Abstract
Background
Evidence suggests that fear of cancer recurrence (FCR) is one of the most frequently cited unmet needs among cancer survivors and is associated with psychological distress, stress-response symptoms, and lower quality of life, as well as increased use of health care resources. Despite these factors, few manualized interventions exist to address FCR among cancer survivors.
Purpose
To develop, manualize, and pilot test the feasibility and preliminary efficacy of a 6-week cognitive-existential (CE) group intervention designed to address FCR in women with breast or ovarian cancer.
Methods
This study was a single-arm multi-site study with pre-, post-, and 3-month follow-up measurement occasions.
Results
A total of 56 breast or ovarian cancer survivors enrolled in the study; 44 completed the CE group intervention. Following the intervention, women experienced a reduction in the primary study outcome measure of FCR and secondary study outcome measures of cancer-specific distress and uncertainty. They also reported improvements in secondary study outcome measures of quality of life and coping. The effect sizes of the observed changes were for the most part in the medium to large effect range; furthermore, almost all changes were sustained at 3-month follow-up.
Conclusion
This brief intervention appears feasible and has shown promising results in addressing FCR and related secondary outcomes of cancer-specific distress, uncertainty, quality of life, and coping; however, it should be further tested using a randomized controlled study design to more definitively assess its efficacy.
Implications for Cancer Survivors
FCR is a near-universal worry for cancer survivors that, when left unaddressed, tends to remain stable over time. This study has important implications for all cancer survivors as it is the first published intervention that provides preliminary evidence of its efficacy in decreasing fear of cancer recurrence.
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Notes
At the time we started the study, there were only 4 longer (i.e. 10+ items) FCR instruments that were available: the concerns about recurrence scale (CARS) [3], the fear of recurrence questionnaire (FRQ) [31], the fear of cancer recurrence inventory (FCRI) [56], and the fear of disease progression questionnaire (FoP-Q) [57]. However, the CARS has been validated with women with breast cancer only. The FCRI and the FoP-Q have been validated with French and German cancer patients, respectively, and while English translations are available for both instruments, empirical validations of these translated versions have yet to be published. This left the FRQ as the most suitable longer measure of FCR because it is applicable to both breast and ovarian cancer patients and because it is validated in English. However, the FRQ does not have a clinical cut-off score. We attempted to select participants with moderate to high FCF by using a score of 4 or more on 50 % of the 22 items of the FRQ as an inclusion criterion. Recognizing that this method had limitations, we also used the validated cut-off score of the Impact of Events Scale (IES) to reliably identify participants who could be considered to have elevated cancer-specific distress.
We compared the effects of the intervention by cancer diagnosis (breast vs. ovarian) using repeated measures ANOVAs with cancer diagnosis as a between factor. Results revealed few differences among the two groups of participants. There was a TimeXDiagnosis difference in the use of active coping (F (2, 34) = 3.31, p < 0.05). Univariate analyses revealed that the use of active coping increased over time only among women with ovarian cancer. There were also main effects of diagnosis on the use of instrumental support (F (1, 36) = 5.35, p < 0.05) and planning coping (F (1, 36) = 5.66, p < 0.05). For both coping strategies, women with breast cancer reported more use of these strategies than women with ovarian cancer but neither group showed changes over time on either strategy.
At the suggestion of one of the reviewers, we performed additional analyses to see if time since diagnosis had any impact on our results. First, we ran bivariate correlations between time since diagnosis and the variables that were significantly impacted by the intervention (FCR, cancer-specific distress, uncertainty, use of emotional and instrumental support coping, positive reframing coping, acceptance coping, and negative quality of life) for each of the three time points. Of possible 24 comparisons, only two were significant (greater time since diagnosis was associated with greater use of acceptance coping at T1 and higher levels of cancer-specific distress at T3). We also recalculated the repeated measures ANOVAs to examine the time effects for FCR, cancer-specific distress, uncertainty, use of emotional and instrumental support coping, positive reframing coping, acceptance coping, and negative quality of life controlling for time since diagnosis as a covariate. Time since diagnosis was not a significant covariate in any of these analyses and the significance of the results remained unchanged. It thus appears that the intervention is equally effective for cancer survivors who have finished treatment, regardless of time since diagnosis.
References
Baker F, Denniston M, Smith T, West MM. Adult cancer survivors: how are they faring? Cancer Causes Control CCC. 2005;104(S11):2565–76.
Muzzin LJ, Anderson NJ, Figueredo AT, Gudelis SO. The experience of cancer. Soc Sci Med. 1994;38(9):1201–8.
