Perceptions of non-Western immigrant women on having breast cancer and their experiences with treatment-related changes in body weight and lifestyle: A qualitative study

Background The number of non-Western immigrants with breast cancer in the Netherlands has increased over the past decades and is expected to triple by 2030. Due to insufficient representation in clinical studies, it is unclear what the specific experiences and needs of these women are. Understanding how culture and religion affect these women’s experience of breast cancer and how they deal with chemotherapy and treatment-related changes in body weight and lifestyle is crucial for health care professionals to be able to provide effective support. Methods A qualitative study was conducted using semi-structured interviews with 28 immigrant women with a history of breast cancer treated with chemotherapy. Results Women often associated breast cancer with taboo, death or bad luck. Religion offered these women guidance, strength and meaning to the disease, but also limited the women to openly talk about their disease. Women perceived lifestyle factors to have little influence on the development and treatment of cancer. After treatment, however, their thinking changed and these lifestyle factors became of paramount importance to them. They realised that they missed out on information about managing their own diet, exercise and body weight and were eager to share their experiences with other women in their culture with newly diagnosed breast cancer. Conclusion Women became aware during and after breast cancer treatment that it was difficult for them to actively deal with their illness under the influence of their culture and religion. Based on their own experiences and acquired knowledge, they would like to give advice to newly diagnosed women on how to deal with breast cancer within their own culture and religion. Their recommendations could be used by mosques, churches, support groups and health care professionals, to ensure interventions during breast cancer treatment meet their religious and cultural needs and thus improve their quality of life.


Introduction
People with an immigrant background in general have a lower risk of getting cancer compared to the native population. This is due to differences in exposure to risk factors, both in their country of origin and in the new country of residence [1,2]. This risk can shift after decades, often in the direction of the risk as found in the native-born population [1]. In the last decades, the composition of the population in the Netherlands has changed, partly due to immigration. To illustrate, in 2015, 10% of the population in the Netherlands was foreign-born [3]. Immigrants primarily originate from non-Western countries such as Turkey, Morocco and the former Dutch colonies Indonesia, Surinam and the Netherlands Antilles [3]. It is expected thatin line with the convergence hypothesis [1,2,4,5,6,7,8,9]-the incidence and mortality rate of cancer among non-Western immigrants will slowly increase and converge with the rates of the native Dutch population. Where breast cancer is concerned, it is expected that by 2030 the proportion of non-Western immigrant women, as part of the total incidence of women with breast cancer in the Netherlands, will have tripled from 2.9% to 8.7% [2].
From most women in Western countries it is known that they perceive breast cancer diagnosis and treatment as a stressful event that threatens all aspects of their lives [10]. It is generally associated with a combination of physical and psychological threats, such as diseaserelated symptoms and treatment impacts, bodily changes and disruption to employment and social life [11,12]. Despite the marginal representation of non-Western immigrant women in breast cancer studies, there are indications that differences in perception on breast cancer and breast cancer treatment exist. Studies from across the world highlight that racial and ethnic disparities in breast cancer treatment prevail, for instance amongst African-American and Hispanic women in the USA [13,14], and women in New Zealand with Maori and Pacific origin [15]. These disparities may contribute to differences in perception and poorer outcomes in women from minorities with breast cancer, probably due to racial discrimination, cultural insensitivity, and poor provider-patient relationships [13,14,15].
