Questions About Cancer? 1-800-4-CANCER

Adjustment to Cancer: Anxiety and Distress (PDQ®)

Health Professional Version
Last Modified: 04/09/2014

Normal Adjustment

Coping Theory
General Factors Influencing Adjustment
Situation-Specific Influences on Adjustment
        Hearing the diagnosis
        Active cancer treatments
        Posttreatment
        Recurrence
        Survivorship

Adjustment or psychosocial adaptation to cancer has been defined [1-5] as an ongoing process in which the individual patient tries to manage emotional distress, solve specific cancer-related problems, and gain mastery or control over cancer-related life events. Adjustment to cancer is not a unitary, single event but rather a series of ongoing coping responses to the multiple tasks associated with living with cancer. Patients are faced with many challenges that vary with the clinical course of the disease. Common periods of crisis and significant challenge include the following:

  • Diagnosis.
  • Treatment (surgery, radiation, and chemotherapy).
  • Posttreatment and remission.
  • Recurrence and palliative care.[6]
  • Survivorship.[3]

Each of these events has certain coping tasks, particular existential questions, many common emotional responses, and specific problems.

Normal or successful adjustment is indicated in patients who are able to minimize disruptions to life roles, regulate emotional distress, and remain actively involved in aspects of life that continue to hold meaning and importance.[5]

Coping refers to the specific thoughts and behaviors a person uses in his or her efforts to adjust.[2] Coping style refers to the most common, more frequent, and longer-term style of coping that an individual tends to use across a variety of life situations. One’s coping style is often closely related to one’s overall disposition and personality (e.g., optimism, pessimism, introversion, extroversion).[7]

Coping strategies refer to those less frequently used and more situation-specific coping efforts, such as readjusting one’s daily routine or work schedule to adjust to the side effects of cancer treatment. Coping strategies comprise efforts to adjust. Although there are many successful coping strategies, three broad categories have been noted:[2,8-10]

  1. Problem focused.
  2. Emotion focused.
  3. Meaning focused.

Problem-focused strategies help patients manage specific problems by directly trying to alter problem situations. Emotion-focused strategies help a person regulate his or her degree of emotional distress. Meaning-focused strategies help patients understand why this has happened and what impact cancer will have on their life. In general, persons who adjust well typically remain committed and actively engaged in the process of coping with cancer and continue to find meaning and importance in their lives. Conversely, persons who do not adjust well often become disengaged, withdraw, and feel hopeless. Thus, assessing the degree of engagement versus giving up may be a way to distinguish between successful and unsuccessful adjustment.[5]

For example, in a correlational study of adolescent cancer patients and their parents, engagement coping by the adolescent (including cognitive restructuring, seeking social support, expressing emotions, and problem solving) was associated with lower levels of distress. Conversely, disengagement coping by parents (including problem avoidance, wishful thinking, social withdrawal, and self-criticism) was associated with increased distress.[11]

In a prospective investigation of different types of problem-focused coping strategies, 146 women with early-stage breast cancer were studied. Study results showed that a strategy of concentrating on symptoms, measured at the end of treatment, was predictive of less improvement in physical and mental quality of life at 6 months' follow-up, while a strategy of information seeking was associated with greater improvement in physical quality of life. These findings suggest that problem-focused coping consists of a variety of specific coping strategies—only some of which may be beneficial to quality of life.[12]

One criticism of the literature on coping with cancer focuses on the assumption that “coping with cancer” is a single unitary event. In reality, coping with cancer involves coping styles and strategies that may differ and vary according to the nature of the stressors being encountered. For example, in a study of 52 adults receiving palliative care for cancer,[13] patients participated in a semistructured interview during which they were asked how they coped with their most significant stressors. Three stressor domains were identified:

  • Social
  • Physical
  • Existential

Three categories of coping were also identified:

  • Problem focused
  • Emotion focused
  • Emotion-focused avoidance

Results showed that most participants used a range of coping strategies; however, there were interactions between stressor domains and coping categories. Problem-focused strategies were used less frequently for the existential stressors, while emotion-focused strategies were used less frequently for the physical stressors.[13]

Coping Theory

One cognitive theory of coping [14] proposes that in response to significant life events, a person asks two important questions:

  • Is this event personally significant to me?
  • What resources do I have to manage/control this event?

