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Understanding the Essential Meaning of Measured Changes in Weight and Body Composition Among Women During and After Adjuvant Treatment for Breast Cancer: A Mixed-Methods Study

Pedersen, Birgith MScN; Groenkjaer, Mette PhD; Falkmer, Ursula PhD; Delmar, Charlotte PhD

doi: 10.1097/NCC.0000000000000427
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Background: Changes in weight and body composition among women during and after adjuvant antineoplastic treatment for breast cancer may influence long-term survival and quality of life. Research on factual weight changes is diverse and contrasting, and their influence on women’s perception of body and self seems to be insufficiently explored.

Objective: The aim of this study was to expand the understanding of the association between changes in weight and body composition and the women’s perception of body and selves.

Methods: A mixed-methods research design was used. Data consisted of weight and body composition measures from 95 women with breast cancer during 18 months past surgery. Twelve women from this cohort were interviewed individually at 12 months. Linear mixed model and logistic regression were used to estimate changes of repeated measures and odds ratio. Interviews were analyzed guided by existential phenomenology.

Results: Joint displays and integrative mixed-methods interpretation demonstrated that even small weight gains, extended waist, and weight loss were associated with fearing recurrence of breast cancer. Perceiving an ambiguous transforming body, the women moved between a unified body subject and the body as an object dissociated in “I” and “it” while fighting against or accepting the body changes.

Conclusions: Integrating findings demonstrated that factual weight changes do not correspond with the perceived changes and may trigger existential threats.

Implications for Practice: Transition to a new habitual body demand health practitioners to enter a joint narrative work to reveal how the changes impact on the women’s body and self-perception independent of how they are displayed quantitatively.

Author Affiliations: Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Denmark (Ms Pedersen and Dr Falkmer); Institute of Public Health, Section for Nursing, Health Faculty, Aarhus University & Aalborg University, Denmark, and University College Diakonova, Oslo, Norway (Dr Delmar); Department of Clinical Medicine, Aalborg University, Clinical Nursing Research Unit, Aalborg University Hospital, Denmark (Dr Groenkjaer).

The study received financial support from Aalborg University Hospital (the PhD student’s [Ms Pedersen’s] salary).

The authors have no funding or conflicts of interest to disclose.

Correspondence: Birgith Pedersen, MScN, Department of Oncology, Aalborg University Hospital, Søndre Skovvej 3, 9000 Aalborg, Denmark (Birgith.pedersen@rn.dk).

Accepted for publication May 31, 2016.

This study integrates findings from 2 studies on changes in weight and body composition in women with breast cancer using a mixed-methods design. Changes in weight and body composition seem to be a complex multifactorial phenomenon associated with bodily changes that affect long-term survival, quality of life, body perception, and self-esteem.1,2 Research on the factual changes caused by breast cancer treatment is diverse and sometimes contrasting,3 and research on the experiences of weight changes on body perception is limited.4 Thus, we conducted a quantitative study on changes in weight and body composition and a qualitative study on the essential meaning of the changes and their influence on the women’s perception of their bodies and selves. The results of these 2 studies have been reported separately elsewhere.3,4 However, separate research on factual bodily changes and experiences of bodily changes seems not to provide a sufficient understanding of the relationship between the 2 perspectives. Combining quantitative and qualitative methods and integrating findings may provide insight into how bodily changes influence the women’s experiences in a more profound way. To expand our knowledge of the essential meaning of changes in weight and body composition by combining the strengths of statistical trends and personal experiences, this mixed-methods article focuses on the integration of the 2 data sets.5

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Breast Cancer and Weight Changes

Over the last decades, breast cancer incidence has increased, which has been suggested to be partly associated with exposure to estrogen from fat tissue.6 Duration of chemotherapy,2,7–9 menopause status,2 estrogen receptor antagonist treatment,10 alcohol use,6,11 and decreased physical activity2,10 may play a role in weight gain among women treated for breast cancer. Weight gain of up to 10 kg is not uncommon, but the observed changes differ as some studies report no changes in weight at 12 to 24 months.12,13 Other studies report changes between baseline and after completed chemotherapy14–16 that even out after 12 months of follow-up.14 Conversely, persistent changes were observed in long-term follow-up studies.7,9,17 Although the majority of studies examine breast cancer stage I–III,7–10,13–21 some do not specify the chemotherapy regimens used.9,17 This may be essential as weight gain is claimed to be overestimated with current antineoplastic agents.18

