CONCEPT ANALYSIS
Survivor in the cancer context: a concept analysis
Megan Hebdon, Karen Foli & Sara McComb
Accepted for publication 30 January 2015
Correspondence to M. Hebdon:
e-mail: hebdon@purdue.edu
Megan Hebdon RN FNP-c
Doctor of Nursing Practice Student
Purdue University School of Nursing and
Family Nurse Practitioner, Indiana
University Health Arnett Internal Medicine
Group, West Lafayette, Indiana, USA
Karen Foli PhD RN
Assistant Professor
Purdue University School of Nursing, West
Lafayette, Indiana, USA
Sara McComb PhD
Associate Professor
Purdue University Schools of Nursing and
Industrial Engineering, West Lafayette,
Indiana, USA
Introduction
Globally, an estimated 170 million years of healthy life
were lost because of cancer in 2008. In fact, cancer is a
leading cause of disease worldwide with approximately
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H E B D O N M . , F O L I K . & M C C O M B S . ( 2 0 1 5 ) Survivor in the cancer context: a
concept analysis. Journal of Advanced Nursing 71(8), 1774–1786. doi: 10.1111/
jan.12646
Abstract
Aim. The aim of this analysis was to define survivor in the cancer context.
Background. Cancer survivor has been used in the cancer lexicon, but may not
represent the individuals it defines.
Design. This concept analysis was completed according to Walker and Avant’s
method.
Data sources. PubMed, PsychInfo, CINAHL, JSTOR, Google and medical and
public health websites.
Review methods. Thirty sources from multiple disciplines, published between
1987–2013, were analysed for recurrent themes and conceptual meaning. Critical
attributes, antecedents and consequences were extrapolated. Model, related and
contrary cases were developed based on an amalgamation of clinical observations.
Illegitimate, borderline and invented cases were excluded for this reason.
Results. Survivor in the cancer context is an individual with a history of
malignancy, who has lived through a personalized challenge and has ongoing
positive and negative consequences. Not all cancer survivors would identify
themselves using the term survivor.
Conclusions. This contributes to the paradigm shift of cancer as a chronic disease
as it establishes the unique nature of the cancer experience while highlighting the
long-term concerns related to this set of diseases. The Theory of Uncertainty in
Illness provides a framework to understand the individualized nature of being a
cancer survivor. Nursing research and practice should address the personal
experiences of cancer survivors while still focusing on general survivorship needs.
Keywords: chronic disease, concept analysis, individual differences, neoplasm,
nurses, stressful events, survivor, uncertainty
32!5 million individuals still living up to 5 years past their
cancer diagnosis (Cancer Research UK 2014). In the United
States in 2012, nearly 13!7 million individuals were living
with a history of cancer (American Cancer Society 2014).
With early diagnosis and advances in treatment modalities,
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JAN: CONCEPT ANALYSIS
Why is this research or review needed?
" Research has suggested that all individuals with a history of
cancer may not identify with the term survivor due to the
positive and negative connotations associated with this term.
" Other concept analyses have focused on cancer survivors,
cancer survivorship, or survivorship in chronic illness, but
there is a need for a cross-disciplinary understanding of
survivor in the cancer context.
What are the key findings?
" A survivor in the cancer context is an individual who has
a diagnosis of malignancy, has lived through a challenging
experience, has positive and negative consequences related
to their disease and whose experience is individualized.
" Survivor is the individual experience of a person living
with a history of cancer and survivorship denotes the gen-
eral needs of individuals after primary cancer treatment
completion.
" With the personal nature of being a cancer survivor, all
individuals who might be defined by this term do not iden-
tify with it.
How should the findings be used to influence policy/
practice/research/education?
" Future researchers should address the personal nature of
being a cancer survivor and the general needs of the cancer
survivorship care period.
" Nurses may use the Theory of Uncertainty in Illness in
addressing the needs of cancer survivors in practice and
research to understand the personal context of their experi-
ence.
this number is projected to increase to 18 million by 2022
(De Moor et al. 2013). The cancer control continuum is a
term that has been used from the mid-1970s to describe the
phases of cancer and its treatment. Survivorship was a more
recent addition to this continuum due to the growing popu-
lation of cancer survivors (National Cancer Institute 2011).
Fitzhugh Mullan, a physician and cancer survivor, was
influential in garnering attention for the survivorship phase
of cancer and cancer survivors with his article ‘Seasons of
Survival’. In this, he states:
Survival is a much more useful concept, because it is a generic idea
that applies to everyone diagnosed as having cancer, regardless of
the course of the illness. Survival, in fact, begins at the point of
diagnosis, because that is the time when patients are forced to con-
front their own mortality and begin to make adjustments that will
be part of their immediate and to some extent, long-term future
