Design of a randomized controlled trial of Internet-based cognitive behavioral therapy for treatment-induced menopausal symptoms in breast cancer survivors

Application and Mechanisms of Internet-Based Cognitive Behavioral Therapy (iCBT) in Improving Psychological State in Cancer Patients

This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (iCBT) in Improving Psychological State in Cancer Patients. iCBT's effectiveness has been investigated in treating and managing conditions like depression, psychiatric disorders, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. iCBT's role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. We conducted a thorough literature search using PubMed, Embase, Google Scholar, and Wanfang with no restrictions on the date. iCBT's role in treating and controlling psychiatric illnesses in cancer patients has been established in the literature. Development and popularization of iCBT, treament forms of iCBT, platforms for iCBT, application of iCBT, strategies and efficacy of iCBT for insomnia in cancer patients, current status of iCBT application, and genetic researches on iCBT for anxiety disorders were all reviewed and discussed in this review. From the data compiled, we conclude that iCBT is useful in treating or improving psychological state in cancer patients.

eHealth Interventions for Dutch Cancer Care: Systematic Review Using the Triple Aim Lens

BACKGROUND

Globally, the burden of cancer on population health is growing. Recent trends such as increasing survival rates have resulted in a need to adapt cancer care to ensure a good care experience and manageable expenditures. eHealth is a promising way to increase the quality of cancer care and support patients and survivors.

OBJECTIVE

The aim of this systematic review was 2-fold. First, we aimed to provide an overview of eHealth interventions and their characteristics for Dutch patients with and survivors of cancer. Second, we aimed to provide an overview of the empirical evidence regarding the impact of eHealth interventions in cancer care on population health, quality of care, and per capita costs (the Triple Aim domains).

METHODS

The electronic databases Web of Science, PubMed, Cochrane, and Ovid PsycINFO were searched using 3 key search themes: eHealth interventions, cancer care, and the Netherlands. The identified interventions were classified according to predetermined criteria describing the intervention characteristics (eg, type, function, and target population). Their impact was subsequently examined using the Triple Aim framework.

RESULTS

A total of 38 interventions were identified. Most of these were web portals or web applications functioning to inform and self-manage, and target psychosocial factors or problems. Few interventions have been tailored to age, disease severity, or gender. The results of this study indicate that eHealth interventions could positively affect sleep quality, fatigue, and physical activity of patients with and survivors of cancer. Inconclusive results were found regarding daily functioning and quality of life, psychological complaints, and psychological adjustment to the disease.

CONCLUSIONS

eHealth can improve outcomes in the Triple Aim domains, particularly in the population health and quality of care domains. Cancer-related pain and common symptoms of active treatment were not targeted in the included interventions and should receive more attention. Further research is needed to fully understand the impact of eHealth interventions in cancer care on participation, accessibility, and costs. The latter can be examined in economic evaluations by comparing eHealth interventions with care as usual.

A randomised controlled trial comparing internet-delivered cognitive behavioural therapy (iCBT) with and without main carer access versus treatment-as-usual for depression and anxiety among breast cancer survivors: Study protocol

BACKGROUND

Depression and anxiety are common problems among breast cancer survivors. Carer support is one of the most important determinants of women's psychological wellbeing. Survivors' distress can be alleviated by giving carers access to survivors' evidence-based treatment, which will help carers understand what survivors have been going through and help survivors feel more supported. Given the limited access to evidence-based treatments, an adapted internet-delivered cognitive behavioural therapy (iCBT) intervention for breast cancer survivors, but also open for carers' access, has the potential to decrease survivors' depression and anxiety symptoms and improve cancer-related communication and relationship quality between survivors and carers.

OBJECTIVES

This study evaluates (1) the effectiveness of a guided iCBT intervention for depression and/or anxiety symptoms among breast cancer survivors with and without main carer access, and (2) the acceptability and satisfaction with the iCBT programme.

