Breast cancer remains the most prevalent malignancy among women worldwide. Data from the World Health Organization indicate that 2.3 million women were diagnosed with breast cancer in 2022, with 670,000 fatalities [1]. In South Korea, the age-standardized incidence rate of female breast cancer reached 109.9 per 100,000 in 2021, making it the most common cancer type among women, with an annual increase of 4.5% since 2007 [2]. Despite these alarming statistics, the survival rates exceed 90% in high-income countries using standard treatments, including local surgical interventions and systemic chemotherapies [3]. In particular, in South Korea, the 5-year relative survival rate has improved considerably from 79.3% (1993–1995) to 93.8% (2017–2021) [2].

As the survival rates continue to improve, the focus on breast cancer treatment has shifted toward improving the patients’ quality of life. There is an increasing interest in interventions that address not only the physical symptoms, such as pain and lymphedema, but also the psychosocial factors, including anxiety and sexual dysfunction [4]. Acupuncture and moxibustion (AM) treatment, which is traditionally used in East Asia, has attracted attention as a supportive care modality for cancer patients in the United States [5]. Research on AM treatment for breast cancer patients is expanding, including quantitative and qualitative studies exploring the experiences of healthcare providers and patients [6,7].

The qualitative research methodology aims to provide more insight into real-world phenomena by collecting data on the experiences, perceptions, and behaviors of participants. It can be used independently or to complement and improve quantitative findings [8]. Qualitative meta-synthesis involves systematically analyzing and integratively interpreting the results of individual qualitative studies, which is increasingly recognized for its ability to offer specific recommendations and expanded knowledge for future research [9,10].

The total cost of breast cancer treatment in Korean traditional medical clinics and hospitals has reportedly increased from approximately $1.16 million in 2013 to approximately $10.04 million in 2022 [11]. Given this growing medical demand, understanding the patients’ experiences and perceptions is crucial to developing improved treatment strategies. Although qualitative studies have been conducted on patients with breast cancer who had undergone AM treatment both nationally and internationally, there have been no systematic reviews to date. Therefore, a qualitative meta-synthesis is warranted to explore more holistic and integrated treatment strategies for breast cancer. The present study used qualitative meta-synthesis to systematically review research studies on patients’ experiences with AM treatment to derive higher-level concepts and provide practical insights for the development of future interventions and formulation of relevant policies.

Among the various qualitative synthesis methodologies, the present study employed Noblit and Hare’s meta-ethnography approach. Meta-ethnography, commonly used in healthcare research, synthesizes the findings of multiple independent studies to offer new insights into the perspectives and experiences of patients and healthcare providers [12].

1. Step 1: get started

The literature search revealed ongoing qualitative research on breast cancer patients’ experiences with integrative healthcare, including AM treatment. However, no specific qualitative synthesis studies have been conducted in this area. A comprehensive understanding of patients’ perceptions and experiences regarding AM treatment was imperative.

2. Step 2: decide what is relevant to the initial interest

1) Literature search and data extraction

To identify qualitative studies conducted in South Korea, we searched the Korea Citation Index, Research Information Sharing Service, and ScienceOn databases. Considering that AM treatment in South Korea is often combined with herbal medicine, chuna, and cupping, the search terms were broadly defined to include “breast cancer,” “acupuncture,” “pharmacoacupuncture,” “electroacupuncture,” “auricular acupuncture,” “electronic moxibustion,” “moxibustion,” “cupping,” “chuna,” “Korean medicine treatment,” and “traditional Korean medicine treatment.”

For the international literature, the Cochrane, EMBASE, and PubMed databases were searched using similar terms. However, recognizing that AM treatment is categorized under traditional Chinese medicine and complementary and alternative medicine globally, the search terms were expanded to include “breast cancer,” “acupuncture,” “electroacupuncture,” “pharmacoacupuncture,” “herbal acupuncture,” “ear acupuncture,” “auricular acupuncture,” “moxa,” “moxibustion,” “herbal moxa,” “herbal moxibustion,” “cupping,” “cupping therapy,” “chuna,” “chuna manual therapy,” “tuina,” “tuina manual therapy,” “Korean medicine,” “traditional Korean medicine,” “oriental medicine,” “herbal medicine,” “Chinese medicine,” “Kampo,” “Kampo medicine,” “complementary and alternative medicine,” “traditional Chinese medicine,” “TCM,” and “native medicine.”

