Understanding the needs of breast cancer patients who have experienced intimate partner violence: Implications for trauma- and violence-informed care

Abstract

Trauma- and violence-informed care (TVIC) aims to minimize re-traumatization and promote equitable outcomes for women who have experienced intimate partner violence (IPV). Breast cancer (BC) patients with trauma histories may delay or avoid care due to fear of re-traumatization, compromising outcomes. This study aimed to explore what aspects of TVIC are important to this patient population and understand how trauma influences lived experiences of BC. Nine women with prior or concurrent BC and IPV participated in 1-on-1 semi-structured interviews, analyzed via Thorne’s interpretive description. Participants emphasized that providers should understand how trauma influences behavior, self-advocacy, and coping. Control and revocable consent were essential for emotional and physical safety. Some women felt prior trauma hindered self-advocacy. Agency and collaboration in care, while important, were challenging to achieve. Resilience related to prior trauma helped some women face BC. This study provides critical insights into improving TVIC in BC for women with IPV histories.

Keywords

breast cancer intimate partner violence trauma- and violence-informed care trauma women

Breast cancer and trauma

In 2024, breast cancer accounted for 25% of all newly diagnosed cancers among Canadian women, establishing breast cancer as the most diagnosed cancer (excluding non-melanoma skin cancers) among this group (Canadian Cancer Society, 2024). In Canada, an estimated one in eight women are diagnosed with breast cancer in their lifetime, and approximately 15 women die every day from the disease (Canadian Cancer Society, 2024).

Receiving a life-altering health diagnosis, especially cancer, can be traumatic (Cordova et al., 2017; Glanz and Lerman, 1992). Trauma is a complex inner experience, including both the experience of, and response to, an overwhelmingly negative event or series of events (Ponic et al., 2021). The adverse effects of trauma span emotional, mental, physical, social, and spiritual domains across the life course (Ports et al., 2019; Substance Abuse and Mental Health Services Administration (SAMHSA), 2024). However, the intersection of trauma with cancer can—and often does—occur before diagnosis, including risky coping mechanisms (e.g. substance use to manage stress), diagnostic/screening activities (e.g. mammograms), and ongoing treatment and follow-up (i.e. palliative, remission, and survivorship care; Farley et al., 2001, 2002; Ports et al., 2019).

Re-traumatization occurs when “a person experiences something in the present that is reminiscent of a past traumatic event” (Hennessy et al., 2023: 1) and is often accompanied by emotional, behavioral, and physiological responses similar to the original event (Duckworth and Follette, 2012). Re-traumatization, or its perceived potential, can compromise patient participation in cancer screening, treatment, and follow-up care; and subsequently, health outcomes (Cordova et al., 2017; Hanna et al., 2020; Regal et al., 2020). Cancer patients with adverse experiences demonstrate reduced treatment adherence (i.e. care delays or avoidance) and greater relational difficulties with providers, with impacts exacerbated among those who experience a greater number of traumatic events (Quach et al., 2012; Regal et al., 2020). The interaction of trauma with adversity (i.e. a cancer diagnosis) is associated with poorer health outcomes (Regal et al., 2020). Treatment delays dramatically compromise cancer outcomes: an 8-week delay in breast cancer surgery increases mortality risk by 17%, with longer delays inferring greater risk (Hanna et al., 2020).

Trauma- (and violence-)informed care

A trauma-informed approach to care (TIC) considers patients’ experiences of trauma essential considerations for optimal care (Wathen and Varcoe, 2021). TIC is distinct from trauma-based forms of care because it does not aim to elicit a description of the trauma, nor treat it directly (Wathen and Varcoe, 2021). According to a 2023 review by Davidson et al., the most dominant definition of TIC in cancer care literature originates from the SAMHSA (2014a), which describes TIC as an approach that acknowledges the widespread impacts of trauma, integrates knowledge of trauma into practice, recognizes its signs and symptoms, and prevents resist re-traumatization (SAMHSA, 2014b).

The concept of TIC has since been expanded to include violence as a critical consideration. Trauma-and violence-informed care (TVIC) improves upon TIC by accounting for the “intersecting impacts of systemic and interpersonal violence and structural inequities on a person’s life” including historical and ongoing contexts (Wathen and Varcoe, 2021: 1). TVIC aims to minimize re-traumatization and associated unintended harms. The Public Health Agency of Canada (PHAC, 2018) describes four principles of TVIC policy and practice: (1) understand trauma and violence, and their impacts on peoples’ lives and behaviors; (2) create emotionally and physically safe environments; (3) foster opportunities for choice, collaboration, and connection; and (4) provide a strengths-based and capacity-building approach to support client coping and resilience (see Appendix 1 for definitions).

