Brief Post‐Surgical Stress Management Intervention Effects on Positive Psychological Well‐Being and Self‐Efficacy in Women Being Treated With Adjuvant Endocrine Therapy for Hormone‐Receptor Positive Breast Cancer

ABSTRACT

Background

Women prescribed adjuvant endocrine therapy (AET) for nonmetastatic breast cancer may experience a decline in positive psychological well‐being (PPWB) and self‐efficacy. Brief cognitive behavioral therapy (CBT) and relaxation training (RT) interventions have shown short‐term efficacy in reducing distress, but their impact on PPWB and self‐efficacy over longer periods among women prescribed AET is unknown.

Aims

We aimed to investigate longitudinal effects of CBT and RT on PPWB and self‐efficacy among women prescribed AET.

Methods

This secondary analysis of a randomized controlled trial comparing 5‐session CBT versus RT versus a time‐matched health education (HE) control for women with nonmetastatic breast cancer examined PPWB (positive affect, benefit finding, positive states of mind, optimism), coping self‐efficacy, and relaxation self‐efficacy at four timepoints over the first‐year post‐diagnosis and at median 8‐year follow‐up. Piecewise hierarchical linear modeling tested intervention effects on longitudinal trajectories among women prescribed AET from the parent study (N = 135).

Results

Over the first‐year post‐surgery, positive affect and relaxation self‐efficacy increased across all conditions (ps < 0.03). Women in CBT reported enhanced positive states of mind compared to those in HE (p = 0.044) and enhanced coping self‐efficacy versus those in RT (p = 0.029). Women in HE reported enhanced coping self‐efficacy versus those in RT (p = 0.043). All intervention effects persisted at 8‐year follow‐up. There were no significant effects on optimism or benefit finding.

Conclusions

Brief interventions may bolster aspects of PPWB and self‐efficacy in women prescribed AET. Testing is warranted to determine whether more PPWB components can be incorporated into these interventions to further enhance outcomes.

1. Background

In the United States, one in 8 women will be diagnosed with a breast cancer in their lifetime [1]. A breast cancer diagnosis triggers a series of stressors throughout the cancer care continuum, from initial surgery and adjuvant treatment through long‐term monitoring and survivorship [2, 3]. These challenges can be prolonged for the approximately 75% of patients with hormone receptor positive (HR+) disease [1], who are prescribed adjuvant endocrine therapy (AET) daily for up to 5–10 years. While AET (i.e., Tamoxifen, Aromatase Inhibitor) can reduce rates of recurrence by up to 50% [4], it comes with significant side effects [5, 6, 7], including menopausal‐related symptoms (e.g., hot flashes, musculoskeletal pain) and mood changes (e.g., depression) [5, 6, 7]^,, which may interfere with adherence. In fact, nearly half of women do not complete the recommended course of AET [8]. Non‐pharmacological strategies, including psychosocial interventions, may be helpful for managing these effects [9].

Cognitive behavioral stress management (CBSM) is a 10‐session, group‐based intervention designed to reduce distress associated with breast cancer diagnosis and treatment [10]. CBSM has been shown to reduce distress among women with nonmetastatic breast cancer with multiple phenotypes [11, 12], with sustained effects years into survivorship [13]. However, the effects of CBSM were not tested specifically among women with HR + breast cancer. To enhance patient accessibility and scalability, a randomized controlled trial (RCT) was conducted to test brief versions of CBSM components for women with newly diagnosed nonmetastatic breast cancer [14]. This three‐armed, dismantling trial tested two intervention conditions—cognitive‐behavioral therapy (CBT) and relaxation training (RT)—against an attention‐matched health education (HE) control condition, all of which were delivered via five weekly in‐person group sessions. Initial results showed immediate pre‐post intervention improvements in factors related to psychosocial distress in both the CBT and RT intervention groups compared to those in the HE control group [14]. Women in the intervention groups also reported specific benefits related to stress management resources, with women in the CBT condition reporting more reliable social support networks and women in the RT group reporting increased confidence in relaxation skills immediately post‐intervention [14]. It is yet to be determined whether this brief intervention has efficacy in women with HR + breast cancer on AET.

