Social relationship challenges perceived by cancer patients and survivors: a qualitative meta-synthesis.

Introduction

In 2022, approximately 20 million individuals worldwide were diagnosed with cancer. This number is projected to rise to 35 million by 2050, driven by factors such as population growth, increased life expectancy, and the persistent prevalence of risk factors [ 1 ]. Advances in medical science have significantly improved survival rates. Over 69% of individuals diagnosed in 2022 survived beyond five years. Furthermore, nearly 47% surpassed the ten-year milestone, and approximately 18% lived at least 20 years post-diagnosis [ 2 ].

The growing population of cancer patients and long-term survivors highlights an urgent need to address their multifaceted challenges. These challenges span physical, psychological, existential, and social dimensions, profoundly affecting quality of life and long-term well-being [ 3 , 4 ].

On a physical level, survivors often endure chronic fatigue, persistent pain, and functional limitations resulting from the long-term effects of cancer treatments [ 5 ]. Psychologically, many patients and survivors struggle with depression, anxiety, and post-traumatic stress disorder, intensified by the trauma of diagnosis, the intensity of treatments, and uncertainty about their prognosis [ 6 ]. Beyond these challenges, cancer raises existential concerns, including questions about meaning, life purpose, and identity [ 4 ]. These struggles are especially pronounced as individuals reconcile their pre-diagnosis identity with the realities of survivorship [ 7 ].

Socially, cancer frequently disrupts relationships, hinders career trajectories, and exacerbates feelings of isolation. Young and middle-aged patients face particular difficulties in navigating intimate and productive social relationships [ 8 – 13 ]. They often encounter obstacles due to physical and mental health challenges caused by cancer and its treatments, such as cognitive impairments, body image concerns, and fear of recurrence [ 10 – 14 ].

A review by Wang and Feng [ 9 ] emphasized the significant disruptions in social relationships that cancer patients and survivors face. These disruptions include marital conflicts and social constraints, such as avoidance or insensitive remarks from others. Such barriers contribute to loneliness and hinder patients from maintaining meaningful social connections. Similarly, a study conducted by Amiri et al. in Iran revealed that many patients limit their social interactions to avoid uncomfortable situations, such as pitying looks or unwelcome comments [ 15 ].

Social relationships are fundamental to human life, defined by a dynamic interdependence in which individuals influence each other’s thoughts, emotions, and behaviors [ 16 ]. These relationships have both structural and functional dimensions. The structural dimension includes quantifiable aspects such as network size and interaction frequency, while the functional dimension focuses on qualitative attributes like emotional support and social distress [ 17 , 18 ]. Evidence suggests that functional quality often outweighs structural quantity; smaller, closely connected networks can provide stronger perceived support [ 19 ].

Cancer patients often rely on a network of support consisting of spouses, immediate family members, relatives, and friends [ 20 ]. While these connections include both structural and functional elements, they are not without challenges. Spouses frequently assume caregiving responsibilities that, although crucial, can create emotional burdens and relational conflicts, reducing the patients’ perceived support [ 21 ]. Family members and relatives may face logistical constraints and emotional fatigue, limiting their ability to provide consistent support [ 22 ]. Friends, on the other hand, might withdraw due to discomfort or uncertainty about how to offer help. This withdrawal can heighten patients’ feelings of isolation and frustration, especially when friends seem to lack empathy or avoid meaningful discussions about the illness [ 23 ].

The implications of these social dynamics go beyond interpersonal relationships. Research consistently links deficiencies in social connections with higher mortality rates, reduced quality of life, and various negative health outcomes [ 24 – 30 ]. Given the critical role of social relationships in health, it is essential to focus on the specific challenges faced by cancer patients and survivors.

The social experiences of individuals diagnosed with cancer are shaped by a complex interplay of societal, structural, and individual factors. Stigma and misconceptions surrounding cancer often lead to isolation. Inadequate social support frequently fails to meet the evolving emotional and practical needs of patients throughout their illness [ 31 ]. Furthermore, patients’ difficulties in navigating interpersonal interactions—particularly with spouses, family members, and close friends—further underscore the profound impact of cancer on social relationships [ 32 ]. Addressing these challenges requires comprehensive approaches that consider patients’ unique perspectives and needs.

Although previous research has explored the psychosocial needs of cancer patients [ 15 , 33 ], the specific challenges related to social relationships remain underexplored. Qualitative research methodologies are well-suited to address these complex issues [ 34 ]. Among these, qualitative meta-synthesis offers a robust approach by integrating findings from multiple studies [ 34 ]. This study utilized qualitative meta-synthesis to investigate the perceived social relationship challenges of cancer patients and survivors, with a particular focus on their close social networks.

The central research question guiding this inquiry was: What specific social relationship challenges are perceived by cancer patients and survivors?

Methods

This study adopted a qualitative meta-synthesis methodology, a rigorous approach designed to analyze and integrate findings from existing qualitative research systematically. Rooted in principles of meta-study, qualitative meta-synthesis sought to move beyond mere aggregation by critically interpreting, recontextualizing, and synthesizing data to reveal overarching patterns, themes, and theoretical insights [ 35 ]. This method allowed for the deconstruction of existing findings and their reconstruction into a cohesive, comprehensive narrative that advanced understanding of complex social phenomena. By synthesizing diverse perspectives from multiple studies, qualitative meta-synthesis facilitated the development of nuanced and multifaceted insights, offering both depth and breadth in addressing the research question and contributing to the refinement of theoretical frameworks and practical applications [ 36 ].

Identification and selection of studies

Research articles were included based on the following inclusion criteria:

Utilization of qualitative methodologies, including but not limited to phenomenology, grounded theory, ethnography, or qualitative case studies. Focus exclusively or partially on the social relationship challenges faced by cancer patients and survivors. Requirement for original data collection involving participants aged 18 years and older. Publication in peer-reviewed journals was mandatory. Access to full-text articles was necessary. Articles must have been published in English or Persian.

Exclusion criteria were established to eliminate studies that:

Employed non-qualitative research methodologies. Were not published in peer-reviewed journals. Consisted of short communications, editorials, or abstracts. Were authored in languages other than English or Persian.

A systematic search strategy was employed to ensure comprehensive coverage of the literature. Initially, relevant keywords aligned with the research objectives were identified and refined through pilot searches and consultation of a reference guide on social relationships from the NIH [ 37 ]. The search was then conducted across multiple international databases, including PubMed, Web of Science, Scopus, and ScienceDirect, as well as national databases such as SID, Noormags, and Magiran, covering the period from 1900 to March 2024 to capture both contemporary and historically relevant studies. MeSH-matching keywords were used to identify pertinent studies, incorporating terms related to cancer, social relationships, interpersonal relationships, social support, loneliness, social alienation, and rejection. Boolean operators (“OR” and “AND”) were applied strategically to combine terms within and across categories, ensuring a targeted and efficient search. In addition, to enhance the precision and relevance of the search results, database-specific filters such as language restrictions, article type, target population, and other relevant criteria were applied in each database.

The study screening process was conducted in multiple stages to ensure that only studies meeting the inclusion criteria were selected. Initially, two authors (BZ and AK) independently performed the screening, starting with the removal of duplicate records identified across various databases to prevent redundancy. In the next stage, studies were reviewed at the title and abstract level, applying the inclusion and exclusion criteria to filter out irrelevant studies. The remaining studies underwent a full-text review by BZ and AK to confirm that they met all inclusion criteria and to resolve any ambiguities identified during the abstract screening. Throughout the process, the two authors independently assessed each study to minimize bias, with their results being compared afterward. Any discrepancies in study inclusion were resolved through discussion and consensus. In cases of disagreement, a third author (MB) was consulted to provide an additional perspective, ensuring a more rigorous and unbiased final selection of studies. Studies not meeting the inclusion criteria were excluded at two stages: during the title and abstract screening phase, clearly irrelevant studies were eliminated, and those with ambiguous relevance underwent a full-text review to determine their eligibility.

Data extraction

The data extracted from each included study comprised the following: author(s), title, country, sample size, participants’ gender, age range, data collection method, and analysis method. Additionally, de-identified participant quotes representing original qualitative transcript data were also included.

Study quality assessment

The methodological quality of the studies included in the review was assessed using the 10-item CASP checklist for qualitative research [ 38 ]. This checklist is widely used for appraising qualitative research and evaluates various aspects of the study. Validity was assessed based on the appropriateness of the chosen qualitative methodology in addressing the study’s aims. Bias was also evaluated by examining the relationship between the researcher and participants. Ethical considerations were assessed based on whether ethics committee approval had been obtained and whether informed consent had been provided. Data collection methods were assessed for appropriateness and clarity. Data analysis was evaluated for clarity, rigor, and justification of the analytical approach, examination of biases, and presentation of sufficient data to support the findings. Transferability was assessed for the applicability of the research to other contexts and the adequacy of sample detail. It should be noted that studies were not excluded based on methodological quality, but this information was used to report, analyze, and discuss the overall review findings. To ensure consistency, independent appraisals of the studies were completed by all members of the review team and compared. Any disagreements were resolved through team discussion.

