The Use of Acceptance and Commitment Therapy in Oncology Settings: A Narrative Review

Acceptance and commitment therapy processes and their association with distress in cancer: a systematic review and meta-analysis

Around 42% of individuals with cancer experience distress. Acceptance and commitment therapy (ACT) can reduce distress, but effects are small, and mechanisms unclear. This review aimed to identify associations between ACT processes and distress in cancer. Search terms included cancer, ACT processes, self-compassion, and distress. Six online databases and grey literature were searched until March 2022. Of 6555 papers screened, 108 studies were included with 17,195 participants. Five meta-analyses of 77 studies were conducted. Random effects meta-analyses of correlations revealed higher scores on flexible processes (acceptance, present moment awareness, self-compassion) were associated with lower distress (rpooled = -0.24, -0.39, -0.48, respectively); whilst higher scores on inflexible processes (experiential avoidance, cognitive fusion) were associated with higher distress (rpooled = 0.58, 0.57, respectively). Meta-analyses displayed moderate-to-high heterogeneity with most studies assessed as low risk of bias. Meta-regressions revealed no significant moderators (stage, time since diagnosis, gender and age). This review provides a theoretically aligned evidence base for associations between ACT processes and distress in cancer, supporting elements of ACT theory and providing targeted directions for intervention development. Due to limited evidence, future research should focus on self-as-context, values and committed action and conduct mediation analysis in controlled trials of ACT processes on distress in cancer.

Effect of acceptance and commitment therapy-based interventions on mental health and cognitive impairment for patients with advanced colorectal cancer

BACKGROUND

The mental and emotional health of persons diagnosed with cancer is frequently affected. The acceptance and commitment therapy (ACT) is one of the psychological interventions that has proven successful in easing these psychological symptoms and enhancing cancer patients' psychological well-being.

METHODS

A two-arm randomized controlled trial study was utilized, 30 eligible clients with colorectal cancer were chosen randomly and were given ACT therapy at a 1:1 ratio. ACT was delivered in six sessions for 3 weeks, followed by 3 months follow-up.

RESULTS

The table shows a statistically significant increase in the mean scores of the mental health and its flourishing level among the study group than those of the control group. Cognitive impairment was significantly decreased among the study group than for those in the control group.

CONCLUSION

The ACT-based interventions may be a promising approach for improving mental health and cognitive function in cancer patients, particularly those with advanced disease.

Improving symptom management for survivors of young adult cancer: rationale and study protocol for a pilot randomized controlled trial

BACKGROUND

Young adult (YA) cancer survivors are a growing, yet underserved population who often face significant and long-lasting cancer-related physical (e.g., pain, fatigue) and emotional (e.g., psychological distress) symptoms. Post-treatment symptoms can persist, disrupting YA's abilities to complete goals consistent with their developmental stage (e.g., completing their education, achieving autonomy and independence, building their careers, establishing peer and romantic relationships, building their families). While symptom management has been identified as a significant issue in YA's transitions to survivorship, the symptom management needs of this population largely go unmet.

METHODS

We developed an eight-session, group-based behavioral intervention that is delivered using videoconferencing to address the unique symptom management needs of YA cancer survivors. The intervention was developed in conjunction with YA survivors, leading to the novel combination of traditional behavioral symptom coping strategies, home-based physical activity, strategies from contemporary cognitive-behavioral approaches (e.g., those derived from acceptance and commitment therapy, strategies to foster self-compassion), concepts from meaning centered psychotherapy, and behavioral strategies to improve communication and health care engagement. Participants receive printed intervention materials and access to a study-specific mobile application, both of which are used throughout the program. Herein, we report on a pilot study that is in progress. Recruitment has been completed. YA cancer survivors were recruited in cohorts of n = 10 or n = 11 (n = 61) and randomized to the intervention or waitlist control arms. All participants completed a baseline assessment and four additional assessments over 1 year, with each involving a battery of self-report measures.

DISCUSSION

The primary objective is to evaluate intervention feasibility and acceptability. As a secondary objective, we will examine patterns of change in intervention targets (i.e., pain, fatigue, emotional distress, symptom interference). Changes from baseline among intervention targets will be estimated for each patient and compared between arms using unadjusted statistical testing. Unadjusted and adjusted multilevel modeling will be used to estimate the effect of the intervention on changes in intervention targets. Interaction models will be used to compare the trajectory of change over time between arms. We expect that this pilot trial will inform our future approach to identify, recruit, and retain participants and provide preliminary data to support a larger, fully powered randomized controlled trial evaluating the intervention.

TRIAL REGISTRATION

NCT04035447 at clinicaltrials.gov; registered July 29, 2019.

Feasibility study of a mobile application (ACT-ON) to complement acceptance and commitment therapy (ACT) intervention in cancer patients

OBJECTIVE

Psychological and physical distress commonly affect cancer patients. Acceptance and commitment therapy (ACT) has shown promising results when it comes to ameliorating symptoms that may develop as a result of this. Meanwhile, it has come to light that the impact of psychological interventions may be enhanced by the use of mobile applications. However, to date no mobile applications have been developed to support ACT-based interventions in cancer patients. The aim of the present study is to develop and test the usability of a mobile application designed to complement face-to-face ACT-based therapy in a group of cancer patients undergoing treatment.

MATERIALS AND METHODS

A total of thirty-nine patients were recruited to participate in this pilot study. Participants had to be: 18 years of age or over, currently undergoing treatment for breast, lung or colorectal cancer, in stage I-III, a smartphone user with daily internet access. The intervention sessions were administered for a period of eight weeks, one hour per week to groups of four to six participants. Patients had the ACT-ON mobile application at their disposal, which provided them with access to therapy-related activities: mindfulness, metaphors and exercises to clarify values.

RESULTS

The application obtained adequate adoption (61.54%) and usage (54.17%) rates. Usability and ease of learning scores were as follows: good usability (M = 79.81, SD = 11.87); high usability (M = 80.53, SD = 14.04); ease of learning (M = 37.5, SD = 23.85).

