The Breast 28 (2016) 156e160

Contents lists available at ScienceDirect

The Breast
journal homepage: www.elsevier.com/brst

Original article

Breast cancer patients' information needs and information-seeking

behavior in a developing country
Khalil Kimiafar a, Masoumeh Sarbaz a, *, Soudabeh Shahid Sales b, Mojtaba Esmaeili c,
Zohre Javame Ghazvini a
a
Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad,
Iran
b
Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
c
Reza Radiotherapy Oncology Charity Center, Mashhad, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Breast cancer is the most common cancer in women both around the world and in Iran. By studying the
Received 13 February 2016 information needs of patients with breast cancer, the quality of the information provided for them can be
Received in revised form improved. This study investigated the information needs of breast cancer patients and their information-
29 April 2016
seeking behavior.
Accepted 26 May 2016
Methods: This cross-sectional study was conducted from March to June, 2015. The research population
was 120 women diagnosed with breast cancer and informed about their disease who referred to
oncology outpatient clinics at a specialized cancer hospital and a radiotherapy oncology center in
Keywords:
Information seeking behavior
Mashhad (the only specialized cancer centers in eastern and northeastern Iran).
Breast cancer Results: Average participant age was 46.2 years (SD ¼ 9.9). Eighty-five percent of patients desired more
Information literacy information about their disease. Results showed that the attending physician (mean ¼ 3.76), television
health channel (mean ¼ 3.30), and other patients (mean ¼ 3.06) were the most popular sources of in-
formation for breast cancer patients. Patients stated their strongest reasons for using information sources
as achieving a better understanding of the disease (mean ¼ 3.59), less anxiety (mean ¼ 3.92), and cu-
riosity to learn more about the disease (mean ¼ 3.66), sequentially. Results further indicated that disease
management (mean ¼ 4.18) and nutritional options during treatment (mean ¼ 4.14) were the most often
mentioned areas in which patients required information, while knowing the progress rate of their dis-
ease was the least (mean ¼ 3.73).
Conclusion: It seems necessary to have a good, organized plan to provide breast cancer patients with
information and increase their information literacy, one of their undeniable rights.
© 2016 Elsevier Ltd. All rights reserved.

Introduction
Among all cancers, breast cancer causes a large number of
mortalities and is one of the first ten causes of death in women
around the world [1]. It is the most common cancer in women both
around the world and in Iran [2], accounting for 24.2% of all cancer
cases in Iran [3]. Asian countries such as Iran have reported a recent
* Corresponding author. Department of Medical Records and Health Information
Technology, School of Paramedical Sciences, Pardis Daneshgah, Azadi Square,
Mashhad, Iran. Tel.: þ98 51 38846725; fax: þ98 51 38846728.
E-mail addresses: Kimiafarkh@mums.ac.ir (K. Kimiafar), Sarbazm@mums.ac.ir
(M. Sarbaz), shahidsalesS@mums.ac.ir (S. Shahid Sales), esmaeilimojtaba@yahoo.
com (M. Esmaeili), javamez2@mums.ac.ir (Z. Javame Ghazvini).
growth in the rate of breast cancer cases [4]. According to a recent
study in Iran, 6160 cases of breast cancer are diagnosed annually,
and around 1063 of them result in death [3]. The annual rate of new
breast cancer cases in Iran is predicted to reach 15,000 by the year
2030 [4].
In recent decades, more attention has been given to having
cancer patients actively participate in their care process. Different
patients have different treatment priorities and request different
amounts and types of information about their disease [5]. The
participation of patients in making decisions about their disease
depends on their being provided with enough suitable information
[6].
Patients with breast cancer have many information needs [7].
Most patients have no clear concept of cancer at the time of

