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Keywords:

  • oncology;
  • psychosocial issues;
  • quality of life;
  • rehabilitation;
  • research: qualitative

Abstract

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies

Purpose

Studies show that younger women have a greater physical, psychological, and social morbidity, and poorer quality of life after a breast cancer diagnosis than older women. With improving survival rates, cancer rehabilitation has an increasing role in the cancer care continuum, particularly for younger women who potentially have many productive years ahead of them. The purpose of this study was to assess the cancer rehabilitation needs of young women after breast cancer treatment.

Methods

In this qualitative, descriptive study, we purposefully sampled 35 breast cancer survivors diagnosed under the age of 50 in Atlantic Canada to participate in two telephone interviews.

Results/Discussion

Recommendations included: improved communication between the various healthcare professionals; healthcare professionals taking on a more proactive approach in recommending rehabilitation after treatment; better insurance coverage or financial assistance for rehabilitation services; and more rehabilitation support for rural populations.

Conclusion

Rehabilitation nurses can play an important role in educating patients, recognizing long-term sequelae, and directing patients to various medical and allied health care professionals to provide proper support and care post-breast cancer treatment.

Due to improvements in the diagnosis and treatment of breast cancer, survival rates are on the rise, and cancer survivorship has become a critical focus in the cancer care continuum (Ellison & Wilkins, 2010). However, many treatment options for breast cancer are associated with short- and long-term side effects, which may have an impact on the physical, psychological and social quality of life of women surviving the disease. According to Johansen (2007), “more than 50% of cancer patients may, during their life after their first cancer diagnosis, have impairments or limitations which could potentially be improved by rehabilitative interventions” (Johansen, 2007, p. 443). Cancer rehabilitation is broadly defined as the process of helping a patient obtain maximum restoration of physical, psychological, social, sexual, vocational, recreational, and economic functioning possible within the limits imposed by the disease and its treatment (Thomas & Ragnarsson, 2009). It refers specifically to the interventions and services aimed at a survivor's needs postdiagnosis and posttreatment, with the aim of helping a person achieve the highest level of function, independence, and quality of life possible.

Interest in the experience of cancer survivorship and the rehabilitation needs of young women with breast cancer is heightened by the growing number of studies demonstrating that younger women have a greater physical, psychological, and social morbidity, and poorer quality of life after a breast cancer diagnosis than older women (Avis, Crawford & Manuel, 2005; Aziz, 2007; Kornblith et al., 2007). Potential long-term physical effects of cancer may include pain, lymphedema, secondary cancers, or sexual impairment. Potential psychological effects include fear and anxiety about cancer recurrence, depression, and feelings of uncertainty and isolation. Social effects may include changes in interpersonal relationships, financial and health insurance issues, difficulty returning to work or seeking employment due to impairment. Specific issues for younger women include survival concerns for those who have young children; concerns about the loss of fertility due to premature menopause and early ovarian decline; body image, and sexuality issues due to surgical alterations of the body and hormonal changes as a result of treatment. Rehabilitation interventions to address these issues may include a broad range of activities such as physiotherapy, psychological support, counseling and information on lifestyle and behavior changes, financial counseling, and information on coping strategies to deal with side-effects and late-effects of the treatment and other clinical issues that may arise (Hewitt, Greenfield & Stovall, 2005; Johansen, 2007).

The purpose of this study was to assess the rehabilitation needs and preferences of young women under the age of 50 with breast cancer in Atlantic Canada and to identify factors that may impact or prevent cancer rehabilitation utilization. This study protocol was reviewed by the Dalhousie University Research Ethics Committee (ref #2008-1828). In this article, we focus specifically on the recommendations provided by the participants of how to improve rehabilitative care in Atlantic Canada.

