Defining Contentment in Quality of Life in the Context of Breast Cancer Experience: A Meta-Synthesis

Octavio Muniz da Costa Vargens; Carina M. Berterö

doi:10.4172/2165-7386.1000239

ISSN: 2165-7386

Journal of Palliative Care & Medicine

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Defining Contentment in Quality of Life in the Context of Breast Cancer Experience: A Meta-Synthesis

Octavio Muniz da Costa Vargens^1,* and Carina M. Berterö²

¹Faculty of Nursing, Rio de Janeiro State University, Rio de Janeiro, Brazil

²Department of Medical and Health Sciences, Faculty of Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden

*Corresponding Author:: Octavio Muniz da Costa Vargens
RN, Midwife, PhD. Associate Professor
Faculty of Nursing
Rio de Janeiro State University
Rio de Janeiro, Brazil
Tel: 55-021-28688236
E-mail: omcvargens@uol.com.br

Received date: July 26, 2014 Accepted date: November 28, 2015 Published date: November 30, 2015

Citation: Vargens OMC, Berterö CM (2015) Defining Contentment in Quality of Life in the Context of Breast Cancer Experience: A Meta-Synthesis. J Palliat Care Med 5:239. doi:10.4172/2165-7386.1000239

Copyright: © 2015 da Costa Vargens OM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Purpose: There has been a great deal of qualitative research conducted that has examined the impact of breast cancer on the concept of Quality of Life (QoL); however, there has been little effort to analyse the psycho-social components of QoL findings from a meta-perspective. Method: Computer searches in electronic databases, search date from 2000 onwards; Publications focusing on women with breast cancer; using qualitative research/studies or combining qualitative and quantitative research, including a clear presentation of qualitative findings; and focused on women’s perspectives and experiences of QoL and affected life situation due to breast cancer. Thirty articles were selected for appraisal and 12 qualitative studies were interpreted and analysed. Results: The fusions identified from this meta-synthesis reveal three aspects of QoL affected by the diagnosis of breast cancer and its treatment: contentment, comfort, and contentedness. The results, understanding what QoL is about from the women’s perspectives may guide nurses and health care professionals when caring for women with breast cancer. Conclusion: The breast cancer experience has powerful impacts on women’s lives, and affects their QoL. This QoL is identified as contentment, comfort and contentedness, which are closely related but diverse. These results of the present study highlight the importance of providing support for women who have breast cancer in order to help them find the best strategies to overcome the impact of the disease and improve their QoL.

Keywords

Breast cancer; Quality of life; Qualitative analysis; Contentment

Introduction

Breast cancer is the most common malignancy affecting women worldwide. In some regions in the western world, it is the most common cause of death from cancer in women [1]. Mortality in breast cancer has been reduced because of early detection and treatment, but also due to improvements in the delivery of care [1,2]. At least half of the women diagnosed with breast cancer will survive, including those living in developing countries. In the developed countries, survival from breast cancer has slowly increased and is now at the level of 85%, but survival in developing countries remains at around 50-60% [3]. Despite the improvement in survival rates, a diagnosis of breast cancer initiates a complex adjustment process that may last for years. Survival statistics cannot capture the physiologic, psychological, and sociologic impact of cancer or the loss of productive years across all segments of the life span [2,4,5].

A breast cancer diagnosis and its treatment is a stressful life event, with profound and obvious consequences for all aspects of human life [4,6], and it will affect Quality of Life (QoL).

Quality of life

Quality of life (QoL) is not easy to define since it is a conceptually subjective term, which refers to a complex multidimensional concept [7,8]. QoL was identified in a study as a person’s sense of well-being, which stems from satisfaction or dissatisfaction with areas of life that are important to the person [9]. This QoL description is based on biomedical and behavioural science domains, including normal life, achievement of personal goals, social utility, natural capacity, and happiness/satisfaction. Two different authors linked life satisfaction and happiness, in the context of QoL, to contentment [10,11]. However, a clear definition of contentment is not available, mostly when related to a breast cancer experience.

Another study showed that the intensity of post-traumatic stress following breast cancer surgery was an important factor affecting lifesatisfaction including the level of depression and anxiety [12]. This seemed to be statistically highly significant in the group of women in their study who had undergone total mastectomy. Lower lifesatisfaction reduced bio-psychosocial functioning.

Supplying care, then means that health care professionals should improve women’s perception of self and teach them how to handle and learn to live with changes due to breast cancer; how to experience QoL [7,13].

