Received: 30 January 2020

DOI: 10.1002/smi.2972

REVIEW ARTICLE
- -
Revised: 26 April 2020 Accepted: 29 June 2020

Emotion regulation and psychological distress in cancer

survivors: A systematic review and meta‐analysis

Svetlana Baziliansky1 | Miri Cohen1

School of Social Work, University of Haifa,

Haifa, Israel Abstract
Emotion regulation may affect the levels of psychological distress of cancer
Correspondence
Svetlana Baziliansky, School of Social Work,
survivors, but inconsistencies exist among studies regarding the direction of this
University of Haifa, 199 Aba Khoushy Ave. effect. The systematic review and meta‐analysis sought to estimate the associations
Mount Carmel, Haifa 3498838, Israel.
Email: [email protected]
between emotion regulation patterns (repression, suppression, experiential avoid-
ance and cognitive reappraisal) and psychological distress among cancer survivors.
Fifteen studies met inclusion criteria for systematic review, and seven studies
focussing on suppression were included in the meta‐analysis. The systematic review
pointed to a marked variability in associations among the emotion regulation
patterns and psychological distress. The three meta‐regressions of the relationships
between suppression and psychological distress found significant fixed‐ and
random‐effect sizes (except marginal significance of a random‐effect model for
partial correlation). Subgroup analysis showed no moderation effect of time since
diagnosis or study quality, but a significant difference (fixed‐effect model only, p ¼
0.005) was found between correlative studies and those controlling for
confounders. The current study suggests that suppression is related to elevated
levels of psychological distress among cancer survivors, although large in-
consistencies exist among studies and publication bias could not be ruled out.
Further studies with large samples and a consistent approach are thus required to
evaluate the associations of emotion regulation patterns and psychological distress.

KEYWORDS
cancer survivors, emotion regulation, meta‐analysis, psychological distress, systematic review

1 | INTRODUCTION Recent studies have shown that psychological distress (measured

in studies with various instruments for depression alone or in com-
Cancer is a life‐threating illness characterized by a potentially all‐ bination with anxiety) among survivors of various cancer types and in
embracing impact on the psychological adjustment of cancer survi- various stages of cancer, including long‐term survivorship, is higher
vors and subsequent presentations of psychological distress (Holland compared to matched controls (e.g., Kang et al., 2018; Maass et al.,
et al., 2010). Psychological distress among cancer survivors is often a 2019). Nevertheless, levels of distress have varied among many
reaction to the multiple stressors they face during the trajectory of studies. For example, a meta‐analysis of 17 articles showed a prev-

-
coping with cancer (Holland et al., 2010) and has been associated alence of symptoms of depression ranging from 9.4% to 66.1% among
with reduced quality of life (Harms et al., 2019) and poor physical breast cancer survivors, concluding that risk of depression is
outcomes (Okubo et al., 2019). increased during the first year post‐diagnosis (Maass, Roorda,

Stress and Health. 2020;1–16. wileyonlinelibrary.com/journal/smi © 2020 John Wiley & Sons Ltd. 1
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Berendsen, Verhaak, & de Bock, 2015). Other studies showed that Suppression also has been conceptualized as a conscious effort
although levels of psychological distress decrease about a year post‐ to create distance from negative emotions, especially anxiety,
diagnosis, for about a third of survivors, levels of distress remain depression and anger (Watson et al., 1984). In most studies with
chronically elevated for years and increase the risk of clinically sig- cancer survivors, suppression has been demonstrated to be positively
nificant depression (Carlson et al., 2014). In contrast, in a few studies, associated with psychological distress (Iwamitsu et al., 2005; Li et al.,
low mean scores of psychological distress were reported for breast 2015; Nakatani et al., 2014). However, in several other studies,
cancer survivors at 1–2 years post‐treatment (Cohen, Levkovich, suppression has been found to be negatively associated (Cohen,
Pollack, & Fried, 2019; Maass et al., 2015). 2013; Erickson & Steiner, 2001; Pedersen & Zachariae, 2010) or has
Emotion regulation has been conceptualized as a process by which no association (Ando et al., 2011; Zachariae et al., 2004) with psy-
individuals modulate emotions and how they experience and express chological distress.
them, consciously and unconsciously (Gross, 2002), to appropriately Cognitive reappraisal has been defined as a conscious process
respond to environmental demands such stressful life events (Gross, that involves reframing an emotion‐eliciting stimulus in a positive
2002). Emotion regulation patterns had been often mentioned as a way, changing how an individual think about a situation to decrease
major predictor of psychological reactions to severe stressors (Cano its negative emotional impact (Gross, 2002). Previous studies have
et al., 2020; Fernández‐Rodríguez, Paz‐Caballero, González‐Fernán- reported that use of cognitive reappraisal is associated with lower
dez, & Pérez‐Álvarez, 2018; Richmond, Hasking, & Meaney, 2017). psychological distress in cancer survivors (Li et al., 2015; Peh et al.,
Four main emotional regulation patterns examined in relation to 2017; Wang et al., 2014). On the other hand, another study found a
cancer (repression, suppression, experiential avoidance and cognitive positive association between cognitive reappraisal and psychological
reappraisal) can influence the psychological reactions of individuals distress in cancer survivors (Manne, Ostroff, Fox, Grana, & Winkel,
during cancer treatment and into survivorship (Li et al., 2015; Peh 2009).
et al., 2017; Wang et al., 2014). Research findings about the associ- The contrasting results among studies regarding associations
ation between emotion regulation and psychological distress among between the emotion regulation patterns and psychological distress
cancer survivors have been inconsistent (Brummer, Stopa, & Bucks, are echoed in studies that examined these associations in relation to
2014; Cohen, 2013). Moreover, comparison of the associations of various stressors, especially among individuals with chronic diseases.
different patterns of emotion regulation and psychological distress For example, repression was mostly found to be associated with low
has not been thoroughly done, and no previous review or meta‐ psychological distress among patients with cardiovascular disease
analysis on this topic has been published. In the current review, we (Denollet, Martens, Nyklícek, Conraads, & de Gelder, 2008). Also,
focused on four main patterns of emotion regulation studied in cognitive reappraisal was found to be associated with low psycho-
relation to cancer: planful, deliberate and rational emotion regulation logical distress among individuals with cardiovascular disease (Kar-
patterns (experiential avoidance [Hayes et al., 2004], suppression ademas, Tsalikou, & Tallarou, 2011) or diabetes (Mocan, Iancu, &
[Watson, Pettingale, & Greer, 1984] and cognitive reappraisal [Gross, Băban, 2018). In contrast, other studies found no significant associ-
2002]) and unconscious emotion regulation processes (repression ations between suppression or cognitive reappraisal and psycholog-
[Weinberger, 1990]). ical distress among individuals with chronic conditions such as
Repression has been defined as an unconscious defence mecha- rheumatoid arthritis, multiple sclerosis (Karademas et al., 2018) or
nism that inhibits feelings or memories associated with negative psoriasis (Ciuluvica, Fulcheri, & Amerio, 2019). Suppression and
emotions (especially anxiety, fear and anger) before reaching the level experiential avoidance were associated with higher psychological
of consciousness (Weinberger, 1990). As a result, the individual is un- distress in individuals with other conditions, such as cardiovascular
able to remember or be aware of disturbing desires, feelings, thoughts diseases (Goodwin & Emery, 2016; Karademas et al., 2011) or
or experiences (Weinberger, 1990). In several studies, repression has fibromyalgia (Bowers, Wroe, & Pincus, 2017).
been associated with low levels of psychological distress in cancer To summarize, research on associations between different
survivors, due to the blocking of negative emotion before it reaches emotion regulation patterns and psychological distress is character-
consciousness (Giese‐Davis et al., 2014; Prasertsri, Holden, Keefem, & ized by inconsistent and contradictory results. Moreover, these
Wilkie, 2011). In other studies, no association was found between studies featured significant diversity in the patterns of emotion
repression and psychological distress (e.g., Zachariae et al., 2004). regulation examined, such that few studies have examined each
Experiential avoidance has been conceptualized as a conscious pattern of regulation in the context of emotional distress in general
effort to control uncomfortable emotional experiences (e.g., emo- and in cancer survivors in particular. A more thorough understanding
tions, thoughts, memories and interceptive cues). Experiential will contribute to theoretical knowledge and its implementation in
avoidance is often related to refraining from needed action to solve a the area of psycho‐oncology. Therefore, the aim of this review and
problem and maintaining experiential and cognitive control of nega- meta‐analysis was to systematically review the studies that assessed
tive emotions (Hayes et al., 2004) and has been demonstrated to be the associations between each of the four emotion regulation pat-
positively associated with psychological distress in cancer survivors terns (repression, suppression, experiential avoidance and cognitive
(Aguirre‐Camacho et al., 2017; Miller, O'Hea, Lerner, Moon, & Foran‐ reappraisal) and psychological distress indexes in the context of
Tuller, 2011). cancer.
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2 | METHODS for the effects of sampling error; values of tau‐squared significantly