Meta-synthesis

The qualitative meta-synthesis was conducted using a thematic synthesis approach, as outlined by Thomas and Harden [ 39 ]. Three coauthors (MB, AK, and BZ) independently extracted relevant quotes and themes from the findings sections of the included studies. These excerpts were then imported into MaxQDA software for coding and further analysis. The thematic synthesis followed a rigorous, three-stage framework. First, the data were coded line by line to capture the nuances of the original findings, identifying quotes pertinent to the research questions and objectives of the current meta-synthesis. After coding, the coauthors collaboratively grouped similar codes, leading to the identification of descriptive themes that closely aligned with those identified in the primary studies. The final stage involved developing analytical themes that went beyond the immediate findings of the individual studies, generating new insights, and providing a higher-level conceptual understanding of the data. This stage also allowed for the identification of emergent issues or novel recommendations related to the topic under investigation [ 40 ]. Throughout the process, all coding and theme development were carried out independently by the three coauthors, with consensus achieved through continuous discussion and comparative analysis. Any discrepancies in coding were resolved by thoroughly examining the original data and how the quotes supported the identified themes in the primary studies. Once the final codes and themes were agreed upon, the data were iteratively reviewed and categorized into coherent groups that reflected common underlying meanings, ensuring the robustness and validity of the synthesis.

Protocol and registration

This qualitative meta-synthesis was conducted as part of a doctoral dissertation in nursing and followed the PRISMA 2020 statement. Due to the qualitative nature of the study and its execution within an academic research framework, the protocol was not registered in any systematic review registry. The methods and procedures were approved by the dissertation supervisory committee prior to the commencement of the study and were implemented throughout the review process in accordance with established principles of qualitative evidence synthesis.

Ethical considerations

This meta-synthesis article was extracted from a nursing doctoral dissertation in nursing. This study received ethical approval from the Ethics Committee of IUMS, Iran (code number: IR.MUI.NUREMA.REC.1402.081).

Results

Study selection

The initial search identified 2,432 articles, from which 586 duplicates were removed, leaving 1,846 articles for title and abstract screening. Following this, 1,672 articles were excluded for failing to meet the inclusion criteria. After full-text review by two independent reviewers (AK, and BZ), an additional 154 articles were excluded. Ultimately, 20 articles were included in the final synthesis, as depicted in Fig. 1 .

Fig. 1 Flowchart of the included studies

Study description

The studies included in this synthesis were conducted across various countries: Iran ( n = 6), the United States ( n = 6), Norway ( n = 2), the United Arab Emirates ( n = 1), Mexico ( n = 1), Australia ( n = 1), the Netherlands ( n = 1), China ( n = 1), and Belgium ( n = 1), with a total of 396 participants. Data collection methods primarily consisted of interviews ( n = 17), supplemented by one focus group, one combined method of open-ended interviews, field notes, and reflexive journals, and another that combined interviews and field notes. Analytical approaches include thematic analysis (8), content analysis ( n = 3), constant comparison methods ( n = 3), phenomenological techniques ( n = 1), and other approaches ( n = 5), highlighting the diverse methodologies used to explore complex psychosocial themes. A summary of the general characteristics of the studies is presented in Table 1 .

Table 1 Characteristics of included qualitative studies No. Author(s) (year) Title Country Sample Type of cancer Participants’ gender Age Data collection tool Analytical approach 1 Zeighami Mohammadi et al. (2018) Pity: a qualitative study on Iranian women with breast cancer Iran 36 patients Breast Female Ages between 24 and 64 years Semistructured interview Conventional content analysis 2 Afrasiabi et al. (2020) Fluctuate Accommodation in Social Interaction by Cancer Patients; a Qualitative Study in Ahwaz Iran 12 patients Colon, stomach, bone marrow, uterus, ovary Male and female Ages between 20 and 65 years Semistructured interview Theoretical coding 3 Azadi et al. (2020) Dignity in Iranian cancer patients: a qualitative approach Iran 20 patients Breast, oral, lymphoma, acute leukemia pancreatic, liver, brain tumor, prostate, uterine Male and female Ages more than 20 years Semistructured interview Directed content analysis 4 van Roij et al. (2019) Social consequences of advanced cancer in patients and their informal caregivers: a qualitative study Netherlands 18 patients Lung, breast, colorectal, esophagus, and prostate Male and female Ages between 38 and 76 years Semistructured interview Content analysis 5 Ginter et al. (2017) Social support needs of breast cancer patients without partners USA 20 patients Breast Female Ages between 36 and 70 years Semistructured telephone and face-to-face interviews Thematic analysis 6 Adams et al. (2016) Cognitive and Situational Precipitants of Cancer Patients’ Loneliness: A Qualitative Analysis USA 15 patients Multiple myeloma or non-Hodgkin lymphoma Male and female Ages between 43 and 77 years Semistructured interview Thematic analysis 7 Zhang et al. (2024) A qualitative Study on the Disease Coping Experiences of Pancreatic Cancer Patients and Their Spouses China 10 patients Pancreatic Male and female Ages between 49 and 75 years Semistructured interview Thematic analysis 8 Wells et al. (2022) The Psychosocial Needs of Underserved Breast Cancer Survivors and Perspectives of their Clinicians and Support Providers USA 25 patients Breast Female Age more than 18 years Semistructured interview Constant comparison method 9 Lie et al. (2018) Coping with changes and uncertainty: A qualitative study of young adult cancer patients’ challenges and coping strategies during treatment Norway 16 patients Lymphoma, gynecological, breast, testicle, colon, sarcoma Male and female Ages between 18 and 35 years Semistructured interview Thematic analysis 10 Goossens et al. (2015) Communication Difficulties and the Experience of Loneliness in Patients With Cancer Dealing With Fertility Issues: A Qualitative Study Belgium 28 patients Breast, lymphoma, testicular, cervical, brain tumor, dysgerminoma, hydatidiform mole, renal cell, and sarcoma Male and female Ages between 19 and 44 years Semistructured face-to-face interviews Constant comparison method 11 Aamir et al. (2022) Understanding the psychosocial needs of breast cancer survivors in the United Arab Emirates: a qualitative study UAE 10 survivors Breast Female Ages between 31 and 62 years Semistructured interview Thematic analysis 12 Sherafat and Taghikhan (2020) A study on the experience of men and women with cancer in Tehran Iran 20 patients Pancreas, breast, lung, leukemia, prostate, uterus, intestine, thyroid, etc. Male and female Ages between 25 and 55 years Semistructured interview Open, axial, and selective coding 13 Hubbeling et al. (2018) Psychosocial needs of young breast cancer survivors in Mexico City, Mexico Mexico 25 patients Breast Female Ages between 37 and 53 years Semistructured interview Thematic analysis 14 Lee et al. (2013) Challenges and Needs of Chinese and Korean American Breast Cancer Survivors: In-Depth Interviews USA 9 survivors Breast Female Mean age of 50 years Structured in-depth interviews with the help of the codebook extracted from the interview guide 15 Moradian et al. (2012) Iranian cancer patients and their perspectives: a qualitative study Iran 30 patients Breast, gastrointestinal, Bladder, testis, lung, sarcoma, etc. Male and female Ages between 19 and 59 years interviews, Field notes Constant comparison method and contrast of themes 16 Rosedale et al. (2009) Survivor Loneliness of Women Following Breast Cancer USA 13 patients Breast Female Ages between 33 and 74 years Open-ended interviews, Field notes, Reflexive journal Qualitative analysis of phenomenology based on Streubert and Carpenter 17 Avutu et al. (2022) Psychosocial Needs and Preferences for Care among Adolescent and Young Adult Cancer Patients (Ages 15–39): A Qualitative Study USA 25 patients not mentioned Male and female Ages between 16 and 39 years Focused groups Inductive thematic content analysis 18 Mardani-Hamooleh & Heidari (2018) Living with cancer challenges: a qualitative analysis of cancer patients’ perceptions in Iran Iran 26 patients Breast, colorectal, leukemia, prostate, and lung Male and female Ages between 37 and 58 years Semistructured interview Conventional content analysis 19 Hauken and Larsen (2019) Young adult cancer patients’ experiences of private social network support during cancer treatment Norway 20 patients Lymphoma, gynecological, breast, testes, colon, Sarcoma, head and neck Male and female Ages between 24 and 35 years Semistructured interview Systematic text condensation 20 Thewes et al. (2004) The psychosocial needs of breast cancer survivors; a qualitative study of the shared and unique needs of younger versus older survivors Australia 18 patients Breast Female Ages between 29 and 78 years Semistructured telephone interviews Methods described by Miles and Huberman (1994) for identifying themes

Quality appraisal

All included studies ( n = 20) met high standards for methodological rigor, receiving a “yes” rating (2 points) for key criteria such as research aims, appropriateness of methodology, and research design. When information was not provided on specific criteria, a “cannot tell” rating (1 point) was assigned. The following factors were assessed: relationships between researchers and participants ( n = 16), rigor of data analysis ( n = 11), appropriateness of recruitment strategies ( n = 5), clarity of findings ( n = 1), and ethical considerations ( n = 3). No study received a “no” rating, and quality scores ranged from 17 to 19 out of 20, ensuring the inclusion of only high-quality studies in the synthesis (Table 2 ).

