Psychosocial correlates of benefit finding in breast cancer survivors in China

Abstract

Breast cancer is number one in incidence and sixth in mortality among all cancers of women in China. Prior work identified positive consequences following diagnosis and treatment, including benefit finding among breast cancer survivors from Western countries. This study evaluated psychosocial correlates of benefit finding in breast cancer survivors in China. A total of 148 participants completed measures of coping, perceived stress, depressive symptoms, social support, and benefit finding. Results indicated that benefit finding was positively related to active coping and negatively related to depression. Future research may evaluate whether interventions to enhance active coping will improve outcomes among Chinese breast cancer survivors.

Keywords

breast cancer cancer survivors Chinese psychosocial women’s health

Introduction

Breast cancer is one of the most prevalent malignancies among women worldwide (Jemal et al., 2011). Although the incidence of breast cancer is relatively low in China compared to Western countries, data indicate that incidence rates have been rising sharply in China in recent years (Chen et al., 2013; Zeng et al., 2014).

Breast cancer is ranked number one in incidence and sixth in mortality among all cancers of women in China (Chen et al., 2011). Although advances in treatment have increased 5-year survival rates and many breast cancer survivors can expect to live a prolonged life, a number of studies involving breast cancer survivors have reported decrements in quality of life associated with the cancer experience, including psychological distress symptoms such as anxiety, depression, feelings of social isolation, and fear of cancer recurrence (Stanton et al., 2002; Stanton and Snider, 1993). A study of Chinese women with breast cancer reported that 50 percent of women experienced prolonged psychological distress for years following diagnosis (Lam et al., 2007).

In contrast, a growing body of literature conducted in Western countries documents the positive life changes that many cancer survivors associate with their illness experience (Stanton et al., 2006). To characterize these positive perceptions, a variety of terms including posttraumatic growth, stress-related growth, positive growth, and benefit finding have been used, which refer to a similar concept: that individuals struggling with highly adverse experience such as cancer can report both positive and negative consequences (Tedeschi and Calhoun, 2004a). In particular, studies of US women have found that breast cancer survivors report certain benefits following treatment including the development of closer ties to family and religion and gaining a more positive outlook on life (Northouse et al., 1995; Stanton et al., 2002). Breast cancer survivors in the United States have also reported improvements in social relations, a greater appreciation for life, a changed sense of priorities, a greater sense of personal strength, and beneficial spiritual changes (Cordova et al., 2001; Manne et al., 2004; Tomich and Helgeson, 2004; Urcuyo et al., 2005). Benefit finding may relate to improved quality of life and health outcomes via pathways involving adaptive coping or greater social support (Tedeschi and Calhoun, 1995, 2004b). This is consistent with general stress-coping theories that recognize cognitive and behavioral coping strategies to be fundamental in the adaptation to a stressful event (Folkman and Moskowitz, 2000; Lazarus and Folkman, 1984). Indeed, several studies of Western women have reported that specific active coping strategies, including positive reframing and acceptance (Bussell and Naus, 2010; Sears et al., 2003; Silva et al., 2012), problem-focused coping (Buyukasik-Colak et al., 2012), humor (Silva et al., 2012), active and planning coping techniques (Bellizzi and Blank, 2006; Lelorain et al., 2012), and religious coping (Bussell and Naus, 2010; Gall et al., 2011; Lelorain et al., 2012) were associated with positive growth. In contrast, avoidant coping strategies, such as denial and behavioral disengagement, were not significantly associated with women’s positive growth (Urcuyo et al., 2005). Among Hong Kong Chinese cancer survivors, a positive coping attitude was associated with more positive growth and avoidant coping not significantly related to positive growth (Ho et al., 2004).

A number of studies have demonstrated that the more cancer was appraised as stressful, the greater the extent of positive growth that was reported (Cordova et al., 2001, 2007). For example, in the Hong Kong Chinese cancer survivor study, Ho et al. (2004) found that positive growth was negatively related to anxiety and depression. In a longitudinal study, Liu et al. (2014) observed a weak negative association between positive growth and psychological distress over time among early stage breast cancer survivors in Beijing, China. However, some studies conducted in the United States have reported no significant associations between positive growth and perceived stressfulness of the breast cancer experience (Manne et al., 2004; Weiss, 2004). Furthermore, among Malaysian cancer patients, Schroevers and Teo (2008) found that the experience of positive growth was not significantly related to the level of psychological distress. It may be that the social support and social resources available to a person experiencing a trauma plays an important role in contributing to an individual’s ability to experience positive benefits from a traumatic event (Tedeschi and Calhoun, 1995). Several Western studies have reported that multiple aspects of social support have a significant relationship with posttraumatic positive growth (Bozo et al., 2009; Svetina and Nastran, 2012; Weiss, 2004). Specifically, individuals who have more social resources tend to be more likely to utilize active or approach coping strategies, which then lead to better adjustment to the stressful event. In contrast, other studies conducted in the United States reported no association between social support and posttraumatic positive growth (Cohen and Numa, 2011; Cordova et al., 2001; Weiss, 2004). Given cultural differences in the utilization of social support for coping with stress in general (Taylor et al., 2004) and across models of breast cancer survivorship more specifically (Ashing-Giwa et al., 2004; Coreil et al., 2012; Wen et al., 2014), associations among positive growth, negative psychological distress, and social support among Chinese women with breast cancer warrant further exploration.