While promising, these initial findings are limited in duration and scope. Further research is needed to determine whether brief intervention effects can be sustained in the long‐term as patients continue into survivorship, as has been demonstrated following more time‐intensive interventions [13, 15, 16, 17]. Moreover, results focus largely on intervention effects on negative psychosocial sequelae, a primary focus of most intervention studies among women with breast cancer, including those prescribed AET [18, 19]. Less is known about brief psychosocial intervention impacts on positive psychological well‐being (PPWB), including positive affect, benefit finding, positive states of mind, and optimism, among women with breast cancer. This is a notable gap in the literature given that PPWB has been linked to reduced morbidity/mortality [20, 21, 22] and improved medication adherence in other disease groups [23, 24].

The Broaden and Build theory of positive emotions [25] posits that PPWB broadens one's mindset in ways that accumulate and compound cognitive (e.g., enhanced focused attention), psychological (e.g., positive coping), and social (e.g., social integration) resources, which may be used to “buffer” the effects of stress. The Upward Spiral Theory expands upon this idea to describe how positive psychological adaptation may enhance health behaviors in the long‐term: as positive psychological phenomena occur in tandem with health behaviors, the motivation to repeat the behavior grows stronger, and this habit is strengthened by the broadened resources gained from the positive psychological experiences that help overcome perceived barriers [25, 26]. Stress management interventions like CBSM teach key skills to increase stress management resources, such as coping and relaxation, offering vast potential for enhanced PPWB. Women who feel more capable of coping with stressors and engaging in relaxation may overcome perceived barriers to achieving PPWB (e.g., greater positive affect; optimism), which in turn may enhance perceived coping and relaxation. Enhanced coping self‐efficacy may also contribute to positive health behaviors in this population. In an RCT testing a telehealth intervention for symptom management, distress, and adherence to AET [18] coping self‐efficacy “buffered” the effect of distress on poor AET adherence [27].

The present study aimed to investigate the effects of two brief stress management interventions—CBT and RT—versus HE control on (1) PPWB, and (2) coping and relaxation self‐efficacy, among women with HR + disease who were prescribed AET at baseline. We assessed intervention effects across two time frames: (1) from post‐diagnosis (pre‐intervention) to 1‐year post‐intervention, and (2) from 1‐year post‐intervention to 8 years post‐intervention. We chose to collect long‐term follow‐up at 8 years post‐intervention to be consistent with past literature in breast oncology demonstrating lasting effects of a psychosocial intervention of at least 8 years [15, 16].We hypothesized that compared to women in the HE control condition, women in both CBT and RT interventions would report enhanced PPWB, coping self‐efficacy, and relaxation self‐efficacy across the first‐year post‐diagnosis and that effects would be maintained across long‐term survivorship.

2. Methods

2.1. Participants

The parent trial (NCT02103387) included both hormone receptor positive and negative cases and was approved by the University of Miami Institutional Review Board. All women who enrolled in the study completed informed consent procedures. The parent trial recruited women from cancer clinics in South Florida ages 21 years or older with nonmetastatic breast cancer who were 2–10 weeks post‐surgery who had not yet begun adjuvant/neo‐adjuvant chemotherapy or radiation. Exclusion criteria from the parent trial included a prior cancer diagnosis or neoadjuvant treatment, severe psychiatric illness, acute or chronic medical conditions that would interfere with study participations, or lack of fluency in English [14]. Of 739 women screened, 298 did not meet eligibility criteria, and an additional 247 declined participation due to a lack of time, transportation concerns, or lack of interest. A total of 194 women gave consent, with 11 withdrawing prior to randomization. Of the 183 women randomized, 135 (73.4%) were prescribed AET for hormone receptor‐positive (HR+) disease and were included in the current study (Figure 1). Further details of the parent trial have been published elsewhere [14].

FIGURE 1.

CONSORT flow diagram. CBT = cognitive‐behavioral therapy; HE = health education control; RT = relaxation training; T1 = baseline (post‐surgery), T2 = 2‐month post‐baseline; T3 = 6‐month post‐baseline; T4 = 12‐month post‐baseline; T5 = 8‐year post‐baseline.

