# "Are you ready?" A longitudinal interpretative phenomenological analysis of couples' experiences with breast reconstruction decision-making

Léa Demeulenaere, Aurélie Untas, Cécile Flahault, Léonor Fasse, Kristopher Lamore

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## To cite this version:

Léa Demeulenaere, Aurélie Untas, Cécile Flahault, Léonor Fasse, Kristopher Lamore. "Are you ready?" A longitudinal interpretative phenomenological analysis of couples' experiences with breast reconstruction decision-making. European Journal of Oncology Nursing, 2025, European Journal of Oncology Nursing, 74, pp.102781. 10.1016/j.ejon.2025.102781. hal-05077499

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Submitted on 21 May 2025

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# “Are you ready?” A longitudinal interpretative phenomenological analysis of couples’ experiences with breast reconstruction decision-making

Léa Demeulenaere<sup>a</sup>, Aurélie Untas<sup>b</sup>, Cécile Flahault<sup>b</sup>, Léonor Fasse<sup>b</sup>, Kristopher Lamore<sup>a,b,*</sup>

## ARTICLE INFO

**Keywords:**

Breast cancer

Breast reconstruction

Couple

Interpretative phenomenological analysis

Qualitative analysis

## ABSTRACT

**Purpose:** In this study, we aimed to explore women's and their male partners' experiences with breast reconstruction (BR) decision and to study the evolution of their experiences since undergoing mastectomy to one year after.

**Methods:** Unstructured individual interviews with four couples facing mastectomy for breast cancer and BR decision-making were conducted following mastectomy (T1) and one year after mastectomy (T2). Longitudinal interpretative phenomenological analysis (LIPA) was conducted on the data.

**Results:** A total of 16 interviews were conducted, revealing seven group experiential themes: six applicable across time and one related to a specific timepoint. The results highlight two critical aspects: the ambivalence surrounding BR and the perceived importance of moving forward. Women and their partners expressed mixed feelings about BR, weighing the potential for improved quality of life and body image against fears of surgery and medical complications. The decision to undergo BR evolved over time, influenced by experiences related to body acceptance, aesthetic considerations, practical concerns, and societal norms for femininity. Partners played a significant role in the decision-making process, offering emotional support and influencing the decision both directly and indirectly. Moreover, the interpretative accounts underline how couples may see BR as a strategy for repairing both physical and psychological damage.

**Conclusion:** Our findings emphasize the importance of understanding BR not only as a medical procedure but also as a deeply psychosocial process shaped by individual and relational factors. Furthermore, we provide reflections on the use of LIPA since it is a rarely used method.

## 1. Introduction

Over the past 25 years, breast reconstruction (BR) has become standard care for women who have undergone mastectomy for breast cancer in several countries (e.g., Nationaal Borstkanker Overleg Nederland, 2024; National Cancer Institute, 2024; National Institute for Clinical Excellence, 2024). The impact of this surgical procedure on the quality of life and psychological wellbeing of women has been widely reported (e.g., improved self-image and body image, decreased emotional distress) (Agency for Healthcare Research and Quality, 2021; Chang, 2023). As 2.3 million women worldwide have been diagnosed with breast cancer in 2022 (International Agency for Research on Cancer World Health Organization, 2024), many women can benefit from BR. However, only about one in two women choose to get BR (Panchal

and Matros, 2017). Women facing mastectomy have various decisions to make: (1) to undergo BR or not (2) to undergo immediate BR (i.e., during mastectomy); or delayed BR (i.e., several months after mastectomy); (3) which reconstructive surgery technique to undergo: implant reconstruction or autologous techniques (e.g., a deep inferior epigastric perforator procedure); (4) whether to get nipple and areola reconstruction; (5) when to undergo delayed BR: following treatment or several months or years thereafter (Agency for Healthcare Research and Quality, 2021; Chang, 2023; Haute Autorité de Santé, 2023). The decision to undergo BR is thus complex.

Usually, this decision is not made by women alone. It is recommended that BR decisions be made within a shared decision-making (SDM) process involving the woman, her oncologist, and/or her surgeon (Li et al., 2021). SDM is considered an international gold standard

<footnote><sup>a</sup> Univ. Lille, CNRS, UMR 9193, SCALab - Sciences Cognitives et Sciences Affectives, F 59000, Lille, France</footnote>

<footnote><sup>b</sup> Laboratoire de psychopathologie et processus de santé, Université Paris Cité, F-92100 Boulogne-Billancourt, France</footnote>

<footnote>* Corresponding author. Laboratoire SCALab UMR CNRS 9193, Université de Lille, Rue du barreau, BP 60149, Villeneuve d'Ascq Cedex, 59653, France.
*E-mail addresses:* lea.demeulenare@univ-lille.fr (L. Demeulenaere), aurelie.untas@u-paris.fr (A. Untas), cecile.flahault@u-paris.fr (C. Flahault), leonor.fasse@u-paris.fr (L. Fasse), kristopher.lamore@univ-lille.fr (K. Lamore).</footnote>
for such decisions and comprises three fundamental components: (1) sharing information, (2) providing support, and (3) making a joint decision (Charles et al., 1999; General Medical Council, 2021). Two other key elements can contribute to the SDM process: (4) assessing patients' preferences and values, and (5) assessing patients decisional needs (e.g., language barriers, health literacy issues, emotional concerns; General Medical Council, 2020). The benefits of SDM have been evidenced in Yang et al. (2023) systematic review, and these include an increase in women's satisfaction with the choice made and favorable patient-physician interactions. However, a SDM process is not always utilized due to a lack of knowledge among physicians and patients, time constraints that physicians perceive, or concerns about overwhelming patients with too much information (Di Pace and Padley, 2024; Lee et al., 2022). Furthermore, achieving SDM for BR can be particularly challenging due to the importance of medical factors (e.g., breast size and shape, skin quality) in decision-making, resulting in physicians frequently assuming the primary decision-making role (Lee et al., 2022; Mendick et al., 2010).

Additionally, external factors may influence the decision-making process, including cultural beliefs, societal norms, and financial constraints (Lee et al., 2022; Panchal and Matros, 2017). These factors are usually discussed when physicians explore patients' preferences, values, and needs. Another important external factor to consider is familial and couple dynamics, with several SDM models mentioning the role of family members in the decision-making process (Laidsaar-Powell et al., 2017). In the case of an illness, the most commonly present relative in treatment decision-making is the partner (Lamore et al., 2017), who can, for example, provide emotional and practical support, assist with information gathering, or serve as advocates. Unfortunately, the influence of partners or relatives in terms of how their presence—without providing support or being present during medical consultations—affects treatment decisions has rarely been studied, and not longitudinally. Nevertheless, longitudinally studying couples' experiences with SDM for treatment decisions is essential considering the impact that breast cancer can have on the couple and on each member of the dyad (e.g., communication and sexual difficulties, emotional distress; Brandão et al., 2017; Valente et al., 2021).

