Stress Management and Resilience Training (SMART) Program to Decrease Stress and Enhance Resilience Among Breast Cancer Survivors: A Pilot Randomized Clinical Trial

doi:10.1016/j.clbc.2011.06.008

Clinical Breast Cancer

Volume 11, Issue 6, December 2011, Pages 364-368

https://doi.org/10.1016/j.clbc.2011.06.008 Get rights and content

Abstract

Introduction

Patients with breast cancer experience stress and anxiety related to their diagnosis, with resulting lower quality of life. The purpose of this study was to assess the effect of a SMART (Stress Management and Resiliency Training) program for increasing resiliency and for decreasing stress and anxiety among mentors who themselves were previously diagnosed with breast cancer.

Materials and Methods

The program consisted of two 90-minute group training sessions, a brief individual session, and 3 follow-up telephone calls. Twenty-four mentors at Mayo Clinic in Rochester, Minnesota, were randomized in a single-blind, wait-list controlled clinical trial to either the SMART intervention or a control group for 12 weeks. Primary outcome measures assessed at baseline and at week 12 included the Connor Davidson Resilience Scale, Perceived Stress Scale, Smith Anxiety Scale, and Linear Analog Self Assessment Scale.

Results

Twenty patients completed the study. A statistically significant improvement in resilience, perceived stress, anxiety, and overall quality of life at 12 weeks, compared with baseline was observed in the study arm. No significant difference in any of these measures was noted in the control group.

Conclusion

This study demonstrates that a brief, predominantly group-based resilience training intervention is feasible in patients with previous breast cancer; also, it may be efficacious.

Introduction

Breast cancer is the most common cancer among women and the most common cause of cancer death in women worldwide and in developed countries.¹ Patients diagnosed with breast cancer experience considerable stress, anxiety, fear, and depression.² The emotional response to breast cancer may be independent of disease stage, because women diagnosed with noninvasive breast cancers also experience powerful emotions.² The emotional impact of a cancer diagnosis and the rigors of cancer treatment adversely affect quality of life (QOL), and this may persist beyond treatment.³

One possible source of support for patients with newly diagnosed breast cancer is from women who have themselves coped with breast cancer. These breast cancer survivors can serve as mentors to provide newly diagnosed patients with first-hand information about what to expect from prescribed cancer treatment, to present coping strategies, provide encouragement, and to offer ways to actively combat barriers to personal recovery. A one-on-one peer mentorship program, the Pink Ribbon Mentorship Program, was developed to provide support to patients with newly diagnosed breast cancer who were receiving care at Mayo Clinic in Rochester, Minnesota. This Pink Ribbon Mentorship Program started offering support to breast cancer patients in December 2006. The mentors who provide support to the patients with newly diagnosed breast cancer themselves have to face the stress of a previous cancer diagnosis. Thus, improving their stress-managing ability might be an optimal strategy to improve their well-being. A key component of this approach is to enhance resilience.

Resilience refers to the ability to thrive despite stress and adversity.⁴ Resilience also is described as invulnerability and hardiness.⁵ The source of resilience is an individual's innate strength that helps the individual adapt to stressors and pursue life's meaning and purpose. Resilience correlates with positive physical and mental health in several studies.6, 7, 8, 9 In terms of brain function, resilience correlates with higher activation of the prefrontal cortex and lower activation of the limbic system, particularly the amygdala.10, 11, 12 Results from a few studies support that individual resilience can be increased by training and that this might have a positive effect on clinically meaningful outcomes.6, 7, 8, 9 Resilience training thus offers a feasible and potentially useful intervention to promote patient well-being. The present study was designed to test a Stress Management and Resiliency Training (SMART) program for enhancing resilience and well-being and for decreasing stress and anxiety among Pink Ribbon Mentors.

Section snippets

Study Design and Population

The Mayo Foundation Institutional Review Board reviewed and approved the study protocol before recruitment and enrollment. The study was designed as a randomized, wait-list controlled, pilot clinical trial that enrolled 25 Pink Ribbon Mentors at Mayo Clinic in Rochester, Minnesota. Inclusion criteria were the following (1) being a Pink Ribbon Mentor; (2) able and willing to participate in all aspects of the study; and (3) provided with, understood, and signed the appropriate informed consent

Demographics

Patient demographics are presented in Table 1. Of the 24 mentors enrolled, 20 (83%) completed the study. One participant was excluded before randomization, and 4 participants declined to participate after randomization due to personal issues (Figure 1). The ages of the 20 patients ranged from 46 to 75 years. Eleven subjects in the active arm participated in the additional one-on-one 30-minute individualized session with a study investigator (K.P.).