(Mullan 1985, p. 271).
© 2015 John Wiley & Sons Ltd
Concept analysis of cancer survivor
This definition of cancer survivor has been echoed by
many institutions and even extended to the inclusion of
caregivers, friends and family as survivors due to their role
in the survivorship experience (Centers for Disease Control
& Prevention 2004, National Cancer Institute (NCI) 2012).
Yet, the prevailing usage of the term ‘cancer survivor’ is for
those who have a personal history of cancer, especially
those who have completed active treatment (NCI 2012).
Clarity of this concept, therefore, is needed, particularly as
it relates to how and when this term is applied in the can-
cer context and its ability to capture the experiences of
individuals living with a history of cancer.
Background
The term survivor has become part of the lexicon in the can-
cer context. Nevertheless, the concept of survivor is not con-
sistently applied nor is it distinguished from other aspects of
cancer care. For instance, overlap between the terms cancer
survivor and survivorship occurs frequently throughout the
literature (Davies 2013). These terms denote very different
phenomena as will be discussed further in this concept analy-
sis. Previous efforts have been undertaken to address the con-
cepts of cancer survivor and survivorship. These analyses
have focused on paediatric and young adult cancer survivors
(Shepherd & Woodgate 2010), African-American breast can-
cer survivors (Farmer & Smith 2002), survivorship in the
context of chronic illness (Peck 2008) and general cancer sur-
vivorship (Doyle 2008). The first two contribute to our
understanding of cancer survivorship in the context of spe-
cific patient populations. The second two provide clarity
around the concept of survivorship. Still missing, however, is
a broader understanding of the term survivor, particularly as
it relates to cancer. Thus, the primary purpose of this concept
analysis is to draw on multiple disciplines to describe the
parameters of the term ‘survivor’ in the cancer context.
Mullan (1985) provides compelling rationale for consid-
ering survival in the cancer context. This term, however,
has become historically, culturally, emotionally and politi-
cally charged and should not be applied casually (Bell &
Ristovski-Slijepcevic 2012). Its genesis may derive from
President Nixon’s declaration of war on cancer in the
1970s (Surveillance Epidemiology & End Results 2014).
Since that time an undercurrent of battle themes has been
prevalent in the research, diagnosis and treatment of cancer.
Indeed, a survivor is viewed in terms of ‘winning the fight’,
when for many individuals with cancer this is not the case
(Bell & Ristovski-Slijepcevic 2012).
Cancer survivors are often left with long-term side effects
and late effects of cancer and its treatment. Rather than
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M. Hebdon et al.
being victors over their disease, they continue a lifelong
struggle due to their cancer diagnosis (Centers for Disease
Control & Prevention 2004). The transition survivors expe-
rience from active treatment to follow-up care may be a
time of uncertainty where the illness meaning they construct
is based on factors such as ambiguity of their illness state,
treatment complexity, information gaps and an unpredict-
able disease course as described in Mishel’s Theory of
Uncertainty in Illness (Mishel 1988). Thus, the victorious
characterization of cancer survivors may be misleading for
the general public, because cancer is a set of diseases with
complicated environmental and genetic influences (Surveil-
lance Epidemiology & End Results 2014). A more appro-
priate war analogy may be the war in Vietnam or the war
on terror, where victory may not come at a single point in
time and multiple battles are fought resulting in an ongoing
series of positive and negative consequences. The secondary
purpose of this concept analysis, therefore, is to consider
whether ‘survivor’ is a relevant term for those who have a
history of cancer.
Data sources
Concept analysis method
This concept analysis followed Walker and Avant (2010)
approach, which includes the eight following steps: concept
selection; determination of aims and purposes of the analy-
sis; identification of all uses of the concept; determination
of defining attributes; construction of a model case;
construction of borderline, related, contrary, invented and
illegitimate cases; identification of antecedents and conse-
quences; and definition of empirical referents (Chinn &
Kramer 2011). The only change to this approach for this
discussion will be the lack of borderline, invented and ille-
gitimate cases. The composite cases presented were devel-
oped based on actual clinical observation and are
representative of an amalgam of observations with exem-
plar individual cases reported. As there were no observed
cases to meet the criteria for borderline, invented, or illegit-
imate cases, these cases were excluded.
Concept analysis context
Cancer is the context where this concept analysis of survi-
vor is embedded. Cancer is a group of diseases, rather than
a singular entity and may be characterized by a solid
tumour or by abnormal cell proliferation in the hematologic
and lymphatic systems (NCI undated). The most descriptive
term of the cancer context for this paper is the term
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malignancy, a group of diseases where abnormal cells
