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The Loss of a Spouse
Following an Oncological
Disease: A Scoping Review
Livia Sani
1
, Yasmine Chemrouk
1
,
Rozenn Le Berre
2
, Delphine Peyrat-Apicella
3
,
and Marie-Frédérique Bacqué
1
Abstract
Objective: Death from cancer is one of the most frequent worldwide and the
spouse is the person most at risk of potentially developing psychological conse-
quences. The following study aims to offer a scoping review of studies on people
who have lost their spouses to cancer and treatments that could be recommended
to prevent psychological consequences. Methods: The Preferred Reporting Items
for Systematic Review and Meta-Analyses guidelines were used to report the findings
of this review. Results: In total, 136 titles and 52 abstracts were selected. Of these
52 articles, 8 articles met all recommendations and inclusion criteria. Conclusions:
Although cancer remains a leading cause of death worldwide, the issue of bereaved
spouses following cancer remains understudied. Several notions and hypotheses
were endorsed, such as possible resistance to and difficulties in conducting research
on this kind of loss and with caregivers, the role of illness and postmortality in the
scientific landscape.
Keywords
cancer, caregiver, grief, spouse, scoping review
1Department of Clinical Psychology, University of Strasbourg, Strasbourg, France
2
Catholic University of Lille, Lille, France
3
Sorbonne Paris Nord University, Paris, France
Corresponding Author:
Livia Sani, Department of Clinical Psychology, University of Strasbourg, 12 rue Goethe–67000, Strasbourg,
France.
Email: lsani@unistra.fr
Original Articles
Illness, Crisis & Loss
1–22
© The Author(s) 2023
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/10541373231202471
journals.sagepub.com/home/icl
Background
According to the latest estimates published by the International Agency for Research
on Cancer (IARC), 18.1 million new cases of cancer were reportedly diagnosed world-
wide in 2018, and 9.6 million people died of cancer. It is estimated that today in
France, where this research was conducted, cancer is the first cause of mortality and
diagnoses amount to approximately 3.8 million, with over 382,000 new cases annually
(Le cancer en chiffres (France et monde)|Fondation ARC pour la recherche sur le
cancer,2022).
Cancer affects not only the patient but also the family. It is a disease that often lasts
several months or even several years and whose aggressive treatments weaken the
patient. The family is called upon to support and accompany the sick relative through-
out this ordeal, but will also have their own concerns raised by the disease.
Being a caregiver for a cancer patient means trying to help the patient as much as
possible. It makes the person a reference figure, the one who mainly provides moral
support, assists with the organization of the treatment path (such as accompanying
medical visits, management of medical and administrative records, etc.), and in the
management of daily life (meals, shopping, home maintenance and organization of
the day).
Therefore, a reorganization of the roles and functions of the various members may
well take place within the family. This new arrangement may also result in significant
fatigue and an increased risk of depression and anxiety for the caregiver during the
illness (Kang et al., 2020).
Generally and not only in the field of cancer, the spouse is the one most at risk of
developing various psychological disorders following the loss. These include
depression, anxiety, and complicated or prolonged grief disorder (Bacqué &
Baillet, 2009; Prolonged Grief Disorder, 2022). There is indeed a greater risk of
complications following the death of a spouse than, for example, the death of a
parent or grandparent (Fernández-Alcántara & Zech, 2017; Garrouste-Orgeas
et al., 2019; Prigerson et al., 2009). It can also be presumed that risks for the
bereaved spouse are also linked to the history of the couple and its internal
dynamics.
Factors related to the person’s life, personality, manner of death, communication
with the health care team and support received are also among the factors that can
influence possible complications (Fasse et al., 2013; Robbins-Welty et al., 2018;
Zech, 2019). Additionally, the risk increases with the age of the bereaved person
and with the presence of previous diagnoses of depression (Fasse et al., 2013), cardio-
vascular disease, and cognitive difficulties (Atalay & Staneva, 2020).
Starting from these notions, this article therefore aims to identify the recent litera-
ture on the psychological consequences for those who have lost their spouse following
an oncological disease.
According to several authors (Higgins et al., 2011; Martin et al., 2020; Yusop et al.,
2022), a literature review corresponds to an analysis that employs systematic and
2Illness, Crisis & Loss 0(0)
explicit methods to select and critically evaluate existing data on a specific topic.
It aims to present and summarize the information gathered from the different studies
in a logical, clear, and analytical way.
