“Don’t be a hero, don’t keep it a secret”: understanding the lived experience of Chinese American patients with cancer through their expressive writing entries

Abstract

Purpose

Cancer is the leading cause of death for Chinese Americans, and research on optimal psychosocial interventions is scarce. Understanding the specific experiences of Chinese Americans with cancer is essential for developing supportive interventions.

This study is a qualitative analysis of patient narratives collected from an Expressive Helping intervention, obtained from Chinese Americans with cancer to explore their experiences and meaning making of their cancer diagnosis and treatment journeys.

Methods

Thirty-one participants completed four 20-min writing sessions related to their cancer experiences. Informed by the Common-Sense Model of illness self-regulation, we used iterative, blended deductive-inductive coding and conducted a thematic analysis to explore meaning making, illness perception/narrative, and peer-helping recommendations.

Results

Significant themes were identified at the intrapersonal, interpersonal, and organizational/community levels. Participants felt initial disbelief and distress at the cancer diagnosis, which were attenuated through reframing of their experiences and finding support from various sources. Participants were also worried about burdening their families with their diagnosis but subsequently came to appreciate their support. They described challenges with navigating the healthcare system but appreciated having access to trusted providers and modern medicine. Patients also provided advice to support other patients on their cancer journey.

Conclusion

Understanding the factors that influence the mental health of patients with cancer and survivors is key to informing responsive supportive strategies. Our analysis of expressive writing narratives by Chinese Americans with cancer illuminates their unique challenges and myriad ways they find resilience and acceptance.

Background

More than two million new cancer cases were projected for 2025 in the United States of America (USA), with over 618,000 cancer-related deaths. Cancer disproportionately affects older adults, with nearly nine in ten diagnoses occurring among individuals aged 50 years and older, and almost 60% among those aged 65 years and above [1]. Cancer imposes significant burdens on the aging USA population, requiring patients to navigate the complexities of diagnosis, treatment, and survivorship [2]. This experience can amplify mental health challenges, often overlooked in traditional cancer care pathways [3]. Older adults with cancer frequently experience significant psychological distress, with one study reporting a 15% prevalence of depressive symptoms, which are linked to poorer physical functioning, reduced quality of life, and increased mortality [4]. Although psychosocial interventions, such as support groups, have demonstrated a positive impact on mental health outcomes [5, 6], they frequently fail to consider the unique needs of immigrant communities, including Asian Americans [7].

Asian Americans, the fastest-growing immigrant group in the USA [8], constitute about 7% of the population, or approximately 25 million people [9]. Cancer is the leading cause of death in this population, with cases expected to increase by 132% by 2050 [10]. This diverse group encompasses East Asians, South Asians, and Southeast Asians, each with unique genetic profiles, sociocultural histories, and environmental exposures that shape their cancer risk [11]. Overall, Asian Americans have lower 5-year cancer survival compared to White individuals [12]. Various factors influence cancer disparities within Asian American communities. Sociodemographic challenges, such as limited English proficiency, social deprivation, and cancer-related fears, may hinder access to healthcare and preventative services [13]. Consequently, cancer screening rates are generally lower in Asian American groups compared to their White counterparts, increasing the risk of late-stage cancer diagnoses [14–16]. While understanding general cancer disparities among Asian Americans is crucial, delving into the specific experiences of subgroups is essential for tailoring interventions that address unique cultural and social nuances.

Research specifically focused on the cancer-care experiences of Chinese Americans is limited, particularly how they make meaning of the illness [7]. To address this gap, our study applies the Common-Sense Model (CSM) of illness self-regulation [17], a widely used framework for understanding illness perception and the process of meaning making. According to the CSM, illness perceptions shape coping responses and predict downstream outcomes including treatment adherence, psychological distress, and quality of life [18]. For many Chinese American immigrants, meaning making and illness beliefs are deeply rooted in social contexts, such as cultural norms, fear and prejudice, health literacy, and language proficiency [19, 20]. Understanding these dynamics is critical to improving survivorship and quality of life for this understudied group and extending the benefits of their experiences to broader communities.

