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Abstract

Acceptance and commitment therapy (ACT) has proven effective in cancer patients, reducing common psychological symptoms and improving wellbeing. Moreover, the use of eHealth technologies makes support cheaper and easier to provide. The aim of this systematic review was to collect results on the effectiveness of internet-delivered ACT for common symptoms in cancer patients and survivors. The review follows PRISMA guidance and was registered in PROSPERO (CRD42022326543). Searches were conducted using PubMed, Web of Science, Scopus, EBSCOhost, and different web platforms of grey literature. Interventional studies were selected which focused on cancer patients and survivors, were published in English or Spanish, included at least two of the six main ACT components, and were partially or fully delivered through the Internet. The risk of bias was assessed following Cochrane’s recommendations. Eleven records from seven studies met the inclusion criteria. Only one study showed significant reductions in anxiety (reliable change index, RCI∈ [2.32, 3.47]) and depression (RCI∈ [2.00, 4.00]). As regards quality of life, significant improvements were observed in certain domains such as cancer-related quality of life (RCI = 2.43), fatigue (d = −0.33), sleep problems (d = −0.53), physical and functional wellbeing (η²_p = .06), and participation in social activities (d = 0.18). ACT processes resulted in significant post-intervention improvements with regard to mindfulness ability and psychological flexibility. Results look promising; however, we believe that limitations such as blinding issues, the heterogeneity of designs and measurement tools, or the use of monetary incentives should be taken into account in future research.

Plain language summary

A review of the efficacy of online, emotion acceptance-based psychotherapy for cancer patients and survivors

Cancer remains one of the most frequently diagnosed diseases worldwide. People undergoing treatment often experience anxiety, depression, insomnia, and a decline in quality of life, among other things. Currently, various alternatives are being explored to alleviate these issues. One promising option is psychological therapy, such as acceptance and commitment therapy (ACT), which focuses on accepting emotions and taking actions aligned with personal values. Furthermore, given the rise of technology in recent years, it is worth investigating whether digital interventions are beneficial, particularly since attending therapy can be challenging for those suffering from treatment side effects or struggling with the sequelae of their illness. Therefore, a systematic review of research utilizing internet-delivered ACT has been conducted to determine if this remote intervention can effectively improve symptoms. A total of seven studies met the inclusion criteria for this review. The findings are promising but not conclusive enough to assert that this type of intervention significantly improves emotional symptoms, quality of life, fatigue, pain, insomnia, physical function, lifestyle, or social function. Improvements were noted in most studies, but not all of them were significant. These mixed results may be attributed to variations in study designs, the use of inadequate questionnaires, or a lack of control over some variables that could have affected outcomes.

Keywords

cancer acceptance and commitment therapy Internet-based interventions systematic review

Introduction

Globally, cancer is the leading cause of death. According to recent data, cancer was the cause of almost 10 million deaths in the year 2020, with breast (2.26 M), lung (2.21 M), and colorectal cancer (1.96 M) showing the highest incidences (World Health Organization, n.d.). In Spain, a similar pattern can be observed, as cancer-related deaths reached 113,054 in 2020. Colorectal (43,379), breast (34,750), and lung cancer (30,948) were the most frequent types diagnosed. And yet, it is possible that the actual incidence rates are even higher, as screening protocols were affected during the COVID-19 pandemic (Sociedad Española de Oncología Médica, 2022).

In cancer patients, psychological and physical impairment in the form of anxiety, depression, fatigue, insomnia, and lower quality of life occur frequently as a consequence of the illness and the subsequent treatments, negatively influencing key aspects of cancer care and survival (Bach et al., 2021; Naser et al., 2021; Polański et al., 2017; Schieber et al., 2019; Shrestha et al., 2019; Wu et al., 2022; Zamani & Alizadeh-Tabari, 2023). In order to deal with such symptoms, different psychological interventions have been developed, including acceptance and commitment therapy (ACT; Cillessen et al., 2019; González-Fernández & Fernández-Rodríguez, 2019; Sauer & Weißflog, 2022; Ye et al., 2018).

ACT is a third-wave behavioural treatment that focuses mainly on changing the patient’s relationship with their negative thoughts and emotions through psychological flexibility, rather than on attempting to modify them. It includes six main components: being present, cognitive defusion, self as context, acceptance, values, and committed action (Hulbert-Williams et al., 2015). In the context of cancer, it is common for patients to face challenging situations at different stages of the disease, which can lead to negative emotions, feelings and thoughts. However, these reactions are not the product of inadequate information processing, but may be a consequence of the patient’s reality (e.g., facing the possibility of death). ACT promotes the realisation of meaningful actions despite the presence of physical or psychological limitations resulting from the disease (Fashler et al., 2018). Foreseeably, recent systematic reviews on the use of ACT aimed at reducing symptoms of anxiety and depression, increasing quality of life, and promoting psychological flexibility in cancer patients showed positive results. However, the heterogeneity of the participants in the studies as well as the differences in the applied interventions suggest the need for further trials with a more adequate level of control (González-Fernández & Fernández-Rodríguez, 2019; Salari et al., 2023).

On the other hand, the use of eHealth technologies (websites, online support groups, video communications, mobile health applications) has become more popular in recent years, as it offers several advantages for patients: It requires fewer resources to reach a greater number of patients, increases confidentiality and privacy, and makes support more accessible and easier to obtain (Willems et al., 2020). Recent systematic reviews of the efficacy of online interventions designed to improve common symptoms in cancer patients, including psychological distress (anxiety and depression) and somatic symptoms (i.e. fatigue, insomnia and pain), have shown positive results, but were inconclusive on account of the heterogeneity of the interventions and outcomes (Fridriksdottir et al., 2018; Trindade et al., 2021).

