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Cited by 0Cancer survivorship and careMindfulness and Compassion InterventionsResilience and Mental Health

Psychological flexibility, distress, and coping in ovarian cancer survivors.

Open access
Telles, Rachel, Hosch, Alexis, Pennington, Kathryn P., Schlumbrecht, Matthew, McGregor, Bonnie A., Heron, Leslie, Zia, Sharaf, Noble, Alyssa +4 more·2026·Journal of Psychosocial Oncology
DOI 10.1080/07347332.2025.2588632PMC PMC13187919
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Abstract

Background: Ovarian cancer survivors report elevated levels of psychological distress due to the high rates of recurrence and mortality, but little is currently known about the coping skills and strengths that survivors draw upon during their cancer survivorship. One such possible strength is psychological flexibility, defined as the ability to stay in the present moment regardless of unpleasant experiences and make behavioral choices based on values. Objective: The study aimed to explore psychological flexibility and coping among ovarian cancer survivors prior to their participation in a web-based psychosocial intervention and to examine potential mediators of distress. Methods: Ovarian cancer survivors were recruited to participate in an 11-week group-based, web-delivered psychosocial intervention. Participants completed assessments of mood, psychological flexibility and coping before the intervention. 165 ovarian cancer survivors provided survey data on psychosocial and clinical characteristics prior to randomization. Multiple mediation models were used to examine potential mediators in the relation of psychological flexibility with depression and anxiety. Results: Survivors reported mild levels of depression and anxiety. Multiple mediation models revealed significant indirect effects of psychological flexibility on both anxiety and depression. The negative association between psychological flexibility and anxiety was partially mediated by avoidant coping (p =.030). Moreover, the association between psychological flexibility and depression was mediated by cancer-related worry (p =.004). Conclusions: Psychological flexibility is associated with less distress in ovarian cancer survivors who present for psychological intervention, and this pathway is partially mediated by avoidant coping and cancer-related worry. Mindfulness techniques and coping skills training may ameliorate these effects and improve psychological functioning.

Integrity signals

Registry

Crossref · 10.1080/07347332.2025.2588632

Cites

46 of 46 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

6 of 23 cited sources checked · 6 supported · 0 flagged

  • Premisecitation

    Cancer-related worry and mindfulness are cognitive strategies linked to distress in cancer patients.

    “Other cognitive strategies associated with distress in cancer patients include cancer-related worry22 and mindfulness.23”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [22] source
    • cites [23] source
  • Findingown data

    Higher avoidant coping was associated with higher anxiety.

    “higher levels of avoidant coping (r = .39, p < .001) and cancer-related worry (r = 43, p < .001) were associated with higher levels of anxiety”
    Quote in the paperSubstantial claim
  • Findingown data

    Greater psychological flexibility was associated with lower depression.

    “greater psychological flexibility was associated with lower levels of anxiety (r = −.46, p < .001) and depression (r = −.647, p < .001).”
    Quote in the paperSubstantial claim
  • Findingown data

    In the depression mediation model with covariates, the indirect effect remained significant.

    “and indirect effect (β = −.27, 95% CI [−0.41, −0.16], p < .001), of psychological inflexibility on depression remained significant after controlling for covariates.”
    Quote in the paperSubstantial claim
  • Findingown data

    Greater psychological flexibility was associated with less avoidant coping.

    “Greater psychological flexibility was also associated with less avoidant coping (r = −.35, p < .001)”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 23
  • Not yet classified. 2
  • May combine two claims. 11

  • Classified as probably not a substantial claim.

    Premisecitation

    Within ACT theory, psychological flexibility is thought to reduce avoidance.

    “In the Acceptance and Commitment Therapy (ACT) framework, psychological flexibility is posited to decrease avoidance,16”
    Quote in the paperSubstantial claim1 of 1 sources checked

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

    Study design and conductcitation

    The Cancer Worry Scale is well-validated for assessing fear of recurrence in cancer patients and survivors.

    “The Cancer Worry Scale is a 6-item self-report measure designed to assess fear of recurrence in cancer survivors that has been well-validated for use in cancer patients and survivors.33”
    Quote in the paperNot a substantial claim1 of 1 sources checked

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The AAQ-II is a validated self-report measure of psychological flexibility.

    “The Acceptance and Action Questionnaire (AAQ-II) is a 7-item self-report scale developed in the context of Acceptance and Commitment Therapy to evaluate psychological flexibility.29,30”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [29] source
    • cites [30] source

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

    Study design and conductcitation

    The POMS-SF anxiety/tension subscale is a well-validated instrument.

    “The Profile of Mood States – Short Form (POMS-SF) is a 37-item well-validated self-report mood inventory that is commonly used in oncology settings.”
    Quote in the paperNot a substantial claim1 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

    The CES-D is a well-validated measure of depressive symptom frequency.

