Psychological and clinical correlates of posttraumatic growth in cancer: A systematic and critical review.

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REVIEW
Psychological and clinical correlates of posttraumatic growth in
cancer: A systematic and critical review
Anna Casellas‐Grau
1
|Cristian Ochoa
1,2
|Chiara Ruini
3
1
Hospital Duran i Reynals. Avinguda de la
Gran Via, Institut Català d'Oncologia,
Barcelona, Spain
2
Facultat de Psicologia. Edifici Ponent –Planta
baixa, Universitat de Barcelona, Barcelona,
Spain
3
Department of Psychology, University of
Bologna, Bologna BO, Italy
Correspondence
Cristian Ochoa, Hospital Duran i Reynals.
Avinguda de la Gran Via, Institut Català
d'Oncologia, 199‐203. 08908 L'Hospitalet de
Llobregat, Barcelona, Spain.
Email: cochoa@iconcologia.net
Funding information
FEDER funds/ European Regional Develop-
ment Fund (ERDF) ‐A way to build Europe‐’’,
Grant/Award Number: Research group
2014SGR0635; Instituto de Salud Carlos III,
Grant/Award Number: FIS PI15/01278
Abstract
Objective: The objective of this study is to describe major findings on posttraumatic growth
(PTG) in cancer, by analyzing its various definitions, assessment tools, and examining its main
psychological and clinical correlates.
Methods: A search in relevant databases (PsycINFO, Pubmed, ProQuest, Scopus, and Web of
Science) was performed using descriptors related to the positive reactions in cancer. Articles were
screened by title, abstract, and full text.
Results: Seventy‐two met the inclusion criteria. Most articles (46%) focused on breast cancer,
used the PTG inventory (76%), and had a cross‐sectional design (68%). The PTG resulted inversely
associated with depressive and anxious symptoms and directly related to hope, optimism,
spirituality, and meaning. Illness‐related variables have been poorly investigated compared to
psychological ones. Articles found no relationship between cancer site, cancer surgery, cancer
recurrence, and PTG. Some correlations emerged with the elapsed time since diagnosis, type of
oncological treatment received, and cancer stage. Only few studies differentiated illness‐
related–life‐threatening stressors from other forms of trauma, and the potentially different
mechanisms connected with PTG outcome in cancer patients.
Conclusions: The evaluation of PTG in cancer patients is worthy, because it may promote a
better adaption to the illness. However, many investigations do not explicitly refer to the medical
nature of the trauma, and they may have not completely captured the full spectrum of positive
reactions in cancer patients. Future research should better investigate issues such as health
attitudes; the risks of future recurrences; and the type, quality, and efficacy of medical treatments
received and their influence on PTG in cancer patients.
KEYWORDS
assessment tool, benefit finding, cancer, oncology, posttraumatic growth, review
1|INTRODUCTION
Cancer has been considered a potentially traumatic event by the DSM‐
IV. Authors have begun to investigate cancer‐related posttraumatic
stress disorder (PTSD) symptoms and other adjustment issues, together
with possible positive consequences associated with the cancer diag-
nosis. The oncological illness could be perceived as traumatic because
the diagnosis itself has a seismic nature in patient's life and the course
of the illness activates a sense of vulnerability and mortality awareness
that are indeed the core characteristics of any traumatic events.
Tedeschi and Calhoun pioneered the study of possible positive
consequences deriving from traumatic events and suggested that the
shattering of basic assumptions in life and the awareness of own vul-
nerabilities could trigger a process of self‐maturation labeled as post-
traumatic growth (PTG). The PTG results out of a struggle in the
aftermath of a trauma, which generates a cognitive recognition of
improvements in individuals' personal strengths and spirituality, in their
relationships with others, and in the appreciation of their own life. The
Tedeschi and Calhoun
1
model has been the dominant one in trauma
research, and its related assessment tool has been used to evaluate
the coexistance of PTG and PTSD in trauma survivors. Recent meta‐
analyses on this issue
2
described an inverted U shape relationship
between PTG and PTSD, where a balanced level of distress may trigger
PTG, but at greater PTSD severity, PTG decreases. This pattern
Received: 4 June 2016 Revised: 13 February 2017 Accepted: 15 March 2017
DOI: 10.1002/pon.4426
Psycho‐Oncology. 2017;26:2007–2018. Copyright © 2017 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/pon 2007

characterized most of traumatized population, with the exception of
survivors of medical illnesses, where this quadratic association was
weak.
2
This finding introduces the question whether PTG might be
the best model to capture positive reactions following medical‐related
trauma, and their beneficial consequences in mental health.
However, other definitions have been suggested to identify such
positive responses, but they seem to present some relevant conceptual
differences that need to be taken into account.
The concept of positive psychological changes was used to
describe benefits reported by traumatized individuals who feel that
they can communicate more openly with others, can experience fewer
fears, are less preoccupied with life's difficulties, and rearrange their
life priorities. Another widely used construct is benefit finding (BF),
referring to the short‐term benefits obtained from the adverse experi-
ence. The BF, in fact, is more prone to emerge just in the close after-
math of an adversity, while PTG tends to appear after a certain
amount of time since trauma.