As regards the use of ACT delivered via eHealth, previous studies suggest the efficacy of this technique in reducing pain, anxiety and depression, and in improving quality of life as well as psychological flexibility in participants with a variety of conditions, including cancer patients (Herbert et al., 2022; Thompson et al., 2021). However, as far as we know, there are no reviews with a specific focus on cancer patients and survivors that have collected and analysed data on the efficacy of ACT delivered via eHealth. Therefore, the objective of this systematic review was to analyse the efficacy of ACT-based interventions which use eHealth technologies in reducing common symptoms in cancer patients and survivors.

Methods

This review follows PRISMA standards (Page et al., 2021), and its protocol, though not published, was prospectively registered in PROSPERO (CRD42022326543).

Study Selection

Inclusion Criteria

Following an initial, more restricted review of the available literature, the authors decided to include studies which met the following PIOS criteria: (P) subjects were cancer patients and survivors, 18 to 70 years old, with any cancer type in stage I-III; (I) interventions included at least two of the six ACT components, and were partially or fully delivered through the Internet (web or mobile application); (O) changes were reported in at least one of the following outcomes: psychological (in)flexibility, anxiety, depression, quality of life, fatigue, pain, insomnia, or healthy lifestyles; (S) they were intervention studies of any kind, published in English or Spanish from 1999 onwards (when the first academic book on the ACT approach was published; Hayes et al., 1999).

Exclusion Criteria

Studies including only minors, participants over 70, patients in cancer stage IV (metastasis) or in palliative care were excluded, as were those without intervention, or those whose main intervention was limited to a single ACT component (e.g., just mindfulness). The same applies to studies that did not include the Internet, were delivered through other media (e.g., telephone), or used only videoconferencing. Studies that did not report outcomes relevant to this review, or were written in a language other than English or Spanish were also excluded.

Search Strategy

For a more comprehensive review, several databases were searched using different engines such as PubMed, Web of Science, or Scopus. In addition, various web platforms were consulted in order to find grey literature (protocols, preprints, theses, etc.; see Table 1). Terms in the strategy were selected from the different database thesauri (when available), and were combined with natural language, which for the most part, was extracted from previous research or is specific to the field of oncology (see Supplemental material 1 for the full search strategy). At the same time, certain relevant authors were contacted via a standard email message, asking for any papers, published or not, that they might have which would reflect our inclusion criteria. Likewise, citations from similar reviews and included articles were checked. The quest was conducted in English on 15 November 2022 (publications from 01/01/1999 to 11/14/2022) and updated on 20 February 2023 (from 11/15/2022 to 02/19/2023).

Table 1.

Search Engines.

Controlled + natural language	Only natural language
PubMedScopusWeb of Science (WOS): Core Collection, Current Contents Connect, KCI-Korean Journal Database, SciELO Citation IndexProQuest: Health & Medical Collection, Nursing & Allied Health Premium, APA PsycInfo, APA PsycArticles, Psychology Database, Periodicals Archive OnlineEBSCOhost: CINAHL Complete, OpenDissertations	World Health Organization’s International Clinical Trials Registry Platform (WHO ICTRP) (trialsearch.who.int/AdvSearch.aspx)Google ScholarOpen Science Framework (OSF) Preprints (osf.io/preprints/discover/)Open Access Theses and Dissertations (oatd.org)NDLTD Global Electronic Theses and Dissertations (ETD) Search (search.ndltd.org/#)

Study Selection and Data Extraction

Both study selection and data extraction were performed by two independent reviewers, AAM and MGC. The level of inter-reviewer agreement was measured employing version 28.0 of SPSS Statistics, using Cohen’s kappa (κ) at two points: after screening by title/abstract, and after full-text screening. Afterwards, data from the included studies were collected following a pre-designed form, which were then tabulated. Disagreements were resolved by consensus and, in case of doubt, FGT played an impartial role in the discussion.

Risk-of-Bias Assessment

Included studies were also independently checked by AAM and MGC for risk of bias following Cochrane’s recommendations (Higgins & Green, 2011), which assess seven areas of potential bias: (1) the allocation sequence generation (i.e. the method used to randomise the allocation); (2) the concealment of this process to prevent researchers from knowing about the assignment; (3) the blinding of participants and personnel involved (e.g., psychotherapists, nurses, general practitioners, etc.), which is unusual in psychotherapeutic research due to the substantial differences between intervention conditions; (4) the blinding of outcome assessors; (5) the processing of incomplete outcome data resulting from withdrawals or other issues (multiple imputation is usually recommended); (6) the selective reporting of results, comparing the study against its protocol; and (7) other sources of bias (e.g., ethical problems, contamination, absence of an intervention protocol, conflicts of interests, etc.). Fields five and six were only assessed for relevant outcomes.

Results

Study Selection

The process of study selection following PRISMA guidelines (Page et al., 2021) is shown in Figure 1. The main search found a total of 2,258 references. After removing duplicates and excluding by title and abstract, 76 records were sought for retrieval. Most of those that were not accessible were protocol records. The reviewers emailed the researchers in charge to ask for preliminary results, and/or when there were doubts about the composition of the intervention, though only some replied. Additionally, along with the retrieved papers that were originally identified, we included eight more that were found with the same study protocol number. Concurrently, 51 additional references arose from citation search, but only 50 could be retrieved. Finally, after the full-text reviewing, 11 reports relating to seven studies were included (Cox, 2022; Grossert et al., 2016; Kinner et al., 2018; Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Mujcic et al., 2018; Neubert et al., 2023; Robertson et al., 2022; Urech, 2014; Urech, Grossert, Alder, et al., 2018; Urech, Grossert, Gloster, et al., 2018). The inter-reviewer agreement before discrepancies were resolved was substantial for title and abstract screening (κ = .74, SE = 0.04, p < .001), and moderate for full-text screening (κ = .57, SE = 0.1, p < .001). All articles finally included were approved by both reviewers. Supplemental material 2 shows the full-text exclusions.