2.2. Procedures

Women completed psychosocial questionnaires at baseline prior to randomization. Study staff collected medical and demographic data via self‐report and verified these characteristics through medical record review. Women completed psychosocial questionnaires at baseline (T1), and then were randomized and scheduled to receive one of the three five‐session interventions. Following the final session of their respective intervention (approximately 2 months post‐baseline) women completed an additional psychosocial questionnaire (T2). Women completed follow‐up questionnaires at 6‐month post‐baseline (T3), and 12‐month post‐baseline (T4). We conducted a long‐term follow‐up assessment using self‐report measures (median 8‐year; range 7–11‐year post‐baseline; T5) on women from the parent trial who were prescribed AET, which included completion of patient‐reported psychosocial questionnaires. All measures were administered via paper surveys.

2.3. Study Conditions

Women in each study condition met once per week over 5 weeks for 90 min. Sessions were conducted in groups ranging in size from 3‐7 participants and were led by one group facilitator. Facilitators were pre‐doctoral clinical psychology students (n = 6) who each completed protocol training on each intervention arm with a licensed psychologist. Fidelity was monitored by two licensed psychologists who viewed the videotaped sessions for all three study conditions, and drift was minimized by weekly supervision with interventionists to provide feedback on competence and adherence to protocol.

There was no significant difference in session attendance across the three different intervention conditions (F(2, 98) = 1.87, p = 0.25), with high overall attendance (median = 4 sessions completed).

2.3.1. Cognitive Behavioral Therapy (CBT)

The CBT intervention was comprised of cognitive behavioral techniques derived from the 10‐week CBSM intervention [10] that were designed to teach adaptive coping skills with an emphasis on cancer‐specific stressors. Women receiving CBT were taught skills in stress awareness, cognitive restructuring, coping effectiveness, and interpersonal communication. Homework assignments were provided weekly to practice CBT skills relevant to the material introduced each session.

2.3.2. Relaxation Training (RT)

The RT intervention, derived from the 10‐week CBSM intervention [10], taught relaxation techniques through weekly in‐session exercises, including deep diaphragmatic breathing, progressive muscle relaxation, guided imagery, and mindfulness meditation. In addition to in‐session practice and discussion, audio recordings of the exercises were provided for at‐home practice.

2.3.3. Health Education (HE)

The HE condition served as the time‐ and attention‐matched control consisting of educational information related to a breast cancer diagnosis and treatment, including available resources, symptom management, and healthy lifestyle choices.

2.4. Measures

The following psychosocial constructs were measured at five timepoints spanning approximately 8 years: baseline (N = 135), 2 months (n = 101), 6 months (n = 96), 12 months (n = 101), and 8 years (n = 59). Average reliability across all timepoints for each measure is listed below.

2.4.1. Positive Psychological Well‐Being

2.4.1.1. Positive Affect

Positive affect was measured using the Affect Balance Scale [28]. The Affect Balance Scale is a 40‐item scale measuring various aspects of positive and negative affect. The positive affect subscale was calculated by taking the mean of the 20 items addressing positive affect; higher scores indicate more positive affect. Reliability was high in this sample (average Cronbach's alpha > 0.90).

2.4.1.2. Benefit Finding

The Benefit Finding Scale (BFS) was used to assess benefit finding, or an individual's ability to identify positive outcomes resulting from a negative event (i.e., breast cancer diagnosis and treatment) [29]. On the BFS, 17 items assessing the degree to which respondents perceived benefits across various domains (e.g., family, social relations, life priorities, or ability to accept circumstances) with 5‐point Likert scale response options ranging from Not at all (1) to Extremely (5). A total score was calculated for all 17 items; higher total scores indicate a greater degree of benefit finding. Reliability for the BFS total score was high (average Cronbach's alpha > 0.95).

2.4.1.3. Optimism

Generalized optimism was assessed using the Life Orientation Test‐Revised (LOT‐R) [30]. The LOT‐R consists of six coded items (three of which are reverse‐scored) that are summed to calculate an overall optimism score, with higher scores indicating greater levels of optimism. Reliability was adequate (average Cronbach's alpha > 0.80).