different from zero are consistent with between‐study heterogene-
The paper consists of two parts: (a) a systematic review of the as- ity. To identify the sources of between‐study variability, several
sociations of the four main emotion regulation patterns (repression, subgroup analyses were conducted. Due to the low number of
experiential avoidance, suppression and cognitive reappraisal) with articles, subgrouping was done separately for time since diagnosis
psychological distress (anxiety and depression) among cancer (less than vs. more than 1 year since diagnosis of cancer); study
survivors and (b) a meta‐analysis conducted with studies that quality (high vs. low–medium) and meta‐analysis of regression co-
assessed associations between suppression and psychological efficients (according to indicator is b ¼ 1, indicating that the effect
distress (due to the few papers that referred to other emotion size is based on a regression coefficient from a regression model with
regulation patterns, as subsequently explained). This systematic re- extra variables that were partialized out, or indicator is b ¼ 0, indi-
view and meta‐analysis were conducted in accordance with cating that the effect size is based on a correlation coefficient and
Preferred Reporting Items for Systematic Reviews and Meta‐Analysis hence is equivalent to effect size based on a single explanatory
(PRISMA) guidelines (Moher, Liberati, Tetzlaff, Altman, & PRISMA variable regression, with no other variables partialized out). Sub-
Group, 2009) and the American Psychological Association's for meta‐ group analysis for other variables such as gender or ethnicity could
analysis reporting methods (Appelbaum et al., 2018). not be applied, due to lack of data on ethnicity (five of seven studies),
high heterogeneity in countries in which the studies were conducted
(six countries) and lack of heterogeneity by gender because five of
2.1 | Eligibility criteria the studies included only women.
The primary measures extracted during the coding process were
Full‐text research articles published in English that reported findings correlations and regression coefficients between suppression and
on the association between psychological distress and specified psychological distress. If multiple measures (anxiety, depression or
patterns of emotion regulation (repression, suppression, experiential their mean score) for psychological distress were included in a study,
avoidance and cognitive reappraisal) in cancer survivors were all relevant correlations were coded and the mean correlation for
eligible. Exclusion criteria included: (a) non‐English articles; (b) liter- each pair of psychological distress measures was calculated using
ature reviews, books, commentaries, case reports and qualitative Fisher's r to Z transformation. In addition, we coded the correlations
studies; and (c) studies focussing on validation of assessment tools. between measures of psychological distress and corrected the vari-
ances for each averaged estimate using a formula presented by
Borenstein, Hedges, Higgins, and Rothstein (2009). In instances
2.2 | Search strategy where the correlation between measures of psychological distress
was not reported, we took the conservative approach of weighting
In July 2019, a literature review was conducted in PubMed, Psy- that estimate by the variance of a single correlation from that sample.
cINFO, ProQuest and Scopus. The key search terms used were: Prior to pooling the results of the studies, we first established the
cancer OR malignancy OR tumour OR neoplasms OR oncology AND homogeneity of the partial correlations (i.e., effect sizes) using the
emotion* regulation OR emotion* control OR emotion* suppression Fisher transformation. Following Naragon‐Gainey, McMahon, and
OR expressive suppression OR emotion* reappraisal OR cognitive Chacko (2017), we calculated meta‐analytic effect sizes twice—once
reappraisal OR positive reappraisal OR emotion* repression OR based on the observed correlations (r) and once after correcting each
psychologic* regulation OR psychologic* control OR psychologic* correlation for the measures' unreliability using the following for-
suppression OR psychologic* reappraisal OR psychologic* repression mula: r_corrected ¼ r_observed ÷ square root (alpha [Measure 1] �
OR experiential avoidance. After duplicates were removed, titles and alpha [Measure 2]). We used the R correct.cor function of the R psych
abstracts were assessed for eligibility independently by two re- library (Revelle, 2018).
searchers. Disagreements were discussed and resolved by consensus. To correct partial correlation for low measure reliabilities, Osborn
We contacted researchers to determine if there were articles on the (2003) demonstrated that both reliabilities of correlated main vari-
subject relevant to the study that had not been published. No such ables and the conditioning variables have an influence on the corrected
studies were found. value. However, in our data, because all main variables were high, and if
we assume that the conditioning variables have high reliabilities, then
correction will not have a dramatic effect. Hence, partial correlations
2.3 | Meta‐analysis statistical method were not corrected regarding internal consistencies.
Assessment of the quality of the studies was conducted using
In the present meta‐analysis, only suppression was estimated (as PRISMA guidelines (Moher et al., 2009) and the Grading of Recom-
detailed in Section 3). R (R Core Team, 2018) was used to calculate all mendations, Assessment, Development and Evaluations criteria
meta‐analytic estimates. We used the most widely used method to (Guyatt et al., 2011). Five factors were evaluated: quality of theory
estimate the between‐study variance: tau‐squared (DerSimonian & and hypotheses, sample size calculation, description of recruitment
Laird, 1986). It is an index of between‐study variability that accounts process, and reporting and assessment of confounding variables.
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Final scores were low–moderate (0–20) and high (21–30). Coding and 2017. The other three studies (20%) were published in 1996 and
