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Cited by 35Cancer survivorship and careMindfulness and Compassion InterventionsPalliative and Oncologic Care

Symptom experiences in metastatic breast cancer patients: relationships to activity engagement, value-based living, and psychological inflexibility

Open access
Mosher, Catherine E., Tometich, Danielle B., Hirsh, Adam, Rand, Kevin L., Johns, Shelley A., Matthias, Marianne S., Outcalt, Samantha D., Bricker, Jonathan +5 more·2017·Psycho-Oncology
DOI 10.1002/pon.4283PMC PMC5359070
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Abstract

Objective: This study examined symptom-based subgroups of metastatic breast cancer (MBC) patients and the extent to which they differed across key constructs of acceptance and commitment therapy (ACT). Methods: Eighty women with MBC completed self-report surveys assessing 10 common symptoms and several ACT variables (ie, activity engagement, psychological inflexibility, value obstruction, and value progress) during a single time point. Results: A cluster analysis yielded 3 patient subgroups: low symptoms, low-moderate symptoms, and moderate-high symptoms. Relative to the subgroup with low symptoms, the other subgroups reported less activity engagement. In addition, compared with patients with low symptoms, the subgroup with moderate-high symptoms reported greater psychological inflexibility (ie, avoidance of unwanted internal experiences) and greater difficulty living consistently with their values. Conclusions: Women with MBC show heterogeneity in their symptom profiles, and those with higher symptom burden are more likely to disengage from valued activities and avoid unwanted experiences (eg, thoughts, feelings, and bodily sensations). Findings are largely consistent with the ACT model and provide strong justification for testing ACT to address symptom interference in MBC patients. Copyright © 2016 John Wiley & Sons, Ltd.

Integrity signals

Registry

Crossref · 10.1002/pon.4283

Cites

41 of 41 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

20 of 56 cited sources checked · 9 supported · 0 flagged · accuracy not yet measured

  • Interpretationown data

    The study findings are largely consistent with the Acceptance and Commitment Therapy model.

    “Findings are largely consistent with the ACT model”
    • Also stated in: § Conclusions · plain
      “These results are largely consistent with ACT theory [17]”
    Quote in the paperSubstantial claim1 of 1 sources checked
  • Premisecitation

    Preliminary evidence suggests that symptoms may disrupt the daily activities of metastatic breast cancer patients.

    “Preliminary evidence suggests that symptoms may disrupt the daily activities of MBC patients [3, 15].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [3] source
    • cites [15] source

      The Results and Discussion report that depressive symptoms, particularly negative affect, predicted increased disruption of social and recreational activities in women with metastatic breast cancer. The claim is broader: the study did not assess cancer-related physical symptoms or the full range of daily activities (Discussion; page not provided). (LLM, conf=0.82)

      Experimental — accuracy not yet measured
  • Premisecitation

    Other common symptoms among cancer patients, such as nausea, neuropathy, swelling of arms and legs, hot flashes, and cognitive problems, have received less attention in the metastatic breast cancer literature.

    “Other common symptoms among cancer patients (e.g., nausea, neuropathy, swelling of arms and legs, hot flashes, cognitive problems) have received less attention in the MBC literature [6, 12–14].”
    Quote in the paperSubstantial claim2 of 4 sources checked
    • cites [6] source

      The Introduction (page unavailable) describes people with metastatic disease as under-researched in quality-of-life research. The paper records nausea and cognitive functioning in its sample, but does not say that the listed symptoms have received less attention than other symptoms in the metastatic breast cancer literature. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [12] source
    • cites [13] source

      The Neuropathy assessment tools section says neuropathy is often underrecognized and underreported and calls for more prospective studies using patient-reported tools in metastatic breast cancer trials. This supports the claim's neuropathy component, but the paper does not establish that nausea, swelling, hot flashes, or cognitive problems have received less attention in the MBC literature. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [14] source
  • Premisecitation

    The PROMIS measures used in the study have undergone rigorous reliability and validity testing.