DISCUSSION

This is the first study to develop and evaluate the usability of an application designed to support ACT-based interventions in cancer patients undergoing treatment. The results show that the ACT-ON app is a feasible tool which achieves high levels of usability. However, said results ought to be confirmed by studies that include a larger number of cancer patients.

Improving Symptom Management for Survivors of Young Adult Cancer: Development of a Novel Intervention

Purpose: Improved symptom management is a critical although unmet post-treatment need for young adult (YA) cancer survivors (aged 18-39 at diagnosis). This study aimed to develop and refine a behavioral symptom management intervention for YA survivors. Methods: Phase I: YA survivors (N = 21) and oncology providers (N = 11) completed individual interviews and an online, self-report assessment to examine symptom experiences, the need for a behavioral symptom management intervention for YAs, and perceptions about potential intervention components, structure, and format. Phase II: YA survivors (N = 10) completed user testing sessions, providing feedback on the prototype intervention materials (paper manual and mobile application), and completed an online assessment. Quantitative data were examined using descriptive statistics. Rapid qualitative analysis, a methodologically rigorous standardized approach, was used. Results: Pain, fatigue, and distress were ranked as top concerns by most YAs and providers. Phase I interviews underscored the need for a symptom management intervention for YAs. YAs and providers highlighted potential coping strategies and program format/structure suggestions (e.g., small group format) to best meet YAs' needs. A prototype intervention was developed combining the following: traditional behavioral symptom coping skills; home-based physical activity; strategies from Acceptance and Commitment Therapy and Meaning-Centered Psychotherapy; and strategies to foster self-compassion. Phase II user testing sessions highlighted strengths and suggestions for refining the prototype materials. Conclusion: Post-treatment symptoms are common for YAs. A tailored behavioral symptom management program was developed and refined with input from YAs and providers and will be examined for feasibility and acceptability in a pilot randomized controlled trial. Clinical Trial: Clinicaltrials.gov identifier NCT04035447.

Building coping skills to relieve distress and physical symptoms: Findings from a quality improvement project of a five-week group psychoeducational program for cancer patients

To examine the effectiveness of Mind Over Matter (MOM), a group psychosocial intervention based on CBT, ACT, and mind-body interventions, from data collected during a quality improvement project. MOM was offered in person prior to COVID-19 and via telehealth after COVID-19 began.

Distress, as measured by anxiety, depression, the severity of physical symptoms and the impact of physical symptoms on daily functioning, was measured pre- and post-MOM.

The sample included 46 participants with an experience of cancer ranging in age from 31 to 75.

Overall, there were significant differences in anxiety, depression, and physical symptom severity and interference pre and post MOM. The in-person intervention showed significant differences in anxiety, depression, and physical symptom interference. There were significant differences in anxiety and physical symptom severity reported in the telehealth groups.

MOM may be an effective psychosocial intervention for addressing cancer-related physical and emotional challenges making it a valuable resource for institutions trying to meet needs identified by distress screenings.

The development of a Cancer Pain Belief Modification Program for patients with oral cancer in China: a feasibility study

BACKGROUND

Acceptance-based pain management interventions have been receiving growing attention in cancer pain care. This study aimed to develop a cancer pain management program based on belief modification to improve the cancer pain experience of Chinese oral cancer survivors and to explore the acceptability and preliminary outcomes of the Cancer Pain Belief Modification Program (CPBMP).

METHODS

A mixed-methods approach was applied to develop and revise the program. The CPBMP was developed and revised using the Delphi technique, and its further improvement was explored with a one-group pre- and post-trial designed with a sample of 16 Chinese oral cancer survivors, and semi-structured interviews. Research instruments included Numeric Rating Scale (NRS), Chinese version of Illness Perception Questionnaire-Revised for Cancer Pain (IPQ-CaCP), and the University of Washington Quality of Life assessment scale (UW-QOL). Descriptive statistics, t-test, and Mann-Whitney U test were used to analyse the data. The semi-structured questions were analysed using content analysis.

RESULTS

The six-module CPBMP was endorsed by most experts and patients. The expert authority coefficient value was 0.75 in the first round of the Delphi survey and 0.78 in the second round. The "pain intense", "negative pain beliefs" scores of pre- and post-testing decreased from 5.63 ± 0.48 to 0.81 ± 0.54 (t = -3.746, p < 0.001); from 140.63 ± 9.02 to 52.75 ± 7.27 (Z = 12.406, p < 0.001); and the "positive pain beliefs", "quality of life" scores increased from 55.13 ± 4.54 to 66.00 ± 4.70 (Z = -6.983, p < 0.001); from 66.97 ± 15.01 to 86.69 ± 8.42 (Z = 7.283, p < 0.001). The qualitative data also indicated that CPBMP was well acceptable.

CONCLUSION

Our study showed the acceptability and preliminary outcomes of CPBMP patients. CPBMP improves the pain experience of Chinese oral cancer patients and provides a reference for cancer pain management in the future.

TRIAL REGISTRATION

The feasibility study has already been registered on the Chinese Clinical Trial Registry (ChiCTR) ( www.chictr.org.cn ) in 11/09/2021. (ChiCTR2100051065).

Exploring the moderated role of two psychological programs on sexual pleasure from physical symptoms, body image distortion and emotional problems of Hispanic women with breast cancer

Decreased sexual pleasure is a common problem in women with breast cancer. The aim of this study was to evaluate the effect of psychoeducation vs. acceptance and commitment therapy to improve sexual pleasure according to the predictive role of physical, cognitive and emotional factors. Results of 139 Hispanic women (Mexico and Spain) diagnosed with breast cancer reveal that only the emotional factor of depression predicts decreased sexual pleasure. Although women who participated in the psychoeducation program presented greater physical symptomatology, body image distortions and emotional distress, the results seem to indicate that psychoeducational guidelines are relevant to improve sexual pleasure in those women who manifest higher levels of previous depression. Future research is required to clarify these issues.

Feasibility of RESTORE: An online Acceptance and Commitment Therapy intervention to improve palliative care staff wellbeing

BACKGROUND

Acceptance and Commitment Therapy is a form of Cognitive Behavioural Therapy which uses behavioural psychology, values, acceptance and mindfulness techniques to improve mental health and wellbeing. Acceptance and Commitment Therapy is efficacious in treating stress, anxiety and depression in a broad range of settings including occupational contexts where emotional labour is high. This approach could help palliative care staff to manage work-related stress and promote wellbeing.