was done independently by two researchers, and disagreements 2006. Among the 15 included studies, nine were cross‐sectional
about five articles were discussed and resolved by consensus. (Classen, Koopman, Angell, & Spiegel, 1996; Cohen, 2013; Ho, Chan,
Following Ahn and Becker (2011), who recommended against the use & Ho, 2004; Kulpa, Ziętalewicz, Kosowicz, Stypuła‐Ciuba, &
of quality weights, we assessed the two quality criteria as a moder- Ziółkowska, 2016; Owen et al., 2006; Peh et al., 2017; Peh, Kua, &
ator to evaluate whether effects differed among higher‐quality Mahendran, 2016; Schroevers, Kraaij, & Garnefski, 2011; Tamagawa
studies versus lower‐quality studies. Publication bias was also et al., 2013), three were longitudinal (Ando et al., 2011; Andreu et al.,
examined using fail‐safe N, which indicates the number of unknown 2012; Wang et al., 2014), one was quasi‐experimental (Achimas‐
studies (i.e., data were collected but not reported or published) with Cadariu, Iancu, Pop, Vlad, & Irimie, 2015) and two were intervention
an average effect size of zero that would be necessary to reduce the studies (Aguirre‐Camacho et al., 2017; Prasertsri et al., 2011). The
observed effect size to non‐significance (p > 0.05; Rosenthal, 1979); countries in which the studies were conducted were geographically
and Egger's intercept test and funnel plots (Egger, Davey Smith, dispersed. Five studies were conducted in Europe: two studies in
Schneider, & Minder, 1997), which quantifies the funnel plot asym- West Europe, specifically Poland (Kulpa et al., 2016) and Romania
metry and performs a statistical test. If the p‐value of Egger's test is (Achimas‐Cadariu et al., 2015); and three in East Europe,
significant (p < 0.05), it indicates substantial asymmetry in the funnel specifically the Netherlands (Schroevers et al., 2011) and Spain
plot that could have been caused by publication bias (Naragon‐ (Aguirre‐Camacho et al., 2017; Andreu et al., 2012). Five studies
Gainey et al., 2017). were conducted in Asia, specifically Hong‐Kong (Ho et al., 2004),
Japan (Ando et al., 2011), Singapore (Peh et al., 2016, 2017) and
China (Wang et al., 2014). Three studies were conducted in the
3 | RESULTS United States (Classen et al., 1996; Owen et al., 2006; Prasertsri
et al., 2011), one in Canada (Tamagawa et al., 2013) and one in
3.1 | Systematic review Israel (Cohen, 2013). Eight studies included breast cancer survivors
(Achimas‐Cadariu et al., 2015; Aguirre‐Camacho et al., 2017; Ando
The literature search involved four patterns of emotion regulation: et al., 2011; Andreu et al., 2012; Classen et al., 1996; Ho et al., 2004;
suppression (Watson et al., 1984), repression (Weinberger, 1990), Tamagawa et al., 2013; Wang et al., 2014). Five studies included
cognitive reappraisal (Gross, 2002) and experiential avoidance mixed samples with various cancer types (e.g., colorectal, lung, arm,
(Hayes et al., 2004). The results are presented in four sections: (a) a leg, head, neck, pancreas, prostate, skin, haematological and renal cell
description of the included studies, (b) a description of the in- carcinoma; Cohen, 2013; Owen et al., 2006; Peh et al., 2016, 2017;
struments used to measure emotion regulation patterns, (c) a Schroevers et al., 2011). One study included ovary and uterus cancer
description of main findings presented by the included studies survivors (Kulpa et al., 2016). One study included lung cancer
regarding dimensions of emotion regulation and their associations survivors (Prasertsri et al., 2011). Nine studies included female sur-
with psychological distress in cancer survivors and (d) a presentation vivors only (Achimas‐Cadariu et al., 2015; Aguirre‐Camacho et al.,
of assessing study quality. 2017; Ando et al., 2011; Andreu et al., 2012; Classen et al., 1996; Ho
et al., 2004; Kulpa et al., 2016; Tamagawa et al., 2013; Wang et al.,
2014), whereas six studies included mixed samples with male and
3.2 | Description of included studies female survivors (Cohen, 2013; Owen et al., 2006; Peh et al., 2016,
2017; Prasertsri et al., 2011; Schroevers et al., 2011).
Figure 1 presents the flowchart of the systematic review selection
process, based on PRISMA (Moher et al., 2009). Of 8207 articles
identified, 3609 were from PubMed, 2208 from PsycINFO, 1593 3.3 | Description of emotion regulation instruments
from Scopus and 797 from ProQuest. After duplicates were removed,
1438 studies remained, and the abstracts were carefully Four patterns of emotion regulation were examined using five in-
screened and evaluated. From these, 1423 were excluded (125 were struments: (a) cognitive reappraisal measured by the Cognitive
non‐English articles; 1058 did not assess any of the four patterns of Emotion Regulation Questionnaire (Garnefski, Kraaij, & Spinhoven,
emotion regulation or did not assess their associations with psy- 2001; see Achimas‐Cadariu et al., 2015; Kulpa et al., 2016; Schro-
chological distress; 230 were literature reviews, books, case reports evers et al., 2011; Wang et al., 2014); (b) suppression measured by
or qualitative studies and 10 were exclusively tool validation studies). the Courtauld Emotional Control Scale (Watson & Greer, 1983; see
The remaining 15 studies were retrieved for full‐text screening and Ando et al., 2011; Andreu et al., 2012; Classen et al., 1996; Cohen,
included in the present systematic review. 2013; Ho et al., 2004; Owen et al., 2006; Tamagawa et al., 2013);
Table 1 summarizes the main features of the studies included in (c) both cognitive reappraisal and suppression measured by the
the systematic review. The pooled sample size was 2071, with Emotion Regulation Questionnaire (Gross & John, 2003; see Peh
individual sample sizes ranging from 38 to 509 in different studies. et al., 2016, 2017); (d) experiential avoidance measured by the
The majority of studies (n ¼ 12, 80%) were published between 2011 Acceptanceand Action Questionnaire (Hayes et al., 2004; see
BAZILIANSKY AND COHEN
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Studies identified via database searching

