Caregiver fear of cancer recurrence: A systematic review and meta-analysis of quantitative studies

Association among financial toxicity, depression and fear of cancer recurrence in young breast cancer patient-family caregiver dyads: an actor-partner interdependence mediation model

PURPOSE

This study aimed to investigate the depression situation and the mediating role of fear of cancer recurrence (FCR) in the relationship between financial toxicity and depression in young breast cancer (BC) patient-family caregiver dyads.

METHODS

A total of 196 young BC patient-family caregiver dyads at four hospitals in China were investigated. The Comprehensive scores for financial toxicity based on patient-reported outcome measures, the Hospital Anxiety and Depression Scale, and the FCR Inventory Short Form were assessed. The actor-partner interdependence mediation model using structural equation modelling in AMOS software was applied to examine the direct and indirect effects.

RESULTS

In this study, there were 196 pairs of patients and family caregivers. The findings indicated a significant correlation between financial toxicity and FCR in both young BC patients and their family caregivers. Two significant partner effects were observed: the family caregiver's financial toxicity significantly influenced the patient's FCR (β=-0.450, P < 0.001), and the patient's FCR influenced the family caregiver's depression (β = 0.570, P < 0.001). Furthermore, financial toxicity in both young BC patients and family caregivers markedly affected both the actor and partner effects on dyadic depression, primarily through the patients' FCR.

CONCLUSIONS

Depression in young BC patients was affected not only by themselves but also by their family caregivers. Emphasis should be placed on the interplay between financial toxicity and FCR of patients and family caregivers, with the aim of improving depression for young BC patients.

CLINICAL IMPLICATIONS

The study emphasized the importance of addressing the experiences of both patient and family caregivers in clinical interventions. By demonstrating how financial toxicity and FCR are interlinked with depression in both parties, the study supports the development of we offer empirical support for developing comprehensive intervention strategies to alleviate mental distress and enhance mental health for patients and family caregivers.

It is Time to Address Fear of Cancer Recurrence in Family Caregivers: Feasibility and Acceptability of a Randomized Pilot Study of the Family Caregiver Version of the Fear of Recurrence Therapy (FC-FORT)

OBJECTIVE

Fear of cancer recurrence (FCR) is common, persistent, and associated with lower quality of life, impaired functioning, and psychological distress in family caregivers (FC) of individuals with a cancer diagnosis. Interventions are needed to specifically target FCR in FC. This study aimed to pilot test the adapted Family Caregiver-Fear Of Recurrence Therapy (FC-FORT) to establish its feasibility, acceptability, and clinical significance.

METHODS

This pilot study used a mixed-method, parallel, two-group randomized control trial (FC-FORT vs. waitlist control group) design. Women FC were recruited through Canadian hospitals, community partners, and social media. FC in the intervention group completed 7 weekly sessions of virtual group therapy (FC-FORT) and an exit interview. All participants completed questionnaires at baseline, post-intervention, and 3-month follow-up. Feasibility (e.g., recruitment, allocation, fidelity), acceptability (e.g., dropout, completion, satisfaction) and clinical significance of secondary outcomes were evaluated. Descriptive statistics, mixed ANOVAs, and conventional content analyses were used.

RESULTS

Regarding feasibility, 22 FC were recruited, 18 were randomized and therapist fidelity was 87%. As to acceptability, 67% of participants completed≥ ${\ge} $ 5 sessions (33% dropout). Questionnaire completion rate was 92%. FC satisfaction was 80%. Analyses did not reveal any significant differences on the secondary outcomes between groups. Qualitative analyses revealed high importance, helpfulness, satisfaction, and group cohesion. Suggestions were made by FC for improvements.

CONCLUSIONS

This is one of the first interventions to address FCR in FC. While acceptability of FC-FORT was good, important feasibility issues need to be addressed before moving forward with a larger randomized control trial.

TRIAL REGISTRATION

NCT, NCT05441384. Registered July 1st, 2022, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05441384.