    “These measures have undergone rigorous reliability and validity testing [29–31].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [29] source
    • cites [30] source
    • cites [31] source
  • Premisecitation

    Co-occurring symptoms have a compounding, negative effect on cancer patients' functional status and quality of life.

    “This analysis was performed because co-occurring symptoms have a compounding, negative effect on cancer patients’ functional status and quality of life [40].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [40] source

      The Introduction says co-occurring symptoms can adversely affect patient outcomes, and the Discussion says multiple symptoms affect quality of life and functional status. But the Introduction says a synergistic effect *may* occur; it does not establish the claim’s unqualified “compounding” effect. Page numbers are unavailable in our copy. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 21
  • May combine two claims. 16
  • The quote only partly states this claim. 1

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

    Premisecitation

    Prior research with other cancer populations has also found heterogeneity in patients' symptom experience.

    “Prior research with other cancer populations has also found heterogeneity with respect to patients’ symptom experience [40].”
    Quote in the paperNot a substantial claim1 of 1 sources checked

  • May combine two claims.

    Premisecitation

    Despite commonly used pharmacologic symptom management, metastatic breast cancer patients have high symptom burden that is a major source of suffering, impairment, and disability.

    “Despite commonly used pharmacologic approaches to symptom management, MBC patients have high symptom burden that is a major source of suffering, impairment, and disability [2–4, 6].”
    Quote in the paperSubstantial claim1 of 4 sources checked
    • cites [2] source
    • cites [3] source
    • cites [4] source
    • cites [6] source

      The Description of the sample reports substantial fatigue, pain and insomnia among the women studied, alongside poorer physical, role and social functioning in a sizeable minority. The Discussion says pain and insomnia remained problems for some women despite being potentially manageable with medication. The paper does not establish that pharmacologic symptom treatments were commonly used in this sample or that symptoms were a major cause of suffering, impairment and disability. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    ACT theorists have proposed that psychological suffering results from attempts to avoid aversive experiences, such as symptoms, which often lead to disengagement from valued activities.

    “Consistent with these findings, ACT theorists have proposed that psychological suffering results from attempts to avoid aversive experiences, such as symptoms, which often lead to disengagement from valued activities [17].”
    Quote in the paperSubstantial claim1 of 1 sources checked

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

    Premisecitation

    Common symptoms in metastatic breast cancer patients include depression, anxiety, sleep disturbance, pain, and fatigue.

    “Common symptoms in this population include depression, anxiety, sleep disturbance, pain, and fatigue [6–10].”
    Quote in the paperNot a substantial claim2 of 5 sources checked
    • cites [6] source

      The Description of the sample reports fatigue (63%), pain (30%) and insomnia (26%) among women with advanced breast cancer. The Introduction also discusses psychological distress, but the paper does not identify depression and anxiety specifically as common symptoms in this sample. Page numbers are unavailable in our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [7] source
    • cites [8] source
    • cites [9] source

      The Discussion reports sleep disturbance in 63% of the women studied, depressive symptoms in 30%, and pain among factors affecting them. The paper discusses fatigue in relation to cancer and sleep but says it was not assessed in this study; it does not establish anxiety as a common symptom in this population. Page numbers are unavailable in our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [10] source

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

    Premisecitation

    The Acceptance and Action Questionnaire-II demonstrated good test-retest reliability and discriminant validity.

    “The AAQ-II demonstrated good test-retest reliability and discriminant validity [38].”
    Quote in the paperNot a substantial claim1 of 1 sources checked

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

    Premisecitation

    Psychological inflexibility occurs when people avoid unwanted thoughts and emotions, which often has the paradoxical effect of increasing distress and decreasing value-based action.

    “Conversely, psychological inflexibility occurs when people avoid unwanted thoughts and emotions, which often has the paradoxical effect of increasing distress and decreasing value-based action [17].”
    Quote in the paperSubstantial claim1 of 1 sources checked

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

    Premisecitation

    Many metastatic breast cancer patients experience symptoms that impair their quality of life and functional capacity.

