Pilot randomized trial of an acceptance-based telehealth intervention for women with ovarian cancer and PARP inhibitor-related fatigue

OBJECTIVE

Poly(ADP-ribose) polymerase inhibitors (PARPi) have dramatically changed treatment for advanced ovarian cancer, but nearly half of patients experience significant fatigue. We conducted a two-site pilot randomized trial to evaluate the feasibility, acceptability, and preliminary efficacy of a brief, acceptance-based telehealth intervention (REVITALIZE) designed to reduce fatigue interference in patients on PARPi.

METHODS

From June 2021 to April 2022, 44 participants were randomized 1:1 to REVITALIZE (6 weekly one-on-one sessions+booster) or enhanced usual care. Feasibility was defined as: ≥50% approach-to-consent among potentially eligible patients and ≥70% completion of 12-week follow-up assessment; acceptance was <20% participants reporting burden and <20% study withdrawal. Fatigue, anxiety, depression, and quality of life were assessed at baseline, 4-, 8- and 12-weeks.

RESULTS

Among 44 participants (mean age = 62.5 years, 81.8% stage III/IV disease), the study was feasible (56.4% approach-to-consent ratio, 86.3% completion of 12-week assessment) and acceptable (0% reporting burden, 11.3% study withdrawal). At 12-week follow-up, REVITALIZE significantly reduced fatigue interference (Cohen's d = 0.94, p = .008) and fatigue severity (d = 0.54, p = .049), and improved fatigue levels (d = 0.62, p = .04) relative to enhanced usual care. REVITALIZE also showed promise for improved fatigue self-efficacy, fatigue catastrophizing, anxiety, depression, and quality of life (ds = 0.60-0.86, p ≥ .05). Compared with enhanced usual care, REVITALIZE participants had fewer PARPi dose reductions (6.7% vs. 19.0%), and dose delays (6.7% vs. 23.8%).

CONCLUSIONS

Among fatigued adults with ovarian cancer on PARPi, a brief, acceptance-based telehealth intervention was feasible, acceptable, and demonstrated preliminary efficacy in improving fatigue interference, severity, and levels. REVITALIZE is a novel, scalable telehealth intervention worthy of further investigation.

Opportunities to improve care for patients with peritoneal carcinomatosis and their caregivers

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Background: Cancers of the gynecologic and gastrointestinal tracts (GYN/GI) often metastasize along the peritoneum (peritoneal carcinomatosis; PC), causing ascites and malignant obstructions of the bowel, urinary tract, and biliary tree. Patients with PC frequently require palliative surgical interventions; e.g., ostomies, gastric tubes, and catheters. To date, few researchers have described the unique needs of these patients and their caregivers. Methods: We recruited adult patients with advanced GYN/GI cancers, a recent hospitalization for PC, and a new complex care need. We invited adult caregivers of enrolled patients to participate. We abstracted patients’ clinical characteristics and outcomes from the medical record. At baseline, patients completed items related to perceived health status and advance care planning, while caregivers completed the Caregiver Reaction Assessment (CRA) and items related to their caregiving role. All participants completed the Hospital Anxiety and Depression Scale. Results: Sixty-five patients and 40 caregivers completed surveys. Fifty-six (86%) patients had GYN and nine (14%) had GI cancers. Most (56/65, 86%) were re-hospitalized within two months, and over a quarter (18/65, 27%) died within six months of enrollment. Twenty-four (37%) reported they were terminally ill, but only nine (14%) had spoken with a physician about the care they would want to receive if they were dying. Caregivers were primarily spouses (27/40, 70%) who provided most or all of the care for their loved one (25/40, 63%) and engaged in caregiving seven days per week (27/40, 68%). Of the four CRA subscales measuring negative caregiving experiences, mean scores were highest for impact on schedule (3.3, SD = 0.8; possible range 1-5, higher scores indicate greater burden), followed by impact on finances (2.3, SD = 1.1), impact on health (2.0, SD = 0.65), and lack of family support (1.8, SD = 0.67). Caregivers reported that they received training on a mean of 1.1 (SD = 1.3) clinical care tasks but performed a mean of 2.9 (SD = 1.7) clinical care tasks. Thirty-two (49%) patients and 9 (23%) caregivers met borderline case or case criteria for depressive symptoms, while 26 (40%) patients and 15 (38%) caregivers met borderline case or case criteria for anxiety symptoms. Conclusions: Patients with PC and their caregivers are highly burdened and distressed. Patients are at high-risk for re-hospitalization, but few have discussed their end-of-life wishes with their medical teams. Interventions that train these patients and their caregivers to perform clinical care tasks, facilitate serious illness conversations, and provide psychosocial support are needed. Clinical trial information: NCT03367247.

Developing and Field Testing BOLSTER: A Nurse-Led Care Management Intervention to Support Patients and Caregivers following Hospitalization for Gynecologic Cancer-Associated Peritoneal Carcinomatosis

Introduction: Peritoneal carcinomatosis (PC) afflicts women with advanced gynecologic cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate symptoms, yet patients and caregivers report feeling unprepared to manage these devices. The purpose of this study was to develop and field test the Building Out Lifelines for Safety, Trust, Empowerment, and Renewal (BOLSTER) intervention to support patients and their caregivers after hospitalization for PC. Materials and Methods: We adapted components of the Standard Nursing Intervention Protocol with stakeholders and topical experts. We developed educational content; built a smartphone application to assess patients' symptoms; and assessed preliminary feasibility and acceptability in two single-arm prepilot studies. Eligible participants were English-speaking adults hospitalized for gynecologic cancer-associated PC and their caregivers. Feasibility criteria were a ≥50% consent-to-approach ratio and ≥80% outcome measure completion. The acceptability criterion was ≥70% of participants recommending BOLSTER. Results: During the first prepilot, BOLSTER was a 10-week intervention. While 7/8 (87.5%) approached patients consented, we experienced high attrition to hospice. Less than half of patients (3/7) and caregivers (3/7) completed outcome measures. For the second prepilot, BOLSTER was a four-week intervention. All (7/7) approached patients consented. Two withdrew before participating in any study activity because they were "too overwhelmed." We excluded data from one caregiver who completed baseline measures with the patient's assistance. All remaining patients (5/5) and caregivers (4/4) completed outcome measures and recommended BOLSTER. Conclusion: BOLSTER is a technology-enhanced, nurse-led intervention that is feasible and acceptable to patients with gynecologic cancer-associated PC and their caregivers.

