The psychological health of cancer survivors varies widely both across individuals and across time. shows several temporal trajectories of psychological health that might be evidenced. Almost all survivors experience some psychological dislocation in the immediate aftermath of a cancer diagnosis. Many survivors eventually recover from their cancer experience, restore their psychological equilibrium, and reestablish their premorbid level of psychological health. Other survivors rebound from the initial diagnosis and treatment but never recover fully. They may experience minor physical, psychological or social impairments as a result of their cancer experience and thus never quite return to their premorbid level of psychological health. While these two trajectories define the majority of survivors, the cancer experience has a more profound impact on other survivors. For some, a cancer initiates a deteriorating, downward spiral characterized by physical, psychological, and social impairment, a spiral from which they never recover. These individuals seemingly succumb to their illness and evidence poor psychological health. For others, a cancer diagnosis initiates an upward trend characterized by enhanced psychological and social adjustment. These individuals seemingly “grow” in the aftermath of cancer and evidence enhanced psychological health.
Temporal Trajectories of Psychological Health in Cancer Survivors.
Identification of factors that influence the trajectory of psychological health evidenced by a cancer survivor is a challenge but is theoretically and clinically important. Theoretically, understanding of factors that influence the trajectory of psychological health can increase understanding of the process of psychological adjustment and recovery. Clinically, understanding of the factors that influence the trajectory of psychological health can enable clinical and public health resources to be targeted toward cancer survivors at greatest risk for poor psychological health.
In general, psychological response to the cancer experience is a function of two classes of variables: the stress and burden posed by the cancer experience and the resources available to cope with this stress and burden (See ). The relative balance of these two factors determines the psychological health of the cancer survivor in the short and long-term. All things being equal, the greater the stress and burden posed by the cancer experience, the greater the risk for poor psychological health. Conversely, the greater the resources available to cope with the stress and burden posed by the cancer experience, the lower the risk for poor psychological health. A couple points should be noted. First, factors can fluctuate across time so the balance between them is dynamic. As one or both factors increase or decrease over time, one would anticipate corresponding changes in psychological health over time. Second, a survivor might be at high risk for poor psychological health even when the stress or burden posed by their cancer experience appears to be low. This would occur if resources were also low. Conversely, an individual might be at low risk for poor psychological health even when the stress or burden posed by their cancer experience appears to be considerable. This similarly paradoxical situation would result if available resources were also considerable.
Factors associated with psychological health in cancer survivors.
Several additional points are worth noting. First, the stress and burden posed by the cancer experience is multi-faceted. Cancer survivors confront stressors which may be physical, psychological, interpersonal, financial, and/or existential in nature (). Consequently, understanding of a survivor’s risk for poor or good psychological health must incorporate information from each of these domains. Second, “stress and burden” is a subjective concept. In other words, “stress is in the eye of the beholder.” The experience of certain physical late effects, such as infertility, fatigue, or weight gain, might be experienced as highly stressful by some cancer survivors while much less stressful by other survivors. Similarly, a poor prognosis might be a persistent source of dread for some cancer survivors while others are more sanguine regarding the same objective prognosis. Consequently, understanding of a survivor’s risk for poor or good psychological health must include not just an objective account of the stresses or burdens confronting them but must also consider their subjective response to those presumed stressors. Finally, the stress and burden posed by the cancer experience is dynamic and fluid across time. Early in the survivorship trajectory, the stress of the cancer experience might be characterized by the existential threat posed by a potentially life-threatening illness, the difficulties involved in making treatment decisions under uncertainty, and anxiety regarding how one will respond to treatment. Later in the survivorship trajectory, the stress of the cancer experience might be characterized by fear that cancer might recur, financial difficulties resulting from loss of employment, difficulties with sexuality and intimacy, or recognition of persistent physical late effects of treatment. Consequently, understanding of a survivor’s risk for poor or good psychological health is based upon knowledge of how the specific stresses and burdens confronting that survivor evolve over time.
The resources available to the survivor to cope with the stress and burden of their cancer experience are also multifaceted. These resources can be grouped into four general categories: intrapersonal, interpersonal, informational, and tangible ().
resources are characteristics which are internal to the cancer survivor. These characteristics might be dispositional in nature and reflect tendencies to think or act in certain ways. When present, these characteristics result in better coping while their absence results in poorer coping. Intrapersonal resources linked to better psychological health in cancer survivors include optimism [14
], self-efficacy [15
], emotional intelligence [16
], and spirituality [17
Social support is an interpersonal
resource which has been linked to better psychological health in cancer patients and survivors [18
]. In general, better coping with the stresses and burdens posed by the cancer experience is fostered when the cancer survivor is embedded within a supportive social environment, one which facilitates their efforts to cognitively and emotionally process their cancer experience [19
]. Conversely, the presence of social constraints can impede the coping process, resulting in poorer psychological health [16
]. Social constraints represent efforts by individuals to prevent or inhibit a cancer survivor from talking about their cancer experience. Such social constraints are thought to inhibit the cognitive and emotional processing critical to the coping process and would thus be considered a risk factor for poor psychological health.
resources are also important determinants of the psychological health of a cancer survivor. Access to accurate and understandable information about their disease, treatment side effects, prognosis, and available support services in their community can be a valuable resource. Greater education is often linked to better psychological health in cancer patients and survivors [20
]. More educated individuals might elicit more information from their care providers, seek additional information on their own, or better understand the information that is provided them. Information might foster appropriate expectations about risk for long-term recovery. Inappropriate expectations regarding physical late effects and long-term recovery can increase risk for poorer psychological adjustment in survivors [21
]. Interestingly, knowledge may not always be power in the cancer setting. Individuals differ in their preferences with regard to the type, amount, and depth of information they are comfortable with. Some people are monitors and tend to actively seek information and are comfortable with efforts to provide them with as much information as possible. Others are blunters and tend to actively avoid information and thus may be uncomfortable with large amounts of detailed information [22
]. So the value of information as a resource in the cancer setting may be moderated by the individual’s information seeking preferences. While information might enhance psychological health for some survivors, the same information might increase risk for poorer psychological health in others.
Finally, coping with the stress and burden posed by the cancer experience is facilitated by access to tangible
resources. Cancer survivors receive medical care in a variety of settings including large academic medical centers, small community hospitals, and private physicians’ offices. The type, extent, and quality of psychological support services that are available to survivors differ enormously across these diverse settings. Available support services might include licensed therapists and social workers, support groups, formal “navigator systems” or informal peer-to-peer networks. Special clinics devoted to the medical and support needs of cancer survivors have been developed [23
]. Poorer access to these support resources is associated with greater risk for poor psychological health. Mental health resources available in the community represent additional tangible resources that can affect survivors’ psychological health. Finally, while money can’t buy happiness, money can facilitate access to resources (education, vocational retraining, mental health services, child-care or housekeeping assistance) that can foster better coping with the stresses and burdens imposed by the cancer experience and thus impact psychological health.
In conclusion, there is a large literature linking a variety of specific demographic, clinical, dispositional, psychosocial, and health system variables to psychological health in cancer survivors. The results of these studies are mixed, suggesting few individual variables possess strong predictive power in isolation. In general, the focus has been upon identifying “risk factors” for poor psychological health in cancer survivors with less effort devoted to identifying “risk factors” for good psychological health. It should also be noted that risk factors for poor and good psychological health are likely not the obverse of each other. For example, while lack of social support has been linked to poor psychological health, it does not necessarily follow that provision of adequate social support results in good psychological health. Good psychological health might be determined by factors that don’t necessarily correspond to those that determine risk for poor psychological health.