METHOD

In this pilot study comparing the effectiveness of an adapted 7-week iCBT without main carer access against the iCBT with main carer access and treatment-as-usual control, 108 breast cancer survivors will be recruited and then randomised to either (1) treatment (n = 72) or (2) treatment-as-usual control group (n = 36) with a 2:1 ratio. The participants in the treatment group will be assigned to either iCBT alone or iCBT with the main carer also having access to the same content based on their preference. The primary outcome measure is the Hospital Anxiety and Depression Scale, and alongside secondary measures such as Cancer-Related Quality of Life, Breast Cancer Worry Scale, Brief COPE, and Medical Outcomes Study Social Support Survey will be completed by the survivors at baseline, post-treatment, and 2-month follow-up. Survivors who have carers will also complete Survivor-Carer Cancer Communication and Relationship Quality measures to provide insights into the effects of carer access. To assess the acceptability and satisfaction with the programme, survivors and their main carers will fill out the Helpful Aspects of Therapy Form (HAT) and Satisfaction with Online Treatment (SAT). Programme effectiveness and the effects of carer access on primary and secondary outcome measures will be evaluated on intention-to-treat and per-protocol basis using Linear-Mixed-Models.

DISCUSSION

This is the first trial comparing the effectiveness and acceptability of iCBT with and without carer access for depression and anxiety among breast cancer survivors. The findings of this study will provide novel data on the acceptability of iCBT programmes for breast cancer survivors and the impact of carer access on them and their carers.

Cognitive-Behavioral Therapy to Alleviate Treatment-Induced Menopausal Symptoms in Women With Breast Cancer: A Systematic Review

BACKGROUND

Numerous women with breast cancer (BC) exhibit early menopausal symptoms after undergoing cancer treatments. Medications that control menopausal symptoms can cause severe side effects and are contraindicated for patients with BC. Therefore, complementary and alternative medicines should be used. This study investigates the use of cognitive-behavioral therapy (CBT) for patients with menopausal symptoms after BC treatment.

OBJECTIVE

A systematic review was conducted to determine the efficacy and availability of CBT interventions in reducing treatment-induced menopausal symptoms in female patients with BC.

METHODS

Keywords were searched in Medical Subject Headings and 5 databases. The search criteria included randomized controlled trials (RCTs), non-RCTs, and single-group pre- and post-studies. Because of the risk of bias in non-RCTs using Joanna Briggs Institute's critical appraisal tools and single-group studies, the Critical Appraisal Skills Programme checklist for qualitative studies and RCTs was appraised using the Jadad scale.

RESULTS

After the review, 9 suitable studies were identified. Standard CBT programs lasted for 6 consecutive weeks, with 1 session of 1.5 hours weekly. The follow-up time was approximately 9 to 26 weeks. Women receiving CBT exhibited improvement in physical function and psychological state. This review supported the use of CBT to effectively improve the mental health of and reduce treatment-induced menopausal symptoms in BC survivors.

CONCLUSIONS

Cognitive-behavioral therapy interventions yielded positive outcomes in patients with BC, particularly in those experiencing menopausal symptoms.

IMPLICATIONS FOR PRACTICE

Cancer treatment generated severe menopausal symptoms in patients with BC. However, health professionals may use CBT to alleviate patients' menopausal symptoms.

Efficacy of health coaching and a web-based program on physical activity, weight, and distress management among cancer survivors: A multi-centered randomised controlled trial

OBJECTIVES

To investigate the efficacy of health coaching and a web-based program on survivor physical activity (PA), weight, and distress management among stomach, colon, lung and breast cancer patients.

METHODS

This randomised, controlled, 1-year trial conducted in five hospitals recruited cancer survivors within 2 months of completing primary cancer treatment who had not met ≥1 of these behavioural goals: (i) conducting moderate PA for at least 150 minutes/week or strenuous exercise for over 75 minutes per week or, in the case of lung cancer patients, low or moderate intensity exercise for over 12.5 MET per week, (ii) maintaining normal weight, and (iii) attaining a score >72 in the Post Traumatic Growth Inventory (PTGI). Participants were randomly assigned to one of three groups: the control group, a web-only group, or a health coaching + web group. The primary endpoint was based on a composite of PA, weight, and PTGI score at 12 months.

RESULTS

Patients in the health coaching + web group (difference = 6.6%, P = .010) and the web-only group (difference = 5.9%, P = .031) had greater overall improvements across the three-outcome composite than the control group. The health coaching + web group had greater overall improvement in PTGI (difference = 12.6%; P < .001) than the control group, but not in PA and weight.

CONCLUSION

The web-based program, with or without health coaching, may improve health behaviours including PA, weight, and distress management among cancer survivors within 2 months of completing primary cancer treatment. The web-based program with health coaching was mainly effective for reducing psychological distress.

