Psychosocial Experiences, Challenges, and Coping Strategies of Chinese-Australian Women with Breast Cancer.

OBJECTIVE: Chinese migrant women with breast cancer are at risk of poorer psychosocial outcomes. However, little is known about the cancer-related challenges experienced by these women, or how they self-manage their concerns. This qualitative study aims to explore the experience of breast cancer for Chinese-Australian women and gain insight into their coping behaviors.
METHODS: Twenty-four Chinese-Australian women, previously diagnosed with breast cancer, participated in a semi-structured interview or focus group session, conducted in the participant's preferred language. Qualitative data were subjected to thematic analysis.
RESULTS: Three main themes emerged, reflecting the psychological impact of the diagnosis, the challenges experienced, and the use of social support and other coping behaviors. The theme of psychological impact highlighted the emotional toll of diagnosis and the ongoing anxiety surrounding the fear of cancer recurrence. The theme of challenges identified stressors relating to treatment side effects and the need for psychological support. The social support and coping theme identified the various levels of social support participants received and how Chinese-Australian women may limit their use of social support to protect others. Participants used several behavioral (e.g., diet and exercise) and cognitive (e.g., reframing) strategies to cope with their cancer experience.
CONCLUSIONS: Chinese-Australian women with breast cancer face significant challenges that impact on their psychological well-being. Varying levels of social support, and the desire to protect others through self-sacrifice, may reflect the cultural expectations of women. The results highlight the need for cultural understanding when developing strategies that optimally support Chinese migrant women with breast cancer. Copyright:

Introduction

Australia is a culturally diverse country, with Chinese immigrants being the largest non-English-speaking migrant group (526,000 migrants, or 2.2% of the total population).[1] While migrants and Caucasian–Australians have similar rates of cancer diagnoses,[2] breast cancer risk increases markedly for women of Chinese descent post migration to Australia.[3] A breast cancer diagnosis is associated with complex physical and psychological challenges,[456] often exacerbated for culturally and linguistically diverse (CALD) patients due to unfamiliarity with the Australian health system and social isolation, that can lead to lower psychological well-being than their non-CALD counterparts.[7891011]

Studies from China, Hong Kong, and Taiwan provide insight into the experiences and outcomes of Chinese breast cancer patients. In terms of psychological outcomes, there is consistent evidence that Chinese women with breast cancer report depression,[121314] anxiety,[1315] distress,[16] and reduced quality of life (QoL).[1315] Physical side effects,[1516] negative impact on appearance,[15] and unmet psychological needs have been associated with poorer QoL,[17] whereas self-efficacy,[15] optimism,[1618] and social support[18] are associated with higher QoL.

Chinese studies have also examined the potential influence of coping responses and social support on outcomes in women with breast cancer. Common coping responses include planning, positive reframing, and self-distraction.[1920] Zou et al.[18] found that appraisal and coping response mediated the associations between several variables (e.g., optimism and symptom distress) and QoL. Specifically, appraising breast cancer as stressful, and engaging in more negative coping responses, especially giving in, was associated with poorer QoL.[18] Recently, Li et al.[21] found that negative copers, characterized by high use of maladaptive and low use of adaptive cognitive coping strategies, reported poorest psychological outcomes, whereas inconsistent copers, characterized by mixed cognitive coping and few behavioral coping strategies, reported high distress. Self-blame has also been found to be negatively associated with general well-being.[19] While cultural expectations may shape the use of social support, studies have emphasized the importance of maintaining social roles[22] and that family and close friends provide essential support[2324] for Chinese patients with cancer.

There has been a growing emphasis on understanding the breast cancer experience and outcomes for Chinese migrants, acknowledging that the needs of patients from minority groups are distinctly different from those of the mainstream, due to cultural beliefs and values, which, in turn, influence their health-care practices.[25] For this reason, the importance of undertaking such research is highlighted. For example, an early work by Huang et al.[26] found that Chinese migrants expressed a preference for the use of culturally specific treatments, and for nondisclosure of poor prognosis, to allow continued optimism and hope as they believe that psychological factors play a role in recovery from cancer.