http://dx.doi.org/10.1016/j.breast.2016.05.011
0960-9776/© 2016 Elsevier Ltd. All rights reserved.
 K. Kimiafar et al. / The Breast 28 (2016) 156e160
diagnosis and require information to better understand and fight
their disease [8]. Their needs for information stem from their
having incomplete information and a lack of understanding about
their current situation [6]. Considering patients' needs for infor-
mation will assist them in making informed decisions and will in-
crease their satisfaction in choosing treatment options. Creating
logical expectations in patients empowers them to cope with
cancer [9,10]. Providing enough information to patients may raise
their level of participation, improve the quality of care [11], relieve
some anxiety about cancer and its treatment process, correct false
beliefs, increase patient adherence to treatment recommendations,
establish better relationships between physicians and patients,
improve one's mental health [12], and increase satisfaction levels
among patients [13].
Recent studies have shown that, despite increasing awareness
and knowledge among clinicians about the information needs of
cancer patients, many patients still feel that they do not get enough
information or have received information that is unclear and not
understandable [12,14,15].
Studies have also indicated that patients use other information
sources, such as the Internet, books, and other patients, to meet
their information needs [16,7].
Many cancer patients would like as much information as
possible about their disease, treatment options, the rehabilitation
process, side effects, and possible outcomes of their disease.
However, the type of information they request will change over
time [8,13].
By studying the information needs of breast cancer patients, the
quality of the information provided for them can be improved. The
present study investigated the information needs of breast cancer
patients and their information-seeking behavior. The important
points of the present study are the simultaneous consideration
given to the information sources of breast cancer patients, the
evaluation of patient trust in each source, the information needs of
patients, and problems in meeting these needs in a developing
country.
Methods
Study design
This cross-sectional study, approved by the Ethics Committee of
Mashhad University of Medical Sciences (Code: 931529), was con-
ducted from March to June, 2015. The research population was
women diagnosed with breast cancer and informed about their
disease who referred to oncology outpatient clinics at a specialized
cancer hospital and a radiotherapy oncology center in Mashhad
(the only specialized cancer centers in eastern and northeastern
Iran).
Oncology physicians in the outpatient clinics identified eligible
patients who were then provided with information about the study.
Those who agreed by implied consent to participate were given a
questionnaire.
Sample
The questionnaire was offered to 150 women with breast can-
cer; 120 patients completed the questionnaire, giving an 80%
response rate. The inclusion criterion was having breast cancer
(regardless of age or level of education). Those patients unable to
take part in the study because of tiredness caused by chemo-
therapy, unwillingness due to mental problems, foreign language-
speaking patients, and men with breast cancer were excluded.
157
Questionnaire design
The questionnaire was designed based on factors identified in
the published literature and included seven parts: (a) demographic
characteristics: gender, age, marital status, education level, occu-
pation, residence; (b) patient attitude toward information; (c) in-
formation sources used by patients; (d) reasons for using
information sources; (e) patients' information needs; (f) the degree
of patient trust in information sources; (g) problems patients faced
while obtaining information about their disease. Patient attitude
toward information was assessed using yes/no questions, the next
five parts rated on a five-point Likert scale (1 ¼ very low to 5 ¼ very
high), and one open-ended question: “In general, what is your
opinion about the accessibility to the medical information?”. The
validity of the questionnaire was analyzed using the content anal-
ysis method (literature review and expert opinions), and reliability
was assessed using the testeretest method (r ¼ 0.78).
Data analysis
Statistical analysis was performed on this data using the t-test
and the chi-squared test. Data was analyzed using SPSS 11.5 soft-
ware. The “cut off” used for the P value was 0.05.
Results
Baseline characteristics
The average participant age was 46.2 years (SD ¼ 9.9). The
majority of patients were married (90.8%); 65.5% had less than a
high school education, 76.7% lived in urban areas, and 91.7% were
housewives.
Patient information-seeking
Results concerning patient attitude toward information indi-
cated that 45% of patients had previous experience in seeking in-
formation about breast cancer; only 10.2% of them sought
information before their diagnosis. Eighty-five percent of patients
desired more information about their disease. There was a signifi-
cant relation between information seeking and age. Younger pa-
tients (46 years) had a higher tendency to seek information
(P ¼ 0.036).
Results showed that the attending physician (mean ¼ 3.76), the
television health channel (mean ¼ 3.30), and other patients
(mean ¼ 3.06) were the most popular sources of information used
by breast cancer patients. Pamphlet or brochure (mean ¼ 1.70) and
hospital e-mail (mean ¼ 0) were the least used sources (Table 1).
Results also identified a significant correlation between use of a
book and age; older patients used fewer books as information
sources than younger patients (P ¼ 0.008).
Responses regarding the degree of patient trust in information
sources revealed that patients trusted their attending physician the
most (mean ¼ 4.32), followed by the television health channel
(mean ¼ 3.30) and other television channels (mean ¼ 3.60).
Patients stated their strongest reasons for using information
sources as achieving a better understanding of the disease
(mean ¼ 3.59), less anxiety (mean ¼ 3.92), and curiosity to learn
more about the disease (mean ¼ 3.66), sequentially. It should be
noted that the weakest reason for using information sources was
that it had been suggested by their attending physician
(mean ¼ 2.13).
158 K. Kimiafar et al. / The Breast 28 (2016) 156e160

