This review used Lazarus and Folkman’s15,39 theory about the connection between stress, appraisal, and coping as the theoretical framework. This theoretical framework was chosen because it describes comprehensively the complexity of coping.
Coping strategies were classified according to the method described by Roesch et al14 into 2 coping categories: (a) approach avoidance and (b) emotion and problem focused. Briefly, coping strategies were classified under 2 overarching subscales, either approach or avoidant (based on definition of COPE,40 the Coping Responses Inventory,41 and a previous meta-analysis).42 Next, coping strategies were classified into problem- or emotion-focused coping categories. Coping strategies could be classified into more than 1 coping classification scheme. The coping strategies that did not fit the Roesch et al14 classification were presented separately. Two investigators independently classified the categories; a third investigator resolved disagreements.
Adjustment was analyzed as an outcome as described by Roesch et al.14 As such, positive adjustment included measures of positive affect: self-esteem, well-being, life satisfaction, marital satisfaction, sexual satisfaction, resumption of precancer activities, and overall quality-of-life measures (eg, as social functioning, physical role limitations, emotional role limitations, urinary function, bowel function, and general health perceptions).
Negative adjustment included measures of negative affect: depression, distress, anxiety, fatigue, and pain.
The results of primary studies were described and summarized. The quality of primary studies was discussed, as well as potential bias (both systematic and random). In addition, any limitations of the review were discussed. Data were extracted using the following categories: reference number (for reviewers’ control), authors, year of publication, country, demographics (age, gender, ethnicity, educational level, socioeconomic status), cancer type, stage and treatment, coping strategies, methods (study design, time points for data collection, participant recruitment or selection bias, measures, intervention details, randomization, and participation rates), outcomes, and limitations.
Articles were initially categorized according to the methodology as quantitative and qualitative methods. The broad findings and conclusions were compared and classified according to Roesch et al14 (data reduction). Categories that did not fit Roesch et al’s classification were shown as separate results. After this classification, results were compared, and relationships were identified; finally, conclusion and verification for accuracy were applied for the final analysis.
Overview of Studies
The search yielded 2144 articles. Additional articles (3) were found after reviewing the reference lists of relevant articles (Figure 1). One hundred thirty-seven article abstracts were relevant for our overview, resulting in a total of 19 articles included in this review. Of the 19 publications that fully met the inclusion criteria, 9 were quantitative studies, involving 6 cross-sectional,20,22–25,27 2 longitudinal,21,28 and 1 cross-sectional with mixed methods26 (Table 2), and 10 studies used qualitative methods29–38 (Table 3). The studies were mainly conducted in the United States. On the basis of the Department of Health (Table 1) typologies of evidence, most of the publications were classified as C1 (descriptive studies with convenience samples).
QUANTITATIVE STUDIES IN COPING AFTER PRIMARY CANCER TREATMENT
There was no quantitative study on colorectal cancer that satisfied the inclusion criteria of this study. Five of the cross-sectional studies focus on breast cancer,20,22–25 and 1 study focused on prostate cancer.27 Of the longitudinal studies, one focused on breast cancer,21 and one focused on prostate cancer.21 The cross-sectional study with mixed methods26 explored coping among patients with breast cancer. Three cross-sectional studies for breast cancer included mainly white women,20,22,24 1 study involved Latinas,25 and 1 study did not specify ethnicity.23 One of these studies included heterosexual women and women of sexual minority,20 and another study involved heterosexual women and their partners.22 Four studies20,21,25,26 involved only nonmetastatic breast cancer, 1 study24 included all stages of breast cancer, and 2 studies did not specify participants’ stage of the disease.22,23 Participants ranged from 4 months to 5 years post their breast cancer diagnosis.20–22,24–26 With regard to educational level, 5 breast cancer studies involved well-educated participants who attended college or higher,20,21,24–26 and 1 study involved women with approximately 6 years of incomplete elementary schooling.23 The mean age of participants with breast cancer ranged from 43.4 to 62.7 years, and most participants were married or partnered at the time of the study.
