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Treating the whole person: How CBT can support mental wellness in cancer survivors | SilverCloud Health

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    February 3, 2022

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Celebrated around the world on February 4th for the past 22 years, World Cancer Day is an initiative of the Union for International Cancer Control (UICC). World Cancer Day is one small part of the World Summit Against Cancer for the New Millennium, which aims to promote research, raise awareness, improve patient care, and prevent cancer. Learn how you can help #closethecaregap at https://www.worldcancerday.org/.

Cancer is a long-term chronic illness that makes individuals vulnerable to psychological distress during the diagnosis, treatment, and beyond treatment completion. According to the National Cancer Institute, cancer survivorship begins at diagnosis and continues until the end of life. Survivorship, by definition, includes individuals living with cancer and who are free of cancer. While the experiences of each cancer survivor are unique and most individuals adjust well, the period after treatment completion can be challenging for some. A subset of long-term cancer survivors is at risk for high psychological distress.

Challenges After Treatment Completion

One of the distinct challenges of the period after treatment completion is related to survivors’ concerns about the success of treatment and experience fear or worry relating to the possibility that cancer will come back or progress (also known as fear of recurrence) (Stanton et al., 2005). Studies suggest that fear of recurrence is one of the most reported problems that persist long after the treatment completion among cancer survivors. Survivors with high fear of recurrence experience significant psychological distress, increased self-examination and health-service use and decreased quality of life.
Another challenge is associated with unrealistic expectations concerning this period, which can hinder survivors’ positive psychological adjustment (Stanton et al., 2005). These expectations can also be described as the myths of treatment completion. There are four common myths:

Myth 1: The end of treatment should be celebrated

Although survivors often experience relief and positive emotions after treatment completion, many also discover that they are only beginning to process what happened. As survivors often do not have a chance to process their emotions during the treatment. Therefore, the treatment completion may bring feelings of loss rather than happiness and celebration.

Myth 2: The person should recover soon after medical treatment is over

Recovery may not happen soon after completing treatment as it requires time, effort in processing feelings, and support from significant others. Some survivors may continue experiencing fatigue, concentration, and memory problems beyond treatment completion despite all these. If individuals are pressured to recover soon, they may push themselves to overcome their own physical limits too quickly, resulting in frustration.

Myth 3: The person should return quickly to their pre-diagnosis sense of self

Cancer diagnosis and treatment are challenging experiences, and one can’t expect survivors to act as though nothing had happened. A new altered self and new meanings in life are possible for survivors. Individuals may experience a new sense of vulnerability with the physical reminders of the cancer treatment. However, they may also experience a new sense of personal strength, life appreciation, and enhanced relationships.

Myth 4: The person should no longer need support once the treatment ends

Cancer survivors often find that the net of safety and support during the acute diagnostic and treatment period diminishes after treatment completion. However, many survivors need emotional support during the adjustment period and a safe environment to express their feelings and concerns. Loss of social support at this period can contribute to a sense of isolation and increased psychological distress.

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Depression and Anxiety in Cancer Survivors

Research shows that 17.9% of long-term cancer survivors continue to experience anxiety, and 11.6% of survivors experience depression (Mitchell, Ferguson, Gill, Paul, & Symonds, 2013). Many interacting factors influence the development of depression and anxiety among cancer survivors. These factors consist of:

  1. individual characteristics (e.g., age, gender, ethnicity, genetics, marital and cohabitation status),

  2. social and contextual factors (e.g., education level, employment status, household income, social support, healthcare system),

  3. prior psychological factors (e.g., pre-existing psychiatric disorders, personality),

  4. psychological response to diagnosis (e.g., distress, coping behaviour, denial, anger, fear, grief, resilience),

  5. characteristics of cancer (e.g., diagnosis experience, symptoms, cancer type, stage, prognosis and curability, recurrence),

  6. cancer treatment (e.g., treatment modality and dose, side effects, long-term complications, cost of treatment, response to treatment).

Depression and anxiety in cancer survivors are associated with significant impairments. Untreated depression and anxiety can hinder recovery and decrease quality of life and survival time (Niedzwiedz, Knifton, Robb, Katikireddi, & Smith, 2019). For example, women with breast cancer and comorbid depression have a higher prevalence of metastasis and experience more intense pain and fatigue than those without depression (Chida, Hamer, Wardle, & Steptoe, 2008). Depression among breast cancer survivors was also associated with a higher risk of relapse or mortality.

