Integrative Care Experience of Patients with Breast Cancer Regarding Korean Medicine Treatment: A Qualitative Study

Integrative Care Experience of Patients with Breast Cancer Regarding Korean Medicine Treatment: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Integrative Care Experience of Patients with Breast Cancer Regarding Korean Medicine Treatment: A Qualitative Study Seungjin Noh, Yejin Hong, Jisu Ha, Sunjoong Kim, Inae Youn, Dongwoo Nam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6468635/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Korean Medicine (KM) has been widely used as a complementary therapy among breast cancer survivors to manage persistent symptoms. However, limited research has explored patients’ perspective and experiences regarding KM treatment. Methods: This qualitative study employed in-depth interviews with patients aged 19–75 years who had received KM treatment following anticancer therapy. The interviews were audio-recorded, transcribed verbatim, and iteratively analyzed via grounded theory methodology with the assistance of MAXQDA software. Results: A total of 15 patients, with a mean age of 51.1 years, participated in the study. Most patients had stage 1 or 2 breast cancer and had received at least two types of anticancer treatments. Five major themes emerged from the data: the decision-making process, recognition of treatment effects, patient-doctor interaction, understanding of the nature of KM treatment, and perceived individual suitability. The decision to pursue KM treatment was largely driven by a strong desire to manage persistent symptoms following anticancer therapy. Integrative treatment programs, insurance coverage, and continuous communication with KM doctors contributed to patient adherence and satisfaction. KM was perceived as a holistic and responsive care strategy that addressed both physical symptoms and psychological distress. Conclusions: KM treatment offered breast cancer survivors an interactive and patient-centered approach to managing residual symptoms after anticancer treatment. This study examined various factors—patient, practitioner, and institutional—that influence the decision to pursue KM treatment, treatment satisfaction, and the adjustment of therapeutic goals. The findings provide a theoretical basis for integrative treatment models that incorporate KM in breast cancer survivorship. Trial registration: The qualitative study protocol was prospectively registered with the International Journal of Qualitative Methods (DOI: 10.1177/1609406924124747) on April 16, 2024. Korean medicine breast cancer qualitative study grounded theory patient experience integrative treatment Figures Figure 1 1. Background Breast cancer is one of the most common malignancies, with a growing number of cases and deaths globally, and isprojected to reach 3 million cases and 1 million deaths by 2040 [ 1 ]. In South Korea, breast cancer is the most prevalent cancer among women, accounting for 21.1% of all cancer cases in 2023. Owing to early detection and advances in treatment, the 5-year survival rate in 2020 was estimated to be 93.8% [ 2 ], leading to growing concerns regarding the chronic health challenges experienced by breast cancer survivors. Patients undergo prolonged anticancer treatments that vary depending on the tumor stage and location. Regardless, all patients suffer from the effects of both primary anticancer treatment and long-term adjuvant therapies, including postoperative pain, lymphedema after mastectomy, neuropathy after chemotherapy, and vasomotor symptoms after hormone therapy [ 3 – 5 ]. Psychological stress, such as anxiety, depression, and a sense of losing control over one’s life has a profound and lasting impact on the recovery and overall well-being of patients with breast cancer [ 6 , 7 ]. The concept of a “survivorship care plan” (SCP) addresses the delayed effects of anticancer treatment, the psychological impact, and issues related to cancer recurrence [ 8 ]. Complementary and alternative medicine (CAM), which includes acupuncture, aromatherapy, biofeedback, and meditation, has emerged to address complex health issues and has achieved several patient needs outlined by the SCP [ 9 ]. KM is a CAM treatment strategy that effectively addresses the adverse effects of anticancer treatments. In particular, acupuncture has been reported to be effective in reducing pain after surgery, chemotherapy, aromatase-induced arthralgia, digestive disorders, and sleep problems [ 10 – 14 ]. In South Korea, 31% of patients with breast cancer have reported choosing KM treatment after anticancer treatment to manage their cancer-related symptoms [ 15 , 16 ]. Although the clinical effectiveness of KM treatment has been demonstrated by quantitative studies [ 10 ], epidemiological investigations have failed to provide practical data on how patients experience and perceive KM treatment [ 17 ]. Potential barriers to KM treatment, and the specific needs and characteristics of patients who opt for it should also be considered. Because healthcare services involve interactions among doctors, patients, and hospitals, it is necessary to explore patients’ perceptions and responses during treatment. Given the growing importance of real-world data in clinical settings [ 18 ], qualitative methodologies are expected to enhance healthcare providers’ insights. Existing qualitative studies have focused primarily on the decision-making process and individual therapeutic interventions rather than examining the entire process of KM treatment [ 19 ]. KM incorporates a range of therapeutic approaches including acupuncture, herbal medicine, moxibustion, and lifestyle modifications, all of which collectively contribute to treatment outcomes [ 20 ]. Furthermore, an integrative perspective on KM treatment that investigates not only the therapeutic aspects but also the institutional and systemic dimensions of care is essential. This qualitative study aimed to understand the motives of patients with breast cancer in deciding to receive KM treatment. Patients’ impressions of specific KM interventions and their perceptions of their therapeutic effects were investigated. This study aimed to explore the changes experienced by patients with breast cancer during treatment. 2. Methods Aim of Research What are the underlying motivations and decision-making processes that lead patients with breast cancer to pursue KM treatment? How do patients with breast cancer evaluate the benefits and challenges of receiving KM treatment? What physical and psychological changes do patients with breast cancer experience after receiving KM treatment? Study design We employed a qualitative research methodology to explore the reasons and perceptions of patients with breast cancer who received KM for breast cancer symptoms and treatment-related complications. In-depth interviews were conducted via semistructured questionnaires. The grounded theory method proposed by Glaser and Strauss was used for data analysis [21]. According to Charmaz, grounded theory is an inductive, iterative, and interactive method that identifies symbols inherent to people’s perceptions and behaviors. The results are reported in accordance with the standards for qualitative research [22]. Participants The interviews were conducted between May and August 2024 at our medical centers. Patients who had started, were currently receiving, or had temporarily discontinued KM treatment were included; inpatients and outpatients were not distinguished. Inclusion criteria 1) Individuals who received KM treatment at least once for breast cancer and breast cancer-related symptoms at a Korean medical clinic. 2) Individuals aged 19–75 years. 3) Individuals who received sufficient explanation of the study voluntarily agreed to participate. Exclusion criteria 1) Individuals with breast cancer who were unable to undergo interviews because of impaired cognitive function caused by cancer-related complications or other types of diseases. 2) Individuals who were deemed unable to participate in interviews because of hearing or language impairments. Recruitment and sample size Extreme and snowball sampling methods were used for recruitment. All participants were informed of the purpose, method, and process of the study, and written consent was obtained. In cases where interviews were conducted via telephone, Glosign, an electronic signature platform, was used to obtain written consent, allowing both the researcher and the participant to retain a copy of the consent form. The planned number of participants was set at 15, on the basis of Gutterman’s recommendation for the number of participants needed in grounded theory research in the health sciences [23]. Data collection In-depth interviews were conducted via semistructured questionnaires (Table 1). The interview questions and guidelines were developed by a research team comprising professionals with profound experience in qualitative research and licenses as KM doctors. Before the interviews, a brief questionnaire was administered to collect demographic information and medical histories (Supplementary Figure 1). The interviews were conducted in-person in separate consultation rooms at the hospital by two female KM doctors (SJ and JS) who had received sufficient qualitative research training. Telephone interviews were also conducted in cases where in-person interviews were not possible due to distance. Each interview lasted approximately 50–70 min, and in cases with insufficient information, up to three additional interviews per person were planned. The interview questions were adjusted during the research procedure and spontaneous interactions were used. In accordance with the grounded theory research methodology, interviews were conducted until theoretical saturation was reached. Data analysis All interviews were recorded and transcribed verbatim, with nonverbal expressions documented by one researcher during the interview. The resulting scripts were reviewed multiple times to extract their meaning and content. MAXQDA software was used for data analysis to determine the efficiency of organizing the data codes. In accordance with the grounded theory approach, following the first interview, an initial analysis was conducted. Open coding was performed to conceptualize and collect data according to themes. Categorization and relationships between concepts were conducted through subsequent axial coding. Through a selective coding process, we conceptualized core categories and derived a grounded theory on the experiences of patients with breast cancer receiving KM treatment. The data were coded by the researcher who conducted the interviews, and the outcomes were interpreted and discussed by other researchers. The analytical content was reviewed by a qualitative research expert who was not affiliated with KM. Patient information and case report forms (CRFs) were not disclosed to the reviewing researchers, and only anonymized transcribed data and analysis results were shared. Ethics All records were identified using subject codes to ensure anonymity. Identifiable information (e.g., name, address, phone number, or registration number) was kept confidential. The data were stored separately in a secure, confidential location and were accessible only to the individuals for analysis. During peer reviews with other researchers, only anonymized records with subject codes were available for examination. This study was approved by the Institutional Review Boards of the participating institutions. Rigor The reliability of this study was based on the trustworthiness criteria proposed by Guba and Lincoln [25]. Trustworthiness is guided by four principles: credibility, transferability, dependability, and conformability. To ensure credibility, interviews were conducted for a period of 50–70 min and transcribed verbatim. Peer reviews were also conducted to this end. For transferability, demographics and medical histories were investigated. With respect to conformability, the interviews were conducted in a private interview room, and open-ended questions and flexible adjustments were made to allow participants to actively and comfortably engage in the interviews. All the data were anonymized to maintain confidentiality during analysis. To ensure dependability, the researcher who attended the interviews closely observed the participants’ responses and maintained their audio and transcription records. This study sought to maintain quality in accordance with the COREQ (consolidated criteria for reporting qualitative research) guidelines (Supplementary Table 1). Table 1. Interview guide Stage Question Motives for choosing Korean medicine (KM) w Have you previously received KM treatment? w How did you first receive KM treatment? w Were there any reasons you hesitated to try KM? KM treatment experience w For what reasons (symptoms) did you use KM treatment, and how did you feel about its effects? w Were there any inconveniences while receiving KM treatment? w How did you perceive KM treatment? w How did KM treatment experience affect your life? w Did you receive any counseling from the KM practitioner about health management (e.g., exercise, sleep, diet, psychological management)? Future plans regarding KM w Do you plan to continue KM treatment in the future? w Would you recommend KM to other patients with breast cancer? Final remarks Is there anything else you would like to add? 3. Results Participant characteristics In total, 15 interviewees were included; the mean ages at diagnosis and at the time of the interview were 49.6 years and 51.1 years, respectively. The participants reported a variety of side effects following different cancer treatments: 12 reported fatigue, 10 reported insomnia, seven reported bowel disorders, and six reported pain. Twelve participants received KM treatment at the Korean Medicine Hospital affiliated with Kyung Hee University, while three participants received it at the National Medical Center, a local KM clinic, or a nursing hospital. All patients received acupuncture: 13 (except P14 and P15) underwent cupping therapy, and 12 (except P5, P14, and P15) underwent moxibustion. Table 2 and Supplementary Table 2 present the demographic data and characteristics of the study participants, respectively. The data analysis revealed four main themes with 26 subthemes, and the quotes supported these individual themes. Table 3 provides additional quotes. Table 2 Participant characteristics (n = 15) Characteristics of participants (n = 15) Number/Median Mean age at diagnosis 49.6 Mean age at interview 51.1 Marital status Single 3 Married 10 Divorced 0 Widowed 2 Education status Elementary 1 Middle School 0 High School 5 University 9 Employment Not employed 6 Working part-time 1 Working full-time 8 Stage of tumor at diagnosis Stage 1 6 Stage 2 7 Stage 3 1 Stage 4 0 Unclear 1 Anticancer treatments received Mastectomy 6 Lumpectomy 9 Chemotherapy 9 Radiation therapy 11 Hormone therapy 11 Targeted therapy 2 Treatment status Completed 1 Ongoing 14 Timing of Korean medicine treatment After surgery 9 After starting chemotherapy 3 After starting radiation therapy 1 After starting hormone therapy 2 After starting targeted therapy 0 Number of treatment visits Fewer than 5 sessions 2 5 to < 10 sessions 1 10 to < 20 sessions 4 ≥ 20 sessions 8 Table 3 Identified themes and additional quotes Subtheme Quote(s) Theme 1. Decision making Initial barriers to KM treatment “I canceled my appointment at first because I didn't think it (KM medicine) would have much therapeutic value.” (P3) “When I was hospitalized, it was written (on the information sheet) that I shouldn’t get acupuncture.” (P14) “After taking chemotherapy drugs, I was diagnosed