Studies on weight changes have primarily focused on weight gain as a contributing factor for recurrence and decreased survival, but weight loss has also been found to affect survival in studies of women in stage I–IV breast cancer.16,22 Only few studies have explored body composition data including fat mass that could be of concern for women’s health and a contributing factor of concern for recurrence.8,10

The experience of changes in weight and body composition is explored in few studies that include a variety of samples and time spans from initial diagnosis to interview.23–25 Changes in weight and body shape are described to be distressing symptoms in the years after active cancer treatment and might become a constant reminder of the cancer diagnosis.23 Tied to negative thoughts and emotions,24,25 the experiences may also be clustered in paradoxes such as vulnerability and control, stress and living well, and uncertainty and confidence.24 Furthermore, women may associate weight gain with disease and risk of recurrence and death, whereas weight loss can induce positive body perception.23

Acknowledged as a significant problem, changes in weight and body composition seem to be a complex multifactual phenomenon associated with bodily changes, long-term survival, and lifestyle diseases, which affect quality of life, body perception, and self-esteem.1,2,6,11,26 However, findings on weight factual changes are diverse and sometimes contradictory, and the experiences of weight changes on body and self-perception among women during and after breast cancer treatment seem to affect the women extensively. Furthermore, it may be questioned whether the essential meaning and the influence of weight changes on women’s perceptions of their bodies and selves may be relative and dynamic during the trajectory of the cancer. Addressing changes and the experience of changes in weight and body composition can help elaborate on and expand the understanding of the essential meaning of this phenomenon.5

However, none of the existing studies investigated the influence of changes in weight and body composition on perception of bodies and selves, combining qualitative and quantitative data analysis to gain and expand knowledge on this topic. Therefore, this study aims to elaborate on how the integration of qualitative and quantitative methods expands the understanding of the association between changes in weight and body composition and women’s perception of their bodies and selves.

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Materials and Methods

Design

There has been an emerging focus on conducting mixed-methods studies when more complex research processes are demanded to capture the complexity of human phenomenon.27 Mixed-methods methodology makes it possible to integrate qualitative and quantitative research questions, methods, techniques, and findings.5,28 Based on the complexities of weight changes among women with breast cancer, this study used a partly convergent and sequential design consisting of a quantitative component (study I) and a qualitative component (study II). To obtain valid and trustworthy findings during the whole research process, these components have to be performed, analyzed, and described in their own logic just as integration requirements must be fulfilled.5 In the next sections, the 2 studies will be presented followed by an integrated mixed-methods interpretation before the final discussion and conclusion.

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Setting, Participants, and Data Collection of Study I and Study II

The study took place between 2012 and 2015. In study I, the participants were included consecutively. Of 101 included women, 6 women were excluded, and data from 95 women entered the final analysis (Figure 1). As the study was descriptive and explorative, this sample of women was considered sufficient to gain data about changes in weight and body composition longitudinally.

Figure 1

Figure 1

Inclusion criteria were as follows: Danish speaking with newly diagnosed breast cancer and allocated to adjuvant treatment for stages I to III breast cancer according to the Danish Breast Cancer Group’s recommendation.29 Weight and body composition data were obtained when the women attended the oncology outpatient clinic for treatment or follow-up with a time schedule of 6 ± 2 months a total of 4 times (baseline to 18 months).

In study II, 12 women were purposefully sampled for interviews from this cohort if they displayed changes in weight and shape or felt essentially changed (Table 1). Sample size in qualitative research is described differently in the literature. For interview studies, 15 ± 10 participants are recommended,30 whereas sample size in phenomenological studies is typically fewer than 10.5,31 The main interest is to include participants who have experienced the phenomenon under study and are able to articulate their experiences.31 In line with this, Dahlberg et al32 argue that variation is more important than the number. In addition to including a homogenous sample of women treated for breast cancer approximately 1 year from diagnosis, heterogeneous variations were sought by different ages, treatment modalities, and body changes. The sample thus represents women who display stable weight, weight gain, and weight loss exposed in preliminary findings from the quantitative study. As these women were able to provide rich data with a wealth of variations on the investigated topic and let patterns that structured the essential meaning of the phenomenon reveal, the sample size was deemed sufficient. The interviews took place between the third and forth measurements after breast cancer surgery. Of the 12 women, 3 were interviewed during outpatient visits, and 9 women were interviewed in their own homes.

