Physical and Emotional Experiences of Chemotherapy: a Qualitative Study among Women with Breast Cancer in Southern Thailand

Abstract

Background:

Chemotherapy treatment can increase survival rates among women with breast cancer elsewhere. However, it also has negative impact on women’s general appearance, body image and psychological functioning. This study aimed to describe the experiences of chemotherapy treatment among Thai women with breast cancer in rural communities, sounthern Thailand.

Methods:

Qualitative approach was employed to gain insights about the experiences of the women. In-depth interviewing and drawing methods were conducted with 20 Thai women who had been diagnosed with breast cancer. Thematic method was used to analyse the data.

Results:

Three themes emerged from the findings: I feel so weak: Lack of physical energy; experiencing physical and emotional burdens and managing health and life. Women were traumatized by effects of chemotherapy and suffered severe physical side effects. Most received inadequate professional support from health care providers and had to rely on their own judgment and use local resources to deal with the effects of their treatment and to improve their health and well-being.

Conclusions:

Chemotherapy brought about traumatic experiences to Thai women with breast cancer. Continual support is needed for the women to reduce the difficulties they might encounter. Support groups should be established for these women when receiving and completing chemotherapy treatment. Our finding suggested that social support programs that meet their need are salient means that could reduce the sufferings of these women. Nurses and other health care professionals in the local community should play their important role to establish such group and make it accessible for all.

Introduction

Breast cancer has been a major public health problem and become a common disease among women worldwide. The risk of getting breast cancer has increased throughout period of times, making breast cancer a significant public health issue. It is a leading cause of death amongst women in both developed and developing countries (Sprung et al., 2011; Torre et al., 2015). In recent years, there has been an increase in the number of newly-diagnosed breast cancer in Thailand (National Cancer Institute, 2014). Approximately 43 per cent out of all kinds of cancer in Thailand was breast cancer. Treatments for breast cancer are available in various forms: surgery, radiotherapy and chemotherapy (Rosman, 2004; Barry and Kell, 2011). Different treatment is considered according to their stage of breast cancer. These treatments have been continually developed (Maughan et al., 2010), with the aim of reducing the risk of recurrence and decreasing death rates from breast cancer (Flatley and Dodwell, 2016).

Modern medical treatment including chemotherapy has been recognized as a main method of breast cancer treatment (Abramczyk and Brozek-Pluskam, 2013). But such treatment which often has negative side effects can lead to many difficulties for women. Their lives become impaired as their healthy lives are turned into ones featured by illnesses and treatments. Breast cancer treatments could reduce women’s quality of life in many ways, causing physical and mental health problems (Davies et al., 2013).

Not only the side effects of chemotherapy that impact on the quality of life of these women (Rosman, 2004), they also experience various difficulties and often have to deal with additional undesirable outcomes (Rosman, 2004; Else-Quest et al., 2009). Most women would experience some forms of stigma because the adverse side effects disrupt their daily lives and interfere with their social interactions. Women with breast cancer experience stigma and discrimination even from people in their own community. This creates social isolation among these women (Rosman, 2004).

A review of literature reveals some recent studies that focus on the perceptions and experiences of breast cancer treatments among women in different societies (Davey et al., 2012). However, there has not been any study that addresses these specific issues among Thai women in Southern Thailand. In this paper, we discuss the experiences of chemotherapy of Thai women with breast cancer in rural communities in Southern Thailand where the social and cultural contexts are unique. Most people in the south, particularly those residing in rural communities, still preserve their traditional ways of life and rely on resources in the locality for health care and maintenance. This uniqueness may influence how these vulnerable women experience chemotherapy treatment dissimilar from the women in other parts of the country. Our findings contribute to existing literature on breast cancer by showing how Thai women experienced chemotherapy and various changes that occurred to them, how the treatment affected their everyday life, and how they dealt with these effects and stigma. These findings are useful for health care providers who wish to provide sensitive care to women with breast cancer especially in rural areas of southern Thailand.

Theoretical framework: Social stigma

Social stigma is a socially constructed process used to distinguish individuals’ characteristic and personality who depart from social norms (Goffman, 1968; Link and Phelan, 2001). Stigma, according to Goffman (1968) is a ‘process of devaluation’ associated with stereotyping and prejudices (p. 3). It is employed by individuals to define certain attributes of others as ‘discreditable or unworthy, resulting in the person stigmatized becoming ‘discounted’ or ‘tainted’ (Thomas, 2006: 3175). Stigma creates the social boundaries between the ‘normal’ and the ‘outsiders’; between us and them. Stigma thus brings about discrimination and social inequality. Stigma, as Thornicroft et al. (2007: 192) contend, ‘is a mark or sign of disgrace usually eliciting negative attitudes to its bearer’.