The psychological outcomes and psychosocial needs of Chinese migrants diagnosed with cancer have also been studied. Butow et al.[27] reported that 9% of Chinese patients (with a mix of cancer diagnoses) experienced clinical levels of depression, over four times the rate of the Anglo-Australian participants (2%), but had comparable levels of clinical anxiety (6%, compared to 9% for Anglo-Australians).[27] A recent review of breast cancer in Asian-Americans concluded that migrants have a higher number of physical issues that are less likely to be resolved than American-born patients, while reported levels of distress and fear of recurrence were comparable to their American peers.[28] Due to these noted disparities in breast cancer patients from Asian minority groups, undertaking the current study provides a first step to informing the development and adaptation of psycho-educational and self-management resources, which can assist in promoting and maintaining the well-being of migrant cancer patients.

There is growing evidence of both benefit[293031] and acceptability to patients[32] of self-management as an avenue for managing the psychosocial demands of cancer and meeting patients' needs. For Chinese migrants, self-management may overcome reported communication barriers or discomfort with traditional support services[33] while also being potentially effective in improving outcomes.[3435] Emerging evidence suggests that Chinese breast cancer survivors can self-manage their disease with lifestyle modifications and traditional medicines, manage ongoing symptoms, maintain a positive outlook, draw on available support services, and manage family relationships and social roles.[36] However, self-management for migrant groups has been less studied, and to the best of our knowledge, nothing in Chinese migrant patients with breast cancer. The aims of the current qualitative study were to (a) explore the experience of breast cancer for Chinese–Australian women and (b) explore the coping behaviors utilized by Chinese women living in Australia. The findings will inform the knowledge of self-management within this minority group and potentially shed light on the needs of this minority group for the development or adaptation of a self-management resource.

Methods

Research design

This descriptive study included in-depth semi-structured focus groups and individual interviews conducted with Chinese–Australian women diagnosed with breast cancer. Ethical approval was obtained by the local ethics committee (South Western Sydney Local Health District Human Research Ethics Committee HREC/14/LPOOL/538), and the study was undertaken in accordance with the standards of the ethics committee and the Helsinki Declaration of 1975 as revised in 2000.

Sample and recruitment

During 2015, participants were recruited through the oldest and largest Chinese cancer support organization in Australia, CanRevive, if they met the following eligibility criteria: (a) women of Chinese heritage, (b) aged 18 years or above, (c) diagnosed with breast cancer in the past 2 years, and (d) not diagnosed with a cognitive impairment or mental illness.

Potentially eligible women were informed about the study in their preferred language during CanRevive support group meetings, or via mail, and invited to either attend a focus group at predetermined times or participate in a face-to-face interview at a location determined by the participant. Of the 24 eligible women who consented to participate, 23 participated in one of the three focus groups (120-min duration), and one elected to participate in a semi-structured interview (60-min duration). Participant characteristics are summarized in Table 1.

Table 1

Participants’ sociodemographic and clinical characteristics

Characteristics	n (%)
Country of birth*
China	13 (61.9)
Hong Kong	3 (14.3)
Vietnam	3 (14.3)
Cambodia	1 (4.8)
Kenya	1 (4.8)
Total	21 (100.0)
Language spoken at home*
Cantonese	11 (73.3)
Mandarin	2 (13.3)
English	1 (6.7)
Both Cantonese and Mandarin	1 (6.7)
Total	15 (100.0)
Current marital status*
Single	5 (26.3)
Married or partnered	14 (73.7)
Total	19 (100.0)
Living situation*
Live alone	3 (15.8)
Living with family	15 (78.9)
Living with relatives other than immediate family	1 (5.3)
Total	19 (100.0)
Education*
Secondary school	11 (55.0)
Postsecondary education	9 (45.0)
Total	20 (100.0)
Postcode*
Major city	15 (88.2)
Inner regional	2 (11.8)
Total	17 (100.0)
Employment*
Employed	6 (31.6)
Unemployed/retired	5 (26.3)
Household duties	4 (21.1)
Other	4 (21.1)
Total	19 (100.0)
Time since diagnosis (months)*
<6	1 (5.9)
6-12	8 (47.1)
>12	8 (47.1)
Total	17 (100.0)
Number of treatments*
1	1 (4.8)
2	6 (28.6)
3	9 (42.8)
4+	5 (23.8)
Total	21 (100.0)
Treatment types*,+
Surgery	21 (100.0)
Chemotherapy	15 (71.4)
Radiation therapy	11 (52.4)
Hormone therapy	10 (47.6)
Other treatments	3 (14.3)

*Some level of missing data; +Proportions representative of total for each treatment type

