Cancer-related trauma, stigma and growth: the 'lived' experience of head and neck cancer

People, places, systems and society:A qualitative exploration of socio-cultural factors in head and neck cancer survivorship

PURPOSE

People living with head and neck cancer (HNC) often endure permanent and life changing adverse effects of treatment and reduced health-related quality of life. Study of post-traumatic growth (PTG), is gaining traction to understand why some people living with cancer have better psychosocial outcomes than others. Current theoretical models on PTG point to the importance of 'socio-cultural influences' but do not provide insight into how such socio-cultural factors influence survivorship outcomes. This research aimed to illuminate pathways to PTG following HNC by exploring socio-cultural factors in experiences of living with, and moving on from, HNC.

METHOD

Semi-structured interviews with people living with HNC (up to 5 years post-treatment) on experiences of diagnosis, treatment and recovery. Qualitative framework analysis using the environmental factors codes from the International Classification of Functioning, Disability and Health (ICF) HNC core set.

RESULTS

20 people living with HNC were interviewed (11 male, 9 female; aged 46-83 years). Four inter-related themes described socio-cultural factors that influence (positively and/or negatively) the experience of living with HNC: (1) people and places; (2) healthcare systems and support services; (3) societal attitudes to cancer; (4) work and finances.

CONCLUSION

Support from family, friends and healthcare professionals, as well as societal attitudes, financial and work security and personal experiences all appear to contribute to an individuals' ability to navigate the HNC experience. These findings could inform development of interventions targeting the socio-cultural factors in the lives of people living with HNC, particularly for those at risk for poorer psycho-social outcomes.

Study protocol for a single-site feasibility study evaluating the adoption and fidelity of Prep-4-RT: prehabilitation for head and neck cancer patients undergoing radiotherapy

INTRODUCTION

Prep-4-RT is a co-designed stepped-care multimodal prehabilitation program for people scheduled to receive radiotherapy for head and neck cancer (HNC). Prehabilitation, which occurs between diagnosis and treatment commencement, aims to improve a patient's health to reduce the incidence and severity of current and future impairments. HNC treatment can be distressing and has detrimental impacts on function and quality of life. HNC patients have increased social vulnerabilities including higher rates of socio-economic disadvantage and engagement in lifestyle habits which increase cancer risk. High levels of physical and psychological impacts of HNC treatment and increased social vulnerabilities of this population warrant investigation of optimal pathways of care, such as prehabilitation. This paper describes a research protocol to evaluate the feasibility of Prep-4-RT, which was designed to prepare HNC patients for the physical and psychological impacts of radiotherapy.

METHODS AND ANALYSIS

At least sixty adult HNC patients, scheduled to receive radiotherapy (with or without chemotherapy), will be recruited over a five-month period. All participants will receive access to Prep-4-RT self-management resources. Participants identified through screening as high-risk will also be offered individualised interventions with relevant allied health professionals prior to the commencement of radiotherapy (psychologists, dietitians, speech pathologists and physiotherapists). Participants will complete evaluation surveys assessing their experiences with Prep-4-RT resources and interventions. Clinicians will also complete program evaluation surveys. Primary feasibility outcomes include adoption (uptake and intention to try) and fidelity (adherence to the specialist prehabilitation pathway). Secondary feasibility outcomes include acceptability (patient and clinician) of and satisfaction (patient) with Prep-4-RT as well as operational costs. Feasibility outcome data will be analysed using exact binomial and one-sample t tests, as appropriate.

ETHICS AND DISSEMINATION

Ethics approval has been obtained at the Peter MacCallum Cancer Centre in Melbourne, Australia. Results will be presented at national conferences and published in peer-reviewed journal(s) so that it can be accessed by clinicians involved in the care of HNC patients receiving radiotherapy. If the model of care is found to be feasible and acceptable, the transferability and scalability to other cancer centres, or for other cancer types, may be investigated.

REGISTRATION DETAILS

ANZCTA (Australian New Zealand Clinical Trials Registry) ACTRN12623000770662.

Cancer stigma: the need for policy and programmatic action

Cancer is a stigmatized disease in many countries that impacts the quality of life and mental health of people affected by cancer. This commentary examines some dimensions of cancer stigma and has been developed based on insights from participants in a Union for International Cancer Control program dedicated to cancer patient organizations in low- and middle-income countries. Aimed at program managers and policy makers, this commentary highlights the importance of developing strategies to reduce cancer stigma in cancer control programs in different contexts, working closely with community-based civil society organizations and those with lived experience of cancer to understand, evaluate, and take action regarding the impact of cancer stigma on health-seeking behavior and patients' quality of life.

A qualitative study on experiences of stigma among postoperative oral cancer patients

AIM

This study aimed to explore the characteristics of stigma in postoperative oral cancer patients to provide a reference for the formulation of targeted intervention measures.

METHODS

A qualitative study was conducted on 25 postoperative oral cancer patients in a tertiary A hospital in Hunan, China, from March to July 2021. Semi-structured face-to-face interviews focused on experiences of stigma were performed. The interview data was analyzed using the NVivo V.12 software based on the reflexive intuitive thematic analysis method. The paper complies with the COREQ.

RESULTS

The stigma experience of postoperative oral cancer patients can be divided into 3 themes: (1) triggers (impaired appearance and oral function and psycho-social pressure); (2) forms (overall isolation, unpleasant feeling of inferiority, and unpleasant social discrimination); (3) coping strategies (positive psychological adjustment, seeking social support and coming out of the unpleasant shadows).

CONCLUSION

Postoperative oral cancer patients clearly articulated that stigma was present in their lives and they experienced multiple forms of stigma. Further work is needed to increase education and awareness about oral cancer to guide them to take positive coping and reduce stigma.