A distinction should also be done between meaning making and
PTG. The first is a way of changing individuals' view of life to integrate
what has happened and to give the event an existential value in the
persons' life framework. Therefore, meaning refers to the process of
understanding how the event fits in ones' life.
Similarly, the concept of sense of coherence underlines the
importance of making sense for adverse life circumstances, and it
incorporates 3 features: manageability, comprehensibility, and
meaningfulness of the event. The concept of resilience is defined with
similar terms, and underlined that it refers to the capability of maintain-
ing stable levels of psychological functioning when being exposed to a
potentially stressful event, especially when it lasts for a long period, as
the case of chronic illnesses and cancer. Finally, thriving has also been
used as a synonym of PTG, but psychological thriving results from a
continued growth and gains in one or more important psychosocial
areas, like personal relationships, self‐confidence, and life skills. Thus,
it would be something more than PTG, being the result of growth
and an increased well‐being (WB).
In sum, substantial differences have been found among the defini-
tions of positive constructs that emerge out of a potentially adverse
event. Accordingly, several measurement tools have been developed
and used interchangeably to assess the diverse positive reactions to
trauma, as indicated in Table S1.
Moreover, when it comes to illness‐related trauma, there is no
clear consensus regarding the specific clinical characteristics that
define these positive reactions, and their beneficial consequences, in
physical and mental health. The PTG and its related concepts, in fact,
derived from psychological trauma research, and not from psychoso-
matic or medical fields of investigation. These considerations may be
particularly relevant for psycho‐oncology for 2 main reasons. First,
cancer is the preferred life‐threatening medical condition that has been
studied in growth, meaning, and spirituality, up to date. Secondly, psy-
cho‐oncology entails the consideration of psychological and medical
variables associated with the illness. Thus, psycho‐oncology would
require a careful examination of possible positive reactions to the ill-
ness, considering both psychological and clinical correlates.
Hence, the main aim of this systematic and critical review of the
existing literature is to analyze the findings obtained for clinical and
psychological correlates of PTG in cancer. We chose to give priority
to the model proposed by Tedeschi and Calhoun (PTG) for many rea-
sons. First of all, it is the prevailing one in current trauma research.
Nevertheless, the question whether it might be the best model to cap-
ture positive reactions in medical trauma remains unanswered.
2
More-
over, the model of PTG encompasses various components (ie, spiritual,
cognitive, and interpersonal). Thus, among the various models
described above, PTG inventory may be the most appropriate to cap-
ture a wider range of positive responses following a cancer illness,
for interpersonal, psychological, and spiritual changes. However, we
included other similar concepts and assessment tools to be as much
inclusive as possible in identifying the psychological and clinical corre-
lates of PTG in cancer.
2|METHODS
2.1 |Literature search strategy
Electronic literature searches were performed using Medline,
PsycINFO, Web of Science, Scopus, and Proquest Psychology Journals
databases using relevant review terms: posttraumatic growth,benefit
finding,personal growth,positive psychological changes,stress‐related
growth,positive posttrauma outcomes,positive posttrauma life changes,
meaning*,sense of coherence,adversial growth,thriving,positive reap-
praisal,resilience combined with cancer and with assessment,tool,inven-
tory,measure,questionnaire, excluding review,metaanalysis, and case
report. There was no restriction on the year of publication. Search
was performed using subject headings, keywords, titles, and abstracts
(up to October 2016). The PRISMA criteria were followed.
2.2 |Study selection criteria
The following selection criteria were applied on the articles found in
databases:
Type of studies
Published primary studies were eligible for inclusion; reviews, edi-
torials, letters, and case reports were excluded. No limitations regard-
ing study designs were used. Language of the articles included was
English. Articles that validated assessment tools were also considered,
as could include cancer patients.
Type of participants
We included only studies where the participation of cancer patients
or survivors was clearly specified in the title, the abstract, or keywords.
There were no restrictions regarding the age or the number of partici-
pants, neither the stage of their disease. We also included articles with
samples composed by cancer patients and other chronic diseases.
Posttraumatic growth‐related constructs
We selected the articles when the assessment of PTG and the
related constructs was specified in title, in the abstract, or in the
2008 CASELLAS‐GRAU ET AL.

keywords, including BF, personal growth, meaning, positive psycholog-
ical changes, stress‐related growth, positive posttrauma outcomes,
positive posttrauma life changes, sense of coherence, adversarial
growth, thriving, positive reappraisal, and resilience. Those articles that
clearly did not refer to PTG, but only to other terms were excluded
after the full‐text screening. Articles not reporting medical and psycho-
logical/psychiatric data were excluded.
2.3 |Review methods
The abstracts of the identified records were screened for relevance.
Articles were rejected if they failed to meet the selection criteria.
When an abstract could not be rejected with certainty, the full article
was appraised. A review template was developed specifying key
details for each study (see Table S1). Details were extracted by one
reviewer, and results were commented with the other reviewers.
