Impact of leisure physical activity and resistance exercise on the prevalence of depressive symptoms in Korean adults: Analysis of the Korean National Health and Nutrition Examination Survey.

BACKGROUND: Various physical activity (PA) guidelines recommend leisure PA and resistance exercise (RE). However, the impact of PA and RE on the prevalence of depressive symptoms remains unclear. We investigated whether meeting PA and RE guidelines is associated with the prevalence of depressive symptoms using nationally representative samples. METHODS: We analyzed data from 11,829 (5111 male and 6718 female) participants aged 19+ years in the Korean National Health and Nutrition Examination Survey (2016 and 2018). Those with doctor's diagnosis of depression or with a cut-off score of ≥11 on the Patient Health Questionnaire-9 were defined as having depressive symptoms. PA and RE were measured using a validated Global PA Questionnaire. Logistic regression analysis was used to examine the association between participating in leisure PA, simultaneously meeting RE guidelines, and experiencing depressive symptoms. RESULTS: Those who participated in leisure PA and met RE guidelines had a lower prevalence of depressive symptoms than those who did not (p for trend <0.001). After adjusting for covariates, those who participated in leisure PA and met RE guideline were significantly less likely to have depressive symptoms in male (OR = 0.52, 95 % CI 0.32-0.84) and female (OR = 0.71, 95 % CI 0.48-1.06), compared with those who did not participate in leisure PA but also did not meet RE guideline. LIMITATIONS: The cross-sectional nature of the data prevented causal claims. CONCLUSIONS: Participation in leisure PA and RE was associated with a lower prevalence of depressive symptoms. This suggests both leisure PA and RE should be encouraged as effective means for preventing depression.

Adjustment to "new normal" after cancer among non-small cell lung cancer survivors: A qualitative study.

OBJECTIVES: Cancer is a life-changing experience, and side effects from treatment can make it difficult for survivors to return to their pre-cancer "normal life." We explored the "new normal" and barriers to achieving it among lung cancer survivors who underwent surgery. METHODS: Semi-structured interviews were conducted with 32 recurrence-free non-small cell lung cancer survivors. We asked survivors how life had changed; how they defined the "new normal"; barriers that prevent them from achieving a "normal" life; and unmet needs or support for normalcy. Thematic analysis was performed. RESULTS: Defining "new normal" subjectively depends on an individual's expectation of recovery: (1) being able to do what they want without pain or discomfort; (2) being able to do activities they could accomplish before their surgery; and (3) being able to work, earn money, and support their family. We found that (1) persistent symptoms, (2) fear of cancer recurrence, (3) high expectations in recovery, and (4) psychosocial stress and guilty feelings were barriers to achieving a "new normal." The needs and support for normalcy were information on expected trajectories, postoperative management, and support from family and society. SIGNIFICANCE OF RESULTS: Survivors defined the "new normal" differently, depending on their expectations for recovery. Informing survivors about the "new normal" so they could expect possible changes and set realistic goals for their life after cancer. Health professionals need to communicate with survivors about expectations for "normality" from the beginning of treatment, and it should be included in comprehensive survivorship care.

A Web-Based Decision Aid for Informed Prostate Cancer Screening: Development and Pilot Evaluation.

BACKGROUND: Prostate-specific antigen-based routine screening is not recommended for the general population due to conflicting results with mortality reduction. We aimed to develop a web-based decision aid (DA) for informed decision making for prostate cancer screening. METHODS: Using the International Patient Decision Aid Standards (IPDAS) development process model, we developed our DA based on patient and clinician interviews and multidisciplinary expert discussions. The prototype consisted of predicting individual prostate cancer risk and informed decision-making, including knowledge, risk and benefit, cost, personal value, and decision making. We conducted a pilot study on 101 healthy men, evaluating the effectiveness of DA by measuring knowledge, attitude, and intention to screen before and after using the DA, as well as decisional conflict and usefulness after using the DA. RESULTS: Of the 101 participants (median age 60 [50-69] years), 84% had not undergone screening for prostate cancer in the past two years. After using the DA, knowledge on prostate cancer screening increased (mean score [of 10] before versus after: 6.85 ± 1.03 versus 7.57 ± 1.25; P < 0.001), and intention to not screen increased from 27.7% to 51.5% (P < 0.001), but attitude toward screening did not change (P = 0.564). After use of the DA, 79 participants reported no decisional conflict, and the usefulness score was high (mean score [of 100] 77.35 ± 7.69), with 85% of participants reporting that the DA helped with decision making. CONCLUSION: Our web-based DA yielded increased knowledge, decreased screening intention, and high perceived usefulness. These findings indicate potential clinical relevance, especially among younger individuals.

