Effects of Resilience and Emotion Regulation on Perceptions of Positive and Negative Life Changes in Cancer Survivors: A Longitudinal Study

Abstract

Background

While many studies have investigated the sociodemographic, clinical, and psychosocial factors associated with perceived positive change after cancer, longitudinal work examining how emotion regulation, and resilience impact perceptions of life change among newly diagnosed cancer survivors is lacking.

Purpose

This study examined the prevalence of perceived positive and negative life changes following cancer and explored the role of emotion regulation and resilience on perceived change over 6 months.

Methods

Data from 534 recent survivors of breast, prostate, or colorectal cancer (M_age = 59.3, 36.5% male) collected at baseline (Time 1) and 6-month follow-up (Time 2) were analyzed. Multivariate linear regressions were estimated separately to examine if resilience or emotion regulation were associated with perceived change at Time 2 after controlling for relevant sociodemographic and psychosocial measures.

Results

At both time points, greater than 90% of participants reported at least one perceived positive change while fewer than a third reported a negative change. Indices of emotion regulation and resilience were positively related to perceived positive change at both time points and negatively related to perceived negative change at Time 1. Emotion regulation but not resilience was negatively associated with perceived negative change at Time 2.

Conclusions

Findings suggest that cancer survivors who are less resilient and struggle with emotion regulation are more susceptible to perceptions of fewer positive and greater negative life changes after cancer. As such, psychosocial interventions should be developed to promote resilience and emotional regulation in cancer survivors.

Introduction

The number of cancer survivors in the U.S. today is estimated at 18 million and is projected to increase to 22.5 million by 2032 [1]. Cancer diagnosis and treatments introduce myriad stressors that do not necessarily attenuate after active treatment. While there is abundant literature describing the adverse effects of cancer and its treatment, contemporary research has found that some survivors also report positive consequences in different aspects of their lives following a diagnosis of cancer. There is debate over terminology to best describe this phenomenon (e.g., benefit finding, stress-related growth), though it is most often referred to as “posttraumatic growth.”

Tedeschi and Calhoun [2] proposed a model of posttraumatic growth that outlines the process by which it emerges. First, a stressful life event occurs that fundamentally challenges the individual’s beliefs about the world, themselves, their goals, and their life meaning and purpose. These threats to one’s worldview can be extremely distressing. However, the cognitive reconstruction of fundamental beliefs about the world and oneself, characterized by rumination and intrusive thoughts, fosters posttraumatic growth. Tedeschi and Calhoun [2] point out that while intrusive thoughts and rumination are often associated with high levels of psychological distress, they can also be used productively to induce deep cognitive and emotional processing to reconcile the impact of the stressor with one’s worldview and thus, to produce posttraumatic growth. Tedeschi and Calhoun [2] note that while many people do not undergo this process with the conscious and explicit goal of extracting meaning or enacting positive changes, these cognitive efforts to integrate old and new beliefs about the world must be somewhat deliberate if they are to avoid chronic psychological distress. As such, psychological distress and perceived posttraumatic growth often co-exist [3].

This meaning-making process that precedes posttraumatic growth hinges on the quality of cognitive and emotional processing and both the internal and external resources at the individual’s disposal. Factors such as personality traits, coping strategies, and social support can influence the likelihood and extent of posttraumatic growth among cancer survivors. Importantly, because there is a dearth of studies that have prospectively assessed cancer survivors pre- and post-cancer diagnosis. Most research on posttraumatic growth in psycho-oncology is not capturing objective posttraumatic growth or positive changes in response to cancer but rather survivors’ perceptions of posttraumatic growth or positive changes, hereto referred to as “perceived posttraumatic growth.” Research has generally found that women report more posttraumatic growth than men, partnered adults report more posttraumatic growth than single people, and racial minority members report more posttraumatic growth than White people [4, 5]. Generally, perceived posttraumatic growth is also inversely related to age and education level [6–10]. Disease characteristics (type of cancer, treatment type, disease severity) are typically unrelated to perceived posttraumatic growth [5, 11]. More optimism, social support, self-efficacy, perceived personal control, and intrusive thoughts tend to be associated with more perceived posttraumatic growth [4, 5, 11]. However, few studies (and none that have assessed both perceived positive and negative changes) have studied the influence of resilience and emotion regulation on perceived changes after cancer.

