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Resilience and related factors in colorectal cancer patients: A systematic review

Open AccessPublished:November 22, 2021DOI:https://doi.org/10.1016/j.ejon.2021.102079

      Abstract

      Purpose

      To explore resilience and its related factors in adult colorectal cancer patients.

      Methods

      Three databases (CINAHL, Scopus and PubMed) were searched for literature published from January 2009 to February 2021 using the terms colorectal and resilience or resilient or resiliency. The review was registered with PROSPERO and followed the PRISMA statement guidelines.

      Results

      The studies (n = 11) showed that most colorectal cancer patients exhibit moderate levels of resilience. Resilience was identified as a mediator in the positive or negative aspects of illness, while three studies investigated resilience as an outcome variable. Resilience was associated with social support, mental and physical burden, post-traumatic growth, hope, and quality of life. The studies showed that resilience might not be an immutable situation; social support seemed to provide patients the tools necessary for managing their illness, as well as helped them confront future events. The interventions designed to help with self-care issues and coping strategies eased a patient's mental and physical burden, and improved resilience.

      Conclusions

      Resilience among colorectal cancer patients was connected to both negative and positive aspects of the illness. Psychosocial and illness-related practical support might be key for strengthening resilience in these patients. However, longitudinal and intervention studies are required to confirm these indications. Research should study resilience as an outcome variable and provide information related to resilience at different phases of cancer, and what type of support is offered by professionals.

      Keywords

      1. Introduction

      Colorectal cancer is a type of cancer that develops in the human large intestine (colon) or rectum (
      • Ratjen I.
      • Schafmayer C.
      • Enderle J.
      • di Giuseppe R.
      • Waniek S.
      • Koch M.
      • Burmeister G.
      • Nöthlings U.
      • Hampe J.
      • Schlesinger S.
      • Lieb W.
      Health-related quality of life in long-term survivors of colorectal cancer and its association with all-cause mortality: a German cohort study.
      ). In 2020, colorectal cancer caused 244,824 deaths in Europe, 69,435 deaths in Latin America and the Caribbean, 63,987 deaths in North America, 7603 deaths in Oceania, and 506,449 deaths in Asia (). Colorectal cancer cases are expected to continue to grow, with estimates expecting 1.1 million deaths on a global level by 2030 (
      • Arnold M.
      • Sierra M.S.
      • Laversanne M.
      • Soerjomataram I.
      • Jemal A.
      • Bray F.
      Global patterns and trends in colorectal cancer incidence and mortality.
      ). However, over 60% of patients can survive colorectal cancer if it does not spread and metastasize (; ). Despite their illness, some colorectal cancer patients show resilience (
      • Üzar-Özҫetin Y.S.
      • Hiҫdurmaz D.
      Effects of an empowerment program on resilience and posttraumatic growth levels of cancer survivors: a randomized controlled feasibility trial.
      ), which is defined as the ability to overcome adversities with confidence in the future and themselves (
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      ;
      • Sisto A.
      • Vicinanza F.
      • Campanozzi L.L.
      • Ricci G.
      • Tartaglini D.
      • Tambone V.
      Towards a transversal definition of psychological resilience: a literature review.
      ).
      Resilience is often described as an outcome, more specifically, an individual response to a difficult life-situation (
      • Deshields T.L.
      • Heiland M.F.
      • Kracen A.C.
      • Dua P.
      Resilience in adults with cancer: development of a conceptual model.
      ) and a psychosocial outcome of growth (
      • Molina Y.
      • Yi J.C.
      • Martinez-Gutierrez J.
      • Reding K.W.
      • Yi-Frazier J.P.
      • Rosenberg A.R.
      Resilience among patients across the cancer continuum: diverse perspectives.
      ). Researchers have stated that resilience is quantifiable, with numerous scales developed for measuring resilience being used on a global level. At present, the most widely used scale for quantifying resilience is the Connor-Davidson Resilience Scale (
      • Windle G.
      • Bennett K.M.
      • Noyes J.
      A methodological review of resilience measurement scales.
      ). However, some researchers have questioned whether resilience can be reliably measured (
      • Bonanno G.A.
      • Westphal M.
      • Mancini A.D.
      Resilience to loss and potential trauma.
      ), including
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      themselves. They have questioned whether the scale measures only characteristics of resilience, and if it is possible to cope poorly in some areas but still score well on the scale (
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      ). However, in measures of resilience, subjects answer questions about themselves (
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      ), which requires them to identify personal resources. As such, resilience requires an awareness action (
      • Sisto A.
      • Vicinanza F.
      • Campanozzi L.L.
      • Ricci G.
      • Tartaglini D.
      • Tambone V.
      Towards a transversal definition of psychological resilience: a literature review.
      ), and, according to
      • Luo D.
      • Eicher M.
      • White K.
      Individual resilience in adult cancer care: a concept analysis.
      , describes an individualʼs ability to confront adversities. Moreover, resilience has been found to be associated with personal factors such as optimism (
      • Edward K.-L.
      • Chipman M.
      • Giandinoto J.-A.
      • Robinson K.
      Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review.
      ;
      • Gao Y.
      • Yuan L.
      • Pan B.
      • Wang L.
      Resilience and associated factors among Chinese patients diagnosed with oral cancer.
      ), self-esteem and self-efficacy (
      • Lee S.-Y.
      • Lee H.
      • Fawcett J.
      • Park J.-H.
      Resilience in Korean with cancer: scoping review.
      ). Additional evidence supports that resilience is also a process. In other words, a person sees possibilities (
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      ) and can utilize personal resources to steer towards a certain outcome (
      • Sisto A.
      • Vicinanza F.
      • Campanozzi L.L.
      • Ricci G.
      • Tartaglini D.
      • Tambone V.
      Towards a transversal definition of psychological resilience: a literature review.
      ;
      • Stainton A.
      • Chisholm K.
      • Kaiser N.
      • Rosen M.
      • Upthegrove R.
      • Ruhrmann S.
      • Wood S.J.
      Resilience as a multimodal dynamic process.
      ). There is prior evidence that certain interventions can build resilience, as well as that resilience can improve personal strength to confront future events, a phenomenon referred to as post-traumatic growth (
      • Ludolph P.
      • Kunzler A.M.
      • Stoffers-Winterling J.
      • Helmreich I.
      • Lieb K.
      Interventions to promote resilience in cancer patients.
      ;
      • Seiler A.
      • Jenewein J.
      Resilience in cancer patients.
      • Üzar-Özҫetin Y.S.
      • Hiҫdurmaz D.
      Effects of an empowerment program on resilience and posttraumatic growth levels of cancer survivors: a randomized controlled feasibility trial.
      ).
      Surviving any cancer requires mental and physical strength. The side effects of treatment (
      • Karimi S.
      • Makhsosi B.R.
      • Seyedi-Andi S.J.
      • Behzadi M.
      • Moghofeh Y.
      • Mohammadinasrabadi K.
      • Abdi A.
      • Ahmadi P.
      Surveying the effect of a self-care education program on severity of nausea and emesis in colorectal cancer patients under chemotherapy.
      ), changes in body image (
      • Bulkley J.
      • McMullen C.K.
      • Hornbrook M.C.
      • Grant M.
      • Altschuler A.
      • Wendel C.S.
      • Krouse R.S.
      Spiritual well-being in long-term colorectal cancer survivors with ostomies.
      ;
      • Melissant H.C.
      • van Uden-Kraan C.F.
      • Lissenberg-Witte B.I.
      • Verdonck-de Leeuw I.M.
      Body changes after cancer: female cancer patients'perceived social support and their perspective on care.
      ), and fear of recurrence (
      • Willems R.A.
      • Bolman C.A.W.
      • Mesters I.
      • Kanera I.M.
      • Beaulen A.A.J.M.
      • Lechner L.
      Cancer survivors in the first year after treatment: the prevalence and correlates of unmet needs in different domains.
      ;
      • Hall D.L.
      • Luberto C.M.
      • Philpotts L.L.
      • Song R.
      • Park E.R.
      • Yeh G.Y.
      Mind-body interventions for fear of cancer recurrence: a systematic review and meta-analysis.
      ) can all considerably affect a cancer patient's health and overall quality of life (
      • Ye Z.J.
      • Qiu H.Z.
      • Li P.F.
      • Liang M.Z.
      • Zhu Y.F.
      • Zeng Z.
      • Hu G.Y.
      • Wang S.N.
      • Quan X.M.
      Predicting changes in quality of life and emotional distress in Chinese patients with lung, gastric, and colon-rectal cancer diagnoses: the role of psychological resilience.
      ). Colorectal cancer patients are a unique group with unique needs. For example, these patients often struggle with bowel function (
      • Perl G.
      • Nordheimer S.
      • Lando S.
      • Benedict C.
      • Brenner B.
      • Perry S.
      • Shmoisman G.
      • Purim O.
      • Amit L.
      • Stemmer S.M.
      • Ben-Ahoron I.
      Young patients and gastrointestinal (GI) tract malignancies – are we addressing the unmet needs?.
      ) and weight loss (
      • Bapuji S.B.
      • Sawatzky J.-A.V.
      Understanding weight loss in patients with colorectal cancer: a human response to illness.
      ). Challenges with sexual life (
      • Grant M.
      • McMullen C.K.
      • Altschuler A.
      • Mohler M.J.
      • Hornbrook M.C.
      • Herrinton L.J.
      • Wendel C.S.
      • Baldwin C.M.
      • Krouse R.S.
      Gender differences in quality of life among long-term colorectal cancer survivors with ostomies.
      ;
      • Perl G.
      • Nordheimer S.
      • Lando S.
      • Benedict C.
      • Brenner B.
      • Perry S.
      • Shmoisman G.
      • Purim O.
      • Amit L.
      • Stemmer S.M.
      • Ben-Ahoron I.
      Young patients and gastrointestinal (GI) tract malignancies – are we addressing the unmet needs?.
      ) are also common. Moreover, if a patient receives an ostomy during surgery, they have to learn special skills to take care of it (
      • Bulkley J.
      • McMullen C.K.
      • Hornbrook M.C.
      • Grant M.
      • Altschuler A.
      • Wendel C.S.
      • Krouse R.S.
      Spiritual well-being in long-term colorectal cancer survivors with ostomies.
      ). Surgery, often with radio- and/or chemotherapy, is the main treatment for colorectal cancer (
      • Ratjen I.
      • Schafmayer C.
      • Enderle J.
      • di Giuseppe R.
      • Waniek S.
      • Koch M.
      • Burmeister G.
      • Nöthlings U.
      • Hampe J.
      • Schlesinger S.
      • Lieb W.
      Health-related quality of life in long-term survivors of colorectal cancer and its association with all-cause mortality: a German cohort study.
      ).
      Colorectal cancer patients need social support that involves both informational and emotional support from their closest relatives and attending healthcare professionals. They need an opportunity to discuss issues related to their life and illness, as well as secure setting in which they can talk about the situation they are dealing with. Conversations that focus on the present and prepare for the future can ease patient's burden (
      • Lee V.
      • Cohen S.R.
      • Edgar L.
      • Laizner A.M.
      • Gagnon A.J.
      Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy.
      ). A patient's hope has been associated with greater functional, social and emotional well-being (
      • Grealish L.
      • Hyde M.K.
      • Legg M.
      • Lazenby M.
      • Aitken J.F.
      • Dunn J.
      • Chambers S.K.
      Psychosocial predictors of hope two years after diagnosis of colorectal cancer: implications for nurse-led hope programmes.
      ), as well as suggested to extend a patient's perspective of possibilities (
      • Doe M.J.
      Conceptual foreknowings: an integrative review of hope.
      ). However, patients do not always get the support that they need (
      • Perl G.
      • Nordheimer S.
      • Lando S.
      • Benedict C.
      • Brenner B.
      • Perry S.
      • Shmoisman G.
      • Purim O.
      • Amit L.
      • Stemmer S.M.
      • Ben-Ahoron I.
      Young patients and gastrointestinal (GI) tract malignancies – are we addressing the unmet needs?.
      ). Also, the human mind is highly complex. Cancer is an emotionally challenging situation that can cause patients to adopt negative coping strategies (
      • Baghjari F.
      • Saadati H.
      • Esmaeilinasab M.
      The relationship between cognitive emotion-regualtion strategies and resiliency in advanced patients with cancer.
      ). For example, in experiential avoidance a person will try to control their emotions by avoiding negative events, memories and pain (
      • Boeschen L.E.
      • Koss M.P.
      • Figueredo A.J.
      • Coan J.A.
      Experiential avoidance and post-traumatic stress disorder: a cognitive mediational model of rape recovery.
      ). It is important to note that positive coping strategies can be taught through interventions (
      • Lee V.
      • Cohen S.R.
      • Edgar L.
      • Laizner A.M.
      • Gagnon A.J.
      Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy.
      ). Self-compassion, awareness of common humanity and treating oneself with kindness are all relevant to a patient's self-care, as these skills can potentially help to ease suffering (
      • Garcia A.C.M.
      • Silva B.D.
      • Oliveira da Silva L.C.
      • Mills J.
      Self-compassion in hospice and palliative care: a systematic integrative review.
      ). These actions can also enhance the use of adaptive emotion regulation strategies, such as cognitive reappraisal, which can gradually improve resilience (
      • Baghjari F.
      • Saadati H.
      • Esmaeilinasab M.
      The relationship between cognitive emotion-regualtion strategies and resiliency in advanced patients with cancer.
      ).
      Interaction with others and the provision of adequate support are critical for helping cancer patients manage their illness (
      • Lee V.
      • Cohen S.R.
      • Edgar L.
      • Laizner A.M.
      • Gagnon A.J.
      Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy.
      ;
      • Zhang H.
      • Zhao Q.
      • Cao P.
      • Guosheng R.
      Resilience and quality of life: exploring the mediator role of social support in patients with breast cancer.
      ;
      • Gao Y.
      • Yuan L.
      • Pan B.
      • Wang L.
      Resilience and associated factors among Chinese patients diagnosed with oral cancer.
      ). Nevertheless, only a few studies have described interventions for improving resilience among colorectal cancer patients. In prior studies on resilience among cancer patients, colorectal cancer patients have been a minor group, or their results were not presented separately (
      • Eicher M.
      • Ribi K.
      • Senn-Dubey C.
      • Senn S.
      • Ballabeni P.
      • Betticher D.
      Interprofessional, psycho-social intervention to facilitate resilience and reduce supportive care needs for patients with cancer: results of a noncomparative, randomized phase II trial.
      ;
      • Üzar-Özҫetin Y.S.
      • Hiҫdurmaz D.
      Effects of an empowerment program on resilience and posttraumatic growth levels of cancer survivors: a randomized controlled feasibility trial.
      ). Several studies have covered resilience in patients afflicted by other cancer types (
      • Zhang H.
      • Zhao Q.
      • Cao P.
      • Guosheng R.
      Resilience and quality of life: exploring the mediator role of social support in patients with breast cancer.
      ;
      • Edward K.-L.
      • Chipman M.
      • Giandinoto J.-A.
      • Robinson K.
      Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review.
      ;
      • Gao Y.
      • Yuan L.
      • Pan B.
      • Wang L.
      Resilience and associated factors among Chinese patients diagnosed with oral cancer.
      ;
      • Lai H.-L.
      • Hung C.-M.
      • Chen C.-I.
      • Shih M.-L.
      • Huang C.-Y.
      Resilience and coping styles as predictors of health outcomes in breast cancer patients: a structural equation modelling analysis.
      ;
      • Aizpurua-Perez I.
      • Perez-Tejada J.
      Resilience in women with breast cancer: a systematic review.
      ), or in cancer patients in general (
      • Molina Y.
      • Yi J.C.
      • Martinez-Gutierrez J.
      • Reding K.W.
      • Yi-Frazier J.P.
      • Rosenberg A.R.
      Resilience among patients across the cancer continuum: diverse perspectives.
      ;
      • Lee S.-Y.
      • Lee H.
      • Fawcett J.
      • Park J.-H.
      Resilience in Korean with cancer: scoping review.
      ;
      • Ludolph P.
      • Kunzler A.M.
      • Stoffers-Winterling J.
      • Helmreich I.
      • Lieb K.
      Interventions to promote resilience in cancer patients.
      ;
      • Seiler A.
      • Jenewein J.
      Resilience in cancer patients.
      ;
      • Tan W.S.
      • Beatty L.
      • Koczwara B.
      Do cancer patients use the term resilience? A systematic review of qualitative studies.
      ). Additional information about resilience among colorectal cancer patients could be beneficial to guiding practitioners in how to adequately support this unique group of patients. Hence, the purpose of this systematic review is to explore resilience and its related factors in adult colorectal cancer patients.