with fatty liver, which made me still feel somewhat cautious about taking herbal medicine.” (P4) Attempting KM treatment “My whole body ached, and it was hard to even pinpoint where the pain was coming from. So, I thought maybe I should try acupuncture.” (P11) “My uncle was a KM doctor, so I’ve never hesitated to take acupuncture since I was a child. In fact, I really like it.” (P1) “My husband likes KM and keeps encouraging me to visit the clinic regularly, telling me to go twice or even three times a week." (P3) “At the information center, they told me that patients with cancer could also receive KM treatment.” (P6) Continuing KM treatment “The doctor came and explained what treatment I will go through. The way she explained it so proactively made me feel motivated, like I should really put in my best effort.” (P4) “Since I have to come here for physical therapy anyway, I thought it’d be good to just get it (acupuncture treatment) done while I’m here.” (P2) “Instead of wasting time outside buying coffee, it’s cheaper, and I can lie down comfortably while waiting and receiving treatment, which is really great.” (P4) Theme 2. Recognizing the effects of KM treatment KM treatment as a ‘set’ “At first, I came for moxibustion treatment, but then I started receiving other treatments as a set.” (P2) “Rather, I felt deeply healed psychologically while taking KM treatment.” (P6) Acupuncture: A distinct modality for pain relief “It feels a bit softer and more flexible. It feels like my muscles are working better.” (P11) “After getting acupuncture and doing some exercise, my shoulder feels much looser. It also hurts less, and movements are smoother.” (P2) “When my scapula was painful, just lifting my arm felt so tight. For a while, it hurt so much that I couldn’t lift it this much (demonstrates 140-degree abduction). But now, while it is still uncomfortable, I can manage to hold my arms up.” (P4) “I think acupuncture suits me better, and I’m not sure if physical therapy is as effective.” (P7) “Doing physical therapy, I have to exercise on my own, but while acupuncture treatment, all I need to do is lie down, which makes me prefer acupuncture more.” (P12) “Acupuncture can treat the muscles or nerves inside.” (P5) Moxibustion: Relief of digestive discomfort and enhanced relaxation “I felt refreshed in the inside, like when you drink fizzy soda. It (moxibustion treatment) helps your indigestion.” (P2) “I feel relaxed during the time. I just don’t think about anything. That’s why I do it.” (P1) Cupping and Chuna treatment: Relief of muscle stiffness “There is a pulling sensation, and it feels somewhat refreshing.” (P1). Herbal medicine: Relief of internal symptoms “I was suffering from poor digestion, and a bit of constipation. So, I wanted some help with herbal medicine (by taking herbal medicine).” (P13) “Herbal medicine in the form of powder tastes quite good. It’s different from herbal decoction.” (P2) Theme 3. Interacting with the KM doctor Detailed explanations and responsive attitudes of the KM doctors “Nowadays, there are a lot of information (on the internet), but it is only fragmented knowledge. However, it didn't match well with real life. The doctor explained how to apply it to my life during the consultation.” (P2) “When I asked about things I couldn't ask during conventional medical consultations, the doctor explained them well, and that was very helpful.” (P9) Personalized care through comprehensive assessment “The loss of postural balance led to back pain, which subsequently caused muscular tension in my neck and shoulders.” (P13) “They told me to eat more vegetables and fresh fruits rather than drinking store-bought juice.” (P8) “I had sleeping problems. The doctor said not to force myself to sleep but rather just lie down comfortably and close my eyes. She said that mediating just with my eyes shut, could also have a similar effect with sleep.” (P3) “The doctor said that my erector muscles were weak and recommended to gain muscle weight. She also advised that heart rate should reach a certain level during exercise.” (P7) Feeling reassured and encouraged “It made me feel really good to know that it wasn’t a severe symptom.” (P6) “The doctor cheered me on quite a lot, saying things like, “There is only one more round of chemotherapy left. It will soon be over.” (P3) Theme 4. Understanding of the nature of KM treatment KM treatment: Immediate but temporary symptom relief “When I get acupuncture for my back, it feels much better at that moment. But after a day or two, the pain rebounds.” (P15) KM treatment: Gradual but lasting improvement in overall health “Over time, I can definitely feel that the symptoms are improving.” (P3) “I experienced consistent improvement of my symptoms, so instead of saying whether the speed is fast or slow, I think the way of treatment of conventional medicine and KM are simply different.” (P6) KM doctors: Patient-Centered Professionals “Since the doctor has been treating me since I finished surgery, she is very familiar with my symptoms. I feel reassured that she will genuinely care about my health.” (P9) Benefits of the integrative medical approach “The KM doctors at least give some response. They tell me, for instance, that acupuncture might not immediately help, but it’s worth a try. But with conventional medicine, there’s simply nothing—it just ends there.” (P15) Theme 5. Perceived suitability and individual response to KM Patient-defined therapeutic goals of KM treatment “I received a lot of acupuncture treatment mostly on my back. (P10).” “It takes time to cure the fundamental problem, so I only expect pain relief. I don’t think KM can completely cure my symptoms. It’s more about maintaining a tolerable level of pain.” (P12) “I think I avoided the worse side effects that other people experienced because I consistently received treatments like acupuncture.” (P6) Differences in individual adherence to KM Treatment “I think it’s because my body responds better to acupuncture.” (P12) Future Intentions and Expectations for KM Treatment “I wish they would explain why KM is necessary and how it works.” (P2) “I’d like to tell others not to suffer and endure it alone but to go and get some help to the KM doctor.” (P13) (Insert Table 2 . Here) A total of five themes and 18 subcodes were identified, illustrating the processes of decision-making, treatment experiences, and perceptions related to KM treatment. These themes encompassed the stages of making the initial decision, continuing treatment, interacting with KM doctors, understanding the nature of KM treatment, and evaluating individual suitability for KM. The overall process involved interactions among patients, doctors, and the healthcare system. The thematic map (Fig. 1) presents the identified themes and subcodes. Theme 1: Decision making Initial barriers to KM treatment Several interviewees were initially reluctant to choose KM treatment, as it was regarded as “irrelevant” to treating cancer patients. Patients lacked an understanding of how KM treatment could improve their symptoms, a challenge further compounded by the perception that its efficacy is not easily quantifiable. Concerns that acupuncture might invasively stimulate the surgical site and that herbal medicine could cause drug interactions during chemotherapy or hormone therapy were also identified as barriers to treatment. “After surgery, I had to visit the surgical and physical medicine department, but I couldn’t understand why I had to visit the acupuncture and moxibustion department. I thought, it has nothing to do with me. So, I asked the nurse, why do I need to go to the acupuncture and moxibustion department?” (P2) “I trusted conventional medicine more because it’s all in the numbers, and I trusted KM a little less.” (P3) Attempting KM treatment The treatment gap in managing post treatment symptoms led patients to choose KM treatment as a last resort, an attempt to “clutch at straws.” Patients commonly experienced persistent symptoms such as pain, fatigue, and paresthesia after anticancer therapy, yet reported limited conventional options other than waiting or using analgesics. Under these circumstances KM treatment was perceived as a final option of symptom relief. “The doctor said there was nothing more he could do, and I felt frustrated. I was in pain but the doctors wouldn’t provide any treatment. So, I decided I should try something like acupuncture at a KM clinic." (P15) Prior experiences and recommendations were additional factors influencing patients’ initiation of KM treatment. Positive experiences-either personal or from family members-facilitated the decision to pursue this approach. Moreover, patients without prior KM experience reported that information about the integrative treatment program was provided by hospital personnel. Collectively, both experiential familiarity and awareness of KM treatment were crucial motivators in the decision to pursue such care. “I have a favorable feeling toward KM. I tend to visit a KM clinic rather than take conventional medicine.” (P12) “My doctor recommended acupuncture because of my misaligned shoulder... After surgery, he(doctor) told me that I might experience pain in my back and shoulder, so he recommended receiving acupuncture together.” (P5) Continuing KM treatment The desire to continue treatment was driven by the initial experiences of symptom improvement and the future aspects for further improvement. The fear that symptoms might recur if treatment were discontinued also led the patients to continue their treatment. Moreover, the accessibility of treatment—considering factors such as cost, time, and distance—was identified as an important consideration. Although treatment effectiveness varied among individuals, all patients reported that health insurance coverage for breast cancer significantly alleviated their financial burden. Additionally, the participants emphasized the convenience of the integrative medical system, which minimized the need to visit multiple medical facilities. “After the acupuncture and moxibustion from the doctor, I felt more relaxed, so I kept coming back. I’d say it’s that sense of expectation. I come back with hope.” (P2) “If I don’t get acupuncture for about a week, the pain might rebound. Then, I might come back for treatment.” (P7) “It (the medical health insurance coverage) was truly helpful. If I had significant financial burdens, I probably wouldn’t have been able to take the treatment.” (P6) Theme 2: Recognizing the effects of KM treatment KM treatment as a ‘set’ While receiving KM treatment, multiple treatment modalities were administered simultaneously, which was perceived as a “set.” Patients perceived that individual interventions collectively contributed to the total effect. KM treatment helped patients improve their physical vitality, enabling them to resume daily activities. Others believed that KM could prevent other complications of anticancer treatment. “Overall, it helped, not necessarily by targeting specific symptoms but by taking care of my general condition.” (P14) “Receiving acupuncture and the whole process of treatment made me feel less worried … When I felt extremely anxious, coming here for treatment helped me forget that I am a patient with cancer, so I could focus only on treatment.” (P14) Acupuncture: A distinct modality for pain relief All participants received acupuncture treatment and reported alleviation of pain, particularly postoperative muscular pain in the neck, scapula, and armpit. Acupuncture treatment was also accompanied by reduced muscle stiffness and improved joint mobility of the shoulder girdle. They reported increased flexibility and a lighter sensation in the shoulder, which allowed them to perform daily tasks and exercise more easily. “Firstly, it doesn’t hurt anymore. My shoulder blade used to hurt a lot, but now it doesn’t … It feels like the stiffness that was all knotted up has loosened up.” (P3) According to patients who received both acupuncture and physical therapy-such as ultrasound and electrotherapy-acupuncture treatment was perceived to “directly stimulated the muscles and connective tissues,” whereas physical therapy was described as focusing on “localized surface areas.” Acupuncture was noted to provide a sensation of deep stimulation, due to the insertion of needles. Some patients expressed a preference for acupuncture over physical therapy for pain relief, perceiving it as more effective in addressing the root cause of their symptoms. “It (physical therapy) feels like just a kind of massage. But it feels refreshing. After doing it, I feel relieved, but I don’t think it’s a fundamental treatment.” (P1) “With acupuncture, the needle is inserted, so it feels like it’s giving some kind of deeper stimulation.” (P4) Moxibustion: Relief of digestive discomfort and enhanced relaxation Some patients who received moxibustion on the abdominal region reported relief from digestive disorders and gastric discomfort. Symptoms such as abdominal bloating and belching following chemotherapy were alleviated, and the treatment was often accompanied by sensations of improved circulation and warmth. Additionally, patients described a sense of mental relaxation, noting that the treatment process itself evoked a meditative experience. “It feels like my internal organs which has been tense, are relaxed. I can even hear gurgling sounds while treatment.” (P9) “Basically, after warming up the body, I felt like my immune system improved. You know how they say your immune system improves if your body temperature is higher.” (P4) Cupping and Chuna treatment: Relief of muscle stiffness Cupping and Chuna therapy have both been reported to be effective in relieving muscle tension. The participants who received cupping therapy reported a tugging sensation and noted reductions in muscle tightness. However, its effectiveness was generally perceived to be lower than that of acupuncture, with only one participant (P10) regard it as the most effective modality. In comparison, three participants (P3, P8, and P14) who received Chuna therapy on the cervical spine reported a reduction in posterior neck pain. “It (cupping therapy) releases the tense muscles, and helps with blood circulation, so there must be some effect.” (P5) “After receiving chuna therapy for thirty minutes or an hour, the pain seems to be somewhat reduced.” (P8) Herbal medicine: Relief of internal symptoms Four participants (P2, P4, P7, and P13) received herbal medicines to address various symptoms, including postoperative throat discomfort (P4), chemotherapy-induced indigestion (P2 and P13), and sleep disturbance (P7). All patients reported immediate relief of symptoms, with the exception of one patient who experienced sleep-onset disturbance and reported difficulty recognizing the treatment effects owing to the short treatment time. Furthermore, the formulations of herbal medicines were diverse, and include powder, extract, and candy forms, which patients find to be convenient to consume and pleasant to taste. “I took it (herbal medicine) when my throat felt uncomfortable, and it felt like a great relief after the surgery.” (P4) “It was my first time trying herbal medicine in powder form. It felt like an herbal latte, as if milk had been added. It went down so smoothly, and it tasted great. I think kids would really like it.” (P7) Theme 3: Interaction with the KM doctor Detailed explanations and responsive attitudes of the KM doctors During consultations, participants reported being able to actively engage with KM doctors. Consultations were characterized by comprehensive explanations and an open, responsive attitude toward patient inquiries, which enhanced understanding of their symptoms