Figure 1.

PRISMA flow chart (both November and February searches are integrated). ^aWOS Core Collection (k = 263); Current Contents Connect (k = 152); KCI-Korean Journal Database (k = 12); SciELO Citation Index (k = 2). ^bHealth & Medical Collection (k = 527), Nursing & Allied Health Premium (k = 192), APA PsycInfo (k = 55), APA PsycArticles (k = 1), Psychology Database (k = 62), Periodicals Archive Online (k = 0). ^cCINAHL Complete (k = 99), OpenDissertations (k = 7). ^dIncluding full-text protocols whose authors did not reply. ^eThose found during the database search were also checked.

Study and Sample Features

Table 2 lists information relating to the seven studies that were included. They were all published between 2018 and 2023; five of them were carried out in European countries, including Switzerland (Urech, Grossert, Alder, et al., 2018), the Netherlands (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022), Germany (Neubert et al., 2023), and the United Kingdom (Cox, 2022), while the other two were from the USA (Kinner et al., 2018; Robertson et al., 2022). Regarding the study design, our results included three open-label randomised controlled trials (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Urech, Grossert, Alder, et al., 2018), a single-blind randomised controlled trial (Neubert et al., 2023), a single-case multiple-baseline experimental design (SCED; Cox, 2022), and two quasi-experimental studies (Kinner et al., 2018; Robertson et al., 2022).

Table 2.

Summary of the Included Studies (k = 7).

Citation	Study design	Sample			Interventions		ACT processes						Outcome^a	Tool	Effect size^b	Risk of bias
Citation	Study design	N	Age [M (SD)]	Sex(% ♀)	Experimental	Control	M	CD	SC	A	V	CA	Outcome^a	Tool	Effect size^b	R	AC	BP	BA	ID	SR	OB
Cox, 2022	MB-SCExp	6	62.5 (7.27)	50	ACT		✓	✓		✓	✓	✓	Anxiety	HADS	RCI * (2)^c	−	?	+	?	?	?	+
													Depression	HADS	RCI * (4)^c
													QoL	CancerDQoL	RCI * (1)^c
													GFlex	MPFI	RCI * (4)^c
Kinner et al., 2018	Quasi-experimental	19	58.89 (6.87)	100	M + ACT + SM		✓			✓	✓		Depression	CESD	g = 0.28	+	+	+	+	−	?	?
													Stress	PSS	g = 0.43*
													OC-QoL	FACT-O	g = 0.62*
													SleepQ	PSQI	g = 0.10
Mujcic, Blankers, Boon, Berman, et al., 2022	Open-label RCT	103	54.6 (11)	83.5	MI + CBT + ACT	Non-interactive web-based information brochure	✓	✓		✓		✓	QALYs	EQ-5D-5L	g = -0.18^d	−	+	+	+	−	?	+
													nDrinks	TLFB	g = 0.21^d,e
													AlcAb	AUDIT	d = 0.30^e
Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022	Open-label RCT	165	54.2 (11.2)	82.4	MI + CBT + ACT	Non-interactive web-based information brochure	✓	✓		✓		✓	QALYs	EQ-5D-5L	g = -0.18^d	−	+	+	+	−	?	+
													nAbs	TLFB	OR = 0.47^e
													nCig	TLFB	IRR = 0.96^e
													NicDep	FTND	d = 0.07^e
Neubert et al., 2023	Single-blinded RCT	157	55.5 (12.4)	68.8	CBT + ACT + Yoga + Qigong	Waiting list	✓	✓					Anxiety	GAD-7	g = -0.06^d	−	−	+	?	−	?	?
													Depression	PHQ-8	g = -0.17^d
													FoP	FoP-Q-SF	g = -0.01^d
													CanFat	QLQ-FA12	g = -0.11^d
Robertson et al., 2022	Quasi-experimental	80	57.5 (11.4)	100	ACT		✓	✓		✓	✓	✓	Anxiety	PROMIS-29	g = 0.21^d	+	+	+	+	?	?	?
													Depression	PROMIS-29	g = 0.23^d
													PhyAct	GLEQ	d = 1.04*
													Fatigue	PROMIS-29	d = -0.33*
													SleepQ	PROMIS-29	d = -0.53*
													PainInterf	PROMIS-29	g = -0.06^d
Urech, Grossert, Alder, et al., 2018	Open-label RCT	129	52 (—)	84.5	CBT + ACT	Waiting list	✓			✓			Anxiety & Depression	HADS	η²_p = 0.02	?	?	+	+	−	?	?
													Stress	DT	η²_p = 0.04*
													QoL	FACIT-F	η²_p = 0.06*

