“Alas … my sickness becomes my family's burden”: A nested qualitative study on the experience of advanced breast cancer patients across the disease trajectory in Indonesia

Introduction Limited research exists exploring the experience of living with advanced breast cancer in Indonesia. We sought to explore the narratives of women with breast cancer across the illness trajectory to understand their experiences from diagnosis to accessing and undergoing cancer treatments to inform the development of cancer care. Methods A nested, exploratory study adopting a qualitative approach. We conducted in-depth face-to-face interviews with women living with advanced breast cancer in Yogyakarta, Indonesia. We purposively sampled participants by age, education and marital status. All interviews were transcribed verbatim with thematic analysis used to identify, analyse and report patterns and themes within the data. Findings Four main themes were derived: 1) Early experiences, prior to accessing health care; 2) Navigating the system to access treatment; 3) Enduring chemotherapy and advancing disease, with crucial family support; 4) Seeking normalcy and belief in treatment. From initial symptoms through to undergoing treatments, the experience of participants was punctuated by barriers and challenges. Discussion Presentation delays were driven by dismissing initial symptoms, seeking alternative medicines, and fear of surgery. Access to healthcare required participants to contend with long-distance travel to facilities, tiered and convoluted referral processes, and adverse effects and financial impact of treatments. Individual determination, belief in God, and the role of families were critical throughout the disease trajectory. Adopting a focus across the disease trajectory facilitated the identification of enduring and persistent challenges to care delivery that can inform targeted development and optimisation of care delivery for women with breast cancer.


Introduction
In 2020, there were an estimated 10 million cancer deaths globally, with 58.3% occurring in Asia [1]. Female breast cancer is the most commonly diagnosed cancer globally [1] with some of the highest breast cancer incidence and mortality rates occurring in Asian countries including Indonesia [2,3]. In the context of Indonesia, the age-standardized incidence and mortality rates of breast cancer are 44 and 15.3 per 100,000 population, respectively [4]. In the country, breast cancer is mostly diagnosed at later stages [5,6] with low survival rates [7]. From limited research, patient and service-level factors are being identified that may influence the timing of interaction with health services and the common late presentation among breast cancer patients in Indonesia. For patients, delays in help-seeking are associated with the use of traditional or alternative treatments to alleviate breast cancer symptoms [8,9]. The economic status of patients is also associated with the timing of presentation to healthcare [10,11]. For example, whilst cancer management is available and can be supported through the national universal insurance program, additional out-of-pocket expenses can be incurred (such as transport, accommodation, and logistics) which can inhibit patient presentation to health facilities [10,11]. At the health service level, delays can be influenced by both health professionals and the intricate, tiered referral pathways from diagnosis to treatment [11].
The concept of an illness trajectory has been explored previously for people living with chronic illnesses, such as advanced cancer patients [12]. A trajectory can provide a framework for exploring different phases of a disease as they are experienced by people, from the initial identification of symptoms through to the advanced stages and dying. From existing research, there is emerging evidence to suggest that Indonesian patients with breast cancer encounter difficulties throughout the trajectory of their disease, from initial symptom identification to help-seeking and undergoing treatment. When breast cancer patients initially experience symptoms, they often first seek opinions from relatives and peers, and mostly present at health care facilities when their conditions have worsened [11]. Following diagnosis, breast cancer treatment processes have also been reported to be complex and intertwined within the sociocultural context [10]. However, Indonesian women's experience of accessing and receiving care for breast cancer remains understudied, with research to date focusing on discrete fragments of their illness. Studies across countries signify the need for a holistic portrayal of breast cancer patients' journey over the course of diagnosis and treatment to understand the broader implications of being diagnosed with breast cancer [6]. This research aims to address this gap in the literature for Indonesia, exploring the narratives of patients with breast cancer to understand their experiences from diagnosis to accessing and undergoing cancer treatments.

Setting
This exploratory study adopted a qualitative approach with women living with advanced breast cancer in Yogyakarta, Indonesia. This nested study was undertaken as part of a larger cohort study on chemotherapy services at Dr. Sardjito Hospital, Yogyakarta, Indonesia. The parent study was "Analyses of chemotherapy toxicities in breast cancer patients, predicting risk factors and the influence on patients' survival and quality of life". All participants in this study received first line chemotherapy.

