Mediators of change in psychosocial interventions for cancer patients: a systematic review

Integrated, cross-sectoral psycho-oncology (isPO): a new form of care for newly diagnosed cancer patients in Germany

Background

The annual incidence of new cancer cases has been increasing worldwide for many years, and is likely to continue to rise. In Germany, the number of new cancer cases is expected to increase by 20% until 2030. Half of all cancer patients experience significant emotional and psychosocial distress along the continuum of their disease, treatment, and aftercare, and also as long-term survivors. Consequently, in many countries, psycho-oncological programs have been developed to address this added burden at both the individual and population level. These programs promote the active engagement of patients in their cancer therapy, aftercare and survivorship planning and aim to improve the patients' quality of life.

In Germany, the “new form of care isPO” (“nFC-isPO”; integrated, cross-sectoral psycho-oncology/integrierte, sektorenübergreifende Psycho-Onkologie) is currently being developed, implemented and evaluated. This approach strives to accomplish the goals devised in the National Cancer Plan by providing psycho-oncological care to all cancer patients according to their individual healthcare needs. The term “new form of care" is defined by the Innovation Fund (IF) of Germany's Federal Joint Committee as “a structured and legally binding cooperation between different professional groups and/or institutions in medical and non-medical care”.

The nFC-isPO is part of the isPO project funded by the IF. It is implemented in four local cancer centres and is currently undergoing a continuous quality improvement process. As part of the isPO project the nFC-isPO is being evaluated by an independent institution: the Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Germany.

The four-year isPO project was selected by the IF to be eligible for funding because it meets the requirements of the federal government's National Cancer Plan (NCP), in particular, the “further development of the oncological care structures and quality assurance" in the psycho-oncological domain. An independent evaluation is required by the IF to verify if the new form of care leads to an improvement in cross-sectoral care and to explore its potential for permanent integration into the German health care system.

Methods

The nFC-isPO consists of six components: a concept of care (C1), care pathways (C2), a psycho-oncological care network (C3), a care process organization plan (C4), an IT-supported documentation and assistance system (C5) and a quality management system (C6). The two components concept of care (C1) and care pathways (C2) represent the isPO clinical care program, according to which the individual cancer patients are offered psycho-oncological services within a period of 12 months after program enrolment following the diagnosis of cancer. The remaining components (C3-C6) represent the formal-administrative aspects of the nFC-isPO that are intended to meet the legally binding requirements of patient care in the German health care system. With the aim of systematic development of the nFC-isPO while at the same time enabling the external evaluators to examine its quality, effectiveness and efficiency under conditions of routine care, the project partners took into consideration approaches from translational psycho-oncology, practice-based health care research and program theory. In order to develop a structured, population-based isPO care program, reference was made to a specific program theory, to the stepped-care approach, and also to evidence-based guideline recommendations.

Results

The basic version, nFC-isPO, was created over the first year after the start of the isPO project in October 2017, and has since been subject to a continuous quality improvement process. In 2019, the nFC-isPO was implemented at four local psycho-oncological care networks in the federal state North Rhine-Westphalia, in Germany. The legal basis of the implementation is a contract for "special care" with the German statutory health insurance funds according to state law (§ 140a SCB V; Social Code Book V for the statutory health insurance funds). Besides the accompanying external evaluation by the IMVR, the nFC-isPO is subjected to quarterly internal and cross-network quality assurance and improvement measures (internal evaluation) in order to ensure continuous quality improvement process. These quality management measures are developed and tested in the isPO project and are to be retained in order to ensure the sustainability of the quality of nFC-isPO for later dissemination into the German health care system.

Discussion

Demands on quality, effectiveness and cost-effectiveness of in the German health care system are increasing, whereas financial resources are declining, especially for psychosocial services. At the same time, knowledge about evidence-based screening, assessment and intervention in cancer patients and about the provision of psychosocial oncological services is growing continuously. Due to the legal framework of the statutory health insurance in Germany, it has taken years to put sound psycho-oncological findings from research into practice. Ensuring the adequate and sustainable financing of a needs-oriented, psycho-oncological care approach for all newly diagnosed cancer patients, as required by the NCP, may still require many additional years. The aim of the isPO project is to develop a new form of psycho-oncological care for the individual and the population suffering from cancer, and to provide those responsible for German health policy with a sound basis for decision-making on the timely dissemination of psycho-oncological services in the German health care system.

