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Patients with cancer and survivors may experience the fear of cancer recurrence (FCR), a preoccupation with the progression or recurrence of cancer. During the spread of COVID-19 in 2019, patients and survivors experienced increased levels of FCR. Hence, there is a greater need to identify effective evidence-based treatments to help people cope with FCR. Remotely delivered interventions might provide a valuable means to address FCR in patients with cancer.
The aim of this study is to first discuss the available psychological interventions for FCR based on traditional cognitive behavioral therapies (CBTs) or contemporary CBTs, in particular, mindfulness and acceptance and commitment therapy, and then propose a possible approach based on the retrieved literature.
We searched key electronic databases to identify studies that evaluated the effect of psychological interventions such as CBT on FCR among patients with cancer and survivors.
Current evidence suggests that face-to-face psychological interventions for FCR are feasible, acceptable, and efficacious for managing FCR. However, there are no specific data on the interventions that are most effective when delivered remotely.
CBT interventions can be efficacious in managing FCR, especially at posttreatment, regardless of whether it is delivered face to face, on the web, or using a blended approach. To date, no study has simultaneously compared the effectiveness of face-to-face, web-based, and blended interventions. On the basis of the retrieved evidence, we propose the hypothetical program of an intervention for FCR based on both traditional CBT and contemporary CBT, named Change Of Recurrence, which aims to improve the management of FCR in patients with cancer and survivors.
Along the trajectory of cancer care, which in recent years has been extended because of new technologies [
Currently, patients with cancer and survivors experience higher levels of loneliness, FCR, anxiety, and depression because of the diffusion of COVID‐19. Indeed, the pandemic forced people to social distance and caused several challenges for patients with cancer and survivors, such as maintaining social support and continuing their cancer treatment or medical check-ups regularly [
In this paper, we aim to critically revise and systematize the available evidence on the effectiveness of different modalities and approaches of CBT psychological interventions for FCR. Specifically, this review aims to summarize studies dealing with face-to-face, remote, and blended interventions based on traditional CBTs or contemporary CBTs, in particular, mindfulness and ACT, used to reduce FCR. Finally, we propose a possible program based on the retrieved literature.
Electronic searches were performed using PubMed, MEDLINE, and Embase between November and December 2020, with no time limits. Original articles were considered in English, Italian, or Spanish languages, with participants aged ≥18 years. Keywords searched in titles and abstracts included
Initially, the search strategy yielded 470 articles that were screened for irrelevant or duplicate articles. The remaining articles were assessed and selected by screening the abstracts, followed by full-text reading and selection according to the predefined inclusion and exclusion criteria. Of the 470 articles, 35 (7.4%) articles that focused on psychological interventions for reducing FCR were selected. The results were organized according to the modality of delivery of the therapy (face to face, remote, and blended).
Psychological interventions for patients with cancer and survivors based on the principles of traditional CBT aim to encourage patients to identify, express, and deal with their fears and emotional reactions related to cancer and improve their ability to cope with them to maintain their QoL and evaluate and alter life priorities [
Clinicians often begin the interventions with psychoeducation on FCR to explain what it is and how it presents and maintains during everyday life [
Psychological interventions based on mindfulness, which is a particular way to pay attention to the present moment without judgment, ensure that people turn away from unhealthy beliefs, thoughts, or emotions, maintaining awareness of the present moment [
Finally, ACT interventions explain psychological distress through psychological inflexibility, a construct that comprises behaving under the strict control of rigid personal thoughts, feelings, and other internal experiences [
Face-to-face psychological interventions.
