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The Effects of Cognitive-Behavioral Stress Management for Breast Cancer Patients

A Systematic Review and Meta-analysis of Randomized Controlled Trials

Tang, Maoting MSN, RN; Liu, Xianliang PhD, RN; Wu, Qian MSN, RN; Shi, Yan PhD, RN

Author Information
doi: 10.1097/NCC.0000000000000804
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Breast cancer is the most common type of cancer among women in both developing and developed countries.1 At least 400 000 women die of this type of cancer annually, accounting for 14% of all cancer deaths.2 Although the survival rate of breast cancer has increased in recent years—it now ranges from 40% in low-income countries to 80% in developed countries3—the quality of life of most patients is low.4–6 Breast cancer diagnosis and treatment (including radiation therapy, surgery, chemotherapy, and hormonal therapy) contribute to excessive stress.7 Indeed, the prevalence of breast cancer–related stress ranges from 5% to 35% for women.8 Cognitive-behavioral stress management (CBSM) allows patients to better deal with the impact of the environment. We therefore see an urgent need for an effective stress management approach to promote the psychological and physical health of patients with breast cancer.

Cognitive-behavioral stress management is one potentially effective psychological treatment that may be suitable for breast cancer patients. This intervention utilizes elements of cognitive-behavioral interventions and stress management skills.9,10 Cognitive-behavioral stress management was developed by Antoni et al to facilitate the psychological adjustment of gay men diagnosed with HIV.11 Since then, studies have also found CBSM effective for individuals with other chronic diseases, such as prostate cancer and AIDS, and those with posttraumatic stress disorder.12,13

Cognitive-behavioral stress management interventions can be delivered face-to-face or via the web. According to past studies9,14,15 on CBSM, the intervention typically comprises aspects of cognitive-behavioral therapy (eg, cognitive reframing, stress reappraisal, effective coping skills training, assertiveness training, anger management, optimizing the use of social support) and relaxation training (eg, progressive muscle relaxation, guided visual imagery, deep breathing). The essential goal is to help individuals develop skills to reduce stress and increase their awareness of both the sources and indicators of stress. Cognitive-behavioral stress management can also help people replace negative thoughts, improve their management of stressors, and maintain social support networks through training in cognitive and interpersonal coping skills.14,16 All these skills may help buffer against the negative effects of cancer.10

There are numerous randomized controlled trials (RCTs) examining the effects of CBSM on the stress of breast cancer patients and its related factors.17–20 However, to our knowledge, these studies have reached no consensus. For example, some RCTs20–22 found that CBSM can significantly reduce depression among breast cancer patients, whereas others19,23 found no significant effects. There is also no integrated evidence on the efficacy of CBSM for breast cancer patients. We conducted this meta-analysis to examine the role of CBSM as a potential benefit for breast cancer patients.


Study Selection

We identified appropriate literature via searches of the following electronic databases: PubMed, EMBASE, the Cochrane Database, MEDLINE, CENTRAL, CINAHL, and PsycNET. We focused on articles published up to November 21, 2017. The following Medical Subject Headings terms were included in the search: breast neoplasms, breast cancer, breast tumors, breast adenocarcinoma, breast carcinoma, cognitive behavioral stress management, cognitive behavior therapy, behavior therapy, cognitive therapy, stress management, relaxation therapy, and meta-analysis. We also searched for eligible studies by screening the reference lists of selected studies and unpublished documents such as degree papers and conference documents, as well as clinical studies on registered sites.

We applied the following inclusion criteria for studies: (1) the study was an RCT; (2) participants were definitively diagnosed with breast cancer based on clinical, radiological, and pathological examinations24; (3) the CBSM intervention comprised elements of cognitive-behavioral therapy (eg, cognitive reframing, cognitive restructuring, coping skills training) and stress management techniques such as relaxation training (eg, progressive muscle relaxation, meditation, guided imagery, deep breathing) or interpersonal skills training (eg, communication skills, anger management, assertiveness training). We created a table of all outcome measures, including their reliability and validity (Table 1). We excluded studies if they were rated as “high risk” during the quality assessment.

Table 1
Table 1:
Reliability and Validity of the Scales

Data Extraction

The following basic data were extracted by 2 reviewers working independently using self-made data extraction tables: the name of the first author, setting, study design, population (ie, number of participants), participant demographics (eg, age), main outcome measures, and the details of the intervention and comparison method. Any disagreements were resolved through discussion or by consulting a third researcher. We also emailed the authors of the RCTs to obtain complete data when necessary.