A systematic review by Fasse et al. (2014) had already highlighted how, out of 76
articles published from 2000 to 2013 on bereaved caregivers following an oncological
disease, only 20 (26%) specifically concerned the spouse. These articles focused on
involvement in a palliative care setting, the experience of being a caregiver, the char-
acteristics related to cancer or its treatments and the individual or social representations
of cancer (Fasse et al., 2014).
Therefore, it seems important to review the recent literature on knowledge about the
experience and psychological consequences on bereaved spouses in oncological con-
texts. Death from an oncological disease can be considered a different grief. It includes
traumatizing experiences, both for the patient and for the spouse. Some of these aspects
can be traced back to the diagnosis and the fear of death, to the change in the percep-
tion of one’s quality of life due to the treatments, and to the alternation between the
sense of hope and comfort experienced during the illness (Fasse et al., 2013; Tsai
et al., 2016).
It is expected that the method implemented in this review will be able to identify the
gaps and determine the future directions and needs that the research must fulfill in
order to be able to support this population psychologically. The aim is to try to identify
and then prevent the risks that can determine the development of pathological factors
in the bereaved spouse.
Starting from these reasons and notions, the authors identified the following
research questions:
•Q1. Is this topic of scientific interest?
•Q2. What does the latest research tell us?
•Q3. Are there any recommended psychological treatments?
Methodology
To respond to the research objectives, the authors decided to conduct a scoping review
according to the recommendations provided by the Preferred Reporting Items for
Systematic Review and Meta-Analyses (PRISMA) protocol (Gedda, 2015).
This modality was considered the most valid since the PRISMA method allows an
exhaustive review of all the literature published in the main databases.
According to Mengist et al. (2020), there are three phases that characterize the
PRISMA method: Identification, screening, and inclusion (Mengist et al., 2020).
After defining the research questions, the authors moved on to the identification
process. This procedure is used to improve the choice of the keywords used, increasing
the likelihood of receiving more relevant articles for review (Shaffril et al., 2021;
Yusop et al., 2022).
Sani et al. 3
Search Strategy
This scoping review used the following databases: PubMed, SciELO, Science Direct,
Cochrane, PsychInfo, Overview, and Google Scholar.
The keywords used for the selection were: spouse OR partner AND grief OR
bereavement OR mourning AND cancer OR oncology.
To minimize conclusion bias based on previous findings and those not relevant to
contemporary research, the selection period was limited to 2012–2023.
The searches were conducted from January to March 2023.
The research was conducted in English, the most widely used language in the sci-
entific landscape.
For each of the databases, the filters used were the keywords, the date of publica-
tion, the English language, and the wish to display only scientific articles (therefore
excluding periodicals, newspaper articles, and book chapters).
Eligibility Criteria
In addition to language, keywords, and publication dates, articles also had to include
the following criteria:
1. the studies had to be scientific articles;
2. articles had to appear in peer-reviewed journals;
3. they must not have to match other literature reviews;
4. they must not have involved any other type of caregiver except the bereaved
spouse;
5. the cause of death had to be related to an oncological diagnosis.
Study Selection
Regarding the selection method, two investigators (L.S., Y.C.) independently
reviewed titles and abstracts of potentially relevant articles in the databases indicated
above.
Next, working as a pair, the researchers reviewed all retrieved articles. They created
and shared an excel file containing the following information: Authors and Year of
publication, Title, Abstract, and name of the examiner who was the first to select
the article in the various databases.
This method also made it possible to exclude and count duplicates.
Both read and analyzed all the articles and expressed their disagreement, consent or
doubts in a column in the file.
In a consultative procedure, consensus on which items to screen was reached
through discussion.
Only articles considered relevant by both based on the criteria and objectives set out
above, were selected for final review.
4Illness, Crisis & Loss 0(0)
During the selection process, for many articles, it was not enough to read only the
abstract because it was unclear whether they focused exclusively on the bereaved
spouse or other caregivers as well. In addition, 20 literature reviews were also read,
to check if any new articles corresponding to the criteria had appeared during the
current research.
Ten articles proved difficult to find, so the reviewers tried to contact the authors
directly (via researchgate.com or email addresses).
After the selection process, the remaining articles were evaluated and analyzed.
Data Collection Process and Quality Assessment
Studies were evaluated using the Mixed Methods Appraisal Tool (MMAT)
(O’Cathain, 2010), a valid tool for evaluating quantitative, qualitative, and mixed
studies and recently successfully used in psycho-oncology reviews (Kuswanto et al.,
2018; Leung et al., 2020; Tavares et al., 2018).
The tool includes five types of studies: Qualitative research, randomized controlled
trials, nonrandomized studies, quantitative descriptive studies, and mixed methods
studies.
