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Current Breast Cancer Reports
Curr Breast Cancer Rep
Improving Breast Cancer Survivors’
Psychological Outcomes and Quality
of Life: Alternatives to Traditional
Angie S.LeRoy, Allison Shields, Michelle
A.Chen, Ryan L.Brown & Christopher
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PSYCHO-ONCOLOGY AND SUPPORTIVE CARE (E SHINN AND C FAGUNDES, SECTION EDITORS)
Improving Breast Cancer Survivors’Psychological Outcomes
and Quality of Life: Alternatives to Traditional Psychotherapy
Angie S. LeRoy
&Michelle A. Chen
&Ryan L. Brown
&Christopher P. Fagundes
#Springer Science+Business Media, LLC, part of Springer Nature 2018
Purpose of Review Breast cancer survivors (BCS) often experience psychological problems and lowered quality of life (QOL).
While helpful, psychotherapy is often costly and inaccessible. This review aims to provide practitioners with the latest informa-
tion on empirically tested interventions among BCS that may be used in lieu of, or in addition to, traditional psychotherapy.
Recent Findings Recent developments in cancer-related psychological interventions include a focus on facilitating emotional
disclosure (e.g., expressive writing), enhancing close relationships (e.g., couples-based interventions), and increasing feasibility
and accessibility via online and computer-based intervention programs. These alternatives to psychotherapy offer a number of
benefits including cost-effectiveness, personalized adaptability, and ease of implementation.
Summary Utilizing these interventions as alternatives or supplements to traditional psychotherapy may offer BCS an opportunity
to increase their QOL, improve psychosocial outcomes, and find meaning in their cancer experience. Choosing the appropriate
intervention requires understanding the unique circumstances for each survivor and their family.
Keywords Breast cancer .Breast cancer interventions .Psychosocial outcomes .Quality of life
An individual diagnosed with breast cancer faces an array of
emotional and physical challenges. There are more than 2.3
million breast cancer survivors (BCS) in the USA, and this
number is expected to increase as new therapies continue to
improve chances of survival . The survivorship period is
commonly marked with psychological problems and lowered
quality of life (QOL). QOL is understood as how much breast
cancer symptoms impair the patient’s ability to function com-
pared to their pre-diagnosis functional abilities . Due to
these psychological issues, most breast cancer survivors
(BCS) may benefit from individualized psychotherapy, but
such treatments are costly and often inaccessible .
Fortunately, there are alternatives to these traditional psycho-
logical treatments, including health-based interventions.
This review will provide practitioners with the latest infor-
mation on empirically tested interventions among breast can-
cer survivors that may be used in lieu of, or in addition to,
traditional psychotherapy. Specifically, we will review
writing-based interventions (e.g., “Expressive Writing”), cou-
ples and family-based interventions, and online/computer-
based interventions. In addition, this review seeks to suggest
future avenues of research that may expand our understanding
of how these and other psychological interventions may ben-
efit BCS as well as inform the design of new dynamic and
Before we begin the review, our use of the term “survivor-
ship”in the current discussion is worth noting. Here, we adopt
the National Coalition for Cancer Survivorship’sdefinitionof
the cancer survivorship period as beginning at the time of first
cancer diagnosis . Thus, at times the term “cancer patient”
This article is part of the Topical Collection on Psycho-Oncology and
*Angie S. LeRoy
Department of Psychology, The University of Houston, 3695 Cullen
Blvd. Rm 126, Houston, TX 77204, USA
Department of Psychology, Rice University, Bioscience Research
Collaborative, Houston, TX, USA
Department of Psychology, Northwestern University, Evanston, IL,
Department of Symptom Research, The University of Texas MD
Anderson Cancer Center, Houston, TX, USA
Department of Psychiatry, Baylor College of Medicine,
Houston, TX, USA
Current Breast Cancer Reports
Author's personal copy
and “survivor”are used interchangeably. It is important to
keep in mind, however, that just because an individual has a
cancer diagnosis, does not mean they identify with the term
“cancer survivor.”With that being said, we will review the
psychological intervention literature, which includes samples
of breast cancer patients post-diagnosis, both during and after