Quality Assessment

Two different reviewers independently assessed the quality of each RCT, and any disagreements were resolved via discussion or by consulting a third reviewer. We used the Cochrane Collaboration’s Risk of Bias Tool31 to assess study quality. This tool assesses the randomization sequence generation, allocation concealment, blinding of participants and study personnel, blinded outcome assessment, incomplete outcome data, selective outcome reporting, and other sources of bias. Each domain is evaluated as “low risk,” “high risk,” or “unclear risk” based on specific judgment criteria (see the Cochrane Handbook for Systematic Reviews of Intervention, Part 2: 8.5). When there was insufficient detail in the data or text to make an assessment, we contacted the author of the RCT by email for more information. We contacted 4 authors, but only 2 of them replied. These 2 authors replied that all of the data were in the article. If the author of the RCT could not be reached, or if the author was unwilling to provide information, and the data available in the RCT could not be pooled, we excluded the study from the meta-analysis.

Statistical Analysis

All the extracted data were input into Review Manager version 5.3 (Cochrane Collaboration, London, United Kingdom) for meta-analysis. Because all the outcomes were continuous variables, we used weighted mean differences (WMDs) and 95% confidence intervals (CIs) for estimates. P < .05 was considered statistically significant. The heterogeneity of the included studies was assessed using the I2 statistic, because this method produces stable and reliable results. Low heterogeneity was indicated as I2 ≤ 25%, moderate heterogeneity as 25% < I2 ≤ 50%, substantial heterogeneity as 50% < I2 < 75%, and extreme heterogeneity as I2 ≥ 75%.23 When the heterogeneity was significant (P < .01, I2 > 50%), we used random-effects models to analyze the data, and when the heterogeneity of a study was greater than 75%, its data were not merged with the others. Otherwise, the data analysis used fixed-effects models. A descriptive analysis was used when the data could not be converted or pooled.


Literature Search

The search initially revealed 1189 articles. After excluding duplicates, 988 abstracts were screened, 73 of which were selected for full-text reading. Of these, we excluded 54 because they were duplicates (n = 17) or the abstract (n = 17), study design (n = 4), participants (n = 1), interventions (n = 14), or results indicators (n = 1) did not meet the inclusion criteria (Figure 1). We excluded an additional article because the quality assessment revealed it was high risk for quality issues.32 Therefore, 18 RCTs14–23,25,33–39 were included.

Figure 1
Figure 1:
Flowchart of study selection for the meta-analysis.

Characteristics of Included Trials

All selected RCTs were published between 2001 and 2016. Furthermore, all were performed in the United States except one, which was performed in Ireland.19 The 18 RCTs contained 2564 patients in total, 1285 and 1279 in the intervention and control groups, respectively. Four of the 18 RCTs14,17,37,38 were conducted by the same authors, but they focused on different outcomes. All patients were women diagnosed with breast cancer, whose mean age ranged from 31 to 73 years. Most RCTs14–17,19,20,22,23,25,33–39 used a face-to-face, group-based CBSM intervention comprising cognitive-behavioral therapy and relaxation training. Only 2 RCTs18,21 used a web-based CBSM intervention, the Coping With Cancer Workbook, which comprises an introduction and 10 chapters and includes both video and audio elements. For most RCTs,14,22,25,35–39 the interventions consisted of 2-hour sessions of peer work over 10 weeks, whereas in 2 RCTs18,19 the intervention lasted for 20 or 5 weeks. The control group methods included a 1-day psychoeducation seminar14–17,20,22,33,35,38,39 or wait lists.18,21,25,36Table 2 shows further RCT characteristics.

Table 2
Table 2:
Basics Characteristics of Each Study in This Systematic Review and Meta-analysis

Quality Assessment

Seven RCTs were low risk,15–17,19,23,33,39 11 were unclear risk,14,18,20–22,25,34–38 and only 1 was high risk32; this last one was ultimately excluded. Nine RCTs15–19,23,33,36,39 reported the details of the randomization sequence generation, but only 1 RCT reported allocation concealment (using sequentially numbered envelopes).19 Ten RCTs14–17,20,22,23,33,35,39 reported blinded outcome assessments, and 5 RCTs14,19,34,35,38 used an intention-to-treat analysis. None of the selected trials contained incomplete outcome data or engaged in the selective reporting of outcomes. Detailed information on the quality assessment is shown in Figure 2 and Figure 3.

Figure 2
Figure 2:
Methodological quality of the included studies. Qualitative assessment of the methodological quality items is presented as percentages across all included studies.
Figure 3
Figure 3:
Risk of bias in the included studies. Qualitative assessment of the risk-of-bias items.