Table 2 Critical appraisal of the included qualitative studies based on the CASP Author (s) (Year) Was there a clear statement of the aims of the research? Is a qualitative methodology appropriate? Was the research design appropriate to address the aims of the research? Was the recruitment strategy appropriate to the aims of the research? Was the data collected in a way that addressed the research issue? Has the relationship between the researcher and participants been adequately considered? Have ethical issues been taken into consideration? Was the data analysis sufficiently rigorous? Is there a clear statement of findings? How valuable is the research? Total Score Zeighami Mohammadi et al. (2018) 2 2 2 2 1 1 2 1 2 2 17 Afrasiabi et al. (2020) 2 2 1 1 2 2 2 1 2 2 17 Azadi et al. (2020) 2 2 2 1 2 1 1 2 2 2 17 van Roij et al. (2019) 2 2 2 2 1 1 2 1 2 2 17 Ginter et al. (2017) 2 2 2 2 1 2 2 2 2 2 19 Adams et al. (2016) 2 2 2 2 2 1 1 1 2 2 17 Zhang et al. (2024) 2 2 2 2 1 1 2 2 2 2 18 Wells et al. (2022) 2 2 2 2 2 1 2 1 2 2 18 Lie et al. (2018) 2 2 2 2 2 1 2 2 2 2 19 Goossens et al. (2015) 2 2 2 2 2 1 2 1 2 2 18 Aamir et al. (2022) 2 2 2 1 1 1 2 2 2 2 18 Sherafat and Taghikhan (2020) 2 2 2 2 2 1 1 1 2 2 17 Hubbeling et al. (2018) 2 2 2 1 2 1 2 1 2 2 17 Lee et al. (2013) 2 2 2 2 1 1 2 1 2 2 17 Moradian et al. (2012) 2 2 2 2 1 1 2 2 2 2 18 Rosedale et al. (2009) 2 2 2 2 1 2 2 2 2 2 19 Avutu et al. (2022) 2 2 2 1 2 1 2 2 2 2 18 Mardani-Hamooleh & Heidari (2018) 2 2 2 2 2 1 2 1 1 2 17 Hauken and Larsen (2019) 2 2 2 2 2 1 2 2 2 2 19 Thewes et al. (2004) 2 2 2 2 2 1 2 1 2 2 18 Notes: ♣ 2 = Yes ♣ 1 = Can’t Tell ♣ 0 = No ♣ Score range (0–20)

Analytical themes

The analysis of qualitative data from the 20 studies revealed various social relationship challenges encountered by cancer patients and survivors. These challenges, specifically related to disruptions in interpersonal interactions and alterations in close social networks, were organized into eight analytical themes: interpersonal strain due to excessive pity and misplaced sympathy, disclosing information challenges, seeking support challenges, perceived gaps in social support, social isolation and reintegration challenges, understanding stigma and rejection, marital and intimate challenges during illness, and practical assistance requirements. These themes are presented in Table 3 .

Table 3 Analytical and descriptive themes derived from reviewed qualitative studies Analytic Themes Descriptive Themes Interpersonal strain due to excessive pity and misplaced sympathy - Social distancing driven by pity - Annoyance with overwhelming emotional reactions and pitying looks - Feeling objectified or singled out - Strained relationships due to misplaced sympathy Difficulties in disclosing information - Emotional impediments to self-disclosure - Discomfort with intrusive questions Challenges in seeking support - Reluctance to seek support due to caregiver burden - Struggles with role reversals in support dynamics Perceived gaps and misalignments in social support - Misinterpretation of actions in close relationships - Challenges in setting boundaries for support - Perceived abandonment by social circles - Decline in family support over time Social isolation and reintegration challenges - Isolation due to perceived lack of empathy - Barriers to reintegration due to physical and emotional strain - Withdrawal driven by fear of intrusive questions - Withdrawal due to impaired body image - Self-imposed isolation due to emotional suppression - Evolving social dynamics and shifting priorities Understanding stigma and rejection - Cancer-related mortality taboo - Moral judgments and blame - Perceived rejection and imposed exclusion - Misunderstandings and fear of contagion - Feelings of inadequacy compared to healthy peers Marital and intimate challenges during illness - Unspoken tensions and diverging life paths - Emotional disconnection as a coping mechanism - Illness as a catalyst for sexual and relational disruption - Perceived rejection and emotional vulnerability following physical changes Practical assistance requirements - Challenges of managing childcare during treatment - Seeking external assistance

Analytical theme 1: interpersonal strain due to excessive Pity and misplaced sympathy

A meta-synthesis of cancer patients’ and survivors’ social experiences highlights that navigating social relationships during illness is often hindered by excessive pity and misplaced sympathy. In some included studies, participants frequently reported emotional and interpersonal distress resulting from these interactions, which exacerbated their isolation and strained their connections with others. The descriptive themes are outlined as follows:

Social distancing driven by Pity

A dominant theme in the data was the emotional toll of social distancing prompted by pity. Some participants reported avoiding interactions with individuals whose behavior they perceived as condescending or overly sympathetic. As one participant noted:

“I tried to escape from some certain people , ie , those who pitied me , and give them the cold shoulder. I attempted to avoid some relationships for their hurtfulness.” [ 41 ].

This distancing reflects a broader pattern in which individuals, seeking to protect their emotional well-being, distance themselves from those whose pity reinforces feelings of helplessness and dependency.

Annoyance with overwhelming emotional reactions and pitying looks

Patients and survivors expressed frustration with the emotional reactions of others, particularly those that drew undue attention to their illness. As one individual noted:

“Uncles , whoever heard , instead of telling me that there is no problem , sitting in front of me and crying and lamenting and such words.” [ 42 ].

This quote illustrates the discomfort participants experienced when others’ emotional responses, often characterized by pitying glances or sorrowful remarks, overshadowed their agency and emotional resilience. Another said:

“I hurt to meet people’s pitying look. It has been for eight years when I go to a party , my relatives say , do you feel better? I hate to hear this word.” [ 43 ].

Such interactions, while well-intentioned, served to reinforce participants’ vulnerability and hindered the reintegration of cancer patients and survivors into regular social contexts.

Feeling objectified or singled out

A recurring concern among participants was the sense of being objectified or excessively focused upon because of their illness. One participant reflected:

“It got to the point where I was beginning to find it rather strange to be the focus of so much attention , I felt like a freak or something; all of a sudden everyone wanted to know all about how things were going.” [ 44 ].

This sentiment captures the alienation that arises when individuals feel reduced to their illness, rather than being seen as whole persons with multifaceted identities beyond their condition.

Strained relationships due to misplaced sympathy

Some interactions, though intended to convey empathy, often evoked feelings of resentment or emotional burden instead of fostering the supportive connections participants desired, as highlighted in the following quote:

“When someone calls on the phone and says , ‘Oh , I just heard about you…I thought my life was crap but you got me beat.’ Like , ‘Well , thank you. I’m glad I made you feel better.’ It put a strain on the friendships.” [ 45 ].

Analytical theme 2: Difficulties in Disclosing Information

The synthesis of previous studies has highlighted they often grapple with significant emotional hurdles sharing their condition. These emotional barriers frequently obstruct meaningful interactions and access to support systems. The descriptive themes are presented as follows::

Emotional impediments to Self-Disclosure

Participants often hesitated to disclose their illness due to inner doubts and fears. As one participant expressed:

“It’d be better if I did have somebody to share it with…I don’t [think] I can do that.” [ 46 ].

These internalized concerns frequently hindered open communication, despite the recognition of potential benefits from sharing their diagnosis. In some cases, patients understood that disclosure could lead to emotional support. As one participant reflected:

“I think if relatives like my aunt’s daughter knew about my illness , it would be different for me. If they pitied me , they would do something to change my mood. They were busy around me and did not allow me to stay alone in this situation.” [ 41 ].

This highlights the complex emotional conflict faced by patients: a deep desire for support, yet a profound fear of the consequences of sharing their condition.

Discomfort with intrusive questions

Interactions with others were often fraught with discomfort due to unsolicited questions about their condition. One participant described:

“For example , one of our problems was family commuting. I hated people who asked me questions. I used to run away. For example , we are a very big clan. I don’t know how some people I have to answer.” [ 42 ].

Such experiences reinforced preferences for privacy and led to avoidance of certain social situations.

Analytical theme 3: challenges in seeking support

Analysis of the included studies indicates that seeking support from others, particularly during times of illness, is frequently met with internal resistance. The descriptive themes are delineated as follows:

Reluctance to seek support due to caregiver burden

A recurring concern was the fear of placing additional stress on caregivers. For instance, one participant shared:

“I certainly hope she can help me , but it is already very difficult for her , and I don’t want to burden her even more…” [ 47 ].

Similarly, another participant noted:

“I am sure if I did (ask for financial help) , they would probably help. But I do not like to do that. They have their own lives and own problems , own bills…” [ 48 ].

These accounts underscore a persistent tension between the desire for support and the reluctance to impose on others.

Struggles with role reversals in support dynamics

For individuals who were accustomed to caregiving roles, transitioning to being the recipient of support was particularly challenging. One participant remarked:

“You know , it is just hard , because I have been the one who liked to support people , so I have never managed to be the one who needs help…Very difficult.” [ 49 ].

Such role reversals disrupted long-standing relational dynamics, contributing to emotional distress.

Analytical theme 4: perceived gaps in social support

The quality and availability of social support varied widely, leaving some patients feeling emotionally disconnected and unsupported. Participants described frustrations with unmet needs, shifting dynamics, and diminishing support over time. The descriptive themes are outlined as follows:

The quality and availability of social support varied widely, leaving some patients feeling emotionally disconnected and unsupported. Participants described frustrations with unmet needs, shifting dynamics, and diminishing support over time.

Misinterpretation of actions in close relationships

Misaligned perceptions of care within close relationships were a drived theme. For example, one participant expressed frustration with their mother’s perceived indifference, later discovering it stemmed from emotional overwhelm:

“My mom just could not spend a lot of time with me while I was going through treatment , and for a couple years , actually , I was very upset with her. I was like , ‘You couldn’t even care to spend time with me.’ I find out later it was because I had told them they couldn’t cry in front of me. She just couldn’t handle watching me go through this.” [ 45 ].

