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Coping Strategies Used by Breast, Prostate, and Colorectal Cancer Survivors: A Literature Review

Lashbrook, Mari P., GradDipEd, BMedSci(Hons), RN; Valery, Patricia C., MD, PhD, MPH; Knott, Vikki, PhD, BP; Kirshbaum, Marilynne N., PhD, MSc, BSc, RN; Bernardes, Christina M., PhD, RN

doi: 10.1097/NCC.0000000000000528
ARTICLES: ONLINE ONLY

Background: Individual coping strategies are a fundamental element underpinning psychosocial distress.

Objective: The aim of this study was to describe coping strategies and their measurement used by survivors of breast, prostate, and/or colorectal cancer after treatment.

Methods: A search of electronic databases (PubMed, CINAHL, and PsycINFO) was conducted from January 1980 to March 2015. Data were extracted using standardized forms and included studies that explored the coping mechanisms of survivorship of breast, prostate, or colorectal cancer.

Results: Two thousand one hundred forty-seven studies were retrieved for potential inclusion; 19 publications met the inclusion criteria and were included in the review.

Conclusions: Breast, prostate, and colorectal cancer survivors seem to use different coping strategies that varied throughout the survivorship trajectory. Breast cancer survivors highlighted the importance of accepting their diagnosis and engaging in physical activities that provided social and emotional support. Personality seemed to have a significant effect on coping for prostate cancer survivors. Colorectal cancer survivors emphasized the importance of seeking information to master self-management and return to social activities.

Implications for Practice: Understanding coping strategies, during the survivorship trajectories, is essential to planning contemporary care after cancer treatment. Nurses and other healthcare professionals may use this knowledge to improve quality of life and decrease distress after diagnosis.

Author Affiliations: QIMR Berghofer Medical Research Institute, Brisbane (Ms Lashbrook and Drs Valery and Bernardes); Menzies School of Health Research (Ms Lashbrook and Drs Valery, Knott, and Bernardes), and Charles Darwin University (Dr Kirshbaum), Queensland, Australia.

P.C.V. was supported by the Australian National Health and Medical Research Council (career development fellowship #1083090). M.P.L. was supported by a postgraduate research scholarship from Charles Darwin University.

The authors have no conflicts of interest to disclose.

Correspondence: Mari P. Lashbrook, GradDipEd, BMedSci(Hons), RN, Clinical Trials and Research Unit, Riverina Cancer Care Centre, 31 Meurant Ave, Wagga Wagga, NSW 2650, Australia (mlashbrook@riverinacancercare.com.au).

Accepted for publication May 25, 2017.

Overall, improvements in early detection and treatment of some of the most common cancers have led to improved survival in many developed regions leading to increased focus on survivorship. With longer survival (eg, breast cancer, if detected early, has ≥90% 5-year survival),1–3 people face an increased risk of long-term morbidity occurring as a result of the cancer diagnosis and treatment. Therefore, practitioners and researchers alike are recognizing the importance of developing follow-up care plans that monitor and support patients to enhance their well-being beyond the end of cancer treatment. Psychosocial distress has been identified as an important issue for patients with cancer. In fact, it is estimated that one-third of people given a diagnosis of cancer will experience significant emotional and psychological distress at some stage during their cancer experience.4 A focus on holistic care, which incorporates psychosocial factors, is also key to providing quality cancer care in survivorship. Indeed, a shift in focus toward “flourishing or thriving after cancer” has led to a renewed focus on understanding the way survivors cope with life after cancer.5 This review used the European Organization of Research and Treatment of Cancer Survivorship Task Force definition of cancer survivorship that describes survivorship as encompassing the period after primary adjuvant treatment has ended and before the onset of advanced disease. It is recognized as a distinct phase of the cancer trajectory with its own unique issues.6