When an event is perceived to be of personal significance (nearly all cancer-related life events would be), and when one’s personal resources are perceived to be inadequate to the demands of managing the event, distress can occur. One way to conceptualize the amount of distress experienced by patients is the balance or ratio between perception of the demands that a situation (e.g., chemotherapy) places upon them and perception of the resources they possess (e.g., effective antiemetics) to effectively manage these demands:

Distress = Perceived Demands/Perceived Resources

Individuals with the same diagnosis or treatment regimen may experience very different levels of distress. A high level of distress could result from an individual’s perceptions that either the demands of a situation are very high or his or her resources are very low (or both). Conversely, low distress is the result of a perception that either the demands of a situation are very low or the individual’s resources are high.[15] To lower distress, therefore, either the perceived demands of the situation should be lowered, or the perceived resources should be increased.

General Factors Influencing Adjustment

Although there are some commonalities in normal adjustment to the varying stressors of cancer, there are also many individual differences. It is difficult to predict how individuals will cope with cancer, so it is important to recognize factors that influence adjustment to cancer. One study of women with stage II or III breast cancer [16] reported that higher levels of stress measured postsurgically at the time of diagnosis predicted lower physical and psychological quality of life. The stress measures included the following:

  • Number of stressful life events in the past year.
  • Cancer-related traumatic stress symptoms.
  • Perceived global stress.

All measures were predictive.[16]

Another study evaluated women with stage 0 breast cancer to stage III breast cancer (N = 89) at three time points: during treatment, at 3 weeks following end of treatment, and at 3 months posttreatment. Most survivors showed good adjustment on general distress indices. The factors predicting sustained distress included young age, history of depression or anxiety, and more extensive treatment. Younger age was the only factor that predicted greater distress across all evaluated measures.[17]

Psychosocial adjustment/adaptation has been determined to be influenced by three broad categories of factors: cancer derived, patient derived, and society derived.[4,18] Cancer-derived factors include the following:

  • Type of cancer.
  • Cancer stage.
  • Prognosis.
  • Where a patient falls in the cancer continuum of diagnosis, treatment, and recurrence.

Patient-derived factors include two types of resources:[19,20]

  • Intrapersonal coping resources.
  • Interpersonal social support (e.g., family support).[21]

Patient-derived factors also include consideration for stage of life [22] (i.e., developmental tasks—young adults may respond quite differently compared with older adults).

Society-derived factors include the general societal views of cancer (e.g., stigma), as well as the influence society has on issues such as availability of treatments, open versus closed discussion of the illness, and popular beliefs about cause.

The personality traits of optimism and pessimism might play a critical role in the psychological well-being of cancer patients. A German study investigated the impact of optimism and pessimism on psychological well-being in 161 newly diagnosed cancer patients with heterogeneous cancers.[23] Patients were assessed for optimism/pessimism and positive/negative emotions before the start of their first chemotherapy session and at 9 months' follow-up. Before the start of chemotherapy, psychological well-being was associated with higher optimism and lower pessimism. Only pessimism predicted negative change in psychological well-being at the 9-month follow-up. Additionally, only pessimism predicted heightened perception of chemotherapy-related side effects.