Table 1

Table 1

The study was approved by the Danish Data Protection Agency (no. 2008-58-0028) and the local ethics committee and complies with the rules on data storage and ethical guidelines.33 Patients were informed orally and in writing and signed informed consent before enrollment in both studies. Anonymity and confidentiality were ensured by safekeeping data and anonymizing names.

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Study I

Study I aimed to describe the extent and patterns of changes in weight and body composition and how the risk of weight changes is associated with current antineoplastic treatment.

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INSTRUMENT

Weight and body composition data such as body fat mass, fat-free mass, and total body water were measured by means of bioelectrical impedance analysis on a Tanita BC-418 Segmental Body Composition Analyzer (selected standard body type; Frederiksberg’s Vægtfabrik, Denmark).34,35 Waist circumference was measured at navel level with a measuring tape. The reliability of the instrument and data production was supported by regular calibration of the weight and having few persons to obtain body composition data. Only 5 of 380 measurements were missing in the final analysis, which provided robust data. Height was self-reported or measured at the clinic.

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STATISTICAL ANALYSIS

Initially, data were tested for normal distribution. Descriptive statistics were used to summarize baseline characteristics of the sample. The patterns of changes in weight and body composition over time were analyzed using linear mixed models with time as a fixed effect and person as a random effect. The parameters of interest were weight, fat mass, total body water, and waist circumference, respectively. To examine associations between patient characteristics and weight changes after 18 months, the weight change was categorized into 3 categories: below −2.4% (weight loss), above +2.4% (weight gain), and ±2.4% (stable weight).22 Stratified into these weight categories, the odds ratio was estimated for weight gain versus stable weight and weight loss versus stable weight using logistic regression. The calculations were based on 5% significance level and 95% confidence interval.

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Study II

Study II aimed to describe the essential meaning of the phenomenon of changes in weight and body shape among women treated for breast cancer and how these changes influence the women’s perception of body and self.

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INTERVIEW FOR DATA GATHERING

Data were collected through individual interviews with 12 women (Table 1). To ensure consistency in these interviews and to allow the women’s perspective to come forward, an open-frame and explorative interview guide were developed and used.4,36 These tools aimed to ensure the focus on the topic under investigation without preventing the women from narrating their experiences. After an opening question,32,37 the women were encouraged to describe their experiences in their own words. The open-frame and explorative interview guide was used as inspiration if the women needed follow-up questions to elaborate on their statements and expand the influence of changes in weight and body shape (Figure 2). Using the interview guide as inspiration, staying in a phenomenological attitude, and discussions in the research group aimed to let the women’s perspectives come forward in the interviews and in the analysis.

Figure 2

Figure 2

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REFLECTIVE LIFEWORLD ANALYSIS

Transcribed verbatim, the interviews were subsequently coded and divided into meaning units. The meaning units were then combined in clusters and patterns that structured the essential meaning of the phenomenon of changes in weight and body shape.4 Interviews and analysis took place using Danish language. During the reporting process, the women’ statements were translated carefully without changing meanings in cooperation with an English expert.

The analysis was based on existential phenomenology and a reflective lifeworld approach. This approach acknowledges the perceiving subject as an inseparable unity of body, mind, and soul in a world that exists but reveals as intersubjectively constructed meanings.32,38,39 Being the object of everyday life, lifeworld is the foundation of lived experiences in a living relationship with time where past and future exist in present.32 Thus, lived experiences are described contextually with what has proceeded and what is expected to follow an experience. From this approach, researchers have to stay in critical self-reflection throughout the research process and endeavor to question those taken for granted.32 This scientific phenomenological attitude aimed to prevent premature closure of the analysis and was undertaken through discussions in the research group combined with self-reflection and attempt to keep preunderstandings bridled.

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Integration of Studies I and II

In addition to integration on the design level, integration is crucial throughout the mixed-methods study process40 and significant for gaining valid and trustworthy findings,5 Thus, it took place on the levels of data collection, data analysis, interpretation, discussion, and finally conclusion.

