BREAST RECONSTRUCTION FROM THE PERSPECTIVE OF WOMEN SUBMITTED TO MASTECTOMY : A META-ETNOGRAPHY

Objective: to analyze qualitative studies published in the national and international scientific literature on breast reconstruction after mastectomy for breast cancer, from the perspective of women. Method: systematic literature review using meta-ethnography, where the synthesis of knowledge is based on the induction and interpretation of the data found. Searches in the electronic databases identified 65 studies. 27 studides meet the inclusion and exclusion criteria. 13 studies compressed the analytical corpus of the review, according to the Critical Appraisal Skills Programme checklist. The data were synthesized by means of the meta-ethnographic approach. Results: the analyzed studies showed similarities regarding the women ́s decision to perform breast reconstruction, the difficulty of choosing the type of surgery and to deal with the experience of the reconstruction, and that the women had difficulties in establishing relationships with certain health professionals, especially with doctors. They refer to the ambivalence of feelings regarding the expectations and results of breast reconstruction and complex process of “carrying on”. Conclusion: this review synthesizes the scientific knowledge regarding women’s perspective regarding the breast reconstruction process and highlights that health professionals must understand the perceptions of women undergoing mastectomy and breast reconstruction in order to improve the care provided. DESCRIPTORS: Women’s health. Breast neoplasms. Reconstructive surgical procedures. Review literature as topic. Qualitative research. RECONSTRUCCIÓN MAMARIA BAJO LA ÓPTICA DE MUJERES SOMETIDAS A LA MASTECTOMÍA: UNA METAETNOGRAFÍA


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2] However, in relation to the involvement of the disease at the time of diagnosis, a Brazilian study reveals that despite the variety of therapeutic possibilities, it is estimated that many women with breast cancer are not cured, and require palliative treatment. 3hus, in Brazil, the incidence of mastectomies is still high, often due to the late diagnosis of cancer, other times due to the woman´s own choice, for fear of local recurrences or because they carry the BRCA1 and BRCA2 genes, with a possible indication of bilateral prophylactic mastectomy, or, in the case of young women, due to the fact that the cancer presents itself in a very aggressive way, situations that lead to the number of mutilating surgeries still performed in our country.] The first attempts to perform breast reconstruction took place at the end of the 19th century, but from 1889 onwards due to the mastery of Halsted´s radical mastectomy technique, there was an impediment to the popularization of breast reconstruction and radical mastectomy was considered standard treatment, worldwide, until the mid-1970s.][6] American studies indicate a progressive increase in the number of bilateral mastectomies after 1998, associated with a decrease in the rate of axillary lymph node dissection and radiotherapy, accompanied by an increase in the rates of breast reconstruction.[10][11] When radical surgery is indicated, meaning the need for breast resection, due to the complexity related to the diagnosis and treatment of breast cancer, and the feelings that women face, both in relation to the need to undergo mastectomy, and in relation to the decision to perform or not perform breast reconstruction and, when deciding on the reconstruction, to have to opt for the immediate or delayed reconstruction, as health professionals, we see the importance of knowing all the issues involved in breast reconstruction after breast cancer, in the perspective of the women.
In addition, the reconstruction can bring benefits, such as the recovery of feelings of femininity and bodily integrity, as well as postoperative complications inherent in any complex surgical procedure, in addition to physical, emotional and social changes involving women's affectivity and sexuality.Taking into account this context, it is believed that the knowledge about the state of the art scientific productions related to breast reconstruction after breast cancer can help the care of these women.

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] And finally, we did not identify any systematic review of qualitative studies on the perspective of women undergoing mastectomy on breast reconstruction.Considering that qualitative studies are essential to the production of knowledge, due to its capacity to incorporate the question of meaning, subjectivity and intentionality as inherent in acts, relationships and social structures, as meaningful human constructions, 17 we have chosen to conduct a study for this purpose.
In order to carry out a literature review using the meta-ethnographic approach, Noblit and Hare 18 recommend that it represents the synthesis of interpretive research, aiming at the construction of appropriate explanations about interpretive studies.Interpretation in qualitative research is an attempt to clarify and give meaning to the object of study, seeking to bring to light a fundamental principle of the coherence of meaning, helping to understanding how phenomena can connect and interact. 18herefore, the present study is justified, based on the question: what is the production of knowledge published in the national and international scientific literature, in qualitative studies, on breast reconstruction after breast cancer mastectomy from the perspective of women?The objective was to perform a meta-analysis of studies published in the national and international literature on breast reconstruction after mastectomy due to breast cancer, from the perspective of women.