European Menopause and Andropause Society (EMAS) and International Gynecologic Cancer Society (IGCS) position statement on managing the menopause after gynecological cancer: focus on menopausal symptoms and osteoporosis

Worldwide, it is estimated that about 1.3 million new gynecological cancer cases are diagnosed each year. For 2018, the predicted annual totals were cervix uteri 569 847, corpus uteri 382 069, ovary 295 414, vulva 44 235, and va​gina 17 600. Treatments include hysterectomy with or without bilateral salpingo-oophorectomy, radiotherapy, and chemotherapy. These can result in loss of ovarian function and, in women under the age of 45 years, early menopause. The aim of this position statement is to set out an individualized approach to the management, with or without menopausal hormone therapy, of menopausal symptoms and the prevention and treatment of osteoporosis in women with gynecological cancer. Our methods comprised a literature review and consensus of expert opinion. The limited data suggest that women with low-grade, early-stage endometrial cancer may consider systemic or topical estrogens. However, menopausal hormone therapy may stimulate tumor growth in patients with more advanced disease, and non-hormonal approaches are recommended. Uterine sarcomas may be hormone dependent, and therefore estrogen and progesterone receptor testing should be undertaken to guide decisions as to whether menopausal hormone therapy or non-hormonal strategies should be used. The limited evidence available suggests that menopausal hormone therapy, either systemic or topical, does not appear to be associated with harm and does not decrease overall or disease-free survival in women with non-serous epithelial ovarian cancer and germ cell tumors. Caution is required with both systemic and topical menopausal hormone therapy in women with serous and granulosa cell tumors because of their hormone dependence, and non-hormonal options are recommended as initial therapy. There is no evidence to contraindicate the use of systemic or topical menopausal hormone therapy by women with cervical, vaginal, or vulvar cancer, as these tumors are not considered to be hormone dependent.

European Menopause and Andropause Society (EMAS) and International Gynecologic Cancer Society (IGCS) position statement on managing the menopause after gynecological cancer: focus on menopausal symptoms and osteoporosis

INTRODUCTION

Worldwide, it is estimated that about 1.3 million new gynecological cancer cases are diagnosed each year. For 2018, the predicted annual totals were cervix uteri 569,847, corpus uteri 382,069, ovary 295,414, vulva 44,235 and va​gina 17,600. Treatments include hysterectomy with or without bilateral salpingo-oophorectomy, radiotherapy and chemotherapy. These can result in loss of ovarian function and, in women under the age of 45, early menopause.

AIM

The aim of this position statement is to set out an individualized approach to the management, with or without menopausal hormone therapy, of menopausal symptoms and the prevention and treatment of osteoporosis in women with gynecological cancer.

MATERIALS AND METHODS

Literature review and consensus of expert opinion.

SUMMARY RECOMMENDATIONS

The limited data suggest that women with low-grade, early-stage endometrial cancer may consider systemic or topical estrogens. However, menopausal hormone therapy may stimulate tumor growth in patients with more advanced disease, and non-hormonal approaches are recommended. Uterine sarcomas may be hormone dependent, and therefore estrogen and progesterone receptor testing should be undertaken to guide decisions as to whether menopausal hormone therapy or non-hormonal strategies should be used. The limited evidence available suggests that menopausal hormone therapy, either systemic or topical, does not appear to be associated with harm and does not decrease overall or disease-free survival in women with non-serous epithelial ovarian cancer and germ cell tumors. Caution is required with both systemic and topical menopausal hormone therapy in women with serous and granulosa cell tumors because of their hormone dependence, and non-hormonal options are recommended as initial therapy. There is no evidence to contraindicate the use of systemic or topical menopausal hormone therapy by women with cervical, vaginal or vulvar cancer, as these tumors are not considered to be hormone dependent.

Internet-based cognitive behavioral therapy aimed at alleviating treatment-induced menopausal symptoms in breast cancer survivors: Moderators and mediators of treatment effects

OBJECTIVES

Results from our recently conducted randomized controlled trial (RCT) indicated that Internet-based cognitive behavioral therapy (iCBT), with or without therapist support, is effective in reducing the perceived impact of hot flushes and night sweats (HF/NS) and overall levels of menopausal symptoms in breast cancer survivors with treatment-induced menopausal symptoms.

