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jhn
This Too Shall Pass:
A Grounded Theory Study of Journal of Holistic Nursing
American Holistic Nurses Association
Filipino Cancer Survivorship Volume 31 Number 1
March 2013 35-46
© The Author(s) 2012
Allan B. de Guzman, PhD, Benito Christian B. Jimenez, RN, 10.1177/0898010112462066
Kathlyn P. Jocson, RN, Aileen R. Junio, RN, http://jhn.sagepub.com

Drazen E. Junio, RN, Jasper Benjamin N. Jurado, RN,

and Angela Bianca F. Justiniano, RN
University of Santo Tomas, Manila, Philippines

Considering the paucity of studies dealing with the holistic aspect of the cancer experience, this
grounded theory study seeks to conceptualize the process of cancer survivorship among Filipinos.
Twenty-seven Filipino cancer survivors were purposively selected, and a two-part instrument, specifi-
cally robotfoto and focus group interviews, was used to gather data. The Glaserian method of grounded
theory analysis was used, and extended texts were analyzed inductively via a dendrogram. Member
checking and correspondence were observed to validate the surfacing stages, leading to the conceptu-
alization of a theoretical model termed as the Ribbon of Cancer Survivorship. The said model describes
the trifling (living before), transfusing (accepting the reality), transforming (being strong), and tran-
scending (living beyond) phases of cancer survivorship. Ten interesting substages were also identified,
namely: tainting, desolating, disrupting, and embracing for the transfusing phase; tormenting, distress-
ing, awakening, and transfiguring for the transforming phase, and trembling and enlivening for the
transcending phase. The resulting theoretical model has clearly and successfully described the entire
process of cancer survivorship among Filipinos. It is hoped that the model be used as a reference for
future studies about cancer survivorship and as a guide for nurses in providing a more empathetic care
among cancer patients.

Keywords:  Philippines; cancer; cancer survivorship; grounded theory

Cancer is a leading cause of death worldwide,
accounting for 7.6 million or around 13% of all
deaths in 2008 (World Health Organization, 2008).
However, the number of cancer survivors is increas-
ing, primarily because of the technological advances
in early detection and treatment. In fact, cancer is
now being viewed as a chronic disease that can be
effectively treated and controlled (Mattioli, Montanaro,
& Romito, 2010), as evidenced by the emergence of
early detection techniques, efficacious therapies,
and screening programs for various cancers (Sant
et al., 2009). Top-of-the-line primary cancer thera-
pies are now being made available, with various
advances currently aimed toward secondary and
comorbid cancer management. As a result of these
concerted efforts, it is projected that the number of
cancer survivors will increase up to 3% every year
(Maddams et al., 2009).
Cancer is perceived both as a bodily reflection
and a human experience (Vivar, Whyte, & Mcqueen,
2009), encompassing a dynamic and lifelong process
termed as “cancer survivorship” (Rasmussen, Hansen,
& Elverdam, 2010). It is described by Hewitt,
Greenfield, and Stovall (2006) as a distinct phase of
cancer that follows primary treatment and lasts until
Authors’ Note: Please address correspondence to Allan B. de
Guzman, PhD, College of Nursing, College of Education, The
Graduate School, Cluster on Cultural, Educational and Social
Issues, University of Santo Tomas, Manila 1015, Philippines;
e-mail: abdeguzman@mnl.ust.edu.ph.

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36  Journal of Holistic Nursing / Vol. 31, No. 1, March 2013
recurrence or end of life. The definition of “survivor”
was later expanded to include family, friends, and
voluntary caregivers who are affected by the diagno-
sis in any way (National Cancer Institute, 2006).
However, despite the increased importance of the
process of survivorship in the development of
patients’ quality of life beyond cancer, systematic
studies concerned with this matter of contention are
limited in nature (Bjordal, Mastekaasa, & Kaasa,
1995; Mols, Coebergh, & van de Poll-Franse, 2007;
Rao & Demark-Wahnefried, 2006). Additionally,
studies on cancer survivorship are not yet well-
developed and findings about cancer outcomes are
poor and insufficient (Mattioli et al., 2010). The
impact of cancer does not end after treatment and
that current approaches fail to address the full range
of physical, psychological, social, spiritual, and
financial needs that cancer survivors may have after
treatment (Feuerstein, Hansen, Calvio, Johnson, &
Ronquillo, 2007; Vivar et al., 2009), further empha-
sizing the need to fully understand what these can-
cer survivors go through as they undergo the process
toward cancer survivorship. Hence, this article seeks
to conceptualize the struggles of Filipino cancer
survivors with the acceptance of their condition and
their fortitude in dealing with its demands, ulti-
mately leading to the development of a theoretical
model that explains the process of survivorship
among these patients.
