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. 2025 Jan 7;52(1):23–40. doi: 10.1188/25.ONF.23-40

Unrelieved Stress, Decreased Resilience, and Disengagement Coping Strategies Are Associated With Lower Levels of Hope in Patients With Cancer

Laura Allaire 1, Astrid Block 1, Sueann Mark 1, Steven M Paul 1, Marilyn J Hammer 1, Yvette P Conley 1, Bruce A Cooper 1, Jon D Levine 1, Christine Miaskowski 1,✉
PMCID: PMC12056870  PMID: 39933108

Abstract

OBJECTIVES

To determine clinically meaningful cut points for the Herth Hope Index and evaluate for differences in demographic and clinical characteristics, as well as stress, resilience, and coping, between patients with lower versus higher levels of hope.

SAMPLE & SETTING

Outpatients with cancer receiving chemotherapy (N = 1,295).

METHODS & VARIABLES

Patients completed the Herth Hope Index, Multidimensional Quality of Life Scale–Patient Version, and stress, resilience, and coping measures prior to their second or third cycle of chemotherapy.

RESULTS

Optimal cut points for the Herth Hope Index were 40 or less (i.e., lower level of hope) and greater than 40 (i.e., higher level of hope). The Lower Hope group had a higher comorbidity burden and lower functional status.

IMPLICATIONS FOR NURSING

Clinicians can use this information to educate patients about interventions that can decrease stress and improve their coping abilities. Patients with cancer may benefit from having conversations with clinicians that authentically convey prognosis and provide a realistic sense of hope.

Keywords: cancer, chemotherapy, coping, cut points, hope, resilience, stress

Hope is a critical factor for the well-being of patients living with any chronic illness, including cancer (Nayeri et al., 2020; Rawdin et al., 2013; Salimi et al., 2022). Dufault and Martocchio (1985) defined hope as “a multidimensional dynamic life force characterized by a confident yet uncertain expectation of achieving a future good which, to the hoping person, is realistically possible and personally significant” (p. 380). The Herth Hope Index (HHI), developed to assess hope in patients with chronic conditions (Herth, 1991, 1992), is one of the most common measures used in studies of patients with cancer. However, as summarized in this article, the limited number of studies that examined the relationships between various demographic and clinical characteristics and levels of hope in patients with cancer receiving curative (Kitashita & Suzuki, 2023) and/or palliative treatments (Nierop-van Baalen et al., 2020) were cross-sectional, evaluated a limited number of characteristics, and used univariable or multivariable analyses. A significant gap in knowledge, which affects the clinical utility of the HHI, is the lack of a clinically meaningful cut point that can be used to categorize patients with cancer with lower versus higher levels of hope. The establishment of clinically meaningful cut points would allow clinicians the ability to identify high-risk patients who may warrant a variety of interventions.

Demographic and Clinical Characteristics

In two systematic reviews, the demographic and clinical characteristics associated with lower levels of hope in patients with cancer receiving curative (Kitashita & Suzuki, 2023) and/or palliative treatments (Nierop-van Baalen et al., 2020) were described. The first review summarized the findings from 33 studies that evaluated patients receiving either curative or palliative treatment (Nierop-van Baalen et al., 2020). The second review, which included 13 studies (of which 4 overlapped with the previous review [Nierop-van Baalen et al., 2020]), focused on patients receiving curative treatment (Kitashita & Suzuki, 2023). Across these 42 studies, findings regarding associations between levels of hope and age, gender, education, marital status, living arrangements, employment status, and income were inconclusive. In terms of clinical characteristics, type of cancer, stage of disease, type of treatment, presence of metastatic disease, and functional status were the only characteristics evaluated and the findings were inconclusive. The authors of both reviews concluded that additional research is warranted with larger sample sizes to identify the demographic and clinical risk factors associated with lower levels of hope in patients receiving active cancer treatment.

Relationships Among Stress, Resilience, Coping, and Hope

A limited number of studies evaluated the relationships between and/or among hope and various types of stress, resilience, and coping. A cancer diagnosis and its treatments are associated with increased levels of stress. This disease-specific stress can exacerbate or synergize with everyday stress (i.e., global stress) and cumulative life stress (Langford et al., 2020). As noted in one review (Long, 2022), evidence suggests that hope is a protective factor that promotes recovery from adversity and increases in resilience. However, research on the relationships between various types of stress and hope in patients with cancer is limited. In one study of patients undergoing radiation therapy for cervical cancer (Li et al., 2017), higher levels of distress, measured using the National Comprehensive Cancer Network Distress Thermometer, were associated with lower levels of hope. In another study of patients with oral cancer (Zhang et al., 2021), higher levels of perceived stress and post-traumatic stress disorder (PTSD) symptoms were associated with lower levels of hope. No studies have evaluated for associations between hope and three distinct types of stress (i.e., global stress, cancer-related stress, and cumulative life stress including adverse childhood experiences [ACEs]) in patients receiving cancer chemotherapy.

Resilience refers to an individual’s capacity to maintain one’s physical and psychological well-being in the face of adversity (Richardson, 2002). As noted in a review by Ong et al. (2023), it is not clear whether hope is a source of resilience. In contrast, findings from reviews of patients with various chronic conditions (Stewart & Yuen, 2011) and colorectal cancer (Sihvola et al., 2022) suggest that higher levels of hope are associated with higher levels of resilience.

