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Introduction: After the declaration of the COVID-19 pandemic, health services have had to adapt to be delivered by eHealth tools. Cancer population has extensively experienced this disruption due to non-urgent in-person visits being deferred to avoid disease aggravations caused by the spread of the virus. Despite the extensive literature assessing the efficacy of telepsychology in cancer, clinical effectiveness remains unclear. Since Therapeutic Alliance in digital settings appears to be established by mechanisms different than those of in-person interventions, Digital Therapeutic Alliance could work as a particular predictor, moderator, or mediator variable of telepsychology effectiveness. The aim of this narrative overview is to present a broad summary that describes the use of eHealth in psycho-oncology, to later focus on exploring the state of knowledge regarding the establishment of Digital Therapeutic Alliance in this particular setting. Method: The search was conducted from July to September 2021 in four electronic databases. There were three search layers: ���telepsychology���, ���psycho-oncology��� and ���therapeutic alliance���. Special attention was paid to reviews and those articles contradicting the regular findings. Results: The research on Digital Therapeutic Alliance in psycho-oncology is limited. The overview has extrapolated the results of general mental health interventions to cancer patients since the characteristics of patients and their diagnoses do not seem to differ when considering previous reviews on the subject. Conclusion and future perspectives: The relational dimension between the therapist and the patient is essential in telepsychology for the development of the therapeutic process and for the intervention outcomes. The literature about Digital Therapeutic Alliance presents uneven and inconclusive results, and the professional���s perspective is poorly developed. It is essential to know how this Alliance is established and which are its barriers and facilitators, both in patients and professionals, and in the different digital formats. With that knowledge, the mechanisms of change and the specific moderators between Alliance and intervention outcomes could be identified. Considering the currently limited access to conventional psychosocial care and leveraging the rapid advances in digital cancer care due to the COVID- 19 pandemic, integrating future findings on Digital Therapeutic Alliance to comprehensive cancer treatments will support the development of more accessible and effective telepsychological interventions., Psicosom��tica y Psiquiatr��a, N��m. 20 (2022): enero-febrero-marzo

Psychosocial interventions prevent emotional distress and facilitate adaptation in breast cancer (BC). However, conventional care presents accessibility barriers that eHealth has the potential to overcome. ICOnnecta’t is a stepped digital ecosystem designed to build wellbeing and reduce psychosocial risks during the cancer journey through a European-funded project. Women recently diagnosed with BC in a comprehensive cancer center were offered the ecosystem. ICOnnecta’t consists of four care levels, provided according to users’ distress: screening and monitoring, psychoeducation campus, peer-support community, and online-group psychotherapy. Descriptive analyses were conducted to assess the platform’s implementation, while multilevel linear models were used to study users’ psychosocial course after diagnosis. ICOnnecta’t showed acceptance, use and attrition rates of 57.62, 74.60, and 29.66%, respectively. Up to 76.19% of users reported being satisfied with the platform and 75.95% informed that it was easy to use. A total of 443 patients’ needs were detected and responsively managed, leading 94.33% of users to remain in the preventive steps. In general, strong social support led to a better psychosocial course. ICOnnecta’t has been successfully implemented. The results showed that it supported the development of a digital relation with healthcare services and opened new early support pathways.

Health education and psychosocial interventions prevent emotional distress, and the latter has been shown to have an impact on survival. In turn, digital health education interventions may help promote equity by reaching a higher number of cancer patients, both because they avoid journeys to the hospital, by and having a better efficiency. A total of 234 women recently diagnosed with breast cancer in a comprehensive cancer center used the digital ecosystem ICOnnecta’t from March 2019 to March 2021. ICOnnecta’t consists of four care levels, provided to patients according to their level of distress. The second level of this intervention consists of an educational campus, which was analyzed to track users’ interests and their information-seeking behavior. Overall, 99 out of 234 women (42.3%) used the educational campus. There were no significant differences in sociodemographic and clinical variables between the campus users and non-users. Among users, the median number of resources utilized per user was four (interquartile range: 2–9). Emotional and medical resources were the contents most frequently viewed and the audiovisual format the most consulted (p < 0.01). Resources were used mainly within the first three months from enrolment. Users who were guided to visit the virtual campus were more active than spontaneous users. Offering an early holistic health educational platform inside a digital cancer ecosystem, with health professionals involved, can reach more patients, promoting equity in the access of cancer information and prevention, from the very beginning of the disease.

