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DOI: 10.1177/0898010105275927
2005 23: 172 J Holist Nurs
Susan Bauer-Wu and Carol J. Farran
Women
Meaning in Life and Psycho-Spiritual Functioning : A Comparison of Breast Cancer Survivors and Healthy
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10.1177/0898010105275927 JOURNALOF HOLISTIC NURSING / June 2005 Bauer-Wu, Farran / LIFE MEANING AND CANCER
Meaning in Life and
Psycho-Spiritual Functioning
AComparison of Breast Cancer Survivors
and Healthy Women
Susan Bauer-Wu, D.N.Sc., R.N.
Dana-Farber Cancer Institute
Carol J. Farran, D.N.Sc., R.N., F.A.A.N.
Rush University
Purpose: Incorporating holistic health perspectives, this study compared and exam-
ined relationships among meaning in life, spirituality, perceived stress, and psycho-
logical distress in breast cancer survivors (BCS) and healthy women. Methods:
Standardized self-report measures were completed once by all participants (N = 78).
Findings: Group comparison revealed statistically significant variances across the
measures. Covariate analysis identified BCS without children had less meaningful
lives and greater stress and distress than BCS with children and participants without
cancer. Significant correlations (p > .001) between meaning in life and spirituality
(r = .43), stress (r = .39), and distress (r = .41) were also identified. Conclusion:
Personal factors (i.e., being a parent) may be especially important in BCS. Also, psy-
chological and spiritual variables are highly correlated, suggesting the use of an inte-
grated termpsycho-spiritual functioning. Implications: Holistic nursing interven-
tions can facilitate self-awareness, interpersonal connection, and living a meaningful
life, particularly in vulnerable patients such as BCS without children.
Keywords: meaning in life; coping; cancer; spirituality; parenting; psychosocial
oncology
Of the estimated 267,000 American women diagnosed with breast
cancer annually, a large majority are expected to survive many years
later (R = 87% for 5 years to 63% for 15 years; American Cancer Soci-
172
JOURNAL OF HOLISTIC NURSING, Vol. 23 No. 2, June 2005 172-190
DOI: 10.1177/0898010105275927
2005 American Holistic Nurses Association
ety, 2003-2004). The Office of Cancer Survivorship at the National
Cancer Institute has set a research priority for studies that examine
the short- and long-termeffects of cancer and its treatment, including
the psychological, physical, social, andeconomic impact onsurvivors
andtheir families. Survivorshipresearchfocuses onpatient outcomes
beyond the treatment phase and seeks to optimize the health and
well-being of people with a history of cancer (Office of Cancer Sur-
vivorship, 2003).
Although the experience of breast cancer is oftentimes a frighten-
ing process that is associated with negative psychosocial conse-
quences (Amir &Ramati, 2002; Johnson Vickberg, 2001), many breast
cancer survivors (BCS) also report positive aspects from a cancer
diagnosis, such as greater appreciation for life and an enhancedspiri-
tual awareness (Carter, 1993; Coward, 1991, 1997; Taylor, 2000; Wyatt,
Kurtz, & Liken, 1993). Similar positive outcomes were identified in
those who experienced other stressful and life-threatening circum-
stances not relatedtocancer (Coward, 1995; Coward&Lewis, 1993).
The American Holistic Nurses Association (AHNA) embraces the
concept of holism: a state of harmony among body, mind, emotions
and spirit within an ever-changing environment (American Holistic
Nursing Association, 2004, para. 4). By better understanding the per-
sonal transformation that occurs in survivors of traumatic and life-
threatening circumstances such as cancer, nurses can assist individu-
als, particularly those who may be most vulnerable, to achieve a state
of harmony and balance during and after stressful experiences.
Bauer-Wu, Farran / LIFE MEANING AND CANCER 173
AUTHORS NOTE: At the time this research was conducted the first author was a doc-
toral student at the Rush University College of Nursing in Chicago, IL.
This research was supported in part by awards from the National Institute of Nursing
Research, the American Cancer Society (Doctoral Scholarship in Cancer Nursing), and
the Oncology Nursing Society Foundation (Doctoral Scholarship). The authors thank
the following individuals who provided direction in the development and implemen-
tationof this study: Janice M. Zeller, Ph.D., R.N., F.A.A.N., andLouis Fogg, Ph.D., at the
Rush University College of Nursing; David F. Cella, Ph.D., Center of Outcomes,
Research and Education, Northwestern University; and Kathleen Knafl, Ph.D., Yale
University School of Nursing. Recognition is also given to Leslie H. Nicoll, Ph.D.,
M.B.A., R.N., andRomelia Salazar, B.A., for their assistance withthe preparationof this
manuscript.