A Discourse of Deviance: Blame, Shame, Stigma and the Social Construction of Head and Neck Cancer

Cancer of the head and neck is a confronting condition, as the disease and its treatments alter the appearance and function of body organs associated with physical appearance and identity. Many of the risk factors for head and neck cancers, including tobacco, alcohol, and human papilloma virus, can also have significant negative social and moral permutations. Language and action (discourse) plays an important role in constructing disease and illness and shape the way it is managed, both institutionally and socially. This research used a critical constructionist lens to investigate how the common discourses surrounding head and neck cancer are constructed within the healthcare context and how this influences patients and healthcare professionals' responses to the illness. Data were collected through semi-structured interviews, field noting, journaling and literature reviews. Analysis was guided by a three-dimensional approach to critical discourse analysis that investigated text, discursive practices, and social context. The overarching finding was that deviance dominates the common discourse and shapes head and neck cancer and responses to it. Deviance is channelled through metaphors, adjectives, descriptors, and collective nouns and is made overt through labelling, avoidance, blaming, shame, and categorization. Discourse is contextualized by a sociocultural understanding that when someone deviates from what is perceived as normal, they are devalued. Open dialogue and reflection on head and neck cancer discourse could enable better understanding of how people experience their condition and inform more supportive responses.

Promoting post-traumatic growth in cancer patients: a randomized controlled trial of guided written disclosure

Background

Cancer is a life-threatening disease that triggers not only vulnerability to distressing symptoms but also a meaning-making process that may lead to post-traumatic growth. As people often struggle to integrate cancer illness into their meaning system to reach an adaptive meaning, psychological interventions focused on a reappraisal of the illness experience can facilitate this process. This multicenter randomized controlled trial (RCT) was primarily aimed at assessing the efficacy of a writing intervention known as a guided disclosure protocol (GDP), compared to a generic writing intervention, in promoting post-traumatic growth in stage I-III breast and colon cancer patients at the end of their adjuvant chemotherapy.

Methods

Between January 2016 and August 2020 recruitment of eligible subjects took place during follow-up clinical consultations. Assessment occurred at baseline (T0), after the intervention (T1, 3 months from baseline), and at 6 months from baseline (T2). Both interventions consisted of three 20-min writing sessions to be performed once every two weeks. Change in post-traumatic growth was assessed using the Posttraumatic Growth Inventory, meaning with the Constructed Meaning Scale, and psychological distress with the Impact of Event Scale and the Hospital Anxiety and Depression Scale.

Results

In the five participating centers, 102 eligible patients were randomized and 72 participants completed follow-up evaluation. Most patients were women (79.4%), had breast cancer (68.6%), and stage I (27.5%), or stage II (44.1%) disease. Mean differences did not reach statistical significance for any of the dependent variables. However, an effect of the GDP, although not statistically relevant, was observed after the intervention in terms of enhanced post-traumatic growth and increased distress measured with the Impact of Event Scale.

Conclusion

This is the first RCT investigating the efficacy of a GDP in cancer patients having post-traumatic growth as the primary aim. Though GDP is a promising intervention in promoting post-traumatic growth, the lack of statistical significance of our findings may be due to the study being underpowered, hence this trial should be replicated with an adequate sample size, paying attention to supporting recruitment.

Clinical trial registration: ClinicalTrials.gov, identifier: 2015/0024360.

Return to valued activities: Survivors' experiences of adaptation and growth after treatment for head and neck cancer

OBJECTIVE

The objective of this study was to explore the experiences of head and neck cancer (HNC) survivors who returned to valued activities to understand how they reconstruct their lives following HNC diagnosis and treatment.

METHODS

A qualitative research approach based on social constructionist theory was used. A total of 21 in-depth semi-structured interviews were conducted with adults diagnosed with any type of HNC in the previous 6 years. Reflexive thematic analysis was used to identify themes.

RESULTS

HNC presents a unique trauma following which some survivors navigate paths back to meaningful activities. The experiences of HNC survivors who adapted to life after treatment described internal and external change and development, identified by three themes; Mindfulness; Gratitude; and Adaptation.

CONCLUSION

People diagnosed with HNC frequently experience lasting effects and other survivorship issues, however some survivors were able to return to valued activities and recreate a meaningful lifestyle reflecting the possibility of post traumatic growth. This study provides insight into the experiences of head and neck cancer survivors who were able to make meaning and find internal and external growth following treatment. These findings can be used to inform advanced communication skills training for oncology health professionals and psychoeducational courses for people diagnosed with head and neck cancer in the future.

Towards a better understanding of the social stigma of facial difference

Facial difference (FD) is not only an individual experience; it is inherently social, reflecting interactions between social norms and individual attitudes. Often FD is stigmatized. In this paper, we employ a widely used stigma framework, namely the social stigma framework put forth by Pryor and Reeder (2011), to unpack the stigma of FD. This framework posits that there are four forms of stigma: public stigma, self-stigma, stigma by association, and structural stigma. We first discuss the social and psychological literature on FD as it pertains to these various forms of stigma. We then describe coping approaches for FD stigma. Lastly, we delineate evidence-based methods for addressing the various forms of FD stigma, such that future efforts can more effectively tackle the stigma of facial difference.

Establishing and integrating a transoral robotic surgery programme into routine oncological management of head and neck cancer - a UK perspective

BACKGROUND

The introduction of transoral robotic surgery into routine management of patients is complex. It involves organisational, logistical and clinical challenges. This study presents our experience of implementing such a programme and provides a blueprint for other centres willing to establish similar services.

METHODS

Implementation of the robotic surgery programme focused on several key domains: training, logistics, governance, multidisciplinary team awareness, pre-operative imaging, anaesthesia, post-operative care, finance, patient selection and consent. Programme outcomes were evaluated by assessing operative outcomes of the first 117 procedures performed.

RESULTS

The success of the transoral robotic surgery programme has been possible because of the scrupulous planning phase before the first procedure, and the time invested on team awareness and training.

CONCLUSION

Implementation of a new transoral robotic surgery service has led to: the development of a dedicated transoral robotic surgery patient care protocol, the performance of progressively more complex procedures, the inclusion of transoral robotic surgery training and the establishment of several research projects.

The nature and content of rumination for head and neck cancer survivors

Introduction

Head and neck cancer (HNC) diagnosis and treatment can be a significant life trauma. Some HNC survivors experience post-traumatic growth (PTG), which has been linked with better health-related quality-of-life. Empirical research on PTG, and theoretical models, point to the importance of being able to purposely make sense of the traumatic experience. Intrusive rumination, by contrast, is linked to poorer outcomes. This study explored HNC survivors’ experiences of rumination.

