Efficacy of acceptance and commitment therapy on psychological rehabilitation in cancer patients treated with proton and heavy ion therapy:a non-randomized controlled trial

Efficacy of acceptance and commitment therapy on psychological rehabilitation in cancer patients treated with proton and heavy ion therapy:a non-randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of acceptance and commitment therapy on psychological rehabilitation in cancer patients treated with proton and heavy ion therapy:a non-randomized controlled trial Fei Qin, Yu Zhu, Shuman Wang, Lijuan Zhang, 子迎 王, Hongwei Wan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4161013/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 8 You are reading this latest preprint version Abstract Objective To develop an appropriate intervention utilizing acceptance and commitment therapy (ACT) tailored specifically for cancer patients undergoing radiotherapy, and to investigate its impact on hope, psychological resilience, psychological flexibility, and psychological distress among cancer patients receiving proton and heavy ion therapy. Methods 80 participants were allocated into either an intervention group (n=40) or a control group (n=40) based on their admission time. Both the control and intervention groups underwent a 3-week health education program, with the intervention group additionally participating in a 3-week, 6-session acceptance and commitment therapy (ACT) group psychological intervention. Discrepancies in hope levels, psychological resilience, psychological flexibility, and psychological distress between the two groups were assessed at baseline, post-intervention, and at a 3-month follow-up using linear mixed-effects analysis (LMM). Results LMM analyses revealed that at the end of the intervention, scores for Hope and Psychological Resilience were higher in the intervention group compared to the control group (P=0.025, P=0.003 respectively), while scores for Psychological Flexibility were lower in the control group (P=0.001). Furthermore, at the 3-month follow-up, HHI scores remained higher in the intervention group compared to the control group (P=0.025), while scores for Psychological Flexibility and Psychological Distress were lower in the intervention group (P=0.001, P=0.001 respectively). These differences persisted even after adjusting for baseline values. Conclusion A psychological intervention program based on the ACT model of treatment helps to promote psychological recovery in cancer patients with radiotherapy. Evidence is provided for the effectiveness of positive clinical psychological interventions. Trial registration: ChiCTR2300068349 Acceptance and commitment therapy Hope Psychological resilience Psychological flexibility Psychological distress Figures Figure 1 Figure 2 Introduction Cancer has emerged as a significant global health challenge. According to the International Agency for Research on Cancer (IARC), approximately 19.3 million new cases of cancer were diagnosed globally in 2020, resulting in nearly 10 million cancer-related deaths[ 1 ]. About 50% of cancer patients need to receive radiotherapy as a primary or adjuvant therapy [ 2 ]. Particle therapy is the most advanced radiotherapy technology, which uses proton or heavy ion rays to achieve the maximum dose release in the tumor target area and reducing the damage to the surrounding normal tissues[ 2 , 3 ]. However, cancer patients treated with particle therapy still face the problems of high treatment cost, uncertainty of treatment effect, adverse reaction, high recurrence rate, and difficulty of treatment after recurrence in the process of particle therapy [ 4 , 5 ]. There are many psychological disturbances in them, such as despair, pain, fear, anxiety, and a series of negative emotions[ 6 – 8 ]. The negative psychological state of cancer patients not only increases the physical burden of patients and reduces their treatment compliance, but also leads to lower quality of life, even affects their prognosis, and increases the rate of suicide [ 9 – 11 ]. Cancer patients with particle therapy have a higher demand for psychological rehabilitation. Psychological Rehabilitation is defined as the process of finding and maintaining hope, re-establishing a positive identity, building a meaningful life, and assuming responsibility and control [ 12 ]. Psychological rehabilitation can help cancer patients better cope with the disease, treatment and life events. Hope is the key to psychological recovery, and can enhance an individual feels in control of his or her life, sees others find a way forward, and "hope" plays an important role in sustaining the individual's activities and supporting the individual's aspirations for a live life[ 13 ]. Research has shown that the level of hope among Chinese cancer patients still needs to be improved [ 14 – 16 ]. Symptoms of psychological distress are present throughout the treatment of tumor patients and are a continuous process of change[ 17 ]. The reduction of psychological distress in cancer patients is an important element in promoting psychological rehabilitation. Meanwhile, psychological resilience is an important psychological quality in the positive psychological rehabilitation of tumor patients, which refers to a personality trait that allows individuals to adapt well to adversity and even achieve self-growth [ 18 ]. Research shows only about 10% of cancer patients can be able to fully recover from a cancer event[ 19 ]. Therefore, there is a need for psychological interventions aimed at rehabilitation to improve the quality of life for cancer patients. The current psychological intervention methods for the psychological rehabilitation of cancer patients are mainly Cognitive Behavioral Therapy (CBT)[ 20 ]. Its aim is to eliminate the patient's negative emotions and behaviors[ 21 ]. However, it focuses on ameliorating negative emotions, which may reinforce the patient's negative cognitive biases[ 22 ]. Acceptance and Commitment Therapy (ACT) is a third-generation behavioral therapy, which was founded by Dr. Steven C. Hayes, a professor of psychology in the United States[ 23 ]. It emphasizes that the root cause of an individual's psychological distress is language and that its goal is to increase psychological flexibility[ 24 ], which is the ability to recognize and accept unwanted emotions and feelings while continuing to live by deeply rooted personal values[ 25 ]. The therapeutic model of ACT involves 6 core techniques: acceptance, cognitive defusion, being present, self as context, value clarification, and committed action[ 23 ]. The six core skills in ACT are stimulated through psychoeducation, positive thinking exercises, metaphor, and experiential exercises. This coincides with the two directions (reducing psychological problems and stimulating latent strengths) that psychosocial rehabilitation is meant to focus on and address. ACT has now demonstrated effectiveness for cancer patients in negative emotions such as fear of cancer recurrence[ 26 ], anxiety and depression[ 27 , 28 ].And most of the studies applied to breast cancer patients[ 29 , 30 ].Participants with different cancer stages or treatments may experience different psychological stresses and needs.Therefore, this study aims to form an ACT group psychological intervention program suitable for radiotherapy patients based on the ACT treatment model and to verify its effects on the hope, resilience, psychological flexibility, and psychological distress of oncology patients with radiotherapy, to ultimately improve their quality of life. Research hypotheses We hypothesized that acceptance and commitment therapy would increase cancer patients' hope, resilience, flexibility, and decrease psychological distress. Methods Study Design and Ethical Considerations This was a a non-randomized controlled trial study. Participants were recruited by convenience sampling. This study was approved by the Institutional Review Board of Shanghai Proton and Heavy Ion Hospital (2107-50-01) and registered in the Chinese Clinical Trial Registry (ChiCTR2300068349).All participants received verbal and written information about the purpose possible benefits and risks of participating in this study. The pre-intervention implementer should explain to patients that they can withdraw at any time throughout the intervention, thus ensuring their autonomy. In case of non-participation, patients are informed that it will not affect future treatment and care. Participants and settings Cancer patients admitted to the oncology department of Shanghai Proton Heavy Ion Hospital affiliated with Fudan University in Shanghai from October 2022 to March 2023 were selected based on the inclusion criteria. Patients admitted from October to December 2022 were assigned to the control group, while patients from January 2023 to March 2023 were allocated to the intervention group. Inclusion criteria:(1) Aged 18 years and older, diagnosed with malignant tumors confirmed by pathological diagnosis;(2) Patients who were informed of the diagnosis and are currently receiving anticancer treatment.(3) Kasper score (KPS) > 90; (4) able to understand Mandarin and express themselves clearly in Mandarin; (5) Voluntarily participate in this study and sign an informed consent form. Exclusion criteria:(1) Patients in the acute stage of the disease, or patients with combined severe liver and kidney function, cardiopulmonary function impairment; (2) Those with severe mental disorders or severe cognitive deficits; (3) Patients who resort to other drugs or psychotherapy during the intervention period. Removal criteria: (1) Patients whose condition changed significantly during the intervention; (2) Patients who were absent from the intervention more than 2 times; (3)Unable to cooperate in completing 3 surveys during the study period. Sample size The sample size was estimated by considering hope as a primary outcome indicator based on the relevant literature[ 31 ]. Using G*Power 3.1 software. We set an alpha error of 0.05, a beta error of 0.80, and effect size = 0.71. Calculations required a sample, and the calculation yielded n1 = n2 = 33, a total of 66 samples. Taking into account the 20% dropout rate, the final sample size included in this study was at least 80 cases, 40 cases in the intervention group, and 40 cases in the control group. Inventions Intervention group Our intervention program was under the guidance of the ACT treatment model, and drawing upon the literature analysis of seminal works such as "Acceptance and Commitment Therapy: The Process and Practice of Mindful Change" and "ACT Made Simple," a preliminary draft of an ACT intervention program for psychological rehabilitation in cancer patients undergoing particle therapy has been crafted, tailored to the unique characteristics of this patient cohort. Ten experts in the fields of oncology, medical psychology, and clinical nursing were invited to attend the on-the-spot meeting. They discussed the form and content. According to the experts' opinions, the research team revised and improved the intervention program and formed the final draft of the intervention. The content of the intervention program was divided into six themes: 1) Understanding each other and acceptance; 2) Cognitive dissociation; 3) Focus on the present moment; 4) Clarification of values and commitment to action; and 5) Feedback and summarization. The details of the intervention program of this study are shown in Table 1 . The intervention program lasted for 3 weeks, with face-to-face group intervention during hospitalization. ACT courses were held 2 times a week, 60–90 minutes each time. A total of 8–10 patients attended it per time.And 3 researchers participated in the intervention course of this study, including the intervention organizer, meditation instructor, and psychological counselor. The intervention organizer was the researcher herself, who was responsible for organizing the arrangement, leading, and regulating the progress of the course in this intervention course. The meditation instructor was responsible for the meditation part of the course and the voice recording in the homework. The psychological counselor was in charge of the course and solved the difficult problems encountered in the intervention. The homework was pushed by WeChat voice at the end of each course, and the nurse in charge of the ward gave feedback. Control group The control group was given routine health education for a period of 3 weeks. The main contents were as follows: 1)Tumor-related knowledge education: explaining the influencing factors of the disease, clinical manifestations, and therapeutic measures; 2) Education about particle therapy: the principle and process of particle therapy, precautions, and adverse reactions during treatment; 3) Exercise guidance: gave suggestions for exercises according to the patient's condition; 4) Psychological care: provided emotional guidance at the right time to alleviate the patient's psychological pain. After the 3-month follow-up data collection, the researcher sent the patients ACT manuals and recorded voice messages via WeChat to the control group, and provided online guidance sessions. Table 1 Acceptance Commitment Therapy Psychological Rehabilitation Intervention Program Time thematic Objectives Content Classroom Format 1st 1. Getting to know each other 2. Acceptance 1. Building relationships gain trust 2. Introduction to ACT 3. Application of acceptance techniques 1. "Snowballing" activity: all the people form a circle, the researcher designates one person as the starting point and direction, introduces his/her information, and the team members introduce their names, illness experiences, and psychological experiences in turn. 2. Introduction to ACT: Explain the mechanisms and influencing factors of negative emotions, the purpose of this activity and ACT-related introduction, the time, frequency, and duration of this activity, as well as the rules and principles of confidentiality to be followed in group counseling. 