Annals of Behavioral Medicine, 2024, 58, 147–155

https://doi.org/10.1093/abm/kaad067
Advance access publication 22 December 2023
Regular Article

Perceived and Received Social Support and Illness

Acceptance Among Breast Cancer Patients: The Serial
Mediation of Meaning-Making and Fear of Recurrence

Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024

Dariusz Krok, PhD1, · Ewa Telka, PhD2, · Dagna Kocur, PhD3,
1
Institute of Psychology, Faculty of Social Sciences, Opole University, Opole, Poland
2
Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
3
Institute of Psychology, Faculty of Social Sciences, University of Silesia in Katowice, Katowice, Poland
Dagna Kocur:
dagna.kocur@us.edu.pl

Abstract
Background and Purpose The literature indicates connections between social support and acceptance of a personal diagnosis of breast cancer,
but these relationships are likely to be mediated due to numerous connections between social support and illness acceptance with meaning-
making and fear of recurrence. We decided to investigate whether meaning-making and fear of recurrence serially mediated the relationship
between perceived and received social support and illness acceptance.
Methods The current research examined 246 adult women patients with a breast cancer diagnosis who were undergoing radiotherapy/chemo-
therapy treatment in oncological hospitals. This cross-sectional study based on a mediational model was reported according to the STROBE
checklist.
Results Our results supported the mediational model in which meaning-making and fear of recurrence serially mediated the relationship of both
perceived and received social support with illness acceptance. Furthermore, the mediating power of meaning-making was more significant than
the fear of recurrence.
Conclusion Meaning structures and anxiety played an important mediating role in breast cancer patients. Finding additional meaning and goals
and experiencing lower fear enables the patients to effectively make use of social support and accept their illness.
Practice implications The current study identified factors that increase illness acceptance among breast cancer patients as it showed that pa-
tients can gain a greater understanding of the nature of their illness by becoming more aware of their own goals and values and reduce anxiety
by learning about their current state of the illness.

Lay summary
Breast cancer is the most common cancer in women in the world, and the hardships of the cancer experience are considered potentially trau-
matic events associated with psychological effects. One of the most important factors responsible for the patient’s daily functioning is illness
acceptance. Therefore, we investigated whether meaning-making and fear of recurrence serially mediated the relationship between perceived
and received social support and illness acceptance. We examined 246 adult women patients with a breast cancer diagnosis. In our study, pa-
tients with breast cancer who received more social support had a better understanding of their illness and lower fear of recurrence. Moreover,
women with breast cancer characterized by a sense of purpose and optimism experienced lower anxiety about a potential relapse of the
disease. Meaning structures and anxiety played an important mediating role in breast cancer patients. Finding additional meaning and goals and
experiencing lower fear enables the patients to make use of social support and accept their illness effectively.
Keywords Social support ∙ Illness acceptance ∙ Meaning-making ∙ Breast cancer patients ∙ Fear of recurrence

Introduction whether meaning-making and fear of recurrence serially me-

Breast cancer is the most common cancer in women in the
world [1]. The hardships of the cancer experience are con-
sidered potentially traumatic events associated with psy-
chological effects [2]. Cancer has a psychologically difficult
nature, among other things, because of the risk of recurrence
and concerns related to the latter [3, 4]. However, factors such
as social support and meaning-making can be very supportive
in adjustment to illness [5, 6]. All this together can translate
into greater acceptance of the disease, which helps in the re-
covery process [7, 8]. Therefore, we decided to investigate
diated the relationship between perceived and received social
support and illness acceptance.
Associations Between Social Support and Illness
Acceptance
Social support is one of the most critical features for coping
with chronic, serious illness, especially cancer. It is very im-
portant for psychological functioning: For instance, social
support is connected with lower levels of depression and
anxiety [9]. Moreover, perceived and available instrumental

© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
148
support is also positively connected with quality of life [10].
Social support is also important in breast cancer patients,
among other things, for predicting emotional well-being.
In this group, social support influences coping strategies.
Greater social support is positively connected with positive
reframing and negatively with self-blame [5]. However, it is
also important on a long-term scale. Received emotional sup-
port, such as reassuring, comforting, and problem-solving,
in the months after the diagnosis significantly predicted
posttraumatic growth even 8 years after the diagnosis [11].
Moreover, social support is essential not only for better psy-
chological functioning, but also for physical functioning [12].
Meta-analyses conducted by Pinquart and Duberstein show
that having high levels of perceived social support was asso-
ciated with a decrease in relative risk of mortality for 25%
of cancer survivors [12]. Additionally, reappraisal, one of the
outcomes of social support, can indirectly lead to the creation
of new meanings and assist in viewing the situation from an
alternative vantage point [13].
Illness acceptance is also significant in struggling with a
chronic disease, becoming a starting point for making choices
essential for the treatment. Notably, illness acceptance is
both connected with greater trust in doctors and treatment
methods and with active participation in therapy [7, 8].
Reaching illness acceptance is a process part and parcel to
psychological adjustment to chronic illness [14]. Previous re-
search has shown that greater acceptance of an illness is as-
sociated with a sense of coherence, improved quality of life,
reduced distress, lower levels of anxiety and depressive symp-
toms, and/or less perceived stress [10, 15–17]. On the other
hand, a lack of illness acceptance or a low level of the latter is
associated with distress, depressive symptoms, anxiety symp-
toms, greater pain, worse sleep, and social isolation [17, 18].
However, high, multidimensional pain makes it difficult to ac-
cept a personal disease diagnosis [19].
Importantly, social support and acceptance of an illness
are interconnected [14, 20, 21]. Greater social support helps
patients accept their illness [16]. For instance, social support
correlated with acceptance-based strategies and acceptance
of emotion, which were connected with illness acceptance; in
addition, acceptance-based strategies and social support sig-
nificantly mediated the relationship between benefit-finding
and depression [22]. The mental adjustment to cancer is con-
nected with acceptance of the illness [21].
Research conducted among cancer patients shows positive
correlations between social relationships and acceptance of
the illness [20]. Moreover, patients who lived alone had sig-
nificantly lower acceptance of the illness [20]. In line with
that are results obtained by Czerw et al. [23], where married
individuals had a higher average acceptance of the illness than
patients who declared themselves single.
To summarize, many studies indicate correlations between
social support and illness acceptance, but none show their
potential mediators. Further investigation is needed to reveal
potential mediational links between these variables.
Meaning-Making and Fear of Recurrence as
Potential Mediators in Chronic Diseases
Confrontation with a life-threatening situation or disease
can evoke existential distress, which is the experience of life
with little or no meaning [24]. Thus, the possibility of death
and an uncertain prognosis propels some cancer patients to
question the meaning and purpose of life, and the answers
ann. behav. med. (2024) 58:147–155
tend to vary. There have been groups of cancer survivors
who succeeded in meaning-making efforts, sometimes ex-
periencing even more meaning in life than before the diag-
nosis [25]. Some of them experienced enhanced meaning
after cancer through relationships, experiences, resili-
ence, goal orientation, and leaving a legacy [26]. However,
there is also a group of cancer survivors who struggle with
meaning-making, have difficulties in this territory, and
keep looking for meaning [27]. Sometimes, they experi-
Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024
ence a loss of meaning in their lives through experiences,
social roles, relationships, and uncertainties about the fu-
ture [26]. The above-mentioned relationships can be more
deeply understood within the meaning-making model devel-
oped by Park [28]. The model makes an essential distinc-
tion between meaning-making efforts (e.g., automatic vs.
deliberate processes or assimilation versus accommodation
processes) and the meanings made as a result of such efforts
(e.g., acceptance, perceptions of growth, integration of the
stressful experience into identity, or reappraised meaning
of the stressor). Such outcomes increase general acceptance
of the situation and acceptance of cancer as a permanent
element of one’s life, translating into less fear of cancer re-
currence. Therefore, it is very likely that the overall level of
illness acceptance in cancer patients will depend not only
on social support, but also on the serial impact of meaning-
making and fear of recurrence, as the latter may undermine
the former in the illness situation. Considering the general
framework through which cancer patients try to reorganize
their lives, meaning-making and fear of recurrence may con-
stitute significant serial mediators between social support
and illness acceptance.
Fear of cancer recurrence and worries about disease pro-
gression are prevalent among cancer patients, especially in
cases of breast cancer [3, 4]. Up to a quarter or even one-
third of women with breast cancer experience moderate to
high fear of disease progression [3, 4]. Such concerns may
persist for many years for long-term cancer survivors and sig-
nificantly affect the functioning of patients. Patients who ex-
perience more fear of cancer recurrence have a lower quality
of life, even 6 years after the diagnosis [29], and in other
studies, they have had higher emotional/psychological dis-
tress, cancer-specific distress, and/or depressive and anxiety
symptoms [17]. Worrying about cancer progression naturally
reduces one’s quality of life, but higher perceived social sup-
port can counteract it [30]. Additionally, socially isolated pa-
tients or patients with lower social support are at greater risk
of experiencing fear of recurrence [31, 32].
The mediating function of meaning-making and fear of re-
currence can be more clearly understood within the broader
framework of stress and coping theory proposed by Park and
Folkman [33]. Meaning-making is described as a psycho-
logical process that elucidates how people construe traumatic
and potentially destructive incidents to achieve a coherent vi-
sion of life. As the meaning-making process consists of cog-
nitive attempts to perceive, interpret, and evaluate personal
experiences and events, it enables individuals to construct-
ively cope with fear and anxiety. Theoretical concepts and
results of empirical studies indicate that people perform a
number of cognitive operations to understand the difficult
and stressful experiences they deal with [28, 34, 35]. The
process makes it possible to adaptively adjust by eliminating
discrepancies in meanings through the reinterpretation and
modification of existing beliefs [28, 35]. As a result of the
ann. behav. med. (2024) 58:147–155
cognitive actions taking place, an individual can develop a
satisfactory system of meanings concerning specific events or
experiences.
Research confirms the mediating value of meaning-
making and fear of recurrence in chronic diseases [6, 36, 37].
Life meaningfulness was found to mediate between posi-
tive reframing and psychological well-being [6] and be-
tween affect and psychological well-being [36]. Moreover,
meaning-making during cognitive behavioral therapy par-
tially mediated between anxiety symptoms and depressive
symptoms before and after treatment [37]. Fear of recur-
rence also mediated between fatalism and depressive and
anxiety symptoms in women with breast cancer [38] and
between external (e.g., contact with health professionals)
and internal cues (e.g., feeling sick) and limited planning for
the future [39].
Methods
Aim and Objective
A recent literature review implies connections between social
support and acceptance of the illness [20, 21]. However, these
relationships are likely mediated. Perceived social support
also predicts patients’ tendency to consider cancer as a chal-
lenge, which could be connected with better meaning-making
and, consequently, decrease the fear of cancer recurrence
[31, 40]. Research suggests that social support and meaning-
making are associated [5]. According to the buffering model
of social support [13], social support may indirectly translate
into meaning-making, among others, thanks to reappraisal.
For example, talking to another person can help one see the
situation from a different perspective. Moreover, according
to the meaning-making model [28], meanings made, which
refer to the products of meaning-making processes, such as
the integration of the stressful experience into identity and
the reappraised meaning of the stressor, may contribute to
