Acceptance and commitment therapy processes and their association with distress in cancer: a systematic review and meta-analysis
Open accessAbstract
Around 42% of individuals with cancer experience distress. Acceptance and Commitment Therapy (ACT) can reduce distress, but effects are small, and mechanisms unclear. This review aimed to identify associations between ACT processes and distress in cancer. Search terms included cancer, ACT processes, self-compassion, and distress. Six online databases and grey literature were searched to March 2022. Of 6555 papers screened, 108 studies were included with a total of 17195 participants. Five meta-analyses of seventy-seven studies were conducted. Random effects meta-analyses of correlations revealed higher scores on flexible processes (acceptance, present moment awareness, self-compassion) were associated with lower distress (rpooled = -0.24, -0.39, -0.48, respectively); whilst higher scores on inflexible processes (experiential avoidance, cognitive fusion) were associated with higher distress (rpooled = 0.58, 0.57, respectively). Meta-analyses displayed moderate-to-high heterogeneity with most studies assessed as low risk of bias. Meta-regressions revealed no significant moderators (stage, time since diagnosis, gender and age). This review provides a theoretically aligned evidence base for associations between ACT processes and distress in cancer, supporting elements of ACT theory and providing targeted directions for intervention development. Due to limited evidence, future research should focus on the under-investigated processes (self-as-context, values, committed action) and conducting mediation analysis of ACT processes on distress in cancer in controlled trials.
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Research on psychosocial interventions for cancer survivors has often targeted depression, anxiety, emotional distress, negative affect, or fear of cancer recurrence rather than positive outcomes such as well-being.
“research on psychosocial interventions for cancer survivors has often targeted depression, anxiety, emotional distress, negative affect, or fear of cancer recurrence as outcomes – rather than positive outcomes, such as well-being [11, 12].”
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 [11]
The Results (Study characteristics; page not provided) report depression, anxiety, and distress far more often than well-being as outcomes, supporting the general contrast. The Introduction also describes ACT intervention reviews assessing anxiety, depression, and emotional distress. But this paper primarily reviews associations between ACT processes and distress, not outcomes of psychosocial interventions, and the cited passages do not establish fear of cancer recurrence as an intervention outcome. (LLM, conf=0.84)
Experimental — accuracy not yet measuredA 2022 meta-analysis of 77 studies examining Acceptance and Commitment Therapy processes among cancer survivors indicated that higher scores on flexible processes and lower scores on inflexible processes were associated with lower distress.
“A 2022 meta-analysis study of 77 studies examining ACT processes among cancer survivors indicated that higher scores on flexible processes (acceptance, present moment awareness, self-compassion) and lower scores on inflexible processes (experiential avoidance, cognitive fusion) were associated with lower distress [11].”
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 [11]
The Abstract reports five meta-analyses of 77 studies and the stated associations between flexible and inflexible ACT processes and distress. However, the cited paper is dated 2024, not 2022; its Abstract says the literature search ran until March 2022. The paper describes its population as people with cancer, not specifically cancer survivors. (LLM, conf=0.90)
Experimental — accuracy not yet measuredResearch has shown Acceptance and Commitment Therapy to improve various outcomes, including fear of cancer recurrence, anxiety, depression, emotional distress, and quality of life.
“research has shown ACT to improve various outcomes, including fear of cancer recurrence, anxiety, depression, emotional distress, and quality of life [9-11].”
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 [11]
The Introduction reports earlier reviews finding improvements in anxiety, depression, emotional distress, and quality of life following ACT interventions for people with cancer. It mentions fears around recurrence as a source of distress, but does not report that ACT improves fear of cancer recurrence specifically. (LLM, conf=0.88)
Experimental — accuracy not yet measuredExisting interventions largely target depression, anxiety, or fear of cancer recurrence as outcomes rather than well-being or other positive outcomes.
“existing interventions largely targeting depression, anxiety, or fear of cancer recurrence as outcomes – rather than well-being or other positive outcomes [11, 12]”
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 [11]
The Results (Study characteristics; page unavailable) report depression as an outcome in 71 of 110 studies and anxiety in 54, versus emotional or psychological well-being in 13. This supports an emphasis on negative outcomes in the reviewed studies, but the paper does not establish that interventions generally target fear of cancer recurrence, or that all the studies counted were intervention trials. (LLM, conf=0.84)
Experimental — accuracy not yet measuredAcceptance is negatively correlated with distress, with a small effect size (r = -.24).
“In a recent meta-analysis, acceptance was negatively correlated with distress, with a small effect size (r = -.24) [16].”
ACT is a process-based therapy that can provide effective treatment for patients facing similar unpleasant emotions and uncertainty.
“Researchers have established that ACT is a “process-based therapy” that can provide effective treatment for patients facing similar unpleasant emotions and uncertainty (Fawson et al., 2024;Hayes, 2019).”
