strategies. Specifically, Chinese-American BCS identified benefit finding as the most salient strategy in coping with breast cancer, whereas Korean- and Mexican-American BCS emphasized the importance of religion/spiritual coping in dealing with breast cancer demands. Similarities in the use of optimism and information seeking coping strategies across cultural ethnic groups were noted. Denial and self-distraction were the least frequently mentioned strategies.

Overall, findings suggest that most women in our sample were resilient in their ability to adjust and incorporate spirituality and religion to their survivorship experience. They illustrate the various cultural aspects of religion and spirituality in coping with breast cancer. For instance, Chinese- and Korean-American narratives emphasized the wisdom found in reading and meditating religious scriptures and referred to the value of honesty when reciting religious hymns, such descriptions convey that the cultural importance placed in spiritual healing often attributed to Asian cultures remains relevant in the context of breast cancer coping. Likewise, Mexican-American BCS narratives of their breast cancer experience often referred to the importance of faith and trust in God, which suggests that faith plays an essential role by fostering a sense of divine protection or feeling that God will take care of them through their illness. This finding is of significant importance when considering that religiosity is embedded in Mexican culture and has been suggested to influence the world view of Mexican-Americans by forming part of their core values (Cervantes & Sweatt, 2004).

Spirituality and religious coping, as opposed to other forms of coping, are more frequent among women, the elderly, the socioeconomically disadvantaged, and people who are psychologically distressed (Holt & McClure, 2006), suggesting that individuals with limited access to secular resources and power may rely more on religion as a coping strategy (Paragament, Koenig, Tarkeshwar, & Hahn, 2004; Umezawa et al., 2012). Spirituality is more often endorsed by cultural ethnic minority and less acculturated BCS than the general public. For example, Ashing (Ashing, Padilla, Tejero, & Kagawa-Singer, 2003) suggested that spirituality is an important aspect of the breast cancer experience of Asian-American women and Lopez-Class et al. (Lopez-Class et al., 2011) found that Latina immigrants rely on spirituality and prayer, and their relationship with God, to comfort them during their breast cancer experience. Our study findings align with these research efforts aimed at understanding breast cancer and coping among underserved groups. While levels of spirituality and religiosity varied in our sample, our study highlights that religion/spirituality in the form of prayer and faith serves a central role in the coping processes of cultural ethnic minority BCS.

Most participants endorsed fatalism and accepted their inability to change the outcome of cancer. However, fatalistic views in cancer survivorship do not necessarily imply adopting a passive attitude characterized by a lack of control. On the contrary, fatalistic coping is complex and can consist of a dynamic coping process in which positive reframing of fatalistic attitudes occurs. Cancer fatalistic coping can also involve an active and religious approach to confronting feelings of powerlessness and can influence the adoption of positive coping strategies (Cheng, Sit, Twinn, Cheng, & Thorne, 2013; Flórez et al., 2009). We found that active fatalistic coping (i.e., reframing cancer fatalistic thought) and religious-oriented fatalistic coping (i.e., intertwining fatalism with religiosity) can facilitate adaptive coping during the breast cancer survivorship experience. These findings are consistent with studies that have emphasized the need to expand the simplistic and negative view of cancer fatalism to better understand its relation to cancer-related health practices (Abraído-Lanza et al., 2007) and adjustment (Cheng, et al., 2013; Umezawa, et al., 2012).

Noteworthy, are the characteristics of benefit finding (Carver & Antoni, 2004; C. G. Davis, Nolen-Hoeksema, & Larson, 1998; Sears, Stanton, & Danoff-Burg, 2003; Tomich & Helgeson, 2004), which have been related to overall quality of life (Antoni et al., 2001; Carver & Antoni, 2004) and better life adjustment (Carver & Antoni, 2004). Our findings voicing the experiences of cultural ethnic minority BCS demonstrates that benefit finding and growth is an important culturally-relevant characteristic of breast cancer coping. Therefore, when addressing the needs Chinese-, Korean-, and Mexican-American BCS, it is important for health care professionals to recognize and build upon the new found strength resulting from dealing with breast cancer difficulties.

Again, religion and spirituality was an important new-found strength in Korean-American BCS and changes in life priorities that included addressing personal needs (vs. family needs) was the most referenced benefit arising from the illness experience of Chinese- and Mexican-American BCS. This finding brings attention to the competing demands surrounding the breast cancer experience in conjunction with family responsibilities. In Asian and Latino cultures, women are often held responsible for family caregiving and well-being (Gil & Vazquez, 1996; Kramer, Kwong, Lee, & Chung, 2002). Health professionals and counselors could use the present study’s findings to make culturally appropriate recommendations for embracing positive life changes during the breast cancer experience as this study uncovered specific characteristics of benefit finding that are viewed as valuable aspects of the coping process in BCS of certain cultural minorities.