The current study analyzes writing narratives from an Expressive Helping intervention [21]. Expressive Helping combines traditional expressive writing (i.e., emotional disclosure over writing) with a session of peer helping writing [22]. Immigrant Chinese American patients may be more hesitant to share distressing emotions and thoughts about cancer through in-person interviews due to cultural norms for emotion suppression [23, 24]. Moreover, interviews may be inaccessible due to limited English proficiency (LEP) of the participants. As such, this study leverages writing entries collected from a trial of Expressive Helping of Chinese Americans with cancer and LEP in New York City to characterize their lived experiences and potentially inform responsive interventions.

Methods

Sample and recruitment

Data for the present study were obtained from Chinese American LEP cancer survivors from the metropolitan New York area who were recruited for an Expressive Helping intervention study [21]. Thirty-one participants were recruited through community-based organizations and small provider practices, online advertisements posted on social media, and advertisements in Chinese-language newspapers. Inclusion criteria were as follows: (1) self-reported being of Chinese descent; (2) 18 years or older; (3) comfort with reading and writing in Chinese; and (4) self-reported diagnosis of cancer (any type). Participants completed four 20-min brief structured writing sessions online via Qualtrics, in a convenient time and place of their choosing, in Chinese, over 4 consecutive weeks. Sessions 1–3 prompted participants to write about their feelings and thoughts regarding their cancer experience, including coping strategies, any potential positive thoughts and feelings they may have experienced, and how cancer may have impacted their lives. Session 4 focused on peer helping, in which participants shared their cancer experience and provided encouragements and advice, with the knowledge that their narratives will be shared with and used as a resource for other Chinese patients and survivors. Exemplar language from the writing prompts includes: “The first three weeks of writing is designed to help us understand your experiences and to help you get ready to write the story you would share with other Chinese individuals. On the fourth week, you will be asked to write a letter to another Chinese cancer patient who have been recently diagnosed with cancer”; “Please write about how you have coped with the stress from your cancer diagnosis and treatment, and your future plans for coping with cancer-related stress”; and “Please write about your deepest feelings and thoughts regarding your experience with cancer and the cancer’s impact on your life.” Each writing session page displayed the writing prompt and a 20-min countdown timer. To ensure that participants wrote for the full duration, the “Next Page” button was programmed to remain hidden until the timer expired. However, participants could continue writing beyond 20 min if they wished. In anticipation of the possibility that participants could experience emotional distress, writing submissions were reviewed by members of the research team, and procedures were in place to provide participants with appropriate mental health resources if any concerning content emerged. No adverse events were reported by participants during the study, and at no point did we need to initiate outreach related to participant distress. The study was approved by the New York University Institutional Review Board (IRB). Informed consent was obtained from all participants.

Qualitative analysis

Writing entries were translated to English by bilingual research staff and reviewed by the senior author (WT) for accuracy and cultural equivalence. Transcripts were then coded and analyzed using Dedoose [25], an online collaborative mixed methods analysis tool. The coding team consisted of two faculty (WT, VN); one post-doctoral fellow (PC); three graduate research assistants (AM, MM, WE); and two project managers (JK, VF). We conducted a thematic analysis [26] to identify emergent trends and patterns of association to explore meaning making [27] and illness perception/narrative [18]. We used iterative, blended deductive-inductive coding; we followed these steps to ensure trustworthiness and rigor of our analytical process: (a) we developed an a priori codebook consisting of common domains of cancer experience (e.g., meaning making in the context of cancer; treatment experience; mental health impacts; barriers and challenges; coping strategies); (b) we all reviewed journal entries from two participants to pilot and refine the initial codebook; (c) paired coders coded a set of two transcripts to determine inter-rater concordance (72 to 93.8%, mean of 82.2%) during the training period; (d) all remaining transcripts were coded by at least two coders; (e) we added emerging codes from the open coding process to the codebook until we reached code saturation; and (f) we held weekly team meetings to debrief code application, maintain an audit trail, and resolve discrepancies through consensus. After coding was completed, we continued our weekly meetings to identify and refine emergent themes, by exploring patterns and associations across codes.

