Characterization of functioning in breast cancer survivors: an interpretive descriptive analysis study based on the International Classification of Functioning, Disability, and Health (ICF) and the Item-Perspective Classification Framework

Abstract Purpose Breast cancer survivors may experience a variety of disabilities that could potentially compromise their independent functioning. This study aimed to examine their perspectives and experts on their functioning and interpret concepts with the International Classification of Functioning, Disability, and Health (ICF) and the Item-Perspective Classification Framework (IPF). Methods Interpretive descriptive methods were used with in-depth interviewing with 16 breast cancer survivors and 22 experts using a semi-structured interview guide. The interviews were recorded, transcribed, and qualitatively analyzed using thematic analysis. The extracted data were linked to the ICF Core Set for Breast cancer and were interpreted by the IPF. Results Four main themes emerged to define the functioning of breast cancer survivors: body functioning, physical functioning, social functioning, and mental functioning. Three other factors were also categorized as modifiers of functioning personal, emotional, and environmental. The 592 extracted meaningful concepts were linked to 38 (47%) categories from the ICF: 16 Body Functions, 14 Activities and Participation, and 8 Environmental Factors. The IPF classified all the extracted concepts, and most rational appraisals fell in the biological (B) domain. The concepts that required emotional appraisal were classified in Psychology (P). Conclusion Psychological and emotional factors were pivotal in defining functioning in patients with BC. IMPLICATIONS FOR REHABILITATION Rehabilitation specialists need to consider a holistic approach to breast cancer survivor care that addresses physical functioning and social, emotional, and environmental factors that may affect their overall well-being. The findings suggest that rehabilitation interventions that aim to improve the functioning of breast cancer survivors should target a range of areas, including body functioning, physical functioning, social functioning, and mental functioning. It is important for rehabilitation professionals to consider personal, emotional, and environmental factors that influence the functioning of breast cancer survivors when designing interventions. Using the ICF Core Set for Breast Cancer and the IPF can help rehabilitation specialists better understand the functioning of breast cancer survivors and develop more effective interventions.


Introduction
Breast cancer is currently the most widespread cancer among women worldwide, with 2.3 million new cases identified in 2020, accounting for 11.7% of all cancers.It is the fifth leading cause of cancer mortality worldwide, with 685,000 deaths [1].The disease's advances in multiple treatment approaches (such as surgery, radiotherapy, chemotherapy, and hormone therapy) have increased the number of breast cancer survivors [2].After treatment, many survivors will experience a wide range of medical, physical, cognitive, and emotional treatment-related symptoms that affect their daily lives [2,3].The type and extent of women's problems are significantly different.Fatigue, cognitive problems, pain, lymphedema, fear of disease recurrence, poor body image, premature menopause, mood disorders, and sexual dysfunction have widely caused long-term distress in these patients [4].Side effects of treatment and inactivity secondary to treatment have impaired women's ability to maintain functioning and participate in meaningful daily activities in self-care, leisure, and social activities, affecting their quality of life and causing long-term disability in these patients [5].These cases may, in turn, negatively affect the economic situation and disrupt interpersonal relationships [6].
Before, functioning was considered a physical function, such as muscle strength, range of motion (ROM), and cardiopulmonary endurance [7,8]; however, the International Classification of Functioning, Disability, and Health (ICF) uses this multidimensional or biopsychosocial approach to describe functioning with a broad perspective that includes one's physical condition and aspects of emotional, psychological, and environmental-social conditions [7].The ICF core sets have been developed for several health conditions, including breast cancer, to facilitate the implementation of the ICF in clinical practice [9].The core set provides a systematic framework to cover a range of functions and disabilities associated with breast cancer.The core set provides a systematic framework to cover a range of functions and disabilities associated with breast cancer.The core set for breast cancer contains 81 categories in different areas: 26 body functions, 9 body structures, 23 activities and participation, and 23 environmental factors [10].Previous studies aimed to develop questionnaires that included the items extracted from the core set [11,12]; however, the content validity of the ICF core set for breast cancer is limited to addressing various cancer-related issues [13].
Findings from validation studies on the ICF core set for breast cancer performed in a limited number of countries, such as Germany, Australia, Ireland, and Korea, have led to adding categories to different parts of this core set [14][15][16][17].The extra extracted codes differ among women with breast cancer in different contexts and environments.For example, in a study by Glaessel et al. some codes were extracted from personal factors, such as lack of knowledge about the disease, pain self-management, and adaptive strategies, which were not considered in the core set of breast cancer [14].Another study reported extra codes such as changing social attitudes, supportive role of pets, economic policies and systems, placement and employment and categorized them in environmental factors [16].
Therefore, considering the socio-cultural differences in the definition of functioning in patients with breast cancer, we aimed to explore the area of functioning in which the patients would have problems based on the experience of therapists and physicians who treated patients with BC with a quantitative method and link the extracted concepts to the ICF categories.

