psychosocial factors related to posttraumatic growth in breast cancer survivors: a review

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Psychosocial Factors Related toPosttraumatic Growth in Breast CancerSurvivors: A ReviewPhilippa Kolokotroni MAa, Fotios Anagnostopoulos PhDa & AnnivasTsikkinis MD, PhDb

a Department of Psychology, Panteion University, Athens, Greeceb First Department of Surgery, Elena Venizelou Hospital, Athens,GreeceAccepted author version posted online: 09 Jun 2014.Publishedonline: 01 Aug 2014.

To cite this article: Philippa Kolokotroni MA, Fotios Anagnostopoulos PhD & Annivas Tsikkinis MD, PhD(2014) Psychosocial Factors Related to Posttraumatic Growth in Breast Cancer Survivors: A Review,Women & Health, 54:6, 569-592, DOI: 10.1080/03630242.2014.899543

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Women & Health, 54:569–592, 2014Copyright © Taylor & Francis Group, LLCISSN: 0363-0242 print/1541-0331 onlineDOI: 10.1080/03630242.2014.899543

Psychosocial Factors Related to PosttraumaticGrowth in Breast Cancer Survivors: A Review

PHILIPPA KOLOKOTRONI, MA,and FOTIOS ANAGNOSTOPOULOS, PhD

Department of Psychology, Panteion University, Athens, Greece

ANNIVAS TSIKKINIS, MD, PhDFirst Department of Surgery, Elena Venizelou Hospital, Athens, Greece

In this article, we reviewed quantitative studies regardingpsychosocial factors associated with posttraumatic growth (PTG)in patients with breast cancer to elucidate our understandingof a model of PTG process. PsycInfo, Embase, Medline, Web ofKnowledge were used for the search. Only quantitative, Englishwritten studies that used the Posttraumatic Growth Inventory(PTGI) measure administered to breast cancer patients wereincluded. The initial search yielded 90 publications. Of those,22 studies satisfied inclusion criteria and formed the basis of thereview. Personality traits (e.g., optimism and openness), cognitiveprocessing of cancer (e.g., deliberate rumination), perceived threatof the disease, coping strategies (e.g., problem-focused), and socialsupport were identified to be related to PTG in women with breastcancer. Demographic characteristics (e.g., age at cancer diagno-sis) were also found to play a key role in PTG. The findings of thisreview provided support to Tedeschi and Calhoun’s functional–de-scriptive model of PTG process. Further directions for research andclinical implications are provided.

KEYWORDS posttraumatic growth, breast cancer, personality,coping, social support, cognitive processing

Received October 6, 2013; revised January 22, 2014; accepted February 23, 2014.Address correspondence to Philippa Kolokotroni, MA, Department of Psychology,

Panteion University, 136 Sygrou Avenue, Postal Code 17671, Athens, Greece. E-mail:[email protected]

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570 P. Kolokotroni et al.

A large number of studies (e.g., Alter et al., 1996; Andrykowski et al.,1998) focused on the negative responses a traumatic event may trigger,such as psychological distress, depression, irritability, and unpleasant phys-ical reactions. A traumatic event may shatter individuals’ core assumptionsand beliefs about life benevolence and justice, which need to be rebuilt inorder to reduce psychological distress (Jannof-Bulman, 2004). Current litera-ture suggests that trauma may be associated with positive changes, as well(e.g., Cordova et al., 2007; Frazier & Kaler, 2006; Linley & Joseph, 2004).Tedeschi and Calhoun (1995, 2004a) introduced the term “posttraumaticgrowth” (PTG) to describe the positive changes observed after a trau-matic event, changes that go beyond the pretrauma adjustment level.People report PTG on the most important domains of their life, such asan increased appreciation for life and changes in priorities, more essentialrelationships with others, a sense of increased personal strength, new pos-sibilities for the future, and existential/spiritual thrive (Tedeschi & Calhoun,2004a).

Based on Schaefer and Moos’ coping theory (1992), Tedeschi andCalhoun (1995, 2004a) attempted to systematically describe how variouspsychosocial factors relate to the different domains of PTG. They con-cluded with a functional-descriptive model of PTG consisting of feedbackloops including intrapersonal and interpersonal elements, which lead to PTG(Tedeschi & Calhoun, 1995, 2004a). The subjective appraisal of traumaticevent severity (Widows et al., 2005) generates emotional distress that acti-vates a process aiming to reduce psychological discomfort. Rumination oftraumatic information, automatic in the beginning and gradually more delib-erate, reflects the activation of cognitive processing, which aims at rebuildingthe shattered fundamental assumptions (Janoff-Bulman, 1992; Tedeschi &Calhoun, 1995, 2004a). Rumination is conceptualized as “a mode of respond-ing to distress that involves repetitively and passively focusing on symptomsof distress and on the possible causes and consequences of these symp-toms” (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008, p. 400). Althoughrumination has a negative nuance, repetitive purposeful thoughts may facil-itate meaning, restoration, and PTG (Jim & Jacobsen, 2008; Tedeschi &Calhoun, 2004a). Tedeschi and Calhoun (2004a) also pointed out that copingprocesses play a key role in the development of PTG. Coping is concep-tualized as cognitive and behavioral mechanisms that people use to dealwith the distress caused by a demanding experience (Lazarus & Folkman,1984). Personality characteristics such as optimism, openness, resilience, andself-efficacy are also included in the functional-descriptive model of PTG(Tedeschi & Calhoun, 2004a), as well as a supportive social environmentthat provides individuals with information and allows them to talk about thetrauma facilitates the cognitive processing and seems to play a significantrole in the PTG process (Tedeschi & Calhoun, 2004a).