Results

Participant characteristics

Table 1 reports participants’ characteristics (n = 31). The average age was 56.93 years (SD = 13.53), approximately 52% were female, all but one were born outside the US, and the average time in the USA was 15 years. More than half (51.6%) of participants only speak Chinese and 42% speak Chinese better than English; only 6.5% speak both languages equally. Most participants (80.7%) had an income below $75,000.

Table 1.

Sociodemographic information and medical characteristics

Variables	N (%)/mean (SD)
Age	56.93 (13.53)
Gender
Female	16 (51.6%)
Male	15 (48.4%)
Marital status
Married	22 (71%)
Single	1 (3.2%)
Divorced/separated	6 (19.4%)
Widowed	2 (6.5%)
Education level
Less than high school	8 (25.8%)
High school	10 (32.3%)
Some college	8 (25.8%)
College degree	2 (6.5%)
Post-graduate degree	2 (6.5%)
Missing	1 (3.2%)
Annual household income
< $15,000	12 (38.7%)
$15,001–$45,000	10 (32.3%)
$45,001–$75,000	3 (9.7%)
> $75,001	2 (6.5%)
Missing	4 (12.9%)
Born in the United States of America
Yes	0 (0%)
No	31 (100%)
Caregiver(s) of participant
None identified	5 (16.1%)
Spouse and other family members	6 (19.4%)
Other family members	7 (22.6%)
Spouse only	11 (35.5%)
Friends	2 (6.5%)
Lives with
Alone	5 (16.1%)
Spouse only	9 (29%)
Child(ren) only	8 (25.8%)
Spouse and their child(ren)	7 (22.6%)
Spouse, child(ren), and extended family	2 (6.5%)
Cancer type
Breast	12 (38.7%)
Lymph	2 (6.5%)
Esophagus	1 (3.2%)
Kidney	1 (3.2%)
Lung	4 (12.9%)
Prostate	2 (6.5%)
Stomach	1 (3.2%)
Liver	4 (12.9%)
Colon	1 (3.2%)
Bile duct	1 (3.2%)
Uterine	1 (3.2%)
Missing	1 (3.2%)
Cancer stage
0–I	12 (38.7%)
II	5 (16.1%)
III	4 (12.9%)
IV	8 (25.8%)
Missing	2 (6.5%)
Month since diagnosis	36.97 (34.37)
English proficiency
Only Chinese	16 (51.6%)
Chinese better than English	13 (41.9%)
Both equally	2 (6.5%)
English better than Chinese	0 (0%)
Only English	0 (0%)

For cancer-related characteristics, the most common cancer type was breast (38.7%), followed by lung (12.9%) and liver cancer (12.9%). The number of months since diagnosis varied across participants, with an average of 37.68 months (SD = 34.78) and a range from 0 to 134 months.

Overview of themes

Guided by the CSM of illness self-regulation [17], we examined how the writing narratives illustrated illness perception and meaning making of cancer across intrapersonal, interpersonal, and organizational/community levels. While participants shared that their initial diagnoses resulted in disbelief, denial, and worry, meaning making through the reframing of their experience and finding support helped transform their cancer journey. Themes demonstrate that distress associated with the initial diagnosis can be mitigated by various factors, such as spirituality; support of family, friends, other patients, and religious community; and trust in their physicians and the healthcare system, demonstrating how the “meaning making process” [28] can help patients accept their diagnosis and build resilience. Participants also provided advice to help other patients on their cancer journey. The main themes and subthemes across intrapersonal, interpersonal, and organizational/community levels are summarized in Table 2.

Table 2.

