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Psychological intervention reduces cancer survivors’ fear of recurrence
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CHICAGO — A psychological intervention called Conquer Fear more effectively reduced cancer survivors’ fear of recurrence than relaxation training, according to long-term results of a randomized phase 2 trial presented at ASCO Annual Meeting.
The reductions were large enough to improve survivors’ psychological and emotional well-being.
“New treatments are increasing survival from cancer, but fear of recurrence is a real issue,” Jane McNeil Beith, MD, PhD, medical oncologist at University of Sydney in Australia, said during a press conference. “This is one of the first studies to show the benefit from a psychological intervention.”
About 50% of all cancer survivors report clinically significant fear of recurrence. That rate approaches 70% for young breast cancer survivors, according to study background.
“This fear can persist over the whole trajectory of their illness and out to over 6 years after diagnosis,” Beith said. “Fear of cancer recurrence is associated with poor quality of life, greater distress, lack of planning for the future, avoidance of or excessive screening, and radical health care utilization.”
Beith and colleagues developed a novel psychological intervention called Conquer Fear to try to modify survivors’ fears of recurrence. They based the intervention on metacognition.
“Metacognition is worrying about worrying,” Beith said. “A cancer survivor will worry that, if they don’t worry about their cancer coming back, that it won’t be caught early and they’ll have worse survival.”
Conquer Fear — used in research but not clinical practice — is designed to help cancer survivors accept the inherent uncertainty about whether cancer will recur; better control worry and where they place their attention; focus on what they want out of life; and choose a sensible level of cancer screening.
Beith and colleagues conducted a parallel randomized controlled trial to assess Conquer Fear’s effect on fear of recurrence among 222 survivors of stage I to stage III breast cancer, colorectal cancer or melanoma.
All study participants had completed treatment 2 months to 5 years earlier, and they were cancer free at baseline.
All participants completed a validated 42-item questionnaire called Fear of Cancer Recurrence Inventory at baseline. Inventory scores range from 0 to 168, with lower scores suggesting less fear of recurrence. Eligible study participants scored above the clinical cutoff (13 or higher).
Researchers randomly assigned 121 survivors to the Conquer Fear intervention, delivered by trained study therapists in five 60- to 90-minute face-to-face sessions over 10 weeks. The sessions incorporated several components, including detached mindfulness, or the ability to focus on the moment; values clarification, or the importance of planning for the future; metacognitive therapy, intended to help survivors learn what to worry about and what not to worry about; and behavioral contract, intended to ensure survivors pursued appropriate follow-up care.
Investigators assigned the other 101 participants to a control regimen of relaxation training, shown in prior studies to reduce anxiety and depression among cancer survivors. The relaxation training, also administered by trained therapists, consisted of five 60-minute, individual face-to-face relaxation sessions over 10 weeks.
Study participants assigned to relaxation training had higher average Fear of Recurrence Inventory scores at baseline (85.7 vs. 82.7).
Beith and colleagues readministered the Fear of Cancer Recurrence Inventory to study participants after completion of their assigned intervention, and at 3 months and 6 months after intervention completion.
Investigators conducted independent t-tests to measure change in fear of recurrence, and they considered a 14.5-point difference to be statistically significant.
Reduction in Fear of Cancer Recurrence Inventory immediately after completion of the intervention served as the primary endpoint.
Participants in both groups demonstrated improvement in all outcomes.
Survivors assigned Conquer Fear demonstrated significantly greater reduction in fear of cancer recurrence than the control group between baseline and immediately after the assigned intervention (difference, –10.5; 95% CI, –16.1 to –4.9).
Those assigned Conquer Fear also demonstrated greater reduction in fear of recurrence at 3 months (difference, –7.6; 95% CI, –13.9 to –1.4) and 6 months (difference, –7.8; 95% CI, –14.2 to –1.4). By 6 months after the intervention, mean Fear of Cancer Recurrence Inventory scores had decreased by 27.2 points among those assigned Conquer Fear and by 17.8 points among those assigned relaxation training.
Beith and colleagues also reported greater positive effect with Conquer Fear on secondary outcomes, including anxiety, cancer-specific distress quality of life and metacognition. These benefits were statistically significant between baseline and immediately after conclusion of the intervention; however, results showed no statistically significant differences at 3 or 6 months.
Although Conquer Fear is effective in a face-to-face format, it is a time- and resource-intensive approach, Beith and colleagues wrote.
It may be possible to deliver the intervention in other formats, such as in a group setting, by telephone or online. A stepped-care approach, in which only those with severe fear of recurrence receive the face-to-face intervention, could be considered, researchers wrote.
Although experienced psycho-oncologists delivered the intervention in this study, it may be possible that community psychologists or other professionals who have basic training in cognitive therapy could be used, Beith added.
“In the future, we will do an economic evaluation, and also explore more accessible and less costly formats, such as online, group or community interventions,” Beith said. – by Mark Leiser
Disclosure: Cancer Australia, beyondblue and National Breast Cancer Foundation funded the study. One researcher reports a speakers bureau role with McGrath Foundation.
Reference:
Beith JM, et al. Abstract LBA10000. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.
Perspective
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Don S. Dizon, MD, FACP
We as oncologists only have about 15 minutes with our patients, and the assessments for our patients — even during follow-up — for the most part concentrate on cancer-related outcomes, because that’s what our patients want to know. When they leave that room, we all assume everybody has a certain level of fear of recurrence, and we accept that as normal. This study shows this fear is a real phenomenon among patients treated for cancer, and it can last out to 6 years. It is important for us to recognize not only that this fear is real — and our patients love to hear that this isn’t just in their minds — but that we can do something about it. If we can’t do an intervention like Conquer Fear, we can at least tell our patients that something as simple as recommending relaxation techniques can improve their lives. We need more interventions and we need to recognize that there are things our patients go through after cancer that are real, that are significant, and that can not only impact their lives but also the lives of their families.
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