Thinking globally to improve care locally: A Delphi study protocol to achieve international clinical consensus on best-practice end-of-life communication with adolescents and young adults with cancer

For the sizeable subset of adolescents and young adults whose cancer is incurable, developmentally appropriate end-of-life discussions are critical. Standards of care for adolescent and young adult end-of-life communication have been established, however, many health-professionals do not feel confident leading these conversations, leaving gaps in the implementation of best-practice end-of-life communication. We present a protocol for a Delphi study informing the development and implementation of clinician training to strengthen health-professionals’ capacity in end-of-life conversations. Our approach will inform training to address barriers to end-of-life communication with adolescents and young adults across Westernized Adolescent and Young Adult Cancer Global Accord countries. The Adolescent and Young Adult Cancer Global Accord team involves 26 investigators from Australia, New Zealand, the United States, Canada and the United Kingdom. Twenty-four consumers, including adolescents and young adults with cancer history and carers, informed study design. We describe methodology for a modified Delphi questionnaire. The questionnaire aims to determine optimal timing for end-of-life communication with adolescents and young adults, practice-related content needed in clinician training for end-of-life communication with adolescents and young adults, and desireability of evidence-based training models. Round 1 involves an expert panel of investigators identifying appropriate questionnaire items. Rounds 2 and 3 involve questionnaires of international multidisciplinary health-professionals, followed by further input by adolescents and young adults. A second stage of research will design health-professional training to support best-practice end-of-life communication. The outcomes of this iterative and participatory research will directly inform the implementation of best-practice end-of-life communication across Adolescent and Young Adult Cancer Global Accord countries. Barriers and training preferences identified will directly contribute to developing clinician-training resources. Our results will provide a framework to support further investigating end-of-life communication with adolescents and young adults across diverse countries. Our experiences also highlight effective methodology in undertaking highly collaborative global research.

Abstract P4-09-01: Incidence of patient-reported fatigue developing in patients receiving palbociclib and endocrine therapy for advanced HR+ HER2- breast cancer

Background: Clinician-rated adverse event data from pivotal trials of the CDK4/6 inhibitor palbociclib (palbo) in patients (pts) with HR+ HER2- metastatic breast cancer (MBC) describe fatigue as a common non-hematologic toxicity. While palbo and endocrine therapy (ET) significantly improve outcomes compared to ET alone, in a pooled analysis of the PALOMA trials, rates of incident Common Terminology Criteria for Adverse Events (CTCAE) all-grade fatigue over 4.2 years of treatment approached 39.2%, with grade 3/4 at 2.5%. As these studies included only provider-rated CTCAE toxicity, it is important to quantify pts’ ratings of fatigue severity, which may differ from clinician assessments. Methods: Eligible pts with HR+ HER2- MBC, initiating standard-dose palbo with ET (aromatase inhibitor or fulvestrant), and without clinically meaningful fatigue prior to initiation of palbo, were followed for the 6 initial treatment cycles. The absence of baseline fatigue was established using the patient-reported Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-F), a 13-item scale (range 0-52, lower score = more fatigue) validated against anemia to indicate clinically meaningful fatigue if FACIT-F score &lt;34. After screening and baseline assessments (several weeks apart), the FACIT-F was repeated during the 3rd week of 6 consecutive cycles. Pts also reported fatigue severity using the NCI Patient-Reported Outcomes for CTCAE (PRO-CTCAE; range 0-4; grade 3/4 = severe) when they completed the FACIT-F. The primary endpoint was new-onset fatigue (FACIT-F score &lt;34) after treatment initiation; the secondary endpoint was severe fatigue on the PRO-CTCAE fatigue severity item. Incident rate of fatigue was estimated based on frequencies (dichotomized FACIT-F scores &lt;34 vs. &gt;=34; PRO-CTCAE fatigue severity grade 3/4 vs. &lt;3). Rate of fatigue incidence on the FACIT-F in the presence of competing risks (e.g., disease progression or study burden) was estimated using the cumulative incidence function. Concurrently rated FACIT-F scores were compared between PRO-CTCAE severe and non-severe cases using linear mixed-models. Results: Of 115 pts enrolled (5/2018-1/2021), 88 were evaluable after excluding those not initiating palbo (n=3), without baseline data (n=13), or with clinically meaningful fatigue between screening and baseline (n=11). Mean (±SD) age was 59.4 ± 11.3, baseline FACIT-fatigue score was 44.4 ± 5.1, and follow-up duration was 5.8 ± 2.0 cycles. The majority (72%) were receiving palbo with letrozole. New-onset fatigue through the 6th treatment cycle was observed in 21 pts, translating to a fatigue incidence rate of 23.9% (95% CI 15.4% - 34.1%). The mean time to new-onset fatigue was 3.8 ± 1.7 treatment cycles. Those who withdrew early (n=26) completed data for 3.7 ± 2.1 treatment cycles; the cumulative incidence of fatigue at 4 treatment cycles was 18.2% (95% CI 10.9 - 26.9). Using the PRO-CTCAE, the incidence rate of severe fatigue was 14.8% (95% CI 8.1% - 23.9%). The mean FACIT-F score when PRO-CTCAE grade indicated severe fatigue was significantly lower (more fatigue) than when the PRO-CTCAE grade was non-severe (26.3 ± 5.1 vs. 44.8 ± 4.8, p&lt;0.0001). Conclusion: In pts with HR+ HER2- MBC initiating palbo and ET, approximately one-quarter develop fatigue within the first 6 cycles based on the FACIT-F, which associates significantly with a PRO-CTCAE severity grade 3/4. While direct comparison cannot be made between provider-rated CTCAE and patient-reported PRO-CTCAE, it is notable that the incidence of severe fatigue with PRO-CTCAE is higher than that observed with provider-rated CTCAE. Ongoing analyses will explore potential associations of factors (e.g., hematological, sleep, activity) with treatment-emergent fatigue developing on palbo and ET therapy.

Citation Format: Shadab A Rahman, Erica L Mayer, Hanneke Poort, Deborah Schrag, Stephanie C Tung, Eric S Zhou, Aleta Wiley, Lauren Finkelstein, Elkhansaa Elguenaoui, Moira Nolan, Hadine Joffe. Incidence of patient-reported fatigue developing in patients receiving palbociclib and endocrine therapy for advanced HR+ HER2- breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-09-01.

