Introduction
Older people account for a significant percentage of cancer cases and deaths. Older people with cancer not only suffer from the disease, but also face other age-related health problems that negatively affect their self-care ability. Family caregivers play an important role in caring for these elderly people. Caring for older people with cancer is very complicated and difficult and affects the health of family caregivers. Several studies have emphasized the importance of developing support programs and interventions for these caregivers. However, studies acknowledge that assessing the needs of family caregivers precedes any effort to develop supportive interventions for them. Information on the support needs of family caregivers of older adults with cancer in Iran is limited. Therefore, the present study aims to investigate the support needs of family caregivers of older people with cancer.

Methods
This is a qualitative study using conventional content analysis method. The study population included family caregivers of older people with cancer, the family members of caregivers, and their health care providers. Participants were selected from the Iranian Cancer Control Center, one private hospital, and five public hospitals in Iran using a purposive sampling method. Data were collected by in-depth semi-structured interviews. The interviews started with general and open-ended questions and continued with more specific questions based on the answers provided by the interviewees in order to achieve the main goal of the research. For example, family caregivers were asked “what support needs have you faced because of your role in caring for the elderly patient?”. Family members of caregivers and health care providers were asked, “What support needs have you identified in family caregivers?” The duration of each interview varied from 30 to 60 minutes. The interviews continued until theoretical data saturation. A total of 37 interviews were conducted with 31 participants (12 family caregivers, 3 family members of caregivers and 16 health care providers). The data was analyzed using Graneheim and Lundman’s approach. To evaluate the trustworthiness, Lincoln and Guba’s criteria (credibility, transferability, dependability and confirmability) were used.

Results
The age range of the family caregivers was 32-74 years. The mean work experience of health care providers was 13.5 years. The analysis of the interviews led to the emergence of 17 sub-themes and 6 themes, which are presented in Table 1.



Need for informational support
This theme consisted of three sub-themes: the need for learning knowledge and skills of caregiving, the need for information about available therapeutic-supportive resources, and the need for simultaneous role management training. Family caregivers were faced with numerous care tasks. Their lack of care knowledge and skills led to stress and additional costs for them. They also needed support resources but were unaware of them. Also, they needed training to balance caregiving with their other tasks.

Need for physical support
This theme included the sub-themes of the need for continuous monitoring of the caregiver’s physical health, the need for comfortable caregiving facilities and equipment, and the need for self-care of the caregiver. Family caregivers faced challenges and physical problems in caring for their older patients and needed support and household equipment of caregiving.

Need to get rid of psychological insecurity
This theme consisted of the sub-themes of need for emotional relief, need for professional psychological counseling, need to be seen, and need to enter and go through the healthy grieving process. Family caregivers experienced emotional distress and crisis in caring for the elderly. They needed emotional support, counseling and appreciation to cope with the challenges and grief associated with caregiving and losing their older patients.

Need to improve spirituality
This theme consisted of the sub-themes of the need to find the meaning of the disease in the older patient and the need to revive and strengthen the “spiritual self”. Family caregivers were looking for the cause of the disease and questioning God’s justice. According to the participants, supporting these caregivers in perception of the disease and re-establishing their spiritual ties are very important for their spiritual well-being.

Need for practical support
This theme included the sub-themes of need for financial support, need to facilitate access to medicines for their older patients, and need for instrumental assistance in caregiving. Caregivers faced financial challenges due to the high costs of medicine, treatment and equipment and needed the help of the government and social organizations. They also needed the help of hospitals in preparing medicines and transporting their older patients. They also needed help from their family and friends in household chores and taking care of their children.

Need for the help of a care team
This theme consisted of two sub-themes of need for the help of a multidisciplinary team and facilitating remote access to the care team. Participants stated that the collaboration of a care team with family caregivers is important in managing the complex needs of older patients. In addition, they considered it necessary to provide guidance, counseling and support to caregivers using technologies, especially in emergency situations, in order to maintain and promote the health of caregivers and improve the quality of care for older patients with cancer.

