Mothers' experiences of having a daughter with breast cancer in Chinese families: A qualitative study.

Introduction
It is estimated that approximately 2.3 million women worldwide were newly diagnosed with breast cancer in 2022, with around 430,000 new cases reported in China alone—making it the most common malignancy among women.1,2 In recent years, the incidence of breast cancer among younger women (under 40 years of age) has been rising, particularly in developing countries.3 In China, younger patients accounted for about 16.4% of new breast cancer cases in 2017.4 Compared to older patients, young women diagnosed with breast cancer are more likely to experience disruptions in life trajectory, grappling with identity crises, fertility-related anxieties, and more complex emotional relationships.5,6
However, the impact of these individual disruptions is heavily shaped by the sociocultural context in which the patient resides. In contrast to cultural orientations that prioritize individual autonomy, Chinese society tends to regard the family as the primary locus for meaning-making and the maintenance of social order, with collective interests and relational harmony occupying a prominent position in the hierarchy of values.7 Consequently, cancer often reverberates throughout the entire family system rather than remaining confined to the individual. Among these dynamics, the intergenerational relationship between adult children and their parents is both lifelong and identity-embedded, frequently surpassing other social ties in significance.8
Within this family-centered sociocultural context, breast cancer is not only an individual health crisis but also a relational disruption that may reshape established parent–child roles and expectations. Previous patient-centered research has examined how breast cancer reshapes women's identities in their role as “daughters,” illuminating the complex process through which illness reconstructs patient–parent relationships.9 Unlike the Western paradigm of unidirectional caregiving grounded in individual independence, Chinese families emphasize a model of reciprocal intergenerational exchange: parents assume responsibilities for nurturing and support during their children's formative years, while adult children are expected to “repay” this care and fulfill filial obligations in later life.10 When cancer strikes, this expectation of reciprocity is challenged. Thus, patients often strive to preserve their autonomy and protect their parents by concealing their diagnosis and enduring suffering in solitude;11 yet in reality, they may become dependent on their aging parents for practical assistance and emotional support.12 Notably, however, the experiences of these parents have received scant scholarly attention.
A limited body of Western literature suggests that when elderly parents witness their adult children confronting cancer and even life-threatening conditions, they frequently endure profound psychological and social upheaval.13 From an existential perspective, life-threatening illness precipitates existential anxiety, heightening awareness of mortality, destabilizing structures of meaning, and eliciting emotions such as guilt and despair.8 Nevertheless, elderly parents often consciously suppress their own anxiety and grief, refraining from displaying vulnerability or emotional dysregulation in the presence of their children.13
Within the Chinese familial structure, mothers occupy an especially salient role. They are not only traditional caregivers but also the central agents of emotional cohesion within the family.14 The hereditary correlation of breast cancer between mothers and daughters further intensifies this bond; research indicates that women with a first-degree relative diagnosed with breast cancer face a two- to threefold increase in risk.15,16 In this sense, mothers of patients may be viewed as “co-sufferers” or “latent patients.” Confronted with a daughter's illness, mothers often experience a heightened sense of responsibility and protective instinct, actively re-engaging in the lives of daughters who had previously achieved independence.14 The mother–daughter relationship may thus shift from a trajectory of gradual individuation back toward emotional attachment and functional dependence. Under cultural imperatives that idealize maternal selflessness and feminine resilience, these women may be expected to serve as silent caregivers, reassuming responsibility for familial stability and emotional sustenance. It is plausible that they, too, perceive such emotional burdens as uncontrollable sources of distress. Prior research suggests that this disruption may compel them to confront questions of life and death at an individual level, destabilize their established life order and systems of meaning, and ultimately prompt a reexamination of intergenerational roles, moral responsibilities, and the value of life itself.8
Crucially, empirical studies specifically addressing the psychological experiences of mothers of patients with breast cancer remain exceedingly scarce and are largely situated within Western sociocultural contexts.17 Chinese families may be uniquely shaped by non-Western cultural norms such as filial piety and familism, influences that have yet to be adequately investigated. Accordingly, this study situates itself within the Chinese sociocultural context to describe the psychological and emotional experiences, as well as coping strategies, of mothers of patients with breast cancer, aiming to examine how cultural systems influence maternal emotional responses. A nuanced understanding of this issue may facilitate the development of culturally attuned and equity-oriented supportive interventions, thereby more effectively addressing caregiving needs embedded within traditional family value frameworks.

Methods

Study design
This study adopted a descriptive qualitative design, which is suitable for identifying patterns in participants’ psychological and emotional experiences, as well as coping strategies. The reporting of this study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Participants and recruitment

Target population and operational definition
The target population comprised mothers of young women diagnosed with breast cancer in Chinese families. In this study, “mother” was operationally defined as the patient's biological mother. Co-residence and primary caregiver status were not mandatory inclusion criteria. However, eligible mothers were required to maintain regular contact with their daughters and possess a clear understanding of their daughters' diagnosis and treatment experiences. Adoptive mothers, stepmothers, and other non-biological female caregivers were excluded.

