Biographical Renewal and its Facilitators in Cancer Survivorship: A Conceptual Paper

INTRODUCTION

The cancer diagnosis invades people’s lives and is a devastating experience. Some of the important challenges encountered by patients and survivors of cancer include treatment-related problems, psychological issues regarding their self-concept, body image, sexual dysfunction, social relationships and the problems of every day.^[1] Uncanny feelings of being deeply threatened by the disease are common, with direct implications for life. With harmful effects on one’s biography, disruption to their conceptions of self, body, and future is evident.^[2]

Biographical disruption is realised and engendered by a turning point (cancer diagnosis) when the individual admits that he and his life are no longer the same as before.^[3] While such outcomes are intimidating and undoubtedly unpleasant, cancer survivors nevertheless strive to find their way back to the pre-illness phase and engage in what is known as ‘biographical work.’^[4,5] This involves reviewing, maintaining, and modifying one’s biography to bridge the past with the present to establish coherence in life. On active and successful working through, the individuals will be able to attain ‘biographical renewal.’ In a recent study among young adults living with a stoma, biographical experiences were captured as a transformative process of forming a new and revised identity after a serious health condition.^[6] This also involves regaining some or all aspects of the pre-illness self. Biographical renewal is a relatively understudied concept in cancer research, although survivors experience a positive life after the conclusion of active treatment.

The article presents the significance of delving into ‘biographical renewal’ in cancer survivorship. We believe that the biographical implications of cancer are mostly emphasised and represented by disruption, and biographical renewal remains unattended despite its relevance and significance. Therefore, biographical renewal is explained and discussed in the milieu of cancer survivorship. We then discuss some of the crucial facilitators that promote biographical renewal.

BIOGRAPHICAL RENEWAL AND CANCER SURVIVORSHIP

Cancer is no doubt a global health concern with its increased prevalence of diagnosis worldwide. However, the latest statistics show declined death rates from cancer.^[7] This is attributable to reasons such as awareness among people, early diagnostic measures, and effective treatment approaches. Hence, the population of cancer survivors is expanding.

This places a great demand for quality care for the survivors because the physical and psychological impacts of the disease are inevitable. For this reason, specialists in healthcare and health sciences are pursuing to provide comprehensive care with a deeper understanding of life after cancer.

The discussions on biographical renewal in cancer survivorship research are only superficial.^[8-10] Being involved in the process of biographical renewal can have major benefits by significantly improving survivors’ quality of life. Encouraging survivors to engage in this process may help them feel liberated from the long-term effects and focus on personal growth.^[6] Thus, within the context of cancer, an experience highly represented as biographical disruption, biographical renewal is relevant and important work during survivorship.

Identity is central to a person’s biography and is important in biographical renewal.^[11] Several aspects, therefore, shape their sense of self. More often than not, individuals feel that cancer has become part of their identity.^[12,13] The major work for survivors would be to shape their self-identity or develop a positive, altered sense of self. In other words, it is a transition from illness identity to a positive altered sense of self. Encouraging survivors to be involved in activities from their pre-illness may be particularly important to engage in biographical renewal. The involvement may not be possible in full range like before for some people due to their health status and the varied nature of the task. For instance, performing in a 9–5 work environment for a full-time employee can be challenging and stressful. Without a flexible work schedule and decreased workload, the survivor may not be able to adapt and function like before. In such cases and similar, involvement may take different forms or even undergo career shifts. Whether individuals return to their old role or find a new one, for instance, marking a career shift, both may be regarded as biographical renewal. By doing so, individuals can experience positive self-efficacy and a new sense of meaning and purpose in life. A study revealed that cancer survivors who had a high degree of pain/ depression, negative perception of cancer, lower well-being status, and social support reported low or negative self-efficacy.^[14] However, being engrossed in old or new activities – personal and professional – can reduce the magnitude of their effect on self-efficacy.^[15]

Cancer often strains interpersonal relationships with family, friends and acquaintances, disturbing social life and social isolation. This has implications for the survivors’ social engagement, identity, and network,^[16] leading to a lack of social support.^[17] Because the very essence of human beings is to experience connection with other beings, losing an active social life impacts their social well-being. Therefore, while limiting interaction with people expected to induce negativity, opportunities to interact in judgment-free environments may be valuable in this context. Having a healthy social life provides comfort and motivation for growth. Nurturing interpersonal relationships within and outside the family will further assist in positive change for the survivor.

