From Loss to Meaning: Therapeutic Group Processes in Parental Grief After Pediatric Cancer From Pain to Meaning: Parental Grief After Pediatric Cancer

From Loss to Meaning: Therapeutic Group Processes in Parental Grief After Pediatric Cancer From Pain to Meaning: Parental Grief After Pediatric Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Loss to Meaning: Therapeutic Group Processes in Parental Grief After Pediatric Cancer From Pain to Meaning: Parental Grief After Pediatric Cancer Valeria Moriconi, María Rueda-Extremera, María Cantero-García This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8926237/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: The death of a child due to cancer constitutes one of the most devastating experiences for parents and is associated with profound emotional, relational, and existential consequences. Pediatric psycho-oncology highlights the need for interventions that go beyond symptom reduction and address grief as a complex process involving emotional expression, social connection, and meaning reconstruction. However, qualitative research exploring parents’ lived experiences of grief-focused group therapy remains limited. Objective: This study aimed to explore the impact of therapeutic group interventions on parental grief following the loss of a child to cancer, focusing on emotional adjustment, social adaptation, and processes of meaning-making. Additionally, it examined parents’ subjective perceptions of the group as a resource for grief elaboration. Method: A qualitative, descriptive-interpretative design was employed. Participants were parents who had attended grief-focused therapeutic groups after the death of a child due to pediatric cancer. Data were collected through focus groups and in-depth semi-structured interviews. A thematic analysis was conducted to identify shared categories and processes of meaning emerging from participants’ narratives. Results: The findings revealed interconnected processes, including a transformation from fear of emotional overwhelm to increased emotional tolerance, a reconceptualization of grief as a non-pathological and ongoing life process, and the reconstruction of the bond with the deceased child through symbolic continuity and legacy. The group emerged as a key therapeutic context characterized by mutual recognition, reciprocity, and sustained emotional support. Participation also facilitated social re-engagement, redefinition of life priorities, and greater existential coherence. Conclusions: Therapeutic group interventions represent a valuable clinical resource in pediatric psycho-oncology, fostering emotional integration, relational support, and meaning reconstruction in parental grief. These findings support the relevance of group-based approaches and underscore the need for further qualitative research and the development of structured intervention models. pediatric psycho-oncology focus group grief intervention Introduction Pediatric cancer remains a potentially life-threatening and highly stressful condition. Despite major therapeutic advances, the diagnosis entails a sustained perception of a vital threat that profoundly affects both the child and the family system (APA, 2023). This persistent threat, even in the absence of a fatal outcome, has been conceptualized as a potentially traumatic experience capable of eliciting intense stress responses and post-traumatic symptoms, particularly during the early phases following diagnosis (Klasjna et al., 2023;Jones et al., 2014). Within this framework, pediatric cancer is increasingly understood as a form of pediatric medical trauma, with significant and systemic psychological consequences for the child and the family as a whole (Barakat et al., 2000; Hoekstra-Weebers et al., 1998). Pediatric psycho-oncology has emerged in response to this complex constellation of psychological distress, chronic stress, and existential disruption that unfolds from diagnosis through treatment, follow-up, and, when applicable, palliative care and bereavement (Kupst & Patenaude, 2016; Kazak & Noll, 2015; Weaver et al., 2016; Jones et al., 2018; Efe et al., 2025). Over recent decades, this field has systematically documented the psychological, social, spiritual, and relational impact of childhood cancer and its treatment on patients, primary caregivers, and other family members (Patenaude & Kupst, 2005; Carlsson et al., 2019; Kazak & Noll, 2015; Long et al., 2018; Barrera et al., 2020; Ibrahim et al., 2025). Although many families demonstrate substantial resilience and achieve acceptable levels of adaptation, a significant proportion experience persistent emotional difficulties, including fear of recurrence, anxiety and depressive symptoms, disruptions in family functioning, and profound existential distress (Patenaude & Kupst, 2005; Kazak & Noll, 2015; Meert et al., 2015; Carlsson et al., 2019; Coughtrey et al., 2018; Ibrahim et al., 2025). From a classical perspective, psycho-oncology is conceptualized as a subspecialty integrating a psychosocial focus—addressing the emotional responses of patients, families, and healthcare professionals—with a biopsychosocial approach that examines psychological, behavioral, and social factors influencing cancer morbidity and mortality (Grassi et al , 2012; Carlsson et al., 2019). This dual orientation renders interdisciplinary and multidisciplinary collaboration a structural requirement for comprehensive and personalized care, encompassing systematic distress screening, evidence-based psychological interventions, and close coordination with medical treatment across the entire care continuum, from diagnosis to survivorship or end-of-life care (Kazak & Noll, 2015; Weaver et al., 2016; Jones et al., 2018; Efe et al., 2025). Within this context, parental bereavement following the death of a child from cancer represents one of the most extreme challenges in pediatric psycho-oncology. The loss of a child is associated with exceptionally high levels of suffering, profound disruptions in identity and meaning, and increased risk for prolonged grief, depression, and other mental health difficulties (Long & Marsland, 2011; Long et al., 2013). Importantly, this process often begins during advanced stages of illness through forms of anticipatory grief (Polita et al., 2020; Lichtenthal et al., 2015; Weaver et al., 2016; Pelacho-Ríos & Bernabé-Valero, 2023; Raguindin et al., 2025). Parents’ experiences are characterized by a dynamic process of meaning reconstruction, maintenance of continuing bonds with the deceased child, and efforts to re-engage with life, wherein vulnerability and potential for post-traumatic growth coexist (Grant et al., 2024; Kazak et al., 2006; Polita et al., 2020; Kim et al., 2025; Pelacho-Ríos & Bernabé-Valero, 2023; Raguindin et al., 2025). Despite advances in psychosocial and palliative care standards within pediatric oncology, the literature consistently highlights persistent unmet needs in parental bereavement care, as well as a scarcity of structured, rigorously evaluated interventions tailored to this population (Weaver et al., 2016; Jones et al., 2018; Pelacho-Ríos & Bernabé-Valero, 2022). Therapeutic groups, in particular, have been identified as a promising modality for providing validation, mutual support, and in-depth work on existential meaning-making (Hoekstra-Weebers et al., 2001). However, their systematic implementation and empirical evaluation in the context of parental grief following pediatric cancer remain limited (Kazak & Noll, 2015; Pelacho-Ríos & Bernabé-Valero, 2022). The present study aims to characterize the specific features of parental grief following the loss of a child to cancer and to examine the role of therapeutic groups as a privileged context for exploring the relational, emotional, and existential dynamics that shape this experience. By focusing on group processes and meaning reconstruction, this work seeks to contribute to the development of more precise, evidence-informed, and clinically sensitive intervention models for bereaved parents within pediatric psycho-oncology. Objectives From a qualitative perspective, the overall aim of this study is to explore and understand the lived experience of bereaved parents who participate in therapeutic groups following the loss of a child to pediatric onco-hematological disease. Specifically, the study pursues the following objectives: O1. To explore how parents describe the effects of group-based therapeutic work on their process of grief adaptation, emotional experience, and social functioning. O2. To understand the meaning parents attribute to the therapeutic group as a space for grief elaboration. O3. To examine the potential influence of sociodemographic variables on parents’ experiences and meaning-making processes within the group context. Method Design A qualitative study with an exploratory, descriptive–interpretative design was conducted. The study aimed to understand the subjective experience of parental grief and the meaning attributed to participation in therapeutic groups following the loss of a child (Barrera et al., 2012) Participants An experienced therapist specialized in psycho-oncology and grief contacted 50 parents who had previously participated in grief-focused therapeutic groups (Moriconi & Cantero-García, 2021). Of these, 41 were eligible for the study, while nine were excluded for the following reasons: (1) four discontinued the group during the initial sessions; (2) two returned to their country of origin and could not be contacted; and (3) two attended only a limited number of sessions, which did not allow the therapeutic process to be considered sufficiently completed for meaningful analysis. Among the 41 parents contacted, 30 agreed to attend the group meetings; two were unable to attend but participated through individual semi-structured interviews; six expressed interest in the study but were unable to participate in the meetings; two declined participation; and one could not be located. Inclusion criteria for participation in the therapeutic groups were: being a parent of a child who had died during pediatric age (up to 21 years) from an onco-hematological disease treated in a pediatric unit; the death having occurred between two months and one year prior to participation; agreement with group norms of acceptable conduct; motivation to engage in grief work; and not participating concurrently in other group-based psychological therapies. Exclusion criteria included: inability to tolerate the group setting; a tendency to assume a disruptive role within the group; non-compliance with group norms; severe incompatibility with one or more group members; and lack of motivation to engage in the therapeutic process. Procedure Participants were contacted approximately two months after the death of their child. During this initial contact, they were offered bereavement support in either individual or group format. Groups were formed based on a relatively homogeneous time frame since the loss, in order to facilitate mutual identification and emotional resonance among participants. Six therapeutic groups were established, each comprising between four and eight participants. Sessions lasted approximately 90 to 120 minutes. Prior to the beginning of the therapeutic process, all participants provided written informed consent, and sessions were audio-recorded to ensure accurate and rigorous collection of narrative data. The initial sessions focused on establishing the therapeutic framework and creating a sense of safety, encouraging personal introductions, sharing of loss experiences, and clarification of motivations and expectations regarding group participation. The therapist established basic group norms aimed at supporting the therapeutic process, fostering emotional containment, and promoting an atmosphere of respect and mutual support. Sessions followed a flexible structure, remaining open to themes emerging from group interactions. The facilitation style was initially active and containing, in order to promote cohesion and safety within the therapeutic field, and gradually became more facilitative as the group process evolved, allowing participants to take a central role in the shared elaboration of their experiences. A variety of therapeutic techniques were used as facilitators of the process, not as ends in themselves but as mediating tools for emotional