Abstract
-
Purpose
Colorectal cancer (CRC) survivors face significant challenges after completing treatment, including returning to work, concerns about the future, and financial difficulties. Understanding how inner strength developed after treatment affects survivors’ lives is crucial for informing patient-centered care. This study explored the unique inner strength exhibited by CRC survivors during their transition to a “new normal.”
-
Methods
We recruited 16 patients from Korea who had completed treatment, to explore their experiences of managing their health. We conducted a qualitative study from July 4, 2022 to July 25, 2022 using individual interviews and directed content analysis. Transcribed interview data were analyzed to interpret meaning from the data, consistent with the naturalistic paradigm.
-
Results
Participants described their transition to a new normal by reframing the cancer experience, struggling to return to normal life, experiencing growth promoted by supportive relationships, and encountering both positive and negative life changes. Throughout these experiences as survivors, inner strength played a critical role in adapting to a new normal.
-
Conclusion
Our findings suggest that inner strength serves as a dynamic psychological resource, enabling CRC survivors to reframe their illness, regain disrupted roles, and reconstruct a meaningful life despite ongoing physical and emotional challenges. In doing so, inner strength facilitates their adaptation to a new normal.
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Key Words: Colorectal neoplasms; Qualitative research; Quality of life; Cancer survivors
INTRODUCTION
Unlike other illnesses, cancer leads to profound changes in one’s life, making a full return to pre-cancer existence ultimately unattainable. Consequently, survivors must forge new lives or adapt to changed circumstances, a process often defined as achieving a “new normal” [
1-
3]. The term “new normal” refers to the standards that arise in response to changing times and contexts. Within this framework, life events and adaptive processes can be understood through the theory of inner strength, which posits that inner strength enables individuals to achieve a new normal and, in turn, influences their quality of life (QOL) [
3].
Inner strength is defined as an individual’s ability to overcome adversity and promote well-being during life-altering events [
4]. Most studies have focused on women’s inner strength when establishing this concept [
5]. For example, Roux et al. [
6] developed a middle-range theory of inner strength using conceptual analysis and meta-synthesis based on qualitative research on women. Further, Roux et al. [
7] expanded the theory, identifying key components such as “anguish and searching,” “connectedness,” “engagement,” and “movement.” Inner strength has been shown to be an important factor in improving the QOL of female patients with breast and lung cancer [
5,
8,
9].
Smith [
10] noted that while inner strength theory was originally developed from women’s experiences, it is also highly relevant to men. Inner strength has been found to play a crucial role in male colorectal cancer (CRC) survivors as well [
11]. However, research specifically investigating men’s inner strength remains limited, aside from some qualitative studies on aging. Among male and female CRC survivors, differences exist not only in QOL but also in the specific symptoms emphasized. Women more often report lower sexual and physical QOL compared to men, while men are more likely to focus on psychological issues [
12-
14]. This underscores the need to listen to the voices of both male and female CRC survivors regarding the role of inner strength in their lives.
Long-term dietary management and bowel issues often occur after CRC treatment, which can restrict daily activities and diminish QOL, making adaptation to a new normal particularly challenging [
15]. In addition to coping with physical symptoms, it is essential to investigate the factors that influence survivors’ lives and inner strength. A cross-sectional study examining inner strength among CRC survivors of both genders found that its characteristics varied by gender and the presence of an ostomy [
11].
While quantitative research is valuable for identifying patterns and group differences—such as those based on gender or ostomy status—it is limited in capturing the nuanced, lived experiences of individuals, especially regarding inner strength and life adaptation. Therefore, a qualitative approach grounded in inner strength theory is necessary to gain an in-depth understanding of how CRC survivors construct meaning and navigate life following diagnosis and treatment.
This study aimed to explore the lived experiences and inner strength of CRC survivors, seeking to verify and expand the application of inner strength theory in this population. By focusing on the adaptation processes of CRC survivors, this research sought to illuminate the internal mechanisms that foster resilience and adjustment, thereby addressing a critical gap in survivorship research. The central research question was: “What is the role of inner strength in the adaptation experiences of CRC survivors after cancer diagnosis?”
METHODS
1. Study Design
A qualitative method utilizing a directed content analysis approach was selected. Following Hsieh and Shannon [
16], who recommend directed content analysis for validating or conceptually extending an existing theory or framework, this study applied and extended the theory of inner strength to CRC survivors of both sexes. Existing theory and research helped focus the research question and guided the identification of key concepts or variables as initial coding categories [
16].
The sample included 16 CRC survivors aged 18 years or older who had been diagnosed with cancer and had completed either internal or surgical treatment. In this study, the term “cancer survivor” refers to individuals who have been diagnosed with cancer, regardless of stage or disease progression, consistent with the American Cancer Society’s definition. Participants were recruited through an online self-help group community for CRC survivors in Korea.
Table 1 presents detailed participant information, including assigned codes for sex, age, marital status, religion, occupation, pathological diagnosis, stage, time since diagnosis, and ostomy status.
