ORIGINAL ARTICLE
Posttraumatic growth and cancer: a study 5 years
after treatment end
Claudia Cormio1
& Barbara Muzzatti2
& Francesca Romito1
& Vittorio Mattioli1
&
Maria Antonietta Annunziata2
Received: 25 July 2016 /Accepted: 11 November 2016 /Published online: 24 December 2016
# The Author(s) 2016. This article is published with open access at Springerlink.com
Abstract
Purpose Cancer survivors often report posttraumatic growth
(PTG). The aims of this study were to assess the presence of
PTG in Italian long-term disease-free cancer survivors (LCS)
and to explore the association between the dimensions of PTG
and clinical, demographic variables, various agents of perceived
social support and psychological distress.
Methods Five hundred forty LCS were assessed with
Posttraumatic Growth Inventory (PTGI), Multidimensional
Scale of Perceived Social Support (MSPSS), Zung SelfRating
Depression Scale, and State-Trait Anxiety InventoryY
(STAI-Y).
Results Mean age was 57.08 years, mean survival was
11.04 years (range 5–32), and the most common cancer diagnosis
was breast cancer (56.9%). The PTGI average total score
was higher in more educated LCS, in those employed, in LCS
with longer time from diagnosis, and in those with no comorbidities.
In this study, PTG was not found correlated with
distress, but it correlated with perceived social support, age,
education, and employment.
Conclusions The absence of a correlation between PTG and
psychological distress and the low levels of PTG found let us
question the importance of talking about PTG when working
as psychotherapists with LCS. It may be suggested that the
need of finding benefit and PTG in LCS has been overcome
by other experiences or worries happened after the cancer, and
LCS may not focus anymore on positive changes occurred.
The relevance of work and of perceived social support as
linked to PTG stresses the need to protect the LCS’s relationship
with work and to promote and sustain their social network,
and this can help them to experience sharing and closeness
to others.
Keywords Cancer survivors . Posttraumatic growth .
Posttraumatic growth dimensions . Social support . Trauma .
Psychological distress
Introduction
In the last decades, many studies have reported positive
changes in people who have experienced various traumatic
events, such as diseases, natural disasters, and wars. Indeed,
in his well-known aphorism, Nietzsche said BWhat does not
kill me, makes me stronger^. Along with religion and philosophy,
psychology has also dealt with this concept [1, 2], and
recently, empirical research has been conducted to better understand
the mechanisms which are at the basis of growth as a
result of adversity.
Tedeschi and Calhoun [3, 4] coined the term posttraumatic
growth (PTG), which describes the positive psychological
change that can occur as a result of a struggle with highly
challenging adverse life events. PTG is what the individual
experiences as a result of trauma, in terms of growth beyond
her/his previous level of functioning, with eventual lifetyle
changes and deeper insight. According to this model, the traumatic
event deeply shakes the pre-traumatic mold, disrupting
the sense of security and the invulnerability of the individual,
their goals, and how they manage emotional stress. Following
this emotional earthquake, ruminating activity begins, aimed
at the search for meaning with respect to what happened and
* Francesca Romito
francescaromito@yahoo.com
1
Experimental Unit of Psycho-Oncology, National Cancer Research
Centre BGiovanni Paolo II^, Bari, Italy
2
Unit of Oncological Psychology, Centro di Riferimento Oncologico
– National Cancer Institute, Aviano, PN, Italy
Support Care Cancer (2017) 25:1087–1096
DOI 10.1007/s00520-016-3496-4
the management of emotions. It seems that individual growth
is better expressed in the relational, individual, and philosophy
of life fields [5]. At the personal level, the individual perceives
an increased sense of self-value, which enables personal resources
such as courage, strength, and endurance. As regards
with life philosophy, it is observed a greater ability to appreciate
the small things and a new scale of priorities. At the
relational level, there seems to be greater empathy and greater
closeness to others.
This construct is also applicable to cancer, as a traumatic
event that breaks the mold of previous life at diagnosis and
stands as a watershed between the before and after in the
patient’s life. Cancer, in fact, places individuals in a life threatening
condition that provokes fear of death and suffering and
can have a devastating effect on the patient’s physical and
psychological functioning [6]. Cancer may represent the
chance for personal and social enrichment, an experience
which is likely to elicit both suffering and growth [7].