2.4.1.4. Positive States of Mind

The Positive States of Mind (PSOM) [31] is a 7‐item scale that measures women's perceived ability to achieve positive experiences that may be perceived as difficult in the context of cancer diagnosis and treatment, including focused attention, productivity, restful repose, sharing, sensuous sexual pleasure, and sensuous nonsexual pleasure. Items are summed to calculate a total score, with higher scores indicating a greater frequency and intensity of positive emotional and cognitive experiences. Reliability was adequate (average Cronbach's alpha > 0.85).

2.4.2. Self‐Efficacy

2.4.2.1. Coping Self‐Efficacy and Relaxation Self‐Efficacy

The Measure of Current Status (MOCS) ‐ Relaxation and Coping subscales [32] were used to measure self‐efficacy specific to skills targeted in the RT and CBT interventions, respectively. Participants were asked to rate their current perceived ability to relax and cope with stressors generally (the MOCS is not specific to coping with cancer‐related stressors). Responses on items within each subscale are averaged to calculate the subscale score, with higher scores indicating a higher degree of self‐efficacy. The internal consistency of the MOCS subscales were adequate (average Cronbach's alpha > 0.80).

2.4.3. Covariates

Covariates for analyses included age at diagnosis, non‐invasive versus invasive disease (stage 0 vs stage I‐III breast cancer), household income, chemotherapy receipt (yes/no), radiation receipt (yes/no), and Hispanic ethnicity (yes/no). We determined covariates based on their relationship with both disease outcomes and behavioral and psychological constructs and those used in prior trials of stress management interventions in breast cancer [14, 33, 34].

2.5. Analytic Plan

We initially screened data for outliers, normality, and homoscedasticity. Participants from the parent trial with HR + disease were included in analyses (N = 135). For all analyses, p < 0.05 was considered an indicator of statistical significance, and p < 0.10 indicated marginal significance.

We used hierarchical linear modeling (HLM) to examine the role of study condition on the trajectories of psychological adaptation over time. We used RStudio to estimate all hierarchical linear models [35]. These models were estimated using restricted maximum likelihood (REML), which allows for the inclusion of participants with partially missing data under the assumption that data are missing at random (MAR). This approach uses all available data points at each time point without listwise deletion, providing unbiased estimates when the MAR assumption holds. HLM differs from traditional longitudinal analyses as it accounts for the non‐independence of the data and does not assume equal number of observations and utilizes all available data, making it an ideal method for long‐term follow‐up analysis with anticipated attrition [34]. A piecewise modeling approach was adopted with a knot at the 12‐month timepoint to model both the trajectory over four timepoints in the first‐year post‐diagnosis (T1‐T4) and the trajectory of long‐term survivorship from 12‐month follow‐up to 8‐year follow‐up (T4‐T5) and to determine the differential impact of study condition on trajectories across different periods along the cancer care continuum. In the case of a significant cross‐level interaction (time*condition) Cohen's f ² effect size was calculated as a measure of practical significance, such that f ² ≥ 0.02 indicated a small effect size, f ² ≥ 0.15 indicated a medium effect size, and f ² ≥ 0.35 indicated a large effect size [36]. Appendix S1 offers detailed information regarding model building for each outcome.

3. Results

3.1. Descriptive Statistics

Women (N = 135) were on average 54.8 years old (SD = 10.19; range 28–80), had invasive disease (88.9%), received radiation (50.4%) and/or chemotherapy (35.6%), and predominately identified as Hispanic (42.2%) or non‐Hispanic White (41.5%) (Table 1).

TABLE 1.

Baseline medical and demographic variables by group condition (N = 135).

