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

For the Long Haul: Management of Long-Term Survivors after Melanoma Systemic Therapy

PURPOSE OF REVIEW

This review summarizes the latest advancements in survivorship care for patients with advanced melanoma who received systemic therapy and emphasizes the areas where more research is needed.

RECENT FINDINGS

Over the last decade there have been remarkable advances in the treatment of advanced and metastatic melanoma. Due to these novel treatments, including several immune checkpoint inhibitors and tyrosine kinase inhibitors, there are and will continue to be increasing numbers of long-term melanoma survivors who have been treated with systemic therapy. These patients will navigate new challenges are they are essentially among the first long term survivors after these novel therapies. Survivorship care focuses on improving the health-related quality of life of patients including the physical, emotional, social and functional effects of cancer that begin at diagnosis and continue through the end of life. Survivorship also includes screening for cancer recurrence and second cancers. As the number of melanoma survivors who received systemic therapy continues to grow, the survivorship care plan will become increasingly important for optimal care of patients even after their cancer treatments. Understanding the many domains of survivorship care for this group of patients is imperative for their care now and to identify unmet needs for future research.

The development and validation of the Worries About Recurrence or Progression Scale (WARPS)

OBJECTIVES

Worry about recurrence or progression is a common concern among people with chronic physical illnesses. Although there are options to measure the fear of cancer recurrence and other illness-specific measures, there is only one transdiagnostic measure of fear of progression, which does not assess the fear of recurrence or relapse.

DESIGN

A multi-phase study outlining the development and validation of a novel transdiagnostic measure of fear of recurrence or progression, the Worries About Recurrence and Progression Scale (WARPS).

METHOD

From a prior systematic review, we used quotes from people with lived experience to generate 55 items. Next, we piloted the items with 10 people with a range of chronic conditions, leading to a final total of 57 items. We then recruited four groups of people with cardiac disease, rheumatic disease, diabetes and respiratory disease (n = 804). An exploratory factor analysis in a randomly split sample resulted in an 18 item, single factor scale. We then performed confirmatory factor analysis on these 18 items in the remaining sample.

RESULTS

The 18-item WARPS demonstrated good construct validity, internal consistency and test-retest reliability. Specifically, the WARPS was strongly correlated with the Fear of Progression Questionnaire, and with illness-specific fears. Significant, moderate correlations were observed with depression, anxiety, stress, and death anxiety. The WARPS demonstrated the validity and reliability amongst people with four of the most common chronic conditions and the factor structure was invariant across genders.

CONCLUSION

The WARPS is a valid and reliable tool to measure transdiagnostic worries about recurrence and progression.

Effectiveness of Cognitive Behavioral Therapy on Fear of Cancer Recurrence in Breast Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Fear of cancer recurrence is one of the psychological distresses that seriously affects the quality of life of breast cancer patients. However, the evidence for cognitive behavioral therapy on fear of cancer recurrence in breast cancer is limited.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of cognitive behavioral therapy in reducing breast cancer patients' fear of cancer recurrence.

METHODS

Seven databases were searched for randomized controlled studies on cognitive behavioral therapy for fear of cancer recurrence in cancer patients from the inception of the database to April 30, 2023, with no language restrictions. Meta-analysis was performed using Stata MP 17. The Cochrane Risk of Bias Tool version 2 was used to assess the quality of the included studies. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation method.

RESULTS

This review includes a total of 13 randomized controlled trials with 1447 breast cancer patients and survivors. When compared with controls, meta-analysis revealed that cognitive behavioral therapy significantly reduced the fear of cancer recurrence (g = -0.44; 95% confidence interval, -0.75 to -0.13; P < .001), whereas subgroup analysis revealed that only mindfulness-based cognitive therapy was significant. The overall risk of bias was high. The Grading of Recommendations, Assessment, Development and Evaluation assessment showed a low overall quality of evidence.

CONCLUSIONS

Cognitive behavioral therapy may be effective in reducing fear of cancer recurrence in breast cancer patients, and mindfulness-based cognitive therapy is particularly worthy of implementation.

IMPLICATIONS FOR PRACTICE

Mindfulness-based cognitive therapy may be used as an additional strategy to help manage breast cancer patients' fears of cancer recurrence.

Feasibility and preliminary efficacy of iConquerFear: a self-guided digital intervention for fear of cancer recurrence

PURPOSE

Approximately 50% of cancer survivors experience moderate-severe fear of cancer recurrence (FCR). Self-guided digital interventions have potential to address the high level of FCR-related unmet needs at scale, but existing digital interventions have demonstrated variable engagement and efficacy. This study aimed to evaluate the feasibility and preliminary efficacy of iConquerFear, a five-module self-guided digital FCR intervention.

METHODS

Eligible curatively treated breast cancer survivors were recruited. Participants reporting clinically significant FCR (≥ 13 on the Fear of Cancer Recurrence Inventory-Short Form; FCRI-SF) were given access to iConquerFear. Feasibility was indicated by > 50% of eligible participants enrolling in iConquerFear and recording moderate (≥ 120 min) or greater usage. Preliminary efficacy was evaluated via changes in self-reported FCR severity, anxiety, depression, intrusions and metacognitions from baseline to immediately and 3 months post-intervention.