Trial registration

The study was pre-registered at the German Clinical Trials Register (https://www.drks.de/DRKS00015326) under the following trial registration number: DRKS00015326; Date of registration: October 30, 2018.

Mindfulness-based stress reduction for breast cancer survivors (MBSR(BC)): evaluating mediators of psychological and physical outcomes in a large randomized controlled trial

MBSR(BC) is known to have a positive impact on psychological and physical symptoms among breast cancer survivors (BCS). The cognitive mechanisms of "how" MBSR(BC) works was addressed in a recent study that found that there was strong consistent evidence that reduced emotional reactivity is a mediator and moderate consistent evidence that mindfulness, rumination, and worry were mediators. The purpose of this study, as part of a larger R01 trial, was to test whether positive effects achieved from the MBSR(BC) program were mediated through changes in increased mindfulness, decreased fear of breast cancer recurrence, and perceived stress. Female BCS > 21 years diagnosed with Stage 0-III breast cancer were randomly assigned to a 6-week MBSR(BC) or a Usual Care (UC)regimen. Potential mediators of 6- and 12-week outcomes were identified by analysis of covariance (ANCOVA), followed by formal mediational analyses of main effects of MBSR(BC) on 6- and 12-week outcomes, including percentage of total effects explained. Among 322 BCS (167 MBSR(BC) and 155 UC), fear of recurrence and perceived stress, but not mindfulness, mediated reductions in anxiety and fatigue at weeks 6 and 12, partially supporting our hypothesis of cognitive mechanisms of MBSR(BC). TRIAL REGISTRATION: Registration Number: NCT01177124 http://www.ClinicalTrials.gov.

Personality (at Intrapsychic and Interpersonal Level) Associated With Quality of Life in Patients With Cancer (Lung and Colon)

The objective of this study was to determine the association of quality of life (QoL) and intrapsychic and interpersonal behaviors (Structural Analysis of Social Behavior [SASB]) of patients with cancer (lung: n = 88; age 62.8 ± 10.1; colon: n = 56; age 60.1 ± 11.4). Personality described by SASB clusters (Cls): SASB-Questionnaire; QoL tests: FACT_G and QLQ-C30. Patients with lung cancer (n = 88; age 62.8 ± 10.1) and colon cancer (n = 56; age 60.1 ± 11.4; all stages of severity). Multiple regression analyses. Multiple linear regression: dependent variable: FACT_G; covariates: physical functioning, cognitive functioning, SASB-Cl3-50°, SASB-Cl6-50°. Analysis of variance and t test confirm validity of the model (P < .001). SASB-Cl3 with FACT_G (P = .034); SASB-Cl6 with FACT_G (P = .002); age with FACT_G (P = .018); physical functioning with FACT_G (P < .001); cognitive functioning with FACT_G (P < .001). Personality traits such as self-critical and oppressive behaviors, low capacity for self-esteem, physical and cognitive functioning, and age (a higher age determines a better QoL) strongly determine QoL in patients with lung and colon cancer. This may suggest areas of therapeutic intervention.

Evaluating a couple-based intervention addressing sexual concerns for breast cancer survivors: study protocol for a randomized controlled trial

Background

Sexual concerns are distressing for breast cancer survivors and interfere with their intimate relationships. This study evaluates the efficacy of a four-session couple-based intervention delivered via telephone, called Intimacy Enhancement (IE). The IE intervention is grounded in social cognitive theory and integrates evidence-based techniques from cognitive behavioral couple therapy and sex therapy to address survivors’ sexual concerns and enhance their and their partners’ sexual, relationship, and psychological outcomes.

Methods

This trial is designed to evaluate the efficacy of the IE intervention in improving survivors’ sexual function, the primary study outcome. Secondary outcomes include survivors’ sexual distress, partners’ sexual function, and survivors’ and partners’ relationship intimacy and quality as well as psychological distress (depressive symptoms and anxiety symptoms). Additional aims are to examine whether treatment effects on patient sexual function are mediated by sexual communication and self-efficacy for coping with sexual concerns and to explore whether survivor age and race/ethnicity moderate intervention effects on survivors’ sexual function. Eligible adult female breast cancer survivors reporting sexual concerns and their intimate partners are recruited from two academic sites in the USA and are randomized to either the IE intervention or to a control condition of equal length offering education and support around breast cancer-related health topics (Living Healthy Together). The target sample size is 120 couples. Self-report outcome measures are administered to participants in both conditions at baseline (T1), post-treatment (T2), 3 months post-treatment (T3), and 6 months post-treatment (T4).