For each item the response categories were “yes”,“no”or “I can’t say”followed by
comments.
The degree of quality is indicated by the number of stars (*) in the tables.
No studies were excluded based on quality assessment, as all were of acceptable
quality.
Before the analysis, the researchers had to extract all relevant data from the selected
articles according to the study research questions. The retrieved data were organized in
a table to facilitate synthesis (see Table 1).
They covered the year of publication, country of origin, number and gender of par-
ticipants, purpose, methodology, research findings, and the MMAT appraisal.
The quality assessment was conducted by two authors (L.S., Y.C.) independently.
Inconsistency in the assessment scores was resolved through discussion.
Results
Study Selection
The PRISMA flow diagram of the study selection process is presented in Figure 1.
After going through the various phases that characterize the identification process, a
total of 1923 articles emerged from the various databases and through the previously
described selection filters.
At first 136 titles and then 52 abstracts were selected. From these 52 articles, 20
were discarded because they were literature reviews, 16 because they did not focus
exclusively on the bereaved spouse, 1 because it was about cancer and spouses but
Sani et al. 5
Table 1. Characteristics of Included Studies.
Author and year Sample Country Aim Type of analysis
Longitudinal
research Instruments
Time between data
collection and death
of the partner Results
Quality of
studies using
Mixed
Methods
Appraisal Tool
(MMAT)
Ásgeirsdóttir
et al. (2013)
691 bereaved
men
Sweden The aim was to
investigate the effect
of experiencing low
preparedness before
awife’s death to
cancer in 2000 and
2001 and the
widower’schronic
pain 4–5yearsafter
the loss.
Quantitative
research
No Hospital Anxiety and
Depression Scale,
and a study-specific
questionnaire of
three sections: (i)
the wife’sdisease
period and the
moments before
death; (ii) the six-
monthperiodafter
loss; and (iii) the
man’shealth
condition at the time
of the study.
4–5yearsafterthe
loss.
Younger widowers (38–
61 years) with a low
degree of
preparedness for
their wife’sdeathhad
a higher risk of
experiencing chronic
pain symptoms 4–5
years after the loss.
Widowers suffering
from chronic pain
were at increased risk
of psychological
morbidity
(depression, anxiety,
and sleep
disturbances).
***
Caserta et al.
(2013)
325 bereaved
spouses (200
women; 128
men). 112
spouses died
of cancer. 213
died of other
causes.
United States
of
America
To longitudinally
examine whether a
terminal prognosis
may provide
opportunities to
prepare for loss,
comparing the
outcomes of people
who lost their
spouses/partners of
cancer versus other
causes.
Quantitative
research
Yes The Texas Revised
Inventory of Grief—
Present Feelings, The
Geriatric
Depression Scale—
Short Form, UCLA
Loneliness Scale—
Short Form.
2–6months,5–9
months, 8–12
months, and 14–
18 months after
the loss.
The lowest levels of
depression, grief, and
loneliness over time
were among those
whose spouses/
partners died
expectedly from
causes other than
cancer. Cancer-
bereavement was as
equally distressing as
any unexpected
death.
**
Langenberg et al.
(2016)
58 bereaved
spouses (39
Netherlands The aim was to explore
partners’experience
of patients’
Quantitative
research
No A general questionnaire
designed about
socio-demographic
Between 6 months
and 2 years after
the loss.
Approximately two years
after the patients’
death, 19% of
***
(continued)
6
Table 1. (continued)
Author and year Sample Country Aim Type of analysis
Longitudinal
research Instruments
Time between data
collection and death
of the partner Results
Quality of
studies using
Mixed
Methods
Appraisal Tool
(MMAT)
women and
19 men).
participation in
phase I studies and
to investigate their
well-being after a
patient’sdeath.
informations and
details on a partner’s
experience during
the patient’s
participation in a
phase I study, the
Beck Depression
Inventory for
Primary Care, the
Hospital Anxiety and
Depression Scale,
the Traumatic Grief
Inventory, and the
RAND-36
Health Survey.
partners scored for
depression, 36% for
psychological distress,
and 46% for
complicated grief, and
partners generally
scored significantly
lower on social and
mental functioning
compared to
normative
comparators.
Madsen et al.
(2019)
10 bereaved
spouses (5
women and 5
men).
Denmark The present study
explores transition
experiences during
courses of incurable
cancer from the
perspective of
bereaved spouses.
Qualitative
research
No Phenomenological
hermeneutic
approach
4 months after the
loss.