Considering this, our research team conducted several studies since 2014 on this topic to provide knowledge about how to improve SDM in hospitals for the benefit of patients and their relatives. First, a retrospective study showed that (1) couples share BR decision-making, viewing it as a stressor affecting both members of the relationship (Fasse et al., 2017); (2) partners play different roles in this choice (i.e., mostly consultative and supportive) (Fasse et al., 2017); (3) giving women time to think about BR is crucial (Lamore et al., 2020b). Second, in a prospective study using quantitative and qualitative methods, we explored the experiences of couples following mastectomy. The quantitative results (Lamore et al., 2020a) showed that women and partners have similar levels of needs for information, emotional adjustment, and perceived SDM before mastectomy. Additionally, partners do not fully understand why women wish to undergo BR or not. The qualitative results (Lamore et al., 2019) confirmed the direct influence of partners in SDM and showed that they also have an indirect influence (i.e., women make decisions by considering how it will impact the couple). Thinking about BR in the weeks following mastectomy, even if BR is not possible until the end of adjuvant treatment, was highlighted as a coping strategy that aids in finding a way to accept mastectomy. However, these results do not capture the evolution of interactions in the SDM process for BR decision-making between women and their partners. To date, only transversal or retrospective studies have been conducted to examine BR decision-making, but the longitudinal approach can be more relevant for better understanding the evolution of decision-making.

Hence, we aimed to explore women's and their male partners' experiences with BR decision-making following mastectomy to one year after mastectomy using longitudinal interpretative phenomenological analysis (LIPA; Farr and Nizzar, 2019). We also present a secondary

analysis of participants' decision-making over time (Lamore et al., 2019).

## 2. Methods

### 2.1. Design and training

The current qualitative study was collaboratively designed and conducted using the interpretative phenomenological analysis (IPA) method, as outlined by Smith et al. (2022). IPA not only serves as a qualitative data analysis method but also defines suitable methodology for conducting research. The sample size was intentionally kept small, consisting of less than 10 interviews (Farr and Nizza, 2019; Smith et al., 2022). Hence, data saturation was not a primary concern. Over the last decade, IPA has become increasingly popular in psychology, while LIPA remains rarely used (Farr and Nizza, 2019; McCoy, 2017).

This methodology was chosen since it can be used to explore participants' lived experiences and perceptions. It was particularly suited to our aim of examining women's and their partners' BR decision-making process following a cancer diagnosis. The longitudinal perspective of this methodology fits particularly well with the dynamic process of decision making that are under consideration in this study.

### 2.2. Population

We presented the study to heterosexual couples in two hospitals and a comprehensive cancer care center in France (two in Paris and one in the Parisian suburbs). In each couple, the woman had received an initial diagnosis of breast cancer without metastasis (excluding the sentinel lymph nodes) and was scheduled for unilateral mastectomy. Participation required both partners to engage in the study, and they had to have been in a relationship for a minimum of one year. Non-inclusion criteria were the presence of a psychiatric disorder that could have affected participation or the partner having a serious medical condition. In our case, consecutive sampling was used.

### 2.3. Procedure

Nurses and surgeons identified eligible patients per the inclusion criteria, and patients were approached about the study after their diagnosis but before undergoing mastectomy. Subsequently, the contact information of interested couples was shared with KL, who then contacted them to discuss the study in more detail. He also sent them an information letter. Upon acceptance, individual interviews were scheduled for during the month following mastectomy (T1). Notably, women and partners were interviewed separately. This approach allowed for the free expression of individual perspectives. One year after mastectomy (T2), couples were invited to participate in a second individual interview. Interviews occurred either at the couple's home or in the hospital, were audio-recorded, and were transcribed verbatim by KL, CD, and ACM (see Acknowledgments). Transcriptions were not given to participants for comment or correction. Interviews were conducted face-to-face by KL, a clinical psychologist and researcher, using field notes. Before the start of the study, participants only knew that KL was a PhD student in psychology. Oral and written consent to participate was obtained the day of the first interview (T1). Oral consent was obtained the day of the second interview (T2).

At T1, each interview was conducted following an unstructured approach, starting with the question, “Could you tell me where you are currently living?” If the subject did not arise spontaneously, participants were prompted with, “Which elements are going to determine your choice or help you decide to undergo BR?” at the end of the interview. At T2, interviews started with a short summary (approximatively 10 lines) of the themes discussed at T1. BR was always mentioned in the summary, indicating the participant's viewpoint at T1. Participants were invited to read the summary. Then, the interview started with the
question, “Today, are these questions and difficulties still present?” and
continued with the question, “Can you tell me about what has happened
since we last met a year ago until today?”.

## 2.4. Data analysis

Interviews were analyzed per the principles of IPA (Smith et al., 2022) and LIPA (Farr and Nizza, 2019). The analytical process was doubly hermeneutical (i.e., researchers tried to understand participants' sense-making). Anonymized transcripts (fictitious names were assigned to each participant) were read and analyzed using an inductive approach to convert descriptive, linguistic, and conceptual aspects into codes. For each participant, codes were organized to identify experiential statements and then clustered to form personal experiential themes. A table was created to present personal experiential themes and identify the links among them, as well as to identify convergence and divergence between the cases. This resulted in the creation of group experiential themes. This method was followed to analyze the data from each measurement timepoint. Then, results were compared across timepoints for each participant and collectively across all participants, resulting in the creation of themes spanning time (i.e., group experiential themes covering succussive timepoints) and themes tied to specific timepoints (i.e., group experiential themes relevant to a single timepoint). Since LIPA helps capture meaning over time, we extended this analytical process into the writing phase to find patterns of convergence and divergence. Results were divided into two main sections: (1) group experiential themes and (2) interpretative accounts. These interpretative accounts were used to analyze participant experiences through experiential themes and by illustrating their discourse, reflecting the principle of double hermeneutics.

In addition, to identify couple dynamics and convergence and
divergence in their discourses, interviews were analyzed individually, as
described above, and for each couple. This allowed us to develop
interpretative accounts of women's, their partners', and couples'
experiences.

KL (with a PhD in health psychology, who specializes in psycho-
oncology and qualitative research; conducted the interviews during
his PhD between 2015 and 2018) and LD (a psychology PhD student;
conducted analysis during her MSc degree in psychology between 2023
and 2024) conducted data analysis. They maintained a reflexive journal
to track and overcome personal inclinations that could have influenced
their work. Analysis was conducted under the supervision of two
experienced female psychology associate professors (CF and LF) with
expertise in qualitative methods and specializing in conducting IPA
research. All the authors discussed the results, and themes were refined
collaboratively. We were careful to meet Nizza et al.'s (2021) markers of
high quality in reporting IPA research.

## 2.5. Ethical considerations

This study was conducted in accordance with the principles of the Declaration of Helsinki and its subsequent amendments. The study was approved by the Comité Consultatif sur le Traitement de l'Information en matière de Recherche (Ref. no. 16.277) and the Conseil d'Évaluation Éthique pour les Recherches en Santé (international review board no. 20160800001072). All participants provided written informed consent prior to enrollment in the study.