Discussion

Evidence-based interventions are needed to address sexual concerns for breast cancer survivors and to enhance their and their intimate partners’ sexual, relationship, and psychological well-being. This randomized controlled trial will allow us to examine the efficacy of a novel couple-based intervention delivered via telephone for breast cancer survivors experiencing sexual concerns and their intimate partners, in comparison with an attention control. Findings of this study could influence clinical care for women with breast cancer and inform theory guiding cancer-related sexual rehabilitation.

Trial registration

ClinicalTrials.gov, NCT03930797. Registered on 24 April 2019.

Experiences of breast cancer patients and helpful aspects of supportive-expressive group therapy: A qualitative study

OBJECTIVE

This study explored the experiences and perceived changes of breast cancer (BC) patients after participating in 16-weekly sessions of Supportive-Expressive Group Therapy (SEGT).

METHODS

A semi-structured interview adapted from Elliott's Client Change Interview was carried out with 12 women (aged 33-60 years) with BC, about 6 months after completing the treatment.

RESULTS

Content analysis identified four main themes: expectations and motivations to participate in SEGT, group processes and experiences, perceived changes enhanced by SEGT and perceptions about the therapeutic relationship. The most helpful aspects of SEGT mentioned by participants were as follows: the expression/normalisation of feelings, thoughts and reactions; the improvement of social support; and the learning opportunities obtained through sharing of experiences among participants. Additionally, participants mentioned that SEGT contributed to improve personal and social skills, such as the capacity to express emotions and the ability to establish satisfactory interpersonal relationships.

CONCLUSIONS

Based on the participants' experiences, SEGT seems to be an effective intervention to support women facing BC during the initial phase of cancer. The use of SEGT by health care professionals is encouraged, but the specific needs/problems of each group member should be carefully attended.

Cancer-related coping processes as predictors of depressive symptoms, trajectories, and episodes

OBJECTIVE

Although numerous studies address the relationships of depression with coping processes directed toward approaching or avoiding stressful experiences, the large majority are cross-sectional in design, assess coping processes at only one timepoint, or solely include prediction of the linear slope of depressive symptoms. In this research, coping processes were investigated as predictors of depressive symptoms, symptom trajectory classes (consistently high, recovery, consistently low), and major depressive episodes (MDEs) over 12 months in the cancer context.

METHOD

Women (N = 460) within 4 months of breast cancer diagnosis completed assessments of cancer-related coping processes, depressive symptoms, and MDEs at 7 points across 1 year.

RESULTS

Beyond sociodemographic and medical variables, coping through cancer-related avoidance an average of 2 months after diagnosis was associated with likelihood of being in the high depressive symptom trajectory class and occurrence of a MDE during the year. Less decline in avoidant coping over time also predicted poor outcomes. In contrast, high initial engagement in approach-oriented coping, as well as increases in coping through emotional expression and acceptance, were associated with lower depressive symptoms across assessments and higher likelihood of being in the recovery or low trajectory class.

CONCLUSIONS

Greater engagement in cancer-related avoidant coping was associated with all three indicators of depression, and greater approach-oriented coping was related to more favorable outcomes (except MDE). Sustained or increasing coping through emotional expression or acceptance predicted recovery from initially high depressive symptoms. Approach- and avoidance-oriented coping processes constitute malleable targets for preventive and ameliorative approaches. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Role of Patient Coping Strategies in Understanding the Effects of Early Palliative Care on Quality of Life and Mood

