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. Author manuscript; available in PMC: 2025 Sep 17.
Published in final edited form as: J Fam Theory Rev. 2025 Jan 28;17(3):549–564. doi: 10.1111/jftr.12612

Quality of life in breast cancer survivors: An ambiguous loss perspective

Caroline Salafia 1,2, Kari Adamsons 1
PMCID: PMC12440391  NIHMSID: NIHMS2076655  PMID: 40963593

Abstract

Breast cancer is the second most common cancer diagnosed among women in the United States. Although advances in detection and medical treatment have improved survival rates, breast cancer survivors experience physical symptoms and psychological distress that can adversely impact their quality of life. Examining the quality of life in breast cancer survivors is important as it may inform supportive services, patient-centered care, and well-being after treatment. Theoretical perspectives such as ambiguous loss theory can assist in understanding the factors that shape quality of life. Ambiguous loss theory, developed by Pauline Boss, refers to a loss that remains unclear, unresolved, and lacks closure. Grief theorists have acknowledged grief associated with symbolic losses, such as the loss of health status. The current article integrates empirical research and established constructs derived from ambiguous loss theory to develop a middle-range theory focused on explaining quality of life among breast cancer survivors.

Keywords: ambiguous loss theory, breast cancer, middle-range theory, mid-range model, quality of life

INTRODUCTION

Breast cancer is the second most common cancer diagnosed and is the second leading cause of cancer death among women in the United States (DeSantis et al., 2019). During the COVID-19 pandemic, there were fewer early stage diagnoses and higher proportions of advanced cancer at diagnosis due to delays in screening and diagnoses (Li et al., 2023). However, as of 2024, breast cancer incidence rates have returned to pre-pandemic trends (Burus et al., 2024; Mentrasti et al., 2022), and breast cancer incidence continues on an upward trend, rising by 1% annually over the past decade (Giaquinto et al., 2024). Although breast cancer does occur in cisgender men and transgender women, such occurrences are rare and account for less than 1% of breast cancer diagnoses (Yalaza et al., 2016); therefore, we focus on cisgender women’s experiences with breast cancer, as both the risk and the psychosocial experience of breast cancer vary based on an individual’s sex and gender identity. The American Cancer Society (2023) recommends using the terminology of a cancer survivor to refer to anyone who has ever been diagnosed with cancer, regardless of where they are in the course of their disease. Optimal cancer care is needed across the cancer care continuum, and women with breast cancer are referred to as survivors in this context, as cancer is considered a chronic disease (Pituskin, 2022).

Breast cancer survivors experience a wide array of physical symptoms and psychological distress that can adversely affect their quality of life (Perry et al., 2007). Quality of life is an important component to assess throughout the cancer care experience and is integral to improved cancer care and outcomes (King, 2006). Although there are a plethora of models, frameworks, and theoretical perspectives that evaluate the quality of life in cancer survivors (Chan et al., 2023; Manne et al., 2023; Nekhlyudov et al., 2019; Révész et al., 2022; Victorson et al., 2007), the present paper provides a critical application of the intersection of ambiguous loss theory, meaning-making, and quality of life.

Ambiguous loss is an important but often unconsidered element of the breast cancer experience and transition to survivorship. Pauline Boss (2016) theorized that there are two kinds of ambiguous loss, one in which an individual is physically absent but psychologically present (PAPP; Boss, 2022), such as in the case of missing from war, kidnapping, or another traumatic event. The second type of ambiguous loss refers to physical presence with psychological absence (PPPA) and entails being physically present but psychologically absent, due to a traumatic event, disaster, or catastrophe (Boss, 2022).

Although grief typically is associated with the death of a loved one, grief theorists have acknowledged the significance of other symbolic losses, such as the loss of health through illnesses such as cancer (Boss, 2010). Physical absence but psychological presence (PAPP) can include the loss of health status due to breast cancer, such as the loss of one’s breast(s) or physical appearance changes, such as scarring that can represent physical absence. These losses and the grief, fear, and other emotions associated with a breast cancer diagnosis and treatment may shape an individual in the long term. At the same time, cancer survivors might feel betrayed by and psychologically detached from their bodies, despite being physically present for treatment, also leading them to experience PPPA. Guided by ambiguous loss theory, this paper outlines a conceptual framework designed to help elucidate the factors that influence and shape the quality of life among breast cancer survivors. A mid-range model that applies ambiguous loss theory to breast cancer would help to inform interventions aimed at improving the quality of life for women.

