TY - JOUR
AU - Tokuyama,, Madoka
AB - Abstract Background The purpose of the present study was to categorize and develop lists of contents of problems, goals, solution plans generated through the brainstorming work in therapy, and selected solutions for execution, that treated in problem-solving therapy (PST) for cancer patients in clinical settings, and to describe their characteristics. Additionally, examining the associations of problem domains with characteristics of participants, was also aimed. Methods We conducted content analysis using records of thirty-one cancer patients (M = 62.6 years old; SD = 10.5) who participated in PST program. Results Problems were categorized into four domains (e.g. psychological and existential problems; physical problems; social relations; social living environment). Participants under treatment at baseline reported psychological and existential problems most often (P < 0.05). Goals were categorized into four domains (e.g. improving mental health; improving physical functions; improving social relations and improving one’s social living environment). Solution plans generated through the brainstorming work in therapy were categorized into four domains (e.g. emotion regulation/cognitive adjustment; health behaviors; adjustment of social relationships and adjusting one’s social living environment). Selected solutions for execution were categorized into four domains (e.g. emotion regulation/cognitive adjustment; health behaviors; adjustment of social relationships and adjusting one’s social living environment). Conclusions We found that various problems, goals and solutions were treated in PST of realistic clinical setting. Creating lists based on our study and making use of it for the materials as aids while implementing the PST or being shared with patients and medical staff would be expected. problem-solving therapy, group therapy, cancer patients Introduction Problem-solving therapy (PST) is a cognitive-behavioral intervention that has been developed based on social problem-solving. It focuses on training in constructive problem-solving attitudes and skills. In cancer patients, the ability to solve problems is said to moderate the relationship between problems and distress; therefore, one’s higher problem-solving ability is considered to decrease distress and vice versa (1,2). Several studies have also examined and suggested the effectiveness and the feasibility of PST for cancer patients, such as in reducing depression and anxiety, and in improving the quality of life and social relationships (3–6). Problem-solving comprises the following five stages: (i) general orientation, (ii) problem definition and formulation, (iii) generation of alternatives (solutions), (iv) decision-making and (v) implementation and verification (7,8). Problem definition and formulation involves assessing the nature of the problem and identifying a set of realistic goals or objects. Training in this component significantly increased the generation of alternative performances (9). Additionally, according to Nezu & D’Zurilla’s work (10), instruction in this component effectively enhanced the decision-making component, which involves the identification of a wide range of potential consequences that might occur if a particular alternative is actually implemented (11). Generation alternatives is to make available as many alternative solutions to the problem as possible, using general brainstorming rules, quantity principles, deferment-of-judgment principles and the variety principles (11). Subjects who receive detailed training in these components can produce higher quality of problem-solving. To strengthen one’s problem-solving ability, it is helpful to develop support materials such as lists of the components (i.e. problems, goals, and solutions). One study made a list on PTS, aiming at increasing the patient’s functional approaches to deal with their problems (12). Teaching cancer patients about such a list would help them to perceive their problems or appropriate goals more efficiently, and to identify and implement more effective solutions. However, few studies have examined the problems as well goals and solutions of cancer patients who received PST or interventions related to PST (Table 1). Therefore, the purpose of the present study was to categorize and develop lists of contents of problems, goals, solution plans generated through the brainstorming work in therapy and selected solutions for execution, that treated in PST for cancer patients in clinical settings, and to describe their characteristics. Table 1. Code of problems, goals and solutions of the previous researches Problems Goals Solutions Kleiboer et al. (15) Cancer Cancer outpatients with major depression, PST Physical symptoms Limitations in functioning Health concerns Sexual problems Psychological symptoms Life perspective Social difficulties Concerns about other people’s well-being Practical concerns Other Lyons et al. (21) Exercise Adapt (Wants to adapt a particular activity) Who (Involving another person) Breast cancer patients, Problem-solving Treatment-Occupational Therapy IADL Find new (Wants to find multiple, mutually exclusive new activities that could solve a general problem) Where (Changing the location of an activity or an aspect of the environment) Work Plan (Figure out what to do first or what the possible steps of a task are) When (Changing the timing or sequencing of an activity) Stress Gather (Gather information about resources or options) What (Doing or not doing some extra, new step or behavior before or after the actual activity) Nutrition How (Changing the actual process by which a specific activity is done) Sleep Leisure Child UEa Social Miscellaneous Lyons et al. (22) Exercise Breast cancer patients, telephone-delivered, Behavioral Activation/Problem-solving intervention Work Nutrition Instrumental activity of daily living Stress management/relaxation Social Child Leisure Habit Smoking cessation Arm exercise/stretching Cognition Sleep Shiozaki et al. (12) Maintaining this living condition Spending one’s own time Specific approaches described by participants were described in Japanese. Pancreatic cancer patients, PST approach Preparing for changes to the environment Not thinking deeply (accepting the present situation) Keeping a sense of control over my own life Looking to the good side of things Dealing with anxiety Maintaining physical condition Restoring the self of pre-illness Adjusting behavior according to the condition of the body Collecting information Maintaining connection with surroundings Preparing for the future so that the surroundings will not be troubled Thinking about the future of children Acting so that the surroundings do not worry Deciding for myself Continuing what I have done so far Doing what I can do now Grasping the situation rationally Problems Goals Solutions Kleiboer et al. (15) Cancer Cancer outpatients with major depression, PST Physical symptoms Limitations in functioning Health concerns Sexual problems Psychological symptoms Life perspective Social difficulties Concerns about other people’s well-being Practical concerns Other Lyons et al. (21) Exercise Adapt (Wants to adapt a particular activity) Who (Involving another person) Breast cancer patients, Problem-solving Treatment-Occupational Therapy IADL Find new (Wants to find multiple, mutually exclusive new activities that could solve a general problem) Where (Changing the location of an activity or an aspect of the environment) Work Plan (Figure out what to do first or what the possible steps of a task are) When (Changing the timing or sequencing of an activity) Stress Gather (Gather information about resources or options) What (Doing or not doing some extra, new step or behavior before or after the actual activity) Nutrition How (Changing the actual process by which a specific activity is done) Sleep Leisure Child UEa Social Miscellaneous Lyons et al. (22) Exercise Breast cancer patients, telephone-delivered, Behavioral Activation/Problem-solving intervention Work Nutrition Instrumental activity of daily living Stress management/relaxation Social Child Leisure Habit Smoking cessation Arm exercise/stretching Cognition Sleep Shiozaki et al. (12) Maintaining this living condition Spending one’s own time Specific approaches described by participants were described in Japanese. Pancreatic cancer patients, PST approach Preparing for changes to the environment Not thinking deeply (accepting the present situation) Keeping a sense of control over my own life Looking to the good side of things Dealing with anxiety Maintaining physical condition Restoring the self of pre-illness Adjusting behavior according to the condition of the body Collecting information Maintaining connection with surroundings Preparing for the future so that the surroundings will not be troubled Thinking about the future of children Acting so that the surroundings do not worry Deciding for myself Continuing what I have done so far Doing what I can do now Grasping the situation rationally aUE = Exercises/activities done to decrease lymphedema and/or to increase strength and/or range of motion of an arm affected by cancer treatment. Table 1. Code of problems, goals and solutions of the previous researches Problems Goals Solutions Kleiboer et al. (15) Cancer Cancer outpatients with major depression, PST Physical symptoms Limitations in functioning Health concerns Sexual problems Psychological symptoms Life perspective Social difficulties Concerns about other people’s well-being Practical concerns Other Lyons et al. (21) Exercise Adapt (Wants to adapt a particular activity) Who (Involving another person) Breast cancer patients, Problem-solving Treatment-Occupational Therapy IADL Find new (Wants to find multiple, mutually exclusive new activities that could solve a general problem) Where (Changing the location of an activity or an aspect of the environment) Work Plan (Figure out what to do first or what the possible steps of a task are) When (Changing the timing or sequencing of an activity) Stress Gather (Gather information about resources or options) What (Doing or not doing some extra, new step or behavior before or after the actual activity) Nutrition How (Changing the actual process by which a specific activity is done) Sleep Leisure Child UEa Social Miscellaneous Lyons et al. (22) Exercise Breast cancer patients, telephone-delivered, Behavioral Activation/Problem-solving intervention Work Nutrition Instrumental activity of daily living Stress management/relaxation Social Child Leisure Habit Smoking cessation Arm exercise/stretching Cognition Sleep Shiozaki et al. (12) Maintaining this living condition Spending one’s own time Specific approaches described by participants were described in Japanese. Pancreatic cancer patients, PST approach Preparing for changes to the environment Not thinking deeply (accepting the present situation) Keeping a sense of control over my own life Looking to the good side of things Dealing with anxiety Maintaining physical condition Restoring the self of pre-illness Adjusting behavior according to the condition of the body Collecting information Maintaining connection with surroundings Preparing for the future so that the surroundings will not be troubled Thinking about the future of children Acting so that the surroundings do not worry Deciding for myself Continuing what I have done so far Doing what I can do now Grasping the situation rationally Problems Goals Solutions Kleiboer et al. (15) Cancer Cancer outpatients with major depression, PST Physical symptoms Limitations in functioning Health concerns Sexual problems Psychological symptoms Life perspective Social difficulties Concerns about other people’s well-being Practical concerns Other Lyons et al. (21) Exercise Adapt (Wants to adapt a particular activity) Who (Involving another person) Breast cancer patients, Problem-solving Treatment-Occupational Therapy IADL Find new (Wants to find multiple, mutually exclusive new activities that could solve a general problem) Where (Changing the location of an activity or an aspect of the environment) Work Plan (Figure out what to do first or what the possible steps of a task are) When (Changing the timing or sequencing of an activity) Stress Gather (Gather information about resources or options) What (Doing or not doing some extra, new step or behavior before or after the actual activity) Nutrition How (Changing the actual process by which a specific activity is done) Sleep Leisure Child UEa Social Miscellaneous Lyons et al. (22) Exercise Breast cancer patients, telephone-delivered, Behavioral Activation/Problem-solving intervention Work Nutrition Instrumental activity of daily living Stress management/relaxation Social Child Leisure Habit Smoking cessation Arm exercise/stretching Cognition Sleep Shiozaki et al. (12) Maintaining this living condition Spending one’s own time Specific approaches described by participants were described in Japanese. Pancreatic cancer patients, PST approach Preparing for changes to the environment Not thinking deeply (accepting the present situation) Keeping a sense of control over my own life Looking to the good side of things Dealing with anxiety Maintaining physical condition Restoring the self of pre-illness Adjusting behavior according to the condition of the body Collecting information Maintaining connection with surroundings Preparing for the future so that the surroundings will not be troubled Thinking about the future of children Acting so that the surroundings do not worry Deciding for myself Continuing what I have done so far Doing what I can do now Grasping the situation rationally aUE = Exercises/activities done to decrease lymphedema and/or to increase strength and/or range of motion of an arm affected by cancer treatment. In this study, we also aimed to examine the associations of problem domains with characteristics of participants. Understanding theses correlations would help us to organize a PST program. Patients and method Participants and procedure We conducted content analysis using records containing problems, goals and solutions, reported by 31 cancer patients who participated in a PST program. These records were created based on pictures of notes written on a whiteboard written by the facilitator, voice records in an IC recorder, notes written by the note taker, and work sheets written by participants. These records were made of nine programs conducted from 2009 to 2012. The study protocol was approved by the Ethics Committee of Hospital A and was conducted in accordance with the guidelines of the Declaration of Helsinki. The eligibility criteria for our study included having been diagnosed with cancer and being an inpatient or outpatient in Hospital A. We recruited cancer patients through posters, pamphlets and direct offers from medical staff in A hospital. Problem-solving therapy program The PST program developed for Japanese cancer patients (3,4) was implemented in a group setting in the present study. This program consisted of five weekly sessions and one follow-up session conducted three months later (90 min per session). The following are the details of the sessions: Session 1: The facilitator instructed the patients about PST; Session 2: Patients organized their problems and set goals; Session 3: They thought about solution plans through brainstorming during therapy, and then they selected some solutions based on their costs or benefits. They received the homework task of implementing the selected solution for one week; Session 4: They reported on their homework (e.g. what they did, its outcome, and