divide without control and can invade nearby tissues or
spread through the blood and lymph systems (NCI
undated). Disease groups included in the definition of
malignancy are: carcinoma, sarcoma, leukaemia, lymphoma
and central nervous system cancers (NCI undated).
Literature search strategy
A literature search was conducted using the term ‘survivor’
in the following databases: PubMed, CINAHL, PsychInfo
and JSTOR. Articles from multiple disciplines published
between 1987–2013 were reviewed for their relevance to
this analysis including: medicine; nursing; psychology;
insurance; mathematics; and English. Google searches were
also completed using the terms ‘survivor’ and ‘survivor defi-
nition’, which yielded dictionary definitions and results
from popular media including television and music. A
search was conducted using the term ‘survivor’ in medical
and public health web sites and the results were also
reviewed for pertinent material. The first fifty hits on each
site were reviewed for inclusion.
Data analysis
A total of 30 sources were analysed and vetted for inclusion
in this analysis by one author (MH). Data were then orga-
nized in Table A1 (Appendix A). Sources were selected
based on their inclusion of the term ‘survivor’, were pub-
lished in English and if they presented ‘survivor’ in a differ-
ent perspective or setting than previously selected sources.
As a team, themes were then extracted and agreed on using
Carper’s ways of knowing, including aesthetic knowing,
empiric knowing, ethical knowing and personal knowing
(Chinn & Kramer 2011). Recurrent themes were noted and
conceptual meaning was induced from these themes. Criti-
cal attributes of the concept were based on the redundant
meanings from the sources. Antecedents and consequences
were formulated based on the literature and relationships to
the critical attributes.
Results
Uses of the concept
There are multiple uses and contexts for the term survivor.
Table A1 (Appendix A) outlines the concept of survivor
among varying disciplines and populations. In the Pubmed
search alone, articles covered survivors of cardiac events,
stroke, cancer, abuse, disaster and traumatic brain injury
© 2015 John Wiley & Sons Ltd
JAN: CONCEPT ANALYSIS
(PubMed n.d.). The root term for survivor is ‘survive’, which
means to remain alive and functional and to persevere. Sur-
vive has Middle English, French and Latin roots. The Latin
prefix ‘super’ means above or surpassing and ‘vivere’ means
to live (The Free Dictionary 2013, Empire.net n.d.).
The recurrent theme among all the sources is that a survi-
vor is a person or entity who survives adversity or elimina-
tion. In sources relevant to individuals, the survivor is one
who has lived through something traumatic, difficult, or
challenging, whether illness, disaster or trauma (Myers
et al. 1987, Arrighi & Picciotto 1994, Mishra & Spreitzer
1998, Travis 2002, Naples 2003, Nutkiewicz 2003, Kahan
2007, Lang 2007, Wlodarski 2007, Berry 2008, Institute of
Medicine 2009, Thon 2009, World Health Organization
2010, Pierce 2011, Centers for Disease Control & Preven-
tion 2012, Chambers et al. 2012, Kazanjian et al. 2012,
Khan et al. 2012, Mayo Clinic 2012, Davies 2013, Garrett
et al. 2013, Godwin et al. 2013, Graven et al. 2013, Ho &
Lee 2013, Jones 2013, Kornhaber et al. 2013, Oxford Dic-
tionaries 2013, National Cancer Institute n.d.a,b, Song
Meanings n.d.). Positive and negative meanings for the term
survivor were identified, highlighting both triumph and con-
tinued obstacles (National Cancer Institute n.d.a,b, Song
Meanings n.d., Myers et al. 1987, Mishra & Spreitzer
1998, Naples 2003, Wlodarski 2007, Institute of Medicine
2009, World Health Organization 2010, Pierce 2011, Cen-
ters for Disease Control & Prevention 2012, Chambers
et al. 2012, Kazanjian et al. 2012, Khan et al. 2012, Mayo
Clinic 2012, Davies 2013, Garrett et al. 2013, Godwin
et al. 2013, Graven et al. 2013, Ho & Lee 2013, Jones
2013, Kornhaber et al. 2013, Nutkiewicz 2003). From per-
sonal communications, a cancer survivor and his spouse
noted that the greatest difficulties for an individual with
cancer are often after cancer treatment (A. Thomas, per-
sonal communication, 6 December 2013; R. Thomas, per-
sonal communication, 6 December 2013).
As noted previously, the themes were evaluated through
Carper’s ways of knowing (Chinn & Kramer 2011).
Empiric and personal knowing are particularly relevant in
the meanings noted among the sources. In multiple sources,
a focus on the personal experience of being a survivor was
identified, rather than the collective norm of being a survi-
vor (Mishra & Spreitzer 1998, Naples 2003, Nutkiewicz
2003, Chambers et al. 2012, Khan et al. 2012, Kornhaber
et al. 2013, A. Thomas, personal communication, Decem-
ber 6, 2013, R. Thomas, personal communication, 6
December 2013). Some people may have been a survivor
based on empiric terms, but did not feel that survivor was
part of their identity (Chambers et al. 2012, Khan et al.
2012). Being a survivor in many sources resulted in
© 2015 John Wiley & Sons Ltd
Concept analysis of cancer survivor
persistent trials and/or the need for support from external
sources (Myers et al. 1987, Nutkiewicz 2003, Institute of
Medicine 2009, World Health Organization 2010, Pierce
2011, Kazanjian et al. 2012, Mayo Clinic 2012, Davies
2013, Godwin et al. 2013, Graven et al. 2013, Ho & Lee