Similarly, misunderstandings of a partner’s supportive actions often led to feelings of neglect, as one participant noted:

“…he supported me , but I did not understand his support” [ 50 ].

Challenges in setting boundaries for support

Patients and survivors faced difficulties in articulating and maintaining boundaries regarding the type and extent of support they required. One participant explained:

“I was very inward. I looked to family for the support. I had to explain to them and they finally got it , I said: ‘Okay , this is happening to me , so I need you to support me in terms of how much support I need or not. If I need to be by myself , or you don’t hear from me for a week , I know you’re concerned , but don’t be. I know you’re there and I will reach out to you.’ That was harder for all of them than it was for me.” [ 45 ].

Another echoed this sentiment, reflecting on mutual uncertainty:

“They (family and friends) want to support you , but they don’t know what they have to do. And I don’t know what I want them to do either.” [ 49 ].

Perceived abandonment by social circles

Cancer often disrupted long-standing social connections, leading to feelings of abandonment. One participant shared:

“…all my other friends , I never hear from them. I call them , they don’t call me back , so I said to myself , the hell with them.” [ 48 ].

Another described how illness altered their relationships entirely:

“You know through this sickness , almost all my people changed , people whom I was with and thought they are close , and I thought they are my relatives.” [ 51 ].

Decline in family support over time

While families often provided strong initial support, survivors frequently noted a gradual decrease in engagement as time progressed. One participant remarked:

“My family doesn’t remember me anymore. At first they were very supportive , but now they are not like before. They don’t call me much. I would like them to call me more.” [ 52 ].

Others highlighted a shift toward minimization of the illness:

“Right now , they always encourage me , ‘You had cancer , you do not have it anymore. You are not sick; you are as normal as anyone. We don’t want to talk about it anymore.’ There are times when I feel like talking about (cancer) but he does not.” [ 53 ].

The persistence of physical and emotional challenges beyond active treatment emphasized the necessity for ongoing support. One survivor shared:

Patients tend to think everything will be over after chemotherapy , but it isn’t… There are lingering pains. I think it will be helpful to patients if family members and other people keep giving attention to patients even after having chemotherapy” [ 54 ].

Misinterpretation of actions in close relationships

Misaligned perceptions of care within close relationships were a drived theme. For example, one participant expressed frustration with their mother’s perceived indifference, later discovering it stemmed from emotional overwhelm:

“My mom just could not spend a lot of time with me while I was going through treatment , and for a couple years , actually , I was very upset with her. I was like , ‘You couldn’t even care to spend time with me.’ I find out later it was because I had told them they couldn’t cry in front of me. She just couldn’t handle watching me go through this.” [ 45 ].

Similarly, misunderstandings of a partner’s supportive actions often led to feelings of neglect, as one participant noted:

“…he supported me , but I did not understand his support” [ 50 ].

Challenges in setting boundaries for support

Patients and survivors faced difficulties in articulating and maintaining boundaries regarding the type and extent of support they required. One participant explained:

“I was very inward. I looked to family for the support. I had to explain to them and they finally got it , I said: ‘Okay , this is happening to me , so I need you to support me in terms of how much support I need or not. If I need to be by myself , or you don’t hear from me for a week , I know you’re concerned , but don’t be. I know you’re there and I will reach out to you.’ That was harder for all of them than it was for me.” [ 45 ].

Another echoed this sentiment, reflecting on mutual uncertainty:

“They (family and friends) want to support you , but they don’t know what they have to do. And I don’t know what I want them to do either.” [ 49 ].

Perceived abandonment by social circles

Cancer often disrupted long-standing social connections, leading to feelings of abandonment. One participant shared:

“…all my other friends , I never hear from them. I call them , they don’t call me back , so I said to myself , the hell with them.” [ 48 ].

Another described how illness altered their relationships entirely:

“You know through this sickness , almost all my people changed , people whom I was with and thought they are close , and I thought they are my relatives.” [ 51 ].

Decline in family support over time

While families often provided strong initial support, survivors frequently noted a gradual decrease in engagement as time progressed. One participant remarked:

“My family doesn’t remember me anymore. At first they were very supportive , but now they are not like before. They don’t call me much. I would like them to call me more.” [ 52 ].

Others highlighted a shift toward minimization of the illness:

“Right now , they always encourage me , ‘You had cancer , you do not have it anymore. You are not sick; you are as normal as anyone. We don’t want to talk about it anymore.’ There are times when I feel like talking about (cancer) but he does not.” [ 53 ].

The persistence of physical and emotional challenges beyond active treatment emphasized the necessity for ongoing support. One survivor shared:

Patients tend to think everything will be over after chemotherapy , but it isn’t… There are lingering pains. I think it will be helpful to patients if family members and other people keep giving attention to patients even after having chemotherapy” [ 54 ].

Analytical theme 5: social isolation and reintegration challenges

The included studies showed that cancer patients and survivors often grapple with profound social isolation and significant challenges in reintegrating into their communities post-diagnosis. These difficulties arise from the interplay of emotional, physical, and social factors that shape their experiences. The descriptive themes are detailed as follows:

Isolation due to perceived lack of empathy

Despite physical proximity to others, patients frequently reported feeling emotionally isolated, often linked to a perceived lack of understanding or support from those around them. Moments of heightened vulnerability, such as anniversaries of diagnoses or surgeries, intensified these feelings. One participant expressed:

“Sometimes I feel tired and no hope for future. I want to see no one because I feel nobody can understand.” [ 55 ].

Another shared:

“I feel lonely a lot. There is a moment where it comes , or I just become more aware of it. There could be everybody home in my house and I still feel really alone. Sometimes I can detect the reason; it is the anniversary of my surgery and nobody remembers or I just remember feeling so terrified and alone. I just feel really lonely all over again.” [ 56 ].

This sentiment reflects a sense of emotional alienation, where even in the presence of others, the lack of empathetic connection fosters a deep feeling of loneliness.

Barriers to reintegration due to physical and emotional strain

The aftermath of cancer treatment, marked by physical exhaustion and emotional struggles, often hindered patients from resuming social activities. Survivors described prolonged periods of isolation and hesitancy in engaging socially. One participant noted:

“I haven’t been out much in the last year…so I have been kind of isolated at home…before I had the medicine , I…didn’t feel like [going out] much…because I didn’t feel good.” [ 46 ].

Another shared:

“I did not tell anyone about my illness. I stayed at home during my chemotherapy period and did not go out. It was like I was in a birdcage , but didn’t even go out to the yard.” [ 41 ].

These experiences illustrate the physical and emotional constraints that limit survivors’ ability to reintegrate into social life, reinforcing their sense of isolation. A further example described:

“I’m in chemotherapy , so I feel not great a lot of the time and seeing friends in person is something that has changed a lot. Being spontaneous is a lot more difficult.” [ 57 ].

Another participant added:

“It’s really difficult for me to approach people. The words don’t come out of my mouth , it’s like there is a knot in my throat.” [ 53 ].

These quotes capture the emotional burden and physical limitations that impede both reintegration and social interaction.

Withdrawal driven by fear of intrusive questions

Concerns regarding physical alterations and societal responses significantly exacerbated tendencies toward self-imposed isolation among survivors. Some individuals expressed apprehension about potential judgment or intrusive questioning, particularly as it pertains to overt indicators of their medical condition. One survivor articulated:

“Actually , I’m afraid of going to ceremonies , I lost my hair due to chemotherapy , I am sure they will search and question me why I lost my hair.” [ 43 ].

This fear of invasive curiosity often led to avoidance of social gatherings, reinforcing the isolation caused by visible changes and perceived social judgment.

Withdrawal due to impaired body image

A key finding of the meta-synthesis study is the profound impact of visible physical changes on patients’ social engagement. These changes frequently result in feelings of embarrassment and a hesitancy to pursue or sustain social connections. One participant explained:

“Some apparent changes like alopecia make the patient feel embarrassed to have social relationships.” [ 58 ].

The visible effects of illness, such as hair loss, can make individuals feel self-conscious and reluctant to engage in social interactions, further contributing to feelings of isolation.

Self-Imposed isolation due to emotional suppression

This theme emphasizes the tendency of individuals to isolate themselves by keeping their thoughts and emotions hidden. Various factors, such as avoiding vulnerability or coping with their struggles alone, drive them to suppress their feelings. However, this emotional suppression often leads to unintended outcomes, such as increased loneliness and a stronger sense of isolation. One participant shared:

“… And yes , keeping all these (thoughts) to myself makes me feel isolated and lonely at times.” [ 56 ].

This emotional withdrawal, while initially aimed at self-preservation, often exacerbates the sense of isolation and disconnection from others.

Evolving social dynamics and prioritization of relationships

The experience of cancer often triggers a profound reevaluation of interpersonal relationships, leading individuals to reassess their social circles and emotional priorities. This introspection frequently results in a stronger inclination towards solitude or the intentional severing of relationships perceived as toxic or draining. One participant shared:

“I got to the point where I didn’t want people who were toxic and took energy out of life , so I did end some friendships and family relationships.” [ 45 ].

Simultaneously, a growing preference for solitude may emerge, becoming an integral part of the healing process. This shift allows for a renewed connection with oneself and a transformed perspective on life. As another participant explained:

“…I have another vision of life. I don’t know. I became isolated. I liked to have friends; I really liked to talk. But now I like being alone and walking alone , seeing the forest , park—alone. I like thinking alone. After I recovered , that’s how I became , very isolated from everyone.” [ 53 ].

