A Novel Intervention to Reduce Fear of Progression and Trauma Symptoms in Advanced Cancer Using Written Exposure to Worst-Case Scenarios.

Background: Adults with advanced cancer experience profound future uncertainty, reflected in elevated fear of cancer progression (FoP) and cancer-related trauma symptoms. These symptoms are associated with physical symptom burden and poorer quality of life, and few interventions exist to manage them. Objective: To develop and pilot a written exposure-based coping intervention (EASE) focused on worst-case scenarios among adults with advanced cancer reporting elevated cancer-related trauma symptoms or FoP. Design: A single-arm intervention development and pilot trial. Participants: The trial enrolled 29 U.S. adults with stage III or stage IV solid tumor cancer (n = 24) or incurable or higher-risk blood cancer (n = 5) reporting elevated cancer-related trauma symptoms or FoP. Among those screened, 74% were eligible, with an eligible-to-enrolled rate of 85%. Design/Measurements: EASE was delivered over five 1:1 videoconferencing sessions. Feasibility and acceptability were evaluated via attendance, surveys, and exit interviews. Outcomes were assessed at five time points through 3-month (FU1, main assessment of interest) and 4.5-month (FU2) follow-up. Results: Participant and interventionist feedback was used to iteratively refine EASE. Among participants, 86% (25/29) completed all five sessions and FU1; surveys and exit interviews indicated high acceptability. Primary outcomes of cancer-related trauma symptoms and FoP improved significantly from pre to both follow-ups by predominantly large effect sizes. Secondary outcomes of anxiety, depression, hopelessness, fear of death/dying, and fatigue, and most process measures improved significantly by FU1 or FU2. Conclusions: EASE, a novel adaptation of written exposure therapy, is a promising approach to reducing FoP and cancer-related trauma symptoms among adults with advanced cancer that warrants further study.

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.

Evaluating the efficacy of common humanity-enhanced exposure for socially anxious young adults.

Despite some evidence of the benefits of self-compassion training among socially anxious individuals, little is known about whether enhancing self-compassion prior to exposure therapy increases initial exposure engagement. Additionally, manipulations have relied on broad definitions of self-compassion, rendering it difficult to distinguish the impact of individual components. This study employed three experiential exercises designed to enhance one facet of self-compassion-common humanity. Socially anxious undergraduates (N = 63) were randomized in groups to 1) common humanity-enhanced exposure (n = 32) or 2) exposure alone (n = 31). In the common humanity condition, participants wrote self-compassionately, shared fears, and completed a common humanity-focused lovingkindness meditation. All participants then completed a speech exposure in front of live judges followed by an optional second exposure. Within the common humanity condition, positive self-responding to the speech exposure increased (b = 0.30, p = .026). Common humanity participants also remained in the first exposure longer, relative to exposure alone (b = -30.92, p = .002). Participants rated exercises as at least moderately helpful, with sharing fears rated most helpful. In sum, a brief group-based multi-modal common humanity induction represents a promising approach to improving initial engagement with feared contexts among socially anxious individuals.

Interpretation Bias in Breast Cancer Survivors Experiencing Fear of Cancer Recurrence.

Introduction: Fear of cancer recurrence (FCR) is a prevalent and persistent challenge that many cancer survivors endure. While the role of interpretation bias, a tendency to perceive ambiguous situations as threatening, has been established in the onset and maintenance of FCR, few studies have examined cancer-related interpretation bias specifically. Grounded in the cognitive formulation of FCR, the current study aimed to fill this gap by investigating the relationship between cancer-related interpretation bias, FCR, and somatic symptoms, and examining whether bias mediates the relationship between somatic symptoms and FCR. Materials and Methods: This study used baseline data from a randomized controlled trial of a cognitive bias modification intervention. Breast cancer survivors (n = 110) provided demographic and medical background information as well as self-report measures of FCR and severity of somatic symptoms. A computer-based assessment of interpretation bias was used to measure cancer-related interpretation bias on several bias indices: percentage of cancer-related threat endorsement, and percentage of benign endorsement; mean reaction time (RT) for threat, and mean RT for benign endorsement. Results: Higher threat endorsement was linked to higher Overall Fear and emerged as a mediator of the relationship between overall somatic symptoms and Overall Fear. We also found that older age was related to longer benign endorsement RT. Conclusion: This study contributes understanding of factors related to cancer-related interpretation bias and provides evidence that bias may influence the relationship between somatic symptoms and FCR in cancer survivors.

