Pathways to post-traumatic growth in Korean female cancer patients: the mediation effects of coping strategies and resilience

ABSTRACT

Background: Cancer is a life-threatening disease in Korean women. Female cancer patients in Korea have reported poor physical functioning and psychological distress after diagnosis. However, some patients experience post-traumatic growth (PTG), which includes positive feelings and changes.

Objective: The main purpose of this study was to examine the relationships between PTG and its associated factors in Korean female cancer patients to understand how female cancer patients achieve PTG while experiencing cancer diagnosis and treatment. This study aimed to improve the quality of life of many Korean female patients with cancer.

Methods: This study investigated the structural model of the paths from the disruption of core beliefs (CBD), coping strategies, and resilience to PTG in a sample of female cancer patients. In total, 164 middle-aged women diagnosed with cancer were included in the final sample.

Results: First, it was determined that the proposed structural model was substantial and had high fit indices. Second, problem-solving was positively associated by the CBD routes. Third, it was also favorably expected that problem-solving would lead to resilience and resilience would lead to PTG. These findings are important for developing future interventions for Korean female cancer patients and can be considered as an important variable to improve their PTG.

HIGHLIGHTS

• The proposed structural model observed paths of how female cancer patients achieve post-traumatic growth while experiencing cancer diagnosis and treatment.

• Disruption of core beliefs as a factor positively associates problem-solving in Korean female cancer patients.

• Problem-solving and resilience as factors positively associate post-traumatic growth in Korean female cancer patients.

Antecedentes: El cáncer es una enfermedad de riesgo vital en mujeres coreanas. El cáncer en pacientes femeninas en Corea ha reportado un pobre funcionamiento físico y malestar psicológico tras el diagnóstico. Sin embargo, algunas pacientes experimentan un crecimiento postraumático (PTG), el cual incluye sentimientos y cambios positivos.

Objetivo: El propósito principal de este estudio fue examinar las relaciones entre el PTG y sus factores asociados en pacientes coreanas femeninas con cáncer para entender cómo las mujeres con cáncer alcanzan un PTG mientras experimentan el diagnóstico de cáncer y durante su tratamiento. Este estudio apuntó a mejorar la calidad de vida de muchas mujeres coreanas con cáncer.

Métodos: Este estudio investigó el modelo estructural de las vías desde la perturbación de las creencias principales (CBD), estrategias de adaptación y resiliencia, hacia el PTG en una muestra de mujeres con cáncer. En total fueron incluidas 164 mujeres de mediana edad diagnosticadas con cáncer en la muestra final.

Resultados: Primero, se determinó que el modelo estructural propuesto fue sustancial y tuvo altos índices de ajuste. Segundo, la resolución de problemas se asoció positivamente con las rutas de CBD. Tercero, también se esperaba favorablemente que la resolución de problemas conduciría hacia la resiliencia y que la resiliencia conduciría a un PTG. Estos hallazgos son importantes para desarrollar futuras intervenciones para mujeres coreanas con cáncer y pueden ser considerados como una variable importante para mejorar su PTG.

背景：癌症对韩国女性来说是一种危及生命的疾病。韩国的女性癌症患者在诊断后报告身体机能不佳和心理痛苦。 然而，一些患者会经历创伤后成长 (PTG)，包括积极的感受和变化。

目的：本研究主要旨在考查韩国女性癌症患者 PTG 与其相关因素之间的关系，以了解女性癌症患者在经历癌症诊断和治疗时如何实现 PTG。 本研究旨在改善许多韩国女性癌症患者的生活质量。

方法：本研究考查了女性癌症患者样本中从核心信念中断 (CBD)、应对策略和心理韧性到 PTG 路径的结构模型。最终样本总共纳入了 164 名被诊断患有癌症的中年女性。