Discrepancies were resolved by consensus. The methodological
quality of the studies was appraised using specific tools for quantitative,
3
mixed‐method,
4
and qualitative
5
designs (see Table S1). No studies
were rejected from the final analysis for low methodological quality
(see Table S1).
3|RESULTS
After removing duplicates, 2205 articles were screened by title from 5
databases. Articles were excluded if (1) did not assess PTG‐related
terms; (2) were not focused on patients or survivors of cancer (eg, they
were focused on careers or family members); (3) were not empirical
articles; (4) were not in English; and (5) were not focused on cancer dis-
ease, or did not include participants with a cancer illness, as illustrated
in Figure 1. The final articles included by full text in this review were 72
and are reported in Table S1. In this table, articles are grouped accord-
ing to the label(s) and tool(s) used when referring to PTG, beginning
with PTG alone, and adding subsequent labels and tools. Categories
“a”to “d”collect articles focused on PTG that assessed it with the
Tedeschi and Calhoun PTGI; with PTGI plus other questionnaires or
qualitative methods; or that assessed PTG with tools other than PTGI,
respectively. Categories “e”and “f”collect articles generically referring
to growth, or personal growth, which was measured with PTGI or
other tools, respectively. Categories “g”and “h”group articles referring
to BF, which was assessed it with the benefit finding scale (BFS), or
with tools other than BFS. Finally, categories “i‐j‐k”group articles
focused on meaning and assessed it with meaning in life scale (MiLS),
with the PTGI, or with tools other than MiLS, respectively. In each of
these groups, articles are alphabetically ordered.
The subsequent tables (Tables 1 and 2) present a subanalysis that
shows in detail the outcome found among studies concerning illness‐
related characteristics (Table 1). the relationships between PTG and
psychological aspects, including psychiatric conditions and other
positive dimensions such as optimism, hope, or meaning (Table 2).
Of the 72 articles reviewed, 46% were addressed to breast cancer
only, and 39% included samples of patients with various cancer diag-
noses. The remaining articles included samples with only colorectal
cancer, others with head/neck cancer, prostate or testicular cancer,
and leukemia.
Most studies (68%) had a cross‐sectional design, while the remain-
ing 32% used a longitudinal design. In addition, most articles assessed
PTG in a specific moment of the illness, and/or confronted cancer
patients' PTG to those of healthy controls, of siblings, or of other type
of traumatic event survivors.
3.1 |Instruments for assessing positive reactions in
cancer
Most investigations (76%) adopted the model of Tedeschi and
Calhoun
1
for analyzing the positive psychological changes occurring
in the aftermath of cancer. Most of the articles that relied on this
model assessed it using the PTG inventory (PTGI) assessment tool,
alone or together with other similar tools. Further, as displayed in
Table S1, some articles referred to the Tedeschi and Calhoun definition
FIGURE 1 Articles search process
CASELLAS‐GRAU ET AL.2009

TABLE 1 Illness characteristics related or not to PTG
Reference Tool/label
Type of relationship between
the illness characteristic
and PTG
Cancer site Widows et al
6
PTG –PTGI 0
Silva et al
7
PTG –PTGI 0
Cormio et al
8
PTG –PTGI 0
Yi and Kim
9
PTG –PTGI 0
Park et al
10
Personal growth (PG) –Perceived
benefits scale (PBS)
0
Cancer stage Widows et al
6
PTG –PTGI 0
Cordova et al
11
PTG‐PTGI 0
Salsman et al
12
PTG –PTGI 0
Wang et al
13
PTG –PTGI 0
Danhauer et al
14
PTG –PTGI 0
Jones et al
15
Positive changes –medical
expenditure panel survey (MEPS)
0
Bellizzi and Blank
16
PTG –PTGI +
Mols et al
17
PTG –PTGI; benefit finding (BF) –
Impact of event scale (IES)
+
Bellizzi et al
18
PTG –PTGI +
Jansen et al
19
PTG –PTGI; BF –benefit finding
scale (BFS)
+
Cancer surgery Bellizzi and Blank
16
PTG –PTGI 0
Ransom et al
20
PTG –PTGI 0
Brunet et al
21
PTG –PTGI 0
Cohen and Numa
22
PTG –PTGI 0
Silva et al
7
PTG –PTGI 0
Wang et al
13
PTG –PTGI 0
Jones et al
15
Positive changes –MEPS 0
Cancer treatment Widows et al
6
PTG –PTGI 0
Mystakidou et al
23
PTG –PTGI 0
Ransom et al
20
PTG –PTGI 0
Salsman et al
12
PTG –PTGI 0
Brunet et al
21
PTG –PTGI 0
Tallman et al
24
Anticipated PTG –PTGI 0
Silva et al
7
PTG –PTGI 0
Turner‐Sack et al
25
PTG –PTGI 0
Cormio et al
8
PTG –PTGI 0
Wang et al
13
PTG –PTGI 0
Lelorain et al
26
PTG –PTGI + chemotherapy –PTG
Hefferon et al
27
PTG –Qualitative methods + chemotherapy –PTG
Jansen et al
19
PTG –PTGI; BF –BFS + chemotherapy –PTG
Danhauer et al
14
PTG –PTGI + chemotherapy –PTG
Rahmani et al
28
PTG –PTGI + radiotherapy –PTG
Mols et al
17
PTG –PTGI; BF –IES ‐radiotherapy –PTG
Time since diagnosis Weiss
29
PTG –PTGI; BF–ad hoc
questionnaire
−
Yi and Kim
9
PTG –PTGI −
Gianinazzi et al
30
PTG –PTGI −
Gunst et al
31
PTG –PTGI −
Sears et al
32
PTG –PTGI; BF –Qualitative
methods
+
Manne et al
33
PTG –PTGI +
Jansen et al
19
PTG –PTGI +
(Continues)