Notes. +: high risk of bias; −: low risk of bias; ?: unclear risk of bias; η²_p : partial squared eta; A: acceptance; AC: allocation concealment; ACT: acceptance and commitment therapy; AlcAb: alcohol abuse; AUDIT: Alcohol Use Disorders Identification Test; BA: blinding of assessors; BP: blinding of participants/personnel; CA: committed action; CancerDQoL: Cancer Dependent Quality of Life questionnaire; CanFat: cancer-related fatigue; CBT: cognitive-behavioural therapy; CD: cognitive defusion; CESD: Center for Epidemiologic Studies Depression scale; DT: Distress Thermometer; EQ-5D-5L: 5-dimension, 5-level, EuroQoL; FACIT-F: Functional Assessment of Chronic Illness Therapy-Fatigue questionnaire; FACT-O: Functional Assessment of Cancer Therapy-Ovarian form; FoP: fear of (cancer) progression; FoP-Q-SF: Fear of Progression Questionnaire-Short Form; FTND: Fagerström Test for Nicotine Dependence; GAD-7: 7-item Generalized Anxiety Disorder subscale; GFlex: global flexibility (includes acceptance, mindfulness, self as context, defusion, values, and committed action); GLEQ: Godin Leisure-time Exercise Questionnaire; HADS: Hospital Anxiety and Depression Scale; ID: incomplete data processing; IRR: adjusted incidence rate ratio; M: mindfulness; MB-SCExp: multiple-baseline, single-case, experimental design; MI: motivational interviewing; MPFI: Multidimensional Psychological Flexibility Inventory; nAbs: number of participants with tobacco abstinence in the past 7 days; nCig: number of cigarettes in the past 7 days; nDrinks: number of European-standard drinking units (10 g. of ethanol) in the past 7 days; NicDep: nicotine dependence; OB: other sources of bias; OC-QoL: ovarian cancer-specific quality of life; OR: adjusted odds ratio; PainInterf: pain interference; PHQ-8: 8-item Patient Health Questionnaire (depression subscale); PhyAct: aerobic physical activity; PROMIS-29: Patient-Reported Outcomes Measurement Information System-29; PSQI: Pittsburgh Sleep Quality Index; PSS: Perceived Stress Scale; QALYs: quality-adjusted life years (mean change); QLQ-FA12: European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-Fatigue 12; QoL: global quality of life; R: randomisation; RCI: reliable change index (significant when > 1.96); RCT: randomised controlled trial; SC: self as context; SleepQ: sleep quality or disturbance; SM: stress management; SR: selective reporting of outcomes; TLFB: timeline followback self-report; V: values.

Only the most relevant outcomes are included here (see Supplemental material 3 for other outcomes).

Pre-post comparisons when there was no control group; between-group comparisons when the study was two-arm (95% CI; see Supplemental material 3 for more results). N may vary from one outcome to another.

Number of participants that got significant results (single-case results).

Corrected standardized mean differences and changes, calculated from the data provided in the study using the formulas suggested by Botella Ausina & Sánchez Meca (2015).

Six-month follow-up (the first end point according to the authors).

p < .05.

Sample sizes ranged from six (Cox, 2022) to 165 (Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022), with a total of 659 participants. Most of these were women (> 80%). In fact, being a woman was an inclusion criterion for two of the studies (Kinner et al., 2018; Robertson et al., 2022). The mean age ranged from 52 to 62.5, with a weighted mean of 54.7. Most of the participants were married and had mid-level education. One of the articles did not include any information of this kind (Neubert et al., 2023). In terms of tumour location, five of the articles included various cancers. In three articles, the breast type predominated (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Urech, Grossert, Alder, et al., 2018); one included a significant variety, with haematological and breast types being the most frequent (Neubert et al., 2023); and in the case study each of the participants had a different cancer (Cox, 2022). The other two focused on gender-specific cancers such as breast or gynaecology-related cancers (Kinner et al., 2018; Robertson et al., 2022). Three studies had samples with active cancer cases (Cox, 2022; Neubert et al., 2023; Urech, Grossert, Alder, et al., 2018), two also included cancer survivors (Kinner et al., 2018; Robertson et al., 2022), and two focused exclusively on the latter (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022). Finally, the percentage of patients in stage I-III ranged from 67.5% (Neubert et al., 2023) to 97% (Robertson et al., 2022). Unfortunately, Cox’s study (2022) did not include sufficient information in this regard.

Interventions

Most of the interventions found included more than two ACT elements (Cox, 2022; Kinner et al., 2018; Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Robertson et al., 2022). The predominant process in the interventions was mindfulness, followed by acceptance and cognitive defusion. In contrast, self-as-context was not included in any study. Furthermore, most of the authors combined ACT with other therapies/techniques such as motivational interviewing (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022), cognitive-behavioural therapy (CBT; Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Neubert et al., 2023; Urech, Grossert, Alder, et al., 2018), yoga or qigong (Neubert et al., 2023), and stress management (Kinner et al., 2018). With regard to the format of the sessions, most were individual, and required weekly homework to be completed remotely, although one of the studies also included a weekly online group meeting (Kinner et al., 2018). As for the timeline of the studies, in one of them participants were encouraged to complete each module in one sitting each week, and on the same day each week over six weeks (Cox, 2022). Another study involved weekly 90 to 120 min. videoconferences, and homework for 10 weeks (Kinner et al., 2018). In two studies, participants were given free access to the material over a period of four weeks (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022). In another, participants accessed two sequential videos per week for a period of four weeks (Neubert et al., 2023), and other two studies involved one session per week for eight weeks (Robertson et al., 2022; Urech, Grossert, Alder, et al., 2018).

Regarding the comparator, only the four RCTs included it: while the studies by Mujcic et al. included an active option in the form of a non-interactive health information website (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022), the other two opted for a waiting-list group (Neubert et al., 2023; Urech, Grossert, Alder, et al., 2018; see Table 2 and Supplemental material 3).

Relevant Outcomes

Table 2 shows the most relevant outcomes found across the studies (more information in Supplemental material 3). Statistical data are provided as in the articles. Some effect sizes were missing, so we calculated them using the data provided by the authors (when possible), and following the formulas suggested by Botella Ausina & Sánchez Meca (2015).

ACT Processes

Cox’s case study (2022) used the Multidimensional Psychological Flexibility Inventory (MPFI) to measure global (in)flexibility, which included the six components of ACT. Global flexibility improved at post-treatment in four out of the six participants (minimal detectable change, MDC∈ [1.25, 1.60], p < .05), and two of them also improved global inflexibility (MDC∈ [1.33, 1.77], p < .05). However, comparing the four-week follow-up to baseline, three participants showed a significant change in global flexibility (MDC∈ [1.53, 2.26], p < .05), and three in global inflexibility (MDC∈ [1.10, 2.07], p < .05). This study also collected mindfulness data through a non-standardised visual analogue scale, and found that mindfulness ability improved significantly in four participants at post-intervention (Tau-U∈ [−.68, −.47], p < .05; weighted average Tau-U = −.43, p < .001), and in two participants at follow-up (compared to post-treatment; Tau-U∈ [−.70, −.47], p < .05; weighted average Tau-U = .14, p = .074).

