Towards a Stepped Care Model for Managing Fear of Cancer Recurrence or Progression in Cancer Survivors

Figures & data

Table 1 Study Characteristics and Results of Included Papers

	Sample Size	Type of Cancer	No. of Arms	Delivery Mode	Intervention	Outcomes	Effect Size
							Cohen’s d (Time of Assessment)
I.Psychoeducation and preventative interventions
Pradhan et al (2021)^Citation38	62	Ovarian Cancer	Single-arm	Online: Psychoeducational booklet	Psychoeducation: Online PDF booklet.	No effect on fear of progression	0.17
							1 week
Liu et al (2021)^Citation32	61	Breast Cancer	Single-arm	Face-to-face	Oncologist delivered preventative intervention	FCR reduced	0.39 (1 month)
							0.68 (3 months)
Dieng et al (2016)^Citation40	164	Melanoma	Two	Psychoeducational booklet	Psychoeducation plus psychodynamic-based psychotherapy	FCR reduced	0.5 (1 month)
							0.3 (6 months)
				3 Telephone sessions
Sterba et al (2015)^Citation83	92	Breast Cancer	Two	Mixed	In-person video sessions and educational booklets	No effect on cancer-related worries	−0.22
II.Self-help and internet-delivered interventions
Otto et al (2017)^Citation42	67	Breast Cancer	Two	Online	Positive psychology: Gratitude intervention	No effect on FCR	0.21 (1 month)
							0.1 (3 months)
Lichtenthal et al (2017)^Citation43	110	Breast Cancer	Two	Online	Cognitive Bias Modification (Interpretation and Attention)	No effect of Cancer Worry Scale	0.35
							Post-treatment
							0.54 (3 months)
van Helmondt et al, (2020)^Citation49	262	Breast Cancer	Two	Online	Cognitive behaviour therapy	No effect on FCR	Not reported
Omidi et al (2020)^Citation39	105	Breast Cancer	Three	Face to face	Group and social network-based self-management education on lymphedema	No effect on FCR	Group education: 0.21
				Online
							Social Network-based education: 0.06 (3 months)
Dirkse et al (2019)^Citation54	86	Multiple	Two	Face to face	Cognitive behaviour therapy	Reduction in FCR	0.93–0.85 (1 month)
				Online
Lengacher et al (2018)^Citation76	15	Breast Cancer	Single-arm	Online	Mobile-based Mindfulness Stress Reduction for Breast Cancer	Improvements in fear of recurrence at 6 weeks follow-up	0.74
Germino et al (2012)^Citation71	313	Breast Cancer	Two	Self-directed	Traditional CBT	No significant improvement in FCR was reported.	Not reported
III.Health-care professionals led interventions
Humphris & Rogers (2012)^Citation25	90	Head and Neck	Two	Face to face, nurse-led	Cognitive behavioural therapy	FCR reduced during treatment, improvement not maintained	0.56 (3 months)
Shields et al (2010)^Citation31	44	Breast Cancer	Two	Single session, tele-coaching	Encourage patients to raise top 3 concerns with oncologist	No effect on FCR	−0.13
Reb et al (2020b)^Citation34	31	Gynaecology	Single-arm	In person and online	Contemporary CBT, hybrid online and face-to-face	Reduction in FoP at 8 and 12 weeks after intervention.	1.3 (8 weeks)
		Lung Cancer
IV.Intensive specialist care
Herschbach et al (2010)^Citation24	265	Multiple	Three	Face to face	CBT and SET (based on personal experiences)	Reduction in FoP scores after 12 months for both intervention groups.	CBT: 0.61
							SET: 0.56 (12 months)
Butow et al (2017)^Citation26	222	Multiple	Two	Face to face	Contemporary CBT and relaxation training	Improvements in both total FCR-I and severity subscale	0.33 (3 months)
							0.39 (6 months)
Van de Wal et al (2017)^Citation28	88	Multiple	Two	Mixed: Face-to-face and online sessions	Blended cognitive behaviour therapy	Improvements in FCR at 3 months post intervention.	0.76
Bannaasan et al (2015)^Citation64	59	Breast Cancer	Two	Face-to-face	Buddhist doctrine-based practice	Reduction in FCR scores after 1 month.	1.38 (1 month)
Tomei et al (2018)^Citation84	25	Multiple	Two	Face to face	Traditional CBT	Reduction in FCR at post-intervention	0.28
Cameron et al (2007)^Citation66	154	Breast Cancer	Two	Face to face	Contemporary CBT for emotional regulation and adjustment	Decrease in cancer recurrence worries after 4 months, not maintained after 6 and 12 months.	0.59
Lengacher et al (2009)^Citation22	84	Breast Cancer	Two	Face to face	Mindfulness-based stress reduction	Improvement in FCR after 6 weeks.	0.6
Crane-Okada et al (2012)^Citation68	49	Breast Cancer	Two	Face to face	Mindful movement program intervention	Decrease in FCR at 6 weeks	0.57
Heinrichs et al (2012)^Citation22	72	Breast and Gynaecological cancer	Two	Face to face	Couple based coping intervention	Decrease in FoP for intervention participants	0.57