# 3. Findings

## 3.1. Participants

A total of nine women were invited to participate in the study with their partners. Three women declined the invitation (without providing a reason), one couple was excluded for not having completed T2 interviews, and one woman was excluded for having participated without

her partner at T1. The final sample comprised four women and their
partners (i.e., four couples), resulting in 16 interviews. The interviews
ranged from 24 to 93 min (M = 63 min) at T1 and from 14 to 60 min at
T2 (M = 38 min).

Participants' characteristics are presented in Table 1. All the women underwent unilateral mastectomy without immediate BR. At the T1 interviews, all participants were awaiting the results of their histo-pathological examination to determine whether treatment would be necessary. Only one woman was receiving neoadjuvant treatment, while they were all receiving adjuvant treatment. At the T2 interviews, women were in remission, even though hormonal therapy was ongoing. Moreover, half the women were non-native French individuals who had been residing in France for an extended period. Although this information was revealed during the interviews and may have impacted couples' experiences, it could not be used due to French legislation prohibiting the collection and treatment of such data, except when it is the main aim of the study. Therefore, specific details about this have been withheld.

## 3.2. Group experiential themes

Seven group experiential themes emerged from participants' accounts, including six themes applicable across time and one theme tied to a specific timepoint (see Box 1). Due to the number of themes, we did not include verbatim examples for themes already outlined in the literature; details are only provided for themes never or infrequently discussed in past research.

### 3.2.1. Theme 1—The cancer survivorship journey: A long period with important consequences

All participants spoke about the cancer survivorship journey. After mastectomy (T1), participants pointed out how they prioritized their health and questioned the care pathway and origin of the disease: “We have a thousand questions because we are absolutely uninformed” (Danielle, T1). One year after mastectomy (T2), even if treatment was completed, the cancer was not fully behind them: “You’re not sure to be cured” (Danielle, T2). Uncertainty about the future was thus present.

Furthermore, while all participants talked about treatment at T1, only women spoke about it at T2. However, participants' discourse mostly covered the side effects and physical sequelae of the treatment. Following mastectomy (T1), side effects were feared, while at T2, couples were experiencing these side effects.

The cancer journey also had a significant emotional and social impact on couples' lives. The disease and its treatment, for example, caused involuntary social withdrawal, disruption of daily life, fatigue, sexual difficulties, feelings of anxiety, mood swings, emotional eating behaviors, and trauma.

Specific difficulties related to mastectomy were also mentioned. This surgery was experienced as an amputation or mutilation for women. One year after mastectomy, three women were still suffering, and two partners reported seeing the emotional impact it had had on their partner: “Right now, not having a breast bothers her a lot” (Eric, T2). This suffering included, for example, poor body image, a loss of self-confidence, and a loss of femininity. Looking at the scar was difficult for some participants. Following mastectomy, participants described it as hideous, and women explained that they may have been in denial about the loss of their breast. One year after mastectomy, women and their partners described how they were coping with the situation. However, it remained difficult for them to look at the scar, which impacted their body image. To avoid the asymmetry caused by mastectomy and the difficulties experienced, bilateral mastectomy was discussed. Following mastectomy (T1), it was considered an option to have similar breasts, while this was not the case one year thereafter: “Now, no. Looking back, I think if they offered it to me now, I would have said no. It remains a part of me” (Elizabeth, T2).
<table><caption>**Table 1**

Characteristics of the participants.</caption><thead><tr><th rowspan="2">Couple</th><th rowspan="2">Fictitious name</th><th rowspan="2">Age at inclusion</th><th rowspan="2">Duration of the relationship (in years) at inclusion</th><th rowspan="2">Marital status</th><th rowspan="2">Number of children</th><th rowspan="2">Socio-professional category</th><th rowspan="2">Interval between mastectomy and interview at T1</th><th rowspan="2">Interval between T1 and T2 interviews</th><th rowspan="2">Surgery and treatment</th><th colspan="2">BR discussed with a physician</th></tr><tr><th>At T1</th><th>At T2</th></tr></thead><tbody><tr><td rowspan="2">1</td><td>Amanda</td><td>49</td><td rowspan="2">23</td><td rowspan="2">Married</td><td rowspan="2">2</td><td rowspan="2">Lower occupation<sup>a</sup><br>Lower occupation</td><td rowspan="2">24 days</td><td rowspan="2">364 days</td><td rowspan="2">Mastectomy followed by chemotherapy, radiotherapy, and hormonal therapy</td><td rowspan="2">No</td><td rowspan="2">Yes</td></tr><tr><td>Alan</td><td>51</td></tr><tr><td rowspan="2">2</td><td>Carolyn</td><td>50</td><td rowspan="2">9</td><td rowspan="2">Married</td><td rowspan="2">5</td><td rowspan="2">Higher occupation<sup>b</sup><br>Higher occupation</td><td rowspan="2">10 days</td><td rowspan="2">375 days</td><td rowspan="2">Chemotherapy followed by mastectomy and radiotherapy</td><td rowspan="2">Yes</td><td rowspan="2">Yes</td></tr><tr><td>Carl</td><td>54</td></tr><tr><td rowspan="2">3</td><td>Danielle</td><td>30</td><td rowspan="2">9</td><td rowspan="2">Free union</td><td rowspan="2">0</td><td rowspan="2">Higher occupation<br>Higher occupation</td><td rowspan="2">16 days</td><td rowspan="2">406 days</td><td rowspan="2">Mastectomy followed by chemotherapy, radiotherapy, and hormonal therapy</td><td rowspan="2">No</td><td rowspan="2">Yes</td></tr><tr><td>Damien</td><td>33</td></tr><tr><td rowspan="2">4</td><td>Elizabeth</td><td>51</td><td rowspan="2">18</td><td rowspan="2">Married</td><td rowspan="2">2</td><td rowspan="2">Self-employed<br>Self-employed</td><td rowspan="2">20 days</td><td rowspan="2">343 days</td><td rowspan="2">Mastectomy followed by chemotherapy, radiotherapy, and hormonal therapy</td><td rowspan="2">Yes</td><td rowspan="2">Yes</td></tr><tr><td>Eric</td><td>57</td></tr></tbody></table>

Legend: BR = breast reconstruction.

### Box 1

Group experiential themes

#### Themes spanning time.

1. The cancer survivorship journey: A long period with important consequences

2. Facing cancer as a couple

3. Beyond survivorship: Reconstructing oneself with breast reconstruction

4. Human but sometimes abusive healthcare providers

5. Testing social relationships: Between unity and disruption

6. Facing the profusion of emotions

#### Theme tied to time-point T2.

7. Moving forward and improving quality of life

### 3.2.2. Theme 2—Facing cancer as a couple

Cancer can disrupt couples' lives. Participants described facing cancer together and how it had impacted their relationship, even if changes were not seen following mastectomy (T1). At both timepoints, couples frequently used the pronouns “we” and “our” to describe their experiences. Three aspects were prevalent in couples' accounts: positive changes, negative changes, and impacts on their roles.