Correspondence concerning this article should be addressed to Susan Bauer-Wu,
D.N.Sc., R.N., The Phyllis F. Cantor Center, Dana-Farber Cancer Institute, 44 Binney
Street, Boston, MA02115; e-mail: susan_bauer_wu@dfci.harvard.edu.
An understanding of the psychological and spiritual experience of
surviving breast cancer could provide direction for the development
of holistic nursing interventions to enhance cancer survivors quality
of life. Additionally, important insights can be gleaned through a
comparison of survivors psychological and spiritual functioning to
that of healthywomenwithout cancer. Thus, the purpose of this study
was to compare personal meaning in life, spirituality, perceived
stress, andpsychological distress inBCS to a groupof healthy women
andsecondarilytoexamine the relationships amongthese variables.
REVIEW OF THE LITERATURE
Meaning in Life and Spirituality
Personal meaning in life is conceptualizedas an integration of ulti-
mate and provisional meaning (Farran, Keane-Hagerty, Salloway,
Kupferer, & Wilken, 1991; Reker, 1992, 1994). Ultimate meaning is
global and expansive seeking to understand life in general, the uni-
verse, or ones own existence and purpose, and provisional meaning
seeks to find fulfillment and purpose in day-to-day activities. The
ability to attain a sense of higher, ultimate meaning comes through an
ongoing quest for meaning of the moment or provisional meaning
(Fabry, 1988; Farran et al., 1991; Reker, 1992, 1994).
Frankl (1992), a psychiatrist andconcentrationcampsurvivor, pos-
tulatedthat survivors of traumatic events findmeaning through their
suffering. The essence of humanexistence is elucidatedwhenone rec-
ognizes that one is, indeed, fallible and mortal. Thus, meaning is
heightened through physical or emotional suffering and when facing
mortality. Frankl called this transcendence of suffering tragic opti-
mism consisting of a triad of pain, guilt, and mortality.
It is an optimism in the face of tragedy and in view of the human po-
tential that at its best allows for: (1) turning suffering into a human
achievement andaccomplishment; (2) deriving fromguilt the opportu-
nity to change oneself for the better; and (3) deriving from lifes transi-
toriness an incentive to take responsible action. (Frankl, 1992, p. 141-
142)
The cancer experience may involve any or all of the elements of the
triad described by Frankl (1992). Pain and other physical symptoms
174 JOURNAL OF HOLISTIC NURSING / June 2005
may result from the disease itself or from treatment-related side
effects (Dodd, Miaskowski, & Paul, 2001). Emotional pain or distress
may also result fromthe inevitable life changes that often accompany
the cancer experience (Amir &Ramati, 2002; JohnsonVickberg, 2001).
Blame and guilt may occur from a feeling that something could be
done to prevent the cancer. Guilt may also be related to putting loved
ones through considerable stress (Jassak, 1992). Last, the diagnosis of
cancer itself connotes a potentiallylife-threateningsituation. Intrinsic
to the cancer diagnosis is a bold reminder of the finiteness of life as
one comes face-to-face with his or her own mortality (Coward, 1997;
Ferrell, 1993).
Spirituality has existential underpinnings that involve finding
meaning and making sense of ones life and of the world within the
context of an intangible connectedness with something or someone
greater than oneself. According to Reed (1992), spirituality involves
creating meaning through three dimensions that empower the indi-
vidual: intrapersonal (connectedness with oneself), interpersonal (a
connectiontoothers andthe natural environment), andtranspersonal
(relatedness to the unseen, God, or a power greater than oneself). The
diagnosis of a life-threatening illness such as cancer often initiates a
period of spiritual disequilibrium, leading to spiritual reflection to
find meaning in ones situation and life in general (Albaugh, 2003;
Coward, 2003; Ferrell, Smith, Juarez, & Melancon, 2003).
