What Is Successful Adaptation To Advanced Cancer

The extant literature on patients with metastatic cancer focuses almost exclusively on two indicators of psychological adjustment: depression/distress and QOL. Reports of the prevalence of emotional distress among individuals living with AC vary depending on the method of assessment and the nature of the sample.29 Several large studies and literature reviews estimate the prevalence of depression in AC to be approximately one-quarter to one-third of patients.29-35 Studies using self-report instruments generally report higher prevalence rates than those using structured psychiatric interviews to diagnose depression,29 and rates may be inflated if measures include somatic symptoms of depression (e.g., fatigue, insomnia).36 Estimates based on the perceptions of caregivers or physicians may also inflate the prevalence of distress, as one study based on palliative care social workers' assessments of patient functioning found that 63% of patients were anxious and 54% were depressed.28 In general, these findings suggest that although distress and depression can be significant in samples with AC, they are not universal. In fact, one noteworthy comparison study concluded that the prevalence of psychiatric disorder in women with early and advanced breast cancer was equal.33 In this study, 37% of 303 women with early-stage breast cancer met criteria for mood disorders, compared to 31% of 200 women with metastatic breast cancer.

In the medical literature, QOL is a standard indicator, often in the context of ascertaining whether biomedical treatments or side effects impair QOL or whether QOL is an independent predictor of survival. Quality of life, an individual's sense of well-being based on his or her current experience of life as a whole, overlaps

Table 2. Correlates of Poor Adaptation in the Context of Advanced Cancer

• Severity of physical symptoms (especially pain) and poor functional status

• Poor prognosis and perceived life threat

• Less satisfactory perceived social support

• Repression of emotional experience or expression

• Low dispositional optimism considerably with distress, as depression and anxiety account for most of the variance in QOL.37 However, QOL instruments often include indices of physical well-being and social role functioning in addition to psychological well-being. Growing evidence supports the prognostic significance of self-reported QOL in the context of AC.38-40 Investigators have argued that this predictive relationship reflects patients' awareness of their health status that is not captured by traditional prognostic markers,40 although the possibility remains that QOL has a causative impact on survival.38

Although measures of depression and QOL provide critical information about the psychological status of AC patients, we argue that a more nuanced view of adjustment could guide clinical practice and stimulate research. Rather than an acute event to which one might adapt and move beyond, living with AC is a dynamic and evolving stressor. The work of adjusting to life with AC continues until one's death, and patients' success at accommodating the losses, life disruption, and existential concerns that accompany AC will vary over time. Perhaps a constructivist approach to adaptive survivorship can provide insight into additional ways to define and measure well-being in this population. Constructivism views individuals as motivated to adapt one's self-concept to disruptions in the life narrative and to find personal meaning in such losses.41 Indeed, the experience of finding meaning or benefit in living with AC is commonly reported and often coexists with distress or depression.11,42 Are survivors living with AC who find existential meaning and purpose in their experience but continue to experience high levels of sadness well-adjusted? What about patients who report no distress related to their AC because they do not acknowledge the severity of their diagnosis? To determine whether patients with AC are managing the adaptive tasks laid out in the preceding section successfully, it may be necessary to assess both psychological distress and dysfunction as well as more positive outcomes, such as a sense of personal strength and self-efficacy, spiritual well-being, and the acceptance and integration of one's cancer experience into a meaningful life narrative. The next section and Table 2 summarize the small literature on correlates of adjustment to AC.

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