Lived Experience of Breast Cancer Survivors: A Phenomenological Study

ABSTRACT Background Breast cancer (BrCa) is the most common cancer worldwide. Five-year survival rates among individuals with BrCa are the highest of all types of cancer, yet there is a paucity of knowledge about the experiences of survivors regarding living through their diagnosis and treatment. In-depth interviews and the systematic analysis of self-reported experiences may provide in-depth information about the BrCa survivorship experience. Purpose This qualitative study was designed to identify and elucidate the lived experiences of Thai women with BrCa who successfully completed their treatment program for BrCa and/or treatment with chemotherapy for over 5 years and are currently cancer-free. Methods A phenomenological method was employed. Survivors of BrCa who met the inclusion criteria were purposively selected and invited to take part in the study. Study data were collected between January and March 2019. An open-ended, in-depth interview guide was used to direct the conversation concerning the participants' experiences and perceptions. Thematic analysis was used for data analysis. Results Data saturation was reached after 12 interviews. The five themes derived from the data include (a) being distressed, (b) accepting treatments and seeking alternative treatments, (c) going through difficult times, (d) becoming a stronger person, and (e) becoming thankful. Conclusions/Implications for Practice The experiences and themes identified enhance scholarly understanding regarding the experience of survivors of BrCa. A true understanding of this experience enables healthcare providers to craft and deliver appropriate interventions that provide quality care and improve women's health, thereby enhancing their quality of life. The results of this study may contribute to the development of new theories by using different qualitative approaches such as grounded theory.


Introduction
The number of survivors of breast cancer (BrCa) has increased since 1990 because of advancements in biomedical technology and medical care that have increased early diagnosis and treatment (World Cancer Research Fund International, 2020). Worldwide, it has been reported that 2,261,419 new cases of BrCa were diagnosed among women, making BrCa the most common cancer worldwide, contributing 12.5% of the total number of new cancer cases diagnosed in 2020 (World Cancer Research Fund International, 2020). In addition, BrCa was the most common cancer in women worldwide, contributing 25.8% of the total number of new cases of cancer diagnosed among this group in 2020 (World Cancer Research Fund International, 2020). Importantly, BrCa is the most prevalent cancer among women in Thailand. Cancer statistics published by the National Cancer Institute, Thailand, showed BrCa to be the leading cancer among Thai women, accounting for 39.8% of all cancers experienced by women (National Cancer Institute, Thailand, 2020).
The BrCa survival rate has increased dramatically because of advancements in medical technologies that has led to early diagnosis and effective treatment (Morales-Sánchez et al., 2021;Shapiro, 2018). This means women are living longer and, perhaps, are more likely to suffer from the consequences of their treatments, which may persist for long periods afterward (Hellerstedt-Börjesson et al., 2016;Shapiro, 2018). Although 5-year survival rates among individuals with BrCa are the highest among all types of cancer (American Cancer Society, 2020), there is a paucity of knowledge about survivors' diagnosis and treatment experiences. Most of the recent research on cancer survivorship has focused on the physiological treatment of the disease (Drageset et al., 2020;Dsouza et al., 2018;Shapiro, 2018).
Prior qualitative studies have also highlighted the factors related to diagnosis and treatment that affect survivorship, relationship and support systems, and the implications of survivorship (Hellerstedt-Börjesson et al., 2016;Jefford et al., 2017). Survivors of BrCa have described the process of coping with the diagnosis and treatment to be a stressful journey requiring major adjustments and changes. In addition, support received from family and friends was almost universally recognized as key to providing the strength and courage necessary to make it through the different stages of treatment (Hellerstedt-Börjesson et al., 2016;Jefford et al., 2017). However, these survivors have found it difficult to articulate what survivorship meant to them. Nevertheless, there is no clear picture of their life-change events and lived experiences. Although BrCa is the most common cancer among women worldwide (American Institute for Cancer Research, 2020), there is little knowledge about the experiences among BrCa survivors in Thailand. In particular, there is a lack of qualitative studies concentrating on how Thai survivors of BrCa have learned to continue living their lives. Therefore, this study was designed to elucidate the lived experiences of Thai women diagnosed with and treated for BrCa who are now cancer-free survivors.