Building out lifelines for safety, trust, empowerment, and renewal: Development, feasibility, and acceptability of the BOLSTER intervention for patients with gynecologic cancers and their caregivers

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Background: Peritoneal carcinomatosis (PC) afflicts over half of women with advanced gynecologic (GYN) cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate their symptoms, yet patients and caregivers report feeling unprepared to manage these devices at home. Our aims were to develop and assess the feasibility and acceptability of an intervention (BOLSTER) to support patients with GYN cancers and their caregivers after hospitalization for PC. Methods: We used the ADAPT-ITT approach to adapt components of the Standard Nursing Intervention Protocol for the target population. First, we assembled a team of stakeholders and topical experts to identify gaps in patient resources. Next, we developed patient- and family-centered educational materials. We augmented written materials with illustrations and produced short videos of patients and caregivers managing medical devices. We developed a protocolized manual for a baccalaureate-prepared nurse to provide care coordination, skills training, and symptom management education across several in-person or telehealth visits. We also created a smartphone application to assess patient-reported outcomes, deliver tailored educational content, and trigger clinical action between visits. Finally, we assessed the feasibility and acceptability of two iterations of BOLSTER in single-arm pilot studies of English-speaking adult patients hospitalized for PC and their caregivers. We defined feasibility as a ≥50% consent-to-approach ratio and acceptability as ≥70% of participants recommending BOLSTER. Results: Intervention characteristics during and the results of each single-arm pilot study are shown in Table. In the first single-arm pilot, 2/4 participants declined home visits, 2/4 wished BOLSTER were shorter, and 3/4 desired access to BOLSTER earlier in their disease course. For the second single-arm pilot, we expanded participant eligibility criteria, eliminated home visits, and reduced the duration of the intervention. Conclusions: BOLSTER is a technology-enhanced, nurse-led care management intervention that is feasible and acceptable to patients with GYN cancer-associated PC and their caregivers. A randomized controlled pilot study of BOLSTER represents a logical next step. Clinical trial information: NCT03367247. [Table: see text]

Condition or cognition? Mechanism of change in fatigue in a randomized controlled trial of graded exercise therapy or cognitive behavior therapy for severe fatigue in patients with advanced cancer

OBJECTIVE

Fatigue remains one of the most common and distressing symptoms during treatment for advanced cancer. The TIRED trial demonstrated cognitive behavior therapy's (CBT) significant and clinically relevant effects to reduce fatigue among patients with advanced cancer, while graded exercise therapy (GET) did not prove beneficial. The present study aims to determine the mechanisms by which CBT and GET affect fatigue.

METHOD

The TIRED trial randomized 134 patients with advanced cancer to CBT (n = 46), GET (n = 42), or usual care (n = 46). At 14 weeks, 126 evaluable patients provided fatigue data and of those 117 received ≥1 CBT or GET session or usual care. We tested a prespecified multiple mediation model with four potential mediators (physical activity, exercise capacity, self-efficacy, and fatigue catastrophizing) assessed at baseline and at 14 weeks. Post-hoc analyses also included perceived physical activity and emotional functioning as potential mediators.

RESULTS

A total of 82 of 117 patients completed all required measures. CBT reduced fatigue indirectly through its effect on self-efficacy, ab = -3.292; 97.5% bootstrap CI [-6.518 to -0.598]. CBT participants experienced an increase in fatigue self-efficacy, with greater self-efficacy associated with decreased fatigue severity. There was no evidence that changes in physical activity, exercise capacity, perceived physical activity, fatigue catastrophizing, or emotional functioning mediated CBT's or GET's effects on fatigue.

CONCLUSIONS

The effect of CBT was attributable to changes in cognition, that is, increased self-efficacy led to reduced fatigue severity. No significant mediators for GET were found. The findings inform further refinement of interventions for fatigue in this seriously ill population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Feasibility and Acceptability of a Mobile Phone App Intervention for Coping With Cancer as a Young Adult: Pilot Trial and Thematic Analysis

BACKGROUND

Many young adult patients do not receive adequate psychosocial services to help them cope with cancer.

OBJECTIVE

This study aims to assess the feasibility and acceptability of a smartphone app (iaya) intervention that was designed to create an engaged community of young adult patients and help them learn emotional coping skills.

METHODS

For this single-group pilot trial, 25 young adult patients aged 18-39 years who were receiving active cancer treatment were asked to use the iaya app for 12 weeks. To collect app use data, we used Mixpanel, an analytics platform for apps. Feasibility was assessed through rates of app sessions and the number of coping exercises engaged, and intervention acceptability was evaluated by using an app usability questionnaire and through qualitative interviews at study completion. We collected patient-reported outcome data at baseline and at week 12 to explore self-efficacy for coping with cancer, self-efficacy for managing emotions, perceived emotional support, and quality of life.

RESULTS

Baseline patient-reported outcome data indicated that participants scored relatively low on perceived emotional support but reasonably high on self-efficacy for coping with cancer and managing emotions as well as quality of life. Participants had a mean of 13 app sessions (SD 14) and 2 coping exercises (SD 3.83) in 12 weeks. Only 9% (2/23) of participants met our combined feasibility definition of ≥10 app sessions and ≥3 coping skills from different categories. The participants' mean usability score was 73.7% (SD 10.84), which exceeded our predefined threshold of ≥70%, and qualitative feedback was generally positive.

CONCLUSIONS

Although perceived acceptable by patients, the iaya smartphone app did not meet the a priori feasibility criteria as a stand-alone app intervention. Future studies should screen participants for unmet coping needs and consider integrating the app as part of psychosocial care for young adult patients.

Cognitive behavioral therapy or graded exercise therapy compared with usual care for severe fatigue in patients with advanced cancer during treatment: a randomized controlled trial

BACKGROUND

Cancer-related fatigue remains a prevalent and burdensome symptom experienced by patients with advanced cancer. Our aim was to assess the effects of cognitive behavioral therapy (CBT) or graded exercise therapy (GET) on fatigue in patients with advanced cancer during treatment with palliative intent.

