Effect of a group-based acceptance and commitment therapy (ACT) intervention on illness cognition in breast cancer patients
Introduction
Breast cancer has the highest incidence rate among all cancers in women, in both developed and developing countries (Chen et al., 2016). In 2019, 268,600 new diagnoses of breast cancer in women were expected in the United States, accounting for 30% of all new cancer diagnoses in women (Siegel, Miller, & Jemal, 2019). In China, 268.6 per 10,000 women were newly diagnosed with breast cancer in 2015 (Chen et al., 2016). Diagnosis and active treatment of cancer is associated with psychological problems (Mehnert et al., 2014; Nakash et al., 2014). In Germany, the 4-week prevalence of psychological disorders (such as anxiety disorder, mood disorder, and adjustment disorder) was 31.8%, and 75% of cancer patients were reported to suffer from emotional distress of a non-clinical nature (Mehnert et al., 2014, 2017). In breast cancer patients, the prevalence of psychological disorder was 41.6%, the highest among the various types of cancers (Mehnert et al., 2014). Psychological problems among breast cancer patients are associated with decreased quality of life (QoL) and diminished treatment tolerance (Duijts, Faber, Oldenburg, Beurden, & Aaronson, 2011).
The literature indicates that illness cognition, coping strategies, and psychological flexibility are predictors of distress and QoL, even after controlling for potentially confounding clinical and sociodemographic characteristics. Gillanders, Sinclair, MacLean, and Jardine (2015) showed that cancer-related cognition and avoidant coping were the strongest predictors of distress, and that they lowered QoL among 105 adults with various cancer diagnoses. Hulbert-Williams and Storey (2016) studied 129 cancer patients and found that psychological flexibility was a strong and consistent correlate of mood, anxiety, depression, stress, QoL, and perceived benefit. Davis, Deane, Lyons, and Barclay (2017) reported that acceptance was the greatest predictor of anticipatory grief among 58 cancer patients in palliative care. Aguirre-Camacho et al. (2017) found that experiential avoidance predicted anxiety and depressive symptoms in breast cancer patients, and had an indirect negative effect on QoL during cognitive behavioral therapy (CBT)-based intervention in 54 women. Mosher et al. (2017) found that women with metastatic breast cancer and moderate/high symptoms reported greater avoidance of unwanted internal experiences and experienced difficulty living consistently with their values. These studies provided preliminary data suggesting that interventions that target illness cognition (including acceptance) and psychological flexibility may be indicated in breast cancer patients.
Acceptance and commitment therapy (ACT) is a third-generation cognitive behavioral approach that aims to promote psychological flexibility. Acceptance and mindfulness processes, and commitment and behavior change processes, are the two core skills of ACT for increasing psychological flexibility, which is defined as “the ability to fully contact the present moment, and to persist in value-based behavior” (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Strosahl, & Wilson, 2012). In ACT, values represent patient-defined life directions and provide a sense of meaning and purpose (Hayes et al., 2006). In contrast with other behavior change theories, ACT influences an individual's relationship with cognitions but does not attempt to directly change cognition or control behavior (Hayes et al., 2012). ACT interventions have shown promising effects on distress, QoL, and health behavior in cancer patients. Four individual-based designs have demonstrated the feasibility and preliminary effects of ACT interventions; among these, two were conducted among adult breast cancer patients (Karekla & Constantinou, 2010; Montesinos & Luciano, 2016), one was conducted among adult brain tumor patients (Kangas, McDonald, Williams, & Smee, 2015), and one was conducted among child/adolescent cancer patients (Cederberg, Dahl, von Essen, & Ljungman, 2017). Three pretest-posttest studies in diverse cancer patient populations found that ACT interventions decreased mood disturbance (Arch & Mitchell, 2016; Feros, Lane, Ciarrochi, & Blackedge, 2013), fear of cancer recurrence (Arch & Mitchell, 2016), and trauma-related symptoms (Arch & Mitchell, 2016), while promoting psychological flexibility (Datta, Aditya, Chakraborty, Das, & Mukhopadhyay, 2015; Feros et al., 2013) and improving QoL (Feros et al., 2013). Three non-randomized studies found that group-based ACT intervention among breast cancer patients reduced anxiety and depression (Mohabbat-Bahar, Maleki-Rizi, Akbari, & Moradi-Joo, 2015), increased life expectancy (Ghasemi, Dehghan, Farnia, Tatari, & Alikhani, 2016), and promoted self-image (Xue et al., 2015) compared with that in a control group.