Identification
n= 8207

Studies after duplicates removed

n= 1676
Screening

Studies excluded
Studies screened n= 1423

n= 1438 Were non-English articles (n=125)

Did not measure aspects of emotion
regulation and it’s associations to
psychological distress (n=1058)
Were literature reviews, books,
case reports or qualitative studies
(n=230)
Were tool validation studies (n=10)

Full-text studies assessed for

Eligibility

eligibility
n= 15

Studies included in systematic

Included

Studies included in meta-

review analysis
n= 15 n= 7

FIGURE 1 Preferred Reporting Items for Systematic Reviews and Meta‐Analysis flow diagram of study selection

Aguirre‐Camacho et al., 2017) and (e) repression measured by a avoidance was examined (Aguirre‐Camacho et al., 2017), and in one
combination of two questionnaires, the Marlowe–Crowne Social study, repression was examined (Prasertsri et al., 2011).
Desirability Scale (Crowne & Marlowe, 1964) and the State‐Trait Six studies involved only regression analysis (Ando et al., 2011;
Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1971; see Classen et al., 1996; Cohen, 2013; Owen et al., 2006; Tamagawa
Prasertsri et al., 2011). et al., 2013; Wang et al., 2014); five studies used Pearson correlation
(Achimas‐Cadariu et al., 2015; Andreu et al., 2012; Ho et al., 2004;
Kulpa et al., 2016; Schroevers et al., 2011) and two studies used both
3.4 | Associations between emotion regulation and hierarchical regression analysis and Pearson correlations (Peh et al.,
psychological distress 2016, 2017). In one study, path analysis was performed (Aguirre‐
Camacho et al., 2017), and in one study, one‐way analysis of variance
In seven of the 15 studies, only suppression was examined (Ando followed by post hoc pairwise comparisons (among the four emotion
et al., 2011; Andreu et al., 2012; Classen et al., 1996; Cohen, 2013; regulation patterns) was performed (Prasertsri et al., 2011).
Ho et al., 2004; Owen et al., 2006; Tamagawa et al., 2013); in four Regarding outcomes, in six studies, a higher level of suppression
studies, only cognitive reappraisal was examined (Achimas‐Cadariu was associated with a higher level of psychological distress (Andreu
et al., 2015; Kulpa et al., 2016; Schroevers et al., 2011; Wang et al., et al., 2012; Classen et al., 1996; Ho et al., 2004; Owen et al., 2006;
2014) and in two studies, both suppression and cognitive reappraisal Peh et al., 2016; Tamagawa et al., 2013). In two studies, no significant
were examined (Peh et al., 2016, 2017). In one study, experiential association was found between suppression and psychological
 6

TABLE 1 Descriptive information for the studies included in the systematic review
-

Emotion
Author, year Sample regulation patterns Psychological distress instruments Main results

Achimas‐Cadariu 51 breast cancer survivors; non‐active disease; survivors had Cognitive reappraisal Endler Multidimensional Anxiety Scale; Negative significant association
et al., 2015 undergone chemotherapy and radiotherapy; now under Beck Depression Inventory— between cognitive reappraisal and
hormone therapy; place: Romania second edition psychological distress (correlation)

Aguirre‐Camacho 54 breast cancer survivors; average time since diagnosis—7 Experiential avoidance Hospital Anxiety and Depression Scale Negative significant association
et al., 2017 months; during chemotherapy and/or radiotherapy (42.6%); between experiential avoidance
during follow‐up (27.8%); pending treatment (9.3%); missing and psychological distress (path
data (20.4%); place: Spain analysis)

Ando et al., 2011 38 breast cancer survivors; active disease; stages 0–IV; Suppression Profile of Mood States; State‐Trait No significant association between
immediately after provision of diagnosis; place: Japan Anxiety Inventory suppression and psychological
distress (regression)

Andreu et al., 2012 102 breast cancer survivors; active disease; stages I–III; during Suppression Brief symptom Inventory‐18 Positive significant association
chemotherapy; place: Spain between suppression and
psychological distress (correlation)

Classen et al., 1996 101 breast cancer survivors; active disease; recurrence or Suppression Profiles of Mood States No significant association between
metastasis; place: USA suppression and psychological
distress (correlation)
Positive significant association
between suppression and
psychological distress (regression)

Cohen, 2013 97 breast and 144 colorectal, lung, and other cancer survivors; Suppression Hospital Anxiety and Depression Scale Negative significant association
average time since diagnosis—28 months; active disease; between suppression and
recurrence or metastasis; during chemotherapy, and/or psychological distress (regression)
radiotherapy, and/or other treatment type; gender: male:
111 (46.1%); female: 130 (53.9%); place: Israel; Jewish:
187 (77.6%); Arab: 54 (22.4%)

Ho et al., 2004 139 breast cancer survivors; non‐active disease; disease‐free in Suppression Hospital Anxiety and Depression Scale Positive significant association
past 5 years; place: Hong Kong between suppression and
psychological distress (correlation)

Kulpa et al., 2016 78 ovary and uterus cancer survivors; active disease; survivors Cognitive reappraisal Hospital Anxiety and Depression Scale No significant associations between
had undergone surgery; during chemotherapy and/or cognitive reappraisal and
radiotherapy; place: Poland psychological distress (correlation)