AIM

To develop, and feasibility test, an online Acceptance and Commitment Therapy intervention to improve wellbeing of palliative care staff.

DESIGN

A single-arm feasibility trial of an 8-week Acceptance and Commitment Therapy based intervention for staff, consisting of three online facilitated group workshops and five online individual self-directed learning modules. Data was collected via online questionnaire at four time-points and online focus groups at follow-up.

SETTING/PARTICIPANTS

Participants were recruited from Marie Curie hospice and nursing services in Scotland.

RESULTS

Twenty five staff commenced and 23 completed the intervention (93%). Fifteen participated in focus groups. Twelve (48%) completed questionnaires at follow-up. Participants found the intervention enjoyable, informative and beneficial. There was preliminary evidence for improvements in psychological flexibility (Cohen's d = 0.7) and mental wellbeing (Cohen's d = 0.49) between baseline and follow-up, but minimal change in perceived stress, burnout or compassion satisfaction.

CONCLUSION

Online Acceptance and Commitment Therapy for wellbeing is acceptable to palliative care staff and feasible to implement using Microsoft Teams in a palliative care setting. Incorporating ways to promote long-term maintenance of behaviour changes, and strategies to optimise data collection at follow-up are key considerations for future intervention refinement and evaluation.

Improving well-being for individuals with persistent pain after surgery for breast cancer, lobular carcinoma in situ, or ductal carcinoma in situ: A randomized clinical trial

>276,000 Americans will be diagnosed with invasive breast cancer, lobular carcinoma in situ, or ductal carcinoma in situ this year and most will undergo breast surgery as part of their care. Although prognosis is excellent, many patients experience persistent post-surgical pain (PSP), which has no satisfactory pharmacological treatment. The causal contributions of pain-associated psychological factors (e.g., catastrophic thoughts about pain, psychological flexibility, self-efficacy) to the continuing burden of PSP have not yet been determined and may be opportune intervention targets. The randomized trial described here will compare the benefits of three manualized behavioral interventions for individuals with PSP. Participants will receive either: 1) self-guided health education (SGHE); 2) interventionist-guided health education (IGHE); or 3) interventionist-guided pain coping skills training with elements of acceptance and commitment therapy that specially target catastrophic thoughts about pain, self-efficacy, and psychological flexibility (CST-PSP). Participants will prospectively complete validated assessments of primary outcomes (PSP severity and interference) at baseline (pre-intervention) and 3-, 6-, and 12-months later. Validated measures of emotional distress and cancer-specific distress will be assessed as secondary outcomes. To test their roles as drivers of PSP, catastrophic thoughts about pain, self-efficacy, and psychological flexibility, will be assessed and statistically analyzed as mediators of hypothesized beneficial effects. The interventions' impacts on pain sensitivity and central sensitization will be investigated to test these physiological pathways as proximal drivers of PSP. To better characterize the patient experience, additional validated measures will be explored for associations with PSP, along with demographic and clinical factors. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04225585, registered January 13, 2020.

Efficacy of a Combined Acceptance and Commitment Intervention to Improve Psychological Flexibility and Associated Symptoms in Cancer Patients: Study Protocol for a Randomized Controlled Trial

Psychological flexibility is a key concept of acceptation and commitment therapy (ACT). This factor has been linked with psychological wellbeing and associated factors, such as quality of life, in cancer patients. These and other positive results of acceptation and commitment therapy in cancer patients found in previous research could be enhanced by using mhealth tools. A three-arm randomized superiority clinical trial, with a pre-post-follow-up repeated measures intergroup design with a 1:1:1 allocation ratio is proposed. A hundred and twenty cancer patients will be randomly assigned to one of the following interventions: (1) face-to-face ACT + mobile application (app), (2) face-to-face ACT, and (3) Waitlist control group. The primary expected outcome is to observe significant improvements in psychological flexibility acceptance and action questionnaire- II (AAQ-II) in the face-to-face ACT + app group, after comparing baseline and post-treatment scores, and the scores will remain stable in the two assessment points, 3 and 6 months after the intervention. Secondary expected outcomes are significant increasing scores in quality of life (EORTC QLQ C-30) and post-traumatic-growth (PTGI-SF), and significant decreasing scores in anxiety and depression (HADS), insomnia (ISI) and fatigue (BFI) at the same assessment points. Also, it is expected that the scores of this group will be higher than the scores of the face-to-face ACT group and the waitlist control group. This study aims to assess the efficacy of a combined intervention (face-to face ACT + app) for psychological flexibility and associated symptoms in cancer patients. The results of this protocol may help to consider the use of acceptation and commitment therapy and mhealth applications in cancer settings as a valid therapeutic choice.

Development and Evaluation of the Usefulness, Usability, and Feasibility of iNNOV Breast Cancer: Mixed Methods Study

BACKGROUND

Despite the efficacy of psychosocial interventions in minimizing psychosocial morbidity in breast cancer survivors (BCSs), intervention delivery across survivorship is limited by physical, organizational, and attitudinal barriers, which contribute to a mental health care treatment gap in cancer settings.

OBJECTIVE

The aim of this study is to develop iNNOV Breast Cancer (iNNOVBC), a guided, internet-delivered, individually tailored, acceptance and commitment therapy-influenced cognitive behavioral intervention program aiming to treat mild to moderate anxiety and depression in BCSs as well as to improve fatigue, insomnia, sexual dysfunction, and health-related quality of life in this group. This study also aims to evaluate the usefulness, usability, and preliminary feasibility of iNNOVBC.