Table 1
Information sources used by patients (rated from 1 (very low) to 5 (very high)).

Information sources Very high High Medium Low Very low Mean
N (%) N (%) N (%) N (%) N (%)

Attending physician 46(38.3) 37(30.8) 7(5.8) 3(2.5) 20(16.7) 3.76

Other physicians 12(10) 6(5) 8(6.7) 8(6.7) 62(51.7) 1.94
Nurses 13(10.8) 6(5) 9(7.5) 10(8.3) 60(50) 2.00
Radio 11(9.2) 12(10) 22(18.3) 4(3.3) 46(38.3) 2.35
Television health channel 27(22.5) 23(19.2) 28(23.3) 4(3.3) 21(17.5) 3.30
Other television channels 20(16.7) 20(16.7) 25(20.8) 7(5.8) 29(24.2) 2.95
Books 10(8.3) 9(7.5) 14(11.7) 6(5) 54(45) 2.09
Pamphlet or brochure 7(5.8) 3(2.5) 7(5.8) 6(5) 59(49.2) 1.70
Journals 4(3.3) 2(1.7) 7(5.8) 10(8.3) 64(53.3) 1.53
Newspaper or magazine 7(5.8) 5(4.2) 9(7.5) 8(6.7) 66(55) 1.73
Internet 15(12.5) 5(4.2) 11(9.2) 6(5) 62(51.7) 2.04
Friends 13(10.8) 9(7.5) 9(7.5) 7(5.8) 55(45.8) 2.12
Family members 23(19.2) 15(12.5) 17(14.2) 3(2.5) 42(35) 2.74
Other patients 30(25) 10(8.3) 22(18.3) 8(6.7) 28(23.3) 3.06
Hospital e-mail 0 0 0 0 0 0

Patients' information needs Discussion

Results indicated that information on disease management Patient information-seeking

(mean ¼ 4.18) and nutritional options during treatment
(mean ¼ 4.14) were the most mentioned needs of patients, while
knowing their disease progress rate was the least (mean ¼ 3.73)
(Table 2). There was a significant relationship between the need to
know the cause of the disease (P ¼ 0.022) and the need to know
their disease progress rate (P ¼ 0.073) and patient education level.
Less-educated patients needed less information about the cause
and progress rate of their disease than more educated participants.
Results identified the most important problems patients faced
in obtaining information about their disease were little familiarity
with medical terminology (mean ¼ 3.73), little familiarity with
information sources (mean ¼ 3.42), and the inaccessibility of reli-
able information sources (mean ¼ 3.30).
There was a significant correlation between having little famil-
iarity with medical terminology and the inaccessibility of infor-
mation in one's native language and education level. Less-educated
patients had more problems in this regard.
Results of the open-ended question about the accessibility of
medical information indicated that some patients were satisfied
with their attending physicians while others desired more infor-
mation about their disease. Patients suggested a need for improving
the provision of information by physicians and nurses, particularly
in the areas of how to live happily, keep spirits up, and increase
emotional and psychological support. Some participants (40%)
were not satisfied with how the nurses gave them information and
notices about their next treatment sessions.
The findings of this study indicated that breast cancer patients
would like to know more about their disease. A study in Sweden
showed that almost half of patients demand more information
about their disease [13]. Findings from recent studies have shown
that the level of satisfaction with information felt by breast cancer
patients has a positive relationship with their health-related
quality of life [13].
The findings of this study showed that the patients' most
important source of information is their attending physician; this
result is similar to previous studies [10,17,18]. Information source
selection depends on success in accessing the desired information
in the fastest and most appropriate way [19,20].
An interesting and important issue noted in the present study
was that Iran's national television Health Channel, dedicated to
broadcasting health information, played a major role in providing
patients with information. This channel ranked second, behind
attending physician and before other healthcare providers, as the
most reliable information source. So, directors and planners of TV
channels should pay more attention to provide evidence-based
content based on the specific needs of patients.
One important patient information source highlighted by the
results of this study was the experiences and knowledge of other
patients. Therefore, the attitudes and knowledge (right or wrong)
of current breast cancer patients will affect the beliefs and attitudes
of new patients.