Study approach/design
Interpretive description [18] was used to help us to understand the functions of women with breast cancer.It is an inductive approach that focuses on capturing themes and patterns within subjective perceptions of the patients and generating an interpretive description to help us understand their functioning.In this method, the investigator does not act as an independent observer but co-creates the knowledge using previous theoretical or practical knowledge [19].This is consistent with the relationship between the study's clinical researchers and the breast cancer community participant members.

Sampling, recruitment
We used purposeful sampling for recruiting the patients and snowball sampling for the experts.Our local ethical committee approved the research protocol.Informed consent was obtained from all subjects involved in the study.We did not report personal factors associated with the quotes to keep anonymity.

Data collection
The interview guide was designed to explore a sequential pathway of topics related to breast cancer patients' functioning and health.We used a semi-structured interview that guided us based on the research question.We included women over 18 years of age, with an initial breast cancer diagnosis, in stages I-III >6 months or <4 years after their initial medical treatment (surgery, radiation therapy, hormone therapy, and chemotherapy).We included patients who could communicate verbally and who consented to express interviews.Hospitalized women with breast cancer were excluded from the study.One experienced occupational therapist conducted the interviews by asking all significant questions and exploring issues that needed clarification or where the participant wished to add additional information based on a semi-structured interview guide.We also interviewed specialists with at least five years of experience treating breast cancer patients.We aimed to know the definition of functioning and the area of functioning in which the patients would have a problem based on the experience of therapists and physicians who treated patients with BC.The participants were interviewed in person or by phone for 45-60 min from November 2020 to April 2021.Most interviews (n = 35) were conducted remotely due to restrictions from the recent pandemic (COVID-19) (Table 1).

Interview guide
Sample of questions in the interview guide for patients the following questions guided the interview (this is a translation from Persian; probes were dependent on responses). 1) "Can you tell me how your life has been affected since you experienced the disease and treatment?

Analysis of data
Data analysis was conducted in three main phases.

Phase one: Thematic analysis
The recorded interviews were transcribed and qualitatively analyzed using thematic analysis within an interpretive description approach.Thematic analysis was used to help us identify, categorize, analyze the transcript, and report the themes concerning the study purpose [20].The analysis was performed based on the proposed six phases of thematic analysis described by Braun and Clarke (familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report) [19,21,22].We did the repeated coding, classifying, and linkages with repeated immersion into the data several times.We also used the field notes on the data collection process and used them for reflection on the themes.Two authors read the transcribed interviews independently and assigned a descriptive phrase or code to the core concepts.After collecting a set of basic codes, they then compared the codes in a joint session until an agreement on them and their meanings.With the identification of new concepts, the codes were expanded or integrated into different conceptual categories, thereby creating the final main themes, subthemes, and initial codes.

Trustworthiness of findings
We did the concurrent data collection and analysis.We used constant comparative analysis to verify our data.To improve trustworthiness, we asked two authors to do the coding independently and multiple groups of patients and experts to assess questions and feedback before finalizing the paper.Any identified gap/ differences were discussed amongst the researchers until consensus was obtained [23].

Phase two: Linking to ICF
The meaningful concepts (codes) extracted from the interviews were linked to categories of the ICF core set for breast cancer based on the modified ICF linking rules [24].Different viewpoints and categorizations of responses were considered in the linking process.Two authors implemented the initial link independently, and any disagreements were resolved by discussion and agreement in a joint session.A third reviewer was consulted to determine the appropriate category for cases with persistent disagreement.The extracted meaningful concepts were linked to the second and third levels of the ICF codes.In the absence of an ICF category covering a specific aspect of a concept, that concept was linked to the "other specified" category; if little information existed for a concept to be assigned to an ICF category, it was linked to the unspecified category.If there were multiple meanings for a meaningful unit, it was linked to more than one ICF category.If a meaningful concept was not covered by the ICF categories but was defined explicitly as personal factors by the ICF, that concept was designated as "pf."Concepts unrelated to the ICF were expressed in two ways.If a concept was not sufficiently defined to decide on its belonging to an ICF category, it was expressed as "nd" (non-definable).If the ICF did not represent a concept, it was labelled "nc" (not covered) (Rule 10) [24].
The ICF linkage was calculated based on the recommendation formula; we calculate absolute linkage to know the percentage of items from a measure that could be linked to ICF codes (Number of items linked to a code (s) appearing in the Core Set/ Total numbers of the item in a measure ×100%)), Core Set Representation ((Number of unique ICF codes from the measure that appear in the Core Set/total number of the codes in coreset) ×100%), and Core Set Unique Disability Representation ((Number of unique ICF codes from the measure that appear in the Core Set/total number of the disability codes in core set) ×100%) [25] (Table 2).