      2. Methods

      This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines and was registered with PROSPERO (CRD42020191121) after finding no prior related reviews via a search of registered and/or work-in-progress study databases. The methodological quality of the articles was assessed using Joanna Briggs Institute (JBI) Critical Appraisal Checklists.

      2.1 Search strategy

      Three electronic databases (CINAHL, Scopus and PubMed) were searched for articles published in English from January 2009 to February 2021 based on article title, abstract, and keywords. The following search terms were used: colorectal and resilience or resilient or resiliency. These terms were also reviewed and considered appropriate by an information specialist. Other terms, such as cancer, did not add for the search results. However, the term colorectal included colorectal cancer. The reference lists of identified articles were also screened for any relevant studies that may have been missed during the screening of databases.

      2.2 Selection phase

      The search produced 298 articles, which were screened using the following criteria. The inclusion criteria were: written in English; measured resilience; and concerned adults (>18 years) with a colorectal cancer diagnosis (no time limitations on the diagnosis were applied). The exclusion criteria were: qualitative study; and research that explored resilience among colorectal cancer patients but did not separately present the results for colorectal cancer patients.
      Following duplicate removal (n = 33), 265 publications remained for further analysis. Two authors independently screened these articles based on titles and abstracts, after which they discussed inclusion and exclusion criteria and accepted articles after coming to a consensus. After screening, 21 full-text articles were assessed for eligibility by three authors. Following the exclusion of nine articles, 12 articles underwent quality assessment.

      2.3 Quality assessment

      The articles were assessed for methodological quality by three researchers using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies (n = 9) and Randomized Controlled Trials (n = 3 intervention studies). The studies were not concerned with exposure, so this part of the JBI checklist was marked as ‘not applicable’. The authors came to a consensus that one of the articles should be excluded from the study because of a low methodological quality score; more specifically, score of only 50% on the JBI Critical Appraisal Checklist (Fig. 1).

      2.4 Synthesis of results

      Since this systematic review included research guided by different study designs, the results were systematically analyzed using inductive content analysis. This process identified several prominent themes, which are presented with the relevant statistical values. The synthesized findings concerning resilience among colorectal cancer patients are presented in the follow section, and further illustrated using tables and figures.

      3. Results

      3.1 Quality of the studies

      Of the studies identified during the systematic review, 11 were considered to be of acceptable methodological quality (Table 1), receiving quality scores of 5–7 out of 8, and 9–12 out of 13, on the JBI Critical Appraisal Checklists. All eleven studies were peer-reviewed.
      Table 1Details of studies included in the systematic review.
      Author (year)

      Country
      Study designStudy population (N)

      Measure-time
      ScalesMain resultsResilience as dependent variableQuality score
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.


      Israel
      Cross-sectionalCRC patients (N = 153), of which ∼26% (n = 40) had rectal cancer and ∼74% (n = 113) had colon cancer.

      1–24 months after surgery
      Resilience Scale-14

      Self-Compassion Scale-Short Forms

      Acceptance and Action Questionnaire

      Emotion Regulation Questionnaire

      State-Trait Anxiety Inventory-6

      The Marlowe-Crowne Social Desirability Scale

      Clinical characteristics

      Demographic characteristics
      Mean resilience was 47.30 ± 7.37 (scale 0–84). Cognitive reappraisal was associated with better economic situation, higher education, higher self-compassion and higher resilience.No5/8
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.


