Background and rationale 
anxiety, cancer, chest pain, Breathlessness, breathlessness, CBTs, breathing difficulties, hyperventilation
DISEASE PROGRESSION, RECURRENCE, CANCER, DISEASE, RECURRENT DISEASE, RECURRENT CANCER
There are over 170,000 people living with and beyond a cancer diagnosis in Ireland [COVID-19 is reported to have initially emerged in Wuhan, China, in late 2019, spreading rapidly and resulting in the global pandemic that has characterised life since early 2020 [In 2021, the Mater Misericordiae University Hospital (MMUH) developed a specialised Psycho-Oncology service seeking to address the psychological issues facing patients with cancer diagnoses. Psychological oncology interventions seek to address the psychological, behavioural, medical and social factors that may influence the disease process and the patients’ experience of their care. It recognises that cancer has a significant psychological impact on patients and families and that this can occur at any time from the time of diagnosis onwards. It has been reported that between 20 and 52% of patients show a significant level of psychosocial distress with between 10 and 15% of that group experiencing significant levels of distress [To our knowledge, the psychological distress caused by a cancer recurrence since the onset of the COVID-19 pandemic has not yet been evaluated, though several studies cite a fear of recurrence or disease progression among patients [Compassion-focussed therapy (CFT) is an increasingly popular form of psychological therapy and is considered part of the third wave of cognitive behavioural therapies (CBTs). It is an approach that helps people develop and work with experiences of inner warmth and acceptance, self-soothing and self-compassion [Breathing pattern retraining (BPR) methods activate bodily reactions linked to hyperventilation and can be utilised to facilitate states of relaxation and self-soothing. Some physical sensations from stress and anxiety present as dysfunctional breathing including breathing difficulties, breathlessness and chest pain, symptoms commonly experienced in cancer. Breathlessness is a symptom that features commonly in cancer, particularly in advanced or recurrent disease, and may be linked to breathing dysregulation often posited to be caused by autonomic nervous system disturbances. Drivers of this include fear, stress and anxiety and can lead to autonomic nervous system arousal which leads to an increased ventilatory drive, which in turn leads to altered breathing patterns becoming established and perpetuating the cycle of dysfunctional breathing and anxiety triggers. Given that effective, efficient, responsive and appropriate breathing patterns are influenced by complex interactions between biochemical, biomechanical and cognitive emotional factors, developing a collaborative programme between both physiotherapy and psychology to address all three elements would support its effective management in this patient group. Dysfunctional breathing symptoms can be helped by (i) breathing retraining exercises, (ii) guided relaxation and (iii) mindfulness. We therefore aim to develop an intervention to address physical and psychological symptoms that impact breathing and anxiety [In summary, our combined intervention seeks to address both the psychological and mechanical processes involved in the mediation of distress, within the context of cancer recurrence during the COVID-19 pandemic. This is the basis of our combined approach. We seek to examine whether a combined psychological and mechanical breathing training intervention can achieve a more reductive effect on general distress than the standard treatment, for individuals with a diagnosis of recurrent cancer since March 2020. Should the study demonstrate effective distress amelioration in the intervention arm, it would serve as the basis to roll out the intervention out at a national level to mitigate the effects of COVID-19 and its impact on healthcare in relation to this sizeable patient cohort. It is important to note that the control group (treatment as usual (TAU)) will be offered the opportunity to avail of the therapeutic intervention at a later date after their participation in the 18-week study protocol.