Bereaved spouses
experienced
meaningful transitions
whenthelifeoftheir
loved one was ending
and related to
receiving palliative
care. Spouses were
challenged by
witnessing their loved
one’s suffering and
experienced a
deviationinthe
quality of professional
palliative care offered
in the system of
healthcare.
****
Reblin et al.
(2019)
58 hospice nurses
(51 women
United States The aim was to identify
the effects of hospice
Mixed research Yes Hospital Anxiety and
Depression Scale
2, 6, and 12 months
after the loss.
Caregivers had moderate
levels of depression at
(continued)
7
Table 1. (continued)
Author and year Sample Country Aim Type of analysis
Longitudinal
research Instruments
Time between data
collection and death
of the partner Results
Quality of
studies using
Mixed
Methods
Appraisal Tool
(MMAT)
and5men)
and 101
bereaved
spouses (60
women and
40 men).
of
America
nurse supportive
communication as
well as caregiver-
nurse exchange of
positive emotions on
family caregiver
depression during
bereavement.
Anxiety Subscale and
Geriatric
Depression Scale—
Short Form.
Content analysis
(Conversations were
coded using Roter
Interaction Analysis
System, RIAS).
study enrollment and
throughout
bereavement.
Multilevel modeling
revealed that
caregiver positive
emotion
communication and
nurse emotional
response
communication are
associated with
caregiver depression
in bereavement.
There was no
significant association
between caregiver
distress
communication and
depression in
bereavement.
Schellekens et al.
(2021)
11 bereaved
spouses (8
women and 3
men)
Netherlands The Aim was to gain
more insight into the
role of Mindfulness
in the dying and
grieving process
from the perspective
of the partner after
the patient’sdeath.
Qualitative
research
No Grounded theory On average 11
months after the
loss.
During the partners’
grieving process,
mindfulness helped
them allow difficult
thoughts and feelings,
and take the time to
grieve, which helped
them to take good
care of themselves,
giving them faith in
the future.
****
Van Hout et al.
(2020)
11 bereaved
spouses (7
Belgium The aim was to gain
more insight into the
Qualitative
research
No Phenomenological
approach
Between 3 and 12 All participants expressed
loss-oriented and
**
(continued)
8
Table 1. (continued)
Author and year Sample Country Aim Type of analysis
Longitudinal
research Instruments
Time between data
collection and death
of the partner Results
Quality of
studies using
Mixed
Methods
Appraisal Tool
(MMAT)
women and 4
men)
psychosocial well-
being of the recently
bereaved spouses
whotookcareof
their partners with
cancer.
months after the
loss.
restoration-oriented
coping strategies.
Also, loneliness is
considered a
dominant feeling
throughout the
bereavement period.
Social contact can
ease these feelings of
loneliness by
providing either
distraction or the
possibility to share
the burden.
Whisenant et al.
(2022)
8 bereaved
spouses (5
women and 3
men)
United States
of
America
The aim was to describe
the experience of
caregivers who have
lost a partner to a
central nervous
system tumor.
Qualitative
research
No Descriptive exploratory
analysis
Between2and9
months
following the
loss.
Bereaved partners of
patients with central
nervous system
tumors described
how difficult it was to
experience the
patient’shealth
decline and feeling
unprepared for the
patient’sdeath,no
matter whether they
had advance notice.
**
9
not about grief, 6 because they did not focus exclusively on cancer and spouses and 1
because it focused on oncological patients.
Finally, as the purpose of this study was to focus on people who have lost their
spouse to cancer, these studies were discarded and just 8 were found to meet all the
search criteria for this study, including one (Ásgeirsdóttir et al., 2013) which was
selected from a previous literature review (Nielsen et al., 2016).
Characteristics of Included Papers
As reported in Table 1, the selected articles were published from 2013 to 2022. They
were mainly conducted in Europe, in particular in Belgium (Van Hout et al., 2020),
Figure 1. Flowchart of the selection of articles according to Preferred Reporting Items for
Systematic Review and Meta-Analyses (PRISMA) guidelines.
10 Illness, Crisis & Loss 0(0)
Sweden (Ásgeirsdóttir et al., 2013), Holland (Langenberg et al., 2016; Schellekens
et al., 2021) and Denmark (Madsen et al., 2019). Three of the searches were conducted
in the United States (Caserta et al., 2013; Reblin et al., 2019; Whisenant et al., 2022).
With respect to the methodologies applied to each article, three studies carried out a
quantitative analysis (Ásgeirsdóttir et al., 2013; Caserta et al., 2013; Langenberg et al.,
2016), four a qualitative analysis (Madsen et al., 2019; Schellekens et al., 2021; Van
Hout et al., 2020; Whisenant et al., 2022), and one study had used a mixed method
(Reblin et al., 2019).