less anxiety, less fear of recurrence, and in turn, to more ac-
ceptance of the illness [28]. Additionally, according to the
model of Simonelli et al. [41], appraisal involving creating
new meaning can reduce fear of recurrence. Last but not least,
the Family model of predictors of fear of recurrence also high-
lights the importance of social support for meaning-making,
which translates into less fear of recurrence [42].
To our knowledge, no one has examined mediational asso-
ciations among perceived and received social support, illness
acceptance, meaning-making, and fear of recurrence among
breast cancer patients. Therefore, the aim of this study is
to investigate whether meaning-making and fear of recur-
rence serially mediate the relationship between perceived
Fig. 1. A model of the serial mediation of meaning-making and fear of recurrence in associations between social support and illness acceptance
149
and received social support and illness acceptance (Fig. 1).
Based on both the meaning-making model and previous re-
search, we formulated three hypotheses: (H1) Higher levels
of perceived and received social support will be positively
related to meaning-making and negatively related to fear
of recurrence; (H2) higher meaning-making and lower fear
of recurrence will be positively related to higher illness ac-
ceptance; and (H3) meaning-making and fear of recurrence
will serially mediate the relationship between perceived and
Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024
received social support and illness acceptance; more specif-
ically, the character of the mediation will consist in higher
meaning-making being related to lower fear of recurrence.
Procedure
Initially, 297 patients were invited to participate in the study,
whereas 31 declined to participate and 20 were not eligible due
to unpredicted health conditions (e.g., seasonal flu, COVID-19
infections, malaise, and high blood pressure). A final sample
of 246 participated in the study. The participation ratio was
83.11%. The participants were approached personally by re-
search assistants while undergoing medical treatment in two
university hospitals—the Maria Sklodowska-Curie National
Research Institute of Oncology in Gliwice and the Voivodship
Hospital in Opole—between September 2020 and June 2022.
Participants were provided with an explanation of the study
and given a set of questionnaires in a closed envelope to be
completed within 2 weeks. Upon study completion, partici-
pants were invited for debriefing. The University of Opole
Institutional Ethics Committee approved the study (approval
number 2/2020). This study was reported according to the
STROBE checklist.
Participants
A total of 246 participants took part in our study. Eligible
participants were adult women patients with a diagnosis
of breast cancer who were undergoing radiotherapy/
chemotherapy treatment in oncological hospitals. Criteria
for inclusion were the following: (a) confirmed diagnosis
of breast cancer (Stages I–III), (b) cognitive capacity to fill
in questionnaires, and (c) positive physiological reactions
to the treatment. Criteria for exclusion were the following:
(a) cognitive deficiencies (e.g., serious memory problems,
medical history of psychiatric disorders), (b) palliative
treatment, (c) metastases to areas other than breasts, or
(d) other serious medical conditions that could modify re-
sponses (e.g., cardiovascular problems, poor eyesight). The
data were collected in Poland, and the participants were not
paid for study participation.
150
Measures
Social support
Two subscales of perceived and received social support from
the Berlin Social Support Scales (BSSS) by Schulz and Schwarzer
were used to measure domains of social support [43]. The BSSS
was adapted and validated in Polish by Łuszczyńska et al. [44].
The subscales measure both cognitive and behavioral aspects
of social support. The perceived social support scale comprises
8 items, and the received social support scale includes 15 items.
People responded to items on a 5-point scale, ranging from 1
(“definitely untrue”) to 5 (“definitely true”). Cronbach’s alpha
coefficients for the present study were 0.81 for perceived social
support and 0.84 for received social support.
Meaning-making
Meaning-making was measured using the Meaning-Making
Questionnaire (MMQ) by Krok and Zarzycka [45]. The
MMQ evaluates one’s cognitive capacity to comprehend and
assimilate challenging or ambiguous life events into coherent
structures of personal meaning, beliefs, and goals. It includes
8 items that are rated on a 5-point scale, ranging from 1
(“never”) to 5 (“very often”). Higher scores represent a more
active process of meaning-making. The Cronbach’s alpha co-
efficient for the present study was 0.86.
Fear of recurrence
The Cancer Worry Scale by Custers et al. was used to assess
fear of recurrence which is conceptualized as worry about the
likelihood of cancer’s recurrence and its interference with daily
functioning [46]. The scale was adapted and validated in Polish
by Krok and Telka [47]. This widely used scale contains 8 items
that are rated on a 4-point scale, ranging from 1 (“never”) to 4
(“almost always”). Higher scores represent more frequent wor-
ries about cancer (i.e., a greater fear of cancer recurrence). The
Cronbach’s alpha coefficient for the present study was 0.89.
Illness acceptance
The Acceptance of Life with the Disease Scale by Janowski
et al. was utilized to assess participants’ adaptation to the
disease in terms of the ability to accept health conditions and
maintain overall life satisfaction [48]. The scale contains 20
items that are rated on a 5-point scale, ranging from 1 (“no”)
to 5 (“yes”). It has three subscales: (a) satisfaction with life,
(b) reconciliation with the disease, and (c) self-distancing from
the disease. The total score, which is computed by adding the
three subscales, was used in the current study. Higher scores
indicate a higher level of illness acceptance. The Cronbach’s
alpha coefficient was 0.90.
Table 1 Means, Standard Deviations, and Correlations Among Perceived and Received Social Support, Meaning-Making, Fear of Recurrence, and Illness
Acceptance
Variables M SD Skewness Kurtosis
1. Perceived social support 3.42 0.54 0.13 0.24
2. Received social support 3.32 0.46 −0.01 0.61
3. Meaning-making 2.95 0.96 0.21 −0.74
4. Fear of recurrence 2.61 0.60 0.10 −0.54
5. Illness acceptance 3.38 0.71 −0.71 0.39
*p < .05; **p < .01; ***p < .001.
ann. behav. med. (2024) 58:147–155
Data Analysis
All statistical analyses were conducted with SPSS (version
28) software. First, we performed a priori power analysis
G* to calculate a sufficient sample size. The following
parameters were applied: 90% power (1 − β), α = 0.05
[49]. The results showed that a total of 236 participants
was required for the study. Next, two-tailed correlations
were calculated among all the variables. Finally, serial me-
diation analysis (Model 6) was used to test the direct and
Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024
indirect effects between the variables [50]. The bootstrap-
ping procedure (5,000 samples; 95% confidence intervals
[CI]) was applied, so the size of our sample (n = 100 or
more) precludes type II errors. We ran our mediation ana-
lysis for two models with perceived and received social
support examined separately as two independent vari-
ables. Therefore, we calculated separate mediation effects
for meaning-making and fear of recurrence under: Model
1 for perceived social support and Model 2 for received so-
cial support. Meaning-making and fear of recurrence were
entered as serial mediators, so indirect effects were calcu-
lated for them separately (i.e., for each mediator: Perceived
social support—Meaning-making—Illness acceptance) and
jointly (i.e., for both mediators: Perceived social support—
Meaning-making—Fear of recurrence—Illness acceptance).
In addition, missing data were handled by using the method
of case-wise mean substitution that imputes average scores
from the corresponding subscale. The level of missing data
in our study was very low, i.e., around 1%, so it was accept-
able to use this procedure.
Results
Descriptive Statistics and Correlational Analysis
The participants were characterized by the following demo-
graphic and medical data: (a) employment status—full-time/
part-time work: N = 121, 49.1%; retired/domestic work:
N = 125, 50.9%, (b) marital status—married/domestic
partner: N = 182, 73.9%; single/widowed: N = 64, 26.1%, (c)
body mass index: M = 22.36, SD = 2.37, and (d) illness dur-
ation: M = 3.59, SD = 4.51. First, we calculated descriptive
statistics for all the variables in our sample (Table 1). In all the
cases, the mean scores were above the scale midpoint, which
was 2.5. Initial correlation analysis demonstrated that all the
Pearson coefficients turned out to be statistically significant.
Both perceived and received social support were positively
associated with meaning-making and illness acceptance, yet
they were negatively associated with fear of recurrence. In
addition, meaning-making was negatively correlated with
fear of recurrence.
Scores range 1 2 3 4
1–5 –
1–5 0.56*** –
1–5 0.35*** 0.30*** –
1–5 −0.38*** −0.23*** −0.27***
1–5 0.36*** 0.31*** 0.49*** −0.33***
ann. behav. med. (2024) 58:147–155 151