Data collection

A total of 24 women consented to taking part in the study. Of these, 23 women participated in one of the three focus groups (two Cantonese and one Mandarin; 120 min each), and one elected to undertake a semi-structured interview conducted at her home (60 min). Two of the focus groups were conducted in Cantonese (n = 11 and n = 3), and one focus group was conducted in Mandarin (n = 9). The interview was conducted in Mandarin. The focus group/interview guide, outlined in Table 2, was adapted to suit the format of the one-to-one interview versus the focus group and applied with flexibility to cover the emerging concepts. The topics covered including the experience of having breast cancer, challenges experienced, emotions, information seeking, communication about cancer, and coping responses. The focus groups and individual interview were conducted by bi-lingual members of the research team in the participants' preferred language, specifically Cantonese (n = 14) or Mandarin (n = 10).

Table 2

Focus group/interview guide

Part 1: Breast cancer experience

Tell me about what it was like having breast cancer?

In what ways do you think your experience may be different from other women who are not from Chinese background?

Part 2: Psychosocial needs and coping responses

What were some of the biggest challenges that you faced throughout your cancer experience?

How did you deal with those challenges? (please prompt for each challenge if needed)

Interviewer should prompt to see if there were other challenges - for example, you mentioned earlier that … was an issue. Tell me about that and how you adjusted to it

How did you deal with some of the emotions that you experienced?

Were there any actions that you took to help you throughout your cancer journey that reflect your Chinese heritage?

Some people with cancer who are from culturally diverse backgrounds find it difficult to get the information that they need about their cancer and treatment. Was that the case for you? If yes, can you tell me a bit about that?

What was your experience of communicating with your doctor and other members of the health-care team?

If your doctor had recommended a referral, would you have acted on a referral to someone like a social worker or a psychologist? Please explain your answer

If participant is unsure of their roles

Psychologist: Someone who can assist you and your family to adjust to the emotional impact of cancer and its treatment

Social worker: Counsel people who are affected by cancer and help them find practical assistance. They also provide information about services that may be available in your community

How openly do you talk about what your cancer experience with other people?

Was your family willing to talk about issues relating to your cancer? Tell me about how this impacted on you

Data analysis

Focus groups and interview recordings were transcribed verbatim, translated, and transcribed into English by a National Accreditation Authority for Translators and Interpreters -qualified translator. Thematic analysis was then independently undertaken by two authors (JL and MG), using the methods proposed by Braun and Clarke, using an experiential (i.e., focus on participants' thoughts, feelings, and actions as reflected through the language they use to represent reality) and inductive (i.e., data driven or bottom-up) orientation.[3738] The detailed methodology has been previously published.[39] In brief, the two coders read and re-read the transcripts, generated codes that aligned with the research questions, discussed and resolved any discrepancies in the assigned codes, and identified the themes to which these codes were assigned. If any discrepancies could not be agreed on between the two authors, a third author was consulted as an impartial third party. With the sample recruited in the present study, data saturation was achieved, consistent with previous qualitative studies that recruited similar sample numbers.[364041]

Results

Overall, five distinct themes emerged from the analyses, including (1) psychological impact of the diagnosis; (2) challenges; (3) social support and coping; (4) information needs and seeking; and (5) communication with health-care professionals, language barriers, and preferences. This manuscript focuses on the first three themes which are detailed below, while themes 4 and 5 have been reported elsewhere.[39] Pseudonyms have been assigned to patients' quotations to maintain participant confidentiality.

Psychological impact of the diagnosis

The psychological impact of a cancer diagnosis emerged as a major theme. Notably, the negative psychological impact was recognized as both a short-term response to the diagnosis and a long-term presence, most frequently experienced as a fear of cancer recurrence (FCR).

Most participants raised the impact of diagnosis, describing their experience as “like a disaster” (Zhen), “psychological torment,“ “a sad cloud all over my sky,” (Chun), “a malicious sickness” (Lei), “very unsettling, very unhappy, very scared” (Ning), and “a great stress inside my heart” (Amy). They expressed a sense of uncertainty, of not knowing what to expect: “I also had that unsettling period during the early days. You would shatter, not knowing what's happening to yourself for a period of time” (Jai). Some felt a sense of not knowing what to do: “I can't think of a solution. At first, I really couldn't think of a solution to it. It was a really great blow.” (Ai).

