A total of 14 patients with cancer who were aware of their diagnosis participated in this study including 8 females and 6 males. Their age was between 30 and 75 years; all of them were married with education level from illiterate to bachelor degree. The time past from their diagnosis was 3 to 24 months and they had different jobs including housewife, storekeeper, worker, farmer, and governmental employee.
During the process of analyzing the data, a total of 10 themes were extracted including: 1- getting shocked, 2- fear, 3- anxiety and stress, 4- hopelessness, 5- guilt, 6- depression, 7- isolation and withdrawal, 8- feeling of lack of affection, 9- preparing for death and, 10- renewed relationship with God.
1) Getting Shocked
One of the reactions that most people had when hearing the diagnosis of cancer was shock. Many patients were shocked after finding out about their cancer; it was so hard for them to believe that they have cancer, and some denied their disease. This state was deeper for people who were diagnosed at an early age, because they did not expect to get cancer. Also, this state was more severe for the patients who were informed suddenly by the physician than those informed by their family and relatives indirectly. In some patients, the shock was associated with severe psychological reactions; some people said that they were going mad when they heard that they have cancer. Usually, severe reactions happened immediately after diagnosis.
One patient said: “I was shocked when the doctor told me I have cancer; I thought, Oh my God, what?! … I could not believe I had cancer“.
Another patient said: “When the doctor told me I have cancer, I was confused and stunned; I thought the world has collapsed on my head”.
Fear was one of the feelings expressed by patients in this study. In the minds of many participants, cancer was considered a terrible and scary disease. Fear of cancer was seen more in patients who thought cancer is the end of their life as well as in those who had the experience of a relative dying of cancer, or among those who believed that cancer has no treatment and cancer is equal to death. Some patients felt that they were helpless against this disease and it will eventually kill them; this led to more fear in patients. Fear of cancer was so severe that even some of the patients said they were even afraid of the word “cancer”. This psychological state was more frequently seen in the early phases of the disease.
In this regard, one of the patients said: “Even the word cancer is frightening; let alone someone telling you that you have cancer. I remember when I got home that night I could not sleep until morning; and I was constantly crying. It was terrible.”
Also, most patients were afraid of treatment, because of the side effects of chemotherapy, such as pain, severe nausea, and changes in their appearance. This type of fear was generally seen during the course of treatment, making the treatment difficult to tolerate so that some patients did not want to continue therapy and mentioned that if their relatives did not insist, they would abandon treatment. The participants stated that their spouse and relative’s support and communication with other patients who experienced similar surgeries and chemotherapy helped them reduce their fear of cancer.
A patient said: “When I went to start chemotherapy, I was afraid. Before the injection of drugs, when I saw them in the hands of the nurses, I was shaking with fear”.
Another patient said: “When I started the first session of chemotherapy, in the same room I was admitted to, a patient died after half an hour chemotherapy. Since then, I was really afraid. I lost heart.”
Another patient said: “For a long time, whenever I passed in front of the hospital, I felt bad”.
3) Anxiety and Stress
Anxiety and stress were other feelings mentioned by the patients, either directly or indirectly. One of the main reasons that caused this condition in patients was finding out about the malignancy of their disease, worrying about the future of their children, concerns about the high cost of treatment, doubts about the effectiveness of treatment, concern about the lack of an oncologist close to their city and the unavailability of drugs. All of these factors led to discomfort and exacerbated stress and anxiety among patients and worsened the patients’ performance. Since the patients thought that they will soon die of cancer, they became extremely worried about the future of their spouse and children and this led to anxiety and stress in patients. Many patients complained of the high cost of treatment and the unavailability of drugs. The difficulties in finding chemotherapy medicine and paying the high cost of treatment were important parts of their concerns.
One patient said: “I was very anxious and I was mostly worried about my children. I was worried about what would they do, if I did not get better.”
Also, chemotherapy and its side effects were one of the very important reasons for stress among patients in this study. Inquiring knowledge about the disease and its therapeutic dimensions was one of the very important factors in reducing stress and anxiety in patients that made them tolerate the treatment better.
Feeling guilty was another topic mentioned by participants. Some people felt guilty and believed that their disease was the result of their sins; therefore, they blamed themselves for getting cancer and were looking for its reason. Even, some patients considered other people’s curse as the reason of their cancer and thought that the reason for getting cancer was their own deeds. Therefore, many patients felt guilty. This feeling usually happened in the early phases of diagnosis and caused a psychological crisis.
One patient said: “… I thought about all sorts of things. I thought what have I done to deserve getting cancer in this age?”
Another participant said: “I had no problem. I had no disease. One day, I argued with my maid; I was angry. I slept that night and in the morning I saw my breast was swollen. After a while the doctor diagnosed that it was cancer. I always think I broke that maid’s heart and … I got this problem”.