2010 CASELLAS‐GRAU ET AL.

of PTG, but used different tools to assess it, such as the silver lining
questionnaire, the perceived benefits scales, or qualitative methods.
Similarly, BF was assessed with the BFS, and also with PTGI and other
instruments, such as Stress‐Related Growth Scale, positive contributions
scale or qualitative methods (categories gand hin Table S1). Thus,
these articles present a certain degree of disagreement in their
methodologies. Poor concordance between the main focus of research
and the methodology used may represent a risk of outcome bias in the
investigations.
Consequently, the results among these investigations were not
always concordant, especially concerning the correlations between
PTG levels and medical or psychiatric characteristics of cancer patients
(see Tables 1 and 2).
3.2 |PTG and illness‐related characteristics
The articles reporting relationships between clinical data and PTG are
38, but only 18 were explicitly looking for these relationships. Among
these, different areas were explored, including characteristics related
to the type of cancer, the type of treatment received, and also the time
elapsed since the traumatic experience. In general, illness‐related
characteristics were poorly related to PTG (see Table 1). Articles found
no relationship between cancer site, cancer surgery, cancer recurrence,
and PTG. Other investigated variables are the elapsed time since
diagnosis, type of oncological treatment received, and cancer stage.
They all presented inconsistent findings:
3.2.1 |Time since diagnosis and treatment
Nearly all the 6 articles that analyzed the relationship between time
since treatment and PTG found no relationship, except for two.
20,41
Barakat et al
41
used a different assessment tool rather than PTGI and
found an inverse relationship between these two variables. Ransom
et al
20
assessed the modification of PTG before and after radiotherapy
in breast and prostate cancer patients and found a direct relationship
between time since treatment and PTG. Another similar variable is
time since diagnosis; and either no relationship or a direct relationship
between this variable and PTG emerged (see Table 1). Thus, elapsed
time since diagnosis and treatment seems to be unrelated to the
occurrence of PTG. However, the definition of PTG itself highlights
the importance of time for the development of PTG. Therefore, as
most of the articles studying this aspect used the PTGI, this questionnaire
might lack of sensitivity in analyzing thepassing of time and the emerging
of PTG in oncological patients.
TABLE 1 (Continued)
Reference Tool/label
Type of relationship between
the illness characteristic
and PTG
Tallman et al
24
Anticipated PTG –PTGI +
Danhauer et al
34
PTG –PTGI +
Pat‐Horenczyk et al
35
PTG –PTGI +
Aflakseir et al
36
PTG –PTGI +
Bellizzi and Blank
16
PTG –PTGI 0
Mystakidou et al
23
PTG –PTGI 0
Olden
37
PTG –PTGI; BF –BFS 0
Salsman et al
12
PTG –PTGI 0
Brunet et al
21
PTG –PTGI 0
Lelorain et al
26
PTG –PTGI 0
Bellizzi et al
18
PTG –PTGI 0
Morris et al
38
PTG –PTGI 0
Silva et al
39
PTG –PTGI 0
Turner‐Sack et al
25
PTG –PTGI 0
Cormio et al
8
PTG –PTGI 0
Jones et al
15
Positive changes –MEPS 0
Time since treatment Widows et al
6
PTG –PTGI 0
Andrykowski et al
40
Growth –PTGI 0
Brunet et al
21
PTG –PTGI 0
Turner‐Sack et al
25
PTG –PTGI 0
Barakat et al
41
PTG –ITSIS −
Ransom et al
20
PTG –PTGI +
Recurrence Olden
37
PTG –PTGI; BF –BFS 0
Yi and Kim
9
PTG –PTGI 0
Gunst et al
31
PTG –PTGI 0
The “0”means no statistically significant relationship; “+”means direct and statistically significant relationship; and “−”means inverse and statistically
significant relationship.