According to Lazarus and Folkman’s (1984) theory of stress and coping, coping is a psychological process in which individuals choose effective coping strategies to manage stress. As noted in the two systematic reviews (Kitashita & Suzuki, 2023; Nierop-van Baalen et al., 2020), in a limited number of studies, higher levels of hope were associated with positive religious coping styles. In contrast, a negative correlation was found between hope and fatalistic coping styles and emotional coping styles. Again, the authors concluded that additional research is warranted on the relationships between hope and coping in patients with cancer receiving active treatment.

Given the positive associations between hope and patients’ and physicians’ estimates of life expectancy (Cripe et al., 2018), additional research is needed to determine potentially modifiable risk factors for lower levels of hope in patients undergoing cancer treatment. Therefore, the purposes of this study, in a sample of patients receiving chemotherapy (N = 1,295), were to determine the optimal cut points for lower and higher levels of hope and determine whether these cut points distinguished between the hope groups on any demographic and clinical characteristics, as well as on measures of stress, resilience, and coping.

Methods

Patients and Settings

This analysis is part of a longitudinal study of the symptom experience of outpatients with cancer receiving chemotherapy (Miaskowski et al., 2014). The theory of symptom management was used as the theoretical framework for the parent study (Weiss et al., 2023). For this analysis, various person (i.e., level of hope, stress, and resilience; demographic and clinical characteristics) and outcome (quality of life [QOL]) concepts were evaluated.

Eligible patients were aged 18 years or older; had a diagnosis of breast, gastrointestinal, gynecologic, or lung cancer; had received chemotherapy within the preceding four weeks; were scheduled to receive at least two additional cycles of chemotherapy; were able to read, write, and understand English; and gave written informed consent. Patients were recruited from two comprehensive cancer centers, one Veterans Affairs hospital, and four community-based oncology programs. The major reason for refusal was being overwhelmed with their cancer treatment.

Study Procedures

The study was approved by the institutional review board at the University of California, San Francisco, and at each of the study sites. Of the 2,234 patients approached, 1,338 consented to participate and provided evaluable data for this analysis. Patients’ refusal to participate was primarily because of being overwhelmed with their cancer treatment. Eligible patients were approached in the infusion unit during their first or second cycle of chemotherapy by a member of the research staff and provided written informed consent. Patients completed assessments, in their homes, using paper questionnaires, a total of six times over two cycles of chemotherapy (i.e., prior to chemotherapy administration [assessments 1 and 4]; about one week after chemotherapy administration [assessments 2 and 5]; and about two weeks after chemotherapy administration [assessments 3 and 6]). Additional measures were completed by the patients at enrollment (i.e., prior to the second or the third cycle of chemotherapy). All of the questionnaires were returned to the research office in postage-paid envelopes. For this analysis, only the enrollment measures were evaluated.

Instruments

Demographic and clinical measures

Patients completed a demographic questionnaire, the Karnofsky Performance Status Scale (Karnofsky, 1977), the Self-Administered Comorbidity Questionnaire (Sangha et al., 2003), the Alcohol Use Disorders Identification Test (Bohn et al., 1995), and a smoking history questionnaire. Medical records were reviewed for disease and treatment information. Toxicity of the chemotherapy regimen was evaluated using the MAX2 score (Extermann et al., 2004).

Measures used to create the cut points

The 12-item HHI measures various dimensions of hope (Herth, 1991, 1992). Each item was rated on a four-point Likert-type scale that ranges from 1 (strongly disagree) to 4 (strongly agree). The total HHI score can range from 12 to 48. Higher scores indicate higher levels of hope. In the current study, its Cronbach’s alpha was 0.86.

The 41-item Multidimensional QOL Scale–Patient Version (MQOLS-PV) assesses four dimensions of QOL (i.e., physical, psychological, social, and spiritual well-being) in patients with cancer, as well as a total QOL score. Each item was rated on a 0–10 numeric rating scale, with higher scores indicating a better QOL. The MQOLS-PV has established validity and reliability (Ferrell, 1995; Ferrell et al., 1995; Padilla et al., 1983, 1990). In the current study, the Cronbach’s alpha for the MQOLS-PV total score was 0.92.

Measures used to validate the cut points

The 14-item Perceived Stress Scale (PSS) was used as a measure of global perceived stress according to the degree that life circumstances are appraised as stressful during the course of the previous week (Cohen et al., 1983). Each item was rated on a 0–4 Likert-type scale (i.e., 0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, and 4 = very often). Total PSS scores can range from 0 to 56. In the current study, its Cronbach’s alpha was 0.89.

The 22-item Impact of Event Scale–Revised (IES-R) was used to measure cancer-related distress (Horowitz et al., 1979; Weiss & Marmar, 1997). Patients rated each item based on how distressing each potential difficulty was for them during the past week “with respect to their cancer and its treatment.” Each item was rated on a Likert-type scale ranging from 0 (not at all) to 4 (extremely). Three subscales evaluate levels of intrusion, avoidance, and hyperarousal perceived by the patient. The total score can range from 0 to 88. Sum scores of 24 or greater indicate clinically meaningful post-traumatic symptomatology, and scores of 33 or greater indicate probable PTSD (Creamer et al., 2003). In the current study, Cronbach’s alpha for the IES-R total score was 0.92.

The 30-item Life Stressor Checklist–Revised (LSC-R) is an index of lifetime trauma exposure (e.g., being mugged, sexual assault) (Wolfe & Kimerling, 1997). The LSC-R assesses whether each stressful event occurred, at what ages the events occurred, how many times each event occurred, how dangerous the event was, and whether the individual had an intense emotional reaction to the event(s). The total LSC-R score is obtained by summing the total number of events endorsed (range of 0–30). If the patient endorsed an event, the patient was asked to indicate how much that stressor affected their life in the past year, using a Likert-type scale that ranged from 1 (not at all) to 5 (extremely). These responses were summed to yield a total “affected” score. In addition, a PTSD sum score was created based on the number of positively endorsed items (of 21) that reflect the DSM-IV PTSD criteria A for having experienced a traumatic event.