From Acceptance and commitment therapy effectiveness for fear of cancer recurrence: A systematic review and meta-analysis. (2025) · cites this paper as Fawson et al., 2024
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“Similar relationships have been found in other physical health populations, such as in fl am-matory bowel disease, multiple sclerosis and diabetes (Hughes et al., 2021; Jedel et al., 2013; Pagnini et al., 2019; Trindade et al., 2016, 2018; Valvano et al., 2016).”
ResultAddressing Survivorship in Cancer Care
McCanney, J., Winckworth-Prejsnar, K., Schatz, A. A., Nardi, E. A., Dwyer, A. J., Lieu, C. H., Biru, Y., & Carlson, R. W. (2018) · Journal of the National Comprehensive Cancer Network · doi:10.6004/jnccn.2018.7054 · Cited by 30 · see citing works
Chatterton, M. L., Chambers, S. K., Occhipinti, S., et al. (2015) · Psycho-Oncology · doi:10.1002/pon.4020 · Cited by 26 · see citing works
Jedel, S., Merriman, P., Hoffman, A., Swanson, B. A., Fogg, L., & Keshavarzian, A. (2012) · Mindfulness · doi:10.1007/s12671-012-0128-z · Cited by 24 · see citing works
Synnot, A., Tong, A., Ryan, R. E., & Hill, S. (2020) · Health Research Policy and Systems · doi:10.1186/s12961-020-00604-x · Cited by 22 · see citing works
Salari, N., Rezaie, L., Khazaie, H., Bokaee, S., Ghasemi, H., Mohammadi, M., & Khaledi-Paveh, B. (2023) · Current Psychology · doi:10.1007/s12144-021-01934-x · Cited by 21 · cited 1× · see citing works
“…for the potential e ff ectiveness of ACT interventions for reducing distress, the included trials are often small, low quality, and with limitations to study design (Fashler et al., 2018; González-Fernández & Fernández-Rodríguez, 2019; Hulbert-Wil-liams, Storey, & Wilson, 2015; Salari et al., 2021).”
BackgroundSelf-compassion in Acceptance and Commitment Therapy for chronic pain: A pilot study
Carvalho, S. A., Gillanders, D., Forte, T., Trindade, I. A., Pinto-Gouveia, J., Lapa, T., Valentim, A., Santos, E., Paciência, J., Guiomar, R., et al. (2022) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2021-0214 · Cited by 21 · cited 1× · see citing works
“Therefore, although self-compassion is interwoven throughout ACT in practice and training and seen as a potential mechanism of change, it is not adequately conceptualised within the model (Carvalho et al., 2022; Ne ff & Tirch, 2013).”
BackgroundPsychometric properties of acceptance measures: A systematic review
McAndrews, Z., Richardson, J., & Stopa, L. (2019) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2018.08.006 · Cited by 19 · cited 2× · see citing works
“However, due to the variation of de fi nitions of acceptance (McAndrews et al., 2019), the COPE may be interpreted by participants as coping with the diagnosis label itself or another stressful life event, rather than the ongoing process of living with cancer.”
BackgroundImpact of psychological distress on outcomes in cancer patients
Fang, C. Y., & Schnoll, R. A. (2002) · Expert Review of Pharmacoeconomics & Outcomes Research · doi:10.1586/14737167.2.5.495 · Cited by 18 · see citing works
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- Authors
- Fawson, S., Moon, Z., Novogrudsky, K., Moxham, F., Forster, K., Tribe, I., Moss-Morris, R., Johnson, C., & Hughes, L. D.
- Affiliations
- King's College London (GB)
- King’s College London
- Imperial College Healthcare NHS Trust (GB)
- Corresponding author
- Hughes, Lyndsay D.
- Venue
- Health Psychology Review
- Publisher
- Informa UK Limited
- Published
- 2023-10-04
- Volume
- 18
- Issue
- 3
- Pages
- 456-477
- ISSN
- 1743-7199 (ISSN-L)
- 1743-7202
- PMC
- PMC11332408
- OpenAlex
- W4387002097
- Cited by
- 40
- References
- 84
- Citations by year
- 2026: 15 · 2025: 16 · 2024: 8 · 2023: 1
- FWCI
- 2.03
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Health Psychology Review (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, cc-by)
- UCL Discovery (University College London) (submittedVersion, cc-by)
- Funders
- National Institute for Health and Care Research
- South London and Maudsley NHS Foundation Trust
- King’s College London
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Social Sciences › Health › Religion, Spirituality, and Psychology
- Keywords
- acceptance and commitment therapy, cancer-related distress, psychological flexibility, experiential avoidance, cognitive fusion, self-compassion, acceptance, present-moment awareness, self-as-context, committed action, values, psychological inflexibility
- MeSH terms
- Psychological Distress, Humans, Neoplasms, Stress, Psychological, Acceptance and Commitment Therapy
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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