Out of the 8, only two studies were conducted longitudinally (Caserta et al., 2013;
Reblin et al., 2019).
Furthermore, the data collection time in the different studies ranges from a
minimum of 2 months to a maximum of five years following the death.
Results of the Quality Assessment
The methodological quality of the studies available on people who have lost their
spouse to cancer averages 55% (good quality), with a range between 40% and 80%.
The results of the MMAT are reported in Table 1.
There were no significant differences between the qualitative and quantitative
studies. The average methodological quality of the quantitative studies is 53.3%,
while that of the qualitative studies is 56%.
Quantitative Results
All quantitative articles, including the one based on a mixed methodology, used val-
idated scales to assess the risk of anxiety, depression, and grief disorders, through
the administration of the following questionnaires: The Texas Revised Inventory of
Grief (TRIG)—Present Feelings (Caserta et al., 2013; Faschingbauer, 1981), the
Geriatric Depression Scale—Short Form (Caserta et al., 2013; Reblin et al., 2019;
Yesavage & Sheikh, 1986), the UCLA Loneliness Scale—Short Form (Caserta
et al., 2013; Russell, 1996), the Beck Depression Inventory for Primary Care (BDI
—PC) (Bellis, 1999; Langenberg et al., 2016), the Hospital Anxiety and Depression
Scale (HADS) (Ásgeirsdóttir et al., 2013; Langenberg et al., 2016; Reblin et al.,
2019; Zigmond & Snaith, 1983), the Traumatic Grief Inventory (TGI) (Boelen
et al., 2003; Langenberg et al., 2016), the RAND-36 Health Survey (RAND-36)
(Langenberg et al., 2016; VanderZee et al., 1996).
Caserta et al. (2013) also investigated the dimension of the bereaved spouse’s per-
ception of loneliness (UCLA) while Langenberg et al. (2016) looked at general health
(RAND-36).
Out of four studies, two used the Geriatric Depression Scale—Short Form (Caserta
et al., 2013; Reblin et al., 2019; Yesavage & Sheikh, 1986) and three used the HADS
(Ásgeirsdóttir et al., 2013; Langenberg et al., 2016; Reblin et al., 2019; Zigmond &
Snaith, 1983).
Sani et al. 11
In addition to the indicated scales, Ásgeirsdóttir et al. (2013) and Langenberg et al.
(2016) administered questionnaires created by the authors and therefore not formally
validated. The questionnaire used by Ásgeirsdóttir et al. (2013) investigated possible
comorbidity between psychological disorders (such as anxiety and depression) and
chronic pain. The questions therefore did not exclusively include elements centered
on the psychological aspects but also related to physical health. The questions were
dichotomous (Yes/No) or to be indicated on a scale from 1 to 7. However, the
article did not report the percentages on which the results were based.
Concerning the article of Langenberg et al. (2016), the authors designed a question-
naire to obtain more information on socio-demographics and to take account of a
spouse’s experience during the patient’s participation in a phase I study, using a 3-
to 5-point Likert-type scale. The questionnaire also assessed changes in the spouse’s
personal situation due to the patient’s illness and treatment, the spouse’s experience
with the terminal phase and death and the personal situation after the loss (e.g.,
current marital status, housing, employment, and other major life events that occurred
during the previous year). Finally, according to the results, the participation of one’s
spouse in a phase I study could have significant consequences, such as depression
(19%), psychological distress (36%), and complicated grief (46%).
The study by Caserta et al. (2013) showed that even if death from cancer could be
considered predictable, those who lost a spouse to cancer had a higher risk of devel-
oping psychological disorders (depression and grief) and loneliness (34%).
The quantitative study by Ásgeirsdóttir et al. (2013), the only one conducted exclu-
sively on a single-gender population (men), suggested that poor preparedness for the
death of a wife may lead to a higher risk of chronic pain (particularly among young
widowers) and increased comorbidity with psychological symptoms, even 4–5 years
after the loss.
Finally, according to Reblin et al. (2019), communication and emotional expression
between the bereaved spouse (in the article called just “caregiver”) and the cancer
patient’s nurses during home hospice care may result in an increased risk of developing
a depressive disorder in the bereaved spouse up to one year after the death. However,
even in this study, the percentages on which the results were based were not reported.
Qualitative Results
As stated above, five articles used a qualitative analysis, one of which corresponds to
the mixed study by Reblin et al. (2019).