how they felt or thought) and then modified their goal or solutions. They implemented the modified solutions as homework before the next session; Session 5: They also reported on their homework and commented about this program. About two to five cancer patients, one facilitator, one or two clinical psychotherapists and one note taker participated in each session. Measures We used the Japanese version of the Hospital Anxiety and Depression Scale (HADS; 13) to assess patients’ depression and anxiety. The HADS contains an anxiety and depression scale, each comprising seven items. All items are rated from 0 to 3. The recommended cutoff scores are 10/11 for adjustment disorders, and 19/20 for major depression (13). Additionally, we obtained the demographic data or medical information of the patients from their medical records. Analysis Content analysis was conducted. One researcher categorized the contents of the problems, goals and solutions based on similarities and differences, and created small-categories that were later converged to create mid-level categories. Subsequently, more conceptualized domains were developed by combining the mid-level categories, and all the categories and domains were assigned labels. Two other people, a psychologist and a nurse, judged the consistency of the contents of the categories and their labels (Kappa coefficient = 0.93 (problems); 0.93 (goals); 0.96 (solution plans) and 0.92 (selected solutions)). Finally, these three people discussed disagreements until consensus was achieved, to avoid subjective decisions. For analysis of the demographic information and quantitative data, we used IBM SPSS Statistics version 21 for Mac. Additionally, to examine the associations of problem domains with characteristics of participants, the following dummy variables were created: 0 when a patient did not report a problem in a domain and 1 when a patient reported a problem in a domain. The Fisher’s exact test was used to assess the significant difference between problem domains and the following demographic variables: age (under/over 65 years), sex (male/female), onset (primary/relapse), disease state (not terminal/terminal), treatment status (no treatment/under treatment) and HADS score (absence/presence of adjustment disorder or major depression). Results Participants (showed in Table 2) Table 2. Demographic information of participants M/N SD/% Age 62.6 10.5 Sex  Male 12 38.7  Female 19 61.3 Origin of the cancer  Stomach 7 22.6  Breast 6 19.4  Lung 3 9.7  Rectum 3 9.7  Bladder 2 6.5  Bowel 1 3.2  Uterine body 1 3.2  Small cell 1 3.2  Small intestinal 1 3.2  Esophagus 1 3.2  Prostate 1 3.2  Appendix 1 3.2  Ureter 1 3.2  Ovary 1 3.2  Pancreas 1 3.2 Primary/Relapse  Primary 27 87.1  Relapse 4 12.9 Terminal or not  Not terminal 27 87.1  Terminal 4 12.9 Treatmennt  Cemotherapy 16 51.6  Cemotherapy + gamma knife treatment 2 6.5  Cemotherapy + hormone treatment 1 3.2  Cemotherapy + radiotherapy 1 3.2  Dropping out of cemotherapy 1 3.2  Operation 1 3.2  Hormone treatment 1 3.2  Radiotherapy 1 3.2  Immunotherapy 1 3.2  No treatment 5 16.1  Unclear 1 3.2 Outpatient/Inpatient  Outpatient 23 74.2  Inpatient 3 9.7  Outpatient→inpatient 2 6.5  Inpatient→outpatient 2 6.5  Inpatient→outpatient→inpatient 1 3.2 Diagnosis (HADS)  Adjustment 8 25.8  Adjustment disorder 13 41.9  Major depression 9 29.0  Unclear 1 3.2 M/N SD/% Age 62.6 10.5 Sex  Male 12 38.7  Female 19 61.3 Origin of the cancer  Stomach 7 22.6  Breast 6 19.4  Lung 3 9.7  Rectum 3 9.7  Bladder 2 6.5  Bowel 1 3.2  Uterine body 1 3.2  Small cell 1 3.2  Small intestinal 1 3.2  Esophagus 1 3.2  Prostate 1 3.2  Appendix 1 3.2  Ureter 1 3.2  Ovary 1 3.2  Pancreas 1 3.2 Primary/Relapse  Primary 27 87.1  Relapse 4 12.9 Terminal or not  Not terminal 27 87.1  Terminal 4 12.9 Treatmennt  Cemotherapy 16 51.6  Cemotherapy + gamma knife treatment 2 6.5  Cemotherapy + hormone treatment 1 3.2  Cemotherapy + radiotherapy 1 3.2  Dropping out of cemotherapy 1 3.2  Operation 1 3.2  Hormone treatment 1 3.2  Radiotherapy 1 3.2  Immunotherapy 1 3.2  No treatment 5 16.1  Unclear 1 3.2 Outpatient/Inpatient  Outpatient 23 74.2  Inpatient 3 9.7  Outpatient→inpatient 2 6.5  Inpatient→outpatient 2 6.5  Inpatient→outpatient→inpatient 1 3.2 Diagnosis (HADS)  Adjustment 8 25.8  Adjustment disorder 13 41.9  Major depression 9 29.0  Unclear 1 3.2 Table 2. Demographic information of participants M/N SD/% Age 62.6 10.5 Sex  Male 12 38.7  Female 19 61.3 Origin of the cancer  Stomach 7 22.6  Breast 6 19.4  Lung 3 9.7  Rectum 3 9.7  Bladder 2 6.5  Bowel 1 3.2  Uterine body 1 3.2  Small cell 1 3.2  Small intestinal 1 3.2  Esophagus 1 3.2  Prostate 1 3.2  Appendix 1 3.2  Ureter 1 3.2  Ovary 1 3.2  Pancreas 1 3.2 Primary/Relapse  Primary 27 87.1  Relapse 4 12.9 Terminal or not  Not terminal 27 87.1  Terminal 4 12.9 Treatmennt  Cemotherapy 16 51.6  Cemotherapy + gamma knife treatment 2 6.5  Cemotherapy + hormone treatment 1 3.2  Cemotherapy + radiotherapy 1 3.2  Dropping out of cemotherapy 1 3.2  Operation 1 3.2  Hormone treatment 1 3.2  Radiotherapy 1 3.2  Immunotherapy 1 3.2  No treatment 5 16.1  Unclear 1 3.2 Outpatient/Inpatient  Outpatient 23 74.2  Inpatient 3 9.7  Outpatient→inpatient 2 6.5  Inpatient→outpatient 2 6.5  Inpatient→outpatient→inpatient 1 3.2 Diagnosis (HADS)  Adjustment 8 25.8  Adjustment disorder 13 41.9  Major depression 9 29.0  Unclear 1 3.2 M/N SD/% Age 62.6 10.5 Sex  Male 12 38.7  Female 19 61.3 Origin of the cancer  Stomach 7 22.6  Breast 6 19.4  Lung 3 9.7  Rectum 3 9.7  Bladder 2 6.5  Bowel 1 3.2  Uterine body 1 3.2  Small cell 1 3.2  Small intestinal 1 3.2  Esophagus 1 3.2  Prostate 1 3.2  Appendix 1 3.2  Ureter 1 3.2  Ovary 1 3.2  Pancreas 1 3.2 Primary/Relapse  Primary 27 87.1  Relapse 4 12.9 Terminal or not  Not terminal 27 87.1  Terminal 4 12.9 Treatmennt  Cemotherapy 16 51.6  Cemotherapy + gamma knife treatment 2 6.5  Cemotherapy + hormone treatment 1 3.2  Cemotherapy + radiotherapy 1 3.2  Dropping out of cemotherapy 1 3.2  Operation 1 3.2  Hormone treatment 1 3.2  Radiotherapy 1 3.2  Immunotherapy 1 3.2  No treatment 5 16.1  Unclear 1 3.2 Outpatient/Inpatient  Outpatient 23 74.2  Inpatient 3 9.7  Outpatient→inpatient 2 6.5  Inpatient→outpatient 2 6.5  Inpatient→outpatient→inpatient 1 3.2 Diagnosis (HADS)  Adjustment 8 25.8  Adjustment disorder 13 41.9  Major depression 9 29.0  Unclear 1 3.2 The mean age of the participants was 62.6 years (SD = 10.5), and the sample comprised 19 males (61.3%). The most common cancer type was that of the stomach (22.6%), followed by breast cancer (19.4%). There were more primary cancer patients (87.1%) than terminal (12.9%). Majority of the participants received chemotherapy as the only form of treatment (51.6%). Further, most of the participants were inpatients in the hospital (74.2%). The mean HADS score at the baseline was 14.9 (SD = 7.3). Based on the cutoff point (13), about 70% of participants were categorized for adjustment disorder (41.9%) or major depression (29.0%). Problems (N = 29) The patients identified 176 problems, with a mean number of 6.1 items per person (range = 1–16). These problems were categorized into 59 small-categories, which converged into 19 mid-level categories and four conceptual domains (Table 3). Table 3. Problems reported by participants (N = 29) Categories N % Examples of contents reported by participants Psychological and existential problems 20 69.0 Anxiety/concern 17 58.6 Concern about death or dying 6 20.7 I cannot help being aware of and thinking about how long I will live. Concern about treatments and side effects 6 20.7 I am not sure if I can adapt well to the side effects of the anticancer drugs. Concern about relapse and metastasis 5 17.2 I gloomy think about the recurrence of cancer. Concern about emotional control 4 13.8 I am worried about whether it is not being bothered by emotion. Concern about coping with problems 3 10.3 I do not know how to formulate my problem. Concern about family issues 2 6.9 I live with my husband and he is diabetic and alcohol dependent. I am worried about what I will do if my husband falls ill. Concern about pain associated with the advancement of the disease 2 6.9 When the cancer progresses and gets painful, how long I will be able to endure. Concern about work 2 6.9 I am concerned about whether I can return to my job. Vague sense of uneasiness 2 6.9 I have to keep myself busy with something, or else I’m filled with anxiety. Concern about acquiring infections 1 3.4 I am worried about catching an influenza infection because the performances are conducted in a crowded place. Concern about decline in physical strength 1 3.4 I am worried about for how long my physical strength will continue to decline. Depressive symptoms 6 20.7 Decreasing motivation or vigor 5 17.2 I feel de-motivated. Feeling depressed 1 3.4 I feel depressed. Irritation 2 6.9 Feeling irritated 2 6.9 I am irritated that I cannot move freely by myself. Uncertain about the prospect of life 3 10.3 Uncertain about future prospects 2 6.9 There is a gap between the general trend (survival rate) and current situation (treatment), so I cannot make a prospect for the future. Whether or not to know about future prospects 2 6.9 I am not sure if I should know about my life expectancy. Unusual sense of time 2 6.9 Experiencing a gap in one’s time perception 2 6.9 I felt that the time moved slowly. For example, a period of less than 1 minute seemed like 5 to 10 minutes. I was perplexed by the gap between my feeling and the reality. Existential pain 4 13.8 Pain about life and death 1 3.4 I cannot think that I am alive. Change in life plan 1 3.4 My life plan has changed due to cancer. Hoping for a good life and death 2 6.9 I want to live with cancer while giving priority to my quality of life. However, I don’t know how I can do it. Physical problems 19 65.5 Distress regarding examinations 2 6.9 Distress regarding hearing a result of an examination 1 3.4 I feel distressed about the results of the monthly check-up. Distress regarding having to undergo an examination 1 3.4 I suffer from side effects of iodine used in CT scans and examination by gastric cameras that I need to undergo once every 3 months or half a year. Side effects and after effects 18 62.1 General symptoms of side effects 6 20.7 I am not sure how to cope with side effects. Sleepiness 2 6.9 Increased drowsiness owing to the increasing dosage of OxyContin. Oral problems 1 3.4 I cannot remove the pus from the tooth root caused by the side effects of the treatment. Wobble 1 3.4 I do not know whether it is due to side effects, but I feel dizzy. Difficulty in controlling weight 1 3.4 Increase in weight as a side effect of the drugs. Nail and skin problems 2 6.9 Detachment of nails due to the side effects of the treatment. Numbness 1 3.4 I do not know the sequelae of side effects, but I experience tingling in my body. Decline in cognitive function 1 3.4 I have become forgetful. I have a short memory span. Things that I cannot control are increasing. For example, I do not remember yesterday’s meal, or a telephone number without writing it down. Nausea 2 6.9 Because of anticancer drugs, I feel nauseated by the smell of food. Difficulty in controlling bowel movements 3 10.3 It is more difficult to manage constipation now than it was before. Fatigue 3 10.3 I do not know whether this is because of the cancer medicine, but I feel fatigued. Difficulty related to eating 4 13.8 I cannot eat. Physical pain 2 6.9 I want to manage pain. Developing another disease as an effect of treatment 1 3.4 I have developed high blood sugar levels because of the effect of chemotherapy. Therefore, I need to take insulin injections. Bad physical condition 9 31.0 When I meet people or go out, I get tired. Physical deconditioning 2 6.9 Decline in physical strength 4 13.8 Decline in my physical strength. Loss of or decline in physical functions 3 10.3 My eyes felt heavy, and I was diagnosed with glaucoma. Metastasis 1 3.4 Just metastasis. Social relations 22 75.9 Dis-communication with others 10 34.5 Dis-communication with family 5 17.2 I trust my family doctor, but my family is opposed to going to the doctor. Dis-communication with medical staff 4 13.8 I have problems in communicating with my doctor. He is a great doctor, so I cannot express what I want to say. Dis-communication with friends or acquaintances 2 6.9 I cannot talk to my tennis friends about my cancer. Negative attitude of people around 2 6.9 Negative attitude of family 2 6.9 My problem is that my husband’s attitude is bewildered. Not having a sense of contribution 2 6.9 Sense of inadequacy for the family 2 6.9 I cannot do enough for my family. I want to help people. Insufficient trust in relationships with others 3 10.3 Insufficient trust in the relationship with medical staff or the hospital 3 10.3 I cannot trust my doctor. Decreased interactions with others 4 13.8 Decreased interactions with friends or acquaintances 4 13.8 I want to maintain the pace of associating with others, but I cannot. Inadequate social support 3 10.3 Absence of social support 2 6.9 Because I live alone, I worry that I may die alone (Kodoku-shi). Receiving unwanted support 1 3.4 My wife’s support is sometime hard for me. Issues related to the family 8 27.6 Need for family caregiving or care 5 17.2 I am stressed about taking care of my wife, who has dementia. Bad relationship between family members 1 3.4 My son does not visit his father in the hospital. Others 3 10.3 Home issues. Issues related to moving our family grave. Social living environment 14 48.3 Interference with daily life 6 20.7 Not being able to spend time in leisure activities 5 17.2 I want to go mountain climbing, but I can’t. not doing disposition before own death 2 6.9 I want to clean up the room before I die. Not being able to plan one’s day 1 3.4 I need to make a list of what to do in everyday life (1week/1 day). How to act. Interference with work or housework 6 20.7 Inability to decide whether to resign from work 4 13.8 I cannot decide whether I can work or not. Interference with work 2 6.9 Because of the pain, I cannot organize my work well. Interference with housework 1 3.4 Housework is not going my way. Economic hardships 3 10.3 Difficulty in meeting medical expenses 2 6.9 Economic issues, including arranging for palliative care. Difficulty in meeting living expenses 1 3.4 My son does not provide me living expenses. Categories N % Examples of contents reported by participants Psychological and existential problems 20 69.0 Anxiety/concern 17 58.6 Concern about death or dying 6 20.7 I cannot help being aware of and thinking about how long I will live. Concern about treatments and side effects 6 20.7 I am not sure if I can adapt well to the side effects of the anticancer drugs. Concern about relapse and metastasis 5 17.2 I gloomy think about the recurrence of cancer. Concern about emotional control 4 13.8 I am worried about whether it is not being bothered by emotion. Concern about coping with problems 3 10.3 I do not know how to formulate my problem. Concern about family issues 2 6.9 I live with my husband and he is diabetic and alcohol dependent. I am worried about what I will do if my husband falls ill. Concern about pain associated with the advancement of the disease 2 6.9 When the cancer progresses and gets painful, how long I will be able to endure. Concern about work 2 6.9 I am concerned about whether I can return to my job. Vague sense of uneasiness 2 6.9 I have to keep myself busy with something, or else I’m filled with anxiety. Concern about acquiring infections 1 3.4 I am worried about catching an influenza infection because the performances are conducted in a crowded place. Concern