Promoting adjustment after treatment for cancer
The transition from the period of diagnosis and medical treatment of cancer to survivorship (i.e., the reentry phase) is an understudied phase in the cancer trajectory. The objectives of this report were 1) to illustrate several adaptive tasks of the reentry phase, 2) to provide examples of research on factors that predict positive adjustment during this phase, and 3) to discuss interventions that address the adaptive tasks of early cancer survivorship. Although the pertinent empirical literature is scarce, accounts from cancer survivors, healthcare professionals, and qualitative researchers converge to suggest several themes in adaptive tasks during reentry. Drawing from the authors' work and that of others, the authors have described common expectancies held by many individuals approaching reentry (e.g., "I shouldn't need support"), typical concerns during this phase (e.g., concern over cancer recurrence), and personal and contextual factors that can facilitate and hinder adjustment. Promising psychosocial interventions have been developed for individuals in the reentry period. Continued research will be necessary to characterize this important phase of cancer survivorship.
Cancer Survivorship: Resilience Across the Lifespan
Supplement to Cancer
Promoting Adjustment after Treatment for Cancer
Annette L. Stanton,
Patricia A. Ganz,
Julia H. Rowland,
Beth E. Meyerowitz,
Janice L. Krupnick,
Sharon R. Sears,
Department of Psychology, University of Califor
nia–Los Angeles, Los Angeles, California.
Division of Cancer Prevention and Control Re
search, School of Public Health and Jonsson Com-
prehensive Cancer Center, University of California–
Los Angeles, Los Angeles, California.
Ofﬁce of Cancer Survivorship, National Cancer
Institute, Bethesda, Maryland.
Department of Psychology, University of South
ern California, Los Angeles, California.
Department of Psychiatry, Georgetown University
Medical Center, Washington, DC.
Psychology Service, Veteran’s Administration
Palo Alto Health Care System, Palo Alto, California.
Presented at Cancer Survivorship: Resilience
Across the Lifespan, Washington, DC, June 2– 4,
Supported in part by Grant R01 CA63028 from the
National Cancer Institute, Bethesda, MD.
Address for reprints: Annette L. Stanton, Ph.D.,
Department of Psychology, 1285 Franz Hall, Box
951563, University of California, Los Angeles, Los
Angeles, CA 90095-1563; Fax: (310) 206-3566;
Received February 28, 2005; accepted May 4,
The transition from the period of diagnosis and medical treatment of cancer to
survivorship (i.e., the reentry phase) is an understudied phase in the cancer
trajectory. The objectives of this report were 1) to illustrate several adaptive tasks
of the reentry phase, 2) to provide examples of research on factors that predict
positive adjustment during this phase, and 3) to discuss interventions that address
the adaptive tasks of early cancer survivorship. Although the pertinent empirical
literature is scarce, accounts from cancer survivors, healthcare professionals, and
qualitative researchers converge to suggest several themes in adaptive tasks during
reentry. Drawing from the authors’ work and that of others, the authors have
described common expectancies held by many individuals approaching reentry
(e.g., “I shouldn’t need support”), typical concerns during this phase (e.g., concern
over cancer recurrence), and personal and contextual factors that can facilitate and
hinder adjustment. Promising psychosocial interventions have been developed for
individuals in the reentry period. Continued research will be necessary to charac-
terize this important phase of cancer survivorship. Cancer 2005;104(11 Suppl):
2608–13. © 2005 American Cancer Society.
KEYWORDS: cancer, survivorship, quality of life, reentry.
ow, every little thing has me petriﬁed! Any ache means the
cancer is back…but, then, I worry that, if part of my mind still
believes the cancer will come back, maybe it will. Just trying to think
positively can cause stress. I think the hardest part of this week has
been the sense of loss I’ve felt being ﬁnished with treatment. You
spend so many months doing everything you can to ﬁght the disease,
even just relaxing to ﬁght it, and then the doctors have completed all
of your treatments. How do I pick up the pieces?”
These words from a breast cancer research participant
recently had completed medical treatments vividly capture some of
the distinct challenges that can accompany the phase of transition
from “cancer patient” to “person,” that is, the period of early survi-
vorship that constitutes the several months after the completion of
primary treatments for cancer. The objectives of this report were 1) to
describe adaptive tasks of the posttreatment phase, 2) to illustrate
research on factors that predict positive adjustment during this phase
of reentry, and 3) to provide examples of promising interventions
designed to address the adaptive tasks of early survivorship.