In practice, TVIC has increased patients’ sense of safety, control, and resilience (PHAC, 2018) and reduced stress and re-traumatization among cancer patients (Niebauer et al., 2021). For example, under standard care models, when a patient does not adhere to recommended care, they may be labeled as “non-compliant.” However, a TVIC-trained healthcare provider would be mindful that “non-compliance” is not only a harmful label, but such patient behavior may be a manifestation of severe psychological distress, the recognition of which empowers them to respond to this behavior differently (Dhawan and LeBlanc, 2022). Rather than assuming the patient is not interested in receiving care, a TVIC provider may seek out strategies to improve the patient’s sense of safety during care and reduce barriers to care participation. TVIC is known to promote equitable health outcomes among women experiencing IPV (Wathen and Mantler, 2022). The Government of Canada recommends integration of TVIC into practice (PHAC, 2018). However, the dearth of evidence-based tools to support implementation in oncology settings—especially breast cancer—presents a significant barrier. The complex impacts of trauma among breast cancer patients and how to best integrate TVIC to address unmet needs have been inadequately addressed in the literature (Dionigi et al., 2020). A 2022 review of trauma-informed cancer care literature in Canada and the United States identified only two studies specifically addressing the breast cancer context (Davidson et al., 2023).

In 1992, Glanz and Lerman suggested directing future research toward understanding special subgroups (i.e. those with trauma histories) among breast cancer patients and developing and testing interventions to improve outcomes. Decades later, in 2025, the literature remains scant regarding tailoring TVIC to support breast cancer patients with trauma histories—and patient voices remain conspicuously underrepresented. Recommendations for TVIC delivery without the requisite resources to support implementation impairs adoption in real-world practice settings.

Accordingly, the aims of this study were twofold: (1) to explore what’s important to women with breast cancer regarding trauma- and violence-informed care; and (2) to understand how women’s experiences of breast cancer are influenced by trauma.

Methods

This paper presents a sub-study of the broader Preparing to Provide TRaUma-and-Violence-Informed Care for Women with BreaST Cancer and a History of Gender-Based Violence (TRUST) project beginning in May 2022. The TRUST study aimed to develop a clinical tool for individualized trauma- and violence-informed breast cancer care that prevents re-traumatization and prioritizes mental and physical health outcomes for patients who have experienced intimate partner violence (IPV).

The purpose of this sub-analysis was to explore the intersections of women’s experiences of breast cancer, IPV, and key tenets of TVIC. This paper presents the qualitative findings from one phase of TRUST data collection (i.e. interviews from May 2023 to October 2023) with women who have experienced both breast cancer and IPV. Ethical approval was obtained from the Health Sciences Research Ethics Board (120685) at the authors’ host institution in May 2022.

Study procedures

TRUST interview eligibility included identifying as a woman, being 18 years of age or older, having safe access to the internet, being diagnosed with breast cancer in the past 5 years, and having experienced (or currently experiencing) IPV. There were no exclusion criteria.

Recruitment included contacting TRUST study participants from previous data collection stages (i.e. focus groups) for participation, as well as newsletter dissemination through Canadian breast cancer organizations, flyers at breast cancer clinics, and advertisements posted to Kijiji (a public, online community forum that includes research studies as a listing category). All materials invited interested women to email the research team to confirm eligibility and provide written informed consent for participation.

Interview participation was determined on a first-come, first-served basis and interested participants were made aware that expressions of interest did not guarantee that an interview would be scheduled. The first nine women participated in a 60-minute, 1-on-1, Zoom-based interview about their experiences of breast cancer, trauma, and TVIC. This sample size was considered sufficient because of the narrow, focused aim of the interview guide and the specificity of eligibility criteria. The interviewer was a female in her late 20s with experience of gender-based violence. While she has never been diagnosed with breast cancer, she has extensive experience with the disease through her family (grandmothers, aunts, and cousins). Data sufficiency was bolstered by the robust interview duration (60 minutes), enabling rich, in-depth insights from each participant (LaDonna et al., 2021). In two cases, participants wished to continue sharing information beyond the 60-minutes allotted for the interview. Each participant was then offered the option to schedule a second 60-minute interview to elaborate on their perspectives and promote data depth. Participants were sent a $20 e-gift card in recognition of their time and contributions.

Data collection

All participants completed a two-part, 60-minute (on average), 1-on-1, Zoom-based interview, including a verbal demographic questionnaire and in-depth, semi-structured interview questions (see Appendix 2).

Before beginning the interview, the interviewer established a safety plan with each participant, inclusive of communication preferences, planning for unsafe situations, and debriefing post-interview (Ford-Gilboe et al., 2015). This procedure has been effectively implemented in the Canadian context to support women’s safe participation in research (Ford-Gilboe et al., 2015, 2017). Audio files were transcribed verbatim post-interview.

