Feelings and Perceptions Facing the Diagnosis of Breast Cancer : an Integrative Review

The aim of this article is to investigate feelings and perceptions presented by women diagnosed with breast cancer from the scientific literature. This is an integrative literature review where the studies were collected in databases SciELO, LILACS, CINAHL, Scopus, PubMed, Web of Science and Psycinfo in the months of April, May and June 2015. The sample included 24 publications. Articles selected on the feelings and perceptions facing the diagnosis of breast cancer were mostly linked to the fear of ideas, anxiety, depression, worry and anxiety. Given these findings, it is important that all patients diagnosed with breast cancer have adequate psychological support during all phases of treatment. Feelings and Perceptions Facing the Diagnosis of Breast Cancer: an Integrative Review RevIew


Introduction
Breast cancer, like other malignancies, results from an uncontrolled proliferation of abnormal cells, which arise due to genetic changes, whether inherited or acquired by exposure to environmental or physiological factors.Such genetic modification can lead to changes in cell growth or cell death, leading to tumor appearance.Breast cancer is a heterogeneous group of diseases with different behaviors [1].
Brazil is one of the countries with the highest incidence of breast cancer worldwide.According to the World Health Organization, it is estimated that each year there are more than 1,050,000 new cases of breast cancer in the world and it is an important cause of death in women worldwide.In Brazil, about 48,930 new cases of breast cancer are registered each year, which it is estimated that there are about 11, 860 deaths from this cause.The National Cancer Institute estimated for 2014, 57,120 new cases in Brazil, of whom 660 were in Rio Grande do Norte.According to the Ministry of Health, breast cancer is a leading cause of death in women in the country, constituting a serious problem for the national public health [2,3,4].
Although the prognosis is optimistic for most of the women diagnosed with an early-stage disease, it is common to believe that cancer results in death, having a profound psychosocial impact on patients and their families [5,6].
The experience of breast cancer diagnosis affects women with a series of stressful events, similar to a disease that threatens their physical integrity.It is believed that the woman has a frightening experience, feeling anxious, insecure and worried about treatment, side effects and survival [7].
Being a stigmatizing disease, breast cancer in women causes a strong association with poor prognosis, suffering, incurability, the possible loss by breast mutilation, dependence on others and fear of aggressive treatment.In these cases, communication between health professionals, patients, and their families is of particular importance [8].
In crises, people need love and emotional support of those who are close to maintaining their identity.A study of women diagnosed with breast cancer shows the need to confront their mortality to help them cope with the uncertainty of the future [9].
Women affected by breast cancer, the confirmation of the diagnosis, and the fact of living with cancer can cause a significant change in their lives and in the way they see the world, they feel around several concepts, prejudices, changes in self-esteem and the restructuring of their image body [10].
Studies show that the consequences of the diagnosis are feelings of anxiety, fear, uncertainty of the future, insecurity, embarrassment, among others.It is also possible to observe women who face the stages of the disease with lightly hope and confidence.[6,11].
Given the above, it is important to consider the feelings and the way women perceive the disease because these feelings cause great impact on their mental health.
Considering the complexity of the disease, the high incidence and the fact that women have their lives changed for the diagnosis and prolonged treatment and, in this way, they experience different feelings and perceptions; the following research question was formulated: What are the feelings and perceptions presented by women diagnosed with breast cancer?The objective to analyze feelings and perceptions presented by women diagnosed with breast cancer from the scientific literature was formulated to answer this question.

Methodology
This is a bibliographic research of integrative review.This research allows the synthesis of multiple published studies, able to understand the state of the subject investigated and enrichment of pre-existing knowledge [12].
The following question was released to clarify and guide the analysis of the results that is, the investigated literature: What are the feelings and perceptions presented by women diagnosed with breast cancer?
Then, the selection of studies was carried, using seven databases accessed at the Federal University of Rio Grande do Norte (UFRN): Scientific Electronic Library Online (SciELO); Latin American and Caribbean Health Sciences (LILACS); Cumulative Index to Nursing and Allied Health (CINAHL); Scopus; Pub-Med; Web of Science and Psycinfo.This selection took place during April, May and June 2015, made by peers, through the search protocol built upon guidance provided by the nursing study subject based on evidence of the Graduate Nursing Program of UFRN.
The inclusion criteria for the selection of the studies were full articles available through access by UFRN and answering the main question of the study.As exclusion criteria, there were studies in editorial format, letter to the editor, review and expert opinion.
The studies were selected from three areas: title analysis, abstract analysis and detailed analysis of the full article.Articles that did not contain related titles to the topics of this study were excluded from the second part of the analysis.Those studies that did not contain abstract to show the feelings and perceptions of women after the diagnosis of breast cancer were excluded from the third part of analysis.This part of the analysis selected or not the article to develop this production.
After the use of eligibility criteria and selection by title and abstract, there were 38 studies, but 6 were duplicated, and they were used only once and at the first searched base.After the reading of 32 articles in full, there were 8 excluded.Thus, in total, there were 24 studies included in this interactive review.Table 1 shows the results of searches, based on data from the crosses described.
An instrument developed by the researchers was used to collect data, which consists of the following variables: authors; the title of the article; country; year of publication; methodological design (a type of study); the level of evidence; description of feelings and perceptions brought in the studies.