Inclusion and exclusion criteria
Mothers were eligible to participate if they met all of the following criteria: (1) their daughters had been diagnosed with breast cancer; (2) their daughters were under 40 years of age at the time of diagnosis; (3) the mother was alive at the time of recruitment; and (4) the mother demonstrated sufficient cognitive capacity and verbal communication skills to participate in an in-depth interview. A prior history of breast cancer in mothers was not considered an exclusion criterion, as it may provide additional insights into caregiving experiences. Mothers were excluded if they met any of the following criteria: (1) reported severe depressive symptoms or suicidal ideation at the time of recruitment, as determined by self-report and the researcher's clinical judgment; or (2) declined participation or withdrew at any stage. Other psychiatric conditions were not excluded, as doing so might have over-excluded mothers with mild or non-severe mental health conditions, thereby limiting the range of experiential insights.

Sampling strategy and rationale
Purposive sampling, a fundamental strategy in qualitative research, was employed to recruit participants whose experiences were closely aligned with the research question and capable of yielding information-rich data. This approach enabled the generation of in-depth and meaningful insights within the constraints of available resources.18 To enhance sample heterogeneity and strengthen the transferability of the findings, maximum variation sampling was further adopted. Mothers whose daughters were at different stages of the disease trajectory—such as newly diagnosed, undergoing active treatment, or in follow-up—were intentionally included. This strategy facilitated exploration of the diversity and complexity of maternal experiences across varying illness contexts.

Recruitment setting and source
Participants were recruited between March 2025 and July 2025 from the breast surgery ward of a tertiary hospital in China. The first author identified potential participants through a systematic review of inpatient medical records, with contact information obtained via the head nurse. Potential participants were initially approached by telephone, during which the study's purpose, procedures, voluntary nature, and confidentiality safeguards were clearly explained. Mothers who expressed interest were then provided with a written informed consent form (paper-based) and asked to review and sign it prior to the interview. Participants were given adequate time to ask questions and consider their participation. Participation was entirely voluntary, and participants could withdraw at any time without consequence. All personal information was treated with strict confidentiality, and data were anonymized during transcription and analysis. Recruitment continued until data saturation was reached, defined as the absence of new themes across three consecutive interviews.19

Data collection
The first author received systematic training in qualitative research methods prior to data collection, including courses on interviewing techniques, qualitative data analysis, and ethical research conduct. Under the guidance of a professor with extensive experience in qualitative research, the first author conducted multiple simulated interviews with volunteers and peers. These sessions involved practice in question phrasing, active listening, probing techniques, and managing participant emotions. Each mock interview was followed by detailed feedback and reflection, which helped refine interviewing skills and enhance sensitivity to participants’ experiences.
Prior to formal data collection, the research team conducted a review of relevant theoretical frameworks and recent studies and used this to develop a semi-structured interview guide with core topics and open-ended questions. This process was intended to support interviewer training rather than to impose predefined analytical frameworks on the data. All interviews were then conducted by the first author to ensure consistency in the interview process and comparability of the data.
During the interviews, participants were encouraged to speak openly and honestly about their experiences and emotional journeys while caring for their daughters. To ensure the guide's clarity and relevance, two pilot interviews were conducted, after which necessary modifications were made. The finalized guide included the following core topics: 1) Can you tell me about your experiences since your daughter was diagnosed with breast cancer? 2) How would you describe your relationship with your daughter, and how has it changed since her diagnosis? 3) What emotions have you experienced during this period? 4) What kinds of support have you received while caring for your daughter? What challenges have you faced? 5) What are your thoughts or worries about your daughter's future? 6) How has your life or daily routine changed since your daughter's diagnosis? Probing and prompting techniques were used flexibly throughout the interviews to gain a deeper understanding of participants' experiences. Questions remained open-ended and broad, allowing participants to explore issues at their own pace, while the interviewer provided gentle guidance to facilitate in-depth discussion when appropriate.
The timing of each face-to-face interview was determined by participant availability. All interviews took place in private single-occupancy rooms within the hospital ward to ensure a quiet and confidential environment conducive to open conversation. Each session lasted approximately 25–42 minutes and was audio-recorded with the participant's consent. Detailed field notes were taken to capture non-verbal cues and emotional expressions. Audio recordings were transcribed by a professional and verified by the research team to ensure transcription accuracy.

