Oncofertility Experience in Young Women with Breast Cancer
Article information
Abstract
Purpose
This study aimed to investigate the oncofertility experiences of young women with breast cancer and elucidate their process of coping.
Methods
Employing a grounded theory approach, in-depth interviews were conducted with 12 women aged 27∼37 with breast cancer who experienced fertility challenges. Data analysis was conducted using the constant comparative method.
Results
The core category identified was a journey to restore daily life with inevitable damage to fertility, and young women with breast cancer experienced three stages: the crisis stage, life restructuring stage, and daily life recovery stage. The causal conditions were chemotherapy and pregnancy planning. The contextual conditions were anxiety about embryo or oocyte cryopreservation, the need to make a decision quickly, and expectations for natural pregnancy. The central phenomenon of oncofertility in women with breast cancer was “choices for an uncertain future.” The action/interaction strategies included increasing immunity, weight control, having a strong mind, and finding knowledge related to breast cancer. The intervening conditions were support from health care providers and family support. The consequences were early onset of menopause and “desperate pregnancy.”
Conclusion
Nurses need to be interested in the decline in fertility of young women with breast cancer and play a role in understanding and actively helping them.
INTRODUCTION
1. Background
Breast cancer is the second most common cancer among women in the United States, about 9% of all new cases of breast cancer in the United States are found in women younger than 45 years of age [1]. Breast cancer accounts for the largest proportion of cancers occurring in Korean women [2], and the number of women diagnosed with breast cancer nearly doubled from 2,956 in 2001 to 5,199 in 2018[3].
In the West countries, breast cancer mostly occurs after menopause, but in Korea often occurs before menopause, so the occurrence average age is low [4]. The age of breast cancer survivors is younger than in the West. Breast cancer among Korean women tends to decline after the age of 50, and the incidence of premenopausal breast cancer is higher than in the West. This suggests that there are many breast cancer survivors of childbearing age [4]. Due to the increase in the number of breast cancer survivors and the extension of the survival period, the interest in quality of life has increased [5].
Meanwhile, one of the important factors in life after re-tirement is fertility [6]. Oncofertility includes fertility preservation (FP) discussion and management, as well as the management of sexual dysfunction, hormonal dysfunction, complex contraception and fertility-related psycho-social support [7,8]. Breast cancer survivors undergo surgery, chemotherapy, and hormone therapy during treatment [7,8], consequently reduce fertility temporarily or permanently [6]. Therefore, fertility can be preserved, if necessary, in many cases. Chemotherapy is often used in women with breast cancer of childbearing age to increase the cure rate and reduce recurrence before and after surgery [9,10], which may lead to premature ovarian insuffi-ciency or premature menopause [11].
Methods for preserving fertility in women with breast cancer include freezing of embryos, eggs, and ovarian tis-sue, and hormone therapy [9]. The decline in fertility that inevitably occurs during the treatment process affects the physical, psychological, and social aspects of cancer survivors [11]. From a psychological point of view, women with breast cancer suffer from stress, anxiety and depression due to reduced fertility. Negative experiences such as regret, frustration, fear, and fertility concerns [12]. Women are frustrated by inadequate or insufficient information related to oncofertility also experienced fear and confusion [13]. They experience uncertainty even when making decisions related to oncofertility, which affects emotional as well as cognitive aspects and coping behaviors [14].
Fertility is an important factor in the lives of breast cancer patients after treatment.[3], especially in cases which pregnancy and childbirth were not completed prior to cancer diagnosis and treatment [3]. Therefore, the medical staff need to help cancer survivors to make decisions about fertility after fully considering themselves. Patients should be provided with sufficient information and support systems when making decisions related to fertility preservation, and their beliefs should be respected [15,16]. For that purpose, nursing staff should provide patients with appropriate information and holistic care.
In Western studies, various approaches have been made to reduce fertility of cancer survivors and problems related to oncofertility [17]. In korea, the guidelines for oncofertility were published in 2017 and started to take an interest in research, but nursing research is still insufficient [18]. As a result of a survey of nurses, only 9.8% of them had guidelines related to oncofertility in their workplaces [19]. This indicates that oncofertility related nursing in Korea is not being actively conducted. Most of the preceding studies related to oncofertility are conducted abroad, and based on this, there is a limit to understanding the oncofertility related experiences of breast cancer patients in Korean.