METHOD
The objective of this study is to synthesize qualitative studies, through a systematic literature review, following the conception of Noblit and Hare, 18 who propose the term metaethnography to designate this type of investigation, where the synthesis of knowledge is based on the induction and interpretation of the found data; it is an interpretative construction, where the researcher/synthesizer seeks to present the "whole" from selective studies of "parts".This review followed three distinct phases: systematic review of the literature, critical analysis of the selected articles and synthesis. 19he qualitative research was conducted in the EBSCOhost Research Database (EBSCO), Public MEDLINE -US National Library of Medicine (PUBMED), SAGE Journals Online (SAGE), Directory of Open Access Journals (DOAJ) and Current Index to Nursing and Allied Health Literature (CINAHL) databases.In addition to this search, the journals indexed and available in the Scientific Electronic Library Online (SciELO) were investigated, as well as a manual search of the references cited in the selected articles, and in the potentially useful published and identified systematic articles.
The criteria used to perform the online search on all databases were a combination of the keywords breast reconstruction and qualitative with the synonyms breast reconstructions and reconstructive breast surgery, along with the terms surgical breast reconstruction, ethnography, phenomenology, grounded-theory, content-analysis, observational-methods, participant-observation, focus-group, according to the Descriptors in Health Sciences -DeCS, Virtual Health Library in English, Portuguese and Spanish.
The inclusion criteria for the selection of the studies were: articles published in journals referring to research using qualitative methodology in the study of breast reconstruction from the perspective of women submitted to mastectomy in the English, Portuguese and Spanish languages, with no initial limit to the date of publication, published no later than December, 31 2015.

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Figure 1 -Flowchart of the selection and analysis process of the qualitative studies Regarding the exclusion criteria, 38 studies were excluded because they used a quantitative/ mixed approach, experience reports, literature reviews, breast reconstruction in the perspective of the partners/relatives of women who had undergone mastectomy, in the perspective of health professionals or approached women who did not undergo breast reconstruction and were duplicate studies.
Regarding the analysis of the studies,the importance of the classification regarding methodological rigor, credibility and relevance was observed, with the intention of excluding studies that did not present these characteristics.In order to do so, the Critical Appraisal Skills Programme (CASP) 20 presents the proposal for a critical analysis, through a checklist, that assists in this analytical process, consisting of ten items, which helps the researcher systematically analyze the issues presented in studies.] In order to synthesize knowledge from qualitative studies, we must appropriate the essential task of the synthesis process, using induction and interpretation, as the key point of the ethnographic synthesis is the comparative analysis.Noblit and Hare 18 point out that the systematic comparison involves interpretivism, the transfer of several studies in another study and that this comparison must 6/17 follow seven phases, in addition to three basic criteria to form adequate metaphors, being that these criteria enable the synthesizer to decide how to treat the relationship between the studies.
Regarding production, metaethnography can be conducted in four ways: synthesis of different themes; synthesis of approximately similar themes; synthesis on studies that refute each other; and synthesis on studies that construct a "line of argument".According to these possibilities, this study was conducted through reciprocal translation, when the analyzed studies present similarities, helping the process of understanding and transferring concepts and ideas, apprehending the particularity of each one and reaching a reduction of the reports, maintaining their meaning in a new interpretation. 18he electronic search of the articles was carried out from December 2015 to January 2016, identifying 65 research reports published until December 2015, which were first selected by title, then by reading the abstract, and then by reading the article in its entirety.After this initial stage, it was observed that 27 studies met the inclusion criteria.The second stage consisted of the analytical process related to the quality of these 27 studies, using the CASP checklist and subsequent classification into categories.As a result of the last step, two studies were classified as class A and 11 were classified as class B, thus having na analytical corpus of thirteen studies, according to Figure 1.