Many cancer survivors report positive life changes following
cancer diagnosis [8–12]. PTG has been studied in various
populations of cancer survivors, and it seems that it has several
moderators and associated factors. For example, time passed
from diagnosis seems to be an important moderator factor: in
the short survival time, a higher growth is linked to a higher
distress [13, 14]. This datum is linked to what Tedeschi and
Calhoun [4] have suggested: the more is the event traumatic
and shocking for the individual previous beliefs and functioning,
the more he/she will experience growth in the short time
after the event. The literature reports that the opposite happens
in the long term where usually higher growth is linked to
higher well-being [13, 14].
Even if several studies have reported PTG in cancer survivors,
most of them were aimed at young adult survivors of
childhood cancer, while very little is known of the PTG in
long-term disease-free cancer survivors (LCS) of adult onset
cancers [10, 15, 16].
As regards with the relationship between PTG and psychological
well-being, the literature data are conflicting, and there
is not enough empirical evidence to confirm which kind of
association exists between PTG and distress and/or psychological
well-being [17]. For example, there are numerous reports
in the literature of a higher growth together with a greater
distress [18, 19], but at the same time, other studies showed
that experiencing positive changes or PTG influences the psychological
adjustment of cancer patients. One of those is the
study by Sears et al. [12] that found that 12 months after the
end of treatment, higher levels of PTG were associated with
increased levels of vigor and positive mood. Furthermore, in a
longitudinal study, Carver and Antoni [20] observed that finding
benefits from the experience of cancer during the first
12 months after the diagnosis predicted a significant reduction
in emotional distress and depression 5 to 8 years later. Despite
the lack of consensus on this topic, a study by Stanton [21]
reviewed numerous researches and found that PTG is mostly
associated with lower levels of emotional distress or better
psychological adjustment.
Previous research also suggests that the perception of social
support plays an important role in posttraumatic growth development:
high levels of posttraumatic growth seem to be
associated with high levels of social support [22–24].
Furthermore, Prati and Pietrantoni in a meta-analysis showed
a moderate correlation between PTG and social support across
different settings for possible trauma [25]. The authors considered
that the effects of social support on PTG also vary as a
function of who provides the support: social support provided
by a spouse or by friends might contribute differently to PTG.
Usually, the researchers consider PTG as one big factor,
although different dimensions of growth are traceable. In fact,
according to the literature, growth covers five dimensions as
measured by the Posttraumatic Growth Inventory [26]: (a)
social dimension, which refers to the closeness with others
and activation of social resources; (b) cognitive dimension,
which concerns feeling stronger and more able to solve problems;
(c) emotional dimension, which covers greater compassion
for the pain of others, the ability to better express emotions
and feelings; (d) physical dimension, which concerns the
assumption of a healthy lifestyle; (e) spiritual dimension,
which refers to changes in life priorities.
Moreover, as it has already been underlined, few data are
present on PTG in LCS of adult onset cancers [10, 15, 16], so
we believe that this population deserves to be more thoroughly
investigated, and this is one of the objectives of the present
study. Furthermore, previous research has mainly focused on
the predictors of PTG and, to our knowledge, the relationship
between the different dimensions of PTG and clinical, demographic,
and psychological variables has not been sufficiently
considered.
That said, the aims of this study were the following: (a) to
assess the presence of PTG and its dimensions in a large sample
of long-term disease-free cancer survivors; (b) to explore
the association between the five different dimensions of PTG
and clinical, demographic, and psychological variables.
This research is part of an Italian national project funded by
the Italian Ministry of Health, which aimed to provide a multidimensional
assessment of the mental and physical health of
LCS who have been disease-free and treatment-free for at least
5 years.
Methods
Between 2009 and 2012, 540 LCS were enrolled in the study
during their routine annual follow-up visit to the Outpatient
Unit at the National Cancer Research Centre, Istituto Tumori
BGiovanni Paolo II^, Bari and at the Centro di Riferimento
Oncologico di Aviano, National Cancer Institute. Survivors
1088 Support Care Cancer (2017) 25:1087–1096
were eligible to participate if they were the following: (a) 23–
85 years old (they had to have been >18 years old at the time
of diagnosis); (b) disease and treatment-free for ≥5 years; (c)
able to speak and understand Italian. Six hundred eligible
patients were invited to participate in the outpatient waiting
room before the follow-up visit. Twenty-one refused to participate,
and the other 579 gave written informed consent to
participate. Thirty-nine participants provided an incomplete
PTGI, so their data were not considered in the study. The study
was approved by the ethical committee of the Institutes involved
and met the ethical requirements.