      Turkey
      Cross-sectionalCRC patients (N = 103), of which 33% (n = 34) had rectal cancer and 67% (n = 69) had colon cancer. About 41% (n = 42) had an ostomy.

      0–21 months after diagnosis (patients undergoing surgery), as well as later time points.
      Connor-Davidson Resilience Scale (25-items)

      Multidimensional Scale of Perceived Social Support
      Mean resilience was 78.68 ± 20.35 (scale 0–100). A positive association between social support and resilience was found.Yes5/8
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.


      Israel
      Cross-sectionalCRC patients (N = 92)

      Dg. 1–5 years before the study
      Wagnild and Young's Resilience Scale (25 items)

      Brief Symptoms Inventory-18

      Cancer-related problem list (40 items)

      Demographic and disease-related details
      Mean resilience was 5.41 ± 0.74 (scale 1–7). Older age, male gender, and mental and physical burden were associated with resilience.No5/8
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.


      Brazil
      Cross-sectionalCRC patients (N = 144), of which ∼31% (n = 44) had an ostomy

      Mainly (77%) 0–12 months after diagnosis.
      Wagnild and Young's Resilience Scale (25 items)

      Sociodemographic and Disease Characteristics

      Social Support Satisfaction Scale

      Perceived Stress Scale (14 items)

      EU's Research and Treatment of Cancer

      Quality of Life Questionnaires C30 (30 items) and CR29 (38 items)
      Mean resilience was 139.4 ± 15.2 (scale 25–175). Resilience was associated with social support, quality of life and mental burden.No5/8
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.


      China
      Cross-sectionalCRC patients (N = 164) with permanent ostomies.

      At least 1 month after surgery (>6 mo, 6–12 mo, >12 mo)
      Connor-Davidson Resilience Scale (10 items)

      Perceived social support Scale (12 items)

      Posttraumatic growth Inventory (21 items)
      Mean resilience was 26.22 ± 7.33 (scale 10–40). Resilience was associated with PTG and social support.No6/8
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.


      Israel
      Cross-sectionalDigestive system cancer patients (N = 200), with 75% (n = 150) being CRC patients, of which 9.5% (n = 19) had rectal cancer and 65.5% (n = 131) colon cancer.

      1–4 years after diagnosis (mean 2 years)
      Connor-Davidson Resilience Scale (25 items)

      Functional status (1 item)

      Medical Details Questionnaire (7 items)

      Positive and Negative Affect Schedule (20 items)

      Posttraumatic growth inventory (21 items)

      Reported Behavior Changes Scale (8 items)

      Short Psychosocial Adjustment to Illness

      Scale-Self Report (26 items)

      Short Social Desirability (33 items)
      Mean resilience level was 80.01 ± 16.04 (scale 0–100). Resilience was associated with PTG, mental burden, positive affect and adjustment.No7/8
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.


      China
      Intervention (RCT)Colon cancer patients after surgery

      (N = 200)
      Connor-Davidson Resilience Scale (25 items)

      Revised Piper Fatigue Scale (22 items)

      Self-rating Anxiety Scale (20 items)

      Self-rating Depression Scale (20 items)

      General demographic information questionnaire

      Intervention, attention and interpretation therapy (AIT) was based on stress management and resilience training.

      It included: meditation, emotion regulation strategies, guidance for individual needs, helping patients live with cancer, encouraging to communicate about cancer and relevant issues.
      Mean resilience in the experimental group prior to intervention was 55.42 ± 3.51, and 63.24 ± 2.21 after the intervention. The corresponding values for the control group were 55.52 ± 3.70 and 55.11 ± 3.86 (scale 0–100), respectively. The intervention reduced mental burden and improved resilienceYes9/13
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.


      China
      Cross-sectionalRectal cancer patients (N = 188), of which ∼35% (n = 65) had undergone ostomy

      About 2–7 years (24–88 mo) after diagnosis and surgery

      (mean 4 years)
      Wagnild and Young's Resilience Scale (25 items)

      International prostate symptom score (8 items)

      Chinese version of Davidson Trauma Scale (17 items)

      Personal characteristics and disease-related variables
      Mean resilience was 130.85 ± 19.43 (scale 25–175). Mental and physical burden were associated with resilience.No5/8
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.


      Brazil
      Cross-sectionalMetastatic CRC patients (N = 44).

      Dg. about 3,5 years before the study
      Connor-Davidson Resilience Scale (25 items)

      Heart Hope Index (12 items)

      Barthel Index (10 items)

      Instrument addressing family and social support

      Visual-numeric scales for pain (1 item) and suffering (1 item)

      Depression (2 items)
      Mean resilience level was 88.5 (scale 0–100). Patients with depressive symptoms also showed moderate resilience levels: mean 74.0 (scale 0–100). Resilience was associated with hope. Patients with depressive symptoms were slightly less resilient than other patients.No6/8
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.


      China
      Cross-sectionalCRC patients (N = 157), of which none had an ostomy.

      Duration of illness: 1 month to ∼ 1 year, possibly even longer.
      Connor-Davidson Resilience Scale (25 items)

      Self-Perceived Burden Scale (10 items)

      Posttraumatic Growth Inventory (21 items)

      General Information Questionnaire
      Mean resilience was 69.03 ± 19.06 (scale 0–100). Resilience was associated with PTG, economic situation, and mental and physical burden.No6/8
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.


      China
      Intervention (RCT)CRC patients (N = 108) with a permanent

      enterostomy (n = 55, n = 53)
      • 1)
        before intervention
      • 2)
        at the time of discharge
      • 3)
        3 mo after discharge
      • 4)
        6 mo after discharge
      Connor-Davidson Resilience Scale (25 items)

      General demographic

      Exercise of Self-care Agency Scale (43 items)

      Stoma-Quality of Life (20 items)

      Ostomy complication

      The intervention, hospital-family holistic care model, based on the theory of “Timing It Right” (TIR) was aimed to help patients ease their physical burden, support selfcare, adjust negative emotions, and maintain good mental health
      Mean resilience was 63.77–78.38 (scale 0–100). The intervention improved patients' QOL and resilience and eased physical and mental burden.Yes12/13
      Abbreviations: CRC - colorectal cancer; Dg. - diagnosis; PTG - post-traumatic growth; QOL - quality of life; RCT - randomized controlled trial; ± - Standard deviation.

      3.2 Study characteristics

      Most of the studies were cross-sectional (n = 9), while a minority (n = 2) represented intervention studies. The analyzed studies were published between 2014 and 2020. Sample sizes varied between 44 and 200 patients. One study also investigated other cancer types, e.g., pancreatic and stomach, but colorectal cancer patients represented 75% of all the participating subjects. The analyzed studies mainly investigated colorectal cancer patients at the onset of the disease, from the early phases to about one year after diagnosis, while some studies reported results recorded years after diagnosis. Most of the studies used the Connor-Davidson Resilience Scale - either the 25-item (n = 6) or 10-item (n = 1) scale. The remaining studies either applied Wagnild and Youngʼs 25-item resilience scale (n = 3), or the Resilience Scale-14 (n = 1). When using the resilience scales, the persons must identify and evaluate their personal resources. Patients provided answers on either a five- or seven-point scale based on the extent to which they agree with each statement.

      3.3 Patient demographics

      The analyzed studies reported resilience among Chinese (n = 5), Israeli (n = 3), Brazilian (n = 2), and Turkish (n = 1) colorectal cancer patients. The mean age of the total sample (n = 1553) was approximately 59 years, with an overall range of 18–87 years. Of the patients investigated in the identified studies, 941 were male and 623 were female, with between 65 and 99% reported to be married. Moreover, 423 of the patients had an ostomy. The studies investigated patients in the following cancer stages: I-IV (n = 5); II-III (n = 2); or II-IV (n = 1).

      3.4 Resilience of colorectal cancer patients

      All of the included studies measured resilience levels, but only three studies included resilience as an outcome variable (
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ;
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ). Resilience was described as a changeable path (
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      ), response (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ), and adaptation process. Resilience was also treated as an individual quality, more specifically, it was described as toughness (
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ), capacity (
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      ;
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ), and a coping ability (
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ). However, in most studies, resilience was seen as a mediator (
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      ) or an ally (
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ) for positive changes (
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      ;
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ;
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      ;
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      ,
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ) and better adjustment (
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      ;
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ;
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ).

      3.4.1 Resilience levels and characteristics of resilient patients

      The patients included in these studies were generally found to show moderate resilience levels; However, in some cases, low or relatively high resilience levels were also described (Table 2). Older age (rho = 0.540, p = 0.002) and female gender (rho = −0.42, p < 0.001) were statistically significantly related to resilience (
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      ). As a part of self-perceived burden, patient economic burden was significantly associated with resilience (r = −0.337, p < 0.01, β = −0.337, p ≤ 0.001) (
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      ). Moreover,
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      noted that the group of patients with better resilience levels also had a better economic status than other patients (F = 7.25, effect size 0.09, p < 0.01).
      Table 2Mean resilience scores, including standard deviation (SD) and Cronbach's alpha values.
      Author (year)Scale (range)Mean (range)SDCronbachʼs α
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      Resilience Scale-14 (0–84)47.30 (27–84)7.370.86
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      Connor-Davidson Resilience Scale 25-item (0–100)78.68 (10–75)20.350.85
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      Wagnild and Young's Resilience Scale (1–7)5.41 (3.67–6.67)0.740.93
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      Wagnild and Young's Resilience Scale (25–175)139.415.20.80
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      Connor-Davidson Resilience Scale, 10-Item (0–40)26.22 (10–40)7.330.93
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      Connor-Davidson Resilience Scale, 25-Item (0–100)80.01 (29–100)16.040.93
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      Wagnild and Young's Resilience Scale (25–175)130.85 (86–175)19.430.94
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      Connor-Davidson Resilience Scale 25-item (0–100)55.42
      Before intervention, and.
      63.24
      10 weeks after intervention in the intervention group.
      3.51
      Before intervention, and.
      2.21
      10 weeks after intervention in the intervention group.
      0.91
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      Connor-Davidson Resilience Scale, 25-Item (0–100)74.0
      Depression -
      88.5
      no depression group.
      0.93
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      Connor-Davidson Resilience Scale, 25-Item (0–100)69.03 (18–100)19.060.93
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      Connor-Davidson Resilience Scale, 25-Item (0–100)63.77
      Discharge.
      70.83
      3 months and.
      78.38
      6 months after discharge in the intervention group**.
      7.18
      Discharge.
      6.05
      3 months and.
      4.61
      6 months after discharge in the intervention group**.
      0.89
      1 Before intervention, and.
      2 10 weeks after intervention in the intervention group.
      3 Depression -
      4 no depression group.
      a Discharge.
      b 3 months and.
      c 6 months after discharge in the intervention group**.