Variable	CBT (n = 44)	Relaxation training (n = 49)	Health education (n = 42)	Test statistic	p
Age at diagnosis	54.84 (9.00)	54.08 (12.12)	55.64 (9.00)	F(2,132) = 0.26	0.77
Years education	16.09 (2.71)	14.98 (3.30)	15.46 (3.20)	F(2,128) = 1.47	0.23
Household income (thousands)	99.58 (70.36)	82.85 (62.94)	137.30 (166.96)	F(2,114) = 2.50	0.09 a
Race/ethnicity				χ 2(6) = 7.25	0.30
Non‐hispanic white	21 (48.8%)	16 (34.0%)	19 (45.2%)
Hispanic	16 (37.2%)	25 (53.2%)	16 (38.1%)
Black	3 (7.0%)	2 (4.3%)	6 (14.3%)
Other	3 (7.0%)	4 (8.5%)	1 (2.4%)
Partnered at diagnosis	31 (72.1%)	28 (59.6%)	25 (59.5%)	χ 2(2) = 1.97	0.37
Stage at diagnosis				χ 2(6) = 1.64	0.95
Stage 0	6 (13.6%)	4 (8.2%)	5 (11.9%)
Stage 1	26 (59.1%)	27 (55.1%)	24 (57.1%)
Stage 2	10 (22.7%)	15 (30.6%)	10 (23.8%)
Stage 3	2 (4.5%)	3 (6.1%)	3 (7.1%)
Positive nodes	6 (14.3%)	14 (29.8%)	13 (31.7%)	χ 2(2) = 4.08	0.13
Surgery				χ 2(2) = 0.20	0.91
Lumpectomy	21 (47.7%)	24 (49.0%)	22 (52.4%)
Mastectomy	23 (52.3%)	25 (51.0%)	20 (47.6%)
Hormonal status
ER positive	40 (93.0%)	45 (97.8%)	360 (94.7%)	χ 2(2) = 1.17	0.56
PR positive	34 (82.9%)	39 (84.8%)	32 (88.9%)	χ 2(2) = 0.57	0.75
Days f/surgery to T1	34.05 (21.14)	38.45 (24.75)	37.43 (20.72)	F(2,132) = 0.48	0.62
Received radiation	23 (52.3%)	21 (45.7%)	24 (58.5%)	χ 2(2) = 1.45	0.49
Received chemo	15 (34.1%)	20 (41.7%)	13 (31.7%)	χ 2(2) = 1.07	0.59

Abbreviations: CBT = cognitive behavioral therapy; chemo = chemotherapy; ER = estrogen receptor; PR = progesterone receptor.

^a p < 1.0.

*p < 0.05.

**p < 0.01.

***p < 0.001.

3.2. Intervention Effects on Positive Psychological Well‐Being

3.2.1. Positive Affect

There was a significant main effect of time during the first‐year post‐diagnosis (B (SE) = 0.18 (0.07), p = 0.023), with positive affect increasing. This trajectory did not persist into the long‐term survivorship period indicating changes were maintained (i.e., did not regress) in the long‐term. There were no significant cross‐level interactions of CBT versus HE, RT versus HE, or CBT versus RT on positive affect in the first‐year post‐diagnosis or during long‐term survivorship (Supporting Information S2: Table 1).

3.2.2. Benefit Finding

There was a marginally significant main effect of time during the first‐year post‐diagnosis (B (SE) = 0.32 (0.17), p = 0.054), with benefit finding increasing. This trend did not persist into the long‐term survivorship period. There were no significant cross‐level interactions of CBT versus HE, RT versus HE, or CBT versus RT in the first‐year post‐diagnosis or during long‐term survivorship (Supporting Information S2: Table 2).

3.2.3. Optimism

There was no significant main effect of time in the first‐year post‐diagnosis or during survivorship. There were no significant cross‐level interactions of CBT versus HE, RT versus HE, or CBT versus RT in the first‐year post‐diagnosis or during long‐term survivorship (Supporting Information S2: Table 3).

3.2.4. Positive States of Mind

There was a significant main effect of time in the first‐year post‐diagnosis (B (SE) = 1.50 (0.39), p < 0.001), with PSOM increasing. This trajectory did not continue in the long‐term. In line with hypotheses, there was a significant cross‐level interaction of CBT condition by time during the first‐year post‐diagnosis as compared to the HE condition (B (SE) = 1.38 (0.68), p = 0.044), which was a medium effect size (f ² = 0.15) (Figure 2). Simple slope analyses demonstrated that the effect of time in the first‐year post‐diagnosis on PSOM was greater among women who received CBT (b = 3.36) as compared to those who received HE (b = 1.98). However, this effect was unique to the CBT versus HE contrast: there were no differences between RT and either HE or CBT on the trajectory of PSOM during this period. In addition, there were no significant cross‐level interactions during long‐term survivorship, indicating benefits were maintained (i.e., did not regress) in the long‐term (Supporting Information S2: Table 4).