Therapy and authors | Cancer | Study design | Intervention and groups | Results | |||||
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Heinrichs et al [ |
BCb or GCc | RCTd |
Side by Side: 4 biweekly couple skills sessions Couples Control Program |
Side by Side had a greater effect on FoPe than the Couples Control Program; however, this difference disappeared by 16 months after the diagnosis. | ||||
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Herschebach et al [ |
Different type | Longitudinal study |
4 session cognitive behavioral group therapy Supportive experimental group therapy UCf |
FoP decreased significantly over time in both intervention groups in contrast to the control group that showed only short-term improvements. | ||||
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Humphris and Rogers [ |
Different type | RCT |
AFTERg: 6 weekly sessions of traditional CBT individual therapy UC |
AFTER intervention improves FCRh only at the immediate short-term follow-up (MWUi: z=2.06; |
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Lebel et al [ |
Survivors of BC or ovarian cancer | A single-arm multisite study |
6-week cognitive-existential group intervention |
Significant reductions of FCR levels immediately after it and at the 3-month follow-up | ||||
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Manne et al [ |
GC | RCT |
CCIj: 7 weekly sessions of individual therapy and 1 telephone session 2 or 3 weeks after session 7 A supportive counseling intervention: 7 weekly sessions of individual therapy and 1 telephone session 2 or 3 weeks after session 7 UC |
CCI did not affect FCR. | ||||
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Savard et al [ |
Different type | Development and feasibility |
4 weekly group CBT sessions |
Significant reductions of FCR levels | ||||
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Tomei et al [ |
Different type | RCT pilot |
FCR intervention: 6-week sessions |
Significant reduction of FCR levels at postintervention and at 3-month follow-up | ||||
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Crane-Okada et al [ |
Survivors of BC | RCT pilot |
12-week mindful movement program intervention |
Significant effect on FCR at 12 weeks posttreatment; however, this effect does not maintain at 18 weeks after treatment | ||||
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Lengacher et al [ |
Survivors of BC | RCT |
6‐week MBSRk program UC |
MBSR reduces FCR more than usual care (11.6 vs 9.3) at 6 weeks. | ||||
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Lengacher et al [ |
Survivors of BC | Feasibility of the intervention |
8-week MBSR program |
Significant effect on FCR | ||||
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Lengacher et al [ |
BC | A single-arm multisite study |
6-week MBSR (BC) program UC |
MBSR (BC) reduces FCR; MBSR (BC) compared with UC had a favorable change in FCR problems that mediated the effect of MBSR (BC) on 6-week change in perceived stress (z=2.12; |
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Lengacher et al [ |
Survivors of BC | RCT |
2-hour sessions once per week for 6 weeks of an MBSR (BC) UC |
Significant improvement of FCR in the MBSR (BC) group compared with usual care | ||||
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Victorson et al [ |
PCl | RCT pilot |
8‐week MBSR intervention An attention control arm |
MBSR significantly reduces PC anxiety and uncertainty intolerance | ||||
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Arch and Mitchell [ |
Survivors of BC | Pilot study |
7 weekly 2-hour sessions of ACTm |
FCR decreases through 1 week following the last group session (post; Cohen |
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Johns et al [ |
Survivors of BC | RCT |
6 weekly 2‐hour group sessions of ACT 6 weekly 2‐hour group sessions of SEn One 30‐minute group coaching session (EUCo) |
SE and ACT reduce FCR severity over time; however, only ACT produced significant reductions at each time point relative to baseline, with between-group differences at time point 4 substantially favoring ACT over SE (Cohen |
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Marín and Soriano [ |
BC | Open trial |
1 session of ACT Waiting list |
Defusion contributes to decreasing FCR, and this effect is maintained 3 months after the intervention. | ||||
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Butow et al [ |
BC or CRCp; BC or CRC or melanoma | Study protocol of an RCT; RCT |
ConquerFear intervention: 5 face-to-face sessions over 10 weeks Taking-it-Easy relaxation therapy: 5 face-to-face sessions over 10 weeks |
ConquerFear is efficacy compared with attention control in reduction of FCR immediately after therapy and 3 and 6 months later | ||||
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Smith et al [ |
BC | Pilot study |
ConquerFear intervention: 5 face-to-face sessions over 10 weeks |
ConquerFear is feasible, acceptable, and shows potential efficacy for FCR |
aCBT: cognitive behavioral therapy.