METHODS

iNNOVBC was developed using a user-centered design approach involving its primary and secondary end users, that is, BCSs (11/24, 46%) and mental health professionals (13/24, 54%). We used mixed methods, namely in-depth semistructured interviews, laboratory-based usability tests, short-term field trials, and surveys, to assess iNNOVBC's usefulness, usability, and preliminary feasibility among these target users. Descriptive statistics were used to characterize the study sample, evaluate performance data, and assess survey responses. Qualitative data were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Overall, participants considered iNNOVBC highly useful, with most participants reporting on the pertinence of its scope, the digital format, the relevant content, and the appropriate features. However, various usability issues were identified, and participants suggested that the program should be refined by simplifying navigation paths, using a more dynamic color scheme, including more icons and images, displaying information in different formats and versions, and developing smartphone and tablet versions. In addition, participants suggested that tables should be converted into plain textboxes and data visualization dashboards should be included to facilitate the tracking of progress. The possibility of using iNNOVBC in a flexible manner, tailoring it according to BCSs' changing needs and along the cancer care continuum, was another suggestion that was identified.

CONCLUSIONS

The study results suggest that iNNOVBC is considered useful by both BCSs and mental health professionals, configuring a promising point-of-need solution to bridge the psychological supportive care gap experienced by BCSs across the survivorship trajectory. We believe that our results may be applicable to other similar programs. However, to fulfill their full supportive role, such programs should be comprehensive, highly usable, and tailorable and must adopt a flexible yet integrated structure capable of evolving in accordance with survivors' changing needs and the cancer continuum.

Acceptance and Commitment Therapy for Demoralization Syndrome and Cancer-related Trauma: A Randomized Clinical Trial Study

Background: Many women with breast cancer in the process of diagnosing, treating, and surviving show psychological distress such as hopelessness and cancer-related stress. On the other hand, Acceptance and Commitment Therapy (ACT) as a psychological intervention provides a good model for coping with the disease. Objectives: This study aimed at investigating the effectiveness of ACT on demoralization syndrome and cancer-related trauma in patients with breast cancer and survivors. Methods: The present study was a clinical trial with pre-test and post-test. It was performed on 52 patients with breast cancer and survivors referred to the Golestan Cancer Patients Association in Gorgan in 2020. Initially, participants were selected by convenient sampling and randomly divided into two treatment groups (patients group and survivors group) and two control groups (patients group and survivors group). Then, the treatment groups underwent ACT for 8 consecutive weekly sessions, but the control groups did not receive any intervention. The data were obtained, using the Demoralization Scale (DS) and Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) and analyzed by multivariate analysis of covariance (MANCOVA). Results: The results of the study showed a significant difference in demoralization syndrome components and PCL-5 between the treatment groups of patients and survivors with control groups of patients and survivors (P < 0.05). Also, there was no significant difference between the treatment groups of patients and survivors in the components of demoralization and PCL-5 (P > 0.05) except for the feeling of failure component (P = 0.048). Conclusions: According to the results, using ACT as a complementary treatment along with medical treatment to prevent and reduce demoralization syndrome and cancer-related trauma is recommended in patients with breast cancer and survivors.

Structure and conceptualization of acceptance: a split-sample exploratory and confirmatory factor analysis approach to investigate the multidimensionality of acceptance of spinal cord injury

Objective

To determine the multidimensionality of acceptance of spinal cord injury (SCI).

Participants

Adults with SCI who were admitted to an SCI centre between 1991 and 2020.

Methods

All eligible participants (n=686) were invited to complete a survey via REDCap. A 4-dimensional model was hypothesized, which included “Accepting Reality”, “Value Change”, “Letting Go of Control” and “Behavioural Engagement”. Items from 3 acceptance scales were selected to collectively reflect these 4 dimensions: (i) Spinal Cord Lesion-related Coping Strategies Questionnaire, (ii) Coping Orientations to Problems Experienced, and (iii) a modified Acceptance and Action Questionnaire. A split-sample principal component analysis (PCA) and confirmatory factor analysis (CFA) approach was used.

Results

Complete data were provided by 431 participants (62.8%). A PCA on sub-sample one suggested a 4-factor model based on eigenvalues ≥ 1, corresponding to the hypothesized model of acceptance. A CFA on sub-sample 2 showed good model fit, adding further support to the model.

Conclusion

These findings suggest that acceptance is a multidimensional construct with 4 facets that represent distinct, but interconnected, psychological processes. This model of acceptance can be used as a framework for future research and clinical practice to deepen our understanding of acceptance processes following severe injuries, such as SCI.

Systematic Review and Meta-Analysis of Effectiveness of Acceptance and Commitment Therapy in Patients With Breast Cancer

BACKGROUND

The physical and psychological well-being of patients with breast cancer is an important global issue. Acceptance and commitment therapy (ACT) aims to equip patients with the skills to respond and adapt to difficult circumstances. However, the extent of the physical and psychological outcomes of this therapy in patients with breast cancer remains unclear.

OBJECTIVES

The aim of the study was to summarize available evidence and assess the efficacy of ACT on physiological and psychological outcomes in patients with breast cancer.

METHODS

Published randomized controlled studies were identified in MEDLINE, PsycInfo, Embase, Web of Science, CINAHL, and CNKI from inception to December 2019 and Cochrane Library, AMED, and Clinical trials.gov from inception to September 2020. Methodological rigor was assessed by two reviewers using the Cochrane Handbook for Systematic Review of Interventions. Sufficient data were statistically pooled with review manager; otherwise, a narrative summary was used.

RESULTS

Thirteen trials were included in the review. Methodological quality varied across the studies. Meta-analyses demonstrated that ACT had moderate to large effects on reducing anxiety, depression, and stress and improving hope. Sensitivity analyses reached results similar to those of the meta-analyses. However, the effects of ACT on the physiological symptoms, fear of cancer recurrence, and psychological flexibility of patients with breast cancer remain inconclusive.

DISCUSSION

ACT has beneficial effects on the anxiety, depression, stress, and hope of patients with breast cancer. The evidence of ACT on physiological symptoms, fear of cancer recurrence, and psychological flexibility needs to be treated with caution. Further studies are needed and should consider different delivery forms and also explore the mechanisms of each component of ACT under different cultural contexts.

