id 26436

RESEARCH ARTICLES

 

Feelings and sources of emotional support for women in pre-operative mastectomy in a teaching hospital

 

Karla Tamyres Santos do NascimentoI; Leila de Cássia Tavares da FonsêcaII; Smalyanna Sgren da Costa AndradeIII; Kamila Nethielly Souza LeiteIV; Tatiana Ferreira da CostaV; Simone Helena dos Santos OliveiraVI

I Nurse. Graduated from the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: karlatamyres_560@hotmail.com
II Nurse. PhD student at the Graduate Nursing Program from the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: leilafonsecarr@hotmail.com
III Nurse. PhD student at the Graduate Nursing Program from the Federal University of Paraíba. Member of the Research Group on Chronic Diseases. João Pessoa, Paraíba, Brazil. E-mail: nana_sgren@hotmail.com
IV Nurse. Master of the Nursing Graduate Program, Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: ka_mila.n@hotmail.com
V Nurse. PhD student by the Graduate Nursing Program at the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. E-mail: tatxianaferreira@hotmail.com
VI Nurse. PhD in the Graduate Nursing Program and Teacher at the Technical School of Health of the Federal University of Paraíba. Leader of the Research Group on Chronic Diseases João Pessoa, Paraíba, Brazil. E-mail: simonehso@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.15598

 

 


ABSTRACT

The study aimed at identifying feelings in face of the diagnosis of cancer and mastectomy as well as sources of emotional support. Descriptive and field study with qualitative approach, conducted with seven women patients at the Surgical Clinic of a reference Teaching Hospital in the city of João Pessoa, Paraíba, Brazil, from February to May, 2011. For data analysis the technique of collective subject discourse was used. Central ideas generated were as follows: Feelings of helplessness; State of tranquility; Foster care; Spiritual comfort and trust in the treatment / cure; Surgery-related stress. In conclusion, in view of the diagnosis of cancer, the woman has many negative feelings such as worry, fear, and sadness, requiring viable strategies to help her cope with cancer and mastectomy.

Keywords: Emotions, breast neoplasm; preoperative care; women's health.


 

 

INTRODUCTION

Breast cancer is a serious problem and accounts for a significant number of deaths among adult women. It is the second most frequent type of cancer in the world, besides being the most common among the female sex. In Brazil, every year, approximately 22% of the new cases of cancer in women are breast cancers, and among the states with the highest incidence, Paraíba is the seventh in the ranking of the highest rates for this type of cancer in the country1.

In 2012, 52,680 new cases of breast cancer were expected in Brazil, with an estimated risk of 52 cases per 100,000 women. In the state of Paraíba, the estimated gross incidence rate for 2012 for malignant breast cancer was 32.41 cases per 100,000 inhabitants. In João Pessoa-PB, this index almost doubled, 63.33/100 thousand inhabitants, a rate higher than the national average2.

In this context, when the diagnosis of cancer brings the need to perform mastectomy, there are serious psychological consequences, due to the importance of the breast for women, seen as a symbol of feminization1. Thus, negative effects of cancer, such as fear of rejection, stigma, mutilation, relapse and death, should be considered as one of the implications of the treatment3.

The motivation for the present study arose from the practices of internship in the surgical block of a teaching hospital in the municipality of João Pessoa-PB where a high number of surgeries related to breast cancer were perceived. Thus, the End-of-Course Paper prepared was entitled:Feelings of women who will undergo mastectomy in a teaching hospital in João Pessoa, with the purpose of paying special attention to the emotional impact caused by the preoperative preparation for mastectomy revealing the feelings and sources of support needed to cope with the disease.

Given this context, the study emerged from the following question: What are the feelings experienced by women in the preoperative period of mastectomy? What are the sources of emotional support sought after the diagnosis? To answer these questions, the study aimed to identify the feelings about the diagnosis of cancer and mastectomy and the sources of emotional support.

 

LITERATURE REVIEW

Breasts are an important component of body aesthetics; the presence of cancer entails the meaning of mutilation and implies a physical and psychological effect, depreciating the symbol of femininity that is a source of pride for women and admiration for men. Thus, the word cancer brings negative emotions and feelings in the course of the illness/treatment process, leading to a low appreciation of the emotional aspect to the detriment of the anatomical aspect of the women, due to the greater visibility of the disease in relation to physical mutilation3,4.

