Factors affecting the fear of recurrence in Breast cancer patients
Dinara Kussainova1, Anar Tursynbekova2, Gulshara Aimbetova3, Fatima Bagiyarova4, Dilyara Kaidarova5
1Master, Head of the Department of Psychological and Social Services, Kazakh Research Institute of Oncology and Radiology, Almaty, Kazakhstan.
2PhD in Medical Sciences The Deputy Chief Physician for Quality Control of Medical Services, Municipal State Enterprise on the Right of Economic Management of “City Clinical Hospital No. 5” of the Public Health Department of Almaty, Almaty, Kazakhstan.
3PhD in Medical Sciences, Associate Professor, Professor Department of "Public Health" Kazakh National Medical University, Almaty, st. Tolebi, 94.
4PhD in Medical Sciences, Head of Department Communication Skills, Kazakh National Medical University named after. S.D. Asfendiyarov, Almaty, Kazakhstan.
5Doctor of Medical Sciences, Professor, Academician of National Academy of Science Chairman of the Board Kazakh Research Institute of Oncology and Radiology, Kazakh Research Institute of Oncology and Radiology, Almaty, Kazakhstan.
*Corresponding Author E-mail: dinara_k2011@mail.ru
ABSTRACT:
KEYWORDS: Breast Cancer, Recurrence, And Fear Of Recurrence.
INTRODUCTION:
Breast cancer is considered one of the commonest cancers in women, which poses a major threat to their long-term health1. Breast cancer comes in second place for the causes of mortality in women posing a major risk to their future health2. Recently, breast cancer treatment is improving as medical technology advances, yet recurrence is a major concern that breast cancer patients confront following diagnosis and treatment. In the United States, over 3.8 million breast cancer survivors are currently present2. In addition, it is very frequent in women and early detection can improve treatment outcomes and minimize the rate of death3. With regular use of early detection and screening, breast cancer survival rates can increase4. During the duration of the breast cancer diagnosis and treatment, psychological issues are detected such as depression, anxiety, irritability, helplessness, uncertainty about the future, fear of cancer recurrence (FCR), a decline in self-esteem, and fear of death5. According to a study by Mehrabi and his colleagues, the reported that majority of treated breast cancer patients experienced FCR6.
FCR is a mental state of anxiety or concern that cancer might return or spread. The incidence of FCR harms the health of the patients, lowers their quality of life and that of their families, uses up too many medical resources, and potentially increases the costs of the healthcare system7. Some of the key contributing elements to FCR in breast cancer patients have been identified as social support, disease uncertainty, and coping strategies7. A study by Hai-Tao and his colleagues reported that having adequate social support is a crucial external resource for promoting mental health. They also assumed that the uncertainty of the disease in breast cancer patients was positively linked with FCR8. According to other studies, FCR typically had a low incidence in breast cancer patients who had stronger social support. In addition, the patient coping style, which explained a person's behaviour and response to his health problems, was another element influencing FCR; different coping styles could have varying effects on patients9,10.
Another study by Tran and his colleagues reported that patients with breast cancer who used more efficient coping methods had low levels of FCR, whereas those who used negative coping strategies, like avoidance, had high levels of FCR levels11. Yet, the intrinsic mechanisms of affecting variables and FCR remain unknown. In this review, we aim to discuss factors affecting the FCR in patients with breast cancer.
METHODS:
Patients and Procedures:
We searched the literature for the most recent published articles from 2017 to 2023 including breast cancer patients. Also, as a part of identifying the factors affecting the FCR in breast cancer patients, we searched for the following topics; the pathophysiology of breast cancer, factors contributing to the occurrence and the recurrence of breast cancer, and different treatment approaches for breast cancer.
Moreover, we described in detail factors affecting FCR in breast cancer patients and different preventive measures for FCR in breast cancer patients including;
1. Mindfulness-Based Stress Reduction (MBSR)
2. Cognitive Behavior Therapy (CBT)
3. Smartphone problem-solving therapy (PST)
In addition, we outlined the association between the FCR and different factors including; age, time since diagnosis, social support, distress, anxiety, neuroticism and exhaustion.
Data Analysis:
Also, we succeeded to perform a meta-analysis on three studies comparing each scale of MBSR treatment with the usual care. We used Review Manager Software (RevMan 5.4.1) to perform our analysis. All outcomes were of continuous data, therefore we expressed the difference between the two groups from baseline and the endpoints as Mean difference (MD) with its standard deviation (SD) and the total number of patients in each group. The significance of the results was settled as P<0.05. Also, heterogeneous values were settled using the Chi-square test (P<0.1) and I² index (I2>50%). All values were homogenous; therefore we used the fixed effect model12.
