This cross-sectional study was conducted on female patients who had received surgery for thyroid cancer at a university-affiliated oncology hospital in Beijing, China.

This study was conducted from 20th April 2023 to 20th October 2023, involving female thyroid cancer survivors. A convenience sampling method was adopted to recruit participants. Participants were included if they met the following criteria: (1) aged between 18 and 80 years old; (2) had undergone surgery for thyroid cancer; (3) possessed a device capable of accessing electronic questionnaires, such as a smartphone or tablet; and (4) voluntarily participated in the study and informed consent. Participants were excluded if they: (1) had a self-reported history of psychological disorders; (2) had severe cognitive impairment that could not guarantee the accuracy of the information; (3) suffered from other conditions that made them unfit to participate in the study, such as dyslexia, visual impairment, and disability; (4) withdrew during the survey or provided incomplete data. The sample size suggested for structural equation modeling (SEM) is that the ratio of the total sample size to parameters should be no less than 10:1 (Kline, 2015). Therefore, at least 490 cases were needed to test a model incorporating 49 free parameters in our study.

The online questionnaire method was adopted in this study to collect data. Throughout the study duration, the QR code for the digital questionnaire was sent to eligible postoperative female thyroid cancer patients and outpatient review participants via an electronic follow-up platform. The online questionnaire's homepage features study's purpose, procedures, risks, benefits, and confidentiality measures. The questionnaire submission is programmed to occur only after all questions have been answered.

Data management and analyses were carried out using SPSS 25.0 in this study. To provide an overview of participant characteristics, descriptive statistics was utilized, with categorical variables presented in frequencies, and continuous variables reported as means and standard deviation (SD). The difference of PTG levels among groups was tested by t-test or one-way ANOVA. Then, Pearson correlation analysis was performed to examine the relationships between perceived social support, psychological resilience, coping strategies, and PTG. To investigate the mediating roles of psychological resilience and coping strategies, AMOS 26.0 was employed for mediation model analysis. Indirect effects were determined through the bias-corrected bootstrapping procedure with 5,000 bootstrap samples. A mediating effect was deemed significant if the 95 % confidence interval (CI) of effect sizes did not span zero. The model's goodness of fit was assessed based on the following criteria: chi-square ratio to degrees of freedom (χ²/df) < 5.0, root mean square error of approximation (RMSEA) < 0.08, goodness-of-fit index (GFI) > 0.90, incremental fit index (IFI) > 0.90, Tucker-Lewis index (TLI) > 0.90, and comparative fit index (CFI) > 0.90 (Wu, 2010). A two-tailed p-value < 0.05 was regarded as statistically significant.

The study was approved by the Ethics Committee of National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (Approved Number: 23/543-4286). Informed consent was obtained electronically from all participants. Prior to data collection, participants were presented with a cover page detailing the study's purpose, procedures, risks, benefits, and confidentiality measures. They were explicitly informed that participation was voluntary and that they could withdraw at any time. Electronic consent was secured by requiring participants to select an “I agree” button after reading the information, affirming their voluntary and informed decision to participate. Only upon selecting this option did they proceed to the questionnaire.

A total of 635 female thyroid cancer survivors, with a mean age of 41.67 years (SD 10.83) (Table 1), were included in this study. Among them, 395 (62.2 %) were aged 18–44 years. Approximately half of the participants (n = 322, 50.7 %) were diagnosed in the past 6 months. Almost all participants (n = 626, 98.6 %) were diagnosed with thyroid papillary cancer. Five hundred and seventy-five (90.6 %) participants underwent their surgery once, of which 93.4 % (n = 537) were classified as stage I according to the 8th edition of the American Joint Committee on Cancer (AJCC) staging criteria for thyroid cancer.

The mean total score for perceived social support was 17.51 ± 5.29, with 261 (41.1 %) participants reporting low perceived social support. Psychological resilience had a mean total score of 19.67 ± 2.87 (Supplementary Table 2), with 57 (9.0 %) participants reporting low and 40 (6.3 %) reporting high psychological resilience. Regarding coping strategies, the mean total scores for problem-focused, emotion-focused, and avoidant coping strategies were 15.38 ± 3.94, 23.12 ± 5.66, and 20.95 ± 5.22, respectively (Supplementary Table 3). The mean total score for PTG was 28.66 ± 12.80, with the subscales scores ranging from 5.09 (spiritual change) to 6.15 (personal strength) (Supplementary Table 1).

The correlation analysis revealed that perceived social support was positively correlated with psychological resilience (r = 0.290, p < 0.001), problem-focused coping strategies (r = 0.570, p < 0.001), emotion-focused coping strategies (r = 0.549, p < 0.001), and PTG (r = 0.441, p < 0.001) (Table 2). Psychological resilience was also positively associated with problem-focused (r = 0.208, p < 0.001) and emotion-focused coping strategies (r = 0.244, p < 0.001) and PTG (r = 0.130, p < 0.01), while negatively associated with dysfunction coping strategies (r = −0.099, p < 0.05). Additionally, all three coping strategies were positively correlated with PTG (all p < 0.01).