Tedeschi and Calhoun [2] recognized that resilience and posttraumatic growth are similar constructs but are distinct and not mutually exclusive. Resilience can be understood as the ability of individuals to adapt in the face of adversity [12] while posttraumatic growth surpasses resilience in that individuals are able to not only navigate but also transcend hardship, ultimately leading to personal growth [2]. Some have argued that resilient individuals cannot experience posttraumatic growth because they do not endure the psychological distress and subsequent cognitive processing that precede posttraumatic growth [13]. However, the limited research that has explicitly examined the relationship between resilience and posttraumatic growth has found a positive association. For example, in studies of Chinese colorectal and breast cancer survivors, those who reported greater resilience also reported more posttraumatic growth [14, 15]. Recent international studies have found that resilience was positively related to perceived posttraumatic growth among cancer survivors after controlling for various sociodemographic variables [16–18]. Although this research provides a valuable starting point for better understanding how resilience and perceived posttraumatic growth are related, these studies were cross-sectional and conducted outside the USA which restricts generalizability to American cancer survivors.

Though processing one’s emotions is a critical component of the meaning-making process and a mechanism of posttraumatic growth in Tedeschi and Calhoun’s model, to our knowledge, no prospective studies have examined the relationship between emotion regulation and perceived posttraumatic growth in cancer survivors. Emotion regulation refers to the process by which individuals manage, monitor, and modify their emotional experiences and expressions [19]. Individuals who are better able to process and express their emotions also tend to have better adjustment, including more life satisfaction and higher self-esteem [19, 20]. Moreover, existing research indicates that effective emotion regulation is related to perceived posttraumatic growth [21–24]. While this research offers insight into the relationship between emotion regulation and perceived posttraumatic growth, generalizability is limited given that they are cross-sectional, conducted internationally, and focused primarily on breast cancer survivors.

Tedeschi and Calhoun [2] recognize that posttraumatic growth does not negate the negative consequences of trauma (i.e., posttraumatic depreciation), which is supported by empirical study. Perceived posttraumatic growth has been reported at moderate to high rates in cancer survivors in numerous life domains, including appreciation of life, social relationships, and religious or spiritual beliefs [3, 25, 26]. Several studies demonstrated that cancer survivors report experiencing both negative and positive life changes simultaneously, though positive change is generally reported more frequently than negative change [3, 27–31]. Most of these studies were conducted on cancer survivors years after their initial diagnosis, and few have studied survivors during the transition from active treatment to early survivorship (i.e., the re-entry period) [32]. The re-entry period has critical implications for cancer survivors’ long-term health-related quality of life [32, 33]. It can be a turbulent time for cancer survivors since they often experience a decrease in social support, readjust to roles both in and out of the home, cope with lingering physical and psychological effects of treatment, manage concerns about recurrence, and attempt to make sense of their cancer experience, all of which may influence their perceptions of positive or negative changes as a result of cancer. The examination of perceived posttraumatic growth during the re-entry period also allows for the exploration of how it emerges after diagnosis. Danhauer and colleagues [34] found that perceived posttraumatic growth increased over time until roughly 1 year after breast cancer diagnosis, at which point it stabilized. However, cross-sectional studies have found no relation between time since diagnosis and perceived posttraumatic growth [6, 31, 35].