Existential issues affect the concepts of well-being and life satisfaction i.e. QoL. Existential issues that should be taken into consideration are fear of recurrence of the disease, fear of one’s own existence and own life, e.g. ‘of one's own death. At this point, the only thing that matters is survival, even when considering the irreparable damage to physical, psychological, or social aspects of one’s life as consequences of breast cancer diagnosis [7,14]. Recent research on QoL outcomes in long-term survivors is promising, but time alone is not a sufficient predictor of psychological adjustment and QoL [15]. When evaluating holistically the QoL of women treated for breast cancer, all spheres of everyday functioning should be taken into consideration: physical, cognitive, emotional and social.

Based on previous research, the following research question was addressed: what is the impact of breast cancer diagnosis and breast cancer treatment on women’s contentment. This was determined by a process of meta-synthesis of the qualitative articles published between 2000 and 2011.

Defining contentment

No single, universally accepted definition of contentment exists. Many definitions are clearly related to different phenomena, including a psychoanalytic perspective. Contentment is a human experience of a satisfying calmness, but it is lived within possible or remembered harsh conditions. Contentment means assenting to or being willing to accept circumstances or a proposed course of action [16,17]. In a comparative study of cancer survivors they were found to have poorer health and well-being than the general population. Despite this poorer health, the majority of cancer survivors reported satisfaction with care services [18]. Contentment seems to be a part of QoL as in different surveys contentment is treated as synonymous with satisfaction [12,19]. Contentment is defined as a state of being; feeling satisfied, tranquil and happy. It can also be a source of satisfaction and arises from sympathetic engagement with family and friends [20]. Perceiving and being thankful for the positivity in the self and in the world is a state of being happy and healthy, and gives a sense of well-being. These harsh circumstances could give a more meaningful life and strengthen transcendental aspects, such as religiosity and spirituality [21].

Contentment is also described with another synonym; gratification/ gratitude, Gratitude is about personality, and one’s disposition to notice, appreciate and respond with grateful emotions and thankfulness to other people’s acts of benevolence and sympathy [22]. Breast cancer patients’ gratitude is strongly associated with posttraumatic growth, reduced distress and increased positive emotions, but surprisingly not with psychological well-being [23].

Contentment could be seen as QoL and linked to satisfaction and adaptation to the life situation. Contentment in this sense is; QoL as what the person there living the life says it is.

Materials and Methods

This report is a qualitative meta-synthesis, i.e. an interpretive integration of qualitative findings that are themselves an interpretive synthesis of data comprising coherent and integrated descriptions or explanations of events, concepts, or phenomena [24-26]. A metasynthesis is an integration that offers more than the sum of the individual data sets because it provides an innovative interpretation of the findings. Such interpretations are conclusions derived from examining all the articles in a sample as a collective group, presenting interpretations which are not found in any one article [24]. The process of meta-synthesis used in this study included three processes: metadata analysis, meta-method, and meta-theory [26]. The meta-data analysis required the researcher to critically examine multiple accounts of a phenomenon to reveal similarities and discrepancies among reports. Hermeneutics was used to guide the meta-synthesis in this study. The process of meta-method analysis required an analysis of the rigor and soundness of the research methods used in each of the studies reviewed to determine the appropriateness of the methods and how they influenced findings. Meta-theory analysis required the researchers to scrutinize the underlying theoretical perspectives of each study that met the criteria for analysis to ensure that the findings were interpreted appropriately. Finally, the process of meta-synthesis required the researchers to reintegrate all the ideas that had been deconstructed in these three processes to realize a new interpretation of a phenomenon that accounts for the data, method, and theory by which the phenomenon has been studied by others. The focus of this report will be on the findings from the meta-data analysis.

Sample

Relevant qualitative research studies were located and retrieved using computer searches in CINAHL, Psych info, Academic Search Premier, Pubmed and Scopus. The articles selected for this synthesis met the following inclusion criteria: (1) the study focused on women with breast cancer; (2) there were explicit references to the use of qualitative research/studies or studies that combined qualitative and quantitative research, but included a clear presentation of qualitative findings; (3) the study focused on women’s perspectives and experiences of quality of life and affected life situation due to breast cancer. There were restrictions related to the date the research was published, i.e., published from 2000 onwards and written in English, with a focus on nursing/caring. Keywords were ‘breast cancer’, ‘quality of life’ and ‘life situation’. Exclusion criteria included research done in the quantitative paradigm and literature reviews. Based on these criteria, the initial completed bibliographic sample consisted of 30 articles.