Methods

Twenty HNC survivors between 9 months and 5 years post-diagnosis were recruited (11 male, 9 female, age range 46–83). They had a range of HNC sub-types and cancer treatments. Participants underwent a semi-structured interview about their cancer diagnosis and treatment. Reflexive thematic analysis identified themes and sub-themes around rumination.

Results

Four themes with linked subthemes on the content and process of rumination were identified. Theme 1 was rumination and worry related to diagnosis. Here, survivors discussed how the HNC diagnosis and plans for treatment had dominated their initial thoughts. Theme 2 was processing the trauma of HNC. This theme reflected rumination on the traumatic experience of diagnosis and treatment and how the participant was reacting to it. Theme 3 was considering the impact. This theme encompassed retrospective thinking (e.g., on treatment decisions made) and comparisons between the participant now versus the early days after diagnosis. Theme 4 was continued rumination. This theme included ongoing intrusive and distressing rumination about the trauma and impact of cancer. Those who expressed ongoing rumination revisited fears (e.g., concerns about their future) or returned to negative experiences (e.g., distressing exchanges with healthcare professionals or what they perceived as poor care).

Conclusion

This study uniquely describes the nature and content of rumination following HNC. Early intrusive rumination is common and may reflect perceptions of cancer as an existential threat. Over time, rumination can become more reflective and move towards deliberate meaning-making. Some HNC survivors may benefit from interventions to reduce barriers to this transition. The content of distressing and difficult to control rumination (commonly focused on ongoing fears or inability to resolve difficult experiences) helps to identify those who may benefit from more directed psychological support.

Considerations for developing supportive care interventions for survivors of head and neck cancer: A qualitative study

OBJECTIVE

This study aimed to describe considerations for developing supportive care interventions targeted to head and neck cancer (HNC) survivors.

METHODS

One-time semi-structured interviews (N = 33) were conducted with HNC survivors who had recently finished treatment (n = 20) and HNC providers (e.g., physicians, nurses; n = 13). Interviews were transcribed verbatim and coded using inductive applied thematic analysis techniques to identify themes.

RESULTS

HNC survivors (75% male; M = 61 years old) and providers (54% physicians; 62% female) were unanimously supportive of developing HNC-specific supportive care interventions. Participants described potential benefits of offering interventions at various points throughout the HNC treatment and survivorship trajectory rather than at a single critical time. Many participants preferred group-based interventions because of the high value of peer-support. Others described how group interventions may not be appropriate for all HNC survivors due to risks for negative social comparisons and exacerbated anxiety. Participants suggested topics that should be addressed in HNC-specific interventions including education about acute and long-term side effects, symptom management, nutritional support, relationship/social role changes, grief/loss, and fear of recurrence.

CONCLUSIONS

HNC-specific supportive care interventions are critically needed, as survivors experience persistent symptoms and distinct psychosocial concerns that impact quality of life. Findings from this study can inform the development of supportive care interventions targeted to the unique psychosocial concerns of HNC survivors.

Barriers and facilitators to physical activity participation in patients with head and neck cancer: a scoping review

BACKGROUND

Patients with head and neck cancer (HNC) usually experienced disfigurement, dysfunction, and psychosocial distress, leading to a decline in their quality of life. Physical activity (PA) is recommended for such patients. Despite the proven benefits of participating in PA, the compliance of patients with HNC is still poor. Hence, the factors influencing PA participation and adherence in patients with HNC need to be explored.

OBJECTIVES

This study aimed to (1) identify barriers and enablers of PA in adult patients living with HNC and (2) map barriers and facilitators to the Capability-Opportunity-Motivation-Behavior (COM-B) model.

ELIGIBILITY CRITERIA

Types of studies: Studies with qualitative, quantitative, and mixed designs were included in this review.

TYPES OF PARTICIPANTS

The current review takes into account patients with HNC aged 18 years or above. Types of interventions: This review considered all studies focusing on full-body PA.

TYPES OF OUTCOMES

This scoping review focused on studies examining health behavior, patients' compliance, and facilitators and/or barriers to PA engagement. Five databases (Ovid Medline, Ovid Embase, CINAHL, Cochrane Library, and PsycINFO) were searched following the methodology for scoping reviews from inception to July 2021.

DATA EXTRACTION

The extracted data included author(s)/year of publication, country, main purpose of the study, sample size/disease site and stage, methodology and methods, type of treatment, and main findings/barriers, or facilitators.

RESULTS

A total of 22 studies were finally selected. The top three barriers were physical-related issues, time pressures, and low motivation or interest. Most facilitators included perceived psychological, health, and social benefits and preference for the model of PA. The most frequent COM-B model components were physical capability, automatic motivation, and physical opportunity.

CONCLUSIONS

Patients with HNC have unique facilitators and barriers to participating in PA. Interventions must leverage facilitators and limit barriers to exercise so as to increase compliance with exercise. Future studies should test the effectiveness of behavioral change measures based on the factors influencing the COM-B model.

Oral cavity squamous cell carcinomas in patients with no identified risk factors: Feeling like an outsider

OBJECTIVES

Head and neck squamous cell carcinomas (HNSCCs) mainly affect smokers and drinkers. However, oral cavity squamous cell cancers (OCSCCs) are increasingly affecting patients with no identified risk factors (NIRFs). This study aimed at characterising their experience of the disease.

METHODS

Qualitative study based on semi-structured interviews of 20 survivors of OCSCC with NIRF. Methods used in grounded theory approach were applied.

RESULTS

Patients with NIRF had a similar experience to that of patients with risk factors regarding treatments. The absence of identified causes led to stigma and led the patients to distance themselves, both from the stereotypic HNSCC cancer patient and the identity as a cancer patient. Furthermore, having no identified risk factors seemed to reinforce the fear of recurrence.

CONCLUSION

This study is the first to address key gaps in knowledge regarding patients with NIRF having survived OCSCC. Their experience is similar to that of patients with orphan diseases. Owing to confrontation with other patients and the repeated questions of caregivers about tobacco/alcohol consumption, these patients felt stigmatised during their treatment. OCSCC patients with NIRF may benefit from guidance and support on how to engage in prevention.