about decline in physical strength 1 3.4 I am worried about for how long my physical strength will continue to decline. Depressive symptoms 6 20.7 Decreasing motivation or vigor 5 17.2 I feel de-motivated. Feeling depressed 1 3.4 I feel depressed. Irritation 2 6.9 Feeling irritated 2 6.9 I am irritated that I cannot move freely by myself. Uncertain about the prospect of life 3 10.3 Uncertain about future prospects 2 6.9 There is a gap between the general trend (survival rate) and current situation (treatment), so I cannot make a prospect for the future. Whether or not to know about future prospects 2 6.9 I am not sure if I should know about my life expectancy. Unusual sense of time 2 6.9 Experiencing a gap in one’s time perception 2 6.9 I felt that the time moved slowly. For example, a period of less than 1 minute seemed like 5 to 10 minutes. I was perplexed by the gap between my feeling and the reality. Existential pain 4 13.8 Pain about life and death 1 3.4 I cannot think that I am alive. Change in life plan 1 3.4 My life plan has changed due to cancer. Hoping for a good life and death 2 6.9 I want to live with cancer while giving priority to my quality of life. However, I don’t know how I can do it. Physical problems 19 65.5 Distress regarding examinations 2 6.9 Distress regarding hearing a result of an examination 1 3.4 I feel distressed about the results of the monthly check-up. Distress regarding having to undergo an examination 1 3.4 I suffer from side effects of iodine used in CT scans and examination by gastric cameras that I need to undergo once every 3 months or half a year. Side effects and after effects 18 62.1 General symptoms of side effects 6 20.7 I am not sure how to cope with side effects. Sleepiness 2 6.9 Increased drowsiness owing to the increasing dosage of OxyContin. Oral problems 1 3.4 I cannot remove the pus from the tooth root caused by the side effects of the treatment. Wobble 1 3.4 I do not know whether it is due to side effects, but I feel dizzy. Difficulty in controlling weight 1 3.4 Increase in weight as a side effect of the drugs. Nail and skin problems 2 6.9 Detachment of nails due to the side effects of the treatment. Numbness 1 3.4 I do not know the sequelae of side effects, but I experience tingling in my body. Decline in cognitive function 1 3.4 I have become forgetful. I have a short memory span. Things that I cannot control are increasing. For example, I do not remember yesterday’s meal, or a telephone number without writing it down. Nausea 2 6.9 Because of anticancer drugs, I feel nauseated by the smell of food. Difficulty in controlling bowel movements 3 10.3 It is more difficult to manage constipation now than it was before. Fatigue 3 10.3 I do not know whether this is because of the cancer medicine, but I feel fatigued. Difficulty related to eating 4 13.8 I cannot eat. Physical pain 2 6.9 I want to manage pain. Developing another disease as an effect of treatment 1 3.4 I have developed high blood sugar levels because of the effect of chemotherapy. Therefore, I need to take insulin injections. Bad physical condition 9 31.0 When I meet people or go out, I get tired. Physical deconditioning 2 6.9 Decline in physical strength 4 13.8 Decline in my physical strength. Loss of or decline in physical functions 3 10.3 My eyes felt heavy, and I was diagnosed with glaucoma. Metastasis 1 3.4 Just metastasis. Social relations 22 75.9 Dis-communication with others 10 34.5 Dis-communication with family 5 17.2 I trust my family doctor, but my family is opposed to going to the doctor. Dis-communication with medical staff 4 13.8 I have problems in communicating with my doctor. He is a great doctor, so I cannot express what I want to say. Dis-communication with friends or acquaintances 2 6.9 I cannot talk to my tennis friends about my cancer. Negative attitude of people around 2 6.9 Negative attitude of family 2 6.9 My problem is that my husband’s attitude is bewildered. Not having a sense of contribution 2 6.9 Sense of inadequacy for the family 2 6.9 I cannot do enough for my family. I want to help people. Insufficient trust in relationships with others 3 10.3 Insufficient trust in the relationship with medical staff or the hospital 3 10.3 I cannot trust my doctor. Decreased interactions with others 4 13.8 Decreased interactions with friends or acquaintances 4 13.8 I want to maintain the pace of associating with others, but I cannot. Inadequate social support 3 10.3 Absence of social support 2 6.9 Because I live alone, I worry that I may die alone (Kodoku-shi). Receiving unwanted support 1 3.4 My wife’s support is sometime hard for me. Issues related to the family 8 27.6 Need for family caregiving or care 5 17.2 I am stressed about taking care of my wife, who has dementia. Bad relationship between family members 1 3.4 My son does not visit his father in the hospital. Others 3 10.3 Home issues. Issues related to moving our family grave. Social living environment 14 48.3 Interference with daily life 6 20.7 Not being able to spend time in leisure activities 5 17.2 I want to go mountain climbing, but I can’t. not doing disposition before own death 2 6.9 I want to clean up the room before I die. Not being able to plan one’s day 1 3.4 I need to make a list of what to do in everyday life (1week/1 day). How to act. Interference with work or housework 6 20.7 Inability to decide whether to resign from work 4 13.8 I cannot decide whether I can work or not. Interference with work 2 6.9 Because of the pain, I cannot organize my work well. Interference with housework 1 3.4 Housework is not going my way. Economic hardships 3 10.3 Difficulty in meeting medical expenses 2 6.9 Economic issues, including arranging for palliative care. Difficulty in meeting living expenses 1 3.4 My son does not provide me living expenses. Table 3. Problems reported by participants (N = 29) Categories N % Examples of contents reported by participants Psychological and existential problems 20 69.0 Anxiety/concern 17 58.6 Concern about death or dying 6 20.7 I cannot help being aware of and thinking about how long I will live. Concern about treatments and side effects 6 20.7 I am not sure if I can adapt well to the side effects of the anticancer drugs. Concern about relapse and metastasis 5 17.2 I gloomy think about the recurrence of cancer. Concern about emotional control 4 13.8 I am worried about whether it is not being bothered by emotion. Concern about coping with problems 3 10.3 I do not know how to formulate my problem. Concern about family issues 2 6.9 I live with my husband and he is diabetic and alcohol dependent. I am worried about what I will do if my husband falls ill. Concern about pain associated with the advancement of the disease 2 6.9 When the cancer progresses and gets painful, how long I will be able to endure. Concern about work 2 6.9 I am concerned about whether I can return to my job. Vague sense of uneasiness 2 6.9 I have to keep myself busy with something, or else I’m filled with anxiety. Concern about acquiring infections 1 3.4 I am worried about catching an influenza infection because the performances are conducted in a crowded place. Concern about decline in physical strength 1 3.4 I am worried about for how long my physical strength will continue to decline. Depressive symptoms 6 20.7 Decreasing motivation or vigor 5 17.2 I feel de-motivated. Feeling depressed 1 3.4 I feel depressed. Irritation 2 6.9 Feeling irritated 2 6.9 I am irritated that I cannot move freely by myself. Uncertain about the prospect of life 3 10.3 Uncertain about future prospects 2 6.9 There is a gap between the general trend (survival rate) and current situation (treatment), so I cannot make a prospect for the future. Whether or not to know about future prospects 2 6.9 I am not sure if I should know about my life expectancy. Unusual sense of time 2 6.9 Experiencing a gap in one’s time perception 2 6.9 I felt that the time moved slowly. For example, a period of less than 1 minute seemed like 5 to 10 minutes. I was perplexed by the gap between my feeling and the reality. Existential pain 4 13.8 Pain about life and death 1 3.4 I cannot think that I am alive. Change in life plan 1 3.4 My life plan has changed due to cancer. Hoping for a good life and death 2 6.9 I want to live with cancer while giving priority to my quality of life. However, I don’t know how I can do it. Physical problems 19 65.5 Distress regarding examinations 2 6.9 Distress regarding hearing a result of an examination 1 3.4 I feel distressed about the results of the monthly check-up. Distress regarding having to undergo an examination 1 3.4 I suffer from side effects of iodine used in CT scans and examination by gastric cameras that I need to undergo once every 3 months or half a year. Side effects and after effects 18 62.1 General symptoms of side effects 6 20.7 I am not sure how to cope with side effects. Sleepiness 2 6.9 Increased drowsiness owing to the increasing dosage of OxyContin. Oral problems 1 3.4 I cannot remove the pus from the tooth root caused by the side effects of the treatment. Wobble 1 3.4 I do not know whether it is due to side effects, but I feel dizzy. Difficulty in controlling weight 1 3.4 Increase in weight as a side effect of the drugs. Nail and skin problems 2 6.9 Detachment of nails due to the side effects of the treatment. Numbness 1 3.4 I do not know the sequelae of side effects, but I experience tingling in my body. Decline in cognitive function 1 3.4 I have become forgetful. I have a short memory span. Things that I cannot control are increasing. For example, I do not remember yesterday’s meal, or a telephone number without writing it down. Nausea 2 6.9 Because of anticancer drugs, I feel nauseated by the smell of food. Difficulty in controlling bowel movements 3 10.3 It is more difficult to manage constipation now than it was before. Fatigue 3 10.3 I do not know whether this is because of the cancer medicine, but I feel fatigued. Difficulty related to eating 4 13.8 I cannot eat. Physical pain 2 6.9 I want to manage pain. Developing another disease as an effect of treatment 1 3.4 I have developed high blood sugar levels because of the effect of chemotherapy. Therefore, I need to take insulin injections. Bad physical condition 9 31.0 When I meet people or go out, I get tired. Physical deconditioning 2 6.9 Decline in physical strength 4 13.8 Decline in my physical strength. Loss of or decline in physical functions 3 10.3 My eyes felt heavy, and I was diagnosed with glaucoma. Metastasis 1 3.4 Just metastasis. Social relations 22 75.9 Dis-communication with others 10 34.5 Dis-communication with family 5 17.2 I trust my family doctor, but my family is opposed to going to the doctor. Dis-communication with medical staff 4 13.8 I have problems in communicating with my doctor. He is a great doctor, so I cannot express what I want to say. Dis-communication with friends or acquaintances 2 6.9 I cannot talk to my tennis friends about my cancer. Negative attitude of people around 2 6.9 Negative attitude of family 2 6.9 My problem is that my husband’s attitude is bewildered. Not having a sense of contribution 2 6.9 Sense of inadequacy for the family 2 6.9 I cannot do enough for my family. I want to help people. Insufficient trust in relationships with others 3 10.3 Insufficient trust in the relationship with medical staff or the hospital 3 10.3 I cannot trust my doctor. Decreased interactions with others 4 13.8 Decreased interactions with friends or acquaintances 4 13.8 I want to maintain the pace of associating with others, but I cannot. Inadequate social support 3 10.3 Absence of social support 2 6.9 Because I live alone, I worry that I may die alone (Kodoku-shi). Receiving unwanted support 1 3.4 My wife’s support is sometime hard for me. Issues related to the family 8 27.6 Need for family caregiving or care 5 17.2 I am stressed about taking care of my wife, who has dementia. Bad relationship between family members 1 3.4 My son does not visit his father in the hospital. Others 3 10.3 Home issues. Issues related to moving our family grave. Social living environment 14 48.3 Interference with daily life 6 20.7 Not being able to spend time in leisure activities 5 17.2 I want to go mountain climbing, but I can’t. not doing disposition before own death 2 6.9 I want to clean up the room before I die. Not being able to plan one’s day 1 3.4 I need to make a list of what to do in everyday life (1week/1 day). How to act. Interference with work or housework 6 20.7 Inability to decide whether to resign from work 4 13.8 I cannot decide whether I can work or not. Interference with work 2 6.9 Because of the pain, I cannot organize my work well. Interference with housework 1 3.4 Housework is not going my way. Economic hardships 3 10.3 Difficulty in meeting medical expenses 2 6.9 Economic issues, including arranging for palliative care. Difficulty in meeting living expenses 1 3.4 My son does not provide me living expenses. Categories N % Examples of contents reported by participants Psychological and existential problems 20 69.0 Anxiety/concern 17 58.6 Concern about death or dying 6 20.7 I cannot help being aware of and thinking about how long I will live. Concern about treatments and side effects 6 20.7 I am not sure if I can adapt well to the side effects of the anticancer drugs. Concern about relapse and metastasis 5 17.2 I gloomy think about the recurrence of cancer. Concern about emotional control 4 13.8 I am worried about whether it is not being bothered by emotion. Concern about coping with problems 3 10.3 I do not know how to formulate my problem. Concern about family issues 2 6.9 I live with my husband and he is diabetic and alcohol dependent. I am worried about what I will do if my husband falls ill. Concern about pain associated with the advancement of the disease 2 6.9 When the cancer progresses and gets painful, how long I will be able to endure. Concern about work 2 6.9 I am concerned about whether I can return to my job. Vague sense of uneasiness 2 6.9 I have to keep myself busy with something, or else I’m filled with anxiety. Concern about acquiring infections 1 3.4 I am worried about catching an influenza infection because the performances are conducted in a crowded place. Concern about decline in physical strength 1 3.4 I am worried about for how long my physical strength will continue to decline. Depressive symptoms 6 20.7 Decreasing motivation or vigor 5 17.2 I feel de-motivated. Feeling depressed 1 3.4 I feel depressed. Irritation 2 6.9 Feeling irritated 2 6.9 I am irritated that I cannot move freely by myself. Uncertain about the prospect of life 3 10.3 Uncertain about future prospects 2 6.9 There is a gap between the general trend (survival rate) and current situation (treatment), so I cannot make a prospect for the future. Whether or not to know about future prospects 2 6.9 I am not sure if I should know about my life expectancy. Unusual sense of time 2 6.9 Experiencing a gap in one’s time perception 2 6.9 I felt that the time moved slowly. For example, a period of less than 1 minute seemed like 5 to 10 minutes. I was perplexed by the gap between my feeling and the reality. Existential pain 4 13.8 Pain about life and death 1 3.4 I cannot think that I am alive. Change in life plan 1 3.4 My life plan has changed due to cancer. Hoping for a good life and death 2 6.9 I want to live with cancer while giving priority to my quality of life. However, I don’t know how I can do it. Physical problems 19 65.5 Distress regarding examinations 2 6.9 Distress regarding hearing a result of an examination 1 3.4 I feel distressed about the results of the monthly check-up. Distress