In order to provide holistic nursing related to fertility preservation needed by breast cancer survivors in Korea, an in-depth understanding of oncofertility related experiences is needed.
The grounded theory, based on symbolic interaction, discovers the shared experiences of its members, and psy-chosocial, it is suitable for delving into the process in depth [20]. Also, the grounded theory methodology is based human behavior and representation. It provides meaningful insights into the social, psychological, and structural manifestations of human and organizational behavior.
Therefore, this study applied grounded theory to understand the oncofertility experience of young women with breast cancer, the problems they experience in the process, and the socio-psychological process of trying to resolve [20].
2. Purpose
The purpose of this study is to conduct an in-depth ex-amination of the oncofertility experiences of young women with breast cancer during cancer diagnosis, treatment, and follow-up processes.
METHODS
1. Study Design
This is a qualitative study employed Grounded theory according to Strauss and Corbin [20] to conceptualize oncofertility experience in young women with breast cancer.
2. Participants
Purposive sampling was used and participants were selected based on the following criteria. First, among those diagnosed with breast cancer women who have completed active treatment such as surgery, radiation therapy, and chemotherapy. Second, women between the ages of 20 and 45 who have not undergone menopause before cancer treatment. Third, those who have not received a psychi-atric diagnosis and are not taking related medications. Fourth, those who comprehend the purpose of this research and can communicate in Korean. A total of 12 participants in the study were sampled until the data was saturated.
3. Data Collection
Research participants were recruited through open recruitment by posting recruitment documents on the breast cancer self-help group site of an online cafe. Interested in-dividuals were instructed to respond to the researcher's phone number, allowing for confirmation of eligibility criteria before being selected as study participants. The interviews were conducted through one-on-one in-depth interviews in an online Zoom meeting room. Before the interview, we explained the purpose and method of the study, progress, and recording of the interview, and then explained participation of the interview if voluntarily agreed.
Data were collected between June and August 2023. Data was collected through major interview questions to understand young women with breast cancer's experiences with oncofertility. The main interview question was “What are your fertility preservation experiences during cancer diagnosis, treatment, and the subsequent process?”
The duration of each interview was 30 minutes to 1 hour. For the meaningful or uncertain parts of the participants’ answers, we were asked again to confirm. Any parts that were unclear or insufficient in the first interview were confirmed through an additional interview over the phone.
During the interview, participants were asked about their thoughts, feelings, and experiences related to the topic and non-verbal communication was observed. As the interview progresses, the attributes and characteristics of the participant's oncofertility experience were integrated with the existing data. Patients with breast cancer who are planning to become pregnant and young are more interested in preserving their fertility, so a theoretical sampling was carried out to take this into consideration.
As the interviews were repeated, the interviews were narrowed down to participants in their 30s, as those in their 30s, who had no children and wanted to become pregnant, who are more interested in preserving fertility and actively engaged in it. Recording were conducted only with those who gave permission, and the recorded data were transcribed as stated for analysis.
Data collection and analysis continued until theoretical saturation was reached.
After collection of the interview data, we conducted theoretical sampling in which analysis of data and further data collection occurred simultaneously [20].
It is repeated until no evidence is found, clearly describing the relationship between concepts and focusing on theory construction. Consistency was maintained by con-ducting analysis simultaneously with data collection, and neutrality was established by recording the participants’ expressions as they were. A phone call was made to confirm the naming and meaning of the categories of collected data. After the 12th interview, no new themes emerged from the data, and we agreed that the data had reached saturation. A limitation of this study is that the interviews were conducted via Zoom meetings, which did not allow for sufficient observation of the participants compared to face-to-face interviews.
4. Data Analysis
The data analysis method employed continuous com-parison and consisted of the stages of open coding, axial coding, and selective coding, with analysis conducted simultaneously with data collection. Similarities and differences of data were compared, categories were discovered, and relationships between categories were identified. While deliberately refuting the extracted categories, descriptions and explanations including typical and atypical elements of the category were included.
A paradigm model was used to structure the process and outcome of causal conditions, mediating conditions, and action interactions. In the selective coding process core category that can comprehensively explain the relationship between all categories was derived.
5. Ethical Considerations
This study was approved by the Institutional Review Board of the university (IRB No. Ewha womans universi-ty-202307-0010-03). Consent was obtained in a non-writ-ten form, and participants’ willingness to engage in the study was confirmed by telephone, and if the subjects voluntarily agreed to participate, they participated in the interview.
