Support Care Cancer (2016) 24:4607–4615

DOI 10.1007/s00520-016-3303-2

ORIGINAL ARTICLE

Seeing the good in the bad: which factors are associated

with posttraumatic growth in long-term
survivors of adolescent cancer?
Diana Christine Maria Gunst 1 & Peter Kaatsch 2 & Lutz Goldbeck 1

Received: 11 January 2016 / Accepted: 6 June 2016 / Published online: 27 June 2016
# Springer-Verlag Berlin Heidelberg 2016

Abstract Purpose While knowledge about late psychosocial
effects in pediatric cancer survivors is growing, investigation of
positive changes, notably posttraumatic growth (PTG), is still
lacking. Recent studies have not established any stable relation-
ship between PTG and posttraumatic stress symptoms (PTSS),
and it is still unclear which factors are associated with PTG in
survivors of childhood cancer. The aims of this study were to give
a quantitative description of PTG in long-term survivors of ado-
lescent cancer and to investigate its association with psychological
variables, especially the recalled amount of fear of death during
treatment, as well as other cancer-related and demographic issues.
Methods A cohort of 784 long-term survivors of adolescent
cancer (age M = 30.4 ± 6.1, time since diagnosis
M = 13.7 ± 6.0 years) completed a set of questionnaires mea-
suring PTG, PTSS, depression, anxiety, fear of death and psy-
chosocial support during treatment, and sociodemographic
and medical variables.
Results More than 5 years after cancer diagnosis, 94.3 % of
participants reported having Bvery strongly^ experienced at
least one positive consequence in the aftermath of the stressful
experience. There were positive correlations between PTG
and fear of death and psychosocial support during treatment,
as well as for current symptoms of depression. No association
with the amount of PTSS was found.
* Diana Christine Maria Gunst
gunst@verhaltenstherapie-aalen.de
1
Department of Child and Adolescent Psychiatry/Psychotherapy,
University Hospital Ulm, Steinhövelstraße 5, 89075 Ulm, Germany
2
German Childhood Cancer Registry at the Institute for Medical
Biostatistics, Epidemiology and Informatics (IMBEI), University
Medical Centre of the Johannes Gutenberg-University Mainz,
55101 Mainz, Germany
Conclusions Findings suggest that experiencing fear of death
during cancer experience as well as utilizing psychosocial
support catalyzes posttraumatic growth in the aftermath.
Further studies should investigate how interventions could
be designed to promote and stimulate PTG in young cancer
patients.
Keywords Posttraumatic growth . Survivor . Cancer .
Adolescence
Introduction
Although cancer is no longer an automatic death sentence, the
diagnosis is still shocking and associated with strain and bur-
den [1]. Since Fourth Edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) potentially fatal dis-
eases, such as cancer, have been recognized as traumatic
stressors and subsequently included as events which can trig-
ger posttraumatic stress disorder (PTSD) [2], this develop-
ment has resulted in emerging literature on the prevalence of
PTSD following pediatric cancer. Recent studies identified
young adult survivors as being at increased risk of developing
posttraumatic stress symptoms (PTSS) even years after the
completion of successful medical treatment [3–6].
Consequently, a substantial number of survivors report diffi-
culties in adjusting to their cancer experiences.
Positive consequences resulting from the cancer
experience
However, focusing on PTSS and distress presents an incom-
plete and misleading portrait of the survivors’ psychological
situation. There are several studies which demonstrate that
although a significant number struggle to adjust, the majority
4608
of pediatric cancer survivors function emotionally well, show
no impairment, and have even better quality of life in the long
term than controls [7–10]. Thus, a large proportion of survi-
vors show resilience, meaning that they are resistant to cancer-
related adversities and bounce back to their previous state of
normal functioning. Furthermore, some seem to be able to see
the good in the bad and actually benefit from their malignant
diagnosis. A review article, which summarizes interview find-
ings asking for positive consequences in survivors of pediatric
cancer, revealed that the domains Blife values,^ Brelations to
others,^ and Brelations to self^ are frequently positively affect-
ed by a pediatric cancer experience [11]. Other studies have
come to similar conclusions and describe positive conse-
quences in up to 90 % of survivors [12, 13]. The most frequent
positive aspects reported pertained to the domains of perspec-
tives in life (changes or more positive view, new priorities,
values, etc.), oneself (greater maturity, self-esteem, confi-
dence, strength, compassion, empathy, etc.), and others
(strengthened relationships and positive interactions) [12–15].