Sampling
Purposive sampling was adopted to recruit patient participants from the parent study. Participants were eligible if they had metastatic breast cancer, were not deemed too ill by the medical team to participate and had been recruited to the parent study within 12 months prior to data collection. A purposive sampling frame identified potential participants with variation according to age, education level and marital status. We sought to recruit up to 20 participants to provide a diverse range of perspectives and experiences across the breast cancer disease trajectory from our target population. The intended sample size was informed by the concept of data saturation given the purposive sampling approach adopted in this study [13]. Data saturation involved monitoring incoming data from interviews to determine a point at which little or no new information relevant to the study objectives was emerging. This was achieved through the interviewer summarising key aspects raised by a participant following an interview, which was subsequently discussed with the wider research team. Key points were described and compiled to support monitoring of interview data during the data collection period. Although the extent of new information being identified reduced after the first ten interviews, we continued to the target sample to ensure maximum diversity across characteristics of the sampling frame.

Data collection
Data collection started from June to November 2019 using semistructured face-to-face interviews. Project-specific consent procedures were developed for this study, including detailed information sheets relating to the planned interviews and an additional consent form. Participants were approached through screening of parent study participants. Those meeting the eligibility criteria were approached by a member of the research team to introduce this study. Potential participants were provided with an information sheet detailing involvement in a nested qualitative component of the parent study. Those who agreed to participate completed a consent form prior to participation. All participants were interviewed once and alone in a private room in the cancer clinic at Dr. Sardjito Hospital, Yogyakarta. Topic guides developed by the research team were used to guide exploration of participants' experiences of first symptoms, initial contact with health care providers and other sources of support, factors influencing the decision to seek support, and experiences of undergoing treatments. All interviews were audio-recorded. Following an interview, researchers made notes which were discussed as part of research team meetings to inform the analysis process and monitor data saturation. All interviews were later transcribed for analysis supported by OpenCode software version 4.03.

Data analysis
We adopted thematic analysis to identify, analyse and report patterns and themes within the data. We outline the process adopted during analysis including the development of themes in Fig. 1. We followed the six stages of thematic analysis as outlined by Braun and Clarke [14]. This included generating initial codes from participant transcripts, grouping codes with similar semantic meaning, from which codes were grouped together to form themes. Themes were formed using explicit or surface meaning of transcript content rather than through interpretation by the research team. Themes were discussed and refined by the research team until consensus was reached. We then adopted a thematic network approach [15] to develop a schematic depicting how principal themes and patterns aligned with the original questions. The schematic was developed iteratively through discussion by the research team. The study is reported in accordance with the Consolidated criteria for reporting qualitative research (COREQ) checklist [16].

Results
In total, 20 participants with metastatic breast cancer participated with a description of participant characteristics presented in Table 1. Interviews lasted a median of 31.41 min.
Four main themes were derived through analysis: 1) Early experiences, prior to accessing health care; 2) Navigating the system to access treatment; 3) Enduring chemotherapy and advancing disease, with crucial family support; 4) Seeking normalcy and belief in treatment. We have included quotations to illustrate findings across the derived themes in Table 2. A schematic depicting how principal themes and patterns aligned with the original questions and with each other is shown in Fig. 2.

Early experiences, prior to accessing health care
All participants initially dismissed their earliest symptoms, often experienced as a painless lump in the breast (quote 1). With the growth of a lump sometimes accompanied by changing breast shape, participants would typically explore self-care using herbal or traditional medicine approaches (quote 2). Most participants decided to seek medical care when symptoms worsened, including lumps becoming painful, changes in the shape or appearance of the breast, and increasing pain in other parts of their body, despite efforts to manage them (quote 3). Some participants endured multiple symptoms without accessing healthcare services, including difficulties with breathing and the feeling of a heavy chest (quote 4). Costs of medical care were perceived as unaffordable by participants, despite continuing to incur costs from traditional medicine providers with little or no improvement in their symptoms (quote 5). Alongside cost, additional factors influencing participants' decisions regarding engagement with healthcare included personal, inner conflicts and the influence and encouragement of family. Participants were reluctant to access healthcare facilities due to fear and assumptions relating to surgery (quote 6), and for women with children, most felt their needs and concerns should be secondary to those of their children (quote 7). Facilitating factors that encouraged engagement included family members urging participants to do so for worsening symptoms (quote 8, quote 9) and neighbours (quote 10).