Consent was obtained in a non-written form, and participants were told about the purpose and method of the study, anonymity of the process and privacy policy, audio recording, and the right to withdraw the study. It was explained that the collected data is strictly managed by coding and encryption and is discarded three years after the completion of the study (a data retention period is required according to the law). Participants were given gifts in appreciation after the interview.
6. Researcher Preparation
This researcher consisted of nursing professors and doctoral student with experience in grounded theory research. Doctoral students took a course in qualitative nursing research methodology and studied the ability to compare and analyze similarities and differences in data while actually analyzing research using grounded theory methods under the guidance of a nursing scholar, and the process of categorization and structuring through the process of comparing and integrating data. In order to acquire theoretical sensitivity, we read the fertility preservation paper in cancer patients well in advance before proceeding with the study.
7. Study Rigor
To establish the study's rigor, we followed the criteria proposed by Sandelowski [21], which include credibility, auditability, fittingness, and confirmability. To ensure credibility, we conducted semi-structured interviews using open-ended questions, creating an environment in which the participants could freely present their opinions in zoom meeting. In the process of analysis and inter-pretation, preconceived notions about the results obtained were eliminated, and efforts were made to find meaning even in negative or extreme data. To ensure auditability, we provided detailed descriptions of the data-collection methods and analysis procedures, and the analysis records were verified by participants to confirm that they matched their experiences and meanings. To ensure fittingness, we included participants of varying ages and cancer types. The data continued until the participant's statements reached saturation. Regarding confirmability, we directly quoted participants’ statements within the analysis to enable the verification of the analysis records. Three participants and one qualitative research specialist reviewed the analysis results of the interviews and provided feedback.
RESULTS
1. General Characteristics of Participants
There was a total of 12 participants in this study. The average age of the participants was 31.5 years old, and range was 27 to 37 years old. The breast cancer types were basal in 3 patients, Luminal A in 5 patients, Luminal B in 2 patients, and HER2 in 2 patients. There were 9 cases of Embryo or oocyte cryopreservation, and 3 cases of non-selection. There were 6 participants who were single, 6 who were married, and 1 participant who had children (Table 1).
General Characteristics of the Participants
2. Analysis of Categories Using the Paradigm Model
As a result of analyzing the interview data, the oncofertility process of young women with breast cancer was structured into a total of 14 categories and 34 subcategories (Table 2). A paradigm model was constructed through axial coding that connects the relationships between each category.
Paradigm, Categories and Sub-Categories of Participants’ Life Experiences
1) Causal condition
Two categories of ‘ Chemotherapy’ and ‘ Pregnancy planning’ were included as causal conditions that lead to the occurrence or development of the central phenomenon.
(1) Chemotherapy
Depending on the type of cancer, pre or postoperative chemotherapy was required for participants. They recognized that the type and stage of breast cancer was deter-mined through a biopsy and chemotherapy was essential. At the same time as the cancer diagnosis, through ob-stetrician consultation, the doctor recommended embryo or oocyte cryopreservation because fertility was expected to decrease.
Doctor said that chemotherapy damages the ovaries and lowers the age of the ovaries. Because the ovaries do not return to their pre-chemotherapy state, the infertility clinic recommended egg freezing. (Participant 2)
As a result of the biopsy, chemotherapy was essential, so I have decided to proceed with oocyte cryopreservation. (Participant 1)
(2) Pregnancy planning
When all participants were advised to embryo or oocyte cryopreservation to preserve their fertility, they made dif-ferent decisions depending on their pregnancy plans. If they were unmarried or had one child, they immediately chose fertility preservation. However, those with a family history of breast cancer and those with no plans to become pregnant tended not to choose.
Since I had a strong desire to have children from a young age, I made the decision to proceed with egg freezing right away. Given that I will be in my mid- 30s by the time my treatment is complete, I decided to freeze my current healthy eggs for future use…. (Participant 5)
After completing the treatment, I will try to get pregnant naturally until 35, and if that doesn’ t work, I want to live a life without children…. (Participant 12)
2) Contextual condition
Contextual condition that influenced the phenomenon included ‘ Anxiety about embryo or oocyte cryopreservation’,’ Need to make decision quickly’, ‘ Expectations for natural pregnancy’.