RESULTS

Fifty-four (83%) of 65 eligible participants enrolled in iConquerFear; six subsequently withdrew. Thirty-nine (83%) participants recorded moderate (n = 24; 120-599 min) or high (n = 15; ≥ 600 min) usage. Engagement levels increased with participant age (p = 0.043), but were lower in participants with higher baseline FCR (p = 0.028). Qualitative feedback indicated engagement was sometimes limited by difficulties with navigation and relating to featured survivors. Participants reported significantly improved FCR (mean reduction (95%CI): baseline to post-intervention - 3.44 (- 5.18, - 1.71), baseline to 3-month follow-up - 4.52 (- 6.25, - 2.78), p =  < 0.001).

CONCLUSION

iConquerFear is a feasible and potentially efficacious intervention for reducing FCR in breast cancer survivors. Easier navigation and more relatable examples may enhance engagement.

IMPLICATIONS FOR CANCER SURVIVORS

iConquerFear may help address moderate but burdensome FCR levels in cancer survivors.

Fear of Recurrence in Advanced Cancer Patients: Sociodemographic, Clinical, and Psychological Correlates

Fear of cancer recurrence significantly impacts advanced cancer patients, prompting emotional distress and increased healthcare utilization. This present study aims to analyze the fear of recurrence among patients with advanced cancer undergoing systemic treatment and its relationship with sociodemographic, clinical, and psychological factors. A multicenter cross-sectional study was conducted in 15 oncology departments across Spain, involving patients with locally advanced, unresectable, or metastatic cancer eligible for systemic treatment. Participants provided demographic information and completed instruments such as the Cancer Worry Scale, Brief Symptom Inventory, Mishel Uncertainty in Illness Scale, and the Duke-UNC-11 Functional Social Support Questionnaire (DUFSSQ). A total of 1195 participants participated: median age 66, 56% male, mostly metastatic cancers (80%), and common tumor sites. Two fear groups emerged: 28% low and 72% high levels of fear. High fear was associated with being female, being younger, lower levels of education, and worse survival estimates. High fear correlated with more depression, anxiety, somatic symptoms, uncertainty, and stronger social support. Multivariate analyses indicated that younger patients, those with shorter survival estimates, higher depression and anxiety scores, more uncertainty, and stronger social support had a greater likelihood of experiencing fear of recurrence, while the opposite was true for older patients. This study underscores distinct fear of recurrence profiles in advanced cancer patients, emphasizing the need for targeted interventions and support. Future research should delve deeper into understanding their repercussions for improving patient care and well-being.

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.

Fear of cancer recurrence in ovarian cancer caregivers: A qualitative study

AIM

Although there is growing research exploring survivor fear of cancer recurrence (FCR), little is known about caregiver FCR. To date, examination of caregiver FCR has largely been conducted through the lens of survivor conceptualisations, limiting the development of caregiver-specific models, measures, and interventions. This study aimed to explore experiences of FCR among caregivers of people with ovarian cancer.

METHODS

Semi-structured telephone interviews were conducted with caregivers of people with ovarian cancer. Participants, recruited through Ovarian Cancer Australia, also completed an online survey collecting participant and patient demographic characteristics, information about the survivor's disease and caregiver levels of FCR using the Fear of Cancer Recurrence Inventory (Caregiver) (FCRI-c). Qualitative interviews explored caregiver fears, how fears and concerns were experienced and the frequency and timing of FCR. Thematic analysis using a Framework Approach was used to analyse the results.

RESULTS

Twenty-four caregivers (54% male) participated in an interview. Most caregivers were providing care for their partner (n = 14). Thematic analysis identified four inter-related themes and associated sub-themes: (1) Fear and uncertainty; (2) Liminality; (3) Hopelessness and (4) Caregiver's protection of the person and self (caregiver's role as protector). Underpinning these themes was an overarching fear of one's family member dying.

CONCLUSIONS

Caregivers supporting people with ovarian cancer experience worries and concerns related to cancer recurrence or progression. These experiences are conceptually different to survivor experiences. Fear of one's family member dying, and the dual nature of caregiver protection/self-protection mean it is imperative that interventions are tailored specifically to caregiver needs. Future research facilitating the development of appropriate measures and interventions is essential to reduce caregiver FCR.

Toward implementation of an evidence-based intervention for fear of cancer recurrence: Feasibility in real-world psycho-oncology practice

OBJECTIVE

Few evidence-based interventions addressing high levels of fear of cancer recurrence (FCR) have been implemented. Understanding how these might be implemented is crucial to bridge the research-practice gap. This study investigated the feasibility of implementing the blended Survivors' Worries of Recurrent Disease (SWORD) intervention in real-world psycho-oncology practice.

METHODS

SWORD was offered for 15 months (2021-2022) as the standard care for clinical FCR in a university hospital, a general hospital, and psycho-oncological center. We evaluated using a mixed-methods design six feasibility outcomes based on Bowen's framework: demand, limited effectiveness, degree of execution, acceptability, practicality, and integration. Anonymous data were collected for all oncology patients on referral. Study participants completed questionnaires before and after treatment, including the Cancer Worry Scale (CWS-6) as the primary measure of effectiveness. Qualitative data included interviews with patients and psychologists, and field notes.

RESULTS

Regarding demand, 81 of 644 patients referred (13%) were eligible for SWORD. The uptake of SWORD was 79% (n = 63/80) and the completion rate 73% (n = 46/63). SWORD was effective in reducing FCR (p < 0.001, ηp2  = 0.694). Regarding execution, a variability in the length, planning and number of treatment sessions was found between different settings. Adherence to the treatment manual's content was high (89%). Regarding acceptability, most patients were satisfied with SWORD (average 8.2/10) and psychologists valued the blended format. Psychologists reported SWORD was practical to deliver given their knowledge and skills. Although differences between settings were found, SWORD integrated well into practice. Referral for FCR and a reluctance to contract new eHealth providers were barriers for implementation.