Telephone Calls

Of the 12 subjects in the intervention arm, 4

Discussion

This pilot study demonstrates that a brief training in resilience when using the SMART program is feasible. Results of the study also suggest that the intervention has a potential to improve resiliency, stress, anxiety, QOL, and fatigue. The brief duration of the training is a particularly appealing aspect of the intervention. Several other studies have evaluated the effects of programs to improve QOL in breast cancer survivors. A randomized controlled trial of 256 breast cancer survivors who

Conclusion

Brief training in resilience by using the SMART program for breast cancer survivors is feasible. Such an intervention has a potential to improve self-reported measures of resilience, QOL, stress, and anxiety, at least for the short term. Larger clinical trials with a longer duration of follow-up with this intervention are warranted.

Disclosure

The authors have no disclosures. The study was funded by the Sponsorship Research Committee, Mayo Clinic College of Medicine.

References (21)

S. Lissek et al.
Classical fear conditioning in the anxiety disorders: a meta-analysis
Behav Res Ther
(2005)
C. Smith et al.
A randomised comparative trial of yoga and relaxation to reduce stress and anxiety
Complement Ther Med
(2007)
D.E. Locke et al.
Validation of single-item linear analog scale assessment of quality of life in neuro-oncology patients
J Pain Symptom Manage
(2007)
A. Jemal et al.
Global cancer statistics
CA Cancer J Clin
(2011)
A.E. Pedersen et al.
The sequelae of anxiety in breast cancer: a human response to illness model
Oncol Nurs Forum
(2010)
B. Gerber et al.
Recurrent breast cancer: treatment strategies for maintaining and prolonging good quality of life
Dtsch Arztebl Int
(2010)
K.M. Connor et al.
Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC)
Depress Anxiety
(2003)
S.C. Kobasa
Stressful life events, personality, and health: an inquiry into hardiness
J Pers Soc Psychol
(1979)
M. Steinhardt et al.
Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology
J Am Coll Health
(2008)
B.G. Bradshaw et al.
Determining the efficacy of a resiliency training approach in adults with type 2 diabetes
Diabetes Educ
(2007)

There are more references available in the full text version of this article.

Cited by (218)