There were three primary aims of the present study. The first was to describe the proportion of cancer survivors who reported experiencing positive and negative change at baseline assessment (Time 1) and 6-month follow-up (Time 2). Since prior research among cancer survivors has generally found that positive changes outweigh negative changes [3, 27–31], we hypothesized that cancer survivors would report high rates of positive change and would simultaneously report negative changes but at much lower rates. Second, because it remains unclear how long it takes for perceptions of positive change to emerge among cancer survivors and if these perceptions differ across time, the next aim was to test whether perceived positive change or negative change differed from Time 1 to Time 2. Given that most studies have not found a significant relationship between time since diagnosis and perceived posttraumatic growth, we hypothesized that neither perceptions of positive nor negative change would change between Time 1 and Time 2. The third aim was to examine whether resilience and emotion regulation were associated with reported positive change and negative change at Time 1 and Time 2 after controlling for other sociodemographic, disease-related, and Time 1 psychosocial factors (e.g., optimism, intrusive thoughts, social support, self-efficacy, and personal control). Guided by theory and empirical evidence, it was hypothesized that cancer survivors who report greater resilience and better emotion regulation would report more positive life changes. Given the dearth of research on predictors of perceived negative change, no a priori hypotheses were generated related to the associations between resilience, emotion regulation, and perceived negative change.

Methods

Participants and Procedures

The current study presents data from a larger longitudinal study of cancer survivors as they transition out of active treatment and into early survivorship. Adults recently diagnosed with breast, prostate, or colorectal cancer were identified by the Yale Cancer Center Rapid Case Ascertainment program and recruited from three Yale New Haven-affiliated hospitals. Patients diagnosed with primary pathologically confirmed breast, prostate, or colorectal cancer in stages 0–III, aged 18–80 at diagnosis, and who had no prior history of cancer were eligible to participate. At study initiation, physicians were contacted via email to inform them of the study and outline physician permission procedures. After confirmation of patient eligibility, physicians were asked to provide consent for the study team to contact their patients. If the physician consented or did not respond within 14 days, the study team mailed letters to eligible patients. The institutional review boards at both the Uniersity of Connecticut and Yale University approved the study.

A study coordinator subsequently called each eligible individual to describe study procedures, answer questions, and gauge interest in participating. At this time, the study coordinator confirmed that the patient was able to read and speak English. Patients who verbally agreed to participate were asked to provide their email addresses by which links to the consent form and subsequent study questionnaires could be sent. Patients who were unable or unwilling to complete study materials electronically were mailed hard-copy versions.

At both Time 1 and Time 2, participants completed a survey containing measures of perceived positive and negative life changes, psychosocial resources, and personality traits. Participants were compensated with a $50 gift card for each completed survey.

Measures

Demographic and disease-related variables

At Time 1, demographic characteristics including gender, age, race/ethnicity, marital status, and education level were collected. Disease-related information was extracted from participants’ medical records, including date of diagnosis and cancer stage. Time since diagnosis was calculated by subtracting the diagnosis date from the Time 1 survey completion date.

Perceived positive and negative life change

The 17-item revised Benefit Finding Scale [36, 37] was adapted to capture perceptions of both negative and positive changes resulting from the cancer experience. Original item stems were maintained (e.g., “Having had cancer… has led me to be more accepting of things”) but the original scale’s response options (a five-point Likert scale ranging from 1 (not at all) to 5 (extremely)) were modified to a five-point scale consisting of 1 (great negative change), 2 (slight negative change), 3 (no change), 4 (slight positive change), and 5 (great positive change).

Scoring was consistent with prior studies that also aimed to capture both negative and positive change [3, 29]. A negative change score was produced for each item by converting responses above 2 (no change or positive change) to 0, “slight negative change” to 1, and “great negative change” to 2. A positive change score was produced for each item by converting responses below 4 (no change or negative change) to 0, “slight positive change” to 1, and “great positive change” to 2. All perceived positive change items were averaged to generate an overall perceived positive change score while all negative change items were averaged to generate an overall perceived negative change score. The scales demonstrated strong reliability; Cronbach’s alpha (α) was .79 at Time 1 and .86 at Time 2 for perceived negative change and .95 at both Time 1 and Time 2 for perceived positive change.

