Nineteen patients diagnosed with MBC (Mage = 55. 95; SDage = 6.87 min. 46–max 70) with different metastasis localizations were involved (Table 1). A total of 42.1% (8) of the patients had no familiarity with breast cancer, while 52.6% (10) had a familiarity with first grade and 5.3% (1) of second grade.

The following four themes emerged from the focus groups: theme 1—individual clinical pathway; theme 2—barriers to adherence to OATs; theme 3—resources to fulfill adherence to OATs; theme 4—patients’ perception of new technologies supporting adherence to OATs (Tables 2 and 3).

Of the nine existing sub-themes within theme 1—“individual clinical pathway,” the most frequent words belonged to two sub-themes, namely, “clinical course” and “side-effects,” indicating that these sub-themes are the most significant in the MBC patients’ experience of OATs. Notable terms that stand out prominently in the word cloud included different elements of the cancer pathway (therapy [n = 16], metastasis [n = 6], specific drugs (respectively, ribociclib [n = 6] and letrozole [n = 4]), and surgery [n = 4]) (Fig. 1). The most frequent words within theme 2—“barriers in the adherence to OATs” were as follows: “side effects” (n = 4), “stomachache” (n = 3), “problems” (n = 4), “lost hair” (n = 3). The higher frequency of these terms suggested the critical role of the specific type of side effects and psychological reactions as potential barriers to regular intake of the prescribed therapy. Further, the terms “physicians” (n = 3) and “oncologist”([n = 2) are present in the context of the patient-doctor relationship, especially concerning ineffective communication and continued changing physicians through clinical follow-ups (Fig. 2).

Wordcloud is based on the most recurring words on theme 1—“individual clinical pathway.” In the Wordcloud, words are displayed in different sizes based on their frequency of occurrence. More prominent words indicate a higher frequency of occurrence, while smaller words indicate a lower frequency

Wordcloud is based on the most recurring words in theme 2—“barriers in the adherence to OATs”

The key terms central to theme 3—“resources to fulfill adherence to OATs” highlighted possible internal and external resources patients use to increase adherent behavior (Fig. 3). In particular, the terms with a higher frequency of occurrence have been “physicians” (n = 6) and “psychologists" (n = 5) suggesting the pivotal role recognized by the patients in supporting adherence to OATs. Besides, the analysis highlights common cancer-related coping strategies, such as “moving forward despite difficulties” and “adopting healthy lifestyles,” such as “having a more active life.” Another relevant term within this theme is “diet” (n = 5), which refers to dietary adjustments that might help with treatment adherence to OATs, fostering overall physical well-being and counteracting the disease. Remote clinical consultations (the use of mobile applications or telemedicine) were also frequently mentioned as possible helpful aids in bolstering adherence.

Wordcloud is based on the most recurring words on theme 3—“resources to achieve adherence to OATs.”

The Wordcloud in Fig. 4 visually represents the most recurring words related to theme 4—“patients’ perception of new technologies in supporting adherence to OATs.” This Wordcloud analysis provides a concise yet informative overview of the human and technological resources that can support adherence. In particular, the most common words were “phone” (n = 3), “doctor” (n = 3), “person” (n = 3), and “support tool” (n = 2) and verbs related to information or knowledge such as “to know” (n = 3), “to find” (n = 3), and “to see” (n = 2). These nouns and verbs highlighted that new technological tools might permit oncologists and psychologists to seek supportive information quickly, improving the sense of community and social support to help each other.

Wordcloud is based on the most recurring words on theme 4—“patients’ perception of new technologies in supporting adherence to OATs.”

Clinical factors, therapies, trust, simplicity, types of side effects, and minimal side effects are the central categories of theme 1, which concerns patients’ experiences with OATs. These elements are part of the subthemes in Theme 1: patient clinical pathway, side effects, treatment management, and trust in the treatment. The centrality of these categories in the patient’s experience of OATs underscores the importance of the type and intensity of side effects, the ease of treatment management, and trust in the treatment as potential determinants of adherence to OATs. The set of keywords associated with each category forms a cluster (greenish background). These keywords are fragments of the emerging themes that have been preprocessed and tokenized. Some words integrate different categories within the theme (Fig. 5).

