The National Cancer Institute defines breast cancer as a disease in which some of the body cells grow and spread to other parts of the body; it is diagnosed by detecting a lump in the breast or armpit, swelling of the breast, pain in the breast or nipple, or nipple discharge (American Cancer Society, 2013) in [1] . Treatment options include surgery (mastectomy, tumor removal, or removal of pectoral/chest muscles), chemotherapy, radiotherapy, hormonotherapy, and immunotherapy treatment [1] . Research has shown that breast cancer surgery may result in psychosocial distress, which negatively affects women’s mental health [2] [3] . Following breast cancer treatment, disfigurement, pain, scars, and alopecia may lead to loss of femininity, impacting sexuality and intimacy [1] [2] [4] - [9] . A high prevalence of depression and anxiety disorders was reported following breast cancer diagnosis and treatment, which is associated with body image dissatisfaction among women [10] [11] [12] [13] . However, there is a growing body of literature suggesting that breast cancer treatment may lead to post-traumatic growth, resulting in a positive change [11] [14] [15] [16] [17] . This review aims to identify studies that view mastectomy experiences from a transformative standpoint and explore the possibility of the transformation of identity and the integration process (rebirth experiences) among women. The author argues that breast cancer may act as a catalyst for women’s personal growth, altering the meaning of life and happenings in their daily lives [18] .

Few published studies view mastectomy experiences from a transformative perspective [19] - [25] . There are even fewer studies that suggest that breast cancer losses may create opportunities for personal transformation [26] [27] [28] [29] [30] . Studies investigating the impact of breast cancer experiences on the patients’ spouses, partners, and families are also limited [5] [21] [31] [32] .

The main objectives of the paper were two-fold: First, the review was to explore trends regarding the factors that influence the meaning of mastectomy experiences for women and their self-image. Second, the review also aimed to unpack the impact of an altered sense of self and to identify emancipatory possibilities to renegotiate identities following mastectomy.

This literature review aimed to increase awareness of the impact of breast cancer treatment, specifically mastectomy, on various aspects of patients’ lives. The review utilized electronic databases such as EBSCO, PsychInfo, Medline, CancerLit, and ProQuest to search for articles related to breast cancer treatment, mastectomy, body image, self-concept, spirituality, resilience, and mental health. The SPIDER tool was used to establish inclusion criteria based on sample, phenomenon of interest, design, evaluation, and research type. The review focused on studies involving women aged 18 to 80 who underwent breast cancer treatments such as chemotherapy, tumor removal surgery, and mastectomy. Studies published between 1990 and 2022 were selected for the review, and included those that utilized narrative and constructionism designs, qualitative methods, story-telling during focus groups, open-ended interview schedules, and peer-reviewed published and unpublished case study reports. A total of 25 studies were selected and analyzed using thematic and content data analysis methods. Results showed that breast cancer treatment, especially mastectomy, had significant impacts on patients’ body image, relationships, and mental well-being.

Theoretical Framework: Jung’s Individuation theory

Jung [33] defined individuation as the process of becoming a unique individual by embracing one’s innermost and incomparable traits. According to Jung, individuation is essential for a person’s well-being as it enables the formation of an individual’s unique personality. The focus of individuation is to discover one’s meaning and purpose, in order to improve one’s life [33] . The process of individuation is influenced by unconscious messages communicated to the individual’s ego [34] , which signals an alarm when the person struggles to adapt to external or internal reality. The subjugation of the ego to the self and the defeat of the ego are important aspects of Jung’s individuation process. The individuation process involves the experiences of “death and rebirth” through struggle, suffering, and a conscious intent to broaden the scope of one’s consciousness [35] ; these stages of individuation significantly influence one’s personality development.

Stage 1 of Individuation Death-Experience

According to Jung [33] , the death-experience signifies the ego disintegration stage, characterized by losses, confusion, despondency, and uncertainty. The death-experience stage is an intense crisis experience filled with the suffering of the individual and the ego [36] . In the context of the Global South, high levels of depression and anxiety disorders were reported following breast cancer diagnosis and treatment and were associated with body image dissatisfaction among women who underwent mastectomy [10] [11] [12] [13] , which negatively affected their quality of life.

