ABSTRACT BACKGROUND: Long-term effects of psychosocial interventions to reduce emotional distress, sleep difficulties, and fatigue of breast cancer patients are rarely examined. We aim to

assess the effectiveness of three group interventions, based on cognitive behavioural therapy (CBT), yoga, and self-hypnosis, in comparison to a control group at a 9-month follow-up.

METHODS: A total of 123 patients chose to participate in one of the interventions. A control group was set up for those who agreed not to participate. Emotional distress, fatigue, and sleep

quality were assessed before (T0) and after interventions (T1), and at 3-month (T2) and 9-month follow-ups (T3). RESULTS: Nine months after interventions, there was a decrease of anxiety

well-being of breast cancer patients. Further research is needed to improve the understanding of the mechanisms of action of such interventions and their long-term effects on quality of

life. SIMILAR CONTENT BEING VIEWED BY OTHERS AN EXAMINATION OF THE EFFECTIVENESS OF MINDFULNESS-INTEGRATED COGNITIVE BEHAVIOR THERAPY ON DEPRESSION, ANXIETY, STRESS AND SLEEP QUALITY IN

IRANIAN WOMEN WITH BREAST CANCER: A RANDOMIZED CONTROLLED TRIAL Article Open access 01 April 2025 FOUR-YEAR FOLLOW-UP ON FATIGUE AND SLEEP QUALITY OF A THREE-ARMED PARTLY RANDOMIZED

CONTROLLED STUDY IN BREAST CANCER SURVIVORS WITH CANCER-RELATED FATIGUE Article Open access 15 February 2023 MOBILE HEALTH INTERVENTION CANRELAX REDUCES DISTRESS IN PEOPLE WITH CANCER IN A

RANDOMIZED CONTROLLED TRIAL Article Open access 10 May 2025 MAIN Cancer diagnosis and treatments have significant side effects: pain; physical dysfunction; fatigue; sleep disturbances; and

hair loss (Ewertz and Jensen, 2011; Die Trill, 2013; Weis and Horneber, 2015), as they are associated with the concomitant psychological and emotional reactions such as anxiety, depression,

and distress (Die Trill, 2013; Tojal and Costa, 2015; Hernández Blázquez and Cruzado, 2016). Given the extent of these negative psychosocial consequences, several group interventions have

been evaluated to improve cancer patients’ quality of life (Faller et al, 2013; de Vries and Stiefel, 2014; Mitchell et al, 2014). These programmes, especially those based on cognitive

behavioural therapy (CBT), had benefits on both anxiety and depression after the intervention (Osborn et al, 2006; Groarke et al, 2013; Gudenkauf et al, 2015). Cognitive behavioural therapy

is a ‘time-sensitive, structured, present-oriented psychotherapy directed towards solving current problems and teaching clients skills to modify dysfunctional thinking and behaviour’ (Beck

Institute for Cognitive Behavior Therapy, 2016). A review showed that CBT interventions were related to short- and long-term effects on quality of life in cancer survivors, with only

short-term effects on depression and anxiety (Osborn et al, 2006). Concerning breast cancer patients, Antoni et al (2009) showed that positive effects of CBT intervention for anxiety

appeared to hold for the 12-month observation period, whereas Stagl et al (2015) showed that a cognitive behavioural stress management programme had positive effects on depression and

quality of life up to 15 years. Finally, in their study, Howell et al (2013) identified several trials that effectively used CBT to increase sleep quality and decrease insomnia in cancer

patients. Mind–body interventions such as yoga and hypnosis have also been studied in oncology settings (Mendoza et al, 2016), mostly in breast cancer patients. Yoga includes various fields

such as ethical disciplines, physical postures, and spiritual practices with the aim of uniting mind and body (Smith and Pukall, 2009), whereas hypnosis is defined as ‘a procedure during

which a health professional or researcher suggests that a patient or subject experience changes in sensations, perceptions, thoughts, or behaviour’ (The Executive Committee of the American