Pathophysiology of Breast Cancer:
Although the etiology of breast cancer is complex and still not completely understood, there are multiple established risk factors. Indeed, the most frequent risk factors are growing older and the female sex13. In addition, more than 10% of breast cancers occurred because of genetic abnormalities, notably BRCA 1, BRCA 2, RAS/MEK/ERK pathway, and the PI3K/AKT pathway. Furthermore, other factors increase the risk of development of breast cancer like a history of ductal carcinoma in situ, a first child at a young age or null parity, an increase of the body mass index, a family history of ovarian or breast cancer, early menarche (before age 13), usage of postmenopausal hormone therapy, and late menopause8.
Moreover, a study by Hou et al and his colugos reported that white women, those with a normal body mass index, and those with thick breasts were the most at risk among postmenopausal hormone therapy users. Females with prior chest radiotherapy were likewise more vulnerable to breast cancer14.
Factors Conditioning Breast Cancer Occurrence:
a) Intrinsic factors:
· Age:
The patient's age at the onset of neoplastic disease diagnosis is the first fundamental element in this group. Breast cancer has a high incidence in women approaching menopause. It is substantially less common in women under the age of 4515. There is an intriguing association between the age at which neoplastic disease is identified and the estrogen receptor expression in the investigated tumor tissue. Overexpression of the estrogen receptor in neoplasms is distinguished by an increasing incidence of opposed to estrogen which occurs more commonly up to the age of 50. This process explains why women after menopause have a higher percentage of estrogen expression malignancies16.
· Sex:
Studying the breast cancer distribution according to sex, we can observe that it is more detected in females while males have a very low incidence with 1% of the whole patients17. However, this low incidence of breast cancer in males is increasing especially in the last three decades which can be explained by civilization advancement which eventually leads to an elevation in the incidence of obesity and the life expectancy of males18.
It is difficult to accurately describe the disease course and prognosis in this group of patients based solely on the literature data. This may be due to a higher degree of basic neoplastic process advancement at the time of diagnosis, the coexistence of diseases related to ageing, or a more aggressive course of the neoplastic disease. A histological study by Hussain and his colleagues reported that archival tissue samples taken from male breast cancer patients revealed a degree of estrogen and progesterone receptor overexpression that was almost 80% higher than that seen in samples taken from breast cancer women19. This overexpression was frequently strictly associated with bcl-2 protein overexpression19. Additional risk factors for breast cancer in both sexes included an elevated estrogen level brought on by obesity, impaired testicular hormonal activity, or Klinefelter syndrome20.
· Race:
The Black race is more likely to develop the neoplasm compared to the White race at a rate of roughly 121.4 per 100,000 people, and 5-year survival rates are 18.2% and 78.6%, respectively21. It is noteworthy to note that Hispanics have a significantly lower prevalence of breast cancer; nevertheless, in their case, the disease is detected at a younger age and frequently exhibits over-expression of HER2 as well as a lack of expression of the estrogen or progesterone receptor22.
· Genes:
In-depth research has been done recently that has identified genes whose dysfunction is linked to an elevated chance of developing malignant breast or ovarian cancer. The susceptibility genes for breast cancer including BRCA1 and BRCA2, which serve as tumor suppressor genes in a cell, are the most crucial. Depending on the kind of mutation, finding mutations in any of two genes; the BRCA1 or BRCA2 is associated with a higher chance of developing breast and/or ovarian cancer in 65% or 45% of the carriers of the mutation, respectively23.