Despite the significant amount of research on benefit finding in breast cancer populations in Western countries, however, relatively little is known about the experience of breast cancer patients in China. There are significant differences in education, culture, social, and lifestyle factors between women in China and Western countries. In particular, the predominant type of coping employed by Chinese women with breast cancer is problem-focused active coping strategy (Li and Lambert, 2007). This may be due, in part, to a Chinese cultural emphasis that one should always work hard and have a “constantly striving spirit” (Leung, 2010). Furthermore, Chinese culture and social norms place a high value on handling negative effect with restraint and other conservative and moderate traits. As a result, Chinese breast cancer patients are likely to employ self-control in dealing with physical, psychological, and social concerns (Lu et al., 1993).

Adaptive coping may, in turn, contribute to benefit finding among newly diagnosed breast cancer women in China, as observed in a recent study by Wang et al. (2015a). Over time, benefit finding predicted fewer depressive and anxious symptoms among Chinese breast cancer patients from diagnosis to 6 weeks postdiagnosis (Wang et al., 2015b). This study sought to extend the literature by characterizing benefit finding among breast cancer survivors during the early survivorship period in China. At present, there is limited empirical literature to describe the experience of cancer survivorship after the completion of primary medical treatments (Stanton, 2012). Therefore, focusing on early survivorship in this study will provide information to guide the development of evidence-based psychosocial care that can be offered to Chinese breast cancer survivors at treatment completion or later to promote long-term survivorship outcomes. Thus, the aim of this study is to investigate the extent to which coping strategies, psychosocial distress (perceived stress and depression), and social support were associated with benefit finding. First, based on prior studies (Ho et al., 2004; Liu et al., 2014), we hypothesized that the majority of our participants would report experiencing benefit finding. Second, we hypothesized that active coping would be positively associated with benefit finding. No significant associations were expected between avoidant coping and benefit finding. Third, we explored the relationship between benefit finding and perceived stress, depression, and social support in Chinese breast cancer survivors.

Methods

Participants and recruitment procedures

This study was approved by Temple University’s (TU) Institutional Review Board and represented an international research collaboration between the Center for Asian Health (CAH) at TU and the Nanjing Cancer Survivors Association (NCSA) in China. As a joint effort through the pooling of resources, the CAH offered guidance in protocol development and research methods, and the NCSA played a central role in study implementation including participant recruitment and data collection. In addition to the onsite training by the principal investigator (PI; Dr Ma), regular conference calls were conducted between the research team members of TU-CAH and NCSA to collaboratively discuss study design, review recruitment progress, and interpretation of the findings. Patient eligibility criteria included (1) completed treatment for early stage breast cancer (stages 0–III), (2) age 21 years or older, (3) be no more than 6 years post-treatment (because this study focused on early survivorship phase), (4) no other history of cancer, and (5) able to provide informed consent. A convenience sampling approach was used to recruit breast cancer survivors through NCSA’s community outreach events, newsletters, and survivor support groups. Eligible women who were interested in participating were provided with a consent form and self-administered questionnaire to return in a self-addressed sealed envelope. Study participation was voluntary without compensation. A total of 148 women participated in the study. The majority of study participants were NCSA members. Data collection occurred over a 6-month period from September 2013 to March 2014.

Measures

Demographic and disease-related variables

Participants provided demographic information including age, marital or relationship status, employment status, annual household income, insurance status, and years of formal education completed. Disease-related characteristics included cancer stage, type of treatment received, time since treatment completion, and follow-up care status.

Benefit finding

A six-item instrument adapted from the Benefit Finding Scale was used (Urcuyo et al., 2005). The statement for each item is “Having breast cancer …,” followed by a potential benefit gained from the experience. The scale includes items such as “has led me to be more accepting of things” and “has brought my family closer together.” Items were scored on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree), and the mean across all items measured total benefit finding. The final selection of the Benefit Finding Scale items was based on the feedback and pilot testing with the NCSA’s advisors and patient focus groups to ensure its cultural relevance and appropriateness (see Table 1 for the included items). In the present sample, the six-item Benefit Finding Scale showed excellent internal consistency (Cronbach’s alpha = 0.80).

Table 1.