Psychological Association – Division of Psychological Hypnosis, 1994). These mind–body approaches began to show short- and mid-term improvements in breast cancer patient fatigue, sleep,

anxiety, and depressive symptoms (Banerjee et al, 2007; Moadel et al, 2007; Farrell-Carnahan et al, 2010; Mustian et al, 2013; Kiecolt-Glaser et al, 2014; Montgomery et al, 2014; Cramer et

al, 2015; Lanctôt et al, 2016). For example, Moadel et al (2007) have shown greater improvements in breast cancer patients at 3 months in the yoga group _vs_ a randomised control group for

quality of life (QoL), emotional well-being, and distressed mood. In addition, Lanctôt et al (2016) demonstrated that compared to a waiting list control group, for which depressive symptoms

increased during 8 weeks of chemotherapy, no similar increase was found in the yoga group. Kiecolt-Glaser et al (2014) have also shown in a randomised controlled 3-month trial for breast

cancer patients that fatigue was reduced and vitality was increased for yoga participants compared to the control group. Groups did not differ on depression at any time. Finally, Mustian et

al (2013) showed the efficacy of a yoga-based intervention to improve sleep quality of cancer survivors. However, Chandwani et al (2014) did not find any differences for mental health or

sleep quality between yoga, stretching, or waiting control groups. Concerning hypnosis, the study of Montgomery et al (2014) randomly assigned breast cancer patients to either CBT plus

hypnosis (CBTH) or an attention control group. They showed that the CBTH group had significantly lower levels of fatigue at the 6-month follow-up, but there was no measure for distress. A

meta-analysis from Cramer et al (2015) also showed that several hypnosis-based interventions positively impacted fatigue and distress. Finally, an online self-hypnosis intervention for

cancer survivors showed promising results in improving sleep (Farrell-Carnahan et al, 2010). These initial results are encouraging, but there is still a lack of long-term data about the

efficacy of yoga (Smith and Pukall, 2009) and hypnosis (Cramer et al, 2015). Our article aims to present the results of a non-randomised study assessing the 9-month follow-up effects of

three interventions (yoga, self-hypnosis, and CBT) in improving emotional distress, sleep quality, and fatigue in breast cancer patients. These three treatment plans will be compared to a

control group, including patients who agreed not to participate in the interventions. For a better understanding of the evolution of the data, we will briefly present the short-term effects

of the interventions (Bragard et al, 2017). We would like to test the hypothesis whether these effects persist over time. MATERIALS AND METHODS PATIENTS AND DESIGN First, 114 patients with

non-metastatic breast cancer were recruited up to 18 months after diagnosis (regardless of cancer stage and type of treatment received). They had to choose to participate in a yoga, a

self-hypnosis, or a CBT group. We chose this kind of design because patients who receive their preferred treatment might be more motivated and could exhibit greater adherence to the

treatment (King et al, 2005; Sedgwick, 2013). Moreover, Mills et al (2015) have already shown that there is not a major difference at baseline between the preference-based groups, as they

are comparable even if they were not randomised. Fifteen of them dropped the study after one or two sessions (6 patients in the yoga group (22.2%); 8 patients in the self-hypnosis group

(10.5%); and 1 patient in the CBT group (9.1%)), leaving a final sample of 99 patients (_N_yoga=21; _N_self-hypnosis=62; _N_CBT=10). Twenty-four patients were also recruited a second time to

form a control group (Figure 1), with the final sample including 123 patients. Inclusion criteria were ⩾18 years old and ability to read, write, and speak French. Patients with a diagnosed

psychiatric disorder or dementia were excluded. After giving written informed consent, participants completed a baseline assessment, including self-reported measures (T0). Three follow-up

assessments were conducted 1 week (T1), 3 months (T2), and 9 months (T3) after the group intervention lasting between 2 and 3 months. For a feasibility issue, the control group completed

questionnaires three times only: at T0; T1; and T3. This paper will focus on the data from the last follow-up (T3), but we will briefly present the results from T1 to give more information

about the evolution of the data. Table 1 shows the principal demographics and medical data of these patients in each group at baseline. INTERVENTIONS Yoga intervention included six weekly 90

 min sessions in groups of 3–8 participants, led by trained teachers and developed in Montréal, QC, Canada (Lanctôt et al, 2010). The Bali Yoga Program-Breast Cancer (based on Hatha yoga)

was specifically designed for breast cancer patients. Each participant received a DVD to encourage home practice. More details about the intervention can be found in Bragard et al (2017).

