Influence of Acceptance Commitment Therapy (ACT) on Quality of Life of Cancer Patients: Literature Review

Introduction: The International Agency for Research on Cancer (IARC) estimates that 1 in 5 men and 1 in 5 women in the world's population will develop cancer at some point in their lives. One in eight men and one in eleven women with cancer will die. Acceptance Commitment Therapy (ACT) is a therapy that can be used to change the negative behavior of cancer patients. Objective: The purpose of this study was to explore the effect of ACT on improving the quality of life in cancer patients. Methods: This research uses a literature review method. The sample consists of 4 journals sourced from the academic databases PubMed, Google Scholar and Elseiver. Result and Discussion: The results showed that ACT had an effect on improving the quality of life of cancer patients. ACT can be given in conjunction with other therapies such as psychoeducational therapy, CBT, AT, assertive group activities, family support and others. ACT is very beneficial for cancer patients, because ACT can improve health behavior and quality of life for patients. Conclusion: ACT has an effect on improving the quality of life. Suggestion Mental Hospital in collaboration with educational institutions to develop ACT as an alternative therapy to improve the quality of life in cancer patients

Liana Pujiastuti, Erin Rika Herwina/KESANS Influence of Acceptance Commitment Therapy (ACT) on Quality of Life of Cancer Patients: Literature Review

Introduction
Cancer is one of the non-communicable diseases that burden the world's health.Cancer is a disease characterized by the uncontrolled growth of abnormal cells and the ability to invade and migrate into the cells and tissues of the body.According to the Global Burden of Cancer (GLOBOCAN) data released by the World Health Organization (WHO), 19.3 million people will be newly diagnosed with cancer in 2020, and around 10 million people will die from cancer (World Health Organization, 2019) The International Agency for Cancer Research (IARC) estimates that one in five men and one in five women of the world's population will develop cancer at some point in their lives.One in eight men and one in eleven women with cancer will die (Kemenkes, 2019) The highest incidence of cancer in men is lung cancer, with 20.1 cases per 100,000 in Indonesia.The highest incidence of cancer in women is breast cancer, which is 44 per 100,000.Of the 396,914 new cancer cases identified in 2020, 9.2% (36,633) were cervical cancer.The incidence of cervical cancer in Indonesia reaches 24.4 cases per 100,000 population, and the average death rate is 14.4 cases per 100,000 population.Cervical cancer is the second leading cause of death in women (GLOBOCAN, 2021).
Cancer is a chronic disease that affects the physical, psychological, social and economic aspects of a person's life.A cancer assessment may be accompanied by mood disturbances and changes in lifestyle or daily habits (Smeltzer & Bare, 2015).After a person is declared to have cancer, they generally experience fear, anxiety, depression and helplessness (Feist & Feist, 2010) Advances in opinion and treatment, support long-lasting cancer survivors.The main forms of cancer treatment (surgery, chemotherapy, hormone treatment, radiation treatment), long-term adverse side effects that often affect the muscles and organs of the body, and interfere with a person's health and quality of life, both large and small.Large form (Potter, 2006).Psychotherapy is important, especially in improving the quality of life in cancer cases.One treatment that can be given is ACT therapy.ACT is said to be highly effective in developing the abilities that people with depression, anxiety, substance abuse, habitual pain, post-traumatic stress disorder, anorexia and schizophrenia have in creating greater acceptance, caring and openness, and in improving life.effective in terms of quality (Widuri, 2012) Several studies in Indonesia have shown that acceptance and commitment (ACT) interventions can increase self-help in patients with chronic kidney failure.Can increase self-acceptance of people with HIV/AIDSv (Widjijati et al., 2014), and can improve personal well-being in adolescent adults after the previous decision (Kusumawardhani & Poerwandari, 2018).However, until now, research on the effect of ACT administration on the quality of life of cancer cases has not been widely carried out and cannot be explained.A study conducted by Fitriawan (Fitriawan, 2013) at one of the Puskesmas in Surabaya, found that some cancer patients experienced a decrease in their quality of life.
Health-related quality of life describes the health of a person who has complaints and undergoes surgery according to certain complaints guidelines (Suharto, 2005).The concept of quality of life for cancer patients includes limited physical health and symptoms, limited brain health, limited social wealth and limited mental health (Potter, 2006).Physical well-being includes similar symptoms and side effects such as pain, fatigue, and poor sleep quality, which affect the ability to perform diurnal conditioning.Brain well-being, refers to the ability to maintain control over anxiety, depression, fear of cancer, and problems with memory and attention.Social welfare, especially Liana Pujiastuti, Erin Rika Herwina/KESANS Influence of Acceptance Commitment Therapy (ACT) on Quality of Life of Cancer Patients: Literature Review relationships with other family members and shooters, including closeness and adultery.Efforts about employment, insurance, and finance also affect social welfare.also, spiritual well-being comes from delineating the meaning of the cancer experience, either in a religious setting or through keeping up with and adapting in the face of questions about the health of the unborn (American Cancer Society, 2011).
ACT is considered the right therapy to address the quality of life of cancer patients because ACT allows a person to accept every experience and event that has occurred and restore normal functions in daily life according to his life goals.Generally, individuals come to treat emotional control.They want to get rid of depression, anxiety, traumatic memories, fear of rejection, anger, sadness, and more.In the application of ACT there is no attempt to reduce, change, avoid or control personal experiences, but by teaching techniques to accept and commit to their experiences and feelings, ACT can be applied to all chronic disease patients, including cancer which is characterized by an adaptive response to maladaptive behavior.help patients become more comfort table and calm by accepting their situation and improve the patient's quality of life with commitments that can be fulfilled.The purpose of this study was to describe the effect of Acceptance and Commitment (ACT) on the quality of life of cancer patients.

