1. Design

A systematic review of literature and qualitative meta-synthesis proposed by Sandelowki & Barroso[7] were used in the study.

2. Systematic Search and Screening

The literature was systemically searched from year 2000 to 2014 using five English-based search engines, i.e., CINAHL, PubMed, ProQuest Nursing, ProQuest Med, and Scopus, and four Korean's, i.e., DBPia, KISS (Korean Studies Information Service System), Korea Med, and RISS. The search terms used were “cancer,” “qualitative research/study,” “Korean,” and “woman/women.” Two terms among four in turn were searched and then the duplicates were excluded. Major nursing journals in Korea including Journal of Korean Association of Nursing, Korean Journal of Adult Nursing, and Korean Journal of Women Health Nursing, to name a few, were also searched using same keywords.

Study inclusion criteria were as follows: 1) research design: original qualitative research, 2) participants: Korean women who live in South Korea, 3) topic: the experiences of various aspects along the cancer continuum, 4) language: English or Korean. The studies on Korean American women who live in U.S. were excluded since the different cultural environment and the identity as Korean immigrants might influence the qualitative study findings. The qualitative studies on both genders, for example, the experiences of couples with breast cancer (5) or the experiences of living world of cancer patients (9), were included in the initial search, but excluded for the final meta-synthesis. The exclusion was decided after the appraisal of the studies, because the voices (text scripts) of women could not be differentiated from men's.

The initially searched list of the articles was examined by title and abstract and the articles who failed to meet the inclusion criteria were excluded. After the remained articles were reviewed in full-text to ensure the contents, the studies which perfectly met the inclusion criteria were selected for final meta-synthesis.

3. Search Outcome and Data Extraction

The systematic search and article selection process were done in four phases (Figure 1). Initial literature search using 9 different search engines produced the list with over twelve hundreds of articles. After reviewing them by title and abstract, 180 studies were selected which were representing qualitative studies about cancer experiences among Koreans. With a full-text reading, 142 studies were excluded either because the participants were Korean Americans or the studies did not recruit women exclusively. The selected 38 studies were reread considering the study phenomena and research quality, ending up excluding 17 studies, in which the findings of research did not describe women's experiences along the cancer continuum substantively. As a result, a total of 21 studies was selected finally for metasynthesis (Appendix).

Figure 1 Flowchart of the search process. Click for larger image

The details of 21 studies were summarized in a table for data extraction (Table 1). Two studies were written in English[a4,a7] and the rest were Koreans. The two thirds of studies were published in nursing journals, the rest in other disciplines, such as social work or women's studies. The selected studies represented a total of 253 Korean women with cancer. Fifteen studies exclusively targeted women with breast cancer, while one study was on thyroid cancer, and one on cervical cancer. Nine out of 21 studies used phenomenological methods, six grounded theory, five thematic analyses, and one triangulation. All studies recruited their participants using a convenient sampling method. Individual interviews were conducted predominantly in most of the studies, whereas focus group interviews were used only in two studies.

Table 1 Summary of the Included Studies Click for larger image

4. Meta-synthesis

With the garnered 21 studies, three steps of data extraction, aggregation, and synthesis were conducted[7]. First, each study was read carefully in full-text for understanding of epistemological standpoints of original authors[8]. The first-level construct, including original authors' intention, language, methodology, and the findings were maximally taken into account for extracting meaning units. Second, the decontextualization and deconstruction of the concepts and meaning units were followed. Then, the concepts and meaning units were aggregated into new categories. Relating and regrouping the concepts cross the categories were carried out for elicit a second-level construct[10]. In the final synthesis phase, the aggregated meanings, concepts, and categories were reconstructed through hermeneutic appraisal and interpretation. This abstraction is differentiated from a thematic analysis due to the essence of an interpretive reconstruction of the relationships between the concepts[8, 11].