Unmet Supportive Care Needs after Non-Small Cell Lung Cancer Resection at a Tertiary Hospital in Seoul, South Korea.

The aim of this study is to identify the prevalence and predictors of unmet needs of non-small cell lung cancer (NSCLC) patients undergoing surgical resection in Seoul, South Korea. A total of 949 patients who completed survey questionnaires that included the Cancer Survivors' Unmet Needs Korean version (CaSUN-K), fear of cancer recurrence (FCR) inventory-short form, and European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) were recruited from January to October 2020. Multivariable logistic regression was used to determine the potential correlation of significant unmet needs, defined as any moderate or strong need, for each domain of CaSUN-K. Of the 949 participants, the mean age was 63.4 ± 8.8 years old, and 529 (55.7%) were male. Overall, 91.8% of participants reported one or more unmet need. The highest domains of moderate-to-strong unmet needs were existential survivorship (59.1%), comprehensive cancer care (51.2%), and information (49.7%). High FCR and poor emotional function were associated with moderate-to-strong unmet needs across all domains of CaSUN-K. NSCLC survivors with a recent diagnosis had more frequent disease-related unmet needs. Interventions to reduce the unmet needs of NSCLC patients should focus on relieving FCR and improving emotional functioning. Furthermore, emphasis should be placed on decreasing disease-related needs, particularly for early survivors of lung cancer during the re-entry phase.

Fear of cancer recurrence and its predictors among patients with non-small cell lung cancer (NSCLC).

PURPOSE: Fear of cancer recurrence (FCR) is a multidimensional phenomenon among cancer survivors. This cross-sectional study aimed to identify the prevalence of FCR and its predictors among survivors of non-small cell lung cancer (NSCLC) in Korea. METHODS: Participants who finished NSCLC treatment one or more months prior completed the Korean version of Fear of Cancer Recurrence Inventory-Short Form (K-FCRI-SF) and the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) at single tertiary hospital in Korea. Multivariate-adjusted logistic regression and stepwise backward selection were used to determine the potential predictors of FCR. RESULTS: Of the total 949 participants (mean age 63.4 ± 8.8 years, 44.3% women), 55.8% had high FCR. Female (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 1.06-1.95), pathologic stage III (aOR 1.97, 95% CI 1.18-3.30), poor overall quality of life (aOR 1.42, 95% CI 1.03-1.95), poor emotional functioning (aOR 3.91, 95% CI 2.64-5.81), poor social functioning (aOR 1.87, 95% CI 1.31-2.68), and severe dyspnea (aOR 2.91, 95% CI 1.03-8.21) were independent predictors of high FCR. Old age (≥ 70 years) was included in the final model (aOR 0.74, 95% CI 0.51-1.06) but did not show clinical significance. CONCLUSIONS: Our study demonstrated that high FCR was prevalent in NSCLC patients in Korea. To prevent this, we suggest screening and early detection of FCR based on sex, pathologic stage, quality of life, emotional and social functioning, and dyspnea. IMPLICATIONS FOR CANCER SURVIVORS: Screening and early detection of FCR based on sex, pathologic stage, quality of life, emotional and social functioning, and dyspnea is suggested.

Tearing down the barriers to exercise after mastectomy: a qualitative inquiry to facilitate exercise among breast cancer survivors.

OBJECTIVE: Proper exercise immediately after breast cancer surgery (BCS) may prevent unnecessary physical and psychological decline resulting from the surgery; however, patients' attitude, barriers and facilitators for exercise during this period have not been studied. Hence, this study aims to explore the barriers and facilitators of exercise among patients with breast cancer through multiple interviews immediately after surgery through 4 weeks after BCS. METHODS: We conducted three in-depth interviews of 33 patients with breast cancer within 1 month after BCS. RESULTS: We identified 44 themes, 10 codes and 5 categories from interview results. Physical constraints and psychological resistance were identified as the barriers to exercise, while a sense of purpose and first-hand exercise experience were identified as the facilitators of exercise. By conducting the interviews over the course of 4 weeks after surgery, we monitored patterns of changes in barriers and facilitators over time. Overall, our analyses identified that professional intervention based on the time since surgery and the physical state after BCS is essential. The intervention would counteract the overwhelming psychological resistance in the early weeks by developing a sense of purpose in the later weeks. CONCLUSIONS: We made suggestions for future research and exercise intervention programmes that can benefit breast cancer survivors based on the categories, codes and themes identified in this study.