Self-hypnosis/self-care intervention included 6 sessions of 120 min every 2 weeks in groups of 3–8 participants. This was developed and led by one of the authors (MEF), an anaesthetist with

experience in oncology who was also trained in hypnosis (Faymonville et al, 2010). It is a negotiating approach that fosters shared decision-making through tasks on general well-being rather

than the health problem itself. At the end of the session, a 15 min hypnosis exercise was conducted. They received CDs with the hypnosis exercises and homework assignments between sessions

(Vanhaudenhuyse et al, 2015). More details are given in Bragard et al (2017). Cognitive behavioural therapy intervention included 6 weekly 90 min sessions in groups of 3–8 participants led

by CBT-trained psychologists with experience in psycho-oncology. This programme was developed by team leaders (AME, IB, and MD) and modelled on the work of Andersen et al (2009) and Savard

(2010). Relaxation training took place at the end of each session and participants performed tasks between sessions. More details about the intervention are given in Bragard et al (2017).

The control group included patients who agreed not to attend any of the groups. They continued to benefit from their usual care throughout the duration of the study. MEASURES The following

measures were contained in the assessment battery. DEMOGRAPHICS AND MEDICAL HISTORY A questionnaire looking at age, marital status, education, and cancer-related variables (e.g., treatment

types) was completed. THE HOSPITAL ANXIETY DEPRESSION SCALE The Hospital Anxiety Depression Scale (HADS) is a reliable and validated 14-item measure assessing anxiety and depression in

physically ill subjects. Seven items for anxiety and 7 for depression are rated on a 4-point Likert scale (0=symptoms not present to 3=symptoms considerable). Each subscale was scored from 0

to 21 (0–7: ‘normal range;’ 8–10: ‘borderline;’ or 11–21: ‘probable presence of anxiety or depressive disorder’) (Zigmond and Snaith, 1983). EUROPEAN ORGANIZATION FOR RESEARCH AND TREATMENT

OF CANCER-QOL CORE QUESTIONNAIRE-30 The core questionnaire (30 items) to assess the QoL of cancer patients incorporates five functional scales, three symptom scales, a global health

status/QoL scale, and several single items for additional symptoms and the perceived financial impact of the disease. The responses indicate the extent to which the patient experienced

symptoms or problems. Each item is scored on a 4-point Likert scale (‘not at all’ to ‘very much’), excepted for the global health status/QoL that is a 7-point scale (‘very bad’ to

‘excellent’) (Aaronson et al, 1993) In this paper, we only discuss the fatigue-related items of this questionnaire (3 items). INSOMNIA SEVERITY INDEX (Savard et al, 2005) This is a 7-item

measure of subjective sleep complaints and associated distress. Items are scored on a 5-point Likert scale, ranging from 0 to 4 with higher total scores representing more severe insomnia

symptoms. The cutoff scores are 0–7 (no clinically significant sleep difficulties), 7–14 (sleep difficulties warranting further investigation), and 15+ (presence of clinically significant

insomnia). The data collected from these questionnaires are displayed in Table 2. OUTCOMES The outcome measures assessed the 9-month follow-up effects of three interventions for breast

cancer patients’ emotional distress (anxiety and depression), fatigue, and sleep difficulties, to then compare the three intervention groups with the control group. DATA ANALYSIS Baseline

(T0) demographic, medical, and psychological data were compared between groups to test for initial group equivalency with ANOVA and _χ_2-tests. To be considered for data analysis, patients

attended at least three sessions and completed the first (T0) and last assessments (T3). Group-by-time changes in emotional distress, fatigue, and sleep difficulties were processed using

multivariate analysis of variance with repeated measures, followed by _post hoc_ comparisons (Tukey’s HSD test). All tests were two-tailed and the alpha was set at 0.05. RESULTS Of the 123

women in the intervention or control groups, 1 patient died in the hypnosis group. Thus, in that group, there were data at T0 and T3 for 67 patients; in the yoga group, there were data at T0