A total of 17 participants were initially recruited, but one withdrew consent and was excluded. Ultimately, 16 participants completed interviews. To clarify ambiguities and confirm data saturation, follow-up interviews were conducted with participants who consented. Data collection concluded once saturation was reached.
3. Data Collection
An information sheet and consent form were posted on an online self-help group platform for CRC survivors. The form outlined the study’s purpose and procedures, emphasizing the importance of anonymity and confidentiality. Those who agreed to participate completed a self-reported survey after submitting the consent form. Before the interview, participants filled out a questionnaire to confirm their CRC diagnosis, including questions about the timing of their diagnosis and medical history.
The first author conducted all interviews from July 4 to July 25, 2022. Prior to the main study, a pilot test was performed to refine the interview process and ensure methodological rigor, involving five CRC survivors and focusing on their experiences of inner strength. No prior relationships existed between the interviewer and participants. Due to coronavirus disease 2019 (COVID-19) restrictions, all interviews were conducted by telephone. To enhance data richness and trustworthiness, strategies such as member checking, peer debriefing, and maintaining detailed field notes immediately after each interview were employed.
After scheduling interviews with consenting participants, telephone interviews were held at predetermined times. Verbal consent was reconfirmed before recording, and participants were informed about data management and security. In second-round interviews, participants were asked to verify the researchers’ interpretation of their first interview and to elaborate on key points as needed. Each interview lasted approximately 60 minutes and followed a semi-structured format to balance consistency and flexibility. Interview questions were based on participants’ experiences with CRC and grounded in the theory of inner strength; specific questions are provided in
Appendix 1. Participants received an honorarium in recognition of their time.
This study was approved by the Institutional Review Board of Chung-Ang University (approval no. 1041078-202203-HR-066). The consent form posted online detailed the study’s purpose and procedures, emphasizing anonymity, confidentiality, and voluntary participation. Participants were informed that interview notes would be used solely for research purposes and that they could withdraw from the study at any time. This information was reiterated before the initial interview. Prior to the interview, the recording process was explained, and verbal consent was obtained. All research materials, including case records, were encrypted and securely stored in the researcher’s private office, with access limited to the research team.
5. Data Analysis
Semi-structured, in-depth interviews were conducted. Participants responded to questions related to the theory of inner strength, focusing primarily on adaptation experiences and sources of inner strength. Interview questions were not provided to participants in advance. All interviews were recorded, transcribed verbatim, reviewed, coded, and analyzed independently by two investigators. Following established strategies for directed qualitative content analysis [
16], each transcript was read multiple times for thorough understanding. Significant statements were highlighted to identify initial codes or meaning units within the text. Texts that did not fit the initial coding scheme were assigned new codes. Data collection continued until saturation, when no new information emerged from additional interviews. Participants were reassured regarding confidentiality and anonymity. The authors certify compliance with the principles of ethical publishing. The Consolidated Criteria for Reporting Qualitative Research (COREQ) [
17] were used for reporting study findings.
In developing and conducting our study on the inner strength of CRC survivors, we embraced a rigorous and reflexive approach to ensure the integrity and depth of our research. Our team engaged in thorough discussions regarding the study’s focus and carefully considered our wording throughout the development process to promote clarity and relevance. To maintain objectivity and enhance rigor, interviewers participated in frequent team meetings, kept reflective journals, and took detailed notes during and after each interview. These regular discussions provided a foundation for collective reflexivity, as we critically examined our roles in data collection and analysis and openly questioned and validated our interpretations of participants’ statements. This ongoing dialogue ensured that our findings were not simply individual perspectives, but were rigorously reviewed and shaped by the team’s collective insight. Ultimately, this process enabled us to approach the research with sensitivity, integrity, and a commitment to producing findings that are both trustworthy and genuinely reflective of the complexities of survivors’ inner strength.
RESULTS
The general characteristics of the participants are presented in
Table 1. Of the 16 participants, five were colon cancer survivors and eleven were rectal cancer survivors. Five had an ostomy, and three had previous experience with an ostomy and had undergone surgery. Analysis of the transcribed interviews yielded 605 codes, 45 categories, 15 sub-themes, and 4 overarching themes (
Table 2). Each theme was associated with the subcategories of “connectedness,” “engagement,” “anguish and searching,” and “movement” from the theory of inner strength [
3]. To ensure validity, the coding process was cross-checked by two researchers.
1) An unacceptable thing
Some participants experienced shock upon discovering they had cancer, questioning, “Why did this happen to me?” and attributing their diagnosis to past actions they viewed negatively. Male participants often confronted their cancer experience assertively, either by reframing it in a positive light or facing it head-on. In contrast, female participants tended to focus more on fears of recurrence or metastasis, concerns for their families after their death, and the difficulties of living with an ostomy.
