Acceptance in Patients With Cancer: A Scoping Review.

Introduction

Cancer and its treatment are generally experienced as a major stressor, leading to distress. The reported prevalence of general distress ranges from 35% to 52% [ 1 , 2 ]. Distress may stem from uncertainty about prognosis, the possibility of a fatal outcome, interference with life goals, symptoms such as pain, fatigue, or nausea, problems in the emotional, social, occupational, or spiritual domain, and practical difficulties [ 3 , 4 , 5 ]. Distress is undesirable in itself and a risk factor for poor decision making in clinical encounters [ 6 ], nonadherence to medical treatment [ 7 ], and a poor outcome in the physical, mental, and social life domain [ 8 ].

According to our clinical experience, distress does not affect all patients with cancer. Occasionally, patients are able to accept their diagnosis and prognosis, even those with advanced stages of the disease and despite the likelihood of a fatal outcome based on their staging. Instead of reacting with distress, these patients respond in a peaceful manner, showing signs of acceptance. In addition, it is not uncommon for patients who initially experience great distress to eventually learn to accept their disease, developing an accepting attitude over time.

Research on acceptance in patients with cancer has been earlier reviewed. Secinti et al. [ 9 ] demonstrated negative associations between acceptance of cancer and general distress, cancer‐specific distress, depressive symptoms, and anxiety symptoms. Quinto et al. [ 10 ] reported positive associations between meaning in life and the acceptance of cancer. Recently, Fawson et al. [ 11 ] reviewed the literature on associations between processes related to acceptance and commitment therapy and distress in patients with cancer. They reported that higher scores on flexible processes (acceptance, present moment awareness, self‐compassion) were associated with lower distress, while higher scores on inflexible processes (experiential avoidance, cognitive fusion) were associated with higher distress.

While these reviews provide important insights, to the authors' knowledge no comprehensive overview of studies on acceptance in patients with cancer exists. A deeper understanding of acceptance can enable clinicians to better support patients experiencing cancer‐related distress in achieving a more accepting state of mind. The purpose of this literature review was therefore to provide a comprehensive overview of existing research on acceptance in patients with cancer.

Materials and Methods

A protocol for the scoping review was developed, using the five‐stages framework from Arksey and O'Malley [ 12 ]. The five stages included: (i) identification of the research question; (ii) identifying relevant studies; (iii) study selection; (iv) charting the data; and (v) collating, summarizing, and reporting the results [ 12 ]. The results are reported in accordance with the PRISMA guidelines for reporting scoping reviews [ 13 ]. No ethics approval was required for this review.

Identification of the Research Question

We developed the following research question: What is known from the existing literature on acceptance in patients with cancer?

Identification of Relevant Studies

Potentially relevant studies were identified through a systematic search using a combination of operator‐specific keywords in PubMed and PsycInfo. The search terms focused on cancer and acceptance. See Appendix A for the search strategy in PubMed. References of included reviews were hand‐searched for eligible studies. The literature search was conducted on 15 November 2023 and updated on 3 January 2025.

Study Selection

Studies were selected if they (i) included a sample of patients with cancer or cancer survivors, aged 18 years or older; (ii) reported data on accepting or dealing in a peaceful way with the disease or one's fate; (iii) were published in English; (iv) were published in peer‐reviewed journals; and (v) had the full text available. Abstracts and articles were excluded if they did not include empirical data.

The study selection consisted of two stages. In the first stage, one reviewer (C.W.) screened all studies by title and abstract. Inter‐rater reliability was checked in a random sample of 61 articles (10% of the initially identified articles). Two reviewers (C.W. and J.D.) independently selected articles. Kappa was calculated, with κ = 0.80 as the preset threshold value that was to be met. The observed κ was 0.89. Because of the high interrater agreement, one reviewer (C.W.) performed the final study selection. In the second stage, the full texts of all studies identified as potentially relevant were read by one reviewer (C.W.). In case of uncertainty, the selection was discussed with two other reviewers (J.D. and M.L.).