Methodology

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies

Study Methods

A qualitative, descriptive design was selected for this study, involving two semi-structured telephone interviews 6–8 months apart. Women over the age of 18 and under the age of 50 who were premenopausal at the time of diagnosis were recruited 1–5 years after their breast cancer diagnosis using a purposeful sampling technique to ensure a diverse representation of participants (age/geographical region/urban-rural). The time postdiagnosis criteria (1–5 years) was selected to recruit participants who were likely to be finished acute cancer treatment, but still early in the posttreatment journey and were more likely to be receiving follow-up care in a cancer clinic. Participants were recruited through information posters at various public locations (i.e., medical clinics, public libraries, gyms), online message boards on relevant websites, and advertisements in community newspapers across Atlantic Canada. The purpose of the first interview was to contextualize the breast cancer experience and to document any posttreatment issues. The follow-up interview was conducted 6–8 months after the first to give participants time to consider rehabilitation needs after discussing their experiences during the first interview, and to see if any of the posttreatment issues experienced resolved or new ones developed. The follow-up interview focused specifically on rehabilitative care services used, preferred, needed, and recommendations to improve supportive care after breast cancer.

Procedures for oral consent were followed prior to the commencement of the interview. Interviews were digitally recorded, transcribed verbatim, and proofed. The transcripts were entered into the qualitative data analysis software program NVivo to facilitate data management and coding. Following an initial reading of the transcripts by team members, themes were highlighted and important ideas noted. Transcripts were read holistically, and then line-by-line to extract significant statements from the interviews, following established guidelines for a thematic analysis (Creswell, 1997). These statements were used to generate specific codes, and each transcript was then coded using this thematic coding scheme. Additional discussions among the research team took place to refine the coding scheme as the data collection progressed. Concepts were compared and contrasted across interviews and similarities and differences were highlighted.

Strategies to ensure rigor throughout the study included: (1) the maintenance of a detailed audit trail that outlined the research process, the evolution of codes, and a recruitment log; (2) regular team meetings to discuss the study progress and emerging findings; (3) a summary of research findings, which was sent out to all study participants with an invitation to comment. The follow-up interview allowed us to review the information from the first interview with each participant, helping to strengthen rapport and served as a form of member checking. It also allowed us to ask very specific and direct questions about rehabilitation experiences and needs after breast cancer based on the information shared during the first interviews.

Study Setting and Population

Atlantic Canada is comprised of four provinces: Prince Edward Island, New Brunswick, Nova Scotia, and Newfoundland and Labrador. It is a unique geographical area with a largely rural and ethnically homogenous population, while economically deprived compared with other regions of Canada. Atlantic Canada has a combined population of under 2.5 million people, of whom almost half (48%) live in rural areas (Statistics Canada, 2009).

Participant Profile

Thirty-five young women from Atlantic Canada participated in our study. At the end of the first telephone interview, participants were asked a number of sociodemographic questions (Table 1). The average age of the participants at time of diagnosis was 40 years old (SD 5.98) and the average age at time of the interview was 42 (SD 6.05). Just over half of the participants (51%) lived in rural areas (population less than 10,000) and more than half (54%) had an annual family income of less than $30,000 per year.

Table 1. Study Sample Characteristics (N = 35)
CharacteristicsN (%)
New Brunswick14 (40)
Nova Scotia10 (28)
Newfoundland and Labrador9 (26)
Prince Edward Island2 (6)
In a relationship (married or common-law partner)29 (83)
Working for pay (full-time, part-time, casual, seasonal)23 (66)
Living in a rural area (population <10,000)18 (51)
Supplemental private health insurance coverage33 (94)
Post-Secondary Education (Community College Diploma, Undergraduate, or Graduate University Degree)26 (74)
Have Children28 (80)
Annual Family Income
<$30,00019 (54)
$30,001–$50,0006 (17)
$50,001–$70,0005 (14)
>$70,0013 (9)
Did not wish to answer2 (6)

Findings

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies

During the interviews, participants discussed their rehabilitation needs and were asked for their recommendations to improve rehabilitative care after breast cancer treatment. We have made a list of the top five cancer rehabilitation services desired by young women after breast cancer treatment (Table 2). Participants were asked what services their “ideal” rehabilitation program would include. Table 2 is a list of the top five most frequently cited rehabilitation services desired by participants. Many of the services are not medical, but are characterized as allied health services. The following themes emerged from the data, followed by the recommendations given by the young women.