Endorsement of individual benefit finding items and results of a principal component analysis of the six benefit finding items.

Having breast cancer …	Endorsement (%)^a	Factor loading^b
Has led me to meet people who have become some of my best friends	96	0.74
Has helped me become more aware of the love and support available from other people	94	0.71
Has led me to be more accepting of things	91	0.54
Has helped me become a stronger person, more able to cope effectively with future life challenges	86	0.82
Has brought my family closer together	83	0.63
Has led me to deal better with stress and problems	81	0.76

Percentage of participants reporting particular benefit experience in agree to strongly agree degree.

Individual factor loading from a principal component analysis that yielded a one-factor structure.

Perceived stress

The Perceived Stress Scale is a standardized, self-report questionnaire used to determine the extent to which a person perceives her or his life to be unpredictable, uncontrollable, and overwhelming (Cohen et al., 1983). The 14-item version was used for this study. Examples of the questions include the following: “How often have you felt nervous or stressed?” and “How often have you felt confident about your ability to handle your personal problems?” Women rated how often they experienced the above feelings in the past month on a 5-point Likert scale ranging from 0 (never) to 4 (very often). Total scores range from 0 to 56, with higher scores indicating greater overall stress. In the present sample, coefficient alpha reliability was 0.80.

Coping

Coping skills were assessed using the Brief COPE scale (Carver, 1997), a 28-item coping inventory. Participants rated how often they employed a particular strategy as a way of coping with their stress from the cancer experience (1 = I have not been doing this at all to 4 = I have been doing this a lot), with higher scores indicating greater use of that particular coping strategy. The brief COPE has previously been validated in Chinese populations (Wang et al., 2007). In this study, only the scales capturing problem-focused active coping and avoidant coping were used. Based on previous research (Marroquín et al., 2010; Sanders et al., 2010; Thornton et al., 2012), we created a composite score of active coping by averaging across all items from the two COPE subscales: coping through planning and active coping efforts (four items, α = 0.70 in this study). Avoidant coping was assessed using the mean of items from the behavioral disengagement and denial subscales (four items, Cronbach’s alpha = 0.70 in this study).

Social support

Social support was measured using the eight-item Duke-UNC Functional Social Support Questionnaire (FSSQ; Broadhead et al., 1988). Participants were asked how strongly they agreed with statements such as “I have people who care what happens to me” and “I have chances to talk to someone I trust about my personal and family problems,” with responses on a Likert scale ranging from 5 (as much as I would like) to 1 (much less than I would like). The mean of all items was computed to derive the overall score, with the higher scores reflecting higher levels of social support. Good internal consistency was observed with the FSSQ in this study (Cronbach’s alpha = 0.90).

Depressive symptoms

The Patient Health Questionnaire (PHQ) was the first self-reported questionnaire specifically designed for use to establish psychiatric diagnoses (Kroenke et al., 2001). Due to its diagnostic validity and ease of scoring, the PHQ nine-item depression module has become widely used in both clinical practice and research. The PHQ consists of one item for each of the nine criterion: (1) anhedonia, (2) depressed mood, (3) trouble sleeping, (4) feeling tired, (5) change in appetite, (6) guilt or worthlessness, (7) trouble concentrating, (8) feeling slowed down or restless, and (9) suicidal thoughts. A 4-point scale from 0 (not at all) to 3 (nearly every day) indicates degree of severity. Severity ratings were summed across each item to create an overall score, which was used as a continuous variable in the subsequent analysis. The PHQ was validated with Chinese populations (Yeung et al., 2008). (Cronbach’s alpha = 0.78 in this study).

Statistical analysis

Descriptive analysis was used to describe the sample characteristics and prevalence of benefit finding. Because a shortened version of the Benefit Finding Scale was used, a principal component analysis was first conducted to evaluate the unidimensional nature of the construct. Next, to identify potential covariates for inclusion in the regression model, correlation and analysis of variance procedures were conducted to determine associations of demographic and disease-related variables with benefit finding. Finally, multivariate linear regression analysis was performed to examine associations of coping, perceived stress, depressive symptoms, and social support (independent variables) with benefit finding (dependent variable).

Results

Participant characteristics and descriptive data

Participants were, on average, 54 years old and predominantly married (91%), had completed a high school degree (67%), retired (70%), with an annual household income less than 60K RMB (equivalent to US$9645; 89%), and had health insurance (98%). China’s National Bureau of Statistics categorizes the Chinese middle class as households with an annual income ranging from 60K to 500K RMB; therefore, the majority of participants in this study were from relatively low-income households in China (Yuan et al., 2011). Furthermore, the majority of participants were diagnosed with stage II breast cancer (64%), had completed both surgery and chemotherapy (89%), were within 1–3 years posttreatment (51%), and were being seen every 6 months for follow-up care (78%). Participants reported relatively high levels of benefit finding (M = 4.1, standard deviation (SD) = 0.4). The perceived stress score correspond to a moderate degree of stress (sum = 25.4, SD = 6.7). Active coping (M = 3.0, SD = 0.7) was endorsed more frequently than avoidant coping (M = 1.9, SD = 0.8). The mean score on the FSSQ was 2.4 (SD = 0.9), suggesting low-to-moderate levels of perceived social support. On the PHQ, the mean depressive symptoms score was 5.9 (SD = 3.7), suggesting a degree of mild depression (Table 2).