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DATA COLLECTION

Inclusion of participants in the study aimed to provide data to answer the overall purpose of the study. The purpose was divided into research questions that required a large sample for the quantitative component (probability) and a small sample for the qualitative component (purposeful). Following a partly mixed-methods sequential design, it was the preliminary analysis of the quantitative data that informed eligible women of the qualitative interview. As mentioned previously, eligibility included women who displayed stable weight, weight gain, and weight loss. Thus, the studies are integrated through sampling.

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ANALYSIS AND INTERPRETATION

Integration during data analysis and interpretation was informed by selected quantitative results that created a frame for the essential meaning of changes in weight and body composition and additional quotes. Matching quotes and lifeworld descriptions with quantitative results illustrated in joint displays provided new findings that drew lines between relative changes, differences between groups, and the women’s self-perception and body perception. This revealed associations and paradoxes between factual and experienced changes and showed how the combination of qualitative and quantitative methods may expand the understanding of the association between changes in weight and body composition and women’s perception of their bodies and selves. Through interpreting and discussion of juxtaposing quantitative results and qualitative findings, meta-inferences, which is one of the main ideas for mixed-methods research,40(p212) were drawn and subsequently highlighted in the conclusion.

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Findings—the Integrated Mixed-Methods Interpretation

This study used a mixed-methods design with quantitative data from weight and body composition measurements and qualitative data from individual interviews to expand the understanding of the experiences of bodily changes after treatment for breast cancer. The integration of findings is illustrated in joint displays with extracts from quantitative and qualitative data that facilitate integration and discussion.27 First, quantitative results from the 3 weight groups provide a frame for corresponding quotes related with the essential meaning of bodily changes (Figures 3–5). These illustrations from each weight group show the associations between changes and experiences on the individual level. Second, the physical changes over time are integrated with condensed descriptions of the women’s perception of body and self in the past, present, and future. These images provide an understanding of relationships at a more general level (Figures 6 and 7).

Figure 3

Figure 3

Figure 4

Figure 4

Figure 5

Figure 5

Figure 6

Figure 6

Figure 7

Figure 7

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The Ambiguous Transforming Body Associated With Relative Weight Changes

In study I, the 95 women included were distributed evenly in 2 groups by initial adjuvant treatment: an endocrine treatment group (EG) and a CT ± endocrine group (CG) (Table 2). From the total cohort, the relative weight of 40 women remained stable between baseline and 18 months. A total of 54 women experienced weight change of greater than 2.5%, distributed in 16 women with weight loss and 38 women with weight gain (Figure 8). Weight variations between ±2.4% (stable weight) may seem insignificant. However, integrating the variation with the women’s experiences, it appears that even these small weight changes combined with extended waist circumference may influence their perceptions of their bodies and selves extensively (Figure 3). Weight gain and extended waist size induced a negative self-perception. Perceived as an adverse effect from cancer treatment, the changes were occasionally seen as a necessary cost for being alive or interpreted as an effect of normal aging.

Figure 8

Figure 8

As stable weight with extended waist affected the women’s perception of their body and self negatively, gains greater than 2.5% similarly influenced the women’s body and self-perception (Figure 4). These changes provided an alienation from former body perception and inflicted sense of womanhood and seeing oneself as an autonomous human being. The weight gain ranged from 2.6 to 10.4 kg, and in addition to the impact on looks and possibilities for normal living, concerns regarding a healthy body occurred, although weight gain could be a necessary cost in attempts to keep up with other adverse effects as nausea (Figure 4). By contrast, it seems that weight loss greater than 2.4% strengthens one’s self-identity and induces a feeling of being able to act autonomously, which leads to increased self-confidence. Weight loss also promoted the ability to be in motion. It was perceived as a means to prevent recurrence and turned the attention away from cancer illness toward a positive body perception (Figure 5).