The availability of social support, as part of a social network, has been found to be related to mortality from breast cancer. In a longitudinal study of 2,835 female nurses with breast cancer, those who, before diagnosis, reported no close contacts (e.g., relatives, friends, or living children) had a twofold increased risk of mortality from breast cancer, compared with those who had more social contacts (e.g., ten or more close relatives). This increased mortality was only found when comparing these two extremes in social ties, suggesting that women with relatively few social contacts or an intermediate number of contacts may not be at increased risk. Overall, these results suggest the important role of close relatives willing to step in and provide needed care.[19]

Situation-Specific Influences on Adjustment

Hearing the diagnosis

The process of adjusting to cancer can begin even before a diagnosis. Patients may respond with normal levels of fear, worry, and concern when they have unexplained symptoms or when they realize that they are undergoing testing to determine the presence of cancer. When they hear the diagnosis, their fears become realized, generating a psychological and existential plight (crisis).[24] Many people wonder, “Could I die from this?”

Receiving a diagnosis of cancer results in a crisis that includes expected and normal emotional distress. One author [25] has described the normal responses to the crisis of cancer as consisting of three phases:

  1. Initial response.
  2. Dysphoria.
  3. Adaptation.

Phase I, the initial response, consists of disbelief, denial, and shock that the news is true. Some patients will attempt to prove that the diagnosis is not true (“Are you sure you have the right test results?”). Most patients will report a period of disbelief accompanied by an inability to clearly process information. They may feel numb or in shock, or as if, “This can’t be happening to me.”

Such a high level of distress can be problematic because many times, immediately after informing patients of their diagnosis, physicians outline the treatment options. Under these emotional circumstances, many patients may be unable to understand or remember this important information. Thus, the presence of others or other means of being able to review the information can be extremely important (e.g., tape recording the discussion about the treatment plan or providing a second appointment at a later date, specifically for reviewing the treatment plan). Although there are many individual differences, this initial response of disbelief, denial, and shock usually lasts about a week in patients who adjust well.

Phase II, dysphoria, consists of a variable period of time (but usually lasting 1–2 weeks) during which the patient is slowly acknowledging the reality of the diagnosis. During this time patients will typically begin to experience a significant degree of distress in the form of depression, anxiety, insomnia, anorexia, poor concentration, and varying degrees of inability to function in daily roles. Intrusive thoughts of illness and death may occur very often and seem to be uncontrollable.

As more information about treatment options is provided, correctly processed, and understood, feelings of hope and optimism begin to emerge more frequently through the dysphoria. Distress levels can be elevated for newly diagnosed patients awaiting surgery. Additional professional support to address problems such as fatigue, insomnia, and depressed mood can be helpful during this time.[26]

Phase III, longer-term adaptation, consists of the extended time during which more long-lasting and permanent adjustment occurs. This period consists of weeks and months. During this period, patients are utilizing a variety of coping strategies and styles.[9] Coping styles are longer-term, established ways for coping with many previous life events; coping strategies are situation-specific efforts to resolve particular cancer-related situations. This combination of longer-term coping styles and short-term coping strategies usually serves patients well in their efforts at adaptation. There is no single best way to cope. The individual differences patients bring to their encounters with cancer will result in varied coping styles and strategies.[5]

Active cancer treatments

During the active treatment phase of the illness, a patient’s adjustment is focused primarily on coping with the many and varied stressors of treatment. These may include apprehension and fears about:

  • Painful procedures.
  • Unwanted side effects (hair loss, nausea/vomiting, fatigue, and pain).
  • Disruptions to daily life (including changes in life roles—for example, the breadwinner who can no longer work).

Patients who adjust well are able to tolerate these short-term stressors via a cost-benefit approach in which they weigh the discomforts of short-term loss against the benefits of long-term gains (e.g., increased survival) and conclude, “It is worth it.”[25] Questions that often occur during active treatment include the following:

  • Will I survive this?
  • Will they get all of the cancer?
  • What side effects will I experience?

As these and related questions arise, patients utilize coping styles and strategies to adapt. Although many different coping strategies are useful during this phase, problem-focused coping—strategies designed to manage specific problem situations (e.g., fatigue, transportation to treatments, altered work schedules, and role changes)—are often utilized.