Importantly, psychological impact was the greatest challenge experienced by some participants: “To me, the major difficulty is psychological” (Zhen). Ning described her physical suffering during treatment as something that “can be endured. But the mood was difficult, especially when you read those information about having a good mood would help recovery of the illness. But it was the opposite. No matter how you tried, you still could not make yourself happy. I have seen some examples where people could face this in a very relaxed way. I really envied them, but I couldn't do it.”

The breast cancer experience had fundamentally changed some participants, as described by Zhen, who was still reconciling this change within herself: “Yes, there were changes to the self-image, personal living, and mentality. It's like changing into a totally different person. This, I think was the biggest difficulty.”

Many participants reported fear that the cancer may recur after treatment cessation. FCR was often associated with uncertainty about the effectiveness of the treatment, which was frequently triggered by participants experiencing bodily discomfort and pain: “I'm now very puzzled. The incision wound there is still hurting until now. The pain is not just a little bit. It was very sharp like a knife cutting you. What does that mean?… Sometimes I couldn't sleep at night. Just pain. Has it recurred?” (Liu Yang).

One element that contributed to participants' FCR was a sense that “no one can guarantee” (Jia) that the women were free from cancer. The participants expressed a belief that the discomfort and pain were indications that “is it possible that the cancer cells has gone to certain places already” (Lei), and asked questions such as “How do we know that the cancer cells are all gone?” (Chun). Notably, FCR was acknowledged as evolving over time, often as an increasing anxiety: “The most troublesome thought was the fear of recurrence. The most common ones are bone pains. You worried that the cancer has gone to the bones. Headaches or dizziness, it has gone to the brain. In the beginning you may not be so aware of it. But slowly, slowly your mind will keep thinking about these things.” (Bao).

Challenges

The participants reported facing various challenges including managing the side effects of treatment and the need for psychosocial support.

The participants reported difficulties with managing the side effects of treatment, including pain, numbness, skin irritation, problems with nails, mouth ulcers, cramps, swelling, and difficulty walking. They noted that that these side effects were disruptive to their daily life and functioning: “There were cramps, cramps. Very uncomfortable and I had to stop the car, pull up to the roadside if I was driving” ( Biyu). The experience of side effects had a significant emotional impact, often described as a very distressing element of women's cancer experience: “There was also pain, whole body pain. Lost all my hair. Every day you looked at the mirror, it was really pitiful. Really wanted to give up at that time … I also worried whether I'd get better or not” (Jun).

Many participants reported that their side effects continued post treatment and were inadequately managed: “After the chemotherapy, I still suffer from the after effects, e.g., the fingers and toes are still numb.… At first, I thought it would only last for a few weeks and I'd be fine. Who knows, I waited for months and months. I have given up on waiting now. I just leave them be” (Ning).

Importantly, the inadequate management of side effects was perceived as having potential long-term impacts, such as contributing to FCR or other psychological disorders such as depression. For example, Sarah recounted how she has ongoing pain, which is worse at night and continues to cause her worry. She expressed the need for better management, highlighting the consequence as: “Otherwise, people will be thinking too much (about their pain) and might end up having depression.”

Psychological health was integrally important to many, and distress and isolation that disrupted their sleep was experienced as “all cooped up inside the heart” (Jun). While their emotional experience was similar, the participants expressed differing views about the value of psychosocial support. One participant described the consultation with a psychologist as “useless” despite their “brain [being] always troubled with this problem” (Liu Yang). Zhen described her engagement with a social worker as: “I think her major role was to listen. I didn't need anyone to listen to me. I feel that the psychological process was very complicated. Everyone's different. After talking to her a few times, I felt that it was meaningless and I stopped.”

In contrast, other participants valued their engagement with psychological services, including the opportunity to “pour out everything” and obtain resources such as a relaxation CD to aid sleep (Jun). For some, while the experience may not have been ideal, access to a psychologist provided some value: “At least there will be someone there telling you, or listening to you. It's better than no one listening to you, no one telling you” (Tina).

Social support and coping

Numerous coping strategies were used to adjust to the diagnosis and arising challenges, including drawing on social support, use of alternative medicines, dietary changes, exercise, spirituality, and cognitive strategies.

Social support from multiple sources, including a formal support group run through a China-specific organization, CanRevive, family, and friends, emerged as contributing to participants' adjustment to having cancer. However, social support also provided some challenges, especially around protecting others.