Network analysis showing the connection and recurrence between the main categories (blue) and the keywords (red) in theme 1

The central category in theme 2 related to barriers to adherence to OATs is psycho-emotional distress, which means symptoms of stress, anxiety, and depression arising from treatment, precisely elements categorized as discontinuity of doctor in charge of the patient care, types of side effects, psychological reactions, clinical results, hospital visits, lack of understanding about the treatment and poor communication with doctors (Fig. 6). All these elements were characterized as barriers to adherence to oral treatment and were directly related to patients’ psycho-emotional distress. A deeper analysis of the integration between these categories reveals the keywords that provide more detail about the emerging themes related to barriers to adherence.

Network analysis showing the connection and recurrence between the main categories (blue) and the keywords (red) in theme 2

The central categories in the theme of facilitators of adherence to OATs (Theme 3) were strategies related to coping with the disease and the adversities arising from therapy, with the central element of adjusting the dose or time of taking the medication. Another category central to the theme was trust in the doctor, which was directly related to the continuity of the doctor, effective communication, the doctor’s humane behavior toward the patient, and reassessment of side effects. This last category had direct associations with diet advice and the possibility of accessing relevant and reliable information about the OAT and its management. Several peripheral categories were also crucial for the topic because they relate to central categories. This was the case for support groups, lifestyles, and remote consultations (telemedicine) (Fig. 7).

Network analysis showing the connection and recurrence between the main categories (blue) and the keywords (red) in theme 3

The network analysis in Fig. 8 illustrates patients’ perceptions of using technology as a facilitating resource for oral treatment adherence (theme 4). The central category in this theme was the sense of community and social support, which refers to the sense of belonging that patients experience when they participate in support groups with other patients having the same disease. Patients understand these virtual communities as an essential strategy for sharing positive experiences, which can be helpful as a form of support and a relevant way to access information and educational content. However, doubt and skepticism about the usefulness of technological tools for treatment adherence were issues present in this theme. The categories of coping strategies and patient-doctor communication, which were relevant in the network analysis of theme 3 (facilitators—Fig. 7), were peripheral in this theme, suggesting that patients may not see the technological tools as a facilitating resource for oral treatment to date.

Network analysis showing the connection and recurrence between the main categories (blue) and the keywords (red) in theme 4

Fear was the most common emotion observed in responses to questions about the OAT experience. This emotion was particularly associated with the categories of “therapy,” “medication,” and “patient clinical factors” (Fig. 9). On the other hand, joy was the least expressed emotion, especially in the categories central in the network analysis for theme 1 (Fig. 5), appearing in the context of simplicity of treatment and trust in the chosen treatment.

Circular relationship between emotions and category for theme 1

For theme 2, which dealt with existing barriers to adherence, the most predominant emotion was fear (Fig. 10). This emotion was particularly present for problems related to clinical values, side effects, and issues associated with the doctor-patient relationship, specifically ineffective communication, and discontinuity of the doctor in charge of the patient care. Besides, feelings of anger and sadness were frequently expressed in the category of types of side effects, highlighting the importance of this aspect as a barrier to adherence to oral treatment.

Circular relationship between emotions and category for theme 2

Compared to the other themes, theme 3, which addressed facilitators of treatment adherence, showed a decrease in feelings of fear and increased expressions of joy, which were balanced (Fig. 11). Within this theme, joy was closely related to nurturing thoughts about coping with cancer daily. In addition, joy was experienced when mentioning the physician’s humane dimension in treating patients.

Circular relationship between emotions and category for theme 3

Regarding patients’ perceptions of the use of technology as an adherence support strategy, the most predominant emotion was joy (Fig. 12), primarily related to the central category of this theme revealed in the network analysis (Fig. 8): sense of community and social support. Despite doubts and skepticism about the theme of technological resources, they were not associated with negative emotions such as fear and sadness but rather with joy. This emotion was also widely expressed in narratives that included sharing experiences with other patients in the same condition and acquiring information and educational content (Fig. 12). Categories not associated with the emotion of joy in this theme but present in theme 3, facilitators of adherence, were coping strategies and doctor-patient communication (Figs. 7 and 11). Although these elements were considered facilitators of oral treatment adherence, they were not associated with the emotion of joy in the context of technological resources, demonstrating less impact of technological tools in the patient-doctor relationship.

Circular relationship between emotions and category for theme 4