Phase three: Classification using IPF
We linked the contents of psychological functioning, the experience of emotions or the impact of negative thinking, which were important for patients with the Item Perspective Classification (IPF) [23].The extracted meaningful concepts from the interviews were classified based on the guidelines proposed by Rosa et al.  [23].In the first step, the context of the meaningful concept was determined, and the type of appraisal presented with the concept (rational or emotional) was identified.Extracted concepts were classified as either "emotional" or "rational" appraisals [26]."Emotional" appraisals (E) were used when the concept was related to the patient's emotions or feelings at present time.Any inquiries into emotions/feelings that have occurred in the past or "in general" were classified as rational appraisals (R) since they require retrieval of memories of previous psychological states.
At the second step, we identified the concept domains represented in extracted meaningful concepts.Based on the IPF framework, four concept domains represent all subjective and objective evolutionary levels of reality that are amenable to human perception, namely inorganic (I), for example: " Does your chair have a proper armrest?:, biological (B), for example, "rate the level of your pain?," social (S), for example, "if the pain affected your social life?" or psychological (P), "do you feel depressed or feel less capable because of your pain?" [27].
In the final step, the relationships between two or more concepts presented within a meaningful concept were identified and described.We used the symbols to classify the nature of relationships, including interactive relationships "*, " "no relationship." Vague, unclear concepts were classified as "open-ended" ("X").

Themes
The present study aimed to provide a comprehensive overview of the functional problems faced by breast cancer (BC) survivors, as well as to identify the factors that act as facilitators and barriers to their functioning.The data was obtained through interviews with BC survivors and specialists who had experience working with this group of patients.A total of 849 initial codes were extracted, from which 660 (78%) codes were related to functioning in BC survivors.
Nine subthemes were identified that defined the factors contributing to functioning in BC patients.These subthemes included factors related to impairment, physical function, mental function, social life, self-perception, emotional interactions with family and friends, cost of treatment, health system, and personal emotions.The subthemes were further categorized into four main themes, including body functioning (189, 29%), physical functioning (186, 28%), social functioning (108, 16%), and mental functioning (177, 27%).
In addition to the functional codes, we also identified other factors that acted as modifiers affecting the level of function.These modifiers were categorized as personal, emotional, and environmental factors.The findings of this study emphasize the importance of considering the multidimensional aspects of functioning in BC survivors and highlight the need for tailored rehabilitation interventions that target the specific needs of these patients (Table 3).

Body functioning
The most reported impairments that were problematic for patients in this study were pain, sensation (74 extracted codes which compromised 39% of entire body function and structured codes) and fatigue (57 extracted codes which compromised 30% of entire body function and structured codes).Sixteen patients (P) and 21 experts (E) reported problems with pain, sensation, fatigue, lymph, skin, heart, and respiratory dysfunctions.
"I have pain in my axilla and side of the affected side" (P12: 21 months since surgery), "I have severe pain in the scapula of the affected side "(P16: one year after surgery), ("Pain in the shoulder area, pain in the chest and back, pain in the arm, pain in the lateral part of the trunk and sides, pain in the axilla, neck pain due to the heaviness of the hand edema."(E11: 5 years of experience in surgery)

Physical functioning
The study identified the most common physical functioning problems reported by patients with disabilities.The most frequently reported issues were related to difficulties in performing self-care, including basic Activities of Daily Living (ADL) such as bathing, dressing, grooming, toileting, eating, and transferring oneself from one place to another, as well as more complex Instrumental Activities of Daily Living (IADL) such as shopping, cooking, managing finances, using transportation, and performing household chores.Seventy-three codes (39% of the body's functional ICF codes) were extracted in this category.
Patients also reported difficulties in sexual (38 extracted codes, 20% of the entire contents of ICF in body functioning), overhead functioning (29 extracted codes, 16% of the entire contents of ICF in body functioning), weightlifting (27 extracted codes, 14.5% of the entire contents of ICF in body functioning), manipulation and pushing (10 extracted codes, 5% of the entire contents of ICF in body functioning), and sleep (9 extracted codes, 5% of the entire contents of ICF in body functioning).These problems were directly related to the patient's impairment level, including pain and sensation, fatigue, and lymph.
Among the categories, problems with self-care, ADL, and IADL were more commonly reported by both groups of participants (16 patients and 16 experts).Household chores such as dusting, cleaning, washing dishes, making the bed, and sweeping received more complaints.
Overall, the study highlights the challenges faced by patients with disabilities in their daily lives, particularly concerning self-care, ADL, and IADL.These findings underscore the importance of addressing these issues in rehabilitation and support services to improve the quality of life for patients with disabilities.
"I cannot clean and dust the house with the injured hand due to heaviness, edema and pressure on the hand" (P14)."By doing repetitive tasks such as sweeping, the hand becomes swollen" (E7: 5 years of experience) and "they are unable to do continuous housework."(E2:10 years of experience) "I am much slower in housework.I am not as hard as I used to be working and living; I cannot go up the stairs quickly, for example, I cannot do housework in a row; whatever I do, I must sit for a quarter to twenty minutes to find some energy to start the next work again."(P2: under 1 year since surgery) Ever since I got sick, I have felt sad and sad about the future of my family life as I cannot support them anymore and I cannot do even my self-care; I think I have been depressed" (P13: 2 years since surgery)" I'm sad that I cannot have the previous routine of my life.(P12: 21 months since surgery)