Vickberg S. The concerns about recurrence scale CARS: a systematic measure of women’s fears about the possibility of breast cancer recurrence. Ann Behav Med. 2003;25(1):16–24.
Simard S, Savard J. Fear of cancer recurrence inventory: development and initial validation of a multidimensional measure of fear of recurrence. Support Care Cancer. 2009;17(3):241–51.
Fitch M, Gray RE, Franssen E. Perspectives on living with ovarian cancer: young women’s views. Rev Can Nurs Oncol. 2000;10(3):101–8.
Mehnert A, Berg P, Henrich G, Herschbach P. Fear of cancer progression and cancer-related intrusive cognitions in breast cancer survivors. Psycho-Oncology. 2009;18(12):1273–80. doi:10.1002/pon.1481.
Herschbach P, Keller M, Knight L, Brandl T, Huber B, Henrich G, et al. Psychological problems of cancer patients: a cancer distress screening with a cancer-specific questionnaire. Br J Cancer. 2004;91(3):504–11. doi:10.1038/sj.bjc.6601986.
Llewellyn CD, Weinman J, Mcguk M, Humphris G. Can we predict which head and neck cancer survivors develop fears of recurrence. J Psychosom Res. 2008;65:525–32.
van den Beuken-van Everdingen MHJ, Peters ML, de Rijke JM, Schouten HC, van Kleef M, Patijn J. Concerns of former breast cancer patients about disease recurrence: a validation and prevalence study. Psycho-Oncology. 2008;17(11):1137–45.
Crist JV, Grunfeld EA. Factors reported to influence fear of recurrence in cancer patients: a systematic review. Psycho-Oncology. 2012;22(5):978–86. doi:10.1002/pon.3114.
Simard S, Thewes B, Humphris G, Dixon M, Hayden C, Mireskandari S, et al. Fear of cancer recurrence in adult cancer survivors: a systematic review of quantitative studies. J Cancer Survivorship. 2013;7(3):300–22. doi:10.1007/s11764-013-0272-z.
Koch L, Jansen L, Brenner H, Arndt V. Fear of recurrence and disease progression in long-term (>/=5 years) cancer survivors—a systematic review of quantitative studies. Psycho-Oncology. 2012. doi:10.1002/pon.3022.
Humphris GM, Rogers S, McNally D, Lee-Jones C, Brown J, Vaughan D. Fear of recurrence and possible cases of anxiety and depression in orofacial cancer patients. Int J Oral Maxillofac Surg. 2003;32(5):486–91.
Mellon S, Northouse LL, Weiss LK. A population-based study of the quality of life of cancer survivors and their family caregivers. Cancer Nurs. 2006;29(2):120–31. quiz 32–3.
Phillips KA, Osborne RH, Giles GG, Dite GS, Apicella C, Hopper JL, et al. Psychosocial factors and survival of young women with breast cancer: a population-based prospective cohort study. J Clin Oncol. 2008;26(28):4666–71.
Lebel S, Tomei C, Feldstain A, Beattie S, McCallum M. Does fear of cancer recurrence predict cancer survivors’ health care use? Support Care Cancer. 2013;21(3):901–6.
Dow KH, Ferrell BR, Leigh S, Ly J, Gulasekaram P. An evaluation of the quality of life among long-term survivors of breast cancer. Breast Cancer Res Treat. 1996;39(3):261–73.
Thewes B, Butow P, Bell ML, Beith J, Stuart-Harris R, Grossi M, et al. Fear of cancer recurrence in young women with a history of early-stage breast cancer: a cross-sectional study of prevalence and association with health behaviours. Support Care Cancer Off J Multl Assoc Support Care Cancer. 2012;20(11):2651–9. doi:10.1007/s00520-011-1371-x.
Herschbach P, Berg P, Waadt S, Duran G, Engst-Hastreiter U, Henrich G, et al. Group psychotherapy of dysfunctional fear of progression in patients with chronic arthritis or cancer. Psychother Psychosom. 2010;79(1):31–8. doi:10.1159/000254903.
Humphris G, Ozakinci G. The AFTER intervention: a structured psychological approach to reduce fears of recurrence in patients with head and neck cancer. Br J Health Psychol. 2008;13(Pt 2):223–30. doi:10.1348/135910708X283751.
Lengacher CA, Johnson-Mallard V, Post-White J, Moscoso MS, Jacobsen PB, Klein TW, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psycho-Oncology. 2009;18(12):1261–72. doi:10.1002/pon.1529.