However, the causal act of the psychological problem will be generated by the physical loss, that is, the loss of the breast leading to mental suffering, since the body and mind are interconnected and there is no separation of these parts in the process of adopting significant changes in the lifestyle of women with this type of cancer4.

Study performed with women with mastectomy stands out what,

the female body is fragmented in its symbols (breast, vagina), in what differentiates it from the male body. At the same time, these symbols 'encircle' their identity as a person in the appreciation of what defines her as a woman, especially in our society where there is the celebration of the perfect and erotic female body5:60.

Thus, the period preceding the confirmation of diagnosis of breast cancer and the initiation of treatment carries sensations related to the psychological suffering that affect the universe of relations of the affected women, leading to an approximation or distancing from those who are around them. We believe that the capacity of resilience is intrinsic to the human being and is influenced by the feelings experienced and the sources of emotional support at the time of the negative experience, which will help them to overcome the stigmatizing and traumatic barrier caused by the absence of a body part.

Mastectomy breaks the unity of the female body into parts, and it is necessary to rethink it as the same and a new body, in the sense of enabling the improvement of relations with others5. Therefore, the health team should be prepared to listen and counsel, especially with regard to breast loss, psychological repercussions and a renewed relationship with the partner and with family members7.

 

METHODOLOGY

This is a descriptive field study with a qualitative approach performed at the Surgical Clinic of a referral teaching hospital in the State of Paraíba, located in the city of João Pessoa - PB.

The study included seven women admitted to the institution and submitted to mastectomy, according to the following inclusion criteria: client hospitalized in the preoperative surgical clinic during the period of data collection; absence of cognitive limitation; age equal to or over 18 years; presence of conclusive diagnosis of breast cancer; agreement to participate in the research by signing the Informed Consent term.

In order to carry out the research, the criteria established in Resolution 196/96 were obeyed and the project was approved by the Research Ethics Committee (REC) of the Lauro Wanderley University Hospital (LWUH), by means of certificate nº 751/10, 385538, CAAE No. 0578.0.126.000-10. It should be pointed out that during the data collection the participants were given guidelines regarding the purpose of the research, as we as they were assured of the guarantee of secrecy, possibility to withdraw, and they read the Free and Informed Consent Form, in compliance with the requirements of Resolution 196/96 of the National Council of Health, which disposes norms and directives regulating research involving human beings8.

Semi-structured interviews were the technique used to collect data, with the help of an Mp4 recorder. Interviews were held from February to May 2011. The approach was for convenience, that is, all the women who were in preoperative period of mastectomy at the surgical clinic were invited to participate. The instrument covered objective questions for sociodemographic characterization of women and the following subjective questions: What were your feelings when you received the news of the diagnosis of breast cancer? How do you feel about going through the surgical procedure? Where did you seek emotional support after the diagnosis?

The technique of Discourse of the Collective Subject (DCS) was used to analyze the data. This proposal consists in the analysis of the verbal material collected, extracting from the testimonies the central ideas and/or anchorages and their corresponding key expressions.

In this way, the DCS aims to give birth to the group of significant individualities that are part of the social imaginary. It is a discourse conceived in the first person singular from the speeches that are repeated, being able to suppress the exaggeration of repetitions throughout the construction, so as to give coherence to the final discourse. It is a technique of organizing discursive data that makes it possible to rescue the understanding of a given phenomenon in a given universe9.

To preserve the anonymity of the research participants, they were identified by the letter W (Woman) and listed in sequential order (W1, W2).

This proposal of speech condensation allowed us to impose a better coherence in the discourse, being adopted for all the central ideas presented in this study. The synthesis of the speeches avoided the exaggeration of the reproductions, which made the speech tiresome and hard to read. Thus, we opted for single sentences that demonstrated the value of all utterances of the same meaning, without losing the original content.

 

RESULTS AND DISCUSSION

Most of women were aged over 50, married, had incomplete primary education and a family income of up to one minimum wage. There are several risk factors that increase the likelihood of a woman developing breast cancer, including age10. In fact, the highest rates of this type of cancer are concentrated in ages above 50. This neoplasm carries with it an also increasing mortality rate in the country11.

There is evidence that women of advanced age do not undergo mammography, which could detect the cancer early and decrease its incidence. Such reality is associated with cultural factors and beliefs socially linked to aging, such as those on self-care related to the reproductive system, up to the existence of a conjugal relationships, and reproductive capacity. Another relevant factor to the development of the pathology is the lack of knowledge about the risks and possibilities of coping with cancer12.