FIGURE 2.

Condition (CBT vs. RT vs. HE) by time interaction on positive states of mind. CBT = cognitive behavioral therapy; HE = health education control; PSOM = positive states of mind; RT = relaxation training. There was a significant cross‐level interaction of CBT condition by time during the first‐year post‐diagnosis as compared to the HE condition (B (SE) = 1.38 (0.68), p = 0.044). The effect of time in the first‐year post‐diagnosis on PSOM was greater among women who received CBT (b = 3.36) as compared to those who received HE (b = 1.98). There were no differences between CBT versus RT or RT versus HE during this period. There were no significant cross‐level interactions during long‐term survivorship, indicating that intervention‐related effects were maintained (did not regress or grow stronger) over the long‐term.

3.3. Intervention Effects on Coping and Relaxation Self‐Efficacy

3.3.1. Coping Self‐Efficacy

There was a marginally significant main effect of time during the first‐year post‐diagnosis (B (SE) = 0.17 (0.10), p = 0.069), with coping self‐efficacy increasing. This trend did not persist into the long term. There was a significant interaction of the CBT condition with time during the first‐year post‐diagnosis, compared to the RT condition (B (SE) = −0.31 (0.14), p = 0.029), which was a medium effect size (f ² = −0.17). A similar interaction between RT and HE was observed (B (SE) = −0.28 (0.04), p = 0.043), which was a medium effect size (f ² = −0.15) (Figure 3). Simple slope analyses showed that the effect of time in the first‐year post‐diagnosis on coping self‐efficacy was positive for women who received CBT (b = 0.10) and HE (0.17) but negative for women who received RT (b = −0.11). There were no differences between CBT and HE regarding the trajectory of coping self‐efficacy during this period. Additionally, no significant cross‐level interactions occurred during long‐term survivorship, indicating benefits were maintained over the long term (Supporting Information S2: Table 5).

FIGURE 3.

Condition (CBT vs. RT vs. HE) by time interaction on coping self‐efficacy. CBT = cognitive‐behavioral therapy; HE = health education control; MOCS‐Cope = measure of current status‐coping self‐efficacy subscale; RT = relaxation training. There was a significant cross level interaction of RT condition by time during the first‐year post‐diagnosis, both as compared to the CBT condition (B (SE) = −0.31 (0.14), p = 0.029) and the HE condition (B (SE) = −0.28(0.04), p = 0.043). The effect of time in the first‐year post‐diagnosis on coping self‐efficacy was positive among women who received CBT (b = 0.10) and HE (0.17), but negative among women who received RT (b = −0.11). There were no differences between CBT versus HE during this period. There were no significant cross‐level interactions during long‐term survivorship, indicating that intervention‐related effects were maintained (did not regress or grow stronger) over the long‐term.

3.3.2. Relaxation Self‐Efficacy

There was a significant main effect of time during the first‐year post‐diagnosis (B (SE) = 0.45 (0.14), p = 0.002), such that women's perceived ability to relax increased. This trajectory did not continue into the long‐term. There were no significant cross‐level interactions of RT versus HE, CBT versus HE, or CBT versus RT in the first‐year post‐diagnosis or during long‐term survivorship (Supporting Information S2: Table 6).

4. Discussion

Brief post‐surgical CBT was associated with enhanced positive psychological well‐being during the first‐year post‐surgery in women with HR + breast cancer, as demonstrated by enhanced positive states of mind (PSOM) compared to HE. In addition, women assigned to CBT had enhanced coping self‐efficacy as compared to those assigned to RT. By testing the ongoing trajectories over 8 years, we demonstrated that these treatment effects were maintained during long‐term survivorship. However, brief CBT was not associated with all measures of positive psychological well‐being in this sample: there were no intervention‐related improvements in positive affect, optimism, or benefit finding. CBT also, as expected, was not associated with relaxation self‐efficacy. However, across all three conditions there was a significant main effect of time suggesting improved relaxation self‐efficacy and positive affect during the first‐year post‐diagnosis.