and offered emotional reassurance. These experiences held particular significance in the context of patients’ prior lack of opportunities to discuss health concerns, their distrust of online information, and their contrast with the typically brief consultations experienced with conventional medical doctors. “The doctor kindly explained everything to me in a way that I could understand. I think that was really good.” (P11) “The doctor said, “If you have any questions, even about minor or daily habits, please feel free to ask.” It made me feel comfortable.” (P2) “There aren't many people around me with whom I can share these concerns in detail. At such times, I felt that these medical consultations were very helpful.” (P14) Personalized care through comprehensive assessment During treatment sessions, KM doctors assessed patients’ overall condition through both physical examinations and ongoing discussions about symptom changes. At the initial visit, various diagnostic tools—such as the Suyang Myung Meridian Function Test, pulse diagnosis, and body composition analysis (e.g., InBody analysis)—were employed to evaluate the patient’s health status. In subsequent sessions, patients engaged in dialogue regarding symptom progression following KM treatment. Through this process, many patients came to recognize that their localized symptoms were interconnected with their overall health and that psychological stress could manifest as physical discomfort. Based on these evaluations, KM doctors tailored treatment strategies and offered individualized lifestyle recommendations, including protein-rich diets, sleep hygiene techniques, and meditation practices, depending on each patient's physical condition. “The doctor mentioned that my body was very stressed out, and explained the sympathetic and parasympathetic nervous system as well. What I remember most is that I realized how stressed I was. I became aware that I was carrying a lot of tension without noticing it.” (P9) “Throughout the treatment process, the doctor would change the acupuncture points based on my symptoms. Having doctors who listen to my symptoms and offer appropriate treatment options made me feel reassured and supported.” (P6) Feeling reassured and encouraged Through counseling with KM doctors, participants were able to openly express their health concerns and gain a deeper understanding of their bodily conditions. Patients reported feeling reassured upon learning that their symptoms were commonly shared by other patients with breast cancer. Furthermore, the encouraging and hopeful remarks provided by the KM doctors helped the patients to have a positive outlook on their situation. As many patients experienced psychological distress following their cancer diagnosis and treatment, this therapeutic interaction was reported to mitigate feelings of depression and anxiety. “The symptoms of pain made me concerned if there was something really bad going on in my body. However, the doctor explained that such symptoms could occur after surgery, and that made me feel better.” (P11) “Those words, “It’s okay. That can happen,” brought me some comfort and helped me feel more at ease. I gained some confidence that I could recover and get better." (P1) Theme 4: Understanding the nature of KM treatment KM treatment: Immediate but temporary symptom relief Regarding the treatment duration and duration of therapeutic effects, some patients reported that KM treatment provided immediate but temporary symptom relief. Pain reduction was most commonly described as immediate, with patients noting that acupuncture provided prompt alleviation of symptoms. Factors such as age and the type of post-treatment side effects were suggested to influence the speed of response. Older participants tended to respond more slowly, likely due to underlying degenerative conditions (P7), and conditions such as neuropathy or sleep disorders were reported to require longer recovery periods than musculoskeletal symptoms (P13). “After treatment, my shoulder feels lighter right away... the effect usually lasts for aprroximately 2–3 days.” (P10) KM treatment: Gradual but lasting improvement in overall health In contrast, some patients perceived KM treatment as 'slow but certain', with effects accumulating over time rather than occurring immediately. This gradual progression did not indicate low treatment efficacy but was instead seen as a distinctive characteristic of KM treatment. The participants described the treatment as progressing from localized to systemic effects—wherein pain relief improved sleep, which subsequently promoted mental relaxation and general well-being. “Like the effects of exercise; as a single session doesn’t immediately change the body. Likewise, you need to receive acupuncture over a longer term. It’s difficult for just one session to make a big difference, so long-term treatment seems necessary.” (P4) “After treatment, I was able to eat more, and sleep better. These treatments had an impact on my mental state, which helped me regain my energy ... Visiting the KM clinic helped me understand my body more, and I realized that everything is connected.” (P13) KM doctors: Patient-centered professionals Participants perceived KM doctors as being more responsive to the patients’ need to manage posttreatment symptoms. Consultations with KM doctors were characterized by a willingness to consult with conventional medical doctors, as consultations with medical doctors were remembered as short visits without solutions for posttreatment side effects, whereas KM doctors were more interested in exploring treatment alternatives and provided detailed explanations. Moreover, patients strongly trusted the expertise and awareness of KM doctors regarding their illnesses and were willing to engage in further treatment sessions. “KM doctors are more patient-oriented; medical doctors are more formal.” (P5) “She is a professional. I’ve heard that she has treated many patients with breast cancer. Explanations from someone so knowledgeable helped me a lot.” (P11) Benefits of the integrative medical approach Participants reported that the integrated approach combining conventional medical treatment and KM treatment offered a more comprehensive and synergistic therapeutic effect. Participants viewed KM as bridging the gap between the end of anticancer treatment and the recovery of daily life functions, particularly in managing postsurgical and postchemotherapy symptoms. Whereas conventional medicine targets the disease, KM emphasizes the ongoing management of patients' general health and quality of life. “Here, they treat things that conventional medicine can’t... surgery or chemotherapy is like a one-time thing. However, for additional care and management, it is KM.” (P3) “Of course, I recommend it. It’s much better to receive both treatments rather than just conventional medicine alone.” (P10) Theme 5: Perceived suitability and individual response to KM Patient-defined therapeutic goals of KM treatment Patients identified their treatment goals as targeting the most bothersome symptoms. Rather than expecting complete symptom resolution, they anticipated gradual and moderate improvement. For some participants, the decision to receive this approach was driven not by the expectation of resolving the disease, but by the desire to relieve symptoms and prevent further worsening. This perspective was partially influenced by the belief that side effects are inevitable while on medication and that recovery from such symptoms typically requires a prolonged period. My shoulder hurt the most, so I just tried to treat that first (P5). “I didn’t expect acupuncture to heal my back pain all at once. Since I did not expect a complete recovery, it was okay.” (P11) Differences in individual adherence to KM treatment Moreover, some interviewees associated the effectiveness of treatment with individual adherence and responsiveness. They believed that their bodies responded well to acupuncture. However, participants also acknowledged that KM treatment may not be appropriate for all patients with breast cancer, suggesting that its efficacy could be limited in patients with advanced-stage cancer or more severe side effects. “People I know who are at stage 2 or above undergo intense anticancer treatments. It seems difficult to recommend acupuncture for these patients. I’d suggest KM treatment to those with milder symptoms such as muscle tension.” (P9) Future Intentions and Expectations for KM Treatment A lack of information was identified as a barrier for patients receiving KM treatment, highlighting the need for improved patient education and guidance. Some participants were unaware of how KM treatment could address symptoms following anticancer therapy, whereas others had limited knowledge of available integrative treatment programs. Following the resolution of informational barriers and direct experience with KM treatment, the participants reported high levels of satisfaction. While some ceased attending the clinic as their symptoms subsided, they expressed intentions to resume treatment in the event of symptom recurrence. Several participants also noted their intention to use KM not only for cancer-related symptoms but also for managing general health concerns. “Many people don’t even know that such treatment exists. It would be better if they were informed.” (P8) “I recommend it a lot. The integrative medical program is great.” (P3) (Insert Table 3 . Here) (Insert Fig. 1. Here) 4. Discussion This study aimed to explore the underlying motivations of patients with breast cancer for choosing and continuing KM treatment, as well as their perceptions and understanding of KM. Patients' decisions were influenced by multiple factors: on a personal level, by the severity of their symptoms and psychological distress; on a medical level, by the limitations of conventional treatment; and on a systemic level, by the presence of integrative care programs, insurance coverage, and the convenience of medical facilities. Experiences were characterized by responsive care and interactive communication processes between patients, doctors, and the medical system. Through these interactions, patients engaged in a process of understanding KM, which gradually transformed their initial curiosity into clarified expectations. Integration with prior research The initial decision of patients with cancer to choose alternative medicine treatment was driven primarily by a desire to fill the “medical gap” created after anticancer treatment. Conventional medical treatment does not actively address the adverse effects of anticancer treatment, and patients expressed a strong need to manage their symptoms [ 25 ]. KM treatment has been suggested as an adjunct therapy that can fill this care gap [ 26 , 27 ]. Patient satisfaction stemmed from the ability to pursue treatment alternatives, rather than the relief of specific side effects [ 28 ]. The therapeutic effects have focused mainly on pain relief and improvements in general conditions. These results corroborate those of previous studies on the effectiveness of cancer-related pain, such as chemotherapy-induced neuropathy or postoperative pain [ 27 – 29 ]. Additionally, the sense of “feeling better” after KM treatment was enhanced not only by symptom relief but also by feeling calm and relaxed [ 30 ], which contributed to positive perceptions regarding it. Over the course of treatment, patients recognized that their localized symptoms were related to their overall physical condition and came to view KM as a holistic approach to treatment. It has been previously reported that the reduced side effects of chemotherapy following KM treatment create a ‘positive feedback loop’ that improves both the physical and psychological well-being of patients with breast cancer [ 31 ]. Information provision systems for KM treatment are essential [ 25 , 26 ]. For patients to adhere to treatment, it is necessary to inform them about integrative medical programs and explain the therapeutic effects of KM. Furthermore, in 2012, a significant economic burden associated with KM treatment was reported due to the lack of insurance coverage, highlighting the substantial impact of health insurance policies on patient satisfaction with treatment [ 32 ]. Strengths and limitations Our study proposed a theoretical model illustrating the experiences of patients with breast cancer throughout the process of receiving KM treatment. Initial motivations, perceived treatment effects, evolving perceptions, and future expectations were comprehensively identified. The interpretation encompassed both micro- and macro-level perspectives—ranging from individual treatment interventions to the broader healthcare delivery system—by considering the interplay among patients, KM doctors, therapeutic modalities, and institutional factors. Through this framework, we were able to understand patients’ treatment goals and expectations regarding KM and the perceived effectiveness of KM treatment for breast cancer care. Several limitations should be acknowledged. First, there is a potential selection bias, as most participants had prior experience with KM treatment and reported positive outcomes. Given that the study employed a snowball sampling method, patients who had been in regular contact with the clinic—likely those with favorable treatment experiences—were more easily reached. This may have inadvertently resulted in the recruitment of a specific subgroup with positive perceptions of KM treatment. Hence, identifying negative perspective and possible drawbacks is challenging. Second, the majority of participants (12 out of 15) received treatment from the same institution, which restricts the generalizability of the findings. Treatment approaches vary by KM doctor, and it is possible that different results would emerge in a multi-institutional setting. Finally, as this study employed a qualitative research methodology based on subjective patient experiences, the objectivity of the findings is inherently limited. Despite its limitations, this study offers valuable insights into the potential usefulness of integrating KM treatment into cancer care from the patient’s perspective. Future perspectives The theoretical model derived from this study is expected to have high applicability in both clinical settings and future research on KM in patients with breast cancer. First, there is a medical gap among patients with breast cancer who have undergone anticancer treatment, and KM appears to be an appropriate treatment option. Different therapeutic modalities have demonstrated positive effects on symptom relief and overall physical vitality. The main target symptoms were postoperative fatigue, pain, and a decline in the general condition. Moreover, perceptions of the speed and nature of KM treatment varied according to the patients’ demographic characteristics and symptoms. Despite these differences, patients developed a new perspective that localized symptoms are interconnected with the whole body, which highlighted KM not only as a therapeutic intervention, but also as a means of redefining patients’ understanding of their bodies. In addition, the characteristics and roles of KM doctors were emphasized, with communication between doctors and patients identified as a critical component of treatment. The key expectations of KM doctors included being “patient-centered,” “positive,” and offering “personalized treatment.” The study also identified patient characteristics who would likely benefit from KM treatment. KM was primarily applied to patients with early-stage cancer (stage II or lower) and those without significant comorbidities. Patients who completed the acute postoperative phase or were receiving adjuvant hormone therapy were considered more suitable for KM treatment. Overall, the findings suggest that KM may be effective in managing cancer survivors and their long-term health problems [ 33 ]. Finally, integrative medical programs should be complemented by a policy that provides information on KM for patients with breast cancer. Patients claimed to have benefited from the “synergistic effect” of receiving both medical and KM care at the same time, underscoring the importance of stronger collaboration between KM and conventional healthcare providers [ 20 ]. 