3. Positive thinking breathing: guide patients to learn the relaxation method of "positive thinking breathing", encourage patients to insist on practicing it, and at the same time improve the respiratory function of patients undergoing particle therapy, which is conducive to improving the cooperation with the treatment. 4. T-puzzle: Identify the most troublesome piece that leads to the uncontrollable nature of negative emotions and learning acceptance. 5. "Push away the paper" game: Through exercises, patients are made aware of the need not to focus excessively on negative emotions, to see the illness and negative emotions as part of the body, not to deliberately suppress thoughts and feelings, and to accept changes in the body and thinking. 6. Homework: positive breathing, complete at least 3 times. exchanges (2 min. per person, 15 min.) PPT and video presentation (15min) Meditation (5min) Game (20min) Game and communication (35min) WeChat voice 2nd cognitive dissonance Distance yourself from negative emotions 1. Review the last course. 2. "Milk Milk": elicits patient-to-patient statements about what worries them most about the diagnosis of the disease. The dissociation of "milk", i.e., thoughts are just thoughts, is accomplished through a 1-minute exercise of reading "Milk Milk". 3. Noticing and naming: each person says a current thought or emotion, e.g., fear of relapse, fear, etc. for the exercise. 4. Leaves Floating in the Stream: guiding members to understand that emotions and behaviors can be separated, and equipping them with the practice of "experiential acceptance". 5. Homework: Experience falling leaves floating with the stream, completed at least 3 times. Communication (10min) Game practice (20min) Game practice and communication (300min) Meditation and communication (30min) WeChat voice 3rd Focus on the present Self-awareness in the face of negative emotions and associated thoughts 1. Review the last lesson via the Passengers on the Bus video. 2. Raisin Exercise: focusing on the present moment, being aware of the self, and not being influenced by negative emotions. 3. Observe your hands: put attention on your hands as in whether you are willing to commit to what you are doing when emotions like fear, pain, etc. occur as if you had just observed your hands. 4. Homework: raisin exercises, completed at least 3 times. Communication (20min) Meditation and Communication (30min) Game and communication (40min) WeChat voice 4th view oneself as a model Experience your surroundings. 1. Review the last course. 2. Clip from "The First Half of My Life": an understanding of conceptualizing the self, leading to a view of the self as a view. 3. The Chessboard Parable segment: allows patients to objectively experience changes in body sensations, roles, emotions, and behaviors, and to recall past experiences of overcoming difficulties. (20min) 4. Crossing Exercise: Learn to treat the self as a background, treat negative emotions as thought events active in the background, and view them objectively without judgment, thus achieving a complete separation of self from thought. 5. Homework: traversal exercises, completed at least 3 times Communication (10min) Video and communication (20min) Video and communication (30min) Meditation and Communication (30min) WeChat voice 5th Value clarification and Commitment to action Clarify values and set goals 1. Review the last course. 2. Value Compass: By rating the 10 major aspects of life value, the visual sense of pictures is used to find out the most important aspects of each person's heart that he/she wants to change the most. 3. ACT Matrix Chart Sensory Experience: Finding the Reasons for Obstruction and Moving Toward Values. (30min) 4. Homework: Making a plan: Invite patients, family members, and healthcare workers to set short- and medium-term action goals together and work together to develop an action plan, so that members can arrange their action plans for three months after discharge according to their values, and share their plans. Communication (10min) Game (40min) Game (40min) Practice 6th Feedback and Summary Sharing and Encouragement 1. Share their respective plans and how they deal with their fear of cancer recurrence 2. Summarize and share the harvest: review the whole process of the activity through PPT. 3. "Make a statement": notes with words of blessing for each other, thinking about the future. 4. CHORUS: The song "Friends," farewell. 5. Participant evaluation and feedback: patients are encouraged to present deficiencies, comments, and suggestions throughout the ACT intervention. (10min) Communication (30min) PPT (30min) Games (10min) Songs (5min) Communication (15min) Data collection Outcome assessments were conducted by another researcher who was unaware of the subgroups and was trained to conduct face-to-face data collection at baseline (T0) and the end of the intervention (T1). Data about 3 months after the intervention (T3) were collected using an online questionnaire. The patient sociodemographic and medical data form was collected simultaneously at the baseline line. During the data collection, data collector2 used a unified instruction to answer any doubts and questions in the process of filling out the questionnaire. When collecting the data face to face, the data collectors checked whether there were any mistakes and omissions, and then corrected them in time to make up for the filling. The data were collected through online questionnaires 3 months after the intervention (T3), and if the patients didn't fill out the questionnaires in time, the collectors contacted them by phone to ensure that the questionnaire data were complete as much as possible. Observation indicators Demographic questionnaire of the participants A study self-developed general demographic data questionnaire for the study population was used, which included general data information such as gender, age, annual income, religion, cancer type, tumor stage, and Complication, etc. Primary outcome The level of hope was assessed by the Herth Hope Index (HHI), which was developed by Herth in 1992 based on the hope model of scholars Dufault and Martocchio in the Herth Hope Scale[ 32 ]. It contains 12 entries with 3 dimensions( positive attitude towards present and future, taking positive action, maintaining close relationships with others). The range of total scores is 12–48, 12–23 is low level, 24–35 is medium level, and 36–48 is high level. The value of Cronbach’s ɑ for this scale was 0.92[ 33 ]. Secondary outcome Psychological resilience, was measured by the Connor-Davidson resilience scale (CD-RISC)[ 34 ].It contains 25 items and total scores range from 0 to 100. The higher scores indicate greater psychological resilience. Its Cronbach's ɑ in cancer patients was 0.89–9.93[ 35 ]. Psychological flexibility was measured by the Acceptance and Action Questionnaire Second Edition (AAQ-II). The total scores range from 7 to 49. Higher scores indicate lower psychological flexibility[ 36 ]. It has been widely used to measure psychological flexibility in oncology patients. The Chinese version of the scale has a Cronbach's ɑ of 0.857 in cancer patients[ 37 ]. We used the distress thermometer (DT) with a scale of 0 (no distress) to 10 (extreme distress). It is a clinical screening tool evaluate psychological distress among patients[ 38 ]. At a cut-off value of 4, the sensitivity and specificity were 0.80 and 0.70[ 39 ]. Satisfaction and feedback forms Patients who completed the intervention course were asked to rate their satisfaction with the intervention on a 5-point Likert scale (1 = very satisfied, 5 = very dissatisfied). Finally, two questions were used to gather participant feedback on the ACT: "What do you think needs to be improved about the content of the program?" and "Would you recommend this counseling therapy to other patients or friends?" Statistical analysis The data obtained from the research were analyzed using the IBM SPSS Statistics version 25.0. Baseline data will be analyzed descriptively using percentages (dichotomous variables) and means and standard deviations (continuous variables). To compare socio-demographic variables and primary and secondary outcome measures between the two groups, chi-square tests will be used to compare categorical variables. Independent t-tests will be used to compare continuous normally distributed variables and the Mann-Whitney-U test will be used to compare non-normally distributed variables. Measures of outcome indicators at three-time points (baseline, immediate post-intervention, and 3 months post-intervention) were conducted using linear mixed-effects models to compare differences between the two groups in levels of hope, psychological resilience, psychological flexibility, and psychological distress during the follow-up period from baseline to 3 months. Intervention and time were fixed effect variables, and study subjects were random effect variables. At the same time, Adjusting the baseline to compare the changes between the outcomes. Per-protocol (PP) analysis was used in this study. All statistical tests were 2-sided, with a level of significance set at 0.05. Results Recruitment and characteristics of participants A total of 102 participants were recruited in this study. 10 participants did not meet the criteria for the nativity, 10 participants were not interested, and 2 participants were unable to attend due to the time of treatment. A total of 80 participants were included in the study. 3 participants in the intervention group dropped out for the reason that 2 people dropped out after participating in 2 activities due to personal reasons, and 1 person was absent from the two activities due to the reason of treatment. In the control group, 3 people dropped out of the program because they lost contact with each other during the follow-up period. Finally, 37 participants in the intervention group and 37 in the control group participated in the whole study. The flow chart of recruitment and specific reasons for participants ' drop-out is shown in Fig. 1 . Finally, 19 patients with lung cancer, 36 patients with head and neck tumors, 13 patients with breast cancer, and 6 patients with prostate cancer were included in this study. The age of the study subjects in the intervention group ranged from 29 to 71 years old, with an average age of (48.19 sh 1.83) years, and the age of the patients in the control group ranged from 26 to 72 years old, with an average age of (51.35 ± 1.87) years. There was no statistically significant difference in terms of general demographic data and related outcome variables between the two groups of patients before intervention (P > 0.05). A comparison of demographic data and clinical characteristics of the patients between the two groups is shown in Table 2 . Table 2 Baseline demographic and clinical characteristics of the patients(n = 74) Variables Control group (n = 37) ‾x± s/n(%) Intervention group (n = 37) ‾x± s/n(%) t/χ 2 P value Age Years 51.35 ± 1.87 48.19 ± 1.83 1.207 0.231 Gender Male Female 13 (35.1) 24 (64.9) 15 (40.5) 22 (59.5) 0.23 0.632 Religion No 29 (78.4) 32 (86.5) 4.259 0.325 Yes 8 (21.6) 5 (13.5) Education Below High school High school 1 (2.7) 14 (37.8) 1 (2.7) 12 (32.4) 0.573 0.95 College 17 (45.9) 18 (48.6) Postgraduate and above 5 (13.5) 6 (16.2) Marital status unmarried 4 (10.8) 2 (5.4) 1.594 0.528 married 32 (86.5) 32 (86.5) Divorced /widowed 1 (2.7) 3 (8.1) Children 0 5 (13.5) 7 (18.9) 1.313 0.759 1 17 (45.9) 17 (45.9) 2 12 (32.4) 12 (32.4) 3 or more 3 (8.1) 1 (2.7) Annual income (yuan/year) Working state 300,000 15 (40.5) 11 (29.7) On the job 14 (37.8) 22 (59.5) 3.756 0.332 Unemployed 7 (18.9) 5 (13.5) Retired 13 (35.1) 9 (24.3) Other 3 (8.1) 1 (2.7) Type of cancer Lung cancer 7 (18.9) 12 (32.4) 4.905 0.163 Head and neck cancer 20 (54.1) 16 (43.2) Breast cancer 5 (13.5) 8 (21.6) Prostate cancer 5 (13.5) 1 (2.7) Tumor stage Phase Ⅰ 7 (18.9) 10(27) 5.564 0.139 Phase II 6 (16.2) 10(27) Phase III 21 (56.8) 11 (29.7) Phase IV 3 (8.1) 6 (16.2) Complication No 19 (51.4) 25 (67.6) 2.018 0.155 Yes 18 (48.6) 12 (32.4) HHI score 28.78 ± 3.90 29.59 ± 3.98 -0.885 0.379 CD-RISC score 51.57 ± 7.08 52.22 ± 7.09 -0.394 0.659 AAQ-II score 28.59 ± 5.26 28.05 ± 5.36 0.438 0.663 DT score 3.95 ± 1.39 4.24 ± 1.61 −0.851 0.398 Note: HHI = Herth Hope Index,CD-RISC = Connor-Davidson Resilience Scale, AAQ-II = Acceptance and Action Questionnaire Second Edition, DT = distress thermometer Effectiveness of ACT interventions on primary outcome The comparison of HHI scores between the 2 groups was not statistically different at baseline ( P = 0.379) (Table 2 ). Linear mixed model analysis showed a statistically significant ( P < 0.001) in the time effect of HHI scores, indicating that the level of hope varied over time in the two groups, and a statistically significant difference in the between-group effect ( P = 0.038), which means that there was a statistically significant difference in the intervention group's HHI scores relative to those of the control group; no significant main effect of group×time interaction ( P = 0.066), indicating that there was a statistically significant change in HHI scores between the intervention and control groups at the 3 time points; HHI scores in the intervention group were higher than those in the control group at T1 and T2, and there was a statistically significant difference between scores of the intervention and control groups at T1 (MD: 2.16, 95% CI: 0.28 to 4.05, P = 0.025) and at T2 (MD: 2.19,95%CI: 0.43 to 3.95, P = 0.015). The difference did not change after adjusting for baseline, as shown in Table 3 and Fig. 2 (A). Effectiveness of ACT intervention on second outcome The comparison of CD-RISC, AAQ-II, and DT scores between the 2 groups were not statistically different at baseline ( P >0.05) (Table 2 ). Linear mixed model analysis showed a significant effect of time on CD-RISC, AAQ-II, and DT scores in the 2 groups ( P < 0.001). There was a statistically significant difference in the between-group effect on CD-RISC( P = 0.043) and AAQ-II scores (P = 0.015). Significant effects of group × time on CD-RISC ( P = 0.037), AAQ-II ( P <0.001), and DT ( P = 0.001) scores were also detected, indicating that there was a statistically significant change on Psychological resilience, flexibility and distress between the intervention and control groups at the 3-time points. CD-RISC scores were higher in the intervention group than in the control group at T1 and T2, at T1 (MD: 4.81,95% CI:1.66 to 7.97, P = 0.003), T2 (MD:1.81,95%CI:-0.76 to 4.39, P = 0.165); AAQ-II scores were lower than that of the control group at T1 (MD: -4.35,95%CI: -6.93 to -1.77, P = 0.001), T2 (MD:-4.62),95%CI: -7.24 to -2.01, P = 0.001);DT scores were lower in the intervention group than in the control group at T1 and T2, and at T1 (MD: -0.35, 95% CI: -0.98 to -0.28, P = 0.268), and T2 (MD:-0.89,95% CI:-1.40 to -0.39, P = 0.001). All the difference was unchanged after adjusting for baseline, as shown in Table 3 and Fig. 2 (B..C.D). Table 3 Comparison of intervention and control participants on outcome at different time points Variables Control group (n = 37) mean (SD) Intervention group (n = 37) mean (SD) Unadjusted P Mean difference (95% CI) Adjusted P Mean difference (95% CI) Linear mixed-effects mode Group F ( P ) Time F( P ) Group×Time F( P ) HII 4.451 (0.038) 50.723 (< 0.001) 2.764 (0.066) T1 31.30 (4.00) 33.46 (4.14) 2.16 (0.28 to 4.05) 0.025 2.36 (0.26 to 2.98) 0.020 T2 30.65 (3.57) 32.84 (4.00) 2.19 (0.43 to 3.95) 0.015 2.40 (0.29 to 3.01) 0.018 CD-RISC 4.231 (0.043) 29.001 (< 0.001) 3.386 (0.037) T1 55.16 (7.27) 59.97 (6.34) 4.81 (1.66 to 7.97) 0.003 4.66 (1.87 to 7.45) 0.001 T2 56.16 (6.34) 57.97 (4.65) 1.81 (−0.76 to 4.39 ) 0.165 1.66 (−1.12 to 4.45) 0.240 AAQ-II 6.222 (0.015) 54.771 (< 0.001) 8.603 (< 0.001) T1 25.86 (4.19) 21.51 (6.67) −4.35 (−6.93 to−1.77 ) 0.001 −3.98 (−6.00 to−1.98) < 0.001 T2 25.24 (3.83) 20.62 (6.99) −4.62 (−7.24 to−2.01) 0.001 −4.26 (−6.27 to−2.25) < 0.001 DT 1.49 (0.226) 58.082 (< 0.001) 7.316 (0.001) T1 2.97 (1.32) 2.62 (1.38) −0.35 (−0.98 to−0.28) 0.268 −0.45 (−1.18 to−0.29) 0.232 T2 3.03 (0.99) 2.14 (1.18) −0.89 (−1.40 to−0.39) 0.001 −0.99 (−1.73 to−0.25 ) < 0.01 Note: T1 = post-intervention; T2 = 3 months follow-up. M = mean; SD = standard deviation.; CI = confidence interval; The p values are from an analysis of covariance, comparing the intervention and control arms at T1 and T2. The p values are from an analysis of covariance, comparing the intervention and control arms at T1 and T2; HHI = Herth Hope Index, CD-RISC = Connor-Davidson Resilience Scale, AAQ-II = Acceptance and Action Questionnaire Second Edition, DT = distress thermometer, Unadjusted = unadjusted baseline, Adjusted = LMM analysis using data after adjusting the baseline. Feedback and satisfaction on ACT intervention The study showed that the majority of patients (91.9%) provided a positive evaluation (very satisfied or satisfied) of the Acceptance Commitment Therapy intervention. No patients were dissatisfied with the intervention. The majority of patients (94.6%) reported that no problems bothered them during the interview. In addition, the majority of patients (89.2%) were willing to recommend the Acceptance Commitment Therapy intervention to other patients or friends. Discussion We found that six sessions of the ACT group psychological intervention contributed to the psychological recovery of radiotherapy cancer patients, and these improvements remained stable even at the 3-month post-intervention follow-up assessment. Hope is a positive motivational state that builds upon an interacting sense of success, including goal-oriented motivation and a planned pathway to achieve the goal[ 40 ]. Hope can give radiotherapy cancer patients the courage to overcome difficulties, help them accept the reality of their disease, actively participate in their treatment, and have a positive impact on patients' prognosis, survival, and quality of life[ 15 , 41 ].A recent meta-analysis indicated that ACT increases the level of hope in cancer patients, but the small sample size and heterogeneity of the study did not allow sufficient evidence of a significant effect of ACT on hope[ 42 ].Our study found that ACT significantly improved patients' levels of hope. Hope is a process in which people identify their goals in the first step, develop strategies to achieve those goals in the second step, and create incentives to implement those strategies and maintain them throughout the process[ 43 ].The reason for this may be that, from the perspective of ACT, psychological rigidity is a major cause of distress, and individuals who avoid thoughts or emotions, as well as important or meaningful activities, are thought to experience greater pain and impairment. This can result in a lack of hopeful motivation in the future for patients[ 44 ]. In this study, the six core techniques of ACT (Acceptance, Cognitive Defusion, Present Moment Awareness, Self-as-Context, Values Clarification, and Committed Action) were utilized as a framework to help patients recognize their dilemmas without becoming entangled in them, to alter the individual's relationship with these issues. Finally, the Values Clarification was employed to identify the aspects within each individual's inner being that were most significant and in need of change. Subsequently, the ACT Matrix diagram was utilized to empower patients to identify obstacles hindering progress towards their values. Additionally, emotional and social support was provided through the collaboration of family members and caregivers to assist patients in formulating appropriate action plans. This study affirms that ACT fosters positive thoughts and hope in patients through a systematic process. Psychological flexibility and resilience are two important concepts that play key roles in mental health and coping strategies. Psychological flexibility is a fundamental aspect of achieving mental health[ 45 ]. And it is a core goal of ACT, reflecting individuals' ability to adjust psychologically in dynamic and changing situations, oriented toward their values, and in the process of realizing valued goals[ 46 ]. 59.5% of participants (44/74) in this study reported clinically significant (DT ≥ 4) levels of distress. There was a significant difference in DT scores between the 2 groups at 3-month follow-up. This suggests that ACT has a long-term significant effect on the psychological distress of patients undergoing radiotherapy. The themes of acceptance, cognitive defusion, present moment awareness, and self-as-context in ACT can activate the insular cortex, believed to play a significant role in higher-order cognitive functions and increase awareness of present moment experiences, helping patients truly accept and effectively cope with psychological distress[ 47 ]. Psychological flexibility is negatively correlated with psychological distress[ 48 ], so improve patients' psychological flexibility could reduce the level of psychological distress in cancer patients. The intervention scheme consistently revolves around addressing psychological distress as the primary target. They are encouraged to focus on the present moment, clarify their values, redefine the meaning of life, and cultivate hope for the future. Through committed actions, patients are assisted in setting future goals and integrating their values into concrete activities, thus effectively mitigating the impact of psychological distress. Additionally, coordinated breathing is necessary for cancer patients undergoing particle therapy. Similarly, the practice of "mindful breathing" in ACT helps patients maintain steady breathing, leading to better therapeutic outcomes. Positive thinking also aids patients in avoiding excessive worry about the possibility of recurrence. Group face-to-face discussions encourage sharing of experiences, mutual learning, and support, thus facilitating continuous self-exploration. Each group consists of 6 to 7 patients, fewer than the originally planned 10, indicating that group-based psychological interventions are more cost-effective. The study included subjects with higher levels of education and younger ages, making them more likely to comprehend the intervention goals and expected outcomes, and more capable of actively participating in the treatment process. The present study found that all outcome indicators also improved in the control group, which contrasts with previous results[ 49 , 50 ]. The reason may be that patients' psychological stress was higher before the intervention due to the lack of knowledge related to radiotherapy, side effects during treatment, and uncertainty about the expected treatment outcome[ 51 ]. The patients in the control group of this study experienced the advanced nature of particle therapy and its low side effects during their hospitalization, and their physical and mental health improved, enabling them to face their illnesses and cope with difficult situations more positively. The difference compared with previous studies[ 52 ] is that the intervention leaders in our study are fixed leaders who contacted with the patients from the beginning to the end of the session. Regular group leaders can increase the trust of team members. The team leader should treat every patient with respect, neutrality, and compassion at all times. They should provide patients with information about cancer radiotherapy and stress management, as well as help patients explore ambivalence regarding behavioral changes. Therefore, this study concluded that having a fixed location and consistent staff member can keep team members in a more open state during activities, improve patient satisfaction, and facilitate the psychological recovery of cancer patients. Limitations This is where our study suffers from several limitations. First, the sample size of our study was relatively small, which may limit the generalizability of the findings. In addition, the study population in this study was drawn from the first proton and heavy ion hospital in China, where most of the patients treated were socioeconomically privileged and well-educated, which may limit the generalizability of our findings to a broader population. Future studies with larger and more