What I presented yesterday were the results of a randomised controlled trial of an intervention we developed. It’s called CALM which is an acronym that’s short for Managing Cancer and Living Meaningfully. That phrase really refers to the whole cluster of practical and profound problems that people with metastatic cancer face. We know there’s a fairly predictable set of challenges that occur when people are diagnosed with cancers that might only have a prognosis of 12-18 months – there are symptoms to manage and there are decisions they need to make in healthcare. There’s the impact on their self-concept, their identity, their relationships. There’s thinking about how they will spend their life, how to make their life meaningful when time is short and how to plan for the end. These are pretty big challenges and there’s a lot of distress that often occurs and a lot of adjustment that’s required but we haven’t had a systematic approach to help patients and families deal with this.
That’s the rationale for the intervention we developed, for CALM. It’s three to six sessions, it’s a supportive care intervention and we’ve trained a range of healthcare providers. We’ve trained nurses and doctors and social workers and psychologists and psychiatrists to deliver it. We wondered at the beginning would it be redundant in the sense that people talk to a lot of healthcare providers but we find that often that talk is brief and very focussed on the cancer and the disease rather than on the person. So these are all the reasons why we developed our intervention.
What I reported yesterday are the results of a randomised controlled trial. We recruited over 300 people, we randomised them to either the invention or to usual care and then we followed them at baseline and at three months and six months. What we reported was a significant effect of the primary outcome, which is depression, at the primary endpoint of the trial, three months. The effect was strengthened at six months. But we also had an effect on a variety of other outcomes, on distress about death and dying, on communication with healthcare providers, on planning for the future and a number of other important secondary outcomes.
This was part of, as you were mentioning, the large block of psychological interventions being discussed; that plays into the Conquer Fear that has been discussed by Dr Beith. If you can tell us more about how this all maybe plays together in terms of personalising therapy.
These are all interventions, which is one thing that ties them, and they’re all interventions focussed on the patient not simply on the disease. Each of them was focussed on a different phase of the disease, on diagnosis, on recurrence and our intervention was focussed on this last year or two of life.
I’ve just made a note of it here, the SWORD study which was published last month in JCO was looking at a blended cognitive therapy, online and face to face. I feel like there is maybe a difference between being able to talk to a human being, maybe then reporting those results back later online, what is the value of open communication between doctor and patient?
We think the face to face communication is extremely important and it’s feasible because patients with advanced disease are often in the cancer centre very often so we try to coordinate the visits. Sometimes if the patient is not able to come we will have electronic communications and we’re also disseminating the intervention globally and we’re going to use electronic means to collect data so that we’ll be able to capture the global impact of the intervention.
Dr Hess mentioned a large pooling study, I think it was for the CHAMP trial from 2013 which was assessing health anxiety overall. Were the findings regarding cancer specifically any different, any surprises there compared to general health anxiety?
Anxiety can be common in the population but we know that it’s much more common in patients with cancer. There are different kinds of concerns at different stages. There are concerns that people have at the time of diagnosis; there’s concerns about recurrence; there’s concerns about reintegration back for people having curable disease. There are a whole other set of concerns that occur when a disease is a progressive and the end of life. There’s something about time being short and all the adjustments that are required that propels this intervention, that adds so much power and urgency to it. We do think there’s value to interventions being tailored to the stage of the disease and the particular problem, which each of these interventions that we’re presenting at ASCO take into account.
At what point in the patient’s journey from diagnosis through recovery and then maintenance, watching for relapse, do you think there should be prescribed psychotherapy, prescribed cognitive behavioural therapy? If there is the cost and time for that.
We think supportive care of these kinds should be available routinely to all patients. That, of course, in addition to adequate symptom control, control of pain and other physical symptoms. Too often it’s only sometimes or only when there’s a crisis that this help occurs but we think this help ought to be a core part of cancer care. One of the things that was interesting about our CALM trial is that not only did it produce a reduction in distress but it prevented the emergence of distress so it has a preventive effect. We think this ought to be routine and early. We know that this is an accident waiting to happen, that the diagnosis of a serious cancer is catastrophic for every family that’s involved, so we think early, routine and preventive interventions ought to take place.
I’m just now thinking of taking this forward to, say, the palliative setting, if there has been any incorporation of lessons learned from there or how this might in turn feed back to that?
Some of the lessons are very similar, that palliative care was too often random and occurred sometimes on occasion. We know now that it needs to occur early and routine. An important part of early palliative care is the psychological distress so we see our intervention actually being a core component of early palliative care for life-threatening cancers.
That answers all of my questions, was there anything else you’d like to add or talk further about?
One of the things that people raise is how generalizable is this, how Western is this or unique to certain countries. What we found as we’ve conducted workshops in the Middle East, in Asia, in Latin America, in other places in the world, is we find these concerns are actually common and there’s a growing voice from patients and families to talk about these things and to get help with the distress they’re experiencing. So we’re now in the process of establishing a global network with the help of a global organisation to have this become a routine part of cancer care more universally.
