Cognitive-Behavioral Therapy Reduces Endocrine Treatment Side Effects in Breast Cancer Patients

Lidia Schapira, MD


April 10, 2019

Efficacy of Internet-Based Cognitive Behavioral Therapy for Treatment-Induced Menopausal Symptoms in Breast Cancer Survivors: Results of a Randomized Controlled Trial

Atema V, van Leeuwen M, Kieffer JM, et al
J Clin Oncol. 2019;37:809-822

Study Summary

Adjuvant endocrine therapy for breast cancer, through treatment-induced profound estrogen deprivation, leads to hot flashes (HF) and night sweats (NS). These symptoms affect women's daily functioning and health-related quality of life and, if severe, may lead to early discontinuation of endocrine therapy.

Prior studies have demonstrated that cognitive-behavioral therapy (CBT) interventions decrease the impact of these symptoms among breast cancer survivors.

Internet-based CBT (iCBT) presents a more accessible and flexible alternative to face-to-face sessions. The investigators hypothesized that it could lead to higher participation rates and better compliance.

In this study, 254 breast cancer survivors in academic and community settings in the Netherlands were enrolled and randomly assigned to a therapist-guided or a self-managed iCBT group or to a waiting list control group. Patients were < 50 years at diagnosis and had undergone chemotherapy and/or oophorectomy and/or endocrine therapy, and had self-reported problematic HF/NS. The 6-week iCBT program included psychoeducation, behavior monitoring, and cognitive restructuring. Questionnaires were administered at baseline and at 10 weeks and 24 weeks post-randomization.

Compared with the control group, the guided and self-managed iCBT groups reported a statistically significant decrease in the perceived impact of HF/NS, as well as improved sleep quality. The guided group also reported significant improvement in overall levels of menopausal symptoms and NS frequency. At 24 weeks the effects remained significant.

The investigators concluded that iCBT, with or without therapist support, has clinically significant, salutary effects on the perceived impact and frequency of HF/NS, overall levels of menopausal symptoms, and sleep quality.


For the growing number of young breast cancer survivors, dealing with menopausal symptoms is challenging. Symptoms range from mild to severe and not only encompass physical domains but also affect relationships, intimacy, productivity, and social function. We also need to bear in mind that when women opt to discontinue adjuvant endocrine therapy, they increase the risk for cancer recurrence.

Through cognitive reframing and restructuring, CBT has been shown to help individuals to better tolerate unpleasant symptoms by boosting coping mechanisms.

Although this trial focused on HF/NS, other topics were addressed in this program, including stress management and sleep problems. It included six modules that provided information through video clips and written texts, with an average time spent per week of 1 hour, plus an additional 30 minutes to carry out relaxation exercises and homework. Participants randomly assigned to the guided group also received a phone call from a therapist and personalized written feedback. It is worth highlighting that CBT is not intended to reduce the intensity or frequency of symptoms directly, but to modulate the way these are experienced and reported.

This study makes a significant contribution to our understanding of the role of self-efficacy interventions to mitigate distress caused by physical symptoms related to cancer treatments. iCBT, with or without therapist support, has a positive effect on the perceived impact of HF/NS, overall levels of menopausal symptoms, sleep quality, and frequency of HF/NS. A Web-based program has the advantage of making it more accessible, thus contributing to improved quality of life.


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