Charting the Data

The following information was extracted from the included studies: authors, year of publication, title of article, country, aim of the study, design, sample size, cancer type (by organ/system, e.g., breast, lung, gastrointestinal), cancer stage, time since diagnosis, age, gender, definition of acceptance, focus of acceptance, measurement of acceptance, acceptance assessed at a specific point in care (diagnosis, test results, etc.), data on acceptance (categorized as a group average or the number of accepting patients), factors (presumably) influencing acceptance, association with metastatic disease, association of acceptance with quality of life and functioning, and acceptance as mediator between other constructs. One reviewer (C.W.) Extracted the data and the second reviewer (J.D.) checked accuracy

Results

Study Selection

The flow diagram and reasons for exclusion are shown in Figure 1. The initial search yielded 718 records. Upon removing duplicates, 711 unique studies remained. Screening on title and abstract excluded 637 studies. Seventy‐four studies were screened based on their full text, leading to the inclusion of 54 studies. The full information extracted from the studies is displayed in Appendix B , Table B1 and summarized in Tables 1 , 2 , 3 .

Study Characteristics

All studies except one were published after the year 2000 (see Table 1 ). Most of the 54 studies originated from Europe ( n = 33), of which 24 were from Poland. The remaining studies were from North America ( n = 11), Asia ( n = 9) and Africa ( n = 1).

The studies aimed to describe the process of acceptance, to develop a measure of acceptance, to assess the level of acceptance, factors and processes associated with and leading to acceptance, the association of acceptance with symptoms, quality of life, psychological functioning and behavior, and the mediating role of acceptance in other psychological processes.

Studies included patients with one type ( n = 24) or multiple types of cancer ( n = 26) (not reported n = 4). These included breast, prostate, gastrointestinal, lung, gynecological, hematologic, or other types of cancer. Cancer stage was described in terms such as palliative, advanced stage, metastatic, not metastasized, early stage, operated, cancer recurrence, or using specific tumor stages. Information on the time since diagnosis was available in 25 studies. The sample size was < 100 in 13 studies, from 100 to 500 in 33 studies, and > 500 in 5 studies, ranging from 13 to 1187; reviews included 464, 15 488, and 17 195 patients, respectively. Patients' age was reported in 46 studies. Most studies ( n = 33) included both male and female patients; 19 studies included only male or female patients (three studies did not report on sex distribution). The studies had a cross‐sectional ( n = 45) or longitudinal ( n = 6) design or were a systematic review or meta‐analysis ( n = 3).

Acceptance

Acceptance was defined in terms of cognition (e.g., acknowledging the reality of the illness, full awareness of experiences), emotion (e.g., emotional experience of coming to accept one's terminal illness, absence of fear, sense of peace), behavior (e.g., a person does not attempt to change the course of their illness), spiritual processes (e.g., faith and spiritual values, religious and spiritual processes), social processes (e.g., sharing) or other terms (e.g., coming to terms with own state of health) (see Table 2 ) Acceptance focused on illness, disease, or health (e.g., feeling unnecessary because of the disease, accepting pain), cancer (e.g., accepting the cancer diagnosis), poor prognosis/imminent death (e.g., knowledge that disease cannot be cured and patient will likely die in the near future), self and emotions, or was not specified (e.g., the extent of feeling a sense of inner calm and tranquility, accepting the situation as it is). Acceptance was measured through interview or with one of the many questionnaires available (see Table 2 ). In Appendix B , Table B2 we have listed the definition, focus, and measurement of acceptance in studies that provided a definition for a better overview of the conceptualization of acceptance. Acceptance was assessed at < 12 months life expectancy, at a treatment transition (e.g., after surgery), and in most studies at an unspecified moment during or after treatment. Most studies reported data on acceptance as a group average (e.g., the mean on a questionnaire); other studies reported the number of patients categorized as accepting, gave a qualitative description of acceptance, or did not report data on acceptance (e.g., a study on acceptance as a mediator, without reporting the acceptance scores).

Factors Presumably Influencing Acceptance

Factors that influence acceptance—according to the authors' conceptualization—included type of tumor, metastatic disease (e.g., associated with lower acceptance), treatment and care (e.g., chemotherapy associated with lower acceptance), time since diagnosis, symptoms (e.g., more symptoms associated with less acceptance), psychological and existential factors (e.g., letting go of control, mindfulness), sociodemographic factors (e.g., sex, socioeconomic status), and the partner (e.g., accepting attitude of the partner, quality of communication) (see Table 3 ).