Method
Research Design
This qualitative investigation used the grounded
theory design. It is considered as a powerful means
for collecting and analyzing qualitative research
data and is inductively derived from the study of
the phenomenon it represents (Allan, 2003; Glaser
& Strauss, 1967; Vijayan, 2009). Most grounded
theory studies undergo four stages of analysis,
starting with coding or the identification of anchors
that represent salient points of the data being
studied. The resulting codes will then be subjected
to concept grouping, and the emerging concepts
will be classified according to distinct categories.
The final step in conducting grounded theory
research is the formulation of a theory that explains
the underlying process of the phenomenon being
studied.
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Research Sample and Instrumentation
The researchers purposively recruited 27 respond-
ents to participate in study. Eligibility criteria for
selection include the following: (a) cancer survivor
for at least 6 months, (b) 40 years and older, and
(c) able to follow oral and written directions.
Respondents were excluded from the study if they
(a) have difficulties in communication and compre-
hension and (b) have a coexisting chronic condition,
such as diabetes.
The researchers used a two-part instrument to
surface the process of acceptance, fortitude, and
recovery among adult cancer survivors. The first
part, as shown in Table 1, is the subject’s robotfoto,
a Dutch term defined as “a cartographic sketch of
the subject” (Kelchtermans & Ballet, 2002) to estab-
lish the baseline characteristics of the cancer survi-
vors under study. It consists of circles and blank
spaces to obtain needed information. The second
part is a focus group interview intended to elicit the
respondents’ own experiences with regard to their
path to recovery, guided by key interview questions
from the aide memoir. Three separate sessions were
conducted to complete the total number of partici-
pants: one for the 13 respondents previously diag-
nosed with breast cancer, another for the 11 who
had colon cancer, and a third for the remaining 3
participants.
Data Collection and
Ethical Considerations
Beguiling the process of the phenomena, a trian-
gulation of data collection strategy was used. Prior
to the data collection procedure, the participants
were asked to sign an informed consent and were
given a full explanation of the purpose and design of
the paper. On the permission of the participant to be
included in the study, focus group interviews were
conducted based on the date and time of their avail-
ability. Interview locations were also chosen by the
participants themselves, with the assumption that
they will be more honest and comfortable in a famil-
iar environment (de Guzman et al., 2009). It also
aims to establish better rapport and to create an
emotionally stimulating environment between the
participants and the researchers. A semistructured
interview was enforced in order to create a free-
flowing conversation without any alterations in the
focus and direction of the interview. Although most
 Filipino Cancer Survivorship / de Guzman et al.  37

Table 1.  Demographic Profile key questions are in the aide memoir, follow-up
of the Respondents (n = 27) questions were also raised to further probe into the
n % participants’ responses during the interview. Each
Age (years)
interview was video-recorded and lasted for 1 to
41-50 5 18.5 2 hours. Respondents were assured of their confiden-
51-60 13 48.1 tiality and were reminded of their right not to answer
61-70 6 22.2
71-80 2 7.4 any question or to stop the interview at any time.
≥81 1 3.7
Gender
Male 4 14.8 Mode of Analysis
Female 23 85.2
Civil status
Single 3 11.1
In this investigation, data and information
Married 15 55.6 yielded from the robotfoto were analyzed descrip-
Separated 1 3.7 tively. Data from the focus group interviews were
Widowed 8 29.6
Type of cancer transcribed verbatim into field text for the purpose
Breast 13 48.1 of undergoing analyses required for grounded theory
Colon 11 40.7
Endometrial 1 3.7 research. Field texts were intensively read and reread
Ovarian 1 3.7 to facilitate identification of significant statements
Synovial 1 3.7
What stage or anchors through the process of cutting and sort-
I 6 22.2 ing. These significant statements then were sub-
II 12 44.4
III 5 18.5 jected into the Glaserian method of ground theory
IV 4 14.8 analysis. It involves the inductive grouping of related
Year of diagnosis
Earlier than 1996 1 3.7 codes via a dendrogram to facilitate theory develop-
1996-2000 7 25.9 ment (Glaser, 1992, 1998, 2004). Common state-
2001-2005 15 55.6
2006-2010 4 14.8 ments were clustered into categories, wherein 4
Treatment(s) received phases with 10 substages emerged from the various
Surgery 19 70.4
Radiotherapy 11 40.7 categories. These phases established a deeper under-
Chemotherapy 17 63.0 standing of the process of survivorship being experi-
Religion
Catholic 26 96.3 enced by cancer survivors. These phases were further
Non-Catholic 1 3.7 subjected into a series of member checking and cor-
Current living condition
Alone 1 3.7 respondence procedures to establish the trustwor-
With own family 26 96.3 thiness of the data collected, leading to the unfolding
Seek medical management
Yes 21 77.8 of the lebenswelt of the process of cancer survivor-
No 6 22.2 ship among Filipinos.