bBC: breast cancer.
cGC: gynecologic cancer.
dRCT: randomized controlled trial.
eFoP: Fear of Progression.
fUC: usual care.
gAFTER: adjustment to the fear, threat or expectation of recurrence.
hFCR: fear of cancer recurrence.
iMWU: Mann-Whitney
jCCI: coping and communication-enhancing intervention.
kMBSR: mindfulness‐based stress reduction.
lPC: prostate cancer.
mACT: acceptance and commitment therapy.
nSE: survivorship education.
oEUC: Enhanced Usual Care.
pCRC: colorectal cancer.
All these approaches, which are delivered face-to-face, present some criticisms: they were relatively expensive and time and resource intensive, and patients could be reluctant to return to the hospital where cancer treatment took place [
Over the past decades, owing to the increasing use of new technologies for the treatment of psychological aspects, clinicians have applied remotely delivered psychological techniques in the field of mental health and health care settings, giving rise to eHealth [
Considering the clinical target, eHealth proved to be effective in the field of mental health and psychological treatments [
eHealth based on CBT involves the delivery of clinical CBT content via the internet and provides content in several formats, for example, text, video, and audio files and interactive elements.
Regarding traditional CBT, Lichtenthal and al [
Regarding contemporary CBT, specifically for the concerns regarding eHealth mindfulness-based programs used alone in the cancer settings, evidence related to FCR is scarce. However, the internet-based MBCT (eMBCT) intervention, which is a combination of MBCT and CBT, demonstrated reductions in FCR (Cohen
Finally, with regard to web-based interventions based on ACT, the studies recovered in the literature were few, and in the oncology field, we found only 11% (4/35) of studies; 50% (2/4) of them were for patients with cancer and the others for partners [
Finally, in the literature, we found examples of web-based interventions based on multiple theories, such as e-TC and iConquerFear [
A summary of the aforementioned studies on psychological interventions delivered through eHealth is provided in
Remote psychological interventions.
Therapy and authors | Cancer | Study design | Intervention | Results | |
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Lichtenthal et al [ |
BCb | RCTc pilot |
AIM‐FBCRd: 8 personalized treatment sessions of 30 minutes each administered twice a week for 4 weeks A control condition program |
The results of the current pilot study suggest the promise of AIM‐FBCR in reducing FCRe in survivors of BC |
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van Helmondt et al [ |
Survivors of BC | Study protocol; RCT |
The Cancer Recurrence Self‐help Training trial: less fear after cancer—a tailored web-based self-help training (2 basic modules and 4 optional modules) UCf |
There was no effect of the CBT‐based web-based self‐help training |
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Compen et al [ |
Different type of cancer | RCT |
Individual internet-based MBCTg: access to a secure website containing material for 8 weeks plus a silent day and an inbox+weekly asynchronous written interaction with a therapist over email MBCT: 8 weekly 2.5-hour group sessions, a 6-hour silent day, and daily home practice assignments guided by audio files UC |
Compared with UC, both interventions reduced FCR |
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Lengacher et al [ |
BC | Feasibility |
mMBSR (BC)h: sitting and walking meditation, body scan, and yoga and is designed to deliver weekly 2‐hour sessions for 6 weeks using an iPad |
There was a significant improvement from baseline to 6 weeks after mMBSR (BC) in FCR |
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Mendes-Santos et al [ |
Survivors of BC | Study protocol |
iNNOVBCi: a 10-week guided internet-delivered individually tailored ACTj influenced CBT intervention UC |
Not yet available |
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Heiniger et al [ |
TCk | Pilot study |
e-TC: 6 interactive modules for 10 weeks |
e-TC appeared to be a feasible and acceptable web-based intervention for survivors of TC |
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Smith et al [ |
Different type of cancer | Study protocol |
iConquerFear: 5 therapeutic modules completed in 1 to 2 hours over 1 to 2 weeks |
Not yet available |
aCBT: cognitive behavioral therapy.