Married women predominated in the group participating in the study. Research shows that for married women, the presence of a companion can help in the confrontation of the disease with respect to complicity and support in face of the new reality and in the decisive behavior in the search for health care13. Regarding family income, preventive breast cancer behaviors are related to better socioeconomic and educational levels, which are associated with higher prevalence of preventive practices as a result of opportunities to access information, leading to early diagnoses that may interrupt the course of the disease in its early stages14.

From data set related to the study questions, the analysis of the answers to the questions presented resulted in the identification of the following central ideas: Feelings of consternation; State of tranquility; Tension related to the surgery; Family shelter; Spiritual comfort and faith in treatment/healing.

The discourse of the collective subject set out below reveals the central ideas about the feelings experienced by the clients in the process of discovering the disease from the question: What were your feelings when you received the news of the diagnosis of breast cancer?

Feelings of consternation

We get a little apprehensive, nervous (W1, W2, W5, W6), desperate and worried (W3, W4, W7). I was afraid, me with a disease that has no cure, it is something that only causes sadness (W1, W3, W4), but I resigned. (W2, W5)

State of tranquility

I did not get upset (W1, W3, W6), I did not cry, I did not lose my sleep any time and I did not worry at all. I was just fine. (W2, W4, W5)

The removal of the breasts causes new perceptions of one's own body image. In this study, the women experienced feelings related to the diagnosis such as concern, nervousness, fear and sadness. These feelings are considered to be part of the female reaction to a surgical procedure that will cause changes in several aspects, bearing in mind that the breasts represent a symbol of femininity, sexuality, aesthetics and motherhood.

Research on the knowledge and expectations of women in the preoperative period of mastectomy identified that feelings of shame, rejection and inferiority are common during the process of removal of breasts and may threaten gender identity and resilience3. Concern, nervousness and fear are present in any individual in unknown situations and bring the idea of ​​danger to health. In turn, sadness was an inherent feeling for women to express their feeling of displeasure before this difficult situation to be circumvented, and for which they believe there is no immediate solution.

On the other hand, it can be considered that the indifference or the state of tranquility was a response of denial on the part of the women to the surgical process and illness. In this case, some women preferred to show detachment from the mastectomy and the disease, shunning the impression that these might pose a life threat. Perhaps, the demonstration of tranquility was a strategy of escape from forthcoming reality or a way of expressing that affliction would not bring any benefit to the new condition or could be a reflection of the state of resilience.

Thus, the expected body modifications that will take place after the surgical procedure lead to changes in the emotional state of the women affected by breast cancer. Nonetheless, psychosocial changes can subsist when there is a real confrontation with the mutilation in the place of what was once only symbolic, since dealing with breast-related body changes is very difficult for women. They need effective and resolutive emotional support to build up their self-esteem. Research on social representations of mastectomies of women showed that feeling calm had positive implications for self-care and repercussions on the adaptation to the new body, reestablishing the identity15.

As the nursing team is more often present and acting integrally in the care of patients, this should seek to establish a bond with mastectomy patients to make them more comfortable and thus promote a greater capacity to overcome this stage of life. The way of speaking, the touch, the clarifications and the willingness to help are factors that contribute to establishing a harmonious relationship and consequently foster the confidence and respect toward these women, soothing their fears and anguishes. Therefore, humanized teamwork makes the process of patient adaptation easier.

In relation to the mastectomy, the central idea was generated from the following question: How do you feel about going through the surgical procedure?

Tension related to the surgery

I am prepared, but I am tense (M2, M7), I am nervous and apprehensive with cold hands and dry throat (W3, W4, W5, W6). Anyway, I am feeling apprehension, tension and nervousness. (W1, W4, W6)

In this study, the women reported stress related to the surgery with a description of symptoms that characterized this reaction, although the discourse showed the feeling of preparation before the procedure. The nervousness related to the fear of the unknown is considered normal, since these women had never experienced similar moments in life, having to undergo a procedure, which despite all the preoperative guidance, undermines the psychological structure of the person, embodying emotions never experienced before.

Tension can interfere negatively in dealing with new situations, especially at adverse times of life with respect of self-image. Diagnosis of breast cancer and mutilation sometimes cause shock, turning the experience into something painful from the psychological point of view. It is believed that the sensation of modification of the body image can provoke feelings of sadness and panic, justifying the discourse of women.