      3.5 Factors related to resilience

      The performed inductive content analysis identified various factors that were related to resilience. These included social support, hope, mental and physical burden (stress, distress, depression, anxiety, fatigue, post-traumatic stress symptoms, different cancer-related problems), quality of life, and post-traumatic growth.

      3.5.1 Social support

      In the identified studies, aspects of social support were evaluated in four separate instances; more specifically, the source (
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ,
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ), availability (
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      ) and satisfaction with (
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ) support. The studies generally reported that colorectal cancer patients received moderate to high levels of social support (Table 3), although
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      found that patients were not always satisfied with their social activities (mean 2.5, range 1–5). A positive association between social support and resilience was reported in several studies (
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ;
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ), and confirmed via structural equation modeling (SEM) by both
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      (β = 0.240, p < 0.05) and
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      (β = 0.440, p < 0.01).
      Table 3Results from social support scales, including mean values, standard deviation (SD), and Cronbach's alpha values.
      Scale (range)Mean (SD)Cronbach's αSampleAuthor
      SSSS (1–5)0.83N = 144, Patients receiving chemotherapy; mainly (77%) at 0–12 mo from dg.
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      Social Activities2.5 (1.1)
      Intimacy3.9 (1.0)
      Family4.6 (0.8)
      Friends4.1 (0.9)
      PSSS (12–84)0.94N = 164, Patients with permanent intestinal ostomies. At least 1 mo after surgery: >6 mo,

      6–12 mo, >12 mo.
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      Family, friends, other support
      Total63.96 (12.89)
      MSPSS (12–84)0.87N = 103, Patients udergoing colorectal cancer surgery
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      Family25.29 (6.82)
      Friend21.33 (10.22)
      Significant other21.15 (10.23)
      Total67.78 (24.61)
      PSFF (0–10) Family9.5
      No depression.
      N = 44, Patients with metastatic cancer, Dg. 0–13 y (Mean 3.5 y) before participation for a study
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      9.3
      Depression.
      9.9
      No depression.
      PSFC (0–10) Community9.5
      Depression.
      Abbreviations: SSSS – Social Support Satisfaction Scale; PSSS - Perceived Social Support Scale; MSPSS - Multidimensional Scale of Perceived Social Support; PSFF- Perceived support from family; PSFC - Perceived support from community; Dg. - Diagnosis; mo. - months; y. - years.
      3 No depression.
      4 Depression.

      3.5.2 Hope

      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      noted that metastatic colorectal patients (n = 44) demonstrated relatively high levels of hope (mean 39–43.5, scale 12–48), which was statistically significantly related to resilience (rho 0.630, p < 0.05). In the same study, depressed patients showed lower levels of resilience and hope than other patients. However, the association between resilience and hope was not impacted by depression, age or gender (p < 0.001).

      3.5.3 Mental and physical burden

      Several studies explored the mental state of colorectal cancer patients (Table 4).
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      found that about 50% of patients had depressive symptoms, with this group of patients demonstrating slightly lower (Z = −2.795, p = 0.005) resilience levels than patients with no depressive symptoms. According to
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      , about 11% of colorectal cancer patients had post-traumatic stress symptoms. However, over 50% of the studied patients also showed moderate levels of resilience. In contrast,
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      reported that colorectal cancer patient showed moderate levels of self-perceived burden (mean 34.81, scale 10–50) and relatively low resilience levels (mean 69.03, scale 0–100). The fact that
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      found low anxiety and depression levels (mean 3.26, scale 0–48), along with relatively high resilience levels (mean 5.41, scale 1–7), showed how the results between the identified studies varied.
      Table 4Results for scales measuring mental state, including mean values, standard deviation (SD), and Cronbach's alpha values.
      Author (year) Scale (possible range)Cronbachʼs αSampleMean (SD)Actual range
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      BSI (0–48)
      0.90n = 923.26 (0.74)0–16
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      PANAS
      n = 200
      PA (0–40)0.8130.53 (6.75)8–40
      NA (0–40)0.8410.15 (7.70)0–34
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      PSS (0–56)
      0.80n = 14420.9 (8.3)
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      SPBS (10–50)
      0.85n = 15734.81 (6.82)19–46
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      n = 1532.49 (1.20)
      Suppression.
      0–5
      ERQ: ess (0–6)0.682.58 (0.48)
      Experiential avoidance.
      1.60–3.70
      SCS-SF (0–4)0.862.62 (0.37)1.36–3.73
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      n = 100
      SAS (20–80)56.14 (2.97), 44.42 (3.64)
      SDS (20–80)56.55 (4.01), 43.95 (4.14)
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      n = 188
      C-DTS (0–136)0.9229.86 (16.94)0–111
      IPSS (0–35)0.877.46 (6.74)0–28
      Abbreviations: BSI - Brief Symptom Inventory; PANAS - Positive and Negative Affect Schedule; PA - Positive Affect; NA - Negative Affect; PSS - Perceived Stress Scale; SPBS - Self-Perceived Burden Scale; ERQ - Emotion Regulation Questionnaire; ess - the expressive suppression subscale; SCS-SF - Self-Compassion Scale-Short Form: SAS – Self-rating Anxiety Scale; SDS – Self-rating Depression Scale; C-DTS – Chinese version of Davidson Trauma Scale; IPSS – International prostate symptom score.
      1 Suppression.
      2 Experiential avoidance.
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      reported that an attention and interpretation therapy (AIT) intervention was effective; this intervention improved resilience levels (mean 55.42 vs. 63.24) and reduced cancer-related fatigue (mean 5.88 vs. 4.04, 6.06 vs. 4.01, 6.56 vs. 4.14, 6.49 vs. 5.21) along with anxiety and depression (mean 56.14 vs. 44.42, mean 56.55 vs. 43.95, respectively, both p < 0.05). The AIT was designed to help patients live with cancer by encouraging communication about cancer and related issues. These findings agreed with what was reported by
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      ; more specifically, patients in the cognitive reappraisal group were more likely to apply positive approaches when dealing with emotions, as well as showed better resilience levels (F = 6.79, effect size 0.08, p < 0.01) and self-compassion (β = 0.210, p < 0.05, F = 5.22 effect size 0.07, p < 0.01), than other patients.
      The reviewed studies reported negative correlations between resilience and mental and physical burden (Table 5).
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      observed moderate resilience levels among the cancer patients (mean 139.4, scale 25–175), and found a negative association between resilience and perceived stress (β = −0.240, p < 0.05). Similarly,
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      found an association between post-traumatic stress symptoms and resilience (β = −0.240, p < 0.001). Physical burden was one aspect of self-perceived burden (
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      ) and cancer-related problems (
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      ), both of which were negatively correlated with resilience, respectively. Mental and physical burden were connected to each other. A stepwise regression model revealed a positive correlation between lower urinary symptoms and post-traumatic stress symptoms (β = 0.740, p = 0.004). Furthermore, post-traumatic stress symptoms were significantly associated with resilience (β = −0.240 p < 0.001) (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ). Side effects explained lethargy and sadness (β = 0.320, p < 0.001), which were also found to be associated with resilience (β = −0.320, p < 0.001) (
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ).
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      observed low overall resilience levels (mean 26.22, scale 0–40), which may be explained by the fact that about 32% of the cancer patients reported complications related to the ostomy, while
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      provided empirical evidence that an intervention can ease patients’ physical burden and enhance well-being by reducing reported ostomy complications and improving self-care abilities and resilience. Notably, the intervention group showed significantly lower ostomy complication rates (X2 = 5.835, p < 0.05), as well as better resilience (F = 92.03, p < 0.05), than the control group (
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ).
      Table 5Correlations between resilience and mental and physical burden.
      VariableResilience (r, rho)p-value
      Anxiety and depression−0.66<0.001
      Cancer-related problems−0.70<0.001
      Self-perceived burden−0.337<0.01
      Negative affect−0.33<0.001
      Experiential avoidance−0.50<0.001
      Post-traumatic stress symptoms−0.32<0.001
      Abbreviations: r - Pearson correlation coefficient; rho - Spearman's correlation.

      3.5.4 Quality of life

      The relationship between resilience and quality of life was explored in two studies. The mean quality of life reported in these two studies was 74.1–83.8 (scale 0–100).
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      used SEM to demonstrate that resilience has a statistically significant positive effect on a patient's quality of life in terms of physical, social, and emotional well-being (β = 0.530, β = 0.390, and β = 0.310, respectively, all p < 0.05). These findings were consistent with what was reported in an intervention study that aimed to help patients ease their physical burden, support selfcare, adjust negative emotions, and maintain good mental health (
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ). More specifically, the intervention group showed higher levels of resilience and quality of life than other patients three and six months after discharge (t = 4.158 vs. 7.406, t = 4.933 vs. 8.611, p < 0.05).

      3.5.5 Post-traumatic growth

      In the included studies, the relationship between resilience and post-traumatic growth was studied both 1–12 months after surgery (
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      ) and two years after diagnosis (n = 150;
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ). Post-traumatic growth covered the following themes: relating to others; new possibilities; personal strength; spiritual change; and appreciation of life. The mean scores for post-traumatic growth varied between 58.05 and 76.78 (scale range 0–105), while a positive association between post-traumatic growth and resilience was reported by several authors: β = 0.390 (p < 0.001), β = 0.460 (p < 0.01), and β = 0.730 (p ≤ 0.001) by
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ,
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      , and
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      , respectively.
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      noted that post-traumatic growth was also associated with social support (r = 0.450, p < 0.01).