CASELLAS‐GRAU ET AL.2011

TABLE 2 Psychiatric and positive dimensions related or not to PTG
Reference Tool/Label
Type of relationship between
psychiatric/positive
dimensions and PTG
Anxiety Abdullah et al
42
PTG –PTGI 0
Jaarsma et al
43
PTG –PTGI 0
Mystakidou et al
44
PTG –PTGI 0
Schroevers et al
45
PTG –PTGI 0
Salsman et al
12
PTG‐PTGI 0
Gunst et al
31
PTG –PTGI 0
Jansen et al
19
PTG –PTGI 0
Canavarro et al
46
PTG –PTGI −
Wang et al
13
PTG –PTGI −
PTSS/PTSD/stress Widows et al
6
PTG –PTGI 0
Salsman et al
12
PTG –PTGI 0
Nenova et al
47
PTG –PTGI 0
Gunst et al
31
PTG –PTGI 0
Tillery et al
48
PTG –BFS 0
Sears et al
32
PTG –PTGI; BF –Qualitative methods +
Barakat et al
41
PTG –Impact of traumatic stressors
interview schedule
+
Mystakidou et al
23
PG/PTG –PTGI +
Morrill et al
49
PTG –PTGI +
Mcdonough et al
50
PTG –PTGI +
Yi and Kim
9
PTG –PTGI +
Distress Schroevers et al
45
PTG –PTGI 0
Rand et al
51
PTG –PTGI 0
Widows et al
6
PTG –PTGI −
Ruini and Vescovelli
52
PTG –PTGI −
Liu et al
53
PTG –PTGI −
Gunst et al
31
PTG –PTGI −
Jansen et al
19
PTG –PTGI −
Concerns about
life/disease/negative
intrusions
Widows et al
6
PTG –PTGI 0
Salsman et al
12
PTG –PTGI 0
Park et al
54
PTG –BFS −
Depression Morrill et al
49
PTG –PTGI PG –personal growth
initiative scale (PGIS)
−
Olden
37
PTG –PTGI −
Morrill
55
PTG –PTGI and PGIS −
Abdullah et al
42
PTG –PTGI 0
Schroevers et al
45
PTG –PTGI 0
Salsman et al
12
PTG –PTGI 0
Moore et al
56
PTG –PTGI 0
Wang et al
13
PTG –PTGI 0
Danhauer et al
14
PTG –PTGI +
Meaning Bower et al
57
Positive meaning/growth –PTGI +
Costa and Pakenham
58
BF –The stress‐related growth scale
(SRGS) and PTGI.
+ (BF as a pathway to achieve meaning)
Jim et al
59
Meaning in life –Meaning in life
scale (MiLS).
+ (PTG is included into meaning)
Jim and Andersen
60
Meaning in life –MiLS + (PTG is included into meaning)
Fleer et al
61
PTG –SRGS –; meaning in life –the life
regard index
Expressive writing enhanced both
PTG/BF and meaning
(Continues)
2012 CASELLAS‐GRAU ET AL.

TABLE 2 (Continued)
Reference Tool/Label
Type of relationship between
psychiatric/positive
dimensions and PTG
Labelle et al
62
PTG –PTGI Both meaning and PTG can be
increased using mindfulness skills
Park et al
10
Growth –PBS +
Park et al
54
PTG –PTGI Both meaning and PTG were
related to better WB
Ruini et al
63
PTG –PTGI Both meaning and PTG directly
related to gratitude
Svetina and Nastran
64
PTG –PTGI + (Meaning as a part of PTG)
Lethborg et al
65
PTG –PTGI 0 between
Manne et al
33
PTG –PTGI 0
Sherman et al
66
Global and illness‐related meaning –
Sense of coherence scale
0
Yanez et al
67
Cancer‐related growth ‐PTGI 0 related growth
Bower et al
57
Meaning –ad hoc positive meaning
scale and PTGI.
Consider PTG and meaning as synonyms
Fleer et al
61
Meaning –life regard index, and two
qualitative questions
Consider PTG and meaning as synonyms
Heinrichs et al
68
PTG/BF/meaning –PTGI Consider PTG and meaning as synonyms
Penedo et al
69
BF/PTG/meaning –positive
contributions scale
Consider PTG and meaning as synonyms.
Wang et al
70
BF/personal growth/PTG/meaning –BFS Consider PTG and meaning as synonyms
Optimism Bellizzi and Blank
16
PTG –PTGI 0
Bellizzi et al
18
PTG –PTGI 0
Sears et al
32
PTG –PTGI; BF –Qualitative question; 0
Bözo et al
71
PTG –PTGI +
Olden
37
PTG –PTGI +
Moore et al
56
PTG –PTGI +
Turner‐Sack et al
25
PTG –PTGI Pessimistics had greater PTG
Positive effect Jaarsma et al
43
PTG –PTGI 0
Schroevers et al
45
PTG –PTGI 0
Salsman et al
12
PTG –PTGI 0
Lelorain et al
72
PTG –Qualitative methods +
Park et al
54
PTG –BFS +
Yu et al
73
PTG –PTGI +
QoL/HRQoL Bellizzi et al
18
PTG –PTGI + Between PTG and mental HRQoL
Morrill
55
PTG –PTGI; PG –PGIS +
Lelorain et al
26
PTG –PTGI +
Zebrack
74
PG –Impact of cancer scale 0
Jansen et al
19
PTG –PTGI; BF –BFS 0
Moore et al
56
PTG –PTGI 0
Hope Sears et al
32
PTG –PTGI; BF –Qualitative question; 0
Bellizzi and Blank
16
PTG –PTGI 0
Yuen et al
75
PTG –PTGI +
Spiritual WB Olden
37
PTG –PTGI; BF‐BFS +
Lelorain et al
26
PTG –PTGI +
Danhauer et al
76
PTG –PTGI +
Psychological WB Ruini and Vescovelli
52
PTG –PTGI +
Happiness Lelorain et al
26
PTG –PTGI +
Gratitude Ruini et al
63
PTG –PTGI +
The “0”means no statistically significant relationship; “+”means direct and statistically significant relationship; and “−”means inverse and statistically signif-
icant relationship.