Summary of themes and subthemes organized by level

Level	Themes	Subthemes
Intrapersonal	Disbelief and denial	Shock at diagnosis; fear of death; stigma and being perceived differently
	Acceptance and resilience	Reframing cancer (chronic, controllable); self-efficacy; becoming a “little expert”
	Role of spirituality	Trust in God; feeling protected; finding meaning through faith
Interpersonal	Family and friends: burden and support	Fear of burdening family; disruptions in roles; emotional and practical support
	Support from other patients with cancer	Modeling coping; sharing experiences; practical advice
	Faith-based organizations and communities	Church activities; prayer; food and visits; reduced isolation
Organizational/community	Health system navigation challenges	Conflicting opinions; complex workup; language barriers; delays
	Appreciation for modern medicine	Trust in care; US health system as safety net; gratitude for technology
	Peer helping: consolidating the journey and sharing support	Encouragement; advice on disclosure and coping; normalizing distress

Intrapersonal level: illness representations within the self

Disbelief and denial

Participants wrote of their initial experience of disbelief and denial about their diagnosis, accompanied with fear and anxiety.

I didn’t believe it when the doctor first told me the results of the test. Because I didn’t have any symptoms, I always feel good about myself, but the reality is harsh, and my family and I have to face it. (776)

My onset was in June 2016. I didn’t want to admit that I’m a breast cancer patient. But every time I remind myself that I am a patient. (103)

Others expressed worry about being perceived differently because of the cancer diagnosis.

Most people believe that if you have cancer you will die, and if you don’t die, you will be like the living dead. They feel inferior and everyone dislikes them. So when I learned that I had liver cancer, a panic of terror struck me. (353)

Later, I began to feel fear and fear, fear of death, fear of losing family members, fear of side effects and harm caused by all treatments, especially fear of hair loss after chemotherapy, fear of strange eyes of family and friends around me, etc. (691)

Acceptance and resilience

However, most participants expressed that once they were able to make the transition to acceptance, they found comfort through reframing cancer from being a “death sentence” to being a “chronic disease that can be controlled.” Many patients wrote that they developed this resilience through their own self-efficacy, learning about the disease, becoming a “little expert,” and shifting their mindset.

It is unacceptable at the moment when the doctor says that you have cancer. But you must comfort yourself, don’t be afraid, cancer is a chronic disease, as long as you have confidence, you don’t have to be afraid of anything. (202)

At the beginning, when I saw the word cancer, I skipped it and didn’t dare to look at it. Now I am a little expert. I will read a lot of cancer cases and news about cancer. I know that cancer is not incurable now as many scientists are constantly working hard to invent the latest medicine to help us cancer patients for a better life and improve our quality of life. (365)

Role of spirituality

Participants’ faith and trust in God were also noted as sources of strength, healing, and hope in their writings.

I walked into the church and prayed to God to free me from everything. My heart has never been weak, and my sense of trust is to put everything down and trust God to give me the best arrangement. (359)

During my illness, I experienced God’s love and healing for me, which made me truly feel the existence of God. At that time, the doctor told me that my illness could not be cured and that I only had about two or three weeks left. Without God’s healing, my life would have ceased to exist. (519)

Interpersonal level: how relationships shape illness perceptions

Friends and family: burden and social support

Participants tended to be concerned about how cancer will impact their relationships and their roles within their families.

The main situation is that my wife can’t work because of my illness and she must take care of me at home, and my biggest regret is that my child had to drop out of college, after being half-way through, because of my sickness my child cannot go to school. (696)

My family and personal work were significantly impacted after I get sick. For example, being unable to do housework, cooking at home and going out to the supermarket to shop are all major limitations. (366)

Several participants also wrote about the difficulties of coping with a cancer diagnosis alone in the US, away from relatives in their home country.