These researchers used the following analysis methodologies: Content analysis
(Reblin et al., 2019), grounded theory (Schellekens et al., 2021), a hermeneutic phe-
nomenological approach (Madsen et al., 2019; Van Hout et al., 2020) and descriptive
exploratory analysis (Whisenant et al., 2022).
Therefore, except for two studies that took a common phenomenological approach
(Madsen et al., 2019; Van Hout et al., 2020), the studies all used different qualitative
analysis methodologies.
12 Illness, Crisis & Loss 0(0)
As highlighted in the summary Table 2, it is possible to state that all five were
driven by similar objectives, namely to understand the process of acceptance, prepara-
tion for death, and the experience of mourning.
Table 2 shows the issues that emerged from the various studies from which it is pos-
sible to highlight common elements, in particular, the pain felt in seeing one’s spouse
deteriorate, shut down, and suffer (Madsen et al., 2019; Schellekens et al., 2021;
Whisenant et al., 2022).
Furthermore, in the study by Madsen et al. (2019), the aspect of the transition from
active care to palliative care stood out (also according to the research objectives).
Unlike the other articles, Van Hout et al. (2020) emphasized feelings of disbelief,
regret, and relief, needs relating to the social support of the bereaved spouse, and per-
ceived loneliness.
The study by Schellekens et al. (2021), focused on the role of mindfulness in the
mourning process from the point of view of the spouse after the loss. It highlights
how this approach helped both the dying patient and the grieving spouse to accept
the death and the mourning process and to communicate their fears and feelings.
Finally, the goal of the mixed study by Reblin et al. (2019) was to identify the
effects of hospice nurse supportive communication and the exchange of positive
emotions between spouses and nurses on family caregiver depression during
bereavement.
The meetings between the nurses and the bereaved spouses were recorded and sub-
sequently coded through content analysis. However, in addition to the quantitative data
regarding the frequency of the themes, the study does not report any citations, frag-
ments, or examples. The various themes expressed are also briefly described.
Discussion
The recent literature review on the loss of one’s spouse following a cancer diagnosis
resulted in the selection of only 8 articles, starting from a survey of 1923 articles.
To answer the first question of interest to this study, it is possible to state that this
issue is not yet totally the center of interest in the psychological scientific landscape—
even if the spouse is the figure most at risk of developing psychopathological conse-
quences (Bacqué & Baillet, 2009) and death from cancer is one of the highest causes of
mortality worldwide (Fernández-Alcántara & Zech, 2017; Garrouste-Orgeas et al.,
2019; Prigerson et al., 2009).
The previously cited article by Fasse et al. (2014) found that, from 2000 to 2013,
only 20 studies mainly concerned the grieving spouse. This systematic review was
conducted on only two search engines, namely PsycINFO and Medline.
Nonetheless, the number of their articles was significantly greater than that found
within this study.
One hypothesis is that this difference could be due to the wider use of keywords.
Fasse et al. did not include ‘spouse’or ‘partner’as keywords, but only terms that con-
cerned grief and cancer (Fasse et al., 2014).
Sani et al. 13
Table 2. Categories and Themes of Qualitative Studies.
Authors Categories Themes
Reblin et al.
(2019)
Positive emotion
Distress
Emotional response
Schellekens
et al. (2021)
Process of dying—as experienced
by patient, as perceived by
partner
Regulating thoughts and feelings
Accepting illness and forthcoming death
Wishing partner a good future
Process of dying—as experienced
by partner
Regulating thoughts and feelings
Accepting forthcoming loss
Taking care of patient
Trying to take care of oneself
Process of dying—mutual
process, as perceived by
partner
Enjoying life together
Communicating openly about
forthcoming death
Process of grieving of the partner Allowing thoughts and feelings
Letting go of the past
Feeling grateful for what has been
Taking care of oneself
Having faith in the future
Madsen et al.
(2019)
Being present when the life of
their loved one is ending
Challenged by suffering
Transitions during the final days
Moving on in life
Meaningful transitions in palliative
care
Changing direction toward palliative
care
Transitions in palliative care
Van Hout et al.
(2020)
The first moments of
bereavement
Grief in progress
Moving on in life
Whisenant et al.
(2022)
Caring for my partner Unrelenting focus on caretaking tasks
Relying on our faith
Being supported in caregiving
Maintaining hope
(continued)
14 Illness, Crisis & Loss 0(0)
Furthermore, according to our results, it also seems possible that over the last
10 years, the scientific literature has focused less on spouses’grief after death from
cancer.