Meta-analysis and Descriptive Analysis of Outcomes


Perceived Stress

Two RCTs19,23 used the Perceived Stress Scale to evaluate perceived stress. When pooling the data using fixed-effect models, we observed no significant differences between intervention and control patients immediately postintervention (WMD, −0.52; 95% CI, −1.41 to 0.37; P = .25) (Figure 4).

Figure 4
Figure 4:
Change in Perceived Stress Scale scores immediately postintervention.
Current Mood Status

Three RCTs14,37,38 used the Measure of Current Status (MOCS) relaxation subscale to assess whether muscle relaxation techniques and mental imagery could reduce tension in breast cancer patients. We pooled the data of 214,37 of these 3 RCTs using fixed-effects models and found that the intervention group showed significantly greater MOCS relaxation scores at 6 months after the intervention than did patients in the control group (WMD, 0.37; 95% CI, 0.16-0.58; P < .01) (Figure 5). The remaining RCT38 had a different measurement period from the first 2 studies, which found that the CBSM group demonstrated greater increases in MOCS relaxation scores every month compared with the control group (P < .05). The MOCS subscales, getting needs met and awareness of tension, did not significantly differ between the intervention and control groups in one RCT,14 whereas the mean coping subscale score was higher in the intervention group. Phillips et al37 found that the MOCS reappraisal subscale also did not significantly differ between the intervention and control groups.

Figure 5
Figure 5:
Change in Measure of Current Status (MOCS) relaxation scores at 6 months after the intervention.
Serum Cortisol

Three RCTs17,37,38 assessed serum cortisol, two17,37 of which used competitive enzyme-linked immunosorbent assay. These 2 found significantly lower serum cortisol levels after a 12-month CBSM intervention compared with a control condition (WMD, −0.07; 95% CI, −0.14 to −0.01; P < .05) (Figure 6). However, no significant differences were observed at 6 months (WMD, 0.04; 95% CI, −0.04 to 0.11; P = .33) (Figure 7). The remaining RCT38 found that, compared with the control group, the intervention group demonstrated a small but significantly greater decrease in cortisol per month (P < .05) as measured by competitive enzyme-linked immunosorbent assay.

Figure 6
Figure 6:
Change in serum cortisol levels after a 12-month intervention.
Figure 7
Figure 7:
Change in serum cortisol levels at 6 months.



Three RCTs17,19,35 reported the effects of CBSM on anxiety, two17,35 of which used the Hamilton Rating Scale for Anxiety. Antoni et al17 found that, compared with the control group, the intervention group showed significantly lower anxiety scores at 12 months after entry; however, in an earlier study,35 no such decrease was observed. Groarke et al19 used the Hospital Anxiety and Depression Scale and reported that the intervention group showed significantly lower anxiety at postintervention compared with the control group.


Five RCTs16,20–23 measured depression using the Center for Epidemiologic Studies Depression Scale. Four16,20–22 of these found that CBSM led to a significantly greater decrease in depression compared with a control condition at postintervention (10 weeks, 5 years, and 11 years after); 1 RCT23 found no significant difference. Only 1 RCT19 used the Hospital Anxiety and Depression Scale to evaluate depression; however, it did not find a significant difference between the groups.

Benefit Finding and Positive Affect

Six RCTs14,18,19,21,22,25 measured benefit finding; however, they used different measures for this construct. Two18,21 used the Benefit Finding Scale, both of which employed a web-based CBSM intervention. However, only one of these RCTs21 reported a significantly higher benefit-finding score in the intervention group than in the control group at 10 weeks; the other18 did not. Three RCTs14,22,25 employed a measure based on breast cancer patients’ experiences of diagnosis and treatment. They all reported that benefit finding showed a significantly greater increase in the intervention group than in the control group after 10 weeks,22 9 months,14 and 12 months.25 One RCT19 used the Silver Lining Questionnaire and showed the same results as these 3 studies at postintervention.

Positive affect was measured in 3 RCTs,14,18,34 two14,34 of which used the Affect Balance Scale (ABS). Both these studies found that a 10-week CBSM intervention led to significantly greater positive affect at 12 months. The remaining RCT18 used the Positive and Negative Affect Schedule–Short Form and found no significant difference between the CBSM and control groups.

Distress, Mood Disturbance, Thought Avoidance and Intrusion, and Negative Mood

Two RCTs25,35 measured distress scores. One25 used a brief scale comprising descriptive adjectives and found no significant difference between the intervention and control groups, whereas the other35 found that CBSM reduced distress (as measured with the ABS) to a significantly greater degree than a control condition. Two RCTs,22,23 both using the Profile of Mood States (to assess mood disturbance), did not find a significantly greater change in the intervention group compared with the control group.