Meta-method

The meta-method procedure used in this study had two steps. The first step was to evaluate the primary research study, with an emphasis on research design and data collection methods, to ensure that the paper met the study’s inclusion criteria [26]. Reviewing the initial sample (30 articles), five articles were literature reviews and five articles were based on quantitative analyses which had simply included qualitative variables. Furthermore, eight articles did not meet the inclusion criteria.

Appraisal of the studies incorporated the reading guide and included both an individual appraisal of each possible study considered for inclusion, together with comparative appraisal across studies. This then allowed the development of a cross-study display, summarising key features of the studies, which resulted in 12 articles (Table 1). Approximately 10 to 12 studies represent an ideal number for a metasynthesis [27]. The study represented the following disciplines: nursing and psychology, with some influences from medicine and sociology (Table 1).

CodeNumber	Authors	Publ.year	Diagnosis	Theoretical Orientation	Methodological Orientation	Major Findings (take-home message)
001♦	ArmanandBackman [28]	2007	Breast cancer	Life situation of women with breast cancer in different care settings	qualitative content analysis and a content analysis with quantification of the categories	Important changes as appreciation of the beauty of life, experiences of threat, introspection into self and meaning of life, and changes in the body. The group that received anthroposophical care seemed to be more orientated towards personal growth and meaning of life.
002♦	Berterö [31]	2002	Breast cancer	Self-esteem and QOL	Narrativism and secondary analysis	Affected self-respect and self-value are important factors affecting QOL
003♦	Drageset, Lindstrøm, Giske,Underlid [29]	2010	Breast cancer	Mishel’s nursing theory of‘Uncertainty in illness’	Qualitative approach	Feeling healthy but having to adapt to disease, waiting, uncertainty, having to tell and existential awareness.
004♦	Elmir, Jackson, Beale andSchmied[37]	2010	Breast cancer	Younger women’s experiences of recovery from breast cancer-relatedbreast surgery.	phenomenology	‘It absolutely encompassed me,’ ‘Being overwhelmed,’ ‘Living with fear and uncertainty’ and ‘Finding strength within.’
005♦	Fu, Xu, Liuand Haber [33]	2008	Breast cancer	Adjustment to breast cancer adapting to chronic illness and QOL	phenomenology	“tried to ‘make the best of it”. “facing the reality of cancer diagnosis”, “taking an active part in the cancer treatment”, “sustaining an optimistic spirit”, “sustaining physically”, “ lessening the impact of cancer on others”, and “reflecting and moving on”.
006♦	Mitchell, Yakiwchuk, Griffin, Gray, Fitch [32].	2007	Breast cancer	Exercise improve better physical and mental health, and the ability to handle stress and to feel more in control of their lives.	constructivist qualitative approach	Pre-session: the body betrayed, the allure of the dragon and dragon quest. Post-session:awakening of the self, common bond, regaining control, uplifting, and transcendence.
007♦	Nizamli, AnooshehandMohammadi[38]	2011	Breast cancer	the experiences of Syrian women with breast cancer regarding their chemotherapy	content analysis	psychological discomfort, physical problems, social dysfunction, and failure in the family role
008♦	Rosedale and Fu [39]	2010	Breast cancer	describe women’s unexpected and distressingsymptom experiences after breast cancer treatment	phenomenology + secondary qualitative analysis	living with lingering symptoms, confronting unexpected situations, losing precancer being, and feeling like a has-been
009♦	Schulman-Green, Bradley,Knobf, Prigerson, DiGiovannaand McCorkle 35]	2011	Breast cancer	experiences of self-management in thecontext of transitions among women with advanced breast cancer	interpretive description	Self-management included developing skills, becoming empowered, and creating supportive networks. Barriers to self-management included symptom distress, difficulty obtaining information, and lack of knowledge about the cancer trajectory..
010♦	Sprung,JanothaandSteckel[36]	2011	Breast cancer	identification of couple characteristics and dynamics against the backdrop of life-threatening or chronic illness.	phenomenology	self-disclosure of emotional reactions to breast cancer over time. Disclosure of the spouse’s emotional reactions to breast cancer over time.
011♦	Tighe, Molassiotis, Morris and Richardson [34]	2011	Breast cancer	the ‘cancer journey’ as a heuristic device to chart women’s experiences in the first year followingdiagnosis	thematic narrative approach	symptom experience, coping and meaning, and relationships.
012♦	Vargens and Berterö [30]	2007	Breast cancer	impact of breast cancer from the perspective of the women’s experiences on women’s body image and intimate relationships.	phenomenology	gaining a positive attitude for life, wanting to be recognized as awoman with certain needs, considering body image/self-image, and making efforts tohide.