On the other hand, in their quasi-experimental study, Robertson et al. (2022) obtained significant increases in cognitive acceptance (mean change = 2.3, SD = 6.9, p = .01, d = 0.35), and behavioural commitment (mean change = 2.5, SD = 5.2, p < .001, d = 0.51) toward physical activity at post-treatment.

Emotional Symptoms

Urech, Grossert, Alder, et al. (2018) measured distress using the National Comprehensive Cancer Network Distress Thermometer (DT). The results showed a significant moderate reduction in the experimental group compared to the control group at post-treatment (ΔM = −0.9, 95% CI [−1.6, −0.1], p = .03, η²_p = 0.04). In addition, from post-treatment to two-month follow-up, distress did not decrease significantly in the experimental group, but it did in the control group with a very small effect size (t(N = 64) = −1.25, 95% CI [−1.90, −0.55], p < .001, d = −0.15). Kinner et al. (2018) also found that stress, measured with the Perceived Stress Scale (PSS), decreased significantly at post-intervention [t(17) = −2.42, p = .03, g = 0.43], and showed a significant relationship with the number of relaxation sessions completed (r = −.52, p = .03).

Five studies measured the effect on depression and anxiety. Cox’s case study (2022) used the Hospital Anxiety and Depression Scale (HADS), and found significant changes for depression in four out of the six participants at post-treatment (reliable change index, RCI ∈ [2.00, 4.00], p < .05), and in five participants at the four-week follow-up (compared to baseline; RCI ∈ [2.69, 6.27], p < .05). A significant improvement of anxiety levels was also observed in two participants at post-treatment (RCI ∈ [2.32, 3.47], p < .05) and at follow-up (compared to baseline; RCI ∈ [3.78, 5.47], p < .05). Cox also used a non-standardised visual analogue scale to do a daily screening of anxiety, finding a significant improvement in three out of the six participants at post-treatment (Tau-U∈ [−.57, −.49], p < .05; weighted average Tau-U = −.35, p < .001), but only in one participant at the four-week follow-up (compared to post-treatment; Tau-U = −.50, p = .004; weighted average Tau-U = −.09, p = .268). On the other hand, Urech, Grossert, Alder, et al. (2018), who also measured using the HADS, only found a significant medium improvement in depression and anxiety from post-intervention to two-month follow-up in the control group (within-group results; t(N = 64) = −2.83, 95% CI [−4.30, −1.36], p < .001, d = −0.35). The other three studies (Kinner et al., 2018; Neubert et al., 2023; Robertson et al., 2022) only analysed changes at post-treatment, but did not get significant results for neither of the two syndromes.

Mood was also measured by two studies: Cox (2022) used a non-standardised visual analogue scale, and found a significant improvement in two out of the six participants at post-treatment (Tau-U∈ [−.71, −.55], p < .05; weighted average Tau-U = −.27, p = .001) and at follow-up (compared to post-intervention; both Tau-U = −.49, p = .005; weighted average Tau-U = −.16, p = .043). However, Kinner et al. (2018) did not observe significant results at post-treatment (perhaps owing to a high variability of data). Finally, Neubert et al. (2023) measured fear of cancer progression between baseline and post-intervention, finding a non-significant decrease.

Quality of Life

Urech, Grossert, Alder, et al. (2018) measured different quality-of-life (QoL) dimensions through the Functional Assessment of Chronic Illness Therapy-Fatigue questionnaire (FACIT-F): fatigue and physical, functional, social, and emotional wellbeing. General QoL improved more in the intervention group at post-treatment with a moderate effect size (ΔM = 8.6, 95% CI [2.5, 14.7], p = .007, η²_p = .06), even though only fatigue and physical, as well as functional wellbeing changed significantly. However, within-group results from post-treatment to two months later only showed a great significant change in the control group (t(N = 64) = 10.95, 95% CI [6.18, 15.71], p < .001, d = 1.35), whereas the change in the experimental group was moderate but non-significant (d = 0.57). On the other hand, the quasi-experimental study by Kinner et al. (2018) used an ovarian cancer-specific version of the same instrument, finding that ovarian cancer-specific QoL had experimented a moderate increase at post-treatment (t(17) = 2.88, p = .01, g = 0.62, 95% CI [−0.05, 1.29]), being the only dimension with significant outcomes. Cox (2022) also used a cancer-specific instrument, the Cancer Dependent Quality of Life questionnaire (CancerDQoL). At post-treatment, only one participant showed a significant improvement (RCI = 2.43, p < .05), whereas at the four-week follow-up, up to three participants showed an increase when compared against baseline (RCI ∈ [2.21, 3.35], p < .05; though two participants appeared as missing cases).

Conversely, Mujcic et al. measured QoL through the quality-adjusted life years with the 5-level, 5-dimension EuroQol (EQ-5D-5L), and did not find any significant therapy effect at any time (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022).

Fatigue

Several studies included some physical outcomes, measured either with a specific tool or as a dimension of a larger instrument. As for fatigue, Cox (2022) performed a longitudinal screening, making use of a non-standardised visual analogue scale, and found a significant improvement in five out of the six participants at post-treatment (Tau-U∈ [−.86, −.40], p < .05; weighted average Tau-U = .46, p < .001), while in the four-week follow-up (compared to post-intervention) only one participant showed a significant change (Tau-U = −.54, p < .001; weighted average Tau-U = −.13, p = .100). Two studies measured fatigue as part of a quality of life assessment: Urech, Grossert, Alder, et al. (2018) observed a significant change at post-treatment (ΔM = 4.5, 95% CI [1.8, 7.2], p = .002), and so did Robertson et al. (2022) with a small effect size (mean change = −2.9, SD = 9.2, p = .02, d = −0.33). Neubert et al. (2023) measured cancer-related fatigue, and found a non-significant decrease in both groups.