Based on the synthesis focus (“breast cancer patients’ perceptions of and experience with AM treatment”), the inclusion criteria were as follows: (1) studies examining breast cancer patients’ perceptions of and experiences with AM treatment; (2) studies using a qualitative methodology; and (3) studies published in Korean or English. The exclusion criteria were as follows: (1) studies not involving breast cancer patients; (2) studies not using AM treatment as a primary intervention; (3) studies focusing on the healthcare providers’ perceptions and experiences; and (4) studies that primarily used methodologies other than qualitative research. There were no restrictions on the year of publication.

A preliminary literature search conducted in February 2024 identified 403 potentially relevant studies. After removing 86 duplicates, the titles and abstracts of the remaining 317 studies were reviewed; a total of 296 studies that did not align with the study objectives were excluded. The full texts of the remaining 21 studies were then assessed and, finally, 11 articles were included in the present study. The selection process involved three researchers (SK, JH, and IY) who resolved disagreements through a discussion to reach a consensus. The process is shown in Fig. 1, depicting a preferred reporting items for systematic reviews and meta-analyses flow diagram.

Figure 1. Flow chart of the study.

2) Assessment of the literature quality

Although there is a lack of consensus on the evaluation of qualitative research [13], researchers applied the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to assess the quality of the 10 interview-based studies. For the remaining study, which used a written mail format, the Standards for Reporting Qualitative Research (SRQR) was used. COREQ comprises 32 questions across three domains (research team/reflexivity, study design, and analysis/findings) with a higher percentage of satisfied criteria indicating a more systematic study quality [14]. SRQR, applicable to various qualitative studies, includes 21 questions in six domains (title and abstract, introduction, methods, results and findings, discussion, and others), which also indicates a more systematic quality with a higher percentage of satisfied criteria [15]. Each researcher independently assessed the literature, compared the results, and resolved disagreements through a discussion to reach a consensus.

3. Step 3: read the studies

In a meta-ethnography, data are organized into primary, secondary, and tertiary structures. The primary structure comprises direct quotes from the participants in the original study, the secondary structure involves conceptual interpretation by the original authors, and the tertiary structure represents new interpretations derived from the synthesis of the secondary structure [16]. In the present study, the researchers thoroughly reviewed the selected studies to understand their themes and details. From the 11 studies, they extracted relevant primary and secondary structures related to breast cancer patients’ experiences with AM treatment, ensuring that the primary structure was preserved in its original form. The texts were repeatedly reviewed to refine content extraction, aligning it with the synthesis goals. Microsoft Excel (Microsoft) was used to compare and organize the recurring concepts in the studies.

4. Steps 4 and 5: determine how the studies are related and translate the studies into one another

To develop themes that provide a comprehensive understanding of breast cancer patients’ experiences, the interrelationships between the juxtaposed data were analyzed. Recognizing that previous research influences subsequent studies [17], the studies were chronologically organized and themes and concepts were compared sequentially from the first study to the second, and so on. This process continued until all studies were reviewed, with closely related topics grouped into the same category.

5. Step 6: synthesize the translations

To develop the tertiary structure, each researcher analyzed the results based on the primary and secondary structures. Discrepancies in interpretation were resolved through discussions during which key concepts were extracted, reorganized, and abstracted from the primary and secondary structures. These were then synthesized into overarching themes to reach a consensus.

6. Step 7: expressing the synthesis

The results of the synthesis are tabulated in Table 1 to facilitate reader comprehension.

Table 1 . Synthesized themes of breast cancer survivors’ experiences with acupuncture and moxibustion treatment.

Primary structures (key concepts)	Secondary structures (sub-themes)	Tertiary structures (themes)
- Physical symptoms, such as facial flushing, gastrointestinal disturbances, and joint pain - Emotional symptoms, such as depression and anxiety	1. Difficulties in daily life due to the physical symptom burden	I. Distress during the standard treatment process of breast cancer
- Guilt and remorse toward family - Impaired intimacy in marital relations - Sense of alienation in social relationships - Withdrawal from professional life	2. Relational alienation
- Loss of control over life - Decrease in the will to survive	3. Existential distress
- Lack of empathy from healthcare providers - Insufficient time allocation - Inadequate information provision	1. Unmet medical needs in relation to healthcare providers	II. Holistic treatment and care needs
- Diagnostic and examination processes that undermine self-control - Insufficient access to holistic care - Passive role as an object rather than a person	2. Preserving human dignity
- Therapeutic expectations based on personal experiences - Therapeutic expectations based on others’ experiences - Burden of additional medication therapy	1. Expectation of the treatment	III. A holistic approach through acupuncture and moxibustion treatment
- Skepticism regarding the therapeutic efficacy - Opposition from healthcare providers - Fear of needles - Cost concerns	2. Negative perception of the treatment
- Alleviation of the physical symptom burden - Reduction of emotional stress - Overall enhancement of vitality	3. Symptom improvement
- Care experiences during the treatment sessions - Holistic and empathetic communication with healthcare providers - Respect as a person	4. Holistic care experience
- Increased motivation for treatment - Improvement in personal and social quality of life - Regaining control over life - Formation of the integrated self	5. Creating an integrated self