Diagnosis and treatment of breast cancer can affect body weight, through changes in diet and physical activity. Studies have illustrated that non-Western immigrant women and Western women show differences in dietary intake which may be due to religious, cultural traditions and social barriers relating to food attitudes and body image ideals. Physical limitations due to an acceptance of larger body weights, which is more common in non-Western populations, may influence physical activity negatively [16,17,18,19,20,21,22,23]. These to have their full transcripts made publicly available. Supporting excerpts from the raw data (quotes from interviews with participants) are available within the text of the paper. Due to ethical restrictions protecting participant confidentiality, the full transcripts of interviews will not be publicly available. Because data contain potentially identifying or sensitive patient information. Instead anonymized excerpts of the transcripts will be available upon request. The data is archived at the differences may lead to higher weight gains during therapy, which is reported to be associated with greater morbidity and poorer survival among breast cancer patients [24,25]. To illustrate, in studies on the toxicity of chemotherapy for breast cancer, significantly greater weight gain after diagnosis and treatment [26,27] was found in African American women compared with Caucasian women. African American women felt frustration about weight gain and perceived it as a stressor [28], not being able to control their weight gain because of pain, fatigue, lack of time and knowledge about healthy eating [29], and health concerns [28,29,30]. However, they also expressed greater tolerance for larger body sizes [26,31,32] and a sense of acceptation of weight gain as a strategy for coping with breast cancer diagnosis [24,33]. Results from the Women's Healthy Eating and Living (WHEL) study showed that African American breast cancer survivors are more likely than Caucasian survivors to consume more fat, sweets and junk food, and fewer servings of fruits (−0.7/day) [34]. Despite a dietary intervention based on counselling and building on self-efficacy, African-American breast cancer survivors are less successful at making and maintaining dietary changes such as reducing fat and increasing fibre [23] and are less successful at engaging in physical activity [22]. However, in a study among Turkish women, it was shown that weight gain after adjuvant systemic therapy was in line with European and American counterparts [35].
Although breast cancer diagnosis and treatment may have different implications for ethnic groups and are not always culturally tailored, it is not clear to what extent this applies to foreign-born immigrants and the second generation born in the Netherlands. To provide effective support, it is crucial to understand how an immigrant background shapes women´s experiences of breast cancer, and how this may influence coping with chemotherapy treatment and its side-effects, in particular focusing on body weight and lifestyle changes. In most studies women from non-Western ethnic backgrounds appeared to have been under-represented. To reach meaningful and generalizable results a better representation of ethnic minorities in clinical trials is required, because treatment effects might differ according to ethnicity.
In this qualitative study, we explored how non-Western immigrant women experienced being diagnosed with breast cancer, and how they experienced chemotherapy and treatmentrelated changes in body weight and lifestyle. Through this qualitative approach, we describe how women experienced and dealt with the cultural and contextual factors of cancer diagnosis and treatment in order to contribute to the development of culturally tailored interventions during and after treatment for breast cancer.