diverse samples are needed to validate and extend our findings. Conclusions Our findings suggest that a 6-session group psychosocial intervention based on the ACT treatment model helped radiotherapy cancer patients increase their level of hope, psychological flexibility, and psychological resilience, and reduce psychological distress. These improvements remained stable for patients at the 3-month post-intervention follow-up assessment. Thus, it has the potential to benefit psychological rehabilitation in the broader cancer population. Declarations Acknowledgments We thank all patients who participated and the staff of the hospital who contributed to this study. Author contribution All authors contributed to the study conception and design. Fei Qin contributed to the conceptualization, analysis, and draft of the original manuscript; Yu Zhu and Shuman Wang contributed to the design, and material; Ziyin Wang and Lijuan Zhang contributed to the investigation, and validation; Hongwei Wan contributed to the conceptualization, writing review, editing, and project administration. All authors read and approved the final manuscript. Funding Shanghai Pudong New Area Science and Technology Development Fund (PKJ2020-Y57); Health and Family Planning Research Project of Pudong New Area Health Commission (PW2022D-10); Fudan University-Fosun Nursing Research Fund (FNF202104, FNF202302); Shanghai Modern Nursing Vocational Education Group Distinguished Part-time Teacher Program( HLZJTPGR202326) Data availability The data supporting the findings of this study can be provided upon reasonable request. Ethics approval This study was approved by the Institutional Review Board of Shanghai Proton and Heavy Ion Hospital (2107-50-01) and registered in the Chinese Clinical Trial Registry, number ChiCTR2300068349. Consent to participate Informed consent was obtained from all participants included in the study. Consent for publication Patients signed informed consent regarding publishing their data. Conflict of interest The authors declare no competing interests. References Sung H, Ferlay J, Siegel RL et al (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. Ca Cancer J Clin 71(3):209–249. https://doi.org/10.3322/caac.21660 Schaub L, Harrabi SB, Debus J (2020) Particle therapy in the future of precision therapy. 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J Contextual Behav Sci 24:31–37. https://doi.org/10.1016/j.jcbs.2022.03.006 Neubert S, Schlecht S, Meng K et al (2023) Effects of a Video Sequence Based Intervention on Anxiety, Fatigue and Depression in Cancer Patients: Results of a Randomized Controlled Trial. Integr Cancer Ther 22:1563468308. https://doi.org/10.1177/15347354231153172 Ghorbani V, Zanjani Z, Omidi A et al (2021) Efficacy of acceptance and commitment therapy (ACT) on depression, pain acceptance, and psychological flexibility in married women with breast cancer: a pre- and post-test clinical trial. Trends Psychiatry Psychother 43(2):126–133. https://doi.org/10.47626/2237-6089-2020-0022 Sakai M, Kondo M, Sugiura T et al (2022) Acceptance and Commitment Therapy in the Transdiagnostic Treatment of a Breast Cancer Survivor: A Case Study. Jpn Psychol Res n/a(n/a). https://doi.org/10.1111/jpr.12422 Ma Y, Shen XY (2022) The effects of acceptance and commitment therapy on hope levels and psychological resilience in breast cancer chemotherapy patients. Contemporary Nursing (Upper) 29(03):101–105. https://doi.org/10.19791/j.cnki.1006-6411.2022.07.027 Herth K (1992) Abbreviated instrument to measure hope: development and psychometric evaluation. J Adv Nurs 17(10):1251–1259. Wang YH (2010) Feasibility study of the Chinese version of the Herth Hope Scale for cancer patients. Nursing Research 24(1):20–21. https://doi.org/10.3969/j.issn.1009-6493.2010.01.008 Richardson GE (2002) The metatheory of resilience and resiliency. J Clin Psychol 58(3):307–321. Zhang Y, Tang R, Bi L et al (2023) Effects of family-centered positive psychological intervention on psychological health and quality of life in patients with breast cancer and their caregivers. Support Care Cancer 31(10):592. https://doi.org/10.1007/s00520-023-08053-2 Cao J, Ji Y, Zhu ZH (2013) Reliability and validity of the Acceptance and Action Questionnaire (AAQ), second edition, Chinese version, in assessing college students. 27(11):873–877. https://doi.org/10. 3969 /j. issn. 1000–6729. 2013. 11. 014 Hu L, Cao J, Zhu ZH (2015) Analysis of psychological flexibility and anxiety-depressive mood states in cancer patients. Chinese Journal of Behavioural Medicine and Brain Science 24(6):517–520. https://doi.org/10.3760/cma.j.issn.1674-6554.2015.06.010 Riba MB, Donovan KA, Ahmed K et al (2023) NCCN Guidelines® Insights: Distress Management, Version 2.2023. J Natl Compr Canc Netw 21(5):450–457. https://doi.org/10.6004/jnccn.2023.0026 Zhang YN, Zhang HW, Song LL et al (2010) Application of the psychological distress thermometer in screening psychological distress in Chinese cancer patients. Chinese Journal of Mental Health 24(12):897–902. https://doi.org/10.3969/j.issn.1000-6729.2010.12.004 Snyder CR. (2000). The handbook of hope: Theory, measurement, and interventions. In, Elliott TKM (ed), Academic, New York. Corn BW, Feldman DB, Hull JG et al (2022) Dispositional hope as a potential outcome parameter among patients with advanced malignancy: An analysis of the ENABLE database. Cancer 128(2):401–409. https://doi.org/10.1002/cncr.33907 Zhao C, Lai L, Zhang L et al (2021) The effects of acceptance and commitment therapy on the psychological and physical outcomes among cancer patients: A meta-analysis with trial sequential analysis. J Psychosom Res 140:110304. https://doi.org/10.1016/j.jpsychores.2020.110304 Montazer A, Nemati F, Dehghani F et al (2017) Efficacy of acceptance and commitment therapy on breast cancer female patients’hope. Iranian Journal of Cancer Prevention 10(2):e5526. https://doi.org/10.5812/ijcp.5526 Ong CW, Barthel AL, Hofmann SG (2024) The Relationship Between Psychological Inflexibility and Well-Being in Adults: A Meta-Analysis of the Acceptance and Action Questionnaire. Behav Ther 55(1):26–41. https://doi.org/10.1016/j.beth.2023.05.007 Rades D, Al-Salool A, Bohnet S et al (2023) Prevalence of and Risk Factors for Emotional Distress in Patients Undergoing Radiotherapy for Lung Cancer. Anticancer Res 43(5):2111–2118. https://doi.org/10.21873/anticanres.16372 Zhang Y, Wang Shujuan, Zhu Zhuohong (2012) The psychopathological model and treatment mode of acceptance and commitment therapy. The Chinese Journal of Mental Health 26(05):377–381. https://doi.org/10. 3969 /j. issn. 1000–6729. 2012. 05. 013 Lee SW, Kim S, Lee S et al (2023) Neural mechanisms of acceptance-commitment therapy for obsessive-compulsive disorder: a resting-state and task-based fMRI study. Psychol Med:1–11. https://doi.org/10.1017/S0033291723001769 Fawson S, Moon Z, Novogrudsky K et al (2023) Acceptance and commitment therapy processes and their association with distress in cancer: a systematic review and meta-analysis. Health Psychol Rev:1–22. https://doi.org/10.1080/17437199.2023.2261518 Kuon J, Blasi M, Unsöld L et al (2022) Impact of molecular alterations on quality of life and prognostic understanding over time in patients with incurable lung cancer: a multicenter, longitudinal, prospective cohort study. Support Care Cancer 30(4):3131–3140. https://doi.org/10.1007/s00520-021-06736-2 Wang, Lina. (2021). ACT on recurrence fear and cardiac flexibility in lung cancer patients. Jilin University. Fabian A, Rühle A, Domschikowski J et al (2023) Psychosocial distress in cancer patients undergoing radiotherapy: a prospective national cohort of 1042 patients in Germany. 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Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 03 Dec, 2024 Reviews received at journal 03 Dec, 2024 Reviewers agreed at journal 03 Dec, 2024 Reviewers agreed at journal 06 Oct, 2024 Reviewers invited by journal 12 May, 2024 Editor assigned by journal 04 May, 2024 Submission checks completed at journal 26 Mar, 2024 First submitted to journal 25 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage11.png","url":"https://assets-eu.researchsquare.com/files/rs-4161013/v1/28658ff36e7cbfe26fd3afe6.png"},{"id":53757095,"identity":"d5b8cced-bd9b-46f1-b49d-9faec65310fa","added_by":"auto","created_at":"2024-03-29 19:06:23","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":211302,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIndicates the change in HHI, CD-RISC, AAQ-II, and DT between the two groups over\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4161013/v1/c3c8a7ebf29ed37015cd93b1.jpeg"},{"id":73694154,"identity":"9f05a0e3-88d3-4a67-9378-c891d8113398","added_by":"auto","created_at":"2025-01-13 16:11:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1516953,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4161013/v1/acc38d31-d2d6-4647-b9f1-0c1cd1364a5b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of acceptance and commitment therapy on psychological rehabilitation in cancer patients treated with proton and heavy ion therapy:a non-randomized controlled trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCancer has emerged as a significant global health challenge. According to the International Agency for Research on Cancer (IARC), approximately 19.3\u0026nbsp;million new cases of cancer were diagnosed globally in 2020, resulting in nearly 10\u0026nbsp;million cancer-related deaths[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. About 50% of cancer patients need to receive radiotherapy as a primary or adjuvant therapy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Particle therapy is the most advanced radiotherapy technology, which uses proton or heavy ion rays to achieve the maximum dose release in the tumor target area and reducing the damage to the surrounding normal tissues[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, cancer patients treated with particle therapy still face the problems of high treatment cost, uncertainty of treatment effect, adverse reaction, high recurrence rate, and difficulty of treatment after recurrence in the process of particle therapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. There are many psychological disturbances in them, such as despair, pain, fear, anxiety, and a series of negative emotions[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The negative psychological state of cancer patients not only increases the physical burden of patients and reduces their treatment compliance, but also leads to lower quality of life, even affects their prognosis, and increases the rate of suicide [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Cancer patients with particle therapy have a higher demand for psychological rehabilitation.\u003c/p\u003e \u003cp\u003ePsychological Rehabilitation is defined as the process of finding and maintaining hope, re-establishing a positive identity, building a meaningful life, and assuming responsibility and control [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Psychological rehabilitation can help cancer patients better cope with the disease, treatment and life events. Hope is the key to psychological recovery, and can enhance an individual feels in control of his or her life, sees others find a way forward, and \"hope\" plays an important role in sustaining the individual's activities and supporting the individual's aspirations for a live life[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Research has shown that the level of hope among Chinese cancer patients still needs to be improved [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Symptoms of psychological distress are present throughout the treatment of tumor patients and are a continuous process of change[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The reduction of psychological distress in cancer patients is an important element in promoting psychological rehabilitation. Meanwhile, psychological resilience is an important psychological quality in the positive psychological rehabilitation of tumor patients, which refers to a personality trait that allows individuals to adapt well to adversity and even achieve self-growth [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Research shows only about 10% of cancer patients can be able to fully recover from a cancer event[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, there is a need for psychological interventions aimed at rehabilitation to improve the quality of life for cancer patients.