Yet everything has changed. I have to deal with medical treatment alone in the United States, without the company of relatives, no one care take care of me, and I have to do everything by myself. (723)

I was told that it was kidney cancer. I didn’t know what to do at the time, because my relatives all returned to Beijing, China, and I was the only one in the United States. I couldn’t find anyone to discuss it. (201)

Relationships with friends and family were also among the most important sources of comfort and encouragement. Participants wrote that family was key to helping them accept the disease and providing a reason to be resilient.

Since my illness, my family and friends have given a lot of support and encouragement. With them, I can let go of my inferiority complex, bravely make friends, and share my sorrows and joys with them. (365)

Only with the support of family members can we face the facts and accept treatment, and the encouragement of family members during the treatment process is also indispensable. (776)

Social support from other patients with cancer

Developing relationships with other patients with cancer provided practical help and support. One participant described her fear of starting chemotherapy until she met another Chinese woman with gastric cancer and witnessed the grace with which she endured chemotherapy, which relieved her fear.

When I first started chemotherapy I thought it was very scary and thought that its side effects would definitely make me live in pure misery, until I met a Shanghai girl in her early twenties with stage 4 gastric cancer. She was so graceful. Unbelievable, if she didn’t say, I really wouldn’t know that she was undergoing chemotherapy. She is wearing a wig, and her mental outlook completely overturned my imagination of cancer and chemotherapy. She is a pianist and is still performing abroad during chemotherapy. Seeing her, I felt relieved. No longer feel fear of chemotherapy. (106)

I met some new friends, people who had the same cancer diagnosis as me. I was provided with some of the experience of the people who came over, and very practical help. (207)

Support from faith-based organizations and faith communities

Support from church friends provided a meaningful source of encouragement and comfort for participants, either through prayer, providing food after surgery, or sharing their cancer experiences.

I went to church for the following few weeks, and then I shared my story with my friends in the church. They all gave me a lot of encouragement and introduced me to the church sister who have the same experience as mine, and let me share the experiences of fighting cancer with her together. It’s been a long time since I had eye contact with others. I have always avoided the gaze from others this year. I always wanted to hide myself. I can finally look at each other and express my thoughts. I feel really comfortable. (365)

During this period, the brothers and sisters in the church would pray for me or join me. This brings me a lot of support and comfort, knowing that I am not alone. Thank you, God, for facing the operation and recovery process with me. Many people would bring me food during my recuperation, come to see us, and encourage us. (207)

One participant also noted that church activities provided relief from overthinking and anxiety.

Fortunately, I am already 58 years old, because there is a church that can accept me to go to their senior center, where I can spend a few days in the morning there and not need to stay at home and overthink. In addition, in the church, there are tutor classes to help students, and I also go there to do volunteer work, so that my life is a little more fulfilled, and not be idle, waiting for death every day drives me crazy. (683)

Trust in doctors and the healthcare system

Some participants wrote about finding comfort from deference to doctors, as well as their perceived “prestige” or “authority.” Furthermore, participants’ trust in their providers helped to ease their worries and anxieties. Participants described that the transition from disbelief and denial to acceptance was driven by detailed explanation and comfort from their providers or treatment teams.

From the early days when I was diagnosed with breast cancer, I was under tremendous pressure and suffering. Because I didn’t understand a lot of information about this disease. Later, after the doctor’s explanation, instructions, and clarification, I started to have a little understanding of the disease, and I was not so afraid because I was in a very early stage. (109)

At that time, the surgeon decided to transfer me to the oncology department. The Chinese-speaking doctor explained in detail the condition, how it formed and developed, and the treatment methods and procedures. At the same time, allowed me to accept the diagnosis and treatment of psychiatrists and psychologists to relieve my psychological pressure. (359)

Organizational and community levels: how systems and institutions shape perceptions

Health systems: navigation challenges and appreciation for modern medicine

The complexity of navigating the US healthcare system was expressed in detail in several participants’ entries. One common logistical challenge was not receiving comprehensive or sufficient health information, especially during the diagnosis and treatment periods. These challenges occurred when patients did not understand the information because of the lack of language access and translation, carried mistrust for the providers, received varying opinions across different providers, or interrupted navigation to services and appointments that led to gaps in care, delays, and misdiagnoses.