Effectiveness of prosthetic rehabilitation and quality of life of older edentulous head and neck cancer survivors following resection of the maxilla: a cross-sectional study

PURPOSE

To evaluate the effectiveness of prosthetic rehabilitation, as well as the quality of life (QOL) of older edentulous maxillectomy patients.

METHODS

Effectiveness of the complete denture obturator prosthesis and QOL of N = 44 older edentulous patients who had resection of the maxilla and were restored with a definitive prosthesis that was in use for a minimum of 1 year was assessed using three instruments: European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30), Head and Neck Cancer Module (QLQ-HN35), and Obturator Functioning Scale (OFS). Data analysis was performed by one-way analysis of variance (ANOVA) on ranks, Spearman rank-order correlation, and hierarchical multivariable rank regression at α = .05 level of significance.

RESULTS

Participants' gender (P < .001), adjuvant treatment (P = .016), surgical approach (P = .017), size of the maxillary defect (P = .028), participants' prosthetic history (P = .047), and dental status of the mandible (P = .038) were significantly related to the self-reported effectiveness of the complete denture obturator prosthesis. Perceived functioning of the prosthesis (P = .001), participants' gender (P = .002), the American Society of Anesthesiologists (ASA) physical status (P = .027), and surgical approach (P = .039) were significant predictors of QOL.

CONCLUSION

Restoration of the edentulous maxillectomy defect is challenging. An effective definitive complete denture obturator appeared to be the strongest predictor for advanced quality of life in older maxillectomy patients. The physical status of the older participants significantly affected the overall QOL, but did not influence the self-reported functioning of the complete denture obturator prosthesis.

Impact of stigma and stigma-focused interventions on screening and treatment outcomes in cancer patients

Background

Stigma is known to negatively influence cancer patients’ psychosocial behaviour and treatment outcomes. The aim of this study was to systematically review the current data on cancer-related stigma across different populations and identify effective interventions used to address it.

Methodology

The protocol, search, appraisal, synthesis, analysis and reporting framework was used for conducting this systematic literature review. CINAHL, PubMed, PsycINFO and Google Scholar databases were searched using the different combination of keywords that include ‘cancer stigma’. Articles publication period was set for 2010–2020. A total of 54 articles (31 quantitative, 19 qualitative, 2 mixed methods and 2 scoping reviews) that met inclusion criteria were reviewed out of the 958 articles initially identified. Quality assessment of included studies revealed the studies had varying levels of methodological quality. Extracted data were organised and narratively analysed.

Results

Cancer stigma was expressed across different segments of the society including amongst the elites and healthcare providers. Developing countries had higher rates of stigma reported and experience of stigma varied by cancer type. Cancer was consistently associated with imminent death in all studies reviewed. Cancer patients experiencing stigma were more inclined to conceal their diagnosis and to seek medical help later. Whilst cancer stigma majorly resulted in negative psychosocial outcomes in patients, there were also instances of posttraumatic growth emanating from the stigma experienced. Literature on cancer-related stigma interventions was scant.

Conclusion

Cancer related stigma remains high in both clinical settings and amongst the general public. There is need for more interventions to combat cancer stigma and its effect in both patient and non-patient population. Anti-cancer public enlightenment campaigns should be sensitively designed to not further fuel stigma against patients with certain types of cancers.

Stigma, depression, and anxiety among patients with head and neck cancer

PURPOSE

Patients with head and neck cancer (HNC) are vulnerable to psychiatric comorbidities, particularly anxiety and depression, and also suffer from cancer stigma. This study aimed to comprehensively compare HNC patients' stigma, depression, and anxiety, and elucidate the underlying relationships among them.

METHODS

This cross-sectional study recruited inpatients with HNC from a medical center. Measurements included a psychiatric diagnostic interview, the Shame and Stigma Scale (SSS), the Hamilton Anxiety Rating Scale (HAM-A), the Hamilton Depression Rating Scale (HAM-D), the Explanatory Model Interview Catalogue (EMIC), and stressors of HNC patients. Structural equation modeling was used to establish models of potential mechanisms.

RESULTS

Those patients having stressors of worry about health (t = 5.21, p < 0.001), worry about job (t = 2.73, p = 0.007), worry about family (t = 2.25, p = 0.026), or worry about economic problems (t = 2.09, p = 0.038) showed significantly higher SSS score than those having no such stressor. The SSS total score was significantly correlated with HAM-A (r = 0.509, p < 0.001), HAM-D (r = 0.521, p < 0.001), and EMIC (r = 0.532, p < 0.001) scores. Structural equation modeling was used to propose the possible effect of stigma on anxiety (β = 0.51, p < 0.001), and then the possible effect of anxiety on depression (β = 0.90, p < 0.001).

CONCLUSION

Stigma is significantly correlated with anxiety and depression and might in HNC patients. Proper identification of comorbidities and a reduction of stigma should be advised in mental health efforts among patients with HNC.

'I Didn't Even Recognise Myself': Survivors' Experiences of Altered Appearance and Body Image Distress during and after Treatment for Head and Neck Cancer

Simple Summary

In interview data collected from 21 people diagnosed with head and neck cancer in the previous six years, participants reported adequate procedural preparation but little or no preparation related to appearance. Body image distress contributed to psychosocial issues for many people, negatively impacting their adaptation to altered appearance. The main themes included; Preparation (sub-themes: Decision-making; and Preparation for Altered Appearance); Altered Appearance (sub-themes: Weight Loss; Face, Skin and Hair Changes; and Reconstructive Surgery); and Consequences (sub-themes Reactions from Others; Adapting to Altered Appearance). Current practice provides information pre-treatment about many aspects of coping; however, the subject of appearance is not routinely addressed. Communication skills training for health professionals that improves their comfort and sensitivity in discussing and conveying compassion around issues of altered appearance, body image, and trauma, is needed to decrease suffering for survivors, support healthy adaptation to living with altered appearance, and increase patient satisfaction with health care.