From this perspective, a study of anxiety in the preoperative period of breast surgeries stated that tension could be associated with concern about lesions that may occur during the surgical procedure, fear of postoperative pain, separation from family, loss of independence, fear of becoming disabled, or of never waking up from surgery, and fear of waking up in the middle of the surgical procedure or fear of complications3.

Moreover, the process of becoming ill demands self-organization due to the disorder caused by the impact of removal of the breast, giving a specific meaning to the existence of this woman in a context that is not only individual, but involves other lives, that is, the lives of the family members who are present throughout the illness16.

Feeling anxious or tense is part of the woman's response to stressing stimuli, which in this case is the surgical procedure. In turn, feeling prepared involves family and religious support, pre-operative guidance, confidence that everything will work out, and possibly the confidence conveyed by the multi-professional team. In this way, minimizing negative feelings should be a goal of health professionals, in order to overcome the repercussions of cancer on the patient's well-being.

The following are the central ideas regarding the search for emotional support by women in this new reality, obtained as response to the question: Where did you seek emotional support after the diagnosis?

Family Shelter

Everyone gave me strength to face what is happening, the strength of my family was also very good, they helped me a lot (W3, W5, W6).

My family, my children, everyone strengthened me (W1, W5, W7). My son is very good, caring and understanding, he gives me strength, he is everything (W1, W2, W4)

Spiritual comfort and faith in treatment/healing

Since the moment I learned that I had to go through the surgery, I'm prepared for what God wants (W3, W5, W7). It is in the hands of God, for everything that comes, with faith in that one up there (W1, W2, W4). With faith in God, I am prepared to perform the surgery. God is the one who will guide me, will take care of me (W2, W3, W6).

Regarding emotional support, women cited family shelter and spiritual comfort and faith in treatment/healing as important aspects for coping with the disease after receiving the diagnosis. We perceived in the discourses how important is the presence of the family and a belief in a higher being as sources of psychosocial and spiritual support in the preoperative moment. These discourses pass the message that women have derived intense encouragement to face the cancer from the sense of strength and comfort on the part of their family and trust and faith in God to accept the condition of illness and the future treatment.

It is important to mention that people who live with women suffering from breast cancer perceive during the process that the presence of the family is essential to the improvement of her emotional state. This study demonstrates that this presence constitutes an empathic approach, attentive to the patient's needs and limitations, since many feelings brought about by breast cancer depend on how they will be seen and embraced by relatives, friends15 and health professionals capable of providing strategies for more effective interventions to the therapeutic teams involved with them17.

In addition, authors have shown that family affection leads to better emotional stability and is a point of support in the fight against the disease, because women will have a relative acceptance of the diagnosis18,19 and they may receive more affection, care and attention at this so delicate moment20.

Regarding the professionals of the area, the research identified that the mastectomy patients expect from the health team, especially the nurses, a broad vision regarding their pathological state, using care techniques in a gentle way and providing clear and individualized guidelines regarding post-surgical self-care20.

Therefore, the present study is in line with the above cited studies when it finds that family support is essential during the confrontation of the disease and during the physical and psychological repercussions to victims of mastectomy.

Added to this is the difficulty in fighting against cancer in view of the need for a treatment that is sometimes exhausting and involves the loss of the breasts, leading the women to a void in their physical completeness. Stigma can be harmful when accompanied by prejudice and blame; however, reluctance in these cases is a preponderant factor to carry on life and not to fall in the abyss of sadness caused by the mutilation.

The diagnosis of breast cancer causes an important psychological impact and triggers experiences of surprise, tension, acceptance, strength and search for religiosity20. Regarding spirituality, a study reveals that the understanding of the net of religious meanings is necessary to establish trust in the certainty of healing, promoting the deconstruction of situations that generate negative feelings and allow more courage to deal with the disease as something controllable. Devotion assists in dealing with situations of distress, depression and fear, which, in turn, provides support, protection, hope and faith4.

Researchers have pointed out that individuals tend to seek answers to the events of their lives from a higher and divine being. Religiosity and the belief in something majestic and inexplicable that transcends matter strengthens the power of shelter and comfort in times of difficulty and is consolidated as a source of healing19. Moreover, studies have pointed to health professionals, especially nursing professionals, as an integral part of the coping system in the cases of cancer, in this painful phase of life21-23.