Additionally, this paper focuses on the key role of family and social support and their associations with meaning-making and quality of life among breast cancer survivors. Although not the focus of this paper, family systems theory highlights how the diagnosis of cancer in one individual affects all family members, as the family is an interconnected unit (Mehta et al., 2009). The family is often involved throughout the breast cancer care trajectory, from diagnosis (e.g., accompanying the individual to doctor’s appointments) to decision-making surrounding treatment (e.g., surgical decision-making) to recovery and care provision, and the family also plays a large role in the psychosocial adjustment and transition to breast cancer survivorship (Hobbs et al., 2015; Muhamad et al., 2011; Perak et al., 2024).

Quality of life in breast cancer survivors

Breast cancer is a disease that can cause tremendous physical and emotional distress to both survivors and their loved ones (Saeedi-Saedi et al., 2015). An individual living with breast cancer faces a stressful and unpredictable situation, which can drastically impact one’s quality of life. Quality of life is a broad and multidimensional construct, which typically includes subjective evaluations and interpretations of both positive and negative aspects of life and an individual’s ability to lead a fulfilling life (Bullinger et al., 1993; Grabowska et al., 2022). Grabowska et al. (2022) analyzed data collected from a representative sample of individuals living in Poland (59% women) and found that individuals with a disability reported a lower quality of life compared to individuals without. Importantly, disability is multidimensional and encompasses a variety of possible limitations, but nearly 30% of cancer survivors report some form of disability (Brick & Tonorezos, 2024; Cao et al., 2024). Cancer survivors are at risk for impairments that arise from either cancer itself or as a consequence of treatment. Many cancer survivors experience functional limitations shortly after treatment initiation or after treatment completion, and some individuals have functional limitations that last for years beyond treatment (Nekhlyudov et al., 2022).

Although cancer care is often primarily focused on physical quality of life, quality of life also encompasses psychological (e.g., depression, self-esteem), spiritual (e.g., religion), relational (e.g., personal relationships, social support), and environmental (e.g., home environment, safety) domains (Chopra & Kamal, 2012; Tully et al., 2019). Quality of life is impacted by a multitude of factors and its analysis and investigation in the context of a chronic illness such as cancer is important (Carmona-Bayonas et al., 2021). For example, a systematic review of the quality of life in breast cancer survivors found that the major constructs surrounding quality of life in breast cancer-free women included physical well-being, psychological and spiritual elements, family role, social effects, and interpersonal relationships, as well as coping and adjustment (Heidary et al., 2023). The quality of family relationships is one of the most influential factors that can influence well-being, and social support from family can serve as a protective resource against adverse life events, such as illness (Ringdal et al., 2007; Thoits, 2010). Research also highlights that social support can buffer against comorbidity burden and psychological distress (Bellizzi et al., 2024; Salafia et al., 2023). Familial support is critical to well-being among breast cancer survivors, with research finding that women who receive familial support tend to have a better prognosis, report greater quality of life, and better adjustment into survivorship compared to women with low levels of familial support (Adam & Koranteng, 2020; Chou et al., 2012; Yoo et al., 2010).

The major dimensions of quality of life for women living with breast cancer specifically include overall survival, physical effects (e.g., pain, nausea, fatigue), the psychological adjustment to a shocking diagnosis, and issues surrounding children and planning for the future (Heidary et al., 2023). Quality of life is a multidimensional construct, and as cancer rates continue to increase and impact both the diagnosed individuals and their families, it is important to examine how various elements of quality of life are affected throughout the care continuum and what factors are associated with reduced or improved quality of life (Perry et al., 2007).