2013, Jones 2013, Kornhaber et al. 2013).
Based on these convergent meanings of survivor, a survi-
vor is defined herein as an individual who lives through a
difficult experience, but has ongoing positive and negative
consequences related to this experience that are specific to
each survivor. In other words, individuals may face the
same challenges, but external and internal factors influence
the individual meaning of the experience and the way the
individual moves forward. This definition is applicable in
the cancer context with the addition of a history of malig-
nancy. In terms of cancer, survivor is distinct from survi-
vorship, with the survivor being an individual and
survivorship being the ongoing healthcare needs, such as
surveillance and treatment of late effects, of an individual
through the end of life (Kazanjian et al. 2012, National
Cancer Institute n.d.b).
Critical attributes
The critical attributes of a concept are those ideas that dis-
tinctly and concisely describe the conceptual meaning. All
of these attributes must be present for a phenomenon to
qualify as an example of the concept of interest (Chinn &
Kramer 2011). The critical attributes for cancer survivor lie
fundamentally in the term survivor. A simple attribute for
cancer survivor would be ‘living with a history of malig-
nancy’, but more complex attributes are found in the term
survivor. Hence, a more comprehensive list of critical attri-
butes of a survivor is an individual who: (a) is living with a
history of malignancy; (b) has lived through a difficult
experience such as cancer treatment; (c) has been impacted
in positive and negative ways by the experience; (d) is in
the follow-up phase of their cancer treatment; and (e)
whose experience is personal and contextual.
Antecedents and consequences
Antecedents and consequences were identified based on the
critical attributes noted above. Antecedents are experiences
that would come before the concept of interest (Chinn &
Kramer 2011). Antecedents for cancer survivor would be
the diagnosis of cancer, the treatment of cancer and being
alive. Consequences are events that follow the concept of
interest (Chinn & Kramer 2011). From the sources dis-
cussed in this analysis, it is clear that a cancer survivor does
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M. Hebdon et al.
not survive unaffected. They have ongoing physical, emo-
tional, financial and social challenges that may require sup-
port and/or medical intervention. Many of the sources
indicate the requirement of support from external sources.
There are also the positive outcomes, such as improved
self-advocacy, sense of well-being and the victory of over-
coming a challenge.
Empirical referents
Empirical referents are specific tools or measurements that
might be used in a research study. Empirical referents for
cancer survivor address some of the dimensions of cancer
survivor: cancer diagnosis, living person, difficult experience
(i.e. trauma, cancer treatment), follow-up care (i.e.
resources utilization, surveillance and screening activities)
emotional challenges (i.e. anxiety or depression), physical
challenges (i.e. disability, health-related quality of life),
social challenges (i.e. employment status, relationships),
social support (i.e. friends, family, medical providers), med-
ical intervention (i.e. number of specialty referrals, number
of medications), self-advocacy (self-advocacy), sense of
well-being (i.e. self-efficacy, happiness) and overcoming
challenges (resilience).
The definition in this analysis indicates that a cancer sur-
vivor is not only an individual who has lived through the
challenge of a cancer diagnosis, but has an individualized
cancer experience with positive and negative consequences.
These consequences may be evaluated by measures such as
the following: the Hospital Anxiety and Depression Scale
for emotional challenges, the Short Form 12 for health-
related quality of life, Quality of Relationships Inventory
for social challenges, the Social Support Questionnaire for
social support and self-reported healthcare utilization for
medical intervention, Cancer Behavior Inventory-Brief for
self-efficacy, Authentic Happiness Inventory Questionnaire
for happiness and Resilience Scale for overcoming adversity
(Sarason et al. 1983, Zigmond & Snaith 1983, Pierce et al.
1991, Heitzman et al. 2001, Ahern et al. 2006, University
of Pennsylvania 2006, Ansah & Powell-Jackson 2013, SF-
36.org n.d.). Figure A1 illustrates the relationship between
the critical attributes, antecedents, consequences and empir-
ical referents of cancer survivor.
Case examples
Model case
RL is a 52 year-old female who was diagnosed with colon
cancer at the age of 50 after a screening colonoscopy. She
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had a significant amount of fear at the time of her diagnosis
due to family members who had died from cancer. RL was
treated with colon resection and chemotherapy. Since then,
she has followed up with her primary care provider and
medical oncologist for her CT scans and carcinoembryonic
antigen (CEA) levels, she has managed her multiple co-mor-
bid conditions and she continues to work as an elementary
school teacher. She has experienced effects related to her
cancer and its treatment, including bowel and sexual dys-
function, depression and cognitive impairment. She receives
medical intervention for these concerns with biofeedback,