· Alterations in Hormones:
It is also fascinating to consider how natural hormonal changes that occur during the maturational phase affect the likelihood of developing breast cancer in adulthood 24. Early menarche is associated with a high risk of developing breast cancer because of a prolonged duration of exposure to estrogen activity25. The risk of development of breast cancer is decreased by 10% for every two-year delay in menarche25. The estrogen expression is stronger with each menstrual cycle. Women who had early menarche with an age younger than 12 years old had higher estrogen expression than others who had menarche at 13 or older years old. Estrogen is the predominant sex hormone in women and plays an important part in the menstrual cycle. Estrogen also has a function in the development of breast tissue. The menstrual cycle is controlled by a number of hormones. Among them the most important are estrogen, luteinizing hormone, and follicle-stimulating hormone1. Estrogen levels normally vary during a woman's menstrual cycle and then drop down significantly after she reaches menopause. In order to metabolize estrogen, cytochrome P450 enzymes such as CYP1A1 and CYP3A4 perform hydroxylation, while estrogen sulfotransferases and UDP-glucuronyltransferases perform conjugation, respectively. Sulfation and glucuronidation are both types of estrogen metabolism. In these systems, estrogens are produced from the hydrolysis of estrogen esters in varying amounts. After the onset of puberty, the body starts to metabolize estrogen in order to rid itself of the hormone via urine and faeces. Estrogen was previously used by the body to control the first half of the menstrual cycle. The expression of estrogen becomes more pronounced with each passing menstrual cycle; moreover, women who reached menarche at an age less than 12 years old had a greater estrogen expression than other women who had menarche at 13 or a later age. Cellular proteins called estrogen receptors become activated when hormones attach to them. They may be divided into two groups: membrane estrogen receptors (mERs), such as GPER (GPR30), ER-X, and Gq-mER, and nuclear estrogen receptors (ER and ER). Estrogens work by attaching to certain receptors, such as the G protein-coupled estrogen receptor 1 (GPER1), estrogen receptor, and estrogen receptor. These receptors—ER, ER, and GPER1—have functions in a range of physiological and pathological processes. Estrogen-related receptors (ERRs) are physically similar to estrogen receptors but are not activated by estrogen. Mammals have two primary subtypes of estrogen receptors, ER (ESR1) and ER (ESR2). Hormone receptor positive (HR positive) breast cancers are those that have estrogen and/or progesterone receptors. Progesterone receptors are expressed by the majority of HR-positive breast tumors. Breast tumors without progesterone receptors are referred to as HR negative and those without estrogen receptors are known as ER negative. Low-risk medications like the selective modulators of estrogen receptors tamoxifen and raloxifene or the inhibitors of aromatase anastrozole, letrozole, and exemestane are among the pharmacological options for treating breast cancer. These medications might be utilized for treating postmenopausal women who are 35 years of old or beyond who are at an increased risk of breast cancer but are also at a low risk of having unfavorable drug side effects. Only tamoxifen should be taken in premenopausal women to prevent primary breast cancer. Most of the medications that are used in targeted treatment focus on targeted abnormalities present inside the cancer cells. Some targeted therapies concentrate their target on HER2, which is also called human epidermal growth factor receptor 2, which is produced by breast cancer cells in abundance. Palbociclib and ribociclib, as cyclin-dependent kinase (CDK) 4/6 inhibitors, are often used as the first endocrine-based treatment in metastatic breast cancer. This therapeutic method is frequently referred to as first-line endocrine-based therapy26.
· Pregnancy and Breast-Feeding:
There is a slightly different relationship when we compared the chance of development of breast cancer with the age of the first successful. Early pregnancy and birth on the scheduled due date have preventive effects and are linked to a lower incidence of breast cancer27. This association primarily affects postmenopausal women who have hormone-dependent (estrogen-positive) breast cancer. By providing a similar preventive effect, prolonged breastfeeding lowers the risk of developing breast cancer28. According to estimates based on epidemiologic observations, breastfeeding lowers the incidence of neoplastic disease by 4.3% every year29.
Unfortunately, this benefit has not been shown in European nations, where breastfeeding duration is typically shorter due to cultural customs and a desire to quickly return to work30. The link between the aforementioned findings and the presence of BRCA1 and BRCA2 gene mutations revealed a 32% reduction in breast cancer risk among BRCA1 mutation carriers who nursed their infants for at least a year31. Nevertheless, BRCA2 gene mutation carriers have not been shown to experience a similar phenomenon. In addition, tumors with overexpression of the estrogen receptors are three times more common in breastfeeding women than in non-breastfeeding women, where breast cancer does occur32.
· Proliferative Lesions f The Mammary Glands:
The chance of developing malignant lesions might be considerably increased by benign proliferative lesions in the mammary glands33.
b) Extrinsic Factors:
· Dietary habits:
Dietary practices that can contribute to obesity are particularly common in developed country populations. A factor boosting the neoplastic transformation process in mammary gland cells may be consuming foods high in fat that cause obesity or excess weight, as well as processed foods that contain a variety of chemicals meant to enhance flavor or preserve food34. This association is linked to an increased risk of breast cancer without an excess of estrogen, progesterone, or HER2 receptors, particularly when shown in postmenopausal women35.
