A scoping review of psychosocial oncology interventions promoting posttraumatic growth

Abstract

Problem Identification: 

Many cancer patients experience posttraumatic growth (PTG), and psycho-oncologists are exploring ways to facilitate PTG through psychosocial intervention. This study utilized a scoping review protocol to provide a comprehensive evaluation of psychosocial interventions aiming to promote PTG in oncology.

Literature Search: 

Three databases were used to identify empirical studies implementing psychosocial interventions to promote PTG in cancer patients, according to Calhoun and Tedeschi's Posttraumatic Growth Inventory.

Data Evaluation: 

Two independent reviewers screened articles for inclusion and extracted data for qualitative synthesis. 8275 abstracts and 116 full-text articles were assessed, with 33 studies included in this review.

Conclusions: 

Common treatment components of psychoeducation, peer support, and mindfulness skills identified by this review may be considered for future interventions targeting post-traumatic growth. The results of this review also identified areas where PTG research may be strengthened, including standardized reporting of PTG outcomes and cancer-related variables.

Tedeschi and Calhoun^[1] first coined the term “posttraumatic growth” (PTG) to describe positive changes resulting from personal efforts to deal with traumatic events. They integrated research from diverse fields such as philosophy, psychology, and religion to explore these changes and describe how growth from struggle and suffering is a concept that it is present in ancient philosophical literature.^[1] Their research is the first to take a systematic approach to the concept of PTG and positive change from the lens of the social and behavioral sciences.^[2] PTG constitutes a qualitative change in functioning that is unique to other concepts such as resilience or optimism.^[2] Within their Handbook for Posttraumatic Growth, Calhoun and Tedeschi^[2] differentiate PTG from these similar constructs by using a 5-factor approach to define specific domains in which this positive growth and transformation can occur following the experience of a traumatic event. These are personal strength, new possibilities, relating to others, appreciation of life, and spiritual change. The Posttraumatic Growth Inventory (PTGI) is a 21-item self-report questionnaire designed to assess each of the 5 factors of PTG in various populations.^[3] During the initial development and validation process, the researchers carried out 3 separate studies and confirmed the scale's internal consistency, test–retest reliability, and construct validity.^[3] The PTGI appeared to be useful in determining the degree of success individuals coping in the aftermath of trauma had in adapting and strengthening their perceptions of self, others, and the events occurring around them.^[3]

Calhoun and Tedeschi^[2] indicate that PTG often presents in the form of positive psychological changes in the context of negative life events, such as undergoing cancer diagnosis and treatment. Cancer is a worldwide public health concern and a leading cause of death in the United States. In addition to intrusive medical procedures, fatigue, and pain, cancer can be a psychosocial stressor with common precursors for both trauma and personal growth.^[4] For example, there is evidence demonstrating that each of the five factors of PTG proposed by Calhoun and Tedeschi^[2] have been observed and objectively measured using the PTGI in cancer patients and survivors.^[5–9] Overall, the factor of “relating to others” appears to be the most commonly reported category of benefit-finding within oncology populations.^[5,7,9] Additionally, researchers found that patients endorsed enhancements in their spirituality and improvements in their perceived personal strengths following their experience with cancer.^[5] Appreciation for life has also been reported as a positive change experienced by patients with cancer.^[6,8] Researchers found that cancer patients have reported a new life perspective, attitude, and outlook following their diagnosis and treatment.^[10] In an early study of benefit-finding in women with breast cancer, participants found increased enjoyment in life following their traumatic experience with cancer.^[10] Thus, experiencing cancer, although stressful, may also lead to various forms of positive growth that represent each of the 5 factors of PTG originally outlined by Calhoun and Tedeschi.

As a result of the evidence outlined above, various efforts have been made to actively promote PTG in the psychosocial care of patients with cancer. One study reviewed existing positive psychology interventions that were applied to the treatment of cancer patients in the hope of promoting PTG.^[11] Casellas-Grau et al.^[11] focused their systematic review on interventions that aligned with at least one of the treatment modalities considered to be a form of positive psychology intervention. In addition to positive psychotherapy, hope, well-being, quality of life, strength-centered, and mindfulness-based approaches are also considered positive psychological interventions.^[12] The results of this systematic review were limited to only 16 studies that primarily utilized mindfulness-based interventions. Seven studies using mindfulness-based stress reduction reported an increase in the quality of life and general well-being in women with breast cancer. The quality of life domains that improved were the psychological, spiritual, and family domains, which remained even 1 month after completing the interventions. Specifics regarding positive growth according to the 5 factors of PTG, however, were not provided. More recently, Arnedo et al^[4] performed a brief review of psychotherapeutic interventions facilitating a constructive stress-growth balance in cancer patients; however, the authors only identified 2 studies^[13,14] that proposed interventions with the specific goal of achieving a constructive and adaptive balance of both stress and growth responses. Additional studies reviewed by Arnedo et al^[4] implemented interventions that facilitated PTG in cancer patients and were all previously identified by Casellas-Grau et al.^[11]

Most recently, Li et al^[15] completed a meta-analysis of RCTs studying the effect of psychosocial interventions on promoting PTG in cancer patients. Study design was limited to RCTs to ensure a minimum level of methodological quality to make quantitative analyses more reliable. The authors of this study reviewed 15 RCTs, 11 of which utilized the PTGI as their PTG outcome measure, with a moderate risk of bias due to low methodological quality. The small sample size and moderate risk of bias in the results of Li et al's^[15] meta-analysis demonstrate the need for additional research on this topic that allow for improved methodological quality going forward. These 3 review articles suggest that cancer is a stressor with common precursors for trauma and growth and that various psychological interventions have successfully promoted PTG among cancer patients.^[4,11,15] These findings highlight the need for future research to develop and promote the use of psychological interventions based on promoting PTG in cancer patients, especially for those reporting higher levels of stress.^[4,11]

The present study

Although previous studies identified important next steps for the field, a comprehensive review of the present psychosocial interventions promoting PTG in cancer patients that is not limited to positive psychology or stress-growth balance interventions is still necessary. An all-inclusive review would facilitate more informed development and targeted implementation of interventions aimed at promoting PTG in oncology. Scoping reviews are used to map or configure a body of evidence and tend to focus on breadth, including studies that are representative of the variation within the evidence base.^[16] In contrast with systematic reviews or meta-analyses that require a more specific research question and use of objective quantitative analyses, scoping reviews are appropriate for synthesizing evidence in a new area of study where methodological inconsistencies are common.^[16]

As such, this study utilized a scoping review protocol to provide a comprehensive evaluation of psychosocial interventions aiming to promote PTG in oncology that does not limit results based on study design or interventional approach. The first aim of this study was to identify the types of interventions that have been implemented in cancer patients to promote PTG (Aim 1). The second aim of this study was to examine the PTGI total scores (Aim 2a), and subscale scores (Aim 2b) reported by all eligible studies to identify trends in the data related to each of Calhoun and Tedeschi's 5 factors of PTG.

Methods

The full scoping review protocol was published for public access to Figshare.com. The protocol was formulated using the PRISMA Statement modified for scoping reviews.^[16] The methods described below include identification of the research question, identification of relevant studies, study selection, charting of the data, and summarizing and reporting the results.^[16]

Data sources and searches

A research librarian was consulted regarding the search protocol and information sources. Electronic literature searches were performed using PsycINFO, CINAHL, and PubMed databases, including publications published up to October 2021. The full search strategy is available in the protocol published on Figshare.com (Table 1). All references were imported into the Zotero Electronic Database for management. All initial records identified through database searching were tracked for inclusion in the final study flow chart (Fig. 1).

Table 1 - Key terms in scoping review search strategy.

AND	OR	NOT
Posttraumatic growth	PTG, growth, personal strength, new possibilities, relating to others, appreciation of life, spiritual change, benefit finding, meaning making	Mice, mouse, HIV, veteran, refuge∗, abuse∗, caregiver∗
Cancer	oncology, neoplasm
Interven∗	Clinical, therapy, positive psychotherapy, psychotherapy, treatment

Figure 1: Scoping review search results.

Eligibility criteria

The following selection criteria were applied to the articles found in PsycINFO, CINAHL, and PubMed.