Table 2.

Correlations between benefit finding and psychosocial variables.

Psychosocial variable	M	SD	Score range	Correlations
Psychosocial variable	M	SD	Score range	r	p
1. Benefit finding	4.1	0.5	1–5
2. Perceived stress	25.4	6.7	0–56	−0.11	0.20
3. Active coping	3.0	0.7	1–4	0.25	0.00
4. Avoidant coping	1.9	0.8	1–4	0.22	0.01
5. Social support	2.4	0.9	1–5	−0.14	0.10
6. Depressive symptoms	5.9	3.7	0–27	−0.22	0.01

SD: standard deviation.

Prevalence of benefit finding

To examine participant experiences, each item was examined individually. Participant responses of 4 (agree) and 5 (strongly agree) were classified as indicating having experienced this benefit. All items were reported by at least 80% of the participants experiencing the specific benefit. The three most frequently endorsed benefit finding statements reported were “ breast cancer has led me to meet people who have become some of my best friends,” “breast cancer has helped me become more aware of the love and support available from other people,” and “breast cancer has led me to be more accepting of things” (Table 1).

Principal component analysis of Benefit Finding Scale

Principal component analysis yielded one factor with eigenvalues greater than 1.0, suggesting a one-factor construct for the shortened version of the Benefit Finding Scale used in this study. All items had factor loadings of >0.5 (Table 1).

Relations with demographic and disease-related variables

To identify potential covariates, we tested the relationship between benefit finding and each of the demographic and disease-related variables reported above using correlation or analysis of variance when appropriate. No significant association was found between benefit finding and any of the demographic or disease-related variables (see Table 3). Thus, these variables were not included in the subsequent regression analyses.

Table 3.

Descriptive statistics for demographics and disease-related variables, and their associations with benefit finding.

	N = 148 (%)	p value of association with benefit finding
Age (years), M (SD)	54.1 (7.39)	0.96^a
Marital status
Married or living as married	134 (90.5)	0.72^b
Divorced or separated	8 (5.4)
Widowed	6 (4.1)
Annual household income^c
Less than 30K RMB	53 (35.8)	0.77^b
Between 30K and 60K RMB	68 (45.9)
More than 60K RMB	16 (10.8)
Missing	11 (7.4)
Highest education
Below high school graduate	48 (32.4)	0.94^b
High school	66 (44.6)
College or above	33 (22.3)
Missing	1 (1.0)
Employment
Employed	21 (14.1)	0.92^b
Unemployed	18 (12.1)
Retired	103 (69.8)
Homemaker	6 (4.0)
Insurance
No	3 (2.0)	0.60^b
Yes	145 (98.0)
Stage of cancer
Stage 0	4 (2.7)	0.87^b
Stage I	40 (27.0)
Stage II	94 (63.5)
Stage III	10 (6.8)
Form of treatment completed
Surgery	148 (100.0)	N/A
Chemotherapy	132 (89.3)	0.98^b
Radiation	56 (38.0)	0.25^b
Years after treatment completion
Within a year	32 (21.6)	0.69^b
1–3 years	75 (50.7)
3–6 years	41 (27.7)
Frequency of follow-up checks^d
Every 3 months	17 (11.5)	0.94^b
Every 6 months	116 (78.4)
Every 12 months	14 (9.5)
Every 2 years	1 (0.7)

SD: standard deviation; ANOVA: analysis of variance.

Correlation analysis.

One-way ANOVA.

Annual household income was reported in RMB (Chinese yuan), the official currency in China. 1 RMB is equal to US$0.15 in January 2016.

The percentages for frequency of follow-up check do not add up exactly to 100% due to rounding.

Benefit finding, coping, psychological functioning, and social support

In correlational analyses, both active and avoidant coping strategies were modestly correlated with benefit finding (see Table 2). Specifically, higher levels of active coping (r = 0.25, p < 0.001) and avoidant coping (r = 0.22, p < 0.01) were both positively correlated with greater benefit finding.

Benefit finding was not significantly correlated with perceived stress. However, benefit finding was negatively correlated with depression (r = −0.22, p = 0.01). Thus, greater positive psychological benefits resulting from the breast cancer experience were correlated with lower levels of depressive symptoms. However, social support was not significantly correlated with benefit finding.