Transitions in coping profiles after breast cancer diagnosis: implications for depressive and physical symptoms

The objective of this study was to determine whether: (a) cancer-related coping profiles change across time; (b) coping profile transition types predict changes in depressive and physical symptoms. Latent transition analysis was conducted with repeated measures of seven cancer-related coping processes from 460 women recently diagnosed with breast cancer. In multilevel models, coping profile transition groups were entered as predictors of symptoms across 12 months. Three coping profiles emerged at study entry, with two profiles at later assessments. Forty-eight percent of women maintained high-moderate approach-oriented coping over time. Specific factors (e.g., age, acceptance of emotions) differentiated the transition groups. Women who increased and then maintained high-moderate approach-oriented coping had relatively high initial depressive symptoms that declined steeply. When cancer-related acceptance predominated, women experienced increasing physical symptoms. Distinct cancer-related coping patterns are related to the level of and change in depressive and physical symptoms longitudinally. Early intervention to increase approach-oriented coping strategies could yield favorable outcomes.

The effects of acceptance and commitment therapy on the psychological and physical outcomes among cancer patients: A meta-analysis with trial sequential analysis

OBJECTIVE

The current study used meta-analysis and trial sequential analysis to estimate the effects of Acceptance and Commitment Therapy (ACT) on the psychological and physical distress of cancer patients, and to identify potential moderators in this body of research.

METHODS

A search of multiple databases in February 2020 identified 25 independent trials (17 randomized controlled trials, 8 non-randomized controlled trials; 2256 participants) on the effects of ACT among cancer patients. Trial sequential analysis (TSA) was used to determine whether the available evidence is sufficient to draw strong conclusions.

RESULTS

ACT significantly reduced cancer patients' psychological distress (g = 0.88), and improved psychological flexibility (g = 0.58), quality of life (g = 1.19), and sense of hope (g = 2.17). TSA showed that there was sufficient evidence to obtain stable estimates of the effect of ACT on psychological distress and quality of life. Effect sizes for psychological distress were larger in studies conducted in eastern countries, in younger samples, and when therapy was of longer duration.

CONCLUSION

Acceptance and Commitment Therapy can effectively improve the mental health of cancer patients, and can be applied to clinical practice as an effective psychological intervention. Researchers are encouraged to take into account stage and trajectory of cancer in future studies.

A nurse-led intervention for fear of cancer progression in advanced cancer: A pilot feasibility study

PURPOSE

To assess the feasibility, acceptability, and preliminary effects of a nurse-led intervention for managing fear of cancer progression in advanced cancer patients.

METHODS

A single group mixed methods study was conducted in patients with stage III or IV gynecologic or lung cancer (n = 31) with dysfunctional levels of fear of progression or distress. The intervention consisted of seven videoconferencing sessions with skills practice. Feasibility measures included enrollment rate, attendance, attrition, and home practice adherence. Acceptability was based on exit interview responses. Content analysis was used to analyze the qualitative data. Participants completed quantitative questionnaires assessing fear of progression and secondary outcomes at baseline, eight, and 12 weeks. Linear mixed model analysis was used to assess changes in outcome measures.

RESULTS

The average enrollment rate was seven participants/month over 4.5 months. Participants attended a mean of 5.3 of seven sessions. Attrition rate was 30%. The analysis showed improvements over time in fear of progression and exploratory outcomes. Participants reported feeling calmer and more focused. The skills practice helped to manage anxiety and fears. Themes included: Struggling with fears, Refocusing the fears, and Realizing/reaffirming what is important in life. The most beneficial components included the values clarification exercise, detached mindfulness and worry postponement practices.

CONCLUSION

The intervention was acceptable; most feasibility criteria were met. Preliminary data suggest that the intervention reduced fear of progression and improved secondary outcomes. The intervention required a significant time commitment by participants, which may have contributed to increased attrition. To decrease burden, we will shorten the intervention.

A systematic review of behavioral interventions for rural breast cancer survivors

Rural breast cancer survivors (RBCS) are at greater risk for poorer health outcomes and face greater treatment barriers compared to their urban counterparts, necessitating behavioral interventions tailored for the unique needs of RBCS. A systematic review of studies examining behavioral interventions delivered to RBCS living in the United States from 2000 to 2020 was conducted following PRIMSA guidelines. Nineteen unique studies were included: eight randomized controlled trials, two matched-control studies, six pre-post intervention feasibility studies, and three post-intervention satisfaction studies. Thirteen interventions aimed to improve psychosocial support, three to improve weight management, and three to improve education. Results indicate interventions' feasibility and acceptability. Six out of eight intervention conditions reported favorable outcomes compared to control conditions, suggesting promise for efficacy. However, variability in intervention objective, duration, delivery, and follow-up timing, and small sample sizes prevent overarching conclusions. Research involving larger sample sizes, higher quality control groups, and longer follow-up data is needed.

Fear of Cancer Progression: Findings From Case Studies and a Nurse-Led Intervention

BACKGROUND

Fear of cancer recurrence or progression (FOP) is a significant concern for cancer survivors. With the advent of new targeted therapies and immunotherapy, many patients with advanced cancer are living longer while dealing with uncertainty and fears related to cancer progression. Although some level of FOP is normal and adaptive, high levels adversely affect quality of life and healthcare costs.

OBJECTIVES

This article describes a nurse-led intervention for managing FOP in two patients with advanced gynecologic cancer. The intervention teaches skills for managing worry, challenging unhelpful beliefs, and modifying unhelpful coping behaviors.

METHODS

Preliminary findings from the two case studies are presented, including a comparison of post-treatment FOP scores to baseline scores.

FINDINGS

The participants reported feeling more focused, less overwhelmed, and more in control of their worries. Both participants achieved statistically reliable improvements in FOP scores.

Longitudinal course and predictors of communication and affect management self-efficacy among women newly diagnosed with gynecological cancers

OBJECTIVE

Self-efficacy is an important psychological resource to assist people in managing chronic illness and has been associated with psychological outcomes among patients coping with cancer. Little is known about the course of self-efficacy among gynecological cancer patients coping with cancer and the sociodemographic, medical, and psychological factors that are associated with the course of self-efficacy among these patients.