Study Design
This study was designed to gain a better understanding of the lived experiences of survivors of BrCa. In this study, Husserl's conception of phenomenology, as modified by Giorgi (2009), was used as the guiding framework to determine their lived experiences. Descriptive phenomenology methods were designed to capture the true meanings of an experience by exploring the reality of the survivors' journeys (Chiaranai et al., 2018;Patton, 2020). Descriptive approaches were also used to illuminate poorly understood aspects of experiences (Chiaranai et al., 2018), moving beyond a clinical model framework to provide deeper insights into the experiences and lives of Thai survivors of BrCa. Although each participant's experience is unique, when the survivors' experiences are scrutinized as a group, the intertwined experiences generate a more complete and clear depiction of their collective reality, improving clarity and understanding (Chiaranai et al., 2018).

Participants
A purposive sampling strategy was used to recruit participants who met the inclusion criteria, including (a) Thai women who successfully completed a treatment program for BrCa and/or treatment with chemotherapy at least 5 years ago and who have been confirmed by a physician as being cancer-free at the time of this study, (b) being at least 18 years old, and (c) being able to converse in Thai. The exclusion criteria were (a) having a prior diagnosis of significant psychiatric problems or (b) still in an active course of treatment. We initially contacted a homecare nurse in a primary healthcare center where women regularly seek posthospitalization care. Next, the homecare nurse invited the potential participants to take part in this study via telephone. Those who agreed to take part in the study were asked to sign a consent form. The researchers then arranged a face-to-face interview at the participant's convenience. Recruitment stopped when data saturation was reached (Creswell & Creswell, 2017).

Ethical Considerations
This qualitative study protocol was approved by the institutional review board at Suranaree University of Technology . After the potential participants were identified, the consent forms were obtained from the participants. Each was informed of the purpose of this study and the potential responsibilities and benefits associated with participation (e.g., psychological or emotional benefits, learning benefits). Moreover, all of the participants were informed of their rights to withdraw from this study at any point in time. In addition, they were assured that the collected data would be kept confidential and be accessible only to authorized persons. To ensure anonymity during reporting, the participants were assigned numbers in place of names (BrCa01, BrCa02, etc.) and all personal identification information was removed from the transcripts. In addition, the consolidated criteria for reporting qualitative research guidelines proposed by Tong et al. (2007) were followed throughout this study.

Data Collection
Data were collected between January and March 2019. An open-ended, in-depth interview guide was used to guide the conversation concerning each participant's experiences and perceptions. The interview guides were developed from published, relevant articles on BrCa published in the literature (Dsouza et al., 2018;Lashbrook et al., 2018;Suwankhong & Liamputtong, 2018). These articles addressed how survivors experienced falling ill and how they had learned to live with their cancer before achieving cancer-free status. The participants were asked to describe "going through" a survival process that involved progressing through several stages. Follow-up questions (e.g., "What was your feeling once you were told that you had breast cancer?" "How did you and your family feel or experience it?" and "Please tell us more") were asked to gain insight into the phenomenon. In addition, the face-to-face interviews were in Thai to retain the subtleties and nuances present in these answers. All of the interviews took place at a time and place of each participant's choosing, which helped the participants authentically express their experiences, feelings, attitudes, and perceptions in detail. Each interview lasted approximately 45-60 minutes. Field notes were used in this study as reflective observational data providing contextual information (e.g., behaviors, activities, reflection, and other features of an observation). With the permission of the participants, the interviews were audiotaped and transcribed verbatim for data analysis.

