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.

Randomized controlled pilot trial of mindfulness-based stress reduction compared to psychoeducational support for persistently fatigued breast and colorectal cancer survivors.

PURPOSE: Cancer-related fatigue (CRF) is a disruptive symptom for many survivors. Despite promising evidence for efficacy of mindfulness-based stress reduction (MBSR) in reducing CRF, no trials comparing it to an active comparator for fatigued survivors have been published. The purpose of this trial was to compare MBSR to psychoeducation for CRF and associated symptoms. METHODS: Breast (n = 60) and colorectal (n = 11) cancer survivors (stage 0-III) with clinically significant CRF after completing chemotherapy and/or radiation therapy an average of 28 months prior to enrollment were randomized to MBSR or psychoeducation/support groups (PES). MBSR focused on mindfulness training; PES focused on CRF self-management. Outcomes included CRF interference (primary), CRF severity and global improvement, vitality, depression, anxiety, sleep disturbance, and pain. Outcomes were assessed at baseline (T1), post-intervention (T2), and 6-month follow-up (T3) using intent-to-treat analysis. RESULTS: Between-group differences in CRF interference were not significant at any time point; however, there was a trend favoring MBSR (d = -0.46, p = 0.073) at T2. MBSR participants reported significantly greater improvement in vitality (d = 0.53, p = 0.003) and were more likely to report CRF as moderately to completely improved compared to the PES group (χ2 (1) = 4.1765, p = 0.041) at T2. MBSR participants also reported significantly greater reductions in pain at T2 (d = 0.53, p = 0.014). In addition, both MBSR and PES produced moderate-to-large and significant within-group improvements in all fatigue outcomes, depression, anxiety, and sleep at T2 and T3 compared to T1. CONCLUSION: MBSR and PES appear efficacious for CRF and related symptoms. Larger trials including a usual care arm are warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01724333.

Randomized controlled pilot study of mindfulness-based stress reduction for persistently fatigued cancer survivors.

OBJECTIVE: Cancer-related fatigue (CRF) is one of the most common, persistent, and disabling symptoms associated with cancer and its treatment. Evidence-based treatments that are acceptable to patients are critically needed. This study examined the efficacy of mindfulness-based stress reduction (MBSR) for CRF and related symptoms. METHOD: A sample of 35 cancer survivors with clinically significant CRF was randomly assigned to a 7-week MBSR-based intervention or wait-list control group. The intervention group received training in mindfulness meditation, yoga, and self-regulatory responses to stress. Fatigue interference (primary outcome) and a variety of secondary outcomes (e.g., fatigue severity, vitality, disability, depression, anxiety, and sleep disturbance) were assessed at baseline, post-intervention, and 1-month follow-up. Bonferroni correction was employed to account for multiple comparisons. Controls received the intervention after the 1-month follow-up. Participants in both groups were followed for 6 months after completing their respective MBSR courses to assess maintenance of effects. RESULTS: Compared to controls, the MBSR group reported large post-intervention reductions as assessed by effect sizes (d) in the primary outcome, fatigue interference (d = -1.43, p < 0.001), along with fatigue severity (d = -1.55, p < 0.001), vitality (d = 1.29, p < 0.001), depression (d = -1.30, p < 0.001), and sleep disturbance (d = -0.74, p = 0.001). Results were maintained or strengthened at 1-month follow-up, the point at which significant improvements in disability (d = -1.22, p < 0.002) and anxiety (d = -0.98, p = 0.002) occurred. Improvements in all outcomes were maintained 6 months after completing the course. MBSR adherence was high, with 90% attendance across groups and high rates of participant-reported home practice of mindfulness. CONCLUSIONS: Mindfulness-based stress reduction is a promising treatment for CRF and associated symptoms.

Comparison of SF-36 vitality scale and Fatigue Symptom Inventory in assessing cancer-related fatigue.