Measures
The survivors completed the questionnaires assessing PTG
and perceived social support and psychological distress (i.e.,
anxiety and depression). Sociodemographic and clinical data
(cancer site, time since diagnosis) and comorbidities were also
collected.
Posttraumatic Growth Inventory
The Posttraumatic Growth Inventory (PTGI) [26] consists of a
21-item scale that measures positive outcomes reported by
people who have experienced a negative event. It provides
separate continuous scores on five dimensions: Relationship
with others (α = 0.85), New possibilities-purpose (α = 0.84),
Appreciation of life (α = 0.67), Spiritual change (α = 0.85),
and Personal strength (α = 0.72). Survivors used a Likert scale
ranging from 0 (no change as a consequence of cancer experience)
to 5 (high change as a result of cancer experience) to
respond to each item. The scale appears to be useful in determining
how successful individuals are in reconstructing or
strengthening their perceptions of self, others, and the meaning
of events in the aftermath of a traumatic event. The Italian
validation was provided by Prati and Pietrantoni [27].
Multidimensional Scale of Perceived Social Support
The Multidimensional Scale of Perceived Social Support
(MSPSS) [28] is a 12-item scale that measures perceived support
from family, friends, and a significant other. Respondents
answered items on a seven-point Likert-type scale (very
strongly disagree to very strongly agree). Also, this tool has
been validated in Italian [29].
Zung Self-Rating Depression Scale
The Zung Self-Rating Depression Scale [30] is a measure of
depression. Scores are proportional to depression intensity;
scores 50–59, 60–69, and 70+ indicate mild, moderate, and
severe depression, respectively. Even if this tool has been
designed in 1965, it has been recently validated in Italian by
Innamorati et al. [31] and gives the possibility to make comparison
with healthy peers and to define cutoff for discriminating
who needs psychological help.
State-Trait Anxiety Inventory-Y (STAI-Y)
This is a self-assessment questionnaire developed to measure
state anxiety (Y1) and trait anxiety (Y2) [32]. Subjects are
asked to rank different statements on a Likert scale (1 = not
at all and 4 = very much) to represent their own behavior. The
items are grouped into two scales of 20 questions each, focused
on how individuals feel generally, or instead what they
feel at particular times. The questionnaire was validated in
Italian [33].
Statistical analysis
Descriptive statistics for PTG and all other psychological variables
were calculated.
One sample t test was performed to compare PTG score
with the mean value reported by Prati and Pietrantoni [27] for
a large (N = 1244) sample of Italian adults who had experienced
a range of adverse life events.
To test the association between PTG and the collected
sociodemographic and clinical data (i.e., gender, age, schooling,
occupational status, marital status, type of cancer, length
of survivorship, and presence or absence of other health issues),
the Mann-Whitney or Kruskal-Wallis test was performed.
To test the association between PTG and the collected
psychological variables (i.e., state and trait anxiety, depression,
perceived social support as provided by friends, the family,
and a significant other), Spearman correlations were
calculated.
A Friedman test using the five PTG dimensions as dependent
variables was performed to verify differences within subjects.
A subsequent analysis was performed to identify the
statistically significant paired comparisons by means of
Wilcoxon signed rank tests and Bonferroni adjustment for
multiple comparisons. For these analyses, scores of each
PTG component were calculated as the mean of their relative
items with a range 0–5. Furthermore, Mann-Whitney tests,
Kruskal-Wallis test, and Spearman correlations were calculated
to verify the association of each PTG component with the
considered sociodemographic, clinical, and psychological
variables (as described above).
Since PTG scores were not normally distributed in our
sample [Shapiro-Wilk (540) = 0.977; p < 0.001], we performed
mostly non-parametric statistics. The p value <0.05
was preset for statistical significance (two tails).
Bonferroni’s adjustment of p value was used, when appropriate,
to avoid errors due to multiple comparisons.
Support Care Cancer (2017) 25:1087–1096 1089
All statistical analyses were performed using SPSS software,
Version 21 (SPSS Inc., Chicago, Ill.).