      4. Discussion

      To the best of our knowledge, the current study represents the first systematic review of resilience in colorectal cancer patients. Researchers have expressed interest in adult resilience during cancer care since the 1990s, but most studies on the topic were only published in the last two decades (
      • Edward K.-L.
      • Chipman M.
      • Giandinoto J.-A.
      • Robinson K.
      Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review.
      , Ludolph et al., 2019), as also presented in this systematic review.
      The studies included in this systematic review confirmed that most colorectal cancer patients show moderate levels of resilience. In fact, resilience levels among colorectal cancer patients were, in some cases, slightly higher than the levels reported for a sample of the general population. Notably,
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      found higher levels of resilience among colorectal cancer patients than
      • Solano J.P.C.
      • Neto L.
      Cross-cultural adaptation and validation of Brazilian Portuguese versions of the dispositional resilience scale and Connor-Davidson resilience scale.
      observed among the general population (Mean 76.68, n = 103 Vs Mean 75.4, n = 103, respectively). In other cases, resilience among colorectal cancer patients was low (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ), and lower (
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ) than other cancer patients, such as breast cancer patients (mean 139.4, n = 144; vs mean 144.04, n = 78) (
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ;
      • Guil R.
      • Ruiz-González P.
      • Merchán-Clavellino A.
      • Morales-Sánchez L.
      • Zays A.
      • Gómez-Molinero R.
      Breast cancer and resilience: the controversial role of perceived emotional intelligence.
      ). This causes us to question whether colorectal cancer patients are less hopeful about the future because they have significantly lower survival rates than breast cancer patients (
      • World Health Organization
      Cancer Today.
      ) or because they have more unmet supportive care needs (
      • Li W.W.Y.
      • Lam W.W.T.
      • Au A.H.Y.
      • Ye M.
      • Law W.L.
      • Poon J.
      • Kwong A.
      • Suen D.
      • Tsang J.
      • Girgis A.
      • Fielding R.
      Interpreting differences in patterns of supportive care needs between patients with breast cancer and patients with colorectal cancer.
      ). However, most of the colorectal cancer patients described in the identified studies had a positive attitude and confidence about the future (
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      ). Hence, despite a cancer diagnosis, they showed resilience. A patient's economic situation (
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      ;
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      ), self-compassion (
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      ), enthusiasm, alertness (
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ), older age and male gender (
      • Cohen M.
      • Baziliansky S.
      • Beny A.
      The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
      ) were found to influence resilience. Resilience was associated with social support, hope, mental and physical burden, quality of life, and post-traumatic growth. However, most of these associations were reported in research employing a cross-sectional design (n = 9), and thus, cannot provide information about how these relationships changed over time. Furthermore, resilience was an outcome variable in only three of the reviewed studies (
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ;
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ).
      Most of the studies included patients at different phases of cancer care; however, resilience findings were presented at the study sample level instead of separating the findings by phase or stage of cancer. Therefore, we were unable to generalize the findings for a particular point in the cancer continuum. Differences in resilience could be expected in the case that some patients had access to curative treatments while other patients did not (
      • Rodin G.
      • Lo C.
      • Mikulincer M.
      • Donner A.
      • Gagliese L.
      • Zimmermann C.
      Pathways to distress: the multiple determinants of depression, hopelessness, and the desire for hastened death in metastatic cancer patients.
      ). However, the studies included in this systematic review demonstrated resilience among colorectal cancer patients, even those with advanced cancer and metastases. Furthermore, the findings presented by
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      caused us to question the perspective of patients with depression, as this group of patients also showed moderate levels of resilience (
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      ).
      In the reviewed studies, social support and hope were both associated with resilience (
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ;
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ), and these findings concur with what has been presented in previous studies concerning other cancer types (
      • Edward K.-L.
      • Chipman M.
      • Giandinoto J.-A.
      • Robinson K.
      Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review.
      ;
      • Gao Y.
      • Yuan L.
      • Pan B.
      • Wang L.
      Resilience and associated factors among Chinese patients diagnosed with oral cancer.
      ;
      • Lee S.-Y.
      • Lee H.
      • Fawcett J.
      • Park J.-H.
      Resilience in Korean with cancer: scoping review.
      ). Cancer patients seek information, as well as social and emotional support (
      • Dubey C.
      • De Maria J.
      • Hoeppli C.
      • Betticher D.C.
      • Eicher M.
      Resilience and unmet supportive care needs in patients with cancer during early treatment: a descriptive study.
      ;
      • Lam W.W.T.
      • Law W.-L.
      • Poon J.T.C.
      • Fong D.
      • Girgis A.
      • Fielding R.
      A longitudinal study of supportive care needs among Chinese patients awaiting colorectal cancer surgery.
      ;
      • Ran L.
      • Jiang X.
      • Qian E.
      • Kong H.
      • Wang X.
      • Liu Q.
      Quality of life, self-care knowledge access, and self-care needs in patients with colon stomas one month post-surgery in a Chinese Tumor Hospital.
      ). The provided support should match their needs (
      • Li W.W.Y.
      • Lam W.W.T.
      • Au A.H.Y.
      • Ye M.
      • Law W.L.
      • Poon J.
      • Kwong A.
      • Suen D.
      • Tsang J.
      • Girgis A.
      • Fielding R.
      Interpreting differences in patterns of supportive care needs between patients with breast cancer and patients with colorectal cancer.
      ;
      • Zebrack B.J.
      • Gorbett V.
      • Embry L.
      • Aguilar C.
      • Meeske K.A.
      • Hayes-Lattin B.
      • Block R.
      • Zeman D.T.
      • Cole S.
      Psychological distress and unsatisfied need for psychosocial support in adolescent and young adult cancer patients during the first year following diagnosis.
      ). Without this kind of support, patients can experience high disease burden and hopelessness, both of which are risk factors for poor mental health (
      • Rodin G.
      • Lo C.
      • Mikulincer M.
      • Donner A.
      • Gagliese L.
      • Zimmermann C.
      Pathways to distress: the multiple determinants of depression, hopelessness, and the desire for hastened death in metastatic cancer patients.
      ).
      Most colorectal cancer patients received social support from their loved ones and healthcare professionals (
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      ;
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ), as well as via interventions (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ). Based on the presented results, support also seemed to help patients identify and utilize their individual resources (
      • Stainton A.
      • Chisholm K.
      • Kaiser N.
      • Rosen M.
      • Upthegrove R.
      • Ruhrmann S.
      • Wood S.J.
      Resilience as a multimodal dynamic process.
      ;
      • Sisto A.
      • Vicinanza F.
      • Campanozzi L.L.
      • Ricci G.
      • Tartaglini D.
      • Tambone V.
      Towards a transversal definition of psychological resilience: a literature review.
      ) and was associated with higher resilience levels (
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ). According to
      • Solano J.P.C.
      • Gomes da Silva A.
      • Soares I.A.
      • Ashmawi H.A.
      • Vieira J.E.
      Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
      , colorectal cancer patients, even those at advanced stages of cancer, were quite hopeful. Previous research has shown that hope is important during life-threatening events (
      • Ebenau A.
      • van Gurp J.
      • Hasselaar J.
      Life values of elderly people suffering from incurable cancer: a literature review.
      ;
      • Gao Y.
      • Yuan L.
      • Pan B.
      • Wang L.
      Resilience and associated factors among Chinese patients diagnosed with oral cancer.
      ;
      • Lee S.-Y.
      • Lee H.
      • Fawcett J.
      • Park J.-H.
      Resilience in Korean with cancer: scoping review.
      ) and has an even greater effect on resilience than social support (
      • Gao Y.
      • Yuan L.
      • Pan B.
      • Wang L.
      Resilience and associated factors among Chinese patients diagnosed with oral cancer.
      ). In fact, the provision of support is not guaranteed to help patients (
      • Bonanno G.A.
      Loss, trauma, and human resilience have we underestimated the human capacity to thrive after extremely aversive events?.
      ;
      • Livingston P.M.
      • White V.M.
      • Hayman J.
      • Maunsell E.
      • Dunn S.M.
      • Hill D.
      The psychological impact of a specialist referral and telephone intervention on male cancer patients: a randomised controlled trial.
      ).
      Resilience was also statistically significantly associated with mental and physical burden. Moreover, mental, and physical burden were also connected to each other, as side effects (
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ), and low urinary symptoms also showed (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ). Previous studies have shown that patients are interested in the side effects of their treatment (
      • Beusterien K.
      • Tsay S.
      • Gholizadeh S.
      • Su Y.
      Real-world experience with colorectal cancer chemotherapies: patient web forum analysis.
      ) as well as practical (
      • Ran L.
      • Jiang X.
      • Qian E.
      • Kong H.
      • Wang X.
      • Liu Q.
      Quality of life, self-care knowledge access, and self-care needs in patients with colon stomas one month post-surgery in a Chinese Tumor Hospital.
      ;
      • Melissant H.C.
      • van Uden-Kraan C.F.
      • Lissenberg-Witte B.I.
      • Verdonck-de Leeuw I.M.
      Body changes after cancer: female cancer patients'perceived social support and their perspective on care.
      ) and psychosocial support (
      • Dubey C.
      • De Maria J.
      • Hoeppli C.
      • Betticher D.C.
      • Eicher M.
      Resilience and unmet supportive care needs in patients with cancer during early treatment: a descriptive study.
      ;
      • Perl G.
      • Nordheimer S.
      • Lando S.
      • Benedict C.
      • Brenner B.
      • Perry S.
      • Shmoisman G.
      • Purim O.
      • Amit L.
      • Stemmer S.M.
      • Ben-Ahoron I.
      Young patients and gastrointestinal (GI) tract malignancies – are we addressing the unmet needs?.
      ). Some of the research covered in this review demonstrated how an intervention aiming to help in practical self-care issues and develop coping strategies can ease mental and physical burden, as well as improve resilience (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ).
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      reported that patients with more adaptive emotion regulation strategies and self-compassion showed better resilience relative to other patients. All of these findings agree with what has been presented in previous studies. For example,
      • Garcia A.C.M.
      • Silva B.D.
      • Oliveira da Silva L.C.
      • Mills J.
      Self-compassion in hospice and palliative care: a systematic integrative review.
      showed that self-compassion supports self-care, as well as improves psychosocial wellbeing. Developing strategies that are useful for self-care (
      • Li M.-Y.
      • Yang Y.-L.
      • Liu L.
      • Wang L.
      Effects of social support, hope and resilience on quality of life among Chinese bladder cancer patients: a cross-sectional study.
      ;
      • Zhang H.
      • Zhao Q.
      • Cao P.
      • Guosheng R.
      Resilience and quality of life: exploring the mediator role of social support in patients with breast cancer.
      ;
      • Edward K.-L.
      • Chipman M.
      • Giandinoto J.-A.
      • Robinson K.
      Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review.
      ) and positively dealing with thoughts and emotions can help patients reduce their mental burden, achieve better resilience (
      • Lim J.-W.
      • Shon E.-J.
      • Paek M.
      • Daly B.
      The dyadic effects of coping and resilience on psychological distress for cancer survivor couples.
      ;
      • Baghjari F.
      • Saadati H.
      • Esmaeilinasab M.
      The relationship between cognitive emotion-regualtion strategies and resiliency in advanced patients with cancer.
      ), and improve the quality of life (
      • Li M.-Y.
      • Yang Y.-L.
      • Liu L.
      • Wang L.
      Effects of social support, hope and resilience on quality of life among Chinese bladder cancer patients: a cross-sectional study.
      ;
      • Zhang H.
      • Zhao Q.
      • Cao P.
      • Guosheng R.
      Resilience and quality of life: exploring the mediator role of social support in patients with breast cancer.
      ;
      • Edward K.-L.
      • Chipman M.
      • Giandinoto J.-A.
      • Robinson K.
      Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review.
      ).
      Resilience in colorectal cancer patients was positively related to quality of life (
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ), which comprises various aspects that are considered valuable to everyday life (
      • Ye Z.J.
      • Qiu H.Z.
      • Li P.F.
      • Liang M.Z.
      • Zhu Y.F.
      • Zeng Z.
      • Hu G.Y.
      • Wang S.N.
      • Quan X.M.
      Predicting changes in quality of life and emotional distress in Chinese patients with lung, gastric, and colon-rectal cancer diagnoses: the role of psychological resilience.
      ;
      • Zhang H.
      • Zhao Q.
      • Cao P.
      • Guosheng R.
      Resilience and quality of life: exploring the mediator role of social support in patients with breast cancer.
      ). According to
      • Ebenau A.
      • van Gurp J.
      • Hasselaar J.
      Life values of elderly people suffering from incurable cancer: a literature review.
      , cancer patients consider hope, optimism, continuity, and preparedness as important life values. These values overlap with resilience, which focuses on problem-solving and confidence about the future (
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      ).
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      found that a specific intervention can help ease patientsʼ physical, social, and emotional burdens, as well as maintain their mental well-being, all of which will improve their quality of life and resilience. These findings agree with what was presented in a recently published systematic review of resilience among breast cancer patients. Notably,
      • Aizpurua-Perez I.
      • Perez-Tejada J.
      Resilience in women with breast cancer: a systematic review.
      noted that adaptive coping strategies and quality of life are associated with resilience. Previous studies have shown that resilience building-interventions can be effective (
      • Ludolph P.
      • Kunzler A.M.
      • Stoffers-Winterling J.
      • Helmreich I.
      • Lieb K.
      Interventions to promote resilience in cancer patients.
      ;
      • Seiler A.
      • Jenewein J.
      Resilience in cancer patients.
      ;
      • Üzar-Özҫetin Y.S.
      • Hiҫdurmaz D.
      Effects of an empowerment program on resilience and posttraumatic growth levels of cancer survivors: a randomized controlled feasibility trial.
      ), and support should satisfy patient needs while also focusing on patient empowerment (
      • Ebenau A.
      • van Gurp J.
      • Hasselaar J.
      Life values of elderly people suffering from incurable cancer: a literature review.
      ;
      • Üzar-Özҫetin Y.S.
      • Hiҫdurmaz D.
      Effects of an empowerment program on resilience and posttraumatic growth levels of cancer survivors: a randomized controlled feasibility trial.
      ).
      Resilience was found to be critical for the development of post-traumatic growth (
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Zhang C.
      • Gao R.
      • Tai J.
      • Li Y.
      • Chen S.
      • Chen L.
      • Cao X.
      • Wang L.
      • Jia M.
      • Li F.
      The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
      ), a phase during which patients learn skills that will benefit them in the future. Previous studies have reported similar results, namely, resilience can predict post-traumatic growth, with both modifiable through intervention (
      • Seiler A.
      • Jenewein J.
      Resilience in cancer patients.
      ;
      • Üzar-Özҫetin Y.S.
      • Hiҫdurmaz D.
      Effects of an empowerment program on resilience and posttraumatic growth levels of cancer survivors: a randomized controlled feasibility trial.
      ).
      This systematic review clarified the phenomenon of resilience among colorectal cancer patients, as well as identified future avenues for research. Although some of the reviewed studies presented resilience as an individual quality (
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ;
      • Baziliansky S.
      • Cohen M.
      Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
      ;
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ), most agreed that resilience might not be an immutable situation for colorectal cancer patients. The reviewed studies provided evidence that well-designed interventions can improve resilience (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ), identified associations between social support and resilience (
      • Costa A.L.S.
      • Heitkemper M.M.
      • Alencar G.P.
      • Damiani L.P.
      • Marques da Silva R.
      • Jarrett M.E.
      Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Ҫakir H.
      • Ҫelik G.K.
      • Ҫirpan R.
      Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
      ), and reported that patients can improve their ability to confront challenging future events (
      • Gouzman J.
      • Cohen M.
      • Ben-Zur H.
      • Shacham-Shmueli E.
      • Aderka D.
      • Siegelmann-Danieli N.
      • Beny A.
      Resilience and psychosocial adjustment in digestive system cancer.
      ;
      • Dong X.
      • Li G.
      • Liu C.
      • Kong L.
      • Fang Y.
      The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ). However, only two of the studies included in this review represented follow-up studies (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ).
      The studies in this systematic review mainly used the Connor-Davidson Resilience Scale, yet
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      have themselves questioned whether the scale can assess resilience as a process. However, it can be argued that colorectal cancer patients in the reviewed studies answered questions concerning resilience and had to identify their personal resources and strengths. In other words, resilience is the kind of process that requires conscious action along with the identification and utilization of personal resources (
      • Sisto A.
      • Vicinanza F.
      • Campanozzi L.L.
      • Ricci G.
      • Tartaglini D.
      • Tambone V.
      Towards a transversal definition of psychological resilience: a literature review.
      ;
      • Stainton A.
      • Chisholm K.
      • Kaiser N.
      • Rosen M.
      • Upthegrove R.
      • Ruhrmann S.
      • Wood S.J.
      Resilience as a multimodal dynamic process.
      ). The results of this systematic review suggest that resilience can be confirmed at different stages of cancer. Furthermore, a resilience scale can be used to assess resilience levels (n = 9) and may be a way to gauge the effect of an intervention (
      • Lin C.
      • Diao Y.
      • Dong Z.
      • Song J.
      • Bao C.
      The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
      ,
      • Lin Y.-H.
      • Kao C.-C.
      • Pan I.-J.
      • Liu Y.-H.
      Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
      ;
      • Zhang X.
      • Gao R.
      • Lin J.L.
      • Chen N.
      • Lin Q.
      • Huang Gf
      • Wang L.
      • Chen Xh
      • Xue Fg
      • Li H.
      Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
      ).
      The results of this systematic review support the notion that resilience may improve with support from others (including healthcare professionals and closest relatives), and challenges whether resilience is a process, that can indeed change through various stages of cancer. The presented findings suggest that resilience is a mediator for positive changes among colorectal cancer patients. The reviewed studies showed that resilience is not only correlated with social support, but also with hope, mental and physical burden, quality of life, and post-traumatic growth. However, this is somewhat expected, as the Connor and Davidson Resilience Scale measures the security of a patient's close relationships, the patient's trust in their instincts and the acceptance of change (
      • Connor K.M.
      • Davidson J.R.T.
      Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
      ). As such, the presented correlations between resilience and other personal factors that are somehow incorporated into the various measures of resilience are not so surprising. Further follow-up studies, along with the application of various distinct statistical methods, will provide more insight into resilience among colorectal cancer patients.