This transformation reflects how the cancer experience can lead individuals to redefine their social world, either by prioritizing solitude or by distancing themselves from toxic relationships.

Analytical theme 6: Understanding stigma and rejection

Cancer-related stigma and prevalent societal misconceptions profoundly impact the social dynamics experienced by patients and survivors, intensifying their feelings of alienation and social rejection. The following describes the outlined descriptive themes:

Cancer-related mortality taboo

Cancer often becomes associated with mortality in the minds of others, leading to significant social discomfort and avoidance. Patients, aware of this societal fear, may feel compelled to hide their illness or withdraw from social interactions to avoid the stigma of being seen as “sentenced to death.” One participant shared:

“I knew I had cancer but I didn’t tell anyone. People commonly have reactions to cancer patients! For example , people point out cancer patients to each other and think they are sentenced to death.” [ 58 ].

This societal reaction leads to both social withdrawal and emotional distress. Another participant shared a painful moment:

“When I asked my husband to buy new furniture for our house he said it is better to think whether you can be alive to use them. I was filled with pain and sadness. I replied only God knows how long I am alive.” [ 55 ].

The emotional toll of the mortality taboo reinforces feelings of alienation and highlights the social rejection faced by patients.

Moral judgments and blame

Cultural and familial perceptions of cancer as a punishment for sins contribute to moral judgments that further stigmatize patients. These beliefs are often internalized by patients, compounding their emotional distress. One survivor recalled:

“During chemotherapy , my skeletal pains were so severe that I could not even stand on my feet. In such condition , my mother continually cried and told me , ‘Repent! Repent! This is the punishment for your sins.’ I answered her , ‘What have I done that deserves repentance? What sins have I committed that all people say this is the punishment for your sins?’” [ 41 ].

Another survivor shared how their spouse’s accusation deepened their emotional pain:

“After my first [cancer] treatment last month , I was still…weak… and my husband just approached me outside and screamed at me that he blamed me– it’s 100% my fault I had cancer.” [ 46 ].

These moral judgments intensify the emotional burden of cancer, reinforcing feelings of shame and guilt, which complicate the patient’s emotional healing.

Perceived rejection and imposed exclusion

Cancer patients and survivors often face rejection from society, which is sometimes perceived as an intentional distancing by friends, family, and even broader social circles. This exclusion is based on misconceptions about the patient’s capabilities or assumptions about their emotional state. One reviewed study’s participant shared:

“Colon surgery affected my social and family relationships. I tried to stay home and not have relationships with others. I believe that society rejects cancer patients in our culture.” [ 58 ].

Another described an incident of imposed exclusion:

“And people just don’t tell you things anymore. Like accidentally discovering that your brother has been to Italy. Then you ask them why they didn’t tell you , and they reply because you can’t go on holiday anymore and they thought it might upset you.” [ 44 ].

This exclusion, whether perceived or actual, reinforces social isolation and makes it difficult for cancer patients to maintain their social connections.

Misunderstandings and fear of contagion

The misunderstanding of cancer, particularly the false belief that it is contagious, contributes to additional social withdrawal and distancing. Patients may feel that their illness makes them a “social pariah,” which further exacerbates feelings of isolation. One participant explained:

“There are some people who can’t understand what cancer is. They think if you get near them , they’ll catch it.” [ 53 ].

This fear of contagion leads to unnecessary social isolation, reinforcing the emotional and social challenges that cancer patients already face.

Feelings of inadequacy compared to healthy peers

Interactions with healthy peers often amplify feelings of inadequacy in cancer patients. Despite outward expressions of sympathy, patients frequently perceive these interactions as patronizing or dehumanizing. One participant explained:

“I felt that she was looking at me from a superior position because she was healthy.” [ 41 ].

This perception of being treated as inferior or pitied fosters a sense of emotional disconnection, making it challenging for cancer patients to maintain genuine relationships with healthy peers.

Analytical theme 7: marital and intimate challenges during illness

The emotional and relational dynamics within marriages and intimate relationships undergo significant strain when one partner is diagnosed with cancer. The effects of illness permeate various aspects of these relationships, especially in areas of communication, emotional connection, sexuality, and physical appearance.

Unspoken tensions and diverging life paths

A common theme that emerged was the difficulty in communicating health-related concerns, especially when one partner’s emotional well-being could be further strained by negative news. Some participants described withholding critical health information in an attempt to protect their spouses from emotional distress, as seen in one participant’s struggle:

“[My husband] gets real depressed , so I…don’t share too much of the information with him…from these scans , year over year , they seem to get worse every time…But I can’t share that with him because he’s going to be really upset if I told him…” [ 46 ].

This reluctance to communicate difficult truths resulted in an emotional disconnect, with some couples experiencing irreparable strain, as illustrated by one participant’s decision to divorce due to a lack of shared understanding on sensitive topics like fertility:

“I decided to get a divorce. because that [fertility] was difficult to talk about. We had a different point of view.” [ 50 ].

The inability to express vital issues such as health concerns or future expectations created tension and fostered relational isolation.

Emotional disconnection as a coping mechanism

Illness often led to emotional withdrawal, a coping mechanism for partners, which in turn worsened relational dynamics. In some cases, this disconnection was marked by avoidance, with one participant recalling:

“… He just pulled away…(…). I was furious [You] cannot just disappear when things get difficult! That was the problem , and then he would hide away at work.” [ 59 ].

Another participant described a more drastic emotional withdrawal when her husband responded to the news of her advanced cancer by distancing himself physically:

“He changed a lot because when he was told his wife had cancer , and it was very advanced , that day he took his pillow , his blanket , and left my bed.” [ 53 ].

Such emotional disconnection often exacerbated feelings of abandonment and further fragmented the relationship.

Illness as a catalyst for sexual and relational disruption

The physical consequences of cancer treatments, including surgery and chemotherapy, frequently disrupted the sexual and relational aspects of partnerships. In particular, sexual dysfunction, as a result of prostate surgery, led to marital dissatisfaction. One participant reflected on how his wife’s disappointment after his surgery created a rift:

“Prostatectomy affected my sexual relationship which led to marital dissatisfaction in my wife. She told me I was no longer a man.” [ 58 ].

Similarly, the effects of a mastectomy contributed to changes in intimacy dynamics. One participant expressed the ongoing dissatisfaction with their sexual relationship, despite being out of the high-risk phase of cancer treatment:

“We have now moved out of the high-risk zone , to a zone where our need for intimacy has increased , our sex life should be back to what it was but it is not.” [ 60 ].

These examples reflect how cancer’s physical toll disrupts not only sexual intimacy but also the emotional and relational connection between partners.

Perceived rejection and emotional vulnerability following physical changes

Physical changes, particularly those resulting from surgery, often lead to feelings of rejection and emotional vulnerability. The emotional impact of visible alterations, such as mastectomy, was evident in participants’ accounts of how their partners’ reactions contributed to relational breakdowns. One participant recalled the emotional pain caused by her ex-husband’s withdrawal following her mastectomy:

“After having a mastectomy , my ex-husband didn’t sleep with me and didn’t touch me at all. I was humiliated and so sad. I thought he despised me because of my cancer and the surgery.” [ 54 ].

Another participant shared the lasting emotional impact of her husband’s jealousy after her mastectomy:

“With my husband , I had some problems. Because I did not have my chest , or out of jealousy , I don’t know. I felt very bad and to date we have managed to fix a lot of things , but not everything.” [ 53 ].

The societal stigma surrounding mastectomy and physical alterations further contributed to this emotional and relational distress, with one participant noting how her husband remarried after her surgery:

“After mastectomy my husband remarried. In our society men cannot accept their wives’ mastectomy and it caused deterioration in the marital relationship.” [ 58 ].

These experiences underscore the significant emotional toll that physical changes can place on both the individual and their relationship.

Analytical theme 8: practical assistance requirements

Cancer treatment often necessitates a range of practical supports to help individuals manage daily responsibilities, particularly those related to childcare and household tasks. Participants frequently reported the emotional burden of needing external assistance, particularly in the context of managing family responsibilities during treatment. The descriptive themes are presented below:

Challenges of managing childcare during treatment

One of the most common practical challenges faced by cancer patients was managing childcare while undergoing treatment. In one case, a participant expressed concern about the well-being of her children while she underwent chemotherapy:

“I didn’t have anyone to leave my children with. I brought them here , and they were in the car. They ate breakfast in the sun , and I was here in chemotherapy. I think childcare is very important because I was worried that my kids were out there.” [ 53 ].

This reflects the stress of balancing caregiving responsibilities with the need for personal care during treatment.

Seeking external assistance

Some cancer patients and survivors required support for daily tasks they could no longer perform independently due to physical limitations. One participant shared how they relied on help for basic tasks:

“…doing things for me that I can’t quite manage now with my arm being as it is.” [ 60 ].

Support from friends, neighbors, or community members played a crucial role in alleviating these burdens. For example, one participant expressed gratitude for the assistance they received:

“I used to be able to do everything , clean the whole house. Unfortunately , those days are over. But two friends come every week to clean; they have set up a cleaning club , especially for the purpose.” [ 44 ].

This support not only helped in managing the household but also relieved some of the emotional and physical strain associated with cancer treatment.

Discussion

This study employs a qualitative meta-synthesis approach to offer an in-depth exploration of social relationship experiences in cancer patients and survivors. Notably, this is the first such meta-synthesis to focus specifically on this crucial aspect of the cancer experience.

