Examining the Role of Resilience, Posttraumatic Growth, and Quality of Life in Women with Breast Cancer: A Serial Multiple Mediator Model Approach

Women with breast cancer are challenged to maintain their quality of life (QOL) when experiencing distressing symptoms. As early as the beginning of cancer treatment, women with breast cancer may start experiencing numerous symptoms that interfere with many facets of life, including mood, general activity, and enjoyment of life.1 Women with early-stage breast cancer have reported that pain was the most severe symptom during cancer treatment.2 Fatigue is another commonly experienced symptom during the first 3 months of chemotherapy.3 Even after the completion of breast cancer treatment, unpleasant experiences with distressing symptoms may persist for 2 years or long.3, 4, 5 Furthermore, other side effects, such as neuropathy, may gradually emerge and persist throughout the cancer trajectory, requiring women with breast cancer to make continual adjustments in order to maintain QOL.6,7

A growing body of research has identified resilience as a way to help people mitigate the impacts of cancer and cancer-related symptom distress and improve QOL.8 Resilience is defined as a learning process by which an individual sustains well-being in the face of adversity, such as cancer, by using internal, external, and existential resources.9 When facing distressing symptoms such as depression and anxiety, individuals with higher resilience may demonstrate higher levels of optimism, flexibility, and self-efficacy to use active coping methods.10, 11, 12 Resilience, however, affects more than psychological well-being. For instance, women aged ≥65 years with greater resilience showed greater improvement than those who were less resilient in the recovery of physical function at 12 months after adjuvant chemotherapy for breast cancer.13 These findings suggest that differences in resilience levels may lead women with breast cancer to respond differently toward distressing symptoms as well as QOL.

In addition to facilitating better adaptation to maintaining QOL, resilience may enhance individuals with cancer to experience positive changes following cancer-related adversity and distressing symptoms. Recent systematic reviews indicate that cancer survivors may perceive positive changes after cancer in relationships with others, self-efficacy, and spiritual beliefs.14,15 Such perceptions of positive change are often referred to as posttraumatic growth (PTG). Calhoun and Tedeschi defined PTG as a positive psychological change occurring as a result of the cognitive processing needed for struggles with a highly challenging experience.16 After being diagnosed with cancer, an individual's resilience may gradually evolve through cognitive processing and appropriate use of their internal, external, and existential resources to address cancer-related challenges. This process may subsequently facilitate PTG.17

Previous studies have suggested the possibility that resilience has a causal effect on PTG.12,18,19 That is, for PTG to develop, individuals need to be resilient first.16,19 Rebounding from life challenges is a characteristic of resilience. Thriving from life challenges is a positive change that develops along the way to meeting new challenges or new normalcy.20 In the case of women with breast cancer, they would need to evaluate what resources they have and how to use their available resources to overcome each distressing symptom they experience. This cognitive learning process promotes resilience and eventually reduces the impact of the distressing symptoms. In addition, their PTG may manifest in increased personal strengths towards managing symptoms and positive relationships with families, friends, and health care providers established during their learning process for the challenges associated with symptoms.15

Earlier studies of adolescents and adults with cancer have found that resilience functioned as a mediator that partially accounted for the negative association between symptom distress and QOL.12,21,22 However, despite the possible association between resilience on PTG and the mediating effect of resilience between symptom distress and QOL, it is unclear how QOL changes after women with breast cancer experience positive changes through resilience and PTG towards symptom distress. An intervention developed for women with breast cancer showed positive effects of resilience on anxiety and stress after 12 weeks of resilience training, but PTG was not included as part of the intervention or a primary outcome of interest.23 Given the positive association between resilience and PTG, this study sought to continue this line of investigation by using a serial multiple mediator model to examine how the relationship between symptom distress and QOL changed through resilience, PTG, and the potential causal effect of resilience on PTG among women with breast cancer in Taiwan.

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