Cause or Effect? The Role of Prognostic Uncertainty in the Fear of Cancer Recurrence

The mediating effect of intrusive rumination on the relationship between illness uncertainty and fear of cancer recurrence in breast cancer survivors

BACKGROUND

Recently, increased awareness of early diagnosis and treatment options has led to an increase in the number of breast cancer survivors. Psychosocial interventions to increase the quality of life in this group are gaining importance. One of the most common psychological problems in breast cancer survivors is fear of cancer recurrence (FCR). It is essential to elucidate the mechanisms of FCR.

AIMS

This study aimed to examine the mediating effect of intrusive rumination on the relationship between illness uncertainty and FCR in breast cancer survivors.

METHODS

The study was designed to be cross-sectional, and 204 breast cancer survivors were included. Participants were given the Mishel Uncertainty in Illness Scale-Community form (MUIS-C), the severity subscale of the Fear of Cancer Recurrence Inventory, and the Event-Related Rumination Inventory-intrusive rumination subscale. Correlation analyses were conducted, and the structural equation method evaluated the mediation effect.

RESULTS

Most participants (74%) reported some degree of FCR. A significant positive relationship was found between illness uncertainty and FCR (r = 0.325; p ≤ 0.001). The path analysis showed that intrusive rumination partially mediates this relationship.

CONCLUSIONS

This study's results shed light on the relationship between illness uncertainty, rumination, and FCR. Planning psychoeducation programs during follow-up to reduce illness uncertainty may positively affect FCR. In addition, metacognitive therapies that can functionalize the ruminative thinking style can also effectively intervene in FCR.

The relationship between uncertainty and fear of disease progression among newly diagnosed cancer patients: the mediating role of intolerance of uncertainty

BACKGROUND

One of the most prevalent unmet needs among cancer patients is the fear of disease progression (FoP). This cross-sectional study aimed to identify the relationships among uncertainty in illness (UI), intolerance of uncertainty (IU), and FoP among newly diagnosed cancer patients and to verify the mediating role of IU in the relationship between UI and FoP.

METHODS

A total of 202 newly diagnosed cancer patients (male: 105, 51.98%; mean age: 47.45 ± 14.8 years; lung cancer: 49, 24.26%) were recruited by convenience sampling. The patients completed a homemade questionnaire that assessed demographic characteristics, the Fear of Progression Questionnaire-Short Form, the Mishel Uncertainty in Illness Scale, and the Intolerance of Uncertainty Scale.

RESULTS

The prevalence of FoP among newly diagnosed cancer patients was 87.62%, and the prevalences of high, medium, and low levels of UI were 15.84%, 73.27%, and 10.89%, respectively. The mean score on the Intolerance of Uncertainty Scale was 41.19 ± 10.11. FoP among newly diagnosed cancer patients was positively correlated with UI (r = 0.656, P < 0.001) and IU (r = 0.711, P < 0.001). Moreover, IU was positively correlated with UI (r = 0.634, P < 0.001). IU partially mediated the effect of UI on FoP, accounting for 47.60% of the total effect.

CONCLUSIONS

Newly diagnosed cancer patients have a high prevalence of FoP. UI can directly or indirectly affect FoP through the mediating role of IU. Healthcare professionals can help newly diagnosed cancer patients mitigate their FoP by reducing IU in light of UI.

Associations between empirically proportionate and disproportionate fears of cancer recurrence and anxiety and depression in uveal melanoma survivors: Five-year prospective study

OBJECTIVE

Fear of cancer recurrence (FCR) may develop into elevated anxiety or depression symptoms, but few risk factors for this development are known. Objective recurrence risk estimation is possible in some cancers. Using theories of risk communication and phobias, we examined whether the proportionality of FCR to known objective recurrence risk influences the development of anxiety and depression symptoms.