Association of Acceptance With Quality of Life and Functioning

Acceptance was found to be associated with psychological and spiritual outcomes (e.g., less distress, more hope for connection with others), coping (e.g., a constructive way of coping with the disease), symptoms (e.g., less pain), physical functioning, social functioning, quality of life, advance care planning, and quality of death (see Table 3 ).

Acceptance as a Mediator

Acceptance was found to mediate the relationship between various constructs (e.g., acceptance mediated the relationship between symptoms and psychological distress). See Table 3 .

Discussion

The definition of acceptance in patients with cancer is not agreed upon: our review revealed that acceptance has been conceptualized in vastly different ways. Furthermore, the review documented significant variations in the focus of acceptance, with some studies emphasizing acceptance of illness or disease (including cancer), others focusing on poor prognosis or imminent death, or referring to a general state of mental tranquility. In a relatively new field of research, with nearly all studies published post‐2000, it is understandable that there is no consensus on the definition and focus of acceptance. Nevertheless, such major discrepancies in both definition and focus preclude synthesizing findings and drawing overall conclusions. To advance the field, it is crucial to develop a generally accepted definition of acceptance and to consistently clarify its specific focus in each study.

The literature includes theoretical analyses of acceptance in general [ 65 ], in chronic disease [ 66 ], or in cancer [ 9 ], as well as syntheses of qualitative studies on acceptance in a specific disease [ 67 ]. This body of work provides valuable background knowledge for developing a comprehensive definition of acceptance. In addition, we recommend using the recently developed general model of adjustment to disease when formulating the definition of acceptance in patients with cancer (see Figure 2 , [ 68 ]). This model was developed to describe how patients adjust to disease and treatment, and it can be used to characterize the process of acceptance. According to this model, cancer and its associated treatment are experienced on a continuum, ranging from a calm, accepting response to a major stressor. A calm, accepting experience triggers corresponding cognitive, emotional, behavioral, and physiological responses, which together lead to the experience of acceptance. When cancer and its treatment are perceived as stressors, corresponding cognitive, emotional, behavioral, and physiological responses emerge. However, over time, patients may learn to modify these responses to such an extent that acceptance can still be achieved. The patient's social and personal background (e.g., social support, spirituality) may modify these processes. We suggest using this model to define acceptance in terms of cognition (both the primary cognitive appraisal of cancer and its treatment, and the secondary cognitive appraisal of illness‐related stressors [ 69 ]), emotion, behavior, and physiology, as well as spirituality and social factors.

We further recommend to consistently specify the focus of acceptance. Without an explicit statement of the focus, patients may interpret questions on acceptance in various ways, leading to studies on “acceptance” that actually address different aspects of acceptance (e.g., acceptance of a poor prognosis versus acceptance of bodily disfigurement). We believe acceptance can not be focused on the disease, cancer, or treatment itself. Instead, acceptance can focus only on the subjectively experienced disease stressors induced by cancer and treatment (see Figure 2 ). Illness stressors, as listed in guidelines on distress management, include physical, emotional, social, practical, and spiritual concerns [ 3 ]. We propose to add cognitive concerns such as uncertainty about prognosis [ 5 ], the possibility of a fatal outcome, as well as life goal interference [ 4 ]. Developing a classification of cancer‐related illness stressors may help to clarify the focus of acceptance and make studies more comparable.

Various interviews and questionnaires were used to measure acceptance. Clearly, standardization of measurement is highly desirable to enhance the comparability of research results. This involves the development of both a standardized interview and a standardized questionnaire. These tools should be aligned well with the definition of acceptance that is to be established. Furthermore, criteria must be defined to interpret measurement results (does the score indicate a high or low degree of acceptance?).

For several factors, evidence was reported that they are associated with, and presumably influence, acceptance—referred to as hypothesized determinants of acceptance. These factors included disease‐ and treatment‐related variables, time since diagnosis, symptoms, psychological and existential factors, and sociodemographic and social factors. Our aim was not to provide a systematic review or meta‐analysis, where available evidence is carefully analyzed and weighed to determine whether a particular association has been demonstrated. Rather, our review highlights which factors have been studied, serving as a first step toward a systematic review and meta‐analysis. Future work is needed to synthesize the evidence, while accounting for the aforementioned heterogeneity in the definition and focus of acceptance, as well as the variation in study design. Notably, most studies employed a cross‐sectional design, precluding causal inference, with only a few longitudinal studies available. Finally, we suggest that the general model on adjustment to disease and treatment (see Figure 2 ) can guide the systematic development of research questions for systematic reviews.