结果：首先，确定所提出的结构模型稳健并且具有较高拟合指数。 其次，问题解决与 CBD 路线呈正相关。 第三，人们还积极预期解决问题会带来心理韧性，而韧性会带来 PTG 。 这些发现对于为韩国女性癌症患者制定未来的干预措施很重要，可以被视为提高其 PTG 的重要变量。

KEYWORDS:

• Female cancer patients
• disruption of core beliefs
• coping strategy
• resilience
• post-traumatic growth

PALABRAS CLAVE:

• Pacientes mujeres oncológicas
• perturbación de creencias principalesl
• estrategias de adaptación
• resiliencia
• crecimiento postraumático

关键词:

• 女性癌症患者
• 核心信念中断
• 应对策略
• 心理韧性
• 创伤后成长

1. Introduction

There is a pressing need to focus on female cancer patients in Korea as cancer is a life-threatening situation and the leading cause of mortality among Korean women. The tremendous responsibility of childcare, housework, family healthcare, and/or fulfilling numerous duties as workers and social members causes female cancer patients, especially in the male-centered Korean culture, to endure extreme stress; consequently, they experience poor quality of life (Kim, 2001). Further, the incidence of cancer among women has been steadily increasing over the past 20 years in South Korea. According to 2019 statistics, the incidence of female cancer patients increased 2.5 times to 120,538 in 2019 from 43,539 in 1999 over the past 20 years (Cancer statistics. National Cancer Center, 2020). The incidence of cancer in Korean women is the highest among Asian countries; in particular, the incidence of thyroid cancer is the highest worldwide.

Even if cancer is excluded from the type of traumatic event that can be lead to a diagnosis of post-traumatic stress disorder (PTSD) as per the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5), it could be considered traumatic due to the shocking and serious nature of the diagnosis itself, which acts almost like a death sentence in patients’ lives (Hefferon et al., 2009). Despite the changes in the taxonomy of DSM 5, some studies have also reported that the prevalence of PTSD in cancer patients is not different from that in patients without cancer, and some researchers continue to use the DSM-IV PTSD criteria when studying oncological groups (Marziliano et al., 2020). Research has shown that female cancer patients experience psychological pain and emotional distress (Kim & Lee, 2008; Seo (2009). Seo reported that breast cancer patients verbalized their psychological shock about their cancer diagnosis with negative emotional expression such as ‘shock,’ ‘scared,’ and ‘despair’ (Seo, 2009).

However, several recent studies have shown that patients diagnosed with cancer report positive feelings and changes while receiving treatment (Marziliano et al., 2020). Seo stated that study participants gradually accepted the fact that they had cancer as a part of life’s ‘distress,’ although psychological pain and poor physical functioning caused by breast cancer diagnosis and treatment were severe (Seo, 2009). Michalczyk et al. showed positive changes in female patients with cancer in terms of appreciation of life, relations with others, and self-perception; they reported that such female cancer patients become more aware of their self-confidence and more committed to their loved ones and family members after positive changes (Michalczyk et al., 2022). This positive change in the process of overcoming cancer is called post-traumatic growth (PTG) and promotes healthy behaviours in female cancer patients (Liu et al., 2020), improves their quality of life (Lim, 2019), and regulates depression to relieve negative emotions (Lim & Kim, 2019). The importance of PTG has been emphasized in studies of patients with cancer (Liu et al., 2014; Silva et al., 2012).

Various associated factors of PTG have been identified in studies on different types of cancer patients. Cancer diagnosis is a traumatic event or high-intensity stressor among female cancer patients, who experience the shattering of basic assumptions in their life after being first diagnosed with cancer. The PTG process begins when the core belief systems of patients diagnosed with cancer are disrupted (Silva et al., 2012). When cancer patients experience disruption of core belief systems (CBD), they begin to use cognitive processing to overcome this situation. Research has consistently reported coping strategies as an associator of cognitive processing in patients with cancer (Tu et al., 2020). However, cancer patients do not cope with a traumatic event such as cancer diagnosis in the same way as patients experiencing other types of trauma, and consequences differ depending on the types of coping strategies (Kim et al., 2021; Kim, 2020; Cao et al., 2018; Choi, 2014).