The 2 quantitative prostate cancer studies involved mainly white participants27,28; however, 1 study also involved African American and Hispanic participants.27 In 1 study,28 participants of all prostate cancer stages were included, whereas the study by Blank and Bellizzi27 only stated that the clinical characteristics of participants indicated that they were mostly a sample with nonaggressive disease. In 1 prostate cancer study, the time from diagnosis was between 1 and 8 years,27 and in one, patients were newly given a diagnosis and followed up for 6 months.28 The mean age of participants in the prostate cancer studies ranged from 67.3 to 69.7 years. Neither of the 2 quantitative prostate cancer studies informed on the marital status of participants, and only 1 study reported on the educational level.28 In this study, most participants had a trade qualification.
QUALITATIVE STUDIES IN COPING AFTER PRIMARY CANCER TREATMENT
Ten qualitative studies were included in this review; 8 studies included breast cancer, 1 study included prostate cancer, and 1 study included colorectal cancer. In the breast cancer studies, data were gathered by in-depth interviews only, in-depth interviews and focus groups,29,30,34,37 in-depth interviews and follow-up telephone calls,33 semistructured interviews only,31,32,36 and semistructured interviews and telephone calls.35 The prostate cancer study used semistructured telephone interviews,38 and the colorectal cancer study used semistructured interviews.37 Breast cancer studies involved mainly white participants,29,35,36 but there were also studies that included South Asian,30,34,37 African American,29,32 and Chinese women.31
The qualitative studies explored coping while managing treatment adverse effects,29 monitoring for recurrence,37 experiences of unpartnered men37 with prostate cancer,38 psychosocial transformations during transition from patient to survivorship,33,36 religion,32 beliefs,31 information preferences,30,34,37 and concerns of older patients in the posttreatment phase.35 Most of the studies involved early stages of cancer and highlighted differences and similarities in coping of survivors after cancer treatment.
No relevant randomized controlled trials were found possibly because they may not be feasible or ethically appropriate to the research question. This may be an area for future study.
Aim 1: Describe the Coping Strategies Used by Patients With Breast, Prostate, and Colorectal Cancer After Completion of Primary Treatment and During the Period of Survivorship
Articles included in this review, after being appraised against Roesch et al's classification, showed that patients with breast, prostate, and colorectal cancer after completion of primary cancer treatment used a variety of approach coping strategies20,21,24–26,28,31,32,35–37 that differed according to tumor group.
Figure 2 shows the coping strategies identified in this review and not previously reported by Roesch and Weiner.42 This figure includes Roesch and Weiner's42 findings on coping using Lazarus and Folkman's39 Transactional Model of Stress, Appraisal and Coping as a framework.
Among patients with breast cancer, the approach strategies used were seeking social support,26 acceptance,24,25,29–31,34,35,37 active coping,24,25 positive reframing,25 planning,25 seeking support,20,32,36 self-efficacy,26 and self-efficacy/self-control.28,29 For patients with prostate cancer, the category of approach coping involved the use of strategies such as acceptance,28 self-control, seeking information, and social support. For participants with colorectal cancer, the approach coping was seeking information.28,37 Social support was important to both genders.28
The avoidance coping category was used only by patients with breast and colorectal cancer.21,24–26,29,36,37 Among patients with breast cancer, avoidance coping included denial,21,24,25 behavioral disengagement,21 mental disengagement,21 distraction,24,25,36 wishful thinking,26 venting,24 religion,24 alcohol and drugs,24,25 self-blame,25 and humor.25 The patients with colorectal cancer used distraction37 in the avoidance category of coping strategies.
The problem-focused coping category was only used by patients with breast cancer. The problem-focused coping strategies included seeking instrumental support,24,25 planning,24 and active coping.25 The emotion-focused category was also used only by patients with breast cancer. Among the strategies used in this category were seeking emotional support,24 positive reframing,24,26 religion,23,24 and emotional approach.21
Aim 2: Identify How Coping Has Been Measured and How Survivors Adjusted to Cancer
Coping was quantitatively measured by validated questionnaires to examine its relationship to adjustment to cancer, for example, quality of life (physical functioning, body image, social life, emotional equilibrium, depression and anxiety, marital satisfaction) and well-being.