regarding having to undergo an examination 1 3.4 I suffer from side effects of iodine used in CT scans and examination by gastric cameras that I need to undergo once every 3 months or half a year. Side effects and after effects 18 62.1 General symptoms of side effects 6 20.7 I am not sure how to cope with side effects. Sleepiness 2 6.9 Increased drowsiness owing to the increasing dosage of OxyContin. Oral problems 1 3.4 I cannot remove the pus from the tooth root caused by the side effects of the treatment. Wobble 1 3.4 I do not know whether it is due to side effects, but I feel dizzy. Difficulty in controlling weight 1 3.4 Increase in weight as a side effect of the drugs. Nail and skin problems 2 6.9 Detachment of nails due to the side effects of the treatment. Numbness 1 3.4 I do not know the sequelae of side effects, but I experience tingling in my body. Decline in cognitive function 1 3.4 I have become forgetful. I have a short memory span. Things that I cannot control are increasing. For example, I do not remember yesterday’s meal, or a telephone number without writing it down. Nausea 2 6.9 Because of anticancer drugs, I feel nauseated by the smell of food. Difficulty in controlling bowel movements 3 10.3 It is more difficult to manage constipation now than it was before. Fatigue 3 10.3 I do not know whether this is because of the cancer medicine, but I feel fatigued. Difficulty related to eating 4 13.8 I cannot eat. Physical pain 2 6.9 I want to manage pain. Developing another disease as an effect of treatment 1 3.4 I have developed high blood sugar levels because of the effect of chemotherapy. Therefore, I need to take insulin injections. Bad physical condition 9 31.0 When I meet people or go out, I get tired. Physical deconditioning 2 6.9 Decline in physical strength 4 13.8 Decline in my physical strength. Loss of or decline in physical functions 3 10.3 My eyes felt heavy, and I was diagnosed with glaucoma. Metastasis 1 3.4 Just metastasis. Social relations 22 75.9 Dis-communication with others 10 34.5 Dis-communication with family 5 17.2 I trust my family doctor, but my family is opposed to going to the doctor. Dis-communication with medical staff 4 13.8 I have problems in communicating with my doctor. He is a great doctor, so I cannot express what I want to say. Dis-communication with friends or acquaintances 2 6.9 I cannot talk to my tennis friends about my cancer. Negative attitude of people around 2 6.9 Negative attitude of family 2 6.9 My problem is that my husband’s attitude is bewildered. Not having a sense of contribution 2 6.9 Sense of inadequacy for the family 2 6.9 I cannot do enough for my family. I want to help people. Insufficient trust in relationships with others 3 10.3 Insufficient trust in the relationship with medical staff or the hospital 3 10.3 I cannot trust my doctor. Decreased interactions with others 4 13.8 Decreased interactions with friends or acquaintances 4 13.8 I want to maintain the pace of associating with others, but I cannot. Inadequate social support 3 10.3 Absence of social support 2 6.9 Because I live alone, I worry that I may die alone (Kodoku-shi). Receiving unwanted support 1 3.4 My wife’s support is sometime hard for me. Issues related to the family 8 27.6 Need for family caregiving or care 5 17.2 I am stressed about taking care of my wife, who has dementia. Bad relationship between family members 1 3.4 My son does not visit his father in the hospital. Others 3 10.3 Home issues. Issues related to moving our family grave. Social living environment 14 48.3 Interference with daily life 6 20.7 Not being able to spend time in leisure activities 5 17.2 I want to go mountain climbing, but I can’t. not doing disposition before own death 2 6.9 I want to clean up the room before I die. Not being able to plan one’s day 1 3.4 I need to make a list of what to do in everyday life (1week/1 day). How to act. Interference with work or housework 6 20.7 Inability to decide whether to resign from work 4 13.8 I cannot decide whether I can work or not. Interference with work 2 6.9 Because of the pain, I cannot organize my work well. Interference with housework 1 3.4 Housework is not going my way. Economic hardships 3 10.3 Difficulty in meeting medical expenses 2 6.9 Economic issues, including arranging for palliative care. Difficulty in meeting living expenses 1 3.4 My son does not provide me living expenses. Associations of problem categories with characteristics of participants We examined the associations of problem domains with characteristics of participants: age, sex, onset, disease state, treatment status and HADS score. Findings revealed that participants under treatment at baseline reported psychological and existential problems most often (P < 0.05), followed by problems related to the social living environment (P < 0.10). Additionally, younger patients reported psychological and existential problems more often (P < 0.10) (Table 4). Table 4. Associations of problem categories and characteristics of participants Psychological and existential problems Physical problems Social Relations Social living environment N % P N % P N % P N % P Age  Young 14 48.3 0.056† 13 44.8 0.443 13 44.8 0.698 11 37.9 0.139  Old 6 20.7 8 27.6 9 31.0 4 13.8 Sex  Male 7 24.1 0.461 8 27.6 1.000 9 31.0 1.000 5 17.2 0.710  Female 13 44.8 13 44.8 13 44.8 10 34.5 Primary/Relapse  Primary 16 55.2 0.272 18 62.1 1.000 19 65.5 1.000 13 44.8 1.000  Relapse 4 13.8 3 10.3 3 10.3 2 6.9 Disease State  Not terminal 17 58.6 1.000 17 58.6 0.278 19 65.5 1.000 12 41.4 0.598  Terminal 3 10.3 4 13.8 3 10.3 3 10.3 Treatment State  No treatment 1 3.4 0.007* 3 10.3 0.311 5 17.2 0.640 1 3.4 0.069†  Under treatment 18 62.1 17 58.6 15 51.7 14 48.3 HADS  Adjustment 6 20.7 1.000 6 20.7 1.000 7 24.1 0.635 2 6.9 0.109  Adjustment disorder/major depression 14 48.3 15 51.7 15 51.7 13 44.8 Psychological and existential problems Physical problems Social Relations Social living environment N % P N % P N % P N % P Age  Young 14 48.3 0.056† 13 44.8 0.443 13 44.8 0.698 11 37.9 0.139  Old 6 20.7 8 27.6 9 31.0 4 13.8 Sex  Male 7 24.1 0.461 8 27.6 1.000 9 31.0 1.000 5 17.2 0.710  Female 13 44.8 13 44.8 13 44.8 10 34.5 Primary/Relapse  Primary 16 55.2 0.272 18 62.1 1.000 19 65.5 1.000 13 44.8 1.000  Relapse 4 13.8 3 10.3 3 10.3 2 6.9 Disease State  Not terminal 17 58.6 1.000 17 58.6 0.278 19 65.5 1.000 12 41.4 0.598  Terminal 3 10.3 4 13.8 3 10.3 3 10.3 Treatment State  No treatment 1 3.4 0.007* 3 10.3 0.311 5 17.2 0.640 1 3.4 0.069†  Under treatment 18 62.1 17 58.6 15 51.7 14 48.3 HADS  Adjustment 6 20.7 1.000 6 20.7 1.000 7 24.1 0.635 2 6.9 0.109  Adjustment disorder/major depression 14 48.3 15 51.7 15 51.7 13 44.8 †P < 0.10, *P < 0.05. Table 4. Associations of problem categories and characteristics of participants Psychological and existential problems Physical problems Social Relations Social living environment N % P N % P N % P N % P Age  Young 14 48.3 0.056† 13 44.8 0.443 13 44.8 0.698 11 37.9 0.139  Old 6 20.7 8 27.6 9 31.0 4 13.8 Sex  Male 7 24.1 0.461 8 27.6 1.000 9 31.0 1.000 5 17.2 0.710  Female 13 44.8 13 44.8 13 44.8 10 34.5 Primary/Relapse  Primary 16 55.2 0.272 18 62.1 1.000 19 65.5 1.000 13 44.8 1.000  Relapse 4 13.8 3 10.3 3 10.3 2 6.9 Disease State  Not terminal 17 58.6 1.000 17 58.6 0.278 19 65.5 1.000 12 41.4 0.598  Terminal 3 10.3 4 13.8 3 10.3 3 10.3 Treatment State  No treatment 1 3.4 0.007* 3 10.3 0.311 5 17.2 0.640 1 3.4 0.069†  Under treatment 18 62.1 17 58.6 15 51.7 14 48.3 HADS  Adjustment 6 20.7 1.000 6 20.7 1.000 7 24.1 0.635 2 6.9 0.109  Adjustment disorder/major depression 14 48.3 15 51.7 15 51.7 13 44.8 Psychological and existential problems Physical problems Social Relations Social living environment N % P N % P N % P N % P Age  Young 14 48.3 0.056† 13 44.8 0.443 13 44.8 0.698 11 37.9 0.139  Old 6 20.7 8 27.6 9 31.0 4 13.8 Sex  Male 7 24.1 0.461 8 27.6 1.000 9 31.0 1.000 5 17.2 0.710  Female 13 44.8 13 44.8 13 44.8 10 34.5 Primary/Relapse  Primary 16 55.2 0.272 18 62.1 1.000 19 65.5 1.000 13 44.8 1.000  Relapse 4 13.8 3 10.3 3 10.3 2 6.9 Disease State  Not terminal 17 58.6 1.000 17 58.6 0.278 19 65.5 1.000 12 41.4 0.598  Terminal 3 10.3 4 13.8 3 10.3 3 10.3 Treatment State  No treatment 1 3.4 0.007* 3 10.3 0.311 5 17.2 0.640 1 3.4 0.069†  Under treatment 18 62.1 17 58.6 15 51.7 14 48.3 HADS  Adjustment 6 20.7 1.000 6 20.7 1.000 7 24.1 0.635 2 6.9 0.109  Adjustment disorder/major depression 14 48.3 15 51.7 15 51.7 13 44.8 †P < 0.10, *P < 0.05. Goals (N = 30) The participants reported 80 goals, with a mean number of 2.6 items per person (range = 1–7). These goals were categorized into 33 small-categories, which converged to 13 mid-level categories and four conceptualized domains (Table 5). Table 5. Goals (N = 30) Categories N % Examples of contents reported by participants Improving mental health 6 20.0 Regulating own emotions 6 20.0 Maintaining own mental state 3 10.0 I want to keep my mind normal. Forgetting about the cancer 2 6.7 I would like to reduce the number of times that I think ‘Why do I do such things’ or ‘Such easy thing.’ Understanding one’s mental status 1 3.3 I have become more aware of my feelings. Improving physical functions 18 60.0 Gathering information about side effects and future prospects 4 13.3 Gathering information from professionals 2 6.7 Summarize questions for asking experts. Gathering information from patients with same disease 1 3.3 Considering the anxiety that I experience, I want to know from members of the patient association about how they handle such feelings. Others 1 3.3 Collecting information on anticancer drugs. Coping with the side effects 9 30.0 Coping with the distress of side effects 2 6.7 To reduce side effects, I am going to read and get some exercise. Improving bowel control 2 6.7 I want to reduce constipation. Improving eating behavior 2 6.7 Looking out for what I can eat. Coping with a pain 1 3.3 I hope that the pain in my hand will heal. Improving sleepiness 1 3.3 I want to manage sleepiness. Reconstructing one’s body 1 3.3 I want to reconstruct my breast. Improving physical condition 12 40.0 Increasing or maintaining physical strength 7 23.3 Developing the physical strength to be able to act for the next six months. Achieving a healthy state 3 10.0 I do not want to have to ultimately visit the hospital. Maintaining one’s current condition 3 10.0 I do not want my physical condition to deteriorate. Controlling one’s weight 2 6.7 I want to lose the weight I gained because of the hormonal drug. Improving social relations 10 33.3 Identifying ways to communicate with others 2 6.7 Organizing the contents of what to say to others 1 3.3 Organizing what you want to say. Others 1 3.3 Preparing to help my wife take her medicines on time. Now, I put her medicines on the calendar. Adjusting one’s relationship with others 4 13.3 Adjusting the relationship with friends or acquaintances 2 6.7 I want to list up the people I associate with and categorize them based on the level of my aggressiveness of interacting with them. Adjusting the relationship with one’s family 2 6.7 I want to keep my ordinary mother in good mood for the youngest child. Adjusting the relationship with medical staff 1 3.3 Improving a relationship of trust with my doctor. Interacting with others 4 13.3 Interacting with friends and acquaintances 4 13.3 Creating opportunities to interact with people. Contributing to others 2 6.7 Being of help for others 2 6.7 I want to help people. Improving one’s social living environment 15 50.0 Planning and executing actions 3 10.0 Activity vitalization 2 6.7 I want to do something fun. Setting a behavioral goal 1 3.3 I want to remember the goals I had before. Planning and engaging in a leisure activity 9 30.0 Engaging in a leisure activity 8 26.7 I want to enjoy my hobbies (karaoke, sewing, painting). Using a service for leisure activity 2 6.7 Participating in a solo travel plan offered by travel companies. Purchasing tools for a leisure activity 1 3.3 Purchasing a new digital camera for motivating oneself. Planning a leisure activity 1 3.3 Planning a enjoyable trip abroad with my family. Thinking about one’s course of work 1 3.3 Consulting with people at one’s workplace 1 3.3 Asking my boss to give me consultation time. I cannot do anything by myself. I ask him/her to hear my story. Working and doing housework 5 16.7 Working 3 10.0 Planning to make my job easier by next week. Doing housework 2 6.7 I implemented the tip of managing the medicine drip. So I devise a plan to make time and visit the supermarket. Improving one’s economic status 1 3.3 Securing funds to cover living costs 1 3.3 Getting living expenses from my son without feeling stressed about it. Categories N % Examples of contents reported by participants Improving mental health 6 20.0 Regulating own emotions 6 20.0 Maintaining own mental state 3 10.0 I want to keep my mind normal. Forgetting about the cancer 2 6.7 I would like to reduce the number of times that I think ‘Why do I do such things’ or ‘Such easy thing.’ Understanding one’s mental status 1 3.3 I have become more aware of my feelings. Improving physical functions 18 60.0 Gathering information about side effects and future prospects 4 13.3 Gathering information from professionals 2 6.7 Summarize questions for asking experts. Gathering information from patients with same disease 1 3.3 Considering the anxiety that I experience, I want to know from members of the patient association about how they handle such feelings. Others 1 3.3 Collecting information on anticancer drugs. Coping with the side effects 9 30.0 Coping with the distress of side effects 2 6.7 To reduce side effects, I am going to read and get some exercise. Improving bowel control 2 6.7 I want to reduce constipation. Improving eating behavior 2 6.7 Looking out for what I can eat. Coping with a pain 1 3.3 I hope that the pain in my hand will heal. Improving sleepiness 1 3.3 I want to manage sleepiness. Reconstructing one’s body 1 3.3 I want to reconstruct my breast. Improving physical condition 12 40.0 Increasing or maintaining physical strength 7 23.3 Developing the physical strength to be able to act for the next six months. Achieving a healthy state 3 10.0 I do not want to have to ultimately visit the hospital. Maintaining one’s current condition 3 10.0 I do not want my physical condition to deteriorate. Controlling one’s weight 2 6.7 I want to lose the weight I gained because of the hormonal drug. Improving social relations 10 33.3 Identifying ways to communicate with others 2 6.7 Organizing the contents of what to say to others 1 3.3 Organizing what you want to say. Others 1 3.3 Preparing to help my wife take her medicines on time. Now, I put her medicines on the calendar. Adjusting one’s relationship with others 4 13.3 Adjusting the relationship with friends or acquaintances 2 6.7 I want to list up the people I associate with and categorize them based on the level of my aggressiveness of interacting with them. Adjusting the relationship with one’s family 2 6.7 I want to keep my ordinary mother in good mood for the youngest child. Adjusting the relationship with medical staff 1 3.3 Improving a relationship of trust with my doctor. Interacting with others 4 13.3 Interacting with friends and acquaintances 4 13.3 Creating opportunities to interact with people. Contributing to others 2 6.7 Being of help for others 2 6.7 I want to help people. Improving one’s social living environment 15 50.0 Planning and executing actions 3 10.0 Activity vitalization 2 6.7 I want to do something fun. Setting a behavioral goal 1 3.3 I want to remember the goals I had before. Planning and engaging in a leisure activity 9 30.0 Engaging in a leisure activity 8 26.7 I want to enjoy my hobbies (karaoke, sewing, painting). Using a service for leisure activity 2 6.7 Participating in a solo travel plan offered by travel companies. Purchasing tools for a leisure activity 1 3.3 Purchasing a new digital camera for motivating oneself. Planning a leisure activity 1 3.3 Planning a enjoyable trip abroad with my family. Thinking about one’s course of work 1 3.3 Consulting with people at one’s workplace 1 3.3 Asking my boss to give me consultation time. I cannot do anything by myself. I ask him/her to hear my story. Working and doing housework 5 16.7 Working 3 10.0 Planning to make my job easier by next week. Doing housework 2 6.7 I implemented the tip of managing the medicine drip. So I devise a plan to make time and visit the supermarket. Improving one’s economic status 1 3.3 Securing funds to cover living costs 1 3.3 Getting living expenses from my son without feeling stressed about it. Table 5. Goals (N = 30) Categories N % Examples of contents reported by participants Improving mental health 6 20.0 Regulating own emotions 6 20.0 Maintaining own mental state 3 10.0 I want to keep my mind normal. Forgetting about the cancer 2 6.7 I would like to reduce the number of times that I think ‘Why do I do such things’ or ‘Such easy thing.’ Understanding one’s mental status 1 3.3 I have become more aware of my feelings. Improving physical functions 18 60.0 Gathering information about side effects and future prospects 4 13.3 Gathering information from professionals 2 6.7 Summarize questions for asking experts. Gathering information from patients with same disease 1 3.3 Considering the anxiety that I experience, I want to know from members of the patient association about how they handle such feelings. Others 1 3.3 Collecting information on anticancer drugs. Coping with the side effects 9 30.0 Coping with the distress of side effects 2 6.7 To reduce side effects, I am going to read and get some exercise. Improving bowel control 2 6.7 I want to reduce constipation. Improving eating behavior 2 6.7 Looking out for what I can eat. Coping with a pain 1 3.3 I hope that the pain in my hand will heal. Improving sleepiness 1 3.3 I want to manage sleepiness. Reconstructing one’s body 1 3.3 I want to reconstruct my breast. Improving physical condition 12 40.0 Increasing or maintaining physical strength 7 23.3 Developing the physical strength to be able to act for the next six months. Achieving a healthy state 3 10.0 I do not want to have to ultimately visit the hospital. Maintaining one’s current condition 3 10.0 I do not want my physical condition to deteriorate. Controlling one’s weight 2 6.7 I want to lose the weight I gained because of the hormonal drug. Improving social relations 10 33.3 Identifying ways to communicate with others 2 6.7 Organizing the contents of what to say to others 1 3.3 Organizing what you want to say. Others 1 3.3 Preparing to help my wife take her medicines on time. Now, I put her medicines on the calendar. Adjusting one’s relationship with others 4 13.3 Adjusting the relationship with friends or acquaintances 2 6.7 I want to list up the people I associate with and categorize them based on the level of my aggressiveness of interacting with them. Adjusting the relationship with one’s family 2 6.7 I want to keep my ordinary mother in good mood for the youngest child. Adjusting the relationship with medical staff 1 3.3 Improving a relationship of trust with my doctor. Interacting with others 4 13.3 Interacting with friends and acquaintances 4 13.3 Creating opportunities to interact with people. Contributing to others 2 6.7 Being of help for others 2 6.7 I want to help people. Improving one’s social living environment 15 50.0 Planning and executing actions 3 10.0 Activity vitalization 2 6.7 I want to do something fun. Setting a behavioral goal 1 3.3 I want to remember the goals I had before. Planning and engaging in a leisure activity 9 30.0 Engaging in a leisure activity 8 26.7 I want to enjoy my hobbies (karaoke, sewing, painting). Using a service for leisure activity 2 6.7 Participating in a solo travel plan offered by travel companies. Purchasing tools for a leisure activity 1 3.3 Purchasing a new digital camera for motivating oneself. Planning a leisure activity 1 3.3 Planning a enjoyable trip abroad with my family. Thinking about one’s course of work 1 3.3 Consulting with people at one’s workplace 1 3.3 Asking my boss to give me consultation time. I cannot do anything by myself. I ask him/her to hear my story. Working and doing housework 5 16.7 Working 3 10.0 Planning to make my job easier by next week. Doing housework 2 6.7 I implemented the tip of managing the medicine drip. So I devise a plan to make time and visit the supermarket. Improving one’s economic status 1 3.3 Securing funds to cover living costs 1 3.3 Getting living expenses from my son without feeling stressed about it. Categories N % Examples of contents reported by participants Improving mental health 6 20.0 Regulating own emotions 6 20.0 Maintaining own mental state 3 10.0 I want to keep my mind normal. Forgetting about the cancer 2 6.7 I would like to reduce the number of times that I think ‘Why do I do such things’ or ‘Such easy thing.’ Understanding one’s mental status 1 3.3 I have become more aware of my feelings. Improving physical functions 18 60.0 Gathering information about side effects and future prospects 4 13.3 Gathering information from professionals 2 6.7 Summarize questions for asking experts. Gathering information from patients with same disease 1 3.3 Considering the anxiety that I experience, I want to know from members of the patient association about how they handle such feelings. Others 1 3.3 Collecting information on anticancer drugs. Coping with the side effects 9 30.0 Coping with the distress of side effects 2 6.7 To reduce side effects, I am going to read and get some exercise. Improving bowel control 2 6.7 I want to reduce constipation. Improving eating behavior 2 6.7 Looking out for what I can eat. Coping with a pain 1 3.3 I hope that the pain in my hand will heal. Improving sleepiness 1 3.3 I want to manage sleepiness. Reconstructing one’s body 1 3.3 I want to reconstruct my breast. Improving physical condition 12 40.0 Increasing or maintaining physical strength 7 23.3 Developing the physical strength to be able to act for the next six months. Achieving a healthy state 3 10.0 I do not want to have to ultimately visit the hospital. Maintaining one’s current condition 3 10.0 I do not want my physical condition to deteriorate. Controlling one’s weight 2 6.7 I want to lose the weight I gained because of the hormonal drug. Improving social relations 10 33.3 Identifying ways to communicate with others 2 6.7 Organizing the contents of what to say to others 1 3.3 Organizing what you want to say. Others 1 3.3 Preparing to help my wife take her medicines on time. Now, I put her medicines on the calendar. Adjusting one’s relationship with others 4 13.3 Adjusting the relationship with friends or acquaintances 2 6.7 I want to list up the people I associate with and categorize them based on the level of my aggressiveness of interacting with them. Adjusting the relationship with one’s family 2 6.7 I want to keep my ordinary mother in good mood for the youngest child. Adjusting the relationship with medical staff 1 3.3 Improving a relationship of trust with my doctor. Interacting with others 4 13.3 Interacting with friends and acquaintances 4 13.3 Creating opportunities to interact with people. Contributing to others 2 6.7 Being of help for others 2 6.7 I want to help people. Improving one’s social living environment 15 50.0 Planning and executing actions 3 10.0 Activity vitalization 2 6.7 I want to do something fun. Setting a behavioral goal 1 3.3 I want to remember the goals I had before. Planning and engaging in a leisure activity 9 30.0 Engaging in a leisure activity 8 26.7 I want to enjoy my hobbies (karaoke, sewing, painting). Using a service for leisure activity 2 6.7 Participating in a solo travel plan offered by travel companies. Purchasing tools for a leisure activity 1 3.3 Purchasing a new digital camera for motivating oneself. Planning a leisure activity 1 3.3 Planning a enjoyable trip abroad with my family. Thinking about one’s course of work 1 3.3 Consulting with people at one’s workplace 1 3.3 Asking my boss to give me consultation time. I cannot do anything by myself. I ask him/her to hear my story. Working and doing housework 5 16.7 Working 3 10.0 Planning to make my job easier by next week. Doing housework 2 6.7 I implemented the tip of managing the medicine drip. So I devise a plan to make time and visit the supermarket. Improving one’s economic status 1 3.3 Securing funds to cover living costs 1 3.3 Getting living expenses from my son without feeling stressed about it. Solution plans generated through the brainstorming work in therapy (N = 26) The participants reported 168 solution plans generated through the brainstorming work in therapy, with a mean number of 5.4 items per person (range = 1–15). These were categorized into 61 small-categories, which converged to 18 mid-level-categories and four conceptualized domains (Table 6). Table 6. Solutions by brainstorming (N = 26) Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 7 26.9 Regulating one’s emotions 4 15.4 Avoiding negative emotions 2 7.7 When I was in the depths of a bad situation, I avoided it for a while. Making recreational plans 2 7.7 Thinking about things that lead to a change of pace. Catharsis 1 3.8 Having a good cry. Using a psychological support service 1 3.8 Participating in A hospital’s cancer support program. Cognitive adjustment 4 15.4 Interpreting things positively 4 15.4 I think that I’m the best. Imagining an ideal situation 2 7.7 Imagining myself as healthy. Monitoring one’s thinking or behavior 1 3.8 I am going to introspect, and identify my weaknesses and ways to cope with them. Monitoring others’ thinking or behavior 1 3.8 Seeing healthy people. Health behaviors 15 57.7 Gathering information about side effects and future prospects 3 11.5 Gathering information from professionals 3 11.5 Asking about examination results and lifespan during a check-up. Consulting books or websites 1 3.8 Researching on side effects. Creating a list of information to be gathered 1 3.8 Listing out the queries I wish to ask my doctor. Gathering information from people with the same disease 1 3.8 Meeting experienced people and experts. Planning coping strategies for health issues 2 7.7 Considering various coping strategies for tackling health issues 2 7.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Leading a regular life 1 3.8 Adjusting one’s sleeping and waking time 1 3.8 Maintaining appropriate waking and sleep times. Relieving the body 4 15.4 Engaging in stretching exercises 2 7.7 Engaging in stretching exercises that can be easily done everyday. Massaging oneself 2 7.7 I’m going to massage to get abdominal muscles. Exercising 9 34.6 Walking 6 23.1 Walking 30 minutes before breakfast, 5 days a week. Engaging in gymnastics 4 15.4 Doing radio exercise, 5 days a week. Using a physical health service 3 11.5 Once a week, I will go to the gym class sponsored by the city. Engaging in some exercises 2 7.7 I will do something in the hospital to make up for the lack of exercise. Riding a bicycle 1 3.8 I will ride a bicycle for 15 minutes. Adjusting eating behaviors 4 15.4 Eating at one’s pace 3 11.5 I eat what I want to eat and when I want to eat. Staying hydrated 3 11.5 I try to stay hydrated. Cooking nutritionally balanced meals 1 3.8 I eat liver. Using a service for managing eating behavior 1 3.8 I’m going to use food-sampling corners in markets. Knowing about one’s physical condition 2 7.7 Buying appliances to assess health 1 3.8 Buying a weighing scale as a solution. Recording one’s health data 1 3.8 Recording my health data. Adjusting social relationships 13 50.0 Identifying ways of associating with others 6 23.1 Organizing ways to associate with others 3 11.5 Identifying the merits and disadvantages of each group that I interacted with before. Using an avoidant coping style 2 7.7 I’m not going to say anything in response to what my wife says. Letting relationships with others take their own course 1 3.8 I’m going to report what happens when I let relationships with others take their own course. Others 1 3.8 Recommending medication with supplements for my wife. Interacting with others 5 19.2 Doing things with someone 3 11.5 Walking with my husband every morning. Conversing with someone 2 7.7 Trying to chat with someone. Participating in a meeting 1 3.8 I would like to participate in a counseling group in which I can tell anything and in a financial planning group, if possible. Expressing one’s thoughts and feelings 3 11.5 Writing a letter or an e-mail 2 7.7 I’m going to write my present feelings and give it. Increasing the frequency of expressing oneself 1 3.8 Expressing persistently. Planning the content before talking with others 1 3.8 Sharing the purpose and reason with my doctor. Obtaining social support 5 19.2 Consulting an expert 3 11.5 Consulting a doctor about what to do when my physical condition changes or when problems occur. Consulting a family member 1 3.8 Consulting with my husband. Creating a list of questions to ask when consulting others 1 3.8 Noting down questions to ask. Seeking help for one’s family 1 3.8 I asked my husband to follow-up. Adjusting one’s social living environment 15 57.7 Planning and executing actions 5 19.2 Taking avoidant actions 3 11.5 Not doing hard. Considering coping strategies for tackling barriers to achieving one’s goal 1 3.8 I think about what to do when I get negative thoughts about not being able to reach my goal. Managing time effectively 1 3.8 I will take a bath by 10 o’clock. Setting a goal for taking action 1 3.8 I’m going to set goals for the morning, afternoon, and night each day. Strengthening the self 1 3.8 I’m going to go abroad as a reward for achieving my goal. Taking action 1 3.8 Acting more rather than thinking. Engaging in leisure activities 15 57.7 Spending time on a leisure activity 7 26.9 Watching DVDs that are not hard but positive. Using a service for a leisure activity 5 19.2 Applying for the offers made by a travel company. Consulting others about the leisure activity 3 11.5 Visiting a Chinese school. Deciding means for engaging in the leisure activity 3 11.5 Deciding whether to go on a tour or on a solo trip. Deciding the time and date for the leisure activity 2 7.7 Deciding when to go on a trip. Determining the contents of the leisure activity 2 7.7 Setting a theme for travel. Making preparations for executing the leisure activity 2 7.7 Preparing travel books from a book store or library. Preparing strategies to cope with worries pertaining to the leisure activity 2 7.7 To achieve my goal of climbing the mountain, I’m going to evaluate aspects I worry about. Recording the leisure activity 1 3.8 I’m going to walk near my home, and I’m going to record or take pictures while doing so. Taking a break 1 3.8 Taking a nap. Considering whether to continue working 1 3.8 Analysing the merits and demerits of one’s course of work 1 3.8 I’m going to consider the merits of retiring from work at the end of this business year. Working and doing housework 4 15.4 Doing housework 3 11.5 Cleaning the house twice a week, on Monday and Thursday. Working 2 7.7 Cleaning the apartment once a week, on Tuesday, as my job. Retiring or deciding to stop working 1 3.8 Retiring from work 1 3.8 Stopping the caretaker at the patient association. Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 7 26.9 Regulating one’s emotions 4 15.4 Avoiding negative emotions 2 7.7 When I was in the depths of a bad situation, I avoided it for a while. Making recreational plans 2 7.7 Thinking about things that lead to a change of pace. Catharsis 1 3.8 Having a good cry. Using a psychological support service 1 3.8 Participating in A hospital’s cancer support program. Cognitive adjustment 4 15.4 Interpreting things positively 4 15.4 I think that I’m the best. Imagining an ideal situation 2 7.7 Imagining myself as healthy. Monitoring one’s thinking or behavior 1 3.8 I am going to introspect, and identify my weaknesses and ways to cope with them. Monitoring others’ thinking or behavior 1 3.8 Seeing healthy people. Health behaviors 15 57.7 Gathering information about side effects and future prospects 3 11.5 Gathering information from professionals 3 11.5 Asking about examination results and lifespan during a check-up. Consulting books or websites 1 3.8 Researching on side effects. Creating a list of information to be gathered 1 3.8 Listing out the queries I wish to ask my doctor. Gathering information from people with the same disease 1 3.8 Meeting experienced people and experts. Planning coping strategies for health issues 2 7.7 Considering various coping strategies for tackling health issues 2 7.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Leading a regular life 1 3.8 Adjusting one’s sleeping and waking time 1 3.8 Maintaining appropriate waking and sleep times. Relieving the body 4 15.4 Engaging in stretching exercises 2 7.7 Engaging in stretching exercises that can be easily done everyday. Massaging oneself 2 7.7 I’m going to massage to get abdominal muscles. Exercising 9 34.6 Walking 6 23.1 Walking 30 minutes before breakfast, 5 days a week. Engaging in gymnastics 4 15.4 Doing radio exercise, 5 days a week. Using a physical health service 3 11.5 Once a week, I will go to the gym class sponsored by the city. Engaging in some exercises 2 7.7 I will do something in the hospital to make up for the lack of exercise. Riding a bicycle 1 3.8 I will ride a bicycle for 15 minutes. Adjusting eating behaviors 4 15.4 Eating at one’s pace 3 11.5 I eat what I want to eat and when I want to eat. Staying hydrated 3 11.5 I try to stay hydrated. Cooking nutritionally balanced meals 1 3.8 I eat liver. Using a service for managing eating behavior 1 3.8 I’m going to use food-sampling corners in markets. Knowing about one’s physical condition 2 7.7 Buying appliances to assess health 1 3.8 Buying a weighing scale as a solution. Recording one’s health data 1 3.8 Recording my health data. Adjusting social relationships 13 50.0 Identifying ways of associating with others 6 23.1 Organizing ways to associate with others 3 11.5 Identifying the merits and disadvantages of each group that I interacted with before. Using an avoidant coping style 2 7.7 I’m not going to say anything in response to what my wife says. Letting relationships with others take their own course 1 3.8 I’m going to report what happens when I let relationships with others take their own course. Others 1 3.8 Recommending medication with supplements for my wife. Interacting with others 5 19.2 Doing things with someone 3 11.5 Walking with my husband every morning. Conversing with someone 2 7.7 Trying to chat with someone. Participating in a meeting 1 3.8 I would like to participate in a counseling group in which I can tell anything and in a financial planning group, if possible. Expressing one’s thoughts and feelings 3 11.5 Writing a letter or an e-mail 2 7.7 I’m going to write my present feelings and give it. Increasing the frequency of expressing oneself 1 3.8 Expressing persistently. Planning the content before talking with others 1 3.8 Sharing the purpose and reason with my doctor. Obtaining social support 5 19.2 Consulting an expert 3 11.5 Consulting a doctor about what to do when my physical condition changes or when problems occur. Consulting a family member 1 3.8 Consulting with my husband. Creating a list of questions to ask when consulting others 1 3.8 Noting down questions to ask. Seeking help for one’s family 1 3.8 I asked my husband to follow-up. Adjusting one’s social living environment 15 57.7 Planning and executing actions 5 19.2 Taking avoidant actions 3 11.5 Not doing hard. Considering coping strategies for tackling barriers to achieving one’s goal 1 3.8 I think about what to do when I get negative thoughts about not being able to reach my goal. Managing time effectively 1 3.8 I will take a bath by 10 o’clock. Setting a goal for taking action 1 3.8 I’m going to set goals for the morning, afternoon, and night each day. Strengthening the self 1 3.8 I’m going to go abroad as a reward for achieving my goal. Taking action 1 3.8 Acting more rather than thinking. Engaging in leisure activities 15 57.7 Spending time on a leisure activity 7 26.9 Watching DVDs that are not hard but positive. Using a service for a leisure activity 5 19.2 Applying for the offers made by a travel company. Consulting others about the leisure activity 3 11.5 Visiting a Chinese school. Deciding means for engaging in the leisure activity 3 11.5 Deciding whether to go on a tour or on a solo trip. Deciding the time and date for the leisure activity 2 7.7 Deciding when to go on a trip. Determining the contents of the leisure activity 2 7.7 Setting a theme for travel. Making preparations for executing the leisure activity 2 7.7 Preparing travel books from a book store or library. Preparing strategies to cope with worries pertaining to the leisure activity 2 7.7 To achieve my goal of climbing the mountain, I’m going to evaluate aspects I worry about. Recording the leisure activity 1 3.8 I’m going to walk near my home, and I’m going to record or take pictures while doing so. Taking a break 1 3.8 Taking a nap. Considering whether to continue working 1 3.8 Analysing the merits and demerits of one’s course of work 1 3.8 I’m going to consider the merits of retiring from work at the end of this business year. Working and doing housework 4 15.4 Doing housework 3 11.5 Cleaning the house twice a week, on Monday and Thursday. Working 2 7.7 Cleaning the apartment once a week, on Tuesday, as my job. Retiring or deciding to stop working 1 3.8 Retiring from work 1 3.8 Stopping the caretaker at the patient association. Table 6. Solutions by brainstorming (N = 26) Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 7 26.9 Regulating one’s emotions 4 15.4 Avoiding negative emotions 2 7.7 When I was in the depths of a bad situation, I avoided it for a while. Making recreational plans 2 7.7 Thinking about things that lead to a change of pace. Catharsis 1 3.8 Having a good cry. Using a psychological support service 1 3.8 Participating in A hospital’s cancer support program. Cognitive adjustment 4 15.4 Interpreting things positively 4 15.4 I think that I’m the best. Imagining an ideal situation 2 7.7 Imagining myself as healthy. Monitoring one’s thinking or behavior 1 3.8 I am going to introspect, and identify my weaknesses and ways to cope with them. Monitoring others’ thinking or behavior 1 3.8 Seeing healthy people. Health behaviors 15 57.7 Gathering information about side effects and future prospects 3 11.5 Gathering information from professionals 3 11.5 Asking about examination results and lifespan during a check-up. Consulting books or websites 1 3.8 Researching on side effects. Creating a list of information to be gathered 1 3.8 Listing out the queries I wish to ask my doctor. Gathering information from people with the same disease 1 3.8 Meeting experienced people and experts. Planning coping strategies for health issues 2 7.7 Considering various coping strategies for tackling health issues 2 7.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Leading a regular life 1 3.8 Adjusting one’s sleeping and waking time 1 3.8 Maintaining appropriate waking and sleep times. Relieving the body 4 15.4 Engaging in stretching exercises 2 7.7 Engaging in stretching exercises that can be easily done everyday. Massaging oneself 2 7.7 I’m going to massage to get abdominal muscles. Exercising 9 34.6 Walking 6 23.1 Walking 30 minutes before breakfast, 5 days a week. Engaging in gymnastics 4 15.4 Doing radio exercise, 5 days a week. Using a physical health service 3 11.5 Once a week, I will go to the gym class sponsored by the city. Engaging in some exercises 2 7.7 I will do something in the hospital to make up for the lack of exercise. Riding a bicycle 1 3.8 I will ride a bicycle for 15 minutes. Adjusting eating behaviors 4 15.4 Eating at one’s pace 3 11.5 I eat what I want to eat and when I want to eat. Staying hydrated 3 11.5 I try to stay hydrated. Cooking nutritionally balanced meals 1 3.8 I eat liver. Using a service for managing eating behavior 1 3.8 I’m going to use food-sampling corners in markets. Knowing about one’s physical condition 2 7.7 Buying appliances to assess health 1 3.8 Buying a weighing scale as a solution. Recording one’s health data 1 3.8 Recording my health data. Adjusting social relationships 13 50.0 Identifying ways of associating with others 6 23.1 Organizing ways to associate with others 3 11.5 Identifying the merits and disadvantages of each group that I interacted with before. Using an avoidant coping style 2 7.7 I’m not going to say anything in response to what my wife says. Letting relationships with others take their own course 1 3.8 I’m going to report what happens when I let relationships with others take their own course. Others 1 3.8 Recommending medication with supplements for my wife. Interacting with others 5 19.2 Doing things with someone 3 11.5 Walking with my husband every morning. Conversing with someone 2 7.7 Trying to chat with someone. Participating in a meeting 1 3.8 I would like to participate in a counseling group in which I can tell anything and in a financial planning group, if possible. Expressing one’s thoughts and feelings 3 11.5 Writing a letter or an e-mail 2 7.7 I’m going to write my present feelings and give it. Increasing the frequency of expressing oneself 1 3.8 Expressing persistently. Planning the content before talking with others 1 3.8 Sharing the purpose and reason with my doctor. Obtaining social support 5 19.2 Consulting an expert 3 11.5 Consulting a doctor about what to do when my physical condition changes or when problems occur. Consulting a family member 1 3.8 Consulting with my husband. Creating a list of questions to ask when consulting others 1 3.8 Noting down questions to ask. Seeking help for one’s family 1 3.8 I asked my husband to follow-up. Adjusting one’s social living environment 15 57.7 Planning and executing actions 5 19.2 Taking avoidant actions 3 11.5 Not doing hard. Considering coping strategies for tackling barriers to achieving one’s goal 1 3.8 I think about what to do when I get negative thoughts about not being able to reach my goal. Managing time effectively 1 3.8 I will take a bath by 10 o’clock. Setting a goal for taking action 1 3.8 I’m going to set goals for the morning, afternoon, and night each day. Strengthening the self 1 3.8 I’m going to go abroad as a reward for achieving my goal. Taking action 1 3.8 Acting more rather than thinking. Engaging in leisure activities 15 57.7 Spending time on a leisure activity 7 26.9 Watching DVDs that are not hard but positive. Using a service for a leisure activity 5 19.2 Applying for the offers made by a travel company. Consulting others about the leisure activity 3 11.5 Visiting a Chinese school. Deciding means for engaging in the leisure activity 3 11.5 Deciding whether to go on a tour or on a solo trip. Deciding the time and date for the leisure activity 2 7.7 Deciding when to go on a trip. Determining the contents of the leisure activity 2 7.7 Setting a theme for travel. Making preparations for executing the leisure activity 2 7.7 Preparing travel books from a book store or library. Preparing strategies to cope with worries pertaining to the leisure activity 2 7.7 To achieve my goal of climbing the mountain, I’m going to evaluate aspects I worry about. Recording the leisure activity 1 3.8 I’m going to walk near my home, and I’m going to record or take pictures while doing so. Taking a break 1 3.8 Taking a nap. Considering whether to continue working 1 3.8 Analysing the merits and demerits of one’s course of work 1 3.8 I’m going to consider the merits of retiring from work at the end of this business year. Working and doing housework 4 15.4 Doing housework 3 11.5 Cleaning the house twice a week, on Monday and Thursday. Working 2 7.7 Cleaning the apartment once a week, on Tuesday, as my job. Retiring or deciding to stop working 1 3.8 Retiring from work 1 3.8 Stopping the caretaker at the patient association. Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 7 26.9 Regulating one’s emotions 4 15.4 Avoiding negative emotions 2 7.7 When I was in the depths of a bad situation, I avoided it for a while. Making recreational plans 2 7.7 Thinking about things that lead to a change of pace. Catharsis 1 3.8 Having a good cry. Using a psychological support service 1 3.8 Participating in A hospital’s cancer support program. Cognitive adjustment 4 15.4 Interpreting things positively 4 15.4 I think that I’m the best. Imagining an ideal situation 2 7.7 Imagining myself as healthy. Monitoring one’s thinking or behavior 1 3.8 I am going to introspect, and identify my weaknesses and ways to cope with them. Monitoring others’ thinking or behavior 1 3.8 Seeing healthy people. Health behaviors 15 57.7 Gathering information about side effects and future prospects 3 11.5 Gathering information from professionals 3 11.5 Asking about examination results and lifespan during a check-up. Consulting books or websites 1 3.8 Researching on side effects. Creating a list of information to be gathered 1 3.8 Listing out the queries I wish to ask my doctor. Gathering information from people with the same disease 1 3.8 Meeting experienced people and experts. Planning coping strategies for health issues 2 7.7 Considering various coping strategies for tackling health issues 2 7.