Systematic review of interventions by non-mental health specialists for managing fear of cancer recurrence in adult cancer survivors

Evaluating Tools for Assessing Fear of Cancer Recurrence in Adults for Nursing Practice: A Systematic Review

OBJECTIVE

To identify, assess and compare internationally validated tools that measure the fear of recurrence in adult survivors of cancer.

METHODS

This systematic review was based on the PRISMA reporting guidelines and COSMIN methodology was applied to analyses the psychometric properties and the validation process of the selected assessment tools. The search was conducted on 6 databases: PubMed/Medline, Cochrane Library, CINAHL, Web of Science, Scopus and LILACS, from 2001 to 2023. The descriptors used were: "fear of cancer recurrence," "tools," "validity," "reliability" and "cancer survivors." Studies focused on the design, validation or cultural adaptation of fear of cancer recurrence tools in adult cancer patients were selected. The COSMIN checklist was used to compare the tools measurement properties, including the following dimensions: conceptual suitability, applicability and psychometric features, and also to assess the methodological quality and the risk of bias of the different studies.

RESULTS

18 studies have been included. Three validated tools were identified for measuring fear of cancer recurrence in adults: CARS, FCRI and FCR7, which were also adapted in various languages. Although there are differences in the validation process, most of the tools were validated with acceptable psychometric properties and with a suitable cultural adaptation.

CONCLUSIONS

The 3 main tools identified are valid to measure fear for cancer recurrence although vary on their level of development, being FCR4/7 the most recent and consistent 1. Despite the availability of these tools, there is a lack of validated instruments in Spanish-speaking contexts. Regular use of these tools in Nursing practice would contribute to early detect fear of cancer recurrence and to effectively manage it, improving the quality of life of cancer patients. Recently, shorter versions have arisen to facilitate its applicability.

Fear of Recurrence and Progression in People with Heart Disease: Risk Factors and Implications for Emotional Support

Support to manage fear of recurrence and progression (FoRP) is a major concern and a commonly unmet need for people with chronic illness. The current study identified profiles of and risk factors for FoRP in people with heart disease. A sample of 241 participants completed 44 cardiac-specific FoRP items and provided demographic, clinical, and psychosocial information. Cluster analysis identified three profiles: a high-, moderate-, and low-FoRP group. Patients who were younger, had a comorbid health condition(s), and higher levels of uncertainty and cardiac-related distress were at the most risk of higher FoRP. By characterizing the nature and correlates of cardiac-FoRP, this study enables health professionals to understand the specific concerns of their patients and assists in identifying those at greatest risk. The findings extend the emerging field of cardiac-FoRP research and will assist in the development of a cardiac-specific screening measure and of tailored and targeted interventions to support cardiac patients in their emotional recovery.

Psychological Intervention for Patients with Biopsychosocial Late Effects Following Surgery for Colorectal Cancer with Peritoneal Metastases-A Feasibility Study

Background: Up to 80% of patients experience late effects (LE) one year after surgery for peritoneal metastases (PM) from colorectal cancer (CRC). We tested the feasibility and outcome of a treatment strategy to address LEs. Methods: During January 2021-May 2023, patients who had undergone surgery for CRC-PM in Denmark were screened for biopsychosocial LEs (anxiety, depression, fear of cancer recurrence, insomnia, cognitive impairment, pain, fatigue). Patients scoring according to clinical cut-offs were referred to a Multi-Disciplinary Team conference (MDT). The patients, surgeon(s), nurse(s), and psychologists participated in the MDT, identified key concerns and proposed a personalized intervention. Pre- and post-intervention, patients completed a "Measure Yourself Concerns and Wellbeing" (MYCaW) questionnaire, rating the two most distressing LEs and general wellbeing on a 7-point Likert scale. Results: Of 28 eligible patients, 13 (59 years (mean), 85% women) accepted referral, participated in the MDT, and were offered a personalized intervention. The intervention was completed by 11 patients. Improvement in MYCaW score was observed 1 month postintervention for all three items: (1) the primary LE (p = 0.003, Hedges's g 1.54), (2) the secondary LE (p < 0.001, Hedges's g 1.65), and (3) general wellbeing (p = 0.005, Hedges's g 1.09). This improvement was sustained 6 months postintervention. The 15 non-participants were, in general, older (66 years (mean), men 73%). Conclusions: Screening for LEs and conducting an MDT can provide a personalized intervention plan, which patients are able to complete and may benefit from.

Assessing the impact of a self-guided digital intervention for fear of cancer recurrence (iConquerFear) in ovarian cancer survivors: a pilot randomised waitlist-controlled trial

BACKGROUND

Approximately 50% of ovarian cancer (OC) survivors report fear of cancer recurrence/progression (FCR/P) as the most challenging aspect of living with cancer. This pilot, randomised waitlist-controlled trial aimed to evaluate the feasibility, acceptability, and safety of iConquerFear, a self-guided online FCR intervention for OC survivors.

METHODS

Stage I-III OC survivors were recruited via Ovarian Cancer Australia (OCA) between October-December 2022. Participants were randomised to access iConquerFear immediately (intervention) or after 8 weeks (waitlist-control). Primary outcomes were feasibility, acceptability, and safety. Secondary outcomes included: engagement barriers/enablers, perceived impact of iConquerFear, and suggested improvements via semi-structured interviews. Exploratory outcomes included group differences in FCR and FoP after iConquerFear use.

RESULTS

Of 62 eligible survivors, 55 (61%) were randomised (intervention n = 29; control n = 26). At baseline 55% (30/55) reported severe FCR (FCRI-SF ≥ 22). Of those randomised, 51% (n = 28) accessed iConquerFear; 16/28 (57%) users completed ≥ 3/5 modules. Mean post-intervention acceptability score (IEUQ) was 3/4 (SD = 0.8). Three (11%) users withdrew due to distress from iConquerFear. Qualitative interviews (n = 13) identified 6 key themes (e.g., participant factors influencing engagement). Differences between intervention and control group changes in FCR/P were non-significant.

CONCLUSIONS

iConquerFear does not appear appropriate for OC survivors in its current format due to limited engagement, varied acceptability, safety concerns and minimal group differences in FCR/P after iConquerFear use. More work is needed regarding how to augment online interventions addressing sensitive issues such as FCR/P in OC survivors (e.g., offering complementary in-person support) to ensure feasibility, acceptability and safety.

TRIAL REGISTRATION

This trial is registered with ANZCTR.org (ACTRN12622000592741p) on 21 April 2022.

