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Abstract

Background: Each year world-wide, more than 14 million people receive a diagnosis of cancer. More than 32 million people have received a cancer diagnosis during the last five years, and this number will exponentially increase in the coming decade thanks to improved medical technologies. For an individual, a diagnosis of cancer includes many practical, physical, psychological and existential challenges. It seems understandable that approximately 12% of all cancer patients experience clinical levels of depression, and up to 70% report distress related to existential challenges, such as having to find new priorities and meaning in life, and being confronted with lifeâ??s hardships. More and more psychological studies show that these existential factors are at the heart of the cancer patientsâ?? experience of stress. That is, difficulties in coping with cancer cannot only be attributed to having â??unhelpful cognitionsâ?? or â??inadequate problem-solving skillsâ??, but also to the inherent existential meaning of having cancer. For that reason, also more and more psychotherapeutic interventions are being developed to help cancer patients to cope with these existential topics. A systematic literature review will discuss the therapeutic techniques and effectiveness of these existential therapies. Method: We will discuss our systematic literature review and meta-analyses of existential psychotherapies for cancer patients. The mean effect size of existential therapies will be calculated, and the effects of possible moderators and therapeutic mechanisms will be discussed. Results: We found 20 Randomized Controlled Trials (RCT) and 27 other trials, comprising a total of more than 4000 participants. We included 14 RCTs with unique data. Nine included cancer-patients, three patients with other physical diseases, and two care professionals; no significant group differences were found. The studies described four different types of existential therapies: meaning-oriented, supportive-expressive, experiential-existential and cognitive-existential therapies. Meaningoriented therapies directly address meaning in life and show large effects on creating positive meaning in life immediately post-intervention and at follow-up, and have moderate effects on anxiety/depression and self-efficacy (n=6 RCTs; Cohenâ??s d=.64, .57, .47, .48, respectively). Supportive-expressive therapies focuses on emotional expression and support and have small post-treatment effects on anxiety/depression (n=4 RCTs; d=.19). Experiential-existential therapies (n=2 RCTs) focus on the emotional-existential experience of having cancer and cognitive-existential therapies integrates cognitive and existential techniques (n=1 RCT), but both show no significant effects. No significant long-term effects were shown for supportiveexpressive, experiential-existential and cognitive-existential interventions. Additional analyses of the 27 non-RCT trials showed very similar results, adding that meaning-therapies can improve bio-immunological functioning, although a larger risk-ofbias was found in the ways how these trials were reported. Moderator and mediation analyses suggested several significant factors, such as existential therapies being more effective when they directly discuss meaning in life with cancer patients, have a structured manualised approach, and explicitly focus on tolerating both positive and negative cancer-related experiences. Discussion: This literature review indicates that it is helpful to explicitly address existential topics with cancer patients. The effect sizes are similar or larger than other psycho-oncological interventions that focus on cognitive-skills, problem-solvingskills, emotional support or mindfulness. Implications are discussed, such as developing therapies integrating different therapeutic approaches and explicitly embedding these therapies in the psychological literature on resilience.

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