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

Abstract

Background: Fear of cancer recurrence or progression (FCR) is common amongst cancer survivors and an important minority develop clinically significant levels of FCR. However, it is unclear how current clinical services might best support the growing numbers of cancer survivors. Purpose: The aim of this study is to develop recommendations for future research in the management of FCR and propose a model of care to help manage FCR in the growing population of cancer survivors. Methods: This is a narrative review and synthesis of empirical research relevant to managing FCR. We reviewed meta-analyses, systematic reviews and individual studies that had investigated interventions for FCR. Results: A recent, well-conducted meta-analysis confirmed a range of moderately effective treatments for FCR. However, many survivors continued to experience clinical levels of FCR after treatment, indicating a clear need to improve the gold standard treatments. Accessibility of interventions is arguably a greater concern. The majority of FCR treatments require face-to-face therapy, with highly skilled psycho-oncologists to produce moderate changes in FCR. With increasing numbers of cancer survivors, we need to consider how to meet the unmet need of cancer survivors in relation to FCR. Although there have been attempts to develop minimal interventions, these are not yet sufficiently well supported to warrant implementation. Attempts to help clinicians to provide information which might prevent the development of clinically significant FCR have shown some early promise, but research is needed to confirm efficacy. Conclusion:The next decade of research needs to focus on developing preventative approaches for FCR, and minimal interventions for those with mild-to-moderate symptoms. When evidence-based approaches to prevent FCR or manage moderate levels of FCR are available, stepped care approaches that could meet the needs of survivors could be implemented. However, we also need to improve existing interventions for severe FCR.

Study protocol for the evaluation of Fear-Less: a stepped-care program for fear of cancer recurrence in survivors with early-stage disease

“…Support for FCR remains a significant unmet need for cancer survivors, where systemic barriers to identifying and treating FCR include lack of routine screening and limited resources to provide interventions for individuals experiencing FCR [ 22 , 23 ]. Specific strategies, such as a stepped-care approach and the refinement of interventions included in this approach, may provide a solution to these barriers [ 26 ].…”

“…This approach involves offering treatments of differing intensity tailored to survivors’ level of symptoms that can be identified through routine screening. For mild-to-moderate symptoms, a low-intensity intervention is offered that is accessible and convenient for survivors and requires minimal specialist time to deliver [ 25 , 26 ]. Examples include brief therapy or a self-help approach.…”

“…Similar benefits may accrue for FCR, where a stepped-care approach provides a framework to support FCR screening and appropriate referrals to treatment. This approach has been recommended by Cancer Australia (Australia’s peak national government cancer agency) to manage FCR [ 31 ] and could improve accessibility to FCR treatment, given most oncology services have limited clinical resources to support all survivors with heightened FCR [ 24 , 26 ]. In this model, the more intensive intervention (e.g., ConquerFear) is reserved for people with clinical FCR.…”

“…Lower intensity interventions can then be offered to survivors experiencing mild-to-moderate levels of FCR. Currently, there is no consensus regarding the type of low-intensity intervention that would be best suited to treat FCR [ 26 ]. One option is a guided self-management, which has shown promise for improving FCR.…”

Feasibility and preliminary efficacy of iConquerFear: a self-guided digital intervention for fear of cancer recurrence

“…Clearer explanation of what iConquerFear involves, how to best use the intervention and more prominent links to in-person support may help increase uptake and engagement. Self-guided interventions may be best suited to people with moderate FCR, with more intensive approaches better suited to those with severe FCR [ 62 ]. Stepped/matched care FCR treatment models, where patients are allocated to interventions they are most likely to engage with and benefit from based on FCR severity, have demonstrated promise in FCR management [ 63 ].…”