Cancer patients frequently face profound social challenges arising from pity and misplaced sympathy, both of which significantly disrupt their interpersonal relationships. Prior studies have identified pity as a critical barrier to effective supportive communication, often diminishing the quality of interactions within social support networks [ 61 – 63 ]. Goldsmith’s synthesis (2004) highlights that while supportive behaviors such as empathy, open communication, and normalization enhance relationships, counterproductive actions like condescension, pity, and unsolicited advice intensify patients’ emotional distress [ 64 ].

Our findings corroborate this research, showing that pity often results in social distancing. Patients tend to withdraw from relationships they perceive as condescending or emotionally overwhelming. This aligns with studies indicating that patronizing behaviors undermine autonomy, hinder meaningful social engagement, and heighten feelings of isolation [ 64 – 66 ]. Excessive expressions of pity or emotional responses act as significant stressors, eliciting frustration and discomfort. These behaviors often objectify patients, reducing their identity to their illness and ignoring the complexity of their personhood—a recurring issue noted in research on illness stigmatization within social contexts [ 67 – 70 ]. Moreover, receiving excessive or intrusive support can unintentionally amplify patients’ perceptions of their condition’s severity, intensifying negative self-perceptions and psychological distress [ 69 – 71 ].

Misplaced sympathy, including unsolicited advice and excessive concern, further strains relationships. Patients often report feeling emotionally burdened by such gestures, perceiving them as detached and unhelpful rather than compassionate or supportive. Research has shown that sympathy, particularly when linked to pity, is frequently resented by patients and associated with demoralization, heightened depressive symptoms, and emotional distress [ 69 – 72 ]. The cumulative effects of pity and misplaced sympathy fundamentally undermine the social foundation critical for fostering emotional resilience in cancer patients. Studies consistently demonstrate that these behaviors erode autonomy, perpetuate stigmatization, and reinforce feelings of “otherness” and social alienation [ 73 – 65 ]. For instance, Shen et al. (2016) found that poor communication, characterized by condescension and limited empathy, exacerbates stigma and emotional distress among lung cancer patients [ 73 ].

The findings of this meta-synthesis shed light on the significant emotional challenges faced by cancer patients when disclosing their diagnosis, which often obstruct meaningful communication and hinder access to crucial support. These emotional barriers complicate patients’ ability to engage with others and seek necessary emotional assistance, thereby exacerbating their sense of loneliness. Many patients exhibit reluctance to disclose their diagnosis due to internal uncertainties and anxieties, reflecting a tension between the desire for emotional support and the fear of being treated differently. This complex emotional conflict has been recognized in previous studies on illness disclosure. For instance, research by Lee and Park (2023) highlights that perceived discrimination and social stigma often discourage patients from revealing their diagnosis [ 74 ]. Recent studies also show that a significant proportion of cancer patients engage in avoidance behaviors regarding discussions about their illness. Specifically, 35% of patients report never initiating the subject, while 24% engage in conversations only when prompted by others. This hesitance often stems from concerns that their disclosures may lead to emotional withdrawal or increased distress in their social circles [ 75 ]. Despite a desire to share their experiences, a striking 80% of patients choose silence, primarily due to the fear of being misunderstood or the intention to protect others from emotional burden [ 76 ]. Additionally, findings from a stakeholders’ study suggest that both patients and their families frequently navigate their circumstances through non-disclosure strategies related to the cancer diagnosis, accompanied by a reduction in social interactions. This approach is adopted to avoid unsolicited sympathy and minimize the risk of receiving potentially harmful information that could negatively affect their emotional well-being [ 77 ].

In addition to the emotional impediments to disclosure, many participants reported discomfort with unsolicited questions about their illness. This discomfort with intrusive questioning often reinforced patients’ preference for privacy and led to the avoidance of social situations. Similar findings have been reported in prior research, where patients expressed distress and social withdrawal in response to unsolicited inquiries, which further exacerbated feelings of isolation [ 76 , 78 ].

The analysis of the studies included in this research highlights a common challenge faced by cancer patients: internal resistance to seeking support during illness. As indicated by the data analyzed in this study, many patients experience internal resistance when it comes to asking for help. This reluctance can be understood through two primary concerns: fear of burdening others, particularly caregivers, and the emotional struggle of adjusting to new roles in support dynamics. A key barrier to seeking support is the perceived burden it may impose on caregivers. These sentiments highlight a common dilemma faced by patients: the desire for support versus the perceived strain on those providing care. This phenomenon aligns with findings from prior studies, which have consistently pointed out that cancer patients often hesitate to seek help due to guilt or concern about overwhelming their loved ones [ 79 ]. The emotional toll of cancer can lead to a sense of isolation, as patients may prioritize the well-being of their caregivers over their own need for assistance.

Another significant challenge identified in this research is the difficulty cancer patients face when transitioning from caregivers to recipients of support. This role reversal can cause emotional distress, especially for individuals who have been accustomed to offering help and support to others. This struggle with shifting roles can undermine the patient’s sense of independence and control, which is often crucial to their identity and well-being. These findings are consistent with research suggesting that individuals with cancer frequently experience difficulties in adjusting to their new role as care recipients, which can exacerbate feelings of vulnerability and emotional discomfort [ 80 ].

The findings regarding perceived gaps in social support illustrate the intricate and evolving nature of social interactions both during and after cancer treatment. This theme emphasizes the significant challenges encountered, which range from emotional disconnection to the decreasing availability of support over time. These dynamics not only reveal critical deficiencies in the understanding and provision of social support but also highlight the relational strain that cancer imposes on patients and their immediate social networks.

The narratives highlight that social support, even when offered with good intentions, can often be misunderstood due to mismatched expectations or incomplete communication. Misunderstanding and miscommunication are inherent to human interaction [ 81 ]. While both family caregivers and patients generally seek open communication to support each other and establish shared goals [ 82 , 83 ], past studies have shown that they often struggle to fully comprehend each other’s needs. This challenge is further compounded by a reluctance to openly discuss the emotional and relational impacts of cancer without external prompting [ 84 – 86 ].

Additionally, various challenges within social networks and social support stem from differing perceptions, cultural influences, and environmental factors. Members of the social network may avoid communication or fail to provide adequate support when it is most needed. Research indicates that these dynamics are particularly pronounced when the individual is facing a stigmatized health condition, such as cancer. Studies have shown that individuals in this situation often experience difficulties in receiving the support they need, as family members and friends may feel uncertain about how to engage or may inadvertently distance themselves [ 87 – 89 ]. This misalignment in expectations and communication can intensify the emotional burden on both patients and caregivers, making it even more challenging for them to navigate the disease together.

The findings from our research indicate that misunderstandings in intimate partnerships, particularly between patients and caregivers, can significantly hinder the provision of effective support, especially when emotional needs are inadequately communicated or addressed. Uncertainty is a fundamental factor in numerous health conditions, including cancer, where it engenders a sense of vulnerability and insecurity for both patients and caregivers [ 90 ]. This heightened state of uncertainty can lead to relational turbulence, a concept central to Relational Turbulence Theory [ 91 ]. This theory posits that transitions in relationships, such as a cancer diagnosis, amplify uncertainty and complicate the recognition and fulfillment of each party’s emotional and practical needs. Consequently, the lack of clarity may provoke increased emotional reactivity, thereby complicating efforts for both individuals to effectively navigate and meet one another’s needs. In these contexts, the importance of effective communication is further magnified, as it facilitates the adaptation of both patients and caregivers to evolving needs and roles, ultimately reducing the negative effects of relational uncertainty on their emotional well-being.

Cancer patients encounter substantial challenges in defining and maintaining boundaries regarding the type and extent of support they require. The multifaceted emotional and physical burdens associated with the disease necessitate a caregiving approach that is both nuanced and adaptable. Nevertheless, patients frequently report difficulties in managing these boundaries, often assuming the role of educators to inform family members about their specific needs. These challenges are frequently attributed to misaligned perceptions of care within close relationships, wherein even well-intentioned support may fail to accommodate the dynamic and evolving needs of patients throughout their treatment and recovery.

Empirical evidence underscores the potential adverse effects of misdirected supportive actions. For example, Merluzzi et al. highlight the detrimental impact of mismatched support, where assistance either does not align with or is unwanted by the patient, leading to frustration and emotional strain [ 92 ]. Cancer patients often rely on family as their primary source of support, yet such support is not always perceived as helpful. In some cases, it may even be viewed as intrusive or burdensome, as families may lack awareness of the specific type of support needed [ 93 , 94 ].

Social support theory provides a critical framework for understanding these dynamics, emphasizing the necessity of aligning caregiving efforts with the unique needs of patients to facilitate effective coping strategies. Excessive or inappropriate support can undermine a patient’s sense of autonomy and self-efficacy, potentially impeding their recovery trajectory. Consequently, achieving an equilibrium between delivering meaningful support and preserving the patient’s independence is essential for fostering a sustainable and constructive caregiving environment [ 95 ].

The findings reveal that feelings of abandonment, both from social networks and familial ties, were prevalent and significant among participants. Many described experiences of being neglected by friends and observed a noticeable decline in family support over time. These themes are consistent with longitudinal studies on cancer survivorship, which highlight the challenges patients face as their support systems diminish. For instance, Caro et al. (2018) note that caregivers often experience feelings of inadequacy, which eventually lead them to reduce their caregiving efforts, as they come to believe they can no longer meet the demands of the situation [ 96 ].