In this secondary analysis, we found an association between the receipt of brief CBT and enhanced PSOM among women prescribed AET, which persisted into long‐term survivorship. While we were unable to explicitly test this hypothesis, CBT may enhance PSOM via improved cognitive flexibility. For example, it is plausible that women may learn to reframe unhelpful thought patterns (e.g., reframing a thought such as “I cannot ever focus because of my breast cancer” to “I may have cognitive side‐effects, but there are steps I can take to lessen the severity”). This cognitive flexibility may bolster women's resilience in the face of stressors that arise during the early stages of survivorship and equip them to overcome stressors and achieve positive experiences. Indeed, prior research has demonstrated that greater PSOM may “buffer” the effects of stress on depression [37] and may be related to higher medical compliance in women with breast cancer [38]. Further research should test cognitive flexibility as a mediator of the effects of CBT on PSOM. It is also important to note that the PSOM assesses both sexual and non‐sexual pleasure. Given the common sexual side effects of AET [39], this may represent a particularly important target of treatment to enhance well‐being and adherence in this population.

In contrast to our hypotheses, women receiving RT did not report longitudinal improvements in PPWB or self‐efficacy as compared to the CBT or HE conditions. This was particularly unexpected as this effect was found in the short‐term immediately post‐intervention [14]. It is possible that a more intensive relaxation intervention (e.g., booster sessions, provision of a mobile app to enhance relaxation practice) may be important to sustain gains. Although there was no difference by intervention, it is worth noting that there was a significant increase in both relaxation self‐efficacy and positive affect across all three conditions in the first‐year post‐diagnosis. These main effects of time may be related to a “recovery” following the baseline (post‐surgery) period in which positive moods and relaxation may be more difficult to achieve. Further research is needed to clarify whether this trajectory of improvement may naturally occur following diagnosis and surgery or whether receipt of all three interventions bolstered recovery in relaxation self‐efficacy and positive affect.

It is important to acknowledge the apparent benefits associated with the active HE control condition: women who received HE reported enhanced coping self‐efficacy over the first‐year post‐diagnosis as compared to women receiving RT, and these results were maintained during the long‐term follow‐up period. Although not provided with any CBT or RT intervention material, women receiving HE participated in a supportive group environment and received material on healthy living, potential autonomy‐supportive experiences that contribute to psychological well‐being according Self‐Determination Theory [40, 41]. Specifically, women may have experienced a greater sense of control and ownership of their health management, particularly related to managing AET, which in combination with peer support may have contributed to sustained improvements in coping self‐efficacy. Prior research supports the notion that health education may impact well‐being in breast cancer. A meta‐analysis including 27 trials demonstrated that health education reduces anxiety and enhances quality‐of‐life; however, health education alone does not impact health behaviors [42]. Another trial of CBT for patients with incurable cancer utilized a similar time‐ and attention‐matched health education control and similarly found improvements in psychosocial functioning across both intervention and control conditions with no significant difference between conditions [43]. Thus, there may be some effect of a health education intervention on psychological adaptation for patients undergoing cancer treatment.

Prior work among this cohort of women demonstrated that receipt of RT was associated with enhanced self‐reported AET adherence [33]. Given the null results of RT on our measures of PPWB and self‐efficacy, we were unable to elucidate the mechanisms by which RT may impact adherence. It is possible that unmeasured factors in the current study contributed to this relationship. For instance, the mindfulness module may have enhanced acceptance of the present moment and of internal experiences, thereby improving women's ability to cope with somatic side effects and engagement in meaningful activities to support AET adherence. Supporting this theory, prior work found that RT was associated with decreased illness‐related social disruption over the first‐year post‐surgery [44]. Given that both low social engagement [45] and greater side‐effect burden [46] are associated with worse AET adherence, these factors represent additional mechanisms that may drive previously found adherence effects.

Contrary to hypotheses, brief CBT and RT interventions were not associated with changes in benefit finding or optimism. As this was a post‐hoc analysis, intervention materials did not specifically target these constructs. In contrast, positive psychological interventions (PPI) directly target these constructs and involve topics such as life review and gratitude journaling, which may enhance benefit finding [47]. Optimism, while significantly related to both health outcomes and health behaviors [22, 48], may be a more difficult intervention target given its trait‐like nature; however, recent PPI work within oncology has shown promising effects on optimism [49]. Results suggest the potential importance of incorporating positive psychological activities to directly address and enhance PPWB in this population.

