Document Type : Original Article


1 Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Department of Midwifery and Reproductive Health, School of Nursing and Midwifery Rafsanjan University of Medical Sciences, Rafsanjan, Iran

2 Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan


Introduction: Traumatic events such as breast cancer along with negative effects on patients
also have positive effects. These cases have been studied less in Iran. Therefore, this study
was conducted with the aim of explanation of positive changes after breast cancer by using a
qualitative approach. Materials and Methods: This qualitative study was conducted in 2012 in
one of the specialized centers for cancer affiliated to Isfahan University of Medical Sciences.
In this study, it was interviewed with 19 women with breast cancer about positive changes
after cancer by using individual, open and deep methods. The interviews were analyzed
with conventional content analysis method. Results: The titles of the three major categories
were included as behavioral changes to maintain and promote health (acquisition of health
information and adopting promoting health behaviors), spiritual development (attention to the
God and sense of meaning in life, revising the values and priorities, strengthening moral and
behavioral traits) and personal growth and flourish (feeling empowerment, confidence and
efforts to achieve the goals and desires). These three categories have led to emerge themes
in this study as the “Awakening after cancer.” Conclusions: The results of this study indicated
positive changes after breast cancer. Considering such changes while providing care and
consulting to patients with breast cancer in addition to facilitate and accelerate positive changes
will be prompted to provide care and proper and influential consulting to promote patient health.


1. Kelly C, Ghazi F, Caldwell K. Psychological distress of cancer and
clinical trial participation: A review of the literature. Eur J Cancer
Care 2002;11:6‑15.
2. Pinquart M, Fröhlich C, Silbereisen RK. Cancer patients’ perceptions
of positive and negative illness‑related changes. J Health Psychol
2007;12:907‑21.impact of cancer and lupus: A cross validation study that extends
the generality of ‘Benefit‑Finding’ in patients with chronic disease.
J Behav Med 2001;24:561‑71.
28. Mols F, Vingerhoets A, Coebergh JW, Van dePoll‑Franse LV.
Well‑being, posttraumatic growth and benefit finding in long‑term
breast cancer survivors. Psychol Health 2009;24:583‑95.
29. Calhoun LG, Tedeschi RG. Facilitating posttraumatic growth:
A clinician’s guide. Mahwah, NJ: Erlbaum Publication; 1999.
30. Linley PA, Joseph S. Posttraumatic growth. Couns Psychother J
31. Brix SA, Bidstrup PE, Christensen J, Rottmann N, Olsen A,
Tjønneland A, et al. Posttraumatic growth among elderly
women with breast cancer compared to breast cancer‑free
women. Acta Oncol 2013;52:345‑54.
32. Dalton SO, Bidstrup PE, Johansen C. Rehabilitation of cancer
patients: Needed, but how? Acta Oncol 2011;50:163‑6.
33. Splevins K, Cohen K, Bowley J, Joseph S. Theories of
posttraumatic growth: Cross‑cultural perspectives. J Loss Trauma
34. Dein S. Explanatory models of and attitudes towards cancer in
different cultures. Lancet Oncol 2004;5:119‑24.
35. Thombre A, Sherman AC, Simonton S. Posttraumatic growth
among cancer patients in India. J Behav Med 2010;33:15‑23.
36. Calhoun LG, Cann A, Tedeschi RG, McMillan J. A correlational
test of the relationship between posttraumatic growth, religion and
cognitive processing. J Trauma Stress 2000;13:521‑7.
37. Emslie C. Women, men and coronary heart disease: A review of
the qualitative literature. J Adv Nurs 2005;51:382‑95.
38. Hsieh HF, Shannon SE. Three approaches to qualitative content
analysis. Qual Health Res 2005;15:1277‑88.
39. Graneheim UH, Lundman B. Qualitative content analysis in
nursing research: Concepts, procedures and measures to achieve
trustworthiness. Nurse Educ Today 2004;24:105‑12.
40. Wang HH, Chung UL. Healthylifestyle changes during the periodbefore
and after cancer diagnosis among breast cancer survivors. Asian
Pac Cancer Prev 2012;13:4769‑72.
41. Wang HH, Chung UL. Breast cancer survivors’ efforts to renew
and preserve their health in Taiwan. Asian Pac J Cancer Prev
42. Alfano CM, Day JM, Katz ML, Herndon JE 2nd, Bittoni MA,
Oliveri JM, et al. Exercise and dietary change after diagnosis and
cancer‑related symptoms in long‑term survivors of breast cancer.
Psychooncology 2009;18:128‑33.
43. Maunsell E, Drolet M, Brisson J, Robert J, Deschênes L, Dietary
change after breast cancer: Extent, predictors, and relation with
psychological distress. J Clin Oncol 2002;20:1017‑25.
