Lived experiences of young adults facing a recent diagnosis of cancer: A phenomenological study

Abstract Introduction Young adulthood is a period of prosperity and freshness characterized by developmental achievement, which can be inhibited by various diseases such as cancer. Typically considered a terminal disease, if diagnosed in young adulthood, cancer may trigger a tremendous psychosomatic shock. The nature of facing a recent cancer diagnosis affects the whole coping process. Addressing young adults' experiences at the confirmation point of cancer diagnosis will facilitate supporting them through the early recognition of probable problems in the future. Therefore, the present study aimed to analyse the lived experiences of young adults facing a recent cancer diagnosis. Methods This qualitative study adopted an interpretive phenomenology design. In this study, 12 patients (with an age range of 20–40) were selected using the purposive sampling method. Data collection was done through in‐depth, semistructured interviews. The data were analysed following the method proposed by Diekelmann et al. Findings Three main themes and nine subthemes were extracted from the data: (1) spiritual detachment and then acceptance through spirituality in the form of denial and then forced acceptance, sense of guilt and spiritual help‐seeking, and anger towards God and then humbleness, (2) the shock of facing an extraordinary life shaped by disturbed role‐play and unusual lifestyle, (3) anticipatory anxiety concerning the sense of rejection, negative perspective towards future, inability to afford the costs and worries about the future of the family members. Conclusion This was the first study providing significant insights into the experiences of young adults facing a recent cancer diagnosis. The diagnosis of cancer can shadow all aspects of young adults' lives. The findings of the present study empower healthcare professionals to provide newly diagnosed young adults with appropriate health services. Patient Contributions To identify and recruit the participants, we explained the objectives of the present study to the unit managers either by phone or in person. The participants were approached and interviewed by three authors. Participation was voluntary and the participants received no financial contribution for their time.


| METHODS
This qualitative study was conducted using an interpretive phenomenology from November 2021 to April 2022 and reported based on a set of consolidated criteria for reporting qualitative research (COREQ) checklist. 11 The research environment was the outpatient chemotherapy department and haematology ward of the largest hospital in one of the northwestern cities in Iran.

| Participants
The purposive sampling method was used to select the participants.

| Data collection
Three authors conducted semistructured, in-depth interviews under the supervision of the senior author. Two of the interviewers were PhD students in Nursing and intensive care/emergency nurses for 14 years, trained in doing qualitative research and conducting interviews. The other interviewer was a clinical nurse with 7 years of experience in the haematology ward. The nurse was trained by the other two interviewers on how to conduct interviews in qualitative research in several sessions before the study. Therefore, the interviewers were familiar with the unit managers and asked them to introduce the eligible patients. The supervisor of this study was a faculty member in Nursing with prior experience in conducting qualitative research. The interview questions were made based on the literature review [12][13][14] and the expert opinions of the researchers.
At the beginning of the interviews, demographic questions were asked, and then continued with more specific questions related to the purpose of the research (Supporting Infomation: Box 1). All interviews were audio recorded with the consent of the participants. A total of 15 interviews were done with 12 participants to reach data saturation, 15 of which three were supplementary to acquire rich and in-depth data. The senior investigator assessed saturation which is presented in authors section. In general, all interviews were SHAHMARI ET AL. | 1875 conducted in person in a quiet place without the presence of others.
The mean, minimum and maximum duration of the interviews were 56, 45 and 80 min, respectively.

| Data analysis
The goal of analysing phenomenological data is to 'transform lived experience into textual expression and thus gain essence'. 16  In this study, data analysis started by repeatedly listening to the recordings to extract the overall idea and then continued according to the abovementioned seven steps. Data management was done using MAXQDA10 software.

| Trustworthiness
The following strategies were carried out to achieve rigour and trustworthiness. 16 Credibility was obtained through prolonged engagement with the participants and data, and the allocation of enough time to data collection. Dependability was ensured by examining the consistency between the quotes and the codes/ subthemes that emerged from the research team and two external observers familiar with qualitative research. Confirmability was ensured by presenting quotes as precisely as extracted from the interviews. Transferability was enhanced by detailing the entire research process, the characteristics of the participants and the research context.