Table 1: Primary research features.

The size of the research sample reported in each article ranged from 4 to 74, with a total sample size in all 12 articles of 322 (mean sample size 18.5). The women in these studies were aged 28 to 91 and represented different countries; Australia, Brazil, Canada, China, Great Britain, Iran, Norway, Sweden, and the USA. The data from the 322 women were based on individual interviews, in one case combined with focus group interviews. All articles had been published from 2002 to 2011.

In the second step, the researchers used a Hermeneutic Appraisal to reinterpret the statements made by subjects in each original study from the analytical perspective of Contentment/Contentedness. The Hermeneutic Appraisal process contributed to an understanding of how the methodology used in the original research had been applied to study a phenomenon and how that methodology had shaped the researcher’s knowledge of the phenomenon being examined [26]. This appraisal was not used to critique the quality of the studies. Instead, the research designs of primary research articles were compared and contrasted to identify the underlying assumptions of research methodologies, as well as the findings reported [24].

The authors of the articles meeting the criteria for this metasynthesis described the methods used as qualitative; using phenomenology, narrativism, constructivist qualitative approach, interpretive description or qualitative content analysis. Some researchers used phenomenology and narrativism for secondary analysis or combined it with thematic analysis. Analysis revealed that there was a range in the rigor with which the tenets of the identified method were applied, as well as a range in the quality and quantity of direct quotes available to the investigators.

Preparing the findings for meta-synthesis

The quality of the way in which findings were presented in the articles varied; the majority of articles presented raw data as thematic surveys and/or direct quotations from participant interviews. The meta-data analysis used the technique of Hermeneutic Appraisal to extract statements from the articles’ findings to evaluate the horizon of the text. The investigators then interpreted these statements within the context of a guiding question: Is this contentment? Working inductively from these interpretations, the researchers were able to identify possible fusions [25,26].

Results

The fusions identified and interpreted in this meta-synthesis were contentment and two associated aspects which are all affected by the diagnosis of breast cancer and its treatment: (1) contentment (2) comfort and (3) contentedness (Figure 1).

palliative-care-medicine-breast-cancer-treatment

Figure 1: Three aspects of Quality of Life affected by the diagnosis of breast cancer and its treatment: contentment, comfort and contentedness.

Contentment

The fusions we identified and interpreted in the 12 articles we analysed, regarding the concept of contentment, were related to four main ideas: meaning of life; self-respect/self-value; enjoying life; and quality of life.

Meaning of life

The first main idea connected to a conception of contentment is that life gives meaning. Due to the breast cancer experience life becomes meaningful. Everything in life becomes meaningful, even the small things or facts in daily life. Different aspects of breast cancer experience allowed women to find meaning in life. One of these aspects was the awareness of own mortality which presents a deeper meaning of life [28].

Some women started thinking about the possibilities of finding ‘meaning’ in getting cancer. According to that way of thinking the breast cancer experience would give them personal mental strength and valuable life experiences, as if they had come out of this experience as wiser persons [29].

Then, in a certain way, due to the breast cancer experience, values are changed in women’s lives. From now on, friendship is important and solidarity is essential for life. It made these women see how wonderful it is to be alive, to have friends, and to be close to nature [30]. For them, all things in nature become deeply filled with meaning, and made them get insights from appreciating the nature. They got new meaning to their situation and as consequence to their lives, and that put matters into perspective. They learn to live in the present moment and they experience everyday life as becoming more important. Even work activities they enjoy it as meaningful [28].

Self-respect/self-value

The second main idea and one of the most important aspects of contentment, considering the context breast cancer experience, is the need of felling valued and respected. And for these women, the first steps towards this feeling are self-respect and self-value.

There are different influences on self-respect and self-value and they area related to the women’s view of themselves and also to the reaction of people in their surroundings towards them. Experiencing human dignity and the feeling of being treated and respected as human beings gives the women worth [31].

For them, having a breast cancer diagnosis is like a wake-up call. They start slowing down and give themselves respect. They realize their necessity to focus more on themselves, to live each day more consciously and to take care of their health [32]. Women learn to appreciate themselves, to recognize they are strong, to get peace, and to know what they can do; getting the strength to meet anything. With the breast cancer experience the women find strength and power inside them and act to maintain self-respect [30].

The feeling of self-value then arises and women start doing activities which can make themselves healthier, mentally, emotionally, physically, and spiritually. Performing physical activities that energized the women can help them on building a sense of accomplishment and pride in a social environment of other women with breast cancer [32]. It also reinforces their self-value and, as consequence, the women can gain inner peace, can achieve contentment.