      4.1 Study limitations

      This review included quite a low number of studies that met the inclusion criteria (n = 11) when compared to a systematic review (n = 39) of resilience among breast cancer patients (
      • Aizpurua-Perez I.
      • Perez-Tejada J.
      Resilience in women with breast cancer: a systematic review.
      ). It should be noted that we only included studies that used scales for measuring resilience, which may have caused certain resilience studies to be excluded. The research presented in this review suggests that certain interventions (n = 2) might be able to improve resilience, with cross-sectional studies (n = 9) reporting correlations between social support and resilience. Nevertheless, we were unable to determine whether colorectal cancer patients need some specific type of support, as well as noted the lack of information concerning how resilience changes throughout cancer. The reviewed studies mainly presented the source of support, with limited details on the kind of support that was provided. In addition, the measurement times varied widely between the different studies.
      It is important to note that the results are not generalizable to all colorectal cancer patients due to differences in the study samples, which ranged from a small pilot study to a large-scale investigation, as well as the country in which the study was conducted. The identified research was mainly conducted in Asia and South America, with only one study from Europe. Therefore, colorectal cancer patients from other continents were not represented in the reviewed research. Most of the studies included patients at various cancer stages (I-IV) and phases of cancer care. Although these details were presented as background variables, resilience findings were not presented separately for patients at different stages of cancers.

      4.2 Clinical implications

      The research covered in this review suggests that employing strategies that focus on thoughts and emotions, as well as provide practical information about cancer and self-care skills, might help patients to identify and use their strengths, build self-care capabilities, as well as improve their resilience. Future research should focus on clarifying whether the act of answering a resilience questionnaire can help patients improve their resilience by identifying their personal resources.

      5. Conclusions

      Resilience in colorectal cancer patients was connected to both negative and positive aspects of the illness. The results presented in this review suggest that psychosocial and illness-related practical support might be crucial to developing resilience among these patients. However, there is a need for follow-up studies to chronicle how resilience changes among colorectal cancer patients. Concurrently, future studies should describe information related to the cancer continuum and what type of content the offered support includes. This type of insight could help healthcare professionals around to world provide colorectal cancer patients with the social support they desire.