Purpose The early integration of oncology and palliative care (EIPC) improves quality of life (QOL) and mood for patients with advanced cancer. However, the mechanisms by which EIPC benefits these outcomes remain unclear. We therefore examined whether EIPC improved patients' coping strategies and if changes in coping accounted for intervention effects on QOL and depressive symptoms. Patients and Methods For this secondary analysis of an EIPC trial, we examined data from 350 patients with newly diagnosed incurable lung or GI cancer. Participants completed assessments of QOL (Functional Assessment of Cancer Therapy-General), depressive symptoms (Patient Health Questionnaire-9), and coping (Brief COPE) at baseline and 24 weeks. We used linear regression to test intervention effects on use of coping strategies and mediation regression models with bias-corrected bootstrapping to examine whether improvements in coping mediated the effects of early palliative care on patient-reported outcomes. Results Compared with usual oncology care, EIPC significantly increased patient use of approach-oriented coping strategies ( B = 1.09; SE = 0.44; P = .01) and slightly reduced use of avoidant strategies ( B = -0.44; SE = 0.23; P = .06) from baseline to 24 weeks. Also, the increased use of approach-oriented coping and reduction in avoidant coping were associated with higher QOL and lower depressive symptoms at 24 weeks. The positive changes in approach-oriented coping, but not avoidant coping, significantly mediated the effects of EIPC on QOL (indirect effect, 1.27; 95% CI, 0.33 to 2.86) and depressive symptoms (indirect effect, -0.39; 95% CI, -0.87 to -0.08). Conclusion Patients with incurable cancer who received EIPC showed increased use of approach-oriented coping, which was associated with higher QOL and reduced depressive symptoms. Palliative care may improve these outcomes by providing patients with the skills to cope effectively with life-threatening illness.

Helping Yourself by Offering Help: Mediators of Expressive Helping in Survivors of Hematopoietic Stem Cell Transplant

BACKGROUND

A randomized experiment by Rini et al. (Health Psychol. 33(12):1541-1551, 2014) demonstrated that expressive helping, which involves three expressive writing sessions regarding hematopoietic stem cell transplant, followed by one writing session directed toward helping other stem cell transplant recipients, reduced psychological distress and bothersome physical symptoms among stem cell transplant recipients with elevated survivorship problems, relative to a neutral writing control condition.

PURPOSE

The current study evaluated whether word use reflective of emotional expression, cognitive processing, and change in perspective mediates the effects of expressive helping.

METHOD

The essays of 67 stem cell transplant recipients with high survivorship problems were analyzed with Linguistic Inquiry and Word Count. Multiple mediation modeling was used to test the hypothesized mechanisms of expressive helping on distress and bothersome physical symptoms.

RESULTS

Relative to the control condition, expressive helping produced significant reductions in psychological distress and marginal reductions in physical symptom bother in the analyzed subset of participants from the parent study. Results indicated that positive emotion word use significantly mediated effects of expressive helping on reduced distress, but only for participants who used average (compared to above or below average) rates of negative emotion words. Cognitive processing and change in perspective did not significantly mediate benefits of expressive helping.

CONCLUSIONS

Expressive helping carried its positive effects on distress through participants' higher expression of positive emotions when coupled with moderate rates of negative emotions. Findings highlight the benefit of expressing both positive and negative emotions in stressful situations.

Mindfulness-Based Cancer Recovery (MBCR) versus Supportive Expressive Group Therapy (SET) for distressed breast cancer survivors: evaluating mindfulness and social support as mediators

Despite growing evidence in support of mindfulness as an underlying mechanism of mindfulness-based interventions (MBIs), it has been suggested that nonspecific therapeutic factors, such as the experience of social support, may contribute to the positive effects of MBIs. In the present study, we examined whether change in mindfulness and/or social support mediated the effect of Mindfulness-Based Cancer Recovery (MBCR) compared to another active intervention (i.e. Supportive Expressive Group Therapy (SET)), on change in mood disturbance, stress symptoms and quality of life. A secondary analysis was conducted of a multi-site randomized clinical trial investigating the impacts of MBCR and SET on distressed breast cancer survivors (MINDSET). We applied the causal steps approach with bootstrapping to test mediation, using pre- and post-intervention questionnaire data of the participants who were randomised to MBCR (n = 69) or SET (n = 70). MBCR participants improved significantly more on mood disturbance, stress symptoms and social support, but not on quality of life or mindfulness, compared to SET participants. Increased social support partially mediated the impact of MBCR versus SET on mood disturbance and stress symptoms. Because no group differences on mindfulness and quality of life were observed, no mediation analyses were performed on these variables. Findings showed that increased social support was related to more improvement in mood and stress after MBCR compared to support groups, whereas changes in mindfulness were not. This suggests a more important role for social support in enhancing outcomes in MBCR than previously thought.