It is now well recognized that a diagnosis of cancer is considered a major stressful life event, with the effects of diagnosis and treatment impacting upon the quality of life of those directly (ie, patients) and indirectly (carers, family members) affected. Research has consistently demonstrated effects on survivors, as well as carers and family members, both in terms of increased distress and also reduced quality of life.7–9 Individual differences in the reporting of impacts on physical and psychological outcomes vary significantly, and many theorists have argued that individual differences in the way in which cancer survivors cope can predict the way in which one adjusts to a diagnosis and/or may predict survival from cancer.10

Consequently, the way in which patients cope and adjust to a cancer diagnosis has been the subject of considerable research. Seminal research conducted by Greer et al11 has been influential in academia and also in the popular press with the proposal that patients who adopt a “fighting” spirit in response to their cancer diagnosis may improve their odds of survival.

The results of research since Greer et al’s original proposal have been mixed—especially with regard to the improved survival claim. In fact, the level of evidence for a link between the adoption of a fighting spirit and improved survival is weak.12 Nevertheless, consistent results across studies tend to indicate that the adoption of a fighting spirit is associated with improved quality of life, whereas the adoption of a hopeless/helpless coping style is associated with increased distress, even among patients with advanced cancer.13

Most research during the past 3 decades on coping among patients with cancer has focused on reactions to diagnosis among patients with breast cancer. An exception is the work conducted by Roesch et al.14 Guided by an earlier work by Lazarus and Folkman,15 Roesch et al focused on coping and adjustment among men with prostate cancer to conduct a meta-analysis that assessed for relationships between an array of coping styles and strategies and outcomes pertaining to physical and psychological adjustment. In their study, the hypothesis proposed was that men with prostate cancer would report being better adjusted (physically and psychologically) when adapting to their diagnosis, using active oriented approach to coping as opposed to avoidant coping methods.

According to Lazarus,16 coping with stress is composed of 2 discrete processes involving primary and secondary appraisal. Primary appraisal involves an individual assessing the extent to which a threat (ie, stressor) is perceived as negative, positive, or neutral. Secondary appraisal refers to an individual’s assessment of whether one has the resources to deal with the threat. A further aspect of Lazarus’16 framework is the proposal that, depending on a person’s perception of controllability of the stressor, one may choose an active approach to coping (either problem focused or emotion focused) or an avoidant approach to coping.

Results from the Roesch et al14 meta-analyses indicated that men who used an avoidant coping strategy in response to their prostate cancer diagnosis tended to have poorer physical and psychological health. In contrast, those men who adopted an active or approach-oriented coping strategy (involving either problem- or emotion-focused coping) had improved physical and psychological well-being. Although Roesch et al's meta-analysis was broad and included a range of literature on coping strategies and styles, categorizing against Lazarus’ approach and avoidant coping framework anticipated that additional coping styles could be identified through a review of literature since the notable 2005 review was published.

Furthermore, generally, the focus of research for the past 3 decades has been on assessing coping strategies and their relationships with outcomes in relation to reactions to a diagnosis. Hodges and Winstanley5 noted that there is an increased need to focus on the period posttreatment because this is a stage in which patients can experience considerable distress and that attention at this stage needs to be focused on promoting well-being.

Other research also confers that this period is a time in which patients experience considerable distress,17 and yet, this is also a time when opportunities for growth through adversity can be achieved.18

Breast, prostate, and colorectal cancer are among the most frequent cancers diagnosed in Australia and have the distinct characteristics of having longer survival and represent cancers with gender differences. The purposes of this structured review were (1) to describe the various coping strategies through which survivors of breast, colorectal, and prostate cancer adjust to their cancer experience after completion of primary treatment and survivorship and (2) to identify how coping has been measured and how survivors adjusted to cancer. With the shift in emphasis toward “survivorship,” we envisage that additional and/or novel coping strategies may be identified through the review. Such a focus may lead to the development of interventions designed to optimize coping strategies to facilitate improved well-being after cancer.

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Significance

This review highlights the importance of exploring new trends for the management of individual coping strategies. Dynamic care plans effectively incorporated into medical care may significantly affect adjustment during the survivorship trajectory and decrease psychosocial comorbidities.

