INTRODUCTION
Life-threatening diseases, such as cancer or HIV, can have an extraordinary influence on an individual's life. The diseases are often believed to cause psychological problems, such as depression, grief, anger, or anxiety (Ogden, 2000; Taylor, 2000). Shontz (1975), on the other hand, suggests that people with life-threatening diseases tend to seek out more positive appraisals of their lives and show personal growth. Such positive appraisals may involve “increased appreciation of personal worth,” “greater willingness of helping sick people,” “renewed recognition of life as a second chance,” or “acceptance of old and renewed personality.” In particular, the positive appraisals of cancer (Taylor, 1983; Collins et al., 1990) and its impacts on mental health (Taylor et al., 1984; Taylor & Brown, 1988; Andrykowski et al., 1996; Mast, 1998) or physical health (Taylor, 2000; Taylor et al., 2003) have been academically acknowledged. The positive appraisals of cancer have been named differently based on the variant perspectives of cancer patients, such as benefit finding (Antoni et al., 2001; Sears et al., 2003), fighting spirits (Cotton et al., 1999; Schou et al., 2005), optimism (Scheier & Carver, 1985, 1992; Peterson, 2000), positive illusions (Taylor & Brown, 1994; Taylor, 2000), positive life changes (Petrie et al., 1999), or posttraumatic growth (Schaefer & Moos, 1992; Cordova et al., 2001). Such appraisals have been energetically researched and portrayed in the academic sphere for the past two decades.
An early investigation of positive appraisals of cancer (Taylor, 1983) found that 53% of breast cancer patients reported positive life changes, and only 17% reported negative life changes following cancer. The study of early-stage breast cancer patients (Sears et al., 2003) also revealed that 83% of the participants reported at least one positive benefit of the cancer-related experience. Thus, the occurrence of positive appraisals of cancer seems to be quite frequent, and may even be higher than that of negative ones. However, the study of Petrie et al. (1999) reported that there were 8 out of 30 breast cancer patients who answered “nothing positive” in the questionnaire that asked about the experience of positive life changes following cancer, so that such positive life changes cannot be considered as inevitable. Therefore, an idea could exist that many patients tend to recognize both positive and negative life changes following their diseases (Zemore et al., 1989).
The above studies showed that cancer patients tend to have positive appraisals of cancer. Now, it seems important to focus on the contents or types of positive appraisals of cancer and get deeper insights. For instance, the open-ended questionnaire-based study of 30 breast cancer patients (Petrie et al., 1999) categorized the types of positive life changes following the diagnosis. It was found that “improved close relationships” (33%) was found to be the most common type of positive appraisal, and “greater appreciation of life” (27%) and “change in personal priorities” (20%) were the next. Overall, this study found positive life changes in social, psychological, and physiological domains. This study suggests that cancer patients were able to recognize their own positive life changes in many cancer-related domains. However, the study of Petrie et al. was based on cancer patients' written responses to an open-ended question. We conducted an interview-based study, which enabled us to obtain larger amount of information to examine the categorization of Petrie et al. The current study focuses on the recognition of cancer patients believing “something has changed after cancer” (in other words, “positive life changes following cancer”), and tries to examine the types of positive life changes to discuss how cancer patients positively appraise their disease, life, and self.
METHODS
The study consists of a group discussion and one-to-one semistructured interviews. All the participants were the regular attendees of a cancer support group in an infirmary in Staffordshire, UK. This support group was voluntarily organized once a week by a cancer treatment professional. The average age was 59, ranging from 50 to 67 years old. The details of the participants in the interview are listed in Table 1.
Characteristics of the participants in interviews about life changes following cancer
The theme of the group discussion was “the things that you think changed positively after you experienced cancer.” The discussion involved six cancer patients (three men, three women). The discussion was not announced to the participants in advance (because we did not want the participants to prepare advance notions of the theme), so the participants were the patients who happened to attend the support group on the day of the discussion. The discussion was organized in the hour of the cancer support group, so that they could discuss the theme in a relaxed manner as they usually do in the group. The group discussion was tape-recorded and transcribed with the participants' permission. The discussion continued approximately 1.5 h. Then, three of the participants of the group discussion agreed to participate in the interview and two others were newly recruited, so that five patients were finally interviewed (two men, three women). The interviews lasted for approximately 35 min. The interviews were also tape-recorded and transcribed with the participants' permission. All the participants were aware that they could refuse to answer the questions if they wanted. All the data were collected by the first author.
Content analysis was conducted by two independent researchers (the first author and a psychology student). The transcription produced 770 statements. The statements were examined based on the seven types of positive life changes illustrated in Petrie et al. (1999): improved empathy, greater knowledge about health, a second chance, change in personal life priorities, greater appreciation of health and life, improved close relationships, and healthy lifestyle change. The researchers discussed until they were in agreement whether each life change fit into the category.