METHOD

Uveal melanoma (UM) patients can opt for reliable prognostic testing. Patients experience either a 'good' or 'poor' prognostic outcome, whereby 10-year mortality due to metastatic disease is, respectively, low or high. In a five-year prospective study of a consecutive sample of 589 UM survivors, we used random intercept cross lagged panel analyses to examine whether proportionality differentially influences whether FCR progresses to anxiety and depression.

RESULTS

Positive cross paths predicting anxiety from FCR were stronger in the poor prognosis group than the good prognosis and not tested groups. Prognostic group differences were not evident for depression.

CONCLUSIONS

FCR was more likely to progress to elevated anxiety symptoms when proportionate to the known objective recurrence risk. Objective evidence may play a prominent role in the development and structure of fear because it assumes a high epistemic weight that activates a wide range of emotional and cognitive responses. Interventions that assist survivors to tolerate FCR in the presence of higher recurrence risks may be important in reducing anxiety symptoms.

Patient and Caregiver Experience With the Hope and Prognostic Uncertainty of Immunotherapy: A Qualitative Study

PURPOSE

Immunotherapy has improved survival for patients with melanoma and non-small cell lung cancer (NSCLC). Yet, as responses vary widely, immunotherapy also introduces challenges in prognostic communication. In this study, we sought to explore how patients and caregivers learned about the goal of immunotherapy and their experience of living with uncertainty.

MATERIALS AND METHODS

We conducted a qualitative study of patients with stage III or IV melanoma or stage IV NSCLC within 12 weeks of initiating or 12 months of discontinuing immunotherapy, and their caregivers. We conducted in-depth interviews with participants to explore how they learned about immunotherapy from oncology clinicians and how they experienced uncertainty. We used a framework approach to analyze interview transcripts and synthesized concepts into themes.

RESULTS

Forty-two patients and 10 caregivers participated; median age was 67 years and most were male (68%), white (95%), married (61%), and had melanoma (62%). We identified four themes: (1) the oncology team shaped participants' hopeful expectations of immunotherapy, including as a potential cure among those with melanoma; (2) distress related to prognostic uncertainty particularly affected patients who experienced toxicity or progressive disease; (3) patients who did not have long-term responses experienced overwhelming disappointment; and (4) some patients and caregivers had conflicting preferences for prognostic information. Participants provided suggestions to improve education and underscored unmet psychosocial needs.

CONCLUSION

Patients and caregivers held optimistic expectations of immunotherapy, which resulted in heightened disappointment among the subset with progression or toxicity. Clinicians should elicit information preferences of both patients and caregivers, as these may be disparate. Our results highlight the need to optimize prognostic communication and support for living with uncertainty among patients receiving immunotherapy.

Parents' preferences for receiving and discussing prognostic genetic information regarding their children's neurodevelopmental condition: A qualitative study

AIM

To investigate parents' preferences and motivations for receiving and discussing prognostic genetic test results.

METHOD

We used a cross-sectional, interpretive description qualitative study design. We collected data through semi-structured interviews with Australian parents, which we analysed using reflexive thematic analysis.

RESULTS

Parents (n = 32) had a child or children with a genetic neurodevelopmental condition, such as fragile X syndrome, DiGeorge (22q11.2 deletion) syndrome, or Angelman syndrome. Parents of mildly impacted or older children were tolerant to prognostic uncertainty. Parents found conversations about their child's prognosis emotional and preferred to discuss their child's potential strengths and challenges. While most were enthusiastic about prognostic tests and described many motivations for testing, the potential for prognostic information to contribute to a loss of hope and stigmatizing societal views were also discussed.

INTERPRETATION

Parents had mixed preferences and motivations for acquiring prognostic genetic information about their child, contrasting evidence in other contexts such as cancer where parents typically have minimal tolerance of uncertainty. Health professionals should consider strength-based framing of prognostic information gained from current and emerging technologies when returning results to families.

WHAT THIS PAPER ADDS

Parents had varied views about receiving prognostic information on their children's neurodevelopmental condition. Some parents preferred prognostic uncertainty about their children's genetic neurodevelopmental condition.