Data analysis
Within 24 hours of each interview, the first author transcribed the audio recordings verbatim to minimize recall bias associated with delay. Data were analyzed using thematic analysis.20 The analytic process proceeded in several steps. First, all three researchers listened to the audio recordings and read the transcripts repeatedly to become familiar with the participants' narratives, emotional tone, and context. Initial impressions and potentially meaningful segments were noted. Second, the first author conducted line-by-line open coding of each transcript. Codes were assigned to meaningful segments of text that reflected participants' emotions, actions, and interpretations. At this stage, coding remained close to participants' own words in order to preserve meaning and avoid premature abstraction. As analysis progressed, similar codes were compared across transcripts, and codes were added, revised, merged, or removed through constant comparison. Third, related codes were grouped according to conceptual similarity and clustered into subthemes. Fourth, the subthemes were further refined and organized into broader themes that captured major dimensions of the mothers’ experiences. Throughout this process, the researchers moved back and forth between original quotations, codes, subthemes, and themes to ensure that the analytic structure remained grounded in the data and that themes were internally coherent and distinct from one another. Fifth, the three researchers met regularly to compare coding decisions, discuss differences in interpretation, and refine the developing thematic structure. Differences in interpretation were resolved through discussion, and the names and definitions of subthemes and themes were clarified. In the final stage, member checking was conducted by sharing a summary of the findings, together with relevant themes, subthemes, and illustrative quotations, with participants to confirm whether the interpretations accurately reflected their experiences and perspectives. Fig. 1 presents a simplified schematic diagram of the qualitative analysis process.

Rigour
To ensure the credibility and methodological rigor of the study, principles of authenticity, auditability, transferability, and procedural transparency were strictly followed. As both participants and researchers were native Chinese speakers, all interviews and analyses were conducted in Chinese to preserve the richness of meaning and emotional nuance.
In terms of authenticity, selected participants were invited to provide feedback on the preliminary themes, while two researchers with oncology nursing backgrounds independently reviewed the coding and thematic development, enhancing the reliability of data interpretation. Regular team meetings were held to discuss ambiguities, with consensus reached through thorough deliberation to ensure consistency in the analytical outcomes.
Auditability was reinforced through the use of analytic memos, documentation of reasoning processes, and ongoing reflexivity. Additionally, no prior relationship existed between interviewer and participants, minimizing potential bias due to role expectations. To ensure accuracy in cross-linguistic interpretation, the final analytical results were translated into English and reviewed by bilingual experts for semantic and cultural equivalence.
No qualitative data analysis software was employed; all themes were manually constructed. Cross-review and consensus among team members ensured both depth and consistency of the analysis. To enhance transferability, detailed descriptions of the research context, participant characteristics, and procedures for data collection and analysis were provided, allowing readers to assess the relevance and applicability of the findings to similar cultural or caregiving contexts.

Results

Participants’ characteristics
A total of 16 mothers who met the inclusion criteria completed the interviews. Their demographic characteristics are presented in Table 1. To protect participant confidentiality, each mother was assigned a code (M1–M16) based on the order of the interviews, replacing their real names.

Thematic analysis
Fig. 2 presents a conceptual model of the four primary themes identified from the thematic analysis: 1) Emotional turmoil; 2) Cultural silence and social withdrawal; 3) Reconfiguring care and family roles; and 4) Meaning-making in the face of illness. This framework was derived from the qualitative data of semi-structured interviews with 16 mothers. Following identification of the core themes, narrative arcs within the mothers’ retrospective accounts were mapped to illustrate psychological transitions. Specifically, the overarching semicircles symbolize the persistent “protective umbrella” of maternal care; the downward arrow reflects external socio-cultural pressures (Theme 2); the horizontal base represents the internal shift from initial shock (Theme 1) toward adaptive strategies (Theme 3); and the upward-curving arrow denotes the emergence of meaning-making (Theme 4). To ensure trustworthiness, the framework was validated through member checking with a subset of participants, who confirmed that the core themes and directional flow captured the essence of their experiences, while acknowledging that individual trajectories vary in intensity and timing. This figure thus represents an aggregated conceptual model rather than a universal sequence for each participant. Table 2 summarizes the themes, subthemes, and representative quotations from participants.

Theme 1: emotional turmoil

Subtheme 1: shock and disbelief
When daughters disclosed their breast cancer diagnoses, their mothers' initial reaction was often denial. Only when faced with undeniable medical evidence did they feel their world collapse instantly, like a thunderclap on a clear day. In every mother's eyes, their daughters were in the prime of youth and just beginning their careers. They carried not only their mothers' unfulfilled dreams but also served as essential pillars of their emotional lives; cancer cruelly shattered it all.“At that moment, it felt as though the sky had fallen, and I was utterly helpless.” (M5)
“… I poured all my love and hopes into her.” (M13)

Though time gradually softened their initial fierce resistance, the mothers quietly admitted that true acceptance had not yet arrived. They described themselves as being pushed by fate to face an irreversible reality. Trying to regain a sense of control, they struggled to find footing amid the storm, yet this reluctant surrender left them caught in a continuous cycle of anguish and turmoil. The thought of their daughters’ empty breasts caused a raw, wrenching pain that almost took their breath away.“I don’t know how to truly accept this reality. In the end, I was forced to accept it. I try to look forward, but every time I see her chest, I cannot bear to look.” (M1)