Ambiguous loss theory

Ambiguous loss theory was developed by Boss (1977) and has been continuously modified and expanded to consider different situations and applications. As previously mentioned, an ambiguous loss is defined as a loss that remains unclear, and because it is unclear, it remains unresolved (Mendenhall & Boss, 2022). Boss (1977) originally aimed to examine families’ experiences with mismatched psychological and physical presence (or absence), such as in the case of families of veterans who were declared missing during the Vietnam War (PAPP) or caregivers of family members with dementia (PPPA). The primary premise of ambiguous loss theory is that, unlike death where a loss is concrete and confirmable, there is ambiguity or lack of clear and definitive information about the whereabouts or status of a loved one, and this loss is often traumatizing for individuals, couples, and families (Boss, 2007). While it was originally considered in the context of families of veterans, Boss has also applied ambiguous loss theory within the context of physical illness and the distress caused by the lack of clarity individuals with chronic illness experience about their status (Boss, 2002).

Ambiguous loss is relevant to the context of cancer, as the trajectory of what will happen to cancer survivors is often difficult to predict. It is not uncommon for those with cancer to wonder if they will die from the disease or survive, what survival will look like, and what the future holds (Boss, 2002). The ambiguity and lack of clarity about one’s prognosis can make individuals feel as though they are on an emotional roller coaster between hope and hopelessness (Boss, 2002). Chronic illnesses such as cancer can create ebbs and flows for individuals, where some days they are able to go on as they were before the illness, while other times they can be preoccupied with pain and hardship (Boss, 2002). Additionally, women diagnosed with breast cancer often have to adjust to physical appearance changes or grieve the potential loss of hair, breasts, and fertility from treatment (Harcourt & Rumsey, 2001). Some women report a period of mourning and bereavement surrounding the loss of their breast(s) due to cancer (Gershfeld-Litvin, 2021). Breast loss following the surgical removal of the breast can also be experienced as disenfranchised grief and an ambiguous loss for women who survive breast cancer, particularly women who report receiving breast reconstructive surgery (Gershfeld-Litvin, 2021). The theory of ambiguous loss has provided intervention points for other populations, and Boss (2002) points to other chronic illnesses and the key role of ambiguity; therefore, it is a promising theory for investigating the well-being of breast cancer survivors.

Meaning-making

Key to effectively dealing with ambiguous loss is the ability to make meaning from one’s experience, and breast cancer diagnosis and survivorship presents several opportunities for meaning-making. A diagnosis of breast cancer and its treatment (e.g., surgery, radiation) can influence physical appearance and functioning and ultimately impact women’s body image (Esplen & Fingeret, 2021). Negative body image in individuals diagnosed with cancer can lead to psychological distress, as well as changes in family functioning and social relationships, which ultimately can result in decreased quality of life (Ahn & Suh, 2023; Cerea et al., 2022; Koçan & Gürsoy, 2016; Paterson et al., 2016; Zhang et al., 2021). Highly stressful events, such as the diagnosis and treatment of cancer, can severely violate people’s meaning systems and can be traumatic life events (Park & Blake, 2020). The experience of loss, both in terms of physical and psychological adjustment to breast cancer, often requires women to engage in meaning-making as a coping mechanism, which can help women find purpose in their experience and help them manage the stress and challenges associated with breast cancer (Marco et al., 2023; Nilsen et al., 2021).

Meaning-making is an important component of ambiguous loss; theoretically, when much-needed answers are unavailable, meaning must be socially constructed to ease stress and suffering (Mendenhall & Boss, 2022). Finding meaning or being able to make meaning out of a situation is especially difficult with ambiguous loss, and the process of finding meaning is not linear (Boss, 2010). Individuals also continuously monitor their experiences and assign meaning (i.e., appraise) to these experiences over time (Park, 2022). Meaning-making has also been viewed as an outcome of a successful coping process in the face of a traumatic experience and is often viewed as an important predictor of resilience in the face of a breast cancer diagnosis (Park et al., 2020; Seiler & Jenewein, 2019). Over the last few decades, increasing empirical evidence suggests that serious life events, such as the diagnosis of a life-threatening illness, can lead not only to psychological distress, but also to positive life changes (Manne, 2004; Seiler & Jenewein, 2019; Thornton & Perez, 2006; Weiss, 2004).