BREAST CANCER STUDIES
In the breast cancer studies, coping was measured using the Brief COPE Scale.24,25 In the study, this scale presented reliabilities with 11 of the 14 subscales (α > .60) and the remaining three (venting, denial, and acceptance) (α > .50). Boehmer et al20 used the Mini-Mental Adjustment to Cancer (MAC) although they did not state the reliability or validity of the instrument in the study and only cited Watson et al43 as a reference; Kraemer et al21 used COPE as described by Carver et al40 and Emotional Approach Scales,44 and internal consistency estimates ranged from an α of .70 to .96; Schreiber22 used Religious-COPE, and in this study, all 21 subscales have been reported to have Cronbach's α higher than .80 except for reappraisal of God's power (α = .78) and marking religious boundaries (α = .61); Religious and Spiritual Coping Scale “Escala do Coping Religioso-Espiritual” used by Veit and Castro23 had Cronbach's α of .97; and Manuel et al26 used Ways of Coping with Cancer, and the reliability ranged from an α of .59 to .83.
With regard to adjustment, breast cancer survivors who used approach-oriented coping strategies (eg, social support, fatalism, future perspective, greater fighting spirit) showed less depression and anxiety and improved vitality. Aguado Loi et al25 found that increased symptoms of depression were associated particularly to higher acceptance, less use of positive reframing, self-blame, and poor body image (P < .001).
Patients and partners’ coping strategies interacted to predict adjustment, and the use of a similar coping strategy predicted better adaptation. The use of avoidant coping by men predicted a decline in marital satisfaction for wives, and men’s approach-oriented strategies predicted an increase in women’s perception of cancer-related benefits.21 Women with breast cancer who engaged in active adaptive coping reported higher levels of posttraumatic growth in their relationships with others (variance, 14.9%; adjusted R2, p < .001).24 Personal growth36 was also improved by engaging in physical activities (eg, dragon boat) that facilitated social support, greater appreciation for life, and emotional benefits.21
Quality of life and well-being were improved when daily living challenges, such as memory loss, were better managed through measures as simple as keeping record of activities,29 resting,26 or learning to leave the cancer experience in the past.35
Spirituality34 and religion22,30–32,37 led to better adjustment outcomes (eg, decreased depression, enhanced quality of life, increased sense of control and well-being) when women had a positive perception of God or used acceptance and belief in karma.
PROSTATE CANCER STUDIES
In the prostate cancer study of Blank and Bellizzi,27 coping was measured through the Brief COPE Scale of Carver and colleagues.40 This study followed the recommendation of Carver et al to perform a factor analysis to create higher-order factors from the subscale of Brief COPE empirically to the data. Factor loading ranged from 0.50 to 0.71 for active coping (active coping, seeking emotional and instrumental support, and planning); maladaptive coping (denial, use of drugs and alcohol) loading factors ranged from 0.42 to 0.56. Paterson et al28 used the MAC Scale, and the reliability in this study was Cronbach’s α of .77 or greater.
For patients with prostate cancer, 30% of the variance (adjusted R2) of global quality of life and depression was explained by coping and social constructs.28 The use of adaptive and escapist coping strategies was positively associated with poorer health outcomes such as depression, negative affect, and impact of events.27
Taylor et al37 conducted a qualitative study that found that guarding (body monitoring, risk management, and seeking assurance) was associated with poorer adjustment with continuous fears of recurrence, expression of anxiety, and health concerns.