Subtheme 2: emotional suppression
Some participants recalled that their daughters often appeared relatively composed when disclosing their breast cancer diagnosis, deliberately omitting certain details about treatment plans or prognosis in an effort to alleviate their mothers' burden through selective information sharing. Simultaneously, the mothers exhibited heightened sensitivity to their daughters’ emotional states and proactively assumed the role of emotional support and regulation within the family. They consciously restrained their own emotional responses, suppressing outward expressions of sorrow or anxiety.“She was the one who told me about the diagnosis. I quietly asked the doctor later, and the situation was worse. But she only said the surgery went well … I knew she was trying not to worry me. I had to pretend I didn’t know. I couldn’t let her see my tears.” (M6)
“She had no choice; she told me only because she was hospitalized and had no one to care for her. I could guess, but she rarely spoke about her illness.” (M3)

Subtheme 3: guilt and self-blame
Mothers often reflected on possible causes of their daughters’ illness, such as work-related stress, irregular diet and routines, or the use of health supplements. However, these reflections frequently morphed into profound self-blame, as they felt they had failed in their maternal duties. Caught in a relentless cycle of “what if” scenarios, they sought potential avenues for change.“She worked so hard, often too busy to even eat a hot meal. It’s all my fault as her mother for not taking better care of her. If only I had reminded her more to eat on time or brought her more nutritious food, maybe this wouldn’t have happened …” (M8)
“She was always watching those health videos online, buying all kinds of supplements. I warned her countless times, but she never listened. Thinking back now, it breaks my heart. If only I had been firmer in stopping her, maybe she wouldn’t have gotten this disease.” (M16)

Several participants admitted they had little understanding of breast cancer before their daughters' diagnoses. Upon learning of the potential hereditary link, they were shocked and overwhelmed with guilt. Despite facing their own risk of developing breast cancer, most mothers exhibited a calm and even self-sacrificing attitude, prioritizing their daughters’ health over their own. As one mother expressed:“The doctor advised me to have regular check-ups too, which means my daughter’s illness might be linked to me. I feel deeply guilty. But there’s no time to dwell on it now. My daughter is what matters most. If I could, I would rather fall ill myself than see her suffer.” (M2)

Subtheme 4: persistent anxiety
Some participants expressed fears that their married daughters might face marital breakdown or abandonment due to their illness. In Chinese culture, the ideal of the virtuous wife and devoted mother defines women's social roles and expectations. The transformation of a daughter from caregiver to care recipient disrupted established standards of what constitutes a good wife and competent woman, provoking deep maternal unease.21“We both know too well the strain illness places on a marriage.” (M11)

For daughters who are still unmarried, mothers feared that a history of cancer would place them at a disadvantage in the marriage market. Marriage is still viewed as a crucial milestone in a woman's life. However, the physical changes brought about by breast cancer treatment, especially mastectomy and reduced fertility, lead mothers to question whether their daughters will be able to fulfill the traditional expectations of marriage and childbirth.“My daughter is still so young, and her life has just begun. She has already undergone a mastectomy, and I’ve heard that her fertility may also be affected. Although I try not to think this way, reality is often cruel. How many families would truly accept a girl who has had cancer?” (M4)

Some participants mentioned the overwhelming emotional distress of losing a child, especially within the context of one-child families. The potential death of a daughter not only threatens generational continuity but also evokes a profound fear of being left alone. This grief is frequently compounded by concerns about their own aging and declining health, leaving them feeling powerless as they struggle to care for both their ill daughter and the younger generation. The pressure from both directions intensifies their sense of uncertainty and helplessness about the future.“We were only allowed to have one child, and she means everything to me. She isn’t married and has no children. If she dies, her father and I will become empty-nest elders waiting for the end, completely alone.” (M13)
“Her child is still so little …” (M1)

Theme 2: cultural silence and social withdrawal

Subtheme 1: linguistic avoidance
Some interviewees adopted avoidance as a primary strategy in coping with their daughters' cancer diagnosis. Although they deeply wished their daughters could openly express their pain, cancer is often regarded as an unspeakable and sensitive subject in many Asian cultures. As a result, these mothers tended to avoid initiating conversations about the illness, prioritizing the preservation of emotional harmony within the family. Deliberate avoidance of vocabulary directly related to the disease was a common feature in their communication.“Whenever we spend time together, we carefully steer clear of sensitive words like ‘breast,’ ‘underwear,’ or ‘recurrence.’ We silently agree to maintain a calm surface, as if nothing ever happened.” (M14)

Some participants shared that when it became impossible to fully avoid discussing the illness, they preferred to use more neutral terms such as “lump” or “mammary gland hyperplasia” instead of explicitly saying “cancer.” For them, euphemistic language helped diminish the negative connotations associated with the disease and softened the emotional blow of confronting a harsh reality.“Yes, I avoid saying ‘cancer.’ I usually say ‘mammary hyperplasia’ or ‘lump’, those words don’t sound as frightening.” (M6)

Subtheme 2: fatalistic interpretations of illness
Some participants perceived breast cancer as an inescapable genetic fate. Having already lost close relatives to the disease, they had long seen themselves as the next in line to be diagnosed. When the illness unexpectedly struck their daughters instead, they were consumed by grief and a profound sense of powerlessness.“My sister died of breast cancer. Those images are still vivid in my mind. I always thought I would be the one diagnosed next. I never expected it would happen to my daughter first.” (M8)