Cancer survivors' perceived vulnerability to COVID-19 and impacts on cognitive, affective, and behavioral responses to the pandemic.

STUDY OBJECTIVES: Given the uncertainty COVID-19 has caused for individuals with prior medical conditions, we examined the extent to which cancer survivors consider themselves at risk for the global COVID-19 pandemic (henceforth COVID), both in general and due to their cancer history. Additionally, we evaluated whether perceived vulnerability to COVID among cancer survivors predicts their cognitive/affective and behavioral responses to the pandemic. DESIGN/SAMPLE: Cancer survivors who completed primary cancer treatment (median months since treatment = 33.00) and were enrolled in prior behavioral trials with our research team (N = 146) completed two surveys in May-July 2020 (95.89% retention). METHODS: Participants rated perceived next-year risk of infection and of dying from COVID. We adapted established scales to assess perceived vulnerability to COVID generally versus as a cancer survivor, catastrophizing about possible COVID symptoms, COVID-related contamination fears, and adherence to COVID prevention behaviors. FINDINGS: In May 2020, on a 1-100 scale with 0 = no chance and 100 = definitely will occur, cancer survivors reported a chance in the next year of contracting COVID of M = 39.94 (SD = 23.90), and dying from COVID of M = 24.46 (SD = 24.84). Cancer survivors reported somewhat greater vulnerability to COVID compared to same-aged peers, increased contamination fears, and high adherence to COVID prevention measures. Similar findings emerged six weeks later, suggesting stability over time. In simple linear regression models, both general and cancer survivor-specific perceived COVID vulnerability predicted COVID symptom catastrophizing and contamination fears; in multivariable models, only general vulnerability remained a significant predictor. General perceived vulnerability and contamination fears predicted greater adherence to COVID prevention behaviors. CONCLUSIONS: Cancer survivors perceived elevated vulnerability to COVID even years after treatment, which predicted adherence to COVID prevention behaviors. Future research should identify the optimal balance between supporting cancer survivors' concerns and minimizing negative impacts on quality of life.

Bereavement risk screening: A pathway to psychosocial oncology care.

OBJECTIVE: This qualitative study sought to obtain feedback from stakeholder cancer caregivers and bereaved family members on the implementation of bereavement risk screening in oncology. METHODS: Semi-structured interviews were conducted with 38 family members of patients with advanced cancer (n = 12) and bereaved family members (n = 26) on when and how to effectively implement bereavement risk screening. Data were analyzed using thematic analysis. RESULTS: Many participants indicated that they would be open to completing a self-report screening measure before and after the patient's death. Several suggested screening at multiple timepoints and the importance of follow-up. Participants viewed screening as an opportunity to connect to psychosocial support. CONCLUSIONS: The findings suggest that family members appear supportive of sensitively approached bereavement risk screening before and after a patient's death as an important component of quality psychosocial care. To optimize implementation, bereavement risk screening would involve screening at multiple timepoints and include follow-up. Findings suggest standardized risk screening using a brief, validated self-report tool would be a pragmatic approach to increasing access to bereavement care.

Acceptability, Feasibility, and Efficacy Potential of a Multimodal Acceptance and Commitment Therapy Intervention to Address Psychosocial and Advance Care Planning Needs among Anxious and Depressed Adults with Metastatic Cancer.