Abstract

Purpose: Preparation for head and neck cancer treatment is focused on practicalities of treatment. Little or no time is spent prior to treatment discussing aesthetic results of treatment or the psychosocial impact of living with an altered appearance after treatment. The objective of this study was to explore the experiences of survivors of head and neck cancers, with a focus on the psychosocial impact of altered appearance. Methods: A qualitative research approach based on social constructionist theory was used. Twenty-one semi-structured interviews were conducted with survivors of head and neck cancer who had been diagnosed in the previous six years. Thematic analysis was used to identify themes. Results: People diagnosed with HNC reported feeling rushed into treatment, with adequate procedural preparation but little or no preparation related to appearance. The main themes included: Preparation (sub-themes: Decision-making; and Preparation for Altered Appearance); Altered Appearance (sub-themes: Weight Loss; Face, Skin and Hair Changes; and Reconstructive Surgery); and Consequences (sub-themes Reactions from Others; Adapting to Altered Appearance). Conclusions: Body image distress related to altered appearance, contributed to psychosocial issues for many people diagnosed with head and neck cancer. Current practice provides information pre-treatment about many aspects of coping; however, the subject of appearance is not routinely addressed. Communication skills training for health professionals that improves their comfort and sensitivity in discussing and conveying compassion around issues of altered appearance, body image, and trauma, is needed to decrease suffering for survivors, support healthy adaptation to living with altered appearance, and increase their satisfaction with health care.

Post-traumatic growth after cancer: a scoping review of qualitative research

Purpose

Interest is growing in post-traumatic growth (PTG) after cancer prompted, in part, by observations of positive associations with health-related quality of life. Qualitative research provides valuable insight into survivors’ experiences. We conducted a scoping review of qualitative evidence on PTG in cancer, determining the number, nature, range and scope of studies, and gaps in the literature.

Methods

We systematically searched Medline, Scopus, CINAHL, Web of Science, and PsycINFO for qualitative research exploring positive changes after cancer published from 1996. From eligible studies, we extracted: terms used for PTG; design, methodological orientation, and techniques, and participant characteristics. Using descriptive mapping, we explored whether study findings fit within Tedeschi and Calhoun’s PTG framework, and evidence for unique positive changes post-cancer.

Results

Twenty-eight studies were eligible. Cancer sites included were: breast, 14; mixed, 6; haematological, 4; head and neck cancer, 2; bone, 1, and testis, 1. Multiple studies were conducted in: the USA (12), Australia (3), Iran (2), and the UK (2). Twenty-three studies collected data using individual interviews (21) or focus groups (2). Definitions of PTG varied. Studies largely focused on descriptive accounts of PTG. Findings mapped onto existing PTG dimensions; health behaviour changes were often reported, under ‘new possibilities’.

Conclusions

A range of PTG outcomes can occur after cancer. Positive health behaviour changes warrant further exploration. Future research should include more diverse patient populations, collect longitudinal data, and focus on pathways towards positive changes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06253-2.

Narrative therapy to relieve stigma in oral cancer patients: A randomized controlled trial

AIMS AND OBJECTIVES

This study aimed to evaluate the efficacy of narrative therapy in relieving stigma in oral cancer patients who underwent major surgical treatment.

BACKGROUND

Health-related stigma compromises mental health and life quality in people with physical or mental abnormalities. Narrative therapy has been implemented to overcome stigma among populations in a diversity of disease states. However, the effectiveness of narrative therapy in relieving stigma among patients with oral cancer is not known.

DESIGN

This study was a randomized controlled trial, in which 100 oral cancer patients were selected and randomly assigned to the 'narrative therapy' group, who received narrative therapy treatment in addition to standard care, and the 'control' group, who was provided standard care only.

METHODS

This research combined measurement of several questionnaires to evaluate stigma. Analysis of variance and paired t tests were employed for data analysis.

RESULTS

Findings in this study demonstrated that narrative therapy treatment effectively relieved oral cancer patients' sense of shame, reducing overall stigma and significantly improving self-esteem and social relationships.

CONCLUSIONS

Narrative therapy was demonstrated to be a promising therapeutic intervention for stigma relief in oral cancer patients.

SUMMARY STATEMENT

What is already known about this topic? Stigma is common among oral cancer patients, especially those who undergo major surgical resection. Psychological intervention is highly recommended in addition to postsurgical care. Narrative therapy might help relieve stigma among oral cancer patients. What this paper adds? Conventional postsurgical care did not improve oral cancer patients' psychological situation. A 7-week intervention of narrative therapy treatment significantly reduced stigma and enhanced sense of self-worth and social support among oral cancer patients. The implications of this paper: Narrative therapy can be clinically accepted as a therapeutic approach to assist oral cancer patients with stigma after major surgery. Tailored approaches, including patient-customized methods, should be encouraged in conducting narrative therapy.

Stigma, depression, and post-traumatic growth among Chinese stroke survivors: A longitudinal study examining patterns and correlations

Background: With the development of positive psychology, several studies show that positive and negative emotions are not always opposing. Understanding how positive and negative emotions correlate and the factors contributing to resilience in stroke survivors requires further research.Objectives: To identify the patterns and correlations of stigma, depression, and posttraumatic growth (PTG) among stroke survivors.Methods: Stroke-related stigma, depression, PTG, and neurological status were evaluated at 1-month and 3 months post-stroke using the Stroke Stigma Scale (SSS), Patient Health Questionnaire-9 (PHQ-9), Chinese version of the Posttraumatic Growth Inventory (C-PTGI), modified Rankin Scale (mRS), and Social Support Rating Scale (SSRS). The paired t-test, nonparametric test, and Spearman's correlation test were used to analyze differences and relationships between results at the two time points.Results: At 3 months compared to 1-month post-stroke, we found significant reductions in mRS and stigma scores, and an increase in PTGI scores, while the PHQ-9 scores reduced non-significantly. SSS, PHQ-9, and mRS scores were positively correlated with each other at time1 (all P < .01), and all showed no significant relationships with PTGI scores (all P > .05). Social support scores were negatively correlated with stigma (P < .01), PHQ-9 (P < .01), and PTGI scores (P > .05) at 3 months.Conclusions: Stroke-related stigma is strongly associated with depression while neither of them has significant relationships with PTG during the early stage of survivors' rehabilitation in our study. Neurological impairment is a risk factor for negative emotions and increasing individualized support may reduce stigma, depression, and promote PTG in the long term.