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The Ambiguous Transforming Body in the Past, Present, and Future

The majority of stable weight is observed in the EG, and although 2.5% to 5% changes are almost evenly distributed in the groups, the serious changes of greater than 5% appear in 17 in the CG compared with 6 in the EG (Figure 8). The women belonging to the CG (n = 48) were mainly premenopausal with less comorbidity than the EG (Table 2). They displayed several changes in body composition data that fluctuated over time and were statistically significant and of concern for health in that body fat mass turned out to be increased at 18 months. Interviewing a selected sample between 12 and 18 months after breast cancer diagnosis demonstrated how they interpreted their bodily changes in the light of past, present, and future. Comparing their bodies before diagnosis and during chemotherapy with an average change of 1.6 kg increase in total body water, they described their body as extremely changed and uncomfortable and seem to be prevented in beings and doings (Figure 6).

Table 2

Table 2

At 12 months, the average changes were decreasing, but now the weight gain of 0.9 kg was associated with excess fat mass. Despite the minor changes, some women experienced an unfamiliar body, confrontation with a transformed identity, new reality, and self-perception. As the body had to be obeyed during chemotherapy, some women now felt responsible for taking care of the bodily changes. Although the changes still prevented their normal beings and doings, some women felt the body was on its way to return to former weight and shape. At this distance from chemotherapy, the women articulated how they wished to perceive and control their bodies in the future to return to their normal weight and shape. In their attempts to regain a friendly and effortless body, they strived to find a new balance between demands, desire, and energy and thus be able to perform activities related to everyday beings and doings. However, at 18 months, the average weight showed an increasing tendency with 1.4-kg fat mass compared with baseline measurement.

The physical changes related to women in the EG (n = 47) was minor, but statistically significant regarding changes in waist circumference (Figure 7). The body changes in these women did not fluctuate as in the CG. Still the changes were perceived as uncontrollable adverse effects that reminded them of their cancer illness and the request for medication to avoid recurrence. In this group, 5 women were exposed for weight changes greater than 5%. However, in line with the quantitative results, it was not the weight changes that were of concern for the women interviewed (n = 5), but the extended waist circumference. The enlarged waist circumference was associated with developing an unhealthy body figure with increased abdominal fat. The total body fat increased with 0.2 kg during 18 months, which do not seem to be in accordance with the women’s experiences of their changed body.

Mean age in the EG was higher (66 years; range, 47–82 years) compared with the CG (50 years; range, 28–68 years) (Table 2), and the women interpreted the changes as a consequence of medication and also a sign of aging. Collaborating with the changed body by keeping an eye on nutrition, being physically active, or hiding the body changes with altered clothing style, the women tried to come to terms with what they perceived as unpreventable changes. This seems to prevent a strong division of the unified body subject as the body subject changed from “I was my body” to “I and my body” while hoping for regaining the former unified body subject.

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Discussion

The changed body reminded women of their illness, affected their sense of womanhood and self-respect, and questioned their ability to maintain or lose control. As such, these changes signaled an unhealthy body in discomfort, whereas regaining their former figure reminded them of being cured. To move to a higher level of comfort when the women perceived the body as diseased and disobedient,41 they endured and found meaning in their condition by interpreting the discomfort as adverse effects of medication or normal aging. Other studies confirm that weight gain influences identity and imposes negative attitudes toward oneself23–25,42 contrasted by weight loss that may strengthen self-identity and sense of being able to act autonomously and thus increased self-confidence.42

In the case of women who were overweight before breast cancer diagnosis, Halbert et al23 found a positive reaction on weight loss. Weight loss in overweight women may be voluntary,43 incentivized by a wish to obtain a healthier lifestyle.17 In the present study, weight loss turned the attention away from illness in the 2 women who lost weight. Furthermore, when attention was focused on the risk of recurrence, the meaning of weight loss was associated with being able to take care of one’s body and self as an autonomous responsible agent. In this context, the changed bodies made the women feel attractive; their body movements were eased, and their relationship with the world was positively affected. Given that modern society prefers the female body to be slim and toned and sees the body as an expression of one’s identity,44 the reaction to the changes may thus be a sign of a changed relationship with the world but is also connected to self-perception and identity. Furthermore, regardless of stable weight, weight gain, or weight loss, the changes seemed to be continuously related to fearing recurrence and death because of awareness of the possible association with fat tissue exposure to estrogen.6 Weight gain intertwined with fear of recurrence and health was also observed in the study of Maley et al.24 Unexpected weight gains inflicted self-blame related to the possible role of excess weight in recurrence, which also played a significant role in the present study.

