Support Care Cancer (2010) 18:1597–1603
DOI 10.1007/s00520-010-0962-2
SHORT COMMUNICATION
A randomised pilot of a self-help workbook intervention
for breast cancer survivors
Lisa Beatty & Melissa Oxlad & Bogda Koczwara &
Tracey D. Wade
Received: 3 December 2009 / Accepted: 20 July 2010 / Published online: 29 July 2010
# Springer-Verlag 2010
Abstract
Purpose The aim of this study is to evaluate the efficacy of
a self-help workbook for improving adjustment for breast
cancer survivors.
Methods An RCT compared the workbook (n=20) with no-
workbook controls (n=20). Coping, traumatic stress and
quality of life were measured at baseline, then 3 and
6 months later.
Results No interactions were found. A significant group
main effect was found for venting coping; controls used
less venting coping than workbook participants (p=0.034).
A significant time main effect was obtained for cognitive
functioning (p=0.003). Reliable change indices showed a
trend towards a protective effect across all coping measures
for workbook participants compared to controls. Qualitative
feedback suggested that participants felt well supported by
the intervention, but would have preferred receiving it
during treatment.
Conclusions While trends showed some promise for im-
proving coping, endorsement for the workbook was not
obtained. The difficulties encountered in recruiting survi-
vors and the resulting implications regarding the feasibility
of offering self-help resources to this population are
discussed.
Submitted to: Supportive Care in Cancer
L. Beatty (*) : M. Oxlad : T. D. Wade
School of Psychology, Flinders University,
GPO Box 2100, Adelaide, South Australia, Australia
e-mail: lisa.beatty@flinders.edu.au
B. Koczwara
Department of Medical Oncology, Flinders Medical Centre,
Adelaide, South Australia, Australia
Keywords Breast cancer . Psychosocial adjustment .
Self-help workbook . Survivorship
Introduction
The psychological impact of breast cancer has been well
documented [1], with long term sub-threshold depression,
anxiety, impaired quality of life (QOL) [2–4], occurring in
up to 30% of patients. Group psychosocial interventions
targeting these issues have demonstrable efficacy and cost
effectiveness [5], however only 14–21% of Australian
women elect to participate [4]. Attendance barriers include
(1) not feeling comfortable with a group setting, (2)
preferring to deal with issues alone and (3) access
difficulties for rural patients.
Self-help interventions provide solutions to these barriers
and have received recent empirical attention. Stiegelis et al.
[6] developed an information booklet for patients undergo-
ing radiotherapy. Patients with high illness uncertainty and
low perceived control experienced less tension, anger and
depression 3 months after receiving the booklet than
controls. Distress was measured cross-sectionally, thus
changes over time could not be examined. However the
psychological literature suggests that providing information
alone is insufficient to facilitate change, and active
cognitive and emotional processing of the cancer is
required to lower distress [7]. Angell et al. [8] provided
this opportunity in their workbook~journal based on
supportive–expressive therapy principles for American
women with breast cancer. Three interactions were
obtained: (1) workbook participants who had completed
treatment experienced fewer post-traumatic stress disorder
(PTSD) symptoms compared to usual care; and rural
practice patients reported (2) decreased fighting spirit and
1598 Support Care Cancer (2010) 18:1597–1603

(3) increased emotional venting if they did not receive the
workbook.
While promising, neither self-help study conducted a
longer term follow-up, treatment engagement was not
measured, and interactive opportunities could be increased.
The current study therefore developed and evaluated a self-
help workbook targeting treatment completion, in order to
replicate Angell et al.'s [8] design and findings. It was
hypothesised that workbook participants would show
significantly greater improvements compared to usual care
(no-workbook) controls over the 6-month study period, in
the primary outcome, coping; and secondary outcomes,
PTSD and QOL.
Methods
Participants
Participants were women with stage I or II breast cancer,
who had completed treatment within the past 3 months,
were English speaking and aged 18 years or over.
Participants were recruited from a single institution
between March 2004 and August 2006. This study was
approved by the Flinders Clinical Research Ethics
Committee.
Procedure
Women were recruited by one oncologist (BK) and
research nurse. Computer-generated block randomisation
in blocks of two was utilised (‘treatment’ and ‘control’).
Allocation was implemented sequentially through num-
bered containers, and the sequence was concealed.
Figure 1 illustrates the flow of participants through the
study. Consenting participants were informed of their
treatment allocation by the research nurse prior to
completing baseline questionnaires (T1), as this was a
requirement of the institution. Upon receiving this ques-
tionnaire, the workbook was posted out to treatment
participants. The research coordinator LB assessed treat-
ment compliance with WB participants by telephone 1 and

