The cancer experience is also notable for its impact on formative belief systems. Issues of race, ethnicity, class, sexual orientation, religion—culture—have a significant influence on how survivors will make sense of their illness: “I'm Japanese-American; I'm not sure how my parents would have handled a ‘woe-is-me” attitude. They wouldn't have reacted negatively, but it would have been a change from the more Japanese approach of ‘internal suffering' and swallowing bitterness.” Religion is another aspect of culture where this dynamic is often expressed. As young adults wrestle with the role that spirituality plays in their lives, cancer can deepen their commitment or threaten their faith. Often it does both.
Whether or not a survivor identifies with a religion, the post-treatment period presents an opportunity to explore spiritual and existential issues. Many young survivors find it deeply healing to consciously process the experience as they seek ways to understand it—to assign it meaning and purpose in their lives. This process of adjusting to a new sense of self can precipitate an early experience of existential “aloneness” that magnifies feelings of difference, isolation, loneliness, envy and, sometimes, contempt for healthy peers who are not confronting these issues in such a powerful way: “I listen to friends now, but I just can't relate. You just want to shake people and tell them to get a grip.”
Ultimately, survivors have a need to process and make sense of the cancer experience as a “whole”; of who they are both in spite of and because of it, to make sense of their peers and their relationships given their altered perspectives: “I feel that I am able to see things much more clearly than before. This clarity sometimes is not wanted.” They need to mourn losses and changes, to learn how to cope with uncertainty while remaining fully invested in their daily lives.
A critical aspect of this “investment” is the willingness to connect with others. Young adult survivors face the challenge of re-entering their peer group with an intimate knowledge of their vulnerability and mortality. The typically healthy young adult may not be able to relate to the experiences of those with a catastrophic illness: “My noncancer friends are well-meaning, but they don't understand and just say, ‘you look great.'” The sense of being misunderstood and unsupported or misunderstood and smothered can fuel an impulse to rethink and even terminate relationships.
These feelings, coupled with fears of rejection and loss, often challenge the ability to build new relationships. “I'm never going to find a mate. Who is going to want me with all this baggage? Who is going to deal with my insanity, my menopausal 80-year-old body?” Issues of disclosure, particularly for those who are dating, become paramount: “You never know when is too early to tell someone but the longer you wait, the more you start to wonder if you waited too long.”
Some young adult survivors will successfully maintain their pre-existing relationships and build new ones, but they too may harbor a sense of “aloneness” that even their most intimate relationships cannot pierce: “This experience with cancer is a very selfish one—I recognize that it impacts those around me—but it truly is mine and mine alone.”
Cancer sparks an “early” confrontation with personal mortality that can deepen the typical existential musings of this group: “When your mortality is brought out of the abstract and turned into a reality, it is a hard cross to bear, and even harder because you do it alone. While my husband may grieve over the possibility of losing me, I would be saying goodbye to him, our son, and to life itself.” This heightened sense of mortality can play itself out in numerous ways. For many, the process of coping with multiple emotional issues and identity shifts can lead to self-imposed pressure to make sweeping lifestyle changes.