Couples reported the positive impact cancer had had on their relationship since diagnosis. In some cases, it strengthened their relationship and helped them perceive their couple as a unit. Positive changes were characterized by understanding, empathy, and compassion, and this positive dynamic was based on communication: “At home, we talk” (Amanda, T1); “If I have advice to give to someone, it’s to discuss, be understanding, and especially listen a lot” (Eric, T2). This involved, for example, respecting each other’s space, or being understanding and reassuring.

Couples also experienced difficulties. The main reported difficulty was a lack of communication and listening (e.g., about their emotions, treatment, the future). For example, Danielle and Damien struggled to

cope after treatment ended. He mentioned struggling to understand Danielle’s current health status, whom he perceived as cured: “Sometimes, it’s hard for me to realize, uh, to put myself in her shoes, in her shoes to understand that indeed, there are still certain difficulties, in certain situations” (Damien, T2). These difficulties sometimes led to tension and disagreements.

Couples also highlighted the roles of their partners throughout the cancer journey. All women perceived their partners as caregivers providing emotional and practical support. Partners also emphasized the importance of supporting their wives throughout the cancer journey, during medical consultations, in their femininity, or by reassuring them. Both women and men felt concerned about each other’s health and wished to protect their partner. For example, Amanda said her husband asked her, “Are you ready?” (T2) when discussing BR to determine that she was sure and had considered all options thoroughly. Nonetheless, individuals’ roles in daily life often changed (e.g., household chores, administration). For example, Eric maintained his role as a life partner but also adopted behaviors that changed the role dynamics within the household. Finally, the most important role that women mentioned was

<footnote><sup>a</sup> In France “lower occupation” = industrial workers, low-skilled craft workers and agricultural, forestry, fishing, aquaculture workers, and employees (e.g., service agents in the civil service, security guards, hotel and restaurant employees, cashiers and self-service employees, employees of private individuals, caretakers and security guards).</footnote>

<footnote><sup>b</sup> In France “Higher occupation” = managerial staff, higher intellectual professions and salaried business leaders.</footnote>
partners' presence. Being present, not doing anything specific, was an important source of support. These roles were also sometimes related to decision-making about care, such as BR.

### 3.2.3. Theme 3—Beyond survivorship: Reconstructing oneself with BR

BR was considered ambivalent: It was desired and feared simultaneously by the women and their partners. At T1, uncertainty was expressed about the wish to undergo BR, which was still present at T2. However, BR was not always perceived as a necessity. The reasons to undergo BR evolved, as illustrated in Carolyn's accounts: "I want to do it for the right reasons, obviously, for me and then for my husband" (Carolyn, T1); "My husband, I want him to have a normal wife, you know ... He saw me with one breast, without hair ... he deserves to have a complete, normal wife" (Carolyn, T2).

BR was viewed as surgery that could improve women's quality of life (i.e., improving their physical and mental wellbeing, reducing their body dissatisfaction). The aesthetic and practical aspects associated with this procedure, as well as the women's representations of femininity and the physical norms associated with being a woman, were important in the decision-making process to undergo BR. The norm of having two breasts was reinforced by the desire to regain bodily symmetry. However, couples reported that choosing to undergo BR was also dependent on women's physical condition and medical factors. This represented a set of arguments in favor of undergoing BR present at T1 and T2.

Additionally, arguments against BR were raised linked to medical aspects and potential repercussions of the surgery (e.g., pain, scars, implant rejection, breast deformation). The aesthetical results (e.g., ugly, not the same as the original breast), the BR technique offered (e.g., autologous with the dorsal muscle), and the wish to leave the medical system were also important reasons to decline BR. One year after mastectomy (T2), Amanda expressed a change in her priority and needs: "I need to move on and get on with my life."

Finally, the decision to undergo BR was influenced by women's relationship with their partner and was perceived as a dyadic process. The medical decision was discussed as a couple and was affected by their roles (e.g., supporter, consultant, motivator in the decision-making process). Partners also indirectly influenced the decision, as illustrated in Carolyn's previous account, by being present in the woman's life. This influence was not always perceived, and woman sometimes believed that the decision was only theirs. In addition to partners, the influence of peers and the media emerged in participants' discourse. Specifically, testimonials and reports about BR were reassuring for couples. The relationship with the surgeon and the surgeon's skills were also important factors for couples. BR decision-making was ultimately up to the women, but BR was discussed with a physician and the choice was influenced by their advice.

### 3.2.4. Theme 4—Human but sometimes abusive healthcare providers

Positive and negative experiences with healthcare providers were reported, without links to BR decision-making. Couples' accounts were similar at T1 and T2.

Positive relationships were predominantly characterized by trust, listening, and attention toward women and their partners, perceived satisfaction with care, and humanity: "I was very very very touched by the humanity of this man" (Carolyn, T2). This satisfaction with care among women was influenced by the perception that they had received quality care, the act of taking time, congruent and accessible medical discourse, being recognized by professionals, feeling reassured, and being surrounded by competent professionals.

Negative experiences were also reported and corresponded to factors opposite to those associated with positive relationships: a lack of information and medical explanations, poor listening and exchanges, a lack of time, perceived medical errors, and conflicts. Participants reported, for example, encountering professionals who were inflexible about medical protocols or experiencing mistreatment.

### 3.2.5. Theme 5—Testing social relationships: between unity and disruption

The cancer journey was discussed with close relatives: family members, friends and colleagues. At T1, couples were satisfied with the support received from their relatives, even though some friends disappeared after learning about participants' cancer diagnosis. However, at T2, less than half of participants believed they had received satisfactory social support, leading to tension or adjusted behaviors with relatives. Amanda explained that the support she received from her family decreased when treatment ended and she entered the post-cancer period, with relatives returning to pre-cancer familial functioning, but her friends remained present and supportive.

Concerning women's needs, support was received through regular contact with and the presence of relatives, friends, and colleagues during and after treatment. For partners, support primarily came from their partner following mastectomy (T1). During treatment, partners started discussing the cancer journey with their relatives a bit more, which eased the burden on women.

### 3.2.6. Theme 6—Facing the profusion of emotions

Couples expressed how they coped with cancer and treatment. They faced a profusion of emotions, predominantly negative, following mastectomy, while their emotions became more balanced one year thereafter. The emotions expressed by participants were related to announcements, treatment, care, and the severity of the illness.

Regarding negative emotions, couples often reported anxious anticipation and fear (e.g., of the consequences, of cancer recurrence), as well as feelings of anger and irritability. Following mastectomy, some participants reported feeling sad, while partners experienced feelings of powerlessness, disappointment, and injustice.

The main positive emotions that women reported were joy and relief. These feelings were more present one year after mastectomy and were associated with receding negative emotions, particularly fear and worries.