PURPOSE: Cancer-related fatigue (CRF) is an important symptom in clinical practice and research. The best way to measure it, however, remains unsettled. The SF-36 vitality scale, a general measure of energy/fatigue, is a frequently cited measure. With only four items, however, its ability to adequately represent multiple CRF facets has been questioned. The 13-item Fatigue Symptom Inventory (FSI) was developed to assess multidimensional aspects of CRF. Our objectives were to assess the convergent validity and to compare the sensitivity to change of the two scales. METHODS: We administered both scales at 1 month (n = 68) and 6 months (n = 96) to a subset of heterogeneous patients receiving treatment in 16 cancer centers who were enrolled in a clinical trial of pain and depression. Distributions of standardized response means (SRMs) were compared to assess sensitivity to change. Results of both scales were compared to scores on a single fatigue item from the Patient Health Questionnaire (PHQ). RESULTS: Mean scores for both the FSI and the vitality scale demonstrated clinically significant fatigue in the sample. The vitality scale was strongly correlated with all three FSI scales (r = -0.68 to -0.77). The vitality and FSI scales also correlated strongly with the PHQ fatigue item. Moreover, distributions of SRMs for both scales were approximately normal. CONCLUSIONS: Both the FSI and the vitality scale are supported as valid measures of CRF. Both demonstrated sensitivity to change across a range of effect sizes. The vitality scale may be an excellent choice when brevity is paramount; the FSI may be more appropriate when tapping specific dimensions is warranted.

The association of depression and anxiety with health-related quality of life in cancer patients with depression and/or pain.

OBJECTIVES: Depression is known to be a major problem in cancer patients, and evidence is emerging about the importance of anxiety. Because the disorders are highly comorbid, we examined the relationship of anxiety and depression with health-related quality of life (HRQL) in cancer patients. METHODS: Sample included 405 adult oncology patients participating in a randomized controlled trial of telecare management for pain and depression. This secondary cross-sectional analysis of baseline data examined independent and additive effects of anxiety and depression on HRQL, disability, and somatic symptom severity. RESULTS: In 397 patients who screened positive for either pain or depression or both, 135 had comorbid anxiety and depression, 174 had depression but not anxiety, and 88 had neither. Differences existed across all nonphysical HRQL domains and were more pronounced incrementally across the three groups in the expected direction. In GLM modeling, anxiety and depression were each associated with all the domains when modeled separately (p<0.0001). When modeled together, anxiety and depression had independent and additive effects on the mental health domains of HRQL and on somatic symptom burden. In other domains (vitality, perceived disability, overall quality of life, and general health perceptions), only depression had an effect. CONCLUSION: Anxiety and depression have strong and independent associations with mental health domains and somatic symptom burden in cancer patients. However, depression has a more pervasive association with multiple other domains of HRQL. Paying attention to both anxiety and depression may be particularly important when addressing mental health needs and somatic symptom distress.

Psychological Processes and Symptom Outcomes in Mindfulness-Based Stress Reduction for Cancer Survivors: A Pilot Study.

OBJECTIVES: Growing evidence supports the efficacy of mindfulness-based interventions for symptoms in cancer survivors. Identifying theory-based psychological processes underlying their effects on symptoms would inform research to enhance their efficacy and cost-effectiveness. We conducted secondary analyses examining the effect of mindfulness-based stress reduction (MBSR) for cancer-related fatigue on mindfulness facets, self-compassion, and psychological inflexibility. We also examined whether changes in these processes were associated with the symptom outcomes of fatigue interference, sleep disturbance, and emotional distress. METHODS: Thirty-five persistently fatigued cancer survivors (94% female, 77% breast cancer survivors) were randomized to either MBSR for cancer-related fatigue or a waitlist control (WC) condition. Self-report measures were administered at pre-intervention, post-intervention, and 1-month follow-up. Then the WC group received MBSR and completed a post-intervention follow-up. RESULTS: Linear mixed modeling analyses of the first three time points showed steady increases over time for certain mindfulness facets (observing, acting with awareness, and nonjudging) and self-compassion in favor of the MBSR group. When analyzing pre- and post-intervention data across study conditions, none of the psychological processes predicted change in fatigue interference. However, increased nonjudging was associated with decreased sleep disturbance (ß = -.39, p = .003), and increased acting with awareness was associated with decreased emotional distress (ß = -.36, p = .003). Self-compassion did not predict change in symptom outcomes. CONCLUSIONS: Results point to specific psychological processes that may be targeted to maximize the efficacy of future MBSR interventions for cancer survivors.

