This is the first study to examine posttraumatic growth in patients diagnosed with hepatobiliary carcinoma and their family caregivers. Using the Posttraumatic Growth Inventory, both the patient (self) and caregiver (patient rating and self rating), were shown to have adequate reliability in this population. Comparing the PTGI mean subscale scores, patients with hepatobiliary carcinoma are generally found to report lower PTG when compared to patients with other cancer types (see ). Breast cancer and bone marrow transplant patients generally report higher scores (Cordova, Cunningham et al. 2001
; Weiss 2002
; Sears, Stanton et al. 2003
; Manne, Ostroff et al. 2004
), whereas colorectal, prostate, and other patients at the end of life tend to report lower mean PTGI scores (Widows, Jacobsen et al. 2005
; Thornton and Perez 2006
; Mystakidou, Parpa et al. 2007
). Differences in PTGI scores may explained by differences observed in cancer types, age of diagnosis, and severity of disease. The cancer types which had lower PTGI scores were predominantly male (e.g., prostate, colorectal, and hepatobiliary), which is consistent with the general literature concerning PTGI in which females tend to report higher levels of PTG.
A small sample of patients followed from diagnosis to 6-months did not show any statistically significant change in PTG with the exception of Relating to Others in which a significant change over time was observed. These results are preliminary and with a larger sample followed prospectively for greater than 6-months may yield changes in the frequency or level of PTG. Also, although these changes over time were not statistically significant, the changes may have been clinically meaningful differences. Further understanding of the development and process of PTG is warranted, however the findings regarding the stability of PTG overtime wais consistent with the literature on PTG in breast cancer patients (Manne, Ostroff et al. 2004
To demonstrate the observability of growth and to potentially differentiate the construct of PTG from positive reappraisal or reframing, caregiver ratings of patient PTG were examined. High levels of agreement were observed between the patient and caregiver on nearly all of the subscales of the PTGI, including Relating to Others, Spiritual Change, Personal Strength, and total PTGI score. No other known studies have analyzed this relationship among proxy ratings of patient PTG.
Alternative explanations may include that the (1) caregiver ratings of the patient are also correlated with caregiver ratings of their own growth, which suggests that caregivers may have simply viewed patients through their own experiences; or (2) patient growth was correlated with optimism, which again suggests that growth is more a product of reframing or reattribution, and (3) that the caregivers simply observe that the patient seems to feel as if he or she had grown. Further research is warranted to better understand the associations observed in the present study.
Prior trauma (within the past 3 years including the loss of a loved one or serious injury) was found to be associated with PTG at the time of diagnosis. Although the assessment of PTG in this study was in regard to the patients' cancer diagnosis, recent trauma may have primed the experience of PTG when diagnosed with cancer. Prior research has suggested that previous traumatic event may be instrumental in allowing individuals to cope with future stressors (Park, Mills-Baxter et al. 2005
Optimism was also highly correlated with PTG, including significant associations with Appreciation of Life, Personal Strength and total PTGI subscales. The results of this study are consistent with previous research with head and neck cancer patients in which optimism was found to be a predictor of PTG (Harrington, McGurk et al. 2008
). Similarly, PTG and optimism were found to be significantly associated in former Vietnam prisoners of war (Feder, Southwick et al. 2008
) and patients diagnosed with breast cancer (Antoni, Lehman et al. 2001
). With the exception of the expression of anxiety and association with the Appreciation subscale of the PTGI, no significant associations were found between expressed emotion and overall PTG in this study. Although a paucity of research exists regarding PTG and expressed emotion, our results were not consistent with other reports in the literature which may suggest an association between these two constructs (Park, Aldwin et al. 2008
Posttraumatic growth was not found to be associated with quality of life and only patients scoring at least a 16 on the CES-D were found to be more likely to report higher scores on the Appreciation subscale scores. This lack of an association between PTG and depression is consistent with the findings in breast and colorectal cancer populations (Cordova, Cunningham et al. 2001
; Salsman, Segerstrom et al. 2009
), but the lack of an association with quality of life is inconsistent with the literature on breast cancer (Stanton, Danoff-Burg et al. 2002
; Schwarzer, Luszczynska et al. 2006
). In a sample of women with breast cancer post-surgery (at 1- and 4-7 years), higher initial benefit finding predicted better quality of life at follow-up (Carver and Antoni 2004
). Due to the poor prognosis, high rates of depression, and poor quality of life at the time of diagnosis in this population, a lack of association between PTG and these clinical outcomes may have been observed. It may be that the process of PTG may require time and emotional resources that may not be available in patients who are confronted with such a life threatening diagnosis.
Alternatively, a recent paper by Frazier and colleagues (2009)
reported in a study of colleague students who reported PTG before and after a traumatic experience, that perceived growth was associated with increased distress (Frazier, Tennen, Gavian, Park, Tomich, & Tashiro, 2009
). In contrast, actual growth was related to decreased distress, suggesting that perceived and actual growth reflect different processes (Frazier et al, 2009
). These authors also found that perceived (but not actual) growth was related to positive reinterpretation coping (Frazier et al, 2009
). These findings may explain some of the inconsistencies found in the literature regarding the association between PTG and psychological and health outcomes.
Both the caregivers' rating of the patients' PTG as well as the caregiver's own PTG was highly correlated with patient PTG. Posttraumatic growth is often a measure of much controversy, yet this association supports the construct of PTG as observable in individuals diagnosed with hepatobiliary carcinoma. The duration as well as the proximity of the relationship between patients and caregivers included in this study likely contributed to the high level of agreement. The duration of the majority of relationships was over 30 years and many of the caregivers were intensively involved in the patients' end of life care. Alternatively, the high level of agreement may suggest that (1) an individual who has greater levels of PTG may be more likely to report a loved one's PTG, (2) people who have PTG may be more likely to partner with people who are more likely to experience PTG after a traumatic event, or (3) the patient or the caregiver may influence the others' level of PTG after a traumatic event.
The present study has several limitations. The results should be considered preliminary as the sample size at follow-up is small and data collection is on-going. Additionally, although females were included in this study, different conclusions might have been reached if the sample constituted a greater number of women. This study found no association between PTG and clinical outcomes, although additional patient follow-up data and more detailed medical, psychological, and family history data could reveal an association similar to other reports.
In summary, PTG is not commonly studied in cancer populations that present at end of life stages. The present study not only contributes to the literature on the association of proxy ratings of PTG, but also reinforces the role of caregivers in the growth process as indicated by agreement between self-reported patient PTG and the caregiver's proxy rating of patient PTG. Ongoing data collection will examine if caregiver PTG is preventative in regard to complicated bereavement after caregiving has ended.