Cancer Management

Managing one’s experience with cancer requires coping with diagnostic procedures, treatment protocols, uncertainty in prognosis and recurrence, and often a reduced capacity to engage in normal, daily activities. These external and internal demands may seem overwhelming at times and challenge an individual’s ability to cope. The term coping has been defined by Richard Lazarus and Susan Folkman as a person’s changing cognitive and behavioral efforts to manage psychological stress resulting from a situation or event appraised as harmful in some way. This widely accepted definition emphasizes a fluid process in which coping responses change depending on one’s subjective evaluation or appraisal of his or her circumstances. Individuals diagnosed with cancer commonly appraise their situation as threatening, harmful, or personally challenging, and they often experience a sense of loss and control. They and their families face practical concerns in terms of paying for medical care, time lost from work or school, and a limited ability to fulfill normal role expectations. Therefore, the goals of adaptive coping with a cancer diagnosis and treatment are most appropriately defined by the quality of life one is able to maintain on a daily basis rather than by the ultimate resolution of the cancer experience.

Common Coping Strategies

Coping strategies are commonly categorized as either approach versus avoidance strategies or problem-focused versus emotion-focused strategies. The coping literature indicates that in the context of an uncontrollable situation such as cancer, approach-oriented strategies such as cognitive restructuring, seeking social support, and information seeking tend to be more adaptive ways of managing one’s disease than avoidant strategies like denial and disengagement. That said, because of each person’s unique personal and situational attributes and the multidimensional nature of the cancer experience, researchers also conclude that there is no one right way to cope. Two seemingly similar coping responses may produce very different results or a strategy that is helpful in one context may not be helpful in another.

For example, two common, approach-oriented, emotion-focused strategies are positive reinterpretation and growth and focusing on and venting of emotions. Both involve the acknowledgment, processing, and expression of emotions. Positive reinterpretation and growth is related to adaptive outcomes and involves cognitively reprocessing distressing emotions resulting from a stressful event into a new framework that incorporates positive aspects as well; it is an individual’s deliberate effort to take knowledge gained from a negative experience and use it to move forward in a positive direction. Focusing on and venting of emotions is a process of attending to and expressing typically distressing feelings. Research indicates that engaging in emotional expression may only contribute to positive adaptation when one is able to express him-or herself in the context of a receptive, supportive network of others who are willing and able to listen. In the absence of a supportive environment, this strategy may lead one to ruminate excessively, thereby compounding the stress already being experienced.

The stress and coping literature suggests that problem-focused coping strategies typically associated with managing external demands may not be effective in reducing the emotional distress generated by uncontrollable factors in situations such as facing cancer. Resolving the ambiguity inherent in living with an uncertain prognosis as well as some limitations resulting from treatment side effects are beyond one’s ability to control. Taking action to resolve these types of problems is not possible, and attempting to do so may further emphasize the uncontrollable aspects of the situation and lead to more anxiety and worry. An important distinction here is the recognition that problem-focused coping doesn’t necessarily imply taking action directed at the broad scope of the problem itself; it may also involve passive, approach-oriented strategies directed at consequences.

For example, managing the daily uncertainty imposed by a cancer diagnosis and treatment requires willingness to approach external demands, like complying with treatment, with a certain amount of deliberate acceptance aimed at increasing one’s ability to tolerate unavoidable physical and psychological distress. Acceptance of one’s situation can be the first step in taking a more active role in understanding the nature of the cancer experience. Cancer patients often report an increased sense of control and well-being when they accept responsibility and become stronger advocates for their own medical care via seeking information and instrumental support. Among men with prostate cancer, approach-oriented coping strategies were related to decreased levels of depression and anxiety, better self-esteem, and more positive mood. Conversely, prostate cancer patients who tended to manage distress through avoidance reported both poorer physical and poorer psychological health.

Individual Differences in the Coping Process

While coping is generally thought of as a transactional process between an individual and the environment rather than as a stable, person-centered trait, individual differences such as personality and dispositional characteristics influence the coping strategies one tends to engage in when attempting to regulate physical, emotional, and behavioral distress. In the area of breast cancer, which has been particularly well researched, women in advanced stages of cancer who were more optimistic exhibited an ability to approach their prognosis with a combination of realism and fighting spirit that was related to significantly lower levels of anxiety and depression than were seen in less optimistic women. Similar findings in other areas of the adult cancer literature indicate that overall, more optimistic cancer patients tend to use more approach-oriented, active, and accepting coping strategies and report less distress during each phase of cancer treatment than patients who are less optimistic.

The Role of Social Support

Social support, broadly defined as having one’s need to feel a sense of belonging, care, affection, and esteem met by others such as spouses, parents, friends, coworkers, and classmates, can be a valuable resource for both adult and pediatric cancer patients and their families. While differences among the types of support offered—that is, how it is offered, when, and by whom—relate to one’s perception of how helpful it is, social support is generally related to better physical and psychological adjustment.