CONCLUSIONS

Despite differences between healthcare settings, the implementation of SWORD was evaluated well. The feasibility of SWORD in different settings should inform a national implementation strategy.

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.

A novel clinician-delivered intervention to reduce fear of recurrence in breast cancer survivors: Results from a Phase I/II implementation study (CIFeR_2)

OBJECTIVE

Fear of cancer recurrence (FCR) is highly prevalent, however there is no formal training for clinicians to address FCR. A novel brief clinician intervention to help patients manage FCR (Clinician Intervention to Reduce Fear of Recurrence (CIFeR)) was shown to be feasible, acceptable, and reduced FCR in breast cancer patients in a pilot study. We now aim to explore the barriers and facilitators of implementing CIFeR within routine oncology practice in Australia.

METHODS

This multicentre, single-arm Phase I/II implementation study recruited surgical, medical and radiation oncologists who treat women with early breast cancer. Participating clinicians completed online CIFeR training and were asked to use CIFeR for the next 6 months. Questionnaires were administered before (T0), immediately after (T1), then 3 (T2) and 6 months (T3) after training to assess confidence in addressing FCR and Proctor Implementation outcomes. The primary outcome was adoption at T2. Secondary outcomes were self-efficacy in FCR management, acceptability, feasibility, costs, barriers and facilitators of implementation.

RESULTS

Fifty-two clinicians consented of whom 37 completed the CIFeR intervention training. Median age of participants was 41.5 (range 29-61), 73% were female and 51% were medical oncologists. The primary endpoint was met, with CIFeR adopted by 82%. Clinician intervention delivery took 7.4 min on average and was deemed acceptable, appropriate and feasible. Self-efficacy in managing FCR improved significantly across all domains (p < 0.001). Lack of time was the greatest barrier to routine CIFeR_2 implementation.

CONCLUSIONS

A structured brief, low-cost clinician intervention to reduce FCR is useful, acceptable and improved self-efficacy with FCR management. Fear of cancer recurrence training should be incorporated into communication skills training of oncologists and surgeons.

TRIAL REGISTRATION

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

TRIAL SPONSOR

Chris O'Brien Lifehouse.

Effectiveness of a guided online primary care intervention for fear of cancer recurrence: A randomised controlled trial

OBJECTIVE

Fear of Cancer Recurrence (FCR) is highly prevalent among cancer survivors and leads to decreased quality of life and increased healthcare costs. We assessed the effectiveness of a guided online primary care intervention for FCR, compared to waiting list.

METHODS

In this RCT, participants were recruited online and randomised 1:1. All adults who finished successful curative cancer treatment between 3 months and 10 years ago, wanted support for FCR, and had sufficient Dutch skills were eligible. The intervention consisted of a 10-week online programme and three to five video calling sessions with a trained mental health worker. After 6 months, the control group received the same intervention. The primary outcome was the difference between the groups in the change in FCR severity from baseline (T0) to 6 months (T2), measured online with the short form of the Fear of Cancer Recurrence Inventory.

RESULTS

One hundred and seventy-three participants were enroled and randomised to the intervention (n = 86) or control group (n = 87). FCR severity dropped 2.1 points more in the intervention group than in the control group (2.7 points (SD = 3.9) versus 0.6 points (SD = 3.6), t(154) = 3.4, p = 0.0007). General mental well-being also improved significantly in the intervention group and remained stable in the control group. These improvements remained at 10 months follow up.

CONCLUSIONS

This easily accessible and relatively inexpensive intervention effectively reduces FCR and has potential to replace or precede existing more intensive psychological treatments, improving patients' access to care.

TRIAL REGISTRATION

The trial was prospectively registered in the Netherlands Trial Register on 25-02-2019 with number NL7573.

The bodily threat monitoring scale: Development and preliminary validation in adult and childhood cancer survivors

OBJECTIVE

Bodily threat monitoring is a core clinical feature of Fear of cancer recurrence (FCR) and is targeted in psycho-oncology treatments, yet no comprehensive self-report measure exists. The aim of this study was the theory-informed development and initial validation of the Bodily Threat Monitoring Scale (BTMS).

METHODS

Adult survivors of breast and gynaecological cancers (Study 1: N = 306, age = 37-81 years) and childhood cancer survivors (Study 2: N = 126, age = 10-25 years) completed the BTMS, designed to assess how individuals monitor for and interpret uncertain symptoms as indicating that something is wrong with their body. Participants completed measures to assess construct and criterion validity of the BTMS, and childhood cancer survivors (Study 2) completed the BTMS again 2 weeks later to assess test-retest reliability.

RESULTS

The 19-item BTMS demonstrated excellent internal consistency across adult and childhood cancer samples (α = 0.90-0.96). Factor analyses indicated two subscales capturing 1. Monitoring of bodily sensations and 2. Threatening interpretations of bodily sensations. Two-week stability estimates were acceptable. For construct validity, the BTMS correlated with body vigilance and anxiety sensitivity. The BTMS also demonstrated criterion validity, yielding significant associations with FCR, intolerance of uncertainty, help-seeking behaviours, and quality of life. The BTMS was associated with FCR while controlling for body vigilance and anxiety sensitivity, indicating a unique contribution of this theory-informed measure.