Results
Sample sociodemographic, clinical, and psychological
characteristics
As shown in Table 1, the final sample comprised 540 participants,
and 76.9% of whom were female. The mean age was
57.08 years (SD = 10.96; age ranging from 25 to 80), and
40.5% of participants had a post-compulsory education (i.e.,
had attended school for more than 8 years). The majority of
participants in the sample had a non-employed status of retired,
homemaker, or unemployed (70.2%) and had a stable
emotional relationship, noted as married or cohabiting (77%).
In terms of clinical data, the most common cancer diagnosis
was breast cancer (56.9%). The mean survivorship was
11.04 years (SD = 5.12; survivorship ranging from 5 to 32),
and 89% of the sample reported other health issues.
Finally, concerning the psychological variables, perceived
social support provided by family was 6.04 (SD = 1.25), perceived
social support provided by friends was 4.67
(SD = 1.98), and perceived social support provided by a significant
other was 6.10 (SD = 1.33). The mean score of state
anxiety was 42.69 (SD = 11.88), trait anxiety was 42.29
(SD = 10.48), and depression was 46.65 (SD = 13.04).
Table 1 Posttraumatic growth
according to sample
characteristics: M (DS)
Number Percentage Mean (standard deviation)
Gender
Male 125 23.1 40.19 (25.56)
Female 415 76.9 41.77 (25.10)
p = 0.466
Age (years)
25–39 39 7.3 48.15 (25.98)
40–49 89 16.6 52.33 (25.12)
50–59 170 31.7 43.04 (24.52)
60–69 169 31.5 37.67 (24.67)
70+ 70 13.0 30.03 (20.79)
p < 0.001
Education
Compulsory
(<9 years)
287 59.5 39.76 (25.39)
Post-compulsory
(9+ years)
195 40.5 46.22 (24.54)
p = 0.006
Occupational status
Employed 160 29.8 48.13 (25.50)
Unemployed 377 70.2 38.35 (24.39)
p < 0.001
Marital status
Partnered 415 77.0 41.12 (25.01)
Non-partnered 124 23.0 42.41 (25.96)
p = 0.689
Cancer diagnosis
Breast 307 56.9 38.98 (24.67)
Colon-rectum 48 8.9 40.71 (25.03)
Lymphoma 114 21.1 49.75 (25.20)
Urogenital 37 6.9 38.76 (25.87)
Other 34 6.2 39.12 (24.89)
p = 0.003
Survivorship length
(years)
<10 268 49.6 38.95 (23.96)
10+ 272 50.4 43.82 (26.17)
p = 0.042
Presence of other
health issues
Yes 419 89.0 39.92 (25.20)
No 52 11.0 49.02 (26.10)
p = 0.014
Total 540 100.0 41.40 (25.19)
Sums may not add up to total because of missing values
1090 Support Care Cancer (2017) 25:1087–1096
Posttraumatic growth
In the present sample, the total score of PTG was 41.40
(SD = 25.19). This score was significantly lower than that of
Italian adults who had experienced a range of adverse life
events [t (539) = −3.30; p = 0.001; 95% confidence interval
of the difference: −5.71; −1.45].
As shown in Table 1, more educated participants
(z = −2.76; p = 0.006), employed participants (z = −4.24;
p < 0.001), participants surviving cancer for ten or more years
(z = −2.04; p = 0.042), and participants not reporting other
health issues (z = −2.45; p = 0.014) displayed higher scores
than their counterparts. In addition, there were statistically
significant associations with age [chi2
(4) = 39.56; p < .001]
and cancer type [chi2
(4) = 15.67; p = 0.003]. In particular, 40–
49-year-old participants displayed higher scores than all the
three older age groups (p < 0.005), and both the youngest age
group (25–39 years) and the 50–59-year-old participants
displayed higher scores than 70+-year-old participants
(p < 0.005). Similarly, lymphoma survivors displayed higher
scores than breast cancer survivors (p < 0.001). Conversely,
there were no differences related to gender (z = 0.73;
p = 0.466) or having a stable emotional relationship
(z = 0.40; p = 0.689).
PTG was found to be positively correlated to the perceived
social support as provided by friends (p < 0.001), the perceived
social support as provided by family (p = 0.005), and
the perceived social support as provided by a significant other
(p < 0.001), but it was not correlated to state anxiety
(p = 0.488), trait anxiety (p = 0.834), or depression
(p = 0.081) (Table 2).