CarersCanADAPT: Study protocol of a stepped care pathway and hybrid type 1 effectiveness-implementation trial of an online cognitive behavioural therapy (iCBT) program for cancer carers with anxiety and depression

BACKGROUND

Family or friend carers of people with cancer report high levels of depression, anxiety, caregiving strain, and unmet needs. Limited strategies for identification and management of distress have been established among cancer carers. This paper describes the protocol of two linked studies: Study 1a, a distress screening and stepped care pathway feasibility study and Study 1b, a hybrid implementation-effectiveness Randomised Controlled Trial (RCT) to assess the benefit of a comprehensive, carer-centred online Cognitive Behavioural Therapy (iCBT) program for carers with anxiety and depression.

METHODS

For Study 1a, 300 cancer carers will be screened for distress. Carers with low distress will be referred to publicly available carer resources. Carers scoring 4 and higher on the distress thermometer will complete depression and anxiety measures. Carers with high anxiety/depression will be recommended psychological therapy. Carers with mild/moderate anxiety and/or depression will be allocated to the Carers iCBT Program, evaluated via a RCT with waitlist control group (Study 1b). For Study 1b, intervention group carers will receive access to a 6-lesson self-directed online iCBT program. Waitlist-controls will access the intervention at 14 weeks. Intervention and control groups will complete baseline, 6 week, and 14 week self-report measures; controls will complete additional measures at 20 and 28 weeks. A sample size of n = 166 carers in the iCBT RCT is needed.

CONCLUSIONS

If acceptable, feasible and effective, this pathway and iCBT intervention could offer a sustainable, scalable and low-cost approach to identifying and managing distress in carers, and potentially improving patient and carer outcomes.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry number: ACTRN12623001341617p.

Exploring the Caregiver Experiences of Symptom Management in Children With Cancer: A Qualitative Systematic Review

Although caregivers of children with cancer play an instrumental role in managing their child's symptoms, the impact of their own experiences or perspectives is under-explored. Understanding these factors is essential as they influence caregiving behaviors and overall well-being. This qualitative systematic review addresses this knowledge gap by synthesizing existing research on caregiver's experiences. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers utilized Rayyan to screen titles and abstracts retrieved from comprehensive keyword searches of five databases including CINAHL, APA PsycINFO, Embase, and MEDLINE. Databases and bibliographies were hand-searched for additional articles. One reviewer completed full text assessment and data were extracted into an Excel spreadsheet. The Quality Assessment with Diverse Studies tool was used to appraise included studies. Thematic content analysis was used to synthesize findings, which are presented narratively. Twelve articles are included, representing the experiences of 597 caregivers, most of which (83%) were undertaken in high-income nations. Quality appraisal scores indicated all studies were of moderate to robust quality. Three main themes were identified including: (1) caregivers as protectors in their role, (2) normalization of symptoms yet they remain disrupting, and (3) communication between the caregiver and child. Findings emphasize the importance of formalized information provision and education to better support caregivers in managing their child's cancer-related symptoms. Nurses are uniquely positioned to provide this essential support thereby improving the quality of life for both caregivers and children.

Fear of cancer recurrence experienced by pediatric survivors of childhood cancer: a scoping review

PURPOSE

In contrast to the extensive literature on fear of cancer recurrence (FCR) experienced by adults, literature evaluating pediatric FCR has just begun to emerge. Given the rapidly expanding body of work assessing FCR in childhood and adolescence, a scoping review was conducted to synthesize existing findings. We aimed to assess (1) the characteristics and methods of this literature, (2) how pediatric FCR has been measured, and (3) the extant knowledge of FCR experienced by pediatric survivors of cancer.

METHODS

Inclusion criteria were: (1) original reports, (2) participants diagnosed with cancer before age 18, (3) current mean age under 18, (4) FCR was explicitly measured (quantitatively) or captured (qualitatively) via survivor self-report, and (6) published in English. Exclusion criteria were: (1) case studies, and (2) grey literature. Three databases (Embase, MEDLINE, PsycINFO) and reference lists from included studies were searched. All studies were screened for inclusion by two authors and all data were extracted by a single author.