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Posttraumatic Growth in Breast Cancer Survivors 571

AIM OF REVIEW

This review is an attempt to identify intrapersonal and interpersonal vari-ables related to PTG among breast cancer patients, based on Tedeschi andCalhoun’s (2004a) theory. This review does not intend to examine the natureand the mechanisms of the PTG phenomenon. Instead, it intends to organizewhat we already know about the PTG associated factors among breast can-cer patients. It focuses on the relationships between the different categoriesof psychosocial variables that have been examined (e.g., sociodemographiccharacteristics, personality traits, cognitive processing, and coping). To ourknowledge, this is the first review on the psychosocial variables related toPTG among breast cancer patients. The diagnosis and treatment of cancershare many common features with other traumas. However, cancer as atrauma has some distinguished characteristics which may affect the PTGprocess in certain ways. More particularly, the stressor does not come fromthe environment, but it has an internal character, it involves an uncertainfuture and not a demanding past experience, while it is not easy to iden-tify a specific cancer-related stressor that emerges in a certain time (Sumalla,Ochoa, & Blanco, 2009). Breast cancer is the most common malignancyamong women. Approximately 232,340 new cases of invasive breast cancerand 64,640 of in situ breast cancer are estimated to be diagnosed in theUnited States during 2013 (American Cancer Society, 2013). As the survivalrate for breast cancer patients improves, a greater number of survivors whoexperience the long-lasting consequences of malignancy exists.

METHODS

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were defined to make a careful selection ofstudies that would inform us about the literature in the area of PTG and indi-vidual differences among breast cancer patients. Only original, quantitativestudies that attempted to examine the relationship between PTG and a vari-ety of psychosocial factors were included in this review. These studies shouldhave used the Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1996),which conceptualizes PTG as positive changes that go beyond pretraumalevels of adjustment. Selected studies included one or more psychosocial fac-tors associated with PTG. Only English language papers published after 1996(when Posttraumatic Growth Inventory [PTGI] was constructed; Tedeschi &Calhoun, 1996) were included. The population of interest was women witha breast cancer diagnosis.

Although PTG and several other terms such as stress-related growth(Park, Cohen, & Murch, 1996), adversarial growth (Linley & Joseph, 2004),

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benefit finding (Affleck & Tennen, 1996) or thriving (Carver et al., 1989),had been used interchangeably, only PTG conceptualized the post traumapositive changes as a possible outcome of a highly stressful crisis (and notas a coping mechanism), as actual changes and not illusions, and finally asa psychological situation that might coexist with distress. We opted to usethe term “posttraumatic growth” because it “best and most clearly expressedthe meaning of the phenomenon: The term ‘posttraumatic’ emphasized thatgrowth happens in the aftermath of an extremely stressful event (traumaticevent), not as the result of any minor stress or as a part of a naturaldevelopmental process” (Zoellner & Maercker, 2006, p. 628).

Studies included in this review were further evaluated for methodologi-cal quality. Specifically, studies were assessed regarding (a) the study design,(b) socio-demographic characteristics of the sample, (c) PTG as an outcomeand the method of its assessment, (d) potential psychosocial factors related toPTG and the method of their assessment, (e) time period of the assessment,and (f) domains of PTG affected and potential association with a variety ofpsychosocial factors.

Search Strategy

Four electronic databases (PsycInfo, Embase, Medline, and Web ofKnowledge) were systematically searched using search terms found in therelevant literature. The time frame of the research was 1996–2013. Thefollowing search terms (and their combinations) were used: posttraumaticgrowth, stress-related growth, breast cancer, personality, predictors, opti-mism, openness, extraversion, locus of control, hardiness, self-efficacy, senseof coherence, explanatory style, coping, cognitive processing, rumination,and social support. Abstracts and, on occasion, full articles, were examinedto determine whether the work met the inclusion criteria. To ensure method-ical search, additional methods were implemented, including searching thereference list of retrieved articles to identify studies that did not come upduring the electronic search and the manual searching of relevant textbooksand journals.

Search Results

EXCLUDED STUDIES

The initial search identified 90 potentially relevant studies (journal articlesand dissertations). After an examination of the abstracts and the full papers,68 studies were excluded because they were review articles, did not measurePTG as an outcome variable, assessed only psychometric properties of PTGI,did not use PTGI to assess PTG, were non-English papers, were interventionstudies, did not use samples of breast cancer patients, used qualitative or

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mixed methodology, did not assess PTG, or did not assess potential factorsrelated to PTG.

INCLUDED STUDIES

The final sample consisted of 22 journal articles and dissertations that wererelevant to the review objective. At least one of the aims of the includedpapers should have been the assessment of psychosocial factors related toPTG. In addition, only quantitative measures should have been used for theassessment of independent and dependent variables. Regarding the studydesign, 15 were cross-sectional studies and 7 were longitudinal studies. Timesince cancer diagnosis, cancer stage and size of sample varied across studies.

Sociodemographic and disease-related factors, age at diagnosis (Bellizzi,2003; Bellizzi & Blank, 2006; Cordova et al., 2007; Gallagher-Ross, 2011);marital status, employment, and lower education (Bellizzi, 2003; Bellizzi &Blank, 2006; Weiss, 2004); income (Cordova et al., 2001), time since diagnosis(Cordova et al., 2001; Hoover, 2005; Lelorain et al., 2010; Manne et al., 2004;Sears, Stanton, & Danoff-Burg, 2003); and some treatment modalities werefound to be related to PTG (Table 1). Younger age seemed to be a significantfactor related to PTG, whereas the relations of other contextual factors, suchas education, socioeconomic status, marital status, and type of treatmentwith PTG, were not robust, or clear (Jim & Jacobsen, 2008; Stanton, Bower,& Low, 2006). The association between race/ethnicity and PTG was assessedby Bellizzi et al. (2010) who reported that religious coping moderated thisrelationship. Other studies failed to find any significant relationship betweenrace and PTG (Manne et al., 2004; Sears et al., 2003). Regarding time elapsedsince cancer diagnosis and its relationship with PTG, a number of studiesreported that more time since the onset of breast cancer was associatedwith greater PTG. In only one study (Weiss, 2004), time since diagnosis wasinversely related to PTG. A number of studies failed to find any significantassociation between PTG and time since diagnosis (Bellizzi & Blank, 2006;Cohen & Numa, 2011; Cordova et al., 2007; Svetina & Nastran, 2012).