Active-adaptive coping strategies have been reported as associated factors that can help cancer patients manage and reconstruct the crisis to achieve PTG in the diagnosis and treatment processes (Choi, 2014; Thornton et al., 2012; Tedeschi & Calhoun, 2004). Coping strategies based on problem solving are ideal rather than those based on oppression or avoidance in stressful situations like cancer diagnosis and treatment, particularly because coping with cancer involves dealing with an unpredictable disease (Ha & Yang, 2015). Park found that coping focused on problem solving increased PTG in a study of people who experienced trauma from the Pohang earthquake in Korea, but avoidance-focused coping decreased PTG (Park, 2020). In addition, Eissenstat et al. proved in a meta-analysis that problem-solving focused coping strategies are more likely to give meaning to traumatic events, which can also lead to PTG (Eissenstat et al., 2022).

Another important way to promote PTG development is resilience, which has been reported as a psychosocial factor affecting PTG in patients with cancer (Kim et al., 2021), Paredes & Pereira, 2018); Park et al., 2016); Seiler & Jenewein, 2019). Resilience is defined as the capacity to improve adaptability in the face of adversity, as well as to recover from negative mental–physical sequelae from traumatic events such as a cancer diagnosis (Smith, 2006). In particular, the resilience of cancer patients was identified as an associator of PTG, leading to positive results by protecting individuals from its negative consequences and allowing them to psychologically recover to a higher level than before diagnosis and treatment (Choi, 2014; Park et al., 2018). In a study by Yeon and Yun, resilience was the most influential factor affecting PTG among breast cancer patients (Yeon & Yun, 2022).

Several studies have demonstrated that coping strategies affect resilience by effectively dealing with traumatic events using intentional, conscious, and cognitive strategies for stressful situations (Choi, 2014; Campbell-Sills et al., 2006; Schaefer & Moos, 1992). In this regard, Macía et al. found that problem-solving-focused coping was positively related to resilience, while avoidance-focused coping was negatively linked to resilience (Macía et al., 2021). In a recent literature review, Gori et al. found that the impact of resilience in PTG is was mediated by positive coping strategies, and at this time, resilience was negatively associated with avoidance strategies that crop up as the result of trauma (Gori et al., 2021).

The three PTG associated factors mentioned above (CBD, coping strategy, resilience) are variables that influence the PTG of people exposed to trauma, especially cancer patients. This finding is consistent with the results of several studies (Marziliano et al., 2020; Lee & Jun, 2016; Danhauer et al., 2013; Teixeira R & Pereira, 2013).

In recent years, as the five-year survival rate of cancer patients has increased owing to the development of diagnosis and cancer treatment methods, it has become important not only to cure cancer but also reduce physical discomfort and maintain daily quality of life as much as possible. Accordingly, research and interest in PTG is increasing to aid cancer patients in positively adjusting and enhancing their quality of life. Although PTG in cancer patients is produced by intricate interactions between these associators, investigations thus far have concentrated on examining the primary relationship between these factors and PTG. Additionally, PTG investigations in cancer patients have traditionally been carried out according to the kind of cancer regardless of sex, and even PTG research in female cancer patients has been severely constrained to patients with breast cancer or, very infrequently, patients with ovarian cancer. Hence, this study examined female cancer patients regardless of the type of cancer to avoid limitations in understanding PTG.

The main purpose of this study was to test a hypothesized structural model with a sample of Korean female cancer patients. This model illustrates the complex relationships between influencing variables to understand how female cancer patients achieve PTG while undergoing cancer diagnosis and treatment. This study aimed to provide a comprehensive understanding of the relationship between PTG and associators in female cancer patients.