In illness, the habitual body acts as a reference point for the present body and highlights how the actual body may be mutilated and obstructed in beings and doings.38 The largest change in measured weight and body composition except for the waist was observed at 6 months among women receiving chemotherapy (Figure 7). This is in accordance with other studies that report increasing weight after completion of chemotherapy.14–16 During and immediately after chemotherapy, the women perceived a body with comprehensive changes, out of control, and an object apart from initial self-perception. Perceived as heavy, hurting, big, and fat, the body was an entity that had to be obeyed. Compared with the habitual body, which used to be strong, enduring, and active, the body during chemotherapy turned into a sick and unknown body. The body subject turned into “I” and “it.”

The changes evened out at 12 months as shown,14 but while some women experienced a body on its way to becoming normal, other experienced a body with remaining and increasing changes. The body was perceived as unfriendly, fragile, and sensitive. The challenge of reconciling to this transformed identity is that the new reality and self-perception could be experienced as transitionally staying in the present body while longing for the habitual body. A healthy transition is perceived as well-being and involves development and movement from one state to another.45 However, staying in between 2 states, one can feel homeless and lost.46 Statements such as “it was not my body” indicate separation and could be a sign of feeling homeless, whereas the metaphor “being the master of one’s own life” points at an attempt to not go into a homeless existence. Struggling to feel at home in one’s body may thus be associated with an unfinished transition and discomfort.

Independently of belonging to the EG or the CG, when talking about the future, the women longed to return to their precancer weight and body, which usually remained unnoticed and required no effort. Some wanted to regain former waist circumference or lose weight, others to keep their weight loss, but all were increasingly focused on doing well for their bodies by being active and eating healthily. Long-term survival served as an internal motivational factor,47 but returning to a precancer body also provided distance from cancer illness and a feeling of being cured.

At 18 months, waist circumference was statistically significantly increased in both women receiving chemotherapy and women receiving endocrine treatment alone. However, the results at 18 months showed almost stable weight, body fat, and total body water among women in EG, whereas increased mean weight now consisted of increased fat mass in women from the CG. In general, the struggle to avoid the exposure to estrogen from fat tissue6 was not successfully accomplished. Body composition changed over time, although the women aimed to find a new balance between demands, desires, and energy and to regain a friendly body able to support everyday beings and doings.

The women struggled against capitulation to unpredictability and disorder by disciplining the body to maintain control.48 To be master of one’s own life, keeping autonomy, personal agency, and capability to carry out certain actions may be a way of seeking predictability. However, in the effort to remove the traces of illness and return to the same body and self as before breast cancer treatment, a disciplinary course of action might encompass fragmentation and dissociate the body as it. Although survival was the major goal, interpreting the changes as vanity and downplaying them as normal aging may be a sign of resignation or acceptance. Resignation and acceptance contribute to reintegration with the world and life with new limits.41 However, the association between fat tissue and breast cancer risk6 implies that some women apparently need special attention and help to maintain or regain a healthy body composition.

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Methods Discussion

Studies I and II have briefly been presented to provide the ability to follow the entire research process through the integration. In a mixed-methods study, the strategies used to enhance validity should address design, data collection, data analysis, interpretation, and conclusion, and the study must satisfy the conditions for a mixed-methods study regarding integration.5,28 At the data collection level, lack of using participants from the same sample is a threat against validity.5,40 Consecutive inclusion that provided a representative sample, few dropouts, and missing data provided robust data from the cohort.49 Subsequently, 12 women from this cohort were interviewed to accommodate integration on sample level. It may be questioned whether repeated interviews could have contributed with a clearer description of changes in the body—and self-perception over time. However, including and interviewing participants for the qualitative component at study initiation could have prevented purposeful sampling and the ability to gain rich data about changes in weight and body shape.

As data have to be analyzed and assessed in their frame of logic,5 the analysis of qualitative data used intercoder agreement and bridling in joint discussions among the researchers to strengthen the internal validity.32,50 By means of statistical tools, the cohort of 95 women was divided into subgroups. Although some results showed a statistically significant difference, they have to be interpreted with caution. The generalizability of the findings from sample to the population of women in adjuvant treatment for breast cancer is thus delimited. However, at the same time, subgroup analysis revealed that a pooled sample can obscure findings at the group and individual levels, and given the adverse effect of increased fat mass, this enables an attention to the risk of these changes among women given chemotherapy.