5. Conclusions This study identified the interconnected processes through which patients with breast cancer chose, experienced, and perceived KM treatment. KM treatment was an effective complementary therapy to alleviate persistent symptoms and psychological distress that conventional treatments failed to adequately address. Communication with KM doctors played a key role not only in symptom relief but also in reshaping patients’ perceptions of their own health. These results emphasize the value of incorporating KM into integrative cancer treatment models. Further mixed-method research is warranted based on these findings, and healthcare institutions may adopt KM treatment modalities to improve survivorship care for patients with breast cancer. Declarations Ethics approval and consent to participate The research received ethical approval from the Institutional Review Boards of the National Medical Center (NMC) and the Korean Medicine Hospital affiliated with Kyung Hee University (KHMC) (IRB No. NMC-2024-02-019, KHMC-2024-01-003) in January and February 2024, respectively. Written informed consent to participate was obtained from all interviewees before enrollment. The study adhered to the ethical standards outlined in the Declaration of Helsinki. Consent for publication Written informed consent for publication was obtained from all participants. The consent explicitly included permission to publish anonymized data and findings in academic journals. Participants were assured that no identifying information would be revealed and that confidentiality would be strictly maintained. Availability of data and materials The datasets generated and/or analyzed in the study are not publicly available due to the ethical restrictions. The protocol for this study has been published in [International Journal of Qualitative Studies] (https://doi.org/10.1177/1609406924124747). Competing interests The author(s) declare that there are no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the National Medical Center, Republic of Korea. (Grant number: I_2024_015). Authors' contributions Seungjin Noh, Yejin Hong, and Inae Youn conceptualized the study and developed the theoretical framework. Seungjin Noh, Yejin Hong, and Jisu Ha conducted the interviews and performed the data analysis. Dongwoo Nam supervised the project. All authors discussed the results and contributed to the final manuscript. Acknowledgement This research is supported by the Korean Medicine Hospital affiliated with Kyung Hee University and the National Medical Center, Republic of Korea. References Arnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. The Breast. 2022;66:15-23. Kang JK, Bang SH, Choi SH, Park EH, Yun EH, et al. Cancer Statistics in Korea: Incidence, Mortality, Survival, and Prevalence in 2020. Cancer Res Treat. 2023;55(2):385-99. Johansen S, Fosså K, Nesvold IL, Malinen E, Fosså SD. Arm and shoulder morbidity following surgery and radiotherapy for breast cancer. Acta Oncologica. 2014;53(4):521-9. Taghian NR, Miller CL, Jammallo LS, O’Toole J, Skolny MN. Lymphedema following breast cancer treatment and impact on quality of life: A review. Critical Reviews in Oncology/Hematology. 2014;92(3):227-34. Rutqvist LE, Rose C, Cavallin-Ståhl E. A systematic overview of radiation therapy effects in breast cancer. Acta oncologica. 2003;42(5-6):532-45. Muzzatti B, Bomben F, Flaiban C, Piccinin M, Annunziata MA. Quality of life and psychological distress during cancer: a prospective observational study involving young breast cancer female patients. BMC Cancer. 2020;20(1):758. Hewitt M, Rowland JH, Yancik R. Cancer Survivors in the United States: Age, Health, and Disability. The Journals of Gerontology: Series A. 2003;58(1):M82-M91. Brennan ME, Gormally JF, Butow P, Boyle FM, Spillane AJ. Survivorship care plans in cancer: a systematic review of care plan outcomes. Br J Cancer. 2014;111(10):1899-908. Baum M, Ernst E, Lejeune S, Horneber M. Role of complementary and alternative medicine in the care of patients with breast cancer: Report of the European Society of Mastology (EUSOMA) Workshop, Florence, Italy, December 2004. European Journal of Cancer. 2006;42(12):1702-10. Kim TH, Kang JW, Lee MS. Current evidence of acupuncture for symptoms related to breast cancer survivors: a PRISMA-compliant systematic review of clinical studies in Korea. Medicine . 2018;97(32):e11793. Friedemann T, Kark E, Cao N, Klaßen M, Meyer-Hamme G, Greten JH, et al. Acupuncture improves chemotherapy-induced neuropathy explored by neurophysiological and clinical outcomes–The randomized, controlled, cross-over ACUCIN trial. Phytomedicine. 2022;104:154294. Hershman DL, Unger JM, Greenlee H, Capodice JL, Lew DL, Darke AK, et al. Effect of acupuncture vs sham acupuncture or waitlist control on joint pain related to aromatase inhibitors among women with early-stage breast cancer: a randomized clinical trial. Jama. 2018;320(2):167-76. Zhang Y, Sun Y, Li D, Liu X, Fang C, Yang C, et al. Acupuncture for Breast Cancer: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes. Frontiers in Oncology. 2021;11. Pinto AC, de Azambuja E. Improving quality of life after breast cancer: dealing with symptoms. Maturitas. 2011;70(4):343-8. Choi Y, Lee J, Cho S. Utilization of Korean medicine treatments by cancer patients. J Korean Med Assoc. 2012;33(3):46-53. Han S, Jang B, Hwang D, Seo H. A focus group study on chemotherapy side effects and experiences with Korean medicine complementary treatment among breast cancer patients. J Korean Obstet Gynecol Med. 2017;30(1):85-94. Renjith V, Yesodharan R, Noronha JA, Ladd E, George A. Qualitative methods in health care research. International journal of preventive medicine. 2021;12(1):20. Liu F, Panagiotakos D. Real-world data: a brief review of the methods, applications, challenges and opportunities. BMC Medical Research Methodology. 2022;22(1):287. de Valois B, Asprey A, Young T. “The monkey on your shoulder”: a qualitative study of lymphoedema patients’ attitudes to and experiences of acupuncture and moxibustion. Evidence-Based Complementary and Alternative Medicine. 2016;2016. Yoon SW, Jeong JS, Kim JH, Aggarwal BB. Cancer Prevention and Therapy: Integrating Traditional Korean Medicine Into Modern Cancer Care. Integrative Cancer Therapies. 2013;13(4):310-31. Strauss AL, Corbin JM. Grounded theory in practice . Thousand Oaks: Sage Publications; 1997. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic medicine. 2014;89(9):1245-51. Guetterman T. Descriptions of sampling practices within five approaches to qualitative research in education and the health sciences. 2015. Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New directions for program evaluation. 1986;1986(30):73-84. Hansol A JB, Hwang DS, Seo HS. A focus group study on breast cancer patients' experiences with side effects of anticancer treatment and complementary Korean medicine treatment. The Journal of Obstetrics and Gynecology of Korean Medicine. 2017;30(1):85-94. McPherson L, Cochrane S, Zhu X. Current Usage of Traditional Chinese Medicine in the Management of Breast Cancer: A Practitioner's Perspective. Integr Cancer Ther. 2016;15(3):335-42. Hung YL, Leung SS, Chiu SP, Li PY, Kan AC, Lo CC, et al. Perceptions about traditional Chinese medicine use among Chinese breast cancer survivors: A qualitative study. Cancer Med. 2023;12(2):1997-2007. Stöckigt DMB, Kirschbaum B, Carstensen DMM, Witt D, Brinkhaus DMB. Prophylactic Acupuncture Treatment During Chemotherapy in Patients With Breast Cancer: Results of a Qualitative Study Nested in a Randomized Pragmatic Trial. Integr Cancer Ther. 2021;20:15347354211058207. Hervik J, Mjåland O. Quality of life of breast cancer patients medicated with anti-estrogens, 2 years after acupuncture treatment: a qualitative study. Int J Womens Health. 2010;2:319-25. Price S, Long AF, Godfrey M. Exploring the Needs and Concerns of Women with Early Breast Cancer during Chemotherapy: Valued Outcomes during a Course of Traditional Acupuncture. Evid Based Complement Alternat Med. 2013;2013:165891. Han JH. Quality of life and experience of breast cancer patients receiving traditional Korean medical care: a qualitative study [dissertation]. Seoul: Graduate School of Dongguk University; 2014. Kim JH, Kim SJ, Kwon SM. Effect of expanding benefit coverage for cancer patients on equity in health care utilization and catastrophic expenditure. Health Policy Manag . 2014;24(3):228–41. Kang E, Yang EJ, Kim S-M, Chung IY, Han SA, Ku D-H, et al. Complementary and alternative medicine use and assessment of quality of life in Korean breast cancer patients: a descriptive study. Supportive Care in Cancer. 2012;20:461-73. Additional Declarations No competing interests reported. Supplementary Files SeungjinNohSupplementaryFigure1Questionnaire.docx SeungjinNohSupplementaryTable1COREQchecklist.docx SeungjinNohSupplementaryTable2PatientCharacteristic.revisedversiondoc.doc Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6468635","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473518267,"identity":"cf696678-d1ba-4a7d-acd1-7dfd782bd698","order_by":0,"name":"Seungjin Noh","email":"","orcid":"","institution":"Kyung Hee University","correspondingAuthor":false,"prefix":"","firstName":"Seungjin","middleName":"","lastName":"Noh","suffix":""},{"id":473518268,"identity":"eeb2409d-00f0-4ede-8009-d6b7196d06f5","order_by":1,"name":"Yejin Hong","email":"","orcid":"","institution":"Kyung Hee University Korean Medicine 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06:34:44","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":27509,"visible":true,"origin":"","legend":"","description":"","filename":"SeungjinNohSupplementaryTable1COREQchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-6468635/v1/bcb54274f51add5236a4b6d0.docx"},{"id":85271011,"identity":"35c42ec2-f803-4d46-903f-b09ed75e3c91","added_by":"auto","created_at":"2025-06-24 06:26:44","extension":"doc","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":100352,"visible":true,"origin":"","legend":"","description":"","filename":"SeungjinNohSupplementaryTable2PatientCharacteristic.revisedversiondoc.doc","url":"https://assets-eu.researchsquare.com/files/rs-6468635/v1/7e19229cae0b22f3c657e07a.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Integrative Care Experience of Patients with Breast Cancer Regarding Korean Medicine Treatment: A Qualitative Study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eBreast cancer is one of the most common malignancies, with a growing number of cases and deaths globally, and isprojected to reach 3\u0026nbsp;million cases and 1\u0026nbsp;million deaths by 2040 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In South Korea, breast cancer is the most prevalent cancer among women, accounting for 21.1% of all cancer cases in 2023. Owing to early detection and advances in treatment, the 5-year survival rate in 2020 was estimated to be 93.8% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], leading to growing concerns regarding the chronic health challenges experienced by breast cancer survivors.\u003c/p\u003e \u003cp\u003ePatients undergo prolonged anticancer treatments that vary depending on the tumor stage and location. Regardless, all patients suffer from the effects of both primary anticancer treatment and long-term adjuvant therapies, including postoperative pain, lymphedema after mastectomy, neuropathy after chemotherapy, and vasomotor symptoms after hormone therapy [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Psychological stress, such as anxiety, depression, and a sense of losing control over one\u0026rsquo;s life has a profound and lasting impact on the recovery and overall well-being of patients with breast cancer [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe concept of a \u0026ldquo;survivorship care plan\u0026rdquo; (SCP) addresses the delayed effects of anticancer treatment, the psychological impact, and issues related to cancer recurrence [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Complementary and alternative medicine (CAM), which includes acupuncture, aromatherapy, biofeedback, and meditation, has emerged to address complex health issues and has achieved several patient needs outlined by the SCP [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. KM is a CAM treatment strategy that effectively addresses the adverse effects of anticancer treatments. In particular, acupuncture has been reported to be effective in reducing pain after surgery, chemotherapy, aromatase-induced arthralgia, digestive disorders, and sleep problems [\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In South Korea, 31% of patients with breast cancer have reported choosing KM treatment after anticancer treatment to manage their cancer-related symptoms [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the clinical effectiveness of KM treatment has been demonstrated by quantitative studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], epidemiological investigations have failed to provide practical data on how patients experience and perceive KM treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Potential barriers to KM treatment, and the specific needs and characteristics of patients who opt for it should also be considered. Because healthcare services involve interactions among doctors, patients, and hospitals, it is necessary to explore patients\u0026rsquo; perceptions and responses during treatment. Given the growing importance of real-world data in clinical settings [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], qualitative methodologies are expected to enhance healthcare providers\u0026rsquo; insights.\u003c/p\u003e \u003cp\u003eExisting qualitative studies have focused primarily on the decision-making process and individual therapeutic interventions rather than examining the entire process of KM treatment [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. KM incorporates a range of therapeutic approaches including acupuncture, herbal medicine, moxibustion, and lifestyle modifications, all of which collectively contribute to treatment outcomes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, an integrative perspective on KM treatment that investigates not only the therapeutic aspects but also the institutional and systemic dimensions of care is essential.\u003c/p\u003e \u003cp\u003eThis qualitative study aimed to understand the motives of patients with breast cancer in deciding to receive KM treatment. Patients\u0026rsquo; impressions of specific KM interventions and their perceptions of their therapeutic effects were investigated. This study aimed to explore the changes experienced by patients with breast cancer during treatment.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cem\u003eAim of Research\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWhat are the underlying motivations and decision-making processes that lead patients with breast cancer to pursue KM treatment?\u003c/li\u003e\n \u003cli\u003eHow do patients with breast cancer evaluate the benefits and challenges of receiving KM treatment?