Owen et al., 2006 21 breast and 50 abdomen, arm/leg, brain, cervix, colon/rectum, Suppression; cognitive Hospital Anxiety and Depression Scale Positive significant association
groin, head/neck, lung, ovary, pancreas, prostate, skin, and reappraisal between suppression and
uterus cancer survivors; average time since diagnosis—34 psychological distress (regression)
months; metastatic disease (40%); chemotherapy and/or
radiotherapy had undergone; gender: male: 20 (28.2%)
BAZILIANSKY

female: 51 (71.8%); place: USA; White: 58 (81.7%); Hispanic:

AND

5 (7.1%); Black: 3 (4.2%); Asian: 2 (2.8%); Native American:

1 (1.4%); Others: 2 (2.8%)
COHEN
 BAZILIANSKY

TABLE 1 (Continued)
AND

Emotion
Author, year Sample regulation patterns Psychological distress instruments Main results
COHEN

Peh et al., 2016 29 breast and 72 brain tumour, gastrointestinal, haematological, Suppression; cognitive Hospital Anxiety and Depression Scale Positive significant association
lung, nasopharyngeal, pancreas, and renal cell carcinoma reappraisal between suppression and
survivors; average time since diagnosis—2 months; active psychological distress. (correlation
disease; early and advanced stages; during chemotherapy, and regression)
and/or radiotherapy, and/or surgery; gender: male: Negative significant association
50 (34.7%); female: 36 (35.6%); place: Singapore; Chinese: between cognitive reappraisal and
62 (61.4%); Malay: 23 (22.8%); Indian: 13 (12.9%); Others: psychological distress. (correlation
3 (3.0%) and regression)

Peh et al., 2017 45 breast and 99 gastrointestinal, gynaecological, head/neck, Suppression; cognitive Hospital Anxiety and Depression Scale No significant association between
haematological, lung, pancreas, and renal cancer survivors; reappraisal suppression and psychological
within 3 months since provision of diagnosis; active disease; distress (correlation)
stages I–IV; survivors received or receiving chemotherapy, Negative significant association
and/or radiotherapy, and/or surgery; gender: male: between cognitive reappraisal and
50 (34.7%); female 94 (65.3%); place: Singapore; Chinese: psychological distress (correlation)
90 (62.5%); Malay: 21 (14.6%); Indian: 16 (11.1%); Others:
17 (11.8%)

Prasertsri 107 lung cancer survivors; active disease; stages I–IV; survivors Repression Center for Epidemiologic Studies— Negative significant association
et al., 2011 received or receiving radiotherapy; gender: male: 76 (71%); Depression Scale between repression and
female: 31 (29%); place: USA; Caucasian: 94 (87.9%); African‐ psychological distress (post hoc
American: 8 (7.4%); Asian: 3 (2.8%); Others: 2 (1.9%) pairwise comparisons)

Schroevers 13 breast and 95 colorectal, leukaemia, lymphoma, and prostate Cognitive reappraisal Positive and Negative Affect Schedule Negative significant association
et al., 2011 cancer survivors; average time since diagnosis—7 years; between cognitive reappraisal and
stages I–IV; survivors had undergone surgery, and/or psychological distress (correlation)
chemotherapy, and/or radiotherapy; about 22% reported
recurrence of cancer in the years following diagnosis; gender:
male: 39 (36%); female: 69 (64%); place: Netherlands

Tamagawa 227 breast cancer survivors; average time since diagnosis—24 Suppression Profile of Mood States Positive significant associations
et al., 2013 months; stages 0–IV; place: Canada between suppression and
psychological distress (regression)

Wang et al., 2014 509 breast cancer survivors; average time since diagnosis from Cognitive reappraisal Center for Epidemiologic Studies— Negative significant association
1 week to 1 month; stages 0–IV; all survivors undergone Depression Scale between cognitive reappraisal and
surgery; place: China psychological distress (regression)

Note: In studies where information on ethnicity was missing, no such information was available.
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7
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TABLE 2 Meta‐analysis studies characteristics

Partial Time since Study

Title of article N r ρ M1_alpha M2_alpha Neff K correlation diagnosis quality

Ando et al. (2011) 38 0.09 0.11 0.90 0.86 34 5 0.24 a M/L

Andreu et al. (2012) 102 0.22 0.25 0.79 0.94 102 1 0.22 a H

Classen et al. (1996) 101 NA NA 0.91 0.91 97 5 0.34 b H

Cohen (2013) 241 0.15 0.16 0.87 0.96 234 8 0.14 b H

Ho et al. (2004) 139 0.35 0.40 0.83 0.92 139 1 0.35 b M/L

Owen et al. (2006) 71 0.33 0.35 0.93 0.94 69 3 0.30 b H

Tamagawa et al. (2013) 227 0.27 0.28 0.96 0.93 223 5 0.20 b H

Abbreviations: a, less than 1 year since diagnosis of cancer; b, more than 1 year since diagnosis of cancer; H, high; K, number of variables in regression;
M1_alpha, alpha for suppression; M2_alpha, alpha for psychological distress; M/L, medium or low; N, sample size; NA, missing value; Neff, pseudo N used
for correct partial correlation Fisher's Z transformation variance calculation; Partial correlation, effect size for regression coefficient; r, correlation
coefficient; ρ, corrected correlation.