RESULTS
Regarding the characterization of the thirteen analyzed studies, nine studies were carried out from 2010 to 2015 and four from 2003 to 2007, with nine studies conducted in Europe, three in North America and one in North America and one in South America.Regarding the area of the periodicals that published the studies, nursing, psychology, medicine (plastic surgery and oncology) and human sciences periodicals were found.
Regarding the professional categories who participated in the studies, four included only nurses, three included psychologists and six included professionals in the following areas: public health, women's health, genetics, philosophy and medical ethics, psychotherapy, surgical oncology, plastic surgery, gynecology/obstetrics, nursing and reconstructive surgery, characterizing interdisciplinary studies.
The thirteen studies analyzed by CASP 20 are presented and characterized in Table 1.

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The meta-ethnography of the articles analyzed, through reciprocal translation, converged into four categories: women's decision to perform breast reconstruction; dealing with the experience of breast reconstruction; describing the advantages and disadvantages of breast reconstruction; women and their relationship with health professionals

Women's decision on performing breast reconstruction
When mastectomy becomes a reality due to necessity, the questions related to the option for breast reconstruction (BR) after the procedure involve desiring symmetry and body proportionality, avoiding the use of external prostheses in the bra, not wishing to remain mutilated, feel "whole" and not feel "empty", wanting to appear "normal" and have the desire to have a different story from the mothers, who performed mastectomy and did not have breast reconstruction causing them unhappiness.Women also cited the possibility of regaining their femininity, sexuality and self-confidence with BR. 21,25- 27,30 Fourteen women talked about ... the feeling of emptiness associated with mastectomy[...]. 26Most opted for reconstruction because they wanted symmetry, and wanted to feel complete, normal. 27he women participants of the studies who did not have a breast reconstruction or did not want to perform breast reconstruction reported that, being alive and being healthy is more important than having a breast.In addition, they expressed concern about the use of an implant, considering it a "foreign body", as well as concern about surgical complications, wishing to avoid feeling more pain and discomfort with additional interventions.2 [...] it is not essential for them to reconstruct the breast, the important thing is their life. 25The process is unnecessary, ... it does not provide any curative benefit and requires additional operations. 24I certainly would not go through all this to have something that does not seem natural. 32

Dealing with the experience of breast reconstruction
Regardless of the type of surgery chosen, BR affects women in a variety of ways: emotionally, physically, and financially.Most women considered themselves unprepared for the complexity of the process, suffering multiple interventions, a lot of pain and a lot of recovery time, but despite these difficulties, they considered the experience positive because it represents the final phase of cancer treatment and helps them to plan the future.The results related to this theme are presented in four subcategories: new body image; personal relationships; social relationships; and adaptation to the new reality.
Regarding the new body image, while the mastectomy represents not only the loss of the breast, but the loss of the woman's identity, the BR makes it possible for women to feel "like themselves", helping to reduce the impact of stress caused by the cancer diagnosis and breast removal, gives them the freedom to wear any kind of clothing.Breast reconstruction enhances the woman's confidence and self-esteem, as well as awakening the feeling of fullness and wholeness.3 [...] described that they felt the reconstructed breast as a natural part of the body [...] and more freedom about choice of clothes. 31[...] were not prepared for the amount of scars,[...] described as appearing to have 'nipples at the waist'; [...] 'ugly scars like a sin'.[...] They make the reconstructed breast look artificial. 29s for personal relationships, the emotional and physical changes resulting from mastectomy and breast reconstruction effect the women's intimate relationships.When women perform late reconstruction, staying for some time without the breast, they prefer not to have sexual relations during this period, feeling more comfortable only after BR.But despite the reconstruction, some women report a greater concern after the end of the treatment, because at the beginning, the issue 10/17 of survival was more important and when they return to 'normal life', they still feel embarrassed to let their partner touch the reconstructed breast, due to lack of sensitivity.] Some said they had no intercourse during the mastectomy period and could start again after the breast reconstruction.[...] they did not remove the bra during sexual relations with their partners, they did not feel comfortable and their relationships were not satisfactory. 25Even with the reconstruction, she did not allow her husband to touch her breast during sexual intercourse. 21egarding social relations, the women in the studies pointed out that there is a great difficulty in resuming social life after breast cancer treatment, that there is the weight of the 'stares' from other people, especially for those who had BR.On the other hand, the women who performed the BR report that it helps to continue working, being treated normally by their colleagues and to continue playing the role of mother, participating in the daily routine of the children.In relation to the socio-cultural dimension of the female identity, we can see that there is a great difference between what society expects and the actual reality of the cultural image of the woman who has undergone mastectomy and breast reconstruction. 21,26,31,33[...]suggested that reconstruction could help protect children from unwanted attention to the surgical area [...]. 33The reconstructed breast, a strange object that would maintain social appearances, would never restore physical integrity or replace the lost femininity. 26n relation to the adaptation to the new reality, women underwent a process of deconstruction and reconstruction of the feminine condition.While the diagnosis of cancer and mastectomy represent the loss of control, the BR allows the resumption of the feeling of drawing the experience of having breast cancer to a close.Although women are often unhappy with the results of BR, they are ready to move on.28][29]31 First I am a human being, then I am a woman and a lesbian woman.No one likes to be disfigured because of a disease. 27[...] the feeling that their new breasts symbolize survival after they have conquered cancer. 31