PATIENTS AND METHODS

A randomized controlled trial was conducted from 1 January 2013 to 1 September 2017. Adult patients with locally advanced or metastatic cancer who reported severe fatigue during treatment [Checklist Individual Strength, subscale fatigue severity (CIS-fatigue) ≥35] were accrued across nine centers in The Netherlands. Patients were randomly assigned to either 12 weeks of CBT or GET, or usual care (1 : 1: 1, computer-generated sequence). Primary outcome was CIS-fatigue at 14 weeks. Secondary outcomes included fatigue measured with the European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire (EORTC-QLQ-C30), quality of life, emotional functioning, physical functioning, and functional impairments at baseline, 14, 18, and 26 weeks.

RESULTS

Among 134 participants randomized, the mean age was 63 (standard deviation 9) years and 77 (57%) were women. Common diagnoses included: breast (41%), colorectal (28%), and prostate cancer (17%). A total of 126 participants completed assessment at 14 weeks. Compared with usual care, CBT significantly reduced fatigue [difference -7.2, 97.5% confidence interval (CI) -12.7 to -1.7; P = 0.003, d = 0.7], whereas GET did not (-4.7, 97.5% CI -10.2 to 0.9; P = 0.057, d = 0.4). CBT significantly reduced EORTC-QLQ-C30 fatigue (-13.1, 95% CI -22.1 to -4.0; P = 0.005) and improved quality of life (10.2, 95% CI 2.4 to 17.9; P = 0.011) and physical functioning (7.1, 95% CI 0.5 to 13.7; P = 0.036) compared with usual care. Improvement in emotional functioning and decrease in functional impairments failed to reach significance. GET did not improve secondary outcomes compared with usual care.

CONCLUSIONS

Among advanced cancer patients with severe fatigue during treatment, a CBT intervention was more effective than usual care for reducing fatigue. Following GET, patients reported lower fatigue, but results were not significant, probably due to a smaller sample size and lower adherence than anticipated.

TRIAL REGISTRATION

Netherlands National Trial Register, identifier: NTR3812.

Lived experiences of women reporting fatigue during PARP inhibitor maintenance treatment for advanced ovarian cancer: A qualitative study

OBJECTIVE

Oral PARP inhibitors (PARPi) have dramatically changed the treatment landscape for patients with advanced ovarian cancer. However, a subset of patients discontinue PARPi due to treatment-related fatigue. The current study sought to explore patients' lived experiences with fatigue on PARPi.

METHODS

We conducted individual semi-structured interviews with N = 23 women receiving PARPi for advanced ovarian cancer who reported moderate to severe fatigue. Audiotaped interviews were transcribed and we used thematic analysis to code transcripts for emergent themes.

RESULTS

Four overarching themes emerged. First, participants described their fatigue as milder than what they experienced on intravenous chemotherapy, but noted it consistently limited their daily activities, including work, and interfered with participation in family and social events. Second, fatigue negatively impacted participants' sense of self and identity. Third, most wanted to continue treatment and believed discontinuing PARPi would lead to a cancer recurrence or death. Finally, many participants reported that their support networks were unaware of their ongoing cancer treatment or the resulting fatigue; a situation that may prove isolating and result in reduced social support.

CONCLUSIONS

Our findings underscore patients' persistent experience of fatigue on PARPi, the impact of fatigue on multiple domains of functioning, and a lack of understanding of side effects resulting from oral maintenance treatments among patients' social networks. Our findings highlight the need for interventions to address treatment-related fatigue to limit the negative impacts of fatigue on ovarian cancer patients' well-being.

Cognitive Behavioral Therapy for Treatment-Related Fatigue in Chronic Myeloid Leukemia Patients on Tyrosine Kinase Inhibitors: A Mixed-Method Study

Treatment-related fatigue significantly limits quality of life among chronic myeloid leukemia (CML) patients receiving tyrosine kinase inhibitors (TKIs), yet no interventions to reduce this symptom have been studied. We examined preliminary feasibility and efficacy of cognitive behavioral therapy for TKI treatment-related fatigue in patients with CML. We used a mixed methods convergent design and collected quantitative data through randomized single-case experiments. We included CML patients receiving TKIs and reporting severe fatigue. Within each participant, we compared CBT to a no-treatment baseline period. Fatigue severity was measured weekly with the Checklist Individual Strength. Fatigue scores were subjected to visual analyses and randomization tests for single-case experimental designs. We conducted qualitative interviews after study participation and focused on feasibility and efficacy of CBT. Visual inspection of line graphs indicated downward trends in the expected direction for fatigue in two of the four participants. The test statistics showed a decrease in fatigue severity for all participants but randomization tests did not reach statistical significance (overall p = 0.18). Participants reported qualitative improvements in level of functioning and coping with fatigue. CBT was considered feasible and acceptable for severely fatigued CML patients. Our study provided preliminary evidence for the feasibility and acceptability of CBT for severely fatigued CML patients receiving targeted therapy. We recommend further efficacy testing of this promising intervention in a pilot randomized controlled trial.

Patterns and predictors of cancer-related fatigue in ovarian and endometrial cancers: 1-year longitudinal study

BACKGROUND

Fatigue is a common and distressing symptom for patients with gynecologic cancers. Few studies have empirically examined whether it spontaneously resolves. This study was aimed at identifying longitudinal patterns of fatigue and predictors of clinically significant fatigue 1 year after treatment completion.

METHODS

This was a prospective cohort study of women with newly diagnosed ovarian (n = 81) or endometrial cancer (n = 181) that did not progress or recur within 1 year of treatment completion. Symptoms of fatigue, depression, and anxiety were assessed after surgery and 6 and 12 months after treatment completion with the Fatigue Assessment Scale and the Hospital Anxiety and Depression Scale. Patients' fatigue scores over time were classified (scores of 22-50, clinically significant; scores of 10-21, not clinically significant). Logistic regression models were fit to examine associations between fatigue and patient characteristics.

RESULTS

Among 262 participants, 48% reported clinically significant fatigue after surgery. One year later, 39% reported fatigue. There were 6 patterns over time: always low (37%), always high (25%), high then resolves (18%), new onset (10%), fluctuating (6%), and incidental (5%). Patients with fatigue after surgery were more likely to report fatigue at 12 months in comparison with others (odds ratio [OR], 6.08; 95% confidence interval [CI], 2.82-13.11; P < .001). Patients with depressive symptoms also had higher odds of fatigue (OR, 3.36; 95% CI, 1.08-10.65; P = .039), although only one-third of fatigued patients reported depressive symptoms.