Data analysis

Thorne’s (2016) interpretive description was employed for data analysis. Interpretive description “is a grounded approach to articulating patterns and themes emerging in relation to various clinical phenomena” (Thorne et al., 2004: 8). This iterative and concurrent approach includes reflecting and asking questions until the data (individually and collectively) reveal new insights (Thorne, 2016). Guba and Lincoln’s (1989) principles of confirmability, credibility, dependability, and transferability also informed this analysis. Memoing supported the identification of theoretical outliers, as well as meaning and theorizations of the data (Thorne, 2016).

To begin, two members of the research team met to create a preliminary coding structure in Quirkos (2021) using the PHAC (2018) key policy and practice principles for TVIC (see Appendix 1). Next, the researchers independently analyzed four randomly assigned transcripts using open and line-by-line coding (Blundell et al., 2020). Then, researchers met to discuss and refine the preliminary coding structure. Once the coding structure and definitions sufficiently covered the data, the structure was applied independently to all transcripts. The final coding structure included TVIC as a parent code, with the four PHAC TVIC principles as child codes.

Results

Demographics

Nine participants were included in this sub-study, with ages ranging between 28 and 61 years. All identified as women (n = 9, 100.00%). Most identified as heterosexual (n = 8, 88.89%). This sample was highly educated; all women reported at least some post-secondary education. Most identified as White (n = 6, 66.67%) and one-third (n = 3, 33.33%) identified as Indigenous to Canada.

Breast cancer

Nearly half the participants in this sample were diagnosed with Stage I breast cancer (n = 4, 44.44%); the remainder varied between Stages II (n = 1, 11.11%), III (n = 2, 22.22%), and IV (n = 1, 11.11%; note one woman (11.11%) did not disclose her stage). Most cases were not metastatic (n = 7, 77.78%). See Appendix 3 for all cancer data.

Gender-based violence by an intimate partner

All participants experienced at least one type of IPV by a male partner (n = 9, 100.00%); verbal (n = 8, 88.89%), physical (n = 7, 77.78%), and emotional (n = 5, 55.56%) violence were most prevalent. Six women (66.67%) experienced violence for the first time before diagnosis, and three women (33.33%) experienced violence for the first time during diagnosis and treatment. For most participants, violence continued beyond treatment (n = 5, 55.56%). Frequency of violence (i.e. before diagnosis to during treatment, or during treatment to after treatment) largely remained consistent (n = 4, 44.44%) or escalated (n = 4, 44.44%). Severity of violence mostly remained consistent (n = 5, 55.56%) or escalated (n = 3, 33.33%). See Appendix 4 for all demographics.

Qualitative findings

Participants described their perspectives of TVIC regarding breast cancer and how trauma influenced their breast cancer journey. The researchers began the analysis using an inductive approach, however, after the first round, it became apparent that the findings would be best interpreted in accordance with the TVIC pillars (per PHAC, 2018). Accordingly, the team pivoted to a deductive framework such that each TVIC pillar composed a main theme, and subthemes were identified as they “mapped” onto each pillar. Participant quotes are presented using pseudonyms.

Pillar 1: Understand trauma and violence, and their impacts on peoples’ lives and behaviors

There is an overarching pattern in my life that has led me to behave the way I do, and it would be nice if someone acknowledged that this is how I need to be approached and handled, right? (Danielle)

Participants consistently identified it was important for providers to understand how the impacts of trauma may manifest in their behavior as a patient, especially pertaining to their attitude toward diagnosis, capacity for self-advocacy, and coping mechanisms. Participants also wished for providers to be aware of potentially harmful assumptions about their behavior and unique challenges that may inform patient behavior.

Attitude toward diagnosis

Diagnosis was frequently re-traumatizing for participants. One woman felt her previous traumatic experiences directly caused her cancer, sharing,

Well, it’s the abuse that has led to this breast cancer, right, like maybe I was affected from all the years of it, or maybe that the stage of it, you know, because I was delayed in the treatment, or the effect, the effectiveness of the treatment, and the trauma of the experience is really, so heightened. (Linette)

Another participant described a similar “what if” feeling, stating, “That’s always, like, you think why this happen, so it, it probably I experience this, this trauma, that might be potential cause . . . ” (Veronica).

Others identified how the re-traumatization of diagnosis impacted their sense of control, and how this was reminiscent of lacking control within an abusive relationship. One participant shared,

At the time of diagnosis, it was absolutely re-traumatizing. I felt like that my whole world was – the floor had fallen out from underneath me; I was completely out of control and terrified. . . and that’s a very familiar feeling, um, in terms of when I experienced trauma. (Zera)

Capacity for self-advocacy

Self-advocacy was a common challenge during care. Many women had learned to self-silence as a protective strategy in abusive relationships, leading to conflict avoidance. As described by one participant,

And then you add trauma on top of it, and like ya, you should be able to advocate for yourself [. . .] It’s way harder than people think it is, depending on who you are, and how you were brought up, and what experiences you had that’s led you to here. (Danielle)

It was difficult to abruptly transition from self-silencing to self-assertion: “Like you’ve been conditioned to not say anything about yourself and put other people first and then all of a sudden like, well, you have to speak up, or no one’s going to.” (Danielle). Self-advocacy was also described as anxiety-inducing due to an undermined sense of self-worth: “I think it’s more of just kind of, an anxiety on getting my needs met. Having that anxiety to talk to somebody else about it and feeling confident enough.” (Ana).