and T3 for 21 patients; in the CBT group, there were data at T0 and T3 for 10 patients; and in the control group, there were data at T0 and T3 for 24 patients (Figure 1). The four groups

did not differ at baseline on demographics, medical history, psychological variables (anxiety, depression, fatigue, and sleep quality), or number of sessions (for each group). The average

attendance rate was 5.8 sessions for yoga, 5.4 for self-hypnosis, and 5.7 for CBT. IMPACT OF INTERVENTIONS ON EMOTIONAL DISTRESS, FATIGUE, AND SLEEP QUALITY AT T1 AND T3 To present the

evolution of the data between T0 and T1, we conducted a multivariate analysis of the psychological variables with repeated measures on time of evaluation. No significant effect by group and

no significant group-by-time interaction effect were revealed, but a significant effect of time of the evaluation appeared (∧=0.862; F(4)=4.59; _P_=0.002; =0.14). _Post hoc_ comparisons

revealed a decrease of anxiety (_P_=0.000), depression (_P_=0.004), and fatigue (_P_=0.045) in the hypnosis group, and a decrease of anxiety (_P_=0.010) in the yoga group. Another

multivariate analysis of the psychological variables with repeated measures on time of evaluation (between T0 and T3) indicated no significant effect by group, except for a significant

effect of time of the evaluation (∧=0.795; F(4)=7.23; _P_=0.000; =0.21), and a significant group-by-time interaction effect (∧=0.830; F(12)=1.80; _P_=0.047; =0.07). _Post hoc_ comparisons

revealed a decrease of anxiety (_P_=0.000); depression (_P_=0.000), and fatigue (_P_=0.002) in the hypnosis group, as well as a decrease of anxiety (_P_=0.024) in the yoga group. There were

no significant improvements for all the investigated variables in the CBT and control groups. The graphic evolution of the results over time in each group is displayed in Figure 2. We can

see that in each experimental group, different variables improved over time, as their means decreased, even though some effects are not significant. DISCUSSION This non-randomised study

assessed the 9-month follow-up effects of three interventions (yoga, self-hypnosis, and CBT) in improving emotional distress, fatigue, and sleep quality in breast cancer patients. In all, 99

breast cancer patients participated in the interventions: 68 in the hypnosis group (1 patient died); 21 in the yoga group; and 10 in the CBT group, while 24 participated as a control group.

The number of participants in the hypnosis group has been previously discussed (Bragard et al, 2017) and could be explained in terms of the notoriety of the trainer, and the greater

availability of yoga or individual psychological counselling outside the hospital compared to self-hypnosis. Patients’ demographic, medical, and psychological characteristics were homogenous

in the four groups at baseline. In the self-hypnosis group, there were improvements 9 months after the intervention for anxiety, depression, and fatigue. In the yoga group, anxiety also

decreased at the 9-month follow-up. Given the lack of long-term results regarding the efficacy of mind–body interventions in oncology settings, it is difficult to contrast our results with

existing ones. However, we see that they contrast with those of Chandwani et al (2014), who found no effect of yoga after 6 months on breast cancer patients’ emotional or mental health, but

positive effects of yoga on fatigue at a 6-month follow-up, as did several other authors at a 3-month follow-up (Bower et al, 2011, 2012; Derry et al, 2014; Kiecolt-Glaser et al, 2014). Our

results are congruent with those of Banerjee et al (2007) who found a positive impact of yoga on anxiety in breast cancer patients undergoing radiotherapy. Concerning hypnosis, our results

contrast with those of Jensen et al (2012) who found no effect of an hypnosis-based intervention on anxiety at a 6-month follow-up, but are congruent with the study of Montgomery et al