Data Analysis
Descriptive and reflective information were used in data analysis. The analysis was performed manually by the first two authors using thematic analysis, as recommended by Colaizzi (1978). First, the participants' descriptions were read and reread in their entirety to obtain a better sense of the whole. Next, statements, including phrases and sentences that directly related to the phenomenon being studied, were separated into cohesive meaning units to enhance manageability. Statements containing the same or almost-the-same thoughts were eliminated. Later, greater understanding was articulated by extracting the meanings from the phrases and statements. As the analysis progressed, the level of understanding became increasingly abstract, and the uncovered meanings were placed in clusters of similar ideas reflected in the original descriptions. Finally, the researchers generated a statement that encompassed all of the descriptions given of the experience of living as a cancer survivor. In addition, through discussion, a consensus was reached between the researchers.

Rigor
Credibility, validity, and trustworthiness were evaluated to ensure the quality of this study. To ensure credibility and trustworthiness, the researchers' knowledge of the phenomenon was bracketed to prevent preconceptions regarding BrCa having an influence on outcomes and allow the analysis of experience of living through BrCa to be the sole focus. An oncology nurse was asked to examine the transcript and findings of this study to further enhance its credibility and validity. Furthermore, trustworthiness was enhanced using member checking. The researchers returned the preliminary results of this study to eight participants, who were then asked to confirm that the researchers' descriptions accurately reflected their experiences.

Results
Data saturation was reached after 12 interviews. As presented in Table 1, the average age of the participants was 58.53 years (range: 50-69 years); their average length of survivorship was 7 years (range: 5-10 years); six (50%) were housewives, two were retired, and four were still employed; six (50%) were diagnosed with Stage II BrCa, three were diagnosed with Stage I BrCa, two were diagnosed with Stage I-II BrCa, and one was diagnosed with Stage III BrCa; seven (58.33%) had received both chemotherapy and hormonal therapy, three had received chemotherapy only, and two had receive a combination of radiation, hormone, and chemotherapy; and 10 (83.33%) had undergone modified radical mastectomy, one had undergone axillary lymph node dissection, and one had undergone breast reconstruction.
After data analysis, the thematic map developed for this study identified five themes: (a) being distressed, (b) accepting treatments and seeking alternative treatments, (c) going through difficult times, (d) becoming a stronger person, and (e) becoming thankful. The final thematic map developed for this study includes these themes and subthemes ( Table 2). The five themes that emerged from the data are detailed below.

Being Distressed
This theme conceptualized the significant reactions of women after being told they had cancer. All of the participants stated that they experienced unpleasant feelings, including "shock," "anxiety," "fright," "hopelessness," "emptiness," "worry," "sadness," "fearful," and "uncertainty." Most of them reported crying continually and being depressed. This perception is illustrated in the following excerpts: I was shocked when I heard my diagnosis. I felt empty and couldn't think of anything. Then, many questions came to me like, Is it true? How long do I have to live? and so on. (BrCa01) The doctor told me that it (the lump) was a cancer. I was not prepared to learn that the lump on my breast turned out to be a bad tumor. Oh! I was shocked, fearful, sad, and never ever wanted to talk to anybody. (BrCa02) …the doctor told me that the lump was an early stage and could possibly be cured. And the lump was a bad tumor (malignancy). I cried unstoppably and my hands were shaking…. (BrCa03)