Individuals who live with chronic illness, such as breast cancer survivors, often must redefine their lives by integrating the meaning of breast cancer (Ohlén & Holm, 2006). Women who were diagnosed with breast cancer have also reported benefits in the face of hardship, such as a change in perspective and a redefinition of priorities, including living life to the fullest, personal growth, lifestyle changes, a greater perspective (e.g., letting go of the little things), and more compassion for others (Martino et al., 2022). Martino et al. (2022) highlighted that it is beneficial for women to integrate the meaning of loss and develop a new sense of self after a breast cancer diagnosis, underscoring the need for clinicians and researchers to acknowledge the role of ambiguous loss and meaning-making in a woman’s breast cancer journey.

Changes in meaning, or meanings made, help to facilitate psychological adjustment in the face of hardship and promote resilience (Park, 2017). Boss and Ishii (2015) state that six research-based guidelines for a resiliency-based approach help address ambiguous loss, which include: finding meaning, adjusting mastery, reconstructing identity, normalizing ambivalence, revising attachment, and discovering new hope. Finding meaning is an important precursor to resilience as individuals cannot cope with a problem until they know what the problem is, so giving the loss a name, such as ambiguous loss, allows individuals to better recognize that what they are experiencing truly is a loss (Boss & Ishii, 2015). It is especially important to normalize ambivalence, especially in the context of a breast cancer diagnosis. A qualitative study on women with breast cancer found several expressions and meanings in the narratives of breast cancer survivors, and the researchers discussed how these women’s stories showed how they were consoled by recognizing unexpected and unpredictable aspects of life and living (Ohlén & Holm, 2006). Women diagnosed with breast cancer are often faced with the challenge of navigating unpredictability and uncertainty related to their prognosis and whether the breast cancer will recur in the future. Ambiguous loss that persists for a long time is shown to be physically and emotionally exhausting to an individual (Betz & Thorngren, 2006; Boss, 2004, 2010; Boss & Carnes, 2012).

Overview of proposed model

Both ambiguous loss theory and quality of life are broad constructs that can be applied to specific contexts and situations. Ambiguous loss is relevant in the context of cancer as the person is physically present but has likely changed given the physical and psychological long-term and late effects of cancer (Stein et al., 2008) and also might experience physical losses (breasts, fertility, hair) that still maintain a psychological presence. Individuals have to navigate an ambiguous and uncertain situation as well, given it is not feasible for medical professionals to always predict accurately and precisely what will happen and may be incapable of giving answers and clarity to individuals regarding their prognosis, long-term outcomes, and the like. While Boss (2002, 2007) discusses the psychological impact of ambiguous loss in the context of chronic illness, there has not been a specific focus on factors contributing to the quality of life for women with breast cancer – a disease that is often (but not always) survivable but nonetheless can substantially alter one’s abilities and outlook.

Drawing from ambiguous loss theory broadly and empirical research on the quality of life in breast cancer survivors, we developed a novel mid-range model (an application of a broader theoretical framework to a particular topical area; see Figure 1). Mid-range models play an important role in bridging empirical observations and research with grand theories and conceptual frameworks (Kislov et al., 2019). The current model applies an ambiguous loss perspective to understanding quality of life among breast cancer survivors.

FIGURE 1.

FIGURE 1

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Mid-range model. This figure provides a visual representation of how ambiguous loss theory can provide insight into the mechanisms affecting quality of life among breast cancer survivors.

Our proposed model suggests that illness characteristics not only directly influence an individual’s quality of life, but also shape meaning-making for breast cancer survivors; these meanings then mediate the effect of the illness on quality of life in positive or negative ways. In addition, individual and social factors such as cancer survivors’ familial support, intimacy and sexual losses, and financial and job/career status, serve as important moderators that influence the meanings that are made from illness characteristics. The general associations among illness, meaning making, and quality of life in breast cancer survivors have been a large topical focus of cancer research and psycho-oncology (Nilsen et al., 2021; Quinto et al., 2022). However, atheoretical lists of empirical findings can be better and more comprehensively understood by applying ambiguous loss as an organizational framework. As such, the remainder of this paper explores both the theoretical basis and any existing empirical support for each proposed path in the model.