Cancer Survivors' Experience of Care and Financial Toxicity: Results From a National Survey

PURPOSE

Financial toxicity (FT) can adversely affect quality of life, treatment adherence, and clinical outcomes. Patient experience of care (PEC) captures patient's perspectives on interactions with health care providers (HCPs) and systems, but the impact of PEC on FT is unknown. This study examined the relationship between PEC and FT.

METHODS

We used data from the 2016-2017 Medical Expenditure Panel Survey (MEPS) Experience with Cancer Survivorship Supplement. PEC was assessed by patient-reported frequencies of their HCPs providing explanations that were easy to understand, listening carefully, showing respect, and spending enough time with the patient. FT was assessed by nine items to measure material, psychological, and behavioral FT. Analyses were performed using multivariable logistic regression controlling for sociodemographic and clinical characteristics and weighted to produce nationally representative estimates and account for survey nonresponse.

RESULTS

Data from 1,068 individuals diagnosed with cancer at age >18 years were assessed. A total of 30% reported material FT, 35% reported psychological FT, and 27% reported behavioral FT. Examining PEC, 64% of respondents indicated that HCPs always explained things, 60% always listened, 66% always showed respect, and 57% always spent adequate time with them. Odds of psychological FT were significantly (P < .05) lower among patients reporting HCPs always (v never/sometimes) listened to them (odds ratio [OR], 0.37 [95% CI, 0.19 to 0.70]), showed them respect (OR, 0.36 [95% CI, 0.16 to 0.81]), and spent enough time with them (OR, 0.47 [95% CI, 0.26 to 0.86]). Significant associations with PEC were also found with MEPS psychological FT items on worry about paying medical bills, family's financial stability, and keeping job/income because of cancer.

CONCLUSION

Worry/anxiety regarding costs can be a major factor affecting individuals diagnosed with cancer. Improving patient-provider interactions to enhance patient experience of care may reduce psychological financial toxicity.

Step-by-step: A clinical pathway for stepped care management of fear of cancer recurrence-results of a three-round online delphi consensus process with Australian health professionals and researchers

PURPOSE

Fear of cancer recurrence (FCR) is not routinely addressed in clinical practice, meaning many cancer survivors forego effective interventions. We established expert consensus on a clinical pathway to help health professionals identify and manage FCR in early-stage cancer survivors.

METHODS

Australian health professionals and researchers working with adult cancer survivors participated in a three-round Delphi study promoted via oncology professional bodies and social media. The Round 1 online survey presented 38 items regarding FCR screening, triage, assessment, referral, and stepped care, based on a literature review, related pathways/guidelines, and expert input. Participants rated how representative of best-practice items were on a 5-point scale (strongly disagree-strongly agree), with optional qualitative feedback. Consensus was defined as ≥ 80% of participants strongly/agreeing with items. Items not reaching consensus were re-presented to Round 1 participants in two subsequent rounds with new items, derived from content analysis of qualitative feedback.

RESULTS

From 94 participants in Round 1 (89% health professionals), 26/38 (68%) items reached consensus. By round 3, 35/38 (92%) items, including 8 new items, reached consensus. Routine FCR screening and triage conversations and stepped care management (i.e. tailored and staged treatment) were endorsed. However, the timing of FCR screening/triage did not reach consensus.

CONCLUSIONS

This world-first FCR clinical pathway incorporating contemporary evidence and expert opinion recommends routine screening and triage to stepped care management of FCR. Some pathway components, such as screening or triage timing, may need tailoring for different contexts.

IMPLICATIONS FOR CANCER SURVIVORS

Implementation of the pathway could aid routine identification and management of FCR, reducing its burden on cancer survivors and the healthcare system.

Protocol for the development and validation of a clinical measurement tool for fear of disease progression and recurrence in cardiac patients

Introduction

One in two cardiac patients fear having another heart event or their heart condition getting worse. Research in other chronic illnesses demonstrates that screening for fear of progression and recurrence is vital for adequately addressing such concerns in clinical care. The current project aims to develop and validate a measure for fear of progression and recurrence in cardiac patients.

Methods

The Fear of Cardiac Recurrence and Progression Scale (FCRP) will be developed through a multistep process. An initial item pool will be generated through a review of the literature and existing measures and consultation with and feedback from key informants. The item pool will be tested in a sample of over 250 adults who have ever had an acute coronary event, undergone cardiac surgery, or a chronic cardiac condition. Exploratory factor analysis will be used to identify the underlying factors, and Rasch analysis will be used to reduce the number of items. A short form version of the FCRP will be developed for use as a brief screening tool, informed by clinical relevance and Rasch psychometric indices.

Discussion

While many cardiac patients experience fears related to the progression or recurrence of their illness, there remains the need for a validated tool with which these concerns can be identified and measured. It is expected that the design and validation of the FCRP will aid identification of cardiac patients suffering from clinically significant levels of fear of progression and recurrence and facilitate the design of tailored psychological interventions to target these fears.

Ecosystem Barriers and Facilitators Linked to the Fear of Cancer Recurrence: An Umbrella Review

The fear of cancer recurrence is an important topic in the healthcare field. In general, approximately 40% of survivors experience high levels of fear of recurrence. This study aims to fill this gap by synthesizing the findings of systematic reviews studies investigating ecosystems, correlates or predictors, and barriers and facilitators of fear of cancer recurrence among cancer survivors. An umbrella meta-synthesis was conducted using the following databases: MEDLINE, PsycINFO, PsycARTICLES, CINAHL, Business source premier, and SOCindex, ending in April 2024 with PRISMA methods. A total of 24 systematic reviews, representing 729 articles, were included in the study. In total, six ecosystems were identified, including family, work, friends, the healthcare system, caregivers, and religion. As part of this umbrella review, 55 specific ecosystemic factors were identified that may contribute to fear of cancer recurrence. Furthermore, the umbrella review identified 12 facilitators and 12 barriers related to fear of cancer recurrence. This umbrella meta-synthesis contributed significantly to our review's strength in synthesizing the main ecosystem and its influence on fears of cancer recurrence. Understanding the interdependence of ecosystems should enable future research on intervention effectiveness or the development of interventions that could reduce the fear of cancer recurrence.

Fear of recurrence in women with ovarian cancer: A qualitative evidence synthesis

PURPOSE

Approximately 80% of ovarian cancers recur after first-line treatments. Women with ovarian cancer (OC) are therefore particularly vulnerable to experiencing fear of cancer recurrence (FCR). This study aimed to synthesise experiences of fear of cancer recurrence among women living with ovarian cancer.

METHOD

A qualitative evidence synthesis (QES) was conducted in accordance with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. A systematic search of seven databases was undertaken to identify all available qualitative research exploring fear of cancer recurrence in women with OC. Thematic synthesis of extracted data from included studies was undertaken and managed in NVivo.