Posttraumatic growth dimensions
Table 3 displays mean, standard deviation, and minimum and
maximum for the five dimensions of PTG. Compared with a
large sample of Italian adults who had experienced a range of
adverse life events [27], the present sample displayed lower
scores in the following dimensions: Relating to others
[t (539) = −2.26; p = 0.024; 95% confidence interval of the
difference: −0.25; −0.02] and in New possibilities
[t (539) = −10.42; p < 0.001; 95% confidence interval of the
difference: −0.69; −0.47]. This sample also displayed higher
scores in Personal strength [t (539) = 3.66; p < 0.001; 95%
confidence interval of the difference: 0.11; 0.36] and Spiritual
changes [t (539) = 2.73; p = 0.007; 95% confidence interval of
the difference: 0.06; 0.38], but no differences were found in
Appreciation for life [t (539) = 1.04; p = 0.300; 95% confidence
interval of the difference: −0.06; 0.20].
Statistically significant differences in PTG component
scores within subjects were found by a Friedman test
[chi2
(4) = 358.53; p < 0.001]. The subsequent analysis
showed Appreciation of life to be higher than all the
other four PTG dimensions (p < 0.001); Personal
strength was lower than Appreciation of life and higher
than the other three dimensions (p < 0.001); Spiritual
change was lower than both Appreciation of life and
Personal strength, but higher than New possibilities
(p < 0.001); Relating to other was lower than both
Appreciation for life and Personal strength, but higher
than New possibilities (p < 0.001). New possibilities
was the component with the lowest score (p < 0.001).
Tables 4 and 5 report data for the five PTG dimensions
separately.
In Relating to others, employed participants (z = −3.60;
p < 0.001) and participants declaring no other health issues
(z = −2.65; p = 0.008) displayed higher scores than their counterparts.
In addition, this PTG component was significantly
associated with age [chi2
(4) = 24.05; p < 0.001] and cancer
type [chi2
(4) = 15.71; p = 0.003]. In particular, 40–49-year-old
participants displayed higher scores than both the 50–59 and
70+ age groups (p < 0.001), and lymphoma survivors
displayed higher scores than breast cancer survivors
(p < 0.001). Finally, Relating to others correlated positively
with perceived social support as provided by the family
(p = 0.002), by friends (p < 0.001), and by a significant other
(p < 0.001).
In New possibilities, more educated participants (z = −4.25;
p < 0.001), employed participants (z = −5.71; p < 0.001), participants
surviving cancer for more years (z = −3.33;
p = 0.001), and participants declaring no other health issues
(z = −3.16; p = 0.002) displayed higher scores than their counterparts.
In addition, this PTG component was significantly
associated with age [chi2
(4) = 51.25; p < 0.001] and cancer
type [chi2
(4) = 29.79; p < 0.001]. In particular, both the 25–39
and 40–49 age groups showed higher scores than the 60–69
and 70+ years age groups (p < 0.001), and the intermediate
age group (50–59 years) showed higher scores than the oldest
Table 2 Spearman correlations
between posttraumatic growth
and anxiety, depression, and
perceived social support
Trait
anxiety
State
anxiety
Depression PSS by
family
PSS by
friends
PSS by a
significant
other
Posttraumatic
growth
0.010 −0.34 −0.077 0.137+ 0.270# 0.194#
+p < 0.01; #p < 0.001
Support Care Cancer (2017) 25:1087–1096 1091
one (p < 0.001), and lymphoma survivors displayed higher
scores than breast cancer survivors (p < 0.001). Finally, New
possibilities was negatively correlated to state anxiety
(p = 0.006) and depression (p < 0.001) and was positively
correlated to perceived social support as provided by friends
(p < 0.001) and a significant other (p = 0.048).