Method
This research is a literature study.The journals come from four databases, namely Google Scholar, Pubmed, Elseiver and ResearchGate.The keywords used in the Google Scholar-based data are a combination of Acceptance Commitment Therapy, quality of life and cancer sufferers.Inclusion criteria were therapy in cancer patients and quality of life using ACT intervention.Journal using Indonesian and English, randomized controlled study or quasi-experimental study and full text.Data analysis using The Joanna Briggs Institute (JBI) Critical Appraisal Tools Result and Discussion 1.

Results
The results of the literature review carried out 4 accredited and indexed journals as national and international journals in accordance with the inclusion criteria in the literature study conducted.From these results, researchers got several nonpharmacological therapies other than ACT that can be given to cancer patients such as CBT, AT, assertive group activities, family support and others.Based on the results of the analysis of researchers from 4 journals, it can be seen that various designs, interventions, and populations were used in the selected research.For examples the population of cervical cancer, breast cancer and mixed cancers (genitourinary, head and neck, lymphoma, lung, and stomach).It can be seen the frequency of ACT administration at intervals of 3 months to 6 months with training sessions between 3-9 training sessions.
While the length of sessions in the included studies varied, it was detected that the sessions lasted 45 to 90 minutes per session.Within the scope of the included studies, the longest study of interventional ACT was 9 sessions over a period of 6 months (Smith et al., 2022), while the shortest study had four sessions.ACT interventions are generally carried out by trained doctors and nurses.
The results of this literature review found that from the 4 journals that became the source of this study, the results were almost the same, namely ACT was effective in improving the quality of life in cancer patients, this was in accordance with the purpose of ACT therapy itself which taught acceptance of events that caused thoughts and feelings to occur.unpleasant feelings of being able to live a more meaningful life by committing to better behavior.So that if the client is able to apply ACT therapy in his ability to deal with problems, it is certain that the behavior carried out can reduce the symptoms that arise from the problems that occur.