According to Goffman (1968), there are three kinds of stigmatizing conditions. ‘Tribal identities’ refer to such identities as gender, race, religion and nationality. The ‘blemishes of individual character’ may include such blemishes as having mental illness or living with breast cancer. ‘Abominations of the body’ could include such bodily conditions as deformities and physical disabilities (LeBel, 2008: 411) that result from having breast cancer and its treatments. Basing on Goffman’s stigmatizing conditions, there are many individuals who would be stigmatized due to their social and health status in many societies, including women living with breast cancer.

There are three components that involve in causing stigmatization of individuals. These include knowledge (ignorance), attitude (prejudice) and behavior (discrimination). Generally, due to their lack of accurate knowledge about the condition that leads to prejudices in individuals and this in turn results in stigmatization (Thornicroft et al., 2007). The stigmatized person has to bear the burden of negative effects in many ways. It could destroy the person’s personal relationships, segregate the person from their social networks, disregard individual rights, and decrease potential roles of individuals. However, stigmatization can also lead to means by which the stigmatized individuals adopt to cope with the stigma that they encounter (Thornicroft et al., 2004; Heijnders and Meij, 2006; Pescosolido et al., 2008; Sprung et al., 2011; Mohabbat-bahar, 2017). We will show in this paper that although the women had to deal with some stigma in their everyday life, they attempted to deal with it in the way that they could do within their own social and cultural means.

Materials and Methods

The study on which this paper is based adopted qualitative approach. Qualitative research is essential when little is known about the issue under investigation (Liamputtong, 2013). This study was carried out in the rural community of southern Thailand. Such area facilities were purposively selected with the assistance of local health care providers who was responsible for community health relating to the research objectives. We later extended number of communities for this study expecting to reach saturation level of the data, making a total of five communities from different locations.

Table 1.

Socio-demographic Characteristics of the Participants (n=20)

Socio-demographic characteristics	n (%)
Age group
40-49	5 (25)
50-59	6 (30)
60-69	3 (15)
70-79	6 (30)
Education level
Primary school	12 (60)
Secondary school	6 (30)
Bachelor’s degree	1 (5)
Master’s degree	1 (5)
Marital status
Married	17 (85)
Divorced	2 (10)
Widowed	1 (5)
Occupation
Housewife	3 (15)
Self-employed	13 (65)
Farmer	2 (10)
Government employee	2 (10)
Monthly income (Thai baht)
<10000	4 (20)
10000-20000	13 (65)
>30000	3 (15)
Stage of breast cancer
1	13 (65)
2	2 (10)
3	3 (15)
4	2 (10)
Diagnosed period (years)
<5	8 (40)
5-10	5 (25)
>10	7 (35)
Family history
Yes	13 (65)
No	7 (35)

The participants in our study were Thai women who had been diagnosed with breast cancer in rural communities in southern Thailand. Purposive sampling was initially employed to recruit those who could share thought and experiences that were relevant to the study purpose (Liamputtong and Suwankhong, 2016). The 20 women were selected purposely based on study criteria: 1) Thai women who had been diagnosed with breast cancer and living in rural community, southern Thailand; 2) they were not hospitalized or being admitted to a hospital 3) received short or long term chemotherapy treatment; 4) showed no signs of fatigue and were reported to be in a healthy state; and 5) willing to reflect on their experiences of breast cancer.

Snowball sampling was also used as a practical method for expanding the number of participants. Such sampling required us to initially select a few research participants and ask them if they knew of others who might meet the criteria of the research and who might be interested in participating. This is a common method of recruitment for research that involves sensitive issues and difficult-to-reach individuals (Sadler et al., 2010; Liamputtong, 2013). The number of participants was determined by saturation theory (Liamputtong, 2013). We continued to recruit the participants until little new data emerged.

In this study, we adopted semi-structure in-depth interviewing and drawing methods as data collection technique. A combined method of data collection ensured the rigor of the study. In-depth interviews were conducted with the women in the local southern Thai language in order to maintain the subtlety of the meanings that expressed by the participants. The women were contacted via telephone to make appointments before the interviews to suit their daily living condition. All interviews took place at the women’s homes. Each interview was audio-taped and lasted about ninety minutes.