Online CBT for Depression and Anxiety in Cancer Survivors

Cognitive behavioural therapy (CBT) has proven effective in treating depression and anxiety among cancer survivors (Ye et al., 2018). However, many cancer survivors cannot access psychological therapies and remain untreated due to the under-recognition of their psychosocial needs and lack of available mental health clinicians (Fallowfield, Ratcliffe, Jenkins, & Saul, 2001). In a previous blog post, we have discussed the barriers for people living with long term health conditions to access psychological therapies. Online CBT programmes have been developed to overcome these barriers to access evidence-based psychological therapies such as CBT.

Online CBT provides the same content and principles of CBT (psychoeducation, cognitive and behavioural techniques) used in face-to-face therapy but is delivered using structured modules written in text. The acceptability and effectiveness of online CBT is well documented in treating depression and anxiety in the general population (Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018; Etzelmueller, Radkovsky, Hannig, Berking, & Ebert, 2018). Similarly, iCBT was found effective for depression and anxiety among individuals with chronic health conditions (Mehta, Peynenburg, & Hadjistavropoulos, 2019). Studies with cancer survivors are recently emerging, with promising findings showing large reductions in their depression and anxiety symptoms (Alberts, Hadjistavropoulos, Dear, & Titov, 2017; Murphy et al., 2019).

One may ask, what are the advantages of online CBT programmes for cancer survivors? Privacy of the online programmes, as opposed to face-to-face therapy, is one thing that makes them more appealing for individuals who are more reserved, private, and concerned about stigma (Alberts, Hadjistavropoulos, Titov, & Dear, 2018; Karageorge et al., 2017). Many survivors who used an online CBT programme also liked its flexibility, convenience and thought it helped them feel less alone following cancer treatment. Indeed these advantages are not unique to programmes for cancer survivors, and they apply to all online CBT programmes for chronic illnesses.

Development of a Programme for Breast Cancer Survivors

Addressing depression and anxiety among people living with and beyond cancer is a public health priority. Given the importance of improving survivors’ access to psychological support, I conducted research on developing an online CBT programme for breast cancer survivors. Breast cancer was the starting point as it is the most common cancer among women globally. According to World Health Organisation (WHO) statistics, in 2020, 2.3 million women were diagnosed with breast cancer.

Under the supervision of Professor David Hevey at Trinity College Dublin and in collaboration with SilverCloud Health, we first conducted interviews with breast cancer survivors to understand their needs. Informed by the interview findings and the literature, an online CBT programme aiming to reduce depression and anxiety among breast cancer survivors was developed. Programme development also involved the perspectives of many breast cancer survivors, their carers, and three experts (one psycho-oncologist, one clinical psychologist, and one health psychologist). This collective effort resulted in a 7-module online cognitive behavioural therapy programme addressing depression and anxiety symptoms of breast cancer survivors. The wide-ranging clinical content includes the following modules:

  • Psychoeducation on breast cancer, depression, anxiety, and CBT approach
  • Understanding and expressing feelings
  • Boosting behaviour
  • Recognising unhelpful and negative thoughts
  • Challenging problematic thinking with more rational alternative thoughts
  • Managing worry more effectively
  • Developing a plan to stay well

After the programme development, we conducted a randomised controlled trial to evaluate the programme acceptability and effectiveness. Seventy-six breast cancer survivors who completed their active treatment and lived in Ireland and the UK were recruited. Participants in the online CBT group were assigned a mental health supporter who provided weekly feedback on their progress and guidance on using the programme. We recently published a protocol paper explaining the aims and design of the study (Akkol-Solakoglu, Hevey, & Richards, 2021). The results will be published soon in a peer-reviewed journal. However, the key findings indicated that survivors who used the programme had a decrease in their depression and anxiety symptoms post-intervention, and this decrease was significant at 2-month follow-up. We also explored survivors’ experiences following the programme completion. Findings revealed that survivors were highly satisfied with the online CBT programme. A large majority of the participants found the online treatment very helpful, felt that the treatment would have a long-lasting effect and mentioned that they would recommend it to others. One particular aspect they liked the most and found helpful was the weekly feedback from their supporters.


Online CBT programmes have a considerable potential to facilitate psychological recovery and alleviate depression and anxiety symptoms among cancer survivors who completed their treatment. Considering the detrimental consequences of depression and anxiety for cancer survivors and the lack of integrated service provision following medical treatment, research in this area should be prioritised. SilverCloud is committed to developing evidence-based programmes to help empower individuals living with chronic health conditions to manage their psychological well-being. We believe in providing support to individuals during the critical recovery process. Hopefully, this will open up a future where medical treatment completion is not the end of the support survivors get.