Accepting Treatments and Seeking Alternative Treatments
Although the participants were not initially prepared for their cancer diagnosis, they came to accept it gradually over time. After the initial shock waned, the participants began to resolutely approach their disease and sought help and assurance related to treating their BrCa. These included accepting treatments and also seeking alternative treatments. In addition to modern medical treatment regimens, 10 of the participants reported using herbal regimens, which were not recommended or prescribed by their physicians, believing they would cure the cancer. The herbal regimens used by the participants included lemongrass juice, astaxantin extract, lingzhi mushroom extract, ginseng, crocodile blood extract, and soursop leaf juice.
I decided to receive the treatment from the doctor. I also used herbal capsules in addition to the medical treatment. The herbal capsule was the so-called crocodile blood extract. I don't know exactly what the ingredients are. I only know that it helped restore my energy.
I had heard that soursop leaves help cure cancer and improve immunity. It said to use it by bringing it to a boil and then reducing the heat to low, simmering for another 20-30 minutes, and drinking it before meals 3 times a day. I did not see any changes, but my condition didn't worsen. (BrCa04) One participant reported using Ya-Mor (unknown mixture of herbal ingredients, usually provided in a package) and Ya-Shood (a set of unknown medicines, usually containing steroids). Unfortunately, she reported experiencing side effects.
…my neighbor told me that Ya-Mor from a herbal healer could cure the tumor. To use it, you must boil the Ya-Mor, let it sit, and drink it 3 times a day. I didn't see any change in my body. Later, one of my friends told me that Ya-Shood from Mr. Shen (name of the seller) was good. Many cancer patients used it and got better. It came in a set of 10 pills. I took it and felt dizzy. My husband took me to the hospital. The doctor said that I was in shock. I stayed in the Only one participant reported, in addition to the cancer treatment, consuming a healthy diet of bioorganic foods and homegrown fruits and vegetables with no processed meats, no alcohol, smoking cessation, and increased regular physical activity.
I read some articles about the cause of cancer and realized that, in addition to genetics, cancer is also caused by the way we put ourselves at risk like drinking alcohol, eating junk food, and not exercising. So, I changed my lifestyle by eating healthy food, of which I prefer bioorganic food, walking every day, and practicing meditation. (BrCa01)

Going Through Difficult Times
This group of participants defined going through difficult times as encountering life circumstances and treatment-related effects that have significant physical, emotional, social, and economical effects. Physically, all of the participants experienced signs and symptoms while under the treatment. The side effects of their treatments included pain, physical weakness, burning, nausea, vomiting, black nail, and hair loss.
BrCa03, who experienced the most side effects of chemotherapy in the sample, explained that: "I thought I would die before the treatment was completed. After the 2 nd cycle, I became very sick. I experienced all sort of symptoms. I was tired. I threw up. I couldn't eat anything. My nails turned black and broke easily. Whenever I brushed my hair, my hair would fall out easily…" (BrCa03).
In addition, seven participants stated that the most suffering came from the red regimen of chemotherapy (doxorubicin), for example, "As soon as I saw that red devil medicine, I automatically felt sick and cried" (BrCa06).
One participant experienced burning in her oral cavity: "…that FU (5-FU) regimen caused burning and blistering in my mouth. I couldn't eat anything but ice chips. It was so terrible that I could barely stand" (BrCa07).
A lowering of immunity was reported by four of the participants that caused delays in treatment: "…I found that my blood was not good in one visit. The doctor told me my immunity was poor [ANC < 1,000/mm3] and that it was not safe to continue the chemotherapy. I had to go back home rest. I ate more eggs and came back in about 2 weeks. I guess that's how the doctor boosted my immunity" (BrCa03).
Emotionally, the participants experienced mental weakness, anger, worry, depression, sorrow, and uncertainty as the treatment continued. The following is a typical example of the mental weakness reported: …Knowing that the stigma of cancer was inside of me, many feelings came over me. I was sad and sorrowful wondering why it had to be me. I cried unstoppably. It was even worse when the side effects of chemotherapy attacked me. It was pained. I got upset very easily…. (BrCa08) Most of the participants reported having no problems related to change in body image (e.g., baldness, having no breasts, darken nails). A 55-year-old participant who had received breast reconstruction stated: "…To me, my new breast is like a piece of art. I am pleased with it. It makes me look female from the outside. But it never made me who I am" (BrCa06).
Nevertheless, two participants reported lower self-confidence in their feminine appearance, which limited their social life.
Before cancer attacked me, I used to have long, smooth, and silky hair. Having my hair fall out, I couldn't stand seeing myself in front of the mirror. I saw a weak, pale, and bald-headed lady. I wouldn't go anywhere without putting a wig on. (BrCa09) The survivors of BrCa in this study faced financial hardships during treatment. Although BrCa treatments in Thailand are covered by the National Health Security Office under the Universal Health Coverage Scheme (UCS), six of the participants noted facing economic hardships associated with their BrCa treatments, stating the need to "use my own savings," "pay out of pocket," and "self-pay." I am thankful that the cancer treatment cost was covered by the government. But going there (to the cancer center), I had to use some of my own savings for transportation and lodging. (BrCa10)