Lengacher CA, Johnson-Mallard V, Barta M, Fitzgerald S, Moscoso MS, Post-White J, et al. Feasibility of a mindfulness-based stress reduction program for early-stage breast cancer survivors. J Holist Nurs. 2011;29(2):107–17. doi:10.1177/0898010110385938.
Cameron LD, Booth RJ, Schlatter M, Ziginskas D, Harman JE. Changes in emotion regulation and psychological adjustment following use of a group psychosocial support program for women recently diagnosed with breast cancer. Psycho-Oncology. 2007;16(3):171–80. doi:10.1002/pon.1050.
Shields CG, Ziner KW, Bourff SA, Schilling K, Zhao Q, Monahan P, et al. An intervention to improve communication between breast cancer survivors and their physicians. J Psychosoc Oncol. 2010;28(6):610–29. doi:10.1080/07347332.2010.516811.
Lee-Jones C, Humphris G, Dixon R, Hatcher MB. Fear of cancer recurrence—a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psycho-Oncology. 1997;6(2):95–105.
Mishel MH. Uncertainty in illness. Image J Nurs Scholarsh. 1988;20(4):225–32.
Ladouceur R, Dugas MJ, Freeston MH, Leger E, Gagnon F, Thibodeau N. Efficacy of a cognitive-behavioral treatment for generalized anxiety disorder: evaluation in a controlled clinical trial. J Consult Clin Psychol. 2000;68(6):957–64.
Kissane DW, Bloch S, Miach P, Smith GC, Seddon A, Keks N. Cognitive-existential group therapy for patients with primary breast cancer—techniques and themes. Psycho-Oncology. 1997;6(1):25–33. doi:10.1002/(SICI)1099-1611(199703)6:1<25::AID-PON240>3.0.CO;2-N.
Kissane DW, Bloch S, Smith GC, Miach P, Clarke DM, Ikin J, et al. Cognitive-existential group psychotherapy for women with primary breast cancer: a randomised controlled trial. Psycho-Oncology. 2003;12(6):532–46. doi:10.1002/pon.683.
Kissane DW, Love A, Hatton A, Bloch S, Smith G, Clarke DM, et al. Effect of cognitive-existential group therapy on survival in early-stage breast cancer. J Clin Oncol Off J Am Soc Clin Oncol. 2004;22(21):4255–60. doi:10.1200/JCO.2004.12.129.
Mishel MH, Germino BB, Gil KM, Belyea M, Laney IC, Stewart J, et al. Benefits from an uncertainty management intervention for African-American and Caucasian older long-term breast cancer survivors. Psycho-Oncology. 2005;14(11):962–78. doi:10.1002/pon.909.
Edelman S, Kidman AD. Description of a group cognitive behaviour therapy programme with cancer patients. Psycho-Oncology. 1999;8(4):306–14. doi:10.1002/(SICI)1099-1611(199907/08)8:4<306::AID-PON387>3.0.CO;2-Y.
Spiegel D, Morrow GR, Classen C, Raubertas R, Stott PB, Mudaliar N, et al. Group psychotherapy for recently diagnosed breast cancer patients: a multicenter feasibility study. Psycho-Oncology. 1999;8(6):482–93.
Northouse LL. The impact of cancer in women on the family. Cancer Pract. 1995;3(3):134–42.
Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosom Med. 1979;41(3):209–18.
Stanton AL. Psychosocial concerns and interventions for cancer survivors. J Clin Oncol Off J Am Soc Clin Oncol. 2006;24(32):5132–7. doi:10.1200/JCO.2006.06.8775.
Faller H, Schuler M, Richard M, Heckl U, Weis J, Kuffner R. Effects of psycho-oncologic interventions on emotional distress and quality of life in adult patients with cancer: systematic review and meta-analysis. J Clin Oncol Off J Am Soc Clin Oncol. 2013;31(6):782–93. doi:10.1200/JCO.2011.40.8922.
Lerman C, Schwartz MD, Miller SM, Daly M, Sands C, Rimer BK. A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style. Health Psychol Off J Div Health Psychol Am Psychol Assoc. 1996;15(2):75–83.
Lee-Jones C, Humphris G, Dixon R, Hatcher MB. Fear of cancer recurrence—a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psycho-Oncology. 1997;6(2):95–105. doi:10.1002/(SICI)1099-1611(199706)6:2<95::AID-PON250>3.0.CO;2-B.
Simard S, Savard J, Ivers H. Fear of cancer recurrence: specific profiles and nature of intrusive thoughts. J Cancer Survivorship. 2010;4(4):361–71. doi:10.1007/s11764-010-0136-8.