Enjoying life/Showing satisfaction

The third idea that composes a conception of contentment is enjoying life and showing satisfaction for that.

After experiencing breast cancer treatment and side effects, women revaluate their lives and priorities in it; they started enjoying life. They try to reflect and move on. In this way, they achieve some insightful realizations, such as taking good care of self, letting go of pressures, changing temperaments, and staying in a good mood to enjoy life [28,33,34].

Once more, the awareness of own mortality associated to the breast cancer diagnosis and treatment make women realize that they cannot prolong their lives, but they can broaden life. Looking forward, they just want to enjoy life and spend more time with family and move on [28,33,30].

Revaluating their lives, women got a deep understanding of the situation; they realize they are strong enough to face the discomfort and overcome it [32,34].

In this sense, contentment may be expressed by experiencing life intensively and not taking anything for granted, by appreciating life and showing gratitude for being alive. Contentment is then a matter of showing satisfaction with the quality in interpersonal relationships, showing satisfaction for enjoying own leisure activities [28,33].

Contentment is also a matter of caring for one’s own health by managing the situation and maintaining quality of life.

Understanding quality of life

The fourth idea that composes a conception of contentment is related to the search of high quality of life, which includes among many ideas the one of changing conception of quality of life. These changes, as pointed out before, are directly related to the conscience of death that comes together with the breast cancer diagnosis.

According to this idea, the awareness of death can give women some relief for living intensely since they know that all human being will die. Reacting to death possibility made them start to act and seek for solutions and assurance of life [30].

One of the more important steps for changing perception of meanings related to high quality of life is the acceptance of the situation and the wish for quality of life as high as possible. Accepting is about change in goal from cure to treatment of cancer, and then to live as good life as possible [35].

Faith is another aspect of relevance in the search for better quality of life. Supported by faith women will struggle, until the bitter end, and they will make all efforts to live life fully and connect with others on a deeper level [30]. Supported by faith some women incorporated the illness in their lives and a “new normal” life started [36].

Women started to see many things in a positive way and they adopt a positive attitude for life. They rethink their lives and they could see themselves as powerful women. They review everything in their lives, they struggle to reach all their objectives, they feel great, and often, they put aside the fact that they have cancer. After the breast cancer diagnosis, they saw a new perspective for their lives and started to believe in themselves, and because of that, they started to live in their own way [30].

In this way, women gain ability to experience inner strength influenced by their life experiences enhancing an optimal quality of life. They become more sensitive and solidary; they made efforts to show other women that they could live in the way they want to. Then, for these women, to live intensely since they realize and know that they will die is a way of getting quality of life [37].

Contentment is then a matter of living life intensely, in the best way women could and that is reaching high quality of life from their new perspective of “living with” breast cancer.

Comfort

Concerning the conception of comfort, the fusions we identified in the articles were described from positive or negative aspects of life related to the breast cancer experience. Thus, comfort is an idea connected to positive emotional responses, to self-control in life, to live life as normal as possible, to an optimistic point of view and a realistic planning of future, and also to have support for living in the present situation.

Positive emotional responses

The first main idea that composes the concept of comfort is related to the way women deal with the emotional responses they experience due to breast cancer diagnosis and treatment.

Having a breast cancer diagnosis provokes powerful emotional responses. Women were experiencing these powerful emotions and they feel like having to face the reality: having a breast cancer. These emotional responses can be positive or negative and, as consequence, they can bring comfort or discomfort to women [33,37].

One of the aspects that are relevant in this context is the different ways of getting inner peace even after having a breast cancer diagnosis. Women can look for strategies of getting inner development by participating in different activities to reach inner peace. This are not related only to their own daily activities but also to the decision for searching for physical activities, for example, as a way of comforting themselves by reaching inner peace [29].

On the other hand, there is a whole complex of situations that brings to women negative emotional responses. Breast cancer may insert women in a world of fear, of uncertainty, vulnerability, worries and anxiety that make them feel uncomfortable [32,38].

Experiencing breast cancer diagnosis is sometimes understood as visualizing death. Some women have death anxiety and are frightening due to breast cancer diagnosis and they expressed a new awareness of death. This death anxiety affects women’s mother role, brings them a feeling of desperation. They prepare themselves to die and it made them feel discomfort [30,38].