expression, exploration of meaning, and integration of painful experiences. These interventions supported both intrapersonal awareness and interpersonal resonance, enabling participants to elaborate their loss through mutual recognition and shared meaning-making. Throughout the process, the individual rhythm of each participant and group was respected, acknowledging the inherent variability of grief processes. The intervention was grounded in a person-centered approach, accompanying each participant according to their needs, limits, and capacity for elaboration. Ethical approval The study received approval from the local Research Ethics Committee (ref. R-0043/22) and was conducted in accordance with the Declaration of Helsinki. Prior to inclusion, all participants provided written informed consent. Data Analysis Data were analyzed using a reflexive thematic analysis, following the framework proposed by Braun and Clarke (2006, 2019). This approach was selected for its suitability in exploring shared patterns of meaning across participants’ narratives while allowing for an interpretative, context-sensitive understanding of complex subjective experiences such as parental grief after pediatric cancer. The analysis adopted an inductive and interpretative orientation, with themes generated from the data rather than imposed a priori. At the same time, the process was theoretically informed by contemporary models of grief, including continuing bonds, meaning-making, and process-oriented conceptualizations of adaptation, which guided the interpretative sensitivity of the analysis without constraining category emergence. Audio-recorded focus groups and individual interviews were transcribed verbatim and analyzed as a single corpus, enabling integration of collective and individual perspectives. Initial familiarization involved repeated reading of the transcripts to gain an in-depth understanding of the emotional, relational, and existential dimensions of participants’ experiences. During this phase, preliminary notes were taken to capture first-order meanings, emotional tones, and recurrent experiential patterns. In the second phase, initial codes were generated across the entire dataset, focusing on explicit content as well as underlying meanings related to emotional processes, relational dynamics, and transformations in parents’ narratives over time. Coding was conducted in a flexible and iterative manner, allowing codes to evolve as new insights emerged. To support the organization, management, and retrieval of qualitative data during this process, the software NVivo (QSR International) was used as an analytic aid. The software facilitated systematic coding and comparison across the dataset but did not replace the interpretative work carried out by the researchers. Codes were then examined for conceptual convergence and organized into candidate themes representing broader patterns of shared meaning. These themes were reviewed and refined through an iterative process of constant comparison, ensuring internal coherence within themes and clear differentiation between them. Particular attention was paid to preserving the complexity and processual nature of grief, avoiding reductionist or pathologizing interpretations. Throughout the analytic process, reflexivity was actively maintained. Given the clinical background of the researchers and their involvement in therapeutic contexts, analytic decisions were critically examined to distinguish participants’ meanings from clinical assumptions. Regular discussions between the authors served to challenge interpretations, refine thematic boundaries, and enhance analytical rigor. To strengthen the credibility and trustworthiness of the findings, several strategies were employed, including methodological triangulation between focus groups and individual interviews, prolonged engagement with the data, and systematic use of participants’ verbatim quotations to ground interpretations in the empirical material. Sociodemographic variables were descriptively examined to contextualize participants’ experiences; however, the primary analytic focus remained on shared meaning-making processes rather than comparative subgroup analysis. The final thematic structure represents an interpretative synthesis of parents’ lived experiences, capturing both common trajectories and variability in grief processes as facilitated through participation in therapeutic groups Instruments Sociodemographic Questionnaire. A sociodemographic questionnaire was administered to collect information on participants’ sex, age, educational level, and occupation. Variables related to current family circumstances were also considered relevant, including changes in marital status, the presence of other children following the loss, and changes in health status. Information concerning the deceased child was gathered, including the child’s age at the time of death, diagnosis, and time elapsed since the child’s death. Additional information was collected across several domains in order to explore other factors relevant to understanding the phenomenon, as suggested by previous research. Specifically, the presence of other significant losses and participants’ prior therapeutic experiences were examined. Semi-Structured Interview . The semi-structured interview guide was organized into five thematic blocks corresponding to the main analytic clusters: (1) emotional expression, (2) adaptation and coping resources, (3) unresolved issues, (4) legacy, and (5) meaning and sense-making. For the two individual semi-structured interviews, an expanded interview guide was used to allow for deeper exploration of participants’ experiences. The interview format was open and dialogical, conducted in depth and structured around four types of questions: rapport-building questions, closed questions, explanatory questions, and elaborative questions, facilitating both narrative flow and analytic depth. Results The qualitative analysis of focus groups and in-depth interviews identified a set of meaning-making processes that describe how bereaved parents experience and elaborate the loss of a child through participation in therapeutic groups. These processes were organized into analytically derived categories and subcategories reflecting the core dimensions of the lived experience; an overview is provided in Table 1 . The identified categories are consistent with key axes of therapeutic work previously described in the literature (Moriconi & Cantero-García, 2021), particularly emotional expression, reconstruction of the bond with the deceased child, coping resources, and meaning-making. – Emotional expression and transformation of suffering Participants’ early narratives were characterized by profound mistrust in their ability to tolerate emotional pain. Parents described an intense fear of “stirring up” suffering, experienced as overwhelming and psychologically threatening: “At first I was afraid to come, I thought that if I started talking I would collapse and wouldn’t be able to get back up” (P7, mother); “I felt that opening all that up could be worse, like opening something I wouldn’t be able to close” (P12, father). As the group process progressed, a marked transformation emerged in the relationship with pain. Parents reported discovering that they could approach suffering without being destroyed by it, developing greater emotional tolerance and confidence in their own resources: “I realized I could touch the pain and not break. I left tired, but whole” (P4, mother); “Before I avoided thinking, now I know I can go there and come back. That gave me a lot of peace” (P19, father). – Grief as a non-pathological process and adaptation to absence Across narratives, grief was consistently reframed away from pathological models. Parents understood suffering as an inevitable and enduring consequence of losing a child—one that does not disappear but can become less intrusive in daily life: “This doesn’t get cured, it doesn’t go away. You learn to live with it, and that’s something else” (P9, mother); “I’m not ill for being sad; I’m living something that will always be with me” (P22, father). Adaptation was described as the capacity to coexist with absence without allowing pain to dominate all aspects of life: “The pain is there, but it no longer rules everything” (P15, mother); “There are good days and bad days, but not everything revolves around the loss anymore” (P30, father). – Reconstruction of the bond and the child’s legacy A central process involved the transformation of the bond with the deceased child. Parents described the child occupying an active symbolic place as an internal reference and existential guide, allowing memories to shift from being solely a source of pain to a sustaining presence: “I feel my child is still with me, not in the same way, but accompanying me differently” (P2, mother); “I often think about what he would do, how he was, and that guides me” (P18, father). Within this framework, the child’s legacy emerged as a core element of meaning-making: “Living well now is a way of honoring him, of making his life still meaningful” (P11, mother); “I don’t want his memory to be only pain; I want it to push me to be better” (P25, father). – The therapeutic group as a relational space The group was described as a privileged relational context for grief elaboration, characterized by mutual recognition and emotional validation. Participants emphasized being able to speak without needing to justify their suffering: “Here I don’t have to explain anything; everyone knows what I mean” (P6, mother); “Outside, people look at me strangely when I talk about my child; here they understand” (P14, father). Reciprocity—being able to help others and be helped in return—was identified as a key therapeutic factor that restored a sense of usefulness and value: “Helping other parents helped me more than I ever imagined” (P21, mother); “I felt that even after losing so much, I could still be of use” (P27, father). The group was also experienced as a support network that extended beyond the formal sessions: “Even if we don’t meet as often, I know they are there” (P1, mother); “The group doesn’t end when the session ends” (P16, father). – Reopening to the world and reorganization of life projects Group participation facilitated a gradual re-engagement with social life and everyday enjoyment. Parents described reconnecting socially and allowing themselves to experience positive emotions without guilt: “I started meeting friends again without feeling I was betraying my child” (P10, mother); “I could laugh again, and I no longer punished myself for it” (P29, father). Changes in employment and life direction were framed as part of a broader redefinition of values and priorities following the loss: “After all this, I didn’t want the same job anymore; I needed something with meaning” (P13, mother); “I lost my job, but I also lost my fear of starting again” (P24, father). – Transversal impact of grief on health and family life Narratives highlighted the pervasive impact of grief on both health and family relationships. Some parents described a weakening of the couple relationship linked to difficulties in accompanying one another through suffering: “Each of us grieved in our own way, and that slowly pulled us apart” (P8, mother); “We didn’t know how to support each other; we were both broken” (P20, father). A significant deterioration in physical and psychological health was also reported, often requiring professional support: “My body collapsed after my child died” (P5, mother); “I couldn’t sleep, I couldn’t eat, and in the end I had to ask for help” (P17, father). INSERT TABLE 1 Discussion The present study aimed, first, to explore the effects of group-based therapeutic work on grief adaptation, emotional functioning, and social adjustment in parents who had lost a child to pediatric cancer; second, to examine parents’ perceived usefulness of the group as a resource for grief elaboration; and finally, to analyze the potential influence of sociodemographic variables on the experience of loss. These objectives are situated within the field of pediatric psycho-oncology, understood—following Holland—as a subspecialty that “addresses the emotional responses of patients at all stages of the disease, of their families and of the healthcare professionals who care for them (psychosocial