The first randomized controlled trial (RCT) to evaluate ACT, which was performed by Rost, Wilson, Buchanan, Hildebrandt, and Mutch (2012), demonstrated a significantly greater increase in QoL in an individual-based ACT intervention group than that observed in a CBT group among late-stage ovarian cancer patients. Mosher et al. (2018) developed a telephone-based ACT intervention for metastatic breast cancer patients with symptom interference, and reported that the intervention group showed significant improvements in fatigue and sleep impairment compared with the control group (involving education and support) in a pilot RCT study. An RCT conducted by González-Fernández, Fernández-Rodríguez, Paz-Caballero, and Pérez-Álvarez (2018) compared group-based ACT, behavioral activation, and wait-list control in cancer survivors. They found that both interventions significantly reduced anxiety and depression compared with that in the wait-list control group. ACT and behavioral activation were equivalent in this study. Hawkes, Pakenham, Chambers, Patrao, and Courneya (2014) developed a group-based ACT intervention to improve multiple health behaviors among colorectal cancer survivors, and 410 survivors were randomized to the intervention group or usual care. Compared with usual care, the intervention improved posttraumatic growth, spirituality, acceptance, and QoL.
Despite these promising results, in a study in the United States, 25% of cancer patients who suffered from distress did not receive psychological services, and most of these cancer patients sought help from family members, friends, oncologists, and nurses to address their psychological problems (Whitney, Bell, Bold, & Joseph, 2015). However, owing to constraints on both providers and patients, most newly diagnosed patients in China faced a lack of cancer-related psychological support, especially during the active treatment stage (Lam, Shing, Bonanno, Mancini, & Fielding, 2012). Given the complex concurrent psychosocial and physiological challenges that many breast cancer patients face, early psychological support is essential for promoting psychosocial and physical adjustment.
The aim of this study was to evaluate the feasibility and preliminary effectiveness of a group-based ACT intervention provided by nurses in improving illness cognition among breast cancer patients undergoing chemotherapy. The study also aimed to provide effect size information for future studies, with greater statistical power.
Section snippets
Study design
The trial evaluated two arms and four assessment time points using a quasi-experimental design. The ACT intervention group received four sessions of group-based ACT in a clinical setting. The control group received one session of group-based HE. Psychosocial assessments were conducted at a pre-intervention time point (T1, baseline), a post-intervention time point (T2, 4 weeks), and two follow-up time points (T3, 8 weeks; T4, 16 weeks). Demographic and clinical data were collected only at
Participants
A total of 204 breast cancer patients were screened during the intervention stage, and 118 patients were eligible for the study. Eighty-four eligible participants were recruited to the study, with a 1:1 ratio of participants in the ACT and HE groups. In the intervention group, there were six subgroups, with 6–8 participants in each group. At 16 weeks, there was no significant difference in retention between the ACT group (90.5%) and HE group (95.2%; p = 0.676), and there were no differences in
Feasibility of group-based ACT intervention
The group-based ACT intervention was found to be feasible in the present sample of breast cancer patients during the chemotherapy treatment period, with a sufficient number of subjects and high recruitment, retention, acceptance, and satisfaction. The feasibility and acceptability were slightly higher than those observed in other ACT interventions among cancer patients (Arch & Mitchell, 2016; Feros et al., 2013). The present intervention may have been feasible for several reasons such as the
Conclusions
The study findings indicated that the group-based ACT intervention was acceptable, with preliminary effectiveness at promoting psychological flexibility, illness cognition, and cancer-specific QoL in breast cancer patients during chemotherapy. Moreover, this intervention clearly indicated that early psychological support was important and helpful for promoting psychological adjustment among breast cancer patients.
Acknowledgements
This study was supported by the National Natural Science Foundation of China (grant numbers 81573016).
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