Pain

Pain measures were also collected by two studies. After the ACT intervention, Cox (2022) observed significant changes in the visual analogue scales used in three participants of the study (Tau-U∈ [−.69, −.49], p < .05; weighted average Tau-U = −.17, p = .040), and in two participants at follow-up (compared to post-treatment; Tau-U∈ [−.66, −.36], p < .05; weighted average Tau-U = −.29, p < .001). In contrast, Robertson et al. (2022) measured pain interference and intensity with the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29), and did not find any significant change at post-treatment.

Sleep Disturbances

Kinner et al. (2018) studied sleep quality using the Pittsburgh Sleep Quality Index (PSQI), and did not find any significant improvement at post-intervention, unlike Robertson et al. (2022), who measured sleep disturbance as part of quality of life (using the PROMIS-29), and found a significant medium decrease at post-intervention (mean change = −4.2, SD = 7.1, p < .001, d = −0.53).

Physical Function

Only Robertson et al. (2022) included this outcome as part of a quality of life assessment (with the PROMIS-29), and found no significant changes at post-treatment.

Lifestyle Behaviours

Three articles analysed variables related to lifestyle. Mujcic, Blankers, Boon, Berman, et al. (2022) studied the number of standard drinks consumed in the previous seven days, and the problematic use of alcohol (measured with the Alcohol Use Disorders Identification Test, AUDIT), and did not find statistical differences in any group at any point when measurements were being taken. However, the authors noted a significant baseline difference between groups in the AUDIT scores (Welch’s t(100.9, N = 103) = 2.03, p = .02). In addition, the tobacco study by the same authors (Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022) did not show significant differences between groups for smoking cessation in the previous seven days (according to odds-ratio confidence intervals), or for nicotine dependence (measured by the Fagerström Test for Nicotine Dependence, FTND). However, the number of cigarettes did decrease significantly throughout the trial in both groups (F(3) = 51.50, p < .001), but without differences between them (according to incidence-rate-ratio confidence intervals).

Robertson et al. (2022) collected data on different exercise outcomes. They measured physical activity level through the Godin Leisure-Time Exercise Questionnaire, and found that the number of minutes of moderate to vigorous aerobic physical activity per week experienced a significant great increase at post-treatment (mean change = 91.6, SD = 114.1, p < .001, d = 1.04), as did the number of bouts of muscle strengthening per week (mean change = 1.3, SD = 1.6, p < .001, d = 1.02), though both were characterised by high variability. These results are in line with the improvement in exercise motivation that the study reported: according to the scores of the 24-item Behavioural Regulation for Exercise Questionnaire-3 (BREQ-3), identified (p < .001, d = 0.37) and integrated regulation (p < .001, d = 0.66) changed significantly, while intrinsic regulation showed no significant increase.

Social Outcomes

The quasi-experimental study by Robertson et al. (2022) was the only study that included social ability as part of quality of life: the ability to participate in social roles and activities showed a very small but significant increase (mean change = 1.3, SD = 5.5, p = .03, d = 0.18).

Risk-of-Bias Assessment

Table 2 and Figure 2 show a risk-of-bias assessment summary. As can be seen in Figure 2, the highest rate of risk was found in the blinding process. It is not uncommon in psychological studies to find high risks relating to participants and personnel blinding, as group conditions tend to be qualitatively different, and people involved can guess the allocation. However, the findings relating to assessor blinding are explained by the inclusion of quasi-experimental studies (Kinner et al., 2018; Robertson et al., 2022) and open-label trials (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Urech, Grossert, Alder, et al., 2018), as well as the lack of information regarding this aspect (Cox, 2022; Neubert et al., 2023). Inclusion of single-group designs (Kinner et al., 2018; Robertson et al., 2022) also affected the results relating to randomisation and allocation concealment. Moreover, allocation concealment was also influenced by the utilisation of minimisation (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022), which may allow investigators to predict the group assignment of the next participant. With regard to selective reporting, a high rate of unclear risk was found due to a generalised lack of information: several secondary outcomes (relevant for this review) were not reported in some articles (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Urech, Grossert, Alder, et al., 2018), and no pre-registered protocol was found for others (Cox, 2022; Kinner et al., 2018; Neubert et al., 2023; Robertson et al., 2022). Lastly, other sources of potential bias were identified: those that stood out had to do with the use of economic incentives (Cox, 2022; Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022), and the contamination of the intervention on account of the use of external support (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Urech, Grossert, Alder, et al., 2018) or medication (Cox, 2022; Urech, Grossert, Alder, et al., 2018). Generally, contamination and other confounding variables were not controlled/reported (treatment duration, instrument validity, etc.; Cox, 2022; Kinner et al., 2018; Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Neubert et al., 2023; Robertson et al., 2022; Urech, Grossert, Alder, et al., 2018), which led to an unclear risk evaluation. See Supplemental material 3 for the assessment justification.

Figure 2.

Risk-of-bias summary (percentage of studies with each type of risk).

Discussion

As far as we know, this is the first systematic review that has attempted to collect results on the effectiveness of internet-delivered ACT for cancer patients and survivors. Surprisingly, only seven studies met the inclusion criteria, which prevented us from conducting a meta-analysis. We ought to consider that the lines of research linking ACT with online interventions are recent, which is why there are few publications on the topic at the moment. Nevertheless, this review provides an overview of the recent literature on the topic and helps identify several limitations of the current research.