MID-RANGE MODEL

Illness characteristics and quality of life

The proposed model first incorporates direct predictors of quality of life in the form of the specific characteristics associated with the cancer diagnosis and illness itself. Characteristics of cancer include aspects such as the types and duration of treatment, age at diagnosis, the presence, absence, or severity of symptoms, and where the individual is on the cancer care continuum, among others. Factors such as younger age at diagnosis, receiving chemotherapy as a treatment, having more advanced cancer, and greater reported symptom burden are associated with both greater distress and lower quality of life (Cheng et al., 2012; Costanzo et al., 2007; Janz et al., 2005; Schou et al., 2005). Among cancer survivors (including but not specific to breast), individuals treated with radiation or chemotherapy and those with more comorbidities had significantly lower health-related quality of life (Manne et al., 2023). Given that abundant research has linked illness characteristics to quality of life, illness characteristics are proposed to be directly associated with quality of life. Though traditionally this association is simply taken at face value and not framed from any particular theoretical perspective, this model proposes that the association between illness characteristics and quality of life should be viewed through an ambiguous loss lens. Doing so introduces a series of moderating and mediating factors that shape the experience of living with breast cancer.

Meaning making as a mediator between illness characteristics and quality of life

Receiving a diagnosis of a potentially life-threatening illness can be the catalyst to searching for meaning, as often, the diagnosis and treatment of cancer bring thoughts of mortality to the forefront of one’s mind (Carreno & Eisenbeck, 2022; van der Spek et al., 2013). Breast cancer is a life-threatening illness in which individuals often have little influence on clinical outcomes. When there is little control over actual situations, meaning-making – the ability to transform meaning – is a highly adaptive coping strategy for psychological adjustment (Park et al., 2001, 2008). Meaning-making has been found to be significantly associated with quality of life, such that a strong sense of meaning was associated with a greater quality of life among cancer patients (Majerníková & Obročníková, 2017). In addition to having a sense of meaning or not, particular meanings or meaning content might be associated with higher or lower quality of life. For example, researchers examining loss and meaning-making after mastectomy have found that women use meaning-making processes to reduce the importance that they attribute to their breasts or place them in a negative context to minimize the significance of their loss and avoid postmastectomy grief (Gershfeld-Litvin, 2021). The meanings that women attribute to their illness and its characteristics have a strong impact on their subsequent quality of life.

Familial, sexual, and financial well-being as moderators between illness characteristics and meaning-making

Although all individuals make meaning of their situations to a greater or lesser extent, this paper proposes that numerous individual and social factors can moderate the association between illness characteristics and meaning-making. Women have diverse experiences with breast cancer and these experiences can be associated with different appraisals and meaning-making, which ultimately impact quality of life (Bloom et al., 1998). Two women with the same diagnosis might experience and assign meaning to the experience very differently, depending on their personal characteristics as well as their environment. Some examples include women’s familial support and obligations, intimacy and sexual losses, and financial and job/career status, all of which can moderate (strengthen or reduce) the association between illness characteristics and meaning making for breast cancer survivors; we discuss each of these examples in more detail below.

Familial support and obligations

A key component of ambiguous loss theory relates to the assumption that cultural beliefs and values influence a family’s tolerance for ambiguity and how it is received (Boss, 2007). Pauline Boss highlights the usefulness of cultural beliefs in understanding family and relational processes that are faced with ambiguity (Boss, 2007). Importantly, both the diagnosed individual and the overall family system can experience the complications of grief and/or ambivalence given the ambiguity of a circumstance. Family support can therefore serve as a potential moderator between illness characteristics and meaning making, as it shapes individuals’ lived experiences with breast cancer and the ambiguity surrounding the future. For example, research has indicated a statistically significant correlation between social support and the meaning of life for women with breast cancer (Jadidi & Ameri, 2022). Additionally, social support has a stress-buffering effect for individuals on chemotherapy for breast cancer, highlighting how social support could potentially buffer the negative impact of illness characteristics (Roy et al., 2021). Research has indicated that relationships and experiences were the most frequently mentioned meaning-making themes for cancer survivors, highlighting how influential and impactful relationships are for meaning making in the context of cancer (van der Spek et al., 2013).