Conclusion
This qualitative study investigated the support needs of family caregivers of older adults with cancer in Iran and indicated their unmet needs that can lead to caregiving burden and impaired health of family caregivers. Neglecting the needs of the family caregivers of older adults with cancer can cause the disruption of the treatment process. Considering the expected increase in the number of older people with cancer, it is necessary to design a comprehensive caregiver-centered program to support family caregivers. The findings of this study can guide the government, policy makers and health care providers in Iran in designing and developing supportive interventions for family caregivers of older adults with cancer. More research is needed to design effective supportive programs for this group.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1398.197). The study objectives were explained to the participants before the study. They were assured of the confidentiality of their information and signed a written informed consent form.

Funding
This article was extracted from the PhD thesis of Batol Mohammadian study at Department of Nursing, University of Social Welfare and Rehabilitation Sciences. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conceptualization: Batol Mohammadian, Farahnaz Mohammadi-Shahboulaghi, Mohammadali Hosseini; Editing & review: Farahnaz Mohammadi-Shahboulaghi, Mohammadali Hosseini; Methodology, initial draft preparation, data analysis: All authors.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank all participants in this study for their cooperation.

References

1. Plöthner M, Schmidt K, de Jong L, Zeidler J, Damm K.Needs and preferences of informal caregivers regarding outpatient care for the elderly: A systematic literature review. BMC Geriatrics. 2019; 19(1):82.  [DOI:10.1186/s12877-019-1068-4] [PMID] [PMCID]
2. Sun V, Puts M, Haase K, Pilleron S, Hannan M, Sattar S, et al. The role of family caregivers in the care of older adults with cancer. Seminars in Oncology Nursing. 2021; 37(6):151232.  [DOI:10.1016/j.soncn.2021.151232] [PMID]
3. Doshmangir L, Khabiri R, Gordeev VS. Policies to address the impact of an ageing population in Iran. The Lancet. 2023; 401(10382):1078. [DOI:10.1016/S0140-6736(23)00179-4] [PMID]
4. Adashek JJ, Subbiah IM. Caring for the caregiver: A systematic review characterising the experience of caregivers of older adults with advanced cancers. ESMO open. 2020; 5(5):e000862.  [DOI:10.1136/esmoopen-2020-000862] [PMID] [PMCID]
5. Vakili M, Kafan S, Tabrizi G, Arabi M, Hashemi Nasabzadeh R. [The role of comprehensive geriatric assessments on the quality of life of disabled elderly cancer patients (Persian)]. Razi Journal of Medical Sciences. 2015; 21(129):68-74. [Link]
6. Miller KD, Nogueira L, Mariotto AB, Rowland JH, Yabroff KR, Alfano CM, et al. Cancer treatment and survivorship statistics, 2019. CA: A Cancer Journal for Clinicians. 2019; 69(5):363-85.  [DOI:10.3322/caac.21565] [PMID]
7. Sun V, Raz DJ, Kim JY. Caring for the informal cancer caregiver. Current Opinion in Supportive and Palliative Care. 2019; 13(3):238-42.  [DOI:10.1097/SPC.0000000000000438] [PMID] [PMCID]
8. Hsu T, Loscalzo M, Ramani R, Forman S, Popplewell L, Clark K, et al. Factors associated with high burden in caregivers of older adults with cancer. Cancer. 2014; 120(18):2927-35. [DOI:10.1002/cncr.28765] [PMID] [PMCID]
9. Molassiotis A, Wang M. Understanding and supporting informal cancer caregivers. Current Treatment Options in Oncology. 2022; 23(4):494-513. [DOI:10.1007/s11864-022-00955-3] [PMID] [PMCID]
