Immunotherapies and targeted therapies have revolutionised treatment of metastatic melanoma and improved survival rates. However, survivors treated with novel therapies are vulnerable to high levels of fear of cancer recurrence or progression (FCR). Existing FCR interventions have rarely been trialled in people with advanced cancer. The current study aimed to evaluate the acceptability and feasibility of Fear-Less: a stepped-care model to treat FCR in people with metastatic melanoma treated with immunotherapy or targeted therapy. Sixty-one outpatients with metastatic melanoma were screened using the Fear of Cancer Recurrence Inventory Short Form (FCRI-SF) and Fear of Progression Questionnaire Short Form (FoP-Q-SF). Survivors with subthreshold FCR were stratified to a self-management intervention while those with clinical levels of FCR were provided with an individual therapy, Conquer Fear. Survivor experience surveys and rescreening were administered post-intervention completion. Results indicated that Fear-Less was an acceptable and feasible FCR intervention. Results provided preliminary support for the potential impact of Fear-Less in reducing FCR. Fear-Less is a promising first step in providing an acceptable and feasible stepped-care model to treat FCR in survivors with metastatic disease.

This is one of a series of occasional articles on therapeutics for common or serious conditions, covering new drugs and old drugs with important new indications or concerns. The series advisers are Robin Ferner, honorary professor of clinical pharmacology, University of Birmingham and Birmingham City Hospital, and Philip Routledge, professor of clinical pharmacology, Cardiff University. To suggest a topic for this series, please email us at practice@bmj.com.A 51 year old woman presents to her general practitioner with troublesome hot flushes and night sweats for the past eight months. She is sexually active and her last period was about 5 months ago. She has taken a number of over-the-counter preparations, but none have been effective. She is anxious about having hot flushes at work and exhausted from sleep disturbance. She wants advice about managing her symptoms. What is hormone replacement therapy?Menopause is a normal physiological event in women, occurring at a median age of 51 years. Hormone replacement therapy (HRT) contains oestrogen for relieving menopausal symptoms; for women who still have their uterus it is combined with a progestogen for endometrial protection. The oestrogen (oestradiol, oestradiol 17β, oestrone, or conjugated equine oestrogen) can be oral, intravaginal, or transdermal. The progestogen can be oral, transdermal, or delivered via an intrauterine device (Mirena, Bayer Schering). In HRT regimens the oestrogen is taken daily, with progestogen added either sequentially (cyclic regimen) or daily (continuous combined regimen) if it is needed. 1 Tibolone is an oral synthetic steroid preparation with oestrogenic, androgenic, and progestogenic actions that can also be used as HRT. Testosterone can be added to HRT, but the role of supplemental testosterone will not be covered in this case.The key indication for HRT or tibolone is the presence of troublesome vasomotor symptoms (hot flushes and night sweats, with or without awakening). Vasomotor symptoms are normal and affect about 80% of women during the menopause transition and are severe in about 20% of these women. The duration of these symptoms varies, with a median of four years, but may continue for as many as 12 years in about 10% of women. 2 HRT may be indicated when menopausal symptoms are adversely affecting quality of life. How well does HRT work?HRT is currently the most effective treatment for troublesome vasomotor symptoms. A systematic review showed a significant mean reduction in the frequency of hot flushes by around 18 a week and in the severity of hot flushes by 87% compared with placebo. 3 Large randomised controlled trials have confirmed that HRT also significantly reduces fracture risk, improves vaginal dryness and sexual function, and may also improve sleep, muscle aches and pains, and quality of life in symptomatic women. 4 5 The figure⇓ provides the estimated absolute benefits from HRT use in postmenopausal women aged 50-59 years or <10 years after menopause, based on background risk in American women, 6 using data from t...

The lack of a male predominance typical of SIDS cases in infants who were sleeping with others, compared to those who were sleeping alone, suggests that these situations may be different. It is possible, therefore, that different lethal mechanisms may be involved in some shared sleeping situations.

Although, there was a trend towards higher brain-body weight ratios in SIDS infants, this did not reach significance. The role of brain weight in the aetiology of SIDS remains controversial.

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