1. General characteristics of the selected studies

A total of 11 studies were identified (conducted in Asia [5], Europe [4], North America [1], and Oceania [1]). The participants were predominantly in their 50s, with the sample sizes ranging from 6 to 61 peoples. The methodologies used included thematic analysis (5), grounded theory (3), narrative inquiry (1), content analysis (1), and directed qualitative content analysis (1). Data collection methods consisted of interviews (10) and written responses by mail (1) (Table 2) [18-28].

Table 2 . Characteristics of the included studies.

No.	Year	Author	Country	Study aim	Sample size (n)	Age range (y)	Methodology	Data collection
1	2010	Hervik and Mjåland [23]	Norway	To examine the quality of life of patients with breast cancer receiving estrogen antagonists at 2 years after undergoing acupuncture treatment for hot flashes	61	51.3	Grounded theory	Postal questionnaires
2	2013	Price et al. [27]	UK	Exploring the needs and concerns of women and the perceived benefits of traditional acupuncture	14	54.0	Grounded theory	In-depth interviews
3	2014	Han [18]	Republic of Korea	To describe the experiences of a breast cancer patient with Korean medicine treatments and to propose the future direction of Korean medicine for the treatment of breast cancer	10	50.6	Narrative inquiry	In-depth interviews
4	2014	Schapira et al. [25]	USA	To identify key decision-making factors among breast cancer survivors considering of entering an acupuncture clinical trial for the treatment of symptoms	25	57.0	Thematic analysis	Open-ended and semi-structured interviews
5	2014	Wang et al. [20]	China	To explore the cancer survivors’ perspectives of and experience with treatment and rehabilitation to promote patient-centered treatment and rehabilitation activities	31	42.0–78.0	Thematic analysis	Focus group interviews
6	2016	de Valois et al. [21]	UK	To explore how patients with lymphedema secondary to cancer treatment perceive the acupuncture and moxibustion treatment	17	58.5	Thematic analysis	Focus groups or individual telephone interview
7	2017	Han et al. [22]	Republic of Korea	To explore the experiences with treatment-related side effects and supportive care among Korean breast cancer survivors	6	48.7	Content analysis	Semi-structured focus group interviews
8	2021	Stöckigt et al. [19]	Germany	To better understand the subjective perspectives of patients on the quality of life during chemotherapy and the perceived effects of acupuncture	20	55.0	Directed qualitative content analysis	Semi-structured individual telephone interviews
9	2022	Ee et al. [26]	Australia	Assessed the feasibility and acceptability of yoga, mindfulness meditation, and acupuncture as adjuncts to lifestyle interventions for weight management in women with breast cancer	37	53.8	Thematic analysis	Online focus group interviews or individual semi-structured telephone interviews
10	2023	Hung et al. [24]	Hong Kong	To explore the use and perceptions of the Chinese Hong Kong breast cancer survivors using traditional Chinese medicine	21	Not stated	Grounded theory approach	Online individual semi-structured interviews
11	2023	Chen et al. [28]	Taiwan	To compare the intention of utilization and the experience with traditional Chinese medicine between patients with early- and late-stage breast cancer	19	55.4	Thematic analysis	Open-ended and semi-structured focus group interviews

2. Quality assessment with Consolidated Criteria for Reporting Qualitative Research and Standards for Reporting Qualitative Research

Ten studies were evaluated using COREQ, with percentage scores ranging from 48.5% to 100%. The analysis by domain revealed that the requirements were last met on the order of domains 1, 2, and 3. Specifically, in domain 1, the researcher’s gender (question 4); in domain 2, the presence of non-participants during interviews (question 15) and checking of participant transcripts (question 23); and in domain 3, participant responses to the results (question 28) were explicitly addressed in one study (Table 3). The single study evaluated with SRQR explicitly described 20 of the 21 items, except for the study location, indicating a relatively high quality (Table 4).