10. Koren D, Laidsaar-Powell R, Tilden W, Latt M, Butow P. Health care providers’ perceptions of family caregivers’ involvement in consultations within a geriatric hospital setting. Geriatric Nursing. 2018; 39(4):419-27. [DOI:10.1016/j.gerinurse.2017.12.013] [PMID]
11. Wang T, Molassiotis A, Chung BPM, Tan JY. Unmet care needs of advanced cancer patients and their informal caregivers: a systematic review. BMC Palliative Care. 2018; 17(1):96. [DOI:10.1186/s12904-018-0346-9] [PMID] [PMCID]
12. Family Caregiver Alliance. National Alliance for Caregiving (NAC), and AARP. California: Family Caregiver Alliance; 2012. [Link]
13. Baider L, Surbone A. Universality of aging: Family caregivers for elderly cancer patients. Frontiers in Psychology. 2014; 5:744.  [DOI:10.3389/fpsyg.2014.00744] [PMID] [PMCID]
14. Jayani R, Hurria A. Caregivers of older adults with cancer. Seminars in Oncology Nursing. 2012; 28(4):221-5.  [DOI:10.1016/j.soncn.2012.09.004] [PMID] [PMCID]
15. Schwartz AJ, Riedel RF, LeBlanc TW, Desai D, Jenkins C, Mahoney E, et al. The experiences of older caregivers of cancer patients following hospital discharge. Supportive Care in Cancer. 2019; 27(2):609-16.  [DOI:10.1007/s00520-018-4355-2] [PMID] [PMCID]
16. Hsu T, Nathwani N, Loscalzo M, Chung V, Chao J, Karanes C, et al. Understanding caregiver quality of life in caregivers of hospitalized older adults with cancer. Journal of the American Geriatrics Society. 2019; 67(5):978-86. [DOI:10.1111/jgs.15841] [PMID]
17. Safaeian Z, Hejazi SS, Delavar E, Hoseini Azizi T, Haresabadi M. [The relationship between caregiver burden, and depression, anxiety and stress in family caregivers of cancer patients referred to Imam Reza Hospital in Bojnurd City (Persian) (Persian)]. Iranian Journal of Psychiatric Nursing. 2017; 5(3):7-14. [DOI:10.21859/ijpn-05032]
18. Becqué YN, Rietjens JAC, van der Heide A, Witkamp E. The effectiveness of a nurse‐led intervention to support family caregivers in end‐of‐life care: Study protocol for a cluster randomized controlled trial. Journal of Advanced Nursing. 2020; 76(5):1266-72.  [DOI:10.1111/jan.14326] [PMID] [PMCID]
19. Donison V, Toledano N, Sigal A, McGilton KS, Alibhai SMH, Puts M. Care provided by older adult caregivers to a spouse in active cancer treatment: A scoping review. Supportive Care in Cancer. 2022; 30(11):8679-88. [DOI:10.1007/s00520-022-07176-2] [PMID] [PMCID]
20. Ahn S, Romo RD, Campbell CL. A systematic review of interventions for family caregivers who care for patients with advanced cancer at home. Patient Education and Counseling. 2020; 103(8):1518-30.  [DOI:10.1016/j.pec.2020.03.012] [PMID] [PMCID]
21. Ferrell B, Wittenberg E. A review of family caregiving intervention trials in oncology. CA: A Cancer Journal for Clinicians. 2017; 67(4):318-25.  [DOI:10.3322/caac.21396] [PMID]
22. Ream E, Richardson A, Lucas G, Marcu A, Foster R, Fuller G, et al. Understanding the support needs of family members of people undergoing chemotherapy: A longitudinal qualitative study. European Journal of Oncology Nursing. 2021; 50:101861. [DOI:10.1016/j.ejon.2020.101861] [PMID]
23. Leonidou C, Giannousi Z. Experiences of caregivers of patients with metastatic cancer: What can we learn from them to better support them? European Journal of Oncology Nursing. 2018; 32:25-32.  [DOI:10.1016/j.ejon.2017.11.002] [PMID]