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Leading a regular life 1 3.8 Adjusting one’s sleeping and waking time 1 3.8 Maintaining appropriate waking and sleep times. Relieving the body 4 15.4 Engaging in stretching exercises 2 7.7 Engaging in stretching exercises that can be easily done everyday. Massaging oneself 2 7.7 I’m going to massage to get abdominal muscles. Exercising 9 34.6 Walking 6 23.1 Walking 30 minutes before breakfast, 5 days a week. Engaging in gymnastics 4 15.4 Doing radio exercise, 5 days a week. Using a physical health service 3 11.5 Once a week, I will go to the gym class sponsored by the city. Engaging in some exercises 2 7.7 I will do something in the hospital to make up for the lack of exercise. Riding a bicycle 1 3.8 I will ride a bicycle for 15 minutes. Adjusting eating behaviors 4 15.4 Eating at one’s pace 3 11.5 I eat what I want to eat and when I want to eat. Staying hydrated 3 11.5 I try to stay hydrated. Cooking nutritionally balanced meals 1 3.8 I eat liver. Using a service for managing eating behavior 1 3.8 I’m going to use food-sampling corners in markets. Knowing about one’s physical condition 2 7.7 Buying appliances to assess health 1 3.8 Buying a weighing scale as a solution. Recording one’s health data 1 3.8 Recording my health data. Adjusting social relationships 13 50.0 Identifying ways of associating with others 6 23.1 Organizing ways to associate with others 3 11.5 Identifying the merits and disadvantages of each group that I interacted with before. Using an avoidant coping style 2 7.7 I’m not going to say anything in response to what my wife says. Letting relationships with others take their own course 1 3.8 I’m going to report what happens when I let relationships with others take their own course. Others 1 3.8 Recommending medication with supplements for my wife. Interacting with others 5 19.2 Doing things with someone 3 11.5 Walking with my husband every morning. Conversing with someone 2 7.7 Trying to chat with someone. Participating in a meeting 1 3.8 I would like to participate in a counseling group in which I can tell anything and in a financial planning group, if possible. Expressing one’s thoughts and feelings 3 11.5 Writing a letter or an e-mail 2 7.7 I’m going to write my present feelings and give it. Increasing the frequency of expressing oneself 1 3.8 Expressing persistently. Planning the content before talking with others 1 3.8 Sharing the purpose and reason with my doctor. Obtaining social support 5 19.2 Consulting an expert 3 11.5 Consulting a doctor about what to do when my physical condition changes or when problems occur. Consulting a family member 1 3.8 Consulting with my husband. Creating a list of questions to ask when consulting others 1 3.8 Noting down questions to ask. Seeking help for one’s family 1 3.8 I asked my husband to follow-up. Adjusting one’s social living environment 15 57.7 Planning and executing actions 5 19.2 Taking avoidant actions 3 11.5 Not doing hard. Considering coping strategies for tackling barriers to achieving one’s goal 1 3.8 I think about what to do when I get negative thoughts about not being able to reach my goal. Managing time effectively 1 3.8 I will take a bath by 10 o’clock. Setting a goal for taking action 1 3.8 I’m going to set goals for the morning, afternoon, and night each day. Strengthening the self 1 3.8 I’m going to go abroad as a reward for achieving my goal. Taking action 1 3.8 Acting more rather than thinking. Engaging in leisure activities 15 57.7 Spending time on a leisure activity 7 26.9 Watching DVDs that are not hard but positive. Using a service for a leisure activity 5 19.2 Applying for the offers made by a travel company. Consulting others about the leisure activity 3 11.5 Visiting a Chinese school. Deciding means for engaging in the leisure activity 3 11.5 Deciding whether to go on a tour or on a solo trip. Deciding the time and date for the leisure activity 2 7.7 Deciding when to go on a trip. Determining the contents of the leisure activity 2 7.7 Setting a theme for travel. Making preparations for executing the leisure activity 2 7.7 Preparing travel books from a book store or library. Preparing strategies to cope with worries pertaining to the leisure activity 2 7.7 To achieve my goal of climbing the mountain, I’m going to evaluate aspects I worry about. Recording the leisure activity 1 3.8 I’m going to walk near my home, and I’m going to record or take pictures while doing so. Taking a break 1 3.8 Taking a nap. Considering whether to continue working 1 3.8 Analysing the merits and demerits of one’s course of work 1 3.8 I’m going to consider the merits of retiring from work at the end of this business year. Working and doing housework 4 15.4 Doing housework 3 11.5 Cleaning the house twice a week, on Monday and Thursday. Working 2 7.7 Cleaning the apartment once a week, on Tuesday, as my job. Retiring or deciding to stop working 1 3.8 Retiring from work 1 3.8 Stopping the caretaker at the patient association. Selected solutions for execution (N = 27) The participants reported 79 selected solutions for execution, with a mean number of 2.6 items per person (range = 1–11). These were categorized into 36 small-categories, which converged to 17 mid-level-categories and four conceptualized domains (Table 7). Table 7. Selected solutions for execution (N = 27) Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 1 3.7 Regulating one’s emotions 1 3.7 Using a psychological support service 1 3.7 Participating in A hospital’s cancer support program. Health behaviors 12 44.4 Gathering information about side effects and future prospects 3 11.1 Gathering information from professionals 2 7.4 Asking the doctor about side effects of anticancer drugs Gathering information from people with the same disease 1 3.7 Meeting experienced people and experts. Consulting books or websites 1 3.7 Reading books to understand my symptoms. Creating a list of information to be gathered 1 3.7 Listing down things that I want to look at myself. Planning coping strategies for health issues 1 3.7 Considering various coping strategies for tackling health issues 1 3.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Exercising 7 25.9 Using a physical health service 4 14.8 Once a week, I will go to the gym class sponsored by the city. Walking 3 11.1 I’m going to walk and go shopping for one or two hours, four times a week. Engaging in gymnastics 1 3.7 I will engage in sitting qigong for 10 minutes daily, by 10 am. Engaging in some exercises 1 3.7 I’m going to play tennis. Relieving the body 2 7.4 Engaging in stretching exercises 1 3.7 Engaging in simple stretching exercises. Massaging oneself 1 3.7 Draining the lymph nodes in the futon when I wake up. Adjusting eating behaviors 1 3.7 Eating at one’s pace 1 3.7 I’m going to look for foods that I might be able to eat. Knowing about one’s physical condition 2 7.4 Recording one’s health data 2 7.4 Taking data of step count and amount of water intake. Improving sleep conditions 1 3.7 Using a service for managing sleep 1 3.7 I’m going to go visit a hospital or clinic that specializes in sleep problems and a pillow. Adjusting social relationships 10 37.0 Identifying ways of associating with others 4 14.8 Being aware of one’s feelings toward others 1 3.7 Recording my feelings. Letting relationships with others take their own course 1 3.7 I’m going to report what happens when I let relationships with others take their own course. Organizing ways to associate with others 1 3.7 Deciding how to reply or act and correspond accordingly. Using an avoidant style of coping 1 3.7 I am going to hand medicine to my wife naturally, and I will not reply to my wife’s words. Interacting with others 4 14.8 Doing things with someone 3 11.1 I’m going to travel with my husband. Conversing with someone 1 3.7 Meeting people or making a phone call, once a day, during hospitalization. Expressing one’s thoughts and feelings 2 7.4 Preparing to express one’s feelings 1 3.7 I am going to draft a letter to my doctor. Writing a letter or an e-mail 1 3.7 On the 25th, I wrote a letter requesting for living expenses by 30th. Obtaining social support 2 7.4 Consulting a family member 1 3.7 Consulting my husband and listening to opinions. Consulting an expert 1 3.7 Consulting a family doctor about how a doctor in a big hospital should be. Adjusting one’s social living environment 14 51.9 Planning and executing actions 2 7.4 Managing time effectively 2 7.4 I am going to sleep by 0 o’clock at least on four nights in a week. Reducing the burden of transfer 1 3.7 Using a transportation service 1 3.7 Calling a taxi. Engaging in leisure activities 14 51.9 Spending time on a leisure activity 7 25.9 Going to Karaoke. Consulting others about the leisure activity 2 7.4 I will search about and list the mountains and parks near B area. Recording the leisure activity 2 7.4 Making a list of the 290 songs that I sang. Using a service for a leisure activity 2 7.4 I am going to join the C art association. Determining the contents of the leisure activity 1 3.7 Setting the theme of the trip and deciding where to go. Working and doing housework 3 11.1 Working 2 7.4 Working on a farm. Doing housework 1 3.7 Cleaning the house twice a week on Monday and Thursday Doing housework by cutting corners 1 3.7 I’m going to stop mopping the floor. Retiring or deciding to stop working 1 3.7 Retiring from work 1 3.7 I have decided to retire. Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 1 3.7 Regulating one’s emotions 1 3.7 Using a psychological support service 1 3.7 Participating in A hospital’s cancer support program. Health behaviors 12 44.4 Gathering information about side effects and future prospects 3 11.1 Gathering information from professionals 2 7.4 Asking the doctor about side effects of anticancer drugs Gathering information from people with the same disease 1 3.7 Meeting experienced people and experts. Consulting books or websites 1 3.7 Reading books to understand my symptoms. Creating a list of information to be gathered 1 3.7 Listing down things that I want to look at myself. Planning coping strategies for health issues 1 3.7 Considering various coping strategies for tackling health issues 1 3.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Exercising 7 25.9 Using a physical health service 4 14.8 Once a week, I will go to the gym class sponsored by the city. Walking 3 11.1 I’m going to walk and go shopping for one or two hours, four times a week. Engaging in gymnastics 1 3.7 I will engage in sitting qigong for 10 minutes daily, by 10 am. Engaging in some exercises 1 3.7 I’m going to play tennis. Relieving the body 2 7.4 Engaging in stretching exercises 1 3.7 Engaging in simple stretching exercises. Massaging oneself 1 3.7 Draining the lymph nodes in the futon when I wake up. Adjusting eating behaviors 1 3.7 Eating at one’s pace 1 3.7 I’m going to look for foods that I might be able to eat. Knowing about one’s physical condition 2 7.4 Recording one’s health data 2 7.4 Taking data of step count and amount of water intake. Improving sleep conditions 1 3.7 Using a service for managing sleep 1 3.7 I’m going to go visit a hospital or clinic that specializes in sleep problems and a pillow. Adjusting social relationships 10 37.0 Identifying ways of associating with others 4 14.8 Being aware of one’s feelings toward others 1 3.7 Recording my feelings. Letting relationships with others take their own course 1 3.7 I’m going to report what happens when I let relationships with others take their own course. Organizing ways to associate with others 1 3.7 Deciding how to reply or act and correspond accordingly. Using an avoidant style of coping 1 3.7 I am going to hand medicine to my wife naturally, and I will not reply to my wife’s words. Interacting with others 4 14.8 Doing things with someone 3 11.1 I’m going to travel with my husband. Conversing with someone 1 3.7 Meeting people or making a phone call, once a day, during hospitalization. Expressing one’s thoughts and feelings 2 7.4 Preparing to express one’s feelings 1 3.7 I am going to draft a letter to my doctor. Writing a letter or an e-mail 1 3.7 On the 25th, I wrote a letter requesting for living expenses by 30th. Obtaining social support 2 7.4 Consulting a family member 1 3.7 Consulting my husband and listening to opinions. Consulting an expert 1 3.7 Consulting a family doctor about how a doctor in a big hospital should be. Adjusting one’s social living environment 14 51.9 Planning and executing actions 2 7.4 Managing time effectively 2 7.4 I am going to sleep by 0 o’clock at least on four nights in a week. Reducing the burden of transfer 1 3.7 Using a transportation service 1 3.7 Calling a taxi. Engaging in leisure activities 14 51.9 Spending time on a leisure activity 7 25.9 Going to Karaoke. Consulting others about the leisure activity 2 7.4 I will search about and list the mountains and parks near B area. Recording the leisure activity 2 7.4 Making a list of the 290 songs that I sang. Using a service for a leisure activity 2 7.4 I am going to join the C art association. Determining the contents of the leisure activity 1 3.7 Setting the theme of the trip and deciding where to go. Working and doing housework 3 11.1 Working 2 7.4 Working on a farm. Doing housework 1 3.7 Cleaning the house twice a week on Monday and Thursday Doing housework by cutting corners 1 3.7 I’m going to stop mopping the floor. Retiring or deciding to stop working 1 3.7 Retiring from work 1 3.7 I have decided to retire. Table 7. Selected solutions for execution (N = 27) Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 1 3.7 Regulating one’s emotions 1 3.7 Using a psychological support service 1 3.7 Participating in A hospital’s cancer support program. Health behaviors 12 44.4 Gathering information about side effects and future prospects 3 11.1 Gathering information from professionals 2 7.4 Asking the doctor about side effects of anticancer drugs Gathering information from people with the same disease 1 3.7 Meeting experienced people and experts. Consulting books or websites 1 3.7 Reading books to understand my symptoms. Creating a list of information to be gathered 1 3.7 Listing down things that I want to look at myself. Planning coping strategies for health issues 1 3.7 Considering various coping strategies for tackling health issues 1 3.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Exercising 7 25.9 Using a physical health service 4 14.8 Once a week, I will go to the gym class sponsored by the city. Walking 3 11.1 I’m going to walk and go shopping for one or two hours, four times a week. Engaging in gymnastics 1 3.7 I will engage in sitting qigong for 10 minutes daily, by 10 am. Engaging in some exercises 1 3.7 I’m going to play tennis. Relieving the body 2 7.4 Engaging in stretching exercises 1 3.7 Engaging in simple stretching exercises. Massaging oneself 1 3.7 Draining the lymph nodes in the futon when I wake up. Adjusting eating behaviors 1 3.7 Eating at one’s pace 1 3.7 I’m going to look for foods that I might be able to eat. Knowing about one’s physical condition 2 7.4 Recording one’s health data 2 7.4 Taking data of step count and amount of water intake. Improving sleep conditions 1 3.7 Using a service for managing sleep 1 3.7 I’m going to go visit a hospital or clinic that specializes in sleep problems and a pillow. Adjusting social relationships 10 37.0 Identifying ways of associating with others 4 14.8 Being aware of one’s feelings toward others 1 3.7 Recording my feelings. Letting relationships with others take their own course 1 3.7 I’m going to report what happens when I let relationships with others take their own course. Organizing ways to associate with others 1 3.7 Deciding how to reply or act and correspond accordingly. Using an avoidant style of coping 1 3.7 I am going to hand medicine to my wife naturally, and I will not reply to my wife’s words. Interacting with others 4 14.8 Doing things with someone 3 11.1 I’m going to travel with my husband. Conversing with someone 1 3.7 Meeting people or making a phone call, once a day, during hospitalization. Expressing one’s thoughts and feelings 2 7.4 Preparing to express one’s feelings 1 3.7 I am going to draft a letter to my doctor. Writing a letter or an e-mail 1 3.7 On the 25th, I wrote a letter requesting for living expenses by 30th. Obtaining social support 2 7.4 Consulting a family member 1 3.7 Consulting my husband and listening to opinions. Consulting an expert 1 3.7 Consulting a family doctor about how a doctor in a big hospital should be. Adjusting one’s social living environment 14 51.9 Planning and executing actions 2 7.4 Managing time effectively 2 7.4 I am going to sleep by 0 o’clock at least on four nights in a week. Reducing the burden of transfer 1 3.7 Using a transportation service 1 3.7 Calling a taxi. Engaging in leisure activities 14 51.9 Spending time on a leisure activity 7 25.9 Going to Karaoke. Consulting others about the leisure activity 2 7.4 I will search about and list the mountains and parks near B area. Recording the leisure activity 2 7.4 Making a list of the 290 songs that I sang. Using a service for a leisure activity 2 7.4 I am going to join the