    “The Center for Epidemiological Studies Depression (CES-D) Scale is a well-validated 20-item self-report scale that assesses the frequency of depressive symptoms during the previous week.26”
    Quote in the paperNot a substantial claim1 of 1 sources checked

  • Not yet classified.

    Finding

    Greater psychological flexibility was associated with less cancer-related worry.

    “Greater psychological flexibility was also associated with less avoidant coping (r = −.35, p < .001) and cancer-related worry (r = −.49, p < .001)”
    Quote in the paperNot yet classified

  • Not yet classified.

    Finding

    In the anxiety mediation model without covariates, the specific indirect effect through mindfulness was not significant.

    “There was no significant specific indirect effect through mindfulness (β = −.08, 95% CI [−0.23, 0.01], p = .137).”
    Quote in the paperNot yet classified

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

    Findingown data

    In the pre-intervention sample, anxiety levels were relatively low.

    “In contrast, anxiety levels were relatively low.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The sample was fairly homogeneous, mostly affluent and white.

    “The population is relatively homogenous, representing a primarily affluent and white group of survivors”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The results suggest that before intervention, cancer-related worry and avoidant coping help convert low flexibility into distress, with mindfulness playing a smaller role.

    “These results suggest that prior to psychological intervention, cancer-related worry and ineffective coping strategies such as avoidance are functioning to translate low levels of flexibility into distress, while mindfulness is less influential in these pathways.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Among ovarian cancer survivors entering a psychological intervention, greater psychological flexibility relates to lower distress, with avoidant coping and cancer-related worry partly explaining this link.

    “Psychological flexibility is associated with less distress in ovarian cancer survivors who present for psychological intervention, and this pathway is partially mediated by avoidant coping and cancer-related worry.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Avoidant coping seemed to relate to both anxiety and depression, whereas cancer-related worry related more specifically to depressive symptoms.

    “Avoidant coping appeared to generalize to higher levels of both anxiety and depression, while cancer-related worry was more specific to higher levels of depressive symptoms.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    Participants filled out psychosocial surveys online within two weeks before group randomization and were unaware of their randomization assignment.

    “Participants completed psychosocial questionnaires online within 2 weeks prior to group randomization for the web-based psychosocial intervention. They did not know their randomization status at the time of survey completion.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The depression scale showed excellent internal reliability in this sample.

    “The internal reliability (ω = 0.9) was excellent.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The mindfulness scale showed excellent internal reliability in this sample.

    “Internal reliability (ω = 0.91) was excellent.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The 11-week intervention may have drawn a select group of participants, which could limit how broadly the findings apply.

    “This could have attracted a select sample of participants willing to engage in an intervention of that length and deterred those uninterested in such an intervention. This may limit the generalizability of these findings.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In ovarian cancer specifically, ACT has been shown to improve quality of life, mood, and cancer-related symptoms.

    “Specifically in ovarian cancer, ACT has been demonstrated to improve quality of life and mood as well as cancer-specific symptom burden.20,21.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [20] source
    • cites [21] source

  • Classified as probably not a substantial claim.

    Premisecitation

    Theory suggests psychological flexibility may operate by changing coping methods, including avoidant coping.

    “and has been theorized to work via altering methods of coping, such as avoidant coping.17”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The analysis looked at associations at a single time point.

    “This analysis examined concurrent associations.”
    Quote in the paperSubstantial claim

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

    Study design and conductcitation

    Acceptable model fit was judged by CFI and TLI at or above .95, RMSEA below .08, and SRMR at or below .08.

    “Model fit was determined using acceptable fit criteria for comparative fit index (CFI) and Tucker-Lewis Index (TLI) of ≥ .95, root mean square error of approximation (RMSEA) of < .08, and standardized root mean square residual (SRMR) of ≤ .08.40”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [40] source

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

    Study design and conductown data

    The anxiety scale showed excellent internal reliability in this sample.

    “Internal reliability was assessed via McDonald’s Omega and was excellent (ω = 0.95).”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    A robust maximum likelihood estimator was used to provide standard errors robust to nonnormal data.

    “Models were estimated with a robust maximum likelihood estimator (MLR) that provides robust standard errors to account for nonnormally distributed data.”
    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 conductnone given

    The study received University of Iowa IRB approval, and all participants gave written informed consent.

    “All procedures at each participating institution were approved by the University of Iowa IRB, who served as the IRB of Record for this study (approval number 201911073).”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The avoidant coping scale showed good internal reliability in this sample.

    “Internal reliability (ω = 0.83) was good.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The cancer worry scale showed excellent internal reliability in this sample.

    “Internal reliability (ω = 0.94) was excellent.”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation

    The Freiburg Mindfulness Inventory is well-validated for measuring mindfulness over time.