Fig. 1 Flow diagram of partic-

ipants' involvement in the rand- Assessed for eligibility
omised trial for breast cancer (n=55)
survivors Excluded (n=13)
- Refused to participate
(n=3)
- Verbally consented but
did not provide subsequent
Randomized written consent
(n=42) (n=10)

Allocated to intervention Allocation Allocated to treatment as usual

(n=20) (n=22)
Received allocated intervention Received allocated intervention
(n=20) (n=20)
Did not receive allocated Did not receive allocated intervention
intervention (n=0) - Unable to contact (n=2)

Provided 3 month follow-up (n=17) Follow-Up Provided 3 month follow-up (n=20)

Lost to follow-up Lost to follow-up (n=0)
-Moved (n=1) Discontinued intervention (n=0)
-No response (n=1)
Discontinued intervention
- Illness (n=1)

Provided 6 month follow-up (n=15) Provided 6 month follow-up (n=20)

Lost to follow-up or discontinued Lost to follow-up or discontinued
intervention intervention (n=0)
- No response (n=1)
- Death (n=1)

Analysed (n=20) Analysis Analysed (n=20)

Support Care Cancer (2010) 18:1597–1603
2 months later. Follow-up questionnaires were completed
3 months (T2) and 6 months (T3) after T1. Control
participants received the workbook after T3 questionnaires
were completed. There were three and five non-
respondents at 3- and 6-month follow-ups respectively.
Intervention
The workbook, entitled ‘Women Moving On: A work-
book~journal for women moving forward after treatment
for breast cancer’, was derived in consultation with
consumers from a series of focus-groups with survivors
[9]. While some themes were suggested by the previ-
ously evaluated American workbook [8], the current
workbook had a different therapeutic basis and content.
Each chapter contained three major components: educa-
tion on common medical and psychosocial issues; sugges-
tions and worksheets to address the issues; and survivor's
stories and quotes. The chapters address (1) maintaining
the medical partnership, (2) physical well-being, (3)
feeling alone, (4) family and friends, (5) emotional
recovery, (6) spirituality, (7) seeking closure, (8) moving
forward, (9) living the life you want, and (10) local and
national resources. Based on cognitive behaviour therapy
and written emotional expression, the workbook included
a relaxation and meditation tape, and was illustrated
throughout. The introduction recommended gradually
reading sections over a 3-month period to reduce partic-
ipant burden, and to select sections of higher relevance,
rather than reading sequentially.
Measures
Demographic and illness variables measured were age,
marital status, education, employment, breast cancer
family history, stage of disease and interventions received
(surgery, chemotherapy, radiation and hormonal therapy).
The primary outcome, coping, was assessed using six
subscales of the Coping Operations Preference Enquiry
[COPE: 10]: planning, restraint coping, seeking social
support (instrumental and emotional), turning to religion,
and venting emotions. Subscale scores range from 4 to 16,
with higher scores indicating greater endorsement of that
style.
Secondary outcomes, traumatic stress and QOL, were
assessed as follows: PTSD symptoms were measured using
the total scale score of the Posttraumatic Stress Scale-Self
Report [10], with scores ranging from 0 to 51. QOL was
assessed using five subscales (global, physical, cognitive,
social and emotional functioning) of the European Organi-
sation for Research and Treatment of Cancer Quality of
Life Core Questionnaire [11]. Higher scores indicate better
functioning.
1599
Follow-up questions
Workbook participants completed a short structured evalu-
ative feedback telephone interview with LB 1 and 2 months
after receiving the workbook, addressing how useful the
workbook components were, which aspects were helpful,
and recommended changes.
Treatment fidelity was assessed at T2 using a self-help
compliance measure [12]. Participants rated the percentage
of (1) information read, (2) suggestions/exercises complet-
ed and (3) the average amount of time spent per week using
the workbook, using three five-point Likert scales. Results
were dichotomised into ‘high’ versus ‘low’ levels. Data was
not collected regarding participant utilisation of other
psychosocial programmes.
Analyses
A repeated measures power analysis was conducted using
Cohen's f2 moderate effect size coefficient of 0.15. With
alpha set at 0.05, and desired power set at 0.80, the required
sample size was 65 (33 per condition). Due to slow
recruitment rates a stopping rule was implemented after
40 women were enrolled, thus resulting in a lack of power
(0.57).
Analyses were conducted using version 14.0 of the
Statistical Package for the Social Sciences. Baseline
differences between groups in demographic, medical and
outcome measures were investigated using t tests or chi-
square tests of independence. Change between groups
over time was assessed using Linear mixed modelling
[13], which offers the benefit of including participants
with missing data in analyses. This approach allows for
direct comparisons between the groups at the 3- and 6-
month follow-ups, respectively, by creating a pooled
baseline mean across groups [14]. Fixed main effects
were treatment-condition (workbook, control), time (3 and
6-month) and the covariate (baseline). No adjustments
were made for multiple comparisons. Within-group effect
sizes (ES) were calculated, obtaining Cohen's d where
0.20 is considered small, 0.50 moderate and 0.80 large.
Reliable change indices (RCI) were calculated as an
indicator of clinical significance according to the method
described by Jacobson and Truax [15].
Results
Forty participants were entered into the study (treatment
n = 20, control n = 20), with an overall mean age of
53.05 years (SD=11.44, range 29–79 years). At baseline,
groups did not differ on any psychosocial outcome
measure, demographic or medical variable (Table 1),
1600 Support Care Cancer (2010) 18:1597–1603