2. Methods

2.1. Participants

For this study, we recruited middle-aged female cancer patients of 40–59 years of age from cancer-specific nursing hospitals, cancer patient self-help groups, and individual patients in South Korea. Data were obtained from the nursing hospital and self-help group using convenience sampling, and from individual participants using snowball sampling. We provided information about the study, including its nature and purpose, to participants as well as the director of the hospital and the leader of self-help groups, and requested consent to collect data. A total of 179 participants who agreed to participate in the study were provided with instructions on how to administer the study questionnaire, which the authors helped them complete. Data were collected within two weeks. All participants were provided with a gift certificate worth 5,000 won as compensation for their participation.

After excluding incomplete responses, the final sample included 164 patients. Among them, 112 were admitted to cancer-specialized nursing hospitals, 29 were self-help members, and 23 were individual patients. The mean age of participants was 55.2 years. Second stage cancer diagnosis (34.1%) was the most common, followed by first stage (25.0%) and then third stage (25.0%). The proportion of cancer patients who experienced recurrence (75.0%) was higher than that of cancer patients who did not experience recurrence (25.0%).

2.2. Ethical considerations

As this study was non-interventional, ethical approval was not required. In spite of this, all experiments were performed in accordance with relevant ethical guidelines and regulations. Specifically, common rules of research ethics in South Korea, such as anonymity of participants, providing participants with information about the purposes and procedures of the study, and voluntary participation and informed consent, were rigorously enforced.

3. Measures

3.1. The core belief inventory

The disruption of core beliefs was measured using the Core Belief Inventory (CBI) developed by Cann et al. (Choi, 2014) and translated by Choi (Can et al., 2010). The CBI is designed to assess the degree to which a traumatic event causes people to reevaluate their assumptive worlds, including fundamental belief in themselves, others, and the world. The CBI consists of nine items (e.g. ‘Because of the event, I seriously examined the degree to which I believe things that happen to people are controllable’; ‘Because of the event, I seriously examined my beliefs about my own abilities, strengths, and weaknesses’). Response options ranged from 1 = not at all to 5 = very much. The original CBI scale has been shown to have good internal reliability ranging from .82 to .92 (Can et al., 2010) and in this study, the alpha coefficient of the Korean version scale was .87.

3.2. Coping strategy indicator

Coping strategy was measured using The Coping Strategy Indicator (CSI) developed by Amirkhan (1990) and validated by Shin (Shin & Kim, 2002). CSI is designed to assess the various ways in which people cope with different circumstances. The scale consists of three factors with 11 items each (total of 33 items): problem-solving-focused coping, avoidance-focused coping, and seeking social support. The problem-solving-focused coping factor assessed the attempt to address situations/problems without stress; the avoidance-focused coping factor assessed the aspect of maintaining a psychological distance from the problematic situation. Representative items on the CSI include ‘Weigh your options very carefully’ (problem-solving focused coping) and ‘Try to distract yourself from the problem (avoidance focused coping).’ Response options ranged from 1 = a lot to 3 = not at all. In this study, the alpha coefficient of the Korean version of the scale was .81, that of problem-solving focused coping was .88, and that of avoidance-focused coping was .74.

3.3. The connor–davidson resilience scale

Resilience was measured using the Connor–Davidson Resilience Scale (CD-RISC) developed by Connor and Davidson (Choi, 2014) and translated by Choi (Connor & Davidson, 2003). The CD-RISC was designed to assess the ability to cope with stress and adversity. The scale consists of 25 items and includes five factors: personal competence/tenacity (eight items), trust in one’s instinct/tolerance for negativity (seven items), positive acceptance of change/secure relationships (five items), control (three items), and spirituality (two items). The validation of the scale for the Chinese context by Yu (Yu et al., 2011) found low reliability (alpha coefficient of .22) of the spirituality factor. This was caused by differences between the concept of spirituality in Western societies such as the United States, where Christianity is most common, and the concept of spirituality in Eastern society, especially in Korea. Therefore, this study used four of the five factors, excluding spirituality. Representative items include ‘When things look hopeless, I do not give up,’ ‘I can deal with whatever comes,’ and ‘I am able to handle unpleasant or painful feelings like sadness, fear and anger.’ Response options ranged from 1 = not at all to 5 = very much. In this study, the alpha coefficient of the Korean version scale was .95.