    “The Freiburg Mindfulness Inventory is a 14-item scale developed for use in mindfulness-based stress reduction (MBSR) interventions. It is well-validated for use in assessing mindfulness levels over time regardless of prior meditation practice.34”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] source

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

    Study design and conductcitation

    The analysis used full information maximum likelihood to handle missing data.

    “Models were fit using FIML estimation, which uses all available data and is the gold standard approach for handling missingness when data are missing at random or completely at random.37”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] source
    • Rests on an assumption: The missing data mechanism is missing at random or completely at random, which justifies FIML.

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

    Study design and conductnone given

    The models were run both with and without covariates: age, stage, and household income as a proxy for socioeconomic status.

    “Models were examined with and without covariates. Covariates included age, stage, and socioeconomic status as approximated by household income.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The psychological flexibility scale showed excellent internal reliability in this sample.

    “Internal reliability (ω = 0.93) was excellent.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Indirect effects used bias-corrected bootstrap confidence intervals based on 10,000 resamples.

    “The indirect effect was estimated with bias-corrected bootstrapped confidence intervals.38,39 Confidence intervals were estimated from 10,000 bootstrap samples.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [38] source
    • cites [39] source

  • May combine two claims.

    Interpretationown data

    Avoidance relates to anxiety, whereas worry relates to depressive symptoms.

    “Avoidance in particular is associated with anxiety, while worry is associated with depressive symptoms.”
    Quote in the paperSubstantial claim

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

    Interpretationreasoning

    Using self-report for all variables may inflate correlations due to response style.

    “Additionally, all variables examined in this study are drawn from self-report scales. Thus, individual response style may artificially inflate correlations among variables”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Across mixed cancer patient samples, psychological flexibility has been linked to better quality of life and fewer mood problems.

    “It has additionally been associated with higher quality of life and lower levels of mood disturbances irrespective of clinical and sociodemographic characteristics in heterogeneous cancer patients.15”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] source
33 of 33

  • The paper relies on this without support.

    The mediation models assume that the temporal ordering runs from psychological flexibility through the mediators to distress, despite the cross-sectional design.

    “This analysis examined concurrent associations.”

  • The paper relies on this without support.

    The missing data mechanism is missing at random or completely at random, which justifies FIML.

    “Models were fit using FIML estimation, which uses all available data and is the gold standard approach for handling missingness when data are missing at random or completely at random.37”
2 of 2

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.

  • Depression mediation proportion does not match the reported effects

    Major

    The reported indirect effect divided by the total effect is about 39%, not 54%. This changes the stated size of the mediated association.

    Reported 0.54 · recomputed 0.390625

  • Depression prevalence is described in opposite ways

    Minor

    The Results say 67% of participants had depressive symptoms in the subclinical range, while the Limitations say 67% had clinically significant depression. These descriptions cannot both characterize the same proportion at study initiation.

  • Depression mediation estimate falls outside its confidence interval

    Minor

    The reported point estimate for the cancer-related-worry indirect effect is −0.096, but its stated 95% confidence interval runs from −0.18 to −0.14 and does not contain that estimate.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Ensel WM. Measuring depression: The CES-D scale. social support, life events, and depression. New York: Academic Press; 1986.

Authors
Telles, R., Hosch, A., Pennington, K. P., Schlumbrecht, M., McGregor, B. A., Heron, L., Zia, S., Noble, A., Goodheart, M. J., Noonan, M., Penedo, F. J., & Lutgendorf, S. K.
Affiliations
  • University of Iowa (US)
  • University of Washington Medical Center (US)
  • University of Miami (US)
  • Orion Center for Integrative Medicine
  • Cancer Survivorship Provider Network
Corresponding author
Telles, Rachel
Venue
Journal of Psychosocial Oncology
Publisher
Informa UK Limited
Published
2025-11-26
Volume
44
Issue
3
Pages
358-375
ISSN
  • 0734-7332 (ISSN-L)
  • 1540-7586
DOI
10.1080/07347332.2025.2588632
PMC
PMC13187919
OpenAlex
W4416723052
Cited by
0
References
46
FWCI
0.00
Type
journal article
Language
en
Open access
Locations
  • Journal of Psychosocial Oncology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion)
Funders
  • National Institutes of Health
  • National Center for Advancing Translational Sciences (UL1TR002537)
Topics
  • Health Sciences › Medicine › Oncology › Cancer survivorship and care
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Clinical Psychology › Resilience and Mental Health
Keywords
ovarian cancer survivors, psychological flexibility, psychological distress, coping, depression, anxiety, avoidance coping, cancer-related worry
MeSH terms
Cancer Survivors, Psychological Distress, Internet-Based Intervention, Psychosocial Intervention, Adaptation, Psychological, Adult

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Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

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