Table 3 . Quality assessment results using consolidated criteria to report qualitative research.

Domain	Content	Details of the content	Price et al. [27]	Han [18]	Schapira et al. [25]	Wang et al. [20]	de Valois et al. [21]	Han et al. [22]	Stöckigt et al. [19]	Ee et al. [26]	Hung et al. [24]	Chen et al. [28]
Domain 1: research team and reflexivity	Personal characters	1. Interviewer/facilitator	•	•		•	•			•	•
		2. Credentials	•	•						•	•
		3. Occupation	•	•						•	•
		4. Gender								•
		5. Experience and training			•		•			•	•
	Relationship with the participants	6. Relationship established		•						•
		7. Participant knowledge of the interviewer		•	•	•	•			•	•	•
		8. Interviewer characteristics		•		•	•			•	•	•
Domain 2: study design	Theoretical framework	9. Methodological orientation and theory	•	•	•	•	•	•	•	•	•	•
	Participant selection	10. Sampling	•	•	•	•	•	•	•	•	•	•
		11. Method of the approach	•	•	•	•	•	•	•	•	•	•
		12. Sample size	•	•	•	•	•	•	•	•	•	•
		13. Non-participation					•		•	•		•
	Setting	14. Setting of the data collection	•	•		•	•		•	•	•	•
		15. Presence of non-participants								•
		16. Description of the sample	•	•	•	•	•	•		•	•	•
	Data collection	17. Interview guide	•	•		•	•	•	•	•	•	•
		18. Repeat interviews					•			•	•
		19. Audio/visual recording	•	•	•	•	•	•	•	•	•	•
		20. Field notes	•							•
		21. Interview duration (mean)	•	•	•	•	•	•		•	•
		22. Data saturation			•		•			•	•	•
		23. Transcripts returned								•
Domain 3: analysis and findings	Data analysis	24. Number of data coders	•			•	•		•	•	•
		25. Description of the coding tree	•	•	•	•	•	•	•	•	•	•
		26. Derivation of themes	•	•	•	•	•	•	•	•	•	•
		27. Software			•		•	•	•	•		•
		28. Participant checking								•
	Reporting	29a. Quotations presented	•	•	•	•	•	•	•	•	•	•
		29b. Quotations identified	•	•	•	•	•	•	•	•	•	•
		30. Data and findings consistent	•	•	•	•	•	•	•	•	•	•
		31. Clarity of the major themes	•	•	•	•	•	•	•	•	•	•
		32. Clarity of the minor themes	•	•	•	•	•	•	•	•	•	•
Stated			21	22	18	20	25	16	17	33	25	20
Not stated			12	11	15	13	8	17	16	0	8	13
% of stated			63.6	66.7	54.5	60.6	75.8	48.5	51.5	100	75.8	60.6

Table 4 . Quality assessment results using standards for reporting qualitative research.

No.	Standards for Reporting Qualitative Research item	Hervik and Mjåland [23]
1	Title	•
2	Abstract	•
3	Problem formulation	•
4	Purpose or research question	•
5	Qualitative approach and research paradigm	•
6	Researcher characteristics and reflexivity	•
7	Context
8	Sampling strategy	•
9	Ethical issues related to human subjects	•
10	Data collection methods	•
11	Data collection instruments and technologies	•
12	Units of study	•
13	Data processing	•
14	Data analysis	•
15	Techniques to enhance trustworthiness	•
16	Synthesis and interpretation	•
17	Links to empirical data	•
18	Integration with prior work, implications, transferability, and contribution(s) to the field	•
19	Limitations	•
20	Conflicts of interest	•
21	Funding	•
Stated		20
Not stated		1
% of stated		95.2

3. Qualitative synthesis

The synthesis of 11 qualitative studies yielded three themes and 10 sub-themes.

1) Tertiary structure I: distress during the standard treatment process of breast cancer

(1) Difficulties in daily life due to the physical symptom burden

Breast cancer survivors reported considerable challenges in daily life due to various treatment-related side effects, including discomfort in the breast area, hot flashes, gastrointestinal issues, joint pain, depression, and low energy, all of which reduced their overall quality of life.