Posttreatment

Before active treatments are completed, most patients look forward to the conclusion of treatment with positive anticipation and hopes of returning to normal. However, the completion of active treatment can be a time of great ambivalence for cancer patients and their families. The completion of treatments suggests a time of celebration and relief, yet it can also be a time of heightened distress, with a renewed sense of vulnerability that comes with the cessation of active medical efforts to fight the disease.[27]

Those who adjust well are able to balance their positive expectations with the realities of ongoing fears and apprehensions. Many patients report enhanced anxiety and worry related to fears of recurrence and decreasing frequency of medical surveillance via less frequent physician contacts. Other adjustment issues include living with uncertainty, returning to previous life roles, and hypervigilance to health concerns.[6]

During remission, patients begin a sequence of regular follow-up appointments with their oncologist. Normal anxiety and worry often intensify as the dates of follow-up appointments approach. Normal anxiety comes from concerns about recurrence and the related emotional consequences (e.g., re-entry into the patient role and renewed feelings of loss of control).[28] Many patients find waiting for test results to be a particularly distressing experience.

In one of the few empirical studies of posttreatment adjustment, 94 women with stage 0, I, II, or III breast cancer who were completing radiation therapy were assessed on measures of depression, anxiety, and quality of life on the last day of treatment and at 2 weeks, 4 to 6 weeks, 3 months, and 6 months posttreatment. Results found elevated symptoms of depression, low-level anxiety, and diminished quality of life on the last day of treatment; however, by 2 weeks later, symptoms of depression decreased significantly, and quality of life improved significantly. No other significant changes were found at any of the later posttreatment time periods, suggesting improvements in depression and quality of life occur quickly in most patients.[29]

Normal adjustment to posttreatment and remission involves utilization of a variety of coping strategies; however, this phase often involves the frequent use of emotion-focused coping strategies (those designed to help regulate the normal emotional distress), given the variety of ambivalent emotional reactions. Those who adjust well are more likely to be comfortable expressing a wide range of both positive and negative emotions. Emotion-focused coping strategies include the following:

  • Honesty with one’s emotions.
  • Awareness of one’s feelings.
  • Nonjudgmental acceptance of one’s feelings.
  • Ability to articulate these feelings to others.
  • Willingness to approach the task of working through these emotions.
  • Availability of support from others willing to listen and accept.
Recurrence

The transition from a curative treatment plan to one of palliative care is extremely difficult for cancer patients.[25] Extreme anguish often accompanies this transition as the patient faces renewed psychological distress, physical symptoms, and the existential crisis of death, all of which combine to result in the suffering often associated with advanced cancer.[30]

The normal adjustment to this crisis is characterized by initial shock, disbelief, and denial followed by a period of significant distress (e.g., depressed mood, difficulty concentrating, frequent intrusive thoughts of death). Normal adjustment may include the following:

  • Periods of significant sadness and crying.
  • Periodic feelings of anger at God or one’s perceived higher power.
  • Periods of withdrawal and isolation.
  • Thoughts of giving up.

However, as with the initial diagnosis, this distress is often followed by a gradual adjustment over a period of weeks. It is important to note that these common reactions do not necessarily indicate psychopathology. Although the intensity of these emotions might be similar to more severe psychopathology, their frequency of occurrence and duration tend to be shorter. Patients experiencing normal adjustment to recurrence and palliative care will typically rally from these strong emotions more quickly than those experiencing a true mental disorder. (Refer to the PDQ summaries on Depression and Post-traumatic Stress Disorder for more information.)