We situated our study within the feminist methodological framework that recognizes women’s voices as key sources of information. The framework requires research that acknowledges women’s needs and concerns and the process of research needs to be undertaken in a respectful manner. This framework calls for qualitative investigation that is more flexible and less structured than that of the positivist discipline (Liamputtong, 2013). Often, it requires more creative means that will allow the women to be able to express themselves. Thus, we also used an innovative method involving drawings in this study (Guillemin and Westall, 2008). Drawings are persuasive as they are about ‘how people see the world in both its simplicities and its complexities’ In our research, the drawing method was employed after the in-depth interviews. All participants were given a packet of 48 colored pens and white blank flip-chart papers for the drawing sessions. They were invited to draw images showing their experience of treatment for breast cancer. When finished, we asked them to describe the image they illustrated. These descriptions were tape-recorded for data analysis. After the interview, each participant was given the compensation for their time in taking part in this study in the form of money with an appropriate amount: 200 Thai baht (US$7).

Ethical considerations

The ethic approval was granted by the University Human Ethics Committees (UHEC) of Thaksin University, Thailand and La Trobe University (REF No. 13-004). Informed consent was sought from all participants before the interview could be started. In presenting women’s verbatim responses, we used fictitious names to preserve confidentiality.

Data analysis

The data were managed and analyzed during the period of the fieldwork to ensure that we have reached saturation in the study (Liamputtong, 2013). Transcriptions of in-depth interviews were transcribed and downloaded electronically into the researchers’ personal laptop. Drawings were kept in the locked personal cabinet. Only the researchers were able to access the data.

Thematic analysis method was adopted to analyze the data (Braun and Clarke, 2006; Liamputtong and Serry, 2017). We initially performed open coding aiming to break down large chunks of information and re-form it, as well as link up discrete parts into new categories which reflect the phenomena under study. Axial coding was then applied to link relevant codes into meaningful themes and is completed when no new categories emerge. This results in themes that can be used to explain the lived experiences of the participants, which are presented in the findings section. The peer review method was used to ensure the rigor of the study (Liamputtong, 2013). The coding was initially done by the first author and codes and themes were reviewed by the second author.

Results

The findings could be categorized into three themes. These are described below.

‘I feel so weak’: Lack of physical energy

All women in our study experienced fatigue as a side effect of chemotherapy and perceived it as problematic burden when it combined with their illness. Many women experienced these soon after receiving the first treatment while some had the effects with later doses. The severity of fatigue increased in relation to the regimes they had in various treatment cycles. The fatigue symptoms remained consistent; they hardly recovered completely before they were required to undergo another dose in accord with the treatment cycles. This caused severe adverse physical and emotional constraints, especially when they were unable to perform daily tasks. Mai spoke with deep sadness about her inability to do normal activities.

I was so weak at that time. I could not help myself like before. It was very hard for me to even drink water. I could not hold the water bottle firmly; it would just fell down from my hand. [My] body has no energy…no strength.

Dang shared her negative experience of the ongoing fatigue from chemotherapy treatment in her drawing presented in Figure 1 below.

Figure 1.

Feeling Exhausted

The additional symptoms commonly experienced by women with breast cancer undergoing chemotherapy were nausea and vomiting. This was very troublesome to most women because this led to lack of appetite, reduced capacity to enjoy food, and resulted in weakness and weighs loss. None received medication for anti-nausea symptoms, although they faced different degrees of nausea and vomiting. They explained that these symptoms were not relieved by rest or sleep and impacted on their daily lives. Wanwisa told us:

I felt like vomiting but nothing came out, only my saliva. I had a dry mouth and the vomit continued for six-seven days. I was weak and frustrated. I did not know what to do. I just lied down and stayed inside the room.

Experiencing physical and emotional burdens

Women with breast cancer participated in our study encountered difficult experiences related to physical and emotional burdens. Pre-menopausal symptoms were perceived as some of the consequences of chemotherapy treatment by women in our study. One third of the women experienced severe hot flushes while a few tended to have more irritable feelings. These symptoms occurred most of the time both during the day and night. This side effect presented clinical depression with undesirable experiences such as anxiety and irritability. Banyen expressed her experience of pre-menopausal symptoms because of side effects of chemotherapy and how these affected her emotional well-being.