Psychological Manifestations of Early Childhood Adversity in the Context of Chronic Hematologic Malignancy

BACKGROUND

Myeloproliferative neoplasms (MPNs), a group of chronic hematologic malignancies, carry significant physical and psychological symptom burdens that significantly affect patients' quality of life.

OBJECTIVES

We sought to identify the relationship between early childhood adversity (ECA) and psychological distress in patients with MPNs, as ECA may compound symptom burden.

METHODS

Patients with MPNs were assessed for ECA (i.e., the Risky Families Questionnaire-subscales include abuse/neglect/chaotic home environment), distress (i.e., Distress Thermometer and Problem List), anxiety (i.e., Hospital Anxiety and Depression Scale-Anxiety [HADS-A]), depression (i.e., Hospital Anxiety and Depression Scale-Depression [HADS-D]), meeting standardized cutoff thresholds for distress (i.e., Distress Thermometer and Problem List≥ 4 or ≥ 7)/anxiety (HADS-A ≥8)/depression (HADS-D ≥ 8), and demographic factors.

RESULTS

A total of 117 participants completed the study (78% response rate). ECA was associated with depression (p < 0.000), anxiety (p < 0.000), and distress (p < 0.000) and problem list variables emotional (p < 0.000), physical (p = 0.004), family (p = 0.01), and spiritual (p = 0.01) by bivariate analysis and only with distress (HADS) (p = 0.038) on multivariate analysis. ECA was associated with meeting cutoff threshold criteria for distress (p = 0.007), anxiety (p = 0.001), and depression (p = 0.02). ECA subscale variables abuse and chaotic home environment were associated with psychological outcomes. ECA was higher based on disease subtypes with greater symptom burden (other > polycythemia vera > myelofibrosis > essential thrombocythemia) (p = 0.047) and taking an antidepressant (p = 0.011).

CONCLUSION

ECA is associated with psychological distress and meets screening criteria for anxiety and depression in patients with MPNs. ECA may help to explain individual patient trajectories, and further understanding may enhance patient-centered care among patients with MPNs.

Examining Mediators and Moderators of Yoga for Women With Breast Cancer Undergoing Radiotherapy

Hypothesis. This study examines moderators and mediators of a yoga intervention targeting quality-of-life (QOL) outcomes in women with breast cancer receiving radiotherapy.Methods. Women undergoing 6 weeks of radiotherapy were randomized to a yoga (YG; n = 53) or stretching (ST; n = 56) intervention or a waitlist control group (WL; n = 54). Depressive symptoms and sleep disturbances were measured at baseline. Mediator (posttraumatic stress symptoms, benefit finding, and cortisol slope) and outcome (36-item Short Form [SF]-36 mental and physical component scales [MCS and PCS]) variables were assessed at baseline, end-of-treatment, and 1-, 3-, and 6-months posttreatment. Results. Baseline depressive symptoms (P = .03) and sleep disturbances (P < .01) moderated the Group × Time effect on MCS, but not PCS. Women with high baseline depressive symptoms in YG reported marginally higher 3-month MCS than their counterparts in WL (P = .11). Women with high baseline sleep disturbances in YG reported higher 3-months MCS than their counterparts in WL (P < .01) and higher 6-month MCS than their counterparts in ST (P = .01). YG led to greater benefit finding than ST and WL across the follow-up (P = .01). Three-month benefit finding partially mediated the effect of YG on 6-month PCS. Posttraumatic stress symptoms and cortisol slope did not mediate treatment effect on QOL. Conclusion. Yoga may provide the greatest mental-health–related QOL benefits for those experiencing pre-radiotherapy sleep disturbance and depressive symptoms. Yoga may improve physical-health–related QOL by increasing ability to find benefit in the cancer experience.

Early Childhood Adversity and its Associations With Anxiety, Depression, and Distress in Women With Breast Cancer

BACKGROUND

Certain vulnerability factors have been found to place patients at risk for depression and anxiety, especially within the context of medical illness.

OBJECTIVES

We sought to describe the relationships among early childhood adversity (ECA) and anxiety, depression and distress in patients with breast cancer.

