Cancer patients perceptions of the meaning in life: a protocol for a meta-synthesis of qualitative research

Introduction

Cancer, one of the diseases that poses a significant threat to human health, has emerged as a critical global public health concern due to its escalating incidence and mortality rates. By 2040, it is projected that there will be 28.4 million cancer cases worldwide, representing a 47% increase from 2020.1 China, with its substantial population, has the highest number of new cancer cases and fatalities globally. The diagnosis and treatment of cancer both inflict physical harm on patients and also give rise to a multitude of psychological and spiritual challenges. These challenges include a diminished meaning in life, depression, despair, psychological distress, fear of recurrence and tendencies towards suicide, all of which severely impact the quality of life and prognosis for cancer patients while disrupting the equilibrium within families and society.2–6 Notably, the issue of a low level of meaning in life warrants attention as it has become a prevalent psychological problem among cancer patients in recent years.7–9

When cancer strikes, the belief system that once offered stability, familiarity and security comes under scrutiny.10 Confronted with cancer, patients inevitably find themselves grappling with profound questions about the meaning in life and the prospect of mortality.10–12 However, some patients experience frustration in their quest for meaning, regardless of the stage of their disease.11 13–15 Research suggests that cancer patients with a strong meaning in life demonstrate superior adaptability and coping abilities,16–18 exhibit greater resilience against negative emotions19–22 and enjoy an overall higher quality of life.23 24 On the contrary, patients with a diminished meaning in life tend to have lower survival rates and higher suicide rates. The profound impact of meaning in life on clinical and survival outcomes in cancer patients underscores the importance of understanding their perceptions and providing appropriate support.

Although several qualitative studies have explored cancer patients’ perceptions of meaning in life, they often concentrate on specific patient populations based on cancer types, stages or age groups.25–27 Cancer patients across different disease types, stages and age groups may exhibit variations in their perceptions of life’s meaning. Furthermore, the majority of studies have been conducted within monocultural contexts, where cultural backgrounds significantly influence individuals’ perceptions of the meaning in life.28 29 In certain Eastern countries, factors such as collectivism, fatalism, extensive secularisation and taboos surrounding death can profoundly influence the meaning in life for cancer patients. Conversely, in Western cultures characterised by individualism, religiosity and a more open attitude towards death, cancer patients may perceive the meaning in life differently compared with their Eastern counterparts. For instance, Indian patients tend to experience meaning more frequently in spiritual and social commitments, while social relationships play a lesser role compared with German patients.28 Therefore, gaining an insight into how cancer patients from diverse backgrounds perceive the meaning in life can unveil differences and potential commonalities. However, there remains a scarcity of comprehensive reviews that fully incorporate cancer patients’ perspectives on meaning in life.

This study will conduct a comprehensive and systematic review and synthesis of Chinese and English databases, delving into the perceptions of the meaning in life among cancer patients from diverse cultures, cancer types, disease stages and ages. The research question we intend to explore is: How do cancer patients perceive and experience meaning in life? This study will assist healthcare professionals in expanding patients’ meaning resources in their clinical work and providing meaning-centred counselling. Additionally, it will serve as a reference for future research, enabling the adaptation of existing interventions and the development of targeted approaches tailored to patients’ specific conditions (such as cultural background, type and stage of disease, age), ultimately enhancing patients’ meaning in life and fostering positive coping with their illnesses.

Methods

Design

Meta-synthesis of qualitative research is a valuable method for integrating and exploring similar or closely related phenomena from various qualitative studies. This approach enables the creation of a more comprehensive view of the phenomenon, thereby enhancing the overall utility of the results from individual component studies.30 The proposed systematic review will adhere to the Joanna Briggs Institute (JBI) Methodology for Systematic Reviews of Qualitative Evidence.31 The review protocol aligns with the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) Protocols checklist,32 and relevant sections of the Enhancing Transparency in REporting the synthesis of Qualitative research (ENTREQ) checklist.33 This study will run from September 2023 until December 2023.

Selection criteria

Types of participants: cancer patients of age 18 years or older, at any stage of cancer. We elected to exclusively incorporate cancer patients aged 18 and above, as the vast majority of qualitative studies examining cancer patients’ perceptions of meaning in life have delineated participants as 18 years or older. This decision was crucial for accessing an adequate quantity and quality of literature resources necessary for thorough synthesis and analysis, thereby enhancing the reliability of our findings and providing a clearer understanding of adult cancer patients’ perceptions on meaning in life.

Phenomena of interest: the perspectives and perceptions regarding the meaning in life among cancer patients (eg, experiences/attitudes/views about meaning in life).

Context: the setting will be any in which cancer patients are interviewed.

Types of studies: qualitative and qualitative component of the mixed-methods studies in English and Chinese, following specific formats such as phenomenology, grounded theory, narrative, hermeneutic, action research, field research, feminism, key informant and ethnography. Studies with a quantitative design, case reports, practice guidelines, case series, conference abstracts, expert opinions and book chapters will not be within the scope of consideration for this study.

Search strategy

The search will encompass databases such as the Cochrane Library, PubMed, MEDLINE, Web of Science, EMbase, CINAHL and PsycINFO, along with Chinese literature databases including the China National Knowledge Infrastructure, Wanfang Data, Chinese Biomedical Literature Database and VIP Database for Chinese Technical Periodicals. These databases will be searched from their inception to December 2023. Grey literature will not be considered in this study.