Posttraumatic growth
To describe the phenomenon of seeing the good in the bad, the
construct of Bposttraumatic growth^ (PTG) has received con-
siderable theoretical and empirical attention over the past de-
cade. As described by Tedeschi and Calhoun [16, 17], PTG is
a positive change which occurs as a result of struggling with a
highly challenging life event. In contrast to resilience, which
indicates that the individual remains on, or returns to a
Bnormal^ level of functioning, PTG implies that the individual
goes beyond resilience and reaches a higher level of function-
ing and well-being than before the adverse event. This concept
has been neglected in the growing literature on pediatric can-
cer survivors so far. A shift toward positive psychology is
needed to gain understanding of how interventions and psy-
chosocial support could be designed to stimulate and promote
psychological growth in young patients.
At the present time, very little is known about the factors
that stimulate or are associated with PTG in survivors of child-
hood and adolescent cancer. Predictors of PTG among former
pediatric cancer patients, which research has revealed so far,
are female gender, older age at diagnosis, non-White, fewer
years since diagnosis, exposure to at least one intense therapy
(e.g., chemotherapy), longer duration of treatment, and a sec-
ond malignancy or a recurrence of the malignant disease
[18–22]. In addition, psychological factors such as optimism
and social support also seem to be positively associated with
PTG [21].
According to the PTG framework of Tedeschi and
Calhoun, growth is the positive outcome of traumatic stress.
Consequently, there have been several attempts to investigate
the relationship between PTSS and PTG. One could hypoth-
esize that the survivors are either overwhelmed and succumb
Support Care Cancer (2016) 24:4607–4615
or are resilient and able to benefit. However, findings demon-
strating such a linear association between distress and growth
in pediatric cancer survivors are rare, and a negative associa-
tion has only been revealed in one Korean study [19]. Another
study [23], examining the relationship between PTSS and
growth in survivors of pediatric cancer, described a positive
association between PTSS and PTG in adolescent survivors of
cancer. At first glance, the latter finding seems to be paradox-
ical, but if PTSS, such as intrusion and avoidance, are seen as
rumination and indicators of cognitive processing, distress
then seems to be a catalyst for growth. However, the findings
of a recent, larger study with 6162 childhood cancer survivors
concluded that there are no indicators of a robust relationship
between PTSS and PTG [24]. Zebrack et al. assumed in their
latest study that the relationship between PTSS and PTG
might then be a curvilinear one instead. But, there is no em-
pirical support for this hypothesis [25]. Thus, the results are
still conflicting and it remains unclear which factors are asso-
ciated with, and contribute to, the development of PTG. Yet, it
remains of great importance to understand how positive adap-
tation and growth can be stimulated in young cancer
survivors.
It has to be noted that all the studies investigating the asso-
ciation between PTSS and PTG in survivors of pediatric can-
cer so far have investigated the simultaneous existence of
PTSS and PTG. No studies have yet examined in what way
the retrospectively perceived amount of stress on diagnosis or
during treatment is associated with the amount of PTG now-
adays. According to the theoretical assumption that a certain
amount of stress, which shakes fundamental views, is a cata-
lyst for a cognitive process of rethinking one’s view of the
world, the future, and oneself, it would be interesting to inves-
tigate in what way the retrospectively perceived amount of
traumatic impact is associated with the development or exis-
tence of PTG. The aim of this study was, therefore, to inves-
tigate the factors associated with PTG in long-term survivors
of adolescent cancer. We expected to find that the amount of
distress on diagnosis and during treatment, indicated by the
amount of recalled fear of death, would be positively associ-
ated with PTG in survivors of adolescent cancer. We expected
PTG to be independent of current distress, indicated by current
PTSS. In addition, we explored the association with current
anxiety and depression, as well as with demographic and
cancer-treatment related issues.