\u003c/li\u003e\n \u003cli\u003eWhat physical and psychological changes do patients with breast cancer experience after receiving KM treatment?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp id=\"_Toc182206980\"\u003e\u003cem\u003eStudy design\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe employed a qualitative research methodology to explore the reasons and perceptions of patients with breast cancer who received KM for breast cancer symptoms and treatment-related complications. In-depth interviews were conducted via semistructured questionnaires. The grounded theory method proposed by Glaser and Strauss was used for data analysis [21]. According to Charmaz, grounded theory is an inductive, iterative, and interactive method that identifies symbols inherent to people\u0026rsquo;s perceptions and behaviors. The results are reported in accordance with the standards for qualitative research [22].\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc182206981\"\u003e\u003cem\u003eParticipants\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted between May and August 2024 at our medical centers. Patients who had started, were currently receiving, or had temporarily discontinued KM treatment were included; inpatients and outpatients were not distinguished.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInclusion criteria\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1) \u0026nbsp;Individuals who received KM treatment at least once for breast cancer and breast cancer-related symptoms at a Korean medical clinic.\u003c/p\u003e\n\u003cp\u003e2) \u0026nbsp;Individuals aged 19\u0026ndash;75 years.\u003c/p\u003e\n\u003cp\u003e3) \u0026nbsp;Individuals who received sufficient explanation of the study voluntarily agreed to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExclusion criteria\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1) \u0026nbsp;Individuals with breast cancer who were unable to undergo interviews because of impaired cognitive function caused by cancer-related complications or other types of diseases.\u003c/p\u003e\n\u003cp\u003e2) \u0026nbsp;Individuals who were deemed unable to participate in interviews because of hearing or language impairments.\u003c/p\u003e\n\u003cp id=\"_Toc182206982\"\u003e\u003cem\u003eRecruitment and sample size\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eExtreme and snowball sampling methods were used for recruitment. All participants were informed of the purpose, method, and process of the study, and written consent was obtained. In cases where interviews were conducted via telephone, Glosign, an electronic signature platform, was used to obtain written consent, allowing both the researcher and the participant to retain a copy of the consent form. The planned number of participants was set at 15, on the basis of Gutterman\u0026rsquo;s recommendation for the number of participants needed in grounded theory research in the health sciences [23].\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc182206983\"\u003e\u003cem\u003eData collection\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn-depth interviews were conducted via semistructured questionnaires (Table 1). The interview questions and guidelines were developed by a research team comprising professionals with profound experience in qualitative research and licenses as KM doctors. Before the interviews, a brief questionnaire was administered to collect demographic information and medical histories (Supplementary Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted in-person in separate consultation rooms at the hospital by two female KM doctors (SJ and JS) who had received sufficient qualitative research training. Telephone interviews were also conducted in cases where in-person interviews were not possible due to distance. Each interview lasted approximately 50\u0026ndash;70 min, and in cases with insufficient information, up to three additional interviews per person were planned. The interview questions were adjusted during the research procedure and spontaneous interactions were used. In accordance with the grounded theory research methodology, interviews were conducted until theoretical saturation was reached.\u003c/p\u003e\n\u003cp id=\"_Toc182206984\"\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll interviews were recorded and transcribed verbatim, with nonverbal expressions documented by one researcher during the interview. The resulting scripts were reviewed multiple times to extract their meaning and content. MAXQDA software was used for data analysis to determine the efficiency of organizing the data codes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn accordance with the grounded theory approach, following the first interview, an initial analysis was conducted. Open coding was performed to conceptualize and collect data according to themes. Categorization and relationships between concepts were conducted through subsequent axial coding. Through a selective coding process, we conceptualized core categories and derived a grounded theory on the experiences of patients with breast cancer receiving KM treatment.\u003c/p\u003e\n\u003cp\u003eThe data were coded by the researcher who conducted the interviews, and the outcomes were interpreted and discussed by other researchers. The analytical content was reviewed by a qualitative research expert who was not affiliated with KM. Patient information and case report forms (CRFs) were not disclosed to the reviewing researchers, and only anonymized transcribed data and analysis results were shared.\u003c/p\u003e\n\u003cp id=\"_Toc182206985\"\u003e\u003cem\u003eEthics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll records were identified using subject codes to ensure anonymity. Identifiable information (e.g., name, address, phone number, or registration number) was kept confidential. The data were stored separately in a secure, confidential location and were accessible only to the individuals for analysis. During peer reviews with other researchers, only anonymized records with subject codes were available for examination. This study was approved by the Institutional Review Boards of the participating institutions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRigor\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe reliability of this study was based on the trustworthiness criteria proposed by Guba and Lincoln [25]. Trustworthiness is guided by four principles: credibility, transferability, dependability, and conformability. To ensure credibility, interviews were conducted for a period of 50\u0026ndash;70 min and transcribed verbatim. Peer reviews were also conducted to this end. For transferability, demographics and medical histories were investigated. With respect to conformability, the interviews were conducted in a private interview room, and open-ended questions and flexible adjustments were made to allow participants to actively and comfortably engage in the interviews. All the data were anonymized to maintain confidentiality during analysis. To ensure dependability, the researcher who attended the interviews closely observed the participants\u0026rsquo; responses and maintained their audio and transcription records. This study sought to maintain quality in accordance with the COREQ (consolidated criteria for reporting qualitative research) guidelines (Supplementary Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Interview guide\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 470px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMotives for choosing Korean medicine (KM)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 470px;\"\u003e\n \u003cp\u003ew Have you previously received KM treatment?\u003c/p\u003e\n \u003cp\u003ew How did you first receive KM treatment?\u003c/p\u003e\n \u003cp\u003ew Were there any reasons you hesitated to try KM?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKM treatment experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 470px;\"\u003e\n \u003cp\u003ew For what reasons (symptoms) did you use KM treatment, and how did you feel about its effects?\u003c/p\u003e\n \u003cp\u003ew Were there any inconveniences while receiving KM treatment?\u003c/p\u003e\n \u003cp\u003ew How did you perceive KM treatment?\u003c/p\u003e\n \u003cp\u003ew How did KM treatment experience affect your life?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ew Did you receive any counseling from the KM practitioner about health management (e.g., exercise, sleep, diet, psychological management)?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFuture plans regarding KM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 470px;\"\u003e\n \u003cp\u003ew Do you plan to continue KM treatment in the future?\u003c/p\u003e\n \u003cp\u003ew Would you recommend KM to other patients with breast cancer?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal remarks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 470px;\"\u003e\n \u003cp\u003eIs there anything else you would like to add?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cem\u003eParticipant characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eIn total, 15 interviewees were included; the mean ages at diagnosis and at the time of the interview were 49.6 years and 51.1 years, respectively. The participants reported a variety of side effects following different cancer treatments: 12 reported fatigue, 10 reported insomnia, seven reported bowel disorders, and six reported pain. Twelve participants received KM treatment at the Korean Medicine Hospital affiliated with Kyung Hee University, while three participants received it at the National Medical Center, a local KM clinic, or a nursing hospital. All patients received acupuncture: 13 (except P14 and P15) underwent cupping therapy, and 12 (except P5, P14, and P15) underwent moxibustion. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and Supplementary Table 2 present the demographic data and characteristics of the study participants, respectively. The data analysis revealed four main themes with 26 subthemes, and the quotes supported these individual themes. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e provides additional quotes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipant characteristics (n\u0026thinsp;\u003cstrong\u003e=\u003c/strong\u003e\u0026thinsp;15)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics of participants (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber/Median\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age at diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age at interview\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElementary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorking part-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorking full-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage of tumor at diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnclear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnticancer treatments received\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMastectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLumpectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRadiation therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHormone therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTargeted therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompleted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOngoing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTiming of Korean medicine treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter starting chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter starting radiation therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter starting hormone therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter starting targeted therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of treatment visits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFewer than 5 sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 to \u0026lt;\u0026thinsp;10 sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 to \u0026lt;\u0026thinsp;20 sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;20 sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIdentified themes and additional quotes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubtheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuote(s)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTheme 1. Decision making\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial barriers to KM treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I canceled my appointment at first because I didn\u0026apos;t think it (KM medicine) would have much therapeutic value.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When I was hospitalized, it was written (on the information sheet) that I shouldn\u0026rsquo;t get acupuncture.\u0026rdquo; (P14)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After taking chemotherapy drugs, I was diagnosed with fatty liver, which made me still feel somewhat cautious about taking herbal medicine.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttempting KM treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My whole body ached, and it was hard to even pinpoint where the pain was coming from. So, I thought maybe I should try acupuncture.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My uncle was a KM doctor, so I\u0026rsquo;ve never hesitated to take acupuncture since I was a child. In fact, I really like it.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My husband likes KM and keeps encouraging me to visit the clinic regularly, telling me to go twice or even three times a week.\u0026quot; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;At the information center, they told me that patients with cancer could also receive KM treatment.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinuing KM treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor came and explained what treatment I will go through. The way she explained it so proactively made me feel motivated, like I should really put in my best effort.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Since I have to come here for physical therapy anyway, I thought it\u0026rsquo;d be good to just get it (acupuncture treatment) done while I\u0026rsquo;m here.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Instead of wasting time outside buying coffee, it\u0026rsquo;s cheaper, and I can lie down comfortably while waiting and receiving treatment, which is really great.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTheme 2. Recognizing the effects of KM treatment\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKM treatment as a \u0026lsquo;set\u0026rsquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;At first, I came for moxibustion treatment, but then I started receiving other treatments as a set.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Rather, I felt deeply healed psychologically while taking KM treatment.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcupuncture: A distinct modality for pain relief\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It feels a bit softer and more flexible. It feels like my muscles are working better.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After getting acupuncture and doing some exercise, my shoulder feels much looser. It also hurts less, and movements are smoother.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When my scapula was painful, just lifting my arm felt so tight. For a while, it hurt so much that I couldn\u0026rsquo;t lift it this much (demonstrates 140-degree abduction). But now, while it is still uncomfortable, I can manage to hold my arms up.