As suggested by Fasse et al. (2014), the researchers and clinicians may be reluctant
to propose research focused exclusively on grieving spouses, out of a fear of destabi-
lizing them or fueling their pain following the loss.
This fear may have affected the results of the most recent literature review, thus
focusing the attention more on the patient or the situations that affect the patient
while he or she is still alive, rather than on the consequences that may develop follow-
ing his or her death.
Moreover, in recent years, arguments within the various research centers regarding
research ethics and the potential side effects of studies have become central, perhaps
making it more difficult to obtain the various approvals. This may have limited
research, also affecting researchers’choices of topic.
Additionally, another aspect taken into consideration to understand the limited
number of articles found on this subject corresponds to the age of the participants.
The average age of cancer deaths worldwide is 70 years (Cancer Death Rate by
Age Group, 2019). At the societal level, we are tempted to think that older people
have developed a resistance that makes them immune to the pain of loss since they
will have lost numerous people during their lifetime (Gilrane-McGarry & O’Grady,
2011). Therefore, it is possible that this aspect has also influenced the low interest
in the bereaved spouse’s experience following death.
On the other hand, to answer the second research question concerning the latest
ideas emerging on this topic, out of 8 studies, three focused on preparing for loss. It
is therefore possible that part of the scientific interest is aimed at trying to prevent pos-
sible discomfort and consequences for the grieving spouse. In particular, these issues
are examined in the quantitative studies of Ásgeirsdóttir et al. (2013) and Caserta et al.
(2013) and in the qualitative analysis by Whisenant et al. (2022).
Table 2. (continued)
Authors Categories Themes
Feeling well cared for by the health care
team
Separation from my partner Grieving my partner’s death
Experiencing my partner’s decline
Never being prepared
Continuing on without my
partner
Being alone
Having to take on new responsibilities
Reframing my life
Being supported in bereavement
Sani et al. 15
Ásgeirsdóttir et al. (2013) have shown that preparedness for the death of a sick
person can be a protective factor. Indeed, those who declared that they had not pre-
pared sufficiently were at risk of chronic pain and at increased risk of psychological
morbidity, such as depression, anxiety, and sleep disturbances, even 4–5 years after
death. Conversely, according to studies by Whisenant et al. (2022) and Caserta
et al. (2013), although death from a cancer diagnosis can be considered expected
and give the spouse time to prepare for the death (as opposed to death from unexpected
causes), the results highlighted the high risk of developing depression, grief disorders
and a strong sense of loneliness.
However, what does it mean to be prepared for the death of one’s spouse? On a psy-
chological level, despite a known poor prognosis, the activation of protective mecha-
nisms (such as avoidance, dissociation, and denial) is a biological reaction (Cramer,
2006). These mechanisms allow the individual’s ego to face up to and experience
the last moments with their spouse before the separation. It is also possible that the
concept of preparedness is not so pertinent when an oncological disease is involved.
The caregiver tends to take on the burden of managing the practical aspects of the
disease (e.g., accompanying the patient for treatment, contacting professionals, regu-
lating drugs, etc.), remaining totally in the here and now and in a more pragmatic
than an emotional sphere.
Another aspect, highlighted by Whisenant et al. (2022) and Madsen et al. (2019),
corresponds to the experience linked to illness and suffering from seeing one’s
spouse shut down, and therefore to the difficulties inherent in the end of life.
Information and data have also emerged relating to the bereaved spouse’s opinion
on health care, especially palliative care (Madsen et al., 2019), on the interaction
between the spouse and nurses, and how such communication can affect the conse-
quences of bereavement (Reblin et al., 2019).
However, only the articles by Madsen et al. (2019) and Reblin et al. (2019) con-
cerned palliative care.
Furthermore, Van Hout et al. (2020) are the only ones who attempted to investigate,
through qualitative analysis, the subjective experiences and psycho-social well-being
of the recently bereaved spouse. Their results highlighted loss-oriented and
recovery-oriented coping strategies, feelings of loneliness, and the importance of
social support.
Finally, as regards the third question and object of research, only one article out of 8
included the evaluation and validation of supportive therapeutic treatment for bereaved
spouses. Schellekens et al. (2021) showed the possible usefulness of the mindfulness
approach. Instead, all other studies focused on analyzing and understanding the griev-
ing spouse’s experience and risks.