CASELLAS‐GRAU ET AL.2013

3.2.2 |Oncological treatment
Regarding the type of oncological treatment received, some discrepan-
cies were found. Most articles (10 of 16) reported no relationship
between this variable and PTG. The remaining ones found a direct rela-
tionship between undergoing chemotherapy and PTG compared to no
chemotherapy, radiotherapy, or their combination, respectfully.
19,26,27
Regarding radiotherapy, one study (which used the Persian version of
PTGI) found a direct relationship between PTG and this treatment ver-
sus chemotherapy or surgery
28
; while another one found an inverse
relationship as compared to surgery.
17
3.2.3 |Cancer stage
Concerning cancer stage, results were also equally divided. Six of 10
articles reported no association; the remaining 40% documented a
direct relationship. These discrepancies appear to be particularly rele-
vant and basically independent from the assessment tool used. Only
few authors
10,54,77
actually stressed out the importance of differentiat-
ing illness‐related, life‐threatening stressors from other forms of
trauma, and the potentially different mechanisms connected with
PTG outcome.
3.3 |PTG and psychiatric conditions
Twenty‐six articles investigated this issue. Ten of them did specifically
focus on the relationship between PTG and psychiatric conditions such
as anxiety, depression, or stress, between others (see Table 2). The
remaining articles were focused on the evaluation of positive function-
ing and, in addition, assessed psychiatric symptoms in cancer patients.
3.3.1 |Anxiety and depression
Most articles (18 of 26) evaluated the levels of anxiety and depression,
and 11 of 18 studies found no relationship with PTG (see Table 2). Only
two
13,46
reported an inverse relationship between anxiety symptoms
and PTG. In the case of depression, 4 of 9 articles found an inverse
relationship between this variable and PTG.
31,37,49,55
However, 2 of
3 articles
49,55
used the personal growth initiative scale rather than
PTGI. The third
37
assessed PTG in cancer patients in a palliative care
setting. The last one
31
used the PTGI in German long‐term survivors
of adolescent cancer. Finally, Danhauer et al
14
found a direct relation-
ship between depressive symptoms and PTG, suggesting that the more
depressive symptoms, the more reflexive the women became and thus
the more PTG emerged. Therefore, the heterogeneity in the assess-
ment methodology could explain such inconsistent findings.
3.3.2 |Posttraumatic stress disorder, distress, negative
rumination
The relationship between PTSD or posttraumatic stress symptoms
(PTSS) and later PTG development in cancer was investigated by 11
studies. No consensus on the results was found: 5 articles
6,12,31,47,48
showing no relationship; and the remaining 6 reporting a direct rela-
tionship. None of these studies reported data on the quadratic rela-
tionship between PTG and PTSD; rather, they focused on the linear
one.
2
Higher consensus was observed regarding distress and PTG: 2
of 6 articles found no relationship between these variables,
51,78
while
another found an inverse relationship. Finally, negative rumination
was studied by only 3 articles: two of them found no relationship with
PTG,
6,12
while the third
54
found an inverse relationship. However, the
assessment of PTG was done using the BFS in this last article.
Also for psychiatric variables associated with PTG, findings seem
to be inconclusive because of heterogeneity in assessing methods.
Thus, correlations between psychiatric conditions and PTG need to
be more accurately investigated in future research with cancer
patients.
3.4 |PTG and other positive constructs
We evaluated the relationship between PTG and other positive con-
structs such as meaning, optimism, WB, hope, and gratitude, between
others (seeTable 2). These were analyzed by 35 articles, nearly the half
(N = 16) of them being explicitly focused on studying these relationships.
Articles documented a direct relationship between PTG and these posi-
tive constructs in oncological patients. However, spiritual and psycho-
logical WB, gratitude, and happiness were studied only in few articles
compared to meaning, optimism, hope, and positive effect. Specifically,
when considering optimism, the results were discrepant, because half
of the articles documented a direct relationship, the remaining ones
found no relationship, and one article found pessimists to display greater
PTG.
25
The same pattern of relationship was also observable for PTG
and positive effect; PTG and quality of life; and PTG and hope.
The area where more consensus emerged was the one concerning
meaning, which was often linked with PTG, positive reappraisal, or
other positive coping styles. Thus, according to the literature exam-
ined, meaning‐making process seems to be a direct path leading to
PTG.
