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Cited by 141Cancer survivorship and careMindfulness and Compassion InterventionsChildhood Cancer Survivors' Quality of Life

Acceptance and commitment therapy for breast cancer survivors with fear of cancer recurrence: A 3-arm pilot randomized controlled trial.

Open access
Johns, Shelley A., Stutz, Patrick V., Talib, Tasneem L., Cohee, Andrea A., Beck‐Coon, Kathleen A., Brown, Linda F., Wilhelm, Laura R., Monahan, Patrick O. +4 more·2020·Cancer
DOI 10.1002/cncr.32518PMC PMC6906228
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Abstract

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.

Integrity signals

Registry

Crossref · 10.1002/cncr.32518

Cites

43 of 43 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

1 of 20 cited sources checked · 0 supported · 0 flagged · accuracy not yet measured

  • Interpretationcitation

    The physical and mental QoL gains reported by ACT participants probably stemmed from both lower anxiety and greater psychological flexibility.

    “This interpretation is supported by ACT participants’ reported physical and mental QoL improvement, which likely resulted from a combination of reduced anxiety and increased psychological flexibility.23–26”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [23]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [24] source
    • cites [25] source
    • cites [26] source

      The Quality of life (QoL) section (page unavailable) reports that most reviewed studies found QoL improvements after ACT, while the Psychological flexibility section reports post-ACT gains in flexibility. The Distress section also describes improvements in distress, including post-stroke anxiety. The review does not establish that reduced anxiety and increased flexibility jointly caused physical and mental QoL gains, and it cautions that other factors may explain post-intervention QoL improvements. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Findingown data

    All three arms had within-group decreases in FCR severity across time.

    “Although each arm showed within-group FCR severity reductions over time”
    • Also stated in: § Primary Outcome · plain
      “Each group showed within-group reductions in FCR severity by T4”
    Quote in the paperNot a substantial claim
  • Findingown data

    At T2, ACT showed significantly larger FCR severity reductions than SE with a moderate effect (d=0.68, p<0.05).

    “compared to SE, ACT showed significantly larger FCR severity reductions with a moderate effect at T2 (d=0.68, p<0.05)”
    Quote in the paperSubstantial claim
  • Findingreasoning

    ACT's efficacy increased with longer follow-up.

    “As more time passed, ACT became more efficacious.”
    Quote in the paperSubstantial claim
  • Findingown data

    No differences between SE and EUC were observed on FCR severity.

    “No differences between SE and EUC on FCR severity were observed.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 24
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 12

  • May combine two claims.

    Findingown data

    At T4, ACT outperformed EUC on 7 of the 12 secondary outcomes, with moderate to large effects.

    “and superior to EUC on 7 of 12 outcomes with moderate to large effect sizes”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    At every time point, between-group comparisons favored ACT, especially at T4.

    “Between-group differences at each time point favored ACT, most obviously at T4”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    At T4, ACT outperformed SE on 10 of the 12 secondary outcomes, with moderate to large effects.

    “by T4 ACT was superior to SE on 10 of 12 secondary outcomes”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Feasibility was supported by accrual of 43.8% among screened and 60.7% among eligible women, attendance of 81.7%, and retention of 94.5%.

    “ACT showed strong evidence of feasibility with high accrual (43.8% of BCS screened; 60.7% of eligible BCS), attendance (81.7%), and retention (94.5%) rates.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed recruitment (43.8%) and retention (94.5%) rates are satisfactory for demonstrating feasibility.

  • May combine two claims.

    Findingown data

    By T4, ACT was superior to SE and EUC on avoidant coping, anxiety, depression, QoL, and FCR-related psychological distress with moderate-to-large effects.

    “By T4, significant moderate-to-large between-group comparisons favored ACT over SE and EUC on avoidant coping, anxiety, depression, QoL, and FCR-related psychological distress.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Compared with baseline, ACT had significant within-group gains on FCR severity and almost all secondary outcomes at every follow-up, while SE and EUC changed little.