The 10-item Connor–Davidson Resilience Scale (CDRS) evaluates a patient’s personal ability to handle adversity (e.g., “I am able to adapt when changes occur”) (Campbell-Sills & Stein, 2007; Connor & Davidson, 2003). Items are scored on a five-point Likert-type scale (“not true at all” to “true nearly all of the time”). Total scores range from 0 to 40, with higher scores indicative of higher self-perceived resilience. The normative adult mean score in the United States is 31.8 (SD = 5.4) (Campbell-Sills et al., 2009; Campbell-Sills & Stein, 2007), with an estimated minimal clinically important difference of 2.7 (Norman et al., 2003). In the current study, its Cronbach’s alpha was 0.9.

The 28-item Brief COPE was used to assess patients’ use of 14 coping strategies (Carver, 1997). Patients rated their use of each coping strategy “since beginning chemotherapy.” Use of each coping strategy was evaluated using two items. Each item was rated on a four-point Likert-type scale that ranged from 1 (“I have not been doing this at all”) to 4 (“I have been doing this a lot”). Scores for each coping strategy can range from 2 to 8, with higher scores indicating greater use of each strategy. Engagement coping strategies and their associated Cronbach’s alphas include active coping (0.75), planning (0.74), positive reframing (0.79), acceptance (0.68), humor (0.83), religion (0.92), emotional support (0.77), and instrumental support (0.77). Disengagement coping strategies and their associated Cronbach’s alphas include self-distraction (0.46), denial (0.72), venting (0.65), substance use (0.87), behavioral disengagement (0.57), and self-blame (0.73).

Data Analysis

Descriptive statistics and frequency distributions were generated for sample characteristics at enrollment using IBM SPSS Statistics, version 29.0. Cut points that divided the sample into lower and higher levels of hope were created using the analytic strategy of Serlin et al. (1995). Fourteen categorical variables, which represented the 14 possible combinations of cut points between 30 and 48, were created (see Table 1) and were related to the mean total score on the MQOLS-PV, using analysis of variance. The criterion that was used to determine the optimal set of cut points for the lower versus higher levels of hope was the analysis of variance that yielded the largest F ratio for the between-category effects. Differences among the hope groups in demographic and clinical characteristics and stress, resilience, and coping measures were evaluated using Independent Student t tests, as well as Mann–Whitney U, Fisher’s exact, and chi-square tests. A p value of < 0.05 was considered statistically significant.

TABLE 1.

Results of the Analysis to Determine the Optimal Cut Point for Lower and Higher Levels of Hope Using the HHI and the Total Score From the MQOLS-PV

Cut Pointsa Rank ANOVA F statistic
30, 31 14 125.251
31, 32 13 157.299
32, 33 12 202.829
33, 34 11 235.738
34, 35 10 282.336
35, 36 8 307.401
36, 37 8 335.702
37, 38 6 379.848
38, 39 4 417.069
39, 40 3 425.226
40, 41 1 448.098
41, 42 2 447.598
42, 43 6 397.257
43, 44 7 377.934
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a

For lower versus higher levels of hope

ANOVA—analysis of variance; HHI—Herth Hope Index; MQOLS-PV— Multidimensional Quality of Life Scale–Patient Version

Note. Bold indicates the optimal cut point.

Results

Cut Point Calculations

As shown in Table 1, of the 14 possible cut points evaluated, the optimal cut point with the largest F statistic was cut point 40, 41 (i.e., lower hope = 40 or less and higher hope = greater than 40). Using this cut point, of the 1,295 patients in the study, 629 (49%) were in the Lower Hope group and 666 (51%) were in the Higher Hope group.

Differences in Demographic and Clinical Characteristics

As shown in Table 2, compared to the Higher Hope group, patients in the Lower Hope group had fewer years of education and were less likely to be married or partnered, more likely to live alone, less likely to be employed, more likely to have a lower annual income, less likely to exercise on a regular basis, and more likely to report a current or past history of smoking. In addition, they had a lower Karnofsky Performance Status Scale score, a higher number of comorbidities, a higher Self-Administered Comorbidity Questionnaire score, a longer time since their cancer diagnosis, and a higher number of metastatic sites; were more likely to self-report lung disease, diabetes, depression, and back pain; and were less likely to receive a highly emetogenic chemotherapy regimen.

TABLE 2.

Differences in Demographic and Clinical Characteristics Between Patients With Lower and Higher Levels of Hope at Enrollment

