Is acceptance and commitment therapy effective in addressing critical outcomes associated with cancer survivorship?

Abstract

The Evidence ACT is a cognitive behavioral intervention focused on enhancing psychological flexibility, which refers to the ability to recognize and adapt to situational demands, to shift mindsets or responses when personal or social functioning is compromised, and to remain open and committed to behaviors that reflect personally chosen values. Although ACT has been found effective in various psychological disorders, its application to psychosocial concerns and health behavior change in medical populations is relatively new. The cancer experience has become an important focus for behavioral interventions because of its negative impact on outcomes associated with both mental and physical health, including increased anxiety and depression, physical pain, fatigue, and reduced physical activity. Furthermore, a recent survey indicated that cancer survivors prefer behavioral interventions for distress over taking psychiatric medication, a preference that is largely unmet. Compared with traditional cognitive behavioral treatments, ACT is uniquely designed to promote shifting away from efforts to get rid of psychological symptoms and toward living in accordance with personal values (who and what one most cares about) within the context of whatever life brings. An approach such as ACT that allows for distress may be well-suited to cancer survivors, whose distress frequently reflects realistic concerns, including fear and reality of cancer recurrence or metastasis, enduring treatment side effects, and the need to change major health behaviors (eg, lose weight, stop smoking). A recent review of 19 studies that included 10 randomized and five nonrandomized trials with 1,545 cancer survivors found that ACT has improved outcomes associated with cancer survivorship. ACT reduced anxiety (7 of 7 trials) and depression (9 of 9 trials), and increased quality of life (5 of 5 trials) and psychological flexibility (11 of 11 trials). In physical health outcomes, a randomized trial with 410 colorectal cancer survivors found that, relative to a group receiving educational brochures on reducing cancer risk as well as dietary and physical activity information, an ACT-based telephone-delivered intervention improved physical activity by 28.5 minutes per week (P5.003), body mass index by –0.9 kg/m (P5.001), and reduced total fat intake by 7% per day (P5.006), including lowering saturated fat intake by 2.8% per day (P5.016), and increasing vegetable intake by 0.4 servings per day (P5.001), with improvements sustained at a 12-month follow-up. In addition, a single-arm pilot study of 42 cancer survivors found that a seven-week ACT group intervention was associated with improvements across a broader range of outcomes based on Cohen’s d effect sizes, including large improvements in anxiety (State-Trait Anxiety Inventory, d51.00, P,.001), depression (Center for Epidemiological Studies Depression Scale, d50.95, P,.001), and cancer-related trauma symptoms (Revised Impact of Events Scale, d50.84, P,.001), andmoderate improvements in fear of cancer recurrence (Concerns About Recurrence Scale, d50.66, P5.001), physical pain (RAND Short Form-36, d50.66, P,.01), as well as life vitality (d50.77,P,.001),meaning (d50.49,P, .001), and comprehensibility (d50.61, P,.001). An important outcome from this study was the finding that, with the exception of anxiety and fear of cancer recurrence, early improvement in cancer-related psychological flexibility predicted later improvement in these outcomes.