In Personal strength, employed participants (z = −3.19;
p = 0.001) displayed higher scores than their counterparts. In
Table 4 Posttraumatic growth
dimensions according to sample
characteristics (M [DS])
RO NP PS SC AL
Gender
Male 1.82 (1.28) 1.70 (1.45) 2.16 (1.41) 1.35 (1.67) 2.56 (1.45)
Female 1.91 (1.40) 1.44 (1.25) 2.30 (1.48) 2.05*
(1.88) 2.64 (1.61)
Age (years)
25–39 2.14 (1.33) 2.17 (1.48) 2.67 (1.48) 1.55 (1.76) 2.92 (1.43)
40–49 2.45 (1.33) 2.15 (1.36) 2.67 (1.43) 2.16 (1.91) 3.16 (1.43)
50–59 1.87* (1.43) 1.54* (1.28) 2.48* (1.44) 1.97 (1.91) 2.78* (1.58)
60–69 1.72 (1.31) 1.24 (1.21) 2.04 (1.45) 1.94 (1.89) 2.45 (1.61)
70+ 1.53 (1.28) 0.85 (0.79) 1.66 (1.29) 1.40 (1.58) 1.86 (1.36)
Education
Compulsory
(<9 years)
1.85 (1.40) 1.35 (1.26) 2.17 (1.48) 2.03 (1.89) 2.44 (1.58)
Post-compulsory
(9+ years)
2.03 (1.34) 1.86*
(1.36) 2.51 (1.40) 1.81 (1.82) 3.04*
(1.45)
Occupational status
Employed 2.20 (1.35) 2.01 (1.39) 2.57 (1.45) 1.74 (1.78) 2.99 (1.50)
Unemployed 1.74*
(1.36) 1.27*
(1.19) 2.13*
(1.45) 1.91 (1.88) 2.46*
(1.58)
Marital status
Partnered 1.87 (1.38) 1.46 (1.26) 2.29 (1.48) 1.85 (1.84) 2.64 (1.60)
Non-partnered 1.95 (1.37) 1.65 (1.44) 2.21 (1.44) 2.00 (1.90) 2.54 (1.49)
Cancer diagnosis
Breast 1.76 (1.40) 1.28 (1.16) 2.21 (1.49) 1.98 (1.91) 2.49 (1.65)
Colon-rectum 1.88 (1.41) 1.43 (1.23) 2.31 (1.40) 1.94 (1.68) 2.48 (1.57)
Lymphoma 2.30* (1.26) 2.15* (1.48) 2.57 (1.43) 1.79 (1.70) 3.01 (1.33)
Urogenital 1.79 (1.28) 1.60 (1.43) 1.90 (1.44) 1.58 (1.91) 2.50 (1.53)
Other 1.75 (1.41) 1.27 (1.12) 2.17 (1.37) 1.68 (2.09) 2.85 (1.61)
Survivorship length
(years)
<10 1.80 (1.38) 1.29 (1.16) 2.17 (1.41) 1.90 (1.82) 2.50 (1.60)
10+ 1.97 (1.37) 1.71*
(1.40) 2.37 (1.52) 1.87 (1.89) 2.74 (1.55)
Presence of other
health issues
Yes 1.81 (1.38) 1.42 (1.29) 2.20 (1.48) 1.86 (1.87) 2.53 (1.60)
No 2.31*
(1.26) 2.14*
(1.50) 2.44 (1.43) 1.67 (1.73) 3.02 (1.37)
RO Relating to others, NP New possibilities, PS Personal strength, SC Spiritual changes, AL Appreciation for life
*p value was statistically significant according to Bonferroni’s correction: p < 0.05/5
Table 3 Posttraumatic growth
dimensions Factor No. of items Mean Standard deviation Minimum Maximum
Relating to others 7 1.88 1.38 0 5
New possibilities 5 1.50 1.3 0 5
Personal strength 4 2.27 1.47 0 5
Spiritual change 2 1.89 1.86 0 5
Appreciation of life 3 2.62 1.58 0 5
1092 Support Care Cancer (2017) 25:1087–1096
addition, this PTG component was significantly associated
with age [chi2
(4) = 29.20; p < 0.001]. In particular, both the
40–49 and 50–59 age groups reported higher scores than the
oldest one (p < 0.001). Finally, Personal strength was negatively
correlated to depression (p = 0.003), and it was positively
correlated to perceived social support provided by the
family (p = 0.001), friends (p < 0.001), and a significant other
(p < 0.001).
In Spiritual changes, females displayed higher scores than
males (z = −3.60; p < 0.001). In addition, Spiritual changes
was positively correlated to trait anxiety (p = 0.027), depression
(p = 0.028), perceived social support as provided by the
family (p = 0.040), and perceived social support as provided
by a significant other (p = 0.021).
In Appreciation for life, more educated participants
(z = −4.09; p < 0.001) and employed participants (z = −3.62;
p < 0.001) displayed higher scores than their counterparts. In
addition, this PTG component was significantly associated
with age [chi2
(4) = 32.39; p < 0.001], where the 25–39, 40–
59, and 50–59 age groups showed higher scores than the
oldest age group (p < 0.001). Finally, Appreciation for life
was positively correlated to perceived social support as provided
by friends (p < 0.001) and a significant other
(p < 0.001).