A multivariate regression analysis was conducted in which benefit finding was regressed on the set of variables that had been found to be related to it individually: depressive symptoms, active coping, and avoidant coping. As a set, these variables accounted for 20% of the variance in benefit finding (F(3, 122) = 7.03, p < 0.001). Significant individual contributions were made by depressive symptoms (β = −0.35, p < 0.001) and active coping (β = 0.18, p < 0.05). Avoidant coping was not significantly related to benefit finding in the multivariate regression analysis (Table 4).

Table 4.

Regression analysis of depressive symptoms, active coping, and avoidant coping on benefit finding.

	Standard B	t	95% CI	p
Depressive symptoms	−0.35	−4.12	−0.06 to −0.02	0.00
Active coping	0.18	2.05	0.004 to 0.21	0.04
Avoidant coping	0.15	1.70	−0.01 to 0.17	0.09

CI: confidence interval.

R² = 0.20, F(3, 122) = 7.03, p < 0.001.

Discussion

This cross-sectional study investigated psychosocial correlates of benefit finding in a sample of 148 Chinese breast cancer survivors and represents one of only a handful of studies on cancer-related positive growth among Chinese survivors. The results indicated that the majority of women reported benefit finding as a result of the breast cancer experience, especially a greater development and recognition of new and existing friendships and support networks surrounding them. This finding is an interesting phenomenon given that inter-connectedness, group values, and harmony are more highly emphasized in Asian cultures (Lam and Fielding, 2003) and reflect a relatively lower emphasis on positive changes in personal strengths, which tend to be more highly emphasized and valued in Western cultures. Furthermore, patients commonly somatize their feelings in Chinese culture (Nilchaikovit et al., 1993), and their emotions are usually controlled and contained in social situations (Holroyd et al., 1998). Thus, the finding of high prevalence of benefit finding contributes to a greater understanding of how Chinese women respond to this health threat. As hypothesized, active coping was positively related to benefit finding. Our results are consistent with the findings from a recent review that identified problem-focused coping strategies to be related to posttraumatic positive changes in women with breast cancer (Kolokotroni et al., 2014). In addition, avoidant coping strategies were not associated with benefit finding in multivariate analyses, similar to the findings reported by Ho et al. (2004), Urcuyo et al. (2005), and Schroevers and Teo (2008). Previous research has demonstrated that interventions that improve problem-focused coping can lead to improvement in outcomes such as quality of life and depressive symptoms in breast cancer patients (Antoni et al., 2001; McGregor et al., 2004). Thus, future research should evaluate whether interventions that enhance the use of active problem-focused coping strategies, in a culturally relevant manner for Chinese breast cancer patients, can increase benefit finding and improve quality-of-life outcomes.

We found that benefit finding was not significantly associated with perceived stress, consistent with previous research (Manne et al., 2004; Weiss, 2004). However, depressive symptoms were correlated with benefit finding, similar to what Ho et al. (2004) reported. It may be that benefit finding is a protective factor against more stable or persistent mental health disorders, such as the development of depressive symptoms or major depressive disorder (Schwarzer et al., 2006), but would not necessarily be associated with the common or routine stressful events and tensions that can fluctuate on a daily or weekly basis. In addition, Stanton et al. (2006) have proposed that the lack of association between positive growth and perceived stress in some studies might be attributed, in part, to the absence of an appropriate indicator of the perceived stressfulness of breast cancer.

In this study, we did not observe any association between social support and benefit finding, similar to other studies in the field (Cohen and Numa, 2011; Cordova et al., 2001; Weiss, 2004). A review of benefit finding in cancer reported that there was inconclusive evidence for the association between social support and benefit finding (Pascoe and Edvardsson, 2013). One explanation for this nonassociation may be that the existence of support networks (such as that captured by the FSSQ) does not reflect the actual utilization of these resources. Cultural beliefs may affect whether Chinese women ask for support, as Asian women are less likely to seek help and social support (Wellisch et al., 1999) and worry about burdening the family (Ashing-Giwa et al., 2004). Thus, future studies among Chinese cancer survivors may need to incorporate measures of support utilization, in order to develop a greater understanding of how support resources may be associated with survivorship outcomes. Consistent with the Stanton et al. (2006) review, we found little evidence of an influence of demographic (age, marital or relationship status, annual household income, employment status, insurance status, and years of formal education completed) and disease-related (cancer stage, type of treatment received, time since treatment completion, and follow-up care status) variables on benefit finding. Some evidence indicates that patients with more advanced cancers report more benefit (Tomich and Helgeson, 2004), suggesting that greater threat to mortality may serve as a precursor to efforts at making meaning from the experience. However, a recent study demonstrated that women with a higher tumor stage at diagnosis experienced less benefit finding in comparison with women with a lower tumor stage at diagnosis (Mols et al., 2009). Our study with predominantly stages I and II breast cancer survivors did not detect any differences in benefit finding by cancer stage, but this may be due in part to the low number of women with advanced disease in this study.

