cancer in women is a public health problem of global magnitude for
two reasons. First of all, the number of cases presented daily is
high, and secondly, because of the negative effects on physical,
health, emotional, mental and social status of women who suffer
it. This last aspect will be explored in the body of this article.
statistical report for 2002 trends of the International Association
of Cancer Registries - IACR,1
which is part of the World Health Organization, states that there
are 1,151,298 annual incidence of patients and a prevalence in five
years of 4,406,080 patients worldwide. For Colombia, the report
points out that in the same period, there were 5,526 annual incidence
of patients and a five years prevalence of 18,223 patients.
the Antioquia region where this investigation took place, according
to a report by the Regional Health Directorate of Antioquia,2
for the years 2002 to 2003, gynecologic cancer- breast and cervix
accounted for 31% of all cancer cases and accounted for 43% of the
top ten types of cancers. Thus, it can be concluded that because
of its high morbidity, breast cancer is a major health problem to
be investigated in order to explore alternatives for prevention,
intervention and rehabilitation.
research on women with breast cancer are numerous and diverse. The
consulted research show the wide range of knowledge concerning women
with breast cancer and indicates the biological, clinical, social,
intervention, and coping aspects among women with breast cancer.
However, none of the research describes what the coping strategies
are in the diagnostic phase, treatment and rehabilitation. Hence,
the author conducted an investigation to understand how women facing
breast cancer adapt to their new living conditions and health. The
secondary objective of the research was to understand how the women
overcame their fight with breast cancer. Both objectives seek to
provide knowledge in this study area in order to improve nursing
care to these women. This article will show how women initiate a
work of integral strengthening from the moment they are diagnosed
with the disease.
a period of one year and a half, twenty in depth interviews were
conducted with twenty women living in Medellin who had completed
their chemotherapy, brachytherapy and radiotherapy over a period
of three months to nineteen years ago. The women signed written
informed consent forms and voluntarily agreed to be interviewed.
The participants were contacted by the oncology services of different
hospitals in the city. Their ages ranged between 35 and 69 years
and most participants lived with a permanent partner. Their educational
background ranged from some elementary education to graduate degrees.
The participant's socio-economic status varied. A qualitative approach
using grounded theory was utilized for the interpretation and data
analysis. This technique included the identification, definition
and development of categories in terms of their properties and dimensions.
Thereafter, these were linked using hypotheses or statements that
Then, the main categories were linked with subcategories, in order
to describe the strategies used by women when facing breast cancer.
factors that influenced the ability of the patients to combat the
illness are: the sociocultural and psychological. The cultural aspect
is represented by social support and the patient's perception of
cancer. These factors facilitate or obstruct the patient's fight
against breast cancer.
time of diagnosis, the patient benefited from a social support network
that included the formal support provided by health professionals
and informal support provided by relatives, neighbors and friends.
These supports were emotional, instrumental or material, value and
The emotional support is represented by the establishment of empathy,
expressions of love and transference of confidence.4
Emotional support was the most outstanding because it helped them
to get out of the emotional crisis the process presented. The instrumental
or material support provided goods and tangibles such as food, furniture,
transportation, physical care, home care, money and shelter.4
Instrumental or material support was displayed by the family when
they rigorously took care of the dejected women during the aggressive
treatments, especially during times they could not exercise self-care.
Family members also brought them food and took responsibility for
household management. The Informational support was given by medical
staff and focused on information about the disease, effects of treatment,
skin care and warning signs during treatment. Value support was
made visible through words of encouragement. This was provided by
health professionals, families and friends.
Spiritual support manifested in the belief in spiritual beings was
another important support during the diagnosis, treatment and rehabilitation.
With the spiritual strategy, the women figuratively gave the disease
to spiritual beings. After releasing their disease to spiritual
beings, they were released from an emotional burden. They acquired
strength and tranquility because they felt that they would be healed
by these beings.