CONCLUSIONS

The BTMS shows evidence of sound psychometric properties and could be used to elucidate the role of bodily threat monitoring in the maintenance and management of FCR.

Effects of Social Support, Family Resilience, and Individual Resilience on Fear of Cancer Recurrence Among Persons With Breast Cancer: A Cross-Sectional Study

BACKGROUND

There is limited research exploring the psychological and social predictors of fear of cancer recurrence (FCR).

OBJECTIVE

This study tested the effects of social support, family resilience, and individual resilience on FCR among persons with breast cancer.

METHODS

A convenience sampling method was used to select 214 participants from March to August 2021 in 1 tertiary hospital in Jinan, China. Data were collected using self-administered questionnaires. Path analysis was adopted to explore the effects of social support, family resilience, and individual resilience on FCR.

RESULTS

Findings showed that 94.6% of the participants reached a clinical level of FCR. Social support (β = -.75, p < .01) and individual resilience (β = -.32, p < .01) negatively and directly impacted FCR. Family resilience indirectly impacted FCR through individual resilience (β = -.22, 95% confidence interval (CI): -.34 to -.08). Social support indirectly impacted FCR through family resilience and individual resilience (β = -.15, 95% CI: -.23 to -.06).

CONCLUSIONS

Persons with breast cancer experienced a high level of FCR. Individual resilience was a mediator between family resilience and FCR. Resilience (individual resilience and family resilience) partially mediated the effects of social support on FCR. The findings indicate that measures focused on improving individual resilience, family resilience, and social support should be considered by nurses, which are helpful for easing FCR.

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.

Is de-escalation of treatment by omission of radiotherapy associated with fear of cancer recurrence in women with early breast cancer? An exploratory study

PURPOSE

Safe de-intensification of adjuvant radiotherapy (RT) for early breast cancer (BC) is currently under evaluation. Little is known about the patient experience of de-escalation or its association with fear of cancer recurrence (FCR), a key issue in survivorship. We conducted a cross-sectional study to explore this association.

METHODS

Psychometrically validated measures including the Fear of Cancer Recurrence Inventory-Short Form were completed by three groups of women with early BC: Women in the PROSPECT clinical trial who underwent pre-surgical MRI and omitted RT (A), women who underwent pre-surgical MRI and received RT (B); and women who received usual care (no MRI, received RT; C). Between group differences were analysed with non-parametric tests. A subset from each group participated in a semi-structured interview. These data (n = 44) were analysed with directed content analysis.

RESULTS

Questionnaires from 400 women were analysed. Significantly lower FCR was observed in Group A (n = 125) than in Group B (n = 102; p = .002) or Group C (n = 173; p = .001), and when participants were categorized by RT status (omitted RT vs received RT; p < .001). The proportion of women with normal FCR was significantly (p < .05) larger in Group A (62%) than in Group B (35%) or Group C (40%). Two qualitative themes emerged: 'What I had was best' and 'Coping with FCR'.

CONCLUSIONS

Omitting RT in the setting of the PROSPECT trial was not associated with higher FCR than receiving RT. Positive perceptions about tailored care, lower treatment burden, and trust in clinicians appear to be protective against FCR.

Healthcare use and fear of recurrence in adult cancer survivors at 2.5 years after a cancer diagnosis: a nationwide register study in Denmark

PURPOSE

To investigate the association between fear of cancer recurrence (FCR) and healthcare use in general practice among cancer survivors.

METHODS

We linked nationwide register data to survey data on FCR in cancer survivors at 2.5 years after a cancer diagnosis. Multiple regression models were used to analyse the association between high FCR level and quartiles of healthcare use at 18-30 months before the cancer diagnosis (habitual healthcare use) and between high FCR level and healthcare use at 18-30 months after the cancer diagnosis (survivorship healthcare use).

RESULTS

We included 1538 cancer survivors in the study. High habitual healthcare use was associated with a high level of FCR (odds ratio = 2.07 (95% confidence interval (CI): 1.36-3.15)) for the 4th quartile of healthcare use compared to the 1st quartile. A high FCR score was also associated with higher healthcare use during cancer survivorship (incidence rate ratio (IRR) = 1.26 (95% CI: 1.14-1.40)). This association remained statistically significant when adjusting for habitual healthcare use (IRR = 1.20 (95% CI: 1.09-1.33)).

CONCLUSION

High healthcare use before the cancer diagnosis was associated with high FCR during survivorship. This indicates that FCR is partly explained by a general (pre-diagnostic) health concern. High FCR predicted high healthcare use during cancer survivorship, even when adjusting for habitual healthcare use.

IMPLICATIONS FOR CANCER SURVIVORS

Our results suggest that FCR in cancer survivors is triggered by a general high level of health concern, and the cancer diagnosis may further exacerbate this concern.

Is digital intervention for fear of cancer recurrence beneficial to cancer patients?: A systematic review and meta-analysis

OBJECTIVE

This study aimed to compare the effectiveness of digital and face-to-face interventions in reducing fear of cancer recurrence (FCR) among individuals with cancer.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for evaluating the efficacy of psychological interventions for FCR published between July 2018 and December 2021. We searched for research papers using PubMed, Embase, and Cochrane and assessed their quality using the Revised Cochrane risk-of-bias tool for randomized trials.