Navigating the system to access treatment
Participants reported difficulties with accessing support for their symptoms, often having to navigate lengthy, convoluted referral processes and enduring the necessary travel across long distances to larger facilities with the capacity to undertake diagnostic tests. Following numerous primary care consultations, a referral to a larger hospital facility occurred for diagnosis by medical specialists (quote 11), followed by further onward referrals to other medical specialists for treatment (quote 12). Multiple delays often took place between each point of access with health providers. Every trip affected and sometimes worsened participants' physical condition due to exhaustion and discomfort during transportation (quote 13). Participants who had no private vehicle would have to use public transportation. These commuting routines resulted in significant expenses for transportation and accommodation (quote 14). Some participants and family members even lost their income sources, as they had to take leave or quit their regular jobs to attend treatment sessions (quote 15). Following referral to specialists for treatment, participants often had to incur waits of up to one month for follow-up consultations and to commence treatment. Despite their efforts to access care, some participants reported feeling discouraged when met with criticism from doctors for presenting with breast cancer at a late, advanced stage (quote 16) and when seeking more effective management of their condition (quote 17).

Enduring chemotherapy and advancing disease, with crucial family support
Cancer-related problems reported by participants included physical deterioration due to late-stage cancer, side effects of chemotherapy, and psychological distress. All participants reported difficult experiences when undergoing chemotherapy with commonly experienced side effects including frequent nausea and vomiting, loss of appetite, and difficulties with eating, swallowing and retaining food despite feelings of hunger and thirst. Participants also reported losing weight and feeling fatigued whilst undergoing treatment (quote 18). Some participants experienced severe pain during chemotherapy which affected mobility and elevated blood pressure and required morphine for its management (quote 19). Participants also highlighted the high levels of distress caused when considering possible outcomes from treatment (quote 20), alongside being emotionally sensitive and dispirited, with a few feeling "like dying" when expressing their suffering (quote 21).
Supportive and protective factors were reported by participants which facilitated coping with treatment. At an individual level, participants coped with their illness through finding joy and spirituality, along with incorporating alternative treatments alongside the medical approach. Some participants sought to divert negative thoughts through leisure activities such as listening to music and activities that made them happy (quote 22). Participants also relied on their spirituality by praying and surrendering to God, holding the belief that cancer is a form of trial to be endured which strengthened hopes for recovery (quote 23). Participants also reported combining alternative treatments to speed up postoperative wound healing (quote 24).
Participants illustrated the critical roles of others. Participants' families often encouraged compliance and adherence to treatment courses. Family members maintained optimism to motivate participants to complete treatment programs, alongside physically accompanying them to hospital visits (quote 25). Family members would take care of participants' needs during and between treatment sessions, including keeping participants motivated and entertained throughout treatment. Participants explained that family roles extend into financial support, as families would collect funds to cover expenses, mostly non-medical, throughout the treatment program (quote 26). Whilst providing a crucial supporting role, participants were often conflicted with the level of strain this could place on family members (quote 27). Supporting that this conflicted with a sense of placing a burden on them. Supportive others included health professionals, who through friendly gestures, such as actively initiating communication and listening to participants' feelings and complaints, encouraged participants to continue treatment (quote 28,29). Wider society-based initiatives and community-based charities were also reported to support participants through free lodging, amenities, and volunteers' assistance during participant stays for treatment (quote 30) and forms of psychological support such as sending      prayers (quote 31).

Seeking normalcy and belief in treatment
Participants reported that they and their families perceived a sense of healing that could be achieved through regaining a sense of normalcy in their daily lives. After completing chemotherapy, most participants in our study felt improvement in physical symptoms, such as a dried wound, regaining appetite and body weight, as well as experiencing improved sleep quality (quote 32, 33). Some participants also reported improved mobility including returning to walking unaided (quote 34). Participants also reported developing confidence and competence with self-management approaches, including treating their wounds at home without support from nurses (quote 35). Most participants reported becoming increasingly positive and motivated to persevere with medical treatments, as they felt more able to manage treatment courses that offered an opportunity for healing (quote 36). As treatment continued, clear communication of their disease and treatment by healthcare professionals facilitated retention of hope for some participants (quote 37). Other participants preferred doctors to communicate with their family on their behalf, particularly when too ill or in physical discomfort which could affect their comprehension of details being provided (quote 38). All participants expressed a determination to persist with and explore options for treatment as a route to improving their condition. Most participants believed that it was important to persevere with treatments and that the outcomes would be determined by God Almighty (quote 39).