I feel like I’m being punished by receiving a cancer diagnosis. It’s my fault. Receiving the diagnosis made me reflect on the past, the wrong things I did, you know, those times when you may have wronged someone. I felt like I was being punished for my wrongdoings. (#7)
2) Fear of death
After diagnosis and as acceptance began to set in, participants described an intense fear of death and contemplation of their own mortality. For some, the prospect of death was not daunting, but for most, it was a challenging concept, and they worried about the loved ones they might leave behind. Over time, however, a sense of hope and belief in the possibility of survival began to take root.
What if I die? I worry about my spouse and children I'll leave behind, thinking about the family I'll leave after I'm gone. However, with advancements in technology, could we potentially cure cancer? If so, I sometimes think, "Oh, maybe I could live longer." (#3)
3) The burden beyond treatment
Even as participants began to believe in the possibility of overcoming cancer, persistent symptoms continued to trouble them. Chemotherapy and radiation therapy were especially taxing. Unexpected events and constant anxiety about recurrence or metastasis added to their distress. While the early stages of treatment were manageable, ongoing symptoms, such as unpleasant odors and discomfort associated with CRC, became increasingly challenging.
During colorectal cancer treatment, I unexpectedly experienced a drop in platelets, preventing me from receiving cancer treatment. It was devastating. Having to undergo treatment but not progressing made it difficult. I also experienced side effects like diarrhea. It seemed I may have eaten something wrong. Unexpected incidents kept happening. (#9)
4) Knowing myself and cancer
Over time, participants sought to better understand cancer and confront the challenges it brought, rather than merely resigning themselves to their fate. Support from medical professionals was important in this process, but CRC survivors often felt they lacked sufficient information. Gradually, they came to see cancer as a disease rather than an insurmountable hardship or death sentence.
Accepting cancer as a disease, I think I’ve begun my second life with cancer, and I just live happily. (#2)
5) Grateful for my ostomy—indispensable!
Although living with an ostomy was initially daunting, participants gradually learned to manage their bodies and came to appreciate the benefits an ostomy could offer. At first, the ostomy was seen as an unwanted presence that damaged their body image. Over time, however, many adapted, gaining a sense of control and even gratitude. For those with permanent ostomies, a sense of shame sometimes persisted, but the ostomy had also become essential to their daily comfort and functioning.
Initially, survival was more critical to me. I was busy with treatments and surgeries, so I didn’t think deeply about the ostomy. But once I had it, meeting people became difficult. Socializing became challenging. Unexpected incidents like the ostomy bag suddenly leaking or bursting happened without warning. So, even though I wanted to meet people, I couldn’t go outside. If I wanted to meet people, I had to avoid gas-inducing foods the day before or not eat at all. Talking to people became exhausting. After eating something, gas would build up in the ostomy bag, preventing me from wearing my old clothes. But now, I manage my ostomy well without any difficulties. It’s not burdensome. (#1)
I thought that having a temporary ostomy would make everything okay again, like in the past. But after the reversal surgery, I had to go to the bathroom dozens of times. So, I asked to have an ostomy again. Now that I have the ostomy again, I can eat, and it’s so comfortable. I’m grateful to the ostomy. Living with an ostomy is better. I am grateful for my ostomy. (#7)
2. Theme 2: Struggle to Return to a Normal Life
1) Disrupted daily life
CRC survivors encountered persistent challenges in maintaining social relationships. Even long after diagnosis, the constant need to manage their diet and frequent trips to the toilet disrupted daily routines and made it difficult to leave home, especially due to concerns about the availability of nearby restrooms. This instilled a fear of venturing outside.
Once, I fainted while outside, and since then, I’ve been afraid of offline gatherings. (#15)
Since I stopped going to work, I’ve been using the bathroom 30–50 times a day. Although my daily life at home remained similar to pre-cancer days, I couldn’t go out at all. During the early days of frequent bathroom visits, I was emotionally overwhelmed. Owing to the toilet issue, I’m scared to go out. (#3)
Some survivors managed to retain their jobs, but for most, cancer significantly disrupted their work and sense of normalcy. For men, the inability to return to work often brought feelings of guilt about not being able to provide for their families.
After my cancer diagnosis, I couldn’t even do small jobs while going to the hospital. I need to earn money. If my body allows, I want to do even small tasks. (#12)
2) If you cannot avoid it, have a positive attitude
Upon accepting their cancer diagnosis, participants described a shift in their attitudes, moving toward a more positive mindset. This outlook was not limited to confronting cancer alone; at times, participants found comfort by comparing their situations to others’ misfortunes and expressed gratitude simply for being alive.
When I hear stories of others with colorectal cancer, those who have experienced metastasis or relapse, I feel comforted about my situation. I am okay now. (#5)
Living with thoughts of happiness, appreciating that there are people in more difficult situations, I am grateful for my current circumstances. Living positively, I enjoy my life with joy. (#7)
3) Belief that I can overcome cancer
Participants conveyed confidence in their ability to overcome cancer, drawing strength from family and friends, trust in medical professionals, or a sense of responsibility toward their families.