“Chemotherapy was really tough. My hair fell out, I felt horrible, and my tongue turned yellow, which made eating very difficult. I also had dry eyes, which was very painful. It was very difficult to recover from all the damage to my organs. During chemotherapy, I felt extremely nauseous and lacked energy. I guess, because I was already weak, those symptoms continued even after chemotherapy. Before chemotherapy, I had no discomfort [18]."

“After surpassing the first shock to some extent and you decided for it [the chemotherapy], I pulled myself together relatively quickly (...) [but] it [the mood] fluctuated (...) there were days where you just cried (...) that’s for sure [19]."

(2) Relational alienation

The treatment process affected relationships in various ways. Some respondents found renewed appreciation for family and friends, whereas others experienced guilt and felt overwhelmed due to their perceived inability to fulfill family roles. Sexual dysfunction often leads to decreased intimacy with spouses. Furthermore, the changes in physical appearance contributed to feelings of social marginalization, sometimes resulting in job changes or resignations.

“I would like to say that I felt sorry for my husband after having this disease. I mean sex, I was so sorry. To be honest, we rarely made love to each other after I had cancer [20].”

“This is worse, because... my career I could hide, nobody needs know about it. But this is awful, you go out... I always bring a cardigan with me in case I get embarrassed because I do sometimes... it was just awful [21].”

(3) Existential distress

The prolonged treatment process led many breast cancer survivors to lose confidence in their safety. They experienced existential distress characterized by increased depression and anxiety, as they felt a gradual loss of control over their lives. This led to a decreased commitment to treatment.

“I couldn’t do anything during chemotherapy. I was in pain from muscle aches that felt like I had the flu. I spent the whole week hunched over. The middle of the cycle was the worst. When I was treated every 3 weeks, I would just huddle alone in my room, as I was unable to do anything because my whole body was aching. It is hard to put this in words. During the second round, I just wanted to give up and die [22].”

“I felt like I was going to die. I just accepted that if it is my time to go, then it will happen [18].”

2) Tertiary structure II: holistic treatment and care needs

(1) Unmet medical needs in relation to healthcare providers

The relationships of survivors with healthcare providers during the standard treatment were generally functional, but they were occasionally dysfunctional. Barriers, such as perceived lack of understanding of their pain, time constraints, and lack of information, hindered communication, contributing to poor treatment adherence.

“The doctor was just not listening to you, he had only one plan. He would never ask about the severity or the kind of treatment that you wanted. Never. I think he should consider my opinion. There was one regimen that I didn’t feel severe pain, while there were other treatments that were very painful [20].”

“I am exhausted. I did not receive any information about the side effects of the chemotherapy and medicines. I had a hard time explaining these problems to the social services personnel and my workmates. As far as I know, these side effects have not been documented. They need to be documented [23].”

(2) Preserving human dignity

The overwhelming wave of tests and treatment often left survivors feeling out of control. Owing to the specialized nature of the medical system, survivors were frequently perceived as mere breast cancer cases, rather than individuals. They described feeling depressed and passively moving through the treatment process, likening their experience to being swept along a conveyor belt.

“I felt so tired from all those investigations. It was frightening. I had a mammogram and biopsy. Then, I had to wait for days to get the results. I had to go to this clinic and that clinic… waiting and waiting… I do not want to remember the process… it was too heavy for me. I wish I was able to control my emotions [24].”

“Doctors do not entertain additional questions outside their own specialty [22].”

“I lost myself. I’d got so used to everybody saying “do this, do that” because when you’re diagnosed you’re put on this train, they lock the doors, and they don’t let you off, you know. And then suddenly you arrive at the station and they say ‘go away for 3 months [21].’”

3) Tertiary structure III: a holistic approach through acupuncture and moxibustion treatment

(1) Expectation of the treatment

Breast cancer survivors opted for the AM treatment, expecting alleviation of various symptoms associated with the standard treatment. Their confidence in the AM treatment was often based on personal experiences or those of others. Furthermore, the burden of managing additional medications sometimes motivated them to explore AM treatment as an alternative.

“I believe in it [acupuncture]. I mean, I think that things like this work. I mean, look at the hot yoga. It’s a perfect example, and I think that, if I could combine that hot yoga with acupuncture, I might really be able to glide through the menopausal part of my life [25].”

“I am on so much medication now. If I had another treatment that wouldn’t be an additional pill bottle, which I would have to worry about its contraindications… I would probably do acupuncture if it was available [25].”

(2) Negative perception of the treatment

The factors that negatively influenced the choice of AM treatment included skepticism about its effectiveness, opposition from healthcare providers, fear of needles, and cost concerns.