    “with many experiencing symptoms which impair their quality of life and functional capacity [2–6].”
    Quote in the paperNot a substantial claim2 of 5 sources checked
    • cites [2] source
    • cites [3] source
    • cites [4] source
    • cites [5] source
    • cites [6] source

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

    Premisecitation

    PROMIS measures were initially developed with cancer patients' input, and a growing body of research has documented their reliability and validity for use with cancer patients, including those with advanced disease.

    “PROMIS measures were initially developed with cancer patients’ input [32], and a growing body of research has documented the measures’ reliability and validity for use with cancer patients, including those with advanced disease [33–35].”
    Quote in the paperNot a substantial claim3 of 4 sources checked
    • cites [32] source
    • cites [33] source

      The Introduction and Results report a study of non-metastatic prostate cancer patients in which PROMIS computer-adaptive tests correlated significantly with the Brief Symptom Inventory, supporting validity in that group. The paper does not report reliability testing or establish validity in patients with advanced disease. The separate claim about cancer patients’ input is attached to citation [32], not this source. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [34] source

      The Methods > Measures section says PROMIS CATs generate reliable and valid symptom scores and use normative data from cancer patients. The paper describes their use in gynecologic oncology outpatient care, but does not establish reliability or validity specifically for patients with advanced disease. The separate claim about cancer patients’ input is attached to citation [32], not this source. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [35] source

      The Methods (sections 2.1–2.4; page unavailable) describe administering six PROMIS-Cancer scales to patients with stage III or IV cancer and assessing measurement precision and correlations with other measures. This provides some evidence about their use in advanced cancer, but the paper focuses on minimally important differences and does not establish the broader claim that research has documented both reliability and validity. The separate claim about patients’ input is attached to citation [32], not this source. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    Novel intervention models seek to shift emphasis from symptom reduction to decreasing symptom-related suffering and interference with valued activities.

    “Novel intervention models seek to shift the emphasis from symptom reduction to decreasing symptom-related suffering and interference with valued activities [17].”
    Quote in the paperSubstantial claim1 of 1 sources checked

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

    Premisecitation

    Another study of metastatic breast cancer patients found that greater depressive symptoms predicted increases in global perceptions of activity disruption over a 3-month period.

    “Another study of MBC patients found that greater depressive symptoms predicted increases in global perceptions of activity disruption over a 3-month period [15].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [15] source

      The Results report that higher depressive-symptom scores at study entry predicted increased activity disruption three months later in women with metastatic breast cancer. However, the Methods describe a six-item measure limited to disruption of social and recreational pursuits, and the Discussion says it may not capture the full range of valued activities. Calling the outcome “global perceptions of activity disruption” overstates its scope. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • The quote only partly states this claim.

    Findingown data

    A cluster analysis of ten symptom severities identified three subgroups of metastatic breast cancer patients: low symptoms, low-moderate symptoms, and moderate-high symptoms.

    “A cluster analysis yielded three patient subgroups: low symptoms, low-moderate symptoms, and moderate-high symptoms.”
    • Also stated in: § Primary analyses · plain
      “A 3-cluster solution was found.”
    • Also stated in: § Conclusions · hedged
      “Results suggested that there were three patient subgroups: those with low symptoms, low-moderate symptoms, and moderate-high symptoms.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Tukey post hoc comparisons showed that Cluster 1 often had lower symptom levels than the other clusters, and Cluster 2 had lower symptom levels than Cluster 3 for hot flashes and fatigue.

    “Tukey’s post hoc comparisons showed that Cluster 1 frequently had lower symptom levels than the other clusters, and Cluster 2 had lower symptom levels than Cluster 3 for hot flashes and fatigue.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Greater psychological inflexibility was related to less value progress and less engagement in roles and activities.

    “Conversely, greater psychological inflexibility was related to less value progress and engagement in roles and activities.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Most symptoms had significant positive associations with value obstruction, with the exceptions of nausea, swelling of arms or legs, and hot flashes.