A number of included papers demonstrated that the more cancer wasappraised as stressful the higher the degree of PTG that was reported(Bellizzi, 2003; Cordova et al., 2001, 2007; Gallagher-Ross, 2011). Otherstudies reported no significant association between PTG and perceivedstressfulness of breast cancer (Manne et al., 2004; Weiss, 2004). It is note-worthy that Manne et al. (2004), who did not find subjective stressfulnessto be associated with PTG, used the intrusion subscale of Impact of EventScale (IES). Cordova et al. (2001) also did not find any association betweenIES scores and PTG. Stanton et al. (2006) speculated that these insignificantresults might be due to the fact that IES was not an appropriate indicator ofperceived stressfuleness.

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TAB

LE1

Rev

iew

edSt

udie

s

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Bel

lizzi

etal

.(2

010)

Unite

dSt

ates

802

57,2

6m

onth

saf

ter

dia

gnosi

s,24

month

saf

ter

bas

elin

e,35

month

saf

ter

bas

elin

e

Longi

tudin

alO

ptim

ism

(LO

T-R

),Rel

igio

sity

(Duke

Rel

igio

nIn

dex

)

No

rela

tion

bet

wee

noptim

ism

and

PTG

.Rel

igio

us

copin

gas

am

edia

tor

bet

wee

nra

cean

dPTG

.B

elliz

zi&

Bla

nk

(200

6)

Unite

dSt

ates

215

601–

4ye

ars

post

trea

tmen

tCro

ss-

sect

ional

Age

atdia

gnosi

s,m

arita

lst

atus,

emplo

ymen

t,ed

uca

tion,

per

ceiv

edin

tensi

tyof

dis

ease

,an

dac

tive

copin

gac

counte

dfo

r34

%,35

%,an

d28

%ofth

eva

rian

cein

grow

thin

rela

tionsh

ipw

ithoth

ers,

new

poss

ibili

ties,

and

appre

ciat

ion

of

life,

resp

ectiv

ely.

Optim

ism

(LO

T-R

),Copin

g(B

rief

CO

PE)

Hope

(HO

PE

scal

e)

Age

atdia

gnosi

s,m

arita

lst

atus,

emplo

ymen

t,ed

uca

tion,

per

ceiv

edin

tensi

tyof

dis

ease

,an

dac

tive

copin

gpre

dic

ted

dom

ains

ofPTG

.N

ore

latio

nbet

wee

noptim

ism

and

PTG

.

574

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Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Bel

lizzi

(200

3)dis

.U

nite

dSt

ates

215

601–

4ye

ars

post

trea

tmen

tCro

ss-s

ectio

nal

Optim

ism

(LO

T-R

),Copin

g(B

rief

CO

PE)

Hope

(HO

PE

scal

e)

Optim

ism

,H

ope,

time

since

illnes

s,su

rgic

alpro

cedure

,prior

hea

lthst

atus,

child

ren,

ethnic

itydo

not

pre

dic

tPTG

.B

ozo

etal

.(2

009)

Turk

ey10

446

,28

2–27

6m

onth

saf

ter

dia

gnosi

sCro

ss-s

ectio

nal

Optim

ism

(LO

T-R

)Per

ceiv

edso

cial

support

(MSP

SS)

Optim

ism

and

soci

alsu

pport

pre

dic

tPTG

.Buss

ellet

al.

(201

0)U

nite

dSt

ates

T1

=59

,T2

=24

T1

=50

yrs

(mea

nag

e),

T2

=49

yrs

(mea

nag

e)

During

chem

oth

erap

y-

at2-

year

follo

wup

Longi

tudin

alCopin

g(B

rief

CO

PE)

Rel

igio

n,posi

tive

refr

amin

g&

acce

pta

nce

acco

unte

dfo

rth

e46

%ofPTG

.Copin

gm

oder

ates

the

rela

tionsh

ipbet

wee

nPTG

-cogn

itive

pro

cess

ing.

Büyü

kasi

k-Çola

ket

al.

(201

2)

Turk

ey90

45.3

72–

60m

onth

sCro

ss-s

ectio

nal

Optim

ism

(LO

T-R

)Copin

g(W

ays

ofCopin

g)

Pro

ble

m-focu

sed

copin

gm

edia

tedis

posi

tional

optim

ism

-post

trau

mat

icgr

ow

thre

latio

n.

(Con

tin

ued

)

575

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TAB

LE1

Rev

iew

edSt

udie

s(C

onti

nu

ed)

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Chan

etal

.(2

011)

Chin

a17

048

.36

4.14

–34.

30m

onth

sCro

ss-s

ectio

nal

Neg

ativ

ean

dposi

tive

atte

ntio

nal

bia

s(C

APN

IS),

Stre

ss-r

elat

edru

min

atio

n(C

IES-

R).

Posi

tive

atte

ntio

nal

bia

san

dposi

tive

cance

r-re

late

dru

min

atio

nw

ere

posi

tivel

yre

late

dto

PTG

.

Cohen

&N

um

a(2

011)

Isra

el12

4(v

ol.8

4)59

,26

(mea

nag

e)(n

on

vol.

40)

58,6

8(m

ean

age)

Ave

rage

(volu

nte

ers)

:12

.5post

dia

gnosi

sAve

rage

(non-

volu

nte

ers)

:7.

5post

dia

gnosi

s

Cro

ss-s

ectio

nal

Em

otio

nal

pro

cess

ing

(EEPS)

.Cogn

itive

pro

cess

ing

(CPS)

.So

cial

support

(MSP

SS).

Cogn

itive

and

emotio

nal

pro

cess

ing

wer

esi

gnifi

cant

pre

dic

tors

of

PTG

.Per

ceiv

edso

cial

support

faile

dto

pre

dic

tPTG

.

576

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ded

by [

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on U

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rsity

] at

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51 0

5 Se

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ber

2014

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Cord

ova

etal

.(2

007)

Unite

dSt

ates

6552

.3Ave

rage

:9

month

spost

dia

gnosi

s

Cro

ss-s

ectio

nal

Appre

ciat

ion

of

life

and

inte

rper

sonal

rela

tionsh

ips

wer

em

ost

freq

uen

tlyid

entifi

ed.N

ewopportuniti

esw

ere

leas

tfr

equen

tlyid

entifi

ed.