Table 2
Patients' Information needs with breast cancer (rated from 1 (very low) to 5 (very high)).

Primary needs for seeking information Very high High Medium Low Very low Mean
N (%) N (%) N (%) N (%) N (%)

Disease management 55(51.9) 31(29.2) 11(10.4) 2(1.9) 7(6.6) 4.18

Nutritional options during treatment 55(51.9) 30(28.3) 10(9.4) 3(2.8) 8(7.5) 4.14
Disease recovery methods 53(51) 30(28.8) 10(9.6) 2(1.9) 9(8.7) 4.12
The best approach to treatment 57(50.4) 34(30.1) 10(8.8) 3(2.7) 9(8) 4.12
Psychological care during treatment 50(48.5) 30(29.1) 11(10.7) 3(2.9) 9(8.7) 4.06
Diagnosis 47(44.3) 27(25.5) 11(10.4) 6(5.7) 15(14.2) 3.80
Cause of disease 56(50) 29(25.9) 10(8.9) 4(3.6) 13(11.6) 3.99
Side effects of treatment 49(46.7) 27(25.7) 15(14.3) 3(2.9) 11(10.5) 3.95
Specific drug information about the disease 49(46.7) 28(26.7) 10(9.5) 5(4.8) 13(12.4) 3.90
Stages of disease 50(46.7) 25(23.4) 16(15) 2(1.9) 14(13.1) 3.89
Find better therapeutic center 44(41.5) 32(30.2) 13(12.3) 2(1.9) 15(14.2) 3.83
Knowing their disease progress rate 43(41) 27(25.7) 14(13.3) 6(5.7) 15(14.3) 3.73
 K. Kimiafar et al. / The Breast 28 (2016) 156e160
The Internet was ranked ninth as a source of information for
breast cancer patients, and hospital e-mail was not used by patients
at all. A study by Li et al. also indicated that the Internet was the
least used information source [17]. However, Littlechild et al.
claimed that more than half of breast cancer patients use the
Internet to obtain information about their disease [7]. It seems that
the lack of a suitable Internet infrastructure and sufficient content
on this disease in developing countries is the main reason patients
do not use this source as much as others. However, suggesting the
Internet as a source of information should be done with caution so
that it will not be a cause of anxiety and confusion in patients [7].
The current study showed that patients place the most trust in
their attending physician among different sources of information.
According to Esbensen et al. [21], this could be because enough
suitable information is provided for patients by their physician.
Previous findings indicate that the quality of care for breast cancer
patients can be improved by some interventions to enhance the
physicianepatient relationship [22,23]. It is suggested that
healthcare professionals spend more time listening to their patients
and patients' interests [21].
Patients' information needs
In the current study, information about disease management
and nutritional options during treatment were identified as the
most important information needs of patients. According to a study
by De Bock, breast cancer patients consider information on the side
effects of treatment, the effects of long-term treatment, and prog-
nosis to be very important issues [24]. In a study by Matsuyama,
similar results were found; many patients would like a lot of in-
formation about their disease, treatment options, laboratory tests,
and self-care [8].
One interesting finding in this study was that patients had a
great interest in information about nutrition during the course of
their disease; this is a good hint for nutritionists and indicates the
necessity of disseminating information regarding nutrition to this
group of patients. Malnutrition in cancer patients is a common
issue [25]. In Iran, around half of the patients with cancer (53.1%)
experience some degree of malnutrition in different stages of their
treatment [26]. Nutrition and diet can change the progress rate of
the disease, the response to treatment, and the survival rate of
patients [27,28,3]. Several studies have shown that obese women
have a greater risk of their breast cancer metastasizing to other
parts of their bodies [29,30]. A study in Spain performed on patients
with locally advanced or metastatic cancer showed that 52% of
patients are somewhat to severely malnourished and 97.6% need
some kind of nutritional intervention or recommendations [31]. In
a study by Genton et al., 70% of breast cancer patients were very