RESULTS
The content analysis of the group discussion and interviews produced seven categories of positive life changes following cancer: improved empathy, greater knowledge about health, renewed recognition of life, change in personal life priorities, greater appreciation of health and life, improved close relationships, and healthy lifestyle change, which basically supported the categorization of Petrie et al. (1999). A second chance, however, was renamed as renewed recognition of life, because the participants showed a variety of changed recognition of life (e.g., life as a second chance, life as finite), so that the category of second chance could expand and include the wider range of recognition changes to explain the positive life changes of cancer patients more comprehensively.
The content analysis produced more specific insights into positive life changes following cancer. The first finding was that the participants tended to feel more empathy toward people who are diagnosed with cancer or other serious illnesses (Table 2). Many of the participants emphasized that they were more encouraged to understand the problems of other people because they once suffered from their own problems. Their improved empathy seemed not restricted to only cancer patients but people with all sorts of serious illnesses. This indicates that cancer could improve the empathy of patients and expand their views toward illness in general.
The contents of improved empathy based on the content analysis
Second, all the participants showed greater knowledge about their own cancer (Table 3). They had precise information about their own cancer and treatment. Moreover, the majority of the participants reported that they learned more about cancer in general, and showed different levels of interest in cancer-related information. For example, some patients were actively searching for information by themselves (e.g., reading books) whereas others tended to be dependent on more passive methods (e.g., watching occasional TV programs, listening to the talk of other support group members). Some participants showed confidence in dealing with cancer through knowing about the disease.
The contents of greater knowledge about health based on the content analysis
Third, the interview questions asked whether the participants recognized their lives as a second chance, which produced both agreement and disagreement (Table 4). They showed not only the change of life recognition as a second chance but also a variety of changes in life recognition, so that this category was renamed renewed recognition of life. In particular, the renewed recognition of death and mortality was often reported. Such recognition of death could encourage them to find the different value of life. For instance, some participants reported that they felt freer from any problems because they had experienced the hardest time in their lives because of the battle with cancer. Increased spirituality and morality were also reported.
The contents of renewed recognition of life based on the content analysis
Fourth, there was a considerable degree of agreement that personal priorities were changed following cancer (Table 5). Their priorities seemed especially changed in the domain of life and people. All of the participants emphasized the importance of time left to live and taking life one day at a time. Also, they reported that they became more people oriented and realized the renewed value of their families and friends. Work, on the other hand, tended to be regarded as less meaningful, particularly for the participants who used to work full time. However, some participants reported that cancer had no impact on their life priorities.
The contents of change in personal life priorities based on the content analysis
Fifth, the majority of the participants showed greater appreciation of health and life following cancer (Table 6). The participants especially emphasized that they realized how they took everything for granted before having cancer, especially their health condition. They tend to rethink about health and lives and appreciate them more, and such appreciation tended to involve a variety of aspects in life from general (e.g., appreciation of nature) to specific (e.g., time with grandchildren).
The contents of greater appreciation of health and life based on the content analysis
Sixth, the majority of the participants emphasized that their families and friends became closer and supportive after they got cancer (Table 7). Instrumental, physical, and psychological support was reported. The most common type of support seemed to be frequent visits by family members. However, although the participants feel closer to their families and friends, some of them tended to avoid discussing cancer and death. Some participants said that their family members were afraid of talking about cancer because they had a chance to inherit the same cancer in the future. Cancer could destroy a patient's relationships and make him/her isolated or stigmatized.
The contents of improved close relationships based on the content analysis
Seventh, healthy lifestyle change was particularly notable. The majority of the participants reported that they were more interested in health and changed to a healthier lifestyle (Table 8). Diet was often improved with the ingestion of more vegetables and fruits or medical pills. The frequency of medical checkups was another important factor of a healthy lifestyle. Some participants started to take regular checkups after they had cancer although they rarely saw the doctor before. Also, some participants pointed out that they had lower levels of stress owing to the absence of work or worry. Another notable finding may be that some participants tried to not only regain a healthy lifestyle but also become healthier than ever before. However, there was no participant who stopped smoking after the diagnosis. This could be because this study had a very limited number of participants and many of them had no experience of smoking.
The contents of healthy lifestyle change based on the content analysis
Eighth, although negative life changes were not asked about in the interviews, all the participants reported them, so they were also categorized independently (Table 9). Negative life changes mainly involved a preoccupation with thinking about cancer, the fear of death, the stress of treatment, a decreased social life, and depression. Many such negative changes seemed to include aspects that are difficult to remove from a participant's mind and body. All the participants reported that they were in real shock when they were diagnosed with cancer, and some of them experienced serious depression, especially people with a high level of illness-related symptoms or physical disabilities.
The contents of negative life changes following cancer based on the content analysis
DISCUSSION
The aim of this study was to examine different types of positive life changes that cancer patients may experience following their diagnosis. A variety of positive life changes were found and the participants reported their own “benefits” of cancer. This finding seems to be consistent with that of Petrie et al. (1999), as they found a high frequency of positive changes in several life domains in the sample of breast cancer patients. Also, the categorization of positive life changes was largely consistent with that of Petrie et al. (1999), but the category of second chance was renamed renewed recognition of life to obtain a more comprehensive explanation of the cancer patients' appraisal of positive life changes. At the same time, negative life changes were also frequently reported. This point also supports previous studies, suggesting that cancer patients tend to experience both positive and negative disease consequences (Zemore et al., 1989).