RESULTS

Twenty-two papers reporting on eighteen studies were included in the synthesis. Three main themes were developed (triggers, responses, and coping) and included ten subthemes. FCR was triggered by factors relating to awareness of prognosis, treatment, and negative communication. Women responded to FCR by performing body checking and protecting their families. FCR led to adverse effects on women's wellbeing as it exacerbated uncertainty about their future. Women attempted to cope with FCR through seeking support, regaining control, and redirecting negative thoughts and actions.

CONCLUSIONS

Women use a variety of approaches to manage their fear of recurrence. Further research on the most appropriate interventions for FCR tailored specifically to the needs of women with OC is needed.

The Evaluation of the Suitability, Quality, and Readability of Publicly Available Online Resources for the Self-Management of Fear of Cancer Recurrence

Cancer survivors often rely on the internet for health information, which has varying levels of readability, suitability, and quality. There is a need for high-quality online self-management resources for cancer survivors with fear of cancer recurrence (FCR). This study evaluated the readability, suitability, and quality of publicly available online FCR self-management resources. A Google search using FCR-related keywords identified freely available FCR self-management resources for cancer survivors in English. Resource readability (reading grade level), suitability, and quality were evaluated using relevant assessment tools. Descriptive statistics and cluster analysis identified resources with higher suitability and quality scores. Mean resource (n = 23) readability score was grade 11 (SD = 1.6, Range = 9-14). The mean suitability score was 56.0% (SD = 11.4%, Range = 31.0-76.3%), indicating average suitability and the mean quality score was 53% (SD = 11.7%, Range = 27-80%), indicating fair quality. A cluster of 15 (65%) resources with higher suitability and quality scores was identified. There were no significant associations between suitability or quality scores and the type of organisation that published the resources. Online FCR self-management resources varied in readability, suitability and quality. Resources with higher quality and suitability scores relative to other resources are identified for use by healthcare professionals and cancer survivors. Resources that are more culturally appropriate, with lower reading grade levels and detailed self-management strategies are needed.

Real-world evaluation of an acceptance and commitment therapy-based group programme for breast cancer survivors with fear of cancer recurrence

PURPOSE

To evaluate the effectiveness and acceptability of a 6-week acceptance and commitment therapy (ACT)-based group programme on participants' fear of cancer recurrence (FCR), quality of life (QoL), psychological distress and psychological flexibility at the end of the programme and 12-week follow-up.

METHODS

A one-group, post-test service evaluation of a real-world psychological programme was carried out to evaluate collected outcome measures and attendance for a total of 21 groups facilitated between 2017 and 2019. Participants were breast cancer survivors who attended a 6-week group programme led by NHS clinicians. Descriptive statistics and repeated measures ANOVA analyses were carried out for each outcome measure. Attendance levels were examined to assess acceptability.

RESULTS

A total of 97 group participants who had completed curative treatment for breast cancer took part. Of whom, 89% completed at least 4 of the 6 weekly group sessions and 76% attended the 12-week follow-up session. Eighty-four (87%) participants returned outcome measures at all three time points relative to group participation (T1 = pre, T2 = post T3 = 12-week follow-up). Group participants were female, mean age 51.9 years. FCR was highest at T1 (mean 25.2, SD 4.7), reduced T2 (mean 21.2, SD 5.4) and further lowered T3 (mean 19.5, SD 6.2). This difference was statistically significant (p < 0.001). QoL was lowest at T1 (mean 62.4, SD 15.7), increased T2 (mean 71.7, SD 18.1) and further increased at T3 (mean 75.9, SD 17.5). This difference was statistically significant (p < 0.001). Psychological distress measures were shown to reduce, and psychological flexibility increased.

CONCLUSIONS

This real-world evaluation of an ACT-based group programme led to improvements in FCR, QoL, psychological distress and psychological flexibility in this population. This evaluation provides basis for further investigation to determine if these results can be replicated by controlled research design across diverse populations.

Validity and screening capacity of the FCR-1r for fear of cancer recurrence in long-term colorectal cancer survivors

PURPOSE

Existing fear of cancer recurrence (FCR) screening measures is being shortened to facilitate clinical use. This study aimed to evaluate the validity and screening capacity of a single-item FCR screening measure (FCR-1r) in long-term colorectal cancer (CRC) survivors with no recurrence and assess whether it performs as well in older as in younger survivors.

METHODS

All Danish CRC survivors above 18, diagnosed and treated with curative intent between 2014 and 2018, were located through a national patient registry. A questionnaire including the FCR-1r, which measures FCR on a 0-10 visual analog scale, alongside the validated Fear of Cancer Recurrence Inventory Short Form (FCRI-SF) as a reference standard was distributed between November 2021 and May 2023. Screening capacity and cut-offs were evaluated with a receiver-operating characteristic analysis (ROC) in older (≥ 65 years) compared to younger (< 65 years) CRC survivors. Hypotheses regarding associations with other psychological variables were tested as indicators of convergent and divergent validity.

RESULTS

Of the CRC survivors, 2,128/4,483 (47.5%) responded; 1,654 (36.9%) questionnaires were eligible for analyses (median age 76 (range 38-98), 47% female). Of the responders, 85.2% were aged ≥ 65. Ninety-two participants (5.6%) reported FCRI-SF scores ≥ 22 indicating clinically significant FCR. A FCR-1r cut-off ≥ 5/10 had 93.5% sensitivity and 80.4% specificity for detecting clinically significant FCR (AUC = 0.93, 95% CI 0.91-0.94) in the overall sample. The discrimination ability was significantly better in older (AUC = 0.93, 95% CI 0.91-0.95) compared to younger (0.87, 95% (0.82-0.92), p = 0.04) CRC survivors. The FCR-1r demonstrated concurrent validity against the FCRI-SF (r = 0.71, p < 0.0001) and convergent validity against the short-versions of the Symptom Checklist-90-R subscales for anxiety (r = 0.38, p < 0.0001), depression (r = 0.27, p < 0.0001), and emotional distress (r = 0.37, p < 0.0001). The FCR-1r correlated weakly with employment status (r =  - 0.09, p < 0.0001) and not with marital status (r = 0.01, p = 0.66) indicating divergent validity.

CONCLUSIONS

The FCR-1r is a valid tool for FCR screening in CRC survivors with excellent ability to discriminate between clinical and non-clinical FCR, particularly in older CRC survivors.