Validity and reliability of Korean version of Modified Fatigue Impact Scale (MFIS) for Korean patients with multiple sclerosis.

BACKGROUND: To determine the validity and reliability of the Korean version of the Modified Fatigue Impact Scale (MFIS-K) questionnaire for patients with multiple sclerosis (MS). METHODS: We prospectively enrolled 52 patients with MS and 102 healthy controls. Subjects were asked to complete the Korean version of Fatigue Severity Scale (FSS) and MFIS-K. To evaluate sleep quality, depression, pain, and quality of life, patients completed the Pittsburgh Sleep Quality Index (PSQI), the Beck Depression Scale II (BDI), the Brief Pain Inventory (BPI), and the Short Form 36 Health Survey (SF-36). RESULTS: It was demonstrated that MFIS-K has appropriate construct validity with distinctive 3 factors (cognitive, physical, and psychosocial). The criterion validity was also confirmed with the total score and the factor scores of the patients with MS, which were all significantly higher than those of healthy controls. Convergent validity of the MFIS-K was verified with the correlations with Fatigue Severity Scale (FSS) and other concurrent measures of sleep disturbances, depression, pain, and limitations in activities due to health problems. Furthermore, the internal consistency, temporal stability, and score consistency of the MFIS-K turned out acceptable. DISCUSSION: Our results indicate that the Korean version of MFIS is a valid and reliable scale to assess fatigue in the Korean MS population.

The relationship between domain-specific physical activity and depressive symptoms in Korean adults: Analysis of the Korea National Health and Nutrition Examination Survey.

BACKGROUND: This study aimed to investigate the associations of domain-specific physical activity (PA) with the prevalence of depressive symptoms. METHODS: We analyzed data from 11,679 (5,056 men and 6,623 women) participants aged ³19 years in the Korea National Health and Nutrition Examination Survey (2016 and 2018 waves). Depressive symptoms were measured using the Korean version of the Patient Health Questionnaire-9 (PHQ-9), with a cut-off score for depression of 11. The participants were first categorized by sex, and then by their PA level in different PA domains into three different groups. We examined the correlations between domain-specific PA and depressive symptoms using logistic regression analysis after controlling for confounders. RESULTS: Total amount of PA was not associated with depressive symptoms. However, in both sexes, those high in leisure and transport PA had lower levels of depressive symptoms compared with those with no leisure and transport PA (p for trend <0.001). After adjusting for covariates, those high in work PA showed a significantly higher likelihood of having depressive symptoms both in male (OR= 2.74, 95% CI 1.56-4.82) and female participants (OR= 2.84, 95% CI 1.70-4.49), compared to those with no work PA. LIMITATION: Cross-sectional nature of the data prevents causal associations. CONCLUSIONS: Although the total amount of PA participation was not associated with depressive symptoms, domain-specific PAs were differently associated with depressive symptoms. Specifically, higher amount of work PA was significantly associated with higher prevalence of depressive symptoms; this topic deserves further attention and future investigation.

Predictors of Posttraumatic Growth: Insights From a Comparison Between Assault Victims and Nonassault Victims.

Posttraumatic growth (PTG) has been investigated in many different areas of trauma, including cancer, occupation-related injuries, and crimes. In the current study, we aimed to examine the effects of traumatic events on the victims' PTG. The current study was a survey study with group comparison. We recruited 143 victims of trauma (74 nonassault victims and 69 assault victims) and compared victims' PTG and its related factors according to the trauma type. Nonassault victims showed better outcomes in terms of adverse childhood experience, depression, anxiety, and acceptance than assault victims. Only for assault victims, PTG was predicted significantly by the individuals' resilience. For nonassault victims, anxiety showed significance in predicting PTG. Assault victims seemed to be at significantly higher risk for psychological issues in adaptation afterward than nonassault victims. The implications of the results, including more tailored support for assault victims, as well as future study suggestions, are discussed.