Characteristic Lower Hope (≤ 40) (N = 629, 49%) Higher Hope (> 40) (N = 666, 51%) Statistics
X̄ SD X̄ SD
Age (years) 57.3 12.6 57 11.9 t = 0.52, p = 0.6
Education (years) 16.1 2.8 16.4 3.2 t = −2.11, p = 0.035
Body mass index (kg/m2) 26.3 5.9 26.1 5.3 t = 0.7, p = 0.484
Karnofsky Performance Status Scale score 77.8 12.5 82.2 12 t = −6.41, p < 0.001
Number of comorbidities (of 13) 2.6 1.5 2.2 1.4 t = 5.6, p < 0.001
Self-Administered Comorbidity Questionnaire score 6 3.4 5 3 t = 5.97, p < 0.001
Alcohol Use Disorders Identification Test score 3.1 2.7 2.9 2.3 t = 1.15, p = 0.126
Time since cancer diagnosis (years)a 2.2 4.2 1.8 3.6 U, p = 0.009
Number of prior cancer treatments 1.7 1.5 1.5 1.5 t = 1.36, p = 0.175
Number of metastatic sites including lymph node involvement 1.3 1.3 1.2 1.2 t = 1.71, p = 0.088
Number of metastatic sites excluding lymph node involvement 0.8 1.1 0.7 1 t = 1.99, p = 0.047
MAX2 score 0.17 0.08 0.18 0.08 t = −0.99, p = 0.325
Characteristic n % n % Statistics
Gender
Female 476 76 530 80 FE, p = 0.095
Ethnicity χ2 = 2.52, p = 0.472
Asian or Pacific Islander 72 12 89 14
Black 38 6 51 8
Hispanic, mixed, or other 67 11 70 11
White 442 71 450 68
Married or partnered
Yes 361 58 461 70 FE, p < 0.001
Lives alone
Yes 165 27 112 17 FE, p < 0.001
Childcare responsibilities
Yes 124 20 156 24 FE, p = 0.136
Care of adult responsibilities
Yes 47 8 46 8 FE, p = 0.633
Currently employed
Yes 184 29 267 41 FE, p < 0.001
Annual household income ($) U, p < 0.001
< 30,000 137 24 76 13
30,000 to < 70,000 136 24 112 19
70,000 to < 100,000 81 14 111 19
100,000 or greater 215 38 292 49
Chronic conditions
Heart disease 42 7 31 5 FE, p = 0.119
High blood pressure 203 32 185 28 FE, p = 0.079
Lung disease 87 14 62 9 FE, p = 0.012
Diabetes 68 11 47 7 FE, p = 0.019
Ulcer or stomach disease 37 6 27 4 FE, p = 0.158
Kidney disease 12 2 7 1 FE, p = 0.25
Liver disease 38 6 44 7 FE, p = 0.732
Anemia or blood disease 79 13 80 12 FE, p = 0.8
Depression 184 29 65 10 FE, p < 0.001
Osteoarthritis 82 13 72 11 FE, p = 0.23
Back pain 177 28 154 23 FE, p = 0.041
Rheumatoid arthritis 19 3 22 3 FE, p = 0.874
Exercise on a regular basis
Yes 411 67 489 75 FE, p = 0.002
Current or past history of smoking
Yes 250 41 202 31 FE, p < 0.001
Cancer diagnosis χ2 = 4.74, p = 0.192
Breast 241 38 282 42
Gastrointestinal 205 33 187 28
Gynecologic 104 17 123 19
Lung 79 13 74 11
Type of prior cancer treatment χ2 = 4.05, p = 0.256
No prior treatment 145 24 170 26
Only surgery, CTX, or RT 251 41 278 43
Surgery and CTX, or surgery and RT, or CTX and RT 126 21 128 20
Surgery and CTX and RT 91 15 74 11
Metastatic sites χ2 = 3.79, p = 0.285
No metastasis 199 32 219 33
Only lymph nodes 125 20 156 24
Only non-lymph nodes 132 21 135 21
Lymph nodes and other sites 164 27 150 23
Cycle length U, p = 0.418
14-day cycle 254 41 280 42
21-day cycle 321 51 338 51
28-day cycle 50 8 44 7
Emetogenicity of the CTX regimen U, p < 0.001
Minimal/low 148 24 104 16
Moderate 369 59 417 63
High 109 17 141 21
Antiemetic regimen χ2 = 1.19, p = 0.755
None 43 7 43 7
Steroid alone or serotonin antagonist alone 123 20 139 21
Serotonin antagonist and steroid 285 47 317 49
Neurokinin 1 receptor antagonist and 2 other antiemetics 156 26 152 23
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a

The median time since cancer diagnosis was 0.46 years for the Lower Hope group and 0.4 years for the Higher Hope group.

CTX—chemotherapy; FE—Fisher’s exact test; RT—radiation therapy; U—Mann–Whitney U test

Note. Because of rounding, percentages may not total 100.

Differences in QOL

As shown in Figure 1, compared to the Higher Hope group, for all of the subscale and total scores on the MQOLS-PV, patients in the Lower Hope group reported significantly lower scores (all p < 0.001).

FIGURE 1.

FIGURE 1

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Differences in MQOLS-PV Scores for the Physical, Psychological, Social, and Spiritual Well-Being Domains and Total QOL Between Patients With Lower Versus Higher Levels of Hope

MQOLS-PV— Multidimensional Quality of Life Scale– Patient Version; QOL—quality of life; SD—standard deviation

Note. All values are plotted as means and SDs. Compared to the Higher Hope group, for all of the subscale and total scores on the MQOLS-PV, patients in the Lower Hope group reported significantly lower scores (all p < 0.001).

Differences in Hope, Stress, and Resilience

As expected, the mean HHI score was significantly different between the two groups (see Table 3). Compared to the Higher Hope group, patients in the Lower Hope group reported significantly higher scores for all the measures of global, cancer-related, and cumulative life stress. In addition, they reported lower CDRS scores.

TABLE 3.