Mediation Analysis acceptance, while fear of recurrence had a negative relation

To investigate whether meaning-making and fear of recur-
rence would serially mediate the relationship of perceived
and received social support with illness acceptance, medi-
ation analysis (Model 6) with the bootstrapping procedure
(sample = 5,000; 95% bias-corrected CIs) suggested by
Hayes [50] was applied to calculate the mediational effects
(i.e., standardized parameter estimates). The results are given
in Table 2.
with it. The examination of indirect effects indicated that
meaning-making and fear of recurrence were serial medi-
ators between received social support and illness acceptance.
Regarding their separate mediational effects, both meaning-
making and fear of recurrence mediated relationships be-
tween received social support and illness acceptance. Total
effects of perceived and received social support on illness ac-
ceptance turned out to be significant, respectively.

Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024

The examination of direct effects revealed that perceived
social support was positively related to meaning-making, but
negatively related to fear of recurrence. Meaning-making
was also negatively related to fear of recurrence. With re-
gard to illness acceptance, meaning-making, and perceived
social support were positively related to it, whereas fear of
recurrence was negatively related. The total indirect effect
showed that meaning-making and fear of recurrence were
serial mediators between perceived social support and illness
acceptance. Taking into account the separate mediational ef-
fects, both meaning-making and fear of recurrence mediated
relationships between perceived social support and illness
acceptance.
Next, received social support was positively associated
with meaning-making but negatively associated with fear
of recurrence. Meaning-making was also negatively associ-
ated with fear of recurrence. Furthermore, meaning-making
and received social support were positively related to illness
Finally, we decided to evaluate the separate mediation ef-
fects of meaning-making and fear of recurrence by using effect-
contrast procedures. For perceived social support, the results
showed differences in the mediating powers of meaning-
making and fear of recurrence (Indirect Effect = 0.09; CIs
[0.01,0.18]), with the first having a stronger mediation effect
than the latter. For received social support, there were also
significant differences in the mediating powers of meaning-
making versus fear of recurrence (Indirect Effect = 0.10; CIs
[0.03,0.17]); the former exerted a stronger mediation effect
than the latter (Fig. 2).
Discussion and Conclusion
Discussion
The aim of the present study was to verify whether meaning-
making and fear of recurrence are serial mediators in the
relationship of perceived and received social support with

Table 2 Mediation Estimates for Meaning-Making and Fear of Recurrence in the Relationship of Perceived and Received Social Support With Illness
Acceptance (Standardized Parameter Estimates)

Variables β SE t Model R2

Direct effects
Perceived social support as Independent Variable
 Perceived social support—Meaning-making 0.35 0.11 5.90*** 0.13***
 Perceived social support—Fear of recurrence −0.32 0.11 −5.21***
 Meaning-making—Fear of recurrence −0.15 0.06 −2.48* 0.16***
 Meaning-making—Illness acceptance 0.40 0.06 7.05***
 Fear of recurrence—Illness acceptance −0.16 0.05 −2.68**
 Perceived social support—Illness acceptance 0.16 0.10 2.67** 0.31***
Received social support as Dependent Variable
 Received social support—Meaning-making 0.30 0.12 4.99*** .09***
 Received social support—Fear of recurrence −0.16 0.12 −2.56*
 Meaning-making—Fear of recurrence −0.22 0.06 −3.45** 0.10***
 Meaning-making—Illness acceptance 0.41 0.06 7.20***
 Fear of recurrence—Illness acceptance −0.18 0.06 −3.26**
 Received social support—Illness acceptance 0.14 0.12 2.51* 0.31***
 Indirect effects Effect SE LLCI ULCI
 Perceived social support—Meaning-making—Illness acceptance 0.14 0.03 0.08 0.21
 Perceived social support—Fear of recurrence—Illness acceptance 0.05 0.02 0.02 0.10
 Perceived social support—Meaning-making—Fear of recurrence—Illness acceptance 0.20 0.03 0.13 0.28
 Received social support—Meaning-making—Illness acceptance 0.12 0.03 0.06 0.20
 Received social support—Fear of recurrence—Illness acceptance 0.03 0.02 0.01 0.06
 Received social support—Meaning-making—Fear of recurrence—Illness acceptance 0.17 0.04 0.09 0.24
Total effect
 Perceived social support—Illness acceptance 0.36 0.11 6.10*** 0.13***
 Received social support—Illness acceptance 0.31 0.12 5.11*** 0.10***