All participants found great value in their involvement with the CanRevive support group, describing it as a platform of empowerment, encouragement, and information, which had a positive impact on their outlook: “At CanRevive, all the friends have had the same kind of experiences. When they told us their experience, our hearts were more settled” (Jun). Notably, CanRevive was perceived as providing valuable support throughout the cancer journey, in normalizing the experience and improving mood: “I obtained a lot of information from CanRevive. I also listened to the discussions between the members and met a few more friends who had the same conditions as mine, I felt a lot happier. And during treatments, I felt that my life was just normal” (Chen).

However, views on support from informal sources were mixed. Family and friends played an important role in providing some participants with emotional support, reassurance, information, and practical assistance: “They ( her children, husband, brother, and friends) all came to see me at once when they heard. They comforted you and tried to relax you. They also tell you that the medical treatments in Australia were quite advanced, there's no need to be scared” (Chen). While support from family and friends was beneficial, some participants revealed an emotional struggle with the shift in family roles: “But they were so used to being looked after, they didn't know how to look after you. My husband,… he doesn't know how to cook. So, it was distressing. He tried to do things. When you were sitting there watching him doing stuff, you would cry. You would cry from inside your heart, thinking how come you got this illness and caused the family to be turned upside down” (Jun).

However, some participants viewed cancer as their disease and believed that family and friends would be able to offer little help: “I felt that even the people who are close to you were unable to help, because this is your own personal problem. The people closest to you won't be able to change anything for you” (Ning). Notably, Ning reported experiencing very low mood and a sense of being lost which she attributed to “no one [being] able to help.”

Participants' level of disclosure about their cancer was mixed, with a tendency to only tell those who needed to know, while protecting others. For example, Jun didn't tell her children “because they knew I would be scared and they would be worried,” and Jia kept it secret from her mother, explaining “I know my mother's character. She would just cry non-stop for a few months.…. I just don't want her to be sad and it would be harmful for her health.” Some participants recognized that their nondisclosure was for their perceived benefit, noting that disclosure “would create a lot of psychological stress. Others will be sympathising with you. I also don't need the sympathies” and “if I kept quiet, no one will interfere with me” (Shu). Some participants were conflicted about telling others: “In the beginning, I never thought of telling anyone at all. I thought I would bear it all by myself. But later, my friends told me, 'you can't do that. what happens if you die'… The children would think, 'oh, how come it happened like that.' I don't know whether I was right or wrong. At the end, I chose the pathway of telling my family” (Chun).

This limited disclosure contradicted their perceptions of Western women, who were perceived as more open and expressive about their disease. Western women were described as being “very open” and that they “talked and asked about details” (Jun) and treated the discussion of their disease “like a small matter” and “can tell anyone” (Susan). Meiying summarized this difference when she reflected: “Yes, the Westerners are very open. Like my neighbour, she would tell me when she would go for an operation. It's nothing. But I never told her that I had breast cancer.”

The participants coped with the physical and psychological impact of breast cancer by using supplements, vitamins, and traditional Chinese medicinal herbs, perceiving that traditional Chinese medicine promoted the recuperation of the body rather than serving as a cure for their cancer. For example, Shu stated: “I had breast cancer, it's related to the liver 'qi'' (note: meaning circulating life force) stagnation. He prescribed herbs that would help the 'qi' to circulate and recuperate the liver;” while Fangsu expressed that she used Chinese medicines because “our central energy (Zhong Qi) was insufficient.” Participants were aware of the need to discuss Chinese medicines with their oncologists, and there was a mix of views regarding whether Chinese and Western medicine could be combined or whether Chinese medicine should be restricted to posttreatment.

Dietary change was perceived by all as an important coping avenue for maintaining health, but views were mixed regarding dietary restrictions, with some participants abstaining from certain foods (e.g., lamb, chicken feet, and cow's milk), whereas others focused on having a more balanced diet. While the discussion of dietary changes generated much debate in the focus groups, the participants acknowledged great value in talking to others who had completed their treatment: “My friend who had chemotherapy before told me, she had already finished, she said, “whatever you want to eat, just eat.” While you are having chemotherapy, you won't want to eat. You won't have the appetite to eat. Now that you have the appetite, just eat. There is no need to abstain from food” (Carol).