Seven RCTs17–19,21–23,35 measured thought avoidance and thought intrusion using the Impact of Events Scale (IES). Of these, 5 RCTs17,18,21,22,35 reported that the intervention groups had significantly lower IES scores; for 2 of these RCTs,18,21 the measurements were at 10 weeks, whereas they were at 6 months for 2 others17,35 and at postintervention for the last.22 However, 2 RCTs19,23 did not find a significant difference in the IES changes between the intervention and control groups.

Four RCTs17,18,21,34 provided data on negative mood. In 2 of these RCTs,18,21 negative mood was evaluated with the Negative Mood Regulation Scale. Both these studies found that negative mood scores were significantly higher in the intervention group than in the control group (P < .05) after a 10-week intervention. In the other 2 RCTs,17,34 the ABS was used to assess negative mood; one34 reported a significant difference between the intervention and control groups at 12 months, whereas the other17 did not. Finally, 2 RCTs21,34 measured negative affect and confusion, respectively, and in both, the intervention group showed a significantly greater decrease in these indicators than did the control group.

Self-efficacy and Emotional Status

One RCT18 reported that a CBSM intervention led to a greater increase in breast cancer patients’ self-efficacy for coping when compared with a control condition (P < .05). One RCT16 assessed emotional well-being and found that it showed a greater increase in the intervention group than in the control group at an 11-year follow-up. By contrast, another RCT22 reported that CBSM had no influence on emotional processing. Three RCTs14,22,34 measured optimism,22 overall affect balance,34 and positive state of mind,14 and all found that the CBSM group had significantly better scores compared with the control group.

Physiological and Social Indicators

Seven RCTs14–16,18,20,23,39 examined various other physiological and social indicators. One16 reported that a CBSM intervention could influence patients’ physical well-being, whereas another18 found that CBSM had no effect on functional or social well-being. Two RCTs20,23 used the Functional Assessment of Cancer Therapy–Breast (FACT-B) to evaluate patients’ quality of life. One of these RCTs20 reported that CBSM led to a significantly greater FACT-B score at an 11-year follow-up when compared with a control condition. However, in the other,23 there was no significant difference between the CBSM and control groups. In Stagl et al,15 a 10-week CBSM intervention led to a significantly longer survival and disease-free interval time when compared with a control condition at an 11-year follow-up. Furthermore, Antoni et al14 found that a CBSM intervention had a positive effect on lifestyle changes, disruption of recreational pastimes, and social and interpersonal activities at 12 months. Finally, Vargas et al39 examined changes in sleep quality and fatigue after a CBSM intervention. They found that CBSM can increase sleep quality and fatigue-related daytime interference to a greater degree when compared with a control condition, although scores on the Pittsburgh Sleep Quality Index and fatigue intensity did not differ between the intervention and control groups.

Biochemical Indicators

Two RCTs33,36 both assessed conserved transcriptional response to adversity and found that the CBSM significantly decreased conserved transcriptional response to adversity expression33 at 6 to 12 months and testosterone36 at 1 week after the intervention, respectively. Furthermore, Antoni et al17 found that the interferon γ, cytokine interleukin 2 (IL-2), and the IL-2–to–cytokine IL-4 ratio significantly differed between the intervention and control groups at 6 months. McGregor et al25 found no significant differences in changes in lymphocyte proliferation between the intervention and control groups.


This systematic review revealed that CBSM leads to significant increases in MOCS relaxation scores, benefit finding, and positive affect, as well as decreases in serum cortisol, anxiety, depression, thought avoidance, thought intrusion, and negative mood. However, no finding supported obvious effects on perceived stress or mood disturbances.

Perceived Stress

Pooling the data of 2 RCTs19,23 revealed that CBSM did not have a significant effect on perceived stress. This is perhaps because the interventions were too short to have any effect. For 1 of these 2 RCTs,23 which focused on African American breast cancer survivors, no differences were found from baseline to 6 months postintervention. This may be because they used a time- and attention-matched control condition rather than a wait-list or no-treatment control condition. Specifically, the control group participated in an intervention consisting of 10 weekly 90-minute sessions, delivered by an African American woman with a postgraduate degree, which focused on culturally targeted information and used the same PowerPoint slides as the intervention group. This might have made the control group intervention stronger than expected, thus accounting for the smaller difference in perceived stress between the groups. The other RCT19 reported that while perceived stress did differ between a 5-week CBSM group and a control group at postintervention, the difference had disappeared by the 12-month follow-up. The 5-week intervention time might have been, in this case, too short to influence patients in the long term.