Table 1 Summary of demo-

graphic and medical Variable Control Intervention Statistic p
characteristics
Age at study entry 55.64 (11.76) 50.46 (10.77) t(38)=−1.45 0.16
Married/partnered 15 (75%) 16 (80%) χ2(1,N=40)=0.14 0.70
Education level completed
Primary school 3 (15%) 5 (25%)
Secondary 9 (45%) 3 (15%)
Tertiary 8 (40%) 12 (60%) χ2(2,N=40)=4.3 0.12
Employed 9 (45%) 11 (55%) χ2(1,N=40)=0.40 0.53
Family history 6 (30%) 13 (65%) χ2(1,N=40)=5.16 0.05a
Stagea
I 5 (26.3%) 2 (10.5%)
II 14 (73.7%) 17 (89.5%) χ2(1,N=38)=1.58 0.41
Nodes (n with positive nodes)a 10 (52.6%) 16 (84.2%) χ2(1,N=38)=4.39 0.08
Oestrogen receptor positivea 12 (63.2%) 14 (73.7%) χ2(1,N=38)=0.49 0.73
Surgery
Partial mastectomy 10 (50%) 12 (60%)
Total mastectomy 9 (45%) 8 (40%)
a
Analysed 38 participants, one Bilateral total 1 (5%) 0% χ2(2,N=40)=1.24 0.54
missing case per condition Chemotherapya 15 (78.9%) 18 (94.7%) χ2(1,N=38)=2.07 0.34
b
Analysed 39 participants, one Radiationb 16 (80%) 16 (84.2%) χ2(1,N=39) =0.12 0.99
missing case in the intervention Hormonala 11 (57.9%) 13 (68.4%) χ2(1,N=38)=0.45 0.74
group

except women in the workbook condition had a higher
frequency of breast cancer family history (65%) compared
to controls (30%).
Repeated measures
No significant group × time interactions were found
(Table 2). A significant fixed effect for group (controlling
for time and baseline) was found for venting coping
[F (1,50.58)=4.74, p=0.034]. Workbook participants had
higher mean scores at 3- and 6-months than controls. A
significant fixed effect for time (controlling for group
and baseline) was found for cognitive functioning
[F (1,35.32) =4.47, p =0.042]. While an improvement
occurred over time for both groups, the ES at 6-months
showed an improvement of d=0.44 for WB participants
compared to a d=0.03 for controls.
Clinical significance
A higher percentage of workbook participants experienced
improvements compared to controls across all coping
domains, except planning coping (Table 3). Workbook
participants also had a lower percentage of deterioration
across all coping domains compared to controls, except
religious coping. Across secondary outcomes, differences
between groups were small, except social function where a
higher percentage of workbook participants experienced
improvement compared to controls.
Engagement and feedback
At T2, 88% had read all the information, 81% had
completed 25% or more of the suggestions and exercises,
and 88% spent 1–15 min or more per week using the book.
The dichotomised engagement items did not significantly
predict outcomes. Qualitatively, two themes emerged: (1)
women said they found the workbook supportive and
affirming, preparing them for potential issues, and provid-
ing strategies to deal with these; and (2) timing; women
stated it may have been more relevant and beneficial to
receive at diagnosis and treatment.
Discussion
In contrast with Angell et al. [8], this pilot study did not
find a strong endorsement for the workbook, as no
interactions were found. However, two trends were
obtained from significant fixed effects and associated effect
sizes. Workbook participants experienced a protective effect
in venting coping, and experienced a benefit compared to
control participants in cognitive functioning. These trends
were supported by the reliable change scores at 6 months,
where workbook participants experienced more improve-
ment and less deterioration in most coping domains
compared to controls.
The trend of a protective effect on coping was consistent
with conclusions drawn by Angell et al. [8]. However,
Support Care Cancer (2010) 18:1597–1603 1601