Stigma in the face of cancer disfigurement: A systematic review and research agenda

INTRODUCTION

An emerging body of work has reported on the psychological impact of disfigurement on cancer patients; however, the extent of research focusing on stigmatisation in this context is unclear. This review aimed to evaluate how stigma associated with disfigurement impacts on cancer patients.

METHODS

A systematic review of literature was conducted using SCOPUS, Web of Science, MEDLINE and PubMed databases. Articles were included if they described a qualitative or quantitative study that investigated the impact of stigma and disfigurement on individuals with cancer and/or their families. Included studies were appraised for methodology and narratively synthesised.

RESULTS

Of the 16 studies which met the inclusion criteria, ten were qualitative and six were quantitative. Publication dates ranged from 1994 to 2020. Results highlighted the varying impact of felt and enacted stigma in people with cancer disfigurement. While individuals cope with stigma in different ways and outcomes can sometimes be positive, most articles documented a negative impact to well-being including emotions such as disgust and shame.

CONCLUSION

This review identified negative and (sometimes) positive consequences of disfigurement and stigma on cancer patients; however, the main finding is that relevant research is in its infancy. Several areas of future research are warranted.

Impact of health-related stigma on psychosocial functioning in cancer patients: Construct validity of the stigma-related social problems scale

OBJECTIVE

The aim of this study was to evaluate the validity of Stigma-related Social Problems scale (SSP) in a cancer population.

MATERIALS AND METHODS

The SSP was sent to 1,179 cancer patients. Mean age was 67.9 year and 43% were women. Tests of internal consistency reliability, construct validity, item-scale convergent validity, ceiling and floor effects and known-group validity were conducted.

RESULTS

The response rate was 62%, and the final sample comprised 728 patients. Reliability coefficients were high for both subscales (Cronbach's alpha = 0.94). Exploratory factor analyses confirmed the unidimensionality and homogeneity of the scales. Item-scale correlations for both scales indicated satisfactory item-scale convergent validity. The proportion of subjects scoring at the lowest possible score level was 26% for the Distress scale and 28% for the Avoidance scale, while ceiling effects were marginal (<1%). The proportion of missing items was low, ranging from 1.4% to 1.5%. Known-group validity tests confirmed that the scales could capture expected differences between subgroups.

CONCLUSIONS

The SSP scale is a feasible instrument with sound psychometric properties that is validated in a study on 728 cancer patients. The instrument can be used to identify cancer patients at risk for psychosocial disturbances and thus in need of support.

Living with cancer of the head and neck: A qualitative inquiry into the experiences of South African patients

OBJECTIVE

To describe the experiences of South African patients living with head and neck cancer.

METHODS

We used a qualitative descriptive design and conducted unstructured interviews with 18 (n = 18) purposive selected participants. Data saturation determined the sample size. Qualitative content analysis was used to analyse the data.

RESULTS

The majority of the sample were Black males; on average, 50.8 years (SD ± 13.6) old. Two themes and eight subthemes arose from the data. The themes were living with the consequences of the illness and treatment, and coping with a changed life. The lives the participants knew before becoming sick changed and became a living hell; pain was a major problem as was eating and for some, communicating. The participants were stigmatised, ridiculed and rejected which added to their suffering. Receiving support from family and friends and their faith in God assisted them to cope with their changed lives.

CONCLUSION

Our study poses various challenges to clinical practice. Pain management is of the utmost importance; the nutritional status of these patients should be monitored and best practices in terms of management applied. Raising awareness of cancer and its complications could improve knowledge and decrease blame, stigmatisation and rejection and improve patient outcomes.

Validation of the Chinese Version of the Shame and Stigma Scale in Patients with Head and Neck Cancer

Purpose

Head and neck cancer (HNC) patients suffer from perceived shame and stigma due to the illness diagnosis, as well as disfigurement following surgery. To measure HNC patients' perception of shame and stigma, the Shame and Stigma Scale (SSS) was developed and preliminarily validated. In this study, we aimed to translate, adapt, and validate the SSS in Chinese.

Methods

This study consisted of a cross-sectional design with consecutive sampling and consisted of two stages: (1) translation of the SSS into Chinese by two bilingual professionals and (2) examination of the Chinese version of the SSS (C-SSS) for internal consistency, inter-rater reliability, test-retest reliability, construct validity, and concurrent validity. In total, 159 inpatients with HNC (mean age: 56.8 years, 95% males) were enrolled at a medical center in Southern Taiwan.

Results

The Principal Component Analysis of the C-SSS revealed a five-factor structure: 4 of the 5 factors were replicated in the original SSS, including Shame with Appearance, Regret, Social/Speech Concern, and Sense of Stigma; only factor 4, Self-discrimination, was newly identified in the current study. C-SSS showed acceptable internal validity (Cronbach's α =0.85), test-retest reliability, inter-rater reliability, and fair concurrent validity with the Taiwanese Depression Questionnaire (TDQ), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and Explanatory Model Interview Catalogue (EMIC).

Conclusion

The findings of this study indicate that C-SSS is a reliable and valid instrument for evaluating HNC patients' perception of shame and stigma in the Taiwanese population.

The pitfall of empathic concern with chronic fatigue after a disaster in young adults

BACKGROUND

Empathic concern (EC) is an important interpersonal resilience factor that represents positive adaptation, such as "relating to others" (a factor of posttraumatic growth [PTG]) after disaster. However, controversy exists regarding whether the changes in EC (e.g., the intra-personal change between the acute phase and the disillusionment phase) positively or negatively affect mental health after a disaster. We hypothesized that increased EC may increase chronic fatigue due to over-adjustment (hypothesis 1). We also hypothesized that increasing the changes in "relating to others" could decrease the changes in chronic fatigue (hypothesis 2).

METHODS

Forty-nine young, healthy volunteers (M/F: 36/13; age at 3 months after the disaster [3 months]: mean ± SD: 21.1 ± 1.7 years) underwent assessments of EC using the Japanese version of the Interpersonal Reactivity Index, chronic fatigue using the Japanese version of the Checklist Individual Strength (CIS-J) questionnaire, and "relating to others" using the Japanese version of the PTG inventory during the acute phase (3 months) and the disillusionment phase (1 year after the disaster). Pearson product moment correlations at 3 months and 1 year were determined for all scores related to EC. The changes (delta = degree of change from 3 months to 1 year) or scores at 1 year were entered into linear structural equation systems to test the hypotheses.