For me, the support of my family was helpful. Thanks to my family, I have confidence to overcome cancer. I am relatively quick to recover compared to others, so I want to work hard and live a healthy life. (#11)
4) Battle with myself
Participants emphasized their desire to fight cancer independently, relying on psychological determination to overcome it on their own terms. Sometimes, this meant choosing not to disclose their difficulties to others.
You have to manage yourself on your own. That’s how you can overcome it. Having the mental determination to fight and overcome cancer is crucial. (#16)
5) Ambivalence
Participants experienced ambivalence, simultaneously wanting to be treated as both cancer patients and as ordinary individuals. They found it difficult when others, especially their children, did not show the care or consideration they hoped for.
I disliked it when people treated me as a cancer patient or tried to comfort me. It was tough being treated as a cancer patient. (#6)
I think, outside, I don’t want to be treated as a cancer patient, but at home, I want consideration from my family. (#13)
3. Theme 3: Growth Promoted by Supportive Relationships
1) Support entwined with guilt as a source of strength
Enduring the challenges of CRC was possible due to support from various relationships. However, rather than feeling only gratitude, participants frequently experienced a sense of guilt for the help they received.
I’ve been sick for a long time. My husband suffered while taking care of me. I’m truly grateful to my husband. There’s a part of me that feels sorry because my husband couldn’t really work properly due to him taking care of me, causing financial difficulties. (#10)
2) Prayer to the trustworthy
Spiritual beliefs and prayer served as important sources of strength. Participants, including those without formal religious affiliations, reported praying for their health or their families, and found comfort in the prayers of others. Notably, even among female participants without a religious background, prayer became a means of emotional support during difficult times.
I’m not religious. However, when I was first diagnosed with cancer, I prayed. I prayed to God, Buddha—everything. I prayed for my health. Praying during really difficult times became a great source of strength for me. (#5)
4. Theme 4: Well-being
1) Interpersonal interaction
The COVID-19 pandemic further complicated socialization for CRC survivors, who turned to online meetings as alternatives to in-person gatherings. While interactions—both offline and online—could be challenging and sometimes had negative outcomes, participation generally had a positive impact. Female participants expressed dissatisfaction with the lack of both online and offline interaction, emphasizing the value of face-to-face connections. In contrast, male participants tended to be more active in online groups but preferred not to reveal their difficulties, coping with challenges more independently.
Being alone makes me feel down. Having meetings, doing exercises, and going out a bit release endorphin. After going out and returning, household chores feel more manageable. (#4)
During online meetings, I often hear bad news from colorectal cancer patients. I can handle bad news from fellow cancer patients without it really bothering me. I don’t care. Moreover, sharing various information about disease in meetings is helpful, I think. (#15)
2) Balance of body and mind
Achieving a balance between body and mind was crucial for participants. Many exercised, rested, and practiced healthy eating habits after diagnosis.
After being diagnosed with colorectal cancer, I quit my job, but recently I started working again. In reality, I want to rest a bit more, due to financial issues, I resumed work. But when taking a break, I listen to music and entrust my body, which improves my mood. (#8)
My days feel short. Working, exercising, resting – I think I’m using my time well these days. (#9)
3) Living a new normal
While many aspired to return to their pre-cancer lives, various challenges made this impossible. Ultimately, participants began to create new paths for themselves, gradually establishing a “new normal.”
After cancer treatment, my role in the household changed. I used to earn money alone, but now my wife works, and I do housework at home. I’ve become quite skilled in cooking. It was a bit uncomfortable at first, but now I’ve adapted. (#14)
Having an ostomy made me different from other people. Though externally, I look like everyone else, sometimes when I experience pain, I suddenly remember that I was a cancer patient. Now, I’ve changed my priorities, and I’m determined to live a family life and enjoy ordinary times after retiring. (#1)
Returning to pre-cancer life proved impossible, but many survivors found their “new normal.” Some even claimed they were now living better lives than before cancer.
I consider myself to have overcome cancer. After defeating cancer, my physical health even improved. (#4)
I believe I have overcome every cancer-related challenge. (#12)
DISCUSSION
Inner strength, initially observed in female patients with chronic illness, has received increasing attention in research involving cancer patients [
10,
11,
18]. Much like resilience, inner strength enables individuals to experience personal growth following negative life events [
4,
19]. For cancer survivors, inner strength is understood in a broader sense—not simply as a means to return to pre-cancer life, but as the foundation for embracing a “new normal” shaped by changes arising from diverse social interactions. Furthermore, attributes of inner strength consistent with those described in existing theories were identified among CRC survivors of both genders. From the moment of diagnosis, these survivors embarked on a journey of accepting or overcoming cancer and designing new lives.
In the established theory of inner strength, individuals recognize their illness, seek assistance—often from a religious perspective—actively participate in overcoming the illness, and ultimately adapt in their own ways. CRC survivors also followed this general trajectory in forging a new life after cancer. However, in contrast to those with chronic diseases, CRC survivors face distinctive challenges, such as long-term dietary management, persistent bowel issues, fear of recurrence and metastasis, and ambivalent emotions about cancer. These disease-specific factors significantly influenced how survivors established their own “new normal.” Their perceptions and coping strategies varied according to gender and ostomy status.