Differences in Hope, Stress, and Resilience Scores at Enrollment Between Patients With Lower and Higher Levels of Hope

Measurea Lower Hope (≤ 40) (N = 629, 49%) Higher Hope (> 40) (N = 666, 51%) Statistics
X̄ SD X̄ SD
HHI score 35.7 3.6 44.7 2.2 t = −53.82, p < 0.001
PSS total score (range = 0–56) 22.7 7.7 14.5 6.4 t = 20.55, p < 0.001
IES-R total sum score (≥ 24 = clinically meaningful PTSD symptomatology) (≥ 33 = probable PTSD) 23.2 14 14.6 10.8 t = 12.25, p < 0.001
 IES-R intrusion 1.1 0.7 0.7 0.6 t = 11.99, p < 0.001
 IES-R avoidance 1.1 0.7 0.8 0.6 t = 7.68, p < 0.001
 IES-R hyperarousal 0.9 0.7 0.4 0.5 t = 12.24, p < 0.001
LSC-R total score (range = 0–30) 6.5 4.2 5.8 3.7 t = 2.87, p = 0.004
LSC-R affected sum (range = 0–150) 13.7 12.3 10.3 9.2 t = 5.03, p < 0.001
LSC-R PTSD sum (range = 0–21) 3.4 3.2 2.8 2.9 t = 3.24, p = 0.001
CDRS total score (X̄ = 31.8, SD = 5.4 = normative score for the U.S. population) 26.7 6.1 33.3 4.8 t = −21.36, p < 0.001
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a

Clinically meaningful cutoff scores or range of scores in parentheses

CDRS—Connor–Davidson Resilience Scale; HHI—Herth Hope Index; IES-R—Impact of Event Scale–Revised; LSC-R—Life Stressor Checklist–Revised; PSS—Perceived Stress Scale; PTSD—post-traumatic stress disorder

Differences in Occurrence of Stressful Life Events

Compared to the Higher Hope group, patients in the Lower Hope group reported significantly higher occurrence rates for family violence in childhood, serious money problems, having a serious physical or mental handicap not related to cancer, having seen a robbery or mugging, and having been robbed or mugged (see Table 4).

TABLE 4.

Differences in the Percentage of Patients With Lower and Higher Levels of Hope Who Were Exposed to Specific Stressors

Stressful Life Event Lower Hope (≤ 40) (N = 629, 49%) Higher Hope (> 40) (N = 666, 51%) Statistics
n % n %
Interpersonal violence, abuse, and neglect
Family violence in childhood 128 27 111 21 FE, p = 0.038
Emotional abuse 115 24 107 20 FE, p = 0.129
Physical neglect 24 5 26 5 FE, p = 1
Sexual harassment 97 20 86 16 FE, p = 0.12
Physical abuse (age younger than 16 years) 74 15 73 14 FE, p = 0.532
Physical abuse (age 16 years or older) 70 15 65 12 FE, p = 0.308
Forced to touch (age younger than 16 years) 63 13 54 10 FE, p = 0.168
Forced to touch (age 16 years or older) 36 8 26 5 FE, p = 0.089
Forced sex (age younger than 16 years) 21 4 24 5 FE, p = 1
Forced sex (age 16 years or older) 34 7 31 6 FE, p = 0.443
Other stressors
Been in serious disaster 197 41 219 41 FE, p = 0.898
Seen serious accident 149 31 184 35 FE, p = 0.228
Had serious accident or injury 120 25 126 24 FE, p = 0.714
Jail (family member) 109 23 99 19 FE, p = 0.119
Jail (self) 38 8 31 6 FE, p = 0.213
Foster care or put up for adoption 12 3 12 2 FE, p = 0.838
Separated/divorced (parents) 114 24 107 20 FE, p = 0.196
Separated/divorced (self) 186 39 183 34 FE, p = 0.151
Serious money problems 115 24 85 16 FE, p = 0.002
Had serious physical or mental illness (not cancer) 113 23 84 16 FE, p = 0.003
Abortion or miscarriage 169 46 182 43 FE, p = 0.431
Separated from child 11 2 9 2 FE, p = 0.505
Care for child with handicap 17 4 20 4 FE, p = 0.868
Care for someone with severe physical or mental handicap 120 25 124 24 FE, p = 0.606
Death of someone close (sudden) 246 52 253 48 FE, p = 0.282
Death of someone close (not sudden) 376 79 413 79 FE, p = 1
Seen robbery/mugging 120 25 104 20 FE, p = 0.049
Been robbed/mugged 143 30 126 24 FE, p = 0.033
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FE—Fisher’s exact test

Differences in the Effect of Stressful Life Events

In terms of the effects of stressors associated with interpersonal violence, abuse, and neglect (see Table 5), compared to the Higher Hope group, patients in the Lower Hope group reported significantly higher effect scores for emotional abuse, physical abuse at age 16 years or older, being forced to touch at age younger than 16 years and age 16 years or older, and being forced to have sex at age younger than 16 years. In terms of other stressors, patients in the Lower Hope group reported significantly higher effect scores for being in a serious accident, seeing a serious accident, being separated or divorced, having serious money problems, having a serious physical or mental illness not related to cancer, having an abortion or miscarriage, being separated from a child, caring for someone with a severe physical or mental handicap, and the not sudden or sudden death of someone close.

TABLE 5.