However, not all
experiences of the support network were healthy for the process
of adaptation. Some women reported stressful situations generated
by the inadequate attention of health personnel.
social perceptions of cancer had become another condition that affects
the adaptation. Adaptation is affected when women perceive the cancer
as "synonymous with death", "disease that invades",
"eat inside" and can "repeat itself". These
perceptions inhibited the adaptation due to the frequency of emotional
and mental imbalances during the process. In the same vein, author
Susan Sontag expresses: "Cancer is the disease that enters
without calling, the disease lived as ruthless and secret invasion,
a role that will continue until the day its etiology is clarified".5
As a result of these perceptions, since their diagnosis, they felt
accompanied by the ghosts of the uncertainty of being healthy
or sick and presentiality of the cancer in their bodies when
they feel a strange symptom or sign.
regards to the psychological factors that affected adaptation, two
personal conditions were found to be essential for the women to
achieve a successful process of adaptation. These two conditions
were: attachment to life and positive mentality.
attachment to life was the motor that helped them start their struggle
to face the disease. It is generated by their enormous wish to live
and because they have a family to live for. In fact, the author
Pryds and her colleagues6
point out that when women decide to continue living, they do not
give up against the disease. Likewise, author Vanistendael and others
wrote that the motivation provided by family produces in people
the capacity to give meaning to life in all kind of experiences
and gives them a reason to continue living and fighting.7
of the women interviewed already had a positive mentality. Those
that did not have a positive mentality developed it during the process.
The women perceive positive mentality as a force that encouraged
them to fight and not give in to the disease.
The work of patients
on strengthening themselves. To understand the work of strengthening,
it is important to consider that the physical, emotional, mental
and social disequilibrium that women experienced after the diagnosis
have actually empowered them. This was experienced as a force that
motivated and mobilized the women8
to seek strategies to achieve a "state of adaptability".9
These strategies are expressed in the integral strengthening
work that women have undertaken to rebalance the affected dimensions
of their lives. Experiencing new needs as a power is illustrated
in the approaching of Max Neef8
about the human needs. According to the author, to the extent that
the needs commit, motivate and mobilize people, they are also empowering.
order to understand how the strengthening works, the sociologist
points out that it is necessary to first make an effort to fortify,
so that a person or community that faces adversity becomes stronger.
Also, the person who needs to be fortified and become more competent
is the person who does the active work. In this study, women made
numerous physical, social, emotional and mental efforts to be fortified.
The strengthening was the final product of their work. This is defined
who argues that the fortitude is not a matter of muscles, but is
the virtue that leads to not worrying; facing difficult situations
without over thinking; doing what you have to do and holding out
what you have to hold out; pressing on the accelerator or the brake;
and finding in each moment the best to bring out the good results
that you aimed for. This definition of fortitude is applied to the
women in the study, in the sense that they fortified themselves:
they brought up strength, struggled and adapted the best way to
all the adversities they experienced since the time they were diagnosed.
explained above, the women undertook the fortifying work after they
learned of the diagnosis and the treatment to be carried out to
eradicate the cancer from the body. With this news, they emotionally
collapsed, but it is also from this moment that they started to
focus on strengthening the emotional dimension which is the most
affected at this time.
collapse is characterized by feelings of sadness, crying, anxiety,
depression, fear and numbness to the point that they felt close
to death. The most shocking news for them was the news about losing
their breasts and hair as consequences of the treatment. They described
it as very hard and horrible news, they felt very bad and immensely
concerned about how they will look without their hair and breasts.
cancer's social perceptions have influenced the magnitude of the
emotional collapse. Some women shared that as a cause of these perceptions,
they were in denial, because they felt their lives were threatened.
How did these women face the emotional collapse? The data shows
that in order to get out of this state, they started focusing on
strengthening their emotional dimension.
Work of emotional
fortitude. Strengthening emotionally is a dynamic process that
arises to face the emotional imbalances. These emotional imbalances
became a power for the adaptation. Thus, women were empowered to
make significant balances in their life, make decisions and undertake
strategies such as seeking spiritual support. Also, the company
of social support helped them to achieve the necessary emotional
fortitude to accept the disease and treatments.
the work of emotional fortitude, the women had to choose between
living with the cancer without treatment or undergoing treatment
and enduring losses such as hair loss and breast mutilation. All
of the women chose to continue living because they preferred to
have losses and continue living. A woman explained that "this
fight is for my life, it is better that my breast is removed so
I can continue living. I had to accept anything in order to live"
(MR10). The women weighed the two options and decided that it was
more important to continue living and endure the loss of their breast.
research data showed that the two important factors that made the
women attached to life were: having a family to live for and an
innate desire to continue living. These reasons became a key stimulus
for women to choose to live, so they undertook work of strengthening
themselves to overcome the disease.
phenomena that simultaneously occurred that contributed to this
work of emotional fortitude is the search for spiritual healing.