Background: Adults with metastatic cancer frequently report anxiety and depression symptoms, which may impact health behaviors such as advance care planning (ACP). Objective: The study leveraged acceptance and commitment therapy (ACT), an evidence-based approach for reducing distress and improving health behaviors, and adapted it into a multimodal intervention (M-ACT) designed to address the psychosocial and ACP needs of anxious and depressed adults with metastatic cancer. The study evaluated M-ACT's acceptability, feasibility, and efficacy potential. Design: The study was designed as a single-arm intervention development and pilot trial. Setting/Subjects: The trial enrolled 35 anxious or depressed adults with stage IV cancer in community oncology clinics, with a referred-to-enrolled rate of 69% and eligible-to-enrolled rate of 95%. Measurements: M-ACT alternated four in-person group sessions with three self-paced online sessions. Acceptability and feasibility were assessed through enrollment, attendance, and satisfaction ratings. Outcomes and theorized intervention mechanisms were evaluated at baseline, midintervention, postintervention, and two-month follow-up. Results: Participant feedback was used to refine the intervention. Of participants starting the intervention, 92% completed, reporting high satisfaction. One-quarter did not begin M-ACT due to health declines, moving, or death. Completers showed significant reductions in anxiety, depression, and fear of dying and increases in ACP and sense of life meaning. In this pilot, M-ACT showed no significant impact on pain interference. Increases in two of three mechanism measures predicted improvement on 80% of significant outcomes. Conclusions: The M-ACT intervention is feasible, acceptable, and shows potential for efficacy in community oncology settings; a randomized trial is warranted.

Presence and predictors of anxiety disorder onset following cancer diagnosis among anxious cancer survivors.

PURPOSE: Despite cancer survivors' frequent endorsement of anxiety symptoms, assessing the full range of anxiety disorders (AD), their timing of onset relative to cancer diagnosis, co-morbidity with mood disorder, and predictors of post-cancer onset, is rare or absent to date. This study provides a step toward addressing these gaps. METHODS: Cancer survivors at re-entry after primary treatment completion who screened positively for anxiety symptoms (N = 133) and sought care through an intervention trial completed standardized diagnostic interviews, dimensional assessment of disorder severity, and timing of disorder onset relative to cancer diagnosis. We evaluated sociodemographic and medical predictors of developing a first AD after cancer diagnosis. RESULTS: Most ADs began after cancer diagnosis (58%); for 68% of affected patients, this represented their first AD episode. The most common was generalized anxiety disorder (GAD; 41%), where "cancer-focused GAD" was distinguished from "typical GAD"; the next most common were specific phobia (14%) and social anxiety disorder (13%). A minority (31%) of ADs were comorbid with major depression. Relative to having no AD, experiencing more lingering treatment side effects predicted developing a first AD after cancer diagnosis. Relative to having an AD that began before cancer diagnosis, reporting a higher cancer stage predicted developing a first AD after diagnosis. CONCLUSIONS: Cancer survivors at re-entry seeking care for anxiety symptoms manifested a broad range of ADs which most commonly developed after cancer diagnosis and were prompted by the experience of cancer. Such disorders represent an unusually late-life, cancer-linked etiology that warrants further investigation and clinical attention.

An open trial of meaning-centered grief therapy: Rationale and preliminary evaluation.

OBJECTIVE: To determine the preliminary feasibility, acceptability, and effects of Meaning-Centered Grief Therapy (MCGT) for parents who lost a child to cancer. METHOD: Parents who lost a child to cancer and who were between six months and six years after loss and reporting elevated levels of prolonged grief were enrolled in open trials of MCGT, a manualized, one-on-one cognitive-behavioral-existential intervention that used psychoeducation, experiential exercises, and structured discussion to explore themes related to meaning, identity, purpose, and legacy. Parents completed 16 weekly sessions, 60-90 minutes in length, either in person or through videoconferencing. Parents were administered measures of prolonged grief disorder symptoms, meaning in life, and other assessments of psychological adjustment preintervention, mid-intervention, postintervention, and at three months postintervention. Descriptive data from both the in-person and videoconferencing open trial were pooled.ResultEight of 11 (72%) enrolled parents started the MCGT intervention, and six of eight (75%) participants completed all 16 sessions. Participants provided positive feedback about MCGT. Results showed postintervention longitudinal improvements in prolonged grief (d = 1.70), sense of meaning (d = 2.11), depression (d = 0.84), hopelessness (d = 1.01), continuing bonds with their child (d = 1.26), posttraumatic growth (ds = 0.29-1.33), positive affect (d = 0.99), and various health-related quality of life domains (d = 0.46-0.71). Most treatment gains were either maintained or increased at the three-month follow-up assessment.Significance of resultsOverall, preliminary data suggest that this 16-session, manualized cognitive-behavioral-existential intervention is feasible, acceptable, and associated with transdiagnostic improvements in psychological functioning among parents who have lost a child to cancer. Future research should examine MCGT with a larger sample in a randomized controlled trial.