Psychosocial variables

Optimism.

The Life Orientation Test-Revised (LOT-R) was used to measure optimism [38]. Participants are asked to rate the degree to which they disagree or agree with each of the 10 items on a scale from 0 (strongly disagree) to 4 (strongly agree). Items (e.g., “In uncertain times, I usually expect the best”) are summed to generate a composite score such that higher scores reflect more optimism (α = .84).

Intrusive thoughts.

The eight-item intrusion subscale of the Impact of Event Scale-Revised assessed intrusive thoughts [39]. Participants are asked to report how frequently in the past 7 days they had experienced each item (e.g., “Any reminder brought back feelings about it”) on a scale from 0 (not at all) to 4 (extremely). Total scores range from 0 to 32 with higher scores denoting more intrusion (α = .89).

Social support.

The Medical Outcomes Study (MOS) Social Support Survey measures four types of perceived social support: emotional/informational, tangible, affectionate, and positive social interaction [40]. On each of the 19 items (e.g., “Someone who understands your problems”), participants rate how frequently that kind of support is available to them on a five-point Likert scale from 1 (none of the time) to 5 (all of the time). Items are summed and converted to a 0–100 scale with higher scores indicating greater functional social support (α = .97).

Self-efficacy.

The Self-Efficacy for Managing Chronic Disease Scale assessed self-efficacy [41]. It is a six-item measure that asks participants to rate how confident they are in doing certain activities (e.g., “keep the physical discomfort or pain of your disease from interfering with the things you want to do”) on a 10-point scale from 0 (not at all confident) to 10 (totally confident). Item responses are summed such that higher scores indicate greater self-efficacy for managing their illness (α = .94).

Personal control.

The six-item personal control subscale from the Illness Perception Questionnaire-Revised assessed survivors’ perceived control over their cancer [42]. Participants were asked to rate the extent to which they agreed or disagreed with each of the six items (e.g., “The course of my illness depends on me”) on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Higher summed scores indicate more positive beliefs about the personal controllability of their illness (α = .82).

Resilience.

The brief Response to Stressful Experiences Scale (RSES) was utilized to assess resilience [43]. The abbreviated RSES is a four-item scale with response options ranging from 0 (not at all like me) to 4 (exactly like me). For each item, participants are asked to consider, “During and after life’s most stressful events, I tend to….” (e.g., “find a way to do what’s necessary to carry on”). Items are summed to generate a total score whereby higher scores indicate greater resilience (α = .86).

Emotional regulation.

Two measures were used to capture emotional processing. First, the emotional approach for coping scale [20] was used to assess emotional processing (four items; e.g., “I take time to figure out what I’m really feeling.”) and emotional expression (four items; e.g., “I allow myself to express my emotions.”). Participants are asked to rate each of the eight items on a four-point Likert scale from 1 (I usually don’t do this at all) to 4 (I usually do this a lot) how they respond under stressful circumstances. Items are summed to produce an overall score whereby higher values indicate greater emotional approach coping (α = .90). The Difficulties in Emotion Regulation Scale Short Form (DERS-SF) was also used to capture emotional processing [44]. The 18-item scale assesses six types of emotional dysregulation: limited access to emotion regulation strategies, non-acceptance of emotional responses, impulse control difficulties, difficulties engaging in goal-directed behavior, lack of emotional awareness, and lack of emotional clarity. Participants are instructed to rate the extent to which each statement (e.g., “I pay attention to how I feel”) applies to them on a five-point Likert scale ranging from 1 (almost never) to 5 (almost always). An overall score was generated by averaging item responses. Higher scores indicate more difficulty regulating emotions (α = .90).