Expressive Writing Interventions
Having the opportunity to express cancer-related emotions
may positively influence a cancer patient’sadjustmenttothe
stressors associated with their cancer . Expressive writing
(EW) interventions are a unique avenue through which indi-
viduals can disclose their deepest thoughts and feelings about
a stressful life event, such as a breast cancer diagnosis. The
traditional EW intervention provides participants with struc-
tured writing exercises, which include a series of writing
prompts . The original writing prompt by Pennebaker and
Beall (1986) involved asking participants to write about their
deepest thoughts and feelings related to traumatic experiences,
which has become known as the “emotional disclosure”(ED)
condition in research trials of EW, where participants are ran-
domly assigned to either the ED condition or some variation
of this original writing prompt . Numerous clinical trials
demonstrate that implementing EW among cancer survivors
leads to positive effects including improvements in physical
symptoms, social support, depressive symptoms, and pain
[7–9]. Furthermore, the structure and format of the interven-
tion itself has changed over time. For example, the original
EW intervention asked participants to write about a traumatic
event for 3–5 consecutive days for 15 to 30 min each day, but
these instructions have, in many cases, since been modified
based on the needs of individual populations. In addition to
the traditional format of the intervention, which involved hav-
ing people write in a journal-like way with paper and pencil,
online versions of the intervention have also been implement-
ed among different clinical samples (e.g., people with mood
disorders) and found positive impacts on psychological health
indicators . This is consistent with research among healthy
samples connecting EW to enhanced well-being and fewer
medical visits [11,12]. Moreover, researchers have
experimented with modifying the writing prompt instructions.
For example, writing about a positive experience (rather thana
traumatic experience) was related to improved physical health
4–6 weeks later .
An article by Stanton et al., 2002 introduced the idea of
using EW to improve BCS’health-related outcomes, using
writing prompts modified from the original ED version .
Sixty early stage (stages I and II) breast cancer patients com-
pleting treatment were randomly assigned to one of three con-
ditions with different writing instructions. Participants re-
ceived the traditional ED instructions or were either instructed
to find benefit in the positive aspects of their cancer experi-
ence, or write about cancer facts unrelated to their emotions
about cancer. The findings revealed that ED reduced physical
symptoms, and ED and benefit finding reduced medical ap-
pointments for cancer-related issues . Specifically, partici-
pants in the ED and benefit-finding condition reported an
average of 0.40–0.90 medical appointments, compared to a
higher average number of medical appointments reported by
those in the control condition (M=2.20).
Researchers continue to explore EW as an alternative inter-
vention to psychotherapy, which may help treat both psycho-
logical and physical issues that stem from the breast cancer
experience. Women wrote about their deepest thoughts and
feelings about their metastatic breast cancer (ED instructions)
in four home-based EW sessions; interestingly, they scored no
differently on a psychological well-being measure than those
who wrote on a neutral control group topic. However, com-
pared to metastatic breast cancer patients who wrote facts
about their cancer diagnosis, those in the ED condition report-
ed greater use of mental health services during the study .
It may be that EW cannot be oversimplified as a one-size-fits-
all intervention. In line with the movement toward a more
personalized approach to patient care, current research is mov-
ing in the direction of identifying for whom this intervention
works best. For example, researchers recently investigated
whether EW may improve QOL among BCS who develop
lymphedema. While they found no statistically significant
main effects of EW on QOL, they did find that EW was more
effective in improving QOL among women higher in opti-
mism and lower in avoidance since their time of diagnosis
with lymphedema . Similar studies suggest that the effec-
tiveness of the intervention may vary based on individual
difference factors, and both researchers and practitioners
would benefit from knowing for which individuals this inter-
vention is best suited.