    “A similar pattern of findings was obtained with respect to value obstruction, with most symptoms showing significant, positive associations with this outcome. Nausea, swelling of arms or legs, and hot flashes were the only symptoms unrelated to value obstruction.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Psychological inflexibility had significant positive associations with six of the ten symptoms-pain, fatigue, sleep disturbance, cognitive concerns, anxiety, and depressive symptoms-and with value obstruction.

    “Finally, psychological inflexibility showed significant, positive associations with six of the ten symptoms (i.e., pain, fatigue, sleep disturbance, cognitive concerns, anxiety, and depressive symptoms) as well as value obstruction.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The three symptom clusters contained 47 patients in the low symptoms group, 14 in the low-moderate symptoms group, and 19 in the moderate-high symptoms group.

    “Cluster 1 was labeled “Low Symptoms,” as it comprised 47 people with low symptom levels across domains. Cluster 2 was labeled “Low-Moderate Symptoms” and comprised 14 people with low to moderate symptom levels across domains. Cluster 3 was labeled “Moderate-High Symptoms,” as 19 people reported moderate to high symptom levels across domains.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Metastatic breast cancer patients with higher symptom burden are more likely to disengage from valued activities and to avoid unwanted internal experiences.

    “those with higher symptom burden are more likely to disengage from valued activities and avoid unwanted experiences (e.g., thoughts, feelings, bodily sensations).”
    • Also stated in: § Conclusions · hedged
      “suggest that MBC patients with greater symptom burden may be more likely to avoid unwanted thoughts, emotions, and sensations and withdraw from valued activities and relationships.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    A small number of pilot studies, most of which were not randomized trials, have examined the efficacy of ACT in cancer patients.

    “A small number of pilot studies—most of which were not randomized trials--have examined the efficacy of ACT in cancer patients [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] source

  • May combine two claims.

    Study design and conductown data

    The study sample was primarily highly educated and Caucasian.

    “The sample primarily consisted of highly educated, Caucasian patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The symptom clusters did not differ significantly on demographic variables (age, income, education, employment status, marital status) or medical factors (surgery, radiation, chemotherapy, hormonal therapy, time since diagnosis).

    “No significant differences were found among the clusters on demographic variables (i.e., age, income, education, employment status, and marital status) and medical factors (i.e., surgery, radiation, chemotherapy, hormonal therapy, and time since diagnosis).”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    A prior study of cancer patients found that greater psychological inflexibility was associated with less success in value-based living in certain domains such as family and leisure.

    “Similarly, a prior study of cancer patients found that greater psychological inflexibility was associated with less success in value-based living in certain domains (e.g., family, leisure) [21].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] source

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

    Premisecitation

    ACT has shown promising effects on psychological distress, quality of life, and self-management among patients with medical conditions such as diabetes and chronic pain.

    “In addition, ACT has shown promising effects on psychological distress, quality of life, and self-management among patients with medical conditions such as diabetes and chronic pain [24, 25].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [24] source
    • cites [25] source

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

    Study design and conductcitation

    Patients were excluded from participation if they made three or more errors on a validated 6-item cognitive screener widely used with cancer patients.

    “Patients were excluded from study participation if they made three or more errors on a validated 6-item cognitive screener that has been widely used with cancer patients [28].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] source

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

    Premisecitation

    The Valuing Questionnaire showed evidence of good internal consistency reliability and concurrent validity with measures of psychological well-being and ACT constructs.

    “The measure showed evidence of good internal consistency reliability and concurrent validity with measures of psychological well-being and ACT constructs [39].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [39] source

  • Classified as probably not a substantial claim.

    Premisecitation

    ACT promotes psychological flexibility so that internal experiences such as thoughts, feelings, and bodily sensations do not impair patients' ability to live a meaningful life.

    “ACT promotes psychological flexibility so that internal experiences (e.g., thoughts, feelings, bodily sensations) do not impair patients’ ability to live a meaningful life [20].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] source

  • Classified as probably not a substantial claim.

    Premisecitation

    Symptom-related suffering and interference are focal points of palliative care for advanced cancer patients.