focus), and examines the psychological, behavioral, and social factors that influence cancer morbidity and mortality (biopsychosocial focus).” This dual perspective provides a clear rationale for the use of a group-based intervention capable of simultaneously addressing psychological suffering, relational dynamics, and functional adaptation in bereaved parents. Value of the Group Modality in Pediatric Psycho-Oncology The findings support the view that group intervention represents a particularly relevant therapeutic modality for parental grief, consistent with the assertion that pediatric psycho-oncology fundamentally revolves around the psychological suffering generated by the stressors and traumatic aspects of the disease and its treatment. In the present study, the group facilitated emotional integration, reconstruction of the bond with the deceased child, and a gradual re-engagement with social life, thereby operationalizing in clinical practice the interdisciplinary and multidisciplinary approach considered essential for comprehensive and personalized care of both patients and their families. These results align with international standards that advocate for structured, evidence-based psychosocial interventions across the entire continuum of pediatric oncology care, including parental bereavement (Wiener et al., 2021; Kearney et al., 2015; Coughtrey et al., 2018). Emotional Expression, Social Isolation, and Core Principles of Bereavement Care In line with the grief and group psychotherapy literature, emotional expression emerged as a central axis of the therapeutic process. Participants emphasized the importance of having a space in which they could openly express both the most painful and the most ambivalent aspects of their experience, empirically supporting the principle—outlined in the theoretical framework—that effective grief care involves normalizing grief reactions and facilitating the expression of emotions and thoughts. The group functioned as a counterbalance to the social isolation that frequently follows the death of a child after a prolonged oncological illness, an experience that often disrupts family life and leaves parents facing an overwhelming and disorienting void. These findings are consistent with reviews showing that verbalizing suffering within a safe relational context helps normalize emotional responses, reduce perceived loneliness, and promote more adaptive grief processing (Kochen et al., 2020; Hasdenteufel & Quintard, 2022; Coughtrey et al., 2018; Polita et al., 2020). Moreover, they reinforce clinical recommendations discouraging the routine use of psychotropic medication to “mask” the grief process, instead prioritizing evidence-based psychosocial interventions and reserving pharmacological treatment for cases of severe and persistent agitation or depression (Wiener et al., 2021; Kearney et al., 2015). Group Cohesion, Universality, and Mutual Aid: From Theory to Practice Sharing grief with others who had undergone similar experiences was identified as a key therapeutic factor. Group dynamics enabled individual distress to be held collectively, such that improvements in one member positively influenced the group as a whole. This phenomenon reflects the classical therapeutic factors of group psychotherapy—universality, cohesion, and mutual aid—and gives concrete clinical expression to the psychosocial dimension of psycho-oncology described by Holland. At the same time, it responds to the well-established notion that, while grief shares common elements across losses, the death of a child represents a uniquely devastating experience in which validation by peers carries particular significance. Grief as a Process, Bond Transformation, and Continuing Bonds Findings related to legacy and the bond with the deceased child directly align with the conceptualization of grief outlined in the theoretical framework. Grief was described as a dynamic process involving the progressive transformation of internal bonds—memories, representations, expectations, emotions, and meanings—linking the bereaved parent to the child. In this study, parents identified unconditional love as the core of their child’s legacy and described how, through group work, the bond was transformed into an active symbolic presence that continued to accompany and orient daily life. These results converge with contemporary grief models emphasizing continuing bonds as an adaptive process, diverging from classical models centered on detachment. In the specific context of pediatric cancer, where families often endure a prolonged illness that profoundly restructures relational life, symbolic continuity of the bond may serve as a pathway for integrating traumatic experience and reconstructing parental identity (Kochen et al., 2020; Schaefer et al., 2020; Polita et al., 2020). Meaning-Making, Existential Crisis, and Post-Traumatic Growth As anticipated, parental adaptation to the death of a child proved to be a highly complex process involving profound existential disruption. Not all parents achieved the same level of existential elaboration, and meaning-making emerged as less prominent than other domains, reflecting the non-linear and deeply individual nature of this process. The death of a child—culturally perceived as “unnatural”—often destabilizes fundamental assumptions about life, death, and priorities. When group participation facilitated a more integrated acceptance of death as part of existence and a gradual decoupling of death from extreme suffering, parents reported greater existential coherence and inner peace. This finding is consistent with literature linking meaning-making processes to post-traumatic growth and increased prosocial orientation (Kochen et al., 2020; Hasdenteufel & Quintard, 2022; Kentor & Kaplow, 2020; Xie et al., 2024). Engagement in volunteering or solidarity-based activities—described by several participants as a way of “feeling close” to their child—can thus be understood as a concrete articulation of legacy and reconstructed meaning. Coping Resources and Vicarious Learning With respect to coping resources, parents reported that group therapy enhanced emotional awareness and fostered a more nuanced understanding of their internal responses. Exposure to other parents’ narratives expanded their repertoire of coping strategies and normalized reactions that might otherwise have been experienced as inappropriate or incomprehensible. This vicarious learning reflects the behavioral dimension highlighted in Holland’s definition of psycho-oncology and aligns with recommendations for early and continuous psychosocial intervention in pediatric oncology care (Wiener et al., 2021; Kearney et al., 2015; Coughtrey et al., 2018; Carlsson et al., 2019). Unresolved Issues and Timing of Assessment The relatively limited prominence of unresolved issues contrasts with some previous findings. This discrepancy may be explained by the timing of assessment—conducted after completion of the group intervention—and by the emphasis on early psychological support and active emotional processing. It is plausible that emotions such as anger, guilt, or resentment had already been expressed, explored, and, in some cases, transformed through forgiveness or symbolic repair. This pattern suggests that therapeutic groups may play a specific role in reducing the emotional burden associated with unresolved issues, further supporting interventions that privilege experiential and relational processing over purely pharmacological approaches (Kochen et al., 2020; Smith et al., 2025; Moray et al., 2025). Sociodemographic Considerations and External Coherence The alignment between cancer diagnoses in the present sample and national pediatric cancer registry data supports the external coherence of the findings. Observed changes in marital status and parental health following the child’s death are consistent with evidence documenting elevated risks of relational strain and physical and mental health problems after such losses. Differences in grieving trajectories within couples further underscore the need for psycho-oncology programs to incorporate interventions specifically addressing couple dynamics and divergent coping styles during illness and bereavement (Kearney et al., 2015; Zhang et al., 2025; Carlsson et al., 2019; Polita et al., 2020). Limitations and Future Directions Several limitations warrant consideration. The specificity and homogeneity of the sample limit generalizability to other forms of bereavement. The qualitative design, while appropriate for capturing complexity, does not allow causal inference or effect size estimation. Additionally, the limited number of prior studies focused specifically on parental bereavement after pediatric cancer constrains systematic comparison. Nonetheless, the study offers relevant theoretical and clinical contributions. Conceptually, it integrates process-oriented models of grief with continuing bonds and meaning reconstruction within the specific context of pediatric cancer. Clinically, it provides qualitative evidence supporting the therapeutic potential of group interventions, consistent with Yalom’s assertion that “the group itself, together with specific techniques and skilled therapeutic interventions, serves as a powerful instrument of change.” Future research should prioritize: (a) controlled studies evaluating structured group interventions for bereaved parents; (b) deeper examination of the interplay between meaning-making and legacy as inseparable processes; and (c) the development of replicable, culturally sensitive group protocols aligned with international psychosocial care standards. Conclusions Parental grief following the death of a child remains a socially silenced experience that intensifies isolation and underscores the need for targeted interventions. Group psychotherapy emerges as a privileged relational space for addressing grief, connecting emotional expression with values, legacy, and continuing bonds. Through this process, families move from passive suffering to active engagement, transforming loss into shared meaning, resilience, and mutual support. Declarations Funding: Not applicable. Clinical trial number: not applicable. Approval committee: R-0043/22 Acknowledgements: The authors wish to express their sincere gratitude to the Aladina Foundation for its invaluable work in supporting children and adolescents with cancer and their families. The authors also wish to thank the mothers and fathers who entrusted them with their stories of love and loss. References Barakat, L. P., Kazak, A. E., Meadows, A. T., Casey, R., Meeske, K., & Stuber, M. L. (2000). Families surviving childhood cancer: A comparison of posttraumatic stress symptoms with families of healthy children. 