Background/Objective: Environmental factors such as psychosocial stress have demonstrated to have an impact on the breast cancer (BC) course. This study aims to explore the impact of psychotherapy and stressful life events (SLE) on BC survivors’ illness trajectories. Method: 68 women with BC underwent Positive Psychotherapy or Cognitive-Behavioral Stress Management and 37 patients were included as a control group. The effects of distress reduction and SLE on their 5-year recurrence were investigated. Additional analyses examined the effect of receiving vs. not receiving psychotherapy and of the type of therapy on survival and disease-free interval, DFI. Results: A one-point decrease of the Hospital Anxiety and Depression Scale (HADS) after psychotherapy predicted a lower risk of 5-year recurrence, OR = 0.84, p = .037, 95% CI = 0.71-0.99). Also, a one point-increase in the number threatening SLE (OR = 1.92; p = .028, 95% CI = 1.07-3.43) was related to higher 5-year recurrence. Conclusions: The findings highlight the necessity of studying not only a given situation (i.e., psychotherapy, SLE) but its specific impact on individuals. Antecedentes/Objetivo: El estrés psicosocial ha demostrado tener un impacto en la evolución del cáncer de mama (CM). Este estudio tiene como objetivo explorar el impacto de la psicoterapia y de los acontecimientos vitales estresantes (AVE) en la supervivencia de pacientes con CM. Método: 113 mujeres con CM recibieron psicoterapia positiva o terapia cognitivo-conductual para manejar el estrés y 37 se incluyeron como grupo control. Se analizaron los efectos de la reducción de la Escala de Ansiedad y Depresión Hospitalaria (HADS) y de los AVE sobre la recurrencia a los cinco años, así como el efecto de recibir psicoterapia y del tipo de enfoque d esta sobre la supervivencia. Resultados: La reducción de un punto en la HADS después de recibir psicoterapia predijo un menor riesgo de recurrencia, OR = 0,84, p = 0,037, IC 95% = 0,71-0,99. Además, cada aumento en el número de AVE vividos como amenazantes (OR = 1,92; p = 0,028, 95% CI = 1,07-3,43) se relacionó con una mayor recurrencia. Conclusiones: Los resultados indican la necesidad de estudiar no solo la presencia de un evento potencialmente impactante en la conducta (psicoterapia o AVE) sino el efecto especifico que ha tenido en cada individuo.

IntroductionPsychosocial interventions for patients with breast cancer (BC) have demonstrated their effectiveness at reducing emotional distress and improving quality of life. The current digitisation of screening, monitoring and psychosocial treatment presents the opportunity for a revolution that could improve the quality of care and reduce its economic burden. The objectives of this study are, first, to assess the effectiveness of an e-health platform with integrated and stepped psychosocial services compared with usual psychosocial care, and second, to examine its cost–utility.Methods and analysisThis study is a multicentre randomised controlled trial with two parallel groups: E-health intervention with integrated and stepped psychosocial services vs usual psychosocial care. An estimated sample of 338 patients with BC in the acute survival phase will be recruited from three university hospitals in Catalonia (Spain) and will be randomly assigned to one of two groups. All participants will be evaluated at the beginning of the study (T1: recruitment), 3 months from T1 (T2), 6 months from T1 (T3) and 12 months from T1 (T4). Primary outcome measures will include number of clinical cases detected, waiting time from detection to psychosocial intervention and proportion of cases successfully treated in the different steps of the intervention, as well as outcomes related to emotional distress, quality of life, post-traumatic stress and growth, treatment adherence and therapeutic alliance. Secondary outcomes will include the acceptability of the platform, patients’ satisfaction and usability. For the cost–utility analysis, we will assess quality-adjusted life years and costs related to healthcare utilisation, medication use and adherence, work absenteeism and infrastructure-related and transport-related costs.Ethics and disseminationThis study was approved by the Ethics committee of the Institut Català d’Oncologia network in Hospitalet, Spain. Findings will be disseminated through peer-reviewed journals, reports to the funding body, conferences among the scientific community, workshops with patients and media press releases.Trial registration numberOnline Psychosocial Cancer Screening, Monitoring and Stepped Treatment in Cancer Survivors (ICOnnectat-B),NCT04372459.