10,54,58‐60,62‐64
Different from other positive dimensions (such
as optimism, hope, and positive effect), existential dimensions in indi-
viduals life (such as meaning and meaning‐making processes) seem to
be more consistently linked to PTG in cancer patients. Accordingly,
when PTG was measured together with, or by using instruments eval-
uating meaning, it seems that more converging areas of positive
changes in dealing with cancer have been detected. Hence, findings
examined in this review tend to be more concordant and conclusive.
4|DISCUSSION
The present review was aimed at analyzing the clinical and psycholog-
ical correlates of PTG in patients diagnosed and treated for oncological
illness. An evaluation of the measurement tools used to assess this
construct and the concordance with their theoretical definition was
also performed.
The limitations of this review of the literature concern the hetero-
geneity of the populations included (different cancer types, stages, age
of participants, etc), the selection of articles written only in English
available as full text, and the inclusion of various psychometric instru-
ments. Considering that PTG research is rapidly growing, we may have
omitted in press or more recent investigations, where full text was not
available, yet.
A total of 72 relevant articles were analyzed. Most of them
included breast cancer patients, referred to the Tedeschi and Calhoun
1
2014 CASELLAS‐GRAU ET AL.

definition of PTG, and used the PTG inventory as the main assessment
tool, alone or in combination with other scales (see Table S1).
Interestingly, most of the 72 articles were published in multidis-
ciplinary or psychological databases/journals (see Figure 1). This
observation may suggest that PTG is particularly investigated by clin-
ical psychologists and less explored in medical journals. The articles
found in medical databases mostly reported stress and other related
physical reactions during cancer, not providing a specific emphasis
on PTG. This observation may have clinical implications, because
researchers, nurses, and physicians working in oncological settings
may not be sufficiently aware of the possible positive psychological
reactions to the illness experienced by their patients. Further, the dis-
tribution of publications in this review on PTG and its clinical corre-
lates suggest that psychosocial concomitants of cancer still remain
confined to humanistic and social sciences, without fully embracing
the medical ones.
A second observation concerns researchers and clinicians have
evaluated phenomena as PTG, BF, meaning, personal growth, thriving,
resilience, and others and subsumed them under the broad umbrella of
positive reactions to the illness. As a result, research is still inconclusive
in identifying clinical predictors, correlates, and mediators of PTG in
this domain as highlighted by Table S1, Tables 1 and 2.
By a methodological viewpoint, the use of one or another assess-
ment tool when measuring PTG can lead to diverse results. Although
most articles clearly refer to the Tesdeschi and Calhoun
1
definition in
their abstracts and introductions, sometimes researchers used another
assessment tool. For example, Barakat et al
41
assessed PTG using an
interview with dicotomic and Likert scales not on the basis of the
Tedeschi and Calhoun's definition of PTG, which encompasses 5 spe-
cific domains. Other articles, like the one by Rand et al
51
used an oppo-
site approach: they were aimed at assessing positive psychological
responses using the Tedeschi and Calhoun PTG inventory, but not on
the basis of their model. Yanez et al
67
and Park et al
54
were aimed at
assessing the cancer‐related growth and PTG, respectively, but then
used the BFS (Table S1). The choice of one or another questionnaire
might have conditioned the emergence of specific variables that better
fitted with the tool itself. Indeed, these investigations yield a relevant
risk of outcome bias.
Further, the discrepancies between PTG definition and the assess-
ment tool(s) used are not the only emerging problems, but the defini-
tion of PTG itself in cancer should be also examined. Specifically,
while most articles distinguished PTG from other constructs, some
others did not. For example, some authors considered PTG and BF as
synonyms (eg, Rahmani et al
28
; Labelle et al
62
), and they used the PTGI,
the BFS, or the Stress‐Related Growth Scale. In other articles, authors
did not distinguish among PTG, BF, and meaning (eg, Bower et al
57
;
Heinrichs et al
68
) and used the PTGI to assess all of them. Again, the
risk of outcome bias is present also in these cases.
Very few articles, however, were aimed at providing a specific
definition of positive psychological reactions following a cancer
illness
21,27,41,43,74
and their peculiar characteristics. Rather, it seems
that researchers and clinicians applied the constructs of PTG, BF, resil-
ience or thriving, which originally derived from research on war, natural
disasters or other type of trauma, to the cancer settings. This may have
contributed to generate confusing and often inconsistent findings,
which do not provide full and valid descriptions of positive reactions
triggered by an oncological illness.
A notable exception among these confusing results may be repre-
sented by investigations focused on meaning and its association with
PTG. As described in the introduction, although distinguishable, these
two concepts share commonalities and similar pathways in identifying
positive trajectories following cancer. For instance, according to Park
et al,
10
growth could be considered a final outcome of meaning‐making
process and a direct ingredient in restoring life meaning (Table 2).
These robust overlaps between meaning and growth were docu-
mented by other articles examined in this review (Table 2). some arti-
cles considered PTG and meaning as synonyms
57,61,68‐70
or one
being a pathway to reach another.