Table 2 Mixed model analyses of dependent variables (Time 1 covariate) by time (2) and group (2)

Measure Baseline Workbook Control

covariate valuea
3 month T1–T2 d 6 month T1–T3 d 3 month T1–T2 d 6 month T1–T3 d

Primary outcome
Coping
Planning 8.76 9.32 (0.53) 0.02 8.46 (0.80) 0.18 8.36 (0.49) 0.10 8.51 (0.70) 0.06
Restraint 7.28 7.56 (0.61) 0.02 7.53 (0.78) 0.02 7.67 (0.56) 0.07 6.97 (0.68) 0.13
Instrumentala 8.47 8.41 (0.69) 0.14 8.18 (0.68) 0.23 8.25 (0.64) 0.10 6.80 (0.60) 0.61
Emotional 10.47 9.60 (0.63) 0.40 10.07 (0.57) 0.25 9.42 (0.58) 0.34 8.32 (0.50) 0.71
Religious 7.76 7.30 (0.37) 0.10 7.51 (0.35) 0.02 7.67 (0.34) 0.05 7.32 (0.31) 0.13
Ventingb 7.88 8.03 (0.59) 0.10 8.09 (0.65) 0.05 6.61 (0.54) 0.36 6.71 (0.57) 0.33
Secondary outcomes
PTSDc 10.71 8.74 (1.63) 0.46 9.07 (1.66) 0.42 10.4 (1.50) 0.06 8.55 (1.43) 0.29
QOL
Global 70.60 73.78 (5.98) 0.25 74.55 (6.20) 0.33 73.84 (5.84) 0.17 73.84 (5.95) 0.17
Physical function 84.91 83.06 (2.55) 0.05 85.30 (2.83) 0.33 86.69 (2.36) 0.14 85.02 (2.48) 0.04
Emotional function 70.02 74.28 (3.41) 0.26 69.78 (5.27) 0.07 75.59 (3.15) 0.24 75.17 (4.60) 0.18
Social function 63.43 72.79 (5.62) 0.38 81.12 (4.12) 0.67 80.55 (5.18) 0.62 81.38 (3.67) 0.65
Cognitive functionc 69.91 69.21 (10.97) 0.14 78.14 (11.24) 0.44 67.92 (10.83) 0.10 72.09 (10.99) 0.03

Baseline covariate value=the pooled baseline mean for both groups

The effect of the baseline value of the dependent variable has been statistically removed to allow for direct comparisons across time and group
a
Significant main effect for time, p=0.057
b
Significant main effect for group, p=0.034
c
Significant main effect for time p=0.003
d within-group effect size calculated using raw (not adjusted) mean scores; effect size magnitude: 0.2=small, 0.5=moderate, 0.8=large
T1 baseline, T2 3 month follow-up, T3 6 month follow-up, QOL quality of life