RESULTS

Of 3906 identified studies, 19 were included. Studies (published 1991 - 2023) encompassed diverse geographical locations, study designs, and measurement methods. Few assessed FCR as a primary aim (n = 6, 32%). FCR was experienced by 43 - 90% of pediatric survivors. FCR was often positively associated with somatic symptoms and negatively associated with quality of life and emotional functioning.

CONCLUSION

FCR is a prevalent issue for children and adolescents. Additional evidence is needed to explore and confirm preliminary findings. Future pediatric FCR studies should aim to align with published priority research areas.

Ecosystem Barriers and Facilitators Linked to the Fear of Cancer Recurrence: An Umbrella Review

The fear of cancer recurrence is an important topic in the healthcare field. In general, approximately 40% of survivors experience high levels of fear of recurrence. This study aims to fill this gap by synthesizing the findings of systematic reviews studies investigating ecosystems, correlates or predictors, and barriers and facilitators of fear of cancer recurrence among cancer survivors. An umbrella meta-synthesis was conducted using the following databases: MEDLINE, PsycINFO, PsycARTICLES, CINAHL, Business source premier, and SOCindex, ending in April 2024 with PRISMA methods. A total of 24 systematic reviews, representing 729 articles, were included in the study. In total, six ecosystems were identified, including family, work, friends, the healthcare system, caregivers, and religion. As part of this umbrella review, 55 specific ecosystemic factors were identified that may contribute to fear of cancer recurrence. Furthermore, the umbrella review identified 12 facilitators and 12 barriers related to fear of cancer recurrence. This umbrella meta-synthesis contributed significantly to our review's strength in synthesizing the main ecosystem and its influence on fears of cancer recurrence. Understanding the interdependence of ecosystems should enable future research on intervention effectiveness or the development of interventions that could reduce the fear of cancer recurrence.

Fear of cancer recurrence and change in hair cortisol concentrations in partners of breast cancer survivors

PURPOSE

Partners of breast cancer (BC) survivors report high rates of psychological distress including fear of cancer recurrence (FCR). Research suggests that partners may have poorer physical health outcomes than the general population, but little research has examined the physiological biomarkers by which distress may impact partner health outcomes. The current study examined the associations between FCR and changes in hair cortisol among BC partners.

METHODS

Male partners (N = 73) of early-stage BC survivors provided hair samples during two visits, one after completion of survivors' adjuvant treatment (T1) and again 6 months later (T2). Two subscales from the Fear of Cancer Recurrence Inventory and one subscale from the Concerns about Recurrence Scale comprised a latent FCR factor at T1. A latent change score model was used to examine change in cortisol as a function of FCR.

RESULTS

Partners were on average 59.65 years of age (SD = 10.53) and non-Hispanic White (83%). Latent FCR at T1 was positively associated (b = 0.08, SE = 0.03, p = .004, standardized β = .45) with change in latent hair cortisol from T1 to T2.

CONCLUSIONS

Results indicated that greater FCR was associated with increases in hair cortisol in the months following adjuvant treatment. This is one of the first studies to examine the physiological correlates of FCR that may impact health outcomes in BC partners.

IMPLICATIONS FOR CANCER SURVIVORS

Findings highlight the need for further research into the relationship between FCR and its physiological consequences. Interventions to address partner FCR are needed and may aid in improving downstream physical health outcomes.

The relationship between fear of cancer recurrence and posttraumatic growth: a meta-analysis

Background

Theoretically, stress is positively correlated with posttraumatic growth (PTG). However, evidence for a correlation between fear of cancer recurrence (FCR), a cancer-specific stressor, and PTG is mixed. The present study aimed to systematically investigate the overall effect size between the two and to explore moderators that may influence this relationship.