Type of study

Published primary studies were eligible for inclusion. Reviews, editorials, letters, and case reports were excluded from the study. There were no limitations regarding the study design. The articles that were included were in English or those that had been translated into English.

Type of participant

Eligible studies were those whose title or abstract specifically indicated the inclusion of cancer patients and included participants over the age of 18 years. There were no restrictions regarding the number of participants, type of cancer, or disease stage.

Type of intervention

Eligible articles were empirical studies that investigated the effects of a psychosocial intervention and utilized the PTGI as one of their outcome measures to assess PTG according to the five factors.

Data extraction

In the first round, 2 reviewers independently screened all titles and abstracts. In the second round, each full-text article was reviewed by the same two reviewers, and relevant data were extracted, including study design, inclusion criteria, sample and cancer-related variables, group comparison, intervention type, and PTGI outcomes. The differences were resolved by a third reviewer when needed. A standardized Excel form was used for the article review and data extraction.

Results

Literature search

A total of 8275 titles and abstracts and 116 full-text articles were assessed for eligibility. The reasons for exclusion are shown in Figure 1. After reviewers screened all full-text articles, the final number of eligible studies was 33.

Characteristics of included articles

Thirty-three studies fulfilled the eligibility criteria and were included in the study. All the studies were published between 2003 and 2021. Fifteen studies on interventions promoting PTG in oncology patients were conducted in the United States^[17–25] or Canada.^[26–31] Three studies were conducted in Australia.^[32–34] Four studies were conducted in the Middle East, specifically in Iran,^[35,36] Israel,^[14] and Turkey.^[37] Six studies were conducted in European countries of Italy,^[38] Switzerland,^[39] the Netherlands,^[40] Spain,^[13,41] and Portugal.^[42] Finally, there was a notable subset of studies that were conducted in Asian countries^[43–47] or implemented psychosocial interventions in a sample of foreign-born Chinese-Americans located in the United States.^[19,25]

Sixteen studies were quantitative, using a randomized controlled trial (RCT) design.^{[18,19,23,26,27,32,35,36,40,42–47]} Five studies implemented a RCT design but were considered pilot or feasibility studies because of the limited sample size and the goal of planning for a future large-scale RCT.^{[24,31,33,37,38]} Four studies were nonrandomized studies that still utilized a comparison group,^{[13,14,28,29]} which allowed for more conclusive evidence to be drawn about the application of certain psychosocial interventions to cancer patients with the goal of promoting PTG than the eight studies that utilized a pre-post-test design with no comparison group.^{[17,20–22,25,30,34,39]} The data are summarized in Table 2.

Table 2 - Characteristics of studies included in the scoping review (N = 33).