Discussion
This cross-sectional study examined the posttraumatic growth
of a large sample of long-term and disease-free cancer survivors,
and to the best of our knowledge, it is one of the few
research efforts so far to have focused on cancer-related
growth over three decades after diagnosis.
Also, as few studies have examined PTG and its dimensions
in detail, our study offers new insights into this phenomenon
[34].
The first interesting finding of our study is the total score of
posttraumatic growth, which was significantly lower than that
of Italian adults who had experienced a range of adverse life
events.
One possible explanation of this finding is that people
whose cancer experience happened a decade or more before
may have integrated the cancer-related changes into their personality.
Meanwhile, other events may have occurred in people’s
lives, so as to reduce the meaning of cancer in their
lifetime. Another possible explanation can be based on the
perception of cancer as a long-lasting experience rather than
a concluded life episode [9]. Studies monitoring well-being
and functioning of this specific population could help in understanding
the reason for this datum.
Associations between posttraumatic growth dimensions
and study variables
Among the study variables that correlate more closely with
PTG were perceived social support, as provided by three different
sources, age, education, and employment.
In our sample, all the PTG dimensions correlated with perceived
social support provided by family, friends, and significant
others. Consistent with these findings, there is a previous
longitudinal research exploring which kind of support is more
related to PTG, finding that emotional support actually received
from others is related to PTG also many years after
diagnosis [35]. The support of close people and the possibility
to talk with them can arouse new cognitive processes and
booster coping responses that may in turn promote positive
changes. Mechanisms implicated may be both cognitive and
emotional: emotional support and talking with others may
offer new perspectives on the traumatic event. On the other
hand, other people may give encouragement and positive reinforcement
with respect to how the patient is addressing the
difficulty contributing to his/her self-esteem and sense of mastery
[36, 37].
Younger age was associated with four dimension of posttraumatic
growth, except for Spiritual change, confirming previous
literature findings [11, 32]. This could be due to the fact
that younger people have expectation of longer life and
Table 5 Spearman correlations
between PTG dimensions and
anxiety, depression, and
perceived social support
Trait
anxiety
State
anxiety
Depression PSS by
family
PSS by
friends
PSS by a
significant
other
Relating to
others
−0.045 −0.008 −0.034 0.153+ 0.288# 0.206#
New
possibilities
−0.085 −0.134+ −0.152# 0.058 0.228# 0.097*
Personal
strength
−0.041 −0.050 −0.132+ 0.167+ 0.235# 0.179#
Spiritual change 0.108* −0.91 0.096* 0.101* 0.075 0.113*
Appreciation of
life
−0.017 −0.035 −0.072 0.086 0.220# 0181#
*p < 0.05; +p < 0.01; #p < 0.001
Support Care Cancer (2017) 25:1087–1096 1093
planning skills that may help them to better enjoy the present
and prepare for the future life. It has also been suggested by
Tedeschi and Calhoun themselves [4] that the more is the
traumatic event shocking for the individual previous functioning
and the more it is disrupting his/her previous identity (e.g.,
sense of immortality, expectations on the future, which are
more present in younger people), the more the person may
develop internal sense of growth after the trauma. Moreover,
often the elderly are more involved in the management of
other stressful life events, such as other comorbidities and
bereavement than younger people. On this note, in our sample,
participants not reporting other health issues showed a
higher level of PTG. This consideration was also supported
by the findings of a study conducted by Bellizzi [38] that
showed that elderly survivors of breast cancer were less worried
by their diagnosis due to the presence of other painful life
events (death of a spouse, visual or hearing impairment etc.).
All PTG dimensions showed correlation to employment,
except Spiritual change. This result is in line with those reported
by Bellizzi and Blank, namely, that the survivors
employed full- or part-time showed higher levels of PTG
[39]. Work could be a protective factor against stress [40]
helping people to focus on various life goals and to find meaning
deriving also from their professional life.
To what concerns the correlation between PTG and
education, we have found that the two dimensions that are
more implicated are New possibilities and Appreciation for
life. We can speculate that having a high level of education
is a positive resource with respect to the ability to overcome
the psychosocial difficulties related to oncological disease. In
fact, Ross et al. reported that people with a higher level of
education have more ease in the construction of social relations,
which are characterized by greater stability. From this, it
arises the possibility of a better social support. [41].