Fear of cancer recurrence in young women 5 years after diagnosis with a good-prognosis cancer: the VICAN-5 national survey

PURPOSE

Fear of cancer recurrence (FCR) is frequent in survivors, but less is known about FCR in long-term survivors with very low risk of relapse. Our aim was to estimate the prevalence and clinical and socio-behavioural factors associated with FCR in young women 5 years after diagnosis of a good-prognosis cancer.

METHODS

Using data from the VICAN-5 survey, conducted in 2015-2016 amongst a national representative French sample of cancer survivors, we included women with non-metastatic melanoma, breast, or thyroid cancer, aged 55 years or under at diagnosis, who experienced no disease progression in the 5 years post-diagnosis. Multinomial logistic regression was used to identify factors associated with FCR, characterised using a three-level indicator: no, mild, and moderate/severe FCR.

RESULTS

Amongst the 1153 women included, mean age was 44 years at diagnosis, and 81.8% had breast cancer, 12.5% thyroid cancer, and 5.8% melanoma. Five years after diagnosis, 35.4% reported no FCR, 46.0% mild FCR, and 18.6% moderate/severe FCR. Women with thyroid cancer were less likely to suffer from mild or moderate/severe FCR, while cancer-related treatment sequelae, fatigue, and anxiety were more likely. Limited health literacy was associated with mild FCR. Women who reported only occasionally consulting a general practitioner (GP) for the management of their cancer had a higher probability of FCR.

CONCLUSION

Moderate/severe FCR affected nearly 20% of young female long-term survivors diagnosed with a good-prognosis cancer, particularly those reporting cancer-related sequelae, suffering from fatigue or anxiety, with breast cancer or melanoma (versus thyroid cancer), and consulting a GP only occasionally for cancer management.

IMPLICATIONS FOR CANCER SURVIVORS

Given the recognised impact of FCR on quality of life, it is essential to detect it as early as possible, and to implement targeted interventions in routine care.

Supportive care needs of breast cancer survivors with different levels of fear of cancer recurrence: A cross-sectional survey study

PURPOSE

To examine the supportive care needs of breast cancer survivors with nonclinical, subclinical, or clinical fear of cancer recurrence.

METHODS

In this cross-sectional study, 385 breast cancer survivors consented and completed a set of online questionnaires. Supportive care needs were assessed by using the 34-item Supportive Care Needs Survey. Fear of cancer recurrence was assessed by using the Fear of Cancer Recurrence Inventory.

RESULTS

One hundred eighty-four (47.8%) participants reported nonclinical fear of cancer recurrence, 147 (38.2%) reported subclinical fear of cancer recurrence, and 54 (14.0%) reported clinical fear of cancer recurrence. Higher levels of fear of cancer recurrence were associated with higher levels of supportive care needs in five domains (β = 0.30-0.60, P < 0.001) after adjusting for places of residence, education, motherhood, and time since diagnosis. Among participants with nonclinical fears of cancer recurrence, the most common needs were in the 'Health care system/Information' domain (50.5%). Among participants with subclinical or clinical fear of cancer recurrence, the most common needs were in the 'Psychological' domain (85.7% and 96.3%, respectively).

CONCLUSION

Fear of cancer recurrence was associated with supportive care needs. The most common needs among participants with subclinical or clinical fears of cancer recurrence were psychological needs.

Protocol of an implementation study of a clinician intervention to reduce fear of recurrence in cancer survivors (CIFeR_2 implementation study)

BACKGROUND

Fear of cancer recurrence (FCR) affects 50-70% of cancer survivors with 30% reporting an unmet need for help with managing FCR. Patients indicate desire to discuss FCR with clinicians, however clinicians indicate discomfort with managing FCR and no formal educational interventions on how to discuss FCR or worry exists for oncology clinicians. Our team developed a novel clinician-driven brief education intervention to help patients manage FCR (the Clinician Intervention to Reduce Fear of Recurrence (CIFeR) intervention). In earlier work, we demonstrated the feasibility, acceptability, and efficacy of CIFeR in reducing FCR in breast cancer patients. We now aim to explore the barriers and facilitators to implementing this low-cost brief intervention within routine oncology practice in Australia. The primary objective is to assess the adoption of CIFeR in routine clinical practice. Secondary objectives are to identify the uptake and sustainability, perceived acceptability, feasibility, costs, barriers and facilitators of implementation of CIFeR in routine clinical practice, and to assess whether training in CIFeR increases clinicians' self-efficacy in managing FCR with their patients.

METHODS

This multicentre, single-arm Phase I/II implementation study will recruit medical and radiation oncologists and oncology surgeons who treat women with early breast cancer. Participants will complete online CIFeR training. They will then be asked to use CIFeR with suitable patients for the next 6 months. Participants will complete questionnaires prior to, immediately after and 3 and 6 months after training to assess confidence addressing FCR, and 3 and 6 months after training to assess Proctor Implementation outcomes. At 6 months, they will also be asked to participate in a semi-structured telephone interview to elicit their feedback about barriers and facilitators to using CIFeR in routine clinical practice.

DISCUSSION

This study will provide further data to support the routine use of an evidence-based, clinician-lead educational intervention to reduce FCR in breast cancer patients. Additionally, this study will identify any barriers and facilitators to implementing the CIFeR intervention in routine care and evidence for integration of FCR training into oncology communication skills education.

TRIAL REGISTRATION

Prospectively registered with the Australian New Zealand Clinical Trials Registry, ACTRN12621001697875.

TRIAL SPONSOR

Chris O'Brien Lifehouse.

PROTOCOL VERSION

2.6, Dated 28th February 2023.

Fear of Cancer Recurrence in Sarcoma Survivors: Results from the SURVSARC Study

Fear of cancer recurrence (FCR) is often reported as an unmet concern by cancer patients. The aim of our study was to investigate (1) the prevalence of FCR in sarcoma survivors; (2) the factors associated with a higher level of FCR; the relationship between (3) FCR and global health status and (4) FCR and use of follow-up care.

METHODS

A cross-sectional study was conducted among sarcoma survivors 2 to 10 years after diagnosis. Patients completed the Cancer Worry Scale (CWS), the global health status subscale of the EORTC QLQ-C30 and a custom-made questionnaire on follow-up care.

RESULTS

In total, 1047 patients were included (response rate 55%). The prevalence of high FCR was 45%. Factors associated with high FCR were female sex with 1.6 higher odds (95% CI 1.22-2.25; p = 0.001); having ≥1 comorbidities and receiving any treatment other than surgery alone with 1.5 (95% CI 1.07-2.05; p = 0.017) and 1.4 (95% CI 1.06-1.98; p = 0.020) higher odds, respectively. Patients on active follow-up had 1.7 higher odds (95% CI 1.20-2.61; p = 0.004) and patients with higher levels of FCR scored lower on the global health status scale (72 vs. 83 p ≤ 0.001).