The countless examinations after that really made me exhausted physically and mentally, because the different opinions of the doctors did put me under a lot of pressure. Some doctors said it was esophageal cancer and needed chemotherapy before surgery. Some doctors are not sure whether it is cancer or not, so they have done a lot of scans, gastroscopy, colonoscopy, plus coronary heart disease, and also performed heart stent surgery. (108)

However, having access to “modern medicine” was also seen as a comfort to many participants.

If you are diagnosed with cancer, it’s no big deal, because the United States’ medical technology is very advanced and it will cure you, and the U.S. system does not give up anyone, regardless of your social status. Don’t worry about money. (696)

Fortunately, after more than three years of treatment and regular check-ups, everything is fine. This is also the greatest comfort to me. I am really glad to be alive and get to do some things within my capacity. I also want to thank the advancement of modern medicine. (108)

Peer helping: how participants consolidated their cancer journey and shared support

Some participants used the pronouns “we” and “us” to share encouragement and practical advice. Many participants encouraged patients to share their diagnosis with their families. Some participants specifically recommended seeking professional mental health support.

I believe that many cancer patients, like me, suffer not only physically, but also psychological pressure. So, I think we all need some professional psychological counseling. We all need comfort and encouragement. Hope someone can listen to our inner pain. What we have experienced simply cannot keep people optimistic. Our body is too fragile. How can we not be mentally affected. (105)

I think the first step in fighting cancer is not to treat it, but to accept it. Only after you have bravely accepted that you are a cancer patient, then can you actively cooperate with various treatments, and only then can your body recover better. Therefore, to bravely accept reality is the first step to successfully fighting cancer. When diagnosed with cancer, everyone is very anxious and wants to cure the cancer as soon as possible. Therefore, after the cancer is diagnosed, carefully cooperating with doctors for treatment and necessary examinations is what needs to be done to fight cancer successfully. (521)

I think my personal experience in dealing with ordeal is that you need to have courage to tell your family member who might have been exposed to this disease the truth. To educate them the reality of what it might happen. But be positive in dealing with cancer. Chinese family usually are very supportive in this matter. Also, seek help with extended family and friends. Don’t be a hero, don’t keep it a secret. Cancer is not a shame. (355)

Discussion

Guided by CSM, our analysis of writing narratives provided insight into the meaning making factors that negatively and positively impacted the cancer journey of Chinese Americans with cancer in NYC. Many of these themes—such as initial shock at diagnosis, the pivotal role of social support, the use of information seeking to regain a sense of control, and healthcare navigation challenges—are consistent with reports from broader cancer survivorship populations [29–32]. Our analysis extends this work by illustrating how these processes unfold within the specific sociocultural contexts of Chinese Americans with cancer.

At the individual level, the mental health distress reported after a cancer diagnosis mirrors themes of disbelief, distress, and fear of being perceived differently by their peers[33] documented in the Asian American cancer literature [34, 35]. The initial shock and despair were attenuated when patients learned more about their diagnosis and treatment, either through their doctor, their own research, or from other patients. These findings also align with the broader literature, showing that the greatest need among Chinese patients with cancer was information on cancer and treatment (79%) [36] and that higher levels of medical uncertainty were negatively related to mental well-being [37]. In addition, faith helped participants cope with their distress, which is consistent with the literature [35, 38].