Table 2. Top 5 Desired Rehabilitation Services to be Included in Cancer Care
1. Physiotherapy
2. Psychologist
3. Sexuality/Fertility Counseling
4. Exercise Program/Personal Trainer
5. Massage Therapy/Manual Lymph Drainage

Theme: Lack of Awareness of Rehabilitation Services

The most prevalent theme that emerged from our data was that the vast majority (94%) of participants reported that they were unaware of available support resources and were not informed by healthcare professionals about breast cancer rehabilitation services in their community during or after treatment. One participant described it as follows:

I'm finding that unless you educate yourself and unless you know what questions to ask, nobody offers you the information…it seems to me that they [healthcare providers] think that you're on a need-to-know basis which drives me crazy because we shouldn't be on a need-to-know basis, we should be told everything. (Interview 29)

Despite the fact that all of the young women interviewed in our study were experiencing some kind of physical or psychosocial issue due to breast cancer and/or its treatment, less than half had ever sought or received any assistance to address these issues. Most participants said that they were unsure of where to go for assistance or who to approach for help after the completion of treatment. For those who did seek and receive rehabilitative care, most of them found assistance by doing their own research or through recommendations from friends or other survivors. Participants expressed a strong desire for better and more information about rehabilitative care. Many participants were disappointed that most healthcare providers did not discuss rehabilitative care options following acute cancer treatment. One participant said:

…somewhere along the way someone should say, “OK these are different services that are available, and if you are interested here's how you can access these services…” and that way you know there can be more widespread knowledge about what's available and make the process of either self-referral or physician-directed referral a bit easier. (Interview 18)

The majority of participants (94%) specifically mentioned the need for healthcare professionals to be more proactive in recommending rehabilitative care after acute breast cancer treatment has been completed. One participant describes a scenario she hopes to see implemented in the future. She said:

Hopefully in a few years time we might actually have teams of rehabilitation experts put together so that when you walk out of the hospital you have a list of phone numbers and you know that if you're going to call a counselor that counselor is going to be somebody who is specially trained to deal with women who are going through breast cancer, you know because we're, it's a desperate, desperate, desperate need and umm and we don't… we just don't have that here. (Interview 31)

Theme: Financial Challenges Related to the Cost of Rehabilitation Services

The cost of rehabilitative care was a significant barrier to receiving assistance after treatment for the majority of young breast cancer survivors. Most rehabilitative cancer services are not covered in the basic Canadian Universal Health Insurance (Medicare). Although almost all (94%) of the participants had supplemental private health insurance, these insurance policies often have severe restrictions on coverage, and many rehabilitative services such as physiotherapy, counseling or massage therapy are not covered or have limited coverage. Hence, many participants faced serious out-of-pocket expenses. One participant said:

…the majority of the work and money for those [rehabilitative care] treatments for me to recover came out of my own pocket. And in fact, I spent about twenty thousand dollars on getting myself better… primarily for massage therapy, the lymphatic drainage, I had a lot of that, and physiotherapy for rehab… It was for items that are not covered under the medical system… (Interview 34)

These extra costs for services combined with the limited or lack of supplemental health insurance coverage were significant barriers to receiving much needed rehabilitative care. As another participant described:

Physiotherapists are available but it's… It's not that easy to get in to see one. And unless you have additional insurance it's expensive. It's very expensive. Um… however I do have insurance but it's the type of insurance where you have to put the money up front and then get reimbursed for it. And at the time I couldn't afford the extra expense 'cause I was off sick from work at that point. So, I didn't seek any further assistance. (Interview 35)

Many participants recommended improving healthcare coverage for rehabilitative care after breast cancer either through publicly or privately funded health insurance policies. Some specifically expressed a desire for alternative therapies (i.e., naturopathy, acupuncture) to be better recognized in the healthcare community, and for improved coverage for these treatments through insurance plans. For example:

I think our health coverage should cover things like Reiki and natural alternatives also, because I know a lot of health coverages don't consider that because it's not western medicine or whatever. I think we should have … as patients, should have a choice as to what route we want to go and have it covered financially. (Interview 4)

Theme: Lack of Continuity of Care and Communication Among Healthcare Team Members and with Patients

Many participants discussed feeling lost and confused at the end of treatment and unsure of what they were supposed to do in terms of their rehabilitative care. They discussed a lack of continuity of care and consistency in what was recommended by the various members of their healthcare team. Many faced particular challenges when transitioning from the care of the oncology team to the care of their family physician. One participant said:

The battle isn't with the disease, the battle's with the doctors…And I, you know, it's been a roller coaster ride and I joke that my obituary if I die from all this, my obituary will read that I died after a lengthy ride on the medical merry-go-round. Not from a courageous battle with a disease itself. (Interview 12)

A number of participants discussed the feeling of inaccessibility to cancer clinic support and services after they completed acute treatment. They felt that they had no place to turn for help, and that they were not “supposed to” or “allowed” to discuss their rehabilitation needs with members of the oncology team. As one participant states:

Basically, all I've been dealing with is the oncologist and the cancer centre. So those issues [rehabilitation needs] are very secondary to them. So they're not really there to address those things, right? They don't have the time or, you know, really that's not their job I guess. They're dealing with the major issues…and patients who are really sick. But then what are we supposed to do? Who's looking out for us? I have no idea. (Interview 8)

Participants recommended involving more patient navigators who could act as a contact point for patients after they have finished treatment. As one survivor describes:

The biggest thing, I think, is to have someone be in charge of that patient, you know, just to kind of be their guide through the whole thing, like the patient navigator. That's where, you know, that's where the big gaping hole is, where the information's all getting lost and the patient's kind of, you know, lost in a shuffle. Like each … like say, the surgeon, they do their thing and they're done, you know, and then…the oncologist, they're going to walk the patient through chemo and they're done… and so on it goes. And if there was someone kind of just to sort of coordinate and guide patients along, who is familiar with the system, familiar with what's available, even like to call them once a month or something and say: Do you know about this? Would you like to try this? That would be the ideal. (Interview 1)

Overall, the majority of the participants in our study (94%) stated that they would like to see better collaboration and communication between healthcare team members and with patients. For the rest of the participants (6%), they specifically mentioned that their satisfaction with rehabilitative care posttreatment can be attributed to the feeling of accessibility to their healthcare providers and support. As one participant who was satisfied with her rehabilitative care describes:

You got to have access to your doctors. Like I've got wonderful doctors. Even my cancer doctor, my radiation doctor, I can pick up the phone now and call one of them and by tomorrow, lunch time, I've got a message back. If … I … I guess that's maybe the biggest thing—have access … to someone with the knowledge to be able to say, like listen, I've got an issue or I'm having a bad time today, or whatever, and be able to get your answer right away. Maybe that's why things are … like I think things are so wonderful. (Interview 31)

Theme: Limited Access to Rehabilitation Services and Resources in Rural Areas

Lack of services and resources was a particular challenge in rural areas of Atlantic Canada. Travel and transportation posed a significant challenge to seeking rehabilitative care in areas where services were not available. Over half of the study sample (51%) lived in a rural area, which means that they had to travel for treatment and follow-up appointments with their physicians and for access to rehabilitative care. In some cases, this led to transportation and financial challenges which would often result in not seeking needed and desired rehabilitation services. As one participant said:

Well if I were to go to see her [the physiotherapist], the first thing I would have to do is I would have to get to [City X] and as I explained that can range from 100 to 200 dollars to get there and back. Umm our insurance plan will only reimburse us about 50 dollars so it's still a fair chunk of change out of my pocket, not to mention the cost of the physio itself. I just can't do it. (Interview 28)