Among covariates, interesting effects arose with regard to ethnicity and chemotherapy receipt. Specifically, Hispanic women reported significantly greater benefit finding than non‐Hispanic women. This is in line with prior research suggesting that Hispanic women may be more likely to engage in coping that involves benefit finding than non‐Hispanic women with breast cancer [50]. It may be particularly important to recognize and encourage this adaptive coping strategy among Hispanic women with breast cancer. In addition, the receipt of chemotherapy was associated with lower relaxation self‐efficacy. This is consistent with longitudinal data suggesting that patients experience stable to decreasing levels of self‐efficacy and emotional well‐being over the course of chemotherapy [51], suggesting that the difficult treatment and associated side effects may erode confidence in utilizing relaxation skills. Results suggest that patients receiving both AET and chemotherapy may represent an important target population for future studies.

4.1. Limitations

The current study is not without limitations. First, the current sample is comprised of women from a high socioeconomic bracket, likely due to recruitment from private practice oncology clinics in South Florida. Thus, results may not generalize to populations of women with fewer socioeconomic resources. In addition, there is significant missing data at long‐term follow‐up, such that only 59 of 135 women completed the final assessment. Although retention rates were similar to those observed in previous long‐term follow‐up studies [16] and were not unexpected due to mortality, morbidity, and loss to follow‐up, attrition limited our ability to detect 8‐year effects and may have biased our findings that gains during the primary treatment period were maintained over the long‐term. Finally, it is important to highlight that this was a secondary, post‐hoc analysis of a prior trial using a convenience sample to generate hypotheses for further testing. The post‐hoc nature of this project precluded investigation into other important constructs related to PPWB (e.g., gratitude, life satisfaction) in this population. While results suggest brief intervention may be associated with some long‐term positive psychological effects, future fully powered studies should investigate the role of brief interventions designed to directly modulate positive psychological well‐being and self‐efficacy among a more diverse sample of women prescribed AET.

4.2. Clinical Implications

Women prescribed AET for HR + breast cancer experience a myriad of psychosocial concerns, including elevated levels of physical and psychological side effects and difficulty adhering to the medication [5, 6, 7]. Although AET is related to a reduction in recurrence risk by up to 50% [4], nearly half of women do not complete the recommended course of AET [8]. Positive psychological well‐being and coping and relaxation self‐efficacy represent modifiable constructs that may enhance both overall well‐being and improve medication adherence among this at‐risk population. Future a priori research is warranted to better understand whether a brief intervention targeting these constructs may enhance well‐being and AET adherence.

5. Conclusions

Brief CBT delivered in the post‐surgical period may improve long‐term aspects of positive psychological well‐being (positive states of mind) and coping self‐efficacy among women with HR + breast cancer prescribed AET. However, brief CBT and RT interventions did not impact positive affect, optimism, or benefit finding, PPWB constructs commonly associated with improved health outcomes and health behaviors. Future work may consider incorporating CBT skills along with evidence‐based motivational interviewing and positive psychological skills [23, 47] to enhance well‐being, health behaviors, and health outcomes in this population.

Author Contributions

Molly Ream, Michael Antoni, and Chloe Taub contributed to the study conception and design. Material preparation, data collection and analysis were performed by Molly Ream, Emily Walsh, Paula Popok, Rachel Plotke, Jamie Jacobs, and Lisa Gudenkauf. The first draft of the manuscript was written by Molly Ream and Chloe Taub. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Conflicts of Interest

Michael H. Antoni is the inventor of CBSM (UMIP‐483) and receives royalties for published CBSM treatment manuals. None of the other authors have conflicts of interest to report.

Supporting information

Supporting Information S1

Supporting Information S2

Ream, Molly , Taub Chloe J., Amonoo Hermioni L., et al. 2025. “Brief Post‐Surgical Stress Management Intervention Effects on Positive Psychological Well‐Being and Self‐Efficacy in Women Being Treated With Adjuvant Endocrine Therapy for Hormone‐Receptor Positive Breast Cancer.” Psycho‐Oncology: e70267. 10.1002/pon.70267.