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think acupuncture suits me better, and I\u0026rsquo;m not sure if physical therapy is as effective.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Doing physical therapy, I have to exercise on my own, but while acupuncture treatment, all I need to do is lie down, which makes me prefer acupuncture more.\u0026rdquo; (P12)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Acupuncture can treat the muscles or nerves inside.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoxibustion: Relief of digestive discomfort and enhanced relaxation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I felt refreshed in the inside, like when you drink fizzy soda. It (moxibustion treatment) helps your indigestion.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I feel relaxed during the time. I just don\u0026rsquo;t think about anything. That\u0026rsquo;s why I do it.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCupping and Chuna treatment: Relief of muscle stiffness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There is a pulling sensation, and it feels somewhat refreshing.\u0026rdquo; (P1).\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHerbal medicine: Relief of internal symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was suffering from poor digestion, and a bit of constipation. So, I wanted some help with herbal medicine (by taking herbal medicine).\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Herbal medicine in the form of powder tastes quite good. It\u0026rsquo;s different from herbal decoction.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTheme 3. Interacting with the KM doctor\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDetailed explanations and responsive attitudes of the KM doctors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Nowadays, there are a lot of information (on the internet), but it is only fragmented knowledge. However, it didn\u0026apos;t match well with real life. The doctor explained how to apply it to my life during the consultation.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When I asked about things I couldn\u0026apos;t ask during conventional medical consultations, the doctor explained them well, and that was very helpful.\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonalized care through comprehensive assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The loss of postural balance led to back pain, which subsequently caused muscular tension in my neck and shoulders.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They told me to eat more vegetables and fresh fruits rather than drinking store-bought juice.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I had sleeping problems. The doctor said not to force myself to sleep but rather just lie down comfortably and close my eyes. She said that mediating just with my eyes shut, could also have a similar effect with sleep.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor said that my erector muscles were weak and recommended to gain muscle weight. She also advised that heart rate should reach a certain level during exercise.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeeling reassured and encouraged\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It made me feel really good to know that it wasn\u0026rsquo;t a severe symptom.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor cheered me on quite a lot, saying things like, \u0026ldquo;There is only one more round of chemotherapy left. It will soon be over.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tabc\" border=\"1\"\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTheme 4. Understanding of the nature of KM treatment\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKM treatment: Immediate but temporary symptom relief\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When I get acupuncture for my back, it feels much better at that moment. But after a day or two, the pain rebounds.\u0026rdquo; (P15)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKM treatment: Gradual but lasting improvement in overall health\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Over time, I can definitely feel that the symptoms are improving.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I experienced consistent improvement of my symptoms, so instead of saying whether the speed is fast or slow, I think the way of treatment of conventional medicine and KM are simply different.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKM doctors: Patient-Centered Professionals\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Since the doctor has been treating me since I finished surgery, she is very familiar with my symptoms. I feel reassured that she will genuinely care about my health.\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenefits of the integrative medical approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The KM doctors at least give some response. They tell me, for instance, that acupuncture might not immediately help, but it\u0026rsquo;s worth a try. But with conventional medicine, there\u0026rsquo;s simply nothing\u0026mdash;it just ends there.\u0026rdquo; (P15)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tabd\" border=\"1\"\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTheme 5. Perceived suitability and individual response to KM\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient-defined therapeutic goals of KM treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I received a lot of acupuncture treatment mostly on my back. (P10).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It takes time to cure the fundamental problem, so I only expect pain relief. I don\u0026rsquo;t think KM can completely cure my symptoms. It\u0026rsquo;s more about maintaining a tolerable level of pain.\u0026rdquo; (P12)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think I avoided the worse side effects that other people experienced because I consistently received treatments like acupuncture.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifferences in individual adherence to KM Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026rsquo;s because my body responds better to acupuncture.\u0026rdquo; (P12)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFuture Intentions and Expectations for KM Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I wish they would explain why KM is necessary and how it works.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;d like to tell others not to suffer and endure it alone but to go and get some help to the KM doctor.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e(Insert Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Here)\u003c/p\u003e\n\u003cp\u003eA total of five themes and 18 subcodes were identified, illustrating the processes of decision-making, treatment experiences, and perceptions related to KM treatment. These themes encompassed the stages of making the initial decision, continuing treatment, interacting with KM doctors, understanding the nature of KM treatment, and evaluating individual suitability for KM. The overall process involved interactions among patients, doctors, and the healthcare system. The thematic map (Fig.\u0026nbsp;1) presents the identified themes and subcodes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Decision making\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInitial barriers to KM treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral interviewees were initially reluctant to choose KM treatment, as it was regarded as \u0026ldquo;irrelevant\u0026rdquo; to treating cancer patients. Patients lacked an understanding of how KM treatment could improve their symptoms, a challenge further compounded by the perception that its efficacy is not easily quantifiable. Concerns that acupuncture might invasively stimulate the surgical site and that herbal medicine could cause drug interactions during chemotherapy or hormone therapy were also identified as barriers to treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;After surgery, I had to visit the surgical and physical medicine department, but I couldn\u0026rsquo;t understand why I had to visit the acupuncture and moxibustion department. I thought, it has nothing to do with me. So, I asked the nurse, why do I need to go to the acupuncture and moxibustion department?\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I trusted conventional medicine more because it\u0026rsquo;s all in the numbers, and I trusted KM a little less.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAttempting KM treatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe treatment gap in managing post treatment symptoms led patients to choose KM treatment as a last resort, an attempt to \u0026ldquo;clutch at straws.\u0026rdquo; Patients commonly experienced persistent symptoms such as pain, fatigue, and paresthesia after anticancer therapy, yet reported limited conventional options other than waiting or using analgesics. Under these circumstances KM treatment was perceived as a final option of symptom relief.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor said there was nothing more he could do, and I felt frustrated. I was in pain but the doctors wouldn\u0026rsquo;t provide any treatment. So, I decided I should try something like acupuncture at a KM clinic.\u0026quot; (P15)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePrior experiences and recommendations were additional factors influencing patients\u0026rsquo; initiation of KM treatment. Positive experiences-either personal or from family members-facilitated the decision to pursue this approach. Moreover, patients without prior KM experience reported that information about the integrative treatment program was provided by hospital personnel. Collectively, both experiential familiarity and awareness of KM treatment were crucial motivators in the decision to pursue such care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have a favorable feeling toward KM. I tend to visit a KM clinic rather than take conventional medicine.\u0026rdquo; (P12)\u003c/em\u003e\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My doctor recommended acupuncture because of my misaligned shoulder... After surgery, he(doctor) told me that I might experience pain in my back and shoulder, so he recommended receiving acupuncture together.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eContinuing KM treatment\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThe desire to continue treatment was driven by the initial experiences of symptom improvement and the future aspects for further improvement. The fear that symptoms might recur if treatment were discontinued also led the patients to continue their treatment. Moreover, the accessibility of treatment\u0026mdash;considering factors such as cost, time, and distance\u0026mdash;was identified as an important consideration. Although treatment effectiveness varied among individuals, all patients reported that health insurance coverage for breast cancer significantly alleviated their financial burden. Additionally, the participants emphasized the convenience of the integrative medical system, which minimized the need to visit multiple medical facilities.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After the acupuncture and moxibustion from the doctor, I felt more relaxed, so I kept coming back. I\u0026rsquo;d say it\u0026rsquo;s that sense of expectation. I come back with hope.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If I don\u0026rsquo;t get acupuncture for about a week, the pain might rebound. Then, I might come back for treatment.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It (the medical health insurance coverage) was truly helpful. If I had significant financial burdens, I probably wouldn\u0026rsquo;t have been able to take the treatment.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 2: Recognizing the effects of KM treatment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eKM treatment as a \u0026lsquo;set\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eWhile receiving KM treatment, multiple treatment modalities were administered simultaneously, which was perceived as a \u0026ldquo;set.\u0026rdquo; Patients perceived that individual interventions collectively contributed to the total effect. KM treatment helped patients improve their physical vitality, enabling them to resume daily activities. Others believed that KM could prevent other complications of anticancer treatment.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Overall, it helped, not necessarily by targeting specific symptoms but by taking care of my general condition.\u0026rdquo; (P14)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Receiving acupuncture and the whole process of treatment made me feel less worried \u0026hellip; When I felt extremely anxious, coming here for treatment helped me forget that I am a patient with cancer, so I could focus only on treatment.\u0026rdquo; (P14)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAcupuncture: A distinct modality for pain relief\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAll participants received acupuncture treatment and reported alleviation of pain, particularly postoperative muscular pain in the neck, scapula, and armpit. Acupuncture treatment was also accompanied by reduced muscle stiffness and improved joint mobility of the shoulder girdle. They reported increased flexibility and a lighter sensation in the shoulder, which allowed them to perform daily tasks and exercise more easily.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Firstly, it doesn\u0026rsquo;t hurt anymore. My shoulder blade used to hurt a lot, but now it doesn\u0026rsquo;t \u0026hellip; It feels like the stiffness that was all knotted up has loosened up.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAccording to patients who received both acupuncture and physical therapy-such as ultrasound and electrotherapy-acupuncture treatment was perceived to \u0026ldquo;directly stimulated the muscles and connective tissues,\u0026rdquo; whereas physical therapy was described as focusing on \u0026ldquo;localized surface areas.\u0026rdquo; Acupuncture was noted to provide a sensation of deep stimulation, due to the insertion of needles. Some patients expressed a preference for acupuncture over physical therapy for pain relief, perceiving it as more effective in addressing the root cause of their symptoms.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It (physical therapy) feels like just a kind of massage. But it feels refreshing. After doing it, I feel relieved, but I don\u0026rsquo;t think it\u0026rsquo;s a fundamental treatment.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;With acupuncture, the needle is inserted, so it feels like it\u0026rsquo;s giving some kind of deeper stimulation.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eMoxibustion: Relief of digestive discomfort and enhanced relaxation\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eSome patients who received moxibustion on the abdominal region reported relief from digestive disorders and gastric discomfort. Symptoms such as abdominal bloating and belching following chemotherapy were alleviated, and the treatment was often accompanied by sensations of improved circulation and warmth. Additionally, patients described a sense of mental relaxation, noting that the treatment process itself evoked a meditative experience.