\u003c/p\u003e \u003cp\u003eThe current psychological intervention methods for the psychological rehabilitation of cancer patients are mainly Cognitive Behavioral Therapy (CBT)[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Its aim is to eliminate the patient's negative emotions and behaviors[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, it focuses on ameliorating negative emotions, which may reinforce the patient's negative cognitive biases[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Acceptance and Commitment Therapy (ACT) is a third-generation behavioral therapy, which was founded by Dr. Steven C. Hayes, a professor of psychology in the United States[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. It emphasizes that the root cause of an individual's psychological distress is language and that its goal is to increase psychological flexibility[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], which is the ability to recognize and accept unwanted emotions and feelings while continuing to live by deeply rooted personal values[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The therapeutic model of ACT involves 6 core techniques: acceptance, cognitive defusion, being present, self as context, value clarification, and committed action[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The six core skills in ACT are stimulated through psychoeducation, positive thinking exercises, metaphor, and experiential exercises. This coincides with the two directions (reducing psychological problems and stimulating latent strengths) that psychosocial rehabilitation is meant to focus on and address.\u003c/p\u003e \u003cp\u003eACT has now demonstrated effectiveness for cancer patients in negative emotions such as fear of cancer recurrence[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], anxiety and depression[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].And most of the studies applied to breast cancer patients[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].Participants with different cancer stages or treatments may experience different psychological stresses and needs.Therefore, this study aims to form an ACT group psychological intervention program suitable for radiotherapy patients based on the ACT treatment model and to verify its effects on the hope, resilience, psychological flexibility, and psychological distress of oncology patients with radiotherapy, to ultimately improve their quality of life.\u003c/p\u003e\n\u003ch3\u003eResearch hypotheses\u003c/h3\u003e\n\u003cp\u003eWe hypothesized that acceptance and commitment therapy would increase cancer patients' hope, resilience, flexibility, and decrease psychological distress.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Ethical Considerations\u003c/h2\u003e \u003cp\u003eThis was a a non-randomized controlled trial study. Participants were recruited by convenience sampling. This study was approved by the Institutional Review Board of Shanghai Proton and Heavy Ion Hospital (2107-50-01) and registered in the Chinese Clinical Trial Registry (ChiCTR2300068349).All participants received verbal and written information about the purpose possible benefits and risks of participating in this study. The pre-intervention implementer should explain to patients that they can withdraw at any time throughout the intervention, thus ensuring their autonomy. In case of non-participation, patients are informed that it will not affect future treatment and care.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and settings\u003c/h3\u003e\n\u003cp\u003e Cancer patients admitted to the oncology department of Shanghai Proton Heavy Ion Hospital affiliated with Fudan University in Shanghai from October 2022 to March 2023 were selected based on the inclusion criteria. Patients admitted from October to December 2022 were assigned to the control group, while patients from January 2023 to March 2023 were allocated to the intervention group.\u003c/p\u003e \u003cp\u003eInclusion criteria:(1) Aged 18 years and older, diagnosed with malignant tumors confirmed by pathological diagnosis;(2) Patients who were informed of the diagnosis and are currently receiving anticancer treatment.(3) Kasper score (KPS)\u0026thinsp;\u0026gt;\u0026thinsp;90; (4) able to understand Mandarin and express themselves clearly in Mandarin; (5) Voluntarily participate in this study and sign an informed consent form. Exclusion criteria:(1) Patients in the acute stage of the disease, or patients with combined severe liver and kidney function, cardiopulmonary function impairment; (2) Those with severe mental disorders or severe cognitive deficits; (3) Patients who resort to other drugs or psychotherapy during the intervention period. Removal criteria: (1) Patients whose condition changed significantly during the intervention; (2) Patients who were absent from the intervention more than 2 times; (3)Unable to cooperate in completing 3 surveys during the study period.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eThe sample size was estimated by considering hope as a primary outcome indicator based on the relevant literature[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Using G*Power 3.1 software. We set an alpha error of 0.05, a beta error of 0.80, and effect size\u0026thinsp;=\u0026thinsp;0.71. Calculations required a sample, and the calculation yielded n1\u0026thinsp;=\u0026thinsp;n2\u0026thinsp;=\u0026thinsp;33, a total of 66 samples. Taking into account the 20% dropout rate, the final sample size included in this study was at least 80 cases, 40 cases in the intervention group, and 40 cases in the control group.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInventions\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIntervention group\u003c/h2\u003e \u003cp\u003eOur intervention program was under the guidance of the ACT treatment model, and drawing upon the literature analysis of seminal works such as \"Acceptance and Commitment Therapy: The Process and Practice of Mindful Change\" and \"ACT Made Simple,\" a preliminary draft of an ACT intervention program for psychological rehabilitation in cancer patients undergoing particle therapy has been crafted, tailored to the unique characteristics of this patient cohort. Ten experts in the fields of oncology, medical psychology, and clinical nursing were invited to attend the on-the-spot meeting. They discussed the form and content. According to the experts' opinions, the research team revised and improved the intervention program and formed the final draft of the intervention. The content of the intervention program was divided into six themes: 1) Understanding each other and acceptance; 2) Cognitive dissociation; 3) Focus on the present moment; 4) Clarification of values and commitment to action; and 5) Feedback and summarization. The details of the intervention program of this study are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe intervention program lasted for 3 weeks, with face-to-face group intervention during hospitalization. ACT courses were held 2 times a week, 60\u0026ndash;90 minutes each time. A total of 8\u0026ndash;10 patients attended it per time.And 3 researchers participated in the intervention course of this study, including the intervention organizer, meditation instructor, and psychological counselor. The intervention organizer was the researcher herself, who was responsible for organizing the arrangement, leading, and regulating the progress of the course in this intervention course. The meditation instructor was responsible for the meditation part of the course and the voice recording in the homework. The psychological counselor was in charge of the course and solved the difficult problems encountered in the intervention. The homework was pushed by WeChat voice at the end of each course, and the nurse in charge of the ward gave feedback.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eControl group\u003c/h2\u003e \u003cp\u003eThe control group was given routine health education for a period of 3 weeks. The main contents were as follows: 1)Tumor-related knowledge education: explaining the influencing factors of the disease, clinical manifestations, and therapeutic measures; 2) Education about particle therapy: the principle and process of particle therapy, precautions, and adverse reactions during treatment; 3) Exercise guidance: gave suggestions for exercises according to the patient's condition; 4) Psychological care: provided emotional guidance at the right time to alleviate the patient's psychological pain. After the 3-month follow-up data collection, the researcher sent the patients ACT manuals and recorded voice messages via WeChat to the control group, and provided online guidance sessions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAcceptance Commitment Therapy Psychological Rehabilitation Intervention Program\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ethematic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObjectives\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClassroom Format\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Getting to know each other\u003c/p\u003e \u003cp\u003e2. Acceptance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1. Building relationships\u003c/p\u003e \u003cp\u003egain trust\u003c/p\u003e \u003cp\u003e2. Introduction to ACT\u003c/p\u003e \u003cp\u003e3. Application of acceptance techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. \"Snowballing\" activity: all the people form a circle, the researcher designates one person as the starting point and direction, introduces his/her information, and the team members introduce their names, illness experiences, and psychological experiences in turn.\u003c/p\u003e \u003cp\u003e2. Introduction to ACT: Explain the mechanisms and influencing factors of negative emotions, the purpose of this activity and ACT-related introduction, the time, frequency, and duration of this activity, as well as the rules and principles of confidentiality to be followed in group counseling.\u003c/p\u003e \u003cp\u003e3. Positive thinking breathing: guide patients to learn the relaxation method of \"positive thinking breathing\", encourage patients to insist on practicing it, and at the same time improve the respiratory function of patients undergoing particle therapy, which is conducive to improving the cooperation with the treatment.\u003c/p\u003e \u003cp\u003e4. T-puzzle: Identify the most troublesome piece that leads to the uncontrollable nature of negative emotions and learning acceptance.\u003c/p\u003e \u003cp\u003e5. \"Push away the paper\" game: Through exercises, patients are made aware of the need not to focus excessively on negative emotions, to see the illness and negative emotions as part of the body, not to deliberately suppress thoughts and feelings, and to accept changes in the body and thinking.\u003c/p\u003e \u003cp\u003e6. Homework: positive breathing, complete at least 3 times.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eexchanges\u003c/p\u003e \u003cp\u003e(2 min. per person, 15 min.)\u003c/p\u003e \u003cp\u003ePPT and video presentation (15min)\u003c/p\u003e \u003cp\u003eMeditation (5min)\u003c/p\u003e \u003cp\u003eGame (20min)\u003c/p\u003e \u003cp\u003eGame and communication (35min)\u003c/p\u003e \u003cp\u003eWeChat voice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecognitive dissonance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistance yourself from negative emotions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. Review the last course.\u003c/p\u003e \u003cp\u003e2. \"Milk Milk\": elicits patient-to-patient statements about what worries them most about the diagnosis of the disease. The dissociation of \"milk\", i.e., thoughts are just thoughts, is accomplished through a 1-minute exercise of reading \"Milk Milk\".\u003c/p\u003e \u003cp\u003e3. Noticing and naming: each person says a current thought or emotion, e.g., fear of relapse, fear, etc. for the exercise.\u003c/p\u003e \u003cp\u003e4. Leaves Floating in the Stream: guiding members to understand that emotions and behaviors can be separated, and equipping them with the practice of \"experiential acceptance\".\u003c/p\u003e \u003cp\u003e5. Homework: Experience falling leaves floating with the stream, completed at least 3 times.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCommunication (10min)\u003c/p\u003e \u003cp\u003eGame practice (20min)\u003c/p\u003e \u003cp\u003eGame practice and communication (300min)\u003c/p\u003e \u003cp\u003eMeditation and communication (30min)\u003c/p\u003e \u003cp\u003eWeChat voice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocus on the present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-awareness in the face of negative emotions and associated thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. Review the last lesson via the Passengers on the Bus video.