3.4. The post-traumatic growth inventory

Post-traumatic growth was measured using the Post-traumatic Growth Inventory (PTGI) developed by Tedeschi and Calhoun (1996) and translated, back-translated, and validated by Song (Song et al., 2006). The PTGI assesses the degree of positive change experienced in a struggle with traumatic events. The scale consists of 21 items and includes five factors: relating to others (seven items), new possibilities (five items), appreciation of life (three items), personal strength (four items), and spiritual change (two items). Representative items include ‘I change my priorities about what is important in life’ and ‘I can better appreciate each day.’ Response options ranged from 1 = not at all to 6 = very much. In this study, the alpha coefficient of the Korean version scale was .96.

3.5. Statistical analyses

Descriptive statistics and zero-order correlations were computed for all study variables using SPSS 22.0. None of the answers to the questions from the data used in the analysis contained any missing information. The proposed structural equation model was then evaluated using a maximum likelihood estimation in Mplus 7.2. Fit indices such as chi-square (χ²), root mean square error of approximation (RMSEA), comparative fit index (CFI) and Tucker and Lewis Index (TLI) were used to evaluate the fit of the model. A non-significant chi-square statistic indicates good fit, but it is overly sensitive to sample size (Byrne, 2001). In general, model fit is deemed satisfactory when the CFI and TLI values are more than .90 and the RMSEA value is lower than .08 (Browne & Cudeck, 1993).

4. Results

4.1. Descriptive statistics and correlations between variables

The descriptive statistics and correlations for the study variables are presented in Table 1. This indicates a normal distribution, which means that the skewness and kurtosis of each variable did not exceed absolute values of 2 and 7. Table 1 also shows the zero-order correlations between the variables. Coefficients among all measures ranged from –.01 to .73. Among these, the correlation coefficient between CBD and deliberate rumination was somewhat high (.57).

Table 1. Descriptive statistics and correlations for study variables.

	M	SD	Skewness	Kurtosis	1	2	3	4	5
1. CBD	33.55	7.03	−0.67	0.06	1
2. Problem-Solving Focused Coping	25.14	4.67	−0.17	−0.65	.41**	1
3. Avoidance Focused Coping	19.74	4.01	0.38	0.39	0.14	0.12	1
4. Resilience	86.86	15.09	−0.38	−0.41	.41**	.56**	−0.01	1
5. PTG	90.89	19.10	−0.38	−0.42	.40**	.43**	0.018	.73**	1

*p < .05. **p < .01.

Note. CBD: Core Belief Disruption; PTG: Post-traumatic Growth.

4.2. Testing the hypothesized structural model

The model’s chi-square value was significant (χ² = 759.126, df  = 448, p < .001), and overall fit indices indicated a good fit between the observed data and the measurement model (RMSEA = .075, CFI = .910, and TLI = .918). The standardized path coefficients in the structural model (Figure 1) were significant (χ² = 768.073, df  = 451, p < .001), Δχ2 (Δdf  = 3) = 8.947, p > .001, and overall fit indices indicated a good fit between the observed data and the structural model (RMSEA = .073, CFI = .917, and TLI = .908).

Figure 1. Structural model of effects of CBD on PTG.

By analyzing the path coefficient, we found that the paths of the CBD were positively associated with problem-solving alone (β = .47, p < .001). The paths from problem solving to resilience (β = .65, p < .001) and from resilience to PTG (β = .79, p < .001) were also positively associated.

Table 2 shows the mediating effect of different coping strategies on both links to resilience between CBD and PTG. To evaluate the significance of the indirect effects, bootstrap tests were conducted with a 95% confidence interval (CI) and 10,000 samples were created randomly with replacement from the original dataset. If the 95% CI of the dataset did not contain 0, this indicated significant indirect effects. The indirect path from problem-solving to PTG through resilience was significant (β = .507, p < .001, CI = .84–1.71).

