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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.
). 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 (
). 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 (
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 (
, describes an individualʼs ability to confront adversities. Moreover, resilience has been found to be associated with personal factors such as optimism (
). 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 (
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 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 (
). Also, the human mind is highly complex. Cancer is an emotionally challenging situation that can cause patients to adopt negative coping strategies (
). 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 (
). These actions can also enhance the use of adaptive emotion regulation strategies, such as cognitive reappraisal, which can gradually improve resilience (
). 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 (
Interprofessional, psycho-social intervention to facilitate resilience and reduce supportive care needs for patients with cancer: results of a noncomparative, randomized phase II trial.
). 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).
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.
CRC 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.
CRC 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.
CRC 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.
CRC 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.
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.
Digestive 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.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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 resilience
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
Rectal 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.
Metastatic 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.
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.
Yes
12/13
Abbreviations: CRC - colorectal cancer; Dg. - diagnosis; PTG - post-traumatic growth; QOL - quality of life; RCT - randomized controlled trial; ± - Standard deviation.
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 (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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.
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.
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 (
). 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) (
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.
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.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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 (
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.
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 (
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.
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.
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.
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.
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).
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
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer 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,
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
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.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer 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
; 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).
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,
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer 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 (
), 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) (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer 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) (
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
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 (
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).
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 (
). 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 (
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.
). 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
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.
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 (
, 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,
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 (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
). 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 (
) 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 (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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 (
). 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
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.
Psychological distress and unsatisfied need for psychosocial support in adolescent and young adult cancer patients during the first year following diagnosis.
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.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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.
, 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 (
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 (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
). 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 (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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,
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.
, 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 (
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,
noted that adaptive coping strategies and quality of life are associated with resilience. Previous studies have shown that resilience building-interventions can be effective (
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.
), 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 (
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 (
), 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 (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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.
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.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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 (
). 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 (
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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 (
). 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 (
). 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.
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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.
Interprofessional, psycho-social intervention to facilitate resilience and reduce supportive care needs for patients with cancer: results of a noncomparative, randomized phase II trial.
The effect of attention and interpretation therapy on psychological resilience, cancer-related fatigue, and negative emotions of patients after colon cancer surgery.
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