However, family systems not only can offer support but also can place demands on women diagnosed with breast cancer, which can alter the meaning they assign to the disease. For example, research suggests that a breast cancer diagnosis is experienced differently by women who are mothers versus women who are not mothers. Billhult and Segesten (2003) found that the meaning of being a mother with breast cancer meant a need to balance the situation of being a mother while also allowing herself to be sick and so included a balance between telling the truth and also protecting children from this truth. Another study found that young mothers reported higher levels of illness intrusiveness compared to those without children (Arès et al., 2014). Although little is known about the impact of motherhood on well-being over time in breast cancer survivors, an ambiguous loss framework could examine how uncertainty about the future shapes meaning making and subsequent quality of life for women over time and with (or without) children of different ages.

Intimacy and sexual losses

Intimacy and sexual losses also can influence the association between illness characteristics and meaning making for breast cancer survivors. Research has indicated that younger-aged women who do not have a spouse or intimate partner have reported heightened concerns about their femininity, attractiveness, reproduction, and future potential for such a relationship after a breast cancer diagnosis (Institute of Medicine (US) and National Research Council (US) National Cancer Policy Board, 2004). Qualitative research conducted on young women with breast cancer found key themes related to decision-making experiences and fertility issues, mostly relating to uncertainty about the future (Sobota & Ozakinci, 2021; Xu et al., 2021).

Given many women do survive breast cancer, it often can be considered a chronic rather than a catastrophic illness (Pillai-Friedman & Ashline, 2014). However, although it may not always be fatal, quality of life issues related to body image and sexuality nonetheless can compromise the trajectories of women with breast cancer (Pillai-Friedman & Ashline, 2014). Women with breast cancer often experience both short- and long-term sexual side effects from both cancer and cancer treatment itself, such as pain, loss of interest in sex, and possibly infertility (Pillai-Friedman & Ashline, 2014). These sexual losses can profoundly shape meaning making and appraisal, depending on individual and social characteristics (e.g., losing fertility before vs. after having children). Healthcare providers, family members, and partners may not acknowledge or consider these sexual losses, making these losses ambiguous, undefined, vague, and unclear (Boss, 2010). Overall, losses in intimacy and sexuality have the potential to alter the meanings assigned to the experience of breast cancer.

Financial and job/career status

As highlighted by Boss (2002), the ambiguous losses surrounding illness keep people uncertain as to what to do or what decisions to make. In the financial and career realm, the experiences and meanings assigned by cancer survivors who are just starting their careers versus those who are retired could vary drastically. For example, research suggests that experiencing breast cancer at a young age was viewed by participants as contributing to an increased desire for work to provide a sense of meaning, along with financial security and a means of obtaining insurance (Raque-Bogdan et al., 2015). For cancer patients in their early 20s, they may be trying to figure out their career, while cancer patients later in life may have been planning for retirement, but a diagnosis of breast cancer can implicate both trajectories and future planning.

A cancer diagnosis also can cause serious financial hardship and derail career plans (Halpern et al., 2023). One study of over 450 breast cancer survivors in Germany found that over 30% of women reported financial problems (Dayan et al., 2023). According to an analysis of national health insurance data, roughly half of all working cancer patients lose their jobs after receiving a cancer diagnosis, and only about 40% of cancer patients are reemployed (Choi et al., 2007). In another study, nearly half of breast cancer survivors reported financial decline due to treatment-related costs (Tangka et al., 2020). Some of the reasons cancer patients are unable to return to work or have difficulty at work include age, the type of job and its demands, chemotherapy and treatment effects, as well as other potential comorbidities and the overall health status of the individual (American Cancer Society, 2019; Park et al., 2008; Tamminga et al., 2019). Overall, a cancer diagnosis puts individuals at risk for poor employment outcomes, including job loss and its related consequences such as bankruptcy (Blinder & Gany, 2020). Finally, employment provides not only financial stability and healthcare benefits but also psychosocial benefits, such as a potential sense of identity, purpose, and belonging (Blinder & Gany, 2020; Thissen et al., 2023; Weston et al., 2021). Such psychosocial losses also impact the meaning that breast cancer survivors attribute to their illness.