At the time of the diagnosis of
the disease and treatment, the support provided by medical staff
was emotional and value. The medical staff provided security, support,
confidence and encouragement to strengthen the women and made them
believe that everything was going to be well. Informal support was
given by family and friends. Their informal support helped to strengthen
the women by inculcating courage, tranquility and hope. Both supports
had a positive outcome; the women were influenced by these voices
of encouragement, so they were at peace. Also, they understood they
had more options and their world is not going to end because of
The search of support
in spiritual being is made by surrendering to their spiritual being
such as God, a saint or the Virgin, one of the women interviewed
states "at the moment I knew I had the disease I surrendered
the disease to my God" (LM02). With this search for spiritual
support, the women experienced strength, resignation, tranquility
and encouragement to keep going and they felt free from the burden
of the disease.
the social and spiritual support helped the women to be emotionally
strong and to accept the disease. However, they must submit to treatment
and this is where they undertake an integral strengthening work
to overcome the disease. Integral strengthening work encompasses
emotional, mental, physical and social fortification.
treatments that the women underwent are quite aggressive and mutilating,
causing physical, emotional, social and mental disequilibrium. During
treatment, the ghosts of uncertainty and presentiality were common
in the testimonies of women when referring to concerns of cancer
recurrence in their bodies.
better understand how the disequilibrium occurred at this stage,
it is important to recognize the human being not as a sum of it
parts, but rather as a holistic being, where any change in one dimension
greatly or to a lesser extent affect the other dimensions. The physical
balance is ruptured by the corporal losses and changes in the functionality
of some parts of the body, such as malaise, gastrointestinal discomfort,
skin changes, hormonal disorders (menopause) and reduction of body's
defenses. All these bodily imbalances generated suffering, affected
the health and well being, and thus, affected the mental and emotional
dimensions. The mental dimension is affected because there are changes
in the way of thinking about life and plans and how to behave with
others. The emotional dimension is reflected in crying, depression,
discouragement, despair and anguish. This affected their self-esteem,
one of the women interviewed commented "I cried for many
things, not just for the vanity, but also because my self-esteem
is down, the process of the medication put my courage down"
The above changes generated
a social imbalance; the women were not able to exercise their roles
as housewife, worker, and caregiver for their body. They felt useless
and anxious. These imbalances empowered the women and helped them
to the adaptation during the process of the treatment; it encouraged
them to constantly rebalance. In order to adapt, they started the
fight to be well characterized by an integral strengthening work
to overcome the disease.
work. The two key conditions to assume the work of strengthening
are attachment to life and a positive mentality. Moreover, the strategy
to carry out this work includes: rigorous body care, maintenance
of self-image and avoidance of situations that affected them. At
this stage, social support and spirituality also play an important
role, consequently these strengthened them emotionally.
a positive mentality: the women related that in spite of the suffering,
discouragement, uncertainty and feelings of giving up, they understood
that the most important strategy to succeed and overcome the disease
is having a positive attitude towards life and the disease. Women
who naturally had a positive mentality maintained it through the
process of the disease. Women who did not naturally have a positive
attitude developed it during the process.
this attitude was assumed, it became a mental strategy that helps
them in difficult moments to be encouraged where they need it, that
means they gained strengthen. For example, a woman said "I
did not let myself be grieved, I say to myself go on, go on"
(LA07). It also helped them to open their minds, have faith in others
and hope that everything will be fine. One on the women interviewed
expressed "I believed in the doctors, I thought I am in
good hands, I will recover" (MR10). A positive mentality
was cultivated in the mind by proclaiming "I'm healthy,
I'm healthy, I am perfect, full of life" (AZ16).
care. The women undertook a work of corporal strengthening,
wherein they strived to carry out a rigorous body care through various
strategies, such as opening their minds to alternative therapies,
and restore the appearance and functionality of their bodies. Rigorous
care was not an easy task and consisted of a series of caring practices
to nurture and restore the functionality of different systems and
body parts, as well as to preserve their appearance and to resemble
their former self before the disease.
undertake this care, the first thing they did was open their mind
to all the things that their medical care, family and friends recommended
to them to achieve normality. Secondly, they sought alternative
therapies such as people and specialists in skin care and teeth.