RESULTS

The delta of EC positively affected the delta of the CIS-J, and the delta of relating to others negatively affected the delta of the CIS-J. Both the EC and relating to others scores were negatively associated with the CIS-J score at 1 year. These results were in accordance with hypothesis 1 and 2.

CONCLUSIONS

We demonstrated the opposite effects of 2 types of ECs, i.e., stability (inherent disposition) and flexibility (degree of change), on the degree of chronic fatigue. Increasing EC with increasing chronic fatigue, but not the change in relating to others, may be a red flag for individuals during the disillusionment phase.

Validation of the Brazilian version of the Shame and Stigma Scale (SSS-Br) for patients with head and neck cancers

OBJECTIVE

To evaluate the psychometric properties of the Brazilian version of the Shame and Stigma Scale (SSS) in a sample of patients with head and neck cancers (HNC).

METHODS

This is a validation study carried out in a Brazilian cancer hospital. Patients over 18 years old who knew about their HNC diagnosis were consecutively recruited, answering the SSS, the Functional Assessment of Cancer Therapy (General and Head and Neck supplement) questionnaire, and the University of Washington Quality of Life Questionnaire. Internal consistency, test-retest procedure, convergent validity, and responsiveness analysis were the psychometric properties evaluated.

RESULTS

A total of 122 HNC patients were included. The SSS showed appropriate internal consistency (alphas ranging from 0.71 to 0.86), test-retest reliability (higher than 0.92 with exception of the "Regret domain"), and convergent validity. The responsiveness analysis with 38 patients was able to discriminate the scores before and after prosthetic procedures.

SIGNIFICANCE OF THE RESULTS

The Brazilian Portuguese version of the SSS may be considered a valid and reliable instrument for the evaluation of Brazilian patients with HNC. Future SSS validation studies are welcome in other developing countries in order to make cancer health providers aware of these negative feelings in their HNC patients.

The relationship between acceptance of cancer and distress: A meta-analytic review

Acceptance of cancer has long been recognized as playing a critical role in psychological adjustment to the illness, but its associations with distress outcomes have not been quantitatively reviewed. Informed by coping theory and third wave conceptualizations of acceptance, we first propose an integrated model of acceptance of cancer. Then we examine the strength of the relationships between acceptance of cancer and general and cancer-specific distress in cancer patients and potential moderators of these relationships. CINAHL, Embase, MEDLINE, PsycINFO, PsycARTICLES, and Web of Science databases were searched. Random-effects meta-analyses were conducted on 78 records (N = 15,448). Small-to-moderate, negative, and significant relationships were found between acceptance of cancer and general distress (r = -0.31; 95% CI: -0.36 to -0.26, k = 75); cancer-specific distress (r = -0.18; 95% CI: -0.21 to -0.14, k = 13); depressive symptoms (r = -0.25; 95% CI: -0.31 to -0.19, k = 41); and anxiety symptoms (r = -0.22; 95% CI: -0.30 to -0.15, k = 29). Age, marital status, and stage of cancer were identified as significant moderators. Findings suggest that acceptance of cancer may be important to target in interventions to reduce general and cancer-specific distress in cancer patients. Future research should focus on developing multifaceted measures of acceptance and identifying theory-based psychological and social processes that lead to greater acceptance.

Undergoing head and neck cancer surgery: A grounded theory

Surgery is the treatment of choice in most head and neck cancers. Very often, the surgery is radical with high impact on the psychosocial, functional and aesthetic fields. The aim of this study is to gain a deeper understanding of the patient's, clinician's and key informant's point of view when surgery is proposed, to improve the quality of pathways in terms of patients' practical, psychological and relational needs. We followed a Grounded Theory approach with semi-structured interviews. Seventeen participants (six patients, nine healthcare professionals and two volunteers) were interviewed immediately before surgery. The study generated a process of "persuading the patient of an obligation" as the core category. The other principal categories that emerged highlighted the patients' doubts and fears regarding the surgery consequences and, in parallel, strategies employed by the healthcare professionals to rebut hindering issues impeding surgery. In particular, healthcare professionals involved patients in an affiliation process through simplified communication to sustain the choice of surgery; the family plays a supportive role in this process. The interplay between the organisational process and patients' experience results in "I will let you convince me" at the end of the decision-making process, where the main aim was to save and be saved.

The experience of head and neck cancer survivorship (including laryngectomy): an integrated biopsychosocial model

PURPOSE OF REVIEW

The head and neck cancer (HNC) survivorship experience is unique among cancer populations. This review seeks to explore the HNC survivor experience associated with altered upper aerodigestive tract (UADT) function using principles of survivorship.

RECENT FINDINGS

HNC survivors experience complex physical, functional, and psychosocial challenges related to UADT dysfunction. Interventions need to address all of these dimensions being mindful of the survivor experience. Studies reveal related unmet needs of both HNC survivors and their family members. An expose of the HNC survivorship experience is timely since 2016/2017 contains the release of landmark position papers and guidelines in the field. These address the unique challenges faced by the HNC population, their management, and the triad psychosocial, functional, and physical survivor burden. Such developments will drive future care.

SUMMARY

The head and neck survivorship experience is characterized by complex changes with broad impact when examined in an experiential framework. HNC survivor care demands clinical excellence from multiple disciplines that are positioned to enact recent HNC guidelines and adopt survivorship principles. Future research in this population that explores experiential aspects of altered UADT function would be valuable in informing clinical practice. A biopsychosocial framework is presented for conceptualizing the HNC survivorship experience.

Impact of health-related stigma on psychosocial functioning in the general population: Construct validity and Swedish reference data for the Stigma-related Social Problems scale (SSP)

Felt stigma is an internalized sense of shame about having an unwanted condition, along with fear of discrimination. The Stigma‐related Social Problems (SSP) scale was constructed to measure the impact of health‐related stigma on psychosocial functioning in people with different diseases and disorders. The performance of the SSP scale was tested in 3,422 subjects from the general population (Mid‐Swed Health Survey) and in subgroups according to gender, age, occupation, and education. The homogeneity and construct validity of the Distress and Avoidance scales were confirmed by exploratory factor analysis and the two factors were accurately reproduced across gender and age subgroups. The internal consistency reliability was high for both the Distress and Avoidance scales. Reliability coefficients were above the 0.90 standard for the Distress scale in all subgroups and for the Avoidance scale in most subgroups. The SSP scale is an instrument with sound psychometric properties that can be used to identify psychosocial disturbances.