The important thing about the support network is the perception of all about the indivisibility of the biological, psychosocial and spiritual aspects of the human being, being the religious beliefs and the trust in a greater being, as well as the presence of relatives and close people, powerful factors to trigger the adaptation to unexpected and negative changes. Allied to this, there must be sensitivity on the part of health professionals in the intention of favoring the search for self-knowledge by the victimized women who face such a difficult situation and that will imply in impact in different individual and collective aspects.

 

CONCLUSION

The central ideas projected were feelings of consternation, state of tranquility, tension related to the surgery, family shelter, spiritual comfort, and faith in treatment/healing. Many biological modifications are generated by breast cancer, and yet there is an unalterable link between the physical, mental and spiritual elements. This fusion endows the human being with subjectivity and specific things that characterize the response of each one to the situations of illness.

Every multiprofessional team should seek viable strategies such as health education and humanized practices to encourage family and spiritual support. This may favor the coping with cancer and mastectomy, in order to reduce the impact of negative feelings and increase the sense of preparation for mastectomy. The support from an interactive network that involves professionals, family members and religious entities is essential for a humanized care practice. In this sense, the role of nurses, as strong agents of health education and enhancers of self-care, stands out.

The limitation of the study was the investigation of feelings regarding the preoperative situation only. The inclusion of women in the post-operative period attending primary, secondary and supportive organizations could further enrich the research. The need for further studies focused on the subject of mastectomy and its psychosocial repercussions is evident, with a view to the planning of qualified interventions that favor the successful coping with this challenge.

 

REFERENCES

1. Ministry of Health (Br). National Cancer Institute. Estimate 2010 - Incidence of Cancer in Brazil. Rio de Janeiro: MS/INCA; 2009.

2. Ministry of Health (Br). [website] National Cancer Institute. Breast cancer. Rio de Janeiro: MS/INCA, 2011. [cited in 05 Feb. 2014]. Available at: http://www.inca.gov.br/conteudo_view.asp?ID=336

3. Alves PC, Silva APS, Santos MCL, Fernandes AFC. Knowledge and expectations of women in the preoperative mastectomy. Rev Esc Enferm USP. [SciELO-Scientific Electronic Library Online] 2010 [cited in 05 Feb 2014]. 44: 989-995. Available at: http://www.scielo.br/pdf/reeusp/v44n4/en_19.pdf

4. Moura FMJSP, Silva MG, Oliveira SC, Moura LJSP. The feelings of post-mastectomy women. Esc Anna Nery. [SciELO-Scientific Electronic Library Online] 2010 [cited in 05 Feb 2014]. 14: 477-84. Available at: http://www.scielo.br/pdf/ean/v14n3/v14n3a07.pdf

5. Aureliano WA. "... and God created woman": rebuilding the female body in the experience of breast cancer. Rev Estud Fem. [SciELO-Scientific Electronic Library Online] 2009 [cited in 05 Feb. 2014]. 17: 49-70. Available at: http://www.scielo.br/pdf/ref/v17n1/a04v17n1.pdf

6. Menezes NNT, Schulz VL, Peres RS. Psychological impact of the diagnosis of breast cancer: a study based on the reports of patients in a support group. Estud psicol (Natal) [SciELO-Scientific Electronic Library Online] 2012 [cited in 05 february 2014]. 17: 233-40. Available at: http://www.scielo.br/pdf/epsic/v17n2/06.pdf . Accessed on 04/12/2014.

7. Cesnik VM, Santos MA. Do the physical discomforts of breast cancer treatments affect the sexuality of women who underwent mastectomy? Rev Esc Enferm USP. [SciELO-Scientific Electronic Library Online] 2012 [cited in 05 Feb 2014]. 46: 1001-8. Available at: http://www.scielo.br/pdf/reeusp/v46n4/en_31.pdf

8. Ministry of Health (Br). National Council of Health. National Commission of Ethics in Research. Resolution No. 196 of October 10, 1996: it approves guidelines and regulatory norms of research involving human beings. Brasília (DF): CNS; 1996.

9. Lefevre F, Lefevre AMC. Social Representation Research - a quantitative and qualitative approach. Series Research. Brasília (DF): Líber Book; 2011

10. Ministry of Health. National Cancer Institute. Organized screening of breast cancer: the experience of Curitiba and the partnership with the National Cancer Institute. Rio de Janeiro: INCA; 2011.