counselling and anti-depressants. She is confident in the
cancer treatment she received, but has ongoing concerns
about recurrence. She relies on the support of her family,
especially her spouse and her healthcare providers. She
plans to continue living life, knowing she will die of some-
thing, if not the cancer.
The above is a model case of a cancer survivor, as RL
was diagnosed with a malignancy, lived through treatment
and is now receiving follow-up care. She continues to deal
with the late effects related to her cancer and treatment,
but also lives her life. Her experience with cancer was
affected by her personal experience with family members
with cancer. She accesses external sources of support in
coping with her cancer and related concerns.
Related case
BA is a 28-year-old female with a family history of breast
cancer. Her mother died at the age of 42 and tested posi-
tive for BRCA-1 and BRCA-2. Both of her mother’s sisters
were also diagnosed with breast cancer, but are still living.
BA received the news that she is positive for the BRCA-1
and BRCA-2 gene. BA chose to have a prophylactic bilat-
eral mastectomy followed by reconstructive surgery. Due
to her risk for cancer, she eats well, exercises, avoids
tobacco and limits her alcohol intake. She hopes to beat
any potential cancer before it has a chance to take hold.
She wants to live past 40 and be able to meet her grand-
children. She is motivated to be healthy for her two chil-
dren and her husband. She is supported by her husband
and medical providers in her decisions about her care.
She occasionally expresses fears about the future, espe-
cially about the risk of ovarian cancer due to her genetic
risk.
BA is an example of a related case, as she was not diag-
nosed with a malignancy, but had the potential for develop-
ing a malignancy. She does exhibit attributes of a survivor
by undergoing treatment for cancer prophylaxis, living
through treatment, engaging in positive behaviours due to
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JAN: CONCEPT ANALYSIS
her risk for cancer, having fears due to her cancer risk and
relying on external support sources.
Contrary case
GR, a 76-year-old man, presented to the emergency room
with a cough and shortness of breath that had been increas-
ing in severity over the past 2 weeks. A chest x-ray showed
a pleural effusion suspicious for pulmonary malignancy.
After chest tube drainage and pathology reports demon-
strated no evidence of malignancy, the patient was treated
for acute pneumonia in the hospital. Rather than expressing
relief to his family that he did not have cancer, he contin-
ued to discuss fears related to a diagnosis of cancer. Two
days after being admitted to the hospital he was being pre-
pared for discharge due to stabilization of his white blood
cell count and clinical response to antibiotic therapy. As the
nurse came into the room to give discharge education, he
was found in cardiac arrest. A code was called, he was
resuscitated and placed on life support. After 24 hours, his
family removed life support per his wishes and he died a
few hours later.
GR is an example of a contrary case because he did not
exhibit any of the critical attributes of a survivor in the
cancer context. He did not have a malignancy, so was not
treated for this condition and did not access support for his
illness. It is unknown whether there were positive and nega-
tive consequences of his experience as he did not express
these factors before his death. In fact, he seemed in denial
regarding the fact that he did not have cancer. He did not
have ongoing needs, due to his unexpected death.
Discussion
Based on this analysis, cancer survivor implies more than
just an individual who is living with a history of cancer.
The accepted views of triumph and overcoming that may
be communicated with the term survivor do not apply to
all those who, by definition, are considered cancer survivors
(Bell & Ristovski-Slijepcevic 2012). The extrapolated mean-
ing of cancer survivor in this analysis includes the diversity
of personal experiences, both positive and negative, that
individuals living with cancer may encounter. This analysis
embraces what Arthur W. Frank discusses in The Wounded
Storyteller about the need for patients to restructure and
acclimate to their postillness world (Frank 1997).
The definition of cancer survivor in this analysis contrib-
utes to the paradigm shift of cancer as a chronic disease
rather than the acute, life-threatening illness it was in the
past. Chronic disease as defined by the Center for
© 2015 John Wiley & Sons Ltd
Concept analysis of cancer survivor
Managing Chronic Disease is a long-lasting condition that
can be controlled, but not cured (Center for Managing
Chronic Disease 2011, para 1). In cancer research and
treatment, the word cure is often used. The American Can-
cer Society (2013) discusses cancer as a chronic disease, but
in terms of an individual who continues on therapy until
the end of life to keep their cancer stabilized. Yet, the
World Health Organization and the Centers for Disease
Control and Prevention list cancer as a chronic disease with
suggestions for integrated prevention and health promotion
(Centers for Disease Control & Prevention 2013, World
Health Organization 2014). The definition of chronic dis-
ease that this concept analysis attempts to address is the
idea of a chronic disease continuum. No two chronic dis-