First author, year	Inclusion criteria	Sample	Cancer-related variables reported	Group comparison	Intervention	PTGI outcomes	Limitations
RCT
Carlson et al, 2016[26]	Women diagnosed with Stage I, II, or III breast cancer; completion of all treatment except hormonal or Herceptin therapy at least 3 mo before study; >18-y old; Score of 4+ on Distress Thermometer; Exclusion: no DSM IV Axis I diagnosis; no present use of psychotropic meds; no concurrent autoimmune disorder; no past participation in MBCR or SET group	N = 252, mean age (SD) = 55.12 (9.84) for MBCR and 54.14 (10.23) for SET, female	Type, stage	MBCR group therapy vs SET group therapy (see intervention column)	MBCR intervention consisted of eight 90-min group sessions per wk plus a 6-h workshop between wk 6 and 7. Sessions focused on mindfulness meditation and yoga practices; SET consisted of 12 wkly group sessions of 90 min each; sessions focused on increasing support, enhancing openness and emotional expressiveness, improving coping skills, doctor-patient relationship, and detoxifying feelings around death, and dying.	Reported PTGI Total Score, Five Subscale Scores; participants in MBCR group had higher scores on Personal Strength and Appreciation of Life subscales at baseline; scores improved for both intervention groups on subscales of New Possibilities, Personal Strength, and Total Score; no differences maintained at follow-up, but total score continued to increase in MBCR group relative to SET.	High attrition rate; large number of tests conducted, and the subscale analyses are considered exploratory; lower baseline scores (stress, spirituality, and PTG subscales) in set group at baseline which may indicate that group differences at may be attributed to baseline differences (however, this is unlikely as the set group showed less change over time than the MBCR group)
Cleary and Stanton, 2015[18]	Women diagnosed with invasive or metastatic breast cancer; 18 y of age or older; did not have personal website; able to complete questionnaires in English	N = 88, mean age = 56, age range = 37–76, female, majority non-Hispanic White	Type, time since diagnosis, treatment	Waitlist control group	Project Connect Online Intervention is a 3-h workshop about creating personal websites. Participants were instructed to create a personal website to communicate with family and friends.	Reported on PTGI Appreciation of Life Subscale, no use of PTGI Total Score or other subscale scores; participation in the PCO group led to increased appreciation of life. Increased appreciation of life was mediated by increase coping self-confidence, perceived social support, and decrease in loneliness.	Lack of objective measures of received social support including number of unique website visitors and content of posts; cannot conclude that change in mediating variables caused change in outcomes.
Crawford et al, 2016[27]	Women with histologically confirmed diagnosis of cervical, endometrial, or ovarian cancer; between ages 18 and 70 y old; living in Edmonton or surrounding area; willing to attend the wall-climbing intervention	N = 35, mean age = 53 ± 11.9, full demographic data reported elsewhere (Crawford et al., in press)	Type, time since diagnosis	Usual care control group	WCI consisted of wall-climbing classes held 2× per wk for 120 min for 8 wk. Classes taught by a certified climbing instructor, participants completed a climbing skills assessment at 2 wk, 4 wk, 6 wk, 8 wk to assess skill progression.	Reported PTGI Total Score, Five Subscale Scores; participants in WCI reported highest growth in areas of personal strength and new possibilities, lowest growth reported in area of spiritual change.	Small sample size, no long-term follow-up, full demographic data reported elsewhere.
Gallagher et al, 2018[19]	Women with previous diagnosis of stages 0–III breast cancer; completed primary medical treatment for breast cancer within the past 4 y; and comfort writing and speaking Chinese (Mandarin, Cantonese)	N = 96, mean age = 54.54, age range = 37–77, all participants foreign born, with majority born in China or Taiwan	Type, stage, time since diagnosis, treatment	EW cancer facts condition vs EW emotional disclosure condition vs EW self-regulation condition	EW intervention—all participants asked to write continuously for up to 30 min or until they completed 1 full page of writing on 3 occasions over a 3-wk period. cancer Facts Condition involved writing objectively about cancer diagnosis and treatment in a detailed manner; Emotional Disclosure Condition involved writing about deepest thoughts and feelings about their cancer experiences; Self-Regulation Condition participants wrote about deepest feelings and thoughts related to cancer experience during wk 1, the coping strategies they used for stress caused by cancer experience during wk 2 and positive thoughts and feelings regarding their cancer experience during wk 3.	Reported PTGI Total Score, no use of subscale scores; PTG decreasing from baseline to final assessment; Self-Regulation condition and Emotional Disclosure Condition resulted in decrease in PTG relative to cancer Facts condition; no conditions resulted in clinically significant improvement in PTG.	Small sample size, secondary analysis of previously published trial so trial was not designed or statistically powered to detect small effect size differences between conditions, cancer facts condition may have prompted some degree of cognitive processing and therefore may not be a true control condition, sample comprises mostly foreign-born Chinese American immigrants and results may not be generalizable to us-born Chinese Americans.
Hamidian et al, 2019[35]	Minimum age of 20 y; reading and writing literacy (no language specified); termination of acute course of disease after initial diagnosis before study; absence of metastasis; lack of cognitive and psychiatric disorders; no crisis over past few mo; elapse of no >5 y from initial cancer diagnosis	N = 85, mean age (SD) = 43.9 ± 8.43 (intervention) and 40.3 ± 10.82 (control)	Type, stage, time since diagnosis	Usual care control group	Cognitive-Emotional Training Group Intervention sessions occurred 2 days a wk, with groups of 4 to 8 subjects each session. Each participant received five 60 to 90 min sessions consisting of normalization of emotional reactions to cancer, training and practicing emotion disclosure, self-regulation, and discussion of fears and concerns related to breast cancer.	Reported PTGI Total Score, no use of subscale scores; mean score of PTG increased from baseline to post-intervention in cognitive-emotional training group.	Short 20-wk interval between the pretest and posttest, small sample size, and significant difference between the study groups in terms of demographic variables of education and occupation.
Han et al, 2021[47]	Participants were recruited from inpatients at the Department of Comprehensive Therapy of Oncology, Jilin Province People's Hospital, China between May 2018 and July 2020. Eligibility criteria included: newly diagnosed advanced cancer patients who had received palliative radiation therapy for 6 wk, able to understand and read Chinese, older than 20 y, Distress Thermometer score >4, with adequate stamina to complete study assessed by physician	N = 130, mean age (SD) = 58.04 (14.21) for treatment and 58.19 (15.23) for control, majority female	Type, stage	Usual care control group	Combined Naikan and Morita Therapy is a systematic psychological therapy based on Eastern philosophy to help patients accept the view that unpleasant symptoms are the normal part of human emotions rather than negative things to be eliminated. The goal is to evoke the patients’ positive emotions and then improve behavioral initiative through seven consecutive weeks of treatment involving guided introspection, distress tolerance, and engage in purpose-oriented behavior.	Reported on PTGI Total Score, Five Subscale Scores; PTGI total and all subscale scores of treatment group were higher than those of control group at post-treatment.	Due to the small sample size, the results should be considered preliminary. Second, the psychological states of patients before the AC diagnosis were not accessed, which is a factor that may be associated with the post-cancer treatments.
Hawkes et al, 2014[32]	≥18 y of age; resident of Queensland; histologically confirmed diagnosis of primary colorectal cancer within 12 mo; ability to understand and provide written informed consent in English; no metastatic disease; no medical conditions that would limit adherence to unsupervised physical activity program; has telephone; at least one poor health behavior consistent with Australian recommendations	N = 410, mean age (SD) = 66.3 (10.1), majority born in Australia, 54% of sample was male	Type, time since diagnosis, treatment	Usual care control group	Can Change is a 6-mo telephone-based health coaching intervention consisting of 11 sessions using acceptance and commitment therapy strategies focusing on physical activity, weight management, diet, alcohol, and smoking	Reported on PTGI Total Score, Five Subscale scores; increase in total PTG within intervention group at 6 mo and 12 mo, increase in PTG subscales of new possibilities and relating to others at 6 and 12 mo in intervention group; increase in PTG subscales of appreciation of life and personal strength at 6 mo in intervention group.	Use of self-report measures and their inherent biases, data collected by telephone interview which limited ability to collect objective biomedical data, possible that false positives occurred by chance due to use of multiple comparisons for study outcomes at alpha = .05
Lleras de Frutos et al, 2020[41]	Women with a range of cancer diagnoses were recruited between January 2016 and January 2019. Inclusion criteria were: age ≥18 y, primary oncological treatment completed, disease-free or clinically stable, ≥10 on the HADS total score, access to high-speed internet, and competence to understand and read Spanish.	N = 269; mean age (SD) = 52.17 (8.36) for PPC and 47.34 (8.05) for OPPC; female	Type, stage	OPPC	Face-to-face group PPC is a therapist-led group program aimed at facilitating PTG through psychotherapeutic methods associated with the development of positive life changes after cancer. PPC is an evidence-based face-to-face treatment consisting of 12 wkly group sessions of 90 to 120 min.Each group was comprised of 8 to 12 patients. OPPC is identical to group PPC in content but delivered via videoconference and consisting of 11 wkly online group sessions of 90 to 120 min with the 12th session conducted in-person.	Reported PTGI Total Score, no use of subscale scores; The observed treatment effect can be regarded as clinically significant in both modalities, PPC and OPPC.	The respect for patient treatment preferences may have partly biased the results, although it also brings them closer to real-world clinical practice. This study does not include a nontreatment control group because it focused on comparing treatment delivery modalities. Other limitations were the difference in the number of individuals in each group, as there were 10 to 12 patients in PPC and 5 to 6 in OPPC groups.These differences may affect the results as group sizes, not just modality, could influence group evolution, alliance, or commitment.
Norouzi et al, 2017[36]	Between 20 and 45 y old; diagnosed with stage II breast cancer; married; preparatory or higher education; Exclusion criteria: multifocal (MF) and multicentric (MC) breast cancer; diagnosis of other serious medical diseases; psychiatric disorders	N = 20, mean age = 38.8, age range = 20–45; female	Type, stage	No treatment control group	MBCT is a group therapy intervention based on the manual created by Williams et al and involved intensive training in mindfulness meditation, provision of theoretical material, and group discussion. The experimental group received 8 sessions of intervention within 2 mo.	Of note, it is unclear whether the total score or all subscales were used. Based of raw data provided, it appears that only one subscale may have been used but that is not specifically noted. There was a significant difference between the control group and the MBCT group PTGI scores post-test and at follow-up, with MBCT group scores improving more than control scores.	Sample limited to women with breast cancer, small sample size, only performed on married women, unclear reporting on PTGI use, scores reported are consistent with a single subscale scoring, but this is not specifically discussed by the author.
Ramos et al, 2018[42]	≥18 y; histologically confirmed stages I–III breast cancer; no evidence of local recurrence or metastatic disease; diagnosed between 1/2011 and 5/2015; spoke fluent Portuguese; and had no other mental or physical disorder	N = 205, mean age (SD) = 55.16 (10.44) control group and 52.17 (8.71) intervention group, female	Type, stage, time since diagnosis, treatment	No treatment control group	PTG group intervention—this intervention consisted of a closed and structured group aimed at facilitating PTG among breast cancer patients. Participants met wkly for 8 sessions of 90 min. Each intervention group included 6 to 8 participants. The intervention consisted of psychoeducation and normalization of emotional reactions, facilitating emotional disclosure and communication, practice of emotional self-regulation skills, fears and concerns related to breast cancer, balance between gains and losses after breast cancer diagnosis, construction of a coherent personal narrative, development of new values and priorities of life, and redefinition of life goals.	Reported PTGI Total Score, no use of subscale scores; the intervention group had significantly higher levels of PTG at T3.	Sample composed mostly of middle-aged and middle-class women with relatively low education, considerable number of participants dropped out at t2 and at follow-up (t3), number of women in intervention group was considerably lower than number of women in control group.
Stanton et al, 2005[23]	Women with newly diagnosed stage I or II breast cancer, primary surgery within the last 6 wk, invasive epithelial cancer histology, any tumor size, any nodal status, surgery as initial therapy, and reconstructive surgery if it was completed within approximately 6 mo; Exclusion Criteria: history of breast cancer, noninvasive breast cancer, metastatic or inflammatory breast cancer, planned use of neoadjuvant chemotherapy or of high-dose chemotherapy with bone marrow or stem-cell rescue, protracted reconstructive surgery or surgical complications, severe physical, cognitive, or psychiatric illness, inability to read and write in English, participation in another clinical trial with a QOL intervention	N = 418, mean age = 58.1, age range = 26–86 y, majority were white, all female	Type, stage, treatment	Standard print control group—participants were mailed a booklet (facing forward) containing general information for cancer survivors about health care after cancer treatment, financial concerns, and managing emotions	Videotape Intervention—participants mailed the facing Forward booklet and a 23-minute video entitled Moving Beyond cancer, which addressed physical health, emotional well-being, interpersonal relations, and life perspectives with the goal of promoting adaptive peer modeling and active coping skills; Psychoeducational Counseling intervention—participants participated in 2 individual sessions with trained cancer educators, during which they reviewed their cancer-related concerns in the 4 life domains described previously, identified a primary concern and their associated goals, developed an approach-oriented action plan to address that concern, and addressed barriers to their plan. They were also given the Moving Beyond cancer videotape and an author-constructed 60-page manual entitled, Moving Beyond cancer: Your Guide to a Successful Recovery.	Reported on PTGI Total Score, no use of subscale scores; no significant effects emerged for intervention on the PTGI.	Randomization failed to equalize the groups om some psychological variables at baseline, participation among all eligible women was 42%, >20% of randomly assigned women lost to follow-up, September 11, 2001 terrorist attacks significantly influenced completion of assessments at dc site, sample primarily made of educated women with early-stage breast cancer which makes results less generalizable to more diverse samples.