Whereas supportive relationships in inner strength theory have often been viewed through a religious lens [
4-
6], CRC survivors formed supportive relationships based on faith, family, and friends. With the advent of the COVID-19 pandemic, many survivors’ lives shifted toward virtual interactions. Concerns about vaccination added another barrier to in-person outings for cancer survivors [
20]. As a result, participants expressed a preference for virtual meetings. Web-based counseling and support, including online chats and participation in self-help support groups, alleviated depression and anxiety in CRC survivors [
21,
22]. Similarly, virtual support groups served as vital avenues for communication and support. However, hearing news of death or relapse during online meetings sometimes led to self-reflection or heightened anxiety, resulting in negative effects.
Because cancer symptoms, recurrence, or metastasis directly impact survivors’ QOL and life expectancy [
23], support from others remains a crucial factor [
24]. Interestingly, while CRC survivors expressed gratitude for the support they received, they also described feelings of guilt, particularly regarding the burden their illness placed on caregivers. Although such mixed emotions are not unique to CRC survivors, this emotional complexity appeared especially salient in our findings. The need for ongoing care due to long-term symptoms or the presence of an ostomy often increased dependence on others and limited social functioning. Thus, gratitude was not always experienced as a purely positive emotion [
25,
26], but was frequently intertwined with self-blame or emotional discomfort. For some CRC survivors, gratitude and guilt were deeply entangled, reflecting a heightened sense of responsibility and relational sensitivity.
Building on the work of Yu and Ryu [
11], this study explored how CRC survivors construct and express inner strength amid their unique challenges. Rather than focusing solely on general characteristics of inner strength, our findings emphasize the lived difficulties that require and shape its development. In particular, restroom-related issues were prominent, as CRC survivors commonly face persistent, long-term bowel problems similar to those described by Rockwood et al. [
27], with critical life-altering consequences. Post-surgical and restroom-related supportive care was crucial. Frequent restroom visits often remained unresolved, acting as a barrier to social participation and resulting in negative outcomes. Limited ability to go out not only restricted social interaction but also hampered physical activity [
28]. Additionally, fears and stigma related to diarrhea were prevalent, highlighting the ongoing challenges of living with such symptoms [
29]. These findings underscore the contextual pressures under which inner strength is tested and cultivated among CRC survivors.
Contrary to earlier negative perceptions, our study shows that CRC survivors do not necessarily regard an ostomy solely as a negative outcome. For many, an ostomy alleviated restroom-related problems, enabling them to leave the house and enjoy certain foods again. Some even regretted undergoing ostomy reversal surgery. Thus, living with an ostomy is not inherently negative. This adaptation over time, following the initial shock, may be due to improvements in symptoms such as frequent bowel movements [
30].
This study also broadens the understanding of inner strength in CRC survivors by including both female and male participants. While Yu and Ryu [
11] examined inner strength and QOL in male and female CRC survivors, it was challenging to discern their specific characteristics. Our findings, however, identified attributes of inner strength unique to both groups. Male participants tended to develop inner strength in a more independent and self-reliant manner. Female participants, by contrast, often expressed ambivalent emotions related to their illness and to others’ reactions, but their inner strength was largely enhanced through interpersonal interactions.
Male CRC survivors, in their efforts to overcome cancer, tended to reject help from others and conceal their emotions, with their social interactions often limited to online gatherings. This phenomenon can be interpreted in light of Confucian and patriarchal values prevalent in East Asian societies. According to traditional gender role socialization, men are expected to be strong, economically active, and leaders within their families [
31]. Such cultural characteristics continue to shape the formation and expression of inner strength among male CRC survivors.
While male CRC survivors primarily focused on how cancer affected their work or social activities, often from a patriarchal perspective, female survivors mainly discussed their symptom experiences and their lives within the home. The experience of having cancer led some women to internalize stigma, manifesting as self-blame for their perceived inability to live a “normal” life. This internalized stigma can foster negative self-criticism, including guilt and shame [
32,
33], and act as a barrier to social interaction. Notably, female survivors expressed a paradoxical desire: they did not want to be labeled as cancer patients, yet at the same time, they wanted to be treated or considered as such. This phenomenon mirrors findings by Tsai and Lu [
34], who reported that ambivalence in emotional experience is closely linked to depression and self-blame. Further studies on ambivalence in CRC survivors are warranted.
In summary, this study expands the theoretical understanding of inner strength by highlighting its role as a dynamic and context-dependent mechanism through which CRC survivors reconstruct identity, regain agency, and achieve psychosocial adaptation. Rather than representing a fixed trait, inner strength emerges as an evolving capacity shaped by illness experience, gendered responses, and relational contexts. This conceptualization underscores the need for tailored interventions that foster survivors’ inner strength to support their transition to a new normal.