58‐60
Thus, when considering the
various proposed definitions of positive reactions following cancer,
the two that basically displayed more commonalities and less discrep-
ant results across investigations are the Tedeschi and Calhoun PTG and
meaning models (Table 2). However, the model of meaning was poorly
investigated in association with cancer clinical correlates, where most
the studies used PTGI or BF (see Table 1).
According to traditional psychosomatic and psycho‐oncology
approach, illness‐related variables should have an influence on
patients' psychological reactions and adaptation to the medical condi-
tion. Nevertheless, in case of cancer and PTG, the only clinical variable
displaying some correlations seems to be time since diagnosis/treat-
ment. According to the Tedeschi and Calhoun definition, PTG needs
time to appear in the aftermath of a traumatic event. Thus, a positive
correlation should have emerged, but some of our findings do not pro-
vide confirmation of this statement, even when the PTGI was used (see
Table 2). Further, the authors state that the intensity and severity of
the stress should be directly related to PTG. However, most of the
investigations documented no significant relationship between sever-
ity of illness, stage, and type of treatment received.
The same discrepancies were also documented in the relationship
with psychiatric conditions where, for example, PTG was inversely or
not related to depression, to negative intrusions and worries, to dis-
tress, and to anxiety (Table 2). The PTSD or PTSS was the only psychi-
atric conditions that displayed a direct relationship with PTG in cancer
populations. However, confirming Shakespeare‐Finch meta‐analyses,
2
the inverted U shape pattern of relationship between PTG and PTSD
is not reported in these investigations, because authors did not usually
evaluate quadratic correlations between PTG and PTSD.
More homogeneous results were found when evaluating the rela-
tionships between PTG and other positive psychological resources,
such as spiritual and psychological WB, happiness, and gratitude. How-
ever, other positive domains, such as hope, optimism, quality of life,
and positive effect, displayed a controversial pattern of correlations
among investigations involving cancer patients (Table 2). These find-
ings confirm the Tedeschi and Calhoun definition of PTG, which
encompasses the presence of positivity and distress at the same time.
In cancer settings, however, this phenomenon seems to be more com-
plex and mediated by other variables, such as type of clinical popula-
tions, and assessment tools used.
We suggest that a possible explanation for the discrepancies
found in this review relies on that the Tedeschi and Calhoun model
of PTG was originally conceptualized as a description of positive
CASELLAS‐GRAU ET AL.2015

changes after traumatic events, not necessarily considering their med-
ical nature. Edmondson
79
suggested to differentiate the nature and
characteristics of PTSD when it is triggered by life‐threatening ill-
nesses, as opposed to other type of trauma. The author proposed the
Enduring Somatic Threat model of PTSD due to acute life‐threatening
medical events, which underlines the differences in symptom manifes-
tations when due to acute manifestations of chronic and severe dis-
ease that are enduring/internal in nature. In cancer, the illness
experience has a nuanced onset (it often begins with routine‐screening
examinations); it continues through cancer diagnosis and treatments
(that may be long‐lasting and invasive), and it goes on for many years
with the fear of future recurrences. However, the specificities of the
medical nature of the trauma are not assessed by the 21 items of
the PTGI.
5|CONCLUSIONS
The Tedeschi and Calhoun PTG is the most used model to describe
positive psychological changes following a cancer illness. The PTG
resulted inversely associated with depressive and anxious symptoms
and directly related to hope, optimism, spirituality, and meaning. Thus,
it seems worthy to evaluate and promote PTG in cancer patients for
better adaption to the illness.
However, PTG entails a direct relationship with PTSD and PTSS
symptoms in cancer, which do not confirm the quadratic correlations
emerging in other traumatic events.
5
Future research is needed to
solve these inconsistent findings.
Cancer‐related variables resulted scarcely and inconsistently asso-
ciated with PTG, probably because the PTGI does not explicitly refer to
the medical nature of trauma. Thus, the Tedeschi and Calhoun model
may not be completely adequate to capture the full spectrum of posi-
tive reactions in cancer.
Future research could benefit from the inclusion of the Enduring
Somatic Threat model toward the development of PTG, as opposed
to PTSD. Similarly, the inclusion of a questionnaire measuring the fear
of cancer recurrences could shed new lights on the development of
PTG, according to the illness characteristics and individual psychologi-
cal reactions.
In the medical context, a complexity of issues may influence the
manifestation of PTG, which current research has often neglected. This
critical review documents that more detailed and extended research is
needed to describe the full spectrum of positive psychological changes
from cancer experience and their time trajectories.
ACKNOWLEDGEMENTS
This work is supported by the Instituto de Salud Carlos III (FIS PI15/
01278), FEDER funds/European Regional Development Fund “A way
to build Europe”, and the Grup de recerca en serveis sanitaris en càncer
(2014SGR0635).
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How to cite this article: Casellas‐Grau A, Ochoa C, Ruini C.
Psychological and clinical correlates of posttraumatic growth
in cancer: A systematic and critical review. Psycho‐Oncology.
2017;26:2007–2018. https://doi.org/10.1002/pon.4426
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