Social functioning
The study identified a total of 108 extracted codes related to different areas of life experienced by patients with disabilities.Most of the problems in the social functioning category were raised by 15 patients and 20 experts, which accounted for 59 codes (55% of the whole ICF social functioning).The other areas identified were leisure and sport (20 codes, 18.5%), work (18 codes, 17%), religious (10 codes, 9%), and driving (1 code, 1%).The problems reported by both patients and experts indicated that the level of impairment and physical functions are significant factors contributing to difficulties in these areas.Notably, the most common problem in social functioning was "Spousal relationships such as intimate and sexual relationships." These findings highlight the various challenges faced by patients with disabilities in different areas of their lives.Therefore, a comprehensive approach to rehabilitation and support services is necessary to address the diverse needs of patients with disabilities.
"Sex with my wife was interrupted because my body's ability and endurance were deficient; then, the menopausal symptoms bothered me a lot; the injections I was taking to disable the ovaries and uterus bothered me a lot." (P2: under one year since surgery)."Decreased sexual intercourse with the spouse and dissatisfaction with sexual activities due to a disorder in the body's appearance and hiding one's appearance from the spouse, discomfort in bed during sexual intercourse due to swelling of the hands and trunk."(E15: 10 years of experience)

Mental functioning
The study identified a total of 10 extracted codes related to mental functions mentioned by two patients and five experts.These codes were related to problems with attention, concentration (5 codes, 50% of the extracted codes), and memory and amnesia (5 codes extracted which accounted for 50% of the entire ICF codes) in daily tasks.
The content of mental functions also revealed that breast cancer survivors experienced various negative emotions such as loneliness, concerns about the disease's impact on personal life, worry about the disease's future, feelings of guilt, hopelessness about the future, among others.The reciprocal relationship between difficulties in performing ADL, IADL, and self-care with emotional problems was also evident.Patients reported negative emotions in response to their level of functioning in self-care, ADL, and IADL.They also expressed that they cannot perform their functional activities due to emotional problems.

Modifiers of function
We also extracted codes that were modifiers of functioning and categorized them into three themes: environmental, personal, and emotional factors.

Environmental factors
Factors related to the costs of treatment.The study also investigated environmental factors that may impact breast cancer survivors' ability to access necessary treatments and support systems.Eight patients and 18 experts reported problems related to the costs of treatment.The extracted codes in this theme included the high cost of treatment (20 codes extracted, which were 41% of the whole ICF environmental factors), lack of insurance coverage for some drugs (13 codes, 26.5%), difficult access to some drugs (7 codes, 14%), and a lack of support systems and charities in the community to pay for assistive devices such as breast prostheses, bandages, and pressure gloves (9 codes, 18%).These findings highlight the financial burden faced by breast cancer survivors and the need for accessible and affordable healthcare options.

Factors related to health systems.
The study conducted by nine patients and 14 experts revealed 13 extracted codes related to environmental factors classified as factors related to the healthcare system.The most commonly reported problem was the "insufficient information about the disease and its treatments from treatment team members" and the "lack of support, understanding, and accompaniment of the patient treatment team," accounting for 26% of the whole ICF codes for the environmental factors.
Concepts related to health systems in this study by breast cancer survivors and specialists mainly indicated deficiencies in providing psychological and palliative services, educational programs, and screening of healthy women.In many cases, there was also a poor understanding and support of the treatment team in informing patients, which could be an inhibitor in improving the performance of these women.
Women are not trained to examine their breasts; if this is done, it will cause women to come sooner, and their disease condition will not worsen, and they will not have to have their breasts removed completely.(P8: under 1 year since surgery)

Personal and emotional factors
Factors related to personal emotions.According to the study, personal and emotional factors were associated with 48 extracted codes, as reported by 15 patients and 21 experts.The two most common issues in this domain were a "sense of distress and sadness," which accounted for 26 codes (54% of the personal and emotional factors codes), and a "sense of fear and fear of relapse," which accounted for 22 codes (46% of the personal and emotional factors codes).Negative emotions experienced by breast cancer survivors included a sense of loneliness, concerns about the disease's impact on their personal life, worries about the future of the disease, feelings of guilt, and hopelessness about the future.The most frequently mentioned negative emotions by patients were a sense of distress and sadness and a sense of fear and fear