keen to obtain nutritional information and recommendations [32];
this result is consistent with the findings of the present study.
The current study also revealed that the most important prob-
lems of patients in seeking information were little familiarity with
medical terminology and information sources and the inaccessi-
bility of reliable information sources. The results of a study by Cox
et al. also indicated that, even though most patients could read the
information forms provided for them, they could not understand
the content well enough to be able to follow the recommendations.
They suggested that the educational content provided to patients
should be written in a suitable and clear language. Moreover,
various communication approaches and tools should be used to
ensure patient understanding [33]. It is suggested that physicians
use simple, clear wording that is easily understood by patients
when consulting with them. When providing information, the pa-
tient's need level should also be considered, because too much or
unnecessary information can cause patients stress and anxiety [34].
159
The findings of the current study indicate that patients are not
satisfied with the performance of the nurses in providing them
with information. They prefer other information sources for gaining
more information about their disease. In contrast with the findings
of this study, Li et al. mentioned that nurses received the highest
score for providing patients with suitable information [17]. There-
fore, since nurses have the most contact with patients [35,36], it is
suggested that nurses should train on how to provide patients with
necessary information.
The findings of this study indicate that patients suggest a need
for improving the provision of information, particularly in the areas
of how to live happily, keep spirits up, and increase emotional and
psychological support. Patients with breast cancer need not only
medical care, but also psychological, social, and information sup-
port. Psychosocial support is a crucial component to the quality of
cancer care, and patient needs in this area should be continually
evaluated [37]. Particular psychosocial issues associated with
breast cancer include depression, anxiety, concerns about social
stigma, body image, and changes in social roles. The kinds of psy-
chosocial support will vary based on available resources and ex-
perts; for example, peer support can be offered at a basic level,
while at an advanced level, the goal would be to offer formal
counseling by a mental health professional [38].
Women with breast cancer in developing countries need psy-
chological support [39], but unfortunately, supportive services are
inadequate [40]. One reason may be the low-skilled healthcare
workforces in this field. Many of these countries assign supportive
care to other professionals such as trained nurses. However, the
findings of some studies indicated a positive impact of applying
these people to improve the quality of cancer care [37,39].
While analyzing the results, some limitations should be
considered, such as the small sample size selected from a local area
and the fact that most participants had less than a high school
education. Moreover, this study was restricted to female patients
only, and the stage of cancer was not considered. More research
with a larger sample size and comparisons with other patient
groups are recommended.
Conclusion
Generally, it seems that a good, well-organized plan to provide
breast cancer patients with information and increase their infor-
mational literacy as one of their undeniable rights is necessary.
However, the implementation of these requirements and meeting
the information needs of patients must be continually evaluated
and monitored.
Conflict of interest statement
Authors declare that they have no conflict of interest.
Acknowledgments
The authors would like to thank the Research Deputy of Mash-
had University of Medical Sciences for the financial and adminis-
trative support of this study and the Cancer Research Center in