Becoming a Stronger Person
The participants described that after they had been through all of their traumatic experiences, they had become stronger persons, both physically and mentally. They used terms like "winner," "passed," "rebirth," and "beat it." The following example highlights this finding: I am amazed that now I am free of cancer. Looking back on those days, I was a very weak person. Now I am a normal person. I could say that I beat it (the cancer) and have become a new me. I passed the life test. (BrCa06) Interestingly, most participants stated that they learned to accept life and became stronger persons mentally by sheer force of will. They talked about "putting the mind at ease," "focusing on the moment," and "following the Buddha's teachings." I realized that life is uncertain. Death, on the other hand, is a certainty. Everyone dies and I will die for sure. I put my mind at ease, focusing on the present moment. Jit-pen-nai-kai-pen-bao (mind is the master controlling the body) is true. When your mind is weak, your body gets weak too…. (BrCa11) I became very sick during the treatment course. I used to think, "Please don't let me die, I want to get better." Then, I realized that this was the wrong way to think and it would lead to suffering. To not suffer, you must say to yourself, "If I recover, I recover. If I die, I die." I just let the treatment take action, I meditated Lived Experience of Breast Cancer Survivors VOL. 30, NO. 6, DECEMBER 2022 and paid attention only to my inner peace. I think I won this life competition. It was challenging (proud smile). (BrCa10) The participants showed having a positive understanding of life.
Well, Lord Buddha taught us that at birth we bring old age, sickness, and death along with us. People are born and eventually die just like all other creatures. By understating the true nature of all things, I struggled less. Finally, inner strength appears in my mind. (BrCa01) Wanting life to last forever is impossible. We must strive to understand that all bodies are impermanent…. I think that reflecting on death with the right attitude is a valuable tool to pursue inner peace. (BrCa04)

Becoming Thankful
Although BrCa is a life-threatening illness that may ultimately lead to death, the survivors of BrCa in this study became thankful for the extra time that allowed them to prepare themselves for many things. They used the words "grateful," "prime time," "incentive," "great opportunity," "valuable experience," "precious time," and "appreciated." These perceptions are illustrated in the following examples: Understanding and facing death as nothing more than a temporary end to a temporary existence through having cancer as a stigma inside of me was a valuable experience. I am grateful that cancer gave me inner strength. I am now preparing for the good death of this life and being ready for a new journey of life after rebirth. (BrCa04) My time as a cancer survivor is an extra, very precious time. Understanding that the time of death should give us incentive to practice good deeds, I would spend this prime time doing only good deeds. All good and bad deeds have their follow-on effects. A good death leads to a good rebirth. (BrCa12) In addition, the participants expressed being thankful for the support provided by family members, spouses, and healthcare providers. These perceptions are illustrated in the following examples: My husband, my best friend, had never taken off from his work. But on the first visit, he did take off from his work and was with me. I blanked out and cried when the doctor told me I had breast cancer.... If he wasn't there, I don't know in what state I would have been that day. (BrCa01) The nurses there (the cancer center) recognized how awful I was last time receiving chemotherapy. They made sure I was in their sights. As soon as I was not okay, they were always there for me. I appreciated their support. (BrCa03) In conclusion, the participants in this study were thankful for the extra time that allowed them to accept the reality of life. The extra time also provided the participants with insights into the nature of existence. Furthermore, they were thankful for all of the support provided by significant others.

