A diagnosis of cancer is a traumatic and unexpected event that puts the patient's life at risk and is sometimes fatal [1]. The stage in which the cancer is detected and treatment begins will influence both the course of the diagnosis [2] and the presence or absence of possible recurrences [3], thus impacting physiological and psychosocial domains. In this regard, depressive, anxious, and post-traumatic symptoms or sleep problems are the most common [2]. The Spanish Society of Medical Oncology [4] reported 19.3 million new cancer cases worldwide in 2020 and forecast 276,239 in Spain by 2021.
Meaning in life (MIL) has been shown to be particularly important when people face very stressful events [5] because an existential crisis leads to a search for meaning [6]. Consequently, MIL has been studied in various populations, such as refugees, immigrants, victims of terrorism or violence, and people diagnosed with chronic diseases, including cancer patients [7].
The term MIL has traditionally been interpreted as the experience of purpose and vital coherence [8], as well as the perception of responsibility in the life course [9]. However, the meaning of this construct is still ambiguous, due to its complexity and conceptual range [10]. Its definition shows wide variability, and it has been conceived as coherence of life [11], objectives, or purpose [12]. Similarly, other authors have pointed out that meaning and purpose have been considered synonyms on some occasions and as having different meanings on others, increasing the confusion in this regard [13].
The importance of MIL in mental health was addressed for the first time in the work by Frankl [14], who viewed it as the main source of motivation in human beings. When it is hindered, an existential emptiness occurs, leading to physical and psychological illnesses. In this way, MIL is associated with markers of well-being such as optimism, self-esteem [5], subjective health, and efficacy [15]. Similarly, it is negatively related to symptoms of anxiety and depression [16], suicidal thoughts [17], and even cancer and cardiovascular mortality rates [15].
In the cancer literature, MIL differentiates between meaning as the comprehension of an adverse event and the reasons it has occurred, which is typical of the first stage of the experience, and meaning as the significance of the philosophical and spiritual implications, as well as the existential consequences of the traumatic experience, which is typical of later stages [18]. The first meaning is related to the cancer diagnosis, challenging the set of personal beliefs [6] and questioning the life purpose, identity, and actions triggered by personal values [13] as patients try to incorporate the experience of the disease into their life scheme [19].
MIL may change through a process of meaning-making, defined as cognitive efforts to reduce the discrepancy between one's appraisal of a stressor and one's global meaning (i.e., beliefs, goals, and MIL) [20]. Park's integrated meaning-making model proposes that stressful life events (e.g., a cancer diagnosis) lead to a discrepancy between the global meaning -an individual’s general orienting system, including goals, feelings, global beliefs, and general concepts through which individuals interpret their world’s experiences- and the situational meaning -meaning in the context of a particular environmental encounter (the cancer diagnosis) that challenges a person's MIL and leads to meaning-making efforts. Successful meaning-making efforts result in a greater or restored sense of MIL and reduced distress. Failure to achieve meaning from the experience will lead to distress and psychopathology [20]. Studies have shown that, in advanced cancer patients, finding meaning leads to an increase in the assessment of their lives as positive and worthy [21].
Studies in cancer patients have found that low MIL is related to distress and a low sense of coherence, according to the results of a meta-analysis [18]. Borreani et al. [7] found a negative relationship between MIL and fear of recurrence, depression, and anxiety in a sample of 75 haematological cancer patients, and a recent systematic review found that MIL was correlated with acceptance of cancer but did not predict the acceptance of the disease [22]. In a multinational study of patients with cancer [23], the results did not show differences in levels of MIL across countries. Moreover, low MIL was predicted by physical symptoms, psychological distress, and existential and financial concerns, whereas higher MIL was associated with being married, being optimistic, and having higher education.
As mentioned above, the meaning-making process may change throughout the cancer process [20]. However, few studies have explored the evolution of MIL longitudinally during the cancer experience. Of them, Campo et al. [24], in a sample of 254 post-stem cell cancer survivors, found that resilience predicted increases in MIL. Another study, carried out with 108 Chinese terminally ill patients admitted to a palliative care unit [25], showed decreases in MIL from the time of admission to the unit, but their levels of faith or peace did not change over time. Moreover, meaning decreased with the increase in depression and pain levels. Moreover, Lin et al. [26] conducted a longitudinal study with 160 Taiwanese cancer patients undergoing radiotherapy whose meaning in life was assessed one week before and one week after radiotherapy. The authors observed higher levels of meaning in life in patients after treatment than before it. Moreover, they found lower levels of meaning in life in Stage IV patients who were unable to receive surgery and in patients who experienced greater distress after radiotherapy. However, only the work by Lin et al. [26] explored the trajectories of MIL throughout the different phases of the cancer experience, in this case, only before and after radiotherapy treatment.
The presence of MIL has been related to coping strategies during the diagnosis and treatment stages of cancer in a scarce number of studies. Jim et al. [27] found that positive coping strategies (e.g. acceptance, positive reinterpretation, active coping, seeking social support, and less denial) predicted higher levels of MIL in breast cancer patients two years after diagnosis. Krok and Telka [28] found that meaning had indirect effects on psychological well-being through the use of problem-, emotion-, and meaning-focused coping strategies in gastric cancer patients, and Krok et al. [29] found that MIL moderated the relationship between illness perception and affective symptoms through problem- and meaning-focused coping. In a meta-analysis, Quinto et al. [22] found that acceptance of cancer was associated with higher MIL.
However, to our knowledge, there are no studies that have explored MIL trajectories throughout the cancer process, that is, after diagnosis, surgery, and oncology treatments, and none have been carried out in Spanish breast cancer patients. Moreover, few studies have explored the relationship between coping at cancer diagnosis and the later MIL status. Thus, the main objective of this study was to explore the evolution of MIL in a sample of cancer patients at the time of their diagnosis and at different time points after surgery (3, 6, and 9 months after surgery). A second objective was to identify the association between coping strategies three months after diagnosis (T2) (fighting spirit, anxious preoccupation, hopelessness, fatalism, and cognitive avoidance) and levels of MIL at the different moments in the cancer process (T1-T4).