Another participant describes the challenge of traveling for rehabilitative services from her rural community. She says:

..like for me to travel, you know, like to go to [City X] just to do these exercises or yoga or something like that or, you know, and it gets costly with … just to travel alone and then you paying for everything, you know what I mean. Yes, there's lots of things like that I would like to try, but like I said, I … the financial part of it makes it a lot harder for me to even, you know, grasp the thought of trying it because I don't want to put that extra financial burden on everybody, right? (Interview 29)

Rural participants expressed a desire for equal opportunities for care in rural areas, either through website resources, mobile rehabilitation units and services, or travel assistance to go to larger centers for care. Even urban participants expressed a desire for standardized rehab services across regions after they learned of programs and services being offered in other regions in their province, or across Canada. One participant states:

I would like to see, like, I guess a more standard thing between the different areas, you know. You speak to someone in [City X] there what services they have available are totally different than what is available in [City Y] in the same province. (Interview 11)

Discussion

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies

The self-referred participants in our study were well distributed throughout the Atlantic region as well as between urban and rural areas. Although 6–8 months lapsed between the first and second interview, all women participated in a follow-up interview. The average age of participants was around 40, with the majority being in a relationship, with children, working for pay, having supplemental health insurance, and having a post-secondary degree. The majority (54%) had incomes below the poverty line (Statisics Canada, 2006). As survivorship rates for breast cancer increase, so too does the need for rehabilitation after treatment (Johnsson, Tenenbaum & Westerlund, 2011). However, as our study shows, rehabilitative care is not always available to patients after acute treatment, particularly in rural areas. Even when rehabilitative services are available, one of the most common themes to emerge from our study was the lack of awareness of these services and the lack of communication with health- care providers about the possible long-term effects of breast cancer and its treatment. Although most cancer patients receive much information on treatment options and procedures when they are first diagnosed, often they lack the support and guidance from healthcare professionals after acute treatment has completed in dealing with possible physical, emotional, social and psychological effects of a cancer diagnosis (Avis et al., 2005). Some of these long-term treatment sequelae that go unresolved can have a tremendous impact on their lives and overall quality of life (Lundgren & Bolund, 2007; Miedema et al., 2008; Thomas-MacLean, Miedema & Tatemichi, 2005). Overall, our study results show that young women want more recognition of the challenges faced after breast cancer treatment and for healthcare professionals to be more proactive in recommending rehabilitative interventions to help address these issues.

On the basis of our findings, we believe that improving collaboration and communication among healthcare team members would contribute positively to the continuity of care for breast cancer patients from diagnosis through to survivorship. Grunfeld and Earle (2010) recognize the transition from acute cancer treatment to survivorship as being a time period fraught with challenges. They cite that a lack of communication between specialists and primary care providers and the lack of clarity about each of their roles can potentially impact the quality and continuity of follow-up and rehabilitative care for cancer survivors (Grunfeld & Earle, 2010). The participants in our study want to be better informed about what to expect in terms of care following acute treatment and who is responsible for what part of their care (i.e., cancer follow-up; rehabilitative care). They also discussed a strong desire to have someone within the system that they could turn to for guidance regarding issues faced after treatment and rehabilitative care.

Survivorship care plans have been suggested as an effective tool to help minimize the gaps in care during the transition from acute treatment to survivorship care (Grunfeld & Earle, 2010; Hewitt et al., 2005). Patient navigators have also been discussed as a viable solution to improving the coordination of overall care for patients (Robinson-White, Conroy, Slavish & Rosenzweig, 2010). Robinson-White et al. (2010) conducted a systematic review of the role of the patient navigator in breast cancer care. Their review found that although the definition and roles of patient navigators varied between studies, the results were generally positive and patient navigators were found to help improve many aspects of breast cancer care. Our study participants recommended the addition of a patient navigator or a rehabilitation counselor to the healthcare team, specifically focused on after-treatment issues and rehabilitative care. This rehabilitation specialist could be a member designated from the existing healthcare team, or could be someone newly trained and brought in to coordinate after-treatment care.