Occupation
Accountant 1 3.7
Business executive 2 7.4
Dentist
Driver
1
2
3.7
7.4
Findings
Employee 3 11.1
None 13 48.1 From the richness and thickness of the descrip-
Professor 1 3.7
Vendor 4 14.8 tions given by the respondents, a distinct and inter-
Monthly family income esting set of phases has emerged, dubbed as the
(pesos)
<25,000 12 44.4 Ribbon of Cancer Survivorship. It describes the pro-
25,000-49,999 7 25.9 cess of trifling, transfusing, transforming, and tran-
50,000-74,999 2 7.4
75,000-99,999 2 7.4 scending among Filipino cancer survivors, as seen
≥100,000 4 14.8 in their individual and collective experiences and
Family orientation
Nuclear 6 22.2
discernments.
Extended 21 77.8
Support system
Parents 9 33.3 Trifling Phase: Living Before Cancer
Siblings 16 59.3
Friends 17 63.0 Looking back, participants reflected on their ear-
Relatives 15 55.6
Spouse 17 63.0 lier lives before they were diagnosed of having can-
Children 8 29.6 cer, termed as the trifling phase of cancer survivorship.

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38  Journal of Holistic Nursing / Vol. 31, No. 1, March 2013
It encompasses their moments of indifference and
negligence toward their health before they were diag-
nosed. Life for them was easy and some have even
verbalized that the only thing that preoccupied them
back then was work. As one participant enunciated,
“Life for me was easy; I was busy with my work.”
Another one articulated, “Our lives were just normal.
We’re working on our jobs.” Some of the participants
have also recalled that they used to be hyperactive in
a sense that they indulge themselves into their work
too much. Majority of the participants have also
described their former selves as someone who was
healthy and cheerful, while one participant put it as
being a happy-go-lucky person. On the other hand,
some have admitted that they are negligent in terms
of their health as one participant verbalized,
I was abusive when it comes to my body. I was a
drunkard, I was a driver then I would work for about
24 hours driving a taxi. I would drink myself to sleep
and then I would eat barbeques. I didn’t even know
that was bad for my health.
Another participant also shared, “Formerly,
I used to go against the flow” in a sense that she
does not even follow advice from other people in
terms of her health.
Transfusing Phase:
Accepting the Reality of Cancer
The process of acceptance in one’s journey
toward cancer survivorship is marked as the transfus-
ing phase in the Ribbon of Cancer Survivorship. A
person is said to be experiencing a so-called “trans-
fusion” once the unfortunate event of being diag-
nosed with cancer happens, resulting to an
overwhelming amount of stress and emotional upset
dealt on the person. One can be observed to be
instilled with shock, denial, and negativity in the
initial stages of finding out about their condition,
but then struck with sanguinity, as they slowly move
toward acceptance.
It is interesting to note that the participants had
undergone different stages in the process of accept-
ing the reality that they indeed were suffering from
cancer. They had never thought that they would ever
be diagnosed with the disease, so they were all very
shocked at first. Some participants shared their ini-
tial responses:
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When I heard that it was cancer, of course your
initial reaction, you would be crying.
I couldn’t get up from bed, and I used to lie all the
time. Then, I suddenly lost hope in life.
Each day that passes, they experienced certain
bodily changes, reflecting the severity of the disease
condition. As one participant expressed, “I was terri-
fied, and I couldn’t even feel any sensation. Why was
it like that?” This period in the process of accept-
ance, known as the tainting stage, binds the partici-
pants together in their journey through cancer. One
respondent had mentioned, “It was as if heaven and
Earth collided unto me.” During these trying times,
dark clouds always seem to hover above their heads
while being blanketed by sorrow and hopelessness.
Some of them responded,
It was more than “Ondoy” [a strong typhoon in the
Philippines]. It was devastating.
We were sure we’re going to die.
After surpassing this gloomy moment in their
lives, the participants gradually moved on to the
next state called the desolating stage. In this
stage, they portray a depressing disengagement.
