1. Can you briefly introduce “Conquer Fear study”?
“ConquerFear is a face-to-face, individual intervention to help cancer survivors better manage their fear of cancer recurrence (FCR), based on the Self-Regulatory Executive Function model (S-REF). Delivered by psychologists and psychiatrists in 5 sessions, ConquerFear does not try to eliminate FCR, which is a normal, not irrational fear, but rather to help patients pay less attention to FCR and live life according to their values and goals. ConquerFear was evaluated in a randomized controlled trial, and shown to be more effective than an active, relaxation control intervention (Taking it Easy) in reducing fear of cancer recurrence immediately post the intervention, and at 6 months follow-up. The study was published in JCO.*”:
Butow P, Turner J, Gilchrist J et al. Randomized Trial of ConquerFear: A Novel, Theoretically Based Psychosocial Intervention for Fear of Cancer Recurrence. J Clin Oncol. 2017; 35(36):4066-4077. doi: 10.1200/JCO.2017.73.1257.
2.How common is fear of cancer recurrence among cancer survivors? Is this only matter for long-term survivors? Are there more vulnerable patients (cancer type, age, family history, mental health)? How about patients diagnosed at advanced stage?
“Fear of cancer recurrence is understandably very common. A systematic review by Sebastien Samard showed that about 70% of cancer survivors have mild FCR, about 50% have moderate FCR and about 7-10% have severe FCR, which might be considered a clinical problem requiring intervention. Patients have reported that FCR began as soon as they were diagnosed, but peaks at the time of treatment completion. Most studies have shown that FCR is stable, and does not reduce over time, although very long-term survivors have reported a reduction in FCR. Vulnerability factors include being younger, having symptoms/side-effects (readily interpreted as signs of cancer recurrence), and having a pre-existing anxiety disorder. There is inconsistent evidence that a worse prognosis and more extensive treatment may predict greater FCR, however subjective risk perception is a stronger predictor than objective risk. Patients with advanced disease experience fear of cancer progression (which falls under the general definition of FCR).”
3. How do you measure FCR? Is there any simple way to assess FCR? How often or when do you need to assess FCR? What would you recommend health professionals at clinic to assess FCR?
“There are many measures of FCR. The most commonly used questionnaire is the 42-item Fear of Cancer Recurrence Inventory (FCRI), developed by Simard and colleagues. The FCRI offers a rich clinical insight into FCR, and has a 9-item short form which can be used to measure severity. This measure is probably optimally used by psychologists or other staff offering an intervention to patients, to enable a full clinical understanding of the problem. A number of shorter screening measures have been developed; for example, Gerry Humphris has developed 4- and 7-item screening measures of FCR, which may be more useful as a regular screening tool in the clinic. The international IPOS Special Interest Group in FCR (FoRWaRDS) is currently developing criteria for a clinical diagnosis of FCR, and this may trigger the need for a new questionnaire that reflects these clinical characteristics. FCR can fluctuate, with peaks common when patients are coming for scans or follow-up, when a family member or friend develops cancer, or when cancer is featured in the media. Therefore, it is probably best to measure FCR when the patient is not facing a scan or test. The optimal frequency of measurement may depend on the study question or clinical purpose.”
4.There are many components in your intervention. What do you think the most beneficial to survivors? If you need to choose one, what would you recommend health professionals to try with low resource (no psychiatrist, less time)?
“ConquerFear has a number of components, including values clarification, attention training, detached mindfulness, meta-cognitive therapy and behavioural contracting for follow-up. Our mediation and moderation analysis showed that changing meta-cognitive beliefs about worry (over-valuing worry as a method to ensure vigilance for signs of cancer recurrence, or fearing worry will increase the likelihood of cancer recurrence) was the component most strongly associated with improved FCR. However, this is probably the most complex component for health professionals untrained in cognitive-behavioural therapy or with little time. I believe that doctors and nurses can help a lot by doing a quick screen for FCR, normalising FCR, ensuring patients have the information they want about prognosis and the most likely signs of cancer recurrence, providing patients with links to existing websites about FCR and making referrals to psychologists if the patient has high or clinical FCR. We are currently evaluating a short ten-minute intervention along these lines, delivered by oncologists at the first follow-up appointment, to see if it can prevent or reduce FCR.”
5.What do you think are the gaps and barriers/challenges for managing FCR in current cancer care system? How should try to resolve them?
“Most services do not screen for FCR, or ask patients at follow-up whether they are experiencing FCR, and therefore most FCR goes undetected. As use of patient reported outcomes become more the norm, a few short screening items for FCR, such as Gerry Humphris’ measure, should be included. Doctors and nurses can play an important role along the lines suggested above, to potentially prevent or reduce FCR, and this will likely take only a few minutes. Normalising FCR and responding empathically when patients raise these fears, will help patients feel comfortable discussing FCR and asking for help if needed.”
6.What is your future plan regarding research and practice at FCR?
“There are lots of exciting developments with ConquerFear. Currently colleagues, in collaboration with the original ConquerFear team, are developing an online form of ConquerFear (Ben Smith, Australia), a group version (Bobby Zachariae in Denmark), a version for nurse-delivery (Anne Reb, USA, as well as colleagues in South Korea) and a version for advanced cancer patients (Louise Sharpe in Australia). The FoRWaRDS IPOS special interest group in FCR is conducting a number of important studies to establish clinical criteria for FCR, and to review the literature in different areas. Interventions for partners is an important area of development also.”
7.Any message to cancer survivors experiencing FCR?
“Anyone diagnosed with cancer is likely to worry about their cancer coming back, or recurring, particularly when a scan or follow-up is due. This sort of normal worry is only a problem if it starts to interfere with your life and cause you ongoing distress. If that happens to you, as it does for about one in ten cancer survivors, it is definitely worth telling your oncologist or GP, because there is help available.”