\u003c/p\u003e \u003cp\u003e2. Raisin Exercise: focusing on the present moment, being aware of the self, and not being influenced by negative emotions.\u003c/p\u003e \u003cp\u003e3. Observe your hands: put attention on your hands as in whether you are willing to commit to what you are doing when emotions like fear, pain, etc. occur as if you had just observed your hands.\u003c/p\u003e \u003cp\u003e4. Homework: raisin exercises, completed at least 3 times.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCommunication (20min)\u003c/p\u003e \u003cp\u003eMeditation and Communication (30min)\u003c/p\u003e \u003cp\u003eGame and communication (40min)\u003c/p\u003e \u003cp\u003eWeChat voice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eview oneself as a model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperience your surroundings.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. Review the last course.\u003c/p\u003e \u003cp\u003e2. Clip from \"The First Half of My Life\": an understanding of conceptualizing the self, leading to a view of the self as a view.\u003c/p\u003e \u003cp\u003e3. The Chessboard Parable segment: allows patients to objectively experience changes in body sensations, roles, emotions, and behaviors, and to recall past experiences of overcoming difficulties. (20min)\u003c/p\u003e \u003cp\u003e4. Crossing Exercise: Learn to treat the self as a background, treat negative emotions as thought events active in the background, and view them objectively without judgment, thus achieving a complete separation of self from thought.\u003c/p\u003e \u003cp\u003e5. Homework: traversal exercises, completed at least 3 times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCommunication (10min)\u003c/p\u003e \u003cp\u003eVideo and communication (20min)\u003c/p\u003e \u003cp\u003eVideo and communication (30min)\u003c/p\u003e \u003cp\u003eMeditation and Communication (30min)\u003c/p\u003e \u003cp\u003eWeChat voice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue clarification and\u003c/p\u003e \u003cp\u003eCommitment to action\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClarify values and set goals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. Review the last course.\u003c/p\u003e \u003cp\u003e2. Value Compass: By rating the 10 major aspects of life value, the visual sense of pictures is used to find out the most important aspects of each person's heart that he/she wants to change the most.\u003c/p\u003e \u003cp\u003e3. ACT Matrix Chart Sensory Experience: Finding the Reasons for Obstruction and Moving Toward Values. (30min)\u003c/p\u003e \u003cp\u003e4. Homework: Making a plan: Invite patients, family members, and healthcare workers to set short- and medium-term action goals together and work together to develop an action plan, so that members can arrange their action plans for three months after discharge according to their values, and share their plans.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCommunication (10min)\u003c/p\u003e \u003cp\u003eGame (40min)\u003c/p\u003e \u003cp\u003eGame (40min)\u003c/p\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeedback and Summary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSharing and Encouragement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. Share their respective plans and how they deal with their fear of cancer recurrence\u003c/p\u003e \u003cp\u003e2. Summarize and share the harvest: review the whole process of the activity through PPT.\u003c/p\u003e \u003cp\u003e3. \"Make a statement\": notes with words of blessing for each other, thinking about the future.\u003c/p\u003e \u003cp\u003e4. CHORUS: The song \"Friends,\" farewell.\u003c/p\u003e \u003cp\u003e5. Participant evaluation and feedback: patients are encouraged to present deficiencies, comments, and suggestions throughout the ACT intervention. (10min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCommunication (30min)\u003c/p\u003e \u003cp\u003ePPT (30min)\u003c/p\u003e \u003cp\u003eGames (10min)\u003c/p\u003e \u003cp\u003eSongs (5min)\u003c/p\u003e \u003cp\u003eCommunication (15min)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eOutcome assessments were conducted by another researcher who was unaware of the subgroups and was trained to conduct face-to-face data collection at baseline (T0) and the end of the intervention (T1). Data about 3 months after the intervention (T3) were collected using an online questionnaire. The patient sociodemographic and medical data form was collected simultaneously at the baseline line. During the data collection, data collector2 used a unified instruction to answer any doubts and questions in the process of filling out the questionnaire. When collecting the data face to face, the data collectors checked whether there were any mistakes and omissions, and then corrected them in time to make up for the filling. The data were collected through online questionnaires 3 months after the intervention (T3), and if the patients didn't fill out the questionnaires in time, the collectors contacted them by phone to ensure that the questionnaire data were complete as much as possible.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eObservation indicators\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eDemographic questionnaire of the participants\u003c/h2\u003e \u003cp\u003eA study self-developed general demographic data questionnaire for the study population was used, which included general data information such as gender, age, annual income, religion, cancer type, tumor stage, and Complication, etc.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePrimary outcome\u003c/h2\u003e \u003cp\u003eThe level of hope was assessed by the Herth Hope Index (HHI), which was developed by Herth in 1992 based on the hope model of scholars Dufault and Martocchio in the Herth Hope Scale[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. It contains 12 entries with 3 dimensions( positive attitude towards present and future, taking positive action, maintaining close relationships with others). The range of total scores is 12\u0026ndash;48, 12\u0026ndash;23 is low level, 24\u0026ndash;35 is medium level, and 36\u0026ndash;48 is high level. The value of Cronbach\u0026rsquo;s ɑ for this scale was 0.92[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSecondary outcome\u003c/h2\u003e \u003cp\u003ePsychological resilience, was measured by the Connor-Davidson resilience scale (CD-RISC)[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].It contains 25 items and total scores range from 0 to 100. The higher scores indicate greater psychological resilience. Its Cronbach's ɑ in cancer patients was 0.89\u0026ndash;9.93[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological flexibility was measured by the Acceptance and Action Questionnaire Second Edition (AAQ-II). The total scores range from 7 to 49. Higher scores indicate lower psychological flexibility[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. It has been widely used to measure psychological flexibility in oncology patients. The Chinese version of the scale has a Cronbach's ɑ of 0.857 in cancer patients[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe used the distress thermometer (DT) with a scale of 0 (no distress) to 10 (extreme distress). It is a clinical screening tool evaluate psychological distress among patients[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. At a cut-off value of 4, the sensitivity and specificity were 0.80 and 0.70[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSatisfaction and feedback forms\u003c/h2\u003e \u003cp\u003ePatients who completed the intervention course were asked to rate their satisfaction with the intervention on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;very satisfied, 5\u0026thinsp;=\u0026thinsp;very dissatisfied). Finally, two questions were used to gather participant feedback on the ACT: \"What do you think needs to be improved about the content of the program?\" and \"Would you recommend this counseling therapy to other patients or friends?\"\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data obtained from the research were analyzed using the IBM SPSS Statistics version 25.0. Baseline data will be analyzed descriptively using percentages (dichotomous variables) and means and standard deviations (continuous variables). To compare socio-demographic variables and primary and secondary outcome measures between the two groups, chi-square tests will be used to compare categorical variables. Independent t-tests will be used to compare continuous normally distributed variables and the Mann-Whitney-U test will be used to compare non-normally distributed variables. Measures of outcome indicators at three-time points (baseline, immediate post-intervention, and 3 months post-intervention) were conducted using linear mixed-effects models to compare differences between the two groups in levels of hope, psychological resilience, psychological flexibility, and psychological distress during the follow-up period from baseline to 3 months. Intervention and time were fixed effect variables, and study subjects were random effect variables. At the same time, Adjusting the baseline to compare the changes between the outcomes. Per-protocol (PP) analysis was used in this study. All statistical tests were 2-sided, with a level of significance set at 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and characteristics of participants\u003c/h2\u003e \u003cp\u003eA total of 102 participants were recruited in this study. 10 participants did not meet the criteria for the nativity, 10 participants were not interested, and 2 participants were unable to attend due to the time of treatment. A total of 80 participants were included in the study. 3 participants in the intervention group dropped out for the reason that 2 people dropped out after participating in 2 activities due to personal reasons, and 1 person was absent from the two activities due to the reason of treatment. In the control group, 3 people dropped out of the program because they lost contact with each other during the follow-up period.\u003c/p\u003e \u003cp\u003eFinally, 37 participants in the intervention group and 37 in the control group participated in the whole study. The flow chart of recruitment and specific reasons for participants ' drop-out is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Finally, 19 patients with lung cancer, 36 patients with head and neck tumors, 13 patients with breast cancer, and 6 patients with prostate cancer were included in this study. The age of the study subjects in the intervention group ranged from 29 to 71 years old, with an average age of (48.19 sh 1.83) years, and the age of the patients in the control group ranged from 26 to 72 years old, with an average age of (51.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87) years. There was no statistically significant difference in terms of general demographic data and related outcome variables between the two groups of patients before intervention (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). A comparison of demographic data and clinical characteristics of the patients between the two groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographic and clinical characteristics of the patients(n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003egroup (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003cp\u003e\u0026oline;x\u0026plusmn; s/n(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003egroup (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003cp\u003e\u0026oline;x\u0026plusmn; s/n(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et/χ \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYears\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (35.1)\u003c/p\u003e \u003cp\u003e24 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (40.5)\u003c/p\u003e \u003cp\u003e22 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.632\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (78.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (86.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.325\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow High school\u003c/p\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003cp\u003e14 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003cp\u003e12 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eunmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.528\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (86.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (86.