Conclusion
The topic of cancer is changing the way we think about illness. Cancers are the dead-
liest diseases in Western countries and are often the leading cause of death in these
16 Illness, Crisis & Loss 0(0)
advanced nations (Le cancer en chiffres (France et monde)|Fondation ARC pour la
recherche sur le cancer, 2022). In terms of bereavement, cancer exposes spouses to
long-lasting stress (Bacqué & Baillet, 2009; Prolonged Grief Disorder, 2022). In addi-
tion, the anguish of watching one’s life spouse die is ambiguous. The husband or wife
may experience the vicarious trauma of cancer diagnosis, follow the effects of treat-
ment on their spouse, lose hope when the disease recurs, but rejoice when treatment
is successful. They oscillate between hope and despair. They alternate between widow-
hood and caring for a reduced, disabled, or dependent spouse.
Our results show that little attention is paid to the possible consequences for and
experiences of those who have lost their spouses to cancer between 2013 and 2023.
The main focus of interest seems to be the lived experience of spouses before the
death and how they experience the disease. It seems essential to prepare for the loss
of a spouse, not only in the case of loss, but also in the here and now of approaching
death. From this point of view, the indispensable preparation concerns communication
and the constellation of emotions and effects. These conditions can only be met if care-
givers are trained to identify the patient’s psychological difficulties, and not just the
practical aspects. This aspect opens an interesting debate about how bereavement
may be perceived and the resistance that may influence professionals’choices on
whether to conduct research on bereaved spouses.
It is therefore essential to broaden this scientific interest, from a multidisciplinary
perspective. Finally, it would be advisable to conduct further studies to evaluate pos-
sible supportive treatments useful in accompanying the spouse in working through
their grief.
Clinical Implications
On a clinical level, this study provides some useful indications of the psychological
support that needs to be provided to the patient’s spouse.
As evidenced by the results, it may be essential to work on preparedness for death.
However, it is important to work from the perspective of loss and on the here and now,
on communication and the emotional sphere. It would be important to try to strengthen
the role of the caregiver, centered exclusively on the practical aspects.
Furthermore, it would be advisable to train health and interdisciplinary profession-
als to accompany the spouse in this process, in order to avoid possible psychological
risks and consequences.
Study Limitations
It is possible that the limited number of studies on bereaved spouses is due to too-
selective a use of keywords. This may therefore have influenced the number of articles
that emerged from the different search engines.
Sani et al. 17
Finally, even if recognized as the most widely used language within the scientific
world, the exclusive use of the English language could be considered another
limitation.
Author Contributorship
All authors contributed to the conception and design of this article. L.S. and Y.C. collected,
screened all papers and interpreted the data. L.S., Y.C., R.L. and D.P-A. drafted the article
and revised it critically for important intellectual content. M-F.B. supervised the project. All
authors reviewed and approved the final manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/
or publication of this article: This work was supported by the Institut National Du Cancer (grant
number INCA_15908).
ORCID iDs
Livia Sani https://orcid.org/0000-0001-9283-8051
Yasmine Chemrouk https://orcid.org/0000-0001-7016-6426
Data Availability Statement
The data that support the findings of this study are available from the author upon reasonable
request.
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Author Biographies
Livia Sani is a clinical psychologist and researcher at the Department of Clinical
Psychology, University of Strasbourg, France. In clinical practice and research, her
main areas of work concern loss, death, and severe illness.
Yasmine Chemrouk, PhD, is a clinical psychologist. Since 2015, she has worked in
the field of psycho-oncology. Her main areas of interest concern serious illnesses,
accompaniment and support for patients and caregivers, work with healthcare
teams, and ethical issues, including the end of life.
Sani et al. 21
Rozenn Le Berre is a Doctor of Philosophy at the Center for Medical Ethics (EA 7446
ETHICS) at the Catholic University of Lille. Her interests include the experience of
bereavement from a philosophical and ethical perspective, narratives of serious
illness, clinical ethics interventions with health care professionals, and palliative
care training.
Delphine Peyrat-Apicella is a clinical psychologist and Doctor of Psychology at the
University Sorbonne Paris Nord (UTRPP - UR 4403). Her interests range from narra-
tives of serious illness to psychological issues of the care relationship at the end of life
and palliative care issues for health care professionals and psychologists in France.
Marie-Frédérique Bacqué is a French psychologist, professor of Psychopathology at
the University of Strasbourg, and psychoanalyst. She is interested in the psychopathol-
ogy of grief, the psychopathology of somatic patients (especially in psycho-oncology),
the assessment of psychoanalytic psychotherapies, and mentalization and projective
methods. She is the author of numerous national and international articles and
volumes, editor-in-chief of the Études Sur La Mort journal and member of the
Parental Bereavement Research in European Framework, International Psycho-
Oncology Society, International Center for Death Studies, and French Balint
Medical Society.
22 Illness, Crisis & Loss 0(0)