Another feeling mentioned by the participants in this study was hopelessness. In this study, losing hope in life after hearing the diagnosis was mentioned by the majority of patients and most patients mistakenly believed that cancer has no cure and they have no opportunity to live. They imagined an uncertain future for themselves and felt hopeless. This feeling made some patients not seek treatment, because they were hopeless about treatment. Fear of inevitable death was one of the main reasons for the patients’ hopelessness. Participants reported all types of hopeless behavior, such as failing to do their job and live their normal life, lack of enjoying their life, low self-esteem, and depression. Due to long term treatment for cancer and hopelessness, they had a sad mood and were not able to have fun and enjoy their life. This situation mainly occurred at the beginning of treatment and caused the patient to feel hopeless and worried about the future.
One patient said: “When I heard I had cancer, it was as if life came to an end for me; I was really hopeless ... I just thought about my illness, … thinking about the disease bothered me, I was totally messed up, and life turned into hell for me and my family”.
The disease and its treatment complications caused different psychological effects among patients. Patients stated feelings such as boredom, lethargy and fatigue, insomnia, anorexia, and demoralization, which are the signs of depression. Some patients had thoughts about death and afterlife that caused more grief. Most of the participants complained about insomnia and nagging thoughts about their disease. Depression usually showed itself during treatment in cancer patients.
One patient said: “I felt so bad and depressed that the drugs had no effect on me up to 4 chemotherapy sessions. The doctors said if you continue to be like this, you won’t survive. You must be strong. Many people had the same disease and now they are cured and are living their lives.”
7) Isolation and Withdrawal
Isolation and withdrawal was one of the other feelings experience by patients. Due to treatment-related side effects such as hair loss, severe weight loss, and physical impairment, the patients felt that they had lost their beauty. This created a sense of inferiority and they tried to stay away from people and hide themselves. Some patients stated that they wore full clothing even at home, so their husband and children would not see them in that condition and they tried to appear less in public. Most participants stated disruptions in their relationship with others and had lack of interest to be seen in public or participate in events. This feeling was usually resolved over time and by support from their family. Most patients who had this condition talked about the effect of their family and spouse’s support to overcome this big problem. This feeling usually appeared after treatment side effects appeared in patients.
A patient said: “I always tried to be alone. I used to go home and cry when taking a shower so that no one would notice or become sad. I had lost all of my hair. I was frightened of myself. I did not want anyone to come to visit me. I wanted to be alone… I hated people… I felt nauseous when they came along … I always slept alone during this time… It was really hard for me”.
Another patient said: “After a while I lost my hair, I became very thin, I looked terrible. I tried not to go out, so that no one could see me. I became very ugly. When my children looked at me… I have two little children; they were frightened and asked what happened to you.... I was so thin that no pants fitted me. Once I took a bath, I asked my wife to come and scrub me and she was afraid. She said where should I scrub? It’s all bones…”
8) Feeling a Lack of Affection
Some patients mentioned that changes had occurred in their emotional state and they felt more dependent on their family and they also felt a lack of affection. This dependency was sometimes so much that even made their families feel worried. Some people wanted all their children to be around them and said they became very tender-hearted and felt an emotional vacuum. This feeling usually happened due to losing their self-esteem during treatment. Also, some patients had become sensitive and paranoid to other people’s behavior. This led to the misunderstandings about other people’s behavior; in many cases they became disappointed of other people’s behavior without reason. This was annoying both for the patients and those around them.
A patient said: “I needed affection; it was as if I lacked affection. I wanted everyone to be kind to me.”
Another patient said: “I became very attached to my family. I wanted them all to be near me. I felt bad when I could not see them even for one day.”
Another patient said: “Everyone was saying she will die. Even my aunt brought me a grave cloth (shroud) from Karbala. However, she didn’t say it to me herself … my husband said she has brought you a shroud. I was very sad when I heard this [the patient said this while crying] ... I told myself that my disease must be very dangerous that they have bought me a shroud, the doctor has certainly told them something, but they do not tell me”.
9) Preparing for Death
Some patients had thoughts about dying, for example, “How will I die? What happens to my family after my death? …”. These negative thoughts had occupied all of their time.
Acts like solitude with God, asking for forgiveness from family, and facing the Qiblah at bedtime showed that patients thought they have become very close to death, and they were preparing themselves for death.
10) Renewed Relationship with God
This study showed that finding out about cancer causes severe psychological crisis and confusion in patients at the beginning, but over time people accept this situation and try to return to normal life. Trust in God and seeking his help and thinking about the disease as a divine test, were among the most important thoughts and feelings mentioned in connection with accepting the disease and gaining hope among patients. Patients with stronger religious beliefs who believed that their fate is in the hand of God accepted their illness sooner and gained hope sooner. Many people, after their improvement, tried to enjoy their lives and felt happy that God had given them a second chance. This feeling usually occurred in the late stages of treatment and strengthened the patients’ spirit and helped them return back to their life.
A patient said: “Now I look at the world differently… You should never give up on God… God always takes care of his people… so why should we get disappointed?”
Another patient said: “After this happened, my life changed… I became more connected with God… I strongly feel that he is the only one that I can ask for help… when I pray I calm down… I feel peace. I used to pray before, but now I feel it with my whole heart.”