Making Internet-delivered cognitive behaviour therapy scalable for cancer survivors: a randomized non-inferiority trial of self-guided and technician-guided therapy



To compare the effectiveness and acceptability of two low-intensity methods of offering a transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) intervention for treating symptoms of anxiety and depression among cancer survivors.


Cancer survivors with symptoms of anxiety or depression (n = 86) were randomly assigned to receive a transdiagnostic ICBT programme (Wellbeing After Cancer) that was either guided by a technician (n = 42) or self-guided (n = 44). Measures of anxiety, depression, fear of cancer recurrence, and quality of life were completed at pre-treatment, post-treatment, and 4 weeks following treatment completion.


Large within-group effect sizes were observed on measures of depression, anxiety, and mental health-related quality of life (d range, 0.98–1.86) at post-treatment. Medium effects were found for reductions in fear of cancer recurrence (d range, 0.65–0.78). Non-inferiority was established for the primary outcome measures of anxiety and depression. All participants reported high satisfaction ratings of the programme; however, technician-guided participants were slightly more satisfied with their level of support (d = 0.57, p = .014).


The Wellbeing After Cancer Course was associated with improved levels of anxiety, depression, fear of cancer recurrence, and quality of life, regardless of how ICBT was offered.

Implications for Cancer Survivors

ICBT is emerging as an accessible and effective treatment for depression, anxiety, and fear of cancer recurrence in cancer survivors. The success of non-therapist-guided options increases the potential scalability of ICBT, which is particularly valuable for cancer survivors from rural areas who have less access to mental health services.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Zucca AC, Boyes AW, Linden W, Girgis A. All’s well that ends well? Quality of life and physical symptom clusters in long-term cancer survivors across cancer types. J Pain Symptom Manag. 2012;43:720–31.

    Article  Google Scholar 

  2. 2.

    Boyes AW, Girgis A, D'Este C, Zucca AC. Flourishing or floundering? Prevalence and correlates of anxiety and depression among a population-based sample of adult cancer survivors 6 months after diagnosis. J Affect Disord. 2011;135:184–92.

    Article  PubMed  Google Scholar 

  3. 3.

    Simard S, Savard J. Screening and comorbidity of clinical levels of fear of cancer recurrence. J Cancer Surviv. 2015;9:481–91.

    Article  PubMed  Google Scholar 

  4. 4.

    Harrington CB, Hansen JA, Moskowitz M, Todd BL, Feuerstein M. It’s not over when it’s over: long-term symptoms in cancer survivors—a systematic review. Int J Psychiatry Med. 2010;40:163–81.

    Article  PubMed  Google Scholar 

  5. 5.

    Linden W, Girgis A. Psychological treatment outcomes for cancer patients: what do meta-analyses tell us about distress reduction? Psycho-Oncol. 2012;21:343–50.

    Article  Google Scholar 

  6. 6.

    Muriel AC, Hwang VS, Kornblith A, et al. Management of psychosocial distress by oncologists. Psychiatr Serv. 2009;60:1132–4.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Miller BE, Pittman B, Strong C. Gynecologic cancer patients’ psychosocial needs and their views on the physician’s role in meeting those needs. Int J Gynecol Cancer. 2003;13:111–9.

    CAS  Article  Google Scholar 

  8. 8.

    Ritterband LM, Tate DF. The science of internet interventions. Ann Behav Med. 2009;38:1–3.

    Article  PubMed  Google Scholar 

  9. 9.

    Hedman E, Ljótsson B, Lindefors N. Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost–effectiveness. Expert Rev Pharmacoeconomics Outcomes Res. 2012;12:745–64.

    Article  Google Scholar 

  10. 10.

    Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One. 2010;5:e13196.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Păsărelu CR, Andersson G, Bergman Nordgren L, Dobrean A. Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: a systematic review and meta-analysis of randomized controlled trials. Cogn Behav Ther. 2017;46:1–28.

    Article  Google Scholar 

  12. 12.