Current Mood Status—Relaxation

Three RCTs14,37,38 reported that the intervention group had a greater ability to relax than did the control group, suggesting that CBSM might help breast cancer patients become more confident in their ability to relax. We expect that this is due to the repetitive relaxation training used in CBSM interventions. For example, Antoni et al14 gave recordings of team leaders’ relaxation exercises to breast cancer patients and urged them to practice muscle relaxation and relaxing imagery training daily. These relaxation-based techniques in turn reduced patients’ tension, depression, and overall negative mood.40 Other studies on CBSM taught participants particular relaxation techniques in each session, such as meditation, abdominal breathing, progressive muscle relaxation, anger management, and self-confidence training,37,38 after which they instructed participants to practice these techniques daily.37 All these efforts might have helped boost participants’ confidence in using relaxation skills.

Serum Cortisol

Serum cortisol is a common method of measuring physiological stress. In pooling the data of 2 of the 3 RCTs that measured serum cortisol,17,37 we observed significant differences between intervention and control groups at a 12-month follow-up, but not at the 6-month follow-up. This is possibly because changes in serum cortisol require a long time to appear. Thus, the impact of CBSM on a patient’s physiological changes would be detected after the patient completed the intervention or had time to practice the skills they have learned (ie, confidence in one’s ability, relaxation, and cognitive reassessment) and integrated them into their lives, which may require a longer follow-up period than 6 months.37 Cognitive-behavioral stress management interventions therefore seem able to reduce stress of breast cancer patients by combining relaxation training with cognitive-behavior techniques.

Anxiety and Depression

The myriad difficulties that breast cancer survivors face often cause them to experience anxiety and depression.39 Two of the RCTs included in this review17,19 found that CBSM led to significantly lower anxiety. Antoni et al17 organized a weekly group meeting for 10 weeks, in which patients exchanged experiences and helped one another solve problems and reduce their negative outlook, which might have played a role in anxiety. Groarke et al,19 however, had patients focus on using their interpersonal skills to share and express their feelings with other survivors, which might have helped reduce anxiety in that study. However, another study by Antoni and colleagues35 did not find a significant difference in anxiety between the intervention and control groups. This was possibly because of a tendency toward higher Hamilton scores in the cognitive-behavior stress management group than in the control group at baseline. This baseline difference may have led to a crossover effect, such that the groups did not differ significantly at any subsequent time point. Four RCTs16,20–22 reported that CBSM could decrease depression in breast cancer patients. These RCTs suggest that an opportunity to learn depression management skills (such as relaxation training and cognitive-behavioral techniques within the CBSM intervention) during active treatment may increase the ability of women to regulate their emotions.12 Relaxation training increases confidence in relaxation skills, which may encourage the use of these techniques to manage symptoms of depression after treatment. This, in turn, can lower depression. Cognitive restructuring and adaptive coping aspects of CBSM address cancer-specific depression regarding fears of recurrence and disease progression. Participants may also continue to use these coping skills after treatment to manage depression caused by fear of recurrence.14 However, 2 RCTs19,23 found no differences between the intervention and control groups in depression scores. In Lechner et al,23 it is perhaps because of their use of a time- and attention-matched comparison condition rather than a wait-list or no-treatment control. As for Groarke et al,19 it might be because the duration of the intervention was only 5 weeks.

Benefit Finding and Positive Affect

Evidence suggests that CBSM not only can reduce negative emotions but also can influence positive emotions. Many of the included studies indicate that CBSM led to greater benefit finding14,19,22,25 and positive affect.14,34 Several skills taught in CBSM are beneficial to both positive affect and benefit finding. Specifically, communication and coping skills might help patients express their feelings to group members, whereas progressive muscle relaxation might make patients feel better about their health. Additionally, patients in CBSM were asked to write a diary about their cancer experience; writing about their own experiences and the positive events in their lives might have had a positive effect on them by promoting their emotional regulation and social sharing.40 However, it should be noted that Carpenter et al18 did not find any significant effects of CBSM on benefit finding in patients’ cancer experience. This is perhaps because seeing the benefit of a cancer experience requires support from other patients and opportunities for emotional expression with other survivors in a safe, supportive environment.16 Carpenter et al used a web-based CBSM intervention, and although they tried to get patients to communicate with other survivors through a discussion board, they noted that patients did not often use this discussion board. This might have prevented patients from perceiving the benefits of the cancer experience, unlike face-to-face CBSM interventions.