RESULTS

Of the 2113 identified studies, we analyzed 17 samples (N = 1482) from 14 studies, of which 13 were RCTs. The overall sample showed a moderate effect size (Hedges' g = 0.607; 0.356 to 0.858; p < 0.001; I2  = 81.29%) in FCR reduction. The overall effect size was 0.621 (95% CI, 0.276 to 0.966; p < 0.001; I2  = 81.78%) for face-to-face interventions and 0.517 (95% CI, 0.093 to 0.941; p = 0.017; I2  = 83.19%) for digital interventions. The difference between the two effect sizes was not statistically significant.

CONCLUSION

Our meta-analysis suggests that digital interventions are moderately effective in reducing FCR, similar to face-to-face interventions. However, given the high degree of heterogeneity, this conclusion should be interpreted with caution. Further studies are required to identify the most effective digital interventions and the populations that may benefit from them.

Comparison of the sense of spousal support, anxiety, depression and their relationship to fear of cancer recurrence between lymphoma patients and their spouses: A cross-sectional study in China

PURPOSE

To investigate the level of fear of cancer recurrence (FCR) in spouses of patients with lymphoma and its relationship with patients' FCR, as well as the correlations between FCR, sense of spousal support (SSS), anxiety, and depression in the couples.

METHODS

A cross-sectional study of 233 couples where one partner had lymphoma was conducted from May 2021 to February 2022. Participants provided demographic information and completed the Spouse Support Inventory and Hospital Anxiety and Depression Scale. The Fear of Progression Questionnaire (for patients) and Fear of Progression Questionnaire for Partners (for spouses) were used to measure FCR. Descriptive analyses, t-tests, variance analysis, Spearman's correlation analysis, and multiple linear regression analysis was performed.

RESULTS

The prevalence of FCR, anxiety, and depression in patients was 37.7%, 68.7%, and 83.3%, respectively. The prevalence of FCR, anxiety, and depression in spouses was 56.2%, 78.1%, and 81.1%, respectively. Spouses' FCR scores were higher than those of patients, whereas patients' SSS and anxiety scores were higher than those of their spouses. Multiple linear regression analysis showed that patients' anxiety and SSS, as well as spouses' FCR were significantly associated with patients' FCR. Variables significantly associated with higher FCR among spouses were anxiety, per capita monthly household income, and patients' FCR.

CONCLUSIONS

Patients with lymphoma and their spouses have a certain degree of FCR, anxiety, and depression. FCR levels in spouses are higher than in patients.

IMPLICATIONS FOR CANCER SURVIVORS

Psychological support interventions for couples may be effective in reducing FCR and facilitating family adaptation to cancer.

Fear of disease progression among breast cancer patients in China: a meta-analysis of studies using the fear of progression questionnaire short form

Background

Fear of disease progression (FoP) is among the most prevalent and major psychological burdens breast cancer patients encounter. Excessive FoP may result in serious adverse effects for patients. FoP in breast cancer patients has gained attention recently; however, its prevalence in China is unknown.

Objectives

This meta-analysis and systematic review aimed to assess the overall FoP among Chinese breast cancer patients to make recommendations for treatment and care.

Methods

Systematic search databases included PubMed, EMbase, The Cohrane Library, Web of Science, CINAHL, PsycINFO and 4 Chinese databases (Wan Fang Data, CBM, VIP and CNKI). The retrieval time ranged from the database's establishment to March 20, 2023. After two researchers independently evaluated the literature, retrieved information, and assessed the risk of bias for the included literature, Stata 15.1 software was used to conduct a meta-analysis.

Results

A total of 37 moderate or high-quality studies involving 9,689 breast cancer patients were included. Meta-analysis showed that the pooled mean score of FoP for Chinese breast cancer patients was 33.84 [95% CI (31.91, 35.77)], prediction interval (21.57 ~ 46.11). The subgroup study found that FoP levels varied among breast cancer patients of different regions, ages, educational levels, marital statuses, residences, illness stages, and disease statuses.

Conclusion

Breast cancer patients have higher FoP scores. Healthcare workers should be concerned. We expect that more relevant research will be undertaken and more effective interventions will be developed. Patients can manage their illness and improve their quality of life by reducing their fears.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO CRD42023408914.

Mortality and mental health funding-do the dollars add up? Eating disorder research funding in Australia from 2009 to 2021: a portfolio analysis

Background

Eating Disorders (EDs) are among the deadliest of the mental disorders and carry a sizeable public health burden, however their research and treatment is consistently underfunded, contributing to protracted illness and ongoing paucity of treatment innovation.

Methods

We compare absolute levels and growth rates of Australian mental health research funding by illness group for the years 2009-2021, with a specific focus on eating disorders analysed at the portfolio level.

Findings

Actual and adjusted data obtained from Australia's three national medical research funding bodies (NHMRC, ARC and MRFF) shows eating disorders receive a disproportionately low allocation of mental health research funding despite having amongst the highest mortality rates. Forty-one category one research grants totalling $AUD28.1 million were funded for eating disorders over the period. When adjusted for inflation, this equates to $2.05 per affected individual, compared with $19.56 for depression, $32.11 for autism, and $176.19 for schizophrenia. Half of all research funded for eating disorders was 'basic' research (e.g., illness underpinning), with little investment in the development of innovative treatment models, novel therapeutics or translation, well reflected by recovery rates of less than 50% in individuals with Anorexia Nervosa.

Interpretation

Significant discrepancy remains between research funding dollars and disease burden associated with the mental health disorders. The extent to which eating disorders are underfunded may in part be attributable to inaccuracies in epidemiological and burden of disease data.