    “Relative to baseline, ACT showed significant within-group improvement on FCR severity and nearly all secondary outcomes at all follow-ups, whereas SE and EUC showed minimal change across outcomes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The trial demonstrated satisfactory recruitment (43.8%) and retention (94.5%).

    “Satisfactory recruitment (43.8%) and retention (94.5%) demonstrated feasibility.”
    • Also stated in: § Feasibility · plain
      “Of 208 BCS assessed for eligibility, 91 (43.8%) enrolled and 117 were excluded (Figure 1). Retention was excellent (94.5%) and 89.0% of participants completed all four assessments.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed recruitment (43.8%) and retention (94.5%) rates are satisfactory for demonstrating feasibility.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The sample was predominantly White (84%), college-educated (65%), and earning at least $50,000 per year (73%).

    “Most participants were White (84%) college graduates (65%) earning ≥$50,000 annually (73%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among 208 breast cancer survivors screened, 91 (43.8%) enrolled and 117 were excluded.

    “Of 208 BCS assessed for eligibility, 91 (43.8%) enrolled and 117 were excluded (Figure 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Attendance was comparable for ACT (81.7%) and SE (86.7%; p=0.47), and all EUC participants attended the one coaching session.

    “Attendance rates were similar across ACT (81.7%) and SE (86.7%; p=0.47) with 100% of EUC participants attending the single coaching session.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The retention rate was 94.5%, and 89.0% finished all four assessments.

    “Retention was excellent (94.5%) and 89.0% of participants completed all four assessments.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Avoidance may briefly relieve cancer-related anxiety, yet rebound effects can keep FCR elevated over time.

    “While avoidant coping allows survivors to escape anxiety-provoking thoughts about cancer in the short-term, rebound-effects produce sustained, elevated levels of FCR over time.42”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [42] source

  • May combine two claims.

    Interpretationcitation

    At six months post-intervention, ACT yielded larger FCR severity reductions than both SE and EUC, and the differences reached clinical significance.

    “six months after intervention, ACT participants reported greater reductions in FCR severity relative to both SE and EUC with differences large enough to be considered clinically significant.40”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [40] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Breast cancer survivors are especially vulnerable to clinically significant FCR, with up to 70% reporting it.

    “Breast cancer survivors (BCS) are particularly vulnerable with up to 70% reporting clinically-significant FCR.”
    • Also stated in: § INTRODUCTION · plain
      “up to 70% of survivors report clinically-significant FCR,8,9 making it the most frequently-reported unmet need of BCS.1,10”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [8] source
    • cites [9] source
    • cites [1] source
    • cites [10] source

  • May combine two claims.

    Interpretationcitation

    Group delivery of ACT appears efficacious and may lower costs and reach more people than individual delivery.

    “First, ACT can be delivered efficaciously to a group, potentially reducing costs and increasing the number of those served over individually-delivered interventions.27,29”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [27]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [29] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    While the Cancer-AAQ assessed avoidant coping, the FCRI-Coping Strategies subscale mainly counts strategies and reveals little about specific coping styles.

    “Although the Cancer-AAQ captured avoidant coping, the FCRI-Coping Strategies subscale is essentially a count measure of adaptive and maladaptive coping strategies and provided little insight into specific coping styles”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    As a pilot, the study lacked full power for efficacy, so a larger randomized trial is needed to confirm the findings.

    “Second, this pilot was not a fully-powered efficacy trial, necessitating a larger randomized trial to confirm results.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The sample was mostly White, wealthy, and college-educated, so findings may not generalize to other groups.

    “A limitation of this study was the largely White, affluent, college-educated sample, limiting generalizability to other groups.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Allocation was masked from participants and research assistants, and participants did not know the study hypotheses.

    “Participants and research assistants were blinded to allocation sequence, and participants were blinded to study hypotheses.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    A general linear model tested between-group differences while controlling for age, cancer stage, education, and treatments received.

    “Between-group differences on change scores of the outcomes were tested using a General Linear Model (GLM) while adjusting for theoretically-important covariates (i.e., age, stage of cancer, education)39 and cancer treatments received, which differed significantly between arms at baseline.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [39] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The study was registered with ClinicalTrials.gov.