Frequency experts
Factor related to health system (50) [patient (9), experts (14)] insufficient information about the disease and its treatments from treatment team members of relapse.They reported that these negative emotions affected their ability to perform self-care, activities of daily living (ADL), and instrumental activities of daily living (IADL).
"I am sad that I cannot have the previous routine of my life (P12: 21 months since surgery).Ever since I got sick, I have felt sad and sad about the future of my family life; I think I have been depressed" (P13: 2 years since surgery) .(The patient becomes depressed and isolated due to a change in their breast appearance and edema of the hand., they feel uncomfortable with the tightness of the clothes she has already worn with the swelling created in her hand."(E9: 5 years of experience) "I am always stressed by the negative impact of chemotherapy and cancer" (P12: 21 months since surgery)."I am afraid of disease and death" (P8: under 1 year since surgery)" Patients have stress and anxiety due to not returning to normal life activities (whether housework or work activities) and are also afraid of leaving their spouse and remarrying."(E15: 10 years of experience) Factor related to self-perception.Out of all the ICF codes related to personal and emotional factors, 46% of the extracted codes were related to problems in self-perception.Specifically, four patients and 19 experts reported such problems.The most common complaint in this area was related to body scheme, which accounted for 17 codes, which are equivalent to 46% of the total codes for emotional factors in the ICF.These issues included changes in appearance resulting from the removal of all or part of the breast, as well as swelling caused by the removal of lymph nodes, which affected the individual's mental image.
The impact of self-perception on communication in social life was also highlighted.
"I was afraid of the bad reaction of my children and my wife to the mutilation and removal of my breast" (P2: under one year since surgery)" Young women felt the loss of physical beauty and acceptance of breast resection."(E16: 8 years of experience) Factors related to emotional interactions with family and friends.Twelve patients and 18 e3xperts reported a total of codes on personal and emotional factors related to problems in emotional interactions with family and friends.These codes accounted for a certain percentage of the overall ICF codes related to personal and emotional factors.The most frequently reported problem in this category was a lack of help, accompaniment, and support from spouses, children, and family members in daily activities, with a total of 21 codes, equivalent to 40% of the codes related to emotional interactions with family and friends.Participants expressed their concerns about emotional interactions, help, and companionship with those who interacted with them in the family and community environment.Some patients reported negative feelings due to incorrect judgments about their capabilities or receiving excessive support or compassion.The most common concept mentioned by patients and specialists in this theme was the need for help, accompaniment, and support from spouses, children, and family members in daily activities, which played a significant role in their emotional interactions with others.
"Sometime after my illness, my wife refused to accompany me, and I even paid for the hospital myself, "everyone around me was kind of tired, or I finally gave up, and after two years, I was left alone." I need someone to accompany me for chemotherapy.I called my relatives to be by my side, but they refused, so I am alone for about 7 or 8 sessions now."(P2: under 1 year since surgery).
We also extracted some extra 30, 3.5% codes that could not be classified as functioning directly; however, they could be considered facilitators or barriers to functioning in BC survivors.Most of the extracted codes were related to coping strategies (19, 63% codes), level of literacy and education (6, 20% codes), and personal views and attitudes toward illness and life (5, 17% codes).
For example, some patients stated that their perception of life had changed for the better: "My outlook on life and the world has changed since I became ill, and I try to enjoy my life more and increase my satisfaction with life and the present" (P7:1 year since surgery), or another patient would say, "After the illness, I try to enjoy more of my free time with my family."(P12: 21 months since surgery) Experts also indicated that individuals' literacy levels sometimes helped them benefit from educational facilities (brochures or YouTube links).However, interviews revealed that patients with lower literacy levels were better able to cope with their illness.In contrast, patients with higher literacy levels were more stressed.Some patients indicated that they tried to change their lifestyle to cope with the illness.They increased the time in their leisure time and tried to have healthy eating and practice doing their self-care independently.
"I think doing my self-care can help me a lot.Everyone should take care of themselves so that one does not take care of oneself and cannot expect from others.For example, I now regularly take my medicine, regularly check with my doctor, or communicate and reach Completely to the sport that I have at home" (P1: 20 months since surgery) " After the illness, my compatibility has improved to cope with the appearance of my body.I listen to music to increase my peace of mind and reduce my mental distress."(P16: under 1 year since surgery) (Figure 1)