    Proudfoot J, Klein B, Barak A, et al. Establishing guidelines for executing and reporting internet intervention research. Cogn Behav Ther. 2011;40:82–97.

    Article  PubMed  Google Scholar 

  13. 13.

    Titov N, Andrews G, Davies M, McIntyre K, Robinson E, Solley K. Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. PLoS One. 2010;5:e10939.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Cuijpers P, Donker T, Johansson R, Mohr DC, van Straten A, Andersson G. Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS One. 2011;6:e21274.

    CAS  Article  Google Scholar 

  15. 15.

    Titov N, Dear BF, Johnston L, Lorian C, Zou J, Wootton B, et al. Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: randomised controlled trial. PLoS One. 2013;8:e62873.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Dear BF, Staples LG, Terides MD, et al. Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: a randomized controlled trial. J Anxiety Disord. 2015;36:63–77.

    CAS  Article  Google Scholar 

  17. 17.

    Titov N, Fogliati VJ, Staples LG, et al. Treating anxiety and depression in older adults: randomised controlled trial comparing guided v. self-guided internet-delivered cognitive–behavioural therapy. BJPsych Open. 2016;2:50–8.

    Article  Google Scholar 

  18. 18.

    Dear BF, Foglaiti VJ, Fogliati R, et al. Treating anxiety and depression in young adults: a randomised controlled trial comparing clinician-guided versus self-guided internet-delivered cognitive behaviour therapy. Australia N Z J Psychiatry. 2018;52:668–79.

    Article  Google Scholar 

  19. 19.

    Baumeister H, Reichler L, Munzinger M, Lin J. The impact of guidance on Internet-based mental health interventions—a systematic review. Internet Interv. 2014;1:205–15.

    Article  Google Scholar 

  20. 20.

    Loughery J, Woodgate R. Supportive care needs of rural individuals living with cancer: a literature review. Can Oncol Nurs J. 2015;25:157–66.

    Article  Google Scholar 

  21. 21.

    Alberts NM, Hadjistavropoulos HD, Dear BF, Titov N. Internet-delivered cognitive-behaviour therapy for recent cancer survivors: a feasibility trial. Psycho-Oncol. 2015;26:137–9.

    Article  Google Scholar 

  22. 22.

    Duffecy J, Sanford S, Wagner L, Begale M, Nawacki E, Mohr DC. Project onward: an innovative e-health intervention for cancer survivors. Psycho-Oncol. 2013;22:947–51.

    Article  Google Scholar 

  23. 23.

    Seitz DCM, Knaevelsrud C, Duran G, Waadt S, Loos S, Goldbeck L. Efficacy of an internet-based cognitive-behavioral intervention for long-term survivors of pediatric cancer: a pilot study. Support Care Cancer. 2014;22:2075–83.

    Article  PubMed  Google Scholar 

  24. 24.

    Wootten AC, Abbott JAM, Chisholm K, et al. Development, feasibility and usability of an online psychological intervention for men with prostate cancer: my road ahead. Internet Interv. 2014;1:188–95.

    Article  Google Scholar 

  25. 25.

    Titov N, Dear BF, Schwencke G, et al. Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial. Behav Res Ther. 2011;49:441–52.

    Article  PubMed  Google Scholar 

  26. 26.

    Titov N, Dear BF, Johnston L, Terides M. Transdiagnostic internet treatment for anxiety and depression. Span J Clin Psychol. 2012;17:237–60.

    Google Scholar 

  27. 27.

    Hadjistavropoulos HD, Nugent MM, Alberts NM, Staples L, Dear BF, Titov N. Transdiagnostic Internet-delivered cognitive behaviour therapy in Canada: an open trial comparing results of a specialized online clinic and nonspecialized community clinics. J Anxiety Disord. 2016;42:19–29.

    CAS  Article  Google Scholar 

  28. 28.

    David N, Schlenker P, Prudlo U, Larbig W. Internet-based program for coping with cancer: a randomized controlled trial with hematologic cancer patients. Psycho-Oncol. 2013;22:1064–72.