While we view biographical renewal in cancer survivorship as transitioning from illness identity to a healthy sense of self, this article presents three important features essential for this transition.

AUTONOMY

Experiencing cancer can change how individuals feel about themselves. They begin to experience new life situations arising from cancer while witnessing very little or no personal choice. Functioning in such persons can feel restricted due to symptoms of the illness or treatment and simultaneously experience a sudden shift in life. Individuals feel a loss of autonomy, espousing illness identity. When the individual feels ‘engulfed,’ meaning that the disease is now dominating their identity and daily life, they become less likely to practice autonomy.^[18] Autonomy is an important characteristic of one’s identity, and making choices depends on the degree to which an individual can exercise autonomy. Therefore, perceived autonomy is vital to cancer survivors to attain biographical renewal. The aim is to help survivors enhance their sense of autonomy.

Certainly, the survivors have a choice, and most of them overlook this. Whether they follow their doctor’s suggestions to maintain personal care to transition from active treatment to wellness or not is a choice, and a consequence will follow accordingly. Similarly, the survivor subconsciously engages in choosing every stage.^[19] Bringing this to survivors’ awareness will help them make informed decisions based on their values and desires. This is important to build confidence and enhance their self-efficacy. Becoming aware of life choices further allows one to become free from thinking within the boundary of illness and make decisions to improve how they live the rest of their lives. In this view, patient autonomy is a widely recognised practice in treatment decision-making^[20,21] and survivorship care.^[22]

The application of autonomy in attaining biographical renewal can be fruitful and advantageous to the cancer survivor. Encouraging autonomous behavior among cancer survivors will help them pick up their life from where they had left it due to the diagnosis. For a few others, it can be useful in forming new goals based on their changed perceptions of values in life. Engaging in such goal-oriented behaviors will lead to a positively altered sense of self in the individual.

PSYCHOLOGICAL ADAPTATION

Receiving a cancer diagnosis can cause significant psychological distress that can persist throughout the early stages of treatment and even beyond.^[1] Often, this makes it hard to possess a positive view of the illness. A lot of them may even exhibit emotional reactions such as anger, shock, and guilt.^[23] However, turning attention to positive changes (in other words, post-traumatic growth) resulting from cancer, such as unexpected social support, reconciliation with friends and family members, and other personal and professional gains are advantageous. Early cancer trajectory characterised by dispositional optimism is beneficial in achieving positive outcomes for cancer patients, especially quality of life.^[24] A positive representation of the disease will allow survivors to adapt.

Psychological adaptation is crucial to cope with distress caused due to serious health conditions.^[25,26] Research has indicated that individuals who adapt well to the situation have a higher quality of life, better health status, and experience fewer depressive symptoms, perceived stress, and intrusive thoughts.^[27] Psychological adaptation also plays a pivotal role in the successful psychosocial rehabilitation of cancer patients.^[28] Various interventions are developed and applied by stakeholders in cancer care to enable individuals to adapt to survivorship.^[29] Moreover, psychological adaptation helps in building resilience, which is fundamental to overcoming the multiple challenges of cancer.

Survivors’ ability to adapt brings about benefits from emerging opportunities to be involved in meaningful work-related activities.^[30] Cancer often offers individuals new gateways to embark on new beginnings and engage in wholly different life purposes from the earlier phase. Being able to adapt can also alleviate the desire to regain the pre-illness self because they find life more meaningful and purposeful now. In addition, demonstrating a capacity to adapt may lead to identity revisions rather than striving to establish a new identity. Psychological adaptation is critical to maintaining coherence even during stressful and uncertain situations in attaining biographical renewal.