Adjustment to recurrence and palliative care often involves shifting expectations from cure to healing. From this perspective, healing involves a process of becoming whole again,[31] of transforming one’s life in a variety of ways in the face of death. This process of adjustment involves maintaining hope, which is viewed as crucial in overall adaptation to crisis.[32]

The patient who successfully adjusts to the crisis of recurrence often shifts expectations and maintains hope in a variety of meaningful life activities. For example, a patient who has confidence that pain and suffering can be controlled will have hope for future quality of life. Patients who believe they are loved and cared for will have hope in their future relationships. Religion and spirituality play a very important role in helping many patients maintain hope. Religion or spirituality can provide a belief structure that helps in coping with the crises of recurrence. During recurrence and palliative care, patients are likely to utilize meaning-based coping strategies and are likely to seek comfort in prayer and in their religious practices/rituals or spiritual beliefs. In addition, one study suggests that prognostic awareness in combination with inner peace is associated with better mental health and quality of death outcomes for patients with advanced cancer and for their surviving caregivers during bereavement.[33]

In a study of women with recurrent breast cancer, significant impairments in physical, functional, and emotional well-being were found within 1 month after recurrence; however, a patient’s self-efficacy (confidence in his or her ability to manage the demands of illness), social support, and family hardiness (family’s internal strength and ability to manage hardship and change) had positive effects on quality of life. Conversely, more distress about physical symptoms, additional life concerns, a sense of hopelessness, and a negative perception of illness or caregiving were associated with a lower quality of life.[34]

Survivorship

The adjustment from posttreatment to long-term survivorship is gradual and extends over many years. However, most patients, despite various cancer diagnoses and treatments, adjust well,[3] with some even reporting benefits to a cancer diagnosis (e.g., greater appreciation of life, reprioritizing of life values, strengthening of spiritual or religious beliefs).[35-38] Patients who have poorer adjustment tend to have greater medical problems, fewer social supports, poorer premorbid psychological adjustment, and fewer economic resources.[3]

As cancer treatments have improved, cancer is becoming a chronic illness, particularly with certain cancer types (e.g., prostate, breast). Each of the various psychosocial areas of functioning with a chronic illness has its own unique adjustment issues. For example, long-term adjustment to being a survivor of cancer involves considerations of how one adjusts psychologically, socially, sexually, vocationally, and, of course, physically.

In general, studies of cancer survivors and healthy comparison groups have found no significant differences in measures of psychological distress, marital and sexual adjustment, social functioning, and overall psychosocial functioning.[3] However, there are some common areas of distress experienced by many cancer patients that are subthreshold or not severe enough to meet diagnostic criteria. These may include the following:[3,39]

  • Anxiety about recurrence.
  • Increased sense of vulnerability.
  • Lowered sense of control.
  • Conditioned reminders of chemotherapy (smells, sights) that produce anxiety and nausea.
  • Post-traumatic stress–like symptoms (such as persistent, intrusive thoughts; recurrent imagery associated with cancer treatments and feelings of estrangement from others).
  • Concerns about body image and sexuality.

In one of the few prospective longitudinal studies of cancer survivors, 752 patients from three U.S. states were asked about a variety of psychosocial problems. About 1 year after diagnosis, 68% were concerned with their illness returning, approximately 60% were worried about recurrence, and 58% had fears of the future. In addition, approximately two out of three survivors were concerned about a physical health problem such as fatigue and loss of strength. Approximately 48% reported concerns with sleep difficulties, and 48% reported concerns with sexual dysfunction. Younger survivors (aged 18–54 years), women, nonwhites, unmarried survivors, and those with lower incomes reported more problems. In comparisons of four common cancers, the most concerns regarding problems in living were reported by those with lung cancer, followed by survivors of breast, colorectal, and prostate cancers.[40]

A large (N = 660) longitudinal study of women breast cancer survivors older than 65 years investigated factors associated with changes in emotional well-being. The overall findings suggest that the 5-year survivorship experience for most women is relatively stable, with few changes in emotional well-being. However, it was noted that women who had fewer than 12 years of formal education and women who perceived themselves as “never being cured” were more likely to experience declines in emotional well-being, while those who had better physical functioning, good emotional support, and the perception of positive physician-patient communication were less likely to have poor emotional health.[41]

References
  1. Brennan J: Adjustment to cancer - coping or personal transition? Psychooncology 10 (1): 1-18, 2001 Jan-Feb.  [PUBMED Abstract]

  2. Folkman S, Greer S: Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other. Psychooncology 9 (1): 11-9, 2000 Jan-Feb.  [PUBMED Abstract]

  3. Kornblith AB: Psychosocial adaptation of cancer survivors. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 223-41. 