van der Spek et al, 2017[41]	Adult cancer survivors who were diagnosed in the last 5 y who were treated with curative intent, and who had completed their main treatment (ie, surgery, radiotherapy, chemotherapy). Participants had to have an expressed need for psychological care and at least 1 psychosocial complaint (eg, depressed mood, anxiety, coping issues, life questions, meaning-making problems, relationship problems); Exclusion Criteria: severe cognitive impairment, current psychological treatment, or insufficient master of the Dutch language	N = 170 (40 male, 130 female), mean age (SD) = 58.6 (10.7) for MCGP condition, 55.5 (9.6) for SGP condition, 57.3 (10.4) for CAU condition	Type, treatment	MCGP-CS vs SGP—8-wk, social support group therapy, 2-h sessions held wkly, no specific attention paid to meaning, focus on positive emotions and expression of feelings vs usual care.	MCGP-CS is a manualized 8-wk intervention that makes use of didactics, group discussions and experimental exercises that focus on themes related to meaning and cancer survivorship. The sessions lasted 2h each and were held wkly. The participants used a workbook (Life Lessons Portfolio) and completed homework assignments every wk.	Reported on PTGI Total Score, no use of subscale scores; No significant difference between groups on course of PTG,	More males in MCGP-CS condition, no clear cut of scores or minimal important difference in criteria are available regarding the primary outcome measures, use of multiple comparisons may have led to significant results by chance; the MCGP-CS and SGP groups were supervised by the same therapists which increases risk of bleed across conditions.
Yun et al, 2017[43]	Adult breast cancer survivors who had completed surgery and/or adjuvant chemotherapy and/or radiotherapy after surgery up to 2 y 6 mo before the study and were receiving follow-up observations on an outpatient basis with or without adjuvant endocrine therapy treatments. Exclusion Criteria: women who experienced relapse or had a primary cancer other than breast cancer and those with psychiatric or other severe, uncontrolled, chronic illnesses were not eligible to participate. Women who have participated in similar programs previously or have any difficulty in participating in all meditation or education sessions were also excluded	N = 52, mean age (SD) = 48.44 (8.16), age range = 30–60 y	Type, stage, treatment	SME group—received education on relationships, communication, stress management, and other health topics. The sessions were held wkly for 2 h over the course of 4 wk.	MSM group was held for 2 h, twice a wk for 8 wk. The first 2 wk provided education on SME, whereas the result of the sessions focused on building up to full-scale meditation. Participants were educated on and instructed to identify difficult mindsets and “subtract” the mindsets through meditation.	Reported on PTGI Total Score, no use of subscale scores; significant improvement in PTGI total score for MSM group.	Small sample size and those participants were recruited from only 1 medical center.
Yun et al, 2017[45]	Cancer registries from 10 South Korean teaching hospitals; survivors who completed primary cancer treatment within the last 24 mo for breast, stomach, colon, and lung cancer within 18 mo of completion of primary treatment; 20 y of age or older; have a platelet count >100,000/mm3;have a serum hemoglobin ≥10 g/dL; have not already met ≥2 behavioral goals aimed for in the study; Exclusion Criteria: were presently receiving cancer treatment, had a progressive malignant disease or a recurrent, metastasized, or additional primary cancer, had a condition that might compromise adherence to an unsupervised exercise program, had a condition that could interfere with ingestion of a diet high in vegetables and fruit, a serious psychological disorder, had visual or motor dysfunction, or were pregnant	N = 206, mean age (SD) = 50.68 (9.43), 79.61% female	Type, stage, treatment	Usual Care control group—provided with health education booklet and received a 4-h health education lecture focused on physical activity, diet, stress management, and cancer screening.	Leadership and Coaching for Health program—participants attended a health education workshop and a leadership workshop. They were also offered individual phone coaching for 16 sessions. The intervention focused on increasing health education and encouraging participants to practice health behaviors.	Reported on PTGI Total Score, Five Subscale Scores; greater increase in PTGI total score from baseline to 12 mo in intervention group as compared to control group.	30.7% Of the patients did not complete the full 12-mo telephone coaching, the participants did not represent the whole cancer population; most of the recruited participants were early-stage, measures of diet and pa were based on self-reports, included wide range of cancer types, which may complicate interpretation of findings.
Yun et al, 2013[44]	Candidates were cancer survivors 5 y past the completion of their primary treatment. Applicants were excluded from the study if they: were receiving cancer treatment, were not psychologically stable (eg, had bipolar disease, schizophrenia, an eating disorder, depression, or anxiety), had a serious acute or chronic illness such as stroke, heart attack, chronic renal failure, or breathing difficulties requiring oxygen use or hospitalization, did not understand the intent of the study, could not read Korean or communicate with others, or were pregnant	N = 70, mean age (SD) = 56.1 (5.6) for intervention group and 55.3 (7.3) for control group, majority of sample were female.	Type, treatment	Waitlist control group	Health Partner Program intervention consisted of 3 components: health education, leadership, and coaching. 8-wk program consisting of 12 telephone sessions in addition to group discussions.	Reported on PTGI Total Score, Five Subscale Scores; personal strength score and total PTGI score showed a statistically greater clinically meaningful improvement in the intervention group than in the control group.	Small number of participants and our use of half of them as a waiting-list control resulted in a small experimental arm; participants went through a highly selective interview process they were likely to be more motivated than the general population; the training program was based on the leadership program of the 7 habits coaching program, but a more specialized program should be developed.
Zhang et al, 2017[46]	Participants were recruited from the department of breast surgery at the Third Affiliated Hospital of Harbin Medical University in Harbin, China. Included females who: were diagnosed with Stages I–III breast cancer, were aged 18 y or older, were within 2–6 mo after the completion of surgery, and had no other major disabling medical or mental disorder. The patients who had participated in a similar intervention were excluded.	N = 60, mean age (SD) = 48.67 (8.49) for MBSR group, 46.00 (5.12) for UC group; age range = 30–62	Type, stage, treatment	Usual care control group	MBSR group received 2-h wkly sessions conducted by a psychologist certified in mindfulness skills. Each session included didactic teaching, experiential exercises, and group discussions with 45 min of meditation and yoga assigned each day for homework	Chinese version of PTGI utilized, Reported on PTGI Total Score, Five Subscale Scores; participants in both groups showed an increase in the PTGI score; the subscales of new possibility and spiritual change showed no group effect, longitudinal MBSR intervention more effectively promoted the development of PTG in the BC patients.	Limited by a modest sample size, an extension of the observation and intervention times is needed, the MBSR (BC) program was administered in 1 hospital, and it should be tested in other settings in future studies.
Feasibility/Pilot RCT
Caruso et al, 2020[38]	The study was carried out on advanced cancer patients referred to the Program of Psycho-Oncology Psychiatry in Palliative Care, University of Ferrara (Ferrara, Italy). Inclusion criteria were age ≥18 y, a diagnosis of advanced cancer (expected survival of 12–18 mo), no cognitive impairment, and a score ≥10 in the Patient Health Questionnaire-9 (PHQ-9) or ≥20 in the Death and Dying Distress Scale (DADDS)	N = 25, mean age (SD) = 60 (11.8).	Type, treatment	Usual care control group	Managing CALM is a brief, manualized, individual therapy with 3–6 sessions delivered over 3–6 mo. The intervention focuses on symptoms management, communication with providers, changes in self and relations with others, sense of meaning and purpose, and concerns about the future and mortality.	Reported on PTGI Total Score, no use of subscale scores, statistically significant improvement on PTGI in CALM group from T1 to T2 as well as in comparison of CALM group versus UC.	The small number of patients indicates the need to expand the sample size. Also, since compared CALM with UC, cannot conclude that CALM is superior to or similar to other meaning-centered psychotherapy.
Kissane et al, 2019[34]	Sample of patients was identified from the oncology and palliative care services of Cabrini Health in Melbourne, Australia, across 2015–2016. Inclusion criteria were patients with: advanced cancer whose prognosis was assessed at ≤12 mo, reasonable use of English; and age >18 y. Exclusion criteria were: cognitive or psychiatric impairment likely to interfere with therapy and pronounced frailty because of advanced disease rendering completion of study requirements unlikely.	N = 57, mean age (SD) = 65 (12.9), 53% male, 75% Australian born	Type, treatment	Waitlist control group	Meaning and Purpose therapy consisted of six, 60-min manualized sessions delivered by psycho-oncologists. The intervention is existentially oriented and focused on recounting a person's life, values, relationships, and the effect of cancer.	Used 3 of its 5 subscales in this study to assess positive outcomes after traumatic events: new possibilities (5 items), personal strength (4 items), and appreciation of life (3 items). Improvements in the intervention arm on all 3 subscales were seen when compared with controls.	Privileged feasibility of recruitment over maximizing demonstration of benefit through the use of a sample most in need; resultant effect sizes are modest for growth and goals, and not seen for outcomes such as depression and demoralization, where some “regression to the mean” potentially conceals such benefit; cannot exclude benefits resulting from nonspecific effects of therapy.
Lo et al, 2019[31]	Adult patients with advanced cancer from the Princess Margaret cancer Centre in Toronto, Canada. Eligibility criteria included adult age; English fluency; and a confirmed diagnosis of Stage IIIB or IV lung cancer, Stage III or IV ovarian or fallopian tube cancer, Stage IV endocrine, breast, gastrointestinal, genitourinary, or gynecological cancer, or pancreatic cancer at any stage due to the aggressiveness of this illness (all diagnoses consistent with an expected prognosis of 12–18 mo). Exclusion criteria included cognitive impairment found on the Short Orientation-Memory-Concentration Test.	N = 60, mean age (SD) = 56.62 (11.36) for UC group and 55.37 (12.13) for CALM group; mostly female and White	Type, stage, time since diagnosis	Usual care control group	Managing CALM is a brief, manualized, individual therapy with 3–6 sessions delivered over 3–6 mo. The intervention focuses on symptoms management, communication with providers, changes in self and relations with others, sense of meaning and purpose, and concerns about the future and mortality.	Reported on PTGI Total Score, no use of subscale scores; no support for treatment effects on PTG.	Small sample size and its representativeness since a majority of participants were married, well-educated, English-speaking, White and female with advanced gastrointestinal cancer. The study was unblinded, which may also have affected study outcomes. Participants were not selected based on elevated distress scores.
Üzar-Özçetin et al, 2019[37]	Sample collected from Hacettepe University Oncology Hospital and Ankara Numune Education and Research Hospital in Ankara, Turkey. Cancer survivors who were in the remission period and continuing only control appointments. Study inclusion criteria were as follows: 25 y and older, being able to communicate in Turkish, being in the remission period of advanced cancer, having completed primary treatment ≤5 y ago, voluntary participation in the study, and having no physical and/or psychiatric condition (schizophrenia, posttraumatic stress disorder, dementia, anxiety disorder, major depressive disorder, among others) that would impede one's ability to participate in the study; Exclusion Criteria: being younger than 25 y, not being able to communicate in Turkish, continuing oncology treatment (chemotherapy, radiotherapy, among others), having completed primary treatment for a maximum of ≥5 y ago, and having a physical and/or psychiatric condition	N = 89, mean age (SD) = 49.28 (7.06) for EG and 48.65 (6.72) for CG, majority of sample was female	Type, stage, time since diagnosis, treatment duration	Usual care control group	Empowerment Group—this intervention program consisted of 10 sessions, each of which had a different topic which built off the previous topic. The topics included cancer experience, relationships between emotion, thought, and behavior, communication, assertiveness, self-perception, coping skills, social support, and a life review.	Used Turkish version of PTGI; reported on PTGI total score, Five Subscale scores; EG scores indicated significant improvements in total PTG compared to CG, increase in personal strength, relating to others, and new possibilities score in EG as compared to CG.	Study was conducted in 2 oncology hospitals, which limits the generalizability of the findings. The post-program follow-up measurements were applied a mo after the program; thus, long-term effects of the program could not be determined.
Victorson et al, 2017[24]	Men were eligible to participate if they were diagnosed with low-risk localized prostate cancer enrolled in an active surveillance (AS) protocol; to be eligible for AS, men had to meet the following criteria based upon 12-core diagnostic TRUS-biopsy and DRE: clinical stage ≤T2a, Gleason score ≤6, ≤3 cores positive, maximum involvement of any core <50%, and tumor volume ≤5% of total biopsy volume; participant accrual occurred at a medium-sized community hospital system in the northern suburbs of Chicago.	N = 43, mean age (SD) = 71.2 (6.5) for control and 69.4 (7.1) for mindfulness; majority White	Type	Control group—participants provided with a book on mindfulness	Mindfulness intervention consisted of 8, wkly 2.5-h sessions with a half day retreat near the end of the intervention. The sessions utilized MBSR intervention strategies.	Reported PTGI Total Score, Five Subscale Scores; increase in PTGI total from baseline to 12 mo follow-up; Of the 5 PTGI subscales, all demonstrated greater increases between baseline and 12 mo among mindful ness group participants as compared to CG, and 2 were statistically significant with large effect sizes: relating to others and personal strength	Small sample size, not generalizable to less educated and more racially diverse groups, does not assess credibility or expectancy to determine the influence of participants” beliefs and expectations about how effective the mindfulness intervention would be.
Nonrandomized Comparison Study
Garland et al, 2007[28]	Patients over the age of 18 who had been diagnosed with cancer and were able to understand English; patients were self-selected and chose which program to attend by placing themselves on either waitlist; eligible participants must have attended at least 5 of the 8 classes for MBSR and 4 of the 6 HA classes.	N = 104, mean age (range) = 52.84 (35–79) for HA group and 52.17 (26–78) for MBSR group; majority of participants were female	Type, stage, time since diagnosis, treatment	HA—this group entailed self-discovery and empowerment through music, journaling, creative writing, and drawing. It was led by a registered clinical social worker who is a visual artist, a clinical psychologist and a professor of dance and kinesiology. The program consisted of 6 wkly 2-h sessions	MBSR program consists of 8 wkly 90-min sessions plus one 3-h weekend intensive silent retreat co-led by 2 clinical psychologists and a registered nurse with professional yoga training. The intervention attempted to increase participant awareness of themselves, their thoughts, and bodies through class discussion, meditation, and yoga exercises. Included daily homework of 45 min of yoga and medication.	Reported on PTGI Total Score, Five Subscale scores; participants in both programs showed improvements in their ability to relate to others, to discover new possibilities, and recognize their personal strengths. Overall, both programs resulted in an increase in total PTG; increased PTG over the course of the program was positively related to increased spirituality in the MBSR program, but not the HA program.	Lack of randomization to the MBSR or HA treatment and the lack of a notreatment or waitlist control group, resulting in an inability to perform formal controlled comparisons.