At the interpersonal level, many patients struggled with the changes to their personal lives and their ability to work and fulfill family duties, and others with being separated geographically from family members. However, social support through family and friends, church communities, and fellow patients and survivors provided relief and built resilience. These findings corroborate multiple studies reporting that although Asian American patients faced difficulty discussing their cancer diagnosis and feelings, the support from other survivors, family members, and faith communities provided comfort and facilitated coping with the diagnosis [33, 35, 36, 39]. While many patients noted the cancer-induced stress of failing to perform their family duties, support from family was an important facilitator to accepting their diagnosis. This dichotomy was previously described for Asian American breast cancer patients, who adopted “self-sacrificing behaviors” to avoid disrupting family harmony [40]. Diagnosis or distress disclosure is commonly avoided by Asian Americans with cancer for fear of burdening their social networks [41, 42], yet it was not frequently mentioned in our study, perhaps due to the average length of time since diagnosis in our sample. Further, participants were describing their distress through expressive writing, which was shown to facilitate emotional disclosure among Asian Americans with cancer [42, 43]. Research also shows that disclosure is viewed more positively if it can lead to tangible or informational support [39, 41], which was echoed in our study.

Finally, at the organizational and community levels, while the logistical challenges of cancer treatments and conflicting physician opinions added to participants’ burden, many found relief in having access to modern medicine and the USA healthcare system. In contrast, many studies show that Asian American patients tend to favor and derive strength from traditional Chinese medicine [42, 44, 45]. This divergence underscores that Asian American patients can have diverse and multifaceted perspectives, which healthcare teams should acknowledge to deliver individualized care.

Peer-helping entries strongly emphasized encouragement and positivity, asserting that distress will ultimately convert to resilience. By drawing from their own meaning-making process, participants sought to reassure other patients that distress was temporary. To our knowledge, this is the first study to incorporate a peer-helping component to expressive writing exercises with Asian Americans; future studies should evaluate how written support from peers is perceived by patients navigating diagnosis and treatment.

Implications

This research contributes to the literature on illness perception and meaning making among Chinese Americans with cancer and can inform the development of tailored and meaningful tools and resources to support them through their cancer journey. An important step to improving the mental health of Chinese American cancer patients is providing accessible information that is in-language and culturally appropriate. Additionally, future initiatives to support Chinese American patients should include education to family and friends and collaborations with faith- and community-based organizations to facilitate interpersonal connections. Finally, these findings suggest that Chinese Americans with cancer may experience additional burdens, such as being disconnected from their familial social network, which may affect their distress and logistical burdens throughout treatment. Screening for health-related social needs and providing navigation support are evidence-based strategies associated with better treatment and survivorship outcomes, particularly for patients with LEP [46].

Limitations

This study has several limitations. First, our sample included Chinese Americans with cancer from NYC; therefore, findings are specific to the local NYC context and may not be generalizable. Second, it included participants with any type of cancer, which introduces heterogeneity in cancer-treatment journeys. Third, our findings were derived from writing sessions that were guided and semi-structured, prompting participants to focus on specific themes—including stress, coping strategies, and peer helping. Future research would benefit from open-ended interviews or focus groups to best reflect patient priorities and lived experiences. Relatedly, the timeframe from cancer diagnosis varied substantially across individuals, and their placement on the cancer continuum may have influenced their recall and responses, including the positive framing of themes in the peer-helping sections.

Conclusion

Understanding the factors that influence the mental health of patients with cancer and survivors is key to informing responsive supportive strategies. Our analysis of expressive writing entries by Chinese Americans with cancer provides insights into their specific challenges and the myriad ways they find acceptance and resilience. The observed transition to resilience, despite initial disbelief and fear of diagnosis, underscores the vital importance of targeted, culturally tailored interventions to empower patients throughout their cancer journey.

Author contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Perla Chebli, Julie Kranick, Melissa Mazor, Weanne Myrrh Estrada, Angel Mui, Victoria Foster, Simona Kwon, Victoria Ngo, Chau Trinh-Shevrin, and William Tsai. The first draft of the manuscript was written by Perla Chebli and Julie Kranick and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This work was conducted from October 2020 to January 2024 and funded by the Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services under Cooperative Agreement Number U48 DP006396. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by the Centers for Disease Control and Prevention, the Department of Health and Human Services, or the U.S. Government.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of the New York University (Approval date: 3/25/2019; Protocol #FY2019-2974).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare no competing interests.