Some participants felt that the dynamics of abusive relationships were reproduced in clinical interactions. One participant’s ex-partner would “punish” her for asserting herself, so she was anxious to speak up at appointments. She described, “I always felt like my nurse, like my oncologist was always annoyed with me, I don’t know if I was projecting that because [ex-partner] was always annoyed with me.” (Linette). She elaborated, “I felt like, you know, I was being a pain if I advocated for, for myself.” (Linette).

Similarly, others equated self-advocacy with creating conflict because of dynamics in past abusive relationships. One woman shared,

I also don’t handle confrontation very well, so like when people like, ‘Just advocate for yourself,’ and like that’s not that straightforward for people, like that’s a really hard thing for someone who has been, you know, sort of put in their place so many times in their life. (Danielle)

She elaborated, “If I just stay small and if I stay in my lane, then they [abuser] won’t be angry [. . .] and so that sort of correlated over into this relation to this [patient-provider] sort of dynamic as well.” (Danielle).

Coping mechanisms

For some, the impacts of trauma primarily affected coping mechanisms. One participant (Ana) shared, “When you’ve been through trauma, your coping mechanisms are different.” Participants emphasized that providers should be prepared to actively support patients’ coping: “There is a level of complexity that goes along with someone who’s sort of had to survive that [trauma] or is surviving it, in how they need to be treated and handled.” (Danielle).

One participant felt that the coping mechanisms that helped her survive violence were insufficient for navigating cancer:

One of my major coping strategies is just, you know, pull up your socks and carry on, and I did that, and I was able to do that until that point, and then it was just like I can’t, I can’t do anymore. (Zera)

She later accessed psychological support, where she uncovered that she was dealing with ongoing traumatic impacts of past IPV: “I started to process unresolved trauma, again . . . And then it started to all make sense as to why I was reacting the way that I was, cause I really – I wasn’t in reflective mode, I was in survival.” (Zera).

Harmful assumptions

Some participants described providers making harmful assumptions about their care, reducing trust. For example, Linette’s oncologist interpreted her husband’s constant presence at appointments as evidence of a supportive home environment, when her husband was abusive. She chose not to disclose this until her partner left her and she needed insurance documentation. She recalled the oncologist apologizing, saying, “I’m, I’m sorry I didn’t realize, I assumed that he was supportive. . .” (Linette).

Another participant (Danielle) was frustrated that her oncologist assumed her appearance correlated with her symptom severity. She attended appointments well-dressed and prepared but struggled significantly with treatment side effects. Her concerns were routinely dismissed until she broke down crying during an appointment:

But she [oncologist] was like, I didn’t realize it was as bad as it is. And so, I’m like, yep. I’ve been saying it for three years, but I show up looking well put together, and I show up cognitively present, and, you know, dressed to go in public and things like that. And so, they just make this assumption that I am well all the time. [. . .] But I don’t know how to show up like a sick person, so you tell me. Is it dishevelled hair? Is it mismatched shoes? Like, what does a sick person look like? (Danielle)

Unique challenges

Participants disclosed several unique IPV-related challenges during breast cancer that impacted their behavior and care, such as concurrent violence, self-care, and traumatic stress.

Women experiencing IPV concurrently with breast cancer were often coerced into neglecting their health to protect themselves at home. One woman shared, “Oh [violence] make, for sure, for sure make it harder, like harder to recover right.” (Veronica). For some, this meant prioritizing their partner over their own healing: “It felt like all of my energy was focused on how to resolve whatever things were upsetting him. . . and you know that really superseded like being able to do anything regarding caring for myself.” (Linette).

Linette experienced suicidal thoughts linked to the cumulative stress of breast cancer, IPV, and access to means of self-harm: “At one point I had, and I had all these pills I knew were in the house, all these medications, and it made me scared because I thought ‘oh that’s what I would do if I was to kill myself’” (Linette). She asked her husband to hide the pills, but he refused, telling her, “I’m not looking after your feelings” and “I loved you better before you got cancer.” She likened his refusal to leaving “a bullet and gun out for somebody with that [suicidality]” (Linette).

Some participants chose not to disclose IPV because of potential stigma. One woman worried that she would be dropped as a patient if her providers knew about the IPV, saying, “I would be scared it would take away from my care, versus like, maybe like if the health care professionals were nervous about this person that they might not want to treat me.” (Eda).