The outcomes of interest found in the process of our review relate to emotional symptomatology, quality of life, fatigue, pain, insomnia, psychological flexibility, and lifestyle behaviours. With regard to emotional symptomatology, the results obtained are inconsistent. Anxiety symptomatology showed a decrease in four studies (Cox, 2022; Neubert et al., 2023; Robertson et al., 2022; Urech, Grossert, Alder, et al., 2018), but only in the case study did they prove to be significant for two out of the six participants (Cox, 2022). Something similar happened with depression: out of the five studies that included it, despite showing a decrease in symptomatology (Cox, 2022; Kinner et al., 2018; Neubert et al., 2023; Robertson et al., 2022; Urech, Grossert, Alder, et al., 2018), only one was significant for four out of the six cases (Cox, 2022). When it comes to stress, the two articles that analysed it showed a significant decrease (Kinner et al., 2018; Urech, Grossert, Alder, et al., 2018). As far as mood is concerned, only one study showed a significant improvement after the intervention (Cox, 2022). As regards fear of relapse, a reduction was shown, although it was not significant (Neubert et al., 2023).

In relation to quality of life, post-intervention results were diverse and thus inconclusive. Two studies showed no significant changes (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022). Others only showed significant improvement in certain subscales such as cancer-related quality of life (Cox, 2022; Kinner et al., 2018), fatigue (Robertson et al., 2022; Urech, Grossert, Alder, et al., 2018), physical and functional wellbeing (Urech, Grossert, Alder, et al., 2018), sleep disturbance or participation in social roles and activities (Robertson et al., 2022).

The results relating to ACT processes were analysed by two studies: the ability to practise mindfulness improved significantly in most participants after the intervention, as did psychological flexibility (Cox, 2022). And when it comes to physical activity, there was a significant increase in cognitive acceptance and behavioural commitment. Furthermore, identified, integrated and intrinsic motivation improved, although only the first two were significant (Robertson et al., 2022).

Finally, in relation to lifestyle, several results were obtained. After the intervention to improve physical activity habits, the minutes spent and the number of bouts of muscle strengthening increased significantly (Robertson et al., 2022). Other studies found that the therapy did not have a statistically significant effect on improving participants’ smoking and drinking habits (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022).

Despite these findings, they must be considered cautiously. In previous reviews of ACT interventions without online components (González-Fernández & Fernández-Rodríguez, 2019; Salari et al., 2023), results were encouraging, showing improvements in different domains such as emotional wellbeing, quality of life, thought tolerance, psychological flexibility, or adherence to treatment. Even so, the inconsistency in terms of study designs and measurement tools made it difficult to draw definitive conclusions. In addition, the number of sessions varied considerably, as some interventions included four sessions (Neubert et al., 2023), while others comprised ten (Kinner et al., 2018). Most of the studies (Cox, 2022; Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Neubert et al., 2023; Robertson et al., 2022) did not present direct feedback with a therapist or previous sessions to help improve adherence to the intervention, so the frequency of practicing what has been learned may not be sufficient to show significant results (Kinner et al., 2018; Neubert et al., 2023). Moreover, participation in the interventions was not imposed by any healthcare professional, which may have impacted the results because the motivation to use what was learned could have been affected (Robertson et al., 2022). Also, the scores of the variables studied may not have been high enough for the changes to be significant (Urech, Grossert, Alder, et al., 2018).

Study Limitations

The studies included in this review present certain limitations that could have affected their outcomes. Firstly, it is difficult to generalise the conclusions obtained, since most of the sample population was female in four of the studies (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Neubert et al., 2023; Urech, Grossert, Alder, et al., 2018), and exclusively female in two others (Kinner et al., 2018; Robertson et al., 2022). Something similar occurs with the type of cancer: most of the participants had been diagnosed with breast (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Robertson et al., 2022; Urech, Grossert, Alder, et al., 2018), gynaecological (Kinner et al., 2018), or haematological cancer (Neubert et al., 2023), which complicates the generalisation of the results. In addition, all the sample sizes were small, which makes it difficult to detect small but significant effect sizes, increasing the probability of committing a type-II error.

Secondly, despite the specificity of the studied population, the tools used to measure the different outcomes were highly heterogeneous. As can be observed in Table 2, no instrument is repeated from one research group to another with the exception of the HADS for depression and anxiety symptoms. Furthermore, while cancer-specific tools were used in some cases (Cox, 2022; Kinner et al., 2018; Neubert et al., 2023), sometimes the instruments were not validated with oncological populations, or their psychometric properties were not reported (Cox, 2022; Kinner et al., 2018; Urech, Grossert, Alder, et al., 2018).

Lastly, the risk of bias assessment highlighted some important limitations. We realised that allocation concealment in two of the controlled studies was compromised due to the use of minimisation, which may have allowed the investigators to know the group assignment of the next participant (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022). The blinding process was also affected, since three out of the four RCTs included were open-label (Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Urech, Grossert, Alder, et al., 2018), which means that anyone could access the trial data. Moreover, two other studies did not outline the method used to blind the assessors (Cox, 2022; Neubert et al., 2023). Furthermore, all articles lacked information on selective reporting of results, and some of the missing outcomes were relevant for this review. It should also be noted that the experimental interventions were conducted with little or no guidance and limited control of the execution of the proposed exercises, so adherence could not have been adequate. In addition, contamination of the experimental intervention was generally neglected. In some cases, participants were not asked to avoid seeking additional support, resulting in them using telephone support, face-to-face interventions, or drug therapy (Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022; Urech, Grossert, Alder, et al., 2018). Finally, although social desirability was controlled for in some research, the occasional use of financial rewards could have biased the responses to the questionnaires (Cox, 2022; Mujcic, Blankers, Boon, Berman, et al., 2022; Mujcic, Blankers, Boon, Verdonck-de Leeuw, et al., 2022).