Other mothers, who had already experienced breast cancer themselves, were even more aware of its hereditary and uncontrollable nature. As they watched their daughters follow the same painful path, the emotional impact of this perceived cycle of fate became even more intense.“I was once a breast cancer patient myself. It feels like fate has come around again, bringing back all the familiar fear and pain. But this time, it is my daughter in the hospital bed. That pain is far greater than what I once endured.” (M3)

Subtheme 3: Protecting family privacy
In traditional Chinese culture, visiting the sick is regarded not only as an important familial ritual but also as a social obligation rooted in ethical norms. However, when confronted with the emotional and physical toll of a breast cancer diagnosis, mothers of patients often felt conflicted about accepting visits from relatives. The discomfort became especially pronounced when conversations touched on sensitive subjects such as the illness or breast surgery. In these situations, mothers frequently struggled with expression and exhibited visible unease. Some chose to decline visits altogether, aiming to protect their daughters' emotional well-being.“Many relatives said they wanted to visit her in the hospital, but I politely turned them all away. It’s not that I’m ungrateful. I just couldn’t bear to see my child forcing a smile through her pain.” (M9)
“Relatives visit out of care and concern, but sometimes it becomes a burden too.” (M10)

Theme 3: reconfiguring care and family roles

Subtheme 1: reactivation of maternal caregiving
The cancer diagnosis disrupted existing generational boundaries and brought many mothers back into caregiving roles they had gradually left behind. Their identities shifted as they became steady sources of support, sharing in both the physical pain and emotional strain of their daughters. This renewed closeness resembled the protective attachment of early childhood, with the mother now offering shelter and care to her adult daughter.13“My daughter needs me now more than ever. How could I not be by her side? Her husband has to work, and the child is still young. Naturally, the responsibility of caring for her falls on me. Watching her suffer from post-surgical pain and sleepless nights, I would take it all on myself if I could.” (M16)
“It’s strange. Seeing her lying in that hospital bed reminded me of the past, when she was little, quietly resting in my arms as I fed her bite by bite.” (M7)

Subtheme 2: strengthening family cohesion
While illness disrupted the established rhythm and structure of daily family life, it also created opportunities for renewed connection and functional realignment within the household. Some participants noted that after their daughters fell ill, family interactions became more frequent and emotionally intimate. The patient gradually became the focal point of family attention, and her physical condition and emotional needs reshaped patterns of communication and care. The demands of caregiving led to a redistribution of roles, forming a close-knit support system centered on shared responsibility.“Since she came home to recover, our family feels like it has returned to how it once was. Her father and I try new recipes every day, looking for ways to nourish her. Oddly enough, these days have brought more warmth and fulfillment than ever before.” (M9)
“There was a time when her father and I barely spoke. But since her diagnosis, we have worked closely together, united in the hope that she will make it through.” (M11)

Theme 4: meaning-making in the face of illness

Subtheme 1: spiritual coping
Participants revealed that when overwhelmed by intense emotional turmoil, they gradually sought comfort in cultural traditions and supernatural faith. Even some former atheists began practicing rituals like incense burning, prayer, and fortune-telling. Although these actions fall outside formal religious frameworks, they provide emotional solace akin to religion, helping to rebuild hope amid chaos and suffering. Several participants admitted that such spiritual practices alleviated their feelings of helplessness and fear when facing uncertainty.“One morning, without telling my daughter, I visited a fortune teller known for being effective. I know I shouldn’t believe in these things, but as a mother, how could I care about that? As long as there is a sliver of hope, I would try anything.” (M6)
“It’s ironic … I never believed in gods before, yet now I deeply wish such beings truly exist.” (M12)

Subtheme 2: preserving memories
Some participants admitted that they had never been inclined to document daily life, viewing everyday moments as ordinary and unworthy of special attention. However, after their daughters were diagnosed with breast cancer, this perspective quietly shifted. The uncertainty of the illness heightened their awareness that many overlooked daily details might become precious memories that can never be recreated. Consequently, they began consciously capturing fragments of life through photos, videos, or writing such as smiling faces at family gatherings, calm words of reassurance from their daughters, or even simple but complete meals.“We never used to take photos, but now we capture every moment of reunion and every memory worth keeping. This way, even if the worst happens, our granddaughter can see her mother’s dimples when she smiled and hear her gentle reminders. It allows love to continue in another form and leaves us with something to hold on to.” (M9)

Subtheme 3: reframing life meaning
Despite the overwhelming uncertainty and emotional turmoil brought by their daughters' illness, some participants strived to maintain a positive and hopeful outlook. They believed that dwelling excessively on fear and sorrow not only hinders practical solutions but also amplifies the family's psychological burden, weakening the collective strength needed to face the disease. Therefore, they chose reason and hope as coping mechanisms, firmly trusting that with scientific treatment, family support, and mental adjustment, the current hardships would eventually pass.“Many people around us have this illness and are living well. My daughter is younger and healthier, and since I am retired, I can accompany her. We have prepared financially for her care. It’s nothing major. By cooperating with doctors and following treatments, everything will be fine.” (M7)