In some cases, participants only began experiencing abuse at home post-diagnosis. One woman stated, “When I broke the news to him, he changed, and he became somewhat abusive.” (Jasmine). Her home became dangerous and she could not safely rest there: “I didn’t have that peace of mind in which I needed being at home.” (Jasmine). The abuse escalated over time and her husband (the primary breadwinner) began refusing to pay for her treatment: “He didn’t want me to get some sort of therapy because I think he was done with me. He didn’t care about me at all; whether I die or whatever happens to my life, he didn’t even care.” (Jasmine). This escalated to severe physical violence that required hospitalization, interrupting her cancer care: “Once he beat me up with a pan. [. . .] He hit me on the head, and I had to get hospitalized for 2 days.” (Jasmine).

For others, the cumulative impacts of past traumatic stress with cancer-related traumatic stress produced severe psychological symptoms, such as memory loss. One participant explained, “I couldn’t take stuff in at all, I couldn’t remember anything, and this was before the treatment. It just got increasingly difficult because I was in absolute flight mode, totally extreme.” (Zera). As the stress accumulated, she became increasingly dysregulated, escalating into verbal conflicts with her care team: “I also lost my temper a lot of times with people on the phone and felt really bad about it, knew it was fear. . .” (Zera). She felt frustrated that her stress was not addressed in care despite its extensive impacts: “Like, I was so cognitively impaired, it wasn’t even funny, and they didn’t talk about that at all.” (Zera). Another participant echoed psychological impacts, stating, “I’m concerned that my mind may take longer than my body to recover from the breast cancer because my trauma [. . .] That stands out.” (Ana).

Others felt isolated while navigating IPV and breast cancer simultaneously, despite having access to support groups:

When I talk just to the domestic violence people, I feel like I’m that cancer lady, right? I don’t quite fit, and when I go to the cancer groups, you know, I’m always kind of apologizing for why I’m talking about these family issues all the time. (Linette)

Pillar 2: Create emotionally and physically safe environments

It just seemed like it would be best to not be disruptive, you know? (Linette)

Participant descriptions of emotionally and physically safe environments largely pertained to consent and a sense of control.

Checking in continuously

Consent as a continuous process was fundamental to participants’ sense of safety. One participant described,

But we talked about also like permission, right? Can I touch you? And the, and then just the constant, like, being reassured, like, are you still okay? And that wasn’t part of the exam. I remember just being touched. They did ask, I do believe they did ask, but it was it should be kind of like continuous when you’re dealing with someone with a lot of trauma. (Ana)

Similarly, one participant shared that check-ins post-appointment dramatically improved her sense of safety: “for example, I’m done with an appointment and then maybe weeks later I get a call from them to like them, them asking how I am feeling. That is amazing for me, like someone is thinking about you constantly.” (Audrey).

Jasmine, who was hospitalized after being assaulted by her husband, said that her team checking in provided an opportunity for disclosure and help-seeking: “I needed someone who I can share and express myself to, and I felt safe to talk to my doctor.” (Jasmine). She was given resources to better understand IPV, saying, “Some videos I can be able to watch some women who have the same thing problem that I have, and was much, much helpful to me.” She then felt empowered to leave the relationship and develop a safety plan, sharing, “Seek somewhere else I can settle for that moment, until I can get better and figure out what’s next.” (Jasmine).

Control

Some participants were uncomfortable when alone with male providers for invasive examinations. One participant shared,

I had a male oncologist who liked to do exams when there was nobody in the room. I didn’t know that wasn’t something that was OK. I had no idea. No one told me. Only until I looked up his reviews and other women were like, what the fuck, like why right so? (Danielle)

Danielle ultimately requested a new oncologist and took control of her care team, saying, “And all [care team members] but one are women and that’s by design.” She emphasized, “It’s so important to someone who’s going through abuse to have any sort of modicum of control in their life . . . ” (Danielle).

Many participants felt compelled to “play the game” to maintain a sense of control in their care, often at the expense of their emotional safety. Several chose to conceal their experiences of IPV out of fear of being labeled “difficult.” One participant explained, “I swallowed my truth in order to not be seen as a difficult patient and just to get along because you’re so vulnerable, you need the help, and you have no power that you have to play a game.” (Zera). Another feared that her care team would notice signs of abuse and ask questions: “In terms of, kind of, financial abuse or physical abuse, sometimes I was kind of afraid that the care team would kind of, kind of see that and ask questions, and I didn’t really want them to ask questions.” (Mona). She worried disclosure would complicate her care: “I just wanted to get better like from the breast cancer, I didn’t wanna, like, make things complicated with other things that are going on.” (Mona). Others minimized their psychological symptoms to be taken seriously: “I don’t wanna appear like I’m, you know, mentally unwell like [ex-partner] would treat me because then you know they won’t, they won’t stick around and answer my questions, they won’t wanna be bothered with me.” (Linette).