Stress-Coping Model
Transactional stress-coping models (Folkman, Lazarus, Dunkel-
Schetter, DeLongis, & Gruen, 1986; Lazarus, 1990; Lazarus &
Folkman, 1984) postulate that the response to stress is individually
determined. Personal experience, value and belief systems, and cop-
ing strategies affect how one cognitively appraises the experience of
stress. Psychological and physical health outcomes vary, depending
on the degree to which a situation is appraised as stressful.
In the context of having had cancer, personal meaning in life and
spirituality can be threaded into the stress-coping framework in a
number of ways. A cancer survivor who encounters a potentially
stressful circumstance may think, If I can survive cancer, I can cer-
tainly survive this; or In the grand scheme of things, this is really
not that important; or God has helped me before and therefore will
be here for me now. One might lookfor meaningina traumatic situa-
tion by asking, What is the significance of this, and how can I learn
from this experience? Spiritual practices, such as prayer, going to
church, meditation, or walking in nature may be used to help cope
with stressful experiences (Feher & Maly, 1999; Gall, Miguez de
Renart, & Boonstra, 2000).
Previous researchers described associations between psycho-
spiritual factors and health-related outcomes in both noncancer and
cancer populations (Hawks, Hull, Thalman, & Richins, 1995; Lin &
Bauer-Wu, 2003). Reker (1994) found personal meaning in life serves
as a stress buffer for physical illness and is associated with a greater
sense of psychological and physical well-being in individuals not
affected by cancer. In a sample of general medical patients, Kass,
Friedman, Leserman, Zuttermeister, and Benson (1991) found that
spirituality was positively associatedwitha sense of purpose andsat-
isfaction and negatively associated with the frequency of stress-
related medical symptoms. In a study of the elderly, Reed (1991)
identified positive relationships between self-transcendence (i.e.,
meaning and spirituality) and mental health outcomes (i.e., well-
being).
Instudies of oncologypatients, psychological adjustment tocancer
positively correlated with meaning in life (Brady, Peterman, Fitchett,
Mo, & Cella, 1999; Taylor, 1993; Thompson & Pitts, 1993) and nega-
tively correlated with psychological difficulties and physical symp-
toms (Coward, 1991; Taylor, 1993). In a sample of individuals with
various types of cancer, spiritual awareness was inversely related to
psychological distress (Brady et al., 1999; Smith et al., 1993). Albaugh
(2003)in a phenomenologic studyidentified associations between
spirituality, finding meaning, and psychological well-being. In par-
ticular, individuals who were newly diagnosed with a life-threaten-
ing illness received comfort, peace of mind, and strength from spiri-
tual beliefs anddescribeda deeper meaninginlife andtrust inGod.
Women with breast cancer have described the postdiagnosis expe-
rience to be one of transformation, including both positive and nega-
tive aspects. Some of the positive aspects were a greater sense of
meaning and appreciation in life, enhanced personal relationships,
restructuring of priorities, and added importance of a higher power
(Carter, 1993; Coward, 2001). In a qualitative study, Taylor (2000) elu-
cidated the process of transformation in women who were newly
diagnosed with breast cancer. Women in this study identified differ-
ent phases of darkness and light in which they found meaning and
moved through the breast cancer experience. These studies and the
guiding principles of the current study are consistent with the
philosophy of the AHNA, which states, Disease and distress are
viewed as an opportunity for increased awareness of the inter-
connectedness of body, mind, and spirit (AHNA, 2004, Philosophy
section, #6).
METHODS
Design
A cross-sectional, two-group design with an unmatched conve-
nience sample of BCS anda comparisongroupof healthy womenwas
used. Self-report measures were completed at one time point.
Participants
In an urban area in the midwestern United States, a total of 78
women (39 in the breast cancer group and 39 in the comparison
group) were recruitedusing a newsletter of a local breast cancer orga-
nization, posters at an academic medical center, and personal con-
tacts. Eligibility criteria for the breast cancer group included 35 to 55
years of age, diagnosed with breast cancer at least 5 years earlier, had
no current evidence of cancer, and had not experienced a breast can-
cer recurrence in the 5-year time period. The unmatched, comparison
group (n = 39) included women in the same age range (35 to 55) who
had never been diagnosed with cancer or other life threatening or
chronic illness and had not experienced a significant personal loss
within the previous 2 years. Sociodemographic variables of the par-
ticipants are presented in Table 1. The majority of participants were
Caucasian, married, and of higher socioeconomic status.