In our sample, Spiritual change behaved differently
from other dimensions: unlike the others, it did not correlate
with age and employment, but it was the only PTG
dimension positively correlated with gender (women
showed higher results than men) and with anxiety and
depression. Survivors who are more depressed and have
a higher level of trait anxiety reported more change in
this dimension, as if they try and find support in spirituality
more than others with less psychological symptoms.
This seems like a kind of outsourcing.
We were also interested in evaluating the relationship between
psychological distress, i.e., a cancer-specific psychological
effect and PTG.
In our sample, PTG as a general construct was not correlated
to depression or to anxiety, as underlined in previous
research [10, 13], but a negative correlation was found with
depression and the dimensions Bnew possibilities^ and
Bpersonal strength^: if other research has found a correlation
between PTG and depression, this can be linked to the fact that
in the short term, people still feel confusion related to the
disruption of previous certainties [18, 19], which may be overcome
in the long-term period, which is the case of the present
study population.
The findings of the present study provide interesting insights
for therapeutic work with cancer patients and cancer
survivors: the absence of a correlation between posttraumatic
growth and psychological distress (depression and anxiety)
and the same datum of low levels of posttraumatic growth in
this population of long-term cancer survivors let us question
the importance of talking about posttraumatic growth when
working as psychotherapists with persons that have lived the
cancer experience many years before. It may be suggested that
for LCS, the construct of PTG has been overcome by other
experiences or worries happened in the years after the end of
treatments, and they did not focus anymore so much on positive
changes occurred after the trauma. Probably the PTG
may better work as a sort of coping strategy, as one way to
make sense of a traumatic experience right or short after the
cancer experience has occurred, in order to help the individual
to find a meaning and a positive interpretation of the illness
experience.
On the other hand, when treating patients still in treatment
or in the short period of survival, the concept of PTG may
bring an interesting clinical perspective in the clinical setting
that allows the psychotherapist and the oncologist to see distress,
disbelief, and the patient’s pain not only as a maladaptive
response but also as possible growth factors [42].
The important information obtained regarding the relevance
of work, for example, stress the need not to marginalize
cancer survivors due to their cancer experience but rather to
protect their relationship with work.
Furthermore, the strong relationship between perceived social
support and PTG suggests that clinicians should look
carefully at the social context of the survivors and promote
and sustain the creation of a social network that can help them
to experience sharing and closeness to others, rather than loneliness.
This could be particularly adapt for the cultural context
where the study has been carried out: people in Italy are used
to rely on partners and extended family members as important
source of support. This kind of support, also in the present
work, has been shown important to help the individual to
cognitively and emotionally find meaning out of the cancer
experience and developing new perspectives of growth.
Limitations of the present study regard the cross-sectional
design that did not allow us to draw conclusion of the causal
relationship between the variables under study. Furthermore,
the present study did not investigate any further crucial life
events of cancer survivors (positive or negative) that could
have affected the results and the development of posttraumatic
growth, in relation to the event cancer. Then, in future research,
it would be useful to evaluate this aspect in order to
understand whether survivors who have been exposed to
1094 Support Care Cancer (2017) 25:1087–1096
significant life events after the cancer may have reduced the
significance of the cancer experience in their personal life.
Moreover, for future research, it would be useful to consider
whether the Italian culture has some specificities in the dimensions
of the PTG that the PTGI does not completely capture.
Acknowledgements This work was supported by the Italian Ministry
of Health that funded the Integrated Research Program in Oncology no. 7
BMedical and psycho-social rehabilitation program for long-term cancer
survivors^.
The authors wish to thank Dr. Caroline Oakley for her valuable assistance
during the linguistic revision of the paper.
Compliance with ethical standards This research is part of an Italian
national project funded by the Italian Ministry of Health, which aimed to
provide a multidimensional assessment of the mental and physical health
of LCS who have been disease-free and treatment-free for at least 5 years.
The study was approved by the ethical committee of the Institutes involved
and met the ethical requirements.
Disclosures None.
Conflict of interest The authors declare that they have no conflict of
interest.
Open Access This article is distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License (http://
creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial
use, distribution, and reproduction in any medium, provided
you give appropriate credit to the original author(s) and the source, provide
a link to the Creative Commons license, and indicate if changes were
made.
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