Table 3 Number (N) and per-

centage (%) of participants who Outcome Workbook (n=15) Control (n=20)
experienced a clinically signifi-
cant level of change from base- RCI ↑ N (%)a ↓ N (%)b RCI ↑ N (%) ↓ N (%)
line to 6-month follow-up, based
on reliable change indices, by Primary outcome
group COPE
Planning 2.54 1 (6.7%) 3 (20%) 2.70 5 (25%) 6 (30%)
Restraint 2.40 3 (20%) 2 (13.3%) 2.48 3 (15%) 5 (25%)
Instrumental 3.63 1 (6.7%) 1 (6.7%) 3.67 1 (5%) 7 (35%)
Emotional 2.12 3 (20%) 3 (20%) 3.47 0 (0%) 7 (35%)
Religious 2.39 1 (6.7%) 1 (6.7%) 2.32 0 (0%) 1 (5%)
Venting 2.42 3 (20%) 2 (13.3%) 2.95 2 (10%) 7 (35%)
Secondary outcomes
PTSD 8.30 2 (13.3%) 1 (6.7%) 8.08 2 (10%) 1 (5%)
QOL
Global 25.46 2 (13.3%) 2 (13.3%) 18.68 0 (0%) 1 (5%)
Physical function 24.75 1 (6.7%) 0 (0%) 20.45 1 (5%) 1 (5%)
a
↑ represents clinically significant Emotional function 22.81 2 (13.3%) 2 (13.3%) 25.02 4 (20%) 0 (0%)
improvement in scores Social function 20.60 7 (46.7%) 0 (0%) 34.69 3 (15%) 0 (0%)
b
↓ represents clinically significant Cognitive function 26.06 3 (20%) 1 (6.7%) 31.41 3 (15%) 2 (10%)
worsening in scores
1602
while Angell et al. reported increased emotional venting for
control participants, the present study reported a decrease.
As our workbook contained numerous worksheets aimed at
facilitating emotional expression, this finding was expected.
Previous studies have posited that emotional venting was
maladaptive [16] as it was theorised to be ruminative and
could thus lead to increased distress over time. However the
opposite argument has also received empirical support: that
venting is adaptive, correlating with post-traumatic growth
[17], and is considered to be a measure of emotional
expression [18]. This in turn has been demonstrated to
reduce psychological distress [7]. In addition, there could
also be cultural differences that may impact whether
venting is considered adaptive or maladaptive. In summary,
this remains an area of controversy, and it is unclear how
venting should be interpreted.
A strength of the present study was the inclusion of
QOL as an outcome measure. The finding of impaired
cognitive functioning at baseline and subsequent im-
provement in both groups is consistent with a recent
meta-analysis [19]. The larger effect size for workbook
participants may indicate that keeping mentally active
through the workbook activities is beneficial for cognitive
functioning.
It was unsurprising that workbook engagement failed to
predict outcomes, given the small sample size. Engagement
was low for completing worksheets, but high for reading
the content; thus future studies need to consider ways to
increase interaction. This sample was difficult to recruit due
to the methodology employed. Women were recruited
through a Medical Oncology Department where only one
medical oncologist actively advertised the study, resulting
in a smaller pool of eligible women. Practical difficulties
occurred regarding ‘catching’ women after they exited
medical treatment; these survivors, by definition, were not
engaging in regular medical contact, resulting in a slower
recruitment rate. This combined with the observed drop-out
rate and qualitative feedback, that participants would have
preferred receiving the workbook during medical treatment,
leads the authors to question the feasibility of offering an
intervention to survivors.
This study followed the CONSORT statement [20],
however three limitations arose. First, the lack of power
reduced external validity and the generalisability of find-
ings. Findings need to be replicated in larger studies before
efficacy conclusions can be drawn. Second, internal validity
threats arose from women being aware of their treatment-
condition at baseline, and from workbook participants
receiving additional contact for qualitative feedback. These
threats could have created demand effects in completing
questionnaires. Finally, a large number of analyses were
performed with no Bonferroni corrections, increasing the
risk of type 1 error.
Support Care Cancer (2010) 18:1597–1603
To conclude, while trends indicate that a self-help
workbook may hold promise in facilitating coping with
breast cancer, firm efficacy conclusions cannot be drawn
due to the lack of power and possibility of chance findings.
The feasibility of implementing a self-help resource after
treatment completion could not be not demonstrated with
feedback; instead indicating that the timing for such an
intervention needs to be considered. Future research
potentially targeting diagnosis and treatment may thus be
warranted.
Acknowledgements The authors wish to thank Clinical Trials Nurse
Alison Richards and staff at Flinders Medical Centre Department of
Medical Oncology for your assistance with recruitment. Thank you
also to all the women who participated in this study. This project was
supported by the Flinders Medical Centre Foundation ‘Blokes for
Breast Cancer’ grant. Lisa Beatty was supported by an Australian
Postgraduate Award and the Flinders Medical Centre Foundation
Helen Wrigley Award. This trial is registered on the Australian New
Zealand Clinical Trials Registry.
Presented at the 42nd Australian Psychological Society annual
conference, Brisbane, Australia, 25–29 September 2007; and the 34th
Clinical Oncology Society of Australia Annual Scientific Meeting,
Adelaide, Australia, November 14–16 2007.
Conflict of interest The authors do not have a financial relationship
with the organisation that sponsored this research. The authors have
full control of all primary data and agree to allow the journal to review
our data if requested.
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