    CAS  Article  Google Scholar 

  29. 29.

    van den Berg SW, Gielissen MF, Custers JA, van der Graaf WT, Ottevanger PB, Prins JB. BREATH: web-based self-management for psychological adjustment after primary breast cancer—results of a multicenter randomized controlled trial. J Clin Oncol. 2015;33:2763–71.

    Article  PubMed  Google Scholar 

  30. 30.

    Willems RA, Bolman CA, Mesters I, Kanera IM, Beaulen AA, Lechner L. Short-term effectiveness of a web-based tailored intervention for cancer survivors on quality of life, anxiety, depression, and fatigue: randomized controlled trial. Psycho-Oncol. 2017;26:222–30.

    Article  Google Scholar 

  31. 31.

    Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317–25.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Thekkumpurath P, Walker J, Butcher I, et al. Screening for major depression in cancer outpatients: the diagnostic accuracy of the 9-item patient health questionnaire. Cancer. 2011;117:218–27.

    Article  PubMed  Google Scholar 

  33. 33.

    Osman A, Bagge CL, Gutierrez PM, Konick LC, Kopper BA, Barrios FX. The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation with clinical and nonclinical samples. Assessment. 2001;8:443–54.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.

    CAS  Article  Google Scholar 

  35. 35.

    Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32:345–59.

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092–7.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Richards DA, Suckling R. Improving access to psychological therapies: phase IV prospective cohort study. Br J Clin Psychol. 2009;48:377–96.

    Article  PubMed  Google Scholar 

  38. 38.

    Simard S, Savard J. Fear of Cancer Recurrence Inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence. Support Care Cancer. 2009;17:241–51.

    Article  PubMed  Google Scholar 

  39. 39.

    Fardell JE, Jones G, Smith AB, et al. Exploring the screening capacity of the Fear of Cancer Recurrence Inventory-Short Form for clinical levels of fear of cancer recurrence. Psycho-Oncol. 2018;27:492–9.

    Article  Google Scholar 

  40. 40.

    Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33.

    Article  Google Scholar 

  41. 41.

    Ashing-Giwa K, Lam CN, Xie B. Psycho-Oncol. 2013;22:704–7.

    Article  Google Scholar 

  42. 42.

    Rozental A, Andersson G, Boettcher J, et al. Consensus statement on defining and measuring negative effects of Internet interventions. Internet Interv. 2014;1:12–9.

    Article  Google Scholar 

  43. 43.

    Julious SA. Sample sizes for clinical trials with normal data. Stat Med. 2004;23:1921–86.

    Article  PubMed  Google Scholar 

  44. 44.

    Dear BF, Gandy M, Karin E, et al. The pain course: a randomised controlled trial comparing a remote-delivered chronic pain management program when provided in online and workbook formats. Pain. 2017;158:1289–301.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Greene, C.J., Morland, L. A., Durkalski, V. L., & Frueh, B. C. (2008). Noninferiority and equivalence designs: issues and implications for mental health research. J Trauma Stress 2008;21:433-439. doi:

  46. 46.

    Liang KY, Seger S. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73:13–22.

    Article  Google Scholar 

  47. 47.

    Karin E, Dear BF, Heller GZ, Gandy M, Titov N. Measurement of symptom change following web-based psychotherapy: statistical characteristics and analytical methods for measuring and interpreting change. JMIR Mental Health. 2018;5:e10200.

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Gyani A, Shafran R, Layard R, Clark DM. Enhancing recovery rates: lessons from year one of IAPT. Behav Res Ther. 2013;51:597–606.

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991;59:12.

    CAS  Article  Google Scholar 

  50. 50.

    Herschbach P, Berg P, Waadt S, et al. Group psychotherapy of dysfunctional fear of progression in patients with chronic arthritis or cancer. Psychother Psychosom. 2010;79:31–8.