Reporting the advantages and aisadvantages of breast reconstruction
The analysis of the studies showed that, when they chose to perform breast reconstruction, the women considered that they were too young to remain without breasts, citing positive and negative points related to the type of surgery: with silicone implant, tissue expander or myocutaneous flap (tissue autologous).
The decision for BR with a silicone implant, in the eyes of women, was associated with shorter surgical time, less complexity, less recovery time when compared to the myocutaneous flap and better esthetic result due to fewer scars.As a negative point related to reconstruction with impants, women mentioned the discomfort of the expansion process, and many did not know how long and uncomfortable this process would be. 28,30,33They preferred to have a lesser impact from the surgery and wanted to return to their former routine as quickly as possible. 30The process of tissue expansion took a year [...] the pain was' unbelievable'. 28egarding the choice of BR with myocutaneous flap or autologous tissue, women felt that surgery could offer long-term benefits in comparison to the use of implants and corresponding complications.In addition, they would benefit from a abdominoplasty during the same surgery and would have a more satisfactory aesthetic result, with the reconstructed breast looking more natural than an implant.While some women felt that the procedure was "uncomfortable but not painful," others experienced significant pain, finding the first few days after surgery very difficult, and considering the whole process as too long and complicated. 28,30[...] I was scared about implants.We heard about silicone leakage [...] the surgery with flap seemed safer. 30They told me that I would not feel normal for a year, but I still was not ready for it. 28

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Women and their relationship with health professionals The involvement of women and health professionals in these cases was established from the diagnosis of breast cancer when the health care process for the women began.The women like for professionals to be honest and considerate at all stages, including during the time of receiving necessary information.
Regarding the establishment of communication during the process, the women mentioned that there is a barrier in the contact with the surgeons, since they are not totally available, they remain with the women for a short time and they are dissatisfied with the fact that they leave the care to their assistants who do not possess the same skills.They also reported dissatisfaction with the fact that doctors decided on the type of reconstruction.9 [...] the surgeon's attitude was a barrier for some women.[...] they overcame this because the nurse was approachable and answered the questions they were unable to ask the surgeon. 22[...]when she discovered that her reconstruction had been done in a way that had not been informed, she was unsatisfied. 29n relation to receiving and evaluating information, in addition to information received from doctors and nurses, women reported receiving information from other sources, such as photographs of other women who went through the process, personal contact with other women, information leaflets and the internet.3] All participants saw photographs of their reconstruction method before surgery.[...] negative reactions to photos: as' shocking 'and' circus of horrors' or varying from 'bad taste' to 'pleasantly admired'. 23