44. Bloom JR, Stewart SL, Chang S, Banks PJ. Then and now:
Quality of life of young breast cancer survivors. Psychooncology
45. Rabin C, Pinto B. Cancer‑related beliefs and health behavior change
among breast cancer survivors and their first‑degree relatives.
Psychooncology 2006;15:701‑12.
46. Pierce JP, Stefanick ML, Flatt SW, Natarajan L, Sternfeld B,
Madlensky L, et al. Greater survival after breast cancer in physically
active women with high vegetable‑fruit intake regardless of obesity.
J Clin Oncol 2007;25:2345‑51.
47. Ballard‑Barbash R, McTiernan A. Is the whole larger than the sum
of the parts? The promise of combining physical activity and diet
to improve cancer outcomes. J Clin Oncol 2007;25:2335‑7.
48. Jones LW, Demark‑Wahnefried W. Diet, exercise, and
complementary therapies after primary treatment for cancer. Lancet
Oncol 2006;7:1017‑26.
49. Sabatino SA, Coates RJ, Uhler RJ, Pollack LA, Alley LG,
Zauderer LJ. Provider counseling about health behaviors
among cancer survivors in the United States. J Clin Oncol
50. Patrick LA. Attachment and Religious Representation and Behavior
in hand book of attachment theory and research. In: Cassidy J,
Shaver PR, editors. New York: Guilford 1999. p. 806‑10.
51. Shojaee MS. The theory of Islam and spiritual needs of its
correspondence with Maslow’s hierarchy of needs Biuarterly.
J Studies in Islam and psychology 2008;1:87‑11.
52. Taleghani F,
 Yekta ZP, Nasrabadi AN. Coping with breast cancer in
newly diagnosed Iranian women. J Adv Nurs. 2006 May; 54:265‑72.
53. Paloutzian RF, Park CL. Handbook of the psychology of religion and
spirituality. USA: Guilford Press; 2005.
54. CiallPC. A two‑part investigation: Examining the relationship between
spirituality and posttraumatic growth, and the multidimensionality
of posttraumatic growth. PhD dissertation. USA: Oklahoma State
University; 2006.
55. Lindstrom CM, Cann A, Calhoun LG, Tedeschi RG. The relationship
of core belief challenge, rumination, disclosure, and socio cultural
elements to posttraumatic growth. Psychol Trauma 2013;5:50‑5.
56. Kallay E, Miclea M. The role of meaning in life in adaptation to life
threatening illness. Cognition, Brain, Behavior, 2007;11;159‑170.
57. Fallah R, Keshmir F, Lotfi Kashani F, Azargashb E, Akbari ME.
Post‑traumatic Growth in Breast Cancer Patients: A Qualitative
Phenomenological Study. Middle East J Cancer 2012;3:35‑44.
58. Zhai J,Liu X,Wu J,Jiang H. What oes posttraumatic growth
mean to Chinese burn patients: A phenomenological study.
J Burn Care Res 2010;31:433‑40.
59. Sharpe L, Curran L. Understanding the process of adjustment to
illness Soc Sci Med 2006;62:1153‑66.
60. Utley R. The evolving meaning of cancer for long‑term survivors of
breast cancer. Oncol Nurs Forum 1999;26:1519‑23.
61. Cordova MJ, Giese‑Davis J, Golant M, Kronenwetter C, Chang V,
Spiegel D. Breast cancer as a trauma: Post‑traumatic stress and
post‑traumatic growth. J Clin Psychol Med Settings 2007;14:308‑19.
62. Pelusi J. The lived experience of surviving breast cancer. OncolNurs
Forum 1997;24:1343‑53.
63. Bertero CM. Affected self‑respect and self‑value: The impact of
breast cancer treatment on self‑esteem and QoL. Psychooncology
64. Arman M, Rehnsfeldt A, Carlsson M, Hamrin E. Indications of change
in life perspective among womenwith breast cancer admitted to
complementary care. Eur J Cancer Care (Engl) 2001;10:192‑200.
65. Schexnzildre MA. Predicting posttraumatic growth: Coping, social
support and posttraumatic stress in children and adolescents after
Hurricane Katrina. Master Thesis. Department of Psychology. USA:
Louisiana State University; 2007.
66. Devine KA, Reed‑Knight B, Loiselle KA, Fenton N, Blount RL.
Posttraumatic growth in young adults who experienced serious
childhood illness: A mixed‑method approach.J ClinPsychol Med
Settings 2010;17:340‑8.
67. Carver CS, Scheier MF. Scaling back goals and recalibration of the
affect system are processes in normal adaptive self‑regulation:
understanding ‘response shift’ phenomena. Soc Sci Med
68. Schwartz CE, Finkelstein JA. Understanding inconsistencies in
patient‑reported outcomes after spine treatment: Response shift
phenomena. Spine J 2009;9:1039‑45.
69. Cordova MJ, Cunningham LL, Carlson CR, Andrykowski MA.
Post‑traumatic growth following breast cancer: A controlled
comparison study. Health Psychol 2001;20:176‑85.