eases are alike just as no two individuals are completely
alike. There are key features of chronic disease including:
acute exacerbations, chronic management with prevention
and treatment strategies, variability in disease expression
(i.e. insulin resistance and gestational diabetes in Type II
diabetes) and long-standing consequences related to the
diagnosis or treatment. For some with a cancer diagnosis,
they may achieve remission with one short-term treatment
modality, while others may continue on treatment for the
remainder of their life. Even for those who are in remission,
as described in this analysis, there are ongoing treatment
and prevention needs and consequences from cancer and its
treatment.
This idea of cancer as a chronic illness aligns with Merle
Mishel’s Theory of Uncertainty in Illness where a cancer
survivor’s uncertainty about their disease trajectory may
lead to either positive or negative coping strategies (Mishel
1988). In Mishel’s theory and in this analysis, those with
chronic diseases such as cancer have individualized experi-
ence influenced by multiple factors including social support,
prior life events, healthcare provider communication and
existing needs or challenges (Mishel 1988). Mckenzie and
Crouch (2004) aptly describe this uncertainty survivors face
due to fear of recurrence. This fear engenders the percep-
tion of being at higher risk than others resulting in interper-
sonal discordance. Understanding this variability in
experience and the potential for uncertainty provides nurses
with an opportunity to extend support and resources to
those who have a history of cancer. For instance, due to the
medical and psychosocial consequences of being a cancer
survivor, they may require ongoing support through social,
medical and community resources (Centers for Disease
Control & Prevention 2004). Ganz (2011) has identified
the three P’s of cancer survivorship care which focus on
palliation of symptoms, prevention of recurrence and late
effects and promotion of wellness. Focusing survivorship
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M. Hebdon et al.
care on these principles may prevent gaps in care. Nurses
must also acknowledge that all patients may not want to be
considered under the umbrella of ‘cancer survivor’ due to
the positive or negative social connotations attached to this
term. Taking the time to understand the individual’s per-
spective of their cancer and their life after cancer can guide
the nurse’s care approach.
Limitations
With the approach of this analysis there are several poten-
tial limitations of this analysis including the broad nature
of the data analysis, the analysis of survivor alone rather
than combined with the term cancer and the use of less
recent sources. The data were analysed across disciplines to
obtain an encompassing view of the term survivor, but this
may affect the use of the term’s application to the nursing
discipline. Survivor alone was used in analysing the data
and then was applied to the cancer context. An analysis of
the terms cancer and survivor together might yield a more
precise definition of this term. Finally, data from sources
older than 10 years was used for this analysis. While this
could potentially affect the currency of the definition found
in this analysis, historical and cross-disciplinary meanings
give a rich understanding of survivor.
Conclusion
This concept analysis can inform research through under-
standing the key differences between the terms survivor and
survivorship. Survivorship is the general term applied to the
care period after active treatment completion (National Can-
cer Institute n.d.b). Cancer survivors are individuals with
very personal experiences of their cancer diagnosis, treatment
and life beyond cancer (Chambers et al. 2012, Khan et al.
2012, A. Thomas, personal communication, December 6,
2013, R. Thomas, personal communication, December 6,
2013). Research and public policy for cancer survivorship
should continue to focus on the broad needs of patients dur-
ing this period of care, but the treatment of specific cancer
survivors should not be lost in the general understanding of
survivorship. Research should address the individual nature
of patient experiences and views of the term ‘cancer survivor’
across the spectrum of cancer diagnoses, stages of disease
and social and cultural contexts. Available measures, such as
those presented herein as empirical referents, may aid
researchers as they work to ascertain the most critical and
efficient approaches to provide individualized care in a direc-
ted, cost effective manner. At this point, cancer survivor may
be the best term available, but further research may lead to
1780
the usage of different terms to identify individuals with a his-
tory of cancer, or it may lead to more intentional use of the
term cancer survivor. Specifically for nurses, research on can-
cer survivor needs grounded in the Theory of Uncertainty in
Illness would lead to interventions that might decrease the
potential psychological and functional burdens of this
chronic illness.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sector.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the IC-
MJE (http://www.icmje.org/ethical_1author.html)]:
• substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
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JAN: CONCEPT ANALYSIS Concept analysis of cancer survivor