bBC: breast cancer.
cRCT: randomized controlled trial.
dAIM‐FBCR: Attention and Interpretation Modification for Fear of Breast Cancer Recurrence.
eFCR: fear of cancer recurrence.
fUC: usual care.
gMBCT: mindfulness-based cognitive therapy.
hmMBSR (BC): mobile mindfulness‐based stress reduction for breast cancer.
iiNNOVBC: a guided internet-delivered individually tailored acceptance and commitment therapy–influenced cognitive behavioral intervention to improve psychosocial outcomes in breast cancer survivors.
jACT: acceptance and commitment therapy.
kTC: testicular cancer.
Currently, in the field of eHealth treatments, the use of blended care is gaining rising visibility. Blended treatment or blended care are defined in literature as “technology-supported care,” with the term
In blended treatments, web-based and offline components are not standalone treatment pathways but rather interrelated methods that are strategically combined to build an intervention that merges the potential benefits of the 2 approaches [
Considering traditional CBT, the Survivors’ Worries of Recurrent Disease study is an example of a BC-CBT intervention that combines traditional CBT, which is delivered face-to-face, with web-based activities (or workbook activities) [
Another example is the blended care for FCR study proposed by Luigjes-Huizer et al [
In literature, there is another blended intervention based on traditional CBT, the colorectal cancer distress reduction intervention, which was proposed for survivors of colorectal cancer, which was not specific for FCR [
Regarding blended mindfulness or ACT-based interventions, there have been studies. On the basis of the aforementioned ConquerFear therapy, researchers want to test the efficacy in the short- and long-terms of a therapist-guided version of iConquerFear in reducing FCR and improving QoL in survivors of colorectal cancer. This intervention differs from iConquerFear because of the presence of the therapist through a messenger function with whom patients can communicate asynchronously. The therapist had the role of a motivator and coach, answering the questions and giving feedback on the exercises and written material [
Blended psychological interventions.
Therapy and authors | Cancer | Study design | Intervention | Results | |
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van de Wal et al [ |
BCb, PCc, or colorectal; survivors; BC, PC, and CRCd | Study protocol; RCTe; RCT | The SWORDf study: 5 individuals 1-hour F2Fg sessions+three 15-minute web-based sessions based on traditional CBT; UCh |
SWORD had a greater effect on FCRi than UC with a moderate-to-large effect size (Cohen d=0.76). SWORD had a greater effect on FCR than UC (mean difference −1.787, 95% CI −3.251 to − 0.323; |
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van de Wal et al [ |
Survivors of BC | Case study | The SWORD study: 7 F2F therapy sessions and 1 telephone session based on traditional CBT |
CBT reduced FCR over time (last follow-up at 12 months after therapy). |
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Luigjes-Huizer et al [ |
—j | Study protocol | BLANKETk: 2 CBT modules+5 optional modules; UC | — |
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Leermakers et al [ |
Survivors of CRC | Study protocol | CORRECTl: 5 F2F sessions +3 telephone sessions and an interactive self-management website; UC | — |
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Döking et al [ |
Survivors of CRC | Case study | CORRECT for 4 months: 5 F2F+3 telephone sessions and an interactive self-management website |
The intervention was successful in reducing the distress of a survivor of cancer. |
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Lyhne et al [ |
Survivors of CRC | Study protocol | Therapist-guided iConquerFear: 5 modules; UC | — |
aCBT: cognitive behavioral therapy.
bBC: breast cancer.
cPC: prostate cancer.
dCRC: colorectal cancer.
eRCT: randomized controlled trial.
fSWORD: Survivors’ Worries of Recurrent Disease.
gF2F: face to face.
hUC: usual care.
iFCR: fear of cancer recurrence.
jThe type of cancer was not specified.
kBLANKET: blended care for fear of cancer recurrence.
lCORRECT: colorectal cancer distress reduction.