A study by De Cicco et al. demonstrated that a low-fat diet significantly reduced the incidence of neoplasm relapse following the initial surgical treatment in a sample of women treated for the neoplastic disease after menopause36. In addition, a 20% relative risk reduction for breast cancer may be attained by consuming foods high in vitamin D or high in antioxidants36. Moreover, a tiny amount of alcohol consumption may increase the risk because it alters the liver's metabolism of estrogen and reduces personal adjustment and quality of life37-39.
· Physical activity:
A study by Friedenreich and his colleagues reported that engaging in regular physical activity three to five times per week lowered the chance of developing breast cancer by 20 to 40%, boosted immunity, enhanced overall fitness, and improved the quality of life40.
Breast Cancer Treatment Approaches:
Chemotherapy, endocrinal therapy, targeted therapy, surgical procedures, and radiotherapy are the main forms of management for breast cancer. Surgical intervention is the standard management for locally advanced cases41. Neoadjuvant treatment is used before surgery to reduce tumor mass41. Adjuvant treatment is typically administered after surgery to ensure complete healing and reduce the chance of metastases41. To lower the likelihood of a local cancer recurrence, radiation therapy can be used to eliminate cancer cells that may not be visible during surgery. Cancer cells are directly exposed to high doses of radiation during the radiation therapy process42.
After surgery, radiation therapy combined with chemotherapy reduces the tumor size. However, there are certain adverse reactions to radiation therapy, including a loss of feeling in the breast tissue or under the arm and skin issues in the treated area such as discomfort, peeling, itching, and redness43. Moreover, many drugs are used to treat breast cancer, including tamoxifen, cyclophosphamide, methotrexate, fluorouracil, trastuzumab, and artesunate which is an antiviral drug and a novel therapy for breast cancer treatment44,45.
Breast Cancer Recurrences:
The knowledge that surgical margins appear to affect breast cancer recurrence further confounds the decision made by surgeons doing breast-conserving therapy46. A study concluded that patients who received breast reconstruction did not have higher rates of local recurrence when they underwent mastectomy with or without breast reconstruction47. Additionally, radiation therapy was typically linked to decreased recurrence in breast cancer, and a study concluded that radiotherapy reduced both the death and recurrence rates in patients who underwent breast-conserving surgery. Intriguingly, this study also found a wide range of variables that could affect how much radiotherapy-induced advantages were felt. These variables included age, the stage of the malignancy, the usage of tamoxifen, the extent of surgery, FCR, and estrogen receptor status48.
Factors Affecting Fear of Breast Cancer Recurrence:
A recent meta-analysis by Zhang and his colleagues reported that anxiety, chemotherapy, sadness, avoidance, intrusive thoughts, distress, rumination, exhaustion, and neuroticism were all strongly connected with the fear of cancer recurrence49. On the other hand, it was adversely connected with time since diagnosis, social support, age, quality of life, and self-efficacy. Additionally, a study by Hengwen and his colleagues reported that teenage and young adult cancer patients typically reported experiencing FCR, anxiety, and depression symptoms. For this high-risk population, adaptable psychological therapies were required50.
RESULT:
FCR PREVENTIVE INTERVENTIONS:
a) Mindfulness-Based Stress Reduction (MBSR)
· Six weeks change of the center for epidemiological studies-depression (CESD) scale:
Analysis of the depression scale included three studies with a total of 359 patients in the MBSR arm and 343 patients in the usual care arm and revealed a significant decrease in the level of depression favoring the MBSR with MD = -1.90 (95% CI (− 2.76 to -1.04), P < 0.0001) with no observed significant heterogeneity (P = 0.12, I2 = 53%)51-53.
Figure 1: Change from baseline in CESD depression scale
· Six weeks change of the state-trait anxiety inventory (STAI) scale:
Analysis of the anxiety STAI scale included three studies with a total of 364 patients in the MBSR arm and 349 patients in the usual care arm and revealed a significant decrease in the level of anxiety favoring MBSR with MD = -3.47 (95% CI (− 5.28 to -1.67), P = 0.0002) with no significant observed heterogeneity (P = 0.65, I2 = 0%) 51-53.