In this study, active coping and depressive symptoms accounted for 20% of the variance in benefit finding. Indeed, these findings suggest that other variables may be contributing to benefit finding, such as self-efficacy (Luszczynska et al., 2005) or marital intimacy (Canavarro et al., 2015; Talley et al., 2010). For example, self-efficacy had direct effects on personal growth among cancer survivors following surgical treatment (Luszczynska et al., 2005) and accounted for about 15% of variance in benefit finding. Therefore, future research with Chinese breast cancer survivors needs to explore these and other factors that may contribute to benefit finding.

This study has several limitations. First, use of a convenience sampling approach may have decreased the representativeness of the sample. It is possible that women who experienced positive growth would be more likely to participate in this survey study compared to women facing more challenges and poorer outcomes during survivorship. Second, due to the cross-sectional nature of the study, we cannot draw conclusions about potential causal relationships between coping and benefit finding. Future studies utilizing a longitudinal research design, a larger sample size, and a more general population of survivors across China is needed to inform our understanding about the dynamic processes that may exist between coping strategies and benefit finding. A third limitation involves the use of a shortened version of the Benefit Finding Scale. Although we used a shortened version of the Benefit Finding Scale, the items were carefully selected and pretested with our NCSA advisors and patient focus group participants to best reflect the culture and relevance of our target population. In addition, it should be noted that the short version of the Benefit Finding Scale demonstrated good internal consistency in this study, and the principal component analysis demonstrated that all items were loaded onto one factor.

Despite these limitations, this is one of the first studies that contribute to the growing literature on benefit finding and coping with breast cancer in a non-Western breast cancer survivor population. Additional studies utilizing a longitudinal design are needed to replicate and extend the findings reported here in larger and more diverse samples (e.g. across different provinces in China, greater heterogeneity in disease stage) to characterize benefit finding over time and across the cancer trajectory among Chinese breast cancer survivors. It is critical in future research that we explore the relationship of various clinical parameters and other psychosocial variables (e.g. risk perception and fear of recurrence) to benefit finding over time. In light of the consistent relationship between active coping strategy and benefit finding, facilitation of such attempts may be clinically useful. Previous research has shown that interventions that improve coping can lead to improvements in outcomes such as quality of life and depressive symptoms in Western patients with breast cancer (Antoni et al., 2009; McGregor et al., 2004). Future studies may evaluate whether culturally relevant interventions to promote proactive coping approaches as a protective factor would contribute positive outcomes among Chinese breast cancer survivors.

Footnotes

Acknowledgements

The authors thank the Nanjing Cancer Survivors Association in China and the breast cancer survivors who participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was partially supported by Faculty Research funds of Center for Asian Health, Temple University (principal investigator (PI): Grace X. Ma, PhD), U54 CA153513 (PI: Grace X. Ma, PhD), and R03TW009406 (PI: Grace X. Ma, PhD).

References

Antoni

Lechner

Diaz

. (2009) Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer. Brain, Behavior, and Immunity 23: 580–591.

Antoni

Lehman

Kilbourn

. (2001) Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychology 20: 20–32.

Ashing-Giwa

Padilla

Tejero

. (2004) Understanding the breast cancer experience of women: A qualitative study of African American, Asian American, Latina and Caucasian cancer survivors. Psycho-oncology 13: 408–428.

Bellizzi

Blank

(2006) Predicting posttraumatic growth in breast cancer survivors. Health Psychology 25: 47–56.

Bozo

Gundogdu

Buyukasik-Colak

(2009) The moderating role of different sources of perceived social support on the dispositional optimism–posttraumatic growth relationship in postoperative breast cancer patients. Journal of Health Psychology 14: 1009–1020.

Broadhead

Gehlbach

de Gruy

. (1988) The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients. Medical Care 26: 709–723.

Bussell

Naus

(2010) A longitudinal investigation of coping and posttraumatic growth in breast cancer survivors. Journal of Psychosocial Oncology 28: 61–78.

Buyukasik-Colak

Gundogdu-Akturk

Bozo

(2012) Mediating role of coping in the dispositional optimism-posttraumatic growth relation in breast cancer patients. Journal of Psychology 146: 471–483.

Canavarro

Silva

Moreira

(2015) Is the link between posttraumatic growth and anxious symptoms mediated by marital intimacy in breast cancer patients? European Journal of Oncology Nursing 19: 673–679.

10.

Carver

(1997) You want to measure coping but your protocol’s too long: Consider the brief COPE. International Journal of Behavioral Medicine 4: 92–100.

11.

