1. Mary M. Step
Ashley M. Sandella
Department of Family Medicine
Case Western Reserve University, Cleveland, OH

2.  Cancer recurrence is traumatic 1-3
 Patients learned coping in primary illness 4-6
 Key is finding or maintaining hope
 Definitions of hope:
 Dynamic, multidimensional life force that is vital to
coping with chronic illness 9-12
 A positive attitude toward future events that is grounded
in subjectively derived sources of meaning in a person’s
life 13

3.  Benefit-finding & hope
 May aid adjustment to chronic disease 16
 Demonstrated across a range of chronic diseases 17-19
 Benefit-finding has been associated with: 21,22
 Optimism 21
 Positive reframing 21
 Religious coping 21
 Posttraumatic growth 22

4.  Hope and benefit-finding are important to coping
with illness, however little is known about how these
resources are experienced by recurrent cancer
patients 23-25
 This study aimed to explore patients’ perceptions of
hope and benefits at the time of cancer recurrence
with an eye toward identifying distinct sources of hope
and types of benefits

5.  Drew on data from a prospective study of clinician-
patient communication during first 6 months of a
cancer recurrence
 Mixed methods featuring semi-structured
interviews, patient reported outcomes, and observations
of visits
 Analyzed segments of patient interviews that were
focused on hope and benefit-finding

6.  Oncologists (n = 11) at a comprehensive cancer center
referred newly recurrent patients (n = 30)
 Eligibility:
 Female
 First distant recurrence of
breast, colorectal, gynecologic, head and neck, or lung
cancer
 ECOG status 0-2
 Disease-free at least six months prior to recurrence
 Enrolled within 4 months of recurrence diagnosis
 No symptomatic brain metastases

7.  Participant demographics:
 Age range:
 42 – 84 years (M = 63.0, SD = 11.5)
 Disease info:
 23 breast
 4 lung
 1 colon
 1 gynecologic
 1 head and neck
 Disease-free time:
 2 – 35 years (M = 7.4, SD = 7.5)

8.  Digital audio and transcribed recordings of interviews
 Interview duration :
 30 – 76 minutes (M = 48.3, SD = 12.1)
 Interview questions organized around themes of
communication, support, prognosis talk and coping
 As the iterative interview process progressed, hope and
benefit-finding were revealed as common themes in the
narratives

9.  Audio and transcripts were imported into QSR NVivo
8 coding software
 Included demographic and disease characteristics
 Age
 Tumor type
 Months of neutral time
 Oncologist continuity

10.  Analysis procedures:
 Following thorough grounding in hope
literature, authors reviewed several cases together to
form consensus of construct definition/features
 Identified transcript sections relating to having or
maintaining hope
 Identified expressed positive benefits
 Independent inter-rater agreement (ϰ = >.80)
 Authors used crystallization/immersion method to
identify potentially thematic constructs

11.  Identified objects of hope:
 Hope for more time
 Image of future
 “Yes. That is more, because what she’s (doctor) given me is a little bit of hope
that maybe in a year I’ll be here for my nephew, and that helps.”
 Doctor’s commitment to maximizing time
 “So you know I feel like she truly is in my corner and that whether I’m an
experiment or whatever I happen to be, that she’s going to read and find
whatever she can to help me make it through every day that I can.”
 Hope for cure
 Miraculous cure
 “…but you know I also look at I have people praying for me all over the
country, and I have people saying to me, ‘You are going to be the miracle
person,’ and you know it’s hard to think that about yourself, but given my
faith I do believe in miracles, so I’ll take it.”
 Medical cure
 “Yeah it gives me hope, and especially when she (doctor) said that ‘We’re
going to find out what this is and we’re going to take care of it.’”

12.  Doctor as object of hope
 MD is gatekeeper of expressed optimism
 “He (doctor) talks very confident. I mean you know he doesn’t
make it sound like, ‘You’re going to be dead in 10 months,’ or you
know what I mean. He’s confidence.”
 Information-giving
 “He’s (doctor) also concrete about exactly what’s happening
medically, biologically.”

13.  Patients identified having a lack of hope:
 Lack of future
 “My outlook ain’t so good right now.”
 Cancer is equated with death
 “Cause you know at that point you’re not having hope. All you hear
is cancer and still cancer is a stigma, you’re going to die.”
 “…the rug was pulled out from under me, you know. When I went
home, I felt like I was going home to get ready to die.”
 Perceptions of absence
 “I mean of course nobody wants to die. I don’t want to die, but my
biggest thing is my grandchildren. I just, that tears me up, because
my oldest one, he’s 11 years old and he’s just one of these
quiet, sensitive kids, and he and I are very close and I just would be
scared to death of what would happen to him. I don’t think he could
handle it, and that scares me, so…”

14.  Identified benefits
 Gratitude
 “So I can remember when she (doctor) gave me all of that
time when I first met her, and one day she was late coming in
and she said, ‘I’m sorry. You know I had a problem,’ and I
said, ‘You know, you take all the time you need, because
when I needed it, you gave it to me.’”
 Avoiding consequences
 “…and so I felt that you were really in a sense, I was blessed
you didn’t have to suffer that.” (Patient’s daughter)

15.  Existential benefits
 “You increase your faith again, I suppose, which shouldn’t be
the way it should be, but you know you do.”
 Authentic friends
 “You learn who really, really cares about you, who comes and
calls and says prayers and you know things like that. You
learn you know that there’s a lot of people that care about
you.”
 Increased ‘other’ orientation
 “I decided after doing quite a bit of reading the first go-round
that if I want people to be open and be there for me, I have to
be open to them.”

16.  Patients’ hope in the early months of cancer recurrence is
deeply tied to a survival time horizon
 This conclusion stems from both the objects of hope and
perceptions on lack of hope described by patients
 Goal is as much survival time as possible
 Cure offers time, whether by science or by more supernatural
means
 Patients consider time from a quantitative rather than qualitative
perspective
 Idea of retaining hope without cure isn’t evident
 Patients’ buffer the scientific reality of their prognosis with
the physician’s expressed optimism
 Verbally
 Nonverbally

17.  Benefit-finding appears to facilitate a shift in focus
from treatment to other interpersonal or existential
sources of hope and comfort
 Future interventions for recurrent patients may best
focus on helping patients generate personal benefits in
order to focus more fully on quality of life
 Limitations
 Small sample size
 Self-reported patient outcomes

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