EW interventions show positive physical and psychologi-
cal benefits for a variety of populations other than non-
Hispanic white cancer survivors. Because participation in
the intervention does not require contact with others, EW
can help minority groups overcome cultural and linguistic
barriers that may arise in face-to-face interventions (e.g., in-
person support groups). For example, EW allows personal
disclosure without having to face stigma associated with hav-
ing breast cancer. This is particularly an issue among the
Chinese culture, making EW a prime candidate for a poten-
tially efficacious and culturally sensitive intervention among
this group . In a recent RCT, 96 Chinese-speaking breast
cancer survivors were randomly assigned to one of three writ-
ing conditions: a traditional ED group, a self-regulation group,
or a cancer-fact group . The self-regulation group wrote
about one’s deepest feelings and coping efforts in addition to
finding benefits from their cancer experience, a combination
of Pennebaker’s original ED writing instructions and Stanton
Curr Breast Cancer Rep
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et al. (2002)’s benefit-finding writing prompt. The cancer-fact
group wrote about facts relevant to their cancer experience.
Chinese speaking breast cancer survivors in the cancer-fact
group reported the highest level of overall QOL at a 6-
month follow-up, compared to the other writing groups. The
self-regulation group had higher emotional well-being com-
pared to the ED group . These data suggest that Asians
may benefit more from writing instructions that facilitate cog-
nitive processes rather than emotional processes. However,
other cultures may respond best to alternative versions of the
writing prompt. It appears, based on the recent work from Lu
et al. (2017), as well as other studies, that emotional expres-
sion may not benefit everyone at all times , and there may
be important moderators of the connection between EW, psy-
chological health, and QOL.
Likewise, in a study of 507 Danish BCS who wrote using
the ED topic or a control topic, researchers found no signifi-
cant differences between the groups on measures of cancer-
related distress, depressive symptoms, and mood .
Interestingly, women who wrote about their cancer had less
improvement in these negative psychological outcomes than
did women who wrote about other traumatic experiences, sug-
gesting that asking women to write specifically about their
breast cancer may not be an ideal topic for BCS . Given
that all other EW studies using BCS samples asked partici-
pants to write specifically about their cancer in their experi-
mental EW conditions, the current literature may not be re-
flective of EW’s true potential in improving psychological
outcomes and QOL among BCS. In addition, women partic-
ipating in some of the previous EW and breast cancer studies
may not have met a sufficient enough distress level to see
change over time . Since we know that EW reduces emo-
tional distress among healthy participants , future research
should continue to investigate whether high levels of cancer-
related distress is a necessary component inorder for EW to be
most efficacious specifically among BCS.
Most EW researchers agree that additional research explor-
ing individual differences among patient characteristics, varia-
tion in writing prompts, and specific health outcome variables
related to EW in BCS must be conducted in order for practi-
tioners to know how best to implement EW among their pa-
tients. In particular, the writing prompt may be an important
place to start looking for ways to adapt EW to target breast-
cancer-specific concerns. The most promising of EW prompts
in improving mental health outcomes and QOL among BCS are
those related to finding benefit from and making meaning of
their cancer experience . For example, breast cancer patients
tended to express more positive emotions and include less dis-
cussion of negative feelings when responding to a benefit-
finding writing prompt compared to when they were simply
asked to write about their deepest thoughts and feelings ,
suggesting that the structure and content of the writing prompt
may impact how patients respond in their writing.
Qualitative studies among individuals with various types of
cancer have reported that EW functions effectively as an outlet
for their deepest thoughts and feelings, and helps them to
develop a sense of control of their life as they attempt to move
on after a cancer diagnosis . Those with cancer also report
appreciating the freedom to participate in EW-based interven-
tions at their own comfort level, not dictated by a manual or
curriculum. Lastly, EW is highly feasible, easy to implement,
and can be tailored to individual populations including ethnic
minorities. However, more research is needed in order to iden-
tify potential cognitive and physiological mechanisms behind
the success of this intervention.
Couples and Family-Based Interventions
BCS often face anxiety, depression, and cancer-related stress.
While BCS identify their partners as their main source of
emotional support, partners are not always able to be support-
ive due to their own challenges with the cancer experience
. For example, partners of women with breast cancer re-
port lower QOL, and higher levels of depression and anxiety,
but having a sense of intimacy in their romantic relationship
can buffer these negative consequences . Interventions
that target couples may help mitigate psychological distress
in both partners by increasing communication, minimizing
conflict, and addressing issues such as self-identity, body im-
age, and sexuality .