Table 2. Direct, indirect, and total causal effect on PTG.

Path	Direct Effect	Indirect Effect	Total Effect
Problem-Solving Focused Coping Through PTG	.01	.51***	.52***
Avoidance Focused Coping Through PTG	.06	-.09	-.03
Resilience Through PTG	.79***		.79***

*p < .05. **p < .01. ***p < .001.

Note. PTG: Post-traumatic Growth. Values shown are standardized path coefficients. Indirect effects are the product of intermediate effects. Total effects are the sum of direct and indirect effect.

5. Discussion

Understanding how female cancer patients diagnosed develop PTG away from negative experiences, such as CBD, is of great importance to develop therapeutic interventions to improve their quality of life after diagnosis and treatment. This study investigated a structural model of the paths from CBD, coping strategies, and resilience toward PTG in a sample of female cancer patients in South Korea.

The main findings of this study can be summarized as follows. First, we found that CBD had a positive effect on the coping strategies of female cancer patients, consistent with the results of previous studies (Choi, 2014; Hanley et al. (2017). This is also in line with Seo’s findings that female cancer patients accept their cancer diagnosis as part of their life’s pain, and PTG occurs by recognizing that such pain passes (Seo, 2009). However, CBD was found to have a positive effect on both problem-solving-focused and avoidance-focused coping. Unlike problem-solving-focused coping, which showed a statistically significant influence on resilience, avoidance-focused coping was not statistically significant on resilience. Previous research has shown that coping strategies, especially problem-solving focused coping, are more likely to increase after a traumatic event (Aldwin & Sutton, 1998). This also suggests that female cancer patients recognize cancer diagnosis as a serious traumatic experience that threatens their survival and leads to different stressful events, including financial and social worries, psychosocial pressure from family, and fear of death (Parikh et al., 2015); consequently, they attempt to protect their lives through active solution-focused coping strategies, such as problem-solving-focused coping over avoidance-focused coping (Senol & Ayvasik, 2010; Bellizzi & Blank, 2006).

Second, resilience is important for improving PTG, and this study proved that coping strategies are a variable related to resilience. However, we found that the effect on resilience differed depending on the type of coping strategies. In other words, it was found that problem-solving-focused coping had a statistically significant positive effect on the resilience of female cancer patients, while avoidance-focused coping had a negative effect that was not statistically significant. Richardson’s resilience model is considered a major factor in the process of ultimately reintegrating negative experiences caused by trauma, including cancer diagnoses (Richardson, 2002; Kim et al., 2011).

Aldwin, however, stated that ‘transformational coping’ in the face of a stressful or traumatic event caused positive or negative changes; a positive coping strategy results in a higher level of function or growth, whereas a negative response induces a lower level of function (Aldwin, 1994). In addition, Holahan and Moos reported that people using active and positive coping strategies have more personal strength and social resources than those who use avoidance-focused coping (Choi, 2014; Holahan & Moos, 1990).

Third, there was a positive association between resilience and PTG in female cancer patients. This result suggests that higher levels of resilience allow female cancer patients to improve their psychological well-being and achieve PTG. This is consistent with previous studies on the relationship between PTG and resilience in patients diagnosed with various cancers across various cultural contexts (Tu et al., 2020; Gori et al., 2021; Markovitz et al., 2015). Resilience and PTG, as salutogenic concepts, are debated over in terms of whether it is similar to resilience or whether PTG is a better concept than resilience. Despite this debate, researchers have explained resilience as having an effect on the positive changes and growth that follow in individuals who have experienced trauma, as it lends them the ability to withstand traumatic situations in a relatively stable and calm manner (Kim & Shin, 2010; Westphal & Bonanno, 2007; Bonnano et al., 2006). This study also confirmed that resilient female cancer patients in South Korea were more likely to reappraise traumatic situations, including their cancer diagnoses, as challenges and exhibit cognitive flexibility, which contributes to positive changes. Conceptualizations of resilience may be shaped by different cultural contexts; hence, this study is important because it sheds light on this issue in the Korean context. The results of this study support the findings of previous studies that resilience is an important factor in achieving PTG amond patients diagnosed with colon cancer and that promoting resilience and PTG should be a critical component of cancer care (Seiler & Jenewein, 2019; Zhang et al., 2019).