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The integration of psychology in pediatric oncology research and practice: collaboration to improve care and outcomes for children and families. The American psychologist , 70 (2), 146–158. https://doi.org/10.1037/a0035695 Kazak, A. E., Kassam-Adams, N., Schneider, S., Zelikovsky, N., Alderfer, M. A., & Rourke, M. (2006). An integrative model of pediatric medical traumatic stress. Journal of pediatric psychology , 31 (4), 343–355. https://doi.org/10.1093/jpepsy/jsj054 Kearney, J., Salley, C., & Muriel, A. (2015). Standards of Psychosocial Care for Parents of Children With Cancer. Pediatric Blood & Cancer , 62. https://doi.org/10.1002/pbc.25761 Kentor, R., & Kaplow, J. (2020). Supporting children and adolescents following parental bereavement: guidance for health-care professionals.. The Lancet. Child & adolescent health , 4 12, 889-898. https://doi.org/10.1016/s2352-4642(20)30184-x Kochen, E., Jenken, F., Boelen, P., Deben, L., Fahner, J., Van Den Hoogen, A., Teunissen, S., Geleijns, K., & Kars, M. (2020). When a child dies: a systematic review of well-defined parent-focused bereavement interventions and their alignment with grief- and loss theories. BMC Palliative Care , 19. https://doi.org/10.1186/s12904-020-0529-z Kupst, M.J., Patenaude, A.F. (2016). Coping and Adaptation in Pediatric Cancer: Current Perspectives. In: Abrams, A., Muriel, A., Wiener, L. (eds) Pediatric Psychosocial Oncology: Textbook for Multidisciplinary Care. Springer, Cham. https://doi.org/10.1007/978-3-319-21374-3_5 Lichtenthal, W. G., Sweeney, C. R., Roberts, K. E., Corner, G. W., Donovan, L. A., Prigerson, H. G., & Wiener, L. (2015). Bereavement Follow-Up After the Death of a Child as a Standard of Care in Pediatric Oncology. Pediatric blood & cancer , 62 Suppl 5 (0), S834–S869. https://doi.org/10.1002/pbc.25700 Long, K. A., Marsland, A. L., & Alderfer, M. A. (2013). Cumulative family risk predicts sibling adjustment to childhood cancer. Cancer , 119 (13), 2503–2510. https://doi.org/10.1002/cncr.28077 Meert, K. L., Eggly, S., Kavanaugh, K., Berg, R. A., Wessel, D. L., Newth, C. J., Shanley, T. P., Harrison, R., Dalton, H., Dean, J. M., Doctor, A., Jenkins, T., & Park, C. L. (2015). Meaning making during parent-physician bereavement meetings after a child's death. Health psychology : official journal of the Division of Health Psychology, American Psychological Association , 34 (4), 453–461. https://doi.org/10.1037/hea0000153 Moray, İ., Çakır, B., & Kargı, A. (2025). Effectiveness of group therapy for prolonged grief symptoms: A systematic review and meta-analysis.. Death studies , 1-13. https://doi.org/10.1080/07481187.2025.2559725 Patenaude, A. F., & Kupst, M. J. (2005). Psychosocial functioning in pediatric cancer. Journal of pediatric psychology , 30 (1), 9–27. https://doi.org/10.1093/jpepsy/jsi012 Pelacho-Rios, L., Bernabe-Valero, G. The loss of a child, bereavement and the search for meaning: A systematic review of the most recent parental interventions. Curr Psychol 42, 25931–25956 (2023). https://doi.org/10.1007/s12144-022-03703-w Polita, N., deMontigny, F., Neris, R., Alvarenga, W., Silva-Rodrigues, F., Leite, A., & Nascimento, L. (2020). The Experiences of Bereaved Parents After the Loss of a Child to Cancer: A Qualitative Metasynthesis. Journal of Pediatric Oncology Nursing , 37, 444 - 457. https://doi.org/10.1177/1043454220944059 Schaefer, M., Wagoner, S., Young, M., Madan-Swain, A., Barnett, M., & Gray, W. (2020). Healing the hearts of bereaved parents: Impact of legacy artwork on grief in pediatric oncology.. Journal of pain and symptom management . https://doi.org/10.1016/j.jpainsymman.2020.04.018 Smith, K., Thew, G., Carr, S., Congrave, P., Rudge, S., & Thompson, E. (2025). Supporting those bereaved by cancer: a service evaluation and investigation of cognitive behavioural mechanisms in the treatment of prolonged grief. European Journal of Psychotraumatology , 16. https://doi.org/10.1080/20008066.2025.2545144 Weaver, M. S., Heinze, K. E., Bell, C. J., Wiener, L., Garee, A. M., Kelly, K. P., Casey, R. L., Watson, A., Hinds, P. S., & Pediatric Palliative Care Special Interest Group at Children’s National Health System (2016). Establishing psychosocial palliative care standards for children and adolescents with cancer and their families: An integrative review. Palliative medicine , 30 (3), 212–223. https://doi.org/10.1177/0269216315583446 Wiener, L., Barnett, M., Flowers, S., Fair, C., & Thompson, A. (2021). Evidence-Based Psychosocial Interventions in Pediatric Psycho-Oncology. Psycho-Oncology . https://doi.org/10.1093/med/9780190097653.003.0088 Zhang, Y., Zhang, Z., Peng, Y., Zhang, W., , G., Lin, S., Chan, C., Cheung, A., Xie, J., & Gu, C. (2025). Impact of technology- and parent-based psychosocial interventions on family dynamics factors in children with cancer: A systematic review. PLOS One , 20. https://doi.org/10.1371/journal.pone.0323483 Xie, J., Hunter, A., Biesty, L., & Grealish, A. (2024). The impact of midwife/nurse-led psychosocial interventions on parents experiencing perinatal bereavement: An integrative review.. International journal of nursing studies , 157, 104814. https://doi.org/10.1016/j.ijnurstu.2024.104814 Table Table 1. Analytical Categories and Subcategories Analytical Category Subcategories Analytical Description 1. Emotional transformation and grief adaptation 1.1. Initial fear of emotional overwhelm Fear of coming into contact with intense emotions associated with the loss and perception of insufficient internal resources to tolerate the pain. 1.2. Progressive confidence in emotional capacity Development of greater emotional tolerance through engaging with pain in a safe environment, fostering a sense of internal competence. 2. Re-signification of grief 2.1. Grief as a non-pathological life process Conceptualization of grief as a natural and enduring experience, distinct from pathology-centered clinical models. 2.2. Learning to live with absence Integration of pain into everyday life without allowing it to dominate the overall lived experience. 3. Reconstruction of the bond with the deceased child 3.1. The child as an active symbolic presence Transformation of the memory of the deceased child into an internal guiding reference and source of meaning. 3.2. Legacy as a vital driving force Living fully as a way of honoring the child’s life by integrating values, lessons, and existential commitments. 4. The therapeutic group as a relational device 4.1. Mutual recognition and emotional validation Experience of being understood without the need for explanation, grounded in identification with other bereaved parents. 4.2. Reciprocity and mutual support Therapeutic experience derived from helping and being helped, restoring a sense of personal usefulness. 4.3. The group as a sustained support network Perception of the group as a source of emotional support that extends beyond the formal boundaries of the sessions. 5. Life reorganization and reopening to the world 5.1. Overcoming social isolation Gradual return to social life, recovery of enjoyment, and reduction of guilt associated with well-being. 5.2. Redefinition of vocational and life projects Occupational and life changes interpreted as part of a reconfiguration of priorities following the loss. 6. Transversal impact of grief 6.1. Fragilization of the couple relationship Crisis of the conjugal project resulting from the cumulative impact of the child’s illness and death. 6.2. Deterioration of physical and psychological health Emergence or worsening of physical and psychological symptoms, highlighting the holistic nature of parental grief. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 May, 2026 Reviews received at journal 17 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviewers invited by journal 06 Apr, 2026 Editor assigned by journal 06 Apr, 2026 Submission checks completed at journal 02 Mar, 2026 First submitted to journal 20 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8926237","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619894039,"identity":"9aaba78a-77b5-4362-82bc-8d183036d65e","order_by":0,"name":"Valeria Moriconi","email":"","orcid":"","institution":"European University of Madrid","correspondingAuthor":false,"prefix":"","firstName":"Valeria","middleName":"","lastName":"Moriconi","suffix":""},{"id":619894043,"identity":"c3aaf446-39d3-46a7-b508-3e7e769d5504","order_by":1,"name":"María Rueda-Extremera","email":"","orcid":"","institution":"Universidad a Distancia de Madrid","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"","lastName":"Rueda-Extremera","suffix":""},{"id":619894046,"identity":"78046ca4-c451-4ad0-aabf-ea264c197200","order_by":2,"name":"María Cantero-García","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYJCCAyg8fhCRUECMFjYoT7IBpMWAGLtgWgzAJuDRott+9uGBHwx28ubyzcc+fPhll298fnXihwcGDPL8YgewajE7k25wsIch2XBnG1vyzJl9yZbbbrzdLAF0mOHM2QnYtRxIYzjAw3CAccMxHmNm3h5mA7MbZzeAtCQY3Mah5fwzhoN/GA7YbzjG/xmopd7AeMbZzT/warmRxnAYaEsi0BZmZp4fhw0M+Hu34bflxjOGwzIGyckbjqUZM85sOG4gcYN3m0WCgQRuv5xPY/74psLOdsPhw48ZPvypNuDvP7v55o8KG3l+aexaIAAWC4xtQEICrFICj3IU8AeI+Q8Qq3oUjIJRMApGCAAAIkRiVRTyw8UAAAAASUVORK5CYII=","orcid":"","institution":"Universidad a Distancia de Madrid","correspondingAuthor":true,"prefix":"","firstName":"María","middleName":"","lastName":"Cantero-García","suffix":""}],"badges":[],"createdAt":"2026-02-20 13:08:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8926237/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8926237/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106960861,"identity":"4b00f208-1d6e-471a-8af8-800a825bb30a","added_by":"auto","created_at":"2026-04-15 09:23:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1017450,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8926237/v1/37bf3be0-65f9-4aae-9db9-05a1fd578d58.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFrom Loss to Meaning: Therapeutic Group Processes in Parental Grief After Pediatric Cancer From Pain to Meaning: Parental Grief After Pediatric Cancer\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePediatric cancer remains a potentially life-threatening and highly stressful condition. Despite major therapeutic advances, the diagnosis entails a sustained perception of a vital threat that profoundly affects both the child and the family system (APA, 2023). This persistent threat, even in the absence of a fatal outcome, has been conceptualized as a potentially traumatic experience capable of eliciting intense stress responses and post-traumatic symptoms, particularly during the early phases following diagnosis (Klasjna et al., 2023;Jones et al., 2014). Within this framework, pediatric cancer is increasingly understood as a form of pediatric medical trauma, with significant and systemic psychological consequences for the child and the family as a whole (Barakat et al., 2000; Hoekstra-Weebers et al., 1998).\u003c/p\u003e\n\u003cp\u003ePediatric psycho-oncology has emerged in response to this complex constellation of psychological distress, chronic stress, and existential disruption that unfolds from diagnosis through treatment, follow-up, and, when applicable, palliative care and bereavement (Kupst \u0026amp; Patenaude, 2016; Kazak \u0026amp; Noll, 2015; Weaver et al., 2016; Jones et al., 2018; Efe et al., 2025). Over recent decades, this field has systematically documented the psychological, social, spiritual, and relational impact of childhood cancer and its treatment on patients, primary caregivers, and other family members (Patenaude \u0026amp; Kupst, 2005; Carlsson et al., 2019; Kazak \u0026amp; Noll, 2015; Long et al., 2018; Barrera et al., 2020; Ibrahim et al., 2025).\u003c/p\u003e\n\u003cp\u003eAlthough many families demonstrate substantial resilience and achieve acceptable levels of adaptation, a significant proportion experience persistent emotional difficulties, including fear of recurrence, anxiety and depressive symptoms, disruptions in family functioning, and profound existential distress (Patenaude \u0026amp; Kupst, 2005; Kazak \u0026amp; Noll, 2015; Meert et al., 2015; Carlsson et al., 2019; Coughtrey et al., 2018; Ibrahim et al., 2025). From a classical perspective, psycho-oncology is conceptualized as a subspecialty integrating a psychosocial focus\u0026mdash;addressing the emotional responses of patients, families, and healthcare professionals\u0026mdash;with a biopsychosocial approach that examines psychological, behavioral, and social factors influencing cancer morbidity and mortality (Grassi et al , 2012; Carlsson et al., 2019). This dual orientation renders interdisciplinary and multidisciplinary collaboration a structural requirement for comprehensive and personalized care, encompassing systematic distress screening, evidence-based psychological interventions, and close coordination with medical treatment across the entire care continuum, from diagnosis to survivorship or end-of-life care (Kazak \u0026amp; Noll, 2015; Weaver et al., 2016; Jones et al., 2018; Efe et al., 2025).\u003c/p\u003e\n\u003cp\u003eWithin this context, parental bereavement following the death of a child from cancer represents one of the most extreme challenges in pediatric psycho-oncology. The loss of a child is associated with exceptionally high levels of suffering, profound disruptions in identity and meaning, and increased risk for prolonged grief, depression, and other mental health difficulties (Long \u0026amp; Marsland, 2011;\u0026nbsp;Long et al., 2013).\u0026nbsp;Importantly, this process often begins during advanced stages of illness through forms of anticipatory grief (Polita et al., 2020; Lichtenthal et al., 2015; Weaver et al., 2016; Pelacho-R\u0026iacute;os \u0026amp; Bernab\u0026eacute;-Valero, 2023; Raguindin et al., 2025). Parents\u0026rsquo; experiences are characterized by a dynamic process of meaning reconstruction, maintenance of continuing bonds with the deceased child, and efforts to re-engage with life, wherein vulnerability and potential for post-traumatic growth coexist (Grant et al., 2024; Kazak et al., 2006; Polita et al., 2020; Kim et al., 2025; Pelacho-R\u0026iacute;os \u0026amp; Bernab\u0026eacute;-Valero, 2023; Raguindin et al., 2025).