*p < .05, **p < .01, ***p < .001.

152
Fig. 2. The final mediation model of meaning-making and fear of recurrence in associations between perceived and received social support and illness
acceptance, respectively, Model 1 and Model 2 (standardized coefficients β, and indirect effects IE)
illness acceptance among breast cancer patients. In general,
our results suggest that while meaning-making and fear of
recurrence were serial mediators between perceived and re-
ceived social support and illness acceptance, respectively, their
mediating powers were different.
Relationships between social support and meaning-making
and fear of recurrence
The result that both perceived and received social support
were positively related to meaning-making, but negatively re-
lated to fear of recurrence is consistent with our first hypoth-
esis as well as previous findings relating the importance of
supportive social relations to meaning-making processes [15,
26]. Women with breast cancer who realize the availability of
supportive actions and actually receive them are character-
ized by a more efficient ability to comprehend and integrate
challenging life events and experience less fear and anxiety
related to potential relapse of cancer than those that do not.
However, while other studies found a stronger effect for per-
ceived social support than received social support [51], in the
current study the strength of these relationships was compar-
able. We extended those findings by showing that both per-
ceived and received social support play a significant role in
cancer patients functioning.
This may be a consequence of a relatively high level of
anxiety and fear experienced by women cancer patients [39].
According to Cicero et al. [40], perceived social support from
others may predict the patient’s tendency to consider cancer
as a challenge and consequently take an active role in thinking
about the illness in constructive terms. In addition, patients
who are not lonely and experience social support report a
lower fear of recurrence [31, 32]. This might stem from the
fact that more frequent social contacts, which help patients
not think about the disease and their future all the time, pro-
vide a sense of availability of potential support in the future.
ann. behav. med. (2024) 58:147–155
Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024
Associations of meaning-making and fear of recurrence with
illness acceptance
In line with our second hypothesis, both meaning-making
and fear of recurrence were significant predictors of illness
acceptance. However, while meaning-making was positively
related to illness acceptance, fear of recurrence had a nega-
tive relation. This finding is consistent with previous research
demonstrating that cancer patients who managed to construct
a coherent vision of life during traumatic and potentially de-
structive incidents are characterized by better adjustment [9,
25, 52], higher well-being [25, 45], and general anxiety [26].
At the same time, the result regarding the negative association
between fear of recurrence and illness acceptance confirms
previous studies in which cancer patients who experienced
worries and fear reported a relatively low quality of life [30]
and adjustment to illness [39]. Yet, our finding extends pre-
vious findings by indicating that both meaning- and fear-
related processes need to be taken into account while dealing
with consequences of cancer. Searching for meaning in life
through programs such as those created by Rębiałkowska-
Stankiewicz not only help participants create new meaning
but also may be very useful, because talking openly about the
disease reduces fear [53].
A potential explanation for these results may lie in the fact
that the ability to form a meaningful perspective may rep-
resent a resource for women confronted with breast cancer
who experience meaning threats regarding their health, body
image, or personal relations. For instance, mothers could
choose to think about their children and their future in a
positive light, which helps them to remain strong and accept
their cancer. Furthermore, the idea of living for children can
prompt women to accept a burdensome therapy [54]. This
view is supported by meta-analyses that confirm positive cor-
relations between meaning in life and acceptance of cancer
[55]. On the other hand, fear of recurrence seems to lower
ann. behav. med. (2024) 58:147–155
the ability to accept the potential detrimental consequences
of breast cancer, which makes the process of accepting the
illness more difficult. Similar effects were found in studies in
which fear of recurrence was related to depressive and anx-
iety symptoms in breast cancer survivors [38].
It is also worth emphasizing that the effect-contrast pro-
cedures showed that the mediating power of meaning-making
was more significant than fear of recurrence. Perhaps because
an effective meaning-making process has more long-term ef-
fects, reformulating the meaning of cancer and important
goals can provide a stable basis and sense of emotional sup-
port for the patient. This is confirmed by a study in which
cancer survivors who succeeded in meaning-making efforts
experienced relatively more meaning in life than before the
diagnosis [25]. In addition, since acceptance of illness has
been conceptualized as a dynamic process of emotion-focused
coping [17], breast cancer patients can also use acceptance
coping that comprises relying on self-compassion or commu-
nicating their own feelings about the illness to other people.
This activity may result in reduced emotional reactivity (i.e.,
less fear of recurrence), reappraisal of cancer-related stressors
(i.e., meaning-making processes), and significant improve-
ment in emotional well-being (i.e., higher acceptance of
illness).
Meaning-making and fear of recurrence as serial mediators
The main finding of this study is a serial mediation of