Although some of the recommendations listed above may be remedied through efforts by medical and allied healthcare team members (continuity of care, improved communication, increased awareness of services), other issues such as financial barriers and access to care may be challenging and require more of a systemic approach. The challenge in Atlantic Canada is that it has a relatively large rural population and does not have comprehensive breast cancer rehabilitation programs (Statistics Canada, 2009). Like many other rural areas, access to care can be a major issue. Bettencourt, Schlegel, Talley and Molix (2007) conducted a literature review that focused on the breast cancer experiences of rural women (Bettencourt et al., 2007). In their review, they found that rural women face unique social and economic costs related to treatment compared with urban women and that anticipation of these costs may affect treatment decisions. Our findings are consistent with the results of their review. Considering over half of our study sample (51%) lived in a rural area, travel for rehabilitative care was common, as was the decision not to seek needed and desired rehabilitation care due to financial and travel concerns. To address these issues, Bettencourt and colleagues recommend that healthcare professionals use approaches and mechanisms that would make supportive services more accessible to rural patients and survivors (i.e., telephone counseling, educational websites) (Bettencourt et al., 2007). They also emphasize that healthcare professionals may be the principal source of support for rural breast cancer patients, and may play a particularly influential role in determining the care and treatments rural women receive (Bettencourt et al., 2007). Our study participants recommended the development of mobile rehabilitation units or that travel assistance programs be put in place to help minimize the out-of-pocket expenses associated with rehabilitative care.

To implement effective rehabilitation strategies, it is important to assess the rehabilitation needs of each breast cancer survivor who has completed acute treatment, to tailor her care plan to meet these needs. Assessments could be performed during follow-up care appointments by the oncologist or by another member of the oncology team; or it could be performed in primary care or by other allied health professionals. Opportunities exist for rehabilitation nurses to educate women about the potential problems after breast cancer as well as available options to prevent and treat symptoms. Focused attention that is only given during the treatment phase could leave the patient feeling deserted and overwhelmed if this support ends at the completion of active treatment, especially as new treatment sequelae and long-term effects are confronted (Lundgren & Bolund, 2007). Cancer patients can benefit greatly from rehabilitative care, because they have potentially many productive years ahead of them, may be able to contribute greatly to society, and most have a desire to return to “normal” (Miedema, Hamilton & Easley, 2007).

Conclusion

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies

Quality of life can be greatly improved for breast cancer survivors through proper rehabilitation efforts. Unmet rehabilitative needs can prevent women from returning to their former social roles, both within the household and within the workforce. Rehabilitation nurses play an important role in educating patients, recognizing long-term sequelae, and directing patients to resources and support services that can provide proper treatment and care. The four recommendations in this study are based on the needs as described by a sample of young breast cancer patients to improve rehabilitative care and to reduce long-term physical, psychological, and social problems after treatment.

Study Limitations

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies

Our study results are based on a relatively small theoretical sample and therefore the results cannot be generalized to all breast cancer patients. As in most research studies, particularly in self-referral studies such as this one, participants who have experienced challenges (in this case, related to breast cancer treatment) may have been more inclined to participate than women who did not. Therefore, although we are able to describe in detail the types of challenges experienced and rehabilitative care needs of young women after breast cancer, we cannot determine how common these problems are posttreatment.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies

We thank Naomi Tschirhart, Tashina Van Vlack and Miles Clayden for their assistance with this project. Financial support for the study was provided by the Canadian Breast Cancer Foundation—Atlantic Chapter.