\u003c/p\u003e\n\u003cp\u003eDespite advances in psychosocial and palliative care standards within pediatric oncology, the literature consistently highlights persistent unmet needs in parental bereavement care, as well as a scarcity of structured, rigorously evaluated interventions tailored to this population (Weaver et al., 2016; Jones et al., 2018; Pelacho-R\u0026iacute;os \u0026amp; Bernab\u0026eacute;-Valero, 2022). Therapeutic groups, in particular, have been identified as a promising modality for providing validation, mutual support, and in-depth work on existential meaning-making (Hoekstra-Weebers et al., 2001). However, their systematic implementation and empirical evaluation in the context of parental grief following pediatric cancer remain limited (Kazak \u0026amp; Noll, 2015; Pelacho-R\u0026iacute;os \u0026amp; Bernab\u0026eacute;-Valero, 2022).\u003c/p\u003e\n\u003cp\u003eThe present study aims to characterize the specific features of parental grief following the loss of a child to cancer and to examine the role of therapeutic groups as a privileged context for exploring the relational, emotional, and existential dynamics that shape this experience. By focusing on group processes and meaning reconstruction, this work seeks to contribute to the development of more precise, evidence-informed, and clinically sensitive intervention models for bereaved parents within pediatric psycho-oncology.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObjectives\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFrom a qualitative perspective, the overall aim of this study is to explore and understand the lived experience of bereaved parents who participate in therapeutic groups following the loss of a child to pediatric onco-hematological disease. Specifically, the study pursues the following objectives: O1. To explore how parents describe the effects of group-based therapeutic work on their process of grief adaptation, emotional experience, and social functioning. O2. To understand the meaning parents attribute to the therapeutic group as a space for grief elaboration. O3. To examine the potential influence of sociodemographic variables on parents\u0026rsquo; experiences and meaning-making processes within the group context.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cem\u003eDesign\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative study with an exploratory, descriptive\u0026ndash;interpretative design was conducted. The study aimed to understand the subjective experience of parental grief and the meaning attributed to participation in therapeutic groups following the loss of a child (Barrera et al., 2012)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAn experienced therapist specialized in psycho-oncology and grief contacted 50 parents who had previously participated in grief-focused therapeutic groups (Moriconi \u0026amp; Cantero-Garc\u0026iacute;a, 2021). Of these, 41 were eligible for the study, while nine were excluded for the following reasons: (1) four discontinued the group during the initial sessions; (2) two returned to their country of origin and could not be contacted; and (3) two attended only a limited number of sessions, which did not allow the therapeutic process to be considered sufficiently completed for meaningful analysis.\u003c/p\u003e\n\u003cp\u003eAmong the 41 parents contacted, 30 agreed to attend the group meetings; two were unable to attend but participated through individual semi-structured interviews; six expressed interest in the study but were unable to participate in the meetings; two declined participation; and one could not be located.\u003c/p\u003e\n\u003cp\u003eInclusion criteria for participation in the therapeutic groups were: being a parent of a child who had died during pediatric age (up to 21 years) from an onco-hematological disease treated in a pediatric unit; the death having occurred between two months and one year prior to participation; agreement with group norms of acceptable conduct; motivation to engage in grief work; and not participating concurrently in other group-based psychological therapies. Exclusion criteria included: inability to tolerate the group setting; a tendency to assume a disruptive role within the group; non-compliance with group norms; severe incompatibility with one or more group members; and lack of motivation to engage in the therapeutic process.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProcedure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were contacted approximately two months after the death of their child. During this initial contact, they were offered bereavement support in either individual or group format. Groups were formed based on a relatively homogeneous time frame since the loss, in order to facilitate mutual identification and emotional resonance among participants.\u003c/p\u003e\n\u003cp\u003eSix therapeutic groups were established, each comprising between four and eight participants. Sessions lasted approximately 90 to 120 minutes. Prior to the beginning of the therapeutic process, all participants provided written informed consent, and sessions were audio-recorded to ensure accurate and rigorous collection of narrative data.\u003c/p\u003e\n\u003cp\u003eThe initial sessions focused on establishing the therapeutic framework and creating a sense of safety, encouraging personal introductions, sharing of loss experiences, and clarification of motivations and expectations regarding group participation. The therapist established basic group norms aimed at supporting the therapeutic process, fostering emotional containment, and promoting an atmosphere of respect and mutual support.\u003c/p\u003e\n\u003cp\u003eSessions followed a flexible structure, remaining open to themes emerging from group interactions. The facilitation style was initially active and containing, in order to promote cohesion and safety within the therapeutic field, and gradually became more facilitative as the group process evolved, allowing participants to take a central role in the shared elaboration of their experiences.\u003c/p\u003e\n\u003cp\u003eA variety of therapeutic techniques were used as facilitators of the process, not as ends in themselves but as mediating tools for emotional expression, exploration of meaning, and integration of painful experiences. These interventions supported both intrapersonal awareness and interpersonal resonance, enabling participants to elaborate their loss through mutual recognition and shared meaning-making. Throughout the process, the individual rhythm of each participant and group was respected, acknowledging the inherent variability of grief processes. The intervention was grounded in a person-centered approach, accompanying each participant according to their needs, limits, and capacity for elaboration.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study received approval from the local Research Ethics Committee (ref. R-0043/22)\u0026nbsp;and was conducted in accordance with the Declaration of Helsinki. Prior to inclusion, all participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using a reflexive thematic analysis, following the framework proposed by Braun and Clarke (2006, 2019). This approach was selected for its suitability in exploring shared patterns of meaning across participants\u0026rsquo; narratives while allowing for an interpretative, context-sensitive understanding of complex subjective experiences such as parental grief after pediatric cancer.\u003c/p\u003e\n\u003cp\u003eThe analysis adopted an inductive and interpretative orientation, with themes generated from the data rather than imposed a priori. At the same time, the process was theoretically informed by contemporary models of grief, including continuing bonds, meaning-making, and process-oriented conceptualizations of adaptation, which guided the interpretative sensitivity of the analysis without constraining category emergence.\u003c/p\u003e\n\u003cp\u003eAudio-recorded focus groups and individual interviews were transcribed verbatim and analyzed as a single corpus, enabling integration of collective and individual perspectives. Initial familiarization involved repeated reading of the transcripts to gain an in-depth understanding of the emotional, relational, and existential dimensions of participants\u0026rsquo; experiences. During this phase, preliminary notes were taken to capture first-order meanings, emotional tones, and recurrent experiential patterns.\u003c/p\u003e\n\u003cp\u003eIn the second phase, initial codes were generated across the entire dataset, focusing on explicit content as well as underlying meanings related to emotional processes, relational dynamics, and transformations in parents\u0026rsquo; narratives over time. Coding was conducted in a flexible and iterative manner, allowing codes to evolve as new insights emerged.\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;To support the organization, management, and retrieval of qualitative data during this process, the software NVivo (QSR International) was used as an analytic aid. The software facilitated systematic coding and comparison across the dataset but did not replace the interpretative work carried out by the researchers.\u003c/p\u003e\n\u003cp\u003eCodes were then examined for conceptual convergence and organized into candidate themes representing broader patterns of shared meaning. These themes were reviewed and refined through an iterative process of constant comparison, ensuring internal coherence within themes and clear differentiation between them. Particular attention was paid to preserving the complexity and processual nature of grief, avoiding reductionist or pathologizing interpretations.\u003c/p\u003e\n\u003cp\u003eThroughout the analytic process, reflexivity was actively maintained. Given the clinical background of the researchers and their involvement in therapeutic contexts, analytic decisions were critically examined to distinguish participants\u0026rsquo; meanings from clinical assumptions. Regular discussions between the authors served to challenge interpretations, refine thematic boundaries, and enhance analytical rigor.\u003c/p\u003e\n\u003cp\u003eTo strengthen the credibility and trustworthiness of the findings, several strategies were employed, including methodological triangulation between focus groups and individual interviews, prolonged engagement with the data, and systematic use of participants\u0026rsquo; verbatim quotations to ground interpretations in the empirical material. Sociodemographic variables were descriptively examined to contextualize participants\u0026rsquo; experiences; however, the primary analytic focus remained on shared meaning-making processes rather than comparative subgroup analysis.\u003c/p\u003e\n\u003cp\u003eThe final thematic structure represents an interpretative synthesis of parents\u0026rsquo; lived experiences, capturing both common trajectories and variability in grief processes as facilitated through participation in therapeutic groups\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInstruments\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003eSociodemographic Questionnaire.\u003c/em\u003e\u0026nbsp;A sociodemographic questionnaire was administered to collect information on participants\u0026rsquo; sex, age, educational level, and occupation. Variables related to current family circumstances were also considered relevant, including changes in marital status, the presence of other children following the loss, and changes in health status. Information concerning the deceased child was gathered, including the child\u0026rsquo;s age at the time of death, diagnosis, and time elapsed since the child\u0026rsquo;s death. Additional information was collected across several domains in order to explore other factors relevant to understanding the phenomenon, as suggested by previous research. Specifically, the presence of other significant losses and participants\u0026rsquo; prior therapeutic experiences were examined.