Some participants displayed a transcendent psychological transformation when confronting trauma and life's uncertainties. They moved beyond focusing solely on the pain and challenges of illness to seek deeper spiritual meaning in their experience. For them, hope did not arise from certainty about outcomes but from the ongoing quest for purpose and spiritual refuge throughout the journey.“I have been searching for the true meaning of life, hoping to find answers through this spiritual journey. Perhaps by placing everything within a higher spiritual dimension, I can explain this unpredictable fate.” (M12)

Additionally, some participants noted that prolonged caregiving led them to recognize the importance of sustaining their own lives. Often encouraged by their daughters, they began to reconsider the balance between caregiving and self-care amid heavy maternal responsibilities.“Now, I’m learning to find a balance between caring for my daughter and living my own life. She encourages me to live my own life, and perhaps that is the only way she can truly feel at ease.” (M3)

Discussion
This study is among the few qualitative investigations examining the impact of breast cancer in adult daughters on their mothers within the Chinese cultural context, particularly highlighting how profound intergenerational emotional bonds are activated and reshaped during major health crises.14,17 Participants described four main themes: emotional turmoil, cultural silence and social withdrawal, reconstructing care and family roles, and meaning-making in the face of illness. These findings offer new theoretical insights into the intergenerational dynamics between patients with breast cancer and their mothers.

Existential anxiety within traditional family contexts
Although significant progress has been made in cancer treatment, some mothers still perceive the disease as an irreversible existential threat and find it difficult to dissociate it from the notion of death. Such emotional responses closely resemble those observed among mothers of minor patients.22 Within Chinese family structures, children are regarded as the primary focal point of familial affection and future expectations; even after reaching adulthood, such emotional investment and projection may persist. This tendency may be deeply influenced by the Confucian concepts of “ben” and “unity,” which emphasize parents as the foundational core and portray the parent child relationship as an inseparable ethical entity.23 As previously discussed, intergenerational responsibility represents a reciprocal system encompassing “ci” (the nurturing role of parents toward their children) and “xiao” (the obligation of children to repay parental care), forming a framework of filial reciprocity.10 Daughters often constitute the central emotional attachment of mothers and serve as critical anchors for elderly support and familial continuity. The threat of disease to a daughter's life may therefore be interpreted by some mothers as the termination of hope and a destabilization of family order, thereby eliciting profound feelings of loss and existential anxiety.
Rooted in Confucian familial philosophy, the tradition of familism assigns the family a central position in medical decision making in China, where family members frequently participate extensively in the reception of diagnostic information and therapeutic deliberations. Previous studies have suggested that health care professionals sometimes collaborate with relatives by adopting selective disclosure or delayed notification strategies to mitigate the emotional shock associated with unfavorable diagnoses.7 Interestingly, in our study, most mothers learned of the diagnosis only when adult patients were compelled to reveal their condition due to emotional support needs or caregiving considerations. In other words, when the patient is a young adult woman, this protection oriented information management pattern may shift directionally, with patients themselves practicing selective disclosure toward their parents. Achieving a balance between honesty and protective concealment thus becomes a significant emotional challenge for young female cancer patients.21 Notably, such practices may generate psychological consequences contrary to their original intention. Consistent with prior findings,22,24 many mothers engaged in self reflection regarding perceived inadequacies in their caregiving role, with some attributing the onset of illness to their own permissiveness toward the daughter's lifestyle, such as allowing prolonged nighttime wakefulness or reliance on health supplements. Furthermore, mothers tended to prioritize their daughter's health over their own cancer risk, with some expressing a willingness to sacrifice their lives in exchange for their daughter's recovery. This attitude is closely associated with social norms in many Asian contexts that encourage women to subordinate personal needs to familial responsibilities.25
Despite the substantial improvement in the social status of Chinese women over recent decades, patriarchal traditions remain deeply embedded within family structures.26 A woman's social value is often closely intertwined with her marital status and reproductive capacity, while she is expected to fulfill multiple roles simultaneously, including that of a virtuous wife, devoted mother, and filial daughter.21,25 For instance, the Chinese proverb “a good marriage outweighs professional success” reflects the cultural prioritization of marital attainment over individual achievement. Similarly, the saying “among the three forms of unfilial conduct, the absence of offspring is the gravest” positions the continuation of lineage at the core of filial ethics. In traditional Chinese society, childlessness after marriage was frequently attributed to the wife, and husbands could dissolve the marriage or remarry on this basis.26 Illness forces daughters to transition from caregivers to recipients of care, temporarily suspending their functional position within the family and provoking maternal anxieties regarding the daughter's future marriage prospects, fertility, and social acceptance. In addition, female bodily attributes such as the breasts are closely associated with fertility, motherhood, nurturing capacity, and sexual attractiveness. In certain cultural perceptions, these physical features are even equated with a woman's intrinsic worth, a value that is often validated through male recognition.27 Consequently, some mothers reported that their anxiety stemmed not only from the severity of the disease itself but also from concerns about whether their daughters would continue to be regarded as valuable individuals after potential loss of the breasts or reproductive ability.
Moreover, this study introduces a novel perspective: mothers in single-child families may experience heightened psychological stress. The one-child policy, implemented in 1980, was originally conceived as a pragmatic measure to curb population growth amid severe scarcity of capital and resources under a planned economy.28,29 Under this policy, each couple was restricted to a single child, with stringent penalties imposed for violations. Although the policy concluded in 2016, its unprecedented demographic interventions have profoundly reshaped the social fabric of China.28,29 Mothers often project their entire emotional investment and hopes onto their sole child. The risk of losing this child threatens to shatter the entire family system. Within traditional Confucian culture, offspring symbolize family continuity and bear the responsibilities of filial piety and lineage preservation. Child loss is viewed as a violation of ethical norms and is sometimes associated with shame, ancestral guilt, or moral punishment.30 Specifically, for mothers without grandchildren, losing an only daughter can feel like the end of life's meaning. For those still caring for grandchildren, they face the dual burden of declining physical function and ongoing caregiving duties. Therefore, clinical practice and policy development must pay greater attention to this vulnerable population.