METHODS

One hundred twenty-five women recently diagnosed with gynecological cancer completed a measure of communication and affective management self-efficacy at baseline, 5 weeks, 9 weeks, 6 months, 1 year, and 18 months post-baseline. Participants also completed measures of functional impairment, holding back, perceived unsupportive behaviors of family and friends, emotional expressivity, cancer concerns, depressive symptoms, cancer-specific intrusions and avoidance, problem-solving, and positive reappraisal coping.

RESULTS

Growth curve modeling suggested that women varied considerably in their average reports of self-efficacy and varied with regard to their linear trajectories of self-efficacy over time. Average affect management self-efficacy increased significantly over time. Greater functional impairment, more holding back, more unsupportive responses from friends and family, less emotional expressivity, more cancer concerns, depression, intrusions, or avoidance predicted lower average self-efficacy over time. Women who were less emotionally expressive or held back sharing concerns less reported lower self-efficacy which increased over time.

CONCLUSIONS

It will be important for providers to identify gynecological cancer patients who report low ability to communicate feelings and needs and manage emotional reactions to cancer and offer them interventions which bolster self-efficacy.

Machine-learned identification of psychological subgroups with relation to pain interference in patients after breast cancer treatments

Background

Persistent pain in breast cancer survivors is common. Psychological and sleep-related factors modulate perception, interpretation and coping with pain and may contribute to the clinical phenotype. The present analysis pursued the hypothesis that breast cancer survivors form subgroups, based on psychological and sleep-related parameters that are relevant to the impact of pain on the patients’ life.

Methods

We analysed 337 women treated for breast cancer, in whom psychological and sleep-related parameters as well as parameters related to pain intensity and interference had been acquired. Data were analysed by using supervised and unsupervised machine-learning techniques (i) to detect patient subgroups based on the pattern of psychological or sleep-related parameters, (ii) to interpret the detected cluster structure and (iii) to relate this data structure to pain interference and impact on life.

Results

Artificial intelligence-based detection of data structure, implemented as self-organizing neuronal maps, identified two different clusters of patients. A smaller cluster (11.5% of the patients) had comparatively lower resilience, more depressive symptoms and lower extraversion than the other patients. In these patients, life-satisfaction, mood, and life in general were comparatively more impeded by persistent pain.

Conclusions

The results support the initial hypothesis that psychological and sleep-related parameter patterns are meaningful for subgrouping patients with respect to how persistent pain after breast cancer treatments interferes with their life. This indicates that management of pain should address more complex features than just pain intensity. Artificial intelligence is a useful tool in the identification of subgroups of patients based on psychological factors.

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Pain interference with daily life is relevant for post-surgery breast cancer patients.

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11.5% of 337 patients belonged to a subgroup with high life interference of pain.

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Life interference was not a function of pain intensity.

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Risk factors were lower resilience, more depressive symptoms and lower extraversion.

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Life-satisfaction, mood, and life in general were impeded by persistent pain.

A feasible and acceptable multicultural psychosocial intervention targeting symptom management in the context of advanced breast cancer

OBJECTIVE

Advanced breast cancer patients around the world experience high symptom burden (ie, distress, pain, and fatigue) and are in need of psychosocial interventions that target symptom management. This study examined the feasibility, acceptability, and engagement of a psychosocial intervention that uses cognitive-behavioral strategies along with mindfulness and values-based activity to enhance patients' ability to manage symptoms of advanced disease in a cross-cultural setting (United States and Singapore). Pre-treatment to post-treatment outcomes for distress, pain, and fatigue were compared between intervention recipients and waitlisted controls.

METHODS

A pilot randomized controlled trial included women with advanced breast cancer (N = 85) that were recruited in the United States and Singapore. Participants either received the four session intervention or be put on waitlist. Descriptive statistics and effect size of symptom change were calculated.

RESULTS

The psychosocial intervention was found to be feasible as indicated through successful trial accrual, low study attrition (15% ), and high intervention adherence (77% completed all sessions). Acceptability (ie, program satisfaction and cultural sensitivity) and engagement to the study intervention (ie, practice of skills taught) were also high. Anxiety, depression, and fatigue scores remained stable or improved among intervention participants while the same symptoms worsened in the control group. In general, effect sizes are larger in the US sample compared with the Singapore sample.

CONCLUSIONS

The cognitive-behavioral, mindfulness, and values-based intervention is feasible, acceptable, and engaging for advanced breast cancer patients in a cross-cultural setting and has potential for efficacy. Further larger-scaled study of intervention efficacy is warranted.

Coping Skills Training and Acceptance and Commitment Therapy for Symptom Management: Feasibility and Acceptability of a Brief Telephone-Delivered Protocol for Patients With Advanced Cancer

CONTEXT

Patients with advanced cancer face a life-limiting condition that brings a high symptom burden that often includes pain, fatigue, and psychological distress. Psychosocial interventions have promise for managing symptoms but need additional tailoring for these patients' specific needs. Patients with advanced cancer in the community also face persistent barriers-availability of interventions in community clinics as well as financial and illness-related factors-to accessing psychosocial interventions.

OBJECTIVES

The aim of the present study was to assess the feasibility and acceptability of telephone implementation of Engage, a novel brief combined Coping Skills Training and Acceptance and Commitment Therapy protocol, for reducing symptoms and increasing quality of life in community patients with advanced cancer.

METHODS

Adult patients with advanced cancer receiving care in the community received Engage, four 60-minute manualized telephone sessions delivered by a trained psychotherapist and completed pretreatment and post-treatment assessments.

RESULTS

Engage was feasible, achieving 100% accrual (N = 24) of a heterogeneous sample of patients with advanced cancer, with good retention (88% completed). Acceptability was demonstrated via satisfaction (mean 29 of 32; SD 2), engagement (95% attendance), and use of skills. Secondary analyses pointed to reductions in pain interference, fatigue, psychological distress, and improvements in psychological acceptance and engagement in value-guided activity after treatment.

CONCLUSION

Engage, our brief novel combined Coping Skills and Acceptance and Commitment Therapy intervention, demonstrated initial feasibility and acceptability when delivered over the telephone and increased access for community clinic patients with advanced cancer. Future research will assess the comparative efficacy of Engage in larger randomized trials.