Significant group differences on four sociodemographic variables
(age, t = 6.29, p > .001; number of children, t = 2.86, p > .005; years of
education, t = 5.35, p > .001; religion, p > .03) were found. As indi-
cated in Table 1, the BCS group in general was older, had more chil-
dren, and was less educated than the comparison group of healthy
women. There were also differences in religious affiliation; the breast
cancer survivor group had fewer Catholics and more Jewish and
members of other religions. There were no significant differences
between the groups on the variables of race, marital status, and level
of income.
Procedures
Following approval by the university institutional review board,
posters and newsletter advertisements were placed at an academic
health sciences center and at local cancer support programs. Inter-
estedwomen initiated a phone call and spoke to the principal investi-
gator, who explained the study and confirmed eligibility criteria.
Written consent was then obtained by the principal investigator,
either in person at the medical center or by mail. After signed consent
was obtained, participants receiveda demographic informationsheet
TABLE 1
Sociodemographics of the Sample (N = 78) for Each
Group (Breast Cancer Survivor Group and
Healthy Women Comparison Group)
Breast Cancer Group Comparison Group
(n = 39) (n = 39)
M M
Age*** 49.41 42.58
Children** 1.87 1.15
Education*** 15.38 18.66
% %
Religion*
Protestant 23 25
Catholic 18 49
Jewish 33 13
Other 13 5
None 13 8
Race
Caucasian 92 90
African American 5 8
Hispanic 3 0
Asian American 0 2
Marital status
Married or partnered 67 72
Single, divorced, or widowed 33 28
Annual household income
$15-30,000 13 3
$31-50,000 27 27
$51-100,000 37 39
More than $100,000 23 31
*p > .03. **p > .005. ***p > .001.
and six paper-and-pencil questionnaires. The questionnaire packets
were completed at the participants convenience (taking approxi-
mately 30 to 45 min), either inpersonat the medical center or at home.
The packets that were completed at home were returned in pre-
addressed, stamped envelopes within 4 weeks. All participants who
consented to the study completed and returned the questionnaires
within the required timeframe.
Instruments
Personal meaning in life. Personal meaning in life was evaluated
with three measures: personal meaning index (PMI; Reker, 1992),
existential vacuum(EV; Reker, 1992), and ladder of life index at pres-
ent (LOLIPRES; Reker, personal communication, October 16, 1995).
PMI and EV are part of the life attitude profilerevised (LAP-R;
Reker, 1992). The LAP-R is a 48-item self-report multidimensional
measure of discovered meaning and purpose in life and the motiva-
tionto findmeaning andpurpose inlife. Content-relatedvalidity was
established through expert consultation, rigorous construct develop-
ment, and careful review of the literature. Convergent validity was
established through comparison with a similar instrument: purpose
in life test (Crumbaugh & Maholick, 1969). Each item of the LAP-R is
rated on a 7-point (1-7 anchors) Likert-type scale of agreement. The
LAP-R is scored and profiled in terms of six dimensions (purpose,
coherence, life control, death acceptance, EV, and goal seeking) and two
composite scales (PMI and life attitude balance index). On careful
consideration of the instrument items, dimensions, and scales with
regard to the conceptual framework of this study, analyses with the
LAP-R focused on one of the composite scales, PMI, and one of the
dimensions (EV).
The 16-item PMI scale is composed of two of the LAP-R dimen-
sions: purpose and coherence. The PMI scale score is used to evaluate
life goals, mission in life, sense of direction, and a logically integrated
sense of self, others, and life in general. The score range for PMI is 16
to112. Higher PMI scores indicate a greater sense of meaninginlife. In
this study, the mean PMI score for the total sample was 67.52 (SD =
13.71). The EV dimension is made up of different items than PMI. EV
identifies a decreased sense of meaning in life, a lack of goals, and
feelings of indifference. The possible score range for EV is 8 to 56.
Higher EV scores, in general, indicate lower sense of meaning in life.
Mean score for this study sample was 14.12 (SD = 8.62). Cronbachs
alpha reliability scores in this study were .86 and .84 for PMI and EV,
respectively, compared to .91 and .80 in a study with middle-aged
adults (Reker, 1992).