CONCLUSIONS

Severe FCR is common in sarcoma survivors and high levels are related to a decreased global health status. FCR deserves more attention in sarcoma survivorship, and structured support programs should be developed to deliver interventions in a correct and time adequate environment.

Relations between recurrence risk perceptions and fear of cancer recurrence in breast cancer survivors

PURPOSE

This study aimed to: (1) determine the accuracy of Dutch breast cancer survivors' estimations of the locoregional recurrence risk (LRR); (2) examine which variables influence (the accuracy of) risk estimations, and risk appraisals; and (3) investigate the influence of the objective LRR risk (estimated using the INFLUENCE-nomogram), risk estimations and risk appraisals on fear of cancer recurrence (FCR). Findings of this study will inform clinicians on risk communication and can improve communication about FCR.

METHODS

In a cross-sectional survey among 258 breast cancer survivors, women's recurrence risk estimations (in odds) and risk appraisals (in high/low), FCR, demographics and illness perceptions, about one year after surgery were measured and compared to the objective risk for LRRs estimated using the INFLUENCE-nomogram.

RESULTS

Half of the women (54%) accurately estimated their LRR risk, 34% underestimated and 13% overestimated their risk. Risk estimations and risk appraisals were only moderately positively correlated (r = 0.58). Higher risk appraisals were associated with radiotherapy (r = 0.18) and having weaker cure beliefs (r = - 0.19). Younger age was associated with overestimation of risk (r = - 0.23). Recurrence risk estimations and risk appraisals were associated with more FCR (r = 0.29, r = 0.39). In regression, only risk appraisal contributed significantly to FCR.

CONCLUSION

Although women were fairly accurate in recurrence risk estimations, it remains difficult to predict over- or underestimation. Recurrence risk estimations and risk appraisal are two different concepts which are both associated with FCR and should therefore be addressed in patient-provider communication.

Interventions addressing fear of cancer recurrence: challenges and future perspectives

PURPOSE OF REVIEW

Fear of cancer recurrence (FCR) is a common concern among cancer survivors and support for FCR is one of the most cited unmet needs. High FCR was found to be related to increased use of healthcare services, specifically primary healthcare and medical consultations, and lower quality of life. In the past decade screening instruments for FCR and interventions have been developed and proven effective.

RECENT FINDINGS

Systematic reviews and meta-analyses have shown that psychological treatments are effective for reducing FCR. The cost-effectiveness of FCR interventions could be increased by considering stepped or matched models for supportive care. Despite availability of evidence-based interventions, the proposed care models are not implemented and most cancer survivors still do not benefit from supportive care.

SUMMARY

The time is right to focus on implementation of FCR interventions into clinical practice. The complexity of optimizing FCR care is characterized by barriers and facilitators in the domains of patients, healthcare professionals, healthcare organizations and the broader economic, and political context. The main challenge for future research is to address these issues so that former investments in high-quality FCR intervention research will pay out in actual practice changes in the benefit of cancer survivors.

Fear of Cancer Recurrence or Progression: What Is It and What Can We Do About It?

Patients with cancer face a trajectory marked by emotional and physical distress that can be associated with both diagnosis and treatment. Fear of cancer recurrence or progression has been considered one of the most common unmet needs reported by patients diagnosed with both localized and metastatic disease. Fear of cancer recurrence or progression has been defined as the "fear, worry, or concern relating to the possibility that cancer will come back or progress." Often overlooked by health care teams, fear of cancer recurrence or progression has been associated with impaired quality of life and psychosocial adjustment, elevated emotional distress, and a range of physical symptoms. Several interventions for fear of cancer recurrence or progression are currently under investigation. Early recognition, support, and validation of feelings associated with fear of cancer recurrence or progression, and appropriate referrals to psychosocial oncology, can be beneficial for many patients. Assessing patients early in their cancer trajectory, and at important milestones, including a change in therapies, at the end of active treatment, and during follow-up visits, can help identify individuals at risk and help individuals engage in supportive programs.

Management of common clinical problems experienced by survivors of cancer

Improvements in early detection and treatment have led to a growing prevalence of survivors of cancer worldwide. Models of care fail to address adequately the breadth of physical, psychosocial, and supportive care needs of those who survive cancer. In this Series paper, we summarise the evidence around the management of common clinical problems experienced by survivors of adult cancers and how to cover these issues in a consultation. Reviewing the patient's history of cancer and treatments highlights potential long-term or late effects to consider, and recommended surveillance for recurrence. Physical consequences of specific treatments to identify include cardiac dysfunction, metabolic syndrome, lymphoedema, peripheral neuropathy, and osteoporosis. Immunotherapies can cause specific immune-related effects most commonly in the gastrointestinal tract, endocrine system, skin, and liver. Pain should be screened for and requires assessment of potential causes and non-pharmacological and pharmacological approaches to management. Common psychosocial issues, for which there are effective psychological therapies, include fear of recurrence, fatigue, altered sleep and cognition, and effects on sex and intimacy, finances, and employment. Review of lifestyle factors including smoking, obesity, and alcohol is necessary to reduce the risk of recurrence and second cancers. Exercise can improve quality of life and might improve cancer survival; it can also contribute to the management of fatigue, pain, metabolic syndrome, osteoporosis, and cognitive impairment. Using a supportive care screening tool, such as the Distress Thermometer, can identify specific areas of concern and help prioritise areas to cover in a consultation.

Affordable Care Act Medicaid expansion and access to primary-care based smoking cessation assistance among cancer survivors: an observational cohort study

Background

Smoking among cancer survivors can increase the risk of cancer reoccurrence, reduce treatment effectiveness and decrease quality of life. Cancer survivors without health insurance have higher rates of smoking and decreased probability of quitting smoking than cancer survivors with health insurance. This study examines the associations of the Affordable Care Act (ACA) Medicaid insurance expansion with smoking cessation assistance and quitting smoking among cancer survivors seen in community health centers (CHCs).

Methods

Using electronic health record data from 337 primary care community health centers in 12 states that expanded Medicaid eligibility and 273 CHCs in 8 states that did not expand, we identified adult cancer survivors with a smoking status indicating current smoking within 6 months prior to ACA expansion in 2014 and ≥ 1 visit with smoking status assessed within 24-months post-expansion. Using an observational cohort propensity score weighted approach and logistic generalized estimating equation regression, we compared odds of quitting smoking, having a cessation medication ordered, and having ≥6 visits within the post-expansion period among cancer survivors in Medicaid expansion versus non-expansion states.