A Two-Day Acceptance and Commitment Therapy (ACT) Workshop Increases Presence and Work Functioning in Healthcare Workers

BACKGROUND

In this controlled naturalistic study performed in healthcare workers we examined the effect of a two-day acceptance commitment therapy (ACT) workshop on work presence and productivity, i.e. the influence the workshop had on treatment efficacy in a routine hospital care setting.

AIM

To examine the influence of ACT on productivity and presence in healthcare workers.

METHOD

Study participants were all healthcare workers (nurses, medical doctors, physiotherapists, social workers, and art therapists) of four inpatient wards for depression. Half of the healthcare workers attended the workshop. Measures were evaluated 3 months after the intervention in the study participants and the patients treated by them in the same time period.

RESULTS

A significantly higher treatment efficacy [as measured with HoNOS (Health of the nation outcome scales) change in the patients treated by the participants] has been observed in the healthcare workers who attended the ACT workshop when compared to the control group who did not attend the workshop. Moreover, the work presence of the participants of the ACT workshop was increased when compared with the time period before the intervention and with the presence of the control group. A cost analysis showed that ACT workshops lead to a significant return of investment for the employer as the costs for the workshop were ten times compensated by the increase of work presence in participants of the workshop.

CONCLUSION

These findings provide support that ACT interventions motivate healthcare workers to work and increase their patients' treatment quality. To our knowledge this is the first study showing an ACT workshop in healthcare workers can influence HoNOS outcome in the treated patients.

The associations of acceptance with quality of life and mental health following spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To identify, critically appraise, and synthesize research findings on the associations between acceptance, quality of life (QOL), and mental health outcomes in individuals living with spinal cord injury (SCI).

METHODS

Five databases (PubMed, PsycINFO, Embase, Web of Science, and Scopus) were systematically searched. Studies were included if they provided findings on the association between acceptance and QOL, mental health outcomes, or both in an SCI population aged 16 years or older. Only peer-reviewed original quantitative and qualitative studies were included. Screening, quality assessment, and data extraction were conducted independently by two researchers. Findings were tabulated and synthesized by outcome.

RESULTS

Forty-one studies were included. Greater acceptance was consistently associated with greater global and psychological QOL, life satisfaction, sense of well-being, mental health, and with lower levels of depression and anxiety. Inconsistent evidence was found with regards to social QOL and post-traumatic stress disorder. Acceptance was generally not associated with adjustment outcomes further than 2 years into the future. Study quality of the quantitative studies was mostly fair (n = 17) followed by good (n = 13), and poor (n = 9).

CONCLUSION

Health-care professionals may regard acceptance as a psychological resource they can aim to support in improving QOL and mental health following SCI. A range of methodological and conceptual limitations were present in the research. Future studies should prioritize longitudinal designs, consider dyadic effects, explore subjective meaning(s) of acceptance, and investigate the effectiveness of therapeutic approaches that stimulate the acceptance process.

[Intervention focused on resources to reduce anxiety and depression disorders in cancer patients: A pilot study]

INTRODUCTION

Cancer, a widespread chronic disease, represented 400,000 diagnoses in France in 2017. The diagnoses as well as the treatments are a major source of stress for most patients concerned. Secondary effects may be painful and disturbing (pain, nausea, fatigue, loss of social and/or professional status, anxiety of death), and may lead to maladaptive coping strategies (avoidant coping), psychological inflexibility, anxiety, depression, and suicide risks which are twice as important as in the general population. Research in the field of psychotherapy for cancer patients represents an important international target, in particular in what concerns enhanced patient quality of life during and after treatment. Cognitive Behavioral Therapy, Mindfulness-Based Stress Reduction, as well as adapted physical activity have shown promising results to enhance patients' quality of life at different stages of the process. However, results mainly show significant short-term effects and usually only for patients with high levels of anxiety and depression symptoms. With the development of third wave Cognitive Behavioral Therapy, more global interventions (not just aimed at anxiety and depression symptoms) have emerged. Research has underlined their efficacy on both symptom reduction (anxiety and depression) and quality of life enhancement through the development of more varied and adaptive responses to stressful situations. Positive psychology interventions, mindfulness, and Acceptance and Commitment Therapy have inspired third wave Cognitive Behavioral Therapy. Emotional acceptance, mindful awareness of thoughts and emotions, and engaging in actions that are coherent with one's values all form part of the means by which these interventions may help patients to find ways to better adjust to their stressful situation. The results of the efficacy trials carried out using these approaches were mixed, and effects were mainly modest. Furthermore, most of the studies only tested one approach at a time, while each approach activated mechanisms, which can be useful for these patients. Hence, the aim of the current study was to test an integrative program based on classical second wave Cognitive Behavioral Therapy as well as on practices from the third wave of Cognitive Behavioral Therapy. We aimed at carrying out a preliminary study assessing the potential effects of the program on cancer patients' anxiety, depression symptoms, well-being and psychological flexibility.

METHOD

Sixteen cancer patients were enrolled in a second and third wave Cognitive Behavioral Therapy workshop composed of six sessions. In-session practices were based on validated practices. Participants completed the following questionnaires before the first workshop (T1) and at the end of the sessions (T2) in order to assess anxiety, depression symptoms, well-being and psychological flexibility: HAD, WEMWBS, MPFI, AAQ-2. Qualitative data regarding acceptability were also collected at the end of the last session.

RESULTS

Among the sixteen participants, nine women (mean age=56.1years old) completed the questionnaires seven of whom had breast cancer. The results of this preliminary study showed a significant pre-to-post reduction in anxiety and depression symptoms (P=0.017) as well as on certain dimensions of psychological flexibility: reduced "self as content" (P=0.011), and enhanced cognitive diffusion (P=0.018). Only marginal differences were found on other dimensions: reduced inaction (P=0.074) and experiential avoidance (P=0.089), and enhanced "self as context" (P=0.062). Content analysis showed (1) increased positive perceptions about experiences with more serenity, (2) positive attitudes towards self (self-compassion), (3) enhanced positive relationships, and (4) ability to accept negative affect.