Chen

W-q

Zhang

S-w

Zou

X-n

. (2011) Cancer incidence and mortality in China, 2006. Chinese Journal of Cancer Research 23: 3–9.

12.

Chen

W-q

Zheng

R-s

Zeng

H-m

. (2013) Incidence and mortality of breast cancer in China, 2008. Thoracic Cancer 4: 59–65.

13.

Cohen

Numa

(2011) Posttraumatic growth in breast cancer survivors: A comparison of volunteers and non-volunteers. Psycho-oncology 20: 69–76.

14.

Cohen

Kamarck

Mermelstein

(1983) A global measure of perceived stress. Journal of Health and Social Behavior 24: 385–396.

15.

Cordova

Giese-Davis

Golant

. (2007) Breast cancer as trauma: Posttraumatic stress and posttraumatic growth. Journal of Clinical Psychology in Medical Settings 14: 308–319.

16.

Cordova

Cunningham

Carlson

. (2001) Posttraumatic growth following breast cancer: A controlled comparison study. Health Psychology 20: 176–185.

17.

Coreil

Corvin

Nupp

. (2012) Ethnicity and cultural models of recovery from breast cancer. Ethnicity & Health 17: 291–307.

18.

Folkman

Moskowitz

(2000) Positive affect and the other side of coping. American Psychologist 55: 647–654.

19.

Gall

Charbonneau

Florack

(2011) The relationship between religious/spiritual factors and perceived growth following a diagnosis of breast cancer. Psychology & Health 26: 287–305.

20.

Chan

(2004) Posttraumatic growth in Chinese cancer survivors. Psycho-oncology 13: 377–389.

21.

Holroyd

Cheung

. (1998) A Chinese cultural perspective of nursing care behaviours in an acute setting. Journal of Advanced Nursing 28: 1289–1294.

22.

Jemal

Bray

Center

. (2011) Global cancer statistics. CA: A Cancer Journal for Clinicians 61: 69–90.

23.

Kolokotroni

Anagnostopoulos

Tsikkinis

(2014) Psychosocial factors related to posttraumatic growth in breast cancer survivors: A review. Women & Health 54: 569–592.

24.

Kroenke

Spitzer

Williams

(2001) The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine 16: 606–613.

25.

Lam

Fielding

(2003) The evolving experience of illness for Chinese women with breast cancer: A qualitative study. Psycho-oncology 12: 127–140.

26.

Lam

WWT

Chan

. (2007) Treatment decision difficulties and post-operative distress predict persistence of psychological morbidity in Chinese women following breast cancer surgery. Psycho-oncology 16: 904–912.

27.

Lazarus

Folkman

(1984) Stress, Appraisal, and Coping. New York: Springer.

28.

Lelorain

Tessier

Florin

. (2012) Posttraumatic growth in long term breast cancer survivors: Relation to coping, social support and cognitive processing. Journal of Health Psychology 17: 627–639.

29.

Leung

(2010) Beliefs in Chinese culture. In: Bond

(ed.) The Oxford Handbook of Chinese Psychology. Oxford: Oxford University Press, pp. 221–240.

30.

Lambert

(2007) Coping strategies and predictors of general well-being in women with breast cancer in the People’s Republic of China. Nursing & Health Sciences 9: 199–204.

31.

Liu

Wang

. (2014) Posttraumatic growth and psychological distress in Chinese early-stage breast cancer survivors: A longitudinal study. Psycho-oncology 23: 437–443.

32.

Chin

Huang

(1993) Coping behaviors of women with breast cancer. Nursing Research (China) 1: 247–256.

33.

Luszczynska

Mohamed

Schwarzer

(2005) Self-efficacy and social support predict benefit finding 12 months after cancer surgery: The mediating role of coping strategies. Psychology, Health & Medicine 10: 365–375.

34.

McGregor

Antoni

Boyers

. (2004) Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer. Journal of Psychosomatic Research 56: 1–8.

35.

Manne

Ostroff

Winkel

. (2004) Posttraumatic growth after breast cancer: Patient, partner, and couple perspectives. Psychosomatic Medicine 66: 442–454.

36.

Marroquín

Fontes

Scilletta

. (2010) Ruminative subtypes and coping responses: Active and passive pathways to depressive symptoms. Cognition and Emotion 24: 1446–1455.

37.

Mols

Vingerhoets

AJJM

Coebergh

JWW

. (2009) Well-being, posttraumatic growth and benefit finding in long-term breast cancer survivors. Psychology & Health 24: 583–595.

38.

Nilchaikovit

Hill

Holland

(1993) The effects of culture on illness behavior and medical care. Asian and American differences. General Hospital Psychiatry 15: 41–50.

39.

Northouse

Laten

Reddy

(1995) Adjustment of women and their husbands to recurrent breast cancer. Research in Nursing & Health 18: 515–524.

40.