Relationship Between Fear of Cancer Recurrence and Quality of Life in Patients Undergoing Active Cancer Treatment: The Mediating Role of Social Support

INTRODUCTION

Socio-psychological factors such as fear of recurrence and presence of social support may affect quality of life (QOL) of cancer patients. Identifying mediating factors that impact QOL are crucial for targeting vulnerability in patients undergoing cancer treatments. The study purpose was therefore to determine relationships between presence of fear of cancer recurrence and QOL of patients, with the mediating role of social support.

METHODS

A predictive correlational design was used to conduct the study with 300 patients with cancer who were undergoing chemotherapy, radiotherapy, or surgery at two medical centers in Tehran. Measures included a demographic information form, the Fear of Cancer Recurrence Inventory (FCRI), the European Organization for Research and Treatment of Cancer QOL Questionnaire (EORTC QLQ-C30), and the Multidimensional Scale of Perceived Social Support (MSPSS). Data analyses included descriptives, and path analysis analyses.

RESULTS

Higher fear of cancer recurrence predicted lower QOL (β = -0.60, p < 0.001). Moreover, individuals with lower fear of cancer recurrence also perceived higher social support (β = 0.32, p < 0.001). Additionally, individuals with higher perceived social support also reported better QOL (β = 0.30, p < 0.001).

CONCLUSION

Perceived social support plays a significant mediating role in the relationship between the fear of cancer recurrence and QOL in patients undergoing active cancer treatment. Enhancing social support among cancer patients may contribute to enhanced QOL, and as does reducing fears associated with disease recurrence.

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.

Making the Best in a Bad Job: A Psychoanalytic Perspective on Communication with Children and Adolescents with Severe Physical Condutions

Ill children/adolescents who suffer from severe organic diseases have to cope with their inner experiences, therapies, and the global burden of the disease. Although sometimes depression, anger, and death anxiety are openly encountered in medical settings, other times they can be partially hidden by a reactive and defensive path. In these scenarios, psychoanalysis is challenged to contribute the best comprehension of the intimate communication, maybe hidden, and the needs of the ill patients to express themselves. The best way a child can talk about himself is through spontaneous creativity. The adult's task is to facilitate the creation of an empty space and to recognize the child's mode of communication. There may be intense emotional reactions that the adult has to tolerate to not move the patient towards an over-adaptation. These over-adaptations entail the child being forced to feel good or have fun, thereby causing them to escape from their inner experience. The loss of the child's reality forms an additional burden to the child. The most valid indicator of this attitude is the ability to not take counterphobic attitudes but to allow the depression to be shared in a contact space between the child's true self and the perceived environment.

Mobile App for Gynecologic Cancer Support for Patients With Gynecologic Cancer Receiving Chemotherapy in China: Multicenter Randomized Controlled Trial

BACKGROUND

Patients with gynecologic cancer receiving chemotherapy often report unmet supportive care needs. Compared with traditional face-to-face clinical interventions, mobile health can increase access to supportive care and may address patients' needs. Although app-based support programs have been developed to support patients with gynecologic cancer, their efficacy has not been adequately tested.

OBJECTIVE

The aim of this study was to examine the efficacy of a mobile app for gynecologic cancer support (MGCS) for patients with gynecologic cancer receiving chemotherapy in China.

METHODS

A multicenter randomized controlled trial was conducted in 2 university-affiliated hospitals in China. A total of 168 Chinese patients with gynecologic cancer were recruited and randomized to receive routine care or MGCS program plus routine care for 24 weeks. The Mishel uncertainty in illness theory guided the development of MGCS program, which has 4 modules: weekly topics, emotional care, discussion center, and health consultation. The primary outcome of this program was the assessment of the uncertainty in illness. The secondary outcomes were quality of life, symptom distress, and social support. All health outcomes were evaluated at baseline (T0), 12 weeks (T1), and 24 weeks (T2). Repeated measures analysis of covariance was used to assess the efficacy of the MGCS program.