Review Limitations

As for the review itself, certain limitations must be taken into account. In terms of inclusion criteria, we excluded papers that focused exclusively on patients in stage IV or in palliative care, minors, and people over 70. Similarly, as for the timing of the disease, the studies were mainly concerned with survivors or newly diagnosed patients. Therefore, results could not be generalised to other patients in treatment. Moreover, we only required the presence of at least two ACT components in the interventions, but we did not exclude those studies which, as mentioned, evaluated treatments that integrate techniques from different therapies. The mix makes it difficult to conclude the differential efficacy of the therapies included. However, if we had focused only on studies with ACT, there would have been fewer papers meeting this condition. At the same time, although it is generally advisable not to exclude quasi-experimental studies from reviews or meta-analyses (Botella Ausina & Sánchez Meca, 2015), the inclusion of designs different from the RCT, with their own methodological limitations, affected the precision of the conclusions. As regards the discrepancies between reviewers, there are several reasons that could explain them. For instance, the interventions were sometimes described in such a way that it was difficult to clearly identify their components and, as a result, distinguish them from ACT. In addition, the use of Cohen’s κ to evaluate the degree of agreement has been questioned by some authors despite its widespread use (Delgado & Tibau, 2019). Lastly, some publications were excluded as they were written in an unfamiliar language.

Future Research Recommendations

In view of the available evidence on the effectiveness of the ACT approach for cancer patients and survivors, the scarcity of pertinent literature evidenced by this review leads us to stress the need to carry out more research on internet-delivered ACT for this population. Fortunately, there are some relevant ongoing trials (see Supplemental material 2). We encourage the authors of these and future studies to take into account the limitations described here. To prevent heterogeneity and in order to standardise future interventions, it is advisable to establish a protocol for online ACT tailored to this population. This protocol should take into consideration factors such as the number of sessions, the use of validated questionnaires, and the control of confounding variables that may influence the results. All this would enhance the comprehensive analysis of the intervention’s effectiveness. We also stress the need for an adequate randomised design. Moreover, since it is usually impossible to ensure the blinding of participants and/or personnel in psychotherapy investigations, the blinding of assessors is recommended as a minimum requirement. We also strongly suggest the use of multiple imputation and the intention-to-treat (ITT) approach when non-adherence and/or attrition are high. On the other hand, the use of an external and parallel intervention should be avoided. In case of contamination, it should be registered and results adjusted (if the cases cannot be excluded per protocol due to ITT analyses) (Magill et al., 2019). Finally, the use of reinforcements that promote extrinsic motivation, like monetary rewards for example, is strongly discouraged.

Conclusions

Although previous research showed the efficacy of ACT with regard to wellbeing in cancer populations, the studies included in this review, which were limited in number, found that internet-delivered ACT does not provide guaranteed effectiveness in improving emotional symptomatology, quality of life, or lifestyle behaviours. These studies, however, were affected by significant limitations and it is, therefore, impossible to draw definitive conclusions about the effectiveness of internet-delivered ACT for cancer patients and survivors. What has become clear though is that more research is required and that efforts have to be made in order to improve study design so that risk of bias can be minimized.

Supplemental Material

sj-docx-1-sgo-10.1177_21582440241297591 – Supplemental material for Internet-delivered Acceptance and Commitment Therapy for Cancer Patients and Survivors: A Systematic Review

Supplemental material, sj-docx-1-sgo-10.1177_21582440241297591 for Internet-delivered Acceptance and Commitment Therapy for Cancer Patients and Survivors: A Systematic Review by Francisco García-Torres, Margarita García-Carmona, Eliana Moreno, Francisco Jurado-González and Ángel Aguilera-Martín in SAGE Open

Supplemental Material

sj-docx-2-sgo-10.1177_21582440241297591 – Supplemental material for Internet-delivered Acceptance and Commitment Therapy for Cancer Patients and Survivors: A Systematic Review

Supplemental material, sj-docx-2-sgo-10.1177_21582440241297591 for Internet-delivered Acceptance and Commitment Therapy for Cancer Patients and Survivors: A Systematic Review by Francisco García-Torres, Margarita García-Carmona, Eliana Moreno, Francisco Jurado-González and Ángel Aguilera-Martín in SAGE Open

Supplemental Material

sj-docx-3-sgo-10.1177_21582440241297591 – Supplemental material for Internet-delivered Acceptance and Commitment Therapy for Cancer Patients and Survivors: A Systematic Review

Supplemental material, sj-docx-3-sgo-10.1177_21582440241297591 for Internet-delivered Acceptance and Commitment Therapy for Cancer Patients and Survivors: A Systematic Review by Francisco García-Torres, Margarita García-Carmona, Eliana Moreno, Francisco Jurado-González and Ángel Aguilera-Martín in SAGE Open

Footnotes

Thanks to all the authors we contacted for their cooperation in answering our requests and doubts.

Author Contributions

Conceptualisation: FGT,AAM,MGC,EM

Methodology: AAM

Investigation: AAM,MGC,FGT

Formal Analysis: AAM,MGC

Data Curation: AAM

Visualization: AAM,MGC

Writing – Original Draft: FGT,AAM,MGC

Writing – Review & Editing: AAM,FGT,MGC,EM,FJG

Supervision: AAM,FGT

Project Administration: FGT

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This review is part of a project funded by the Consejería de Economía,Conocimiento,Empresas y Universidades of the Junta de Andalucía (Spain),grant number P20_00485. The authors declare that the funding body has not been involved in any phase of this research.

Ethical Approval

Not applicable.

ORCID iDs

Francisco Garcia-Torres

Margarita García-Carmona

Eliana M. Moreno Osella

Francisco Jurado-González

Ángel Aguilera-Martín

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Supplemental Material

Supplemental material for this article is available online.

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