Coping and Positive Emotions

The literature on adaptation to chronic illnesses, including cancer, has shifted away from measuring coping outcomes solely by an absence of distress toward also determining whether positive mental and emotional states are present. The experience of positive emotions is considered an adaptive response that may help to sustain an individual’s inner resources during lengthy periods of stress, to maintain much needed social support networks, and to contribute to more optimal use of adaptive coping strategies. Research indicates that it is not at all uncommon to experience positive moods and emotions, such as benefit-finding, in the midst of simultaneous feelings of psychological distress produced by ongoing stressors. In Shelley Taylor’s theory of cognitive adaptation to trauma, benefit-finding is a subjective evaluation that operates as a way to enhance and maintain one’s self-esteem in a threatening, aversive situation such as cancer. Cancer patients frequently identify benefits resulting from their cancer experience, such as closer family relationships, deepening of values, and a reordering of life’s priorities. Benefit-finding among cancer patients and survivors has been positively linked to better mood, stronger self-efficacy, and better social support. Increased levels of benefit-finding have been documented in people with more advanced cancers compared to those with earlier-stage diagnoses and may help these patients maintain a balance between the positive, soothing aspects of their lives and the threatening reality of their cancer.

Coping With Cancer in Childhood and Adolescence

Family, caregiver, and environmental factors, as well as a child’s age and developmental stage at diagnosis and throughout treatment, play a significant role in shaping an experience very different from that of an adult cancer patient. How pediatric cancer patients and their families cope varies greatly depending on a host of situational factors. Because children may look to their families and other adults around them for cues to help them understand and manage their cancer experience, the responses of parents, caregivers, and others in their immediate environment impact their adjustment. In general, children who perceive less cancer-related stress in their environment exhibit better adjustment than those who experience more stress. Children are better able to adjust when their families are supportive, adapt positively to changing circumstances, and are able to work together. Furthermore, an open style of communication among family members seems to foster a child’s ability to communicate more openly about his or her experience and is positively related to more optimal outcomes. When a child is undergoing a diagnostic or treatment procedure, parents or other caregivers are usually present. Adults’ responses, including to pain, are significantly related to a child’s subjective experience of these events. Children whose parents and caregivers support them with expressions of warmth, concern, and empathy during these procedures perceive significantly less pain and distress and exhibit better adaptive outcomes than children whose fears and concerns are not validated or soothed by their adult caregivers.

Developmental Factors

Because of the normal growth and maturational processes simultaneously occurring in childhood and adolescence, the physical and psychosocial late effects of cancer have the potential to be more detrimental for pediatric cancer patients than for adults. Advances in neuroscience have increased our ability to understand cognitive and affective developmental trajectories across the life span. Overall, children with higher levels of cognitive abilities typically exhibit better adjustment than children with developmentally less advanced cognitive abilities. Higher-order cognitive processes such as the ability to plan and think abstractly, to regulate emotion, and to coordinate one’s cognitions and emotions do not begin to fully develop and mature until adolescence. These maturational growth processes proceed independently and at different rates for each individual.

In terms of coping with a cancer diagnosis, this means that an adolescent cancer patient may have developed the ability to perceive the serious long-term implications of his or her diagnosis but still not have the emotional maturity to cope with the ensuing distress. The interaction of these varying developmental stages has the potential to heighten an adolescent’s perception of threat over and above what may be perceived by an adult with a better ability to gauge risk and cope with intense thoughts and emotions. Because cognitive and emotional processes continually factor into their ongoing appraisals of the events composing their cancer experience, their develop-mental stage significantly influences their coping abilities as well as strategies used. Therefore, children and adolescents face unique challenges coping with the negative emotions produced by their experience with cancer.

Pediatric Physical and Psychosocial Late Effects

Physical late effects following pediatric cancer treatment may include compromised sensory functioning; neurocognitive impairment; problems with endocrine function; damage to the kidneys, liver, and heart; and infertility. Some physical late effects, such as infertility, vary according to age and gender and may not be fully appreciated until adult roles are being assumed. As pediatric cancer patients mature, deficits in specific areas of functioning can arise, including decreased academic achievement, employment difficulties, fewer social relationships, a poorer sense of self and identity, and symptoms of posttraumatic stress.

Despite well-documented evidence of physical and psychosocial impairments, research shows that most pediatric cancer patients adapt and cope very well, and there is very little evidence of overall maladjustment. Adolescent cancer survivors typically rate themselves significantly higher than their noncancer peers in terms of physical and emotional functioning, academic functioning, overall quality of life, and frequency of positive mental states, and they rate themselves as having fewer experiences of emotional distress. The contradictions between these objective and subjective indicators of adjustment suggest that coping strategies used by adolescent cancer survivors enable them to effectively suppress distress and view themselves in a positive light.

Repressive Coping Style

In the larger body of psychological literature, individuals who avoid distress by blocking out or repressing negative stimuli are termed repressors. Repressors report a pattern of low levels of anxiety combined with high levels of defensiveness even under difficult circumstances. Adult repressors who have never experienced a cancer diagnosis often exhibit increased levels of stress-related health problems, including high blood pressure, ulcers, migraines, and irritable bowel syndrome. Some children with cancer may adopt a repressive adaptive coping strategy whereby they minimize the distressing aspects of their disease.

Research shows that repressive coping among both adult and pediatric cancer patients arises as an adaptive response to a seriously threatening event. It has been related to significantly decreased levels of depression in pediatric patients, especially among adolescents in the active treatment phase. As an adaptive strategy, it is sustained across time as children struggle to cope with and manage levels of distress for which they are developmentally ill prepared. However, extant research on adolescent patients with cancer shows increased rates of repressive coping persisting as long as 12 months after diagnosis compared to just 12 weeks in adults with cancer. Repressive coping strategies that become habitual and long-term in pediatric cancer patients raise additional concerns regarding their future well-being in light of the poor health outcomes seen among adult repressors. When, how, and if repressive coping strategies subside among pediatric cancer patients as the length of their cancer survival time increases are questions that remain unanswered.

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