Results

Cancer survivors in expansion states had higher odds of having a smoking cessation medication order (adjusted odds ratio [aOR] = 2.54, 95%CI = 1.61-4.03) and higher odds of having ≥6 office visits than those in non-expansion states (aOR = 1.82, 95%CI = 1.22-2.73). Odds of quitting smoking did not differ significantly between patients in Medicaid expansion versus non-expansion states.

Conclusions

The increased odds of having a smoking cessation medication order among cancer survivors seen in Medicaid expansion states compared with those seen in non-expansion states provides evidence of the importance of health insurance coverage in accessing evidence-based tobacco treatment within CHCs. Continued research is needed to understand why, despite increased odds of having a cessation medication prescribed, odds of quitting smoking were not significantly higher among cancer survivors in Medicaid expansion states compared to non-expansion states.

Towards a Stepped Care Model for Managing Fear of Cancer Recurrence or Progression in Cancer Survivors

Background

Fear of cancer recurrence or progression (FCR) is common amongst cancer survivors and an important minority develop clinically significant levels of FCR. However, it is unclear how current clinical services might best support the growing numbers of cancer survivors.

Purpose

The aim of this study is to develop recommendations for future research in the management of FCR and propose a model of care to help manage FCR in the growing population of cancer survivors.

Methods

This is a narrative review and synthesis of empirical research relevant to managing FCR. We reviewed meta-analyses, systematic reviews and individual studies that had investigated interventions for FCR.

Results

A recent, well-conducted meta-analysis confirmed a range of moderately effective treatments for FCR. However, many survivors continued to experience clinical levels of FCR after treatment, indicating a clear need to improve the gold standard treatments. Accessibility of interventions is arguably a greater concern. The majority of FCR treatments require face-to-face therapy, with highly skilled psycho-oncologists to produce moderate changes in FCR. With increasing numbers of cancer survivors, we need to consider how to meet the unmet need of cancer survivors in relation to FCR. Although there have been attempts to develop minimal interventions, these are not yet sufficiently well supported to warrant implementation. Attempts to help clinicians to provide information which might prevent the development of clinically significant FCR have shown some early promise, but research is needed to confirm efficacy.

Conclusion

The next decade of research needs to focus on developing preventative approaches for FCR, and minimal interventions for those with mild-to-moderate symptoms. When evidence-based approaches to prevent FCR or manage moderate levels of FCR are available, stepped care approaches that could meet the needs of survivors could be implemented. However, we also need to improve existing interventions for severe FCR.

A systematic mixed studies review of fear of cancer recurrence in families and caregivers of adults diagnosed with cancer

PURPOSE

Fear of cancer recurrence (FCR) may be equally prevalent, persistent and burdensome in cancer caregivers as in survivors. This systematic review evaluated FCR prevalence, severity, correlates, course, impact and interventions in cancer caregivers.

METHODS

Electronic databases were searched from 1997 to May 2021. Two reviewers identified eligible peer-reviewed qualitative or quantitative studies on FCR in adult caregivers or family members of adult cancer survivors. The risk of bias was assessed using the Cochrane Risk of Bias tools for randomised and non-randomised studies and the Mixed-Methods Appraisal Tool. A narrative synthesis and thematic synthesis occurred on quantitative and qualitative studies, respectively.

RESULTS

Of 2418 papers identified, 70 reports (59 peer-reviewed articles, 11 postgraduate theses) from 63 studies were included. Approximately 50% of caregivers experienced FCR. Younger caregivers and those caring for survivors with worse FCR or overall health reported higher FCR. Most studies found caregivers' FCR levels were equal to or greater than survivors'. Caregivers' FCR was persistently elevated but peaked approaching survivor follow-up appointments. Caregivers' FCR was associated with poorer quality of life in caregivers and survivors. Three studies found couple-based FCR interventions were acceptable, but had limited efficacy.

CONCLUSIONS

FCR in caregivers is prevalent, persistent and burdensome. Younger caregivers of survivors with worse overall health or FCR are at the greatest risk. Further research on identifying and treating caregivers' FCR is required.

IMPLICATIONS FOR CANCER SURVIVORS

Caregiver and survivor FCR are similarly impactful and appear interrelated. Addressing FCR may improve outcomes for both cancer caregivers and survivors.

A systematic review of fear of cancer recurrence related healthcare use and intervention cost-effectiveness

OBJECTIVE

Fear of cancer recurrence (FCR) is a common and burdensome psychological condition affecting cancer survivors. This systematic review aims to synthesise current evidence regarding: (1) FCR-related healthcare usage and costs and (2) the cost-effectiveness of FCR treatments.

METHODS

We searched MEDLINE, CINAHL, Cochrane and other electronic databases using MeSH headings and keywords for cancer, FCR and costs from their inception to September 2019. Identified studies were screened for eligibility. Original, peer-reviewed journal articles reporting quantitative data from samples of adults treated for cancer written in English were included. Quality was appraised using the Drummond checklist for economic evaluations or the relevant Joanna Briggs Institute Critical Appraisal Tool.

RESULTS

Data from 11 studies were extracted and synthesised. Seven studies addressed the costs of FCR and suggested an increase in the use of primary and secondary healthcare. Four studies addressed the cost-effectiveness of different FCR treatments and suggest that some treatments may cost-effectively reduce FCR and improve quality of life. Reviewed treatments had an incremental cost-effectiveness ratio between AU$3,233 and AU$152,050 per quality-adjusted life year gained when adjusted to 2019 Australian dollars. All studies were of sufficient quality to be synthesised in this review.

CONCLUSIONS

FCR appears to be associated with greater use of certain healthcare resources, and FCR may be treated cost-effectively. Thus, appropriate FCR treatments may not only reduce the individual burden, but also the strain on the healthcare system. Further high-quality research is needed to confirm this and ensure the future implementation of efficient and sustainable FCR treatments.

Patients' and oncologists' perspectives on a novel Clinician-led Fear of Cancer Recurrence (CIFeR) Intervention

PURPOSE

Despite strong demand from breast cancer survivors, there is a dearth of flexibly delivered, accessible psychological interventions addressing fear of cancer recurrence (FCR). This study aimed to explore patients' and clinicians' perspectives concerning the experience, utility and barriers to a novel clinician-led FCR intervention (CIFeR).

METHODS

Twenty female participants (mean age, 59.8, SD = 11.43), diagnosed with early-stage breast cancer (mean years since diagnosis = 2.8, SD = 1.37 years) participated in telephone interviews, and their five oncologists completed a semi-structured electronic survey. Thematic qualitative analyses were performed on interview transcripts and survey responses.