This review provided an update of coping strategies reported in the literature since Roesch et al’s review in 2005, identified the main psychometric measures, and reported on the adjustment to cancer of survivors of the 3 cancer types. The studies reviewed were mainly descriptive with small sample sizes, some had no response rates reported, and a few had response rates greater than 60%. The assessment tools varied between studies, and in general, psychometric properties of these scales have been reported inconsistently. Because tools are translated to other languages and techniques of exploratory factor analyses are in some cases being inappropriately used, some psychometric properties remain controversial.37,45 For instance, the Brief Cope, although validated in various countries, presents with a wide variation of psychometric results.46,47 The MAC Scale, also frequently used to assess psychological adjustment to cancer, has been questioned for not being able to distinguish between state and trait anxiety.37,45 Watson and Homewood45 recommended that the MAC Scale should be used alongside measures of specific problems to clarify targets for psychological therapy. In fact, Parker and Endler's48 findings on coping assessment tools seem to remain relevant to date because the reproduction of coping scales with different constructs makes it difficult to collect valid information and generalize results.
This review also highlighted previous findings49 on the distinction between coping strategies and coping styles. Whereas coping strategies can be learnt and used according to a specific stress situation, coping styles, however, relate to the way people approach a stress situation and depend on personality and specific dispositional factors.
Overall, the findings suggest that coping strategies used by patients can differ within and between individuals, and potentially, an individual’s approach to coping can change over time. For example, breast cancer survivors often used approach coping involving “acceptance,” whereas others used avoidance strategies, such as those involving “denial”21,24,25 or “distraction.”24,25,36 Similarly, patients with breast cancer coped using both problem-focused (eg, planning) and emotion-focused (seeking support) coping. When determining which strategy was most effective, it is difficult to make judgments on the basis of the data reviewed. A combination of qualitative and quantitative studies prevents any empirical assessment of the strength of any potential associations. Furthermore, from a theoretical perspective, it is likely that patients will use both problem- and emotion-focused coping, depending on the particular issue faced by the individual. For instance, when one is making decisions regarding longer-term outcomes, such as returning to work, it is likely that a patient uses a problem-focused approach involving the seeking of information regarding their work readiness. However, in situations where the level of control over the outcome is low (eg, feeling fatigued due to returning to work), an individual is likely to use an emotion-focused strategy (eg, engaging in activities involving relaxation or rest).
Acceptance seems to be an important aspect of coping with cancer, with previous research noting that acceptance can predict adjustment up to 3 years posttreatment.50 Interestingly, congruence between the coping strategies of patients and partners seemed to impact positively on indices of well-being and perceptions of cancer-related benefits.21
For patients with prostate cancer, as well as patients with colorectal cancer, coping strategies used tended to be problem focused and involve seeking information and support. Patients with prostate cancer showed a decline in quality of life and more depression if the perceived social support was low and when more sexual and urinary symptoms were present. In a prospective longitudinal study, social support and perceptions of the quality of the support were significant predictors of well-being.28 Seeking of information among patients with colorectal cancer seems particularly important. This is quite expected because many of the patients with colorectal cancer need a colostomy bag and mastering the technique for self-management.
Although many of the coping strategies identified by Roesch et al’s review were similar to those found in this review, additional (and perhaps unique) strategies were identified in this review. For instance, Taylor et al37 found that patients with colorectal cancer would use guarding as a coping strategy. Guarding is a concept that is linked with fears of recurrence and tends to involve behavioral manifestations such as ongoing monitoring of risk and health concerns and increased anxiety. Similarly, a tendency toward growth, as opposed to a focus on distress or the negative outcomes of cancer, was evident in the studies reviewed. Other coping strategies were also identified in this review and, although not new, relate to concepts measured via the MAC Scale (eg, fighting spirit, fatalism, hopeless, denial).43 Again, although not new, it is evident that concepts pertaining to spirituality and religion are important concepts to consider with regard to coping.
STRENGTHS AND LIMITATIONS
A number of methodological strengths and limitations are associated with this review investigating the coping strategies used by patients with breast, prostate, and colorectal cancer. Among the strengths, this study involved a comprehensive review of all publications in the last 35 years in 3 important databases in the field of psycho-oncology and included languages other than English.