Some participants improved their sense of control during care using reframing and coping techniques. One participant who struggled with memory loss from post-traumatic stress relied on meticulous documentation, saying, “Well, I tried to like apply as much control as I possibly could. Like I had my own system for my treatment, I’ll document it [. . .] so all of that, super hypervigilant, pre-planning. . ..” (Zera). Another participant in palliative care reframed her perspective so that she was the boss instead of the oncologist:

Oh, so you’re not in charge, I’m in charge. I got it, got it. So then now I describe it to people as I’m the CEO, and they [care team] all work for me. [. . .] I am not a burden on them, right? They don’t have a job unless I show up. (Danielle)

Privacy

Privacy was central to women’s sense of safety during care. For example, one participant felt very unsafe when her oncologist asked about care delays in front of her abusive partner:

I remember him [oncologist], like, why, why if you had such a large tumour, why didn’t you come sooner? [. . .] I remember when he asked that, thinking, ‘How are women supposed to answer these questions if they have a husband in the room?’ (Linette)

She could not answer openly out of fear of retaliation, as her husband was the reason; she recalled thinking, “Because I didn’t want to upset him.” (Linette). Her sense of safety further deteriorated when she was asked about past contraception, implying sexual activity with other partners:

Oh God, one of the questions was like, ‘how long were you on birth control for, what years were you on birth control’ [. . .] I wasn’t comfortable with it, and I know some women who would be particularly like dangerous to be sharing ‘well I was on birth control in these years, before I met my husband’ right?” (Linette)

Ultimately, this participant withheld information to protect herself: “It just seemed like it would be best to not be disruptive, you know?” She felt her partner was more dangerous than cancer: “I actually ended up telling a friend, [. . .] I said, ‘if anything happens, you know, I feel like [ex-partner] would rather me be dead than alive.” (Linette).

Participants wanted to keep abusers as distant as possible from care to prevent them from weaponizing information. As one participant shared, “I would’ve rather had to like go through all that by myself than with that person knowing anything.” (Eda).

Pillar 3: Foster opportunities for choice, collaboration, and connection

I keep harping on the word control, but having a voice and actually being able to stand up for yourself is really, really challenging after you’ve been through something like you know, like the gaslighting and dog whistling and all that kind of stuff, and really feeling like you’re not a valuable part of society. . . (Danielle)

Choice, collaboration and connection in care were extremely important to participants. However, many lacked the necessary information and collaboration with their care team, impeding their capacity for choice. One participant expressed frustration with the lack of information: “How do I know to ask these questions [for accommodations]? I have no idea. I don’t know I’m allowed to ask these questions; no one gives you a book . . . ” (Danielle).

All participants emphasized the importance of collaboration in care, especially when their priorities diverged from those of their providers. One participant (Linette) felt pressured into breast reconstruction by her oncologist and husband, despite being sure she wanted a flat closure. She recalled the oncologist saying, “Oh, it’ll look better,” and “You’re a married woman.” Her husband became “giddy” after the oncologist said they could “make them look better than they did to start off with.” Linette felt this experience “definitely felt like a gender-based violence kind of thing” because of the expectation of having breasts. This pressure continued at follow-up appointments: “My oncologist still says something, and it’s like, in order to be desired I’m gonna need this part of my body, and I just think, well, I don’t want anybody like that, I’m okay on my own, you know.” (Linette).

Overall, while collaboration in care was very important to patients, this often was not part of their care team relationship, undermining their ability to tailor care to their needs and preferences.

Pillar 4: Provide a strengths-based and capacity-building approach to support client coping and resilience

I think everything I’ve gone through is a learning phase, and I have been able to know that I am also strong the way I am. (Audrey)

Some participants transformed their perspective of trauma from deficit-based to strengths-based by recognizing their own resourcefulness and resilience required for survival. One participant (Ana) shared, “What I would say to people is that I have dealt with a lot of difficult situations, and I have the skills to be able to handle this.” Another participant echoed this idea, saying, “I guess in general, like you’ve gotten through it once and, and you kind of made it out alive [laughs] so I guess it’s a positive thing.” (Mona). One participant, who concurrently experienced IPV during cancer, described this sentiment by saying, “I know how to buckle down and get the job done.” (Zera).

Some described a psychological “turning point,” where the combination of past trauma and cancer diagnosis shifted their self-perception: women began to recognize their worth and believe they deserved to be treated with kindness and respect. One participant reflected, “I feel like I’m a strong person, [ . . . ] I can do these things for myself, and it’s ok, and I’m capable.” (Ana). For some, past trauma enabled greater assertiveness: “Sometimes I think the pendulum swings the other way after you’ve been in an abusive situation. [. . .] I’m pretty assertive now and would put up with very little crap from anybody.” (Zera). Others framed past experiences as lessons in resilience: “Everything I’ve gone through is a learning phase and I have been able to know that I am also strong the way I am.” (Audrey). Although participants recounted some of the most traumatic experiences of their lives, many emphasized the strength they cultivated through them.