Bower et al (2015)^Citation65	71	Breast Cancer	Two	Face to face	Mindfulness-based intervention	Improvements in FCR at 3 month follow-up in intervention group	1.39
Dodds et al (2015)^Citation70	33	Breast Cancer	Two	Face to face	Meditation-based program called CBCT	Reduction in FCR in intervention group	−1.38
Lengacher et al (2016)^Citation75	322	Breast Cancer	Two	Face to face	Mindfulness-Based Stress Reduction for Breast Cancer	Improvements in FCR at 6 and 12 week follow-up	0.3 (6 weeks)
							0.28 (12 weeks)
Merckaert et al (2016)^Citation78	159	Breast Cancer	Two	Face to face	CBT and hypnosis	Reduction in FCR severity post intervention	0.33
Manne et al (2017)^Citation77	352	Gynaecological Cancer	Three	Face to face and 1 telephone session	Communication-enhancing intervention (CCI) and supportive counselling (SC)	No effect on FCR	0.11
Victorson et al (2016)^Citation85	43	Prostate	Two	Face to face	Mindfulness Based Stress Reduction	Reduction in recurrence fears	0.15
Gonzalez-Hernandez et al (2018)^Citation72	56	Breast Cancer	Two	Face to face	Compassion-based intervention	Reduction in FCR related stress at post-intervention and 6 mth follow-up	0.68 (post-intervention)
							0.46 (6 months)
Chambers et al (2012)^Citation67	19	Prostate	Single-arm	Face to face	Mindfulness-based cognitive therapy group intervention	Reduction in FCR	0.28
Lebel et al (2014)^Citation74	56	Breast and ovarian cancer	Single-arm	Face to face	Cognitive-existential (CE) group intervention	Reduction in FCR	0.73
Seitz et al (2014)^Citation81	20	Multiple cancers	Single-arm	Online	Traditional CBT	Decrease in FoP	0.48
Smith et al (2015)^Citation82	8	Multiple cancers	Single-arm	Face to face	Contemporary CBT	Reduction in overall FCR scores and severity subscale at 2-month follow-up	FCR Severity: 1.9
							FCRI-Total: 1.8
Arch & Mitchell (2015)^Citation63	42	Multiple cancers	Single-arm	Face to face	ACT	FCR decreased at post intervention, but 1 mth follow-up	0.66 (post-treatment)
							0.11 (1 month)
Momino et al (2017)^Citation79	40	Breast	Single-arm	Face to face	Collaborative care and need-based intervention	No effect on FCR	0.15
				Telephone sessions
Savard et al (2018)^Citation80	33	Multiple cancers	Single-arm	Face to face	Group-based CBT	Significant decrease in FCR at post-treatment	Not reported
Davidson et al (2018)^Citation69	16	Breast Cancer	Single-arm	Telephonic sessions	Intervention based on CBT	Decrease in FCR after 1 week follow-up	0.8
Johns et al (2019)^Citation73	91	Breast Cancer	Three	Face to face	Group-based ACT and Survivorship education	Significant decrease in FCR severity in ACT group	0.61 (6 months)
Stepped care
Lynch et al (2020)^Citation56	61	Melanoma	Single-arm	Mixed	Three step intervention: (1) Treatment as usual; (2) Self-management intervention (3) Individual therapy: contemporary CBT.	Contemporary CBT reduced FCR and FoP.	Self-management-0.11 for FCR
							0.02 for FoP
							Individual therapy
							0.64 FCR
							0.4 FOP

Abbreviations: ACT, Acceptance and Commitment Therapy; AFTER, adjustment to the fear expectation or threat of recurrence; bCBT, blended cognitive behavioural therapy; CAREST, cancer recurrence self-help training; CAU, care as usual; CBT, cognitive-behavioral group therapy; CBCT, Cognitively–Based Compassion training; FCR, fear of cancer recurrence; FoP, fear of progression; MCT, meta-cognitive therapy; SET, supportive-experiential therapy; S-REF, Self-Regulation of Executive Function.

Figure 1 Stepped care model to fear of cancer recurrence/progression in oncology services.

Table 2 Recommendations to Guide Future Research

Recommendations for Future Research
1. Development and evaluation of universal minimal interventions (eg clinician-delivered, psychoeducational interventions, informational resources, apps) designed to help prevent FCR.
2. Development and evaluation of minimal interventions (eg internet-delivered treatments) that are targeted for those with mild to moderate FCR
3. Up-skilling oncology professionals to deliver interventions targeting FCR in routine clinical practice.
4. Research to improve existing interventions for severe FCR.
5.Adapting available evidence-based FCR interventions for those with advanced disease.
6. Testing models of stepped care to develop the most efficacious and highly implementable service model.

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