Beyond the bucket list: Unfinished and business among advanced cancer patients.

OBJECTIVE: The study aims to examine the prevalence and common themes of unfinished business (UB) and its associations with distress among advanced cancer patients. METHODS: A total of 223 patients from a larger randomized controlled trial of Individual Meaning-Centered Psychotherapy (IMCP) completed self-report questionnaires that assessed UB and UB-related distress, hopelessness, desire for hastened death, anxiety and depression, quality of life, spiritual well-being, and purpose/meaning. Unfinished business themes were identified by qualitative analysis of open-ended data. RESULTS: A total of 161 (72%) patients reported the presence of UB. The mean UB-related distress score was 7.01 (SD = 2.1) out of 10. Results of independent t tests showed that patients with UB reported significantly higher levels of anxiety and lower levels of existential transcendence than patients without UB. Linear regression equations indicated that UB-related distress significantly predicted hopelessness (F1,154  = 9.54, P < 0.05, R2  = 0.058), anxiety (F1,154  = 4.31, P < 0.05, R2  = 0.027), personal meaning (F1,136  = 6.18, P < 0.05, R2  = 0.043), and existential transcendence (F1,119  = 6.7, P < 0.05, R2  = 0.053). Ten UB themes emerged from open-ended responses; UB themes were not associated with UB-related distress or psychological adjustment. CONCLUSIONS: Unfinished business was both prevalent and distressing in our sample. Findings underscore the need to develop and implement interventions designed to help patients resolve or find solace with UB.

A pilot randomized controlled trial of cognitive bias modification to reduce fear of breast cancer recurrence.

BACKGROUND: The most common, persistent concern among survivors of breast cancer is the fear that their disease will return, yet to the authors' knowledge, few interventions targeting fear of cancer recurrence (FCR) have been developed to date. The current pilot study examined the feasibility, acceptability, and preliminary efficacy of a home-delivered cognitive bias modification intervention to reduce FCR. The intervention, called Attention and Interpretation Modification for Fear of Breast Cancer Recurrence (AIM-FBCR), targeted 2 types of cognitive biases (ie, attention and interpretation biases). METHODS: A total of 110 survivors of breast cancer were randomized to receive 8 sessions of 1 of 2 versions of AIM-FBCR or a control condition program. Computer-based assessments of cognitive biases and a self-report measure of FCR were administered before the intervention, after the intervention, and 3 months after the intervention. RESULTS: Improvements in health worries (P = .019) and interpretation biases (rates of threat endorsement [P<.001] and reaction times for threat rejection [P = .007]) were found in those survivors who received AIM-FBCR compared with the control arm. Although only 26% of participants who screened into the study agreed to participate, the trial otherwise appeared feasible and acceptable, with 83% of those who initiated the intervention completing at least 5 of 8 sessions, and 90% reporting satisfaction with the computer-based program used. CONCLUSIONS: The results of the current pilot study suggest the promise of AIM-FBCR in reducing FCR in survivors of breast cancer. Future research should attempt to replicate these findings in a larger-scale trial using a more sophisticated, user-friendly program and additional measures of improvement in more diverse samples. Cancer 2017;123:1424-1433. © 2016 American Cancer Society.