Easterling DV, Leventhal H. Contribution of concrete cognition to emotion: neutral symptoms as elicitors of worry about cancer. J Appl Psychol. 1989;74(5):787–96.
Asmundson GJ, Taylor S, Cox BJ, editors. Health anxiety: clinical and research perspectives on hypochondriasis and related conditions. New York: Wiley; 2001.
Humphris G, Ozakinci G. The AFTER intervention: a structured psychological approach to reduce fears of recurrence in patients with head and neck cancer. Br J Health Psychol. 2008;13:223–30.
Miedema B, Tatemichi S, MacDonald I. Cancer follow-up care in New Brunswick: cancer surveillance, support issues and fear of recurrence. Can J Rural Med. 2004;9(2):101–7.
Mishel MH. The measurement of uncertainty in illness. Nurs Res. 1981;30(5):258–63.
Langlois F, Ladouceur R. Treatment for hypochondriasis. Cogn Behav Pract. 2004;11:393–404.
Furer P, Walker JR, Freeston MH. Approach to integrated cognitive-behavior therapy for intense illness worry. In: Asmundson GJ, Taylor A, Cox BJ, editors. Health anxiety: clinical and research perspectives on hypochondrias and related conditions. New York: John Wiley & Sons Ltd.; 2001. p. 161–92.
Zebrack BJ, Ganz PA, Bernaards CA, Petersen L, Abraham L. Assessing the impact of cancer: development of a new instrument for long-term survivors. Psycho-Oncology. 2006;15(5):407–21.
Carver CS. You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med. 1997;4(1):92–100. doi:10.1207/s15327558ijbm0401_6.
Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991;59(1):12–9.
Cohen J. A power primer. Psychol Bull. 1992;112(1):155–9.
Olfson M, Mojtabai R, Sampson NA, Hwang I, Druss B, Wang PS, et al. Dropout from outpatient mental health care in the United States. Psychiatr Serv. 2009;60(7):898–907. doi:10.1176/appi.ps.60.7.898.
Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychol Bull. 1986;99(1):20–35.
Kendall PC, Panichelli-Mindel SM. Cognitive-behavioral treatments. J Abnorm Child Psychol. 1995;23(1):107–24.
Deacon BJ, Abramowitz JS. Cognitive and behavioral treatments for anxiety disorders: a review of meta-analytic findings. J Clin Psychol. 2004;60(4):429–41. doi:10.1002/jclp.10255.
Simard S, Savard J. Fear of cancer recurrence inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2009;17(3):241–51. doi:10.1007/s00520-008-0444-y.
Herschbach P, Berg P, Dankert A, Duran G, Engst-Hastreiter U, Waadt S, et al. Fear of progression in chronic diseases: psychometric properties of the fear of progression questionnaire. J Psychosom Res. 2005;58(6):505–11. doi:10.1016/j.jpsychores.2005.02.007.
Jacobsen PB, Donovan KA, Trask PC, Fleishman SB, Zabora J, Baker F, et al. Screening for psychologic distress in ambulatory cancer patients. Cancer. 2005;103(7):1494–502. doi:10.1002/cncr.20940.
Gottlieb BH, Wachala ED. Cancer support groups: a critical review of empirical studies. Psycho-Oncology. 2007;16(5):379–400. doi:10.1002/pon.1078.
Herschbach P, Book K, Dinkel A, Berg P, Waadt S, Duran G, et al. Evaluation of two group therapies to reduce fear of progression in cancer patients. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2010;18(4):471–9. doi:10.1007/s00520-009-0696-1.
Acknowledgments
This research was supported in by the Canadian Institutes of Health Research through a Catalyst grant to Sophie Lebel (PI) and Christine Maheu (co-PI) and from a matching fund from the Canadian Nurses Foundation, Nursing Care Partnership Program to Christine Maheu (PI) and Sophie Lebel (co-PI). We appreciate the efforts of our research assistants on this project: Megan McCallum, Christina Tomei, and Ai Tinamizu.
Conflict of interest
I, Sophie Lebel, declare that myself or my institution (University of Ottawa) or my co-authors have no relationship, financial or otherwise, with individuals or organizations that could influence the authors’ work inappropriately.
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Lebel, S., Maheu, C., Lefebvre, M. et al. Addressing fear of cancer recurrence among women with cancer: a feasibility and preliminary outcome study. J Cancer Surviv 8, 485–496 (2014). https://doi.org/10.1007/s11764-014-0357-3
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DOI: https://doi.org/10.1007/s11764-014-0357-3