Soci

alConst

rain

ts(S

CS)

Younge

rag

ean

dper

ceptio

nof

cance

ras

atrau

mat

icst

ress

or

wer

eas

soci

ated

with

grea

ter

PTG

.St

age

ofdis

ease

or

trea

tmen

tw

ere

notre

late

dto

PTG

.So

cial

const

rain

tsw

ere

unre

late

dto

PTG

Cord

ova

etal

.(2

001)

Unite

dSt

ates

70BC

&70

HC

54.7

and

54.7

>2

month

sto

<5

year

sCro

ss-s

ectio

nal

BC

surv

ivors

reported

grea

ter

grow

thin

rela

tionsh

ips

with

oth

ers,

appre

ciat

ion

of

life

and

spiritu

alch

ange

.

Soci

alsu

pport

(DU

KE-S

SQ),

SCS,

and

Intrusi

on

and

avoid

ance

(IES)

.

Tal

king

about

cance

r,in

com

e,ca

nce

ras

trau

ma

wer

eposi

tivel

yre

late

dto

PTG

.So

cial

support

was

unre

late

dto

PTG

.D

isea

sere

late

dfa

ctors

faile

dto

pre

dic

tPTG

.Cord

ova

(199

9)dis

.U

nite

dSt

ates

70BC

&70

HC

54.7

and

54.7

>2

month

sto

<5

year

sCro

ss-s

ectio

nal

Soci

alsu

pport

(DU

KE-S

SQ),

Soci

alco

nst

rain

ts(S

CS)

,In

trusi

on

&av

oid

ance

(IES)

.

Gre

ater

soci

alco

nst

rain

tsre

late

dto

inhib

ited

cogn

itive

pro

cess

ing

and

intu

rnto

less

PTG

.

(Con

tin

ued

)

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] at

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TAB

LE1

Rev

iew

edSt

udie

s(C

onti

nu

ed)

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Gal

let

al.

(201

1)Can

ada

8760

.95

(T1)

2–4

day

saf

ter

bio

psy

,(T

2)1

wee

kpre

surg

ery,

(T3)

1,(T

4)6,

(T5)

12,(T

6)24

month

spost

surg

ery.

Longi

tudin

alA

ppra

isal

of

cance

rse

verity

Rel

igio

us

open

nes

san

dpar

ticip

atio

nG

od

imag

e(G

IS)

God

imag

edes

crip

tions

(GID

)Rel

igio

us

Copin

g(R

CO

PE)

Rel

igio

us

invo

lvem

entat

pre

-dia

gnosi

sw

aspre

dic

tive

of

less

PTG

at24

month

spost

-surg

ery.

Neg

ativ

eas

pec

tsofsp

iritu

ality

wer

em

ore

consi

sten

tlyre

late

dto

grow

th.

Gal

lagh

er-

Ross

(201

1)dis

.

Unite

dSt

ates

142

45.8

56–

60m

onth

sCro

ss-s

ectio

nal

Younge

rag

ew

asnotas

soci

ated

with

appre

ciat

ion

oflif

ean

dnew

poss

ibili

ties.

Thre

atprim

ary

appra

isal

and

har

m/lo

ssw

asnotre

late

dto

spiritu

alch

ange

.

Har

din

ess

(DRS)

Attac

hm

ent

(ECRR)

Cogn

itive

Appra

isal

(CA

HS)

Young

age

and

thre

at/ch

alle

nge

prim

ary

appra

isal

pre

dic

ted

PTG

.H

ardin

ess

and

atta

chm

entfa

iled

topre

dic

tPTG

.Fa

ctors

wer

eas

soci

ated

with

dom

ains

ofPTG

indiffe

rent

pat

tern

s.

578

Dow

nloa

ded

by [

Ast

on U

nive

rsity

] at

01:

51 0

5 Se

ptem

ber

2014

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Ho

etal

.(2

011)

Hong

Kong

9046

.89

7m

onth

s–9

year

sCro

ss-s

ectio

nal

Optim

istic

expla

nat

ory

styl

eis

rela

ted

toin

trap

erso

nal

dim

ensi

ons

of

PTG

butnotto

inte

rper

sonal

dim

ensi

ons.

Attributio

nal

styl

e(A

SQ),

IES

Optim

istic

expla

nat

ory

styl

efo

rgo

od

even

tspre

dic

tspost

trau

mat

icgr

ow

th.

Hoove

r(2

005)

dis

Unite

dSt

ates

6156

.05

>1

year

post

dia

gnosi

sCro

ss-s

ectio

nal

Tim

esi

nce

dia

gnosi

sw

asposi

tivel

yas

soci

ated

with

appre

ciat

ion

of

life

subsc

ale.

Copin

g(C

OPE)

Per

ceiv

edso

cial

support

(SSQ

)

More

trea

tmen

tsw

ere

asso

ciat

edw

ithhig

her

PTG

.Q

uan

tity

ofso

cial

support

pre

dic

ted

PTG

.Le

lora

inet

al.

(201

0)Fr

ance

307

62.4

5–15

year

saf

ter

dia

gnosi

sCro

ss-s

ectio

nal

Copin

g(B

rief

CO

PE)

Posi

tive

affe

ctiv

ity(P

AN

AS)

Dis

posi

tional

posi

tive

affe

ctiv

ityan

dad

aptiv

eco

pin

g(a

ctiv

e,posi

tive,

rela

tional

and

relig

ious

copin

g)hav

est

rong

effe

cton

PTG

.M

anne

etal

.(2

004)

Unite

dSt

ates

162

49T1

(after

trea

tmen

t),T2

(9m

onth

saf

ter

the

bas

elin

eas

sess

men

t),T3

(18

month

saf

ter

the

bas

elin

eas

sess

men

t)

Longi

tudin

alPosi

tive

reap

pra

isal

(CO

PE),

Em

otio

nal

pro

cess

ing

(EPS)

,M

arita

lsa

tisfa

ctio

n,IE

S

Cogn

itive

and

emotio

nal

pro

cess

ing

pre

dic

tPTG

.