In the beginning, they keep to themselves, not
uttering words that might hint to others that they
had cancer, as one of the survivors expressed, “At
first, I just kept it to myself, and before, I was
hesitant to join others.” For most participants, it
was not very easy to accept the reality, and they
felt an overwhelming uproar of thoughts and emo-
tions. Most of them turned to prayer and com-
pletely submitted themselves to God. They had
asked Him why such thing happened to them,
and when all their efforts seemed to have gone to
waste, they resorted to bargaining, as reflected by
their responses:
I’m still too young to die.
It is hard to accept. Actually, I asked the Lord,
“Why me?”
I bargained and said, “Lord, I want to believe that
my mission is already done, but I’m still young; I can
still do a lot of things. Give me another chance to
serve You.”

After some time, wallowing in their sadness,
the participants transitioned into a somehow, more
accepting state of mind called the disrupting state.
This took place when they experienced bothersome
alterations in their everyday lives, and had to learn
how to deal with their insecurities. As most of them
verbalized,
I really felt incomplete deep inside.
Let’s say I have a meeting at 1 p.m. I have to prepare
while it’s still early because I have to tend to this
[colostomy].
It’s like there’s an abnormality with your movements.
Finally, the embracing stage defines the last step
of the participants’ experience of acceptance, where
their openness to disclose their condition to their
loved ones became more apparent and learned to
accept facts and face the truth that they have can-
cer. While developing an optimistic perspective
along the way, their readiness to embark on a new
chapter was typified by their tendency to share
their strategies in overcoming this overwhelming
battle against the disease with others. As shared by the
participants:
If you have a positive outlook, healing process will
hasten.
We just believe that we’re already healed. Then
you’ll find yourself very happy and contented.
Interestingly, almost all the participants devel-
oped a kind of vigilance and awareness of the other
aspects of their lives. They found themselves taking
more risks and becoming more appreciative of life.
We don’t take ourselves for granted anymore. We
don’t think we’re Superman.
We eventually learned to accept it, and we feel that
we’re better people. We’re better women, because
we look at other things like, our love for our
children, our love for our spouses, and all the better
things in life. We realized that we should be thankful
for so many things.
As shown, spirituality has become integral in the
growing of ease of the participants. They turned to
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Filipino Cancer Survivorship / de Guzman et al.  39
prayer and surrendered their lives to God, thanking
Him for each day that they are alive and for the
opportunity to fulfill their mission in life.
I lift it all up to the Lord. I lift up everything to Him.
It’s prayer, what’s most important. Pray to Him
because He will really guide you and the ultimate
pillar is God.
We still have a mission on this Earth. Why do
I believe in that? It’s because He’s keeping me alive.
I asked God, “Is it time to go?” And if it’s not time
to go, that means You have something for me to do.
And if You want me to do something, I am deaf and
blind. You drop it on my lap. That’s what He did,
exactly.
Transforming Phase: Being
Strong in the Midst of Cancer
Eventually, one progresses from a state of denial,
fear, and hopelessness to a state of acceptance and
positivity. This phase is represented in the Ribbon of
Cancer Survivorship as the transforming phase. A
cancer patient is assumed to be in the process of
“transformation” when he goes through a variety of
changes in his attitude toward cancer and life. This
phase takes into account four substages, namely tor-
menting, distressing, awakening, and transfiguring.
In the process of facing cancer, one of the most
crucial stages one experiences is the overwhelming
sense of emotional torture. This burden was described
to be unbearable and painful, as other aspects of
their existence were affected by the drastic changes
that their condition has brought on them as well as
their families and friends. This point in the process
typifies the tormenting stage, for it lumbered down
the lives of these unsuspecting individuals.
It is very hard for me to have this!
I am shouting because of pain!
I really refused chemotherapy. I don’t want to feel
miserable with how you feel.
When I was in the dark, thick walled room, I imagined
that I was already dead, and I was 6 feet under the
ground.
40  Journal of Holistic Nursing / Vol. 31, No. 1, March 2013
As a consequence of the tormenting phase, one
undergoes a state of isolation from society, mostly
because of the social stigma that comes with cancer.
Since most of the participants had external indica-
tors of their disease (mastectomies, colostomies),
they had a hard time accepting the fact that they are
now incomplete, disrupting their body image, rela-
tionship with society, and overall self-esteem. This
can be described as the distressing stage of cancer
survivorship because of the emotional and psycho-
logical struggles that these people encounter. As
shown in their articulations,
Imagine having only one breast! We feel we are not
females anymore. The only visible identity of women
is having breasts!