LOLIPRES measures meaning in life at present. This item is from
the 3-itemladder of life index (LOLI) and is rated on a 10-point scale
(0 = least meaningful, 10 =most meaningful). Possible scores range from
0 to 10. LOLI was createdandvalidatedto serve as a simple andquick
assessment of meaninginlife andhas establishedconvergent validity
with LAP-R (Reker, personal communication, July 1996). The mean
score for this study was 8.42 (SD = 1.86). Internal consistency of the
LOLI usingCronbachs alpha was .72 inthis study, whichis consistent
with previous testing (.73; Reker, personal communication, July
1996).
Spirituality. Spirituality was measured with the index of core spiri-
tual experiences (INSPIRIT; Kass et al., 1991), a 7-item instrument
measuring the occurrence of experiences that convince a person that
God exists and evoke feelings of closeness with God or a higher
power. Construct validity was established with expert advice and
feedback from heterogeneous groups. Scores range from 1.0 to 4.0,
with higher scores indicating a greater degree of spirituality. When
used in adult outpatients with chronic medical disorders, Cronbachs
alpha reliability coefficient was .90 and the mean score was 2.8 (SD =
0.83; Kass et al., 1991). In the present study, the Cronbachs alpha reli-
ability was .87, and the mean score was 2.94 (SD = 0.83).
Perceived stress. Perceived stressthe degree to which a person
finds life unpredictable, uncontrollable, and overloadedwas mea-
sured with the perceived stress scale (PSS; Cohen, Kamarck, &
Mermelstein, 1983). This scale consists of 14 items, with each item
scored from 0 to 4 (0 = never, 4 = very often). The score range is 0 to 56:
Higher scores indicate greater perceived stress. High discriminant
and convergent validity have been established (Cohen et al., 1983). A
mean score of 25.6 (SD = 8.2) for women from a general community
sample and coefficient alpha reliability of .84, .85, and .86 in three dif-
ferent samples have been reported for the PSS (Cohen et al., 1983). In
the present study, the overall sample mean was 19.54 (SD = 7.64) and
internal consistency reliability was 0.85.
Psychological distress. The short form of the profile of mood states
(Brief POMS) was chosenfor its well-establishedreliability andvalid-
ity as a simple measurement of psychological distress in large sam-
ples of cancer patients (Cella et al., 1987). Initial testing of this instru-
ment foundhighconvergent validity withthe total mooddisturbance
score of the original 58-item POMS: r (df = 294) = 0.92, p > .001 (Cella
et al., 1987). Brief POMS consists of 11 adjectives to describe different
negative moods, on a 0 to 4 scale (0 = not at all, 4 = extremely). Scores
range from0 to 44: Higher scores indicated greater psychological dis-
tress. The sample mean in this study was 16.39 (SD = 9.34). Internal
consistency using Cronbachs alpha was .91 in the present study,
whichwas consistent withanearlier studyof participants withmixed
cancer diagnoses (.91; Cella et al., 1987).
RESULTS
Because this study design did not employ randomization or
matching, t-test and cross-tabulation procedures were performed on
the sociodemographic variables. Group differences in means and
variances of the sociodemographic variables were tested for simple
effects using two-tailed t tests (see Participants section and Table 1).
Covariate analysis was conducted for sociodemographic variables
identified as disproportionately distributed between the two groups.
Finally, bivariate correlational analysis examined relationships
among the study variables (personal meaning in life, spirituality, per-
ceived stress, and psychological distress).
Group Comparison
Comparison of simple group differences identified nonsignificant
mean differences between groups except for the PMI scores (t = 2.01,
p = .05). When correcting for sociodemographics mean differences
in PMI were no longer significant. However, there were significant
variances identified on almost all of the study measures: LOLIPRES,
F = 3.05, p = .0001; INSPIRIT, F = 2.43, p = .006; PSS, F = 1.73, p = .05;
Brief POMS, F = 2.66, p = .01. This indicates that participants in
the BCS group varied significantly in their responses and scores
of these measures compared to the participants in the comparison
group of healthy women who were much more consistent with their
responses.
Of note, when correcting for having children, there was reduction
invariance belowstatistical significance for all of the study measures.
This finding was not identified when correcting for other socio-
demographic variables.
Subsequent analysis (comparing participants with children to
those without children) showed that BCS participants without chil-
dren had lower PMI, LOLIPRES, and INSPIRIT scores and higher EV,
PSS, and POMS scores (see Table 2) compared with the other partici-
pants. The women in the breast cancer group with children scored
similarly to the comparison group with or without children on all
study measures. Although these results were not statistically signifi-
cant, owing to the small sample size, the comparison of these scores is
notable. (Figures 1 and 2 illustrate the scores of PMI and POMS, re-
spectively, for each group, with and without children.)