Although there may be experiences of distress during the breast cancer survivorship period, several BCS in this study expressed that they possessed an optimistic life outlook, which describes a general disposition that views the future as holding positive things. This further suggests that despite their struggle with breast cancer, women from underrepresented cultural ethnic minority groups in the US are able to embrace life difficulties with optimism and sustain a positive mental attitude. Future studies could quantitatively examine how optimism may influence adaptive coping mechanisms, with implications for enhancing the survivorship experience of cultural ethnic minority BCS.

Study findings illustrate that having a fighting spirit (or willingness to surpass breast cancer) forms part of the coping strategies employed by BCS of certain cultural minorities in the US. Cultural ethnic minority and underserved populations often have the desire to succeed and work hard toward achieving their goals. For example, studies examining the cultural values of Asian-Americans (Kramer, et al., 2002) and Latinos (Figueroa Rodríguez, Figueroa, Figueroa Rodríguez, & Hernández Rosas, 2012), have reported that the high value placed on hard work is a core cultural value that influences behavior; our findings suggest that this fighting spirit mentality transcends to the breast cancer experience. Moreover, participants’ narratives further highlight that the impetus to fight breast cancer is linked to the desire to survive for the good of others and thus findings reveal that the value of collectivism—in which identity is conceptualized in relation to others and the group is more important—may influence the motivation for adopting coping strategies such as fighting spirit. On a related note, research in cross-cultural psychology has found that Asian and Latino cultures place greater value on collectivism (Myers, 2002). It is notable that our study expands the limited literature exploring fighting spirit, breast cancer, and culture. It is important to examine positive coping strategies, such as fighting spirit, which may be helpful in alleviating the burden of confronting a breast cancer diagnosis. Earlier research in non-minority populations has documented that for cancer survivors, feeling in control of their cancer was associated with a fighting spirit and lack of control was associated with depression (Link, Robbins, Mancuso, & Charlson, 2002). Future studies could examine fighting spirit coping in relation to psychological health indicators among cultural ethnic minority BCS.

It is not uncommon for immigrant and cultural ethnic minority populations to lack large social network support systems capable of offering tangible assistance or resources in times of need, including illness. In fact, some women in this study noted the need to seek support (e.g., community support groups) and search for breast cancer information. In addition to socioeconomic disparities in health information experienced by cultural ethnic minority BCS, present findings indicate that culture influences the extent to which women talk about topics concerning breast cancer health with their social networks. For example, a Mexican-American BCS mentioned that when confronted with the breast cancer diagnosis she had to seek information regarding her family history of the disease and thus, uncovered that breast cancer is an issue not talked about in her family. Similarly, other researchers have suggested that cultural ethnic minority families do not openly talk about illness (Corona, Rodríguez, Quillin, Gyure, & Bodurtha, 2013). This highlights the complexity of the multiple challenges cultural ethnic minority BCS encounter when coping with breast cancer.

Limitations

Some methodological limitations warrant consideration when drawing conclusions from this study. First, this study was cross-sectional, thus, we are unable to determine whether coping strategies change over time or if these strategies are characteristic of specific phases of cancer survivorship. Longitudinal studies are needed to add to our understanding of coping processes, to assess whether coping fluctuates over time, and to examine the possible role of acculturation and age in breast cancer coping. Another study limitation is that we did ask participants to disclose their specific religious affiliation.

Conclusion

The present study contributes to our understanding of culturally-relevant coping strategies employed among cultural ethnic minority women. Findings provide perspective on the important role of culture in coping with breast cancer. Most women highlighted how their coping strategies led to positive experiences including personal development and growth. Religion/spirituality was a prominent strategy among Korean- and Mexican-American BCS. To date, fatalism has mostly been examined in cancer prevention and screening literature; however, the present findings add to a small but growing body of evidence highlighting the importance and complexity of fatalism in the context of coping and cancer survivorship (e.g., (Cheng, et al., 2013).

Health care professionals are in a unique position to encourage positive and culturally-relevant coping strategies that assist cultural ethnic minority BCS in successfully coping with their diagnosis and transition to survivorship. Research linking coping strategies to health outcomes in cultural ethnic minority women is needed to inform culturally tailored cancer support interventions with the potential in reducing psychosocial health disparities among the growing population of cultural ethnic minority BCS in the US.

Acknowledgments

This research was supported by grants from the NIH P20 CA118755, National Cancer Institute, Redes En Acción: The National Latino Cancer Research Network (U01 CA114657-05 and 1U54CA153511). The authors alone are responsible for the content and writing of this paper.

Footnotes

The authors report no conflicts of interest.

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