Funding

This work was in-part funded by the Australian Government Department of Health and the National Eating Disorder Research & Translation Strategy. The funder was not directly involved in informing the development of the current study.

Psychometric validation of the fear of progression questionnaire-short form in acute pancreatitis patients

Introduction

Fear of progression (FoP) is associated with the quality of life and behavioral change in acute pancreatitis (AP) patients, but lack of assessment tools.

Aim

This study aimed to develop and evaluate the psychometric properties of the Fear of Progression Questionnaire-Short Form in AP patients (AP-FoP-Q-SF).

Methods

Internal consistency, factorial structure, convergent validity, and criterion validity of AP-FoP-Q-SF were assessed. A receiver operating characteristic (ROC) curve analysis was performed to identify the cutoff value for high FoP. Associations between patient variables and FoP were evaluated using multiple logistic regression. Wilcox rank sum test was used to analyses the costs and length of hospital stay of the patients with high FoP.

Results

The two-factor structure showed a good fit. Internal consistency was acceptable (Cronbach's α = 0.771). The cutoff of 26 identified 35.3% of patients with high FoP. High FoP scores were associated with age (OR = 0.96, 95%CI: 0.94-0.98), recurrence times (OR = 1.22, 95%CI: 1.02-1.45) and anxiety (OR = 1.27, 95%CI: 1.16-1.40). Patients with high FoP spent more cost and time in the hospital.

Conclusions

The AP-FoP-Q-SF is a good FoP tool for AP patients in China.

Implications for practice

Clinicians can use the AP-FoP-Q-SF to assess FoP and take promotion programs to avoid worse effects.

Relationship between social support and fear of cancer recurrence among Chinese cancer patients: A systematic review and meta-analysis

Background

To quantitatively analyze the association between social support (SS) and fear of cancer recurrence (FCR) by reviewing current evidence from observational studies.

Methods

A comprehensive literature search was performed in nine databases from inception to May 2022. Observational studies that used both SS and FCR as study variables were included. Regression coefficient (β') and correlation coefficient (r) were calculated with R software. Subgroup analysis was utilized to investigate the degree of the relationship between SS and FCR as well as the impact of various forms of SS on FCR in cancer patients.

Results

Thirty-seven studies involving 8,190 participants were identified. SS significantly reduced FCR risk [pooled β' = -0.27, 95% confidence interval (CI) = -0.364 to -0.172], with moderate negative correlations (summary r = -0.52, 95% CI = -0.592 to -0.438). Meta-regression and subgroup analysis showed that types of cancer and study type were the source of heterogeneity. However, types of SS [actual SS, perceived social support (PSS), and others], source of actual SS, and source of PSS were not significant moderators.

Conclusion

To the best of our knowledge, this is the first systematic review and meta-analysis to quantitatively investigate the association between SS and FCR in Chinese cancer patients using β' and r coefficients. The results re-emphasized that social workers should enhance the use of SS by cancer patients and establish a sound SS system by either implementing more relevant research or developing targeted policies. Based on meta-regression and subgroup analyses, moderators of the association between SS and FCR should also be studied closely as they may help identify patients in need. In addition, longitudinal research, as well as mixed research, should be conducted to more comprehensively explore the relationship between SS and FCR.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42022332718.

Evaluating the capacity of the distress thermometer to detect high fear of cancer recurrence

OBJECTIVES

Fear of cancer recurrence (FCR) is common and burdensome to patients, but often remains undetected. Oncology professionals report need for tools to improve FCR detection in routine care. Oncology care guidelines recommend the Distress Thermometer (DT) for distress screening, but it has not been validated for FCR. This study evaluated the capacity of the DT and accompanying problem list to detect FCR.

METHODS

Amalgamated data of two studies with 149 breast cancer and 74 colorectal cancer survivors were used. We evaluated the Dutch DT including the DT score, problem list fears item and emotional domain score using Receiver Operating Characteristic analyses. The Dutch Cancer Worry Scale-6 (CWS-6) was used as reference measure, with validated cut-off scores ≥10 and ≥12 for high FCR. Sensitivity, specificity, negative and positive predictive values were calculated.

RESULTS

The DT score showed poor performance in discriminating between low and high FCR. The recommended cut-off ≥4 had low sensitivity (65% for CWS-6≥10; 72% for CWS-6 ≥12) and specificity (67% and 58%). No other cut-off had an acceptable combination of sensitivity and specificity. The fears item had low sensitivity (29% and 44.9%) and high specificity (95% and 94%). The emotional domain score had fair performance in discriminating between low and high FCR but there was no cut-off with acceptable sensitivity and specificity.

CONCLUSION

The DT as currently recommended in oncology care guidelines is not suitable to effectively detect FCR in routine care. To improve patients access to psychosocial care, it should be investigated how FCR-specific measures can be integrated in oncology practice.

Barriers and facilitators for implementation of the SWORD evidence-based psychological intervention for fear of cancer recurrence in three different healthcare settings

Purpose

Fear of cancer recurrence (FCR) interventions are effective, but few are implemented. This study aimed to identify barriers and facilitators for implementing the evidence-based blended SWORD intervention in routine psycho-oncological care.

Methods

Semi-structured interviews with 19 cancer survivors and 18 professionals from three healthcare settings assessed barriers and facilitators in six domains as described by the determinant frameworks of Grol and Flottorp: (1) innovation, (2) professionals, (3) patients, (4) social context, (5) organization, and (6) economic and political context.