Ordinary Responses to an Extraordinary Disaster: Sewol Ferry Sinking and the Victim Families' Experience.

Sewol Ferry sinking was a man-made disaster that happened on April 16, 2014, in South Korea, resulting in 304 deaths. In the 2 years following the disaster, the Special Investigation Commission on the Sewol Ferry Disaster conducted a qualitative study with the victim families to investigate their experience. One hundred forty-five interviews were conducted with parents, aunts, and grandparents of high school student victims by a team of clinical and community psychologists. Based on 54 in-depth interviews with parents and parent figures randomly selected out of the 145 interviews conducted, we aimed to understand the lived experience of the victim parents. The grounded theory yielded 59 codes and five categories, whose core variable was self-empowerment of the victim community. The community of victim families was supported by the engagement of other citizens, as well as the victim families themselves. The meanings implicated in the results, along with the practical implications in the community, are discussed.

Attributes of caregivers' quality of life: A perspective comparison between spousal and non-spousal caregivers of older patients with cancer.

PURPOSE: With the aging population, our current understanding of patients with cancer and their family caregivers needs to be expanded to older patients with cancer and their caregivers. By differentiating spousal caregivers and non-spousal caregivers, we aimed to investigate the universalities and particularities of caregiving for older patients with cancer. METHODS: Through 11 cancer centers in South Korea, 358 patient-caregiver pairs were recruited in this cross-sectional study. Patients were of gastric, colorectal, or lung cancers, and caregivers were those who accompanied the patients to the clinic. Along with socio-demographic variables, medical records of the patients, and caregiving-related measurements, the caregiver's quality of life (AC-QOL) was rated both by patients and by caregivers. RESULTS: Statistically significant attributes of ACQOL included patient's age, caregiving duration, caregiver's concern about financial burden, caregiver's self-evaluation of their own physical health, and work conflicts due to caregiving for spousal caregivers (R2 = 0.687). For non-spousal caregivers, caregiving duration, caregiver's concern about financial burden, caregiver's self-evaluation of their own physical health, and family conflicts due to work were found significant (R2 = 0.272). Also patients rated ACQOL in higher accordance with their spousal caregivers than with non-spousal caregivers. CONCLUSION: The needs of spousal caregivers and non-spousal caregivers might vary, which should inform the effective and efficient channeling of support for family caregivers. Future research suggestions, along with the study limitations, are discussed.

Patient-family communication mediates the relation between family hardiness and caregiver positivity: Exploring the moderating role of caregiver depression and anxiety.

Purpose: Despite the theoretical and empirical significance of positive aspects of caregiving in caregiver well-being, relatively little is known regarding family-related predictors of caregiver positivity. This study examines whether patient-family communication (p-f communication) mediates the relation between family hardiness and caregiver positivity and whether the mediating effects of p-f communication are moderated by the levels of caregiver depression and anxiety. Design/Sample: This study used secondary data obtained from a large-scale cross-sectional national survey conducted in South Korea. Participants were 544 spousal cancer patient-caregiver dyads recruited from the National Cancer Center and nine government-designated regional cancer centers in South Korea. Methods: To test the hypotheses, a simple mediation model and two moderated mediation tests were conducted using the PROCESS macro for SPSS. Findings: Higher family hardiness was related to higher p-f positive communication and higher caregiver positivity. The effects of family hardiness were partially mediated by p-f communication, controlling for caregiver sex, education, health status, depression and anxiety, time spent caregiving, and patient depression and anxiety, cancer stage, and time since diagnosis. The mediating effects of p-f communication were not significantly moderated by caregiver depression and anxiety. Conclusions/Implications: Health care professionals could consider p-f communication as a reasonable target of intervention to increase caregiver positivity, even for caregivers with heightened depression and anxiety.

What We Talk about When We Talk about Caregiving: The Distribution of Roles in Cancer Patient Caregiving in a Family-Oriented Culture.