    “This study is registered with ClinicalTrials.gov ().”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    A 6-month follow-up is less rigorous than 12- or 24-month assessments for long-term effects.

    “While intended to assess long-term effects of treatment, the pilot’s 6-month follow-up is only modestly rigorous compared to a 12- or 24-month follow-up assessment”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    An intent-to-treat approach analyzed all available data, irrespective of attendance or adherence.

    “Using an intent-to-treat design, all available data were analyzed regardless of participants’ attendance or adherence.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    A biostatistician created the allocation sequence using randomly varied blocks, and it was hidden in opaque, sequentially numbered envelopes.

    “The allocation sequence was generated by the biostatistician in randomly-varied block sizes of three or six and concealed in opaque sequentially-numbered envelopes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Normality and equal variances were met, as checked with histograms and scatterplots.

    “Assumptions of normality and homogeneity of variances were satisfied and assessed with histograms and scatterplots.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Fidelity averaged 95.6% in ACT and 93.8% in SE.

    “Average fidelity ratings were 95.6% for ACT and 93.8% for SE.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    ACT, but not SE or EUC, might lower maladaptive avoidance and thus help manage FCR and related distress over time.

    “Unlike SE or EUC, ACT may reduce maladaptive avoidant coping, thereby contributing to long-term management of FCR and associated distress.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The Indiana University IRB approved study procedures.

    “The Indiana University Institutional Review Board (#1507511085) approved study procedures.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    SE and EUC provided indirect FCR resources but did not directly teach coping with fearful thoughts and emotions, which might be crucial for comorbid distress and FCR.

    “Both offered resources to indirectly manage FCR but did not directly promote adaptive coping with fearful thoughts and emotions, which may be key in addressing comorbid distress and FCR.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Pairwise arm comparisons used Tukey-Kramer tests with family-wise alpha set at 0.05 per outcome.

    “Post-hoc Tukey-Kramer tests assessed pairwise differences between arms while controlling the family-wise alpha at 0.05 for each outcome.”
    Quote in the paperNot a substantial claim
30 of 30

  • The paper relies on this without support.

    The observed recruitment (43.8%) and retention (94.5%) rates are satisfactory for demonstrating feasibility.

    “Satisfactory recruitment (43.8%) and retention (94.5%) demonstrated feasibility.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The average fidelity rating across all rated TACTICs sessions was 98.6% (SD = 0.03), indicating high adherence to the intervention manual.

    “The average fidelity rating across all sessions rated was 98.6% (SD = 0.03), suggesting the interventionist delivered TACTICs in a manner that was highly adherent to the intervention manual.”

    From Feasibility and acceptability of an acceptance and commitment therapy intervention for caregivers of adults with Alzheimer’s disease and related dementias (2021) · cites this paper as [36]

    The Methods > Interventions > Treatment Fidelity passage reports average fidelity ratings of 95.6% for ACT and 93.8% for survivorship education, not 98.6%. It does not identify an intervention called TACTICs or report an SD of 0.03. No page number is available in our copy. (LLM, conf=0.90)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured

  • Strong evidence of feasibility and acceptability was reported, with high accrual and retention or enrollment rates and high satisfaction with the sessions.

    “Strong evidence of feasibility and acceptability was reported, with high accrual and retention or enrollment rates [44, 45], high ratings for essentialness and effectiveness of the intervention [47], moderate to high ratings for usefulness or expected benefits from the intervention [48, 52, 54], and high degree of satisfaction with the sessions [45, 46, 48, 51] (see Table 4 for details).”

    From Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model (2021) · cites this paper as [44]

    The Discussion reports strong evidence of feasibility, citing high accrual and retention, and Results > Feasibility gives the corresponding rates. Our copy does not report participant satisfaction with the sessions, so that part of the attributed claim is unsupported. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • In a 3-arm pilot randomized controlled trial addressing fear of cancer recurrence among breast cancer survivors, Acceptance and Commitment Therapy demonstrated greater acceptability and improvements in mental and physical quality of life, cognitive flexibility, and a reduction in avoidant coping skills, relative to survivorship education and enhanced usual care.