      Declaration of competing interest

      The authors declare no conflicts of interests.

      Acknowledgements

      The authors thank the Finnish Nurses Association for a grant received in 2019.

      References

        • Aizpurua-Perez I.
        • Perez-Tejada J.
        Resilience in women with breast cancer: a systematic review.
        Eur. J. Oncol. Nurs. 2020; 49101854https://doi.org/10.1016/j.ejon.2020. 101854
        • Arnold M.
        • Sierra M.S.
        • Laversanne M.
        • Soerjomataram I.
        • Jemal A.
        • Bray F.
        Global patterns and trends in colorectal cancer incidence and mortality.
        Gut. 2017; 66: 683-691https://doi.org/10.1136/gutjnl-2015-310912
        • Baghjari F.
        • Saadati H.
        • Esmaeilinasab M.
        The relationship between cognitive emotion-regualtion strategies and resiliency in advanced patients with cancer.
        Int. J. Cancer Manag. 2017; 10e7443https://doi.org/10.5812/ijcm.7443
        • Bapuji S.B.
        • Sawatzky J.-A.V.
        Understanding weight loss in patients with colorectal cancer: a human response to illness.
        Oncol. Nurs. Forum. 2010; 37: 303-307https://doi.org/10.1188/10.onf.303-310
        • Baziliansky S.
        • Cohen M.
        Emotion regulation patterns among colorectal cancer survivors: clustering and associations with personal coping resources.
        Behav. Med. 2020; 10: 1-11https://doi.org/10.1080/08964289.2020.1731674
        • Beusterien K.
        • Tsay S.
        • Gholizadeh S.
        • Su Y.
        Real-world experience with colorectal cancer chemotherapies: patient web forum analysis.
        Ecancermedicalscience. 2013; 7: 361https://doi.org/10.3332/ecancer.2013.361
        • Boeschen L.E.
        • Koss M.P.
        • Figueredo A.J.
        • Coan J.A.
        Experiential avoidance and post-traumatic stress disorder: a cognitive mediational model of rape recovery.
        J. Aggress. Maltreat. Trauma. 2001; 4: 211-245
        • Bonanno G.A.
        Loss, trauma, and human resilience have we underestimated the human capacity to thrive after extremely aversive events?.
        Am. Psychol. 2004; 59: 20-28https://doi.org/10.1037/0003-066X.59.1.20
        • Bonanno G.A.
        • Westphal M.
        • Mancini A.D.
        Resilience to loss and potential trauma.
        Annu. Rev. Clin. Psychol. 2011; 7: 511-535https://doi.org/10.1146/annurev-clinpsy-032210-104526
        • Bulkley J.
        • McMullen C.K.
        • Hornbrook M.C.
        • Grant M.
        • Altschuler A.
        • Wendel C.S.
        • Krouse R.S.
        Spiritual well-being in long-term colorectal cancer survivors with ostomies.
        Psycho Oncol. 2013; 22: 2513-2521https://doi.org/10.1002/pon.3318
        • Ҫakir H.
        • Ҫelik G.K.
        • Ҫirpan R.
        Correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery: a descriptive study.
        Psychol. Health Med. 2021; 26: 899-910https://doi.org/10.1080/13548506.2020.1859561
        • Cancer Research UK
        Survival.
        2020
        • Cohen M.
        • Baziliansky S.
        • Beny A.
        The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study.
        J. Geriatr. Oncol. 2014; 5: 33-39https://doi.org/10.1016/j.jgo.2013.07.009
        • Connor K.M.
        • Davidson J.R.T.
        Development of a new resilience scale: the connor-davidson resilience scale (CD-RISC).
        Depress. Anxiety. 2003; 18: 76-82https://doi.org/10.1002/da.10113
        • Costa A.L.S.
        • Heitkemper M.M.
        • Alencar G.P.
        • Damiani L.P.
        • Marques da Silva R.
        • Jarrett M.E.
        Social support is a predictor of lower stress and higher quality of life and resilience in Brazilian patients with colorectal cancer.
        Cancer Nurs. 2017; 40: 352-360https://doi.org/10.1097/NCC.0000000000000388
        • Deshields T.L.
        • Heiland M.F.
        • Kracen A.C.
        • Dua P.
        Resilience in adults with cancer: development of a conceptual model.
        Psycho Oncol. 2016; 25: 11-18https://doi.org/10.1002/pon.3800
        • Doe M.J.
        Conceptual foreknowings: an integrative review of hope.
        Nurs. Sci. Q. 2020; 33: 55-64https://doi.org/10.1177/0894318419881805
        • Dong X.
        • Li G.
        • Liu C.
        • Kong L.
        • Fang Y.
        The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: a structural equation model analysis.
        Eur. J. Oncol. Nurs. 2017; 29: 47-52https://doi.org/10.1016/j.ejon.107.04.007
        • Dubey C.
        • De Maria J.
        • Hoeppli C.
        • Betticher D.C.
        • Eicher M.
        Resilience and unmet supportive care needs in patients with cancer during early treatment: a descriptive study.
        Eur. J. Oncol. Nurs. 2015; 19: 582-588https://doi.org/10.1016/j.ejon.2015.03.004
        • Ebenau A.
        • van Gurp J.
        • Hasselaar J.
        Life values of elderly people suffering from incurable cancer: a literature review.
        Patient Educ. Counsel. 2017; 100: 1778-1786https://doi.org/10.1016/j.pec.2017.05.027
        • Edward K.-L.
        • Chipman M.
        • Giandinoto J.-A.
        • Robinson K.
        Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review.
        Br. J. Nurs. 2019; 28: S6-S14https://doi.org/10.12968/bjon.2019.28.10.s4
        • Eicher M.
        • Ribi K.
        • Senn-Dubey C.
        • Senn S.
        • Ballabeni P.
        • Betticher D.
        Interprofessional, psycho-social intervention to facilitate resilience and reduce supportive care needs for patients with cancer: results of a noncomparative, randomized phase II trial.
        Psycho Oncol. 2018; 27: 1833-1839https://doi.org/10.1002/pon.4734
        • Finnish Cancer Registry
        Survival.
        2018
        • Gao Y.
        • Yuan L.
        • Pan B.
        • Wang L.
        Resilience and associated factors among Chinese patients diagnosed with oral cancer.
        BMC Cancer. 2019; 19: 1-9https://doi.org/10.1186/s12885-019-5679-0
        • Garcia A.C.M.
        • Silva B.D.
        • Oliveira da Silva L.C.
        • Mills J.
        Self-compassion in hospice and palliative care: a systematic integrative review.
        J. Hospice Palliat. Nurs. 2021; 23: 145-154https://doi.org/10.1097/njh.0000000000000727
        • Gouzman J.
        • Cohen M.
        • Ben-Zur H.
        • Shacham-Shmueli E.
        • Aderka D.
        • Siegelmann-Danieli N.
        • Beny A.
        Resilience and psychosocial adjustment in digestive system cancer.
        J. Clin. Psychol. Med. Settings. 2015; 22: 1-13https://doi.org/10.1007/s10880-015-9416-9
        • Grant M.
        • McMullen C.K.
        • Altschuler A.
        • Mohler M.J.
        • Hornbrook M.C.
        • Herrinton L.J.
        • Wendel C.S.
        • Baldwin C.M.
        • Krouse R.S.
        Gender differences in quality of life among long-term colorectal cancer survivors with ostomies.
        Oncol. Nurs. Forum. 2011; 38: 587-596https://doi.org/10.1188/11.onf.587-596
        • Grealish L.
        • Hyde M.K.
        • Legg M.
        • Lazenby M.
        • Aitken J.F.
        • Dunn J.
        • Chambers S.K.
        Psychosocial predictors of hope two years after diagnosis of colorectal cancer: implications for nurse-led hope programmes.
        Eur. J. Cancer Care. 2019; 28e13010https://doi.org/10.1111/ecc.13010
        • Guil R.
        • Ruiz-González P.
        • Merchán-Clavellino A.
        • Morales-Sánchez L.
        • Zays A.
        • Gómez-Molinero R.
        Breast cancer and resilience: the controversial role of perceived emotional intelligence.
        Front. Psychol. 2020; 11595713https://doi.org/10.3389/fpsyg.2020.595713
        • Hall D.L.
        • Luberto C.M.
        • Philpotts L.L.
        • Song R.
        • Park E.R.
        • Yeh G.Y.
        Mind-body interventions for fear of cancer recurrence: a systematic review and meta-analysis.
        Psycho Oncol. 2018; 27: 2546-2558https://doi.org/10.1002/pon.4757
        • Karimi S.
        • Makhsosi B.R.
        • Seyedi-Andi S.J.
        • Behzadi M.
        • Moghofeh Y.
        • Mohammadinasrabadi K.
        • Abdi A.
        • Ahmadi P.
        Surveying the effect of a self-care education program on severity of nausea and emesis in colorectal cancer patients under chemotherapy.
        J. Multidiscip. Healthc. 2017; 10: 301-307https://doi.org/10.2147/jmdh.s131111
        • Lai H.-L.
        • Hung C.-M.
        • Chen C.-I.
        • Shih M.-L.
        • Huang C.-Y.
        Resilience and coping styles as predictors of health outcomes in breast cancer patients: a structural equation modelling analysis.
        Eur. J. Cancer Care. 2020; 29: 1-7https://doi.org/10.1111/ecc.13161
        • Lam W.W.T.
        • Law W.-L.
        • Poon J.T.C.
        • Fong D.
        • Girgis A.
        • Fielding R.
        A longitudinal study of supportive care needs among Chinese patients awaiting colorectal cancer surgery.
        Psycho Oncol. 2016; 25: 496-505https://doi.org/10.1002/pon.3946
        • Lee V.
        • Cohen S.R.
        • Edgar L.
        • Laizner A.M.
        • Gagnon A.J.
        Meaning-making intervention during breast or colorectal cancer treatment improves self-esteem, optimism, and self-efficacy.
        Soc. Sci. Med. 2006; 62: 3133-3145https://doi.org/10.1016/j.socscimed.2005.11.041