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Akkol-Solakoglu, S., Hevey, D., & Richards, D. (2021). A randomised controlled trial of an adapted internet-delivered cognitive behavioural therapy (iCBT) with main carer access for depression and anxiety among breast cancer survivors: study protocol. Internet Interventions. https://doi.org/10.1016/j.invent.2021.100367

Alberts, N. M., Hadjistavropoulos, H. D., Dear, B. F., & Titov, N. (2017). Internet-delivered cognitive-behaviour therapy for recent cancer survivors: a feasibility trial. Psycho-Oncology, 26(1), 137–139. https://doi.org/10.1002/pon.4032

Alberts, N. M., Hadjistavropoulos, H. D., Titov, N., & Dear, B. F. (2018). Patient and provider perceptions of Internet-delivered cognitive behavior therapy for recent cancer survivors. Supportive Care in Cancer, 26(2), 597–603. https://doi.org/10.1007/s00520-017-3872-8

Carlbring, P., Andersson, G., Cuijpers, P., Riper, H., & Hedman-Lagerlöf, E. (2018). Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cognitive Behaviour Therapy, 47(1), 1–18. https://doi.org/10.1080/16506073.2017.1401115

Chida, Y., Hamer, M., Wardle, J., & Steptoe, A. (2008). Do stress-related psychosocial factors contribute to cancer incidence and survival? Nature Clinical Practice Oncology. https://doi.org/10.1038/ncponc1134

Etzelmueller, A., Radkovsky, A., Hannig, W., Berking, M., & Ebert, D. D. (2018). Patient’s experience with blended video- and internet based cognitive behavioural therapy service in routine care. Internet Interventions, 12(August 2017), 165–175. https://doi.org/10.1016/j.invent.2018.01.003

Fallowfield, L., Ratcliffe, D., Jenkins, V., & Saul, J. (2001). Psychiatric morbidity and its recognition by doctors in patients with cancer. British Journal of Cancer, 84(8), 1011–1015. https://doi.org/10.1054/bjoc.2001.1724

Karageorge, A., Murphy, M. J., Newby, J. M., Kirsten, L., Andrews, G., Allison, K., … Butow, P. (2017). Acceptability of an internet cognitive behavioural therapy program for people with early-stage cancer and cancer survivors with depression and/or anxiety: thematic findings from focus groups. Supportive Care in Cancer, 25(7), 2129–2136. https://doi.org/10.1007/s00520-017-3617-8

Mehta, S., Peynenburg, V. A., & Hadjistavropoulos, H. D. (2019). Internet-delivered cognitive behaviour therapy for chronic health conditions: a systematic review and meta-analysis. Journal of Behavioral Medicine, 42(2), 169–187. https://doi.org/10.1007/s10865-018-9984-x

Mitchell, A. J., Ferguson, D. W., Gill, J., Paul, J., & Symonds, P. (2013). Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: A systematic review and meta-analysis. The Lancet Oncology, 14(8), 721–732. https://doi.org/10.1016/S1470-2045(13)70244-4

Murphy, M. J., Newby, J. M., Butow, P., Loughnan, S. A., Joubert, A. E., Kirsten, L., … Andrews, G. (2019). Randomised controlled trial of internet-delivered cognitive behaviour therapy for clinical depression and/or anxiety in cancer survivors (iCanADAPT Early). Psycho-Oncology, 29(1), 76–85. https://doi.org/10.1002/pon.5267

Niedzwiedz, C. L., Knifton, L., Robb, K. A., Katikireddi, S. V., & Smith, D. J. (2019). Depression and anxiety among people living with and beyond cancer: A growing clinical and research priority. BMC Cancer, 19(1), 1–8. https://doi.org/10.1186/s12885-019-6181-4

Stanton, A. L., Ganz, P. A., Rowland, J. H., Meyerowitz, B. E., Krupnick, J. L., & Sears, S. R. (2005). Promoting adjustment after treatment for cancer. Cancer, 104(11 SUPPL.), 2608–2613. https://doi.org/10.1002/cncr.21246

Ye, M., Du, K., Zhou, J., Zhou, Q., Shou, M., Hu, B., … Liu, Z. (2018). A meta-analysis of the efficacy of cognitive behavior therapy on quality of life and psychological health of breast cancer survivors and patients. Psycho-Oncology, (September 2017), 1–9. https://doi.org/10.1002/pon.4687

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