This study extends the theory of inner strength by including both male and female CRC survivors. However, the generalizability of the findings is limited due to the focus on Korean participants and the small number of ostomy holders, whose experiences of stigma may not reflect those of all CRC survivors. Gender-related patterns emerged during analysis rather than through stratified sampling, indicating a need for further validation. Future studies should recruit more diverse populations to strengthen the applicability of these findings.
CONCLUSION
This study explored the role of inner strength in the lived experiences of CRC survivors, particularly in their adaptation to a “new normal” following diagnosis and treatment. The findings revealed that CRC survivors did not seek to return to their pre-cancer lives but instead aimed to reconstruct their lives by accepting and adjusting to persistent symptoms, lifestyle changes, and shifting social roles. Inner strength played a central role in this adaptation process, enabling participants to find meaning, regain agency, and navigate daily challenges. Inner strength helped individuals accept and reinterpret cancer as part of life, redefine their roles amid changed circumstances, and enhance psychological resilience through external support, faith, and family responsibility. It also served as a foundation for meaning-making in relationships characterized by both guilt and gratitude, and for sustaining self-care behaviors. Notably, differences in the expression of inner strength were observed based on gender and the presence of an ostomy. Male survivors often internalized their struggles and developed strength in a more self-reliant manner, while female survivors emphasized relational support and more frequently expressed emotional ambivalence, including feelings of guilt and gratitude. These findings highlight the contextual nature of inner strength and underscore its importance in fostering psychological adaptation and resilience among CRC survivors. Future efforts should focus on developing supportive interventions that nurture inner strength in alignment with survivors’ lived realities, ultimately enhancing their QOL as they construct and live their “new normal.”
-
CONFLICTS OF INTEREST
The authors declared no conflict of interest.
-
AUTHORSHIP
Study conception and design acquisition - HY and ER; data curation and analysis - HY; interpretation of the data - HY and ER; and drafting or critical revision of the manuscript for important intellectual content - HY and ER.
-
FUNDING
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2021R1F1A1055687).
-
ACKNOWLEDGEMENT
None.
-
DATA AVAILABILITY STATEMENT
The data can be obtained from the corresponding authors.
Table 1.Demographic and Disease-related Characteristics of the Study Participants (N=16)
|
No. |
Sex |
Age (year) |
Marital status |
Religion |
Job |
Pathological diagnosis |
Stage |
Time since diagnosis (month) |
Ostomy status†
|
|
1 |
Female |
54 |
Divorced |
None |
No |
Rectal |
4 |
64 |
Yes |
|
2 |
Male |
60 |
Divorced |
None |
No |
Rectal |
4 |
43 |
Yes |
|
3 |
Male |
65 |
Married |
None |
Yes |
Rectal |
3 |
41 |
No |
|
4 |
Female |
46 |
Married |
None |
No |
Rectal |
2 |
33 |
Yes |
|
5 |
Female |
58 |
Married |
None |
Yes |
Colon |
2 |
94 |
No |
|
6 |
Male |
53 |
Married |
Protestantism |
Yes |
Rectal |
3 |
57 |
Previous |
|
7 |
Male |
69 |
Divorced |
Buddhism |
No |
Rectal |
4 |
57 |
Yes |
|
8 |
Female |
49 |
Married |
None |
Yes |
Colon |
3 |
51 |
No |
|
9 |
Female |
40 |
Married |
Protestantism |
No |
Rectal |
3 |
41 |
No |
|
10 |
Female |
58 |
Married |
Protestantism |
No |
Rectal |
3 |
56 |
Previous |
|
11 |
Male |
56 |
Married |
Buddhism |
Yes |
Rectal |
3 |
103 |
Previous |
|
12 |
Male |
68 |
Divorced |
None |
No |
Rectal |
4 |
37 |
No |
|
13 |
Female |
54 |
Married |
Protestantism |
No |
Colon |
3 |
85 |
No |
|
14 |
Male |
58 |
Married |
None |
Yes |
Rectal |
3 |
81 |
Yes |
|
15 |
Female |
58 |
Married |
None |
No |
Colon |
3 |
89 |
No |
|
16 |
Male |
46 |
Married |
Buddhism |
Yes |
Colon |
1 |
48 |
No |
|
|
|
|
|
|
|
|
|
|
Table 2.Themes and Sub-themes Related to Colorectal Cancer Survivors’ Inner Strength
|
Themes |
Sub-themes |
|
Reframing cancer trajectory |
An unacceptable thing |
|
Fear of death |
|
The burden beyond treatment |
|
Knowing myself and cancer |
|
Grateful for my ostomy—indispensable! |
|
Struggle to return to a normal life |
Disrupted daily life |
|
If you cannot avoid it, have a positive attitude |
|
Belief that I can overcome cancer |
|
Battle with myself |
|
Ambivalence |
|
Growth promoted by supportive relationships |
Support entwined with guilt as a source of strength |
|
Prayer to the trustworthy |
|
Well-being |
Interpersonal interaction |
|
Balance of body and mind |
|
Living a new normal |
REFERENCES
- 1. Lee G, Kim SY, Ahn A, Kong S, Nam H, Kang D, et al. Adjustment to “new normal” after cancer among non-small cell lung cancer survivors: a qualitative study. Palliat Support Care. 2024;22(3):487-92. https://doi.org/10.1017/s1478951523001815
- 2. Ha S, Ryu E. Perceived new normal and inner strength on quality of life in breast cancer patients receiving adjuvant endocrine therapy. Asia Pac J Oncol Nurs. 2021;8(4):377-84. https://doi.org/10.4103/apjon.apjon-2081
- 3. Smith MJ, Liehr PR, Carpenter RD. Middle range theory for nursing. 5th ed. New York, NY: Springer Publishing; 2023.