Discussion

The broader TRUST study aimed to develop a clinical tool for individualized TVIC for patients who had experienced IPV. This paper describes an important sub-analysis regarding what’s important to women with breast cancer regarding TVIC and how women’s experiences of breast cancer are impacted by IPV-related trauma. These findings serve the broader study by providing a patient-lefted lens through which to interpret potential changes to standard care and integration of TVIC practices.

This sub-study identified that despite encouragement to self-advocate during care, many women’s previous experiences of trauma deeply affected their capacity and comfort level in doing so. Women also described that their emotional and physical safety were primarily affected by their sense of control over care and capacity to revoke consent at any time. Choices and collaboration were key care priorities for women; however, they often faced barriers to these in the clinical context. Lastly, many women emphasized that because they had survived prior trauma, they possessed the required resilience to navigate breast cancer.

Challenges with self-advocacy

This study identified that women’s self-advocacy in breast cancer care is deeply impacted by experiences of trauma and violence, which can discourage open communication with providers. Among women with cancer, self-advocacy is understood as a skill-set that patients develop or learn to exhibit behaviors necessary to ensure their preferences, needs, and values are reflected in their care (Thomas et al., 2021). Self-advocacy is associated with improved patient outcomes; however, patients who have experienced traumatic stress face psychological and behavioral impacts that can diminish their capacity to self-advocate (Thomas et al., 2021) and increase potential for dysfunctional conflict resolution (Cherrier et al., 2023).

The most common symptoms related to cancer treatment are fatigue, sleep disturbances, memory problems, and depression (Hagan et al., 2018; Huang et al., 2016), which mirror those of anxiety, mood, and post-traumatic stress disorders – well-established long-term health sequelae of IPV (Fedina, 2024). Symptom severity is inversely correlated with effective communication with one’s care team (Hagan et al., 2018) – women experiencing greater traumatic symptoms may be the least able to self-advocate. This is consistent with the present study, as many women described how cumulative, compounding traumatic stress compromised their self-advocacy during care.

Extant literature considers self-advocacy a key consideration in TVIC. While certainly important, this focus can unintentionally place the burden of disclosure and advocacy primarily on patients. As noted by Machtinger et al. (2015), systems must avoid relying on patients to self-identify and advocate, and instead proactively inquire and respond to patient needs. TVIC has improved comfort and confidence in care among patients experiencing IPV (Ford-Gilboe et al., 2018; Wathen and Mantler, 2022) these outcomes supported improved mental and physical health for patients (Ford-Gilboe et al., 2018). The adoption of TVIC in breast cancer care could provide the necessary scaffolding to better support patient self-advocacy and lighten the burden for patients to self-disclose through system improvements. Future research should identify how healthcare practices and systems can better support self-advocacy among patients who have experienced trauma and identify patients’ individual needs in the absence of self-advocacy.

Promoting a sense of control and safety

Women in this study felt strongly that a sense of control was essential to feeling safe during care. The immense stress of a cancer diagnosis is known to precipitate feelings of loss of control over one’s life (Westman et al., 2025). However, women in this study also identified diagnosis as a “turning point” for regaining their sense of control and prioritizing self-care, which is consistent with previous research. Cancer diagnosis often acts as a “turning point” for women to identify their needs and become more active in their healthcare (Thomas et al., 2021).

Multiple international literature reviews have identified post-traumatic growth (PTG) after the trauma of a cancer diagnosis as an opportunity to improve holistic patient wellbeing (Amedu, 2024; Huang et al., 2025; Nisyraiou et al., 2025). When encouraged, PTG is associated with benefits spanning cognitive, emotional, social, and health-related domains (Huang et al., 2025). Similarly, PTG has been well-documented as an asset to holistic wellbeing in IPV-specific literature (Machinga-Asaolu, 2025). However, to the best of the authors’ knowledge, the concept of PTG has yet to be explored within the specific context of the intersecting, compounding trauma of breast cancer and IPV, as well as the unique context of the Canadian healthcare system. Future research should explore this intersection and explore how to best promote PTG for this unique patient population.