| Ethical considerations
The ethics committee approved this study, and permission was obtained from the relevant authorities. The purpose of the study and relevant information were clarified. The researchers also highlighted the voluntary nature of participation, its confidentiality and the right to withdraw. Verbal and written consent was obtained before the interview. Permission to record the interview with an audio recorder was also obtained.

| FINDINGS
The participants aged between 20 and 40 were predominantly female (Table 1). Three main themes and nine subthemes were extracted from the data reflecting the lived experiences of the young adults facing the recent diagnosis of cancer (Table 2).

| Spiritual detachment and then acceptance through spirituality
Facing a recent cancer diagnosis is the most traumatic event in young people that leads to experiencing contradictory feelings of spiritual detachment and then acceptance through spirituality in the form of denial and then forced acceptance, sense of guilt and spiritual helpseeking, and anger towards God then humbleness.
T A B L E 1 Demographic characteristics of the participants.

| Sense of guilt and spiritual help-seeking
Guilt was another paradoxical emotion that some participants experienced. According to them, being diagnosed with cancer is a punishment from God for committing sins, so they blamed themselves.
In the beginning, I was always crying, thinking about the bad things I did and why I got sick. This must be because of my sins. (Participant 5) On the other hand, more than half of the participants stated that they tried to accept the disease and endure the exhausting process by asking God through praying, reciting the Quran and giving vows.
They referred to their close relationship with God as a source of their peace. In case of experiencing the alleviation of symptoms, they were grateful to God.

| Anticipatory anxiety
Another theme evident in nearly all participants' statements was excessive worries about potential future events such as a sense of rejection, negative perspective towards the future, inability to afford the costs and worries about the future of the family members as the sub-themes.

| Sense of rejection
More than half of the participants stated that they believe cancer is not a disease that can be cured quickly. They even considered it a terminal disease that may cause them to be worried about being The altered body image reinforced the sense of rejection which was specifically more common among married women who were worried about their husbands leaving them at any moment.

| Inability to afford the costs
Another main concern of all patients is treatment costs since it has been relatively accepted in society that the treatment of this disease is costly. Concerns about affording treatment were mostly reported. Besides, work-related difficulties arise from extended leaves, which may lead to an insurance cut-off. These  lifestyle. In contrast, another study investigating young women with metastatic breast cancer reported that participants experienced higher shock and impaired quality of life compared to their first diagnosis. 22  For most of the participants, cancer was equivalent to excessive worry about bad happenings in the future, indicating concern about the change in the mental image of the body resulting in fear of rejection, negative perspective towards future, fear of not being able to provide financial expenses and concern about the future of the family. The present study showed that young people were so worried about physical changes in their bodies, such as hair loss, weight loss, colour change and so on, that they avoided attending parties, meeting others and choosing their clothes. Other studies have similarly demonstrated that changes in body image, feeling ashamed of being in public and dealing with negative attitudes and stigma are the main challenges that women with breast cancer may experience. 20,21,25 One of the bitter experiences of some participants, especially the married ones, was their concern about the future of their family and children, which was stated as one of the main factors in pursuing treatment. In the same way, in other studies, concerns about the future of children and family members, as well as the acceptance of the spouse, is reported to be the most important psychological and emotional reaction of women with cancer. This concern is also one of the main factors in starting the treatment .

21,24
The patients also had negative perspectives towards the future when thinking about the uncertain future of the disease and the fear of being incurable, being in an unknown situation and being hopeless about recovery that may activate the thoughts about suicide in some participants. In other studies, fear of death and uncertainty about the future has been reported as the main concerns for people with cancer. 13,21 On the other hand, in many studies, having an optimistic attitude, including the hope of recovery and returning to a healthy life, has been reported as a very motivating resource for adapting to cancer at different ages . 21,26,27 Cancer treatment has caused an enormous cost to families and societies. 20 As in the current study, most young people with cancer expressed financial problems as a primary concern for continuing treatment. Hamid et al. 21  Emotional turmoil, including anger at God, denial of the disease and extreme embarrassment were among the common immediate reactions of the young patients. However, they accepted the reality and used different methods to deal with their illness over time.

| Implications and suggestions
Relying on the findings of this study, healthcare providers can facilitate offering health services to young adults who have recently