Sociocultural constraints on emotional expression
In our study, some mothers tended to perceive breast cancer as a matter of fate, viewing their daughters’ illness as a continuation of genetic destiny or even a consequence of their own behavior or parenting. This perspective has been extensively discussed in previous research.31,32 Within Chinese culture, emotional restraint and maintaining dignity are highly valued, and overt expressions of grief are often deemed inappropriate.33 When the illness involves intimate areas such as the breasts, it can trigger feelings of shame related to the female body. Accordingly, mothers often cope with psychological distress through avoidant language and emotional restraint. As several interviewees described, they preferred using terms such as “mass” or “breast hyperplasia” to refer to the condition while avoiding the word “cancer.” However, prior research suggests that such avoidance strategies may produce paradoxical effects, inadvertently intensifying emotional suffering and activating traumatic memories.24 In reality, the social support available to mothers is limited, and traditional customs of social visits and interpersonal obligations may impose additional psychological burdens. This aligns with findings by Jin and colleagues regarding parents of children with cancer, who often reduce social activities and avoid contact or discussions about the illness to prevent reactivation of trauma memories.24 Over time, mothers may develop a pattern of emotional suppression and behavioral avoidance characterized by social withdrawal, restricted self-expression, and diminished internal emotion regulation, manifesting as psychological rigidity.24,34 Fundamentally, the thoughts themselves are not threatening; the real issue lies in whether individuals become trapped within these distressing cognitions.24 Given this, it is essential to develop more supportive interventions targeting mothers of patients with breast cancer in clinical practice, such as establishing peer support groups and conducting focused interviews based on emotional expression and value clarification. Through shared experiences and social connection, these approaches can help alleviate emotional distress, restore psychological resilience, and rebuild a sense of meaning in life.35

Family role adaptation in caregiving contexts
Our study also revealed positive findings. When mothers perceive caregiving for their daughters as a meaningful engagement, especially when they feel needed, it often enhances their subjective well-being and role identity.17 According to Walsh's family resilience theory, major stressors can activate integrative mechanisms within the family system, strengthening goal alignment and a sense of belonging among members.36 At the level of belief systems, mothers tend to view caregiving as a continuation of life's responsibilities and a personal mission, positioning themselves as ever-ready supporters sharing the burden of illness with their daughters. In terms of organizational patterns, family members adapt daily routines and redistribute responsibilities to establish more flexible cooperation, thereby enhancing family stability and adaptability. On the communication and emotional level, the illness fosters more frequent and emotionally rich interactions, repairing and reshaping previously existing intergenerational estrangement. As Ali and colleagues found, over half of patients with breast cancer reported that their diagnosis brought them closer to their mothers.37 However, it is important to emphasize that this is not always entirely positive. Behind the strengthened intimacy, mothers may also bear heavy caregiving burdens and emotional suppression. Therefore, positive family adaptation ultimately depends on the supplementation of external social resources.37