Methods
Procedure
The investigation of PTG in this study was part of a survey
with adult survivors of adolescent cancer, which included sev-
eral other variables pertaining to psychological (e.g., current
Support Care Cancer (2016) 24:4607–4615 4609

posttraumatic stress, depression, anxiety, and satisfaction with
life) outcomes of a cancer experience [26]. The inclusion
criteria were adults between the ages of 15 and 18 years on
first cancer diagnosis with an onset at least 5 years prior to the
beginning of the study. Eligible persons were identified based
on the population of the German Childhood Cancer Registry
(GCCR). Subsequently, a total of 1876 cancer survivors were
invited to participate. The GCCR sent all eligible long-term
survivors a package, including study information and the set
of questionnaires. If 4 weeks passed without the questionnaire
being returned, a reminder letter was sent. The study was
approved by the ethics committee at the University of Ulm,
and all participants gave written informed consent. There was
no compensation for participation. On request, participants
received a letter with their individual diagnostic findings.
Questionnaires were returned by 820 adult long-term cancer
survivors, resulting in a response rate of 43.7 %. A compari-
son of sex, diagnosis, and age at diagnosis of responders and
non-responders (n = 1056) revealed that there was a higher
proportion of females and survivors of lymphoma and bone
tumors, but fewer survivors of CNS tumors among the partic-
ipants. In the analysis of this study, only survivors with a
complete set of responses on the PTGI were included. This
resulted in a subsample of 784 survivors, with a mean age of
30.42 ± 6.07 (51.5 % female). Table 1 gives the
sociodemographic and medical characteristics of the sample.
Stress Diagnostic Scale (PDS) [30]. The PDS is a self-
report questionnaire with DSM-IV criteria of PTSD. The
symptom scale consists of 17 items, which include the
subscales Bintrusions,^ Bavoidance,^ and Bhyperarousal.^
The scale showed excellent internal consistency in the
present study (Cronbach’s α = 0.91).
Hospital Anxiety and Depression Scale The German version
of the Hospital Anxiety and Depression Scale (HADS) was
used to determine the current number of symptoms of anxiety
and depression. The instrument was developed to detect states
of depression and anxiety in physically ill patients [31]. It is
also known to perform well in the general population [32].
The questionnaire consists of 14 items, seven for each sub-
scale. The possible scores range from zero to 21 for anxiety as
well as depression. In the current study, internal consistency
was good (Cronbach’s α of 0.83) for both scales.
Socioeconomic and medical information In addition, the
questionnaires included items on socioeconomic background,
the medical information related to cancer illness (oncology
treatment, second malignancies, or cancer relapse), fear of
death during treatment, and utilization of psychosocial ser-
vices during treatment (psychotherapists and psychologists,
social workers, and other professionals). Information

Measures Table 1 Sample description

Survivors (n = 784)
Posttraumatic Growth Inventory The Posttraumatic
Growth Inventory (PTGI) [27] was used to assess the extent Age in years at study (M ± SD) 30.42 ± 6.07
to which the long-term survivors currently experienced posi- Sex (m/f) 380:404 (48.5 %:51.5 %)
tive consequences as a result of their cancer experience. The Partnership
inventory is a multidimensional self-report questionnaire Stable relationship at time of follow-up 547 (70.0 %)
consisting of 21 items, which can be divided into five sub- No stable relationship at time of follow-up 234 (30.0 %)
scales. The subscales are Bnew possibilities^ (five items), Educational level
Brelating to others^ (seven items), Bpersonal strengths^ (four Low (mandatory basic school 96 (12.2 %)
items), Bappreciation of life^ (three items), and Bspiritual with 9 years of schooling)
change^ (two items). In this study, we used a German version Middle (intermediate type of advanced 246 (31.4 %)
school with 10 years of schooling)
of the questionnaire [28] in which every item is answered on a
High (advanced school with 409 (52.2 %)