Labelle et al, 2015[29]	Patients were recruited from those who had signed up and were waiting for an upcoming program. Patients were deemed eligible for the study if they met the following inclusion criteria: age 18 y or older, a diagnosis of any type of cancer, at any time in the past, speak and read English sufficiently to complete questionnaires, and had not previously participated in an MBSR group	N = 211, mean age (SD) = 52.7 (11.0), majority female and White	Type, time since diagnosis, treatment	Waitlist control group	MBSR program consisted of 8 wkly, 90 min group sessions with one 6-h intensive session between wk 6 and 7. Each session included didactic teaching, experiential exercises, and group discussions with 45 min of meditation and yoga assigned each day for homework.	Reported on PTGI Total Score, no use of subscale scores; at study outset, MBSR group participants had significantly higher PTG scores relative to controls; MBSR program participants demonstrated greater increases in PTG total score over intervention period than controls.	Lack of randomization; factors other than intervention itself may have contributed to change in mediator and outcome variables, including preexisting group differences and regression toward the mean.
Ochoa et al, 2017[13]	Participants were referred by medical oncologists or nurses to the psycho-oncology unit of a southern European cancer center if they presented emotional distress at the end of their primary oncological treatment. Participants meeting the following inclusion criteria were then invited to participate: age 18–70 y old; presence of a single primary cancer; primary oncological treatment (surgery, chemotherapy, or radiotherapy) completed; presence of significant clinical distress, with a global score of 10 or more on the HADS; and ability to understand and read Spanish. Exclusion Criteria: prior cancer, prior or present other severe mental disorders, major concurrent medical diseases impacting cognitive performance	N = 126, mean age (SD) = 48.93 (9.48) for PPT Group and 48.49 (11.90) for CG	Type, stage, first diagnosis, time since diagnosis, treatment	Waitlist control group	Positive Psychotherapy intervention consisted of twelve 90- to 120-min sessions with 8–12 patients in each group. The intervention focused on assimilating to the cancer experience and encouraging accommodation and personal transformation from the experience.	Reported PTGI Total Score, no use of subscale scores; PTG could be facilitated by the PPC program, and that increases in PTG were associated with decreases in emotional distress and post- traumatic stress. PPC group compared with WL group showed an increase in PTG from pre-intervention (T0) to post-intervention (T1), that was maintained at 3 and 12 mo of follow-up, but this increase was not statistically significant	Absence of a randomized assignation of participants to study conditions; control group was not ideal because, besides the ethical problem of waiting for treatment, the expectation of waiting could have influenced the results; not possible to discern which elements of the program are those with greater or less psychotherapeutic impact with present study design.
Pat-Horenczyk et al, 2015[14]	Participants recruited from Rabin Medical Center, a tertiary, university-affiliated hospital in central Israel; participants had to be Hebrew- speaking and aged 25–75 y, with a first-time diagnosis of breast cancer and no other chronic illness	N = 94, mean age (SD) = 51.5 (10.7)	Type, first diagnosis, stage, time since diagnosis, treatment	No treatment control group	Building Resilience group intervention consisted of eight, 1.5-h sessions focused on teaching coping strategies and enhancing resilience.	Reported on PTGI Total Score, no use of subscale scores; more than half of the participants reported PTG over a 6-mo period, with the intervention group reporting a greater increase in PTG and coping than the control group. Furthermore, the intervention participants reported more constructive growth (a rise in PTG and improved coping) and less illusory growth (a rise in PTG, but no improvement in coping) than the nonparticipants.	Based on a convenience sample, and the participants in the intervention group were self-selected, results were based on self-reports and additional perspectives may be useful in providing further support for our results, the outcome measurement of PTG was collected 6 mo after the intervention and later follow-up measurements were necessary for verifying the trajectory of PTG, researchers did not have enough information about those who opted neither to participate in the group nor to fill out the questionnaires.
No Comparison Group
Campo, 2017[17]	Study eligibility criteria included the following: present age 18–29 y, cancer diagnosis at age ≥15 y, initial cancer treatment completed (defined as not presently scheduled for or undergoing treatment [adjuvant therapies were allowed, eg, breast cancer hormonal therapies]), computer and high speed internet, able to communicate via e-mail, no participation within 6 mo in a mindfulness- or compassion-based program, no consistent meditation practice (≥30 min daily), and fluent in English language; hose to exclude YAs undergoing initial cancer treatment due to the potential feasibility bias of factors related to initial treatment	N = 57, mean age (SD) = 26.7 (2.0) at baseline, majority female, non-Hispanic, White	Type, time since diagnosis, treatment	Pre-posttest comparison	Adapted 8-wk group videoconference intervention from the MSC program and the Making Friends with Yourself program; eight 90-min sessions led by an instructor who had completed the MSC teacher training program and had 3 y of mindfulness-based instructor experience; Sessions consisted of didactic instruction, experiential activities, lessons on meditation, and group discussion.	Reported on PTGI Total Score, Five Subscale Scores; increase in PTGI Total Score post-test; increases on all subscale scores, although not significant.	Interpretation of these is limited without comparison to a control group in a larger sample; all participants were well-educated females (more than half had college degrees, almost a third were in graduate school); therefore, findings cannot be generalized to females with lower levels of education or to male; participants were self-selected and likely highly motivated to participate; we included conservative eligibility criteria of a current age range between 18 to 29 y and access to necessary technology. The age range of AYA cancer survivors has been defined by national oncology guide- lines as ages 15–39.
da Rocha Rodrigues et al, 2019[39]	Adults with: advanced cancer, an adequate health status determined by a nurse and a physician, and the ability to cognitively understand and consent to the study. Patients with cognitive disorders related to memory loss or a speech impairment were excluded, as were individuals whose command of the French language was insufficient to complete questionnaires.	N = 41, mean age (SD) = 57.78 (11.6), age range = 30–75; 58.5% female; majority Swiss nationality	Type, time since diagnosis	Pre-posttest comparison	Revie ⊕ is a Theory-guided, life review intervention, focusing on strength and resources, for patients with advanced cancer. The intervention was delivered by 8 trained nurses. Two sessions were delivered over the course of 1 wk to 30 days. The 1st session involved a 46-min face-to-face meeting conducted by the intervention nurse. The 2nd session involved a 20-min meeting conducted by the researcher and allowed for presentation of a booklet to the participant. This booklet was filled with photos, excerpts from poems, prayers, songs, images, personal messages to patients’ partners.	Reported on PTGI Total Score, Five Subscale scores; a high level of PTG was observed at baseline. No statistically significant difference was found in the total PTGI score or subscale scores from pre to post-test.	No control group, large sample size needed in future study.
Garlan et al, 2011[20]	Recruited through fliers placed at the UCSF and Stanford cancer supportive care centers; to be eligible for participation in the study, potential participants had to have received a cancer diagnosis and be at any stage of treatment, recovery, or palliative care; feel they had the interest and endurance to complete the interview and three packets of measures (no specific minimum time-since-diagnosis was specified); and be available for interview within the several San Francisco Bay Area counties. Exclusion Criteria: <18 y of age, did not speak English, or were unwilling to complete the informed consent and assessments.	N = 60, mean age (SD) = 56.3 (15.99), age range = 27–89, majority female, White	Type, time since diagnosis	Pre-posttest comparison	Life Tape Project: brief existential family intervention to increase family support and understanding and allow the patient to reflect on their life. It involves a 1- to 2-hour semistructured videotaped interview with the cancer patient and family or loved ones. Patient is asked question about their life, lessons they’ve learned, personal philosophy and their impact on others. Videotapes are then edited, and cancer patients are provided with a copy.	Reported PTGI Total Score, no use of subscale scores; participants meeting criteria for PTSD at baseline reported higher PTG total scores post-intervention when compared to participants that did not meet criteria at baseline.	Did not include a control group with whom changes over time, in the absence of the interview, could be compared; small sample size; all measures were self-report in nature; the generalizability of findings may be limited because all patients in the present study were well enough to participate, had families and/or close friends also willing to contribute, and volunteered to participate in the study; as a group, these participants were well educated and affluent.
Garlick et al, 2011[21]	Women had to be 18 y of age or older. Women had to have been diagnosed with breast cancer in stages 0–3 within the past 10 y and presently not have metastatic disease. Participants were also required to be physically capable of attending all 24 of intervention trainings and to be capable of reading and writing English. Women with bipolar or psychotic disorders, intrusive suicidal thoughts, or present drug and alcohol abuse were excluded from the sample.	N = 24, mean age (SD) = 53 (7.48), age range = 40–66, majority of women in sample were White	Type, stage, time since diagnosis, treatment	Pre-posttest comparison	PSIT is an 8-wk group intervention which aims to address patients’ worldview, life purpose and life meaning. It involves teaching participants meditation and stress management skills.	Reported on Five Subscale scores; did not report PTGI Total Score; significant improvements found from pre to post-test on Personal Strength Subscale.	No control group, small sample size, future research should examine whether the PSIT program can be useful to other populations, including patients diagnosed with other types of cancer or other illnesses, men, and ethnic minority populations.
Lieberman et al, 2003[22]	Women with breast carcinoma. Each woman was required to have their physician verify their diagnosis by filling out a questionnaire with information from their pathology report. No additional eligibility criteria offered.	N = 32, majority of participants were between ages 40 and 49 y	Type, stage	Pre-posttest comparison	Electronic Support Group for women with breast cancer—16 wkly sessions; each ESG meeting was facilitated by a trained facilitator. The women also had access to a private newsgroup for their cohort in which they were free to post pictures, their cancer stories, and chat during the time between group sessions. This was available 24 h a day and was a place in which women exchanged information, stayed in touch with each other outside of the regularly scheduled chat sessions, and read transcripts of meetings they had missed.	Reported on Five Subscale scores, did not report PTGI Total Score; demonstrated a trend toward increased new Possibilities and Spirituality on the PTGI	Insufficient reporting on eligibility criteria and sample demographics, lack of randomization and control group comparison, small sample size.
Lo et al, 2014[30]	Recruitment occurred at Princess Margaret cancer Center, part of the University Health Network, in Toronto, Canada. Eligible patients were at least 18 y of age; had a confirmed diagnosis of Stage IV cancer, or Stage III lung cancer; did not have cognitive impairment documented in their medical chart; were sufficiently fluent in English to provide informed consent and to participate in the intervention; and were interested in individual psychotherapy to assist in their coping with disease.	N = 41, mean age (SD) = 52 (12), majority female	Type, stage, time since diagnosis	Pre-posttest comparison	Managing CALM is a brief, manualized, individual therapy with 3–6 sessions delivered over 3–6 mo. The intervention focuses on symptoms management, communication with providers, changes in self and relations with others, sense of meaning and purpose, and concerns about the future and mortality.	Reported PTGI Total Score, no use of subscale score; nonsignificant increase in PTG from pre to post-test.	Small sample size, substantial loss to follow-up, sample mostly white or European, English-speaking, and well-educated; no randomization or control group
Stafford et al, 2013[34]	Women with a diagnosis (new or recurrent) of breast or gynecologic cancer for which treatment or active follow-up was presently being received were recruited. Other inclusion criteria were age of 18 y or older, ability to provide informed consent, absence of cognitive impairment or mental illness, physical ability to attend and participate in the program, and ability to read, write, speak, and understand English.	N = 42, mean age (SD) = 50.15 (10.0, age range = 31 to 66	Type, treatment, time since diagnosis	Pre-posttest comparison	MBCT—this group intervention was delivered in 2 rounds of 3 groups consisting of 8–10 women. The intervention consisted of training in mindfulness and meditation, psychoeducation, and group discussion.	Reported on PTGI Total Score, no use of subscale scores; scores on the PTGI improved significantly from T1 to T2.	Small sample size, information regarding reasons for women not being interested in the study was not recorded. It is recognized that the sample was highly self-selected and that it is likely that very motivated individuals, who were willing and open to learning new skills, attended the program. Clinical and demographic data of non-participants were not collected, so the representativeness of the sample is not known, some 60% of this sample had high levels of education, nonrandomized design, no control group.
Warmoth et al 2020[25]	The study was advertised in local communities, and potential participants were contacted through Chinese community networks. Those survivors who were interested in the intervention were screened for eligibility. Any woman who was: diagnosed with breast cancer (stage 0-III), comfortable reading and speaking Chinese (Mandarin or Cantonese), and completed her primary treatment (eg, mastectomy, chemotherapy, radiation therapy, and reconstruction surgery) were invited to participate in the JLA. Participants no longer undergoing treatment for cancer included because they faced unique challenges after the completion of treatment/	N = 39, mean age (SD = 52.74 (9.75), age range = 40–64	Type, stage, treatment	Pre-posttest comparison	The JLA intervention involved wkly 3-h sessions for 6, 8, or 10 wk. The intervention involved peer-monitoring and education and focused on topics such as self-care, emotional management, health, self-esteem and more	Reported on PTGI Total Score, Five Subscale Scores; found moderate effect sizes in the improvement of overall PTG and the Relating to Others subscale. However, they were not statistically significant improvements after the JLA.	Small pilot program without a controlled comparison, evaluations were only conducted pre- and immediately post-intervention and cannot conclude any long-term or lasting effects.