(1) Anxiety about embryo or oocyte cryopreservation
It was found that there was anxiety regarding the daily self-injection of ovarian stimulation injections and the results and potential side effects of the embryo or oocyte cryopreservation procedure.
I was anxious because if the eggs were immature, they would be discarded even if they were collected and would be difficult to freeze. (Participant 2)
It was difficult to make a hasty choice because there were side effects during the procedure. (Participant 3)
I was worried that ovulation induction could lead to conditions such as polycystic ovarian syndrome and ascites. (Participant 4)
(2) Need to make decision quickly
There was very little time to choose egg freezing, and in cases of rapid cancer progression, chemotherapy was chosen instead of egg freezing as recommended by the doctor. The priority was to prioritize current health over future pregnancy possibilities, and to seek rapid treatment.
I was worried that the ovulation injection could ac-celerate the progression of the cancer because it was a hormone-positive cancer, and I didn’ t want my pre- cancer treatment to be delayed by more than two weeks due to egg freezing.(Participant 3)
Because it was triple-negative cancer and the cell division rate was too fast, the doctor recommended starting chemotherapy earlier rather than choosing egg freezing. (Participant 1)
(3) Expectations for natural pregnancy
Since embryo or oocyte cryopreservation is not covered by medical insurance, it incurred significant costs. If the participant was in their late 20s or early 30s, they gave up embryo or oocyte cryopreservation in the hope of becoming pregnant naturally after completing cancer treatment.
Since it was not covered by insurance, it was also a burden in terms of cost… I saw many people in online breast cancer community getting pregnant naturally after receiving chemotherapy, so I thought it would be okay for me as well. (Participant 3)
3) Central phenomenon
(1) Choices for an uncertain future
The central phenomenon experienced by the participants in this study was ‘ Choice for an uncertain future.’ The subcategories are ‘ Insurance for future pregnancies’, ‘ Double the pain’, ‘ Anxiety about the future’
The participants were diagnosed with breast cancer at such a young age that they were faced with embarrass-ment, fear of complete recovery, and anxiety about the possibility of recurrence. In a crisis situation, participants were placed in a situation where they had to make urgent decisions to preserve their fertility. They also experienced anxiety that the cancer could get worse. They were placed in a very unstable situation because they chose the current hardship and delayed treatment situation in preparation for the uncertain situation in the future. Participants per-ceived embryo or oocyte cryopreservation as a type of insurance against the difficulties of pregnancy expected after cancer treatment. They were suffering enough from the sudden onset of cancer, but they suffered doubly due to the fear of losing their ovarian function.
I think I purchased expensive insurance to prepare for an unexpected situation. Anyway, my ovaries are the youngest right now. Isn’ t there a high probability of recurrence? If I manage it, can it prevent recurrence? Can I get married? Endless anger and anxiety filled my head. (Participant 7)
4) Intervening conditions
(1) Support from health care providers
During fertility preservation treatments, the comforting and supportive words from the doctor and nurse were a great source of solace. Their encouragement and hopeful messages when the follicles were not developing well were especially beneficial.
The obstetrics professor was kind. Now that I am going through chemotherapy, she warmly tells me, like a mother, to eat well, exercise moderately, and re-ceive good treatment… (Participant 2)
The doctor who gave me counseling was full of energy and gave me a lot of positive energy. (Participant 5)
(2) Family support
For the participants, the unconditional encouragement and support of their husbands and parents helped them overcome the difficult process.
My family came to my house and gave me an injection. (Participant 6)
My parents paid for the cost of egg freezing and were next to me whenever I was having a hard time, which was a great help. (Participant 2)
5) Action/Interaction strategies
(1) Increase immunity:
To keep their bodies warm, participants brought and drank warm beverages, sought to consume natural foods, avoid drinking alcohol and late-night snacks, and opted for moderate food choices.
I drank a juice that I made by blending carrots, cab-bage, and tomatoes. If I consistently eat a healthy diet, I can feel that my immunity is improving. Immunity is very important. (Participant 10)
When I drink cold water, my body temperature drops and my immunity deteriorates, so I rarely drink it. Reduce flour and eat substitute foods.(Participant 11)
(2) Weight control
Participants tried to maintain a balance between exercise and rest and controlled their weight to prevent cancer recurrence. They mainly did walk exercise and did not exercise too much depending on my physical condition.