“We’ve got probably three or four ladies undergoing acupuncture regularly while they’re having their chemo who swear by it, and others have said that their oncologist said ‘No, don’t have any needles into your skin at all while you’re having chemotherapy [26].’”

“I felt myself being a bit cynical. It (moxibustion) struck me as a bit sort of… gosh what do you call those… witchdoctor-ish… they put it on and set it alight and whip it off…. I would have preferred pure acupuncture [21].”

(3) Symptom improvement

Following AM treatment, the survivors reported relief from various symptoms, including upper extremity pain, lymphedema, hot flashes, and gastrointestinal issues. In addition to localized relief from symptoms, they experienced improvements in emotional well-being and energy levels.

“Acupuncture greatly helped with my swelling. After 10 acupuncture sessions, there was an obvious improvement in the edema, and I had more muscle strength [24].”

“It kept me bubbly. Yeah, it’s kept me bubbly because otherwise I would have been down…. Because I have suffered with depression quite badly. So, I don’t want to go down that road again. Because it’s like a no-return sometimes, as you can get that far down. So I prefer to stay on the high notes and be all bubbly-bubbly… So I never felt down. I never got depressed [27].”

(4) Holistic care experience

Beyond the clinical effectiveness of AM treatment, survivors valued the caring experience during treatment sessions and interactions with healthcare providers. Feeling respected as individuals rather than as patients with a disease and receiving empathetic understanding contributed to a sense of safety and comfort.

“All in all, this whole package (…) with this attached acupuncture (…) from the oncologist and acupuncture therapist (…) gave such positive impulses (…) supporting me [19].”

“Compared with western medicine doctors, the Chinese medicine doctors prefer to communicate with you. The four diagnostic methods of traditional Chinese medicine demand doctors to ask for more details [20].”

(5) Creating an integrated self

Survivors reported that the AM treatment improved their willingness to participate in the treatment, improved their personal and social quality of life, and helped them regain control over their lives. Furthermore, they felt that the treatment process allowed them to positively reframe their experiences, allowing them to view and accept breast cancer as just one event in their lives, rather than as the main focus.

“When I came back in January… I told her, ‘I’ve joined Weight Watchers, I’m really being positive about this and I’m really working on my exercises for lymphoedema; I am really working hard’… and I honestly say this is due to the acupuncture and moxibustion treatment… it changed the way I thought about myself [21].”

Qualitative research provides an in-depth insight into individual or group experiences. Synthesizing multiple qualitative studies enables the development of comprehensive theories by integrating diverse perspectives [29]. Meta-ethnography, a widely used qualitative synthesis method in healthcare, effectively encompasses phenomena by deriving shared underlying concepts from varied patient experiences across different settings [30]. This methodology has been successful in synthesizing the healthcare experience of patients with head and neck [31] and hematologic [32] cancers, leading to the development of new concepts and theories.

Before content synthesis, the authors assessed the quality of the individual qualitative studies using both COREQ and SRQR. Although both tools aim to improve the quality of qualitative research, they have different purposes. SRQR focuses on understanding the theoretical foundations of qualitative research [33], whereas COREQ, used primarily for interviews or focus group studies, emphasizes transparency by requiring researchers to disclose personal characteristics and relationships with participants [34].

From a transparency perspective, eliminating the personal biases of researchers is challenging; therefore, researchers must clearly disclose their personal characteristics [14]. In our review of 11 qualitative studies, only a few studies explicitly mentioned such details, and only one study specified the gender of the researcher. A previous research on post-cancer social networking behavior has shown that men often seek information to address their illness, whereas women are more likely to adopt a holistic view and focus on the emotional aspects [35]. Furthermore, a previous meta-analysis has demonstrated that interviewee responses and interviewer interpretations can be influenced by the gender of the interviewer [36]. Given that breast cancer mainly affects women, considering the interviewers’ gender is crucial to achieve a more unbiased understanding of the survivors’ perceptions and experiences. Future qualitative research involving patients with breast cancer should explicitly state the interviewer’s gender, as it is difficult for the reader to infer this information based only on their international names.

When evaluating the study design and analysis results, we found that several issues, such as the presence of non-participants during interviews, use of field notes, and participant verification of transcripts and analysis results, were inadequately addressed by the studies. The presence of non-participants, particularly family members, may influence the interviewer behavior and potentially inhibit the discussion of sensitive topics [14]. Therefore, future studies should clearly specify whether non-participants are present during the interviews. Additionally, ensuring accuracy through participant verification of transcripts and analysis results, as well as incorporating content analysis of non-verbal cues recorded in field notes, should be standard practice.