- 4. Lundman B, Alex L, Jonsen E, Norberg A, Nygren B, Santamaki Fischer R, et al. Inner strength: a theoretical analysis of salutogenic concepts. Int J Nurs Stud. 2010;47(2):251-60. https://doi.org/10.1016/j.ijnurstu.2009.05.020
- 5. Dingley CE, Roux G, Bush HA. Inner strength: a concept analysis. J Theory Constr Test. 2000;4(2):30. https://doi.org/10.1016/j.ijnurstu.2009.05.020
- 6. Roux G, Dingley CE, Bush HA. Inner strength in women: metasynthesis of qualitative findings in theory development. J Theory Constr Test. 2002;6(1):86.
- 7. Roux G, Lewis K, Younger J, Dingley C. Development and testing of the inner strength questionnaire. J Cult Divers. 2003;10(1):4-6.
- 8. Dingley C, Roux G. The role of inner strength in quality of life and self-management in women survivors of cancer. Res Nurs Health. 2014;37(1):32-41. https://doi.org/10.1002/nur.21579
- 9. Lee YE, Ryu E. Moderating effect of inner strength between mood status and quality of life in female patients with lung cancer. Asian Oncol Nurs. 2021;21(1):24-32. https://doi.org/10.5388/aon.2021.21.1.24
- 10. Smith CS. Inner strength in men: a descriptive phenomenology [dissertation]. The Grand Forks, ND: University of North Dakota; 2017.
- 11. Yu H, Ryu E. Colorectal cancer survivors' inner strength, multiple identities, and quality of life by gender and ostomy presence: a cross-sectional study. Korean J Adult Nurs. 2024;36(2):171-80. https://doi.org/10.7475/kjan.2024.36.2.171
- 12. Couwenberg AM, Burbach JPM, Intven MP, Consten EC, Schiphorst AH, Smits AB, et al. Health-related quality of life in rectal cancer patients undergoing neoadjuvant chemoradiation with delayed surgery versus short-course radiotherapy with immediate surgery: a propensity score-matched cohort study. Acta Oncol. 2019;58(4):407-16. https://doi.org/10.1080/0284186x.2018.1551622
- 13. Adams SV, Ceballos R, Newcomb PA. Quality of life and mortality of long-term colorectal cancer survivors in the seattle colorectal cancer family registry. PLoS One. 2016;11(6):e0156534. https://doi.org/10.1371/journal.pone.0156534
- 14. Grant M, McMullen CK, Altschuler A, Mohler MJ, Hornbrook MC, Herrinton LJ, et al. Gender differences in quality of life among long-term colorectal cancer survivors with ostomies. Oncol Nurs Forum. 2011;38(5):587-96. https://doi.org/10.1188/11.Onf.587-596
- 15. Song Q, Liu C, Lv X, Wang J, Yin G. Course and predictors of psychological distress among colorectal cancer survivors with ostomies: a longitudinal study. Eur J Oncol Nurs. 2022;59:102170. https://doi.org/10.1016/j.ejon.2022.102170
- 16. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-88. https://doi.org/10.1177/1049732305276687
- 17. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. https://doi.org/10.1093/intqhc/mzm042
- 18. Roux G, Bush HA, Dingley CE. Inner strength in women with breast cancer. J Theory Constr Test. 2001;5(1):19.