meaning-making and fear of recurrence in the relationship of
both perceived and received social support with illness accept-
ance, which confirms our third hypothesis. This result seems
interesting as it justifies investigating meaning-making and
fear of recurrence as factors operating in concerted action.
Therefore, it sheds new light on previous research regarding
the relationship of social support with adjustment to illness
[16, 22] by demonstrating a concrete function of meaning and
fear. Although they are independent psychological constructs,
examining both in relation to illness acceptance provides
more information than investigating either alone. From a psy-
chological point of view, their co-occurrence seems justified,
as people who are able to develop a sense of meaning and
purpose and are optimistic about the future will experience
lower anxiety about a potential relapse of the disease than
those who do not [37]. This can consequently translate into a
relatively higher level of illness acceptance.
The serial mediation function of meaning-making and
fear of recurrence can be understood within Park’s [28, 35]
meaning-making model, according to which cancer symp-
toms challenge people’s beliefs and goals, generating distress
which, in turn, activates a meaning-making process. In this
context, perceived and received social support can be an im-
portant source of mental strength and motivation to make
meaning. Individuals try to reduce their distress by finding
meaningful views and goals through cognitive activities that
decrease their fear of future detrimental consequences and
potential relapses of cancer [51]. This enables cancer patients
to constructively reorganize their lives on the basis of new
meanings and goals, which are formulated in response to per-
ceived and received forms of social support. Therefore, the
serial mediation effects demonstrated two significant things.
First, the interplay of meaning-making and fear of recurrence
determines the extent to which breast cancer patients are able
to accept the negative consequences of their illness. Second,
the prerequisite for a positive attitude of acceptance is the
153
attainment of constructive meanings and goals and the op-
timal reduction/management of the fear of recurrence as much
as possible. As a consequence, breast cancer patients can come
to understand the illness in a different, more optimistic way
and reorganize their beliefs and goals in order to restore inner
cognitive and emotional stability. This interpretation is sup-
ported by the finding obtained by Pasek et al. [16] in which
sense of coherence (i.e., the construct including structures of
meaning) mediated the relationship between perceived social
Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024
support and illness acceptance in cancer patients.
Limitations
The present study is not without limitations. First, as our
results emerge from a cross-sectional study design, the
mediational model does not allow us to draw any causal con-
clusions regarding the observed relationships. Longitudinal
research, especially with a meaning-making intervention
among patients with different levels of social support, would
be needed to determine causality. Second, the method we used
to measure meaning-making in this study may be questioned.
Even though the MMQ [45] is a recognized and empirically
verified tool, meaning-making is a dynamic process that might
require assessment at different stages of a disease. Third, our
study only considered perceived and received social support.
Different kinds of social support could play different roles
in breast cancer coping, like the actual frequency of social
contacts and their quality, financial support, or the perceived
or real adequacy of social supports. Finally, as our study was
conducted in Poland, the results may not be fully general-
izable to other countries in Western Europe or the USA, as
they have a different clinical or medical system (e.g., specific
cancer prevention systems, more diverse approaches to psy-
chosomatic interventions or the use of radiotherapy/chemo-
therapy treatment interventions), resulting in differences in
the mental experience of breast cancer patients.
Conclusions
In sum, despite the above limitations, the current study has
shed new light on the mediational model with a serial medi-
ation of meaning-making and fear of recurrence in the rela-
tionship of both perceived and received social support with
breast cancer and perhaps general, serious illness acceptance.
Notably, our analysis showed that the mediating power of
meaning-making is more significant than fear of recurrence.
It suggests that creating an intervention that combines pro-
viding aid in enhancing meaning-making and lowering fear of
recurrence might benefit women with breast cancer.
Implications for Practice
The novelty of this research is the identification of meaning-
making and fear of recurrence as important clinical factors
that underlie the relationship of social support with illness
acceptance among patients with breast cancer. By focusing
on the sphere of meaning and purpose, care for patients
with breast cancer can become more effective. In addition,
strategies aimed at decreasing fear of recurrence will have
an impact not only on effective coping with the illness, but
also on the quality of social support offered to the patients.
Furthermore, the mediating function of meaning-making and
fear of recurrence should be acknowledged and encouraged
in the process of providing medical care to patients with
breast cancer. By increasing the knowledge of intrapersonal
cognitive (meaning-making) and emotional (fear and anxiety)
154
processes, the results of this study may contribute to the im-
plementation of treatment programs that provide cancer pa-
tients with adequate and effective forms of social support.
Acknowledgements
