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How can health care help female breast cancer patients reduce their stress symptoms?: A randomized intervention study with stepped-care
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Research and Development, Gävleborg.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
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2012 (English)In: BMC Cancer, ISSN 1471-2407, Vol. 12, 167- p.Article in journal (Refereed) Published
Abstract [en]

Background: A life threatening illness such as breast cancer can lead to a secondary diagnosis of PTSD (post traumatic stress disorder) with intrusive thoughts and avoidance as major symptoms. In a former study by the research group, 80% of the patients with breast cancer reported a high level of stress symptoms close to the diagnosis, such as intrusive thoughts and avoidance behavior. These symptoms remained high throughout the study. The present paper presents the design of a randomized study evaluating the effectiveness and cost-effectiveness of a stress management intervention using a stepped-care design.

Method: Female patients over the age of 18, with a recent diagnosis of breast cancer and scheduled for adjuvant treatment in the form of chemotherapy, radiation therapy and/or hormonal therapy are eligible and will consecutively be included in the study. The study is a prospective longitudinal intervention study with a stepped-care approach, where patients will be randomised to one of two interventions in the final stage of treatment. The first step is a low intensity stress-management intervention that is given to all patients. Patients who do not respond to this level are thereafter given more intensive treatment at later steps in the program and will be randomized to more intensive stress-management intervention in a group setting or individually. The primary out-come is subjective distress (intrusion and avoidance) assessed by the Impact of Event Scale (IES). According to the power-analyses, 300 patients are planned to be included in the study and will be followed for one year. Other outcomes are anxiety, depression, quality of life, fatigue, stress in daily living and utilization of hospital services. This will be assessed with well-known psychometric tested questionnaires. Also, the cost-effectiveness of the intervention given in group or individually will be evaluated.

Discussion: This randomized clinical trial will provide additional empirical evidence regarding the effectiveness of a stress-management program given in group or individually during adjuvant therapy in terms of decreased stress, minimizing fatigue, and maintaining or enhancing patients' quality of life and psychological well-being.

Place, publisher, year, edition, pages
2012. Vol. 12, 167- p.
Keyword [en]
Breast cancer, Randomized multicenter interventions study with stepped-care approach, Stress management
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-181950DOI: 10.1186/1471-2407-12-167ISI: 000307557300001OAI: diva2:558228
Available from: 2012-10-02 Created: 2012-10-02 Last updated: 2014-09-08Bibliographically approved
In thesis
1. Distress, Emotional reactivity and Fatigue following Breast Cancer: A Theoretical Approach and a Randomised Intervention Study
Open this publication in new window or tab >>Distress, Emotional reactivity and Fatigue following Breast Cancer: A Theoretical Approach and a Randomised Intervention Study
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Aim: Overall aims were to evaluate a stress management intervention with a stepped care approach among women with breast cancer and to explore distress, emotional reactivity and fatigue, both using a theoretical approach and self-reported assessment.

Methods: A total of 821 women were approached, 372 women rejected participation, 23 women failed to return the questionnaire and one died, hence, 425 patients (52%) accepted participation. Study I evaluated the cognitive processing model with the aid of an untreated patient group, including 189 women according to the main study protocol. Sixty-six of these women were ineligible for the intervention, as they did not report clinical levels of distress. The remaining 123 women were eligible but they declined participation. Study II explored the validation of the ELSS and emotional reactivity among women with breast cancer. The population comprised of all 425 women (breast cancer sample) and 176 women randomly selected from the PAR register (random women sample). Studies III and IV evaluated the intervention and included all 425 women.

Main findings: Study I: avoidance does not mediate the relationship between intrusion and later psychological distress in an early stage breast cancer population. Study II: the ELSS has acceptable validity and reliability. The factor structure of the ELSS was similar in both samples and correlated well with the STAQ (gold standard). Younger age was the only variable associated with emotional reactivity at the start of curative treatment. Studies III and IV: a stepped care approach did not reduce the number of women who require a more extensive treatment at three-months post-diagnosis. Both intervention groups (group/individual) reduced their levels of distress, but there were no significant differences between them. Only about half of the women who were randomised in the second step of the intervention accepted participation.

Conclusions: The present thesis provides information regarding distress, emotional reactivity and fatigue among women with breast cancer. A majority of women with early stage breast cancer seem to process the trauma of a cancer diagnosis in a satisfactory way but may experience some emotional reactivity, and younger women may experience more emotional distress. The results also highlight the need for validated measures and carefully planned psychosocial interventions.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. 67 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1012
Breast cancer, randomised intervention study, Group vs. individual therapy, Oncological rehabilitation, cognitive processing, validation
National Category
Medical and Health Sciences
Research subject
Caring Sciences
urn:nbn:se:uu:diva-229042 (URN)978-91-554-8982-3 (ISBN)
Public defence
2014-09-10, Universitetshuset, Sal IX, Biskopsgatan 3, Uppsala, 09:15 (Swedish)
Available from: 2014-08-20 Created: 2014-07-28 Last updated: 2014-09-08

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Nordin, KarinRissanen, RitvaAhlgren, JohanBurell, GunillaFjällskog, Marie-LouiseBorjesson, SusanneArving, Cecilia
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