Since gaining weight is the most dangerous thing, I managed my diet and never exceed 55 kg.(Participant 10)
(3) Having a strong mind
Although they are currently in a difficult and challenging situation, they tried to stay strong and overcome in a positive way. If the participant had children, she gained new strength by looking at their children.
I decided to only think about happy thoughts. (Participant 1)
Even if I have a family history of cancer, I can pro-tect my body. (Participant 7)
Looking at my child's face, I can gather my strength and push forward with all my effort. (Participant 9)
(4) Finding knowledge related to breast cancer
Information about treatments and regimens was mainly obtained through the Internet, exploring the experiences of people in similar situations and applying the information to one's own situation.
I look up posts from breast cancer patients in internet everyday. (Participant 2)
I received information from online breast cancer community that there are breast cancer patients who successfully achieve natural pregnancy. (Participant 3)
I remember a long time ago when I was worried about whether pregnancy and childbirth was possible and searched for success stories in online. (Participant 9)
6) Consequences
(1) Early onset of menopause
Participants experienced menopause due to decreased ovarian function resulting from chemotherapy, anti-hor-mone therapy, radiation therapy, and targeted therapy. They experienced joint pain, facial flushing, hot flashes, dry skin, and sexual dysfunction.
My bones make a sound every day and I feel pain. I suddenly feel middle-aged. My skin was too dry, it was hot and then cold, and I couldn’ t control my body temperature well. (Participant 6)
(2) Desperate pregnancy
There were cases where pregnancy was difficult after breast cancer treatment, and pregnancy was successfully achieved through additional In vitro fertilization. After treatment was completed, the desire to become pregnant grew, and sometimes I regretted not choosing embryo or oocyte cryopreservation.
I was diagnosed with a 5-year complete recovery and now preparing to become pregnant. Five years ago, I tried artificial insemination pregnancy using frozen embryos, but it failed. (Participant 11)
Since hormone therapy has led to induced menopause, I now regret not having preserved my eggs earlier. (Participant 3)
3. Process Analysis
The oncofertility process of young women with breast cancer was confirmed to be a process in which the Central phenomenon, Action/Interaction strategies, and Consequences develop sequentially according to Causal, Contextual, and Intervening conditions. The Core category that explains this process is ‘ A journey to restore daily life with inevitable damage to fertility’, which is the process of restructuring one's life and finding stability in life while fighting cancer. This progresses through the crisis stage, life restructuring stage, and daily life recovery stage (Figure 1).
Oncofertility experience in young women with breast cancer.
1) Crisis stage
This is the stage where they are suddenly and unex-pectedly diagnosed with breast cancer at a young age, and while very scared and surprised, they hear the doctor's opinion that a decrease in fertility is anticipated. In particular, if they are single and have no children, patients are rushed to a situation where they are given the only choice: whether to freeze oocytes or embryos. They experience anxiety about the possibility of cancer recurrence, chemotherapy, surgery, and radiation treatment, and fear that they may not be able to become pregnant in the future.
2) Life restructuring stage
After freezing oocytes or embryos to preserve fertility, it is a stage of restructuring one's life while receiving stand-ardized treatment for cancer, including chemotherapy, surgery, radiation therapy, and targeted therapy. They re-structured their way of life to treat cancer and prevent recurrence. This is the stage of bringing about lifestyle changes such as food regimen, exercise and rest, sleep, and stress management, exploring knowledge and experience related to breast cancer, and applying it to one's life.
3) Daily life recovery stage
After medical treatment for breast cancer is completed, it is a time to return to daily life while receiving regular checkups. This is the stage in which a person experiences severe menopause, recognizes that ovarian function has significantly decreased, and makes efforts to restore fertility. They are at the stage of making a pregnancy plan and attempting artificial insemination using frozen embryos. Along with the recovery of physical function, there have been instances of achieving natural pregnancy. The focus gradually shifts from interest in cancer treatment to recovery in everyday life.
DISCUSSION
This study was conducted to explore and understand young women with breast cancer's oncofertility experiences from their perspective. As a result, the core category derived from their experiences was ‘ A journey to restore daily life with inevitable damage to fertility.’ The participants were suddenly diagnosed with breast cancer at a young age and experienced unexpected damage to their fertility. Even after medical treatment is completed, fertility impairment remains unresolved, leading to a long-term process of focusing on pregnancy and childbirth issues and seeking solutions. This study revealed the process of oncofertility experience that was not seen in previous studies. The process is crisis stage, life restructuring stage, and daily life recovery stage.