24. Chua GP, Pang GSY, Yee ACP, Neo PSH, Zhou S, Lim C, et al. Supporting the patients with advanced cancer and their family caregivers: What are their palliative care needs? BMC Cancer. 2020; 20(1):768. [DOI:10.1186/s12885-020-07239-9] [PMID] [PMCID]
25. Speziale HS, Carpenter DR. Qualitative research in nursing: Advancing the humanistic imperative. Philadelphia: Lippincott Williams & Wilkins; 2011. [Link]
26. Lindgren B‑M, Lundman B, Graneheim UH. Abstraction and interpretation during the qualitative content analysis process. International Journal of Nursing Studies. 2020; 108:103632.  [DOI:10.1016/j.ijnurstu.2020.103632] [PMID]
27. Elo S, Kääriäinen M, Kanste O, Pölkki T, Utriainen K, Kyngäs H. Qualitative content analysis: A focus on trustworthiness. SAGE Open. 2014; 4(1):2158244014522633. [DOI:10.1177/2158244014522633]
28. Kim H, Yi M. Unmet needs and quality of life of family caregivers of cancer patients in South Korea. Asia-Pacific Journal of Oncology Nursing. 2015; 2(3):152-9. [DOI:10.4103/2347-5625.158019] [PMID] [PMCID]
29. Ashrafian S, Feizollahzadeh H, Rahmani A, Davoodi A. The unmet needs of the family caregivers of patients with cancer visiting a referral hospital in Iran. Asia-Pacific Journal of Oncology Nursing. 2018; 5(3):342-52. [DOI:10.4103/apjon.apjon_7_18] [PMID] [PMCID]
30. Maheshwari P, Mahal R. Relationship of preparedness and burden among family caregivers of cancer patients in India. Journal of Health, Medicine and Nursing. 2016; 22:35-44. [Link]
31. Onogwa H. Providing support to family caregivers of older adults: A scoping review [BSc dissertation]. Vassa: University of Applied Sciences; 2021. [Link]
32. Demiris G, Oliver DP, Washington K, Pike K. A problem‐solving intervention for hospice family caregivers: A randomized clinical trial. Journal of the American Geriatrics Society. 2019; 67(7):1345-52.  [DOI:10.1111/jgs.15894] [PMID] [PMCID]
33. Chen SC, Lai YH, Liao CT, Huang BS, Lin CY, Fan KH, et al. Unmet supportive care needs and characteristics of family caregivers of patients with oral cancer after surgery. Psycho‐Oncology. 2014; 23(5):569-77.  [DOI:10.1002/pon.3458] [PMID]
34. Abd Elhameed SH, Alam RR. Relationship between burden of caring for older adult patients with chronic diseases and family caregivers health status. Alexandria Scientific Nursing Journal. 2016; 18(1):43-60. [DOI:10.21608/asalexu.2016.208624]
35. Goldzweig G, Merims S, Ganon R, Peretz T, Altman A, Baider L. Informal caregiving to older cancer patients: Preliminary research outcomes and implications. Annals of Oncology. 2013; 24(10):2635-40.  [DOI:10.1093/annonc/mdt250] [PMID]
36. Aneshensel CS, Pearlin LI, Mullan JT, Zarit SH, Whitlatch CJ. Profiles in caregiving: The unexpected career. Amsterdam: Elsevier; 1995. [Link]
37. Mohammadi F, Fallahi M, Khanke H. [Needs of caregivers of elderly patients with Alzheimer’s: An analysis of the experience of family caregivers (Persian)]. Advances in Nursing and Midwifery (Shahid Beheshti University of Medical Sciences). 2011; 21(72):29-36. [Link]
38. Hashemi M, Irajpour A, Taleghani F. Caregivers needing care: The unmet needs of the family caregivers of end-of-life cancer patients. Supportive Care in Cancer. 2018; 26(3):759-66.[DOI:10.1007/s00520-017-3886-2] [PMID]
39. Fu F, Zhao H, Tong F, Chi I. A systematic review of psychosocial interventions to cancer caregivers. Frontiers in Psychology. 2017; 8:834. [DOI:10.3389/fpsyg.2017.00834] [PMID] [PMCID]
40. Mollaei F, Borhani F, Abbaszadeh A, Khabazkhoob M. [Correlation between spiritual well-being and burden of care in family caregivers of cancer patients (Persian)]. Hayat. 2019; 24(4):296-309. [Link]