Jung’s death-experience stage of the individuation theory resonates with the onset of symptoms of breast cancer illness before and following diagnosis and during treatment. Women were found to react with shock and numbness following a cancer diagnosis, which raised fear of death, and most were anxious about the experience of chemotherapy and physical mutilation related to mastectomy. A cancer diagnosis is thus associated with significant stress, fear, and anxiety, reinforcing silence among women diagnosed with breast cancer [6] . Benson et al.’s [2] study uncovered the significantly high prevalence of depression (84.2%) and anxiety (92.5%) among women who underwent mastectomy. Turner [37] referred to the treatment stage as a state of liminality during which the sick person may embark on surgical treatment, yet her future health status remained uncertain.

Jung’s [33] individuation process during the death-separation stage can be applied to the sick woman who is in isolation, and during that alone time, the woman must embark on a process of internal work. This may enable the woman to enter into an internal dialogue of the conscious and unconscious, find the opportunity to process her distinct experiences, and formulate and author her stories. At this point, the woman may become aware of her experiences and the opinions, emotions, and thoughts she holds concerning these experiences [38] .

In their qualitative study, de Souza et al. [26] sought to identify the impact of breast cancer on the family life of Brazilian women. One woman reported her experience of loneliness during treatment: “I felt alone, my husband kept on denying it. My brother never came to visit me. And my father came before the chemo. When I did the chemo, he said that he lacked the courage to come see me” (p. 6) [26] . Similarly, some women who were undergoing breast cancer treatment were highly distressed when there was a sense of abandonment and neglect from significant others [39] . Some women with mastectomies developed a sense of helplessness/hopelessness [24] , while others described cancer as an experience of woundedness [39] . For those women, the cancer experience brought feelings of helplessness and powerlessness [39] .

Studies have shown that breast cancer treatment, including surgery, radiation, and chemotherapy, can negatively impact women’s sexual capabilities [8] [20] . For many women, the loss of reproductive organs due to breast cancer also means a loss of fertility and the opportunity for future sexual and intimate relationships [27] . In some cases, women may also develop a negative body image due to weight gain and feelings of betrayal by their bodies [27] . Furthermore, marriages may face tension and divorce incidence may escalate following mastectomy [31] [40] [41] . Women may also experience a deterioration of physical strength and ability that can interfere with their capacity to perform traditional gender roles.

Despite the death-like experiences of breast cancer diagnosis and treatment, Grogan and Mechan [27] found that younger women who underwent mastectomy were able to find acceptance by separating themselves mentally from the breast that was removed and embracing the sick role. Patel et al. [42] also found that psycho-spiritual integrative therapy (PSIT) helped breast cancer survivors let go of old ways of being and embrace the sick role. Therefore, Jung’s rebirth experience stage of the individuation theory may also be a necessary component in the cancer treatment journey.

Stage 2 of Individuation Rebirth Experience

Jung [43] described the rebirth experience as a process of adopting a new perspective in one’s psychic condition, arising from the critical examination of the unconscious. According to Robins [44] , transitioning from the sick role to the survivor role requires reconfiguration of the stigma and isolation into a positive and life-affirming identity. Jung [33] argued that merging the ego and the unconscious can enhance the dimension of living with meaning. This stage is referred to as reincorporation, in which the individual begins to get physically and psychologically well [37] . The patient is emerging from being regarded as a sick person and transitioning into a life-affirming identity while attempting to move beyond the loss [45] .

Jung’s rebirth experience within the individuation process is significant in someone becoming a centered and whole individual. For instance, Park [46] found that the survivor identity was a critical identity that was linked to promoting empowerment for those in post-cancer journey experiences. The survivor identity was correlated with psychological well-being and post-traumatic growth, as well as active involvement in a personal growth orientation, a sense of life purpose, mastery, and social relationships.

Grogan and Mechan [27] conducted a qualitative online study that revealed how women renegotiated their identities post-mastectomy. Through the process of acceptance, some women recognized the need to adjust to their changed bodies and viewed their post-mastectomy bodies as giving them a new identity. Some women found they could renegotiate how they should be treated as women; one woman stated, “body image has never worried me. I am who I am and I don’t go out to impress people” (p. 12) [27] .