### 3.2.7. Theme 7—Moving forward and improving quality of life

This theme was only connected to timepoint T2. During the post-cancer phase, two main points of improvement for women's quality of life were reported. First, their overall health improved, both physically and mentally. Couples observed this improvement, expressing it as a decrease in pain, physical discomfort, fatigue, and concerns related to the illness, as well as the return to a healthy weight, the sense of being healed, and acceptance of alopecia. Second, women returned to work, activities, or projects: "I returned to work full-time, um, I immersed myself in my projects and tried to forget everything related to the illness" (Danielle, T2).

Over half of participants desired to move forward, which included the desire to live again, travel, return to their previous life, and forget about the illness: "[The current goal is] to forget. To finish this, um, this phase" (Carolyn, T2). In addition, Amanda, Carl, and Damien wanted to live their lives more intensely than before and were less hesitant less to pursue their desires.

### 3.3. Interpretative accounts

Interpretative accounts focusing on BR decision-making were developed individually for women and for partners and in combination for couples. These accounts were influenced by LD's and KL's theoretical knowledge of health psychology, coping, and SDM models.

Two meaning-making profiles for women's experiences were built, which underlined the importance partners placed on BR decision-making. The first was a solution to forget what had happened and move forward. BR was seen as favorable for overcoming cancer and a future-oriented coping strategy. Women saw BR as necessary to build a future free from any cancer-related sequelae: "Well, it's hard to, to ... to take it all on. We've dealt with the hair, ok, it'll grow back. But my breast won't. And the reconstruction, why? Yes, I want to do it"
(Carolyn, T1); "It will be a scar for me if I don't reconstruct" (Carolyn, T2). It allowed women to feel whole again by addressing the negative effects of mastectomy. For women, mastectomy was socially interpreted as a mutilation depriving them of their femininity. It led to psycho-physical difficulties that caused decreases in self-confidence and self-esteem. Therefore, BR was seen as a way to improve women's well-being: It would make their lives more practical and "normal," even just within their couples. The second meaning-making profile revealed a paradox: Women wished to undergo BR to be normal again but simultaneously did not want to undergo this surgery. Their desire to regain their pre-mastectomy bodies, the influence of social norms, and the fear of losing their partner led them to desire BR. However, accepting their bodies, feeling good in their relationship, and the desire to move away from the medical system caused them to choose to go flat. This option was not proposed to women and may be difficult to accept socially.

Two meaning-making profiles were developed for partners' experi-
ences. Following mastectomy, their discourse was focused on breast loss
and BR, as it was more difficult for them to think about a disease they
could not see. One year after mastectomy (T2), cancer was part of their
daily life, and BR was not as important as before. The first meaning-
making profile referred to their role. Partners perceived themselves as
protectors, guiding women to decide on what would be best for them.
Since the woman was ill and considered vulnerable, her partner inten-
ded to protect her from medical errors and poorly considered decisions
and guide women's choices so that they would positively impact her
quality of life: "If she decides to refuse [BR], why is she refusing? To find
out if it's for the right reasons. If it's not ... someone who's been telling
her something, or something she saw on the internet, or some crap like
that" (Alan, T1); "The one they propose here seems, um, very painful ... I
tell her 'no', if that's it, you don't do anything" (Carl, T2). The second
meaning-making profile was about the reconstruction of a pre-cancer
figure. Compared to women, who wanted to forget about what had
happened, partners wanted their wives' former bodies back. "Recon-
structing" or "reconstituting" the breast was desired and considered the
best path to a positive future without illness: "Having both breasts, like
before" (Damien, T2). Partners' manner of speaking about BR reflected
their desire for recovery from cancer and to continue to live without
sequae in their relationship. However, it was difficult for partners to
admit and share their desires for BR.

Couples' experiences with BR decision-making were perceived
through their preferences and attitudes. First, BR decision-making was
considered a process. The decision to delay BR evolved. The surgeon's
opinion and a reduction in fear associated with surgery were potential
driving factors for a decisional change. Following mastectomy, BR was
desired to stay "normal" and not lose their partner. One year after
mastectomy, women and their partners had experienced living with an
asymmetrical, new body and faced new couple dynamics that had been
strengthened during the cancer journey. Second, as identified in
women's and partners' meaning-making profiles, BR was considered a
strategy for repairing what had been damaged, both physically and
psychologically. Women primarily needed to reclaim their bodies,
which had been medicalized during the care journey, returning their
bodies to being a source of contact and functionality. The couple needed
to re-establish their physical connection, and the woman's body needed
to become a means of attraction and seduction again, which led to
considering BR. Third, seeking information about BR was seen as
exerting control over cancer. Couples' feelings of control and reassur-
ance were supported by obtaining information about an unknown sur-
gical procedure: "I was worried before the operation because I didn't
have enough information about how the reconstruction was going to be
done" (Danielle, T1); "The idea of having things explained to you helps
you prepare for what's going to happen" (Carl, T2). This restoration of
control was a compensatory phenomenon or coping strategy for facing
fear and a lack of control experienced by couples during the treatment
phase.

4. Discussion

In this study, we comprehensively examined the lived experiences of couples navigating the cancer survivorship journey, with a focus on BR decision-making. Moreover, this is one of the first studies in oncology to use LIPA. The findings highlight two critical aspects: the ambivalence surrounding BR and the perception that it is important to move forward. Women and their partners expressed mixed feelings about BR, balancing the desire for improved quality of life and body image against fears of surgery and medical complications. The decision to undergo BR evolved over time, influenced by time (e.g., body acceptance), aesthetic considerations, practical concerns, and social norms of femininity. Additionally, the role of partners was significant, as they provided emotional support and influenced the decision both directly and indirectly. These findings underline the importance of understanding BR not only as a medical procedure but also as a deeply psychosocial process shaped by individual and relational factors. To follow, we also provide reflections on the analysis method used, LIPA.

4.1. *Is BR a fully controlled choice? Navigating social norms, physical constraints, psychological adjustment, and partners' support*

Our results evidence how women and their partners cope with body
modifications and BR decision-making during the first year after a
cancer diagnosis. The results observed are similar years after the end of
treatment (Fasse et al., 2017; Zehra et al., 2020). This is because cancer
treatment and mastectomy impact body image, self-esteem, sexuality,
and couple relationships (Agency for Healthcare Research and Quality,
2021; Chang, 2023), and, as found in our results, BR can be seen as a
solution to these difficulties. It provides a sense of control to women and
partners, as women usually make the final decision—while considering
their partner and after discussing BR with their physician—to undergo
BR. This is different than treatment (e.g., chemotherapy, radiotherapy,
surgery), where women feel powerless (Brown et al., 2015). We noted
that women's breasts partly "belong" to their partner, with women
describing how they make the choice to undergo BR by considering that
their partner has always known them to have two breasts. Women
positively perceive the support and role of partners, while in some ways,
this describes a form of appropriation of the woman's body by her
partner. Furthermore, a sense of control can be balanced by social
norms. In several countries worldwide, like in France, female breasts are
a symbol of femininity, and there is social body pressure related thereto
(Wallner et al., 2023). Women must have two breasts to conform to
societal expectations and avoid stigmatization or the feeling of being
incomplete due to deeply ingrained cultural standards. This suggests
that women may not have complete ownership of their breasts, as
partners and society play a significant role in BR decision-making, as
indicated by our findings.