Pascoe

Edvardsson

(2013) Benefit finding in cancer: A review of influencing factors and health outcomes. European Journal of Oncology Nursing 17: 760–766.

41.

Sanders

Bantum

Owen

. (2010) Supportive care needs in patients with lung cancer. Psycho-oncology 19: 480–489.

42.

Schroevers

Teo

(2008) The report of posttraumatic growth in Malaysian cancer patients: Relationships with psychological distress and coping strategies. Psycho-oncology 17: 1239–1246.

43.

Schwarzer

Luszczynska

Boehmer

. (2006) Changes in finding benefit after cancer surgery and the prediction of well-being one year later. Social Science & Medicine 63: 1614–1624.

44.

Sears

Stanton

Danoff-Burg

(2003) The yellow brick road and the emerald city: Benefit finding, positive reappraisal coping and posttraumatic growth in women with early-stage breast cancer. Health Psychology 22: 487–497.

45.

Silva

Crespo

Canavarro

(2012) Pathways for psychological adjustment in breast cancer: A longitudinal study on coping strategies and posttraumatic growth. Psychology & Health 27: 1323–1341.

46.

Stanton

(2012) What happens now? Psychosocial care for cancer survivors after medical treatment completion. Journal of Clinical Oncology 30: 1215–1220.

47.

Stanton

Snider

(1993) Coping with a breast cancer diagnosis: A prospective study. Health Psychology 12: 16–23.

48.

Stanton

Bower

Low

(2006) Posttraumatic growth after cancer. In: Calhoun

Tedeschi

(eds) Handbook of Posttraumatic Growth: Research and Practice. Mahwah, NJ: Lawrence Erlbaum Associates, pp. 138–175.

49.

Stanton

Danoff-burg

Huggins

(2002) The first year after breast cancer diagnosis: Hope and coping strategies as predictors of adjustment. Psycho-oncology 11: 93–102.

50.

Svetina

Nastran

(2012) Family relationships and post-traumatic growth in breast cancer patients. Psychiatria Danubina 24: 298–306.

51.

Talley

Molix

Schlegel

. (2010) The influence of breast cancer survivors’ perceived partner social support and need satisfaction on depressive symptoms: A longitudinal analysis. Psychology & Health 25: 433–449.

52.

Taylor

Sherman

Kim

. (2004) Culture and social support: Who seeks it and why? Journal of Personality and Social Psychology 87: 354–362.

53.

Tedeschi

Calhoun

(1995) Trauma and Transformation: Growing in the Aftermath of Suffering. Thousand Oaks, CA: SAGE.

54.

Tedeschi

Calhoun

(2004a) Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry 15: 1–18.

55.

Tedeschi

Calhoun

(2004b) Target article: Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry 15: 1–18.

56.

Thornton

Owen

Kernstine

. (2012) Predictors of finding benefit after lung cancer diagnosis. Psycho-oncology 21: 365–373.

57.

Tomich

Helgeson

(2004) Is finding something good in the bad always good? Benefit finding among women with breast cancer. Health Psychology 23: 16–23.

58.

Urcuyo

Boyers

Carver

. (2005) Finding benefit in breast cancer: Relations with personality, coping, and concurrent well-being. Psychology & Health 20: 175–192.

59.

Wang

Lambert

(2007) Anxiety, depression and coping strategies in post-hysterectomy Chinese women prior to discharge. International Nursing Review 54: 271–279.

60.

Wang

Zhu

Yang

. (2015a) What factors are predictive of benefit finding in women treated for non-metastatic breast cancer? A prospective study. Psycho-oncology 24: 533–539.

61.

Wang

Zhu

. (2015b) Benefit finding predicts depressive and anxious symptoms in women with breast cancer. Quality of Life Research 24: 2681–2688.

62.

Weiss

(2004) Correlates of posttraumatic growth in married breast cancer survivors. Journal of Social and Clinical Psychology 23: 733–746.

63.

Wellisch

Kagawa-Singer

Reid

. (1999) An exploratory study of social support: A cross-cultural comparison of Chinese-, Japanese-, and Anglo-American breast cancer patients. Psycho-oncology 8: 207–219.

64.

Wen

K-Y

Fang

(2014) Breast cancer experience and survivorship among Asian Americans: A systematic review. Journal of Cancer Survivorship 8: 94–107.

65.

Yeung

Fung

S-C

. (2008) Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans. Comprehensive Psychiatry 49: 211–217.

66.

Yuan

Guanghua

Khor

(2011) The rise of the middle class in the People’s Republic of China. Economics Working Paper Series No. 247, Mandaluyong City: Asian Development Bank.

67.

Zeng

Zheng

Zhang

. (2014) Female breast cancer statistics of 2010 in China: Estimates based on data from 145 population-based cancer registries. Journal of Thoracic Disease 6: 466–470.