Statistical Analyses

SPSS version 29 was used to conduct descriptive statistics to characterize the analytic sample and conduct chi-square tests, t-tests, and ANOVAs while Mplus 8 was used to run regression analyses. Chi-square tests and t-tests were used to examine differences between the analytic sample and individuals who did not complete the Time 2 assessment because they either dropped out of the study prior to Time 2 or missed that assessment. For Hypothesis 1, each of the 17 life change items was examined to determine the prevalence of perceived negative and positive change. To test Hypothesis 2, paired-samples t-tests with a Bonferroni correction were used to determine whether perceived negative or positive change remained stable from Time 1 to Time 2. For Hypothesis 3, Pearson’s correlations, independent samples t-tests, and ANOVAs were employed to identify the Time 1 correlates of perceived positive change and perceived negative change at Time 1 and Time 2 to be included in multivariate linear regression analyses. Three demographic variables were dichotomized for analyses: race/ethnicity (0 = non-Hispanic White, 1 = People of Color), marital status (0 = not partnered, 1 = partnered), and education level (0 = less than bachelor’s degree, 1 = at least a bachelor’s degree). Two longitudinal multivariate regression models were conducted to examine the Time 1 variables associated with perceived positive and negative change at Time 2.

Results

Sample Characteristics

Of the 1,902 potentially eligible patients, a study coordinator made contact with 1,201 (63.1%), and 569 (48.3% of eligible participants who we spoke with) ultimately completed a consent form. Five-hundred and fifty-seven (97.9%) of the 569 consented participants completed at least part of the Time 1 survey. However, due to the aims of the present study, analyses include data from individuals who completed the measure of perceived positive and negative change at Time 1. These data were collected from March 2019 to June 2022. The final analytic sample is 534 cancer survivors.

Rates of data missingness among the variables of interest at Time 1 were between 0% and 6%. Due to attrition, the rate of missingness on perceived negative and positive change scores at Time 2 was 13.5%. The assumption of missing at completely random on study variables was not rejected based on Little’s MCAR tests (ps > .05). Missing data were handled using Full Information Maximum Likelihood estimation in Mplus [45].

The analytic sample comprised 534 breast (58.2%), prostate (32.0%), and colorectal (9.7%) cancer survivors. Means and standard deviations for demographic and disease-related characteristics are displayed in Table 1. Participants were largely older, middle-aged adults who were, on average, 59 years of age (SD = 11.5) and seven months post-diagnosis at Time 1. Most participants were well-educated, non-Hispanic White, and partnered. Forty-five men with prostate cancer (27.1%) were in watchful waiting and had no active treatment. Of the breast and colorectal cancer survivors, nearly half had stage I cancer and only 14% had stage III.

Seventy-two participants who were included in the analytic sample either dropped out of the study before Time 2 (n = 55) or did not do the Time 2 assessment (n = 17). These 72 participants were compared to participants who completed Time 2 on all baseline study variables. Participants who did not complete Time 2 were more likely to be individuals of color (X² (1, n = 532) = 9.26, p = .002) and less likely to have earned at least a bachelor’s degree (X² (1, n = 521) = 14.39, p < .001) than participants who completed both time points. Men in watchful waiting were also less likely to have completed Time 2 compared with men who received active treatment (X² (1, n = 166) = 6.73, p = .01). Participants who did not complete Time 2 were also younger (t(532) = 2.17, p = .03) than those who completed Time 2.