RESULTS

In this trial, 67 patients in the control group and 69 patients in the intervention group completed 2 follow-up assessments (response rate, 136/168, 81%). At 12 weeks, no significant differences were observed in any of the health outcomes between the 2 groups. At 24 weeks, compared to patients in the control group, those in the intervention group reported significant decreased uncertainty in illness (P<.001; d=-0.60; adjusted mean difference -7.69, 95% CI -11.31 to -4.07) and improved quality of life (P=.04; d=0.30; adjusted mean difference 4.77, 95% CI 0.12-9.41).

CONCLUSIONS

The MGCS program demonstrated efficacy in supporting patients with gynecologic cancer receiving chemotherapy. This trial illustrates that an app-based program can be incorporated into routine care to support patients with cancer and suggests that allocation of more resources (grants, manpower, etc) to mobile health in clinics is warranted.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000033678; https://www.chictr.org.cn/showproj.html?proj=54807.

Mediating Effect of Intolerance of Uncertainty and Cancer-Related Dysfunctional Beliefs About Sleep on Psychological Symptoms and Fear of Progression Among Cancer Patients

OBJECTIVE

This study aimed to explore the mediating effects of cancer-related dysfunctional beliefs regarding sleep and intolerance of uncertainty on the effect of depression, insomnia, and anxiety on fear of progression (FoP).

METHODS

We retrospectively reviewed medical records of patients with cancer who visited the Sleep Clinic for cancer patients in Asan Medical Center for the first time between December 2021 and March 2022. Data collected included age, sex, types of cancer, staging, current treatment modalities, and history of surgical procedures. In addition, psychological symptoms were rated using the Insomnia Severity Scale (ISI), Patient Health Questionnaire-9 items (PHQ-9), State subcategory of the State and Trait of Anxiety Inventory (STAI-S), Short form of Fear of Progression Questionnaire, Cancer-related Dysfunctional Beliefs about Sleep scale (C-DBS), single item of pain and fatigue, Connor Davidson Resilience Scale 2-item (CD-RISC2), and Intolerance of Uncertainty-12 (IUS-12). The predictive variables for FoP were determined by linear regression analysis.

RESULTS

The FoP was significantly correlated with age (r=-0.289), ISI (r=0.178), PHQ-9 (r=0.703), STAI-S (r=0.377), fatigue (r=0.452), CD-RISC2 (r=-0.270), IUS-12 (r=0.585), and C-DBS (r=0.427, all p<0.01). A mediation analysis showed that intolerance of uncertainty and dysfunctional beliefs about sleep mediated the relationship of FoP with insomnia, depression, or anxiety.

CONCLUSION

Psychological support for intolerance of uncertainty and cancer-related dysfunctional beliefs about sleep in patients with cancer may be beneficial to reduce their FoP.

Oncologist approaches to communicating uncertain disease status in pediatric cancer: a qualitative study

Background

Most patients with cancer and their caregivers desire honest, clear prognostic communication, yet oncologists often disclose prognosis inconsistently. Prognostic communication becomes even more challenging when disease progression is unclear or equivocal. Presently, oncologist approaches for discussing uncertain disease findings are poorly understood.

Methods

In this prospective, longitudinal study, we audio-recorded serial disease reevaluation conversations between children with high-risk cancer, their families, and their primary oncologists over 24 months and conducted content analysis at recorded timepoints when oncologists categorized disease progression as equivocal.

Results

Of the 265 medical discussions recorded across the illness course for 33 patient-parent dyads, a total of 40 recorded discussions took place at equivocal timepoints, comprising > 500 min of medical dialogue. Prognosis talk encompassed < 3% of dialogue and was absent in nearly half of equivocal discussions (17/40, 42.5%). Curability statements were identified in only two conversations. Inductive content analysis of dialogue revealed four distinct patterns for communicating equivocal disease status: (1) up-front reassurance, (2) softening the message, (3) describing possible disease progression without interpretation, (4) expressing uncertainty without discussing the bigger picture.