Most interventions for BCS and their partners are com-
prised of individual couple or group therapy sessions imple-
mented by trained psychological personnel (e.g., psycholo-
gists, social workers, or therapists) . Although psychother-
apeutic interventions are widely used, a systematic review of
these interventions targeting couples facing breast cancer re-
vealed mixed efficacy . While two of the studies reviewed
did not find improvements in QOL  or post-traumatic
growth  in the intervention groups, the majority of the
ten studies reviewed reported other improvements. Benefits
following couples-based psychotherapy interventions includ-
ed significantly better self-reported psychological well-being,
post-traumatic growth, communication, sexual functioning,
and relationship functioning in both partners. However, gen-
eralization of these results is limited due to small sample sizes,
heterogeneous samples, lack of consideration of potential
moderators, and lack of control for pre-intervention function-
ing, suggesting a need for more controlled intervention studies
for BCS and their partners .
In practice, treating individual couples with therapy-type
interventions often lacks feasibility. Conducting interventions
in a group setting, rather than with one individual couple,
allows for wider dissemination of the intervention as well as
an added social support component. Due to a lack of research
on group psychological interventions for couples facing breast
cancer, Manne, Seigel, Heckman, and Kashy (2016)
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conducted a randomized clinical trial to evaluate the efficacy
of two couple-focused group interventions . Three hun-
dred two early stage breast cancer patients and their partners
were randomly assigned to one of two groups: the Enhanced
Couples Group (ECG), a structured skill-based group focused
on building relationship communication, problem solving,
and stress management between partners, or a Support
Group (SG), which did not teach specific skills but allowed
couples to express their emotions with supportive peers. Both
groups consisted of eight weekly 90-min sessions led by
trained therapists. Participants’self-reported decreased anxi-
ety, depression, and cancer distress over time, and increased
well-being over time regardless of intervention type, suggest-
ing that breast cancer patients and their spouses benefit from
both skill-based and non-skill-based group therapy. Further,
couples who had higher distress levels at baseline benefited
more from the Support Group, while couples who had lower
baseline distress benefited more from the Enhanced Couples
Group. Specifically, couples who had higher ratings of pre-
intervention cancer distress were found to report lower anxiety
and depression if they were in the SG rather than the ECG
condition, while couples who had lower ratings of pre-
intervention cancer distress were found to have lower anxiety
and depression if they were in the ECG rather than the SG
condition. Overall results are consistent with current research
suggesting a “one size fits all”approach to psychotherapy
does not benefit all cancer survivors .
Therapy-type psychological interventions can be costly
and time-consuming. Another option is to address BCS and
their spouses through brief informational sessions or leaflets
as preventative interventions rather than treatment interven-
tions. Blais and colleagues (2014) piloted information they
plan to use in a future informational intervention with 35
breast cancer patients and their spouses . Participants
attended focus groups in which they were asked to discuss
messages such as “ask for the help you need”for breast cancer
patients and “show your tenderness in ways that are not sex-
ual”for their spouses. Transcriptions of the focus groups were
coded for relevance and acceptability of each message (i.e.,
whether messages were perceived as helpful and whether they
were clear and appropriate, respectively). Proposed interven-
tion themes included communication, practical consider-
ations, life as a couple, and sexuality. With few exceptions,
messages were judged as both relevant and acceptable.
Participants drew issue with the brevity and imperative tense
used in the messages, noting that this format made it seem like
there are right and wrong ways to adjust to a cancer diagnosis
. While this study provides preliminary support for ac-
ceptability of brief informational interventions for breast can-
cer patients and their partners, a revised intervention needs to
be piloted before a randomized trial can assess efficacy.