Prevalence of Perceived Positive and Negative Life Change in Adults with Cancer

Four hundred and eighty-seven participants (91.2%) reported at least one positive change while 162 participants (30.3%) reported at least one negative change at Time 1. Rates of reported positive change at Time 1 were significantly higher than rates of reported negative change at Time 1 (t(533) = 25.93, p < .001, 95% CI [0.61, 0.71]). Similarly, at Time 2, 426 participants (92.2%) reported at least one positive change while 132 participants (28.6%) reported at least one negative change, with rates of positive change far outweighing those of negative change (t(461) = 24.76, p < .001, 95% CI [0.64, 0.75]). Forty-two participants (7.9%) at Time 1 and 31 participants (6.7%) at Time 2 did not report change on any of the 17 items. One hundred and fifty-seven individuals (29.4%) reported at least one positive change and one negative change at Time 1 while 126 (27.3%) reported at least one positive change and one negative change at Time 2. Table 2 shows the proportion of participants who reported positive change and negative change on each item at each time point. The positive change reported by most at Time 1 and Time 2 (71.0% and 69.1%, respectively) was “My awareness of the love and support available from other people.” The two negative changes most frequently reported at both Time 1 and Time 2 were “My patience” (15.0% and 9.8%, respectively) and “My ability to deal with stress and problems” (13.7%).

Perceived Positive and Negative Change Over Time

Reported positive change scores at Time 1 (M = 0.72, SD = 0.55) did not significantly differ from reported positive change scores at Time 2 (M = 0.76, SD = 0.56), (t(461) = −1.93, p = .06). Reported negative change scores at Time 1 (M = 0.05, SD = 0.12) also did not significantly differ from reported negative change scores at Time 2 (M = 0.06, SD = 0.15), (t(461) = −1.21, p = .23). However, one perceived positive change item (“My acceptance of things”) significantly differed from Time 1 to Time 2 after the Bonferroni correction was applied.

Bivariate Differences in Perceived Positive Change and Negative Change

Descriptive information on sociodemographic, disease-related, and psychosocial factors and their correlations are presented in Table 3. Gender differences were found; females reported more negative change at Time 1 (t(532) = 2.69, p = .007, 95% CI [0.01, 0.05]) and Time 2 (t(460) = 2.37, p = .02, 95% CI [0.005, 0.05]) and more positive change at Time 1 (t(532) = 7.17, p < .001, 95% CI [0.24, 0.43]) and Time 2 (t(460) = 5.48, p < .001, 95% CI [0.18, 0.38]) compared to males. Individuals with less than a bachelor’s degree reported more positive change at Time 1 (t(519) = 2.64, p = .009, 95% CI [0.04, 0.24]) but not Time 2 (t(451) = 0.89, p = .38, 95% CI [−0.06, 0.17]) when compared to individuals with at least a bachelor’s degree, but no differences in reported negative change were observed. There were also racial/ethnic differences in terms of perceived positive but not negative change. People of Color reported more positive change at Time 1 (t(530) = −2.07, p = .04, 95% CI [−0.24, −0.006]) and Time 2 (t(458) = −2.11, p = .04, 95% CI [−0.26, −0.001]) than non-Hispanic White participants. There were no differences in reported positive or negative change at Time 1 or Time 2 between partnered and unpartnered individuals. All the psychosocial variables were correlated with perceived negative change at both time points. Self-efficacy was not related to positive change at either time point and was therefore excluded from perceived positive change regression analyses. Emotional dysregulation was positively correlated with perceived negative change, but uncorrelated with perceived positive change. However, as a key variable of interest, it was included in all subsequent regressions.

Correlates of Reported Positive Change and Negative Change at Time 2

Results of the longitudinal multivariate regression analyses are presented in Table 4. The linear regression model accounted for 22.5% of the variance in Time 2 perceived positive change (p < .001). After controlling for all other variables included in the model, the variables that significantly contributed to the prediction of the model were age (b = −0.01, p = .026), resilience (b = 0.02, p = .006), intrusive thoughts (b = 0.01, p = .003), and emotional approach coping (b = 0.03, p < .001). In other words, younger cancer survivors and those who were more resilient, experienced more intrusive thoughts, and used more emotional approach coping were more likely to report having experienced positive life changes from their cancer experience 6 months later.

The linear regression model accounted for 18.2% of the Time 2 perceived negative change variance (p < .001). Self-efficacy (b = −0.002, p = .045) and difficulties with emotional regulation (b = 0.06, p < .001) significantly accounted for the variance in reported Time 2 negative change (1.35% and 4.41%, respectively), which suggests that cancer survivors who reported less self-efficacy and more emotional dysregulation were more likely to indicate 6 months later that they had experienced more negative changes following their cancer than those who reported more self-efficacy and less emotional dysregulation.