Conclusion

Oncologists rarely discuss prognosis with children with high-risk cancer and their families at timepoints when disease progression is not definitive. Formal guidance is needed to better support oncologists in navigating uncertainty while sharing honest, person- and family-centered information about prognosis.

Supplementary information

The online version contains supplementary material available at 10.1186/s12885-022-10190-6.

Symptom burden and emotional distress in advanced lung cancer: the moderating effects of physicians' communication skills and patients' disease understanding

PURPOSE

The elevated physical symptom burden in advanced lung cancer can disrupt patients' emotional well-being, and current literature suggests that physicians' good communication skills might be a buffer. However, little is known about for which group of patients this buffering effect is most effective. Based on a cross-sectional study in patients with advanced lung cancer, the present study examined whether the moderating effect of physicians' communication skills on the association between physical symptoms and emotional distress would further depend on patients' perceived disease understanding.

METHODS

Patients with advanced lung cancer (n = 199) completed a questionnaire including measures of physical symptoms related to lung cancer, anxiety, and depressive symptoms, perceptions of physicians' communication skills, and self-reported understanding of their disease.

RESULTS

Hierarchical regression analyses indicated a significant three-way interaction among physical symptoms, perceptions of physicians' communication skills, and perceived disease understanding on both anxiety and depression. Specifically, physicians' good communication skills exerted a buffering effect only for patients with lower levels of disease understanding.

CONCLUSION

Our findings indicate that improving physicians' communication skills may be especially beneficial for reducing the maladaptive emotional reactions to symptom burden for patients with limited disease understanding. When time and resources for communication are restricted, enhanced awareness and focused training may be directed at communicating with patients who possess limited knowledge about their disease.

SKP, Raj Z, Nair CK. Fear of Recurrence and Somatic Symptom Severity in Multiple Myeloma Patients: An Institution-Based Cross-Sectional Study

Introduction Psychosocial concerns especially fear of cancer recurrence (FCR) is less commonly addressed among patients with multiple myeloma in India. Myeloma being incurable, an understanding of this problem is essential for adequately addressing them.

Objectives To study the prevalence of FCR among patients with multiple myeloma and determine the prevalence of somatic symptoms among patients with multiple myeloma.

Materials and Methods A cross-sectional study was performed at our institution among patients with multiple myeloma who had been on treatment for 1 year or more. The study was conducted between July 01 and July 31, 2015. At least 49 patients were required to be recruited into this study to meet its first objective. Patients were administered fear of cancer recurrence inventory (FCRI) questionnaire and Physical Health Questionnaire-15 (PHQ-15) questionnaire.

Results Sixty-four patients participated in the study. The median age was 60 years (34–80 years) and majority were females (N = 38, 60%). ISS staging information was available in 53 (83%) patients. Of 53, 24 (45%) were ISS stage 3, 12 (23%) were ISS stage 2 and remaining stage 1. The mean total FCRI score in the study population was 27.95 (SD: 24.5). Moderate to high levels of FCR were seen in 40% (N = 26). Using PHQ-15, 54 (84%) patients had mild or lesser somatic symptom burden. Disease status of patients at the time of this study had a significant statistical association with PHQ-15 scores (mean score in partial response (PR) or more group 6.02 versus 8.00 in less than PR group, p = 0.02).

Conclusions Overall, FCR scores and somatic symptom severity were low among our patients with multiple myeloma. However, a significant proportion had moderate to high levels of FCR. Further studies involving larger numbers in a prospective manner required to confirm our findings of fear of cancer recurrence among patients with multiple myeloma.

Uncertainty and Guilt in Ovarian Cancer Survivorship

Uncertainty is high in the ovarian cancer context; yet, limited research has focused on how uncertainty is experienced and managed by patients/survivors. This study, thus, examined sources and management of uncertainty among ovarian cancer patients/survivors. It analyzed qualitative interview data from 28 patients/survivors and found that possibility of disease recurrence, limited social buffer, and exposure to death contributed to uncertainties in women about finances, health, and relationships. Depending on how uncertainties were appraised, women managed these by adapting, regulating social interaction, or maintaining a sense of control. Also, survivor guilt was identified as a component of ovarian cancer survivorship.