Design
A qualitative explorative study was conducted using semi-structured interviews with 28 non-Western first and second-generation immigrant women with breast cancer, treated with chemotherapy. We defined non-Western women as women who originally came from Turkey, Morocco, Surinam and the Netherlands Antilles, the Middle East and Africa. We made an exception for one woman who originally came from Portugal. She took part in our research because of her knowledge gained through her voluntary work for an organization for non-Western women with breast cancer and because of her conversion from Christianity to Islam.
The Medical Ethics Committee of the Wageningen University approved the entire COBRA study (ABR NL40666.081.12).
chemotherapy. Respondents were recruited via hospitals and general practices in Amsterdam and Rotterdam. It became evident that in practice this would not generate enough respondents. Therefore, organizations that specifically target non-Western immigrant women with breast cancer, and organizations for non-Western immigrant women in general, were approached and agreed to participate in the recruitment of women. Furthermore, through the network of the researchers and snowball sampling, a total of 28 non-Western immigrant women agreed to participate. Four of the respondents from the organisation for non-Western immigrants currently worked as volunteer breast cancer consultants to support women newly diagnosed with breast cancer.

Data collection
The semi-structured interviews were guided by a topic list [36] based on existing knowledge and complementary literature search. Examples of topics that were included are: the reaction to diagnosis, experiences during and after chemotherapy with weight gain, nutrition and physical health, coping with illness, and the cultural and religious influences on experiences of diagnosis and treatment. We also asked women what advice they would like to give to someone from the same country of origin who is now diagnosed with breast cancer.
The research team reassessed the topic list after the first six interviews. The topic list was expanded with a topic 'the perception on the cause of breast cancer' as the first interviews showed that this perception partly shaped women's reaction after knowing their diagnosis of breast cancer.
Most of the women were interviewed at home by AK, RC, GS and AS; three of the women were interviewed in a quiet room in the hospital where the women had their follow-up appointment. None of the physicians or nurses who treated the patients were present during the interview. During one interview a health care advisor for non-Western patients was present, as this was explicitly requested by the respondent. Furthermore, most of the women were capable to express their feelings and thoughts well in the Dutch language except for two women who were therefore respectively assisted by a friend and a daughter. All women were informed about the study goal prior to the interviews and signed an informed consent. All women were interviewed after their treatment for breast cancer (mean 4.3 y (range 1-12) after diagnosis). The interviews lasted between 30 min and 2 hours (mean 81 min) and were recorded with a voice recorder.

Data analysis
The verbatim transcribed interviews were analyzed according to a thematic approach [37]. All interview transcripts were summarized and partial first analysis was conducted by AS, GL and MF. Final total analysis was performed through several phases of coding to analyze the data manually after close reading by two researchers (RC, AK). Labels were given to each text fragment of the interview in a system known as open coding. Two interviews were independently coded by two researchers (AK, RC). The findings were discussed via peer-debriefing until consensus was reached. Subsequently, through axial coding the labels were interpreted and clustered into sub-themes and main themes. The next phase of the analysis was selective coding, identifying the essence of each theme, searching for differences and similarities within and across respondents and looking for deviant cases through constant comparison. The framework of themes and the preliminary conclusions based on this analysis were thoroughly discussed among the two researchers (AK, RC), a member of the research team (MW), and with one of the interviewed women (FB). RC as researcher and Muslim woman, and FB as voluntary breast cancer consultant at an organisation for non-Western immigrant women and a Muslim woman as well, helped to interpret the results and to formulate the needs and recommendations of the women, through their shared knowledge of culture and religion of the respondents. The recommendations describe what had changed for the women after being diagnosed with breast cancer and having undergone treatment, what they would do differently with the knowledge of today and how it will help other women newly diagnosed.
To ensure further validity, the researchers used 'member check', i.e. returning a summary of an interview to a participant to check for accuracy and whether it resonated with their experiences [38], in two ways; 1) ten of the respondents received a summary of the transcript of their interview and were asked if they recognized themselves in what was written and whether they felt their story had been expressed correctly, and 2) with eight other previously interviewed women the results of the interviews were discussed in a group meeting and they were asked if they recognized themselves in the interpretation.

Results
All twenty-eight women were treated with (neo) adjuvant chemotherapy and surgery and/or radiation and/or hormone therapy. Twenty-three women had migrated to the Netherlands of whom two were refugees (mean 28,1y (range 7-50) and five women were born in the Netherlands. We were able to deduct the religious status of 25 women; 17 identified their religion as Islam, 4 women as other, and 4 women identified themselves as non-religious although three of them were originally Muslim. For further demographic characteristics of the women see Table 1.
The results of the analysis are described in three themes, including needs and recommendations from women for fellow patients, that offer a good illustration of what it means for these women to have breast cancer and to undergo treatment: In reporting the themes, we used the quotes of the women themselves as much as possible to show their story as extensively as possible.

I. Role of culture and religion
Perceptions on cause of breast cancer and disclosure of breast cancer diagnosis. All women experienced breast cancer diagnosis as a very traumatic experience and the word cancer carried such weight that it is not or hardly pronounced. Some women mentioned how breast cancer is viewed in their country of origin; it is the unnamed disease for which there is hardly any treatment. Four women talked about having breast cancer in their country of origin: One of the Surinamese women described cancer as a non-identifiable, bad disease, if you have it you will die. The Sudanese woman mentioned that in her country of origin the word cancer is not pronounced, a doctor will usually not dare to tell the diagnosis to the patient. In Kurdistan, the word cancer is not mentioned because people cannot or do not want to spend money on the treatment of cancer, because the loss of a breast due to treatment for breast cancer is unacceptable. Furthermore, few women can afford the treatment. One of the women from Turkey described that in a less cosmopolitan and more conservative area than Istanbul, cancer is still a taboo. These women were grateful they lived in the Netherlands and could be treated here.
Most of the women explained that their country of origin, their culture, and religion, shaped how they dealt with the diagnosis of breast cancer.
The majority of the women were religious and religion is an important part of their daily life:

PLOS ONE
Non-Western women with breast cancer, their experiences with diagnosis and treatment, a qualitative study Despite the fact that women experienced breast cancer as a test or a punishment, they believed faith gave them strength and a second chance to come closer to God:

II. Impact of chemotherapy
Women reported during and directly after treatment well-known side effects such as; nausea, vomiting, hair loss, loss of energy and fatigue, taste and smell alterations, psychological distress and chemotherapy-related-hospitalizations. Due to these side effects and feelings about diagnosis breast cancer and treatment, women became more aware of the need to take better care of themselves, of their health and their body: Only two women called in the help of a dietician, one because of extreme weight loss and the other because of extreme weight gain. They both followed their diet strictly: 'I was happy, I received a dietary scheme and I ate everything that was on that scheme' (Sudanese woman, 35 y) Nutrition. Before diagnosis most women were used to eating a variety of foods, including fruits and vegetables. There were also unhealthy food products in their diets, such as sugary drinks, a lot of red meat and confectionery: 'I ate a lot of unhealthy food, I realize that now' (Turkish woman, 53 y) This Syrian woman found it important to watch her diet already before diagnosis: '. . .and I eat healthy, but little. I don't eat three times a day, but I eat a good sandwich with cheese. I also drink milk, I always eat healthy vegetables and fruit. I don't smoke, I don't drink, and I eat no fat' (Syrian woman, 52 y) During chemotherapy the majority of the women mentioned their diet changed due to chemotherapy and lacked variety because of their symptoms:

'I wanted to try Ramadan and if it did not work, I would stop. I could actually get meds and everything through the drip the doctor gave me. And I felt really good, fasting isn't harmful, it is good for your body, it is purifying for your body' (Moroccan woman, 36 y)
After treatment a small majority of the women mentioned that they changed their diet, because they became more conscious of their eating habits and tried to decrease the amount of unhealthy foods in their diets: 'I try not to cook with deep-frozen products or ready-to-serve dinners but I try to make everything fresh by myself. I try. . . yes, it is not always easy . . . to eat vegetables and drink organic milk. I am more aware of healthy food now, snacks are really poison for me'. Physical activity. Before diagnosis women had different tasks during the day. They sometimes combined household chores, taking care of the children (especially if they were young) with a job. Some of them had also taken on the task of caring for their (sick) parents. About half of the women felt that their days were completely filled with household chores and work: 'My daily activity consisted of my household chores and working as a cleaning lady, that was exercise for three hours a day, going back and forth, this was enough physical activity for me' (Turkish woman, 56 y) A few women mentioned that their lives take place in and around the house. They usually stay at home and only go outside for a reason:

'I only go outside if I have an appointment or if I want to go shopping' (Sudanese woman, 35 y)
However, the other half of the women described how they were doing sports next to household chores and raising their children:

'I went three times a week to the gym. I worked six hours a day. I started at nine and was home at three o'clock, I was constantly busy; I can't remember that I was at home on an afternoon' (Turkish woman, 48 y)
During treatment the majority of the women were too tired to be physically active and they were sometimes not even able to go outside due to the tiredness they felt. For some women, the chemotherapy did not have much impact on their physical activity. They felt weak, for a couple of days at the most, but after that, they would continue their normal daily activities.
'The first day of chemo, I was brought home, the second day I couldn't cycle, but I was able to continue with my normal daily activities the third day.' (Portuguese woman, 44y) '. . ..at the end of the chemo, my husband drove beside me in the car and I rode the bike. He thought it was really ridiculous that I was still on the bike. I just have to go. I thought it's just not healthy if you get a whole bag of poison through your body and you just sit or lie down. You should move, you just have to stay active, it just has to be, it just has to flow through your body' (Turkish woman, 54 y) However, they could not perform intensive physical activities such as working every day or going to the gym three times a week.
Directly after treatment, hardly any of the women were able to be as active as they were before the treatment. Women still suffered from tiredness, fuzziness and they sometimes felt lazy. Some women picked up their normal daily activity routine, but did so in a less intensive manner: 'After the chemo, I started to go to the gym again, but just two times a week and for half an hour' (Surinamese woman, 40 y) For some women, the tiredness gradually diminished. However, for other women, fatigue continues to affect their daily lives and they feel incapable of physical activity:

'10 years after chemotherapy, I still get tired very quickly. I get tired quickly after physical strain' (Kurdish woman, 48 y)
Just a few of the women were able to pick up their normal daily activities as previously. Several women indicated they were confronted with too many emotional events such as the death of a son, spouse, mother or divorce, which meant that physical activity was totally disregarded.
Respondents' needs and recommendations. Women indicated that changes in diet and exercise during and after chemotherapy require information:

III. Social support
Partner and family. Social support was identified as important for all women. In particular, many married women experienced their husbands as providing the greatest support. The emotional support of the immediate and extended family during and after the treatment was also a source of hope and help to endure this period.
Partners responded in many different ways to the emotions and needs of their wives suffering with breast cancer: with hope and support, but also with a feeling of helplessness: 'He did not expect me to do no cooking anymore and that the house was not always clean, he never did anything. . . . and suddenly he came home with another woman' (Surinamese woman, 40y).

He left me after 28 years of marriage because I became ill and he could not tolerate my illness.
If he had cancer or another disease, I would never do this to him. Never. I would've stayed with him with all my love. I would care for him. My heart is broken into a thousand pieces. Even cancer didn't cause me so much pain; this is the most difficult part.' (Kurdish woman, 48 y) Women did not want to burden their families, as they already felt helpless. They said they would hide their feelings from their family and would only take care of themselves after they had fulfilled all their duties towards their husbands and children. That is why some of them sometimes wanted to go to their appointments alone and be sick on their own: 'I just sent my husband to his work and I only wanted to cry when the children were in school or already in bed' (Turkish woman, 41 y, 3 kids) Families were sometimes very shocked about the breast cancer diagnosis and often did not know much about cancer. Women could not talk openly with their family about their illness because cancer is a taboo and some women felt ashamed of having cancer: 'I had terrible reactions from my family, they were busy but mainly concerned with their own fear and sadness. . . I thought I am the cancer patient but it is only about you. . .' (Turkish woman, 54 y, widow) 'People did not dare to come because cancer is taboo, even my own family did not want to hear about it' (Sudanese woman, 35 y) 'For my family it was new, I was the first in the family to have cancer so they were all very upset and could not talk about it. Much later it turned out that two cousins also had breast cancer, they never told anything about it. They thought that you should be ashamed of having had cancer, and that disappointed me' (Surinamese woman, 54 y) Friends. From their community, women experienced support. Paying visits to people who are ill is a social and religious obligation for Muslims. Many of the Islamic respondents talked about receiving a lot of visitors during their treatment: 'My sister was here, my neighbours were kind to me, my friends. Everyone was really nice to me. Yes, really. . . They also came to bring food. They are such lovely people. The whole room was full of flowers. Some people, so many people had come, that really helps you. You are not alone. I had visit, after visit, after visit, and I was really happy with it..'. (Turkish and Muslim woman, 48 y) Some women experienced the community support negatively:

'I did not need it. I don't want to be called or visited. Only my sisters knew, no one else. No, I do not want to be called every time, I'm not waiting for that and that happens when everyone knows' (Moroccan and Muslim woman 36 y)
Not all of the women had a reliable social network they could depend on, due to emigration to the Netherlands. Most family members, who could provide support, still lived in their home country. Due to the vast distance and the financial costs, these women were not able to receive support from their relatives: Other women explained they did not like talking with fellow patients nor going to a support group, because these sessions put them in a negative mind-set.
Several women said they came into contact with Mammarosa (a contact group for women with breast cancer women for whom Dutch is not their mother tongue) in various ways:

Discussion
In this qualitative study, we found that experiences of non-Western women with breast cancer during diagnosis and treatment were often influenced by religion and culture. Many women perceived the cause of breast cancer as the will of God, punishment, as a test, or bad luck. However, faith also gave strength and made it possible to come closer to God. For most women cancer is still synonymous with dying and their greatest fear is leaving behind their children and missing the opportunity to raise them. Besides the well-known side effects of treatment, women also reported weight gain as a frequent and lasting struggle even in the period after chemotherapy. The advice of health care professionals on weight gain, whether or not to participate in Ramadan during treatment, and on physical activity, were sometimes misinterpreted by women due to their communication skills and language barriers. Social support was given by spouses, family, friends and fellow patients. Visits from family and friends, based on the social and religious obligation for Muslims to visit those who are ill, were not always appreciated. This sometimes resulted in family members and friends not being told about the breast cancer diagnosis, especially when breast cancer was indicated as a taboo or something to feel ashamed of. Conversely, other women talked openly about their disease to family members and friends and needed these visits, especially from family members. Contact with fellow patients was not always experienced positively, as the stories of others gave a negative mindset. However, other women felt supported through the support group for breast cancer patients. Women became aware that it was difficult for them to actively deal with their illness due to their culture and religion. They felt they were unable to exert much if any influence on the development and treatment of their cancer. After treatment, however, they realised that they had missed out on information about managing their own diet, exercise and body weight and were eager to share their experiences with other women with newly diagnosed breast cancer in their culture. They would like mosques, churches, support groups and health workers to adopt their recommendations in order to meet the religious and cultural needs of non-western women during breast cancer treatment, thereby improving their quality of life.
The majority of women (17 of 28) in our study are Muslim, and their perceptions of breast cancer and breast cancer treatment were often shaped by their religion and culture. However, for the non-religious women culture also influenced their perceptions of breast cancer and breast cancer treatment. This religious and cultural influence on the perceptions of breast cancer and breast cancer treatment is confirmed by studies exploring the reactions of Turkish women to their cancer diagnosis [39,40,41]. These studies found that cancer was perceived as death and suffering [40], family support was very important but inadequate [41], and difficulty to accept illness negatively affected quality of life [41].
Almost half of the women in our study gained weight during and or after treatment. Women experienced problems with dietary intake and physical exercise as part of their weight gain. They viewed weight gain as a source of distress and as a health concern. While this finding is consistent with prior research [28,29,30], our results also highlight that some women viewed weight loss as a positive experience. Women were frustrated they were not able to control changes in their weight and experienced these weight changes as unrelated to their eating or activity behaviours. Our results are in line with a recent qualitative study with African-American breast cancer survivors, which demonstrated that women experience difficulty maintaining weight control efforts because of barriers such as pain, fatigue, lack of time, lack of knowledge about what to eat and how to prepare foods in a healthy way [29]. In addition, African-American breast cancer survivors have been shown to be less likely than Caucasian survivors to report that they changed their diet or increased their physical activity following diagnosis and treatment [24]. This may be because of a greater tolerance for larger body sizes among African-American women [31,32]. This could be the same among the Surinamese and older Turkish and Moroccan women in our study. Perhaps it is different for younger Turkish women born in the Netherlands, as they seem to think it is important to watch their weight before diagnosis but also during treatment.
This study shows the influence of culture and religion on the women's perceptions of chemotherapy and treatment-related changes in body weight and lifestyle. Studies examining the behaviour of women in response to these treatment related changes show that not many women, including non-Western women, succeed in positive long-term behavioural change [42,43,44]. With the growing number of cancer survivors, there is a need for effective behavioural interventions. To our knowledge, this is one of the few studies in which non-Western women reflected on their experiences of breast cancer and breast cancer treatment in order to made recommendations available for effective interventions of cancer patients within minority populations.