  4. Nicholas DR, Veach TA: The psychosocial assessment of the adult cancer patient. Prof Psychol 31 (2): 206-15, 2000. 

  5. Spencer SM, Carver CS, Price AA: Psychological and social factors in adaptation. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 211-22. 

  6. Loscalzo M, Brintzenhofeszoc K: Brief crisis counseling. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 662-75. 

  7. Schou I, Ekeberg Ø, Ruland CM, et al.: Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psychooncology 13 (5): 309-20, 2004.  [PUBMED Abstract]

  8. Pearlin LI, Schooler C: The structure of coping. J Health Soc Behav 19 (1): 2-21, 1978.  [PUBMED Abstract]

  9. Rowland JH: Intrapersonal resources: coping. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 44-57. 

  10. Ahmad MM, Musil CM, Zauszniewski JA, et al.: Prostate cancer: appraisal, coping, and health status. J Gerontol Nurs 31 (10): 34-43, 2005.  [PUBMED Abstract]

  11. Trask PC, Paterson AG, Trask CL, et al.: Parent and adolescent adjustment to pediatric cancer: associations with coping, social support, and family function. J Pediatr Oncol Nurs 20 (1): 36-47, 2003 Jan-Feb.  [PUBMED Abstract]

  12. Ransom S, Jacobsen PB, Schmidt JE, et al.: Relationship of problem-focused coping strategies to changes in quality of life following treatment for early stage breast cancer. J Pain Symptom Manage 30 (3): 243-53, 2005.  [PUBMED Abstract]

  13. De Faye BJ, Wilson KG, Chater S, et al.: Stress and coping with advanced cancer. Palliat Support Care 4 (3): 239-49, 2006.  [PUBMED Abstract]

  14. Lazarus RS, Folkman S: Stress, Appraisal, and Coping. New York, NY: Springer Publishing Co, 1984. 

  15. American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000. 

  16. Golden-Kreutz DM, Thornton LM, Wells-Di Gregorio S, et al.: Traumatic stress, perceived global stress, and life events: prospectively predicting quality of life in breast cancer patients. Health Psychol 24 (3): 288-96, 2005.  [PUBMED Abstract]

  17. Costanzo ES, Lutgendorf SK, Mattes ML, et al.: Adjusting to life after treatment: distress and quality of life following treatment for breast cancer. Br J Cancer 97 (12): 1625-31, 2007.  [PUBMED Abstract]

  18. Holland JC: Clinical course of cancer. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 75-100. 

  19. Kroenke CH, Kubzansky LD, Schernhammer ES, et al.: Social networks, social support, and survival after breast cancer diagnosis. J Clin Oncol 24 (7): 1105-11, 2006.  [PUBMED Abstract]

  20. Arora NK, Finney Rutten LJ, Gustafson DH, et al.: Perceived helpfulness and impact of social support provided by family, friends, and health care providers to women newly diagnosed with breast cancer. Psychooncology 16 (5): 474-86, 2007.  [PUBMED Abstract]

  21. Baider L, Ever-Hadani P, Goldzweig G, et al.: Is perceived family support a relevant variable in psychological distress?. A sample of prostate and breast cancer couples. J Psychosom Res 55 (5): 453-60, 2003.  [PUBMED Abstract]

  22. Ganz PA, Guadagnoli E, Landrum MB, et al.: Breast cancer in older women: quality of life and psychosocial adjustment in the 15 months after diagnosis. J Clin Oncol 21 (21): 4027-33, 2003.  [PUBMED Abstract]