As depicted in Figure 1, perceived social support emerged as a significant predictor of psychological resilience (p < 0.001), problem-focused coping strategies (β = 0.556, p < 0.001), emotion-focused coping strategies (β = 0.528, p < 0.01), avoidant coping strategies (β = 0.109, p < 0.05), and PTG (p < 0.001). Moreover, psychological resilience was found to exert a significant positive influence on emotion-focused coping strategies (β = 0.109, p < 0.01) while negative influence on avoidant coping strategies (β = −0.108, p < 0.05), which in turn positively predicted PTG (p < 0.05). However, the direct effect of psychological resilience on PTG was not statistically significant (p > 0.05).

Figure 1 presents the mediating models examing the relationship between perceived social support and PTG, all of which showed acceptable model fit (Table 3). The bootstrap analysis of mediating effects indicated that perceived social support significantly predicted PTG, with total effects of 0.451 (95 %CI 0.368–0.526) in Model 1, 0.457 (95 % CI 0.375–0.532) in Model 2, and 0.452 (95 % CI 0.370–0.528) in Model 3 (Table 4), thus supporting hypothesis 1. Specifically, the direct effects of perceived social support on PTG were 0.251 (95 % CI 0.142–0.353) in Model 1, 0.312 (95 % CI 0.207–0.412) in Model 2, and 0.440 (95 % CI 0.354–0.523) in Model 3. Additionally, the results revealed that psychological resilience and coping strategies partially mediate the effect of perceived social support on PTG, with the total indirect effects being 0.200 (95 % CI 0.136–0.271) in Model 1, 0.145 (95 % CI 0.087–0.212) in Model 2, and 0.012 (95 % CI −0.015–0.040) in Model 3. This included a single mediating pathway from perceived social support to problem-focused/emotion-focused/avoidant coping strategies to PTG (indirect effect size of 0.197 in Model 1, 0.141 in Model 2, and 0.009 in Model 3, hypothesis 3), and a chain mediating pathway from perceived social support to psychological resilience to emotion-focused/avoidant coping strategies to PTG (indirect effect size of 0.008 in Model 2 and −0.003 in Model 3, hypothesis 4). The bootstrap 95 % CI did not include zero for the above two indirect effects, confirming that the above two mediating effects were significant (p < 0.05). However, the mediation pathway from perceived social support to psychological resilience to PTG was not significant in any of the models (p > 0.05), leading to the rejection of hypothesis 2.

PTG has been extensively studied in cancer patients and survivors, demonstrating its contribution to improved quality of life. However, the research into PTG in female thyroid cancer survivors has been relatively limited. This study addressed this gap by examining the status and the underlying mechanisms of PTG in female thyroid cancer survivors. The findings revealed that female thyroid cancer survivors had an average PTG score of 28.66 ± 12.80, which was directly influenced by perceived social support and indirectly influenced through both single mediating effects involving problem-focused/emotion focused/avoidant coping strategies and a chain mediating effect involving psychological resilience and emotion focused/avoidant coping strategies.

The findings of the present study underscore the significant role of perceived social support in predicting PTG among female thyroid cancer survivors. This aligns with prior research conducted on patients and survivors of other types of cancers, such as breast cancer and colorectal cancer (Dong et al., 2017; Ofei et al., 2023). Perceived social support impacts PTG in multiple ways. Firstly, external social support creates a supportive environment that encourages open communication and cognitive reappraisal and provides fresh perspectives (Mah et al., 2024), ultimately promoting individuals into deliberate rumination and fostering PTG (Tedeschi and Calhoun, 2004). Additionally, perceived social support can indirectly influence PTG by serving as a buffer against distress (Cohen and Wills, 1985). Specifically, when cancer patients encounter stress or challenges, perceived support from the community can bolster them, thereby attenuating the adverse impact of such stressors on their mental wellbeing (Applebaum et al., 2014; Haugland et al., 2016). Therefore, ensuring adequate social support for female thyroid cancer survivors, particularly during their diagnosis and treatment journey, plays a pivotal role in fostering their PTG.

