Groarke, A., Curtis, R., & Kerin, M. (2013). Cognitive-behavioural stress management enhances adjustment in women with breast cancer. British Journal of Health Psychology, 18, 623-641. 

Evaluate whether a brief cognitive behavioral (CBT) intervention can reduce stress and distress in women with breast cancer and identify characteristics of those most likely to benefit

After pre-surgery assessment, women were randomized to the intervention or control conditions. Assessments were conducted post-intervention and 12 months later in both groups. Participants were accrued over a five-year period. The intervention focused on provision of relaxation training at every session with daily home practice to address phsyiologic, cognitive, and emotional aspects of stress. Sessions were provided in a group setting for three hours per week for five weeks. Women who lived a great distance from the center where sessions were held were offered transport and/or overnight accommodations. Data also were obtained at 12 months post-intervention.

• N = 179    
• MEAN AGE = 53.7 years (SD = 10.2 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS All had breast cancer; the majority were stage II or lower. Sixty-two percent had excision, and the rest had mastectomy.

• SITE:  Single site  
• SETTING TYPE:  Outpatient

PHASE OF CARE: Transition phase after active treatment

Randomized controlled trial

• Hospital Anxiety and Depression Scale (HADS)
• Impact of Event Scale (IES)
• Perceived Stress Scale
• Silver Lining Questionnaire

Reports of global stress were lower in the intervention group at the end of the study (p = .003), but no difference was observed between groups at 12 months. Analysis of covariance showed a significant group-by-time effect on anxiety scores, with the intervention group reporting greater decreases in anxiety immediately after the intervention (p = .03). However, no difference was observed between groups at 12 months. Depression scores did not differ between groups. Global stress and anxiety decreased more among participants with higher global stress at baseline.

A brief CBT approach intervention may be beneficial in reducing short-term stress and anxiety among women with breast cancer. However, individuals in this study had anxiety and depression levels on the HADS that are not generally deemed to be clinically relevant. No long-term benefits were observed.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%
• Almost 50% loss to follow-up. Baseline anxiety and depression levels were not clinically significant, so measurement may have been subject to floor effects. Whether patients were in current treatment was unclear. The cost of transportation and accommodations may be prohibitive for this type of program for providers with a large catchment area. The control condition was not clearly described.

Findings suggest that CBT approach interventions in patient group settings might have a beneficial effect on stress and anxiety, but the study has several limitations. Effects seen were short-term, showing benefit immediately after the intervention, but were not maintained over the longer term. These results suggest that ongoing interaction probably is needed for patients to continue to practice relaxation and other behaviors.