  23. Pinquart M, Fröhlich C, Silbereisen RK: Optimism, pessimism, and change of psychological well-being in cancer patients. Psychol Health Med 12 (4): 421-32, 2007.  [PUBMED Abstract]

  24. Weisman AD, Worden JW: The existential plight in cancer: significance of the first 100 days. Int J Psychiatry Med 7 (1): 1-15, 1976-77.  [PUBMED Abstract]

  25. Holland JC, Gooen-Piels J: Principles of psycho-oncology. In: Holland JC, Frei E, eds.: Cancer Medicine e.5. 5th ed. Hamilton, Ontario: B.C. Decker Inc, 2000, pp 943-58. 

  26. Visser MR, van Lanschot JJ, van der Velden J, et al.: Quality of life in newly diagnosed cancer patients waiting for surgery is seriously impaired. J Surg Oncol 93 (7): 571-7, 2006.  [PUBMED Abstract]

  27. Sherman AC, Simonton S: Family therapy for cancer patients: clinical issues and interventions. The Family Journal: Counseling and Therapy for Couples and Families 7 (1): 39-50, 1999. 

  28. Harpham WS: After Cancer: A Guide to Your New Life. New York, NY: WW Norton & Company, 1994. 

  29. Deshields T, Tibbs T, Fan MY, et al.: Ending treatment: the course of emotional adjustment and quality of life among breast cancer survivors immediately following radiation therapy. Support Care Cancer 13 (12): 1018-26, 2005.  [PUBMED Abstract]

  30. Cherny NI, Coyle N, Foley KM: Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care 10 (2): 57-70, 1994 Summer.  [PUBMED Abstract]

  31. Dienstfrey H: Training for cancer: an interview with Michael Lerner. Advances: The Journal of Mind-Body Health 10 (2): 27-37, 1994. 

  32. Beck AT, Weissman A, Lester D, et al.: The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol 42 (6): 861-5, 1974.  [PUBMED Abstract]

  33. Ray A, Block SD, Friedlander RJ, et al.: Peaceful awareness in patients with advanced cancer. J Palliat Med 9 (6): 1359-68, 2006.  [PUBMED Abstract]

  34. Northouse LL, Mood D, Kershaw T, et al.: Quality of life of women with recurrent breast cancer and their family members. J Clin Oncol 20 (19): 4050-64, 2002.  [PUBMED Abstract]

  35. Polinsky ML: Functional status of long-term breast cancer survivors: demonstrating chronicity. Health Soc Work 19 (3): 165-73, 1994.  [PUBMED Abstract]

  36. Curbow B, Somerfield MR, Baker F, et al.: Personal changes, dispositional optimism, and psychological adjustment to bone marrow transplantation. J Behav Med 16 (5): 423-43, 1993.  [PUBMED Abstract]

  37. Belec RH: Quality of life: perceptions of long-term survivors of bone marrow transplantation. Oncol Nurs Forum 19 (1): 31-7, 1992 Jan-Feb.  [PUBMED Abstract]

  38. Tartaro J, Roberts J, Nosarti C, et al.: Who benefits?: distress, adjustment and benefit-finding among breast cancer survivors. J Psychosoc Oncol 23 (2-3): 45-64, 2005.  [PUBMED Abstract]

  39. Smith MY, Redd WH, Peyser C, et al.: Post-traumatic stress disorder in cancer: a review. Psychooncology 8 (6): 521-37, 1999 Nov-Dec.  [PUBMED Abstract]

  40. Baker F, Denniston M, Smith T, et al.: Adult cancer survivors: how are they faring? Cancer 104 (11 Suppl): 2565-76, 2005.  [PUBMED Abstract]

  41. Clough-Gorr KM, Ganz PA, Silliman RA: Older breast cancer survivors: factors associated with change in emotional well-being. J Clin Oncol 25 (11): 1334-40, 2007.  [PUBMED Abstract]