Current state and future prospects of research on fear of cancer recurrence

A protocol for an updated and expanded systematic mixed studies review of fear of cancer recurrence in families and caregivers of adults diagnosed with cancer

BACKGROUND

Fear of cancer recurrence (FCR) is reportedly common, persistent, associated with significant morbidity and often higher in cancer caregivers than cancer patients. This review will summarise empirical research on FCR to understand its prevalence, severity, correlates, course and impact in families and caregivers of adults diagnosed with cancer, and identify tested interventions that reduce its effects.

METHODS

This review will include peer-reviewed, empirical, qualitative and/or quantitative studies on fear, worry or concern of patients' cancer returning or progressing among adult family members or caregivers of the cancer patient. It will exclude records reporting no original empirical research on FCR. We will search CINAHL, Embase, PubMed, PsycINFO, ProQuest Dissertations and Theses GLOBAL from 1997 onwards. Pairs of reviewers will conduct independent screening, data extraction and risk of bias assessment. Risk of bias will be assessed with the Cochrane Risk of Bias tool for randomised studies, the Risk of Bias Assessment tool for Nonrandomized Studies and the questions for qualitative studies in the mixed methods appraisal tool. We will conduct a narrative synthesis of quantitative studies and a thematic synthesis of qualitative studies.

DISCUSSION

This review will provide further clarity on the prevalence and severity of FCR in families and caregivers and differences by caregiver and care recipient demographic and medical characteristics. Any intervention studies located may indicate therapies or treatments that could reduce FCR in families and caregivers. Findings are expected to provide guidance for individuals and organisations working to manage FCR in families and caregivers of those with cancer.

SYSTEMATIC REVIEW REGISTRATION

This protocol will be registered with PROSPERO after peer-review.

Beyond the fear that lingers: The interaction between fear of cancer recurrence and rumination in relation to depression and anxiety symptoms

OBJECTIVE

The Fear of Cancer Recurrence (FCR) is reported to be a normal response to cancer, but little is known about the interaction between FCR and maladaptive cognitive processes, which may increase the risk for depression and anxiety disorders among cancer survivors. Previous studies have shown the influence of rumination on depression and anxiety in other populations. Thus, the present study aimed to examine how FCR and rumination may relate to depression and anxiety symptoms among cancer survivors.

METHODS

The present study included cancer survivors (N = 388) who had completed their active treatment at the National University Cancer Institute Singapore, and achieved complete remission from cancer. All participants completed self-report measures of FCR (Fear of Cancer Recurrence Inventory), rumination (Rumination Response Scale), depression, and anxiety symptoms (Hospital Anxiety and Depression Scale).

RESULTS

The present study observed that (1) FCR and rumination were associated with more severe depression and anxiety symptoms, and (2) the interaction between FCR and rumination was associated with more severe depressive symptoms (p = .01). Specifically, rumination was significantly associated with higher depressive symptoms in individuals with high FCR (p < .001), while rumination was not associated with depressive symptoms in individuals with low FCR (p > .05).

CONCLUSION

Habitual rumination may be a maladaptive cognitive style to cope with high FCR. Therefore, the present study's findings elucidate the moderating effect of rumination on FCR, and such findings may better inform psychological interventions to reduce the risk of depression and anxiety among cancer survivors who experience high FCR.

Re-validation and screening capacity of the 6-item version of the Cancer Worry Scale

OBJECTIVE

Fear of cancer recurrence (FCR) is one of the major existential unmet needs of cancer survivors. Due to growing availability of evidenced-based interventions for high FCR, valid and reliable brief measures of FCR are needed. This study aimed to validate the 6-item Cancer Worry Scale (CWS) and to establish a cut-off score for high FCR.

METHODS

Participants in this study were 1033 cancer survivors and patients recruited as part of 5 existing studies on FCR involving patients and survivors with gastro-intestinal stromal tumors, colorectal, breast, and prostate cancer. De-identified data of the CWS, Fear of Cancer Recurrence Inventory (FCRI), Impact of Event Scale, Hospital Anxiety and Depression Scale, and EORTC-QLQ-C30 were amalgamated for the analyses. Confirmatory factor analysis of the CWS was performed. Sensitivity and specificity were tested with the FCRI as gold standard.

RESULTS

Results confirmed that the 6-item version of the CWS maintained good construct validity, convergent and divergent validity, and high internal consistency (α 0.90). The optimal cut-off for the 6-item CWS was 9 versus 10 using the 12 vs 13 FCRI-SF score (sensitivity 82%, specificity 83%) and the 15 vs 16 FCRI-SF score (sensitivity 88%, specificity 73%). Using the highest FCRI-SF cut-off (21 vs 22), the optimal CWS cut-off was 11 vs 12 (sensitivity 88%, specificity 81%).