Discussion
This study was designed to elicit a better understanding of how survivors of BrCa experience their life situations and problems. The themes we uncovered reflect the participants' experiences becoming survivors of BrCa. These findings share similarities and differences with other studies of the life experiences of survivors of BrCa, as detailed in the following.

Being Distressed
The finding of this study is consistent with prior studies of patients with cancer (Dsouza et al., 2018;McConkey & Holborn, 2018;Smit et al., 2019), which found that the most frequent reactions of these patients were shock, disbelief, anger, fear, sadness, and anxiety. In addition, it is now well recognized that the diagnosis of cancer is a major stressor in the life of these individuals, with the effects of diagnosis and treatment directly affecting quality of life. Most people perceive cancer as an incurable disease that leads directly to either death or a severely shortened life span. Having advanced cancer is bad news and may be incredibly jarring and turn the patient's world upside down.

Accepting Treatments and Seeking Alternative Treatments
It is very difficult for patients with BrCa to admit that they are ill and need help. However, once they accept and acknowledge the situation, they realize that there are resources available to put them on the path to resilience so that they can fulfill their lives while managing their illness. In other words, the sooner a patient accepts their illness, the quicker they learn to manage their illness and achieve self-management, which is key to patients learning to live with cancer and regaining a normal life (Jeffs et al., 2016).
Nevertheless, with respect to seeking alternative treatments for BrCa, the findings of this study differ somewhat from Suwankhong and Liamputtong (2018), who studied the lived experiences of women with BrCa. These researchers similarly reported their participants using homegrown herbs, which were free of chemicals and dangerous substances. In addition, they sought herbal medicines prepared by renowned traditional healers. Fortunately, the participants in that study reported good results from their alternative treatment regimens (Suwankhong & Liamputtong, 2018). In contrast, the alternative treatments chosen by the participants in this study were not recommended by the physicians, and most of the participants did not see any significant changes attributable to these treatments. Moreover, some of the participants in this study experienced adverse effects from their alternative treatments that delayed the progress of their main treatment. The findings of The Journal of Nursing Research Chantira CHIARANAI et al. this study support that failure to comply with clinician recommendations and the use of inappropriate self-medication regimens affect the overall health of patients with BrCa negatively.

Going Through Difficult Times
The findings of this study illustrate the importance of extending personal experiences burdened by symptoms associated with treatments, which is consistent with previous studies conducted on patients with cancer (Suwankhong & Liamputtong, 2018;Tsaras et al., 2018). The researchers found that the burden of cancer and its treatment affected greatly the physical and emotional state of the participants.
Most of the participants in this study placed little importance on body image, which differs from other studies (Kołodziejczyk & Pawłowski, 2019;Wu et al., 2021) that found self-esteem to be negatively affected by poor body image in patients with BrCa. In other words, body image has been reported to enhance self-efficacy and self-esteem. One explanation may be that most of the participants of our study were older adults and thus perceived their physical appearance to be less important than their overall health and functionality.
However, the results also indicate that few of the socially active participants reported a lowering in self-esteem related to their physical appearance. This finding is echoed in Dsouza et al. (2018), who studied the experiences and needs of survivors of BrCa. Their participants voiced that being stared at by others made them feel uncomfortable and caused feelings of self-consciousness (Dsouza et al., 2018). This may be explained that, from the perspective of women, having long hair and breasts are directly associated with femininity, motherhood, and beauty. Therefore, changes in body image (e.g., hair loss, breast resection, uncomfortable situations) are associated with lower self-confidence, reduced sexual function, poorer social relationships, and depression, which can affect their ability to return to a normal life (Smit et al., 2019;Wu et al., 2021).
The participants in this study experienced financial constraints associated with their cancer treatments, which is similar to findings of studies conducted in both Western and Eastern countries (Chiaranai et al., 2018;Knaul et al., 2020). More specifically, this study yielded findings similar to those conducted by Chiaranai et al. (2018). These researchers also noted that Thailand's healthcare system (UCS) guarantees healthcare for all Thai nationals. This scheme helps increase access to healthcare services and reduces the incidence of devastating health expenditures for Thai citizens. Similarly, our findings revealed that the participants received care covered by UCS but that the associated, primarily nonmedical expenses were a hardship. Thus, the participants faced not only physical and social hardships but also financial hardships.