The effects of the intergenerational transmission of the Holocaust trauma on family functioning, resilience, anxiety and depression: A case-control study
2024, European Journal of Trauma and Dissociation
Effects of Intergenerational transmission of a major trauma from one remains unclear. The present case-control study aims to clarifying the mechanisms of transmission among families of Holocaust Survivors (HS). We hypothesized that the high level of depressive and anxiety disorders (DAD) among HS impairs family system, which results in damaging resilience of their children (CHS) yielding a higher level of DAD
49 CHS and 28 control subjects complete the Resilience Scale for Adults, the Hopkins Symptom Checklist-25 and the Family Adaptability and Cohesion Scale. We test a mediation model with Family types as the predictor; resilience as the mediator;and DAD as the outcome variable.
Results confirm that CHS'family types are more often dysfunctional than in the control group. Moreover, growing in a dysfunctional family seems to impede development of resilience and, therefore, enhance the occurrence of DAD.
The present investigation is correlational and should be confirmed by other prospective investigations. Moreover, our entire set of measures is based on self-report questionnaires.
We propose a mechanism of transmission of the noxious effects of a major trauma from one generation to the next. It appears that it is not the trauma per se that affects the levels of DAD but its effects on family dynamics, altering the development of resilience skills and the risk of DAD. We discuss both theoretical and clinical implications of our findings.
Effects of interventions for enhancing resilience in cancer patients: A systematic review and network meta-analysis
2024, Clinical Psychology Review
Various interventions appear to enhance cancer patients' resilience. However, the best intervention options are still unknown. This systematic review and network meta-analysis aimed to examine the impact of different interventions on resilience and identify the most effective interventions.
Nine major English and Chinese databases were systematically retrieved for randomized controlled trials (RCTs) published from inception to 13 November 2023. The outcome was resilience. The analysis was conducted using Software Review Manager 5.4, R 4.2.3, and STATA 14.0.
The network meta-analysis included 32 RCTs and evaluated 12 interventions. Regarding effectiveness, compared to routine care, the relative effect sizes of attention and interpretation therapy, cyclic adjustment training, cognitive intervention, expressive therapy, positive psychological intervention, social support intervention, and work-environment therapy had statistically significant enhancing resilience, with the SMD (95%CI) of 1.42 (0.75, 2.07), 1.97 (0.76, 3.18), 1.26 (0.76, 1.77), 0.93 (0.08, 1.78), 1.02 (0.55, 1.50), 1.01 (0.48, 1.56), 1.65 (0.94, 2.37), respectively. Considering the rank probability, statistical power, and efficacy, the most effective interventions for improving resilience were attention and interpretation therapy, cognitive intervention, and positive psychological intervention. With the limited quantity of RCTs, the effectiveness of cyclic adjustment training and work-environment therapy still needs to be explored.
Attention and interpretation therapy was the first best choice for boosting resilience out of the 12 interventions. Cognitive intervention and positive psychological intervention were also better choices for improving cancer patients' resilience. Due to the low quality and quantity of included RCTs, the need for multi-center, higher-quality trials with larger samples should be carried out.
PROSPERO ID: CRD42023434223. The study did not receive funding support.
A systematic review and meta-analysis of interventions to reduce perceived stress in breast cancer patients
2024, Complementary Therapies in Clinical Practice
Breast cancer (BC) patients commonly face stress that causes severe psychological and physiological problems. The main objective of the review was to confirm the effect of interventions on breast cancer patients’ perceived stress, and the secondary objective was to explore the impact of interventions on anxiety, depression, and inflammatory markers.
A systematic and comprehensive search for randomized controlled trials (RCTs) that reported interventions’ effects on perceived stress in breast cancer patients was performed in nine databases.
Twenty-four RCTs, including 1887 participants, met the inclusion criteria, summarizing six categories for the intervention group: mindfulness and yoga, exercise, cognitive-behavioral stress management, self-regulation, relaxation training, and acupuncture. Compared with usual care or other types of care, mindfulness and yoga had excellent effects against perceived stress, anxiety, and depression; self-regulation could reduce perceived stress and anxiety; exercise could reduce perceived stress; acupuncture could reduce the level of depression; mindfulness could improve the TNF-α level, and yoga can reduce the level of salivary cortisol and DNA damage.
This systematic review indicated that nondrug interventions, such as mindfulness and yoga, effectively reduce perceived stress, anxiety, and depression. Rigorous studies with large sample sizes are needed to address the limitations of small sample sizes and shortcomings in methodology in this area.
Resilience in patients with lymphoid malignancies: The REPLY study
2024, Annales Medico-Psychologiques
The role of resilience in lymphoid malignancies is not fully elucidated. The aims of this cross-sectional study were to investigate resilience and to explore its relationships with quality of life and mental health outcomes in patients with lymphoid malignancies, in a University Hospital in Uruguay. RS-14 Resilience Scale, Hospital Anxiety and Depression Scale (HADS) and EQ-5D-5L scale were used. Results: 106 patients were enrolled: 77 non-Hodgkin lymphoma, 16 Hodgkin lymphoma and 13 chronic lymphocytic leukemias. The median RS-14 score was 85.5 (95% CI: 82.4–88.2), corresponding to a ‘moderately high’ level of resilience. Resilience negatively correlated with anxiety (r = –0.487, P < 0.01) and depression (r = –0.607, P < 0.01), and positively correlated with quality of life as assessed by the EQ-VAS (r = 0.507, P < 0.001) and EQ-index (r = 0.345, P < 0.001). When further exploring the dimensions within the EQ-5D system we found that high resilience patients reported significantly less problems than moderate and low resilience patients. Moreover, among patients who did not report problems in any of the dimensions (i.e.: EQ-index = 1), 66.7% were high resilients, 26.7% moderate and 6.7% were low resilients, further highlighting the importance of resilience in the ability to cope with the disease. In conclusion, resilience could be a protective factor for patients with lymphoid malignancies. Stimulating resilience through specific interventions could positively impact their quality of life.
