Resilience is broadly defined as an individual's ability to maintain physical and emotional well-being in the face of adversity. How to measure and promote resilience in clinical settings, however, is less clear. We have found that patients who: recognize or manage stress (rather than become overwhelmed); plan and hope for the future beyond their concurrent doubt; maintain optimism over pessimism; and identify supportive family and friends rather than live in isolation may have healthier, happier, and maybe even longer lives.
Although these elements of resilience seem intuitive, they may be particularly hard to come by for adolescents and young adults with cancer. Indeed, while we have improved survival for older adults and younger pediatric patients with cancer, we have not been as successful among adolescents and young adults. Reasons for these disparities include distinct cancer biology of adolescent and young adult tumors, limited access to health care and insurance in this age group, and their unique developmental and psychosocial needs. Taken together, adolescent and young adult cancers seem harder to overcome.
Standard adolescent and young adult oncology recommendations, therefore, should include a holistic view of cancer treatment that incorporates psychosocial and developmental needs assessments.
Identify, Quantify Resilience
Theories conflict about how and when to measure resilience. Briefly, investigators have suggested resilience is a pre-existing personal characteristic; an on-going process of coping and adaptation; a relatively positive outcome or state of being after cancer; or some combination of the above.
Regardless of which theory is endorsed, however, most agree that individuals may harness personal resources to promote positive outcomes. These “resources” can include pre-existing or learned individual skills, gathering of social supports, and existential or spiritual beliefs. Taken together, these resources enable patients to maintain well-being during and after cancer therapy, move beyond their experience with hope and insight, and better adapt to future adversity.
Patient Resilience and Survival
In our work with adolescents and young adults with cancer at Seattle Children's Hospital, we used both quantitative and qualitative methods to identify key resources necessary to promote resilience. These include skills to recognize and manage stress; goal-set and plan for the future; maintain optimism; and find meaning from adversity. We have developed standard tools to teach these skills to adolescent and young adult patients who may not yet have had the life opportunities to learn them.
Skills that promote resilience in adolescent and young adult cancer patients are teachable and promote psychosocial well-being. In a 2014 study in the Journal of Adolescent and Young Adult Oncology, we describe patient-reported resilience and identify contributors and inhibitors of resilience in patients 14 to 25 years old who were enrolled 14 to 60 days following their diagnosis of cancer (2014;3:185-193).
Five themes emerged as predominant contributors or inhibitors of resilience:
- Stress and coping;
- Goals, purpose, and planning;
- Gratitude and meaning; and
- Connection and belonging.
Our analysis suggested that adolescent and young adult resilience is a balance that may be enabled by promoting certain skills. We found that learned skills in stress management, goal-setting, and benefit-finding may empower these patients during cancer and improve their long-term psychosocial outcomes.
Fostering and promoting resilience in young cancer patients must be intentional, so researchers are studying the best ways to identify and encourage it. In a 2015 study in the Journal of Pediatric Psychology we delivered the Promoting Resilience in Stress Management (PRISM) intervention among two groups of adolescents and young adults at risk for poor outcomes: Patients with Type 1 diabetes, or cancer (2015;40:992-999). The goal of PRISM was to develop a practical intervention that bolstered resilience in chronic disease management to improve long-term psychosocial outcomes. The patients were 12 to 25 years of age.
The intervention was designed as two 30- to 50-minute main sessions administered two to four weeks apart and one follow-up session to reflect on skills learned and resources needed. Participants also received “cheat sheets” describing each skill and how to practice the techniques.
We found the intervention was valued highly by patients and their parents. Patients and families in our study universally confirmed that stress management, goal-setting, positive reframing, and benefit-finding were all skills that could and should be taught to patients with serious illness.
Others have taken a similar approach. In a 2014 study published online in The Gerontologist, researchers studied if people who have resilience have lower levels of disability and if resilience moderates new chronic conditions and subsequent disabilities in American adults ages 51 to 98 (doi: 10.1093/geront/gnu068). The researchers found that high levels of resilience can protect against the negative impact of disability in later life.
In a 2011 study in Clinical Breast Cancer, researchers found that offering an intervention called Stress Management and Resilience Training (SMART) to women diagnosed with breast cancer improved resilience, perceived stress, anxiety, and overall quality of life at 12 weeks compared with baseline (2011;11:364-368).
Some researchers have explored the use of arts and media to study resilience. In a 2014 study in Cancer, researchers studied the use of a therapeutic music video intervention in patients ages 11 to 24 who were undergoing hematopoietic stem cell transplants (2014;120:909-917). The intervention, delivered by a board-certified music therapist, included the patients learning songwriting, selecting music, brainstorming lyrics, selecting visuals for the video, and recording a video. The researchers found that the intervention resulted in improved positive health outcomes of courageous coping, social integration, and family environment during high-risk cancer treatment.
Recognize and Foster Resilience in the Clinic
How can oncologists in clinics promote resilience for adolescent and young adult patients, and other patients?
- Oncologists can enable patients to recognize their strengths and supports, as well as their struggles. Clinicians should promote strengths and supports, and normalize struggles.
- Ask a few simple questions about the following:
- Thoughts: How do you see your experience?
- Actions: What do you do when things are hard?; and
- Supports: Who supports you?
Cancer treatment in adolescent and young adult cancer patients is a particular challenge for them because they are already in the midst of major emotional and developmental changes. By taking steps to encourage resilience in this population, oncologists can change their patients' approach to emotional coping and enhance quality of life for young cancer patients.
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