Influences of facial disfigurement and social support for psychosocial adjustment among patients with oral cancer in Taiwan: a cross-sectional study

OBJECTIVE

To explore the influences of facial disfigurement and social support for psychosocial adjustment in patients with oral cancer.

DESIGN

A cross-sectional design was used for the study.

PARTICIPANTS AND SETTING

A convenience sample of 77 patients with oral cancer was recruited from the otolaryngology and oral and maxillofacial surgery outpatient clinics of three general hospitals in Taiwan.

MEASURES

Data were collected using the study questionnaires, including the Facial Disfigurement Scale, the Social Support Scale and the Psychosocial Adjustment to Illness Scale.

RESULTS

The mean score on the Psychosocial Adjustment to Illness Scale was 413.01 (SD=32.32); 71.4% of the participants were maladjusted. Results of multiple regression analysis showed statistically significant main effects of tumour site (beta=0.37), facial disfigurement (beta=0.35) and social support (beta=-1.01), and the interaction effect of facial disfigurement and social support (beta=0.79) (all p<0.05) on psychosocial adjustment after controlling for other sociodemographic and clinical variables. All variables together explained 62% of the variance in psychosocial adjustment (F(16, 55)=14.98, p<0.001).

CONCLUSIONS

The level of psychosocial adjustment in patients with oral cancer was suboptimal. Poorer psychosocial adjustment was reported by patients with more severe facial disfigurement and less social support. Patients with cancers in other areas of the oral cavity also reported poorer psychosocial adjustment than patients with cancers in the buccal mucosa. Medical professionals may use these variables to identify higher risk groups for early intensive intervention.

Advance Care Planning and End-of-Life Issues in Head and Neck Cancer

Advance Care Planning and End of Life discussions are critical in all cancers but are often overlooked or delayed. Head and Neck Cancer patients have the added stigma of visible morbidity and negative quality of life issues. We present a case example and discussion of these issues in the Head and Neck cancer clinic.

Posttraumatic growth in head and neck cancer survivors: Is it possible and what are the correlates?

OBJECTIVES

Posttraumatic growth (PTG) is a possible positive consequence of a traumatic event, such as cancer. Head and neck cancer (HNC) may be particularly traumatic, given its adverse effects on functional, psychological, and social wellbeing. We investigated the extent of PTG, factors associated with PTG, and associations between PTG and health-related quality-of-life (HRQoL) in HNC survivors.

METHODS

HNC survivors (ICD10 C00-C14, C32), identified from the population-based National Cancer Registry Ireland, completed a postal survey. PTG was assessed using the Posttraumatic Growth Inventory (PTG-I) and HRQoL with FACT-G and FACT-H&N. Associations between socio-economic characteristics, social support, and clinical variables and PTG were examined using multivariable linear regression. Total HRQoL scores were compared in those with none-low PTG vs moderate-high PTG.

RESULTS

A total of 583 survivors participated (response rate = 59%). The mean PTG score was 55.74 (95%CI 53.15-58.33); 60% had moderate-high PTG. Survivors scored highest in the PTG-I domain appreciation of life. In multivariable analysis, being female, being younger, having more social support, and having cancer-related financial stress were significantly associated with more PTG. HRQoL was significantly higher in those with moderate-high than no-little PTG (P < .01).

CONCLUSIONS

A notable proportion of HNC survivors report PTG but growth is, on average, lower than reported for other cancers. Nonetheless, higher PTG appears related to better HRQoL. Further research would be valuable to understand the pathways by which HNC may lead to PTG and inform development of strategies to support and encourage PTG in this survivor population.

Narrative: The Fear of Disfigurement in Cancer Patients

Fear of disfigurement affects patients with cancer, in whom the disease or its treatment leaves them permanently marked. Contrary to our thought, disfigurement is equally distressing to male patients, and it causes severe dislocation in their lives. We describe two cases in which disfigurement caused tremendous change in our patients; these cases underline the need for psychotherapy in patients suffering from cancer.

The influence of stigma on the quality of life for prostate cancer survivors

The purpose of the present study was to investigate the influence of stigma on prostate cancer (PCa) survivors' quality of life. Stigma for lung cancer survivors has been the focus of considerable research (Else-Quest & Jackson, 2014); however, gaps remain in understanding the experience of PCa stigma. A cross-sectional correlational study was designed to assess the incidence of PCa stigma and its influence on the quality of life of survivors. Eighty-five PCa survivors were administered survey packets consisting of a stigma measure, a PCa-specific quality of life measure, and a demographic survey during treatment of their disease. A linear regression analysis was conducted with the data received from PCa survivors. Results indicated that PCa stigma has a significant, negative influence on the quality of life for survivors (R² = 0.33, F(4, 80) = 11.53, p < 0.001). There were no statistically significant differences in PCa stigma based on demographic variables (e.g., race and age). Implications for physical and mental health practitioners and researchers are discussed.

Social networks, social support and social negativity: A qualitative study of head and neck cancer caregivers' experiences

Head and neck cancer is a serious form of cancer that can generate substantial physical and psychosocial morbidity. Informal caregivers can help patients to manage head and neck cancer and its emotional impacts, both during and after treatment. Caregivers, however, can experience considerable stress as a result of their caring activities. Supportive relationships can protect caregivers from psychosocial strain. Thirty-one head and neck cancer caregivers were interviewed about their experiences of accessing social support from their social networks; difficulties that they experienced accessing this support; and strategies that they used to address these difficulties. Results suggest that head and neck cancer caregivers strongly value social support, but can find it difficult to obtain, and a number of them experience socially negative responses from their networks. Some carers attempt to answer or supplement support deficiencies by turning to non-human coping supports, such as pets, spiritual figures or medication. Implications for theory and practice are discussed.