PURPOSE: When it comes to cancer care, the psychological well-being of family caregivers has gotten its deserved attention. However, the specific roles that the family caregivers take have not been examined as much. The current study aimed to investigate the distribution of family caregivers' roles, particularly in a family-oriented culture, Korea. MATERIALS AND METHODS: A sample of 439 participants was recruited from 11 national and regional cancer centers in Korea. The participants who were 60 years old or above went through treatments for their gastric, colorectal, or lung cancer. The individual survey included questions regarding the family type, living arrangement, and the sources of support when it comes to their physical, emotional, financial, and decision-making needs. RESULTS: The responses from the participants showed that cancer caregiving is shared by multiple family caregivers; the major source of support for elderly cancer patients on diverse domains was their spouse; patients' reliance on their daughter(s) increased for emotional support; and patients' reliance on their son(s) stood out for financial support and decision-making support. Also, the older the patients were, the heavier their reliance was on the adult children, including sons, daughters, and daughters-in-law. CONCLUSION: Future support programs for elderly cancer patients are suggested to involve multiple family caregivers to encourage effective and efficient intervention. Also, the limitations of the current study and the suggestions for future research are discussed.

Experience with age discrimination and attitudes toward ageism in older patients with cancer and their caregivers: A nationwide Korean survey.

OBJECTIVE: It is not clear whether age-related differences in treatment and treatment decision-making are the result of age discrimination or just a reflection of older patients' elevated risk and their own preferences. Therefore, it is critical to understand older patients' own views toward their care in regard to its relationship to age. MATERIAL AND METHODS: 439 older patients with cancer (age ≥ 60) and 358 family members from eleven cancer centers participated in this cross-sectional survey. RESULTS: Almost all patients (91.2%) and caregivers (92.7%) thought that older patients should be treated equal to younger patients, across all questionnaire items. The proportions of patients who reported having experienced age discrimination according to each item were: disease information (12.3%), treatment information (11.0%), participation in treatment decision (10.7%), attention from healthcare professionals (6.2%), supportive care (5.2%), and treatment (3.2%). Increasing age was the only demographic characteristic that was associated with greater ageism experience (p < .001). Patients' ageism attitudes, as well as caregivers' ageism attitudes, were negatively associated with ageism experience. Ageism experience was associated with a higher depression score, as well as a lower quality of life. CONCLUSION: Discrimination in treatment and the treatment decision process based on age was not justified. Interventions that address ageist attitudes in older patients, family caregivers, and healthcare professionals are needed to reduce age discrimination, and thereby improve the quality of life of older patients with cancer.

Factors associated with quality of life of people with Myasthenia Gravis.

PURPOSE: As most of patients with Myasthenia Gravis have limitations in their physical functioning, many experience changes in psychological states and often have depression. The objective of the current study was to examine the roles of communication with medical professionals, patients' loneliness, and patients' depression, in relation to their effects on the patients' quality of life. METHODS: For 120 patients with MG of 18 years and older, demographic variables, along with communication with medical professionals, loneliness, depression, and quality of life were measured. RESULTS: As a result, people suffering from MG experienced lower quality of life when their career has changed due to the illness. At the same time, depression was a significant predictor of their quality of life, both in physical and mental domains. CONCLUSIONS: The implications for clinical settings and the suggestions for future research are discussed.

Social relationship changes in victim families due to a social disaster: Experiences of student victims' families in the South Korean Sewol ferry disaster.

The Sewol ferry incident on April 16, 2014 in South Korea claimed the lives of 304 individuals, including about 250 high school students on a school trip. The majority of South Korean citizens were watching live updates on the capsized Sewol ferry, anxiously watching on TV how the vessel fully sunk over time. They were desperately hoping for the rescue of the survivors inside. However, their anxiety had become shock, anger, and helplessness, and the disaster has become a daunting, collective trauma, not just to the victims and their families, but also to the citizens who were exposed only through the media. In this study, we interviewed victims' families two years after the incident. We explored how they have experienced changes in their social relationships. We conducted semi-structured interviews of 54 family members of the student victims. We qualitatively examined the data applying a thematic analysis. Changes in their social relationships were largely divided into the relationships in the proximal environment and the relationships in distal environments. The former included subcategories such as immediate family, coworkers, friends, relatives, survived students and their parents, and concepts corresponding to each subcategory. The latter involved subcategories such as neighbors, other citizens, the victims' family committee, government, and society, and concepts subject to each subcategory. Based on these findings, rehabilitation plans for trauma victims and their families should take into account the significant changes in their social relationships and the further consequences of those changes.

The moderating role of social support on depression and anxiety for gastric cancer patients and their family caregivers.