It felt like cold and hot [inside body] at the same time…like pen khai [getting sick]… sometimes I sweated. I cannot sleep well and am always tired. It makes me wake up and it is difficult [for me] to go back to sleep…very depressing.

Most women mentioned hair loss as the most noticeable side effect of chemotherapy treatment. They perceived that chemotherapy was a powerful medication that could make their hair falling out. Some reported that extensive hair loss developed soon with their early doses but some noticed that their hair fell out within a few weeks after starting chemotherapy. This was a very distressing consequence among the women. All the women were concerned about losing their hair as the loss of hair was a visible sign that they had cancer. Rasri described her experience of hair loss:

My hair fell out. It happened just after the second dose. It kept falling and falling. I laid down and looked in the mirror. [I] was very afraid of going out as people would stare at me. We sometime feel awkward and have no confidence in public. I have rok rai (a severe disease)…

Rasri also illustrated the bad feeling of hair loss through drawing below (see Figure 2).

Figure 2.

Feeling Bad about Hair Loss

Apart from the visible changes from hair loss, most were concerned that hair loss would make their appearance unattractive. They considered healthy hair as the most important characteristic for being normal or healthy women because it signified a woman’s feminine image. All women had difficulties accepting their image resulting from their cancer treatment. It became easier for others to see them and treat them as a cancer patient. Hairless women appeared to be unhealthy and frail attributes. They would look more like an older woman of the same age who had good health. According to most women, their hair loss was perceived as the greatest threat to their well-being. Rasri remarked:

Hua laan [Baldness] looks so unpleasant. I never want to meet people with artificial hair in my life. The lack of hair is not looking good for women. Baldness itself is not good for our feelings.

Many women were reluctant to continue chemotherapy treatment in order to avoid their hair falling out. However, some women did not react to hair loss in this way. A number of women accepted the hair loss as an inevitable effect of this treatment. They expected that it would re-grow when the treatment was completed. Thus, all continued the treatment as this would prolong their lives.

The changes of physical appearance after receiving chemotherapy brought about perceived stigmatization among the women in our study. This was because the treatment created visible features which could be noticed easily by community members. Everyone can see the difference between healthy and unhealthy women. The obvious visible sign reported by the participants participated in this study was the loss of their hair. This physical sign made the women who underwent chemotherapy look different to other women in the community, and attracted their attention. This created un-easy feelings among the women. Lamyong told us: “About 10 days after underwent chemotherapy, hair was falling till bald…it is an embarrassment… people tended to stare at me.”

Managing health and life

Most women with breast cancer in this study tried to seek ways to manage health and well-being based on individuals afford and self-reliance. When the women encountered the side effects of chemotherapy, they found that they had no one they could discuss the problems with when needed. All then had insufficient information about how to manage those symptoms and the side effects properly. Each expected the doctor who first provided care and treatment to be the one who would continue to provide such support. But the doctor was not always available for them. The women had to consult a general doctor on the basis of their daily schedule and received not sufficient advice about some aspects that they were concerned about and needed detailed information. These women made many attempts to improve their own well-being as they had to live with the cancer. They encouraged themselves to fight against and live with breast cancer through the care and support of their family members.

Many women readjusted their attitudes toward illness, tried to return to a normal life or to appreciate the life they currently had. In doing so, they sought additional information about the illness and health practices from various sources that they could access in the locality such as traditional healers, their neighbors and relatives. At the same time, they attempted to use natural products, herbs and fruits that are available in the local community. There was a common belief among the women that such products could increase the energy, diminish unwanted side effects of chemotherapy treatment and improve their general well-being.

Most women sought care from traditional healing practices. Herbal drinks were commonly used by the women during the recovery period. Most often, the herbs were home grown and free from chemicals or any dangerous substances. Herbal drinks also helped them to feel not too weak from the effects of chemotherapy. They also believed that the herbs would destroy any harmful agents resulting from the biochemical therapy.

After the operation, I started taking nam samunpri [herbal drinks]. They are made of different kinds of herbs. I grind the fresh herbs together and boil them in water. I drink these herbal drinks as water all day. I was told that they will get rid of the poison from my body. (Sinjai)

Wanwisa described what she did to relieve nausea and vomiting:

I remembered well my mum bought some sour fruits and salt with chilli pepper. When I saw this, my saliva was coming out and I felt so crave about it. Then I took it and it helped me to feel better.