distress (Ando et al., 2011; Peh et al., 2017). One study found a suppression and depression and anxiety were acquired from the
higher level of suppression was associated with a lower level of author (Cohen, 2013).
psychological distress (Cohen, 2013). Regarding cognitive reap-
praisal, five studies found a higher level of cognitive reappraisal was
associated with a lower level of psychological distress (Achimas‐ 3.6 | Sample description
Cadariu et al., 2015; Peh et al., 2016, 2017; Schroevers et al., 2011;
Wang et al., 2014), whereas one study found no statistically signifi- The final dataset for meta‐analysis featured seven independent
cant correlations between cognitive reappraisal and psychological studies with 919 participants, ranging from 38 to 241 participants
distress (Kulpa et al., 2016). Another study found a higher level of each (Table 2). One of the correlation coefficients (r) was missing in
cognitive reappraisal was associated with the level of psychological one study (Classen et al., 1996); hence, we included this article only in
distress only for Pearson correlations, whereas hierarchical regres- the partial correlation analyses.
sion analysis showed no significant relationships between variables Correlation coefficients (r) ranged from 0.15 to 0.35, and cor-
(Peh et al., 2016). A higher level of experiential avoidance was rected correlation coefficients (ρ) ranged from 0.16 to 0.40. The αs
associated with a higher level of psychological distress in one study for suppression ranged from 0.79 to 0.96 and αs for psychological
(Aguirre‐Camacho et al., 2017). A higher level of repression was distress ranged from 0.86 to 0.96. Pseudo N for the seven studies
associated with a lower level of psychological distress in one study was 898, ranging from 34 to 234. The number of variables in
(Prasertsri et al., 2011). the regression ranged from 1 to 8. Partial correlation ranged from r ¼
0.24 to 0.35. In two studies, time since diagnosis was less than 1
year, whereas in five studies, time since diagnosis was more than 1
3.5 | Meta‐analysis results year. Five studies showed high study quality, whereas two studies
showed low‐medium study quality.
Our initial aim was to conduct the meta‐analysis on studies of the
four emotion regulation patterns in association with distress mea-
sures. However, of the 15 studies included in the systematic review, 3.7 | Effect sizes
six were excluded from the meta‐analysis because they assessed
only differences in levels of emotion regulation patterns among Three meta‐analytic methods of analysis of the relationships be-
different groups, not in association with psychological distress tween suppression and psychological distress were employed—
(Achimas‐Cadariu et al., 2015; Kulpa et al., 2016; Peh et al., 2016, namely, meta‐analysis of the regression coefficients using partial
2017; Schroevers et al., 2011; Wang et al., 2014); a single study each correlations as effect sizes, meta‐analysis of the raw correlations
had assessed only experiential avoidance or repression and needed and meta‐analysis of the correlations after correcting for measures
to be excluded (Aguirre‐Camacho et al., 2017; Prasertsri et al., 2011, unreliability. The three meta‐analysis revealed moderate, significant
respectively). Thus, the present meta‐analysis featured only the and positive effect sizes of 0.12 to 0.17 for the fixed‐effect model
seven studies that examined suppression. In studies that included and 0.16 to 0.21 for the random‐effect model; only the random‐
two time measures (Ando et al., 2011) or four time measures effect model for partial correlation was not significant (95% con-
(Andreu et al., 2012), only measures at baseline were analysed. In fidence interval [CI] ¼ 0.01, 0.33, p ¼ 0.06; see Table 3 and
another study, information about Pearson correlations between Figure 2).
BAZILIANSKY AND COHEN
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TABLE 3 Three meta‐analytic correlations between suppression and psychological distress

Egger's
Type of meta‐analysis FE (95% CI) RE (95% CI) τ2 FSN intercept

Partial correlations (effect size for regression coefficients) 0.15*** (0.08; 0.21) 0.16 ( 0.01; 0.33) 0.04*** 47 0.39

Correlationsa 0.15*** (0.09; 0.22) 0.19* ( 0.01; 0.36) 0.05*** 45 0.69

Correlations corrected for measure unreliabilitya 0.17*** (0.10; 0.24) 0.21* (0.01, 0.40) 0.06*** 58 0.71

Abbreviations: CI, confidence interval; FE, fixed effect estimate; FSN, fail‐safe N; RE, random effects estimate.
a
Classen et al. (1996) article is not included in this analysis due to missing correlation.
*p < 0.05; ***p < 0.001.

3.8 | Publication bias correlation for measure unreliability) for both differences in time
since diagnosis and study quality did not explain significantly the
Calculation of fail‐safe N (Rosenthal, 1979) revealed the number of statistical heterogeneity between studies, neither in the random‐ef-
missing studies with an average effect size of zero (r ¼ 0) that would fect model nor in the fixed‐effect model.
be required to reduce the observed effect sizes of associations to Despite low power, a significant difference was found for the
non‐significance (p > 0.05): 45–58 null studies would be required to fixed‐effect model (Cochran's test for subgroup differences for fixed‐
bring the suppression–psychological distress relationship to non‐ effect model ¼ 7.77, p ¼ 0.01) but not the random effects model
significance, indicating that many studies would be required to bring (Cochran's test for subgroup differences for random‐effect model ¼
the mean effect sizes to a non‐significant level. 2.06, p ¼ 0.15) between studies in which effect size was based on a
Egger et al.'s (1997) intercept showed non‐significant values regression coefficient from a regression model with extra variables
(Figure 3) for all the three meta‐analyses, indicating no marked that were partialized out compared to articles in which the effect size
asymmetry of the funnel plots. However, visual inspection of the was based on a correlation coefficient (i.e., no variables were parti-
contour‐enhanced funnel plots revealed the ‘file‐drawer effect’ alized out). The effect size for the meta‐analytic relationship by
(Rosenthal, 1979), because nearly all studies had statistically regression, while controlling for possible confounders, was small and
significant effect sizes (black or grey background); only one did not non‐significant for the random‐effect model (fixed effects: 0.09, 95%
(white background). Hence, there was no asymmetric bias, but both CI ¼ 0.01, 0.16; random effects: 0.11, 95% CI ¼ 0.11, 0.32). In
non‐significant negative and positive effects might be missing (white contrast, the meta‐analytic relationship by correlation, without con-
triangle is missing). trolling for possible confounders, was found to be small and signifi-
cant (fixed effects: 0.30, 95% CI ¼ 0.17, 0.41; random effects: 0.29,
95% CI ¼ 0.16, 0.42). To explore these results further, reviewing
3.9 | Heterogeneity Figure 4 reveals that in three of the studies, effect size regression
reported a positive effect, whereas two reported a negative effect,
Heterogeneity analysis showed that all tau‐squared values were resulting in a low combined effect. In contrast, the two studies in
significant (Table 3), indicating that the amount of between‐study which effect sizes were based on correlations demonstrated a posi-
variability was greater than would be expected by chance; thus, tive relationship.
subgroup analysis was conducted to identify potential study‐level
factors contributing to the variability (Borenstein et al., 2009).
4 | DISCUSSION