Discussion
Our in-depth exploration of the experience of women with advanced breast cancer provides a novel depiction across the disease trajectory from initial symptoms, to presentation, and undergoing chemotherapy treatments. We highlight common delays in the presentation to health providers when initially experiencing symptoms that were later determined to be indicative of breast cancer. Waiting for symptoms to worsen and resorting to alternative medicines were often driven by psychological and economic factors. Once accessing health facilities for treatment of breast cancer, participants commonly had to contend with long-  distance travel to facilities, tiered and convoluted referral processes, and multiple adverse effects and financial burden from undergoing treatment. Critical throughout these stages of the disease trajectory was the role of individual strength and determination, belief in God, and the role of families who were crucial advocates and sources of support. While living with advanced disease, access to treatment provided a sense of healing when participants felt they were regaining the ability to undertake aspects of daily activities as they sought to return a sense of normalcy to their lives. Our findings provide the first report on the experiences of women with metastatic breast cancer that explores experiences across the disease trajectory in the context of a low-and middle-income country setting. Existing phases of a breast cancer pathway have been derived through a recent systematic review and meta-synthesis of qualitative evidence [17]. However, the pathway was derived from studies commonly focusing on a limited timepoint in the disease trajectory (e.g. receiving an early diagnosis of breast cancer, or having undergone breast cancer surgery) alongside highlighting the need for more research exploring the experiences of women from developing countries [17]. The concept of trajectory introduced by Strauss incorporates not just the 'physiological unfolding of a patient's disease but the total organization of work done over the course of illness and the impact on those involved with that work and its organization' [18]. The broader temporal focus presented in this study enables exploration and identification of both factors that are limited to specific phases, and those that are enduring and persistent. Reported experiences of women in this study align with the key phases of a breast cancer pathway whilst contributing novel elements; the integral role of family, and the persistent challenges experienced relating to convoluted and complex referral processes across services and settings. At a regional level, our findings correspond with existing literature from the South East Asia region whilst providing novel contributions for the context of Indonesia. Poor recognition of breast cancer symptoms is a cause of delayed presentation in Malaysia [19]. Furthermore, a low perception of disease severity upon discovering initial symptoms and tended to see symptoms as normal pain or signs of psychological distress aligns with experiences of Iranian women with breast cancer [20]. The response could be indicative of low health literacy among participants (i. e. the ability to understand and use information to make decisions about their health); the most common barrier to cancer diagnosis in LMICs [21]. For those receiving a confirmed diagnosis of cancer, feelings of fear, shame, denial and financial concerns were common among participants, aligned with previous work in Indonesia [22]. Surrounding participants from initial symptoms through to undergoing treatments were family. Family caregivers and members influenced decision making to engage with and seek support from health services. This included prioritisation of the need of their children over their own health, alongside the role of families in persuading participants to seek care. This aligns with Indonesian society; a country with strong social cohesion and regarded as one of the least individualistic societies globally [23,24].
Cancer control efforts span risk factor modification and prevention, early diagnosis, treatment, and palliation [21]. There is limited development across all stages in Indonesia. For prevention, programs are often implemented under Puskesmas (Primary Health Care), including an existing breast cancer awareness program initiated by the Indonesian Health Ministry; the BCearly detection program. BCearly targets primary prevention of breast and cervical cancers [25]. Government-led initiatives often occur alongside those led by non-governmental organisations (e.g. the Indonesian Cancer Foundation and oncology societies), charities, cancer support groups, and survivor societies. Campaigns generally seek to deliver public education by cancer experts and survivors, often targeting high-risk individuals (e.g. family members of cancer patients). Participants' dismissing of symptoms and fears around accessing care evidence a need for further development and evaluation of current campaigns. Primary care is a key requirement of universal health coverage [26] but there is known inequity in service provision across Indonesia [27]. With the development and refinement of campaigns, there needs to be structural investment in primary healthcare to accommodate increased demand from women with breast cancer, irrespective of location. Following presentation to cancer care services, the experience of commencing and undergoing treatments was complex for participants. Unmet support