(2014), where CBTH created lower levels of fatigue at a 6-month follow-up. Despite the fact that we did not investigate the effects of our intervention later than at 9-month follow-up, our

study seems to give a first argument in favour of a long-term effect of alternative psychotherapeutic approaches, especially hypnosis, as part of self-care intervention for emotional

distress and fatigue in breast cancer patients. We found no improvement in the CBT group after 9 months. These results contrast with the review of Osborn et al (2006), showing that CBT

interventions were related to short-term effects on depression and anxiety in cancer survivors, but they are congruent with those of Groarke et al (2013) and Boesen et al (2011), who did not

find long-term effect on distress in their studies. Considering our results, we concluded that the two mind–body interventions led to better outcomes than the control and CBT did,

especially self-hypnosis in terms of improvement of emotional distress and fatigue. The two mind–body interventions were also the only ones to lead to positive results immediately after the

group. More specifically, 1 week after the intervention, emotional distress and fatigue improved in the hypnosis group, whereas anxiety improved in the yoga group. These results suggest that

self-hypnosis is a powerful tool to improve well-being quickly. To explain these differences between the interventions, we can focus on the mechanisms of change of these different

techniques. On one hand, mind–body techniques in general focus on balancing the autonomic nervous system by activating its parasympathetic branch, to reduce the physiological response to

stress. Indeed, mind and body seem to constantly communicate in a bidirectional way (Sawni and Breuner, 2017). Yoga is known to reduce expressive suppression (Dick et al, 2014) and to

develop calmness (Sherman et al, 2013) and mindfulness, which increases attention regulation, body awareness, and emotion regulation. These mechanisms can help to decrease patients’ anxiety.

Hypnosis has three major components, which can influence cognition and emotional regulation: absorption, which is the involvement in a perceptual, imaginative, or ideational experience;

dissociation, which is the mental separation of different components of experience that would usually be processed as a whole; and suggestibility, which is the responsiveness to social

clues, enhancing the propensity to comply with hypnotic instructions and suspending critical judgment (Vanhaudenhuyse et al, 2014). Those hypnotic suggestions also facilitate mind–body

connection and lead to physical, emotional, and behavioural changes (Sawni and Breuner, 2017), which could explain the impact of that intervention on patients’ emotional distress and

fatigue. On the other hand, CBT does not directly address the body, as it focuses on emotion, cognition, and behaviour. This fundamental difference between the techniques used could explain

the differences in our results, especially given the fact that our participants were oncologic patients, all suffering from physical difficulties linked to their cancer. The fact that the

body is very impacted by the disease could explain why mind–body approaches are so pertinent and beneficial for such patients. There are some limitations of this study. First, the small

number of participants in the yoga, CBT, and control groups requires caution in interpreting the findings, as well as the fact that the number of participants in the self-hypnosis group was

significantly higher than in the other groups. Second, our study was not randomised but included a control group to compare to the intervention groups. However, it is likely that patient

interest, driving the intensity of practice and its enjoyment, has a positive role (Carlson and Bultz, 2008). Carlson et al (2014) showed in a randomised study that patient preference was a

strong predictor of outcomes. In their study comparing two active psychosocial interventions in a control group, breast cancer patients who were assigned to their preferred intervention

reported significantly greater improvement in QoL compared to women who received their non-preferred intervention. Another limitation is that the control group did not benefit from the

intervention at all in our study. Indeed, even if they agreed not to participate, the interventions proposed could have been positive for them and it seems important to figure out how to

motivate such patients to engage in the process. In addition, participants in the control group did not complete all the questionnaires for feasibility reasons, which limits some analyses.

Finally, we were only able to assess the effects of the intervention at a 9-month follow-up, despite the fact that more and more studies collect data over longer periods of time. Future

research might investigate the associations between the variables discussed by adopting an experimental design, such as a randomised-controlled trial, which is the most scientifically

rigorous trial design for assessing the efficacy of an intervention (Pocock, 1983; Millat et al, 2005), and by collecting data during longer periods of time. Larger sample sizes would also

help measure more significant effects. Future research might include all types of cancer, not only breast cancer, and some objective measures of emotion regulation and sleep quality such as

cardiac frequency, activity, or sleep pattern monitoring. At a clinical level, our study highlights a need to consider the psychological impact of cancer and proposes different interventions

to help patients cope with it. Our study strongly argues in favour of alternative psychotherapeutic approaches, especially hypnosis-based interventions, to improve fatigue and emotional

distress. As patients are interested in those kinds of therapeutic interventions, increasing our knowledge about them and their mechanisms; thus, proposing them in an appropriate way in the

oncology care routine could be very useful both for health professionals and patients. In conclusion, this study showed the benefits of self-hypnosis in improving anxiety, depression, and

fatigue of breast cancer patients immediately after the intervention and until the 9-month follow-up. Yoga also seems to be useful in decreasing anxiety quickly after the intervention, with

this effect lasting at least 9 months. Larger samples would be necessary to determine differences between the three types of interventions. CHANGE HISTORY * _ 07 NOVEMBER 2017 This paper was