(Con

tin

ued

)

579

Dow

nloa

ded

by [

Ast

on U

nive

rsity

] at

01:

51 0

5 Se

ptem

ber

2014

TAB

LE1

Rev

iew

edSt

udie

s(C

onti

nu

ed)

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Sear

s(2

004)

dis

.U

nite

dSt

ates

T1

(bas

elin

eas

sess

men

t)=

92,T2

(2m

onth

saf

ter

bas

elin

e)=

92T3

(12

month

saf

ter

bas

elin

e)=

60

51.5

7T1

(after

prim

ary

med

ical

trea

tmen

tco

mple

tion-

bas

elin

eas

sess

men

t)T2

(3m

onth

saf

ter

bas

elin

eas

sess

men

t)T3

(12

month

saf

ter

bas

elin

eas

sess

men

t)

Longi

tudin

alO

ptim

ism

(LO

T-R

),Posi

tive

reap

pra

isal

copin

g(C

OPE)

Hope

(HO

PE

scal

e),IE

S

Optim

ism

and

Posi

tive

reap

pra

isal

copin

gar

ere

late

dposi

tivel

yto

PTG

.

Sear

set

al.

(200

3)U

nite

dSt

ates

T1

(bas

elin

eas

sess

men

t)=

92,T2

(3m

onth

saf

ter

bas

elin

e)=

92T3

(12

month

saf

ter

bas

elin

e)=

60

51.5

7T1

(after

prim

ary

med

ical

trea

tmen

tco

mple

tion-

bas

elin

eas

sess

men

t)T2

(3m

onth

saf

ter

bas

elin

eas

sess

men

t)T3

(12

month

saf

ter

bas

elin

eas

sess

men

t)

Longi

tudin

alO

ptim

ism

(LO

T-R

),H

ope

(HO

PE

scal

e)Posi

tive

reap

pra

isal

copin

g(C

OPE)

Intrusi

on

&Avo

idan

ce(I

ES)

Optim

ism

and

Posi

tive

reap

pra

isal

copin

gar

ere

late

dposi

tivel

yto

PTG

.G

reat

erper

ceiv

edca

nce

rst

ress

and

longe

rdia

gnosi

sdura

tion

pre

dic

ted

PTG

.So

cio-

dem

ogr

aphic

fact

ors

faile

dto

pre

dic

tPTG

.

580

Dow

nloa

ded

by [

Ast

on U

nive

rsity

] at

01:

51 0

5 Se

ptem

ber

2014

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Silv

aet

al.

(201

2)Portuga

l50

52.1

T1

(tim

eof

surg

ery)

T2

(during

adju

vant

trea

tmen

t)T3

(6m

onth

spost

trea

tmen

t)

Longi

tudin

alPer

sonal

reso

urc

esan

dsk

ills,

new

poss

ibili

ties

and

life

appre

ciat

ion,

stre

ngt

hen

ing

of

soci

alre

latio

nsh

ips,

spiritu

aldev

elopm

ent

Copin

gst

rate

gies

(Brief

CO

PE).

PTG

occ

urr

edsh

ortly

afte

rtrea

tmen

t.Copin

gst

rate

gies

such

aspla

nnin

g,ac

cepta

nce

,re

fram

ing,

hum

or,

wer

eposi

tivel

yas

soci

ated

with

PTG

.Se

ekin

gso

cial

support

was

asi

gnifi

cant

pre

dic

tor

ofPTG

.Sv

etin

a&

Nas

tran

(201

2)

Slove

nia

190

61.7

1-5

year

sCro

ss-s

ectio

nal

Fam

ilyre

latio

nsh

ips

(FACES

IV)

Copin

gSt

rate

gies

(CRI)

Fam

ilyre

late

dfa

ctors

pre

dic

ted

PTG

more

than

copin

g-re

late

dst

rate

gies

and

soci

o-

dem

ogr

aphic

sfa

ctors

.

(Con

tin

ued

)

581

Dow

nloa

ded

by [

Ast

on U

nive

rsity

] at

01:

51 0

5 Se

ptem

ber

2014

TAB

LE1

Rev

iew

edSt

udie

s(C

onti

nu

ed)

Study

Country

NA

ge(m

ean

age

inye

ars)

Tim

esi

nce

onse

tSt

udy

des

ign

Dim

ensi

ons

of

PTG

IVar

iable

sre

late

dto

PTG

Res

ults

Wei

ss(2

004)

Unite

dSt

ates

7254

.21-

5.5

year

sCro

ss-s

ectio

nal

Spiritu

alch

ange

was

rela

ted

toed

uca

tion.

Rel

atin

gto

oth

ers

was

asso

ciat

edto

grea

ter

husb

and

support

Soci

alsu

pport

(SSQ

)Q

ual

ityof

rela

tionsh

ip(Q

RI)

Exp

osu

reto

am

odel

ofposi

tive

chan

ges

pre

dic

ted

PTG

.M

arita

lem

otio

nal

support

pre

dic

ted

post

trau

mat

icgr

ow

th.Clo

ser

toth

etim

eof

dia

gnosi

san

dlo

wer

educa

tional

leve

lw

ere

rela

ted

tom

ore

PTG

.