Metacategory: carrying on
Through the meta-synthesis, the interpretive and inductive process of the thirteen analyzed studies resulted in four categories, which present relations with the situations found in them.In addition, a new category has emerged, called the metacategory: Carrying on, as it involved questions that emerged implicitly from the analysis of these qualitative research.In an analogy to the Brazilian samba song "Volta por cima", which states "get up, shake the dust off and carry on ", women fell down when they received the diagnosis of breast cancer and the needed to have a mastectomy, but " raised up and shook the dust off "when they made their decision about the BR, facing difficult times and bearing the consequences of their decision, to remain without breast or to have a new breast.In either case, they became a new woman and when they opted for the BR, they had to learn to deal with this experience, which is considered to be long, difficult and complex.They also learned to re-evaluate their relationships with the team of professionals involved in the process, understanding that a closer and caring communication needs to be established with the responsible physicians.By facing this process and deciding to find a new way of living and seeing themselves, they have chosen to turn around, overcome difficulties and accept the new feminine condition. 12/17

DISCUSSION
Regarding the methodology used, referring to the synthesis of qualitative studies, the authors point out that this is a tool to be researched and used in the scope of health and nursing, aiming at perfecting the methodology and validating it, given the production of qualitative research existing in health and nursing, with important aspects of the care and care profession. 34he diagnosis of breast cancer, the need for aggressive treatment, the removal of the breast and breast reconstruction arouse a series of negative feelings in women and causes them to enter into a movement called mourning, which abates any human being.After the initial moment of despair and hopelessness, time causes other more positive feelings to arise.Although dissatisfaction with BR results may occur, at some point women show that they overcome the difficulties and go on to resume their personal, domestic and professional activities, demonstrating that the illness and the treatment lead to the reflection and reassessment of the priorities in their life.9,31 Given that, in this study, situations were similar, highlighting the same reactions of women faced with the problem.
[10] The option for mastectomy and non-reconstruction may be related to their indifference with their new body or the wish to avoid having other surgical procedures. 35Thus, these results corroborate the findings of the present study.] When choosing to perform BR, most women expect scaring, but they are not clear on the size or the healing process of the incisions, referring to surprise and discontent in the postoperative period.Women were reluctant to accept the scars and demonstrated negative reactions, using terms such as "ugly" and "hideous."][38] While for some women, breast reconstruction represents negative feelings about the new body image and decreased self-confidence, as well as the difficulty in resuming a social life after the treatment of breast cancer, the feeling of "pity" or "curiosity" demonstrated by family/friends/colleagues; for others reconstruction means the return of their femininity and of identity as a woman, helping to return to "normal" life, 21,26,36 feelings also present in the statements of the women participating in the studies analyzed in this review.
] BR is seen as the final step in the process of treating breast cancer, which helps in emotional recovery and overcoming bad memories, and represents the end of disease and suffering and, thus, allows the emergence of a new woman and the beginning of a new life. 39

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One of the important aspects in the BR process is the relationship established between women and the health team and, according to the women, health professionals should value complaints more because they feel better when they show personal interest and their experiences.9 Likewise, in this review, the similarities of the results regarding the relationship between professionals and women were evident.
In addition, health professionals represent the main source of information for women who start breast cancer treatment, and they affirm that this information is important, both preoperatively and postoperatively, as it decreases the anxiety involved in the process.Thus, women want to receive all the necessary guidance, in an individual, holistic and comprehensive way. 5,35

CONCLUSION
In summary, studies on breast reconstruction from the perspective of women, show that they have similarities regarding the decision to perform BR or not, and, after opting for reconstruction, and they face difficulty in choosing the type of BR.In addition, women need to learn how to deal with BR and experience difficulties in establishing relationships with certain health professionals, especially physicians.The studies still indicate the ambivalent feelings of the women involved in the breast reconstruction process, with many factors influencing the expectations and the results, demonstrating the complexity of carrying on and demonstrating that the interdisciplinary work in this care is far from the ideal.Thus, the results highlight the need to know the perceptions of women with breast cancer, in order to improve the understanding of the personal and social consequences for the woman with breast reconstruction and to improve the quality of care provided.

Table 1 -
Qualitative research on breast reconstruction from the perspective of women submitted to mastectomy, published by 2015 (N=13)