A Randomized Non-Inferiority Trial of Technician-Guided and Self-Guided Transdiagnostic Internet-Delivered Cognitive Behaviour Therapy for Cancer Survivors: Making Treatment Scalable

Abstract

Many cancer survivors face difficulties adjusting to life after cancer; approximately 14-24% of cancer survivors experience clinical problems with anxiety, depression, and/or worry about the future. Depression and anxiety have significant consequences for survivors in terms of distress, quality of life, and physical health. In turn, depression and anxiety result in increased costs to the health care system. Cognitive behaviour therapy (CBT) has demonstrated efficacy treating anxiety and depression in cancer patients and survivors; however, many individuals do not seek mental health treatment for these problems or are not referred to available services. Barriers to receiving treatment include: geographical distance, mobility, inconvenience, stigma, and time constraints. Internet-delivered CBT (ICBT) overcomes these barriers and is well established as an efficacious treatment for anxiety and depression. ICBT has only recently been used within a cancer population, with only a few large randomized controlled trials. ICBT when guided by a coach or technician has demonstrated comparable efficacy to therapist-assisted ICBT. Moreover, guided ICBT overcomes challenges associated with therapist licensure, providing individuals across the country access to treatment. The primary advantage of ICBT is accessibility; as such, two forms of nontherapist assisted ICBT were investigated in the present study. Cancer survivors with symptoms of anxiety or depression (n = 86) were randomly assigned to receive a transdiagnostic ICBT program (Wellbeing After Cancer) that was either guided by a technician or self-guided. Participants completed measures of anxiety, depression, and fear of cancer recurrence pre-treatment, post-treatment, and four-weeks following ii treatment completion. Secondary objectives were to examine participants' satisfaction with the program as well as explore their preference for differing levels of support. The results of the present study provided evidence for the effectiveness of both non-therapist assisted ICBT options. Participants in both the technician-guided and selfguided groups evidenced significant improvements in depression, anxiety, fear of cancer recurrence, distress, and quality of life. While power limited the ability to draw conclusions about the equivalence of the groups on several measures, analyses revealed no differences in treatment effects between groups on primary outcome measures of anxiety and depression. Furthermore, participants in both groups reported high satisfaction ratings of the program and the majority did not express a need for additional support. Results of the present study demonstrate that both forms of non-therapist assisted ICBT were effective and acceptable treatment options for cancer survivors experiencing symptoms of anxiety and depression. The present study is one of few large-scale trials of ICBT with cancer survivors, the first of its kind in North America. The results demonstrate the ability to provide effective service to all Canadian cancer survivors with symptoms of anxiety and depression from one centralized site. Providing ICBT has the potential to change the mental health care landscape for cancer survivors across Canada. Future research should focus on best practices for implementation of ICBT.