Methods

From the earliest available date to October 2023, a comprehensive search was conducted in seven databases. Correlation coefficients (r) were calculated using Stata software. Publication type, continent, trauma role, gender, FCR measurements, PTG measurements, sample size, age, and time since diagnosis were used to examine moderating effects. The National Heart, Lung, and Blood Institute's (NHLBI) assessment tool was used to evaluate study quality.

Results

A total of 14 studies, involving 17 samples and 3,701 participants, were included. The studies found a small association between FCR and PTG (r = 0.161, 95% CI: 0.070-0.249, p < 0.01) and large heterogeneity (I2  = 85.5%). The strength of the association varied according to the publication type and FCR measurement.

Conclusion

The current review suggests a small but significant positive correlation between FCR and PTG. Future studies would benefit from exploring additional moderators and the use of standardized, validated FCR measurement tools.

Systematic review registration

PROSPERO, identifier CRD42023460407.

Development and validation of the CARE-FCR: A caregiver-specific measure of fear of cancer recurrence and progression

OBJECTIVES

Fear of cancer recurring or progressing (FCR) is a concern reported by people living with cancer and caregivers alike. Whilst advances in survivor FCR have been made, less is known about caregiver FCR. As a result, measurement of caregiver FCR has relied on instruments developed for survivor populations. Findings from qualitative research indicate caregiver experiences of FCR differ. This study aimed to develop and evaluate the psychometric properties of a caregiver specific measure of FCR (CARE-FCR).

METHODS

Four-hundred and thirty-eight caregivers (56% female, Mage = 50.53 years, SD = 17.38) completed the online survey including demographic questions, information about care provided, the person they care for, as well as the CARE-FCR. Convergent validity was assessed using pre-existing measures of fear of recurrence and progression, depression, anxiety, death anxiety and meta-cognitions. The extraversion dimension of the Big Five Personality Trait questionnaire was used to assess divergent validity. The survey was completed 2 weeks later to assess test-retest reliability. Exploratory factor analysis (EFA) was used to determine factor structure, followed by confirmatory factor analysis.

RESULTS

EFA indicated a 3-factor structure: progression, recurrence, and communication. Evidence for convergent, divergent, and test-retest reliability was adequate. Internal consistency for the CARE-FCR was strong, overall Cronbach's α = 0.96 (progression = 0.94, recurrence = 0.92 and communication = 0.78).

CONCLUSIONS

We present a theoretically informed and psychometrically robust measure of caregiver FCR. The CARE-FCR facilitates quantification of caregiver FCR, capturing unique aspects specific to this population.

Supporting the support person: Oncologists' roles in reducing support people's uncertainty and facilitating psychological adjustment

OBJECTIVE

Support people of cancer patients are at significant risk for psychological distress. Additionally, cancer patients' well-being is reciprocally associated with support peoples' psychological well-being. Informed by Uncertainty in Illness Theory, this study tests whether support person psychological well-being is influenced by provider communication and uncertainty reduction.

METHODS

We tested a multiple mediation model to investigate how empathic communication facilitates psychological adjustment in support people of cancer patients and how this process is mediated by support peoples' illness uncertainty and caregiver burden. Support people of cancer patients (N = 121; including spouses, adult children, etc.) completed an online questionnaire about their perceptions of oncologists' empathy, uncertainty about the cancer patients' illness, perceived caregiving burden, and their psychological adjustment to diagnoses.

RESULTS

Path analysis revealed that (1) more perceived oncologist empathy was associated with less illness uncertainty, (2) more illness uncertainty was associated with worse psychological adjustment and more perceived caregiver burden, and (3) more burden was associated with worse adjustment (χ2 (2) = 1.19, p = 0.55; RMSEA < 0.01; CFI = 1.00; SRMR = 0.02).

CONCLUSIONS

Given the reciprocal nature of well-being between cancer patients and their support people, it is critical to understand and bolster support people's psychological well-being. Results demonstrated how empathic provider communication can support psychological well-being for support people of cancer patients. Additionally, this study offers theoretical contributions to understandings of illness uncertainty in caregiver populations.

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.

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.