Three separate brief psychological interventions aimed at helping cancer patients cope with distress have shown improvements in quality of life and well-being across the continuum of cancer care. The interventions were studied—respectively—in newly diagnosed cancer patients, survivors after cancer treatment, and people living with advanced cancer. Results of the studies were presented at the 2017 ASCO Annual Meeting.
In all three studies, the support provided by the brief psychological interventions improved patient outcomes. Two of the interventions were delivered face-to-face by a therapist, and one was Web-based but also therapist-guided.
Newly Diagnosed Patients
Viviane Hess, MD
Taking advantage of the proclivity for the majority of cancer patients to use the Internet, a Web-based intervention called STREAM improved patients’ quality of life, reduced fatigue, and lowered stress in a study conducted in newly diagnosed cancer patients.1 STREAM is a therapist-guided intervention developed at the University Hospital of Basel in Switzerland, and this type of therapy is potentially accessible to anyone with a computer and an Internet connection.
“Seventy percent of cancer patients use the Internet to get information. This therapist-guided Web-based intervention overcomes many patient and physician barriers and seems similarly effective as face-to-face therapy for a variety of mental disorders, including anxiety and depression,” said lead author Viviane Hess, MD, a medical oncologist at the University Hospital of Basel.
“[The STREAM intervention] reduced distress and fatigue levels and improved quality of life.”— Viviane Hess, MD
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Within 12 weeks of initiating anticancer treatment, 129 patients with newly diagnosed cancer were randomized to an immediate Web-based intervention group or a control group (who received a delayed Web-based intervention). STREAM consists of 8 weekly modules with weekly written feedback (“minimal contact”) from a psychologist through a secure online portal. Patients are able to contact the psychologists directly via a chat function, if needed.
The modules are based on well-established cognitive behavioral approaches for stress management. The topics covered in the modules include bodily reaction to stress, cognitive stress reduction, feelings, and social interactions. For each weekly topic, participants received written and audio information and then completed exercises and questionnaires.
The majority of patients (84%) were female and treated in the curative setting (91%) for breast cancer (71%). The median age was 52 years.
Postintervention, patients in the intermediate intervention group had greater improvement in quality of life compared with the control group, according to the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) total score, which is based on 27 questions and yields a maximum score of 160. The mean FACIT-F score increased by 8.59 points more in the intervention group vs controls (P = .007, ANCOVA).
On the Distress Thermometer 10-point scale, the mean distress score decreased from 6 to 4 points in the intervention group but did not change from the baseline score of 6 in controls (P = .03, ANCOVA). No significant differences in anxiety or depression were observed between the two groups, according to the Hospital Anxiety and Depression Scale in the intervention-to-treat population.
“The study shows this intervention is feasible during active treatment and that we could recruit patients via the Internet. At baseline, 75% of patients had high levels of distress. This intervention reduced distress and fatigue levels and improved quality of life,” Dr. Hess said.
Fear of Recurrence
Jane Beith, MD, PhD
Fear of recurrence is common among cancer survivors, with about 50% of all survivors and 70% of young breast cancer survivors reporting moderate to high levels of fear of cancer recurrence over the trajectory of illness, which can affect mood, relationships, work, and quality of life. However, few interventions have addressed managing fear of recurrence directly.
A phase II randomized clinical trial reported at the ASCO Annual Meeting found that among people treated for cancer, those who received a psychological intervention called Conquer Fear had a significantly reduced fear of recurrence compared with controls undergoing relaxation training.2
“The reduction in fear of recurrence in the psychological intervention group was large enough to improve survivors’ psychological and emotional well-being,” said lead author Jane Beith, MD, PhD, a medical oncologist at the University of Sydney in Australia.
“In the future, we will explore ways to make [the Conquer Fear] intervention more accessible and less costly.”— Jane Beith, MD, PhD
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Developed by Dr. Beith and her colleagues, the Conquer Fear intervention is based on a theoretical framework and is currently a research tool. In the study, Conquer Fear was delivered by trained therapists in five 60-minute, individual, face-to-face sessions over 10 weeks. Sessions focused on accepting uncertainty around recurrence, teaching strategies to control worry, identifying future goals, and choosing and adhering to a sensible level of cancer screening.