Implications for practice
The recommendations of, in particular, Muslim women are numerous and valuable. These recommendations are based on their own needs and experiences during the treatment of breast cancer. These recommendations can be considered more or less in accordance with the Self-Determination Theory (SDT) [45]. Muslim women indicated that there should be more open talk about breast cancer and not in terms of punishment or penance. They want to make their own conscious decision to live more healthily, they want to be able to make autonomous choices. They need more time and more information from health care professionals about healthy food choices and encouragement to exercise more. That is in line with their own religious values and norms, such as the requirement in the Quran that you must take good care of your own body. More than half of the women contacted others such as fellow sufferers through support groups to help them with their own experiences, while the other women do not want contact with others. Further development of these recommendations in line with SDT provides starting points for interventions to support these women and clearly contributes to a better quality of life during and after chemotherapy. We describe their recommendations as implications for three different groups: 1) all people around them, 2) breast cancer support groups, and 3) health care professionals. These groups will be able to support women with newly diagnosed breast cancer by taking responsibility for these recommendations and helping with the implementation (see Box 1).

BOX 1. Implications for practice
For all network members: • Help women to create opportunities for talking openly about breast cancer • Help women to take good care of themselves, and not only take care of others first For breast cancer support groups: • Beware that some women have a negative attitude towards breast cancer due to stories they heard from fellow patients • Continue to create a meeting place for women of all kinds of ethnic minorities for support, information, and an opportunity to share stories • Encourage women to eat healthy and exercise and maintain a healthy body weight during and after treatment For health care professionals: • Create more time during doctor's visits and ensure that interpreters are available so that patients can fully understand the consequences of a breast cancer diagnosis and its treatment

Strength and limitations
The strength of this study lies in the diversity of the stories told. The interviewed women had different ethnic backgrounds and religions, and they had experienced a variety of breast cancer treatments. These interviews were thus very rich and informative, offering a great variety of insights.
The approach and methods were chosen carefully. A patient-expert, one of the interviewed women converted from Christianity to Islam, and one of the researchers (RC) helped to interpret the results especially in relation to the meaning within Islam, in order to better understand the women and their struggles, and to gain insight into the recommendations, beliefs and perceptions of these women.
The primary limitations of this study are related to the method of sampling. The recruitment of women took a lot of time and effort. That is why convenience sampling was chosen as the method of sampling. This meant that women who were easiest to find, ended up in our sample. Despite this, it was a diverse sample with women who were very open in telling their story. As mentioned above, this is one of the strengths of the study. However, if subsequent studies are meant to convey something about a specific group, such as groups with the same religion or the same cultural background, it is recommended that ample time be allowed for recruitment and that a more heterogeneous sampling method is chosen. The fact that only women with a reasonable command of the Dutch language were selected could mean that the sample represents only a part of the non-Western immigrant population of women with breast cancer, namely women who were already better integrated into Dutch society.

Conclusions
Women became aware during and after breast cancer treatment that it was difficult for them to actively deal with their illness due to their culture and religion. At diagnosis, most women perceived lifestyle factors to have little influence on the development and treatment of cancer. After treatment, however, their thinking changed and these lifestyle factors became of paramount importance to these women. They realised that they missed out on information about optimal diet, exercise and body weight during and after treatment. Based on their own experiences and acquired knowledge, they are eager to give advice on how to deal with breast cancer to newly diagnosed women within their own culture and religion. A set of recommendations was formulated to support health care professionals, breast cancer support groups, mosques and churches to meet the religious and cultural needs of non-western women during breast cancer treatment and thus improve their quality of life.