Return to valued activities: Survivors' experiences of adaptation and growth after treatment for head and neck cancer

The objective of this study was to explore the experiences of head and neck cancer (HNC) survivors who returned to valued activities to understand how they reconstruct their lives following HNC diagnosis and treatment.

Illness work precipitates identity work in that people find their life story or biography, altered in such a way that they feel transformed, hence work does not only encompass vocational work but also internal adaptation work. 12 It is rare that survivorship research touches on all of these aspects of recovery and, although some studies have explored returning to valued roles and activities in other cancer types, 11 this has not been investigated in survivors of HNC.
The aim of this study was to explore the experiences of HNC survivors who returned to valued activities in order to understand how they reconstructed their lives following HNC diagnosis and treatment.
This project is part of a larger study investigating psychosocial support and education needs of people diagnosed with HNC, 13 and the experiences of the health professionals 14 and family caregivers 15,16 who support them.

| Design
An in-depth qualitative design was adopted and semi-structured interviews used. Social constructionist theory underpinned the design and provided a basis for understanding how realities and views of the world are individual-specific and created through a combination of complex interactions with society, including interactions between participants and researchers, acknowledging the lens of the researcher and the meanings that individuals attribute to such interactions. 17,18

| Ethics
The project was approved by the Curtin University Human Research Ethics Committee (HRE2018-0691), and the ethics committees at participating tertiary hospitals (SCGOPHCG HREC number RGS0000001145).

| Participants
The sample comprised 21 adults diagnosed with head and neck cancer in the last 6 years, having completed treatment in

| Procedure
Convenience sampling was used whereby health professionals engaged in HNC care recruited patients by providing information sheets and with permission providing contact details to the researcher. 13 Consenting participants were contacted by the lead author by email or phone, and interviews arranged. Nineteen interviews were conducted face-to-face, and two via a video conferencing platform. Interviews were 45-75 min (mean = 61 min). All interviews were digitally audio-recorded and professionally transcribed verbatim.

| Data analysis
Initial analysis was completed by the first author and discussed with all authors. It involved repeated reading of transcripts to understand participants' perspectives. 19 Data were transported into NVivo12 for data management. Following the inductive process

| RIGOR
Data collection and analysis were conducted using reflexive thematic analysis; saturation is acknowledged as a contentious concept in this approach to qualitative research, 23 however in this study, data analysis was stopped when no new information emerged and the research team were satisfied that meaningful themes had been identified from the data. 21 3. Adaptation-finding a way to restore interrupted sense of self through work, sport, and hobbies even if they are somewhat altered.

| Theme: Mindfulness
In response to the unique trauma of HNC diagnosis and treatment, and in the absence of formal instruction in mindfulness, several survivors found a self-reflective state of moment-to-moment nonjudgemental awareness which encompassed acceptance and equa-

| Theme: Adaptation
Survivors returned to activities that they valued pre-treatment, experienced decreased anger, sadness and frustration. 28 It also reflects earlier work on coping after HNC, including Lang et al. who found that people with HNC undertook continuous meaning-making, 29 Harding who found positive psychological change in some HNC survivors, 30  which, in turn, improves psychological and existential outcomes (e.g., a sense of meaning in life). Experiential acceptance as described by our participants, is the opposite to experiential avoidance, and recent work 35 suggests it is acceptance more than attention monitoring, which improves psychological wellbeing.
Experiential acceptance of cancer may lead to growth in selfcompassion, courage, and value-based living, which are theoretically linked to increased psychological flexibility and better psychological well-being. 36 Our findings show that people recovering after treatment for HNC are able to find benefits, and extract meaning from their experience in creative ways. Similar to our theme of Gratitude, Costa et al. 37  Work was important to many participants who cited financial, social and identity related reasons for wanting to return to work.
However, for several participants, work had become less important and prioritising lifestyle and relationships drove decisions to change careers or retire. These factors have been investigated in the literature on returning to work after different cancer types, including in HNC survivors. 10 We found that the mindfulness experiences participants described, fostered a deepened capacity for meaningmaking and greater engagement with life, and for some survivors, prompted previously unfelt empathetic understanding and altruism for others with cancer, also aligning with positive psychology research on shaping a purposeful life. 40 These examples of personal growth and positive adaptation after HNC can be conceptualised as post-traumatic growth (PTG), a term which describes the process by which trauma is processed and integrated. 41 43 Moreover, greater PTG is associated with higher health related quality of life, 46 and increased health behaviours, 47 suggesting strategies to encourage and support PTG in HNC survivors may yield benefits.
Tedeschi and Calhoun argue that traumatic events (such as cancer and its treatment) are, in themselves, insufficient to cause PTG.
Instead, an individual must reflect on their experiences and seek to find meaning in them, that is, growth arises from adaptation to the trauma and rebuilding one's sense of the world, 42 much as participants did in this study. While work in other cancer types has shown promise for promoting healthy adaptation and fostering growth, 48 future research to determine the optimal timing, content and delivery of interventions which aim to facilitate personal growth is warranted for head and neck cancer survivors.

| Limitations
Only 38% of participants had a post-school qualification compared with 69% of the general population (Australian Bureau of Statistics 2020) which may contribute to less representation of middle and higher earning survivors. 49  -405