It is important to note that most individuals who confront a
cancer diagnosis adjust well. On general measures of psychological
adjustment and quality of life, it is often found that cancer patients
are indistinguishable from the general population by 1 or 2 years after
diagnosis, given that treatment is complete and the cancer con-
Within this context of overall positive adjustment, however,
two points deserve mention. First, there is substantial variability in
adjustment. The majority of patients do well, and a subset are at risk
for high distress and life disruption.
Second, rather than producing
© 2005 American Cancer Society
Published online 24 October 2005 in Wiley InterScience (www.interscience.wiley.com).
global dysfunction, cancer may engender what
Andersen et al. have called “islands” of disruption that
occur in particular life domains and at particular
points in the cancer trajectory.
We focus here on the
posttreatment phase as one potential island of disrup-
tion. Research focusing on this phase is sparse com-
pared with that on the earlier phases of diagnosis and
treatment; however, as one woman with gynecologic
cancer said, the treatment period is only the ﬁrst
Furthermore, extant research primarily tar
gets women with breast cancer. Although no standard
exists for deﬁning the boundaries of this transition,
and individual variability in its experience is likely, we
view the year after completion of primary medical
treatments (i.e., surgery, radiotherapy, chemotherapy)
as constituting the reentry phase.
The Adaptive Tasks of Reentry
Cancer patients themselves and the clinicians working
with them alerted us to the distinct challenges accom-
panying the reentry phase. Twenty years ago, Dr.
Fitzhugh Mullan, Chief Medical Ofﬁcer of the Ofﬁce of
Medical Applications of Research at the National In-
stitutes of Health, wrote about his own experience
with cancer and what he called the “reentry”
The themes Dr. Mullan described in his
process of the resumption of life as an active adult
are remarkably similar to those that were identiﬁed by
other cancer survivors,
and qualitative researchers
over the next
2 decades. An important point made by those writers
was that the challenges faced during reentry often are
unanticipated and leave the individual feeling ill-pre-
pared to manage them.
Instead of being able to
predict the challenges, many patients and their inti-
mate others hold expectancies that we may describe
as the “myths of treatment completion” (see Table 1).
The ﬁrst myth is the expectation that the end of
treatment should be celebrated. Although treatment
completion represents a major milestone in the can-
cer trajectory and often is accompanied by relief and
many also discover that the work
of processing emotions and ﬁnding meaning are just
beginning. For instance, one research participant said
that treatment just “ﬂew by” and that she was not hit
with the reality of having cancer until the end of
treatment. Furthermore, treatment provides a vehicle
for control, a focus for the patient’s energy, and a way
to cope through active engagement. At treatment
completion, the individual may be left with the loom-
ing question, “…what do I do now?”
A second common expectation is that the individ-
ual should recover soon after the completion of treat-
ment. After all, medical treatments are supposed to
leave you feeling better. If lingering fatigue or other
physical compromises come as a surprise, then they
may prompt self-imposed demands to push past their
own physical limits too quickly or misattributions,
such as a fear that the cancer is still there. The inter-
personal circle also can promote such expectations in
communicating an assumption that the individual will
return promptly to old roles once treatment is com-
pleted. Patients sometimes perceive that individuals
on the outside assume that, once the patient is cured,
they will be ready to return to whatever they did
before with the full vim and vigor they had before
cancer, as though nothing had happened.
A third expectation is that the patient should re-
turn quickly to their prediagnosis sense of self. How-
ever, an altered sense of self is possible. In one report,
a breast cancer patient commented that, when she
stood in front of a mirror, she was bothered less by the
missing breast than the fact that her hair color was
different: She still saw a sick person when she looked
in the mirror, which was a reminder of what she went
through during treatment.
In addition to confront
ing physical reminders of the cancer experience and a
new sense of vulnerability, however, individuals with
cancer also may experience an enhanced sense of self
and the world after treatment. Consistent evidence
demonstrates that cancer patients ﬁnd beneﬁt in their
experience. For example, Sears et al.
shortly after the completion of treatment, 83% of a
sample of breast cancer patients cited at least 1 beneﬁt
in their experience, enjoying a new sense of personal
strength (9% of beneﬁts cited), spiritual growth (6%),
life possibilities (11%), life appreciation (12%), atten-
tion to health behaviors (13%), and enhanced relation-
A fourth myth is that the patient no longer should
need support after treatment is over. Both the inter-
personal support system and the medical treatment
team rallies around the affected individual during the
acute diagnostic and treatment period. Cancer pa-
tients often comment on the relatively sharp down-
turn in active support once they complete treat-
Patients sometimes have no one to talk with
once their treatment is over.