Mindfulness-Based Relationship Enhancement (MBRE) is
a psychological intervention that has shown improvements in
relationship satisfaction, relationship stress, and overall stress
in non-distressed couples . The design of the intervention
adds a relationship strengthening component to the traditional
Mindfulness-Based Stress Reduction (MBSR) techniques,
which include practices such as meditation, yoga, and present
moment awareness. Mindfulness-based interventions have
been previously found to be effective in lowering depression,
fear of recurrence, and increasing energy, physical function-
ing, and QOL among BCS individually . MBRE shows
promise in enhancing QOL for not only the breast cancer
survivor, but also their romantic partners who may be suffer-
ing due to their partner’s cancer diagnosis. MBRE may im-
prove mental and physical health outcomes by promoting re-
lationship closeness, improving body image, and helping BCS
adjust to their new sense of self , though these ideas have
not yet been tested. See Bower in this edition for a more
detailed review of mind-body interventions for cancer
As a result of the limitations of in-person interventions,
online-based interventions have been developed to increase
access, convenience, cost-effectiveness, flexibility, and ano-
nymity . Additionally, web-based social interactions may
be perceived as less stigmatizing than face-to-face interactions
. After participating in web-based interventions, cancer
patients report higher health status andQOL, as well
as lower global symptom distress , anxiety , and de-
pression , compared to controls. Caregivers have also
benefited from web-based studies, showing an increase in
sexual function/satisfaction , and less caregiver burden
and negative mood .
Modern technology allows for the opportunity to adapt
interventions previously delivered face-to-face into online in-
tervention programs. A recent study adapted an in-person pro-
gram that showed positive outcomes for both patients and
caregivers into a web-based format using tailored
psychoeducation messages . This web-based intervention
consisted of three sessions over a 6-week period, spaced
2 weeks apart to allow the participants to practice the skills
they learned during program sessions. The program aimed to
facilitate communication between dyads, to increase support,
and to enhance participants’ability to manage illness-related
demands. The computerized format allowed the intervention-
ists to tailor the messages by using algorithms that utilized
participants’baseline questionnaire data (e.g., questionnaires
about communication, support, and self-efficacy), which were
used to identify areas of concern for each individual and dyad.
The intervention showed significant improvements in the
dyad’s overall QOL, physical, and functional QOL from pre-
to post-intervention, as well as a significant time by role in-
teraction that demonstrated the effectiveness of the
Curr Breast Cancer Rep
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intervention for patients and caregivers, respectively. Patients
had greater improvements in their physical QOL and their
perceived benefits of illness over time than caregivers, while
caregivers had greater improvement in their self-efficacy over
time than patients . These findings are particularly impor-
tant as previous studies have shown that caregivers often lack
confidence in addressing patients’needs. The psychoeducation
provided by this online-intervention may have given caregivers
greater confidence about ways to help the patient, significantly
improving their self-efficacy over time . One of the most
noteworthy conclusions of this study is the feasibility of trans-
lating an in-person program to a usable, web-based format that
yields high retention rates. In fact, retention rates were higher in
the new web-based program (86%) compared to the original
nurse-delivered program (62–83%), and participants reported
that they liked completing the online program in the comfort of
their own home .
Building on Northouse et al. (2014), Couplelinks was de-
veloped as a fully integrated online program to help hetero-
sexual couples manage the stressors of breast cancer and im-
prove their coping through intimacy, communication skills,
and relationship awareness . The intervention includes
relationship enhancement exercises and other articles relevant
to young couples dealing with breast cancer. At the end of
each module, a facilitator communicates feedback with the
couple on the intervention website. Many benefits were re-
ported, including enhanced communication and self-other
knowledge, creation of opportunities for meaningful, cancer-
related discussion, affirmation of relationship strengths, and a
greater sense of closeness between partners. Similar to
Northouse et al. (2014), where participants reported high sat-
isfaction with the program’seaseofuse,thosewhocompleted
Couplelinks reported high satisfaction with the program,
website usability, and professional facilitation . These
findings are critical given the small number of dyadic web-
based interventions for cancer patients and their caregivers or
romantic partners. Further research is needed to test more
dyadic web-based interventions given the positive effects, us-
ability, and user satisfaction reported in these studies.