Some women were afraid of losing control over the situation. Some of them feel uncertain with the possibility of having something more. When women think, for example, about future or about the relationship with their partners and/or their significant others they can feel insecure for not knowing how to respond to that [30,38]. In the same way, the reactions of people in their surroundings can affect negatively them. The negative effect of self-respect originates from others’ acceptance or non-acceptance of the women’s cancer disease would cause discomfort [35,38]

The breast cancer experience makes women concerned about disfigurement and reduced womanliness. Some women feel anxiety and discomfort with their own body and functioning. Many women noticed only what they disliked about their appearance. As everyone, they want to be loved and treated as they always were and there is uncertainty about others’ reactions. They feel the need of being accepted as normal persons by the society. These emotional responses cause discomfort [35,36,39].

So, comfort is a matter of experiencing positive or negative emotional responses due to the way women deal with impact of breast cancer diagnosis to themselves and/or to their social relationships.

Self-control in life

A breast cancer diagnosis is an event where usually women lose control over their life situation. Loosing self-control in life makes them feel uncomfortable. Then, the second idea we identified related to comfort in the situation of breast cancer experience is having life situation under control.

Breast cancer often emerges from a seemingly healthy body. The women were feeling physically well, but had a breast cancer diagnosis [29,32]. They spent a lot of time pondering whether they were healthy or ill and they have difficulties to accept the illness since they are feeling healthy. This can cause them discomfort.

When women got a breast cancer diagnosis, they realize they cannot control the cancer. However, they also realize they can control their bodies and they need to take some decisions about the life situation in order to have it under control [35]. Losing control on the situation, not knowing what to do, or what decision to take make, or not feeling able to manage as before, make the women feel discomfort [32,35].

Women try to get back control. They search for cancer resources, and try to take active part in care planning [29,35]. This allows them get back control on the situation. Getting empowered to manage the new life situation make them feel comfort [36].

So, comfort can also be understood as the feeling of being empowered enough to have self-control or to have life situation under control.

Living life as normal as possible

The third idea that composes a conception of comfort is related to the search of ways or strategies by which women could move on with their lives as they lived before the breast cancer diagnosis. Some women feel that they could not be able to perform their lives as before. It affects their wellbeing and causes discomfort. This can be understood as an inner perspective and also as how the others perceive them.

Women see themselves as the same women as they always were; the one who can live a normal life. That is why try to continue their lives as before. Living a normal life could bring comfort. They realize they have to continue their daily responsibilities and they have to manage the situation. Their nature of being performing daily activities most of their lives pushed them to continue doing the same despite the situation [28,29,37].

Despite the powerful emotions provoked by a breast cancer diagnosis, some women got to live as normal while waiting for surgery and treatment. In their mind, they had enough time to rethink their lives and move it on. Some women meant that this waiting time had passed too fast and they had not enough time to revaluate what happened to them and to comprehend it fully, bringing them discomfort. So, comfort is being able to perform daily activities as always [34].

Women want to live a normal life despite the physical limitations and changed body appearance. They were concerned about disfigurement and reduced womanliness and they want to be loved as they are. They like to be treated as they were before the illness. They become concerned about how the others would perceive them. They need to feel understood as having some limits for doing current things of a normal life. In their thoughts they have to prove to others that they are able to work and to live a normal life despite the physical limitations. These feelings could bring them discomfort [29,30,35,37].

Some women recognize their family as ashamed for their breast cancer and this interferes on the women’s social life; they lose their right for living a free life. Women, then, try to hide the disease thinking on self-protection, avoiding people with negative thoughts about them or their cancer. This is for them a safe way to continue living a normal life, as a way of getting comfort [30,33].

Comfort is then a matter of feeling able to perform daily life as normal as possible, feeling understood as a woman with certain needs and limitations, but able to perform daily activities as they always did.

Optimistic point of view

The fourth relevant aspect we identified concerning the idea of comfort in the context of a breast cancer experience was related to a positive attitude for life, an optimistic point of view [29]. Women can feel comfortable if thinking positively about their experience and their future. That also makes them think on a realistic planning of future.

Women tried to sustain an optimistic point of view of life or other events around them. They search for avoiding negative influences. Very often they made efforts to stay away from the ‘negative comforters’ to preserve comfort [29].In their minds, putting themselves and own wellbeing as a priority is an interesting strategy for getting comfort [30,33,35].

Some women may feel pessimistic as consequence of physical responses due to treatment and it can make them feel discomfort. However, some women were just concerned about getting cured and preserving their lives. By distracting themselves, focusing on the positive aspects as strategy to overcome distress symptoms and having an optimistic point of view for life can bring them comfort [33,35].