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced /widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAnnual income\u003c/p\u003e \u003cp\u003e(yuan/year)\u003c/p\u003e \u003cp\u003eWorking state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;150,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.493\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150,000-300,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;300,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (40.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOn the job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.332\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLung cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHead and neck cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (54.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (43.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProstate cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhase Ⅰ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.139\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhase II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhase III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (56.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhase IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (67.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHHI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003escore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.78\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.59\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.379\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003escore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.57\u0026thinsp;\u0026plusmn;\u0026thinsp;7.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.22\u0026thinsp;\u0026plusmn;\u0026thinsp;7.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.659\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAAQ-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003escore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.05\u0026thinsp;\u0026plusmn;\u0026thinsp;5.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.438\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003escore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: HHI\u0026thinsp;=\u0026thinsp;Herth Hope Index,CD-RISC\u0026thinsp;=\u0026thinsp;Connor-Davidson Resilience Scale, AAQ-II\u0026thinsp;=\u0026thinsp;Acceptance and Action Questionnaire Second Edition, DT\u0026thinsp;=\u0026thinsp;distress thermometer\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness of ACT interventions on primary outcome\u003c/h2\u003e \u003cp\u003eThe comparison of HHI scores between the 2 groups was not statistically different at baseline (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.379) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Linear mixed model analysis showed a statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the time effect of HHI scores, indicating that the level of hope varied over time in the two groups, and a statistically significant difference in the between-group effect (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.038), which means that there was a statistically significant difference in the intervention group's HHI scores relative to those of the control group; no significant main effect of group\u0026times;time interaction (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.066), indicating that there was a statistically significant change in HHI scores between the intervention and control groups at the 3 time points; HHI scores in the intervention group were higher than those in the control group at T1 and T2, and there was a statistically significant difference between scores of the intervention and control groups at T1 (MD: 2.16, 95% CI: 0.28 to 4.05, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025) and at T2 (MD: 2.19,95%CI: 0.43 to 3.95, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015). The difference did not change after adjusting for baseline, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (A).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness of ACT intervention on second outcome\u003c/h2\u003e \u003cp\u003eThe comparison of CD-RISC, AAQ-II, and DT scores between the 2 groups were not statistically different at baseline (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Linear mixed model analysis showed a significant effect of time on CD-RISC, AAQ-II, and DT scores in the 2 groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was a statistically significant difference in the between-group effect on CD-RISC(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043) and AAQ-II scores\u003cem\u003e(P\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015). Significant effects of group \u0026times; time on CD-RISC (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037), AAQ-II (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and DT (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) scores were also detected, indicating that there was a statistically significant change on Psychological resilience, flexibility and distress between the intervention and control groups at the 3-time points. CD-RISC scores were higher in the intervention group than in the control group at T1 and T2, at T1 (MD: 4.81,95% CI:1.66 to 7.97, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), T2 (MD:1.81,95%CI:-0.76 to 4.39, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.165); AAQ-II scores were lower than that of the control group at T1 (MD: -4.35,95%CI: -6.93 to -1.77, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), T2 (MD:-4.62),95%CI: -7.24 to -2.01, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001);DT scores were lower in the intervention group than in the control group at T1 and T2, and at T1 (MD: -0.35, 95% CI: -0.98 to -0.28, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.268), and T2 (MD:-0.89,95% CI:-1.40 to -0.39, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). All the difference was unchanged after adjusting for baseline, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (B..C.D).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison of intervention and control participants on outcome at different time points\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c3\" namest=\"c2\" rowspan=\"2\"\u003e \u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIntervention group (n\u0026thinsp;=\u0026thinsp;37) mean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003eUnadjusted \u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003eAdjusted \u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c13\" namest=\"c9\"\u003e \u003cp\u003eLinear mixed-effects mode\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003cp\u003eF (\u003cem\u003eP\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003cp\u003eF(\u003cem\u003eP\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eGroup\u0026times;Time\u003c/p\u003e \u003cp\u003eF(\u003cem\u003eP\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.451 (0.038)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e50.723 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e2.764 (0.066)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e31.30 (4.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.46 (4.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.16 (0.28 to 4.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.36 (0.26 to 2.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e30.65 (3.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.84 (4.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.19 (0.43 to 3.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.40 (0.29 to 3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.231 (0.043)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e29.001 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e3.386 (0.037)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e55.16 (7.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.97 (6.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.81 (1.66 to 7.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.66 (1.87 to 7.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e56.16 (6.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.97 (4.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.81 (\u0026minus;0.76 to 4.39 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.66 (\u0026minus;1.12 to 4.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAAQ-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6.222 (0.015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e54.771 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e8.603 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e25.86 (4.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.51 (6.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;4.35 (\u0026minus;6.93 to\u0026minus;1.77 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;3.98 (\u0026minus;6.00 to\u0026minus;1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e25.24 (3.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.62 (6.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;4.62 (\u0026minus;7.24 to\u0026minus;2.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;4.26 (\u0026minus;6.27 to\u0026minus;2.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.49 (0.226)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003e58.082 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003e7.316 (0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.97 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.62 (1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.35 (\u0026minus;0.98 to\u0026minus;0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.45 (\u0026minus;1.18 to\u0026minus;0.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.03 (0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.14 (1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.89 (\u0026minus;1.40 to\u0026minus;0.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.99 (\u0026minus;1.73 to\u0026minus;0.25 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eNote: T1\u0026thinsp;=\u0026thinsp;post-intervention; T2\u0026thinsp;=\u0026thinsp;3 months follow-up. M\u0026thinsp;=\u0026thinsp;mean; SD\u0026thinsp;=\u0026thinsp;standard deviation.; CI\u0026thinsp;=\u0026thinsp;confidence interval; The p values are from an analysis of covariance, comparing the intervention and control arms at T1 and T2. The p values are from an analysis of covariance, comparing the intervention and control arms at T1 and T2; HHI\u0026thinsp;=\u0026thinsp;Herth Hope Index, CD-RISC\u0026thinsp;=\u0026thinsp;Connor-Davidson Resilience Scale, AAQ-II\u0026thinsp;=\u0026thinsp;Acceptance and Action Questionnaire Second Edition, DT\u0026thinsp;=\u0026thinsp;distress thermometer, Unadjusted\u0026thinsp;=\u0026thinsp;unadjusted baseline, Adjusted\u0026thinsp;=\u0026thinsp;LMM analysis using data after adjusting the baseline.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eFeedback and satisfaction on ACT intervention\u003c/h2\u003e \u003cp\u003eThe study showed that the majority of patients (91.9%) provided a positive evaluation (very satisfied or satisfied) of the Acceptance Commitment Therapy intervention. No patients were dissatisfied with the intervention. The majority of patients (94.6%) reported that no problems bothered them during the interview. In addition, the majority of patients (89.2%) were willing to recommend the Acceptance Commitment Therapy intervention to other patients or friends.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe found that six sessions of the ACT group psychological intervention contributed to the psychological recovery of radiotherapy cancer patients, and these improvements remained stable even at the 3-month post-intervention follow-up assessment.