Positive Psychological Change in Head and Neck Cancer populations

Demographic factors across the papers showed similar patterns of relationships across PPC; that higher education/qualification and cohabitation/ marriage are associated with increased PPC. Limited research reported longitudinal patterns of change and showed that for people with lower stage tumours and those who only had a surgical intervention greater PPC developed over time. Multivariable modeling adjusting for psychosocial variables found that PPC had a quadratic relationship with time since diagnosis, increasing initially and leveling off after 18 months.


Introduction
There is evidence from the literature that some people report benefit from illness [1][2][3][4][5][6] .In some cases, these benefits go some way to mitigating the negative consequences of illness, but there are also instances where people report an overall benefit of being ill.Positivity in adversity has been cited in the context of other stressful life events such as combat and imprisonment, divorce, care giving and bereavement 7 .Stress-related growth in adversity is reported to be 'remarkably common' 7 .
There is a growing body of literature supporting the suggestion that a stressful or traumatic event may be a catalyst for positive psychological change 8,9 .In 1991 Yalom and Lieberman 10 used the term 'positive psychological changes' to refer to positive changes in the perceptions of oneself, social relationships with family and friends and life priorities and appreciation of life.These positive changes, which have also been referred to as 'perceived benefits', 'benefit finding', 'thriving', 'stress-related growth', 'adversarial growth', 'post-traumatic growth', or 'existential growth', may concern changes in the perceptions of oneself, social relationships with family and friends and life priorities and appreciation of life.The term 'Post-traumatic growth' is widely used due to its ability to describe the need for individuals to have experienced trauma before they experience positive change over time.However, premininent researchers in this field, Tedeschi and Calhoun, have suggested this these terms are roughly synomous 11 .In this paper, positive psychological change (PPC) will be used unless reporting data directly from a journal article where they use another term such as PTG.The choice of PPC over PTG was made due to the nature of the trauma experienced by the people with and following cancer.In presenting work on PPC to people who have received a diagnosis of head and neck cancer (HNC) the author has found that the word 'growth' has significant negative meaning, as it is a word associated with a cancerous tumour.In working with this group of people, Harding et al 12 suggest that the phrase positive psychological change was better received and facilitated communication.
Within the field of cancer, breast cancer (BC) has received the greatest amount of investigation into PPC [13][14][15][16][17][18] .There is evidence indicating that a substantial number of BC survivors experience such positive changes, especially in the long term [15][16][17]19,20 . Cance survivors from tumours in a range of locations frequently report having altered priorities including more concern for others, a greater sense of purpose and a greater appreciation of themselves and their lives life 4,[21][22][23][24] .A challenge for HNC clinicians is to understand what factors are associated with the developed of PPC.Only eight quantitative articles have been published within the field of HNC and PPC [25][26][27][28][29][30][31][32] .Tables 1 and 2 provide an outline of the study designs, participants, and variable.What variables are associated with PPC in people following treatment for HNC Some variables may mediate the relationship between trauma and PPC.Within studies, these variables can be categorized as demographic, clinical and psychological.

Demographic factors
Using a cross-sectional design with mixed cancer sites, Park et al 33 found, in a mixed cancer site study, that women consistently reported higher levels of PPC than men.However, this study was of a largely young female cohort, over a comparatively short period (1 year) which makes it difficult to extrapolate to HNC survivors or other cancer sites, especially over an extended time frame.
In contrast to this, studies across cancer sites have found no relationship between gender and PPC in colorectal cancer 34 , hepatobiliary (having to do with liver, bile ducts, and bile) cancer 35 or HNC 25,27,28 .Holtmaat et al 29 found females developed more PPC than their male cohort in an HNC population, although no reason for this is offered.
To date, no published studies have found an impact of age on PPC in HNC, though it has been found that younger participants with BC reported higher levels of PPC 36,37 .The greater number of studies undertaken with BC patients, and the larger participant numbers in those studies (due to the greater occurrence of BC in the general population), has identified age as a factor in the trajectory of change in, and final level, of PPC in BC 15,16 .
No clear relationship has been found between to ethnicity and PPC.Bellizzi et al 13 found that African-Americans treated for BC showed higher levels of PPC than Caucasians, whereas Kent et al 18 found Caucasians with BC had higher PPC than African-Americans but not higher than Hispanics 13,18 .Studies of PPC across other traumas also found a mixed pattern.Milam 38 , for example, investigated AIDS/HIV and found that African-American and Hispanic participants reported higher levels of PPC than Caucasians respondents.
Educational attainment also lacks a clear relationship with PCC.A narrative systematic review by Koutrouli et al 39 found that most studies reported that people with BC and lower education levels experienced higher levels of PPC.One study of HNC found higher educational level was associated with greater PPC 32 and another found no association with education 28 .
Three studies following treatment for HNC reported a beneficial effect of marriage or stable cohabiting over single status in the reporting of PPC 25,26,2 .Although when assessed longitudinally Harding 25 found no impact from marital status.In a study that examined the perspectives of BC patients and their partners, Manne et al 37 measured marital quality and, despite concluding that partners influenced the course of PTG over time, they were not responsible for its prediction.This suggests that a stable social support system may have advantages over and above a high-quality one-to-one interaction.
Only one HNC study assessed the impact of socioeconomic status and found that those participants with high or low socio-economic status reported greater levels of PPC than those in the middle of the scale 25 .