Women mentally prepare themselves for changes in life; negative changes which can make them feel discomfort. Women, then reframe what was happening in a positive way and refocus their attention on the positive aspects as a way to cope with this. They start thinking on a realistic planning of future and it brings them comfort [30,35].

Support for living in the present situation

The breast cancer experience is understood as a hard life experience that provokes powerful emotional responses and to face it women need support. Then, feeling supported to face the situation is the last main idea that composes the concept of comfort in the context of breast cancer experience. This support can be from health care professionals, from other women who lived the same experience or from family and familiars [35,39].

Feeling supported by health care professionals allows women to find strength in themselves for adjustment to the diagnosis and treatment. They feel that trusting in health care team they can put their lives in their hands [33,36,37]. This feeling of trusting doctors and nurses also allows them to take active part in treatment. This brings them comfort.

Women can also get confidence to overcome the cancer by seeing other women who have survived cancer. They can find comfort and safety in joining other women in an environment and activity where the cancer experience is shared; a silent shared experience by a glance. The shared experience promoted a sense of comfort [32]. Then, searching for and performing activities suitable for women with breast cancer can make them see themselves in a comfortable situation.

The breast cancer also impacts on family and some women experience non-support and distancing due to partners anxiety about them to die. Feeling abandoned, non-supported and distanced from partners bring women discomfort. Some women recognize that husbands and friends treat them different and they are persons who they need and want them to understand and to support them in their special needs [35,36,39].

Living the breast cancer experience women realize changes in family functions. When they experience support from partners and family this make them feel comfort. Women feel the need of trusting in who is by their side in order to make them comfortable in the situation [35,36].

Comfort is then a matter of living life as normal as possible with an optimistic point of view. Is a matter of having self-control in life, finding strategies for facing the cancer with positive emotional responses, and also to have support for living in the situation.

Contentedness

Concerning the conception of contentedness, it is about being satisfied or getting inner satisfaction in the situation. In the fusions we identified, contentedness was understood as related to being able to manage the situation and getting inner satisfaction performing women’s social role.

Managing the situation

The first main idea we identified concerning the concept of contentedness in the context of breast cancer experience was related to women’s abilities or possibilities of feeling satisfied or getting satisfaction by being able to cope with the situation they are living.

Breast cancer is a distressful situation for those who live it. To conquer the cancer women have to manage the situation by overcoming distressful circumstances in their lives due to the disease itself and the treatment. It pushes women to the need of making decisions in order to handle life situation. These circumstances made them revaluate their lives and priorities in it as a way to manage the situation and to feel pleased [28,29,34,35].

In a certain way accepting the situation helps to manage it. Knowing about the surgery, searching for cancer resources and taking active part in care planning makes them feel secure. Getting insights giving wisdom or getting enough empowered by learning new skills in order to manage the new situation makes women feel quite satisfied. They do not desire for more in this situation. This gives them control on the situation, which made them pleased. Women can get satisfaction if they get to keep the situation’s status quo and not deteriorate [29,32,35].

Getting inner satisfaction performing women’s social role

The other relevant aspects in the concept of contentedness in the context of breast cancer were those related to the feeling of being satisfied in the life situation. It includes the idea of women getting inner satisfaction if they get to continue performing women’s social role, despite the changes provoked by the disease and treatment.

Women need to feel they are able to work and to live a normal life despite the limitations imposed by the breast cancer experience. If they feel like facing difficulties for performing mother role in home due to side effects or any kind of inability to perform daily activities as before they can feel distress and misunderstood. This situation makes them feel unpleased with the situation. Thus, having limitation in functioning; not being able to perform things they wanted to perform made the feel frustrated and dissatisfied with the present situation [33,37]. Then, to keep home life as normal as possible makes them feel satisfied with the situation.

In the same way, if working activities are experienced as a good thing for women and they feel able to continue working, this allows them to manage daily activities and get inner satisfaction in the situation [30,37].

Feeling able to perform daily activities at home or at work allows them to have a positive self-value due to feeling secure in their role as wife, mother and grandmother or even as working women [32,35,39]. This brings them satisfaction. So, it is important that partners, familiars and working colleagues continue seeing them as the women they were before and this made them satisfied with the situation [29].

The idea of contentedness by getting satisfaction is also related to the experience of being among other women with breast cancer and seeing them all carrying on and still continuing to live; fully lives, active lives [32]. Seeing that they are satisfied with the situation makes them realise they can get inner satisfaction in the same way.