Initially, index terms will be determined based on an initial search conducted on PubMed. Subsequently, according to all the identified subject headings, keywords and synonyms, a customised search strategy will be employed to explore multiple databases. The reference lists of all included studies will be examined to identify any additional relevant studies. The complete search strategy is shown in online supplemental appendix 1. The research team will conduct a final rerun of the searches before publishing the systematic review to ensure the inclusion of the latest studies and avoid any omissions.

Supplemental material

Literature screening

After conducting the search, all identified citations will be imported into EndNote V.20. Duplicate records will be removed. Initially, the titles and abstracts will undergo preliminary screening, conducted by two researchers (WSM and ZMM) who have received literature training and will adhere to the predetermined selection criteria. Subsequently, the full text of the selected citations will be thoroughly reviewed. Reasons for the exclusion of full-text studies will be documented. If any essential information is lacking in the desired final full-text articles, we will promptly reach out to the authors for clarification, allowing them a 1 month timeframe to provide feedback. Should the authors fail to respond within this period, we will exclude those studies from this review to ensure impartiality and prevent bias. The findings will be presented comprehensively in the final systematic review and displayed in a PRISMA flow diagram.34

Quality assessment

Two researchers (WSM and ZMM), both trained in evidence-based methodology, will independently assess the quality of the literature using the JBI Critical Appraisal Checklist for Qualitative Research (online supplemental appendix 2).35 This tool comprises 10 items that evaluate various aspects, including research methodology, philosophical foundation, data collection, data analysis and representation, interpretation of the results, beliefs and values of the researcher, influences between the researcher and the research, representation of the participants, ethical approval and the interpretation of the data. Each of the 10 evaluation items will be rated as ‘yes’, ‘no’, ‘unclear’ or ‘not applicable’. Based on standard requirements, the appraisal results can be categorised into three levels: a weak rating for scores below or equal to 6, a medium rating for scores between 7 and 8 and a strong rating for scores between 9 and 10. In the end, only studies with a rating of moderate or above will be included for data synthesis. Any discrepancies in the evaluation results will be discussed and resolved, or if necessary, decided on by a third researcher (XWJ).

Data extraction

Data extraction from the included studies will be carried out by two independent reviewers (WSM and ZMM) using the standardised JBI Qualitative Data Extraction Tool for Qualitative Research (online supplemental appendix 3).36 The information to be extracted will include author details, year of publication, methodology, data collection method, geographical location, setting, participants, data analysis approach, phenomena of interest and findings. In cases where disagreements arise between the reviewers, they will be resolved through discussion or by involving a third reviewer (XWJ) as an arbitrator. To ensure comprehensive data coverage, the authors of the studies will be contacted to provide any missing or additional data, as required. The extracted data will be presented in both tabular and narrative formats to facilitate a comprehensive and insightful analysis.

Data synthesis

This review will employ the meta-aggregative strategy to synthesise the results obtained from the included studies (online supplemental appendix 4).31 To ensure rigour and comprehensibility, two independent reviewers (WSM and ZMM) will thoroughly analyse the findings from each qualitative study. They will seek to understand and interpret the philosophical ideas and methodologies present in the data. Similar findings will be grouped together to create new categories, which will then be integrated to derive new ideas or interpretations. The integration results will be presented either through verbal text or in tables, providing a description of specific events or phenomena, as well as potential contradictions. Moreover, the reviewers will offer practice and research recommendations based on their interpretations. In case of any disagreements between the reviewers, they will engage in discussions to reach a consensus. If necessary, a third reviewer (XWJ) will be involved to help resolve the discrepancies. NVivo V.12 will be utilised to facilitate the processing and analysis of text, enabling the generation of codes and topics in a standardised and convenient manner.

Assessing the certainty of findings

The JBI ConQual approach will be employed to assess the confidence, including dependability and credibility, of each synthesised finding.37 The outcomes will be presented in the ConQual summary of findings table. The level of confidence for each synthesised finding will be scored as high, moderate, low, or very low.

Patient and public involvement

None.

Discussion

The significance of existentialism in cancer patients is often overlooked by researchers and healthcare professionals. Thus, the aim of this systematic review will be to delve into cancer patients’ perspectives on the meaning in life across all stages of their journey. The results will hold immense potential in helping healthcare professionals develop a profound understanding of how these patients perceive meaning in life during this critical phase and how their unique values and preferences will come into play. Such understanding will be pivotal for clinicians and nurses to effectively assist cancer patients in approaching the disease with a positive mindset, regaining a sense of normalcy, openly addressing death and self-esteem and ultimately improving their overall quality of life. Moreover, the findings of this study will guide healthcare professionals in broadening patients’ reservoirs of meaning and delivering meaning-centred counselling in their clinical practice. Additionally, they will serve as valuable references for developing interventions aimed at enhancing the meaning in life of cancer patients.

Beyond its impact in cancer care, exploring cancer patients’ perceptions of meaning in life will contribute to the broader field of existential studies. It will deepen our understanding of how individuals find or construct meaning in the face of adversity, death and life-changing experiences. These findings will have implications for fields beyond cancer, guiding us in how to address existential questions and pursue meaning in other contexts.

This post was originally published on https://bmjopen.bmj.com