Note

:PTG

=post

trau

mat

icgr

ow

th,

LOT-R

=Li

feO

rien

tatio

nTe

st-R

evis

ed,

CARN

IS=

Atten

tion

toPosi

tive

and

Neg

ativ

eIn

form

atio

nSc

ale-

Chin

ese

vers

ion,

CIE

S-R

=Chin

ese

vers

ion

of

Impac

tof

Eve

ntSc

ale–

Rev

ised

,EPS

=Em

otio

nal

Pro

cess

ing

Scal

e,CPS

=Cogn

itive

Pro

cess

ing

Scal

e,M

SSS

=The

Multi

dim

ensi

onal

Scal

eofPer

ceiv

edSo

cial

Support,SC

S=

Soci

alConst

rain

tsSc

ale,

DU

KE-S

SQ=

Duke

–UN

CFu

nct

ional

Soci

alSu

pport

Ques

tionnai

re,IE

S=

Impac

tofEve

ntSc

ale,

GIS

=G

od

Imag

eSc

ale,

RCO

PE

=Rel

igio

us

CO

PE,D

RS

=D

isposi

tional

Res

ilien

ceSc

ale,

ECRR

=Exp

erie

nce

sin

Clo

seRel

atio

nsh

ips-

Rev

ised

,CAH

S=

Cogn

itive

Appra

isal

ofH

ealth

Scal

e,ASQ

=A

ttributio

nal

Styl

eQ

ues

tionnai

re,C

OPE

=Copin

gIn

vento

ry,S

SQ=

Soci

alSu

pport

Ques

tionnai

re,P

AN

AS

=Posi

tive

and

Neg

ativ

eA

ffec

tSc

hed

ule

,Q

RI=

Qual

ityofRel

atio

nsh

ipIn

vento

ry,dis

=D

isse

rtat

ion.

582

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ber

2014


Eleven studies examined the relationship between personality traits(optimism, negative and positive attentional bias, hardiness and attachment,attributional style, positive affectivity, and hope) and PTG. The results ofthis review regarding the relationship between dispositional optimism andPTG were ambiguous and contradictory. In particular four studies (Bozo,Gündogdu, & Büyükasik-Colak, 2009; Büyükasik-Çolak, Gundogdu-Akturk,& Bozo, 2012; Sears, 2004; Sears et al., 2003) found a positive relation-ship between optimism and PTG, whereas (Bellizzi 2003; Bellizzi & Blank,2006; Bellizzi et al., 2010) failed to find any association between these twofactors. However, participants who used to attribute positive personal expe-riences to internal, global and stable causes were likely to report higherlevel of posttraumatic growth (Ho et al., 2011). In addition, positive atten-tional bias was positively related to PTG (Chan et al., 2011). Hope (Bellizzi,2003; Bellizzi & Blank, 2006; Sears, 2004; Sears et al., 2003), hardiness, andattachment style (Gallagher-Ross, 2011) were not significantly related to PTG.

Social support, in the form of perceived social support, talking to othersabout cancer, seeking social support, and supportive family relationships, aswell as social constraints (“negative social responses to disclosure of cancer-related concerns” [Cordova et al., 2007, p. 310]) was assessed in eight studies.Findings were quite contradictory. Three studies failed to find any significantassociation between social support and PTG (Cohen & Numa, 2011; Cordovaet al., 2001; Weiss, 2004). On the other hand, Bozo et al. (2009) reported asignificant positive association between PTG and social support, Cordovaet al. (2001, p. 182) reported that “talking about cancer predicted PTG,”while Cordova (1999) found that greater social constraints related to inhib-ited cognitive processing which in turn related to less PTG. Hoover (2005)reported that quantity of social support was associated with PTG. Svetina& Nastran (2012) and Weiss (2004) suggested that family relationships andmarital support were related to more PTG.

The relations between cognitive and emotional processing and PTGwere assessed in only three studies, and the results showed that positivecancer-related rumination (e.g., the positive sides of the disease are the cen-ter of attention; Chan et al., 2001), cognitive (e.g., “seeking a reason forthe traumatic event”; Cohen & Numa, 2010, p. 69) and emotional process-ing (e.g., “to understand . . . the feelings evoked by the trauma”; Cohen &Numa, 2011, p. 69), and more contemplate reason for breast cancer (Manneet al., 2004) were positively associated with PTG. The association betweena variety of coping strategies and PTG was investigated in nine studies andthe results demonstrated a rather robust association between PTG and mul-tiple coping strategies. Specifically, some aspects of religious coping (e.g.,collaborative) were positively associated with PTG (Bellizzi et al., 2010;Bussell & Naus, 2010; Gall, Charbonneaua, & Florack, 2011; Lelorain et al.,2010), including active coping techniques (e.g. planning; Bellizzi & Blank,2006; Lelorain et al., 2010), positive reframing, and acceptance (e.g., “see

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a stressful situation in a more positive light”; Bussell & Naus, 2010; Searset al., 2003; Silva, Crespo, & Canavarro, 2012, p. 1326), problem-focusedcoping (Buyukasik-Colak et al., 2012), and humor (“e.g., to have a humorousapproach to breast cancer”; Silva et al., 2012, p. 1327).

DISCUSSION AND CONCLUSION

The aim of this review was to examine studies that had focused onpsychosocial factors related to PTG in women with breast cancer, to describea pathway model of PTG. The findings seem to provide support for thefunctional-descriptive model of Tedeschi and Calhoun (1995, 2004a). PTGdoes not develop automatically and does not relate directly to breast can-cer experience. Several psychosocial factors seemed to fulfill sophisticatedfunctions during the PTG process (Figure 1).

The perceived threat of breast cancer seems to shatter the existing fun-damental beliefs of patients, cause higher levels of intrusion and avoidance,and elicit different coping strategies (Cordova et al., 2001; Sears et al., 2003).It seems that this was a more significant factor related to PTG than the dis-ease and treatment-related factors (Cordova et al., 2001). These findings are

Trauma

Subjective appraisal of threat

Personality characteristics

(e.g., optimistic explanatory style)

Different types of cognitive processing

(e.g., automatic rumination)

Coping strategies(e.g., religious

coping, positive reframing)

Socialsupport

Posttraumatic growth(multiple dimensions)

FIGURE 1 Hypothesized model of posttraumatic growth in patients with breast cancer.Personality Characteristics: e.g., optimism, optimistic explanatory style, dispositional positiveaffectivity.Types of cognitive processing: e.g., automatic rumination, deliberate rumination, emotionalprocessing.Coping strategies: e.g., religious coping, positive reframing, acceptance, humor, planning.Social support: e.g., perceived social support, exposure to a peer-to-peer model of positivechanges, social constraints.