Results

In the innovation domain, there were few barriers. Facilitators included high reliability, accessibility, and relevance of SWORD. In the professional domain, physicians and nurses barriers were lack of self-efficacy, knowledge, and skills to address FCR whereas psychologists had sufficient knowledge and skills, but some were critical towards protocolized treatments, cognitive behavioral therapy, or eHealth. Patient domain barriers included lack of FCR awareness, negative expectations of psychotherapy, and unwillingness/inability to actively engage in treatment. A social context domain barrier was poor communication between different healthcare professionals. Organization domain barriers included inadequate referral structures to psychological services, limited capacity, and complex legal procedures. Economic and political context domain barriers included lack of a national implementation structure for evidence-based psycho-oncological interventions and eHealth platform costs.

Conclusions

Implementation strategies should be targeted at patient, professional, organizational and economic and political domains. Identified barriers and facilitators are relevant to other researchers in psycho-oncology that aim to bridge the research-practice gap.

Implications for cancer survivors

This study contributes to the implementation of evidence-based psychological interventions for cancer survivors, who can benefit from these services.

Study protocol for the evaluation of Fear-Less: a stepped-care program for fear of cancer recurrence in survivors with early-stage disease

BACKGROUND

Fear of cancer recurrence (FCR) is a significant unmet need amongst cancer survivors and is consistently associated with psychological distress and impaired quality of life. Psychological interventions for FCR, such as ConquerFear, have demonstrated efficacy in reducing FCR and improving emotional wellbeing. Unfortunately, there are barriers to the uptake of evidence-based FCR treatments in clinical practice. A stepped-care FCR treatment model may overcome these barriers and has demonstrated potential in people with advanced melanoma. This study aims to evaluate the acceptability, feasibility, and impact of a stepped-care FCR treatment model (Fear-Less) in people with other cancer types, who have completed treatment with curative intent.

METHODS

Sixty people with early-stage cancer (defined as individuals who have received treatment with curative intent and with no metastatic disease) will be screened for FCR using the Fear of Cancer Recurrence Inventory-Short Form (FCRI-SF). Individuals reporting moderate FCR (FCRI-SF between 13 and 21) will be offered a clinician-guided self-management resource; those reporting high FCR (FCRI-SF ≥ 22) will be offered individual therapy according to the ConquerFear protocol. Participants will complete purpose-built evaluation surveys assessing their FCR screening and intervention experiences. Clinicians will also complete a survey regarding their experiences of the treatment model. Fear-Less will be evaluated in terms of (1) acceptability (i.e., patient and clinician experience), (2) feasibility (i.e., referral uptake, treatment adherence, and time taken to screen and deliver interventions), and (3) impact (i.e., pre- to post-intervention FCR changes).

DISCUSSION

The Fear-Less stepped-care model is a novel framework for screening FCR and stratifying survivors to the appropriate level of treatment. Our study will provide an indication of whether Fear-Less is a feasible and acceptable FCR model of care amongst survivors with early-stage disease and inform further investigations of this model.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR); ACTRN12622000818730 .

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.

Health Anxiety and Its Relationship to Thyroid-Hormone-Suppression Therapy in Patients with Differentiated Thyroid Cancer

Differentiated thyroid cancer (DTC) has a good prognosis; however, patients often need lifelong follow up, and they face potential side effects. The aim of this study was to investigate health anxiety among DTC patients and its relationship to TSH suppression. In 2020, patients from a previous cohort who were from Stockholm completed the 14-item Short Health Anxiety Inventory (SHAI-14; 0−42; 18 being the threshold for clinical significance) and a study-specific questionnaire. Clinical information was also retrieved from medical records. Linear regression was used to investigate the relationship between the TSH levels and the SHAI-14, while adjusting for potential confounders. In total, 146 (73%) patients were included. A total of 24 respondents (16%) scored 18 or more on the SHAI-14, and the mean score was 11.3. Patients with TSH levels of 0.1−0.5 (mE/L) scored, on average, 3.28 points more (p-value 0.01) on the SHAI-14 compared to patients with TSH levels > 0.5. There was no statistically significant difference between patients with TSH levels < 0.1 and TSH levels > 0.5. Thus, we found no linear relationship between the TSH values and health anxiety. Clinically significant levels of health anxiety are slightly higher than those in the general population, but do not appear to be a major psychiatric comorbidity among patients with DTC.

Psychological Problems among Head and Neck Cancer Patients in Relation to Utilization of Healthcare and Informal Care and Costs in the First Two Years after Diagnosis

Background: To investigate associations between psychological problems and the use of healthcare and informal care and total costs among head and neck cancer (HNC) patients. Method: Data were used of the NETherlands QUality of Life and Biomedical Cohort study. Anxiety and depression disorder (diagnostic interview), distress, symptoms of anxiety and depression (HADS), and fear of cancer recurrence (FCR) and cancer worry scale (CWS) were measured at baseline and at 12-month follow-up. Care use and costs (questionnaire) were measured at baseline, 3-, 6-, 12-, and 24-month follow-up. Associations between psychological problems and care use/costs were investigated using logistic and multiple regression analyses. Results: Data of 558 patients were used. Distress, symptoms of anxiety or depression, FCR, and/or anxiety disorder at baseline were significantly associated with higher use of primary care, supportive care, and/or informal care (odds ratios (ORs) between 1.55 and 4.76). Symptoms of anxiety, FCR, and/or depression disorder at 12-month follow-up were significantly associated with use of primary care, supportive care, and/or informal care (ORs between 1.74 and 6.42). Distress, symptoms of anxiety, and FCR at baseline were associated with higher total costs. Discussion: HNC patients with psychological problems make more use of healthcare and informal care and have higher costs. This is not the result of worse clinical outcomes.