In the first stage, the crisis stage, they experience the double pain of being diagnosed with cancer and simultaneously facing a future situation where their fertility is damaged. Under time pressure, they must make their own decisions about fertility preservation treatment. In cases where chemotherapy is unavoidable and women are unmarried and childless, embryo or oocyte cryopreservation is usually recommended by doctors. Plans for future pregnancies influenced the choice of fertility preservation treatment. This supports previous research. Factors that influence fertility preservation decisions include age, presence of children, economic power, and the attitudes of people around them [22]. The younger the age, the higher the intention to preserve fertility. Compared to women who were pregnant and gave birth before a cancer diagnosis, childless women were more likely to wish to have a future pregnancy, and their demand for fertility preservation before and after treatment was also high [23].
There were cases of hesitation about fertility preservation when there were expectations about the possibility of natural pregnancy, financial burden, and uncertainty about the success of fertility preservation. Women experience uncertainty when making decisions related to oncofertility. Uncertainty is influenced by values, fertility status, and fertility counseling experience at the time of diagnosis, and affects emotional and cognitive aspects and even coping behavior [14].
When the cancer progressed quickly, such as triple negative cancer, rapid chemotherapy was performed without preserving fertility according to the doctor's recommendation. Also, they have not chosen to preserve fertility if they prioritize their current health over plans for future pregnancies and these are supported by previous research. When treatment was a priority, chemotherapy was ad-ministered as an emergency, and the burden of the cost of fertility preservation procedures was an obstacle to fertility preservation treatment [24].
The central phenomenon in this study was ‘ Choices for an uncertain future’. Experiencing anxiety and fear about cancer treatment and the possibility of future infertility, they opted for fertility preservation treatment as a form of insurance for the future in this uncertain situation.
Although the doctor's recommendation and family's support influenced the choice to preserve fertility, the final decision rests solely on the patient, which made it a difficult choice. This is similar to previous research. Breast cancer patients feel lonely during the decision-making process regarding fertility preservation. It was found that the doctor's provision of information and family support increased certainty and provided a sense of stability to breast cancer patients. However, time constraints, insufficient information, and concerns about the risk of recurrence increase uncertainty for patients [25]. Therefore, medical professionals should easily convey information related to breast cancer patients, such as decreased fertility, cancer treatment process, and the possibility of recurrence, and create an environment that helps patients fully discuss it with their family or spouse.
Breast cancer in Korea has a high incidence of premenopausal cancer [4], so the psychological, physical, and social difficulties associated with the decline in fertility that inevitably occur during the treatment process of breast cancer are greater. In particular, due to the lack of counseling related to fertility decline in the early stages of cancer diagnosis, there were many cases where egg embryo steri-lization could not be chosen without careful decision.
Therefore, in Korea, it is necessary to support young women with breast cancer so that they can assess their needs, provide accurate information related to fertility decline, and have the opportunity to make their own decisions about fertility preservation.
In the second stage, the life restructuring stage, fertility preservation is completed and medical treatments for cancer such as chemotherapy, surgery, radiation therapy, and targeted treatment are received. This is a period of adjusting the lifestyle maintained before cancer diagnosis and concentrating on dietary practices for cancer treatment. To increase immunity, body temperature was kept warm, natural food intake was increased and decided to avoid consuming processed foods. Recognizing obesity as a risk factor for breast cancer recurrence, they focused on exercise to maintain a normal weight and tried to strengthen mind. In particular, young breast cancer patients tended to obtain information about regimens that help preserve fertility and treat cancer through the internet or self-help groups and compare their own experiences. This supports previous research. Sharing fertility preservation information with patients and medical staff through Internet blogs acts as a positive factor in making choices about fertility preservation [26].
In the third stage, the daily life recovery stage, medical treatment has ended but menopausal symptoms are experienced. This is the stage of coping with declining fertility, finding a solution, and returning to daily life. While a decline in fertility was an anticipated issue after cancer treatment, ovarian function remains at the level of 40s, and the ongoing menopausal symptoms have caused anxiety and fear regarding infertility. Previous studies have also shown that breast cancer survivors experience menopausal symptoms such as osteoporosis, vasomotor symptoms such as flushing and hot flashes, vaginal dryness, and sexual dysfunction due to reduced fertility, and are negatively affected in terms of sexual health [27].