We propose that financial stability and career status moderate the association between illness characteristics and meaning making. While ambiguous loss has not been applied in the specific context of financial and career status for breast cancer patients and has not been empirically tested specifically in this context, theoretically, it is clear that this is an important area for future research. The ambiguity and lack of clarity of whether a cancer patient will be able to build a career, continue with their job, or retire (thinking across the lifespan) may interact with illness characteristics (disease progression, age of disease onset, treatment type, symptom severity, etc.) to impact the meanings assigned by breast cancer survivors to their experiences.

Empirical testing of the mid-range model

Mid-range theories play an informative and bridging role between raw empirical observations and grand theoretical schemes (Kislov et al., 2019). Researchers have empirically tested the relationship between illness characteristics and quality of life, highlighting that greater symptom distress (e.g., fatigue, pain) is associated with lower quality of life among breast cancer survivors (Heidrich et al., 2006; Park et al., 2024). However, researchers could expand these findings by testing the potential mediating and moderating role of factors such as meaning-making, ambiguous loss, and experiences of stress related to sexuality, finances/career, and familial roles and obligations. Testing these associations with longitudinal data and designing and evaluating interventions intended to support breast cancer survivors in these areas would help to establish potential casual relationships, as well as provide insight into the strength and ordering of associations.

DISCUSSION

This mid-range model of quality of life in breast cancer survivors is grounded in the application of ambiguous loss theory. The associations between illness characteristics and quality of life in breast cancer survivors are well established, but the application of an ambiguous loss framework helps to further understand variability in women’s experiences of living with breast cancer via the process of meaning-making. Second, the subjective life experiences and factors such as familial support, intimacy and sexual losses, and financial and job/career status all moderate the association between illness characteristics and meaning making. This model has potential clinical implications in terms of helping survivors build positive and constructive meanings from their experiences, which has the potential to impact quality of life in breast cancer survivors.

Although these findings could be considered in a variety of clinical interventions, bereavement groups could provide a unique opportunity to address ambiguous loss. This model has been applied to the context of those who have lost a loved one to dementia. Researchers for this population have highlighted how group intervention can help individuals see that they are not alone in this experience, help provide normalization and a name for their experiences, and help individuals develop an adaptive meaning reconstruction of their experiences (Nathanson & Rogers, 2021). In Germany, social service counseling is integrated into cancer treatment to support patients in reintegrating into their everyday lives (Dayan et al., 2023) and in Turkey, women who participated in a sexual health counseling program that provided information and training on sexual health reported higher quality of life scores compared to women who did not participate (Olcer & Oskay, 2022). Systematic reviews have also shown that psychological interventions are associated with improvements in sexual functioning, sexual satisfaction, sexual relationships, and lower sexual distress among women with breast cancer (Xu et al., 2023). These psychosocial support services are essential for women navigating breast cancer and should be integrated into care services across the United States. Additionally, medical professionals, both in physical and psychological medicine, should be trained and aware of ambiguous loss so that they can look for signs and characteristics that a patient may be struggling with the uncertainty of their situation and offer solutions and resources. Physicians may not be equipped to understand or help manage the numerous and varied losses associated with breast cancer (e.g., body image, sexual, relational, work ability), even though such an understanding would be beneficial to the patient. Physicians should consider referring women to other services like counseling or support groups that can validate and provide support for the role that ambiguous loss is playing in women’s experience.

Previous research has highlighted that meaning making influences people’s well-being and quality of life and can be a crucial process when dealing with ambiguous loss; this mid-range model explores the connections between illness characteristics, individual and social characteristics, meaning making, and quality of life from an ambiguous loss perspective. Many individual and social characteristics have the potential to be modified via interventions, such as increasing familial support or providing financial planning or employment services for women with breast cancer. Acknowledging the ambiguity and uncertainty inherent in breast cancer may provide validation to women’s hardships, which can further promote resilience and survivorship outcomes. Supporting women through ambiguous losses (whether through support services, acknowledgment and validation from healthcare professionals, providing tangible resources to help buffer financial stressors or other supports) can help create positive meanings for breast cancer survivors to attribute to their experiences, which ultimately can improve quality of life.