The validity of integration of findings illustrated in joint displays builds on the validity of the 2 studies. In addition, the meta-inferences drawn and the validity of the mixed-methods study are enhanced when knowledge is found valuable and transferred to other contexts.32 This assessment will take place in the audience of health professionals. On behalf of the insight from this study, we argue that the influence of changes in weight and body composition on body and self-perception do not follow a linear relationship. Instead, the perception and meaning of the changes are filled with multiple meanings that change over time.

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Conclusion, Implications for Practice and Future Research

The overarching meta-inferences from integrating quantitative and qualitative data showed that weight changes analyzed by statistical tools in a pooled sample do not account for or correspond with the perceived changes. Lack of understanding the women’s experiences may push to bodily alienation and social changes and challenge self-identity and integrity as even small changes in weight combined with extended waist circumference affected the women’s perception of body and self extensively and triggered fear of recurrence, shame, and self-blame. To cope with the unmanageable changes, the unified body-subject risk to become and remain dissociated keeps the women in an illness condition. Thus, quantitative findings suggesting that weight changes in general are overestimated must be challenged in a healthcare context that aims to provide holistic care.

Women in adjuvant antineoplastic treatment for breast cancer are at risk of changes in weight and body composition with serious implications. In addition to this health threat, the overall influence of the changes on the women’s perception of their body and self calls for ongoing attention from health professionals in their effort to provide a distance from the cancer illness and induce feelings of being cured. Staying in a transitional state between their habitual and present body, they need help to deal with bodily changes, as well as their influence on perception on body and self. The goal for the health professionals may thus be to support women in reintegrating their bodily changes into a new habitual body in accordance with the individual woman’s body and self-image.

Implementation of individual interventions regarding physical, psychological, and social concerns in the transition period from patient to survivor has demonstrated to reduce cancer-specific distress.51 Concrete suggestions for women in this transition period could address how to minimize weight-related adverse effects by educating the women in doing well for their body by being physically active, healthy eating, and controlling hunger. For example, attention has been on the effect of physical activity on quality of life among breast cancer survivors and clinic-based weight management programs.52 However, the question is whether “fixing or normalization” of the changed body contributes to a feeling of wholeness, a unified body subject, as no direct correlation is found between the degree of changes and the women’s experiences.

In addition to concrete recommendations and assessments by means of breast cancer–related quality-of-life questionnaires, Slatman,53 from a phenomenological and hermeneutical point of view, suggests that body evaluation in oncology after-care involves a narrative approach. Before deciding any interventions, the health practitioners must enter a joint narrative work with the women. During a quest narrative, the narrator may, in collaboration with the professional, tell, build, and interpret her story aiming to deal with the present situation with a special focus on how she values her physical appearance and sense of wholeness.53 From this stance, it may be possible to support the woman in the transition from one habitual body to a new one, while taking her body perception seriously independent of how the changes are displayed quantitatively. Furthermore, it may provide health professionals with directions for interventions that may influence the women’s perception of body and self in a positive way and thus provide comprehensive care for these vulnerable women.

Implementation of this joint orientation in a busy outpatient clinic may be a challenge. In line with a mixed-methods approach, long-term follow-up regarding body composition may be manageable as data collection on a bioelectrical impedance analysis is a cheap, easy, and noninvasive procedure. This will provide data on factual changes and knowledge of long-term changes. However, combining these measurements with breast cancer quality-of-life questionnaires is not sufficient to develop sensitivity to individual body experiences as they do not contain adequate vocabulary for the experiences.53 Developing a vocabulary from the women’s expressions of body changes and organizing it in a theme guide may provide the professionals with a tool to be used in clinical settings. This may be an assignment for future research.

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ACKNOWLEDGMENT

The authors thank the women for their valuable contribution in providing knowledge of weight changes during and after antineoplastic treatment for breast cancer.

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References

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Keywords:

Body composition; Body perception; Body weight changes; Breast neoplasm; Descriptive analysis; Mixed methods; Phenomenology; Self-perception; Weight changes

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