Introduction
Cancer is a life-threatening disease whose diagnosis and treatment may be stressful for patients [1] and experience different levels of stress [4]. Stress is a risk factor that can increase the vulnerability of patients with cancer [5]. Anxiety and depression are also common among these patients, which can affect their quality of life (QoL) [2, 3]. Psychotherapy is considered a common non-pharmacological approach to reduce the psychological distress of cancer patients [10]. Compassion-focused therapy (CFT) is a new therapeutic approach from the third wave of cognitive therapies [13]. The basic principle of CFT is that external thoughts, emotions, images, and palliative behaviors should be internalized so that the human mind can control itself internally as a response to these external factors. In fact, CFT emphasizes relaxation, self-compassion, and mindfulness, which play a major role in relaxing the mind, reducing stress, and controlling negative automatic thoughts [13]. The CFT has become important in improving the psychological well-being of patients with physical illnesses. This study aims to investigate the effects of CFT on depression, anxiety, stress, and QoL of patients with cancer. 

Method
This a randomized controlled clinical trial with a pre-test/post-test/follow-up design conducted in Imam Khomeini Hospital, Tehran, Iran. We selected 30 patients with cancer based on inclusion and exclusion criteria. They were randomly assigned to the intervention and control groups. They filled out three questionnaires including the self-compassion scale, the depression anxiety stress scale, and the EORTC Core quality of life questionnaire before (pre-test), immediately after (post-test) and two months after (follow-up) the intervention. MANOVA was used for data analysis.

Results
In this part, the mean and standard deviation score of participants before and after intervention are presented in Table 1.


There were significant differences in depression, anxiety, and stress levels before and after intervention. This effect remained after the follow-up. The CFT reduced the level of depression, anxiety, and stress in patients with cancer (Table 2).


There was a significant difference in QoL before and after the intervention. This effect remained after the follow-up. Th CFT increased the QoL of patients with cancer (Table 3).



Discussion
The findings showed that CFT was effective in reducing depression, anxiety, and stress, and in improving the QoL of patients with cancer. The study findings are consistent with the results of some previous studies that showed a reduction in depression, stress, and anxiety levels [30, 31, 32]. Self-compassion can be considered an emotion-focused coping strategy, because it emphasizes the conscious awareness of one’s emotions, acceptance of unpleasant and painful emotions (instead of avoiding them), and understanding them as common feelings among humans. Based on this approach, individuals first recognize their emotional experiences based on consciousness and then find a compassionate attitude towards their negative emotions [12, 13]. CFT helps individuals employ more adaptive coping skills in different situations and teaches them to be more compassionate towards their painful emotions instead of avoiding them. Therefore, CFT can protect cancer patients against psychological disorders, which in turn influence the course of the disease.

Ethical Considerations
Compliance with ethical guidelines
This research was approved by the Research Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1397.098) and was registered by the Iranian Registry of Clinical Trials (IRCT no: IRCT20141108019855N4).

Funding
This article was extracted from a research project funded by Iran University of Medical Sciences, Tehran, Iran.

Authors contributions
Conceptualization, design, and draft preparation: Mahsa Mirzakhani, Banafsheh Gharaee, Komeil Zahedi Tajrishi; data interpretation and investigation: Mahsa Mirzakhani and Sajad Khanjani; writing original draft: Mahsa Mirzakhani; editing & review, and supervision: Banafsheh Gharaee  and Sajad Khanjani. All authors read and approved the final manuscript.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank Shahriar Fardad (oncology specialist) for evaluation and selection of patients, Niko Arbab (a psychologist in the oncology department), and all participants for their cooperation.


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