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eSemi-Structured Interview\u003c/em\u003e. The semi-structured interview guide was organized into five thematic blocks corresponding to the main analytic clusters: (1) emotional expression, (2) adaptation and coping resources, (3) unresolved issues, (4) legacy, and (5) meaning and sense-making. For the two individual semi-structured interviews, an expanded interview guide was used to allow for deeper exploration of participants\u0026rsquo; experiences. The interview format was open and dialogical, conducted in depth and structured around four types of questions: rapport-building questions, closed questions, explanatory questions, and elaborative questions, facilitating both narrative flow and analytic depth.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Results","content":"\u003cp\u003eThe qualitative analysis of focus groups and in-depth interviews identified a set of meaning-making processes that describe how bereaved parents experience and elaborate the loss of a child through participation in therapeutic groups. These processes were organized into analytically derived categories and subcategories reflecting the core dimensions of the lived experience; an overview is provided in \u003cstrong\u003eTable 1\u003c/strong\u003e. The identified categories are consistent with key axes of therapeutic work previously described in the literature (Moriconi \u0026amp; Cantero-Garc\u0026iacute;a, 2021), particularly emotional expression, reconstruction of the bond with the deceased child, coping resources, and meaning-making.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ndash; \u003cstrong\u003eEmotional expression and transformation of suffering\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u0026nbsp; Participants\u0026rsquo; early narratives were characterized by profound mistrust in their ability to tolerate emotional pain. Parents described an intense fear of \u0026ldquo;stirring up\u0026rdquo; suffering, experienced as overwhelming and psychologically threatening: \u003cem\u003e\u0026ldquo;At first I was afraid to come, I thought that if I started talking I would collapse and wouldn\u0026rsquo;t be able to get back up\u0026rdquo;\u003c/em\u003e (P7, mother); \u003cem\u003e\u0026ldquo;I felt that opening all that up could be worse, like opening something I wouldn\u0026rsquo;t be able to close\u0026rdquo;\u003c/em\u003e (P12, father). As the group process progressed, a marked transformation emerged in the relationship with pain. Parents reported discovering that they could approach suffering without being destroyed by it, developing greater emotional tolerance and confidence in their own resources: \u003cem\u003e\u0026ldquo;I realized I could touch the pain and not break. I left tired, but whole\u0026rdquo;\u003c/em\u003e (P4, mother); \u003cem\u003e\u0026ldquo;Before I avoided thinking, now I know I can go there and come back. That gave me a lot of peace\u0026rdquo;\u003c/em\u003e (P19, father).\u003c/p\u003e\n\u003cp\u003e\u0026ndash; \u003cstrong\u003e\u003cem\u003eGrief as a non-pathological process and adaptation to absence\u003cbr\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Across narratives, grief was consistently reframed away from pathological models. Parents understood suffering as an inevitable and enduring consequence of losing a child\u0026mdash;one that does not disappear but can become less intrusive in daily life: \u003cem\u003e\u0026ldquo;This doesn\u0026rsquo;t get cured, it doesn\u0026rsquo;t go away. You learn to live with it, and that\u0026rsquo;s something else\u0026rdquo;\u003c/em\u003e (P9, mother); \u003cem\u003e\u0026ldquo;I\u0026rsquo;m not ill for being sad; I\u0026rsquo;m living something that will always be with me\u0026rdquo;\u003c/em\u003e (P22, father). Adaptation was described as the capacity to coexist with absence without allowing pain to dominate all aspects of life: \u003cem\u003e\u0026ldquo;The pain is there, but it no longer rules everything\u0026rdquo;\u003c/em\u003e (P15, mother); \u003cem\u003e\u0026ldquo;There are good days and bad days, but not everything revolves around the loss anymore\u0026rdquo;\u003c/em\u003e (P30, father).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ndash; \u003cstrong\u003eReconstruction of the bond and the child\u0026rsquo;s legacy\u003cbr\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e A central process involved the transformation of the bond with the deceased child. Parents described the child occupying an active symbolic place as an internal reference and existential guide, allowing memories to shift from being solely a source of pain to a sustaining presence: \u003cem\u003e\u0026ldquo;I feel my child is still with me, not in the same way, but accompanying me differently\u0026rdquo;\u003c/em\u003e (P2, mother); \u003cem\u003e\u0026ldquo;I often think about what he would do, how he was, and that guides me\u0026rdquo;\u003c/em\u003e (P18, father). Within this framework, the child\u0026rsquo;s legacy emerged as a core element of meaning-making: \u003cem\u003e\u0026ldquo;Living well now is a way of honoring him, of making his life still meaningful\u0026rdquo;\u003c/em\u003e (P11, mother); \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t want his memory to be only pain; I want it to push me to be better\u0026rdquo;\u003c/em\u003e (P25, father).\u003c/p\u003e\n\u003cp\u003e\u0026ndash;\u003cem\u003e\u0026nbsp;\u003cstrong\u003eThe therapeutic group as a relational space\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;The group was described as a privileged relational context for grief elaboration, characterized by mutual recognition and emotional validation. Participants emphasized being able to speak without needing to justify their suffering: \u003cem\u003e\u0026ldquo;Here I don\u0026rsquo;t have to explain anything; everyone knows what I mean\u0026rdquo;\u003c/em\u003e (P6, mother); \u003cem\u003e\u0026ldquo;Outside, people look at me strangely when I talk about my child; here they understand\u0026rdquo;\u003c/em\u003e (P14, father). Reciprocity\u0026mdash;being able to help others and be helped in return\u0026mdash;was identified as a key therapeutic factor that restored a sense of usefulness and value: \u003cem\u003e\u0026ldquo;Helping other parents helped me more than I ever imagined\u0026rdquo;\u003c/em\u003e (P21, mother); \u003cem\u003e\u0026ldquo;I felt that even after losing so much, I could still be of use\u0026rdquo;\u003c/em\u003e (P27, father). The group was also experienced as a support network that extended beyond the formal sessions: \u003cem\u003e\u0026ldquo;Even if we don\u0026rsquo;t meet as often, I know they are there\u0026rdquo;\u003c/em\u003e (P1, mother); \u003cem\u003e\u0026ldquo;The group doesn\u0026rsquo;t end when the session ends\u0026rdquo;\u003c/em\u003e (P16, father).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ndash; \u003cstrong\u003eReopening to the world and reorganization of life projects\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u0026nbsp; Group participation facilitated a gradual re-engagement with social life and everyday enjoyment. Parents described reconnecting socially and allowing themselves to experience positive emotions without guilt: \u003cem\u003e\u0026ldquo;I started meeting friends again without feeling I was betraying my child\u0026rdquo;\u003c/em\u003e (P10, mother); \u003cem\u003e\u0026ldquo;I could laugh again, and I no longer punished myself for it\u0026rdquo;\u003c/em\u003e (P29, father). Changes in employment and life direction were framed as part of a broader redefinition of values and priorities following the loss: \u003cem\u003e\u0026ldquo;After all this, I didn\u0026rsquo;t want the same job anymore; I needed something with meaning\u0026rdquo;\u003c/em\u003e (P13, mother); \u003cem\u003e\u0026ldquo;I lost my job, but I also lost my fear of starting again\u0026rdquo;\u003c/em\u003e (P24, father).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ndash; \u003cstrong\u003eTransversal impact of grief on health and family life\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u0026nbsp; Narratives highlighted the pervasive impact of grief on both health and family relationships. Some parents described a weakening of the couple relationship linked to difficulties in accompanying one another through suffering: \u003cem\u003e\u0026ldquo;Each of us grieved in our own way, and that slowly pulled us apart\u0026rdquo;\u003c/em\u003e (P8, mother); \u003cem\u003e\u0026ldquo;We didn\u0026rsquo;t know how to support each other; we were both broken\u0026rdquo;\u003c/em\u003e (P20, father). A significant deterioration in physical and psychological health was also reported, often requiring professional support: \u003cem\u003e\u0026ldquo;My body collapsed after my child died\u0026rdquo;\u003c/em\u003e (P5, mother); \u003cem\u003e\u0026ldquo;I couldn\u0026rsquo;t sleep, I couldn\u0026rsquo;t eat, and in the end I had to ask for help\u0026rdquo;\u003c/em\u003e (P17, father).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eINSERT TABLE 1\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eThe present study aimed, first, to explore the effects of group-based therapeutic work on grief adaptation, emotional functioning, and social adjustment in parents who had lost a child to pediatric cancer; second, to examine parents’ perceived usefulness of the group as a resource for grief elaboration; and finally, to analyze the potential influence of sociodemographic variables on the experience of loss. These objectives are situated within the field of pediatric psycho-oncology, understood—following Holland—as a subspecialty that “addresses the emotional responses of patients at all stages of the disease, of their families and of the healthcare professionals who care for them (psychosocial focus), and examines the psychological, behavioral, and social factors that influence cancer morbidity and mortality (biopsychosocial focus).” This dual perspective provides a clear rationale for the use of a group-based intervention capable of simultaneously addressing psychological suffering, relational dynamics, and functional adaptation in bereaved parents.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eValue of the Group Modality in Pediatric Psycho-Oncology\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe findings support the view that group intervention represents a particularly relevant therapeutic modality for parental grief, consistent with the assertion that pediatric psycho-oncology fundamentally revolves around the psychological suffering generated by the stressors and traumatic aspects of the disease and its treatment. In the present study, the group facilitated emotional integration, reconstruction of the bond with the deceased child, and a gradual re-engagement with social life, thereby operationalizing in clinical practice the interdisciplinary and multidisciplinary approach considered essential for comprehensive and personalized care of both patients and their families. These results align with international standards that advocate for structured, evidence-based psychosocial interventions across the entire continuum of pediatric oncology care, including parental bereavement (Wiener et al., 2021; Kearney et al., 2015; Coughtrey et al., 2018).\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eEmotional Expression, Social Isolation, and Core Principles of Bereavement Care\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eIn line with the grief and group psychotherapy literature, emotional expression emerged as a central axis of the therapeutic process. Participants emphasized the importance of having a space in which they could openly express both the most painful and the most ambivalent aspects of their experience, empirically supporting the principle—outlined in the theoretical framework—that effective grief care involves normalizing grief reactions and facilitating the expression of emotions and thoughts. The group functioned as a counterbalance to the social isolation that frequently follows the death of a child after a prolonged oncological illness, an experience that often disrupts family life and leaves parents facing an overwhelming and disorienting void.