needs were evident across three domains aligned with breast cancer treatment [28]; i) health system and information, ii) physical, and iii) psychological. All were prominent in this study, with adverse physical and psychological effects aligned with existing reports of trauma caused by intense pain, fear of death, and stress when undergoing breast cancer treatments in Indonesia [29]. There is, however, a lack of holistic care for people with advanced breast cancer in Indonesia, despite the need [30]. Critical areas of clinical importance that include physical symptom control, psychosocial support, physical activity, nutrition support, and advance care planning, could be supported through provision of palliative care. Whilst the Ministry of Health developed a palliative care policy in 2007, progress with implementation has been slow with very limited, disparate provision across the country.
We outline findings that can inform multiple routes to improving care for women with breast cancer in Indonesia. Firstly, health professionals reflecting empathy and good communication can improve the experience of care for patients; sincere motivational words can be perceived positively by patients with cancer in Indonesia [29]. Secondly, families need to be considered as key stakeholders in the development of future approaches that seek to improve the delivery of care for women with breast cancer. Family caregivers and members greatly influence decision making to engage with and seek support from health services, including participants reporting prioritisation of the need of their children over their own health, with family members continuing to play a key supportive role throughout treatment. Thirdly, once undergoing treatments participants reported a determination to endure and complete treatments. Exploring ways of providing support during treatment such as leveraging digital health approaches to support self-management [31,32] or adaptation of remote monitoring of adverse events [33] may provide valuable tools to augment the delivery and quality of care. Lastly, palliative care development to better meet the needs of women undergoing treatments and living with advanced disease should be prioritized through, for example, building capacity and increasing the palliative care workforce, creating care models that provide services in the community, and exploring integration across oncology care and other disease groups. There is also scope to use our findings to guide provision of both country-or region-specific care pathways, drawing on crossover in experiences of women with breast cancer in this study and those in other countries in Southeast Asia, such as Singapore, where similar factors (e.g. fear and a lack of information) have been identified as affecting initial presentation [34]. Devising tailored care pathways could guide Indonesia and countries in the region towards universal health coverage [35]; where achieved it is independently associated with decreasing breast cancer mortality [36]. Beyond Southeast Asia, this study highlights the value of exploring experiences across the disease trajectory to augment the evidence base for breast cancer care in low-and middle-income countries, providing an approach to understand both phase-specific and enduring factors to inform prioritisation for service development.
The study was conducted by a team of experienced researchers in the field of oncology, psychology, medical science, public health, and bioethics. We recruited participants that reflected diversity in age, education, marital status, occupation, time since diagnosis and stage at diagnosis. However, the study took place in one cancer centre in Indonesia and undergoing chemotherapy hence the results may not resemble the experiences of patients in other centres in the country and women experiencing other treatment modalities. Furthermore, ethical approval obtained for the study required all interviews to take place in the hospital setting and not in the home of participants. Subsequently, the research team was not able to follow up with participants in the community to seek further input from participants on the study findings to verify their accuracy in the portrayal of their experiences.

Conclusions
Delays in presentation to health providers when initially experiencing symptoms indicative of breast cancer were common across participants. From initial symptoms through to undergoing treatments, the experience of participants was continually punctuated by barriers and challenges. However, family members were a constant source of support and influence across the illness trajectory. Family caregivers should be considered key stakeholders in the development of approaches to improve the delivery of breast cancer care across the stages of risk factor modification and prevention, early diagnosis, treatment, or palliation. While interventions are being developed across each of these four elements of cancer control in Indonesia, there is a dearth of evidence to indicate their acceptability and effectiveness. Future research spanning the disease trajectory could facilitate the identification of enduring and persistent challenges to care delivery that can be targeted to guide the development and optimisation of support for women with breast cancer.

Author contributions
YSP, SSH and MJA conceived the idea. Data collection was performed by SS, WH, YSP. Data analysis and interpretation, as well as manuscript writing and finalisation were performed by all authors.