    “in a 3-arm pilot RCT addressing fear of cancer recurrence among breast cancer survivors, ACT demonstrated greater acceptability and improvements in mental and physical quality of life, cognitive flexibility, and a reduction in avoidant coping skills, relative to survivorship education and enhanced usual care [43].”

    From A digital, coach-assisted intervention to address the psychosocial needs of young adult cancer survivors: Randomized controlled trial protocol and intervention adaptation process (2024) · cites this paper as [43]

    Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • The 13 reviewed articles were published between 2015 and 2019 and came from studies conducted in the USA, Australia, Spain, and Iran.

    “The 13 articles selected for review were published between 2015 and 2019 from studies conducted in USA [44–46], Australia [47–52], Spain [53, 54], and Iran [55].”

    From Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model (2021) · cites this paper as [44]

    The Methods > Procedures passage identifies this as a study of breast cancer survivors receiving care at clinics in Indiana, supporting its inclusion among the USA studies. Our copy does not establish the claimed 2015–2019 publication window or the review’s total of 13 articles; this individual trial cannot substantiate the studies attributed to Australia, Spain, and Iran. (LLM, conf=0.81)

    Experimental — accuracy not yet measured

  • Eight studies reported time since cancer diagnosis; the average time post-diagnosis was 36.45 months, with a range of 27 to 64.08 months.

    “Eight studies reported time since cancer diagnosis for the participants; the average time post-diagnosis was 36.45 months, with a range of 27 months [47] to 64.08 months [44].”

    From Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model (2021) · cites this paper as [44]

    The Results, under Participant Characteristics (page unavailable), report a mean time since diagnosis of approximately 64 months for this trial, consistent with the upper end attributed to [44]. Our copy does not substantiate the more precise figure of 64.08 months. The eight-study average is the citing authors’ summary, not a finding attributed to this individual trial. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Weiss D, 1997, Assessing Psychological Trauma and PTSD: A Practioner's Handbook, 339

Cited by

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Related

Authors
Johns, S. A., Stutz, P. V., Talib, T. L., Cohee, A. A., Beck‐Coon, K. A., Brown, L. F., Wilhelm, L. R., Monahan, P. O., LaPradd, M. L., Champion, V. L., Miller, K. D., & Giesler, R. B.
Affiliations
  • Regenstrief Institute (US)
  • Indiana University Indianapolis (US)
  • West Virginia University (US)
  • Butler University (US)
Corresponding author
Johns, Shelley A.
ORCID
Venue
Cancer
Publisher
Wiley
Published
2019-09-20
Volume
126
Issue
1
Pages
211-218
ISSN
  • 0008-543X (ISSN-L)
  • 1097-0142
DOI
10.1002/cncr.32518
PMC
PMC6906228
OpenAlex
W2974123878
Cited by
141
References
43
Citations by year
2026: 18 · 2025: 20 · 2024: 19 · 2023: 25 · 2022: 29 · 2021: 21 · 2020: 8 · 2019: 1
FWCI
6.15
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Cancer (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • IUScholarWorks (Indiana University) (submittedVersion)
Funders
  • Indiana University Health (0952)
  • National Cancer Institute (K05CA175048)
  • Walther Cancer Foundation (0175.01)
Topics
  • Health Sciences › Medicine › Oncology › Cancer survivorship and care
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Childhood Cancer Survivors' Quality of Life
Keywords
acceptance and commitment therapy, fear of cancer recurrence, breast cancer survivors, group therapy, survivorship education, psychological flexibility, avoidance coping, anxiety, depression, post-traumatic stress, quality of life, psychological distress, feasibility
MeSH terms
Cancer Survivors, Involuntary Commitment, Adult, Aged, Anxiety, Breast, Breast Neoplasms, Depression, Fear, Female, Humans, Middle Aged, Neoplasm Recurrence, Local, Neoplasm Staging, Phobic Disorders, Quality of Life, Stress Disorders, Post-Traumatic

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