With regard to the limitations, the vast majority of publications included reported on coping strategies used by women with breast cancer. This is not surprising given that breast cancer is one of the most common cancer types diagnosed in women,26,51 regardless of their ethnicity.50 For example, in 2014 in Australia, it was estimated that 15 270 women were given a diagnosis of breast cancer,51 with a likelihood of 5-year survival for women aged between 45 and 74 years of 91% to 92%.51 Of the studies reviewed, several studies had an overrepresentation in the sample in terms of ethnicity (mainly white), marital status (married), education (well educated), and socioeconomic status (employed or with higher income). In addition, the response rate was not always reported and, in some studies, was very low and consequently might have introduced selection bias to the studies. Finally, this review was limited in the number of colorectal cancer studies and a small number of studies involving prostate cancer.
Implications for Practice
The findings suggest that understanding the diversity and interconnection of coping strategies during survivorship trajectories is essential for quality care planning. Although the current evidence suggests that coping strategies play a key role in the way survivors adjust to cancer, methodological issues limited the generalization of results. Sample size with enough power to demonstrate results and assessment tools with psychometric properties are two of the issues that need to be addressed. Nurses and other health professionals should be aware that there are differences in coping strategies between gender and cancer type. By understanding these differences, nurses and health professionals should encourage patients to identify their coping styles and, when possible, actively guide their patients toward using the most effective strategies for the individual. This could enhance survivors’ ability to deal with their disease by addressing daily living challenges and adopt more positive attitudes to their experience with cancer.
Implications for Survivorship Care Plans
It is clear that, throughout the survivorship trajectory, survivors of cancer will use different coping strategies, at different times and potentially simultaneously, in response to different challenges experienced. It is important to recognize that different approaches to coping are not necessarily adaptive or maladaptive but, instead, the flexibility of one’s coping strategy to suit the demands of the stressor or issue is what is important. Engaging in a conversation with patients regarding how they are coping with cancer and its treatment, as well as issues regarding the longer-term impacts of cancer, is a first step. Patients should be encouraged to explore an array of coping strategies to suit the demands of the stressor at different time points. For instance, a rigid application of a problem-focused approach to coping when there is low control over the stressor will not be effective in the longer term. Further research is required; however, it seems that men with prostate cancer or colorectal cancer may show a tendency toward using strategies involving problem-focused coping. In some situations, these men could be encouraged to engage in relaxation training, meditation, or other supportive therapies to reduce distress and improve quality of life (see, eg, Klafke et al52).
When developing survivorship care plans, monitoring of coping strategies used may be important to determine whether the strategy is effective for the particular individual at the particular point in time toward adjustment. Therapies involving the facilitation of acceptance could be recommended when individuals are in a continued state of denial or when it is evident that the patient is engaged in activities involving denial (eg, increased alcohol use or other activities aimed at distraction).
Future research is required to develop and implement intervention protocols. Then, these protocols can be integrated confidently into the care plans during the course of the cancer trajectory. Finally, adequately powered and well-planned randomized controlled trials are required using consistently validated instruments to assess the effectiveness of the modified care plans to help the individual through the cancer trajectory in the best possible way.
The review identified that patients with various diagnoses of cancer use a range of coping strategies. Although individuals may use specific strategies based on personality or coping style, there is potential to modify the coping strategies used through professional guidance in the use of alternative strategies.
Nurses and other healthcare professionals can draw on contemporary knowledge pertaining to theory and literature on the ways in which patients cope with cancer and can attempt to facilitate conversations to assess the adequacy of coping strategies used. Individualized management plans that address any potential rigidity with respect to coping may provide patients with additional resources to draw upon throughout their cancer experience. An important step is the systematic assessment of how patients are coping with their cancer at the different time points during their journey. As such, construction of care plans remains a dynamic process. The development of care plans should be based on these assessments and tailored to patients’ choices.
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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
Breast; Cancer; Colorectal; Coping; Prostate; Survivorship