Results and Discussions
Through the analysis of the selected articles, it was possible to observe the predominance of studies with a qualitative methodology, developed in the United States, with evidence level IV [13].
Table 2 presents the articles selected for the final composition of the integrative review.
About the feelings and perceptions, the focus of study by the question, we prepared Table 3 for better observation.
The breast cancer diagnosis is a period of transformation in women´s lives, so facing it is different as the singularities involving human beings [38].
Cancer is also related to the belief that the patient is doomed to die, sometimes because by the ignorance of the disease and its current therapeutic possibilities.The diagnosis of cancer usually involves a devastating effect on a person's life that receives it.This may be related to the fear of mutilation and disfigurement that treatments can cause, as well as the fear of death or many losses, both emotional, social, and equipment [39].
Living with the disease and with negative feelings from it, bring feelings of insecurity and several un- certainties.The feelings generated by breast cancer are diverse and vary according to the individual woman´s interpretation of the social meaning attributed to the disease.They can be modified and acquire different meanings, depending on the stage of treatment in which the woman experiences it [40].Feelings are varied; it is possible to observe the surprise of women in the elucidation and confirmation of the diagnosis process, emerging at this stage, feelings of despair to find the lump, anxiety during the examinations, and indifference, fear and uncertainty to receive confirmation of diagnosis [41].
The articles of this study selected on the feelings and perceptions facing the diagnosis of breast cancer were mostly linked to the fear of ideas, anxiety, depression, concern and anxiety, common feelings to unfamiliar situations, bringing the idea of danger, putting health at risk.

Feelings and Perceptions of Women Facing Breast Cancer Diagnosis
Fear [14,17,19,22] and concern [17,18,19,21] with the unexpected are some conditions that will eventually cause the loss of emotional balance.When a lump or change is detected, the feeling of fear becomes present.A woman can take two simultaneous aspects: it cannot be anything serious or be cancer, usually she thinks the worst [42,43].At that stage, it is emphasized the importance of therapeutic support groups in the emotional restructuring of women.Support comes through dialogue, questioning, the experiences and the exchange of information, the emergence of new learning, giving conditions for women to understand the disease and its consequences, favoring resilience [44].
Based on the diagnosis, the woman goes through instability, marked by fears, frustrations, conflicts and insecurity.This suffering is associated with the serious nature and the idea of possible death.The aversion to women for breast cancer is because its biopsychosocial and physical effects, profound and significant affecting them.
Therefore, it is essential to understand the experience of living with breast cancer, because the uncertainty is a constant presence in the lives of these women and it is usually manifested by fear of disease recurrence [45].
The breast loss and other sequels of cancer and its treatment become part of women´s lives and constantly bring to mind the experiences of illness, being able to produce suffering and psychological distress [46].
Considering the illness, the experienced losses and the various symptoms that cancer causes and may contribute to the worsening of the disease during treatment, the diagnosis of cancer is experienced as a moment of distress and anxiety, because the disease is labeled as painful and deadly, and consequently triggering concerns about death [47].
Studies [16,27,28,36,37] reported that anxiety becomes present in the lives of these women through all stages involving the disease.The yearning for the test results, the next cycle of treatment, changes in body image, knowing how it will end, contributes to the increased amount of anguish and concern [47].In addition to involvement with the stages of the disease, there is a need to reorganize the roles of mother, wife, housewife, professional, caring women because of redistributing responsibilities (48].
The many feelings listed in the study are part of the individual diagnosed with cancer since they are found as a form of protection for the time of pain and suffering.The way to demonstrate what they feel is entirely related to the particularities of each woman, from the psychological factor to the way of seeing the world.
Each of them has different motivations and supports, and this reflects in the way they will face the disease.During the readings, positive feelings and perceptions at diagnosis were found, even though in smaller numbers, some studies have brought women who had the confidence, faith, peace, optimism, hope as part of their feelings.
The courage and strength found to cope the disease and seek treatment come from their children, attributed to God, faith providing the will to live with greater optimism (25].Spiritual support generates a kind of responsibility, where the search for a cure, rehabilitation, force is transferred to God [38].
Then, it can be seen that the duality of feelings shown in studies reveals the emotional imbalance of women affected by cancer, requiring psychological support for those women may mature in the period of difficulty.The maturity previously mentioned does not mean the acceptance and development only of positive feelings, but learning to live with the fears, anxieties and concerns.
Knowing how women understand in their subjective dimension, the meanings of the disease and how they feel facing it, may represent an important contribution both to the reflection of health professionals on the need to establish an interpersonal relationship and care suitable, as the best approach to this issue in the training and practice of health professionals.
As health professionals, we need to offer a warm, comfortable environment where these women feel the urge to talk, share their feelings, answer questions, being heard and accepted.Information and clarification should be provided to patients and families, making clear how the treatment developments and possible complications of the disease are, demonstrating respect for the autonomy of the patient [25].

Conclusions
After the assessment of the data on the feelings and perceptions facing the diagnosis of breast cancer, held in databases, this study showed the main feelings generated by the breast cancer diagnosis in women, observing that the diagnosis involves not only the physical and physiological condition but also the psychological and social area of the patient´s life.
The psychological changes together with breast cancer start from the time of diagnosis and women are seen around several concepts and (pre) concepts.The main feelings and sensations found in the studies found were associated with changes in self-image, low self-esteem, and biopsychosocial effects caused by fear, anxiety, depression, worry and anguish, and the restructuring of body image when there is mastectomy whether partial or total.
Given these findings, it is important that all patients diagnosed with breast cancer have adequate psychological support during all phases of treatment.
Cancer prevention should be understood as a multifaceted condition with socioeconomic, political and cultural influences, and the subjectivity found in feelings should be considered by health professionals in the practice of care targeted to women with breast cancer.

Table 1 .
Distribution of the domains and facets of QoL.João Pessoa, PB, 2015.

Table 3 .
Feelings and perceptions from the studies.