    Article  PubMed  Google Scholar 

  51. 51.

    Lebel S, Maheu C, Lefebvre M, et al. Addressing fear of cancer recurrence among women with cancer: a feasibility and preliminary outcome study. J Cancer Surviv. 2014;8:485–96.

    Article  Google Scholar 

  52. 52.

    Tomei C, Lebel S, Maheu C, Mutsaers B. Addressing fear of recurrence: improving psychological care in cancer survivors. Support Care Cancer. 2016;24:2815–8.

    Article  PubMed  Google Scholar 

  53. 53.

    van de Wal M, Thewes B, Gielissen M, Speckens A, Prins J. Efficacy of blended cognitive behavior therapy for high fear of recurrence in breast, prostate, and colorectal cancer survivors: the SWORD study, a randomized controlled trial. J Clin Oncol. 2017;35:2173–83.

    Article  Google Scholar 

  54. 54.

    Titov N, Dear BF, Staples LG, et al. Disorder-specific versus transdiagnostic and clinician-guided versus self-guided treatment for major depressive disorder and comorbid anxiety disorders: a randomized controlled trial. JAnxiety Disord. 2015;35:88–102.

    CAS  Article  Google Scholar 

  55. 55.

    Newby JM, Mewton L, Andrews G. Transdiagnostic versus disorder-specific internet-delivered cognitive behaviour therapy for anxiety and depression in primary care. J Anxiety Disord. 2017;46:25–34.

    Article  PubMed  Google Scholar 

  56. 56.

    Titov N, Dear B, Nielssen O, et al. ICBT in routine care: a descriptive analysis of successful clinics in five countries. Internet Interv. 2018;13:108–15.

    Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    van Straten A, Hill J, Richards DA, Cuijpers P. Stepped care treatment delivery for depression: a systematic review and meta-analysis. Psychol Med. 2015;45:231–46.

    Article  Google Scholar 

  58. 58.

    Urech C, Grossert A, Alder J, et al. Web-based stress management for newly diagnosed patients with cancer (STREAM): a randomized, wait-list controlled intervention study. J Clin Oncol. 2018;36:780–8.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  59. 59.

    Rozental A, Boettcher J, Andersson G, Schmidt B, Carlbring P. Negative effects of Internet interventions: a qualitative content analysis of patients’ experiences with treatments delivered online. Cogn Behav Ther. 2015;44:223–36.

    Article  PubMed  Google Scholar 

  60. 60.

    Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ (Clinical Research Ed). 2000;321:694–6.

    CAS  Article  Google Scholar 

  61. 61.

    Andersson G, Hedman E. Effectiveness of guided Internet-based cognitive behavior therapy in regular clinical settings. Verhaltenstherapie. 2013;23:140–8.

    Article  Google Scholar 

  62. 62.

    Andersen BL, Dorfman CS. Evidence-based psychosocial treatment in the community: considerations for dissemination and implementation. Psycho-Oncol. 2016;25:482–90.

    Article  Google Scholar 

  63. 63.

    Butow P, Shaw J, Shepherd HL, et al. Comparison of implementation strategies to influence adherence to the clinical pathway for screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP): study protocol of a cluster randomised controlled trial. BMC Cancer;18:1077.

Download references


This work was made possible in part as a result of funding provided by the Canadian Institutes of Health Research (reference numbers 293379, 152917), Saskatchewan Health Research Foundation, Rx & D Health Research Foundation, and the University of Regina Faculty of Graduate Studies and Research.

Author information



Corresponding author

Correspondence to D. Dirkse.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dirkse, D., Hadjistavropoulos, H., Alberts, N. et al. Making Internet-delivered cognitive behaviour therapy scalable for cancer survivors: a randomized non-inferiority trial of self-guided and technician-guided therapy. J Cancer Surviv 14, 211–225 (2020).

Download citation


  • Internet
  • Cognitive behaviour therapy
  • Anxiety
  • Depression
  • Cancer survivor
  • Randomized trial