The motivation of loved
ones to see the patient as cured, the lack of regular
contact with other cancer patients while awaiting
medical treatment, and the medical team’s congratu-
latory “I’ll see you in 3 months!,” all can contribute to
Myths of Treatment Completion
I should be celebrating
I should feel well
I should be the precancer me
I should not need support
Promoting Posttreatment Adjustment/Stanton et al. 2609
a sense of isolation once treatment ends. The com-
fortable net of safety and support can diminish
observed clinically that individu
als are more likely to seek a support group after treat-
ment completion than in the phases of diagnosis and
Counter to the expectation that treatment com-
pletion and full recovery of health and well being
occur simultaneously, the literature suggests that
treatment completion can be disruptive psychologi-
cally. For example, Beisecker et al.
reported that, 6
months after the completion of treatment, the major-
ity of their breast cancer patient sample had not an-
ticipated the lingering effects of chemotherapy. Fur-
thermore, Ward et al.
found that 30% of a sample of
38 breast cancer patients reported that treatment
completion was upsetting, and some in our own group
have observed that 27% of patients rated the end of
radiation and 48% rated the end of chemotherapy as
moderately or extremely stressful in a study of 160
women with breast cancer.
In a longitudinally de
signed study, McQuellon et al.
found that energy
levels had recovered to only 70% of normal at 1 year
after bone marrow transplantation.
We suggest that the individual completing treat-
ment often confronts adaptive tasks in four domains:
emotional functioning, physical functioning, interper-
sonal relationships, and life perspectives. These do-
mains resemble those identiﬁed in quality-of-life
However, the content and relative impor
tance of the facets within each domain are the factors
that are likely to vary as a function of the speciﬁc point
in the cancer trajectory. Central concerns of partici-
pants in a completed trial illustrate these domains.
Our randomized, controlled trial tests a structured,
educational intervention (Moving Beyond Cancer) for
women who are beginning the reentry phase after
breast cancer treatment. We used behavioral self-reg-
and stress and coping theories
guide our hypothesis that gaining preparatory infor-
mation on what to expect during the phase of cancer
recovery and instruction and encouragement in the
use of coping strategies oriented toward actively ap-
proaching the adaptive tasks will contribute to posi-
tive adjustment in the four life domains, perhaps
moderated by perceived preparedness for reentry.
Women were registered for the trial shortly after they
underwent surgery for breast cancer, and they com-
pleted baseline measures and were randomized (n
⫽ 558 patients) to 1 of 3 intervention arms within
approximately 3 months after the completion of pri-
mary medical treatments. In one arm, women partic-
ipated individually in two structured sessions with a
trained educator. Women reviewed their own con-
cerns in the four domains as part of the ﬁrst session;
then, they identiﬁed a primary concern for which to
develop an action plan.
Fully 51% of the women in this trial arm had
central concerns in the emotional domain, with 39%
reporting fear of cancer recurrence as their dominant
concern. The physical domain was of most concern
for 26% of women (e.g., weight gain, menopausal
symptoms). Of course, the content of these facets
would change given a different sample. Incontinence
and erectile dysfunction would be included for men
with prostate cancer, for example.
of women reported primary concerns in each of the
domains of interpersonal relationships (e.g., partner,
work relationships) and life perspectives (e.g., lifestyle
change, ﬁnding meaning). Only ﬁve women identiﬁed
no major concern for the reentry phase.