three-point scale of Bnot at all^ (0), Bsomewhat^ (1), and Bvery 12 to 13 years of schooling)
strong^ (2). Scores for each subscale and a total score for PTG Other/none 25 (3.2 %)
can be computed by adding up the scores of the corresponding Employment status
items. In order to compare the amount of PTG of the sub- Employed or still in education 614 (79.3 %)
scales, we calculated standardized mean scores for each sub- Not employed 160 (20.7 %)
scale by dividing the sum score by the amount of items per Age at diagnosis in years (M ± SD) 15.77 ± 0.88
scale. The internal consistency of the total scale (Cronbach’s Time since diagnosis in years (M ± SD) 13.67 ± 6.02
α = 0.89) and subscales (Cronbach’s α = 0.69–0.88) was Type of cancer diagnosis
satisfactory. Leukemia and lymphoma 391 (49.9 %)
Brain tumor 72 (9.2 %)
Posttraumatic Stress Diagnostic Scale The current number Solid tumor 321 (40.9 %)
of symptoms of posttraumatic stress was measured by Relapse or second malignancy 110 (14.3 %)
an authorized German version [29] of the Posttraumatic
4610
pertaining to cancer type and age at cancer onset was extracted
from the medical records saved in the GCCR.
Statistical analyses
In order to investigate the association of the amount of PTG
with fear of death during treatment, other psychological vari-
ables (amount of depression, anxiety, and current PTSS), and
time since diagnosis, Pearson correlation coefficients were
calculated for interval-scaled variables and Spearman correla-
tion coefficients for ordinal-scaled variables. To compare the
amount of PTG between distinct groups (male vs. female;
single vs. steady partnership; employed vs. unemployed; sec-
ond malignancy/recurrence vs. no such event; unexpected
complications during treatment vs. no complications; psycho-
social support vs. no support), Student’s t tests were per-
formed as long as the distribution of variance was equal in
the two groups tested. In case of an inhomogeneity of vari-
ances, Welch’s t tests—a non-parametric adaptation of
Student’s t tests—were conducted. A statistical level of
p < .05 was used to indicate significance for the previously
mentioned analyses. In order to reduce the risk of type I errors
due to multiple comparisons, a Bonferroni-corrected α level
of p < .01 was applied when significant effects for the total
score were found, and subsequent analyses for the five do-
mains of the PTGI were conducted. Cohen’s d effect sizes
were also calculated. According to Cohen [33], effect sizes
of d ≥ 0.20 are considered small, d ≥ 0.50 medium, and
d ≥ 0.80 large.
In a second step, a multiple linear regression was conduct-
ed to investigate the association of PTG with the significant
parameters found in the analyses above. This was done to
minimize the influence derived by the intercorrelations be-
tween the parameters investigated. All significant variables
Fig. 1 Standardized mean scores
in the subdomains of the PTGI:
Bnot at all^ (0), Bsomewhat^ (1),
and Bvery strongly^ (2)
Support Care Cancer (2016) 24:4607–4615
were tested backwards by the removal method to generate a
linear regression model with all remaining associated vari-
ables. Variables were removed until only those remained
which contributed with p values <.10. The explanatory power
of the resulting models was determined by the adjusted R2
statistic. The statistics (except for Cohen’s d) were performed
using the statistics program PASW Statistics 18.
Results
Quantitative description of posttraumatic growth
in survivors of adolescent cancer
The descriptive analysis of the survivors’ response in the
PTGI revealed that 94.3 % (n = 739) of the participants re-
ported Bvery strongly^ experiencing at least one of the 21
positive consequences in question. At least five of the positive
consequences were very strongly experienced by 64.5 %
(n = 506) in the aftermath of the cancer experience. Overall,
at least ten positive consequences were described by 25.8 %
(n = 202) of the adult survivors. The greatest amount of PTG
was found for the subscale appreciation of life (M = 1.40,
SD = 0.52) followed by personal strengths (M = 1.25,
SD = 0.48) and relating to others (M = 1.13, SD = 0.43).
Only little growth was revealed for the domain spiritual
growth (M = 0.56, SD = 0.68) (see also Fig. 1).