Moreover, physical conditions are an important criterion to consider
before undergoing BR. Women must be in overall good health, free from
any medical conditions that may complicate surgery or recovery (Chang,
2023; Haute Autorité de Santé, 2023). Women's wellbeing may be
related to body reappropriation, for example, through BR or other
procedures such as adapted physical activity (Brunet et al., 2013).
Hence, even if women and couples feel like they have control over the
decision, the decision is influenced by external factors.

Different dynamics between T1 and T2 (during versus after treat-
ment) were found in our results. As underlined in the literature, the
cancer journey is sometimes lived differently by patients and relatives.
During the remission phase, relatives frequently believe that the cancer
is cured, and life can go back to normal (Keesing et al., 2018; Zimmer-
mann, 2015), while patients want to go back to a normal life but present
sequalae and fear of cancer recurrence (Keesing et al., 2018; Renshaw
and Burton, 2023). However, normality is subjective, so a new "normal
life" should be defined together. This can generate couple difficulties or
tension (Keesing et al., 2018; Zimmermann, 2015). This dynamic is also
observed in BR decision-making. Following mastectomy, couples think about BR and a future in which the woman has two breasts, as observed in our study. One year thereafter, when treatment has ended, BR is seen as a way to "get back to normal," to return to something akin to normality, as described in Renshaw and Burton's (2023) study. For these authors, women may perceive this return to normality as achieving a sense of happiness with and acceptance of their bodies. Body acceptance was one of the main challenges faced by women and their partners in our study, and it influenced their decision-making.

Finally, our results can be considered from the perspective of post-traumatic growth, a concept introduced in the mid-1990s by Tedeschi and Calhoun (1996). In oncology, posttraumatic growth refers to the positive psychological changes that some cancer survivors experience as they struggle with and overcome the challenges of their diagnosis and treatment. It describes how some good can emerge from a traumatic event and how individuals can experience growth in various aspects of their lives after cancer. In our study, couples mentioned how the cancer journey had changed their relationships positively and had resulted in the desire to live more intensely than before. This was found in previous research (Fasse et al., 2017; Lamore et al., 2019; Valente et al., 2021), as well. Here, discussing BR and wanting BR can help overcome the trauma caused by a cancer diagnosis. This can facilitate women's integration of their body schemas (Phoosuwan and Lundberg, 2023) and decision of whether to undergo BR. Supporting posttraumatic growth by discussing BR is thus an additional argument in favor of the existing recommendations for BR discussion when women must undergo mastectomy.

## 4.2. LIPA: A complex and novel methodology

The use of LIPA in this study gave us insights into the evolving process of BR decision-making. LIPA, as articulated by Farr and Nizza (2019), offers a robust framework for examining the dynamic nature of participants' lived experiences over time. By employing repeated data collection points, we could capture the nuanced shifts in perceptions, emotions, and decision-making processes that static, cross-sectional methods might not address. The longitudinal aspect of LIPA is particularly advantageous for health psychology research, as it aligns well with the temporal and evolving nature of health-related experiences (McCoy, 2017).

Our findings suggest that LIPA not only enhances the depth and richness of qualitative data but also strengthens the trustworthiness of the study by allowing for the verification and elaboration of themes across multiple timepoints. This approach also provides a more comprehensive understanding of how individuals navigate complex decisions and cope with changing circumstances over time. Furthermore, its idiographic focus allows researchers to deeply investigate individual trajectories, providing rich, detailed accounts of how personal meanings and experiences change over time. This makes LIPA particularly well-suited for studies exploring significant life transitions or interventions where temporal aspects are crucial.

However, LIPA remains underutilized in qualitative research since conducting LIPA studies requires significant time and resources. The need for multiple data collection points over extended periods can be logistically challenging and resource intensive. Researchers must also coordinate repeated interactions with participants, manage and analyze large volumes of data, and ensure continuity and consistency throughout the study. Compared to quantitative data, the most challenging aspect of using this method for us was managing the large amount of qualitative data while maintaining analytical rigor. This was made possible by including two researchers in the analysis (LD and KL), which allowed for discussions on the findings and enhanced the reliability of interpretations. This collaborative approach allowed for a deeper engagement with the data, facilitating a nuanced understanding of participants' experiences over time.

To encourage the adoption of LIPA and address its associated challenges, we propose the following recommendations.

1. Methodological Training: Provide comprehensive training for researchers in LIPA methodology, emphasizing its unique aspects and practical challenges.

2. Collaborative Research: Encourage collaboration in research teams to distribute the workload and bring diverse perspectives to analysis. This can enhance the depth and reliability of the findings.

3. The Publication of Detailed Methodologies: Encourage researchers to publish detailed accounts of their methodological processes and challenges. This can provide valuable guidance for others and contribute to the development of best practices in LIPA research.

4. Technological Support: Utilize qualitative data analysis software (e. g., NVivo, QDA Miner) to manage and analyze large volumes of data efficiently. These tools can assist in organizing data, coding, and identifying patterns across multiple timepoints.

5. Interdisciplinary Approaches: Foster interdisciplinary research collaboration to enrich the analytical process and introduce different methodological perspectives and expertise

Points 1 to 3 are based on our experience of the analysis conducted and presented in this article, while points 4 and 5 are additional reflections aimed at enhancing the robustness and depth of future LIPA studies.

## 4.3. Limitations

This study had some limitations. First, the couples interviewed had good marital relationships, so conflicts and tension within the couples were rare. Partners were mostly empathic toward and understanding of women, and BR decision-making was perceived as the women's decision, even if partners considered themselves to be involved in discussions. Conclusions about couples with poorer marital relationships or where the male partner is less supportive should be drawn with care. Second, the four women included in this study underwent mastectomy only. Given the study's longitudinal nature, follow-up data (T2) from one couple in which the woman had mastectomy with immediate BR were lost. This may have occurred because this couple was projecting themselves into a future without cancer, and the illness was not central in their lives, at T1 already. Third, only heterosexual couples were included. Therefore, research on same-sex couples and women who choose to undergo immediate BR is needed, in addition to research with participants from different cultures, as social and cultural norms may impact individuals' decisions significantly (Derrington et al., 2018).