Exercise was a routine practice among most women with breast cancer in our study. They understood that regular exercise could promote their health. It could strengthen their muscles, boost the body immune system, increase good blood circulation, ease stress, reduce anxiety and promote positive self-esteem. These positive outcomes could improve the appearances and changes resulting from adverse side effect of chemotherapy. However, the common exercise that women preferred was light exercises such as walking and cycling. Both types of exercise suited their lifestyles and cost them nothing. Dang told us: “I would go around the village in the early morning for two or three rounds…[I] stopped when I was getting sweat. I felt fresh afterwards and it helped”.

As mentioned, hair loss was the worst side effect identified by the women with breast cancer in this study. The fear of being seen as difference in peoples’ eyes made these women hide the visible effects so that they could feel more confident about their appearance. The women used various ways to hide their vulnerability, depending on the availability of materials and resources. Most told us that wearing a hat was the usual tactic they used to hide their hair loss. Several women simply used scarves to cover the lack of hair when they had to go out and meet people or visit the hospitals. Having a short haircut was a popular way of preparing for the inevitable hair loss. They thought that cutting their hair shorter could reduce visible sign of hair loss. They also believed that the shorter hair the less hair could fall out. However, many women stayed home to avoid being seen as women with breast cancer.

Some women went further by becoming a mae shi (a Buddhist nun). This was a practical option among women with breast cancer in Thailand including the women in our study. As a nun, who has to shave hair, it helped to hide their lack of hair because of side effect of chemotherapy treatment and they could appear as having a normal health to outsiders. Banyen chose to change her status to a nun to hide the side effects of chemotherapy when she noticed that her hair started to fall out rapidly. She said:

I have to become a nun so that I can be like a normal person. I can also do mediation to help with my condition, hoping to improve it. Others did not observe me as a cancer person.

A few women with breast cancer in this study decided to shave their hair without changing their status to a nun. This was because they found that the side effects would cause their hair to fall out continuously and they would eventually become bald-head person. So they preferred to shave it sooner rather than allowing it to fall out.

Discussion

The women living with breast cancer in our study suffered from negative consequences of chemotherapy treatment. Chemotherapy treatment affected the women in many ways: their activities in a daily life, their usual roles, social interaction with members in their community, their emotional well-being and quality of life (Donovan et al., 2004; Rosman, 2004; Hassett et al., 2006; Rasmussen, 2010). Although these side effects are relatively common conditions that most breast cancer patients have to face, they do decrease self-worth and the quality of life of women with breast cancer (Sprung et al., 2011). Many women in our study felt that they became disabled because of these side effects. Their work was disrupted and had to leave most of their responsibilities to family members and relatives. Indeed, they felt very shameful about the negative effects they had experienced. Basing on the stigma theory theorized by Goffman (1968), Rosman (2004) suggests that these changes in condition could be seen by others as negative traits and thus these individuals would be discredited. To most women in our study, the side effects of the treatment also lessened their capacity for independence. The symptoms interfered with their normal lifestyles. Thus, breast cancer treatment interfered with the capacity of the individual to lead a normal life (Arroyo and López, 2011; Sprung et al., 2011).

It can be seen that the consequences of chemotherapy treatment brought about stigma among women with breast cancer in this study. The changes of appearance and feature after receiving chemotherapy affected their normal life in many ways. This created much anxieties as they would be seen as being difference by others in the community. This phenomenon is in line with the stigma theory theorized by Goffman (1968). If a woman has characteristic and personality that are deviated from social norms, she will be blamed and discriminated. However, the woman would attempt to seek means to manage stigma so that she would be able to lead a normal life like other healthy women. The women in our study attempted to cope with it in the way that they could do within their social and cultural contexts (Mohabbat-Bahar, 2017).

What is interesting, however, our findings revealed that although all the women in this study attempted to improve their conditions, they received little professional support to help them to cope better. Most participants in our study did not receive sufficient information about how to look after their health following chemotherapy treatment. They were expected to be able to return to their routine activities. We contend that this might relate to the coverage in the health schemes they held. Most women in our study obtained care under the 30 Baht co-payment scheme; an inexpensive form of coverage under the Universal Coverage Scheme provided to people from low-income families. Currently, there are three main health coverage schemes operating in Thailand. These are: the Civil Servants Medical Benefits Scheme; the Social Security Scheme; and the Universal Coverage Scheme or 30 Baht co-payment scheme (Pittayapan, 2016). However, it has been reported by some participants in this study that the standard of care provided through each of the schemes can be unequal, and the worse health care provision remained located within the 30 Baht co-payment scheme (Jankhotkaew et al., 2011; Pittayapan, 2016). It is not too surprising that the women in our study did not receive good quality health care as they expected from health care providers.