Imagine you cannot wear fashion clothes anymore!
No more plunging necklines!
A lot of people are saying, ‘That’s gross!
Imagine their insults! It is a very big shame for us!
Over time, when one has imbibed the essence of
this painful experience, the distressing stage for-
wards itself into an increasingly positive view toward
the experience. The participants were enlightened in
a way that they have risen from their misery and
began reconnecting with others. They started to
change for the better as well as making amends with
their Creator. Thus, these moments in their lives are
collectively termed as the awakening stage. This
described how they were struck with enlightenment,
and how it urged them to face their most challeng-
ing hurdle head-on. They bravely shared,
I believe that God forgave me and this is when I felt
at peace, when I accepted its totality.
As if God whispered to me and said, “Go back to
who you used to be!”
I noticed that my one breast was bigger than the
other one, but that’s it. Life went on, and I still
continued running my business!
I cherished every minute that I spend with them
[my family and friends]
Indeed, through faith, as one submits himself to
God, one’s strength as a person is being boosted;
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sooner or later, one develops a more positive outlook
in life; and eventually, rebuilds oneself into a faith-
fully strong person. This process may be described
as the transfiguring phase, wherein one undergoes
metamorphosis, from a confused person to a com-
pletely ideal strong person. As some of the partici-
pants verbalized,
I did not take any medicine, I only took daily
prayers! I started to rebuild myself! I became very
happy again! I forgot being materialistic! In fact, it
was very easy for me to accept and let go when lots
of my expensive jewelries were stolen!
When I was operated I did not think that that would
be my last. It was nothing to me. I was not scared.
It didn’t enter my thoughts, that when I get home
from the hospital I might end up somewhere else.
My faith was in God, I believed that when I get out
I’d be healthy!
Transcending Phase:
Living Beyond Cancer
The last facet of the Ribbon of Cancer
Survivorship is the transcending phase, which speaks
of the extension of the person’s consciousness onto
others, gathering their experiences about cancer and
going beyond themselves to help and inspire other
people currently suffering the condition. The partici-
pants also shared the process that they have under-
gone after learning about their full recovery from
cancer. Though they were assured that they were
fully healed, the thought of possible recurrence was
always present in their minds, to the point that they
feel they still suffer the condition. This is termed as
the trembling stage of cancer survivorship. While it
can be seen in Figure 1 that this stage is part of the
transcending phase, it is also interesting to note its
placement in the model. It was positioned near the
transfusing phase because of the cyclical nature of
cancer. A possible recurrence predisposes the person
to “fall back” to the earlier stages of tainting, desolat-
ing, disrupting, and embracing. Some respondents,
for instance, shared the following:
Even though I’m a survivor now, my doctor reminded
me that there is always a possibility of recurrence.
On other cases, I was told that it might attack a
different organ the next time around. It’s a scary
thought.

Figure 1.  Ribbon of Cancer Survivorship
Not only am I scared of experiencing the physical
pain, but I can’t stand the fact that we’ll have to
spend a lot of money again.
However, it is also important to understand that
because a person has already gone through the whole
experience of having cancer, he will more likely be at
ease toward facing the disease the second or third
time around. As one respondent exemplified,
When I had my recurrence, of course I was scared,
but not as scared as before. I was surprised, but
I was more equipped with knowledge the second
time around. Plus, I have my family, my friends, and
my support group with me, so it was definitely easier
for me to accept and survive once again.
However, if one does not have a recurrence of
his cancer, he eventually reaches the enlivening
stage, which talks about the extension of one’s life
beyond the cancer experience. Most of the respond-
ents shared their joy in making new friends and
forming strong bonds with them. They consider it as
a “blessing in disguise” because it made their lives
worth living for, not just during the disease process,
but most important, beyond the horrors of cancer.
For example, they fondly said thus:
It’s just the same. It’s as if nothing happened. I had
more friends though, like in the cancer association.
It’s a good feeling to have more acquaintances.
It’s so nice to bond with your fellow survivors. We
know each other, we laugh together, we cry together.
We understand each other, and we share so much.
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Filipino Cancer Survivorship / de Guzman et al.  41
Some of them also expressed the desire to share
their experiences with other cancer sufferers. As
they pointed out, one can truly become empathetic
if he has actually experienced the condition already.
They hope that through their stories and advices,
they can somehow touch the lives of these people, as
reflected in these statements:
For us survivors, the only people that can fully
understand what we’ve gone through are our
co-survivors.