70. Mystakidou K, Tsilika E, Parpa E, Kyriakopoulos D, Malamos N,
Damigos D. Personal growth and psychological distress in advanced
breast cancer. Breast 2008;17:382‑6.
3. Tokgoz G, Yalug I, Ozdemir S, Yazici A, Uygun K, Aker T.The
prevalence of posttraumatic stress disorder and posttraumatic
growth in patients with cancer. New Symposium. 2008;46:51‑61.
4. Tedeschi RG, Calhoun LG. Post‑traumatic growth: Conceptual
foundations and empirical evidence. PsycholInq 2004;15:1‑18.
5. Linley PA, Joseph S. Positive change following trauma and
adversity: A review. J Trauma Stress 2004;17:11‑21.
6. Siegel K, Anderman SJ, Schrimshaw EW. Religion and coping
with health‑related stress. Psychol Health 2001;16:631.
7. American Cancer Society. Cancer Facts and Figures 2014. Atlanta:
American Cancer Society; 2014. Available from: http://www.
acspc‑042151.pdf. [Last accessed on 2015 Apr 12].
8. Homaei F. Center for Cancer Research. Available from: http://www. [Last accessed on 2012 Jan 12].
9. Kjaer TK, Johansen C, Ibfelt E, Christensen J, Rottmann N,
Høybye MT, et al. Impact of symptom burden on health related
quality of life of cancer survivors in a Danish cancer rehabilitation
program: A longitudinal study. Acta Oncol 2011;50:223‑32.
10. Ewertz M, Jensen AB. Late effects of breast cancer treatment and
potentials for rehabilitation. Acta Oncol 2011;50:187‑93.
11. Carver CS, Antoni MH. Finding benefit in breast cancer during
the year after diagnosis predicts better adjustment 5–8 years after
diagnosis. Health Psychol 2004;23:595‑8.
12. So WK, Marsh G, Ling WM, Leung FY, Lo JC, Yeung M, et al.
Anxiety, depression and quality of life among Chinese breast cancer
patients during adjuvant therapy. Eur J Oncol Nurs 2010;14:17‑22.
13. Fann JR, Thomas‑Rich AM, Katon WJ, Cowley D, Penning M,
McGregor BA, et al. Major depression after breast cancer:
A review of epidemiology and treatment. Gen Hosp Psychiatry
14. Brandberg Y, Sandelin K, Erikson S, Jurell G, Liljegren A,
Lindblom A, et al. Psychological reactions, quality of life, and
body image after bilateral prophylactic mastectomy in women at
high risk for breast cancer: A prospective 1‑year follow‑up study.
J Clin Oncol 2008;26:3943‑9.
15. Vazquez‑Calatayud M, Carrascosa‑Gil R, Vivar CG. The transitional
survivorship inbreast cancer: A narrative review. Rev Enferm
16. Jacobsen, PB, Jim, HS. Consideration of quality of life in cancer
survivorship research. Cancer Epidemiol Biomarkers Prev
17. Manne S, Ostroff J, Winkel G, Goldstein L, Fox K, Grana G.
Post‑traumatic growth after breast cancer: Patient, partner, and
couple perceptives. Psychosom Med 2004;66:442‑54.
18. Carboon I, Anderson VA, Pollard A, Szer J, Seymour JF.
Post‑traumatic growth following a cancer diagnosis: Do world
assumptions contribute? Traumatology 2005;11:269‑83.
19. Sears SR, Stanton AL, Danoff‑Burg S. The yellow brick road and
the emerald city: Benefit finding, positive reappraisal coping and
posttraumatic growth in women with early‑stage breast cancer.
Health Psychol 2003;22:487‑97.
20. Kucukkaya PG. An exploratory study of positive life changes in
Turkish women diagnosed with breast cancer. Eur J Oncol Nurs
21. Tomich PL, Helgeson VS. Is finding something good in the bad
always good? Benefit finding among women with breast cancer.
Health Psychol 2004;23:16‑23.
22. Horgan O, Holcombe C, Salmon P. Experiencing positive change
after a diagnosis of breast cancer: A grounded theory analysis.
Psychooncology 2011;20:1116‑25.
23. Frazier P, Conlon A, Glaser T. Positive and negative life changes
following sexual assault. J Consult Clin Psychol 2001;69:1048‑55.
24. Tallman BA, Altmaeir E, Garcia C. Finding benefit from cancer.
J Couns Psychol 2007;54:481‑7.
25. Simonelli LE, Fowler J, Maxwell GL, Anderson BL. Physical
sequelae and depressive symptoms in gynecologic cancer
survivors: Meaning of life as a mediator. Ann Behav Med
26. Ho SM, Chan CL, Ho RT. Posttraumatic growth in Chinese cancer
survivors. Psychooncology 2004;13:377‑89.
27. Katz RC, Flasher L, Cacciapaglia H, Nelson S. The psychosocial