Association of posttraumatic growth with fear of death,
psychological, demographic, and cancer-related variables
With respect to psychological variables, the analyses showed
no association between the total amount of PTG and the total
score of the posttraumatic stress diagnostic scale (r = .02; n.s.).
Support Care Cancer (2016) 24:4607–4615 4611

However, current PTG was significantly positively associated
with the amount of fear of death during cancer treatment
(r = .19; p < .001). A negative correlation with current symp-
toms of depression (r = −.08; p < .05) was found. There was,
however, no association with current anxiety (r = .01; n.s.). In
addition, we observed that survivors, who received some form
of psychosocial support during their hospital stay, reported
more growth than those who did not receive this supportive
help (see Table 2). Additional analyses revealed that this effect
is true for all domains except Bspiritual growth^ after
Bonferroni correction of the alpha level.
A significant gender effect was revealed, with females
reporting more growth than males (see Table 2). Additional
analyses revealed that the difference between the two sexes
was—after Bonferroni correction—especially true for the do-
main appreciation of life (t782 = −3.61; p < .001; d = 0.26),
where females also showed more growth than males. No sig-
nificant associations were found for the survivors’ age
(r = −.02; n.s.), whether they are currently in a stable partner-
ship or their employment status (see Table 2).
In terms of cancer-related variables, the analyses revealed a
significant negative association with the amount of PTG and
time since treatment, indicating that the shorter the time since
cancer, the greater the PTG (r = −.08; p < .05). Furthermore,
survivors who experienced unexpected complications during
their cancer treatment reported significantly more PTG than
those who subjectively did not face such events. Survivors
who were diagnosed with a second malignancy or suffered
from a relapse of their cancer diagnoses did not significantly
differ in terms of their amount of PTG from those who did not
experience such an episode (see Table 2).
To integrate the factors impacting PTG, we conducted lin-
ear regression analyses, which included the significant param-
eters previously mentioned (fear of death during cancer treat-
ment, current symptoms of depression, psychosocial support
during hospital stay, gender, time since treatment, and unex-
pected complications during treatment). The final regression
model explained 9.1 % of the variance and revealed three
significant factors associated with the survivors’ amount of
PTG. The greatest partial correlation was observed for the
fear of death during treatment followed by the amount of
symptoms of depression today and the utilization of psy-
chosocial support during treatment. Whereas the associa-
tion with past fear of death and psychosocial support dur-
ing treatment was positively associated, symptoms of cur-
rent depression were negatively correlated with the amount
of PTG (see Table 3).
As there is a significant range in age, time since diagnosis,
and age at diagnosis which could affect the regression model,
we conducted a post hoc analysis in which we tested the final
regression model again, controlling for these important covar-
iates. The results showed that the covariates alone only ex-
plain 0.6 % of the variance and do not significantly contribute
to explaining the variance in PTG (F1,3 = −1.52; p = .208).
When entering the variables of the pictured regression model
in a second step, the explained variance escalates to 10.2 %
and the regression model is highly significant (F1,8 = −10.67;
p < .001).