RESULTS

Findings indicated both patients and clinicians were positive about CIFeR with perceived cognitive, behavioural and emotional benefits of CIFeR most pronounced for patients with clinically significant FCR. All patients, however, found that receiving CIFeR (especially the tailored prognostic information) from their oncologists with whom they had a long-standing relationship added a much-needed human element to addressing FCR. Similarly, clinicians valued CIFeR as a clear and consistent way to address unmet needs around FCR, with some barriers around time, language and cultural issues noted.

CONCLUSION

Overall, all participants perceived CIFeR as strongly beneficial in reducing FCR and related worries, thus warranting further evaluation of its utility in clinical practice.

Is a Brief Online Booklet Sufficient to Reduce Fear of Cancer Recurrence or Progression in Women With Ovarian Cancer?

Background: Fear of cancer recurrence or progression (FCR/P) is a common challenge experienced by people living with and beyond cancer and is frequently endorsed as the highest unmet psychosocial need amongst survivors. This has prompted many cancer organizations to develop self-help resources for survivors to better manage these fears through psychoeducation, but little is known about whether they help reduce FCR/P.

Method: We recruited 62 women with ovarian cancer. Women reported on their medical history and demographic characteristics and completed the Fear of Progression Questionnaire-Short Form (FoP-Q-SF). They then read a booklet on FCR specifically created for Ovarian Cancer Australia by two of the authors (ABS and PB). One week after reading the booklet, 50/62 women (81%) completed the FoP-Q-SF and answered questions about their satisfaction with the booklet.

Results: More than half of the women (35/62; 56.5%) scored in the clinical range for FCR/P at baseline. Of the completers, 93% said that they would recommend the booklet to other women. Satisfaction with the booklet was relatively high (75.3/100) and more than two-thirds of women rated it as moderately helpful or better. However, FCR/P did not change significantly over the week following reading the booklet [t₍₄₉₎ = 1.71, p = 0.09]. There was also no difference in change in FCR/P between women in the clinical vs. non-clinical range on the FoP-Q. Women high in FCR/P rated the booklet as less helpful in managing FCR/P (r = −0.316, p = 0.03), but overall satisfaction with the booklet was not associated with degree of FCR/P (r = −0.24, p = 0.10).

Conclusions: These results suggest that a simple online FCR booklet is acceptable to women with ovarian cancer and they are satisfied with the booklet, but, it was insufficient to change in FCR/P levels. These results suggest that such resources are valued by women with ovarian cancer, but more potent interventions are necessary to reduce FCR in this population.

Setting an International Research Agenda for Fear of Cancer Recurrence: An Online Delphi Consensus Study

Background

Fear of cancer recurrence (FCR) is common amongst cancer survivors. There is rapidly growing research interest in FCR but a need to prioritize research to address the most pressing clinical issues and reduce duplication and fragmentation of effort. This study aimed to establish international consensus among clinical and academic FCR experts regarding priorities for FCR research.

Methods

Members of the International Psycho-oncology Society (IPOS) Fear of Cancer Recurrence Special Interest Group (FORwards) were invited to participate in an online Delphi study. Research domains identified in Round 1 were presented and discussed at a focus group (Round 2) to consolidate the domains and items prior to presentation in further survey rounds (Round 3) aimed at gaining consensus on research priorities of international significance.

Results

Thirty four research items were identified in Round 1 and 33 of the items were consolidated into six overarching themes through a focus group discussion with FCR experts. The 33 research items were presented in subsequent rounds of the delphi technique. Twenty one participants contributed to delphi round 1, 16 in round 2, and 25 and 29 participants for subsequent delphi rounds. Consensus was reached for 27 items in round 3.1. A further four research items were identified by panelists and included in round 3.2. After round 3.2, 35 individual research items were ratified by the panelists. Given the high levels of consensus and stability between rounds, no further rounds were conducted. Overall intervention research was considered the most important focus for FCR research. Panelists identified models of care that facilitate greater access to FCR treatment and evaluation of the effectiveness of FCR interventions in real world settings as the two research items of highest priority. Defining the mechanisms of action and active components across FCR/P interventions was the third highest priority identified.

Conclusion

The findings of this study outline a research agenda for international FCR research. Intervention research to identify models of care that increase access to treatment are based on a flexible approach based on symptom severity and can be delivered within routine clinical care were identified as research areas to prioritize. Greater understanding of the active components and mechanisms of action of existing FCR interventions will facilitate increased tailoring of interventions to meet patient need.

The Relationship Between Fears of Cancer Recurrence and Patient Gender: A Systematic Review and Meta-Analysis

Background: A significant concern for patients treated for cancer is fear of cancer recurrence (FCR). Although a common experience, some patients report high levels of FCR that are difficult to manage and result in over vigilant checking and high use of health services. There has been speculation about the relationship of FCR with gender with mixed reports from several systematic reviews.

Aims: To determine the association of FCR with gender in previous reported studies and investigate the strength of this relationship with various moderators including year of publication, type of cancer and measurement attributes of self-reported FCR instruments.

Methods: A systematic review was conducted with searches of the literature from the MEDLINE, PubMed, Embase, and PsycINFO databases following PRISMA guidelines. All the included papers were divided into two groups, namely: “pure” that comprise only of patients with cancer types that both men and women can contract and “mixed” that report on patients with a variety of cancer types. The association between gender and FCR level was assessed by meta-analysis. A meta-regression was performed to investigate the moderating effects of factors including: the year of publication, cancer type, mean age of the sample and the length of the FCR scale measurement. This review was registered with PROSPERO, ID: CRD42020184812.

Results: Finally, 29 studies were included. The N size of pooled participants was 33,339. The meta-analysis showed females to have an overall higher level of FCR than males (ES = 0.30; 95% CI, 0.23, 0.36). The meta-regression of moderating or control variables found little, if any, systematic variation in effect-sizes.

Conclusion: This systematic review has clarified a potentially confused pattern of previous results in understanding the relationship between gender and FCR. Women report higher levels of FCR than men and this feature is one that clinicians and researchers can factor into their practice and future studies. The effect size is moderate, hence there is ample variation in FCR level, independent of gender, that requires further investigation.

Novel Clinician-Lead Intervention to Address Fear of Cancer Recurrence in Breast Cancer Survivors

PURPOSE

Fear of cancer recurrence (FCR) affects 50%-70% of cancer survivors. This multicenter, single-arm study sought to determine the participant-rated usefulness of an oncologist-delivered FCR intervention.