CALM = Cancer and Living Meaningfully, EW = Expressive Writing, HA = Healing through creative arts, JLA = Joy Luck Academy, MCGP-CS = Meaning-Centered Group Psychotherapy for cancer Survivors, MBCR = mindfulness-based cancer recovery, MBCT = mindfulness-based cognitive therapy, MBSR = mindfulness-based stress reduction, MSC = Mindful Self-Compassion, MSM = Mind Subtraction Meditation, OPPC = online group positive psychotherapy for cancer survivorship, PPC = positive psychotherapy for cancer survivorship, PSIT = Psycho-Spiritual Integrative Therapy, PTG = posttraumatic growth, PTGI = Posttraumatic Growth Inventory, RCT = randomized controlled trial, SET = Supportive expressive therapy, SGP = Supportive Group Psychotherapy, SME = Self-Management Education, WCI = Wall-Climbing Intervention.

The cancer-related variables of the study participants were not consistently recorded or reported. Two studies identified cancer type, stage, time since diagnosis, whether it was a first-time cancer diagnosis or cancer recurrence, or information about the type of treatment received or time since primary treatments were completed.^[13,14] The remainder of the studies provided various lesser amounts of cancer demographic information about their sample, with the most consistently reported data being cancer type or stage and time since diagnosis. Additionally, various studies limited the sample to a specific gender demographic, with 16 studies utilizing only female participants^{[14,18,19,21–23,25–27,34–36,41–43,46]} and 1 study selected from an all-male population.^[24] These studies appeared to limit the sex of their sample as a function of targeting a population with a specific type of cancer diagnosis (eg, breast, prostate) to promote PTG. The demographic and medical information provided by each study is summarized in Table 2.