Exercising as a coping strategy helped “keep yourself in a cheerful mood” (Shu) and distracted the participants from negative thoughts. Following their doctors' advice for “exercises which are not too vigorous” (Shu), the participants reported doing Tai chi (thought to be very useful in combatting depression), walking, and using weight machines at the gym. For some participants, this represented a distinct change in behavior designed to improve their health and be “obedient” (Jia) to doctors' wishes: “Doing more exercises than before … the doctor has told me. The doctor explained that exercises are a must. Doing them more now” (Lan).

The participants drew upon numerous cognitive coping strategies including faith and cognitive reframing. Some participants revealed that their spirituality aided them, through praying and reciting scriptures, helping them come to terms with their illness, as well as providing them with a sense of hope: “I sat there and recited my scriptures hoping that I'd be able to pull through this juncture. So slowly, slowly, may be, my brain only had that one thing and it helped” (Jun).

The participants also used cognitive reframing, including a conscious choice to focus on gratitude: “I'm very thankful and I consider myself lucky for the fact that I can look after myself today” (Ai). Jia chose to minimize the perceived impact of her illness to improve her situation, stating: “I will slowly try to ease out the anxiety myself. I told myself that it's not the end of the world. It makes me happier, and put myself back to work, back to the living.” Chun recounted a clear moment of reframing to focus on the positive elements of her situation: “I was talking to the psychologist on the phone, looking outside the window, one side was black, the other side was white. It depends on whether you see the black or the white, simple as that.”

The cognitive reframing was also experienced through a cultural lens using the concept of “qi” (circulating life force) where positive moods were perceived to impact upon “qi” and consequently, their physical well-being, for example, “the major key to the problem is to be in good mood. He said, when your mood is good, the “qi” in your body moves smoothly. When your “qi” is smooth, your blood will not be deficient” (Shu).

Discussion

This qualitative study reported on the experience of breast cancer for Chinese–Australian women, highlighting its psychosocial impact, the challenges women experienced in managing the disease and their emotional well-being, and identifying their coping strategies. The data identified the sustained psychological impact, present as FCR, and highlighted the complexity of social support for Chinese–Australian women with breast cancer.

The psychological impact of their breast cancer diagnosis included experiencing sadness and anxiety and a sense of uncertainty in both the short term regarding knowing what to expect and how to deal with the diagnosis, but also in the long term with FCR. Such findings are similar to the report of high distress in Chinese women with cancer[942] and other migrant groups.[43] Indeed, like the present study, Kwok and White found that FCR was almost universal in their sample, and that the presence of such concerns neutralized women's attempts to maintain positive attitudes. The pervasive presence of uncertainty, as both a short- and long-term issue, clearly highlights an ongoing need for women with breast cancer, especially migrant women who may face challenges in obtaining information and may not be able to adequately express their worries to health-care professionals.

The significant challenges experienced included dealing with treatment-related side effects and obtaining psychological support. Treatment-related side effects are a significant concern particularly when they are of sustained duration and have a significant impact on day-to-day life and emotional well-being.[44] For many participants, side effects were not adequately resolved, and some had persisted long term, contributing to poorer psychological outcomes, including depression and FCR. Health-care professionals, particularly nurses who may have more regular contact with the women undergoing their adjuvant treatment and follow-up care, can play a significant role in directing women to in-language resources as well as linking them to support services to help with their anxiety, distress, and FCR.

Views regarding the value of psychological services were mixed. Despite questioning the value of available services, most women recognized the need for support in addressing their psychological challenges. This reflects a possible area of unmet need for minority women and highlights a significant need for culturally appropriate and inclusive support services for people with cancer in culturally diverse countries such as Australia. Evidence from the United Kingdom suggests that Chinese migrants have lower uptake of general practitioners and hospital services, and that migrants generally may be unaware of available services or perceive services to be culturally inappropriate or insensitive.[4546]

Through the use of service referral embedded within many cancer care centers throughout Australia (such as through cancer nurses/oncologist), the system would enable itself to potentially close the loop between the self-identified need for psychological support and the ability to provide that support from a trusted source (such as their cancer nurses). Many participants held their health-care professionals to a very high regard, placing their absolute trust in them, and therefore, this would enable the said health-care professionals the opportunity to provide support to an eager and willing patient.

We found mixed results regarding the utilization of social support, with some participants drawing on family and friends, and others choosing nondisclosure of their diagnosis. Protective buffering and self-sacrificing, previously reported in Chinese women with breast cancer,[474849] are attributed to a desire to lessen the impact of cancer on others. Limited disclosure may be associated with cultural expectations of women, as Chinese women are expected to maintain harmony within family units through being a good wife and mother.[48] Of interest, the Chinese–Australian women in our study perceived their level of disclosure as different to Western women they had contact with. Future research may shed light on this perceived difference and how cultural perception of the role of women may influence their well-being.