Cancer-related fatigue and its associations with depression and anxiety: a systematic review.

BACKGROUND: Fatigue is an important symptom in cancer and has been shown to be associated with psychological distress. OBJECTIVE: This review assesses evidence regarding associations of cancer-related fatigue with depression and anxiety. METHOD: Database searches yielded 59 studies reporting correlation coefficients or odds ratios. RESULTS: The combined sample size was 12,103. Almost all studies showed a correlation of fatigue with depression and with anxiety. However, 31 different instruments were used to assess fatigue, suggesting a lack of consensus on measurement. CONCLUSION: This review confirms the association of fatigue with depression and anxiety. Directionality needs to be better delineated in longitudinal studies.

Mindfulness: an intervention for anxiety in schizophrenia.

Despite evidence that individuals with schizophrenia spectrum disorders experience significant and persistent symptoms of anxiety, there are few reports of the use of empirically supported treatments for anxiety in this population. This article describes how we have tried to adapt mindfulness interventions to help individuals with schizophrenia who experience significant anxiety symptoms. Although mindfulness has been widely used to help individuals without psychosis, to our knowledge, this is the first study adapting it to help those with schizophrenia manage worry and stress. We provide an overview of the intervention and use an individual example to describe how our treatment development group responded. We also explore directions for future research of mindfulness interventions for schizophrenia.

Acceptability and Feasibility of a Meaning-Based Intervention for Patients With Advanced Cancer and Their Spouses: A Pilot Study.

BACKGROUND: Constructing meaning in cancer leads to improved psychosocial outcomes for patients and survivors. AIM: We tested the feasibility and preliminary efficacy of a meaning-based intervention for couples. DESIGN: The single-arm pilot study tested a 4-session, tailored, activities-based couple's intervention. SETTING/PARTICIPANTS: Twelve adults with incurable cancer and their partners participated either in a university office or at the couple's home. RESULTS: The study showed good feasibility. One of the two patients depressed at baseline was no longer depressed at postintervention. Patients' threat appraisals decreased and transcendence increased. In partners, depression, anxiety, and challenge appraisal decreased; threat and secondary appraisals and peace with illness increased. CONCLUSIONS: Our findings suggest feasibility and efficacy, and further research and continued evaluation of this intervention are warranted.

Randomized controlled pilot trial of mindfulness-based stress reduction for breast and colorectal cancer survivors: effects on cancer-related cognitive impairment.