However, these quality assessment results were not used as criteria to include or exclude articles, as they only serve as tools to help understand studies, rather than serve as absolute selection criteria [37]. The results of the quality assessment were used as additional resources to evaluate the significance and relevance of the content of the studies relative to the research objectives. After a discussion, the researchers completed a content synthesis of the 11 qualitative studies.

Studies that involve interviews with long-term breast cancer survivors suggest that these women often perceive their experience as offering positive personal insights rather than simply as a negative event [38]. Furthermore, women who have survived breast cancer for > 5 years without recurrence reported that their experience not only improved their confidence in managing life’s crises but also facilitated a deeper understanding of their true self [39].

Despite the improvements in breast cancer survival rates with standard medical treatments, survivors continue to highlight the need for holistic healthcare. This approach extends beyond medical treatment to include respect for human values and psychological and social support during the treatment process [40]. It also aimed to allow survivors to live vibrantly and maintain their dignity as individuals rather than merely survive as patients [41]. Survivors often perceive the diagnosis and treatment phases, before achieving integrated acceptance of the disease, as considerable threats to their dignity. Specifically, the discomfort from the treatments’ side effects [42], emotional stress from fear of recurrence and changes in body image [43], and reduced independence due to decreased performance [44] are identified as primary threats to their sense of dignity.

Recent research is increasingly supporting the efficacy of AM treatment, which is traditionally practiced in East Asia, in alleviating various symptoms in breast cancer survivors. Recognized for its effectiveness and safety in pain management [6], the AM treatment has also been reported to improve chemotherapy-induced peripheral neuropathy [45] and alleviate mental and emotional problems related to insomnia and hormone therapy [46]. This qualitative synthesis, based on the interviews with breast cancer survivors, corroborates these findings, revealing that the AM treatment effectively mitigates symptoms, such as upper extremity pain, lymphedema, hot flashes, and gastrointestinal problems. Given these results, the AM treatment could be a valuable therapeutic approach for addressing the ongoing unmet needs of breast cancer survivors.

Despite its therapeutic benefits, the negative perceptions of the AM treatment remain significant barriers to its acceptance. The present qualitative synthesis identified several of these perceptions, including skepticism about the efficacy of treatment, fear of needles, superstitions related to smoke from moxibustion, and opposition from medical staff. These findings were consistent with the results of a previous research on foreign perceptions of acupuncture in South Korea, where needle phobia and lack of scientific evidence were noted as barriers [47]. Furthermore, a study conducted in Australia found that 20–77% of cancer patients conceal their use of complementary and alternative medicine from their doctors due to concerns about medical disapproval [48].

Previous meta-analyses have shown that acupuncture can effectively alleviate breast cancer-related symptoms, such as fatigue [49] and insomnia [50]. However, to confirm its efficacy and safety, more research with more rigorous designs and larger sample sizes is needed. Given the need for more objective evidence on the AM treatment from breast cancer survivors, it is advisable to perform randomized controlled trials (RCTs). Future studies should prioritize the symptoms explicitly reported as improved by survivors, including upper extremity pain, lymphedema, and gastrointestinal problems, to improve the relevance and applicability of the research findings.

Despite the negative perceptions, breast cancer survivors often undergo AM treatment due to unmet healthcare needs arising from the standard treatments. An important unmet need highlighted is poor communication with healthcare providers during the standard treatment [51]. Although the survivors in this study generally reported satisfaction with their relationships with healthcare providers, they also noted barriers, such as self-centered attitudes and lack of empathy from these providers. Contrarily, the interactions with the AM treatment providers were characterized by better communication and a caring approach, which contributed to a more positive experience for survivors.

The process of AM treatment involves inserting needles or applying moxibustion at specific body points, which inevitably requires physical contact. A recent meta-analysis from the Netherlands found that tactile interventions effectively reduce pain, depression, and anxiety, and more frequent interventions produce more positive results [52]. Beyond the direct therapeutic effects of acupuncture, recent research is exploring the emotional benefits of touch. Specifically, physical contact during acupuncture can activate the C-tactile fibers, which are linked to limbic touch responses, thereby promoting feelings of calm and well-being [53]. This may address some of the unmet emotional needs of survivors.