STUDY DESIGN

We used data of 235 women and compared the iCBT groups combined (n = 156) with the control group (n = 79). Bootstrapped multiple regression analyses with interaction terms (group x potential moderator) or indirect effects (mediation pathway) were conducted.

MAIN OUTCOME MEASURES

Reductions in perceived impact of HF/NS and overall levels of menopausal symptoms.

RESULTS

Women with lower levels of education benefited most from the iCBT. Age, time since diagnosis, current endocrine treatment, oophorectomy, frequency of HF/NS, and psychological distress did not moderate the treatment effects. Factors that mediated treatment effects were the development of healthier beliefs about experiencing hot flushes in a social context, about the impact of night sweats on sleep and daily functioning, and about the ability to control and cope with hot flushes. The acquisition of behavioral coping strategies and decreased psychological distress did not mediate treatment effects.

CONCLUSION

The results suggest that women with lower levels of education may benefit most from the current iCBT program, with or without therapist support. The development of healthier HF/NS beliefs contribute significantly to the observed positive effect of iCBT on the burden of menopausal symptoms.

CLINICAL TRIAL INFORMATION

NCT02672189.

Cost-utility, cost-effectiveness, and budget impact of Internet-based cognitive behavioral therapy for breast cancer survivors with treatment-induced menopausal symptoms

Purpose

Internet-based cognitive behavioral therapy (iCBT), with and without therapist support, is effective in reducing treatment-induced menopausal symptoms and perceived impact of hot flushes and night sweats (HF/NS) in breast cancer survivors. The aim of the current study was to evaluate the cost-utility, cost-effectiveness, and budget impact of both iCBT formats compared to a waiting list control group from the Dutch healthcare perspective.

Methods

A Markov model was constructed with a 5-year time horizon. Costs and health outcomes were measured alongside a randomized controlled clinical trial and included quality-adjusted life years (QALYs), overall levels of menopausal symptoms, and perceived impact of HF/NS. Uncertainty was examined using probabilistic and deterministic sensitivity analyses, together with a scenario analysis incorporating a different perspective.

Results

iCBT was slightly more expensive than the waiting list control, but also more effective, resulting in incremental cost-utility ratios of €23,331/QALY and €11,277/QALY for the guided and self-managed formats, respectively. A significant reduction in overall levels of menopausal symptoms or perceived impact of HF/NS resulted in incremental costs between €1460 and €1525 for the guided and €500–€753 for the self-managed format. The estimated annual budget impact for the Netherlands was €192,990 for the guided and €74,592 for the self-managed format.

Conclusion

Based on the current trial data, the results indicate that both guided and self-managed iCBT are cost-effective with a willingness-to-pay threshold of well below €30,000/QALY. Additionally, self-managed iCBT is the most cost-effective strategy and has a lower impact on healthcare budgets.

Efficacy of Internet-Based Cognitive Behavioral Therapy for Treatment-Induced Menopausal Symptoms in Breast Cancer Survivors: Results of a Randomized Controlled Trial

PURPOSE

We evaluated the effect of Internet-based cognitive behavioral therapy (iCBT), with or without therapist support, on the perceived impact of hot flushes and night sweats (HF/NS) and overall levels of menopausal symptoms (primary outcomes), sleep quality, HF/NS frequency, sexual functioning, psychological distress, and health-related quality of life in breast cancer survivors with treatment-induced menopausal symptoms.

PATIENTS AND METHODS

We randomly assigned 254 breast cancer survivors to a therapist-guided or a self-managed iCBT group or to a waiting list control group. The 6-week iCBT program included psycho-education, behavior monitoring, and cognitive restructuring. Questionnaires were administered at baseline and at 10 weeks and 24 weeks postrandomization. We used mixed-effects models to compare the intervention groups with the control group over time. Significance was set at P < .01. An effect size (ES) of .20 was considered small, .50 moderate and clinically significant, and .80 large.

RESULTS

Compared with the control group, the guided and self-managed iCBT groups reported a significant decrease in the perceived impact of HF/NS (ES, .63 and .56, respectively; both P < .001) and improvement in sleep quality (ES, .57 and .41; both P < .001). The guided group also reported significant improvement in overall levels of menopausal symptoms (ES, .33; P = .003), and NS frequency (ES, .64; P < .001). At longer-term follow-up (24 weeks), the effects remained significant, with a smaller ES for the guided group on perceived impact of HF/NS and sleep quality and for the self-managed group on overall levels of menopausal symptoms. Additional longer-term effects for both intervention groups were found for hot flush frequency.

