Participants included 10 women and 11 men, the majority over 60 years of age, with half working in manual jobs. Many participants had only reached education at primary school level. The disease (colon and rectal cancer) and its most common treatments (especially chemotherapy and colostomy) are homogeneously represented (Table 1).
The results are presented in two blocks: coping modes used (1) during the disease and (2) during survival. Following the Lazarus and Folkman model (5), we divide each block into two sections: problem-centred and emotion-centred strategies (Table 2).
Pure coping strategies are not observed in this series. Instead, strategies are generally combined and even contradictory. Furthermore, although coping patterns are sometimes identified, they vary within each person interviewed. Tables 3 and 4 show quotations selected based on clarity and relevance to illustrate the results.
Coping during illness
The coping strategies during the disease originate from stressful experiences at the time of diagnosis or of treatments such as surgery or chemotherapy. Table 3 shows the quotations for this section.
Problem-centred coping strategies
We differentiate between three approaches when challenged with cancer: (1) direct (confrontation); (2) detached (distancing); and (3) intermediate (acceptance). Strategies with a central cognitive component are categorised as attitudes and strategies with a central behavioural element as actions.
Attitudes. Regardless of age or gender, the most common strategy during illness is acceptance. Most participants explain that it is important to let time go by and to be patient because, eventually, they will adapt to the situation. They also frequently endorse confrontational positions such as willpower, strength and fighting spirit, which they consider beneficial to face these situations.
At the opposing end, some attitudes that involve detachment from the problem imply a certain passivity in coping with the illness. Here, patients minimise their own role during these moments and stress the importance of letting professionals do their job. Placing hope in health professionals, generally in physicians, is another common theme that emerges when assessing what has helped in braving the disease.
Denial, i.e., refusing to acknowledge having experienced any type of distress, is considered an extreme example of distancing. Feedback with coping strategies close to self-sufficiency also emerged in the discourses, even a certain self-perception of invulnerability. It is essential to underscore reasonings that promote these attitudes, such as the cancer requiring a single surgery or having suffered from other cancers. Extreme coping modes are not common, although men provided shorter answers aiming to belittle any suggestions of vulnerability. Women were more inclined to explore these experiences and their coping strategies.
Actions. Coping can also involve a behavioural response represented through the confrontation-acceptance-distancing axis. Participants explained that leisure activities, work-related activities and daily routines helped coping with difficult moments of the disease. Keeping the usual routines and responsibilities after diagnosis facilitates adaptation. Leading a normal life, avoiding giving in to fear, getting out of the house and staying active was positively evaluated.
Connected to the need to continue the previous life or start new activities, participants stress a purpose of these actions closer to distancing: these activities allow us to disconnect, to avoid thinking and to put aside fears related to the illness and its possible consequences. Another common premise not linked to specific actions was avoiding obsessing over the problem.
Trying to understand the disease from a medical point of view constitutes another type of confrontation. In this case, patients acknowledge their need to read about cancer, it is possible causes or how to prevent it. This coping mode has been observed in younger people; it is usually followed by doubts and might result in greater discomfort.
Emotion-centred coping strategies
Emotions are pivotal in the discourses of the people interviewed, who believe that they can play a favourable role in coping and communicate the need to control them. There is a prevailing belief that "you have to stay positive" when facing cancer, that it is important to think that everything will be alright and even to have (religious) faith. Numerous quotations convey the need for optimism and the positivity imperative with minimal variations.
The ubiquity of this type of quotation contrasts with the scarce reference to opposing discourses. The main examples of negative attitudes, generally considered unhelpful, include pessimism, sadness, desire to be alone, anger and feelings of unfairness, fragility and vulnerability. Perhaps to help ease the impact on them, participants sometimes explain that these feelings may be important and necessary to other people. None of the interviewees reported that expressing anger helped them cope with the disease, and there is advice on avoiding negativity. Notably, negativity predominantly appears in women's discourses.
Coping during survival
Survival in cancer begins when the person is medically considered disease free with minimal chances of recurrence. The people interviewed do not talk so much about facing survival, a positive event that mitigates anxiety, but about how they cope with medical follow-ups, sequelae and, mainly, uncertainty and worry about a possible relapse. See Table 4 for quotations.
Problem-centred coping strategies
During survival we can also classify the results observed in attitudes and actions along the axis confrontation-acceptance-distancing.
Attitudes. Among the different ways of coping with uncertainty during survival, the most common attitude alternates between acceptance and distancing, forgetting and moving on, reiterating the need to turn the page, leaving the disease behind and not looking back.
As an example of confrontation, some people cope with survival through some life-transforming changes. They explain that cancer has changed them, that it has been an opportunity to see life anew, that they now enjoy everyday things and appreciate what is really important. This idea of the good side of cancer is observed in younger people and does not exclude disorientation or feeling lost because of the uncertainty about a possible relapse and how to prevent it.
Most participants were overjoyed with the news of having defeated cancer and accepted that they were starting a new stage in their lives. We found some exceptions, indicating the extreme distancing of denial among participants who refused to acknowledge any impact of the disease and that survival is the beginning of a new phase. Another exception is found among the younger participants, who either because of their longer life expectancy they feel more at risk of a new cancer or for generational reasons, do not so conclusively express joy or carelessness at having overcome the disease.
Actions. This section features daily routines and new activities with the purpose not only of mitigating survival anxiety, but also of confronting or distancing in the face of uncertainty. The relevance of lifestyles and, in younger participants, alternative therapies or psychotherapy, emerges at this stage.
Regarding helpful activities after surviving cancer, the most common coping strategy is improving lifestyles, mainly in relation to diet and physical activity. Advised by health professionals or found through self-education, participants might refer to these recommendations with frustration and even guilt due to compliance difficulties. Lack of compliance-willpower and the imprecision-multiplicity of recommendations were the main hindrances to success. The discomfort is sometimes explained as conflicting social imperatives, since daily obligations do not facilitate these behaviours.
Although many people interviewed talk about these activities and their preventive role regardless of their age, older interviewees do not show active interest in inquiring about these issues and relativize compliance.
Emotion-centred coping strategies
In illness and survival, positive feelings are considered helpful. Negative feelings are either deemed unhelpful or outright censored.
A positive feeling is feeling proud. Some patients underscore their ability to overcome adversity and their own worth as strengths that allow them to better face the concerns of this stage. This attitude is only observed in men. Feelings of gratitude are also common. Many participants acknowledge feeling lucky to have defeated the disease, since other patients have succumbed to it. On the other hand, feeling lucky is also perceived as an obligation, since not showing enough appreciation can be considered ungrateful.
The uncertainty that accompanies survival is rarely verbalized as fear; that is fear of relapse and of not managing to keep up with regular life, which is considered negative feelings to be avoided.