\u003c/p\u003e \u003cp\u003eHope is a positive motivational state that builds upon an interacting sense of success, including goal-oriented motivation and a planned pathway to achieve the goal[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Hope can give radiotherapy cancer patients the courage to overcome difficulties, help them accept the reality of their disease, actively participate in their treatment, and have a positive impact on patients' prognosis, survival, and quality of life[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].A recent meta-analysis indicated that ACT increases the level of hope in cancer patients, but the small sample size and heterogeneity of the study did not allow sufficient evidence of a significant effect of ACT on hope[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].Our study found that ACT significantly improved patients' levels of hope. Hope is a process in which people identify their goals in the first step, develop strategies to achieve those goals in the second step, and create incentives to implement those strategies and maintain them throughout the process[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].The reason for this may be that, from the perspective of ACT, psychological rigidity is a major cause of distress, and individuals who avoid thoughts or emotions, as well as important or meaningful activities, are thought to experience greater pain and impairment. This can result in a lack of hopeful motivation in the future for patients[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In this study, the six core techniques of ACT (Acceptance, Cognitive Defusion, Present Moment Awareness, Self-as-Context, Values Clarification, and Committed Action) were utilized as a framework to help patients recognize their dilemmas without becoming entangled in them, to alter the individual's relationship with these issues. Finally, the Values Clarification was employed to identify the aspects within each individual's inner being that were most significant and in need of change. Subsequently, the ACT Matrix diagram was utilized to empower patients to identify obstacles hindering progress towards their values. Additionally, emotional and social support was provided through the collaboration of family members and caregivers to assist patients in formulating appropriate action plans. This study affirms that ACT fosters positive thoughts and hope in patients through a systematic process.\u003c/p\u003e \u003cp\u003ePsychological flexibility and resilience are two important concepts that play key roles in mental health and coping strategies. Psychological flexibility is a fundamental aspect of achieving mental health[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. And it is a core goal of ACT, reflecting individuals' ability to adjust psychologically in dynamic and changing situations, oriented toward their values, and in the process of realizing valued goals[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. 59.5% of participants (44/74) in this study reported clinically significant (DT\u0026thinsp;\u0026ge;\u0026thinsp;4) levels of distress. There was a significant difference in DT scores between the 2 groups at 3-month follow-up. This suggests that ACT has a long-term significant effect on the psychological distress of patients undergoing radiotherapy. The themes of acceptance, cognitive defusion, present moment awareness, and self-as-context in ACT can activate the insular cortex, believed to play a significant role in higher-order cognitive functions and increase awareness of present moment experiences, helping patients truly accept and effectively cope with psychological distress[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Psychological flexibility is negatively correlated with psychological distress[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], so improve patients' psychological flexibility could reduce the level of psychological distress in cancer patients. The intervention scheme consistently revolves around addressing psychological distress as the primary target. They are encouraged to focus on the present moment, clarify their values, redefine the meaning of life, and cultivate hope for the future. Through committed actions, patients are assisted in setting future goals and integrating their values into concrete activities, thus effectively mitigating the impact of psychological distress. Additionally, coordinated breathing is necessary for cancer patients undergoing particle therapy. Similarly, the practice of \"mindful breathing\" in ACT helps patients maintain steady breathing, leading to better therapeutic outcomes. Positive thinking also aids patients in avoiding excessive worry about the possibility of recurrence. Group face-to-face discussions encourage sharing of experiences, mutual learning, and support, thus facilitating continuous self-exploration. Each group consists of 6 to 7 patients, fewer than the originally planned 10, indicating that group-based psychological interventions are more cost-effective. The study included subjects with higher levels of education and younger ages, making them more likely to comprehend the intervention goals and expected outcomes, and more capable of actively participating in the treatment process.\u003c/p\u003e \u003cp\u003eThe present study found that all outcome indicators also improved in the control group, which contrasts with previous results[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The reason may be that patients' psychological stress was higher before the intervention due to the lack of knowledge related to radiotherapy, side effects during treatment, and uncertainty about the expected treatment outcome[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. The patients in the control group of this study experienced the advanced nature of particle therapy and its low side effects during their hospitalization, and their physical and mental health improved, enabling them to face their illnesses and cope with difficult situations more positively.\u003c/p\u003e \u003cp\u003eThe difference compared with previous studies[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] is that the intervention leaders in our study are fixed leaders who contacted with the patients from the beginning to the end of the session. Regular group leaders can increase the trust of team members. The team leader should treat every patient with respect, neutrality, and compassion at all times. They should provide patients with information about cancer radiotherapy and stress management, as well as help patients explore ambivalence regarding behavioral changes. Therefore, this study concluded that having a fixed location and consistent staff member can keep team members in a more open state during activities, improve patient satisfaction, and facilitate the psychological recovery of cancer patients.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis is where our study suffers from several limitations. First, the sample size of our study was relatively small, which may limit the generalizability of the findings. In addition, the study population in this study was drawn from the first proton and heavy ion hospital in China, where most of the patients treated were socioeconomically privileged and well-educated, which may limit the generalizability of our findings to a broader population. Future studies with larger and more diverse samples are needed to validate and extend our findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings suggest that a 6-session group psychosocial intervention based on the ACT treatment model helped radiotherapy cancer patients increase their level of hope, psychological flexibility, and psychological resilience, and reduce psychological distress. These improvements remained stable for patients at the 3-month post-intervention follow-up assessment. Thus, it has the potential to benefit psychological rehabilitation in the broader cancer population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003eWe thank all patients who participated and the staff of the hospital who contributed to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study conception and design. Fei Qin contributed to the conceptualization, analysis, and draft of the original manuscript; Yu Zhu and Shuman Wang contributed to the design, and material; Ziyin Wang and Lijuan Zhang contributed to the investigation, and validation; Hongwei Wan contributed to the conceptualization, writing review, editing, and project administration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eShanghai Pudong New Area Science and Technology Development Fund (PKJ2020-Y57); Health and Family Planning Research Project of Pudong New Area Health Commission (PW2022D-10); Fudan University-Fosun Nursing Research Fund (FNF202104, FNF202302); Shanghai Modern Nursing Vocational Education Group Distinguished Part-time Teacher Program( HLZJTPGR202326)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e The data supporting the findings of this study can be provided upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003eThis study was approved by the Institutional Review Board of Shanghai Proton and Heavy Ion Hospital (2107-50-01) and registered in the Chinese Clinical Trial Registry, number ChiCTR2300068349.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e Patients signed informed consent regarding publishing their data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL et al (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 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Plos One 17(5):e267887. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0267887\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0267887\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Acceptance and commitment therapy, Hope, Psychological resilience, Psychological flexibility, Psychological distress","lastPublishedDoi":"10.21203/rs.3.rs-4161013/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4161013/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e To develop an appropriate intervention utilizing acceptance and commitment therapy (ACT) tailored specifically for cancer patients undergoing radiotherapy, and to investigate its impact on hope, psychological resilience, psychological flexibility, and psychological distress among cancer patients receiving proton and heavy ion therapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003e80 participants were allocated into either an intervention group (n=40) or a control group (n=40) based on their admission time. Both the control and intervention groups underwent a 3-week health education program, with the intervention group additionally participating in a 3-week, 6-session acceptance and commitment therapy (ACT) group psychological intervention. Discrepancies in hope levels, psychological resilience, psychological flexibility, and psychological distress between the two groups were assessed at baseline, post-intervention, and at a 3-month follow-up using linear mixed-effects analysis (LMM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e LMM analyses revealed that at the end of the intervention, scores for Hope and Psychological Resilience were higher in the intervention group compared to the control group (P=0.025, P=0.003 respectively), while scores for Psychological Flexibility were lower in the control group (P=0.001). Furthermore, at the 3-month follow-up, HHI scores remained higher in the intervention group compared to the control group (P=0.025), while scores for Psychological Flexibility and Psychological Distress were lower in the intervention group (P=0.001, P=0.001 respectively). These differences persisted even after adjusting for baseline values.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eA psychological intervention program based on the ACT model of treatment helps to promote psychological recovery in cancer patients with radiotherapy. Evidence is provided for the effectiveness of positive clinical psychological interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e ChiCTR2300068349\u003c/p\u003e","manuscriptTitle":"Efficacy of acceptance and commitment therapy on psychological rehabilitation in cancer patients treated with proton and heavy ion therapy:a non-randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-29 19:06:19","doi":"10.21203/rs.3.rs-4161013/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-04T01:03:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-03T16:46:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234700410771892224131861266992598562075","date":"2024-12-03T10:51:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266278697322738122273078578274359849554","date":"2024-10-06T07:28:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-13T01:24:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-04T05:36:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-26T05:41:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-03-25T06:06:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a8a70518-0782-4f17-94f0-d470ff16e21e","owner":[],"postedDate":"March 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T16:04:56+00:00","versionOfRecord":{"articleIdentity":"rs-4161013","link":"https://doi.org/10.1007/s00520-024-09126-6","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-01-07 15:57:06","publishedOnDateReadable":"January 7th, 2025"},"versionCreatedAt":"2024-03-29 19:06:19","video":"","vorDoi":"10.1007/s00520-024-09126-6","vorDoiUrl":"https://doi.org/10.1007/s00520-024-09126-6","workflowStages":[]},"version":"v1","identity":"rs-4161013","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4161013","identity":"rs-4161013","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}