METHODS

Women who completed treatment for early breast cancer (could be receiving endocrine therapy) with baseline FCR > 0 were invited to participate. FCR was measured using a validated 42-item FCR Inventory. The brief oncologist-delivered intervention entailed (1) FCR normalization; (2) provision of personalized prognostic information; (3) recurrence symptoms education, (4) advice on managing worry, and (5) referral to psycho-oncologist if FCR was high. FCR, depression, and anxiety were assessed preintervention (T0), at 1 week (T1), and 3 months (T2) postintervention. The primary outcome was participant-rated usefulness. Secondary outcomes included feasibility and efficacy.

RESULTS

Five oncologists delivered the intervention to 61/255 women invited. Mean age was 58 ± 12 years. Mean time since breast cancer diagnosis was 2.5 ± 1.3 years. Forty-three women (71%) were on adjuvant endocrine therapy. Of 58 women who completed T1 assessment, 56 (97%) found the intervention to be useful. FCR severity decreased significantly at T1 (F = 18.5, effect size = 0.39, P < .0001) and T2 (F = 24, effect size = 0.68, P < .0001) compared with baseline. There were no changes in unmet need or depression or anxiety. Mean consultation length was 22 minutes (range, 7-47 minutes), and mean intervention length was 8 minutes (range, 2-20 minutes). The intervention was perceived as useful and feasible by oncologists.

CONCLUSION

A brief oncologist-delivered intervention to address FCR is useful and feasible, and has preliminary efficacy in reducing FCR. Plans for a cluster randomized trial are underway.

A nurse-led intervention for fear of cancer progression in advanced cancer: A pilot feasibility study

PURPOSE

To assess the feasibility, acceptability, and preliminary effects of a nurse-led intervention for managing fear of cancer progression in advanced cancer patients.

METHODS

A single group mixed methods study was conducted in patients with stage III or IV gynecologic or lung cancer (n = 31) with dysfunctional levels of fear of progression or distress. The intervention consisted of seven videoconferencing sessions with skills practice. Feasibility measures included enrollment rate, attendance, attrition, and home practice adherence. Acceptability was based on exit interview responses. Content analysis was used to analyze the qualitative data. Participants completed quantitative questionnaires assessing fear of progression and secondary outcomes at baseline, eight, and 12 weeks. Linear mixed model analysis was used to assess changes in outcome measures.

RESULTS

The average enrollment rate was seven participants/month over 4.5 months. Participants attended a mean of 5.3 of seven sessions. Attrition rate was 30%. The analysis showed improvements over time in fear of progression and exploratory outcomes. Participants reported feeling calmer and more focused. The skills practice helped to manage anxiety and fears. Themes included: Struggling with fears, Refocusing the fears, and Realizing/reaffirming what is important in life. The most beneficial components included the values clarification exercise, detached mindfulness and worry postponement practices.

CONCLUSION

The intervention was acceptable; most feasibility criteria were met. Preliminary data suggest that the intervention reduced fear of progression and improved secondary outcomes. The intervention required a significant time commitment by participants, which may have contributed to increased attrition. To decrease burden, we will shorten the intervention.

A controlled pilot trial of a nurse-led intervention (Mini-AFTERc) to manage fear of cancer recurrence in patients affected by breast cancer

BACKGROUND

Fear of cancer recurrence (FCR) is common in people affected by breast cancer. FCR is associated with increased health service and medication use, anxiety, depression and reduced quality of life. Existing interventions for FCR are time and resource intensive, making implementation in a National Health Service (NHS) setting challenging. To effectively manage FCR in current clinical practice, less intensive FCR interventions are required. Mini-AFTERc is a structured 30-min counselling intervention delivered over the telephone and is designed to normalise moderate FCR levels by targeting unhelpful behaviours and misconceptions about cancer recurrence.This multi-centre non-randomised controlled pilot trial will investigate the feasibility of delivering the Mini-AFTERc intervention, its acceptability and usefulness, in relation to specialist breast cancer nurses (SBCNs) and patients. This protocol describes the rationale, methods and analysis plan for this pilot trial of the Mini-AFTERc intervention in everyday practice.

METHODS

This study will run in four breast cancer centres in NHS Scotland, two intervention and two control centres. SBCNs at intervention centres will be trained to deliver the Mini-AFTERc intervention. Female patients who have completed primary breast cancer treatment in the previous 6 months will be screened for moderate FCR (FCR4 score: 10‑14). Participants at intervention centres will receive the Mini-AFTERc intervention within 2 weeks of recruitment. SBCNs will audio record the intervention telephone discussions with participants. Fidelity of intervention implementation will be assessed from audio recordings. All participants will complete three separate follow-up questionnaires assessing changes in FCR, anxiety, depression and quality of life over 3 months. Normalisation process theory (NPT) will form the framework for semi-structured interviews with 20% of patients and all SBCNs. Interviews will explore participants' experience of the study, acceptability and usefulness of the intervention and factors influencing implementation within clinical practice. The ADePT process will be adopted to systematically problem solve and refine the trial design.

DISCUSSION

Findings will provide evidence for the potential effectiveness, fidelity, acceptability and practicality of the Mini-AFTERc intervention, and will inform the design and development of a large randomised controlled trial (RCT).

TRIAL REGISTRATION

ClinicalTrials.gov: NCT0376382. Registered 4th December 2018, https://clinicaltrials.gov/ct2/show/NCT03763825.

The relationship between fears of cancer recurrence and patient age: A systematic review and meta-analysis

BACKGROUND

Fears of cancer recurrence (FCR) is one of the most prevalent concerns and a common unmet need reported by cancer patients. Patient age is a demographic variable that has been linked to FCR, among others. Although it is recognised by researchers that age and FCR may be negatively correlated, the strength of this correlation has yet to be established.

AIM

The aims of this study were to (a) conduct a meta-analysis to investigate the overall association of patient age in years with FCR across studies from 2009 to February 2019 and (b) scrutinise for patterns of these effect sizes across studies.

METHODS AND RESULTS

Peer-reviewed papers were gathered from the literature via online databases (PubMed, EMBASE, MEDLINE, and PsycINFO). Systematic review guidelines including a quality assessment were applied to the 31 selected studies (pooled participant N size = 19 777). The meta-analysis demonstrated a significant negative association between age and FCR (ES = -0.12; 95% CI, -0.17, -0.07). Meta-regression revealed the association of patient age and FCR significantly reduced over the last decade. A significant effect (β = -0.17, P = 0.005) of breast cancer versus other cancers on this age by FCR association was also identified.

CONCLUSION

The reliable and readily accessible personal information of age of patient can be utilised as a weak indicator of FCR level especially in the breast cancer field, where the majority of studies were drawn. The suggestion that age and FCR association may be attenuated in recent years requires confirmation.