Mashhad for their assistance in this study (Grant number: 931529).
References
[1] WHO. Global health observatory data repository, ten leading causes of death.
Word Health Organization; 2015 [cited 2015 Oct 22]. Available from: http://
apps.who.int/gho/data/view.wrapper.MGHEMORTCAUSE10-2012?
lang¼en&menu¼hide.
[2] Globocan IARC. Estimated cancer incidence, mortality and prevalence
worldwide in 2012. International Agency for Research on Cancer; 2012 [cited
160 K. Kimiafar et al. / The Breast 28 (2016) 156e160
2015 Oct 22]. Available from: http://globocan.iarc.fr/Pages/fact_sheets_
population.aspx.
[3] Alizadeh Otaghvar H, Hosseini M, Tizmaghz A, Shabestanipour G, Noori H.
A review on metastatic breast cancer in Iran. Asian Pac J Trop Biomed
2015;5(6):429e33.
[4] Asadzadeh Vostakolaei F, Broeders MJM, Mousavi SM, Kiemeney LALM,
Verbeek ALM. The effect of demographic and lifestyle changes on the burden
of breast cancer in Iranian women: a projection to 2030. Breast 2013;22(3):
277e81.
[5] Jefford M, Tattersall MHN. Informing and involving cancer patients in their
own care. Lancet Oncol 2002;3(10):629e37.
[6] Goss C, Deledda G, Bottacini A, Chiodera F, Mazzi MA, Ballarin M, et al. In-
formation needs of female Italian breast cancer patients during their first
oncological consultation. Eur J Oncol Nurs 2015;19(5):451e7.
[7] Littlechild SA, Barr L. Using the Internet for information about breast cancer: a
questionnaire-based study. Patient Educ Couns 2013;92(3):413e7.
[8] Matsuyama RK, Kuhn LA, Molisani A, Wilson-Genderson MC. Cancer patients'
information needs the first nine months after diagnosis. Patient Educ Couns
2013;90(1):96e102.
[9] Ryh€ anen AM, Siekkinen M, Rankinen S, Korvenranta H, Leino-Kilpi H. The
effects of Internet or interactive computer-based patient education in the field
of breast cancer: a systematic literature review. Patient Educ Couns
2010;79(1):5e13.
[10] Rutten LJF, Arora NK, Bakos AD, Aziz N, Rowland J. Information needs and
sources of information among cancer patients: a systematic review of
research (1980e2003). Patient Educ Couns 2005;57(3):250e61.
[11] Joosten EA, DeFuentes-Merillas L, De Weert G, Sensky T, Van Der Staak C, de
Jong CA. Systematic review of the effects of shared decision-making on pa-
tient satisfaction, treatment adherence and health status. Psychother Psy-
chosom 2008;77(4):219e26.
[12] Warren E, Footman K, Tinelli M, McKee M, Knai C. Do cancer-specific websites
meet patient's information needs? Patient Educ Couns 2014;95(1):126e36.
[13] Bergenmar M, Johansson H, Sharp L. Patients' perception of information after
completion of adjuvant radiotherapy for breast cancer. Eur J Oncol Nurs
2014;18(3):305e9.
[14] Alamanou GD, Balokas AS, Fotos VN, Patiraki E, Brokalaki H. Information needs
of cancer patients: validation of the Greek Cassileth's information styles
questionnaire. Eur J Oncol Nurs 2016;20:49e57.
[15] Wittmann E, Beaton C, Lewis W, Hopper A, Zamawi F, Jackson C, et al. Com-
parison of patients' needs and doctors' perceptions of information re-
quirements related to a diagnosis of oesophageal or gastric cancer. Eur J
Cancer Care 2011;20(2):187e95.
[16] Levinson W. Physician-patient communication: a key to malpractice pre-
vention. Jama 1994;272(20):1619e20.
[17] Li PW, So WK, Fong DY, Lui LY, Lo JC, Lau S. The information needs of breast
cancer patients in Hong Kong and their levels of satisfaction with the provi-
sion of information. Cancer Nurs 2011;34(1):49e57.
[18] Ankem K. Use of information sources by cancer patients: results of a sys-
tematic review of the research literature. Inf Res 2005;11(3):4.
[19] Sarbaz M, Naderi HR, Aelami MH, Eslami S. Medical information sources used
by specialists and residents in Mashhad, Iran. Iran Red Crescent Med J
2016;18(3):e22483. Epub 2016-03-06.
[20] Sadoughi F, Kimiafar K, Ahmadi M, Shakeri MT. Determining of factors
influencing the success and failure of hospital information system and their
evaluation methods: a systematic review. Iran Red Crescent Med J
2013;15(12).
[21] Esbensen BA, Swane CE, Hallberg IR, Thome B. Being given a cancer diagnosis