Table 2 Comparison of
posttraumatic growth between (M ± SD) t p d
subgroups of survivors with
different demographic and Sex
cancer-related characteristics Male 22.31 ± 7.87 −2.27 .024* 0.16
Female 23.58 ± 7.90
Partnership
Stable relationship at time of follow-up 23.10 ± 7.83 −0.66 .510 0.05
No stable relationship at time of follow-up 22.70 ± 8.11
Employment status
Employed or still in education 23.05 ± 7.82 −0.90 .368 0.08
Not employed 22.42 ± 8.27
Psychosocial support
during treatment
Yes 24.65 ± 7.55 4.53 <.001** 0.34
No 22.01 ± 7.95
Unexpected complications during treatment
Yes 23.57 ± 7.60 −2.33 .020* 0.17
No 22.25 ± 8.13
Second malignancy or relapse
Yes 23.44 ± 7.81 −0.66 .511 0.06
No 22.91 ± 9.97

**<.001; *<.05
4612
Table 3 Variables associated
with the amount of posttraumatic
growth as indicated by the final
multiple regression model Fear of death at treatment
(adjusted R2 = .091) Amount of depression today
Psychosocial support during treatment
Sex
Variables included symptoms of depression today, fear of death at cancer treatment, psychosocial support during
treatment, sex, time since treatment, and unexpected complications during treatment
b unstandardized regression coefficient, SE standard error, β standardized regression coefficient, t t-value,
p significance
**<.001, *<.05
Discussion
First, we aimed to provide a quantitative description and in-
vestigation of PTG in long-term survivors of adolescent can-
cer. The findings demonstrate that the majority of the former
cancer patients are able to see the good in the bad and to report
at least one positive consequence in the aftermath of the stress-
ful diagnosis. These findings are consistent with previous
qualitative studies reporting positive consequences in a large
majority of former cancer patients [18, 23, 34]. The highest
PTGI mean score was identified for the domain appreciation
of life, which is also consistent with the findings of
Kamibeppu et al. [34] and Zebrack et al. [18] in survivors of
childhood and adolescent cancer. Compared to the sense of
growth in the other domains and the findings of the latter
study, there was little experience of spiritual growth by the
former cancer patients in our study. When looking at studies
investigating PTG in other populations, it seems as if there are
cultural differences, and individuals from the USA [35, 36]
are more likely to experience positive spiritual changes than
German [28] or Swiss childhood cancer survivors [20]. This
difference might be due to the lower spread of religious faith
in Germany [28]. When comparing the means with the
German reference sample of students and medically ill per-
sons, used to validate the questionnaire, the standardized
means of the AYA sample are slightly higher for all domains
(new possibilities (M = 0.95 vs. M = 0.85), relating to others
(M = 1.13 vs. M = 1.10), personal strengths (M = 1.25 vs.
M = 0.95), Appreciation of Life (M = 1.40 vs. M = 1.17),
and Spiritual Change (M = 0.56 vs. M = 0.34). The difference
is particularly noticeable for the domains appreciation of life
and personal strength. This might be due to the type of trau-
matic events. Whereas in our study, all of the participants had
faced their own potential death, this was only true for 50 % in
the reference sample. This is in line with our finding that more
peri-traumatic distress (indicated by a stronger fear of own
death) is associated with more growth in the aftermath.
As expected and shown in other studies, we did not find a
relationship between current PTSS and PTG but, instead, a
positive association between the current amount of PTG and
Support Care Cancer (2016) 24:4607–4615
B SE β t p
1.21 .21 .19 5.82 <.001**
−0.38 .08 −.17 −4.87 <.001**
2.61 .57 .16 4.59 <.001**
1.02 .55 .07 1.87 .062
the amount of distress at the time of diagnosis and treatment,
indicated by the retrospectively perceived amount of fear of
death during treatment. The findings suggest that PTSS and
PTG might rather be largely independent constructs or even
independent dimensions of well-being, rather than polar op-
posites. These findings do, however, indicate that the recalled
perception of threat of the diagnosis, indicated by a fear of
death, and the subjective experience of unexpected complica-
tions during treatment might promote PTG in survivors of
pediatric cancer. Unfortunately, symptoms of acute stress dis-
order during the cancer disease were not measured. It could
now be hypothesized that those recalled feelings of fear of
death and unexpected complications during treatment could
be considered a proxy for acute stress disorder during treat-
ment. Thus, peri-traumatic distress might predict PTG. This
should be investigated in future studies.
With respect to other psychological variables, we did find a
significant association between PTG and the current levels of
depression, with more symptoms of depression indicating less
PTG. However, there was no association between anxiety and
PTG. Knowledge about the relationship between growth and
distress following cancer diagnosis is still limited, but findings
retrieved from, for instance, breast cancer patients indicate that
there might be a linear or curvilinear relationship. A meta-
analysis, examining the impact of health stressors and other
traumatic events, also revealed that benefit finding and growth
are related to fewer symptoms of depression but unrelated to
current levels of anxiety [37]. This is plausible since certain
fears (e.g., of recurrence) can be considered as rational, appro-
priate, and even adaptive when they motivate the former pa-
tients to regularly attend routine follow-up examinations. An
increased amount of depression, however, is restricting and
disabling and may be a risk factor for limited growth beyond
the diagnosis.