3.10 | Subgroup analysis This systematic review combined with a meta‐analysis is the first to
review studies that assessed associations between emotion regula-
Subgroup analysis for the current study had low power due to the tion patterns and psychological distress among cancer survivors.
low number of studies; hence, its capability to detect meaningful However, following the selection process, only 15 studies were
differences between studies was limited (Higgins & Thompson, 2004). included in the systematic review. These studies showed inconsistent
However, because heterogeneity in the current meta‐analysis was results (either negative, positive or no association with psychological
high and studies revealed findings in opposite directions, we con- distress) for each of the assessed emotion regulation patterns. This
ducted several subgroup analyses to determine whether one of the inconsistency may be at least partially due to the few studies
possible grouping variables (i.e., time since diagnosis or studies available for the review and the extensive variability among sample
quality), hypothesized to moderate the effect sizes, was significantly characteristics (e.g., type of cancer and country), sample size and type
related to the values of the effect sizes. of data analysis. Moreover, this review focused on the most assessed
The subgroup analyses showed that all three meta‐analytic emotion regulation patterns in relation to psychological distress
correlations (correlation, partial correlation and corrected among cancer survivors to enable comparison.
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- BAZILIANSKY AND COHEN

FIGURE 2 Forest plots of correlations between suppression and psychological distress

Other studies have presented a variety of conceptualizations of (Graves et al., 2005; Politi, Enright, & Weihs, 2007). Other studies
emotion regulation and used various tools (e.g., Rationality/Emotional included emotion regulation as a part of emotion‐focused coping
Defensiveness by Spielberger, 1988; Control of Feeling Scale by strategies (e.g., COPE Inventory; Carver, Scheier, & Weintraub, 1989)
Weihs, Enright, Simmens, & Reiss, 2000), but were very seldom and thus, were not reviewed due to the different conceptualization
assessed in relation to psychological distress among cancer survivors and measurement. This points to the unclarity and confusion in
BAZILIANSKY AND COHEN
- 11

Partial correlations Correlations

0.00 contour−enhanced funnel plot (fixed=dashed random = dotted) contour−enhanced funnel plot (fixed=dashed random = dotted)

0.00
0.1 > p > 0.05 0.1 > p > 0.05
0.05

0.05 > p > 0.01 0.05 > p > 0.01

Standard Error

Standard Error

0.05
Cohen_2013 • Tamagawa_2013 • < 0.01 Cohen_2013 • Tamagawa_2013 • < 0.01
Ho_2004 • •
0.10

Ho_2004
• •

0.10
Andreu_2012 Classen_1996 Andreu_2012 •
Owen_2006 • Owen_2006 •
0.15

0.15
Ando_2011 • Ando_2011 •

−0.4 −0.2 0.0 0.2 0.4 −0.4 −0.2 0.0 0.2 0.4

Fisher's z transformed correlation Fisher's z transformed correlation

Corrected correlations corrected for measure unreliability

contour−enhanced funnel plot (fixed=dashed random = dotted)

0.00

0.1 > p > 0.05

0.05 > p > 0.01
Standard Error

0.05

Cohen_2013 • Tamagawa_2013 • < 0.01

Ho_2004 •
0.10

Andreu_2012 •
Owen_2006 •
0.15

Ando_2011 •

−0.4 −0.2 0.0 0.2 0.4

Fisher's z transformed correlation

FIGURE 3 Contour‐enhanced funnel plots for correlations between suppression and psychological distress

research on emotion regulation patterns and their relationship with evaluated by correlations, partial correlations and corrected
psychological distress in cancer survivors. Also, inconsistent results correlations. These relationships are consistent with findings of
regarding the associations between emotion regulation patterns and previous studies among individuals with chronic conditions (Bowers
psychological distress were reported in studies among patients with et al., 2017; Gouin; Deschênes, & Dugas, 2014; Karademas et al.,
other severe health conditions (Karademas et al., 2011, 2018); this 2011), those experiencing major life stressors (Cano et al., 2020), or
inconsistency also could be seen in the present study. Another point nonclinical populations (Ma & Fang, 2019; Richmond et al., 2017) that
that needs attention is that most of the studies reviewed were cross‐ showed that individuals who exerted higher suppression reported
sectional (Classen et al., 1996; Cohen, 2013; Ho et al., 2004; Kulpa higher levels of psychological distress.
et al., 2016; Owen et al., 2006; Peh et al., 2016, 2017; Schroevers However, in the seven studies analysed, five studies found a
et al., 2011; Tamagawa et al., 2013). Therefore, the direction of the positive association between suppression and psychological distress,
associations between emotion regulation patterns and psychological whereas one study with the largest sample size found a negative
distress could not be determined. Although as suggested, emotion association between suppression and psychological distress (Cohen,
regulation patterns such as suppression may increase psychological 2013). One study with a small sample size reported no significant
distress due to preventing the individual from actively coping with association between suppression and psychological distress (Ando
these emotions and processing or ventilating them, they also obstruct et al., 2011), but when inspecting partial correlation effect sizes, a
any action to resolve the situation causing the psychological distress negative association emerged (Ando et al., 2011). Possible explana-
(Gross & John, 2003). It may also be that when psychological distress tion for the noted differences is that four of the seven studies
is high, the tendency to suppress emotions may increase as a result included in the meta‐analysis used the Profile of Mood States
(Frattaroli, 2006). Moreover, it may also be that other factors such as Questionnaire to assess psychological distress (Ando et al., 2011;
personal characteristics interfere in this association (e.g., neuroticism Classen et al., 1996; Owen et al., 2006; Tamagawa et al., 2013). These
or extroversion; İzci et al., 2018). items relate to a wide range of emotions, including positive emotions
Therefore, we call for more studies that assess the four regula- (McNair, Lorr, & Droppleman, 1992). Psychological distress may be
tion patterns reviewed in this study, using similar sample selection less threatening for cancer survivors, who tend to suppress negative
and methodologies, to create a more consistent picture of the emotions. In contrast, the other three studies (Andreu et al., 2012;
connection between emotion regulation patterns and distress among Cohen, 2013; Ho et al., 2004) used the Brief symptom Inventory‐18
cancer survivors. and the Hospital Anxiety and Depression Scale (Derogatis, 2000;
Due to the low initial number of studies, the meta‐analysis was Zigmond & Snaith, 1983, respectively), whose items examine
conducted with seven studies that examined suppression. However, emotional symptoms and may elicit more of the suppression pattern.
despite the few studies, the meta‐analysis included a relatively large These mixed results may point to the need for more research to
total sample of 919 cancer survivors. Results revealed moderate better understand the relationship between emotion regulation and
positive relationships between suppression and psychological psychological distress in general and especially among cancer
distress in cancer survivors that resulted in significant effect sizes, as survivors.
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- BAZILIANSKY AND COHEN