CONCLUSION

iCBT, with or without therapist support, has clinically significant, salutary effects on the perceived impact and frequency of HF/NS, overall levels of menopausal symptoms, and sleep quality.

An Internet-based cognitive behavioral therapy for treatment-induced menopausal symptoms in breast cancer survivors: results of a pilot study

OBJECTIVE

Previous studies demonstrated that a cognitive behavioral therapy (CBT) program delivered in group sessions is effective in alleviating treatment-induced menopausal symptoms in women with breast cancer, but also that in-person CBT is inconvenient for some women and can result in low levels of program compliance. A promising, alternative approach is to use the Internet to make this form of CBT more accessible and feasible for patients. The objective of this study was to evaluate the feasibility and to generate preliminary data on the efficacy of a guided, Internet-based CBT program.

METHODS

Twenty-one participants with treatment-induced menopausal symptoms started the guided Internet-based CBT program. Self-report questionnaires were completed at baseline and at 10 weeks (posttreatment). Counselors' evaluations were obtained via interviews. Primary outcomes were program usage, compliance rates, and participant and counselor satisfaction. Secondary outcomes were overall levels of endocrine symptoms and hot flush/night sweats problem rating.

RESULTS

Ninety percent of participants completed the program as planned. Satisfaction rates were high among participants and counselors. Small revisions to the program were advised. There was a significant decrease over time in overall levels of endocrine symptoms and hot flush/night sweats problem rating.

CONCLUSIONS

These findings suggest that an Internet-based CBT program for women with treatment-induced menopausal symptoms is feasible and promising in terms of efficacy. The efficacy of the CBT program is currently being investigated in a larger randomized controlled trial.

A meta-analysis of the efficacy of cognitive behavior therapy on quality of life and psychological health of breast cancer survivors and patients

OBJECTIVE

The aim of this study was to examine the effect of cognitive behavior therapy (CBT) on quality of life (QOL) and psychological health of breast cancer survivors and patients.

METHODS

A total of 1289 references were examined from an overall literature search in PubMed, Embase, CINAHL, and the Cochrane Database of Systematic Reviews. Randomized controlled trials assessing the efficacy of CBT compared with a range of comparators in cancer survivors. We assessed the effect of CBT by using the standardized mean difference as effect size.

RESULTS

Among 1289 abstracts and 292 full-text articles reviewed, 10 studies were included. At the posttreatment period, the pooled effect size for CBT on QOL was 0.57 (95% CI, 0.44 to 0.69; P < .001), on depression was -1.11 (95% CI, -1.28 to -0.94; P < .001), on stress was -0.40 (95% CI, -0.53 to -0.26; P < .001), on anxiety was -1.10 (95% CI, -1.27 to -0.93; P < .001), and on hyperarousal cluster of symptoms was -0.18 (95% CI, -0.30 to -0.05; P < .001). The QOL was considered statistically medium effect sizes. The depression and anxiety were considered statistically large effect sizes.

CONCLUSIONS

Cognitive behavior therapy is an effective therapy for psychological symptoms of cancer survivors and patients, with meaningfully clinical effect sizes. These findings suggested that CBT should be used as the intervention for breast cancer survivors and patients when possible.

Psychosocial interventions in breast cancer survivorship care

Cancer distress screening and subsequent referral for psychosocial intervention has been mandated for continued cancer center accreditation. Increasing emphasis is being placed on the referral component of this mandate, ensuring that patient distress is not only identified but also effectively treated. Many evidence-based interventions exist for cancer distress. Specific interventions can effectively target biopsychosocial impacts of stress and promote adaptive coping, focusing on problem-solving, social support utilization, assertive communication, sexual health and intimacy, adherence to medical and supportive care recommendations, health behavior change, and emotional processing and expression. In randomized clinical trials, specific interventions have also been associated with biological improvements, including neuroendocrine and immune functioning, decreased rates of breast cancer recurrence, and improved survival rates. As cancer treatments advance and patients live longer, it is pertinent to treat the impacts of breast cancer with evidence-based interventions.