Fear of cancer recurrence (FOR) is a leading concern for
BCS due to its associations with increased psychological dis-
tress  and decreased QOL , as well as increased health
care use . In Otto et al. (2016), women with early stage
breast cancer were randomly assigned to either a 6-week on-
line gratitude intervention or a 6-week online control condi-
tion. Participants in the gratitude condition were instructed to
spend 10 min per week writing a letter of gratitude to “some-
one [who] did something for you for which you are extremely
grateful,”which they could choose to deliver to the recipient
or keep private. Those in the control condition, who simply
wrote a list of recent activities they had participated in, expe-
rienced a significant decline in positive affect while death
worry remained relatively stable. Alternatively, those in the
gratitude intervention experienced a significant decrease in
death worry while positive affect remained relatively stable
. Because FOR and death worry is one of the most prev-
alent and disturbing concerns among BCS, there is a pressing
need to further develop interventions for FOR . These
studies suggest that providing online gratitude interventions
may reduce FOR and emphasize the need to develop similar
interventions in the future.
While research on the implementation of web-based inter-
ventions has grown, only recently have researchers sought to
explore the mechanisms of these interventions’effects .
Using participants of Project Connect Online (PCO), Clearly
and Stanton conducted the first randomized controlled trial of
a web-based intervention supporting existing social networks
of breast cancer patients . Their aim was to assess media-
tors at multiple time points after participants went through a
3-h workshop about creating a personal website to communi-
cate with family and friends. The workshop session featured a
presentation about the function, creation, and maintenance of
personal websites and the benefits of having one. Patients had
the option of bringing a friend or family member to the work-
shop for the support. Researchers hoped the 3-h workshop and
patients’creation of their personal website would enhance
coping self-efficacy and active coping strategies, and provide
a medium through which patients could seek social support
and express their feelings. As a result, those in the Project
Connect Online (PCO) condition showed significant improve-
ments 6 months after the workshop in depressive symptoms,
positive mood, and life appreciation relative to the control
group. Moreover, the hypothesized mediators increased cop-
ing self-confidence, decreased loneliness, and increased social
support from friends mediated the relationship between the
PCO intervention and improvement in depressive symptoms.
Coping self-confidence also mediated the relationship be-
tween PCO and enhanced positive mood, and social support
from friends mediated the relationship between PCO and in-
creased life appreciation . In highlighting these mediators
in the PCO intervention, these findings show that intervention
research questions must expand further to address potential
mediators. In addition, continued investigation of web-based
programs is essential in order to address concerns of inconve-
nience, stigma, and lack of access imposed by many in-person
These interventions may offer BCS an opportunity to increase
their QOL, improve psychosocial outcomes, and find meaning
in their cancer experience. There are a number of benefits to
expressive writing as an intervention for BCS, including cost-
effectiveness, ability to personalize prompts to be culturally
flexible, and ease of implementation. The most promising
Curr Breast Cancer Rep
Author's personal copy
results from EW occur when the prompts focus on finding
meaning in one’s experience with cancer, but there are clear
individual differences in the effectiveness of EW interven-
tions. Thus, practitioners must be adept at understanding the
sociocultural and interpersonal factors that may impact the
efficacy of EW for each survivor.
BCS and their partners/caregivers each face unique
challenges in grappling with the cancer experience.
Traditional therapy-type interventions have produced
mixed results but couples-based therapy-type interven-
tions have had early success in increasing psychological
well-being and relationship functioning. However, the
cost, time, and necessary personalization of these face-
to-face couples-based interventions make them difficult
to effectively execute. Fortunately, online-based inter-
ventions may be one way to address these issues.
Online/computer-based interventions are a convenient
and cost-effective alternative that may provide a level
of anonymity for survivors that in-person interventions
cannot. These programs may better retain survivors and
caretakers over time due to the convenience and flexi-
bility of online-based interventions. In sum, choosing
the appropriate intervention relies on understanding the
unique circumstances for each survivor and their family.
Future research is needed in order to identify potential
mechanisms that may explain why these interventions
are linked to positive outcomes.
Funding Preparation of the manuscript was supported by a grant from the
National Heart, Lung, and Blood Institute (R01HL127260-01) to C. P.
Compliance with Ethical Standards
Conflict of Interest Christopher P. Fagundes has received a grant from
the National Heart, Lung, and Blood Institute (R01HL127260-01).
Angie S. LeRoy, Allison Shields, Michelle A. Chen, and Ryan L.
Brown declare that they have no competing interests.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
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