Appendix A

Table A1 Survivor Sources and Definition Summaries.

Sources Definitions

Dictionary and thesaurus

Oxford A person who survives, especially a person remaining alive after an event in which others have died; the remainder of a
Dictionaries group of people or things; a person who copes well with difficulties in their life; a joint tenant who has the right to the
(2013) whole estate on the other’s death.
Economics
Myers et al. The survivor is the widow left after the death of her spouse. These widows have a high potential for poverty without
(1987) survivor benefits and therefore, are reliant on spouses to ensure survivor benefits.
Epidemiology
Arrighi and Survivors in the workforce are those workers who remain following a continuing selection process. This process is due
Picciotto to the presence of illness that makes some individuals unable to work. The remaining individuals are healthy enough to
(1994) work.
Immunology
Travis (2002) Epstein–Barr virus is a ‘viral survivor’, because it evades detection and elimination by the immune system through
attaching to memory B cells and viral proteins.
Literature
Lang (2007) Fictional account of a Jew delving into Holocaust literature. The survivor is one who lived through the Holocaust, but
the reader is a survivor as well by partaking in the experience.
Thon (2009) Short story discussing survivors from tragedy and those who do not survive. Discusses the relationship between a
mother and her son who survive conflict, the mother’s negligence and the son’s anger. The ending line is about
forgiveness as the key to their survival.
Management
Mishra and Survivors of corporate downsizing are those that remain after layoffs. These individuals may experience job stress and
Spreitzer burnout or find the opportunity for personal growth. Survivors do not all respond the same to downsizing.
(1998)
Mathematics
Kahan (2007) A mathematical survivor is the sole remaining number following a series of mathematical manipulations.
Medical and Public Health Websites
National One who remains alive and continues to function during and after hardship. In cancer, an individual from the time of
Cancer diagnosis to death. Distinct from survivorship, which focuses on the healthcare needs of a cancer survivor until the end
Institute of life.
(n.d.b)
Centers for Those who have experienced and lived through cancer, disaster (World Trade Center bombing), traumatic brain injury,
Disease sexual assault, parasites, etc.
Control and
Prevention
(2012)
Mayo Clinic Those who have experienced and lived through cancer. There are ongoing concerns for these individuals and they
(2012) require support from family, friends and healthcare providers.
World Health Those who have experienced and lived through accidents, disasters, infectious disease (i.e. malaria, polio, tuberculosis),
Organization sexual assault, acid violence, cancer. There are ongoing needs after the experiences described above.
(2010)
Institute of Those who have experienced and lived through cancer and/or sexual assault. Impact of those events results in needs for
Medicine those who are survivors.
(2009)
Medicine
Khan et al. The term ‘cancer survivor’ was a narrow definition of a patient’s experience of not being killed by cancer. Some felt the
(2012) experience of cancer treatment was not serious enough to warrant the term ‘survivor’, and that term should be reserved
for more aggressive cancers. ‘Cancer survivor’ is pretentious because everybody survivors something. Cancer survivor
denotes a choice in surviving cancer, when it often comes down to care and luck for those who survive and those who
do not. Survivor implies a cure, but recurrence is always a risk. Cancer survivor is a label and identity that some do
not want. Cancer survivor implies an advocacy role.