This study revealed that coping strategies played a significant mediating role in the relationship between perceived social support and PTG in female thyroid cancer survivors. This result was partially supported by a recent systematic review which identified social support as a predictor of coping strategies among cancer patients (Bottaro et al., 2023). Moreover, coping strategies have been highlighted as pivotal in the original growth model proposed by Tedeschi and Calhoun for the development of PTG (Tedeschi and Calhoun, 2004). Collectively, it could be inferred that perceived social support may influence PTG through coping strategies in female thyroid cancer survivors. This can be reasoned as follows: perceived social support from family, friends, healthcare professionals, and other sources may encourage patients to adopt positive and effective coping strategies to navigate the challenges and stresses inherent in cancer treatment (Calderon et al., 2021; Mishra and Saranath, 2019), such as seeking support, acquiring information, and regulating emotions. By utilizing positive coping strategies, patients can more effectively navigate the challenges and impacts of their illness, fostering personal growth and development while facilitating the progression of PTG. Notably, a longitudinal study has shown the enduring effects of positive coping strategies on PTG in breast cancer survivors 6 months and 2 years post-surgery (Hamama-Raz et al., 2019). Consequently, coping strategy training emerges as a promising intervention to enhance PTG among female thyroid cancer survivors.

A novel finding of the present study was the identification of a chain mediating role played by psychological resilience and emotion-focused/avoidant coping strategies in the relationship between perceived social support and PTG among female thyroid cancer survivors. However, psychological resilience did not exhibit a direct significant mediating effect between social support and PTG. This suggests that while psychological resilience serves as an essential internal resource when confronting trauma, it facilitates PTG primarily through indirect pathways, specifically by empowering individuals to adopt more adaptive and proactive coping strategies such as seeking social support and engaging in positive reappraisal. This may be explained by the treatment cycle of thyroid cancer. Generally, thyroid cancer treatment involves a relatively short clinical course but distinct and prolonged psychological stressors, patients may become particularly dependent on their selected coping mechanisms during the early post-operative adjustment phase, while psychological resilience provides the internal foundation and support for the adaptive behaviors. Therefore, clinical interventions should aim not only to strengthen psychological resilience, but also to provide specific coping strategies tailored to address issues such as body image and fertility-related distress.

Additionally, it is important to acknowledge that existing research has reported mixed results regarding the direction of the relationship between psychological resilience and coping strategies. For example, in alignment with our findings, a previous study showed that resilience level directly and indirectly predicted PTG or post-traumatic symptoms among cancer patients, with different coping strategies as mediators (Gori et al., 2021). Conversely, a recent study among Korean female cancer patients suggested that problem-focused coping strategies might bolster resilience, consequently fostering PTG (Choi et al., 2023). Hence, further research is warranted to explore the causal relationship between psychological resilience and coping strategies. Nonetheless, the chain mediating model uncovered in our study contributes to the development of interventions aimed at enhancing PTG in female thyroid cancer survivors, and potentially benefiting other cancer patients and survivors as well.

Given the significant impact of perceived social support on PTG among female thyroid cancer survivors, healthcare professionals should recognize its crucial role and help individuals access tailored resources to address their specific needs. These resources may include support from partners, empathy, family caregiving, and information provision (Korotkin et al., 2019), all of which contribute to improved mental wellbeing and overall quality of life. In particular, regarding information provision, healthcare providers should not only supply disease-related knowledge, treatment options, and side-effect management guidance, but also offer early fertility counseling to reduce reproductive anxieties (Benedict et al., 2020; Wang et al., 2021), thereby promoting PTG. In addition, incorporating psychological resilience training, such as cognitive-behavioral therapy and mindfulness practices aiming to enhance acceptance of bodily changes resulting from treatment (e.g., surgical scars or hormone therapy), could also aid patients in effectively managing stress and trauma. Similarly, implementing coping strategy training programs offers another viable pathway to foster PTG. For example, expressive arts (e.g., painting or body mapping) can facilitate the processing of negative emotions, while practical skills workshops (e.g., clothing coordination techniques) can assist in scar camouflage, both contributing to the development of PTG.

To the best of our knowledge, this study represents the first exploration of the chain mediating role of psychological resilience and coping strategies between perceived social support and PTG in female thyroid cancer survivors. The encouraging findings from this study shed light on the underlying mechanisms by which perceived social support influences PTG in female thyroid cancer survivors. Furthermore, this study particularly focuses on female thyroid cancer survivors to enhance the accuracy of the research conclusions, considering the differences in coping mechanisms and psychological adjustment between males and females (Hasan et al., 2022). The findings from this study may also have broader applicability to other female cancer patient cohorts.

Nevertheless, it should be noted that this study also has several limitations. First, the use of an online survey to collect data may introduce selective bias in the sample and result in lower response rates, as only those with internet access could participate. Second, the study sample comprised solely female thyroid cancer survivors, which may limit the generalizability of the findings to male thyroid cancer survivors, who have been reported to experience lower levels of PTG compared to females (Powroznik et al., 2018). Third, the chain mediation model was developed using cross-sectional data, the nature of which limited our ability to establish causality between perceived social support, psychological resilience, coping strategies, and PTG. Future studies are recommended to use longitudinal designs to ascertain the causality between variables to validate our results and provide a comprehensive understanding and insights for enhancing PTG in female thyroid cancer survivors.