espanolIntroduccion: A pesar de que los tratamientos psico-oncologicos han demostrado su efectividad en disminuir el malestar emocional y mejorar la calidad de vida de las personas con cancer, aun existen numerosas barreras que limitan su acceso. La transformacion a online de esta atencion se plantea como una solucion para aumentar la cobertura del servicio y mejorar su coste-utilidad. Objetivo: Crear un ecosistema digital de salud para reducir el impacto del cancer, aumentando el bienestar y la calidad de vida del ciudadano con cancer. Metodo: Programa dirigido a pacientes diagnosticadas de cancer de mama en fase de supervivencia aguda. Es un programa de atencion escalonada dividido en 4 niveles de intervencion jerarquizados por complejidad: Nivel 1, cribado y monitorizacion psicosocial; Nivel 2, Campus: psicoeducacion y educacion sanitaria; Nivel 3, soporte psicosocial comunitario; y Nivel 4, tratamiento psicoterapeutico grupal. Resultados: En 2019, 259 mujeres fueron incluidas en el programa (39,91% de los nuevos casos de cancer de mama en los centros participantes). Solo el 3,47% (n = 9) requirio atencion clinica especializada (Nivel 4).Conclusion: El programa Iconnecta’t adopta un modelo integrado de atencion psicosocial en cancer que se adecua a las necesidades especificas de los supervivientes. Da solucion a algunas de las barreras de la atencion sanitaria tradicional, democratizando el acceso a los servicios mediante el uso de tecnologias de uso comun en la mayoria de ciudadanos. En un futuro proximo se preve la implementacion progresiva a otras neoplasias, junto con un ensayo clinico controlado y aleatorizado que evaluara su eficacia EnglishIntroduction:Although psycho-oncological treatments have already demonstrated theireffectiveness in reducing emotional distress and improving quality of life in people with cancer, there are still numerous barriers limiting their access. The digital transformation of care is proposed as a solution to increase service coverage and improve its cost-utility. Aim: Create a digital health ecosystem to reduce the impact of cancer, increasing users’ well-being and quality of life. Method: The program is addressed to patients diagnosed with breast cancer in the acute survival phase. It is a stepped-care intervention divided into 4 levels ordered by complexity: Level 1, psychosocial screening and monitoring; Level 2, Campus: psychoeducation and health education; Level 3, psychosocial community support; and Level 4, psychotherapeutic group treatment. Results: In 2019, 259 women were included in the program (39.91% of new breast cancer cases in participating centers), and only 3.47% (n= 9) required specialized clinical care (Level 4). Conclusions: The Iconnecta’t program adopts an integrated model of psychosocial care in cancer that adapts to survivors’ specific needs. It overcomes some of the barriers of traditional healthcare, democratizing service access through the use of common technologies among the vast majority of citizens. In the near future, progressive implementation to other cancer diagnoses is planned, together with a randomized controlled trial to evaluate its effectiveness

Background: The therapeutic role of humor and hospital clowns has become a focus of interest in recent decades. Most of the research in the area has focused on children; here, we explore the influence of clown performances on adult cancer patients, their companions, and health-care staff.Methods: Ninety-nine cancer patients and 113 companions were assessed pre- and post-interventions performed by professional clowns; 31 health professionals were asked about the possible influence of the presence of clowns in hospital on their work.Results: Patients felt that clowning performances helped to reduce their level of psychological symptoms, but not their physical symptoms. Companions reported improvements in all the psychological symptoms explored. Health professionals reported that the presence of clowns in the workplace improved their well-being.Conclusions: Clowning performances helped to improve psychological functioning in all the populations studied, especially in companions. Adult hospitals should consider promoting clowning interventions to improve general well-being.

Objective To study the impact of the spontaneous use of Internet on breast cancer patients and on their relationship with health professionals. Methods A mixed methodology was used. Two questionnaires were designed through three focus groups, and then administered to 186 patients and 59 professionals in order to assess: (1) patients' use of Internet for health-related information and (2) the impact of this information on patients' psychological outcomes and on their relationship with professionals. Results Patients spent more time looking for illness-related information after diagnosis, using interactive communities more than static information websites. Patients and professionals disagreed about the use of Internet in terms of the knowledge it provides, and its psychological impact. The main barrier reported by patients regarding the sharing of online information with their professionals was the belief that it would damage their relationship. Conclusions Both professionals and patients have a protectionist conception of the therapeutic relationship. This attitude tends to dismiss the positive impact that the use of Internet and the new communication tools may have in cancer patients. New resources should provide an "Internet Prescription" and modes of interaction to facilitate a more open digital communication.