Integrated Moving on After Breast Cancer and Culturally Adapted Cognitive Behaviour Therapy Intervention for Depression and Anxiety Among Pakistani Women With Breast Cancer: Randomised Controlled Trial

Abstract

Aims

Breast cancer is major cause of mortality in females, affecting 2.1m women annually. Annual mortality rates are double within south Asian women compared with high-income countries. Pakistan has very high rates of breast cancer. Co-morbid depression and anxiety is reported in more than one third of breast cancer survivors and predict higher recurrence and poorer survival.

Objective:

To evaluate the clinical effectiveness of Moving on After Breast Cancer Plus Cognitive Behaviour Therapy (Moving on ABC Plus) to reduce depression and anxiety in breast cancer survivors in Pakistan.

Methods

A mixed method randomized controlled trial with 354 survivors of breast cancer recruited from the in- and out-patient services of oncology departments both from public and private hospitals of 5 major cities in Pakistan.

Individuals scoring 10 or higher on either the Patient Health Questionnaire-9 (PHQ-9) or the Generalized Anxiety Disorder scale (GAD-7) were enrolled. All participants underwent assessments using the PHQ-9, GAD-7, Functional Assessment of Cancer Therapy—Breast; EuroQol-5D; Multidimensional Scale for Perceived Social Support; Intrusive Thoughts Scale; and Rosenberg Self-Esteem Scale at the baseline and were randomly assigned to one of two trial groups: Moving on ABC plus or routine care. Those in the intervention group received 12 individual sessions of Moving on ABC plus, facilitated by trained master-level psychologists over 4 months. Follow-up assessments were conducted at 3- and 6-months after randomization. Individuals in routine care group continued their standard care. Qualitative interviews were conducted with 15 participants from the intervention group upon completion of the intervention.

Results

The trial established the effectiveness of the integrated intervention, at 6-month follow up preserving 96% of retention. Intervention group reported a significantly higher reduction in depression, anxiety and intrusive thoughts, and improvement in health-related quality of life and self-esteem compared with routine care arm at end of the intervention. They endorsed the usefulness of intervention during qualitative interviews with improvement in psychological well-being, social support network, and interpersonal relationships. Fatigue was reported as a potential barrier to participating in the intervention.

Conclusion

Results of this trial are in favour of psychological intervention; therefore, such programs should be implemented as part of routine care to reduce psychological distress and improve quality of life of this vulnerable population.