\u003c/p\u003e\n\u003cp\u003eThese findings are consistent with reviews showing that verbalizing suffering within a safe relational context helps normalize emotional responses, reduce perceived loneliness, and promote more adaptive grief processing (Kochen et al., 2020; Hasdenteufel \u0026amp; Quintard, 2022; Coughtrey et al., 2018; Polita et al., 2020). Moreover, they reinforce clinical recommendations discouraging the routine use of psychotropic medication to “mask” the grief process, instead prioritizing evidence-based psychosocial interventions and reserving pharmacological treatment for cases of severe and persistent agitation or depression (Wiener et al., 2021; Kearney et al., 2015).\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eGroup Cohesion, Universality, and Mutual Aid: From Theory to Practice\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eSharing grief with others who had undergone similar experiences was identified as a key therapeutic factor. Group dynamics enabled individual distress to be held collectively, such that improvements in one member positively influenced the group as a whole. This phenomenon reflects the classical therapeutic factors of group psychotherapy—universality, cohesion, and mutual aid—and gives concrete clinical expression to the psychosocial dimension of psycho-oncology described by Holland. At the same time, it responds to the well-established notion that, while grief shares common elements across losses, the death of a child represents a uniquely devastating experience in which validation by peers carries particular significance.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eGrief as a Process, Bond Transformation, and Continuing Bonds\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eFindings related to legacy and the bond with the deceased child directly align with the conceptualization of grief outlined in the theoretical framework. Grief was described as a dynamic process involving the progressive transformation of internal bonds—memories, representations, expectations, emotions, and meanings—linking the bereaved parent to the child. In this study, parents identified unconditional love as the core of their child’s legacy and described how, through group work, the bond was transformed into an active symbolic presence that continued to accompany and orient daily life.\u003c/p\u003e\n\u003cp\u003eThese results converge with contemporary grief models emphasizing continuing bonds as an adaptive process, diverging from classical models centered on detachment. In the specific context of pediatric cancer, where families often endure a prolonged illness that profoundly restructures relational life, symbolic continuity of the bond may serve as a pathway for integrating traumatic experience and reconstructing parental identity (Kochen et al., 2020; Schaefer et al., 2020; Polita et al., 2020).\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eMeaning-Making, Existential Crisis, and Post-Traumatic Growth\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eAs anticipated, parental adaptation to the death of a child proved to be a highly complex process involving profound existential disruption. Not all parents achieved the same level of existential elaboration, and meaning-making emerged as less prominent than other domains, reflecting the non-linear and deeply individual nature of this process. The death of a child—culturally perceived as “unnatural”—often destabilizes fundamental assumptions about life, death, and priorities.\u003c/p\u003e\n\u003cp\u003eWhen group participation facilitated a more integrated acceptance of death as part of existence and a gradual decoupling of death from extreme suffering, parents reported greater existential coherence and inner peace. This finding is consistent with literature linking meaning-making processes to post-traumatic growth and increased prosocial orientation (Kochen et al., 2020; Hasdenteufel \u0026amp; Quintard, 2022; Kentor \u0026amp; Kaplow, 2020; Xie et al., 2024). Engagement in volunteering or solidarity-based activities—described by several participants as a way of “feeling close” to their child—can thus be understood as a concrete articulation of legacy and reconstructed meaning.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eCoping Resources and Vicarious Learning\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eWith respect to coping resources, parents reported that group therapy enhanced emotional awareness and fostered a more nuanced understanding of their internal responses. Exposure to other parents’ narratives expanded their repertoire of coping strategies and normalized reactions that might otherwise have been experienced as inappropriate or incomprehensible. This vicarious learning reflects the behavioral dimension highlighted in Holland’s definition of psycho-oncology and aligns with recommendations for early and continuous psychosocial intervention in pediatric oncology care (Wiener et al., 2021; Kearney et al., 2015; Coughtrey et al., 2018; Carlsson et al., 2019).\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eUnresolved Issues and Timing of Assessment\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe relatively limited prominence of unresolved issues contrasts with some previous findings. This discrepancy may be explained by the timing of assessment—conducted after completion of the group intervention—and by the emphasis on early psychological support and active emotional processing. It is plausible that emotions such as anger, guilt, or resentment had already been expressed, explored, and, in some cases, transformed through forgiveness or symbolic repair. This pattern suggests that therapeutic groups may play a specific role in reducing the emotional burden associated with unresolved issues, further supporting interventions that privilege experiential and relational processing over purely pharmacological approaches (Kochen et al., 2020; Smith et al., 2025; Moray et al., 2025).\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eSociodemographic Considerations and External Coherence\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe alignment between cancer diagnoses in the present sample and national pediatric cancer registry data supports the external coherence of the findings. Observed changes in marital status and parental health following the child’s death are consistent with evidence documenting elevated risks of relational strain and physical and mental health problems after such losses. Differences in grieving trajectories within couples further underscore the need for psycho-oncology programs to incorporate interventions specifically addressing couple dynamics and divergent coping styles during illness and bereavement (Kearney et al., 2015; Zhang et al., 2025; Carlsson et al., 2019; Polita et al., 2020).\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eLimitations and Future Directions\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eSeveral limitations warrant consideration. The specificity and homogeneity of the sample limit generalizability to other forms of bereavement. The qualitative design, while appropriate for capturing complexity, does not allow causal inference or effect size estimation. Additionally, the limited number of prior studies focused specifically on parental bereavement after pediatric cancer constrains systematic comparison.\u003c/p\u003e\n\u003cp\u003eNonetheless, the study offers relevant theoretical and clinical contributions. Conceptually, it integrates process-oriented models of grief with continuing bonds and meaning reconstruction within the specific context of pediatric cancer. Clinically, it provides qualitative evidence supporting the therapeutic potential of group interventions, consistent with Yalom’s assertion that “the group itself, together with specific techniques and skilled therapeutic interventions, serves as a powerful instrument of change.”\u003c/p\u003e\n\u003cp\u003eFuture research should prioritize: (a) controlled studies evaluating structured group interventions for bereaved parents; (b) deeper examination of the interplay between meaning-making and legacy as inseparable processes; and (c) the development of replicable, culturally sensitive group protocols aligned with international psychosocial care standards.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eParental grief following the death of a child remains a socially silenced experience that intensifies isolation and underscores the need for targeted interventions. Group psychotherapy emerges as a privileged relational space for addressing grief, connecting emotional expression with values, legacy, and continuing bonds. Through this process, families move from passive suffering to active engagement, transforming loss into shared meaning, resilience, and mutual support.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding: Not applicable.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: not applicable.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eApproval committee: R-0043/22\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors wish to express their sincere gratitude to the Aladina Foundation for its invaluable work in supporting children and adolescents with cancer and their families. The authors also wish to thank the mothers and fathers who entrusted them with their stories of love and loss.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBarakat, L. P., Kazak, A. E., Meadows, A. T., Casey, R., Meeske, K., \u0026amp; Stuber, M. L. (2000). Families surviving childhood cancer: A comparison of posttraumatic stress symptoms with families of healthy children. \u003cem\u003eJournal of Pediatric Psychology, 25\u003c/em\u003e(6), 843\u0026ndash;856\u003c/li\u003e\n \u003cli\u003eBarrera, M., Atenafu, E., Doyle, J., Berlin-Romalis, D., \u0026amp; Hancock, K. (2012). 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The integration of psychology in pediatric oncology research and practice: collaboration to improve care and outcomes for children and families. \u003cem\u003eThe American psychologist\u003c/em\u003e, \u003cem\u003e70\u003c/em\u003e(2), 146\u0026ndash;158. https://doi.org/10.1037/a0035695\u003c/li\u003e\n \u003cli\u003eKazak, A. E., Kassam-Adams, N., Schneider, S., Zelikovsky, N., Alderfer, M. A., \u0026amp; Rourke, M. (2006). An integrative model of pediatric medical traumatic stress. \u003cem\u003eJournal of pediatric psychology\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(4), 343\u0026ndash;355. https://doi.org/10.1093/jpepsy/jsj054\u003c/li\u003e\n \u003cli\u003eKearney, J., Salley, C., \u0026amp; Muriel, A. (2015). Standards of Psychosocial Care for Parents of Children With Cancer. \u003cem\u003ePediatric Blood \u0026amp; Cancer\u003c/em\u003e, 62. https://doi.org/10.1002/pbc.25761\u003c/li\u003e\n \u003cli\u003eKentor, R., \u0026amp; Kaplow, J. (2020). Supporting children and adolescents following parental bereavement: guidance for health-care professionals.. \u003cem\u003eThe Lancet. Child \u0026amp; adolescent health\u003c/em\u003e, 4 12, 889-898. https://doi.org/10.1016/s2352-4642(20)30184-x\u003c/li\u003e\n \u003cli\u003eKochen, E., Jenken, F., Boelen, P., Deben, L., Fahner, J., Van Den Hoogen, A., Teunissen, S., Geleijns, K., \u0026amp; Kars, M. (2020). When a child dies: a systematic review of well-defined parent-focused bereavement interventions and their alignment with grief- and loss theories. \u003cem\u003eBMC Palliative Care\u003c/em\u003e, 19. https://doi.org/10.1186/s12904-020-0529-z\u003c/li\u003e\n \u003cli\u003eKupst, M.J., Patenaude, A.F. (2016). Coping and Adaptation in Pediatric Cancer: Current Perspectives. In: Abrams, A., Muriel, A., Wiener, L. (eds) Pediatric Psychosocial Oncology: Textbook for Multidisciplinary Care. Springer, Cham. https://doi.org/10.1007/978-3-319-21374-3_5\u003c/li\u003e\n \u003cli\u003eLichtenthal, W. G., Sweeney, C. R., Roberts, K. E., Corner, G. W., Donovan, L. A., Prigerson, H. G., \u0026amp; Wiener, L. (2015). Bereavement Follow-Up After the Death of a Child as a Standard of Care in Pediatric Oncology. \u003cem\u003ePediatric blood \u0026amp; cancer\u003c/em\u003e, \u003cem\u003e62 Suppl 5\u003c/em\u003e(0), S834\u0026ndash;S869. https://doi.org/10.1002/pbc.25700\u003c/li\u003e\n \u003cli\u003eLong, K. A., Marsland, A. L., \u0026amp; Alderfer, M. A. (2013). Cumulative family risk predicts sibling adjustment to childhood cancer. \u003cem\u003eCancer\u003c/em\u003e, \u003cem\u003e119\u003c/em\u003e(13), 2503\u0026ndash;2510. https://doi.org/10.1002/cncr.28077\u003c/li\u003e\n \u003cli\u003eMeert, K. L., Eggly, S., Kavanaugh, K., Berg, R. A., Wessel, D. L., Newth, C. J., Shanley, T. P., Harrison, R., Dalton, H., Dean, J. M., Doctor, A., Jenkins, T., \u0026amp; Park, C. L. (2015). Meaning making during parent-physician bereavement meetings after a child\u0026apos;s death. \u003cem\u003eHealth psychology : official journal of the Division of Health Psychology, American Psychological Association\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(4), 453\u0026ndash;461. https://doi.org/10.1037/hea0000153\u003c/li\u003e\n \u003cli\u003eMoray, İ., \u0026Ccedil;akır, B., \u0026amp; Kargı, A. (2025). Effectiveness of group therapy for prolonged grief symptoms: A systematic review and meta-analysis.. \u003cem\u003eDeath studies\u003c/em\u003e, 1-13. https://doi.org/10.1080/07481187.2025.2559725\u003c/li\u003e\n \u003cli\u003ePatenaude, A. F., \u0026amp; Kupst, M. J. (2005). Psychosocial functioning in pediatric cancer. \u003cem\u003eJournal of pediatric psychology\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(1), 9\u0026ndash;27. https://doi.org/10.1093/jpepsy/jsi012\u003c/li\u003e\n \u003cli\u003ePelacho-Rios, L., Bernabe-Valero, G. The loss of a child, bereavement and the search for meaning: A systematic review of the most recent parental interventions. \u003cem\u003eCurr Psychol\u003c/em\u003e 42, 25931\u0026ndash;25956 (2023). https://doi.org/10.1007/s12144-022-03703-w\u003c/li\u003e\n \u003cli\u003ePolita, N., deMontigny, F., Neris, R., Alvarenga, W., Silva-Rodrigues, F., Leite, A., \u0026amp; Nascimento, L. (2020). The Experiences of Bereaved Parents After the Loss of a Child to Cancer: A Qualitative Metasynthesis. \u003cem\u003eJournal of Pediatric Oncology Nursing\u003c/em\u003e, 37, 444 - 457. https://doi.org/10.1177/1043454220944059\u003c/li\u003e\n \u003cli\u003eSchaefer, M., Wagoner, S., Young, M., Madan-Swain, A., Barnett, M., \u0026amp; Gray, W. (2020). Healing the hearts of bereaved parents: Impact of legacy artwork on grief in pediatric oncology.. \u003cem\u003eJournal of pain and symptom management\u003c/em\u003e. https://doi.org/10.1016/j.jpainsymman.2020.04.018\u003c/li\u003e\n \u003cli\u003eSmith, K., Thew, G., Carr, S., Congrave, P., Rudge, S., \u0026amp; Thompson, E. (2025). Supporting those bereaved by cancer: a service evaluation and investigation of cognitive behavioural mechanisms in the treatment of prolonged grief. \u003cem\u003eEuropean Journal of Psychotraumatology\u003c/em\u003e, 16. https://doi.org/10.1080/20008066.2025.2545144\u003c/li\u003e\n \u003cli\u003eWeaver, M. S., Heinze, K. E., Bell, C. J., Wiener, L., Garee, A. M., Kelly, K. P., Casey, R. L., Watson, A., Hinds, P. S., \u0026amp; Pediatric Palliative Care Special Interest Group at Children\u0026rsquo;s National Health System (2016). Establishing psychosocial palliative care standards for children and adolescents with cancer and their families: An integrative review. \u003cem\u003ePalliative medicine\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(3), 212\u0026ndash;223. https://doi.org/10.1177/0269216315583446\u003c/li\u003e\n \u003cli\u003eWiener, L., Barnett, M., Flowers, S., Fair, C., \u0026amp; Thompson, A. (2021). Evidence-Based Psychosocial Interventions in Pediatric Psycho-Oncology. \u003cem\u003ePsycho-Oncology\u003c/em\u003e. https://doi.org/10.1093/med/9780190097653.003.0088\u003c/li\u003e\n \u003cli\u003eZhang, Y., Zhang, Z., Peng, Y., Zhang, W., , G., Lin, S., Chan, C., Cheung, A., Xie, J., \u0026amp; Gu, C. (2025). Impact of technology- and parent-based psychosocial interventions on family dynamics factors in children with cancer: A systematic review. \u003cem\u003ePLOS One\u003c/em\u003e, 20. https://doi.org/10.1371/journal.pone.0323483\u003c/li\u003e\n \u003cli\u003eXie, J., Hunter, A., Biesty, L., \u0026amp; Grealish, A. (2024). The impact of midwife/nurse-led psychosocial interventions on parents experiencing perinatal bereavement: An integrative review.. \u003cem\u003eInternational journal of nursing studies\u003c/em\u003e, 157, 104814. https://doi.org/10.1016/j.ijnurstu.2024.104814\u003cu\u003e\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1.\u0026nbsp; Analytical Categories and Subcategories\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnalytical Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubcategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnalytical Description\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Emotional transformation and grief adaptation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e1.1. Initial fear of emotional overwhelm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eFear of coming into contact with intense emotions associated with the loss and perception of insufficient internal resources to tolerate the pain.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e1.2. Progressive confidence in emotional capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eDevelopment of greater emotional tolerance through engaging with pain in a safe environment, fostering a sense of internal competence.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Re-signification of grief\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e2.1. Grief as a non-pathological life process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eConceptualization of grief as a natural and enduring experience, distinct from pathology-centered clinical models.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e2.2. Learning to live with absence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eIntegration of pain into everyday life without allowing it to dominate the overall lived experience.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Reconstruction of the bond with the deceased child\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e3.1. The child as an active symbolic presence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eTransformation of the memory of the deceased child into an internal guiding reference and source of meaning.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e3.2. Legacy as a vital driving force\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eLiving fully as a way of honoring the child\u0026rsquo;s life by integrating values, lessons, and existential commitments.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. The therapeutic group as a relational device\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e4.1. Mutual recognition and emotional validation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eExperience of being understood without the need for explanation, grounded in identification with other bereaved parents.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e4.2. Reciprocity and mutual support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eTherapeutic experience derived from helping and being helped, restoring a sense of personal usefulness.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e4.3. The group as a sustained support network\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003ePerception of the group as a source of emotional support that extends beyond the formal boundaries of the sessions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Life reorganization and reopening to the world\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e5.1. Overcoming social isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eGradual return to social life, recovery of enjoyment, and reduction of guilt associated with well-being.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e5.2. Redefinition of vocational and life projects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eOccupational and life changes interpreted as part of a reconfiguration of priorities following the loss.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Transversal impact of grief\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e6.1. Fragilization of the couple relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eCrisis of the conjugal project resulting from the cumulative impact of the child\u0026rsquo;s illness and death.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e6.2. Deterioration of physical and psychological health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 280px;\"\u003e\n \u003cp\u003eEmergence or worsening of physical and psychological symptoms, highlighting the holistic nature of parental grief.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"pediatric psycho-oncology, focus group, grief, intervention","lastPublishedDoi":"10.21203/rs.3.rs-8926237/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8926237/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The death of a child due to cancer constitutes one of the most devastating experiences for parents and is associated with profound emotional, relational, and existential consequences. Pediatric psycho-oncology highlights the need for interventions that go beyond symptom reduction and address grief as a complex process involving emotional expression, social connection, and meaning reconstruction. However, qualitative research exploring parents’ lived experiences of grief-focused group therapy remains limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This study aimed to explore the impact of therapeutic group interventions on parental grief following the loss of a child to cancer, focusing on emotional adjustment, social adaptation, and processes of meaning-making. Additionally, it examined parents’ subjective perceptions of the group as a resource for grief elaboration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e A qualitative, descriptive-interpretative design was employed. Participants were parents who had attended grief-focused therapeutic groups after the death of a child due to pediatric cancer. Data were collected through focus groups and in-depth semi-structured interviews. A thematic analysis was conducted to identify shared categories and processes of meaning emerging from participants’ narratives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The findings revealed interconnected processes, including a transformation from fear of emotional overwhelm to increased emotional tolerance, a reconceptualization of grief as a non-pathological and ongoing life process, and the reconstruction of the bond with the deceased child through symbolic continuity and legacy. The group emerged as a key therapeutic context characterized by mutual recognition, reciprocity, and sustained emotional support. Participation also facilitated social re-engagement, redefinition of life priorities, and greater existential coherence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Therapeutic group interventions represent a valuable clinical resource in pediatric psycho-oncology, fostering emotional integration, relational support, and meaning reconstruction in parental grief. These findings support the relevance of group-based approaches and underscore the need for further qualitative research and the development of structured intervention models.\u003c/p\u003e","manuscriptTitle":"From Loss to Meaning: Therapeutic Group Processes in Parental Grief After Pediatric Cancer From Pain to Meaning: Parental Grief After Pediatric Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-13 09:22:37","doi":"10.21203/rs.3.rs-8926237/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"28179508769543275696049631189560961915","date":"2026-05-12T05:24:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T02:45:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5720188600945301445010622039515121725","date":"2026-04-08T21:12:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-06T19:09:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-06T19:07:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-03T02:38:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-02-20T12:58:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2dc8d297-47dd-4a99-9220-91b0a0545ee8","owner":[],"postedDate":"April 13th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"28179508769543275696049631189560961915","date":"2026-05-12T05:24:17+00:00","index":24,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T09:22:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-13 09:22:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8926237","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8926237","identity":"rs-8926237","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}