TABLE 2
Group Mean Scores for Personal Meaning, Spirituality, Perceived
Stress, and DistressBased on Having Children
Breast Cancer Group Comparison Group
With Children No Children With Children No Children
(n = 32) (n = 7) (n = 24) (n = 15)
M SD M SD M SD M SD
LOLIPRES
a
8.4 2.2 6.6 2.7 9.0 1.0 8.4 1.7
PMI
b
67.1 14.5 52.1 18.0 73.1 9.8 66.7 15.2
EV
c
14.3 10.3 21.1 4.3 11.8 6.2 14.2 9.3
INSPIRIT
d
2.9 1.0 2.5 0.9 2.9 0.7 3.3 0.5
PSS
e
18.9 8.5 22.3 9.1 19.1 6.5 20.3 6.6
POMS
f
16.4 10.5 22.1 14.6 15.4 6.3 15.3 7.8
a. LOLIPRES = ladder of life index at present; higher scores indicate greater personal
meaning in life.
b. PMI = personal meaning index; higher scores indicate greater personal meaning in
life.
c. EV = existential vacuum; higher scores indicate lower personal meaning in life.
d. INSPIRIT = index of core spiritual experiences; higher scores indicate greater
spirituality.
e. PSS = perceived stress scale; higher scores indicate greater perceived stress.
f. POMS = brief profile of mood states; higher scores indicate greater psychological
distress.
Relationships Among Variables
As shown in Table 3, significant relationships were found between
all of the measures, with the exception of INSPIRIT, which was not
correlated with PSS and POMS.
DISCUSSION
The most striking finding of this study is that the presence or
absence of children may affect psychological and spiritual function-
ing in women with a history of breast cancer. Specifically, personal
meaning in life and spirituality are lower and psychological stress
and distress are higher in BCS without children compared to those
Figure 1: MeaninginLife Scores (Personal MeaningIndex) for EachGroup, With
and Without Children
NOTE: Breast cancer group without children (n = 7); comparison group without chil-
dren (n = 15); breast cancer group with children (n = 32); comparison group with chil-
dren (n = 24).
with children, whereas having children did not affect these outcomes
in the comparison group of healthy women. It is worthwhile to con-
sider the reasons why the absence of children may be an important
factor in the psycho-spiritual well-being of women who have sur-
vived breast cancer.
After the diagnosis and treatment of premenopausal breast cancer,
women often cannot have children because of therapy-induced
menopause (Bauer et al., 2001; Bines, Oleske, &Cobleigh, 1996). They
may also be advised against pregnancy because of the uncertainty of
hormonal effects of pregnancy on the recurrence of breast cancer
(Burstein&Winer, 2000). Thus, womenmay findthemselves ina situ-
ation that dampens the possibility or hope of ever having a child.
Feelings of grief and regret may result that subsequently affect the
Figure 2: Distress Scores (Brief Profile of MoodStates) for EachGroup, Withand
Without Children
NOTE: Breast cancer group without children (n = 7); comparison group without chil-
dren (n = 15); breast cancer group with children (n = 32); comparison group with chil-
dren (n = 24).
womans sense of meaning and purpose in life, faith in God, per-
ceived stress and control of her life, and thus her overall psychologi-
cal well-being.
Research examining infertility after cancer treatment and its effect
on childless cancer survivors is limited. There has been some initial
research of men with testicular cancer that has produced findings
similar to this study that are relevant to the issue of infertility in child-
less BCS. In a comparison study with a matched control group of
healthy men, childless survivors of testicular cancer experienced sig-
nificant infertility distress that had a negative impact on personal
relationships and mental outlook (Rieker et al., 1989). In a subse-
quent study evaluating determinants of attitudes and behaviors
toward treatment-induced infertility in testicular cancer survivors,
being childless was one of the greatest risk factors for distress (Rieker,
Fitzgerald, & Kalish, 1990). The investigators concluded that the pre-
rogative to have children is very important and being childless when
diagnosedwithcancer predisposes mentomaladaptive behavior and
distress during and after treatment (Rieker et al., 1989). It is impossi-
ble to know whether the distress associated with infertility among
male and female cancer survivors is similar, but existing data suggest
that it may be.