Some women rejected traditional views on how women’s bodies should look and opted to develop new body identities that were different from before their illness. One woman said, “I am happy enough with how I look with clothes on. I am accepting the scars and reconstruction. I have to be to move on and get on with life” (p. 10) [27] . Another woman said, “My scars were war wounds”, and she was proud of them (p. 12) [27] . One woman who had undergone reconstructive surgery after mastectomy stated that “my breasts are different and not natural but it doesn’t change who I am” (p. 12) [27] . Grogan and Mechan [27] also reported a single woman who had undergone mastectomy less than a year previously, with no intention of reconstruction, who learned to compensate for the perceived lack of femininity associated with breast removal through wearing clothes that emphasized her legs and increasing the amount of makeup she wore.

In less physical terms, Trachtenberg [25] reported that one participant shared that the cancer experience was a wakeup call to start looking after herself and following her dreams. In Knaul et al.’s [28] study, Mexican women living with breast cancer responded to open-ended questions pertaining to their concept of cancer survivor identity and said it meant an identity that encouraged self-preservation, by learning to negotiate and establish new boundaries and learning to care for self. For example:

“Yes, I’m very grateful for cancer experience because before I had cancer, I did not have time for myself. I used to work and had little time for rest... and now every month I don’t fail to come to the support group, it’s my me time, because it’s like recharging my batteries...” (p. 5) [28] .

Knaul et al.’s [28] study results resonated with Park’s [46] study by concluding that experiences of living through cancer can lead to new identities. In particular, the cancer survivor identity can bring positive experiences of transformation that are beneficial to the long-term physical, social, psychological, spiritual, and existential impact of cancer on one’s life. According to Jung [47] , individuation necessitates self-reflective awareness, which involves questioning preconceptions and inspiring new actions. Breast cancer treatment challenges existing dominant identities that are no longer useful. For instance, Mohammedi et al. [29] studied coping strategies for altered body image among Iranian women who underwent mastectomy and found that women adopted psychological self-empowerment skills, increased spiritual practices, and intentionally demonstrated self-compassion, leading to self-acceptance and transformation. The women also practiced self-care by managing their limits, modifying their rest and sleep patterns, and following a healthy lifestyle.

In the rebirth stage of the individuation process, sharing one’s story and employing new mechanisms of expression can aid in developing patient identity [48] [49] . Fook [49] referred to such openness as a seed to harvest freedom, which is critical acceptance that promotes consciousness and autonomy for informed judgments. Jung [33] argued that the formulation of the story characterizes the rebirth stage, generating awareness and preparing for reintegration by bringing the unconscious into consciousness and understanding one’s masculine and feminine facets. Through individuation, one defines oneself as both separate from, and a part of, humanity [30] .

Parker’s [30] storytelling study identified the potential alignment between personal experience such as mastectomy and transformation, resonating with Jung’s individuation process. Shared stories in the group process revealed the unconscious content influenced by the group’s way of creating images and resolving personal dilemmas [50] . According to Boyd [15] , shared stories identified collective points based on personal experiences, creating ideas for the desired changes across the life span, expanding consciousness, and inspiring new actions.

Breast cancer treatment presents opportunities for women to embark on the reconstruction of their feminine identity [29] and create new body identities [51] . Patel et al. [42] found that psycho-spiritual integrative therapy (PSIT) helped breast cancer survivors move beyond self-criticism and denial toward a more empowered perspective, becoming aware of their self and their own needs. Women learned to care for their feelings and act in their best interest, seeking interpersonal connections, external sources of support, and transcending the separate. Sheriff’s [16] study showed that having a purpose for living can increase a sense of urgency to accept cancer treatment and motivate one to own the healing process. For example, South Asian women with breast cancer sought to take control of their own illness, according to Patel [11] .