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It feels like my internal organs which has been tense, are relaxed. I can even hear gurgling sounds while treatment.\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Basically, after warming up the body, I felt like my immune system improved. You know how they say your immune system improves if your body temperature is higher.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eCupping and Chuna treatment: Relief of muscle stiffness\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eCupping and Chuna therapy have both been reported to be effective in relieving muscle tension. The participants who received cupping therapy reported a tugging sensation and noted reductions in muscle tightness. However, its effectiveness was generally perceived to be lower than that of acupuncture, with only one participant (P10) regard it as the most effective modality. In comparison, three participants (P3, P8, and P14) who received Chuna therapy on the cervical spine reported a reduction in posterior neck pain.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It (cupping therapy) releases the tense muscles, and helps with blood circulation, so there must be some effect.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After receiving chuna therapy for thirty minutes or an hour, the pain seems to be somewhat reduced.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eHerbal medicine: Relief of internal symptoms\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eFour participants (P2, P4, P7, and P13) received herbal medicines to address various symptoms, including postoperative throat discomfort (P4), chemotherapy-induced indigestion (P2 and P13), and sleep disturbance (P7). All patients reported immediate relief of symptoms, with the exception of one patient who experienced sleep-onset disturbance and reported difficulty recognizing the treatment effects owing to the short treatment time. Furthermore, the formulations of herbal medicines were diverse, and include powder, extract, and candy forms, which patients find to be convenient to consume and pleasant to taste.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I took it (herbal medicine) when my throat felt uncomfortable, and it felt like a great relief after the surgery.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It was my first time trying herbal medicine in powder form. It felt like an herbal latte, as if milk had been added. It went down so smoothly, and it tasted great. I think kids would really like it.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Interaction with the KM doctor\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eDetailed explanations and responsive attitudes of the KM doctors\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eDuring consultations, participants reported being able to actively engage with KM doctors. Consultations were characterized by comprehensive explanations and an open, responsive attitude toward patient inquiries, which enhanced understanding of their symptoms and offered emotional reassurance. These experiences held particular significance in the context of patients\u0026rsquo; prior lack of opportunities to discuss health concerns, their distrust of online information, and their contrast with the typically brief consultations experienced with conventional medical doctors.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor kindly explained everything to me in a way that I could understand. I think that was really good.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor said, \u0026ldquo;If you have any questions, even about minor or daily habits, please feel free to ask.\u0026rdquo; It made me feel comfortable.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There aren\u0026apos;t many people around me with whom I can share these concerns in detail. At such times, I felt that these medical consultations were very helpful.\u0026rdquo; (P14)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePersonalized care through comprehensive assessment\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eDuring treatment sessions, KM doctors assessed patients\u0026rsquo; overall condition through both physical examinations and ongoing discussions about symptom changes. At the initial visit, various diagnostic tools\u0026mdash;such as the Suyang Myung Meridian Function Test, pulse diagnosis, and body composition analysis (e.g., InBody analysis)\u0026mdash;were employed to evaluate the patient\u0026rsquo;s health status. In subsequent sessions, patients engaged in dialogue regarding symptom progression following KM treatment. Through this process, many patients came to recognize that their localized symptoms were interconnected with their overall health and that psychological stress could manifest as physical discomfort. Based on these evaluations, KM doctors tailored treatment strategies and offered individualized lifestyle recommendations, including protein-rich diets, sleep hygiene techniques, and meditation practices, depending on each patient\u0026apos;s physical condition.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor mentioned that my body was very stressed out, and explained the sympathetic and parasympathetic nervous system as well. What I remember most is that I realized how stressed I was. I became aware that I was carrying a lot of tension without noticing it.\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Throughout the treatment process, the doctor would change the acupuncture points based on my symptoms. Having doctors who listen to my symptoms and offer appropriate treatment options made me feel reassured and supported.\u0026rdquo; (P6)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFeeling reassured and encouraged\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThrough counseling with KM doctors, participants were able to openly express their health concerns and gain a deeper understanding of their bodily conditions. Patients reported feeling reassured upon learning that their symptoms were commonly shared by other patients with breast cancer. Furthermore, the encouraging and hopeful remarks provided by the KM doctors helped the patients to have a positive outlook on their situation. As many patients experienced psychological distress following their cancer diagnosis and treatment, this therapeutic interaction was reported to mitigate feelings of depression and anxiety.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The symptoms of pain made me concerned if there was something really bad going on in my body. However, the doctor explained that such symptoms could occur after surgery, and that made me feel better.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Those words, \u0026ldquo;It\u0026rsquo;s okay. That can happen,\u0026rdquo; brought me some comfort and helped me feel more at ease. I gained some confidence that I could recover and get better.\u0026quot; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 4: Understanding the nature of KM treatment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eKM treatment: Immediate but temporary symptom relief\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eRegarding the treatment duration and duration of therapeutic effects, some patients reported that KM treatment provided immediate but temporary symptom relief. Pain reduction was most commonly described as immediate, with patients noting that acupuncture provided prompt alleviation of symptoms. Factors such as age and the type of post-treatment side effects were suggested to influence the speed of response. Older participants tended to respond more slowly, likely due to underlying degenerative conditions (P7), and conditions such as neuropathy or sleep disorders were reported to require longer recovery periods than musculoskeletal symptoms (P13).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After treatment, my shoulder feels lighter right away... the effect usually lasts for aprroximately\u003c/em\u003e 2\u0026ndash;3 \u003cem\u003edays.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eKM treatment: Gradual but lasting improvement in overall health\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eIn contrast, some patients perceived KM treatment as \u0026apos;slow but certain\u0026apos;, with effects accumulating over time rather than occurring immediately. This gradual progression did not indicate low treatment efficacy but was instead seen as a distinctive characteristic of KM treatment. The participants described the treatment as progressing from localized to systemic effects\u0026mdash;wherein pain relief improved sleep, which subsequently promoted mental relaxation and general well-being.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Like the effects of exercise; as a single session doesn\u0026rsquo;t immediately change the body. Likewise, you need to receive acupuncture over a longer term. It\u0026rsquo;s difficult for just one session to make a big difference, so long-term treatment seems necessary.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After treatment, I was able to eat more, and sleep better. These treatments had an impact on my mental state, which helped me regain my energy ... Visiting the KM clinic helped me understand my body more, and I realized that everything is connected.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eKM doctors: Patient-centered professionals\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants perceived KM doctors as being more responsive to the patients\u0026rsquo; need to manage posttreatment symptoms. Consultations with KM doctors were characterized by a willingness to consult with conventional medical doctors, as consultations with medical doctors were remembered as short visits without solutions for posttreatment side effects, whereas KM doctors were more interested in exploring treatment alternatives and provided detailed explanations. Moreover, patients strongly trusted the expertise and awareness of KM doctors regarding their illnesses and were willing to engage in further treatment sessions.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;KM doctors are more patient-oriented; medical doctors are more formal.\u0026rdquo; (P5)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;She is a professional. I\u0026rsquo;ve heard that she has treated many patients with breast cancer. Explanations from someone so knowledgeable helped me a lot.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eBenefits of the integrative medical approach\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eParticipants reported that the integrated approach combining conventional medical treatment and KM treatment offered a more comprehensive and synergistic therapeutic effect. Participants viewed KM as bridging the gap between the end of anticancer treatment and the recovery of daily life functions, particularly in managing postsurgical and postchemotherapy symptoms. Whereas conventional medicine targets the disease, KM emphasizes the ongoing management of patients\u0026apos; general health and quality of life.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Here, they treat things that conventional medicine can\u0026rsquo;t... surgery or chemotherapy is like a one-time thing. However, for additional care and management, it is KM.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Of course, I recommend it. It\u0026rsquo;s much better to receive both treatments rather than just conventional medicine alone.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 5: Perceived suitability and individual response to KM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePatient-defined therapeutic goals of KM treatment\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003ePatients identified their treatment goals as targeting the most bothersome symptoms. Rather than expecting complete symptom resolution, they anticipated gradual and moderate improvement. For some participants, the decision to receive this approach was driven not by the expectation of resolving the disease, but by the desire to relieve symptoms and prevent further worsening. This perspective was partially influenced by the belief that side effects are inevitable while on medication and that recovery from such symptoms typically requires a prolonged period.\u003c/p\u003e\n \u003cp\u003eMy shoulder hurt the most, so I just tried to treat that first (P5).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t expect acupuncture to heal my back pain all at once. Since I did not expect a complete recovery, it was okay.\u0026rdquo; (P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eDifferences in individual adherence to KM treatment\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eMoreover, some interviewees associated the effectiveness of treatment with individual adherence and responsiveness. They believed that their bodies responded well to acupuncture. However, participants also acknowledged that KM treatment may not be appropriate for all patients with breast cancer, suggesting that its efficacy could be limited in patients with advanced-stage cancer or more severe side effects.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;People I know who are at stage 2 or above undergo intense anticancer treatments. It seems difficult to recommend acupuncture for these patients. I\u0026rsquo;d suggest KM treatment to those with milder symptoms such as muscle tension.\u0026rdquo; (P9)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFuture Intentions and Expectations for KM Treatment\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eA lack of information was identified as a barrier for patients receiving KM treatment, highlighting the need for improved patient education and guidance. Some participants were unaware of how KM treatment could address symptoms following anticancer therapy, whereas others had limited knowledge of available integrative treatment programs. Following the resolution of informational barriers and direct experience with KM treatment, the participants reported high levels of satisfaction. While some ceased attending the clinic as their symptoms subsided, they expressed intentions to resume treatment in the event of symptom recurrence. Several participants also noted their intention to use KM not only for cancer-related symptoms but also for managing general health concerns.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Many people don\u0026rsquo;t even know that such treatment exists. It would be better if they were informed.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I recommend it a lot. The integrative medical program is great.