Results of this study also support a conceptual integration of exis-
tential and stress-coping perspectives, which is consistent with other
work identifying similar relationships among personal meaning in
TABLE 3
Correlations Between Study Measures in Breast Cancer Survivors
and Healthy Women
Study Measures LOLIPRES PMI EV INSPIRIT POMS PSS
LOLIPRES 1.00 0.70*** 0.41*** 0.36*** 0.31** 0.33**
PMI 1.00 0.67*** 0.43*** .39*** 0.41***
EV 1.00 0.22* 0.39*** 0.35**
INSPIRIT 1.00 0.15 0.18
POMS 1.00 0.64***
PSS 1.00
NOTE: LOLIPRES =ladder of life at present; PMI =personal meaning index; EV=exis-
tential vacuum; INSPIRIT =index of core spiritual experiences; POMS =brief profile of
mood states; PSS = perceived stress scale. N = 78 is the total sample size used in this
analysis.
*p > .05. **p > .01. ***p > .001.
life, spirituality, stress, and distress. Meaning in life and spirituality
are relatedtoeachother (Albaugh, 2003; Kass et al., 1991; Lin&Bauer-
Wu, 2003) and inversely related to stress and psychological distress
(Bauer, 1997; Coward, 1991; Lin & Bauer-Wu, 2003; Smith et al., 1993;
Targ&Levine, 2002). The correlational results of this studyandothers
support the notion that psycho-spiritual factors (i.e., living a more
meaningful life and feeling connected to higher power) have the
potential to buffer an individuals reaction to stressful experiences
such as a cancer diagnosis and treatment.
Limitations. This nonprobability sample from a single geographic
area consisted primarily of women who were Caucasian, educated,
married, and of higher socioeconomic status. Hence, it is not reason-
able togeneralize these findings toother populations. Because match-
ing was not employed, the two groups turned out to be significantly
disproportionate on four demographic factors (age, children, educa-
tion, and religion). Although statistical procedures were conducted
for these confounding variables, this practice is inferior to careful
matching. Corroboration of these findings in a more carefully
matched sample would provide added confidence about their
validity.
It is also important to note that the findings related to the childless
BCS are based on a very small sample. The statistical analyses on this
issue (children) were secondary in nature, with results that were
revealed while trying to explain the high variance within the BCS
group. Therefore, this result is certainly in need of replication. Also,
given the small sample size in this study with two groups andseveral
study variables, it is important to recognize ambiguity whenrejecting
the null hypothesis.
The cross-sectional design of this study was descriptive in nature;
therefore, causal statements cannot be made about surviving breast
cancer andthe studyvariables. Althoughrelationships betweenthese
variables have been identified, the actual path and interaction among
them remains unclear. The study findings do raise interesting ques-
tions: (a) Could meaning in life and spirituality affect how one per-
ceives stress? and (b) Can the level of psychological distress cloud
ones ability to find meaning in life or affect the way one perceives
stress?
CONCLUSIONS
The findings of this study provide support for potential clinical
application and future research related to psycho-spiritual issues in
BCS andother cancer patients as well as other womenwith chronic or
life-threatening diagnoses. Nurses and other health care providers
can assist patients in expressing and processing their psychological
and spiritual concerns or provide referrals to counselors, chaplains,
or other spiritual guides, which might help to alleviate stress and its
associated mental and physical health consequences. Holistic nurs-
ing interventions can be implemented as they promote healing of the
whole personbody, mind, emotions, andspiritthroughsuchther-
apeutic processes as facilitating self-awareness, living meaningfully,
and fostering connection to others and to nature and a higher power.
Because female cancer survivors without children seemto be particu-
larly vulnerable, healt hcare professionals can be mindful of the
special concerns of this population.
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SusanBauer-Wu, D.N.Sc., R.N., is the director of the Phyllis F. Cantor Center for
Research in Nursing and Patient Care Services at Dana-Farber Cancer Institute in
Boston, Massachusetts, and an instructor of medicine at Harvard Medical School.
Dr. Bauer-Wu has long-standing clinical and research interests in interventions that
promote meaningful living and optimal psychological and physical functioning in
cancer patients.
Carol J. Farran, D.N.Sc., R.N., F.A.A.N., is a professor inthe Department of Com-
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Chicago, Illinois. Dr. Farrans research interests are in the mental and physical effects
of caring for an elderly person with dementia.

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