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consistent with the notion that traumatic life events have a “seismic” charac-ter, generate a high level of distress that requires further cognitive processingand core beliefs reconstruction (Janoff-Bulman, 2004; Tedeschi & Calhoun,2004a). However, issues of operationalization of subjective threat of cancershould be taken into account in the future.

Personality traits, such as optimism (Bozo et al., 2009; Büyükasik-Çolaket al., 2012; Sears et al., 2003), optimistic explanatory style and dispositionalpositive affectivity (Lelorain et al., 2010) were found to be related to PTG,as well as to cognitive processing and coping strategies (Bozo et al., 2009;Büyükasik-Çolak et al., 2012; Lelorain et al., 2010; Sears et al., 2003; Tennen& Affleck, 1998). The findings confirmed Tedeschi and Calhoun’s (1995)theory, which suggested a complex relationship between the traumatic event,personality traits, coping, and PTG process. It is noteworthy that only anarrow range of personality variables has been assessed in breast cancerpatients, whereas traits such as openness (Tennen & Affleck, 1998; Zoellner& Maercker, 2006) have not yet been investigated in relation to PTG amongbreast cancer patients.

Consistent with Schaefer and Moos’ (1992) coping theory, cognitive pro-cessing of cancer and coping strategies are key factors in the PTG course.Some types of cognitive processes seemed to be related in a more significantway to PTG than others. Intrusive thoughts, indicating a more automaticrumination, may not be associated with PTG (Cordova et al., 2001, 2007;Manne et al., 2004). This finding was consistent with Morris and Shakespeare-Finch’s (2010) findings that deliberate rumination, instead of an intrusive one,was related to PTG. On the other hand, emotional processing was not relatedto PTG, as it might lead to an endless rumination about feelings that can-cer caused (Stanton et al., 2000). Many different types of coping strategiesdemonstrated significant positive associations with PTG. Problem-focusedcoping strategies and positive cognitive-type of coping strategies, such asreligious coping, positive reframing, acceptance, humor and planning, weresignificantly associated with PTG and explained a great amount of PTG vari-ance (Bellizzi & Blank, 2006; Bellizzi et al., 2010; Bussell & Naus, 2010;Büyükasik-Çolak et al., 2012; Gall et al., 2011; Lelorain et al., 2010; Searset al., 2003; Silva et al., 2012). These findings were consistent with Tedeschiand Calhoun’s (1995, 2004a) theory that postulated that positive coping isnecessary for PTG to arise. Personality traits, such as optimism, were relatedto the coping techniques an individual used to deal with the negative con-sequences of the stressful event (Büyükasik-Çolak et al., 2012). As a copingstrategy, “talking about cancer” was associated with PTG, reflecting individu-als’ engagement to more cognitive processing of cancer and their intentionalattempts to restore the core beliefs that were shattered because of the cancerdiagnosis (Calhoun & Tedeschi, 2000; Cordova et al., 2001). Moreover, talk-ing about cancer facilitates the sense of belonging and the meaning search(Cordova et al., 2001; Manne et al., 2004).

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A number of studies suggested that multiple aspects of social sup-port had a significant relationship with PTG (Bozo et al., 2009; Cordovaet al., 2001; Hoover, 2005; Svetina & Nastran, 2012; Weiss, 2004). Consistentwith a previous review (Jim & Jacobsen, 2008), women who sought andperceived more social support, tended to express their thoughts and feel-ings about cancer. Exposure to a peer-to-peer model of positive changes,namely talking with a breast cancer survivor who had experienced PTG,has been found to be a significant contextual factor that facilitates cogni-tive processing of cancer and offers an alternative perspective on thinkingabout malignancy. It seems that the way others react to a woman’s needto talk about cancer is an important issue (Silva et al., 2012), though socialconstraints fail to relate to PTG (Cordova et al., 2007). Further investigationinto the role of social constraints could help explain the function of inhib-ited expression of cancer-related thinking and feeling among breast cancerpatients. Furthermore, certain social support sources were found to be asso-ciated more strongly with growth than other factors (Hoover, 2005). Maritaland family relationships seem to have a strong influence on breast cancerpatients’ ability to experience positive changes when struggling with cancer(Bozo et al., 2009; Manne et al., 2004; Svetina & Nastran, 2012; Weiss, 2004).A supportive partner, and a supportive family offers a “safe place” where thepatient can bear the distress cancer causes, can focus on the new traumaticinformation and make a new narrative about her life including breast cancerexperience (Weiss, 2004). Although attachment style was not associated withPTG (Gallagher-Ross, 2011) different aspects of the way patients relate toothers, either as personality traits or coping techniques, as well as the qual-ity of social relationships, should be investigated regarding their influenceon cognitive processing and PTG development. Personality characteristics,such as optimism may affect the way people perceive the available supportprovided by their social network and use it (Harper et al., 2007).

With reference to the sociodemographic variables, age at cancer diag-nosis appeared to be a consistent factor related to PTG. Younger womenwere more likely to report self-perceived PTG, than older women (Bellizzi,2003; Bellizzi & Blank, 2006; Gallagher-Ross, 2011; Manne et al., 2004).We speculate that young women suffer more psychological distress becauseof the cancer diagnosis, given that their fundamental beliefs about them-selves and life are disconfirmed; so they have more opportunities to activatePTG mechanisms (Janoff-Bulman, 1992; Tedeschi & Calhoun, 2004a).

One of the most significant findings of this review is the multidimen-sionality of PTG as different dimensions of PTG were related to differentpsychosocial factors, constructing multifaceted pathways (Bellizzi & Blank,2006). For example, an optimistic explanatory style seems to relate onlyto the intrapersonal dimensions of PTG (e.g., “spiritual and life orientationdomains”; Chan et al., 2011, p. 547), revealing that personality variables mayinfluence specific aspects of growth and this information would have been

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lost if total PTG scores had only been used. Moreover, temporal parametersof PTG seemed to play a significant role in the way factors were related toPTG (e.g., Bussell & Naus, 2010).