Discussion

In this meta-synthesis, data from 12 research studies on women with breast cancer were reinterpreted to gain a deeper understanding of how a breast cancer diagnosis and its treatment affect a woman’s QoL. The starting point for all interpretations was that the QoL was presented by the authors of the 12 analysed articles. We used the women’s quotations presented as raw data from which to draw an interpretation and gain an understanding of the components of QoL, including contentment.

The credibility (validity) of the data interpretations in this study is supported because they are the result of a systematic approach [24] and can always be arbitrated for or against a variety of other interpretations. The researcher’s task is to argue that his/her interpretation is more apparent than other achievable interpretations. The data analysed in this study comprised primary research conducted with women from different cultures and contexts, but all having a breast cancer diagnosis.

Contentment was identified as an important component of QoL and the women did different things to reach contentment e.g. evaluated their lives. This is in agreement with another study about the impact of breast cancer on women’s everyday life [40]. That study showed that women felt that the cancer had initiated a transformation of their lives in a positive way. According to these authors, there is a different life perspective, which can improve relationships, and when weighed against troubles due to the disease and its treatment, the positive aspects stand out. Contentment is also about finding meaning and living within a certain situation, even if the situation is harsh. These findings are quite similar to those in a study who stated that women who were long-term survivors after a breast cancer diagnosis and treatment often presented some deficits in important aspects of life such as emotional, cognitive, and social functioning that could persist over years [41]. Even so, some women could rate their QoL as fairly high, as if these women could reach contentment in their life situation. Breast cancer has different impacts depending on how each woman lives her life. It is a matter of transition in the life context [40]. Contentment could be seen as accepting life changes; from cure to treatment of cancer, and then to live as good a life as possible. A study found especially one theme, Liberation: towards an embodied self, which points out the strength and freedom of these women. It highlights how life should be lived in the presence of cancer and of ownership of the body; this could be seen as a form of contentment [13].

Still concerning the idea of contentment as a main component of QoL, in the study of [42], stress management was evaluated as a factor for improving quality of life after treatment for breast cancer. The expression of contentment was related to positive outcomes and positive emotional experience, and it was directly associated with QoL. In another study the expression of contentment was associated with the idea of being satisfied with the life situation after a prophylactic mastectomy [43]. These results reinforce our findings when we associate QoL with contentment and when we state that contentment is a matter of living life with inner strength, accepting changes and reevaluating life. Women may attain a high quality of life from their new perspective of “living with” breast cancer.

The women in these studies included in the analysis tried to improve their QoL by searching for positive and pleasant feelings that bring women comfort, i.e. a sense of physical or psychological ease, wellbeing or relief. They started performing some activities that brought them more into contact with the outside world, such as going to concerts or the theatre, attending study courses, taking up positions on committees or singing in a choir. Some of them started trying to do other creative things such as painting, drawing and handcraft making. This is in line with a study that states that these activities enhanced feelings of contentment and happiness, and also gave comfort in women’s everyday lives [44]. This is also in agreement with another study about using art as treatment [13].

According to the present meta-synthesis, contentment was also understood as a matter of feeling comfortable with the life situation. Considering the emotional impact and responses related to the breast cancer experience it is important to highlight the idea that comfort is an essential component of contentment and is often associated with pleasant and positive feelings, including happiness and an optimistic approach to life [45].

Quality of life also consisted of contentedness, which is about being satisfied or achieving inner, peaceful satisfaction with the situation. This life satisfaction can be achieved, no matter the life situation the individual is going through, depending on how the individual perceives the situation. Such an understanding has been pointed out by different authors [7,8,46,47]. This contentedness was shown by the women in the present study, in that they revaluated their lives and priorities to manage the situation and to feel happy. This priority could be seen in another study [48] as “living intensely”, which was pointed out as a way of, showing that women were getting inner satisfaction with their life situation despite the changes in life due to breast cancer. Another study pointed out greater appreciation of life; a positive change in the women’s worldview, being connected to life [49]. This is a good example of contentedness.

Conclusion

The breast cancer experience has powerful impacts on women’s lives, and affects their QoL. This QoL is identified as contentment, comfort and contentedness.

The present meta-synthesis demonstrates that contentment in the context of breast cancer can be defined as living life intensely, in the best way women could, searching for strategies for reaching a high QoL from their new perspective of “living with” breast cancer. It includes finding comfort and contentedness, which can be understood as living life as normally as possible with an optimistic point of view, and as having self-control in life, facing the cancer with positive emotional responses.

The results of the present study highlight the importance of providing support for women who have breast cancer in order to help them find the best strategies to overcome the impact of the disease and improve their QoL.