Due to advances in detection and treatment, approximately 2 in 3 adults diagnosed with cancer today can be expected to survive more than 5 years (Ries et al., 2006
). This improved survival rate, combined with the aging population, has led to a substantial increase in the number of cancer survivors in the U.S., now numbering more than 10.5 million individuals (Ries et al., 2006
). While the medical concerns of cancer survivors are gaining attention (Hewitt, Greenfield, & Stovall, 2005
; President’s Cancer Panel, 2005-2006
), there is also growing interest in understanding their psychosocial concerns.
Cancer diagnosis and treatment, and their sequelae, are typically thought of as adverse experiences. For most individuals, they represent significant stressors, and for some, the diagnosis of cancer is a traumatic event (Kangas, Henry, & Bryant, 2002
; Koopman et al., 2002
). O’Leary and Ickovics have proposed a model to describe three potential responses to adversity (O’Leary & Ickovics, 1995
), which has been further elaborated by Carver (Carver, 1998
). Following initial decline in functioning after adverse experience, Carver describes survival with impairment
as continuing compromised functioning, but he distinguishes this pattern from resilience
, defined as a return to normal or baseline functioning, which is then further distinguished from thriving
, described as exceeding one’s original level of functioning. While most previous work has focused on identifying impairment among cancer survivors, psychological thriving or growth among cancer survivors is of growing interest (Cordova & Andrykowski, 2003
; Cordova, Cunningham, Carlson, & Andrykowski, 2001
; Widows, Jacobsen, Booth-Jones, & Fields, 2005
Understanding the extent to which cancer survivors show psychological impairment, resilience, or thriving necessitates a reference for “normal” or “baseline” functioning. National survey data or health care registries, which include cancer survivors as well as population-based reference groups, partially address this issue. Most studies of this type support the survival with impairment model, with cancer survivors exhibiting greater psychological distress, poorer mental health, greater role impairment due to emotional problems, and poorer social well-being relative to those without a cancer history (Arndt, Merx, Stegmaier, Ziegler, & Brenner, 2004
; Baker, Haffer, & Denniston, 2003
; Hewitt, Rowland, & Yancik, 2003
; Rabin et al., 2007
). The disadvantage of these datasets is that most were designed to focus on broad health outcomes and thus have only brief measures assessing limited domains of psychosocial functioning. Studies designed specifically to address quality of life and psychological well-being among cancer survivors include more comprehensive and detailed psychosocial measures. These studies generally provide contrasting results to the population-based studies, with findings more consistent with the resilience model. For example, studies of breast and gynecologic cancer survivors have found no significant differences between survivors and age-matched comparison groups in multiple domains of psychosocial functioning including mental health, psychological distress, and emotional and social well-being (Bradley, Lutgendorf, Rose, Costanzo, & Anderson, 2006
; Dorval, Maunsell, Deschenes, Brisson, & Masse, 1998
; Ganz, Rowland, Desmond, Meyerowitz, & Wyatt, 1998
; Helgeson & Tomich, 2005
; Wenzel et al., 2002
The source of these discrepant findings is unclear. Brief measures utilized in large-scale population studies may not accurately capture survivors’ psychosocial functioning. On the other hand, studies examining narrower samples of cancer survivors may be less representative of cancer survivors as a whole, and therefore, less likely to include survivors who are functioning poorly. The present study addressed these issues by drawing our sample from the National Survey of Midlife Development in the United States (MIDUS), designed to study health and well-being during midlife. Unlike most national health surveys, MIDUS respondents completed comprehensive batteries of psychosocial measures, thereby also providing the opportunity to compare those with a history of cancer to those with no such history on diverse psychological outcomes. In addition, the MIDUS dataset includes two waves of data, the second obtained approximately 9 years after the initial wave. This afforded the unique opportunity to examine psychological functioning both prior to and following diagnosis among individuals who were diagnosed with cancer between the two assessments. Determining whether the trajectory of pre-to post-diagnosis change was most consistent with impairment, resilience, or thriving models and comparing such dynamics to those without cancer were key objectives of our investigation.
Although most previous studies of cancer survivors focus on mental health symptoms and negative mood, such areas neglect ideas of thriving (i.e., positive psychological outcomes following cancer). The concept of “posttraumatic growth” suggests that individuals often experience transformations in self-perceptions, life philosophies, and interpersonal relationships following traumatic experience (Tedeschi & Calhoun, 1996
). Cancer survivors have reported closer intimate relationships, positive changes in spirituality, an enhanced sense of personal strength, and an increased appreciation of life (Cordova & Andrykowski, 2003
; Manne et al., 2004
; Sears, Stanton, & Danoff-Burg, 2003
; Widows et al., 2005
). While a few studies suggest these changes exceed personal growth reported by individuals not contending with the challenge of a cancer diagnosis (Andrykowski et al., 1996
; Cordova et al., 2001
), most work has not included a normal or baseline reference, making it unclear whether hypothesized growth areas actually change or differ from the rest of the population following a cancer diagnosis. Therefore, in addition to traditional measures of mental health and mood, we included assessments in multiple domains where psychological growth is thought to occur.
An additional focus pertained to the question of age. Prior studies have revealed extensive age differences in psychosocial profiles (Ryff, in press
), and among cancer survivors, previous work has suggested that younger adults may be more vulnerable to impairment than older survivors, with younger patients consistently reporting poorer emotional well-being, greater depressive symptomatology, and greater anxiety after treatment ends (Arndt, Merx, Sturmer et al., 2004
; Mor, Allen, & Malin, 1994
; Wenzel et al., 1999
). Developmental theorists propose that “off-time” life events occurring outside of typical age ranges are more likely to be distressing or traumatic (Neugarten & Hagestad, 1976
), and this may be true for cancer as well. Because studies of age-related differences in cancer survivors have typically not included matched comparison groups, it is, however, unknown whether the prior age effects are specific to cancer survivors or reflect similar age trends found in the general population. While there are an almost unlimited number of demographic and psychosocial factors that may potentially explain variability in psychosocial adjustment among cancer survivors, we chose to focus our investigation on age given the well-documented relationships between age and well-being in the literature, and because the broad age spectrum and developmental focus of MIDUS was particularly well-suited to investigate this issue.
In summary, the primary objectives of the present study were to examine psychosocial impairment, resilience or thriving among cancer survivors in the general population by comparing them to individuals without a cancer history, with both evaluated longitudinally. We focused on four psychosocial domains: a) distress, as defined by mental health symptoms and mood, b) psychological well-being, c) social well-being, and d) spirituality. Domains in which cancer survivors reported poorer functioning and decline in functioning following diagnosis relative to the comparison group were classified as areas of impairment. Areas showing equivalent functioning (both pre-post comparisons and cancer-noncancer comparisons) were designated as evidence of resilience. Finally, domains in which cancer survivors reported superior functioning (both pre-post and relative to the comparison group) were classified as areas of thriving. Regarding age, we hypothesized that younger adults who had been diagnosed with cancer would show the most impairment and least resilience or thriving relative to their peers with no cancer history.