Discussion
Based on the 4 journals that became the source of this literature review, all of them conducted research on the effect of ACT on improving the quality of life.However, there is also 1 journal that not only examines the effect of ACT on quality of life but also examines the effect of ACT on treatment decision making, namely a study conducted by Smit (Smith et al., 2022).Based on the analysis of journals conducted, all (4 journals) obtained the same result, namely ACT has a significant influence in improving the quality of life of cancer patients.
Starting from this research, it can be explained that ACT is very effective in improving the quality of life of cancer patients, because ACT is given to train individuals to be active and open to what they feel in themselves so that this increases the patient's awareness and ability of what he wants in his life.This is in accordance with the opinion expressed by Corey G. (Gerald, 2013) that it is appreciated.ACT utilizes homework and behavioral exercises as a way to create larger patterns of effective action that will help patients live by their values.The focus of ACT is to allow experiences to come and go while pursuing a meaningful life.
A review of the research conducted by Suhardin (Suhardin et al., 2016) showed that the average score of the respondents' quality of life before the ACT was carried out was 48.6 and after the ACT the average score of the respondents' quality of life increased to 62.5.The results of the bivariate paired t test on the general health/quality of life (QoL) scale have a significance level or p-value = 0.000, which means that giving ACT has an effect on improving the quality of life of cancer patients.
The results of a study conducted by Kasdi (Kasdi et al., 2015) obtained the results of the average quality of life of cervical cancer patients 1, before ACT was 60 and after being given ACT increased to 103.As for respondent 2 that the average value of quality of life before ACT was 64 and the average quality of life after ACT is 94.Based on these results, it can be proven that ACT is more effective than Respondent 2 in improving the quality of life of Respondent 1.
This happens because Respondent 2 refuses the diagnosis, causing him to delay getting himself checked, even though he already knows that These symptoms cause cervical cancer.Respondent 2 is afraid of being diagnosed with cervical cancer.Respondent 2's refusal was also seen during further examination and action, the body became tense, it was difficult to do a biopsy (tissue removal), and general anesthesia was needed.When blood is drawn or infused, the body can become so tense that the blood vessels cannot be seen clearly and must be stabbed repeatedly.This actually hinders the examination process and makes it more painful.
A study conducted in Australia, it was found that ACT had an effect on improving the quality of life of cancer patients, increasing significantly from pre to post and from pre to follow-up (Feros et al., 2013).In a study that met the study criteria, ACT has been reported to improve the quality of life of female patients with early-stage breast cancer on adjuvant endocrine therapy (Shi et al., 2021) Liana Pujiastuti, Erin Rika Herwina/KESANS Influence of Acceptance Commitment Therapy (ACT) on Quality of Life of Cancer Patients: Literature Review Based on the results of a literature study on ACT on improving the quality of life of cancer patients, in addition to ACT (Acceptance Commitment Therapy), in its development process, according to Vernon, A., & Doyle, KA (2017), there are several types of approaches therapy that specifically involves changes and affects the way of thinking or better known as Cognitive Behavior Therapy (CBT).The second generation of CBT.The most popular ones today are those that add emotion to the therapy, namely Emotional Freedom Therapy (EFT) and Spiritual Emotional Freedom Technique (SEFT).
According to the chronology (DiGiuseppe et al., 2017), have reported that the initial stage of therapy in influencing thinking is known as Cognitive therapy, namely therapy that focuses on identifying, analyzing and changing thinking patterns that inaccurate or distorted.These inappropriate thoughts will then affect the emotional response and individual behavior problems.Psychologically, thoughts, feelings and behavior have a very close relationship and influence each other.There is a cycle between thoughts, feelings and behavior.
In this systematic review 4 studies investigated the effects of ACT interventions on the quality of life of cancer survivors.The aim of this review is to integrate evidencebased knowledge and experience related to the use of ACT in the cancer population into the nursing literature.Overall, the results provide support that the ACT intervention has a positive effect on improving the quality of life in cancer patients.This study provides an opportunity to reflect on the effects of ACT in clinical settings, and in populations with different symptom structures.Due to this heterogeneity, further studies are needed to support the findings.This review of literature shows that various interventions and improvements in the quality of life of cancer patients are varied.This can be due to the number of samples in different studies.For this reason, the findings should be considered in the present context of the limited literature published for the year of publication.