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(Insert Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Here)\u003c/p\u003e\n \u003cp\u003e(Insert Fig. 1. Here)\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to explore the underlying motivations of patients with breast cancer for choosing and continuing KM treatment, as well as their perceptions and understanding of KM. Patients' decisions were influenced by multiple factors: on a personal level, by the severity of their symptoms and psychological distress; on a medical level, by the limitations of conventional treatment; and on a systemic level, by the presence of integrative care programs, insurance coverage, and the convenience of medical facilities. Experiences were characterized by responsive care and interactive communication processes between patients, doctors, and the medical system. Through these interactions, patients engaged in a process of understanding KM, which gradually transformed their initial curiosity into clarified expectations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIntegration with prior research\u003c/em\u003e \u003c/p\u003e\u003cp\u003eThe initial decision of patients with cancer to choose alternative medicine treatment was driven primarily by a desire to fill the \u0026ldquo;medical gap\u0026rdquo; created after anticancer treatment. Conventional medical treatment does not actively address the adverse effects of anticancer treatment, and patients expressed a strong need to manage their symptoms [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. KM treatment has been suggested as an adjunct therapy that can fill this care gap [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Patient satisfaction stemmed from the ability to pursue treatment alternatives, rather than the relief of specific side effects [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe therapeutic effects have focused mainly on pain relief and improvements in general conditions. These results corroborate those of previous studies on the effectiveness of cancer-related pain, such as chemotherapy-induced neuropathy or postoperative pain [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Additionally, the sense of \u0026ldquo;feeling better\u0026rdquo; after KM treatment was enhanced not only by symptom relief but also by feeling calm and relaxed [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], which contributed to positive perceptions regarding it.\u003c/p\u003e\u003cp\u003eOver the course of treatment, patients recognized that their localized symptoms were related to their overall physical condition and came to view KM as a holistic approach to treatment. It has been previously reported that the reduced side effects of chemotherapy following KM treatment create a \u0026lsquo;positive feedback loop\u0026rsquo; that improves both the physical and psychological well-being of patients with breast cancer [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInformation provision systems for KM treatment are essential [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. For patients to adhere to treatment, it is necessary to inform them about integrative medical programs and explain the therapeutic effects of KM. Furthermore, in 2012, a significant economic burden associated with KM treatment was reported due to the lack of insurance coverage, highlighting the substantial impact of health insurance policies on patient satisfaction with treatment [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e \u003cem\u003eStrengths and limitations\u003c/em\u003e \u003c/p\u003e\u003cp\u003eOur study proposed a theoretical model illustrating the experiences of patients with breast cancer throughout the process of receiving KM treatment. Initial motivations, perceived treatment effects, evolving perceptions, and future expectations were comprehensively identified. The interpretation encompassed both micro- and macro-level perspectives\u0026mdash;ranging from individual treatment interventions to the broader healthcare delivery system\u0026mdash;by considering the interplay among patients, KM doctors, therapeutic modalities, and institutional factors. Through this framework, we were able to understand patients\u0026rsquo; treatment goals and expectations regarding KM and the perceived effectiveness of KM treatment for breast cancer care.\u003c/p\u003e\u003cp\u003eSeveral limitations should be acknowledged. First, there is a potential selection bias, as most participants had prior experience with KM treatment and reported positive outcomes. Given that the study employed a snowball sampling method, patients who had been in regular contact with the clinic\u0026mdash;likely those with favorable treatment experiences\u0026mdash;were more easily reached. This may have inadvertently resulted in the recruitment of a specific subgroup with positive perceptions of KM treatment. Hence, identifying negative perspective and possible drawbacks is challenging. Second, the majority of participants (12 out of 15) received treatment from the same institution, which restricts the generalizability of the findings. Treatment approaches vary by KM doctor, and it is possible that different results would emerge in a multi-institutional setting. Finally, as this study employed a qualitative research methodology based on subjective patient experiences, the objectivity of the findings is inherently limited. Despite its limitations, this study offers valuable insights into the potential usefulness of integrating KM treatment into cancer care from the patient\u0026rsquo;s perspective.\u003c/p\u003e\u003cp\u003e \u003cem\u003eFuture perspectives\u003c/em\u003e \u003c/p\u003e\u003cp\u003eThe theoretical model derived from this study is expected to have high applicability in both clinical settings and future research on KM in patients with breast cancer. First, there is a medical gap among patients with breast cancer who have undergone anticancer treatment, and KM appears to be an appropriate treatment option. Different therapeutic modalities have demonstrated positive effects on symptom relief and overall physical vitality. The main target symptoms were postoperative fatigue, pain, and a decline in the general condition.\u003c/p\u003e\u003cp\u003eMoreover, perceptions of the speed and nature of KM treatment varied according to the patients\u0026rsquo; demographic characteristics and symptoms. Despite these differences, patients developed a new perspective that localized symptoms are interconnected with the whole body, which highlighted KM not only as a therapeutic intervention, but also as a means of redefining patients\u0026rsquo; understanding of their bodies. In addition, the characteristics and roles of KM doctors were emphasized, with communication between doctors and patients identified as a critical component of treatment. The key expectations of KM doctors included being \u0026ldquo;patient-centered,\u0026rdquo; \u0026ldquo;positive,\u0026rdquo; and offering \u0026ldquo;personalized treatment.\u0026rdquo;\u003c/p\u003e\u003cp\u003eThe study also identified patient characteristics who would likely benefit from KM treatment. KM was primarily applied to patients with early-stage cancer (stage II or lower) and those without significant comorbidities. Patients who completed the acute postoperative phase or were receiving adjuvant hormone therapy were considered more suitable for KM treatment. Overall, the findings suggest that KM may be effective in managing cancer survivors and their long-term health problems [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinally, integrative medical programs should be complemented by a policy that provides information on KM for patients with breast cancer. Patients claimed to have benefited from the \u0026ldquo;synergistic effect\u0026rdquo; of receiving both medical and KM care at the same time, underscoring the importance of stronger collaboration between KM and conventional healthcare providers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis study identified the interconnected processes through which patients with breast cancer chose, experienced, and perceived KM treatment. KM treatment was an effective complementary therapy to alleviate persistent symptoms and psychological distress that conventional treatments failed to adequately address. Communication with KM doctors played a key role not only in symptom relief but also in reshaping patients\u0026rsquo; perceptions of their own health. These results emphasize the value of incorporating KM into integrative cancer treatment models. Further mixed-method research is warranted based on these findings, and healthcare institutions may adopt KM treatment modalities to improve survivorship care for patients with breast cancer.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research received ethical approval from the Institutional Review Boards of the National Medical Center (NMC) and the Korean Medicine Hospital affiliated with Kyung Hee University (KHMC) (IRB No. NMC-2024-02-019, KHMC-2024-01-003) in January and February 2024, respectively. Written informed consent to participate was obtained from all interviewees before enrollment. The study adhered to the ethical standards outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants. The consent explicitly included permission to publish anonymized data and findings in academic journals. Participants were assured that no identifying information would be revealed and that confidentiality would be strictly maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed in the study are not publicly available due to the ethical restrictions. The protocol for this study has been published in [International Journal of Qualitative Studies] (https://doi.org/10.1177/1609406924124747).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare that there are no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the National Medical Center, Republic of Korea. (Grant number: I_2024_015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeungjin Noh, Yejin Hong, and Inae Youn conceptualized the study and developed the theoretical framework. Seungjin Noh, Yejin Hong, and Jisu Ha conducted the interviews and performed the data analysis. Dongwoo Nam supervised the project. All authors discussed the results and contributed to the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research is supported by the Korean Medicine Hospital affiliated with Kyung Hee University and the National Medical Center, Republic of Korea.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eArnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. The Breast. 2022;66:15-23.\u003c/li\u003e\n \u003cli\u003eKang JK, Bang SH, Choi SH, Park EH, Yun EH, et al. Cancer Statistics in Korea: Incidence, Mortality, Survival, and Prevalence in 2020. 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Real-world data: a brief review of the methods, applications, challenges and opportunities. BMC Medical Research Methodology. 2022;22(1):287.\u003c/li\u003e\n \u003cli\u003ede Valois B, Asprey A, Young T. \u0026ldquo;The monkey on your shoulder\u0026rdquo;: a qualitative study of lymphoedema patients\u0026rsquo; attitudes to and experiences of acupuncture and moxibustion. Evidence-Based Complementary and Alternative Medicine. 2016;2016.\u003c/li\u003e\n \u003cli\u003eYoon SW, Jeong JS, Kim JH, Aggarwal BB. Cancer Prevention and Therapy: Integrating Traditional Korean Medicine Into Modern Cancer Care. Integrative Cancer Therapies. 2013;13(4):310-31.\u003c/li\u003e\n \u003cli\u003eStrauss AL, Corbin JM. \u003cem\u003eGrounded theory in practice\u003c/em\u003e. Thousand Oaks: Sage Publications; 1997.\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic medicine. 2014;89(9):1245-51.\u003c/li\u003e\n \u003cli\u003eGuetterman T. Descriptions of sampling practices within five approaches to qualitative research in education and the health sciences. 2015.\u003c/li\u003e\n \u003cli\u003eLincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New directions for program evaluation. 1986;1986(30):73-84.\u003c/li\u003e\n \u003cli\u003eHansol A JB, Hwang DS, Seo HS. A focus group study on breast cancer patients\u0026apos; experiences with side effects of anticancer treatment and complementary Korean medicine treatment. The Journal of Obstetrics and Gynecology of Korean Medicine. 2017;30(1):85-94.\u003c/li\u003e\n \u003cli\u003eMcPherson L, Cochrane S, Zhu X. Current Usage of Traditional Chinese Medicine in the Management of Breast Cancer: A Practitioner\u0026apos;s Perspective. 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Exploring the Needs and Concerns of Women with Early Breast Cancer during Chemotherapy: Valued Outcomes during a Course of Traditional Acupuncture. Evid Based Complement Alternat Med. 2013;2013:165891.\u003c/li\u003e\n \u003cli\u003eHan JH. \u003cem\u003eQuality of life and experience of breast cancer patients receiving traditional Korean medical care: a qualitative study\u003c/em\u003e [dissertation]. Seoul: Graduate School of Dongguk University; 2014.\u003c/li\u003e\n \u003cli\u003eKim JH, Kim SJ, Kwon SM. Effect of expanding benefit coverage for cancer patients on equity in health care utilization and catastrophic expenditure. \u003cem\u003eHealth Policy Manag\u003c/em\u003e. 2014;24(3):228\u0026ndash;41.\u003c/li\u003e\n \u003cli\u003eKang E, Yang EJ, Kim S-M, Chung IY, Han SA, Ku D-H, et al. Complementary and alternative medicine use and assessment of quality of life in Korean breast cancer patients: a descriptive study. Supportive Care in Cancer. 2012;20:461-73.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Korean medicine, breast cancer, qualitative study, grounded theory, patient experience, integrative treatment","lastPublishedDoi":"10.21203/rs.3.rs-6468635/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6468635/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Korean Medicine (KM) has been widely used as a complementary therapy among breast cancer survivors to manage persistent symptoms. However, limited research has explored patients’ perspective and experiences regarding KM treatment.\u003c/p\u003e\n\u003cp\u003eMethods: This qualitative study employed in-depth interviews with patients aged 19–75 years who had received KM treatment following anticancer therapy. The interviews were audio-recorded, transcribed verbatim, and iteratively analyzed via grounded theory methodology with the assistance of MAXQDA software.\u003c/p\u003e\n\u003cp\u003eResults: A total of 15 patients, with a mean age of 51.1 years, participated in the study. Most patients had stage 1 or 2 breast cancer and had received at least two types of anticancer treatments. Five major themes emerged from the data: the decision-making process, recognition of treatment effects, patient-doctor interaction, understanding of the nature of KM treatment, and perceived individual suitability. The decision to pursue KM treatment was largely driven by a strong desire to manage persistent symptoms following anticancer therapy. Integrative treatment programs, insurance coverage, and continuous communication with KM doctors contributed to patient adherence and satisfaction. KM was perceived as a holistic and responsive care strategy that addressed both physical symptoms and psychological distress.\u003c/p\u003e\n\u003cp\u003eConclusions: KM treatment offered breast cancer survivors an interactive and patient-centered approach to managing residual symptoms after anticancer treatment. This study examined various factors—patient, practitioner, and institutional—that influence the decision to pursue KM treatment, treatment satisfaction, and the adjustment of therapeutic goals. The findings provide a theoretical basis for integrative treatment models that incorporate KM in breast cancer survivorship.\u003c/p\u003e\n\u003cp\u003eTrial registration: The qualitative study protocol was prospectively registered with the International Journal of Qualitative Methods (DOI: 10.1177/1609406924124747) on April 16, 2024.\u003c/p\u003e","manuscriptTitle":"Integrative Care Experience of Patients with Breast Cancer Regarding Korean Medicine Treatment: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-24 06:26:40","doi":"10.21203/rs.3.rs-6468635/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a7d8fc8a-947c-41b4-8ba7-9a95b7f89aa9","owner":[],"postedDate":"June 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T09:53:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-24 06:26:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6468635","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6468635","identity":"rs-6468635","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}