While earlier research on family social support framed these interactions largely in positive terms [ 64 , 97 ] [ 98 ], more recent studies have revealed a much more nuanced reality. Negative perceptions of family support are now recognized as common, with issues such as family conflict and dissatisfaction frequently emerging within caregiving contexts [ 99 – 101 ]. This shift in understanding emphasizes the dual nature of family dynamics in caregiving, where both supportive and strained interactions coexist. In this context, the evolving needs of patients and caregivers often lead to misunderstandings, resulting in strained relationships despite well-intentioned efforts. Thus, these findings highlight the complexity of caregiving dynamics, where both positive and negative experiences are integral to the support process.

The findings of this meta-synthesis illuminate the profound and multifaceted social isolation experienced by cancer patients and survivors, as well as the intricate challenges they face in reintegrating into their social environments. This discussion critically evaluates these dynamics, emphasizing the interplay between emotional, physical, and societal factors that perpetuate isolation and complicate reintegration.

The results indicate that social isolation among cancer survivors often stems from a profound disconnect between their need for empathetic support and the perceived lack of understanding from those around them. This emotional alienation underscores a persistent challenge in their social interactions, compounded by insufficient support systems. Many survivors report profound loneliness due to the absence of individuals with whom they feel comfortable discussing cancer-related experiences [ 102 , 103 ]. This isolation is further intensified by external avoidance and widespread misunderstandings about the long-term impact of cancer on their lives [ 104 ]. Moreover, the decline in support from family members and healthcare providers after the initial treatment phases often leaves survivors feeling powerless and abandoned, despite their continued need for care and connection [ 104 , 105 ].

The findings reveal that cancer patients and survivors often find themselves trapped in a cycle of physical exhaustion and emotional fatigue, which significantly hampers their capacity to re-engage socially. This dual burden not only deepens their sense of isolation but also perpetuates a self-reinforcing loop that is difficult to disrupt. Among the key contributors to social isolation, physiological changes stand out as the most prevalent antecedent. Physical and functional impairments resulting from cancer and its treatments frequently limit survivors’ ability to integrate socially [ 106 , 107 ]. For example, gastrointestinal cancer survivors often face barriers to social engagement due to condition-specific challenges, including ostomy leakage and incontinence, which deter them from leading active social lives [ 107 , 108 ]. As their physical health declines, survivors frequently become more dependent and withdrawn, leading to profound social isolation and diminished capacity to sustain or establish relationships [ 109 , 110 ].

Furthermore, studies have shown that people with cancer with impaired psychological status demonstrate higher social isolation levels [ 111 ]. A qualitative study conducted in Ireland found that cancer survivors experience persistent symptoms of fatigue, anxiety, depression, and pain after receiving treatment, which increases their social isolation and reduces their activity levels. Notably, the first year after treatment involves managing the transition to survivorship and returning to daily life; survivors often feel isolated during this time [ 112 ].

The apprehension surrounding intrusive inquiries, particularly concerning visible indicators of illness such as alopecia or fluctuations in weight, emerged as a prevalent theme that contributed to increased social withdrawal among cancer survivors. Research indicates that some cancer survivors opt for self-isolation, often demonstrating reluctance to engage in discussions with others regarding specific details of their illness [ 103 , 107 ]. For many individuals, the societal scrutiny represents a symbolic barrier to successful reintegration into their communities. This highlights the urgent need for community education and awareness initiatives aimed at normalizing the post-treatment appearances and experiences of these individuals.

Impaired body image has emerged as a key factor driving self-imposed isolation among cancer survivors, particularly those grappling with significant physical changes. This reluctance to engage socially aligns with broader cultural narratives that equate appearance with self-worth, further compounding the psychological burden on affected individuals. These findings are consistent with previous research [ 113 ]. The fear-avoidance model [ 114 ] provides a valuable cognitive-behavioral perspective on this issue, suggesting that fear of altered appearance and functionality triggers avoidance behaviors. These behaviors are reinforced by persistent thought patterns that amplify perceived flaws, creating a self-perpetuating cycle of fear and withdrawal. For survivors who struggle to adjust to physical changes, this cycle can significantly hinder social reintegration. Addressing these challenges requires targeted nursing interventions that explore and mitigate the cognitive and psychological drivers of avoidance.

The use of emotional suppression as a coping mechanism highlights a complex paradox in the social dynamics of cancer survivors. Initially adopted as a protective strategy, emotional suppression can inadvertently deepen feelings of loneliness and alienation. Research indicates that many patients and survivors report feeling isolated and often limit their emotional disclosures to intimate partners or medical professionals [ 102 , 103 ]. This restricted communication may hinder emotional relief and limit opportunities for broader social understanding and support, contributing to ongoing isolation. Additionally, low self-esteem, often associated with self-discrimination, has been identified as a negative emotional experience among some patients. This group may encounter negative self-perceptions or self-denial due to cancer-related physiological changes, leading to social avoidance [ 103 ]. Behaviors associated with social avoidance are closely linked to negative emotional experiences. Furthermore, low self-esteem can manifest as a fear of humiliation in social settings [ 115 ].

A notable trend among cancer survivors is the deliberate reevaluation and restructuring of their social networks. This process frequently results in the dissolution of detrimental relationships, while simultaneously cultivating a deeper engagement with solitude and introspection. This behavior aligns with existential theories related to chronic illness, suggesting that life-threatening experiences can catalyze a fundamental reassessment of one’s values and life priorities. For many cancer survivors, solitude is redefined as a catalyst for self-renewal and empowerment [ 116 ].

The results of this meta-synthesis indicate that stigma and rejection associated with cancer are deeply ingrained in societal attitudes, resulting in alienation, emotional distress, and disruption of social networks. In the perceptions of others, cancer is frequently linked to mortality, which fosters considerable social discomfort and avoidance. The societal framing of cancer as a “death sentence” influences both the behavior of others and the self-perception of patients. Knapp et al. (2014) provide evidence of the internalization of stigma, where cancer fatalism is a belief that cancer inevitably leads to death. This fatalistic outlook can hinder engagement in cancer prevention practices and screening, stigmatize others, and lead to stigmatized individuals internalizing these attributions [ 117 ].

Cancer-related stigma, often rooted in perceptions of moral failings or viewed as a punishment for sins, significantly exacerbates the emotional and psychological burden that patients endure. Cultural and religious beliefs contribute to deep feelings of shame and guilt, while judgments from family and society further intensify this distress. These stigmatizing beliefs not only affect how patients perceive themselves but also influence how they are treated by others, complicating their emotional recovery and social reintegration.

Moreover, the misconception that cancer is contagious plays a critical role in isolating patients, leading to their social exclusion. In many communities, cancer is misunderstood and surrounded by myths, which contribute to the stigma that patients face [ 118 , 119 ]. As a result, individuals diagnosed with cancer often choose not to disclose their illness, especially when seeking employment, due to concerns about how it might affect their perceived physical capabilities. In addition to the fear of contagion, cultural taboos and deeply ingrained beliefs about cancer further amplify the stigma. In certain societies, cancer is viewed not only as a contagious illness but also as a consequence of an individual’s past wrongdoings or sins. These misconceptions increase the risk of stigmatization and reinforce social isolation for those living with cancer [ 117 , 118 ].

The perception of rejection, whether intentional or unintentional, significantly hinders the social reintegration of cancer patients, often intertwining with the dynamics of stigma. Friends and family may inadvertently create emotional distance due to misconceptions about the patients’ abilities, fears of saying the wrong thing, or assumptions about their emotional fragility. This distancing can lead patients to feel excluded and devalued, amplifying their sense of rejection. Such experiences align closely with the broader definition of stigma, which encompasses “exclusion, rejection, blame, or devaluation stemming from experience, perception, or a reasonable anticipation of negative social judgment toward an individual or group associated with a specific health condition” [ 120 ]. Also, the result of the previous study by Yi and Li (2024) showed that some cancer survivors expressed experiencing “confusion in social reintegration due to social prejudices” and voiced significant concerns about encountering unwanted sympathy or discrimination during their reintegration efforts. These challenges stemmed from society’s negative perceptions of cancer, which heightened their sensitivity to social attention. As a result, many participants preferred not to disclose their cancer journey, aiming to avoid the stigma and discomfort associated with being identified as a cancer patient [ 8 ].

Our findings revealed that the nuanced dynamics of interactions with healthy peers often add complexity to the social experiences of cancer patients. Although expressions of sympathy are generally intended to provide support, they may be perceived as patronizing, inadvertently reinforcing feelings of inadequacy among survivors. The societal perception and engagement with cancer survivors can significantly influence their self-esteem, identity, and overall quality of life. Survivors frequently encounter difficulties in reconciling their pre-illness roles and capabilities with their present circumstances, and the unintentional reinforcement of their vulnerabilities by healthy peers further complicates this adjustment [ 9 , 121 ].

The findings underscore the complex and multi-dimensional challenges that cancer poses to marital and intimate relationships, encompassing emotional distress, communication barriers, and physiological alterations. The identified challenges within these relationships are inherently personal, yet they also resonate with broader societal and cultural contexts. The stigma surrounding physical changes associated with the disease, coupled with traditional gender norms, exacerbates the relational strain faced by couples.

Some participants of included studies have emphasized that the inability to discuss sensitive topics—such as fertility concerns or the progression of the disease—frequently results in unresolved tensions. These tensions can exacerbate feelings of alienation and, in some instances, contribute to separation or divorce. This finding is consistent with previous studies indicating that cancer patients often feel restricted in their ability to communicate their concerns with their partners, while partners may distance themselves from the emotional distress experienced by the patient [ 122 – 124 ].