41. Spatuzzi R, Giulietti MV, Ricciuti M, Merico F, Fabbietti P, Raucci L, et al. Exploring the associations between spiritual well-being, burden, and quality of life in family caregivers of cancer patients. Palliative & Supportive Care. 2019; 17(3):294-9. [DOI:10.1017/S1478951518000160] [PMID]
42. Kim Y, Carver CS, Cannady RS. Caregiving motivation predicts long-term spirituality and quality of life of the caregivers. Annals of Behavioral Medicine. 2015; 49(4):500-9. [DOI:10.1007/s12160-014-9674-z] [PMID]
43. Shirinkam F, Shamsalinia A, Torabi Chafjiri R, Ghaffari F. [Spiritual attitude of family caregivers in elder with stroke (Persian)]. Caspian Journal of Health and Aging. 2020; 4(2):37-44. [Link]
44. La IS, Johantgen M, Storr CL, Cagle JG, Zhu S, Ross A. Spirituality among family caregivers of cancer patients: The Spiritual Perspective Scale. Research in Nursing & Health. 2020; 43(4):407-18.  [DOI:10.1002/nur.22044] [PMID] [PMCID]
45. Puchalski CM. Spirituality in the cancer trajectory. Annals of Oncology. 2012; 23(Suppl 3):49-55. [DOI:10.1093/annonc/mds088] [PMID]
46. Ghezelsefli Z, Ahmadi F, Mohammadi E, Puts Rn M. Experiences of end-of-Life care of older adults with cancer from the perspective of stakeholdersin Iran: A content analysis study. Asian Pacific Journal of Cancer Prevention: APJCP. 2021; 22(1):295-300.  [DOI:10.31557/APJCP.2021.22.1.295] [PMID] [PMCID]
47. Keramatikerman M. A systematic review on challenges faced by family caregivers of cancer patients. Journal of Biomedical Science. 2020; 2(4): 421-4. [Link]
48. Malmir S, Navipour H, Negarandeh R. Exploring challenges among Iranian family caregivers of seniors with multiple chronic conditions: A qualitative research study. BMC Geriatrics. 2022; 22(1):270. [DOI:10.1186/s12877-022-02881-3] [PMID] [PMCID]
49. Ratcliff CG, Vinson CA, Milbury K, Badr H. Moving family interventions into the real world: What matters to oncology stakeholders?. Journal of Psychosocial Oncology. 2019; 37(2):264-84. [DOI:10.1080/07347332.2018.1498426] [PMID] [PMCID]
50. Ambroggi M, Biasini C, Del Giovane C, Fornari F, Cavanna L. Distance as a barrier to cancer diagnosis and treatment: Review of the literature. The Oncologist. 2015; 20(12):1378-85.  [DOI:10.1634/theoncologist.2015-0110] [PMID] [PMCID]
51. Fernandes R, Osarch S, Bell CL, Flynn BW, Nguyen LV, Abad MJ, et al. Aging and caregiving in the Republic of Palau. Journal of Cross-Cultural Gerontology. 2013; 28(2):167-80. [DOI:10.1007/s10823-013-9192-7] [PMID]
52. Bahrami M, Sadeghi A, Mosavizadeh R, Masoumy M. Challanges of meeting the palliative care needs of colorectal cancer patients in Iran: A qualitative research. Iranian Journal of Nursing and Midwifery Research. 2022; 27(4):325-30. [DOI:10.4103/ijnmr.ijnmr_444_21] [PMID] [PMCID]
53. Sato T, Fujisawa D, Arai D, Nakachi I, Takeuchi M, Nukaga S, et al. Trends of concerns from diagnosis in patients with advanced lung cancer and their family caregivers: A 2-year longitudinal study. Palliative Medicine. 2021; 35(5):943-51. [DOI:10.1177/02692163211001721] [PMID] [PMCID]
54. Maggiore RJ, Gorawara-Bhat R, Levine SK, Dale W. Perceptions, attitudes, and experiences of hematology/oncology fellows toward incorporating geriatrics in their training. Journal of Geriatric Oncology. 2014; 5(1):106-15. [DOI:10.1016/j.jgo.2013.10.003] [PMID]
55. Suhag V, Sunita B, Sarin A, Singh A. Challenges in cancer care of elderly. International Journal of Medical Physics, Clinical Engineering and Radiation Oncology. 2015; 4(01):25. [DOI:10.4236/ijmpcero.2015.41004]
56. Hashemi M, Taleghani F, Kohan S, Yousefi A. Iranian caregivers, silent mediums in caring for relatives suffering from cancer. Iranian Journal of Nursing and Midwifery Research. 2014; 19(7):S83-90. [PMID]
57. Douglas SL, Mazanec P, Lipson AR, Day K, Blackstone E, Bajor DL, et al. Videoconference intervention for distance caregivers of patients with cancer: A randomized controlled trial. JCO Oncology Practice. 2021; 17(1):e26-35. [DOI:10.1200/OP.20.00576] [PMID] [PMCID]