On the basis of the data presented in the literature, we could infer that a psychological intervention based on CBT is efficacious in managing FCR, especially at posttreatment [
Regarding psychological interventions based on mindfulness, only 1 RCT study compared MBCT and eMBCT with usual care and found that MBCT and eMBCT were equally efficacious compared with treatment as usual in reducing FCR [
The retrieved studies in the literature on ACT reported only protocols and feasibility or qualitative studies, with no quantitative data on the effectiveness of such an approach, except for 2 RCTs—1 that provided a face-to-face intervention and the other 1 a web-based intervention [
Finally, there were 2 programs based on multiple theories: ConquerFear, which clinicians could use face to face, via the web, or as blended; and e-TC. However, there was only quantitative data supporting the efficacy of face-to-face ConquerFear, which had a short and long-time effect on FCR [
Hence, it was difficult to decide which one to choose. If for interventions based on traditional CBT, there were more data, for the contemporary CBT, the information would still be limited, even more so if we take into consideration the new methods of administering the interventions. Although it is normal given the youth of these new modalities, the need to find effective web-based or blended treatments is increasingly urgent. Furthermore, when it comes to clinical applications, the choice of what should be interactive is not trivial. Indeed, it has been shown that therapists believe that the complexity of patients’ problems requires tailored blended treatment. It has also been found that therapists and patients have different points of view regarding what components of the therapy they would prefer to be presented in a web-based-remote way [
Patients and survivors might benefit from blended interventions as they have the potential benefits of face-to-face and web-based approaches. In particular, through a blended intervention, patients might maintain the therapeutic alliance with the therapist without the necessity of meeting them weekly because of, for example, a website in which they have to do some homework to practice the skills learned during the face-to-face session. We believe that an integrative intervention based on both traditional CBT and contemporary CBT would be the best choice.
On the basis of the retrieved evidence, we propose the hypothetical program of an intervention for FCR based on both traditional CBT and contemporary CBT, named Change Of Recurrence, which aimed to improve the management of FCR in patients with cancer and survivors. We would opt for a blended intervention for 3 reasons. First, given the health emergency that we have been experiencing for the COVID-19 outbreak, a blended intervention would allow us to guarantee the safety of the patient who will rarely have to go to the hospital while maintaining the therapeutic alliance, which is fundamental to the effectiveness of any psychological intervention [
The program would be structured by first conducting face-to-face sessions at the hospital where the patient is treated or where the survivor undergoes check-ups. This choice could help patients and survivors follow the therapy, especially if we insert the session on the same day that the patient or survivor goes to the hospital for other visits or checks. Indeed, dropout from psychological interventions is a relevant issue to be considered. In addition, we will create a web-based platform comprising 10 modules that can be accessed only when patients finish the previous one. The web-based platform will provide interactive sessions, psychoeducational exercises, and homework. The latter has the objective of trying to render patients as autonomous as possible by applying the techniques learned in the face-to-face sessions.
During the first face-to-face session, the therapist gets to know the patient, assessing the level of FCR both qualitatively and quantitatively, using the questionnaire Fear of Cancer Recurrence Inventory. In particular, the patient provides details about him or herself and has the opportunity to discuss diagnosis; treatment; recovery; and, in general, his or her experience. Moreover, this will be a psychoeducational session in which the therapist will explain the FCR model, identify the internal and external triggers that increase the FCR, and focus on the patient’s FCR experience, particularly on their maladaptive thoughts and coping strategies. At the end of the session, the therapist will give the patients a link to the web-based platform. Through the platform, the patients will be asked to write their negative automatic thoughts using a typical 3-column grid.
In the first web-based module, the patient will find a summary of the key concepts addressed during the first face-to-face session and exercises to do, such as writing down the thoughts and actions that he or she performs and that increase the FCR.