Discussion

The current study examined the prevalence, stability, and correlates of perceived positive and negative life changes among a sample of adults recently diagnosed with breast, prostate, or colorectal cancer. This research adds to the existing literature as it is the first study to longitudinally measure both perceived positive and negative life change on equivalent items in both male and female cancer survivors during the re-entry period. Another contribution of the present study is the examination of resilience and emotion regulation to perceptions of positive and negative change.

In support of the first hypothesis, results indicate that reports of positive life changes were much more common than reports of negative life changes. Over 90% of the sample reported at least one positive life change at both time points, while only about 30% of the sample reported at least one negative life change at each time point. Compared with other studies of both perceived positive and negative life changes in cancer populations [3, 29, 46], the present sample reported more overall positive change and less overall negative change. While this finding is encouraging, at both assessments, the two most-cited items in terms of perceived negative change were “My patience” and “My ability to deal with stress and problems.” Cognitive-behavioral stress management interventions, which have demonstrated strong efficacy among cancer survivors [36, 47, 48], may be useful in preventing perceptions of the negative impact of cancer and bolstering survivor’s feelings of empowerment to deal with existing and future stressors.

The results also support the second hypothesis; perceived positive life changes and perceived negative life changes did not change from Time 1 to Time 2. Though some studies have found that posttraumatic growth increases within the first year of cancer diagnosis [34], the results of the current study are more consistent with those that have found that posttraumatic growth remained stable within the first year of diagnosis [49, 50]. The current null finding also aligns with earlier findings of others who also captured perceived positive and negative change [27, 28]. This lack of consensus may be caused by methodological differences between studies, particularly variations in measures used to capture posttraumatic growth and sample characteristics (e.g., cancer type, cancer stage, age, etc.). Time since cancer diagnosis may be an exceptionally instrumental variable in posttraumatic growth development. Most studies that have examined trajectories of perceived growth or decline have not assessed survivors until many months or years after their initial diagnosis. However, a large study of breast cancer survivors found a quadratic relationship between time since diagnosis and posttraumatic growth, such that posttraumatic growth increased until 1 year after diagnosis and then leveled off [34]. Another study of posttraumatic growth in adults undergoing treatment for acute leukemia found that posttraumatic growth increased over time when assessed three times within 14 weeks of diagnosis. Though the present study assessed cancer survivors relatively early in their cancer experiences (7 months after diagnosis, on average, at baseline), levels of perceived positive and negative life change may have stabilized already. Future research should examine the trajectories of perceived positive and negative change over time to identify individuals who could most benefit from intervention (e.g., cancer survivors who persistently perceive negative change).

There was partial support for our third hypothesis. As predicted, greater resilience and emotional approach coping were associated with higher levels of perceived positive change at Time 2. Similarly, as we hypothesized, emotional dysregulation was positively associated with reported negative change at Time 2, however, there was no significant relationship with resilience in the regression analysis. The positive association between resilience at Time 1 and positive life change at Time 2 implies that survivors who demonstrate greater resilience are more likely to perceive personal growth, find new perspectives, and discover positive aspects resulting from their cancer experience. This highlights the adaptive and transformative nature of resilience in the context of cancer survivorship. Although resilience at Time 1 was negatively correlated with perceived negative change at Time 2, regression analyses revealed that, after controlling for other sociodemographic and psychosocial variables, it did not significantly account for variance in perceived negative change at Time 2. While resilience may contribute to perceived positive change over time, other factors, such as emotion regulation and self-efficacy, may play more significant roles in influencing the perception of negative changes.