In addition to ACT, there are other factors that can affect the quality of life of cancer patients, including psychological morbidity, more severe physical symptoms, functional disorders, and non-adherence to treatment.The quality of life of cancer patients can also be improved by adherence to treatment and reducing health care costs.Several studies have shown that theory-based health behavior modification therapy is more successful than non-theory-based treatments.According to health behavior theory, behavior is influenced by individual, inter-group, and group/organization/society levels.There are various theories of health behavior that have been used: the transtheoretical model, the social cognitive theory, the health belief model, and the reasoned action theory/planned action theory.Using a variety of cognitive transformation strategies, these theories aim to directly change problematic attitudes and cognitions (eg, goal setting).
ACT-based treatments were used for the first time in the Can Change study to improve various health behaviors among cancer survivors."Psychotherapy," a sciencebased third-generation cognitive behavioral therapy, is defined as "the ability to participate in the present moment more fully as a conscious human being and the ability to modify or persist in behavior, when doing so, it achieves the desired outcome."This is because ACT believes that cognition is real.Unlike other behavior modification theories, this theory focuses on changing a person's relationship with cognition, whereas other behavior modification theories seek to change the person's interactions; In order to change one's behavior, one must make a conscious decision to act according to one's personal ideals.
Liana Pujiastuti, Erin Rika Herwina/KESANS Influence of Acceptance Commitment Therapy (ACT) on Quality of Life of Cancer Patients: Literature Review Internal barriers to establishing and maintaining a positive quality of life include pressure and self-defeating beliefs.Consequently, by encouraging connection and commitment to personal values associated with self-management of positive health behaviors, ACT expands existing intervention techniques.Cancer, chronic pain, diabetes, epilepsy, smoking, and obesity have all been shown to be beneficial with ACT treatment in several trials.As a result, ACT therapy proved to be effective.This review that researchers have done, needs to be done on a larger scale.In order to generalize the results of this review to cancer patients, it is necessary to take into account that each cancer is different in terms of its natural history and pathology, as well as in terms of treatment procedures and side effects.The focus of previous studies was on quality of life and behavioral health outcomes, as opposed to psychological consequences.
This review examines the quality of life of cancer patients, as well as the development of post-traumatic measures such as chemotherapy for cancer patients, there is a relationship between post-traumatic development (PTSD) and spirituality.Examining the impact and function of actions such as self-acceptance and attention, this study also examines that a number of previous ACT therapies have shown that ACT can improve the quality of life of cancer patients.In addition, ACT also has a beneficial impact on psychological functioning.This ACT intervention was designed to improve psychosocial outcomes (post-traumatic development and spirituality, coupled with adversity and barriers) and cancer-specific quality of life in addition to greater gains in cancer-specific outcome measures (acceptance and attention).This means that changes in the ACT process factors must have an impact on the quality of life

Conclusion
There are several methodological considerations in connection with the results of a literature study which shows that there is an effect of Acceptance Commitment Therapy (ACT) on improving the quality of life of cancer patients.This is because from the 4 journals used as sources in this study, there are differences in population and when, who and how long ACT interventions are given to patients, but the results of this literature review can be used as initial evidence that ACT can be applied as an alternative to standard treatment in cancer patients.ACT has a positive effect on improving the quality of life of cancer patients.ACT is seen as a logical to be used and carried out by mental nurses in providing nursing care to cancer patients who have decreased quality of life.
ACT therapy can be given in conjunction with other therapies such as CBT therapy, AT, psychoeducation, assertive group activities, family support and others.ACT is very beneficial for cancer patients, because ACT is able to improve patient behavior, reduce symptoms of mental disorders and can increase patient compliance with treatment programs.
Liana Pujiastuti, Erin Rika Herwina/KESANS Influence of Acceptance Commitment Therapy (ACT) on Quality of Life of Cancer Patients: Literature Review