The findings of this study would suggest some interesting features of positive life changes following cancer. First, all the participants reported some kinds of positive life changes, which could indicate that the recognition of positive life changes could be a natural experience for cancer patients. The ideas of positive illusions could pose another insight in this argument (e.g., Taylor & Brown, 1988; Taylor & Armor, 1996). The authors insisted that unrealistically positive views of the self (e.g., optimistic future perspectives, exaggerated illusion of controlling difficulties) could be found in people facing life-threatening events. Hamera and Shontz (1978) also suggested that such positive illusions were more likely to be perceived by patients themselves rather than their families or hospital staff. These studies indicate that positive life changes could also be subjective ideas of “something has positively changed,” so that the patients may not necessarily realize the true extent of their life changes. To that extent, positive life changes could be the skewed recognition of personal life, which is highly likely to occur in the face of life-threatening events. Positive life changes following cancer could be a “natural” experience for cancer patients, so researchers could not recognize it as a special or unusual feature of cancer patients to understand the psychological states of cancer patients accurately.
Second, many of the reported positive life changes could be correlated with a sense of controlling self, disease, and life. For instance, the ideas of greater knowledge about health (e.g., “I feel I can fight against cancer by having greater knowledge.”) or renewed recognition of life (e.g., “I realize I have to find positive aspects of my life by myself.”) seem to indicate that knowledge gain or new life recognition are not only positive life changes but also effective ways of controlling self, disease, and life. The study of Thompson et al. (1993) showed that cancer patients with a high sense of controlling daily emotion and physical symptoms had better adjusted to cancer. In other words, cancer patients who possess a sense of controlling self may be more likely to experience positive life changes. In this sense, the feeling of control would be considered as an important keyword to capture the recognition of positive life changes. Heijmans (1999) also found that Addison's disease patients who believed their disease to be uncontrollable showed a high level of physical, social, and mental disability. A good sense of controlling the disease could be one of the essential factors in establishing positive life consequences. This point, however, is not strongly argued by the results of this study, so further research will be continued.
Third, the findings of improved close relationships indicate that cancer could be equally likely to increase or decrease a patient's relationships. Some people would be encouraged to have a closer relationship with the patient by knowing that he/she has cancer, but other people would be discouraged and leave him/her. Such results could indicate how difficult it was for people to accept the fact that their family member or friend had cancer. However, the relationships between patients and their families or friends could be one of the most important features of life that encourage patients to see their worlds more positively. The study of social support in ovarian cancer patients (Houck et al., 1999) also showed that “concern for family and friends” could decrease the patients' quality of life. Thus, the presence or absence of close relationships could be an important indicator of the experience of positive life changes.
Fourth, some participants suggested that the life of cancer patients who experience positive life changes could be considered as a better life than before having cancer. For example, some patients reported that they were in a more moral or healthier lifestyle than before cancer. This idea indicates that cancer could be a factor that encourages them to develop stronger morality or a healthier lifestyle than they ever had. In one sense, life following cancer would be recognized as not an extended life but a perfectly renewed life by some patients. Although it is difficult to produce empirical backups for that idea, cancer could be a strong watershed that could change the recognition of patients in many ways.
Fifth, the recognition of positive life changes seemed less related to the seriousness of disease because those with both curable and incurable cancer were equally likely to agree with such changes. Kreitler and his colleagues (1993) indicated that the life satisfaction of patients with a serious disease was not related to the domain of health. In other words, although patients were not satisfied with their health conditions, they could find other domains (e.g., economic state, social life) to maintain their life satisfaction at the same level as that of healthy individuals. Although the direct impact of cancer involves damages to health (e.g., physical disabilities), the patients could find their own advantages, which could explain the irrelevance between positive life changes and the seriousness of cancer.
This study has several limitations. First, the current study involved only a small number of participants. This number is insufficient to conduct any statistical tests. Additionally, the time spent on each interview was relatively short. This was because most interviews took place before the time of the support group meeting, so the researcher had to stop the interview when the group meeting was started. The researcher sometimes asked only quick questions or stopped the interview although she had more issues to discuss.
Second, a sampling bias exists. All the participants were the attendees of the same support group, which could greatly influence the ideas or attitude that patients had toward cancer. In particular, the support group aimed to change the negative outlook of the patients, so they might have more positive attitude toward cancer than those outside the group. In this sense, the findings of this study might not be generalized easily.
Future research may involve cancer patients from several conditions (e.g., hospital patients, patients in/outside the support group) to improve the generalizability of the findings. Although it is believed that interviewing is the best method to gain deeper understanding of the participants, quantitative studies would be a key to understanding the frequency of positive life changes.
ACKNOWLEDGMENTS
Gratitude is expressed to Dr. Jane Williams for making her cancer support group open to us and the cancer patients who voluntarily participated in this study. The authors are also grateful to Dr. Kei Hirai for his helpful comments on a previous version of this article.