Figure 2: Change from baseline in anxiety STAI scale
· Six weeks change perceived stress scale (PSS):
Analysis of the PSS stress scale included three studies with a total of 361 patients in the MBSR arm and 348 patients in the usual care arm and revealed a significant decrease in the level of stress favoring MBSR with MD = -1.99 (95% CI (− 3.09 to -0.89), p = 0.0004). Low heterogeneity was found (P = 0.82, I2 = 0%)51-53.
Figure 3: Change from baseline of PSS stress scale
· Cognitive Behavior Therapy (CBT):
Multiple forms of CBT have been developed as a preventive intervention in the case of FCR in breast cancer patients. A study by Marieke van de Wal and his collogues demonstrated that blended cognitive behavior therapy (bCBT) was a potential new therapeutic technique that had a statistically significant influence on the severity of FCR in survivors patients of cancer54. The study found that Individuals who received bCBT had lower FCR than those who received the usual care therapy. Clinically meaningful improvement in FCR was 29% in the bCBT group compared to 0% in the usual care group. In addition, self-rated improvement was similarly 71% in the bCBT group compared to 32% in the usual care group. Moreover, a study by Rens Burm and his colleagues reported that in the long term, bCBT was clinically and statistically more successful than usual care for cancer survivors with FCR55.
· Smartphone problem-solving therapy (PST):
The smartphone guided psychotherapy presents a new tool to decrease the FCR which can overcome the decreased resources and the increased number of patients. A study by Fuminobu Imaia and his colleagues reported that smartphone PST reduced the FCR between breast cancer treated patients56. The study found that when compared to baseline, the overall worry measured by the concern about recurrence scale was much lower at eight weeks. In addition, a comparison of four weeks to eight weeks and baseline to eight weeks revealed a significant decrease. This was in line with Tatsuo 2023 et al, who found that the smartphone PST significantly decreased the FCR57.
DISCUSSION:
Our major goal in this article was to identify factors that affect FCR in patients with breast cancer and assess preventive measures to decrease FCR in breast cancer patients and improve their quality of life.
Factors affecting FCR in breast cancer patients:
Our literature search revealed different factors that increased the FCR in breast cancer patients including anxiety, chemotherapy, sadness, avoidance, intrusive thoughts, distress, rumination, exhaustion, and neuroticism. Also, we identified other factors that decreased the FCR in breast cancer patients including low time since diagnosis, high social support, young age, high quality of life, and high self-efficacy49,50. Moreover, our results were in line with the results of the meta-analysis conducted by Hua-ping 2015 et al58. He demonstrated that MBSR significantly decreased depression, anxiety, and stress as well as enhanced the overall quality of life in the treated breast cancer patients58. Another meta-analysis presented a significant negative correlation between the FCR and age (ES= -0.12, 95% CI (-0.17 to -0.07)59. Also, a scoping review included studies done on breast cancer patients and identified several unique factors for FCR. These factors concluded regret about treatment decisions, poor problem-solving skills, concern about the financial issues of the treatment, unable to depend on another one or another thing and the unpredictable and unambiguous nature of the disease60.
They identified also different common factors between the FCR, worry, health anxiety and uncertainty of illness factors. These factors included excessive behaviour of repeated check-ups, misunderstanding different body symptoms, excessive seeking medical advice for reassurance, adoption of avoided-oriented coping and anxious preoccupation60. Another systematic review of patients who had different types of cancers revealed a weak significant association between external-beam radiotherapy and FCR (r = 0.053, 95% CI (0.021 to -0.085), P = 0.001); however, the difference was non-significant for breast cancers (P=0.538)61. Similarly, the chemotherapy had a weak significant association with the FCR (r = 0.093, 95% CI (0.062 to 0.123), P˂0.001)62.
Preventive Measures Against FCR:
· MBSR therapy:
We performed meta-analyses that included three studies comparing the MBSR therapy to the usual care as a preventive therapy against FCR. Also, we found that breast cancer patients who underwent MBSR therapy had significant improvements in psychological domains including depression scale (CESD) with P<0.001, anxiety inventory scale (STAI) with P=0.0002 and stress scale (PSS) with P=0.0004. We were in the line with the previous literature. A comprehensive analysis comprising 327 patients found that the MBSR was better at lowering anxiety and depression when compared to conventional therapy63. Also, according to a randomized controlled trial done on Japanese patients who had non-metastatic breast cancer, the MBSR group had significant improvement in FCR compared with the control group (P<0.05)64. Meanwhile, the effect of MBSR could be sustained over time, but it may not be visible in outpatients.