© 2015 John Wiley & Sons Ltd 1783

M. Hebdon et al.

Table A1 (Continued).
Sources Definitions

Kornhaber Burn survivors are those who survive after severe burns. These individuals encounter challenges due to their injury,
et al. require rehabilitation and must come to terms with their injury and body image.
(2013)
Graven et al. Stroke survivors are those who live through stroke and return to the community. They require ongoing services and
(2013) community support in the chronic phase after a stroke.
Music
Wlodarski Schoenberg’s A Survivor From Warsaw is a musical crescendo of Jewish suffering and horror defeated by unwavering
(2007) faith.
Destiny’s Survivor talks about overcoming, becoming stronger and continuing on with life.
Child
(Song
Meanings
n.d.)
Nursing
Godwin et al. Stroke survivors are those who have survived a stroke. These individuals and caregivers experience co-morbidities and
(2013) lifestyle changes. Health-related quality of life is affected and negative stroke-related outcomes persist for years after
the stroke, with some worsening over time.
Davies (2013) A survivor is someone who is successfully treated and survives long term. Survivors cope with late effects of cancer and
treatment, including pain. Survivors should be considered those who have finished active treatment, have no evidence
of disease and are under cancer surveillance. Survivorship is defined as beginning at diagnosis and extending to the end
of life.
Kazanjian Cancer survivors are those living with a history of cancer, their families and their caregivers. They may experience
et al. physical, psychological and social consequences of cancer and its treatment. Cancer survivorship is a phase of the
(2012) cancer trajectory.
Pierce (2011) Discusses parents of children who have committed a sexual offense as survivors. These individuals experienced shock,
anger, questions and they learnt to deal with it. The offense affected every part of their life, but they felt they were
stronger from the experience. They knew life would continue to be difficult.
Oral History
Nutkiewicz Holocaust survivors are those who lived through the Holocaust. These individuals experience public and private trauma.
(2003) They struggle with the competing needs of staying quiet and forgetting vs. memorializing and speaking out.
Pedagogy
Berry (2008) Use of the television show, Survivor, as a basis for active learning. The survivor is the last person left in the game, but
their success is promoted through tribal interaction.
Personal Testimony
R. Thomas ‘Everyone will die of something, so it comes down to how you can live a productive life. I still have Guianne Barre and
(2013) cancer, but it is okay. I can live my life completely even with these conditions. I guess I am a survivor of both of these.
I will die of something, but I don’t dwell on that. I feel like asthma impairs me more than anything. I still take stairs
even if I can’t breathe or I am walking with a cane. You can’t let things keep you from the things you enjoy’.
A. Thomas ‘I think that the hardest thing for someone with cancer is after treatment. It is living with the aftermath. It does not all
(2013) go away for years, if forever. The ‘new normal’ is hard’.
Philosophy and Sociology
Naples (2003) Sexual abuse survivors are those who have lived through the abuse and redefined their relationship with the experience
from the victim status. Survivors’ experiences are affected by class, race, sexuality, identity and history.
Popular Media
Survivor A televised contest where the last contestant standing after a series of challenges and physical extremities is the winner.
(Wikipedia Participants are reliant not only on themselves, but those in their tribes for their success
2013)
Psychology
Chambers A cancer survivor is a person from the time of diagnosis to the end of life. Cancer survivor identity is overly heroic,
et al. unrealistically positive, minimizes physical and emotional cost of cancer, alienates individuals with advanced disease or
(2012) who will ultimately die from the cancer and defines people by their disease. In contrast, some felt an empowered
identity, improved self-esteem, healthy lifestyle behaviours and better cancer-related survival. Those who identified
themselves as cancer survivors had higher personal and interpersonal growth, acceptance and life satisfaction scores
than those who identified themselves as persons who have had cancer. Increased life satisfaction and physical activity
for cancer survivors over all groups.

1784 © 2015 John Wiley & Sons Ltd

JAN: CONCEPT ANALYSIS Concept analysis of cancer survivor

Table A1 (Continued).
Sources Definitions

Garrett et al. Patients transition from active cancer patients to survivors. Cancer survivors suffer from psychosocial sequelae and often
(2013) do not adhere to health promotion activities.
Ho and Lee Traumatic brain injury survivor is an individual that lives after the injury. These individuals have major challenges to
(2013) overcome and require rehabilitation.
Jones (2013) Soldiers and veterans as survivors are those who are living, but have experienced or might experience anger, anxiety,
depression, post-traumatic stress, adjustment to life outside the armed forces, marital and relationship challenges and
effects of physical injury.

Appendix B

Figure A1 Survivor in the Cancer Context.

Economic Challenges

Physical Challenges
Difficult Experience

Cancer Diagnosis Follow-up Care Emotional Challenges

Critical Attributes of Cancer Social Challenges

Survivor:
Living with a history of
malignancy Consequences:
Surviving a difficult experience Overcoming
Antecedents: Challenges
such as treatment
Cancer Diagnosis
Having positive and negative Sense of Well-Being
Cancer Treatment effects from cancer and Self-Advocacy
Being Alive treatment Ongoing Challenges
Receving follow-up care for Need for Support
cancer
Having a personal, contextual
cancer experience Social Support
Self-Efficacy
Living Person
Medical Intervention
Resilience

Happiness

Empirical Referents

© 2015 John Wiley & Sons Ltd 1785

M. Hebdon et al.

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