Le rôle de la résilience dans les tumeurs malignes lymphoïdes n’est pas entièrement élucidé. Les objectifs de cette étude transversale ont été d’étudier la résilience et d’explorer ses relations avec la qualité de vie et les résultats de santé mentale chez les patients atteints de lymphome, dans un hôpital universitaire d’Uruguay. L’échelle de résilience RS-14, l’échelle d’anxiété et de dépression hospitalière (HADS) et l’échelle EQ-5D-5L ont été utilisées. Résultats : 106 patients ont été recrutés : 77 lymphomes non hodgkiniens, 16 lymphomes hodgkiniens et 13 leucémies lymphoïdes chroniques. Le score médian RS-14 était de 85,5 (IC 95 % : 82,4–88,2), correspondant à un niveau de résilience « modérément élevé ». La résilience est corrélée négativement à l’anxiété (r = –0,487, p < 0,01) et à la dépression (r = –0,607, p < 0,01), et positivement corrélée à la qualité de vie évaluée par l’EQ-VAS (r = 0,507, p < 0,001) et l’indice EQ (r = 0,345, p < 0,001). En explorant davantage les dimensions du système EQ-5D, nous avons constaté que les patients à haute résilience signalaient beaucoup moins de problèmes que les patients à résilience modérée et faible. De plus, parmi les patients qui n’ont signalé aucun problème dans aucune des dimensions (c’est-à-dire: EQ-index = 1), 66,7 % étaient très résilients, 26,7 % modérés et 6,7 % étaient peu résilients, soulignant encore l’importance de la résilience dans la capacité de faire face à la maladie. En conclusion, la résilience pourrait être un facteur de protection pour les patients atteints de tumeurs malignes lymphoïdes. Stimuler la résilience grâce à des interventions spécifiques pourrait avoir un impact positif sur leur qualité de vie.
Relationships among self-esteem, ego-resilience, and caregiver burden among families of children with hematologic and oncologic disease: A cross-sectional study
2023, Heliyon
Pediatric hematology and oncology disease is a physically and emotionally demanding health condition for families. High self-esteem and ego-resilience among caregivers, which have recently gained increased recognition, might help ease caregiver burdens. Few studies, however, have simultaneously investigated the relationships between self-esteem, ego-resilience, and caregiver burden among caregivers of children with hematologic and oncologic disease.
The purpose of this study is to investigate the relationships between caregiver burden, self-esteem, and ego-resilience and examine whether ego-resilience plays a role in mediating the relationship between self-esteem and caregiver burden among family caregivers of children with hematologic and oncologic disease.
Descriptive correlational study.
The outpatient clinic of the department of pediatric hematology and oncology at a flagship university hospital in a metropolitan city in South Korea.
The sample comprised 109 primary family caregivers of children with hematologic and oncologic disease. Convenience sampling method was used.
The participants completed the Ego-Resiliency Scale, Rosenberg Self-Esteem Scale, and Family Burden Questionnaire. One-way analysis of variance, independent t-tests, and correlation analyses were conducted using IBM SPSS 25.0. The mediating effect of ego-resilience was estimated using the PROCESS macro and bootstrap method in SPSS.
Caregiver burden showed significant negative associations with self-esteem and ego-resilience, with moderate effect sizes (r = −.391 and −0.361, respectively, p = .001). Ego-resilience mediated the relationship between self-esteem and caregiver burden (b = −0.019; 95 % bias-corrected bootstrap confidence interval −0.035 and −0.001).
Self-esteem and ego-resilience may lessen caregiver burden among families of children with hematologic and oncologic disease, and self-esteem of caregivers tends to promote their ego-resilience. Therefore, self-esteem and ego-resilience should be improved among family caregivers to reduce their caregiver burden.
Effectiveness of resilience interventions among cancer patients – A systematic review, meta-analysis, and meta-regression of randomised controlled trials
2023, European Journal of Oncology Nursing
This systematic review, meta-analysis and meta-regression aimed to (1) evaluate the effects of resilience interventions on cancer patients’ resilience and posttraumatic growth and (2) identify essential contents and features of resilience interventions.
A systematic review, meta-analysis, and meta-regression analyses were conducted. Published and unpublished randomised controlled trials evaluating the effects of resilience interventions among cancer patients were retrieved from nine databases, trial registries, and grey literature. The mean and standard deviation scores were used to compute the effect sizes.
23 randomised controlled trials comprising 3287 cancer patients were included. The random effects model found that resilience interventions had beneficial impacts on patients' resilience, posttraumatic growth, quality of life, anxiety, and depressive symptoms with moderate to large effects. The subgroup analyses concluded that theoretically guided interventions that adopted synchronous communication delivered physically had greater effect sizes. Interventions comprising skills that promote patients’ cognitive flexibility, self-efficacy, self-esteem, self-regulation, and coping had greater effect in comparison with interventions lacking these components. The meta-regression analyses revealed that sample size has a significant effect on posttraumatic growth scores. More well-designed trials are needed to confirm the effects of resilience interventions.
There is merit in utilizing resilience interventions to improve cancer patients’ resilience and psychological well-being. Resilience interventions should be incorporated into the routine care for cancer patients and survivors.

View all citing articles on Scopus

View full text

Original studyStress Management and Resilience Training (SMART) Program to Decrease Stress and Enhance Resilience Among Breast Cancer Survivors: A Pilot Randomized Clinical Trial

Abstract

Introduction

Materials and Methods

Results

Conclusion

Introduction

Section snippets

Study Design and Population

Demographics

Telephone Calls

Discussion

Conclusion

Disclosure

Behav Res Ther

Complement Ther Med

J Pain Symptom Manage

Global cancer statistics

CA Cancer J Clin

The sequelae of anxiety in breast cancer: a human response to illness model

Oncol Nurs Forum

Recurrent breast cancer: treatment strategies for maintaining and prolonging good quality of life

Dtsch Arztebl Int

Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC)

Depress Anxiety

Stressful life events, personality, and health: an inquiry into hardiness

J Pers Soc Psychol

Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology

J Am Coll Health

Determining the efficacy of a resiliency training approach in adults with type 2 diabetes

Diabetes Educ

Original study
Stress Management and Resilience Training (SMART) Program to Decrease Stress and Enhance Resilience Among Breast Cancer Survivors: A Pilot Randomized Clinical Trial