CONCLUSION

Nearly half of women with gynecologic cancers had clinically significant fatigue after surgery, whereas 44% and 39% had fatigue 6 months and 1 year later; this suggests that spontaneous regression of symptoms is relatively rare. Women who reported fatigue, depressive symptoms, or 2 or more medical comorbidities had higher odds of reporting fatigue 1 year later. Future studies should test scalable interventions to improve fatigue in women with gynecologic cancers.

Patient-reported and clinician-rated performance status and general health among women with gynecologic cancers on palliative chemotherapy

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Background: Oncologists’ perceptions of patients’ performance status (PS) and general health are key determinants of eligibility for chemotherapy and clinical trials. We sought to examine correlations between patient-reported and clinician-rated Eastern Clinical Oncology Group PS (ECOG-PS) and general health status (EQ5D) in women with incurable recurrent gynecologic cancers, as well as step counts from accelerometry as a proxy for objective PS. Methods: We used baseline data from a randomized trial evaluating a mobile health intervention that collects patient-reported outcomes and passive smartphone data and provides tailored symptom management advice. Half of participants also received a wearable accelerometer. We calculated Pearson correlations to determine agreement between ECOG-PS and EQ-5D assessments in patient-clinician dyads. We also calculated the median (IQR) step counts among a subset of women with ≥7 days of ≥8 hours wear time. Results: Data from 78 patient-clinician dyads demonstrated a moderate correlation between patient-reported and clinician-rated ECOG-PS (r = .47; P< .000). Among dyads, 38 (49%) had perfect agreement; 36 (46%) had higher patient-reported ECOG-PS, indicating more patient-reported functional limitations, compared with clinician reports; and 4 (5%) had lower patient-reported ECOG-PS. Comparisons between patient-clinician ratings of EQ-5D subscales indicated moderate agreement for mobility (r = 0.44; P< .001), pain/discomfort (r = 0.45; P< .001), and usual activities (r = 0.36; P= .002); and weak or no agreement for anxiety/depression (r = 0.31; P= .007) and self-care (r = 0.02; P> .05). Participants’ daily step counts varied widely (median = 5,511 steps, IQR = 3,784, range 1,736-13,961) and were not associated with patients’ or clinicians’ ECOG-PS estimates (r = -.12; P= 0.44 and r = -0.03; P= 0.84) or patient-reported mobility (r = -0.10; P =0.51). Conclusions: Among women with incurable gynecologic cancers, patients’ and clinicians’ perceptions of patients’ ECOG-PS were moderately correlated, although 46% of clinician ratings were more optimistic than patients’ ratings. There was also moderate agreement between dyads for mobility and pain/discomfort. Patients’ step counts were not correlated with ECOG-PS or patient-reported mobility. Future studies should examine these measures longitudinally to determine which is the most sensitive predictor of clinical outcomes. Clinical trial information: NCT03022032 .

Natural Language Processing to Assess Palliative Care and End-of-Life Process Measures in Patients With Breast Cancer With Leptomeningeal Disease

Background:

Palliative care consultation during serious life-limiting illness can reduce symptom burden and improve quality of care. However, quantifying the impact of palliative care is hindered by the limitations of manual chart review and administrative coding.

Objectives:

Using novel natural language process (NLP) techniques, we examined associations between palliative care consultations and performance on nationally endorsed metrics for high-quality end-of-life (EOL) care in patients with leptomeningeal disease (LMD) secondary to metastatic breast cancer.

Methods:

Patients with breast cancer with LMD were identified using administrative billing codes and NLP review of magnetic resonance imaging reports at 2 tertiary care centers between 2010 and 2016. Next, NLP was used to review clinical notes to (1) determine the presence of palliative care consultations and (2) determine the performance of process measures associated with high-quality EOL care, including discussions of goals of care, code status limitations, and hospice. Associations between palliative care consultation and documentation of EOL process measures were assessed using logistic regression.

Results:

We identified 183 cases of LMD. Median age was 56 (interquartile range [IQR]: 46-64) years and median survival was 150 days (IQR: 67-350). Within 6 months of diagnosis, 88.5% of patients had documentation of ≥1 process measure, including discussions of goals of care (63.4%), code status limitations (62.8%), or hospice (72.1%). Palliative care consultation was a predictor of subsequent documentation of goals of care (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.58-6.27) and hospice discussions (OR, 4.61; 95% CI, 2.12-10.03).

Conclusion:

Palliative care involvement is associated with increased performance of EOL process measures in patients with breast cancer with LMD.

Predictors and trajectories of fatigue in ovarian and uterine cancer

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Background: Fatigue is one of the most common and distressing symptoms reported by patients with gynecological cancers, but few studies have empirically examined whether it resolves without intervention. The aims of this study were to identify: 1) clinically-distinct subgroups of patients with fatigue over time and 2) medical and psychological predictors of clinically-significant fatigue one-year post-diagnosis. Methods: Secondary analysis of a prospective cohort study. Symptoms of fatigue, depression, and anxiety were assessed at diagnosis, 6-months, and 12-months with the 10-item Fatigue Assessment Scale (FAS), and the Hospital Anxiety and Depression Scale (HADS), respectively. Group-based trajectory modeling was used to classify patients by their fatigue scores over time, and logistic regression models were fit to examine associations between clinically-significant fatigue and demographic, clinical, and psychosocial characteristics. Patients with recurrent or primary progressive cancers were excluded from the primary analysis. Results: Among 312 participants with newly diagnosed ovarian (n = 112) or endometrial (n = 200) cancers, the median age was 66 years (IQR = 60-72 years), 36% had ovarian cancer, and 79% had early stage disease. At baseline, 49% reported clinically significant fatigue and one year later, 42% had persistent fatigue. During the year after diagnosis, there were three distinct trajectories of fatigue that persisted: (1) severe fatigue (15%), (2) moderate fatigue (45%), and (3) no fatigue (41%). Patients with ≥2 comorbid conditions (odds ratio [OR] 2.52, 95% confidence interval [CI] = 1.21-5.27, P = 0.01), clinically significant fatigue at baseline (OR 5.47, 95% CI = 2.71-11.03, P < .0001), and those reporting depressive symptoms at baseline (OR 3.45, 95% CI = 1.13-10.55, P = 0.03) were more likely to report clinically-significant fatigue at 12 months. Conclusions: Half of women with gynecologic cancers have clinically-significant fatigue at diagnosis and 42% of survivors have persistent fatigue one year later, suggesting spontaneous regression of symptoms is rare. Importantly, depressive symptoms contribute to persistent fatigue and are modifiable with psychological interventions. Future studies should test scalable psychological interventions to address depressive symptoms, reduce fatigue, and improve quality of life in women with gynecologic cancers.