Psychological adaptation is rewarding to the individual due to the resulting positive effect. While worrying about the effects and outcomes of cancer is natural, experiencing positive emotions is just as crucial. Positive effect is to subjectively experience positive moments, for instance, interest, enthusiasm, cheerfulness, and joy. Maintaining a positive effect in some cases may not change the course of the disease due to its physical nature. However, positive affect may improve the survivor’s subjective well-being. It has demonstrated unique benefits to health-related stress while also being associated with improved social functioning, positive changes, reduced depression and anxiety, and high psychological well-being.^[31,32] Hence, successful adaptation to survivorship may evoke positive emotions in the individual and complement the process of biographical renewal.

A SOCIAL RITUAL

Social rituals are integral to human life in various ways, such as in substantiating social structures, defining relationships, authorising professional milestones, and sometimes finding meaning in particular life events.^[33] Broadly speaking, ritualistic behaviors are symbolic, help represent difficult times in oversimplified images, and empower a person. In the modern period, rituals relate to celebrating milestones in personal and professional life, such as birthdays, marriage, graduation, and promotions. They are how community people behave and live life, for instance, their health practices, food habits, and self-care.^[34] Extending the study of ritualistic behaviors and practices in health psychology has pointed to important links. Janca and Gaspar^[35] claim that social rituals are important in determining one’s mental illness. Further, Fiese and Wamboldt^[36] highlight the significance of rituals in managing health conditions such as asthma.

Similarly, organising a social ritual for cancer survivors after completing the active treatment can facilitate the first step toward biographical renewal. They may include family members, friends, well-wishers, and others closely related to the individual. The significance of this ritual will be to mark and celebrate the victory of combatting a life-threatening illness, the life transition of the survivor from a status of illness to being cured, to encourage a readiness in the survivor to embark on a new phase of life, and embrace a new sense of identity.^[4] The ritual would then allow the individual to share their cancer experience, reflect on the journey, and conclude the status of the illness identity. The event’s significance lies in their social interaction from then onwards.

IMPLICATIONS

Caregivers may consider biographical renewal as a substantially new goal in the survivorship care plan so that individuals will benefit in improving their overall health progress. To help survivors attain biographical renewal, the contribution of several people is important. Counselors and therapists can use this knowledge to encourage clients to be involved in pre-illness activities or those that fit the peculiar context of the person. Developing an action plan for the future can be affirming while addressing obstacles. Shifts in personal and professional roles should be encouraged and positively regarded. Acknowledging and celebrating their renewed sense of identity adds more value to their life. Developing and administering various biographical activities in this regard, individually or in groups, can be beneficial. Because biographical renewal is a gradual process, the therapist’s role is crucial in facilitating guidance to return to the previous phase or make shifts. Educating individuals about their role in working toward biographical renewal will increase the speed and efficiency of attaining the goal. Formal and informal caregivers will be able to identify the needs specific to each cancer survivor and facilitate biographical work by emphasising work in those areas. Social rituals in the form of family and friends get-togethers can be practiced. This can also be planned within the cancer communities, making way for best wishes and support from beloved people.

The insights from this article have implications for psychosocial practice in palliative care as palliative care has a focus beyond terminal illness, serving people still undergoing treatment and those who have survived cancer. Moreover, persons with terminal illnesses may not be able to attain a functional biographical renewal. However, biographical work may aim to cognitively amalgamate the present with the past self. Social rituals can be significantly constructive in attaching a new or renewed meaning and purpose to their life. End-of-life care can take new turns by incorporating biographical amalgamation and improving these individuals’ dying quality.

CONCLUSION

Biographical renewal, although not studied widely, can be a valuable asset and an important milestone in the life trajectory of cancer. Working toward biographical renewal can be affirming to the survivors and further improve their quality of life. A desire to unite with the pre-illness phase of life or begin a new life is always present in the survivors of cancer. Explicitly focusing on biographical renewal will serve their subjective well-being and overcome illness identity. While adding to the comprehensive cancer care, they are important in revising perspectives and enhancing specialists’ knowledge of an important occurrence in survivors’ lives.