        • Lee S.-Y.
        • Lee H.
        • Fawcett J.
        • Park J.-H.
        Resilience in Korean with cancer: scoping review.
        J. Hospice Palliat. Nurs. 2019; 21: 358-364https://doi.org/10.1097/njh.0000000000000543
        • Li W.W.Y.
        • Lam W.W.T.
        • Au A.H.Y.
        • Ye M.
        • Law W.L.
        • Poon J.
        • Kwong A.
        • Suen D.
        • Tsang J.
        • Girgis A.
        • Fielding R.
        Interpreting differences in patterns of supportive care needs between patients with breast cancer and patients with colorectal cancer.
        Psycho Oncol. 2013; 22: 792-798https://doi.org/10.1002/pon.3068
        • Li M.-Y.
        • Yang Y.-L.
        • Liu L.
        • Wang L.
        Effects of social support, hope and resilience on quality of life among Chinese bladder cancer patients: a cross-sectional study.
        Health Qual. Life Outcome. 2016; 14: 1-9https://doi.org/10.1186/s12955-016-0481-z
        • Lim J.-W.
        • Shon E.-J.
        • Paek M.
        • Daly B.
        The dyadic effects of coping and resilience on psychological distress for cancer survivor couples.
        Support. Care Cancer. 2014; 22: 3209-3217https://doi.org/10.1007/s00520-014-2334-9
        • Lin C.
        • Diao Y.
        • Dong Z.
        • Song J.
        • Bao C.
        The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
        Ann. Palliat. Med. 2020; 9: 3261-3270https://doi.org/10.21037/apm-20-1370
        • Lin Y.-H.
        • Kao C.-C.
        • Pan I.-J.
        • Liu Y.-H.
        Lower urinary symptoms, resilience, and post-traumatic stress symptoms among rectal cancer patients after surgery.
        Jpn. J. Nurs. Sci. 2020; 17e12320https://doi.org/10.1111/jjns.12320
        • Livingston P.M.
        • White V.M.
        • Hayman J.
        • Maunsell E.
        • Dunn S.M.
        • Hill D.
        The psychological impact of a specialist referral and telephone intervention on male cancer patients: a randomised controlled trial.
        Psycho Oncol. 2010; 19: 617-625https://doi.org/10.1002/pon.1609
        • Ludolph P.
        • Kunzler A.M.
        • Stoffers-Winterling J.
        • Helmreich I.
        • Lieb K.
        Interventions to promote resilience in cancer patients.
        Dtsch. Arztebl. Int. 2019; 116: 865-872https://doi.org/10.3238/arztebl.2019.0865
        • Luo D.
        • Eicher M.
        • White K.
        Individual resilience in adult cancer care: a concept analysis.
        Int. J. Nurs. Stud. 2020; 102103467https://doi.org/10.1016/j.ijnurstu.2019.103467
        • Melissant H.C.
        • van Uden-Kraan C.F.
        • Lissenberg-Witte B.I.
        • Verdonck-de Leeuw I.M.
        Body changes after cancer: female cancer patients'perceived social support and their perspective on care.
        Support. Care Cancer. 2019; 27: 4299-4306https://doi.org/10.1007/s00520-019-04729-w
        • Molina Y.
        • Yi J.C.
        • Martinez-Gutierrez J.
        • Reding K.W.
        • Yi-Frazier J.P.
        • Rosenberg A.R.
        Resilience among patients across the cancer continuum: diverse perspectives.
        Clin. J. Oncol. Nurs. 2014; 18: 93-101https://doi.org/10.1188/14.cjon.93-101
        • Perl G.
        • Nordheimer S.
        • Lando S.
        • Benedict C.
        • Brenner B.
        • Perry S.
        • Shmoisman G.
        • Purim O.
        • Amit L.
        • Stemmer S.M.
        • Ben-Ahoron I.
        Young patients and gastrointestinal (GI) tract malignancies – are we addressing the unmet needs?.
        BMC Cancer. 2016; 16: 630https://doi.org/10.1186/s12885-016-2676-4
        • Ran L.
        • Jiang X.
        • Qian E.
        • Kong H.
        • Wang X.
        • Liu Q.
        Quality of life, self-care knowledge access, and self-care needs in patients with colon stomas one month post-surgery in a Chinese Tumor Hospital.
        Int. J. Nurs. Sci. 2016; 3: 252-258https://doi.org/10.1016/j.ijnss.2016.07.004
        • Ratjen I.
        • Schafmayer C.
        • Enderle J.
        • di Giuseppe R.
        • Waniek S.
        • Koch M.
        • Burmeister G.
        • Nöthlings U.
        • Hampe J.
        • Schlesinger S.
        • Lieb W.
        Health-related quality of life in long-term survivors of colorectal cancer and its association with all-cause mortality: a German cohort study.
        BMC Cancer. 2018; 18: 1156https://doi.org/10.1186/s12885-018-5075-1
        • Rodin G.
        • Lo C.
        • Mikulincer M.
        • Donner A.
        • Gagliese L.
        • Zimmermann C.
        Pathways to distress: the multiple determinants of depression, hopelessness, and the desire for hastened death in metastatic cancer patients.
        Soc. Sci. Med. 2009; 68: 562-569https://doi.org/10.1016/j.socscimed.2008.10.037
        • Seiler A.
        • Jenewein J.
        Resilience in cancer patients.
        Front. Psychiatr. 2019; 10: 208https://doi.org/10.3389/fpsyt.2019.00208
        • Sisto A.
        • Vicinanza F.
        • Campanozzi L.L.
        • Ricci G.
        • Tartaglini D.
        • Tambone V.
        Towards a transversal definition of psychological resilience: a literature review.
        Medicina. 2019; 55: 1-22https://doi.org/10.3390/medicina55110745
        • Solano J.P.C.
        • Neto L.
        Cross-cultural adaptation and validation of Brazilian Portuguese versions of the dispositional resilience scale and Connor-Davidson resilience scale.
        World Psychiatric Association, Section on Epidemiology and Public Health. 2012; 10: 44-46
        • Solano J.P.C.
        • Gomes da Silva A.
        • Soares I.A.
        • Ashmawi H.A.
        • Vieira J.E.
        Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients.
        BMC Palliat. Care. 2016; 15: 1-8https://doi.org/10.1186/s12904-016-0139-y
        • Stainton A.
        • Chisholm K.
        • Kaiser N.
        • Rosen M.
        • Upthegrove R.
        • Ruhrmann S.
        • Wood S.J.
        Resilience as a multimodal dynamic process.
        Early Interv. Psychia. 2019; 13: 725-732https://doi.org/10.1111/eip.12726
        • Tan W.S.
        • Beatty L.
        • Koczwara B.
        Do cancer patients use the term resilience? A systematic review of qualitative studies.
        Support. Care Cancer. 2019; 27: 43-56https://doi.org/10.1007/s00520-018-4456-y
        • Üzar-Özҫetin Y.S.
        • Hiҫdurmaz D.
        Effects of an empowerment program on resilience and posttraumatic growth levels of cancer survivors: a randomized controlled feasibility trial.
        Cancer Nurs. 2019; 42: E1-E12https://doi.org/10.1097/ncc.0000000000000644
        • Willems R.A.
        • Bolman C.A.W.
        • Mesters I.
        • Kanera I.M.
        • Beaulen A.A.J.M.
        • Lechner L.
        Cancer survivors in the first year after treatment: the prevalence and correlates of unmet needs in different domains.
        Psycho Oncol. 2016; 25: 51-57https://doi.org/10.1002/pon.3870
        • Windle G.
        • Bennett K.M.
        • Noyes J.
        A methodological review of resilience measurement scales.
        Health Qual. Life Outcome. 2011; 9: 1-18
        • World Health Organization
        Cancer Today.
        2021 (accessed 14 April 2021)
        • World Health Organization
        Cancer Today.
        2021
        Date accessed: April 14, 2021
        • Ye Z.J.
        • Qiu H.Z.
        • Li P.F.
        • Liang M.Z.
        • Zhu Y.F.
        • Zeng Z.
        • Hu G.Y.
        • Wang S.N.
        • Quan X.M.
        Predicting changes in quality of life and emotional distress in Chinese patients with lung, gastric, and colon-rectal cancer diagnoses: the role of psychological resilience.
        Psycho Oncol. 2017; 26: 829-835https://doi.org/10.1002/pon.4237
        • Zebrack B.J.
        • Gorbett V.
        • Embry L.
        • Aguilar C.
        • Meeske K.A.
        • Hayes-Lattin B.
        • Block R.
        • Zeman D.T.
        • Cole S.
        Psychological distress and unsatisfied need for psychosocial support in adolescent and young adult cancer patients during the first year following diagnosis.
        Psycho Oncol. 2014; 23: 1267-1275https://doi.org/10.1002/pon.3533
        • Zhang H.
        • Zhao Q.
        • Cao P.
        • Guosheng R.
        Resilience and quality of life: exploring the mediator role of social support in patients with breast cancer.
        Med. Sci. Mon. Int. Med. J. Exp. Clin. Res. 2017; 23: 5969-5979https://doi.org/10.12659/msm.907730
        • Zhang C.
        • Gao R.
        • Tai J.
        • Li Y.
        • Chen S.
        • Chen L.
        • Cao X.
        • Wang L.
        • Jia M.
        • Li F.
        The relationship between self-perceived burden and posttraumatic growth among colorectal cancer patients: the mediating effects of resilience.
        BioMed Res. Int. 2019; 6840743https://doi.org/10.1155/2019/6840743
        • Zhang X.
        • Gao R.
        • Lin J.L.
        • Chen N.
        • Lin Q.
        • Huang Gf
        • Wang L.
        • Chen Xh
        • Xue Fg
        • Li H.
        Effects of hospital-family holistic care model on the health outcome of patients with permanent enterostomy based on the theory of ‘Timing it Right’.
        J. Clin. Nurs. 2020; 29: 2196-2208https://doi.org/10.1111/JOCN.15199