All of us have experienced the disease already. There
may be slight differences, but it’s essentially the
same.
We compare notes, we compare what medicine that
we took, and what is the reaction that we had. So we
empower them and make them understand that
they are not alone in their fight.
However, it should also be noted that while they
were cancer free, all of them showed their determi-
nation to stay that way through healthy lifestyle
modifications. Cancer, as they say, made them a bet-
ter person physically, very much unlike the person
that they were before the diagnosis. Some of their
responses include the following:
We’re very vigilant now. That why we’re careful with
what we eat. We avoid stress, if we can.
We’re now more health conscious, especially when
it comes to food. If we feel something, we go to the
doctor immediately.
Last, it is also interesting to note that most of
them shared a positive change in their outlook in
life. As they journey to life beyond cancer, they feel
that it is important to learn from that experience in
order to blossom into a new person. Because of this
“new life” God has given them, they now accept this
mission to guide those suffering from cancer in trav-
elling the road to recovery. These realizations from
them include,
What I can say about cancer is that you can easily
fight it off, especially if you are not alone. That is
why I’ll always be available to help them.
Don’t postpone anymore; do what you can do now.
Do not take things for granted.
42  Journal of Holistic Nursing / Vol. 31, No. 1, March 2013
I’ll forever thank God for giving me another chance
to live. I know that He gave me this opportunity to
inspire other people who are currently suffering just
like me before, and I’m very much willing to accept
that mission.
Discussion
Considering the dearth of nursing literature
encompassing the entire cancer experience, this study
explores the process of cancer survivorship among a
select group of Filipinos in a holistic lens. This
resulted to the surfacing of the Ribbon of Cancer
Survivorship that consisted of 4 phases and 10 sub-
phases pertaining to the experiences cancer survivors
undergo as they journey toward accomplishing remis-
sion and survival. The said model has successfully
provided a rich description of what commences on
each phase. For instance, the trifling phase serves as
a starting point for these survivors, unlike past studies
concerning the process of cancer survivorship that
only starts from the point at which the participants
only started to learn about their diagnosis (Eliott &
Oliver, 2002; Walton, 1999; Walton & Sullivan,
2004). It is integral in the study of cancer patients
and survivors alike that their premorbid states be
clearly defined, for it may have crucial implications
to their prognosis, coping, and overall quality of life
(Klastersky, Schimpff, & Senn, 1999).
It is also interesting to note that one’s attitude
changed drastically from the moment they found out
they have cancer. The process of acceptance in a
cancer survivor’s journey toward cancer survivorship
then starts, and is represented by the transfusing
phase. From the initial moments of learning about
their diagnosis, it was found that the participants
had experienced astonishment and disbelief, fol-
lowed by extreme sadness and anxiety. This stage is
termed as such because the participants seemed like
they are being instilled with this burden they never
asked for. In this study, several accounts from the
participants’ shared stories were deemed significant
as they revealed stressful moments that lead them to
describe their lives to be “falling into pieces.” As
defined by the National Comprehensive Cancer
Network (2008) of the United States, distress is a
multifactorial unpleasant emotional experience of a
psychological, social, and spiritual nature that may
interfere with the ability to cope effectively with
cancer.
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As their condition progresses, they then move to
the next stage wherein they experience the conse-
quences of cancer dampening their spirits, which
runs parallel with Zabora, BrintzenhofeSzoc,
Curbow, Hooker, and Piantadosi’s (2001) findings
that about 29% to 43% of cancer survivors have
manifestations of clinical depression. Furthermore,
the study also agrees with Passik and Grummon
(1998) that experiences after medical procedures
and related activities associated with the treatment
of cancer have significant effects on the memories
and feelings of a survivor, especially toward the
development of fear of relapse when he achieves
remission. In response to the diagnosis and treat-
ment of cancer, a considerable number of cancer
patients also show symptoms of psychological dis-
tress, such as embarrassment, fear, sadness, anger,
depression, and anxiety (Kim et al., 2011). The
respondents attest to this as they shared stories
wherein they encountered moments of anxiety, inse-
curity, and difficulty in dealing with life as a cancer
patient.
It was also suggested by the findings as well as
previous studies (Schilling, 1993) that ending up
alone, living with illness, or an altered health status,
can “leave people alone with their body.” Several
participants even felt abandoned and helpless as
they faced this sad plight in their life in solitude.