CONCLUSIONS

The present results provide researchers and clinicians with a brief valid and reliable measure of FCR which is suitable for measuring FCR in cancer patients and survivors.

Current directions in research and treatment of fear of cancer recurrence

PURPOSE OF REVIEW

An expert meeting in Ottawa in 2015 galvanized efforts to answer key questions relevant to the understanding and management of fear of cancer recurrence (FCR). The aim of this review is to summarize key developments.

RECENT FINDINGS

A consensus on the definition of FCR has helped to further research in this area. There have been a number of theories put forward to account for the development of FCR, all of which share key components. Importantly, a number of important trials have been published that confirm both brief and more intensive interventions can successfully treat FCR.

SUMMARY

The consensus definition of FCR is an important development, as is the development of treatments for FCR. There are now evidence-based options for the management of patients with clinical levels of FCR. Future research priorities include determining the optimal cut-off points for identifying clinically significant FCR, testing the major tenets of the recent theoretical formulations of FCR; and determining the relative efficacy and cost-effectiveness of different treatment approaches for managing FCR.

Fear of Progression in Cancer Patients and Survivors

Fear of progression (or fear of recurrence) is an appropriate, adequate response to the real threat of cancer. However, elevated levels of fear of progression can become dysfunctional, affecting well-being, quality of life, and social functioning. Research has shown that fear of progression is one of the most frequent distress symptoms of patients with cancer. As a clear consensus concerning clinically relevant states of fear of progression is still lacking, it is difficult to provide a valid estimate of the rate of cancer patients who clearly suffer from fear of progression. Current evidence suggests that probably 50% of cancer survivors experience moderate to severe fear of progression. Furthermore, many patients express unmet needs in dealing with the fear of cancer spreading. These results underscore the need to provide effective psychological treatments for clinical states of fear of progression. Some psychosocial interventions for treating fear of progression have been developed. Our own, targeted intervention study showed that clinical fear of progression can be effectively treated with brief group therapy.

Translation and validation of the Dutch version of the Fear of Cancer Recurrence Inventory (FCRI-NL)

OBJECTIVE

The study objectives are to translate the FCRI in Dutch, and to explore the factor structure and the psychometric qualities of the Dutch translation of the Fear of Cancer Recurrence Inventory (FCRI-NL).

METHOD

The original French-Canadian FCRI had been forward-backward translated into English by the developers, and this method was also used to translate the English version of the FCRI into Dutch. Patients were recruited via patient organizations between July 2011 and October 2013. To replicate the original 7-factor structure of the FCRI, confirmatory factor analysis (CFA) was performed. To examine the psychometric qualities, reliability (Cronbach's alpha), test-retest reliability (intra-class correlations; ICC), and convergent and divergent validity (Spearman's correlations) were calculated.

RESULTS

From 290 cancer patients, 255 (88%) were eligible for analysis (aged 51.0±9.8years, 88.6% women). CFA showed a reasonable yet suboptimal fit of the hypothesized model to the data. The FCRI-NL has good reliability (Cronbach's α=0.93 for the total scale and α=0.75-0.92 for the subscales) and test-retest reliability (ICC=0.84 for the total scale and ICC=0.56-0.87 for the subscales). Convergent (r=0.53-0.66 for the FCRI-NL and r=0.48-0.57 for the FCRI-SF-NL) and divergent (r=-0.20--0.07 for the FCRI-NL and r=-0.28--0.17 for the FCRI-SF-NL) validity was demonstrated.

CONCLUSION

The FCRI-NL seems to have sufficient psychometric properties. However, the FCRI-NL total score should be interpreted with caution. The Severity subscale (FCRI-SF-NL) may be a valuable screening tool for fear of cancer recurrence severity in clinical care.

The association between fear of cancer recurrence and quality of life among Chinese cancer survivors: main effect hypothesis and buffering hypothesis

PURPOSE

The aim of the present study is to examine whether fear of cancer recurrence (FCR) is related to health-related quality of life (HRQOL) among Chinese cancer survivors, an understudied population (i.e., main effect hypothesis). Also, we investigated whether the FCR-HRQOL link is moderated by two coping strategies, avoidance and positive reappraisal (i.e., buffering hypothesis).

METHODS

This is a cross-sectional study conducted among 238 Chinese cancer survivors in Beijing. Participants completed a set of questionnaires including FCR, coping, and HRQOL.