PURPOSE: Cancer-related cognitive impairment (CRCI) is a common, fatigue-related symptom that disrupts cancer survivors' quality of life. Few interventions for CRCI exist. As part of a randomized pilot study targeting cancer-related fatigue, the effects of mindfulness-based stress reduction (MBSR) on survivors' cognitive outcomes were investigated. METHODS: Breast and colorectal cancer survivors (n = 71) with moderate-to-severe fatigue were randomized to MBSR (n = 35) or a fatigue education and support (ES; n = 36) condition. The Attentional Function Index (AFI) and the Stroop test were used to assess survivors' cognitive function at baseline (T1), after the 8-week intervention period (T2), and 6 months later (T3) using intent-to-treat analysis. Mediation analyses were performed to explore mechanisms of intervention effects on cognitive functioning. RESULTS: MBSR participants reported significantly greater improvement on the AFI total score compared to ES participants at T2 (d = 0.83, p = 0.001) and T3 (d = 0.55, p = 0.021). MBSR also significantly outperformed ES on most AFI subscales, although both groups improved over time. MBSR produced greater Stroop accuracy rates relative to ES at T2 (r = 0.340, p = 0.005) and T3 (r = 0.280, p = 0.030), with improved accuracy over time only for the MBSR group. There were no significant differences in Stroop reaction time between groups. Improvements in mindfulness mediated the effect of group (e.g., MBSR vs. ES) on AFI total score at T2 and T3. CONCLUSIONS: Additional randomized trials with more comprehensive cognitive measures are warranted to definitively assess the efficacy of MBSR for CRCI. IMPLICATIONS FOR CANCER SURVIVORS: This pilot study has important implications for all cancer survivors as it is the first published trial to show that MBSR offers robust and durable improvements in CRCI.

Longitudinal relationships between fatigue and depression in cancer patients with depression and/or pain.

OBJECTIVE: Fatigue is one of the most common and debilitating symptoms reported by cancer patients, yet relatively little is understood about its etiology. Recently, as researchers have begun to focus attention on cancer-related fatigue (CRF), depression has emerged as its strongest correlate. Few longitudinal studies, however, have examined directionality of the relationship between the two symptoms. Our aim was to evaluate the directionality of the association between depression and CRF. METHOD: The study used a single-group cohort design of longitudinal data (N = 329) from a randomized controlled trial of an intervention for pain and depression in a heterogeneous sample of cancer patients. Participants met criteria for clinically significant pain and/or depression. Our hypothesis that depression would predict change in fatigue over 3 months was tested using latent variable cross-lagged panel analysis. RESULTS: Depressive symptoms and fatigue were strongly correlated in the sample (baseline correlation of latent variables = 0.71). Although the model showed good fit to the data, χ(2) (66, N = 329) = 88.16, p = .04, SRMR = 0.030, RMSEA = 0.032, and CFI = 1.00, neither structural path linking depression and fatigue was significant, suggesting neither symptom preceded and predicted the other. CONCLUSIONS: Our findings did not support hypotheses regarding the directionality of the relationship between depressive symptoms and fatigue. The clinical implication is that depression-specific treatments may not be sufficient to treat CRF and that instead, interventions specifically targeting fatigue are needed.

Breast cancer in a wife: how husbands cope and how well it works.

BACKGROUND: Husbands of patients with breast cancer (HBCs) experience as much as or even more distress than patients. Husbands' coping strategies may predict their level of distress. OBJECTIVE: The present study examined the coping strategies of HBCs compared with husbands of women without cancer (HWCs) and the relationship between coping and various psychosocial variables. METHODS: Psychosocial and physical health correlates of coping in both groups were assessed. Husbands of women with breast cancer (n=83) and without breast cancer (n=79) completed self-report questionnaires including the Ways of Coping Questionnaire, the Center for Epidemiological Studies Depression Scale, the Subjective Stress Scale, the Satisfaction With Life Scale, and the Locke-Wallace Marital Adjustment Test, in addition to measures of burden. RESULTS: The HBC and HWC groups were significantly different for 6 of the 8 coping styles assessed, with HBC using these strategies less than HWCs. Among HBCs, higher use of distancing, accepting responsibility, and escape-avoidance was associated with higher stress and symptoms of depression, and distancing and accepting responsibility were associated with lower marital satisfaction. CONCLUSIONS: Results suggest that coping strategies may be different when dealing with cancer in a wife than at other times and that coping relates to well-being and is therefore worthy of focus. IMPLICATIONS FOR PRACTICE: Simple assessments of primary coping strategies may help clinicians identify HBCs in need of interventions. Husbands of women with breast cancer can be given problems to solve that will help them cope and help the patient and clinic staff as well. Interventions aimed at the couple, and not exclusively the HBC, may be particularly helpful.