Meaning-making and spiritual coping in illness experience
Although many Chinese do not identify with organized religion, spiritual beliefs rooted in cultural traditions profoundly influence how individuals cope with major crises.33 This study found that, faced with the intense emotional impact of their daughters’ breast cancer diagnoses, some mothers actively turned to folk beliefs and spiritual practices such as incense burning, prayer, divination, and temple visits. While these informal spiritual behaviors may not constitute formal religious faith, they provide a culturally therapeutic function at the psychological level, helping mothers construct mental order, seek meaning and hope amid chaos and pain, and regain motivation to live.38
Simultaneously, some mothers demonstrated a proactive tendency toward meaning reconstruction, recognizing that dwelling in grief hinders problem-solving and weakens family resilience. They emphasized a balanced approach combining scientific treatment, family support, and emotional rationality. Under cultural pressures, they exhibited remarkable psychological resilience and adaptability. This coping style aligns with Chinese philosophical views on post-traumatic growth, which regard life as a natural journey filled with suffering and impermanence, and acceptance as a form of life wisdom and an appropriate attitude.39 Some mothers also gradually realized the importance of self-care during long-term caregiving. Encouraged by their daughters, they began to rekindle interests, restore social connections, and strive to find a new balance between motherhood and individual identity. Additionally, they sought to imbue daily life with continuity and value through means such as visual documentation, preserving moments of life and fostering new self-understanding and meaning construction.

Implications for nursing practice and research
The findings of this study hold important implications for oncology nursing practice within the Chinese cultural context. Given the protective role of family support in illness coping, nursing professionals may consider integrating culturally sensitive family support strategies that attend to mothers' emotional needs during the caregiving process for their daughters. In Chinese family caregiving contexts, emotional expression is often indirect and privately conveyed; mothers may demonstrate anxiety and concern through behavioral care rather than explicit verbal disclosure. Therefore, nursing practice should recognize such nonverbalized forms of emotional support and provide psychological assistance while respecting familial emotional boundaries. The sense of responsibility and self blame within the mother daughter relationship reflects a complex psychological interplay, suggesting the need to combine cognitive and meaning reconstruction approaches to help mothers reassess the relationship between caregiving obligations and personal emotional burden. By fostering family members’ understanding of the reciprocal value of supportive coping in the context of illness, it may be possible to reduce excessive self blame and promote more positive patterns of family interaction. Health care institutions should strengthen training programs for nursing staff in family communication skills and cultural sensitivity, encouraging nurses to recognize psychological distress signals among mothers involved in cancer caregiving and to explore pilot family oriented supportive interventions suitable for Chinese oncology settings. Future research should focus on developing culturally appropriate family caregiving assessment instruments and conducting multicenter studies to compare maternal caregiving experiences across different family structures and health care resource environments, ultimately providing more precise psychosocial support strategies for Chinese breast cancer families.

Limitations
This study has several limitations that should be acknowledged. First, although efforts were made to recruit mothers of patients at different stages of cancer treatment, the sample did not include mothers whose daughters had died from breast cancer, which limits the representation of extreme grief experiences and may restrict the understanding of bereavement-related maternal emotions. Second, all qualitative data were collected from a single tertiary hospital in mainland China. The participants shared relatively similar socioeconomic backgrounds, cultural beliefs, and access to health care resources. Therefore, caution should be exercised when generalizing the findings to other regions or cross-cultural populations. Third, due to the qualitative nature of this study and the relatively small sample size (n = 16), structured subgroup comparisons across participant characteristics such as maternal age, education level, employment status, caregiving intensity, and prior personal health history were not conducted. The study primarily focused on exploring experiential meaning through thematic analysis rather than examining differences across demographic variables. It should be noted that these factors may have influenced participants’ emotional expression and coping patterns to some extent, but potential subgroup variations were not further explored due to methodological constraints. Finally, due to study limitations, a longitudinal design could be considered in future research to provide deeper insight into the dynamic emotional changes and caregiving experiences of mothers over time.

Conclusions
This study focuses on the psychological distress experienced by mothers in the Chinese cultural context when their adult daughters are diagnosed with breast cancer. The findings reveal that influenced by Confucian ethics and traditional gender roles, these mothers often exhibit excessive guilt, self-blame, and emotional avoidance, which further exacerbate their psychological burden and emotional challenges. A deeper understanding of these psychological experiences can assist health care professionals in developing culturally sensitive interventions and support systems to more effectively help mothers cope with grief and emotional difficulties.

CRediT authorship contribution statement
All authors contributed to the study conception and design. Yujing Gu: Writing review & editing, Writing original draft, Methodology, Data curation, Formal analysis, Conceptualization. Yun Zhao: Writing review & editing, Resources, Data curation, Validation, Formal analysis. Shujun Fan: Methodology, Software, Data curation. Zhouzhou Lu: Methodology, Software. Mengchen Xing: Supervision, Resources, Project administration. Jun Xie: Writing review & editing, Supervision, Investigation. All authors have read and approved the final manuscript.

Ethics statement
This study was approved by the Ethics Committee of Wuxi People's Hospital (Approval No. KY25038) and was conducted in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent.

Data availability statement
The data that support the findings of this study are available from the corresponding author, JX, upon reasonable request.

Declaration of generative AI and AI-assisted technologies in the writing process
During the preparation of this work the authors used ChatGPT in order to improve language. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Funding
This study was supported by the Top Talent Support Program for young and middle-aged people of Wuxi Health Committee (Grant No. BJ2023091) and the Wuxi Science and Technology Development Fund (Grant No. K20253007). The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Declaration of competing interest
The authors declare no conflict of interest.