TIRED: A randomised controlled trial evaluating efficacy of cognitive behavior therapy and graded exercise therapy in severely fatigue patients with advanced cancer

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Background: Patients with advanced, metastatic cancer frequently suffer from severe fatigue. We assessed the effect of cognitive behavioral therapy (CBT) and graded exercise therapy (GET) on fatigue during cancer treatment with palliative intent. Methods: This randomized study took place between Jan 1, 2013 and Sep 1, 2017 at Radboud University Medical Center (Nijmegen, Netherlands). We enrolled adult patients from nine medical oncology clinics. Eligible patients had advanced cancer and reported severe fatigue (Checklist Individual Strength, subscale fatigue severity [CIS fatigue] ≥ 35) during cancer treatment. Participants were randomized to CBT, GET, or usual care (1:1:1 ratio, using a computer-generated sequence, stratified by study site and minimized for sex). We measured fatigue (CIS fatigue and European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire-Core 30 [EORTC-QLQ-C30] fatigue), quality of life, emotional functioning, physical functioning (all by EORTC-QLQ-C30), and functional impairments (Sickness Impact Profile [SIP8]) at baseline, 14, 18, and 26 weeks. The primary outcome was CIS fatigue at 14 weeks; secondary outcomes included scores for the aforementioned scales. We registered the trial with TrialRegister.nl (NTR3812). Results: 134 participants completed baseline measures (46 CBT, 42 GET, 46 usual care); 126 completed assessment at 14 weeks. There was a significant difference in CIS fatigue scores between CBT and usual care (-7.22, 97.5% CI -12.73 to -1.72; p = .003, d= 0.72), but no significant difference between GET and usual care (-4.70, -10.24 to 0.85, p = .057, d= 0.44). Secondary outcomes showed significant differences for EORTC-QLQ-C30 fatigue (-13.05 [95% CI -22.12 to -3.97]; p = 0.005), quality of life (10.15 [2.37 to 17.93]; p = 0.11), and physical functioning (7.10 [0.48 to 13.72]; p = 0.036), but not for emotional functioning or SIP8 functional impairments (p's > 0.05). There were no significant differences in secondary outcomes between GET and usual care. Conclusions: The findings support CBT for severe fatigue in patients with advanced cancer during treatment. Clinical trial information: NTR3812.

Process measures of palliative and end-of-life care among young adults who died from cancer

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Background: Timely delivery of palliative and end-of-life care (EOL) are essential components of high-quality cancer care. To date, however, few studies have examined process measures for EOL care in young adult (YA; ages 18-35 years) cancer decedents. Methods: We conducted a retrospective study using medical records of YA decedents who received cancer treatment at an academic cancer center between Jan. 1, 2012 and June 13, 2018. We used natural language processing (NLP) with validated key words to identify documentation of four process measures – palliative care involvement, and discussions of goals of care, code status, and hospice – from documented clinical encounters in the medical record within 6 months of death. Results: During this period 146/2,878 (5.1%) YA patients had a recorded death date and a first note at least 31 days prior to death. In this decedent cohort, the mean age was 28.2 years (SD=4.4) and 58.9% were men. The most common diagnoses were brain cancer (33.6%), sarcoma (19.9%), and breast cancer (12.3%). The 146 patients accrued 26,441 clinical notes during the last 6 months of life (median=116.5 notes, IQR 37.0-222.0). Using NLP, we identified that 68.5% of the 146 YAs had at least one process measure documented in the last 6 months of life, including: 54.1% palliative care involvement; 56.8% discussions of goals of care; 47.3% discussions of code status; and 51.4% discussions of hospice. On average, palliative care was documented 7.5 times (range 0-75); goals of care 6.1 times (range 0-43), code status 1.9 times (range 0-12), and hospice 8.1 times (range 0-67). Late documentation of process measures (defined as first recorded within 30 days of death) included: hospice (45.3%), code status (30.3%), palliative care (20.8%), and goals of care (9.6%). Notably, in 31.5% of YAs, we did not detect documentation of any process measures prior to death. Conclusions: In this cohort of YA cancer decedents, nearly one-third of YAs did not have documentation of any process measures, highlighting the importance of efforts to improve EOL care communication with this young population.

Psychosocial interventions for fatigue during cancer treatment with palliative intent

BACKGROUND

Fatigue is a prevalent and burdensome symptom for patients with incurable cancer receiving cancer treatment with palliative intent and is associated with reduced quality of life. Psychosocial interventions seem promising for management of fatigue among cancer patients.

OBJECTIVES

To assess the effects of psychosocial interventions for fatigue in adult patients with incurable cancer receiving cancer treatment with palliative intent.

SEARCH METHODS

We searched the following databases: CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and seven clinical trial registries; we also searched the reference lists of articles. The date of our most recent search was 29 November 2016.

SELECTION CRITERIA

We included randomised controlled trials that compared psychosocial interventions in adults aged 18 years or over undergoing cancer treatment with palliative intent for incurable cancer versus usual care or other controls. Psychosocial interventions were defined as various kinds of interventions provided to influence or change cognitions, emotions, behaviours, social interactions, or a combination of these. Psychosocial interventions of interest to this review had to involve at least two interactions between the patient and the care provider in which the care provider gave the patient personal feedback concerning changes sought by these interventions. We included trials that reported fatigue as an outcome of interest.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data, including information on adverse events. We assessed the quality of evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings' table.