## 4.4. Clinical and research perspectives

Our results show that one decision is not addressed: the choice to go flat (i.e., opting to go flat on one or both sides; Paganini et al., 2024). This option has rarely been investigated to date (Paganini et al., 2024) and has not been proposed for clinical practice in several countries, including France. Usually, this choice corresponds to not having BR, as presented in our results. Women opting to go flat are also frequently grouped with women wanting to undergo BR but who have not yet done so. However, opting to go flat is a unique decision with different surgery options for obtaining the aesthetic of a flat chest, but there is a lack of literature addressing the technical aspects of such surgery options (Morrison and Karp, 2022). A survey conducted in the USA found that this option is not offered to about one in two women due to "flat denial" (i.e., surgeons advising against going flat or not offering the option; Baker et al., 2021). Due to this flat denial and the lack of clear surgical recommendations, it is not surprising that the couples in our study did not discuss this option with their surgeon. However, it is surprising that not undergoing BR, meaning not undergoing surgery, was not an option discussed. To achieve SDM, the option to not undergo any surgery or to go flat should be offered to women, ensuring they are fully informed about their available choices and can make decisions aligned with their personal preferences and values. Furthermore, we believe that to go flat
should be discussed with women as a reconstructive surgery option. To date, BR refers to surgical techniques to recreate breast volume (Haute Autorité de Santé, 2023; National Institute for Clinical Excellence, 2024). Presenting the option to go flat as a BR technique would circumvent the choice to undergo surgery, where “not” having breast volume reconstruction is perceived negatively. This may positively impact women’s decisions, as well their personal physical and psychological reconstruction pathways after mastectomy. A quantitative study can be conducted to assess this, while the psychological adjustment (e. g., body image, distress, self-esteem) of women and their partners can be assessed in a randomized controlled trial. One arm can serve as a control group, receiving usual care (i.e., during BR decision-making, the physician may or may not present the option to go flat), while the other arm can offer BR that includes both volume reconstruction and going flat options presented at the same level. Should the study demonstrate a favorable impact, new recommendations can be formulated to place BR techniques and the choice to go flat on the same level. This may result in the adaptation of existing decision aids for BR, ensuring that they address the diverse needs and values of women and their partners.

In addition, national recommendations for BR can be rephrased to encourage the significance of initiating discussions about BR at diagnosis. This approach would allow physicians to tailor their consultations to the specific needs of women who are seeking information about their treatment options at diagnosis.

## 5. Conclusion

Our findings provide a comprehensive understanding of BR decision-making among couples. BR decision-making is a difficult and long process, affected by several factors. Women and their partners may wish to undergo BR in the weeks following a cancer diagnosis, but this decision can be more balanced one year after mastectomy and after having experienced living with an asymmetrical body. These findings emphasize the need to recognize BR as both a medical procedure and a deeply psychosocial process influenced by individual and relational factors.

### CRediT authorship contribution statement

**Léa Demeulenaere:** Writing – review & editing, Writing – original draft, Formal analysis, Data curation. **Aurélie Untas:** Writing – review & editing, Supervision, Project administration, Methodology, Conceptualization. **Cécile Flahault:** Writing – review & editing, Validation, Methodology, Conceptualization. **Léonor Fasse:** Writing – review & editing, Validation, Methodology, Conceptualization. **Kristopher Lamore:** Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

### Funding

KL's working time was funded by a grant from the French National Cancer Institute (grant INCA/16136) in collaboration with the Université de Lille, the SCALab laboratory, the ONCOLille Institute, and the Centre Oscar Lambret, which support the research chair with “innovations in psycho-oncology and intervention research.” Notably, the SCALab laboratory is part of the ONCOLille Institute.

### Declaration of competing interest

The authors report there are no competing interests to declare.

### Acknowledgments

We are grateful to the women and their partners who participated in this study. We also wish to acknowledge all the nurses and surgeons who proposed this study to the couples and helped in our research: Dr. Denis

Heitz, Dr. Fabien Reyal, Dr. Tunon de Lara, and Dr. Charlotte Ngo. Finally, we want to thank our research team for their contributions to this study: Professor Bruno Quintard, Dr Christel Vioulac, and Professor Anna van Wersch, as well as Coline Escarnot and Alice Calvez-Maes, who transcribed some of the interviews.

### References

Agency for Healthcare Research and Quality. 2021. Breast reconstruction after mastectomy: a systematic review and meta-analysis. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-245-breast-reconstruction-after-mastectomy-updated-1.pdf. (Accessed 27 December 2024).

Baker, J.L., Dizon, D.S., Wenziger, C.M., Streja, E., Thompson, C.K., Lee, M.K., DiNome, M.L., Attai, D.J., 2021. "Going flat" after mastectomy: patient-reported outcomes by online survey. Ann. Surg Oncol. 28 (5), 2493-2505. https://doi.org/10.1245/s10434-020-09448-9.

Brandão, T., Pedro, J., Nunes, N., Martins, M.V., Costa, M.E., Matos, P.M., 2017. Marital adjustment in the context of female breast cancer: a systematic review. Psycho Oncol. 26 (12), 2019-2029. https://doi.org/10.1002/pon.4432.

Brown, A.J., Sun, C.C., Urbauer, D.L., Bodurka, D.C., Thaker, P.H., Ramondetta, L.M., 2015. Feeling powerless: locus of control as a potential target for supportive care interventions to increase quality of life and decrease anxiety in ovarian cancer patients. Gynecol. Oncol. 138 (2), 388-393. https://doi.org/10.1016/j.ygyno.2015.05.005.

Brunet, J., Sabiston, C.M., Burke, S., 2013. Surviving breast cancer: women's experiences with their changed bodies. Body Image 10 (3), 344-351. https://doi.org/10.1016/j bodyim.2013.02.002.

Chang, E.I., 2023. Narrative review of patient-reported outcomes of breast reconstruction. Ann. Transl. Med. 11 (12), 415. https://doi.org/10.21037/atm-23-1528.

Charles, C., Gafni, A., Whelan, T., 1999. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc. Sci. Med. 49, 651-661. https://doi.org/10.1016/s0277-9536(99)00145-8.

Derrington, S.F., Paquette, E., Johnson, K.A., 2018. Cross-cultural interactions and shared decision-making. Pediatrics 142 (Suppl. 3), S187-S192. https://doi.org/10.1542/peds.2018-0516J.

Di Pace, B., Padley, R.H., 2024. Empowering patients through shared decision making in breast cancer consultations. Aesthetic Plast. Surg. Forthcoming. https://doi.org/10.1007/s00266-024-03937-y.

Farr, J., Nizza, I.E., 2019. Longitudinal interpretative phenomenological analysis (LIPA): a review of studies and methodological considerations. Qual. Res. Psychol. 16 (2), 199-217. https://doi.org/10.1080/14780887.2018.1540677.

Fasse, L., Flahault, C., Vioulac, C., Lamore, K., Van Wersch, A., Quintard, B., Untas, A., 2017. The decision-making process for breast reconstruction after cancer surgery: representations of heterosexual couples in long-standing relationships. Br. J. Health Psychol. 22 (2), 254-269.

General Medical Council, 2020. Decision making and consent. https://www.gmc-uk.org/-/media/documents/gmc-guidance-for-doctors-decision-making-and-consent-engli sh_pdf-84191055.pdf. (Accessed 27 December 2024).

Haute Autorité de Santé, 2023. Reconstruction mammaire ou buste plat : vos souhaits et options. https://www.has-sante.fr/jcms/p_3351381/fr/reconstruction-mammaire-ou-buste-plat-vos-souhaits-et-options. (Accessed 27 December 2024).