BACKGROUND: There is a consensus that cancer care should go beyond physical care as cancer patients and their family caregivers experience psychological burden, financial difficulty, as well as social relation issues. The current study aimed to investigate the moderating impact of social support on depression and anxiety of cancer patients and their family caregivers. METHODS: Gastric cancer patients and their family caregivers who visited a university medical center in Seoul were approached for participation in the study. Fifty-two pairs of adult patients and caregivers participated in the study. Along with demographic information and the physical condition of the patients, such as pre-operation cancer stage and the type of gastrectomy, social support, depression, and anxiety were measured for patients and caregivers, respectively. RESULTS: In the first round of analysis, patients' depression was associated with age, while patients' anxiety was related to income. On the other hand, caregivers' depression was not associated with patients' health and living arrangement. In the second round of analysis to examine the moderating effect of social support, patients' income and social support were related to depression and anxiety, but the interaction of income and social support was only observed for anxiety. For caregivers, no interaction effects were found. Social support decreased the negative effects of low income status on the patients. CONCLUSION: While the income of the families with cancer cannot be adjusted in the short-term, their experience of social support can be managed by a proper support system. Diverse implications in medical settings are discussed.

Perceived social support and its impact on depression and health-related quality of life: a comparison between cancer patients and general population.

OBJECTIVE: It is well known that cancer patients' perception of social support is associated with their depressive symptoms and health-related quality of life. However, there have been little studies that compared the variates of cancer patients with the general population. We sought to compare differences in the level of perceived social support and the impact of perceived social support on depressive symptoms and health-related quality of life between cancer survivors and the general population. METHODS: Data were collected from 1818 cancer patients treated at the National Cancer Center and regional cancer centers in South Korea. The control group of the general population was composed of 2000 individuals without cancer from community. RESULTS: Cancer patients reported significantly higher level of perceived social support than the general population, while they reported lower health-related quality of life and were more susceptible to depression. The positive associations of higher perceived social support with lower depressive symptoms, as well as with higher health-related quality of life, were stronger among cancer patients than among the general population. CONCLUSIONS: The interaction effect suggests that the impact of social support would be stronger among cancer patients than the general public. Thus, it would be beneficial to pay attention to providing social support to cancer patients, particularly to those who are more vulnerable. Furthermore, investigation of the most effective and efficient methods to deliver social support interventions would be worthwhile.

Temperamental predictors of developmental trajectories of inattention and hyperactivity-impulsivity problems in schoolchildren.

BACKGROUND: The current study aimed to examine the temperamental predictors of developmental trajectory subgroups of children's inattention and hyperactivity-impulsivity problems through a short-term longitudinal study. METHODS: Children (n = 1344) were divided into younger (age 6-8 years) and older (age 9-11 years) groups in order to observe changes in inattention and hyperactivity-impulsivity problems. Inattention and hyperactivity-impulsivity problems were measured three times at 5-month intervals and Cloninger's four temperaments (novelty seeking, harm avoidance, reward dependence, and persistence) were examined on the first occasion only. A cohort sequential design and growth mixture model were used for investigating trajectory subgroups and multiple logistic regression analysis to examine the temperamental predictors. RESULTS: Developmental trajectories of inattention and hyperactivity-impulsivity showed different subgroupings depending on the age group of children. Temperament (high score on novelty seeking and low score on persistence as well as high score on reward dependence) and gender predicted the likelihood of belonging to high-risk versus low-risk subgroups. CONCLUSION: Suggestions taking into account the predictors of developmental trajectories in inattention and hyperactivity-impulsivity problems for future research are discussed along with the limitations of the current study.

What cancer means to the patients and their primary caregivers in the family-accounted Korean context: A dyadic interpretation.

OBJECTIVE: When cancer hits a family, the entire family members start to adapt to the new status. This study aimed to investigate the main issue of the family with cancer patient and their way of solving it. METHODS: In-depth interviews were conducted as a qualitative research. Thirty-three participants described their experience either as cancer patients or as family caregivers. RESULTS: Guided by the grounded theory, we identified the main concern of the families being primary caregiver selection. The primary caregiver was determined by the conditions of the patient and the family, but the primary caregiver accepted his/her role believing no alternative was plausible in the family. The processes of the entire family have change since cancer showed their "adapting living," which was identified as the core variable. CONCLUSIONS: On the basis of the current study's limitations, suggestions were made for future studies in which cultural attributes are distinguished from the medical system attributes.