However, it should be noted that the women in our study acted on their own agency to deal with the impact of chemotherapy treatment. Some of the strategies they used are socially and culturally situated within the Thai context. Many women with breast cancer in the south of Thailand made use of local resources and cultural practices to help them to deal with the effects of chemotherapy. Traditional health care has often been seen to represent a therapeutic strategy among people living with cancer (Torre et al., 2012; Pihlak, 2014; Liamputtong and Suwankhong, 2016).

Most women sought care from traditional healing practices. In rural community of Thailand, traditional healing practices have provided valuable health care for many Thai people (Suwankhong et al., 2012). As we have demonstrated, herbal drinks were commonly used by the women during the therapeutic and recovery periods.

Our study also showed that women had different strategies to camouflage the negative effects of chemotherapy. Interestingly, some women used a religious practice as a means to hide the negative impact of chemotherapy treatment. Religious practices have been adopted for dealing with health and difficulties in life by many people including women with breast cancer (Cebeci et al., 2012; Davey, 2012; Koenig et al., 2012). Some women in our study decided to become a Buddhist nun when they were losing hair in order to hide the impact of chemotherapy treatment. As a nun, a woman must shave her hair and this would stop neighbours asking questions about their illness.

It appeared that support and continue care for women with breast cancer during their treatment process are limited, although the provision of personal care and support is essential for this vulnerable woman. Health care providers who work at the local level of health care system need to provide consistent information for the women as they could manage the adverse side effects of chemotherapy treatment on their return home. The specific information provided should emphasis the whole process of chemotherapy treatment and combine various approaches to increase women’s knowledge and understanding of breast cancer and its treatment. An information package would be valuable to help individuals cope with and enhance their self-care. Thus, women with breast cancer may suffer less from the side effects of traditional chemotherapy option (Chou et al., 2012; Liamputtong and Suwankhong, 2016).

Implications for health care and policy

Support and continue care for women with breast cancer during their treatment process are limited although the provision of personal care and support is essential for this vulnerable woman. It is clearly shown in this study that all women with breast cancer who suffered from chemotherapy in our study received insufficient health information and support from health care professionals. Health care system needs to reform its service to meet the need of clients. Improving information support system could fulfil their need and this can lead to better quality of life among women with breast cancer.

Health care providers including nurses who work at the local level of health care system need to provide consistent information for their patients in order for the women to manage the adverse side effects of chemotherapy treatment on their return home. The specific information provided should emphasize the whole process of chemotherapy treatment and combine various approaches to increase women’s knowledge and understanding of breast cancer and its essential treatment. An information package would be valuable to help the individuals coping with and enhance their self-care better. Thus, women with breast cancer may suffer less from the side effects of traditional chemotherapy (Sitzia and Wood, 1998).

We suggest that the establishment of self-help and breast cancer support group at the local level could be an important source of support for women receiving chemotherapy treatment. This kind of support group should be integrated into routine breast care practice thus making the experience of chemotherapy treatment for women less traumatic while contributing to a better quality of life.

Chemotherapy brought about traumatic experiences to women with breast cancer and they faced difficulties in living a normal life. Despite their sufferings, these women act in their own agency and look for means that they can hope to continue their lives as a ‘normal woman’ (Hassett et al., 2006). Our findings contribute to a better understanding about the physical and emotional experiences of chemotherapy among women with breast cancer in rural community of Thailand. These findings add to existing literature regarding the lived experience of women with breast cancer in a non-Western context. They should assist nurses and other health care providers to develop appropriate strategies to help the women dealing with difficulties that they have to encounter during chemotherapy treatment, so that they would suffer less during the vulnerable period of their breast cancer trajectory.

Our findings suggest that continual support is needed for the women to reduce the difficulties they might encounter. Support groups should be established for these women when receiving and completing chemotherapy treatment. Such practice needs to be integrated in the routine procedures offered by nurses and other health care providers. Women with breast cancer might therefore suffer lesser impact and trauma from such treatment, which would lead to a better quality of life among the women.