Key Practice Points
  • Cancer rehabilitation is becoming increasingly more important as cancer survival rates increase
  • Studies show that younger women often face greater physical, psychological and social challenges and poorer quality of life after a breast cancer diagnosis than older women.
  • Many treatment options for breast cancer have side effects which may have an impact on the quality of life of women surviving the disease.
  • Opportunities exist for rehabilitation nurses and other health care professionals to educate women about the potential problems after breast cancer and the available rehabilitation services and support to help prevent and address these issues.
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References

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies
  • Avis, N. E., Crawford, S., & Manuel, J. (2005). Quality of life among younger women with breast cancer. Journal of Clinical Oncology, 23(15), 33223330.
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  • Bettencourt, B. A., Schlegel, R. J., Talley, A. E., & Molix, L. A. (2007). The breast cancer experience of rural women: A literature review. Psychooncology, 16(10), 875887.
  • Creswell, J. W. (1997). Qualitative Inquiry and Research Design: Choosing Among Five Traditions. London: Sage Publications.
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  • Johnsson, A., Tenenbaum, A., & Westerlund, H. (2011). Improvements in physical and mental health following a rehabilitation programme for breast cancer patients. European Journal of Oncology Nursing, 15(1), 1215. doi: 10.1016/j.ejon.2010.05.004.
  • Kornblith, A. B., Powell, M., Regan, M. M., Bennett, S., Krasner, C., Moy, B. et al. (2007). Long-term psychosocial adjustment of older vs younger survivors of breast and endometrial cancer. Psychooncology, 16(10), 895903. doi: 10.1002/pon.1146.
  • Lundgren, H., & Bolund, C. (2007). Body experience and reliance in some women diagnosed with cancer. Cancer Nursing, 30(1), 1623.
  • Miedema, B., Hamilton, R., & Easley, J. (2007). From “invincibility” to “normalcy”: Coping strategies of young adults during the cancer journey. Palliative and Supportive Care, 5(1), 4149. doi: 10.10170S147895150707006X.
  • Miedema, B., Hamilton, R., Tatemichi, S., Thomas-MacLean, R., Towers, A., Hack, T. F. et al. (2008). Predicting recreational difficulties and decreased leisure activities in women 6-12 months post breast cancer surgery. Journal of Cancer Survivorship, 2(4), 262268. doi: 10.1007/s11764-008-0068-8.
  • Robinson-White, S., Conroy, B., Slavish, K. H., & Rosenzweig, M. (2010). Patient navigation in breast cancer: A systematic review. Cancer Nursing, 33(2), 127140. doi: 10.1097/NCC.0b013e3181c40401.
  • Statistics Canada (2006). Low Income Cut-Offs for 2005 and Low Income Measures for 2004 (I. S. Division, Trans.). Ottawa: Statistics Canada.
  • Statistics Canada (2009). Population urban and rural by province and territory. Retrieved February 28, 2012, from http://www40.statcan.ca/l01/cst01/demo62a-eng.htm
  • Thomas, D. C., & Ragnarsson, K. T. (2009). Principles of Cancer Rehabilitation Medicine. In W. K. Hong, R. C. Bast Jr, W. N. Hait, D. W. Kufe, R. E. Pollock, R. R. Weichselbaum, T. S. Gansler, J. F. Holland, & E. Frei III (Eds.), Holland-Frei Cancer Medicine (8th ed.) (pp. 810822). Shelton, CT: People's Medical Publishing House.
  • Thomas-MacLean, R., Miedema, B., & Tatemichi, S. R. (2005). Breast cancer-related lymphedema: Women's experiences with an underestimated condition. Canadian Family Physician, 51, 246247.

Biographies

  1. Top of page
  2. Abstract
  3. Methodology
  4. Findings
  5. Discussion
  6. Conclusion
  7. Study Limitations
  8. Acknowledgments
  9. References
  10. Biographies
  • Julie Easley, PhD (c), is a research assistant at the Dalhousie University Family Medicine Teaching Unit, Dr. Everett Chalmers Regional Hospital, Fredericton, New Brunswick, Canada. Address correspondence to julie.easley@HorizonNB.ca.

  • Baukje Miedema, PhD, is Professor and Research Director at the Dalhousie University Family Medicine Teaching Unit, Dr. Everett Chalmers Regional Hospital, Fredericton, New Brunswick, Canada.