Participants either succeeded in becoming pregnant using pre-frozen embryos or failed to conceive and discarded the frozen embryos and prepared for natural pregnancy. In order to become pregnant, they stopped anti-hormone treatment in consultation with doctor and made efforts to become pregnant. In the process, they be-came frustrated and identity as woman was damaged. Previous studies have also reported a decline in quality of life. Breast cancer survivors may experience a decline in their quality of life due to oncofertility, and while the effects may be temporary, they may persist for a long time after treatment. It has been shown that it can last for as long as 15 years after the treatment has completed [6]. In other words, even after cancer treatment is completed, decreased fertility continues to cause stress, depression, anxiety, frustration, regret, and frustration, which negatively affect quality of life.
One participant expressed regret about not choosing to preserve her fertility. Although she was still single and have completed 3-year medical check-up, she regretted that she should have made a more careful decision as pregnancy issues are important when she get married in the future. Breast cancer survivors were frustrated when they did not recognize the decline in fertility right away and found out that their fertility had declined only after some time had passed [28,29]. In previous studies, when appropriate information related to fertility preservation and care including counseling and support were provided, women's stress and regret related to fertility were reduced [7].
In relation to preserving the fertility of cancer survivors, the role of not only oncologists but also nurses and other medical staff is important [9]. In addition to providing education and counseling related to oncofertility, nurses can act as coordinators connecting patients with other medical staff and can play the role of advocates and ensure that cancer survivors maintain a state of well-being [30].
In this way, it was found that the decline in fertility in young women with breast cancer is not limited to simply temporary and physical problems. In particular, physical and psychological problems related to fertility occur not only during treatment but also after treatment and affect quality of life over the long term. Therefore, nurses must provide the nursing care needed by young women with breast cancer from the time of cancer diagnosis to after treatment, taking into account both physical and psychological aspects related to decreased fertility.
The nursing implications of this study are as follows. Aspects of nursing research, this study provided an understanding of the oncofertility experience of young women with breast cancer by describing the experience, social, and psychological processes through a grounded theoretical approach. In terms of nursing practice, this study provided the basis for nursing practice based on the three stages of young women with breast cancer's oncofertility experience and laid the foundation for the development of a nursing intervention. In the aspect of nursing education, this study has educational significance in enabling the ap-plication of theory-based practice to nursing students and nurses by presenting the oncofertility experience of young women with breast cancer. Considering the cultural differences in Korea's higher incidence of premenopausal breast cancer compared to the West, it is necessary to develop a multidisciplinary, collaborative nursing strategy to preserve the fertility of young women with breast cancer and to expand the role of nurses.
CONCLUSION
In this study, as a result of applying the grounded theory method to in-depth explore the oncofertility experience of young women with breast cancer. The core category that explains this process is ‘ A journey to restore daily life with inevitable damage to fertility’, which is the process of restructuring one's life and finding stability in life while fighting cancer. This progresses through the crisis stage, life restructuring stage, and daily life recovery stage.
The implications of this study are as follows. First, this study provided a basis for describing and understanding the rapidly increasing oncofertility experience of young women with breast cancer from the participants’ perspective.
Second, this study derived the process of young women with breast cancer's experience of oncofertility, which was not revealed in existing research.
Third, it provided basic data for the development of a nursing intervention program that can help young women with breast cancer who experience decreased fertility.
This study suggests the development of an intervention program aimed at addressing the difficulties faced by young women with breast cancer in their oncofertility experiences and supporting their coping strategies. Nurses should be interested in oncofertility and development of nursing strategies based on multidisciplinary collaboration to help preserve fertility in young women with breast cancer is necessary.
CONFLICTS OF INTEREST
The authors declared no conflict of interest.
AUTHORSHIP
Study conception and design acquisition - Park J and Kim A; Data collection - Park J and Kim A;; Data analysis & Interpretation - Park J and Kim A;; Drafting & Revision of the manuscript - Park J and Kim A.
DATA AVAILABILITY
The data that support the findings of this study are available from the corresponding author upon reasonable request.