Furthermore, a qualitative data study provides more evidence for MBSR use in lowering psychological difficulties in treated breast cancer patients. Treated participants with MBSR had many benefits enhanced calmness, an increase in sleep quality, a high level of energy, reduced physical pain, and improved well-being65.
· Other interventions, including CBT, and the smartphone PST:
We found their efficacy in decreasing the FCR; however, we could not perform meta-analyses to pool their effects due to the decreased number of clinical trials. A systematic review presented different techniques of CBT. They included mindfulness awareness practices (MAPS), Cognitively Based Compassion Training (CBCT), Acceptance and Commitment Therapy (ACT), cognitive-existential psychotherapy, blended CBT and CBT-based online selfhelp training66. Most of these techniques reduced the FCR for breast cancer patients as well66. Additionally, recent studies suggested using CBT as a preventive intervention in the case of FCR. Marieke et al 2017 reported that bCBT was a potential new therapeutic technique that significantly influenced FCR severity among survivors54. In the same manner, a randomized controlled trial included patients with breast, prostate and colorectal cancers. The patients were allocated to either bCBT or a control group. Patients allocated to bCBT had a significant improvement in FCR at different endpoints of three (P<0.0001), nine (P<0.0001) and 15 months (P=0.015)55. Also, they had a significant improvement at three months in quality of life (P<0.0001), cognitive function (P<0.0001), social function (P=0.042) and emotional functioning (P<0.0001)55.
Correspondingly, according to a study by Imaia 2019 et al., smartphone PST was preferred by the survivors and improved the FCR56. In addition, the level of general anxiety as judged by the concern about the recurrence scale was significantly lower at eight weeks than it was at baseline. A significant decrease was also seen when comparing baseline to eight weeks and four weeks to eight weeks. Furthermore, the smartphone PST showed reduced FCR in a study by Tatsuo 2023 et al.57. Also, a randomized controlled trial was done on breast cancer survivors and patients were allocated into smartphone PST and behavioural activation group or control group. Compared with the control group, patients who were allocated to smartphone PST had behavioral activation and had lower significant FCR in the short-term (MD= -1.65, 95%CI (-2.41 to -0.89) and P<0.001)67.
CONCLUSION:
The occurrence of breast cancer is affected by different intrinsic factors including young age, black race, presence of BRCA1 and BRCA2 genes, having lesions of the mammary glands and early menarche or late menopause. Also, it's affected by different extrinsic factors including dietary and physical activity. On the other hand, some factors are found to decrease significantly the incidence of breast cancer including pregnancy and breastfeeding. Also, regular physical activity is known to decrease the incidence of breast cancer by 20 to 40 folds. Moreover, a diet containing low fat is known to decline the incidence of breast cancer compared with a diet containing high fat. Breast cancer is considered to be one of the commonest cancers among women. Additionally, there's continuous development and advances in modalities of treatment. Different modalities of treatment were established including surgical, radiotherapy and chemotherapy. The surgical treatment involving breast-conserving therapy treatment is the best when a patient has a locally invasive tumor. Despite the continuous development of treatment of breast cancer, breast cancer patients are still afraid of its recurrence.
Different factors have proven their negative effect on FCR for breast cancer patients including the use of chemotherapy and radiotherapy, anxiety, depression, sadness, avoidance, intrusive thoughts, distress, exhaustion and the unpredictable nature of the disease. The FCR in breast cancer patients worsens their quality of life and their families respectively. Fortunately, patients can overcome the FCR by having good social support, and good self-efficacy. Also, younger patients are less affected by FCR than older ones. Moreover different preventive strategies were established to reduce the FCR including MBSR, CBT, and Smartphone PST. According to our meta-analysis, the MBSR proved its significant effect on anxiety, depression and stress scale. Also, it decreased the FCR among breast cancer patients. Patients who underwent MBSR also had significant improvement in the quality of life, cognitive functions and physical functions. Moreover, CBT included different techniques MAPS, ACT, CBCT, cognitive-existential psychotherapy, blended CBT and CBT-based online self-help training. All of these techniques also have proven their significant effect on decreasing FCR and depression among breast cancer patients. Finally, the smartphone PST has proven its significant effect in decreasing FCR among breast cancer patients.
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Received on 20.05.2023 Modified on 18.07.2023
Accepted on 22.08.2023 © RJPT All right reserved
Research J. Pharm. and Tech 2024; 17(1):314-322.
DOI: 10.52711/0974-360X.2024.00049