CONCLUSION

Patients' qualitative feedback highlighted the potential feasibility and adaptability of the program for this population. The results of this preliminary study show promising avenues for research in the field of cancer patients' adaptive coping enhancement as well as reduce anxiety and depression symptoms. This type of workshop can be considered as complementary to individual psychotherapies as they may tap into different mechanisms that help foster psychological flexibility as the group format enhances decentering processes. Further research avenues are proposed in order to assess the efficacy of such interventions in cancer patients compared to other types of interventions. Further research should also look into individual differences in order to orient patients towards practices that fit them best.

Acceptance and commitment therapy for breast cancer survivors with fear of cancer recurrence: A 3-arm pilot randomized controlled trial

BACKGROUND

Fear of cancer recurrence (FCR) has a profound negative impact on quality of life (QOL) for many cancer survivors. Breast cancer survivors (BCS) are particularly vulnerable, with up to 70% reporting clinically significant FCR. To the authors' knowledge, evidence-based interventions for managing FCR are limited. Acceptance and commitment therapy (ACT) promotes psychological flexibility in managing life's stressors. The current study examined the feasibility and preliminary efficacy of group-based ACT for FCR in BCS.

METHODS

Post-treatment BCS (91 patients with stage I-III disease) with clinical FCR randomly were assigned to ACT (6 weekly 2-hour group sessions), survivorship education (SE; 6 weekly 2-hour group sessions), or enhanced usual care (EUC; one 30-minute group coaching session with survivorship readings). FCR severity (primary outcome) and avoidant coping, anxiety, post-traumatic stress, depression, QOL, and other FCR-related variables (secondary outcomes) were assessed at baseline (T1), after the intervention (T2), 1 month after the intervention (T3), and 6 months after the intervention (T4) using intent-to-treat analysis.

RESULTS

Satisfactory recruitment (43.8%) and retention (94.5%) rates demonstrated feasibility. Although each arm demonstrated within-group reductions in FCR severity over time, only ACT produced significant reductions at each time point compared with baseline, with between-group differences at T4 substantially favoring ACT over SE (Cohen d for effect sizes, 0.80; P < .001) and EUC (Cohen d, 0.61; P < .01). For 10 of 12 secondary outcomes, only ACT produced significant within-group reductions across all time points. By T4, significant moderate to large between-group comparisons favored ACT over SE and EUC with regard to avoidant coping, anxiety, depression, QOL, and FCR-related psychological distress.

CONCLUSIONS

Group-based ACT is a feasible and promising treatment for FCR and associated outcomes in BCS that warrants testing in larger, fully powered trials.

A guided internet-delivered individually-tailored ACT-influenced cognitive behavioural intervention to improve psychosocial outcomes in breast cancer survivors (iNNOVBC): Study protocol

BACKGROUND

Internet-delivered interventions can provide remarkable opportunities in addressing breast cancer survivors' unmet support care needs, as they present an effective strategy to improve care coordination and provide access to efficacious, cost-efficient and convenient survivorship care. Nevertheless, research focusing on improving survivors' psychosocial needs using internet-based tools is scarce and its practical implementation is limited.

OBJECTIVES

To study the acceptability, feasibility, efficacy and cost-effectiveness of iNNOVBC, a 10 weeks guided internet-delivered individually-tailored Acceptance and Commitment Therapy (ACT)-influenced cognitive behavioural (CBT) intervention developed to improve mild to moderate anxiety and depression in Breast cancer survivors when compared to treatment as usual (TAU) in a waiting list control group (WLC).

METHODS

A two-arm, parallel, open label, multicentre, waiting list randomized controlled trial will be conducted to investigate the efficacy and cost-effectiveness of INNOVBC. The primary outcomes in this research will be anxiety and depression. Secondary outcomes will include psychological flexibility, fatigue, insomnia, sexual dysfunction and Health Related Quality of Life (HRQoL).

ETHICAL APPROVAL

This study has been reviewed and approved by Comissão Nacional de Proteção de Dados; Instituto Português de Oncologia do Porto Francisco Gentil; Unidade Local de Saúde de Matosinhos, EPE; Centro Hospitalar de São João and Ordem dos Psicólogos ethical committees.

EXPECTED RESULTS

It is anticipated that iNNOVBC will show to be an efficacious and cost-effective program in improving the outcomes of interest in this study, as opposed to a WLC under TAU. The results of this research will be published in accordance with CONSORT-EHEALTH guidelines.

CONCLUSIONS

This study will inform on the acceptability, feasibility, efficacy and cost-effectiveness of iNNOVBC, in improving psychosocial outcomes in breast cancer survivors when compared to TAU in a WLC. Its conclusions will contribute to understand the idiosyncrasies of designing and implementing internet-delivered interventions in breast cancer survivors.Trial Registration code: INNOVBC (NCT03275727).

The relationship between acceptance of cancer and distress: A meta-analytic review

Acceptance of cancer has long been recognized as playing a critical role in psychological adjustment to the illness, but its associations with distress outcomes have not been quantitatively reviewed. Informed by coping theory and third wave conceptualizations of acceptance, we first propose an integrated model of acceptance of cancer. Then we examine the strength of the relationships between acceptance of cancer and general and cancer-specific distress in cancer patients and potential moderators of these relationships. CINAHL, Embase, MEDLINE, PsycINFO, PsycARTICLES, and Web of Science databases were searched. Random-effects meta-analyses were conducted on 78 records (N = 15,448). Small-to-moderate, negative, and significant relationships were found between acceptance of cancer and general distress (r = -0.31; 95% CI: -0.36 to -0.26, k = 75); cancer-specific distress (r = -0.18; 95% CI: -0.21 to -0.14, k = 13); depressive symptoms (r = -0.25; 95% CI: -0.31 to -0.19, k = 41); and anxiety symptoms (r = -0.22; 95% CI: -0.30 to -0.15, k = 29). Age, marital status, and stage of cancer were identified as significant moderators. Findings suggest that acceptance of cancer may be important to target in interventions to reduce general and cancer-specific distress in cancer patients. Future research should focus on developing multifaceted measures of acceptance and identifying theory-based psychological and social processes that lead to greater acceptance.