11. Novaes CO, Mattos IE. Prevalence and associated factors with the non-use of mammography in elderly women. Cad Public Health. [SciELO-Scientific Electronic Library Online] 2009 [cited in 05 Feb 2014]. 25: 310-20. Available at: http://www.scielo.br/scielo.php?pid=S0102-311X2009001400013&script=sciarttext

12. Silva TBC, Santos MCL, Almeida AM, Fernandes AFC. The perception of mastectomy women's partners on life after surgery. Rev Esc Enferm USP. [SciELO- Scientific Electronic Library Online] 2010 [cited in 05 Feb 2014]. 44: 113-9. Available at: http://www.scielo.br/pdf/reeusp/v44n1/en_a16v44n1.pdf

13. Silva SED, Vasconcelos EV, Santana ME, Rodrigues ILA, Leite TV, Santos LMS, et al. Social representations of mastectomy women and their implications for self-care. Rev Bras Enferm. [SciELO-Scientific Elec- tronic Library Online] 2010 [cited in 05 Feb 2013]. 63: 727-34. Available at: http://www.scielo.br/pdf/reben/v63n5/06.pdf

14. Ministry of Health (Br). National Cancer Institute. General Coordination of Strategic Actions, Coordination of Prevention and Surveillance. Estimate 2012: incidence of cancer in Brazil [Internet]. Rio de Janeiro; 2011 [cited in 05 Feb 2014]. Available at: http://www1.inca.gov.br/estimate/2012/estimate20122111.pdf

15. Santos MCL, Sousa FS, Alves PC, Bonfim IM, Fernandes AFC. Therapeutic communication in preoperative mastectomy care Rev Bras Enferm. [SciELO-Scientific Electronic Library Online] 2010 [cited in 05 Feb 2014]. 63: 675-8. Available at: http://www.scielo.br/scielo.php?pid=S0034-71672010000400027&script=sciarttext

16. Azevedo RF, Lopes RLM. Body design in Merleau-Ponty and mastectomy women. Rev Bras Enferm. [SciELO-Scientific Electronic Library Online] 2010 [cited in 05 Feb 2013]. 63: 1067-70. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S003471672010000600031&lng=en&nrm=iso&tlng=en

17. Salci MA, Sales CA, Marcon SS. Feelings of women upon receiving the diagnosis of cancer. Rev Enferm UERJ. 2009 [cited in 05 Feb 2014]. 17: 46-51. Available at: http://www.facenf.uerj.br/v17n1/v17n1a09.pdf

18. Zilmer JGV, Schwartz E, Burille A, Linck CL, Lange C, Eslabão A. Links of cancer and family clients: a known dimension. Ill. Enferm glob. [Scielo Scientific Eletronic Library Online] 2012 [cited in Feb. 05, 2013]. 11: 45-52. Available from: http://scielo.isciii.es/pdf/eg/v11n25/en_clinica3.pdf

19. Ferreira DB, Farago PM, Reis PED, Fhunguetto SS. Life after breast cancer: perceptions and repercussions under the eyes of couples. Rev Bras Enferm. [Scielo Scientific Electronic Library Online] 2011 [cited in Feb. 05, 2014]. 64: 536-44. Available from: http://www.SciELO.br/scielo.php?script=sci_arttext&pid=S0034-71672011000300018&lng=en&nrm=iso&tlng=en

20. Mendes ABP, Costa ML, Leite AP. Women's care in the view of mastectomized women. Ill. [SciELO-Scientific Online Electronic Library] 2012 [cited in Feb 05, 2014]. 11: 427-37. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1695-61412012000200026&nrm=iso&tlng=en

21. Barros AG, Melo MCP, Santos VEP. Meanings attributed to cancer by a group of women. Rev Enferm UERJ. 2014 [cited in Jan. 25, 2015]. 22: 129-33. Available from: http://www.facenf.uerj.br/v22n1/v22n1a20.pdf

22. Silva CM, Vargens OMC. Strategies for demedicalization in gynecological nursing consultation. Rev Enferm UERJ. 2013 [cited in Jan. 25, 2015] 21: 127-30. Available from: http://www.facenf.uerj.br/v21n1/v21n1a21.pdf

23. Rosa LM, Radünz V. Therapeutic itinerary in breast cancer: a contribution to nursing care. Rev Enferm UERJ. 2013 [cited in Jan. 25, 2015] 21: 84-9. Available from: http://www.e-publicacoes.uerj.br/index.php/enfermerauerj/article/view/6369