Recovery from Breast Cancer : Investigating the role of resilience in breast cancer survivorship

Abstract: Breast cancer is a common event among women, one in ten women receiving a breast cancer diagnosis in their lifetime. The experience of breast cancer is a complex process that entails a multitude of interlinked potentially highly stressful events. It is thus evident that the manner in which one reacts to such stressors can have a substantial impact on both physical and mental health. Resilience is a construct that encompasses a positive adaptation to adverse events, and has been shown to be associated with both physical and mental health-related outcomes in breast cancer patients and survivors. Nevertheless, resilience is a complex construct which has been poorly operationalized in previous research. Additionally, there is a gap in research on how resilience changes over time, how these changes relate to the recovery process, as well as the lived experiences relevant for resilience in breast cancer survivors. The present thesis aims to address these gaps in knowledge. The general aim of this thesis was to better understand the role of resilience in recovery from breast cancer. The main aim of Study I was to elucidate the factor structure of the Connor-Davidson Resilience Scale (CD-RISC), the most widely used instrument for assessing resilience, as well as to determine its discriminant and predictive validity in the Swedish non-clinical setting. The aim of Study II was to explore whether resilience changes from the time of receiving a breast cancer diagnosis to after treatment, as well as whether these changes in resilience mediate or moderate physical and mental health-related recovery from breast cancer. It also aimed to identify biopsychosocial risk factors for poor or slower recovery. Study III aimed to explore the lived experiences and aspects of resilience among breast cancer survivors.Study I suggested that a 22-item unidimensional model of CD-RISC should be retained. It suggested that factors related to religion and spirituality may not play a role in resilience in this setting. Study I found that CD-RISC had good discriminant validity, being a separate construct from emotion regulation. Moreover, it had good predictive validity, as it predicted physical and mental health-related quality of life after adjusting for health and sociodemographic factors. Study II found that resilience was associated with both mental and physical health-related quality of life in breast cancer patients across time. However, resilience did not change substantially over time, and the process of recovery could thus not be explained by the changes in resilience. More resilient patients over time also did not have a faster recovery. Nevertheless, resilience was found to be protective, especially for mental health at diagnosis. Study II also identified a variety of clinical and sociodemographic factors which may be risk factors for poorer recovery, most notably ER negative and HER2 positive tumors, more advanced cancer at diagnosis, receiving adjuvant chemotherapy, and lower socioeconomic status. Study III identified three important aspects relevant for resilience in breast cancer survivors. Having agency in relation to one’s health, treatment procedures, feelings, thoughts, and daily functioning was one important aspect of resilience. Important others play a complex direct and indirect role in resilience in the context of breast cancer. Conceptualizing breast cancer as a closed chapter as opposed to a constant was an important aspect of resilience throughout survivorship.Overall, the studies included in this thesis suggest that resilience plays an important role in breast cancer survivorship, with implications for not only mental, but also physical health. Interventions aimed at enhancing resilience in breast cancer survivors may focus on increasing agency and social support, as well as changing beliefs about the finality of breast cancer.