Extracted meaningful concepts from the interview with breast cancer survivors
Of the 338 concepts extracted from patient interviews, 146 (43%) concepts were linked with the ICF Body function and structure, 121(36%) to activity and participation, 44(13%) to environmental factors and 11 (3%) to personal factors category.
Some of the raised difficulty areas from the patient's view could not be linked with any codes and categories of the core set for breast cancer.However, they were linked to eight codes from body function and 14 codes from activity and participation (Table 4).
The other 27 concepts could not be linked to the ICF.The content of the meaningful concepts, which could not be assigned to the most precise ICF categories, were classified into three concepts based on the updated linking.The concept refers to mental health (nd-mh: Sense of losing the beauty of appearance, Sense of loneliness, feeling guilty, sense of hopelessness about the future, Sense of disability and disablement and Sense of failure in performing tasks and duties) and concepts that cannot be covered by the ICF (nc; non-coverage of treatment costs by health insurance firms), and the concepts referred to personal factors(one's lifestyle) (Table 4).
The other 47 concepts could not be linked to the ICF.The content of the meaningful concepts, which could not be assigned to the most precise ICF categories, were classified into three concepts based on the updated linking.The concept refers to mental health (nd-mh: Sense of losing the beauty of appearance, Sense of loneliness, feeling guilty, Sense of burdensomeness and inattention in the family, Sense of hopelessness about the future, Sense of disability and disablement, mental fatigue) and concepts that cannot be covered by the ICF (nc; non-coverage of treatment costs by health insurance firms), and the concepts referred to personal factors(one's lifestyle, levels of education and literacy) (Table 5).
In total, 592 meaningful concepts were linked with at least a comprehensive ICF Core Set category for BC, resulting in an absolute linkage score of 70%.Thirty-eight meaningful concepts were linked with a unique code comprehensive Core Set for BC, resulting in a unique linkage score of 4%.Concepts extracted in this study represented the Core Set for BC with 47% of coverage.The disability representation score for the extracted concepts was 61%.

Classifica3tion of the extracted meaningful concepts based on IPF
Two hundred seventy-one concepts from the interview with patients and 398 concepts extracted from the interview with specialists required rational appraisal.In contrast, 67 concepts from the interview with patients and 113 meaningful concepts extracted from the interview with the specialist required emotional appraisal.
Out of 271 Concepts from the interview with patients which required rational appraise, 195 concepts fell within the biological (B) domain, 34 concepts in the social (S) domain, 11 concepts in the psychological (P) domain, 18 concepts in the Inorganic (I) domain and 13 Concepts in open-ended (X) domain.41concepts of the biological domain (B) were interactively related to this domain (B*B), and 19 other concepts of this domain were related to Social (S) domain (B*S).
Also, out of 67 concepts from interviews with patients which required emotional appraise, 58 concepts were classified in the domain of Psychology (P) and nine concepts in the domain of Biology (B). 9 concepts of the biological domain (B) were related to concepts of the psychological domain (P)(B*P), and 16 of the concepts of Psychological (P) were related to concepts of the social domain (S) (B*S).
Among the 398 meaningful concepts extracted that required rational appraise from interviews with experts, 255 concepts fell in the biological (B) domain, 71 concepts in the social (S) domain, 14 concepts in the psychological (P) domain, 41 Concepts in Inorganic (I) domain and 17 concepts in open-ended (X) domain.Thirty-eight concepts of the biological domain (B) were interactively related to this domain (B*B), and 42 other concepts of this domain were related to the social(S) domain (B*S).
Also, out of 113 concepts from the interview with experts that required emotional appraisal, 105 concepts were classified in the psychological domain (P) and eight in the biological domain (B).Eight concepts of the biological domain (B) were related to the concepts of the psychological domain (P) (B*P), and 22 of the concepts of Psychological (P) were related to the concepts of the social domain (S) (B*S).
The domains of concepts and their relationships are presented in Tables 3-5.In the patients' chart, 60% of the extracted concepts were related to the biological (B) domain.Among the concepts appraised in the biological domain, 41% were classified as "No-related," which indicated no relationship between 41% of the biological concepts and other concepts.In contrast, 19% of the concepts appraised in the biological domain provided dynamic/ interactive relationships with biological concepts(B*B) (12%), social concepts (B*S) (5%), and psychological concepts (2%).
In the experts' chart, 51% of the extracted concepts were appraised to the biological (B) domain.Among the concepts appraised in the biological domain, 34.5% were classified as "No-related," which indicated no relationship between biological concepts and other concepts extracted from medical specialists.In contrast, 16.5% of concepts appraised in the biological domain provided dynamic/interactive relationships with biological concepts (7%), social concepts (8%), and psychological concepts (1.5%).