A similar comment applies to the association between acceptance and quality of life and functioning, as the hypothesized outcomes of acceptance. Acceptance was found to be associated with psychological and spiritual outcomes, coping, symptoms, physical functioning, social functioning, quality of life, advance care planning, and quality of death. Future reviews and meta‐analyses are needed to determine what evidence exists for the hypothesized outcomes of acceptance. In addition, the conceptualization of the outcome of acceptance must be improved because studies were highly heterogeneous in this respect as well. In line with the general model on adjustment to disease and treatment [ 68 ], we propose to conceptualize the outcome in terms of the World Health Organization health domains: disorder or disease, somatic and mental functions and structures, activities and participation, social and environmental factors, and personal factors [ 70 , 71 ]; to this could be added advance care planning, quality of death, and related constructs.

Evidence was reported on acceptance as a mediator between various constructs, which we consider building blocks for a future theoretical model on the role of acceptance in quality of life and death in patients with cancer. There is a need for further original research in this area, as only five studies examined acceptance as a mediator.

The present review is limited to studies published in English and in peer‐reviewed journals. We did not consider studies written in another language, nor did we examine the gray literature. However, we believe our conclusion on heterogeneity in both definition and focus and our conclusion on the assumed determinants and outcomes of acceptance would not change if we had. Another limitation is that we did not differentiate by stage of cancer, and in particular, we did not differentiate between patients and survivors. Cancer stage was reported in a variety of ways, precluding distinction between patients and survivors.

The clinical experience that some patients accept a poor prognosis in a peaceful way was the starting point for us to conduct this review. In the review on acceptance, we came across the great heterogeneity in the focus of acceptance. This was an impediment to making generalizing statements about peaceful acceptance of a poor prognosis. We identified a number of studies focusing on acceptance of a poor prognosis or death [ 14 , 25 , 34 , 43 , 44 , 46 , 50 , 52 ]. We suggest a focused review of these studies in order to clarify the nature of peaceful acceptance of a poor prognosis or death in patients with cancer. The current review can serve as background knowledge in doing so.

Clinicians play an important role in the management of distress in patients with cancer [ 72 , 73 ]. A better understanding of acceptance may assist clinicians in this task. The current review provides initial insights into how this might be accomplished, such as by encouraging patients to shift their focus or to relinquish control, or by fostering sharing with relatives and friends. However, a deeper understanding of acceptance, including its determinants and consequences, is needed to provide clear guidance for clinical practice.

In conclusion, acceptance of disease, cancer, or poor prognosis and imminent death is a relatively new area of research, characterized by significant heterogeneity in the definition and focus of acceptance, as well as in the hypothesized determinants and outcomes. To advance this field, it is essential to develop a generally accepted definition of acceptance and to consistently specify its focus. The present scoping review provides a solid foundation for this endeavor.

Author Contributions

Joost Dekker: conceptualization, investigation, analysis, supervision, validation, writing – original draft preparation. Chris Welling: investigation, writing – review and editing. Mariette Labots: conceptualization, analysis, supervision, validation, writing – review and editing.

Conflicts of Interest

The authors declare no conflicts of interest.

Search Strategy in PubMed

CANCER:

(“Neoplasms”[Mesh] Intitle OR neoplas*[Title] OR tumor*[Title] OR tumor*[Title] OR cancer*[Title] OR lymphoma*[Title] OR malignan*[Title] OR oncolog*[Title] OR carcinom*[Title] OR melanom*[Title]).

AND

ACCEPTANCE:

(Peace*[Title] OR peaceful[Title] OR acceptance[Title] OR calm[Title] OR serene*[Title] OR equanimity*[Title] OR harmony*[Title] OR tranquil*[Title] OR relaxed*[Title]).

Tables B1 and B2

Dekker J., Welling C., and Labots M., “Acceptance in Patients With Cancer: A Scoping Review,” Cancer Reports 8, no. 11 (2025): e70324, 10.1002/cnr2.70324.

Funding: The authors received no specific funding for this work.

Data Availability Statement

The data that supports the findings of this study are available in Appendix B .

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Associated Data

Data Availability Statement

The data that supports the findings of this study are available in Appendix B .