Differences Between the Patients With Lower and Higher Levels of Hope in the Effect of Stressors on Life in the Past Yeara

Stressful Life Eventb Lower Hope (≤ 40) (N = 629, 49%) Higher Hope (> 40) (N = 666, 51%) Statistics
X̄b SD X̄b SD
Interpersonal violence, abuse, and neglect
Family violence in childhood 2 1.2 1.8 1.2 U, p = 0.239
Emotional abuse 2.8 1.2 2.3 1.4 U, p = 0.001
Physical neglect 3.1 1.3 2.5 1.3 U, p = 0.091
Sexual harassment 1.5 0.9 1.5 1 U, p = 0.438
Physical abuse (age younger than 16 years) 2.1 1.2 1.8 1.3 U, p = 0.101
Physical abuse (age 16 years or older) 2 1.2 1.7 1.2 U, p = 0.036
Forced to touch (age younger than 16 years) 2.2 1.4 1.8 1.3 U, p = 0.049
Forced to touch (age 16 years or older) 2.1 1.3 1.6 1.1 U, p = 0.039
Forced sex (age younger than 16 years) 2.6 1.5 1.5 0.8 U, p = 0.007
Forced sex (age 16 years or older) 1.9 1.2 1.7 1.2 U, p = 0.263
Other stressors
Been in serious disaster 1.5 0.9 1.2 0.7 U, p < 0.001
Seen serious accident 1.5 0.9 1.4 0.8 U, p = 0.025
Had serious accident or injury 1.7 1.1 1.5 0.9 U, p = 0.066
Jail (family member) 2.1 1.5 1.7 1.2 U, p = 0.096
Jail (self) 1.9 1.3 1.5 1.1 U, p = 0.152
Foster care or put up for adoption 2.4 1.6 2.3 1.4 U, p = 0.923
Separated/divorced (parents) 1.9 1.2 1.7 1 U, p = 0.492
Separated/divorced (self) 2.3 1.4 1.9 1.3 U, p < 0.001
Serious money problems 2.9 1.7 2.3 1.5 U, p = 0.017
Had serious physical or mental illness (not cancer) 2.7 1.3 2.2 1.4 U, p = 0.005
Abortion or miscarriage 1.7 1.2 1.4 0.8 U, p = 0.006
Separated from child 3.6 1.5 1.9 1.2 U, p = 0.016
Care for child with handicap 3.5 1.3 3.1 1.4 U, p = 0.341
Care for someone with severe physical or mental handicap 2.7 1.5 2.4 1.5 U, p = 0.033
Death of someone close (sudden) 2.4 1.4 2 1.3 U, p < 0.001
Death of someone close (not sudden) 2.4 1.4 2 1.2 U, p < 0.001
Seen robbery/mugging 1.6 1 1.5 1 U, p = 0.111
Been robbed/mugged 1.7 1.1 1.6 1.1 U, p = 0.663
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a

These data are reported for patients who reported the occurrence of the stressor (see Table 4).

b

Range = 1 (not at all) to 5 (extremely)

U—Mann–Whitney U test

Differences in Coping

In terms of the engagement coping strategies (see Table 6), compared to the Higher Hope group, patients in the Lower Hope group reported significantly lower scores for the use of active coping, planning, positive reframing, acceptance, humor, religion, using emotional support, and using instrumental support. In terms of the disengagement coping strategies, patients in the Lower Hope group reported significantly higher scores for the use of denial, venting, substance use, behavioral disengagement, and self-blame.

TABLE 6.

Differences in the Brief COPE Subscale Scores Between the Patients With Lower and Higher Levels of Hope

Subscalea Lower Hope (≤ 40) (N = 629, 49%) Higher Hope (> 40) (N = 666, 51%) Statistics
X̄ SD X̄ SD
Engagement coping strategies
Active coping 5.5 1.6 6.5 1.6 t = −10.83, p < 0.001
Planning 5.1 1.7 5.5 1.9 t = −3.44, p < 0.001
Positive reframing 4.9 1.8 5.9 1.9 t = −9.71, p < 0.001
Acceptance 6.4 1.4 7 1.2 t = −9.06, p < 0.001
Humor 4.2 1.9 4.5 2 t = −2.6, p = 0.009
Religion 4.5 2.2 5.5 2.3 t = −7.65, p < 0.001
Using emotional support 6 1.7 6.6 1.6 t = −6.08, p < 0.001
Using instrumental support 5.1 1.7 5.5 1.8 t = −3.75, p < 0.001
Disengagement coping strategies
Self-distraction 5.5 1.6 5.5 1.8 t = 0.5, p = 0.617
Denial 2.7 1.2 2.3 0.9 t = 5.2, p < 0.001
Venting 4.1 1.6 3.9 1.7 t = 2.6, p < 0.009
Substance use 2.3 0.8 2.2 0.7 t = 2.35, p = 0.019
Behavioral disengagement 2.4 0.9 2.1 0.5 t = 7.34, p < 0.001
Self-blame 3.2 1.5 2.5 0.9 t = 10.63, p < 0.001
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a

Each item was rated on a 4-point Likert-type scale that ranged from 1 (I have not been doing this at all) to 4 (I have been doing this a lot). Each coping strategy is evaluated using 2 items. Scores can range from 2 to 8, with higher scores indicating greater use of each of the coping strategies.

Discussion

This study is the first to identify clinically meaningful cut points for the HHI in a large sample of outpatients receiving chemotherapy. Using this previously reported analytic method with total MQOLS-PV scores (Miaskowski et al., 2022; Paul et al., 2005; Serlin et al., 1995), two distinct cut points were determined (i.e., 40 or less versus greater than 40) and validated using measures of stress, resilience, and coping. Although direct comparisons cannot be made, the mean HHI score of 40.3 (median = 41, range = 14–48) for the total sample is slightly higher than the 36.9 (range of scores = 30.8–40.3) reported in one systematic review (Salimi et al., 2022). In addition, it is higher than the mean scores of 36.1 and 31.8 reported in studies of patients with gastric cancer (Wu et al., 2021) and cervical cancer (Li et al., 2017), respectively. In terms of the MQOLS-PV, it should be noted that the differences between the Lower Hope and Higher Hope groups in all of its subscale and total scores represent not only statistically significant but also clinically meaningful differences in all of the domains of QOL, as well as the patients’ overall appraisal of their QOL (i.e., physical well-being [d = −0.51], psychological well-being [d = −0.97], social well-being [d = −0.65], spiritual well-being [d = −0.73], and overall QOL [d = −1.03]) (Guyatt et al., 2002). Additional research is warranted to confirm the current study’s validated cut points in patients with different types of cancer; in patients receiving different types of cancer treatment; in patients at different stages across the continuum of cancer care (e.g., survivorship, palliative care); and with a different QOL measure or other clinically meaningful patient-reported outcome.