Are Fear of Cancer Recurrence and Fear of Progression Equivalent Constructs?

Background

The predominant definition of fear of cancer recurrence (FCR) conflates FCR with fear of progression (FOP). However, this assumption has never been tested. Importantly, if FCR and FOP are distinct and have different predictors, existing interventions for FCR may not be equally effective for survivors who fear progression rather than recurrence of their disease. The present study aimed to determine whether FCR and FOP are empirically equivalent; and whether they are predicted by the same theoretically derived variables.

Methods

Three hundred and eleven adults with a history of breast or ovarian cancer were analysed (n = 209, 67% in remission). Exploratory factor analysis was conducted on the items of the FCR Inventory severity subscale and short‐form FOP Questionnaire together. Structural equation modelling was conducted to predict FCR and FOP and determine whether theoretical models accounted equally well for both constructs, and whether models were equally relevant to those with and without current disease.

Findings

The factor analysis demonstrated that the FCR Inventory severity subscale and the short‐form FOP Questionnaire loaded onto distinct, but related, factors which represented FCR and FOP. Structural modelling indicated that risk perception and bodily threat monitoring were more strongly associated with FCR than FOP. However, both FCR and FOP were associated with metacognitions and intrusions.

Interpretation

These findings suggest that whilst FCR and FOP are related with some overlapping predictors, they are not the same construct. Hence, it is necessary to ensure that in clinical practice and research these constructs are considered separately.

What is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis

Objective

Care for fear of cancer recurrence (FCR) is considered the most common unmet need among cancer survivors. Yet the prevalence of FCR and predisposing factors remain inconclusive. To support targeted care, we provide a comprehensive overview of the prevalence and severity of FCR among cancer survivors and patients, as measured using the short form of the validated Fear of Cancer Recurrence Inventory (FCRI‐SF). We also report on associations between FCR and clinical and demographic characteristics.

Methods

This is a systematic review and individual participant data (IPD) meta‐analysis on the prevalence of FCR. In the review, we included all studies that used the FCRI‐SF with adult (≥18 years) cancer survivors and patients. Date of search: 7 February 2020. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool.

Results

IPD were requested from 87 unique studies and provided for 46 studies comprising 11,226 participants from 13 countries. 9311 respondents were included for the main analyses. On the FCRI‐SF (range 0–36), 58.8% of respondents scored ≥13, 45.1% scored ≥16 and 19.2% scored ≥22. FCR decreased with age and women reported more FCR than men. FCR was found across cancer types and continents and for all time periods since cancer diagnosis.

Conclusions

FCR affects a considerable number of cancer survivors and patients. It is therefore important that healthcare providers discuss this issue with their patients and provide treatment when needed. Further research is needed to investigate how best to prevent and treat FCR and to identify other factors associated with FCR.

The protocol was prospectively registered (PROSPERO CRD42020142185).

Fear of Progression in chronic illnesses other than cancer: A systematic review and meta-analysis of a transdiagnostic construct

Fear of cancer recurrence (FCR) is the most common psychosocial issue amongst cancer survivors. However, fear of progression (FoP) has been studied outside of the cancer context. This review aimed to: (1) meta-synthesize qualitative studies of FoP in illnesses other than cancer; and (2) quantify the relationship between FoP and anxiety, depression, and quality of life (QoL) in non-cancer chronic illnesses. We identified 25 qualitative and 11 quantitative studies in a range of chronic illnesses. Participants described fears of progression and recurrence of their illness, including fears of dying, and fears of becoming a burden to family. Fears were often triggered by downward comparison (i.e. seeing people worse off than themselves). Participants coped in different ways, including by accepting the illness or seeking knowledge. Those for whom these fears caused distress reported hypervigilance to physical symptoms and avoidance. Distress, and seeking information, were associated with adherence. In quantitative analyses, FoP was moderately associated with QoL, and strongly associated with anxiety and depression. These results suggest that FoP in illnesses other than cancer is similar to FCR. FoP appears to be an important transdiagnostic construct associated with distress. Evidence-based FCR interventions could be adapted to better manage FoP in other illnesses.

Prospective longitudinal study on fear of cancer recurrence in patients newly diagnosed with head and neck cancer: Course, trajectories, and associated factors

Background

This study assessed the course of fear of cancer recurrence (FCR) in patients newly diagnosed with head and neck cancer (HNC), identified FCR trajectories and factors associated with FCR trajectories.

Methods

Six hundred and seventeen HNC patients from the NET‐QUBIC cohort study completed the Cancer Worry Scale‐6 at diagnosis, 3 and 6 months post‐treatment. FCR trajectories were identified using Latent Class Growth Analysis. Associations were explored between FCR trajectories and baseline demographic and medical variables, coping and self‐efficacy.

Results

Overall, FCR decreased slightly between baseline and 3 months post‐treatment and remained stable up to 6 months. Two FCR trajectories were identified: “high stable” (n = 125) and “low declining” (n = 492). Patients with high stable FCR were younger, reported more negative adjustment, passive coping, and reassuring thoughts, and less avoidance.

Conclusions

The majority of HNC patients have low declining FCR after diagnosis, but one in five patients experience persistent high FCR up to 6 months post‐treatment.

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.