Interventions promoting PTG in oncology

These data were synthesized by the reported intervention type and PTG-related outcomes. These data are described in detail below and are summarized in Table 2.

Types of intervention

The eligible studies identified in this scoping review utilized a variety of interventions in cancer patients with the goal of promoting PTG among other psychosocial outcomes. Twenty-one studies implemented a psychosocial intervention using a group therapy modality and emphasized importance of peer support as a means of promoting positive growth in the context of cancer. Sixteen studies specifically noted psychoeducation as a treatment component incorporated within the intervention period, such as common emotional responses to cancer and normalizing frustration with the cancer process. Seven studies utilized the interventional approaches of mindfulness-based stress reduction, mindfulness-based cancer recovery, and mindfulness-based cognitive therapy. Nine studies implemented meaning-centered interventions or other positive psychotherapy approaches designed to promote benefit-finding following negative life events. Four studies utilized interventions that focused on creating health behavior changes, such as increased physical activity, in the context of recovering from cancer to promote adaptive coping and subsequently PTG. Two studies involved existential life-review interventions with end-of-life cancer patients^[39] and patients at various stages of diagnosis, treatment, or recovery.^[20] Various other psychosocial treatment approaches were utilized, and a brief description of each intervention is provided in Table 2.

PTG outcome reporting

The PTGI provides a total score and 5 subscale scores.^[3] The results of this review revealed that fifteen studies reported on PTG outcomes using the total score alone. Thirteen studies reported on and interpreted their PTG-related outcomes based on PTGI total and subscale scores. Four studies included in the final review measured PTG using only ≥1 subscale scores and not the PTGI total score.

Discussion

This review identified thirty-three eligible studies that implemented psychosocial interventions to promote PTG in the oncology population. The studies identified in this review implement a variety of different interventions in patients across the cancer continuum located throughout the world, as long as they were published in English. Although inconsistencies in study design and reporting of PTGI scores make it difficult to compare across studies, the studies identified in this scoping review incorporate components of psychoeducation, peer support, and mindfulness skills into psychosocial treatments for cancer patients. Sixteen of thirty-three studies specifically identified psychoeducation as a component of treatment. Psychoeducation is important for normalizing emotional distress and difficulties in coping among cancer patients.^[48] This is consistent with long-standing research and theory on stress, coping, and social learning in cancer patients, which suggests that cancer survivors recover well if their goal expectancies for life after their diagnoses and treatments are realizable and they have access to the resources to achieve them.^[49] Psychoeducation on emotions and coping skills in the context of cancer may help facilitate more adaptive adjustment on behalf of the patient and allow for more experiences of PTG. Thus, psychoeducation was identified as a common treatment theme in the results of this review and will likely be an important component to incorporate into the development and implementation of future psychosocial interventions in oncology.