in old age: a phenomenological study. Int J Nurs Stud 2008;45(3):393e405.
[22] Liang W, Burnett CB, Rowland JH, Meropol NJ, Eggert L, Hwang Y-T, et al.
Communication between physicians and older women with localized breast
cancer: implications for treatment and patient satisfaction. J Clin Oncol
2002;20(4):1008e16.
[23] Vogel BA, Leonhart R, Helmes AW. Communication matters: the impact of
communication and participation in decision making on breast cancer pa-
tients' depression and quality of life. Patient Educ Couns 2009;77(3):391e7.
[24] De Bock G, Bonnema J, Zwaan R, Van de Velde C, Kievit J, Stiggelbout A. Pa-
tient's needs and preferences in routine follow-up after treatment for breast
cancer. Br J Cancer 2004;90(6):1144e50.
[25] von Meyenfeldt M. Cancer-associated malnutrition: an introduction. Eur J
Oncol Nurs 2005;9(Suppl. 2):S35e8.
[26] Khoshnevis N, Ahmadizar F, Alizadeh M, Akbari M. Nutritional assessment of
cancer patients in Tehran, Iran. Asian Pac J Cancer Prev 2012;13(4):1621e6.
[27] Davies M. Nutritional screening and assessment in cancer-associated
malnutrition. Eur J Oncol Nurs 2005;9:S64e73.
[28] Leandro-Merhi VA, de Aquino JLB, Chagas JFS. Nutrition status and risk factors
associated with length of hospital stay for surgical patients. J Parenter Enter
Nutr 2011;35(2):241e8.
[29] Bentzon N, Düring M, Rasmussen BB, Mouridsen H, Kroman N. Prognostic
effect of estrogen receptor status across age in primary breast cancer. Int J
Cancer 2008;122(5):1089e94.
[30] Prentice RL, Caan B, Chlebowski RT, Patterson R, Kuller LH, Ockene JK, et al.
Low-fat dietary pattern and risk of invasive breast cancer: the women's health
initiative randomized controlled dietary modification trial. Jama 2006;295(6):
629e42.
[31] Segura A, Pardo J, Jara C, Zugazabeitia L, Carulla J, de las Pen~ as R, et al. An
epidemiological evaluation of the prevalence of malnutrition in Spanish pa-
tients with locally advanced or metastatic cancer. Clin Nutr 2005;24(5):
801e14.
[32] Genton L, Kyle UG, Balmer Majno S, Pichard C. Body composition changes in
breast cancer patients during curative radiation therapy. e-SPEN Eur E J Clin
Nutr Metab 2006;1(1):2e8.
[33] Cox N, Bowmer C, Ring A. Health literacy and the provision of information to
women with breast cancer. Clin Oncol 2011;23(3):223e7.
[34] Casap N, Alterman M, Sharon G, Samuni Y. The effect of informed consent on
stress levels associated with extraction of impacted mandibular third molars.
J Oral Maxillofac Surg 2008;66(5):878e81.
[35] Kimiafar K, Sadoughi F, Sheikhtaheri A, Sarbaz M. Prioritizing factors influ-
encing nurses' satisfaction with hospital information systems: a fuzzy analytic
hierarchy process approach. Comput Inf Nurs 2014;32(4):174e81.
[36] Sheikhtaheri A, Kimiafar K, Sarbaz M. Evaluation of system quality of hospital
information system: a case study on nurses' experiences. Studies in health
technology and informatics 2014;205:960.
[37] Liao M-N, Chen S-C, Lin Y-C, Chen M-F, Wang C-H, Jane S-W. Education and
psychological support meet the supportive care needs of Taiwanese women
three months after surgery for newly diagnosed breast cancer: a non-
randomised quasi-experimental study. Int J Nurs Stud 2014;51(3):390e9.
[38] Distelhorst SR, Cleary JF, Ganz PA, Bese N, Camacho-Rodriguez R, Cardoso F,
et al. Optimisation of the continuum of supportive and palliative care for
patients with breast cancer in low-income and middle-income countries:
executive summary of the Breast Health Global Initiative, 2014. Lancet Oncol
2015;16(3):e137e47.
[39] Sajjad S, Ali A, Gul RB, Mateen A, Rozi S. The effect of individualized patient
education, along with emotional support, on the quality of life of breast cancer
patients e a pilot study. Eur J Oncol Nurs 2016;21:75e82.
[40] Ganz PA, Yip CH, Gralow JR, Distelhorst SR, Albain KS, Andersen BL, et al.
Supportive care after curative treatment for breast cancer (survivorship care):
resource allocations in low- and middle-income countries. A Breast Health
Global Initiative 2013 consensus statement. Breast 2013;22(5):606e15.