Weight Weight
Study Total Correlation COR 95%−CI (fixed) (random)

is_b = 1
Ando_2011 34 −0.24 [−0.53; 0.11] 3.5% 10.3%
Classen_1996 97 0.34 [ 0.15; 0.50] 10.7% 14.3%
Cohen_2013 234 −0.14 [−0.26; −0.01] 26.3% 16.2%
Owen_2006 69 0.30 [ 0.07; 0.50] 7.5% 13.3%
Tamagawa_2013 223 0.20 [ 0.08; 0.33] 25.1% 16.1%
Fixed effect model 657 0.09 [ 0.01; 0.17] 73.2% −−
Random effects model 0.11 [−0.11; 0.32] −− 70.2%
Heterogeneity: I 2 = 86%, τ2 = 0.0529, p < 0.01

is_b = 0
Andreu_2012 102 0.22 [ 0.02; 0.39] 11.3% 14.5%
Ho_2004 139 0.35 [ 0.19; 0.49] 15.5% 15.3%
Fixed effect model 241 0.30 [ 0.17; 0.41] 26.8% −−
Random effects model 0.29 [ 0.16; 0.42] −− 29.8%
Heterogeneity: I 2 = 17%, τ2 = 0.0018, p = 0.27

Fixed effect model 898 0.15 [ 0.08; 0.21] 100.0% −−

Random effects model 0.16 [−0.01; 0.33] −− 100.0%
Heterogeneity: I 2 = 84%, τ2 = 0.0440, p < 0.01
Residual heterogeneity: I 2 = 83%, p < 0.01 −0.4 −0.2 0 0.2 0.4

F I G U R E 4 Post hoc subgroup analysis by type of partial correlation in studies of meta‐analytic correlations between suppression and
psychological distress

The high heterogeneity indexes suggest that between‐study traditional societies, in contrast to Western ones, tend to suppress
variability was high, pointing to potential moderators that could be negative emotions more (Cohen, 2014; Goldblatt, Cohen, & Azaiza,
responsible for this variability among study outcomes (Naragon‐ 2016). Again, because of the high diversity of countries in which
Gainey et al., 2017). However, time since diagnosis was not a the studies included in the meta‐analysis took place (six of seven)
significant moderator of the relationships between suppression and and missing data on ethnic subgroups, analysing the moderating
psychological distress. This is in contrast to previous studies (Geue effect of culture and ethnicity was not possible.
et al., 2019; Lu et al., 2016) that reported that time since diagnosis Regarding the moderating role of quality of studies, it was
was related to level of psychological distress among cancer sur- previously suggested to be assessed as potential source of between‐
vivors, although it was not a factor in levels of psychological study heterogeneity (Naragon‐Gainey et al., 2017). In several
distress in other studies (Cohen, 2013; Cohen, Baziliansky, & Beny, meta‐analysis that examined different aspects of coping with cancer,
2014). In addition, a previous study (Shand, Brooker, Burney, study quality was found to be a moderator in relationships between
Fletcher, & Ricciardelli, 2015) did not find a statistically significant study variables (Linden & Girgis, 2012; Sheeran et al., 2016). It should
association between time since diagnosis and posttraumatic stress be noted that similar to all other tests of significance, not rejecting a
symptoms in cancer survivors. However, as already mentioned, no null hypothesis of differences between subgroups might be caused by
prior meta‐analysis had assessed the relationship between emotion insufficient statistical power and not by lack of differences between
regulation and psychological distress in cancer survivors. There- groups.
fore, the present meta‐analysis provided support to the notion that The subgroup analysis of differences in study results according to
time since diagnosis has no effect on the relationship between whether results were based on correlation alone or controlled for
suppression and psychological distress. Several other background confounding variables suggests that after controlling for appropriate
variables could account for between‐study variability, such as type control variables, there is no evidence for a relationship between
of cancer, gender and culture‐related variables like the country in suppression and psychological distress. This finding indicates that
which the study occurred or different ethnic groups. However, coping with and reacting to cancer is a complex process, and it may be
subgroup analysis could not be conducted, because five of the that reporting associations based on correlations only is too simplistic
seven samples featured only women, mostly breast cancer survi- and not sufficient to derive accurate conclusions from the results.
vors, and the rest had mixed samples that could not be parsed. Reporting results of a meta‐analysis always has the potential
Moreover, culture and ethnicity were previously reported to affect of publication bias (Rothstein, 2008), especially due to the ‘file‐
how individuals regulate, experience and express negative emo- drawer effect’ (Rosenthal, 1979); that is, results are biased towards
tions such as depression and anxiety (Sanchez‐Birkhead et al., published studies, whereas studies with null results are less often
2017). Moreover, studies have shown that individuals from sent for publication or have higher rejection rates (Rosenthal,
BAZILIANSKY AND COHEN
- 13

1979). Although there is no direct strategy to assess this dis- A CK NO W L E D GE M E NT

turbing potential effect, we tried to control it by sending letters to We sincerely thank Dr. Alexander Beny, director of the colorectal
relevant researchers to ask for unpublished results but found cancer oncology unit at the Rambam Health Care Campus at the time
none. Second, we employed statistical procedures to assess this of the study, for his generous assistance in implementing the study.
possibility. Fail‐safe N (Orwin, 1983) and Egger's intercept (Egger This study was not supported by any sources.
et al., 1997) procedures did not reveal a publication bias. However,
it may be that both non‐significant negative and positive effects CO N F L I C T O F I N T E R E S T
might be missing. Therefore, publication bias cannot be ruled out The authors declare no conflict of interests.
(Naragon‐Gainey et al., 2017).
The results of the present systematic review and meta‐analysis DA T A A V A I L A B I L I T Y S T A T E M E N T
have several theoretical and clinical implications. To the extent that Data will be available upon the request.
emotion regulation has an effect on the emotional well‐being of cancer
survivors, it is important to identify potential groups of cancer survi- OR CI D
vors that experience high levels of suppression, and therefore are at Svetlana Baziliansky https://orcid.org/0000-0003-1565-7120
high risk of developing psychological distress. This would enable pro- Miri Cohen https://orcid.org/0000-0003-1220-3852
fessionals to provide interventions that reduce or treat the develop-
ment of psychological distress. In addition, suppression, by definition, is RE F ER E N CE S
a situational response rather than a personal characteristic; therefore, Achimas‐Cadariu, P., Iancu, M., Pop, F., Vlad, C., & Irimie, A. (2015). Psy-
when it is identified in cancer survivors, psycho‐oncology therapies can chological screening and health related quality of life in Romanian
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