We would like to thank all the participants and medical staff
in the Oncology Hospitals in Opole and Gliwice who contrib-
uted their time, ideas, and assistance.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Compliance with Ethical Standards
Authors’ Statement of Conflict of Interest and Adherence
to Ethical Standards Authors Dariusz Krok, Ewa Telka, and
Dagna Kocur declare that they have no conflict of interest.
All procedures, including the informed consent process, were
conducted in accordance with the ethical standards of the re-
sponsible committee on human experimentation (institutional
and national) and with the Helsinki Declaration of 1975, as
revised in 2000.
Authors’ Contributions Dariusz Krok (Formal analysis:
Lead; Investigation: Equal; Methodology: Lead; Project ad-
ministration: Lead; Supervision: Equal; Writing – original
draft: Equal), Ewa Telka Telka (Conceptualization: Equal;
Data curation: Lead; Investigation: Equal; Validation: Equal),
and Dagna Joanna Kocur (Investigation: Equal; Supervision:
Equal; Validation: Equal; Writing – original draft: Equal)
Ethical Approval All procedures performed in studies
involving human participants were in accordance with the
ethical standards of the institutional and/or national re-
search committee and with the 1964 Helsinki declaration and
its later amendments or comparable ethical standards. The
University of Opole Institutional Ethics Committee approved
the study (approval number 2/2020).
Transparency Statements In terms of transparency state-
ments, neither this study nor the analysis plan were formally
pre-registered. The data for the current study are publicly
available at Open Science Framework: https://osf.io/dnc6k/
References
1. DeSantis C, Siegel R, Bandi P, Jemal A. Breast cancer statistics,
2011. CA Cancer J Clin. 2011;61(6):408–418.
2. Martino ML, Lemmo D, Gargiulo A. A review of psychological
impact of breast cancer in women below 50 years old. Health Care
Women Int. 2021;42(7-9):1066–1085.
3. Herschbach P, Keller M, Knight L, et al. Psychological problems of
cancer patients: A cancer distress screening with a cancer-specific
questionnaire. Br J Cancer. 2004;91(3):504–511.
4. Mehnert A, Berg P, Henrich G, Herschbach P. Fear of cancer pro-
gression and cancer-related intrusive cognitions in breast cancer
survivors. Psychooncology. 2009;18(12):1273–1280.
5. Kim YJ, Lee KJ. Relationship of social support and meaning of
life to suicidal thoughts in cancer patients. J Korean Acad Nurs.
2010;40(4):524–532.
6. Park CL, Edmondson D, Fenster JR, Blank TO. Meaning making
and psychological adjustment following cancer: The mediating
roles of growth, life meaning, and restored just-world beliefs. J
Consult Clin Psychol. 2008;76(5):863–875.
ann. behav. med. (2024) 58:147–155
7. Boryczko-Pater B, Baron A, Szaleniec J, Gierowski JK, Składzień J.
Dynamika przystosowania do choroby i jej akceptacji u pacjentów
z nowotworami głowy i szyi. Otolaryngol Pol. 2011;65(3):48–53.
8. Piotrkowska R, Terech-Skóra S, Mędrzycka-Dąbrowska W,
Jarzynkowski P, Król M. Factors determining acceptance of disease
and its impact on satisfaction with life of patients with peripheral
artery disease. Nursing Open. 2021;8(3):1417–1423.
9. Gonzalez-Saenz de Tejada M, Bilbao A, Baré M, et al; CARESS-
CCR Group. Association between social support, functional status,
and change in health-related quality of life and changes in anx-
Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024
iety and depression in colorectal cancer patients. Psychooncology.
2017;26(9):1263–1269.
10. Iwanowicz-Palus G, Zarajczyk M, Pięta B, Bień A. Quality of life,
social support, acceptance of illness, and self-efficacy among preg-
nant women with hyperglycemia. Int J Environ Res Public Health.
2019;16(20):3941.
11. Schroevers MJ, Helgeson VS, Sanderman R, Ranchor AV. Type
of social support matters for prediction of posttraumatic growth
among cancer survivors. Psychooncology. 2010;19(1):46–53.
12. Pinquart M, Duberstein PR. Associations of social networks with
cancer mortality: A meta-analysis. Crit Rev Oncol Hematol.
2010;75(2):122–137.
13. Cohen S, Wills TA. Stress, social support, and the buffering hypoth-
esis. Psychol Bull. 1985;98(2):310–357.
14. Dijkstra A, Buunk AP, Tóth G, Jager N. Psychological adjustment
to chronic illness: The role of prototype evaluation in acceptance of
illness. J Appl Biobehav Res. 2007;12(3-4):119–140.
15. Bussell VA, Naus MJ. A longitudinal investigation of coping and
posttraumatic growth in breast cancer survivors. J Psychosoc
Oncol. 2010;28(1):61–78.
16. Pasek M, Dębska G, Wojtyna E. Perceived social support and the
sense of coherence in patient-caregiver dyad versus acceptance of
illness in cancer patients. J Clin Nurs. 2017;26(23-24):4985–4993.
17. Secinti E, Tometich DB, Johns SA, Mosher CE. The relationship
between acceptance of cancer and distress: A meta-analytic review.
Clin Psychol Rev. 2019;71:27–38.
18. Obiegło M, Uchmanowicz I, Wleklik M, Jankowska-Polańska B,
Kuśmierz M. The effect of acceptance of illness on the quality of
life in patients with chronic heart failure. Eur J Cardiovasc Nurs.
2016;15(4):241–247.
19. Krok D, Telka E, Zarzycka B. Total pain and illness acceptance
in pelvic cancer patients: Exploring self-efficacy and stress in a
moderated mediation model. Int J Environ Res Public Health.
2022;19(15):9631.
20. Budna B, Bolanowska Z, Juzwiszyn J, Chabowski M. Impact
of illness acceptance on the quality of life in cancer patients
after surgical treatment. Srp Arh Celok Lek. 2020;148(5-6):
338–343.
21. Ruszkiewicz M, Kreft K. Correlates of the acceptance of illness in a
group of cancer patients. Psychoonkologia. 2017;21(2):37–44.
22. Manne SL, Kashy DA, Virtue S, et al. Acceptance, social support,
benefit-finding, and depression in women with gynecological
cancer. Qual Life Res. 2018;27:2991–3002.
23. Czerw AI, Bilińska M, Deptała A. The assessment of the impact of