Recently, there has been a shift in the medical community toward patient-centered care, focusing on patient involvement in decision making rather than adhering to a paternalistic approach in which physicians dictate treatment [54]. AM treatment aligns with this patient-centered model by focusing on personalized care rather than on a one-size-fits-all approach [55]. In the present study, the survivors reported that the AM therapists provided care that addressed their overall well-being rather than just their specific medical issues, encouraging a sense of respect and recognition of their individuality. This is consistent with the finding of a previous research that demonstrated that empathetic communication during therapy can alleviate the burden of the symptoms of breast cancer [56].

Breast cancer survivors reported that AM treatment helped them regain a sense of agency and control over their lives. This is consistent with the results of previous studies reporting that long-term survivors often develop a more integrated understanding of their lives through their illness experience [38,39]. However, to fully understand the benefits of AM treatment beyond symptom relief, more research is still needed to explore its impact on self-understanding and acceptance among survivors. A recent qualitative study on acupuncture had investigated both the specific effects of needle insertion and non- specific factors, such as patient perception, attitudes toward the therapist, practice environment, and interpersonal relationships [57]. Future qualitative research involving breast cancer survivors should refine the interview items to better capture these nuanced aspects.

In conjunction with conducting further research, the findings derived from this qualitative synthesis can be applied in clinical settings. When selecting clinical techniques and manipulation methods, therapists should consider approaches that minimize the patients’ needle-related anxiety. Furthermore, it is imperative to establish a clinical environment that maximizes a patient’s experience of care and nurturing, which can be facilitated through physical contact and empathetic communication inherent in the treatment process.

Through these considerations, survivors may be able to engage in daily activities beyond their passive role as patients undergoing treatment [58]. Additionally, practitioners can perform medical interventions that contribute to breast cancer survivors’ self-understandings and integration, transcending mere symptom alleviation. This holistic approach has the potential to greatly enhance the overall quality of care provided to breast cancer survivors.

The present study has several limitations. First, the qualitative synthesis mainly analyzed data obtained from interviewees in their 50s, potentially limiting the applicability of the findings across a broader age range. Furthermore, most of the interviewees were from East Asia, a region with a strong familiarity with AM treatment, which may limit the study’s reflection of ethnic and cultural diversity.

Despite these limitations, the study is valuable, because it is the first to synthesize qualitative research studies involving patients with breast cancer who have received AM treatments. The study data confirm the therapeutic effects of AM treatment in alleviating breast cancer-related symptoms based on the survivors’ interviews and highlight that the preservation of human dignity is a fundamental unmet need with which the AM treatment aligns from an integrative perspective. The findings of the present study suggest that future qualitative research should further explore the components of the AM treatment experience and address barriers, such as distrust in the efficacy of the treatment. Furthermore, larger and more rigorous RCTs that focus on the symptoms that survivors report as having improved with AM treatment are warranted in the future. Addressing these limitations will facilitate a more integrated and holistic approach to breast cancer treatment.

We elucidated the breast cancer survivors’ experiences with AM treatment by synthesizing 11 qualitative articles. The following three key themes emerged: (1) the distress associated with the standard treatment; (2) the need for holistic care; and (3) the benefits of AM in providing comprehensive care. Despite the improved survival rates, breast cancer diagnosis and treatment remain life-changing and often threaten a person’s dignity. The AM treatment offers a valuable approach to improving the survivors’ quality of life and preserving their dignity, which aligns with the patient-centered care principles to address unmet needs. Future research should focus on expanding the evidence base for AM treatment in breast cancer care through rigorous RCTs and exploring the experiences of diverse populations receiving AM treatment. The current synthesis provides a foundation for understanding the multifaceted benefits of AM treatment in breast cancer survivorship, emphasizing its potential as a more integrated and patient-centered approach to cancer care.

The authors thank Soohyun Lee from the medical information library of the National Medical Center for her assistance.

Conceptualization: SK, IY. Data curation: SK, JH, IY. Formal analysis: SK, JH, IY. Funding acquisition: YH, IY. Investigation: SK, JH, IY. Methodology: YH, IY. Project administration: YH, IY. Resources: SR, SN. Software: SR, SN, YH. Supervision: YH, IY. Validation: JH, IY. Visualization: SR, SN. Writing – original draft: SK. Writing – review & editing: SK, IY.

The authors have no conflicts of interest to declare.

This work was supported by a grant from the National Medical Center, Republic of Korea (grant number: I_2024_015).

This research did not involve any human or animal experiments.