Another important strategy while doing the rigorous body care was
the effort they put into it. This means they were dedicated and
disciplined to achieve their goals. For instance, a woman emphasized
"I was limited, but I can not continue being like this...
I could not be with a motionless arm and the present pain, so I
exercise and I'm fine, because I put effort and willpower"
The women were not alone
in this process, the family commitment and involvement in this care
was astounding. They provided companionship and attention during
To adapt to their new body image, the women worked in a creative
way. They used the strategy of maintaining self-image. They acted
differently depending on the environment that they were in. In a
public environment, they try to go unnoticed, using scarves, hats,
and wigs to disguise hair loss. Furthermore, they use prosthesis
such as patchworks, birdseeds or silicones to hide the loss of their
breast, thus they continue keeping their body image. One of the
women interviewed stated that "I felt empty and I said people
do not have to notice it, so in my house, my family invented prosthesis...
so I put a filler to disguise the absence of the breast"
(MR10). With this strategy, they strengthened their emotional dimension
when they presented themselves as "normal" to society
and were not pitied. In the family context, everything changed,
it was not important to conceal the losses and to be ashamed. At
home, they had the confidence of show themselves as they are.
that affected them. In order to be protected from having new
disequilibrium, women worked to avoid situations that affected them
psychologically and emotionally; so they remain strengthened. The
data showed that women repeatedly avoid two situations: looking
at their bodies and having situations that they believe affect them.
These women were afraid to look at their maimed body and their bald
head. A woman stated "I can not imagine myself bald, I never
looked at my head" (CR13). They do not want to experience
situations that reminded them of the reality that they are living
and potentially can cause emotional imbalances, such as funerals
and wakes. However, they preferred to attend parties or take trips.
they avoided talking about their illness in order to not have a
complex and inspire pity because of their cancer. A woman says "I
do not want anyone to know... I feel like everyone feels sorry for
me, I always feel a complex" (A12). In concordance with
this finding, Susan Sontag expresses: "Given the numerous metaphorical
flourishes that have made cancer synonymous of bad, many people
have experienced it as shameful, therefore something to hide".5
avoid thinking about their situation, they spent their time doing
diverse activities. For example, a women commented "to take
away those thoughts of this chemo, I did house chores, I painted
on fabric, I was enjoying doing something" (DE08).
an emotional equilibrium was not an easy and it meant the women
actively worked towards behavior changes and modification of situations
to maintain control of their disease. They avoided worries and sufferings
and made themselves believe that all was going well. It is also
noteworthy that this work of integral strengthening included formal
and informal support and seeking support in spiritual beings.
with the breast cancer was a complex process for the women because
they continually had to face many imbalances that affected their
emotional, physical, mental and social dimension. Additionally,
they coped with the sufferings that accompany the diagnosis of disease
they considered fatal. They also faced bodily looses and changes
in the roles they played in their daily life. Moreover, they lived
with the ghost of uncertainty about their future health and cancer
presentiality in their lives.
facing these imbalances, women were not passive; on the contrary
they were seeking balance through a work of integral strengthening
in the emotional, physical, social and mental health dimensions.
This strategy reflected the effort, creativity, commitment and dedication
that women undertook to get ahead of their situation.
of the important strategies of the strengthening work was having
or developing a positive mentality. This mentality helped them to
cope when they passed through difficult moments in the course of
treatment. Moreover, this mentality helped them in those moments
when they felt faint and too weak to continue. Finally, they were
convinced that with this mentality, they would overcome the tumor.
key factor in overcoming the disease was the formal and informal
social support, which helped the women to have emotional, physical
and mental strength. Similarly, their spirituality gained importance
because it gave them vigor and courage to move forward and to get
free from the disease.
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