The phase II trial randomly assigned 222 survivors of stage I to III breast cancer, colorectal cancer, or melanoma who had high levels of baseline fear of cancer recurrence to either the Conquer Fear intervention or to relaxation training. All survivors had completed treatment 2 months to 5 years earlier, and all were cancer-free at enrollment. They were assessed at baseline, end of intervention, and 3 months and 6 months post intervention.
Participants in both groups improved on all measures, but those in the Conquer Fear group had greater reductions in fear of recurrence as assessed by the 42-item Fear of Cancer Recurrence Inventory (FCRI). Immediately after the intervention, the average reduction in FCRI score was 18.1 points vs a 7.6-point reduction for controls (P < .001). The FCRI score continued to decrease over time in both groups, with significantly greater reductions observed at 3 and 6 months in the Conquer Fear group compared with the relaxation training group (P = .02, for both comparisons).
“This is one of the first studies to show a benefit from a psychological intervention in cancer patients,” Dr. Beith noted. “In the future, we will explore ways to make this intervention more accessible and less costly.”
Patients With Advanced Cancer
Gary Rodin, MD
A randomized controlled trial found that an intervention called Managing Cancer and Living Meaningfully (CALM), which was specifically developed for individuals with advanced cancer, improved depressive symptoms and made it less likely that patients would develop depressive symptoms compared with usual care at 3 and 6 months post intervention.3
CALM is a brief talking therapy that provides 3 to 6 individualized 45- to 60-minute sessions delivered by a trained therapist over a period of 3 to 6 months. The intervention focuses on four broad domains that encompass symptom control, medical decision-making, and relationships with health-care providers; changes in self-concept and personal relationships; spiritual well-being and sense of meaning and purpose in life; and future-oriented concerns, hope, and mortality.
“CALM addresses practical and profound existential concerns facing people with advanced cancer. It is distinct from other interventions in that it is meant to help patients live with advanced cancer, not only prepare them for the end of life,” explained lead author Gary Rodin, MD, Head of the Department of Supportive Care at the Princess Margaret Cancer Centre in Toronto. Dr. Rodin and colleagues developed CALM, and they plan to broaden this approach to other centers.
“CALM is distinct from other interventions in that it is meant to help patients live with advanced cancer, rather than prepare them for the end of life.”— Gary Rodin, MD
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The study included 305 patients with advanced cancer randomized to CALM plus usual care or to usual care alone (controls). At 3 months, 52% of patients in the CALM group had a clinically important reduction in severity of depressive symptoms compared with 33% of patients who received usual care. At 6 months, 65% of CALM patients vs 35% of controls had a clinically important reduction in depressive symptom severity.
Moreover, CALM participants who were not depressed at baseline were less likely to become depressed at 3 months. Among these patients, 13% in the CALM group vs 30% in the usual-care group had depressive symptoms at 3 months.
“This approach is generalizable. We are establishing a global network to deliver CALM and evaluate its effectiveness in many countries around the world,” Dr. Rodin noted.
DISCLOSURE: Drs. Hess, Beith, and Rodin reported no conflicts of interest. ■
1. Hess V, Grossert A, Alder J, et al: Web-based stress management for newly diagnosed cancer patients (STREAM): A randomized, wait-list, controlled intervention study. 2017 ASCO Annual Meeting. Abstract LBA10002. Presented June 2, 2017.
2. Beith JM, Thewes B, Turner J, et al: Long-term results of a phase II randomized controlled trial of a psychological intervention (Conquer Fear) to reduce clinical levels of fear of cancer recurrence in breast, colorectal, and melanoma cancer survivors. 2017 ASCO Annual Meeting. Abstract LBA10000. Presented June 2, 2017.
3. Rodin G, Lo C, Rydall A, et al: Managing cancer and living meaningfully (CALM): A randomized controlled trial of a psychological intervention for patients with advanced cancer. 2017 ASCO Annual Meeting. Abstract LBA10001. Presented June 2, 2017.
Richard L. Schilsky, MD (left)
Don Dizon, MD
“[THE STREAM, Conquer Fear, and CALM] studies focus on the psychosocial aspects of coping with cancer. One theme that binds them is that oncologists take pride in the fact that we treat people with cancer [with the emphasis on people]...!-->!-->!-->!-->