PTD benefits cancer survivors by translating an emotional process or cognitive development into change toward positive behaviors (Morris et al., 2012). In our study, 37.2% of participants were identified as reporting moderate to high PTD five years after diagnosis. Older age and the report of depressive symptoms were associated with low PTD. Being satisfied with the time spent by HCT on answering questions, having received psychological support at diagnosis, having increased physical activity and/or adopting healthier diet were associated an increased likelihood of having moderate to high PTD.
Numerous associations have been identified so far between medical conditions, socio-demographic factors and PTD experience, such as gender (Teixeira & Pereira, 2013), young age (Cormio et al., 2015), time since diagnosis, and advanced disease stage (Koutrouli et al., 2012;(Moreno & Stanton, 2013). As previously described, our results found an association between PTD and younger age. Female gender was also associated with higher levels of PTD in the univariate analysis, but only remained marginally associated after multiple adjustments. Cancer site was not associated with PTD after multiple adjustments, probably because it was closely linked to age and gender. Moreover, we did not find an association between PTD and cancer evolution five years after diagnosis. In contrast, participants who reported significant fatigue without depressive symptoms also reported higher levels of PTD. Fatigue and its repercussions on daily life is one of the major sequelae of cancer (Berger et al., 2015), and may play a role in the recall of the disease; the report of general sequelae may recover various problems which may explain the absence of a relationship with PTD.
Our attention was focused on modifiable factors, as was a previous study (Connerty & Knott, 2013) that explored and identified factors that facilitate growth. Interestingly, the study highlighted the value of modifiable factors such as physical activity and searching for information as promoting the level of PTD. However, this study only included expert patients. Our study conducted upon a representative sample of the cancer survivor population confirmed the impact of increased physical activity on PTD, and the importance for patients that HCT spent sufficient time answering questions. It also highlighted the association between PTD and the adoption of a healthy diet, as well as the benefit of psychological support.
PA and healthy diet are part of the foundation for improved health and wellness, especially for cancer survivors (Shapiro, 2018; Zhai et al., 2019; Mourouti et al., 2017). This suggests that, after cancer, advice regarding lifestyle habits should have their place, particularly in the need for individuals to optimize their diet. Adopting behaviors that contribute to health benefits could be associated with certain areas of development. This result is consistent with a previous study showing that functional well-being was associated with high PTD in elderly survivors (Yang & Ha, 2019). In our study, of those who reported a diet change, only 37.5% had access to a dietitian, so it seems therefore relevant to reinforce this access. Increased PA could also be a catalyst for PTG, as outlined in a previous study (Sabiston et al., 2007) in breast cancer patients included in a dragon boat program. The researcher suggests that, as part of a team sport challenge, support from others sharing the same experiences is helpful in facilitating PTG. This would be consistent with the concept of physical PTG explored in prostate cancer patients (Walsh et al., 2018). In the same way, a systematic review (Zhai et al., 2019) showed a relationship between growth and challenging activities for breast cancer survivors. Furthermore, there is a positive association between PA and a reduction of the risk of recurrence and overall mortality in patients with non-metastatic breast, colon and prostate cancer (Duclos, 2021). Another systematic review (Mishra et al., 2012) showed that exercise interventions may have beneficial effects on HRQoL. For all these reasons, adapted PA should be advocated more systematically for cancer survivors.
We observed an association between the access to psychological support at diagnosis and a high/moderate level of PTD, while long-term depressive symptoms were associated with a lower level of PTD. These results are consistent with a previous study showing that access to psychological support (Üzar-Özçetin & Hiçdurmaz, 2019) incorporating empowerment programs offered to cancer survivors improved PTD and resilience levels. These results are also confirmed in a review (Tomita et al., 2017) of previous studies reporting that PTG is associated with lower psychological distress, less depression, greater well-being and higher quality of life. The benefits of psychological support seem to be unanimous, but show considerable inter-individual variability (Porro et al., 2019) depending on certain areas of development such as relationships with others and the perception of new opportunities. Moreover, psychological group interventions are related to greater PTG (Lechner & Antoni, 2004);(Ramos et al., 2018)
Satisfaction with the time spent by HCT answering questions was associated with higher levels of PTD. Cancer survivors who are satisfied with the information they received have a better QOL, and are less anxious and depressive (Blödt et al., 2018). Information plays a role in cancer survivors that is clearly associated with regaining control in the face of a seemingly uncontrollable situation, becoming confident in their own decisions, understanding the impact of the disease on their lives, overcoming fear, etc. (Blödt et al., 2018). Despite this finding, numerous studies (Kent et al., 2012; Faller et al., 2016) have shown that the level of information still needs to be improved. According to Miller's study (Miller et al., 2018), information seeking in people who had cancer in childhood is associated with higher levels of PTD. Sufficient information could allow many individuals to use self-management (Coffey et al., 2016) and to better adapt to post-cancer conditions. Moreover, responding to patients' need for information encourage them to play an active role in their own care (Blödt et al., 2018). Information is one of the tools of adaptation that is closely linked to the individual's trajectory and interactions with HCT. We assume that meeting patients' need for information by devoting the necessary time to it would make it possible to improve their survivorship.
We did not find an association between PTD and QOL. We noted in a previous meta-analysis (Liu et al., 2020) that most studies found a positive relationship between QOL and PTG, suggesting that PTG may play a role in successful coping following cancer. This association is still unclear and the different measurements of overall HRQoL may also account for this heterogeneity. However, it appears to be an outcome of quality of life and encourages an understanding of the way to promote PTD. To understand this, longitudinal data are needed; adaptation process is complex and dynamic and response shift approaches are needed to highlight the link.