- 19. Herrman H, Stewart DE, Diaz-Granados N, Berger EL, Jackson B, Yuen T. What is resilience? Can J Psychiatry. 2011;56(5):258-65. https://doi.org/10.1177/070674371105600504
- 20. Mejri N, Berrazega Y, Ouertani E, Rachdi H, Bohli M, Kochbati L, et al. Understanding COVID-19 vaccine hesitancy and resistance: another challenge in cancer patients. Support Care Cancer. 2022;30(1):289-93. https://doi.org/10.1007/s00520-021-06419-y
- 21. Wang JW, Zhang TR, Shen Q, Yang ZQ, Liu C, Chen SJ, et al. The experience of cancer survivors in community-based psycho-social support activities in Shanghai, China: a qualitative study. Qual Life Res. 2015;24(12):2815-22. https://doi.org/10.1007/s11136-015-1021-8
- 22. Wan SW, Chng YJD, Lim SH, Chong CS, Pikkarainen M, He HG. A systematic review and meta-analysis on the effectiveness of web-based psychosocial interventions among patients with colorectal cancer. J Adv Nurs. 2022;78(7):1883-96. https://doi.org/10.1111/jan.15258
- 23. Rutherford C, Muller F, Faiz N, King MT, White K. Patient-reported outcomes and experiences from the perspective of colorectal cancer survivors: meta-synthesis of qualitative studies. J Patient Rep Outcomes. 2020;4(1):27. https://doi.org/10.1186/s41687-020-00195-9
- 24. Le D, Holt CL, Pisu M, Brown-Galvan A, Fairley TL, Lee Smith J, et al. The role of social support in posttreatment surveillance among African American survivors of colorectal cancer. J Psychosoc Oncol. 2014;32(3):245-63. https://doi.org/10.1080/07347332.2014.897293
- 25. Weiner B. Attribution, emotion, and action. In: Sorrentino RM, Higgins ET, editors. Handbook of motivation and cognition: foundations of social behavior. New York, NY: Guilford Press; 1986. p. 281-312.
- 26. Gallagher MW, Lopez SJ. Positive psychological assessment: a handbook of models and measures. 2nd ed. Washington, DC: American Psychological Association; 2019.
- 27. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43(1):9-16. https://doi.org/10.1007/bf02237236
- 28. Corradi G, Theirs C, Garcia-Garzon E, Barrada JR. A silent burden: how negative experiences with public toilets impact quality of life and life satisfaction. Scand J Psychol. 2023;64(4):495-503. https://doi.org/10.1111/sjop.12914
- 29. Alenezi A, McGrath I, Kimpton A, Livesay K. Quality of life among ostomy patients: a narrative literature review. J Clin Nurs. 2021;30(21-22):3111-23. https://doi.org/10.1111/jocn.15840
- 30. Davis D, Ramamoorthy L, Pottakkat B. Impact of stoma on lifestyle and health-related quality of life in patients living with stoma: a cross-sectional study. J Educ Health Promot. 2020;9(1):328. https://doi.org/10.4103/jehp.jehp_256_20
- 31. Levant RF. The new psychology of men. Prof Psychol Res Pr. 1996;27(3):259-65. https://doi.org/10.1037/0735-7028.27.3.259
- 32. Corrigan PW. The stigma of disease and disability: understanding causes and overcoming injustices. Washington, DC: American Psychological Association; 2014.
- 33. Crocker J, Quinn DM. Social stigma and the self: meanings, situations, and self-esteem. In: Heatherton TF, Kleck RE, Hebl MR, Hull JG, editors. The social psychology of stigma. New York, NY: The Guilford Press; 2000. p. 153-83.
- 34. Tsai W, Lu Q. Ambivalence over emotional expression and intrusive thoughts as moderators of the link between self-stigma and depressive symptoms among Chinese American breast cancer survivors. J Behav Med. 2019;42(3):452-60. https://doi.org/10.1007/s10865-018-9996-6
Appendices
Appendix 1.
- Interview questions
1. Please provide a self-introduction.
1-1. What is your diagnosis?
1-2. What treatments have you received?
1-3. What is your current treatment status? (Ongoing/Recovered)
2. What experiences have you had regarding your illness, diagnosis, treatment (and bowel incontinence)?
2-1. What were your feelings when you were first diagnosed with cancer?
2-2. What emotions did you experience during the diagnosis and treatment process for colon cancer?
2-3. Were there any unexpected events related to the illness?
2-4. If so, what emotions did you experience?
2-5. Do you experience any discomfort in your daily life?
2-6. Are there any difficulties in your daily life?
2-7. Have you disclosed the cancer diagnosis to others?
3. Are you currently part of any group?
4. What role do you currently play within your family?
4-1. What experiences did you have when you returned home after treatment?
4-2. Are there any difficulties you feel as a family member related to the disease?
4-3. Are there any positive aspects gained from family members related to the disease?
5. What experiences are you having in your current affiliations (with friends, work, hobbies)?
5-1. Are there any difficulties you feel in your affiliations?
5-2. Are there any positive aspects gained from members of your affiliations?
5-3. Do you have someone you can rely on, such as family, friends, or coworkers?
5-4. Do you maintain a balance between rest and work? Can you have time for yourself?
6. Do you have a religion?
6-1. (If yes) Please talk about your experiences through religious activities.
6-2. (If yes) What prayers do you offer through religious activities? (For others/for yourself?)
6-3. (If yes) What are the positive/negative aspects of religious activities related to the disease?
7. After treating colon cancer, what other difficulties do you face?
8. Do you think you have adapted to or overcome the difficulties caused by the disease?
8-1. What events/people helped you overcome all these experiences and difficulties?
8-2. Do you believe you can overcome the difficulties related to the disease?
9. What are your life plans?
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