Limitations

This mid-range model is not without limitations. First, a key assumption of ambiguous loss theory is that a phenomenon can exist even if it cannot be measured or quantified. While ambiguous loss theory has grown and expanded to many different situations, its application, measurement, and empirical testing need more work (Boss, 2007). Additionally, because ambiguous loss impacts the individual, couple, and family, measurement from the partner and other family members such as adult children, rather than just assessing ambiguous loss from the individual, would be informative (Boss, 2007). Family members may think they are being supportive, or the individual with cancer thinks that they are protecting their children, when in fact the other person views the situation differently (as unhelpful or as hiding information/lying to them). Such multifaceted and systemic perspectives should be explored and used to enhance the current model.

The largest limitation, but also the largest potential contribution, of the present mid-range model is that most of its proposed paths have not been tested empirically. Many of the proposed individual pathways, such as from specific illness characteristics to quality of life, have been demonstrated in research, but the overall model needs to be tested empirically using a research design and questions that explicitly utilize an ambiguous loss perspective.

Future directions

The current mid-range model is the first that examines how ambiguous loss theory can be applied in the context of predicting quality of life in breast cancer survivors. While ambiguous loss has been applied broadly to chronic illness (Boss & Couden, 2002), its application in breast cancer specifically would be beneficial. The ambiguous loss inventory (Comtesse et al., 2023), a measure of psychological reactions to the disappearance of a loved one, could examine whether existing measures of ambiguous loss work within the breast cancer context for both survivors and their loved ones, and empirically test this model. Future research should also apply ambiguous loss theory in the context of patient–provider communication for breast cancer survivors. Depending on the quality of communication and degree of support from physicians, clarity in prognosis, and the like, cancer survivors may experience different levels of ambiguous loss and assign different meanings to their illness and their experiences.

Relatedly, recent research indicates that individuals with cancer may have different perceptions of their prognosis compared to doctors (Gramling et al., 2016), and it could be beneficial to examine how these discordances influence quality of life from an ambiguous loss framework. As mentioned previously, cancer treatment has the potential to impact fertility, sexual functioning, and more, and patient–provider communication is an important factor for discussing realistic expectations for women (Sobota & Ozakinci, 2021). Poor patient–provider communication, from an ambiguous loss perspective, could mean more uncertainty and lack of clarity about these issues, which could greatly impact quality of life.

Additionally, future research could attempt to tease apart potential distinct influences of PAPP and PPPA on quality of life among breast cancer survivors, or whether these separate experiences necessitate separate interventions. It might be that physical losses are more or less amenable to solutions such as wigs or reconstructive surgeries, and such concrete tangible signs of loss might impact women differently than psychological challenges such as uncertainty about the future.

Lastly, future research could examine how ambiguous loss theory can be applied to medical decision-making, as according to ambiguous loss theory, ambiguity freezes the grieving process and prevents cognition, thus blocking decision-making processes (Boss, 1999). Future research that applies ambiguous loss theory also would be very beneficial for examining how women with breast cancer make decisions when experiencing ambiguous loss, for example, when selecting treatment plans or when assessing compliance with medical recommendations, which could have important implications for physicians and supportive services as well as the individuals themselves and their families.

Conclusion

Overall, women with breast cancer experience a series of hardships physically, psychologically, and socially that can drastically impact quality of life. This mid-range model uses theoretical constructs and propositions to guide a deeper understanding of the factors and processes that can influence quality of life for women with breast cancer and emphasizes the role that ambiguous loss plays. This model can help to inform a variety of perspectives, both clinical and research focused, ultimately aimed at improving quality of life among breast cancer survivors.

Funding information

Caroline Salafia is supported by National Cancer Institute & National Institute on Aging Grant/Award Number: T32CA009461; and acknowledges Memorial Sloan Kettering Cancer Center, Grant/Award Number: P30CA008748

Footnotes

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

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