MAIN RESULTS

We identified 14 studies (16 reports) that met inclusion criteria for this review and involved 3077 randomised participants in total. Most of these studies included a mixed sample of participants; we obtained data for the subset of interest for this review (diagnosis of incurable cancer and receiving cancer treatment) from the study investigators of 12 studies, for which we included 535 participants in the subset meta-analysis for fatigue post intervention. Researchers investigated a broad range of psychosocial interventions with different intervention aims and durations. We identified sources of potential bias, including lack of description of methods of blinding and allocation concealment and inclusion of small study populations.Findings from our meta-analysis do not support the effectiveness of psychosocial interventions for reducing fatigue post intervention (standardised mean difference (SMD) -0.25, 95% confidence interval (CI) -0.50 to 0.00; not significant; 535 participants, 12 studies; very low-quality evidence). First follow-up findings on fatigue suggested benefit for participants assigned to the psychosocial intervention compared with control (SMD -0.66, 95% CI -1.00 to -0.32; 147 participants, four studies; very low-quality evidence), which was not sustained at second follow-up (SMD -0.41, 95% CI -1.12 to 0.30; not significant; very low-quality evidence).Results for our secondary outcomes revealed very low-quality evidence for the efficacy of psychosocial interventions in improving physical functioning post intervention (SMD 0.32, 95% CI 0.01 to 0.63; 307 participants, seven studies). These findings were not sustained at first follow-up (SMD 0.37, 95% CI -0.20 to 0.94; not significant; 122 participants, two studies; very low-quality evidence). Findings do not support the effectiveness of psychosocial interventions for improving social functioning (mean difference (MD) 4.16, 95% CI -11.20 to 19.53; not significant; 141 participants, four studies), role functioning (MD 3.49, 95% CI -12.78 to 19.76; not significant; 143 participants, four studies), emotional functioning (SMD -0.11, 95% CI -0.56 to 0.35; not significant; 115 participants, three studies), or cognitive functioning (MD -2.23, 95% CI -12.52 to 8.06; not significant; 86 participants, two studies) post intervention. Only three studies evaluated adverse events. These studies found no difference between the number of adverse events among participants in the intervention versus control group.Using GRADE, we considered the overall quality of evidence for our primary and secondary outcomes to be very low. Therefore, we have very little confidence in the effect estimate, and the true effect is likely to be substantially different from the estimate of effect. Limitations in study quality and imprecision due to sparse data resulted in downgrading of the quality of data. Additionally, most studies were at high risk of bias owing to their small sample size for the subset of patients with incurable cancer (fewer than 50 participants per arm), leading to uncertainty about effect estimates.

AUTHORS' CONCLUSIONS

We found little evidence around the benefits of psychosocial interventions provided to reduce fatigue in adult patients with incurable cancer receiving cancer treatment with palliative intent. Additional studies with larger samples are required to assess whether psychosocial interventions are beneficial for addressing fatigue in patients with incurable cancer.

Prevalence and impact of severe fatigue in adolescent and young adult cancer patients in comparison with population-based controls

Purpose

The current study determined the prevalence of severe fatigue in adolescent and young adult (AYA) cancer patients (aged 18–35 years at diagnosis) consulting a multidisciplinary AYA team in comparison with gender- and age-matched population-based controls. In addition, impact of severe fatigue on quality of life and correlates of fatigue severity were examined.

Methods

AYAs with cancer (n = 83) completed questionnaires including the Checklist Individual Strength (CIS-fatigue), Quality of Life (QoL)-Cancer Survivor, Hospital Anxiety and Depression Scale (reflecting psychological distress), and the Cancer Worry Scale (reflecting fear of cancer recurrence or progression).

Results

The vast majority of participants had been treated with chemotherapy (87%) and had no active treatment at the time of participation (73.5%). Prevalence of severe fatigue (CIS-fatigue score ≥35) in AYAs with cancer (48%, n = 40/83) was significantly higher in comparison with matched population-based controls (20%, n = 49/249; p < .001). Severely fatigued AYAs with cancer reported lower QoL compared to non-severely fatigued AYAs with cancer (p < .05). Female gender, being unemployed, higher disease stage (III–IV) at diagnosis, receiving active treatment at the time of study participation, being treated with palliative intent, having had radiotherapy, higher fear of recurrence or progression, and higher psychological distress were significantly correlated with fatigue severity (p < .05).

Conclusions

Severe fatigue based on a validated cut-off score was highly prevalent in this group of AYAs with cancer. QoL is significantly affected by severe fatigue, stressing the importance of detection and management of this symptom in those patients affected by a life-changing diagnosis of cancer in late adolescence or young adulthood.

Study protocol of the TIRED study: a randomised controlled trial comparing either graded exercise therapy for severe fatigue or cognitive behaviour therapy with usual care in patients with incurable cancer

BACKGROUND

Fatigue is a common and debilitating symptom for patients with incurable cancer receiving systemic treatment with palliative intent. There is evidence that non-pharmacological interventions such as graded exercise therapy (GET) or cognitive behaviour therapy (CBT) reduce cancer-related fatigue in disease-free cancer patients and in patients receiving treatment with curative intent. These interventions may also result in a reduction of fatigue in patients receiving treatment with palliative intent, by improving physical fitness (GET) or changing fatigue-related cognitions and behaviour (CBT). The primary aim of our study is to assess the efficacy of GET or CBT compared to usual care (UC) in reducing fatigue in patients with incurable cancer.

METHODS

The TIRED study is a multicentre three-armed randomised controlled trial (RCT) for incurable cancer patients receiving systemic treatment with palliative intent. Participants will be randomised to GET, CBT, or UC. In addition to UC, the GET group will participate in a 12-week supervised exercise programme. The CBT group will receive a 12-week CBT intervention in addition to UC. Primary and secondary outcome measures will be assessed at baseline, post-intervention (14 weeks), and at follow-up assessments (18 and 26 weeks post-randomisation). The primary outcome measure is fatigue severity (Checklist Individual Strength subscale fatigue severity). Secondary outcome measures are fatigue (EORTC-QLQ-C30 subscale fatigue), functional impairments (Sickness Impact Profile total score, EORTC-QLQ-C30 subscale emotional functioning, subscale physical functioning) and quality of life (EORTC-QLQ-C30 subscale QoL). Outcomes at 14 weeks (primary endpoint) of either treatment arm will be compared to those of UC participants. In addition, outcomes at 18 and 26 weeks (follow-up assessments) of either treatment arm will be compared to those of UC participants.

DISCUSSION

To our knowledge, the TIRED study is the first RCT investigating the efficacy of GET and CBT on reducing fatigue during treatment with palliative intent in incurable cancer patients. The results of this study will provide information about the possibility and efficacy of GET and CBT for severely fatigued incurable cancer patients.

TRIAL REGISTRATION

NTR3812 ; date of registration: 23/01/2013.