Distress, Mood Disturbance, Thought Avoidance and Intrusion, and Negative Mood

Two RCTs25,35 measured distress and found different results. We attribute the discrepancy to differences in the number of participants and the scale used. McGregor et al25 included only 29 patients, and they used a brief scale consisting of descriptive adjectives to assess distress. Antoni et al,35 on the other hand, focused on 79 patients and used the ABS.

In 2 of the selected RCTs,22,23 CBSM did not lead to lower mood disturbance compared with a control group. We could attribute this to the fact that the control groups provided a condensed version of the information delivered to the CBSM group, rather than using a no-treatment or wait-list control group.

Thought intrusion refers to the sudden occurrence and persistence of stress-related thoughts, ideas, or pictures, to the point where they can disrupt normal thought processes and daily living. Thought avoidance, on the other hand, refers to an individual’s efforts to avoid thinking about a situation.18,35 Five of the included RCTs17,18,21,22,35 reported that the intervention groups had significantly lower IES scores than did the control groups. This might be because CBSM involves teaching stress reduction skills to patients, such as focusing on rational thinking to help patients remodel their assessment of stress conditions.17 Cognitive-behavioral stress management also gives patients the opportunity to engage in role playing, discover other patients’ coping skills, and participate in relaxation training, all of which might have helped reduce patients’ thought avoidance and thought intrusion.18,21,35 However, 2 RCTs19,23 did not find a significant difference in the changes in the IES between the intervention and control groups. For Lechner et al,23 this might occur because the intervention content did not substantially differ between the CBSM and control groups. For Groarke et al,19 it is perhaps because some patients sought professional psychological help throughout the course of the study and because their intervention was only 5 weeks long.

Three RCTs18,21,34 reported that the CBSM groups had significantly lower negative mood scores than did the control group. Possible reasons for this are that relaxation training and cognitive-behavioral techniques can reduce patients’ anxiety and stress, restore patients’ perceived control over their life, and help patients in coping with their diagnosis.21 Breast cancer patients might also have had more confidence in their ability to cope, making it easier for them to manage their own situation and thereby reducing stress and negative mood.18 However, Antoni et al17 did not find any difference between the intervention and control groups. A possible reason is that although they measured changes in negative affect in the study, the measure used (ABS) did not focus on depressed mood exclusively and was not affected by CBSM.17

Other Indicators

Some of the studies in our review reported on other outcomes, including self-efficacy; emotional status; various MOCS indicators; and various physiological, social, and biochemical indicators such as confusion,34 optimism,22 emotional well-being,16 quality of life,20,23 sleep,39 disruption of social life, and testosterone.35,36 However, only 1 study reported on each of these outcomes. Thus, we could not conclude whether the CBSM intervention has an actual effect on these outcomes. Further research is necessary to demonstrate the impact of the CBSM intervention on these variables.

Study Limitations

This study has some limitations, which might have influenced the results. First, the number of RCTs was too small to use a funnel plot analysis. Thus, we could not determine whether there was publication bias in these studies. Second, some of the RCTs had small sample sizes.25,36 Third, several RCTs did not mention randomization sequences, allocation concealment, blinding, and so on, or described them in too little detail, which obscured our methodological assessment. Fourth, several RCTs had no data on specific outcomes or included these data in a variety of forms, thus preventing us from combining these outcomes for meta-analysis. Finally, because we did not find any unpublished articles on CBSM interventions for breast cancer patients, our results might be somewhat biased.


This systematic review provides a detailed summary of the evidence on the effect of CBSM interventions. This study indicates that CBSM can improve breast cancer patients’ MOCS relaxation scores, cortisol, anxiety, depression, benefit finding, positive affect, thought avoidance and intrusion, and negative mood. However, there remains a need for more high-quality RCTs in the future that may help to clarify the relationship of CBSM with multiple outcomes including perceived stress, mood disturbance, self-efficacy, emotional status, other MOCS subscales, negative affect, confusion, and various other physiological, social, and biochemical factors.

Implication for Practice

Cognitive-behavioral stress management is one potentially effective psychological treatment for breast cancer patients, as it appears to help increase their relaxation, benefit finding, and positive affect, which can buffer them against the negative effects of cancer. Furthermore, it can help breast cancer patients replace negative thoughts by improving patients’ confidence in coping with disease, making it easier for them to manage themselves and thus reduce negative emotions. Further, CBSM can help maintain breast cancer patients’ social support networks through training in cognitive and interpersonal coping skills. Nurses play an important role in CBSM and hence need to master the skills of CBSM in order to identify in a timely way the emotional changes in breast cancer patients, provide relaxation training for patients with negative emotions, help patients relax, encourage patients to communicate with peers and express their feelings, maintain the patient’s social support network, and teach patients to use CBSM skills to relieve stress, anxiety, and negative emotions. If necessary, they should refer these patients to the doctor to provide them with relevant drugs to relieve their stress and negative emotions. After treatment, the patient’s emotional state should be actively assessed and monitored to promote faster recovery.