Demographic and Clinical Characteristics

As shown in Table 2, a number of demographic and clinical characteristics were associated with lower levels of hope. Although the majority of studies included in the two systematic reviews found no correlations (Kitashita & Suzuki, 2023; Nierop-van Baalen et al., 2020), the current authors’ findings are consistent with two studies that found that lower levels of education were associated with lower levels of hope (Li et al., 2021; Wakiuchi et al., 2015). Consistent with previous studies, patients who lived alone (Sabanciogullari & Yilmaz, 2021) or were not married or partnered (Li et al., 2021) reported lower levels of hope. These relationships may be partially explained by a lack of social support (Zhang et al., 2010) and/or feelings of social isolation (Paun, 2022) or loneliness (Li et al., 2024; Yu et al., 2022; Yu & Song, 2022). Although one study did not confirm the current authors’ association with employment status (Zhang et al., 2010), in two studies (Kavradim et al., 2013; Zhang et al., 2010), a lower income was associated with lower levels of hope. This association may be related to the added stress associated with the lack of financial resources to adequately manage treatments for cancer and other chronic conditions (Hussaini et al., 2022).

Associations between levels of hope and clinical characteristics warrant consideration. Although no associations were found with type of cancer, consistent with a previous report (Wakiuchi et al., 2015), patients in the Lower Hope group had an increased number of metastatic sites and a longer median time since their cancer diagnosis. Equally important and not reported previously, a higher number of comorbid conditions, a higher overall comorbidity burden, and a poorer functional status were associated with membership in the Lower Hope group. These findings are extremely important given that 40%–69% of patients with cancer experience multimorbidity (i.e., two or more chronic conditions) (Haase et al., 2021; Johnston et al., 2019; Søgaard et al., 2013).

In terms of specific chronic conditions, a higher percentage of patients in the Lower Hope group reported diabetes, back pain, lung disease, and depression. Although no studies of patients with cancer reported on associations with diabetes, several studies identified that this chronic condition is associated with feelings of hopelessness (Tok Özen et al., 2024; Winarsunu et al., 2023) as well as with feelings of depression (Robert et al., 2023). Similar associations were found between feelings of hopelessness and depression in patients with low back pain (Bener et al., 2013; Hülsebusch et al., 2016).

Although the causes of lung disease in the current sample are not known, evidence suggests that complex relationships exist between feelings of hopelessness and depressive symptoms in patients with chronic obstructive pulmonary disease (Andersen et al., 2018; Schuler et al., 2018). This association may be linked to the higher percentage of patients in the Lower Hope group who reported a current or past history of smoking. Although previous research has not linked cigarette smoking to hope or hopelessness, the stigma associated with smoking is positively correlated with higher levels of depressive symptoms (Brown Johnson et al., 2014; Maguire et al., 2019).

The current findings regarding depression are consistent with previous reports in patients with cancer (Balsanelli & Grossi, 2016; Schofield et al., 2016; Sjoquist et al., 2013). This association may be partially explained by the concept of demoralization. As noted in one review (Fava et al., 2023), 36%–52% of patients with cancer exhibit demoralization syndrome. This syndrome is characterized by despair, hopelessness, helplessness, and persistent inability to cope. The authors noted that although a considerable overlap exists between the symptoms of depression and demoralization, they are distinct conditions. One of the mechanistic hypotheses for demoralization is that the recurrent stress from a cancer diagnosis and its treatments increases a patient’s allostatic load (i.e., cumulative biologic burden exacted on the body because of repeated adaptation to stressors over time [McEwen, 2017]). This hypothesis is supported by the additional findings in the current study regarding stress and coping.

Stress

As noted in the Introduction, limited information is available on the associations between hope and stress in patients with cancer (Li et al., 2017; Zhang et al., 2021). As expected, scores for all three types of stress were higher in the Lower Hope group. Although no clinically meaningful cut point exists for the PSS, the score of 22.7 reported by the Lower Hope group is slightly higher than the average of 21.8 reported by patients with advanced gastrointestinal cancer (Miceli et al., 2019) and the mean scores of 18.8 and 20.2 reported by male and female participants, respectively, in a probability sample drawn from the U.S. population (Cohen & Williamson, 1988).

In terms of the IES-R total score, a measure of cancer-specific stress, compared to the Higher Hope group, a higher percentage of patients in the Lower Hope group met the criteria for clinically meaningful PTSD symptomatology (16.7% versus 42.9%) and probable PTSD (6% versus 16.7%). This finding is consistent with a review that noted that lower levels of hope were associated with higher rates of PTSD (Long, 2022). Given that the prevalence rates for PTSD in patients with cancer range from 7.3% to 13.8% (Abbey et al., 2015), these findings suggest that clinicians need to assess for PTSD symptoms in patients undergoing chemotherapy, evaluate its relationship with levels of hope, and make referrals for psychological services.