socio-economic factors in accepting cancer using the Acceptance of
Illness Scale (AIS). Współczesna Onkol. 2016;20(3):261–265.
24. Lee V. The existential plight of cancer: Meaning making as a con-
crete approach to the intangible search for meaning. Support Care
Cancer. 2008;16:779–785.
25. Yanez B, Edmondson D, Stanton AL, et al. Facets of spirituality
as predictors of adjustment to cancer: Relative contributions
of having faith and finding meaning. J Consult Clin Psychol.
2009;77(4):730–741.
26. van der Spek N, Vos J, van Uden-Kraan CF, et al. Meaning
making in cancer survivors: A focus group study. PLoS One.
2013;8(9):e76089.
27. Tomich PL, Helgeson VS. Five years later: A cross-sectional
comparison of breast cancer survivors with healthy women.
Psychooncology. 2002;11(2):154–169.
ann. behav. med. (2024) 58:147–155
28. Park CL. Making sense of the meaning literature: An integrative
review of meaning making and its effects on adjustment to stressful
life events. Psychol Bull. 2010;136(2):257–301.
29. Koch L, Jansen L, Brenner H, Arndt V. Fear of recurrence and disease
progression in long-term (≥5 years) cancer survivors-a systematic
review of quantitative studies. Psychooncology. 2013;22(1):1–11.
30. Waters EA, Liu Y, Schootman M, Jeffe DB. Worry about cancer
progression and low perceived social support: Implications for
quality of life among early-stage breast cancer patients. Ann Behav
Med. 2013;45(1):57–68.
31. Koch-Gallenkamp L, Bertram H, Eberle A, et al. Fear of recur-
rence in long-term cancer survivors—Do cancer type, sex, time
since diagnosis, and social support matter?. Health Psychol.
2016;35(12):1329–1333.
32. Mehnert A, Koch U, Sundermann C, Dinkel A. Predictors of fear of
recurrence in patients one year after cancer rehabilitation: A pro-
spective study. Acta Oncol. 2013; 52(6):1102–1109.
33. Park CL, Folkman S. Meaning in the context of stress and coping.
Rev General Psychol. 1997; 1(2):115–144.
34. Kopacz MS, Lockman J, Lusk J, et al. How meaningful is meaning-
making? New Ideas Psychol. 2019; 54:76–81.
35. Park CL. Meaning making in the context of disasters. J Clin
Psychol. 2016;72(12):1234–1246.
36. Krok D, Gerymski R. Affect and psychological well-being in
spouses of cancer patients: the mediating role of meaning in life
and self-efficacy. Family Forum. 2022;11:267–286.
37. Marco JH, Alonso S, Baños R. Meaning-making as a mediator
of anxiety and depression reduction during cognitive behavioral
therapy intervention in participants with adjustment disorders.
Clin Psychol Psychother. 2021;28(2):325–333.
38. Tsai W, Wang JH. Fatalism and psychological distress among
Chinese American Breast Cancer Survivors: mediating role of
perceived self-control and fear of cancer recurrence. Int J Behav
Med. 2022;30(5).
39. Custers JAE, Gielissen MFM, de Wilt JHW, et al. Towards an
­evidence-based model of fear of cancer recurrence for breast cancer
survivors. J Cancer Surviv. 2017;11:41–47.
40. Cicero V, Lo Coco G, Gullo S, Lo Verso G, Lo Verso G. The role of
attachment dimensions and perceived social support in predicting
adjustment to cancer. Psychooncology. 2009;18(10):1045–1052.
41. Simonelli LE, Siegel SD, Duffy NM. Fear of cancer recurrence: A
theoretical review and its relevance for clinical presentation and
management. Psychooncology. 2017;26(10):1444–1454.
155
42. Mellon S, Kershaw TS, Northouse LL, Freeman-Gibb L. A family-
based model to predict fear of recurrence for cancer survivors and
their caregivers. Psychooncology. 2007;16(3):214–223.
43. Schulz U, Schwarzer R. Soziale Unterstützung bei der
Krankheitsbewältigung: Die Berliner Social Support Skalen (BSSS).
Diagnostica. 2003;49(2):73–82.
44. Łuszczyńska A, Kowalska M, Mazurkiewicz M, Schwarzer R.
Berlińskie Skale Wsparcia Społecznego (BSSS): Wyniki wstępnych
badań nad adaptacją skal i ich własnościami psychometrycznymi.
Studia Psychologiczne. 2006;25(2):17–27.
Downloaded from https://academic.oup.com/abm/article/58/3/147/7491576 by Biblioteka Uniwersytetu Opolskiego user on 03 April 2024
45. Krok D, Zarzycka B. Self-efficacy and psychological well-being
in cardiac patients: Moderated mediation by affect and meaning-
making. J Psychol. 2020;154(6):411–425.
46. Custers JAE, van den Berg SW, van Laarhoven HWM, Bleiker
EMA, Gielissen MFM, Prins JB. The cancer worry scale. Cancer
Nurs. 2014;37(1):E44–E50.
47. Krok D, Telka E. Skala Lęku przez Nawrotem Choroby. Opole:
Instytut Psychologii UO; 2022.
48. Janowski K, Steuden S, Pietrzak A, et al. Social support and ad-
aptation to the disease in men and women with psoriasis. Arch
Dermatol Res. 2012;304:421–432.
49. Faul F, Erdfelder E, Buchner A, Lang A-G. Statistical power analyses
using G*Power 31: Tests for correlation and regression analyses.
Behav Res Methods. 2009;41(4):1149–1160.
50. Hayes AF. Introduction to Mediation, Moderation, and conditional
Process Analysis: A Regression-based Approach. 2nd ed. New
York, NY: Guilford Publications; 2018.
51. Luszczynska A, Pawlowska I, Cieslak R, Knoll N, Scholz U. Social
support and quality of life among lung cancer patients: A system-
atic review. Psychooncology. 2013;22(10):2160–2168.
52. Park CL, Pustejovsky JE, Trevino K, et al. Effects of psychosocial
interventions on meaning and purpose in adults with cancer: A sys-
tematic review and meta-analysis. Cancer. 2019;125(14):2383–2393.
53. Mianowski J, Gajewska M, Rębiałkowska-Stankiewicz M.
Searching for meaning in life by taking part in drama. The per-
spective of mentees of the Fight Cancer Academy in Toruń. Studia
Humanistyczne AGH. 2018;17(3):61–78.
54. Liamputtong P, Suwankhong D. Living with breast cancer: The
experiences and meaning-making among women in Southern Thai-
land. Eur J Cancer Care (Engl). 2016;25(3):371–380.
55. Quinto RM, De Vincenzo F, Campitiello L, Innamorati M, Secinti
E, Iani L. Meaning in life and the acceptance of cancer: A system-
atic review. Int J Environ Res Public Health. 2022;19(9):5547.