During the second face-to-face session, the therapist will discuss the patient’s homework to clarify the eventual unsolved aspects. In this way, the patient will be encouraged to share his or her experience and start to work on it. The therapist will then introduce the notion of cognitive restructuring, and through the Socratic questioning of cognitive therapy, attempt to challenge the negative automatic thoughts written by the patient during homework. Finally, the therapist and patient will start to reframe negative thinking into alternative thoughts that are more based on reality to explain the homework that the patient will have to do during the week.
In the second web-based module, the patient will find a summary of the key concepts addressed during the second face-to-face session. The assigned homework that the patient will have to do is to write the negative automatic thoughts using a typical 5-column grid and reframe them into realistic thinking.
During the third web-based interactive session, the therapist will review the patient’s homework. Then, the therapist and the patient will discuss their thoughts and feelings related to cancer and the actions they will take to get rid of or escape those feelings and those that increase the FCR. In particular, the therapist will provide psychoeducational concepts about worry, explaining the importance of expressing fears. To do that, the patient will have to describe their worst-fear scenario related to cancer, providing thoughts and behaviors that he or she will engage in. Then, the therapist will use metaphors such as the bus metaphor, in which the patient will identify thoughts, feelings, and memories or images as
Following the third module, the patient will find a summary of the key concepts addressed during the third face-to-face session on his or her platform. The patient will also be provided with other metaphors and experiential exercises (eg, daily body scan meditation) aimed at improving the strategies built in the web-based interactive session with the therapist.
During the fourth face-to-face session, the therapist will focus on adaptive coping strategies that enhance acceptance, cognitive defusion, awareness, and psychological flexibility in general. In this way, the patient will begin to become aware and accept thoughts and emotions about cancer, eliminate rigid thoughts and beliefs about cancer, and define personal values and commit to pursuing meaningful activities in line with those values. Finally, the therapist will introduce the concept of mindfulness and its basic principles.
In this web-based module, the patient will be provided with a summary of the key concepts addressed during the fourth face-to-face session, with particular attention to mindfulness. Specifically, the patient will be presented with mindfulness and relaxation exercises through audio and videotape. The audio clips will contain fully automated exercises meant to bring awareness to breathing and bodily sensations. The video clips will provide additional explanations on the techniques, along with some practical guidelines on how to practice during the daytime without clips.
During the last face-to-face session, the therapist will evaluate the changes that occurred in the patient’s emotional and cognitive reactions, making a summary of the current situation and the changes that occurred. The therapist and the patient will talk about the differences between how the patient coped with FCR before the treatment and how he or she copes now. Moreover, the therapist and the patient will draw up an action plan based on the patient’s values. Finally, the therapist will build, together with the patient, an exercise schedule to maintain the improvements. The contents of the exercises (audio or video clips) will be available on patients’ platforms and will be accessible for a year.
A final web-based interactive session will be provided 1 month after the fifth face-to-face session to monitor the psychological state of the patients.
If effective, this program would lead to a time and cost-saving care pathway for treating FCR, putting together the benefits of real-time interaction with the clinical staff and the ease of having tailored clinical materials available daily to allow for a continuous improvement.
To conclude, this overview has some limitations. Regarding the first part (review of the psychological interventions), the limitations of the methodology of the included studies and between-study heterogeneity reduced the overall strength of the evidence. Moreover, some of the studies were selected from other systematic reviews, whereas others were selected manually. Regarding the second part, it is only a preprotocol that must be evaluated by experts and patients.
acceptance and commitment therapy
Attention and Interpretation Modification for Fear of Breast Cancer Recurrence
breast cancer
blended care cognitive behavioral therapy treatment
cognitive behavioral therapy
internet-delivered mindfulness-based cognitive therapy
fear of cancer recurrence
mindfulness-based cognitive therapy
mindfulness-based stress reduction
quality of life
randomized controlled trial
None declared.