With improved survival from cancer there has been a lot of focus on survivorship; in the more recent years there has been a focus on looking at fear of recurrence. This has been shown to be moderate to high, or clinically significant, in up to 50% of cancer survivors. There have not been many trials and interventions and a lot of health professionals find it difficult to treat this as there are no evidence based guidelines.
We developed a theoretical model on fear of a cancer that people who go through the cancer experience, they have a stress and many patients will come out with a new norm. People who have unhelpful worries or focus on the cancer or have underlying risk factors or have not been told a lot about what to worry about in their cancer returning have increased fear of recurrence. Based on this model we developed Conquer Fear, an intervention which was to try and modify this fear of cancer recurrence. This was based a lot on metacognition and metacognition is worrying about worrying. So a cancer patient would think if they didn’t worry about the cancer coming back that it would be more likely that they wouldn’t catch it earlier and therefore they’d have a worse prognosis.
We then put this intervention into a clinical trial. We randomised 222 patients with either colon, breast or melanoma; they were all early stage and had to be two months to five years from diagnosis. In fact in the trial 90% of the patients were breast cancer patients. These patients were randomised to the Conquer Fear intervention or taking it easy. Conquer Fear was our intervention where the taking it easy arm had relaxation sessions. There were five sessions over a period of ten weeks that these patients underwent. We did baseline, post-intervention and three and six months surveys. Our primary aim was fear of cancer recurrence. This was shown to be significantly reduced at the end of the treatment and at three and six months afterwards. The severity of fear of recurrence was also reduced at these time points.
Our secondary endpoints of anxiety, quality of life and metacognition were reduced at the end of the intervention but not significantly at three and six months. Of interest, both arms had a decrease in all of the endpoints.
The importance of this study is that fear of cancer recurrence is a real entity and now there is an intervention that we can actually do to actually help this from occurring so people can get on with their lives. Fear of recurrence stops people moving on, planning for the future. We are looking in the future to do an economic analysis of this and also to look at doing more cost effective interventions such as online or community-based intervention
Something of a theme in yesterday’s conference there was the talks from Drs Hess and Rodin as well which all kind of blends towards this great idea of treating a patient, not the disease.
Yes, I think it’s really important. This is growing, a lot of the focus and funding has been into newer drug treatments, improving survival but we really need to look at the actual cancer patient as a person and actually make sure that they’re surviving in the best quality of life they can do.
Especially when you mention the cost, you can spend millions on drugs which might not work whereas five sessions over ten weeks, that seems much more achievable. Do you think that could be a focus for oncologists, clinicians to be aware of, that when you’re treating a patient to recommend or even prescribe this kind of…?
I definitely think it is important. Again, there is a cost if you’re looking at using psychologists to do it but from a medical oncologist’s point of view oncologists could actually just tell the patient about what they should worry about would be a start and a help in trying to get them to decrease their fear of recurrence. But certainly looking at more cost-effective online ones like Dr Hess had, certainly looking at very, very achievable and widespread interventions.
The SWORD trial was published last month which was blended cognitive therapy but they did find that people who didn’t complete the trial didn’t do quite as well as those who completed all of their sessions. Do you feel like there might be something about patient maintenance, patient adherence to the schedule?
Yes, I think it’s going to be a combination of online and actual face to face or by phone intervention as well.