There are some limitations which should be considered
when interpreting the findings. First, it should be noted that
this is a retrospective follow-up study and we did not have any
information about the actual amount of fear of death during
diagnosis. A recall bias might be possible, and we cannot
suggest any causal link between the recollected fear of death
Support Care Cancer (2016) 24:4607–4615
and PTG. Only a longitudinal and prospective study could
truly suggest the directionality of the effects. The response
rate was comparable to other studies. Nevertheless, only about
half of the eligible persons were reached, and a systematic
selection bias might be possible. Our key outcome fear of
death was measured retrospectively with a single item and
should be investigated in more detail in future studies. The
final regression model explained only about 10 % of the var-
iance. Thus, there may be other factors of relevance with re-
gard to positive consequences in the aftermath of a cancer
experience, such as family functioning and social support, a
history of other stressful experiences, coping processes, or
particular personality traits [38–40]. Although they were not
the subject of the current study, they should be considered and
investigated in future research. The cross-sectional design and
lack of a comparison group of persons without a cancer expe-
rience limit the interpretation of the findings obtained and
should also be considered in the future.
In summary, the findings lead to relevant and important
implications for the healthcare of young adult cancer survi-
vors. We showed that survivors who utilized psychosocial
support during treatment reported higher levels of growth than
survivors who did not use or had no access to appropriate
supportive care. Fortunately, the provision of psychosocial
support is, nowadays, an integral part of comprehensive pedi-
atric cancer treatment, and the International Society of
Pediatric Oncology published a series of guidelines for psy-
chosocial issues in pediatric cancer [e.g., 41]. The main goals
of psychosocial support are to encourage patients’ resources
and to provide professional assistance in difficult situations.
However, evidence-based pragmatic interventions that ad-
dress the specific needs of pediatric cancer patients and ad-
justment to the traumatic and malignant disease are rare [42,
43]. Only a small proportion of the survivors are reached by
these psychosocial interventions [44]. However, the promo-
tion of PTG could be a strategy to support coping and adjust-
ment, and it should, therefore, be integrated into psychosocial
care. Future studies could evaluate interventions designed to
facilitate PTG and investigate how they influence the amount
of distress experienced and adjustment to the disease. In the
context of PTG, the BJanus face^ metaphor is used to postulate
two components of PTG [45, 46]. Constructive growth is sup-
posed to be a functional aspect, which is correlated with
healthy adjustment. Illusory growth seems to be a dysfunc-
tional aspect which involves self-deception and may compen-
sate or mask the emotional distress [45, 46]. A recent study
with breast cancer patients revealed that women participating
in an intervention focusing on building resilience and enhanc-
ing cognitive emotion regulation strategies reported more con-
structive growth and less illusory growth than non-
participants [47]. Cognitive emotion regulation strategies are
targets for more effective interventions. It might, therefore, be
useful to focus, for instance, on self-reflection, emotion-
4613
focused coping, and cognitive restructuring with regard to
the traumatic or negative experiences associated with the can-
cer diagnosis in terms of shifting toward finding a meaning
and benefit by reappraisal and positive reframing [48, 49].
Given that a certain amount of perceived threat is necessary
to evoke growth, one could also assume that it is rather debil-
itating to minimize or trivialize the threat of the disease.
Exploited feelings of helplessness, hopelessness, and fear of
the future, characteristic of depressive episodes, however, also
hinder the appearance of growth as demonstrated in the study.
It is, therefore, necessary to screen for signs of depression and
plan early interventions since those symptoms can superim-
pose growth, irrespective of whether they are attributed to the
cancer experience or another cause.
Acknowledgments The study was funded by the Deutsche Krebshilfe
e.V., Bonn, Germany (Grant Number: 107452).
Compliance with ethical standards
Conflict of interest The authors declare that they have conflict of
interest.
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