The authors thank the authors of the included articles, who provided them with additional data.


1. American Cancer Society. Breast Cancer Facts & Figures 2017–2018. Atlanta, GA: American Cancer Society, Inc; 2017.
2. Parkin D, Fernández L. Use of statistics to assess the global burden of breast cancer. Breast J. 2006;12:S70–S80. doi:10.1111/j.1075-122X.2006.00205.x.
3. Walsh P. Cancer survival in five continents: a worldwide population-based study (CONCORD). J Urol. 2010;183:1385–1386.
4. Günüşen N, İnan FŞ, Üstün B. Experiences of Turkish women with breast cancer during the treatment process and facilitating coping factors. Asian Pac J Cancer Prev. 2013;14:3143–3149. doi:10.7314/APJCP.2013.14.5.3143.
5. Phillips SM, Awick EA, Conroy DE, Pellegrini CA, Mailey EL, McAuley E. Objectively measured physical activity and sedentary behavior and quality of life indicators in survivors of breast cancer. Cancer. 2015;121:4044–4052. doi:10.1002/cncr.29620.
6. Ganz PA. Quality of life across the continuum of breast cancer care. Breast J. 2015;6:324–330. doi:10.1046/j.1524-4741.2000.20042.x.
7. Saeedi-Saedi H, Shahidsales S, Koochak-Pour M, Sabahi E, Moridi I. Evaluation of emotional distress in breast cancer patients. Iran J Cancer Prev. 2015;8:36–41.
8. Gold JI, Douglas MK, Thomas M, Elliott JE, Rao SM, Miaskowski C. The relationship between posttraumatic stress disorder, mood states, functional status, and quality of life in oncology outpatients. J Pain Symptom Manage. 2012;44:520. doi:10.1016/j.jpainsymman.2011.10.014.
9. Gudenkauf L, Antoni M, Stagl J, et al. Brief cognitive-behavioral and relaxation training interventions for breast cancer: a randomized controlled trial. J Consult Clin Psychol. 2015;83:677–688. doi:10.1037/ccp0000020.
10. McGregor B, Dolan E, Murphy K, et al. Cognitive behavioral stress management for healthy women at risk for breast cancer: a novel application of a proven intervention. Ann Behav Med. 2015;49:873–884. doi:10.1007/s12160-015-9726-z.
11. Carrico A, Antoni M, Pereira D, et al. Cognitive behavioral stress management effects on mood, social support, and a marker of antiviral immunity are maintained up to 1 year in HIV-infected gay men. Int J Behav Med. 2005;12:218–226. doi:10.1207/s15327558ijbm1204_2.
12. Laperriere A, Ironson G, Antoni M, et al. Decreased depression up to one year following CBSM+ intervention in depressed women with AIDS: the SMART/EST Women’s project. J Health Psychol. 2005;10:223–231. doi:10.1177/1359105305049772.
13. Penedo F, Dahn J, Molton I, et al. Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma. Cancer. 2004;100:192–200. doi:10.1002/cncr.11894.
14. Antoni M, Lechner S, Kazi A, et al. How stress management improves quality of life after treatment for breast cancer. J Consult Clin Psychol. 2006;741:143–152. doi:10.1037/0022-006X.74.6.1152.
15. Stagl J, Lechner S, Carver C, et al. A randomized controlled trial of cognitive-behavioral stress management in breast cancer: survival and recurrence at 11-year follow-up. Breast Cancer Res Treat. 2015;154:319–328. doi:10.1007/s10549-015-3626-6.
16. Stagl J, Vargas S, Antoni M, et al. Does partnership status moderate the benefits of a stress management intervention on quality of life for women with non-metastatic breast cancer? Psychooncology. 2012;21:105–106. doi:10.1111/j.1099-1611.2011.03029_1.x.
17. Antoni M, Lechner S, Diaz A, et al. Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer. Brain Behav Immun. 2009;23:580–591. doi:10.1016/j.bbi.2008.09.005.
18. Carpenter K, Stoner SA, Schmitz K, McGregor BA, Doorenbos AZ. An online stress management workbook for breast cancer. J Behav Med. 2014;37:458–468. doi:10.1007/s10865-012-9481-6.
19. Groarke A, Curtis R, Kerin M. Cognitive-behavioural stress management enhances adjustment in women with breast cancer. Br J Health Psychol. 2013;18:623–641. doi:10.1111/bjhp.12009.
20. Stagl JM, Antoni MH, Lechner SC, et al. Randomized controlled trial of cognitive behavioral stress management in breast cancer: a brief report of effects on 5-year depressive symptoms. Health Psychol. 2015;34:176–180. doi:10.1037/hea0000125.