Additional evidence suggests that individuals with
cancer confront speciﬁc concerns during the reentry
phase, with accompanying information needs. Luker
found that 105 patients with breast
cancer reported gaining useful information at the time
of diagnosis from medical professionals. At an average
of 21 months later, however, this sample reported
gaining information primarily from the popular media
and often reported discomfort in requesting informa-
tion from medical providers. The majority (66%) re-
ported information needs that had not been met at
follow-up (e.g., information about the likelihood of
cure of breast cancer and about the risk to family of
developing cancer). In a sample of 223 women who
were treated for early-stage breast cancer within the
the most frequent concerns were fear of
cancer recurrence, pain, death, harm from adjuvant
treatment, and medical bills. In a sample of 231 breast
(note that most had been diagnosed
3–5 yrs earlier), 48% reported moderate-to-high un-
met needs for information on dealing with fears about
cancer recurrence, the most frequently endorsed un-
met need among 52 rated information needs. Younger
patients with breast cancer reported greater informa-
tion needs in the psychological arena than older
women. The evidence that many cancer patients en-
counter unanticipated and lingering difﬁculties in
multiple life domains during this phase signals the
importance of identifying factors that contribute to
positive adjustment in the year after treatment.
Predictors of Positive Adjustment During the Reentry
Stress and coping theories
provide a general con
ceptual framework for identifying contributors to pos-
itive adjustment after cancer treatment. Figure 1
shows that such contributors to adjustment in the four
domains can arise from the interpersonal and envi-
ronmental context; attributes of the individual; dis-
2610 CANCER Supplement December 1, 2005 / Volume 104 / Number 11
ease and treatment characteristics; and what the indi-
vidual thinks and does in response to the cancer
experience. Little research has focused speciﬁcally on
predictors of positive adjustment during the reentry
Stanton and colleagues
have conducted two
studies focusing on the reentry phase in patients with
early-stage breast cancer. In the ﬁrst study,
followed 92 patients with breast cancer from shortly
after treatment completion through 3 months, with an
additional assessment at 1 year. It was hypothesized
that approach-oriented coping strategies (i.e., coping
directed toward active engagement with the stressor,
such as planning, problem-solving, emotional expres-
sion, and positive reappraisal) would promote en-
hanced physical and psychological health across time.
The roles of coping through emotional expression and
through positive reappraisal were of particular inter-
est. The investigators predicted that these strategies
would be particularly useful for women in receptive
social contexts and for women high in hope, which is
a sense of goal-directed determination and ability to
generate pathways to meet goals.
Analyses revealed that coping through emotional
expression maintained consistent relations with the
dependent variables, controlling for initial values on
the dependent variables and participant age.
ically, women who, at treatment completion, reported
coping with their cancer experience through express-
ing their emotions demonstrated enhanced physical
health, had fewer medical appointments for cancer-
related morbidities, and reported lowered distress and
increased vigor over the next 3 months compared with
women who were less expressive emotionally. Coping
through positive reappraisal predicted increased vigor
and enhanced self-reported health at 3 months and at
12 months as well as greater self-reported posttrau-
matic growth at 1 year.
Personal and social factors also were important
during this reentry phase. Emotionally expressive cop-
ing predicted a decrease in distress and fewer cancer-
related medical appointments for women high in
hope, and it predicted improved quality of life for
women in receptive social contexts. Furthermore, ap-
proach-oriented coping strategies mediated the rela-
tions between hope and positive outcomes.
These ﬁndings suggest that positive social con-
texts, personal attributes, and particular approach-
oriented coping strategies can contribute to adjust-
ment in several domains during the reentry phase.
Other research has suggested that good candidates for
predictors of cancer-speciﬁc adjustment problems in
this phase may be younger age,
receipt of chemo
and use of more avoidant coping pro
Continued research will aid in identifying
additional protective and risk factors for adjustment in
the reentry phase, revealing whether predictors of
positive adjustment during this phase bode well for
adjustment over the long run and determining the
utility of these ﬁndings for the development of clinical
Interventions to Promote Posttreatment Adaptation
Longitudinal research has demonstrated that coping
through emotional expression and positive reap-
praisal predicts positive adjustment across time, but a
stronger test of the utility of these coping strategies
involves an experimental design. An example of such
research is a small, randomized, controlled trial of a
writing intervention to promote reentry adjustment.
In that trial, the researchers hypothesized that induc-
ing women to write about either their deepest
thoughts and feelings about their breast cancer expe-
rience or the positive aspects of their experience
would promote positive psychological and physical
health outcomes compared with writing about the
facts of their experience with cancer. A second hy-
pothesis was that women who tend to avoid their
thoughts and feelings regarding cancer may beneﬁt
more from focusing on the positive aspects of their
experience, whereas women who are low in avoidance
may beneﬁt more from full expression.