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Methods

A review of the scientific literature on qualitative and quantitative research was conducted. This review encompassed studies that identified the various coping mechanisms through which people given a diagnosis of breast, colorectal, or prostate cancer adjust (physically and psychologically) to their cancer experience after completing primary cancer treatment. The publications included are from January 1, 1980, to March 24, 2015. The purpose of the extended review was to capture relevant articles from the past 10 years.

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Searching and Identifying the Evidence

Two authors independently searched online peer-reviewed journal articles indexed in PubMed, CINAHL, and PsycINFO. The search terms were restricted to medical subject headings terms including “neoplasms or cancer,” “cope or coping or manage or handle or survive or deal with,” “survivorship,” and “breast or colorectal or colon or rectum or rectal or prostate.” The articles found in each database were combined and then compared.

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Inclusion and Exclusion of Studies

The selection of publications was determined by the following criteria: first, the study should include at least 1 coping variable and 1 outcome variable (referred here as adjustment, either psychological or physical). Second, participants in each study should have completed primary cancer treatment of breast, prostate, and colorectal cancer (the cancer types selected aim to address gender-specific coping strategies). The approach used in this review is based on the typologies of supporting evidence identified by the Department of Health in the National Service Framework and the inclusion criteria and rationale.19

Publications were excluded if they were literature reviews, books, or commentaries or did not contain full text. In addition, the studies including patients receiving primary treatment, focusing on survival, without mention about the treatment (primary or not), and with survivorship time greater than 10 years were excluded from this review.

The search results were imported into EndNote X7, and duplications were removed. Both reviewers screened all selected journal abstracts for relevance to the topic being reviewed (Table 1). The search was then complemented by a manual review of the references of retrieved articles. Two investigators independently reviewed all titles; articles that addressed some or all of the criteria were read in their entirety by both authors. Those fully satisfying the inclusion criteria were given a score (Table 1) that informed the decision to include in the current research.

Table 1

Table 1

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Quality Assessment

We selected abstracts with relevant content for full manuscript review. Two members independently reviewed manuscripts (M.L. and C.M.B.); a third member adjudicated disagreements (P.C.V.). A quality assessment was carried out through a standard form where quantitative publications were scored from 0 to 12 and qualitative publications were scored from 0 to 7. The studies were assessed for the following:

  • Aims and/or research question stated clearly (0, no; 1, yes)
  • Study design (3, randomized controlled trial; 2, case-control and longitudinal; 1, cross-sectional and qualitative studies)
  • Recruitment strategy stated clearly (0, no; 1, yes)
  • Data collection methods (2, face-to-face interviews; 1, online or mailed questionnaires)
  • For quantitative studies (0, use of nonvalidated tool to assess coping; 1, use of validated tool to assess coping)
  • Analysis (methods applied for the analysis were in accordance with the objectives of the study [0, no; 1, yes]; sufficient data to allow the analysis [0, no; 1, yes])
  • Response rate for quantitative studies (0, not reported; 1, reported)
  • Assessment of confounding for quantitative studies only (0, no; 1, yes)
  • Theory-based analysis (qualitative study) (0, no; 1, yes)

Studies were excluded from our review if not describing at least three of these criteria. Failure to mention the details about the criteria items was considered a failure to fulfill the criterion. A qualitative, descriptive approach was used to analyze and synthesize data, with the reporting of most of the previously mentioned details in Tables 2 and 3.

Table 2

Table 2

Table 3

Table 3

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Theoretical Framework

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.

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Nomenclature

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.

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ADJUSTMENT

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.

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Data Extraction

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.

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Evidence Summary

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.

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Results

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).

Figure 1

Figure 1

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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.

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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.

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Aims

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.

Figure 2

Figure 2

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

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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.

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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 R 2, 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.

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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 R 2) 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

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COLORECTAL STUDY

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.

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Discussion

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.

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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.

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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.

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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).

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Future Research

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.

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Conclusions

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:

Breast; Cancer; Colorectal; Coping; Prostate; Survivorship

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