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and depression scale. _Acta Psychiatr Scand_ 67: 361–370. Article  CAS  Google Scholar  Download references ACKNOWLEDGEMENTS This work was supported by the ‘Plan National Cancer’ of Belgium

(Grant number 137). We are grateful to all the patients who participated in the study. We also thank the yoga teachers (R Blauwaert, J Van Brabant, and D Dubois), the yoga trainer from

Montreal (A Anestin), the psychologists (I Willems, B Brouette, C Jourdan, and A Wagener), the data managers (I Jupsin and S Uccello), and the psychology students (S Coudert and M Beaupain).

All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its

later amendments or comparable ethical standards. The study was approved by the Institutional Ethics Board ‘Comité d'éthique Hospitalo-Facultaire Universitaire de Liège’

(B707201215157), with each participant providing written consent. AUTHOR CONTRIBUTIONS IB and CG participated in the conception and design of the study, in the acquisition and interpretation

of data, and in drafting the manuscript. A-ME, M-EF, PC, GD, DL, and GJ participated in the conception and design of the study, in the interpretation of data, and in revising the manuscript

critically for important intellectual content. All authors read and approved the final manuscript, and agree to be accountable for all aspects of the work in ensuring that questions related

to the accuracy or integrity of any part of the work are appropriately investigated and resolved. AUTHOR INFORMATION Author notes * Charlotte Grégoire and Isabelle Bragard: These authors

contributed equally to this work. AUTHORS AND AFFILIATIONS * Health Psychology Department, University of Liege, Liege, 4000, Belgium Charlotte Grégoire & Anne-Marie Etienne * Public

Health Department, University of Liege, Liege, 4000, Belgium Isabelle Bragard * Medical Oncology Department, CHU, Liege, Liege 4000, Belgium Guy Jerusalem * Radiation Oncology Department,

CHU Liege, University of Liege, Liege, 4000, Belgium Philippe Coucke * Psychology Department, University of Quebec at Montreal, Montreal, H2L 2C4, QC, Canada Gilles Dupuis & Dominique

Lanctôt * Algology-Palliative Care Department, CHU Liege, University of Liege, Liege, 4000, Belgium Marie-Elisabeth Faymonville Authors * Charlotte Grégoire View author publications You can

also search for this author inPubMed Google Scholar * Isabelle Bragard View author publications You can also search for this author inPubMed Google Scholar * Guy Jerusalem View author

publications You can also search for this author inPubMed Google Scholar * Anne-Marie Etienne View author publications You can also search for this author inPubMed Google Scholar * Philippe

Coucke View author publications You can also search for this author inPubMed Google Scholar * Gilles Dupuis View author publications You can also search for this author inPubMed Google

Scholar * Dominique Lanctôt View author publications You can also search for this author inPubMed Google Scholar * Marie-Elisabeth Faymonville View author publications You can also search

for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to Charlotte Grégoire. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no conflict of interest.

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ABOUT THIS ARTICLE CITE THIS ARTICLE Grégoire, C., Bragard, I., Jerusalem, G. _et al._ Group interventions to reduce emotional distress and fatigue in breast cancer patients: a 9-month

follow-up pragmatic trial. _Br J Cancer_ 117, 1442–1449 (2017). https://doi.org/10.1038/bjc.2017.326 Download citation * Received: 08 May 2017 * Revised: 22 August 2017 * Accepted: 24 August

2017 * Published: 19 September 2017 * Issue Date: 07 November 2017 * DOI: https://doi.org/10.1038/bjc.2017.326 SHARE THIS ARTICLE Anyone you share the following link with will be able to

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initiative KEYWORDS * group interventions * emotional distress * breast cancer * yoga * self-hypnosis