Discussion
In this study, we aimed to use the ICF core set for breast cancer to identify areas of functioning in breast cancer survivors from the perspectives of both patients and specialists.Our results showed that breast cancer survivors reported impairments in body functions and structures, activity limitations, and participation restrictions that were different from what experts defined as functional problems in this population.Patients reported difficulties in mobility, support, relationship, and mental function, while experts considered emotional problems as the cause of physical function limitations in breast cancer survivors.
BC survivors experience problems and difficulties in response to changes in their body function and structure, affecting their level of function and interaction with society.Most of their problems were related to support, relationship, mental function, and mobility.Patients reported problems in mobility; however, the experts considered emotional problems as a cause for physical function limitations in breast cancer survivors.The results of linking the extracted meaning concepts with IPF [23] showed that patients had problems in the biological (B) domain, which required emotional appraisal and were categorized in the field of Psychology (P).Both groups indicated that problems in support and relationship and attitudes are the most prominent aspect of difficulties in this population.
This study identified problematic body function and structure, which affected the functioning of the patients.The research participants reported problems in different categories in the current version of the comprehensive core set.Besides, similar to previous studies, additional ICF categories were identified that are not currently included in the Comprehensive Core Set for breast cancer [10].Previous qualitative studies also reported similar problems extracted from interviews with patients and experts, such as reduced physical ability and fatigue during daily living and working activities [17], skin problems such as skin discoloration, darkening, dryness, thinness, tightness, and changes in nails [16,28], respiratory problems such as dyspnea and severe cough, and heart problems [14,16].Like previous studies, we also identified cognitive and emotional problems, such as attention and concentration problems, memory problems, and amnesia resulting from chemotherapy and hormonal therapy, affecting the patient's daily activities [14,16,17,29].
Our study identified several issues that were not included in the current ICF core set for breast cancer, such as difficulties with completing long-term movements with fingers and wrists, grasping fine/small objects by hands, maintaining a lying position on the affected side, and numbness.Including patients in the chronic phase may have contributed to these differences, as, they may  be experiencing ongoing emotional and psychological difficulties that are not currently captured in the ICF core set for breast cancer.These problems were also identified and reported in previous qualitative studies on patients with BC [14][15][16].This difference between extracted concepts and categories of ICF core set for BC can be due to differences in participants in different studies.
The ICF core set for BC was generated from interviewing women with BC in their acute phase after surgery; however, this study and some other validation studies of the ICF core set for BC interviewed patients in their chronic phases [10].In the chronic phase, psychological and emotional problems also affected the level of function; however, they could not be linked with any ICF categories related to mental health and psychological problems.
The results of the current study showed that women with breast cancer experienced difficulties participating in gatherings such as attending meetings, religious ceremonies, friendly and formal parties, the workplace, and communicating with others, which are absent in the ICF core set for breast cancer.Other studies on cancer survivors have shown that this population faces challenges in sexual activity, sleep, leisure participation, exercise, and education which caused changes in their family roles, loss of relationships and the deterioration of their social roles [15,16,30].In contrast with other studies on BC patients, this study reported problems in their leisure and sport participation, which was not reported in patients in the early stages of the disease [14][15][16].Including patients in the late stages of their diseases increases the frequency of difficulties in their participation.
High costs of treatment, financial inability to provide assistive devices such as breast prostheses, bandages, and pressure sleeves, lack of support and accompaniment from employers, such as employers' understanding of the patient's disease, and inaccessibility of disease-related training programs and its treatments at hospitals and treatment clinics such as group therapy programs were reported by experts and patients in this study.Some additional factors in environmental-personal factors categories were raised, which may act as barriers to functioning or assisting with everyday living.Among these, the codes "e330 People in positions of authority" and "d870 Economic self-sufficiency" were also identified in previous studies that validated the ICF core set for breast cancer [14][15][16].
In the interviews of most participants in this study, religious beliefs were considered a facilitating and influential factor in improving their disease and performing their functions, which was reported in previous studies [31].However, in some cases, they stated that cancer development caused the breakup of their beliefs and religious systems.The multitude of emotional concepts in this study suggests that emotional issues play a pivotal role in defining their functioning despite the treatment completion and the disease's stability, even after 2-3 years of initial treatment.Evidence shows that the BC survivors are concerned least with one emotional problem experienced as a fear of relapse, sense of sadness, emotional turmoil, identity problems, anxiety, and depression, which may be experienced years after diagnosis [28].In addition, treatment or disease progression can cause a range of neuropsychological consequences (e.g., anxiety, depression, sexual dysfunction, and body image disorder) [30,32,33].
Interpretation of the functioning of breast cancer patients differed between patients and experts in this study.While both groups agreed on reporting difficulties related to body function and structure categories, as well as the influence of emotional and psychological factors, a disagreement was found in the ICF activity and participation category.Patients reported challenges with mobility, whereas experts identified problems in patients' interpersonal and social relationships.Additionally, both patients and experts identified support, relationships, and attitudes as influential factors in patient functioning.These findings suggest that a multifaceted approach, which considers the perspectives of both patients and experts, is necessary for understanding and assessing the functioning in breast cancer survivors.Previous studies defined functioning as a problem in body function and structure via the lens of experts, physiotherapists, and oncologists [14,17].However, patients raised difficulties in other areas of function, such as participation, social interaction, and emotional problem.The patient has reported results that provided valuable information about disorders in the mental, energy, sexual, and pain levels [34].The results reported by experts provided more valuable information about physical disorders (edema).Activity restrictions and participation restrictions can be obtained through self-report or observation reports.
Definition of functioning varies between different specialists and differs from the patients' view and interpretation.Difficulties in "body structures" categories are mainly limited to surgeons, medical oncologists, oncology nurses, and physiotherapists.On the other side, psychologists and social workers mainly raise problems in the "Activities and Participation" and the "environmental factors" sections [35].In the early phase of the disease, the most important issues for patients are using bandage socks, the shape of movement-related structures and the support and relationships.However, experts consider problems in health services, systems, and policies; besides the immune system function, looking after one's health, products, and technology for personal use in daily life, and dressing affect the function of BC survivors [36,37].
Our study interviewed both physicians and rehabilitation teams to define health and function in BC survivors comprehensively.Involving both health professionals and patients in this study elucidates the definition of health and function in BC survivors from different perspectives.