RESULTS

FCR was related to lower physical, psychological, social, and spiritual well-beings, even when demographics, cancer-related factors, and coping were taken into account. There was only one moderation effect between FCR and avoidance coping. Surprisingly, the detrimental effect of FCR on spiritual well-being was lessened among those with high avoidance coping such that the negative association between FCR and spiritual well-being was only found in those with low avoidance coping and not among those with high avoidance coping.

CONCLUSIONS

Findings largely supported the main effect hypothesis. FCR was associated with diverse domains of HRQOL among Chinese cancer survivors. The buffering hypothesis was largely not supported in this population. Rather, in some cases, the effects of FCR and coping strategies on HRQOL were independent. Thus, ways to attenuate the harmful effects of FCR on HRQOL among Chinese cancer survivors remain unresolved. It is urgent and timely that future studies focus on FCR and HRQOL in this population.

The health professionals' perspectives of support needs of adult head and neck cancer survivors and their families: a Delphi study

PURPOSE

The aim was to identify the views of Australian and New Zealand health professionals regarding the support needs of people with head and neck cancer (HNC) and their families and current gaps in service delivery.

METHODS

A modified Delphi process assessed support needs of people with HNC following acute medical management. A systematic review of the literature was used to develop items relevant to seven key concepts underpinning the psychological experience of living with HNC. A panel of 105 health professionals was invited to participate in two questionnaire rounds.

RESULTS

Of the potential panellists, 50 (48%) completed round 1, and of these, 39 (78%) completed round 2. Following two rounds, there was consensus agreement on the concepts uncertainty and waiting, disruption to daily life and fear of recurrence. The concepts the diminished self, making sense of and managing the experience, sharing the burden and finding a path did not achieve consensus. There were no differences in responses according to gender, organization type or location. Medical professionals had significantly higher agreement for the concept uncertainty and waiting compared to allied health professionals, and professionals with five years' or more experience had significantly higher agreement than those with less experience.

CONCLUSIONS

Health professionals agreed that many psychosocial support needs of HNC survivors and families are not being met and that they experience difficulties in meeting these needs. Findings may inform evidence-based treatment programs for HNC survivors and their families to promote psychological resilience and quality of life in this vulnerable population.

Exploring characteristics, predictors, and consequences of fear of cancer recurrence among Asian-American breast cancer survivors

BACKGROUND

To address the fear of cancer recurrence (FCR) research gap, we used prospective data to explore FCR predictors and FCR associations with health-related quality of life among Asian-American breast cancer survivors (BCS).

METHODS

A total of 208 diverse Asian-American BCS completed T1 survey, and 137 completed T2 survey after 1 year.

RESULTS

Fear of cancer recurrence scores (range = 0-4) were 2.01 at T1 and 1.99 at T2 reflecting low-to-moderate FCR. Scores of FCR were stable over the 1-year period (t(126) = .144, P = .886). Multiple regression analyses showed that Chinese women reported lower FCR both at T1 (t(193) = -2.92, P = .004) and T2 (t(128) = -2.56, P = .012) compared to other Asian women. Also, more positive health care experience at T1 predicted lower FCR at T2 (β = -.18, P = .041). Controlling for other covariates, greater FCR at T1 predicted poorer outcomes 1 year later including lower physical (β = -.31, P < .001), emotional (β = -.37, P < .001) and functional (β = -.16, P = .044) well-being and health-related quality of life specific to breast cancer at T2 (β = -.31, P < .001).

CONCLUSIONS

We found substantial consistencies and some divergences between our findings with Asian-American BCS and the existing literature. This prospective investigation reveals new information suggesting that Asian-American subgroup variation exists and health care system factors may influence FCR. Thus, FCR studies should consider Asian subgroupings, cultural aspects, ie, level of acculturation and health care system factors including provider-patient communication and treatment setting. Future research may benefit from contextualizing FCR within a broader distress framework to advance the science and practice of patient-centered and whole-person care.

Moderating effects of perceived growth on the association between fear of cancer recurrence and health-related quality of life among adolescent and young adult cancer survivors

We examined whether (1) fear of cancer recurrence was related to lower health-related quality of life and (2) perceived growth moderated the link between fear of recurrence and health-related quality of life. About 292 adolescent and young adult cancer survivors (diagnosed with cancer at ages 15-34) completed a cross-sectional survey. Fear of recurrence was related to poorer physical and mental health-related quality of life. The negative association between fear of recurrence and mental health-related quality of life was moderated by perceived growth. Fostering perceived growth may mitigate the adverse associations of fear of recurrence and health-related quality of life.