21. Eaton LH, Doorenbos AZ, Schmitz KL, Carpenter K, McGregor BA. Establishing treatment fidelity in a web-based behavioral intervention study. Nurs Res. 2011;60:430–435. doi:10.1097/NNR.0b013e31823386aa.
22. Antoni M, Carver C. Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol. 2001;20:20–32. doi:10.1037//0278-6133.20.1.20.
23. Lechner S, Whitehead N, Vargas S, et al. Does a community-based stress management intervention affect psychological adaptation among underserved black breast cancer survivors? J Natl Cancer Inst Monogr. 2014;2014:315–322. doi:10.1093/jncimonographs/lgu032.
24. Senkus E, Kyriakides S, Ohno S, et al. Primary breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015;20(suppl 4):8–30. doi:10.1093/annonc/mdt208.
25. McGregor B, Antoni M, Boyers A, Alferi SM, Blomberg BB, Carver CS. Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer. J Psychosom Res. 2004;56:1–8. doi:10.1016/S0022-3999(03)00036-9.
26. Stern AF. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361–370. doi:10.1111/j.1600-0447.1983.tb09716.x.
    27. Schwab JJ, Bialow MR, Clemmons RS, et al. Hamilton rating scale for depression with medical in-patients. Br J Psychiatry. 1967;113:83–88. doi:10.1192/bjp.113.494.83.
      28. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med. 1979;41:209–218. doi:10.1097/00006842-197905000-00004.
        29. Horowitz M, Adler N, Kegeles S. A scale for measuring the occurrence of positive states of mind: a preliminary report. Psychosom Med. 1988;50:477–483. doi:10.1097/00006842-198809000-00004.
          30. Cohen S. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–396. doi:10.2307/2136404.
            31. Higgins J, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. London: The Cochrane Collaboration; 2011.
            32. Cruess D, Antoni M, McGregor B, et al. Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer. Psychosom Med. 2000;62:304–308. doi:10.1097/00006842-200005000-00002.
            33. Antoni M, Bouchard L, Jacobs J, et al. Stress management, leukocyte transcriptional changes and breast cancer recurrence in a randomized trial: an exploratory analysis. Psychoneuroendocrinology. 2016;74:269–277. doi:10.1016/j.psyneuen.2016.09.012.
            34. Antoni M, Lutgendorf S, Blomberg B, et al. Cognitive-behavioral stress management reverses anxiety-related leukocyte transcriptional dynamics. Biol Psychiatry. 2012;71:366–372. doi:10.1016/j.biopsych.2011.10.007.
            35. Antoni M, Wimberly S, Lechner S, et al. Reduction of cancer-specific thought intrusions and anxiety symptoms with a stress management intervention among women undergoing treatment for breast cancer. Am J Psychiatry. 2006;163:1791–1797. doi:10.1176/ajp.2006.163.10.1791.
            36. Cruess D, Antoni M, Kumar M, et al. Effects of stress management on testosterone levels in women with early-stage breast cancer. Int J Behav Med. 2001;8:194–207. doi:10.1207/S15327558IJBM0803_2.
            37. Phillips K, Antoni M, Carver C, et al. Stress management skills and reductions in serum cortisol across the year after surgery for non-metastatic breast cancer. Cogn Ther Res. 2011;35:595–600. doi:10.1007/s10608-011-9398-3.
            38. Phillips K, Antoni M, Lechner S, et al. Stress management intervention reduces serum cortisol and increases relaxation during treatment for nonmetastatic breast cancer. Psychosom Med. 2008;70:1044–1049. doi:10.1097/PSY.0b013e318186fb27.
            39. Vargas S, Antoni M, Carver C, et al. Sleep quality and fatigue after a stress management intervention for women with early-stage breast cancer in southern Florida. Int J Behav Med. 2014;21:971–981. doi:10.1007/s12529-013-9374-2.
            40. Flor H, Birbaumer N. Psychology of pain and psychological treatment. In: Gebhart GF, Schmidt RF, eds. Encyclopedia of Pain. Berlin, Germany: Springer; 2013:2043–2051. doi:10.1007/978-3-540-29805-2_3637.

            Breast cancer; Cognitive behavioral stress management; Meta-analysis

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