International Agency for Research on Cancer, World Health Organization, 2024. Global cancer observatory. https://gco.iarc.fr/en. (Accessed 27 December 2024).

Keesing, S., Rosenwax, L., McNamara, B., 2018. The implications of women's activity limitations and role disruptions during breast cancer survivorship. Womens Health (Lond), 14, 1745505718756381. https://doi.org/10.1177/1745505718756381.

Laidsaar-Powell, R., Butow, P., Charles, C., Gafni, A., Entwistle, V., Epstein, R., Juraskova, I., 2017. The TRIO framework: conceptual insights into family caregiver involvement and influence throughout cancer treatment decision-making. Patient Educ. Counsel. 100 (11), 2035-2046. https://doi.org/10.1016/j.pec.2017.05.014.

Lamore, K., Montalescot, L., Untas, A., 2017. Treatment decision-making in chronic diseases: what are the family members' roles, needs and attitudes? A systematic review. Patient Educ. Counsel. 100 (12), 2172-2181.

Lamore, K., Flahault, C., Fasse, L., Untas, A., 2019. "Waiting for breast reconstruction": an interpretative phenomenological analysis of couples' experiences of mastectomy for breast cancer. Eur. J. Oncol. Nurs. 42, 42-49.

Lamore, K., Flahault, C., Untas, A., 2020a. Women and partners' information need, emotional adjustment and breast reconstruction decision-making before mastectomy. Plast. Surg. (Oakv). 28 (3), 179-188.

Lamore, K., Vioulac, C., Fasse, L., Flahault, C., Quintard, B., Untas, A., 2020b. Couples' experience of the decision-making process in breast reconstruction after breast cancer: a lexical analysis of their discourse. Cancer Nurs. 43 (5), 384-395.

Lee, P.Y., Cheong, A.T., Ghazali, S.S., Rashid, A.A., Ong, S.C., Ong, S.Y., Alip, A., Sylvia, M., Chen, M.F., Taib, N.A., Jaganathan, M., Ng, C.J., Teo, S.H., 2022. Barriers of and strategies for shared decision-making implementation in the care of metastatic breast cancer: a qualitative study among patients and healthcare professionals in an Asian country. Health Expect. 25 (6), 2837-2850. https://doi.org/10.1111/hex.13590.

Li, X., Meng, M., Zhao, J., Zhang, X., Yang, D., Fang, J., Wang, J., Han, L., Hao, Y., 2021. Shared decision-making in breast reconstruction for breast cancer patients: a scoping review. Patient Prefer. Adherence 15, 2763-2781. https://doi.org/10.2147/PPA.S335080.
McCoy, L.K., 2017. Longitudinal qualitative research and interpretative phenomenological analysis: philosophical connections and practical considerations. Qual. Res. Psychol. 14 (4), 442-458. https://doi.org/10.1080/14780887.2017.1340530.

Mendick, N., Young, B., Holcombe, C., Salmon, P., 2010. The ethics of responsibility and ownership in decision-making about treatment for breast cancer: triangulation of consultation with patient and surgeon perspectives. Soc. Sci. Med. 70 (12), 1904-1911. https://doi.org/10.1016/j.socscimed.2009.12.039.

Morrison, K.A., Karp, N.S., 2022. Not just a linear closure: aesthetic flat closure after mastectomy. Plast. Reconstr. Surg. Glob. Open. 10 (5), e4327. https://doi.org/10.1097/GOX.0000000000004327.

Nationaal Borstkanker Overleg Nederland, 2024. Mammacarcinoom. Landelijke richtlijn, versie: 2.0. http://www.oncoline.nl/mammacarcinoom. (Accessed 27 December 2024).

National Cancer Institute, 2024. Breast cancer treatment (health professional). http://www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional. (Accessed 27 December 2024).

National Institute for Clinical Excellence, 2024. Early and locally advanced breast cancer: diagnosis and management. https://www.nice.org.uk/guidance/ng101/chapter/recommendations/breast-reconstruction. (Accessed 27 December 2024).

Paganini, A., Westesson, L.M., Hansson, E., Ahlstedt Karlsson, S., 2024. Women's decision process when actively choosing to 'go flat' after breast cancer: a constructivist grounded theory study. BMC Wom. Health 24, 178. https://doi.org/10.1186/s12905-024-03015-0.

Panchal, H., Matros, E., 2017. Current trends in postmastectomy breast reconstruction. Plast. Reconstr. Surg. 140 (5), 7S-13S. https://doi.org/10.1097/PRS.0000000000003941.

Phoosuwan, N., Lundberg, P.C., 2023. Life satisfaction, body image and associated factors among women with breast cancer after mastectomy. Psycho Oncol. 32 (4), 610-618. https://doi.org/10.1002/pon.6106.

Renshaw, J., Burton, A.E., 2023. 'I don't know if I understood the whole process from the beginning': a photo-elicitation exploration of the experience of mastectomy and breast reconstruction decision making. PEC Innov. 3, 100178. https://doi.org/10.1016/j.pecinn.2023.100178.

Smith, J.A., Flowers, P., Larkin, M., 2022. Interpretative Phenomenological Analysis: Theory, Method and Research, second ed. Sage Publications Ltd, London.

Tedeschi, R., Calhoun, L.G., 1996. The posttraumatic growth inventory: measuring the positive legacy of trauma. J. Trauma Stress 9 (3), 455-471. https://doi.org/10.1007/BF02103658.

Valente, M., Chirico, I., Ottoboni, G., Chattat, R., 2021. Relationship dynamics among couples dealing with breast cancer: a systematic review. Int. J. Environ. Res. Publ. Health 18 (14), 7288. https://doi.org/10.3390/ijerph18147288.

Wallner, C., Huyghebaert, T., Drysch, M., Wagner, J.M., Sogorski, A., Dadras, M., von Glinski, M., Verena Schmidt, S., Reinkemeier, F., Lehnhardt, M., Behr, B., 2023. Digital media play a key role in influencing female breast perception. Cyberpsychol., Behav. Soc. Netw. 26 (1), 11-21. https://doi.org/10.1089/cyber.2022.0141.

Yang, S., Yu, L., Zhang, C., Xu, M., Tian, Q., Cui, X., Liu, Y., Yu, S., Cao, M., Zhang, W., 2023. Effects of decision aids on breast reconstruction: a systematic review and meta-analysis of randomised controlled trials. J. Clin. Nurs. 32 (7-8), 1025-1044. https://doi.org/10.1111/jocn.16328.

Zehra, S., Doyle, F., Barry, M., Walsh, S., Kell, M.R., 2020. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer 27 (4), 534-566. https://doi.org/10.1007/s12282-020-01076-1.

Zimmermann, T., 2015. Intimate relationships affected by breast cancer: interventions for couples. Breast Care 10 (2), 102-108. https://doi.org/10.1159/000381966.