Findings from the LSC-R provide important information on the specific life stressors that may contribute to lower levels of hope in patients with cancer. Consistent with a previous study of healthy adults (Mefford et al., 2021), stressful life events, including ACEs, are risk factors for lower levels of hope. In terms of specific stressors associated with interpersonal violence, abuse, and neglect (that are often characterized as ACEs), only family violence in childhood had a higher occurrence rate in the Lower Hope group. However, five of the ACEs had higher effect scores in this group of patients (i.e., emotional abuse, physical abuse at age 16 years or older, forced to touch at age younger than 16 years and 16 years or older, and forced sex at age younger than 16 years). ACEs are defined as traumatic experiences that overwhelm an individual’s ability to cope. ACEs are associated with poorer physical and mental health outcomes. In addition, they impair an individual’s ability to develop positive coping skills and behaviors (Gardner et al., 2019; Petruccelli et al., 2019).

Resilience

Consistent with reviews of patients with colorectal cancer (Sihvola et al., 2022) and other chronic conditions (Stewart & Yuen, 2011), patients in the Lower Hope group reported lower resilience scores. In fact, this group’s CDRS scores were lower than the normative score for the general population of the United States. Resilience is a positive characteristic that is used by patients to cope with their cancer and its treatments (Axelsson et al., 2018; Mohlin et al., 2020). However, as noted in one review (Ong et al., 2023), although an understanding of hope as a source of resilience is an active area of research, additional research is warranted to understand the complex relationships among hope, stress, and resilience.

Coping

Except for self-distraction, patients in the Lower Hope group had lower scores for the use of engagement coping strategies and higher scores for the use of disengagement coping strategies. These results are consistent with a study of patients with lung cancer that found that individuals who did not use positive coping strategies (e.g., task-oriented coping, social diversion) and who used disengagement coping strategies (e.g., denial, substance use, self-blame, behavioral disengagement) reported lower levels of hope (Bando et al., 2018).

As noted in two reviews (Li et al., 2017; Zhang et al., 2021), most of the research on the relationship between hope and coping focused on religiosity and spirituality. Specifically, higher levels of hope were associated with higher levels of religiousness (Ripamonti et al., 2016) and trust in religion (Proserpio et al., 2015). Although no relationship was found between hope and any religious affiliation (Rawdin et al., 2013), these findings suggest that some patients may benefit from referrals to pastoral services for support.

Limitations

Although this study included patients with heterogeneous types of cancer, the sample was primarily female, White, and well educated, which limits the generalizability of the findings. Given that evidence from the Health and Retirement Study suggests that the relationship between hopefulness and allostatic load is influenced by self-reported race and ethnicity (Mitchell et al., 2020), future studies need to include more diverse samples and evaluate for associations with other social determinants of health. In addition, given the study’s cross-sectional design, to demonstrate causal relationships between and among hope, stress, resilience, and coping, longitudinal studies are warranted. Equally important, the cut points for the HHI warrant confirmation at different points across the continuum of cancer care (e.g., time of diagnosis, time of recurrence, transition to palliative care).

Implications for Clinical Practice and Research

Findings from this study have numerous implications for clinical practice and research. As noted by Kenny et al. (2023), in the era of precision oncology, the “parameters of hope” are being reconfigured for patients and their family caregivers. Clinicians need to assist patients and family caregivers to understand how to have “realistic levels of hope” in the context of medical advances. Given the complex relationships identified in this study among hope, stress, resilience, and coping, clinicians need to assess patients’ level of stress and experiences with ACEs, as well as their use of various coping strategies. Once these assessments are completed, clinicians need to provide referrals for the most appropriate and targeted interventions to increase hope (e.g., healthcare communication that authentically conveys prognosis [Feldman & Corn, 2023]), decrease stress (e.g., mindfulness-based stress reduction [Pedro et al., 2021], psychological counseling), improve resilience (Wang et al., 2023), and enhance the use of engagement-type coping behaviors (Pieczynski et al., 2020; Yeganeh et al., 2024). Equally important, patients may require referral for financial counseling.

As noted previously, longitudinal studies are needed to evaluate for differences in levels of hope among patients with different types of cancer and how hope changes at different times during the trajectory of cancer care. Additional research is needed on the most effective interventions to increase hope and enhance patients’ ability to cope with the stress associated with cancer and its treatments. Equally important, studies are needed that determine the underlying mechanisms associated with interindividual differences in hope, stress, and resilience and the interactions among these concepts. This research will allow for the tailoring of interventions to meet patients’ unique needs.

KNOWLEDGE TRANSLATION.

  • ■ Patients in the Lower Hope group reported a higher comorbidity burden and a lower functional status that warrants evaluation and referral to physical therapy.

  • ■ Patients in the Lower Hope group reported higher levels of global, cancer-specific, and cumulative life stress as well as significant effects from stressors that can be categorized as adverse childhood experiences.

  • ■ Clinicians need to assist patients and family caregivers to understand how they can have “realistic levels of hope” in the context of medical advances.

Funding Statement

This study was funded, in part, by a grant from the National Cancer Institute (CA134900).

Footnotes

This study was funded, in part, by a grant from the National Cancer Institute (CA134900). Miaskowski is an American Cancer Society Clinical Research Professor.

Conley and Miaskowski contributed to the conceptualization and design. Miaskowski completed the data collection. Paul, Cooper, and Miaskowski provided statistical support. Allaire, Conley, Cooper, and Miaskowski provided the analysis. Allaire, Block, Mark, Hammer, Conley, Levine, and Miaskowski contributed to the manuscript preparation.

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