Strengths and limitations
This study aimed to identify the functional problems of breast cancer survivors using the International Classification of Functioning, Disability, and Health (ICF) framework.A particular emphasis was placed on gathering the perspectives of rehabilitation specialists and patients to gain a more comprehensive view of the patient's functional issues.In this section, we will discuss the strengths and limitations of this study.
One of the major strengths of this study was the involvement of rehabilitation specialists and patients in identifying the functional problems of breast cancer survivors.The study gained a more nuanced understanding of the patient's experiences by including these experts' opinions.Moreover, the use of the ICF classification allowed for a comprehensive and standardized approach to evaluating the functional problems of these patients.
Another strength of this study was its potential to improve the evaluation, prevention, and treatment strategies for breast cancer survivors.By identifying the major functional problems experienced by these patients, healthcare providers can develop targeted interventions to improve their overall quality of life.
Despite these strengths, the study had limitations.One significant limitation was the inability to conduct face-to-face patient interviews due to the Covid-19 pandemic.As a result, the findings may not be generalizable to all breast cancer survivors, particularly those in different countries or cultures.Cultural differences may influence how patients perceive and describe their level of function, and these findings may not be generalizable to other cultural contexts.Further research could be conducted to examine the relationship between cultural factors and the description of function in breast cancer patients across different countries or regions.
Another limitation was the lack of involvement of physician specialists in rehabilitation medicine in the study.Although efforts were made to include these experts, time constraints and other obstacles prevented their participation.As a result, the study may not have fully captured the perspectives of all medical experts with experience treating breast cancer survivors.
In conclusion, this study has provided valuable insights into breast cancer survivors' functional problems, particularly through the ICF classification and perspectives from rehabilitation specialists and patients.While there were some limitations, such as the inability to conduct face-to-face interviews and the lack of participation from physician specialists in rehabilitation medicine, the study's strengths suggest that it can inform future research in this area and guide the development of more effective interventions for breast cancer survivors.

Conclusion
The main functional problems of breast cancer survivors raised by the patients and experts participating in this study were difficulties in body functions.They indicated that the emotional and psychological issues determined the functioning of this group of patients.The patients indicated problems in their mobility, but the specialists reported that the significant issue in the BC survivor's functioning is in their interpersonal and social relationships.Also, in the environmental factors category, both participants mentioned support, relationship and attitudes as the most influential factors in patient functioning.Psychological and emotional factors define functioning in patients with BC.Different issues in the functioning of the BC survivors are not covered by the ICF core set for BC.

Figure 1 .
Figure 1.interactions between the components of iCF.
2)What actions can you not do during the day, or what actions make you feel uncomfortable?alternatively, what actions make you feel most irritated?"3) What factors can help you cope better with your condition?or what are the factors that make you perform better?"or what factors are making your functional condition worse?" 4) What factors hold back your progress in doing your actions? or what factors stop you from doing your actions better?4) What factors hold back your progress in doing your actions? or what factors stop you from doing your actions better?

Table 1 .
Demographic characteristics of patients and experts.

Table 2 .
Formulas for iCF linkage coverage.
number of unique iCF codes from the measure that appear in the Core set/total number of the codes in coreset ×100% Core set unique disability representation number of unique iCF codes from the measure that appear in the Core set/total number of the disability codes in core set ×100%

Table 3 .
Frequencies of main themes, and initial codes (core codes) of functioning in patients and experts.
5 non-coverage of treatment costs by health insurance firms 2 Financial inability to provide assistive devices such as breast prostheses, bandages, and compression sleeves (use of support systems or donors to undertake treatment costs) 2 total 14

Table 4 .
iCF categories and iPC linked to the meaningful concepts were obtained from the interview with breast cancer survivors.

Table 5 .
iCF categories and iPC linked to the meaningful concepts were obtained from the interview with medical specialist.