Clinical factors
Eight HNC studies have investigated clinical factors of PPC [25][26][27][28][29][30][31][32] using quantitative PPC measures.Harrington, McGurk, and Llewellyn 27 did not find any relationship between PPC and treatment, time since treatment, stage of cancer or diagnosis of further illness in people treated for HNC.Leong et al 31 did not find an association with stage of the tumour with development of PPC either.This pattern was partially reinforced by the findings of, Harding 25 , Harding and Moss 26 , Holtmaat et al 29 and Llewellyn et al 32 .
Ho et al 28 found that following HNC people with more advanced cancer (stages III and IV) reported a lower levels of PPC, but different treatment modalities did not significantly influence PPC.The pattern of tumour stage was supported by the work of Harding 25 and Harding and Moss 26 .In relation to treatment modalities, Harding 25 and Harding and Moss 2 found that participants who had surgery alone reported more positive change than both those who had surgery with radiotherapy and those who were not treated surgically, but who had received radiotherapy with or without chemotherapy.

Psychological factors
Harrington, McGurk, and Llewellyn 27 recruited people with HNC and found that dispositional optimism and positive reframing could account for 23% of the variance in PPC and additionally that higher levels of religious coping were correlated with greater PPC.They did not find any relationship between PPC and anxiety, or depression.Llewellyn et al. 32 supported Harrington et al's 27 findings related to dispositional optimism and positive reframing, and also found that increased use of emotional support and a decrease in self-blame positively affect PPC.This combination of factors was found to account for 39% of PPC variance.Ho et al 28 also investigated people who had been diagnosed as having HNC and found that the Hope scale, the Life Orientation Test-Revised (LOT-R), and the Post Traumatic Growth Inventory (PTGI) were all positively correlated.Results of regression analyses comparing hope and optimism in relation to PPC found that they contributed to a 25% variance of PPC as measure by the PTGI.However, only 'hope' was a significant individual indicator of PPC.
Lebel et al 30 investigated the impact of stigma as a predictor of benefit finding and although they report their results as a mixed group of Lung and HN cancer, they found that when controlled for stressful life events and matched for cancer status, stigma and benefit finding predicted well-being.
Quality of Life (QoL) is an important psychological factor, and Llewellyn et al 32 found that an increase in emotional growth was negatively related to the mental component summary (MCS) score.This indicates that higher levels of emotional growth are associated with poorer mental health-related QoL (HRQoL), but the study by Llewellyn et al 32 did not use a HRQoL measure specifically designed to assess HNC HRQoL factors.Harding 25 used a HNC specific measure of HRQoL and SF-12 (Table 1 & 2) and found that several subscales related to HNC and the Physical Component scale of the SF-12 were related to the development of PPC longitudinally.
Holtmaat et al 29 found that lower levels of depression as measured by that sub-scale on the hospital anxiety and depression scale combined with higher levels of social functioning resulted in greater PPC.

Impact of time since diagnosis or treatment completion
A key limitation of 6 of the 8 HNC studies is the short time frame over which data was collected 26,[28][29][30][31][32] .One of those that looked at a greater time span only measured data once, so a trajectory of PPC developed could not be assessed 27 .To date, only Harding 25 has tried to determine a longitudinal trajectory of the development of PPC and further work is needed to examine associations with trajectories of PPC over time.Harding 25 goes some way to examine this, but was not able to differentiate if sub-groups with differing patterns of PPC development exist.Danhauer et al 16 yielded a BC model with six PPC trajectories.They found age, race, chemotherapy status, use of adaptive coping strategies, illness intrusiveness, depressive symptoms and social support, all differed among the groups.The Danhauer et al 15,16 work supports the idea that there are likely to be sub-groups within the HNC population.Greater numbers of people post HNC treatment are required to more fully understand differentiating factors.

Implications for clinicians
A recent systematic review 40 across cancer cohorts found that the vast majority of research has focused on BC, and that the majority of PPC research has focused on psychologcal variables, over looking cancer-realted variables.With the small number of HNC papers it is hard to draw comparisions with other cancer cohorts, due to the different gender, ages, rates of recurrance and 5-year surviaval times.However, the work of Danhauer 15,16 and Harding 25 suggest that their are similarilities in the development of PPC over time.
If PPC is going to be of benefit to health care professionals and service users, it needs to be harnessed as an intervention or elements of intervention packages.A meta-analysis assessed the relationship between intervention participation and PTG but failed to find any studies that included an outcome measure of PPC 41 .Roepke 41 suggests that there is a modest increase in PPC following intervention, but due to the limited research reported on the natural development and time course of PPC, it is possible that even this modest increase could be due to the passage of time.Future clinical practise needs to be mindful of these factors and include a measure of PPC in the development and delivery of interventions.

Table 1 :
This over view of the current literature will describe Study Descriptors.

Table 2 :
Participants and Variables.
variables have been found to be associated with PPC in people following HNC.The current research literature does not provide many clear associations due to the limited number of studies.Most studies are also short duration which makes it more difficult to evaluate changes over time about identified variables. which