    “Given that symptom-related suffering and interference are focal points of palliative care for advanced cancer patients [18]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] source

  • May combine two claims.

    Premisecitation

    Psychological flexibility has been associated with reduced anxiety and depressive symptoms and better well-being in patients with common cancers.

    “This flexibility has been associated with reduced anxiety and depressive symptoms and better well-being in patients with common cancers [21, 22].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [21] source
    • cites [22] source

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

    Premisecitation

    ACT has been successfully applied to a range of clinical disorders, including anxiety, depression, and posttraumatic stress disorder.

    “ACT has been successfully applied to a range of clinical disorders, including anxiety, depression, and posttraumatic stress disorder [23].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] source

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

    Study design and conductown data

    Of 107 metastatic breast cancer patients who received mailed information, 85 (79%) completed the screening assessment, 12 (11%) could not be reached by phone, and 10 (9%) refused participation.

    “Of the 107 MBC patients who received mailed information about this study, 85 (79%) completed the screening assessment, 12 (11%) could not be reached via phone, and 10 (9%) refused study participation.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    One study found that greater symptom severity and interference were associated with greater daily activity impairment and reduced work productivity in metastatic breast cancer patients.

    “One study found that greater symptom severity and interference were associated with greater daily activity impairment and reduced work productivity in this population [3].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] source

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

    Study design and conductown data

    Eighty patients (96%) completed the standardized phone assessment.

    “Eighty patients (96%) completed a standardized phone assessment consisting of the measures described below.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Acceptance and Commitment Therapy is one psychological intervention that holds promise for reducing symptom-related suffering and functional interference in cancer patients.

    “One psychological intervention that holds promise for reducing symptom-related suffering and functional interference in cancer patients is Acceptance and Commitment Therapy (ACT) [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] source
32 of 32

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?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Activity-engagement scoring direction conflicts with item wording

    Minor

    For the negatively worded sample items, "never" indicates greater engagement and is already assigned the highest rating, 5. Reversing those ratings would instead give higher scores to greater activity limitation, contradicting the stated interpretation of the summed score.

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Authors
Mosher, C. E., Tometich, D. B., Hirsh, A., Rand, K. L., Johns, S. A., Matthias, M. S., Outcalt, S. D., Bricker, J., Schneider, B., Mina, L., Storniolo, A. M., Newton, E., & Miller, K.
Affiliations
  • Indiana University – Purdue University Indianapolis (US)
  • Regenstrief Institute (US)
  • University of Washington (US)
  • Indiana University School of Medicine (US)
Corresponding author
Mosher, Catherine E.
ORCID
Venue
Psycho-Oncology
Publisher
Wiley
Published
2016-10-11
Volume
26
Issue
11
Pages
1944-1951
ISSN
  • 1057-9249 (ISSN-L)
  • 1099-1611
DOI
10.1002/pon.4283
PMC
PMC5359070
OpenAlex
W2522216850
Semantic Scholar
fee72d338e331964e56b1cc15e1fed4db9fb7634
Cited by
34
References
41
Citations by year
2026: 3 · 2025: 1 · 2024: 2 · 2023: 9 · 2022: 3 · 2021: 2 · 2020: 8 · 2019: 3 · 2018: 2
FWCI
0.90
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Psycho-Oncology (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • IUScholarWorks (Indiana University) (submittedVersion)
  • Purdue University Indianapolis (Indiana University) (submittedVersion)
Funders
  • National Cancer Institute (K05CA175048, R25CA117865, K07CA168883)
  • Walther Cancer Foundation
Topics
  • Health Sciences › Medicine › Oncology › Cancer survivorship and care
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
Keywords
metastatic breast cancer, symptom burden, symptom profiles, activity engagement, psychological inflexibility, acceptance and commitment therapy, symptom interference, patient subgroups
MeSH terms
Emotional Adjustment, Adult, Aged, Breast Neoplasms, Emotions, Female, Humans, Middle Aged, Quality of Life, Surveys and Questionnaires, Self Report, Acceptance and Commitment Therapy

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