They chose to keep this predicament to themselves,
feeling that they were the only ones having this
encounter, and that no one else could possibly save
them from this dreadful occurrence. Moreover, the
participants opted to hide their condition from soci-
ety with fear of being treated differently, the end
product of which is isolation from being singled out
as different from the rest. This observation is in
accordance with other findings (Kelly, Pearce, &
Mullhall, 2004) that stress the tendency of newly
diagnosed cancer patients to withdraw themselves
from society.
Survivors are often left with the physical remind-
ers as a result of cancer and its treatment, such as
pain, fatigue, sterility, and loss of sexual function.
Indeed, the aftermath of treatment has been
described as worse than the disease itself (Doyle,
2008). They became aware of the changes they went
through, and thus, surfaced a sense of insecurity
with their bodies. Counterintuitively, these individu-
als were imparted with a ray of hope and started to
finally blossom their way out of that abyss. Amidst
their fears and hardships, they got back on their feet

and chose to live anew. They eventually shared their
resentment, instead of facing their challenges alone.
They learned to accept reality and did not just bear
it in silence.
Meanwhile, it is in the transforming phase
where cancer patients experience transference of
their attitude toward cancer from a negative to a
positive light. Similarly, Lewis, Mooney-Somers,
and Kerridge (2010) associated cancer to a trans-
formative experience, a promoter of change in
one’s outlook in life, and a provider of much-
needed wisdom and insight. In a similar vein,
Doyle (2008) also mentioned that the opportunity
to redefine oneself does not occur often in life, but
a cancer diagnosis may be one of those occasions
that this opportunity comes up. This notion is
unanimously backed up by a wealth of literature
attesting to the transformative potential of cancer
(Breaden, 1997; DeMarco, Picard, & Agretelis,
2004; Leigh & Logan, 1991; Meraviglia, 2006;
Vachon, Cerhan, Vierkant, & Sellers, 2001; Wallwork
& Richardson, 1994).
In line with the tormenting and distressing sub-
stages in the study, wherein one experiences physi-
cal and emotional agony as a response to the disease
process, numerous studies (Aziz & Rowland, 2003;
Cheng, Thompson, Ling, & Chan, 2005; Dow,
2003; Mellon, Northouse, & Weiss, 2006) agree
that the negative aspects of being diagnosed with
cancer are usually associated with biomedical issues,
such as depression, fatigue, pain, dyspnea, cognitive
impairment, sterility, and loss of sexual function.
Moreover, fear of social isolation and loss of signifi-
cant relationships or roles can have a great impact
on a person’s chances of surviving cancer, as affirmed
by past research (Deimling, Sterns, Bowman, &
Kahana, 2005; Mellon et al., Weiss, 2006; Vachon et
al., 2001).
Notably, as one surpasses the course of treat-
ment and endures the fight for survival, he experi-
ences an adjustment in his attitude and outlook in
life. As evinced in the study, participants were driven
from their wretchedness and began relating with
others. Getting support from the people around
them and with a substantial faith in God, they
develop a more positive viewpoint and, in due
course, transfiguring into a more resilient personal-
ity. This is embodied in the Ribbon of Cancer
Survivorship as the awakening and transfiguring sub-
phases. This metamorphosis is termed as biological
revisioning, which speaks of the process of identity
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Filipino Cancer Survivorship / de Guzman et al.  43
reconstruction undertaken in response to the experi-
ence of cancer (Lewis et al., 2010).
One final feature of the theoretical model that
warrants discussion is the emergence of the tran-
scending phase of cancer survivorship. To “tran-
scend,” in colloquial terminology, means to “go
beyond,” and it is further described by Immanuel
Kant as knowing how to experience things as they
were meant to be experienced (Powell, 1990; Wood,
2005). To achieve transcendence, according to him,
one must develop a synthesis between his experi-
ence per se and his self-consciousness of the experi-
ence. It can also be seen in a phenomenological
sense by examining one’s collection of noema and
the formed noesis (Solomon, 1977). The entire tran-
scending phase exemplifies these establishing, for it
serves both as a culmination and a pinnacle of the
entire survivorship process.
To have a better grasp of how transcendence
develops in a cancer survivor, a deeper analysis of
the entire process must be done first. As the partici-
pants start from the trifling phase, they advance to
the process of accepting their situation, fulfilling the
“experience” requirement. A clearer understanding
occurs within them as they go through the desolat-
ing and disrupting phases of accepting their situa-
tion. Finally, they reach the embracing stage, where
they integrate their past experiences of acceptance
with their personhood in order to achieve self-
consciousness. This “subprocess” then repeats itself
during the transforming phase, ultimately leading to
these cancer survivors not only achieving self-
consciousness of what has transpired, but also con-
sciousness beyond their own, which is transcendence
in its purest form.