Communicating is analogous to caring: A systematic review and thematic synthesis of the patient-clinician communication experiences of individuals with ovarian cancer

OBJECTIVE

To systematically review and synthesize the patient-clinician communication experiences of individuals with ovarian cancer.

METHODS

The CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science databases were reviewed for articles that described (a) original qualitative or mixed methods research, (b) the experiences of individuals with ovarian cancer, and (c) findings related to patient-clinician communication. Relevant data were extracted from study results sections, then coded for descriptive and analytical themes in accordance with Thomas and Harden's approach to thematic synthesis. Data were coded by two authors and discrepancies were resolved through discussion.

RESULTS

Of 1,390 unique articles, 65 met criteria for inclusion. Four descriptive themes captured participants' experiences communicating with clinicians: respecting me, seeing me, supporting me, and advocating for myself. Findings were synthesized into three analytical themes: communication is analogous to caring, communication is essential to personalized care, and communication may mitigate or exacerbate the burden of illness.

SIGNIFICANCE OF RESULTS

Patient-clinician communication is a process by which individuals with ovarian cancer may engage in self-advocacy and appraise the extent to which they are seen, respected, and supported by clinicians. Strategies to enhance patient-clinician communication in the ovarian cancer care setting may promote patient perceptions of patient-centered care.

End-of-Life Decision Making Between Doctors and Parents in NICU: The Development and Assessment of a Conversation Analysis Coding Framework

We report the development and assessment of a novel coding framework in the context of research into neonatal end-of-life decision making conversations. Data comprised 27 formal conversations between doctors and parents of critically ill babies, recorded in two neonatal intensive care units. The coding framework was developed from a qualitative analysis of the recordings using the method of conversation analysis (CA). Codes underpinned by our qualitative analysis had in the main moderate to strong agreement (inter-rater reliability) between coders; three codes had lower agreement reflecting the use of euphemisms for death and disability. Coding these interactions confirmed the significance of the doctors' talk in terms of parental involvement in decision-making, whilst highlighting areas warranting further qualitative analysis. This quantifiable representation provides a novel outcome based on evidence that is internal to the conversation rather than influenced by other factors related to the baby's care or outcome.

Cancer Services During the COVID-19 Pandemic: Systematic Review of Patient's and Caregiver's Experiences

PURPOSE

Cancer patients have faced intersecting crises during the COVID-19 pandemic. This review aimed to examine patients' and caregivers' experiences of accessing cancer services during the pandemic and its perceived impact on their psychological wellbeing.

PATIENTS AND METHODS

A protocol-led (CRD42020214906) systematic review was conducted by searching six databases including EMBASE, MEDLINE and CINAHL for articles published in English-language between 1/2020 and 12/2020. Data were extracted using a pilot-tested, structured data extraction form. Thematic synthesis of data was undertaken and reported as per the PRISMA guideline.

RESULTS

A total of 1110 articles were screened, of which 19 studies met the inclusion criteria. Studies originated from 10 different countries including the US, UK, India and China. Extracted data were categorised into seven themes. Postponement and delays in cancer screening and treatment, drug shortages and inadequate nursing care were commonly experienced by patients. Hospital closures, resource constraints, national lockdowns and patient reluctance to use health services due to infection worries contributed to the delay. Financial and social distress, isolation, and spiritual distress were also commonly reported. Caregivers in addition felt anxious about infecting cancer patients with COVID-19.

CONCLUSION

Patients and caregivers experienced delays in cancer screening, treatment and care during the COVID-19 pandemic and negatively affected their psychological wellbeing. Their views and preferences should be accounted to minimise the impact of the current and any future pandemics and ensure resilient cancer services.

PROTOCOL REGISTRATION

Published protocol registered with Centre for Review and Dissemination CRD42020214906 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214906).