1. Spaced out from the Usualness

Korean women who were diagnosed with cancer and underwent its treatments addressed in the original interviews that ‘cancer took them apart and spaced them out from their usual life.’ From the moment of diagnosis, ‘an unforeseen journey with cancer’ began without any bargain with them. The diagnosis of cancer was perceived either as ‘a punishment for their wrong-doing or an unfortunate fate’ to the women in the given studies. Being diagnosed with cancer implied not only that they were no longer ensured to ordinary and healthy life, but also they no longer belonged to the majority group that healthy people belonged to. Such thought of inferiority and a sense of shame consistently intruded upon their emotional tranquility.

The emotional burden of having a diagnosis of cancer was rather easy to endure than the actual suffering from cancer treatments. Serial cancer treatments gradually deteriorated the women's everyday routines, relationships, and even their mind and body. The women's day to day was fully scheduled with ‘never-ending hospital appointments.’ Their routines were ‘withheld from the moment of cancer diagnosis.’ The women were no longer able to fulfill their culturally-expected roles of mother and a wife, with which they once identified themselves. The roles in the family were pushed to be changed irresistibly. The fact that they were ‘unable to fulfill the role of mother’ broke the women's heart. Emotionally and sexually unsatisfied relationships with husband situated the women facing ‘a marital crisis’ with different levels, which they never thought they might encounter.

The women's mind and body were no longer like as they used to be. ‘Emotional turmoil,’ ‘the feeling of being on edge,’ ‘chemo-brain’(forgetfulness and malfunction), and ‘consistently intruding bad thoughts’ made the women feel like standing on the edge of a cliff by oneself. In most women, their body was unable to abide by striking symptoms induced by cancer treatment. To sum up, a cancer diagnosis and its treatment experiences dismantled the women's usualness, i.e., their usual life, usual mother and a wife role, and even their usual mind and body, and pushed the women to feel spaced out from their routineness.

2. Mindfulness on Profound Desires

Nonetheless the women wanted to avoid it if they could, they had to inevitably suffer from cancer diagnosis and its treatment. The painful suffering they had was felt like that ‘they were walking through an inflamed tunnel’ in a tough life. As a result, unnecessary, small things, and superficial relationships were taken apart. Evidently dismantled relationships involved marital relationships and social get-togethers.

On the contrary, the women become aware of their apparent, even reinforced innate desires. After they got ‘a sense of mortality at cancer diagnosis,’ they realized their ‘strong desire for life.’ ‘Every moment with a breath became meaningful,’ and the routines in each day were felt renewed. They confessed that they would take any troubles for the cost of life. Moreover, the women viewed ‘their inner self of longing for feminine beauty’ with different levels. Experiencing serious harm on the women's beauty such as breast deformation, surgical scars, hair loss, and darkened skin due to medical treatment shook them enough emotionally and psychologically. Motivations for actions, information seeking, or get-togethers were rooted on the desire for recovering their feminine beauty.

Unlike the marital relations, the maternal affection of being a mother is never weakened. With the diagnosis and even with the recurrence of cancer, the women denied their mothering role to be burdensome. Rather, fulfilling her role as a mother in the family has ‘a priority over anything.’ As they become aware of their physical limitations and mortality, they ‘lowered their expectation on their children's achievement’ as well. In sum, the women, who went through the hurdle of cancer treatment, became more mindful on their profound desires for life, beauty, and motherhood.

3. Redefinition of Every Relation

Despite cancer treatments were completed and the women came back to their routines, their lives had been changed so much from what they used to be. The women obtained ‘better insights into their own identity’ apart from traditional women-should-be. After the women ‘saw their bottommost limitation’ in terms of physical, emotional, and social stances, they were then aware of their profound desires. Those changes made them to redefine all relations surrounded them.

The relationships between the women and their family members were redefined. Some ensured the marital affection, while the other faced severe cracks in their marital life. The women reconfirmed ‘their duty of being a mother,’ which made them even stronger. They ‘rearranged their social relationships’ no longer spending time on superficial relationships, instead, having new relationships such as survivors' group or religious meetings.

The women's relations with environment for a healthy lifestyle were redefined as well. The women tried to ‘make harmonious relations with others, foods, and the environment’ as much as possible. They pursued a healthier lifestyle by eating fresh food, doing physical exercise, maintaining proper body weight, and managing everyday stresses. In sum, the women took the advantage of illness experience for rearranging their relations with surrounded world.