Promoting agency and collaboration

Agency was central for all women in this study, yet perspectives differed in how helpful it was to be presented with all care options. Some experienced the volume of information as overwhelming, exacerbating their sense of losing control, while others found detailed explanations improved their sense of control. When patients are offered choices about a condition they are only beginning to understand, they often feel overwhelmed and lack the criteria needed to evaluate those options (Westman et al., 2025). However, information about diagnosis, treatment, and side effects can support patients’ sense of control (Blödt et al., 2018; Hamaker et al., 2022). Although clinicians can help patients navigate this influx of information, the stress-related cognitive impairment that accompanies a cancer diagnosis may limit patients’ capacity to process it (Westman et al., 2025), as was observed in the present study. Researchers should therefore explore strategies to improve cancer-related communication with patients experiencing traumatic stress (Green et al., 2016) and consider how to best address the cumulative, compounding impacts of the intersection of cancer and IPV traumatic stress. Clinicians might also consider the benefits of multi-modal approaches (Braaf et al., 2018), including the use of patient advocates who can support trauma-informed, patient-lefted communication and support patients’ navigation of information beyond the immediate appointment context (Hartwell et al., 2016).

The tension between agency and overwhelm when receiving information may be partially reflective of the dominance of non-person-lefted discourse within the biomedical model (Siouta et al., 2019); such discourse is linked to difficulties raising questions and concerns during appointments. Similarly, experiencing IPV can erode women’s trust in their own decision-making, further discouraging self-agency (Gerber et al., 2021). Person-lefted communication, which prioritizes patients’ perceptions and experiences rather than biological indicators (McCormack et al., 2010), may help ensure that patients have sufficient time and opportunity to process the information while maintaining autonomy in their care (Siouta et al., 2019).

Participants also reported that collaboration in care was hindered when providers held pre-conceived notions of “ideal care” and patient priorities, leaving them feeling as though their needs went unheard. For some, this reproduced control-related dynamics similar to those in past abusive relationships. Perceived control influences motivation to act and behavior among women who have experienced violence (Lausi et al., 2023), and its absence can therefore discourage participation in care. Future research should identify strategies that foster collaborative care environments by tailoring care to individual patient needs, especially as they pertain to IPV (Thomas et al., 2021), and investigate how dynamics in abusive relationships, including those mirrored in patient-provider interactions, influence patient decision-making.

Drawing upon resilience to promote coping

A key theme in this study was the importance of recognizing the resilience of breast cancer patients who had experienced violence. This acknowledgment enabled women to identify their skills and prioritize their needs through self-advocacy and self-care. Recognition of the experiences that contribute to women’s resilience can improve women’s sense of control (Wathen and Mantler, 2022). In healthcare settings, implementation of strengths-based approaches can improve psychosocial well-being, empowerment, and self-efficacy among women who have experienced violence (Gerber et al., 2021). To help women uncover their strengths, healthcare providers can use practice strengths-based questioning about skills, behaviors, relationships, and experiences that foster resiliency, social connectedness, and hope (Kimberg and Wheeler, 2019). Future research should identify additional no-cost, strengths-based approaches that healthcare providers can integrate into routine breast oncology care and assess their effectiveness.

Limitations

Some limitations should be considered to contextualize these findings. As a sub-analysis, participants were not asked directly about TVIC pillars, and their perspectives may therefore be incomplete. The small sample size also limits representativeness and precludes exploring variation in perspectives based on demographics (e.g. age, ethnicity, diagnosis, and timing of violence). This sample only included women who experienced abuse by a male partner; the perspectives of women in non-heterosexual relationships are not represented. This study did not account for traumatic experiences beyond IPV. Future research should validate these findings among larger, more diverse samples and ensure the inclusion of underrepresented groups.

Conclusion

This study examined how trauma related to IPV affected women’s experiences of breast cancer and identified what they considered important for TVIC. Guided by PHAC’s four pillars of TVIC, self-advocacy, control, agency and collaboration, and resilience emerged as central themes. Women with breast cancer who have experienced trauma view TVIC as valuable. Implementing TVIC in breast cancer settings should aim to reduce barriers to self-advocacy, maximize women’s sense of control in their care, support agency and collaboration in decision-making, and promote strengths that underpin resilience. These changes have the potential to enhance women’s engagement and satisfaction with care and ultimately contribute to improved, more equitable cancer outcomes.

Footnotes

Appendices

Acknowledgements

We are grateful for the women who shared their experiences with the research team. We would also like to thank M. Adnan, H. I. Choban, M. Drummond, D. K. Matharu, D. Meremyanina, B. Nagano, J. E. Oresti, G. Patel, P. H. Stevenson, M. Zangari, and C. Zheng for their contributions to recruitment and data collection.

ORCID iD

Cara A. Davidson

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Health Sciences Research Ethics Board at Western University in May 2022 (ID: 120865).

Consent to participate

Informed consent for participation was obtained from all participants involved in the study.

Consent for publication

Consent for publication is not applicable to this article as it does not contain any identifiable data.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by an internal Western University-Canadian Institutes of Health Research seed grant. Cara A. Davidson’s doctoral research is supported by the Canada Graduate Research Scholarship (Doctoral).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets generated during and analyzed during the current study are not publicly available as participants did not provide consent for this.

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