Interestingly, a substage termed as the trembling
stage surfaced as a part of the transcending phase,
primarily dealing with the most common fear among
cancer survivors: the fear toward recurrence (Passik
& Grummon, 1998). It is important to note that, as
implied in the findings, this stage has a two-way
path. Its proximity with the transfusing phase
emphasizes the potential of cancer survivorship to
become a cyclical process, should recurrences occur.
However, it is also an imperative to understand that
because of the awareness and support systems
formed during the first encounter with cancer, those
suffering from recurrences will generally have an
easier time when dealing with the demands of their
disease condition. Another point to remember as
health care providers when taking care of these
44  Journal of Holistic Nursing / Vol. 31, No. 1, March 2013
people is that this fear toward recurrence is usually
permanent in nature, coinciding with the notion
that survivorship is a lifelong process (Rasmussen
et al., 2010). Whether they were warned by their
physicians about the possibility of recurrence or not,
recurring thoughts about their past bouts with can-
cer nevertheless prevail.
Meanwhile, if ever recurrence does not occur, a
cancer survivor will eventually reach the enlivening
phase of survivorship, wherein one uses his new-
found strength and awareness in inspiring others
who are currently battling the disease. The partici-
pants themselves emphasized the major role of sup-
port systems in one’s coping with cancer. It is very
much natural for Filipinos to be social people, and
this is especially evident during times of need or
crises (Licuanan, 1988). They value the presence of
their support system as their “emotional sounding
board,” especially when they know that these people
have already experienced what they are currently
going through. That is the reason most of the
respondents expressed their desire to fulfill their
mission of inspiring others through their own experi-
ences. They believe that having concerned people to
be with as one journeys through cancer can be ben-
eficial in lessening the burden of the individual. This
is backed up by past international studies (Ell, 1996;
Quittner, 1992; Wortman, 1984) stressing that
meaningful cancer support systems has its place in
cancer management.
Conclusion
Corollary to the different issues concerning the
worldwide increase in the number of cancer survi-
vors and its implications in cancer research, this
qualitative undertaking purported to describe the
process toward cancer survivorship among Filipinos.
Four main phases emerged from the interviews done
with the participants, namely, the trifling, transfus-
ing, transforming, and transcending stages, providing
a greater understanding of how Filipino cancer sur-
vivors go through the whole cancer experience, from
their lives before the disease to the point that they
grow beyond the confines of their condition. This
study introduces a theoretical model that will prove
to be integral in the development of nursing theory,
research, and practice. The Ribbon of Cancer
Survivorship has its implications in future cancer
survivorship studies by serving as a comprehensive
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theoretical model in the field. Nurse educators, stu-
dents, and practitioners will also benefit from the
study, because they can now identify the process of
recovery among their cancer patients in a holistic
manner, and not just the biomedical cancer staging
that nurses are more familiar with. A more empathetic
nursing care will then be provided because of their
clearer understanding of their patients’ experiences.
The utilization of the Glaserian grounded theory
method allowed the researchers to inductively and
creatively explore for phases of cancer survivorship.
This, in combination with the adequacy of the par-
ticipants, accounts for the richer description of the
lebenswelt of Filipino cancer survivorship.
As there was a preponderance of female partici-
pants in the study, the researchers call for future
grounded theory studies on cancer survivorship that
feature a more diverse gender mix in order to ade-
quately capture the experiences of male respondents
as well. It is also suggested that further research be
carried out covering other cancer types, as most of
the participants in this study either had breast or
colon cancer. Last, it is recommended that applica-
tions of this qualitative study be implemented on a
variety of demographic and cultural populations in
order to explore for additions or alterations in the
emerged theoretical model. Through these sugges-
tions, the researchers hope that this will all lead to a
better appreciation of the experiences of accept-
ance, resilience, growth, and inspiration among
cancer survivors.
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Allan B. de Guzman handles pedagogy, management, and
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the University of Santo Tomas. He has extensively published
more than 75 articles in various ISI-listed journals and has
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Benito Christian B. Jimenez graduated from the University of
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Kathlyn P. Jocson is is now a registered nurse and finished her
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Aileen R. Junio graduated Cum Laude from the University of
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Drazen E. Junio graduated from the University of Santo Tomas
with a Bachelor of Science in Nursing degree and is at the
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Jasper Benjamin N. Jurado graduated Cum Laude from the
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Medicine in the same university.
Angela Bianca F. Justiniano graduated from the University of
Santo Tomas and is currently a registered nurse.

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