The findings highlight emotional withdrawal as a coping strategy adopted by some partners. Participants described experiences of abandonment or physical distancing, underscoring the profound relational disruptions caused by emotional withdrawal. These patterns align with existing literature, which highlights that avoidance behaviors—such as physical distancing, suppressing open communication, or downplaying the illness— that may occur in cancer patients’ intimate relationships, tend to intensify psychological distress for both individuals, ultimately contributing to relational fragmentation [ 122 , 123 ].

Negative dyadic coping further compounds these challenges. Behaviors such as feigned cheerfulness, dismissing the illness’s impact, or avoiding meaningful discussions leave patients feeling unsupported or isolated. Even when partners strive to maintain normalcy, their actions may inadvertently communicate rejection or abandonment. Research also emphasizes the detrimental effects of perceived unsupportive behaviors, whether overt (e.g., critical remarks about coping efforts) or subtle (e.g., changing the subject to avoid discussing illness-related issues). Although less frequent, such behaviors are profoundly distressing, significantly amplifying emotional strain for both patients and their partners [ 125 , 126 ]. These dynamics highlight the critical need for fostering supportive, open communication to mitigate relational and psychological stress during the cancer journey.

Our findings revealed that the physical consequences of cancer and its treatments—such as surgical scars, changes in body shape, and sexual dysfunction—create significant obstacles to intimacy in interpersonal relationships. These physical changes often disrupt patients’ body image and sexual identity, leading to reduced self-confidence and heightened emotional distress. Societal stigma surrounding these physical changes further intensifies the challenges, particularly in cultures where physical appearance is strongly linked to self-esteem and the stability of marital relationships. Consistent with previous research [ 127 , 128 ], our results highlight that partner responses play a pivotal role in shaping relational dynamics. Negative or unsupportive partner reactions can amplify emotional strain and exacerbate the decline in intimacy. This complex interplay of physical, emotional, and social stressors illustrates the multifaceted impact of cancer on relationships and the challenges patients face in maintaining connection and intimacy [ 127 ]. Drawing on coping theory, as proposed by Folkman et al., these challenges can be understood through the lens of cognitive appraisal and behavioral strategies. An individual with a rigid and narrow conceptualization of sexual function—equating it solely with the ability to engage in sexual intercourse—may perceive sexual dysfunction as a fundamental threat to their capacity for sexual expression and intimacy. Such appraisals often lead to maladaptive coping responses, such as avoidance of intimacy, which further perpetuates relational difficulties. Conversely, a more flexible approach to coping, involving both cognitive shifts (redefining sexual activity to encompass a broader range of intimate behaviors) and behavioral adjustments (engaging in alternative forms of intimacy), could mitigate the negative impact of these challenges. This theoretical framework highlights the importance of fostering adaptive coping mechanisms and promoting partner support to navigate the intricate interplay of physical and emotional consequences of cancer on intimate relationships [ 129 ].

The findings indicate that individuals diagnosed with cancer often rely on instrumental support to navigate the daily challenges posed by their condition. While extensive research has examined the role of social support in improving patient outcomes, there is limited understanding of which specific types of support are most critical for these individuals. The concept of “optimal matching”, the alignment of the type and level of support provided with the individual’s needs, delivered by the appropriate member of their social network, emerges as a vital framework for effective support [ 130 , 131 ]. For instance, cancer survivors may prioritize instrumental or tangible support, such as assistance with daily tasks or medical care, from their caregiver or spouse over spiritual or emotional support typically offered by broader community members [ 132 ]. This highlights the importance of tailoring support to the unique needs of patients and ensuring the suitability of the source of support to enhance its effectiveness.

In the pursuit of optimal patient-centered care, a crucial aspect lies in empowering patients to become active participants in managing their health. This empowerment can be achieved through a three-pronged approach. First, fostering the ability of patients to accurately assess their own needs is paramount. Educational resources and clear communication from healthcare providers can help patients identify not only their medical concerns but also the practical challenges associated with treatment or illness.

Second, healthcare professionals can play a vital role in helping patients recognize and leverage the potential of their existing social support network. By facilitating open discussions about needs and limitations, patients can identify individuals within their network who can best provide various forms of assistance. Finally, empowering patients with care planning skills allows them to actively engage in the development of a personalized healthcare plan. This collaborative approach ensures that the plan addresses their specific needs and resources, fostering a sense of ownership and promoting better adherence to treatment regimens.

Limitations

One notable limitation of this study is that 6 out of the 20 studies analyzed were specifically centered on Iranian cancer patients. This focus arose because the Iranian national databases were utilized separately to facilitate the search for relevant articles. This approach was intended to enhance the comprehensiveness and robustness of the search process. Because some valuable qualitative studies conducted in Iran are published in Persian and are not readily available in international databases. Furthermore, the studies included in this synthesis exhibited considerable heterogeneity, particularly in terms of patient characteristics (such as age, cancer type, and stage) and research methodologies (including variations in data collection and analysis techniques). This variability posed challenges in achieving a cohesive synthesis of the findings. Additionally, the exclusion of grey literature, including PhD theses and other non-peer-reviewed sources, constitutes another limitation. The emphasis on peer-reviewed publications was intentional to ensure methodological rigor and maintain a high standard of evidence quality. While grey literature may offer valuable, complementary insights, its inclusion could introduce potential variability and affect the consistency of the synthesis. To address these limitations, future research could focus on more specific subpopulations, such as cancer patients and survivors within distinct cultural or geographical contexts, thereby providing a more nuanced understanding of their experiences. Moreover, incorporating grey literature into future meta-syntheses could enhance the scope of findings, offering a more comprehensive perspective on the subject matter.

Implications

The social relationship struggles of cancer patients and survivors present a critical challenge within the healthcare landscape, profoundly impacting their mental and emotional well-being. These struggles can undermine treatment adherence and overall health outcomes, underscoring the urgent need for a comprehensive, integrative care model. Healthcare providers, particularly nurses, must move beyond traditional medical interventions to incorporate psychosocial support as an integral part of care. This requires specialized training to identify and address patients’ social and emotional needs and the development of effective communication strategies to facilitate open and honest dialogue.

Structured training programs for family members, caregivers, and social networks are crucial for improving the quality of support provided to cancer patients. These programs should focus on enhancing emotional intelligence and communication skills, emphasizing empathy, and discouraging counterproductive behaviors—such as pity, condescension, or unsolicited advice. By fostering supportive and respectful interactions, these efforts can alleviate the emotional distress often experienced by patients, thereby strengthening their social bonds and overall well-being.

The integration of optimal matching frameworks into care practices further enhances the alignment of support with patient-specific needs. For example, instrumental support, such as assistance with daily tasks or medical care, is often best provided by close caregivers, while emotional or spiritual support may be more effectively delivered by community networks. Tailoring support in this way reduces the risks of mismatched or intrusive assistance, ensuring that interactions are both meaningful and effective in meeting patients’ unique needs.

Empowering patients to navigate social interactions and strengthen their connections with their support networks is also essential. Evidence-based communication tools, such as educational materials, communication guides, and technology-based platforms, can help patients articulate their emotional needs and manage social concerns effectively. These tools provide patients with strategies to set boundaries, manage expectations, and engage confidently with their social networks. Collaborative care planning, involving patients and their caregivers, ensures that care aligns with evolving preferences and circumstances, fostering resilience and autonomy.

Policy changes are equally critical in addressing the social challenges associated with cancer. Expanding access to support groups and resources, increasing insurance coverage for mental health services, and fostering partnerships between healthcare providers and community organizations can help mitigate the risk of social isolation. Targeted programs designed to address stigma and support social reintegration are particularly important for improving the quality of life for cancer patients and survivors.

By adopting these evidence-based strategies, healthcare systems can address the multifaceted social challenges faced by cancer patients and survivors. This integrative approach prioritizes both the medical and psychosocial dimensions of care, ultimately enhancing emotional well-being, treatment adherence, and long-term outcomes. It reaffirms the necessity of holistic, patient-centered care to support individuals navigating the complex journey of cancer recovery.

Conclusion

This review comprehensively explores the multifaceted social relationship challenges faced by cancer patients and survivors. It delves into challenges such as interpersonal strain due to excessive pity and misplaced sympathy, difficulties in disclosing information, challenges in seeking support, perceived gaps in social support, social isolation and reintegration challenges, understanding stigma and rejection, marital and intimate challenges during illness, and practical assistance requirements. These insights equip healthcare professionals with essential knowledge to develop targeted interventions that effectively address these challenges, ultimately enhancing patient well-being and improving overall care outcomes.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1

Publisher’s note

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Acknowledgements

Not applicable.

Author contributions

BZ and AK conducted screening to select relevant articles and evaluated the selected ones. BZ, AK, and MB performed data analysis and synthesis. BZ was the main contributor in writing the manuscript, while AK, MB, and HBH reviewed and revised it. All authors reviewed the final manuscript.

Funding

Funding was provided by the Research Council of IUMS (Grant No. 3402365), which solely supported the financial aspects of the study without involvement in the design, execution, analysis, or reporting of the research.

Data availability

Data are available from the corresponding author upon reasonable request.

Declarations

Ethics approval

This meta-synthesis article was extracted from a nursing doctoral dissertation in nursing. This study received ethical approval from the Ethics Committee of IUMS, Iran (code number: IR.MUI. NUREMA. Rec.1402.081).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

National Institutes of Health

Scientific Information Database

Noor Specialized Magazines

Iran’s Publication Database

Critical Appraisal Skills Programme

Max Weber Qualitative Data Analysis

Isfahan University of Medical Sciences

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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