These hypotheses were tested in a trial of 60 pa-
tients with early-stage breast cancer who were ran-
domized to 1 of 3 writing arms shortly after they
completed medical treatment and engaged in 4 writ-
ing sessions, with 1-month and 3-month follow-up
With regard to psychological outcomes,
the writing intervention was effective differentially for
women high and low in cancer-related avoidance,
whereas the conditions revealed main effects on phys-
ical health outcomes. Speciﬁcally, as hypothesized,
women who were high in avoidance became less dis-
FIGURE 1. This chart illustrates the conceptual framework for posttreatment
Promoting Posttreatment Adjustment/Stanton et al. 2611
tressed if they wrote about the positive aspects of their
cancer experience, and less avoidant participants be-
came less distressed if they wrote about their deepest
thoughts and feelings. With regard to physical out-
comes, the expressive disclosure condition produced a
signiﬁcant decrease in self-reported somatic symp-
toms relative to the fact control (i.e., writing about
facts of the breast cancer experience). In addition,
both the expressive disclosure and beneﬁt-ﬁnding
conditions were superior to the fact control on an-
other health-related outcome, yielding fewer medical
appointments for cancer-related morbidities over the
following 3 months.
The demonstrated effectiveness of the beneﬁt-
ﬁnding condition deserves mention. We agree strongly
with Holland and Lewis
who have cau
tioned against the tyranny of positive thinking
cancer patients. Characteristics of this trial may have
allowed for this condition’s effectiveness. First,
women on average had been diagnosed for several
months when they entered the trial and likely had the
opportunity to express negative emotions during that
time. Thus, the beneﬁt-ﬁnding condition may have
prompted balanced emotional expression. Asking
women to describe beneﬁts immediately upon cancer
diagnosis may have produced very different out-
comes. Second, we did not prescribe particular bene-
ﬁts to women but, rather, encouraged women to iden-
tify the positive aspects of their experience on their
own. We also note that the expressive disclosure con-
dition did show a narrow advantage over the beneﬁt-
ﬁnding condition on health outcomes, suggesting that
full emotional processing may be particularly effec-
tive. Of course, emotional expression is likely to be
more beneﬁcial for individuals with particular charac-
teristics in speciﬁc contexts, and these potential mod-
erators require further study.
We also implemented a reentry intervention in the
Moving Beyond Cancer randomized, controlled trial
described above. This is a multisite trial that was de-
signed to promote realistic expectancies and ap-
proach-oriented coping for women in the breast can-
cer reentry transition. The three arms involved
combinations of written material, a peer-modeling
video, and brief, structured psychoeducational ses-
sions, which included identiﬁcation of a target con-
cern, development of an approach-oriented action
plan for addressing the concern, and implementation
and evaluation of the plan. The objective is not only to
address the target concern but also to promote ap-
proach-oriented planning for other concerns encoun-
tered in the reentry transition. Findings from this trial
and another reentry trial are now available.
Summary and Directions for Research
To summarize, most individuals who face cancer report
positive global adjustment at reentry, although treat-
ment completion and the ensuing months are likely to
constitute an island of disruption, with effects in multi-
ple life domains. Contributors to positive adjustment
during this phase are beginning to be identiﬁed, and
promising interventions are being developed. However,
we have far to go in understanding the reentry transition.
Although clinical and qualitative writings provide a rich
description of the problems of the reentry phase, little
empirical work is available. Longitudinal research docu-
menting the experience of reentry is needed, with as-
sessment of cancer-speciﬁc outcomes and of positive
indicators of adjustment as well as pathology. It also
should be noted that the reentry transition may be very
different for individuals with early-stage disease versus
those with poorer prognoses, for whom the end of treat-
ment often is demarcated less clearly and the transition
to survivorship is less certain.
Theoretically driven research to identify protec-
tive and risk factors for adjustment in multiple do-
mains is essential as data accumulate to characterize
the nature of the reentry transition. Translation of this
work into randomized, controlled trials of interven-
tions to promote reentry adjustment in diverse groups
of cancer patients and their loved ones also is needed.
The ﬁndings that personal and contextual factors in-
ﬂuence cancer-related adjustment suggest that such
factors may moderate the effects of psychosocial in-
terventions on outcomes
and that interventions may
be targeted most productively to those at highest risk
for poor adjustment. Finally, evaluation of the links
between aspects of the reentry experience and long-
term health outcomes is vital. Such research may es-
tablish the reentry phase as a pivotal transition that
sets the stage for adaptive long-term survivorship.
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