The importance of the concept of qi emerged in relation to two coping strategies, cognitive reframing and diet. In Chinese culture, qi is the person's energy and his/her vital life force, and therefore enhancing or balancing qi is linked to the healing process.[50] The data suggest that positive thoughts and food are used to balance the energy within the self to promote positive health. Diet is often reported as a self-management strategy utilized by Chinese cancer patients.[1036] The participants provided numerous opinions about dietary changes and supplements, and that Chinese views were occasionally in contradiction to medical professionals. Similar findings were reported in another Australian study,[43] highlighting diet as a tool that Chinese–Australians often draw upon to promote health during cancer treatment and beyond. From an information-seeking perspective, however, it may be important to address misconceptions about dietary changes and diet as a contributing factor to cancer development.

Study limitations

While the support of CanRevive was essential to the success of this project, it is also a limitation. In response to recruitment materials, only one participant contacted the researchers directly, with all the other participants being recruited directly through CanRevive. As such, our sample primarily comprised women who have actively sought support for their breast cancer experience. While this may reflect a subgroup who are at greater need of support and hence have actively sought it, the alternative explanation is that these women are connected enough to have found an in-language support group. Hence, the significant challenges and psychosocial burden they expressed in this qualitative may in fact be an underrepresentation of the burden in the broader population. Future research that engages other members of minority groups who are relatively isolated within the community throughout their experience with cancer may provide additional insights and reveal alternative coping strategies and sources of social support. In addition, the use of focus groups rather than individual interviews may be considered a limitation, with potential for the extent of sharing of experiences being affected by the presence of other participants. Future research involving individual interviews may help provide a deeper understanding of this topic. Furthermore, collecting information about the length of time postmigration to Australia and level of acculturation in future studies may shed light on differences in perceptions associated with these factors.

Practice implications

The insight into the experience of Chinese–Australian women with breast cancer identifies some opportunities for enhancing the support available to minority women. The challenges related to treatment-related side effects and the link to FCR are important findings as they have a direct impact on both physical and psychological well-being. It is, therefore, suggested that enhanced communication about what to expect regarding treatment-related side effects, strategies to ameliorate such issues (both medical and self-management), and the management of the psychological reaction to such side effects need to be enhanced.

This study revealed that for Chinese women, social support can be both valuable and a challenge, which may not lead to optimal patient outcomes. The obvious value of the CanRevive support group was evident; therefore, it is strongly recommended that health-care facilities consider how they can engage with culturally diverse women, potentially creating ethnically based groups or engaging with broader community organizations that are already familiar to these women.

The findings may help inform the gap in knowledge regarding suitable content for culturally sensitive self-management materials that will aid in promoting and maintaining well-being throughout a cancer journey. The study results have identified several areas which are important to this group, including cultural concepts such as qi, alternative medicines, and self-sacrifice, as a gendered expectation for Chinese woman may guide development of such resources. However, extensive community consultation is required with stakeholders within the minority group, at all stages of resource development (e.g., drafting, evaluating, and disseminating) to ensure relevance and suitability.[51] The study results strengthen the notion that resources cannot merely be translated into any given language and disseminated to a non-English-speaking cohort; the community consultation must firstly be undertaken in order to produce a document or resource that is truly applicable and accepted by another culture. This study is therefore the first step in identifying the areas important to this minority group and sheds light on the types of topics that could be included in a self-management resource.

Conclusion

Chinese women affected by breast cancer experience various challenges, which has detrimental consequences on their psychological well-being. The challenges experienced by the women in this study included treatment-related side effects as well as their need for adequate psychological support. In response to the challenges associated with their diagnosis, women relied on the support from their family, friends, and support group. In addition, women adopted various behavioral and cognitive coping strategies, including diet adjustment and positive reframing of their situation, in order to cope with these challenges. These findings highlight the dire need for cultural awareness and sensitivity when developing strategies that support Chinese migrant women with breast cancer.

Financial support and sponsorship

This study was financially supported by a charitable donation from Dartwest Developments to the Ingham Institute for Applied Medical Research.

Conflicts of interest

There are no conflicts of interest.