The included papers varied regarding the study design and sample size.Thus, some of the inconsistencies in the findings may have been due to suchdifferences. For example, although the relationship between optimism andPTG seemed to be unclear regardless of whether the studies were cross-sectional or longitudinal, the time of assessment since diagnosis may havehad some impact on the relationship between independent variables andPTG. When the first administration was close to diagnosis (e.g., Silva et al.,2012; Sears et al., 2003), it seemed that more significant relations were foundbetween PTG and factors such as optimism or coping, than when the base-line measurement occurred in a later period (Weiss, 2004). In the presentreview, the size of sample greatly varied, but this variation did not seem toaccount for the contradictory findings. Moreover, the majority of the includedpapers conducted statistical analysis, such as multiple regressions, to exam-ine the relations between PTG and independent factors with adjustment forpotential confounding variables (e.g., Gall et al., 2011; Manne et al., 2004) sothat the differences in findings were not likely due to uncontrolled confound-ing, although they might have been due to control for different confoundingvariables across studies.

Limitations

Findings of this review should be interpreted after taking into consider-ation several methodological limitations. First of all, this review includedonly quantitative studies, excluding studies that used a qualitative or mixedmethodology design and, thus, a better understanding of the PTG phe-nomenon in women with breast cancer might be constricted to some extent.In addition, the failure of some published studies to emerge in the electronicsearch might have affected the present review. However, we tried to diminishthe dissemination bias by reviewing the reference list of retrieved papers andsearching the reference list of previous review papers. Additionally, thoughthe dependent variable was assessed with the same questionnaire (i.e., PTGI)in all studies, various scales were used to measure the independent variables,such as cognitive and emotional processes, coping processes and social sup-port. This was a barrier for us to evaluate the magnitude of the associations.Furthermore, several studies assessed psychosocial factors in breast cancerpatients at different times in the cancer trajectory, and for this reason it wasdifficult for us to compare their results.

In addition, a number of limitations have been noted in the includedstudies. For example, self-report instruments were used to assess indepen-dent and dependent variables, and consequently reporting bias might haveaffected patients’ responses. Weiss (2004) reported that the use of self-report

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measures did not give any information about the validity of PTG reports.Future studies should evaluate significant others’ perspective on patients’PTG and compare these reports with patients’ self-reports of PTG. Silva et al.(2012) and Sears et al. (2003) noted that the small sample of their studies pre-vented them from more informed statistical analyses to take place. In futurestudies, larger samples are necessary for investigators to apply more sophis-ticated statistical techniques and examine direct and indirect relationshipsamong variables. Additionally, Lelorain et al. (2010) noted that that PTGreported by participants might not be due to the struggle with cancer andcomparisons between control groups and cancer patients would be help-ful to confirm statistically significant differences in PTG reports. A furtherlimitation was that most of the studies had a cross-sectional design; thus,conclusions about temporal or causal relationships among variables couldnot be drawn, and the directional nature of the associations could not bedetermined.

Theoretical and Clinical Implications

Future studies should examine whether the relationship betweenpsychosocial factors and PTG is linear or curvilinear. For example, the sever-ity of the disease seemed to have a curvilinear association with PTG. Thisfinding is consistent with previous studies (Lechner et al., 2003; Linley &Joseph, 2004) that have suggested that high levels of distress may help anindividual to experience growth, whereas too much distress may inhibit PTGprocesses. An investigation on the possible curvilinear relationship betweenPTG and independent variables may shed some light on inconsistent findingsin the field of PTG.

The temporal course of PTG in breast cancer patients should be exam-ined in longitudinal studies. Additionally, personality characteristics, suchas openness and extraversion (two of the Big Five personality dimensions,including extraversion, emotional stability, agreeableness, conscientiousness,and openness to experience; McCrea & Costa, 1989), optimistic explanatorystyle (in comparison with dispositional optimism), and the way someone isrelated to others (as a dispositional tendency) should be further assessedin breast cancer patients to obtain a better understanding regarding theirrelationship with PTG and how they are associated with other psychosocialfactors related to PTG, such as cognitive processing and coping. Moreover,future studies should examine the differences between younger and olderbreast cancer patients regarding personality aspects, coping techniques,rumination style and social support in order to understand the inner or exter-nal sources that help younger women to report greater PTG. Various modesof rumination, such as intrusive or deliberate (e.g., goal-related rumination),and reflection (“thinking that is motivated by self-curiosity and a search forself-knowledge” [Kane, 2007, p. 22]) and brooding (“dwelling of negative

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states and/or moods” [Kane, 2007, p. 22]) should be measured by means ofvalid and reliable questionnaires. A more systematic assessment of patients’goals (e.g., disengagement of pretrauma goals) and influence on PTG pro-cess is recommended (Tedeschi & Calhoun, 2004a). Different aspects ofsocial support, such as quality and quantity of a social network, seek-ing social support and social constraints should be systematically assessedregarding their direct effect on PTG, and the indirect one through theireffect on rumination process and coping techniques. Although various stud-ies have examined distinct segments of Tedeschi and Calhoun’s (2004a)model, it would be valuable if future studies would assess concurrentlymultiple variables related to the PTG process to provide researchers witha better understanding of their interrelations and the different tracks PTGmay follow. The cultural dimension of factors potentially related to PTGshould also be assessed in future studies. For example, interpersonal ele-ments of the PTG model, such as social support, should be examined inthe light of cultural differences (Dirik & Karanci, 2008; Tedeschi & Calhoun,2004b).

Psychosocial oncology interventions should take into account the pos-sibility of PTG (apart from psychological distress reports), and cliniciansshould investigate how they can enhance self-perceived PTG throughsociocognitive processing of trauma (e.g., Andersen, 1992; Trijsburg, vanKnippenberg, & Rijpma, 1992). Clinicians should emphasize the endorsementof constructive rumination and active coping strategies, and the improve-ment of personality characteristics that form an appropriate ground forPTG to flourish in a supportive social environment. Intervention studiesshould aim at assessing the possibility to influence factors that may facilitatePTG taking into account the temporal parameters of growth and recog-nizing the concurrent positive and negative narratives of breast cancerexperience.

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psychosocial factors related to posttraumatic growth in breast cancer survivors: a review

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