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.
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.
This study was a single-arm multi-site study with pre-, post-, and 3-month follow-up measurement occasions.
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.
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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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) , the fear of recurrence questionnaire (FRQ) , the fear of cancer recurrence inventory (FCRI) , and the fear of disease progression questionnaire (FoP-Q) . 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.
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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
- Fear of cancer recurrence
- Pilot study
- Cognitive-existential intervention
- Breast cancer
- Ovarian cancer