Participants were board certified breast specialists with a track record of treating breast cancer with chemotherapy in Japan. In Japan, doctors who specialize in this area tend to be surgeons rather than oncologists, and perform diagnosis, surgery, and chemotherapy. In selecting participants, we performed theoretical sampling combined with snowball sampling and, in order to collect data in as wide a range as possible (in terms of affiliated hospital size, record of treating patients, personal history and gender, and access to resources in palliative medicine). All participants gave their written informed consent for participate in this study. This study was approved by the research ethics committee of the University of Tokyo Faculty of Medicine (No. 10,317).

Data collection

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All interviews were conducted by one of the authors (ROH). ROH is a physician and has experience working in a department of palliative medicine, and holds a PhD in qualitative research, and thus is well versed in qualitative studies. In terms of participant background (Table 1), there were 16 men and 5 women, with a median age of 48 years (range, 35–56 years). Semi-structured interviews were conducted in a private room to ensure privacy, for an average of 86 mins (range, 70–120 mins).

(To view a larger version of Table 1, click here.)

An interview guide was created based on previous research on diverse cancer patients as well as pilot interviews to breast surgeons. Participants were questioned about their thoughts and experiences about their practices of deciding chemotherapy for breast cancer recurrence/metastasis. During a later phase of the study, the interview guide was revised to include questions about communication with patients and family members regarding prognosis (Box 1).

Data analysis

All interviews were audio taped and transcribed verbatim. The process of data collection and analysis followed the Grounded Theory Approach.7 Verbatim records of interviews were analyzed using ATLAS.ti.7.1.7 (Science Software Development GmbH, Berlin). Open Coding, Axial Coding, and Selective Coding were performed. Concepts were generated to explain the decision-making process of doctors regarding chemotherapy, and additional data were collected to develop these concepts. Data collection and analysis were continued until theoretical saturation was reached.7 To ensure credibility of the analytical process and analytical results, periodic peer debriefings were held with colleagues who conduct qualitative research.8 In addition, member checks9 were conducted, ie, the authors explained the preliminary analysis report to two participants for feedback.

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