In addition to psychoeducation, peer support was identified as a common theme across the groups of identified studies. Twenty-one of the reviewed interventions were delivered in a group modality and incorporated aspects of social support into their treatment approaches. This emphasis on social support as a psychosocial treatment component is consistent with existing studies indicating the role of social support in enhancing PTG in cancer patients.^[6,9,50] Not only does generalized social support in the context of cancer facilitate adaptive coping, but group psychosocial interventions in oncology provide patients with a designated space to discuss aspects of their life that only other cancer patients can understand.^[51] In other words, there are unique aspects of the cancer experience that patients’ other social supports may not understand without having been through it themselves.^[52] As such, incorporating aspects of social support or interaction with other cancer patients when implementing psychosocial interventions is likely important for facilitating or enhancing PTG in this population.

Finally, mindfulness skills for adaptive coping support PTG in patients with cancer. In addition to the 7 studies that utilized evidence-based and manualized mindfulness-based treatments, other studies incorporated some aspects of mindfulness meditation, mindful self-compassion, or other mindfulness techniques into their interventions.^[17,21,43] This observation is consistent with other observations that in the past 2 decades, mindfulness has emerged as an accessible and cost-effective vehicle for health behavior change and psychosocial wellness in general.^[53] When evaluating this recent surge in mindfulness-based interventions applied to cancer patients, Calhoun and Tedeschi^[54] suggest that mindfulness contributes to processes of positive reappraisal, which can facilitate the shift from intrusive to deliberate rumination, which can lead to experiences of PTG. In other words, mindful attention to one's cognitive and emotional experiences following a traumatic experience can provide an opportunity for perspective taking and potential positive reappraisal processes.^[54]

A question of generalizability arose as a result of this scoping review, which revealed a noteworthy subset of psychosocial interventions aiming to promote PTG in Asian or Asian-American populations.^{[19,25,43–47]} Although the group of eligible studies as a whole represents research completed in various parts of the world, these 7 studies offer important insights into the application of this concept of promoting PTG in cancer patients through various psychosocial interventions within Asian and Asian-American communities that may differ from non-Asian and Asian-American samples. For example, Gallagher et al^[19] implemented an expressive writing (EW) intervention within foreign-born Asian-Americans that consisted of different conditions. The “Cancer Facts Condition” involved writing objectively about cancer diagnosis and treatment in a detailed manner while the “Emotional Disclosure Condition” involved writing about deepest thoughts and feelings about their cancer experiences.^[19] Although neither of the EW conditions resulted in clinically significant improvement in PTG outcomes, the “Cancer Facts Condition” demonstrated greater improvements in PTG as compared to the condition that prompted more emotional processing and reflection, which was contrary to the study hypothesis that interventions focused on emotional expression would be more effective for the promotion of PTG in cancer patients.^[19] These findings suggest the importance of multicultural considerations when developing and testing psychosocial interventions in cancer patients with diverse backgrounds. More specifically, considering population characteristics and ethnic minorities when empirically testing interventions that are otherwise well-validated among White, European, or European-American populations will be important for advancing research on this topic.

Overall, the results revealed 21 studies that utilized a RCT design or implemented an RCT design within a pilot or feasibility study. Given the experimental benefits and sound conclusions that can be drawn from a study utilizing this type of design, the results reported on this topic of promoting PTG in oncology demonstrated a promising trend toward new developments in the field. In addition to the above clinical themes, the results of this scoping review highlighted specific trends pertaining to research practices that are worth noting. First, there were apparent inconsistencies in the recording and reporting of cancer-related variables within the study samples. Only 2 studies identified in this review provided cancer-related information on their sample pertaining to cancer type, stage, time since diagnosis, whether it was a first diagnosis, and type or timing of treatment received.^[13,14] The remaining studies provided fewer combinations of cancer information on their sample, with the most consistently reported category of information being the type of cancer.

Second, this review highlighted methodological inconsistencies in the reporting of PTG outcome scores when using the PTGI. The PTGI is a validated assessment based on Calhoun and Tedeschi's 5-factor model, which was designed to yield a total score and 5 subscale scores.^[3] If researchers are setting out to measure PTG in their sample by utilizing the PTGI, interpreting outcomes based solely on the total score or ≥1 of the subscale scores may not be fully representative of the PTG construct. This impacts researchers’ ability to compare results across studies that also use the PTGI, and it may influence the overall understanding of how to successfully promote PTG in cancer patients through psychosocial intervention.

Limitations

Although this scoping review revealed some trends in research on PTG promotion in oncology, there are some limitations to the review as well. Because of limited research in this area, there are a small number of studies in total, and an even smaller number of studies used a randomized controlled design. Additionally, many of the studies noted a small sample size to be a limitation of the studies themselves. Furthermore, inconsistencies in the recording and reporting of cancer-related variables within study samples limit the ability to generalize the results of one intervention to that of other cancer populations.

Similar issues arise from inconsistent reporting of PTG outcome data across studies, despite consistent use of the PTGI as the instrument of assessment. This scoping review required the use of the PTGI as a measurement of PTG within its eligibility criteria to compare the impact of interventions on PTG across studies. The inconsistent use of PTGI total scores and/or subscale scores makes it difficult it difficult to interpret and compare data across studies. Finally, this scoping review included studies that were available in English and full-text due to authors’ primary language and parameters of institutional databases. It is possible that applying these filters to the search strategy led to the exclusion of studies that would otherwise meet eligibility criteria for this review.

Implications for psychosocial oncology

Despite these limitations, some clinical and research implications prevailed. The common elements of psychoeducation, social support, and mindfulness skills identified in the results of this review appear to be important components of interventions to promote PTG in oncology. These treatment components may also be important to consider in future research examining possible mechanisms of change within interventions promoting PTG in oncology populations. Future research should examine the generalizability of these PTG-promoting intervention strategies across oncology patients with different cultural backgrounds. Future studies utilizing the PTGI as a measure of PTG should report and analyze both the total PTGI score and the five factor scores that reflect Calhoun and Tedeschi's 5-factor model. This will improve the ability to compare the results of interventions across studies, which will be crucial for determining future clinical directions in this population. Although the variability in cancer information presented may be considered a positive, in that PTG is evident across patients with different cancer experiences, future research should prioritize the standardization of reporting of cancer-related variables in the samples. This should include cancer type, stage, whether the present cancer is a primary diagnosis or secondary diagnosis, first time cancer diagnosis versus relapse or diagnosis of a second type of cancer, time since diagnosis, type of treatment received, and whether patients are actively in treatment or have completed treatment before engaging in the study. This will be crucial for clarifying the impact of psychosocial interventions on various types of cancer patients when aiming to promote PTG. This standardization in reporting will also allow future studies to examine possible moderating effects of cancer-related variables on the promotion of PTG in oncology patients.

Conclusions

This scoping review provides an advanced understanding of psychosocial interventions aimed at promoting PTG in adult oncology patients. Clinicians using mindfulness, social support, psychoeducation, and normalization of psychosocial distress within the cancer experience may be able to assist adults undergoing a variety of treatments for a range of cancer diagnoses experience positive personal growth that can contribute to their overall well-being. Additionally, multicultural considerations should be made when implementing psychosocial interventions in global populations, given that the mechanism of change for promoting PTG in cancer patients may vary depending on the individual and cultural norms that inform one's coping with psychosocial stress or the definition of personal growth or well-being. The results of this review also helped identify areas for growth in standardized reporting of all relevant PTG outcomes when using the PTGI and cancer-related variables across study samples. Standardizing these reports in future research may allow for additional investigation in possible moderating effects of cancer-related variables on the promotion of PTG in oncology patients and improve the overall methodological quality in this area of study.

Conflicts of interest statement

The authors report no conflicts of interest.