When examining cancer treatment experiences through the lens of the individuation process, it became evident that women reported experiences that made them re-examine their self, enabling reconnection and integrating their sense of self. Studies showed that breast cancer treatment also influenced male partners to reconnect to their true self, identifying the non-sexual value of women and developing the relatedness value required to protect partnership during the process of transition, shaping the process of wholeness. The death-experiences outlined in Jung’s individuation theory were signified by deficit-based research [1] [2] [4] - [9] [20] . The negative outcomes of surgery, and mastectomy are attributed to changes in sexual capability [8] [20] , with mastectomy associated with depression and anxiety disorders, disfigurement, scars, and pain, all leading to a deep sense of loss of self-image, femininity, sexuality, and intimacy among women, as well as a loss of true self and dis-identification of their identity [56] .

On the other hand, cancer experiences that resonated with Jung’s rebirth experience within the individuation process were associated with the restoration of wholeness. The rebirth stage can be described as reincorporation, when the individual starts to become physically and psychologically well [37] . The few reviewed studies were compelling [19] - [25] [39] [57] . Rebirth was attributed to changes that transformed women’s identities through cancer experiences. Such experiences contributed to personal transformation and a renewed sense of self [15] [26] [27] [28] [29] [42] [46] , with related losses viewed as opportunities for women to transform and attain individuation.

Cancer experiences enabled women to embark on emancipatory learning that shaped the redefinition of their self through self-advocacy and improved self-care management [22] . Some women showed resilience to negotiate renewed identities through breast cancer illness [24] [25] . Women had to start with their self, make their own lives better, and develop new relationships with themselves [39] . Women questioned their caregiver role, learned to prioritize their own needs to promote agency, and made alterations regarding their boundaries [94] .

Women challenge socially constructed assumptions regarding gender roles [25] and alter their views in response to breast cancer experiences [20] . Limited research has investigated the impact of breast cancer on partners as caregivers [5] [21] [23] [31] [32] [41] . The rebirth stage includes spouses’ transformation through emancipatory learning, resulting in increased awareness of their partner’s emotions [18] . Positive relationships with others lead to post-traumatic growth for cancer patients [14] , while support from family, spouses, friends, and church members is linked to positive coping and improved quality of life [23] [28] [29] . Women’s mastectomy experiences have the potential to balance relational dynamics with spouses, but research on the transformative potential of spouses is scarce [5] [21] [23] [31] [41] . Discussion of breast cancer illness may facilitate genuine communication and reposition spouses as advocates for social justice [31] [80] .

Spirituality plays a major role in cancer diagnosis and treatment [15] [34] [39] [85] [95] , with women adopting an attitude of acceptance and non-attachment to maintain peace [39] . Indigenous native cultures value spirituality throughout the breast cancer journey, with spiritual practices leading to deeper levels of inner knowing and integration [34] . Cancer can be seen as a gift, leading to personal growth [39] , and women must rebuild and reconstruct their femininity after undergoing body changes [25] .

The literature lacks knowledge on an asset-based approach to cancer experiences (such as individuation), resulting in a gap in understanding. The current review highlights that changes to women’s identities (as nurturers, caregivers, intimate partners, or spouses) were transformative and contributed to personal growth and a renewed sense of self after mastectomy. Emancipatory learning occurs when one faces new experiences and seeks to formulate a new perspective on its meaning [18] . Additional research is necessary to empirically establish the emancipatory possibilities of cancer treatment for women’s identities.

Furthermore, the review revealed that breast cancer experiences, including mastectomy, catalyzed changes in spouses [5] [21] [23] [31] [41] . Gabriel’s [31] study indicated that discussing breast cancer within marital and family relationships can encourage genuine communication. Additional research is needed to investigate the transformative potential of spouses when their partner is diagnosed with breast cancer and how cancer alters the spouse’s meaning of life. Moreover, further research is needed to examine how children experience changes in their mother’s health resulting from breast cancer.

This work is based on research supported by the National Institute for the Humanities and Social Sciences.

The author declares no conflicts of interest regarding the publication of this paper.

Lekeka, M. (2023) Breast Cancer Treatment (Mastectomy Experiences) May Initiate Individuation Process That Redefines Identities: A Systematic Review. Health, 15, 1277-1297. https://doi.org/10.4236/health.2023.1511084