METHODS

Patients with breast cancer (stages 0-IV) were assessed for ECA (i.e., the Risky Families Questionnaire subscales include Abuse/Neglect/Chaotic Home Environment), distress (i.e., Distress Thermometer and Problem List), anxiety (Hospital Anxiety and Depression Scale-Anxiety), depression (Hospital Anxiety and Depression Scale-Depression), meeting standardized cut-off thresholds for distress (Distress Thermometer and Problem List ≥4 or ≥7)/anxiety (Hospital Anxiety and Depression Scale-Anxiety ≥8)/depression (Hospital Anxiety and Depression Scale-Depression ≥8) and demographic factors.

RESULTS

A total of 125 participants completed the study (78% response rate). ECA was associated with depression (p <0.001), anxiety (p = 0.001), and distress (p = 0.006), meeting cut-off threshold criteria for distress (p = 0.024), anxiety (p = 0.048), and depression (p = 0.001). On multivariate analysis, only depression (p = 0.04) and emotional issues (i.e., component of Distress Thermometer and Problem List) (p = 0.001) were associated with ECA. Neglect, but not Abuse and Chaotic Home Environment, was associated with depression (β = 0.442, p < 0.001), anxiety (β = 0.342, p = 0.002), and self-identified problems with family (β = 0.288, p = 0.022), emotion (β = 0.345, p = 0.004), and physical issues (β = 0.408, p < 0.001).

CONCLUSION

ECA and neglect are associated with multiple psychologic symptoms, but most specifically depression in the setting of breast cancer. ECA contributes to psychologic burden as a vulnerability factor. ECA may help to explain individual patient trajectories and influence the provision of patient-centered care for psychologic symptoms in patients with breast cancer.

Randomized controlled trial of cognitive behavioral stress management in breast cancer: a brief report of effects on 5-year depressive symptoms

OBJECTIVE

Survivors of breast cancer experience stress and are at risk for depressive symptoms following primary treatment. Group-based interventions such as cognitive-behavioral stress management (CBSM) delivered postsurgery for nonmetastatic breast cancer (BCa) were previously associated with fewer depressive symptoms over a 12-month follow-up; few studies have examined the longer-term benefits of such psychosocial interventions. This 5-year follow-up study of a previously conducted trial (#NCT01422551) tested whether group-based CBSM following surgery for nonmetastatic BCa was associated with fewer depressive symptoms.

METHODS

Women (N = 240) with Stage 0-IIIb BCa were recruited 2-10 weeks postsurgery and randomized to a 10-week CBSM intervention group or a 1-day psycho-educational control group. Women were recontacted 5 years poststudy enrollment and reconsented to participate in the follow-up study (N = 130). Depressive symptomatology was assessed using the Center for Epidemiologic Studies-Depression scale (CES-D). ANOVA and ANCOVA analyses were employed to test for group differences on the CES-D at 5-year follow-up accounting for relevant covariates.

RESULTS

Participants assigned to CBSM reported significantly fewer depressive symptoms (M = 9.99, SE = 0.93) at the follow-up compared with those in the control group (M = 12.97, SE = 0.99), p = .030. With covariates, the group difference remained significant, p = .012.

CONCLUSION

Women who received CBSM postsurgery for BCa reported fewer depressive symptoms than those in the control group in this 5-year follow-up. Psychosocial interventions early in treatment may influence long-term psychological well-being in BCa survivors.

Psychological interventions for patients with cancer: psychological flexibility and the potential utility of Acceptance and Commitment Therapy

Cancer is an illness affecting patients' physical and psychosocial well-being: high numbers report problematic levels of distress at many points through diagnosis, treatment and survivorship. Conclusive evidence for the long-term benefits of psychological interventions is lacking and this may be because (1) they employ a too limited scope of underlying therapeutic model; or (2) that they are too focused on improving psychopathological outcomes. Acceptance and Commitment Therapy (ACT) may add components not emphasised elsewhere and may provide a more suitable model of adjustment and coping. Following a comprehensive literature search a theoretical and conceptual discussion of the potential for ACT-based oncology interventions is presented. Only a small number of studies have purposively studied the application of ACT within the cancer setting, but this nonetheless presents useful pilot data. The data demonstrate potential clinical- and cost-effectiveness for a range of patients, including those with psychological comorbidity. Within the context of wider cancer adjustment, ACT offers an intervention framework to appropriately build upon the strong empirical base already established for Mindfulness within this specific patient population. The evidence available suggests that the underlying framework of ACT offers an intervention model that is potentially more suited to the individualistic nature of cancer adjustment.