Becoming a Stronger Person
Participants in this study used the Buddhist belief of the cycle of life to adjust their thinking and attitudes and gradually accepted their illness. Spiritual/religious beliefs played an important role in the coping process and the alleviation of suf-fering in the survivors of BrCa in this study. The findings of this study yielded similar findings to previous studies (Drageset et al., 2020;Kugbey et al., 2020;Phenwan et al., 2019), which also found that religious/cultural beliefs strengthen the faith of survivors of BrCa in God/Buddha and allow them to deal with the challenges associated with living with BrCa, thus enhancing emotional well-being. This means that they can better prepare their mind to handle the related hardships, eventually becoming a stronger person both physically and mentally (Chiaranai et al., 2018;Drageset et al., 2020;Kugbey et al., 2020). In summary, living a life inspired by spiritual/religious beliefs marked by performing good deeds, engaging in mind exercises, adjusting thought patterns, maintaining positive thinking and attitudes, and meditating also helped survivors of BrCa endure the hardships and gain control over their illness.

Becoming Thankful
Having others to lean on while going through a cancer treatment and recovery experience is very helpful, reduces perceived stress, and helps with the recovery process. The findings of this study are supported by several studies conducted on patients with chronic illnesses (i.e., BrCa, chronic kidney disease). It has been well established that patients with chronic illness rely on spouses, friends, family members, and health care providers (HCPs), who help bolster their determination to take a greater part in living life alongside their illness (Chiaranai et al., 2018;Kugbey et al., 2020;Tran et al., 2019).

Conclusions
The purpose of this qualitative phenomenological study was to explore the lived experiences of survivors of BrCa. Data were collected via 12 face-to-face interviews using open-ended, in-depth interview questions. Thematic analysis was used, and five major themes emerged, including (a) being distressed, (b) accepting treatment and seeking alternative treatments, (c) going through difficult times, (d) becoming a stronger person, and (e) becoming thankful. The findings of this study provide insight into the journeys of Thai survivors of BrCa. The participants described their experiences during diagnosis, treatment, and posttreatment periods as a stressful journey.

Limitations
This study is affected by several limitations. First, because the findings of this study predominantly reflect the experiences of middle-aged survivors of BrCa, the experiences of younger survivors should be explored to further clarify and validate the findings. Another possible limitation is the possible innate biases of the participants (i.e., key informant bias). Thus, we cannot be certain that the views of the participants in this study are typical of the views held by survivors of BrCa in general. Finally, because of the small sample size used, the findings may not be typical of the entire population and may not be generalizable to all Thai survivors of BrCa. However, the concepts should still be generally applicable to survivors in similar circumstances.

Implications for Practice
The results of this study yield significant implications for HCPs who work with women with BrCa. The findings provide guidance for HCPs caring for women with BrCa. A true understanding of the experiences of BrCa survivors will help HCPs craft and deliver appropriate interventions that provide quality care and improve women's health, thereby enhancing patients' quality of life. Therefore, understanding the coping strategies used during the survivorship trajectory is essential to promoting the continuation of care after the completion of cancer treatments. In addition, HCPs who have an intimate understanding of the lived experience of women with BrCa may use this understanding to help them successfully traverse the illness trajectory by using approaches that are adjusted to account for these limitations, while also incorporating cultural influences and religious/spiritual beliefs into standardized care programs. Moreover, the results of this study may contribute to the development of new theories. Future research using different qualitative approaches such as grounded theory is recommended. In addition, further studies on the lived experiences of young survivors of BrCa are needed.