Fatigue in Advanced Cancer Patients: Congruence Between Patients and Their Informal Caregivers About Patients' Fatigue Severity During Cancer Treatment With Palliative Intent and Predictors of Agreement

CONTEXT

Informal caregivers (ICs) are increasingly involved in the monitoring of symptoms during advanced cancer patients' treatment with palliative intent. A common but subjective symptom during this extended treatment phase is fatigue.

OBJECTIVES

This exploratory longitudinal study aimed to determine agreement between patients and ICs about patients' fatigue severity. In addition, predictors of agreement over time were studied.

METHODS

A sample of 107 patients with advanced cancer (life expectancy ≥ six months) and their ICs completed the subscale fatigue severity of the Checklist Individual Strength based on the patient's status at baseline and six months later. This eight-item subscale has a validated cutoff to determine the presence of clinically relevant levels of fatigue. ICs' own fatigue severity, strain, self-esteem, and relationship satisfaction were examined as predictors of agreement.

RESULTS

A total of 107 dyads completed measures at baseline and 69 dyads six months later. At baseline, ICs' significantly overestimated patients' fatigue severity (P < 0.001) with a moderate amount of bias (Cohen's d = 0.48). In 81 of the 107 dyads (76%), there was congruence about the presence or absence of severe fatigue. On a group level, congruence did not significantly change over time. On a dyad level, there was a tendency to either remain congruent or reach congruence. Next to baseline congruence, ICs' fatigue severity and strain predicted ICs' fatigue ratings (R(2) = 0.22).

CONCLUSION

Most ICs accurately predict presence or absence of clinically relevant levels of patients' fatigue. ICs' own fatigue severity and strain should be taken into account as they influence agreement.

Prevalence, Impact, and Correlates of Severe Fatigue in Patients With Gastrointestinal Stromal Tumors

CONTEXT

The introduction of the tyrosine kinase inhibitor (TKI) imatinib in the treatment of gastrointestinal stromal tumor (GIST) in 2000 was the start of a new era of targeted treatment. Since then, the median survival of patients with GIST has substantially increased. Prolonged survival and chronic TKI use are associated with treatment-induced symptoms, such as fatigue, which can compromise quality of life (QoL).

OBJECTIVES

This study determined the prevalence of severe fatigue in GIST patients compared to matched healthy controls, the impact of fatigue on daily life, and associations between fatigue and current TKI use.

METHODS

One hundred nineteen patients treated with surgery and/or a TKI for GIST were asked to participate. Participants completed questionnaires including the Checklist Individual Strength-Fatigue Severity scale (CIS-fatigue), Short-Form 36-Item Health Survey, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, Fatigue Catastrophizing Scale, Self-Efficacy Scale, and the Hospital Anxiety and Depression Scale.

RESULTS

Eighty-nine GIST patients (75%) completed questionnaires, 61 patients (69%) were on a TKI. Prevalence of severe fatigue measured with CIS-fatigue was significantly higher in GIST patients (30%) than in 234 matched healthy controls (15%). The prevalence of severe fatigue did not differ significantly between patients receiving treatment with curative (29%) or palliative intent (36%). Severely fatigued patients reported lower QoL and more impairment on all functional domains. TKI use, more psychological distress, and lower physical functioning were associated with fatigue.

CONCLUSION

Severe fatigue occurs in 30% of GIST patients and in 33% of GIST patients on a TKI. The fatigue is disabling and is not only associated with current TKI use but also with psychological distress and physical functioning. GIST patients should be informed about these associated factors of fatigue that deserve appropriate management.

A randomized controlled trial of web-based cognitive behavioral therapy for severely fatigued breast cancer survivors (CHANGE-study): study protocol

BACKGROUND

About one third of breast cancer survivors suffer from persistent severe fatigue after completion of curative cancer treatment. Face-to-face cognitive behavioral therapy (F2F CBT), especially designed for fatigue in cancer survivors, was found effective in reducing fatigue. However, this intervention is intensive and treatment capacity is limited. To extend treatment options, a web-based version of CBT requiring less therapist time was developed. This intervention is aimed at changing fatigue-perpetuating cognitions and behaviors. The efficacy of web-based CBT will be examined in a multicenter randomized controlled trial.

METHODS

In total, 132 severely fatigued breast cancer survivors will be recruited and randomized to either an intervention condition or care as usual (ratio 1:1). Participants will be assessed at baseline and 6 months thereafter. The intervention group will receive web-based CBT, consisting of three F2F sessions and maximally eight web-based modules over a period of 6 months. The care as usual group will be on a waiting list for regular F2F CBT. The total duration of the waiting list is 6 months. The primary outcome of the study is fatigue severity. Secondary outcomes are functional impairments, psychological distress and quality of life.

DISCUSSION

If web-based CBT is effective, it will provide an additional treatment option for fatigue in breast cancer survivors. Web-based CBT is expected to be less time-consuming for therapists than regular F2F CBT, which would result in an increased treatment capacity. Moreover, the intervention would become more easily accessible for a larger number of patients, and patients can save travel time and costs.

TRIAL REGISTRATION

Dutch Trial Registry--NTR4309.

Adding imagery rescripting during extinction leads to less ABA renewal

OBJECTIVE

Although extinction is highly effective in reducing a conditioned fear response, return of the fear response (renewal) outside the extinction context often occurs. The present study investigated whether US devaluation, through imagery rescripting during extinction, resulted in less renewal than mere extinction.

METHOD

Seventy psychology students were subjected to a fear conditioning paradigm. During fear acquisition CS+ was always followed by the US, whereas CS- was never followed by the US. For all groups the acquisition phase took place in context A. During extinction both CS+ and CS- were offered, but no US was presented. For three groups extinction was conducted in a different context, context B (ABA groups). The fourth group received extinction in the acquisition context (AAA group) in order to demonstrate that renewal indeed took place. During extinction, participants received either an imagery rescripting (IR) instruction to devaluate the US (ABAir), a US-unrelated imagination instruction to assess the general influence of imagination (ABAcont), or no instruction at all (ABAno and AAAno). Subsequently, testing occurred for all groups in the acquisition context A.

RESULTS

The results indicated that renewal of the US expectancy ratings was reduced if imagery rescripting (ABAir) was added to mere extinction (ABAno). Next to the reduction in renewal, imagery rescripting (ABAir) also resulted in the devaluation of the US valence, indicating that the mental representation of the US had changed. These findings are not only in line with contemporary conditioning theories, but also suggest that adding imagery rescripting to extinction might be beneficial in the treatment of anxiety problems.