Cancer survivors who used a more emotional approach to coping (conceptualized as a combination of emotional processing and expression) reported more positive change 6 months later while those who had reported fewer difficulties in regulating their emotions reported less negative change 6 months later. This positive association indicates that survivors who actively and openly explore and process their emotions may perceive more personal growth and fewer negative changes as a result of their cancer experience. This finding highlights the potential adaptive function of emotional expression and suggests that encouraging cancer survivors to engage in emotional processing and expression may contribute to more positive reflections on the cancer experience.

The current study is not without its limitations. The sample was majority female and consisted largely of White, well-educated, and partnered individuals, which makes it difficult to discern whether findings would vary in a less privileged sample. Only cancer site and time since diagnosis were included in the present analyses; however, studies in this area would benefit from the inclusion of clinical variables such as treatment type, length, and location. The limitations of the current study’s measure of perceived life change must also be acknowledged. The use of adapted response options to the Benefit Finding Scale addresses the positive response bias, but the scale does not encompass all life domains that may be affected by cancer (e.g., sexual function, body image, health behaviors, financial well-being, employment, or retirement plans, etc.). Future studies may want to use more comprehensive instruments that allow respondents to indicate perceived positive and negative change. In addition, it is important to note that our study used self-report questionnaires and thus captured perceived positive and negative change as a result of cancer, which is not the same as genuine change [51]. Research has demonstrated that people are not reliable reporters of actual growth [52, 53]. Therefore, findings from this study should not be used to make assertions about veridical change, whether positive or negative.

Despite these limitations, the present study underscores the complex nature of perceived positive and negative change after cancer. Self-efficacy, resilience, emotional approach coping, and emotional regulation abilities are all modifiable factors that can be targeted by clinicians and therapists to decrease the likelihood of patient-perceived negative change and increase perceived positive change. By strengthening these psychosocial factors, individuals may be better prepared to navigate the challenges of cancer survivorship and embrace opportunities for personal development and positive changes in their lives. There is emerging evidence that supports the effectiveness of stress management interventions designed to facilitate perceived growth [54]. Numerous intervention studies in cancer populations have been conducted to enhance self-efficacy [55], resilience [56], and emotional regulation, and coping [57–59]. It is important to recognize that the experience of cancer and its aftermath can involve both positive and negative changes. Healthcare professionals and support networks should consider providing comprehensive support that addresses both positive and negative aspects of survivorship, including promoting resilience, self-efficacy, and emotion regulation.

Acknowledgements

The authors wish to acknowledge the contributions of numerous individuals to the research project from which the data for this study originates: Dr. Tara Sanft, Rajni Mehta, Dr. Kate Dibble, Dr. Kaleigh Ligus, Caroline Salafia, Sinead Sinnott, Katherine Gall, and Zachary Magin.

Funding

This study was funded by the National Cancer Institute (5UH3CA220642).

Role of the Funder

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Compliance with Ethical Standards

Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards The authors declare no conflicts of interest.

Authors’ Contributions Emily Fritzson (Conceptualization [Equal]; Data curation [Equal]; Formal analysis [Lead]; Investigation [Equal]; Writing – original draft [Lead]; Writing – review & editing [Lead]), Keith M. Bellizzi (Conceptualization [Equal]; Funding acquisition [Lead]; Methodology [Lead]; Supervision [Lead]; Writing – review & editing [Supporting]), Na Zhang (Conceptualization [Supporting]; Formal analysis [Supporting]; Supervision [Supporting]; Writing – review & editing [Supporting]), and Crystal L. Park (Conceptualization [Supporting]; Funding acquisition [Lead]; Supervision [Supporting]; Writing – review & editing [Supporting])

Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Connecticut and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained from all individual participants included in the study.

Transparency statements

Study registration: This study was not formally registered. Analytic plan pre-registration: The analysis plan was not formally pre-registered. Data availability: De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author. Analytic code availability: Analytic code used to conduct the analyses presented in this study are not available in a public archive. They could be available by emailing the corresponding author. Materials availability: Materials used to conduct the study are not publicly available.

References