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.

Acceptance and Commitment Therapy Processes and Mediation: Challenges and How to Address Them.

Acceptance and commitment therapy (ACT) emphasizes a focus on theory-driven processes and mediating variables, a laudable approach. The implementation of this approach would be advanced by addressing five challenges, including (a) distinguishing ACT processes in measurement contexts, (b) developing and rigorously validating measures of ACT processes, (c) the wide use of psychometrically weaker ACT process measures and the more limited use of stronger measures in earlier work, (d) the inconsistency of past evidence that ACT processes are sensitive or specific to ACT or mediate ACT outcomes specifically, and (e) improving statistical power and transparency. Drawing on the existing literature, we characterize and provide evidence for each of these challenges. We then offer detailed recommendations for how to address each challenge in ongoing and future work. Given ACT's core focus on theorized processes, improving the measurement and evaluation of these processes would significantly advance the field's understanding of ACT.

Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations.

PURPOSE: Providers treating adults with advanced cancer increasingly seek to engage patients and surrogates in advance care planning (ACP) and end-of-life (EOL) decision making; however, anxiety and depression may interfere with engagement. The intersection of these two key phenomena is examined among patients with metastatic cancer and their surrogates: the need to prepare for and engage in ACP and EOL decision making and the high prevalence of anxiety and depression. METHODS: Using a critical review framework, we examine the specific ways that anxiety and depression are likely to affect both ACP and EOL decision making. RESULTS: The review indicates that depression is associated with reduced compliance with treatment recommendations, and high anxiety may result in avoidance of difficult discussions involved in ACP and EOL decision making. Depression and anxiety are associated with increased decisional regret in the context of cancer treatment decision making, as well as a preference for passive (not active) decision making in an intensive care unit setting. Anxiety about death in patients with advanced cancer is associated with lower rates of completion of an advance directive or discussion of EOL wishes with the oncologist. Patients with advanced cancer and elevated anxiety report higher discordance between wanted versus received life-sustaining treatments, less trust in their physicians, and less comprehension of the information communicated by their physicians. CONCLUSION: Anxiety and depression are commonly elevated among adults with advanced cancer and health care surrogates, and can result in less engagement and satisfaction with ACP, cancer treatment, and EOL decisions. We offer practical strategies and sample scripts for oncology care providers to use to reduce the effects of anxiety and depression in these contexts.

A Systematic Review and Meta-Analysis of Interventions to Promote Adjuvant Endocrine Therapy Adherence Among Breast Cancer Survivors.

PURPOSE: Adjuvant endocrine therapy (AET) adherence among breast cancer survivors is often suboptimal, leading to higher cancer recurrence and mortality. Intervention studies to promote AET adherence have burgeoned, more than doubling in number since this literature was last reviewed. The current aim is to provide an up-to-date systematic review and meta-analysis of interventions to enhance AET adherence and to identify strengths and limitations of existing interventions to inform future research and clinical care. METHODS: Systematic searches were conducted in three electronic databases. Studies were included in the systematic review if they examined an intervention for promoting AET adherence among breast cancer survivors. Studies were further included in the meta-analyses if they examined a measure of AET adherence (defined as compliance or persistence beyond initiation) and reported (or provided upon request) sufficient information to calculate an effect size. RESULTS: Of 5,045 unique records, 33 unique studies representing 375,951 women met inclusion criteria for the systematic review. Interventions that educated patients about how to manage side effects generally failed to improve AET adherence, whereas policy changes that lowered AET costs consistently improved adherence. Medication reminders, communication, and psychological/coping strategies showed varied efficacy. Of the 33 studies that met the inclusion criteria for the systematic review, 25 studies representing 367,873 women met inclusion criteria for the meta-analysis. The meta-analysis showed statistically significant effects of the adherence interventions overall relative to study-specified control conditions (number of studies [k] = 25; odds ratio, 1.412; 95% CI, 1.183 to 1.682; P = .0001). Subgroup analyses showed that there were no statistically significant differences in effect sizes by study design (randomized controlled trial v other), publication year, directionality of the intervention (unidirectional v bidirectional contact), or intervention type. CONCLUSION: To our knowledge, this is the first known meta-analysis to demonstrate a significant effect for interventions to promote AET adherence. The systematic review revealed that lowering medication costs and a subgroup of psychosocial and reminder interventions showed the most promise, informing future research, policy, and clinical directions.

Anxiety trajectories among cancer survivors during the COVID-19 pandemic.

PURPOSE: To describe trajectories of general and bodily vigilance anxiety among cancer survivors during COVID-19 and examine associated factors. DESIGN: Longitudinal survey study (May-December 2020). SAMPLE: Colorado-based cancer survivors (N = 147). METHODS: Latent class growth analyses were used to examine trajectories for two types of anxiety (general and body vigilance), and to evaluate associations with fear of cancer recurrence (FCR), loneliness, and emotional approach coping. FINDINGS: Anxiety levels remained stable over time. Most participants were best characterized by the mild general anxiety and moderate bodily vigilance anxiety classes. FCR predicted both general and bodily vigilance anxiety class, and loneliness distinguished between mild and moderate bodily vigilance anxiety classes. CONCLUSIONS: Current cancer survivors experienced mild general anxiety and moderate body vigilance anxiety during the early pandemic with no detectable improvement over time, and FCR consistently predicted anxiety outcomes. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: These findings provide insight into the anxiety profiles of cancer survivors during COVID-19 and possible therapeutic targets.

Cancer survivors' cancellations of healthcare appointments during the COVID-19 pandemic: Associations with anxiety and depression.

OBJECTIVE: Though it is well-documented that cancer survivors experienced healthcare delays during the COVID-19 pandemic, who initiated those delays has not been examined. This longitudinal study distinguishes rates of patient-from provider-cancelled healthcare appointments at three timepoints during the pandemic, and examines psychosocial factors associated with patient-cancelled appointments. METHODS: Cancer survivors (N = 147) in the United States completed psychosocial and health behavior measures three times between May and December 2020. We examined rates of patient- and provider-cancelled healthcare appointments, including cancer screening appointments, at each timepoint and change between timepoints. Logistic regression was used to determine if anxiety symptoms, depression symptoms, and COVID-19 fears were associated with self-cancelled healthcare appointments. RESULTS: In May 2020, one third (33.79%) of participants reported one or more self-cancelled appointments within the prior 2 months and nearly half (45.89%) reported one or more provider-cancelled appointments. Rates of provider-cancelled appointments decreased to 35.71% in June/July 2020 and to 9.24% in November/December 2020 (both reflected p < 0.05 reductions compared to the previous timepoint). Rates of self-cancelled appointments, however, remained more stable (ps > 0.144). In June/July and November/December 2020, higher depression and anxiety symptoms, but not COVID-19 fears, were associated with greater likelihood of self-cancelled appointments. CONCLUSIONS: Cancer survivors cancelled their healthcare appointments at a stable rate even as provider-cancelled appointments declined. Depression and anxiety symptoms, but not COVID-19 concerns, were associated with patient cancellations. Interventions that address anxiety and depression symptoms may help to promote adherence to cancer survivorship care during the pandemic.