C art association. Determining the contents of the leisure activity 1 3.7 Setting the theme of the trip and deciding where to go. Working and doing housework 3 11.1 Working 2 7.4 Working on a farm. Doing housework 1 3.7 Cleaning the house twice a week on Monday and Thursday Doing housework by cutting corners 1 3.7 I’m going to stop mopping the floor. Retiring or deciding to stop working 1 3.7 Retiring from work 1 3.7 I have decided to retire. Categories N % Examples of contents reported by participants Emotion regulation/cognitive adjustment 1 3.7 Regulating one’s emotions 1 3.7 Using a psychological support service 1 3.7 Participating in A hospital’s cancer support program. Health behaviors 12 44.4 Gathering information about side effects and future prospects 3 11.1 Gathering information from professionals 2 7.4 Asking the doctor about side effects of anticancer drugs Gathering information from people with the same disease 1 3.7 Meeting experienced people and experts. Consulting books or websites 1 3.7 Reading books to understand my symptoms. Creating a list of information to be gathered 1 3.7 Listing down things that I want to look at myself. Planning coping strategies for health issues 1 3.7 Considering various coping strategies for tackling health issues 1 3.7 I will organize my thoughts in terms of ‘causing an urge to defecate’. Exercising 7 25.9 Using a physical health service 4 14.8 Once a week, I will go to the gym class sponsored by the city. Walking 3 11.1 I’m going to walk and go shopping for one or two hours, four times a week. Engaging in gymnastics 1 3.7 I will engage in sitting qigong for 10 minutes daily, by 10 am. Engaging in some exercises 1 3.7 I’m going to play tennis. Relieving the body 2 7.4 Engaging in stretching exercises 1 3.7 Engaging in simple stretching exercises. Massaging oneself 1 3.7 Draining the lymph nodes in the futon when I wake up. Adjusting eating behaviors 1 3.7 Eating at one’s pace 1 3.7 I’m going to look for foods that I might be able to eat. Knowing about one’s physical condition 2 7.4 Recording one’s health data 2 7.4 Taking data of step count and amount of water intake. Improving sleep conditions 1 3.7 Using a service for managing sleep 1 3.7 I’m going to go visit a hospital or clinic that specializes in sleep problems and a pillow. Adjusting social relationships 10 37.0 Identifying ways of associating with others 4 14.8 Being aware of one’s feelings toward others 1 3.7 Recording my feelings. Letting relationships with others take their own course 1 3.7 I’m going to report what happens when I let relationships with others take their own course. Organizing ways to associate with others 1 3.7 Deciding how to reply or act and correspond accordingly. Using an avoidant style of coping 1 3.7 I am going to hand medicine to my wife naturally, and I will not reply to my wife’s words. Interacting with others 4 14.8 Doing things with someone 3 11.1 I’m going to travel with my husband. Conversing with someone 1 3.7 Meeting people or making a phone call, once a day, during hospitalization. Expressing one’s thoughts and feelings 2 7.4 Preparing to express one’s feelings 1 3.7 I am going to draft a letter to my doctor. Writing a letter or an e-mail 1 3.7 On the 25th, I wrote a letter requesting for living expenses by 30th. Obtaining social support 2 7.4 Consulting a family member 1 3.7 Consulting my husband and listening to opinions. Consulting an expert 1 3.7 Consulting a family doctor about how a doctor in a big hospital should be. Adjusting one’s social living environment 14 51.9 Planning and executing actions 2 7.4 Managing time effectively 2 7.4 I am going to sleep by 0 o’clock at least on four nights in a week. Reducing the burden of transfer 1 3.7 Using a transportation service 1 3.7 Calling a taxi. Engaging in leisure activities 14 51.9 Spending time on a leisure activity 7 25.9 Going to Karaoke. Consulting others about the leisure activity 2 7.4 I will search about and list the mountains and parks near B area. Recording the leisure activity 2 7.4 Making a list of the 290 songs that I sang. Using a service for a leisure activity 2 7.4 I am going to join the C art association. Determining the contents of the leisure activity 1 3.7 Setting the theme of the trip and deciding where to go. Working and doing housework 3 11.1 Working 2 7.4 Working on a farm. Doing housework 1 3.7 Cleaning the house twice a week on Monday and Thursday Doing housework by cutting corners 1 3.7 I’m going to stop mopping the floor. Retiring or deciding to stop working 1 3.7 Retiring from work 1 3.7 I have decided to retire. Discussion We categorized problems, goals, solution plans generated through the brainstorming work during therapy, and selected solutions for execution treated in PST program for cancer patients. Problems Our study revealed the various problems experienced by cancer patients, which were mostly distress themselves or could lead to distress. The most common problems were problems with social relations (75.9%), followed by psychological and existential problems (69.0%) and physical problems (65.5%). A previous study on Japanese cancer patients’ problems revealed the following distribution: psychological issues (52.9%), physical suffering including pain (48.1%), family/household issues such as conjugal or parent–child relations (29.1%) and relationships with medical staff (8.0%) (14). Our results partly showed similar trends regarding the contents and rate of reporting problems. However, problems related to social relations were reported more often in our study, and the same was observed in several other previous works on PST (12,15). Therefore, the social relations items should be more recognized as significant problems. Moreover, except for studies that focused on activities, no other previous study reported about leisure activities (Table 1). As most cancer patients are elderly, leisure time may occupy most part of their day if they are retired. Therefore, considering how patients had spent before being diagnosed is important. Further, the present study revealed that participants who were currently undergoing treatment tended to reported more psychological and existential problems and problems related to the social living environment. These findings suggest that cancer patients, especially being in treatment, may be more affected physically and mentally and their daily life may be more restricted owing to the treatment. Goals Despite differences in the problems expressed by the patients, the most commonly identified goal was improving physical functions (60.0%). The contents of goals identified in the present study were similar to those reported by previous studies. However, some patients reported goals that might not be achievable, or they may be too difficult to achieve, like achieving a healthy state. Therefore, it is necessary to prepare a list of such difficult or unsolvable problems. Subsequently, facilitators should provide advice and help patients to set appropriate and realistic goals. Additionally, both types of goals; problem-focused and emotion-focused are important to maximize effective problem-solving coping attempts (11). The present study revealed that the participants set a few direct emotion-focused goals such as improving mental health (20.0%), while some set goals related leisure activity (30.0%). Engagement in leisure activities contributes to subjective well-being (16) and a sense of purpose in life (17). Solutions Our study showed that the solution plans generated through the brainstorming work during the PST and the selected solutions for execution were categorized into four domains. The most common solution was adjusting one’s social living environment (respectively, 57.7% and 51.9%) and health behaviors (57.7% and 44.4%, respectively, for solution plans and solutions selected for execution). Meanwhile, few participants generated solutions related to emotion regulation/cognitive adjustment or selected them for execution. This may be because the former two alternatives might be easy to conceive and carry out for participants as a means to achieve their goal. Additionally, the present participants generated several specific solutions regarding interpersonal relationships, so it is valuable information and expected utilized. Additionally, Hirai et al. (4) reported an improvement in social relationships as a part of EORTC (18) and BCWI (19) by PST. As reported in our results, contents pertaining to social relationships comprised a relatively large part of all the components. Therefore, an improvement in psychological and physical distress, as well as in social relationships, was indicated. Besides, family and medical staff are prone to attract attention as significant interpersonal relationships for cancer patients, however, the present study suggested importance of friends and acquaintances to some extent. Conclusions The present study revealed that various problems, goals, and solutions were treated in the PST of realistic clinical setting. As mentioned earlier, this list of problems, goals and solutions can be used as an aid while implementing the PST, or can be shared with patients directly. In Japan, there is a lack of opportunities to implement a PST program, owing to issues such as difficulty in paying medical fees and securing human resources with skills related to psychotherapy. Therefore, the present framework and skills pertaining to PST need to be implemented in clinical settings by therapists as well as by other medical staff (20). This might help prevent severe problems or depression in cancer patients. The list generated based on our results is also expected to be of use in such settings. Limitations We surveyed in only one institution, which limited our sample. Additionally, all our participants had relatively good bodily functions. However, as bodily functions decline, it is assumed that the type and choice of goals and solutions will change. Therefore, there is a need for research targeting patients in a more severe condition. Nevertheless, our study is meaningful in that it was the first to classify and describe the four aspects of PST for cancer patients in a clinical setting. Conflict of interest statement None declared. Acknowlegments The authors thank the following individuals for assistance with the research; Motoko Hasegawa and Tsukasa Teraguchi. Funding The authors received no financial support for the research, authorship and publication of this article. References 1 Nezu AM , Nezu CM , Houts PS , Friedman SH , Faddis S . Relevance of problem-solving therapy to psychosocial oncology . J Psychosoc Oncol 1999 ; 16 : 5 – 26 . Google Scholar Crossref Search ADS 2 Nezu CM , Nezu AM , Friedman SH , et al. Cancer and psychological distress: two investigations regarding the role of social problem-solving . J Psychosoc Oncol 1999 ; 16 : 27 – 40 . Google Scholar Crossref Search ADS 3 Akechi T , Hirai K , Motooka H , et al. Problem-solving therapy for psychological distress in Japanese cancer patients: preliminary clinical experience from psychiatric consultations . Jpn J Clin Oncol 2008 ; 38 : 867 – 70 . Google Scholar Crossref Search ADS PubMed 4 Hirai K , Motooka H , Ito N , et al. Problem-solving therapy for psychological distress in Japanese early-stage breast cancer patients . Jpn J Clin Oncol 2012 ; 42 : 1168 – 74 . Google Scholar Crossref Search ADS PubMed 5 Hopko DR , Funderburk JS , Shorey RC , et al. Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: randomized trial . J Consult Clin Psychol 2011 ; 79 : 834 . Google Scholar Crossref Search ADS PubMed 6 Nezu AM , Nezu CM , Felgoise SH , McClure KS , Houts PS . Project genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients . J Consult Clin Psychol 2003 ; 71 : 1036 – 48 . Google Scholar Crossref Search ADS PubMed 7 D’Zurilla TJ , Goldfried MR . Problem solving and behavior modification . J Abnorma Psychol 1971 ; 78 : 107 . Google Scholar Crossref Search ADS 8 D’Zurilla TJ , Nezu AM . Problem-solving therapy. In: Dobson KS , editor . Handbook of cognitive-behavioral therapies . 3rd ed . New York : Guilford Press , 2010 ; 197 – 85 . 9 Nezu A , D’Zurilla TJ . Effects of problem definition and formulation on the generation of alternatives in the social problem-solving process . Cognit Ther Res 1981 ; 5 : 265 – 71 . Google Scholar Crossref Search ADS 10 Nezu A , D’Zurilla TJ . Effects of problem definition and formulation on decision making in the social problem-solving process . Behav Ther 1981 ; 12 : 100 – 6 . Google Scholar Crossref Search ADS 11 Nezu AM , Nezu CM , Perri MG . Psychotherapy for adults within a problem-solving framework: focus on depression . J Cogn Psychother 1990 ; 4 : 247 – 56 . Google Scholar Crossref Search ADS 12 Shiozaki M , Sakami A , Sato T , et al. Creating a list of psycho-social problems and solutions for patients with pancreatic cancer by applying the social problem-solving process . Palliat Care Res 2015 ; 10 : 146 – 93 . (In Japanese with English abstract). Google Scholar Crossref Search ADS 13 Kugaya A , Akechi T , Okuyama T , Okamura H , Uchitomi Y . Screening for psychological distress in Japanese cancer patients . Jpn J Clin Oncol 1998 ; 28 : 333 – 8 . Google Scholar Crossref Search ADS PubMed 14 Joint Study Group on the Sociology of Cancer . A report on research into the anxieties and burdens of cancer sufferers. Shizuoka Cancer Center. 2004 Retrieved From http://www.scchr.jp/yorozu/pdf/taiken_koe_eng.pdf (November 24, 2014) 15 Kleiboer A , Bennett F , Hodges L , Walker J , Thekkumpurath P , Sharpe M . The problems reported by cancer patients with major depression . Psychooncology 2011 ; 20 : 62 – 8 . Google Scholar Crossref Search ADS PubMed 16 Kuykendall L , Tay L , Ng V . Leisure engagement and subjective well-being: a meta-analysis . Psychol Bull 2015 ; 141 : 364 – 403 . Google Scholar Crossref Search ADS PubMed 17 Chun S , Heo J , Lee S , Kim J . Leisure-related predictors on a sense of purpose in life among older adults with cancer . Act Adapt Aging 2016 ; 40 : 266 – 80 . 18 Kobayashi K , Takeda F , Teramukai S , et al. A cross-validation of the European Organization for Research and Treatment of Cancer QLQ-C30 (EORTC QLQ-C30) for Japanese with lung cancer . Eur J Cancer 1998 ; 34 : 810 – 5 . Google Scholar Crossref Search ADS PubMed 19 Hirai K , Shiozaki M , Motooka H , et al. Discrimination between worry and anxiety among cancer patients: development of a brief cancer‐related worry inventory . Psychooncology 2008 ; 17 : 1172 – 9 . Google Scholar Crossref Search ADS PubMed 20 Hirai K . Application of Problem-solving Therapy Approach for the Japanese Cancer Patients . Jpn J Behav Med 2014 ; 20 : 7 – 11 . (In Japanese with English abstract). 21 Lyons KD , Erickson K , Hegel MT . Problem-solving strategies of women undergoing chemotherapy for breast cancer. Canadian Journal of Occupational Therapy . Revue Canadienne D’ergotherapie 2012 ; 79 : 33 – 40 . Google Scholar PubMed 22 Lyons KD , Svensborn IA , Kornblith AB , Hegel MT . A content analysis of functional recovery strategies of breast cancer survivors . OTJR (Thorofare N J) 2015 ; 35 : 73 – 80 . Google Scholar PubMed © The Author(s) 2019. Published by Oxford University Press. All rights reserved. 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TI - Problems, goals and solutions reported by cancer patients participating in group problem-solving therapy
JF - Japanese Journal of Clinical Oncology
DO - 10.1093/jjco/hyy191
DA - 2019-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/problems-goals-and-solutions-reported-by-cancer-patients-participating-2Pm0kWI4vs
SP - 245
VL - 49
IS - 3
DP - DeepDyve
ER -