Finally, this study investigated the structural relationship between CBD, coping strategies, resilience, and PTG, and confirmed the separately mediated effect and serial mediation effect of problem-solving-focused coping and resilience. We found mediation effects of problem-solving-focused coping between CBD and resilience, and of resilience between problem-solving-focused coping and PTG. We also found a serial mediation effect between CBD and PTG. However, this study showed that the mediating effect of avoidance-focused coping was not significant for Korean female cancer patients, which was different from the findings of Choi’s study (Choi, 2014) of Korean college students exposed to traumatic events in the past. One possible explanation for this result is that cancer diagnosis is a life-threatening traumatic event, and female cancer patients have a strong will to overcome the situation through active coping strategies, such as problem-solving-focused coping, while experiencing CBD after cancer diagnosis and treatment.

6. Strengths and limitations

The findings of this study have theoretical and practical implications. We found that the associated variables identified through PTG studies in cancer patients (CBD, coping strategy, and resilience) are related to each other. To date, most studies on PTG have verified the primary relationship between PTG and each associator in traumatic situations. However, this study provides a comprehensive understanding of the process of achieving PTG in female cancer patients by establishing and investigating an integrated hypothetical model between variables related to PTG. The serial mediation pathway between CBD and PTG via problem-solving-focused coping and later resilience was also confirmed by this study. This serial mediation pathway adds another significant piece of evidence to the body of literature by providing additional potential explanations for the relationships between CBD and PTG among female cancer patients. By finding sequential pathways of problem-solving-focused coping and resilience, we determine that the two mediators are significant target factors for designing future interventions for Korean female cancer patients and can be regarded as significant variables with the potential to enhance PTG.

Despite these implications, two limitations of this study should be noted and addressed in future studies. First, as this study investigated a hypothesized structural model using a cross-sectional design, there is a need to implement an inductive approach to determine causal pathways among associators and PTG. Further, this study is hesitant to use terms that imply cause and effect, and these results reflect a developmental path following a cancer diagnosis. Therefore, longitudinal studies using panel data are necessary to better understand our findings. Second, although the recent research trend in academia deals with PTG and PTSD, this study focused on PTG, rather than PTSD. In future studies, it is necessary to shed light on the relationship between PTG and PTSD beyond what has been covered in this study.

Finally, as the data used herein were collected before the COVID-19 outbreak, this study does not consider the possible effects of COVID-19 on patients’ cancer development experience and PTG. Thus, considering the potential significant impact of COVID-19 on these aspects, future studies must examine the pandemic affected the development of PTG in female cancer patients.

7. Conclusions

This study examined the mediating effects of coping strategies and resilience on the path to PTG in Korean female cancer patients. This study has significant contribution as this is a topic on which scant research has been done, even though cancer is the leading cause of death among Korean women. To comprehend how female cancer patients accomplish PTG while receiving cancer diagnosis and therapy, this model depicts the intricate interactions between the contributing elements. Furthermore, the results allow us to comprehensively understand the relationship between PTG and associators in female cancer patients. Finally, the findings can help with the development of physical and psychosocial therapies that help Korean female cancer patients live better lives following diagnosis and treatment and attain PTG.

Author contributions

All authors contributed equally to the study and read and approved the final manuscript.

Availability of data and materials

The dataset used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors report there are no competing interests to declare.

Acknowledgements

This study was supported by Konkuk University in 2018.

Disclosure statement

No potential conflict of interest was reported by the author(s).